A CLINICAL TEXT-BOOK 
OP 
MEDICAL DIAGNOSIS 
FOR 
PHYSICIANS AND STUDENTS 
BASED ON THE MOST RECENT METHODS OF EXAMINATION. 
BY 
OSWALD VIERORDT, M.D., 
PROFESSOR OF MEDICINE AT THE UNIVERSITY OF HEIDELBERG, 
FORMERLY PRIVAT-DOCENT AT THE UNIVERSITY OF LEIPZIG ; LATER, PROFESSOR OF MEDICINE 
AND DIRECTOR OF THE MEDICAL POLYCLINIC AT THE UNIVERSITY OF JENA. 
AUTHORIZED TRANSLATION FROM 
THE SECOND IMPROVED AND ENLARGED GERMAN EDITION, 
WITH ADDITIONS. 
BY 
FRANCIS H. STUART, A.M.,M.D., 
MEMBER OF THE MEDICAL SOCIETY OF THE COUNTY OF KINGS, NEW YORK ; FELLOW OF THE 
NEW YORK ACADEMY OF MEDICINE, MEMBER OF THE BRITISH MEDICAL ASSOCIATION, ETC. 
Second Edition Revised. 
WITH ONE HUNDRED AND SEVENTY-EIGHT ILLUSTRATIONS, 
Many of which are in colors. 
PHILADELPHIA: 
W. B. SAUNDERS, 
913 Walnut Street. 
1892. Entered according to the Act of Congress, in the year 1891, by 
W. B. SAUNDERS, 
m the Office of the Librarian of Congress at Washington, 
EDWARD STERN & CO., PRINTERS, 
PHILADELPHIA. YORWORT DES AUTORS ZUR ENGLISCHEN AUFLAGE. 
Es gereicht mir zur lebhaften Genugthuung, Herrn Francis II. 
Stuart, M.D., meinen Dank dafiir auszusprechen, dass er es unter- 
nommen hat, meine Diagnostifc in das Englische zu dbersetzen. 
Ich bezweifle nicht, dass die Ubersetzung ihm gut gelungen ist, 
und gebe ihr den Wunscli mit auf den Weg, dass sie sich in der 
neuen Welt ebenso viele Freunde erwerben moge, wie die deutsche 
Ausgabe in Deutschland gefunden hat. 
Heidelberg, 30sten M'arz, 1891. 
Prof. Dr. 0. VIERORDT, 
Director der Poliklinik. 
III PREFATORY NOTE TO THE SECOND EDITION. 
So short a time has elapsed since this work was issued that it has 
not been possible to make any material change in it for the Second 
Edition. Yet the work has been revised: errors, where discovered, 
have been corrected, slight changes have been made in many places, 
and the index has been farther improved. 
The hearty reception and commendation given the book by the 
Medical Press and Profession has stimulated the Translator to greater 
endeavor to make it more worthy of the praise it has received, and to 
secure for it the place in medical literature which it deserves. It is 
hoped that this desire on the part of the Translator may be an assur- 
ance of his gratification that this valuable Avork of Professor Yierordt 
has met in its English dress such universal Avelcome and appreciation. 
FRANCIS H. STUART. 
Brooklyn, N. Y , September, 1891. 
IV TRANSLATOR’S PREFACE. 
The work of which a translation is here offered is one of the best 
that has yet been written upon the subject. When it first came into 
the hands of the translator he had no thought of ever using it except 
as a work of reference. But as he read it he became convinced that 
it had such merit that it would certainly be welcomed by a large class 
of readers if it were rendered into English. Accordingly, after com- 
municating with the author and his publisher, the work of translation 
was begun, and has been prosecuted at such intervals of time as could 
be secured from an active professional life. If the work shall com- 
mend itself to others as it has to him, the translator will feel amply 
rewarded for the effort he has made to put it into their hands. 
Here and there slight additions have been made, which the trans- 
lator trusts will increase the value of the work. A very full index 
has been prepared, which, it is believed, comprises a reference to 
every material statement in the book. 
The translation was almost completed when a copy of the second 
edition of the original was received from the publisher. The author 
has made numerous additions which have enhanced its value, and the 
translation has been made to correspond with this enlarged edition. 
It is gratifying to the translator to find that a second edition has so 
soon been called for, and that his own favorable opinion has been 
further confirmed by the fact that Italian and Russian translations of 
the work have been made. 
FRANCIS H. STUART. 
123 JORALEMON STREET, BROOKLYN, N.Y., 
March, 1891. 
V AUTHOR’S PREFACE TO THE SECOND EDITION. 
In this edition the book has received, as I think, not incon- 
siderable additions and improvements. To mention only the most 
important ones: The section upon the examination of the contents 
of the stomach has been almost entirely rewritten, and so have some 
portions of the section on the examination of the organs of the senses, 
especially that of the eye. The laryngoscopic examination of the 
larynx has been treated anew, and much more extensively than in the 
first edition. A short section, almost entirely new, has been added 
upon the enlargement of the vessels of the brain, and at the end 
of the book a concise presentation of those peculiarities of micro- 
organisms whose recognition and discrimination are made possible 
by cultures and inoculation. Finally, with the hearty cooperation 
of the publisher, the illustrations of the most important micro- 
organisms are printed in colors, and also some entirely newT figures 
have been added. 
I am indebted to the friendly assistance of Professor Gartner 
in the department of bacteriology, of which I here make public 
acknowledgment. 
Jena, August, 1889. 
OSWALD YIERORDT. 
VI PREFACE TO THE FIRST EDITION. 
The book which is here offered to the medical public was under- 
taken at the solicitation of a number of associates, and in view of the 
experience which I have acquired during more than four years of work 
as Teacher of Diagnosis in the Medical Clinic at the University of 
Leipsic. Originally I had in view a very extensive treatise com- 
prising a detailed explanation of normal and pathological anatomy 
and physiology as a foundation for diagnosis. But this plan I 
abandoned with a view to the convenience and general usefulness 
of the book. 
Regarding the principles which have guided me, and which I hope, 
particularly in the “ Special Part,” notwithstanding the brevity of the 
presentation, have been made plain, I may be permitted here to 
specify the following. I have here, as well as in my teaching, taken 
pains to emphasize that, besides availing ourselves of the constantly- 
increasing finer methods of diagnosis, the simple use of our senses, 
especially of the unaided eye, must not be forgotten. Still more the 
manifold labors with the microscope and in the laboratory ought not 
to permit the physician to forget that a preparation or a chemical 
reaction is not enough for a diagnosis, but that the whole organism 
must always be brought under consideration. In other words, in 
diagnosis as well as therapeutics this rule is imperative: We must 
individualize the case. Should the book to any extent antagonize 
the inclination of our time to theorizing, it would afford me especial 
satisfaction. 
Lsipsici June, 1888. 
OSWALD VIERORDT. 
VII CONTENTS. 
PART I. 
CHAPTER I. 
INTRODUCTION. 
J*AOE 
Anamnesis 18 
Mode of Taking the Anamnesis 19 
What the Anamnesis Comprises 20 
Previous History of the Patient 20 
The Present Disease 22 
CHAPTER II. 
EXAMINATION OF PATIENTS. 
What the Examination Comprises 24 
[Note by the Translator upon Keeping Records of Cases, and a Form 
for Recording the Results of a Medical Examination] ... 24 
PART II. 
CHAPTER III. 
GENERAL EXAMINATION. 
I. The Psychical Condition of the Patient 31 
II. The Position of the Patient 31 
III. The Structure of the Body and Nutrition 33 
IV. Skin and Subcutaneous Cellular Tissue 36 
A. The State of Nutrition of the Skin 36 
b. The Moisture of the Skin ; Perspiration 36 
IX X 
CONTENTS. 
PAGE 
C. The Color of the Skin 38 
1. The Pale Skin 39 
2. Abnormal Redness of Skin 41 
3. The Blue-red Skin, Cyanosis 42 
4. The Yellow Skin, Icterus, Jaundice 45 
5. The Bronze Skin 48 
6. The Gray Skin of Silver Deposit 49 
D. Other Pathological Appearances of the Skin which are of 
General Diagnostic Value 49 
1. Acute Exanthematous Diseases 49 
2. Exanthemata from Poisons and the Use of Medicines . 50 
3. Hemorrhages in the Skin 51 
4. Scars 52 
E. CEdema of the Skin and Subcutaneous Cellular Tissue 
(CEdema, Anasarca) 52 
F. Emphysema of the Skin 55 
V. The Temperature of the Body. Fever 57 
1. The Terms Used and the Method of Taking the Temperature 57 
2. The Normal Temperature of the Body 59 
3. Elevated Temperature. Fever 60 
4. The Subnormal Temperature 63 
5. Diagnostic Value of the Temperature, especially of its General 
Course 64 
6. Local Elevation or Lowering of the Temperature ... 71 
PART III. 
CHAPTER IV. 
EXAMINATION OF THE RESPIRATORY APPARATUS. 
Examination of the Nose and Larynx 73 
1. The Nose 73 
2. The Larynx 74 
Examination of the Lungs .76 
Topographical Anatomy of the Lungs 76 
The Anatomical Boundaries of the Lungs with Reference to the 
Thorax 77 
Inspection of the Thorax 81 
1. Normal Form of Thorax and Normal Respiration . . 81 
2. Pathological Forms of Thorax 83 
3. Anomalies of Respiration ... .... 89 CONTENTS. 
XI 
PAGE 
Palpation of the Thorax 100 
1. Pain caused by Pressure upon the Thorax .... 101 
2. Testing the Movement during Respiration .... 102 
General and Preliminary Remarks Regarding Percussion . . 103 
1. History and Methods 104 
2. Qualities of Sounds 106 
3. The Conditions that determine the Quality of the Sounds 
and their Production in the Body. The Feeling of Re- 
sistance 109 
4. Topographical Percussion: Determining the Parietal Bound- 
aries of Organs 116 
Percussion of the Thorax, Especially of the Lungs . . .118 
1. Methods 118 
2. Normal Sound over the Lungs, Trachea, and Larynx. The 
Normal Boundaries of the Lungs . . . . .119 
3. Abnormal Sound over the Lungs. Abnormal position of 
the Border of the Lungs 125 
The Second Quality of Sound which is found over Diseased 
Lungs * 130 
Auscultation of the Lungs 138 
1. History. The Sphere of Auscultation at the Present Time 138 
2. Methods of Auscultation 138 
3. Auscultatory Signs in Normal Respiration .... 141 
4. Pathological Sounds in the Respiratory Apparatus . . 144 
Palpation of Vocal Fremitus (Auscultation of the Voice) . . 156 
Exploratory Puncture of the Pleura 160 
Methods of Measuring and Stethography 162 
Measuring the Thorax 162 
Spirometry, Pneumatometry, and Stethography .... 163 
Cough and Expectoration 164 
Expectoration, Sputum 167 
1. General Characteristics of the Expectoration . . . 168 
2. Foreign Substances in the Sputum which are Visible to the 
Unaided Eye 171 
3. Microscopical Examination of the Sputum .... 175 
CHAPTER V. 
EXAMINATION OF THE CIRCULATORY APPARATUS. 
Examination of the Heart 191 
Anatomy of the Normal Heart 191 
Preliminary Remarks necessary to Understand the Physical Phe- 
nomena of the Heart 193 XII 
CONTENTS. 
PAGE 
Inspection and Palpation of the Region of the Heart . . . 197 
The Apex-beat . . 197 
Alteration in the Width and Strength of the Apex-beat . . 200 
The Neighborhood of the Heart in general .... 202 
The Epigastrium 204 
Percussion of the Heart 204 
Normal Percussion Figure of the Heart 205 
Methods of Percussion 205 
Enlargement of the Area of Heart-dulness .... 208 
Diminution or Loss of Heart-dulness 210 
Displacement (dislocation) of the Heart-dulness . . . 210 
Auscultation of the Heart 211 
Method and Normal Condition 211 
Pathological Changes in the Heart-sounds .... 216 
Organic Endocardial Heart-murmurs 221 
Inorganic, Anaemic Murmurs. (Synonyms : accidental, blood 
murmurs.) 229 
Pericardial Murmurs. [Friction-sounds.] .... 230 
Examination of the Arteries 234 
i. The Pulse, its Palpation and Graphic Representation . . 234 
Palpation of the Pulse 234 
1. The Normal Pulse 234 
2. Pathological Frequency of the Pulse .... 237 
3. Want of Rhythm of the Pulse 241 
4. Quality of the Pulse 241 
5. Symmetry of the Radial Pulse 245 
II. Other Phenomena in Arteries 253 
Examination of the Veins 260 
Inspection and Palpation of Veins 260 
1. Increased Fulness of Veins 260 
2. Phenomena of Circulation in the Jugular Veins . . . 262 
3. Phenomena of Circulation in Other Veins .... 267 
4. Venous Thrombosis 268 
Auscultation of Veins 268 
Examination of the Blood 270 
Preliminary Remarks 270 
1. Color and Spectroscopic Character of the Blood . . . 270 
2. Microscopic Examination of the Blood .... 273 
CHAPTER VI. 
EXAMINATION OF THE DIGESTIVE APPARATUS. 
Mouth, Palate, and Pharyngeal Cavity 284 
Examination of the (Esophagus 291 CONTEXTS. 
XIII 
PAGE 
Examination of the Stomach 297 
Anatomy of the Stomach 297 
Inspection and Palpation of the Stomach 299 
Percussion of the Stomach 304 
Auscultation of the Stomach 307 
Examination of the Intestines 308 
Inspection and Palpation 308 
Percussion of the Intestine 311 
Auscultation of the Intestine 312 
Examination of the Peritoneum . 312 
Inspection of the Abdomen . 313 
Examination of the Liver 319 
Inspection of the Liver 320 
Palpation of the Liver 323 
Percussion of the Liver 326 
Examination of the Spleen 332 
Inspection of the Spleen 334 
Palpation of the Spleen 334 
Percussion of the Spleen 336 
Auscultation of the Spleen 339 
Examination of the Pancreas, Omentum, Retro-peritoneal Glands . 340 
Examination of the Contents of the Stomach 341 
Examination of the Process of Digestion 342 
Stomach-digestion and its Disturbances 342 
Mode of Procedure in Examining the Stomach-digestion . 347 
Vomiting, and the Examination of What is Vomited .... 358 
The Vomit 359 
Animal Parasites 377 
CHAPTER VII. 
EXAMINATION OF THE URINARY APPARATUS. 
Examination of the Kidneys 392 
Anatomy 392 
Local Examination of the Kidneys 394 
Pathological Conditions of the Kidneys 394 
Examination of the Ureters and Bladder 398 
Examination of the Urine 399 
(A) Normal Urine 401 
(B) Pathological Urine 406 
Sediments of Organic Bodies, or Direct Products of These . 416 
Inorganic Sediments 428 
Examination of the Urinary Constituents in Solution . . 433 
Bile-pigments and Bile-acids 442 
The Urine as Affected by Medicines 450 XIV 
CONTENTS. 
CHAPTER VIII. 
EXAMINATION OF THE NERVOUS SYSTEM. 
PAGE 
Anatomy; Normal and Pathological Physiology 452 
1. The Cortico-muscular Tract (the Pyramidal Tract, Flechsig) . 452 
2. The Sensitive or Centripetal Tracts 459 
3. Centres and Tracts of the Special Senses 460 
4. Remarks upon the Vessels Supplying the Brain . . . .461 
Symptomatology and Methods of Examination 463 
Examination of the Seat of Disease 463 
The Spinal Column 467 
The Peripheral Nerves and their Surroundings .... 468 
Examination of the Condition of the Mind 469 
Disturbances of Sensibility .' 472 
1. Sensitiveness to Peripheral Irritation 472 
(a) Sensibility of the Skin 473 
(5) Deep Sensibility 479 
The Knowledge of Form (Stereognosis) . . . . . 481 
2. Sensible Phenomena of Irritation and Pain from Pressure upon 
Nerves 482 
1. Parsesthesia 482 
2. Spontaneous Pain 482 
3. Distribution of the Sensory Cutaneous Nerves .... 484 
Disturbances of Motility 488 
1. Paralysis 488 
2. Disturbance of the Nutrition and Tone of the Muscles . . 489 
3. The Reflexes 495 
1. Skin Reflex 495 
2. Tendon Reflexes (periosteal, fascial reflex) .... 497 
4. Electrical Examination of the Nerves and Muscles . . . 501 
Regarding the Physics, and the Instruments Employed . . 501 
Methods of Examination and their Physiological Results upon 
the Living Human Body 505 
General Methods, and Explanation of the Terms Employed in 
Galvanic Examinations 506 
Method of Examination in Detail. Normal Condition . . 507 
1. Points of Stimulation 508 
2. Examination 510 
(a) Faradic Examination 512 
(b) Galvanic Examination 515 
3. What to Observe in Determining the Electrical Re- 
action 516 
Faradic Current 517 
Galvanic Current 517 CONTENTS. 
XV 
PAGE 
1. The Reaction of Degeneration (EaR) 519 
(a) Complete EaR 519 
(b) Partial EaR 519 
Varieties of EaR 523 
(c) Mixed Electrical Reaction 523 
2. Myotonic Reaction (Erb) 524 
3. Diagnostic Value of the Electrical Condition . . . 524 
4. Mechanical Excitability of Muscles and Nerves . . . 526 
5. Coordination and Ataxia 527 
6. Spasms of the Voluntary Muscles 530 
7. Voluntary Muscles, their Innervation, their Function, and 
the Diseases that Disturb Them 536 
Disturbances of Speech (Lalopathy) 548 
I. Dysarthria and Anarthria 548 
II. Aphasic Disturbances, Disturbance of Graphic Communica- 
tion (of Mimicking and Singing) 549 
Mode of Procedure in Testing for Aphasic Disturbances . . 555 
Sense Organs 561 
Disturbances of the Vegetative System in Nervous Diseases . . . 575 
1. General Phenomena 575 
2. Disturbances of the Respiratory Apparatus . . . 575 
3. Disturbances in the Circulatory Apparatus .... 576 
4. Disturbances of the Digestive Apparatus .... 577 
5. Disturbances of the Urinary Apparatus .... 579 
6. Disturbances of the Genital Apparatus .... 580 
7. Disturbances of the Skin 581 
Bones and Joints 583 
The Diagnostic Value of the Symptoms in Nervous Diseases . 583 
APPENDIX. 
1. Laryngoscopic Examination of the Larynx 589 
Paralysis of the Muscles of the Larynx 597 
2. Examination with the Ophthalmoscope 600 
3. Bacteria which come under Consideration in the Diagnosis of In- 
ternal Diseases 602 MEDICAL DIAGNOSIS. 
PART I. 
CHAPTER I. 
INTRODUCTION 
The physician arrives at an opinion regarding his patient in two 
ways: by inquiry of the patient or of friends of the patient, and by 
his own objective examination. The result of the former is called the 
Anamnesis; the latter reveals the Present Condition of the Patient. 
The notes which the physician makes from time to time in the course 
of his continued observation of the patient, and in which he records 
the changing phenomena of the disease, constitute the History of the 
Case. 
The judgment formed in this way is expressed by the Diagnosis. 
In a narrow sense such a judgment simply consists in giving a name 
to the disease that is found; or, if there are several diseases together, 
or special complications of one, names to several diseases. But in the 
wider sense, a diagnosis must always consist of something more than 
this. The physician must endeavor to form a clear conception, in a 
given case, as to how the whole organism has been affected from the 
beginning, what is the character of the disease, or what harm it has 
wrought already in the organism as a whole, as well as locally. If 
in the narrow sense the diagnosis is schematic, so that the disease 
can be classified, then the diagnosis is in a broader sense indi- 
vidualized. A complete, exhaustive presentation of the peculiarity 
and severity of the existing disease and of the patient’s prospects 
17 18 
MEDICAL DIAGNOSIS. 
(prognosis) is presented only by this method. This alone is a sure 
guide in treatment. 
We attain to a diagnosis in this wider sense only by having our 
perception of the general behavior of patients quickened and by 
carefully combining with it the experience derived from previous 
examinations. 
Since the chief object of this work is the teaching of the examination 
of patients and the presentation of the methods of conducting it, we 
begin with but a very few words in regard to obtaining the 
Anamnesis. 
What is it necessary for the physician to know, beyond what his 
examination reveals, in order to recognize a given disease in itself and 
to form a critical judgment regarding the patient in a larger sense? 
It is difficult to define this. Facts which appear insignificant in 
themselves in experience often exercise a decided influence upon the 
special diagnosis, and especially in forming a judgment regarding 
the constitution of the patient, or upon the timely recognition of a 
secondary disease. From having at hand clear knowledge of the 
symptoms of the different diseases, both of their remote or predisposing 
and of their directly exciting causes, the physician is constantly able 
to select what is essential from the past, and so to avoid too great 
prolixity. But it is always well for the beginner to secure as com- 
plete an anamnesis, or prior history, as possible, in order that he may 
allow nothing of importance to escape his attention. 
The anamnesis generally begins with and involves the question as 
to whether the disease is acute or chronic, what organs are affected, 
or are inclined to be diseased. This determines the examination to 
follow, in that certain organs are examined with greater exactitude 
than others. But the examiner must guard himself from too great 
influence or prejudice from the result of the anamnesis; the objectivity 
of the objective examination must be kept in view ; and this, in turn, 
may give occasion for supplementing the anamnesis, by occasioning 
additional inquiries regarding certain occurrences and appearances, 
and thus a conclusion is finally reached. It is advisable for the 
student, under all circumstances, with all the patients he examines, 
and for the physician at least with his more important cases, to note INTRODUCTION. 
19 
down in regular order the results both of the anamnesis and of his 
examination. [See Translator’s note, page 24 et seq.~\ 
Mode of Talcing the Anamnesis. 
First, we always note the name, occupation, age, residence of the 
patient. Then we conduct, as simply as possible, a dialogue with the 
patient, or in the case of a child or of a person who is insensible, 
unconscious, or mentally disturbed, with his neighbors or relatives. 
How much we may allow them simply to tell, how much we must 
learn by asking questions, must depend upon the cultivation and 
intelligence of the person who is giving the information. We must 
particularly guard against asking the patient leading questions—that 
is, influencing his reply by the manner in which we put the questions. 
To the question: “ Have you then really never had any pain in the 
bowels V' or, “ Did you never have any pain in the bowels?” we shall 
almost certainly receive an affirmative answer, either from indifference, 
or from a desire to make his complaints as interesting as possible and 
enlarge upon them ; or, lastly, whether because he is of a very impres- 
sionable nature, and the mere calling to mind the question of pain 
suggests to him what in reality he has not had. 
On the other hand, we must exercise close scrutiny of what we 
learn, a scrutiny which it is generally best not to allow the patient to 
know of. This scrutiny may be made with reference to three points: 
(a) We must not accept without further inquiry the name the 
patient gives to a disease he has formerly passed through, since mis- 
chief is often done by the laity in the use of the names of diseases, 
as of diphtheria, typhus, etc. In any doubtful case we inquire its 
symptoms, and also what the physician who attended the patient had 
called the disease. 
(b) The simulation of a disease is common. This was confined in 
large part to the domain of hysteria; but, now-a-days, from certain 
social reasons, it is much more frequent. Neuralgia, rheumatism, 
trembling, spasms, lameness, also pains in the bowels, asthmatic 
attacks, are the conditions which are most often simulated. The 
attempt to deceive is made not only with reference to the anamnesis, 
but also during the objective examination. 
(c) The concealment of the appearances of disease is manifest with 
reference to the different sexual diseases, especially syphilis. Women, 20 
MEDICAL DIAGNOSIS. 
moreover, often attempt to avoid all statements in regard to the 
sexual apparatus, even when it alone is diseased. Inebriates, and 
those who practise onanism, often confess their habits to the physician 
only with great reluctance. 
What the Anamnesis Comprises. 
The exact knowledge of the etiology and symptomatology of internal 
diseases is here the only correct guide, and, at the same time, gives us 
complete information respecting the cases which, under various cir- 
cumstances, come under consideration. We are content with indi- 
cating the essential point of view by the introduction of a few 
examples. We may divide every anamnesis into the following two 
parts: 
I. Previous history of the patient: This comprises all that it is 
important to know up to the beginning of the disease on account of 
which the patient consults the physician. 
II. The present disease: This relates to the exciting causes, the 
commencement, and the course to the present time. 
Previous History of the Patient. 
1. Hereditary disease {heredity). This is of importance in so 
many diseases that in each and every case we have to inquire regard- 
ing the parents, brothers and sisters of the patient, and also very often 
regarding the brothers, sisters, and parents of the parents. There 
especially come into view in this connection, syphilis, tuberculosis, 
diseases of the brain, and certain general neuroses. Heredity, as 
regards rheumatism, carcinoma, and diseases of the heart, is of sec- 
ondary importance, yet not immaterial. These diseases are in part 
inherited as such, in part they confer upon the descendants only the 
organic foundation, the disposition to the new development of the 
same or related diseases. Different descendants are variously divided 
by heredity. Often individuals, or a majority, are wholly exempt. It 
also happens that one generation is entirely passed over, and the 
trouble reappears in the following generation (hence the question 
regarding the grandparents). 
Of the infectious diseases, smallpox and syphilis can, without INTRODUCTION. 
21 
doubt, be conveyed in utero; but the intra-uterine communication of 
tuberculosis from the mother to the child is extremely improbable. 
2. The manner of life, habits, profession, occupation, residence, 
experiences as to fatigue, other harmful influences to ivhich they have 
been exposed, whether they have descendants, and, the case of 
women, the number and character of their confinements, compose this 
group. 
Under the manner of life are considered the diet, character of 
dwelling, and the clothing. Injurious habits play a very important 
part in the manner of life, especially immoderate use of alcohol and 
tobacco; so, also, venereal excesses must be taken into account. But 
it is important to remember that, at least within certain limits, the 
harmful limit of these things differs with the individual. 
Profession and occupation on the one hand affect the whole consti- 
tution, and on the other are often to be regarded as predisposing or 
exciting causes of disease; finally, they may exert a favorable or an 
unfavorable influence upon the course of an existing chronic disease. 
Thus, for instance, stonecutters and polishers, by continually inhaling 
fine dust from the stone, are very frequently inclined to bronchial 
attacks and diseases of the lungs; thus, too, the occupations that have 
to do with lead (type-setting, type-polishing, painting), or with mer- 
cury (making mirrors, etc.), frequently cause chronic poisoning by 
these metals. Persons who are engaged about sheep, swine, horses, 
or with the fresh skins and hair of these animals, are apt to have 
malignant pustule and other diseases. 
Thq place of prior residence is to be considered with reference to 
miasmatic (intermittent), endemic diseases, or epidemics which may 
have prevailed there at that time. With travellers, exotic diseases, 
which less frequently occur in their native places, as lepra, certain 
exotic animal parasites, etc., must be thought of. 
As regards fatigue, army marches are to be regarded as particularly 
fruitful sources of disease; so of exposure to harmful influences. A 
fall, slight, perhaps, but whose effects continue; or a wound, without 
other immediate sequelae except that it does not heal—of these, account 
must be taken ; and also of very harmful momentary experiences, as 
sorrow, care, severe fright, anxiety. 
Where there is sterility we consider anomalies of the sexual apparatus 
of the man or woman, but especially the question of syphilis. The 22 
MEDICAL DIAGNOSIS. 
puerperal period, even when it does not pursue an unfavorable course, 
may in various ways be a source of disease. 
3. Diseases which one has had, not only acute diseases, but the 
temporary outbreak of a chronic disease ending in apparent or real 
recovery. 
Certain acute diseases may have as sequel* certain other diseases 
which either are directly connected with them, as paralysis following 
diphtheria, nephritis after scarlet fever; or which appear after a 
shorter or longer period, as valvular disease of the heart from endo- 
carditis in acute articular rheumatism, arising during scarlet fever. 
The outbreaks of a chronic disease are often spoken of by patients 
as diseases which they have gone through; as, especially, the primary 
and secondary affections of syphilis, temporary manifestations of 
tuberculosis of the lungs, etc. 
This point is of special importance in two ways: 1. There are 
certain acute diseases which one does not easily have a second time, as 
scarlet fever, measles, typhoid fever. On the other hand, others 
readily occur again, as erysipelas, pneumonia, articular rheumatism, 
typhlitis. 2. Certain diseases of childhood are especially to be con- 
sidered—for example, scrofulosis as early indications of tuberculosis; 
manifestations of hereditary syphilis; frequent convulsions as an 
early sign of anomalous condition of the nervous system. The dis- 
eases ordinarily designated as “children’s diseases ” generally have 
no significance as to the future, but yet sometimes, unfortunately, 
they leave lasting suffering behind them, as emphysema after whooping- 
cough, etc. 
The Present Disease. 
1. The possible exciting causes must be first considered. It is 
especially important for the early diagnosis of an infectious disease to 
inquire whether the patient has been exposed to infection. Many 
diseases are conveyed by a very short exposure, others require a 
longer, or even a personal contact. Also the period of incubation 
must be considered. This is the period from the moment of infection 
until the outbreak of the disease. With most transferable diseases 
this period is of a known, somewhat exactly defined duration. More- 
over, “taking cold,” over-exertion, improper eating and drinking, 
taking of poison, etc., come under consideration. INTRODUCTION. 
23 
It is to be remarked that the laity often assume something as an 
exciting cause, thus especially “taking cold.” 
2. The first appearances and the course of the disease up to the 
time of examination. 
With chronic diseases the first appearances are sometimes at the 
beginning scarcely noticeable: they often consist only in a change 
from the previous behavior, unless the new condition in itself directly 
appears to be one of disease; a person who previously had red cheeks 
becomes paler (all kinds of wasting diseases), a stout person without 
other reason becomes thin, one who always previously ate and drank 
little, all at once eats and drinks considerably (diabetes), a person 
formerly very orderly becomes disorderly, forgetful (disease of the 
brain, especially progressive paralysis). Even when they have made 
considerable progress, such gradually developing disturbances often 
are not at all noticed by ignorant and indifferent people. CHAPTER II. 
EXAMINATION OF PATIENTS. 
The examination of the patient comprises : 
1. A general examination, which takes into account certain phe- 
nomena of disease which concern the organism as a wThole, and are the 
expression of a pathological change of the whole organism. 
2. A special examination, which inquires into the different regions 
and organs, the secretions and excretions of the body. At the bed- 
side we generally proceed in such a way that, beginning at the head, 
we gradually go downward, in order to facilitate the investigation by 
examining contiguous organs. But in many cases it is better to group 
together organs that are functionally related, no matter what their 
anatomical location may be, since we thus quickly obtain a compre- 
hensive view of the way in which the affected organs or systems are 
disturbed. Thus, in diseases of the heart, the heart and bloodvessels, 
in diseases of the nervous system, the central and peripheral nervous 
systems are examined together. Sometimes, as in the case of very 
weak or very unruly patients, as children, the examination of the 
body must be very brief. Here the expertness of the physician espe- 
cially is put to the test to the utmost degree. 
It will best answer the purposes of study if the division of the 
subject throughout strictly conforms to the organ-systems, and hence 
the special part is divided into : 
I. Examination of the respiratory apparatus. 
II. Examination of the circulatory apparatus. 
III. Examination of the digestive apparatus. 
IV. Examination of the urinary apparatus, including also in part 
the sexual apparatus. 
Y. Examination of the nervous system. 
[note by the translator upon keeping records of cases, and a 
FORM FOR RECORDING THE RESULTS OF A MEDICAL EXAMINATION. 
It is not practicable at the bedside to go through any set form for 
conducting the inquiry regarding the present illness. The most direct 
24 EX AMIN A TION OF PATIENTS. 
25 
way of getting at it, and the one that will lead to the most satis- 
factory replies to our interrogatories, is to ask the question, What is 
your complaint ? How are you sick ? or some such direct question 
as this. In this way we get at once at the disease we are called upon 
first to diagnose and then to treat. As we proceed we will arrange 
the facts in our minds, and when we make the record, we shall place 
them in a natural and logical order. Having a regular form for 
keeping records of cases soon develops an order of procedure in 
accordance with it. 
Case-taking is a most valuable aid to the student in clinical study. 
1. He learns to make a systematic examination of the patients he 
sees. He forms the habit of bringing before his mind each factor in 
the case in orderly succession. There are two advantages from this. 
First. He forms the habit of thoroughness in examining his cases. 
Second. He can readily compare one case with another—having 
arranged the factors of each in like order. While it is not necessary 
in making the examination to have or to follow strictly a printed 
form, yet it is desirable to have some regular form for making the 
record, so that cases that are similar can be readily compared. One 
case may require going over only a few points, in another it will be 
necessary to examine every organ in the body. 
2. The memory is greatly strengthened. Memory depends upon 
attention and repetition. Case-taking cultivates both of these in an 
eminent degree. Facts and symptoms that else would escape notice 
entirely, or be only slightly noted, are brought prominently before the 
mind for consideration. Their value or bearing is weighed, and so 
they are strongly impressed upon the mind. 
3. The mind is developed by this habit of carefully reflecting upon 
every feature of a case. Thought is both stimulated and made easy. 
Clearness and power of thought are increased. Independence of 
judgment is cultivated. Both knowledge and intellectual cultivation 
are acquired. “By knowledge is understood the mere possession of 
truths; by intellectual cultivation, or intellectual development, the 
power, acquired by exercise of the higher faculties, of a more varied, 
vigorous and protracted activity." (Sir William Hamilton.) 
4. Ease and habit of writing are almost unconsciously acquired. 
This is most valuable. The great majority of physicians keep no 
records of cases. Many never record or publish important ones, 26 
MEDIC A L DIA GNOSIS. 
because they have not the facility of writing which comes with prac- 
tice. Anything is easy to the practised hand. “ Who can estimate 
how much we have lost, from the fact that generations of men gifted 
with powers of acute and shrewd observation, have passed away 
without leaving one record behind them ? Think not that it is the 
hospital physician or surgeon alone who can advance the progress of 
medicine. There is not a practitioner who could not aid this great 
work. But he can only add to it with efficiency if he has faithfully 
recorded his observations, and does not trust to the general and vague 
impressions of unassisted memory. Therefore, on all grounds, per- 
sonal to yourselves and general for medical science, so engrain this 
habit within you that it becomes a second nature.” (Coupland.) 
The Anamnesis. 
Personal and Previous History. 
Name, Address, 
Birthplace, Age, Sex, 
Family history—Heredity : 
Father, 
Mother, 
Brothers, 
Sisters, 
Other relatives. 
Manner of life, habits, occupation, residence, etc., 
Previous diseases—character and results. 
(Note each one that was of such a character as to have any lasting 
effect upon the health or vitality.) 
Present Illness. 
Duration, 
Possible exciting cause, 
How began—suddenly or not; prodromal symptoms, 
Course of the disease till the time of examination. EXAMINATION OF PATIENTS. 
27 
Examination of the Patient 
General examination: 
Appearance, 
Psychical condition, 
Position in bed, 
Structure and nutrition, 
Skin and subcutaneous tissues, 
Temperature, 
Pulse. 
This covers the general features of every case. Attention has been 
directed, by what has been learned thus far, to some one or more of 
the special organs or systems of the body. It is usually best first to 
examine that, and to make this examination very full and thorough. 
Then the remaining organs of the body can be examined with greater 
or less fulness, according as they are found to be affected by the 
principal disease, or as they are related to the one specially diseased. 
It is well to form the habit of following a certain order in examining 
each organ. One is much less apt to overlook any part; and, too, 
as has already been pointed out, the records will be more easily con- 
sulted and compared. For this purpose, it is well to take the order of 
the text-book, so as to become thoroughly familiar with each subject. 
It is not of so much importance that this or that one is adopted, pro- 
vided it is a good one. But we have here a notable illustration of the 
truth and value of the Spanish proverb: “ Beware of the man of one 
book.” 
Presuming that those who use this work will follow the order laid 
down in it, the form now given conforms with the order in which the 
systems are treated. 
Special Examination. 
Examination of the respiratory apparatus: 
Nose, 
Mouth, 
Larynx. 28 
MEDICAL DIAGNOSIS. 
Examination of the lungs : 
Inspection of thorax, 
Palpation of thorax, 
Percussion of thorax, 
Auscultation of lungs, 
Auscultation of voice, 
Measurement of thorax, 
Cough and expectoration. 
Examination of circulatory apparatus: 
Inspection and palpation of the region of the heart, 
Percussion of the heart, Apex-beat, 
Auscultation of heart, 
Examination of the arteries and veins, 
Examination of the blood. 
Examination of the digestive apparatus: 
Mouth, gums, and pharynx, 
Stomach, 
Intestines, 
Peritoneum, 
Liver, 
Spleen, 
Pancreas, 
Contents of the stomach and vomited matters, 
Feces. 
Examination of the urinary apparatus : 
Kidneys, 
Ureters and bladder. 
Examination of the urine: 
Amount in twenty-four hours, 
Reaction, Odor, 
Specific gravity, 
Sediment, 
Albumin, 
Blood, 
Bile, 
Sugar, 
Other constituents. EX AMIN A TION OF PA TIE NTS. 
29 
Examination of the nervous system : 
Disturbances of sensibility, 
Location of, 
Superficial or deep, 
Motor disturbances, 
Disturbances of speech, 
Condition of the organs of special sense. PART II. 
CHAPTER III. 
GENERAL EXAMINATION. 
This consists of a number of subordinate divisions, namely: we 
have to consider: 
I. The psychical condition of the patient. 
II. The position in bed. 
III. The general structure of the body and the nutrition. 
IV. The skin and the subcutaneous cellular tissue. 
I 
Y. The temperature and the pulse. 
I. The Psychical Condition of the Patient. 
From this—that is, from the clearness of his intelligence, his sus- 
ceptibility to external impressions, his power of thought, from the 
possible presence of depression or irritability—we may often obtain 
important points of diagnosis ; both for diagnosis in the narrower 
sense, certain diseases being accompanied with definite manifestations 
of this kind, and for diagnosis in a broader sense, since the severity 
of a disease, the possible turn for better or worse, often becomes 
manifest by the psychical condition of the patient. (Regarding this 
and the way in which the examination in this direction is conducted, 
see the section on “Examination of the Nervous System.”) 
II. The Position of the Patient. 
This furnishes a very simple aid to diagnosis, because generally it 
can he determined by a single glance of the eye. From it conclusions 
in various directions may be drawn. People in health or only slightly 
sick usually assume the dorsal position, or a position upon one side, 
31 32 
MEDICAL DIAGNOSIS. 
in a certain unconstrained comfortable position (the active dorsal or 
side position). On the contrary, patients who either are not wholly 
conscious, or who have become very weak, frequently are inclined to 
slide down toward the foot of the bed and sink into a heap there, a 
position which manifests weakness, and hi some respects, but espe- 
cially for breathing, is very unfavorable (the passive dorsal and side 
position). 
In acute infectious diseases, more than elsewhere, the passive dorsal 
position is specially noteworthy. It is particularly so when apathy 
and clouded intelligence are combined with great muscular weakness, 
as is frequently the case in typhoid fever, where such a condition of 
the patient is so frequently and sometimes early present that it may 
aid in the diagnosis. 
But in still another way the position in bed is sometimes charac- 
teristic. Patients with acute affections of the chest organs involving 
only one side (pneumonia, pleurisy, pneumothorax) generally lie upon 
the side, and for the most part upon the side affected. This may be 
due to various causes. The pain caused by breathing is generally in 
this way diminished, because by lying upon the side the motion of 
that side is very much lessened, while, on the other hand, the motion 
of the opposite side in breathing is greater than when the patient 
lies upon the back ; hence the sound side, when the patient lies upon 
the diseased side, can better compensate for the loss of the portion 
diseased. In exudative pleuritis frequently there is the further 
advantage in lying upon the affected side that the exudation least 
interferes by pressure with the healthy side. 
Yet patients with pneumonia not infrequently lie upon the healthy 
side, because they have least pain in this position. That in diseases 
of the chest in general patients are inclined at the beginning of the 
disease to lie upon the sound side, and later upon the diseased side, 
I am not able to affirm. 
Difficult breathing, dyspnoea, if extreme, prompts one to assume 
the upright sitting posture in bed or in an easy chair—orthopnoea ; 
because in this attitude the action of the accessory muscles of respira- 
tion is more effective than when lying down. Orthopnoea may, there- 
fore, occur with all diseases which are accompanied with marked 
interference with respiration : as in narrowing of the air-passages in 
disease of the lungs (comparatively rare with phthisis—see under GENERAL EXAMINATION. 
33 
“Dyspnoea”), in diseases of the pleura, heart, pericardium, with large 
effusions into the abdominal cavity, which press the diaphragm up; 
and in general dropsy with effusions into the cavities of the body. 
In the severest cases the patients may indeed be obliged to keep 
the sitting posture, even to sleep. The continued exertion of sitting 
and the diminished sleep obtained in this position, besides the great 
anxiety and excitement these patients generally have, usually quickly 
bring on exhaustion. 
Another group of characteristic situations and positions in bed refer 
to diseases of the brain and its membranes. Thus meningitis betrays 
itself often at the first glance by opisthotonus, with the head boring 
into the pillow, so-called contraction of the neck; in circumscribed 
disease of the cerebrum the head is sometimes persistently inclined to 
be drawn forcibly to one side: forcible contraction of the head; in 
affections of the cerebellum, also of the crus cerebelli, we not infre- 
quently see the whole body continually, as one lies in bed, drawn 
sharply to one side, and, when turned over to the dorsal position, 
returning immediately again to this constrained position. These 
phenomena, however, are in part to be reckoned as convulsive con- 
ditions, which indeed bring about the greatest variety of characteristic 
positions and attitudes of the body. These latter, however, are gener- 
ally quite transitory. 
III. The Structure of the Body and Nutrition. 
The development of the skeleton determines the form of the body. 
Generally firm bones and broad, flat chest are characteristic of strong 
and enduring health; while those persons of delicate skeleton, espe- 
cially with slender ribs and narrow chest, are considered capable of 
both limited life and endurance. Yet this is only a general rule. 
We often see people of delicate build who are remarkably tough and 
enduring, both with reference to exertion and disease; and not infre- 
quently we find robust people with little power of resistance, especially 
to acute diseases. 
Unusually small development of the skeleton is often observed in 
idiots and cretins ; and, in more rare cases, in dwarfs, without any 
other anomaly. 
The form of the thorax is of especial importance. With a slight 34 
MEDICAL DIAGNOSIS. 
and narrow chest-cavity there is a proportionally frequent disposition 
to tuberculosis of the lungs ; and, on the other hand, a certain fulness 
carries with it a tendency to emphysema of the lungs. This will be 
more particularly spoken of under Respiratory Organs. 
The significance of the structure of the pelvis is manifest in the 
practice of obstetrics. 
The muscles, the subcutaneous tissues, and the skin furnish a 
means of judging of the nutrition, and also of the weight. In general, 
well-nourished and healthy persons have a certain volume and firm- 
ness of muscles. There is also a relation between the muscles and 
the skeleton. But even in perfectly normal persons there is a very 
marked difference in the volume of the muscles, which is not always 
explained by differences of occupation. By experience the eye grad- 
ually becomes quick in recognizing a suspiciously small muscular 
volume; yet the firmness of the muscles is a better guide to an 
opinion than their volume. 
The fat of the subcutaneous tissues may be very differently de- 
veloped in persons of good health. As a rule, it varies with the age, 
being greater for the first years of life up to the forty-fifth or fiftieth 
year. Beyond this it again, as a rule, becomes less. It also some- 
times varies in a shorter time without being caused by disease, as in 
women at about twenty years of age. It varies also, as a matter 
of course, with the kind and the richness of food, as well as with 
the occupation. Loose adipose tissue generally indicates a weak 
organization. 
A marked degree of leanness of the subcutaneous tissue is, under 
all circumstances, suspicious, and suggests an examination as to 
whether it may be caused by disease. In the same way the accumu- 
lation of fat beyond a certain degree becomes pathological. The 
measure or degree can only be established by experience. 
Of much greater importance is a commencing, even though a slight, 
wasting away of the subcutaneous fat, and eventually also of the mus- 
cles. As we have said, this is sometimes physiological. It can also 
take place, as among the poorer classes, from very poor nourishment. 
But in the majority of cases it is caused by disease, and it is, there- 
fore, important not to overlook it. This wasting can only really be 
learned by the physician when he has known the patient for some 
time. When this is not the case he must rely upon the statements of GENERA L EX A MINA TION. 
35 
the patient and his surroundings, and, therefore, this subject properly 
belongs to the “ previous history.” When the emaciation is marked, 
its proof is furnished by the condition of the skin. In these cases the 
skin of the patient’s whole body is loose, and can easily be taken up 
in folds. 
Excessive wasting is denominated atrophy, emaciation ; and when 
this is accompanied by general loss of strength and failure of function, 
marasmus or cachexia. 
The weight of the body is an excellent index and one which is 
superior to all other signs of corpulence, and its increase or diminu- 
tion. The absolute value of the weight of the body in the different 
periods of life has no diagnostic interest, for the reason that it varies 
within wide limits. Likewise the relation of the weight of the body 
to the height and the circumference of the chest has scarcely any 
significance for our purposes. On the other hand, change in the 
body-weight wrought by disease is of the greatest importance. In 
chronic diseases this is an extremely valuable means of determining 
whether the disease is increasing, standing still, or is being recovered 
from. Taking the weight regularly (say, weekly) in cases of tubercu- 
losis is especially to be recommended, also in diseases of the digestive 
apparatus. In convalescence from acute diseases, following the weight 
of the body is also a very important aid, especially for the early recog- 
nition of the possibility of the disease becoming chronic, or of the 
presence of associated chronic diseases. Moreover, in all these cases 
we must remember that oedema (which see) produces a deceptive 
increase in the weight of the body. 
According to Bornhardt (cited by H. Vierordt), the relation of the 
weight of the body, P, to the height, II (in cm.), and to the average 
circumference of the chest, C (measured at the level of the nipples, 
in cm.), for the average individual, may be reckoned as follows: 
/H0*\ 
P = kilograms. 
The weight of the body of the newly-born and its increase during 
the first months is of special significance. Regarding this subject, 
see works upon obstetrics and diseases of children, also Daten und 
Tabellen, by II. Vierordt. 
Diseases of the alimentary tract, more than others, produce emacia- 36 
MEDIC A L DIA GNOSIS. 
tion; next, all febrile diseases, whether acute or chronic (of the latter 
especially tuberculosis), then severe forms of diabetes mellitus, and, 
finally, all malignant growths. A certain degree of emaciation can 
be produced by any disease of an internal organ. 
IV. Skin and Subcutaneous Cellular Tissue. 
In medical diagnosis the condition of the skin and subcutaneous 
tissue is considered with reference to the following points: 
A. The condition of general nutrition. 
B. The moisture of the skin; perspiration. 
C The color of the skin. 
D. Certain pathological appearances of general diagnostic value 
(characteristic eruptions, hemorrhages, scars, etc.). 
E. The presence of oedema. 
F. Possible emphysema of the skin. 
Skin diseases proper and certain acute infectious diseases, with 
special localization upon the skin (the co-called acute exanthematous 
diseases) are not considered in this work. 
A. THE STATE OF NUTRITION OF THE SKIN. 
In old age the nutrition of the skin is diminished over the whole 
body. This is physiological. In earlier years a noticeable general 
atrophy of the skin exists only where there is a very severe cachexia. 
The skin is then thin and generally dry. It loses its tone, and when 
taken up in a fold resumes its place slowly. 
The different forms of circumscribed atrophy of the skin which 
have been described do not interest us here. They belong to works 
upon skin diseases. 
B. THE MOISTURE OF THE SKIN ; PERSPIRATION. 
Physiology teaches us that the moisture of the skin, as well as the 
visible secretion of perspiration, is influenced by various circumstances. 
It is increased during active exertion, by increased temperature of the 
blood, by moist heat, by mental impressions, especially fear; finally, 
by certain ingesta, as hot tea, by pilocarpine, etc. GENERAL EXAMINA TION. 
37 
In some of these cases there is at the same time an increase of heat 
of the body, which is overcome by the perspiration, cooling being 
caused by its evaporation. 
Perspiration is a regulator of the temperature of the body. 
The loss of water by evaporation (the greater part of the insensible 
perspiration) in health is, cceteris paribus, greater at night than during 
the day. It seems to alternate with the secretion of the urine. 
In healthy people the secretion of perspiration is in this way very 
changeable. But it is still more so in cases of illness. It may be 
increased to such a degree that the whole bed may be wet through 
(hvperidrosis). On the other hand, it may be so diminished (hyphi- 
drosis) that the skin is perfectly dry (anidrosis). Hyperidrosis of the 
whole body is called hyperidrosis universalis; if confined to a part of 
the body, hyperidrosis localis. The latter may be unilateral (hemi- 
drosis). 
A general perspiration may take place in cases of illness: 
1. When there are present conditions which are analogous to those 
which produce it in persons in a state of health, as in cases of strong 
tetanic convulsions by the increased muscular work and heart-action. 
On the contrary, in cases of epileptic, hysterical, and other convul- 
sions we have either no perspiration or at least none corresponding 
with the very great muscular exertion ; in all possible diseased con- 
ditions connected with great excitement, especially fear, or with severe 
pain; and again, sometimes (not always, see below under Anidrosis) 
from a high degree of atmospheric heat, warm baths, moist warm 
pack, or sudorifics (pilocarpine, etc.). Morphine, also, with some 
persons, induces perspiration. 
2 In difficult breathing—dyspnoea. This is generally connected 
with sweating. (In the same way sweating sometimes occurs with 
heart disease, accompanied by an engorged condition of the “greater” 
circulation ; also with all diseases of the respiratory organs and their 
surroundings, which interfere with respiration.) 
3. In febrile diseases. Sweating usually occurs with the fall of the 
temperature in these diseases. The most important instances are (a) the 
critical sweat of a rapid definite decline of the fever especially frequent 
in pneumonia and febris recurrens [relapsing fever]; (b) the sweat 
which regularly accompanies the fall of temperature in intermittent 
fever and pyaemia (diseases which manifest themselves by rapid rise 38 
MEDICAL DIAGNOSIS. 
and fall of temperature), the night-sweats of the hectic fever of 
phthisis and the sweat of the remittent (hectic) fever of typhoid 
fever; and (c) the cold sweat of collapse (that is, the sudden failure of 
strength in the death struggle). 
Acute articular rheumatism manifests itself by considerable perspi- 
ration, which may not depend upon a fall of temperature. Finally, 
there is always the inclination to perspiration in the commencement 
of convalescence from severe diseases and in parturient patients, when 
there is great weakness and the heart is easily excited. 
Local sweating occurs in various neuroses, also in organic diseases 
of the nervous system. Theie is very frequently sweating of the 
whole of one side (hemidrosis), or of the head alone, as in Basedow’s 
disease, migraine, hysteria; localized disease of the brain, and in 
mental diseases. 
Diminished secretion of sweat, even to complete anidrosis, is ob- 
served chiefly in high continued fever. It is, moreover, a peculiarity 
of all diseases which are accompanied with considerable loss of water 
by the bowels or the kidneys, of severe diarrhoea of any kind, con- 
tracted kidney, and diabetes. The anidrosis which exists with general 
dropsy, in consequence of the angemia of the skin produced by the 
pressure and stretching, has a peculiar appearance. 
The anidrosis of high fever and general dropsy is very persistent, 
often resisting all therapeutic measures, both those acting directly 
upon the skin (moist heat, etc.) and the medicines already mentioned. 
Qualitative alterations of sweat exist sometimes in severe jaundice, 
when it contains the coloring-matter of bile and is yellow in color; 
also, when the urinary secretion is greatly diminished or entirely sup- 
pressed, as in nephritis, diseases of the urinary tract, and cholera. It 
then contains considerable quantities of urinary products, which, by 
the evaporation of the perspiration, crystallize upon the skin (espe- 
cially upon the nose and forehead) in small white scales. This is 
called uridrosis, the scales giving the reaction of urinary ingredients. 
C. THE COLOR OF THE SKIN. 
As is well known, races differ in the color of the skin, but even in 
the Indo-Germanic race there are variations depending upon the 
stock, the climate (blonde, brunette). In some nations the pale, in GENERAL EXAMINATION. 
39 
others a more florid, complexion, especially of the face, prepon- 
derates. We know that there are differences depending on the mode 
of life; also that, even as regards the so-called healthy color of skin, 
considerable individual variations exist. But, after all, the hue of the 
skin stands in intimate relation to a large number of diseases of in- 
ternal organs. It is considered most suitable to judge from the color 
of the countenance, the portion of the skin most generally reddened ; 
and, since on every hand we have opportunity for practice, it is well 
to sharpen the eye for critically examining this part of the body. 
But the color of the countenance can sometimes deceive us (vide 
especially under “red skin ”), and it is therefore advisable always to 
examine the mucous membrane of the lips, mouth, and throat,1 and, 
besides, to glance at the color of the skin of a part of the body usually 
covered by the clothing. 
We recognize the following abnormal colorations of the skin: 
1. A pale skin. 
2. The abnormally red skin. 
3. The blue-red cyanotic skin. 
4. The yellow skin of icterus. 
5. The bronze skin. 
6. The gray skin produced by nitrate of silver. 
1. The Pale Skin. 
This can to a certain extent be physiological, especially in persons 
who spend little time in the open air. In these cases a glance at the 
mucous membrane gives further information. But one can be de- 
ceived regarding such persons, who, having exposed the face (also 
arms and hands) frequently to radiant heat, or to cold and heat in 
rapid succession, often have a local redness of face. This redness of 
face may arise from other causes (p. 41). 
Only experience can enable one to distinguish between physiological 
paleness and that produced by disease. The recognition of the latter 
is frequently aided in that it is associated with a grayish, yellowish 
color (see below). The color of the skin is produced by the fulness 
1 The conjunctival mucous membrane is not included. It is not decisive, since many 
persons in whom the teguments are elsewhere pale, at times have the conjunctiva 
easily injected. 40 
MEDICAL DIAGNOSIS. 
of its capillary vessels. The abnormal paleness may be dependent 
upon disturbance of the circulation (and in consequence of diminished 
force of the heart or active narrowing of the peripheral arteries), 
or by a lessening of the quantity of the blood constituents, chiefly 
of the haemoglobin. We distinguish : (a) Temporary paleness, which 
is partly physiological and partly pathological. It occurs with strong 
emotion, especially fright; in syncope or fainting; in the chill of 
fever, which ordinarily accompanies a rapid, considerable elevation of 
temperature; and in spasm of the capillary vessels, (b) Paleness 
lasting a longer or shorter time. This comes on sometimes quite 
rapidly, at least in the course of a few moments, during profuse 
hemorrhage and in sudden collapse—that is to say, in sudden failure 
of the heart as it occurs in acute, and sometimes chronic, diseases, 
and in acute poisoning. It is accompanied by a rapid and small 
pulse, increasing weakness, and, finally, loss of consciousness. Where 
there is external hemorrhage the condition is perfectly plain. But 
cases of severe internal hemorrhage, especially of the stomach or 
bowels, of ruptured aneurism, hemorrhage from internal wounds of 
any kind, are declared only by this sudden jialeness, sometimes even 
before the patients themselves, if quiet in bed, complain of weakness. 
In a case of endocarditis which I saw, the patient became pale, as 
one does from an internal hemorrhage, with increased frequency of 
pulse and stupor, within less than ten minutes. At the autopsy there 
was found a recent total rupture of an aortic valve. 
This paleness can develop more slowly, within a few hours or days, 
by considerable repeated hemorrhages; as a symptom of weakening 
of the heart’s activity in all acute and chronic diseases of the heart 
and pericardium; also in diseases of parts adjacent to the heart, as 
pleurisy and abdominal affections, with much pressure upon the dia- 
phragm, in case they interfere with the action of the heart; finally, in 
many acute diseases, especially in diphtheria, in heart-failure from 
diseases affecting the muscular structure of the heart; and very often, 
and in a very striking way, in acute catarrh of the stomach (acute 
dyspepsia). 
Finally, paleness of the skin comes on in certain conditions gener- 
ally unnoticeable, insidious, and is a chronic condition : in the so-called 
special diseases of the blood and of the blood-making organs—indeed, 
most unfortunately, from a diminution of the haemoglobin; hence, in GENERA L EX AMIN A TION. 
41 
chlorosis, also in pernicious anaemia, leukaemia, pseudoleukaemia. In 
this list also probably belongs malarial cachexia. Paleness is a 
symptom of all slowly-developing secondary anaemias (cachexia) as 
they occur in a large number of diseases, such as all chronic febrile 
diseases, especially tuberculosis; in suppurations without fever; in 
continuing slight hemorrhages, as in many tumors and in anky- 
lostoma [Egyptian chlorosis] ; in all chronic diseases of the digestive 
tract; in most diseases of the female generative organs; in the dif- 
ferent forms of chronic nephritis, especially the large white kidney; 
in chronic poisoning, especially by mercury and lead ; sometimes, also, 
in constitutional syphilis; in malignant growths, especially in cancer 
proper; and in chronic diseases of the heart, but especially in fatty 
heart and mitral and aortic stenosis. 
In most of these conditions there is, moreover, not only paleness of 
the skin, but its color has a still further characteristic appearance. In 
severe anaemias we often have a peculiar waxy appearance, which not 
rarely has a yellow tone. A striking, light white skin often exists 
with the so-called large white kidney, also in a certain proportion of 
the cases of lead-poisoning (which latter is often of a grayish white), 
of leukaemia and of tuberculosis. In chlorosis the skin has a greenish 
hue; in diseases of the heart-muscle and in mitral insufficiency the 
skin is generally a smutty yellow, wdiile in the cachexia of cancer it 
is often gray-yellow. 
In striking contrast is a large development of adipose tissue in cases 
of most marked paleness. This is very often so in diseases of the 
blood-making organs and in heart diseases. (It is not to be mistaken 
for oedema, vide under (Edema.) 
2. Abnormal Redness of Skin. 
This is an expression of a superfluity of normal blood, since a 
genuine plethora does not necessarily give rise to such a condition. 
General abnormal redness of the skin exists as a sign of hypenemia 
of the cutaneous capillaries in high fevers—especially in continuous 
fevers. It also is present during the perspiration following a warm 
bath. Finally, in poisoning with atropine, even in very mild cases, 
it is developed like the redness of scarlet fever. (The scarlet-fever 
redness, being connected with a disease of the skin, does not belong 
here.) 42 
MEDICAL DIAGNOSIS. 
Local redness, depending upon a dilatation of the capillaries, exists 
very frequently in the face, and indeed is physiological in those who 
labor in the sun. It comes and goes quickly, as in blushing (rubor 
pudicitiae), in nervously excitable persons in consequence of very 
slight psychical impressions, also not infrequently as a result of 
physical exertion. Moreover, we see redness of the face in fever; 
finally, one-sided redness of face in the “paralytic” form of hemi- 
crania. 
Tuberculosis is characterized by a very marked variation in the 
fulness of the capillaries of the face: if the patients are entirely at 
rest and without fever they are generally pale, but under excitement 
or exertion, after eating, and, lastly, during fever, they exhibit a very 
striking, generally bright, redness of the cheeks, and often a sharply- 
defined spot (hectic redness). 
In the slight forms of anaemia, especially if it is associated with 
nervous irritability of heart (likewise with local vasomotor disturb- 
ances), there is sometimes intense redness of the face which may con- 
ceal the anaemia from the physician. 
For distinction of circumscribed hyperaemia from hemorrhage in 
the skin, see under the latter. 
3. The Blue-red Skin, Cyanosis. 
This is most plain on the parts that normally are bright red, hence 
more than elsewhere on the mucous membranes, on the lips, cheeks, 
etc.; also on the knees, the phalanges of the fingers, and under the 
finger-nails. A moderate degree of cyanosis, therefore, would only 
be discovered at these parts. A marked degree, on the other hand, 
exhibits a blue color spread over the whole body, while those parts, 
especially the mucous membrane, become black-blue. 
The cyanosis of the newborn, with heart-failure, is so striking to 
the experienced observer, that it is regarded by him as pathognomonic. 
One only sees anything like it in the death agony, and, exceptionally, 
in severe spasms with marked interference with breathing. The 
combination of cyanosis with great paleness is designated as “ livid 
skin.” 
Cyanosis arises from the blue-red color of the capillaries, and this, 
as is well known, is caused by an accumulation of carbonic acid and GENERAL EXAMINATION. 
43 
deficiency of oxygen—that is to say, by the venous or hypervenous 
character of the capillary contents. 
Carbonic acid in the blood (serum and red corpuscles) arises from: 
1. Interference with the exchange of gases in the lungs. 2. From 
the slowing of the capillary circulation and the consequently dimin- 
ished gas-exchange in the tissues, that is to say, the diminished giving 
up of C03 by the tissues to the blood. 
Cyanosis arises, therefore: 1. In disturbed respiration and circular 
tion through the lungs; 2. In disturbance of the “ greater circulation,” 
which may be general or circumscribed according as the stoppage maj 
be general or local. The two causes may be combined. 
Here belong to 1 : 
(a) All conditions which cause a narrowing of the larger air* 
passages or of a large number of small bronchi: inflammation of the 
neighborhood of the pharynx or entrance to the larynx; retro- 
pharyngeal abscess, angina Ludovici; very exceptionally a diphtheria 
of the throat. (In all of these cases the interference with respiration 
is e’ther direct or dependent on oedema of the glottis.1) The following 
are enumerated: spasm of the glottis, paralysis of the dilator of the 
glottis (crico-arytenoideus post.), all acute and chronic inflammations 
of the larynx, but especially croup; tumors of the larynx; cicatricial 
narrowing of the larynx; foreign bodies in the larynx (something 
swallowed or vomited); also foreign bodies, croup and scars in the 
trachea or one or both primary bronchi, compression of these from 
without by enlarged glands, aneurism of the aorta, etc.; mediastinal 
tumors, etc.; bronchial spasm ; and severe diffuse bronchitis, espe- 
cially the acute croupous form. 
(b) All diseases of the lungs and diseases in the neighborhood of 
the lungs which hinder their expansion or wholly compress them: 
emphysema of the lungs ; all forms of consolidation; pleuritic and 
great pericardial exudation, pneumothorax; tumors in the chest- 
cavity ; abdominal diseases with marked upward pressure of the 
diaphragm. 
(c*) Paralysis of the respiratory muscles: bulbar paralysis, periph- 
eral neuritis; paralysis of diaphragm from peritonitis; spasm of the 
1 A very distressing case of suffocation from the lodgement of a large piece of meat 
in the pharynx, and the consequent closure of the entrance of the larynx, presented 
itself at the Leipzig medical clinic. 44 
MEDICAL DIAGNOSIS. 
muscles of respiration, epilepsy, tetanus, but, on the other hand, verj/ 
rarely hystero-epilepsy; special muscular diseases: myopathic forms 
of progressive muscular atrophy, trichinosis, myositis ossificans. 
Disturbances of the circulation through the lungs occur in a number 
of the diseases which interfere with respiration. In emphysema a large 
number of capillary channels are closed, also in tuberculosis and other 
chronic lung affections ; a large pleural exudation not only compresses 
the lungs, but also the capillaries. This acts in the same way as a 
hindrance to respiration. 
(d) Diseases of the heart which result in obstruction of the pul- 
monary circulation. It is to he noticed that in the conditions named 
under (b) a disturbance of the respiration interferes with pulmonary cir- 
culation. Moreover, we must emphasize the fact that in several of these 
conditions (especially diseases of the pleura, of the peritoneum, in 
trichinosis of the diaphragm and intercostal muscles) the insufficient 
breathing, as well as the cyanosis, will be increased by the pain caused 
by the act of breathing. If the physician correctly recognizes the 
chain of events he will he able to bring relief by the use of narcotics. 
In persons very much wasted, especially from tuberculosis, cyanosis 
may be absent even in spite of the loss of a large part of the breathing 
surface of the lungs, since the remaining normal portion suffices for 
supplying the required quantity of oxygen to the diminished quantity 
of blood. 
Under heading 2 : 
Slowing of the blood-current in the capillaries of the greater circula- 
tion is dependent upon stopping of the venous outlet. This can be 
general and caused by all the conditions of the first category, general 
cyanosis, or it can be occasioned by a venous stopping of an extremity 
or of the head, and so produce a local cyanosis. 
General venous damming occurs in diminished pumping power of 
the right ventricle (valvular deficiency, congenital stenosis of the 
pulmonary artery, diseases of the heart-muscle, large pericardial exu- 
dation with hindering of the heart’s action, considerable emphysema 
of the lungs with excessive damming of the smaller circulation), and 
in the rare case of compression of a large venous trunk just before it 
enters the right auricle (tumors of the mediastinum). 
Local venous stasis is caused by closure or marked narrowing of a 
more or less large venous trunk. This closure may be produced by GENERA L EX A MINA TION. 
45 
compression or by thrombosis of the vein (compression of the cava or 
the extremity of a venous trunk by tumors); compression of the cava 
inferior in connection with the common iliac artery by very large 
effusion in the peritoneum, or by tumors; atrophic thrombosis of a 
vein of the extremity, especially the femoral. Not infrequently the 
collateral veins of the skin take up the conveyance of the blood of 
the venous stasis; they then become enlarged and sometimes tortuous 
(vide examination of the veins). 
For the cyanosis produced by certain poisons, see Examination of 
the blood. 
4. The Yellow Skin, Icterus, Jaundice. 
The jaundiced state of the skin exists in well-marked cases, with 
slight differences, almost equally over the surface of the whole body 
It is found especially in the conjunctiva, and in slight cases exclu- 
sively there and in the other mucous membranes, if the observer will 
render the spot anfemic by pressure (best done by means of a micro- 
scopic slide pressed upon the everted lip or upon the tongue). Ac- 
cording to the intensity of the jaundice the tissues are but slightly 
tinged with yellow, or citron color, or yellow-green. Only in very 
severe cases (melas-icterus) does the skin become green or brownish- 
yellow. 
Jaundice cannot be detected by the ordinary means of illumination, 
since the yellow, artificial light does not enable one to distinguish 
between white and yellow. In slight cases it will first be detected in 
the conjunctiva. But this must not be confounded with the yellow 
fat that sometimes exists there, especially in elderly people. In 
persons with yellow or brown skin the jaundice is revealed by an 
examination of the mucous membrane. 
The yellow color of the skin after taking picric acid or santonine 
has no relation to jaundice. We distinguish this condition from 
jaundice by analysis of the urine (q. v.) and by the etiology of the 
former. 
Jaundice of the skin is the yellow coloration of almost the whole 
body by the coloring matter of the bile in the blood. Very much the 
most frequent form is the jaundice of simple engorgement, hepato- 
genous or mechanical jaundice, according to the old designation. It 
is occasioned by a primary biliary engorgement in the liver, resulting 46 
MEDICAL DIAGNOSIS. 
from a purely local interference with the discharge of bile. This 
interference is at the ductus choledochus, the transverse fissure of the 
liver, or within the liver. 
But there are also so-called hsematogenous forms of jaundice which 
have this in common, that at the first indication of the existence of 
jaundice there is haemoglobinaemia, because haemoglobin is set free 
from the red blood corpuscles. In many of these cases (poisoning, see 
below), according to recent investigations, it is to be assumed that, 
from the decomposition of the red blood-corpuscles, there is secreted in 
the liver a very concentrated, thick bile, and that this cannot flow 
through the ductus choledochus, thus producing engorgement and 
jaundice. It is still uncertain whether this explanation can be applied 
to all cases of jaundice which are not to be referred to primary biliary 
engorgement. It is not inconceivable (although more and more 
doubtful) that haematoidin or bilirubin (these two being identical) is 
formed from the haemoglobin which has become free within the blood- 
vessels. This would be a purely “blood-jaundice” in the old sense. 
In all these cases the coloring-matter of the bile passes into the 
urine, although when the jaundice is very slight it may not do so (see 
particularly under 2 of this section). The occurrence of the bile- 
acids in the blood and its appearance in the urine can, of course, 
only take place in primary or secondary jaundice due to engorgement. 
Hence, these would be an infallible indication as to whether the jaun- 
dice was due to engorgement, or was “blood-jaundice,” provided 
there was, on the one hand, no trace of bile-acids in the normal 
urine; or, on the other, if they very rapidly disappeared after passing 
into the blood. Thus, even in cases of undoubted engorgement- 
jaundice, the bile-acids might not appear in the urine. 
In very marked jaundice the coloring-matter of the bile is also 
found in the perspiration and in the saliva. 
It is to be remarked that by no means every case of haemoglobin- 
semia results in jaundice ; sometimes it simply results in hemoglobin- 
uria, sometimes also in urobilinuria. 
1. Hepatic jaundice is almost always purely the result of a biliary 
stoppage. The cause of the penning-up of the bile may exist in the 
bowel; in gastroduodenal catarrh, with catarrhal swelling of the 
mucous membrane, and accumulation of mucus in the ductus choled- 
ochus ; in tumors which press upon the duodenal orifice of the ductus GENERA L EX A MINA TION 
47 
choledochus, and especially cancer of the head of the pancreas; in 
ascarides, or round-worms (q. v.) which enter the ductus choledochus ; 
and also in gall-stones, which lodge there. 
There may be compression of the hepatic duct or of the large gall- 
duct at the entrance of the liver by tumors (carcinoma, echinococcus), 
or by scars, or by closure of the same by gall-stones. Closure of 
many small bile-ducts may be caused by so-called intra-hepatic gall- 
stones ; possibly also compression of these by marked damming in the 
branches of the veins of the liver from general venous stasis; finally, 
catarrh of the smallest bile-ducts may possibly cause bile stasis and 
jaundice, as in phosphorus-poisoning. 
In case the flow of bile is much hindered or is wholly stopped, then, 
partly from the want of bile and partly from the fatty contents, the 
stools become light, perhaps entirely white or gray-white. The par- 
ticulars of this condition of the stools and of urine in jaundice are 
explained in the chapters devoted to these subjects. 
In some cases of severe jaundice there may be still other appear- 
ances : itching, various skin affections, minute cutaneous hemorrhages, 
slowing of pulse, or simple nervous manifestations. In very severe, 
long-standing jaundice, there may be marked heart disturbances, 
hemorrhagic diathesis may develop, or, finally, there may arise severe 
nervous manifestations (cholaemia, cholaemic manifestations). 
Moreover, hepatic jaundice may be produced by the sudden diminu- 
tion of pressure in the portal vein while the pressure in the bile-ducts 
remains the same, as at the moment of birth—icterus neonatorum 
(Frerichs). 
2: Hsemato-jaundice, whose primary cause is to be regarded as a 
decomposition of the blood, takes place in certain acute infectious dis- 
eases (pyaemia, yellow fever, probably also sometimes in pneumonia); 
and from certain poisons (chloroform, ether, chloral, chlorate of potash, 
solution of arsenic, toluylendiamin). 
In this case, as well as in the jaundice of damming, there may be 
bile coloring-matter in the urine. Not infrequently, as in pyaemia, 
well-marked signs of bile coloring-matter may be wanting, and this 
has diagnostic value for the assumption that we have a case of haemato- 
jaundice. 
It is very important to notice that in real blood-jaundice the flow 48 
MEDICAL DIAGNOSIS. 
of bile into the intestine is not disturbed, and hence there is no altera- 
tion of the color of the stools. 
Urobilin-icterus. In diseases of the liver, in prolonged hemor- 
rhages of whatever nature, also in the hemorrhagic diathesis, finally, 
in fever, a larger quantity of urobilin is removed by the urine (see 
Urine). Hence in rare cases a mild jaundice is observed: Tro- 
bilin-icterus (Gerhardt, Jaksch). 
The origin of urobilin is to be explained as follows: First hsema- 
toidin or bilirubin is formed, and then urobilin is formed from this by 
reduction in the tissues or in the bloodvessels. 
5. The Bronze Skin. 
Unlike cyanosis and jaundice, this is a condition pertaining only to 
the skin and mucous membrane. We speak of the chief symptom, 
instead of the true anatomical seat, of the disease, viz., the supra- 
renal capsule—the so-called Addison’s disease. (Very frequently it 
is tubercular.) [The association of this peculiar brown discoloration 
of the skin is not constant in Addison’s disease. It is not so constant 
in cancerous, but is more common with cheesy, degeneration. The 
latter condition may be present without bronzing of the skin. On 
the other hand, the skin may be bronzed, just as “in Addison’s dis- 
ease without the existence of cheesy degeneration or any other change 
in the supra-renal capsules. These facts have induced many observers 
to attribute the cutaneous discoloration rather to changes in the 
neighboring sympathetic nerves—the solar plexus and the semilunar 
ganglia.”] 
The bronze skin is characterized by a brown, gray to black dis- 
coloration, especially of the face and hands. There is also the common 
normal pigmentation of the skin in spots. The discoloration may 
gradually extend over the whole surface of the body, only the nails 
and cornea remaining clear. 
It is very important to notice that the same discoloration appears 
upon the mucous membrane of the mouth, and more rarely upon the 
lips, as very sharply circumscribed, frequently quite small, browrn 
specks. 
The discoloration is caused by deposit of pigment in the rete Mal- 
pighii. Of course, pressure with the finger does not at all diminish it. GENERA L EX A MINA TION. 
49 
6. The G-ray Skin of Silver Deposit. 
After long-continued administration of nitrate of silver there may 
be deposits, in certain organs, of very fine black particles (metallic 
silver or silver albuminate ?), as in the kidneys, intestine, and also in 
the skin, and especially in the corium, the tunica propria of the sweat- 
glands. 
The skin of such persons, especially of the face and hands, is gray 
or blackish. The color is not changed by pressure. In severe cases 
we also observe corresponding gray specks in the mucous membrane 
of the mouth. 
In a strict sense this is not a diseased condition: these people are 
perfectly well. 
D. OTHER PATHOLOGICAL APPEARANCES OF THE SKIN OF GENERAL 
DIAGNOSTIC VALUE. 
1. Acute Exanthematous Diseases. 
In some acute infectious diseases a characteristic eruption of the 
skin has so marked an appearance that these diseases are designated 
as “acute exanthemata.” They are: Scarlet fever, measles, German 
measles, smallpox, and varicella. Here we may pass over these dis- 
eases, since they are closely connected with the complete description 
as they are taught at the bedside. 
On the other hand, there are certain other acute exanthematous 
diseases, less striking, but at the same time of great diagnostic im- 
portance. We may here briefly mention : 
(a) Roseola. This presents a small, round, rose-red, slightly ele- 
vated spot. 
It is generally scattered, is found most frequently upon the abdomen 
and lower part of the back, more rarely upon the breast and extremi- 
ties in typhoid fever. It appears about the beginning, and generally 
fades at the end, of the second week. Now and then secondary 
roseolar spots appear later, which are connected with exacerbations of 
the disease (involving new portions of the intestine ?). 
Secondly, they appear in most cases of typhus fever. But, except 
in light cases, they are in this disease petechial—i. e., the location of 
small hemorrhages, which are slowly absorbed. 50 
MEDICAL DIAGNOSIS. 
Further, they exist in some cases of acute miliary tuberculosis, and 
finally in animal poisoning. 
(b) Herpes facialis. This consists of a group of small vesicles upon 
a slightly red base. The vesicles contain at first clear water, then are 
cloudy, then yellow from pus contained in them. They may be con- 
fluent. After a few days they dry up and scale. Most frequently 
this exanthem is found in the neighborhood of the mouth—herpes 
labialis ; or of the nose—herpes nasalis ; it may also appear upon the 
cheeks or the ear. 
It makes its appearance at the beginning of some acute diseases 
and seems to be especially peculiar to very rapidly rising fever. Above 
all it accompanies croupous pneumonia, then epidemic cerebro-spinal 
meningitis (in this disease it is often quite extensive), finally, some- 
times in angina (angina herpetica), and a light febrile disease named 
in consequence, febris herpetica. 
An herpetic eruption also sometimes accompanies the development 
of intermittent fever and the chill of pyaemia. 
(c) Miliaria or sudamina. These are small, remarkably clear vesi- 
cles, which reflect the light strongly, generally in large numbers., 
especially upon the abdomen. They appear if a patient, after long- 
continued anhidrosis, begins to sweat profusely, especially in acute, 
but also sometimes in chronic, diseases. It is necessary to mention 
them here only because the explanation of their diagnostic, and like- 
wise pathological, meaning ought to be made prominent. 
Still other exanthemata of diagnostic importance could be mentioned 
here, as the (rare) scarlet redness in the beginning of typhoid fever, 
the different eruptions of sepsis, pycemia, and other diseases. 
2. Exanthemata from Poisons and the Use of Medicines. 
These are of varied character, since they sometimes resemble those 
of acute diseases, viz., scarlet fever, measles, etc. They may, there- 
fore, easily cause an error in diagnosis. It is sufficient here to point 
out the diagnostic importance of these exanthemata. The particulars 
regarding them belong to works on diseases of the skin, and also to 
pharmacology and toxicology. GENERAL EXAMINATION. 
51 
3. Hemorrhages in the Skin. 
They arise chiefly by diapedesis, and take place particularly, but 
not exclusively, in dependent parts, especially the lower extremities. 
They may be of every size—from the smallest perceivable point to 
the size of the palm of the hand, or even larger. The small, puncti- 
form hemorrhages, ecchymoses or petechiae, are most apt to appear at 
the hair-follicles. The color of fresh hemorrhages is like venous blood. 
During absorption they are brown-red, later becoming bright brown. 
A hemorrhage is distinguished from a circumscribed inflammatory 
redness of skin in that it does not disappear upon pressure. (The 
small ecchymoses in the hair-follicles, mentioned above, are easily 
confounded with the latter, especially in cyanosis; further, petechiae 
in parts previously inflamed, as in measles, are easily overlooked.) 
Simplest test: Press a piece of glass, a microscope slide, upon the 
suspected spot. A hemorrhage is rendered more distinct, while the 
surrounding part becomes anaemic; an inflammatory hyperaemia, on 
the other hand, disappears. 
Hemorrhages appear: 
1. As evidences of a marked hemorrhagic diathesis. They are 
then generally extensive in the skin, and, moreover, occur in con- 
nection with hemorrhages from internal organs. They occur in 
scorbutus, purpura hemorrhagica; in severe acute infectious diseases, 
especially pyaemia, smallpox, and scarlet fever; in acute phosphorus- 
poisoning and acute yellow atrophy of the liver; and in all severe 
cachexiae. 
2. Without internal hemorrhages, as a condition limited to the 
skin : in peliosis rheumatica [«. e., purpura occurring with severe pain 
in the extremities] ; also as small petechiae; almost constantly in 
typhus fpver (see Roseola), often in measles, and scarlet fever; more- 
over, on the legs when the convalescent patient first stands up, espe- 
cially after typhoid fever; and in badly nourished persons where they 
have been bitten by pediculi. 
3. In marked venous stasis, local as well as general (see Cyanosis). 
4. As traumatic hemorrhages in and under the skin. They are 
sometimes of importance for determining the occurrence of an injury, 
especially upon the skull. 52 
MEDICAL DIAGNOSIS. 
4. Scars. 
These are often important marks for limiting or explaining the 
clininal history, which, by reason of the scars, can be confined to past 
local or general diseases, or to injuries received. 
Thus come under consideration “ pock ” (smallpox) marks and the 
scars which may remain after the different scrofulous and syphilitic 
diseases of the skin and deeper organs, especially the bones and 
glands. In internal medicine, scars from mjuries have importance in 
many nervous diseases (injuries upon the head, the spine, in the 
course of peripheral nerves). 
Here also belong the scars of pregnancy, strice, upon the lower part 
of the abdomen and the upper part of the thigh. Exactly the same 
scars occur in marked oedema (see the following section), and also 
sometimes in very fat persons. 
E. (EDEMA OF THE SKIN AND SUBCUTANEOUS CELLULAR TISSUE 
((EDEMA, ANASARCA). 
By these terms we designate an abnormal, marked saturation of the 
tissues with fluid, which, fluid remains wholly or in part distributed in 
the cellular meshes and lymph-spaces, instead of a corresponding 
quantity of fluid existing in bulk, as its transudation takes place from 
the bloodvessels to be removed by the lymph-current. 
(Edema is recognized by pufliness of the skin causing increase of 
volume of the affected part, and hence, also, the normal contour, the 
prominences of the joints, as well as depressions, are obliterated, and, 
moreover, there is a tendency to an equal roundness. The skin is 
smooth, generally slightly shining, and hence very pale in conse- 
quence of the diminished circulation. It is very noticeable that the 
oedematous tissue loses its elasticity, so that a depression made by the 
point of the finger remains for a certain time, sometimes for hours. 
In general or widely extending oedema it is most manifest in de- 
pendent parts, or where the skin is tender and the subcutaneous 
cellular tissue is loose. Hence, in those persons who walk and stand 
it appears first at the ankles or on the dorsum of the feet (not on the 
soles and toes, since here the skin is too thick or closely attached ;) 
in bed-ridden patients, on the inner side of the thigh or in the scrotum GENERAL EXAMINATION. 
53 
and penis, where it is often enormous; on the lower part of the hack ; 
sometimes first of all, in the loose cellular tissue beneath the lower 
eyelid. One must examine all of these points if he would detect the 
first evidences of oedema. 
In very marked cases the deeper parts, especially the muscles, 
become oedematous; the legs may then attain enormous proportions. 
Moreover, in marked general dropsy there are fluid accumulations in 
the cavities of the body, giving rise to hydroperitoneum or hydrops 
ascites, hydrothorax, hydropericardium. 
In long-continued oedema the skin of the legs and the lower part 
of the abdomen may become thickened, as in elephantiasis. 
We recognize three causes for dropsy of the skin (as for dropsy in 
general) : 
1. Venous stasis (hydrops mechanicus). 
2. Altered condition of the blood, particularly its becoming watery. 
3. Inflammations. 
Hence, these corresponding diseases cause oedema : 
1. All diseases, local or general, which hinder the return of venous 
blood to the right side of the heart, as those that have been already 
mentioned under Cyanosis (see p. 44). 
In local stasis the oedema is naturally confined to the roots of the 
corresponding veins, as, for example, thrombosis of the right crural 
vein, causing dropsy of the right leg, or compression of the vena cava 
inferior by an abdominal tumor, causing dropsy of both lower ex- 
tremities. 
2. All forms of hydraemia (anaemia), acute and chronic nephritis, 
in which the diminished excretion of water, on the one side, and the 
loss of albumin from the blood, consequent upon the albuminuria 
(which see), on the other hand, occasions the hydraemia, which is the 
chief factor in the condition which permits frequent and often marked 
oedema. Yet the hydraemia does not always explain the existence of 
the oedema (Cohnheim and Leichtheim ; see under Albuminuria). 
All other kinds of anaemia (hydrsemia, see Blood) come under this 
head when they appear as diseases of the blood or of the blood-making 
organs, and are secondary to the appearance of wasting diseases and 
severe acute diseases (as oedema of the ankles, when the convalescent 
patient first stands up). 
The anaemia caused by long-continued slight hemorrhages (as those 54 
MEDICAL DIAGNOSIS. 
occurring in ankylostomo-ansemia) may also lead to moderate oedema, 
for here also we have hydrmmia, in that the loss of blood is replaced 
by water in the blood. 
3. (Edema, sometimes of considerable extent, occurs in the neigh- 
borhood of inflammation (“ inflammatory oedema,” “collateral oedema’ ). 
This may be of great diagnostic importance, since it sometimes reveals 
a deep-seated inflammation. 
This is of more interest to the surgeon. To the physician it is 
important, for instance, in pleuritis with oedema of the chest-wall. It 
shows, with tolerable certainty, that the pleuritis is purulent. Deep 
muscular abscesses in severe diseases, as in typhoid fever, may easily 
be overlooked, and may first be recognized by the appearance of 
oedema in the neighborhood, as along the femur. 
The oedema in these different, but so heterogeneous, cases does not 
have a uniform character: that from stasis is sometimes soft, some- 
times very elastic, the latter especially (in marked stasis) exists in the 
extremities, when it is often difficult, and sometimes impossible, to 
leave the mark of the pressure with the finger; moreover, in cases of 
nephritis, writh a small quantity of urine and marked albuminuria, 
it is sometimes very considerable, but now and then softer. In the 
different anaemias the oedema is mostly slight—a scarcely noticeable 
puffiness. 
Slight oedema disappears between morning and evening, or evening 
and morning, according to the change of position of the body. 
The question, Why does oedema result from venous stasis, hydraemia, 
or inflammation ? has not in all respects been satisfactorily answered. 
Until recently it seemed to be proved that this is entirely to be 
ascribed in these three conditions to an injury of the endothelium of 
the vessels, and by this means occasioning increased transudation into 
the tissues (Cohnheim). Recently the view has been advanced, and 
it seems to me has become well established, that the loss of elasticity 
and the diminished squeezing-out of lymph from the tissues by their 
being relaxed plays an important, perhaps a chief, part in causing 
oedema (Landerer). This relaxation of the tissues might be caused 
by the stasis from the increased transudation, or by the hydrsemia 
from the deficient nourishment of the tissues by the morbidly thin 
blood; or, finally, it might be caused by inflammation excited in the 
neighborhood. GENERAL EXAMINATION. 
55 
In conclusion, we must not omit to mention that, in rare cases, 
oedema exists without any other possible morbid disturbance. Here 
belong the essential oedema of children and the oedema of the feet 
after forced marches. 
F. EMPHYSEMA OF THE SKIN. 
By emphysema of the skin is understood the entrance of air into 
the cellular tissue. It may be limited to one region of the body, as 
the neck or the upper part of the chest, or the upper part of the 
abdomen. But it may be spread over almost the whole of the body. 
It is a very rare condition. 
We recognize emphysema of the skin by the very pale skin over a 
region which is decidedly elevated above its surroundings. Indeed, 
on account of the loose fixation of the skin in certain parts, even de- 
pressions, as that over the clavicle, or the axillary space, or the inter- 
costal spaces, may be filled up, so that sometimes on a first glance at 
the part it seems like marked oedema. Sometimes at such places 
there may even be an elevation of the skin like a pillow. Upon pal- 
pation we find that the part is very yielding, like a soft pillow. Quite 
unlike oedema, however, the depression made by pressure immediately 
disappears. Moreover, upon palpating the part, we feel and hear an 
unusually fine crackling. 
The so-called spontaneous emphysema of the skin does not here 
concern us. It arises from decomposition of a blood extravasation, or 
abscesses with formation of putrid gases. 
The so-called emphysema of skin from aspiration arises from the 
entrance of air or gas into the subcutaneous tissue, either from without 
through a wound of the skin, or from within from an organ containing 
air or gas. 
(a) The entrance of air from without after a wound of the skin 
belongs to surgery. It is especially observed in wounds of the neck, 
of the breast, in the lower part of the face (so-called wounds of the 
mucous membrane). The wounds in question are sometimes remark- 
ably small. 
(b) Of much greater interest in themselves, as well as from a diag- 
nostic point of view, is emphysema from air or gas entering the cellular 
tissue from within. Under all circumstances it is occasioned by the 56 
MEDICAL DIAGNOSIS. 
rupture, either spontaneously or traumatically, of the wall of an organ 
containing air or gas. Hence, emphysema1 from “aspiration” may 
arise— 
1. From any portion of the respiratory tract, from the larynx down. 
Deep-seated ulceration of the larynx or trachea may invade the 
walls of these organs, and thus the air may escape and enter the sub- 
cutaneous cellular tissue. 
Cavities of the lungs (after previous, repeated adhesions between 
the pulmonary and parietal pleura) may ulcerate into the chest-wall, 
until, finally, communication Avith the cellular tissue is established. 
Then the pressure of a severe paroxysm of cough may cause the air 
in large quantity to spread out quickly under the skin. Single pul- 
monary alveoli may burst from any very high intra-thoracic pressure, 
as severe cough, especially in children with wdiooping-cough, bronchitis, 
or emphysema; sharp crying; severe exertion, as blowing on wind- 
instruments, or women in childbirth; and air may enter under the 
pleura or into the inter-alveolar tissue, reach the mediastinum, pass 
along the mediastinal space into the subcutaneous tissue of the neck, 
and so spread onward. 
Wounds of the lungs (as fracture of the ribs without external 
wound) may either directly cause emphysema of skin, or, passing the 
mediastinum as above, take the same course. 
2. From the oesophagus, stomach, or intestines, and, indeed, from 
the oesophagus again through the mediastinum ; from the stomach or 
intestines by adhesions with the abdominal Avail and invasion of the 
cellular tissue there; from traumatic rupture of the oesophagus, more 
frequently from ulceration, especially in connection Avith carcinoma of 
the oesophagus; with any kind of deep-seated ulcerations of the 
stomach and bowels. 
Sometimes there occurs extensive decomposition of the cellular 
tissue, especially if emphysema of the skin is produced by gases 
from the intestinal canal (mixed with intestinal contents). Very often, 
however, the emphysema remains without such action. It may then 
spontaneously disappear. But at the same time, the emphysema is 
generally a final development, partly on account of the severity of the 
1 The name “ emphysema ” is not quite accurate, since generally the air is driven 
in under pressure, as is shown by what follows. GENERAL EXAMINATION. 
57 
primary disease, and partly because it causes severe dyspnoea, as, 
for instance, that in the mediastinum, and hence is a very serious 
condition. 
From a diagnostic point of view, emphysema of the skin is of great 
importance, since it affords a conclusion regarding the diseases men- 
tioned. Under some circumstances it may afford the first and only 
symptom, as in the affections of the oesophagus. 
Y. The Temperature of the Body. Fever. 
It is a well-known peculiarity of warm-blooded animals that they, 
if the organization is otherwise sound, with remarkable constancy, 
maintain a certain internal temperature which is subject to very slight 
variations. If that peculiarity is lost, if the temperature departs from 
the normal, then, almost without exception, a morbid disturbance is 
present. A knowledge of this fact, and especially of the elevation of 
the specific heat in disease, attracted the attention of physicians to the 
temperature of the body from the earliest time. Recently, however, 
the measurement of the temperature has become of the greatest diag- 
nostic aid. In what way this is so will be explained at length. 
1. The Terms Used and the Method of Taking the Temperature. 
Judging of the temperature by laying on of the hands is under all 
circumstances deceptive. Great errors cannot be avoided even if 
covered parts of the body are selected, while uncovered parts cool so 
rapidly as to furnish no standard. 
We measure the temperature with the Centigrade or Celsius's ther- 
mometer, with the scale divided into tenths, from about 30° to 45°. 
There is no need for a thermometer with indications below 30° (see 
below). 
In France the Reaumur scale is sometimes used; in England and 
America the Fahrenheit is generally used. To convert from one 
standard to another the following formula is used: 
1° C. = f° R. = (I + 32)° Fahr. 
It is further to be remarked, that in Germany still, especially at 
the public baths, the baths are frequently measured and are prescribed 
according to Reaumur standard. 58 
MEDIC A L DIA GNOSIS. 
Regarding the selection of the instrument, it concerns us to 
remember that there are many incorrect thermometers. Exact com- 
parison with a standard at the time of purchase, and at least every 
two years thereafter, is indispensable, since all thermometers register 
somewhat higher with age. Thermometers with a cylindrical column 
of mercury are to be preferred, since they are more reliable and like- 
wise easier to use. Maximal thermometers are strongly recommended, 
but the index must work exactly; moreover, it is of course always 
to be remembered that every time before using the thermometer the 
index must be shaken down as far as (in certain cases below) the 
normal mark. 
When a comparison with a normal thermometer cannot be made, 
an approximate determination may be made by taking the temperature 
in the axilla of a healthy person upon say six different days an hour 
after breakfast. A thermometer which is correct in its reading: must 
then give an average reading of 37° C. or a little less (Liebermeister). 
The temperature may be taken in the axilla, the rectum, or in the 
vagina. (Taking the temperature in the mouth, and especially from 
freshly-passed urine, is to be avoided.) Of the three places mentioned, 
the rectum or vagina would be preferred, since their temperature most 
nearly corresponds with that of the inside of the body, since the ther- 
mometer lies very equally in either of these situations, and because it 
requires less time, the maximum being there soonest reached. But 
from reasons of delicacy we only take the temperature there when it 
is not possible to take it in the axilla. 
Therefore, ordinarily, the thermometer is placed in the axilla (which 
should be first carefully wiped dry, if it is moist) as high as possible, 
and then the flexed arm should be pressed against the chest. [The 
maximum is indicated in from three to five minutes. Some thermom- 
eters accurately indicate it in one minute; but these are so delicate 
a,s to require special care to avoid breaking. The thermometer is to 
be left in as long as the index continues to rise. One can easily 
ascertain how long a given thermometer requires by testing it in warm 
water at various temperatures.] 
If the patient is unconscious the arm must be held. In cases of 
marked unconsciousness, of unruly persons, and of children, it is better 
to take the temperature in the rectum or vagina. 
If there are fecal accumulations in the rectum the result is unre- GENERA L EX A MINA TIO N. 
59 
liable. The thermometer is to be oiled and passed in to the depth of 
about 5 cm. The maximum is indicated in about five minutes. In 
the rectum the temperature is usually about 0.2° C. = 0.36° F. higher 
than in the axilla. 
If the thermometer is not self-registering, it must, of course, be 
read before it is removed. After using the thermometer in either the 
rectum or vagina it must, in every case, even when there is no infec- 
tious disease of either of these organs, be carefully disinfected. [No 
matter where the thermometer is used, it ought always to be imme- 
diately cleaned most thoroughly.] 
A single use of the thermometer may be of great value. But it is 
still more important, as will be shown below, to follow the state of the 
temperature progressively, and to ascertain its course. For this pur- 
pose it is necessary to measure it at stated intervals. How frequently 
this must be done in order to ascertain the course of the temperature, 
must be determined by the particular disease. The thermometer 
should be used at least twice in twenty-four hours (at about 8 A. M. 
and again at about 5 P. M.). In diseases with high fever, according 
to the rapidity with which the oscillations of the temperature are 
completed, the thermometer must be used every three hours, every 
two hours, or even hourly. Where the changes of temperature are 
very marked, it may be of interest to observe it every quarter-hour. 
It is to be understood that, where it is proper to do so, the use of the 
thermometer should, as far as possible, be suspended at night, in 
order not unnecessarily to disturb the patient’s sleep. 
The record of the course of the temperature may be indicated by a 
curve. Charts suitable for this purpose of various kinds are to be 
had. They serve also for the record of the pulse and respiration. 
Now-a-days, in every case of severe fever, the physician ought to 
prepare such a fever-curve. 
In what follows, the statements regarding the temperature refer to 
measurements taken throughout in the axilla. 
2. The Normal Temperature of the Body. 
The average temperature is 37° C., and varies from this about 
from 36.25° to 37.5° C. 
The variations are of different kinds and have different causes. Of 
least interest, since they are only very insignificant, are those de- 60 
MEDICAL DIAGNOSIS. 
pendent upon age (in children, except the day after birth, a few tenths 
higher than later; in old people, again, a little higher); an elevation 
after meals; an elevation after severe exertion. 
But the periodic daily variations are more important. They follow 
the following course: In early morning, between two and six, the 
“ daily minimum ” is reached, and then with considerable (not per- 
fect) regularity it rises to the “ daily maximum,” between 5 and 8 in 
the evening. From that point it again, during the night, declines. 
The difference between the minimum and maximum, the “ daily dif- 
ference,” is about 1° C. (in rare cases even nearly 2° C.). 
After severe exertion, the temperature rises quite a considerable 
amount higher, especially in the sun (Obernier observed that in the 
case of a person running it rose to 39.6° C.)and in very warm baths. 
3. Elevated Temperature. Fever. 
Every elevation of temperature which is not dependent in a marked 
way upon over-heating or severe exertion of the body, wre call fever. 
The febrile elevation of temperature is generally for a certain dura- 
tion, hut it may exist in single cases as a single short period, “ a 
febrile paroxysm.”1 
But it is here important to remember that fever does not alone 
consist of an elevation of temperature, but is a complex symptom, 
whose separate manifestations are occasioned partly by an increase of 
tissue-changes, partly by disturbance of the functions of certain 
organs. To it also belong the elevation of the specific heat; also 
general feeling of being sick, relaxation, sometimes mental disturb- 
ances ; increased frequency of pulse and respiration with exhalation 
of C02; loss of appetite, increased thirst, disturbance of bowels. The 
urine is generally diminished in quantity, wfith increase of excretory 
products of the body, especially of urinary products, of uric acid and 
diminished chlorides. In case the fever continues there is notable 
wasting. Although a part of these appearances may be caused by 
over-heating of the organism, yet in febrile disease they are doubtless 
not to be regarded as simple results of high temperature. Hence it 
results, among other things, that the increased frequency of the pulse, 
1 The definition of fever as “ a continued elevation of temperature,” therefore, is not 
suitable. GENERAL EXAMINATION. 
61 
the mental manifestations, and the disturbances of the bowels, do not 
have a constant relation to the height of the temperature, but, on the 
contrary, have a markedly different expression according to the cause 
of the fever—that is, the nature of the disease. Nevertheless, the 
height of the temperature is a very practical index of the severity of 
the fever, and these two factors clinically become fully identified. 
But the physician must never forget to pay attention to still other 
manifestations of fever beside. 
With reference to bodily temperature, Wunderlich has prepared the 
following table: 
I. Normal temperature, 37° to 37.4° C. 
II. Subfebrile temperature, 37.5° to 38° C. 
III. Febrile temperature, 
a, slight fever, 38° to 38.4° C.; 
b, moderate fever, 38.5° to 39° C. morning, and 39.5° C. 
evening 
c, considerable fever, 39.5° C. morning, and 40.5° C. 
evening; 
d, high fever, 39.5° C. morning, and 40.5 C. evening. 
[Comparison of Thermometric Scales: 
Cent. 
Fahr. 
05 
o 
93.2° 
35 
95 
36 
96.8 
Normal temperature, 37 
98.6 Normal temperature. 
38 
100.4 
39 
102.2 
40 
104 
41 
105.8 
42 
107.6 
43 
109.4] 
If the temperature reaches 42° C. then we speak of hyperpyrexia, 
hyperpyretic fever. While the higher temperatures even of high fevers 
do not occasion direct danger to the organization, in hyperpyrexia 
the temperature is directly dangerous to life; it generally leads to a 
fatal issue. 
1 Regarding this difference between morning and evening temperatures, see under 
Remission. 62 
MEDICAL DIAGNOSIS. 
There is uncertainty regarding the highest temperatures that have* 
been observed. Temperatures of 45° C. have been published as 
curiosities. One case of injury to the spine, which resulted in re- 
covery, is reported by Teale to have repeatedly had a temperature of 
122° F. = 50° C. 
The course of the temperature in twenty-four hours can vary much 
only in fever. Most fevers show distinct fluctuations, in that toward 
morning the temperature falls more or less, remission, until it reaches 
the daily minimum, thence in the course of the day it rises, exacerba- 
tioni, and toward evening reaches the daily maximum. 
The difference between the daily maximum and the daily minimum 
in fever is called, as in normal temperature, the daily difference. 
While the course of the temperature in fever is analogous to that of 
health, not unfrequently the minimum and maximum come at quite a 
different time, as, for instance, the maximum may be at midday or at 
midnight; a complete reverse may even take place so that the maxi- 
mum occurs in the morning and the minimum in the evening: typus 
inversus. 
From this it is seen how the temperature must be exactly measured 
every hour of the day and night if it is of importance to know whether 
a patient has fever or not. There have been cases when the persons 
were thought to be without fever until the physician thought of ascer- 
taining the temperature at night. 
The exacerbation of the fever is frequently connected with shivering. 
If the temperature rises very rapidly (it may rise several degrees in a 
single hour) generally there is a chill, that is, a decided feeling of 
chilliness with severe shaking of the whole body, chattering of teeth, 
when the high internal temperature of the body is then very quickly 
contrasted with the subjective feeling of chilliness. The skin is at 
first pale, livid, and generally cool; toward the end of the chill, how- 
ever, it is regularly very hot. On the other hand, a rapid remission 
of the temperature is generally accompanied with sweats. 
According to the amount of the daily difference we distinguish 
three types of fever: 
Continued fever: daily difference not more than 1° C. (chiefly high 
temperature). 
Remittent fever: daily difference over 1° C. GENERAL EXAMINATION. 
63 
Intermittent fever: maximum very high, minimum within the 
normal (or even below). 
An important peculiarity of fever is that the temperature does not 
long remain at the same point, as it does in health. It is very 
changeable. Warm clothing, high temperature of the room, and 
sometimes the taking of nourishment, cause a very marked rise of the 
temperature in fever; likewise also psychical influences, as fright or 
anger. On the other hand, a cool room and (especially) a cool bath, 
also gradual loss of blood, as in menstruation, cause it to fall. It is 
absolutely necessary to know this if we wish to ascertain the cause of 
many remarkable variations of temperature in fever. Moreover, the 
sudden fall of the temperature is sometimes a sure indication of an 
internal hemorrhage. 
4. The Subnormal Temperature. 
It begins at 36.25° C.; the lowest observed temperature is 22° C. 
1. It is observed in febrile diseases as an expression of two directly 
opposite conditions, namely: 
a. In a sudden fall of the high fever with an advance to recovery, 
the “crisis,” the critical decline of the fever. In this case the tem- 
perature falls during perspiration sometimes to below 34° C., and 
only in the course of one, two, or three days again returns to the 
normal. We recognize the “crisis” by the simultaneous diminution 
of the frequency of the pulse and the respiration, and the feeling of 
comfort and returning health by the patient. 
b. In the so-called collapse. In this condition there is generally a 
very rapid fall of the temperature, and at the same time a sudden 
failure of the heart, with (as is the contrary in “ crisis ”) increase of 
the frequency of the pulse, with paleness and general failure of 
strength. The condition of collapse may pass over, when there 
generally is an immediate rise of temperature again to the former 
point; or it may pass on to a fatal termination. 
On the chart of the fever-curve the line of the falling temperature 
is crossed by the rising line of the line of the pulse-curve in a charac- 
teristic way (see Pulse). Sometimes, in a case of collapse ending 
fatally, the pulse-line sinks parallel with the temperature-line (see 
Pulse). 
2. It occurs sometimes temporarily in severe hemorrhages, also 64 
MEDICAL DIAGNOSIS. 
sometimes in all kinds of chronic diseases, especially in those of the 
heart and the lungs. If the temperature suddenly falls, accompanied 
by weakness of the heart and general prostration, then also we speak 
of collapse. 
3. Continuing subnormal temperature, extending into a number of 
weeks, is very rare. It may exist in all severe wasting diseases and in 
diseases of the brain. 
5. Diagnostic Value of the Temperature, especially of its General 
Course. 
Under certain circumstances a single, or, in other wrords, the first 
measurement of the temperature may be of the greatest diagnostic 
value. Of this a few examples may be given. 
1. Frequently the elevated temperature, with some indistinctive 
complaints (or, in the case of children, abstinence from food with rest- 
lessness), is the only sign of a disease just commencing, or of one that 
has been going on for some time. Ascertaining the temperature is 
then of great service, in that it leads to a more careful examination 
and more extended observation, and to directing suitable care of the 
patient. A high morning temperature points directly to an acute 
infectious disease. 
2. In marked cachexia, without distinct organic disease, the exist- 
ence of temporary fever indicates wTith considerable probability tuber- 
culosis. 
3. A single chill accompanied with a rise of the temperature to 
about 40° C. may, in a given case, say of a disease which from expe- 
rience sometimes causes suppuration, lead to the diagnosis of suppura- 
tion, as in gall-stones, renal calculi, after injuries to the skull, as brain 
abscess; also here belongs puerperal fever, or, under certain circum- 
stances, it may possibly be malaria. 
But the continued observation of the course of the temperature is of 
still greater importance. It advances medical knowledge in various 
ways: 
1. The course of the fever in a number of diseases is so typical 
that from the temperature alone the diagnosis may often be made 
with great probability, sometimes with certainty. At any rate it is 
always, taken in association with other symptoms, an important aid in 
diagnosis. GENERAL EXAMINATION. 
65 
2. Moreover, during the progress of a febrile disease, the tempe- 
rature not infrequently gives notice, by its unusual behavior, of the 
occurrence of an unusual event. Hence, not infrequently, we first 
become aware of an exacerbation or of a complication in a given dis- 
ease by a specially high rise of the temperature. A sudden fall of 
the temperature may give notice of collapse, or a change to a fatal 
issue, or an internal hemorrhage, as of the bowels in typhoid fever. 
In the following the most important typical courses of fever are 
briefly set forth : 
1. Continued fever exists especially in two diseases: Typhoid fever 
and croupous pneumonia; also in typhus fever, sometimes in erysipelas 
and miliary tuberculosis. In a case of severe fever, with the diagnosis 
doubtful, a fever continued through several days points with proba- 
bility to typhoid fever; and next to acute miliary tuberculosis. 
In abdominal typhus [typhoid fever] the fever rises for several days 
by equal steps, “ initial period reaches the summit, at which it 
remains as a continued fever one, two, or more weeks; then it, as a 
rule, gradually becomes a remittent fever, of such a character that at 
first the daily maximum remains high, with the minimum going lower 
(“the double stage” [“the long-continued paroxysm”]—the mini- 
mum may even go below the normal); then the defervescence begins, 
Fig. 1. 
Day of illness: 
Initial period. 
Acme. 
Defervescence. 
Fever-curve of a regular mild typhoid fever. (Wunderlich.) 
the maximum declining; this usually reaches the normal in a few 
days. The remittent and defervescent stages may be protracted for 66 
MEDICAL DIAGNOSIS. 
some time, even as much as a week : “ slow typhus.” Moreover, the 
temperature may, after it has somewhat declined, again rise: “ recur- 
rence or the disease, after the temperature has reached the normal, 
may begin anew, in the same manner as at first: “ renewing’’ (see 
regarding these points Figs. 1, 2, 3). 
Day of illness: 
Fig. 2. 
Long-continued paroxysm of typhoid fever. 
There are all manner of variations from this behavior of the tem- 
perature in typhoid fever, so that a single case seldom really pursues 
a typical course. Particular variations partly declare themselves by 
Fig. 3. 
First attack. 
Defervescence. 
Typhoid fever, with recurrence of fever. 
Second attack. 
the earlier change of the temperature to the changeable character, 
mentioned on page 67 ; but the fever-curve will especially be affected GENERAL EXAM1NA TION. 
67 
by the administration of antipyretics.1 But, particularly, every 
exacerbation of the temperature should cause the physician to think 
of complications, and a fall of the temperature, of collapse, and also 
of possible intestinal hemorrhage. 
In pneumonia (see Figs. 4 and 5) the temperature rises very 
rapidly (“initial period,” lasting a few hours), often accompanied by 
chill, then remaining as a high continued fever. From this it may 
decline, also very rapidly—in a few hours—to or below the normal, 
with a simultaneous decline of the pulse and the respiration, and 
generally with severe sweating. Or the defervescence may be some- 
Fig. 4. 
Day of illness: 1 
Pseudo-crisis. 
Fever curve of croupous pneumonia. (Strumpet,l.) 
what slower, occupying one or two days. The former way is called 
“crisis ” (critical sweat), the latter “lysis”; midway between these 
two is “ protracted crisis.” 
Sometimes the day before the crisis the temperature suddenly falls 
very rapidly, and then again rises—“ pseudo-crisis ” (distinguished 
1 The antipyretic treatment, especially with internal remedies, has, no doubt, the 
result of rendering the course of the fever untypical, and so destroying its diagnostic- 
value. Therefore, until the diagnosis has been established in a case of febrile disease, 
the internal antipyretic treatment ought, if possible, to be suspended. 68 
MEDICAL DIAGNOSIS. 
from collapse by the pulse and the general condition, as referred to 
under “the subnormal temperature"). Or there is exacerbation of 
the temperature just before the crisis, rising from, say, 40° to 41° C. 
—“ critical perturbation.” 
Fig. 5. 
Fig. 6. 
Pay of illness: 
Pseudo-crisis and crisis in pneu- 
monia. (Wunderlich.) 
Remittent and intermittent fever (catarrhal 
pneumonia). (Wunderlich.) 
2. Remittent fever is often met with. It may exist some time 
during the course of any febrile disease. While the temperature of 
continued fever is generally high—about 40°—the fever may remit, 
whatever its height. If the maximum is 1owt, the minimum is possibly 
normal—a behavior which, strictly speaking, must be considered as 
intermittent fever. Remittent fever belongs especially to chronic 
tuberculosis. 
Fig. 7. 
Hectic fever in tuberculosis of the lungs. 
If the maximal points of the curve are high, the temperature often 
falls pretty rapidly, accompanied with chills and night-sweats (hectic 
fever). Similar conditions are observed in the fever of pus-formation. A few Professional Opinions of‘ A New Pronouncing Dictionary 
of Medicine,” by John M. Keating, M.D., LL.D. 
“This superb work is placed on the right-hand side of my desk, there to 
remain as long as I am interested in the best ‘medical ’ literature.” 
(Signed) ALEX. J. C. SKENE, M. D., 
Dean of the Long Island College Hospital, Professor of Medical and Surgical 
Sept. 5, 1892. Diseases of Women, Long Island Medical College, Brooklyn, N. Y. 
“ I will point out to my classes the many good features of this book as com- 
pared with others, which will, I am sure, make it very popular with students.” 
(Signed) JOHN CRONYN, M. I)., LL. I)., 
Professor of Principles and Practice of Medicine and Clinical Medicine; 
Aug. 23, 1892. President of the Faculty Medical Dept. Niagara University, Buffalo, N. Y. 
“ I am convinced that it will be a very valuable adjunct to my study table, 
convenient in size and sufficiently full for ordinary use.” 
(Signed) C. A. LINDSLEY, M. D., 
Professor of Theory and Practice of Medicine, Medical Dept. Yale University ; 
Aug. 15, 1892. Secretary Connecticut State Board of Health, New Haven, Connecticut. 
“1 have perused the work carefully, and am highly pleased with it. The 
phonetic method of pronunciation is complete and perfect. I have looked in 
vain in every other dictionary for the pronunciation of ‘ Micrococci,’a word 
more frequently mispronounced than any other term in present use. I shall 
unhesitatingly recommend the work to my classes.” 
(Signed) J. A. CLOSE, M. I)., 
Professor of Principles and Practice of Medicine and 
Aug. 15, 1892. Microscopy, St. Louis College of Physicians and Surgeons. 
“I am much pleased with Keating’s Dictionary, and shall take pleasure in 
recommending it to my classes next winter.” 
(Signed) HENRY M. LYMAN, M. D., 
Professor of Principles and Practice of Medicine, 
Aug. 5, 1892. Rush Medical College, Chicago, HI. 
“My examination and use of it have given me a very favorable opinion of 
its merit, and it will give me pleasure to recommend its use to my class.’’ 
(Signed) J. W. II. LOVEJOY, M.D., 
Professor of Theory and, Practice of Medicine, and President 'of the Faculty, 
Aug. 20, 1892. Medical Dept. Georgetown University, Washington, D. C. 
“A very good dictionary, and likely to be acceptable to medical men and 
students. Its price is moderate, and it contains a vast amount of information. 
Its special feature as a pronouncing dictionary will enhance its value to many. 
I will place it on our list of recommended ‘ medical dictionaries ’ ” 
(Signed) W, B. GEIKIE, M. I)., 
Professor of Principles and Practice oi Medicine, 
Aug 15. 1892. Trmlt; Medical CNJcnp. (favada, 70 
MEDIC A L DIA GNOSIS. 
sweating stage, of going into collapse; in fact, a condition of collapse 
sometimes exists with the fall of the temperature (see Fig. 8). 
In a narrower sense, however, we designate as intermittent fever 
the course of temperature of a special form of malaria. In this there 
is a continual alternation between times without fever (apyrexia); a 
quick, high rise, and, after a short time, again, a rapid fall of tem- 
perature (often below normal)—“fever paroxysm.’’ Severe chills 
and perspiration accompany these attacks of fever. The attacks recur 
with great regularity, either every twenty-four hours (quotidian), or 
forty-eight hours (tertian), or seventy-two hours (quartan). Some- 
times the attacks recur one or more hours earlier on successive days 
(anticipating), or they may recur later each time (postponing). In 
these forms of fever the diagnosis is made certain by the fever-curve 
(see Figs. 9, 10, 11). 
Fig. 12. 
Febris recur rens. 
1. Apyrexia. 
(Wunderlich.) 
1. Relapse. 
Compare p. 69. 
2. Apyrexia. 
4. Recurrent fever only exists as a renewal of a febrile disease, or 
a disease known as recurring typhus. There is an attack of fever 
very like that of pneumonia, with sharp transitions and very severe 
sweating, the temperature falling often to 34° or 35° C., and apyrexia; 
then a relapse after five to eight days, with a chill, followed by a high 
continued fever, which, in turn, ends in five or six days by a critical GENERAL EXAMINATION. 
71 
sweat; new apyrexia, fresh relapse; and so, over and over again, but 
each new attack with less fever and of shorter duration. 
5. Not infrequently a quite irregular fever will be met with. Its 
course is such that sometimes one cannot speak of any daily remission 
—at least, the lowest daily temperature comes at a variable hour of 
the day or night. But this fever may be of diagnostic value. In 
acute meningitis a continuing irregular movement of the temperature 
speaks against tuberculosis and against ordinary purulent meningitis, 
but, on the contrary, for epidemic cerebro-spinal meningitis. Again, a 
pronounced irregular fever in an acute disease in general speaks 
against any of those diseases which manifest themselves by any 
typical fever. 
6. Local Elevation or Lowering of the Temperature. 
1. Elevation of the temperature. In internal medicine this is 
seldom of diagnostic aid. We meet it where there is any kind of 
inflammation which is near the surface, as in surgery. In unilateral 
pneumonia, also, a careful measurement shows an elevation of the 
temperature in the axilla of the affected side. In recent paralysis of 
any sort the temperature of that side is somewhat higher for a short 
time; then the temperature usually falls. Rare cases of hysteria 
exhibit a one-sided elevation of temperature with redness of the skin 
and perspiration. 
2. Lowering of the temperature. This is the expression of local 
disturbance of the circulation. In heart-failure, also in collapse and 
near-approaching death, the extremities and also the nose become 
cool. Coolness of the affected limb is observed in venous thrombosis, 
in paralysis of long standing in consequence of diminished venous 
blood-current, and in arterial embolism and thrombosis. PART III. 
SPECIAL DIAGNOSIS. 
CHAPTEK IY. 
EXAMINATION OF THE RESPIRATORY APPARATUS. 
Examination of the Nose and Larynx. 
1. The Nose. 
Inspection of the nose sometimes reveals diseased conditions which 
concern the bony structure, and, therefore, belong to surgery: defor- 
mities, fistuke, ulcers, with deeply-seated destructive process at the 
root of the nose. 
Only one of these conditions has interest for us as physicians: the 
so-called saddle nose, arising from necrosis and removal of a part of 
the bony framework of the nose, is an almost infallible sign of consti- 
tutional syphilis. 
Swelling and redness of the nostrils indicate inflammation of the 
nasal mucous membrane. Not infrequently we also see traces of a 
muco-purulent or purulent, sometimes an ill-looking bloody, serous 
secretion ; the latter is sometimes offensive in odor. 
Patients with obstructed nose (with severe catarrh or tumors) 
breathe through the mouth. On the other hand, in severe dyspnoea 
(q. v.) there is likewise motion of the alae nasi. 
Upistaxis shows itself most plainly by the flow of blood from the 
nose. However, with persons entirely unconscious or healthy per- 
sons while asleep upon the back, the blood flows backward into the 
pharynx or even into the stomach. Then the hemorrhage may be 
overlooked, or the first symptom of epistaxis may be vomiting of 
blood. 
73 74 
SPECIAL DIAGNOSIS. 
In all important diseases of the nose it is necessary to make use of 
the nasal speculum. (For the use of this in examinations, see the 
Appendix.) 
Palpation of the interior of the nose may be necessary (see works 
upon Surgery). 
Acute muco-purulent and purulent catarrh of the nose is symp- 
tomatic in measles, diphtheria, and equinia. Chronic catarrh is a 
common symptom of scrofula (in which disease the whole nose is often 
swollen) and of syphilis. In the former disease there is sometimes an 
inflammatory thickening of the whole nose, particularly of its lower 
walls. Inflammation of an acute form, with very foul-smelling and 
ill-looking secretion, most frequently indicates diphtheria of the nose 
and pharynx. 
2. The Larynx. 
The larynx is examined with reference to its functions (voice, 
cough, breathing) and the local appearances; the latter includes the 
external and internal examination (see also under Sputum). 
(a) The Function.—The voice is changed in all affections of the 
larynx. It may be muffled, rough, hoarse, even to the entire loss of 
voice—“ aphonia.” In severe diseases it may have a whistling or 
sibilant (strident) quality : This indicates stenosis of the larynx; or it 
is very hoarse and deep: this points to deep-seated ulceration. 
In diseases of the larynx the cough is hoarse, loud, or barking. 
In extensive destruction and in certain paralyses of the crico-aryte- 
noid muscles, cough is either more difficult or is impossible, since the 
power to close the glottis preceding the cough, as is normally the case, 
is wanting (see Cough). 
Breathing is obstructed in all conditions that narrow the larynx, as 
in inflammation resulting in hypertrophy, in new formations, in scars 
with contraction. Then there is an inspiratory and expiratory 
dyspnoea (which see), and a peculiar noise of stenosis, “ stridor laryn- 
geus.” In marked stenosis, especially when the thorax is weak, as in 
children, there is a drawing-in of the lower part of the thorax in 
front, in the region of the insertion of the diaphragm (seethe chapter 
on Anomalies of Respiration). 
Stenosis only in inspiration, causing inspiratory dyspnoea, is ob- EXAMINATION OF THE RESPIRATORY APPARATUS. 
75 
served in paralysis of the crico-arytenoid muscles, the dilators of the 
larynx. 
Laryngeal stenosis is distinguished from tracheal stenosis at the 
first glance, in that in the former condition the larynx moves up and 
down with each breath, and the neck is stretched to the fullest extent, 
while in the latter the larynx remains quiet and the head is always 
somewhat bent forward. 
(b) Local Examination.—The external examination is made with 
reference to pain, to deformities revealed to the sight or touch (these 
are very rare, resulting from destruction by periostitis), and laryngeal 
fremitus. 
Laryngeal fremitus is a trembling of the thyroid cartilage during 
speech. It is stronger or weaker on one side in unilateral paralysis. 
It has no special diagnostic value. 
The internal examination. By great care, and in the case of 
patients who have themselves under good control, sometimes the 
entrance to the larynx and the tissues even as far as the glottis can 
be touched. This method, however, has now little value, since it has 
been entirely superseded by the examination Avith the laryngeal mirror, 
which is the best means of examining the larynx. (Regarding its use 
see the Appendix.) 
In inflammatory conditions, patients complain of pain in speaking, 
but sometimes, even with severe disturbances, there is no pain; now 
and then there is dyspnoea, especially on exertion. Pain in swallow- 
ing in chronic diseases of the larynx frequently indicates serious con- 
ditions : extension of new formation (carcinoma) toward the oesophagus, 
or destructive suppuration. 
The leading symptomatic indications of diseases of the larynx with 
reference to other possible internal diseases, are as follows: acute 
laryngitis, with manifestations of an acute infectious disease, points 
especially to measles, croup (and also to smallpox). Chronic laryn- 
gitis points to tuberculosis and syphilis; to constriction by scars, to 
syphilis. Of paralyses, recurring paralysis is of special diagnostic 
importance, since it often arises from pressure upon nerves, espe- 
cially upon the left side from aneurism of the aorta, carcinoma of the 
oesophagus, tumors of all kinds in the mediastinum. Certain paral- 
yses indicate hysteria. 76 
SPECIAL DIAGNOSIS. 
Examination of the Lungs. 
TOPOGRAPHICAL ANATOMY OF THE LUNGS. 
For localizing the surface of the chest with reference to height and 
depth we make use partly of anatomical prominences and partly (for 
determining the breadth) of certain local lines which we think of as 
drawn upon the surface of the thorax. 
Upon the front side of the thorax are the important anatomical 
regions: the fossa supraclavicularis (above the clavicle and bounded 
by the sterno-cleido-mastoid and trapezius muscles) and the fossa in- 
fraclavicularis. The latter has no distinct lower boundary. We under- 
stand it as the region immediately below the clavicle, about as far as 
to the second rib. From the second rib downward we designate the 
height by the ribs and intercostal spaces: as above the fourth, under 
the fourth rib, the fourth intercostal space. The number of the par- 
ticular rib is determined by counting from the second rib downward. 
It is always easy to find this rib : it is in articulation with the sternum 
exactly where the manubrium and corpus sterni unite, ordinarily 
forming a very slight angle (angulus Ludovici), and this place is 
plainly to be felt, and often seen, as a cross-line or prominence. We 
feel for this prominence and find the second rib to be its prolongation. 
We count the ribs from that downward, feeling somewhat obliquely 
outward as we go down. Morenheim’s depression [the outer part of 
the infraclavicular depression] and the so-called Sibson’s furrow (the 
under border of the pectoralis major) are sometimes, although not very 
practically, useful as points for locating internal organs. 
For determining the breadth the vertical lines now to be mentioned 
are useful (the subject is supposed to be standing): the middle line, 
drawn through the sternum; the two sternal lines, drawn parallel 
along the sides of the sternum ; the mammillary lines, drawn through 
the male nipple; and the parasternal lines, drawn midway between 
the sternal and the mammillary lines. 
On the two sides we determine the height by the ribs, which we 
count in front; and the breadth by the middle axillary line (drawn 
through the middle of the axilla, the arm being extended sidewise), 
the anterior and posterior axillary lines (drawn perpendicularly from EX AMIN A TION OF THE RESPIRATORY APPARATUS. 
77 
the points where the pectoralis major and latissimus dorsi muscles 
leave the thorax, with the arm raised sidewise to the horizontal). 
Upon the hack, wTe name the fossa supraspinata; above that, the 
suprascapular space; the fossa infraspinata; the interscapular space, 
between the two scapulae ; the infrascapular space, under the shoulder- 
blades. Exact determination of height is made by counting the ribs, 
which, however, are difficult to count, especially in fat persons. They 
can be determined by three methods: 
(a) By counting the vertebral prominences from the vertebra 
prominens (the seventh cervical). 
(b) By counting from the lower angle of the scapula; this over- 
hangs the seventh rib in the average person when the shoulders 
hang comfortably and the arms rest against the chest with the fore- 
arms folded lightly. 
(c) By the point of the twelfth rib, which is easily felt (the best 
way for the lower ribs). 
Moreover, we have the scapular line, which is drawn upon the two 
sides of the spine through the lower angle of the scapulae (at the point 
already mentioned under (b)). 
It is to be observed that some of the vertical lines are not deter- 
mined exactly. This is true regarding the mammillary line (always 
very important) more than any other. In women it is generally very 
variable. On this account it is always to be thought of as drawn upon 
a male thorax. But even in the male the nipple is an uncertain 
point. By much practice the eye is cultivated so as to recognize 
what is to be regarded as the average location of the nipple in the 
male, and by this we must always correct the mammillary line. The 
attempts to substitute other lines for this one have not been accepted. 
The designation “ infrascapular space ” is little used. The expres- 
sions, “right, left; behind, below,” correspond to it, and are much to 
be recommended: behind or below the right, the left, scapula. 
THE ANATOMICAL BOUNDARIES OF THE LUNGS WITH REFERENCE 
TO THE THORAX. 
In front the lungs reach to the sixth, and behind to the tenth, rib, 
and are almost everywhere directly in contact with the chest-wall. 
They are not in contact with the chest-wall in the neighborhood of the 
heart nor behind a small portion of the upper part of the sternum. SPECIAL DIAGNOSIS. 
78 
The accompanying figure exhibits the anatomical boundaries of the 
lungs. They project with their summits into the fossa clavicularis 
from three to five cm. above the clavicle, and with their inner anterior 
borders converging downward, so that behind the angulus Ludovici, 
not exactly behind the middle of the sternum, but a little to the left, 
they come to lie very close to each other; then they continue parallel 
Fig. 13. 
Position of the thoracic viscera, of the stomach and of the liver, from in front. The 
portions of the heart and liver which are drawn with unbroken hatched lines represent 
the parietal portions of those organs. The portions that are not in contact with the 
chest-wall, but are covered by the lungs, are represented by broken (clear) hatched 
lines. The line ef, border of the right lung; g h, border of the left lung; dotted lines 
( ) a b and c d, the boundaries of the complementary pleural space; i, the boundary 
between the right upper and middle lobes; k. the boundary between the right middle 
and lower lobes of the lung; l, boundary between the left upper and lower lobes; 
w, greater curvature of the stomach. (Weil-Luschka.) 
downward to the insertion of the fourth rib. From there the inner 
border of the right lung proceeds still further downward to the top of 
the insertion of the fifth rib, then gradually bends toivard the right so 
that it follows along the sixth rib, on the upper border of which it 
meets the mammillary line. Then it continues approaching the hori- EXAMINATION OF THE RESPIRATORY APPARATUS. 
79 
zontal (in the upright posture) so that it lies, in the middle axillary 
line, upon the seventh or eighth rib, in the scapular line upon the 
tenth rib (this location on the dead body is about one cm. higher than 
in quiet respiration in the living subject). On the left side, the 
border of the lung bends sharply round from the fourth rib to give 
place to the heart, continues behind the fourth rib as far as the left 
Fig. 14. 
Position of the lungs, liver, spleen, and kidneys, seen from behind. The liver and 
spleen are represented by the same hatching as in Fig. 1.3. a b, the lower border of the 
lungs; c d ( ), complementary space; {(dotted line) (broken line), border of the 
liver; ef (dotted line), boundary between the upper and lower lobes of the lungs; 
g, boundary between the upper and middle lobes of the right lung. (Weil-Luschka.) 
parasternal line, then bends vertically downward, making a small bow, 
which converges toward the right; then sharply bending again behind 
the sixth rib so as to pass the mammillary line under the sixth rib 
(hence, somewhat lower than on the right side), it passes the axillary 
line between the seventh and eighth, and the scapular line at the tenth, 
rib. 
The boundaries of the lungs are different according to age, as well 
as in individuals. (See section on Percussion of the Lungs.) 80 
SPECIAL DIAGNOSIS. 
The boundaries of the pleural sacs—that is, the lines on which the 
pleura costalis (sternalis) leaves the wall of the thorax and bends inward 
—agree in reality with the course of the inner borders of the lung. 
But along the lower borders of the lungs and at the cardiac concavity 
the pleural space extends considerably beyond the border of the lungs 
(in quiet breathing), making the sinus phrenico-costalis and the comple- 
mentary pleural sinus The size of these corresponds with the form. 
The largest is the complementary pleural sinus in the two axillary 
lines. This is there about ten cm. high. 
The pleural sinuses are therefore important, since into them extend 
the lungs at every deep inspiration and also in the pathological, 
chronic inflation, emphysema pulmonum; and also, because in them 
fluid effusions into the pleural cavity ordinarily first accumulate. 
The under surface of the lungs rests directly upon the diaphragm. 
The diaphragm in the dead body rises at its highest part, as a dome, 
about as high as the insertion of the fourth rib, a little higher upon 
the right than the left side. The average situation of the dome of the 
diaphragm in life, during quiet breathing, is a little lower. 
Finally, it is necessary to mention the course of the boundaries of 
the lobes of the lungs, since they sometimes have an important part in 
diagnosis: at the back, near the spine, the boundary between the 
upper and lower lobes is at the height of the lower angle of the 
scapula ; upon the left it gradually slopes forward and outward in such 
a way that in the axillary line it stands at the fourth rib, and meets 
the lower border of the lung (that is, at the sixth rib) in the mammil- 
lary line. On the right side the boundary-line divides near the outer 
border of the scapula into two diverging lines: the line between the 
upper and middle lobes and that between the middle and lower lobes. 
The former proceeds at first behind the third rib, and terminates at the 
inner border of the lung at the insertion of the fourth rib ; the latter 
meets the lower border of the lung somewhat within the mammillary 
line, and, therefore, behind the sixth rib. 
Hence, in front upon the right side, we have the upper lobe; about 
at the third intercostal space, from there downward really the middle 
lobe; in front on the left side, for the whole distance we really have the 
upper lobe; on the side at the right, we have the middle lobe above 
and the lower lobe below; on the side at the left, we have the lower EXAMINATION OF THE RESPIRATORY APPARATUS. 
81 
lobe; behind we have only the apices, formed by the upper lobes ; all 
the rest is lower lobe. 
INSPECTION OF THE THORAX. 
The examination of the thoracic organs must always begin with the 
inspection of the thorax. Nothing is more faulty than to take up 
some other method of examination first. Inspection of the thorax is 
important because a very large number of the diseases of the lungs 
and pleura manifest themselves in the form of the chest cavity and a 
change of the respiration. Certain diseases of the internal organs 
have a causal relation to changes in the form of the thorax. In other 
cases, as it appears, a given form of thorax accompanies a “ disposi- 
tion ” of the lungs to certain diseases (emphysema, phthisis). It 
is very probable, although it is difficult positively to establish, that 
sometimes the thorax by its form either causes or favors the develop- 
ment of the given disease. Moreover, we know that there are deform- 
ities of the chest which in other ways injure or render useless the 
thoracic organs; there are such, also, as have no influence upon the 
lungs or heart. 
Method of procedure. During inspection (as in all examinations 
of the thorax) attention must be given to having the patient straight, 
but without undue muscular tension. The light should fall symme- 
trically upon the front or back, whichever is under examination; the 
eyes of the examiner should, if possible, be directly before the middle 
line of the body. The general structure of the thorax (and neck) 
should first be considered, next possible peculiarities, then the motions 
of respiration, first during quiet, then deeper, respiration. 
1. Normal Form of Thorax and Normal Respiration. 
In a well-constructed thorax we expect, first, perfect symmetry 
(this is departed from almost always normally, in that there is a very 
slight curvature of the dorsal vertebrae toward the right). Moreover, 
the clavicular depressions may only be indicated; the angulus Ludo- 
vici [also called the angle of Louis] (the angle formed by the junction 
of the manubrium and corpus sterni) may just be recognizable; the 
true ribs should so leave the sternum that from the top downward there 82 
SPECIAL DIAGNOSIS. 
is increasing obliquity, making the angle formed by the two opposite 
bendings of the ribs, “ the epigastric angle,” almost a right angle; the 
thorax should be well developed; the scapulae should, in the upright 
position, lie flat upon it; the intercostal spaces should be visible only at 
the lower ribs; finally, the dimensions of the chest and the size of the 
body should have a certain relation to each other. Very seldom does 
the normal thorax correspond to this ideal, and there are many de- 
partures from it in persons who are perfectly sound. Such “ physio- 
logical ” departures may be mentioned; a slight asymmetry in a 
gradually-acquired spinal curvature or a deformity of the ribs self- 
established ; further, a peculiar form of thorax, where the upper part 
is somewhat shallow, but the lower of increasing depth, so that the 
lower aperture of the thorax is very large; also more marked angle of 
Louis (Braune); again, in a shorter thorax, a more acute epigastric 
angle may sometimes be observed in healthy persons (hence, also, 
without signs of emphysema, see below) The supra-clavicular de- 
pressions are often both deepened, with the apices of the lung entirely 
normal (unequal deepening of them is, however, very suspicious of 
tuberculosis, see below) ; single ribs, more frequently the second, third, 
also the fourth, sometimes on account of greater curvature, project 
more in front; on the other hand, the lower ribs will often be found 
pressed into the side and from there flattened forward, and other 
variations. The boundary between the unsymmetrical and the path- 
ological form of chest is much confused; it can only be recognized in 
the individual case by attention to the location and function of the 
thoracic organs. 
Normal breathing takes place in this wise: inspiration only is 
active, that is, is accomplished by muscular action; expiration, on 
the contrary, is produced wholly by the elasticity of the lungs, the 
weight of the chest wall, and the pressure of the abdominal organs 
upon the diaphragm. The number of respirations to the minute in 
the newborn is about 44 ; at five years, about 26 ; from the twentieth 
year, about 16 to 20. It is very easily influenced by a number of con- 
ditions : in sitting and standing it is somewhat higher than in lying; 
it is increased by bodily activity and psychical impressions. There- 
fore, it can only be determined during perfect quiet, with the atten- 
tion withdrawn from the examiner, or during sleep. For counting EXAMINATION OF THE RESPIRATORY APPARATUS. 
83 
it, it is generally most advantageous to lay the hand lightly upon the 
chest (or upon the epigastrium). 
The breathing is generally regular, and the single breaths of equal 
strength; but under the influence of the slightest psychical disturbance 
it easily becomes irregular and unequal. Many persons of sound 
health, as snorers in sleep, often breathe irregularly or unequally 
deeply. Breathing is either exactly or very nearly symmetrical, though 
the left side frequently inclines to breathe a trifle stronger. 
The inspiratory enlargement of the thorax is occasioned by the 
elevation of the ribs and the sternum, and the simultaneous drawing 
of the former upward and outward (intercostales externi and interni 
muscles—“ costal breathing" f, moreover, by the contraction of the 
diaphragm, and, hence, flattening of its dome. The latter movement, 
at the same time, draws down the intestines, and so with every inspira- 
tion the whole anterior wall of the abdomen projects, but especially 
the epigastrium (diaphragmatic, or abdominal, breathing). The com- 
bination of costal and diaphragmatic breathing varies in the two 
sexes in that in the male the latter, and in the female the former, 
preponderates. But in aged females, with firm thoracic wralls, dia- 
phragmatic breathing increases; Avhile, on the other hand, male as 
well as female children incline to the costal type of breathing. From 
this it seems that the degree of flexibility of the thorax influences the 
kind of breathing. 
In the costal breathing of women, even in quiet respiration, the 
scaleni muscles (elevators of the first and second ribs) take a part; 
while in men these muscles belong to the auxiliary muscles of respira- 
tion (see below). 
2. Pathological Forms of Thorax. 
(a) The inflated or emphysematous thorax. This refers to a 
chronic symmetrical extension in all directions, conforming somewhat 
to the form of the chest during inspiration (the inspiratory position). 
The antero-posterior (the sterno-vertebral) diameter is increased. In 
many cases it appears as if the thorax became enlarged, especially at 
about the height of the middle of the sternum, making a barrel-shaped 
chest; however, this may be entirely w’anting. The ribs are generally 
strong, and are at right angles to the sternum, hence the epigastric 84 
SPEC I A L DIAG NOS IS. 
angle is larger than normal; the thorax is generally short. Fre- 
quently the angle of Louis is very prominent. 
The supra-clavicular depressions may vary very much ; sometimes 
they are deepened, again, shallow or even projecting like pillows (the 
latter condition obtaining in emphysema of the upper part of the 
lungs). The lower intercostal spaces are sometimes drawn in during 
inspiration. 
In the emphysematous thorax the breathing is so changed that 
the expiration is both slower and imperfect in consequence of the 
diminished elasticity of the lungs; it is prolonged, and, in marked 
emphysema, it is assisted by muscular action, especially by the 
transversus abdominis and the quadratus lumborum. We can then 
plainly see the abdominal wall energetically flattened, and we are 
directly impressed with the idea that the thorax is forcibly expanded. 
But the inspiration is also altered in consequence of the rigidity of 
the chest-wall; ordinary costal breathing is wanting; it is very im- 
perfect ; and in its place we notice that the front of the chest, as a 
whole, has been drawn up by the powerful action of the sterno-eleido- 
mastoidei muscles. Consequently, in emphysema we have the breathing 
rendered difficult; in severe cases it may become so to a high degree 
(see Dyspnoea). 
The typical emphysematous thorax points almost with certainty to 
emphysema, and hence its name; however, we must guard against 
the mistake of calling every short chest an emphysematous one. On 
the contrary, also, we not infrequently find a general emphysema of 
the lungs in a chest that has no trace of the “ emphysematous ” form. 
Active expiration, expiratory dyspnoea, is much more characteristic 
than the form of the thorax; besides emphysema, it exists in no other 
condition except certain diseases of the larynx (see Dyspnoea). 
(b) The paralytic or phthisical thorax. This is the direct opposite 
of the preceding: it is flat, especially in the upper part; is often 
also narrow; the intercostal spaces are wide; the ribs are generally 
delicate, are sharply inclined downward from the sternum, and, 
hence, must be bent at a sharp angle again in order to come back 
to the vertebrae. This sloping from the sternum makes the epigastric 
angle very sharp; the chest, as a whole, chiefly in consequence of the 
course of the ribs, is long. The angle of Louis is often very marked. EXAMINATION OF THE RESPIRATORY APPARATUS. 
85 
The depressions are generally deep. The shoulder-blades frequently 
stand out like wings. 
Quiet breathing may be almost normal; by exertion it is generally 
immediately very much increased in frequency ; it is shallow ; even 
in women the costal type is often wanting, especially at the upper 
part of the chest. 
This form of chest corresponds wuth that of tuberculosis. A well- 
marked paralytic thorax, except where phthisis of the lungs has early 
developed, is very infrequently seen; but yet this disease occurs very 
often where the phthisical thorax is wholly absent—indeed with an 
emphysematous thorax. In a paralytic thorax, with phthisis already 
developed, by means of the latter the form of the thorax and the 
breathing will become essentially and variously changed. See above 
under (a) and below under (d). 
But one must be very careful not to conclude that a thorax narrow 
from great emaciation, and especially one that appears flat, is a 
paralytic one. For example, a beginner is apt to find that a patient 
convalescent from typhoid fever has a paralytic chest. Strictly 
speaking, also, every plain or flattened thorax is not to be called a 
paralytic one. Moreover, emaciation and flattening of the upper parts 
of the chest, in cases of developed phthisis, frequently render the 
thorax paralytic, which it originally was not. 
(c) One-sided extension of the thorax, a relatively infrequent 
affection, occurs in disease, or functional loss, of the opposite lung. 
The dilated side is then the seat of the so-called “ vicarious em- 
physema ” of the lung. This is distinguished from true emphysema 
by the absence of expiratory dyspnoea. 
The dilated side is much more frequently the diseased one. The 
widening of the chest-cavity is more plainly seen from the front than 
from behind. Very frequently the mamma and the scapula are 
further removed from the median line than upon the normal side. 
The intercostal spaces are level or are projecting; in contrast with 
this, the diseased side drags after the other—that is, in inspiration it 
rises later and less than the sound side, and it may even not rise at 
all. Hence, the spinal column is sometimes bent toward the diseased 
side. 
Marked expansion is met with in pneumothorax and in extensive 
pleuritic exudation ; while the development of the latter usually first 86 
SPECIAL DIAGNOSIS. 
manifests itself by expansion and lagging behind at the posterior and 
lower part of the chest. A very slight expansion of one half of the 
chest is, moreover, sometimes seen in croupous pneumonia of the 
whole of the affected lung. 
Circumscribed forward expansion of the chest occurs especially 
with tumors of the pleura, and is sometimes humped, and, again, 
uniform; empyema which inclines to breaking through, pushes the 
affected region prominently forward, and, at the same time, the skin 
is generally oedematous. Encapsulated pleuritic exudations or circum- 
scribed pneumothorax seldom cause expansion, yet the first causes a 
smoothing out of the neighboring intercostal spaces, besides lagging 
behind. Local projections, moreover, occur not infrequently from 
inflammatory affections of the ribs or the subcutaneous cellular tissue. 
Local expansions of the thorax are seen in cases of enlargement of 
other organs. The cardiac region may be bulged out in enlargement 
of the heart or distention of the pericardium (see under Examination 
of the Heart); a marked enlargement of the liver may press out the 
lower ribs on the right side, and enlargement of the spleen on the 
left; and sometimes, especially in children, a very marked expansion 
of the whole lower part of the thorax, an enlargement of the lower 
aperture of the chest, is observed in cases of considerable expansion 
of the whole, or the upper part, of the abdomen (meteorismus, ascites, 
peritonitis, tumors). Then the upper part of the chest seems quite 
small in comparison with the lower part; the whole trunk is, hence, 
shaped like a bee. From the drawing up of the diaphragm there 
results interference with diaphragmatic breathing, and generally there 
is severe dyspnoea. 
It is very important to remember that the expansion of the chest, 
especially that caused by pleuritic exudation, varies with the flexibility 
of the thoracic wall. If the wall is soft, as is the case with children, 
the expansion is very pronounced; if rigid, as in subjects of em- 
physema, sometimes a very large pleuritic exudation causes no 
noticeable expansion. Therefore, while we expect in general that an 
extensive pleuritic exudation will manifest itself by an enlargement of 
the affected side of the chest, yet, where the walls are rigid, we must 
not conclude from the absence of expansion that there is no exudation. 
(d) Drawing-in or shrinking of one side. This is seen more or 
less frequently as a symmetrical drawing-in of the whole side, so that EXAMINATION OF THE RESPIRATORY APPARATUS. 
87 
the affected side is altogether smaller than the other; the ribs are 
close together, and in the lower part they may even overlap, like 
shingles on a roof. The shoulder of that side hangs down; the mamma 
and scapula are nearer the median line. The spinal column is curved 
with its convexity toward the healthy side; hence, the whole carriage 
is affected. There is diminished breathing, or no breathing at all, on 
the side drawn in ; on the healthy side, there develops a vicarious 
emphysema. This condition is observed in recovery from extensive 
pleuritic exudations, and in long-continued contraction of the lungs. 
In pleurisy, it is the loss of elasticity and thickening of the pleura, 
with adhesions of pleural surfaces, in shrinking of the lungs, and the 
development of connective tissue in the lungs, which not alone hinder 
the lungs from following the inspiratory expansion of the thorax, but 
from the tendency to contract, as in scars of the skin, draws in the 
chest-wall. This inward traction, however, does not concern the 
thorax alone: the mediastinum, heart, and diaphragm are pulled 
toward the sunken side. Hence, there is displacement of the heart 
toward the diseased side, and the diaphragm is high in the chest. 
More frequently there is an unequal degree or a partial shrinking 
on the affected side; with it also is always connected a more or less 
marked lagging. It is most frequently observed above in front, here 
sometimes noticeable at the first commencement as a deepening of the 
supra-clavicular depression (an important symptom of contraction of 
the apex of the lung from tuberculosis). Again, a partial drawing-in 
is often seen, most frequently low down posteriorly, after the disap- 
pearance of a small pleuritic exudation. But there may be shrinking 
of any part of the chest-wall, as after gangrene and abscesses of the 
lungs 
One must be careful not to confound a deformity of chest from 
disease of the thoracic organs with deformities that are dependent on 
a primary bending of the spine and thorax. Concerning these, see 
the following section. 
A repaired fracture of the ribs may also cause deformity; a fracture 
of the clavicle which has healed with an angle forward may deepen 
the supra- and infra-clavicular depressions, and so deceive one; one- 
sided defect or atrophy of the pectoralis major, of course, flattens that 
side. All of these cases may be excluded by a more careful examina- 
tion. 88 
SPEC IA L DIA GNOSIS. 
(e) Extension or retraction of the chest hy 'primary deformity of the 
skeleton. Kyphosis, or bending backward, and scoliosis, the bending 
sidewise of the spine, but, still more, the combination of both, kypho- 
scoliosis, occasion sometimes deformities of the chest that are enormous. 
Most frequently one side is smaller in front, while the other side 
appears as if enlarged; and the picture of one-sided contraction of 
pleura or lung is more complete from the dragging-after of the smaller 
side. In consequence of a peculiar twist of the spine and its effect 
upon the course of the ribs, the back is generally very crooked. This 
is spoken of more particularly in works upon surgery. Whether 
we have to deal with a primary deformity of the chest or with a 
contraction of the lung or pleura is generally made clear by the ex- 
amination of the spine; in rare cases, however, this, and even the 
minutest examination of the thoracic organs, does not give a positive 
diagnosis. Moreover, the thoracic organs are almost always much 
displaced; the lungs are in part functionally very much disturbed. 
These patients have short breath on the least exertion ; and in case of 
disease of the chest organs, especially in acute infectious diseases, are 
more in danger than others. The distinction of the different kinds of 
spinal curvature and their origin belongs to surgery. 
Rhacliitis is frequently the cause of such deformities, but it may 
also cause all other possible bendings of the chest. Of these espe- 
cially characteristic are : 1. The rhachitic chest, a thickening of the 
point of transition from the cartilage to the bony ribs. The several 
prominences arising from it form on both sides of the sternum a line 
passing as an arch outward and downward. 2. The pigeon-chest. 
The chest seems to be compressed sidewise and pressed forward. The 
ribs run sharply backward from the front, so that the sternum stands 
forward like the keel of a ship, the sterno-vertebral measurement 
being much increased. 3. A circular drawing-in in the neighbor- 
hood of the costal attachment of the diaphragm. The ribs, as is well 
known, form a fixed point for the diaphragm ; if, as in rhachitis, the 
chest is abnormally yielding, it is drawn inward by the contraction of 
the diaphragm, and this especially is the case if there is increased 
action of the diaphragm—that is, if from any cause there is difficulty 
of breathing. 
Funnel-breast (Fig. 15). This deformity consists in a sinking-in 
of the sternum, especially of the lower portion of it; it may be EXAMINATION OF THE RESPIRATORY APPARATUS. 
very considerable (as much as seven cm.). The affection is generally 
congenital, and, according to our experience, in very marked cases it 
may prove a hindrance to respiration. Shoemakers -breast exhibits 
a sort of acquired funnel-breast, caused by pressure of tools against 
the lower part of the sternum and the xiphoid cartilage; the depres- 
sion never becomes very great, and involves only the cartilage; it 
has no pathological significance. 
Fig. 15. 
Funnel-breast. (Ebstein.) 
According to recent experience, the funnel-breast sometimes is 
observed in several branches of a family. In individual cases it 
occurs as a sign of degeneration, with other errors of development, or 
associated with neuropathic or psychopathic disease or hereditary 
taint. 
3. Anomalies of Respiration. 
In the preceding section the anomalies of breathing which accom- 
pany the several pathological forms of thorax have been briefly 
referred to. But these require a further separate description. In 90 
SPEC I A L DIA GNOSIS. 
giving this it will not be possible to avoid a partial repetition of what 
has already been said. 
(a) Anomalies of the manner of breathing. The type of 
breathing which, as has been mentioned above, in the normal human 
being is typically different in the two sexes, and is denominated costal 
and costo-abdominal, may be influenced by a number of different 
pathological conditions. 
1. The activity of the diaphragm, from some cause or other, may 
be restricted or entirely stopped ; it may then be replaced by increased 
thoracic breathing; this causes the costal type peculiar to women to 
be still more prominent, while the male type is reversed; instead of 
the abdominal predominating, the costal becomes predominant or 
entirely prevails—that is, may take on the female type. 
Such a restriction or prevention of the action of the diaphragm is 
occasioned by pain, or mechanical restraint, or by weakness or paralysis 
of the diaphragm. Such is the action of all inflammations of the 
abdominal or pleural cavities in case they involve the corresponding 
serous covering of the diaphragm, markedly impairing diaphragmatic 
breathing; they often act so because they are painful; but also some- 
times, especially in inflammation of the diaphragmatic peritoneum, 
actual paralysis of the diaphragm quickly develops, which is recog- 
nized by the entire disappearance of abdominal breathing (see above, 
p. 85). This takes place quite commonly in diffuse peritonitis; it is, 
however, also sometimes the only symptom of a beginning local “sub- 
phrenic” peritonitis. Marked distention of the abdomen by tumors, 
fluid, and accumulations of gas in the intestines, hinder diaphragmatic 
breathing in a high degree. Finally, there occurs paralysis of the 
diaphragm in organic diseases of the nervous sj’stem (bulbar paralysis; 
neuritis of the phrenic nerve in the various forms of multiple neuritis), 
as well as a manifestation of functional neurosis (hysteria). 
The action of the diaphragm is recognized, as has frequently been 
mentioned, by the protrusion of the epigastrium during inspiration. 
Of course, this does not take place when there is no contraction. In 
complete paralysis the diaphragm is sometimes even completely sucked 
into the thorax; in hysteria, during inspiration, the epigastrium 
sometimes sinks in extraordinarily deep. One-sided failure of action 
of the diaphragm may also occasionally be made out. (See Palpation.) 
2. But sometimes, also, hindered thoracic breathing may be replaced EXAMINATION OF THE RESPIRATORY APPARATUS. 
91 
by increased diaphragmatic breathing; hence, in such a case, if the 
patient is a female, the type of breathing is changed—that is, ab- 
dominal breathing predominates instead of costal. 
Therefore, in very rigid thorax (emphysema), sometimes also in 
women, diaphragmatic breathing predominates. Here belong paralysis 
of the muscles of inspiration (bulbar paralysis), and myositis ossificans 
(rare), since it causes a rigid condition of the thorax. A peculiar 
disease of the skin, schleroderma, may, if located upon the thorax, 
also entirely abolish thoracic breathing. 
It has been shown above, under emphysematous thorax, how, in 
lieu of the peculiar costal breathing, this may in part be replaced by 
the movement of the thorax as a whole by the (auxiliary) muscles— 
the sterno-cleido-mastoidei. 
3. Asymmetry of breathing, which is occasioned as follows: the 
whole side, or the upper or lower part of one side, either (very rarely 
plainly) expands somewhat later than the opposite side, or (most fre- 
quently) expands less strongly or not at all—which condition has 
already been mentioned several times. 
Such a lagging may be caused by a unilateral painful affection of 
any kind; moreover, by all diseases of the thoracic organs which 
interfere with respiration upon one side. This “lagging behind” is 
a valuable symptom, especially in phthisis (lagging in the infra- 
clavicular depression), also in the beginning of pneumonia and 
pleurisy, when other symptoms are wanting. (See Palpation of the 
Thorax.) 
(b) Anomalies of breathing as regards frequency and 
rhythm. Diminished frequency of breathing may take place in all 
severe diseases of the brain and its meninges, hence in large hemor- 
rhages, tumors, etc., and in all forms of meningitis; thereby exists 
always more or less dulness of intellect; the slowness of breathing 
may sometimes pass into the Cheyne-Stokes respiration (see below). 
Further, in acute infectious diseases, with marked mental dulness, 
the respiration may be slower; finally, it is generally so in the death 
agony. 
A very important form of diminished frequency of respiration is 
observed with stenosis of the upper air-passage; this belongs in the 
section on Dyspnoea. Increased frequency of respiration as a patho- 92 
SPECIAL DIAGNOSIS. 
logical manifestation belongs, without exception, to a large group, 
which will also be discussed in the next section. 
It has already been mentioned that we meet with temporary irregu- 
larity of breathing in healthy persons. It is of pathological, and 
generally of grave, import in all cases of marked mental dulness (as 
in apoplectic, uraemic, and the coma of severe typhus), and very 
especially in the death-agony. 
The so-called Cheyne-Stokes breathing is a very peculiar form of 
breathing, which is periodically repeated. It is unequal and arhyth- 
mic: in typical cases one or two quite superficial breaths are followed 
by four or five that are successively deeper and more noisy, with strong 
action and snorting or snoring, sometimes also a sort of deep sighing; 
then the respirations are again regular, become also sometimes some- 
what slower; the fourth or fifth from the acme is even hardly notice- 
able ; then follows a pause of variable length without any breath 
(4; apnoea”); this may last as much as a minute; then the course as 
above described is repeated. Frequently, also, there is a regularly 
recurring apnoea alternating with ordinary deep breaths. 
Very remarkable cases, of which I have seen a few, but of which 
others have observed many, are those in which patients, ordinarily 
unconscious, become conscious regularly with each return of the deep 
breathing; they open the eyes, raise the head a little, and may pos- 
sibly even ask questions; but, with the return of the apnoea, the 
patient again sinks into unconsciousness. In individual cases this 
form of breathing occurs with patients who are almost entirely 
conscious. 
The Cheyne-Stokes respiration is observed in all forms of meningitis 
and in hemorrhages, tumors, etc., of the brain; likewise, in heart- 
failure in consequence of heart-disease of whatever sort, but especially 
from fatty heart (Stokes), in uraemia (uraemic coma); finally, in 
poisoning by opium or morphine. Besides, it may occur occasionally 
in any deep coma. 
It is very difficult to explain the significance of this phenomenon, 
in that it is not always a fatal one. We have seen it frequently with 
favorable result in uraemia, and also in one case of apoplexia cerebri, 
and once in a case of acute diffuse peritonitis of the vermiform ap- 
pendix. In heart diseases it seems at any rate to indicate approaching EXAMINATION OF THE RESPIRATORY APPARATUS. 
93 
death. It may last hours and days; it is said to have even been 
observed to continue for almost seven months. 
It is, without question, dependent upon a disturbance of the function 
of the respiratory centre in the medulla oblongata. But we are in 
want of any exact description of the nature of this disturbance. 
A simple diminution of the irritability of these ganglion-cells cer- 
tainly must, from the blood containing C02, have eventually, as a less 
frequent result, deep or superficial (possibly irregular) breathing, as is 
seen in the death-agony. To ascribe a different degree of irritability 
to particular cells or groups of cells, as some have done, is at least a 
great refinement. In short, we have no clear explanation of this 
phenomenon. Moreover, the peculiar change of consciousness, and 
the other manifestations that have sometimes been observed to accom- 
pany it (the contracted pupils in apnoea, jerking of the muscles at the 
close of the apnoea), do not throw any clear light upon the subject.1 
(a) Difficult breathing, dyspnoea. We have to designate that 
form of dyspnoea as physiological which results when the respiratory 
centre is supplied with blood which contains less than the normal 
quantity of 0, or an increased amount of C02. The pathologist and 
the clinician speak of dyspnoea if the respiration is labored, whether 
the number of respirations be normal, or prolonged, or more frequent. 
Finally, in all cases of increased respiration, if rapid and labored 
breathing are combined, dyspncea is caused by all those conditions 
that interfere in any way with the exchange of gases in the lungs (see 
under Cyanosis). But there is another condition which manifests 
itself by an increased formation and giving off of C02; that condition 
is fever. 
Labored respiration with normal or diminished frequency takes 
place in stenosis of the upper air-passage—that is, of the larynx and 
trachea. Intra-tracheal tumors, foreign bodies, inflammations (espe- 
cially croup), cicatricial strictures (generally syphilitic), granulations, 
also, compression from without, and lastly paralyses of certain laryngeal 
muscles (see under Inspiratory Dyspnoea), produce narrowing of the 
air-passage. 
1 Recently, Mosso points out that there is a like oscillation in the sleep of healthy 
persons, and explains it by the assumption of a “breathing luxus”; he considers the 
Cheyne-Stokes phenomenon simply as a pathological example of the same phenomenon; 
but the condition is not explained by this. 94 
SPECIAL DIA GNOSIS. 
Strictly speaking, this form of dyspnoea often occurs in diseases of 
the brain (also see above, page 91). At the acme of respiration in 
Cheyne-Stokes breathing we must speak, too, of there being dyspnoea. 
Increased Frequency of Respiration Occurs : 
(a) In fever. Here it is often simply increased frequency, the 
breaths being deeper, but sometimes, also, we notice that they become 
somewhat labored (without its being a question of complication of the 
thoracic organs). The amount of quickening of the respiration varies 
very much, according to the nature of the disease and with the indi- 
vidual. Nervous persons often breathe remarkably rapidly in fever; 
with children, respirations as high as sixty or more to the minute 
have often been observed. Nevertheless, in fever every case of marked 
increase in frequency of breathing must lead to an especially careful 
examination of the thoracic organs. The cause of fever-dyspnoea is, 
moreover, not alone the increased formation of C02, but is also the 
result of the irritation of the respiratory centre by the warmer blood. 
Fever-dyspnoea may be increased by association with that caused 
by diseases of the respiratory apparatus. 
(b) In all conditions that are connected with pain in breathing. 
Here belong all diseases of the pleura or the lungs in connection with 
the pleura (especially croupous pneumonia), inflammatory affections 
of the diaphragm (trichinosis), of the peritoneum (especially the 
diaphragmatic peritoneum), fracture of ribs, and severe rheumatism 
of the muscles of the thorax. 
Rightly to explain this form of dyspnoea is often of the greatest 
therapeutic value; it may sometimes (not always) be relieved by a 
narcotic. 
(c) In diseases of the bronchial tubes, which narrow or close the 
tubes by the secretion or exudation. Here belong all forms of bron- 
chitis, and also bronchial asthma. In the latter disease there is much 
less swelling and exudation than from bronchial spasm of neurotic 
origin, which chiefly causes the dyspnoea. No doubt spasm of the 
diaphragm is associated with this sometimes, which causes a prolonged 
inspiratory expansion of the lungs, and, of course, this increases the 
dyspnoea. 
Where there is bronchial asthma and croupous bronchitis in addi- 
tion to laryngeal croup, there is generally very severe dyspnoea with 
quicker and very forced respiration. Simple catarrh of the bronchial EXAMINATION OF THE RESPIRATORY APPARATUS. 
tubes generally leads to quickening of the respiration without the breaths 
being deeper; for a complete closure of the bronchial tubes cuts off a 
large section of lung, and so breathing is entirely lost in this section, 
as in capillary bronchitis, especially in children. The consideration 
of this condition properly belongs to the next section, in that it results 
in the lung-tissue itself becoming diseased. 
(d) In all conditions in which the breathing surface of the lungs is 
diminished or the volumetric variation of the lungs, which is necessary 
for respiration, is disturbed. These are: 
All diseases of the lungs : the different forms of pneumonia, oedema 
of the lungs, infarction, tuberculosis, emphysema (this not only on 
account of the diminished breathing surface, but also the loss of 
elasticity, and hence diminished contraction of the lungs during 
expiration); the different forms of pleurisy with exudation, pneumo- 
thorax ; tumors in the chest-cavity which diminish its capacity; abdom- 
inal affections which push up the diaphragm ; marked Jcypho-scoliosis 
with the resulting deformity of the chest and consequent unfavorable 
condition for breathing; paralysis of the muscles of respiration ; and 
also tonic and clonic spasm of the muscles of the chest, as in tetanus 
and epilepsy, which may occasion the most severe dyspnoea. 
As is evident, these diseases differ widely from one another. Those 
that diminish the chest-cavity, if they are inconsiderable, sometimes 
merely restrict the inspiratory expansion of the chest, and so affect 
the lungs; but, if they are marked, then they directly compress the 
lungs, and hence diminish their breathing-surface. 
O’ O 
It has been already stated that in a number of these conditions the 
need of oxygen may be met by a substitution of diaphragmatic 
breathing in place of the diminished costal breathing, and vice versa. 
It is, of course, very calamitous when there is a combination of several 
causes of dyspnoea, as, for example, when a subject of kypho-scoliosis 
has an abdominal affection which presses up the diaphragm, or has 
inflammation of the lungs. 
Accommodation, adaptation, plays an important part in many 
chronic diseases which occasion dyspnoea. This becomes most 
strikingly evident if we compare the terrible dyspnoea of beginning 
pneumo-thorax with the relatively comfortable condition of patients 
who have continually at their disposal for breathing only one 
lung, or even only a part of a lung. In many of these cases it is 96 
SPEC I A L DIA G NO SIS. 
easy to understand this accommodation; chronic cases, especially 
phthisical patients, who here come prominently into view, are generally 
anaemic, and therefore require, at least when quiet, only a very small 
interchange of gases in the lungs; but every effort at muscular exer- 
tion immediately causes dyspnoea. On the other hand, “lung dys- 
pnoea” is generally considerably increased in one who has an acute 
disease, by the fever. Likewise, there are cases where we cannot 
dispense with the idea, which formerly was not clear, of an “accom- 
modation.” 
Dyspnoea farther occurs: 
(e) In diseases of the heart which cause stasis of blood in the lung 
circulation. These are mitral insufficiency or stenosis of the left 
auriculo-ventricular opening; also heart-failure, which may occur in 
all diseases of the heart. 
It is evident that slowing of the capillary circulation of the lungs 
diminishes the interchange of gases in the whole quantity of the 
blood; but generally we have, beside this, a diminution of the alveolar 
lumen, from the capillaries being swollen, especially in the so-called 
brown induration of the lungs. 
Increased and forced respiration. Forced respiration may at any 
time be associated with rapid breathing by increase of dyspnoea. The 
only exceptions to this are those cases that arise from pain and 
paralysis, both from reasons that are easily intelligible. 
Mechanism of forced respiration. This is, in the most charac- 
teristic way, different from normal breathing, namely, that while the 
muscles of ordinary inspiration and the mechanical conditions of ex- 
piration no longer suffice, inspiration and expiration are assisted by 
the action of the auxiliary muscles of respiration. 
The auxiliary muscles of inspiration are : the scaleni muscles in the 
male (in the female they act even in quiet breathing), as elevators of 
the two first ribs; the sterno-mastoidei draw up the sternum when the 
head is fixed; the pectoralis major and minor, the levatores costarum, 
the serratus post, super., all of which act as elevators of the ribs, the first 
named when the upper arms are fixed. In more severe dyspnoea the 
trapezius, the levator scapula, the rhomboideus, are brought into 
action to elevate the scapula; in severest dyspnoea the extensors of 
the neck assist also, and then we notice the expansion of the alne 
nasi (see under Nose); when the mouth is open the soft palate is EXAMINATION OF THE RESPIRATORY APPARATUS. 
97 
seen to be drawn up during inspiration; and, finally, even those mus- 
cles that dilate the mouth and depress the larynx may be brought 
into action. 
The muscles have very varying degrees of importance, the greatest 
being the work of lifting up the ribs, the sternum, and the shoulders. 
The expansion of the alse nasi as a symptom is not unimportant, but 
really does not at all assist in breathing. 
In expiration the following muscles act in assisting respiration : Of 
first importance are the broad muscles of the abdomen, especially the 
transversus, which compress the abdominal contents, thus pressing up 
the diaphragm ; further, the quadratus lumborum and serratus post, 
infer., which draw down the lower ribs. 
It is easy to distinguish the moderate drawing-in of the thorax and 
epigastrium which occurs in normal passive expiration from the active 
expiration of dyspnoea, by the energy of the act in consequence of 
muscular contraction. Moreover, the contraction of the broad mus- 
cles of the abdomen is plainly to be seen. 
Patients with forced respiration exhibit still other appearances 
which partly stand in direct relation to the increased energy of the 
breathing. 
That the thorax may be entirely easy and that the auxiliary mus- 
cles may be able to act better, patients prefer the upright posture to 
lying down (Orthopnoea, p. 32)—indeed, in very severe dyspnoea, they 
may not be able to lie down at all; the arms are fixed in order that 
the upper arms and shoulders may furnish a fixed point for the 
auxiliary muscles; and, in order that the sterno-cleido-mastoidei may 
act most efficiently in assisting respiration, the neck is stretched and 
the face somewhat elevated. 
Not infrequently the breathing is audible; in forced respiration, it 
is panting, groaning. In stenosis of the larynx or trachea we hear 
the before-mentioned hissing—stridor laryngeus vel trachealis. The 
voice is weak, often suppressed ; the patient speaks with short, un- 
natural pauses; broken speech. 
Here belongs the so-called inspiratory “drawing-in.” Even in 
healthy people we sometimes notice with forced respiration that the 
lower intercostal spaces in the beginning of inspiration sink in some- 
what (a simple flattening-out takes place from the contraction of the 
intercostal muscles). Drawing-in that is more marked and is pro- 98 
SPECIAL DIAGNOSIS. 
longed during the whole of inspiration, under all circumstances is 
pathological; with very yielding thorax (children), even the ribs and 
the lower part of the sternum may share in the condition. It shows 
that the lungs do not follow the motion of the thorax—that, there- 
fore, the air is prevented from entering the alveoli. 
Hence, all forms of stenosis of the larynx (especially frequent with 
croup) and of the trachea (likewise both bronchi) cause inspiratory 
drawing-in of both sides, most markedly of the lower part of the 
sternum, the lower ribs, and intercostal spaces; if the stenosis is very 
marked, the condition is extended to the upper ribs and intercostal 
spaces, as far as the jugular and supra-clavicular spaces. Stenosis of 
a bronchus causes inspiratory drawing-in of one side when the 
breathing has a certain degree of force, beside “lagging” of the 
affected side. Bronchitis of the smaller tubes (especially in children) 
may occasion inspiratory drawing-in in a more circumscribed way, as 
only the lower part upon one side. But we may also sometimes see 
an extended, very marked drawing-in Avith extensive capillary bron- 
chitis (with atelectasis, broncho-pneumonia) in children. 
There are two reasons why stenosis of the upper air-passage causes 
the drawing-in to be greatest at the lower part of the chest, and which 
may also affect the ribs of this part: first, the air entering the lungs, 
reaches the lowest part, as being the furthest removed, last; secondly, 
if the thorax is yielding, it is drawn in by the contraction of the dia- 
phragm ; for if the diaphragm cannot descend when it contracts, 
since the lung does not follow it, then the dome of the diaphragm 
becomes a fixed point, and the thorax in the neighborhood of the 
insertion of the diaphragm is drawn inward and upward. 
Also, expiratory bulging sometimes takes place in the supra- 
clavicular depression, especially in marked emphysema of the upper 
part of the lung, as, for example, after whooping-cough (see p. 76); 
or in the upper intercostal spaces, when large cavities are adherent to 
the chest-wall, as in pulmonary phthisis. With this appearance there 
is a strongly-marked pressure in the thorax ; hence it is observed only 
in very forced expiration, and especially in strained coughing. 
Very frequently we find in cases of lung-cavities with expiratory 
bulging—especially frequent in the second intercostal space—the 
affected intercostal muscles very much shrunken, sometimes fatty 
degeneration of them. EXAMINATION OF THE RESPIRATORV APPARATUS. 
99 
Finally, the picture of such an unfortunate will he completed by 
the expression of subjective anxiety; sometimes of the most fearful 
agony ; by the peculiar expression of the eyes, the consequence of the 
dilatation of the pupils which always exists in dyspnoea (see Nervous 
System); lastly, by the cyanosis and frequent cold sweat (q. v.). 
According as inspiration or expiration, or both, are difficult, or the 
auxiliary muscles of respiration are brought into action, we distinguish 
an inspiratory (pure or preponderating), an expiratory (pure or pre- 
ponderating), a mixed, dyspnoea. 
Purely inspiratory dyspnoea exists with paralysis of the posterior 
crico-arytenoid muscles (dilators of the glottis); here expiration is 
free, since the escaping current of air presses the vocal bands apart; 
on the other hand, the in-rushing air brings them, like valves, in 
contact, and hence inspiration may be hindered even to threatened 
suffocation. Tumors and foreign bodies may, moreover, be sometimes 
so located as, by valve-like closure, almost completely to preclude 
inspiration. Further, inspiratory dyspnoea occurs with increased 
activity of other muscles when certain respiratory muscles are para- 
lyzed (as, for example, in paralysis of the diaphragm, increased 
thoracic breathing is accomplished by the auxiliary muscles). 
Purely expiratory dyspnoea is observed with movable tumors 
situated below the glottis; the out-going air pushes them against the 
rima glottidis, but in expiration they are drawn to one side. 
Moreover, a preponderating expiratory dyspnoea is peculiar to 
bronchial asthma (in addition to the always present inspiratory). 
Probably we correctly assume that the smallest tubes, spasmodically 
narrowed, are still more compressed by the pressure in the thorax 
during expiration. 
The disease that most frequently causes expiratory dyspnoea is 
emphysema of the substance of the lungs; the diminished power of 
expiration is chiefly from the loss of elasticity of the lung-tissue, the 
contracting force of the lungs ; generally there is, besides, diminished 
thoracic breathing—since, if the thorax is too rigid to expand during 
inspiration, then it is also not contracted, either by virtue of its own 
elasticity or the traction of the lungs. 
Bronchial asthma of long duration always causes emphysema of 
the lungs; then, of course, there is a twofold cause of expiratory 
dyspnoea. 100 
SPECIAL DIAGNOSIS. 
In genuine emphysema of the lungs there is always also well-marked 
inspiratory dyspnoea, on account of the atrophy of lung-tissue and 
capillaries of the lung, and hence diminished breathing-surface. More- 
over, it will be understood that whenever there is expiratory dyspnoea, 
if the difficulty of expiration is not equalized by forced or prolonged 
expiration, there must result a simultaneous inspiratory dyspnoea ; 
there is a diminished interchange of gases in the lungs resulting from 
the incompleteness of the act of expiration; there is a demand for 
oxygen, and hence forced inspiration. There is no expiratory dyspnoea 
with vicarious emphysema of the lungs. 
Mixed dyspnoea—that is, where it is manifest in equal degree in 
inspiration and expiration—is by far the most frequent. It accom- 
panies all the diseases of the respiratory organs not mentioned here, 
also diseases of the heart, and fever. 
Palpation of the Thorax 
This method of examination has, on the one hand, an independent 
value, and on the other it confirms and, with sufficient practice, even 
adds to the results of inspection. It is, therefore, very wrong to omit 
it. It is indispensable on account of its simplicity, and because, like 
inspection, it quickly furnishes a result in a general way; moreover, 
its result is often decisive in differential diagnosis, in a certain direc- 
tion, relative to vocal fremitus. 
Palpation of the thorax, with reference to the respiratory organs, is 
made for the purpose of ascertaining : 
1. Possible pain upon pressure. 
2. The respiratory movements of the thorax, especially as to 
symmetry. 
3. Any friction-sounds or rfiles that may be felt. 
4. Vocal fremitus. 
In addition, there are some rare appearances that are not unim- 
portant in differential diagnosis. 
The examination with reference to the first and second points may 
be combined with inspection ; the trial of the third point may suitably 
be settled during auscultation, either before or after. Ordinarily we 
test the vocal fremitus after the completion of percussion and auscul- EXAMINATION OF THE RESPIRATORY APPARATUS. 
101 
tation, hence we conclude the physical examination of the thoracic 
organs by noticing the vocal fremitus. 
We pause here, in the course of the examination, and only speak of 
the first and second points; the two others will be introduced under 
the heads of Percussion and Auscultation. 
1. Pain caused by Pressure upon the Thorax. 
In diseases of the chest pain is common, accompanying the diseases 
or elicited by pressure. In case it really refers to an internal organ, 
and not to the chest-wall, it indicates disease of the pleura or compli- 
cation with the pleura. By carefully feeling the intercostal spaces 
with the tips of the fingers, the region that is tender on pressure may 
be very exactly defined; it is generally less extensive than the terri- 
tory of spontaneous pain, since the latter ordinarily “radiates.” 
This tenderness sometimes exists with exudative pleuritis, but in 
this disease it is often wanting ; more frequently it is seen in croupous 
pneumonia which involves also the pleura, and also in phthisis. In 
the latter disease it generally depends upon callous thickening of the 
pleura. 
It is very important, but also frequently difficult, to distinguish 
between pleuritic pains produced by pressure from those arising in 
the soft parts of the chest-wall or the ribs. Phlegmonous inflam- 
mations and abscesses of the chest are, of course, easily recognized. 
Pain proceeding from a rib is generally characteristic; quite circum- 
scribed, it occurs only when pressure is made upon the affected rib 
(caries, periostitis, over fractured ribs, slight pressure); also, rheu- 
matism of the chest-muscles occasions no great difficulty, at least when 
it is jn the superficial muscles; the muscle is ordinarily sensitive if 
pressed between two fingers. On the other hand, it is often not easy 
to distinguish between pleuritic pain and intercostal neuralgia; the 
latter can sometimes be distinguished by Yalleix’s points of tender- 
ness, which stand wholly out of relation to deep breathing or cough. 
(See Nervous System.) It is important to remember that neuralgic 
intercostal pain may be present in affections of the pleura, as in 
tubercular thickening of the pleura in the lower part of the thorax. 
In short, we ought, in the absence of other indications which point 
to a disease of the internal thoracic organs, to refer a pain produced 102 
SPECIAL DIAGNOSIS. 
by pressure upon the thorax rather to something else than to the 
pleura; only continuous pain, always at the same places, over the 
upper sections of the lungs, arising either spontaneously or from 
pressure, is suspicious; this may indicate irritation of the pleura 
from tuberculosis of the apices. 
Fractures of the ribs are recognized by crepitation, and also by 
dislocation of the fragments; also, often by the fact that pressure 
at any part of the broken rib causes pain at the seat of fracture. 
Moreover, fracture of the rib may cause pleurisy. Caries of the rib 
may also excite pleurisy. Then, in recognized pleurisy, caries may 
be proved to be the cause by the circumscribed pain elicited by 
pressure upon the rib. 
It must also be mentioned that if a purulent pleuritis breaks out- 
ward (empyema necessitatis), it causes peripleural inflammation, and 
with this there is pain upon the slightest pressure, besides swelling, 
redness, heat, oedema of the skin, and, lastly, fluctuation. 
To the above-mentioned conditions revealed by palpation of the 
thorax must be added pulsations of the heart felt through a portion 
of infiltrated lung ‘lying over the heart, and also in the so-called 
empyema pulsans (empyema pulsatile). 
This occurs when there is an accumulation of pus lying over the 
heart, almost always upon the left side, to which the pulsation of the 
heart is communicated. In some cases it is very difficult to distin- 
guish it from aneurism of the aorta. It can only be done by taking 
a comprehensive view of the case. (We must be on our guard in 
puncturing or in making an exploratory puncture.) Sometimes pulsa- 
tions are even found on the left lower posterior portion of the thorax. 
Usually several causes combine to produce the pulsation: paresis of 
the intercostal muscles, higher pressure of the exudate, direct contact 
with the heart, lastly, as indispensably necessary, powerful action of 
the heart. 
2. Testing the Movement during Respiration. 
With special reference to symmetry, with some practice, palpation 
is a most excellent method. It gives more exact results than inspec- 
tion, and makes the further examination easier, in that it directs the EXAMINATION OF THE RESPIRATORY APPARATUS. 
103 
attention immediately to the diseased side or the region of the thorax 
affected. 
The respiration is examined by placing the two hands alike upon 
the two sides of the chest. In order to test the breathing of the upper 
divisions of the lungs, place the hands flat in front, gradually diverging 
below, so that the tips of the fingers reach to the lower border of the 
clavicle. For examining the lower parts, spread out the hands with 
the thumbs extended so that the thumbs rest upon the angle of the 
ribs. Behind, only the respiration of the lower lobes will be tested 
by laying the flattened hands, with the thumbs extended, upon the 
surface in such a way that the points of the fingers reach about to the 
middle axillary lines. 
For exact examination, it is necessary, if possible, for the physician 
to be exactly before or behind his patient; the latter position espe- 
cially is often difficult when the patient sits in bed; it is best, then, to 
have the patient slide somewhat down toward the foot of the bed. 
When palpation is well performed, “lagging” over the apex in 
beginning phthisis, or the “lagging” of the lower part of one side in 
pneumonia, pleurisy, infarction, etc., is recognized with great exact- 
ness ; this is of great importance, because, as I have already said, 
“ lagging ” may be in many diseases for some time the only symptom. 
We may also test the action of the diaphragm 'with reference to its 
symmetry by palpation. We place the hands so that the finger-tips 
cover the epigastrium ; in this way may be detected the lack of con- 
traction upon one side (pleuritis diaphragmatica, local peritonitis, 
paralysis of one phrenic nerve). Failure to contract upon both sides 
is, of course, seen at once. 
GENERAL AND PRELIMINARY REMARKS REGARDING PERCUSSION.1 
In daily life we learn on every hand that bodies of different physical 
structure give forth different sounds when struck. We also sometimes 
strike an object in order to determine from the sound it gives forth 
what its physical condition is—that is, whether it is hollow or solid. 
1 In this chapter the author follows in many ways, but not entirely, the views and 
methods of presentation of Weil, whose personal pupil he was for ten years and whose 
teachings, in the courses upon percussion which the author has conducted for four 
years, were in many respects a rule of conduct to him. 104 
SPECIAL DIAGNOSIS. 
This is the principle upon which percussion is practised on the human 
body; from the sound elicited by the blow, we judge of the physical 
condition of the part which lies beneath the covering of the body 
within the sphere of our percussion-stroke. 
Hence, percussion gives direct information regarding organs or 
parts of organs which lie approximatively near to the surface of the 
body; in general, by this method, we penetrate only to the depth of 
five, or, at most, seven cm. 
1. History and Methods. 
The honor of the discovery of percussion belongs to a physician of 
Vienna, named Auenbrugger; the paper in which he made known 
his method appeared in 1761 under the title, Inventum novum ex 
percussione thoracis humaniut signo abstrusos interni pectoris morhos 
detegendi. For almost half a century Auenbrugger’s discovery was, 
on the one hand, declared to be without importance, and, on the 
other, was ridiculed, until the year 1808, when Corvisart, body 
physician to Napoleon I., emphatically revived and largely improved 
it by a translation into French, with a commentary. Then the truth 
began really to prevail, especially by the influence of Piorry in France 
and Skoda in Vienna. The former was the founder of topographical 
percussion. During fifty years the method gradually became common 
professional property. Further, and up to the most recent time, it 
experienced improvement and explanation of every kind, especially 
by Wintrich, Traube, Biermer, Gerhardt, and Weil. For several 
years, especially since the labors of Veil, it appears that a degree of 
certainty has been reached in regard to this proceeding. 
In the course of the development of percussion several methods of 
striking the body have been discovered, most of which still have value 
to-day. 
Auenbrugger struck directly upon the thorax with the tips of the 
fingers: direct or immediate percussion. 
Piorry discovered indirect or mediate percussion, in that he placed 
under the percussing finger a small plate of ivory—a pleximeter. 
Wintrich introduced the percussion-hammer, which had already 
been sometimes used by Laennec and Piorry, in place of striking with 
the fingers. EXAMINATION OF THE RESPIRATORY APPARATUS. 
105 
But finally, in more recent times, the method of indirect percussion, 
without instruments, has very widely prevailed. The index- or middle 
finger of the left hand is used as the pleximeter, which is placed upon 
the spot to be percussed, and it is struck with the index- or middle 
finger of the right hand (finger-percussion). 
Of these methods, that of Auenbrugger, the direct, has been 
dropped as being less practical, while now-a-days the three in use are 
all examples of the indirect method: 
I. Finger-percussion. 
II. Finger-pleximeter percussion. 
III. Hammer-pleximeter percussion. 
All three are practised and taught by good teachers of percussion; 
all three, in reality, yield equally exact results; the secret of their 
value lies in their application. 
One who thoroughly understands finger-percussion can very quickly 
acquire a knowledge of the two other methods. Hence, I am most 
heartily in accord with those who, in their teachings and writings, 
emphatically recommend their students at first to practise the finger 
method of percussion exclusively. 
I think it superfluous for me here to go into particulars regarding 
the technique ; these can only be made clear in the clinic; but I must 
remark that the greatest difficulty in finger-percussion is in holding 
the percussing finger crooked, like a hammer, and, at the same time, 
having the wrist-joint move quite freely. Also, the numerous forms 
of percussion-hammers and pleximeters (the latter of glass, ivory, 
hard rubber, and wood, in different forms) cannot be described here. 
It appears to me that the hammer with a wooden handle and a metal 
head, not too heavy, is rather to be recommended; likewise, a 
medium-sized oblong ivory pleximeter, about two cm. wide, and the 
so-called double pleximeter of Seitz. Even to those who practise 
finger-percussion this last is recommended for percussing the supra- 
clavicular depressions. There is one point of great importance : that 
the individual should, as much as possible, be homogeneous in his 
method and in accord with it throughout: in percussing, if the finger 
method is used, he should always strike upon the index- or always 
upon the middle finger of the left hand; the pleximeter, if that is 
used, should always be used in exactly the same way, etc. Nothing 
is worse than frequently to change methods or instruments, be the 106 
SPECIAL DIAGNOSIS. 
change ever so slight. But if physicians, as is true of many, are 
accustomed at certain parts of the thorax wdiere it is difficult to use 
finger-percussion, regularly to employ a pleximeter, or both pleximeter 
and hammer, there is no objection to this twofold method ; only he 
must be master of the two methods wThich he employs. It is well, 
also, always to repeat the same method upon the same parts of the 
body. 
2. Qualities of Sounds. 
By our striking upon the body we cause a sound. This percussion 
sound differs according to the condition of the part of the body which 
is shaken by our percussion blow. 
Two principal sentences contain the foundation of percussion : 
1. When we strike upon a solid portion of the body entirely free 
from air we elicit a toneless sound of the least possible intensity and 
duration; it is designated as “absolutely deadened,” or as a “thigh 
sound,” since it is like that caused by striking upon the thigh. 
[Deadness: I have frequently used this word and its derivations as 
giving a useful and accurate discrimination from the familiar English 
terms, flatness, dulness. Deadness is more than dulness.] 
2. If organs containing air lie in the range of our percussion blow, 
then these give forth a sound of a certain intensity, duration, and 
tone ; this sound is designated as “ clear.” 
The clear sound of organs containing air may have only a different 
degree of intensity or clearness. Its intensity depends upon : 
1. The length of the oscillation. It is, therefore, stronger, the 
stronger the blow; and, moreover, the nearer the organ containing 
the air is to the percussing finger—that is to say, the less the per- 
cussion-stroke is weakened by the tissue, as fat, muscles, bones [also 
clothing], intervening between it and the air-cavity. 
2. By the volume of the parts of the air-containing tissue set in 
motion. 
Hence, with equal strength of percussion, wre have in different parts 
of the body different intensity and different clearness of sound, 
according to the greater or less amount of air wdiich the tissues con- 
tain, or according to the nearness or distance of the air-cavity from 
the surface of the body—that is, from the percussing finger. 
It is according to the change of these conditions in the human EXAMINATION OF THE RESPIRATORY APPARATUS. 
107 
body that we obtain the different clear sounds; we may meet every 
grade from absolute deadness to a very clear—the peculiarly clear— 
sound. These intervening grades are designated as “ relative dead- 
ness ” (that is, in comparison with a real clear sound it is dead). 
Fig. 16. 
Fig 17. 
Fig. 18. 
Lung 
Lung 
Limy 
Fig. 16.—Diagrammatic representation of the difference between weak and strong 
percussion under circumstances that are otherwise alike. The length of the arrows 
corresponds with the strength of the percussion; the size of the triangle designates the 
volume of the portion of lung affected by the blow, and, at the same time, the intensity 
of the sound. 
Fig. 17.—Representation of the difference of result with a percussion-stroke of equal 
strength, but when the thickness of the covering of the body varies. Clear sound, 
relatively deadened sound, no resonance—that is, absolutely deadened sound. 
Fig. 18.—Representation of the effect upon percussing over a thick covering of the 
body. Over the apex and border of the lung the sound is less intense than over the 
rest of the lung, on account of the diminished volume of lung-tissue, the percussion- 
stroke having the same force, and this tolerably strong. 
Absolutely dead or dull sounds differ according as they proceed 
from muscle, bone, etc. We cannot ivholly ignore these differences, 
as if not existing. 
On the other hand, the clear sounds fall into the two following 
important divisions: 
1. Tympanitic sound (the name is from tympanon; the kettle- 
drum or tymbal, not exactly, but very nearly, produces it). This 
approaches a musical note, so that we can exactly define its place on 
the musical scale, and it is actually shown formed from regular oscil- 
lations in the rotating reflected image of the sensitive gas-flame. It 
shows, also, according to the different conditions to be described later, 
sharply definable differences of pitch. A tympanitic sound such as is 
frequently met with in the body can easily be produced if one strikes 108 
SPECIAL DIAGNOSIS. 
upon his own cheeks, which have been inflated, but not too strongly 
stretched. 
2. The clear sound called non-tympanitic, also more briefly “lung- 
sound”—a very practical designation. This has no sound definable 
by its pitch, but yet it may be known in general as “ high ’’ or 
“ deep.” 
Hence, both the tympanitic and the non-tympanitic sound have a 
certain intensity and duration; but, while the latter only approxi- 
may be designated as high or deep, the pitch of the tone 
brings it toward the tympanitic. Both occur in a very high degree 
of clearness and in all degrees of relative dulness (“relative deadness” 
or “dull tympanitic sound”), even to an often unnoticeable transition 
to absolute deadness. 
1. In the foregoing, we give those designations which, in late 
years, we have without exception employed in our instruction on per- 
cussion. Regarding the large number of other terms for qualities 
of sound which the older teachers of percussion have introduced, 
but which, to the great advantage of clearness of mutual under- 
standing, have more and more disappeared from the literature of the 
subject, we refer to the classical work by Weil on Topographical 
Percussion. We have in fact, as will be seen, followed the nomen- 
clature proposed by Weil, with only one exception ; the term dull is 
avoided, and in place of it we have employed the expression (which, 
it is true, is somewhat circumstantial) “absolutely smothered,” or 
“ thigh-sound.” This was done because, over and over, we found 
that pupils were reminded of the “dull sound of the kettle-drum,” 
“ dull roaring,” etc., and, hence, were confused ; in short, because the 
expression does not grammatically designate what is intended in 
teaching percussion. “Absolute smothered sound ” has this advantage 
—that, to the beginner, it is a new association of words; it cannot, 
therefore, so easily occasion confusion. Moreover, the expression 
always summons one to a more exact testing as to whether, at the 
particular place, there is really absolute or only relative deadness; 
and every teacher of percussion knows how much this is needed—that, 
for instance, in percussing in the lower part of the right mammillary 
line the so-called relative liver-deadness is spoken of as absolute 
deadness. 
2. For the .sake of brevity and clearness, we also have really not EX A MINA TION OF THE RESPIRA TOR Y A PPA RA TUS. 
109 
gone into the many ideas and the manner of explaining them pre- 
sented by others, on this subject, which was formerly quite confused, 
and is even yet difficult. But we cannot abstain from citing here the 
three fundamental sentences from Skoda : 
(a) All fleshy parts, not containing air (except tense membranes 
and filaments), also fluid accumulations, give an entirely dead and 
empty, scarcely distinguishable percussion-sound, which can be demon- 
strated by striking upon the thigh. 
(h) Only bones and cartilage when directly struck give a peculiar 
sound. 
(c) Every sound which we elicit by percussing the thorax and 
abdomen, and which differs from the sound of the thigh or bone, 
comes from air or gas in the chest or abdominal cavity. 
3. The acoustic character of the clear, and that of the relative or 
absolutely deadened, sound is clearest expressed if we say: the 
deadened sound is a very slight noise of short duration; the clear, 
non-tympanitic sound is a noise louder and of longer duration, with a 
trace of being a note; this latter, however, is so little apparent that it 
either cannot at all be recognized, or only in general, as to its being 
high or deep. In the tympanitic sound, with the discordant mingling 
of tones, a tone predominates of such a character that it is plainly 
heard and its musical pitch distinguished. 
The Conditions that determine the Quality of the Sounds arid their 
Production in the Body.— The Feeling of Resistance. 
The tympanitic sound exists : 
1. Over cavities that contain air or gas, if they are surrounded by 
walls moderately smooth and capable of reflexion, and if they com- 
municate with the external air through an opening, the walls being 
stiff1 or yielding. The intensity of the tympanitic sound thus pro- 
duced depends upon the conditions (mentioned on page 107) influ- 
encing the intensity of clear sounds in general. The musical pitch of 
the sound is determined by : 
(a) The size of the communicating opening; the larger it is the 
higher the tone. 
(b) The volume of the cavity containing the air; the larger, the 
deeper the tone. 110 
SPECIAL DIAGNOSIS. 
(c) If the walls are yielding, membranous, by their tension; lax- 
membranous Avails make the tone deeper. 
2. Over air-containing cavities with yielding, membranous walls, if 
the cavities are closed—that is, do not communicate with the external 
air; only the Avails, and with them the enclosed air, must not be too 
tense. Here the pitch is determined only : 
(a) By the volume of the air-cavity. (See above under b.) 
(b) By the tension of the wall. (See above under c.) 
But if the tension of the wall (and Avith it the enclosed air) of a 
closed cavity reaches a certain degree, then the percussion-tone be- 
comes clear and non-tympanitic. LikeAvise, cavities that are closed 
on all sides by stiff Avails give a non-tympanitic sound. 
The tympanitic sound mentioned under 1 is called “open,” that 
under 2 “closed;” the former has a much more pronounced tym- 
panitic character—that is, the pitch of the tone appears more dis- 
tinctly than the latter. 
When the cavities are cylindrical, communicating outward by an 
opening, the pitch of the tone is determined by the length of the 
cylinder ; the longer it is, the higher the tone. Some experiments,, 
illustrating Avhat has been said, are easily performed and are strongly 
recommended to beginners : Take an empty Florence flask and percuss 
upon its mouth, either directly or hold the pleximeter lightly over its 
mouth, then diminish the quantity of air by partly filling the bottle 
with Avater; if possible, also compare the differences of pitch wdiich 
are produced by different lengths of the neck of the bottle, other con- 
ditions remaining the same. Percuss a rubber gas-bag which is at 
first only moderately inflated, then more tensely, with air. In this 
way one can very easily illustrate the most important of the laws that 
have been mentioned. 
3. Finally, tympanitic sound occurs under quite other conditions, 
namely, in certain conditions of the lungs Avhich have this in common 
—that they probably accompany a Avant of tension of the lung-tissue. 
Referring to what Avas said above under 1, Ave add that the open 
tympanitic sound occurs in the human body, under normal relations, 
when the mouth, larynx, and trachea are percussed; pathologically, 
when percussing lung-cavities which are in open communication Avith 
the air-passages ; further, if in consequence of shrinking of the apices 
of the lungs, the trachea, or in consequence of shrinking or thickening EXAMINATION OF THE RESPIRATORY APPARATUS. 
111 
of the lung where it covers a fissure, a primary bronchus, would be 
reached by the percussion-stroke, and would, therefore, be itself per- 
cussed ; and, finally, the open tympanitic sound sometimes occurs with 
open pneumothorax. 
Herewith we notice a peculiarity of this sound, which truly stands 
in a certain (although still not altogether clear) relation to the laws 
above enunciated regarding the pitch of the open tympanitic sound: 
the sound is higher with the mouth open, deeper with the mouth 
closed. If this occurs when percussing a lung-cavity (or, also, in 
open pneumothorax) it is called Wintrich's change of sound; if on 
percussion of the trachea or a primary bronchus, then we speak of 
Williams s tracheal tone. 
In addition to what was said above under 2, we remark that in the 
human body the closed tympanitic sound is heard over the stomach 
and bowels; in rare cases over closed pneumothorax; and, finally, 
in pneumopericardium. 
Now, while it is difficult to apply the rules regarding the change of 
pitch to the open tympanitic sound, since the cavities of which we are 
speaking are of most extremely complicated form and have very dif- 
ferent wTalls, the influence, on the one side, of the volume of the cavity,, 
and on the other, the influence of the tension of a membranous wall, 
are shown over the stomach and intestines. A greater volume, as in 
the stomach and colon in comparison with that of the small intestine, 
deepens the sound; while increased tension heightens it, and even 
renders it non-tympanitic. 
We add to what was said above under 3, that the normally clear, 
non-tympanitic sound over the lung becomes tympanitic if the tension 
of the lung-tissue diminishes—i. e., if the lung, following the pull of 
its elasticity, is able to retract. This is true in all cases where the 
pleural cavity is diminished, hence, especially in exudative pleuritis. 
The tympanitic sound is found where the retracted lung lies against 
the thorax. All the other changes of the thoracic and abdominal 
cavities, working in the same way which have been before mentioned, 
occasion these phenomena. 
Probably, for the same reason—i. e., in consequence of the relaxa- 
tion of the lung-tissue—a tympanitic sound is heard in croupous 
pneumonia during the stages of engorgement and of resolution; in 
oedema of the lungs ; and, finally, in the neighborhood of thickened 112 
SPECIAL DIAGNOSIS. 
parts of the lungs. In the latter relation the tympanitic sound over 
the apices of the lungs in the beginning of tuberculosis, where lung- 
tissue containing air is situated between groups of small tubercular 
masses, is of some diagnostic importance. 
In these cases we must assume that the lung-tissue has become 
loose and ductile, and has, therefore, lost its power of stretching. It 
has not yet been established that this explanation is correct. 
Metallic sound. We thus designate such a variety of tympanitic 
sound by which a metallic character, produced by a very high over- 
tone, either occurring with the sound itself, a peculiar metallic tone, 
or it is produced afterward, metallic after-sounds. The metallic sound 
exists over not too small, very smooth-walled, regular cavities, both open 
and closed. Hence, we find it sometimes over the normal stomach, 
intestines, and sometimes over lung-cavities, in pneumothorax, pneumo- 
pericardium. It is best brought out in percussing with the so-called 
rod pleximeter, or in percussion-auscultation (Heubner). (See later.) 
The clear non-tympanitic sound occurs where, “ within the sphere 
of action of acoustics, there is found tissue containing air, but whose 
capacity for vibration is more diminished than in those cases in which 
the tympanitic sound occurs’’ (Weil, Handbook of Topographical 
Percussion, 2d ed., p. 35). It is heard over the normal lungs—a 
remarkable fact, since a lung that has been removed from the body, 
even if it is inflated to a volume corresponding with the condition 
during life, gives a sound that more nearly approaches the tympanitic 
than the non-tympanitic. Why a lung in the thorax loses wholly the 
tympanitic character of its sound is not entirely clear; but we cannot 
help thinking that, in some way or other, the chest-wall is the cause. 
The intensity of this lung-sound is sufficiently explained by the 
rules given above; its pitch, only approximately recognizable, is 
chiefly influenced by the tension of the lung-tissue. We have men- 
tioned above that retracted and relaxed lung-tissue gives a tympanitic 
sound; if the tension is only slightly diminished, then there is only a 
very deep {and abnormally clear) non-tympanitic sound. This occurs, 
also, in emphysema of the lungs, but sometimes in exudative pleurisy, 
and also in pneumonia in the air-containing, infiltrated adjacent sec- 
tions of the lungs. The transition from the non-tympanitic to the tym- 
panitic sound over the lungs may be thus summarized: According to 
the diminution of the normal tension of the healthy lungs, there takes EXAMINATION OF THE RESPIRATORY APPARATUS. 
113 
place in the thorax a change of the clear non-tympanitic sound to an 
abnormally clear and deep, and, in very marked relaxation, to a 
tympanitic sound. To the above corresponds the fact that in very 
deep respiration, at the height of inspiration, at many points of the 
thorax, the respiratory sound is distinctly higher, while in deep 
expiration it is deeper (“ change of respiratory sound,” Friedreich). 
Moreover, we hear the lung-sound over the stomach and bowels, if 
they are very much inflated with gas, where gas, as well as wall, is 
under marked tension; finally, in entrance of air into the cavities of 
the body, in case their walls are thereby made tense; this especially 
happens in most cases of 'pneumothorax (except that open pneumo- 
thorax frequently gives a tympanitic sound). (See above.) 
The deadened sound. Absolutely deadened or thigh-sound is met 
with “ if only structures that are free from air lie within the sphere 
where the percussion-stroke acts acoustically ” (Weil). Since this, at 
best—i. e., with the strongest percussion—reaches only to the depth 
of six to seven cm., and not so much as this in a lateral direction, 
therefore, in case of only strong percussion, absolutely deadened sound 
Fig. 19. 
Entirely deadened 
Lvntf 
Clear: 
Covering of the body 
Diagrammatic representation of percussion over a thick covering of the body. The 
short arrow indicates weak, the long one strong, percussion. With weak percussion we 
have absolutely deadened resonance; with strong percussion a clear, although less 
intense, sound (indicated by the hatched triangle). 
would, after all, be found where we percussed over airless structure 
of sufficient size, in case an organ containing air was not directly in 
contact with it. If we percuss still less strongly, we should, as a 
matter of course, the sooner receive an absolutely deadened sound. 
In the human body we have next to consider the internal organs 
not containing air, called “ parietal ” if they lie in contact with the 
wall of the body ; and, also, the coverings (subcutaneous fat, muscles, 114 
SPECIAL DIAGNOSIS. 
bones) if they are of sufficient magnitude. Thus, frequently, in the 
neighborhood where the heart is parietal, and, further, where the liver 
also is, even with strong percussion there is absolutely deadened sound. 
Not infrequently, however, especially over the heart, absolute deaden- 
ing does not exist, since the structures containing air lying under or 
near by may be reached chiefly through transmission by the chest- 
wall, though it may be only by its vibration, and may give the clear 
sound belonging to the air-containing structures. 
As regards the skeletal coverings, in abnormally fat persons, and 
in oedematous diseases, these sometimes attain such proportions 
that even strong percussion yields an absolutely deadened sound; in 
normal, moderately fat persons it is only the fossa infraspinata that 
very frequently gives absolutely deadened sound. 
But, further, parietal tumors, and especially fluid accumulations 
in the pleura and peritoneum (more rarely, thickening of the lungs), 
occasion absolutely deadened sound in case they, together with the 
skeletal covering, possess sufficient depth and breadth. 
Moreover, over ribs markedly bowed, as over the point of sharpest 
bending-out of the thorax in kypho-scoliosis, absolutely deadened 
sound may take the place of the lung sound; also, here, often a 
peculiar change of the lung (aplasia) plays some part. 
Relatively deadened sound occurs where air-containing structures 
of only small size are percussed, or where structures containing air 
are only feebly shaken by percussion, or where these two conditions 
are met with together. Thus, a relatively deadened sound is obtained 
with feeble percussion of air-containing structures, while strong per- 
cussion of the same yields a clear sound; the blow reaches only a 
small volume of the air-containing organ, and it moreover causes in 
it oscillations of only moderate amplitude. Likewise, where the 
volume of lung-tissue is small, as over the apices and just over the 
lower border of the lungs, the sound is relatively deadened, and this 
is true even with strongest percussion, since there is here only a small 
portion of air-containing material to be acted upon. Finally, every 
layer of airless tissue which lies over an air-containing tissue or space 
causes a deadening of the percussion-sound of the latter—i. e., a rela- 
tively deadened sound—if the overlying layer is not so thick as to 
cause an absolutely deadened sound. Subcutaneous flit, muscles, 
bones, parietal tumors, thickening of lungs, layers of fluid, callosities EXAMINATION OF THE RESPIRATORY APPARATUS. 
—all these, as overlying airless masses, deaden the sound in proportion 
to their size. 
A special description is required both of parietal and of deeply 
seated airless parts which normally contain air, such as appear 
Fig. 20. 
Relatively dull: 
Clear: — 
No difference in 
clearness: 
Lung 
Lung 
Weak percussion. 
Strong percussion. 
Diagrammatic representation of the value of gentle percussion in determining parietal 
condensation in the lungs. The length of the arrow indicates the strength of the per- 
cussion, the size of the hatched triangle the extent of the vibrations in breadth and 
depth. We notice that weak percussion is better, because it gives a deadened sound 
over the thickening, while over the lung it gives a clear sound. 
especially in the lungs as acute and chronic pneumonic thickenings, 
infarction, and tumors For ascertaining such solidifications it is 
necessary not to percuss too strongly; then we shall plainly make 
Fig. 21. 
Clear 
Absolutely dull: 
Less difference 
in clearness: 
Lung 
Lung 
Diagrammatic representation of the value of strong percussion in determining con- 
densation in the lungs lying at some distance from the surface. The strength of the 
percussion-stroke is indicated by the length of the arrows. The hatched triangle shows 
the extent of the oscillations in breadth and depth. 
Strong percussion. 
Weak percussion. 
out the place where there is air by the difference in sound, if the 
given patch of thickening measures as much as about five cm. in 116 
SPECIAL DIAGNOSIS. 
breadth and two cm. in depth (see Fig. 20). Deposits which are 
located at about three to four cm. in depth, if they are correspond- 
ingly large, may be detected, but only by very strong percussion; 
then we elicit a relatively deadened sound in the midst of what is 
quite normal, as is shown by Fig. 21. 
Sensation of Resistance.—We introduce here the description 
of this symptom, although it really belongs under Palpation, but in 
truth it is most intimately connected with Percussion. 
With the percussing finger (less distinctly with the hammer) the 
examiner forms an opinion of the degree of resistance, or, to express it 
better, concerning the degree of capacity of the parts lying beneath it 
to vibrate. This feeling of resistance is strongest, the power to vibrate 
least conceivable, where it is absolutely deadened, the sound identical 
with the “thigh sound”; hence, normally, where we strike upon thick 
muscle, also bones and muscles; pathologically, it is especially distinct 
over large pleuritic exudations, very thick pleura, solid parietal 
tumors of the chest; over large solid abdominal swellings; and in 
extremely rare cases, in extensive thickening of lungs, where the 
bronchi are completely stopped (as in the so-called “ massive pneu- 
monia" of the French. 
When the percussing hammer is used to ascertain the feeling of 
resistance the index-finger is placed upon the head of the hammer, 
which has always seemed to me a very poor substitute for finger- 
percussion. 
Other authors, as Weil, find a marked feeling of resistance only over 
massive layers of fluid. I have often convinced myself of the presence 
of marked resistance in the cases above mentioned. 
4. Topographical Percussion: Determining the Parietal Boundaries 
of Organs. 
Only of a part of the internal organs can we determine the bound- 
aries by percussion on the surface of the body. The conditions of such 
determinations are these: 
(a) That the given organ be parietal. 
(b) That it yield a sound differing from its surrounding tissues. 
Hence we can mark off the boundaries of a parietal organ that gives 
an absolutely deadened sound from one that gives a clear (tympanitic EXAMINATION OF THE RESPIRATORY APPARATUS. 
117 
or non-tympanitic) sound, as the liver from the lung or stomach, the 
heart from the lung; of a parietal organ that gives a tympanitic 
sound from one that yields a non-tympanitic sound, as the lung from 
the stomach or the intestine; of parietal organs with tympanitic 
sounds of different pitch, as the stomach from the intestines; and 
also, though very seldom, two organs of non-tympanitic sound, in case 
they are of very different pitch, as pneumothorax from lung lying 
against the opposite side. 
But we can never recognize the boundaries between two organs 
giving deadened sound (heart and lungs), nor between the heart and 
fluid effusion in the pleura (see below). 
Method of Determining the Boundary.—Generally we percuss 
from an organ that yields a clear sound toward that which gives a 
deadened sound and upon the line which stands perpendicular to the 
expected boundary-line (hence the pleximeter or the pleximeter-finger 
is placed parallel to the boundary-line). We proceed by long stages 
upon this perpendicular (striking it at intervals of about 3 cm.), 
until the sound has so distinctly changed that we are convinced that 
we are over another organ. Then we define the boundaries by placing 
the pleximeter at shorter and shorter intervals until we have defined 
the boundaries as sharply as possible. This is traced by means of a 
blue pencil. After the boundaries have been determined at various 
points and they have been thus marked, then the points are united in 
a line, which is the boundary-line of the particular organ. The rule 
most important to observe is to percuss very lightly along the border 
of the organ we are trying to locate. 
It is easy to see the reason for this: 1. By strong percussion, 
as of the liver close to the lower border of the lungs, we should at the 
same time disturb the adjacent lung and so would elicit a noticeable 
clear sound, and we should then easily think that we were still over 
the lung. In the same way, in determining the lower border of the 
liver, by strong percussion we disturb the intestine which here lies 
under the thin portion of the liver, and so get a tympanitic tone. 
2. The ear perceives the very slight differences of sound which exist 
upon the border-line (we remember the lower border of the lung, how 
the clear sound yielded by it must have slight intensity) better if the 
sound is itself slight. 
For those who are trained, the simplest method may be recom- 118 
SPECIAL DIAGNOSIS. 
mended, that on approaching the boundary between the two organs one 
should successively percuss the more lightly. 
After this indispensable explanation of the general rules for per- 
cussion, we again take up in succession the methods of examination of 
the respiratory organs. 
PERCUSSION OF THE THORAX, ESPECIALLY OF THE LUNGS. 
1. Methods. 
It is best first to percuss patients who are out of bed in the stand- 
ing posture, and later, if necessary for the front of the chest, lying 
down. Upon bedridden patients the examination of the chest is con- 
ducted with the patient in the dorsal position ; for percussing the 
back, we have the patient sit up. We must then take care that the 
patient sits in a symmetrical position, but with the least possible ten- 
sion of muscles; the head is held exactly straight, and especially in 
percussing the supraclavicular depressions it must not be turned; in 
the dorsal position the arms lie quietly by the side of the thorax. 
Both in sitting and standing the patient bows the back a little, in- 
clines the head slightly forward, allows the shoulders to hang and 
folds the forearms across the chest. Every contracting muscle in- 
creases the thickness of the covering by its swelling and increases the 
impression of dulness; hence contraction of the muscles of the thorax 
must as much as possible be prevented. 
In finger-percussion of the front of the chest with the patient in the 
dorsal position, we approach the bed if possible so as to stand on the 
left side of the patient. From the other side it is not possible to 
place the finger of the left hand, used as a pleximeter, symmetrically 
(see below) upon the two sides in both supraclavicular spaces. 
We proceed in such a way as to compare at every situation the 
percussion-note of points that are symmetrically located. We must 
take particular care to strike exactly upon symmetrical points, other- 
wise the “comparative percussion” has no value. Moreover, since 
we wish to make an exact comparison throughout, we take care also 
not only to percuss at symmetrical points, but to percuss with equal 
strength, and somewhat moderately. 
We first percuss the supraclavicular depressions, first on the right, EXAMINATION OF THE RESPIRATORY APPARATUS. 
119 
then on the left, whereby, in cases where it is of special importance, 
we determine the upper boundaries of the apices of the lungs; then, 
in the same way, the infraclavicular spaces are percussed; on the two 
sides in finger-percussion we must, if possible, hold the pleximeter 
hand in such way as always to have the wrist toward the middle line 
of the thorax and the pleximeter finger pointing outward. 
Then we percuss the third intercostal space right and left, then 
downward only on the right, and usually only in the intercostal 
spaces. We do not further compare it with the left side, since the 
heart lies here, which is percussed by itself. Then follows the deter- 
mination of the right lower border of the lungs according to the rules 
given above regarding the determination of parietal organs. We 
percuss upward, comparing the two sides of the thorax, again in the 
intercostal spaces. When we wish to percuss high in the axillae, the 
arms are to be abducted. Then follows the determination of the 
boundaries of the right and left borders of the lungs in the middle 
axillary lines. Sometimes it is valuable also to percuss from the 
infraclavicular spaces sideward and downward upon a line which is at 
right angles with the course of the ribs. 
In percussing the back we first compare the sound over the apices 
of the lungs, thus completely defining their upper boundaries; then we 
percuss on the right and the left, comparing corresponding intercostal 
spaces as we proceed downward to the lower borders of the lungs. 
Then we percuss on the sides of the spine below the angles of the 
scapulae, comparing symmetrical points. The boundaries of the lungs 
are best determined in the scapular lines. 
In this way the thorax is generally to be percussed. But the 
presence of pathological conditions that require one to be especially 
careful in the examination of certain parts may give the preference to 
special methods of examination. These have been in part already 
mentioned in the general division. They follow directly from what 
was said there. They will be again mentioned in the description of 
percussion in pathological conditions of the lung. 
2. Normal Sound over the Lungs, Trachea, and Larnyx. The 
normal boundaries of the lungs. 
It is shown that in percussion of the lungs in general over the 
normal lung there is elicited a non-tympanitic sound. But this sound 120 
SPECIAL DIAGNOSIS. 
as regards its intensity is individually very different in different 
persons, also, in each single chest it is not alike throughout, but 
exhibits individual regional differences. 
The individual variations arrange themselves first according to the 
amount of fat. Very fat bodies give a less clear thoracic sound, or in 
order to yield a clear sound they must be percussed more strongly, 
requiring perhaps the use of the hammer; but it is evident, as we 
have said, that this is unfavorable for determining the boundaries, 
for which the rule is to employ very light percussion. 
Farther, the percussion-note of the chest differs according to age: 
with children, having a more elastic thorax, as well as with aged per- 
sons with thin structural coverings and somewhat lax or rarefied 
lungs, it is higher in pitch than in persons in middle life. 
But also in the individual thorax the different regions normally 
give different clearness of sound. In other words, one region com- 
pared with another yields a relatively deadened sound, and according 
to the two chief points of view previously mentioned, namely, accord- 
ing to the varying thickness of the covering and according to the size 
of the lungs. Hence we remark the following facts: 
(a) Over the apices of the lungs, even with strong percussion, the 
sound is not very intense; for though the covering is thin, the volume 
of the lung tissue is small. 
(b) In the infraelavicular spaces, and still more in the second inter- 
costal spaces, the sound is very intense (covering thin, more lung 
tissue). 
(c) Farther down, not only in the male, but in still higher degree 
in the female, the sound is deadened by the pectoral muscle or by this 
and the mamma; in the female the sound may be absolutely deadened 
over the mamma; and this notwithstanding the fact that the lung- 
tissue is here very considerable. 
(d) Upon the back, the apices yield a sound of very slight inten- 
sity, since here there is a very small volume of lung and a very thick 
body of muscle. Over the scapulce there is likewise a very deadened 
sound, at the spine, and directly below, even a thigh-sound. In the 
interscapular spaces the sound is clearer. 
(e) Below the scapulce and at the sides of the chest the sound is 
very intense. EXAMINATION OF THE RESPIRATORY APPARATUS. 
121 
(/) Strictly speaking, here also belongs the description of the so- 
called “ relative heart and liver deadening.” (See page 124.) 
Now, it is further very important to know which similarly situated 
points on the thorax normally give the same kind of sound, since it is 
especially by comparative percussion that we seek to ascertain the 
presence of disease on one side. We may say that in healthy people 
marked dissimilarity of sound at symmetrical parts of the chest on 
the right and left sides exists only : 
In the neighborhood of the heart, as compared with the corre- 
sponding part on the right. 
At the two sides: on the left side normally the sound, almost as far 
hack as the spine and forward in front at varying height as far some- 
times as the fourth rib, is often clearer than on the right, and of some- 
what tympanitic tone (combining with the sound of the stomach or 
colon). 
In addition, there is a slight inequality sometimes posteriorly over 
the apices. In right-handed persons, the sound on the right side at 
that location may sometimes he met with a little less clear, because 
the muscles are somewhat more developed. On the left side, in left- 
handed persons, the case is reversed. 
Lastly, it is necessary to mention a point of greater importance— 
that over the whole sternum there is a clearer, non-tympanitic sound, 
even where there is no lung-tissue at all, as at the upper part of the 
manubrium (trachea) and over the left half of the lower part of the 
corpus sterni. The sternum acts as an unusually thick pleximeter, 
and yields therefore throughout, and in equal strength, the sound of 
the lung lying in contact, spread out over its inner surface. 
The larynx and trachea in the neck in front give the tympanitic 
sound of a hollow cavity with smooth walls. This has the peculiarity 
of being higher and more plainly tympanitic with the mouth open than 
with it closed (Williams’s tracheal tone, tracheal change of sound). 
The cause of this phenomenon is not quite clear; the explanation 
given by Neukirch, and accepted by Weil, is based upon the assump- 
tion of the resonance of the mouth changing with its opening and 
closing. This will he referred to later. 
Normal Percussion-boundaries op the Lungs. — It is not 
possible to define the boundaries of the lungs perfectly by percussion. 
Moreover, by percussion we can only establish : 122 
SPECIAL DIAGNOSIS. 
1. The apices so far as they rise above the clavicle: they are dis- 
tinguished by their clear sound in comparison with the deadened 
sound of their surrounding soft parts. 
2. The boundaries of the left lung at the incisura cardiaca: the 
lung sound from the absolutely deadened sound of the heart—the 
lung-heart boundary. 
3. The lower borders of the lungs, this especially at the lower 
border of the right lung: the lung sound marks the boundary of the 
absolutely deadened sound of the liver—the lung-liver boundary. 
Fig. 22. 
Boundary of the lungs as determined by percussion in front. (After Weil.) g h, the 
extent of the lung upward; e f, the lower limit of the lungs; b d, the relations of the 
lung and heart at the ineisura cardiaca. The strongly-hatched surface represents the 
portions of the heart and liver which are parietal; the lighter hatching shows the so- 
called relative heart and liver deadness. (See below.) 
At the lower border of the left lung, first about from the mam- 
millary to the middle of the middle axillary line, the lung sound 
marks the boundary of the tympanitic sound (stomach, or more rarely 
also intestines)—lung-stomach boundary ; next, the lung sound from 
the deadened sound of the spleen—lung-spleen boundary; and, EX AMIN A TION OF THE RES PIRA TOR Y A PR A RA TUS. 
123 
lastly, from the deadened sound of the kidney—the lung-kidney 
boundary. 
It is difficult to determine the boundaries of the lungs, since the 
difference of sound is often slight, especially as the tympanitic sound 
of the stomach often mingles with the lung sound higher up than the 
anatomical border of the lower limits of the lung; moreover, the 
lower boundaries of the lungs close up to the spine on both sides, 
because of the thick layers of the erector spinge, require strong per- 
cussion, and this is unfavorable for determining the boundaries. (See 
above.) 
Fig. 23. 
Boundary of the lungs as determined by percussion upon the back. (After Weil.) 
a b, the upper limits of the lungs; c d, lower limits. 
We cannot determine by percussion the front borders of the lungs 
behind the sternum. This is the case because the lungs lie close to 
each other for some distance there, and also because the sternum, like 
a firm bone, yields a uniform sound and it is not possible to recognize 
a difference of sound in what lies beneath it: it yields throughout a 
clear sound, very like the lung resonance over the ribs. 124 
SPECIAL DIAGNOSIS. 
Hence, it may also be explained that even the lower part of the 
anterior border of the right lung, which behind the sternum is limited 
by the heart, cannot be defined by percussion; we much more 
receive, instead of the actual boundary of the right lung, one that is 
apparent—where the uniform sternal sound is exchanged for the 
absolutely deadened sound of the heart at the left border of the 
sternum. 
Relative heart- and liver-deadness. The determination of the lung- 
heart and the lung-liver boundaries is made more difficult by the 
peculiar circumstance that, on account of the small volume of lung- 
tissue at the border of the lungs, the resonance of the lungs imme- 
diately over the borders has very slight intensity, a relatively deadened 
sound. We percuss from the lung toward the liver with strong or 
moderately strong strokes, and find, say in the mammillary line at the 
fifth rib, a strong relatively deadened sound which the beginner is 
inclined to regard as absolute liver-deadness. But this, as has been 
said, corresponds with the thinning of the lungs at the lowTer border. 
In this way a zone of relative deadness manifests itself over the whole 
of the lower border of the right lung, except close to the spine behind, 
and in a similar, but somewhat smaller zone, the heart-deadness bows 
round and to the left; this is the (incorrectly) so-called relative liver- 
and relative heart-deadness, as indicated by the light shading in Figs. 
22 and 23. Also, sometimes, there is such a relative deadness over 
the lung-spleen boundary. It does not exist over the lung-stomach 
boundary, because here, by moderate percussion, the coincident sound 
of the stomach causes a low tympanitic sound. 
These zones are diagnostically important only in isolated cases, and 
they have nothing to do with enlargement of the heart, liver, or 
spleen. 
In order to avoid deception by these conditions, when determining 
the boundaries it is necessary to take care : 
1. To percuss lightly in determining the boundaries of the lungs. 
2. To mark the lung-heart and the lung-liver boundary, that is 
the border of the lungs where the relative deadness passes into abso- 
lute deadness, or, in other words, where, in percussing from the lungs 
toward the heart and the liver, the deadness begins to be so marked 
that it no longer increases. 
On the average, that is, in middle life, we thus find (compare Figs. EXAMINATION OF THE RESPIRATORV APPARATUS. 
125 
22 and 23) : the lung-liver boundary in the mammillary line at the 
sixth, in the middle axillary line at the eighth, in the scapulary line 
at the tenth rib ; the lower border of the left lung: in general as high 
as the right only in the mammillary line at the lower border of the 
sixth rib; the lung-heart boundary: at the fourth rib and more or 
less just without the parasternal line ; the upper limits of the apices of 
the lungs: three to five cm. above the clavicle. 
Differences by reason of age. In children, the lower border of the 
lungs is from a half to a whole intercostal space higher; in old per- 
sons, it is that much lower (Weil). There is a like difference as 
regards the lung-heart boundary. That is, the lungs increase with 
the years, as compared with other organs. 
Displacement of lower border of the lungs is manifest by percussion: 
1. In deep inspiration and expiration (active mobility): in the mid- 
dle axillary line the lower border sinks with deepest inspiration about 
three to four cm.; in the mammillary and scapular lines about two to 
three cm.; in deepest expiration it rises up not quite so much above 
the average location (Weil). With deep inspiration, at the incisura 
cardiaca the lung moves so as quite to cover the heart; and it may 
even entirely obscure the heart dulness. 
2. In change of position (passive mobility): when lying upon one 
or the other side the lower border of the lung of the opposite side 
moves down as much as three to four cm. (Gerhardt, Salzer, Weil). 
3. Abnormal Sound over the Lungs. Abnormal position of the 
border of the lungs. 
A. Deadened Resonance.—In order not to overlook slight dead- 
ening we must remember what was said upon comparative percussion 
on page 124; if the comparison with the opposite side is inadmissible, 
as when both sides are diseased, then the comparison is made with 
the adjacent parts upon the same side, bearing in mind the normal 
regional differences of intensity of sound. 
Thus, in disease of both apices we sometimes recognize the dead- 
ness of the apex to be less affected by comparing the resonance over 
the latter with the percussion-resonance a little lower down ; remem- 
bering that normally the resonance over the first and second inter- 126 
SPECIAL DIAGNOSIS. 
costal spaces must be clearer than in the supraclavicular space, and 
clearer than over the third intercostal space. 
But also, without further consideration, we must not designate every 
deadness as due to an internal organ, but consider the deadening 
influence of a sharply-bowed rib, etc. Slight deadening, without any 
other pathological evidence, especially over the apices, is to he given 
value with very great caution. 
(a) Resonance is deadened by the development of airless tissue in the 
lungs either by condensation or by solid new formations in them. 
In croupous 'pneumonia the lung-tissue in the height of the disease is 
in the stage of hepatization. Generally in a large region it is completely 
deprived of air through the filling of the alveoli with inflammatory 
exudation. An intense deadening is coextensive with this condition. 
It seldom becomes absolutely deadened like the thigh-sound, hut there 
can generally be recognized a slight tympanitic tone. The feeling of 
resistance is generally likewise correspondingly increased, but not so 
much as is the case with a pleuritic exudation. 
Thigh-dulness and very marked feeling of resistance may exist with 
croupous pneumonia if, besides the lung-tissue, the bronchial tubes of 
that part of the lung are likewise completely filled with the exudation 
(“ massive pneumonia ”), or if the croupous pneumonia is complicated 
with a large pleuritic exudation, which is then almost always behind 
and low in the chest. The extent of the deadening in croupous pneu- 
monia very frequently corresponds with a lobe of the lung, because 
of its being a lobar pneumonia, or there is evidence of an enlargement 
of the lobe in all directions (the inflammatory exudation spreads out 
to a considerable extent). Often, therefore, in this disease we may 
recognize the boundaries of the lobe in the figure of the area of dead- 
ening, or the boundaries which correspond to the tracing of the lobe 
enlarged in all directions. The infiltrated part of the lung may, how- 
ever, be also smaller, especially on the surface of the lungs, occupying 
so small an extent as not to cause any recognizable deadening. 
Auscultation (which see) here leads to a conclusion sooner than per- 
cussion. 
In the neighborhood of an infiltration the resonance is generally 
abnormally loud and deep, even slightly tympanitic (compare what is 
said of croupous pneumonia under B. Tympanitic Sound). 
Since the infiltrated lobe of the lung is somewhat larger than EXAMINATION OF THE RESPIRATORY APPARATUS. 
127 
normal, sometimes in pneumonia of the whole lower lobe deadness 
will be found posteriorly as far up as the apex Avithout the apex being 
involved. Percussion upon the front of the chest then yields a very 
loud, deep sound over the upper part of the upper lobe. Further, for 
the same reason, in pneumonia of the left lower lobe the lower borders 
of the deadness may overstep the region of the normal boundaries of 
the lungs, as the marking out of the lung-stomach boundary then 
shows that the so-called “halfmoon-shaped space” is somewhat 
smaller. (See under Digestive Apparatus.) 
Also in catarrhal or lobular pneumonia and tuberculosis (in the 
so-called infiltrated tuberculosis of a larger part of the lungs) there 
may be an extended thickening and a corresponding deadening. 
Often, indeed, there are pathological deposits so small that their 
presence is not revealed by percussion; but though widely scattered, 
they are interspersed with points still containing air and hence give a 
clear sound. Then, because the tissue of the parts still remaining 
normal is somewhat lax, the resonance is often tympanitic. Or, the 
latter sound is mingled Avith that of deadness from the infiltrated parts 
—the tympanitic deadened sound. 
In tuberculosis of the apices of the lungs there is, at the beginning, 
in very slight measure, a mingling of thickened parts with tissue con- 
taining air, but relaxed; hence the resonance in the beginning over 
the diseased apex is very often tympanitic or tympanitic-deadened, in 
comparison with the healthy apex. Moreover, there is early retraction 
of the upper boundary of the apex upon the affected side. (See under 
Diminution of the Boundaries of the Lungs.) 
Large hemorrhagic infarctions and sections of the lungs compressed 
even to the point of not containing any air, as from pleuritic exuda- 
tions, tumors, and large pericardial exudations, may likewise give a 
deadened sound. Finally, it is conceivable that solid tumors of the 
lungs (sarcoma, carcinoma) produce the same effects in case they lie 
upon the surface or attain to a certain size. 
(b) Resonance is deadened by the presence of a deadening medium 
over the lungs—that is, between it and the percussing finger. 
Most important of these is pleuritic exudation. Generally, this first 
appears Ioav down posteriorly in the complementary space and above 
it, and if it amounts to as much as 400 cubic cm. it may even be 
recognized by light percussion. Corresponding with the increase of 128 
SPECIAL DIAGNOSIS. 
the exudation the area of deadness will gradually become more 
extensive; its limits ordinarily correspond with a fluid surface 
which, while the patient is in the posture most frequently assumed, is 
somewhat horizontal; that is to say, in bedridden patients the fluid 
levels itself high up on the posterior wall of the thorax, and the 
limits on the sides and in front drop olf sharply; wdiile with people 
who are much out of bed, or may still be at work, the fluid stands 
equally high in front and at the back of the chest. When the effusion 
is very large the deadness may extend even to the apex, both 
anteriorly and posteriorly. It quickly becomes, with considerable 
effusion, an absolute deadening and with the most marked feeling of 
resistance. 
Corresponding with the increase of the fluid the lung becomes lax 
in an ever-increasing area, since it may then follow its elastic trac- 
tion ; immediately over the fluid it gives deadness, and wdien there 
is a large exudation, where at least there is ordinarily left a district 
with clear sound, namely, high in front, it yields an abnormally 
loud and deep, or a tympanitic sound, sometimes with the noise of a 
spinning-top (see page 134). A very large exudation may even 
compress the lung to such a degree as to expel all air. 
When there is a certain amount of exudation its weight presses 
upon the diaphragm, increases the affected pleural cavity toward the 
side, presses out the side of the thorax (see above), and pushes the 
mediastinum and the heart over toward the sound side (see Displace- 
ment of the Heart). The downward pressure of the diaphragm in 
cases of pleurisy of the right side is recognized by the liver being 
lower (see Percussion of the Liver). In pleurisy of the left side, it 
may directly be made out by locating the upper boundary of the so- 
called “ halfmoon-shaped space.” 
When the pleural surfaces directly over the exudate are glued 
together, then in change of position of the patient the pleuritic exuda- 
tion is not movable, and the boundaries of the deadness are therefore 
not changeable; not infrequently the exudation is entirely “ capsu- 
lated ” by the adhesion of the pleural surfaces. If the exudation is 
reabsorbed, then the evidences of expansion and of displacement, on 
the one hand, and the deadness (and, indeed, according to its extent, 
likewise its intensity), on the other hand, steadily disappear. Often EXAMINATION OF THE RESPIRATORY APPARATUS. 
the upper border of deadness then shows as a bowed line with its 
convexity upward (Damoiseau’s curve). 
If a new pleuritic exudation takes place between pleural surfaces 
already adherent from a former attack, then, of course, it remains 
confined within the space thus prepared—“ encapsulated, circumscribed 
pleurisy.” The boundaries of the exudation may, in these cases, take 
a very varying course. 
Hydrothorax practically gives rise to similar appearances; but it 
is generally on both sides, yet not infrequently with a very different 
amount upon the twro sides. Further, hydrothorax always shows in 
change of position, although only after a certain time, a change of its 
relation to the thorax in such a way that it tends to take possession 
of the part of the thorax that, for the time being, is the lowest; 
accordingly, there is what may be called a passive mobility of the 
boundaries of deadness. 
Serous or purulent, or ichorous, effusion into the pleural cavity com- 
plicating pneumothorax (sero-, pyo-pneumothorax) is distinguished 
from the above by its mobility with the change of posture. It be- 
haves like the water in a bottle when the position of the latter is 
changed; in every situation the fluid maintains a horizontal surface, 
and occasions at the same time, with every change of place or location 
of the thorax, a prompt variation of the upper boundaries of the 
deadness. 
Further, a deadening of the resonance is occasioned by the thick- 
ening of the pleura, which either remains after an exudative pleuritis 
or in conjunction writh processes slowly going on in the lungs. The 
latter is the case very frequently in tuberculosis of the apices of the 
lungs; marked deadening, appearing early in the beginning of the 
disease, is generally caused by pleural thickening. The intensity of 
the deadness is determined by the amount of the thickening; it may 
even become like thigh-deadness. The feeling of resistance is generally 
very markedly increased; with very thick deposit this is positive. 
Tumors, as a matter of course, likewise cause deadening. This latter 
deadening generally exhibits an irregular boundary, if it is not, as is 
rarely the case, complicated by pleuritic exudations. 
It is sometimes very difficult to distinguish between a thickened 
pleural surface and a portion of pleural exudation left behind with 
moderate thickening; this question often especially arises where the 130 
SPECIAL DIAGNOSIS. 
deadness is low down posteriorly. In arriving at a decision the first 
thing to consider is whether there is expansion or contraction, or 
whether there is a deep or a high position of the diaphragm. 
But here, as well as in the often very difficult differential diagnosis 
between pleural exudations and tumors, as of the lungs, pleura, or 
chest-wall, the application of the explorative puncture is the best 
means of deciding. 
Finally, the resonance of the thorax is deadened by all processes 
in the chest-wall which lead to its being thickened—tumors, peri- 
pleuritis, oedema. 
The second quality of sound which is found over diseased lungs is 
B. Tympanitic Sound.—(a) It occurs, pathologically, if the lung 
is in a state of elastic equilibrium : we know that this condition 
is a consequence of retraction of the lung: with large pleuritic 
exudation as well as shrinking in connection with pleurisy; further, 
in all other affections of the chest which decrease its capacity. Hence 
tympanitic resonance exists over the lungs in the neighborhood of 
tumors of all kinds; sometimes in the neighborhood of the heart in 
exudative pericarditis, more rarely in hypertrophy and dilatation of 
the heart; lower in the thorax : in diaphragmatic pleurisy; in high 
position of the diaphragm from subphrenic tumors, abscesses, etc.; 
and in general peritonitis, general distention of the abdomen from 
ascites, tumors, etc. 
We may also think of the same condition of approaching equilibrium 
of elasticity as arising from relaxation of the lung-tissue (Weil); and 
this will explain the tympanitic resonance that exists with croupous 
pneumonia in the stage of engorgement and resolution; over many 
small catarrhal-pneumonic and tubercular deposits, since the inter- 
vening tissue containing air has become lax; and finally, in oedema 
of the lungs. 
(b) In consequence of marked shrinking and thickening of the 
lung, in strong percussion of the supraclavicular fossa, it arises from 
the trachea, while in percussing the first or second intercostal space 
it arises from this or the primary bronchus, directly from the percus- 
sion-blow, and so the broncho-tracheal column of air is put in vibra- 
tion ; thus arises a peculiar change of sound in the trachea, the EXAMINATION OF THE RESPIRATORY APPARATUS. 
131 
sound with the mouth open being more distinctly tympanitic and 
higher (Williams’s tracheal tone). 
(c) Over cavities within the lungs, caverns (vomicce). 
We may have here, according as the cavity does or does not com- 
municate with the outer air by means of a pervious bronchial tube, 
the open or the closed tympanitic resonance. In the former case the 
sound is under all circumstances more distinctly tympanitic and also 
more intense; in the latter case, on the other hand, much less distinct 
and weaker, all the more since we must assume that the cavities, 
because they lie in the thorax, have more or less stiff walls, and since 
the rigidity of the wall with the cavity closed hinders the condition 
that causes the tympanitic sound. 
How large the cavity must be in order to give a tympanitic sound 
it is not possible exactly to state, since besides the size, the situation 
of the cavity (whether parietal or deep), the amount of fluid secretion 
it contains, its walls (whether smooth and vibratory), the condition of 
the surrounding lung-tissue, and finally the vibratory capacity of the 
given thorax must also be taken into consideration. Generally, cavi- 
ties occurring in the apices from tuberculosis exhibit more distinct 
physical characteristics than cavities in the lower portions of the 
lungs, which frequently are of the nature of bronchiectasis, since these 
even when of moderate size must reach to the surface of the lungs, 
and generally have thickened walls. Cavities as large as a walnut in 
the upper parts of the lungs generally give a distinctly tympanitic 
resonance. 
If the cavity is very large with relatively smooth walls a metallic 
tone is added to the tympanitic resonance. 
If the cavity is covered by thickened lung-tissue or with thickened 
pleura (this very frequent) then the sound becomes tympanitic-dead- 
ened ; if by a very thick layer of airless tissue, absolutely deadened. 
Temporarily marked filling of the cavity with secretion deadens the 
tympanitic sound also, sometimes even to absolute deadening; further, 
the sound becomes temporarily indistinctly tympanitic and deadened- 
tympanitic if a bronchus connecting with it, otherwise open, becomes 
closed (with secretion or from dipping below the fluid contents of the 
cavity). 
Under different conditions tympanitic sound over a cavity may 
change its pitch ; change of sound may take place. 132 
SPECIAL DIAGNOSIS. 
1. The so-called simple Wintrich’s change of sound. The tym- 
panitic sound becomes louder, more distinctly tympanitic, and higher, 
if the patient opens the mouth wide (and, what is desirable, at the 
same time protrudes the tongue a tittle). This can only occur over 
those cavities that freely communicate with the broncho-tracheal 
column of air. 
We percuss, not too strongly, while the patient lies or stands 
quietly and alternately opens and closes the mouth; but it is neces- 
sary for the patient to breathe as superficially as possible, or we must 
compare the sound in the same stage of the breathing, since the sound 
also sometimes changes its pitch according to the stage of the breath 
(compare under 4. Respiratory change of sound). 
The explanation of this symptom, as of the tracheal change of 
sound which is exactly similar, is that it is from the change of con- 
sonance of the mouth-throat cavity. 
This Wintrich’s change of sound may also occur over cavities in 
such a way that the sound with the mouth closed is markedly 
deadened, with only a trace of tympanitic sound (especially with 
marked callous formations over the cavity), and only with the mouth 
open does the sound become tympanitic (at the same time becoming 
louder and noticeably higher). 
I would like, therefore, in opposition to Weil, to insist that we 
ought, if there is only a slight possibility of the existence of a 
cavity, and also in the case of tympanitic sound slightly distinct, even 
indistinct, with dulness, to apply the test of Wintrich’s change of 
sound. 
It is very easy to confound the simple Wintrich's change of sound 
with Williams’s tracheal tone. We should take notice : (1) Whether 
there is very marked shrinking, when it is much more likely to indi- 
cate change of sound than Williams’s tracheal tone. (2) Whether in 
order to cause the change of sound only weak percussion (cavity) or 
strong percussion (trachea or bronchus) is required. (3) Whether 
there are other symptoms of a cavity. 
Simple Wintrich’s change of sound points with greater probability 
to a cavity. But its value as an indication is diminished by the 
above-mentioned possibility of being confounded with Williams’s 
tracheal tone. 
2. Interrupted Wintrich’s change of sound (Gerhardt, Moritz). It EXAMINATION OF THE RESPIRATORY APPARATUS. 
133 
is distinguished from the simple in that in some positions of the body 
it is plain, in others it is indistinct or is wanting. The explanation 
of this is that in one position the bronchus leading to the cavity is 
open, while in the other it dips into the secretion in the cavity and so 
is closed. In this way the tracheal change of sound cannot possibly 
be interrupted 
This change of sound is very rarely met with, but it is to be 
regarded as a positive sign of a cavity. 
3. G-erhardt's change of sound. A tympanitic sound changes its 
pitch if the patient changes his posture (upright, dorsal, side position); 
and sometimes, if the patient changes from the dorsal to the upright 
Fig. 24. 
Fig. 25. 
Gerhardt’s change of sound.—Schematic representation of the behavior of the contents 
of a cavity with a change of position of the body of the patient. 
position, the sound becomes deadened-tympanitic or absolutely dead- 
ened over the lower part of the cavity, because in this position the 
fluid contents of the cavity come into contact with the chest-wall. 
Gerhardt’s change of sound may take place over communicating, as 
well as over closed, cavities. The change of pitch, in case the cavity 
is open, may have very different causes, which we will not discuss here. 
In closed cavities it is really due to a change in the tension of the 
chest (and cavity ?) wall, perhaps also to a change in the size of the 
part of the cavity containing air—a change caused by different loca- 
tion of the secretion. (See Figs. 24 and 25, from Weil's Handbook.) 
Gerhardt’s change of sound is in every form an almost certain 
symptom of a cavity, but, like the former, it is very rare. 
4. Friedreich’s or the respiratory change of sound: the sound 134 
SPECIAL DIA GNOSIS. 
becomes higher at the height of a deep inspiration. This occurs not 
alone over cavities, but may be observed in any case of tympanitic 
sound over the lungs. It depends upon the increased tension during 
inspiration of the chest-wall and lung-tissues, likewise of the wall of 
the cavity. 
It does not have diagnostic significance. But it is important to 
know it in order that we may not be misled by it in the examination 
of other changes of sound; therefore, we ought in testing this to 
observe the rule to percuss during very superficial breathing, or still 
better always to percuss at the same stage of the breathing, as has 
been said above. 
(d) Finally, the tympanitic sound occurs in very rare cases in 
pneumothorax and sometimes entirely in cases that have permanent 
and completely-open fistulee ; this “ open ” pneumothorax is generally 
circumscribed. In pneumothorax the tympanitic sound may some- 
times exhibit Wintrich’s change, since the physical conditions upon 
which it depends are also present, as in large communicating cavities : 
open communication of an air-space with the broncho-tracheal column 
of air. Here we have also metallic tone (see p. 135). 
Noise of the spun-top, \_Cracked-pot] (bruit de pot file). It seems 
that this is the most suitable place to describe this phenomenon, which, 
while very surprising and remarkable, is of very subordinate diagnostic 
significance. It consists of a peculiar click (“clinking of coin” or 
“trembling”), which sometimes accompanies the clear sound and 
indeed generally the tympanitic, more rarely the clear, non-tympanitic. 
It corresponds to the noise which occurs when we strike a cracked 
plate or pot, or when we hold the palms of the hands together lightly 
and then strike them upon the knee. It occurs in the thorax if 
an instantaneous current of air of a given force is driven from the 
lungs against the larynx by the percussion-stroke, or if during expira- 
tion a stream of air flowing outward is for a moment suddenly sharply 
arrested. This symptom requires strong percussion, yielding thorax, 
and thin covering (generally in front superiorly, and also below 
posteriorly). It occurs sometimes in normal cases, especially in 
children. 
Pathologically it occurs: 
1. Over large parietal cavities, here often remarkably intense. 
2. In pneumothorax with open fistula, especially if circumscribed. EX AMIN A TION OF THE RESPIRATORY APPARATUS. 
135 
3. Over pneumonic deposits. 
4. Over retracted lung tissue, especially above large pleuritic exuda- 
tions (high in front), rarely in the neighborhood of thickened portions 
of lung. 
This phenomenon is always more distinct if we percuss during 
expiration; very often, especially in case of cavity and open pneumo- 
thorax, it becomes louder by opening the mouth. 
As above remarked, this symptom has almost no diagnostic meaning, 
since it is present with such varying conditions. 
The noise is caused by a swift current of air striking at a narrowed 
point; this happens at the glottis, in a cavity at the mouth of a 
bronchus, and at the puncture in the pleura in case of pneumo- 
thorax. Sometimes a rattling sound is mingled with the trembling 
(“ the moist cracked-pot sound’’). 
C. Abnormally Loud and Deep Sound.—This occurs: 
1. In severe emphysema of the lungs, designated as “ band-box 
note ’ ’ (Biermer). 
2. In decreased tension of lung tissue above a pleuritic exudation : 
a zone of this abnormal sound lies just above the line of deadness pro- 
duced by the exudation in the neighborhood of pneumonic thickening 
—as anteriorly in pneumonia of a whole lower lobe; sometimes in the 
neighborhood of the heart in pericarditis exudativa, but also with 
dilatation and hypertrophy ; likewise, and especially, in the neighbor- 
hood of encroaching tumors, and with a high position of the diaphragm 
consequent upon abdominal affections. 
As was said before, in most of these cases, if the tension of the 
lung-tissue is very considerable, tympanitic resonance may arise (see 
p. 130). 
3. With pneumothorax. Here the sound, in consequence of the 
strong tension of the chest-wall, is almost always non-tvmpanitic, 
loud and deep. Only (a rare case) in open pneumothorax, especially 
if it be circumscribed, is tympanitic sound sometimes met with (see 
p. 134). 
This abnormally loud and deep, even tympanitic sound of pneumo- 
thorax gives almost regularly the metallic sound, only seldom recog- 
nizable, however, by the ordinary methods of percussion, but very 
admirably by the rod-pleximeter percussion described by Heubner. 136 
SPECIAL DIAGNOSIS. 
Mode of application. Rod-pleximeter percussion is best conducted 
by two examiners. One strikes with the handle of the percussion- 
hammer, or with a pencil upon a pleximeter; the other auscults 
the thorax. If both manipulate over a pneumothoracic cavity the 
second hears the strokes as the finest metallic, generally a silvery, 
clear ringing. f 
This, moreover, is sometimes also observed with very large and 
smooth-walled cavities with thin covering. With pneumothorax 
accompanied with fluid (pyo-, sero-pneumothorax) the metallic sound, 
almost without exception, changes its pitch with the change of posi- 
tion ; in sitting up it is generally deeper, but sometimes also higher 
(Biermer’s change of sound). If the effusion is so large as entirely, 
or almost entirely, to fill the pleural cavity of course the metallic sound 
disappears. 
It will be mentioned in the appropriate sections that this metallic 
ringing in pneumothorax not only accompanies such an artificially 
created noise, but also may be present with rhonchus, respiratory 
sound, and heart-sound. 
D. Changed Condition (and Diminished Power of Displace- 
ment) of the Boundaries of the Lungs.—{a) Extension of the 
boundaries of the lungs takes place in emphysema: the lower borders 
usually move sidewise and deeper, both front and back, in the most 
marked cases. The mammillary line will be at the eighth rib, the 
axillary line at the tenth, the scapular line at the eleventh or twelfth. 
Heart deadness may also or quite disappear, from the expanded 
lung lying over it from the side. At the apices of the lungs some- 
times a slight enlargement of the lungs may be made out; in rare 
cases even expansion of the apices may likewise take place (as after 
whooping-cough in children). “ Relative liver-deadness ” and “heart- 
deadness ” is very small; simultaneously with the expansion, the 
lung loses its power of displacement, both active and passive, even 
past recognition. 
One-sided downward movement of the boundary of the lung occurs 
in vicarious emphysema, but the capacity to change its boundaries is 
preserved in this case. 
Apparent one-sided expansion of the boundary—that is to say, the 
appearance of a clear sound upon one side quite beyond the normal 
boundary of the lung—takes place in diffuse pneumothorax: the EXAMINATION OF THE RESPIRATORY APPARATUS. 
137 
lower border of the clear sound is sometimes met with even deeper 
than in emphysema; this border is immovable, and always very 
sharply defined. The side of the thorax is expanded, the heart and 
also liver are displaced, or the tympanitic sound of the “ half-moon- 
shaped ’’ space is replaced by the sound of pneumothorax. Displace- 
ment of the mediastinum in right-sided pneumothorax is generally 
distinctly recognized by the change of sound between it and the left 
lung (the boundary-line lies to the left of the upper part of the 
sternum). 
(b) Diminished volume of the lungs is shown by the lower boundaries 
of the lungs being higher than normal on both sides, by the diaphragm 
being pressed up from below or from its being paralyzed; one-sided 
diminution, by shrinking from disease of the lung or a past pleurisy. 
The motility of the borders is thus diminished or destroyed. The 
liver stands correspondingly higher (see Liver), or the “ half-moon- 
shaped ” space is enlarged. 
Sometimes diminution in size of an apex in phthisis manifests itself 
by the deeper position of the upper border of the lung upon one side. 
(c) Diminution of the motility alone, especially during respiration, 
without change of the average condition of the borders, sometimes 
exists low down posteriorly as the first symptom of pleurisy, and also 
as the only sign of a past pleurisy, in which case it is noticed along 
the whole lower border of a lung or a part of the same, as at the 
heart; here, also, it is a residuum of pericarditis externa. (See 
Examination of the Heart.) 
Retraction of the lungs in the neighborhood of the heart by 
shrinking permits the latter to come in contact with the chest-wall 
to a larger extent than normal; there is displacement of the heart- 
border of the lung to the left and upward, and, hence, hypertrophy or 
dilatation of the heart may at first be mistaken for the real condition. 
(See Heart.) 
On the other hand, diseased conditions in the neck (tumors, scars, 
etc.) may influence the position of the apices, and thus at first may 
deceive the inexperienced in leading him to conclude that there is 
one-sided shrinking of the lung. 138 
SPECIA L DIA GNOSIS. 
AUSCULTATION OF THE LUNGS. 
1. History. The Sphere of Auscultation at the Present Time. 
It now appears to us very strange that the idea of percussing the 
body was only so lately brought into medical practice. It is yet 
more difficult to understand that methodical auscultation of the body 
is only a child of the most recent time. It is true that Hippocrates 
heard what he named a succussion-sound, and also, no doubt, rattling 
and rubbing sounds ; but to the two latter he did not attach any great 
importance, and in all the centuries from the Greek physician to the 
time of Laennec no real attention was given to the audible phenomena 
of the healthy and diseased body. Only a few voices—that of the 
often-mentioned Hooke more than any other (second half of the 
seventeenth century)—were timidly raised, and these were not heeded. 
Only in consequence of the discovery and general consideration of 
the value of percussion was auscultation developed, and this by 
Laennec, the discoverer of the stethoscope. His epoch-making work 
is called Traite de VAuscultation mediate et des Maladies des Poumons 
et du Coeur. After him, Skoda, by critical sifting and by his own 
efforts, which traced the new phenomena to their physical causes, 
rendered imperishable service to this branch of knowledge. But up 
to the present time the work has still been going on, which, in part, 
has made new discoveries, and, in part, has investigated the nature of 
what was already known. 
The sphere of auscultation—of listening—in its widest sense 
extends to all that we are able to take note of by the ear, hence, in 
the first place, to the voice, cough, noises caused by breathing, by 
mucus in the upper air-passages, which may often be heard in the 
furthest corner of the sick-chamber. But, strictly speaking, ausculta- 
tion concerns only those phenomena which the ear perceives, either 
by direct application to the body or which are brought to it by an 
instrument, as a stethoscope or an ear-trumpet. These, so far as they 
refer to the respiratory apparatus, form the subject of the following 
section. 
2. Methods of Auscultation. 
Nowadays we employ both immediate (direct) and the mediate 
(indirect) auscultation. In the first, the ear is directly applied to the EX AMIN A TION OF THE RESPIRA TOR Y APPARA TUS. 
139 
person to be examined; in the latter, we employ a stethoscope or ear- 
trumpet. While, as will be referred to later, we employ almost 
exclusively the direct method in examining the heart and vessels, both 
methods are applied in the examination of the respiratory apparatus, 
and particularly of the lungs. In applying both, where it is possible, 
we must endeavor to have the body bare; in no case should the cover- 
ing be more than a single thickness, and that should be as thin as 
possible, and must be perfectly smooth. [By the use of a solid—a 
wooden or hard-rubber—stethoscope it is not absolutely necessary to 
remove the clothing; by pressing the instrument firmly against the 
chest with the fingers friction of the clothing is prevented ] 
The application of the ear to the body consists simply in laying the 
ear lightly over the particular part to be examined. In order to place 
the ear exactly over the spot which we wish to auscult, it is well to 
place the tip of the index-finger at the point and keep it there until 
the ear is placed at the point indicated, when the finger is withdrawn. 
For stethoscopic auscultation, almost universally used in Germany at 
the present time, preference is given to the simple hollow stethoscope, 
the tube being about twelve to eighteen cm. long, with a not too small 
ear-plate. No doubt the plate has this disadvantage—unless the 
examiner is sufficiently careful—that it does not lie smoothly upon the 
outer ear; but, nevertheless, it is the most suitable form, since the 
stethoscope with hollowed ear-pieces, especially those recently devised, 
which, embracing the head of the auscultator, lie over the whole outer 
ear, for most persons have a most disturbing roar—a disadvantage 
which quite outweighs the advantage that, by increasing the resonance, 
it so well conducts the noises from the body; and the cone-shaped 
ear-pieces which are inserted into the outer ear, in the short stetho- 
scopes with stiff tubes, cannot long be borne by the examiner. 
These stethoscopes may have the further peculiarity that the end 
that rests upon the body measures, on the average, not more than two 
to five cm.; hence they conduct to the ear impressions of sound from 
a much smaller region than will be heard from by direct auscultation. 
They are made of various material (wood, hard rubber, ivory), but 
this is of small importance. The flexible stethoscopes (rubber tubing 
instead of the stiff tube, and ear-cones instead of the ear-plate) come 
less into use because it is difficult, at least in the beginning of their 
use, to exclude the marked noises that are associated with them. Of 140 
SPECIAL DIAGNOSIS. 
the double stethoscopes I only mention that of Camman, since it is 
decidedly very useful; but it is a complicated instrument. 
In general the use of the stethoscope resembles the practice of 
percussion in that everyone, especially while learning, ought always 
to use the same kind of instrument, in order that he may learn to 
judge correctly of the auditory impressions which his instrument 
furnishes. In my teaching I have always found that those students 
who each time they wished to make an examination had to borrow an 
instrument from their fellows did not hear anything. 
There are a large number of forms of stethoscopes, especially of the 
hollow stiff ones, the separate models of which it is not possible to 
describe. It may be remarked that the microphone has recently been 
employed. 
P. Niemeyer’s solid stethoscope with ear-cones (acuoxvlon) is deci- 
dedly not to be recommended; it has not proved practical, nor are the 
theoretical grounds of its construction sound. 
It is very important in the beginning not to make pressure with 
the stethoscope. Hence it is advisable to steady the instrument with 
two fingers, and not to hold it in place with the head. 
As was said above, it is decidedly to be recommended in the exam- 
ination of the lungs to employ both direct and indirect auscultation. 
The former is here preferable, since by it we can generally listen at 
one time to a large region of the lung; hence it is on the one hand 
more comprehensive, and on the other hand furnishes collectively 
louder sounds. Moreover, in the examination of the chest posteriorly 
of very sick patients it cannot be dispensed with, since by its compre- 
hensiveness it furnishes the means of conducting the examination 
with the necessary quickness. On the other hand the stethoscope is 
employed: 
1. Where the ear cannot be applied, as over the supraclavicular 
spaces. 
2. If we wish to listen quite separately to noises existing in a 
narrow limited space. 
3. Sometimes from reasons of delicacy, as over the female breast. 
4. If the physician wishes to avoid being soiled, the risk of receiv- 
ing or getting parasitic insects, or infections. 
In a general examination it is well to auscultate after percussing. 
After percussing the front of the chest, auscultate over the same EX A MINA TION OF THE RES PIR A TORT A PPA RA TUS. 
141 
region and then percuss and auscult the back. Generally the patient 
should breathe deeply; it is not at all preferable to have him breathe 
very hard and quickly. Not infrequently we hear best with mode- 
rately deep breathing. Where it is possible, as in percussion, sym- 
metrical parts should be compared. The particular points where it is 
necessary to take care are described in the following section. 
3. Auscultatory Signs in Normal Respiration. 
1. Sound of bronchial breathing. If we auscult the larynx or 
trachea of a healthy person during inspiration and expiration we hear 
a loud aspirating sound which corresponds somewhat exactly with that 
we can make with the mouth when we put it in position to pronounce 
“h” or “ch” and then inspire or expire. We designate this sound 
as the laryngeal and tracheal, or by the collective expression, bron- 
chial breathing sound. Its peculiarity is its more or less pronounced 
sharpness (ch or h sound) and moreover a somewhat rising pitch ; 
again, it is ordinarily somewhat louder (and deeper) in expiration than 
during inspiration. The sound is formed in the glottis by the eddies 
which are here formed in the current of air by the sudden narrowing; 
it is louder in expiration, because the rima glottidis is narrower then 
than during inspiration. The strength and rapidity of the breathing 
have a great influence upon the loudness of the sound. 
Besides over the throat in front, where the larnyx and trachea lie 
superficially, we hear this sound over the vertebra prominens at the 
back of the neck in healthy persons during moderately strong breath- 
ing, also, sometimes, over the upper part of the sternum; very 
frequently, too, in the interscapular space, and more plainly upon the 
right than to the left of the median line (region of the bifurcation). 
Bronchial breathing may be noticed at other parts of the thorax at 
a varying distance from the above regions during strong breathing, 
especially with violent, coughing expiration. It is heard earliest over 
the upper sections of the chest. There may be great individual 
differences and yet be within the limits of the normal. Confounding 
bronchial breathing with the diseased conditions to be mentioned later 
will be avoided by noting the approximate symmetry of this breathing- 
sound, the condition in feeble breathing, and also the result of the 
further examination. 142 
SPECIAL DIAGNOSIS. 
A noise which arises in the pharnyx and at the lips of the person 
examined not infrequently disturbs or deceives the beginner; closing 
the free ear is here recommended. 
2. Vesicular breathing. In healthy persons this is heard wherever 
the lungs lie in contact with the chest wall (with the exception of in 
the interscapular space ; see above). It is of a very slight shuffling 
character, resembling the sound we may produce by placing the lips 
in position to say “f” or “v.” The pitch of this sound can only be 
approximately recognized (like the clear non-tympanitic sound). 
This sound can only he heard in inspiration, and most plainly at 
the end of inspiration. In a sound lung expiration has a very slight 
breathing sound which maybe said to be of bronchial character. Not 
infrequently it is wholly imperceptible; sometimes, however, we find 
inspiration which is simply like a very much weakened vesicular 
inspiratory sound. 
The force of vesicular breathing varies very much. It is most 
determined by the strength of the breathing; in very strong respiration 
it is often so loud that it is also heard over the organs adjacent to the 
lungs, as over the heart, liver, and stomach. In the majority of healthy 
persons the vesicular murmur is louder upon the left side than upon 
the right (Stokes). Otherwise the strength of this breathing sound is 
determined by the loudness of the pulmonic sound; over thin portions 
of the lung, as the apices, it is very slight, and likewise it may he 
weakened by the thickness of the covering even to such a degree as 
not to be heard at all. Moreover, there are individual differences 
which depend chiefly upon the differences in the width of the glottis, 
also on the elasticity of the chest on the one hand and on that of 
the lungs on the other. 
Puerile breathing (Laennec). The vesicular murmur in children is 
remarkably different from that of maturity; the former up to about 
the twelfth year of age exhibits a remarkably distinct, loud and sharp 
vesicular breathing sound, which approaches bronchial breathing, 
especially also in that often it is nearly as strong in expiration as in 
inspiration. Generally, also, women have a stronger vesicular murmur 
than men. 
Origin. Vesicular breathing sound is nothing more than the 
bronchial breathing sound as it is heard over the trachea or larynx, EX A MINA TION OF THE RESPIRA TORY A PPA RA TVS. 
143 
as it is formed at the rima glottidis (see above), but changed by being 
prolonged into the air-containing lung. It is the air-containing lung 
which causes that sharp sound, having a musical pitch, to reach our 
ears so changed in character. Any tissue not containing air, and, 
indeed, the lung-tissue that has been deprived of air by the products 
of disease, as will be shown below, conducts the bronchial breathing 
unchanged from the large tubes in which it forms to the surface of the 
chest, and so to the ear; and, on the other hand, a piece of animal 
lung inflated, placed upon the neck, when auscultated changes the 
laryngeal breathing sound to a vesicular. (Penzoldt.) 
In our opinion, this explanation is probably correct. Moreover, it 
has this decided preference—that it forms a good foundation for com- 
prehending almost all the pathological appearances. Hence, we do 
not mention other ways of explaining vesicular breathing here, but 
remark that very excellent authorities, particularly Dehio, prefer other 
explanations. Thus far, positive proofs have not been produced for 
any of the assumed methods of producing vesicular breathing. 
Sometimes there are special peculiarities of vesicular breathing 
sound quite within the normal, which may easily mislead the beginner. 
We may see during inspiration interrupted or jerking respiration in 
persons who, at discretion, take deep breaths imperfectly, in a jerking 
manner; and, further, in whining children, who half suppress their 
sobs. This kind of jerking breathing exists over all portions of the 
lungs alike. Moreover, in the portion surrounding the heart, and as 
far up as to the apex of the left lung, the vesicular murmur, exhibits 
interruptions exactly corresponding to the action of the heart (systolic 
vesicular breathing, depending upon the unequal entrance of air into 
this portion of the lung in consequence of the changed condition of 
the heart, and, hence, often especially plain in disturbed heart’s 
action). 
To learn to distinguish between the bronchial and vesicular 
breathing is, for the beginner, among the most difficult things in 
diagnosis. For the comprehension of the latter sound it is strongly 
recommended always to auscult directly, since the sound is then 
louder and its nature can thus be more clearly recognized. More 
than this, it is well to place the ear frequently, for comparison, upon 
the patient’s neck, so as there to hear the bronchial sound. 144 
SPECIAL DIAGNOSIS. 
4. Pathological Sounds in the Respiratory Apparatus. 
The following are enumerated : 
(a) Certain changes in the vesicular breathing. 
(b) Bronchial breathing, in place of vesicular breathing. 
(c) The so-called indefinite breathing. 
(d) Dry rales. 
(e) Moist rales. 
(/) Crepitant rales. 
(g) Friction-sound of the pleura. 
(A) Succussion-sound of Hippocrates. 
From this enumeration, and still more from wrhat follows, it is 
evident that the number of pathological sounds to be heard with the 
diseases of the respiratory apparatus is not small. The chief difficulty 
is that very often different ones are to be heard at the same time, so 
that one sound conceals another. It is urgently recommended that 
the beginner at first practise in such a way that, in auscultating, he 
endeavor always in the first place to learn to recognize only the 
breathing sound, and that he then endeavor to direct his attention to 
other possible so-called accessory sounds (rales, friction-sounds). One 
can acquire the power to exclude one sound in order to be able more 
exactly to pay attention to another—to acquire a certain dexterity 
which very much facilitates auscultation. 
(a) Alterations of Vesicular Breathing.—1. The vesicular 
breathing sound may be increased in inspiration, or sharpened. This 
takes place whenever the respiration is increased, as in active deep 
breathing; in the acme of Cheyne-Stokes breathing; in certain forms 
of dyspnoea, as of diabetic coma; and where one section of lung is 
vicariously performing the work of others which have been shut off. 
Moreover, it forms a very important sign in bronchitis, here occa- 
sioned by the local narrowing of small bronchial tubes in consequence 
of swelling of the mucous membrane and accumulation of mucus. Not 
infrequently beginning tuberculosis of the apex is revealed solely by 
sharpened vesicular breathing in comparison with the sound side, as 
evidence of accompanying catarrh of small bronchial tubes. 
Here the one-sidedness of the sharpened vesicular breathing is of 
the greatest importance ; two-sided sharpened breathing of the upper 
portion of both lungs almost never has this signification; not infre- EXAMINATION OF THE RESPIRATORF APPARATUS. 
145 
quently it exists in tightly-laced women, also in children who breathe 
poorly with the lower portions of the lungs in consequence of a high 
position of the diaphragm, due to abdominal affections. 
2. Vesicular breathing maybe diminished, either in bronchial catarrh 
in case the entrance of air into a section of lung is notably diminished 
by the swelling and secretion; or if bronchial branches are more or 
less closed by foreign bodies or compression. Diminished breathing 
of a portion of lung is also a consequence of pleural thickening, and 
of many conditions which give pain in respiration, manifested by the 
lessened, weakened breathing of the affected side. Diminished inter- 
change of air everywhere, and, hence, a two-sided extensive weakened 
breathing exists in emphysema, also in stenosis of the upper air- 
passages. All thickenings of the chest-wall (tumors, etc., oedema) 
weaken the respiratory sound by rendering the conduction more diffi- 
cult ; and, finally, marked weakening develops rapidly with pleural 
exudations, both on account of the diminished breathing and the more 
difficult propagation of the breathing sound by the layer of fluid. 
In all these cases the breathing sound may even completely dis- 
appear ; most frequently is this the case with pleural exudations, also 
in complete closing of a large bronchial branch, but it may exist even 
in emphysema. 
3. Prolonged expiration. This occurs when the exit of the air from 
the alveoli is more prolonged than is normal, and this condition may 
be dependent upon diminished elasticity of the lung-tissue: emphysema 
or bronchitis—a certain degree of bronchial narrowing, which does 
not hinder the entrance of air, but its exit only. Of these two con- 
ditions, prolonged expiration is an important diagnostic mark, and 
here, again, especially comes into consideration bronchitis which ac- 
companies the commencement of tuberculosis of an apex of the lung. 
The prolonged expiration of bronchitis is also generally sharpened, 
more markedly aspirant, somewhat more distinctly bronchial than 
normal. With pronounced bronchial expiration thickening may be 
conjectured to have taken place. (See below.) 
4. Jerking inspiration may likewise be a sign of bronchitis, namely, 
in case the two conditions are excluded which, within the normal, 
cause these or a like phenomenon (see above, Sec. 3, p. 143). This 
pathological jerking respiration, according to its prominence, is con- 
fined to the region of the bronchitis, generally to an apex, as in 146 
S PE Cl A L DIA GNOSIS. 
phthisis, and thus is distinguished from the interrupted inspiration of 
awkward breathing; but it exists always at the beginning of the 
examination. It results from the delayed entrance of the air into the 
lung portion of the bronchial tubes, if these are narrowed by catarrh. 
It takes place with sharpened and with jerking breathing, and 
breathing with prolonged expiration, since in the majority of cases it 
is called forth or is accompanied by bronchitis, generally, also, tone- 
less rales. (See below.) 
(b) Bronchial Breathing.—In order to understand the patho- 
logical development of this respiratory sound, it first is of the greatest 
importance that it should be made clear how the respiratory sound 
normally at the glottis, pathologically also at every sudden narrowing 
of a not too small bronchus, exists as a bronchial sound, how it is 
further conveyed by the subdivided columns of air in the bronchial 
tree as a bronchial sound, and how in healthy persons it is deadened 
by lung-tissue normally containing air into the vesicular breathing 
sound. There is no breathing sound without open bronchial tubes ; 
there is no vesicular breathing without lung-tissue containing air. If 
between the bronchi and the ear there is no air-containing lung-tissue, 
if anything at all is heard, it is bronchial breathing. 
Pathologically, bronchial breathing occurs in thickening of lung- 
tissue of a certain extent—that is, in case it involves an extent that 
reaches as far as moderately sized bronchial tubes. Here belong acute 
and chronic pneumonia, infarction, under some circumstances new 
formations; and, also, compression of the lungs so that the air is 
expelled by a correspondingly large pleuritic exudation (this is 
generally near the upper posterior boundaries), or by tumors of any 
kind in the chest-cavity, or by very high position of the diaphragm. 
If these conditions, which encroach upon the space of the chest, 
only involve retraction of the lungs so that they still contain air, the 
breathing remains vesicular; on the other hand, if they are so strong 
that they also compress the larger bronchial tubes, then we do not 
hear anything at all. 
If a pneumonia is combined with a stopping of the bronchial tubes 
(mucus, fibrin), then, on account of this imperviousness, we do not 
hear anything, but after a cough the bronchial tubes may become 
pervious: there is bronchial breathing. 
Moreover, we hear bronchial breathing over the lung-cavities and EXAMINATION OF THE RESPIRATORY APPARATUS. 
147 
in open pneumothorax; and besides, over the former, sometimes over 
the latter, we always hear it in the form of amphoric breathing (see 
below). It is only when the cavity is near the surface that we have 
bronchial breathing over it, when it is surrounded by tissue that 
contains no air and is in open communication with a not too small 
bronchial branch. In both conditions the bronchial sound really 
arises from the fact that the air, flowing out of the bronchus that con- 
nects with the cavity, or which, connected with a pleural cavity, enters 
into a larger air-space, or out of this air-space, again, into a narrow 
bronchial canal, is set into whirling motion. But there is no doubt 
that, besides, the sound that is conveyed from the glottis joins with it 
as broncLal. (See further upon this point under Amphoric 
Breathing.) 
In the cases just mentioned, the bronchial breathing sound may, 
under various circumstances, become weakened, namely, either when 
the advance of the sou .id to the ear is made difficult, or when the 
breathing is weakened. Thus, of an exudative pleuritis, in conse- 
quence of the fluid which generally lies between the ear and the 
compressed lung, a slight, distant-sounding bronchial breathing is 
characteristic (“breathing of compression”); while, on the other 
hand, in croupous pneumonia, almost always there exists a very loud, 
sharp bronchial sound E"t in pneumonia otherwise rare conditions 
in their turn may weaken the bronchial breathing; in closure of the 
bronchial tubes, as was mentioned before, we hear low bronchial 
breathing, or else nothing at all; further, in the so-called central 
pneumonia it may happen that from the part of the lung containing 
air which lies superficially, a vesicular, and, almost concealed by this, 
a low bronchial breathing sound is produced. Also, the loud pneu- 
monic bronchial breathing may be weakened if the pneumonia is com- 
plicated with an exudative pleurisy. 
In all these cases the low bronchial sound is usually most distinct 
during expiration (compare what was said above regarding expiration), 
often even only perceptible in expiration as a weak “ch” kind of 
blowing. 
The bronchial breathing of a hollow space may be weakened, or 
even lost—weakened, in temporary narrowing or closing of the 
bronchus leading to it, by mucus (hence, loosened by cough); or lost, 
by the filling of the cavity with secretion. On the other hand, a thick 148 
SPEC IA L DIA GNOSIS. 
callous pleura covering a cavity may be the occasion of deadness before 
bronchial breathing is affected. 
Special forms of bronchial breathing are the amphoric and the 
metamorphosing breathing. The former exists with very large, 
smooth-walled, communicating cavities and in open pneumothorax. 
It is a bronchial sound with metallic tone, exactly analogous to the 
metallic percussion sound that arises by resonance in large smooth- 
walled cavities. 
It may, moreover, be found besides in open pneumothorax (and 
where there is valvular connection), also in closed, although more 
rarely and only very softly, since here the (bronchial) sound of the 
air flowing into the trachea acquires a resonance in the air-containing 
pleural cavity; likewise, rales, heart-sounds may acquire a metallic 
tone. 
Metallic associated sound may also, in rare cases, accompany un- 
defined—that is, bronchial breathing unnoticeably weakened; thus 
also, not rarely, in pneumothorax. It might, indeed, be suitable 
to designate it not as “amphoric,” but as “undefined, with metallic 
associated sound.” 
Metamorphosing breathing (Seitz). In this the inspiration is 
divided : it begins distinctly bronchial, like the sound of stenosis, and 
suddenly changes to a weak bronchial breathing, which is then also 
heard during expiration. This phenomenon is very rare; it is said 
to be a sure sign of cavity. It is explained that the bronchus leading 
to the cavity is always first narrowed, and in the second part of 
inspiration it becomes dilated by the current of air (?). 
(c) Undefined Breathing.—The breathing sound may in two 
ways be of such a character that it may be designated either as dis- 
tinctly vesicular or as distinctly bronchial. It may be so weak that 
its character remains indistinct, or it is concealed or drowned by other 
sounds, particularly by rales; or, while it can be heard, it does not 
entirely correspond to either type of breathing, but seems rather to 
stand between the two, thus sometimes inclining more to bronchial, 
at other times more to vesicular, breathing—“transition breathing,” 
“hinted or indistinct bronchial or vesicular breathing,” “sharp 
breathing with bronchial breath in expiration,” etc. 
The causes of what is included in the first category are very various 
(see what was said above concerning the strength and weakness of the EXAMINATION OF THE RESPIRATORY APPARATUS. 
149 
breathing sound). Of course, the examiner’s sharpness of hearing is 
an important factor here. Rales that may be present may frequently 
be removed or diminished by coughing strongly. 
The second group of undefined breathing is, of course, much more 
numerous with beginners than with those who are practised in 
auscultation. It is well, however, for the latter also to impose upon 
themselves some reserve in pronouncing whether it is vesicular or 
bronchial. The determination is often actually possible either by 
the tone itself or by the strength of expiration in relation to inspira- 
tion. Frequently, also, as in beginning phthisis, in various lobular 
pneumonic deposits, the physical conditions resulting from the 
pathologico-anatomical changes cause it to appear that there is a 
“ transition breath ”—that is, a mingling—in that the infiltrated part 
of the lung favors the transmission of the bronchial sound unchanged, 
the parts containing air convey the breath-sound to the ear toned 
down to the vesicular sound. Hence, wre may under no circumstances 
miss this idea of “transition breathing,” and it is best in such cases 
simply to describe the breath-sound. 
id) Dry Rales (Rhonchus, Humming, Whistling, Hissing).— 
Like all rales, these are pathological sounds; they appear when there 
is a bronchial catarrh, which furnishes a tough, scanty secretion; they 
constitute those audible phenomena that are caused by the rushing 
together of the air and secretion in the bronchial tubes. It is as 
difficult to make a sharp distinction between a “ tough ” and a “fluid” 
secretion of the bronchial tubes as in a stricter sense it is to separate 
the so-called “ dry ” from what is later referred to as “moist” rales— 
much more, since transitions are everywhere present. Meanwhile, 
however, the class of sounds here referred to take a somewhat special 
place, both on account of the auditory impression they make and be- 
cause they exactly correspond to the very toughest bronchial secretions. 
The humming, hissing, whistling sounds (sonorous, sibilant rales) 
arise from the fact that the swelling and mucus narrow the bronchial 
air-passage, and, hence, they are sounds of stenosis; but, besides, some 
of the very fine high hissing and whistling tones may be caused by 
the presence in the bronchial lumen of tense threads of mucus stretched 
across, which, like the strings of an iEolian harp, are blown upon by 
the current of.air. 
Sibilant rales very often have such a high musical tone that it 150 
SPECIAL DIAGNOSIS. 
cannot be deadened even by the air-containing lung. Under some 
circumstances they may be confounded with the so-called ringing rales 
[metallic rales]. The dry humming often shows unnoticeable transi- 
tions to the character of the sound of the moist rales, approaching 
more nearly to crepitation. According to my view, they may still 
as dry, become ringing, rales—that is, may exhibit a ringing character 
like bronchial breathing. This is the case when we have thickening 
of the lungs and at the same time bronchitis with tough mucus. (See 
ringing rales, under Moist Rales.) 
The humming, hissing, wdiistling may be abundant or scanty, loud 
or soft. It may occupy the whole time of inspiration and expiration 
and completely conceal the breath-sound, or it may only be heard at 
the end of inspiration. A very fine soft whistling is sometimes heard 
during the whole of expiration, since then, so far as vesicular breathing 
is concerned, the breath-sound is very soft. When they are very loud 
they may even be heard at a distance (a distinguishing peculiarity of 
emphysema). Finally, there are buzzing sounds in the chest which 
may be felt when the hand is applied to it. Cough has sometimes the 
effect of diminishing, and sometimes of increasing, them—at least the 
humming is generally very markedly changed by it. 
It is not easily possible to confound the humming sounds with the 
pleuritic friction sounds (q. v). On the other hand, I have not in- 
frequently found that a very soft, fine humming was mistaken by 
beginners for sharp, even bronchial, breathing sound. This, as well 
as the distinguishing of whistling and hissing from a peculiar ringing 
rale, can only be learned by practice. 
Conclusions. Humming, whistling, hissing sounds, as has been 
shown above, show a dry bronchial catarrh. Spread over the lungs, 
they are present with diffuse bronchitis, with tough secretion, when it 
occurs independently, but especially as an accompaniment of emphysema, 
in which they are almost never wholly wanting. In these cases the 
lower lobes of the lungs are generally the seat of the catarrh. When 
there is simply bronchitis, then these rales and a sharpened or 
weakened breathing are the only local physical signs of disease. In 
emphysema the percussion and auscultatory signs of this condition 
are also present. Localized dry rales exist as signs of catarrh of the 
apices, which accompanies commencing tuberculosis; here a low 
whistling in a perhaps somewhat prolonged expiration may for a long EXAMINATION OF THE RESPIRATORY APPARATUS. 
151 
time form the only symptom. Ringing dry rales are rare; I have 
most frequently heard them in pneumonia at the beginning of the 
second stage. 
In all these cases the dry rdles may be combined with the moist; 
regarding these see below. 
(e) Moist Rales.—These arise in the bronchial tubes, except the 
smallest, and in the pathological cavities of the lungs [vomicae]. 
Their production requires more or less fluid secretion; the more fluid 
there is the more moist the sound; if it is tougher, then there are 
“ viscid-moist ” rales, a transition to the dry. Generally, the ear 
directly receives an impression of a greater or less degree of moisture. 
Formerly, moist rales were explained as being produced by the 
bursting of bubbles which the current of air caused upon the surface 
of the fluid. More recently, they have received another explanation : 
according to the analogy of the bubbles which we see formed when 
we blow through a tube one end of which is immersed in water, it is 
supposed that the current of air separately moves the air-bubbles 
which present projections into the bronchial tubes, and that as one 
such quantity of air breaks the bridge through the fluid and advances, 
the fluid behind it, immediately rushing on again and occupying the 
space, shares the vibration in the pent-up air (Talma, Baas). It is 
to be added that many consider moist rales in part due to stenosis; 
and, finally, that it is said that the to-and-fro motion of the secretion 
produced by the current of air causes rdles (Traube). The explana- 
tion by Talma and Baas will serve very well for the rdles formed in the 
medium-sized bronchial tubes ; for vomicae it only serves in case the 
bronchial tubes leading thereto are immersed in the fluid secretion, 
which, indeed, is ordinarily not the case. Here, and with large 
bronchial tubes at any rate, we must think of bursting bubbles. 
Moist rales may be so numerous that they can be heard in both 
inspiration and expiration, even outlasting the expiration. If they 
are scanty, then we are apt to hear them during inspiration, under 
some circumstances only toward the close of inspiration. A slight 
cough may increase them, or cause them, in case they were for the 
time being absent. 
In cases where the rdles are very scanty, scarcely to be heard, it is 
useful to inquire as to the time of day the cough is the most frequent, 
and to listen to them before the occurrence of the paroxysm of cough, 152 
SPECIAL DIAGNOSIS. 
so as to make the examination before the bronchial tubes have been 
cleared of mucus (as shortly after waking). 
The different moist rales make an impression upon the ear of dif- 
ferent “size,” and even beginners can without difficulty judge approxi- 
mately whether they are found in a large or a small bronchus or cavity; 
we speak of large, small, also medium-sized rales. The discrimination 
of rdles in this respect is very important; for instance, we may distin- 
guish whether we have a bronchitis of only the large, or whether the 
smaller tubes have become involved; the dangerous capillary bronchitis 
of childhood is manifested by very small, fine rales, and also by crepi- 
tant rales (see below, page 154). Large rfiles may furnish an index 
in the examination of the apices: these contain only very small 
bronchi; hence, if in an apex there are large or only medium-sized 
rales, these cannot arise from the bronchi there, hence there must be 
a pathological space—a cavity. If there are large rale sounds which 
undoubtedly arise in the apex, they are a most certain sign of cavity. 
The loudness of the rales does not depend upon their number, but 
upon the strength of the breathing. But the loudness furnishes an 
indication of the place where they arise : cceteris paribus, the sound 
will be loudest at the point where the ear is nearest to them. It may 
be of the very greatest importance to locate them exactly. Here, 
again, the most striking example concerns the diagnosis of phthisis, 
and, too, of the ominous catarrh of the apex. By a superficial exami- 
nation it may easily happen to the inexperienced, especially in the 
examination of the back, that he locates rales which come from the 
neighborhood of the root of the lungs and are those of a benign 
bronchitis in the apex, and hence makes the diagnosis of phthisis. 
It is of the very highest value, but often not easy, to distinguish 
whether we have a ringing or “consonant ” (Skoda), or a non-ringing 
rale-sound. The former is acoustically related to the latter, as the 
bronchial breathing sound is to the vesicular (as tympanitic percussion 
note to lung-sound), and, like that, ringing rales appear if there be 
present either a thickening of the lung of sufficient extent, or if there 
be a cavity. But yet bronchial breathing and ringing rfiles, and 
vesicular breathing and non-ringing rales, are not always necessarily 
associated together; thus, not infrequently when there are small 
cavities, and even large ones, especially in the lower lobes, in case 
they are covered by a not very thick layer of air-containing tissue, we EXAMINATION OF THE RESPIRATORY APPARATUS. 
153 
hear ringing rales when the breathing is undefined, yet hinting toward 
the vesicular. In children, even when there is no trace of cavity or 
thickening, in simple bronchitis the rales may reach the ear as loudly 
ringing (from the elasticity of the lungs and of the thorax). On the 
other hand, in pneumonia and pleurisy we sometimes hear bronchial 
breathing and non-ringing rdles. 
But now, corresponding to “ transition breathing,” very frequently 
there are to be heard such rales as stand between the non-ringing and 
the pronounced ringing (“hinted” or slightly ringing rales). It is 
often difficult to interpret these. In general, with children they fur- 
nish no reason for the supposition of thickening or cavity more than 
with adults. 
Loud ringing, hinted ringing, and non-ringing rales are often found 
together; we may even say that almost never do we hear ringing rales 
alone at one place. But, of course, if they are present they predominate. 
Though they exist very near together, yet they can be locally separated, 
as sometimes in emphysema ; here, with extensive humming, whistling, 
and non-ringing rales at a certain point of the lower lobe, there may 
be ringing rales (perhaps without bronchial breathing, and without 
deadened or tympanitic resonance): this makes a bronchiectatic 
cavity probable. But, also, by the same signs, in general bronchitis 
a broncho-pneumonic deposit may be made known. 
As the ringing rales correspond to bronchial breathing, so in their 
manifestation the so-called metallic rales correspond to amphoric 
breathing (metallic percussion note); but again in such a way that 
the two symptoms are not necessarily united together. The metallic 
rfiles then occur in correspondence with very large, smooth-walled, 
superficially-located cavities, and also in pneumothorax, where, arising 
from sections of the lungs which are breathing (even if on the other 
side), they are to be regarded as rale-sounds in the air-containing 
pleural cavities endowed with resonance. 
Sounds of falling drops. These are often only separate, generally 
very much inflated, moist rales, which have a high metallic note; 
sometimes, indeed, there is only one in each phase of the breathing; 
then the above-mentioned designation of it serves. 
Water-whistling, or the sound of lung-fistula (Unverricht, Riegel). 
We thus designate a metallic rale, or very fine metallic gurgling or 
splashing, which occurs in open pneumothorax, if the patient’s position 154 
SPECIAL DIAGNOSIS. 
is such that the opening in the pleura is directly below the smooth 
surface of the fluid, and if the patient then draws a breath (first 
observed by Unverriclit while puncturing and aspirating a case of 
hydro-pneumothorax. 
(/) Crepitant Rales (Crepitation).—Briefly expressed, by this 
we understand the finest rdle sounds. It occupies a special place on 
account of its acoustic peculiarity, on account of its cause, which 
permits its classification either under the moist or under the dry rales, 
and, finally, on account of its special diagnostic meaning. 
The so-called atelectatic crepitation occurs in health, and still more 
in disease, over parts of the lung which have for a time been breathing 
poorly and now are again distended by a full breath. Most frequently 
is it observed after quite long, especially low, dorsal position, over the 
lower parts of the lower lobes. It is purely inspiratory, and disap- 
pears generally after the first deep respirations. 
Like this are crepitant r&les which are to be heard in croupous 
pneumonia during the first and in the beginning of the third stage 
(crepitatio indux and redux), sometimes in catarrhal pneumonia, 
moreover in infarction, in individual cases (according to the author’s 
observation) of caseous pneumonia, and, finally, especially in oedema 
of the lungs. 
In all these cases we have to do with crepitation, heard during 
inspiration, or, at most, only the beginning also of expiration, which 
occurs in very fine and equal-sized bubbles. It is well compared to 
the noise produced by rubbing a lock of hair between the fingers in 
front of the ear, or by separating the thumb and finger moistened and 
pressed together as they are held before the ear (Eichhorst). It arises 
in the smallest bronchial tubes, the alveolar spaces, and in the alveoli 
when these are collapsed and glued together, or partly filled with 
secretion, and then during strong inspiration their walls are torn 
apart or freed from secretion.1 
The non-uniform crepitation, so called, forms the transition from 
these sounds to the fine bubbling r&les. More than elsewhere it 
occurs with capillary bronchitis and also in oedema of the lungs. It 
is to be understood as a mixture of peculiar crepitations and small 
1 It is only in individual cases that this crepitation is heard in expiration, and still 
more rarely only in expiration. (Penzoldt.) EX AMIN A TION OF THE RESPIRA TOR Y A PPARA TUS. 
155 
bubbling rales, and it accordingly is, in its coarse sounds, to be heard 
also in expiration. 
(g) Pleuritic Friction-sounds.—The respiratory gliding of the 
pleura costalis upon the pleura pulmonalis, which normally is noise- 
less, is perceived by the ear and can also be felt when the hand is laid 
upon the chest when there are inflammatory deposits upon the serous 
surfaces. Thus, it is really the pleuritis sicca that causes it. Only 
in rare cases of unevenness of the pleura is this phenomenon observed 
in the absence of inflammation, as in acute miliary tuberculosis of the 
lungs and pleura; also in pneumono-Jconiosis. The conditions most 
favorable for the occurrence of this sound are where the respiratory 
movement of the lungs (forward and downward) is most marked: be- 
low and especially at the sides. But this sound may also exist farther 
up, even almost as high as the apex. 
Pleuritic friction sounds like regular scraping, or like a scratching, 
creaking, beginning in distinct pauses, which ordinarily is louder dur- 
ing inspiration than expiration. Quite in the same way as it comes to 
be heard, it can be felt: the “sensible frictions” are best recognized 
by the laying on of the flat hand. It is not changed by cough, but 
continued deep breathing often causes it to disappear, since in this 
way the unevenness, upon which it depends, is smoothed out. 
When this friction-sound is very loud and characteristic it is easily 
recognized. A difficulty may arise when it is very softly heard; this 
often occurs from the fact that the examiner does not auscultate at 
the right spot, for friction-sound is heard in only a circumscribed 
area, since it is poorly transmitted. A further difficulty lies in dis- 
tinguishing it from certain medium-sized, tough, moist rales (cracking 
rales) and from soft buzzing; here it is most important to take note 
of the character of the particular sound, and the knowledge and recog- 
nition of this can only be acquired by practice. We may make use 
of the effect of coughing as an aid. Sometimes moderate pressure 
with the stethoscope increases the pleuritic sounds; also, palpation 
may help us to recognize them. Rale-sounds are seldom, or, at most, 
only slightly, to be felt. 
It is to be remembered that friction- and rdle-sounds may occur at 
the same time. Besides in pneumonia, I have observed it most fre- 
quently in disseminated tuberculosis and in caseous pneumonia of the 
lower lobes. 156 
SPECIAL DIAGNOSIS. 
Friction occurs with all kinds of pleuritis. It occurs (seldom) in 
acute exudative pleuritis in the beginning of the attack, and also, as a 
favorable sign, later with the absorption of the fluid exudation. There 
can be no friction-sound while there is fluid present, since it is only 
heard when the pleural surfaces are in contact. In chronic pleuritis 
it may last indefinitely and over a large extent. Of the diseases of 
the lungs which usually are accompanied by pleuritis sicca many are 
first revealed by the friction-sounds which the latter causes: thus, 
phthisis, also pycemic deposits in the lungs, infarction, bronchiectasis 
with reactive pneumonia, and pleuritis with emphysema. 
Regarding pleuro-pericardial friction-sounds (pericarditis externa), 
see under Auscultation of the Heart. 
(h) Hippocratic Succussion.—This is a phenomenon very easy 
to understand. 
In sero- and pyo-pneumothorax, after a strong shaking of the chest, 
as in any vessel partly filled with fluid, there is splashing. This 
splashing, through the resonance associated with metallic tone, like all 
the audible phenomena of pneumothorax, is heard at a distance or by 
applying the ear to the chest. 
This sign is usually most distinctly manifest when there is a small 
effusion and when it is serous. It is almost pathognomonic of hydro- 
pneumothorax in that it only elsewhere occurs in very isolated cases 
of large cavity with quite fluid contents. 
The direction of Hippocrates was to shake the patient by the 
shoulders; but, on account of the grave condition of most of these 
patients, the greatest care is necessary. Many quickly learn to shake 
the body so as to produce the sound themselves. 
Confounding this with the splashing from the stomach or colon will 
be avoided by local examination of these organs and by repeated 
examinations. 
PALPATION OF VOCAL FREMITUS (AUSCULTATION OF THE VOICE). 
Strictly speaking, this method of examination belongs in part to 
Palpation and in part to Auscultation; but at the same time it has a 
place here, because this comes next in the course of a thorough exam- 
ination of patients. It is, besides, of sufficient importance in itself 
to be treated separately, because after Inspection, Palpation, Percus- EXAMINATION OF THE RESPIRATORY APPARATUS. 
157 
sion, and Auscultation have been completed, not infrequently it hap- 
pens that this casts the decisive vote. 
The vibrations of the glottis in phonation (speaking, singing, 
screaming) originate in the column of air in the trachea and bronchial 
tubes rather than in their walls; they traverse the lung-tissue, where, 
in case this is normal, they become considerably weakened, then the 
wall of the thorax and its coverings, and may be felt by the hand laid 
upon the chest as a whizzing: voice vibration, voice fremitus, pectoral 
fremitus (besides heard as indistinct humming ; see below). 
The technique of this method of examining is as follows : While the 
patient counts aloud, or, still better, repeats the same word (one, for 
example), the hand is laid upon different parts of the chest. Gener- 
ally we employ the palm of the hand, but for finer examination it is 
preferable to apply the ball of the little finger or the tips of the first, 
second, and third fingers. Regular practice perfects one in the use 
of auscultation of the voice. Differences of voice vibration are dis- 
tinguished by comparison of different locations and particularly of 
symmetrical points. It is quite unnecessary in making this compari- 
son to apply both hands at the same time to the two sides of the chest; 
the difference is much more distinctly felt if we examine with the same 
hand, first upon one side and then upon the other. 
Within normal limits, vocal fremitus is stronger the stronger the 
voice; it is very distinct when the voice is rough and deep, weak if 
the voice is high, and even not to be felt at all when the voice is high 
and thin (light), as is sometimes the case in women and children. 
The separate vibrations are felt more distinctly the richer and more 
prolonged they are. The fremitus is stronger upon the right side of 
the chest than the left, probably because the right bronchus is the larger 
in diameter. It is, moreover, very noticeably influenced by the thick- 
ness of the covering (muscles, mamma, subcutaneous flit). 
There may be pathological conditions present upon one side that 
will not propagate the vibration of the voice so well as a normal con- 
dition would do, which may diminish or remove the vocal fremitus; 
on the other hand, they may better propagate it; strengthen the 
vocal fremitus. 
Weakness or suppression of vocal fremitus occurs with pleuritic 
exudation (on account of the narrowing of the bronchial tubes from 158 
SPECIAL DIAGNOSIS. 
compression and on account of the encroachment of the fluid); with 
;pneumothorax, on the one hand, either on account of the poor con- 
duction through the bronchial tubes of the retracted or the compressed 
lung, or, on the other, because it is not conducted through the air- 
cavity. If, however, there should he growths on the pleural surfaces, 
even if only in the form of fine fibres, these ordinarily act as good 
conductors of vocal fremitus. Finally, vocal fremitus is wTeak or sup- 
pressed with tumors of the pleura, and all thickenings of the chest- 
wall (abscess, oedema), and in closure of the bronchial tubes, since 
these are the most important means of propagating the oscillations 
(closure from mucus, masses of fibrin, foreign bodies, compression). 
Increase of vocal fremitus is observed in pneumonia, since the 
solidified lung-tissue is a better conductor than when it contains air; 
for the same reason, sometimes, when the lung is compressed against 
the thorax-wall; above pleuritic exudation, and generally posteriorly 
at the roots of the lungs; and in cavities with open bronchus and 
small secretion—here partly by the good conduction of the sound and 
partly by consonance. 
Vocal fremitus is an extremely valuable means of distinguishing 
between pneumonia and pleuritic exudation. Yet it may, in rare cases, 
so far deceive as that in pneumonia, if the bronchial tubes are stopped 
by secretion, there is no increase of vocal fremitus; it is even dim- 
inished, and, occasionally, with complete filling-up of the bronchial 
tubes, may even disappear altogether. Under some circumstances 
after cough and expectoration, as after a cool bath, it may return. It 
is easy to see how various the result may be if pneumonia and pleurisy, 
or if a cavity and thickened pleural walls, are combined. 
In most cases, in my opinion, auscultation of the voice may be dis- 
pensed with where one is thoroughly trained in testing the vibration 
of the voice by palpation, especially by using the tip of the fingers. 
In reality, its result is fully analogous to that of palpation. Normally, 
over the thorax, we hear the voice of the person examined as an 
indistinct humming, which pathologically may be weakened or lost; 
but it may be strengthened to an extraordinary loudness (bronchoph- 
ony), wholly under the conditions which correspond to those that 
influence vocal fremitus. 
We sometimes find a very marked bronchophony over those cavities EXAMINATION OF THE RESPIRATORY APPARATUS. 
159 
where we hear amphoric breathing and metallic rales. Here, also, 
the bronchophony may acquire a kind of metallic quality (Laennec’s 
pectoriloquy). 
JEgophony, “ bleating-voice,’’ is a peculiar nasal, bleating pec- 
toriloquy, as we hear it, with pleuritic exudations, in the neighborhood 
of the upper boundary of dulness. 
Auscultation of the whispered voice was introduced by Baccelli. 
He found that it was propagated by serous exudations of the pleura, 
but not by purulent, since the latter dispersed the sound-waves. In 
most cases this method must be considered as without value, since in 
large serous exudations with marked compression of the lungs we as 
often do not hear the whispered voice. We may recognize it in very 
small and fresh purulent exudations, unconnected with thickening of 
the pleura. 
Palpation and auscultation of the voice, of course, cannot be made 
in all those cases where the voice cannot be produced, as in uncon- 
sciousness and exhaustion, or when the patient is dumb (aphonic), or 
where, from caution, we do not wish to have the patient speak aloud, 
as in haemoptysis, peritonitis, etc. Scherwald has recently devised a 
new procedure, which can be recommended—plegaphonia, or ausculta- 
tion during percussion upon the larynx or trachea. The vibrations 
produced in this way take the place of those of the vocal cords during 
phonation, and this procedure is exactly synonymous with auscultation 
of the voice. 
Mode of application : We have some one else place a large ivory or 
hard-rubber pleximeter upon the surface of the thyroid cartilage or 
upon the trachea, and percuss with a hammer (sometimes the patient 
himself can do both). The patient closes his mouth. By preference 
we auscult during expiration. Ausculting on the thorax, we hear 
the blows : 1, over the sound lung, very markedly weakened (loudest 
over the apices), as if it were vanishing, not tympanitic, but with a 
cracked-pot sound; 2, over infiltrated lung, very loud, tympanitic, 
with Wintrich’s change of sound [which see] ; here, also, the ear has 
a sensation as if the blows were upon itself; 3, over an exudation, 
simply weak, even to complete absence; 4, over cavities, the same as 
over tissue empty of air; over large open cavities, very loud, “smiting”; 
5, over pneumothorax, a metallic sound. 160 
SPECIAL DIAGNOSIS. 
Exploratory Puncture of the Pleura. 
Mode of procedure: For this small operation we employ either an 
ordinary large hypodermic syringe, or, better, a larger syringe of the 
same construction with a slightly larger canula—about seven cm. long. 
The syringe must always be kept very clean, and before using must 
be disinfected most carefully with carbolic acid or bichloride of mer- 
cury. The packing must be very tight. The needle is inserted in an 
intercostal space perpendicular to the surface with the piston pushed 
in, and then the piston is withdrawn. If the point of the needle rests 
in fluid, this will rush into the syringe. 
Directly before making the exploratory puncture the patient must 
be placed in exactly the same position he is to occupy during the 
operation, then be carefully examined, and especially percussed. 
In this way we may ascertain whether there is fluid in that portion 
of the thorax, and of what kind it is. It is especially applicable in 
the diagnosis of pleuritis (more rarely in hydrothorax and hydro- 
pneumothorax). It is to be performed in the following cases : 
1. When there is the slightest doubt whether there is pleuritis or 
not. In the first place we have to consider the differential diagnosis 
between pneumonia, tumors of the chest-cavity, and thickening of 
the pleura (compare p. 158). In either of these three conditions 
the syringe will draw out nothing at all, or, at most, only a drop of 
blood. But positiveness of conclusion is limited in two ways: (1) 
Sometimes we do not reach the fluid with the syringe if the pleural 
exudation is buried behind a thick pleural membrane, or behind 
tumors of the chest-wall, because it does not penetrate as far as the 
exudation. (2) Even when the fluid is within reach, we often do not 
obtain any in case it contains floccules of fibrin, or it is a thick puru- 
lent fluid; either of which will close the needle. With these two 
possibilities, a limited value must always be assigned to the negative 
result of exploratory puncture. 
2. To determine the nature of the fluid in the pleural cavity. If 
the small quantity of fluid withdrawn is quite or almost clear, like 
water, if it contains no material elements, if there is no coagulation of 
fibrin, and if on boiling1 there is little or no albumin, then the fluid is 
1 This test is difficult with a small quantity, but yet by care it may be applied by 
using a small test-tube, and adding water. EXAMINATION OF THE RESPIRATOR F APPARATUS. 
161 
a transudation ; otherwise it must be regarded as an exudation. The 
exudation may be serous, sero-fibrinous, sero-purulent, purulent, 
hemorrhagic, odorless or ichorous, or feculent. With purulent ex- 
udation there are never wanting, in the microscopic examination, 
besides the pus-cells, micrococci (streptococci and diplococci); of other 
organisms in pleural exudation, the tubercular bacillus comes into 
consideration (for the manner of demonstration see p. 188), and 
actinomyces (see p. 189). The latter elements, however, can hardly 
be obtained by the hypodermic syringe. Absence of tubercle bacillus, 
even the negative result of culture, does not decide positively against 
tubercular pleurisy. Even in empyema of tuberculous origin, cultures 
and inoculations are generally negative. (A. Frankel.) The bacilli 
and spores are only present in the exudations if disintegration of 
tubercle takes place upon the diseased pleura. Micrococci are always 
found in great quantities in septic pleuritis. 
In carcinomatous pleuritis, carcinomatous cells are sometimes found 
in the exudations. However, Quincke, the greatest authority upon 
this subject, has acknowledged that single carcinomatous cells cannot 
with certainty be distinguished from the pleural endothelium, and at 
best that this method of diagnosis is extremely difficult. Both species 
of cells, affected with fatty degeneration or granular, are found filled 
with large “ vacuoles.” If very abundant, both may form a cream- 
like layer upon the surface of the fluid drawn off. We must think of 
carcinomatous cells (which, moreover, can only occur when a carcinoma 
has ulcerated into the pleura), if the cells exist in abundance, are in 
balls, show great variations in form and size, and are colored brown 
by iodine (glycogen reaction). 
Hemorrhagic exudation makes the existence of tubercle or car- 
cinoma of the pleura probable. If the exudation is feculent, there is 
some connection with the intestine. But, sometimes, there is no 
disease of the pleura at all, but a diaphragmatic peritonitis (see), 
which simulates a pleuritis. 
When pleuritis is complicated with erysipelas we ought to look for 
the coccus of that disease. But this is very difficult to distinguish 
from other cocci (especially streptococcus pyogenes, one of the most 
important pus-cocci), and it can only be distinguished by breeding and 
inoculation. 162 
SPECIAL DIAGNOSIS. 
Exploratory puncture, finally, must always be made— 
3. Before operative procedure when pleurisy has been diagnosed, 
even if the diagnosis seems to be perfectly certain. 
In making the exploratory puncture the needle and syringe em- 
ployed must be always first thoroughly cleaned and disinfected with 
carbolic acid or corrosive sublimate. The syringe must have good 
suction. From what has been said it is clear that we operate only 
upon the lower part of the chest, not higher than the fourth rib in 
front and the sixth behind. Of course, we must avoid the region of 
the heart, and when there is a suspicion of aneurism explorative 
puncture must be omitted; otherwise there is no need of anxiety. 
When the exploratory puncture is made with the observance of every 
possible precaution it is not a dangerous procedure. The puncture is 
made quickly, in an intercostal space, as far as the needle will reach ; 
if nothing is obtained, the needle is slightly withdrawn and suction 
again made. We may sometimes puncture at several points. 
Methods of Measuring and Stethography. 
Measuring the Thorax. 
This serves, in measuring once, to determine the size of the chest, 
and to secure an approximate point of departure for determining its 
relation to the development of the rest of the body. But it does not 
furnish knowledge of diseases any better than, with sufficient practice, 
is given by inspection and palpation. 
On the other hand, it has a very great value in connection with 
tracing the cross-section of the chest upon paper, if it is employed to 
determine the changes which the chest undergoes in the course of a 
certain disease. 
We measure the diameter of the thorax with the caliper-compasses, 
and it is best to take the broad diameter at the highest point of the 
axilla, the deep, or sterno-vertebral, diameter on the level with the 
nipple and the insertion of the second rib. In tracing a cross-section 
of the thorax upon paper we must, of course, make the transverse 
and antero-posterior diameters at the same level (whether at the nip- 
ples or lower down). The circumference of the breast is generally 
measured at the level of the nipple, but sometimes over the highest EXAMINATION OF THE RESPIRATORY APPARATUS. 
163 
points of the axillrn and at the lower end of the corpus sterni. The 
length of the chest may be ascertained by measuring in the mammil- 
lary line from the clavicle to the border of the ribs. The linea costo- 
articularis is very useful for determining any change in the length. 
The delineation of the form of a cross-section of the chest is made 
in the following manner: The opposite diameters at a given point are 
measured, and are marked upon a sheet of paper. Then a lead hoop 
or wire is accurately fitted first to one and then the other side of 
the chest at that level, then carefully removed and traced upon the 
paper. Instead of the leaden hoop (which is entirely satisfactory) we 
may employ Woillez’s Cyrtometer, which is a chain with links that 
move stiffly. 
Frequent measurements of the diameters and circumferences, as 
well as tracing the cross-section in the course of disease may give not 
unimportant results: in determining an increase or diminution of the 
quantity of pleural exudation or of the progress toward recovery by 
the amount of shrinking; in retraction of the lungs; but especially 
in all kinds of tumors of the chest-cavity. Thus, where aneurism is 
suspected, or a mediastinal tumor, the slightest increase in the antero- 
posterior diameter or of the circumference of the chest is of great 
significance. 
In view of what has been said, the statement of the exact measure 
is impossible. It is only important to know that the right side of the 
chest measures, in people who are right-handed, about 1 to 11 cm. 
more than the left; also, that the circumference of the chest at the 
level of the nipples in healthy persons is increased in inspiration about 
5 to 7 cm. 
Spirometry, Pneumatometry, and Stethography. 
If we here discuss these three methods of examination somewhat 
briefly and dogmatically, let it be understood that this is only from 
the point of view of clinical diagnosis. But as to the application of 
these methods to physiological and pathological examinations in ani- 
mals and man we take exactly the opposite view, for they, like meas- 
urements of the chest, can furnish many important conclusions. 
Spirometry is employed to ascertain the vital capacity of the lungs 
—that is, the quantity of air which, after deepest inspiration, can be 164 
SPECIAL DIAGNOSIS. 
given off by the deepest expiration. This is done by means of a 
Hutchinson’s spirometer, which is constructed on the principle of a 
gasometer. 
The relations of the size of the body to the vital capacity of the 
lungs are relatively the most constant. Von Ziemssen found that in 
men, if to each cm. of stature there was less than 20 c.cm. of vital 
capacity (or, in the case of women, less than 17 c.cm.), there probably 
was a considerable disturbance in the organs of respiration (phthisis, 
emphysema, adhesive pleuritis, bronchitis), or it already definitely 
existed. On the other hand, where the relation was as 1 : 25 (or 
1 : 22) this was improbable. The vital capacity is of more importance 
for supplementing other methods of examination in the course of 
observation of a patient, for the reason that it changes with the 
recovery from, or exacerbation of, the given disease. It is to be 
observed that there seems to be an increase in the vital capacity of 
every patient in consequence of increased practice. Spirometry does 
not here have an independent value. 
Pneumatometry is the determination of the pressure of the respira- 
tory air during inspiration and expiration. It is determined by means 
of the pneumatometer of Waldenburg, improved by Biedert and Eich- 
horst, a modified mercurial manometer. We find that in health the 
expiratory pressure is always greater than the inspiratory, but the 
absolute results vary still more than those obtained by spirometry. 
The diminution of the expiratory pressure in emphysema is important, 
and furnishes a certain conclusion as to the severity of the disease, as 
well as of improvement or extension. Diminished inspiratory pres- 
sure in stenosis of the air-passages, in phthisis, and in exudative 
pleuritis has no diagnostic meaning. 
Stethography is the graphic delineation of the respiratory motions 
of the chest and of the diaphragm. In many ways it is instructive 
and yields results that are valuable with reference to physiology and 
pathology, but it may be entirely dispensed with for the purposes of 
clinical diagnosis. 
Cough and Expectoration 
Cough is caused in the following way : By the closure of the glottis, 
after a deep inspiration has been taken, the pressure in the thorax EXAMINATION OF THE RESPIRATORY APPARATUS. 
by means of the auxiliary muscles of expiration is increased, and then 
suddenly the glottis is opened ; there results an audible outrush of air, 
which in turn brings with it the substances forming the expectoration 
(which substances cause rales). 
The ability to cough is lost, not only when the crico-arytenoideus 
muscle in the larynx, but also the respiratory muscles, are paralyzed 
(bulbar paralysis). Pain, also, may cause suppression of cough. 
Cough may be spontaneous or reflexive. Reflexive cough-irritation 
may arise from all parts of the mucous membrane' of the larynx, 
trachea, and bronchial tubes, as well as from inflamed pleura (“ pleural 
cough ”), no doubt occurring not infrequently. The trachea is espe- 
cially irritable, and particularly the region of the inter-arytenoidean 
space, likewise the bifurcation; inflamed mucous membrane is more 
irritable than normal. There is never any irritative cough from the 
lung-tissue. 
Cough may also arise from the abdominal organs reflexively, as 
from the stomach. I have known three persons who had a “nervous ” 
cough at the beginning of each menstrual epoch. The cough of 
hysteria must be regarded as reflex, or direct from the nervous 
centres (?). < 
The cough which is caused by disease of the respiratory organs at 
the points above mentioned, either because these are themselves dis- 
eased or because they are irritated by diseased products, is a most 
important sign of disease. Moreover, in spite of the existence of 
irritation, there may be no cough in any patient whose mind is 
markedly obtunded (as, .for example, in typhus abdominalis [typhoid 
fever], in disease of the brain, in carbonic-acid poisoning, in the 
death agony, etc.); hence, in these cases there is often considerable 
mucus rattling in the trachea, without any expectoration. The sudden 
stopping of cough and expectoration in consequence of unconscious- 
ness, often accompanied with weakness, is, therefore, particularly in 
many diseases of the lungs, as in pneumonia, a bad sign; in phthisis, 
also, it sometimes denotes approaching death. It has already been 
mentioned that cough may disappear as a result of paralysis of the 
muscles concerned in coughing. 
We can draw no diagnostic conclusion from the frequency of the 
cough. Regarding the time of day when it is most apt to occur, 166 
SPECIAL DIAGNOSIS. 
frequently in phthisis, and also in chronic bronchitis, this regularly 
occurs soon after waking. 
Dry cough is one that is not accompanied with expectoration. It 
is generally weak: “slight cough” (especially in the beginning of 
phthisis, also as “pleural cough” (see above); but also “nervous,” 
from bad habit). 
There is a cough w’ith tough expectoration, difficult to be dislodged, 
brought up generally after a long series of labored efforts; at the end 
there is generally hawking; the patient often pauses to rest, and then 
continues to cough until a final hawking and expectoration, as in 
emphysema with tough bronchitis, and in croupous pneumonia. 
Moist cough with fluid (more purulent) expectoration is easier, 
“looser.” Here it is often remarkable what a quantity of sputum is 
thrown off, as from a cavity—sometimes from two efforts at coughing. 
Moreover, with patients who are weak and very miserable, often a 
series of efforts are necessary, which efforts then generally end with 
hawking (phthisis in extremis). 
In whooping-cough the cough occurs in pronounced paroxysms. 
Here the inspiration is noisy, because it must be taken as quickly as 
possible, and also because the glottis is narrowed by swollen mucous 
membrane. In consequence of the prolonged effort at coughing, of 
the constantly increasing intra-thoracic pressure, and the diminished 
breathing, which causes a disturbance of the interchange of gases and 
blood-stasis, there is cyanosis; here, as otherwise in long-continued 
labored efforts at coughing, especially in phthisis, they finally very 
frequently end in vomiting. Severe attacks of coughing, moreover, 
result from swallowing the wrong way, as in paralysis of the throat 
from various causes. Unconscious patients often swallow the wrong 
way without any cough. 
The tone of the cough may be unnaturally deep and rough, like the 
voice, in ulceration of the larynx; in stenosis of the larynx it is 
either a short stenosis sound, or rough and bellowing (the latter with 
children with diphtheria or false croup); in continued aphonia the 
cough is sometimes toneless, sometimes remarkably rough and sharp. 
Hawking only brings up masses lodged in the pharynx, larynx, or 
the upper part of the trachea; but it must not be understood that 
what is thus brought up is formed at these locations; it may be EX AMIN A TION OF THE RESPIRA TOR Y A PP. 1RA TUS. 
167 
brought to the lower part of the larynx by previous cough or by the 
motion of the ciliated epithelium. 
EXPECTORATION, SPUTUM. 
By these terms is understood all that is brought up from the air- 
passages by coughing and hawking. According to the existing 
disease, they are formed from the secretions of the laryngeal, tracheal, 
and bronchial mucous membrane, from the contents of the alveoli of 
the lungs, and, lastly, from the contents of pathological cavities of 
the lungs, or from the lung tissue. In rare cases purulent exudations 
from the pleural cavities, from rupture of the pleura, may reach the 
air-passages and appear as sputum; still more rarely, by communication 
of the oesophagus or rupture of an aneurism, particles of food or blood 
may pass this way. The secretion of the mucous membrane or of the 
glands of the throat, of the mouth, of the nose, and also other sub- 
stances from these locations (as blood, microorganisms, particles of 
food), mingled in various proportions with the expectoration, may give 
rise to error. Expectoration may be entirely wanting, even when the 
material for expectoration may be present in the air-passages in con- 
siderable quantity, when there is absence of cough, or when the cough is 
feeble (see page 165); finally, it may sometimes happen in all diseases 
of the respiratory organs that there is either no cough at all, or only a 
dry cough. It is not unimportant to note that blood escaping from 
the stomach by vomiting may give occasion for swallowing and then 
be expelled by coughing; but, on the other hand, in hemorrhage of 
the lungs a part of the blood—sometimes a considerable quantity— 
may be swallowed, and may give rise to symptoms of hematemesis. 
When possible, it is best to collect the expectoration in a transparent 
glass vessel (as a matter of fact, we may readily understand that we 
shall generally have to employ a non-transparent receptacle). As 
much as possible, mixture with other substances, as vomited matters, 
is to be avoided. A white porcelain plate, with one-half of its surface 
blackened with asphalt, enables one to scrutinize more exactly the 
expectoration. The expectoration upon both halves of the plate is to 
be examined, and, in order to separate it or to remove a portion for 
microscopical examination, we employ a pair of microscopic needles. 168 
SPECIAL DIAGNOSIS. 
1. G-eneral Characteristics of the Expectoration. 
We must take into consideration the quantity, reaction, consistence, 
or form (here are included also the quantity of air mingled with it, 
and its arrangement in layers), its color and transparency, and, 
finally, its odor. 
The quantity of expectoration changes with the amount of material 
which is in a condition to he thrown off (and this differs very much 
with different diseases) and with the strength of the cough. We have 
already referred several times to the influences that determine this. 
In general, patients with certain forms of bronchitis (broncho-blennor- 
rhoea) and with cavities, especially those with bronchiectasis, have the 
most abundant expectoration; it may amount to one or two litres a 
day. Sudden marked increase of expectoration occurs with the 
rupture of empyema into the lungs. 
When not much contaminated with vomited matter the reaction of 
the expectoration is always alkaline. 
From the above-mentioned general peculiarities [consistence, form, 
color, except only the odor) we may recognize, according to its chief 
constituents, in which class the expectoration belongs. Accordingly, 
we distinguish : 
Mucous sputum. 
Muco-purulent sputum. 
Purulent sputum. 
Serous sputum. 
Bloody sputum. 
Mucous sputum. This is either quite glassy and transparent or 
whitish-gray, generally with some consistence, and tough; if more 
fluid, then it consists chiefly of saliva. It occurs in the first stage of 
acute bronchitis from the very slight—what may be called the physio- 
logical—secretion of mucus in the trachea. Yery often its source is 
higher up in the pharynx. 
Muco-purulent sputum. It consists of a mixture of mucus and pus 
in varying proportions. The latter is recognized by its yellowish- 
green color and its want of transparency. It may be distributed 
through the mucus in small particles or strings, or it may form larger 
flocks or balls held together by mucus; the latter, placed in wrater, are 
bullet-shaped; spread out upon the bottom of an empty glass, they EX A MIN A TI ON OF THE RESPIRATORY APPARATUS. 
169 
sometimes flatten out in circular form (coin-shaped sputa in case of 
cavities, but sometimes, also, in ordinary purulent bronchitis, as in 
measles); finally, in the scanty, spongy mucus with slight consistence, 
the pus of the separate sputa may run together (“confluent sputa”). 
If the sputum contains many air-bubbles, then these cause the separate 
lumps and balls to float in the wratery part of the sputum (serous fluid, 
or very watery mucus, or saliva). Mucus in three layers consists of 
an upper layer of masses and balls, which the air-bubbles cause to swim 
and from which hang down into the second layer, consisting of watery 
mucus and serum, slimy, purulent strings; on the bottom is a layer 
entirely confluent, like a deposit of decomposed pus (fetid bronchitis, 
gangrene of the lung). 
Purulent sputum consists of almost pure pus, whose source is either 
an abscess of the lung which has given way, or an empyema. Some- 
times almost pure pus may be coughed up when there is a sudden 
very considerable discharge from a cavity. As it traverses the air- 
passages, there is always some mucus mixed with it. 
Serous sputum is a special peculiarity of the sputum of oedema of 
the lungs. It is very fluid, but not so much so as blood-serum, being 
mixed with mucus. It consists of blood-serum, and, hence, contains 
albumin ; for this reason it retains air vesicles for a long time, as do 
all fluids containing much albumin ; it is markedly frothy. It is 
either a quite light gray and transparent, or, as is frequently the case, 
like a solution of flesh, owing to a slight admixture with blood; when 
containing much blood, it is the color of plum-juice (oedema of the 
lungs with pneumonia). 
Bloody sputum. All of the varieties of sputum previously mentioned 
may be mixed with blood. Slight mixture of blood is seen in the 
expectoration of tough mucus as bloody streaks (generally from the 
upper air-passages, often from the throat or nose, but yet sometimes 
from the lungs or the smallest bronchial tubes, as in pneumonia). 
A small quantity of blood with partial escape of coloring matter of the 
blood, intimately mixed with tough, glassy mucus, colors the sputum 
uniformly bright red with a greenish tinge, or, by transformation of 
the coloring matter of the blood, makes it yellowish-red, rusty, even 
greenish (all of these with pneumonia). In muco-purulent sputum, 
blood appears either in streaks or as little spots, as in phthisis, or 
intimately mixed : the pus is then reddish-yellow, brownish-yellow, or 170 
SPECIAL DIAGNOSIS. 
more markedly reddened (not infrequent with cavities). When there 
is only a small amount of blood, serous sputum is the color of solution 
of muscle. 
If there is considerable hemorrhage with the expectoration, it is 
markedly colored with blood; sometimes there may apparently be no 
sputum, but fluid blood may be expectorated in a liquid state, coagu- 
lating afterward. This is described as hemoptysis. When a pulmonary 
hemorrhage is quickly coughed up, the blood is bright-red and frothy 
from being mixed with the sputum ; but sometimes it gushes out in such 
quantity that there is no cough. It is distinguished from blood that 
comes from the stomach in that the latter, from longer stagnation and 
from the effect of the secretion of the stomach, generally is darker, 
quite brown, like coffee-grounds ; besides which it is often mixed with 
food and has an acid reaction. Yet the blood from the lungs, though 
only when there is considerable quantity, may be also dark, even 
black-red, if it has stagnated in the lungs or air-passages : thus, a 
patient who has had an hemoptysis may continue for a whole day to 
throw off* markedly bloody sputum, which becomes more and more 
dark in color. 
Hemorrhage of the lungs occurs very much more frequently with 
tuberculosis than from other causes. In this disease there occur all 
varieties of hemorrhage, from the scarcely-visible particles of blood or 
a slight coloring of the purulent discharge from a cavity to the pro- 
fuse, almost immediately fatal hemorrhage. Moreover, in infarction 
of the lungs there may be bloody sputum, or even pure blood may be 
discharged. Croupous pneumonia and oedema of the lungs are gen- 
erally accompanied with slight quantities of blood intimately mixed 
with the sputum. 
Sometimes it is perfectly easy to diagnose hemorrhage of the lungs, 
and again it is extremely difficult. Particles and streaks of blood 
occurring in the midst of purulent material are very suspicious. If 
they occur with gray mucus, it is generally quite unimportant (pharynx, 
nose); but when there is considerable hemorrhage, there may be doubt 
as to whether the blood comes from the stomach or lungs if the blood is 
expectorated very rapidly, and so is yet bright-red, and if, during the 
act of vomiting, some blood is aspirated and causes cough. On the 
other hand, blood from the lungs may seem to come from the stomach 
if, from stagnation, it is unusually dark, or if a part of it is swallowed EXAMINATION OF THE RESPIRATOR}' APPARATUS. 
171 
and then vomited. Blood from the nose and throat, when the patient 
is unconscious or asleep, may be drawn into the air-passages, and 
then, after considerable has accumulated, be coughed up, but more 
frequently it flows into the stomach. In the latter case, by inspection 
of the throat we may sometimes see a streak of blood marking the 
track upon the posterior wall of the pharynx. In all such cases a 
decision is to be reached by the most careful examination of both the 
lungs and stomach. 
A peculiar sputum, like raspberry jelly, is observed in cases of 
tumor of the lungs. Sometimes in hysteria there is an expectoration 
from the pharynx or oesophagus of a peculiar raspberry red, which 
may mislead one (recently described by E. Wagner). 
The odor of sputum is ordinarily stale; when it is scanty, it is often 
offensive from mixture with the secretions of the mouth, especially 
among the lower classes or when the patient is very sick. Purulent 
sputum from a cavity, if it has been long retained, may be putrid or 
have a peculiar putrid-rancid odor (only with phthisical patients in 
extremis). In cases of fetid bronchitis, bronchiectasis, and gangrene 
of the lungs a more marked and very characteristic, sharper and more 
penetrating, quite offensive odor from the muco-purulent sputum 
decomposing in the air-passages, is commonly present; but in the 
last-mentioned disease it may be entirely wanting (“odorless gan- 
grene”). Offensive odor of sputum may sometimes be caused by 
decomposition of particles of food in the mouth or by offensive plugs 
in the lacunae of the tonsils, and thus one may be entirely deceived. 
2. Foreign Substances in the Sputum which are Visible to the 
Unaided Eye? 
The inhalation of coal-soot (most frequently by those especially 
exposed to it, but also by all dwellers in cities) colors the sputum, in 
streaks or diffusely, blackish-gray. When iron-dust is inhaled, it 
1 Nowadays the microscopical examination of the expectoration, with its brilliant, 
but partial, results, is carried to such an extent, and so calls the chief attention to this 
secretion, that it seems necessary to draw attention to the importance of examining it 
with the unaided eye. Carefully conducted, it not infrequently brings the physician, 
in difficult cases, directly to a correct diagnosis, beside facilitating the use of the micro- 
scope in showing how to find the right spots. Hence, this section is introduced with 
careful consideration. 172 
SPECIAL DIA G XOSIS. 
colors the sputum quite black, or ochre-yellow and red (see on this 
point, also, under Microscopical Examination). When the sputum is 
scanty it is more deeply colored than when it is abundant, since in 
the former case the coloring-matter is more concentrated. 
We have already referred to the addition of blood. The presence 
of hcematoidin is sometimes evident to the unaided eye by a yellowish 
or brownish-red color in separate spots; it occurs in the lungs when 
there is disease of the heart, in cases of abscess of the lungs, and in 
empyema (confirmation by the microscope, see page 181). 
In icterus the bile pigment is sometimes present in the expectora- 
tion ; it has often been observed by myself (as well as others) that in 
'pneumonia with icterus, more particularly, it colors the sputum a 
distinct yellow-green or green. 
In abscess of the lung we observe lung-tissue in the shape of larger 
or smaller pieces. These “lung sequestra ” may sometimes be very 
large—2.5 cm. long. (Salkowski, of Leyden). Pieces of cartilage 
from the trachea or the bronchial tubes, in deep ulceration and the 
accompanying perichondritis of these organs, will sometimes be 
coughed up. 
Fibrinous tubes, formed in the bronchial tubes as a result of fibrinous 
inflammation there, may form a more or less considerable part of the 
expectoration. We may have a firm cast of an entire dichotomous 
ramification of a large bronchial trunk even to the finest branches 
(even to the alveolar tubes and the alveoli ?); more frequently they 
come from the smaller bronchi, and are only divided two to five times. 
Very often these casts are thrown off while they are fresh, as is evident 
by their white color; they are also often yellowish-brown, or else 
reddish, from the addition of blood. They are often found as irregular 
lumps covered with mucus or small flakes, so that the inexperienced 
do not recognize their true character. In order to make them out, it 
is necessary to isolate them by shaking them up with water in a test- 
tube. Generally they exist only as casts of the smaller bronchial 
tubes in croupous pneumonia, and are most abundant before and 
during resolution ; as dense large casts in chronic croupous bronchitis, 
and in acute croupous bronchitis, in consequence of laryngeal and 
tracheal croup. 
Complete casts of the trachea, and even of the larynx, are some- 
times thrown off in croup. Casts wholly from the smallest bronchial EXAMINATION OF THE RESPIRATORY APPARATUS. 
173 
tubes, or, in reality, from the alveolar channels, occur in bronchial 
asthma; and, more rarely, in croupous pneumonia as the so-called 
Fig. 26. 
Large bronchial coagulum (chronic fibrinous bronchitis). (After Riegal.) 
spirals. In the expectoration their smallest forms constitute dimin- 
utive gray transparent or whitish opaque flocks or lumps which 174 
SPECIAL DIAGNOSIS. 
frequently, on close examination, look like fine hairs rolled together. 
(On these bodies, see p. 179.) 
Regarding echinococcus bladders, and the exotic Distoma pulmo- 
num (Biilz), found in the sputum, see under Microscopical Examination. 
Of the crystals occurring in the sputum (which, of course, can only 
be perfectly made out by examination with the microscope), sometimes 
by careful examination with the naked eye two forms may possibly be 
Fig. 27. 
Bronchial coagulum, natural size, with croupous pneumonia. In this disease the 
small forms are very frequent, the large ones very rare, but frequent with chronic 
fibrinous bronchitis. 
recognized. In the fetid sputum in three layers (fetid bronchitis and 
gangrene of the lungs) there exist peculiar grayish-yellow, very 
offensive lumps, which may be barely visible, or may be as large or 
larger than lentils; these lumps inclose fat-crystals (see p. 181). 
These same bodies occur as offensive plugs from the lacunae of the 
tonsils, although never in so large a quantity as in the other condi- 
tions. Hence, when they are found in the sputum we must always 
carefully examine the tonsils. 
Further, in chronic croupous bronchitis and in bronchial asthma 
there are found embedded in the sputum, sometimes adhering to the 
concretions, peculiar, small bodies, yellowish kernels, like grains of 
sand, which easily strike the practised eye ; these, generally numerous, 
are the so-called Charcot-Leyden’s crystals (see p. 181). 
It remains to mention some fungi found in the sputum, whose EXAMINATION OF THE RESPIRATORY APPARATUS. 
175 
presence may be indicated by the macroscopical examination, but this 
examination would be without diagnostic value unless confirmed by 
the microscope. Different kinds of mould (especially Aspergillus 
fumigatus) are very rarely found, except as a pathological result, and 
generally in phthisical cavities, which are noticed as gray or greenish, 
little collections; muguet (see), as white tufts almost always arising 
from the mouth and throat (hence, these are to be carefully examined); 
leptothrix buccalis, sometimes mixed in the mouth with expectoration ; 
if it stands some time in a warm place, developing as a yellow coating 
—all exceptional appearances of slight importance. 
The finding of actinomgces in the expectoration is of greater im- 
portance, but of yet greater rarity. It can be recognized by the naked 
eye by the little kernels of uniform size, shaped like millet-seeds, 
greenish-yellow or yellowish-white, sometimes somewhat glassy (I 
have seen them in one case); of course, they are only to be accurately 
recognized by the microscope. 
Also, we may sometimes conjecture the presence of the tubercle 
bacillus with the naked eye (which makes the microscopical examina- 
tion easier), by the presence of yellowish, generally flat lumps— 
“lentils ”—in the sputum from cavities, which, besides, usually con- 
tains many elastic fibres (see p. 177); and, also, although much more 
rare, if there are small white (scarcely visible) scales, very like those 
of which the artificial pure culture of the bacillus tuberculosis consists. 
Both elements, especially the latter, usually contain or consist of 
masses of bacilli. It is very easy to be deceived by the admixture of 
food-particles. Chiefly is this the case from the small white lumps of 
coagulated milk (which not infrequently contain fat-crystals) and 
minute particles of bread. 
3. Microscopical Examination of the Sputum. 
Small particles are placed under a glass cover, which is to be only 
moderately pressed. It is to be examined with a No. 7 or 8 
Hartnack, or E or F Zeiss. 
In all mucous and muco-purulent sputum there are threads of mucus 
and mucous corpuscles; the former are more sharply defined the tougher 
the mucus is. In pneumonia and asthma they are often spiral, and 176 
SPECIAL DIAGNOSIS. 
in these diseases they pass by imperceptible gradations over into the 
finest and most delicate fibrinous formations. (See Spirals.) 
White blood-corpuscles are found in all expectoration, but in much 
greater numbers in the purulent parts. They are generally of various 
sizes, granular, not infrequently filled with drops of fat and myelin, 
or contain particles of soot; and lastly, and more rarely, minute 
lumps of hseinatoidin (see). 
Red blood-corpuscles are found in the different kinds of bloody 
sputum, generally with the form well preserved, but often paler, even 
as rings; when long stagnated they are granular. 
Epithelium. Flat epithelial cells from the mouth are a common 
ingredient of the sputum. They are easily recognized by their size 
and thinness, which manifests itself by numerous cracks and folds. 
Flat epithelium, which probably comes from the oesophagus, occurs in 
large clusters in the so-called bloody sputum of hysteria. 
Fig. 28. 
Epithelium from the sputum, a. Flat epithelium from the mouth, b. The so-called 
alveolar epithelium, containing little drops of fat and myelin, d. A red blood-corpuscle. 
Changed cylindrical epithelium of the air-passages in the form of 
mucous and goblet cells are observed in all cases of catarrh of the 
trachea or of the bronchi, and sometimes in large numbers. On the 
other hand, it is rare to find these epithelial cells in their original 
condition, with homogeneous protoplasm, with bladder-like nucleus, 
covered with cilia; and still more rare to obtain the motion of the 
cilia, or to find it responsive to heat. The possible origin of these 
cells in the nose is not to be overlooked. They have diagnostic value. 
The so-called alveolar epithelium (see Fig. 28) was formerly con- 
sidered an important constituent of the sputum. But it is neither 
possible to affirm its source nor to give its diagnostic value. There 
are elliptic, or round, not infrequently somewhat flattened, cells with EXAMINATION OF THE RESPIRATORY APPARATUS. 
177 
an often indistinguishable nucleus (made visible by the addition of 
acetic acid), larger than the ordinary white blood-corpuscle. The proto- 
plasm is fine or coarsely granular, sometimes filled wdtli drops of fat 
or myelin (Virchow); also we may see complete fatty degeneration 
with formation of large fat and myelin drops. These cells contain 
particles of coal or iron dust (the latter made dark green by sulphide 
of ammonium, blue by yellow prussiate of potash and muriatic acid). 
In the lungs of cases that have died with heart disease they are found 
filled with lumps of haematoidin. 
This alveolar epithelium occurs in bronchitis and all kinds of acute 
and chronic pneumonia, hence does not have any diagnostic value. 
Its epithelial character is not at all constant. I think it quite prob- 
able that it is mostly or altogether made up of white blood-corpuscles, 
enlarged by metamorphosis, or their protoplasm, and partly by ab- 
sorption of small particles. In part, also, this may come from the 
deeper layer of the bronchial epithelium (Panizza, Fischl, Senator). 
On the other hand, the so-called cells of heart disease containing 
hoematoidin are significant in recognizing the lungs of cases that have 
died from disease of the heart. 
Elastic threads are an important constituent of sputum, since they 
infallibly show the destruction of lung tissue (less frequently of the 
tissue of the bronchi), but still more because they indicate such a 
severe disease of the lungs often before there are physical signs. 
They occur in tuberculosis, gangrene, abscess of the lungs. They 
generally have a double outline; now and then there are branching 
fibres, which have a serpentine course or large irregular curves. 
They generally lie in bundles, and often show the structure of the 
lung-vesicles. 
They always exist in clusters and with a remarkably alveolar 
arrangement in the shreds of lung tissue in abscess of the lungs, and 
when there is suppurating gangrene; further, almost always in the 
so-called “lintels” of tubercular sputum. When elastic threads occur 
singly, which may be in all the conditions named, it is very difficult 
to say which is their special cause. Then, also, it is not easy to 
distinguish them from fat crystals (see), and farther from elastic fibres 
in food. Besides, since the discovery of the bacillus tuberculosis their 
importance for the early diagnosis of phthisis has disappeared; but 178 
SPECIAL DIAGNOSIS. 
for determining whether we have a more or less destructive form of 
phthisis they are as valuable as ever. 
To obtain elastic fibres, when they are not present in quantity, a 
Fig. 29, 
Elastic fibres. (After Struempell.) 
Fig. 30. 
Curschmann’s spirals, natural size. (After Curschmann.) 
portion of sputum is boiled with an equal quantity of an 8 to 10 per 
cent, solution of caustic potash; then the jelly-like mass is to be diluted 
with water and allowed to stand for twenty-four hours. The elastic EXAMINATION OF THE RESPIRATORY APPARATUS. 
179 
fibres, as distinct organic substances, settle to the bottom, but are much 
swollen and not readily distinguished from fibres of the food. 
In individual cases of gangrene of the lungs, but by no means in 
all, elastic fibres may be wanting: possibly they may be destroyed by 
the action of a ferment (Traube). Moreover, simple gangrene of the 
lungs is rare; we generally have a suppurating gangrene, and this can 
hardly fail to furnish the shreds of lung tissue previously described. 
Spirals (Leyden, Curschmann, Zenker). They exhibit the finest 
forms of bronchial products, and hence correspond probably to a 
(fibrinous) catarrh of the smallest bronchial tubes. With some prac- 
tice they are recognizable by the naked eye (Fig. 30), and under a 
glass cover when somewhat spread out by very slight pressure, even 
without any amplification, there may be seen a spiral twist, and often 
in the centre a bright line which is generally wavy. When very 
Fig. 31. 
Fig. 32. 
Fig. 33. 
Curschmann’s spirals, a. Central fibre. (After Curschmann.) 
slightly magnified (best seen with a simple microscope of good power) 
we can plainly see the spirals formed out of fibres wound like a cork- 
screw; and further, we can see the streak in the middle, the central 
thread, as a homogeneous, a somewhat bluish-tinted structure, coursing 
exactly along the middle of the tube. This central fibre, which may 
be entirely wanting, does not exhibit a sharply-defined contour, no 
matter how much it is magnified or how the focus of the microscope 
is adjusted. It is probably not a material structure, but an optical 
image of a space-cavity or of a strand of tightly-twisted fibres in the 
centre of the spiral. Regarding the peculiar finely granular cells 
accompanying them, and Charcot-Leyden’s crystals, see page 182. 180 
SPECIAL DIAGNOSIS. 
Curschmann has affirmed that these spirals have an important diag- 
nostic, and indeed a causal relation to bronchial asthma (“bronchio- 
litis exudativa,” Curschmann). They are especially abundant in 
these cases, in many patients only at the time of the attack, so that 
as the attack passes off, they are excreted in quantity. Rarely, and 
without diagnostic importance, they are present in croupous pneumonia 
(0. Yierordt, von Jaksch, and others). I saw them in a case of very 
chronic tuberculosis of the lungs. According to Pel, they consist 
largely of mucin. 
Starch corpuscles. They are often found in hemorrhage of the 
lungs (Friedreich), and in gangrene (von Jaksch), hut are as yet 
without significance. 
Crystals. Crystals of hmmatoidin are brownish-yellow, if pure, of 
a shining color, rhombic plates, or fine needles, and these single, or 
two or three crossed, or in tufts. The crystalline formation may also 
occur as grains and lumps; not infrequently in the centre is a white 
blood-corpuscle, and it may be that the needles are arranged with 
their points standing out from the cells. 
Fig. 34. 
Fig. 35. 
Crystals of haematcidin 
Needles of fatty acids. (After 
Struempell.) 
They indicate that blood has been long retained : in gangrene with 
formation of abscess; in the pus of empyema which has perforated a 
long time before, as in one case that came under my observation of a 
slow hemorrhage into the lungs from a thoracic aortic aneurism. 
O O EXAMINATION OF THE RESPIRATORY APPARATUS. 
181 
Sometimes there are spots macroscopically visible when there is 
hsematoidin in the sputum. (See p. 172.) 
Crystals of fatty acid (margaric acid crystals, see Fig. 35). They 
are long, thin, slender needles, slightly or very markedly bent, which 
are found singly, in large bundles or druses, or quite irregularly 
arranged. They are generally distinguished from elastic fibres by 
the uniformity of their curving. When a portion of sputum is dried 
in the air, without heat, they are completely dissolved upon the addi- 
tion of ether, while the elastic fibres under the same circumstances 
are not changed. They occur generally in masses, in gangrene of the 
lungs and fetid bronchitis, and especially in the lumps or plugs pre- 
viously mentioned (page 174) ; they are also found in the plugs which 
are formed in inflamed tonsils (see); finally, they may occur singly 
in any inuco-purulent sputum, especially after standing in a warm 
place for some time. 
Fig. 36. 
Crystals of oholesterine (After Struempell.) 
Cholesterine crystals. These are thin rhombic plates with the 
corners cut out, which become green and then red when treated with 
dilute sulphuric acid and tincture of iodine. They are sometimes 
found in old perforating pus, also in tuberculosis. 
Charcot-Leydens crystals. These are slight, somewhat blue, 
shining, elongated octahedrals of great variety of size, sometimes 
visible with a simple microscope, often only to be seen with a No. 8 
Hartnack. They seem to be identical with the crystals found in the 
blood and marrow in leukaemia, also sometimes occurring in the feces. 
They probably consist of a mucous substance (Salkowski). 182 
SPECIAL DIAGNOSIS. 
As a sign of bronchial asthma they are of great diagnostic impor- 
tance (see Spirals) ; they then occur most abundantly during and 
after the attacks (Leyden). They are less frequently found in acute 
bronchitis, chronic croupous bronchitis, and tuberculosis. 
Fig. 37. 
Charcot-Leyden’s asthma crystals. (After Riegel.) 
The points in the expectoration of asthma where these are found 
can often be easily recognized with the naked eye as dry crumbs (see 
p. 174). They are very often mixed with peculiar, fine, granulated 
round cells which look as if filled with dust; at the same time with 
these are found spindle-formed figures with a slight glistening—a 
transition stage to Charcot’s crystals (?). These crystals are found 
especially numerous upon and in the “spirals,” and also with them 
these spindle-formed cells. 
In isolated cases there are found in the sputum tyrosin (fetid bron- 
chitis, empyema, according to Leyden), oxalate of lime (diabetes, 
Fiirbringer; asthma, Ungar), and triple phosphate (see chapter on 
L'rine, the section upon these substances). 
Animal parasites. We may have whole echinococcus bladders or 
their fragments (recognized upon cross-section by the remarkable, EXAMINATION OF THE RESPIRATORY APPARATUS. 
183 
uniform streaking), and also the hooks of the scolices in the sputum, 
in case one of these parasites enters the bronchial tubes by rupture 
from the lungs or liver (slight increase in size). 
Fig. 38. 
Echinococcus. (Scolices, hooks, after Heller ) 
The (exotic) Distoma pulmonalum (Balz) which causes hemorrhage 
without any other manifestation, declares itself by its eggs in the 
sputum (to be seen by the simple microscope). 
Fig. 39. 
Infusoria (Monas, Cercomonas-Kannenberg) are found in gangrene; 
they are seemingly without significance. 
Fungi (for the macroscopic evidences of the presence of some of 
them see p. 175). 
Echinococcus membrane, cross-section enlarged. 184 
SPECIAL DIAGNOSIS. 
Leptothrix buccalis is present in the yellow scum arising on sputum 
that has been standing some time, as has already been mentioned, 
in the bronchial plugs in putrid bronchitis (besides crystals of fatty 
acids), and also occurring separately. Either it is first mixed in the 
sputum in the mouth, or it has entered the air-passages from the 
mouth; but it is present there without any known pathological 
significance. Specific reaction: With iodine and potass, iod., it is 
stained blue-red. [For formula, see p. 189.] Without this reaction 
it may be confounded with elastic threads, even with fatty acids (see 
the chapter on the Digestive Apparatus). 
Fig. 40. 
Tubercle bacilli in the sputum, first colored with anilin-fuchsine and then with 
methylene-blue. Zeiss’s homog. immersion j Oc. 4, camera lucida drawing. Mag- 
nified about 1000 diam. 
Sarcina pulmonalis is a fungus formed by division from developing 
endogenous spores (Hauser). While it is similar, although smaller, 
it has nathing to do with sarcina ventriculi. The recent views upon 
their frequent presence may be somewhat questioned (confounded with 
Microccus tetragcnus (?) Fliigge). It has no known pathological 
significance. EX A MINA TION OF THE RESPIRA TOR Y A PPARA TUS. 
185 
Tubercle bacillus (Koch). This generally occurs in the purulent 
parts of the sputum of tuberculosis of the lungs or trachea. Excep- 
tionally it may be mixed with the sputum from the throat and pharynx 
(nose), in case a tubercle breaks up at that point. They are generally 
very abundant in the so-called “lintels,” and (rarely) in very small 
white scales (see p. 175). These split fungi are straight or moderately 
—rarely much—bent, very thin rods of somewhat variable length (2 
to almost 4 —that is, very like the diameter of a moderate-sized white 
blood corpuscle). They often contain spores. On account of their 
thinness and because they are without motion, they are with difficulty 
seen in the sputum unless they are colored. In order to bring them 
into view we stain them, and by a method which at the same time 
produces a special reaction, and so a very certain proof that it is the 
tubercle bacillus and not one of the numerous other bacilli. It is to 
be magnified 600-400, or, for those accustomed to examine for it, 300 
diameters—that is to say, with a Abbe oil immersion lens, or a 
Hartnack No. 8 or at most No. 7. 
Methods. I. (Weigert-Ehrlich.) With perfectly clean needles 
we place some sputum upon a plate with a black surface, and there 
spread it out with the needles. From this is selected a suitable por- 
tion (see above) and place it upon a glass cover, and then it is to be 
broken up with the needles. Upon this is now placed another glass 
cover and the two are pressed firmly together. What is squeezed out 
upon the edges is to be washed away, and then the two glasses are to 
be carefully separated, so that there may remain upon each the thinnest 
possible layer, equally distributed. These are then laid aside to 
dry. Then 20 drops of anilin oil are thoroughly mixed with a small 
test-tube full of distilled water, it being shaken till it is intimately 
mixed. The mixture is allowed to stand for a short time, and then 
some of it is to be filtered through a moistened filter into a watch-glass. 
From a previously prepared concentrated alcoholic solution of fuchsine 
there is then to be added sufficient to make the mixture turbid or to 
cause a slight metallic shimmer to appear upon the surface; about 6 
drops are necessary. Good fuchsine S. is necessary. 
The glass covers are allowed to dry in the air, and then each is 
passed three times through the flame of a spirit-lamp and laid in the 
P The Greek letter /x represents one-thousandth of a millimetre (fi= 0.001 mm.), and 
is the sign of & micro-millimetre, or a micron.'] 186 
SPECIAL DIAGNOSIS. 
coloring-solution with the sputum side down. The watch-glass, 
covered over, is allowed to stand for twenty-four hours, or it is slowly 
warmed over the spirit-lamp until a slight deposit of moisture appears 
not only upon the edges, but also upon the middle, and then it is set 
aside for about ten minutes. 
The manipulation is continued by washing the glass cover in water 
and then for a few seconds dipping it in a mixture of one part of 
nitric acid and two of water (without letting go of it with the pincers) 
until it, being again washed in water, continues to show a slight 
violet shimmer. Then the preparation may be immediately examined 
in water: the tubercle bacilli are colored an intense violet, while all 
the rest is colored a pale reddish tone. It is advisable to stain the 
glass cover a second time with a watery solution of methylene-blue, 
which is done by placing it in this solution for a minute or two after 
taking it out of the acid mixture and thoroughly washing it with 
water, then again washing it, when it may be examined. 
Instead of fuchsine- and methylene-blue we may, in exactly the 
same way, employ Bismarck-brown or the gentian-violet,. The pre- 
parations are preserved by first drying them in the air, then passing 
them three times through the flame before laying them upon an object- 
glass upon which has been placed a drop of xylo-Canada balsam. 
The staining with the nitric acid solution must not be too strong, 
else the bacilli lose their coloring. With preparations that are to be 
preserved, the nitric acid must be very carefully removed by repeated 
washings with water, because the acid destroys the color. 
The alcoholic gentian-violet, as well as the fuchsine solution, retains 
its color very well. Sometimes the Bismarck-brown, and also the 
methylene-blue, must be filtered before using. Besides these, one 
needs for his work a black plate, two needles, a pincette with broad 
beak, some watch-glasses, object-glasses and covers, and a spirit-lamp. 
Biedert has recently recommended the following method for 
demonstrating the bacilli when they are scant in numbers: A tea- 
spoonful of sputum and two teaspoonfuls of water are boiled with 
fifteen drops of solution of caustic soda, then four teaspoonfuls more of 
water are added and the whole again boiled till it forms a homogeneous 
fluid. It is allowed to stand for two days (not longer) in a conical 
glass ; possible bacilli (and elastic fibres) form a sediment. The sedi- 
ment is stained, not by the method described above, but by the EXAMINATION OF THE RESPIRATORY APPARATUS. 
187 
method recommended by Ziehl-Neelsen : instead of the aniline water 
and gentian-violet, we use a mixture of 90 parts of a 5-per-cent, 
solution of carbolic acid and 10 parts of concentrated alcoholic solu- 
tion of fuchsine, staining by heat as above described; the other pro- 
cedures are also the same as above referred to. 
Where one is not accustomed to examine for bacillus tuberculosis, 
for the purpose of controlling the degree of staining some sputum 
that is known to contain the bacillus should be colored at the same 
time. 
II. A new and decidedly useful mode of procedure is given by 
Oabbett. A dry preparation, which has been passed through a flame 
is placed for two minutes in a solution of 1 part of fuchsine S. in 100 
parts of a 5 per cent, solution of carbolic acid and 10 parts of abso- 
lute alcohol, and then, immediately after, for one minute in a solution 
of two parts of methylene-blue to 100 parts of 25-per-cent, sulphuric 
acid. It is rinsed with water, and then, for preservation, is washed 
with alcohol, dried, and mounted in Canada balsam. For the sake of 
greater certainty, it may be warmed in the first solution. The 
preparations are very beautiful and permanent. The method seems 
to be a very distinct one. It is necessary to make very thin, and 
likewise uniformly thin, preparations. 
The tubercle bacilli are distinctly recognized by their red (or blue) 
staining. Since the spores that may be present are not stained, they 
may be seen in the interior of bacilli as clear points, and they may be 
so abundant as to cause the bacilli, when only slightly magnified, to 
look like the chain coccus (Fig. 40). 
The presence of this bacillus in the sputum indicates tuberculosis 
of the lungs (unless there may be tuberculosis of the larynx). Quite 
a close approximation of the severity of the disease may be made by 
their abundance, but more closely by the quantity of the spores. 
Bacilli may often be discovered when the physical signs are still indis- 
tinct or are altogether wanting. 
Absence of the bacilli at a single examination is without value. So, 
also, when the sputum is scanty and not very purulent, if they are 
absent in repeated examinations this fact is to be considered with 
greater caution. On the other hand, in sputum that is not too 
scantily purulent, the constant failure to find bacilli points with 
greater probability against tuberculosis. It is to be understood that 188 
SPECIAL DIAGNOSIS. 
the staining material is as it should be (see above), that the staining 
has been properly done, and that the most careful examination of the 
preparation has been made. The culture-test, with the material in 
question, would come still nearer the truth. (See also in Appendix.) 
Pneumonia cocci: The reports regarding these cocci are still con- 
flicting. Friedliinder has found micrococci both in the sputum and in 
the tissue-fluid, of oval form, single, or two or three arranged together, 
lying in a capsule which can be stained. But Friedlander himself 
acknowledges that, without the existence of pneumonia, these cocci— 
or cocci which cannot be microscopically distinguished from them— 
are also found in the sputum. We have found Friedlander’s cocci 
Fig. 41 
Frankel’s pneumonia coccus, bred from the expectoration. Prepared by Prof. Gartner. 
Oil immersion lens, one-twelfth; eye-piece No. 4. 
in numerous cases of broncho-pneumonia and bronchitis. The cocci 
which A. Frankel found in the lungs in pneumonia are lancet-shaped 
and they generally occur as double cocci, and are, like Friedlander’s, 
in a capsule. Frankel’s coccus is likewise found in empyema and 
meningitis, which complicate croupous pneumonia. It also occurs in 
normal saliva. Finally, Pio Foa has discovered in the tissue-juice of 
the pneumonic lung a diplococcus inclosed in a capsule which is very 
like both of the cocci named above. 
Staining of Friedlander’s coccus : A dry covering-glass preparation 
is placed for a few minutes in a 1-per-cent, solution of acetic acid, 
then this is blown away with a pipette; dry in the air; dip for a few 
seconds in aniline water and gentian-violet solution (see above), rinse 
in water (Friedliinder.) Frankel’s coccus is stained with all aniline 
dyes. Pio Foh recommends Gram’s method for his coccus. 
3. Micrococci and bacilli of all sorts, also spirochceta, are found EXAMINATION OF THE RESPIRATORY APPARATUS. 
189 
in every specimen of mouth-sputum. They are very much increased 
in fetid bronchitis, in br one hied atic cavities, and gangrene of the 
lungs; and also in every sputum that has stood long and become foul. 
Fig. 42. 
Micrococci, bacilli, spirals, spirochseten, from the expectoration. (After Pfluegge.) 
There may be a simple staining of the dry preparation with 
methylene-blue, after which it is to be rinsed in water. Or, the prepa- 
ration, stained according to Gram, with gentian-violet solution and 
aniline water (see p. 187), may be taken from this and immersed for 
Fig. 43. 
Actinomyces. (After v. Jaksch.) 
two or three minutes in the following preparation: Iodine, 1, potass, 
iod., 2, aq. destil., 300; then in absolute alcohol till the color disap- 
pears. Only the microbes are stained, but these are intensely colored. 
4. Actinomyces. In actinomycosis of the lungs or of the pleura, 
in isolated cases, this fungus is found in the sputum. I have observed 
it in the characteristic small kernels (see p. 175). It is recog- 
nized by the projections, like clubs, closely pressed together, which 
project from the surface of a confused mass, which look much 
like detritus. We can best see the club-like projections without 190 
SPECIAL DIAGNOSIS. 
staining. The fungus can be distinctly stained by Gram’s method 
[described on the preceding page]. 
Mould (aspergillus, mucor) and isolated yeast-cells, when seen in 
the sputum are without significance. The microbe of whooping-cough 
of Letzerich and Berger still needs confirmation. 
Chemical Examination.—This has a minor place, considered 
with reference to diagnosis. 
There occur in the sputum albuminous corpuscles in the form of 
mucin, nuclein, serum-albumin. The latter is very abundant in 
oedema of the lungs. Peptone is found very abundantly in the 
sputum after the crisis of pneumonia (Kosselt); it is also found in 
excess in all purulent sputum. Temporary fatty acids occur very 
abundantly in gangrene of the lungs (Hoppe-Seyler, Leyden, and 
Jaffe). 
Finally, it is notable that in gangrene of the lungs and bronchitis 
there is found a ferment like the pancreas ferment (Filehne, Stol- 
nikow). CHAPTER Y. 
EXAMINATION OF THE CIRCULATORY APPARATUS. 
Examination of the Heart. 
The development of the methods of local examination of the heart 
is closely connected with the introduction of percussion and ausculta- 
tion. So we have here also chiefly to thank Laennec and Skoda, as 
well as Piorry, Friedreich, Bamber, and Gerhardt. 
ANATOMY OF THE NORMAL HEART. 
The heart lies upon the diaphragm, sloping obliquely forward in 
such a way that its long axis is inclined forward and toward the left. 
It extends from about 8 or 9 centimetres to the left of the median 
line (apex of the heart), to about 4 or 5 centimetres to the right of 
the same (i. e., about one and a half finger-breadths to the right of 
the right border of the sternum—right auricle), so that about two- 
thirds of the heart is in the left half of the chest, and one-third in the 
right half. Its highest point (the left auricle) is at the lower border 
of the sternal insertion of the second rib, its lowest point at the upper 
border of the sixth costal cartilage, or the fifth intercostal space (see 
Fig. 44). The three borders of the heart are formed as follows: the 
right by the right auricle, the lower by the right ventricle, and the 
left by the left ventricle. The latter lies with only a diminishing 
portion on the anterior surface, much the greater part of which is 
formed by the right ventricle. 
The figure (Fig. 44) shows how the lungs glide over the heart, so 
that only a small four-cornered portion, belonging exclusively to the 
right ventricle, is in contact with the wall of the chest. Of the bor- 
ders of this superficial part of the heart, the one toward the right lies 
between the middle line and the left sternal line, the upper behind 
the fourth rib, the left somewhat outside of the left parasternal line. 
Below, the heart is in relation with the liver in such a way that it 
191 192 
SPECIAL DIAGNOSIS. 
overlaps the latter with its lower border. It can be seen from the 
course of the line c d, which indicates the complementary space of 
the incisura eardiaca lob. sup. sinistra, what a considerable portion 
of the heart which is in contact with the chest-wall would became still 
smaller if the lung should completely fill the complementary space. 
Fig. 44. 
Position of the contents of the thorax, of the stomach, and of the liver from in front. 
(Weil-Luschka.) The portions of the heart and liver which are drawn with unbroken 
hatched lines represent the extent to which these organs are in contact with the chest- 
wall. The portions that are not in contact with the chest-wall, but are covered by the 
lungs, are represented by broken (clear) hatched lines, e/, border of the right lung, 
g h, border of the left lung; a b and c d (. . . .), the boundaries of the complementary 
pleural sinus, i, boundary between the upper and middle lobes of the right lung; k 
boundary between the middle and lower lobe of the right lung; l, boundary between 
the upper and lower lobe of the left lung, w, stomach (greater curvature). 
These are the location and extent as they are found in the adult in 
the dorsal or upright position. With children the heart (as well as the 
diaphragm and the lower bordei’S of the lungs) is about one rib higher. 
It is also, since it is proportionately larger, to a larger extent in con- 
tact with the wall of the chest; with increasing age, on the other- 
hand, it moves lower down (to the lower border of the sixth rib (the EXAMINATION OF THE CIRCULATORY APPARATUS. 
193 
sixth intercostal space) with a smaller portion parietal, since the lungs 
lie over it to a larger extent. In the side position, especially on the 
left side, the heart always sinks very considerably to the lower side. 
(See under Apex-beat.) 
Situs viscerum inversus exhibits the heart in such a wray that 
“right” and “left” are exactly reversed, like the reflection in a 
mirror. Hence we need not say anything more about it. 
Preliminary Remarks necessary to Understand the Physical 
Phenomena of the Heart. 
What follows is a brief explanation of those facts regarding the 
physiology and the general pathology of the heart, which must be 
always kept in mind by the educated physician in examining and 
forming a judgment of the heart. 
1. The movement of the blood in the heart. The blood flows from 
the body through the cavce into the right auricle, from whence, during 
the ventricular diastole, it passes through the right auriculo-ven- 
tricular opening, the tricuspid valve, into the right ventricle, being 
urged forward toward the end of the diastole by the weak muscular 
contraction of the right auricle. The systole which immediately fol- 
lows drives the blood out of the ventricle, the tricuspid valve being at 
the same time closed, through the open pulmonary semilunar valve 
into the pulmonary artery. The blood, prevented from flowing back 
into the ventricle during the diastole which immediately follows by 
the closure of the pulmonary semilunar valve, passes through the 
lungs, and from them flows into the left auricle, whence, by the dias- 
tole of the ventricle, it flows through the left auriculo-ventricular 
opening, the mitral valve, into the left ventricle, whither it is again 
assisted at the end of the diastole by the contraction of the auricle. 
The left ventricle discharges its contents during the systole (the mitral 
valve being closed) into the commencement of the aorta, through the 
open aortic-semilunar valve, whence it is prevented from returning to 
the ventricle when the pressure from the ventricle ceases and the 
diastole begins, by the closure of the aortic semilunar valve. The 
blood then flows from the conus aortce into the body. 
2. Valvular insufficiency and its effects upon the movement of the 
blood. From the foregoing it is evident that the openings of the 194 
SPECIAL DIAGNOSIS. 
heart are very important factors, on the one side being the entrance 
and exit of the ventricles, and on the other being the location of the 
valves of the heart which hinder any backward flow of the blood. 
The motion of the blood can only in two ways be interfered with by 
pathological processes at the openings of the heart: either by nar- 
rowing at the opening (stenosis of valve), or by the valves losing their 
power to close (insufficiency of the particular valve). 
Stenosis of an opening may be caused by products of endocarditis,, 
which cause adhesion of the flaps of the valve, with formation of a 
cicatricial narrowing ring at the base of the valves. Insufficiency 
may likewise be caused by endocarditis (general shortening of the 
flaps and of the tendinous processes of the papillary muscles), and 
this is the most frequent cause of insufficiency; but the condition 
may also arise from a distention of the opening so that the flaps are 
too short to close it (relative valvular insufficiency, in weak heart 
with dilatation). 
An opening that is narrowed hinders the passage of the blood 
through it. If it is an auriculo-ventricular opening (mitral or tri- 
cuspid stenosis), then, at the moment of diastole of the heart, the blood 
is hindered in its entrance into the ventricles: there is imperfect 
filling of the ventricles; if it is an arterial opening that is narrowed 
(aortic or pulmonary stenosis), then the exit of the blood from the 
ventricles at the systole is interfered with. If the valvular mechanism 
is in such a condition that it cannot perfectly close, then at the 
moment when it ought to close it allows a part of the blood to flow~ 
backward. If the difficulty is with the entrance to the ventricles 
(insufficiency of mitral or tricuspid valve), then with the systole a 
part of the contents of the ventricle flows back into the auricle; but 
if the deficiency is at the outlet of the ventricle (insufficiency of the 
aortic or pulmonary valve), then at the end of the systole, during the 
diastole which follows, a part of the blood that has just been thrown 
into the artery will be thrown back into the ventricle. 
In one respect all the defects that have been mentioned are alike: 
they check the blood current, they cause a stasis of blood in that 
chamber of the heart which is, with referehce to the direction of the 
blood current, just behind the defective opening. Thus a defect of an 
arterial opening causes stasis in the corresponding ventricle; a defect. EXAMINATION OF THE CIRCULATORY APPARATUS. 
195 
in an auriculo-ventricular opening occasions stasis in the corresponding 
auricle, and also beyond this in the corresponding veins. 
3. Compensation, accommodation of valvular deficiency. The 
abnormal resistance which is exerted against the blood-current from 
the valvular defect would immediately lead to more considerable dis- 
turbances of the blood-current if it were not promptly equalized by the 
increased work of that section of the heart lying (in the course of the 
blood-current) above the point of resistance. But this does not con- 
tinue, for with increased work the overloaded section of the heart 
becomes hypertrophied—compensatory hypertrophy. This condition 
is extremely simple in defects at the aortic opening. They are com- 
pensated by hypertrophy of the left ventricle, which is associated with 
dilatation (eccentric dilatation). The latter is especially marked in 
insufficiency of the aortic valve, and this is explained by the fact that, 
with aortic insufficiency, the left ventricle during the diastole receives 
blood from two sources, hence very much more than normal. With 
mitral insufficiency the auricle must accommodate for the defect; but, 
notwithstanding the fact that it becomes dilated and hypertrophied, it 
cannot perform the necessary work, cannot overcome the stagnation : 
the accumulated blood passes through it to the veins of the lungs, 
capillaries and arteries of the lungs, and so on till it reaches the right 
ventricle; this becomes dilated and hypertrophied, and thus causes the 
increase of the propulsive power necessary for the accommodation. 
Though defect of the valve of the pulmonary artery is rare, the 
actual consequences are the same as of defect of the aortic valve, 
defect of the tricuspid, which is likewise rare, with the exception of 
relative insufficiency, and produces accommodation of hypertrophy of 
the right auricle, but only to a very slight degree; for the increased 
pressure in the general venous system has no effect upon the pressure 
in the arteries of the body, and hence cannot produce any notable 
compensatory hypertrophy of the left ventricle. 
Thus, insufficiency and stenosis of the aorta cause hypertrophy of 
the left, and insufficiency and stenosis of the mitral valve hypertrophy 
of the right, ventricle. But with mitral insufficiency something more 
follows: during the diastole of the left ventricle there flows into it 
from the dilated auricle the blood which has accumulated there under 
very much increased pressure and in increased quantity ; it becomes 
dilated, and, since it also has to dispose of the increased quantity of 196 
S PE Cl A L DIA GNOSIS. 
blood, which it does by driving part of it forward into the aorta and 
part backward through the mitral orifice into the auricle, it also 
becomes hypertrophied. Hence mitral insufficiency leads to hyper- 
trophy and dilatation of both ventricles. 
These different hypertrophies are aids in the diagnosis of the indi- 
vidual valvular lesions. 
4. Hypertrophy of the heart from other causes. Besides the val- 
vular defects, certain other conditions lead to hypertrophy: thus, the 
left ventricle becomes hypertrophied by the increased resistance in 
the general arterial system produced by sclerosis of the arteries; it 
sometimes results from continued excessive muscular exertion (idio- 
pathic hypertrophy), further, from different forms of chronic nephritis, 
and in this it is more marked the longer the general vigor is main- 
tained (hence most marked in renal atrophy); finally, also in 
acute nephritis, if it lasts long enough. The right ventricle becomes 
hypertrophied whenever there is continued increased resistance in the 
pulmonary circulation, most regularly and markedly in emphysema 
(from destruction of the capillaries of the lungs from atrophy of the 
tissue), in marked contraction of the lungs, in marked Jcypho-scoliosis. 
5. The form of the heart is changed in consequence of the hyper- 
trophy (and dilatation): hypertrophy of the left ventricle broadens 
the heart to the left and somewhat lengthens it; if there is dilatation 
also, the broadening to the left is still more increased. Hypertrophy 
and dilatation to the right ventricle simply broaden the heart to the 
right. Hypertrophy and dilatation of both ventricles broaden the 
heart in both directions and lengthen it. 
6. Simple dilatation. This results entirely from weakness or 
paralysis, and is dependent upon a diminished tone of the heart-muscle 
with a simultaneous loss of its power to contract. It may also occur 
in a heart that was previously dilated and hypertrophied, and it then 
results in a very great enlargement of the heart. In dilatation of the 
heart the enlargement is nearly symmetrical in all directions. 
The diagnosis between enlargement of the heart from hypertrophy 
(with dilatation) and the dilatation just mentioned is chiefly made by 
the consideration of the evidences of the amount of work the heart is 
doing. 
7. The extent to which the heart is in contact with the chest-wall 
is in very close relation to the size of the heart (regarding the peri- EXAMINATION OF THE CIRCULATORY APPARATUS. 
197 
cardium, see later). An enlarged heart always has a larger area in 
contact with the chest-wall than does a normal heart, if there are no 
conditions in the neighborhood of the heart which keep it away from 
the chest-wall. This may be occasioned by emphysema of the lungs, 
or by an increase in the volume of the lungs, whether from anomaly 
of both lungs or only of the left lung, either chronic or temporary. 
In emphysema a normal heart therefore would be to a less extent 
parietal than if the lungs were normal; hence in case of emphysema 
an enlarged heart may possibly not be manifest by its size, as it would 
be if the lungs were normal. When there are both enlargement of 
the heart and emphysema of the lungs the heart may be found to be 
parietal only to the normal extent, or may be so to an even less extent 
than normal (overlying of the heart). 
Still another condition has its effect: inflammatory adhesion of the 
border of the lungs at the incisura cardiaca with the parietal pleura. 
This unchangeably determines the parietal relation of the heart. And 
yet, often in this condition, just the opposite takes place, as in the pre- 
vious case; from shrinking, the lung is somewhat drawn away from 
the heart and thus it is more largely parietal than, according to its 
size, it would be. Enlargement of the heart may thus be simulated. 
Hence in forming an opinion as to the size of the heart from the 
extent to which it is in contact with the chest-wall we must always 
bear in mind the possibility of the presence of these conditions (see 
Percussion ; “ absolute heart dulness ”). 
INSPECTION AND PALPATION OF THE REGION OF THE HEART.1 
Both these methods of examining the heart, like the foregoing, will 
he best practised in a moderately high dorsal position. There are 
technical difficulties in examining a patient either standing or sitting; 
but sometimes in severe heart diseases the latter cannot be avoided on 
account of the existence of orthopnoea (see pp. 32, 97). Palpation may 
be performed either with the tips of the first and second fingers, or 
with the flat, bare hand. 
The Apex-heat. 
Normal conditions. The apex-beat is of the greatest importance 
as an anatomical starting-point, for it corresponds either exactly to 
1 The two methods of examination have such close connection with reference to the 
heart that to separate them would seem to be artificial. 198 
SPECIAL DIAGNOSIS. 
the apex or to a spot very close to it, a little nearer to the median 
line. In the majority of healthy persons it is recognizable, by the 
eye, as well as by the finger applied to the spot, as a rhythmical 
and systolic projection forward about the breadth of the finger, which 
in the adult in the upright or dorsal position occurs in the fifth 
intercostal space just within the mammillary line; only exceptionally, 
chiefly with persons with very short chest, it is found in the fourth 
intercostal space. In children, up to the age of ten years, it is 
usually found in the fourth intercostal space and either in the 
mammillary line or just outside of it (see above in the section on 
Anatomy). In old age, on the contrary, it is sometimes found in 
the sixth intercostal space. Much fat, or the mamma, also narrow 
intercostal spaces, render it invisible, but yet it may generally be felt. 
Moreover, without a distinct cause, it may sometimes be entirely 
wanting in healthy persons. 
Quiet breathing produces no change in the apex-beat. With deep 
inspiration, it is covered by the distended lung, which then occupies 
the complementary space ; if it be still evident, it moves sometimes an 
intercostal space lower down, corresponding to the inspiratory sinking 
of the diaphragm. 
The effect of change of posture is very noticeable in the side posi- 
tion : the left-side position moves the apex-beat outward beyond the 
mammillary line, even as far as the anterior axillary line; the right- 
side position causes the beat to disappear or moves it somewhat to the 
right. 
Physical exertion and mental excitement, the chief physiological 
disturbers of the heart’s action, may noticeably change the apex-beat 
in perfectly sound persons, but still more in nervous persons: it may 
become plainly stronger and even broader, or move somewhat to the 
left. 
There is much dispute as to the cause of the apex-beat. It is 
certain that it is produced by a variety of causes. Briefly stated they 
are as follows: 
1. Change in the form of the heart at the systole: its transverse 
measurement (antero-posteriorly) increases (Ludwig); the apex moves 
forward, to the right, and upward (Filehne, Penzoldt). 
2. Change in the location of the heart: it revolves upon its long 
axis, so that the stronger left ventricle moves toward the front. EXAMINATION OF THE CIRCULATORY APPARATUS. 
199 
The assumption that has hitherto been made that the apex-beat is 
wholly or in part to be explained by the recoil (the so-called Gutbrod- 
Skoda, better Alderson’s, theory), must henceforth be regarded as 
abandoned, since Martius has proved that, at the time when the apex- 
stroke takes place, the semilunar valves are not yet closed, and the 
gush of the blood into the vessels consequently does not begin till the 
apex-stroke is over. 
Displacement (dislocation) of the apex-heat in disease. It may be 
brought about: (a) by dislocation of the heart, (h) by enlargement of 
the heart. 
(a) Dislocation of the heart. The apex-beat is a very important 
sign for determining this, since the other methods often have a very 
indefinite result, or may entirely fail. 
Deformity of the thorax may cause displacement in all possible 
directions. It may happen that in a chest that is flattened or pressed- 
in in the neighborhood of the heart the apex-beat (likewise the heart) 
will be found considerably outward or considerably inward. 
Emphysema of the lungs, in case the apex-beat is not lost by the 
■overlapping, presses it down into the sixth intercostal space (depression 
of the diaphragm). 
In exudative pleuritis and pneumothorax the heart and apex-beat 
are pushed toward the sound side, in the worst cases as far to the left 
as the middle axillary line, but to the right very rarely beyond the 
mammillary line. Likewise, the mediastinum and the base of the 
heart move over, although not so far as the apex. Mediastinal 
tumors may have the same effect as pleuritis of the right side. 
In pleurisy of the right side the apex is sometimes pushed not only 
to the left but also upward into the fourth intercostal space. We are 
not certain why this is so. It is highly improbable that the left lobe 
of the liver rises up while the right is dragged down, for the point of 
traction, the suspensory ligament, brings it still lower by the pressure 
-of the exudation upon the right side. The location of the heart when 
pressed upon is subject to many disturbances, which we cannot 
describe at this time. 
Shrinking of the lungs and of the side of the chest after a pleuritis 
draws the mediastinum and the heart into the diseased side, and at 
the same time draws the diaphragm up; hence in shrinking of the 
right side the heart moves upward and to the right side, but in disease 
■of the left side it is drawn upward or upward and to the left. 200 
SPECIAL DIAGNOSIS. 
If the heart chances to be drawn to the right so much as to bring 
it under or close up to the sternum, where the intercostal spaces are 
very narrow, of course we cannot observe the apex-beat. 
In exudative pleuritis it sometimes happens that the heart becomes 
fixed by inflammatory adhesions, and then the apex-beat remains 
at that point even after the cause of the displacement has been 
removed. 
Elevation of the diaphragm as a result of peritonitis or of simple 
mechanical pressure from below, or from neurotic paralysis of the 
diaphragm, causes dislocation of the heart upward or upward and to 
the left. 
(b) Enlargement of the heart. Hypertrophy and dilatation of the 
left ventricle are made manifest by displacement of the apex-beat 
outward or outward and downward, and under some circumstances as 
far as to the posterior axillary line and the eighth intercostal space. 
The apex-beat is also broader and stronger, see below. 
The conditions which bring about hypertrophy and dilatation of 
the left side have been referred to on page 195. Likewise hyper- 
trophy and dilatation of the right ventricle displace the apex-beat a 
little toward the left, since the large right ventricle pushes the left 
somewhat to one side. But the displacement is always quite small, 
at most not beyond the mammillary line. 
Alteration in the Width and Strength of the Apex-beat. 
We judge of the breadth both by inspection and palpation. We 
seldom have an increase in the breadth without an increase in the 
strength as well: in the normal heart, if it becomes parietal over a 
larger area from shrinking of the lungs; moreover, I have sometimes 
seen it with deformity of the chest (without hypertrophy of the heart) 
and where there was marked wasting, so that the patient was very lean. 
As a rule, breadth of the apex-beat is associated with a strong beat. 
The strength of the apex-beat can only be made out by palpation. 
By constant practice with the hand it can be distinctly recognized 
An apex-beat that is so strong that it lifts the finger that is mod- 
erately pressing over it is called “heaving.” 
Temporary, often notably strengthened and moderately broadened 
impulse is caused by increased heart-work (see above) in consequence EXAMINATION OF THE CIRCULATORY APPARATUS. 
201 
of exertion and mental excitement. For this reason the heart ought 
always to be examined only when these two conditions can be 
excluded. 
In nervous palpitation, Basedow's disease, and sometimes in chronic 
nicotine-poisoning, the heart-beat may for a time be very much 
stronger and even somewhat broader, as an indication of the increased 
work of the heart, without any organic change in it. The same thing 
occurs, though in a moderate degree, in fever. Moreover, the apex- 
beat may be stronger at the same time that the heart’s work is not 
increased, if the heart is pressed firmly against the chest-wall, as in 
mediastinal tumors. 
Continued strength and breadth of apex-beat is the most important 
sign of hypertrophy of the left ventricle. In well-marked cases the 
beat is “heaving,” and is as wide as several fingers—being displaced 
toward the left and downward (see above). 
It is assumed that an enlarged heart works with strength increased 
in proportion to its increased volume. If the heart becomes weak, 
then there is a diminution as regards the breadth and strength; and 
yet it may be distinctly recognized as diseased. 
In many cases it is difficult to separate the apex-beat from the 
“heart-beat” in general, for which see p. 203. 
Weakening of the apex-beat. It has been mentioned already that 
the apex-beat may be weak in persons who are perfectly healthy, or 
it may be entirely wanting. 
Pathologically it is diminished or lost : 
By the activity of the heart being concealed by overlapping: from 
emphysema of the lungs, by a pleuritic or pericardial exudation, and 
by tumors. 
By oedema, emphysema of the skin, inflammatory diseases of the 
chest-wall in the neighborhood of the heart. 
By diminution of the work of the heart, as takes place with any 
kind of degeneration of the heart-muscle; here we may mention: 
myocarditis, lipomatosis cordis, weakness or degeneration of an hyper- 
trophied heart, especially with incompensation with valvular deficiency, 
weakness in febrile diseases (especially collapse). 
The disappearance of an apex-beat which has previously been dis- 
tinct is sometimes the only sure, and hence is a very important, sign 
of the development of exudative pericarditis. But diminution of the 202 
SPECIAL DIAGNOSIS. 
work of the heart is more distinctly declared at the radial pulse than 
by the apex-beat; see below for the explanation of the meaning of all 
these conditions. Moreover, the radial pulse is the only direct meas- 
urer of what the heart does in all the above-mentioned cases of con- 
cealment of the work of the heart. It is especially important in 
pericarditis. 
Where the apex-beat is covered by fluid in the pericardium it often 
again becomes distinct when the patient sits up or bends forward, 
because the heart then, on account of its greater weight, rests against 
the chest-wall. It is then often found in the sixth intercostal space, 
because the distended pericardium presses the diaphragm down. This 
sign, of course, is wanting in cases where the apex-beat is missed from 
weakness of the heart. 
Further, the apex-beat is wanting where there are pericardial 
adhesions (see below under Systolic Drawing-in), and sometimes in 
stenosis of the commencement of the aorta, and this notwithstanding 
the existence of hypertrophy of the left ventricle (slow ventricular 
contraction resulting from difficulty in emptying itself). 
So far as experience goes, “ systolic drawing-in ” in the neighbor- 
hood of the apex-beat has no diagnostic value. Regarding systolic 
drawing-in of the whole lower region of the heart, see below. 
Doubling of the apex-beat, so that a single pulsation of the carotid 
corresponds to two beats at the apex, occurs in hemisystole (Leyden). 
By this we have understood an action of the heart in which both ven- 
tricles do not contract exactly simultaneously, so that then the con- 
traction of the left ventricle, as well as the right, causes an apex-beat. 
But it is probable that we here have in these cases simply an 
alternating action of the heart (see Pulsus Alternans), in which the 
contraction of the heart is too feeble to produce a perceptible pulse 
every time. 
The application of the graphic method to the apex-beat (cardi- 
ography) has thus far yielded no notable contribution to pathology. 
The Neighborhood of the Heart in general. 
Projection of the neighborhood of the heart, including the ribs and 
sternum, takes place gradually in marked hypertrophy and dilatation ; 
when there are hypertrophy and dilatation of both ventricles or of the EXAMINATION OF THE CIRCULATORY APPARATUS. 
203 
right alone the swelling extends sometimes beyond the sternum ; in 
hypertrophy of the left ventricle alone it lies more to the left. Peri- 
carditis exudativa sometimes causes a distinct swelling. 
This sign depends upon two factors : the size of the heart or of the 
pericardium, and the flexibility of the chest-wall. If the latter is 
marked the swelling develops quickly, as in acute pericarditis, and is 
very marked (enlargement of the heart in children); when the thorax 
is rigid there may be no projection, though the heart is very large. 
This condition is not to be confounded with the pressing forward of 
the heart from mediastinal tumors—aneurism. Generally when there 
is a broad heart-beat in the intercostal spaces in the neighborhood of 
the heart, and even upon the ribs and sternum, it is from a hyper- 
trophy of the heart. But, also, when there is contraction of the left 
lung, with the heart free from attachment, the motions of the heart 
may be seen as well as felt over a broader extent in the intercostal 
spaces. If, in such cases, the heart’s action is excited, there is the 
impression of a notable hypertrophy of the heart, even when the heart 
is quite normal in size. 
If, in a case where the heart, from dilatation or retraction of the 
lungs, is more extensively parietal, weakness of the heart occurs, then 
we not infrequently see a broader waving in the intercostal spaces, 
which, by its evident lack of energy, is visibly in contrast with its 
former powerful motions. 
It is sometimes very difficult to distinguish a broadened heart-beat 
from the ordinary apex-beat; but generally it can be distinguished by 
its having peculiar vigor, more than other heart motions. 
Pulsations at the base of the heart sharply limited to the second 
intercostal space on the right and left side of the sternum come from 
the aorta or pulmonary artery. They are rarely visible; generally 
they can only be felt. If they are systolic they may indicate aneurism 
of these vessels. More frequently we may feel a diastolic shock, but 
especially upon the left over the pulmonary artery. If the lungs and 
heart are normal it cannot be felt; but if the lungs are drawn back 
from the base of the heart (by shrinking, or by enlargement of the 
heart), or if there is thickening, then it may be felt, especially if it is 
simultaneously strengthened by hypertrophy of the right ventricle. In 
emphysema of the lungs there exists the peculiar condition that, al- 
though the closure of the pulmonary valve is in a marked degree stronger, 
jet it cannot be made out because the inflated lung lies over it. 204 
SPECIAL DIAGNOSIS. 
Pulsation in the region about the heart occurs in empyema lying 
near the heart upon the left side (empyema pulsans); farther in, aortic 
aneurism (which see). 
Although systolic drawing-in at the apex of the heart is of no 
significance (see above), yet systolic drawing-in of several intercostal 
spaces in the neighborhood of the heart, but especially of the ribs and 
the lower part of the sternum, is of diagnostic value: it is probable 
that there is pericarditis adhesiva with mediastinal pericarditis, 
accompanied by thickening. But yet these signs may be entirely 
wanting, although the condition is present; and, on the other hand, 
they may be observed in cases wdiere this condition does not exist. 
The drawing-in may be caused by a dense mediastinum being adherent 
to the spine and again by pericardial adhesion to the chest-wall; its 
contraction—that is, its constantly becoming shorter—must of necessity 
cause a drawing-in of the chest-wall. 
“ Buzzing ” and friction-sounds that may be felt in the neighborhood 
of the heart accompany very marked endocardial or pericardial sounds 
(see under Auscultation). 
The Epigastrium. 
In inspecting and palpating the heart this must always be considered. 
Systolic trembling, or even systolic pulsation, may be observed here if 
the heart, more particularly the right ventricle, is drawn nearer the 
abdominal wall by the depression of the diaphragm, but especially is 
this the case when, at the same time, the right ventricle is hypertrophied 
—emphysema of the lungs. 
This epigastric pulsation must not be confounded with that which 
is to be seen from the abdominal aorta when the abdomen is very 
empty, and the abdominal wall very thin, whether the aorta pulsates 
normally strongly or not, or whether there is an aneurism of the 
abdominal aorta. This pulsation is, moreover, best transmitted when 
a tumor of the lymphatic glands, of the stomach, or a thin but firm 
liver, lies over the aorta. Sometimes (not always) the pulse is felt 
noticeably later than the systole of the heart. 
Percussion of the Heart. 
This has for its object the determination : 
1. Of the absolute, “small” dulness of the heart, which corre- EXAMINATION OF THE CIRCULATORY APPARATUS. 
205 
sponds with the portion of the heart that is in contact with the chest- 
wall ; and which has an almost definite relation to the size of the 
heart. 
2. The so-called relative heart-dulness, which lies above and to the 
left of the absolute dulness, and which is determined by the thinness 
of the lungs around its border (see above, page 124). It often stands 
indirectly in some relation to the size of the heart, but it is not appli- 
cable for ascertaining it. It does not even show the exact size of the 
heart. 
To these two, Ebstein has added : 
3. Palpatory percussion of the “ heart's resistance,” which is deter- 
mined by ascertaining the anatomical size of the heart; regarding 
this method see below. 
METHODS OF PERCUSSION. 
Normal Percussion Figure of the Heart. 
1. Absolute heart-dulness. This is determined by light per- 
cussion, and corresponds, in fact, to the portion of the heart that 
is parietal. In two respects it departs from this, though not essen- 
tially ; the small strip of the heart wrhich is parietal behind the 
sternum between its left border and the inner border of the right 
lung, is not dull as would be expected, but gives a clear sound, as 
indeed occurs over the whole surface of the sternum (see above, 
page 123); on the other hand, the lingula of percussion is con- 
cealed, since it is not strong enough; over it we notice absolutely 
deadened sound. Thus we have the following figure of the absolute 
heart dulness in persons in middle life (Fig. 45): the boundary 
on the right is the left sternal line, the upper boundai'y lies upon the 
fourth rib, the left boundary is outside of the left parasternal line. 
The lower boundary toward the liver cannot be exactly determined, 
it being defined by the apex-beat, and generally also by the upper 
border of the sixth rib. In children the area of heart-dulness 
(absolute) is somewhat greater, the heart being relatively larger, the 
upper boundary in the third intercostal space; hence the apex-beat is 
generally in the fourth intercostal space, the left boundary near the 
mammillary line; in old age, however, it is smaller (from inflation of 
the lungs) about over the fifth rib, or the parasternal line. 206 
SPECIAL DIAGNOSIS. 
In quiet breathing the dulness does not distinctly change; in deep 
inspiration it is very decidedly diminished, or entirely disappears, 
because the costal cartilages come close together at the sternum. 
Compare the course of the boundary of the complementary space 
(Fig. 44). It makes no difference whether the examination is made 
in the dorsal or the upright position. Examination upon the side 
makes considerable alteration of the area of dulness. 
Fig. 45. 
Percussion boundary of the lungs in front (Weil), q h. The upper limits of the lungs; 
e f, the lower limits of the lungs; b d, boundary between the lungs and heart at the 
incisura cardiaea. The strongly hatched surface represents the portions of the heart 
and liver that are in contact with the wall of the chest; the lighter hatching the so- 
called relative heart and liver deadness (see later), m. Spleen deadness. 
The beginner is apt to be much confused, because in a considerable 
part of the location of heart-dulness, even within the entire region, 
he will find a tympanitic resonance. This is especially frequent in 
short persons with a short, thick thorax and a full abdomen. The 
resonance is from the stomach, which lies under the heart, and is 
more promptly elicited by strong than by weak percussion. When 
there is an otherwise normal condition of the heart and lungs this 
phenomenon has no pathological significance. EXAMINATION OF THE CIRCULATORY APPARATUS. 
207 
2. Relative heart-dulness. This forms a border around the abso- 
lute dulness to the left and above it, and it corresponds with the 
thinned-out portion of the lungs. It is revealed by stronger, and, in 
its upper part, by comparative percussion. It no doubt depends, in 
a certain degree, upon the perceptions of the individual making the 
examination as to where he will fix the limits between it and those of 
normal lung sound. Hence, an individual examiner may, if he is 
accustomed to examine carefully with reference to its determination, 
be able to fix upon a line of demarcation very satisfactorily for him- 
self, but different examiners would not be able to agree among them- 
selves. Hence, the differences among authors as to the size and diag- 
nostic value of the area of relative heart-dulness. 
According to Weil, its course is as follows (see Fig. 45): It begins 
above at the lower border of the third rib, continues in a curve down- 
ward toward the left, within the mammillary line. In rare cases 
there is also a relative dulness at the right of the absolute dulness, 
which is limited by the lower end of the sternum. In children the 
relative dulness begins in the third intercostal space, it extends some- 
what beyond the left mammillary line, and is also constantly present 
on the right, and, indeed, reaches even beyond the right side of the 
sternum. 
Whatever may be the meaning and value which these two regions 
of dulness may have as subjects for instruction and knowledge for 
physicians, there is no doubt that at least that of absolute dulness 
must be considered, since only regarding it is perfect agreement pos- 
sible, and since the amount of time and trouble which every student 
and young physician can and must employ in the practice of percus- 
sion suffices for learning how to determine it. 
It is true, that in pathological cases a difficulty accompanies the 
determination of absolute dulness; it indicates the parietal state of 
the heart, but this is dependent, not alone upon the size of the heart, 
but also upon that of the lungs, though, of course, in an opposite 
sense. This may make a conclusion regarding the size of the heart 
from the extent of absolute dulness difficult; however, a person who 
accustoms himself every time he makes an examination to consider 
carefully the condition of the lungs when he is determining by per- 
cussion the figure of the heart, whether there is emphysema or shrink- 
age—such a person may very materially diminish this difficulty. 208 
SPECIAL DIAGNOSIS. 
Opinion is divided regarding Ebstein’s newer method of determin- 
ing by direct palpatory percussion the resistance of the heart as the 
true image of the total size of the heart. Indeed, Eichhorst is the only 
one who warmly espouses the idea. It seems to me that there is no 
doubt of its use in many cases—that is to say, in those with delicate 
thorax having thin covering of flesh. At the same time I cannot 
recommend it as a subject for instruction to others, since it is liable 
to give rise to many mistakes, and in my opinion ’: is very difficult to 
learn. 
Riess has recently very strongly entered a plea for relative heart- 
dulness. He thinks that by a consideration of the relative dulness a 
figure could be drawn which would very nearly represent the anatom- 
ical boundaries of the heart. We think this is going much too far, 
and that we must maintain the position that we have set forth 
above. 
3. Method of percussing the heart. We percuss strongly on 
both sides close to the sternum going downward, and note the upper 
boundary of relative heart-dulness; then we percuss lightly the 
upper boundary of absolute heart-dulness ; next we percuss upon the 
outer ends of radii drawn from the middle of what is thought to be 
area of absolute dulness (first the one obliquely upward to the right, 
then from the right, always beginning beyond the sternum ; then on 
the left obliquely upward ; lastly, from the left), always strongly at first 
to determine a possible relative dulness, then lightly for the absolute. 
At first we percuss at longer intervening spaces, of at least 1J centi- 
metres, and when a difference of resonance is found then at short 
intervals of space over the particular region. In Fig. 45 the lines 
and the directions in which we ought to percuss are designated by 
arrows. 
Enlargement of the Area of Heart-dulness. 
Generally, relative and absolute dulness exist in about equal pro- 
portions, but, now and then, the relative may be very small. Always 
in enlargement of the right side of the heart, and sometimes in 
enlargement of the left side, relative dulness toward the right is 
increased as compared with the absolute. 
Heart-dulness is increased : 
1. In hypertrophy and dilatation of the heart. If of the right 
ventricle, the dulness spreads toward the right, sometimes also slightly EXAMINATION OF THE CIRCULATORY APPARATUS. 
209 
toward the left, the whole involving the right half-circle. If the left 
ventricle is changed, the increased dulness is toward the left and 
downward, not infrequently also upward, but scarcely any, or at most 
very little, toward the right. Regarding a small independent dulness 
which sometimes is found on the right near the upper end of the 
sternum, see Aorta. 
2. In dilatation of the heart (weak heart). This causes the pre- 
viously existing dulness, it may he of a normal heart or of one that 
was already hypertrophied, to spread out on both sides. (For dis- 
tinguishing from hypertrophy see “apex-beat” and “ radial pulse.”) 
3. Fluid in the 'pericardium {pericarditis exudativa and hydro- 
pericardium). Generally, this causes the dulness to enlarge at first 
upward and then to the right and left. Not infrequently the area of 
dulness has a three-cornered shape—one point above close to the 
sternum, one on the right on the other side of the sternum below, and 
one on the left also below on the outer side of the mammillary line; 
the relative dulness is generally very small. If the exudation is very 
large, the lung surrounding it is generally retracted, and hence around 
the dulness there is a border of tympanitic resonance. In sitting, the 
area of dulness is greater than in lying, and, when bending forward, 
still greater than in sitting, because there is a change in the extent of 
that which is parietal. 
Regarding the apex-beat in pericarditis, see p. 202; in the latter 
disease it is often deeper and not on the left border of the dulness, as 
in enlarged heart, but further toward the right and generally within 
the mammillary line (a not unimportant point in differential diagnosis). 
The pulse (which see) is often important. 
4. With normal heart, hut to a greater extent parietal, on account 
of retraction of the lung. In this case the mobility of the border of 
the lungs in deep breathing is completely wanting. The apex-beat 
may be normal, but by simultaneous displacement it is further to the 
left. 
5. Apparent enlargement of the heart is noticed if anywhere in its 
neighborhood there is a diseased condition which causes absolute dul- 
ness. Of this kind we may name thickening of the lungs, of the 
pleura, of the mediastinum, and especially aneurism. It is almost 
impossible to mark the boundary between the heart and. such patho- 
logical structures, since we are denied the aid of percussion ; on the 210 
SPECIA L DIA GNOSIS. 
other hand, an approximate determination may often be attained 
during auscultation by the appearances of motion (apex-beat, etc.), 
and sometimes by the vocal fremitus. 
Pulsating affections give especial difficulty, as aneurism and the 
empyema pulsans previously mentioned. Here the object is some- 
times attained by repeated examinations. For distinguishing em- 
pyema pulsans from aneurism, see the latter. 
Diminution or Loss of Heart-dulness. 
This takes place : 
1. In emphysema of the lungs. It affects the parietal condition of 
the heart, whether it is normal or enlarged. If the heart is normal 
there is considerable diminution of the area of dulness, even, possibly, 
to its entire disappearance. If the heart is, at the same time, enlarged 
(as it has already been mentioned, it generally is in consequence of the 
emphysema, which causes hypertrophy of the right ventricle), the 
emphysema makes the dulness smaller than it would be with a heart 
of the same size and normal lungs. Hence, when there is emphysema 
we must make some addition to the extent of the dulness we are able 
to map out before we form a judgment regarding the heart. A normal 
area of heart-dulness, with the existence of a marked emphysema, 
indicates considerable hypertrophy of the heart, if there is no adhesion 
of the borders of the lungs. Hence, we must notice their active 
movability. 
2. In pneumo-pericardium, entrance of air into the pericardium, 
either from without by an external injury or from Avithin by perfora- 
tion of the oesophagus, stomach, or intestine, we may have the condi- 
tion of pneumothorax. There is then tympanitic or abnormally loud 
and deep resonance in the neighborhood of the heart (also, metallic 
heart-sound). Finally (very rarely) in emphysema of the mediastinum. 
(See p. 57.) 
Displacement (dislocation) of the Heart- dulness. 
This, of course, arises from displacement of the heart, as is declared 
by the apex-beat; but in this case, for various reasons, it is generally 
an imperfect sign of such change. For one thing, it often happens EXAMINATION OF THE CIRCULATORY APPARATUS. 
211 
that the condition which causes the dislocation itself presents dulness, 
which invades the region of heart-dulness. This is the case when a 
pleuritic exudation displaces the heart, or when shrinking of the pleura 
or lungs distorts the heart. Again, it is usually especially difficult to 
determine the location of the heart by percussion if there exists a 
vicarious emphysema on the left side simultaneously with considerable 
shrinking on the right. In this case the heart is sometimes moved 
over to the middle of the thorax (mesocardia). 
Still further, the extent to which the heart is parietal is frequently 
changed by dislocation ; thus, when the diaphragm stands very high 
the heart is pushed upward, usually causing an increased area of 
dulness, since the heart is then more flat against the chest than is 
normal. 
If there is an apex-beat in such cases, it is a very sure sign; often 
it is necessary to employ auscultation to aid in establishing by the 
location of the greatest intensity of sound, at least approximatively, 
the position of the heart. 
Auscultation of the Heart. 
Method and Normal Condition. 
Method. Ordinarily we are to auscultate the heart exclusively by 
the stethoscope. After long practice and experience the examiner 
may think it advisable to compare what he hears with the stethoscope 
with the results of direct auscultation ; but these are exceptions. The 
very urgent reason for the use of the stethoscope is that by it we are 
able to distinguish as sharply as it is possible to do the impressions of 
sound which come from the different points, so as to be able to refer 
every sign to its proper place of origin. 
First of all, we are to examine the patient when he is in the greatest 
possible quietude of body and mind ; in some cases we may then, after 
we have begun, find it advantageous to increase the activity of the 
heart by having the patient make a certain amount of exertion (as by 
sitting up in bed several times in succession or moving about), since 
we can thus sometimes obtain certain signs clearer. This will be 
referred to from time to time. The position of the patient during the 
examination will, in general, be the same as for percussion, already 212 
SPECIAL DIAGNOSIS. 
referred to. However, we often hear much plainer in the upright 
position, and hence in doubtful cases auscultation in this position is 
not to be neglected. 
More than anywhere else, in auscultation of the heart it is neces- 
sary to examine several times. The rapidity and strength of the 
heart’s action, and possible extraneous sounds, have a great influence 
upon the distinctness of what is heard. In severe diseases of the 
heart, especially with heart-failure from different causes which will be 
mentioned, the impression is generally so confused that no physician 
of experience will pronounce a definite opinion until, by appropriate 
treatment, the heart has been restored to a degree of strength. 
Normal condition. Over the whole region of the heart, and for a 
certain distance beyond it, we hear, corresponding with each pulsation 
of the heart, two “ sounds ”—one coincides with the ventricular con- 
traction, the “systolic,” the “first” sound: one, which is heard at 
the beginning of the diastole, the “diastolic,” the “second” sound. 
Corresponding with the greater duration of the diastole, the pause 
between the second and the following first sound is always greater 
than that between the first and second. 
The rhythm in general is as represented here: 
12 12 12 12 
Syst. Diast. Syst. Diast. Syst. Diast. Syst. Diast. 
The apex-beat coincides in time with the systolic sound, and like- 
wise, as we can directly observe, with the pulse in the common carotid 
in the neck. But the pulse of the peripheral arteries occurs notice- 
ably later, so that the radial pulse is felt between the first and second 
sounds of the heart. 
The expression “ tone ” is not to be taken in a strictly acoustic 
sense. In reality it is a short, sharply-defined noise which only 
approaches a tone. But the term is not so inappropriately selected, 
as everyone must be impressed who compares these phenomena of 
sounds with the peculiar heart-sounds to be spoken of hereafter. 
These two—the first and second heart-tones—can be heard over 
the whole region of the heart; but at different points they are of 
different nature and origin, as is partly declared by the character of 
their tone. A part of each sound has its origin in each of the four 
portions of the heart, and hence is in all eightfold: EXAMINATION OF THE CIRCULATORY APPARATUS. 
213 
1. The sudden tension and closure of the mitral and tricuspid 
valves cause a systolic sound, which naturally is most distinctly heard 
in the neighborhood of these valves or over the ventricles. 
2. The closure of the semilunar aortic and pulmonary valves causes 
a diastolic flapping tone, heard most distinctly over those valves or in 
their neighborhood. 
3. The sudden contraction of the ventricle causes a dull systolic 
sound of short duration. 
4. The sudden filling of the conus arteriosus, aortic and pulmonary, 
in consequence of the motion of the blood, or, more probably, of the 
sudden tension of the walls of these vessels, causes a short, somewhat 
ringing sound. 
Thus, we see that the valves have a very essential part in the pro- 
duction of the heart-sound; and since, as has already been remarked 
in the “preliminary observations” [p. 194], the heart-sounds arising 
in certain circumstances are only connected with the valves or the 
different openings, these are the chief consideration in auscultation. 
Hence, we have chiefly to attend to the auscultation of the mitral 
valve, the mitral orifice, the aortic valve, the aortic orifice, etc. 
Hence, it follows that we always first listen at those four points of 
the chest which lie nearest to these valves. But experience has 
shown that for two of these this is not the best method, as is easily 
understood from the anatomical relations. 
We cannot auscultate the aortic valves at the point of the chest 
which lies nearest to them, since they are obliquely behind the 
pulmonary valves, and at that point the sound which comes from the 
pulmonary artery and its valves predominates; hence, we must 
auscultate at the beginning of the aorta; and we do not ordinarily 
hear the sounds of the mitral most distinctly at the point where it is 
located, since a layer of lung there covers the heart, but better at the 
apex of the heart. The points of election for auscultating the heart 
are as follows (compare Fig. 46): 
Mitral valve, 
Left auriculo-ventricular opening. 
Apex of the heart. 
Tricuspid valve, 
Right auriculo-ventricular opening. 
Over the sternum. 
Aortic semilunar (ost. aort.): 2d intercostal space, right of sternum. 
Pulm. semilunar (ost. pulm.): 2d intercostal space, left of sternum. 214 
SPECIAL DIAGNOSIS. 
The accompanying figure exhibits the situation of the openings and 
the points where they may be best auscultated. We see that the 
auscultation-points of the mitral and aortic valves are so related to the 
respective openings that they lie downward from them with reference 
to the normal course of the blood-current. 
Fig. 46. 
The anatomical situation and the points for auscultating the valves of the heart and 
its orifices. The small letters show the location of the valves: the large ones the 
points for auscultating, a A = the aorta; mM — mitral valve; pP = the pulmonary 
orifice; tT= tricuspid. 
The “ tones ” that can be heard in health at the four points men- 
tioned correspond with the occurrence of the sounds just referred to in 
the following way: 
Apex of the heart (mitral orifice): 
1st sound: Closure of the mitral valves and ventricular contrac- 
tion. 
2d sound : Prolonged aortic second sound (closure of aortic valve). 
Under the sternum (tricuspid orifice): 
1st sound: Closure of the tricuspid valves and ventricular con- 
traction. 
2d sound: Prolonged pulmonary second sound. 
Second intercostal space right or left [aorta, pulmonary art.) : 
1st sound: sudden filling of the beginning of the aorta, of the 
pulmonary artery, and continuation of the first ventricular 
sound. 
2d sound : closure of the semilunar valves of the aorta, or of the 
pulmonary artery. 
Thus the first sound is a mixed one composed of muscle, valve, or 
also of vessel-sound; it is dull and somewhat prolonged. The second EXAMINATION OF THE CIRCULATORY APPARATUS. 
215 
sound is throughout wholly from the semilunar valves; it is short, 
flapping. Hence I represent the first by a dash, the second by a 
short curved line. The heart’s action is hence represented in the 
following way: 
Fig. 47. 
Representation of normal heart-sounds. 
and since we hear the second sound over the ventricle only as con- 
ducted from above against the current of blood, over the ventricle 
it is very light, hence the accent at the apex and [over the sternum, 
i. e.,] under the sternum is represented as follows : 
Fig. 48. 
In auscultating, however, at the mouth of the arteries we hear the 
second sound at the place of its origin; it is here louder, and indeed 
louder than the first, and hence the accent is at the base of the heart: 
Fig. 49. 
either 
or 
according as the first sound is like the ventricular tone or not. 
1 S = systole. 2 D= diastole. 
3 This representation departs from the habit of authors, who draw the comparison 
'with the trochaic and iambic foot, and this does violence to the length of the sounds, 
merely for the sake of making the comparison. I maintain that the above representa- 
tion is more in accordance with the facts. 216 
SPECIAL DIAGNOSIS. 
Differences of variations within normal limits. The absolute 
strength of the heart-sounds varies very much in persons in health. 
It depends upon the elasticity and delicacy of the thorax: children 
and persons with delicate thorax generally have loud heart-sounds; 
with the former (children), they are widely conducted by the lungs, 
and this for the same reason that with them the breathing-sound is 
sharper (see). Further, the thickness of the covering of the chest has 
its effect: large mammae, thick layer of fat, weaken the sounds. Tem- 
porary excitement of the heart may increase the sounds so very much 
that even an experienced person may be tempted to suppose that they 
are increased by pathological conditions. 
The tone of the heart-sounds also varies : with many the first sound 
as well as the second is more “tone-like,” with others less so. Espe- 
cially variable are the first sounds: sometimes shorter, sometimes 
longer, noise-like, “ impure ” ; further, sometimes very deep and not 
clear, “ dull.” 
The first sound of the heart (much more rarely the second) may 
even in health be doubled: 
Fig. 50. 
Normal first sound doubled. 
This is generally only at the end of expiration and the beginning of 
inspiration, probably disturbed by the ventricles not contracting syn- 
chronously (see also under Pathological Doubling). 
Regarding the measurement of the heart-sounds see page 217. 
Pathological Changes in the Heart-sounds. 
G-eneral strengthening of the sounds indicates increased activity 
of the heart: this may occur, as above indicated regarding healthy 
persons, but to a still higher degree, from temporary excitement in 
nervous disease of the heart, and also in Basedow’s disease; it is also EXAMINATION OF THE CIRCULATORY APPARATUS. 
217 
a frequent accompaniment of fever—this without the heart being 
hypertrophied. But also, it corresponds with the increased work of the 
heart in hypertrophy, especially of the left ventricle; and we meet a 
strength and hence often a flapping character of sound not infre- 
quent in ancemia, and especially in chlorosis. 
Strengthened heart-sounds are, as a matter of course, heard over a 
larger area beyond the heart than normal. They may be heard over 
the whole thorax. However, such more extended perception of heart- 
sounds may be due to condensation of the lungs (pneumonia, chronic 
contracting phthisis). 
It is difficult to measure exactly the strength of the sounds of the 
heart. Recently a very ingenious method has been proposed by H. 
Yierordt. Its significance will be greatly affected by the changing 
dulling effect of the chest-wall and its covering, also of the lungs. It 
is interesting to note that normally the mitral first sound is the loudest 
and the aortic first sound the softest. Dull sounds, which by the usual 
mode of auscultation the ear is accustomed to consider light, by this 
method sometimes manifest themselves as louder, like flapping, thus 
apparently more intense. 
Strengthening of separate sounds. Strengthening of a second sound 
(more emphatic closure of the semilunar valves), if persistent, is a 
very sure sign of hypertrophy of the corresponding ventricle. Only 
we must not consider a slight emphasis of the aortic or pulmonary 
second sound as a pathological strengthening. (Regarding the con- 
ditions which lead to hypertrophy of the ventricle see the Preliminary 
Remarks.) Abnormally strong, accentuated pulmonary second sound 
is thus a very important sign of hypertrophy of the right ventricle, 
and it is the more important since in this condition percussion is often 
omitted. Strengthened aortic second sound, especially in sclerosis of 
the aorta, becomes slightly sonorous, ringing. In hypertrophy of the 
left ventricle from insufficiency of the aortic valves accentuation is 
wanting, because in the main the second sound is wanting, and be- 
cause of the failure of the valves to close. 
This accentuation of the second sound immediately disappears when 
the heart becomes weak, when heart failure takes place. The disap- 
pearance of the accentuation of the pulmonary second sound is there- 
fore of especial diagnostic value, since we have no other direct sign of 218 
SPECIAL DIAGNOSIS. 
commencing failure of the right ventricle. If there occurs a relative 
tricuspid insufficiency from a high degree of weakness and dilatation 
of the right ventricle (see Preliminary Remarks), then the pulmonary 
second sound almost entirely fails, since the blood now has an outlet 
upon both sides, backward through the ostium venosum, and forward 
into the pulmonary artery, and thus the pulmonary pressure falls off 
very greatly. 
In a case of disease of the heart the importance of the second pul- 
monary sound cannot be too strongly impressed upon the beginner in 
making his observations; it is a measure of the activity of the right 
ventricle, as the pulse is of the work of the left (see Pulse). 
Not infrequently both pulmonary sounds (much less frequently both 
aortic sounds') are strengthened because the base of the heart is in con- 
tact with the chest-wall, when there is shrinking of the lungs. An 
accented pulmonary second sound from hypertrophy of the right ven- 
tricle may be felt thus as a diastolic stroke in the left second intercostal 
space. The author once found, in a case of mitral insufficiency with 
hypertrophy of the left ventricle with shrinking of the lung, an aortic 
second sound that could be felt in the right second intercostal space. 
Pathological strengthening and flapping character of the first sound 
at the apex are so frequently occurrences in mitral stenosis that to the 
experienced observer they have diagnostic value. The phenomenon 
is ordinarily explained as being a consequence of diminished filling of 
the left ventricle which follows from the lessened size of the orifice by 
which it is filled, the segments of the mitral valve at the end of the 
diastole are still very lax, and so come together with more energy at 
the beginning of the systole. This explanation does not appear to us 
to be wholly acceptable. 
Weakness of all the sounds of the heart (more inclined to concern 
the second sounds) occurs in all cases of weak heart, as takes place 
in hearts previously sound in consequence of over-exertion, severe 
hemorrhages, carbonic acid poisoning, or any kind of interference 
with breathing (see), any other kind of poison, as heart poison, in 
acute febrile diseases; finally, in central or peripheral paralysis of 
the vagus, as follows disease of the heart-muscle, or as generally at 
last from some cause or other overtakes an hypertrophied heart. 
Hypertrophy of one division of the heart is, as referred to in the EXAMINATION OF THE CIRCULATORY APPARATUS. 
219 
Preliminary Remarks, generally u compensatory"—that is, it is said 
to accompany any obstruction of the circulation. If a hypertrophic 
heart can no longer meet the demands made upon it, we then use the 
term “ incompensation.” Then heart-sounds that in part were pre- 
viously strengthened at first become about normal, and then become 
weaker than normal. 
Moreover, when an emphysematous lung forms a layer over the 
heart, the heart-sounds are found to be persistently weakened, even to 
marked indistinctness, and this involves, also, the pulmonarysecond 
sound, which, in emphysema, is strengthened. This weakening occurs 
with large pericardial exudations or hydro-pericardium ; more rarely 
from a tumor or pleural exudation pressing against the heart. 
Weakening of individual sounds. If there is an “ organic heart 
murmur” (see p. 221), then the sound with which it occurs, or at Avhich 
it ceases, becomes either weakened or indistinct, or it is entirely wanting, 
so that the “murmur” takes the place of the sound. But also with 
certain valvular defects there occurs weakening of other sounds, such 
as of the aortic second sound in mitral stenosis, in consequence of 
which the left ventricle has only a little blood to throw into the aorta 
(see Preliminary Remarks); weakening of the same aortic second sound 
in stenosis of the aorta, as the pulmonary second sound in stenosis of 
the pulmonary artery, as a consequence of those valves being less free 
in their action. Not without diagnostic value, also, is a high degree of 
weakening (even to complete disappearance) of the first sound at the 
apex in aortic insufficiency. This is explained by the reflux from the 
aorta, with the normal afflux from the auricle, filling the ventricle 
abnormally full; it becomes dilated, and thus the tips of the mitral 
valves, even before the beginning of the systole, are somewhat pushed 
up. When the systole takes place, there is then only a moderate 
increase in its tension. Moreover, in aortic insufficiency, over the 
aorta the first sound is often weak and very impure, without other 
contemporaneous signs of aortic stenosis being present. (See Heart 
Murmurs, and Pulse.) 
Divided or double heart-sounds. These ordinarily are without sig- 
nificance if the condition otherwise is one of health (see p. 217). They 
occur also in pathological conditions, and are then of diagnostic mean- 
ing. We bring together here (Fig. 51) the cases in which, instead of 220 
SPECIAL 1)1 A GNOSIS. 
two heart-sounds we hear three, without sharply separating between 
“divided’’ and “doubled” sounds. 
Division of the second sound at the apex occurs in mitral stenosis„ 
It may conceal a diastolic sound, which, with the patient in the up- 
Fig. 51. 
(Divided:) 
(Doubled:) 
Different kinds of division and doubling of the heart sounds. 
right position and heart excited, sometimes can only be distinctly 
heard by placing the stethoscope at the outer left end of the apex-beat. 
We may especially refer a divided second sound at the apex, accord- 
ing to my experience, to mitral stenosis, in case there are, besides, 
undoubted signs of mitral insufficiency. 
Further, a divided second sound is heard (pericarditis adhesiva and 
systolic drawing-in of the apex beat, Friedreich, whose explanation of 
the phenomenon may be doubted). 
Finally, here belongs the gallop rhythm, sometimes present: 
Fig. 52. 
or also: 
Gallop rhythm. 
that is, three similar short ringing sounds, of which either the second 
or third has an accent, but in many cases neither has an accent. EXAMINATION OF THE CIRCULATORY APPARATUS. 
221 
This gallop rhythm may, but quite exceptionally, be observed in 
health with excited action (I have seen two cases). It is also observed 
in emphysema, contracted kidney, arterial sclerosis, heart disease with 
slight incompensation. But it generally indicates severe, often fatal 
heart-failure, and especially in infectious diseases. It is particularly 
frequent in children ; it may here, for example, in diphtheria, be the 
first sign of beginning paralysis of the heart, even before the pulse 
becomes markedly quickened. In my opinion the gallop rhythm may 
be explained in the same way as the divided sound, the ventricles not 
contracting at the same time. This question will be variously an- 
swered by different authors. 
Metallic heart-sounds. They come from the resonance of a large 
smooth-walled layer of air close over the heart, as is the case in 
pneumo-pericardium, not infrequently in pneumothorax, and in indi- 
vidual cases of large cavity in the lung with smooth walls which lies 
close to the heart. Intestinal or peritoneal meteorism (see both of 
these), or a very much inflated stomach, may sometimes cause metallic 
heart-sounds. 
In pneumo-pericardium, also in cases of inflation of stomach with 
gas, if the action of the heart is very strong or excited, the sounds 
may be so loud that the first, or even the first and second, can be 
heard at a distance. 
Organic Endocardial Heart-murmurs. 
By endocardial heart-murmurs, as the name implies, we understand 
murmurs arising within the heart in distinction from those arising in 
the pericardium. Endocardial murmurs are again distinguished as 
organic and inorganic, according as they are dependent upon anatomical 
changes or not. We now consider the former. 
Organic heart-murmurs will be caused by stenosis of the openings 
or by imperfect closure of the valves or insufficiency, both the ordinary 
and the relative insufficiency of the valves (see Preliminary Remarks, 
paragraph 2). They furnish us with an important means of recogniz- 
ing the so-called valvular defects. 
If fluid is flowing through a tube which suddenly at a certain point 
is contracted, from this stenosis eddies in the current will arise below 
that point, and these eddies will cause murmurs. If the fluid flows 222 
SPECIAL DIAGNOSIS. 
very rapidly the eddies and their sounds are increased. Normally 
the blood passes through the openings of the heart without sound, 
since there is no notable narrowing of the course of the blood; but if 
an opening is narrowed, then eddies and sounds are produced, and so 
much the more markedly if there is compensation, when the blood 
from the section of the heart lying behind the narrowed opening is 
driven with much greater rapidity than normal through the narrowed 
opening (see Preliminary Remarks). 
Such a murmur will be heard at the moment when normally the 
blood passes through that opening—that is, at the systole, if an arterial 
opening is narrowed, at the diastole if a venous opening is affected 
(auriculo-ventricular). 
But murmurs are produced by insufficiency of the valves, which are 
to be explained in the following way: The effect of insufficiency is 
such that the blood, which, in the preceding stage of the heart’s action, 
passes through the affected opening, in the following stage, in which 
the valves of that opening would have closed, partly flows back; it 
likewise flows against the blood normally flowing into the cavity and 
rebounds with it: thus eddies arise and also a murmur. The intensity 
of this murmur depends, in the first place, upon the degree of insuf- 
ficiency, and, again, very materially varies with the strength of the 
heart’s action ; for the greater this is the more marked is the differ- 
ence in pressure and the more violent the backward current which it 
causes. 
Likewise, there occurs the murmur of insufficiency in that stage of 
the heart’s action in which the affected valves ought normally to close 
—that is, at the arterial openings with the diastole, and at the venous 
openings with the systole. 
Moreover, it appears to me to be unquestionable that, in the great 
majority of cases of insufficiency, the murmur is increased by the 
simultaneous occurrence of a murmur from stenosis; for the reflux 
current of blood certainly flows through a narrow opening if the 
insufficiency is not greater than it usually is. I also think that, in 
connection with this, in cases of severe aortic insufficiency (N. B., with 
full compensation), we find the diastolic murmur especially soft. (See 
further regarding this the following, upon the influences that affect 
the loudness and character of the heart-murmurs.) EXAMINATION OF THE CIRCULATORY APPARATUS. 
223 
Loudness of the endocardial murmurs. From what has already 
been said it is evident that the loudness of the murmur is not alone 
dependent upon the severity of the valvular lesion. It is also a very 
great mistake to draw a conclusion about the degree of the stenosis or 
insufficiency from the loudness of the murmur; regarding this, the 
effects of the valvular lesions upon the heart and circulation, especially 
the pulse (which see), are much more determinative. 
Murmurs are very much affected by the strength of the action of 
the heart: they are plainly louder when the heart is excited, and hence 
when they are indistinct, if the patient is able to do so and is not 
harmed by it, he can first move about or can sit up and lie down 
again several times in bed before we auscultate him. On the contrary, 
a murmur previously distinct becomes, without exception, more feeble 
if the strength of the heart declines. In very marked weakness of 
heart the murmur may even become entirely imperceptible, hence, in 
disease of the heart, the murmurs entirely disappear if an unfavor- 
able turn takes place ; also, they disappear in cases of heart disease 
where the patient is overtaken with a severe febrile disease (see above). 
Hence, an exact diagnosis of disease of the heart, if the heart is weak, 
is always uncertain, and often impossible, whenever the action of the 
heart is accelerated. (See Relation of Heart-murmurs to the Time of 
Action of the Heart, p. 224.) Hard (calcareous) or rough valves have 
the effect of strengthening or sharpening the murmurs of stenosis, or, 
perhaps, also of insufficiency; also, in individual cases, the murmur 
may be changed by the relaxation or rupture of the tendinous cords 
of the valves (see Character of the Murmurs). In other respects the 
strength of the murmurs is dependent upon the same influences as 
affect the heart-sounds (which see). 
In rare cases the heart-murmur is so marked that it may be heard 
at a distance, without laying the ear over the chest. Such murmurs 
may sometimes be perceived by the patient. Only those arising at 
the aortic orifice have this peculiarity. 
Localization of the murmurs. The next diagnostic point of 
importance is that we can determine, from the location in the region 
of the heart where a murmur can be heard most distinctly or where it 
is loudest, whence it arises—that is, at which opening the valves are 
diseased. The auscultation-points already mentioned serve here as 
points of departure. We listen— 224 
SPECIAL DIAGNOSIS. 
At the apex of the heart—that is to say, at the point of the apex- 
beat—for the mitral valve, the left venous opening. 
Over the lower part of the sternum—for the tricuspid valve, the 
right venous opening. 
In the right second intercostal space, close to the sternum—for the 
[aortic] opening and the auricular semilunar valves. 
In the left second intercostal space, close to the sternum—for the 
opening [of the pulmonary artery] and the pulmonary semilunar 
valves. 
But it is to be noticed that the murmur caused by aortic insufficiency 
is, as a rule, not heard in the right second intercostal space, but is 
most distinct over the sternum, sometimes even in the left third inter- 
costal space at the left of the sternum; since it is caused by the 
backward flow of the blood, it is conducted in the direction of the 
ventricle. Analogously, but only exceptionally, the murmur of insuf- 
ficiency of the mitral valves may be noticed most markedly, not at the 
apex, but on the left of the base of the heart—that is, in case the 
dilated left auricle, with its appendage, lies somewhat forward 
(Naunyn). 
The murmur of stenosis of the left auriculo-ventricular opening, 
often only rough, is distinctly heard at the outer end of the apex- 
beat. 
Relation of the heart-murmurs to the time of action of the heart. 
It follows from the above discussion that the organic heart-murmurs 
are very closely connected with certain instants of the action of the 
heart, and, further, that they are divided into systolic and diastolic. 
And thus we hear in— 
Stenosis of the aorta: A systolic murmur in the right second 
intercostal space. 
Fig. 53. 
Aortic insufficiency: A diastolic murmur at the same place, or, 
better, lower down to the left of this, over the sternum. EXAMINATION OF THE CIRCULATORY APPARATUS. 
225 
Fig. 54. 
Mitral stenosis: A diastolic murmur at the apex, the first sound 
closely succeeding it, or almost at the same time, in case the second 
sound is heard close to it. (See more exactly below.) 
Fig. 55. 
Mitral insufficiency: A systolic murmur at the apex of the heart. 
Fig. 56. 
Fig. 56. 
or: 
Quite analogously, in pulmonary stenosis and tricuspid insufficiency, 
we hear a systolic murmur, in pulmonary insufficiency and tricuspid 
■stenosis, a diastolic murmur at the corresponding points (see above). 
Of these valvular defects of the right side of the heart the only one 
frequently present is tricuspid insufficiency, and this is relatively 
much more frequent (in great weakness of the heart) than insufficiency 
caused by endocarditis. Pulmonary insufficiency and stenosis are 
almost always congenital, and then are very often associated with a 
permanently open foramen ovale (regarding which see later). 
Systolic murmurs in stenosis of the aorta and insufficiency of the 
mitral valve, and the diastolic murmur from aortic insufficiency 
generally are directly joined with the sound affected by them; but 226 
SPECIAL DIAGNOSIS. 
these sounds are thus always weakened, or the sound completely dis- 
appears and the murmur takes its place. In such cases the sound 
may still be heard if we remove the ear a short distance from the ear- 
plate of the stethoscope. Probably the weakened sound is not to be 
referred to the valve that is affected, but is conducted so as to be 
heard elsewhere. 
On the other hand, a peculiar condition commonly belongs to the 
diastolic murmur of mitral stenosis; it occurs at the end of the 
diastole as a so-called presystolic murmur, or, in case it is present at 
the beginning of the diastole, it becomes stronger toward the end; 
hence, either: 
Fig. 57. 
or: 
The explanation of this remarkable phenomenon is very simple: 
toward the end of the diastole the auricle contracts and drives the 
blood with greater rapidity through the narrow ostium venosum; 
hence, the strengthening of the eddy and murmur. 
In most cases a little practice enables one to recognize in what 
period of the action of the heart an endocardial murmur belongs. But 
if there remains the slightest doubt whether a murmur is systolic or 
diastolic, then the examiner must observe the action of the heart by 
palpating at the same time he is auscultating, and this is best done by 
applying a finger to the common carotid in the neck ; here the pulse 
is almost simultaneous with the ventricular systole, and hence 
demonstrates the time of its occurrence. 
We cannot employ the radial pulse, because it is felt too long after 
the systole. When the action of the heart is very irregular, and 
still more when it is very much accelerated, it is very difficult, or it 
may be entirely impossible, to distinguish between systole and 
diastole. EXAMINATION OF THE CIRCULATORY APPARATUS 
227 
Murmurs differ very much in character: murmurs of insufficiency 
are, as a rule, softer, blowing, and, indeed, the murmur of aortic 
insufficiency manifests itself often by its length and remarkable 
delicacy (it may easily be overlooked), while that of mitral insufficiency 
usually is louder, but not quite so long. Of the murmurs of stenosis, 
that of the aorta is generally loud, “ sawing ”; mitral stenosis, on the 
other hand, is almost always very soft, peculiarly rolling or “flowing,” 
or seeming to consist of several very soft sounds. This murmur is 
sometimes imperceptible, even with strong action of the heart. 
Under some circumstances aortic or mitral murmurs of insufficiency 
may be musical—that is, they contain a sound which approaches a 
distinct, always very high musical tone. In such cases there have 
frequently been found at the autopsy the suspected causes of this 
phenomenon in that the semilunar valve has been found to be per- 
forated, also torn floating shreds of valves, sinewy threads in the 
lumen of the ventricle, floating torn shreds of papillary muscle, etc. 
These conditions generally furnish no indication as to the particular 
heart-lesion; it is, therefore, of no value to recognize them during 
life. In many cases, moreover, of which two came under my own 
observation, it happens that at the autopsy nothing is found to explain 
the occurrence of the musical murmurs during life. 
Metallic murmurs occur under the same conditions as metallic 
heart-sounds (see): in general, if there is a resonant air-space near to 
the heart. 
Murmurs that may he felt: endocardial whizzing, “ fr6missement 
cataire,” cat’s purring. This occurs generally, but by no means 
always, with murmurs that are distinguished by their loudness. 
Locally, their most distinct perception by touch always corresponds 
with the locations where they are heard most distinctly. We palpate 
with the hand or finger-tips and recognize thus, though only in rare 
cases, a fine whizzing, which is most like what we feel when we stroke 
the back of a purring cat. 
In this way, by the aid of palpation, we may prove the existence 
at the apex of systolic and diastolic, or presystolic mitral murmurs, 
and in the right second intercostal space of systolic and diastolic 
aortic murmurs. Defects of the right heart seldom produce murmurs 
that can be felt. The palpation of endocardial murmurs has so 228 
SPECIAL DIAGNOSIS. 
subordinate a value that we can never permit ourselves to dispense 
with auscultation, which yields so much sharper and clearer results. 
Transmission of heart-murmurs. It is understood that an endo- 
cardial murmur is very often not confined to that spot on the thorax 
where it is auscultated, but will be heard at some distance away from 
it. The conduction takes place especially in the direction of the blood- 
current. Thus an aortic systolic murmur is often heard even over 
the carotid in the neck. On the other hand, the diastolic aortic 
murmurs generally are perceived over the sternum, even louder than 
in the right second intercostal space; but they are also often to be 
heard as far down as the apex. Systolic blowing in mitral insuffi- 
ciency is sometimes conducted toward the right as well as further 
upward. On the other hand, diastolic [presystolic] murmur from 
mitral stenosis is always sharply confined to the left border of the 
heart. An inorganic systolic pulmonary murmur which can be 
heard some distance downward from the base of the heart very often 
disturbs or deceives us. 
Combination of several murmurs. This results from the combina- 
tion of several valvular defects. It more frequently happens that 
insufficiency of a valve is connected with stenosis of the opening to 
which that valve belongs. Then we hear at a particular spot a 
murmur with each of the two stages of the heart’s action. It is more 
difficult to interpret what is heard when the disease affects different 
openings or valves, and especially if there are two murmurs both of 
which occur with the systole (mitral insufficiency and aortic stenosis), 
or both in the diastole (mitral stenosis and aortic insufficiency). Then, 
it may happen that only one valve is supposed to be diseased and that 
the second murmur which is heard is transmitted from the first. But 
also a mistake in the opposite direction may be possible, namely, that 
Ave assume that there is a combination of two valvular affections when 
in fact there is only one, as when a murmur of aortic insufficiency 
Avhich is heard at the apex is considered as a new, independent mur- 
mur produced by mitral stenosis. The differentiation by auscultation 
is made in two ways : 1. By the character of the murmur. If one is 
blowing and the other is rough there certainly are two murmurs; if 
both are alike then there may be only one, Avhich is conveyed from 
the opening where it arises to a second opening. Yet it might be 
that even in this case there were two murmurs, with different origin. EXAMINATION OF THE CIRCULATORY APPARATUS. 
229 
2. We auscultate step by step from the point where we can hear one to 
where the other exists, as from the apex to the aorta. If the murmur 
is everywhere distinct, only that toward one spot it gradually becomes 
louder, then it arises at this point and is conveyed to another. But 
if it is lost somewhere on the way from the apex to the aorta and is 
again heard at the aorta, then there are two murmurs. 
This procedure may answer the purpose, but it often fails, and in 
such difficult cases auscultation alone cannot decide, but we must take 
a view of the whole picture of the heart and vessels in order to reach 
a diagnosis. This will be treated of further on. 
Finally, murmurs that arise in the neighborhood of the heart may 
be mistaken for heart-murmurs. Those that come from the trachea 
and bronchi can easily be excluded by having the patient, if necessary, 
hold the breath. But it is more difficult to discriminate between heart- 
murmurs and those that have their origin in the aorta (especially 
aneurism), regarding which see below. 
Inorganic, Anaemic Murmurs. (Synonyms: accidental, 
JZoocZ murmurs.) 
These are so designated because they occur in all forms of anaemia, 
both light and severe, but especially in chlorosis, in all wasting dis- 
eases, and also in febrile diseases, without there being any disease at 
all of the heart or vessels. They serve as a sign of ansemia; they 
generally entirely disappear with the removal of this condition. 
In very pronounced cases there are very soft, systolic, blowing 
murmurs which are heard over the pulmonary artery or lower down 
with indefinite location, or they may even be heard over the apex. 
But not very infrequently such an inorganic murmur is also sharp, 
even very loud; on the other hand, it is very seldom diastolic; also 
we may almost say that it never is heard over the aorta. Thus the 
other signs of valvular disease are wanting, especially hypertrophy of 
a ventricle, while the pulse gives evidence of anaemia, and there are 
murmurs in certain vessels, especially the veins of the neck. 
Sometimes there is at the same time considerable dilatation of the 
heart, as takes place in anaemia (which see) ; on the other hand, we 
have those marked dilatations which give rise to murmurs from 230 
SPECIAL DIAGNOSIS. 
relative valvular insufficiency and which may also exist in severe con- 
ditions, with which we are not at present concerned. 
It is very difficult to explain anaemic heart-murmurs. Nothing of 
what has already been said regarding murmurs seems to us to he 
applicable here; we think with others that the nature of the phenom- 
ena differs in different cases, and in many cases we may apply Sahli’s 
supposition that venous murmurs from the large veins in the thorax 
lie behind these heart-murmurs. 
For distinguishing them from the organic heart-murmurs it is in 
the first place necessary to call to mind what has been mentioned as 
characteristic of anaemic murmurs, and then to observe whether there 
are other signs of anaemia present. Further, a valvular defect is to 
be excluded by the most careful examination of the heart and pulse. 
It is true that in many cases the phenomena are such that we can 
only obtain a clear idea by long observation, especially remarking 
whether treatment of the anaemia removes the murmur. It is very 
difficult to decide that a diastolic murmur is due to anaemia. 
The author recalls having seen two cases of pronounced pernicious 
anaemia complicated with mitral endocarditis and mitral insufficiency, 
in both of which the differential diagnosis between anaemic murmurs 
and the valvular disease mentioned could not be positively established 
during life. In both there existed simultaneously considerable emphy- 
sema which concealed the slight hypertrophy of the left and right 
ventricles. 
Pericardial Murmurs. [.Friction-sounds.] 
The name explains the situation of these murmurs. Their nature 
is the same as pleuritic friction-sounds; they are caused by the fric- 
tion of the visceral and parietal pericardium made by the action of 
the heart when their opposing surfaces rub against one another ; they 
do this when the surfaces are rough, exceptionally even if they are 
simply unusually dry. 
We have near to the ear a ringing, short scratching, scraping, 
shuffling, more rarely a creaking sound, one which with a little prac- 
tice is generally easily correctly recognized by its acoustic character. 
It is generally very sharply defined as to location, and is most fre- 
quently heard at the base of the heart, hut often farther down at the 
left of the sternum. EXAMINATION OF THE CIRCULATORY APPARATUS. 
231 
Of greater importance is the relation of the friction-sound to the 
action of the heart: it occurs, not in close conjunction with the sounds, 
but between them, either only during the systole, or more frequently 
in both stages, but generally louder with the first sound: 
Fig. 58. 
Pericardial murmurs, 
More rarely, tolerably closely before and after the second sound: 
Fig. 59. 
Or covering the first sound : 
Fig. 60 
The rubbing of marked pericardial friction-sounds can be felt bj 
applying the hand to the spot. Several special peculiarities of these 
friction-sounds will be mentioned when we treat of differential diagnosis. 
Pericardial friction-sounds occur: 
In Pericarditis, when the surfaces of the pericardium, where the 
fibrinous exudation exists, rub against each other without becoming 
adherent. Hence, we hear friction-sounds in pericarditis sicca so long 
as it is not adhesive, and in pericarditis exudativa, if there is fibrinous 
exudation without enough fluid completely to separate the surfaces of 
the pericardium. This is why the friction-sound is generally heard 
at the base of the heart or near to it; it is not infrequently heard 232 
SPECIAL DIAGNOSIS. 
there as the first sign, and then often disappears as the exudation 
increases, and it may again return when the exudation diminishes. 
The disappearance of a previously existing pericardial friction-sound 
may depend upon one of four causes: 1. The complete decline of a 
pericarditis, without any sequelae. 2. By the addition of a fluid 
exudation. 3. By adhesion of the pericardial surfaces. 4. From 
great weakness of the heart. It is necessary to ascertain in every 
case which of these four causes is operating. If there is no evidence 
of the second or the fourth, then the first and third must he considered; 
and between these it is possible to make a differential diagnosis only 
in very rare cases. 
They also occur in rare cases of tuberculosis of the 'pericardium 
(which usually results in adhesion), quite exceptionally with fragments 
of fibrinous cords and calcifications in the pericardium, and in abnor- 
mal dryness of the pericardium, as in cholera. 
The differential diagnosis between pericardial and endocardial 
murmurs is generally very easy for those who are accustomed to hear 
both sounds, frequently by the character of the pericardial sounds and 
the circumstance that they sound so near the ear. Musical persons 
generally also immediately recognize the difference in time (see above). 
But the following may enable us to distinguish between them: 
(a) Very much the most important is the consideration of the 
whole picture of the disease (form of the dulness, apex-beat, sounds, 
pulse, etc.). 
(b) Change of position. The pericardial sound almost always 
changes, and much more than the endocardial, with change of 
position. 
(c) Strong pressure with the stethoscope. If we press exactly at 
the right spot, especially if it be in an intercostal space, sometimes 
the pressure very strikingly increases a pericardial sound, but never 
an endocardial one. But in the majority of cases, even of the former, 
the sounds are not increased by pressure; hence, it is merely confirma- 
tory when it exists, but failure to notice it has no meaning. 
(d) Pericardial sounds often change their location, strength, and 
character in a few hours; they may even very quickly disappear and 
very suddenly return (see above). Endocardial murmurs are markedly 
chronic and regular. Very exceptionally they come and disappear EXAMINATION OF THE CIRCULATORY APPARATUS. 
233 
suddenly, if they are organic, and only in exceptional cases when due 
to heart weakness. 
Extra-pericardial friction-sounds. The friction-sounds wrhich are 
heard close to the heart, and even over it, and wdiich resemble them 
in sound, may he very easily confounded with the pericardial sounds. 
This extra-pericardial sound is, in the great majority of cases, a pleuritic 
friction-sound which is caused by the contact of the pleura with the 
heart, especially at the lingula, and which by the mechanical effect of 
the action of the heart results in thrusts which correspond with the 
movements of the heart. It is distinguished from pericardial friction- 
sound in that it is greatly influenced by the breathing: it is often 
heard only with deep inspiration, or, on the contrary, during very 
superficial breathing. In individual cases we hear it as pleuritic 
friction with strong breathing, while with quiet breathing it has the 
time of pericardial friction-sound. 
There occurs, also, a peritoneal friction with peritonitis involving 
the lower surface of the diaphragm (subphrenic peritonitis), and quite 
exceptionally over the liver. This sound is transmitted by the motion 
of the heart upon the diaphragm as a pseudo-pericardial sound 
(Emminghaus). 
The differential diagnosis of these sounds from pericarditis will 
depend upon the other signs of a pleurisy or peritonitis, and with 
reference to pleuro-pericardial friction the effect of the breathing is 
to be considered. Hence, the differential diagnosis may here be very 
difficult, because sometimes a pleurisy close to the heart may by 
contiguity awaken a pericarditis. 
Fine crepitations, like those in emphysema of the skin (see p. 55), 
occur in the neighborhood of the heart, synchronous with the action 
of the heart, in mediastinal emphysema. 
Metallic pericardial splashing results from fluid and air in the 
pericardium (pyo-pneumocardium), exactly as wre have succussion-sound 
with hydro-pneumothorax, only that the succussion is caused by the 
heart itself. Moreover, after the analogy of extra-pericardial friction- 
sound, a pseudo-pericardial—in fact, pleuritic—splashing, simultaneous 
with the motions of the heart, occurs with hydro-pneumothorax, where 
the motions of the heart are communicated to the fluid. This happens 
exceptionally, too, with large cavities close to the heart or when the 
stomach is filled with fluid and air. But these are merely curiosities. 234 
SPECIAL DIAGNOSIS. 
Exploratory puncture of the heart is only to be undertaken with 
reference to the performance of puncture, and hence belongs under 
therapeutics. 
Examination of the Arteries 
Usually we select the radial pulse, which, because of its importance, 
requires a separate and complete consideration. Then we can add to 
this the description of the characters of the other arteries. 
I. THE PULSE, ITS PALPATION AND GRAPHIC REPRESENTATION. 
From the commencement of medical study the radial artery has 
been examined where it passes between the styloid process of the 
radius and the tendons of the long flexors of the hand and fingers. 
The examination of the pulse is not a simple thing. It requires 
practice, and hence it is the more important, in order to be able to 
recognize the differences and peculiarities of different cases, always to 
take the pulse at the same artery ; hut it is easy to understand that 
the radial artery is preferable because of its location, and hence it has 
been selected. 
Palpation of the Pulse. 
The arm being held in an unconstrained position, we palpate the 
radial by making slight pressure upon it with the tips of the first 
and second fingers. Generally the impression is threefold : we learn 
the condition of the artery itself, the general state of its fulness with 
blood, and its pulsatory dilatation and contraction. This latter con- 
stitutes the pulse in its narrow sense. 
We study the pulse with reference to its frequency, its rhythm 
(whether the succession of beats is regular or not), and its quality. 
First we consider the normal pulse; then the pathological departures 
from it with reference to these three points of view. 
1. The Normal Pulse. 
Its frequency varies with the period of life, being highest in the 
newly born—about 140 heats in the minute. It becomes constantly 
less up to the twentieth year, when in the adult male or female it is, EXAMINATION OF THE CIRCULATORY APPARATUS. 
235 
on the average 70 to 75, and again somewhat rises with age up to 
about 80 heats. Sex makes a slight difference, the female average 
being a few beats more than the male at the same age. Moreover, 
the size of the body has some influence; the average of large persons 
is somewhat less than that of smaller persons, cceteris paribus. 
The daily variations in the frequency of the pulse correspond with 
those of the bodily temperature; the maximum is generally between 
noon and evening, the minimum in the early morning; the difference 
is generally less than ten, seldom more than twenty heats. Of about 
the same value is the variation of the pulse with reference to the 
position of the body: its frequency is highest in standing, less while 
sitting, and least while lying down. It varies also with the external 
temperature, in case the latter changes considerably from the average: 
the lower the temperature the higher the pulse. 
Meals, especially of food that is rich, and of hot dishes and drinks, 
quicken the pulse for one or two hours. Sleep has no essential effect, 
though the pulse rises, and generally considerably for a short time at 
the moment of waking, even when this is without noticeable excite- 
ment (see below). 
Movement of the body always increases the frequency, under some 
circumstances even till the frequency is doubled. Active deep breath- 
ing increases it. Mental excitement of any kind, as fright, anxiety, 
joy, joyful or painful tension likewise quickens the pulse, but very 
differently in amount in different individuals according to their gen- 
eral excitability. 
All the above-mentioned influences manifest themselves with very 
marked variations according to the bodily constitution and the char- 
acter of the nervous system [temperament]. Pale, delicate persons, 
who are also excitable, show the greatest increase in frequency. 
During convalescence merely rising in bed, a little food, joyful or sad 
newTs considerably quickens the pulse. In disease this is still more 
the case, of which see below. 
Method of observing the pulse: After excluding the temporary 
influences that have been mentioned, we count by the second-hand of 
the watch for twenty seconds ; where greater exactness is required 
for a half or full minute. Sometimes in hospitals the nurses employ 
small sand-glasses ; of course, their accuracy must be carefully tested. 
[In England and America these glasses are not used.] Sometimes in 236 
SPECIAL DIAGNOSIS. 
sickness the pulse is so frequent that it cannot be counted. It has 
been recommended, under these circumstances, to try to count every 
other beat, and then to double the result. In case the radial pulse 
cannot be felt, or if we suspect that some beats drop out (see under 
Intermittent Pulse), we can then count while we auscultate the heart. 
In connection with the employment of temperature-charts we have 
become accustomed to note upon the chart, every time the tem- 
perature is taken, also the frequency of the pulse and respiration; 
thus we obtain upon the fever-chart a continuous line representing 
the pulse, which materially aids in forming a judgment of it. (Re- 
garding the value of this continued observation of the pulse, see 
below.) 
The rhythm of the pulse in perfect mental quiet and during quiet 
breathing is in health regular. But mental excitement easily makes 
the pulse somewhat irregular, especially in nervous persons. Again, 
the rhythm of the pulse is changed with many persons during deep 
breathing, especially, too, in nervous persons. Usually at the end of 
expiration and the beginning of inspiration it is quicker, while at the 
height of inspiration and the beginning of expiration it is slower. 
Normally the pulse at the two radials is exactly simultaneous, the 
crural pulse is also approximatively simultaneous with the radial. 
But if we compare the radial with the action of the heart we notice 
that it is always notably later than the corresponding systole. 
Regarding the quality of the pulse: the radial in health has a cer- 
tain general fulness and hardness, and the separate pulse-waves also 
have a certain size, hardness, and form, All these peculiarities ex- 
hibit not inconsiderable variations within the normal. Correct esti- 
mate of them by palpation is a matter of much careful practice. (For 
particulars regarding the different forms of pulse which we meet, see 
below.) Here it is next to be remarked that in the normal pulse 
equality of its separate heats is desirable (equal pulse); only quite 
small, scarcely perceptible inequality sometimes occurs, again especi- 
ally with nervous persons. A general symmetrical increase in the 
hardness of the pulse and enlargement of its waves are results of phys- 
ical exertion, mental excitement, etc.; in short, from anything that 
temporarily quickens the action of the heart. EX A MINA TION OF THE CIRCULA TOR Y A ERA RA TVS. 
237 
2. Pathological Frequency of the Pulse. 
We distinguish a pulsus rarus (slow, infrequent pulse) and a fre- 
quent pulse (accelerated pulse). 
The slow pulse occurs : 
1. In individual cases of pathological increase of the work of the 
heart, namely, in acute nephritis, especially the nephritis of scarlet 
fever. Hypertrophy of the left ventricle is often included here. But 
the diminished frequency of the pulse is very slight. 
2. In the opposite condition of diminished pressure in the arterial 
system in consequence of hemorrhage; and in individual cases of 
febrile diseases with fatal collapse. 
3. In disease of the heart-muscle, especially in fatty heart, but 
also in fibrinous myocarditis (but here Ave must be on our guard not to 
confound it with intermittent pulse, which see); 48 to 36 beats are 
here not at all infrequently met with. The lowest number pretended 
to have been observed is 8. 
4. In old age, without any disease of the heart (this is very excep- 
tional, but yet it sometimes occurs, as I have been able in one case to 
confirm by autopsy that there was no disease), and in marked inani- 
tion (from stenosis of oesophagus, pylorus, etc.). Here, also, the 
slowing of the pulse may be considerable—even to 48 or less. 
5. Sometimes Avith stenosis ostii aortce; here the difference is very 
slight—about 60 beats. 
6. In disease of the brain or of the meninges, which results in 
irritation of the vagus centre. This may really be only mechanical, 
from increased intracranial pressure (tumors, hemorrhages, hydro- 
cephalus), or from inflammatory irritation (acute meningitis, especially 
basilar). The slowing is considerable. 
7. In the critical decline of fever in acute febrile diseases, possibly 
from the effect of certain products of the fever upon the heart or the 
vagus centre, an effect which is only manifest when the quickening 
effect of the high temperature (which see) upon the pulse is past. It 
is a considerable, but quite temporary slowing. 
8. In heptogenic icterus, from the effect upon the heart of the gall- 
acids circulating in the blood. The pulse is diminished quite 
frequently as low as to 48, sometimes still lower. 
9. In individual cases, with acute articular rheumatism. 238 
SPECIAL DIAGNOSIS. 
It has been recently stated that slowness of the pulse (“ brachy- 
cardia”)in many of these cases is accompanied with characteristic 
maladies (attacks of fainting, a feeling of oppression of breathing, 
apoplectiform attacks). It has also been observed as a seemingly 
independent condition without any sign whatever of an anatomical 
disease, hence as a “neurosis” (Grob). We have never seen any 
cases of this kind. 
Frequent pulse occurs: 
1. In fever, as its chief manifestation. We recognize a general 
relation between the elevation of the temperature and quickening of 
Fig. 61. 
Fig. 62. 
Diminution of frequency of pulse 
after critical fall of temperature in 
pneumonia. The unbroken line 
represents the temperature-curve, 
the broken one the pulse-curve. 
Abdominal typhus in the third to the fourth 
week. The rise in the pulse corresponds with 
the beginning of pneumonia. 
the pulse—to every degree of heat above 87° the pulse increases 8 
beats above the normal (Liebermeister); but there are very great 
variations from this proportion, according to the kind of febrile disease, 
its localization in particular organs, and, further, with the age of the 
patient, the strength of the heart. Thus, in abdominal typhus, so 
long as it is not complicated, there is only a moderate quickening of EXAMINATION OF THE CIRCULATORY APPARATUS. 
239 
the pulse; hence, in this disease, a pulse of 120 has a graver meaning 
than, for example, it has in pneumonia. This moderate quickening 
of the pulse, peculiar to typhus abdominalis, is even an aid in 
diagnosis in severe cases, as distinguishing it from acute miliary 
tuberculosis and pyaemia. It has already been mentioned that in 
meningitis there is slowing of the pulse: when meningitis is added to 
a febrile disease it may lower the pulse, previously quickened, to the 
normal, or may even bring it below the normal. On the other hand, 
during an abdominal typhus, the addition of a complicating pneumonia 
will, under some circumstances, be first noticed by the increased 
frequency of the pulse. (See Fig. 62.) 
Fig. 63. 
Fig. 64. 
Very rapid action of the heart 
(mitral insufficiency). 
Very rapid action of the heart 
(convalescence from typhus; sus- 
picion of mitral insufficiency). 
Febrile diseases with complicating heart disease usually have a 
quicker pulse than the same diseases when the heart is normal. With 
children the pulse is always very much higher in febrile diseases than 
with adults. 
In the course of febrile diseases the constant observation of the 240 
SPECIAL DIAGNOSIS. 
frequency of the pulse is of the greatest importance for estimating the 
strength of the heart, and with it the general vigor, or showing the 
occurrence of complications, etc. (See further, hereafter.) It is also 
to be observed that in fever the frequency of the pulse is immediately 
increased by the least exertion or by excitement. 
In general it is an unfavorable sign when adults have a pulse of 
over 120, and the case requires special consideration. But when it 
reaches 140 it is a grave symptom. 
2. In valvular disease of the heart, except only in stenosis of the 
aorta (see above), and also even with complete compensation. Attacks 
of great frequency of the pulse—180 and over—are infrequent occur- 
rences, which chiefly accompany mitral defects (palpitation of the 
heart). 
Fig. 65. 
Increased frequency of the pulse in fatal collapse (erysipelas) 
3. In heart-failure or paralysis. Thus, in the collapse of febrile 
diseases (see Fig 65), Avhere there is a simultaneous fall of the 
temperature and rise of the pulse; in the arrested compensation of 
heart disease, and in weakening of the heart in consequence of disease 
of the substance of the heart; finally, with central and peripheral 
paralysis of the vagus. 
4. In certain neuroses: Basedow’s disease, nervous palpitation, 
angina pectoris (without the nature of this phenomenon being clear). 
5. In any condition of anxiety, and with severe pain. EXAMINATION OF THE CIRCULATORY APPARATUS. 
241 
3. Want of Rhythm of the Pulse. 
Instead of the normal equal succession of the heats there may be 
complete irregularity (arhythm); in the most marked degree this is so 
in mitral stenosis (even when there is perfect compensation). Moderate 
or marked arhythm is very frequent in myocarditis (sometimes the 
inequality of the pulse is here the only sign). It occurs during the 
stage of incompensation in all cases of heart-defect, and sometimes in 
all forms of marked heart-weakness. Moreover, the inequality of the 
pulse [irregularity of volume] is more important in judging of the 
weakness of the heart than arhythm. 
If, in such arhythm, there are individual pauses in which no pulse 
is felt, then we speak of “suspended” pulse, which may be pulsus 
deficiens—that is, the pauses indicate real pauses in the action of the 
heart; or it may be a pulsus intermittens: they result from weak 
contractions of the heart, which cannot be felt as far as the radial. 
We determine, in a given case, which of the two kinds of pulse it is 
by auscultating the heart. 
But there are other forms of irregularity of pulse in which the 
irregularity of the beats follows a rule: pulsus bigeminus, p. 
trigeminus (where two or three beats are regular and then follows a 
longer pause). These forms generally indicate moderate weakness of 
the heart. 
Lastly, we must mention an especially frequent form of irregularity 
which stands somewhat between the two last-named forms and com- 
plete irregularity—the pulsus intercidens: after several perfectly 
regular beats, suddenly there is one that follows immediately after 
the last regular one (which is also always weaker), then there generally 
follows a slight pause. Most frequently it indicates considerable 
weakness of heart, and is often the forerunner of severe heart-weak- 
ness. It occurs in valvular disease and myocarditis. 
In order to determine the succession of pulse-beats it is sometimes 
useful to employ the graphic method (which see). 
4. Quality of the Pulse. 
As has been already mentioned above, a correct judgment of the 
size and tension of the radial artery and of the size and form of the 242 
SPECIAL DIAGNOSIS. 
individual waves can only be attained by much practice. It is indis- 
pensably necessary that there should be acuteness of feeling in the 
examining finger, much experience of what is normal and what is 
pathological, and of the boundaries between the two, which cannot be 
sharply defined in words. 
The inequality of the examination must be taken into consideration, 
as it is affected by somewhat individual differences of the location of 
the arteries, the difference in the subcutaneous fat, or as affected by 
arterial sclerosis. The exact examination of the pulse may not he 
possible on account of the abnormal course of the radial artery—the 
most frequent variation being where the artery Avinds around the radius 
to its dorsal surface above the styloid process. 
We distinguish the different forms of pulse according to the follow- 
ing points of view: 
1. According to the size of the pulse: full or empty pulse, pulsus 
plenus—vacuus; a not very clear method of designation. It would, 
he much more suitable to describe the average fulness of the artery, 
or, still better, its thickness at the moment of its systole—that is, in 
the depression betAveen two pulse-Avaves. In this sense the pulse is 
full in almost all those cases in which it is large in so far as it depends 
upon work of the heart, which is strong or increased. But it further 
depends, to a certain extent, upon the amount of blood in the system; 
a certain fulness of the pulse, which, in a strong person, is not remark- 
able, in an anaemic subject indicates a pathological increase in the 
work of the heart. Within certain limits, moreover, the difference in 
the fulness of the pulse is individual, being simply dependent upon 
the internal diameter of the arteries. We are not to confound a full 
pulse Avith a case where there is thickening of the wall of the artery 
by arterial sclerosis. 
Larger and small pulse: pulsus magnus—parvus. When the work 
of the heart is simply increased, and still more Avhen there is hyper- 
trophy of the left ventricle, the pulse is large. There is an exception 
to this when we have the two valvular defects, in which the left ven- 
tricle, notAvithstanding its hypertrophy, is able to force only a mod- 
erate quantity of blood into the aorta (aortic stenosis, see under pulsus 
tardus), and mitral insufficiency. The reason for the former is clear; 
the explanation of the letter is, that Avith every systole a part of the 
blood contained in the left ventricle flows back into the left auricle. EXAMINATION OF THE CIRCULATORY APPARATUS. 
243 
Absence of pulse depends upon diminished work of the heart, upon 
an obstruction between the heart and the aortic system (aortic steno- 
sis, aneurism), and upon marked anaemia. It is present in the highest 
degree in mitral stenosis, since in this condition the left ventricle con- 
tains an abnormally small quantity of blood, and hence it can drive 
but little into the aorta. 
]f the pulse is very small, and at the same time very empty, it is 
called thread-like or filiform. The trembling pulse (pulsus tremulus) 
is caused by a moderately full artery, in which the wave is impercept- 
ibly small. Both are noticed when the heart is very weak. 
Regular and irregular pulse [as to volume] : pulsus cequalis—in- 
cequalis. As was previously stated, there occur in health insignificant 
irregularities in the individual pulse-waves. A very marked inequality 
is a most important sign of weak heart, more important than the 
irregularity which almost always accompanies it. Only in mitral ste- 
nosis we have a very markedly unequal (and irregular) pulse without 
the heart being really weak. 
Often, too, there exists in a measure a condition between inequality 
and irregularity as follows : A pulse follows the previous one with a 
shorter pause, then after a longer pause there is one with a stronger 
beat. Especially in pulsus intercidens (see p. 241) the between-beat 
that immediately follows a pulse-wave is always small. 
Pulsus alternans is so called when a larger wave alternates- with a 
smaller one. At the same time it is generally bigeminus. (See 
above.) 
We call a pulse pulsus paradoxus which has the peculiarity that in 
deep breathing, toward the end of inspiration, it becomes weaker, or is 
once or more times omitted. It is an important sign of pericarditis 
adhcesiva with callous mediastino-pericarditis, and it arises from the 
breaking or distortion of large arterial branches as the thorax is 
broadened in the act of inspiration and the diaphragm is pressed 
down. 
2. We distinguish the form of the pulse-wave as quick or slow, 
pulsus celer—tardus. Here also belongs the pulsus dicrotus. 
In the quick pulse the artery quickly enlarges and immediately 
becomes narrow with a like quick contraction. But with a slow pulse 
the enlargement and contraction are slower than normal, and the artery 
also lingers in the diastole during a portion of time which a trained 244 
SPECIAL DIAGNOSIS. 
finger may recognize. With the quick pulse the examiner notices 
that the stroke is very short, while in the latter it is more a pressure 
in the vessel against the palpating finger. 
Every pulsus magnus may exhibit a moderate celerity. Only in 
aortic insufficiency the pulse is decidedly quick. It is a miniature 
picture of the large fluctuations of pressure in the aorta which quickly 
follow one another, as with every systole it receives from the dilated 
and hypertrophied left ventricle an abnormally large quantity of blood 
which it immediately disposes of in two directions—sending part back 
again into the ventricle, and part forward into the body. 
It is remarkable that also in heart-weakness there is sometimes a 
light, quick pulse. It is true that it is always very easy to compress 
it, and between the pulse-waves the walls of the artery fall together 
very decidedly (pulsus vacuus, and at the same time celer). 
Pulsus tardus is an especial peculiarity of aortic stenosis, and at 
the same time it is generally smaller than normal. How much it may 
be diminished in size depends upon the degree of stenosis and the 
strength of the heart. Pulsus tardus occurs also with arterial scle- 
rosis., likewise with lead colic, but also sometimes with other colics as 
well as in peritonitis. 
Pulsus dicrotus will be more exactly described with the sphygmog- 
raphy of the pulse (see p. 248). 
3. According to the hardness of the pulse (tension of the arterial 
wall) we distinguish hard or tense, and soft pulse, pulsus durus {ten- 
sus)—mollis. Here we must especially guard against confounding it 
with arterial sclerosis, which imparts to the wall of the vessel a hard- 
ness which has nothing to do with its tension. 
We test the hardness of the pulse by endeavoring to compress it 
with the finger; it is easy to compress a soft pulse. 
Again, it is really the power of the heart that produces these pecu- 
liarities, as well as the active tension of the wall of the vessel. In 
heart-weakness the small pulse is also always a soft pulse; the large 
pulse is likewise often hard. With pulsus tardus there is almost 
always a strong action of the heart, and if the heart is hypertrophied 
the pulse at the same time is often hard. When the pulse is quick 
there are constantly marked variations in its hardness. 
The hardness of the pulse is especially characteristic in contracted 
Tcidney with hypertrophy of the heart, also in lead colic (“ wire pulse”). EXAMINATION OF THE CIRCULATORY APPARATUS. 
245 
The pulse is tense also in apoplexy cerebri and in commencing menin- 
gitis, no doubt from irritation of the vasomotor centre. 
V. Basch has constructed a sphygmomanometer, which is very use- 
ful for measuring exactly the tension in the arterial wall, and thus the 
blood-pressure. Unfortunately, we cannot affirm that the absolute 
height of the blood-pressure in its finer gradations leads to results that 
have diagnostic value. The reason of this is that, as v. Basch himself 
found, the limits of the normal are very wide apart; moreover, from 
the fact that the arterial pressure is the result of two forces acting in 
opposition, the contraction of the heart and the active contraction of 
the vessel. Lastly, as has already been intimated, the anatomical 
peculiarity of the arteries (arterial sclerosis) has an influence upon the 
hardness—that is, the compressibility of the pulse. Yet, after all, we 
think that v. Basch’s instrument is very excellent for determining the 
variations of the blood-pressure in the course of making observations 
upon a patient. 
5. Symmetry of the Radial Pulse. 
As has been already mentioned, apart from anatomical variations 
of the artery upon one side, the pulse upon the two sides is perfectly 
alike as to time and quality. It may be disturbed, even to complete 
absence of the pulse upon one side. 
1. By surgical diseases of the arm, as fracture of the bone, injuries 
or operations which displace the radial, or which result in narrowing, 
compression, or cicatricial contraction of the radial, brachial, or 
axillary artery; in which case the pulse upon that side is found to be 
smaller. 
2. By tumors of the chest cavity, of the supra- or infra-clavicular 
fossa, or of the axilla, which press upon the innominate, subclavian, or 
axillary artery of one side. They weaken the radial pulse even to 
complete obliteration. 
3. By aneurism of the aorta, innominate (in what way, see below), 
also by aneurism of the subclavian, axillary, and brachial (all very 
rare; see works upon surgery). 
4. By emboli and autocthonous clots toward the centre from the 
location of the pulse. In this case the pulse is commonly entirely 
wanting. 
5. In pneumothorax, also large pleuritic exudation with com- 246 
SPECIAL DIAGNOSIS. 
pression and distortion of the subclavian. Sometimes the pulse upon 
the affected side is smaller, also frequently later. 
Sphygmography of the Radial Pulse.—K. Yierordt originated 
the idea of sphygmography. With continued improvements of the 
apparatus the idea has been further developed by Marey, Wolff, 
Landois, Sommerbrodt, Riegel [and others]. 
Sommerbrodt’s sphygmograph is the one now most generally used, 
but it has defects. Recently Ludwig has very decidedly improved 
upon Marey’s instrument, as it seems to me. It can be obtained 
from Petzold, instrument-maker, in Leipzig. [The instrument devised 
by Dr. Richardson, of London, is, in the opinion of the Translator, the 
most practically useful one yet brought out.] 
The sphygmograph has little value for the purposes of diagnosis, 
but is of great value in clinical instruction. 
In health the pulse-curve obtained with this instrument shows 
elevations and depressions, ascending and descending line correspond- 
ing with the expansion and collapse of the artery. The expressions 
“apex curve” (c g) and “ curve at the base ” (b) do not need further 
explanation. At both these points the curve stops only a very small 
portion of time. 
The ascension line (a 1) is even almost perpendicular; that is, the 
rise follows very quickly. The descent (d) is more drawn out and 
shows several small Avaves, Avhich generally (not always) may be 
distinguished as a marked elevation (r), the backAvard-stroke elevation, 
caused by a Avave of blood Avhich results from the closure of the semi- 
lunar valve, and tAvo (sometimes also three) or only one weaker, 
elevation produced by elasticity (e); the elastic secondary oscillation 
of the wall of the artery (according to Landois, but othenvise 
explained by others). 
The elevation (r), the “recoil,” has hitherto been regarded as a 
positive centrifugal wave due to the closure of the aortic valves. 
But recent investigations have shown that this positive wave is cen- 
tripetal, and that it is probably to be regarded as a reflected Avave 
from the peripheral end of the circulation of the body, as from the 
end of a closed tube (v. Frey and Krehl). The opinion formerly 
expressed that r Avas more marked the nearer Ave were to the heart, 
by the new theory Avould be explained by saying that it was the sum- 
mation of the reflected Avaves arising from the various arterial regions. EXAMINATION OF THE CIRCULATORY APPARATUS. 
247 
It is worthy of notice with regard to the backward-stroke elevation 
that it increases with the diminution of the tension of the artery. 
Thus it is a sort of indication of the blood-pressure. But the eleva- 
tion produced by elasticity is just the opposite. It is to be remarked 
Fig. 66. 
Normal pulse-curve in a healthy man, aged twenty-five years. (After Eichhorst.) 
regarding the sphygmography of other arteries that r becomes more 
marked the nearer we go to the heart. 
The following are the essential pathological forms of sphygmo- 
graphic pulse-waves : 
1. A descending line with several very marked elasticity elevations, 
but smaller backward-stroke elevations (often difficult to make out) 
which correspond with the increased tension in the aortic system 
(lead colic, contracted kidney and acute nephritis, etc.). 
Fig. 67. 
2. On the other hand, diminution of the elasticity elevation with 
more marked backward-stroke elevation shows diminished blood- 
pressure. Such increase of r is called “ dicrotic,” and the pulse 
“dicrotic pulse.” Such a pulse, even if it is only moderately pro- 
nounced, can be recognized by palpation. It occurs in certain condi- 
tions which accompany a moderate diminution of strength of the 
heart, but especially a diminution of the tone of the arteries: 
a. In acute febrile diseases, and indeed in so marked a degree and 
so early in typhus abdominalis that in diagnosis we may attach some, 
though small, value to this symptom. 248 
SPECIAL diagnosis. 
b. In chronic wasting diseases, especially febrile, more than others 
in tuberculosis. Here, according to my observation, it is not infre- 
quent. 
c. In other weak conditions, as after great loss of blood, and in 
general in all forms of anaemia. 
Fig. 68. 
Different forms of dicrotic pulse. (After Eichhorst.) 
The above curves show that in the dicrotic pulse the backward-stroke 
elevation may fall in the descending line (sub-dicrotic pulse), as well 
as in the middle of the basis curve (complete dicrotic pulse), likewise 
in the ascending line of the next following wave {super-dicrotic pulse). 
The so-called monocrotic pulse (no visible backward-stroke elevation) 
is a sort of super-dicrotic pulse. 
What has been said in general regarding dicrotic pulse expresses 
the diagnostic value of all these forms of pulse. 
3. To the pulsus celer corresponds a curve with a very steep 
ascending line and an unnaturally high apex-curve (in consequence of 
the quickness of the arterial diastole the recording lever of the appa- 
ratus is always thrown too high up). Moreover, the apex-curve is EXAMINATION OF THE CIRCULATORY APPARATUS. 
249 
sharp-pointed, and the descending line is almost as steep as the 
ascending line. The elasticity elevations are marked. With pulsus 
celer due to arotic insufficiency there is, of course, no backward-stroke 
elevation, as the semilunar valve does not close. Compare what has 
been said on p. 243 upon Pulsus celer. 
Fig. 69. 
Pulse-curve in aortic insufficiency. (After Strtjempell.) 
4. Pulsus tardus, as in palpation (see p. 244) so in the curve, is the 
exact opposite of the preceding. With it there are usually more com- 
plete loss of the elasticity elevation and indistinct backward-stroke 
elevation. 
Fig. 70. 
Pulse-curve in stenosis of the aortic orifice. (Ibid.) 
Fig. 71. 
Pulsus tardus in atheroma of the arteries. (After Eichhorst.) 
A peculiar combination of pulsus celer and tardus manifests itself 
with insufficiency and stenosis of the aorta. 250 
S PE CIA L DIA G NOSIS. 
Fig. 72. 
Pulse with anacrotic elevation in aortic insufficiency with moderate stenosis of the 
orifice and arterial sclerosis. 
In pulsus tardus the quickness of the apparatus is completely 
wanting on account of the slowness of the ascension, hence it always 
seems small in comparison with the normal pulse-wave; and with that 
of pulsus celer (see above) still smaller than is really the case 
It is quite impossible to form an estimate of the size of the pulse 
from the sphygmographic curve. The unequal pulse will generally 
be very beautifully delineated by the apparatus, but it cannot be more 
exactly depicted than it can be learned by exact palpation. It is true 
that the apparatus includes small waves that the finger cannot recog- 
nize, but often these cannot be distinguished from the elevations 
indicating the backward stroke. 
Fig. 73. 
Pulse-curve with marked mitral stenosis. (After Struempell.) 
The rhythm of the pulse will, of course, even if only for a very 
short distance, be very Avell exhibited, and it is in this direction that 
the graphic delineation is very useful in giving instruction. But 
here sphygmography is wholly wanting for diagnostic purposes, since 
every notable useful irregularity can be felt just as well. 
Annexed is an example of pulsus bigeminus (after Riegel). 
Fig. 74. 
Pulsus bigeminus. f After Riegel.) EXAMINATION OF THE CIRCULATORY APPARATUS. 
251 
Diagnostic Value of the Examination of the Pulse.—From 
what has been said it is sufficiently evident that for the purposes 
of diagnosis palpation of the radial pulse is preferable to sphyg- 
mography. The latter is more circumstantial, and gives, at best, to 
one sufficiently practised in palpation in general, no better result 
than that it occasionally shows a dicrotic pulse which the sense of 
touch does not detect. It very easily even deceives, especially regard- 
ing the size of the pulse, but sometimes also its form, from reasons that 
lie in the apparatus. The great value of the sphygmograph for the 
clinician consists almost exclusively in its usefulness in giving instruc- 
tion, for exhibiting a characteristic anomaly of the pulse to a large 
number of hearers, or it may serve to show a pupil what he ought to 
feel. 
In what follows will be briefly indicated in which direction the 
examination of the pulse is of value for diagnosis, and how it can be 
turned to account. 
1. The pulse very often directly serves to determine the diagnosis; 
not that it alone is sufficient, but in connection with other phenomena 
it is. We are to bear in mind here what has previously been said 
regarding the behavior of the pulse in the various febrile diseases. 
But in diseases of the heart it especially has such an important place 
that a diagnosis is never to be made without taking into consideration 
the condition of the pulse. 
In what follows is brought together what can be said regarding the 
behavior of the pulse in the most important of the diseases of the 
heart. 
In mitral insufficiency the pulse does not markedly or notably vary 
from the normal. But in addition the signs of hypertrophy of the 
right and left ventricles are present: systolic murmur at the apex. 
Mitral stenosis: Pulse absent, unequal, or irregular, its frequency 
often much increased. (In addition, signs of hypertrophy of the right 
ventricle and a presystolic murmur at the apex.) 
Aortic insufficiency: Pulse quick, frequency either normal or 
increased; generally equal and regular. In addition there are the 
signs of hypertrophy of the left ventricle and a diastolic blowing 
murmur at the aorta. (For the conditions at certain arteries, etc., see 
p. 256.) 252 
SPECIAL DIAGNOSIS. 
Stenosis of the aorta: Pulse small, slow, normal or diminished fre- 
quency, equal and regular. In addition, signs of hypertrophy of the 
left ventricle; only the apex-beat is often very strong and a systolic 
murmur heard over the aorta. 
Myocarditis: Pulse more or less small and soft, almost always 
irregular in quality, and generally so in time (here especially we have 
sometimes pulsus incidens, bigeminus). Frequency is increased, 
normal, or diminished. Nothing abnormal at the heart, or signs of 
dilatation of one or both ventricles (or of hypertrophy); no murmurs. 
Pericarditis exudativa: Pulse strong if the heart remains so, 
generally somewhat quickened. In addition, at the heart all signs 
of its activity diminished or removed by being covered over, marked 
dulness; in paralysis of the heart no pulse, or very much quickened; 
sometimes pulsus paradoxus. 
We are particularly to notice the opposite condition of the pulse in 
aortic insufficiency and stenosis, and also that in myocarditis the pulse 
may he the only sign. 
In combined valvular disease the pulse is of importance in 
ways : it betrays the existence of a second valvular disease besides the 
one already made out, as is especially the case in mitral insufficiency 
and stenosis. The latter near the former may be overlooked because 
very slight, or may even be entirely wanting, and because it produces 
hypertrophy of the right ventricle, which is also produced by the 
former, for there may be a very small, unequal, irregular pulse, which 
alone indicates the stenosis. Also, an aortic stenosis, besides insuffi- 
ciency of the aorta, is sometimes certainly discovered only by the 
pulse, since there may be a weak systolic murmur at the aorta without 
stenosis. Thus the question as to which cardiac orifice is concerned 
in the murmur, or whether we have one murmur widely conducted, or 
two murmurs independent of each other, may be determined by the 
pulse. 
Moreover, in a patient with combined valvular disease the pulse 
may very greatly assist in determining which disease is the more 
marked or important. This is especially true in insufficiency and 
stenosis of the aorta (the distinctness of the murmurs is, of course, not 
at all indicative, see above), also of the mitral, or for combined disease 
of the aortic and mitral valves. 
Thus we would diagnosticate a preponderating insufficiency and a EXAMINATION OF THE CIRCULATORY APPARATUS. 
253 
very slight stenosis of the aorta when we have the signs of hyper- 
trophy of the left ventricle, a loud sawing systolic and a very slight 
diastolic aortic murmur and a pronounced pulsus celer. Thus, with 
the signs of aortic insufficiency and mitral stenosis, a very small pulse 
points to the preponderance of the latter. 
It is impossible to make a diagnosis of the particular heart-lesion, 
either from the general symptoms or from the pulse, so long as there 
is continued evidence of incompensation. 
Moreover, in the cases where the heart and its action are concealed, 
especially in pericarditis exudativa, also in emphysema, sometimes in 
marked deformity of the thorax, displacement of the heart, tumors of 
the chest-wall, the pulse is the only sure sign of what work the left 
ventricle is doing. In pericarditis the contrariety that exists between 
a diminishing apex-beat, the slight, almost imperceptible, heart-sound, 
and a strong pulse, is sometimes a very important diagnostic point. 
2. The pulse enables us to judge of the strength of the heart in all 
other possible, especially febrile, diseases. Even the first examination 
of the pulse furnishes, in this case, important information; but the 
signification of indications furnished by repeated examinations of the 
pulse (palpation and representation of its varying frequence upon the 
temperature-chart) becomes very much more valuable. These indica- 
tions furnish still more important diagnostic points, some of which 
have already been spoken of. They have reference to the beginning 
of complications in acute infectious diseases, especially those affecting 
the heart, the lungs (which are very frequent), the kidneys, as in scarlet 
fever, when the pulse has greater tension and diminished frequence, 
and to the brain (decline in frequency in meningitis); also, the effect 
of treatment, as of cold baths, may be determined partly by the behavior 
of the pulse; in general, it often determines the treatment; further, 
we are to mention all diseases which in any way affect the heart, as 
pleuritis, pericarditis, peritonitis, in which the pulse, especially as a 
measure of treatment, has any part. 
II. OTHER PHENOMENA IN ARTERIES. 
The Aorta.—Sometimes a pulsation is to be seen and felt in the 
neck; exceptionally, also, in health (higher location of the arch); 
likewise, in hypertrophy of the left ventricle (most marked in aortic 254 
SPECIAL DIAGNOSIS. 
insufficiency, since this causes a broadening of the commencement of 
the aorta); and, finally, in aneurism of the arch of the aorta. 
The occurrence of pulsation that can be seen and felt in the right 
second intercostal space is always pathological. It occurs in hyper- 
trophy of the left ventricle, and also especially in insufficiency of ihe 
aorta ; further, in aneurism of the aorta, see below. In rare cases, 
when there is marked hypertrophy, the second aortic sound may be 
felt (of course, this can newer occur in aortic insufficiency). 
In rare cases of aortic insufficiency the commencement of the aorta 
is accessible for percussion. It is to be remembered that here it is 
very much broadened, and to the right of the sternum, from the lower 
border of the second rib to the third rib, there is a small area of dulness. 
Sometimes over the aorta (in the right second intercostal space), in 
marked atheroma, there ought to be heard a systolic murmur, even 
when there is no endocarditis aortica. 
Aneurism of the aorta requires a special description. It most 
frequently occurs in the ascending portion or the arch of the aorta, 
and gives rise to the following phenomena: Only when the aneurism 
is large is a swelling to be seen, and this, if present, is seen either 
above the sternum or close to the right of it. It generally pulsates— 
that is, becomes larger in all directions—with the systole of the heart. 
From stagnation (see p. 261) the enlarged veins of the skin are very 
early visible; later they may become red from inflammation, or even be 
necrotic. In large aneurism, under some circumstances, when we pal- 
pate, we feel the pulsation, and besides, not infrequently, a peculiar 
whizzing or rushing. With large tumors, also, it further shows that the 
bones and cartilages over them have been absorbed. Repeated meas- 
urement of the thorax shows a gradual increase of the sterno-vertebral 
diameter. Percussion generally very early exhibits dulness, usually on 
the right, close to the sternum and over the manubrium ; more rarely 
to the left of the sternum, and this either in connection with the area 
of heart-dulness or distinct from it. Auscultation not infrequently re- 
veals the systolic whizzing, which has already been referred to as being 
felt, or also only two dull, impure sounds, or they may not be heard at 
all. The radial pulse, also the carotid, is not infrequently early upon 
one side smaller and a little later than on the other in consequence of 
the compression of the particular branches of the aorta or distortion of 
their openings at the point of origin. Aneurism of the ascending aorta EXAMINATION OF THE CIRCULATORY APPARATUS. 
255 
affects the vessels of the right side, and of the arch of the aorta some- 
times affects those of the left side. Not infrequently, also, there exists 
insufficiency of the aorta with hypertrophy of the heart. As by all 
tumors in its neighborhood, the heart may be crowded toward the left 
side; also, we see, in examining the larynx, evidences of pressure by 
these tumors upon the trachea, the oesophagus, the left (seldom the 
right) recurrent nerve, and the large veins of the body (p. 261). 
Aneurism of the innominate produces about the same symptoms as 
aneurism of the ascending aorta, only generally somewhat higher up. 
Aneurism of the descending aorta (rare) may cause corresponding 
phenomena upon the left side, posteriorly, near the spine. The pulse 
in the abdominal aorta and its branches is usually later. 
Aneurism of the abdominal aorta (likewise rare) is generally at the 
level of the tripus coeliacus. It may be felt as a pulsating tumor in 
the upper part of the abdomen, and sometimes exhibits the whizzing 
mentioned above. 
Considerable stenosis or even closure of the aorta at the junction of 
the ductus arteriosus is a very rare congenital condition which is recog- 
nized by the fact that certain arteries furnish collateral circulation 
between the ascending aorta and the region of the descending thoracic 
aorta, or the abdominal aorta. These collateral vessels become very 
much enlarged, and pulsate so as to be seen and felt. Diagnostically, 
the most important are the internal mammary, the anterior superior 
and inferior epigastric anteriorly, the transversus scapulae and dorsalis 
posteriorly. 
The Pulmonary Artery.—In very rare cases aneurism of the 
pulmonary artery may give rise to almost the same symptoms as 
aneurism of the aorta, except in being at the left of the sternum. A 
systolic murmur over the pulmonary artery may, besides, be caused by 
stenosis of the pulmonary opening or by narrowing of the artery itself. 
This may be congenital or be developed later, in the latter case by 
shrinking of the upper portion of the left lung. In such cases the 
second pulmonary sound is generally accentuated (hypertrophy of the 
right ventricle), and, under some circumstances, may even be felt (see 
above). 
The Other Arteries.—Excepting during excitement of the heart 
(by mental excitement or physical exertion), we observe in health a 
visible pulsation of the carotid in the neck just under the angle of the 256 
SPECIAL DIAGNOSIS. 
jaw; also of the temporal artery. A marked pulsation of the carotid, 
especially when there is perfect mental and physical quietude, or, 
again, a general visible pulsation of smaller vessels, as of the temporal, 
the brachial, in the sulcus of the brachial muscle or at the bend of the 
elbow, of the radial, peroneal, dorsalis pedis, points to hypertrophy of 
the left ventricle. These abnormal pulsations are most marked in 
insufficiency of the aortic valves and in arterial sclerosis ; in the first 
case on account of the fulness of the pulse, in the latter case on account 
of the thickened and stiffened vessels being prominent. In both 
classes of cases the smaller arteries are very tortuous. 
Here, also, a capillary pulse is to be mentioned : alternating between 
marked fulness and emptiness of the capillaries occasioned by the 
pulse in the arteries, the pulse may become visible under the finger- 
nails, more rarely over the tendons, in case these variations are con- 
nected with a large and quick pulse in the arteries, which, in turn, 
have large and quick alternations of size. Then, in examining the 
finger-nail, we see the red part rhythmically become alternately white 
and red: capillary pulse of the bed of the nail.1 This is a sign of 
aortic insufficiency with marked hypertrophy of the left ventricle 
(which would also be present in some cases of marasmus). 
Palpation. Medium-sized and small arteries sometimes feel 
thickened and moderately stiff, or scattered in their walls we feel 
separate rigid patches, very like the plates of cartilage of the bronchial 
tubes, or the rings of a small trachea (“ goose’s throat ”). The latter 
become especially plain if we slip the tip of the finger up and down 
along the course of the artery. This is the condition in arterial 
sclerosis. Hence, the vessels are often tortuous (see above), and show 
variations of the pulse (see). It is very easy to recognize arterial 
sclerosis in the temporal, radial, and brachial arteries. From the 
condition of these we can correctly estimate the condition of other 
arteries of the same size. 
Palpation of the radial artery has already been described. Of the 
other arteries of the extremities the pulse of which we can feel in 
health, we may mention the brachial, in many persons the ulnar, the 
crural, the popliteal, and in most people the peroneal. Increased 
P This is often an unfavorable situation for making the observation. Quincke, who 
first described the capillary pulse, now recommends rubbing gently a spot upon the 
forehead. Berliner klin. Wochenschr., March 24, 1890.] EXAMINATION OF THE CIRCULATORY APPARATUS. 
257 
pulsation in arteries that can be felt, its occurrence in small arteries 
that can be felt, which in health are never made out, takes place in 
aortic insufficiency. A pulsation that can be felt in the dorsalis pedis 
artery is here very frequent, but the same thing may take place in 
still smaller arteries—in the digital, in the coronarim labii inferior., 
superior., and the like. Very exceptionally in aortic insufficiency we 
may even observe an “ arterial liver-pulse ”—that is, a continuous 
to-and-fro swelling of the liver from the marked pulse in the arteries 
of the liver (quite like the venous liver-pulse, see p. 266). Still more 
rare is an arterial pulse at the spleen (see under Examination of the 
Spleen). 
When in symmetrical vessels, like the two radials, we find a pulse 
that is unequal as to strength or time, we may generally conclude 
that there is a mechanical hindrance to the passage of the blood- 
current. We then have to seek toward the centre from the weaker or 
later pulsating artery for a compressing tumor, thrombosis (autoch- 
thonous or embolic), or for an aneurism. Moreover, there are 
observed variations of the pulse in symmetrical vessels, caused by 
vasomotor influences from the nerve-centres. Finally, we must not 
overlook the possibility of anatomical variations. 
Auscultation. Mode of procedure: Here, it is to be understood 
throughout, the stethoscope is to be employed, and that ordinarily it 
is to rest upon the surface without pressure. We auscultate the 
carotid with the neck somewhat extended, but not stretched, in the 
intersterno-cleido-mastoid fossa or at the angle of the jaw; the sub- 
clavian, in the angle between the clavicle and the clavicular head of 
the sterno-cleido-mastoid muscle; the brachial, on the inner border of 
the biceps in the bend of the elbow, with the arm slightly extended; 
the crural, close below Poupart’s ligament. 
Normal condition. In health we usually hear over the carotid, as 
well as the subclavian, two sounds—one corresponding to the pulse, 
with the systole of the heart (the conducted aortic first sound and local 
diastolic sound in the vessel). In individual cases the first sound is 
impure, or is entirely wanting. In health the diastolic heart-sound 
is never wanting. We sometimes hear over the abdominal aorta and 
the crural artery a sound which corresponds with the pulse, or at any 
rate arises locally from the tension of the vessels. We usually hear 
nothing over any of the small vessels. If we press with the stetho- 258 
SPECIAL DIAGNOSIS. 
scope over the given vessel, then we hear the so-called acoustic 
pressure-sound, not alone over the aorta and subclavian, but also 
regularly over the abdominal aorta and crural artery, and usually, 
also, over the brachial. Thus, over these vessels by moderate pressure 
we hear a pressure-murmur corresponding to the arterial pulse; by 
stronger pressure, which almost, but not quite, closes the artery, this 
murmur is changed into a tone—pressure-tone. That these acoustic 
phenomena, resulting from pressure, are everywhere present, are the 
chief reasons why the pathological conditions over the large vessels, 
which are to be mentioned later, have only conditional diagnostic 
value. 
We must also mention a phenomenon frequently present in healthy 
children, called “cerebral blowing”; it is heard between the third 
month and the sixth year, with the systole of the heart, or, more 
exactly, as a blowing corresponding with the carotid pulse, which is 
heard sometimes light, sometimes tolerably loud, over the fontanelle 
while still open, but also sometimes after it has closed, and elsewhere 
over the head. Jurasz has, in most cases, found at the same time a 
blowing over the carotid, and thinks that the cerebral blowing is 
merely this murmur conducted upward. He explains the latter by 
the compression which the carotid sustains in the carotid canal during 
the development of the skull. 
Pathological conditions. In aortic stenosis there will be heard 
over the carotid, in place of the first sound, a rough systolic heart- 
murmur (the stethoscope must rest very lightly). 
In aortic insufficiency the second sound of the carotid and sub- 
clavian is wanting, or it is replaced by blowing with the diastole of 
the heart (rare). This, as well as the systolic murmur previously 
mentioned, is conducted from the mouth of the aorta. The former, 
arising in a current of blood flowing forward, would naturally, as a 
rule, be more loudly conducted than the latter, which comes from a 
backward-flowing blood-current. 
Sounds in such arteries as in health very seldom or never furnish a 
sound, accompany aortic insufficiency, being produced by the quick 
and strong tension of the vessels during their diastole. We then hear 
a sound corresponding with the pulse over the crural, brachial, radial, 
even the ulnar, peroneal, dorsalis pedis arteries; sometimes, even, 
over still smaller vessels. A sound is also observed over the crural EXAMINATION OF THE CIRCULATORY APPARATUS. 
259 
in high fever, as well as in anaemia and chlorosis (and as well in some 
healthy persons). 
A double sound over the crural artery (Traube) is heard in 
individual cases of aortic insufficiency. But this phenomenon has 
also, although very exceptionally, been observed with mitral stenosis 
(Weil), likewise in lead-poisoning (Matterstock), lastly, in pregnancy 
(Gerhardt). Much more important is the double murmur which is 
heard when considerable pressure is made with the stethoscope— 
Duroziez’s double murmur. In the experience of observers thus far, 
this occurs only with aortic insufficiency, and this when there is good 
compensation, and this has all the greater significance from the fact 
that it is decidedly more frequent than was previously supposed. 
Double sound, as well as double murmur, can only occur when 
there is a large and quick pulse. In the first phenomenon, the double 
sound is caused by the sudden collapse of the artery; with double 
murmur, the second murmur is probably to be explained by the short 
reflux blood-current which may be assumed to flow into the large 
vessels when there is aortic insufficiency (?). A double sound can 
also be heard over the crural artery if one of the two sounds, or even 
if both sounds arise from the crural vein. (See, regarding this, in 
the next chapter.) 
A systolic subclavian murmur is sometimes heard on both sides, or 
sometimes only on one side (especially the left), as a very disturbing 
addition to the breath-sounds at the apex of the lungs. It is stronger, 
or, perhaps, only to be heard toward the end of inspiration. When 
it occurs upon both sides it, as a rule, does not indicate a pathological 
condition; when unilateral it also has no significance, and yet it 
always gives the suspicion of phthisis, with which we often meet it. 
It is explained by a temporary pulling or bending, and, hence, nar- 
rowing of the subclavian artery during deep breathing. In phthisis- 
this is caused by adhesion of the pleural surfaces at the anterior sur- 
face of the apex of the lungs. We do not know exactly why this 
murmur occurs also with persons apparently perfectly healthy, but it 
may possibly be from the same cause. 
Loud blowing murmurs over the lymphatic glands sometimes occur 
in all forms of struma. These murmurs may be felt. They are not 
infrequent with struma of Basedow’s disease, but here they are caused 
by the excited action of the heart. 260 
SPECIAL DIAGNOSIS. 
The murmurs which in some cases are heard over aneurism have 
been already mentioned. 
Examination of the Veins 
We examine chiefly, in many cases exclusively, the jugular veins 
(external and internal in the neck), but also the cutaneous veins of 
the body and extremities. Only in special cases (thrombosis) do the 
deep veins of the extremities become accessible for examination. The 
ophthalmoscopic examination of the ophthalmic veins does not come 
within the scope of this book. It is important that we are able to 
judge of the abnormal fulness (engorgement) of certain deep veins by 
its effect upon particular internal organs, as enlargement of the liver 
and spleen, also ascites, and, lastly, the suppression of urine. 
The examination of the veins is made by inspection, or sometimes 
by palpation, and auscultation. 
INSPECTION AND PALPATION OF VEINS. 
By these means we ascertain the degree of fulness, the condition of 
the circulation, and, under some circumstances, the existence of venous 
thrombosis. An unusually empty condition of the veins does not 
come under consideration. This would also be very difficult to deter- 
mine, for the reason that even in health, especially in fat people, the 
superficial veins may be indistinct or entirely invisible. 
It remains to describe : 1. Increased fulness of veins; 2. Circu- 
lation in the veins of the neck ; 3. Circulation in the other veins ; 
4. Venous thrombosis. 
1. Increased Fulness of Veins. 
This is the result of stoppage of the blood in its course toward the 
centre. It is general or local, according to the cause of the engorge- 
ment—whether this be central or at some place in the course of the 
nerves that control the circulation. 
General increased fulness is the result of general venous engorge- 
ment. We first recognize it by the swelling of the internal and 
external jugular veins upon both sides. The first of these is usually 
visible in health (but not always, especially in fat people), coursing EXAMINATION OF THE CIRCULATORY APPARATUS. 
261 
obliquely over the sterno-cleido-mastoid muscle. When the head is 
turned toward the opposite side it usually swells still more. With 
the increased fulness it becomes distinct, perhaps can be felt. With 
normal fulness the internal jugular cannot be made out, situated, as 
it is, under the sterno-cleido-mastoid muscle, where it is divided into 
the clavicular and sternal portion just in the angle between these at 
the bottom of the intersterno-cleido-mastoid fossa. Where it passes 
into the bulbus jugularis it has a valve (ordinarily exactly at the 
upper border of the sterno-clavicular articulation, but sometimes, 
especially in consequence of the engorgement, located somewhat 
higher up). Abnormal fulness of the jugular vein fills up the inter- 
sterno-cleido mastoid fossa, or it may cause a projection there. 
Dorsal posture increases the fulness. Fulness of the cutaneous veins 
of the trunk and extremities, not occurring without general engorge- 
ment, is usually not so pronounced as that of the veins of the neck, 
especially on account of the marked oedema which accompanies the 
damming. Important associated symptoms of general engorgement 
are cyanosis, oedema, effusion into the cavities of the body, enlarge- 
ment of liver and spleen, disturbance of the bowels, and so-called 
suppression of urine (which see). 
This condition arises when the right heart is not able to propel the 
required quantity of blood into the lungs. It occurs in various dis- 
eases of the heart, in emphysema of the lungs, and in all the conditions 
that lead to marked interference with the action of the heart, especially 
pericarditis. The most marked engorgement occurs in general when 
the right side of the heart is paralyzed after it has been obliged for a 
long time previously to meet unusual demands, and hence has become 
hypertrophied; hence with mitral, and, more rarely, pulmonary defects 
and emphysema, and likewise, in the very rare tricuspid stenosis and 
insufficiency (see under 3). 
General abnormal fulness of the veins may also be the result, 
exceptionally, of diminished flow of blood from the two cavee into the 
right auricle in consequence of pressure by a mediastinal tumor. 
Local increased fulness of the veins may be caused by a considerable 
narrowing or closure anywhere of a venous trunk by a thrombus or by 
compression. The larger the vessel thus affected, the more extensive 
the area of abnormal fulness. Thus sometimes abnormal fulness of 
the jugular and its branches, also of the ophthalmic vein (recognized 262 
SPECIAL DIAGNOSIS. 
by the ophthalmoscope), will be caused by a mediastinal tumor which 
presses upon the cava. Also the superficial veins of the skull between 
the ear and the fontanelle will become distended and tortuous if the 
longitudinal sinus of the dura is stopped. Fulness of the veins of an 
arm points to compression of the axillary vein (generally tumors or 
scars from operations in the axilla). The swelling of single small 
cutaneous veins over the sternum and in its neighborhood is a very 
important early sign of mediastinal tumor. The cutaneous veins of 
the leg are enlarged when there is thrombosis or compression of the 
femoral vein of that side. The veins of both legs may swell as the 
result of double thrombosis or compression of the vena cava inferior 
or both iliac veins (ascites, tumors). In all these cases there may be 
local oedema (which see). This may even give a better and earlier 
sign of local engorgement, but, on the other hand, it may conceal the 
fulness of the veins. 
In the majority of such cases the cutaneous veins supply the neces- 
sary collateral circulation. But this is especially the case in engorge- 
ment of the portal vein (see also Enlargement of the Spleen and 
Ascites), whether due to cirrhosis of the liver or compression or 
thrombosis of the portal trunk. Here we may see the abdominal 
veins enlarged, part of which go upward to the thorax and part down 
to the inguinal region. In individual cases there is a crown of such 
veins around the navel—“ caput Medusae ”—since the umbilical vein, 
remaining open, receives a part of the overflow of blood which the 
portal is not able to carry. 
Very extensive enlargement and tortuosity of a large part of the 
cutaneous veins of the trunk, or of the chest (generally symmetrical), 
or enlargement of single cutaneous veins of an extremity also occurs 
without any possible assignable cause (perhaps closure of a deep 
branch), so that recently we are inclined to the assumption that in 
such cases there is a congenital condition or disease of the wall of the 
vein itself. 
2. Phenomena of Circulation in the Jugular Veins. 
Respiratory motions. The suction-action of the chest with inspi- 
ration causes a rapid emptying of the blood from the veins of the body 
into the heart during inspiration, as well as during expiration. On EXAMINATION OF THE CIRCULATORY APPARATUS. 
263 
the other hand, a forced expiration, likewise strong effort, and very 
especially the increased internal pressure within the chest which 
takes place in coughing before each cough-impulse, checks the dis- 
charge. The alteration in the fulness of the veins in the neighbor- 
hood of the heart which is thus caused is usually only to be ob- 
served in the jugular veins. But in normal fulness of these veins the 
simple respiratory oscillation of their volume is not noticeable. Such 
veins only distinctly swell with marked pressing and coughing (whoop- 
ing-cough), and then the veins of the face become very full. Yet 
when the veins of the neck are constantly abnormally full or engorged, 
then in ordinary breathing they show a corresponding to-and-fro 
swelling, and with forced expiration, pressing or coughing, they stand 
out very distinctly. The bulbus jugularis may then appear as a round 
bunch between the heads of the two sterno-cleido-mastoidei muscles; 
but even the whole internal jugular may swell and contract if the 
valve over the bulb does not close. This phenomenon occurs in the 
most marked degree with the labored expiration of emphysema. 
Here, also, in very rare cases, this variation in the fulness extends to 
the cutaneous veins of the face, the chest, and arms. 
The opposite condition of the veins of the neck, becoming tumid 
with inspiration and emptying with expiration, may be caused by cal- 
lous mediastinitis (mediastino-pericarditis). The cause of the phe- 
nomenon, like that of pulsus paradoxus (which see), is the traction and 
bending of the large vessels during inspiration (Kussmaul). 
Venous pulse. Circulatory movements in the veins or the neck, 
which directly or indirectly depend upon the action of the heart, and 
hence are rhythmic, are designated as venous pulse. This motion 
may be communicated, or be really in the vessels (autochthonous, real 
pulse). The former is only the pulsation in the carotid communicated 
to the internal jugular, which shows most frequently and plainly when 
the carotid pulsates very strongly, or when the internal jugular is 
very full, or if both conditions exist. (For distinction between this 
and genuine systolic venous pulse, see p. 267.) 
We divide the real venous pulse, pulsation in the veins of the neck, 
into that which occurs in health, the so-called “normal,” or negative; 
and the positive, which is always pathological. The normal venous 
pulse is presystolic, and usually is only observed in the external 
jugular. It would be best designated as a collapse of the vein 264 
SPECIAL DIAGNOSIS. 
accompanying the systole of the heart; for the external jugular, ex- 
actly corresponding with the apex-beat and the carotid pulse, quickly 
empties itself and immediately again slowly fills, sometimes visibly in 
two intervals, so that it attains its complete distention before the next 
systole of the heart, and hence is presystolic. 
This phenomenon depends upon the part the auricle plays in the 
action of the heart: during the ventricular systole it is in diastole, 
Fig. 74. 
Normal venous pulse or venous collapse with systole of the heart, and (broken line) 
carotid pulse. (After Riegel.) 
and thus favors the flow of blood from the veins. Shortly after the 
beginning of the ventricular diastole it begins to contract, and thus 
the flow of the venous blood from the cava into the auricle is impeded. 
It seems to me that the first elevation of the ascending side of the 
tracing of the curve of the venous pulse has not yet been explained. 
In health this pulse is seen to a very small, scarcely noticeable degree ; 
it is beautifully seen in dogs when the jugular is laid bare. In 
healthy persons, without any known reason, it is in some cases strong 
enough to be observed. But it is still stronger sometimes when the 
external jugular is abnormally full, hence in engorgement. Often 
this pulse occurs only indistinctly, its rhythm is difficult to recognize, 
and also affected by the pulsations of the carotid. Then we speak of 
undulation in the veins of the neck. 
The positive venous pulse is systolic, hence is contemporaneous 
with the carotid pulse. It is a pathognomonic sign of insufficiency 
of the tricuspid valve, and is caused by the contraction of the right 
ventricle, which causes a regurgitant positive blood-wave into the cava 
and its nearest branches through the imperfectly closed right ostium EXAMINATION OF THE CIRCULATORY APPARATUS. 
265 
venosum. It first and most markedly appears in the internal jugulars 
or their bulb, and generally only here. The very direct course of the 
innominate and right jugular from the cava causes the right jugular 
vein to show the phenomenon more frequently and stronger than the 
left. 
If the valve of the vein closes above the bulb of the jugular then 
the regurgitant wave ends there. This pushes the bulb up and dis- 
Fig. 75. 
Positive jugular pulse compared with ((7) carotid pulse. (After Riegel.) 
tends it, and it is then seen, enlarged and pulsating, in the inter- 
sterno-cleidomastoid fossa (bulbar pulse). The bound of the pulse- 
wave against the valve sometimes causes a valvular sound in the 
jugular. But ordinarily the valve is insufficient from previous en- 
gorgement (or is congenitally so), or it becomes so from the distending 
action of the pulse, and then the pulse-wave passes into the internal 266 
SPECIAL DIAGNOSIS. 
jugular, and exceptionally also into its branches in the face. This 
systolic pulse must likewise be supposed to be propagated to a certain 
extent also in all other veins that are directly given off from the cava; 
but they cannot be examined in a large venous territory: the veins 
of the liver. Here the pulse manifests itself by a constant systolic 
swelling and diastolic collapse of the organ, the venous liver pulse. 
Palpation of a liver thus constantly enlarged frequently shows the 
phenomenon of systolic venous pulse to a high degree. 
The systolic jugular pulse may be graphically represented, as is 
shown in Fig. 75. 
The mode of procedure in palpating the liver is as follows: One 
hand is placed upon the right hypochondrium or the epigastrium, the 
other is passed around the chest at the level of the eleventh and twelfth 
ribs posteriorly. We can then feel that the organ is systolically 
enlarged, and thus we may avoid confounding it with lifting up of the 
liver by the aorta or even with marked epigastric pulsation. More- 
over, wre recognize the liver-pulse in this way easier—that is sooner— 
than by simply palpating in front. The liver is usually enlarged, 
almost always by the previously existing stagnation (see Enlargement 
of the Liver); at least, it immediately becomes so if tricuspid insuf- 
ficiency occurs, as we very distinctly observed in a case of mitral 
insufficiency and stenosis, in which relative tricuspid insufficiency 
occurred, then subsided and again reappeared. 
Arterial liver-pulse is exactly like venous liver-pulse in its phenomena 
(in aortic insufficiency, see p. 257). 
For the production of a recognizable venous liver-pulse, as well as 
a strong jugular-pulse, there is, of course, required a certain moderate, 
and, if it has not been met with before, also it must not be too fre- 
quent action of the heart. As the heart growls more and more weak 
the liver-pulse fails and the jugular-pulse gradually becomes smaller 
and more slow, until finally there is only a slight to-and-fro movement 
toward swelling of the vein. 
In order to make a differential diagnosis of the different kinds of 
pulse in the veins of the neck it is necessary to bear in mind the 
following : 1. The imparted pulse will be best distinguished from the 
positive real pulsation, occurring at the same time with it, by placing 
the finger, or, better still, a pleximeter, writh its edge in the middle of 
the neck i pon the vein : if the pulsation is communicated it disappears EXAMINATION OF THE CIRCULATORY APPARATUS. 
267 
in the central empty portion and becomes more distinct in the periphery 
from the engorgement of the distended portion; on the other hand, a 
positive genuine pulse remains centrally unchanged. 2. The negative 
true pulse is distinguished from the positive and from the communicated 
pulsation generally by comparison with the apex-beat as well as by 
comparison with the carotid pulse. (We seize the left carotid, and 
at the same time observe the right jugular.) It is also to be observed 
that with the negative pulse the collapse of the vein is usually quick 
and that it refills slowly. In this way, with a little practice, one can 
often immediately judge correctly. 
In order more exactly to observe and study these phenomena it is 
well to have the patient for a time breathe very superficially, or, if 
possible, to hold the breath, so as to eliminate the respiratory to-and- 
fro swelling of the veins. 
We must still mention some occurrences that are extremely rare or 
are of very little diagnostic value : 
Diastolic collapse of the cervical veins (Friedreich), which looks 
very like systolic venous pulse, sometimes occurs in adhesive pericar- 
ditis and callous mediastinitis, and is connected with systolic drawing- 
in in the neighborhood of the heart which occurs with this condition. 
The springing forward in the diastole, together with the forward 
movement of the anterior wall of the chest, probably produces an 
aspiration of the contents of the large veins. 
Systolic venous pulse may exceptionally occur with mitral insuf- 
ficiency and open foramen ovale: through the latter and the left 
ostium venosum the contraction of the left ventricle produces a 
recurrent pulse-wave in the cavse and their nearest branches (very 
rare, being thus far only observed in one case). 
Double positive venous pulse (Leyden) is observed in hemisystole. 
3. Phenomena of Circulation in other Veins. 
Systolic true pulse may, as has already been mentioned, be 
propagated to the veins of the face, hut this is rare. It has, in 
individual cases, even been observed in the cutaneous veins of the 
arm, in the small branches of the internal mammary (of which I have 
seen one case), in the vena cava inferior (Geigel), etc. 
The so-called progressive venous pulse (Quincke) has been seen in 268 
SPECIAL DIAGNOSIS. 
the veins of the hand and the back of the foot with existing capillary 
pulse (aortic insufficiency, also in severe anaemia; likewise reported 
to have been seen in health), as a pulse-wave flowing centrally, and 
later appearing as the radial pulse (a very great rarity). 
It can be regarded as nothing else than the arterial pulse propagated 
through the capillaries. 
4. Venous Thrombosis. 
The transformation of the soft venous tubes into firm round cords 
that can be felt exhibits venous thrombosis. The thrombosed vein 
may often also be perceived by pressure. In internal medicine, of 
especial interest and importance is thrombosis of the large veins of the 
lower extremities as it sometimes occurs in the course of severe acute 
infectious diseases, as the result of chronic invalidism, and in marasmus 
of the aged. Frequently, but never while resting in bed, it occurs in 
the oedema of engorgement in the affected limb. 
AUSCULTATION OF VEINS. 
1. Sounds and murmurs of short duration are sometimes heard 
over the jugular and crural veins : 
In tricuspid insufficiency there is a systolic recurrent blood-wave, 
which, by its impulse against the closing valve above the bulbus 
jugularis and against those in the crural vein at Poupart’s ligament, 
and also by the sudden tension of the vein itself, causes a sound which 
will he heard by very lightly placing the stethoscope at these points. 
But a sound has also been heard where the crural valve was defective. 
In such cases it must be alone caused by the sudden tension of the 
venous tube. If these valves are insufficient there may be a corre- 
sponding short murmur (very rare). 
Jugular sound generally accompanies the bulbar pulse of tricuspid 
insufficiency. A venous sound over the crural is, however, rare, 
because the recurrent wave only exceptionally reaches this vessel. 
Quite exceptionally there may be with tricuspid insufficiency a double 
sound PVer the crural vein, indicating first auricular, then ventricular, 
contraction (Friedreich). It can be distinguished with certainty from 
the sounds, double sounds, and murmurs of the crural artery only 
when there exist signs of aortic or tricuspid insufficiency (hence, how EXAMINATION OF THE CIRCULATORY APPARATUS. 
269 
small is the diagnostic value of these phenomena !). Crural, arterial, 
and venous sounds may be combined when there exist at the same 
time aortic and tricuspid insufficiency. 
Now and then, even in health, especially in thin persons, a sound 
is produced over the crural vein by sudden straining or coughing 
(expiratory valvular sound in the crural vein—Friedreich). 
2. A continuous murmur, designated as venous humming, venous 
murmur, or buzzing, is often heard in anaemic, and especially in 
chlorotic, patients, but sometimes also in many healthy persons, over 
the jugular veins. It is usually louder on the right side. It sounds 
like a regular humming or a very fine whizzing or like the humming 
of a top. If it is very marked it can also be felt. The murmur is 
caused by the "whirl in the blood as it flows from the narrow jugular 
into its wider bulb. The whirls are the more marked, the more rapid 
the stream ; and hence the murmur becomes louder in deep inspiration, 
and for the same reason it is generally louder in the upright position 
than wrhen lying down. And likewise it is not infrequently louder in 
the diastole than in the systole of the heart. Also, the predominance 
of the right jugular over the left is explained by the difference in the 
rapidity of the current caused by the different shape of opening into 
the cava (see above, p. 265). This murmur will be increased by slight 
compression, as may be produced by the stethoscope or by turning 
the head to the opposite side. This latter effect comes from the 
tension of the fascia colli, and probably also from the contraction of 
the omo-hyoideus muscle. 
As to what the occurrence of this murmur means we must rest upon 
the old idea that it chiefly occurs with anaemic and especially chlorotic 
patients. Friedreich’s claim that it is more marked in these cases, 
while in health it is usually only to be heard as a soft humming, 
seems to me to be very far-fetched. Strictly speaking, no diagnostic 
importance is to be attached to this phenomenon. 
Similar murmurs occur exceptionally in other veins, and it is to be 
noted, almost exclusively in anaemia; thus in the large veins of the 
extremities and also in the intrathoracic trunks. Here the murmur 
is always much stronger during the heart’s diastole and can thus 
appear to be interrupted. It has already been mentioned that Sahli 
declared the anaemic heart-murmurs to be in part propagated from 
the venous trunks in the chest. 270 
SPECIAL DIAGNOSIS. 
Examination of the Blood. 
PRELIMINARY REMARKS. 
In health the entire quantity of blood in the body amounts to about 
one-thirteenth of its weight. At the bedside we can in no way reach 
an approximation of the quantity of the blood, although it is evident 
that the capacity of the arteries (assuming that there is an equal pro- 
portion of blood in the circulation) must in general determine the 
total quantity of blood. But the loss arising from this defect' in our 
methods of examination is only very small, because, according to our 
present knowledge, the quantity of the blood is affected in a way that 
is characteristic and understood by us only in isolated conditions, as 
for instance, immediately after loss of blood, with extensive watery 
discharges, as in Asiatic cholera and in severe diarrhoea, especially in 
children. 
On the other hand, according to our present knowledge of path- 
ology, and our methods of examination, there are a number of condi- 
tions of the blood which relate to its morphological constituents or 
morphological admixtures, which are, as also the amount of haemo- 
globin, and certain relations of this substance with 0, C02, etc., of 
the greatest importance in recognizing certain diseases. There are 
some less important diagnostic chemical departures from the normal. 
Besides the inspection of the skin, which is not entirely without value, 
the methods which chiefly come into consideration are: the examina- 
tion of a drop of blood with the naked eye, spectroscopic examination, 
and that which is made with certain apparatus for approximative 
determination of the intensity of the color (amount of haemoglobin). 
1. Color and Spectroscopic Character of the Blood. 
Blood taken directly from a healthy person is of a recognized color; 
if arterial it is brighter, rich in oxygen, that is, rich in oxyhemo- 
globin. If venous, it is darker; if bluish-red, it is poor in oxygen. 
The marked deficiency of oxygen in the blood of a person suffering 
from dyspnoea or venous engorgement, or both, makes the blood very 
dark. In carbonic acid poisoning the blood is bright cherrv-red; 
from chlorate of potash, anilin, and in severe poisoning by hydro- EXAMINATION OF THE CIRCULATORY APPARATUS. 
271 
cyanic acid and nitrobenzole it is brownish-red or chocolate color. In 
severe anaemia and chlorosis (hydraemia) the blood is watery; in 
marked leukaemia it looks a peculiar whitish-red as if mixed with 
milk, or chocolate color. 
These changes in the color of the blood all have an effect upon the 
color of the patient’s skin, as has partly already been mentioned. 
Hence patients with carbonic acid poisoning look strikingly rosy, 
while poisoning with chlorate of potash causes the skin and mucous 
membrane to be the color of anilin, nitrobenzole, a cyanotic or a pecu- 
liar grayish blue, even black. These discolorations of the skin, as well 
as the differences in the color of a drop of blood obtained by pricking 
with a needle, have too little distinction to be directly of diagnostic 
use. But, especially with regard to the poisons that have been men- 
tioned, if they are recognized as unusual, they demand that a timely 
and thorough examination of the blood be made by the spectroscope 
or microscope. In this lies the great value of a knowledge of these 
discolorations. 
For recognizing haemoglobinaemia (from the haemoglobin that 
appears in solution in the serum of the blood originating from the 
red blood-corpuscles) it is necessary to employ a wet cupping-glass. 
The blood thus withdrawn is allowed to stand covered for twenty-four 
hours, if possible in an ice chest, and then the serum, separated from 
the coagulum, is to be examined. That from normal blood is yellow, 
in haemoglobinaemia it is rubin-red, and in the spectroscope gives the 
bands of oxyhaemoglobin (see below). 
Approximative determination of the amount of haemoglobin : A 
diminution in the amount of the haemoglobin may be conditioned 
upon a diminished number of red corpuscles or upon a decrease in the 
amount in single corpuscles, or upon both (see below). It is recog- 
nized by the paleness, and if the loss be very great, the practised eye 
recognizes it by the clear watery look of a drop of blood. A variety 
of apparatus, called haemochromometer, has been devised for deter- 
mining this condition (Quincke, Bizzozero), but recently these have 
been surpassed in simplicity and utility by the haemometer of Fleischl. 
The principle of this is as follows: 
A certain very small quantity of blood (obtained by a prick) is 
thinned by a definite quantity of water, and then by lamp or gaslight 
the color of this mixture is compared with the color of a glass wedge 272 
SPECIAL DIAGNOSIS. 
which has been colored with Cassius’ gold purple and carries a 
movable scale. Upon this scale the figure 100 corresponds with the 
intensity of color of a mixture of normal blood. Material that has 
less intensity has the numbers 90, 80, etc., down to 10, thus giving 
directly the percentage relation of the mixture of blood that is being 
examined to that of normal blood with reference to the quantity of 
hsemoglobin. Thus 90 indicates, if the mixture of blood has been 
properly prepared and corresponds in color with the color of the glass 
wedge at that point of the scale, that this blood contains only ninety 
per centum of normal quantity of hsemoglobin. 
But the determination of the exact quantity of hsemoglobin can 
only he made by quantitative spectrum analysis (Iv. Yierordt). It 
would exceed the limits of this book to give a description of the 
method of procedure. 
Spectroscopic condition of the blood. In certain cases its examin- 
ation has decided significance. Recently it has been rendered very 
much more easy by very practical clinical and uncomplicated apparatus, 
of which we may mention the spectroscope devised by Desaga (Heidel- 
berg), and still more recently Hering’s very cheap spectroscope without 
lenses. According to our own experience and also the opinion of 
Jaksch, the latter after a little practice is entirely satisfactory for 
clinical purposes. 
In three classes of cases the spectroscopic examination of the blood 
gives a valuable result: in hsemoglobinsemia there is no doubt about the 
presence of the coloring matter of the blood in the serum (see previous 
page) if the serum shows the absorption band of oxyhsemoglobin ; one 
in yellow near green (close to D, Frauenhofer), and one in green near 
the former, between D and E. Moreover, in carbonic oxide poisoning 
there appear in the blood two absorption-bands which are very near 
the two above mentioned, only a little nearer the violet line, and 
hence they may be confounded with them, but they are very distinctly 
separated from bands of oxyhemoglobin in that they do not disappear 
on the addition of ammonium sulphate (since carbonic oxyhemoglobin 
is not thus reduced). Lastly, it has recently been discovered that 
in poisoning with chloride of calcium methemoglobin occurs in the 
blood, and this indeed in the living body. In acid and neutral solu- 
tions this causes an absorption-band in yellow (between C and D, 
besides three others more faint), which coincide with that of haematin, EXAMINATION OF THE CIRCULATORY APPARATUS. 
273 
but which are distinguished from it in that upon the addition of ammo- 
nium sulphate it first gives place to the absorption-bands of oxyhsemo- 
globin, then to that of 0, free haemoglobin (a broader band in green 
and yellow from D almost to E). In alkaline solution, methsemoglobin 
shows a narrow band in yellow near to D, and one in yellow-green 
and green. 
There are still other changes in the blood partly relating to its 
color and partly relating to its behavior in the spectrum, when animals 
are poisoned, but they do not seem to require mention in this book. 
2. Microscopic Examination of the Blood. 
Mode of procedure. When we wish to examine a patient’s blood 
we first clean an object-glass and a cover as carefully as possible. 
Then cleaning the tip of the finger with water or a 1 to 2 per cent, 
solution of salt as carefully as possible, we puncture the finger-tip with 
a clean needle and allow a drop of blood as it escapes to fall upon the 
object-glass and without pressure cover it, or we move the cover 
lightly, without disturbing the finger, over the escaping blood, and 
then immediately very cautiously place it upon the object-glass. It 
is not advisable to squeeze the patient’s finger in order to force the 
blood out. 
In examining for microorganisms all instruments or apparatus must 
be especially cleaned, and the finger scrubbed with soap and a brush, 
then with alcohol and ether. According to the special object of the 
examination we employ a magnifying power of from 300 to 700 
diameters. 
If, instead of the finger, we prick the lobe of the ear, it is just as 
well, and the whole proceeding is much less painful to the patient. 
The normal structures of the blood consist of red and white blood- 
corpuscles, and blood-plates. Clinically the latter of these have pre- 
viously had no interest. The pathological conditions that are recog- 
nizable by the microscope may be divided into alterations in the 
number or appearance of the blood-cells, and into foreign substances, 
as microorganisns. 
In general, we again distinguish the changes in the number and 
character of the blood-corpuscles with reference to diminution of the 
red corpuscles (oligocythsemia) and changes in the structure and size 274 
SPECIAL DIAGNOSIS. 
of the red corpuscles (poikilocythsemia and microcythaemia). But 
these forms often pass into each other. 
1. Oligocythsemia, diminution in the number of red corpuscles, is 
the change which takes place in anaemia (not in chlorosis). If very 
marked, it is even recognized by the watery appearance of a drop of 
blood. At all events, by the practised eye it may be recognized 
without farther examination of the ordinary microscopical preparation 
(although very little reliance can be placed upon such a superficial 
examination). For exactly determining the number of blood-corpuscles 
we employ an apparatus devised for counting the corpuscles in a given 
quantity of blood. 
It is in the first place to be remarked that counting of the red 
corpuscles is very seldom absolutely necessary for making a diagnosis 
of the different forms of anaemia (of which see below), but it may be of 
great value in judging of the course of a given disease, especially as 
regards the effect of treatment. 
The Thoma-Zeiss apparatus for counting the number of corpuscles 
is the best of all those now in use. It consists of a mixer and a 
Hayem’s counting chamber. 
The mixer serves to distribute the blood in as equal a manner as 
possible, a very important point. For thinning the blood a 3 per 
cent, solution of salt is recommended. The mixer is a kind of 
measuring pipette with a very fine canal, and with a spherical 
enlargement containing a little glass ball. The portion of the tube 
below the cavity has the marks 0.5 and 1.0. Just above the cavity 
is the mark 101. The first two marks are those to which the blood, 
directly after it has been drawn from the finger, is sucked. If we 
wish a mixture of 1 to 200 we draw it up to 0.5; if a mixture of 
1 to 100 to 1.0. In both cases we wash off the blood clinging to the 
point, and draw in a 3 per cent, solution of salt to 101. Then 
the mixer is shaken several times so that the glass ball equally mixes 
its contents. We next expel the contents of the fine tube, which 
consist of salt solution, after which we fill from the mixture a 
Hayem’s counting chamber. This consists of an object-glass with a 
circular excavation; it is a space exactly 1 mm. deep, the floor of 
which is divided into microscopic squares, whose sides are mm. 
long. The cubic capacity of the space over each square is 3rV X 12V 
X iV c.mm. = c.mm. EXAMINATION OF THE CIRCULATORY APPARATUS. 
275 
Into this cavity some of the blood-mixture is blown and then 
covered with a glass cover after carefully expelling any air bubbles. 
After waiting a moment in order that the blood-corpuscles may as 
far as possible equally distribute themselves, we magnify it about 50 
diameters and count the number of corpuscles in the larger number 
of the above-named squares, and thus obtain an average of the 
contents of say sixteen of them. If we count these sixteen squares 
several times we shall secure a more accurate determination. We can 
calculate the number of corpuscles in a cubic millimetre from the 
proportions of the mixture and the cubic contents of the squares, as 
given above. 
Immediately after use, the mixer must be most carefully washed 
with water, alcohol and ether. 
Normally, in a cubic millimetre of human blood, there are in the 
male about five million, in the female about four and a half million 
red corpuscles (C. Vierordt, Laache). We may only positively afiirm 
that there is a pathological diminution when, examining a case for 
the first time, the enumeration gives half of the number or less. 
The least quantity observed in disease is about 400,000 to the cubic 
millimetre. 
Besides diminution in the number of red corpuscles, in anaemia 
(hydraemia) we observe the following : 1. They manifest diminished 
or even no tendency to the formation of rouleaux, which is a well- 
known peculiarity of normal blood. 2. Star forms, mulberry forms, 
which are also usual in normal blood as soon as it is withdrawn, 
seldom or do not occur at all. 3. The red corpuscles are paler in 
simple anaemia (very markedly so in chlorosis), on account of the 
diminished amount of haemoglobin. The opposite condition is not 
infrequent in poikilo-microcythaemia (which see). 4. In a certain 
proportion of cases there occurs a slight alteration in the form and 
size of the red corpuscles, as referred to under 3. 5. The white 
corpuscles are, in proportion to the red, somewhat increased (relative 
leucocythaemia). 
Oligocythaemia is always connected with diminished amount of 
haemoglobin in the blood, whether there is a diminution in the number 
of the red corpuscles or the individual corpuscles are paler. The 
diseases in which both conditions exist are the different forms of 
anaemia, pernicious anaemia, leucaemia. On the other hand, only a 276 
SPECIAL DIAGNOSIS. 
diminished quantity of haemoglobin in the blood, that is to say, no 
notable diminution in the number of red corpuscles, occurs in 
chlorosis. In observing the progress of the first-named diseases we 
must make an enumeration and examine with reference to the amount 
of haemoglobin, while in chlorosis it is only necessary to examine for 
the latter. In the former case the number of red corpuscles and the 
haemoglobin seem to go hand in hand. Hence it seems to me that, 
especially on account of its simplicity and its approximate accuracy, 
Fleischl’s haemometer may be very strongly recommended to physicians 
for examining the color of the blood in the course of an anaemia 
(strictly speaking, chlorosis), thus answering in a great majority of 
cases, on account of the particular care which the enumeration 
requires, unless there should be some indication for counting the 
corpuscles. 
2. Alterations in the size and form of the red corpuscles. Formerly 
this was, iiL its totality, considered as a diagnostic sign of pernicious 
anaemia. Now we know that there are other conditions that accom- 
pany such variations. The simplest way of determining the size is to 
compare a preparation of blood with that of a-healthy person (the 
examiner himself). The normal average of red blood-corpuscles is 
7, 7—8, 0 fi. 
Microcythaemia. By this we understand the occurrence of forms 
containing haemoglobin, which are smaller than red blood-corpuscles, 
in which the form is nearly or quite perfect, or, if they are very 
small, they are simply globular. We see the former in the new 
formations of blood after hemorrhages, and also in all kinds of anaemia. 
They are probably young red corpuscles. The latter—microcytes, 
strictly so-called—occur especially frequently in pernicious anaemia, 
and also in all other forms of anaemia. The supposition that they are 
formed upon the glass slide is possibly correct, because they may even 
be found in normal blood when the preparation contains air, is pressed, 
or is old. I have never seen them when examining a perfectly 
fresh, otherwise normal preparation of blood, except at the border (the 
effect of air). 
Macrocytes—abnormally large red corpuscles, besides those of 
normal size and very small ones—occur in individual cases of marked 
and simple anaemia, but especially in pernicious anaemia. This 
disease must always be suspected when they are present. Corpuscles EXAMINATION OF THE CIRCULATORY APPARATUS. 
277 
that are larger than normal are almost always also poikilocytes, like 
the following: 
Poikilocytes, strictly speaking, are red corpuscles changed in form. 
They may assume the greatest variety of forms—club, biscuit, pear, 
flask, and drum-stick are the most usual forms. In many ways 
poikilocytes correspond to enlarged red corpuscles. In individual 
cases they exhibit amoeboid movements. In a wider sense we employ 
the expression poikilocytosis to a mixture of such forms with micro- 
cytes and macrocytes, which are almost always present. 
Fig. 76. 
Poikilo-, macro-, microcytosis (as represented by the letters d, b, c). a, normal blood- 
corpuscle; e, product of decomposition of a red blood-corpuscle; f, nucleated red blood- 
corpuscle (marked anaemia). (After Quinckk.) 
We must avoid confounding with them the mulberry and thorn- 
apple forms, which occur normally, or mechanical or chemical products, 
by using the greatest care in making the preparations and then imme- 
diately examining them. 
Poikilocytosis is not at all a pathognomonic symptom of pernicious 
anaemia, although in other forms of anaemia it does not occur so 
regularly and in so marked a degree as in pernicious anaemia. It 
may occur with any severe form of anaemia and cachexia, as in tape- 
worm, or cancer-cachexia. 
As a matter of course, all these changes in the red corpuscles 
usually very notably accompany diminution in their number and of 
the amount of haemoglobin. Hence, as has already been mentioned, 
the amount of haemoglobin in separate blood-corpuscles is not infre- 
quently increased. 278 
SPECIAL DIAGNOSIS. 
3. Increase of the white blood-corpuscles (leukaemia, leucocytosis). 
The proportion of white blood-corpuscles to the red in normal blood, 
drawn by pricking the finger, if we take the average of the reported 
observations, is about 1:400 to 1:700, which is a considerable 
variation. 
Where this proportion varies temporarily and slightly in favor of 
the white corpuscles, we designate the condition as leucocytosis; if it 
is long continued and very marked, as leukaemia. 
Ordinarily we can easily distinguish at the first glance between 
these two conditions, since leukaemia is generally accompanied with a 
very marked increase, and leucocytosis with but a slight increase of 
the white cells. Hence, we rarely have cases that are on the border 
between the two. 
Fig. 77. 
Blood of leukaemia. (After Funke.) 
During digestion, leucocytosis is observed as a physiological condi- 
tion. It is also seen in acute infectious diseases, especially in typhoid 
fever and in relapsing fever, inflammation of the spleen, etc. We 
have inflammatory leucocytosis in swelling of the lymphatic glands 
from inflammation of all kinds, especially in erysipelas. Lastly, we 
meet with cachectic or hydraemic leucocytosis in all forms of anaemia, 
and this may be either relative, dependent upon a diminution of the 
red corpuscles, or, as enumeration shows, it may be absolute. In the 
latter case, it is explained by the undoubted slowing of the lymph- 
current in consequence of hydraemia. EXAMINATION OF THE CIRCULATORY APPARATUS. 
279 
Under the microscope, leukaemia is manifest in that usually there is 
a remarkable increase in the white corpuscles. Very frequently there 
has been found a proportion of 1 white cell to 10 red cells. When 
the proportion is more than 1 to 20, many wish to apply the term 
leukaemia. In extreme cases, which are rare, the number of red and 
white corpuscles become about equal. 
At any rate, the number of red corpuscles is always diminished: 
Jaksch found the average of a number of cases to be two to three 
million cells (red and white) in a cubic millimetre of blood. The size 
of the white corpuscles usually remains normal; but very often re- 
markably large leucocytes are found, some of which have strikingly 
large nuclei. Moreover, we sometimes find nucleated red corpuscles 
(probably transition forms from the white to red). The red corpuscles 
often have the forms of poikilocytosis. Ehrlich found a remarkable 
behavior of leucocytes—that is, their protoplasmic granules—in the 
presence of certain aniline colors. His most important result is the 
discovery that only in leukaemia are there found in the blood white 
cells called eosinophile—that is, that are distinctly colored with eosin. 
In doubtful cases this fact would seem to be useful in diagnosing 
leukaemia. 
Ehrlich dries a preparation upon a covering glass, as thin as possible, 
in the air or exsiccator, heats it for ten to twelve hours in a drying 
chamber at 120°-130° C., and quickly stains it with eosin-glycerin. 
Then he washes it with water, and mounts it dry in Canada balsam. 
Opinion is divided as to whether it is possible to recognize the 
different pathological, anatomical, or clinical forms of leuksemia by 
the condition of the blood—that is, to discriminate whether the leu- 
ksemia exists by participation with lymph-glands, the spleen, medulla 
of the bones (lymphatic, splenic, myelogenic leuksemia). It seems 
true that the above-mentioned transition-forms between red and white 
blood-corpuscles point to alterations in the medulla of the bones. 
Moreover, many think that the small cells are more connected with 
the lymph-glands and the large ones with the spleen. 
In extremely rare cases of leuksemia, crystals are found in the blood 
(Charcot): they are colorless, shining, long octahedral, like Charcot’s 
crystals found in the stools and expectoration, or they are identical 
with them. 280 
SPECIAL DIAGNOSIS. 
4. Abnormal additions to the blood. Of these we first mention 
melanaemia and lipsemia. 
Melancemia occurs directly after severe attacks of malaria and in 
malarial disease. We sometimes find, swimming free in the blood, 
brownish-black or yellow-brown lumps and granules, or, also, white 
blood-corpuscles filled with such granules. They result from breaking 
up of red corpuscles. 
By lipcemia we understand the occurrence of extremely fine drops 
of fat in the blood, as in drunkards, in diabetes, and in chyluria; but 
they are also sometimes seen in health. 
In recent times we have learned to recognize microorganisms as 
most important additions to human blood. They are exclusively 
schizomycetes. 
Fig. 78. 
Anthrax bacilli in the arterial human blood (fuchsine-staining. Ziess’s homogeneous 
immersion lens Af> eye piece 4, camera lucida, magnified about 1000 diameters). The 
white line in the middle of the bacilli indicates only reflections. Prepared by Dr. 
Freimuth in Danzig. 
Anthrax bacilli in the blood has been repeatedly established in 
poisoning by anthrax, although always in considerable quantity. 
The defect in the microscopical proof does not exclude, however, a 
general infection: a test by vaccinating mice may, however, succeed. 
We may have several bacilli of anthrax often occurring together, 
not threads ; spores may be entirely wanting. The bacilli are recog- EXAMINATION OF THE CIRCULATORY APPARATUS. 
281 
nized, without staining, as tolerably thick clubs, possibly twice the 
length of the diameter of a red blood-corpuscle. Regarding staining, 
see below. 
Fig. 79. 
Recurrent spirals in the blood (After Jaksch.) 
The first microorganisms that were seen in the blood were the 
recurrent spirals (Obermeier). We find them during an attack of 
recurrent fever. • They disappear shortly before the decline of the 
fever. By careful examination they can always be demonstrated, 
although sometimes there are only a few of them. 
In a fresh drop of blood they appear (Hartnack 8, Zeiss F) as 
extremely fine threads, about five times as long as the diameter of a 
red corpuscle, with extremely active spiral, serpentine motion. They 
occur either singly or several close together, sometimes lying together 
like a group of rats’ tails. I have very often first seen them near 
white blood-corpuscles. The white or red corpuscle against which it 
lies is usually set slightly in motion by the microbe, and hence we 
find them there first. Moreover, there often occurs in the blood slight 
leukocytosis; also, we sometimes meet with shining granules (elemen- 
tary granules ? spores ?). As to staining, which, after a little practice, 
is not necessary, see below. 
Tubercle bacillus exists in the blood as the sign of miliary tubercu- 
losis. But in this disease we may lack this proof. With the excep- 
tion of one case observed by Jaksch, it always occurs quite isolated. 
A special treatment is required for obtaining this microbe. We 
arrange a thin layer of blood upon the glass cover just as we do a 
preparation of sputum (see Sputum). 
Typhus abdominalis bacilli have in several cases been found in the 282 
SPECIAL DIAGNOSIS. 
blood as a short (one-third the diameter of a red corpuscle), thick 
club, rounded at the end. See examination of the Stools (for staining, 
see below). 
The bacilli of glanders are, in general, a liltle longer than the pre- 
ceding, but considerably slimmer. They have likewise been found a 
number of times in the blood of this disease. It is necessary to stain 
them (see below). 
There is still doubt about the diagnostic value of plasmodium malarice, 
although Marchiafava and Celli are tolerably certain that they have 
produced malaria by inoculation where it did not previously exist. They 
are protoplasmic bodies within the red corpuscles, which can be stained 
by methylene-blue. No cultures of it have yet been obtained. 
The greatest care and cleanliness are necessary in arranging a 
preparation of blood for microscopic examination for microorganisms, 
although the minutiae of disinfection and sterilization, as in preparing 
for culture, are not required. In malignant pustule and febris recurrens 
staining can be dispensed with. When it is necessary to stain a 
preparation, it is prepared by drying a small drop of blood which has 
been spread out and made as thin as possible by pressing two covers 
together. Then they are separated, allowed to dry in the air, and 
afterward passed two or three times through the flame of a spirit-lamp 
or a Bunsen’s burner. If, now, we wish to examine for tubercle 
bacilli, a special treatment is necessary, as has already been described 
under Sputum. For other microorganisms wre stain with basic aniline 
colors (vesuvine, fuchsine, particularly methylene-blue, etc.), and then 
carefully rinse and examine in or, after drying, in Canada balsam. 
The staining is much more beautiful if we first briefly dip them in 
Fig. 80. 
Fig. 81. 
Distoma haematobium with eggs. 
(After Jaksch.) 
Filaria sanguinis hominis. 
(After Jaksch.) 
gentian-violet-aniline water (see above under Sputum), and then stain 
them a few minutes in Gram’s iodine-iodide-of-potassium solution EXAMINATION OF THE CIRCULATORY APPARATUS. 
283 
(iodine 1 part, iodide of potassium 2 parts, aq. destil. 300 parts), 
then in absolute alcohol. 
Finally, we briefly refer to two animal parasites which are met with 
in the blood, though they do not belong in this book : thefilaria san- 
guinis hominis, which causes hsematochyluria (in British India and 
Brazil), generally only found in the blood at night-time, and distoma 
hcematobium (Bilharz), which causes a kind of hoematuria, chiefly 
occurring in Egypt. (See under Urine.) 
Chemical Examination of the Blood.—We content ourselves 
with a few hints regarding this department, since it lies almost 
entirely outside of the limits of diagnosis. 
Recently, in certain diseases, the degree of alkalescence of freshly- 
drawn blood has been determined by various methods, and it has 
been found that in severe anaemia, fever, and diabetes (Jaksch) the 
alkalescence is considerably diminished. Uric acid in unusual quantity 
has been found in the blood in gout. 
The quickness with which blood coagulates after it has been with- 
drawn varies in different diseases. In health, coagulation takes place 
in about nine minutes. It is slower than this where the nutrition is 
chronically disturbed. (H. Vierordt.) CHAPTER VI. 
EXAMINATION OF THE DIGESTIVE APPARATUS. 
Mouth, Palate, and Pharyngeal Cavity. 
The inspection of these parts requires good illumination, and for a 
portion of them, in many cases, a quick view. Bright daylight is better 
than artificial light. The mouth is to be opened widely, the tongue 
protruded, and not only put out, but, for inspecting its borders, turned 
from side to side. (For examining it with reference to paralysis, see 
Nervous System.) In order to inspect the mucous membrane of the 
mouth, wc turn out the upper and lower lips with the finger, the 
mouth being closed; then, the mouth being opened, we carefully lift 
the mucous membrane of the cheeks from the back teeth with a 
mouth-spatula (made of ivory, hard rubber, horn, or metal). The 
gums are examined by opening the mouth as widely as possible and 
holding the tongue down carefully with a tongue-depressor (a teaspoon 
serves very Avell). The back of the mouth is best brought into view 
by having the patient say distinctly “ae” (full elevation of the soft 
palate). 
The patient should be required to drink some water, also to clear 
the throat thoroughly before it is examined. If we meet with 
opposition, especially in children, it is sometimes necessary to hold 
the nose, and thus compel them to open the mouth. When a child 
cries, we are able to see very well. It is often useful to cause the 
sensation of strangling by putting the tongue-depressor far back, and 
thus we are able to see the tonsils better—of course, only for an 
instant. [One learns, by practice, to take a very perfect and com- 
plete view of the whole cavity of the mouth and pharynx in this 
instant of strangulation, and then can carry the mental picture long 
enough to note all its particulars.] 
But we must guard against being too harsh or rough with children 
with diphtheria, or with any very sick patient. In diphtheria, imme- 
284 EXAMINATION OF THE DIGESTIVE APPARATUS. 
285 
diate death may follow an effort at examining the throat. With those 
who are unconscious, it is necessary to cause gagging in order to 
inspect the posterior part of the mouth. In marked cases of this 
character, it is often impossible to obtain a view at all. 
Palpation is only rarely employed for examining the tongue, floor 
of the mouth (making counter-pressure from without), the tonsils, or 
the back part of the pharynx. We employ the index, or this and the 
middle fingers, which have been carefully washed in the presence of 
the patient. 
The odor from the mouth is, in many cases, important. A foul 
odor—-foetor ex ore—results from imperfect cleansing of the teeth, 
caries of the teeth, or dyspepsia. From this odor we distinguish the 
stale, and at the same time foul, fetor from considerable old deposit 
in the mouth of patients who are very ill. If the sense of smell is 
acute, one can also distinguish a slight cadaveric odor upon patients 
who are very sick, even if the mouth is quite clean, and sometimes it 
precedes death. 
Of much more diagnostic value are the different odors which we 
meet with in poisoning from prussic acid, phosphorus, alcohol, and 
chloroform; but the two former, even in recent cases, may possibly 
be wanting. Lastly, we mention the odor of fruit, wrongly called 
“ acetone ” odor, very like fresh apples, which sometimes occurs with 
the so-called chloride of iron reaction of the urine (see) in diabetes, 
especially before or during the onset of diabetic coma. 
The lips. With regard to their color (pale, cyanosed, etc.), we can 
refer to what has already been said when speaking of the mucous 
membrane. Dryness of the lips is seen in connection with dryness of 
the tongue (which see). There is marked dryness in severe febrile 
diseases, with a dirty looking crust adherent to the mucous membrane, 
which easily bleeds when this is removed (fuliginous deposit). Small 
cracks (rhagades, crevices) are, in themselves, without significance. 
On the contrary, in children, rhagades are an important, generally a 
positive, sign of hereditary syphilis. 
The teeth and gums. We must take both into consideration, and, 
besides, as to whether the teeth are sound. In small children we 
notice whether the first teeth have all come; in the later years of 
childhood, the change to the permanent set. 
There is often marked caries of the teeth in diabetes mellitus, 286 
SPECIAL DIAGNOSIS. 
though it is very common without this disease. A circular excavation 
of the lower edge of the upper middle incisor teeth of the second 
dentition [Hutchinson’s teeth] is usually a positive, almost pathogno- 
monic, sign of congenital syphilis (with catarrh of the middle-ear and 
parenchymatous keratitis, the whole forming the infallible Hutchin- 
son’s triad). Imperfect and diseased teeth, interfering with mastica- 
tion, are often the chief cause of dyspepsia. 
Loosening of the teeth, and the gums discolored bluish-red, receding 
from the teeth, easily bleeding, and even inflamed, are important 
symptoms of scorbutus. Loose teeth, with moderate swelling, is a 
sign of chronic poisoning with mercury. 
A grayish deposit upon the teeth, and a gray line along the dental 
border of the gums, results from chronic lead-poisoning. In poisoning 
by copper, we have sometimes the same condition, only the color is 
greener. 
The eruption of the first teeth is a source of much disturbance in 
the mouth of the little patients. Occasionally it gives rise to serious 
disturbances—diarrhoea in rare cases, epileptiform attacks (eclampsia 
of children, infantile convulsions, spasms of dentition), also spasm of 
the glottis. Second dentition and the eruption of the wisdom-teeth 
are not infrequently accompanied with limited or general oral dis- 
turbances, sometimes likewise the cause of abscess. To the red border 
upon the gum, observed by Fredricq-Thompson, which in young 
subjects is said to be a very suspicious sign of tuberculosis, we have 
given careful attention for a long time, and conclude that it has no 
significance. 
The tongue. For paralysis and neurotic atrophy of the tongue, see 
under, the Nervous System. 
Enlargement of the tongue, if slight, is only to be determined from 
the indentations on its borders by the lower teeth. This occurs with 
the various forms of stomatitis. Marked enlargement of the tongue 
may be caused by parenchymatous glossitis, tumors, and also by 
severe angina, which produce venous engorgement of the tongue. 
Moreover, there are very great individual variations in the size of the 
tongue. 
Circumscribed swelling and hardness, or the latter alone, are the 
first evidences of carcinomatous or syphilitic formations of the tongue. 
It is extremely difficult to make the very important differential diag- EXAMINATION OF THE DIGESTIVE APPARATUS. 
287 
nosis between these new growths, and usually it can only be made by 
microscopically examining a small piece, which can easily be removed 
from it. (See, regarding this, in works upon surgery.) 
Wounds and the resulting scars, sometimes accompanied with 
swelling, are frequent appearances after epileptic attacks, and result 
from biting the tongue (see Scars). We never see the tongue bitten 
in hystero- epilepsy. 
If the tongue trembles when it is protruded, or if it does so when 
within the mouth, it is a valuable sign of chronic alcoholism. This 
is also the case in severe fevers, and especially early in typhus abdomi- 
nalis [typhoid fever]. In these cases, when there is marked herbetude, 
the patient often will not draw in his tongue after protruding it unless 
he is directed to do so. 
The color of the tongue is affected by that of the blood: cyanosis 
affords the most marked instance of this. It is quite common to find 
local redness with febrile conditions. It often goes side by side with 
the febrile redness of the cheeks. Mulberry tongue is one in which 
there is a decided redness with swelling of the papillae, and is an 
important sign of scarlet fever, which, in individual cases, may 
develop before the cutaneous eruption. Very often the coating of 
the tongue conceals the color of the mucous membrane. 
When the saliva is glutinous or diminished it causes the tongue to 
be sticky or dry. In connection with dryness of the throat, febrile 
diseases cause thirst. When the fever is very high, the dryness is 
often increased by the patient keeping his mouth constantly open. 
Then the surface of the tongue, if free from coating, first becomes 
horny, then quickly very smooth, and soon rough and cracked. 
Coating of the tongue, as a thin white layer, is often constant in 
health. When a tongue which previously was clean becomes coated, 
especially if thickly coated, it indicates dyspepsia. There is very 
marked coating of the tongue in severe acute and chronic diseases of 
the stomach and with the dyspepsia of fever. With the latter, it is 
often discolored brownish-red from small hemorrhages of the mucous 
membrane. When there is great dryness of the tongue, it becomes 
crusty and adheres so closely that when removed the mucous membrane 
bleeds. Articles of diet may cause temporary coating, or they may 
color the coating that is already there (milk, cocoa, coffee, etc.). 
A thick white—often, also, a discolored—coating on the tongue 
may depend upon the development of thrush (Oidium albicans). In 288 
SPECIAL DIAGNOSIS. 
very pronounced cases it forms separate small tufts about the size of 
a millet-seed which spread out and coalesce. It is cheesy and tolerably 
adherent. It may cover the surface of the tongue, the soft and hard 
palate, the mucous membrane of the cheeks; it may even extend 
down into the oesophagus; occasionally, we see the whole surface of 
the mouth and throat covered with it. Small children have it quite 
often; adults only in cases of severe illness when the care of the 
mouth is neglected, especially in fevers, diabetes, tuberculosis, etc. 
Whenever there is a thick coating in the mouth wTe must think of this 
growth, because its early recognition is very important. The diagnosis 
is promptly made by the aid of the microscope (see below). 
For scars from biting of the tongue during an attack of epilepsy, 
see above under Wounds. Dense, often depressed, scars upon the 
surface of the tongue indicate healed syphilitic ulcers. 
When there is a suspicion of syphilis, the mucous membrane of the 
mouth must be examined with the greatest care (scars, ulcers [mucous 
patches]); also, when there is a possibility of poisoning w*ith strong 
mineral acids or alkalies, corrosive sublimate, carbolic acid (superficial 
gray color and under it marked injection of the mucous membrane, 
raw patches). 
It may also be the seat of catarrhal ulcers as well as of the develop- 
ment of thrush (see above). Cancrum oris (Noma) usually begins 
with a circumscribed bluish-black discoloration of the mucous mem- 
brane of the cheek or an ulcer with this condition around it and with 
a thick, inflammatory infiltration of the cheek. It is a kind of 
spontaneous gangrene with a decided reactive inflammation in poor, 
wasting children. It is a rare disease. 
We examine the floor of the mouth by palpation from within and 
without. It may be the seat of very dangerous inflammation (angina 
Ludwigii). 
Salivary glands and saliva. Of the former we notice only the 
parotid gland. When it is inflamed there are pain and swelling, and 
if it proceeds to the formation of an abscess, there are also redness 
and fluctuation above the angle of the jaw. 
The saliva is increased (salivation, ptyalism) by all kinds of irrita- 
tion that affect the mucous membrane of the mouth: physiologically 
by eating, pathologically by all inflammatory conditions of the mouth 
(ulcers, inflammation of the gums in connection with affections of the EXAMINATION OF THE DIGESTIVE APPARATUS. 
289 
teeth, dental abscess, etc.; corrosive action of acids, alkalies in the 
mouth and throat); also, in chronic mercurial poisoning, and, lastly, 
sometimes in disease of the medulla oblongata (see Bulbar Paralysis). 
The saliva is diminished in febrile diseases, in diabetes, in severe 
diarrhoea (cholera). Thus far the chemical examination of the saliva 
has been of no diagnostic value. It is of interest that in nephritis it 
may contain urea, and also that thus far there has never been discov- 
ered in it any coloring matter from the bile nor any sugar. Many 
substances, like iodide of potassium, after they have entered the 
stomach appear remarkably quickly in the saliva. 
Microscopic examination of the contents of the mouth. Normally 
we find fiat epithelial cells from the upper layer of the mucous mem- 
brane of the mouth, separate white blood-corpuscles, and likewise 
micrococci, bacilli, and spirochaeta (especially a microbe like the 
cholera bacillus and one like the recurrens spirilla). Among these 
microorganisms, no doubt, there are some which may become patho- 
genic for the individuals in whom they occur. In the coating of the 
teeth we find these microorganisms very abundantly, and besides the 
leptothrix buccalis (long bacilli, often forming long threads, wdiich are 
colored blue-red by iodide of potassium, see Fig. 82). 
Fig. 82. 
Leptothrix buccalis, 1000 :1 (after Flugge). 
There is an unusually large quantity of the different schizomycetes, 
especially cocci, in any case where the contents of the mouth are 
decomposed {scorbutus, severe chronic mercurial poisoning, in any 
severe disease where there is difficulty in swallowing, especially if the 
mouth is not carefully cleaned). We also usually find an abundance of 
red and white blood-corpuscles. 290 
SPECIAL DIAGNOSIS. 
In the common white coating of the tongue there are abundant flat 
epithelial cells and fungi; these, together with a quantity of brown 
detritus, as well as red corpuscles, are found in the coating when 
discolored. 
It is easy to recognize the thrush fungus under the microscope by 
the characteristic, tolerably broad, light fungus-threads (they are more 
than half as broad as a white blood-corpuscle) and by their roundish- 
oval, clear granules. 
Inflammation in the mouth proceeding from the inferior maxilla 
may, in rare cases, give rise to actinomyces. Whenever there is a 
discharge of pus into the mouth we must remember the characteristic 
kernels (see p. 175; Microscopic Examination, see p. 189). 
Of the soft palate, we are chiefly interested in the tonsils. We take 
note of their size and the appearance of their surface. Large tonsils 
with deep, empty lacunae indicate frequent attacks of tonsillitis; 
prominent white scars, syphilis. If active disease be present, we are 
to notice whether there are plugs in the lacunae (follicular tonsillitis) ; 
whether there is a deposit upon the tonsils, and, in case there is, 
whether it is confined only to the tonsils and lacunae (in both cases, 
angina necrotica)-, whether it extends over upon the arches (diph- 
theria); whether it is loose or adherent, testing it with the spatula, 
and whether we find beneath it a necrosis of the tonsil going on. 
Diphtheria may cause a deposit upon the arches of the pharynx, the 
uvula, all of the soft palate, and even a part of the hard palate. We 
recognize an abscess of the tonsil by its [usually] being on one side 
only, with swelling of the anterior arch, by the fluctuation (which is 
felt with the finger). Lor g-continued ulcers of the tonsils and soft 
palate are generally syphilitic; more rarely, tubercular. In the 
latter case there is often a broad, reticulated, purulent discoloration 
of the mucous membrane, which reminds one of slightly-inflamed 
pleura covered with a fine fibrinous exudate. (Paralysis of the Throat, 
see Nervous System.) 
In the pharynx, we look for possible chronic or acute inflammation 
and ulcers; in children who, for some unknown reason, swallow badly 
and have distress in breathing, for possible swelling of the posterior 
pharyngeal wall (retropharyngeal abscess, the fluctuation in which 
may be detected by palpation). 
We must always examine the lymphatic glands in the neck in con- EXAMINATION OF THE DIGESTIVE APPARATUS. 
291 
nection with the examination of the throat. In all acute inflammations 
of the latter they swell, most markedly in diphtheria, also in chronic 
inflammations, especially syphilis. 
In diseases of the palate and pharynx the microscope gives very 
little assistance. It is chiefly useful in tuberculosis. When there is 
a suspicion of a tubercular ulcer, we scrape a little directly from the 
surface of the ulcer, but yet we cannot be certain that we have not 
taken some tubercular sputum which has adhered there. Long- 
standing plugs from lacunae (often quite free from irritation) frequently 
contain leptothrix (pharyngomycosis leptothricia). The important 
differential diagnosis between diphtheria and benign necrosis of the 
tonsils cannot, with our present knowledge, be made by the aid of the 
microscope. 
Pharyngomycosis leptothricia (algosis faucium leptothricia) may, as 
has been observed in individual cases, extend from the tonsils, par- 
ticularly to the follicular glands at the root of the tongue, or even 
still further into the trachea itself. They manifest themselves as a 
number of distinct, elevated, yellowrish-white specks. The nature of 
these deposits is easily recognized under the microscope, especially 
after the addition of iodine (see preceding page). 
Examination of the (Esophagus. 
Preliminary anatomical remarks: The oesophagus begins at the 
level of the cricoid cartilage of the larynx (= the lower border of the 
sixth cervical vertebra), and extends to the stomach, at about the 
height of the base of the xiphoid process. At first it lies immediately 
in front of the vertebrae, then it comes a little forward, and, at about 
the seventh dorsal vertebra, it bends a little to the right, then again to 
the left, to reach the oesophageal opening in the diaphragm. In 
adults, the oesophagus is about twenty-five cm. long. When we 
employ an oesophageal sound, we estimate the distance from the incisor 
teeth to the stomach at about seventeen cm., in the newly born, while 
with adults it is about forty cm. In the latter, the distance from the 
incisor teeth to the bifurcation of the trachea is about twenty-two cm. 
The oesophagus does not have the same diameter throughout: its 
narrowest points are at the commencement, and the point where it 
perforates the diaphragm. The neighboring organs with which it has 292 
SPECIAL DIAGNOSIS. 
important relations in different diseases are : the trachea for the upper 
seven to eight cm. of the oesophagus, the bronchial glands, the pleura, 
the pericardium, the aorta from the bifurcation of the trachea down- 
ward, lastly, the recurrent nerve from the bifurcation upward. It is 
only in the neck that the oesophagus can be felt from without. Below 
the neck, we cannot employ the usual methods of examination. 
Characteristic difficulties almost always occur with certain diseases 
of this organ, namely, with those conditions which result in stenosis 
(stricture): there are more or less deeply-seated difficulties in swal- 
lowing ; the patient, after taking food, has a feeling of pressure, 
or even of pain, in the neck or the chest—a feeling that what has 
been taken cannot be passed down. According to the place or degree 
of the stenosis, the patient experiences difficulty only after taking 
large, slightly comminuted bites of food, or even after swallowing soup 
or fluids, either immediately after the former or only after many bites 
or swallows. Moreover, the food may be regurgitated, wholly or in 
part, some time after it has been taken. Then we distinguish it from 
vomiting by the absence of odor, of acid reaction, and of muriatic 
acid. Pain in swallowing, without stenosis, occurs with inflammation 
of the mucous membrane of the oesophagus or in its near neighbor- 
hood (mediastinum). 
Examination of the oesophagus is almost confined to direct palpa- 
tion from within by means of the sound, excepting that, in the cervical 
portion, we can employ inspection and palpation from without. 
Auscultation furnishes little, percussion no, aid. But it is very 
important in many cases to examine the neighborhood, particularly 
the thorax. 
Only in exceptional cases do inspection and palpation of the cervical 
portion yield any result, because the great majority of diseases of the 
oesophagus are located quite below the bifurcation of the trachea. We 
can feel a carcinoma of the cervical portion (likewise swelling of the 
glands of the neck); we can feel, and often also see, pulsating 
diverticula when they are full—that is, after the patient has eaten. 
Carcinoma of the lower end of the oesophagus can be felt from the 
abdomen, if the cardiac end of the stomach is encroached upon. Pain 
from pressure in the neck occurs in the conditions above named and 
in inflammations, as after swallowing acids and alkalies. EXAMINATION OF THE DIGESTIVE APPARATUS. 
293 
Direct Palpation ; Examination with the Sound.—For 
diagnostic sounding of the oesophagus we employ either a whalebone 
or English oesophageal sound. The former consists of a thin staff 
with an olive-shaped ivory knob screwed upon one end. We have 
knobs of different sizes, in order to determine and measure the degree 
of the stenosis (see below). Before using, we are to make certain that 
the bulb is secure upon the staff, and also that the staff is perfectly 
smooth, so as not to catch anywhere and thus mislead us. This sound 
furnishes the most positive information, and yet it requires the greatest 
dexterity and caution in using it. The English oesophageal sound is 
a cylindrical India-rubber tube, tolerably stiff when cold, with its end 
slightly smaller and closed, but having two openings at the side. 
Before using, it must be somewhat softened by dipping it in warm 
water. We must have at hand several such sounds of different sizes. 
The end should always be rounded and perfectly smooth, so as not to 
produce a rupture. 
Before introducing it, we are to moisten only the knob of the 
whalebone sound, but the whole of the English sound with glycerin 
or white-of-egg (not with olive oil, nor with water). The patient sits 
upon a chair or the edge of the bed with the chin somewhat elevated. 
The index and middle fingers of the left hand are introduced into the 
mouth, and with them we slowly feel as far as the root of the tongue. 
Then we seize the sound with the right hand, like a pen-holder, and 
slowly push it along the tongue under the two fingers. As soon as it 
passes beyond the ends of the fingers, we press its end somewhat 
downward with the tip of the fingers, and at the same time elevate 
the right hand, so that the sound may not strike against the back of 
the throat. The sound is then with gentle pressure pushed on, 
always holding it as if writing. The left hand is now withdrawn. 
Special precautionary measures, such as placing a cork between the 
teeth, or anything to hold the jaw, are usually not necessary, since this 
operation is not performed upon unwilling or unconscious patients 
(see Sounding the Stomach). Only with children are we sometimes 
obliged to use the cork. Many patients bear a skilfully-performed 
sounding very well, but others can only become accustomed to it 
from considering its beneficial results. If the motions of strangling 
are not severe, we need not be disturbed by them, but if there is 
vomiting we must at once withdraw the sound in order that there may 294 
SPECIAL DTA GNOSIS. 
be no swallowing. A slight spasm of the glottis and momentary 
arrest of breathing have no significance, yet attention is called to the 
second paragraph below. 
We sometimes meet with a resistance which is not pathological: 
1. At the posterior wall of the throat, but only with unskilful intro- 
duction of the sound (see above). 2. Sometimes, if the cricoid cartilage 
of the larynx overlaps the oesophagus somewhat, from the point of the 
sound striking against it; this is easily passed by withdrawing it a 
little, and then pushing it on again. 3. By spasm of the oesophagus, 
caused by the sound, which disappears soon by waiting. 
Two occurrences may endanger the life of a patient: 1. The intro- 
duction of the sound into the trachea, which very rarely happens. At 
any rate, as soon as there is marked difficulty in breathing the sound 
is to be withdrawn. If the patient is able to pronounce “a” clearly, 
moreover, if the portion of the sound introduced is longer than the 
trachea, then we know that it has not entered the trachea. Other 
signs are deceptive. 2. A still greater danger is that the wall of the 
oesophagus may be injured or ruptured. This results from nai-rowing 
of the canal, if it has become thin and fragile from a crumbling new 
formation, or by an ulceration, or when an abscess or aneurism near 
the oesophagus is thus perforated. The results of these are either 
ichorous mediastinus or pleurisy with fatal termination, or if an aneu- 
rism, with immediately fatal hemorrhage. We must never employ 
force if the sound meets with resistance. If we can confirm the 
suspicion of an aneurism by examining the chest, we are always to 
omit using the sound. 
Examination with the sound gives information in the following ways: 
1. Sometimes a deep-seated pain occurs after the examination has 
been made several times, although the sound has only been introduced 
a certain distance. It may depend upon inflammation in that neighbor- 
hood (for determining its height, see under “ Stenosis ”), upon an ulcer, 
a carcinoma not causing stenosis, a purulent oesophagitis, or perioeso- 
phagitis. 
2. The sound meets with resistance. Then the patient, in many 
cases, is sensible of pressure, or has a sensation of pain; sometimes 
there is severe strangulation. We move the sound back and forth, and 
endeavor to advance it with very slight pressure. We mount a smaller 
knob upon the whalebone sound, or take a thinner rubber one. But EXAMINATION OF THE DIGESTIVE APPARATUS. 
295 
the smaller the sound the greater the danger, and hence greater caution 
is required in using it. 
If we are at length able to advance it further, then we feel resist- 
ance just so long as the knob is in the stenosed portion. After passing 
the narrowed part, it again passes easily, but, of course, meets with 
resistance at the same point as it is withdrawn. 
We obtain information regarding the situation of a stricture, by 
bearing in mind the rules given when referring to the anatomy of the 
parts. We introduce the sound as far as the stenosis, note the loca- 
tion, starting from the incisor teeth (by seizing the sound accurately 
with the fingers), draw it out and measure it. 
Regarding the degree and length of the stenosis: we learn the former 
by the thickness of the sound that will just pass the stricture; the 
length of the stricture will best be ascertained by employing whale- 
bone sounds, in that we can mark the place where the incisor teeth 
touch the sound when it enters the stenosis, and as it passes through 
the stenosis. Also, if there is a double stenosis, it is indicated (see 
Fig. 83). 
We can learn almost nothing regarding the nature of the stenosis, 
unless we should catch in the fenestrum of an India-rubber sound a 
shred of tissue which would enable us to diagnose a carcinoma, or 
unless we should meet with the condition described in the next sec- 
tion (3). 
Fig. 83. 
Diagrammatic representation of sounding the oesophagus when there is a short, 
long, and a double stenosis. 
3. By repeated introductions of the sound, we are sometimes able 
to pass it through, but if again we meet with an insuperable obstruc- 
tion we must be very careful: this points to a diverticulum, though 296 
SPECIAL DIAGNOSIS. 
not indeed with absolute certainty, since it may be met with in other 
kinds of stenosis. 
4. In a case of stenosis which we have repeatedly examined, we 
suddenly find ourselves unable to get the smallest sound through, 
where it has frequently passed easily. This 
may indicate an obstruction by a foreign body, 
as was the case in one instance under my 
observation, which ended fatally, where a 
cherry stone was found in the stenosis. 
5. The end of the sound may meet with 
opposition upon one side and not upon the 
other. This indicates a dilatation of the 
oesophagus (generally above the stenosis). 
Stenosis may be caused by scars resulting 
from swallowing a corrosive fluid some time 
before (Anamnesis), or by carcinoma of the 
oesophagus, or by diverticula (see above under 
3); these are generally high up in the oesoph- 
agus; or by compression of the oesoph- 
agus. Congenital stenosis (difficulty in 
swallowing from birth), and stenosis caused 
by thrush, are both very rare. 
Examination of the neighborhood of the oesophagus, that is of the 
neck and thorax, is of the greatest importance. We are thus able to 
discover compressing tumors, or to exclude them with probability. 
We may aid the diagnosis by giving attention to the larynx, and 
observing whether there is a recurrent paralysis, which may exist even 
though the voice be quite clear. Compression of the recurrent nerve 
sometimes occurs in carcinoma of the oesophagus, with aneurism of the 
aorta (particularly the left nerve). Moreover, we take into considera- 
tion the examination of the chest, especially whenever there is any 
evidence of a rupture, as in pleuritis, gangrene of the lungs, rupture 
into the trachea or bronchus, with coughing up of particles of food; 
pericarditis, and emphysema of the skin (see). 
Percussion of the oesophagus itself can be of almost no aid. Large 
diverticula in the neck may show dulness, provided they are full. 
Exceptionally, a dilatation above a stenosis in the thoracic portion may, 
if full, also produce dulness. 
Fig. 84. 
a. Sounding the oesopha- 
gus when the diverticulum 
is full; b. sounding when 
the diverticulum is empty. EXAMINATION OF THE DIGESTIVE APPARATUS. 
297 
Auscultation of the oesophagus is of very subordinate value. It 
can be employed as far as to the seventh thoracic vertebra at the left 
of the spine, in examining the lower part of the oesophagus; or we 
may .listen over the spine or to the right of it. In health, when fluids 
are being swallowed, we can hear a gurgling in the whole extent of 
the oesophagus. When there is stenosis, we sometimes notice that the 
gurgling ceases just at that point. The sounds of swallowing which 
we hear at the stomach are less certain signs than this phenomenon; 
in health, there is sometimes heard a sound six or seven seconds after 
an act of swallowing, as of something being pressed through, and some- 
times preceding this is a sound of squirting (Kronecker and Meltzer, 
B. Friinkel). 
(Esophagoscopy (illuminating the oesophagus with an electric light) 
has not yet attained a position as a recognized method of examination. 
Examination of the Stomach. 
Topography of the abdomen. This is represented in the accom- 
panying figure. We form the different sections by prolonging the mam- 
millary lines (or a line which passes from the middle of Poupart’s 
ligament upon each side); also by lines which, in the upright position, 
are drawn through the ends of the eleventh ribs, and through the 
anterior superior spines of the ilei. By these latter lines, the section 
lying between the mammillary lines is divided into the epigastrium, 
mesogastrium, and hypogastrium. It is further to be added that the 
region, directly over Poupart’s ligament, which extends inward toward 
the symphysis pubis, and outward somewhat over the middle of the 
ligament, is called the inguinal region, and the territory below the 
ends of the ribs, the hypochondrium. So far as the abdominal 
contents are parietal, their relations to the separate regions of the 
abdomen are plainly indicated in the accompanying figure. 
ANATOMY OF THE STOMACH. 
Only a little more than the pyloric portion [one-sixth] of the 
stomach lies in the right half of the body, the rest [five-sixths] being 
on the left of the median line. It slopes obliquely from the left 
downward toward the right, so that the cardia is about behind the 298 
SPECIA L DIA GNOSIS. 
sternal insertion of the seventh rib, the pylorus between the right 
sternal and parasternal lines, on a level with the apex of the xiphoid 
cartilage. The fundus—the portion situated the highest, clinging to 
the left side of the dome of the diaphragm—rises as high as the fourth 
Fig. 85. 
Right mammillary line. 
■Left mammillary line. 
Position of the abdominal contents. 
CA. Ascending colon. CD. Descending colon. RJ-C. Ileocecal region. RJ. Inguinal 
region. RHs. Left hypochondrium. EE. Epigastrium. RTJ. Umbilical region. H. 
Hypogastrium. 
intercostal space. The lesser curvature forms a bow with its con- 
vexity arranged obliquely downward toward the left. It, with the 
cardia and pylorus, which it connects, lies more posteriorly, covered 
by the liver, while the greater curvature extends forward toward the 
abdominal wall; so that a line drawn from the lowest point of the EXAMINATION OF THE DIGESTIVE APPARATUS. 
299 
lesser, to the lowest point of the greater, curvature would incline 
forward and downward. The situation of the greater curvature varies 
very much with the degree of distention of the stomach. In health, 
it only very exceptionally extends to the umbilicus. 
The fundus of the stomach is adjacent to the diaphragm, the spleen, 
and the left kidney; its greater curvature, and also the lower part of 
its posterior surface, to the transverse colon; the pylorus, lesser 
curvature, and that portion of its anterior surface which is near to 
these, to the left lobe of the liver. Behind and above the stomach, 
situated at the upper part of its posterior surface, is the sinus of the 
peritoneal cavity, the bursa omentalis (pathologically not unimportant), 
and also the pancreas. 
When the stomach is moderately distended, a part of the anterior 
surface, and the greater curvature, are parietal, so far as they are not 
prevented by the lung or heart from above, or by the spleen on the 
left, and by the left lobe of the liver on the right. That part of the 
parietal surface of the stomach which is covered by the left lower 
portion of the ribs comprises the important region to which Traube 
gave the name of “ halfmoon-shaped space.” We see from this 
description that, with moderate distention, only a small part of the 
healthy stomach can be directly examined. The most important 
parts, the cardia and pylorus, are bent deeply in. But we have a 
favorable moment for examining the latter in certain pathological 
conditions, where it is desirable to be able to judge of it, it being often 
pushed down with the lesser curvature below the liver. 
INSPECTION AND PALPATION OF THE STOMACH. 
There is scarcely any place where inspection and palpation are so 
closely connected as at the abdomen, and especially the stomach. The 
patient is placed so as to lie comfortably, with the upper portion of 
the body moderately raised. We look at the region of the stomach 
with the greatest care, illuminating it from all possible directions ; 
then palpate with the tips of the first, second, and third fingers, 
and thus notice first the tenderness (always at first proceeding very 
cautiously), then the objective condition, finally completing the palpa- 
tion with inspection, or vice verm. 
The result of the two methods of examination will be affected by 300 
SPEC I A L DIA G NOS IS. 
several factors—by the size, sharpness of the boundaries, and density 
(resistance) which we discover in the abdominal wall, and its condition. 
As regards the latter, it is important for the examiner to avoid 
causing contraction of the abdominal muscles, by having the patient 
in the recumbent posture, cautioning him to keep the muscles lax, 
and by proceeding slowly with the palpation, the hands being warmed. 
Contraction of the recti abdominis, with their short tumor-like sec- 
tions of muscle, may very much disturb, or even deceive, one in 
making an examination. As to the general thickness of the abdominal 
walls in chronic diseases of the stomach, especially if very severe, this 
is very much lessened by wasting—a condition favorable for making 
an examination. 
The normal stomach cannot at all distinctly be recognized or 
defined through the abdominal wall. It can only exceptionally be 
done when there is extreme emaciation. 
I remember two cases wffiere, in extremely wasted females with 
very lax walls, the greater curvature and peristalsis of the anterior 
wall of the stomach could be clearly seen. In both cases the stomach 
was very slightly distended, and in both cases the autopsy showed a 
normal condition of the stomach. 
On the other hand, the healthy stomach, distended with food or 
gas, sometimes enables us to imagine its condition by the projection 
in the epigastrium, and still more by a high halfmoon-shaped space— 
that is, by tympanitic resonance over the left lower lobe of the lung 
in the side (see under Percussion). We can sharply bound a healthy 
stomach only in individual cases when it is inflated with gas (see 
method of procedure, p. 301). Thus, it has been found that the 
greater curvature of a normal stomach, when very greatly distended, 
may reach as far as the umbilicus. Of course, wre cannot ascertain 
the location of the lesser curvature. Moreover, the distensibility of 
the healthy stomach varies very much with different persons, so that 
on trial one person earlier, and another later, has difficulty, especially 
oppression, which marks the limit of distention. 
The chief pathological signs furnished by the stomach are, its dis- 
tention or displacement, its thickness, and amount of peristaltic action 
of its walls, also signs of circumscribed tumors in its walls. Other 
important signs are to be added to those already mentioned. Pain 
upon pressure during palpation requires a special description. EXAMINATION OF THE DIGESTIVE APPARATUS. 
301 
Distention is more or less distinctly made out by inspection and 
palpation, according to its extent and the thinness of the abdominal 
walls. But it may also entirely elude examination. In favorable 
cases, we can see and feel (easily when looking down from the patient’s 
head) the greater curvature. To a varying extent it moves down, 
often below the umbilicus, more rarely nearly to the symphysis, and 
in so doing it shows the bend toward the left. The position of the 
greater curvature, of course, varies with the degree of fulness of the 
stomach, but usually, unless artificially emptied, as by emesis or the 
stomach-pump, it does not come up above the umbilicus. Thus, the 
pyloric portion behaves peculiarly, in that it influences the situation 
of the stomach and renders the pylorus, as well as the lesser curva- 
ture accessible for examination. When the stomach is, for the time 
being, distended by a large quantity of food, in the upright position 
of the patient, it pulls the pylorus forward from under the liver, and 
with it, under some circumstances, the lesser curvature. This, in 
rare cases, is seen in the upper epigastrium, in a line' convex down- 
ward (when the light falls from the foot of the bed), when it may even 
be felt. Also the portio pylorica, and the pylorus itself, may be felt 
(see under Tumors). In consequence of this displacement of the 
pylorus, the whole stomach slopes more strongly downward toward 
the right. * 
In rare cases, the pylorus stands as low down, without there being 
any dilatation of the stomach. The condition is congenital, or caused 
by strong adhesions (Kussmaul). 
As has already been mentioned, tbe distinctness with which the 
figure of the stomach can be made out is largely influenced by the 
extent of its fulness. Hence, for the purpose of making the examina- 
tion, we must artificially distend it (Frerichs). Until very recently, 
this was always done with carbonic acid, by giving the patient as 
much as two teaspoonfuls of tartaric acid and bicarbonate of soda dis- 
solved in a little water. The gas quickly develops in the stomach, 
and demonstrates clearly the situation and size of the organ, rendering 
the examination of its walls easy (see under Peristalsis and Hyper- 
trophy). But this procedure sometimes gives rise to a feeling of 
oppression, and even of symptoms of collapse; and recently there has 
been devised a method of inflating the stomach which is much more 
to be recommended, because the amount of gas for distending the 302 
SPEC I A L DIA G NOS IS. 
stomach can be regulated exactly, and, if necessary, it can be emptied 
out in an instant. A Nelaton stomach-sound is introduced (just as in 
sounding the oesophagus), and then the stomach is inflated with air 
through the sound by means of an India-rubber ball, introducing as 
much as is necessary, or as the patient can bear. At any time the 
air can immediately be let out through the sound. 
By inflating the stomach, Eichhorst has several times easily recog- 
nized the so-called hour-glass stomach (twice it was formed by a scar 
which strictured it in the middle). In the same way, we can discover 
that the pylorus does not close, by the fact that the gas blown in does 
not distend the stomach, but immediately enters the small intestine. 
Ziemssen still gives the preference to distention with carbonic acid. 
In his last communication he gives the proportions for adult men as 
seven grammes of bicarbonate of soda and six grammes of tartaric 
acid, for adult women, one gramme less of each. 
The sound may be employed in the same way as with the oesophagus 
to determine stenosis at the cardia, due to cancer. (The employment 
of an English oesophageal sound for ascertaining the size of the 
stomach [Leube] requires the greatest caution. The sound is intro- 
duced into the stomach and pushed on until it meets resistance at the 
greater curvature, and then we ascertain where the end of the sound 
is by palpation from without.) 
Regarding palpation by striking and the resulting splashing, see 
under Auscultation. In the neighborhood of the stomach we may 
have epigastric pulsation (see p. 204), liver-pulse (see p. 206), lastly 
it may be communicated from the aorta or from aneurism of the 
abdominal aorta. With tumors of the stomach, the pulsation from the 
aorta is usually very distinctly transmitted. 
Increased resistance; peristaltic motions. The former occurs 
simultaneously with the general distention of the stomach in conse- 
quence of the hypertrophy of the muscular portion, which generally 
accompanies dilatation of the stomach. Hence, it is an indirect sign 
of dilatation. 
If it is found within a limited area, as in the right half of the epi- 
gastrium, even if it is not sharply defined, it may indicate carcinoma. 
We must be careful not to confound it with contraction of one of the 
bellies of the rectus abdominis. Peristaltic motions which can be 
felt as well as seen are very important, being often the first signs of EXAMINATION OF THE DIGESTIVE APPARATUS. 
303 
a hypertrophy, and, thus, a dilatation. By their situation and extent, 
they may also indicate the size of the stomach. It is very rare for 
them to occur without dilatation—in nervous “ peristaltic unrest ” of 
the stomach (Kussmaul). Generally it extends in the normal direc- 
tion from the fundus to the pyloric region. But sometimes it is 
reversed (marked pyloric stenosis, Kussmaul)—antiperistalsis. It will 
often he excited or increased by gentle strokes, and by faradization; 
sometimes by irritation of the skin, as by simply uncovering it. With 
very lean persons, we must think of the possibility of it being, under 
some conditions, intestinal peristalsis. 
Tumors in the region of the stomach are often only to be felt, 
not seen. They cannot be demonstrated if connected with a 
part of the stomach that is not parietal: cardia, lesser curvature, 
posterior wall of the stomach, commencing cancer of the pylorus. 
These tumors are most frequently cancer of the stomach (more rarely 
a dense scar from ulcer), and are most often located to the right of 
the middle line, because they belong to the portio pylorica or to the 
pylorus itself. In the latter case, they can generally only be felt 
when the pylorus is pushed downward, as has already been mentioned. 
Carcinoma usually feels uneven and dense. Less frequently it is 
smooth, and can then easily be overlooked, or be mistaken for a belly 
of the rectus (see above, under Resistance). Projection of the stomach 
during deep breathing, as a result of the movements of the diaphragm, 
usually does not take place at all, for the reason that the stomach is 
not a solid body. We observe a slight, or possibly a marked, respira- 
tory displacement when there is adhesion of the distended pylorus and 
the liver (see), or if there is a tumor which extends from the sub- 
phrenic region to a parietal portion of the stomach. Dense scars 
from ulcers and the infrequent hypertrophy of the pylorus, also solid 
bodies that have been swallowed, may feel like tumors. Mistaking 
them for scybala in the transverse colon (see Intestine) is not likely 
to happen. 
In all diseases of the stomach, pain upon pressure during palpation 
may be wanting. It is absent least frequently with ulcer of the 
stomach. If there is pain, it may vary very much: in acute catarrh 
of the stomach, also sometimes in chronic, it is dull and quite diffuse; 
with ulcer, it is often very much circumscribed, limited to a spot the 
size of a dime, extremely severe, often shooting through to the back 304 
SPEC!A L DIA GNOSIS. 
(especially toward the left); in carcinoma, there is sometimes a marked 
insensibility, sometimes a more diffuse, sometimes a narrowly-defined, 
pain of various intensity. 
PERCUSSION OF THE STOMACH. 
This applies to that portion of the anterior wall of the stomach 
which lies against the abdomen and the anterior (left lower) wall of 
the thorax. It yields, in much the greater majority of cases, a very 
deep tympanitic sound; and sometimes, when there is marked tension 
Fig. 86. 
Percussion boundary of the lungs in front. (Weil.) g,h, the upper boundary of the 
lungs; e,f, the lower boundary of the lungs; b, d, boundary between the lung and 
heart at the incisura cardiaca. The dark hatched surface represents the portions of the 
heart and liver that are in contact with the chest-wall; the light hatching, the so-called 
relative heart- and liver deadness (see later), m, spleen-deadness; n, the average 
position of the lower boundary of the stomach. 
of the stomach, a clear non-tympanitic sound. If the stomach con- 
tains a considerable amount of food it may, in part (especially in 
standing), have an absolutely dull sound. But we hardly ever find it 
dull throughout the whole extent of that portion of the stomach that EXAMINATION OF THE DIGESTIVE APPARATUS. 
305 
is parietal, because it almost always contains considerable gas as well 
as food. The tympanitic, as well as the non-tympanitic, stomach- 
sound frequently has a metallic quality. 
The boundaries of the stomach are determined by topographical 
percussion (see Fig. 86). 
On the side toward the liver, there is a dull sound; it is often 
difficult to make out, because the border of the liver is thin (see Per- 
cussion of the Liver). On the side toward the lung, there is a non- 
tympanitic, clear sound. Here it is often difficult to mark sharply the 
boundary line, on account of the thinness of the border of the lung and 
the similarity of the two sounds. 
Sometimes we can determine a boundary toward the heart, should 
its apex reach further toward the left than the liver; sometimes 
toward the spleen, if the stomach should be stretched out somewhat. 
We can separate it from the large and small intestine, both of which 
give a tympanitic sound. 
Except these last named, the boundary lines are all dependent 
upon the situation and size of the surrounding organs. Therefore, 
and because there are no true boundary lines for the stomach, except 
its parietal boundaries, we do not employ percussion for the stomach. 
The only real boundary is that on the side toward the intestine, which 
gives the situation of the greater curvature. 
But it is almost always very difficult to determine this line (there 
being a tympanitic sound on both sides of it, with only a difference in 
pitch). We can hardly even maintain its correctness without the aid 
of inspection and palpation. Thus, percussion of the stomach, for the 
great majority of cases, has an extremely doubtful value. 
On the whole, we get the best results from percussion in health, and 
particularly when the stomach has been artificially dilated. With the 
former, we then find that the greater curvature usually is somewhat above 
the umbilicus, sometimes reaching to it. When the stomach is moder- 
ately full, it commonly stands about midway between the apex of the 
xiphoid process and the umbilicus. If the stomach is dilated, the 
boundary is lower down (see Inspection, Palpation). Likewise, should 
the lesser curvature be lower down, it can be made out by the aid of 
percussion. 
Another procedure, but one which is not always successful, is first 
to empty the stomach as much as possible (see Emesis), then to percuss 306 
SPECIAL DIAGNOSIS. 
the abdomen, the patient being in the standing position. Usually we 
do not find any boundary for the stomach. Then we have the patient 
drink freely, and again percuss while he is standing. In the lower 
part of the stomach, hence above the greater curvature, about in the 
middle line, we shall find a dulness which indicates the situation of the 
greater curvature, and thus a possible dilatation may be recognized 
(modified after Penzoldt). This dulness may sometimes be directly 
proved, without any preliminary procedure, if the stomach is partly 
filled with fluid. The dulness disappears when the patient lies down. 
There is distinct dulness with tumors of the abdomen (strong per- 
cussion) only when they are very thick, and this is not often the case. 
Hence they usually give stomach-resonance. But tumors of the liver 
and spleen, on the other hand, almost always are dull because they are 
larger. Yet this difference is not an entirely sure sign. 
Rod-pleximeter-percussion (see p. 136) over the stomach usually 
gives a beautiful silver tone. It is employed for determining the 
boundary, under the supposition that in this way the person who is 
listening over the stomach must hear the high silver tone just so long 
as his assistant percusses over the stomach ; but the result of this pro- 
cedure is hardly ever positive enough to give it value. 
That part of the left lower lobe of the lung is designated as the 
“ circular stomach-lung space,” where a tympanitic sound may be 
heard with strong percussion (Ferber). We may likewise speak of a 
“circular stomach-liver space,” sometimes even of a “stomach-heart 
space ” (see page 206). None of these have any value for determining 
the size of the stomach. 
The Half-moon-shaped Space (Traube).—It is that portion of 
the lower left part of the thorax which lies below the lung (or heart) 
between the liver and spleen, and, as a rule, in health gives a tympa- 
nitic sound, most frequently a stomach sound, but not infrequently 
also an intestinal sound, or both. It is discovered by gentle per- 
cussion. Occasionally, in health, we here find dulness instead of 
tympanites, and then only when the stomach is decidedly full, or when 
the full transverse colon is here parietal, or when the greater omentum 
is unusually loaded with fat (Weil). 
In enlargement of the liver, of the left heart, and of the spleen, 
this space will always be found correspondingly smaller. But its 
behavior in certain conditions of the left lung, or of the left pleura, is EXAMINATION OF THE DIGESTIVE APPARATUS. 
307 
of especial diagnostic interest. Exudation in the left pleura usually 
causes dulness correspondingly early in the upper portion of this space, 
in that it first collects in the complementary pleural sinus. As the 
exudation increases, the half-moon-shaped space diminishes more 
and more, the dulness sometimes extending as far as the bend of 
the ribs, depending upon the amount of downward pressure of the 
diaphragm (unless there are pleuritic adhesions in the pleural sinus, in 
which case we do not have the space diminished). As the pleuritic 
exudation is absorbed, the space resumes its normal proportions, and 
if there is shrinking after the absorption, it becomes greater than 
normal, for the reason that the lower border of the lungs does not 
again come dowTn to it3 former place, and, on the other hand, the 
diaphragm stands higher. Rarely, with pneumonia of the whole left 
lung, or its lower lobe, the half-moon-shaped space becomes very slightly 
smaller, as a result of the enlargement of the lung during hepatization, 
and also, probably, from a small pleuritic exudation. 
It is to be observed that in an acute disease of the left half of the 
chest, an early distinct diminution of the half-moon-shaped space is 
made manifest by a certain degree of dulness; a marked diminution of 
the space indicates very plainly a pleuritic exudation; and if there is 
extensive dulness in the left half of the chest, if the differential diag- 
nosis between pneumonia and pleurisy is uncertain (see p. 158), then 
a decided diminution in the size of the space speaks with strong 
emphasis in favor of the latter. 
AUSCULTATION OF THE STOMACH. 
This has value in only one direction, but that is not to be under- 
valued. When palpation is made by strokes upon the region of the 
stomach, striking more or less strongly, according to the sensibility of 
the patient, very short blows with the tips of the fingers, we some- 
times hear a splashing which is loud enough to be heard at a distance. 
This results from a certain relation between the fluid and the gas in 
the stomach even in health, but very much more frequently in dilata- 
tion. Hence, in making a careful examination of the stomach, wc 
must always employ it. In itself it does not indicate anything, even 
though it is often found when the examination is frequently repeated. 
If we apply the ear when the stomach is inflated with carbonic acid 308 
SPECIAL DIAGNOSIS. 
we shall hear a loud seething. We can recognize the same thing, but 
less distinctly, in dilatation of the stomach with fermentation of its 
contents. 
It is evident from the above that very often anatomical diseases of 
the stomach exist without any physical signs. This is almost always 
the case in the different forms of nervous dyspepsia, which are accom- 
panied with marked subjective symptoms. Hence, in most cases of 
affection of the stomach, the examination of its contents gives much 
more important conclusions than the local examination. Therefore, 
especial attention is called to the former. 
Examination of the Intestines 
INSPECTION AND PALPATION. 
In employing the former, there must of course be illumination. 
The patient being in the dorsal position, we inspect the trunk as a 
whole, from a distance; in detail, close at hand, palpating with a warm 
hand. Then, carefully grasping a part, we notice always first as to 
the amount of tenderness, when, if there is any suspicion of simula- 
tion or exaggeration, it is best not to ask whether we are causing pain, 
but simply to notice the result of a moderate and also stronger pres- 
sure. After completing the first examination, which gives one the 
bearings of the case, inspection and palpation go very closely, hand 
in hand, together; for this reason, we speak of them together. 
Pain produced by pressure [Tenderness]. A diffuse dull pain often 
occurs with intestinal catarrh. A like diffuse, but generally an extremely 
severe, pain is observed with acute general peritonitis. Circumscribed 
tenderness is especially frequent in the right iliac fossa. It is often 
quite marked in abdominal typhus [typhoid fever], often more severe 
in intestinal tuberculosis, moderately severe in typhlitis and affections of 
the vermiform appendix, in both the last-named diseases generally (not 
always), in connection with other local signs (which see). Pain in 
the left iliac fossa is connected with the descending colon (especially 
dysentery). Very circumscribed severe pain shifting about, may 
occur with a circumscribed affection of the small intestine, as invaod- 
nation (see Palpation, Intestinal Tuberculosis). In many cases ruptures EXAMINATION OF THE DIGESTIVE APPARATUS. 
309 
require very especial attention. (Works upon surgery are to be con- 
sulted regarding these). It is to be further remarked that pain in the 
abdomen, according to its location, may come from any of the organs 
contained in its cavity, and also from its walls; from the anterior 
abdominal wall (abscess); pain in the inguinal region, from psoas 
abscess in the iliac regions, from the sacral spines (inflammation, 
tumors). 
The general extent of the abdomen may be diminished by a layer 
of fat, by gas in the intestines (intestinal meteorism, tympanites), as 
it occurs continually, scarcely pathologically, after hearty eating, often 
wdth a large development of fat; but we may also have it in every 
variety of degree as a pathological condition: in acute• and chronic 
catarrh of the intestine, intestinal stenosis, in acute and chronic perito- 
nitis, and in abdominal typhus [typhoid fever], where it is often of 
diagnostic value. According to the amount of distention, the abdomen 
is more or less full, which changes its normal soft condition to one of 
marked resistance. When there is marked meteorism, the liver and 
diaphragm are pressed upon, and by the latter the lungs and heart 
are pressed upward. 
In a case of typhus abdominalis [typhoid fever] I once saw an ex- 
tensive inflammatory undermining of the abdominal wall, which very 
closely simulated meteorism by considerably distending the abdomen, 
which proved to be an abscess in the abdominal muscle. For distention 
of the abdomen with fluid and air in the peritoneal sac, see Peritoneum. 
There may be circumscribed distention of the abdomen from a great 
variety of causes: most frequently from some condition in the peri- 
toneum (which see, and also the next page under Tumors). 
Diminished volume of the abdomen (drawing-in, sinking-in) results 
from an insufficient amount of nourishment from any cause (especially 
from diseases of the oesophagus, pyloric stenosis, any cachexia—in 
short, from any disease that requires, or results, in restricted diet. 
Usually this condition is more especially manifested by the absence of 
fat and wasting of the abdominal muscles. A particularly marked 
—the so-called “scaphoid”—drawing-in, probably related to an active 
contraction of the abdominal muscles, occurs in meningitis, particularly 
basilar, and in lead-colic. 
Intestinal peristalsis exceptionally can be seen when the abdominal 
wall is very thin and lax. It occurs almost exclusively in women 310 
SPECIAL DIAGNOSIS. 
who have had children (particularly if there is a separation of the 
recti muscles). It is to be distinguished from its similarity to what is 
described as pathological peristalsis only by the absence of other 
phenomena, and by the narrowness of the intestinal figure. 
Peristalsis that is pathological is an important visible and palpable 
sign of stenosis of the intestine, and occurs in the portion of intestine 
above the stenosis. We observe a round projection, with the slow 
motions of a worm, now disappearing and often immediately reappearing 
in a spot not far distant, so that we have the phenomenon of peristalsis. 
The intestine, as it becomes prominent, is moderately resistant, and 
is often distinctly distended. [During the instant of greatest disten- 
tion the prominence is more distinctly tympanitic.] The resistance may 
become greater in chronic stenosis of the intestine with hypertrophy. 
Sometimes the last swelling—that is, the one just above the point of 
stenosis—is the largest, and subsides with a loud cooing or bursting 
sound. This phenomenon may have a very great variety of manifes- 
tations, generally with a pressing, choking pain, and it may manifest 
itself under gentle blows, with faradization, or even by merely ex- 
posing the surface to the air. It is usually very difficult to draw 
any conclusion regarding the portion of the intestine involved by the 
location of the phenomenon or the direction of the peristalsis. On 
account of its thickness, we are apt to mistake a dilated loop of small 
intestine for a portion of the colon. 
Circumscribed tumors of the intestine are always felt before they 
can be seen. They may be : 1. Balls of feces, scybala, in the large 
intestine, often recognized by being arranged in a circular form, by 
their location (which is often deceptive), or by their retaining an 
indentation. Sometimes we are only able to be positive regarding 
their nature by their disappearance after free purgation. 2. Tumors 
of the intestine are either new formations, which are generally very 
firm, uneven, or, from invagination of one portion of the small 
intestine into another or into the large intestine, which are round 
vermiform tumors. The former are entirely fixed, the latter 
may suddenly disappear. Both may be connected with signs of 
stenosis of the intestine. If they belong to the small intestine, they 
usually more or less change their location. (For distinguishing these 
tumors from those of the other abdominal organs, of the peritoneum, 
and of the abdominal wall, see below. For inflammatory tumors of 
the intestine, perityphlitis, etc., see Peritoneum.) EXAMINATION OF THE DIGESTIVE APPARATUS. 
311 
Tumors of the rectum cannot be recognized from the abdomen (see 
for these, below). Those at the point of union between the transverse 
and the descending colon are often recognized late, because they lie 
concealed. They may easily be confounded with tumors of the spleen 
or with the kidneys (which see). In this connection we must bear in 
mind the phenomena of stenosis. (For peritoneal friction-sounds, see 
Peritoneum; for cooing-sounds that can be felt, see Auscultation of 
the Intestine.) 
Palpation of the rectum. The rectum must be examined with the 
finger if the movement of the bowels or the character of the stools 
indicate disease of this organ, or if disease in the neighborhood (as the 
wall of the true pelvis, the prostate in men, the uterus and its annexae 
in women) is suspected. In making the examination, we first obtain 
a view of the anus externally (as to varices, pedunculated new forma- 
tions, which sometimes come into view at the anus from above the 
flexure, an external rectal fistula). Sometimes it is also necessary to 
obtain a thorough emptying of the bowel beforehand. The index- 
finger is to be oiled and introduced with the patient either lying on 
the side or back. (For examining during narcosis by introducing the 
whole hand, see works upon surgery.) When the rectal sound is 
employed, in order to reach a stenosis beyond the reach of the finger, 
the greatest care is necessary. It is best to employ a sound open at 
the end, so as to throw in some lukewarm water by means of an 
irrigator, so that any obstruction to the passing of the sound may be 
gotten out of the way. Sometimes a large quantity of water is thus 
employed, as recommended by Hegar (see also the works upon surgery 
for the employment of the mirror in making the examination). 
Distending the descending colon by inflating it with air introduced 
from the anus through the sound, if carefully done, is not dangerous, 
and is very strongly recommended for determining the location of the 
colon with reference to other organs, tumors (see spleen, kidneys), the 
figure and condition of the colon itself. 
PERCUSSION OF THE INTESTINE. 
Generally the intestine gives a tympanitic sound; with meteorism with 
great tension, it may become clear non-tympanitic. Over large intes- 
tinal loops, and also over the stomach (with like tension), the sound is 312 
SPECIAL DIAGNOSIS. 
deeper than over narrow portions; over lax portions, it is deeper than 
over those under strong tension. But we can hardly ever determine 
as to the width of any portion of intestine by the resonance, chiefly 
because of the influence of tension, which, for a single loop of intestine, 
we cannot at all control. Hence, we cannot with certainty determine 
by percussion the boundary between the colon and small intestine, a 
dilatation above a stenosis from another portion, or intestine from the 
stomach. At most, we can only determine the boundary of the 
descending colon by ai’tificially inflating it. 
(For determining by percussion the boundaries of the abdominal 
organs that do not contain air, see under the different ones.) Intes- 
tinal tumors do not always become so large as to give dulness. In 
percussing them, we first press tolerably deeply with the finger used 
as pleximeter, and if we do not find dulness we press still deeper, in 
order that we may push aside any fold of intestine that may lie over 
the tumor (“deep percussion,” Weil). 
AUSCULTATION OF. THE INTESTINE. 
Borborygmi and splashings, which may often be heard at a distance, 
and are in themselves very troublesome (especially in women who 
have had children), do not have any further significance. A loud 
cooing is not without diagnostic value, if it occurs at the close of an 
attack of pain like strangulation. Even if we cannot see any intes- 
tinal peristalsis, we must remember the possibility of stenosis of the 
intestine. Although formerly too much importance was attached to 
it, yet there is some diagnostic value in the cooing, which is more fre- 
quently felt than seen in the ileo-csecal region in typhoid fever (ilio- 
caecal cooing). 
Examination of the Peritoneum 
Pathological conditions of the peritoneum are, in part, of such a 
character that they alfect the outer layers, the coverings of the other 
abdominal viscera, hence possible anomalies of the peritoneum may 
be overlooked in the direct examination. Thus, very many diseases 
of other abdominal organs are combined with those of the peritoneum. 
This fact and the anatomical interrelations of the diaphragm and 
certain other organs make it very difficult to give a separate descrip- EXAMINATION OF THE DIGESTIVE APPARATUS. 
313 
tion of its physical diagnosis. In what follows we mention what may 
be learned in peritoneal diseases by the separate methods of examina- 
tion, but we call attention to the point that the examiner ought to 
learn to give his attention to all the abdominal organs, by inspection, 
palpation, etc., at the same time. 
INSPECTION OE THE ABDOMEN. 
In diseases of the peritoneum, this may reveal distention of the 
abdomen, which may be quite considerable, and quite like intestinal 
meteorism. Meteorismus peritonei—that is, escape of air into the 
abdominal cavity from the intestine or stomach—is a very serious 
condition, which always results in peritonitis. (See below.) 
There is general, though often unequal, distention when there is 
freely-movable fluid in the peritoneal cavity: ascites. Such a fluid 
effusion collects in the most dependent part of the abdominal cavity, 
first in the true pelvis; then, as the amount increases, it rises higher, 
reaching the abdominal wall, where its level may stand at different 
heights. The abdominal organs that contain air float upon the top of 
the fluid so far as the peritoneal fold permits. In consequence of the 
increased internal pressure, the abdomen is broader, and the lower 
part contains the fluid, while the intestine, containing air, lies at the 
upper part, and is in contact with the abdominal wall. But the fluid, 
since it is freely movable, occupies always the most dependent part 
with every change of position of the body, and, if the tension of the 
abdominal wall is not too great, there often results an unequal disten- 
tion of the abdomen which varies with the position of the body. In 
the dorsal position, it is quite toward the sides ; when lying upon the 
side, it is over the inguinal and lumbar regions upon each side; 
while in the sitting posture, it fills the dependent abdominal sides, the 
upper portions being empty; and in standing, the lower part of the 
abdomen projects. If there is so large an effusion as to fill the abdo- 
men very full there is no change in the distention, and it is also more 
regular, like that we have with marked meteorism. (Regarding the 
high position of the diaphragm, when there is distention of the abdo- 
men, see Respiratory Organs and Liver.) 
If the skin is examined when there is marked effusion it will not at 
all look as it usually does: on account of the tension, it is smooth, 314 
SPECIAL DIAGNOSIS. 
shining, and shows, especially in the dependent parts, a peculiar 
bluish shimmer. When the tension is of long standing, there are 
colorless streaks or striae which are formed in the skin by the con- 
tinuous stretching, as in the scars resulting from pregnancy, so-called 
from their chief cause. The umbilicus may be obliterated or even 
project. In marked ascites, the cutaneous veins of the abdomen are 
found enlarged, since, as collateral veins, they must take up the over- 
flow of the intra-abdominal veins, which are compressed. Under some 
circumstances, there may be oedema of the legs from compression of 
the iliac veins. (Regarding the caput medusae and the abdominal 
veins in general in cirrhosis of the liver, see under Liver.) 
Ascites that moves about generally results from transudation into 
the abdominal cavity from stasis, being rarely, except in the beginning 
of a disease, dependent upon inflammatory exudations. In the former 
case, it is either a partial indication of general dropsy, and connected 
with oedema (see), or entirely the result of obstruction of the portal 
vein (cirrhosis of the liver, compression, and thrombosis of the vein). 
In the latter case it is a sign of peritonitis. (See under Palpation, 
Percussion.) 
Circumscribed distention of the abdomen, where there has been little 
or no change in posture, may be due to inflammatory fluid exudations, 
which are enclosed between adhesions of the intestine to itself or the 
abdominal wall, or by any kind of tumor in the abdominal cavity; 
and also by tumors or abscess in the abdominal wall itself. Circum- 
scribed distention, with inflammatory redness, indicates a discharge 
outward of an abscess, either fecal or some other collection of pus in 
the abdominal cavity, or of the abdominal wall. 
In diseases of the peritoneum, palpation gives very important signs : 
Pain in all inflammatory affections. It is usually very severe in 
acute peritonitis, sometimes so great that the slightest motion, or even 
the lightest covering upon the abdomen, cannot be borne. This sensi- 
bility is an important indication of peritonitis, especially in distinguish- 
ing the ordinary intestinal meteorism from the intestinal meteorism with 
peritonitis, sometimes also in distinguishing inflammatory ascites from 
dropsical ascites. Circumscribed pain may indicate a circumscribed 
peritonitis, as it occurs more particularly over tumors, abscess of the 
stomach and intestine. In chronic peritonitis, especially in tubercu- 
losis, sometimes there is entire absence of tenderness. EXAMINATION OF THE DIGESTIVE APPARATUS. 
315 
Now and then, in chronic peritonitis there is a general, more or less 
symmetrical, hardness of the abdominal wall—that is to say, it feels as 
if it were thickened. This is to be distinguished from the general 
increased resistance from tension due to marked distention of the 
abdomen from meteorism and ascites. Thus, there is a marked differ- 
ence between the resistance of fluid and that of meteorism in a fold of 
intestine. The latter has more the feeling of an air-pillow, the former 
is more like a material substance. But we recognize fluid with much 
more certainty by the feeling of fluctuation, undulation. A hand is 
laid flat upon the surface of the abdomen, and then the abdominal wall 
is tapped lightly with one or two fingers, just as in direct percussion. 
If both hands are used, fluctuation is found in a place where there 
is an accumulation of fluid, and the stroke of the wave is felt with 
every tap of the fingers. In this way the presence of even a small 
amount of fluid in the abdominal cavity can be made out with great 
certainty. When there is great effusion under high pressure this 
sign may fail. On the other hand, we may be deceived in the case of 
persons who have a large accumulation of fat in the abdomen by the 
trembling of the layers of fat, and possibly, also, by the fat in the 
abdominal cavity, in the omentum especially. 
Very much increase of resistance, and thus an indistinct fluctuation, 
generally occurs when the peritoneal fluid is encysted. Circumscribed 
hard resistance, now like a round ball and again cord-like, occurs with 
extremely great variations in chronic peritonitis, not alone of the 
tubercular variety, but also in the so-called simple peritonitis from in- 
flammatory new formations; nevertheless, the former is usually the 
much more frequent condition. Particularly often in this, although 
sometimes also in simple chronic peritonitis, we feel above the navel a 
dense transverse string: the omentum is shrunken and thickened by 
inflammatory products. Besides there are usually, but not always, 
the signs of encysted or even of free fluid in the peritoneal cavity. 
Exactly the same phenomena are present in carcinoma and sarcoma of 
the peritoneum. 
There occurs in an acute way resistance in the neighborhood of the 
caecum in typhlitis and perityphlitis. Here there is generally a cir- 
cumscribed globular, or flattened globular, tumor, usually immovable, 
which, at first at least, is extremely tender. It indicates a fixed mass 
of feces in the caecum, or an inflammatory deposit upon the serous side 316 
SPECIAL DIAGNOSIS. 
of the caecum, or both. In inflammatory cases, there remains for a 
long time, or even permanently after recovery, a dense spot (a scar from 
shrunken inflammatory new formation in the peritoneum). In inflam- 
mation of the vermiform appendix, we can seldom affirm that there is 
a tumor. 
Palpation of the peritoneum through the vagina in order to dis- 
cover whether there are tumors, exudations in Douglas’s space and 
anywhere in the neighborhood of the uterus, especially the different 
forms of peritonitis, belongs to gynecology. It is not necessary to 
measure the circumference of the abdomen for establishing a diagnosis, 
but yet it is valuable for the purpose of observing the course of an 
abdominal affection, and particularly for ascertaining the increase and 
diminution of fluid exudations. It is generally sufficient to measure 
the abdominal circumference across the navel and the lower lumbar 
vertebrae. It is better also to measure the distance between the 
xiphoid process and the symphysis pubis. 
Percussion gives valuable information regarding the peritoneum, as 
to whether there is fluid effusion in the peritoneal cavity, its location 
and nature. By percussing with some force at what we suppose to be 
the boundary line, we can easily determine the boundary between the 
dulness of fluid and the tympanitic resonance of the intestine; but 
we can never distinguish it from that of those organs that do not con- 
tain air, as the liver, spleen, etc. The superior surface of a freely- 
movable effusion is always horizontal, and hence its upper boundary 
line must correspond to a section of a horizontal plane drawn through 
the abdomen, in whatever position the patient may assume. When- 
ever the patient changes his position, immediately the effusion changes 
its relations to the abdominal cavity (see above, under Inspection). 
Hence the result of percussion changes with the position of the body : 
if the patient lies upon the right side, then the portion of the abdo- 
men Avhich is now lowest gives a deadened sound, while the upper 
boundary is horizontal; in the left half of the cavity, there is tympan- 
itic resonance; if the patient turns upon the left side, this is now dull, 
and the right is tympanitic. This is an important sign, not only that 
the fluid is movable, but often that there is fluid present. Small effu- 
sions, which rarely rise only a little above the pelvis, will hence be first 
recognized by percussing when the patient stands upright. If there 
is then dulness above the symphysis pubis, it immediately disappears EXAMINATION OF THE DIGESTIVE APPARATUS. 
317 
when the patient lies upon the back. Very large effusions may fill 
the abdomen so full that the intestines, on account of a short mesen- 
tery, cannot float, and hence cannot come in contact with the abdom- 
inal wall. Then the strongly-distended abdomen gives a dull sound 
throughout, and we sometimes notice a change of the boundary of dul- 
ness only in the position on the side, when the upper portion gives a 
clear sound. 
When the fluid moves about with difficulty, slowly and incompletely 
changing its location with the change of position of the body, and 
still more if it is entirely immovable, inflammatory exudation with 
glueing or adhesion of the intestines together and to the abdominal 
wall is indicated. If the fluid does not move it is said to be en- 
cysted. But not infrequently even inflammatory exudation, at least 
in the beginning of its effusion, is freely movable. 
Percussion may be an important aid in recognizing meteorismus 
peritonei in so far that in many cases, if adhesions have not already 
been formed before the occurrence of perforation, it gives a perfectly 
uniform tympanitic or, if the tension is great, a non-tympanitic sound 
over the whole abdomen, also over the region of the liver and spleen, 
and besides, on account of the diaphragm being arched high up, as 
far as the fifth, or even the fourth, rib. Not infrequently in this way 
we obtain Heubner’s rod-pleximeter phenomenon (see p. 112). 
Subphrenic peritonitis, pyopneumothorax subphrenicus (Leyden), 
sub phrenic abscess. We understand by this an ichorous-purulent, 
sacculated peritonitis below the diaphragm. From paralysis (partly 
also from irritation), the diaphragm is pushed very high into the 
thorax, causing a marked retraction or compression of the lung of 
that side. That half of the thorax is broadened, and by the presence 
of pus and gas in the cavity, one is apt to mistake the condition for 
pyopneumothorax. Peritonitis of this character usually begins at the 
stomach as an ulcer, or at the intestine, especially at the vermiform 
appendix and caecum. In making a differential diagnosis, we observe 
whether, in the status prcesens or in the previous development, there 
were indications of disease of the lungs or, on the other hand, of the 
abdomen, and also whether the lung of the diseased side still performs 
the motions of respiration. During puncture, it has frequently been 
found that the pressure rises during inspiration in a subphrenic cavity, 318 
SPECIAL DIAGNOSIS. 
while it falls, of course, in a pleural cavity. This can be recognized 
by the varying rapidity of discharge from the aperture made by the 
needle, or by introducing a manometer into the cavity. 
The presence of air which has escaped into the peritoneal cavity is 
shown in many cases by the clear, metallic ringing, intestinal sound in 
the upper part of the abdominal cavity, sometimes even a metallic, 
transmitted breathing sound, which it yields to auscultation. More- 
over, with the inflammatory deposits upon the reduplications of the 
peritoneum, especially over the liver and spleen, there occurs syn- 
chronously with breathing a peritoneal friction sound, exactly corre- 
sponding to the pleuritic friction sound. . It is very rarely produced 
by peristalsis over the intestines. If the friction sound is pronounced, 
it can also be felt. 
When it is advisable, as a therapeutic measure, to draw off fluid from 
the peritoneal cavity by puncture, it may be of diagnostic value in two 
ways : 
1. It is then possible to examine the organs in the abdominal cavity, 
which previously Avere concealed by the ascites. Not only does the 
fluid prevent the examination of the organs more or less completely 
covered by it, but the folds of the intestine floating upon it also do so, 
in that they crowd in between certain parts, especially the liver and 
spleen, and the anterior abdominal Avail. When the abdomen has 
been emptied, its Avail, Avhich before was tensely stretched, is very lax, 
and this renders the examination extremely easy. Hence we can 
now usually very easily discover the diseases which caused the effusion 
(cirrhosis of the liver, tumors, which press upon the portal Amin ; 
cancer of the stomach, ovarian tumor, etc.), or certain results of peri- 
tonitis (bands of scar tissue, Avhich compress the intestine, swollen 
mesentery, etc.). 
2. The fluid that has been draAvn off can be examined. It is as 
important to do this as to examine pleural fluid (Avhich see, p. 160). 
The ordinary hypodermic syringe, holding one gramme—not the 
one recommended for puncturing the pleura—is to be employed for 
puncturing the abdomen. 
Exploratory puncture, by means of a large hypodermic syringe, is 
useful in distinguishing encysted peritoneal fluid from the solid and 
fluid contents of certain tumors (see Abdominal Tumors). 
Chylous ascites has been observed in some cases of compression of EXAMINATION OF THE DIGESTIVE APPARATUS 
319 
the thoracic duct; the ascitic fluid is, to a varying extent, milk-like 
in appearance. It contains molecules of fat and a ferment that forms 
sugar. 
Examination of the Liver. 
Anatomy.—The liver, covered by the peritoneum, lies close to the 
diaphragm—within its arch—and is held in place by the suspensory 
ligament and by the intra-abdominal pressure exerted upon its lower 
Fig. 87. 
Location of the thoracic contents, of the stomach, and of the liver, from in front. 
(Weil-Luschka.) The unbroken hatched lines represent the portions of the heart and 
liver that are in contact with the thoracic wall. The portions of these organs that are 
not in parietal contact and are covered by the lungs are represented by the light hatch- 
ing. ef( ), border of the right lung ; g h { ), border of the left lung: a&,andcc£ 
(. . . .), boundary of the complementary pleural sinus; i, boundary between the upper 
and middle lobes of the right lung; k, boundary between the middle and lower lobes; 
l, boundary between the upper and lower lobes of the left lung; w, stomach (greater 
curvature). 
surface. About three-fourths of it is in the right side of the body, 
and one-fourth in the left. With reference to its superficial topog- 
raphy, a larger portion of it belongs to the right hypochondrium, 320 
SPECIAL DIAGNOSIS. 
extending into the epigastrium, and with a small portion into the left 
hypochondrium. Usually it does not extend so far to the left as the 
apex of the heart. Above, the lungs and heart glide over it, and it 
glides over the stomach (see Fig. 13, p. 78). 
The extent to which its surface is in contact with the thoracic wall 
is determined by the relation of its upper surface to the diaphragm. 
Hence, during expiration it rises in the right half of the body as high 
as the fourth intercostal space, and with its extreme left end to the 
fifth rib. The lower border, in the scapular and middle axillary line, 
stands about at the eleventh rib, in the mammillary line, just at the 
border of the ribs, then proceeds obliquely upward toward the left, 
through the epigastrium, under the left border of the ribs, and almost 
to the apex of the heart. 
In the middle line, it stands about midway between the xiphoid 
process and the umbilicus. The gall-bladder lies just where the lower 
border of the liver passes under the right border of the ribs, hence 
close within the right mammillary line. 
The organs that border upon the liver are the lungs, heart, and 
the diaphragm above, and the right kidney, colon and stomach below. 
That portion of its upper convex surface which is not covered by the 
lungs or heart is parietal. This parietal portion is very small behind. 
As it comes forward, it is much broader, and is, for the most part, 
covered by the chest-wall, except in the epigastrium, where it is free 
from its bony covering. 
With children, the liver is in all dimensions proportionally larger, 
so that its lower border is in the axillary line below the border of the 
ribs. 
Normally, the liver, strictly speaking, only moves in connection 
with the diaphragm. 
This is made with the body in the dorsal position moderately 
elevated. 
In the healthy condition, in adults, absolutely nothing can be made 
out. The right and left hypochondriac regions are exactly alike. In 
small children, we can sometimes notice a moderate projection of the 
right hypochondrium. 
INSPECTION OF THE LIVER. EXAMINATION OF THE DIGESTIVE APPARATUS. 
321 
Projection of the right hypochondrium, or also of the epigastrium 
and the region below the right border of the ribs, indicates enlarge- 
ment of the liver. This must be pretty well marked, in order to be 
noticed in this way. Where the thorax is very stiff, the ribs do not 
usually project; but when the ribs are very flexible (children, young 
females), where it can relatively easily take place, the projection of 
the abdominal wall is plainer if the abdomen is a little full and the 
covering thin. 
Fig. 88. 
Location of the lungs, liver, spleen, and ofthe kidneys, from behind. ( Weil-Luschka.) 
The liver and spleen are represented by the same kind of hatching as in Fig. 87. a b 
( ), lower border of the lungs; cd (....', complementary space; i ( ), border 
of the liver; ef (. . . .), boundary between the upper and lower lobes of the lungs; 
g, boundary between the upper and middle lobes of the right lung. 
If the projection is entirely of the portion of the abdomen below 
the border of the ribs, it points more to a displacement of the liver 
downward. There may he very marked distention when an enlarged 
liver is so displaced. 
It is very rare to see or to feel the lower border of the liver. Bat 
it may be, if, on account of enlargement or displacement, or both, it 322 
SPECIAL DIAGNOSIS. 
is located low down, and if the abdominal wall is thin. We can then 
also observe how the border of the liver moves downward with the 
motion of the diaphragm in deep inspiration. For observing this the 
light must come from the head of the bed. 
When the wall is very thin, tumors on the surface of the liver in 
contact with the abdominal wall, or on the lower surface of the border, 
and also a distended gall-bladder, can be seen. With deep breathing, 
they make the motions of the diaphragm very plain, and they transmit 
the motions to tumors of the stomach or omentum, which may be 
adherent to them, or, like them, visible. 
Finally, arterial or venous liver-pulse may be visible, especially the 
latter, which always accompanies enlargement of the liver. 
Enlargement of the liver may be dependent upon different diseases 
of this organ. In engorgement of the liver, especially in mitral 
defects and in emphysema, in fatty or amyloid liver, or when it is due 
to obstruction of the gall-bladder, and in diffuse hepatitis, in certain 
acute infectious diseases, the enlargement of the liver is tolerably 
uniform, its form being retained. It manifests itself by its lower 
border moving down into the abdomen, but, on the other hand, the 
diaphragm is pressed upward only when the liver is very greatly 
enlarged, or when the general abdominal pressure is increased (espe- 
cially in ascites) The liver is irregularly enlarged in carcinoma, 
echinococcus, generally in syphilis, and in abscess. To what extent 
it is noticeable depends upon the location of the swelling, whether 
anterior, inferior, or superior, with displacement of the diaphragm. 
Downward displacement or dislocation of the liver occurs generally 
with depression of the diaphragm, with severe emphysema, with 
pleurisy or pneumothorax of the right side. Left-sided pleurisy or 
pneumothorax, pericarditis, though generally only to a slight degree, 
press the point of the left lobe of the liver downward, and thus the 
lower border of the liver in the epigastrium is horizontal. Moreover, 
under some circumstances the liver is pressed downward by sub- 
phrenic abscess (see above), which at the same time pushes up the 
diaphragm. Lastly, here belongs the “wandering” liver, due to 
relaxation of the suspensory ligament (occurring in women who have 
borne children). It is only in the two conditions last named that it 
is not in contact with the diaphragm. EXAMINATION OF THE DIGESTIVE APPARATUS. 
323 
It is to be observed that the lower border of the liver moves down- 
ward not only when it is enlarged, but also when it is displaced. 
These two conditions will be distinguished chiefly by palpation and 
percussion, and the consideration of the accompanying conditions of 
the organs in the chest and abdomen. 
Displacement of the liver upward, can, of course only take place 
when the diaphragm is higher than normal, as in retraction of the 
lungs, pressure from below, inflammatory or neurotic paralysis of the 
diaphragm. 
PALPATION OF THE LIVER. 
In every relation, this is the most important and certain method of 
examining this organ, and hence must be most diligently practised by 
the beginner. It is best to have the patient in the dorsal position, and 
the abdominal wall as relaxed as possible. We first seize, with the warm 
hands, the whole abdominal sac, have the patient open the mouth and 
breathe quietly. Drawing up the limbs is of little aid and disturbs 
the examination. We very frequently make use of deep breathing, 
because in this way the parts hidden under the ribs move deeper, and 
the border or any small unevenness, etc., can be felt more distinctly 
as it moves against the examining fingers; and lastly, because the 
liver can be distinguished from other organs (kidney, colon, omentum, 
often stomach, abdominal wall) by its motions during deep breathing. 
By striking palpation we understand a brusque stroke with the tips of 
the fingers. We employ it in meteorism and ascites in order to push 
aside for the moment a layer of intestine lying over the liver or fluid, 
and thus be able to reach the liver with the tips of the fingers. (See, 
moreover, what is said on page 318 regarding palpation of the abdomen 
after puncture.) 
Normally, in the adult, with the ordinary thickness of abdominal 
wall, we can feel scarcely anything of the liver. If there is a thin 
lax wall (especially in women), we not infrequently feel the edge of 
the liver in the mammillary line at the border of the ribs, seldom also 
in the epigastrium, particularly if it is pressed down in deep inspira- 
tion. In children it is often very distinct. 
For example, we take a condition bordering on the normal, the 
so-called constricted liver, a disease almost without significance. It 
occurs in women who have laced themselves very tightly for a long 324 
SPECIAL DIAGNOSIS. 
time. Corresponding to the anatomical condition of the liver, we can 
feel a tongue-like prolongation of the right lobe, which prolongation 
is separated from the mass of the liver by a constricting furrow close 
under the border of the ribs. Sometimes the constricted liver is sensi- 
tive on pressure. 
In ascertaining the pathological conditions of the liver by palpation 
a series of points of view come under consideration: 
1. The existence of tenderness. There is no tenderness with the 
fatty, amyloid, cirrhotic liver, with echinococcus (if there is no forma- 
tion of pus), nor engorged liver (infrequent), if it has been for a long 
time uniformly engorged; the syphilitic liver is usually not tender, 
but sometimes it is so. Generally, in the beginning of cirrhosis the 
liver is sensitive, also in biliary engorgement. According to the extent 
to which the peritoneum is involved, carcinoma of the liver may be 
entirely without tenderness, or it may be very sensitive, also, when 
engorgement of the liver has rapidly developed, it may he very tender. 
When an abscess of the liver is parietal, possibly involving the peri- 
toneum, there is a circumscribed area of great tenderness ; with deep- 
seated abscess, there is no pain. Tenderness of the liver may, besides, 
he caused by chronic (often tubercular) peritonitis, without there being 
any trouble with the liver itself. 
2. The size and form. Depression of the lower border, without 
change in form, indicates uniform enlargement, but possibly also dis- 
placement. Unless there is considerable enlargement, it is often 
difficult to distinguish between these two conditions. If there is 
simultaneously tenderness and hardness (see below), or if there are 
conditions of other organs which make enlargement of the liver prob- 
able, as valvular disease of the heart with engorgement, a disease 
causing an amyloid condition, then we are very seldom wrong in the 
supposition that there is an enlargement. On the other hand, for 
example, the existence of pleuritic exudation, dextra, etc. (see above), 
makes displacement more probable. There also may be at the same 
time enlargement and downward displacement. But it must be remem- 
bered that, when a liver is markedly displaced downward, the impres- 
sion is easily made that it is also enlarged, because, by traction about 
its transverse axis, it becomes parietal to a larger extent. 
When a downward-displaced liver is distinctly movable by pressure 
with the finger, in such a way that in the dorsal position it can be EXAMINATION OF THE DIGESTIVE APPARATUS. 
325 
brought back to its normal position, then we have a “ wandering ” 
liver. 
The form of the liver is recognized with varying distinctness, accord- 
ing to the increased extent to which it lies against the abdominal wall, 
when it may be enlarged. It has already been mentioned under what 
conditions the liver retains its form. Tumors of all kinds (especially 
carcinoma, gummata, echinococcus) and scars (syphilis) change its 
form. Whole portions of the parenchyma of the liver may often, not 
always, be marked off by the scars of syphilis if they are very deep: 
“tabulated liver.” 
3. Again, the surface of the liver can be judged by the portion of the 
upper surface or the lower border which is accessible to palpation, and 
we can do this best by moving the finger-tips with the abdominal wall 
back and forth over the liver. In individual cases it is only possible 
to feel a portion of the lower surface. In engorgement of the liver, in 
fatty liver, in amyloid liver, in a portion of the first stage of cirrhosis, 
and in the so-called hypertrophic liver, the surface will be found to be 
smooth ; also, in echinococcus, carcinoma, and syphilis of the liver, if 
we palpate a portion entirely free from tumor or scars. Small inequali- 
ties, generally to a certain extent uniform over the whole palpable 
portions of the surface, sometimes so fine that if the abdominal wall is 
thick it is difficult to feel them, are the characteristic signs of ordinary 
cirrhosis of the liver (interstitial hepatitis, granulated liver) toward 
the end of the first stage and into the second. Here, for two reasons, 
it is usually very difficult to reach the liver with the fingers: first, 
because in the second stage it is smaller, and hence is to a less extent 
parietal, and second, because the disease is commonly associated with 
ascites. For this reason, what has been said regarding “stroking 
palpation ” and examination after puncture, applies especially here. 
It is further to be remarked that the surface of the liver in chronic, 
and especially in tubercular peritonitis, may feel tuberculated in conse- 
quence of inflammatory growths upon the serous coat, and this without 
there being any cirrhosis (although not infrequently this exists at the 
same time). Large rough tumors, from the size of a cherry to that 
of an apple, often mingled with small knots, are the usual appearances 
with carcinoma of the liver. We can sometimes recognize upon the 
top of these carcinomatous knots a depression, the cancer navel; but 
they are of neither positive nor negative diagnostic weight. More 326 
SPECIAL DIAGNOSIS. 
smooth, flat projections, especially if, besides, we can feel scar-like 
depressions, indicate the presence of syphilitic gummata. Echino- 
coccus causes smooth tumors which, according to their location, are 
flat or elevated, or they may even stand out prominently from the 
surface of the liver; thus also abscess of the liver causes smooth promi- 
nences of different sizes and elevations. 
4. The consistence of the liver is uniformly, and generally markedly, 
increased in amyloid disease, engorged liver, and in cirrhosis. Car- 
cinoma manifests itself, as elsewhere, usually by great density. 
Abscess of the liver and echinococcus bladders may distinctly fluctu- 
ate ; the latter often, if tightly full, feel dense as well as elastic, and 
we can sometimes recognize by quick, short strokes of the opposing 
hands a peculiar whizzing—the hydatid vibration. 
In many cases exploratory puncture will be indicated, as in order 
to recognize or exclude echinococcus or abscess. (Regarding the 
condition when there is echinococcus, particularly of the effects, 
see pp. 322, 325.) Moreover, it is necessary to compare the 
results of palpation, in the broad sense of the word, with the accom- 
panying appearances of other organs, which belong to the individual 
diseases of the liver. These may stand in a causal relation (constitu- 
tional syphilis, primary cancer of the stomach, etc.), or they may be 
results (ascites in cirrhosis of the liver or pressure from tumors, scars 
of the portal vein, rigors in abscess of the liver, etc.). 
The gall-bladder. If this is normal, it is only in cases of extreme 
emaciation that it can occasionally be felt. This is much sooner 
possible when it is abnormally full of fluid, as in biliary engorgement, 
hydrops vesicce fellece, suppuration, or when it is distended with gall- 
stones. In biliary engorgement and catarrhal icterus it is possible to 
diminish the gall-bladder by carefully compressing it, and expelling 
the contents into the ductus choledochus and the duodenum. When 
there are gall-stones, if the abdominal wall is thin, we sometimes get 
the distinct impression of a sac filled with angular stones rubbing 
against one another. A dense, rough tumor indicates carcinoma of 
the gall-bladder. 
PERCUSSION OF THE LIVER. 
Wherever, the liver is in contact with the thoracic or abdominal 
wall, we, of course, have dulness, and this is an absolutely deadened EXAMINATION OF THE DIGESTIVE APPARATUS. 
327 
sound where the liver receives the whole of the percussion-stroke, and 
the stroke is not permitted to reach to an underlying air-containing 
organ, as the intestine or stomach. A relative dulness, with tympanitic 
associated sound, occurs when a thin layer of liver lies over the 
stomach or intestine, as is the case in the neighborhood of the lower 
border of the liver. To a certain extent it depends upon the strength 
Fig. 89. 
g h, the upper limits of the lungs; e f, the lower limits of the lungs; b d, the boun- 
dary between the lung and heart at the incisura cardiaca. The darkly-hatched surface 
represents the portions of the heart and liver that are in contact with the chest-wall; 
the light hatching, the so-called relative heart and liver deadness; wi, spleen deadness; 
n, the average position of the lower border of the stomach. 
Percussion boundary of the liver in front (Weil). 
of the percussion-stroke whether we have a relative or an absolutely 
deadened sound (see p. 117): the weaker the stroke, the sooner do we 
have absolute dulness. The varying thickness of the covering of the 
liver is confusing—consisting partly of ribs and partly of abdominal 
wall. Still more confusing for exact examination is it that the border 
of the arch of the ribs, at the most important point in the mammillary 
line, normally exactly corresponds with the lower border of the liver. 328 
SPECIAL DIAGNOSIS. 
The difference in sound which is caused b j this change in the covering 
alone obscures the exact examination of the liver at this point. 
The limits of the liver, so far as they are determined by percussion, 
are ascertained by gentle percussion at the right lower border of the 
lung, by the transition from the clear lung-sound (or relative liver - 
dulness) to the absolutely deadened sound. Thus, the upper boundary 
of the parietal part of the liver is easily found, with the exception of 
a small portion, where the liver lies against the heart (see Fig. 87). 
Here we cannot determine the boundary by percussion, because the 
heart-dulness and liver-dulness cannot be distinguished. The lower 
border of the liver near the spine cannot be pointed out, because it 
joins the kidney (see Fig. 88), but everywhere else its sound could be 
very easily distinguished from the tympanitic sound of the stomach 
and intestine if its anterior part were not too sharp—that is, if the 
liver were not here too thin. For this reason, even with the most 
gentle percussion in the epigastric region, it is usually found too high. 
Often no distinct liver-dulness can be perceived in any portion of the 
epigastrium. Moreover, we must guard against being deceived by the 
dulness of one of the bellies of the rectus abdominis (lax abdominal 
wall). 
The relative liver-dulness lying above the absolute does not corre- 
spond to the anatomical size of the liver, which lies much further back 
than this, as is shown by a comparison of the anatomical figure with 
the boundary as determined by percussion. This is because the lung 
becomes thinner at its lower border; moreover, it is only anteriorly 
and at the side that it is always distinctly present. It usually fails 
between the scapular line and the spine, owing to the thick wall and 
the diminished sharpness of the edge of the lung. 
Mode of procedure: We percuss strongly or lightly down a known 
vertical line on the thorax, for determining the beginning of relative 
liver-dulness, and thus fix the lung-liver boundary—that is, the transi- 
tion from the relative to the absolute liver-deadness. Then we percuss 
downward, through the extent of liver-dulness, until by the gentlest 
percussion, we get the entirely pure tympanitic sound. From this 
point we go again upward till we get the first indication of relative 
dulness. We determine the exact boundary lines by exclusion (see 
p. 117). EXAMINATION OF THE DIGESTIVE APPARATUS. 
329 
The average boundary-lines of the liver, as determined by percus- 
sion, are about as follows : 
The upper, the lung-liver boundary : Middle line, base of the ensi- 
form cartilage; mammillary line, sixth rib ; middle axillary line, eighth 
rib ; scapular line, tenth rib. 
The heart-liver boundary cannot be determined by percussion, but 
it lies near the apex-beat. 
The lower, the liver-stomach (intestine) boundary: Left of the 
middle line, toward the half-moon-shaped space, ascending obliquely 
to about the sixth rib in the parasternal line ; middle line, not lower— 
often higher—than midway between xiphoid process and the umbili- 
cus ; mammillary line, at the bend of the ribs ; middle axillary line, 
the tenth rib ; scapular line, the eleventh rib. 
But from these there is frequently a considerable departure, even 
normally. Throughout, the lower boundary has been found much 
higher, this being caused by a fold of intestine lying over the liver 
and thus diminishing the extent to which it is parietal. This is par- 
ticularly the case with the ugly, but not pathological, form of the 
thorax where it is short and its lower aperture is quite wide; also, in 
persons who have a full abdomen. In this way the liver-dulness may 
sometimes be entirely wanting: at the upper boundary of the half- 
moon-shaped space we pass, in percussing, from lung-sound into 
tympanitic resonance. 
Extreme elevation of the liver-dulness, although very variable within 
normal limits, is not at all applicable in diagnosis. 
Mobility of the boundaries of the liver. In deep breathing, there 
is a more marked active displacement of the upper boundary (corre- 
sponding to the respiratory excursion of the border of the lung) than 
of the lower, which displacement is the expression of the movement 
of the dome of the diaphragm. As regards passive movement, we 
only notice that in the left-side position both boundaries move down- 
ward, the upper distinctly so (see Lungs) ; the lower, very little. 
Pathological Relations.—1. The upper boundary of dulness is 
found higher. The cause of this can first of all be found in the 
pleural cavity : pleural exudation, tumors of the pleura, of the lungs, 
pneumonia; or in the chest wall: tumors, peripleuritis. Then, of 
course, it is not possible to distinguish the dulness of what lies above 
the liver from that of the liver itself, since two media that on per- 330 
SPECIAL DIAGNOSIS. 
cussion give dulness cannot be distinguished from one another. If 
there is exudative pleuritis upon the right side, the diaphragm is deeper 
and the liver moves down, causing its lower boundary of dulness to be 
lower, and thus in this disease there may be an extensive dulness, 
reaching from high in the thorax to far below the border of the ribs— 
dulness of the exudation plus liver-dulness. 
If the conditions just named are excluded, then we may have 
(a) Displacement of the liver upward, with high position of the 
diaphragm. Then, at the same time, the lower border of the liver is 
higher, and indeed the latter is displaced upward further than the 
former, because the liver, as it moves upward, in a sense turns on its 
axis—that is, the lower border turns up, so that it is to a less extent 
parietal—the square position of Frerichs. (For the conditions which 
displace the liver, see above.) 
(b) A tumor, of the convexity of the liver, as a new formation, 
an abscess, echinococcus, when the upper boundary of dulness pur- 
sues an irregular course, according to the form of the tumor; or a 
subphrenic abscess. In these cases, the liver is usually displaced 
downward, often very markedly so; hence, the lower boundary of the 
liver at the same time stands deeper. 
(c) A simultaneous general enlargement of the liver. This is rare, 
occurring only when the liver is very large. Here also the lower 
boundary of dulness is considerably deeper. It is often very difficult 
to distinguish, and then only by inspection (projection) and palpa- 
tion of the surface and consistence of the liver, and other evidences 
of disease referred to under (6). 
2. The upper boundary of dulness is found deeper. This occurs : 
(a) With a simultaneous normal position of the lower boundary, in 
slight substantive, and in vicarious, emphysema. Although in this case 
the lung moves down into the complementary space, and thus covers 
the liver somewhat more than is normal, yet the dome of the diaphragm 
does not become deeper. 
(h) With simultaneous downward displacement of the lower boun- 
dary : low position of the diaphragm with the liver: marked emphy- 
sema with low position of the diaphragm ; pneumothorax. We can 
have the same percussion result with considerable emphysema and en- 
largement of the liver. Finally, there may be low position of both 
boundaries resulting from the low position and enlargement of the EXAMINATION OF THE DIGESTIVE APPARATUS. 
331 
liver, as is a frequent occurrence in severe emphysema, because of 
the existing engorgement of the liver. 
W hen the liver is displaced downward it easily gives the impression 
of being enlarged without such being the fact, because it is often 
parietal for a larger area than is normal. Also, for this reason, the 
liver-dulness is higher than it is normally on the average; especially 
in pneumothorax is it often distinct. 
3. The behavior of the lower boundary when the upper is displaced 
has in general been already mentioned. It remains to be noticed that, 
when the liver is pushed down by a thoracic affection on the right side 
{pleurisy, pneumothorax), it stands obliquely, that is, the right lobe 
is deeper than the left, hence the depressed lower boundary of dulness 
stands steeper than normal, sloping from the right toward the left. On 
the other hand, when we have a pleurisy or pneumothorax upon the 
left side, or marked pericarditis exudativa, since the left end of the 
liver (lob. sinistra) is then alone pressed down, the lower line of dulness 
is found more horizontal. 
With a normal upper border, the lower boundary stands deep and 
reaches further into the half-moon-shaped space when the liver is en- 
larged; on the other hand, it is higher than normal, under some circum- 
stances even until the liver dulness completely disappears in the 
following conditions : (a) If the liver is smaller, as in cirrhosis, acute 
yellow atrophy, here occurring rapidly. (b) As happens much more 
frequently than (a), in case the liver, though perfectly sound, is less 
parietal than normal, or is not at all so, as in those who are on the 
whole well, in meteorism, ascites, entrance of air into the peritoneum. 
In this way even an enlarged liver may elude examination. In yet 
two Other rare cases is the liver dulness entirely wanting; in situs 
inversus viscerum and in cases of “wandering liver.” With the 
latter, sometimes a portion of the upper surface of the liver will be 
found in contact with the abdominal wall further down. 
Apparent low position of the lower border occurs when there is an 
airless mass below the liver, as with a full colon, or a large tumor 
of the colon, of the omentum, or of the stomach, although these are 
rare. 
The form of the lower border departs from the normal when there 
is unequal enlargement of the liver (see above); also sometimes in 
marked enlargement of the gall-bladder, seldom determined by per- 332 
SPECIAL DIAGNOSIS. 
cussion. (For the different kinds of enlargement, see under Palpa- 
tion.) 
4. Relative liver-dulness is diagnostically of little interest. It is 
relatively high, if the diaphragm rises steeply upward and inward 
from the thoracic wall, and very low, if the diaphragm goes off per- 
pendicularly from the thoracic wall, as in severe emphysema, but 
especially in pneumothorax. 
All in all, percussion of the liver, when rightly performed and cor- 
rectly interpreted, is of very great value. But where palpation can 
be employed, as is usually the case whenever the inferior border of 
the liver is lower than normal, it must yield to the latter method of 
examination, which is more anatomical and hence more exact. If the 
border of the liver can be felt, then we note its course upon the body 
by the results of palpation and not of percussion, and proceed with 
the diagnosis in accordance with this position. 
Examination of the Spleen. 
Anatomy.—The spleen, a long, generally almost oval, organ, lies 
in the left hypochondrium, between the ninth and eleventh ribs, in 
such a way that its long diameter in the dorsal position of the body 
lies almost exactly behind and parallel to the tenth rib. Its posterior 
end lies about two centimetres from the tenth dorsal vertebra; its 
anterior end, normally, scarcely reaches to a line drawn from the tip 
of the eleventh rib to the left sterno-clavicular articulation (linea 
costo-articularis), at any rate does not pass beyond it. The upper 
(anterior—upper1) of the two borders of the spleen exhibits one or 
two notches. 
The spleen lies close to the under surface of the diaphragm, in the 
periphery of that portion which rises sharply upwai'd, and toward its 
inner lower end it covers a small portion of the upper part of the left 
kidney, also the colon and stomach. Topographically, with reference 
to the thorax, its location is as follows: Its upper third, during moderate 
respiration, is covered by the lung. The lower two-thirds are in con- 
1 In what follows I designate the two borders of the spleen as “ upper ” and “ lower,” 
because from the topographical standpoint that always seems to me the most natural. 
We speak of an upper and lower border of all the ribs, even of the lower ones, which are 
oblique. I cannot understand why one of the two ends of the spleen should be called 
the “ upper” and the other the “ anterior,” as is done by Weil. EXAMINATION OF THE DIGESTIVE APPARATUS. 
333 
tact with the thoracic wall, but it changes its relation somewhat with 
the position of the body by reason of the passive mobility of the 
border of the lung (which see). Its upper border follows the ninth 
rib, forms the outer boundary of the “half-moon-shaped space/’ and 
Fig. 90. 
Position of the spleen. (Weil.) M, the middle line of the back; A, B, C, the 
axillary lines; Sc, the scapular lines; abed, spleen; a be'd, unusual rhomboidal form 
of the spleen; ef g, outer boundary of the kidney; lb c, the spleen-lung and d h g, the 
spleen-kidney angle; n m, the lower border of the liver. 
stands at a sharp angle with the lower border of the lung (see figure), 
called the spleen-lung angle, whose apex, in the upright position, is 
about at the posterior axillary line, but when in the right-side position, 
in consequence of the movement downward of the lower border of the 
lung, it moves somewhat forward, even as far as the anterior axillary 
line. Its lower border follows the eleventh rib, and for the most part 
hounds the left kidney. 
The spleen is in parietal contact only in its lower two-thirds, but it 
cannot be reached by the finger except sometimes by turning the 
abdominal wall under the border of the ribs. SPECIAL DIAGNOSIS. 
334 
INSPECTION OF THE SPLEEN. 
In the normal condition, and even when greatly enlarged, inspec- 
tion of the spleen gives no result. A very considerable enlargement 
causes a projection of the left hypochondrium, and of the abdominal 
region obliquely inward and downward from it. When the abdominal 
wall is thin, the border of the enlarged organ or a circumscribed 
swelling on its parietal surface may be seen. Then if the upper end 
of the spleen has not left its place close to the diaphragm (see below), 
it usually plainly descends with deep inspiration. 
PALPATION OF THE SPLEEN. 
Palpation is very much the most important method of examination, 
because its results are much more reliable than is the case with per- 
cussion. Ordinarily, in order to employ palpation, it is necessary for 
the patient to assume what is called the diagonal position on the right 
side, that is to say, a position midway between the dorsal and the right- 
side position, and also for the reason that percussion can be practised 
very much better in this position, and because the unity of the position 
is useful for comparing the results of the two methods of examination. 
When the patient is very sick, it is better to palpate in the dorsal posi- 
tion. When the spleen is of very considerable size, this is also best 
(then, too, it is preferable for percussion). If it is difficult to find the 
spleen, then we try the right-side position, because this more fully 
relaxes the left side of the abdominal wall. If we have the patient 
take several deep inspirations, a slight swelling of the spleen can 
usually be made out, because we can feel the anterior end of the 
organ close to the border of the ribs, at about the tenth rib, where it 
comes in contact with the tip of the finger. Without further investi- 
gation, we cannot refer a simple increase of resistance at the edge of 
the ribs to the spleen; but we must further seek to feel its border. 
The spleen can be felt: 
1. In individual cases in health, when the abdominal wall is very 
lax ; also, sometimes, in persons with deformed chest (kypho-scoliosis). 
2. If it is enlarged. It may be enlarged and yet retain its form. 
It is uniformly enlarged in certain acute infectious diseases, as in 
typhoid, exanthematous, recurrent, fever; in scarlet fever, usually in EXAMINATION OF THE DIGESTIVE APPARATUS. 
335 
severe smallpox; malaria, here relatively very large; in erysipelas, 
here often very little enlarged; in sepsis and pyaemia; sometimes in 
acute miliary tuberculosis; in engorgement of the spleen, especially 
in cirrhosis of the liver; in occlusion of the portal vein ; in general 
venous engorgement; in amyloid disease of the spleen ; in leukaemia 
(greatest enlargement), and in splenic anaemia; sometimes, in infarc- 
tion of the spleen (heart disease); and also in tubercular peritonitis. 
We must here also mention the apparent enlargement of the spleen 
where there are thick peritoneal deposits (perisplenitis). 
It may also be unequally enlarged by new formations, especially 
by carcinoma, and by echinococcus and abscess. 
3. It may be felt if it is displaced, with low position of the dia- 
phragm (rare); the “wandering” spleen. 
In palpating we take notice of: 
Pain. Tenderness, probably always from the peritoneum, some- 
times occurs in acute infectious diseases, in suddenly developed engorge- 
ment, in infarction of spleen, new formations, abscesses. There may 
sometimes, in abscesses and infarction, be tenderness to pressure upon 
the ribs in the neighborhood of the spleen. 
Size. The largest tumors of the spleen, often reaching into the 
right side of the abdomen, occur in leukaemia. On the other hand, 
in the acute infectious diseases, we have moderate enlargement of the 
spleen, which does not come below the border of the ribs. In other 
diseases the splenic tumor varies very much in size. Pulsating splenic 
tumor has been observed now and then in cases of aortic insufficiency. 
Consistence. As a rule, the consistence increases with the size, 
and is more dense in chronic, than in acute, cases. Generally, the 
consistence is not a guide in diagnosis. 
Form, surface. It has already been mentioned in what diseases 
the spleen is uniformly, and in what unequally, enlarged. In diseases 
of the first group, we can almost always, and in the latter sometimes, 
feel distinctly the notches in the upper border, if the spleen projects 
far enough beyond the border of the ribs. In carcinoma, the surface 
shows hard, uneven tumors; in echinococcus, they are round, tense, 
elastic. But in leukaemia, the surface is not always uniform, for it 
may sometimes exhibit flat elevations. 
Mobility. We have already mentioned the downward movement of 
the spleen with deep inspiration. I have seen cases of very great SPECIA L DIA GNOSIS. 
336 
enlargement of spleen where this did not take place, because the 
spleen had pushed the diaphragm high up on the left side (see Percus- 
sion), and hindered its contraction. 
Wandering spleen, having diminished respiratory movement, but 
passively movable, and sometimes even showing displacement down- 
ward with change of posture, occurs only in women. The spleen may 
wander astonishingly far from its place, even into the true pelvis, and 
it has been found in the abdominal cavity entirely free from its attach- 
ments ; but usually there is only slight displacement. Tumors of this 
kind are recognized as wandering spleen by their form and by the 
notches. Often, it is at the same time enlarged. A spleen displaced 
by the low position of the diaphragm can seldom be felt. (See further 
regarding displacement, under Percussion of the Spleen.) 
Relation of the colon to the spleen. Enlarged and wandering 
spleen lies in front of the colon. We can best prove this by inflating 
the colon with air in connection with palpation and percussion. 
PERCUSSION OF THE SPLEEN. 
Percussion is limited to that portion of the spleen which is not 
covered by the lung (Weil). It is bounded above by the lung; toward 
the front superiorly, we have the upper border, inferiorly, the anterior 
end, and a portion some distance behind (inferior border), against the 
stomach and intestine; further back, against the kidney. But this 
latter portion cannot be defined, there being dulness against dulness. 
When we can only percuss with the patient in one position, as 
with very sick patients, we do so in the right diagonal posture. 
But if we wish to be very exact, and the patient can bear it, it is 
best also to percuss in the upright posture. Let it be repeated, that 
palpation generally, even though the physician be skilful in per- 
cussion, gives a much more certain result. But percussion must 
never be omitted. When the spleen is very much enlarged, we may 
examine the patient in the dorsal position. The diagonal posture is 
only required to determine whether, and how much, the spleen pushes 
up the diaphragm. 
' In both the diagonal and the upright posture, we begin by determining 
the lower border of the left lung. It is normally in the upright position: EXAMINATION OF THE DIGESTIVE APPARATUS. 
337 
mammillary line, sixth rib; middle axillary line, eighth rib; scapular 
line, tenth rib. In the diagonal position, it varies from the seventh 
to the eleventh rib. From here, if 
we percuss in the vertical line, over 
the border of the lung downward, 
and, in the diagonal position, about 
in the anterior or middle axillary 
line, below the border of the lung, 
we will meet dulness instead of the 
tympanitic sound of the half-moon- 
shaped space: spleen-dulness. The 
place at the border of the lung 
where the dulness is met with is the 
apex of the spleen-lung angle (see 
anatomy, p. 333). We now per- 
cuss vertically downward, through 
this angle beyond the deadened 
sound, till we come to a tympanitic 
(intestinal) resonance: the boundary 
line is the lower border of the 
spleen. Then we percuss from the 
half-moon-shaped space and from 
the abdomen, upon lines which cross what we suppose to be the arena of 
spleen-dulness, and thus ascertain where the tympanitic stomach or 
intestinal resonance changes to dulness. This marks the line of the 
spleen. If we mark these points, and connect them, we obtain the 
figure of the parietal portion of the spleen, which we can complete by 
determining the lower border of the spleen in the posterior axillary 
line, or in a vertical line between this and the scapular line. 
In the upright position, the conditions are altered in such a way 
that the border of the lungs, and with it the lung-spleen boundary, 
stands somewhat higher (see above), and hence we find the apex of 
the lung-spleen angle in the middle or posterior axillary line. 
As has already been said, the size of the spleen-dulness, with 
careful percussion and under favorable conditions (see below), cor- 
responds to the parietal part of the spleen. From this we must 
estimate the size of the spleen. In measuring it, we have only two 
points of departure: the height of the spleen-dulness in the vertical 
Fig. 91. 
Shape of the spleen-deadness. 338 
SPECIAL DIAGNOSIS. 
line passing through the apex of the spleen-lung angle, and the rela- 
tion of the anterior end of the spleen to the linea costo-articularis. 
The average in health has been found to be (Weil): 
In the diagonal posture, the height of the spleen is 5.5 to 7 cm., the 
anterior end at most reaching to the linea costo-articularis. 
In the upright position, the height is 4.5 to 6 cm., the anterior end 
under some circumstances passing a little beyond the linea costo- 
articularis: the spleen-lung angle more pointed—that is, the spleen is 
a little more horizontal. 
We are interested in the mobility of the spleen-dulness in deep 
inspiration only so far as it affects the boundary between the spleen 
and lung (see what has been said regarding active mobility of the 
border of the lung). 
Weil, in his work upon Topographical Percussion, has sufficiently 
explained why we must forego the determination of the portion of the 
spleen which is covered by the lung. In the first place, we percuss 
tolerably strongly. If in that way we obtain no result, we then 
percuss very lightly. With strong percussion over the spleen, we very 
seldom get resonance, also, with moderately strong, only rarely abso- 
lute deadness. Also, we must often be satisfied, by gentle percussion, 
with a relative dulness, associated with tympanitic accompaniment. 
Departures from what has been called the “ average ” in health: 
(a) The dulness of the spleen is only approximated as regards size or 
intensity: a very frequent occurrence when it is covered by intestine, 
or the spleen is thin and the intestines near it are distended by gas. 
(5) The area of spleen-dulness is larger, while its form is retained or 
is changed: this occurs when the stomach is overloaded with food, 
when there are fecal masses in the neighboring colon, when there is 
corpulence (the greater omentum loaded with fat) ; but, also, some- 
times without these conditions being present. We must guard against 
deception as respects the stomach and intestine by repeated examina- 
tions, especially with abstinence from food and after free purgation. 
When there is obesity, we ought not, on the whole, to draw any con- 
clusion from a large area of spleen-dulness. 
But, at any rate, we must never, by a single examination, diagnos- 
ticate a spleen-tumor from percussion alone. 
Pathological Relations.—As mentioned above, diminution of 
spleen-dulness is often met with in health. In sickness, it occurs from EXAMINATION OF THE DIGESTIVE APPARATUS. 
339 
overlapping of the spleen from above by the lung: this happens with 
emphysema of the lung, when the lung spreads into the comple- 
mentary space; sinking down of the lower border of the spleen and 
its anterior end, as evidence of displacement downward by flattening 
of the diaphragm, but in emphysema this cannot be proved. There 
is always diminution of spleen-dulness (even to complete disappear- 
ance) when it is displaced upward, as in shrinking after pleurisy, 
contraction of the lung, high position of the diaphragm. Here, 
generally, there is no spleen-dulness at all, on account of the intestine 
lying over it. 
Enlargement of spleen-dulness. If we make out such a condition 
we ought to call to mind the sources of error mentioned above. We 
should never make the diagnosis of enlarged spleen from a single 
percussion, without the support afforded by palpation. We must 
notice whether the enlarged dulness shows the relations of the figure 
of the spleen; if it does, then it is quite probable that the spleen is 
enlarged; likewise, if the examination in the diagonal and the standing 
position shows a similar result, with change of dulness that distinctly 
corresponds with the changed position of the border of the lung and 
the spleen. 
Enlargement of the spleen is to he assumed when the vertical 
measurement of dulness is as much as 9 cm. or more; also, if the 
area of dulness extends considerably beyond the linea eosto-articularis ; 
and, lastly, if the dulness is very decided, with moderately strong 
percussion absolute. When there is considerable enlargement of the 
spleen, the area of dulness upward is larger, and, hence, the diaphragm, 
and with it the border of the lung, moves higher in the chest. More- 
over, in every upward enlargement of the spleen-dulness it is to be 
remembered that it may be merely apparent, being caused by pleuritic 
exudation, infiltration of the lungs, or pleural tumor. 
When there is a decided enlargement of the spleen, it considerably 
diminishes the half-moon-shaped space. If there is, simultaneously, 
tumor of spleen and liver, the space may be entirely deadened. 
AUSCULTATION OF THE SPLEEN. 
In rare cases, auscultation enables us to recognize peritoneal friction- 
sounds should there be inflammatory deposits upon the serous coat of the 340 
SPECIAL DIAGNOSIS. 
spleen and the parietal portion of the peritoneum opposite to it, 
if the diaphragm is not paralyzed by the peritonitis or the spleen has 
not become adherent. Peritoneal friction-sound over the spleen (and 
over the liver) seems to me to have greater weight as evidence that 
the first of the two last-named conditions is wanting, than as the sign 
of peritonitis, for the latter usually appears to be plainer from other 
symptoms. It may easily happen that we find it difficult to distin- 
guish whether we really have peritoneal, rather than pleuritic, friction- 
sound. Auscultating with the stethoscope enables us to localize the 
sound more exactly. We must also take into consideration the whole 
picture of the disease. 
Examination of the Pancreas, Omentum, Retro-peritoneal 
Glands. 
The pancreas is accessible for examination, and even to palpation, 
if it is the seat of new formation, as of carcinoma, especially of the 
caput pancreatis, and hence is larger and harder than normal: we 
have a roundish tumor in the right epigastrium which does not move 
during respiration, about midway between the point of the xiphoid 
cartilage and the umbilicus, hence, directly under the border of the 
liver; or a somewhat longer tumor across the epigastrium. Unless there 
are characteristic associated symptoms (compression of the ductus 
choledochus and pancreaticus, biliary engorgement, and change in the 
character of the stools), the diagnosis of tumor of the pancreas can 
scarcely be made from such a tumor, which may also belong to the 
omentum, but especially to the retro-peritoneal glands. 
The omentum, also, is only perceptible when it is thickened by 
inflammation or new formations, or by both. It frequently shrinks 
up to a transverse band which lies close above the umbilicus, as in 
tuberculosis, but doubtless also in “simple” chronic peritonitis. Car- 
cinomatous knots in the omentum are best to be distinguished from 
similar deposits in the anterior wall of the stomach, by examining the 
latter, both when empty, and full, or inflated. Sometimes it is very 
difficult to distinguish them from carcinoma of the liver, especially if 
the omentum, from adhesion with the liver, moves with each respira- 
tion. Echinococcus of the omentum is quite rare. 
Enlargement of the retro-peritoneal glands generally occurs in EXAMINATION OF THE DIGESTIVE APPARATUS. 
341 
secondary carcinoma as firm, immovable bunches, which are located 
in the cavity of the abdomen, about on the level with the umbilicus ; 
but sometimes they reach even deeper. They may compress the side 
of the inferior vena cava or the iliac vein. This may easily be con- 
founded with aneurism of the aorta, especially if it is a round tumor 
and propagates pulsations, and it may also even communicate a hum- 
ming murmur of stenosis from the aorta. 
We must again call attention to the importance of always emptying 
the intestines and bladder in all cases of this character where the 
diagnosis is difficult. 
This is not the place to explain the differential diagnosis of a large 
number of other affections of the abdomen, especially tumors of the 
uterus, ovaries; also, pregnancy. (We refer for these to works upon 
Gynaecology and Pregnancy.) 
Examination of the Contents of the Stomach. 
In general we may obtain the contents of the stomach for examina- 
tion in two ways: when the patient vomits, or when, by emptying the 
stomach by means of an oesophageal catheter, we remove a portion of 
its contents. The catheter may be introduced for therapeutic purposes, 
or only for the purposes of diagnosis. 
The latter way of obtaining some of the contents of the stomach, it 
is readily seen, is the more exact for making a diagnosis, because 
we regulate the time for doing it by the object we have in view. 
First, with reference to the most important problem in the diagnosis 
of the contents of the stomach, namely, the examination of the stomach- 
digestion and the secretion of gastric juice, it is only necessary to 
empty the stomach to obtain the object required. At the same time, 
it is to be remembered that, in many cases, the examination of vomited 
matters or the fluid employed in rinsing out the stomach (especially 
in cases of poisoning) is of very great importance, and is, then, not to 
be overlooked. 
Artificial emptying of the stomach or removal of some of its contents 
for the purposes of diagnosis is, as has been said, the only method 
which enables us to form a reliable opinion regarding the gastric 
secretion and the process of digestion, for the reason just given, that 
such an opinion can usually only be formed when the contents of the 342 
SPECIAL DIAGNOSIS. 
stomach have been obtained in a pure state and at a definite time after 
partaking of a meal. Vomiting can make the artificial emptying of 
the stomach unnecessary only when it occurs at exactly the time 
desired, and when the material vomited does not contain bile and not 
too much mucus (see below). 
Induction of emesis is contra-indicated when there is a tendency to 
hemorrhage, and in poisoning, where we have reason to think the 
poisons, as acids and alkalies, have caused erosion of the oesophagus 
or stomach. Sounds, even soft ones, are to be employed with the 
greatest caution if there has ever been any hemorrhage of the stomach, 
and also when there is any suspicion of an ulcer of the stomach or of 
a carcinoma that is eating through the walls. 
Knowledge regarding the secretion of gastric juice and stomach- 
digestion is important really in three directions, because, by means of 
it, certain diseases may be recognized early, before inspection, palpa- 
tion, etc., are of any value, or where these methods do not in any way 
give any result. And even where other methods of examination have 
led to a positive conclusion, the diagnosis is not only made still more 
definite by this knowledge, but likewise the effect of a disease of the 
stomach upon its functions is determined. Lastly, there is sometimes 
a flat contradiction between the severe complaints of the patient 
regarding the stomach and a perfectly normal gastric digestion. In 
this case, the examination of the contents of the stomach immediately 
furnishes an explanation, as in some forms of “nervous” dyspepsia. 
EXAMINATION OF THE PROCESS OF DIGESTION. 
Stomach-digestion and its Disturbances. 
1. After partaking of a meal which contains albumen and starch 
(fat does not come under consideration, because it is not digested by 
the stomach), there first occurs, under the influence of the ptyalin of 
the saliva, the amylolytic period of digestion: the starch contained in 
the food taken gradually disappears, and dextrine takes its place 
(achroo- and erythro-dextrine) and there is a slight amount of grape- 
sugar ; any cane-sugar that has been taken is inverted, that is, is partly 
transformed into grape-sugar. These processes go on tolerably rapidly. 
Moreover, under the influence of microorganisms that excite fermenta- EXAMINATION OF THE DIGESTIVE APPARATUS. 
343 
tion, there occurs a partial lactic-acid fermentation of the grape-sugar, 
and hence lactic acid is formed (lactic-acid fermentation). 
This amylolytic period varies in length according to the size of the 
meal; on the average, it lasts three-quarters of an hour. As a matter 
of course, it is entirely absent if only meat is eaten; then, also, there 
is no lactic acid. 
Immediately after food is taken, the mucous membrane of the stomach 
begins to secrete muriatic acid and pepsin, and the stomach-juice mixes 
with the alkaline chyme. But at first the muriatic acid is in combi- 
nation, and we do not have free muriatic acid in any quantity until, on 
the average, one-half to three-quarters of an hour; thus the amylo- 
lytic period is brought to a close, because the diastatic action of the 
saliva cannot go on in an acid solution. Instead, there begins the 
peptonizing action of the secretion of the stomach upon the albuminous 
bodies. The lactic acid disappears, and after the first hour none, or 
only a trace of it, can be detected. The stomach now contains an 
increasing amount of free muriatic acid, and this reaches its maximum, 
0.2 per cent., or less, according to the size and character of the meal, 
from two to five hours after the time it was eaten. From now on there 
appear peptones and their precursors (syntonin and propeptone). 
Simultaneously with the free muriatic acid, the [milk-curdling 
ferment] rennet-ferment appears, under whose action the casein of 
the milk that has been taken is coagulated. 
The pepsin and rennet-ferment are not secreted as such by the 
mucous membrane of the stomach, but are formed by their zymo- 
gens ferment], propepsin and rennet-zymogen. Both, under 
the influence of the muriatic acid, become transformed into pepsin 
and rennet-ferment. The lactic acid, although in very much larger 
quantity, has this effect upon the zymogens also. 
This second or muriatic-acid period of stomach-digestion, now shows 
the very important peculiarity that, during its course, under the influ- 
ence of the 0.2 per cent, of free muriatic acid, we have the antiseptic 
action of the gastric juice, by which the greater proportion of the 
microorganisms swallowed with the food and drink, particularly those 
that excite fermentation and putridity, as well as certain pathogenic 
ones, as the cholera bacillus, are destroyed. 
During the progress of stomach-digestion the food is mixed by peris- 
talsis, and partly by the aid of the ferments is comminuted and reduced 344 
SPECIAL DIAGNOSIS. 
to a homogeneous mass. A small portion of the fluid resulting from 
digestion is absorbed ; but besides, at the pyloric end of the stomach, a 
continuous separation of the solid and fluid portions is going on, and 
the latter, during the whole period of digestion, passes little by little 
into the duodenum. 
2. About six hours after a mixed meal of moderate quantity (much 
sooner after a smaller one), the stomach has become entirely empty, 
or at most contains only small particles of food. In the interval 
until the next meal, in the great majority of healthy persons, it appears 
that the stomach contains a very scant amount of clear fluid, with a 
neutral reaction, but no muriatic acid or pepsin. 
The stomach-digestion of nurslings has as yet been very little 
studied. According to Leo, the fasting stomach of a nursling almost 
always contains free muriatic acid, while during digestion free muriatic 
acid cannot at all, or only after an hour, be demonstrated; this is 
not because there is none secreted, but because it is neutralized by the 
milk. Leo always found rennet-ferment, excepting in one case where 
there was rennet-zymogen. After half an hour, the greater portion of 
the milk has passed into the intestine, and in one, or at most two hours, 
the stomach is empty. Leo also thinks that the peptonizing of the 
milk in the stomach is a subordinate process. He regards the stomach 
as really a milk-reservoir, and perhaps as offering a barrier to patho- 
genic microorganisms. • 
3. The chief points in regard to the effect of pathological disturb- 
ances of the gastric secretion, of the motions of the stomach upon 
digestion, and the sterilization of the food and its further transporta- 
tion into the intestine, are as follows: 
Diminished secretion of muriatic acid (subacidity, hypacidity) 
interferes with the digestion of albumen and the power of the 
stomach to prevent decomposition and fermentation. 
When the muriatic acid is increased (superacidity, hyperacidity), 
free acid is present earlier, and thus there is interference with the 
digestion of the starches, because this only goes on while the contents 
of the stomach have an alkaline reaction; likewise, the albuminous 
bodies are either normally, or more rapidly, peptonized, but in some 
cases it is remarkable that they are more slowdy peptonized. 
Diminution of the muriatic acid generally appears to go parallel 
with a diminution of the pepsin. On the other hand, this parallelism EXAMINATION OF THE DIGESTIVE APPARATUS. 
345 
is generally not present when there is superacidity; with increase of 
the muriatic acid, there even appears to be an absence of pepsin. At 
least, this latter condition alone explains those cases where the pepto- 
nization of the albuminous bodies is prolonged, although the free acid 
is increased. 
Hence, with subacidity (inacidity) not only are the albuminous 
bodies imperfectly digested, but under the influence of the unrestrained 
development of microdrganisms there occurs an abnormal decomposi- 
tion, and particularly of fermentation with formation of lactic acid in 
excess of the normal time and amount, as well as of other organic 
acids. This abnormal chemical activity in turn produces a paralysis 
of peristalsis and muscular tone. The removal of the food stops for 
this reason, and probably also because the pylorus does not readily 
allow material to pass into the duodenum which is in an abnormal 
chemical, and in part physical, condition. The food remains too long 
in the stomach, and hence the stomach-digestion is prolonged. Lastly, 
if the condition persists, there is ectasia or dilatation of the stomach. 
It is to be remarked that by the word dilatation alone is always meant 
permanent dilatation, in contradistinction from temporary dilatation, 
which occurs after every meal. 
Quite similar in its final results is the effect of a hindrance to the 
emptying of the stomach, as is particularly frequent with pyloric 
stenosis; only here the disturbance is on the whole much more marked. 
In stenosis of the pylorus, the difficulty in expelling the food is at first 
overcome by an hypertrophy of the muscular coats of the stomach, 
but gradually there becomes manifest a disproportion between the 
strength of the stomach and the narrowed passage. Part of the con- 
tents of the stomach remain behind at the time of the next meal, and 
so the stomach becomes more and more dilated. There is an accumu- 
lation of material (peptones, albuminates, muriatic and phosplioiic 
acid salts); and the muriatic acid, though free, is yet so interfered 
with that it no longer exerts its peptonizing and antifermentative 
action. There is no further digestion, but in place of it the food 
accumulated in the stomach takes on fermentation, with formation of a 
great amount of lactic acid, butyric acid, acetic acid, and alcohol. 
Through this abnormal chemical action, peristalsis and the muscular 
tone are still more weakened: there results a true circulus vitiosus of 
the motor and chemical phenomena. 346 
SPECIAL DIAGNOSIS. 
4. The chief points in the symptomatology of a distended stomach 
are the following: 
Subacidity or inacidity may be recognized by the diminished per- 
centage of muriatic acid or its absence. Further, there are signs of 
abnormal fermentation, of which the most important is the unusual 
duration and amount of lactic acid. Digestion is usually prolonged: 
the siomach is not empty after seven hours; it still contains un- 
changed particles of meat, discernible microscopically or even macro- 
scopically. If we institute experimental digestion with the gastric 
juice in an incubator (see below), we find that it is diminished, or that 
it has lost its power to digest albumen. 
Superacidity during digestion shows an increased amount of free 
muriatic acid : usually the free acid makes its appearance too early ; 
the amylolytic period is thus shortened, and there is unchanged 
starch (microscopically and chemically demonstrable). Albuminous 
digestion in the incubator may be quickened. 
Increased difficulty in conveying the food from the stomach (especi- 
ally when due to stenosis of the pylorus) is connected with diminution 
or absence of free muriatic acid. Thus, the secretion of acid may be 
normal or even increased; but the muriatic acid is loosely connected 
with the bulky remaining albuminates, peptones, and salts, and hence 
is without chemical or antiseptic action on the one hand, and, on the 
other, its presence is “concealed,” or cannot be established by the ordi- 
nary reactions. The great amount of lactic acids (butyric and acetic 
acids) is shown by the amount of fermentation. The diminished 
digestion of all kinds of food shows this plainly. In the incubator 
the albumen is not digested. 
5. A peculiar anomaly as respects the gastric secretion consists in 
the fact that even when the stomach is empty, muriatic acid, pepsin, 
and rennet-ferment, or propepsin and rennet-zymogen, are secreted 
(supersecretion, hypersecretion). A very considerable amount of this 
gastric secretion may be accumulated in the stomach; and this is 
still more increased by the fact that, generally, the presence of an acid 
fluid in the stomach stimulates the secretion of saliva. The saliva 
swallowed is not, however, sufficient to neutralize the acid fluid. 
Schreiber has recently found that, even in persons who are in per- 
fect health, there is a small quantity of acid gastric secretion in the 
fasting stomach. This is in direct contradiction of the statements of EXAMINATION OF THE DIGESTIVE APPARATUS. 
347 
former authors. We will again enter (p. 355) upon the question of 
the gastric secretion in the fasting stomach. 
Mode of Procedure in Examining the Stomach-Digestion. 
The action of the stomach is divided into the chemical effect of its 
secretion and the assistance furnished by mechanically mixing the 
food and reducing it to small particles; the passing-on of the digested 
or sterilized material, and the absorption of a portion of it. Com- 
pared with that which is passed along, the amount absorbed seems to 
be small. These processes imply, as has been shown above, a certain 
length of time, which, in health and when a meal of moderate size is 
eaten, takes place within tolerably definite limits. 
Thus, the examination of the action of the stomach is connected 
with the determination of the' duration of digestion, the examination 
of the chemical action during digestion, lastly, the relation of the 
onward movement and absorption. 
I. Duration of digestion. Since the duration of digestion very 
much depends upon the kind and size of the meal, in making the 
examination, it is indispensably necessary to arrange similar conditions 
artificially. This requirement will be met by Leube’s experimental 
meal, consisting of a plate of water-gruel, an ordinary piece of beef- 
steak, and white bread. After partaking of this meal, the patient takes 
nothing until seven hours from the time it was eaten, when the 
stomach is to be emptied by means of an oesophageal catheter. 
When the digestion is normal, the stomach after this space of time 
is empty, or contains only a few particles of the remains of the food. 
The stomach is emptied or washed out by means of an oesophageal 
catheter and a siphon, or exceptionally by employing a stomach- 
pump. We employ a soft oesophageal catheter of at least 
0.6 cm. internal diameter, to which we attach a piece of rubber 
tubing, 1 m. to 1.20 m. in length, with a short piece of glass tubing 
inserted along its course; on the other end of the tubing is a glass 
funnel. The catheter is introduced without a guide; in short, like 
any other oesophageal sound (see p. 293). After it has been used 
several times, the patient learns to introduce it himself, which he does 
by a sort of swallowing motion. Care must be taken lest the sound 
goes clear down, as has more than once happened. 348 
SPECIAL DIAGNOSIS. 
If the stomach is quite full, then immediately after the catheter is 
introduced its contents well up through it, even if the rubber tube 
and funnel have not been attached. If the stomach is only moder- 
ately full, then it is often simply necessary to press the patient in 
order to bring up the contents of the stomach through the catheter. 
If, in this way, we do not receive anything, then, if there is no reason 
to suspect an ulcer or a carcinoma that will bleed easily, we may 
carefully aspirate with a stomach-pump. If, even then, we do not 
get anything, we must wash out the stomach with a small, but 
measured, amount of water, so as to see whether there are still some 
remaining particles of food. For this purpose we fill the tube and a 
part of the funnel with lukewarm water, before connecting it with the 
catheter, and then we pour more water into the funnel, hold it high 
and allow the water to run into the stomach. Next, before it is quite 
empty, we lower the funnel quickly into a vessel standing ready upon 
the floor: the tubing and funnel act as a siphon, and suck out the 
contents of the stomach. By filling and emptying it several times, the 
stomach will generally be completely emptied. 
If, in this way, we cannot obtain sufficient siphon-action, we can 
increase the suction power of the apparatus by placing the funnel in 
a vessel of water, extending the rubber tube, and then lifting the 
funnel a little in the water. 
If the rinsings of the stomach after seven hours contain at most 
only a few remnants of food, in most cases the digestion is normal. 
At any rate, if it is tolerably certain that there is diminution of gas- 
tric juice, an injurious effect from emptying the stomach is entirely 
excluded. But it is possible that there is superacidity, and, as a 
matter of course, supersecretion. If this is the case, we repeat the 
experiment, except that the catheter is introduced one or two hours- 
sooner. 'In this way we determine the duration of digestion. 
If, after seven hours, the stomach still contains considerable por- 
tions of food, then digestion is prolonged : subacidity, or there is inter- 
ference with the physiological emptying of the stomach: stenosis of 
the pylorus, diminished peristalsis, or dilatation. Digestion of a simple 
meal (see above) lasting longer than seven hours is, in health, only 
observed in menstruating women. 
II. The chemistry of digestion. We may again employ Leube’s 
experimental meal for investigating the chemistry of digestion. Some- EXAMINATION OF THE DIGESTIVE APPARATUS. 
349 
times we may make use of what we obtain while determining the dura- 
tion of digestion—that is, if seven hours after the meal we find the 
stomach yet full. If it is empty, then we repeat the experimental 
meal, and make the trial five hours after it. If we then find it empty 
(which, normally, is not seldom the case), we go back to four hours. In 
such cases, at any rate, where there is free muriatic acid, we endeavor 
to examine the contents of the stomach at the height of the muriatic- 
acid digestion—that is, at the time when the muriatic acid has its 
chief value. This is usually about an hour before the close of the 
period of gastric digestion. 
Ewald has introduced an important simplification of this examina- 
tion. He gives a test-breakfast, consisting of a dry roll and luke- 
warm water or dilute tea, which are taken fasting. The period of 
digestion is thus so shortened that, one hour after, digestion has 
reached its highest point. 
In regard to the dispute as to which is preferable, the experimental 
meal or the experimental breakfast, we take the ground that the latter 
is decidedly to be preferred for settling the important points we are 
seeking, particularly for the practising physician, who is not able to 
control his patients, and hence must choose the experiment lasting 
one hour rather than the other, where he is obliged to be away from 
his fasting patient from four to six hours. But, on the other hand, we 
must, with others, emphasize the fact that the experimental breakfast 
makes too slight a demand upon the stomach to permit of a nice judgment 
as to what it can do. Hence, our experience leads us to believe that the 
experimental breakfast may mislead us in two diametrically opposite 
directions—in many cases, by the digestive power of the stomach seem- 
ing greater than it is; or, in other cases, that it does not appear to be 
as strong as it really is, because it is too little stimulated (in certain 
nervous dyspepsias, also in many cases of chronic catarrh, as alcoholic 
catarrh). The greater “cleanliness” of his experiment, as Ewald 
maintains, cannot be recognized as regulative; after filtration, in all 
cases, we obtain after the experimental meal a perfectly clear fluid, 
which responds very well to the reactions presently to be described. 
Jaworski gives as the experimental meal the albumin of two boiled 
eggs with 100 gm. of water—a simplification which we do not think 
useful or necessary. It is an unnatural experiment, as the well-known 
instinctive disgust for food of pure albumin proves. 350 
SPECIAL DIA GNOSIS. 
The following procedure is recommended for making the examina- 
tion : 
1. We satisfy ourselves whether there is any bile, blood, or pus in 
the contents of the stomach (see Vomit). If there is not, then we 
filter a portion for further examination. 
2. We carefully examine the residuum upon the filtering-paper 
with the naked eye. If an experimental meal has been given, then we 
observe how thoroughly the masses of meat have been macerated, especi- 
ally whether the maceration is uniform ; further, we notice whether 
there are any unchanged particles of bread. (Regarding certain things 
seen under the microscope, see Vomit.) 
3. We test the reaction of the fluid-filtrate with litmus (paper or 
tincture). An acid reaction may be due to muriatic acid or organic 
acids, or both. 
4. Then follows the qualitative examination for free muriatic acid 
and lactic acid. 
For testing for free muriatic acid we recommend the test with 
tropaolin-paper.1 We moisten the paper with a drop of the filtrate, 
then place the bit of paper in a watch-glass and heat it. If there is 
free HC1, the tropaolin-paper first becomes brown, then, as it dries, 
lilac color. Approximately equivalent is the test with a saturated 
alcoholic solution of OO-tropiiolin, which has been mixed with a double 
quantity of the filtrate in a small porcelain dish, distributed by 
rinsing. After pouring off the surplus, it is to be slowly heated : free 
HC1 yields a lilac-red reflection. Lactic acid gives no reaction, even 
when tolerably concentrated (0.6 per cent.). It is very distinct when 
the solution of IIC1 is pure—about 0.05 per cent. In the presence 
of albumin, peptones, phosphates, it is much less distinct. 
Still more certain and much more distinct, while its distinctness is 
much less affected by other substances, is the phloroglucin-vanillin test. 
The reagent consists of phloroglucin 2 parts, vanillin 1 part, to absolute 
alcohol 30 parts. Of this, one or two drops are placed in a shallow por- 
celain dish, with an equal amount of the filtrate, and carefully heated. 
Free IIC1 gives a deep red, or, if the quantity is small, a bright 
rosy-red deposit; if there is no HC1, then the deposit is brown-red 
or brown. It is distinct—even to 0.05 per thousand. It is very 
1 Filter-paper soaked with a saturated solution of 00-Tropaolin. EXAMINATION OF THE DIGESTIVE APPARATUS. 
351 
nearly absolutely certain ; its only drawback is that the reaction takes 
place also in the presence of sulphuretted hydrogen (hence, after 
tainted eggs have been eaten). This test very much surpasses all 
others. It is sufficient to employ this only. 
Of the numerous other tests we only mention : The reaction with 
methyl-violet, which is applied as follows: two reagent-glasses are 
half-filled with a transparent solution of methyl-violet, and to this 
some of the filtrate is added. Free HC1 colors methyl-violet blue. 
The reaction is not very distinct, nor is it very reliable; it can be 
imitated by table-salt, and it may be concealed by albuminate, pep- 
tone, etc. There are also to be named: congo-paper, blue ultramarine, 
and, lastly, resorcin, recently recommended by Boas (resorcin 5 
parts, sugar 3 parts, dilute spirit to 100 parts). 
The examination for lactic acid is conducted in the way suggested 
by Uffelmann : to about 100 gm. of a 2-per-cent, solution of carbolic 
acid we add one to two drops of a solution of chloride of iron, when 
the mixture becomes steel-blue. To this we add some of the stomach- 
fluid. If lactic acid is present, the solution is discolored and 
becomes yellow or yellowish-green; on the other hand, if there is 
only HC1, the solution becomes clear, like water. Butyric and 
acetic acids give it a more yellowish-red color; moreover, they are 
recognized by their odor, at any rate after shaking up some of the 
stomach-fluid with ether and evaporating the ether. The test is a 
very delicate one, and shows 0.01 per thousand of lactic acid. Its 
certainty is somewhat detracted from by the fact that lactic-acid salts 
give the same reaction. It is more important that alcohol, sugar, and 
acid salts cause the solution of chloride of iron and carbolic acid to 
assume a straw-yellow color. For this reason, in case there is no 
pronounced greenish-yellow, but a straw-yellow coloration, we must 
employ a more certain method: we simply agitate some of the filtrate 
with ether in a reagent-glass, pour off the ether, and then evaporate 
the residue over hot water, not a flame. We dissolve the deposit in 
water, and apply Uffelmann’s reaction by the addition of a few drops 
of the reagent (Ewald). 
5. The quantitative examination of the muriatic acid has a certain 
value in subacidity, but still greater when there is a suspicion of 
superacidity. Let it be once more remarked that the latter may be 
the case not only when the duration of the digestion of albuminous 352 
SPECIAL DIAGNOSIS. 
material is diminished, but also when it is normal, or even when its 
duration is prolonged. Two methods may be employed, in both of 
which the supposed time of greatest amount of HC1 is selected. Pus, 
blood, bile, a large amount of saliva must be excluded. Repeated 
examination is necessary. If the quantity of IIC1 exceeds 0.3 per 
cent., it may certainly be regarded as pathological. As much as 0.6 
per cent, of free acid has been found. 
First method: The determination of the total acidity is made by 
neutralizing it with a normal solution of soda. Of course, this will 
<_3 ' 
be understood to have value only in case there are no organic acids 
present, or not an appreciable amount of them. It is treated with a 
1 to 10 normal solution of soda and litmus or phenol-phtallein ; 1 
c.c. of the 1 to 10 soda solution neutralizes 0.0365 HC1. 
Second method: As suggested by Giinzburg, we can employ the 
phloroglucin-vanillin reaction for an approximative quantitative de- 
termination of HC1, by remembering that the reaction still positively 
takes place in the presence of 0.05 per thousand of HC1. Hence we 
have to dilute the stomach-fluid with a definite quantity of distilled 
water so long as the reaction is produced sufficiently to be recognized. 
Since Giinzburg’s reaction is not disturbed by lactic acid, the simul- 
taneous presence of lactic acid does not interfere with this method. 
It is still very desirable that there should be an exact revisional proof 
of this method. 
6. Examining the digestion in an incubator. The examination of 
the digestive power of the gastric juice is of especial value for demon- 
strating pepsin. At any rate, experience shows that when there is 
free muriatic acid, pepsin is usually present; on the other hand, when 
muriatic acid is absent, no pepsin is present, for the reason that the 
mucous membrane of the stomach does not secrete pepsin itself, but 
secretes its zymogen, propepsin, and because muriatic acid has the 
exclusive, or at least the chief, power to form pepsin out of propepsin. 
For these reasons, it may suffice, in most cases, to examine for muri- 
atic acid alone. But the thorough examination is of the greatest 
value for arriving at a complete judgment. 
We test the digestive power of the gastric juice upon a piece of the 
white of a hard-boiled egg. A piece about a centimetre square and a 
millimetre thick placed in a reagent-glass full of normal stomach-fluid 
should be dissolved in about an hour. If the solution is delayed, or EXAMINATION OF THE DIGESTIVE APPARATUS. 
353 
does not take place at all, it proves that there is a deficiency in the 
normal amount of pepsin only when we are able to determine that 
there is also a deficiency in muriatic acid. For this reason, it is best 
to conduct the examination simultaneously in two reagent glasses, to 
one of which a few drops of HC1 have been added. 
The coagulating effect of the gastric juice—that is to say, of the 
rennet-ferment—upon the casein of milk is proved by the fact that, at 
the temperature of the body, neutralized stomach-filtrate with neutral 
(or amphoteric) milk is coagulated ; in fifteen to thirty minutes, if the 
rennet-ferment is present, there is coagulation of the casein. This 
test, it seems, can generally be omitted if it concerns nurslings, in 
whom it is of special interest: for it has been shown that when free 
HC1 and pepsin are present, the rennet-ferment is never absent; 
even in most cases of absence of both the others, rennet-ferment 
indeed seems not to be met with, but rennet-zymogen, which requires 
muriatic acid in order to transform it into rennet-ferment. In order 
to prove the presence of rennet-zymogen in gastric juice which is 
deficient in IICl and rennet-ferment, we supply the deficiency by 
adding HC1 and then allow it to stand in an incubator for two 
hours, after which we apply the test for the ferment mentioned above. 
In atrophy of the mucous membrane of the stomach, there is entire 
absence of rennet-zymogen, as well as of HC1 and pepsin. 
Of the somewhat difficult methods of examining the products of 
digestion we can here mention the two following: 1. The transforma- 
tion of the starches into erythro- and achrob-dextrin can be quali- 
tatively followed by means of dilute Lugol’s solution (lod. 1 part, 
iodide of potash 2 parts, aq. dest. 200 parts); it colors starch blue; 
erythro-dextrin, purple-red; achrob dextrin remains colorless or be- 
comes yellow. A mixture of starch and dextrin with the first drops 
of the iodine solution becomes colorless, but upon further addition it 
becomes red and then blue. 
2. Peptone and propeptone in alkaline solution, upon the addition 
of a solution of sulphate of copper, give a wonderfully beautiful purple 
color; albumin makes it blue-violet; hence, on account of this simi- 
larity of colors, it is often extremely difficult to distinguish albumin 
from peptone, particularly if the stomach-fluid is turbid. 
Ill The effort has been made in various ways to ascertain what 
part the movements of the stomach play in digestion. No method 354 
SPECIAL DIAGNOSIS. 
that has thus far been devised meets the requirement; hence, we only- 
mention them very briefly. 
The peculiarity of salol that it splits up into salicylic acid and 
phenol only in the intestine, whereupon the appearance of salicylic 
acid in the urine is easily proved, has been employed by Ewald to 
determine the rapidity of the passage of food from the stomach into 
the intestine. Salicylic acid is recognized in the urine after the addi- 
tion of chloride of iron by the violet reaction in the urine. In order 
to recognize the first traces, we must make the test upon an ethereal 
extract [of the urine. (Compare what is said later regarding the 
Urine after the Administration of Medicines.)]. Ewald found that in 
health the first positive reaction took place one-half to one hour after 
it had been taken; when the process of transportation from the 
stomach had been interrupted, it was later. However, the results of 
this procedure seem to be quite variable. 
The same thing must be said of the use of pills of iodide of potash 
coated with keratin, which very evidently are preferable, because we 
do not need to employ the urine in proving the absorption of the 
iodide, hut we can make use of the saliva. But Stintzing has found 
that these pills are sometimes dissolved in the stomach. 
Finally, Klemperer has attempted a method, which, from a purely 
technical standpoint, is very exact, hut is decidedly impracticable. 
He introduces into the empty stomach 100 grammes of olive oil, and, 
after a certain interval, washes the stomach out. From healthy 
stomachs he found that, in two hours, 70 to 80 grammes of the oil had 
been discharged into the intestine, while in cases of catarrh of the 
stomach about half, and in one case of atrophy a quarter, of that 
amount had in the same time disappeared from the stomach. This 
method is less objectionable, because the oil is sometimes not borne in 
the patient’s stomach—it may even be rejected. But it is much more 
so because it does not sufficiently irritate the stomach. 
Lastly, the absorptive power of the stomach has been frequently the 
object of examination. 
Penzoldt. gives 0.2 iodide of potassium in gelatin capsules, and then 
at once tests the saliva to see whether the capsule was close and free 
from iodide of potassium upon its outer surface. For this purpose we 
have the patient, moment by moment, spit upon a piece of filter-paper 
saturated with a solution of starch, upon which we place a trace of EXAMINATION OF THE DIGESTIVE APPARATUS. 
355 
fuming nitro-hydrochloric acid; the appearance of the iodide in the 
saliva will be recognized by the red and blue coloration of the paper. 
In health, the iodide will make its appearance, if it has been taken 
upon an empty stomach or three hours after eating, in from six and a 
half to eleven minutes; if directly after a meal has been eaten, after 
twenty to forty-five minutes. In cases of dilatation, if taken upon a 
fasting stomach, its earliest appearance is after fifteen to thirty 
minutes. It also seems to he delayed in carcinoma, chronic catarrh, 
and in fevers. 
The question is, whether we can draw a conclusion as to the 
absorption of the products of digestion from the behavior of the 
iodide. 
The examination of the fasting stomach has for its object the 
determination of the behavior of the gastric secretion after the com- 
pletion of stomach-digestion. Hence, it is conducted with reference 
to the diagnosis of a possible hypersecretion. 
Method. Recent investigations upon this subject show that it is 
very important to avoid making use of the secretion of the stomach 
which results from any mechanical irritation. Hence, we must be 
very cautious and proceed very rapidly. We recommend a Nelaton’s 
sound, without an eye, but, instead, a number of fine openings at the 
end, which is to be introduced into the stomach some hours after we have 
washed it out in order to make sure that it was empty. Or, still better, 
we first determine the duration of digestion, then we allow the stomach 
to be quiet after the expiration of the last meal. Then a stomach- 
pump is quickly introduced ; aspirate, withdraw the sound, and empty 
it into a vessel. Next we examine the fluid thus obtained as to its 
reaction, and, if acid, for muriatic acid; further, as to its digesting 
qualities. For passing judgment upon the results of this procedure 
and its diagnostic significance, see the following pages. 
Finally, on account of its historical interest, we mention here the 
method given by Leube, but superseded by his experimental digestion. 
He introduced ice-water into the empty stomach and then aspirated it, 
in order to obtain for examination the gastric secretion pure—that is, 
diluted with water. 
Results of the examination of stomach-digestion : their value. 
1. If the examination of the duration of digestion shows that it is not 
prolonged, then, as a rule, .the process of digestion is normal; but 356 
SPECIAL DIAGNOSIS. 
the period of digestion may be shortened, and this sometimes is the 
case when there is superacidity. If the period of digestion is pro- 
longed, this must be further investigated. 
2. Free muriatic acid, which belongs to the time when normal 
digestion is at its height, may be completely wanting (inacidity, 
anacidity). This almost uniformly occurs when there is complete 
destruction (corrosion) of the mucous membrane of the stomach, when 
it is atrophied, or has undergone amyloid degeneration. Further, 
inacidity is almost always present in carcinoma ventriculi with dilata- 
tion, more rarely, although also very frequently, in all other kinds of 
dilatation. Of these we must mention especially that which occurs 
with chronic gastric catarrh. The dilatation produced by the scar of 
an ulcer (at the pylorus), or accompanying an ulcer, is associated with 
diminution or absence of free HC1. Subacidity, or even inacidity, is 
further observed in severe anaemia of all kinds and with fever, and, 
lastly, in certain cases of nervous dyspepsia. 
Accompanying this condition is the more or less markedly increased 
formation of lactic acids (butyric, acetic acids, alcohol)—a sign of 
abnormal fermentation. In very severe cases it may result in fetid 
decomposition of the contents of the stomach. Moreover, for an 
unusual length of time or continuously, there may be undigested 
masses or fine particles of meat. 
For reasons that are l'eadily understood, the behavior of the stomach 
in cases of phthisis has been very much studied; the results vary 
in a very remarkable degree. The general conclusion from these 
examinations (Liebermeister, Hildebrand, Brieger) seems to be that 
in cases of severe phthisis with continued fever, very often no free IIC1, 
sometimes even no rennet-zymogen, is found, but that free muriatic acid 
is also sometimes wanting in remittent fever. At any rate, the ex- 
amination of the stomach-digestion in phthisis for prognostic and 
therapeutic reasons is to be recommended in every single case. 
3. Increased amount of HC1 at the height of digestion, shortening 
of the time (normal maximum of one hour) during which lactic acid 
is present, are signs of superacidity. Thus the period of digestion is 
shortened, or normal, or sometimes even prolonged. As evidence of 
disturbed amylolysis, we have unchanged starch during the whole period 
of digestion. EXAMINATION OF THE DIGESTIVE APPARATUS. 
357 
Superacidity is present in the majority of cases of ulcer, also in 
certain nervous dyspepsias (gastroxynsis, pyrosis hydrochlorica), lastly 
in acute and sometimes in chronic gastric catarrh. It is also observed 
in the forms of insanity accompanied with depression. 
4. It has been shown by recent investigations (Schreiber, and par- 
ticularly E. Pick), regarding the significance of the presence of acid- 
secretion of the stomach, that a positive conclusion from the examina- 
tion can only be drawn with caution, because the irritation of the 
sound seems to stimulate the stomach to pour out its secretion very 
rapidly. We can only diagnosticate supersecretion (hypersecretion), 
when by a rapid, careful procedure at least about 200 c. c. of acid 
gastric secretion are obtained. 
Supersecretion occurs in the gastric crisis of tabes and certain 
neuroses, as hysteria and nervousness. It is sometimes also observed 
with ulcus ventriculi, in individual cases of carcinoma, and in acute 
and chronic catarrh. 
Emptying the stomach for therapeutic purposes, or washing it out, 
must be undertaken, in the first place, in cases of recent acute poisoning, 
and frequently for the purpose of diagnosis. This is the case in almost 
all cases of poisoning, where the poison has been swallowed. But it 
must be remembered that in poisoning with substances that are corro- 
sive, as acids and alkalies, on account of the danger of perforation of 
the oesophagus or stomach, the sound must be used with the greatest 
caution, or even not at all. The detection of the kind of poison in 
the contents of the stomach belongs to toxicology. Some poisons 
entirely escape detection. 
What has been said above regarding the examination of the con- 
tents of the stomach, explains the therapeutic use of washing out the 
stomach when it is diseased, in that it can be employed for observing 
the course of the disturbance of digestion in diseases of the stomach. 
For instance, it is evident from what has been said that it is not 
without value occasionally to institute a daily washing out of the 
stomach, in case it is diseased, to determine whether it contains lactic 
acid many hours after the last meal was taken. Also, frequent micro- 
scopical examination of the sediment of the rinsings of the stomach 
(in sarcina ventriculi, etc., see Vomit) is of undoubted value. SPECIAL DIAGNOSIS. 
358 
Vomiting, and the Examination of what is Vomited. 
The act of vomiting consists of one or several strong forcible contrac- 
tions which occur simultaneously in the oblique abdominal muscles and 
the diaphragm. In this way the stomach is compressed, and, by the 
simultaneous opening of the cardiac orifice, its contents escape upward. 
Otherwise the stomach takes no active part in expelling the food. From 
the not infrequent presence of bile in the last portions that are vomited 
toward the end of a severe effort at vomiting, it is evident that the 
pylorus also sometimes does not entirely close. 
In this connection we do not include the vomiting, or rather the 
expulsion of food from dilated parts of the oesophagus when there is 
stenosis or diverticula. (See Examination of the (Esophagus.) 
Vomiting may occur in a great variety of ways, and in diseases which 
differ greatly in character. We suppose that the so-called vomiting- 
centre is situated in the oblongata. This may be stimulated from the 
periphery, chiefly through the sensory portion of the vagus, and so 
give rise to reflex vomiting. Moreover, it may be stimulated directly 
or by impressions from other portions of the brain (central vomiting). 
Children generally vomit easier than adults. There are also indi- 
vidual differences. Clinically, we distinguish: 
1. Vomiting occasioned by reflex influences from the stomach. It 
occurs in all diseases of the stomach, but also in irritation of the mucous 
membrane of the stomach by different poisons, certain emetics, etc., 
and also by overloading the stomach. 
2. Reflex vomiting caused by other abdominal organs, as from the 
female sexual apparatus in menstruation, pregnancy, diseases of the 
sexual apparatus; from inflammation of the peritoneum ; also, in renal 
and biliary colic, etc. 
Likewise, vomiting may be caused by irritation or tickling of the 
fauces. Probably here also belongs vomiting which occurs at the end 
of a severe fit of coughing, as in whooping-cough and phthisis. 
3. Central vomiting. It may result from irritation of the brain of 
various kinds: as different evident diseases of the brain, especially 
tumors; in the different forms of meningitis; in neuroses, particularly 
hysteria; and from uraemia. Vomiting occurs also in the beginning 
of certain acute infectious diseases, as pneumonia, scarlet fever, small- 
pox, erysipelas, [remittent fever]. EXAMINATION OF THE DIGESTIVE APPARATUS. 
359 
Vomiting is almost always accompanied by certain other phenomena: 
previous malaise, often severe sweating, quickening of the pulse; 
exhaustion, with the feeling of relief, but also evidences of collapse. 
In diseases of the brain, it sometimes occurs without any preliminary 
indisposition, even quite suddenly and unexpectedly. 
As regards the time wdien the vomiting begins, in diseases of the 
stomach, it often (not always) follows eating. Also in peritonitis, vomit- 
ing is often excited by the taking of food; but here also it takes place 
quite independently of this. The vomitus matutinus of drunkards, as 
a rule, regularly occurs early in the morning, when the stomach is 
empty. Also in certain nervous dyspepsias there are apt to be attacks 
of vomiting when the stomach is empty. When there is severe vomit- 
ing without phenomena of stomach or other abdominal disturbances, 
we must take into consideration the other conditions named above— 
acute infectious diseases, disease of the brain, uraemia, hysteria— 
according to the circumstances. 
The frequency of vomiting is extraordinarily variable, and is of 
little moment in diagnosis; only that it might be mentioned that in 
very marked dilatation of the stomach, from pyloric stenosis, vomiting 
occurs remarkably infrequently, but in most cases tolerably regularly, 
at intervals of several days (but then very profusely). 
There may be eructation in all the conditions in which vomiting 
occurs. It is observed, especially, in slight and severe diseases of the 
stomach of all kinds. The odor of the eructation corresponds to that 
of the contents of the stomach, as a matter of course. (See under 
Odor of the Vomit.) In individual cases, combustible gases have been 
observed (marsh gas, and probably also other gases). There occur 
with nervous persons very distressing and entirely odorless eructa- 
tions. 
The Vomit. 
When we examine the vomit, we notice the quantity, the macro- 
scopical and microscopical appearance, the odor, and the reaction. 
The chemical examination can probably occasionally enable us to 
judge of the character of the stomach-digestion. This is especially 
the case in those diseases which we cannot include in a methodical 
investigation, as, particularly, inclination to hemorrhage, etc. (See 
above.) Of course, we must consider the relation of the vomiting to 360 
SPECIAL DIAGNOSIS. 
the time of the last meal, and what this meal consisted of. The 
points of view are to be taken from what has been said above regard- 
ing experimental digestion. Where there are macroscopical appear- 
ances of blood and coloring matter of bile, we must farther apply the 
chemical tests for these substances. 
The quantity vomited. Here we must consider the time and fre- 
quency of the vomiting, as well as the amount of food taken. When 
there is vomiting from an empty stomach, there is usually only a little 
mucus, seldom much mucus or saliva that has been swallowed (yomitus 
matutinus potatorum), or more or less pure gastric juice (hypersecre- 
tion). In acute infectious diseases, diseases of the brain, uraemia, 
sometimes scarcely anything at all is vomited. 
A vomiting which seems to result from the ingestion of food, but 
the amount of which considerably exceeds the quantity of food and 
drink last taken, is an almost mathematically sure proof of dilatation 
of the stomach. Here the contents of the stomach may accumulate 
for a number of days and then be thrown off en masse, to the amount 
of several litres. 
The macroscopical appearance. This will naturally depend very 
much upon the food taken. It was mentioned above, when speaking 
of the experiments with digestion, that under some circumstances we 
can form a conclusion regarding digestion by the comminution of the 
food. Some foods, as coffee, cocoa, red wine, huckleberries, etc., 
markedly color the vomit, and may sometimes give rise to mistake, if 
it is superficially examined, by causing one to think that there has 
been haematemesis (the laity being not infrequently thus deceived, and 
hence we must be very careful in accepting the anamnesis). When 
preparations of iron have been taken, the vomit is black ; but it is 
also sometimes black in acute lead-poisoning. Apart from the food, 
we can, from some prominent constituents (when the contents of the 
stomach are abnormal), make certain important distinctions in what is 
vomited, as well as in the sputum. 
Watery, watery-mucous, mucous vomit. The first and the second 
named may ordinarily have two very different meanings. In both 
cases we have a somewhat turbid fluid, resembling saliva or fluid 
mucus, which is vomited from a fasting stomach. It has an alkaline 
reaction, and usually indicates chronic gastric catarrh. The fluid 
consists of mucus from the mucous membrane of the stomach, and of EXAMINATION OF THE DIGESTIVE APPARATUS. 
361 
saliva that has been swallowed. In this way the frequently men- 
tioned “water-brash” of drunkards (vomitus matutinus potatorum) 
especially manifests itself in the early morning, immediately after 
rising. Also such vomiting occurs (rare) in nervous dyspepsia. If 
the fluid smells sour, and has an acid reaction, and if it shows the 
muriatic acid reaction and power of digestion, then wre have gastric 
juice secreted by the empty stomach : hypersecretion. This gastric 
juice is often over-acid—hypersecretion with hyperacidity (over 0.3 
per cent.). This occurs in certain kinds of nervous dyspepsia (gas- 
troxynsis, gastroxia; also hysteria; tabes), but also in dyspepsia fol- 
lowing healed ulcer, and acute and chronic gastric catarrh. In these 
cases the quantity vomited may amount to several hundred grammes. 
A special form of watery-mucous vomit is peculiar to Asiatic 
cholera. In this disease there is often vomited a great quantity of 
alkaline, stale-smelling fluid, like rice-water (very like the stools of 
cholera) (which see). The small flocks, like rice, are mucous flocks. 
It is not possible to separate mucous from watery-mucous vomit. 
Sometimes a great quantity of mucus is observed in chronic catarrh 
of the stomach. 
Vomiting of bile. As previously mentioned, bile may be mixed 
with every vomit, and this is especially apt to be the case in very 
severe efforts at vomiting, so that toward the end almost pure bile is 
ejected. The vomit looks yellowish-green or green, and smells 
decidedly bilious. It exhibits the reaction of the coloring matter of 
the bile. (See Urine.) 
A grass-green bilious vomit, occurring with tolerable uniformity, 
with every act of vomiting whether violent or not, is a not unimpor- 
tant peculiarity of peritonitis, and of marked obstruction of the 
bowels. 
Bloodv vomit, vomiting of blood (hsematemesis). Blood from the 
nose, throat, and oesophagus may become mixed with the vomit in the 
act of vomiting. Small quantities, in streaks, are usually of no sig- 
nificance. Large hemorrhages from the oesophagus, as in varices 
of the lower portion of the oesophagus, and in cirrhosis of the liver, 
usually after it has run down into the stomach, cause severe haemate- 
mesis. Also blood from the nose, and even from the lungs, may 
reach the stomach and be vomited up (see p. 170). We must be 
careful not to confound such an occurrence with hemorrhage of the 362 
SPECIAL DIAGNOSIS. 
stomach. In doubtful cases the anamnesis is of less value than the 
examination of the stomach, nose, and lungs. (See p. 170 for further 
particulars regarding the distinction of hemorrhage of the lungs from 
that of the stomach.) 
Small points of blood and streaks in the vomit, moreover, even if 
they come from the stomach, according to our experience, are generally 
without significance ; that they are from the stomach is proved by the 
presence, not infrequently, of bloody suffusion of the mucous mem- 
brane of the stomach at the autopsy. Streaks of blood frequently 
recurring, whose source the autopsy proves to be the stomach, are not 
at all uncommon in cirrhosis of the liver. 
Bloody vomit, from hemorrhage of the stomach, takes place in ulcer 
of the stomach, carcinoma ventriculi, portal engorgement from cir- 
rhosis of the liver, closure of the portal vein (rare in general venous 
stasis), in severe lesions of the mucous membrane of the stomach by 
corrosive poisons, also in general hemorrhagic diathesis (see cutaneous 
hemorrhages), in yellow fever, melaena neonatorum ; in the last-named 
cases there usually occurs simultaneous hemorrhage of the bowels. 
Very decided, and sometimes fatal, hsematemesis is chiefly peculiar to 
ulcus ventriculi (also melaena). In carcinoma we notice very fre- 
quently repeated, but always moderate, hemorrhages. Moreover, in 
all these conditions the vomiting of blood may be entirely wanting, 
either because there is no escape of blood into the stomach, or because 
the blood is not vomited. 
When we suspect hemorrhage of the stomach, which is not vomited, 
we are to examine the stools (which see). Sometimes, in ulcer of the 
stomach, the patient becomes suddenly pale, may collapse, or may 
even die from a hemorrhage of the stomach, without there being any 
vomiting of blood. In order to observe exactly an ulceration of the 
stomach, it is particularly necessary to observe uninterruptedly the 
stools. 
Pure blood is seldom vomited, unless there is a great quantity of it, 
or it is vomited directly after or during the hemorrhage. Moreover, 
it is never of so clear an arterial color as in hemorrhage of the lungs. 
The blood is almost always more or less changed by the gastric juice: 
it is very dark, black-brown, and has an acid reaction. If it has been 
in the stomach for some time, as is quite often the case in carcinoma 
with dilatation, because the hemorrhages are usually small and there EXAMINATION OF THE DIGESTIVE APPARATUS. 
363 
are long pauses between the hemorrhages, under the influence of the 
acids, by the breaking-up of the red corpuscles and the haemoglobin, 
and the appearance of haematin, it becomes coffee-brown and also of 
the consistence of coffee-grounds. Then, in case it is abundant, it is 
easy, with some experience, to recognize it; yet it is easy to confound 
it with other substances, as coffee, cocoa, etc. (See above.) For this 
reason, and because we cannot here employ the microscope, it is 
preferable, in this case, always to make a special test of the blood. 
Testing the blood: 1. Very correctly, the haemin test is generally 
employed, because it is certain and distinct. The following is the best 
way to make it: Some of the coffee-grounds material is filtered; a 
Fig. 92, 
Crystals of hsemin. Zeiss’s apochromatic lens No. 8, eye-piece No. 8, camera lucida. 
Magnified about 300 diameters. 
little of this is to be evaporated in a watch-glass. Scrape off some of 
the dried material, mix it with a trace of finely-pulverized salt, place 
the dried mixture upon an object-glass, cover it with a glass cover, 
and allow one or two drops of glacial acetic acid to flow under it; then 
the acetic acid is again evaporated very slowly, and, after it is thor- 
oughly dry, one or two drops of distilled water are allowed to flow undei 
to dissolve any crystals of salt that may be present. Undei the 
microscope, there can be seen crystals of hsemin (hydrochlorate of 
hsematin) in coffee-brown or reddish-brown crystals in rhombic plates, 
which must be considerably magnified, as the crystals are very small. 364 
SPECIAL DIAGNOSIS. 
The following method (an adaptation to the vomit of Heller’s test 
for blood-coloring material in the urine, which see) leads to a result 
more quickly: We place some of the filtered stomach-fluid in a 
reagent-glass, with a like quantity of normal urine, make it strongly 
alkaline with liquor potassse, and heat it. The urine-phosphates are 
precipitated and carry with them the coloring-material of the blood, 
and when blood is present, we have a cloudy, flocculent, reddish-brown 
deposit. 
Vomiting of pus. Pus, as a macroscopically visible constituent of 
the vomit, is somewhat unusual, and is only observed in isolated cases 
of phlegmonous gastritis or of abscess of a neighboring organ, breaking 
into the stomach. Probably it can then only be observed when it 
pours into the stomach in such quantities and so quickly that it 
makes the contents of the stomach alkaline, for only thus will it avoid 
immediate digestion. Regarding separate white corpuscles, see below. 
Fecal vomiting (miserere, ileus). In this condition, either there 
are considerable quantities vomited which do not look distinctly 
feculent, probably coming rather from the stomach or the upper 
portion of the small intestine, and the fecal addition is betrayed by 
its odor, or there are distinctly fecal masses, even balls of excrement. 
This kind of vomit occurs in severe diffuse peritonitis and in serious 
occlusion of the bowels (see Inspection and Palpation of the Abdomen). 
It indicates an extremely serious and, in most cases, fatal condition; 
yet it does not by any means have the absolutely fatal significance 
which was formerly ascribed to it. 
As visible admixtures which can be seen with the naked eye, are 
still to be mentioned: 
Round worms, which come from the small intestine, probably 
brought into the stomach by the first efforts at vomiting, and are 
afterward seen in the material vomited up. It is a startling appear- 
ance, but in itself has no significance. Also : 
Membranous rags of echinococcus, in case one should break into 
the stomach from the liver or spleen. In these cases, the microscope 
sometimes shows the scolices and hooks of the parasite (see illustration, 
p. 183). 
Moreover, in individual cases, there are found in the vomit, also, 
oxyuris, anchylostomen, trichinae (see these under Stool). 
Microscopical examination. This is of very little independent EXAMINATION OF THE DIGESTIVE APPARATUS. 
365 
value in determining the processes of digestion. In vomiting which 
takes place during digestion, we, of course, expect to find portions of 
food in very varying condition, according to the time the vomiting 
occurs. 
Starch-grains in considerable quantity, for the time when the 
amylolytic digestive period ought to be past, indicate incomplete 
amylolysis, as is almost always produced by hyperacidity (in conse- 
quence of the too early appearance of free muriatic acid). 
Mucous corpuscles are found in watery and mucous vomit; epithe- 
lium, from the mouth, throat, oesophagus, also sometimes from the 
stomach, is observed; unchanged red blood-corpuscles are very rare; 
in hemorrhage of the stomach, the microscope generally is useless, 
because the red blood-corpuscles are broken up. Also, it is rare to 
find white blood-corpuscles that are well-preserved. 
Fig. 93. 
Vomited material (Jaksch). «, Muscular fibre; 6,white blood-corpusclec,c c 
flat and cylindrical epithelium; d, starch-corpuscles; e, fat-globules;/, sarcma ven- 
triculi; o,y east-ferment; h, i, cocci and bacilli (those near A were once found by Jaksch 
in a case of ileus, hence arising from the intestine); k, fat-needles, connective tissue; 
l, vegetable cells. 
Sarcina ventriculi (schizomycetes) and torula cerevisue (germinating 
fungus) are not entirely without value, as indications that the stomach 
retains its contents for a long time, as, especially, in dilatation. 366 
SPECIAL DIAGNOSIS. 
Of the two fungi, the sarcina is the more important. If it is not 
macerated or deformed by pressure with the covering-glass, it is 
generally easily recognized, when strongly magnified, by its peculiar 
resemblance to a ball wrapped with a string crossing at right-angles. 
It is stained a reddish-brown by a weak solution of iodine, or iodide 
of potassium. 
Torulse of different kinds and sizes (the latter very much like a 
small white blood-corpuscle, generally smaller) are easily distinguished 
as small bodies strung along together, sharply defined, which refract 
the light and are egg- or elliptical-shaped. Isolated ones are observed 
in the contents of the stomach with normal digestion. When the 
quantity is considerable, it shows that it has been a long time in the 
stomach, whose contents have undergone alcoholic fermentation. 
Other different kinds of bacilli and cocci, which have only recently 
been carefully studied, are found in the vomit, but as yet they have 
no diagnostic value. 
Also, there are found in the vomit aphthae (probably originating 
in the oesophagus, see above) and favus, achorion Schonleinii. 
Reaction of the vomit. This is usually acid from muriatic or 
organic acids (see above, under Digestion). It may be alkaline when 
a considerable quantity of blood is vomited, as in water-brash, the 
watery vomit of Asiatic cholera ; also, rarely, in cadaverous vomiting, 
as in ulcerating cancer of the stomach, and in the vomiting of kidney- 
disease (see below, under Odor). Moreover, oesophagus-vomiting 
manifests itself by being always alkaline (see under Examination of 
the (Esophagus). 
Odor of the vomit. In many respects this is very important. 
Thus, particularly the presence of sebacic acid is recognized with 
great certainty by its characteristic pungent odor. 
The odor is very important in many poisons, as with phosphorus 
(odor of garlic), bitter almonds, or nitro-benzole (odor of bitter 
almonds), ammonia, carbolic acid, etc. 
There is fecal odor with ileus, cadaveric odor in ulcerating car- 
cinoma, also in fresh hemorrhage of the stomach. 
The odor is ammoniacal in nephritic patients, especially when there 
is uraemia. It is thought to result from the separation of urea by the 
mucous membrane of the stomach, by the urea in the stomach changing 
into carbonate of ammonia. EXAM IN A TION OF THE DIGESTIVE APPARATUS. 
367 
Examination of the Feces. 
As in examining the contents of the stomach, the inquiring physician 
must pursue his task from two points of view : 
On the one hand, he is to draw a conclusion from the character of 
the intestinal discharges as to the intestinal digestion, and any pos- 
sible disturbances of it from the abnormal chemical changes, and also 
an opinion regarding the present disease. On the other hand, he is 
to form a diagnosis directly from the occurrence of certain products 
of disease, or even of substances generated by disease, as intestinal 
parasites or microorganisms found in the stools. Unfortunately an 
explanation from the point of view first mentioned is difficult for sev- 
eral reasons : first, because we have to do with the last step of an 
extremely complicated process, and then, in many respects, we do not 
sufficiently understand this process itself, or its pathological variations. 
With reference to the other point, and especially regarding organic 
exciting causes of disease, we have only a few sure principles, part of 
which are old, and part have only recently been acquired. 
We have next to consider : 
The intestinal discharges, with reference to their frequency and 
their possible, usually subjective, accompanying symptoms 
The more particular examination of the stools: quantity, consist- 
ence, or form, color, odor. In addition, there are the admixtures 
which are visible by the naked eye, and those to be seen only by the 
aid of the microscope. 
As yet, it is not possible to form an estimate of the intestinal diges- 
tion by the character of the intestinal fluid. It is well known that 
sometimes (especially by evacuating the fasting stomach) there enters 
into the stomach a fluid mixed with bile which is to be regarded as a 
mixture of pancreatic and intestinal fluids, since with an alkaline reac- 
tion it digests albumin, starch is changed into dextrine and maltose, and 
fat is split up. But this occasional occurrence has not yet been employed 
for consecutive examinations. Boas recently, after carefully rinsing out 
the stomach with soda and having it tightly squeezed, has endeavoied, 
by employing an oesophageal sound, to obtain the intestinal juice. 
But his results have not yet been completely published ; hence it is 
not possible to form an opinion as to what assistance his method will 
be for the purposes of diagnosis. 368 
SPECIAL DIAGNOSIS. 
Intestinal discharges. In health their frequency varies individu- 
ally very much. Ordinarily, at all ages, excepting nursing children 
who have three or four movements a day, there is one stool in twenty- 
four hours; but many persons regularly have a movement twice in 
the twenty-four hours, while others only have one in two or three 
days, or even at longer intervals, without experiencing any inconveni- 
ence [or disorder]. But in scarcely any other way do physiology and 
pathology so much encroach upon each other’s limits as with reference 
to the frequency of the intestinal discharges, for sometimes a move- 
ment even once in two days may be troublesome, and the physiological 
habitual constipation, in many cases, cannot in any way he distin- 
guished from the pathological condition. 
Constipation, or, better, pathological constipation, is called obstipa- 
tion ; the expression obstruction (severe obstruction) is often inten- 
tionally used for constipation in a serious sense. The opposite to this 
condition is looseness, diarrhoea. 
The frequency of the discharges is directly connected with the 
quantity of food taken; hence a person who is fasting is always 
constipated. This point must often be thought of. The character of 
the food, too, has an influence upon the frequency of the discharges, 
and upon the passage of food through the intestinal canal. (See 
under “quantity.”) Thus rapid peristalsis causes diarrhoea, slow 
peristalsis, obstipation. Hence, any mechanical obstruction in the 
alimentary canal brings on constipation. 
Diarrhoea is the most important sign of intestinal catarrh. This 
is brought about by errors of diet, by cold, by infectious causes, as 
the intestinal catarrh of typhus, dysenteric inflammation of the large 
intestine, and also many intestinal catarrhs which were formerly 
referred to the cause first mentioned. In this condition, the stools are 
always thin (see the second section below and Consistence of the 
Stools); their frequency may be increased, even to occurring hourly, 
or yet oftener. 
Moreover, medicines or poisons may increase the peristalsis alone, 
or intestinal catarrh, and thus result in diarrhoea. 
In all these cases the increased peristalsis increases the fluidity of 
the intestinal contents, even causing effusion from the intestinal wall 
into the intestinal cavity (cholera), until we have the condition of diar- 
rhoea. (See below.) EXAMINATION OF THE DIGESTIVE APPARATUS. 
369 
Obstipation may be a disease which is relatively harmless, although 
very troublesome, becoming habitual. But it is of much greater diag- 
nostic significance, however, as an early sign of peritonitis from 
paralysis of the intestine. Of still greater importance is severe ob- 
struction in all forms of stenosis of the intestine, as fecal accumulation, 
particularly in the caecum; strangulation, invagination, intussuscep- 
tion of the intestine; new formations, scars in the intestinal wall, 
compressing tumors external to the intestine ; constrictions, bends 
produced by peritoneal exudations. In many cases of chronic intes- 
tinal occlusion, as in chronic peritonitis, constipation alternates with 
diarrhoea. 
But the condition of obstipation or diarrhoea is still more affected 
by a possible increased or diminished abstraction of fluid from the 
intestinal contents; the more fluid there is, the quicker it passes 
through the bowel. Now, if the intestinal contents part with much 
fluid when there is slow peristalsis, as a result of prolonged retention, 
they become dry and hard, hence are carried forward with difficulty. 
If the peristalsis is quicker, the contrary exists. The effect of slow or 
quick peristalsis is felt in the transit [of the intestinal contents], caus- 
ing either obstipation or diarrhoea. 
The severest diarrhoea occurs in cholera Asiatica, because in this 
disease there is great effusion of fluid from the intestinal wall into the 
lumen of the intestine. 
1. It is to be understood that an ordinary constipation and severe 
obstruction are to be sharply distinguished from each other, for a 
quite ordinary obstipation may be very obstinate. Here the decision 
is made by considering other phenomena, as vomiting, pain, and par- 
ticularly by examining the abdomen. This can never be omitted in 
any sudden attack of obstipation, special attention being given to the 
hernial orifices and the csecum. 
2. Persons who eat little or. nothing, whom many things either 
strangle (stenosis of the oesophagus), or cause vomiting, as in diseases 
of the stomach, but especially pyloric stenosis, in which case there is 
infrequent but considerable vomiting at a time, cannot have fiequent 
stools 5 hence they must be obstipated. buch cases are easily over- 
looked, particularly if the patients complain a good deal of obsti- 
pation. 370 
SPECIAL DIAGNOSIS. 
The special peculiarities which precede the examination of the 
bowels are of diagnostic importance : 
Pain with the movements. There will be pain at the anus or at 
the lower portion of the abdomen in all kinds of inflammatory affec- 
tions of the anus, the rectum, or their neighborhood. We have severest 
pain when the lower portion of the rectum is compressed by a large 
inflammatory (purulent) exudation, especially in the exudation of peri- 
and para-metritis ; also in fissure of the anus and abscesses from 
peri-proctitis (see Surgery). Likewise, in carcinomatous, syphilitic, 
gonorrhoeal stenosis of the rectum, but also in the usually harmless 
hemorrhoids, the pain at stool is characteristic. Sometimes in all 
these conditions, and particularly in all inflammations of the large 
intestine, but most pronounced in dysentery, there is usually painful 
straining at stool, and pain after it—tenesmus. Whenever there is 
pain at stool there must be a careful inspection of the anus and pal- 
pation of the rectum. 
Involuntary discharges of the bowels, incontinentia alvi, are most 
frequently dependent upon the cloudiness of intelligence which ac- 
companies any severe disease; but they may result from paralysis, 
particularly in diseases of the spinal cord. If the stools are thin, 
then incontinence occurs with less loss of intelligence than if they are 
firm. Slight incontinence manifests itself sometimes by the fact that 
the patient must hasten to go to stool as soon as he has the impulse. 
Incontinentia is opposed to retentio alvi as regards its neurotic origin. 
(See Examination of the Nervous System.) 
Physical and chemical peculiarities of the feces. Assuming an 
unobstructed passage, the amount of the stools is determined by the 
quantity and quality of the food taken. In the latter respect it 
depends upon how much of the food is digested and taken up ; hence, 
all vegetable foods make copious stools. 
Also, the quantity of the stools is increased in diarrhoea, because 
too little of the fluid portion of the intestinal contents is taken up. 
The greatest increase occurs in cholera, from the effusion of quantities 
of fluid into the intestine. 
Enormous quantities of firm, solid stools may be passed after pro- 
longed obstipation or serious obstruction. 
We may form an estimate from the amount of the stools, or of their 
weight, of the resorption of food, if we know how much of resorbable EXAMINATION OF THE DIGESTIVE APPARATUS. 
371 
substances the food taken contains, and if we can decide that a par- 
ticular stool comes from the food taken within the period of observa- 
tion, by the admixture of substances which give a distinctive color. 
However, we neglect the addition made to the feces during digestion 
from the digestive juices. On the one side, there is a too rapid move- 
ment of the food along the alimentary canal, and, on the other, dis- 
turbance of the resorption of the food. We learn from the recent 
investigations of F. Muller, that in mild enteritis and in mild amyloid 
degeneration only the fat, but in severe cases of disease of the mucous 
membrane all the nutritive material, is poorly resorbed; further, that 
a deficiency of pancreatic juice makes no special disturbance; defi- 
ciency of bile and tuberculosis of the lymphatic glands disturb the 
absorption of fat (see below); finally, that absorption is only slightly 
disturbed by accumulation in the intestinal canal. 
Consistence, or form of the stool. Normally, it is firm or mushy. 
The fact has already been stated, and the reason given, why in 
diarrhoea the stool is more or less thin, or like thin soup. The stool 
may really be watery, as in cholera Asiatica, but also in all severe 
acute cases of enteritis, also in dysentery. The dried fecal balls 
which are passed with or after obstipation are very hard. 
The form of firm feces does not have any independent value. 
Especially the stool which is like the stool of sheep (small, hard balls, 
about the size of a cherry) is not characteristic of stenosis of the 
rectum, because it also occurs in ordinary constipation. Band-like 
flat scybala rather indicates stenosis, more especially compression of 
the rectum antero-posteriorly. 
Here may be mentioned the arrangement in layers of the thin and 
the mushy stools which not infrequently are met with. In these the 
firm portions settle so that the upper part of the stool consists of a 
clear watery layer. This is the kind of stool we have in typhus 
abdominalis [typhoid fever], but we also have it in other thin stools, 
and it is very commonly a result of the admixture of urine. 
Odor of the stools. The variations from the normal fecal odor not 
infrequently have distinct diagnostic value. In nursing children a 
slightly sour odor is normal. 
The alcohol-stool is offensive, but does not always really have a 
foul odor. An odor like sebacic acid (with acid reaction? from acid 
fermentation) is peculiar to the slight forms of infantile diarrhoea. A 372 
SPECIAL DIAGNOSIS. 
decidedly foul smell (putrid albumin, alkaline fermentation) belongs 
to severe forms of this disease. The stools of cholera and dysentery 
often smell flat, like semen (cadaverin, Brieger). Cadaverous, foul, 
stinking stools characterize gangrenous dysentery, carcinomatous or 
syphilitic ulceration of the rectum. When blood or pus is mixed 
with the stool in considerable quantities the fecal odor may be masked 
and replaced by a mild, stale odor. Often the stool is ammoniacal, 
from admixture with urine which has decomposed. 
Reaction of the stools. Only in children, particularly nurslings 
(in whom it is normally slightly acid) is the reaction diagnostic, and 
gives important indications for treatment. Decided acid reaction is 
observed in acid fermentation in the intestinal canal; alkaline reac- 
tion in alkaline fermentation with putrid albumin. In both condi- 
tions there is intestinal catarrh. 
Color, constituents, admixtures of the stools, so far as they can be 
recognized by the naked eye. The normal color of the stools varies 
from bright- to blackish-brown. It is in part due to the addition of 
bile (that is, products of decomposition of the coloring matter of the 
bile, particularly hydrobilirubin), and partly to the food. By the 
latter, the stool may be unusually colored, as by huckleberries, which 
color it black, and may be confounded with blood. 
In the normal stool, portions of food can be recognized with the 
naked eye, if things that cannot be digested—like cherry-stones, 
particles of wood, etc.—have been swallowed. We also see grape- 
seeds, the skin of many kinds of fruit, etc. Large fibres of con- 
nective-tissue, undigested portions of grains, mushrooms, etc., may 
sometimes be met with in the stools, if the patient has eaten rapidly 
or has swallowed his food in quantities. With the naked eye, we 
can see fibres and pieces of undigested substances, the old designa- 
tion for which was lientery, like portions of muscle, flocks of casein, 
in the stools of children ; sometimes somewhat friable, perhaps slimy ; 
or even portions of starch. All of these indicate disturbance of 
digestion in the small intestine, or also in the stomach, as is seen in 
intestinal catarrh, or catarrh of the stomach, or in the dyspepsia of 
fever, with increased peristalsis. 
In the rare condition of communication between the stomach and 
colon (perforating ulcer of the stomach), we find the coarsest admix- 
ture of digestible portions of food in the stool. EXAMINATION OF THE DIGESTIVE APPARATUS. 
373 
Occasionally, extraordinary forms of remains of vegetables (orange- 
like, etc.) have given rise to mistake. With children, hysterical 
persons, and imbeciles, we must be prepared for all sorts of pre- 
posterous foreign bodies in the stools. 
The stools of nurslings and of adults who live upon milk illustrate 
the appearance of the stool when colored only by bile-pigment. Firm 
stools are generally darker than thin ones, because more concentrated. 
In severe diarrhoea, but especially in cholera, dysentery, also severe 
enteritis, after the first evacuations have swept out the intestinal con- 
tents, the stools always become brighter, afterward grayish-white and 
watery, or, in dysentery, colored by blood, etc. 
When there is diminished flow of bile into the intestine, as occurs 
in hepatogenous icterus, the stools are lighter. If the bile is cut off, 
they are grayish-white, clayey, and faintly glistening. This is due 
not alone to the want of the transformation of the bile-pigment, but 
also, it would seem, chiefly to the large amount of fat in the so-called 
alcoholic stools. The increased amount of fat, in turn, shows dimin- 
ished digestion of the fat, due to the deficiency of bile. 
We designate as bilious stools those which contain the coloring- 
matter of the bile unchanged. A quick passage of the contents of 
the intestine, and profuse diarrhoea, always bring about this kind of 
stool. We see it most frequently in acute intestinal catarrh, especi- 
ally in children; perhaps there is here also an increased effusion of 
bile. The bilious stool is bright-yellow, green-yellow, or green, and 
has the reaction of the coloring-matter of the bile. We filter it, and 
treat the filtrate as we do when testing for bile in the urine (which 
see). 
Mucous stool. When mucus can be distinctly recognized in the 
evacuations of the bowels, it always indicates catarrh of the mucous 
membrane of the intestine, and hence something pathological; though 
in many cases the disturbance in the intestines may be regarded as 
without significance. There are unnoticeable transitions from the 
normal secretion of mucus by the intestine to a decided stimulation by 
chemical or mechanical irritation, even to a true enteritis. Nothnagel 
considers that small, visible particles of mucus interspersed in firm 
stools, belong to a normal condition. 
Larger masses of mucus, in the form of more or less thick shreds, 
always indicate with greater probability a catarrh of the large intestine. 374 
SPECIAL DIAGNOSIS. 
Certain small, roundish particles of mucus, like sago granules, must 
usually come from this portion of the intestine. Catarrh of the large 
intestine then can be definitely diagnosed from the stools, if firm fecal 
balls are passed which are covered with mucus. Sometimes we find 
spread over the scybala a layer of thick, tough mucus. An abundant 
admixture of mucus in thin stools occurs, especially in acute intestinal 
catarrh, if the large intestine is also affected, and in catarrhal 
dysentery. 
We designate as intestinal infarction cylindrical tubes which consist 
entirely of mucus (or partly of fibrine), and which form casts of the 
large intestine. In rare cases they occur in chronic catarrh of the 
large intestine, and are usually passed with great pain (mucous colic). 
If there are fine and equal portions of mucus in solid fecal balls, 
we then think of catarrh of the small intestine. But, also, mucus 
occurring in thin stools may have its origin in the small intestine. Then 
it is usually finely divided, and is soft. In cholera Asiatica (also in 
cholera morbus) the stools are watery, and contain particles of mucus 
which look like boiled rice (rice-water stools). 
Nothnagel utters a warning against regarding all small, slimy-look- 
ing particles in the stools as mucus. They may come from the food. 
The chemical reaction determines in a doubtful case. 
Watery stools. To these we have already referred repeatedly. 
They occur in severe acute intestinal catarrh, in dysentery, and in 
cholera Asiatica, and express profuse diarrhoea, by which the intestinal 
contents are completely expelled. Even bile, or its transition products, 
are not usually found in watery stools. 
Fatty stool. This is usually recognized by its slightly glistening, 
and its greasy look. When there is much fat, the stools are clayey- 
looking, or whitish, even when the bile is not cut off from the intes- 
tine. When the stool contains considerable fat, moreover, it has the 
peculiarity of becoming softer and more glistening with the eleva- 
tion of the temperature of the body. For further regarding fatty 
stool and its occurrence, see under Microscopical Examination. 
Bloody stool. This has an extremely variable appearance, dependent 
upon the more or less change in the blood, and whether it is not at all, 
or is intimately, mixed with the feces. 
When firm scybala are covered over with blood, it indicates hemor- 
rhage of the rectum, or large intestine. If the blood does not look EXAMINATION OF THE DIGESTIVE APPARATUS. 
375 
at all changed, it is from the rectum or anus. When there is an 
admixture of blood with thin stools, if the blood retains its color, and 
is not intimately mixed with feces, mucus, or pus, it points with 
tolerable certainty to the large intestine or anus. However, there may 
be intimate mixture of blood even in hemorrhage from the large 
intestine, and in watery stools, as in meat-juice stools in dysentery, 
and in severe catarrh of the large intestine in children. 
Hemorrhage of the large intestine occurs most frequently with 
hemorrhoids in the lower portion of the rectum, carcinomatous ulcera- 
tion, again chiefly from the rectum, and in other ulcerations of the 
large intestine of any kind, as in dysentery. 
When the blood is intimately mixed with the feces, it indicates 
hemorrhage from the small intestine or from the stomach. Besides, in 
this case the blood is usually more or less changed, brownish-red, even 
deep-black, the color of tar, from breaking up of the red corpuscles 
and of haemoglobin (formation of sulphate of iron ?). 
The degree of change which the blood undergoes depends upon the 
length of time it has been in the intestinal canal, and the way in 
which it is mixed with the feces. There is the least change, the blood 
sometimes remaining red, with preservation of the red corpuscles, 
when a large quantity of blood from the lower part of the ileum passes 
quickly into the colon, because of existing diarrhoea. This happens 
with the profuse hemorrhage of the bowels in typhus abdominalis. 
Blood which comes from the stomach, duodenum (in ulcer of the 
stomach, ulcus duodenale) becomes as black as tar before it is evacu- 
ated, because of its slow transit and the usual absence of diarrhoea. 
Moreover, with gastric hemorrhage, the blood may appear in the stool 
like coffee-grounds (see above, p. 363). 
In most cases, in order to prove the existence of blood, it does not 
suffice merely to examine with the naked eye. Then we employ the 
microscope to make out the red blood-corpuscles, and if they are 
broken up, then it is necessary to test for haemin. (See above, p. 363.) 
1. We have already repeatedly spoken of the importance of giving 
continued attention to the stools whenever there is a suspicion of 
hemorrhage in the alimentary canal. This obtains particularly with 
ulcer of the stomach or duodenum. 
2. It is evident that any blood which reaches the stomach, having its 
origin in the oesophagus, or coming from farther up and being swallowed, 376 
SPEC IA L DIA GNOSIS. 
may appear in the stools (see examination of the nose, expectoration, 
oesophagus). 
Purulent stools. A considerable quantity of pure pus is not so very 
rare, happening as a sign of a rupture somewhere of a collection of 
pus (generally of a parametric exudation) into the intestines, especially 
the rectum. Therefore, whenever there is a febrile affection of the 
abdomen, where the formation of the pus is either made out, or at least 
is thought to be possible, we ought always, but especially if there has 
been a sudden decline of the fever, carefully to examine the stools as 
well as the urine (which see). 
Moreover, dysenteric, catarrhal, syphilitic, and carcinomatous, ulcera- 
tions of the large intestine produce some, or possibly considerable, 
accumulation of pus, according to their extent; likewise, periproctitic 
abscesses. 
Gall-stones, enteroliths. The former come either from the gall- 
bladder or the intrahepatic gall-passages (intrahepatic stones, much 
smaller than the others, rare) through the ductus choledochus, and, as 
they come into the intestine, often produce severe colic and jaundice. 
Whenever there is abdominal colic, particularly if it is connected with 
jaundice, and generally whenever there is jaundice, we must look out 
for gall-stones in the stools. In rare cases, if there is suppuration of 
the gall-bladder, they come from the gall-bladder, there being adhesion 
with the colon, into which they break, and thus directly reach the 
intestine. 
When we are looking for gall-stones the stool must be passed 
through a sieve. If it is formed or mushy, it must be broken up by 
pouring a stream of water upon it. The gall-stones are generally 
very easily recognized by their shining appearance, smooth surface, 
and many angled (facets) form. Small, especially intrahepatic, 
stones may not have facets, and be more crumbling. They consist 
chiefly of cholesterin, and also contain coloring matter of the bile. 
Enteroliths are rare. They usually come from the vermiform 
appendix, and their centre commonly consists of solid, undigested 
portions of food, as a cherry-stone, around which have been deposited 
some lime or magnesium salts. 
Portions of tissue from the intestinal canal. In very rare cases, 
when there is invagination of the intestine, the whole of the portion 
that is turned in sloughs off, the intestine forming new adhesions, EXAMINATION OF THE DIGESTIVE APPARATUS. 
377 
and thus life is preserved. This entire piece may appear in the stool. 
Shreds of mucous membrane from the large intestine in dysentery, 
portions of tissue of carcinoma, or other new formations, may appear 
in the stools. 
Animal Parasites. 
In what follows it will be shown that some of the animal parasites 
that exist in the human alimentary canal have no pathological signifi- 
cance ; others, on the other hand, are very important factors as excitors 
of disease. The examination for these latter or for their eggs cannot 
be made too frequently, or too carefully. An examination of the stools 
for parasites must be undertaken not alone when there are complaints 
or symptoms which directly indicate intestinal parasites, or in general 
when there are evidences of intestinal catarrh, but in any case of 
anaemia, when there is any general nervous depression, in certain other 
phenomena of the nervous system (see works upon pathology), if the 
cause of the particular complaint does not appear to be clear. The 
cases are numberless where, after long fruitless search elsewhere, the 
discovery of a joint of a tapeworm, for instance, leads to the correct 
apprehension and treatment of the patient. 
In order not to separate what belongs together, we collect here all 
that is to be said regarding the occurrence of intestinal animal para- 
sites and their eggs in the stools, whether in the examination we 
employ the naked eye, the simple or the compound microscope. 
Tape-worm (cestodes). Its habitat is exclusively the small intes- 
tine. It gives rise to very great pathological disturbances (intestinal 
catarrh, anaemia, nervous manifestations of varying severity). It 
consists of a very small head and neck, and a ribbon of flat joints 
(proglottides), several meters long, which constantly push off at the end 
of the worm, and grow again from above. It clings to the wall of 
the intestine by its head. 
It can be recognized by a single joint, which can easily be seen 
with the naked eye, or by the presence of eggs in the stools (micro- 
scopical examination). 
1. Tcenia, solium. This is 2 or 3 meters long. Its head is the 
size of the head of a pin, glistening gray; the rest of the worm is 
white, or yellowish-white. Upon the head are four pigmented suck- 
ing cups (to be seen with a simple microscope), which surround a 
crown of chitin hooks, “ crown of hooks.” The ripe proglottides— 378 
SPEC I A L DIA GNOSIS. 
that is, those on the lower end of the worm—are about 10 mm. long, 
5 or 6 mm. broad, and are like gourd-seeds (but are smaller). From 
the peculiarity of these ripe joints, which are continuously thrown off 
and passed with the stool, we are able to make the differential diagnosis 
Fig. 94 
Fig. 95. 
Fig. 96. 
Fig. 94.—Taenia solium, head enlarged. (Heller.) 
Fig. 95.—Taenia solium. Kipe joint, magnified 6 times. (Heller.) 
Fig. 96.—Egg of taenia solium. (Heller.) 
between this and the other tape-worms. The joints show a longitu- 
dinal canal (the uterus), from which, toward both sides, as many as a 
dozen branches go off which ramify like the branches of a tree. 
The eggs of T. solium (which require the use of a moderate micro- 
scopic power in order to find them, stronger to examine them care- 
fully) are round, and, if they are ripe, have very thick shells (which 
show radiating lines, and which, with a little pressure upon the cov- 
ering glass, break into hard pieces. In the finely granular contents 
we often see a few chitin hooks. 
2. The Tcenia mediocanellata, seu saginata, grows to 4 or 5 meters. 
The head is somewhat larger than that of the solium, is also more 
strongly pigmented. It has no crown of hooks, but four sucking 
cups, which are much stronger than those of the solium. On the 
whole, the rest of the worm, as respects its individual joints, is fatter 
and thicker than the first-named. The ripe proglottides are passed, 
not only by the stool, but wander independently from the anus, having 
strong, very energetic, independent movements. They are distin- 
guished from the T. solium in that the uterus gives off more and finer 
branches on each side, which divide dichotomously. EXAMINATION OF THE DIGESTIVE APPARATUS. 
379 
The egg of the T. mediocanellata looks extremely like that of the 
T. solium, except that on the average it is somewhat larger. 
Fig. 97. 
Fig. 98. 
Fig. 99. 
Fig. 97. —Taenia mediocanellata. Head darkly pigmented. (Heller.) 
Fig. 98.—Taenia mediocanellata. Ripe joint, magnified 6 times. (Heller.) 
Fig. 99.—Egg of taenia mediocanellata. (Heller.; 
3. Bothriocephalus lata (sinus head) is found in Germany, only 
in the neighborhood of the North and East Seas, of Lake Geneva, 
and in Northwestern Russia [Sweden, Poland, Belgium, Holland. 
Fig. 100. 
Fig. 101. 
Fig. 102. 
Fig. 103. 
Fig. 100.—Head of bothriocephalus latus. (Heller.) 
Fig. 101.—Ripe joint of bothriocephalus latus enlarged six times. (Heller.) 
Fig. 102.—Egg of bothriocephalus latus. (Heller.) 
Fig. 103.—Egg of bothriocephalus latus, with developed embryo. (Leuckart.) 
“ Low-lying damp regions near the borders of seas and lakes are those 
in which it is most often abundant.”] It is the largest of the tape- 380 
SPE ClA L DIA GNOSIS. 
worms, and reaches to 7 or 8 meters in length. Its head is elongated, 
and has two narrow, long-drawn out sucking cups. The illustration 
shows its form and the shape of the uterus. 
The ripe joints are not given off singly, but a large piece of the 
worm is always passed at one time, and then, after a long interval, 
another; most frequently in the spring and fall. 
Wr this reason we here refer to the finding of the eggs (which are 
always present in the stools). They are oval (see Fig 102), and much 
larger than those of two other kinds of tape-worm. The shell is 
bright brown, relatively thin, and, on one end of the oval, has an 
opening which is closed with a cover of exactly the same kind. The 
contents of the egg are granular. 
As has recently become known, the bothriocephalus gives rise to 
severe anaemia, with changes in the blood like those in severe per- 
nicious anaemia; for this reason, and because there are no joints 
thrown off, this tape-worm is very easily overlooked for a long time. 
4. Tcenia cucumerina, 5-20 cm. long, 2 mm. wide; the head is 
somewhat long, and has sixty hooks; the last joints are reddish, and 
have the form of pumpkin seed. Six to fifteen of the eggs lie together 
in the so-called cocoon. It occurs in dogs, cats, and not infrequently 
in men, especially children (Leuckart). Its pathological significance 
is not known. (See Fig. 104.) 
Fig. 104. 
Tasnia cucumerina (Birch-Hirschfeld). a, joint, natural size; b, enlarged 
12 times; c, cocoon, enlarged 290 times. 
Round worms—Ascaris lumbricoides. This is easily recognized 
from its likeness to the common earth-worm. Its habitat is the small 
intestine. Very frequently it gives rise to little or no complaint, but 
it sometimes, and especially in children, causes very uncomfortable 
phenomena of all sorts, particularly of the nervous system. Occa- 
sionally, when there is severe vomiting [and sometimes when there EXAMINATION OF THE DIGESTIVE APPARATUS, 
381 
has not been any vomiting at all], it gets into the stomach and is then 
vomited. Moreover, it may crawl into the ductus choledochus, and 
thus cause obstinate jaundice. These worms appear in the stools; and 
sometimes, in sleep, they will crawl out of the anus. They are said 
sometimes to come out of the mouth and nose while the person is 
sleeping. 
The fresh eggs of the ascaris lumbricoides have a very peculiar 
appearance, since its chitin capsule is covered with an uneven, as it 
were, humped albuminous envelope. (See Fig. 105.) 
Fig. 105. 
Fig. 108. 
Fig. 106. 
Fig. 107. 
Fig. 105.—Ascaris lumbricoides (Jaksch). a, worm natural size; b, head; c, egg. 
Fig. 106.—Oxyuris vermicularis. Natural size. 1, female; 2, males. 
Fig. 107.—Egg of oxyuris vermicularis (enlarged). 
Fig. 108.—Oxyuris vermicularis, enlarged, a, ripe, but unimpregnated female: 
b, male ; c, female containing eggs. 382 
SPECIAL DIAGNOSIS. 
Oxyuris vermicularis is a small, white worm (Fig. 106) found 
particularly in the large intestine. It may wander from the anus into 
the vagina. It has very slight pathological significance. It appears 
in the stools, and also it is not infrequently found by itself in the 
neighborhood of the anus. When first passed, it has usually very 
lively peculiar movements. The eggs are commonly unsymmetrical. 
(See Fig. 107.) 
Anchylostoma duodenale, very like the last in form, but often 
longer, even twice as long; usually inhabits the upper part of the small 
intestine, especially the duodenum. 
Formerly it was only observed in other countries [discovered by 
Dubini in 1838, in northern Italy], more recently also in Switzerland 
(first during the building of the St. Gothard tunnel), and finally it was 
noticed among brickmakers. Because it continually sucks blood from 
the wall of the intestine, it causes severe, sometimes fatal, anaemia 
(anchylostomiasis, formerly “ Egyptian-chlorosis,” Griesinger). It is 
difficult to discover the -worms in the stools unless some vermifuge is 
used, but, on the other hand, the tolerably characteristic eggs are always 
present. They are as large as, or perhaps a little larger than, those of 
Fig. 109. 
Anchylostoma duodenale (Jaksch). a, male; b, female, natural size; c, male; 
d, female, slightly magnified; e, head; f, egg. 
the oxyuris. They have a thick covering, and contain two or more 
segmentation globules. By allowing the stool to stand for several EX AMIN A TION OF THE DIGESTIVE APPARATUS. 
383 
days in a warm place, we can see the embryos develop in the eggs. 
In this very serious disease the stools often contain blood. 
Besides the intestinal parasites already mentioned, there are the 
following, part of which are pathologically unimportant, and others 
are very rare: 
Tricocephalus dispar. Its habitat is the colon, especially the 
caecum. It is of no importance. Both the worms and eggs are highly 
characteristic in form. (See Figs. 110 and 111.) 
Fig. 110. 
Fig. 111. 
Fig. 110.—Trichocephalus dispar, natural size. (Heller.) 
Fig. 111.—Egg of trichocephalus dispar, moderately enlarged. 
Trichina spiralis. It very rarely occurs in the intestine, but some- 
times in the first stage of the trichinosis, the stomach-stage, with 
intestinal phenomena, it is found in the stools. Since the early recog- 
nition of trichinosis is of the greatest importance, in a suspicious case 
the stool is to be examined with the greatest care, best after the adminis- 
tration of an aperient. 
The appearance of the intestinal trichina is shown in Fig. 112. It 
is only one-third as long as the oxyuris, and hence cannot be seen with 
the naked eye. 
Distoma hepaticum and D. lanceolatum, two rare, but pathologi- 
cally important, parasites, which inhabit the gall-passages of the liver, 
sometimes make themselves known by their eggs, which, passing out 
into the intestine with the bile, appear in the stools. The egg of the 
D. hepaticum is much larger than the other parasites previously men- 
tioned, about three times as large as those of ascaris lumb. The egg 
of the D. lanceolatum is somewhat smaller than that of the oxyuris. 
For its other characteristics see Fig. 114. 
Infusoria of very great variety of species are found in the stools of 
all kinds of diarrhoea: in acute and chronic intestinal catarrh, in 384 
SPECIAL DIAGNOSIS. 
typhoid fever, in tuberculosis of the intestine. Immediately after the 
evacuation of the bowels they manifest very active movement. Their 
pathological and diagnostic significance are both negative. 
Fig. 112. 
Fig. 113. 
Fig. 114. 
Fig. 112.—Adult intestinal trichina, human. Male, female, and two embryos slightly 
magnified. (Birch-Hirschfeld.) 
Fig. 113.—Trichina (Jaksch.) a, male; b, female intestinal trichina; c, muscle 
trichina. 
Fig. 114.—Egg of distoma hepaticum and distoma lanceolatum. (Heller.) EXAMINATION OF THE DIGESTIVE APPARATUS. 
385 
Microscopic examination of the feces. Thin, or thin-mushy stools, 
are examined without making any addition to them. To thick, mushy, 
or solid stools, about a half per cent, of solution of salt is added ; and 
the solid portions must, of course, be broken up. Somewhat of a selec- 
Fig. 115. 
Monads from the feces (Jaksch). a, tricomonas intestinalis; b, cercomonas intes.; 
c, Amoeba coli; d, paramsecium coli; e, living monads; /, dead monads. 
tion must be made from the different portions of the stool, according 
to the object of the examination. In what follows are presented 
the details. The amplification also varies with the object of the exami- 
Fig. 116. 
Microscopical constituents of the stools (partly from J aksch ). a, vegetable fragments ; 
b, muscular fibres; c, white blood-corpuscles; d, saccbaromyces; e, microorganisms; 
f, crystals of triple phosphate; g, fatty acid crystals. 
nation. In general, we employ the dry method. When looking for 
parasites (which have already been described), it is better, on the 
other hand, to make use of a tolerably strong amplification. 386 
SPECIAL DIAGNOSIS. 
1. Undigested portions of food. These may be found in every 
stool, and in varying quantities, according to the kind of food eaten. 
We mostly meet with coverings of vegetable cells, elastic fibres, etc. 
2. Portions of digested food. Although these, if visible with the 
naked eye, indicate disturbed digestion in the small intestine, yet 
microscopical particles of these substances are seen in small quantities 
in normal stool, as well as small portions of muscular fibre, with the 
transverse striations, shreds of connective tissue, starch granules, and 
fat. 
But considerable quantities of the substances named always indicate 
disturbed digestion either in the small intestine or the stomach, and 
hence have the same significance as the occurrence of larger pieces, 
which can be seen without being magnified. When the microscopical 
particles are colored a bright-yellow, as we commonly see small por- 
tions, particularly of muscular tissue, but sometimes almost all the 
solid portions of the stools, it shows that there is unchanged bile 
in the stool, and catarrh of the small intestine. 
Fat, in the shape of polygonal glassy lumps, of needle-shaped 
crystals, and also in the form of drops, is a very frequent constituent 
of the stools. The glassy lumps occur very frequently in health, and 
are often colored yellow or yellowish-red. They are recognized as 
fat, fatty acids, or soap, by their transformation upon the addition of 
sulphuric acid, and, when warmed, into drops of fat (Muller). Drops 
of fat occur in the stools with milk-diet (hence, particularly in those 
of children), when taking cod-liver oil, likewise castor-oil, and, if there 
is intestinal catarrh, then in very considerable amount. 
The needles of fat have pathological significance. They sometimes 
occur singly, and, again, in bundles and druses. They are changed 
by simply warming them, or by the addition of acid and then warm- 
ing, into drops of fat, and this takes place whether they consist of 
fatty acids or (lime-) soap. 
When there are great numbers of fat-needles, it is a pathological 
sign of disturbance of the resorption of fat, as may result from 
shutting off of the bile from the intestine, from any form of enteritis, 
of tuberculosis, amyloid degeneration of the intestine, and, lastly, 
from disease of the mesenteric glands. 
The increase of the fat in the stool is not, as was formerly assumed, 
characteristic of a want of pancreatic juice (disease of the pancreas, EXAMINATION OF THE DIGESTIVE APPARATUS. 
387 
closure of the ductus Wirtungianus). As a matter of fact, the 
absence of pancreatic juice does not seem to hinder the resorption of 
fat (Muller). 
Detritus. The amount of detritus in the stools is very great, 
because we cannot determine separately the amount of kernels, 
husks, etc. 
3. Additions to the stools from the alimentary canal. A micro- 
scopical quantity of mucus occurs in the stools of persons in health. 
Small glassy lumps of mucus may also he present, which come from 
the cells of plants. Usually the examination with the naked eye is 
sufficient to determine whether there is a pathological admixture of 
mucus. 
It is necessary only to mention that a firm stool, abundantly inter- 
spersed with small light lumps of mucus, is observed with intestinal 
catarrh (Nothnagel). In these cases, we can generally discover the 
mucus, if we carefully examine, without any artificial aid. 
Epithelium. Some cylindrical cells, often mucous metamorphosis, 
are a frequent occurrence. If the quantity is large, it indicates 
intestinal catarrh. Very abundant cylindrical epithelium occurs in 
chronic catarrh of the large intestine, especially in mucous colic, in 
this case caused by mucous “infarction.” It has already been men- 
tioned that regular shreds of mucous membrane are found in the 
stools, also portions of tissue. 
Red and white blood-corpuscles. These are present in quantities 
in fresh bloody, and in purulent, stools. When seen but once, they 
do not have significance. 
4. Crystals. Except the fat crystals mentioned above, there are 
almost no crystals which are brought into requisition for the purposes 
of diagnosis. Crystals of ammoniaco-magnesian phosphate (see these 
under the examination of the urine), no doubt, occur in the stools in 
enteritis and abdominal typhus. But they may also be found in any 
other stools, if they are not kept separate from the urine and stand 
for a long time. 
Lime-salts of all kinds, partly with inorganic, partly with organic, 
acids, in the form of wedges, dumb-bells, needles, etc., sometimes 
colored an intense yellow by the bile in the stool, have no diagnostic 
import. 
Charcot’s crystals, in appearance and probably also chemically 388 
S PE CIA L DIA GNOSIS. 
entirely agreeing with the Charcot-Leyden crystals of asthma, are 
observed in rare cases of dysentery, typhus abdominalis, intestinal 
tuberculosis, anchylostomiasis. 
5. Vegetable 'parasites. We may divide the large number of 
vegetable microorganisms which we find in the stools, from the stand- 
point of clinical diagnosis, into two classes : 
(a) Those which, primarily, for clinical diagnosis are only of sub- 
ordinate significance, because we do not know that they have any 
definite connection with any diseases. Here, also, we class those 
which are indirectly harmful—that is, they cause abnormal decom- 
position of the intestinal contents. This class is extremely numerous, 
and great numbers of one kind or another are present in every 
stool. The knowledge of the different kinds has recently been greatly 
extended by the important labors of Nothnagel, Bienstock, Escherich, 
and others. But the point has not yet been reached which makes 
them as available, for clinical diagnosis, as the other peculiarities of 
the stools. For this reason we will treat of them only very briefly 
here. 
Of the fungus-spores we have (very rarely) that of thrush in 
children who are suffering from thrush in the mouth. Germi- 
nating fungus, and, indeed, the different kinds of torula cerevisise 
(see Fig. 116, d), occasionally occur in all stools, especially in the 
milk-stools of children. In intestinal dyspepsia with acid fer- 
mentation they are generally more abundant than in normal diges- 
tion. But the schizomycetes belong to the numberless micro- 
organisms which are seen in every microscopical preparation of the 
stools, whether normal or pathological. Of chief importance are the 
micrococci and bacilli. A very large part of these are colored yellow 
or brownish writh iodine and iodide of potassium; others are colored 
by the same reagent blue or violet (Nothnagel). These latter, 
according to Jaksch, are increased in intestinal catarrh. 
We are already able to conclude that the knowledge of these 
intestinal bacteria furnish diagnostic indications of anomalies in 
intestinal digestion, and that the different kinds of bacilli possess 
extraordinary biological peculiarities. Some require for their rapid 
development a neutral or slightly alkaline reaction, while others an 
acid reaction, of the intestinal contents; some are aerobiotic, others EXAMINATION OF THE DIGESTIVE APPARATUS. 
389 
anaerobiotic ; and while some have the power to transform starch into 
sugar, others cause the decomposition of albumin. 
(b) Pathogenic fungi. These we are able to isolate, and from 
them diagnosticate the disease they cause, as the tubercle-bacillus in 
the sputum. 
Here, also, belong the pathogenic schizomycetes. These are: Koch’s 
cholera bacillus, the bacilli of typhus and tubercle. 
Cholera bacilli (comma bacilli) are the pathognomonic sign of 
Asiatic cholera. They are short, more or less crooked rods, which 
are sometimes connected one to another in such a way as to form 
“spirals,” like a screw. The curve may be very slight, even want- 
ing; or marked, even semicircular. In general, they are shorter, 
but thicker, than the bacilli of tubercle. 
Fig. 117. 
Fig. 118. 
Comma bacillus, pure culture (prepared 
by Prof. Gartner). Zeiss’s immersion 
lens one-twelfth, eye-piece No. 2, camera 
lucida. Magnified about 600 times. 
Cholera dejections upon a damp sheet. 
(Two days old.) a, S-form bacilli, 600 : 1. 
(Koch.) 
Habitat: mode of preparation. They are particularly found in 
the free mucous floccules of rice-water stools, also very abundantly 
upon the linen soiled by the dejections, and, indeed, here after two 
or three days, provided the linen has been kept moist. A mucous 
floccule (or a drop of the stools), or some of the deposit on the linen, 
is placed upon a covering-glass. First dry it in the air, then pass it 390 
SPECIAL DIAGNOSIS. 
two or three times through the flame of a spirit-lamp, and stain it 
with methylene-blue or fuchsin by warming it one to five minutes. 
These bacilli have been found, we may say, constantly in the stools 
of Asiatic cholera by a great many other examiners besides Koch, 
and they are found in no other stools. They must, therefore, 
diagnostically be of pathognomonic value to even those who doubt 
Koch’s teachings concerning their pathogenic character. 
Fig. 119. 
Covering-glass preparation of a mucous floccule in Asiatic cholera. Zeiss's homogeneous 
immersion one-twelfth, eye-piece No. 2, drawn by a camera lucida. Magnified about 
650 diameters. 
But since the morphological peculiarities of the cholera bacillus in 
the microscopical preparation do not furnish an absolutely certain 
recognition, and, on the other hand, since there is no specific reaction 
(as with the tubercle bacillus), in order to determine an isolated case, 
it is indispensably necessary to establish a pure culture. (See, 
regarding this, the works upon bacteriology.) 
Comma bacilli are also, in individual cases, found in the vomit of 
Asiatic cholera. 
Morphologically, but not biologically, they are like Finkler and 
Prior’s spirals of cholera nostras, which possibly stand in the same 
relation to this latter disease that the comma bacillus does to Asiatic EXAMINATION OF THE DIGESTIVE APPARATUS. 
391 
cholera. They are positively distinguished from the bacilli of Asiatic 
cholera by pure culture. 
A bacillus which is morphologically like the comma bacillus occurs 
in tooth-mucus (Lewis and Miller), and just such an one, also, in old 
cheese (cheese-spirals, Deneke). Biologically, they differ from Koch’s 
comma bacillus and from each other. 
Typhus abdominalis bacillus. These bacilli are regularly found in 
typhus abdominalis, in the diseased portion of intestine, in the mesen- 
teric glands, the spleen and liver, in the kidneys, and also frequently 
in the blood (which see). They have also frequently been found in 
Fig. 120. 
Fig. 121 
Spirillum (Finkler and Prior), 700 :1. 
(Flugge.) 
Typhus abdominalis bacillus in pure cul- 
ture. Zeiss’s homogeneous immersion lens 
one-twelfth, eye-piece No. 2, drawn with 
camera lucida. Magnified about 650 times. 
the stools of typhus. But since they are distinguished (just at the 
end they are rounded; are about as long as the tubercle bacillus, but 
are much thicker—about one-third as thick as long) both by their form 
and by a specific color-reaction from the other bacilli which occur in 
the stools, their microscopical proof is extremely uncertain; pure 
cultures are here much more necessary for the positive determination. 
The typhus abdominalis bacillus is best stained with methylene-blue 
in a dry preparation upon the glass cover. 
Tubercle bacillus. These are frequently found in tuberculous 
ulcers of the intestine. It is not yet sufficiently established whether 
they are always present, chiefly because not infrequently tubercular 
ulcers of the intestines do not have any symptoms, and particularly 
do not cause diarrhoea; and so, often enough, the firm stools are not 
examined for bacilli. On the other hand, in phthisical patients, the 
tubercle bacillus is sometimes observed in the stools without there 
being any intestinal tuberculosis. They come from swallowing 
tuberculous sputum. CHAPTER YII. 
EXAMINATION OF THE URINARY APPARATUS. 
This comprises the examination of the urinary organs themselves 
and the examination of the urine. Indeed, in very many cases, the 
latter examination only is made, or it forms the chief part, whether 
in its relation as being the secretion of the kidneys, or whether it be 
in reference to admixtures or alterations of the urine, which occur in 
the course of its transit through the urinary passages. The local 
examination of the urinary organs is now not often required, but if 
it is, the result of the examination generally confirms the diagnosis. 
This direct examination, therefore, ought never to be neglected. 
Moreover, where the kidneys themselves are diseased there come into 
consideration certain resulting phenomena in the different organs of 
the body. 
Examination of the Kidneys, 
Anatomy. 
The kidneys, about 10 to 12 cm. long, about 5 cm. broad, of well- 
known form, lie upon the two sides of the spinal column, upon the 
anterior surface of the quadratus lumborum muscle and the lumbar 
portion of the diaphragm, and reach from the level of the twelfth dorsal 
vertebra to the level of the second or third lumbar vertebra. The 
lower portions diverge somewhat downward, and hence lie with their 
lower ends somewhat further from the median line of the body (about 
three fingers’ breadth) than the upper ends (about two fingers’ breadth). 
The right kidney is a little lower down than the left. 
The upper half of both kidneys is covered by the eleventh and 
twelfth ribs, the extreme upper portion also by the complementary 
pleural sinus (see Fig. 122); hence, the lower border of the lungs does 
not extend as low down as the kidneys. It is very important to note 
that the outer border of both kidneys corresponds tolerably exactly 
392 EXAMINATION OF THE URINARY APPARATUS. 
393 
with the outer border of the thick fleshy layer of the sacro-spinalis 
muscle. 
The left kidney at its upper end, rather by its suprarenal capsule, 
is in contact with the spleen; the right kidney, with the under surface 
of the liver. Both organs encroach upon the upper end of the kidney 
of their respective sides, like the tiles of a roof (see Fig. 122). The 
figure also furnishes information regarding the so-called spleen-kidney 
and liver-kidney angle. 
Fig. 122. 
Anatomical situation of the kidneys. (Weil.) «, d, borders of the lungs; c, e, limits 
of the pleural sacs; /, angle between the spleen and kidney; g, angle between the liver 
and kidney. 
The superior surface of each kidney is covered by the parietal 
peritoneum, and in front of it lies the ascending or descending colon. 
The anterior inner border of the right kidney is not far from the 
ductus choledochus and the duodenum. 
In the rare condition known as horseshoe-kidney, the lower ends of 394 
SPECIAL DIAGNOSIS. 
the two kidneys are connected by a transverse band consisting of 
kidney-parenchyma. This transverse portion passes, like a bridge, 
across the aorta and the spine, about on a level with the second 
lumbar vertebra. 
Local Examination of the Kidneys. 
In every respect its result is almost negative. The normal kidney, 
of course, cannot be inspected. In remarkably exceptional cases 
we may, by employing bimanual palpation, with the legs drawn 
well up (one hand being placed behind in the lumbar region and 
the other pressing deeply in front), get some information, provided 
the abdominal covering is very unusually lax and thin, and the 
stomach is empty. Of late, percussion of the kidneys has very 
rightly come more and more into discredit. It must be perfectly 
evident to every one that it is impossible to point out the normal 
kidneys, or even moderately enlarged ones, if he remembers that the 
kidney is less voluminous than the spleen; that, moreover, it lies 
much less favorably; and, besides, if he takes into consideration how 
often the normal spleen is with difficulty, or cannot at all, be made 
out. The kidney is unfavorably located for percussion, because the 
sacro-spinalis muscle (of considerable mass) lies over it, but especially 
for the reason that its lateral border almost exactly corresponds 
with the convex border of the kidney. So we cannot with certainty 
determine whether the kidney lies under the muscle, nor where its 
limits are. 
Individual exceptional cases, where very thin or atrophic sacro- 
spinalis muscles permit of percussion of the kidneys, may nevertheless 
occur, as the cases mentioned above, where the normal kidneys can 
be felt. But we cannot consider the result of percussion of the 
kidneys as of great value. 
Pathological Conditions of the Kidneys. 
Inspection. The kidney can only be inspected when it is very 
much enlarged, or enlarged and displaced. Tumors of the kidney 
may make their appearance in the lumbar region, in the side, and in 
the lateral anterior portion of the abdomen, near the border of the 
ribs. According to their nature, they are smooth, roundish, irregular, EX AMIN A TION OF THE URINARY APPARATUS. 
395 
or uneven (see Palpation). They do not move with respiration. Their 
appearance may strikingly vary, but not necessarily so, with the 
changes of position of the body (the dorsal position, lying down). If 
the tumor is very large, then it generally presses the colon, ascending 
or descending, toward the anterior abdominal wall, and then the colon, 
according to the amount of its distention, may lie up against the 
abdominal wall (see Palpation). 
If the kidney is the seat of a tumor, it very often departs from its 
place high up against the diaphragm, and becomes the so-called 
wandering kidney. In this case it is much easier seen from in front. 
A normal kidney wandering so much as to be visible, is a curiosity 
(Bartels). 
A roundish, symmetrical swelling, located in the dorsum in the 
region of the kidney, or somewhat sidewise from it, points to purulent 
perinephritis. Sometimes it extends upward in the abdominal cavity, 
from the diaphragm being pushed up. Qften there is oedema of the 
skin at the spot (deep formation of pus, see p. 52), or there may be 
inflammatory redness. Moreover, abscess, due to the congestion 
accompanying caries of the spine, may break here. Also, large peri- 
nephritic abscesses have been seen as tumors above the border of 
Poupart’s ligament in the iliac region. 
Palpation. This is most important in the local examination of the 
kidneys. We employ it in the dorsal position with the knees well 
drawn up, but sometimes also in the abdominal position. In both 
cases, we always first examine bimanually, one hand being upon the 
region of the kidney and the other upon the abdomen. 
Tenderness upon pressure occurs: sometimes in acute, almost never 
in chronic, nephritis ; also in tumor of the kidney, stone in the pelvis 
of the kidney, in case it excites inflammation; in inflammatory 
hydronephrosis, and in perinephritis (here there is often very great 
sensibility). 
When the kidney is enlarged from engorgement, amyloid disease, 
or nephritis (large white kidney), it is never perceptible to palpation 
except it leave its place (wandering kidney), or we have one of the 
exceptional cases in which even a kidney of normal size and location 
can be felt (see above, Local Examination of the Kidney). Very 
large new formations, as carcinoma, sarcoma, hydro- and pyo-nephro- 
sis, echinococcus, and perinephritis, only are palpable. The tumor 396 
SPECIAL DIAGNOSIS. 
can be felt in one side of the lumbar region, or at one side of the 
anterior abdominal region. With new formations it is usually uneven; 
in hydronephrosis, smoothly round, more or less tense, under some 
circumstances fluctuation can be distinctly made out. Echinococcus 
is usually smooth and tensely elastic; it may show hydatid vibration 
(see above, p. 326). 
It is important to remember that tumor of the kidney is only very 
rarely movable upon pressure (for if it descends, then we have a 
wandering kidney). We have never seen a case where one moved 
with respiration; but it seems that in some cases there is this move- 
ment. At any rate, the absence of respiratory movement points to 
the kidney, and especially against the spleen or a tumor fixed to the 
liver. 
In a considerable number of cases it will be found that the ascend- 
ing and descending colon is in front of the kidney-tumor and pressed 
by it against the abdominal #wall. In these cases, this fact has great 
value for differential diagnosis. In other cases, the tumor will be 
found lying exactly in the median line, and then it is of significance 
for differential diagnosis, especially from ovarian tumor. The location 
of the colon, moreover, is usually only made out with certainty when 
it can be felt, and particularly when it contains air. It is, therefore, 
advisable to inflate it (see p. 311). 
Wandering kidney; movable kidney. By this we understand 
downward dislocation of the kidney, whether much or little. Almost 
always only one is dislocated, and this is usually the right one. In 
these cases the kidney is commonly of normal size, but it may be 
enlarged, and this is most frequently due to hydronephrosis caused 
by the bending of the ureter, or also because it is the seat of a new 
formation. 
It is generally very easy to recognize a kidney that is very much 
out of place, but when it is still high up, near the liver or the spleen, 
it is often very difficult to do so. The diagnosis is based upon the 
bean-shaped form of the kidney, eventually, upon its being of the 
appropriate size, and upon its mobility by pressure, which is almost 
never wanting; also, sometimes, with the changes of position of the 
body. Not infrequently the kidney can be perfectly replaced. In 
some cases dyspeptic symptoms, even dilatation of the stomach, also 
jaundice from engorgement, have been observed when the right EXAMINATION OF THE URINARY APPARATUS. 
397 
kidney was displaced (from compression of the duodenum or of the 
ductus choledochus). Those cases are rarities where the pulse can be 
felt in the renal artery. 
Percussion. We employ percussion to establish the existence of 
tumors of the kidney which give a deadened sound, on account of their 
solidity; but they are almost always clearly made out by palpation. 
Its value in determining dislocation of the kidney was formerly very 
much over-rated. * It was thought that we were able to prove one-sided 
dislocation of the kidney, because, when the patient was lying upon 
the abdomen, the resonance of the two sides in the neighborhood of 
the kidneys was found to be different: clearer upon the side of tha 
wandering kidney, in contrast with the absolute dulness of the normal 
side. In our opinion, even in the most favorable cases, such a con- 
dition cannot be employed for deciding the diagnosis. 
But, on the other hand, percussion may be of the greatest value, 
either to determine the relation of a tumor in one side of the abdomen 
to the colon, or to determine the course of the colon over a tumor of 
the kidney (see above). In such a case, distending the colon with air 
is of the greatest assistance. Further, it might possibly occur that a 
considerable enlargement of the kidney could be made probable (never 
certain) by an area of dulness upon the back, extending from the region 
of the kidneys toward the side. 
Diagnosis of tumor of the kidney. The positive evidence of tumor 
of the kidney has just been spoken of. We may have to make a dif- 
ferential diagnosis between a right kidney which is not very much 
displaced downward and a distended gall-bladder, or an echinococcus 
located upon the lower surface of the liver. If there is respiratory 
mobility, this speaks against it being the kidney, but if the tumor can 
be replaced, so that it may even disappear, then it speaks for it 
being the kidney. Both wandering kidney and a pedunculated echi- 
nococcus may be easily movable upon pressure. It may often be 
impossible to determine exactly the form of a tumor situated close 
under the liver. 
A wandering left kidney is distinguished from a wandering 
spleen by the form, which is made out by percussing the neighbor- 
hood of the region of the spleen : in wandering spleen, we may find 
notches ; if it is the kidney, we may feel the pulse at the hilus. We 
distinguish tumor of the left kidney from tumor of the spleen by the 398 
SPECIAL DIAGNOSIS. 
form and relation to the colon. Sometimes respiratory mobility 
decides in favor of the spleen; but with this it may also be wanting; 
while notches on the upper border of the tumor may speak with prob- 
ability for the spleen, yet in one case, where they could be very dis- 
tinctly felt, they led us to a false diagnosis; it was found to be a 
carcinoma of the kidney. 
We know of one case where a movable tumor of the left side of 
the abdomen was, by a recognized master of percussion, pronounced a 
wandering kidney on account of the tympanitic resonance in the 
region of the left kidney. It was operated upon ; it proved to be a 
wandering spleen. It was extirpated with permanently favorable 
result. 
Examination of the Ureters and Bladder 
Simon, by introducing the hand into the rectum, has repeatedly 
felt of the ureters (see works upon Surgery). Recently Heger- 
Kaltenbach and Sanger have proposed, in the case of women, to palpate 
them per vaginam. We can feel their lower ends where they come 
down on either side of the neck of the uterus and enter the lower side 
of the bladder. With some practice often even a normal ureter, but 
still more one that is thickened, can be felt in the lateral and anterior 
fornix vaginae and the anterior vaginal wall close to the middle line. 
In this way it is not difficult to recognize thickening or tenderness 
of one or both kidneys. Both occur in cystopyelitis and in tubercu- 
losis of the urinary apparatus; thickening and distention may some- 
times be observed also in pyelitis calculosa (renal calculus). 
The bladder lies behind the symphysis pubis, when ordinarily dis- 
tended, it rises above it, but only when it is excessively full, as in 
paralysis of the bladder, spasm of the sphincter, stone in the bladder, 
stricture of the urethra, does it swell so much as to be noticed (rarely) 
by inspection; but especially by palpation and percussion, as a 
roundish tumor, which, of course, is dull in sound. In men it can 
also be felt from the rectum. We are able to decide with certainty 
whether a tumor in the hypogastrium is a distended bladder or not 
by drawing off the urine with a catheter. It may be confounded 
with a pregnant uterus, and also with other swellings. Always before 
undertaking an examination of the abdomen, we must see that the 
bladder is empty, partly to avoid confounding the distended bladder EXAMINATION OF THE URINARY APPARATUS 
399 
with something else, and partly because, if the bladder is full, it inter- 
feres with the examination of the abdomen. 
Anomalies located in the wall of the bladder can usually be felt 
best when the bladder is full. The external examination is made per 
vacjinam, per rectum, and sometimes bimanually. 
Surgery and gynecology teach the complicated methods of examining 
the bladder and ureters. With reference to the examination of the 
male urethra, we refer to the lectures and hand-books upon Surgery. 
Examination of the Urine. 
Under normal conditions and when free from admixture, the urine, as 
it issues from the orifice of the urethra, exhibits the renal secretion in 
a state of purity, since, in its transit through the urinary passages, it 
receives scarcely any additions from the mucous membrane that are 
worth mentioning; and further, since, at the time of its discharge 
from the body, and for some time after, its physical and chemical 
conditions are the same as at the moment of secretion. In a number 
of pathological conditions, also, the urine is the pure and unaltered 
secretion of the kidneys; while, in a second series of diseases, it is 
changed by its exit from the body, and, indeed, by admixtures from 
the urinary passages, or by decomposition of its constituents in the 
bladder. To the first series belong the anomalies of the secretion 
itself; to the second, the diseases of the urinary passages. 
In women the urine may be contaminated by admixture of material 
from the vagina or uterus, and of these the most frequent and impor- 
tant is the menstrual fluid. In order to avoid this contamination, we 
are sometimes obliged to draw off the urine with the catheter. It is 
usually contaminated by fecal material only from carelessness of the 
patient or of the attendant. But sometimes it results from commu- 
nication of the intestine with the urinary passages, as of the rectum 
with the bladder or with the vagina. 
Becent investigations by Lustgarten and Mannaberg show that the 
former assumption that the urine is normally free from bacteria must 
be given up. The urine of healthy persons contains a number of 
microfirganisms which have their origin in the urethra. The most 
important are a large streptococcus, a diplococcus which resembles the 
gonococcus, also like that in epithelium, but, of course, it is not found 400 
SPECIAL DIAGNOSIS. 
in pus-corpuscles, and lastly, a bacillus which morphologically and in 
its color-reactions agrees with the tubercle bacillus, and which probably 
is the smegma bacillus, which also occurs in the preputial sac. This 
latter may give occasion for the erroneous supposition that there is 
tuberculosis. But that it has its origin in the urethra is shown by the 
fact that it is observed even when the preputial sac has been most 
carefully cleaned previous to urination, though it is only found in 
individual cases, while in cases of tuberculosis it is always abundantly 
found in the urine. Sometimes inoculation must decide (see Appen- 
dix). We may avoid the urethral bacillus by drawing the urine with 
a catheter, but then also, sometimes, possible tubercle bacilli from the 
prostate or genital apparatus may be found in the urine. 
In case of disease of one kidney or pelvis of the kidney, the question 
may arise as to what part of the urine passed is from the right, and 
what from the left, kidney. If one kidney fails, the other acts vicari- 
ously. In tuberculosis of the urinary passage and in pyelitis, it may 
happen that for a time one ureter is stopped; the urine comes only 
from the other kidney, and it may be quite normal. Then, suddenly, 
the character of the urine will change, showing considerable white 
blood-corpuscles, seed-like particles, tubercle bacilli, or calculi, and 
blood. The quantity of urine is, for the time being, increased; for 
the closed side has again opened. 
In certain diseases of the urinary apparatus, the manner of passing the 
urine shows characteristic peculiarities ; but in many of the conditions 
under consideration, the urine is passed in a perfectly normal wav. 
Painful strangury, frequent urination, a feeling of burning in the 
urethra while passing the urine, may result from the urine being 
much concentrated, such as is passed when there is engorgement of 
the kidneys, and in the majority of cases of acute nephritis. Very 
pronounced tenesmus of the bladder—that is, painful urgency, ex- 
tremely frequent, very painful urination, in which only a small 
quantity of urine is passed at a time—indicates cystitis. We must 
mention here, further, retention and incontinence of urine, nocturnal 
enuresis (regarding these, see under Examination of the Nervous 
System). 
In regard to the mode of procedure in examining the urine, let it 
be here remarked, in the first place, that we should take care that the 
urine is received in vessels that are perfectly clean—if possible, in EXAMINATION OF THE URINARY APPARATUS. 
401 
glass vessels; and, also, that forjudging of certain general character- 
istics, it is necessary to examine the mixed urine passed during 
twenty-four hours, or that passed during the day and during the 
night, separately. For certain examinations it is necessary to separate, 
in the most careful way, the urine passed each twenty-four hours. In 
the warm season of the year, the urine ought to be examined as soon 
as possible after it is passed. In order to examine the sediment, the 
upper portion of the urine is to be carefully poured off, and the re- 
maining cloudy portion is put into a conical glass, in which it is 
allowed to stand till the sediment is deposited ; then we take up a few 
drops from the bottom of the glass with a pipette. 
When there is unconsciousness or difficulty in passing the urine, 
we must employ the catheter. The artificial emptying of the bladder, 
for the purposes of examination, must never be omitted in any case of 
unconsciousness. We briefly describe the characteristics of the normal 
urine. 
(A) Normal Urine. 
1. Amount. In twenty-four hours, with healthy persons, it amounts 
on the average to about 1500 grms. But its variations within physi- 
ological limits are very considerable, since every increase in the 
amount of water taken increases the amount of the urine, and every 
increase in the amount of water disposed of in other ways diminishes 
the urine. In the latter respect, in health we have to consider the 
loss of water by respiration and by perspiration, from heat and from 
active bodily exertion. It is superfluous in the cases just referred 
to to specify the maximal and minimal figures for the amount of the 
urine; only when those conditions are wanting, must a departure 
from the average quantity of urine given above cause us to think 
of a pathological condition. 
Within the twenty-four hours, the least urine is passed at night, or 
in the early morning, very much the greater portion being passed 
during the course of the day. Usually, the amount of urine passed 
increases about an hour after taking fluid. Emotional excitement, 
especially anxiety, sometimes temporarily increases the secretion of 
urine. 
2. Color; transparency. In health, the color is usually dark straw- 
color to reddish-yellow. Generally, the greater the amount of urine 402 
SPECIAL DIAGNOSIS. 
the clearer it is. In this respect as well as in the quantity, with 
physiologically exceptional cases, it shows marked variations from the 
average; from being almost as clear as water, after a great amount of 
fluid has been drunk, to a decidedly dark reddish-yellow (concentrated 
urine), after severe sweating. The coloring-materials which give the 
normal color to the urine are not yet all exactly known. The most 
important pigment seems to be urobilin; moreover, indican interests 
the clinician. Both coloring-materials may, in disease, be pathologi- 
cally increased. (See Pathological Colors of the Urine.) 
Urine freshly passed is, in health, always perfectly clear and 
transparent; but in these respects it may change some time after it 
has been passed. 
(a) In almost all normal urine, after standing a short time, there is 
formed a slight cloud of mucus. This is from the urinary passages, 
chiefly from the bladder. 
(b) It not infrequently happens, with healthy persons, that the 
urine, if somewhat concentrated, is cloudy when it becomes cool from 
the separation of the uric-acid salts. Gradually, the salts sink down 
and form a sediment of clear brick-dust red or flesh-color (associated 
coloring-matter of the urine, brick-dust sediment, lateritious sedi- 
ment). It has the peculiarity—by which it is likewise recognized— 
that it is again immediately dissolved as socn as the urine is warmed. 
After a long march in the heat, this sediment occurs very regularly, 
because the urine is then concentrated; but it also is observed in 
urine that is not so very dark, if it is allowed to stand in a cool place. 
(See further regarding the Urinary Sediments, p. 428.) 
(c) Urine that stands exposed for a long time, both clear and dark, 
likewise sometimes becomes cloudy, because it undergoes ammoniacal 
fermentation. The urea is changed into carbonate of ammonia, 
which makes the urine alkaline, whence there is a deposit of phos- 
phates (ammonio-magnesian phosphates or triple-phosphates, also 
phosphate of lime). Urate of ammonia also is formed and deposited. 
These separations and numerous bacteria render the urine cloudy and 
gradually form a whitish sediment. In hot weather this ammoniacal 
fermentation takes place within a few hours after the urine is passed; 
in a cool place, it does not begin before 86 to 48 hours, or not at all. 
For a more particular account of the condition when there is ammo- 
niacal fermentation of the urine, see p. 413. EXAMINATION OF THE URINARY APPARATUS. 
403 
3. Specific gravity. In health it usually varies between 1015 and 
1020. It depends upon the amount of solids held in solution by the 
urine, hence, on the one hand, upon the absolute quantity of the 
solids, and, on the other, of the amount of the watery portion of the 
urine, or the quantity of the urine. The abundant urine which 
follows drinking a great amount of water is always of low specific 
gravity, and, therefore, clear. A scanty urine, from the loss of water 
in other ways, is always of high specific gravity, and hence is dark. 
Then, also, in health the specific gravity, under some circumstances, 
temporarily oversteps very considerably the figures given above, from 
as low as 1003 to as high as 1025, or even higher. In the absence 
of “ physiological causes,’’ these figures are always of pathological 
significance. 
Mode of procedure : We measure the specific gravity of the urine 
by means of an areometer graduated for taking the specific gravity of 
the urine (that is, from 1000 to about 1040, “ urometer”). We take 
a portion of the urine which we wish to weigh (generally a mixture 
of that which has been passed during the previous twenty-four hours) 
and pour it into a not too narrow cylindrical glass until the column 
of urine is longer than the urometer. With filter-paper or a pipette, 
we remove any air-bubbles from the surface, and then introduce into 
it a perfectly clean and dry urometer; wait until it has become quiet, 
and then observe the figure that stands opposite the lower border of 
the meniscus of the fluid. 
None of the simple medical instruments is so often useless as the 
urometer. We should never use one until its accuracy has been 
tested. It is always desirable to have a urometer upon which is given 
the temperature for which its scale is arranged; not that wTe must 
always have the urine at this temperature, but because the absence of 
this requisition from the instrument shows very certainly that it has 
been prepared without care. 
4. Reaction: In general, this is always acid, chiefly from the 
presence of acid urates and phosphates. The degree of acidity varies 
individually; moreover, it is a constant quantity in every individual 
case of health, and when the food is approximately alike. 
But in the twenty-four hours the reaction varies considerably, so 
as to be even alkaline, and yet physiological. The variations proceed 
in such a way that, after every meal consisting of a mixed diet, the 404 
SPECIAL DIAGNOSIS. 
acidity declines until, after about two hours, it becomes alkalescent— 
but this quickly passes so as to give place again to an acid reaction 
(Gorges). These variations have been referred by many to the loss 
by the body of acids and alkalies in stomach and intestinal digestion. 
Hence it is assumed that the separation of HC1 in the stomach in- 
creases the alkalescence of the blood, and hence the urine becomes 
less acid, or alkaline. But, according to recent investigations by 
Noorden, this increased alkalinity of the blood does not exist. By a 
graphic representation of the reaction of the urine during twenty-four 
hours we obtain the so-called “ acid-curve.” This, with some healthy 
persons, and under like conditions (as to time and quality of food), is 
tolerably constant, but with other healthy persons it varies consider- 
ably. 
Sometimes the reaction of the urine is amphoteric—that is, it colors 
red litmus blue, and at the same time colors blue litmus red. 
The neutral or alkaline urine of health at the time of passing is 
usually clear. But it quickly becomes cloudy from the withdrawal 
of the phosphates, which gradually form a sediment. The cloudiness 
does not disappear upon the application of heat, but becomes more 
marked; on the other hand, the urine again becomes clear upon 
adding acetic acid, which dissolves the phosphates. 
5. Odor. The normal aromatic odor of urine is well known; it is 
changed by certain foods. Most frequent and most striking is the 
stench of urine after eating asparagus; garlic gives its odor to the 
urine. During alkaline fermentation we may have the development 
of ammonia, which gives its known pungent odor. 
6. Sediments. With reference to the cloudiness, the urate sediment 
of the acid, and the phosphatic sediment of the alkaline urine, have 
been mentioned on p. 402. (Regarding the microscopical condition 
of the sediment, see p. 430.) 
Whenever there is a sediment it is not unimportant to remember 
that different things may have been mixed with the urine after it was 
passed ; see above, p. 390. 
7. The portions in solution. The constituents of normal urine, 
which, from our present knowledge, are of importance to the clinician, 
besides the coloring materials, are the following: urea, uric acid, 
kreatinin, oxalic acid, chloride of sodium, sulphates, phosphates, 
carbonates. EXAMINATION OF THE URINARY APPARATUS. 
405 
Urea j> passed in twenty-four hours amounts in the 
adult to about 30 grammes (men somewhat more, women somewhat 
less). However, the amount of urea varies within wide limits: it is 
dependent upon the amount of albuminous material in the food taken, 
and, on the other hand, it is almost independent of the amount of 
muscular exertion. 
Uric acid, like urea, is a product of the metabolism of albu- 
min ; in man the quantity is much smaller than the former, being 
in proportion to the urea about as 1 : 45 ; but it is to be remarked that 
great variations take place, chiefly under the influence of the food ; 
and this in such a way that albuminous food increases the acidity of 
the urine. Hence, with reference to clinical diagnosis, the uric acid as 
well as the kreatinin is chiefly of interest, because they may place 
difficulties in the way in examining the urine for sugar, in that they 
sometimes simulate the reaction of sugar. Sometimes, on the other 
hand, they hinder the reaction of sugar (see under Mellituria). 
Chloride of sodium, the most important of the inorganic con- 
stituents, in health corresponds in amount with tolerable exactness to 
the amount of salt in the food taken. On the average, it usually is 
proportioned to the urea as 1 : 2 to 1: 3. 
Exceptionally, in health, there is found in the urine: 
Albumin, the so-called physiological albumin. There is still great 
difference of opinion regarding this subject; while it is doubted by 
some, others maintain (Senator, recently Posner) that traces of albu- 
min exist in the urine in every healthy person. It occurs in very 
small quantity (about one per cent.) after severe exertion or hearty 
eating. The urine of the newly-born not infrequently contains some 
albumin. 
Sugar (grape sugar) is observed in individual cases in very small 
quantities. After partaking freely of cane sugar, this may appear in 
the urine. 
Bile acids are likewise observed in very small quantities in normal 
urine. 
Fat is recognizable generally only in microscopical drops (or only 
in ether extract), and is found when the food has contained a great 
abundance of fat, as of cod-liver oil. 406 
SPECIAL DIAGNOSIS. 
(B) Pathological Urine. 
Anomalies in the Quantity. 
Increased amount (polyuria) is observed. 
]. In a watery condition of the blood, in the different forms of 
anaemia or hydraemia. The increase here is never very great: 2000 
grammes or less; there may be no increase, and if the heart is weak 
(see below) it may even be diminished. 
2. In the different forms of contracted kidney, and this in conse- 
quence of the accompanying hypertrophy of the left ventricle, which 
causes increased pressure in the whole arterial system, and thus also 
in the renal arteries (here even to 3500 grammes or more). Here the 
chief cause of the polyuria is the increased arterial pressure from the 
increased action of the heart (see below). 
3. When the exudation or transudation in the serous cavities of the 
body, or the fluid in the cellular tissues (oedema), is resorbed, the daily 
excretion of urine sometimes amounts to four thousand grams or more. 
The increased arterial pressure from quickening of the action of the 
heart, which occurs at the same time, is also a prominent factor in 
producing polyuria. 
4. In diabetes. Both diabetes insipidus and mellitus (mellituria) 
manifest themselves by the increase, often an enormous amount of 
urine: 4000 to 10,000 grammes, and more. Sometimes in diabetes 
mellitus there is only a moderate polyuria, or, for a time, in this dis- 
ease there is even complete absence of polyuria (diabetes decipiens). 
(See under Specific Gravity and Sugar in the Urine.) 
5. As a necessary consequence of abnormal thirst, polydipsia, as it 
is sometimes particularly observed in hysteria. 
In this connection we must further mention the quite temporary 
polyuria which sometimes occurs in nervous persons after great mental 
excitement. Finally, there is the polyuria which occupies a place by 
itself, resulting from an obstruction somewhere in the urinary pas- 
sages, where the urine is held back, and then the passage again 
becomes free (see under Obstruction). 
Finally, we must briefly refer to some drinks which temporarily 
increase the amount of the urine, as coffee, beer, and wine, which 
increase the quantity of urine more than the amount of water repre- 
sented. Likewise there are to be mentioned certain articles of diet 
which have the same effect, partly in that they increase the blood- EXAMINATION OF THE URINARY APPARATUS. 
407 
pressure by affecting the action of the heart, partly in that they stim- 
ulate the secreting action of the kidneys. 
In the above pathological conditions, where we do not have a 
removal from the organism of water that has accumulated there, then 
the polyuria must be made up, of course, by imbibing an increased 
amount of drink (polydipsia). Whether we have the increased thirst 
from increased loss of water, or whether the polyuria is the result of 
the polydipsia, is not entirely clear, especially in many cases of dia- 
betes insipidus. In diabetes mellitus the polyuria is probably only a 
purely secondary result of the polydipsia, which, in turn, is to be 
regarded as the consequence of the glukmmia (Cohnheim). 
Diminution in the amount of urine, under some circumstances even 
to the extent of not passing any (anuria), occurs: 
From diminution in the secretion of urine: 
1. In the loss of water in other ways: in severe sweating (see, 
also, Normal Urine); in any kind of severe diarrhoea, particularly in 
Asiatic cholera, where for days together there is continuous anuria. 
Thus, also, during the formation of a pleuritic or peritoneal exuda- 
tion, where fever is to be taken into account as a cause (see below). 
2. In fever, and largely in consequence of the loss of water in 
other ways; by increased perspiration and the greater loss of water 
by the lungs. 
3. By reduced blood-pressure resulting from the diminished work 
of the heart; hence, in diseases of the heart-muscle : incompensation 
in valvular disease, in weakening of the hypertrophic heart of con- 
tracted kidney, in emphysema, in all the diseases, frequently men- 
tioned, which harmfully affect the action of the heart. In these 
conditions the amount of the urine is the chief means of forming a 
judgment of the course of the disease, and furnishes the indications 
for treatment. 
4. In acute nephritis, subacute and chronic nephritis, except con- 
tracted kidney (regarding which see also under 3). In these diseases, 
also, the amount of the urine is a symptom which indicates the 
severity of the case. In acute nephritis there not infrequently is, for 
a time, anuria. 
5. From suppression of urinary secretion due to nervous causes, 
especially in a still indistinct reflex way in trauma, as from operations 
affecting the abdomen. 
Also, there may be a less quantity of urine from difficulty in mic- 408 
SPECIAL DIAGNOSIS. 
turition ; from a very narrow stricture of the urethra (surgery) ; from 
retention in the bladder; from obstruction in the ureters. In regard 
to the latter, when one kidney is cut off, the other generally vicari- 
ously performs the work of both; but there may also be anuria when 
one ureter is closed, as from stone in the kidney, and this, in fact, 
from a kind of reflex suppression in the other kidney (see Shock). 
The great zeal in using the catheter in recent times has given us 
as a result, among other things, the knowledge of the fact that in 
health with every urination the bladder is completely emptied, even 
to a few drops. If a certain amount of urine remains in the bladder 
(residual urine) there is a pathological cause for it. This may be a 
purely mechanical hindrance to the emptying of the bladder, as 
stricture, hypertrophy of the prostate, urinary calculi; or it may 
result from the mechanical hindrance, atony of the bladder; or there 
may be primary nervous paresis of the detrusor, as occurs in tabes 
and in all diseases of the lumbar cord. The amount of residual urine 
is said to be tolerably constant; it is measured by having the patient 
pass his urine, and then use the catheter immediately afterward. 
Color and Transparency of the Urine in Disease. 
Primarily, the color varies according to the degree of concentration, 
in the same way as in normal urine; and as in health, so also in 
general in disease, it stands in a certain relation to the amount of the 
urine: the greater the amount the clearer the urine. But, like the 
variations of quantity from the average, the changes in the color of 
the urine are also much more significant in disease than is the case 
in normal urine. The scale of colors of the urine passes from the 
almost colorless to the straw-yellow, reddish, red-brown, even browrn- 
black. It is not necessary to have a very exact determination of the 
color of the urine by comparing it with those of a table of colors, as 
was proposed by Vogel, because it could only have a value in deter- 
mining the degree of concentration, and generally for this the specific 
gravity is much more exact (see). 
Patients with cirrhosis (without icterus, which see) sometimes pass 
urine that, in proportion to its amount, is very dark. Anaemic (chlo- 
rotic) persons, on the other hand, often pass remarkably clear urine. 
In fever the urine is relatively dark—reddish or brownish-red (see 
below, Urobilin. EXAMINATION OF THE URINARY APPARATUS. 
409 
In diabetes mellitus there is a peculiarity in the very striking con- 
tradiction between the clear color and great amount of the urine on 
the one side, and its high specific gravity upon the other, which is of 
diagnostic importance. 
As special pigments of the urine, the following are to be men- 
tioned : 
1. Color due to the increase in the normal 'pigments. Two of these 
come into consideration here : 
Indican, occurring in increased amount may sometimes give to the 
urine a bluish or bluish-black color, if it has been decomposed in the 
urinary passages and changed into indigo-blne ; but very often we do 
not recognize that the urine contains more indican, because indigo 
has not yet been formed. Hence, when there is a suspicion of 
indican, or if we wish to make use of its possible presence for the 
purposes of diagnosis, even when the urine appears to be perfectly 
normal, we must examine it with reference to this substance. When 
urine containing indican has been standing for some hours, it can 
generally be recognized by the bluish shimmer of the residuum, from 
the drops of urine from the upper part of the urine-glass sprinkled 
and spread out as thin as possible, and sometimes, also, by a bluish 
film upon the surface of the urine. Besides, all of the urine is some- 
times blackish-blue, and this is most markedly the case when the 
urine putrefies (for its chemical reaction, see below). 
Indican urine—that is, increase of the indican—occurs: when 
there is accumulation of the intestinal contents, especially of the con- 
tents of the small intestine, hence in occlusion of the intestine from 
any cause, as peritonitis or obstinate obstipation; likewise, in all 
forms of severe cachexia, as well as in Asiatic cholera; lastly, in 
individual cases in health. 
Urobilin, if it exist in considerable quantity in the urine, colors it 
a decided red or brownish-red. The foam of the urine sometimes 
looks yellowish-red or yellowish-brown. 
While there is only a small quantity of it in health, it is abundant 
in febrile diseases and where there is at any time resorption of large 
effusions of blood. When there is a marked separation of it which 
continues for some time, a brownish discoloration of the skin is 
observed in the so-called urobilin-icterus, though there is still dispute 
as to its nature. 
Proof of the increase of indican : The following reaction establishes 410 
SPECIAL DIAGNOSIS. 
the presence of indican in increased amount, because it does not 
operate in the presence of the small quantity found in normal urine. 
We mix equal parts of urine and fuming nitro-muriatic acid in a 
reagent glass; into this we drop two to three, or at most four, drops 
of a concentrated solution of chlorinated potash ; immediately, or after 
a few seconds, there is formed just beneath the surface a blue-black 
cloud—indigo-blue. By stirring the solution of potash in the urine we 
obtain, according to the quantity of indigo formed, a more or less 
dark coloration of the whole fluid. If, then, we add a few drops of 
chloroform and agitate (not shake) the reagent-glass several times, we 
have the blue color at the bottom from the settling of the chloroform 
(it becomes green if too much of the solution of chlorinated potash 
has been added, from the further oxidation of the indigo-blue). 
Tests for urobilin. 1. Spectroscopic : Absorption bands in green- 
blue, between Frauenhofer’s lines b and F (sometimes it is necessary 
to dilute the urine with water, in order to be able to make the exami- 
nation). 2. Chemically: We add ammonia to the reddish urine in 
the reagent-glass. If there is much urobilin there, it gradually 
becomes a clear green ; it is then filtered; and, sometimes, upon the 
addition of a few drops of a watery solution of chloride of zinc, there 
appears the rose-red-greenish fluorescence that is peculiar to urobilin. 
2. Discoloration of the urine from the presence of the coloring- 
matter of the blood, and of the bile. That of the blood colors the urine 
variously according to the amount that is mixed with the urine, also 
whether it is fresh or has been changed, and according to the original 
color (concentration) of the urine: flesh-red or blood-red with green- 
ish shimmer with the light passing through it, corresponding to the 
dichrotic behavior of the blood ; or an untransparent brown, even 
blackish. Frequently the bloody color is easily recognized; but, 
generally, the reaction-test for blood coloring-matter is necessary (see 
Coloring Matter of the Blood). 
Coloring-matter of blood occurs in the urine : 1. In hsematuria, and 
this in the sediment. It is circumstantially described in the section 
on Admixture of Blood with the Urine. 2. In haemoglobinuria. 
In this condition the haemoglobin is found entirely dissolved or in 
granular lumps, but no red blood-corpuscles, or very few, are found 
in the urine. This results from hsemoglobinaemia (see p. 271), and 
this condition may arise from very different causes: from poisons 
(chlorate of potash, mineral acids, arsenical solutions, pyrogallic acid, EXAMINATION OF THE URINARY APPARATUS 
411 
naphthol, poison of the edible mushroom, helvella esculenta; after 
transfusion of animal blood, as of lamb’s blood); in infectious diseases 
(as scarlet fever, abdominal typhus, malaria, syphilis); after extensive 
burns; lastly, we have to mention a form of haemoglobinuria which 
occurs as an independent disease—paroxysmal hsemoglobinuria. 
Coloring matter of the bile exists in the urine in icterus (icteric 
urine). Such urine is most frequently a beer-brown, sometimes brown- 
green, or even black. If the urine of icterus, as is very seldom the 
case, is very thin, then it may have a golden-reddish tone. The 
foam that forms when it is shaken is then highly characteristic: from 
clear to dark yellow, green-yellow, even brownish. (Regarding the 
chemical tests for bile coloring-matter, and more particularly regard- 
ing its presence and that of the bile acids in the urine, see section on 
Coloring Matter of the Bile.) 
3. Staining of the urine from medicines. It is very important to 
recognize these changes in color, so that one may be on the guard 
against deception by confounding them with the coloring matter of 
the bile and the blood. 
The chrysophanic acid contained in rhubarb and senna passes olf 
by the urine. It colors the urine slightly, making it at most a little 
brownish, if it is normally acid; but if it is alkaline, or is made so, 
then it becomes a purplish-red. 
After taking logwood, alkaline urine also becomes reddish or violet. 
Santonin colors the urine yellow or greenish-yellow, with a yellow 
foam ; upon the addition of an alkali the color changes to red. Picric 
acid makes the urine yellow, but there is no change in color after 
changing the reaction. 
Carbolic acid, naphthalin, creasote, and other preparations of tar, 
as well as the infusion of the leaves of uvae ursi (arbutin) produce a 
greenish or greenish-black color of urine. 
Brownish or blackish discoloration of the urine after standing for 
some time in the air is observed in patients with melanotic tumors, 
because the pigment which forms the coloring matter of the blood in 
those tumors passes off by the urine. A similar behavior of the urine 
is found in the presence of an abnormal amount of pyrocatechin, an 
extremely rare occurrence. 
Transparency of the urine. A loss of transparency by turbidness 
may take place even in normal urine when it has been allowed to stand 
(see above). Urine that is turbid when passed is always pathological. 412 
SPECIAL DIA Cl XOSIS. 
This is the case, first of all, in nephritis, in consequence of the forma- 
tion of organic constituents ; in all diseases of the urinary passages, 
for the same reason (here particularly on account of mucus); but 
especially in severe cystitis, because the urine in this condition is 
alkaline when it is passed (alkaline fermentation in the bladder), and 
hence, besides the organic constituents, contains a deposit of phos- 
phates. Admixture of blood and pus always makes the urine turbid 
to some extent. The most striking, and, at the same time, the rarest 
kind of turbidness is that caused by fat in the urine, chyluria. Here 
the urine is milky, as if mixed with pus (galacturia) from the emulsi- 
fied fat; or it contains large drops of fat or fat-bubbles swimming 
upon its surface (lipuria). By shaking the urine up with ether it 
becomes clear. But when it is allowed to stand, part of the fat settles 
as a sediment, and part forms a cream-like layer on top. (See further 
regarding Chyluria.) 
The Specific Gravity of the Urine in Disease. 
The specific gravity of the urine may vary from a little over 
1000 to over 1060 (in diabetes mellitus). Apart from certain 
special admixtures (we mean particularly sugar, which increases the 
specific gravity without changing its color, and the special pig- 
mentary admixtures, which, on the other hand, darken the color 
without essentially adding to the specific gravity), almost always in 
disease, as in health, a scanty, dark urine has a high specific gravity; 
an abundant, clear urine, a low specific gravity. According to Hseser 
and Neubauer, from the specific gravity we can obtain an approxima- 
tion to the amount of solid constituents of the urine by multiplying 
the last two figures of the specific gravity by 2.33. This product 
represents the quantity of solid constituents in 1000 grammes of the 
urine. If we have 1200 grammes of urine with a specific gravity of 
1021, then 1000 grammes of this contains 21 X 2 33 = 48.93 grammes 
of solids, and the whole amount = 58.7 grammes. But not much 
has been said regarding the change of material upon which it chiefly 
depends, because the different solid constituents of the urine have 
very different specific gravity, particularly urea, which, as compared 
with chloride of sodium is as 2 to 3. Hence, we can never draw defi- 
nite conclusions from the specific gravity alone, and even where we 
can exactly determine the solids, as by examining the various material EXAMINATION OF THE URINARY APPARATUS. 
413 
changes, the quantitative determination of the urea or of the nitrogen 
is indispensably necessary. 
The chief value in the determination of the specific gravity with 
reference to diagnosis consists in the following: 
© © 
1. High specific gravity with clear and abundant urine points to 
diabetes mellitus. We may even say that a specific gravity of 1040 
and over, the urine being clear, can only be caused by sugar, and 
hence is pathognomonic of diabetes. 
2. Repeated or continued examination of the urine in general 
engorgement is of value, because this, as well as the quantity of the 
urine, measures the labor of the heart. 
It is not unimportant to know further : 
3. A low specific gravity, when there is a small amount of urine 
which is often high colored, occurs in nephritis from diminished excre- 
tion of urea, also in severe diarrhoea and vomiting. 
Reaction of Urine in Disease. 
For the reasons previously given (under Reaction of the Normal 
Urine), the reaction of the urine is reliable only a short time after it 
has been passed. 
Neutral or alkaline reaction of the urine is met with in sickness: 
1. Under the same conditions that make it neutral or alkaline in 
health. 
2. When there is resorption of transudates and exudation in the 
cavities of the body, also from large effusions of blood, especially in 
the pleura and peritoneum. 
3. With dilatation of the stomach, and particularly if the contents 
of the stomach must frequently be brought up, either by vomiting or 
artificially. The reason given is that the blood and the organism 
lose their acidity because free HC1 is not again resorbed (?) (See 
above, under Reaction of the Normal Urine.) 
4. Considerable admixture of blood or pus. In the cases of alka- 
line urine previously mentioned the urine is clear, or is turbid from 
the deposit of phosphate; it contains no bacteria, or only a few. 
5. With alkaline fermentation of the urine in the bladder. This 
accompanies severe forms of cystitis. Here the urine is turbid, 
because of the presence of pus-corpuscle's, abundant bacteria, deposit of 
triple-phosphates, urate of ammonia, carbonate and phosphate of lime 
and magnesia. Sometimes it has a peculiar, urinous smell, and is 414 
SPECIAL DIAGNOSIS 
pungent from the free ammonia. By this latter a strip of red litmus- 
paper, just held free over the fluid, is colored blue. 
Further regarding the formed constituents of simple alkaline urine, 
and that which has been the subject of alkaline fermentation, see 
under Sediment. 
The acidity of the urine may be determined by a simple, but 
really not very accurate, method: Prepare a 10-per-cent, solution of 
caustic soda (1 of soda to 9 of distilled water), and pour this from a 
burette into the urine until a piece of very sensitive litmus becomes 
blue. 1 c.cm. of the soda solution corresponds to 0.0063 of oxalic acid. 
Works upon analysis of the urine teach the more exact methods. 
Pathological Odor of the Urine. 
Here we must mention as worthy of recognition the pathological 
departures from the odor of normal urine. A urinous, more or less 
pungent, ammoniacal odor, in cases of severe cystitis, shows ammo- 
niacal fermentation in the urine that is passed. Then there is the 
feculent odor when the urine is mixed with feces, whether the admix- 
ture takes place after the urine is passed (see Contamination, p. 399), 
or whether it has taken place from communication between the bladder 
and the intestine, with discharge into the bladder. 
The most notable, and at the same time diagnostically important, 
odor of the urine is the fruity (apple-odor), or like chloroform. The 
substance which has this peculiar odor seems to be acetone (Fetters) 
[compare what is said later regarding Acetone]. The urine which 
has this odor, upon the addition of chloride of iron, sometimes gives a 
burgundy-red reaction (“ chloride-of-iron reaction,” Gerhardt), which 
shows the presence of acetic acid (see further below). Usually the 
odor of apples is more noticeable in the breath of the patient even 
than in the urine, and it may be noticed in the breath alone. 
The apple-odor is observed in individual cases of diabetes mellitus. 
It especially occurs in diabetic coma or as the precursor of this con- 
dition, but it also exists, and, indeed, often for a long time, without 
the occurrence of coma. 
Unusual odors may be imparted to the urine by medicines: after 
taking turpentine, violet odor; after cubebs and copaiva, the aromatic 
odor of these drugs. 
Foul, albuminous urine, but especially urine that contains pus, 
develops, as the result of certain organisms, sulphuretted hydrogen : EXAMINATION OF THE URINARY APPARATUS. 
415 
hydrothionic urine. Sometimes this fermentation, with the develop- 
ment of sulphuretted hydrogen, seems to take place in the bladder 
(cystitis). On the other hand, if the urine, when first passed, is 
clear, and upon being promptly examined is found to contain sul- 
phuretted hydrogen, it is probable that there has been resorption of 
SH2 into the blood or into the bladder from the intestine, or from a 
depot of pus in the neighborhood of the bladder; under which circum- 
stances the general symptoms of poisoning have recently been observed. 
Urinary Sediments. 
We are to call to mind the sediments, previously mentioned, which 
may occur in normal urine. On the other hand, these same sedi- 
ments may sometimes be observed as pathological signs, as is shown 
in wThat follows: 
All formed constituents which separate when the urine is allowed 
to stand are reckoned as “sediments,” whether they can be recog- 
nized with the naked eye or only under the microscope, or whether 
they are organized or are really “deposits.” As previously men- 
tioned, in order to examine the sediment it is desirable carefully to 
pour off from the vessel containing the urine the upper part; the 
lower turbid or already settled portion is to be put into a glass with a 
pointed bottom, and again allowed to settle. Then follows the 
examination with the naked eye and with the microscope. For the 
latter, we take up some of the sediment with a pipette by introducing 
it [closed by one finger upon the upper end] to the bottom of the 
pointed glass, when it is to be opened again for a moment, then it is 
withdrawn and carefully wiped off, and a drop of its contents allowed 
to flow upon an object-glass. [An object-glass with a depression in the 
centre making a shallow cell is very convenient, since a larger drop can 
be examined at each time.] Upon this we place a glass cover, and 
examine it wdth a magnifying power of about 400 diameters. If the 
sediment is very scanty, we are to focus the microscope so as first to 
examine the edge of the covering-glass. It may happen that the 
sediment is so scanty that we cannot see anything at the bottom of 
the glass with the naked eye, but by carefully removing a drop from 
the bottom of the glass and placing it under the microscope we may 
possibly make out formed constituents, as a few casts (contracted 
kidney). 
It is necessary to color the urinary preparations only wheD 
examining for certain microorganisms (see below). 416 
SPECIAL DIAGNOSIS. 
1. Sediments of Organic Bodies or their Direct Products. 
Mucus. Physiologically this exists only in small quantities. It 
is increased in all diseases of the urinary passages, but especially 
in cystitis, and also in fever. 
Some mucous forms are characteristic : In the form of minute 
roundish floccules, the size of a millet-seed or the head of a pin, they 
are tolerably characteristic of mild cystitis. Under the microscope 
they show white blood-corpuscles lying closely to one another, and 
they are apparently conglomerations of white corpuscles. 
In the form of threads, one to two centimetres long—gonorrhoeal 
threads—sometimes more purely mucous in character, and, again, 
containing abundant pus-corpuscles: they occur in chronic gonorrhoea 
or as the residuum of a past attack. 
Finally, we find microscopical mucous threads, cvlindroid (see Fig. 
123, p. 417), which may be confounded by the inexperienced with 
the so-called urine-casts. The origin and diagnostic significance of 
these is not clear. They are found in nephritis by the side of the 
casts, in cystitis, but also in health. They will be distinguished from 
the urinary casts by their usually being of considerable length, their 
mucus-thread texture, their very varying thickness (as fine as threads, 
especially at the end), and their tape-like appearance. 
Chemical proof of mucus in solution : The addition of acetic acid 
makes a flocculent precipitate, which is not again dissolved by an 
excess of acid, nor is it again dissolved by heat, as is the case with a 
precipitate of urates produced by acetic acid. 
In women mistakes may arise from the admixture of vaginal mucus 
with the urine. 
Blood, or red blood-corpuscles. The appearance of the urine varies 
very remarkably in hsematuria. Sometimes there is a considerable 
blood-red sediment, not infrequently partly congealed; again, only 
a fine deposit of red blood-corpuscles spread out evenly; and lastly, 
sometimes, a more brown-red, clear, or dark-brownish sediment. The 
red blood-corpuscles may be so scanty as to escape detection with 
the naked eye. This distinction pertains to the amount of the blood 
and its having been for a longer or shorter time in the urine—that 
is, with reference to the location of the hemorrhage. (Regarding the 
color of the urine, see p. 401.) EXAMINATION OF THE URINARY APPARATUS. 
417 
Hcematuria occurs : 
(a) In diseases of the kidneys—that is to say, in acute and chronic 
hemorrhagic nephritis, in embolic hemorrhagic infarction of the kidney 
(valvular disease of the heart), in septic 
hemorrhage of the kidneys (acute en- 
docarditis), in marked engorgement of 
the kidney, with new formations, and, 
lastly, in injuries to the kidney. 
(b) In certain diseases of the urinary 
passages, and also of the pelvis of the 
kidney (nephrolithiasis, tumors), of the 
bladder (severe cystitis, tumors, stone), 
of the urethra (gonorrhoea with parasites 
of the urinary canal; see below). 
Moreover, haematuria has symptoma- 
tic significance for recognizing diseases 
of other kinds. Thus it occurs in scor- 
butus, morbus Werlhofii, hgemophile, 
and, lastly, in the rare hemorrhages of 
the kidney or urinary tract that are due 
to leukaemia. 
From the appearance of the sediment 
and the way it is passed, a conclusion 
with reference to the location of the 
hemorrhage and the kind of disease will 
be made from the following points of 
view : 
A small amount of blood, or, at least 
a not too abundant quantity of blood, 
uniformly mixed with the urine, the color 
of the blood being retained, or, more 
frequently, 'changed into a brownish 
color, points to a hemorrhage of the kid- 
ney. That this is its source can be more certainly proved by the 
microscope showing blood-casts (see below). Where there is renal 
hemorrhage, the blood-corpuscles are always more or less discolored, 
as rings or shadows. Cells and casts, if present, are stained brown 
by the coloring-matter of the blood. A brown color of the sediment 
Fig. 123. 
Cylindroids (see p. 416). (Jaksch.) 418 
SPECIAL DIAGNOSIS. 
and of the urine indicates acute hemorrhagic nephritis. The sudden 
occurrence of bloody urine, with valvular disease of the heart, points 
to renal infarction. Individual red blood-corpuscles occur in very 
concentrated urine in renal engorgement. 
In hemorrhage of the pelvis of the kidney, especially that caused 
by stone, the urine usually alternates between being bloody and free 
from blood, and this, either because there are temporary hemorrhages 
or because the ureter of the diseased side is for the time being stopped, 
and then the urine that is passed only comes from the sound side. 
The blood may for a time escape very freely; in rare cases it may be 
passed in the form of vermiform coagula (casts of the ureter), which 
give great pain as they are passed. 
Cystic hemorrhages, especially in villous tumors, may be so free as 
to be fatal. The urine is not intimately mixed with blood, especially 
if the patient lies quietly in bed; at first there is little or no blood at 
each urination; but then, again, pure blood is sometimes passed. On 
the other hand, in hemorrhage from the urethra, blood comes only at 
the beginning of the urination. Here, sometimes, there is an escape 
of blood between the urinations. Works upon surgery treat more at 
length of hemorrhages of the bladder and urethra. 
Microscopical examination. In every respect this is the most 
valuable method for recognizing hsematuria, especially from the 
following points of view: 1. Because the separate red blood-corpuscles 
can be discovered where neither the fluid portion of the urine nor the 
sediment shows the color of blood, and where, also, the fluid portion 
does not show the reaction of the blood-pigment (see below). 2. 
Because it alone establishes the differential diagnosis between haema- 
turia and haemoglobinuria. 3. Because, from the condition of the 
red blood-corpuscles, from the presence of possible blood-casts (see 
Casts), we can sometimes determine that there is renal hemorrhage. 
In haematuria we find more or less abundance of red corpuscles. 
In decided hemorrhage, especially from the lower portion of the 
urinary tract, these are only slightly changed. If retained for some 
time in the urine, and particularly if they are scanty, as in renal 
hemorrhage, they are smaller, have granular contents, or are more or 
less markedly discolored. If they are very pale, then we have the 
so-called rings. If there are no red blood-corpuscles in a urine that 
is bloody and certainly contains haemoglobin (see Examination of the EXAMINATION OF THE URINARY APPARATUS. 
419 
dissolved portion), or if they are very scanty in a urine that contains 
a good deal of haemoglobin, then we have haemoglobinuria (which 
see). 
Besides red blood-corpuscles, we frequently find in the sediment, 
according to the disease present, still other formed constituents: in 
cystitis, first of all, white blood-corpuscles, phosphate crystals; in 
nephritis, casts and white blood-corpuscles. A considerable amount 
of blood in the urine makes it somewhat albuminous. 
With women, we must remember the possibility of being deceived 
by the menstrual blood. 
Hcemoglobin. In haemoglobinuria there is usually a brown or 
brown-black sediment, which consists of brown flakes and fine granular 
detritus. A few red blood-corpuscles are likewise found. If casts 
and epithelium are present, they are often colored brown. 
Pus, or white blood-corpuscles. It is rare that a considerable 
amount of pus is passed by the urethra. It happens if a neighboring 
depot of pus breaks into the urinary canal: in perinephritic abscess 
with discharge into the pelvis of the kidney, but particularly in ab- 
scesses of all kinds in the neighborhood of the bladder. Here the 
discharge of pus takes place suddenly, and after a short time the 
urine becomes normal again. But the discharge of pus into the 
urinary passage may continue for some time, or it may indicate 
cystitis. 
Sediments of pus or white blood-corpuscles are more frequent, 
being caused by inflammation of the mucous membrane of the urinary 
tract, or by nephritis. In the latter case they are less abundant than 
in the former. The sediment is yellow to white, in nephritis; in 
catarrhal cystitis it is sometimes very like phosphatic sediment (which 
see). In inflammation of the urinary tract, generally the sediment 
becomes a peculiar compact jelly, from mucus; in alkaline urine, it is. 
due to the mucous swelling of the white blood-corpuscles (see above); 
in nephritis, it is quite spongy. 
The microscopical examination shows the white blood-corpuscles 
more or less changed according to their amount, the length of time 
they have been in the urine, and the reaction of the latter. In alka- 
line urine they are very clear and much swollen. Of the diseases of 
the kidneys, acute hemorrhagic nephritis, and sometimes the sub- 420 
SPECIAL DIAGNOSIS. 
chronic (chronic parenchymatous) nephritis, show a relatively abundant 
amount of pus-corpuscles. 
To a slight degree, pus makes the urine albuminous ; a considerable 
amount of albumin in the urine is always due to renal albuminuria. 
When the quantity of albumin in the urine is slight, the question 
may arise whether we have nephritis, either as a separate disease or 
as a complication of cystitis or pyelitis. This can only be answered 
by the infallible sign of nephritis—that is, casts in the urine. 
Fat-drops. The fat accompanying chyluria may, as was previously 
mentioned, exist in the urine as a sediment, but also as a cream-like 
or swimming layer, or in the form of large drops. We must remember 
that it may be due to impurities, as the use of an oiled catheter. The 
microscope shows minute particles of fat or large drops, which 
markedly refract the light. In the first case the fatty character of 
the sediment may be most quickly recognized by the grease-spot 
formed upon paper by the sediment. We may also shake it up with 
ether, and then allow the ether to escape by evaporation. 
The occurrence of fat-drops free and attached to casts, adipose 
white blood-corpuscles, is very important in diagnosing large white 
kidney. 
Epithelium. We find in the urine the epithelium of the urinary 
passages and the epithelium of the renal urinary channels [urinary 
tubules]. In addition, in women we have very frequently, but espe- 
cially when there is leucorrhoea, flat epithelium from the vulva. The 
cells of epithelium in transition are everywhere very similar. But 
renal epithelium is usually easily recognized as such. 
While in normal urine only individual flat epithelial, and some- 
times, caudate cells occur, we meet a large quantity of the three 
species of cells named in inflammation of the urinary passages. 
Usually, they are well preserved. It is misleading to form a conclu- 
sion from the kind of cells as to the location of the inflammation 
(especially whether of the pelvis of the kidney or of the bladder). 
The vulva being excluded, a large quantity of flat epithelium points 
to the bladder. Abundant caudate, but especially overlapping, “ tile- 
like,” roundish cells with large nuclei, were formerly often regarded 
as characteristic of inflammation of the pelvis of the kidney; but 
more recently this view has come into discredit. EXAMINATION OF THE URINARY APPARATUS. 
421 
Renal epithelia occur in considerable numbers only in affections of 
the kidney, and especially in nephritis. If their form is well pre- 
served, they are recognized without difficulty as polygonal or round- 
cornered cells of peculiarly sharp contour, with large oval nuclei and 
a decidedly granular, often yellowish-looking, protoplasm. They are 
small—not larger than white blood-corpuscles, sometimes smaller. In 
acute hemorrhagic nephritis they are often coarsely granular, brownish 
in color; in the large white (butter) kidney, but sometimes also in the 
first disease, we not infrequently see them in all stages of fatty 
degeneration. 
Fig. 124. 
Epithelium from the urine, a, b, epithelium from the bladder, from the pelvis of 
the kidney; c, caudate epithelium (pelvis of the kidney?); d, renal epithelium, 
partly changed into fat. 
Regarding cylindrical epithelium, see under Casts. 
Shreds of tissue. Shreds of connective-tissue and “ caseous 
crumbs ” are found in tuberculosis of the urinary apparatus. 
Particles of carcinomatous tissue are separated in carcinoma, but 
are more frequently found in carcinoma villosum of the bladder. 
Only particles which distinctly show the structure of carcinomatous 
tissue are of importance here. Single, or, also, several pretended 
“ cancer-cells ” lying close to one another have no diagnostic value. 
Spermatozoa. After every discharge of semen these are seen in 
the urine. Hence, they are not unimportant for detecting masturba- 
tion. They also occur in spermatorrhoea. Lastly, sometimes they 
are found after epileptic attacks; also, now and then with severe 
diseases of all kinds, as in typhoid fever patients. 
Casts. The so-called urinary casts (Ilenle, 1842) are incontestably 
the most important form-elements in pathological urine. They are 422 
SPEC I A L DIA GNOSIS. 
found with renal albuminuria. Aside from quite individual excep- 
tional cases, they occur without simultaneous albuminuria only in one 
condition: hepatogenous icterus. Here they have no diagnostic 
interest further than that, from their occurrence, we may suspect the 
presence of bile-acids in the urine. They are intensely stained with 
the bile-pigment. 
We concern ourselves only with the occurrence of casts with albu- 
minuria. By their presence these not only permit a conclusion that 
there is a disease of the kidneys which causes albuminuria, but, by 
their quantity and character, also enable us to diagnose the exact 
nature of the disease. Regarding their numbers the casts are scanty, 
and then usually hyaline (see below), in engorgement of the kidneys, 
in fever, in physiological albuminuria; and, lastly, they are tem- 
porarily present in contracted and amyloid kidney. There is often 
here a sediment which is scarcely, or not at all, visible. In making 
a preparation we must, with the greatest care, take a few drops from 
the bottom of the urine-glass and examine the preparation with great 
thoroughness. It is advantageous, but not indispensable, to stain any 
casts that may be present by the addition of a little gentian-violet 
solution placed upon the edge of the covering-glass. The casts are 
very abundant in acute, and frequently also in chronic, nephritis. 
In these diseases they may form the principal portion of a tolerably 
abundant sediment. 
Variation in the quantity of the casts is to be observed in all the 
diseases named. Sometimes it seems as if, after a period of stagna- 
tion, the casts are passed in greater abundance. This is not very 
rare in amyloid nephritis, also in acute attacks of nephritis. 
In size and form the casts vary greatly. We will speak further 
regarding this. 
As to their nature, we distinguish the following kinds of casts: 
Hyaline casts. These are of great variety as to length and 
breadth ; sometimes not so broad as a white blood-corpuscle (thin 
hyaline casts), and, again, five or six times as broad (thick or medium 
casts). In length they may be as much as one millimetre. They 
are homogeneous and clear as water, with a very fine outline, hence 
often very difficult to see; the ends look as if broken off, rounded, or 
even clubbed (for aggregation of substances within them, see below). 
They occur in company with other forms in all diseases of the kidney. EXAMINATION OF THE URINARY APPARATUS. 
423 
Exclusively hyaline casts occur most frequently in contracted and 
amyloid kidney, also in fever and with [renal] engorgement. 
A special kind of hyaline casts are the waxy, so named from their 
smooth form and usually yellowish color. Sometimes they show the 
amyloid reaction with iodine and iodide of potassium—brown, then 
violet with sulphuric acid. We cannot form a conclusion from them 
as to the nature of the disease 
of the kidney; certainly they 
are not pathognomonic of amy- 
loid kidney. 
Additions to the hyaline, and 
also to the waxy, casts fre- 
quently occur in the form of 
red and white blood-corpuscles, 
renal epithelium, crystals, gran- 
ular masses, which, in turn, 
may show urates, phosphates, 
Fig. 126. 
Fig. 125. 
Hyaline casts (narrow and tolerably 
broad ones). 
Waxy casts. (Jaksch.) b, a cast containing 
crystals of oxalate of lipie. 
albuminous or fat granules, and, lastly, bacteria. Among these 
additions those of special significance are red blood-corpuscles, as in 
hemorrhagic nephritis, possibly adipose renal epithelia, white blood- 
corpuscles (granular spheres), and free fat-granules. These adipose 
elements, if abundant, are important for the diagnosis of large white 
or fatty kidney. 
In some cases of pyelonephritis we have seen hyaline casts which 424 
SPECIAL DIAGNOSIS. 
were split like a pair of trousers. These might possibly have their 
origin in collective tubes (?). 
Casts that are coarse or finely granular are generally hyaline, with 
additions to their contents, as above. But, especially in acute 
nephritis, conglomerate casts of albumin in lumps and granules also 
occur; sometimes stained or mixed with hgematoidin. 
Blood casts are conglomerations of red blood-corpuscles held 
together by coagulation. They are important as indisputable signs of 
renal hsematuria. 
Epithelial casts are either hyaline casts with the addition of renal 
epithelium (recognized by their sharp outline and distinct large 
nuclei), or they are true epithelial tubes. In both cases they have 
the same significance—the free desquamation of renal epithelium, 
especially as it occurs with acute hemorrhagic nephritis. 
Fig. 127. 
Fig. 128, 
Fig. 129. 
Fig. 127.—Granular casts. (Jaksch.) 
Fig. 128.—Red blood-corpuscles, partly as “rings’’ and casts of red blood-corpuscles. 
(Eichhorst.) 
Fig. 129.—Epithelial cast. (Jaksch.) 
Casts of lumps of haemoglobin in haemoglobinuria, urate-casts in 
the newly born (uric acid infarction in connection with ammonio-uric 
acid), and casts of bacteria in pyaemia(?) are very rare occurrences. 
We may confound casts with cylindroids (see p. 416), also Avith 
threads of linen or other adventitious materials in the urine. Practice 
in examining and cleanliness guard one from mistake 
Animal Parasites. 
Echinococcus. Shreds from echinococcus bladders, scolices, are 
met with in the urine if an echinococcus of the kidney 01 from the EXAMINATION OF THE URINARY APPARATUS. 
425 
neighborhood of the urinary apparatus breaks into the urinary passage. 
The passing of urine is often attended with severe pain, especially by 
attacks of colic during its transit through the ureters. They may be 
preceded by anuria from obstruction of the urethra, obstruction of 
one ureter, and “ reflex ” suppression of secretion upon the sound 
side (or reflex spasm of the sphincter vesicse). , 
Distoma hcematobium, an exotic from Egypt, located in the roots of 
the portal vein, also particularly in the plexus vesicalis, causes hsema- 
turia. The eggs of the parasite make their appearance in the urine. 
Strongylus gigas located in the pelvis of the kidney causes pyuria 
and hsematuria. 
Filaria sanguinis, an exotic from East India, Japan, China, and 
Australia, located in the large lymph-vessels, among other things 
causes engorgement of the lymph-vessels of the bladder: chyluria (and 
likewise galacturia, see) and hsematuria (peach-red urine). Besides, 
the urine contains embryo filaria, round worms of delicate structure, 
lying in a fine sheath, with lively motion. Its width is about that of 
a red blood-corpuscle ; its length, two to three millimetres. 
Oxyuris vermieularis, trichomonas vaginalis (an infusorium), and, 
in one case under my observation, the larva of the fly family, musca 
vomitoria (!) may become mixed with the urine from the vagina. 
Vegetable Parasites and Fungi. 
Normal fresh urine, free from impurities, is not entirely free from 
fungi (see p. 399). A number of bacilli and cocci colonize in urine 
that has been standing for some time, of which those of special interest 
are the ones which cause alkaline fermentation, changing the urea 
into carbonate of ammonia (see p. 402). 
The micrococci and bacilli of alkaline fermentation, and, with them, 
the signs of this fermentation—alkaline urine, crystals of triple- 
phosphate and carbonate of ammonia (see below)—however, occur in 
fresh urine in severe cystitis, particularly as the result of the use of a 
catheter that is unclean, in cases of weak or paralyzed bladder; but 
this is no doubt also caused by paralysis of the bladder alone, and the 
spontaneous entrance of fungus germs through the urethra. The 
fungi produce cystitis by the fermentation they set up, and this, in 
turn, favors the development of the fungi. If these schizomycetes 
are very numerous they may form the greater part of the abundant 426 
SPECIAL DIAGNOSIS. 
sediment. Under the microscope we see chiefly the chain-coccus 
(micrococcus urern, micrococcus urege liquifaciens) and bacilli (chiefly 
bacillus urese, Leube), not so long, but thicker than the bacillus 
tuberculosis; all these forms of fungi being in the most lively motion. 
It is the presence of these fungi that distinguishes simple alkaline 
urine (see p. 413) from urine that is alkaline from fermentation. 
Tubercle bacilli in the urine are an absolutely sure sign of ulcer- 
ating uro-genital tuberculosis. But in this disease, especially when 
there is tuberculosis of the pelvis of the kidney or of the kidney of 
only one side, the ureter of that side is temporarily or permanently 
stopped. In regard to the occurrence of single bacilli having the 
form and the color-reaction of tubercle bacilli, compare what has been 
said regarding smegma bacilli, p. 400. If tubercle bacilli appear at 
all in the urine, they are generally abundant, not infrequently even 
Fig. 130. 
Pure culture of tubercle bacilli in the urine in tuberculosis of the genito-urinary 
apparatus. Zeiss’s homogeneous immersion one-twelfth eye-piece No. 4. Drawn with 
a camera lucida. Magnified about 1100. Author’s observation. 
in masses and with an arrangement which reminds one of a pure 
culture. Fig. 130 exhibits an excessive development of this kind 
(personal observation). In purulent urinary sediment they can be 
demonstrated just as distinctly as in the sputum. If there is decided 
anaemia, wasting, and continued fever, as well as in cases of long- 
continued gleet, every purulent urinary sediment should be examined 
for tubercle bacillus. EXAMINATION OF THE URINARY APPARATUS. 
427 
Gonococci(Neisser)occur in the pus of recent gonorrhoea in clusters, 
in epithelial cells, and in pus-cells. The latter circumstance is char- 
acteristic of gonococci, and distinguishes them from other bacteria 
which resemble them. Gonococci are chiefly met with as diplococci, 
and since the individual coccus seems to be divided into two by a 
bright transverse band, it often makes the so-called roll-form. In 
gleet and in persons who have formerly had gleet, but have for years 
Fig. 131. 
Gonococci in the pus from the urethra. Zeiss’s homogeneous immersion one-twelfth, 
eye-piece No. 2 Drawn with a camera lucida. Magnified about 650. 
teen free from any symptoms, we find a (liplococcus which resembles 
the gonococcus. But by recent investigations it has been discovered 
that even in the urethral secretion of persons in health, who have 
never had gonorrhoea, there occurs a diplococcus, free as wrell as 
enclosed in epithelia (although, of course, not in pus-corpuscles). 
This diplococcus has a form very much like the gonococcus (Lust- 
garten and Mannaberg). The gonococcus is to be stained with 
gentian-violet or methylene-blue, or fuchsin, and then rinsed in water. 
Pathogenic fungi which circulate in the blood are, in individual 
eases, found in the urine: thus, tubercle bacilli in acute miliary 
tuberculosis, equinia, erysipelas cocci in erysipelatous nephritis 
(Fehleisen), spirillum recurrens in complicating hemorrhage of the 
kidney (Kannenberg), pus-micrococci in pyaemia and endocarditis 
(Weichselbaum). Also, casts of micrococci are described in septic 
processes (Litten and others). 
Lastly, in cases of acute nephritis, bacteria have recently been found 
in the urine and in the kidney, which have been regarded by different 
authors as the specific excitants of the nephritis. These cases are too 
much isolated to permit us to form a definite conclusion as yet. 428 
S PE Cl A L DIA G NOS IS. 
A small form of sarcina is found rarely in alkaline fermentation in 
the urine. It, as well as the other fungi named, is regarded as the 
cause of the transformation of the urea. Leptothrix buccalis occurs 
as a foreign substance, as from the preputial sac (Huber). 
The occurrence of the yeast fungus, saccharomyces, in urine con- 
taining sugar is not unimportant. Here it causes acid fermentation. 
In urine that does not contain sugar, some yeast-cells are found occa- 
sionally, but they do not increase. 
2 Inorganic Sediments 
These consist of materials which are ordinarily found in the urine 
in a state of solution, hut which, for various reasons, are absent, 
chiefly because the urine is very much concentrated, or because its 
reaction has changed. These bodies show the forms of more or less 
pure crystals ; they may be crystalline, or amorphous, but neverthe- 
less often have a peculiar symmetrical form. Here we really consider 
the finer urinary sediments ; urinary calculi, which belong to surgery, 
will be mentioned at the end and only very briefly. 
(a) The more frequent inorganic sediments. From acid urine 
there are deposited: 
Uric acid, uric acid salts (sodium, lime), oxalate of lime. 
From the faintly acid, neutral (amphoteric), alkaline urine there 
are deposited: 
Ammonio-magnesian phosphates, phosphate of lime, carbonate of 
lime, urate of ammonia, and sometimes uric acid. 
All these substances may occasionally be deposited from healthy 
urine (see p. 402). 
TJric acid. As is stated above, we find this as a deposit not only 
in acid, but sometimes in neutral and alkaline, urine. It can often 
be recognized with the naked eye in the form of yellowish-red, 
glittering granules, which are located upon the side of the urine-glass, 
or in the form of a yellowish-red powder at the bottom of the glass. 
Uric acid deposited from the urine always has this yellowish-red 
color, while the chemically pure uric acid is colorless. Under the 
microscope it shows the greatest variety of crystal forms and crys- 
talline figures (see Fig. 132). The basis form is the rhomboidal 
plate. But this is rare. More frequently we have derivatives of EXAMINATION OF THE URINARY APPARATUS. 
429 
this, the so-called “whetstone” (with a cross or in druses), “barrel- 
shaped,” also peculiar bundles of prisms, lastly, amorphous lumps and 
clubs with separate, shining, smooth surfaces—all easily recognized 
by their distinct color. We may artificially produce a separation of 
uric acid deposit by adding to the urine some concentrated solution 
of salt and allowing it to stand for twenty-four hours. Ordinarily, 
chemical reaction is not necessary. 
Fig. 132. 
Fig. 133. 
Uric acid and uric acid salts. (Funke.) 
Oxalate of lime. (Laachb.) 
The occurrence of uric-acid crystals in the urine only shows that 
uric acid is not exactly wanting in the urine, and nothing more. It 
is said that the frequent separation of amorphous forms indicates 
urinary calculi (Ultzmann). 
Urate of soda and lime. When concentrated urine cools there is 
often a very abundant sediment, colored a flesh-red by the urinary 
pigment, “brick-dust sediment,” or sedimentum lateritium. When 
cooled to zero, C., we can obtain it from any urine. It will be most 
easily recognized by the fact that it immediately completely dissolves 
when the urine is warmed (not boiled, because then there is a phos- 
phatic cloudiness, and also coagulation of albumin, if present). Under 
the microscope the urates of soda and of lime are seen as very fine 
grains. They incline to settle upon the casts, and especially upon 
mucus threads. Uric-acid crystals form about half an hour after the 
addition of some muriatic acid. 
From concentrated urine the lateritious sediment is deposited at 430 
SPECIAL DIAGNOSIS. 
the ordinary temperature of the room, especially in engorgement of 
the kidneys, in attacks of diarrhoea, in fever, and also in health (see 
p. 402). We should never conclude from its presence that there is 
increased separation of uric acid. We can only determine this by 
ascertaining the amount of uric acid and urate separated in twenty- 
four hours. 
Oxalate of lime. Single crystals of this may appear in any urine 
that has been standing for some time. The crystals are almost always 
tolerably small, sometimes minute regular octahedra, which are con- 
spicuous by their perfect form and strong refraction of light (envelope- 
form). They are rarely hour-glass- and dumb-bell-shaped. The 
crystals are insoluble in water, and are thus distinguished from 
chloride of sodium. 
Fig. 134. 
Fig. 135. 
Triple-phosphates; urate of 
ammonia. (Laache.) 
Phosphate of lime. (Laache.) 
These crystals occur in the urine in great abundance after eating 
certain fruits and vegetables, as apples, pears, cauliflower, and the 
different kinds of sorrel; and also in diabetes mellitus, catarrhal 
icterus, hypochondria. Moreover, we cannot conclude, without 
further evidence than the mere occurrence of a somewhat large amount 
of these crystals, that there is increased separation of oxalic acid 
(oxaluria). The disease described by English physicians (and Can- 
tani) as oxaluria does not seem to be a unity. This oxaluria occurs 
in cachexia (tuberculosis, cancer). EXAMINATION OF THE URINARY APPARATUS. 
431 
Ammoniaco-magnesian phosphate (triple-phosphate) is found in 
urine that is simply alkaline and that is undergoing alkaline fermenta- 
tion. Sometimes it forms the principal portion of the whitish sedi- 
ment. The basis form is the rhombic prism; it is well formed in the 
“coffin-lid crystals,” often also of various other forms, and is then 
more difficult to recognize. The triple-phosphates are all perfectly 
colorless, and soluble in acetic acid, thus contrasting with oxalate of 
lime. 
Phosphoric acid as a basic salt occurs in amorphous grains in 
alkaline fermentation of the urine. It is soluble in acetic acid, but 
not by heat. As a neutral salt it occurs in simple alkaline urine in 
the form of long wedges or knife-blades. These disappear in alkaline 
fermentation. 
Fig. 136. 
Fig. 137. 
Carbonate of lime. (Laache.) 
Leucin and tyrosin. (Laache.) 
Carbonate of lime, in the form of spherules or crossed drum-sticks, 
seldom occurs in alkaline urine. [“ In highly alkaline urine, in 
which the alkalescence is caused by carbonate of ammonia set free by 
decomposition of urea, carbonate of lime occurs in small quantity, but 
in an amorphous form. This is the only form in which I have yet 
seen carbonate of lime in human urine.”—Beale.] It is dissolved 
by the addition of muriatic acid, with effervescence. 
The so-called phosphaturia is a condition in which phosphates and 
carbonates are precipitated before or immediately after the urine is 
passed. But there is no increase in the phosphoric acid. The 432 
SPECIAL DIAGNOSIS 
precipitation is probably produced by tbe alkalinity of the urine. 
Phosphaturia occurs in neurasthenia, hypochondria, chronic articular- 
rheumatism. 
TJrate of ammonia accompanies triple-phosphate in alkaline fer- 
mentation. The characteristic form is that of the thorn-apple 
(grayish-yellow or brownish opaque balls, from which fine needles 
project). When muriatic acid is added, there develop under the 
covering-glass uric-acid crystals. 
(b) More rare inorganic sediments. Hsematoidin is exceptionally 
found in the forms of needles and plates mentioned before (p. 180). 
Sometimes we see white blood-corpuscles which contain hsematoidin 
needles, which project through the cell-membrane. 
Leucin and tyrosin (see Fig. 137). The characteristic forms of 
these substances, which almost always appear together, are sometimes 
found in the sediment, more often only when we have evaporated the 
urine in a water-bath to the consistence of syrup, or until we slowly 
boil down a drop of urine upon an object-glass until it is almost dry. 
Leucin appears in the form of faintly shining spheres, which some- 
times, if they are large, show radiating lines and concentric rings. 
Tyrosin crystallizes in very fine needles, which commonly form 
druses and bundles. 
Leucin and tyrosin are products of the decomposition of albumin. 
They do not occur in normal urine. Diseases in which they are 
found and for which they may have diagnostic value, are acute yellow 
atrophy of the liver and acute poisoning by phosphorus. They are 
also seen in variola and typhus abdominalis [typhoid fever], as well 
as in pernicious anaemia (Laache). 
Cystin sometimes occurs in the urine in health. Large quantities 
of cystin in the urine may cause the formation of cystin-calculi and 
excite cystitis, and are thus a pathological condition in themselves. 
According to recent investigations (Baumann, Brieger) there seems to 
be a connection between the occurrence of ptoma'ines and cystin in 
the urine. Brieger assumes that by the presence of certain ptomaines 
in the intestinal canal (hence, in mycotic enteritis) the cystin forms a 
combination with the ptomaines in the intestine, which overflows into 
the urine. There the compound decomposes, and cystin is again set 
free. Sometimes this does not take place, and so calculi are formed. 
The ptomaines, in turn, may cause inflammation, especially cystitis. EX A MIN A TION OF THE URINARY APPARATUS. 
433 
Cystin, besides occurring in the urine in the form of calculi, is seen 
in the form of extremely thin, six-sided, and very perfectly formed 
colorless plates. 
(c) Concretions in the urine. We are interested only in the con- 
cretions that arise in the pelvis of the kidney, as in nephrolithiasis, 
pyelitis calculosa. Those that form in the bladder belong to surgery. 
The former are named, according to their size, renal sand, renal 
gravel, renal calculi. If they attain a certain size, they cause severe 
attacks of pain in their transit through the urethra (renal calculi 
colic). Most frequently the concretions consist chiefly of uric acid 
and urates. They are then brown or brown-black, and tolerably 
smooth on the surface. Stones of oxalate of lime are densely hard 
and have a rough surface (mulberry calculi); they are dark brown. 
A combination of layers of uric acid and oxalate of lime is likewise 
met with. Phosphatic calculi are tolerably soft, but not infrequently 
they contain a kernel of the first-named substances (phosphate de- 
posited upon the stone from the alkaline urine of cystitis [excited by 
the original stone]. Finally, we must mention stones of cystin and 
(extremely rare) xanthin. All these stones, with the exception of the 
phosphatic calculi, are formed in acid urine. 
For the exact chemical examination of the concretions we refer to 
the text-books upon Urinary Analysis. 
Examination of the Urinary Constituents in Solution. 
1. Anomalies in the Quantity of the Normal Constituents. 
In disease the normal constituents of the urine are variously increased 
or diminished. These quantitative variations, however, can only excep- 
tionally he made use of for the diagnosis of disease. But they are 
important for determining the change of material and the removal of 
material that can be carried off hy the urine in various diseases. This 
requires throughout an exact quantitative analysis, for the different 
u approximative methods ” have no value at all. We cannot here go 
into an explanation of the exact methods, but must refer to the hand- 
books upon urinary analysis. However, we mention briefly the most 
important anomalies which belong here. We have already mentioned 
the quantities of the normal constituents of the urine, p. 404. 
Urea. This is increased in fever, either absolutely, as in pneu- 434 
SPECIAL DIAGNOSIS. 
monia, or relatively—that is, in relation to diminution in the amount 
of food taken. It is also increased in diabetes. We find it diminished 
in all forms of nephritis, hut especially in uraemia; in cachexia of all 
kinds, especially if there is dropsy; and, lastly, sometimes in acute 
yellow atrophy of the liver. The very decided increase in the amount 
of excretion of urea which takes place immediately after the crisis in 
pneumonia is designated as post epicritical. It is probably con- 
nected with the increase in the amount of water secreted by the 
kidney. 
Sehrwald has recently (Munclien med. Wochensclirift, 1888, No. 
46) devised a simplification of Knop-Hiifner’s method of determining 
the amount of urea, which seems to us to be very practical and rela- 
tively exact. We have not yet had an opportunity to test thoroughly 
the method. At least, we recommend that it be tried. * 
Uric acid is usually increased in fever parallel with the urea. 
Besides, it is increased in leukaemia and pernicious anaemia (with the 
first, often very markedly), also in all diseases which affect the inter- 
change of gases in the lungs; and, lastly, with the uric-acid or gouty 
diathesis, apart from attacks of gout, during which it is often dimin- 
ished. 
The total amount of nitrogenous material in the urine, the most 
important for determining the metamorphosis of tissues, approximately 
agrees with the amount estimated from the urea, because the uric 
acid, kreatinin, and xanthin bodies are insignificant in amount com- 
pared with the urea. Besides, the most practicable method for the 
quantitative determination of the urea (Liebig’s) is really a determina- 
tion of the total amount of nitrogen, expressed as urea (C. Yoit, 
Salkowski, and Leube). When determining both nitrogen and urea, 
of course, it must be done apart from any possible albumin—that is 
to say, the latter must first be removed. 
Chloride of sodium is pathologically increased during the resorp- 
tion of transudations and exudations, and also in intermittent fever, 
from the destruction of red blood-corpuscles (Kast). It is diminished 
in fever, nephritis, and in many cachectic conditions. [In pneumo- 
nia, during the stage of exudation and until resolution begins, the 
chlorides are diminished or disappear from the urine. While the dis- 
appearance of the chlorides from the urine is not characteristic of EXAMINATION OF THE URINARY APPARATUS. 
435 
this disease alone, it shows that exudation is still going on, or that 
resolution has not yet commenced.] 
Sulphuric acid interests us chiefly with reference to the associated 
ethylsulphuric acid (phenol-, indoxyl-sulphuric acids). It is found 
with increased separation of indican and carbolic acid. Regarding 
the former, see p. 409. The latter occurs with the internal and 
external use of carbolic acid. 
It has been found that the phosphates are diminished in rhachitis, 
also in acute yellow atrophy of the liver. In nephritis they are not 
infrequently diminished. 
2. Abnormal Constituents. 
Albumin. Except in the rare cases of physiological albuminuria 
already mentioned, any separation of albumin in the urine is patho- 
logical. This is always so if it continues. The albuminous substances, 
which in the conditions reckoned as albuminuria in the narrow sense 
can be separated, are serum-albumin and serum-globulin. Their 
amount varies from a trace to one-half per cent.—very exceptionally 
more. Generally, it remains below one-half per cent. The secretion 
of hemialbuminose is very rare, and thus far has not been found to 
have special diagnostic significance. Of late, we are not accustomed 
to regard peptonuria as albuminuria. It will be considered at the 
close of this chapter. 
Albuminuria occurs : 
1. As true renal albuminuria, in all forms of acute and chronic 
nephritis, in amyloid kidney, in engorgement of the kidneys; in 
hydraemic conditions of the blood, as anaemia, leukaemia; in fever, 
and in acute poisoning; in these two cases, especially in the latter, 
there occur, besides all the transitions to nephritis; lastly, after epi- 
leptic attacks, apoplexy (transitory albuminuria). 
Besides, there has recently been discovered a peculiar form of 
albuminuria which is distinguished from other forms by the absence 
of all pathological signs in the urine, especially of cylinders : cyclic 
albuminuria. See, regarding this, p. 437. 
2. Further, albumin in solution in the urine may also pass over 
into the urinary passages when blood and pus are mingled with the 
urine in the bladder. The amount of albumin, however, is always 
small. 
Qualitative tests for albumin. We select a few from the great 
number of tests for albumin, which have the tolerably uniform approval 436 
SPECIAL DIAGNOSIS. 
of authors (see, regarding them, Penzoldt’s Old and New Urinary 
Tests), and which, according to our experience, have the preference. 
The preliminary condition is that the urine be not contaminated, 
as by menses or leucorrhoea, and that it be clear. The latter is the 
more necessary in proportion as the amount of the albumin is small. 
In order to be able to discover it when only a very little is present, 
it is necessary to filter the urine until it is perfectly clear. 
(a) Addition of acetic acid and ferro-cyanide of potassium. By the 
acetic acid the urine is rendered distinctly acid, and then the cold 
urine is mixed with a few drops of a watery solution of potas. ferro- 
cyanide. Even with a very small amount of albumin, very fine 
floccules are formed, often almost milky cloudiness, though when there 
is only a very small quantity of albumin it is somewhat delayed. 
This very certain and distinct test is strongly recommended for use at 
the house of the physician. 
(b) Boiling and the addition of nitric acid. If the urine is neutral 
or alkaline, acetic acid must be added to it to render it acid before 
boiling. If there is cloudiness, it can only be due to one of two 
causes: albumin or phosphates. To determine which of these it is, 
we add about ten drops of nitric acid, when the phosphatic deposit is 
immediately dissolved; but if the deposit is of albumin, it is made 
more distinct. When the albumin is somewhat abundant, the deposit 
can be immediately recognized by its floccular appearance. The 
test is a sharp one, showing even 0.005 to 0.01 per cent, of albumin, 
and, being tolerably certain, is in general to be recommended. 
(c) Picric-acid test. We add to the urine a few drops of a con- 
centrated watery solution of picric acid : if it immediately becomes 
cloudy, it shows albumin; but cloudiness appearing later shows 
nothing (Johnson, Penzoldt). It is a certain and sharp test, not less 
to be recommended than the others. 
As portable tests for albumin, we can proportionally recommend the 
following as best: 
(d) Geisler’s albumin test-papers.1 These consist of a piece of 
filter-paper saturated with a concentrated solution of citric acid, and 
of another saturated with a three-per-cent, solution of iodide of potas- 
sium added to a twelve or fifteen-per-cent, solution of corrosive subli- 
[! They may be obtained of Parke, Davis & Co., and other manufacturing chemists.] EXAMINATION OF THE URINARY APPARATUS. 
437 
mate. We first put one of the strips of the first into the urine—if 
very alkaline, more than one—then one of the second papers, and 
shake it. Cloudiness due to albumin appears pretty promptly. Pep- 
tone is also precipitated, which, in many cases, can cause deception 
(see Peptonuria). In concentrated urine, urates are also precipitated, 
but these can afterward be dissolved by heat. Deception from the 
solution of particles of paper making a cloudiness is not possible, if it 
is carefully examined. As a preliminary test at the sick-bed, this 
method is to be recommended. But we ought not to be satisfied with 
its result, and should always afterward employ one of the tests pre- 
viously mentioned. 
If we examine the urine a number of times in twenty-four hours, 
and find that there is a periodic presence and absence of albumin, we 
designate this condition as cyclic albuminuria.1 It never occurs after 
rest at night; the albumin is generally separated after exertion. In 
case this condition is suspected, we are to examine the urine several 
times during the day, and especially toward evening, also directly 
after rising in the morning. 
Klemperer has made a very clear demonstration of the course of 
the separation of the albumin. He places about five c.cm. of the 
urine, passed at different times during the day, in a series of reagent- 
glasses, and then boils them with the addition of nitric acid. The 
height of the deposit in the glasses, as they are arranged in a row, may 
be regarded as a direct delineation of the “albumin curve.” 
Quantitative test for albumin. Here, as in all quantitative de- 
terminations, the urine of exactly twenty-four hours must be mixed, 
and a portion from this mixture examined. The urine for exactly 
twenty-four hours can be obtained if we have the patient urinate 
early, say shortly before seven o’clock, and then keep all the urine 
that is passed till the next morning at exactly the same hour, passing 
his urine again at seven o’clock. 
It is possible to make an exact quantitative determination only by 
completely separating the albumin from a measured quantity of urine. 
Filter, wash the residue upon the filter-paper, dry, and weigh it. (For 
particulars regarding these processes, see text-books upon Urinary 
[i In the British Medical Journal, January 31,1891, p. 218, Dr. Herringham gives a 
valuable and careful study of a case of Cyclical Albuminuria which was under his care 
at the West London Hospital.—Translator.] 438 
SPECIAL DIAGNOSIS. 
Analysis.) This examination can only be conducted in a laboratory. 
There is no mode of procedure which is more simple, nor one that is 
so nearly exact as this. The polarizing method is only applicable 
when there is a considerable amount of albumin. 
A substitute for the exact quantitative determination is quite com- 
monly found by endeavoring to estimate the amount of deposit which 
results from the qualitative determination, especially by the boiling 
nitric-acid test: wTe wait along time—till it settles in the reagent- 
glass—and then we speak of one-half, one-quarter, or the 
whole being albumin, by comparing the volume of albu- 
min that can be seen with the whole amount of urine in 
the reagent-glass. It may be assumed that one-half the 
volume of albumin, if the reagent-glass has stood for one 
hour, corresponds to about 0.2 to 0.6. This estimate is 
extremely unreliable, being chiefly dependent upon the 
size and thickness of the flakes of albumin. But, if we 
always employ the same test for albumin, it is certainly 
not valueless forjudging of the variations in the separa- 
tion of albumin in the course of disease. 
More exact is the method with Esbach’s albuminometer, 
although it acts upon the same principle, and so is only 
approximative. What exactness it has depends in reality 
upon the employment always of the same reagents, mix- 
ing them with an equal amount of urine, and always 
allowing the same time for the deposit of the precipitate. 
The albuminometer—a graduated thick reagent-glass 
—is filled with urine to the mark U, from there to R 
with the reagent. This reagent consists of 10 grammes 
of picric acid and 20 grammes of citric acid to 1000 of 
distilled water.1 The glass is then closed with a rubber 
cork, turned upside down ten times, and allowed to stand undis- 
turbed for twenty-four hours, best in a special stand. After this 
period of time we notice at what mark of the scale on the glass the 
albuminous deposit stands. The marks each give one-tenth per cent, 
of albumin. As the scale only goes as far as 0.7 per cent., urine that 
Fig. 138. 
Esbach’s 
Albuminom- 
eter. 
1 The exact amounts of both acids (chemically pure and dry) are to be dissolved in 
1000 grammes of water, made hot, and, after cooling, any deficit in the amount of fluid 
is to be made up by the addition of water to 1000 grammes. EXAMINATION OF THE URINARY APPARATUS. 
439 
is strongly albuminous must be diluted in a definite way before the 
test. We must avoid producing air-bubbles, because these cause the 
precipitate, or a part of it, to swim, and for this reason we are not to 
shake the glass. If there are air-bubbles, they must be removed with 
a pipette. 
In most cases the method is tolerably exact (an error of one-tenth 
to two-tenths of albumin), but in individual cases, and often without 
any recognizable cause, the precipitate does not sink down as well as 
it usually does. Nevertheless, it is to be recommended as an improve- 
ment upon the simple, rough “ volumetric ” estimate. [The apparatus 
is not at all expensive. It can be obtained in New York of Eimer & 
Amend.] 
Rare Forms of Albumin. 
Peptone (von Jaksch, Maixner, and others). This never occurs in 
healthy urine. Pathologically, it occurs sometimes in ordinary albu- 
minuria, and, again, independently—peptonuria. It occurs in a great 
number of very different conditions : in large abscesses, in emphy- 
sema, sometimes in pneumonia; likewise in acute rheumatism, scor- 
butus, phosphorus-poisoning; also, in carcinoma ventriculi, in puerperal 
fever, in typhus abdominalis [typhoid fever], etc. Hence, this very 
remarkable substance has no value for diagnosis. Its determination, 
even qualitative (biuret reaction), is, for various reasons, difficult. 
Hemialbumose (hemialbuminose, propeptone) very rarely exists in 
the urine (albumosuria). There must arise a suspicion of these 
albuminous bodies, which, according to the latest researches, show a 
mixture of four albuminous substances (Kiihne, K., and Chittenden), 
if there is a precipitate in the urine after it has been subjected to the 
boiling and nitric-acid test. For demonstrative tests, see the text- 
books upon the subject. Hitherto this substance has had no diag- 
nostic significance. 
Kahler has recently observed hemialbumose in multiple primary 
lympho-sarcoma of the spinal cord. 
Fibrin occurs in the urine in haematuria, in deep-seated inflamma- 
tion of the urinary passages, in tuberculosis, in poisoning with can- 
tharides, and in chyluria. It is recognized by the fact that it 
coagulates spontaneously in the urine, although sometimes only after 
the urine has stood for some time. The coagula are then to be 
further examined. 440 
SPECIAL DIAGNOSIS. 
In this place are to be mentioned two phenomena that occur in 
those diseases of the kidney that stand in close relation to albumin- 
uria : dropsy and uraemia. 
The dropsy of kidney disease manifests itself, very frequently, first 
in the skin of the face, especially at the eyelids. With contracted 
kidney the oedema is very fugitive, often changing its place; in a 
large number of cases, it is entirely wanting during the entire course 
of the disease. With large white kidney it is more decided and stable; 
there is often a very soft, doughy oedema. In this respect acute 
nephritis varies very much. In all foi’ms of Bright’s disease, from 
its association with heart-weakness, a new factor may come into play 
for the development or increase of the oedema and effusion into the 
cavities of the body (dropsy of engorgement). 
With reference to the cause of the dropsy in kidney-disease, no 
doubt the most important element is the diminished elimination of 
water by the kidneys. This retention of water often, especially if 
excessive, has the effect that even a slight, perhaps a scarcely notice- 
able, dropsy of the skin and subcutaneous tissue considerably disturbs 
the excretion of water by perspiration. At any rate, it is certain that 
the dropsy of kidney-disease is, in many cases, not explained by the 
retention of water; but neither is Cohnheim’s hypothesis, that the 
walls of the vessels are abnormally pervious, at all generally accepted. 
This whole matter is still an open question. 
Uraemia is an association of nervous manifestations which, at least 
in the majority of cases, is dependent upon the retention in the blood 
of urinary products (especially uric acid). In individual cases of 
“ uraemic ” manifestations, however, this explanation is not correct, 
and the nature of such cases is not yet clear (oedema of the brain (?), 
Traube; sometimes anatomical changes in the brain (?), Striimpell, 
etc.). We coincide with Strumpell’s view, that uraemia is a multi- 
farious condition—a number of conditions, which by their presence 
and their phenomena seem to belong together, are in reality different. 
• Slight uraemic symptoms may last, with slight changes, for weeks, 
even months, as somnolence, restlessness, headache, malaise, vomiting, 
dyspnoea (uraemic asthma), indications of Cheyne-Stokes respiration, 
slight transitory disturbances of vision. The more severe symptoms 
are: decided cloudiness of intelligence, even to coma or delirium; 
maniacal conditions; convulsions, from single convulsive movements EXAMINATION OF THE URINARY APPARATUS. 
441 
to pronounced epileptic attacks; and temporary amaurosis. There 
may be slowness of the pulse, with acceleration later, and fever. In 
individual cases there occur evident symptoms of cerebral congestion: 
convulsions, parsesthesia, paralysis of an arm or of one side of the 
body, and aphasic manifestations. 
Mucin. It has already been mentioned when this appears in the 
urine. When the mucin is dissolved, its presence can be established 
by the addition of acetic acid: it forms a flocculent, thready pre- 
cipitate in cold urine, which is not again dissolved by an excess of 
acetic acid. 
Coloring-matter of the blood. The occurrence of this body has 
also been previously mentioned (p. 410). Here we have to refer to 
testing for haemoglobin, or haematin in solution. 
First, it must be mentioned that, of course, the urine shows the 
presence of albumin in both haematuria and haemoglobinuria. The 
amount of albumin is always small, provided there is no albuminuria 
besides. 
Blood-pigment will be shown to be present by the following pro- 
cedures : 
(a) Heller's test. A portion of urine is made decidedly alkaline 
with caustic potash, and boiled in a reagent-glass: tbe phosphates 
are precipitated as very delicate floccules, which look like mucus, and 
slowly sink to the bottom. They accompany the blood-pigment, and 
hence look brown or red-yellow. When the urine is concentrated, we 
dilute it, after boiling, by filling the reagent-glass with water, because 
the color of the floccules is easily concealed. Urine that is poor in 
phosphates, as in nephritis, gives no phosphatic deposit. Such urine 
must be mixed with some that has the normal amount of phosphates, 
before making the test. The color described as belonging to the 
phosphatic deposit occurs nowhere else, except with urine containing 
chrysophanic acid, but this latter is recognized by its change in color 
after the reaction. This test is very simple, certain, and, with clear 
urine, is tolerably distinct. 
(b) Test with tincture of guaiac. The reagent consists of tinct. 
guaiac, ol. terebinth, ozonisat., aa 10 parts. A small portion of this, 
placed in a reagent-glass, is carefully covered with urine : when 
the coloring-matter of the blood is present, there is, besides the dirty 
white deposit of resin, an indigo-blue ring. When shaken up, the 442 
SPECIAL DIAGNOSIS. 
whole contents of the glass become a non-transparent bright blue. 
The test is a very distinct one. 
(<?) Test for hcemin. This is made Avith a large drop of urine or 
urinary sediment, exactly in the same Avay as has been described 
already (p. 363) for finding it in the material vomited. The test is 
more distinct than the preceding, particularly if we boil it down in a 
porcelain dish and then apply the reaction. 
(d) Spectroscopic examination. This gives the absorption-bands 
of metlnemoglobin, namely, in yellow, green, and red. Of course, 
this is an extremely distinct test. 
Bile-pigments and Bile-acids. 
Grmellins test for bile-pigments. We pour a small quantity of 
nitric acid into a reagent-glass and add to it one or two drops of 
fuming nitric acid, forming a trace of an admixture of nitrous acid. 
To this mixture we very cautiously add a layer of urine, by permitting 
it to flow from a pipette, down the side of the glass held obliquely. 
When the bile-pigment is abundant, if the fluids are kept carefully 
distinct, there is a ring of green (blue), violet, and red. The first 
named constitutes the test. There is no reaction when there is only 
a small amount of bile-pigment. 
Jlosenbaclfs modification is decidedly more distinct. Filter some 
urine, not too little (about 200 c.cm.), through a medium-sized filter, 
and pour upon this the mixture of nitric and nitrous acids. The 
colored rings form upon the filtrate. 
Still sharper is Gmellin’s test, if, after acidulating the urine with 
acetic acid, we shake it up Avith chloroform, pour off the urine, and 
then with the chloroform, colored yellow by the bile-pigment, make 
a layer with the nitric-acid mixture. 
Penzoldt recommends a filtrate prepared as in the Gmellin-Rosen- 
bach test (alloAving a good deal of urine to flow through), over which 
acetic acid is poured, and this is alloAved to flow into a broad glass 
vessel, so as to have it in a shallow, but broad, layer. The acetic 
acid becomes yellow-green, gradually becomes green (quicker, if it is 
warmed), even bluish-green. Penzoldt declares that this test is vei’y 
distinct. 
Pettenkofers test for bile-acids: glycocholic, taurocholic, and EXAMINATION OF THE URINARY APPARATUS. 
443 
cholal acids. This test is based upon the fact that the addition of a 
weak solution of cane-sugar (1 to 500) and a trace of concentrated 
sulphuric acid to urine causes a violet-red color. We must be care- 
ful not to have the resulting elevation of temperature too high, at 
most not higher than about 50° C. 
For various reasons this last reaction is uncertain. Its result is 
reliable only when the bile-acids, if present, have been isolated. At 
any rate, the bile-acids have only a slight diagnostic value: a trace 
sometimes occurs in normal urine, while we find in undoubted cases 
of jaundice due to engorgement of bile, often none, or only a trace, 
because frequently in the transmission it becomes broken up in the 
blood. Hence, we cannot account for the absence of the bile-acids in 
the urine in cases of icterus by the assumption that it is not an 
hepatogenous icterus. On the other hand, an abundance of bile-acids 
in the urine proves that the jaundice is due to engorgement of bile. 
Moreover, it is clear that if we wish to explain “hepatogenous” 
icterus by the idea of engorgement of bile in the liver, logically, we 
must assume an increase of the bile-acids in this jaundice also. As a 
matter of fact, this is found to be the case in toxic “ hemato-hepato- 
genous’’ icterus (arseniuretted hydrogen, toluylendiamin, Stadelmann). 
Gbrape-sugar. Pathologically, grape-sugar occurs in the urine: 
1. In diabetes mellitus, usually in considerable quantity—as much 
as two to five per cent, (minimum one-half, maximum ten per cent.). 
The urine is increased in amount, is bright and clear, of higher specific 
gravity, as has already been mentioned. 
2. As glycosuria (Frerichs), usually in small quantity. It is 
almost always temporary after poisoning with carbonic oxide, curare, 
amyl nitrite, turpentine; sometimes with mercury, morphia, chloral, 
prussic acid, sulphuric acid, alcohol; again, in acute infectious dis- 
eases (typhus, scarlet fever, diphtheria, etc.; in diseases of the 
oblongata (but here it is more lasting); and from other neurotic causes, 
as excessive mental exertion, neuralgia, injuries to the central nervous 
system, concussion of the brain, etc.; also, after epileptic convulsions 
and apoplexia cerebri. 
It is to be remarked that the urine is always to be examined for 
sugar when it has a decidedly high specific gravity ; but particularly 
if it is clear and abundant, and, at the same time, has a high specific 
gravity. 444 
SPECIAL DIAGNOSIS. 
Qualitative Tests for Sugar. 
Bismuth test (with Nylander’s modification). For this purpose, we 
employ Nylander’s reagent: 2 parts basic nitrate of bismuth and 4 
parts soda tartrate, to 100 parts of an 8-per cent, solution of caustic 
soda. Of this we take 1 part to 10 of urine, and boil them together. 
After a few minutes, if there is only a little sugar—sometimes only 
after it has cooled—it becomes black from the reduction of the 
contents of the reagent-glass with the formation of the oxide of bismuth, 
if the urine contains as much as one per cent, of sugar. 
It is evident that this is a very distinct test. It is only uncertain 
when there is albumin in the urine (arising from the black sulphuret 
of bismuth) ; here it had better not be employed. 
Trommer’s test. To a given quantity of urine we add about one- 
third as much liq. potassae, and to this, drop by drop, of a 10-per-cent, 
solution of the sulphate of copper, as long as it is held in solution by 
mixing ; then it is heated. A precipitate of yellowish-red hydrated 
cupric suboxide, which may appear even before the fluid has been 
boiled, shows the presence of sugar with the greatest probability. The 
yellow color of the liquid, or a precipitate that takes place later, may 
be caused by a very small amount of sugar, but also by uric acid and 
creatinin. Thus, the test is uncertain when the quantity of sugar is 
small; hence, in brief, it is not a sharp one. 
Phenyl-hydracin test (von Jaksch). About two grains of muriate 
of phenyl-hydracin and three of acetate of soda are put into a reagent- 
glass which is filled half-full of water. After heating, the glass is to 
be filled with the urine to be tested. It is allowed to stand for 
fifteen or twenty minutes in boiling-water, then it is put into a beaker- 
glass filled with cold water. When there is a large amount of sugar, 
there is formed a macroscopically visible deposit. With a small 
amount of sugar, after standing, there is a deposit, which can be seen 
with the microscope, of yellow needles, single and in druses—phenyl- 
glucosazon. Yellow plates and brown balls prove nothing. Albumin 
that may be present must previously be removed by boiling the urine. 
Jaksch urges this test because it is a very exact one. Its difficulty 
consists in this, that the needles of phenyl-glucosazon are sometimes 
not alike clearly characteristic in distinction from the yellow plates, 
etc., which prove nothing, these latter not being crystallizable in 
alcohol. Nevertheless, the test seems to be a very sharp one. EXAMINATION OF THE URINARY APPARATUS. 
445 
Of the other very numerous tests for sugar we only mention the 
following: 
Moore s liq. potassce and boiling test, which causes urine that con- 
tains sugar to become brown—not a very certain and sharp test; and 
the test with diazo-benzol-sulphuric acid and potash, recommended by 
Penzoldt. 
One test, of great importance and highly recommended on account 
of its absolute certainty, is somewhat troublesome : 
Fermentation test. This rests upon the peculiarity that yeast has 
of separating sugar into alcohol and carbonic acid (succinic acid, etc.). 
The test may be made in a simple way, as follows: Three perfectly 
clean reagent-glasses are filled about two-thirds full of mercury. The 
first is then to be filled with some of the urine to be tested and a 
little yeast; the second is to be filled with normal urine and some 
yeast; the third with a thin, watery solution of sugar and yeast. It 
is to add to each a drop of a solution of tartaric acid. All three 
tubes are now placed upside down in a tray of mercury, by covering 
the opening with the thumb as we invert them. The second tube 
should not show any development of carbonic acid, but if it should do 
so the yeast was not perfectly free from sugar, and the experiment 
must be repeated with yeast that is perfectly pure. The third glass 
should show the development of carbonic acid, otherwise the yeast has 
become inactive. The first tube shows carbonic acid or not, according 
to the state of the urine under examination in respect to its containing 
sugar. The development of carbonic acid is recognized by the 
existence of gas in the upper part of the inverted tube. Its presence 
is made certain by its being absorbed when potash-lye is introduced 
into the tube. 
Fermentation-tubes are very helpful in employing the fermentation 
test (see Salkowski-Leube, Penzoldt). 
This is indispensable, if a case of diabetes is to be carefully observed, 
particularly for determining its severity, its course, especially the effect 
of treatment. From the qualitative examination we cannot draw satis- 
factory conclusions as to the amount of sugar, except by a comparison 
of the specific gravity of the urine with its quantity. 
We make use of the urine that is passed in exactly twenty-four hours. 
Quantitative Determination of Sugar. 446 
SPECIAL DIAGNOSIS. 
1. Estimating it with Fehlings solution (after Salkowski-Leube, 
Penzoldt). The principle is that in Trommer’s test, the oxide of 
copper in an alkaline solution of grape-sugar is reduced to a lower 
state of oxidation : five parts of anhydrous grape-sugar will reduce 
34,639 parts of pure sulphate of copper to oxydul. The problem is 
to determine how much of a specimen of urine is necessary to reduce 
a certain amount of sulphate of copper. 
Solution I. 34,639 grammes of pure sulphate of copper are, by 
warming, dissolved in about 100 grammes of water, and the solution 
is then diluted to 500 c.c. It is to be set away well corked. 
Solution II. 173 parts of tartrate of soda and 100 parts of officinal 
solution of caustic soda of the specific gravity of 1034, dissolved in 
water to 500 parts. This is to be kept in a well-stoppered bottle; 
but it must not be allowed to become too stale. 
Mode of procedure: Equal parts of I. and II. are mixed together. 
The mixture (Fehling’s solution) must not, when boiled, separate any 
oxydul. 10 c.c. of the mixture and 40 c.c. of water are placed in 
a deep porcelain saucer. Thoroughly mixing the urine of twenty-four 
hours, we take a portion of this and dilute it with 9 parts of water 
(urine 1, water 9), and with this we fill a burette. The mixture in 
the saucer is brought to the boiling-point, and into this the urine in 
the burette is allowed to flow: there occurs a separation of oxydul 
and oxydul-hydrate, and the blue color of Fehling’s solution disap- 
pears. The instant when the fluid (if we incline the saucer) first 
loses its color, shows the completion of the reduction. We allow the 
amount of urine necessary to complete the reduction to flow from the 
burette. 
Calculation: Since 0.05 gramme of grape-sugar reduces 10 c.c. 
of Fehling’s solution, therefore the quantity of the mixture which has 
escaped from the burette contained 0.05 gramme of grape-sugar We 
represent that quantity of the mixture by “ q,” then the mixture in 
, , . 0.05 X 100 5 
the burette contains = - per cent, of sugar. And, 
q q r G 
since the mixture of urine was diluted tenfold, the urine itself contains 
5 X 10 50 
= — per cent, sugar—that is, 5 times the amount diluted, 
divided by the quantity of the mixture in the burette that was used. EXAMINATION OF THE URINARY APPARATUS. 
447 
The dilution of the urine is to be varied according to the amount of 
sugar it contains. 
2. Determining the sugar by circumpolarization. This depends 
upon the property of sugar to turn the plane of polarization to the 
right. Recently, the method has come somewhat into discredit, or it 
has been shown to be exact only when we exclude oxybutyric acid and 
any levulose that may be present (which, according to Kulz, some- 
times occurs in severe forms of diabetes). Regarding complicated 
methods (complete fermentation, etc.), see hand-books upon Urinary 
Analysis. 
We do not give a description of the method by polarization, as a 
description of its use always accompanies the different apparatus sold. 
(We recommend particularly the simple apparatus made by Zeiss.) 
Other Soluble Constituents of the Urine. 
Levulose sometimes occurs in the urine, in addition to grape-sugar, 
in cases of diabetes mellitus. It gives the chemical reaction of the 
latter, and for this reason it cannot, without complicated methods, be 
recognized, chiefly on account of a striking difference between the 
quantitative determination by Fehling’s solution, on the other side, 
and the polarizing apparatus on the other. Levulose turns it to the 
left; but we must be on guard with reference to oxybutyric acid. 
Lactose, occurring in puerperal patients, inosite in diabetes in- 
sipidus, albumin, can only be demonstrated in the urine when they 
are isolated. 
Lipuria, as has been already mentioned, occurs in chyluria. It 
has, in one instance (Ebstein), been found in pyonephrosis; small 
quantities of fat occur, with large white kidney (see Sediments), in 
poisoning by phosphorus, and in diabetes mellitus, but also in health 
after taking very much fat, as cod-liver oil. The proof is by shaking 
it up wTith ether. Lapaciduria (fugitive fatty acids in the urine) has 
Recently been much studied, but thus far, from the standpoint of 
diagnosis, without significance. 
Diaceturia, resulting from glacial acetic acid in the urine (Jaksch), 
never occurs under physiological conditions. It is observed (always 
with a simultaneous abundance of acetone, see below) in diabetes, and 
especially in the severe forms, which then sometimes end in coma; 
and in fever, especially with children; also, according to Jaksch, as 
an independent disease, likewise particularly in children. Diaceturia 448 
SPECIAL DIAGNOSIS. 
is generally, especially if it occurs in adults, associated with severe 
symptoms, particularly nervous, which are to be regarded as signs of 
auto-intoxication [poisoning] ; hence, it may result in deep coma and 
be the direct precursor of death. As to its significance when it 
occurs in children, Jaksch, by recent investigations, arrives at the 
supposition that the convulsions which so frequently occur with them 
in acute diseases are explained by diaceturia. 
Test. Some solution of chloride of iron is slowly added to the 
urine; sometimes there occurs a precipitate of phosphates, which 
must he removed by filtration; then more iron chloride must be added. 
If glacial acetic acid is present, the urine becomes a Bordeaux-red. 
Then the test must be repeated with urine that has been boiled. 
Further, a poition of urine must be mixed with sulphuric acid, ex- 
tracted with ether and repeated with the extract; lastly, it must be 
examined for acetone (see below). Diaceturia is present if, in the 
presence of the chloride-of-iron reaction of the fresh urine, 1, the 
boiled urine shows no, or only a slight, chloride-of-iron reaction; 2, 
if the ether extract shows a chloride-of-iron reaction which fades in 
the course of twenty-four hours at the longest; 3, if acetone is present 
at the same time (Jaksch). 
Acetonuria, in contradistinction from the preceding, is, it seems, in 
most cases a phenomenon without significance. It occurs in health (a 
trace), in fever, in diabetes, with inanition, but also without these in 
carcinoma, in psychoses. There also seems to be an auto-intoxication 
[poisoning] with acetone (v. Jaksch), which accompanies symptoms 
of cerebral irritation (also epileptic convulsions), states of depression. 
The cases hitherto observed have ended in recovery. Thus, an 
abundance of acetone is found in the urine, but no glacial acetic acid 
(see above). 
The exact proof is complicated. Several methods have been given, 
which, if one wishes to be certain, it is best to employ simultaneously: 
1. Distil the urine with some phosphoric acid. Several cubic centi- 
metres of this distillate are mixed with a few drops of solution of 
iodine and iodide of potassium ; an immediate precipitate of iodoform- 
crystals proves acetone (Lieben). 2. We add to the urine some 
freshly-prepared oxide of mercury, obtained by mixing an alcoholic 
solution of potash with chloride of mercury. Filter it, and cover the 
filtrate with sulphate of ammonium : a black ring of sulphate of mer- 
cury shows acetone (Reynolds). Legal (cited by Jaksch) has devised EXAMINATION OF THE URINARY APPARATUS. 
449 
a test for acetone which is a useful preliminary one: Several cubic 
centimetres of urine are treated with a few drops of a concentrated 
solution of sodium nitroprusside and somewhat concentrated liquor 
potassae. If acetone be present, a bright red color is seen, which 
quickly fades, but upon the addition of some acetic acid changes to 
purple or violet-red. 
Acetone is a product of normal decomposition of albumin. If this 
body is abundant in the urine it indicates an increased decomposition 
of albumin. It is worthy of note that acetic acid easily breaks up 
into acetone and carbonic acid, and that acetic acid, in turn, is a 
product of oxidation of /3-oxybutyric acid. This acid is found in 
diabetic coma, as it seems, exceptionally in very large quantities in 
the urine (Stadelmann, Minkowski); and it becomes more and more 
probable that it, in union wTith other fatty acids, must be regarded as 
the cause of diabetic coma, as the pupils of Naunyn, mentioned 
above, have for years maintained. Hence, in diabetic coma wre have 
to deal with an acid-intoxication of the organism, in which it is to be 
assumed that the given acids only as acids are poisonous—that is, 
by the withdrawal of alkalies from the blood. 
In close relation with the withdrawal of the acids stands (according 
to Hallervorden, Stadelmann) the separation of a substance with 
which the organism, as long as possible, attempts to neutralize the 
pernicious acids: the separation of ammonia in the urine. We cannot 
go into the subject here, for the reason that the quantitative deter- 
mination of ammonia does not come within the province of this work. 
[The Translator adds here a summary of Stadelmann’s observations 
upon “Diabetic Coma,” as given in thq American Journal of the 
Medical Sciences, taken from Deutsch. med. Wochenschrift, 1889, 
No. 46 : 
“ 1. Diabetic coma, apart from accidental coma due to other causes, 
occurs only in the case of diabetic patients whose urine contains 
oxybutyric acids. 
“ 2. Almost equivalent in value with the recognition of oxybutyric 
acid is the determination of the amount of ammonia in the urine; 
while it is also far easier of performance. 
u 3. Diabetic patients with an excretion of ammonia of more than 
one and one-tenth grammes per day, are in danger of becoming 
severe cases of the disease. 450 
SPEC I A L DIAG NOS IS. 
“4. Patients excreting two, four, six, and more grammes of am- 
monia daily, need constant watching by the physician, and are in 
constant danger of passing into diabetic coma. 
“5. If the determination of the presence of oxybutyric acid, or the 
estimation of the amount of ammonia, cannot be carried out, at least 
the chloride-of-iron test should be made. If this gives a more positive 
reaction, oxybutyric acid is present in the urine, and the cases answer 
to the statements made in the third and fourth conclusions. The 
converse of this, however, is not always true, for there are cases of 
diabetes with oxybutyric acid in the urine, and even suffering from 
diabetic coma, the urine of which does not give the chloride-of-iron 
reaction.”] 
Regarding the occurrence of the two compounds of sulphuric acid 
or of the products of their decomposition (here also belong indican, 
which has been previously mentioned, indoxylsulphuric acid), also of 
ptomaines, ferments (especially pepsin), see the various special works 
upon these subjects. 
The Urine as Affected by Medicines. 
The determination as to whether a medicine has been taken or not 
may often be of diagnostic importance. A number of medicines may 
be directly detected in the urine; to those not easily, or not at all, 
demonstrable to a slight extent, according to Penzoldt’s recommenda- 
tion of a particular case, we can add one easily demonstrable. 
If we find in the urine the reaction of demonstrable medicines that 
have been given, then we can naturally assume that any other which 
was mixed with it has been taken. 
Iodide of potassium. Add a couple of drops of red fuming nitric 
acid and about one-quarter as much chloroform as there is of urine; 
shake it; the chloroform gradually settles down, colored reddish- 
violet. 
Bromine. The same method; chloroform colors it brown-yellow. 
Salicylic acid. The urine is made a blue-violet by the chloride of 
iron (not Burgundy-red, see Diaceturia). When the amount of sali- 
cylic acid is small, we shake up the urine (to which some sulphuric 
acid has been added) with ether and then apply the test. 
Rhubarb and senna, see p. 411. EXAMINATION OF THE URINARY APPARATUS. 
451 
Carbolic acid, also naphthalin, resorcin, etc. Upon standing, the 
urine becomes olive-green to brown-black, even black (hydrochinon). 
Exact determination requires particular methods. 
Salol. Urine containing this, as well as carbolic acid, becomes 
green to black, and, at the same time, responds to the tests for sali- 
cylic acid. 
Antifebrin. Add one-fourth volume of a concentrated solution of 
hydrochloric acid in a reagent-glass; boil for a few minutes; cool; 
add a few c.c. of a three-per-cent, solution of carbolic acid and a drop 
of dilute solution of chromic acid. The mixture becomes red ; after 
the addition of ammonia up to an alkaline reaction, a beautiful blue. 
(After Muller.) 
Antipyrin, thallin. Red coloration with chloride of iron: more- 
over, thallin urine is green-brown. 
Works upon Chemical Analysis and Toxicology give further 
information. CHAPTER VIII. 
EXAMINATION OF THE NERVOUS SYSTEM. 
Anatomy; Normal and Pathological Physiology. 
Only a sketch of what is most important can be given here. For 
further particulars, see the special text-books upon the subject. 
1. THE CORTICO-MUSCULAR TRACT (THE PYRAMIDAL TRACT, FLECHSIG). 
It has its origin in the so-called psycho-motor centres of the 
cortical substance of the cerebrum. These lie in the motor-cortical 
Fig. 139. 
lObuhis paracenfralis 
Lateral view of the brain. (Combined from Ecker.) Gyri and lobuli marked with, 
antique type, the sulci and fissures with italic type. 
452 EXAMINATION OF THE NERVOUS SYSTEM. 
453 
Fig. 140. 
Diagram of the motor tracts of the facial nerve and of the nerves of the extremities. 
(Edinger.) At A, B, C, are indicated supposed local diseases. A, lesion of the left 
side of the internal capsule, causing right hemiplegia on the right side; B, lesion of 
the left half of the pons, touches the pyramidal tract of the extremities of the right side 
and of the left facial, causing crossed paralysis; C, shows the rare condition of uncrossed 
facial paralysis and paralysis of the extremities from lesion in the pons. 454 
SPECIAL DIAGNOSIS. 
region, which includes the anterior and posterior central convolutions 
and the lobus paracentralis of each hemisphere. It has been found 
that the centre for the lower portion 
of the face (the countenance, exclud- 
ing the forehead), and the tongue, is 
from the lower section of the anterior 
rather than the posterior central con- 
volution. 
The centre for the arm is in the 
middle portion of the anterior central 
convolution. 
The centre for the leg is in the 
lobus paracentralis and the upper 
section of both central convolutions. 
Thus, the centres of the cortex lie 
tolerably wide apart. 
The tracts course from there, and 
next converge in the corona radiata, 
in a fan-shape, to the internal capsule, 
where they lie close together in its 
anterior segment, hence between the 
lenticular nucleus and optic thalamus. 
They lie close behind a point midway 
between these [but do not connect 
with them]. From thence they go to 
the foot of the crus cerebri, passing 
about in the middle of it. In the 
pons, the pyramidal tracts are split 
up by transverse fibres. They unite 
again to form pyramids at the an- 
terior portion of the medulla ob- 
longata, and here the pyramidal 
tracts of the two sides lie very close 
together. [From the circumstance 
that they form the anterior pyramids 
of the medulla, they receive their 
name, “ pyramidal tracts.”] At the 
lower end of the medulla the right 
Fig. 141. 
Diagram of the innervation of the 
muscles. (Partly from Edinger.) 
The radiation of the Py-tracts varies 
at different portions of the cortex 
(seep. 452). Py-H, pyramidal tract 
for the cervical spinal cord; Py-L, 
pyramidal tract for the lumbar por- 
tion of the cord ; II, cervical cord; 
L, lumbar cord; Py- V is omitted. 
Notice that down to the lumbar por- 
tion of the cord Py-L passes in the 
lateral column. EXAMINATION OF THE NERVOUS SYSTEM. 
455 
and left pyramidal tracts interlace, so that very much the larger part 
of the fibres go to form the lateral column of the opposite side of the 
spinal cord (lateral pyramidal tract). Only a small part of the fibres 
[of the external aspect of the pyramids], without crossing to the 
opposite side, pass to the anterior column of the spinal cord [forming 
the columns of Tiirck]. (Anterior pyramidal tracts, Py- V.) 
At different levels of the cord, from the lateral pyramidal tracts, 
fibres continually pass to the ganglion cell-groups of the same side, 
and from these ganglion cells arise the anterior roots of the [nerves 
of the] spinal cord. These unite with the posterior, and form with 
them the mixed peripheral nerves. In these the motor tracts pass to 
the muscles. 
The tracts for the motor cranial nerves separate successively in the 
pons and oblongata from the pyramidal tracts, decussate and, at the 
floor of the fourth ventricle, enter the grey nuclei of the pons and 
oblongata, which consist of ganglion cells, perfectly analogous to the 
anterior horn ganglia. 
Fig. 142. 
Location of the nuclei of the cranial nerve3. (Edinger.) The oblongata and pons 
are represented as transparent. The nuclei of sensation are red, the motor are 
black. 
The centres of the cortex are those of voluntary motion; the 
centres of the anterior horns simply convey these to the peripheral 
nerves. Moreover, they are the reflex spinal centres, in that they 
receive sensible irritation from the posterior roots of the spinal cord 456 
SPECIAL DIAGNOSIS. 
(see below) and transpose them into motor stimuli, which they convey 
to the anterior roots. 
But both central apparatuses also have trophic influences—that is, 
they preside over the nutrition of a certain section of the cortico- 
muscular tract. The cortical centres preside over the nutrition of the 
fibres until they enter the ganglia of the anterior horn. These latter 
control the nutrition of the peripheral nerve-fibres and of the 
muscles. 
Paralysis is produced by any lesion (local disease: hemorrhage, 
softening, inflammation, tumor) at any point in the cortico muscular 
tract which disturbs the central ganglia or interrupts the course of 
the tract. According to the location of the lesion, this paralysis 
show's different characteristics; and these may primarily be studied 
from three points of view : 
1. If the lesion is located in the cortex, or affects the tracts above 
the point of decussation, then the paralysis is upon the opposite side 
of the body; on the contrary, lesion below the decussation produces 
paralysis of the same side. If located in the pons, it may happen, 
for example, that besides the pyramidal tract, which as yet has not 
decussated, it affects the fibres of the facial, which have already 
crossed over (see above), it then causes paralysis of the opposite side 
of the body and of the same side of the face, hence these two cross 
each other—hemiplegia cruciata sen alterans. 
2. If the lesion affects a cortical centre, or a point in the pyramidal 
tract in the brain, the pons, the oblongata, the spinal cord above the 
point of entrance of the particular tract into ganglia of the anterior 
horn (or the analogous gray nuclei of the oblongata or of the pons), 
then, because the trophical influence of the cortical centre from above 
ceases at that point, the affected tract degenerates just up to the cor- 
responding cells of the anterior horn, while these and the peripheral 
nerves and the muscles do not degenerate. This degeneration of the 
pyramidal tract does not in itself cause any further clinical phe- 
nomena. On the other hand, if the lesion is in the anterior horn, or 
downward from there in the motor tract, there is degeneration 
downward of the nerves and muscles supplied by the portion which is 
the seat of the lesion. In the latter case, we have the clinical evi- 
dences of degeneration (rapid diminution in volume, diminution or 
loss of electrical reaction, and other signs of degeneration, see below). EXAMINATION OF THE NEIi VO US SYSTEM. 
457 
3. Since the centres and tracts in the different sections in some 
instances lie wide apart and in others close together, a certain extent 
of lesion, according to its location, will cause a paralysis widely 
different in its extent: 
(a) A lesion of' considerable extent located in the cortex, or in the 
corona radiata, just under it, generally affects the centre for one-half 
of the countenance, or an arm, or a leg (monoplegia). 
(b) If located in the internal capsule, then the lesion need not be 
so very large in order to produce a paralysis of the whole of the 
opposite side of the body—hemiplegia. This points to the crus 
cerebri. 
(c) If the lesion is in the cord, where the motor organs and all 
the other nervous organs of the body lie close together, it easily 
causes paralysis of both sides: thus, lesion of the dorsal portion of 
the cord produces paralysis of both lower extremities, or paraplegia 
inferior; lesion of the cervical portion of the cord sometimes causes 
paralysis of both arms and both legs, or only the former—paraplegia 
superior seu brachialis. 
To the above statements we may add still another: 
(d) If the lesion is in the pons and oblongata, it may easily affect 
to a considerable degree the centres that are very essential to life, 
as the respiratory-centre, vagus-centre for the heart, and death may 
soon follow. Often, if there is hemorrhage or softening, it may take 
place immediately. 
A local disease at the base of the brain injures the cranial nerves 
which go off from that point. If it is located in the anterior 
cranial fossa, the olfactory nerve will be affected; if in the middle 
cranial fossa, it may cause disease of the opticus, oculomotorius, 
trochlearis, abducens, sometimes also the olfactorius; if in the 
pqsterior fossa, the trochlearis, abducens, facialis, acusticus, glosso- 
pharyngeus, vagus, accessorius, come under consideration. The 
disease may be bilateral. See the illustration, which shows how the 
different nerves come together at the base of the skull. From 
simultaneous injury to the crus cerebri, pons, and oblongata, the 
pyramidal tracts may become affected, and paralysis of the extremi- 
ties results. In basilar affections, this is generally less marked than 
is the paralysis of the cranial nerves. 458 
SPECIAL DIAGNOSIS. 
The foregoing contains only the introduction to the points of 
diagnosis in these directions. We must refer for particulars to the 
Fir, 143. 
Points of exit of the cranial nerves from the skull (IIenle.) The Roman figures 
indicate the cranial nerves; Vi, V2, V3, first, second, and third branches of the tri- 
geminus; V*\ Gasserian ganglion. 
clinical text-books. We refer here to text-books upon clinical medi- 
cine, and particularly to the second edition of Edinger’s book on the EXAMINATION OF THE NERVOUS SYSTEM. 
459 
Structure of the Central Organs of the Nervous System, the second 
edition of which has just appeared. 
2. THE SENSITIVE OR CENTRIPETAL TRACTS. 
The tract of the sensibility of the skin of the trunk and of the 
extremities passes from the sensitive terminal fibres of the skin in the 
mixed nerves, then into the posterior root to the cord. From there 
it, for the most part, enters the posterior horn (it is doubtful whether 
a small portion may not enter the lateral column); it decussates soon 
after its entrance into the cord—how, we do not know. Above the 
cord we do not know the behavior of this tract till it reaches the 
tegumentum cruris cerebri, into which it passes. Then it enters the 
inner capsule behind the pyramidal tract—that is, in the posterior 
third of the posterior peduncle. Beyond this, we do not exactly 
know its course. 
The tract of deep sensibility (usually called the muscular sense) 
probably has the same course as that we have just described. Most 
probably it ends in the motor cortical zone of the central convolutions 
and the lobus paracentralis. 
An important centripetal, but not in the strict sense a sensitive, 
tract, are the columns of Goll, which likewise arise from the posterior 
roots, which, moreover, only from the upper part of the dorsal portion 
of the cord, and above that point, form a compact bundle in the 
median portion of the posterior column. We know nothing positive 
of their function. Also, the lateral column of the tract of the cere- 
bellum is centripetal, which, in the upper portion of the cord, 
springing from the columns of Clarke, goes into the cerebrum. Its 
function, also, is not entirely clear; probably it is of service in 
preserving equilibrium. 
Severe lesions, or complete interruption of the tract of sensibility of 
the skin in the peripheral nerves, or in the cord, or in the internal 
capsule, cause total anaesthesia of the skin. If the lesion is not 
severe, there is diminution of the sense of touch or a partial loss of 
sensibility—a partial paralysis of sensibility, as the sense of pain— 
and this latter is frequent, especially in disease of the spinal cord. 
Anaesthesia from local disease of the internal capsule, or of the spinal 
cord, manifests itself upon the opposite side. 460 
SPECIAL DIAGNOSIS. 
3. CENTRES AND TRACTS OP THE SPECIAL SENSES 
(a) Sight. This tract passes from the retina in the eye to the 
chiasm. Here occurs a peculiar partial decussation (semi-decussation), 
which is reproduced in Fig. 144: the optic nerve-fibres belonging to 
the outer half of the retina do not cross, those belonging to the inner 
half do. Then it passes in the optic tract to the anterior corpus 
quadrigeminum, and from there in the posterior third of the posterior 
limb of the internal capsule entering into relation with the pulvinar 
of the optic thalamus and the corpus geniculum ext., and then spreads 
out obliquely backward and upward in the cortex of the occipital lobe. 
The most important points in relation to this nerve are the following: 
Fig. 144. 
Diagram of the optic nerve-fibres in the chiasm. 
1. That pathological processes at the base of the brain, and lesions 
in the posterior end of the inner capsule (causing a simultaneous hemi- 
anaesthesia), of the pulvinar of the optic thalamus, or of the occipital 
lobe, produce disturbances of vision. 
2. That every complete destruction of the cortical centres in the 
occipital lobes, as well as of the tract from there to the chiasm, cuts 
off the impressions of sight from the outer half of the retina of the 
same side and the inner half of the opposite side, thus from synony- 
mous halves of the two retinae. Thus, hemiopia and hemianopsia are 
produced (see under Eye). 
(b) Hearing. The acoustic nerve passes, together with the facial, EXAMINATION OF THE NERVOUS SYSTEM. 
461 
to the oblongata, to the acoustic ganglion, in regard to which we 
cannot here enter into further detail. In its central course it comes 
into relation with the cerebrum, and then appears, probably, in the 
most posterior, sensitive portion of the internal capsule, whence it 
spreads out in the cortex of the temporal lobe (see Word-deafness). 
(<?) Smell. Of the olfactory nerve perhaps nothing more is to be 
said than that its centripetal tract seems to pass through the posterior 
portion of the internal capsule. 
(d) Taste. The sense of taste is located [chiefly] in the glosso- 
pharyngeus nerve, distributed to the palate and the posterior third of 
the tongue, by which nerve it is conveyed to the oblongata. The 
course for the anterior two-thirds, however, is complicated: as the 
chorda tympani, it first passes in the lingual nerve, but leaves this 
and goes to the facial, leaves this again at the geniculate ganglion, and 
probably extends, as the greater superficial petrosal nerve, Vidian, and 
the spheno-palatine ganglion, to the trigeminus (second branch), going 
toward the centre with this. We again meet the fibres of taste in the 
posterior portion of the inner capsule. 
It is very important to note the participation of the sense of taste 
at the anterior portion of the tongue in peripheral paralysis of the 
facial, and also (according to Erb and others) in disease of the tri- 
geminus situated high up, as well as in lesions of the posterior portion 
of the inner capsule (hemisesthesia). 
Until we come to the symptomatology, we delay speaking of all 
other points regarding localization of the brain, especially regarding 
aphasia and the phenomena associated with it, and regarding the 
origin of certain forms of convulsions, of vertigo, coordination, etc. 
' 4. REMARKS UPON THE VESSELS SUPPLYING THE BRAIN. 
The brain is supplied with blood from the two internal carotids and 
from the vertebral artery. The right and left vertebral unite at the 
basilar surface of the pons to form the basilar artery; this, again, 
divides at a point corresponding to the anterior inferior border of the 
pons into the two posterior cerebral arteries, which, by the posterior 
communicating arteries, form a connection with the carotids (the circle 
of Willis). Besides the ophthalmic and the posterior communicating, 
the carotid gives off the anterior communicating, which, with its 
opposite fellow, completes the circle of Willis. There also arises from 462 
SPECIAL DIAGNOSIS. 
the carotid the middle cerebral, the [largest, and] most important 
vessel of the brain. 
Of these vessels the greatest interest attaches to those which supply 
the pons and medulla, and the most important part of the cortex and 
the internal capsule. 
The pons and medulla are chiefly supplied by the basilar and 
vertebrals. The branches of these are terminal arteries—that is, they 
do not anastomose with each other, or with other branches in their 
neighborhood. Hence, thrombosis or emboli of such branches, or, for 
instance, of a part of the basilar, immediately produces arrest of func- 
tion, and, besides, unless the stoppage is again removed, produces 
anaemic necrosis of the affected portion of the pons or medulla. 
The region of next importance is that supplied by the middle 
cerebral artery (the artery of the fissure of Sylvius). This, as well as 
the regions of the cerebrum supplied by each of the two other arteries 
supplying portions of the cerebrum, divides distinctly into two parts, 
which do not anastomose with each other, into an inner and a cortical 
portion. The inner region, supplied by the middle cerebral artery 
and its branches, embraces the internal capsule, with the exception of 
its posterior section (sensory tract), the lenticular nucleus, the greater 
part of the caudate nucleus, and a part of the optic thalamus. This 
internal region of the middle cerebral artery (artery of the fossa of 
Sylvius) is sharply distinguished from the neighboring regions of the 
other arteries of the brain: there are no anastomoses; hence, con- 
tinuous occlusion of this vessel at its root must inevitably result in 
softening of the above-named central portion of the brain. The 
cortical region of the middle cerebral artery extends over the third 
frontal convolution, the anterior central convolution (with the excep- 
tion of the upper portion, which belongs to the anterior cerebral 
artery), the posterior central convolution, the superior and inferior 
parietal lobes, the whole region in the neighborhood of the fissure of 
Sylvius, lastly, the second and third temporal convolutions. This 
cortical portion of the artery of the fossa of Sylvius seems to anasto- 
mose, in individual instances, with the neighboring cortical regions in 
a great variety of ways ; for this reason, occlusion of the artery in only 
a part of the cases results in softening of this cortical portion of the 
brain. 
The optic centime of the occipital lobe, the corpora quadrigemina, EXAMINATION OF THE NERVOUS SYSTEM. 
463 
and the posterior portion of the internal capsule are supplied by the 
posterior cerebral artery. 
The prominence of the middle cerebral artery consists not only in 
the fact that it supplies the most important portion of the cerebrum, 
but also because it is within this region that both hemorrhages and 
emboli most frequently occur. These two disturbances chiefly affect 
the internal region of the artery—the hemorrhages, probably, because 
the pressure is highest in the branches that go directly off from its 
root, or that here is felt most strongly the rapid changes in the power 
of the heart; but emboli much more frequently disturb the inner 
territory than the cortical, because, as was mentioned before, there 
are no anastomoses in the former region, while in the cortical there 
are. In the relation of the left carotid to the aorta (going off at a 
very acute angle) seems to lie the explanation as to why emboli are 
much more frequent in the left middle cerebral artery than in the 
right. 
Symptomatology and Methods of Examination. 
EXAMINATION OF THE SEAT OF DISEASE. 
We learn from the physiological properties of the nervous system 
that when alfected by disease there is little or nothing to be seen at 
the seat of the disease, while the symptoms are manifest at other por- 
tions of the body often quite distant from it. Besides, the brain and 
spinal cord are almost entirely removed from the possibility of being 
examined, on account of their bony casements. Lastly, very often a 
local disease of the nervous system, although it causes pronounced 
phenomena, is locally very indistinct. For all these reasons, the local 
examination of the nervous system, in a number of its diseases, is 
quite subordinate. Still, we place its consideration first, because in 
a systematic examination it belongs there, and because the expression 
of our opinion cannot at all affect the value which it, nevertheless, in 
many respects possesses. 
The Skull.—The majority of the diseases of the brain and its 
coverings run their course without any manifest effect upon the skull; 
indeed, there is no disease of that organ in which it may not more or 
less frequently happen that alterations in the skull were entirely 
wanting. If there are such alterations in a portion of the cases, 464 
SPEC IA L DU GNOSIS. 
they are secondary in their nature, dependent upon disease on the 
inner surface; in other, more rare cases, the alterations of the skull 
are the cause of the disease of the brain. 
As methods of examination,- we mention inspection, palpation, and 
measuring or tracing the shape of the cranium upon paper. 
The Size of the Cranium.—Generally this is determined by the 
circumference of the head over the glabella and the occipital protu- 
berance, and by estimating the relation between the brain-case proper 
and the face. This latter can be measured simply by the eye. In 
the newly born the circumference of the head is 39 to 40 cm. (accord- 
ing to others somewhat less). In the course of the first year it 
increases to about 45 cm., and from then to the beginning of the 
twelfth year to 50 cm.; in adults it amounts to about 55 cm. (in women 
it is generally somewhat less than in men). 
Marked enlargement of the cranium, macrocephalus (to 80 cm. and 
more in circumference), occurs with hydrocephalus, if the fontanelles 
have not yet closed. Then the frontal hones particularly project; the 
countenance is proportionally too small, the eyes are directed down- 
ward, the expression is often peculiarly staring; the fontanelles are 
very large and remain open for a long time; the cranial bones are 
thin. Hydrocephalus which occurs later, when the skull has already 
closed, causes little or no enlargement of the head. 
Moreover, a somewhat considerable macrocephalus is peculiar to 
the rhachitic skull, and is here dependent upon thickening of the 
bones of the skull. But it is generally somewhat angular (caput 
quadratum). There is no notable recession of the bones of the face 
as in the former; the bones give the impression of being dense, only 
the occipital bone is sometimes very thin, even as paper, sometimes 
upon pressure crackling like parchment (be careful!). Here, too, 
the fontanelles remain open abnormally long—sometimes into the 
third year. The distinction from hydrocephalus is made in the first 
place by an examination of the nervous system, which in this disease 
is almost always injuriously affected (as respects its psychic, intel- 
lectual, and motor functions), while in rhachitis it is normal; also 
the evidences of rhachitis are to be sought at other points (the infe- 
rior maxilla, the thorax, the bones of the extremities). Moreover, we 
may have a combination of hydrocephalus and rhachitic thickening 
of the cranium. EXAMINATION OF THE NERVOUS SYSTEM. 
465 
Abnormally small skull, microcephalus, is naturally connected with 
abnormally small brain, thus necessarily with idiocy (see). 
Form of the Skull. — Departures from the typical form. Here 
belong dolichocephalus, brachycephalus, and other forms of head which 
are often met with without any pathological condition of the brain, 
but also in congenital malformation of the brain, as in idiots. Asym- 
metry of the skull likewise occurs with this condition, but also not 
infrequently with persons who are perfectly healthy and intelligent. 
We discover the asymmetry of the skull by viewing it from above or 
by tracing it upon paper: measuring the sagittal and the large trans- 
verse diameters of the cranium with the calipers, and making an 
outline with a strip of lead as was described upon page 168, in the 
examination of the form of the thorax. 
Circumscribed projections and depressions have much greater path- 
ological significance, the latter, however, very frequently not with 
reference to disease of the brain but as signs of a general disease. 
Projections occur in disease of the cranial walls and of the dura mater,1 
and these are chiefly syphilitic gummata, carcinoma, and sarcoma. 
Sinking-in, depressions, impressions, may be traumatic. If there is 
defect of the bony wall the defect may feel like a fontanelle. Soft 
and slightly depressed [or depressible] round spots are sometimes 
present in carcinoma of the cranial vault. Very important, lastly, 
are scar-like, round depressions over which the scalp is adherent, and 
which often contain an actual scar: these occur as the result of healed 
syphilitic gummata or deep ulcerations. All these appearances, but 
especially the traumatic and syphilitic depressions, are of the greatest 
diagnostic importance. When the skull is thickly covered with hair 
they may be easily overlooked, if we do not examine it with the 
greatest care by feeling all points. 
In'making the examination of the cranium, it is of the greatest 
importance that we should have a clear conception of the location of 
the brain and its different parts with reference to its bony casement. 
We cannot here go into particulars, but attention is called to Fig. 145, 
from which we especially learn the relation of the so-called motor 
cortical regions of the temporal and occipital lobes to the cranium. 
1 The knowledge and significance of tumors of the cranium caused by meningocele 
and cephalocele are taught in works upon surgery. 466 
SPECIAL DIAGNOSIS. 
The most important point is that the motor cortical region lies just in 
front of a vertical line drawn through the external orifice of the 
auditory canal. 
Fig. 145. 
Explanation of the topographical relation between the surface of the brain and the 
skull, c, fissure of Rolando; JTGand VC, posterior and anterior central convolu- 
tion ; S, S, S, fossa of Sylvius ; F, F, upper and lower parietal lobes; 0, occipital 
lobe; Cb, cerebellum ; T, temporal lobe; El Frontal lobe. (Strumpell from Eckek.) 
Sensibility of the Cranium to Pressure. — This is ascertained 
by pressure with the finger or by gentle stroke with the tip of the 
finger or the percussion hammer. General sensibility to pressure 
occurs in nervousness, especially nervous pain in the head. We also 
sometimes meet with circumscribed sensibility to pressure in nervous- 
ness, also in hysteria; but sometimes the latter corresponds with a 
circumscribed meningitis, as this may be caused chiefly by tumors, 
abscess of the brain, etc. If there are other signs of a disease of this 
character present, then its topical diagnosis may be aided by palpation 
and percussion; by itself its results must be received with caution. 
Regarding the significance of dilatation of the veins of the skull, 
see page 260. EXAMINATION OF THE NERVOUS SYSTEM. 
467 
Suppuration of the ear and nose (the latter seldom) plays an im- 
portant part as causes of meningitis and abscess of the brain. 
THE SPINAL COLUMN. 
Form. The significance of the expressions scoliosis, kyphosis 
(lateral and posterior curvature of the spine) and kyphoscoliosis have 
already been referred to on page 88. Lordosis is an abnormal cur- 
vature forward. If these curvatures are obtuse-angled, none of them 
have a deleterious effect upon the spinal cord, or at least only excep- 
tionally. Acute-angled kyphosis (gibbous), as is usually caused by 
caries of the vertebrae, also by fracture of a vertebra, is of much 
greater importance, [causing] compression of the cord. It is to be 
remarked that in order to recognize slight lateral curvature it is 
desirable to mark the spines of the vertebrae, without moving the skin, 
with a blue crayon, a, id then to observe carefully the line that is thus 
formed. Any weak less or paralysis of the muscles of the spine on 
one or both sides may lead to secondary curvature of the spine, espe- 
cially to scoliosis and lordosis; see still further regarding this under 
Function of the Muscles. 
Diminished mobility of the spinal column, if it occurs with respect 
to the whole length in persons of mature years, is often not patho- 
logical. Complete general stiffness occurs, also, in arthritis deformans. 
If the stiffness is limited to a certain portion, while the rest of the 
vertebrae have free motion, this is of pathological significance (almost 
always due to caries, and here we sometimes have stiffness without 
curvature of the spine). Forcible bending is then generally painful. 
The spinal column is abnormally mobile when there is weakness or 
paralysis of its extensor or flexor muscles in young persons. This is 
especially marked in juvenile muscular atrophy, often in connection 
with habitual curvature. 
Sensitiveness of the vertebral column to pressure (especially of the 
spines of the vertebrae) may have a great variety of significance. 
There may be palpable disease, especially caries, but also tumors of 
the vertebrae, of the spinal meninges, spinal meningitis, or tabes; but 
it may likewise occur with spinal irritation (particularly in the neck 
and between the shoulder-blades), as well as in hysteria, and here it 
may be excessive. We discover this sensibility by strong pressure, 468 
SPECIAL DIAGNOSIS. 
or by striking the spines of the vertebrae. Often, but by no means 
always, there is at the same time painful sensibility when a hot sponge 
or the cathode of the galvanic current is passed over it. 
Here, also, belongs the rigidity of the neck in meningitis, particu- 
larly basilar—an important sign of this disease; also, the rigidity of 
the whole spinal column in spinal meningitis. With the former, by 
the contraction of the cervical extensors of the head, the latter is 
often bent back to a marked degree, “ boring into the pillow.” 
Backward bending of the vertebral column—opisthotonus—likewise 
occurs with attacks of tetanus; with epileptic, and especially hys- 
terical, convulsions. With the latter, as the “ arc de cercle,” there 
are sometimes incredible distortions. 
The anatomical relation of the cord to the spinal column is as 
follows: the cervical enlargement of the cord corresponds about with 
the third cervical or the first dorsal spine, the lumbar enlargement 
about on the level with the ninth dorsal to the first lumbar vertebral 
spine; the conus terminalis begins at the first or second lumbar 
vertebra. 
THE PERIPHERAL NERVES AND THEIR SURROUNDINGS. 
The nerves, as the seat of disease, come into consideration in all 
peripheral paralyses and in neuralgias (also among others, in reflex 
epilepsy). In order directly to examine a nerve-trunk, an exact 
knowledge of its course is necessary, and also of the organs that 
surround it, from which an injurious effect upon the nerve may 
proceed. 
By the examination of a nerve we learn its anatomical condition: 
any possible symmetrical thickening, with neuritis or perineuritis, 
unequal thickening or tumors in the nerve, with neurofibroma, 
neuroma; also any possible sensibility to pressure, as occurs with 
neuritis along the whole length of the diseased nerve, although this 
may be entirely absent. Finally, here belong the sensitive points in 
neuralgias (see below). 
Moreover, a special examination must be made of certain points, 
which, from any cause whatsoever, may easily be the starting-point 
of a disease of a peripheral nerve. These are: (a) those points where 
a nerve is especially exposed to traumatism, because it lies near the EXAMINATION OF THE NERVOUS SYSTEM. 
469 
surface of the body (especially if it at the same time lies over a bone). 
These situations essentially coincide, in part, with the electro-motor 
points to be mentioned later. Severe injuries, deep punctures, etc., 
of course, may destroy a nerve at any point. They are: (b) neigh- 
borhoods where a nerve may be exposed to injury from other organs. 
Here belongs compression by development of callus about the seat 
of fracture, especially of the bones of the extremities; also com- 
pression and sometimes inflammatory irritation from glandular tumors 
(axilla, neck, etc.), aneurism, hernia (crural nerve); lesion of the 
facial nerve caused by caries of the petrous portion [of the temporal 
bone], etc. Indeed, in case of lesion of a peripheral nerve we are 
frequently able to find the seat of the disease in this sense; but in 
every single case it must be looked for. 
An extremely instructive case from the standpoint of diagnosis 
of the locus morbi was observed by Erb, which was reported by the 
author. It was a case of ulnar neuritis resulting from exposure of 
the ulnar nerve from the fracture of the internal condyle of the 
humerus. The author has recently seen a similar case : both internal 
condyles of the humerus projected; the sulcus ulnaris was broad and 
shallow. In the first case there was a unilateral, in the second a 
bilateral, ulnar neuritis resulting from frequent injury to the nerve 
at its exposed point. 
EXAMINATION OF THE CONDITION OF THE MIND. 
In this section, which touches upon a territory foreign to this work, 
—the mental state—we must, of course, limit ourselves to a brief 
mention of what is necessary in making a medical examination. 
Mode of examination. An attentive observation of the behavior of 
the patient in bed, the expression of his countenance, his position, 
the reaction to external impressions, give many disclosures regarding 
the faculty of perception, and of his sensibility [or well-being]. By 
engaging the patient in conversation (taking the anamnesis, page 18), 
we are able to discover more regarding these points, and to judge of 
the intellectual activity: memory, imagination, possible delusions, the 
ability to think logically. In testing the memory, we take notice of 
the recollection of things that are long past, as well as of more recent 
events, or of what has taken place during the present illness. The 470 
SPECIAL DIAGNOSIS. 
test of the power of thought and of the imagination is made by more 
or less simple arithmetical problems and by questions which are suit- 
able to the social position and the occupation of the patient. We 
observe the great difference which various degrees of education pro- 
duce in patients affected with the same disease, and we also take 
into consideration the age of the patient. We observe any possible 
diminution or increase of action, both instinctive, as the taking of 
food, or sexual indulgences, and of actions with conscious purpose. 
This expresses in general terms the course of the examination. 
To be sure, we shall very frequently be obliged, in order to recognize 
the first traces of a mental disorder, to take into consideration 
whether the patient has changed in his nature or behavior. Thus, 
for example, if a person becomes suddenly forgetful, careless, and 
disorderly, this will have quite a different significance than if he 
had always from his youth been so. Of course, in regard to these 
things we must chiefly rely upon the statements of his relatives. 
In what follows is given the explanation of the terms that have 
been adopted in the medical clinic, and the phenomena that accom- 
pany the several conditions : 
Disturbances of consciousness are designated, according to their 
severity, as : stupor, also somnolence (sleepiness, lethargy, from 
which the patient can easily be awakened); sopor, in which the 
patient can only be awakened by decided appeals to his senses ; coma, 
or complete loss of consciousness, in which the patient cannot be 
awakened in any way. The slightest degree of obtunded conscious- 
ness manifests itself in the scarcely noticeable trouble which it costs 
the patient to collect himself in order to answer a question, or by his 
indifference with respect to being sick—a subjective sense of well- 
being. Further, there is an indication given by the sensibility to 
pain, and the arbitrary or involuntary voidance of the stools and 
urine. In this respect, the sensibility to pain often does not coincide 
with the other manifestations of consciousness. 
Disturbance of consciousness occurs : in acute infectious diseases ; 
especially in typhoid fever (see more below), where the early mani- 
festation of dulness has diagnostic value; but it may accompany any 
infectious disease, and may pass into deep coma; in acute poisoning 
of various kinds, especially from narcotics; as uraemic, diabetic, carci- 
nomatous coma; as epileptic, apoplectic coma; in meningitis; in the EXAMINATION OF THE NERVOUS SYSTEM. 
471 
most varying diseases of the brain, especially in tumors of the brain 
and its meninges. In the different forms of meningitis, however, 
consciousness may be retained for a remarkably long time. In tumors 
of the brain there is often for a long time a slight obscuration. It 
occurs also in injuries and concussion of the cranium; in large hemor- 
rhages ; in all chronic cachexia at the end of life, at any rate in the 
last moments. 
A patient who is in deep coma when he comes under the eye of 
the physician always causes great difficulty in diagnosis, the greatest 
when he can make no inquiry in regard to the patient. Systematic 
examination of the whole body is to be made: of the cranium for 
wounds; of the heart and vessels; for evidences of apoplexy, menin- 
gitis ; for signs of poisoning; of the urine, which is to be drawn with 
the catheter (for sugar, reaction for chloride of iron, for albumin, 
casts; for certain poisons or as evidence of certain poisons, haemo- 
globin) ; lastly, of the stomach by evacuation (poisons). 
SPECIAL PHENOMENA OF OBTUNDED CONSCIOUSNESS. 
Delirium, that is, talk and gesticulations arising from delusions. 
It may follow any disturbance of consciousness, but it occurs especially 
frequently with acute infectious diseases; with severe cachexia, often as 
the end of life approaches; finally, as delirium tremens seu potatorum, 
in chronic alcoholic poisoning. The latter manifests itself by talkative- 
ness, restlessness, rapid alternations between passion and great anxiety, 
fear, hallucinations of sight (small black animals, especially mice, etc.), 
loss of sensibility to pain and cold; besides alcoholic trembling (see). 
The expression “ muttering delirium ” is used to designate a low 
murmuring with profound disturbance of consciousness. It is always 
a serious indication of great weakness and occurs particularly with 
typhoid fever. 
Hysterical delirium forms a transition to the true psychoses, which 
cannot be treated here. 
Spasms, vomiting, see below. 
Loss of consciousness, which quickly passes off, occurs as “ syn- 
cope,” “ dizziness.” This may be very benign, as in anmmia and 
chlorosis, nervousness, great excitement, or severe pain. But it 
may have a serious significance in elderly people as precursors of 
apoplexy, or as slight epileptic attacks (petit mal); lastly, it occurs 
in all possible chronic diseases of the brain, but especially in progres- 472 
SPECIAL DIA GNOSIS. 
sive paralysis. All of these conditions must be thought of when 
attacks of dizziness occur frequently in the same individual. 
Dizziness, vertigo. In many respects this is to be looked upon as 
a slight, temporary loss of consciousness, or connected with it (see 
above). But it only indicates a disturbance of the sense of equilibrium 
and occurs as such most purely as a swimming of the eyes in diplopia 
(see Eyes) from deception regarding the location of objects in space 
and regarding the level of the floor. It also occurs in affections of 
the ear (vertigo ab aure lsesa); in tumors of the brain, especially of 
the vermiform process of the cerebellum ; in multiple sclerosis; with 
diseases of the stomach (vertigo a stomacho laeso); in anaemia, and in 
cerebral neurasthenia. 
Pathological depreciation of the power of the mind to perform its 
functions is designated as imbecility. It occurs in all gradations 
from moderate diminution in the perceptive faculties, to a complete 
animal condition. Congenital imbecility is designated idiocy, when 
accompanied with certain physical manifestations as cretinism. As 
an acquired condition it occurs as dementia senilis, also in organic 
diseases of the brain, especially tumors, apoplexy, multiple sclerosis; 
but also, as a temporary condition in convalescence from severe dis- 
eases, there is a slight imbecility. Imbecility with delusions of great- 
ness is a tolerably characteristic sign of progressive paralysis. 
Of disturbances of volitional impulses are to be mentioned: abulia 
(hypochondria, drunkenness, indulgence in morphia); loss of desire 
for food : anorexia; certain forms of pathological excesses : boulimia 
(a morbidly great and unnatural appetite for eating all sorts of things), 
nymphomania and satyriasis (abnormal sexual desires). 
Disturbances of Sensibility. 
1. SENSITIVENESS TO PERIPHERAL IRRITATION. 
The determination of the sensibility which a patient has for irrita- 
tions applied from the periphery (by the physician) is made difficult 
by the fact that the estimation of them must rest with the patient, who 
is the subject of the experiment. Subjective sensibility, especially to 
pain, without doubt varies with individuals: with “ torpid ” persons EXAMINATION OF THE NERVOUS SYSTEM. 
473 
and with the aged it is depreciated. Moreover, in a varying degree, 
it is diminished with persons who are unconscious to the point of 
entire loss of sensation. Further, it will be influenced, when the irri- 
tation is slight, by the attentiveness of the person examined. The 
report of what is discovered in such examinations depends wholly 
upon the sincerity and good-will of the patient. We must always 
think of the possibility of simulation and concealment, and the absence 
of favorable intention. 
Very little weight must be given to the statements of the patient 
as to his capacity to feel. The most brief examination is best, as 
securing the most exact answers, for we very often meet with erroneous 
conceptions of the condition of the sensibility of the skin. 
Whenever we are testing the sensibility, it is advisable to prevent 
the patient from seeing what we are doing. If the disease is uni- 
lateral, it is desirable to make use of this circumstance to compare the 
diseased with the healthy side. How we are to guard against decep- 
tion by simulation, see below. 
Finally, it is most emphatically recommended that the individual 
should employ the utmost similarity possible in the methods of 
making his examinations; for only in this way is it possible con- 
stantly to sharpen his own judgment. Moreover, every record of an 
examination should contain a statement of how the result was ob- 
tained. 
Passing over the higher senses, the sensibility to peripheral irrita- 
tion is divided into (a) cutaneous sensibility, (h) the so-called deep 
sensibility. 
(a) Cutaneous Sensibility. 
This -again is divided into a number of qualities whose relation to 
each other and distinction one from the other is not yet entirely clear. 
We avoid any discussion of disputed points, and treat the qualities 
from the stand-point of clinical interest. 
1. The sense of touch, sensibility to contact. We test this by 
gently touching the skin with the tip of the finger, the patient keeping 
his eyes closed, and whenever he feels the touch saying “now”; it is 
better if he will also say “ on the hand,” or on the given finger, etc. 
Thus we approximately test the sense of locality (see below). And it 
is also recommended, in order to shorten the examination, to test the 474 
SPECIAL DIAGNOSIS. 
latter immediately more exactly by having the patient designate with 
the tip of the finger the spot that is touched. If he is able to do this 
then his sense of touch and of locality is normal; if he cannot, 
there may be several reasons for his inability, as disturbance of the 
sense of touch and of locality, sometimes of the muscular sense (see 
below). Then we must endeavor to separate the sense of touch from 
the sense of locality. 
In many cases of slight disturbance the patient is able to feel the 
contact, but it is duller and different from what it is in normal places. 
Then we often obtain more exact information if we touch him with 
rough and soft materials, and the like. In other cases this procedure 
is unnecessary. 
2. The local sense, the power of localization, is tested by having 
the patient tell exactly where he has been touched. A healthy per- 
son can tell this with different degrees of accuracy, according to the 
portion of the body which is touched. This about corresponds with 
the distances on the body which the related sense of space has been 
found to give. (See below.) 
Testing the sense of space (only required when from any reasons 
the sensibility must be tested with the greatest exactness) is best done 
with Sieveking’s aesthesiometer: by means of two sliding points we 
are able to measure the shortest distance at which the two points can 
be recognized as two separate objects. In health the minimal dis- 
tance, on the average, is as follows : 
At the tip of the finger . . . 2.5 to 5 mm. 
In the palm of the hand . . . 8 to 12 “ 
On the back of the hand . . .31 
The forearm and the leg . . . about 40 “ 
The back . . . . . . 40 to 70 “ 
The upper arm and thigh . . . about 75 “ 
Analogous, although in its results not wholly corresponding to 
those of the above-mentioned method, is that of testing the sensation 
of movements (Leube): it relates to the power to distinguish points 
and the shortest lines that can be drawn upon the skin. 
3. The sense of pressure residing in the skin is tested by the ability 
of the patient to determine the smallest differences between weights EXAMINATION OF THE NER VO US SYSTEM. 
475 
placed upon the skin. The limb must lie firmly, so that the muscular 
sense (see) is excluded. It is best to take blocks of wood of the 
same size (instead of metal), but made of different weight by being 
loaded with lead. The healthy person perceives differences of weight 
which are equal to about to of the absolute weight of the bodies 
employed. Partial paralysis of the sense of pressure is frequently 
observed, especially in tabes. 
4. The sense of warmth and cold. This is most quickly and 
simply tested by breathing and blowing upon the skin. Healthy 
persons distinguish the first from the second perfectly well. This 
method, however, is entirely unsatisfactory, because the finer disturb- 
ances of the sense of cold and heat are not revealed by it. Somewhat 
more exact is the test made by means of two test-tubes filled with 
water at different temperatures. We must select-a difference of tem- 
perature which we ourselves distinctly recognize, as, for instance, by 
passing the hand over them. If, with one of these methods, we find 
a disturbance of one of the two temperature-senses, then we can more 
exactly determine the degree of this disturbance by employing tem- 
peratures which vary still more; hence, very low or very high (ice, 
hot water). At the same time we can thus determine the temperature 
at which cold- or heat-pain begins. 
A finer test of the sense of heat is made by the aid of the thermses- 
thesiometer We recommend Nothnagel’s—two cylindrical wooden 
vessels, with metal bottoms, into each of which is dipped a thermom- 
eter to test the temperature of the water that is poured into them. 
In a very imperfect way we may make a substitute for this thermses- 
thesiometer by using two reagent glasses half filled with water. In 
these are" placed thermometers surrounded by pledgets of wadding. 
The temperature of the glasses is varied by dipping them into vessels 
of cold or hot water. The thermaesthesiometer enables us to deter- 
mine exactly the fineness of the sensibility to heat and cold. The 
normal fineness of the sensibility to heat differs with the absolute 
height of the temperature which we select. The temperatures between 
27° C. and 33° C. are most delicately distinguished. Here the 
recognizable differences in health average 0 5° C., except over the 
legs, where the number may be somewhat larger, and on the back, 
where it is about 1° C. On the cheeks it is about 0.25° C. 476 
SPECIAL DIAGNOSIS. 
5. Sensibility to pain.1 We recommend to test exclusively by 
pinching a fold of skin between two fingers, because in this way, with 
some practice—it depends very much 
upon the size of the fold of skin that is 
taken, and it is recommended always to 
press the rounded portion of the skin 
—we can best attain some uniformity 
in regard to the amount of irritation 
employed each time. (Regarding pain 
caused by faradization, see below.) 
With patients who are unconscious it 
very often happens that the sensibility 
to pain is the only quality of sensation 
that is accessible to examination. 
When there is very decided uncon- 
sciousness we are made aware of it by 
the possible distortion of the counte- 
nance on account of pain or even a 
withdrawing of an extremity (not to be 
confounded with reflex of the skin, see 
below). 
6. Electric sensibility. By the galvanic as well as the faradic 
current we can develop an objectively-visible as Avell as subjectively- 
painful sensibility of the skin. We confine ourselves to the descrip- 
tion of the farado-cutaneous sensibility. 
It is best obtained by employing Erb’s electrode for testing farado- 
cutaneous sensibility (made by Stohrer, in Leipzig), which is a cable 
of insulated copper wires cut at right angles with its axis. We mount 
this electrode upon the cathode of the opening current of a Dubois’s 
induction-coil (the other electrode may stand anywhere upon the 
body), and notice the distance of rotation when the point of the skin 
under examination becomes sensitive (minimum of sensation), and 
also where it stands when pain is produced. Then, besides, we are 
to test the galvanic resistance at each point tested (see under Elec- 
trical Examination for Motility), in order to have an approximate 
guide as to how strong a current, furnished by Dubois’s apparatus, is 
Fig. 146 
Erb’s electrode for testing the sen- 
sibility of the skin, a, tube of hard 
rubber; b. free surface of the elec- 
trode. (Erb.) 
1 Corresponding with the mode of procedure in making an examination, this is 
included here, although it properly belongs with common sensation (which see). EXAMINATION OF THE NERVOUS SYSTEM. 
477 
exhausted by the resistance of the body (or of the skin) at the indi- 
vidual points; hence, how much of it is used up each time in produc- 
ing the irritation of the skin. The following table gives the average 
figures of health as found by Erb, but we remark that the figures 
change according to the strength and construction of the induction 
apparatus employed, and also that the deviation of the needle (for 
testing the galvanic resistance) was attached to an old galvanometer 
without absolute divisions. For both of these reasons the relation of 
the figures from each other, rather than the absolute‘variation of the 
needle indicated by them, is of value: 
Points of resistance. 
Minimum. 
Pain. 
Deviation of the needle 
with 8 elements ; con- 
Cheeks . 
. 200-220 
130 
duction resistance 150. 
26° 
Neck 
. 180-200 
120 
22° 
Upper arm . 
200 
120 
21° 
Forearm 
190 
115 
O 
oo 
rH 
Back of the hand . 
175 
110 
15° 
Tip of the finger . 
125 
90 
2° 
Abdomen 
190 
120 
bO 
o 
o 
Thigh . 
180 
115 
21° 
Lower leg 
170 
110 
19° 
Back of the foot . 
175 
110 
10° 
Sole of the foot 
110 
80 
5° 
The method is further liable to error, regarding which we cannot 
speak here. 
Farado-cutaneous sensibility does not go entirely parallel with any 
other quality of sensibility. Most frequently, but not always, the 
sensations of pain produced by pinching, and the minimal sensations 
of pain produced by the faradic current, correspond with each other 
(this is especially the case in tabes). The method has not yet been 
sufficiently studied to be of independent diagnostic significance, and 
particularly to have a value for special diagnosis. Its application is 
chiefly to be recommended in unilateral slight disturbance of sensi- 
bility, from the possibility of making a comparison with the sound 
side, which cannot be quite certainly established when there is normal 
irritability of the skin. (Regarding stereognosis, see p. 481.) 
Now, if by testing the sensibility we find it diminished, wTe speak 
of Jiypcesthesia, often incorrectly spoken of as anaesthesia. If none 
is found—that is, if the strong or maximal irritation employed, which 478 
SPECIAL DIAGNOSIS. 
is always to be stated as accurately as possible, meets with no response 
—then we speak of loss of sensibility, or anaesthesia. Heightened 
sensibility is hypercesthesia, or sensibility to variations of temperature 
and to pain. In many cases, especially in diseases of the peripheral 
nerves, the sensibility is equally altered in all its qualities ; in others, 
and especially in diseases of the spinal cord, in cerebral anaesthesia, 
and not infrequently in hysteria, there exists a partial paralysis of 
sensibility. Of this, the most frequent form is the diminution or 
absence of sensibility to pain—analgesia. 
When sensibility is slowly conducted (“delayed sensibility ”), it is 
recognized by requiring the patient, with his eyes closed, to call out 
“ now ” the instant he has a sensation. Sometimes, the pause can be 
measured by seconds (ten seconds, and more). This phenomenon is 
most frequently observed with reference to pain, as in tabes and in 
peripheral paralysis. If we take hold of the skin, to pinch it. the 
patient will often call out “now” twice, because he felt the touch, 
and then, later, the pinch: there is double sensibility. For this 
reason, it is best to take up the skin first, without pressing it, and 
then suddenly to pinch it. 
Gradual increase of the sensibility to pain, when inflicted, so that 
just at the moment of being pinched it is inconsiderable, and, later, 
the pain increases markedly, appears by its phenomena and occurrence 
to be related to delayed communication of the pain. 
Perverse sensibility to changes of temperature (Striimpell) consists 
in cold being experienced as heat. According to our recent views of 
the complete opposition of the sensibility to heat and the sensibility 
to cold, this disturbance is not, as yet, explicable. Yet it has an 
analogy in those rare anomalies of sensibility where a gentle touch is 
felt as cold. 
After-sensibility (Naunyn) is a term used to describe a pain that, 
when first inflicted, immediately subsides, but for some time after 
returns, and, indeed, with increase of intensity. 
Polycesthesia (Fischer): when one point of the sesthesiometer is 
placed upon the surface, it feels as if there were two. 
Allochiria (Obersteiner): when the right extremity is touched, it 
is referred to the left, and vice versa, as in tabes, myelitis, hysteria, 
multiple sclerosis. 
Local manifestations of disturbed sensibility. Of course, these EXAMINATION OF THE NERVOUS SYSTEM. 
479 
are to be determined as accurately as possible. This is very easily 
done when the disturbance of sensibility is sharply bounded; how- 
ever, not infrequently the region of disturbed sensibility of the skin 
passes very gradually and indistinctly into the normal portion. Total 
anaesthesia is a curiosity. Unilateral anaesthesia, or hemiancesthesia, 
not passing beyond the middle line of the body, sometimes affecting 
the head, trunk, and extremities (including the mucous membrane), 
in a similar way, occurs with certain deposits in the internal capsule 
(in the posterior third of its posterior limb), and in hysteria. In the 
latter, and (it is said) also in the first case, there is simultaneously 
exact unilateral disturbance of all the higher senses. Para-ancesthesia 
is anaesthesia of both lower or both upper limbs. A zone of dis- 
turbed sensibility, a territory of any extent, may exist in all imagin- 
able parts of the body. If it is small, it may easily be overlooked, 
unless the search for it is very carefully made; this is particularly 
apt to be the case in the extremities. Here, especially (but also on 
the trunk), we must carefully determine whether the anaesthesia cor- 
responds with the region of distribution of a cutaneous nerve or of a 
mixed nerve-trunk (see p. 484), or whether it is not confined to such 
a territory—that is, “ diffuse ” or “ washed out.” In the first case it 
would indicate an isolated disease of that particular nerve. Anaes- 
thesia (analgesia) affecting an extremity which is limited to the por- 
tion distributed about a joint (say, as far as the wrist, or up as far as 
the elbow-joint, etc.), has been met with in certain functional neuroses, 
especially of the so-called hystero-traumatic neuroses of the French. 
It may happen—indeed, it very frequently does—that an anaesthetic 
territory does not really comprise the limits of a nerve of the ex- 
tremities, but the inner half of it is wanting. Thus, in a radial 
paralysis, there may be an anaesthetic zone (easily overlooked) con- 
fined to a small part of the dorsal side of the forearm. This results, 
either because the nerve is not interrupted throughout its whole trans- 
verse section, or because we have that very puzzling phenomenon, 
the “ vicarious ” participation of a neighboring nerve. 
(b) Beep Sensibility. 
This is divided into the less important categories of the dynamic 
sense, the sensation of spasm of the muscles, and the important 480 
SPECIAL DIAGNOSIS. 
so-called muscular sense, which is a generic name for a series of 
sensations. 
Dynamic sense is the capacity to recognize the weight or the 
difference of weight between different bodies which one lifts. It may 
be exactly tested only with the upper extremities, and even here it is 
not wholly separable from the pressure-sense of the skin. Different 
weights are placed in a cloth-sling pulled over the hand on to the 
wrist. A healthy person will recognize differences of one-tenth. 
Sensation of spasm is the unpleasant sensation or pain which is 
experienced in very strong contraction of the muscles, as in cramp in 
the calf of the leg, or strong faradic muscular stimulus with anaesthesia 
of the skin. 
Muscular sense. By this we understand the ability to recognize, 
with the eyes closed, the position a limb is in (conception of location), 
and the active and passive motions of a limb. It is due to the sensi- 
bility of the muscles, joints, and their ligaments, by the feeling of 
varying tension of the skin in flexion and extension of a joint, by the 
impressions of touch which come from portions of skin being in con- 
tact, as in the axilla and elsewhere. We test the sensation of location 
and of motion in the arm (with the eyes closed), in persons wTith uni- 
lateral disease very simply: we place the diseased arm in different 
positions, and have the patient with the sound hand take hold of the 
wrist of the diseased arm. The same method may be employed in 
unilateral disease of the leg. Besides, it is well, when there is disease 
of the legs and bilateral affection of the arms, to have the patient 
describe the positions in which they are placed or the passive motions 
of the joint that are made. We can also have the patient describe and 
represent numbers in the air with his hands. 
Romberg's symptom. The patient places his feet close together, 
and as soon as he closes his eyes he begins to reel, sometimes he may 
fall down. The phenomenon is dependent upon anaesthesia of the 
soles of the feet and disturbance of the muscular sense of the legs, 
which is no doubt increased by the existing ataxia (which see), because 
in this condition the motions to correct the swinging are too violent; 
this is especially characteristic of tabes dorsalis. [But something of 
this symptom may be present in health, owing to the lack of vision to 
correct incipient lateral movements. This may be made clear by 
closing the eyes and then attempting to stand on one foot.] EXAMINATION OF THE NERVOUS SYSTEM. 
481 
A finer test of the muscular sense may be made by placing before 
the patient a table with numbered squares like a chess-board, each 
square measuring about 10 cm. on a side, and having him point them 
out with the eyes open until he has them all in his head, and then 
with closed eyes to touch them with the hand; or, on the other hand, 
the patient moves his hand about the squares and names the fields as 
he comes to them. With the legs, the same test may be made with 
cubes measuring 10 cm. on a side, placed one on top of another and 
then side by side. This test, however, requires a certain degree of 
intelligence on the part of the patient. 
Conception of space (“finding one’s position in space”) can be 
tested by placing substances of different thicknesses between his thumb 
and forefinger to ascertain the smallest perceptible differences of 
thickness. 
In testing the conceptions of active motions, we see that it is very 
much disturbed in paralysis, ataxia, and chorea; regarding these, see 
below. 
The Knowledge of Form (Stereognosis), 
We recognize the form of bodies partly by the sensibility of the 
skin and partly by deep sensibility. The former is employed more 
for very small bodies (which we are able to grasp with the hand; 
here, indeed, the hand is the chief means), the latter more for large 
substances. Thus far only the recognition of small bodies has been 
sought, especially in an exact wTay by Hoffmann. 
To make this test he selected a ball, half-ball, segment of a ball, a 
cone, a three-cornered pyramid, a regular octahedron, and a dodec- 
ahedron—all of a size for the hand to grasp. He chiefly tested the 
hand of persons in health and sick people as regards their ability to 
recognize these bodies (to which popular names were given). 
Hoffmann and others have found that the recognition of small 
bodies was principally made by the skin and sense of space and of 
pressure of the skin, and to a less degree by the sense of motion in 
the joints and the power of determining the location in space. Also, 
that the active to-and-fro motion of the body in the hand, for a dif- 
ferent reason, comes into consideration : if the active motion is want- 
ing, then the stereognosis is hindered, but not abolished. 
Formerly the examination of stereognosis did not have an inde- 482 
SPECIAL DIAGNOSIS. 
pendent value; testing the separate qualities of sensation is superior 
to it. According to our experience, the most important result of 
Hoffmann’s examination is the knowledge that the separate factors of 
stereognosis may very perfectly act one for another when there are 
pathological disturbances. 
2. SENSIBLE PHENOMENA OF IRRITATION AND PAIN FROM PRESSURE 
UPON NERVES. 
1. Parcesthesia. 
This occurs as a subjective sensation of touch, like fur, creeping 
of ants, creeping of insects, falling asleep; also as a subjective sensa- 
tion of pain, as a fine stinging or pricking, and also a severe pain; 
lastly, as a subjective sensation of cold and heat or painful burning. 
The so-called feeling of constriction, which occurs most frequently 
upon the trunk in the region of the thoracic vertebra, especially in 
tabes, but also in local disease of the spinal cord and its meninges, 
belongs here. Generally it is a sensation of tension, but it also occurs 
in all stages of transition to genuine neuralgic pains, when it is deeply 
located (see Neuralgia). 
2. Spontaneous Pain. 
Headache (cephalalgia). This, according to the manner of its 
occurrence as well as its significance, may be extremely varied in its 
character. Its chief forms are : 
(a) Headache produced by palpable disease of the meninges in the 
different forms of meningitis; in all those diseases of the cranium and 
the brain which accompany meningitis. If the affection is circum- 
scribed, the headache may likewise be so, and it then sometimes 
indicates the location of the disease; but, also, often enough in this 
case it is not located. 
Related with this are the nocturnal headaches of syphilis. 
(h) The headache of neurasthenia is quite various in its onset. 
Sometimes it appears as a painful pressure in the head, sometimes as 
extremely severe pain; again it is diffuse, then localized, especially at 
the crown of the head. There is the hysterical headache, not infre- 
quently circumscribed at the cro\yn (clavus hystericus). EXAMINATION OF THE NERVOUS SYSTEM. 
483 
(c) Migraine. This is generally an unilateral headache occurring 
with pauses of extremely varied duration, with disturbances of the 
stomach, scintillations (see the eye), tinnitus aurium, dilatation or 
contraction of the pupil of the affected side, accompanied with other 
pains. The condition is idiopathic or symptomatic, especially in tabes, 
tumors of the brain, also sometimes in diseases of the nose, etc. 
(d) Neuralgia in the head, see below. 
(e) Toxic headache occurs particularly in chronic poisoning with 
lead, mercury, alcohol, nicotine. Here, also, belongs the headache of 
uraemia. 
(/) There is a headache which occurs in the beginning and during 
the course of acute infectious diseases, especially intense and long 
continued in typhoid fever. 
(g) Anaemic headache; headache with gastric dyspepsia; abdominal 
diseases of all kinds, especially diseases of the female sexual organs. 
{K) The so-called habitual headache. Often there is an hereditary 
disposition to headache, which occurs with exertion, excitement, bodily 
disturbance, as catching cold, etc., and the disposition generally lasts 
during the greater part of one’s life. 
Pain in the spine may concern the vertebrae, as in chronic rheuma- 
tism, arthritis deformans, caries; the spinal muscles, as in muscular 
rheumatism; the spinal cord or its meninges, especially in meningitis 
and in tabes with tumors. But it occurs very frequently, and is 
especially torturing, in neurasthenia and spinal irritation. (See, also, 
what was previously said regarding the vertebrae.) 
Neuralgia. This is generally a severe paroxysmal pain occurring; 
in the region of one or more distinct nerves. It may be idiopathic 
or result from catching cold, but it may also be symptomatic, with 
the greatest variety of significance. The principal varieties of neu- 
ralgia are those produced by mechanical irritation (pressure of a 
tumor, aneurism, periostitis, etc.); sequela of inflammation of the 
affected nerve; neuralgia dependent upon infectious or toxic influences 
(malaria, syphilis, lead, mercury, nicotine, etc.); or accompanying 
constitutional diseases, as diabetes, gout, phthisis. In every neuralgia, 
we are to keep in mind the whole course of the affected nerve, and 
consider where and how it may be injured, and how such a local 
injury may directly or indirectly be discovered. 
Of special importance are the neuralgic, lightning, lancinating 484 
SPECIAL DIAGNOSIS. 
pains, in the initial stage of tabes dorsalis. They occur very much 
more frequently in the lower extremities and the trunk in the region 
of the intercostal nerves, and nowadays are not infrequently con- 
founded with rheumatism. Also in the beginning of multiple neuritis 
there are neuralgic pains, although generally of moderate intensity. 
We have previously mentioned the pain produced by pressure upon 
the head and upon the vertebrae. The peripheral nerve are sensitive 
to pressure in neuritis whenever this is accompanied by actual inflam- 
matory phenomena in the nerve, or there is perineuritis. Very fre- 
quently there is especially pronounced tenderness of the nerve during 
an attack of neuralgia, but also often, although to a slighter degree, 
in the intervals. This tenderness is very great at certain points of 
the nerves, especially where the nerve can be pressed against the bone 
(Yalleix’s points) [points douloureux]. 
Tenderness and spontaneous pain in the joints, without anatomical 
changes, and generally very changeable in severity, are characteristic 
of articular neuralgia. 
3. DISTRIBUTION OF THE SENSORY CUTANEOUS NERVES. 
It is recommended that the accompanying figures [Figs. 147 and 
148] he studied, in connection with which we will draw attention to 
a few points which seem to us to be especially important. 
1. The nerves of the head. It is to be noticed that the nerve Vl 
also supplies the conjunctiva and a portion of the mucous membrane 
of the nose; further, that when it is paralyzed, we observe severe 
inflammation and ulceration of the eye (ophthalmia neuroparalytica), 
which, until recently, were regarded by most persons as arising from 
lesions, as by dust, etc., which were not warded off because they had 
not been seen. The author inclines to the old view that the disturb- 
ance of nutrition forms the starting-point of the trouble. Nerve V2 
supplies the mucous membrane of the superior maxilla, a part of the 
gums and of the nose, the upper teeth, and the chorda [tympani] ; 
hence sometimes there is disturbance of the taste at the anterior por- 
tion [two-thirds] of the tongue. Nerve V3 supplies a portion of the 
tongue and the mucous membrane of the cheek, and presides over the 
secretion of saliva. It contains motor fibres, of which the most im- EXAMINATION OF THE NERVOUS SVSTEM. 
485 
portant are those distributed to the muscles of mastication (masseter, 
temporalis, pterygoideus ext. et int.) 
2. Nerves of the neck and trunk. These do not require any fur- 
ther explanation. 
3. Nerves of the shoulder, arm, and hand. Here we are especially 
to note the smallness of the cutaneous filaments of the radial nerve 
that supply the dorsal side of the forearm. Anaesthesia here may 
Fig. 147. 
Fig. 148. 
Figs. 147 and 148. Distribution of the cutaneous sensitive nerves upon the head 
(Seeligmueller). oma, omi, F. occipit. rnaj. and minor (from the F. cervical, II. and 
III.); am, F. auricular, magn. (from F. cervic. III.); cs, F. cervical, superfic. (from F. 
cervie. III.); V„ first branch of the fifth (so, F. supraorbit.; st F., supratrochl.; it, F. 
infratrochl.; e, F. ethmoid; l, F. lachrymal); V2, second branch of the fifth (sm, F. 
subcutan. malae seu zygomaticus); V3, third branch of fifth (at, F. auriculo-tempor. 5 
b, F. buccinator.; m, F. mental); B, posterior branches of the cervical nerves. 
easily be overlooked. It is to be remarked, also, that the distribution 
of the cutaneous nerves to the fingers, and also to the hand, is sub- 
ject to some changes, so that slight variations from the arrangement 
usually described ought not to lead to mistake. Lastly, very often 
on examination of a peripheral paralysis it is found that the extension 
of the sensory disturbance lags behind that of the motor. The 
phenomenon is largely explained by a vicarious participation of neigh- 
boring cutaneous nerves in a portion of the territory affected (not- 486 
SPECIAL DIAGNOSIS. 
Fig. 149. 
Distribution of the cutaneous nerves to the shoulder, arm, and hand (Henle). The 
region of the N. radial is represented by the unbroken hatched line, that of the IV. 
ulnaris by the broken hatched lines, a, anterior, b, posterior surface; sc, Nn. supra- 
scapular (plexus cervicalis); a.r, chief branch of N. axillar; cps, cpi, Na. cutanei post, 
sup. and inf. (from ~N. radialis) ,• ra, terminal branches of IT. radial; cm, cl, Nn. cutanei 
medius (also to the plexus) and lateralis (chiefly to the N. medianus); cp, IV. cutan. 
palmar., N. rad.; cmd, IV. cutan. medialis; me, N. medianus; u, N. ulnaris; epu, N. 
cutan. palm, ulnaris. 
withstanding the many investigations regarding its existence, this 
idea of vicarious action has not yet been as clearly explained as is 
desirable). EXAMINATION OF THE NERVOUS SYSTEM. 
487 
Fig. 150. 
Distribution of the cutaneous nerves of the lower extremity. (Henle.) it, It. ileo- 
inguinal (plex. lumb.;; li, It. lumbo-inguinal (to the genito-crural. plex. lumbal.); se, 
It. spermat.ext. (to the gcnito-crural.); cp, It. cutan. post. (plex. ischiad.); cl, It. cutan. 
lateral, (plex. lumb.); cr, tST. cruralis (plex. lumbal.); obt, It. obturator, (plex. lumb.); 
sa, It. saphen. (plex. lumbal.); cpe, It. commun. peron. (It. peron. tibial.); cti, 1ST. 
commun. tibial.; per', per", It peronsei ram. superfic. et prof.; cpm, It. cutan. post, 
med. (plex. ischiad.); cpp, It. cut. plant, propr. lit. tib.); plm,pll, It. plantar, medial, 
et lateral. (It. tib.). 
Paralysis of the brachial plexus at Erb’s point (see Electrical Ex- 
amination) sometimes causes anaesthesia in the region of the median 
nerve. Paralysis from compression of the radial [musculo-spiral] at 488 
S PE CIA L DIA GNOSIS. 
the point where it passes around [the humerus] causes sensory disturb- 
ance only at the hand (see Electrical Examination), because the pos- 
terior cutaneous nerves [internal, supplying the posterior and internal 
aspects of the arm as far as the elbow; and external, arising from the 
nerve on the outer border of the arm, is distributed to the back of the 
forearm] are given off above the point of circumflexion. On the other 
hand, compression of the radial in the axilla (crutch-paralysis) often 
causes anaesthesia of the forearm. 
4. Nerves of the lower extremities (See the accompanying 
figure—Fig. 150.) 
Disturbances of Motility, 
In this connection we consider not alone the disturbances of mus- 
cular action in the strict sense, but also the manifestations as respects 
tonus and the nutrition of the muscles, the cobrdination of their 
actions, their electrical and mechanical irritability, and their reflex 
manifestations. 
1. PARALYSIS. 
By paralysis of a voluntary muscle, we understand a condition in 
wdiich, by the action of the will, it can only to a diminished extent, 
or cannot at all, be made to contract. If there is complete absence of 
voluntary contraction, we call the condition paralysis; if the power 
of voluntary contraction is only diminished, it is called paresis. 
Paralysis is the result of some anomaly of the muscular nervous 
system or of its motor terminal apparatus. 
The loss of motion due to stiffness of the joint has nothing to do 
with paralysis. Such inability to move a joint is especially frequent 
in the extremities, and may lead the inexperienced into error. If 
there is simultaneous stiffness of the joint and paralysis, it may be 
extremely difficult to determine the existence of the latter. Diminu- 
tion of power of motion caused by pain has nothing to do with paralysis 
when there is only a want of self-control on the part of the patient. 
However, very severe pain may cause a local restriction of movement, 
which is, in fact, to be considered as a paralysis. 
Phenomena of paralysis; methods of examination. Paralysis is 
recognized by the complete absence of the power of motion in the 
sense of action of the affected muscles, and, as regards the muscle EXAMINATION OF THE NER VO US SYSTEM. 
489 
itself, by the absence of contraction that can be seen or felt. An 
extensive paralysis, if it causes the muscles to be lax (see below), pro- 
duces a characteristic atonic behavior of the affected limb : if we take 
it up and then let go, it falls down—an important symptom of loss of 
consciousness. As regards those muscles, and there are many such, 
whose failure does not in a very noticeable degree affect the motion of 
a limb, because their actions are replaced by others, we recognize the 
paralysis by observing and feeling the muscles during active movements 
of the joint which would likely call them into action; among such 
belongs the supinator longus. Paresis is recognized by the diminu- 
tion of “native vigor” when resistance is called for; and also, sup- 
posing the joint to be free and an absence of tension on the part of 
the antagonizing muscles, by diminished freedom and rapidity of 
motion. Again, we sometimes resort to an attentive examination and 
careful feeling of the body of the muscle. On the other hand, we may 
be deceived by the statement of the patient that he has a feeling of 
lassitude, etc. 
Extent of the paralysis. Paralysis of one-half of the body, with or 
without paralysis of the corresponding side of the face, is called 
hemiplegia. Paralysis of one side of the face, of an arm, a leg, is 
called monoplegia facialis, brachialis, cruralis. We also speak of 
monoplegia brachio-facialis. Paraplegia inferior is paralysis of both 
legs; paraplegia superior, of both arms. Hemiplegia cruciata signifies 
paralysis of the arm of one side and the leg of the opposite side; 
hemiplegia alternans, or likewise cruciata, paralysis of an extremity 
of one side and of the facial or oculomotorius of the other side. 
The extent of the paralysis is an extremely important aid in 
diagnosis, as follows from the anatomical remarks made at the opening 
of this section. For anatomical diagnosis, see further below. 
2. DISTURBANCE OF THE NUTRITION AND TONE OF THE MUSCLES. 
Nutrition shows manifest differences that are very striking, and of 
the highest diagnostic importance. It is determined by the volume 
of the muscle and by its electrical behavior (see Electrical Examina- 
tion). More or less symmetrical diminution in the volume of the 
muscles of a portion of the limb is designated as diffuse atrophy; when 
it affects a single muscle, as circumscribed atrophy. A corresponding 490 
SPECIA L DIA G NO SIS. 
increase in the volume is called hypertrophy or pseudo-hypertrophy 
(see below). The existence of atrophy, and its extent, are determined 
by inspection and palpation ; if possible, also, by measuring. When- 
ever one side alone is affected, we are always to compare it with the 
healthy side. Requiring the patient to make active motion, by which 
the muscle under examination is made to contract, or which causes 
contraction in the surrounding muscles, often makes the impression 
much clearer. We can easily combine testing of the strength with 
the examination of the state of nutrition. 
The volume of an extremity is measured with the tape-measure 
while the limb is extended at rest (both arms and both legs are to be 
in exactly the same position), and it is best done at certain points of 
election. 
We measure the upper arm at the point of its greatest circum- 
ference; the forearm, 2 to 3 cm. below the lower margin of the inner 
condyle of the humerus; the thigh, 15 cm. above the upper edge of 
the patella; the calf of the leg, at its greatest circumference. 
Thus, in measuring the forearm and the thigh, we must first fix 
the point where we are going to take the measure, and mark it with a 
blue pencil. 
Atrophy is divided into the following varieties, which are to be very 
sharply distinguished from each other: 
(a) Atrophy of inactivity. This consists of a diminution in the 
volume of the muscles, which is very slight and which very slowly 
develops in the course of months of inactivity. Almost without ex- 
ception, it supervenes in cases of paralysis, and also in any long- 
continued inaction of the muscles, as in surgical diseases which 
require the limb to be kept at rest. In this form of atrophy, as will 
be shown later, the electrical sensibility of the muscles is qualitatively 
unchanged. 
(h) Degenerative atrophy, with the so-called atrophic paralysis. 
This quickly leads to a high degree of atrophy of the affected muscles, 
and to a qualitative change in their electrical sensibility—the reaction 
of degeneration (see below). This degenerative atrophy only occurs 
if the centre which presides over the nutrition of the muscle, hence 
that portion of the gray matter of the anterior horn corresponding 
to the affected muscle, is disturbed or is separated from the muscle; 
therefore, in all primary and secondary diseases of the anterior horns, EXAMINATION OF THE NERVOUS SYSTEM. 
491 
in local separations or interruptions of the connection with the 
anterior roots or peripheral nerves, in peripheral neuritis. 
Here belong: poliomyelitis acuta, subacuta, chronica; progressive 
muscular atrophy of spinal origin ; amyotrophic lateral sclerosis; all 
processes within and of the spinal cord which destroy the gray sub- 
stance (tumors, hemorrhages, softening); compression of the anterior 
roots and the peripheral nerves; traumatic complete separation, 
severe contusion; pressure-necrosis of these ; and all forms of acute 
and slow degeneration or degenerative neuritis. 
Also, it will be understood (see above, p. 456) that the motor nerves 
below the seat of the lesion, as far as the muscle, atrophy; see also 
Electrical Examination. 
On the other hand, degenerative atrophy is wanting in all paralyses 
which are due to a disease of a motor tract above the anterior horn 
ganglia—that is, in the pyramidal tract of the spinal cord, of the 
brain, in the cortex of the brain. Therefore, in these cases, we only 
have the atrophy of inactivity. Moreover, degenerative atrophy is 
wanting in paralyses of myopathic origin (see below) and in functional 
paralyses. 
Nevertheless, degenerative atrophy in many diseases occurs in such 
a wray as to cause great clinical difficulties : the rapid (developing 
within fourteen days) diminution in the volume of a muscle, of course, 
can only occur when the whole of the affected muscle, or a large 
compact portion of it is suddenly, at an approximately definite time, 
completely paralyzed by disease of the anterior horn or of a peripheral 
nerve (poliomyelitis acuta, section of a nerve, rheumatic facial paral- 
ysis, etc.). A disease developing slowly, in the course of weeks and 
months, causes slowly progressive atrophy, at first disseminated in 
the separate muscular fibres, only gradually becoming general. There 
are also difficulties in determining the reaction of degeneration in such 
slowly extending degenerative atrophy (see below). We have the 
greatest difficulty in making out degenerative atrophy when the dis- 
ease is a disseminated one, in which bundles of muscular fibre that 
are still normal are distributed everywhere between diseased bundles. 
(Regarding this, see further under Electrical Examination.) 
It is to be remarked that all cachexias cause general atrophy, as 
well as atrophy of the muscles. But it is worthy of still further note 
that, under the influence of a general atrophy, the paralyzed muscles 492 
SPECIAL DIAGNOSIS. 
often become excessively atrophied, even when the atrophy is not a 
degenerative one. In cases of myelitis transversa and simple atrophy 
of inactivity of the legs, when there comes to be a general atrophy, 
we have often seen the legs become extremely atrophied, quite out of 
proportion to the volume of the arms. 
But there is no reaction of degenera- 
tion, and this fact furnishes diagnostic 
assistance. 
It is often extremely difficult for 
the beginner to form a conception of 
the behavior of the anterior gray col- 
umns when there is disease of a trans- 
verse section of the spinal cord, and 
to answer the question in connection 
with it, what sort of paralysis will 
result from such disease. For this 
reason two examples are presented: 
In a severe contusion of the promi- 
nence of the neck (fracture of a 
cervical vertebra, for instance) it may 
happen that the wrhole section of the 
anterior gray columns, which inner- 
vates the arms, is disturbed, and that 
simultaneously the pyramidal-tract 
fibres for the muscles of both legs are 
unbroken (at H in the figure): there 
follows a degenerative atrophic par- 
alysis of the arms and a non-atrophic, 
“ simple ” (spastic, see under Tonus) 
paralysis of the legs. The pyramidal- 
tract fibres of the latter degenerate as 
far as the lumbar portion of the cord 
(as far as X), but the degeneration 
stops here : the anterior horn ganglia 
remain normal, and hence the periph- 
eral nerve and muscle also. 
A myelitis transversa of the dorsal portion of the cord interrupts 
the pyramidal tracts to the legs: these become simply (spastically) 
Fig. 151. 
Schema of the innervation of the 
muscles (partly from Edinger). The 
radiation of the Py-tracts varies at 
different portions of the cortex (see p. 
454). EXAMINATION OF THE NERVOUS SYSTEM. 
493 
paralyzed; a myelitis transversa of the lumbar portion of the cord 
disturbs the anterior horn ganglia of the legs : these are affected with 
atrophic paralysis. 
(c) Primary myopathic atrophy. This is a disease of the muscle, 
the nervous system being intact. It manifests itself by the fact that, 
in this disease, the muscle gives less response, corresponding to a 
simple diminution in its volume: or, if it becomes completely shrunken, 
there is complete paralysis ; and further, by the fact that the electrical 
examination, as a rule, does not exhibit any trace of the reaction of 
degeneration. This kind of atrophic paralysis occurs in two quite 
dissimilar forms: 
(a) In muscular dystrophia (Erb), the myopathic form of progres- 
sive muscular atrophy (here often combined with hypertrophy or 
pseudo-hypertrophy) (see belowr). 
(b) In severe chronic diseases of the joints. 
The parallelism between atrophy and paralysis mentioned above is, 
moreover, generally present also in degenerative-atrophic paralyses, 
provided they develop gradually (subacute and chronic). A distinct 
disunion of atrophy and paralysis occurs only in acute degenerative- 
atrophic paralysis (poliomyelitis acuta, injury, etc., of the nerve, 
acute degenerative neuritis): here the paralysis develops more or less 
rapidly, but atrophy only becomes manifest in the course of weeks. 
Charcot has recently discovered, in certain hystero-traumatic 
paralyses, a functional paralysis wTith more marked atrophy, but 
without the reaction of degeneration. But the atrophy here is not 
so decided as degenerative atrophy, being rather between this and 
the atrophy of inactivity. 
In very exceptional cases, when there is disease of the cerebrum, 
particularly of its cortex, there has been found a considerable mus- 
cular atrophy, which appears early, sometimes even before the occur- 
rence of paralysis, without the reaction of degeneration. In indi- 
vidual cases of this character, contractures were completely wanting, 
and tendon-reflex was not increased. 
Genuine hypertrophy of muscles occurs in Thomsen’s disease 
[general myopathic spasm]; also sometimes in individual muscles, 
especially the gastrocnemius muscle, in dystrophia musculorum ; here, 
also, belongs the muscular hypertrophy which develops in the sound 
leg w'hen one is paralyzed (as in long-standing infantile paralysis). 494 
SPECIAL DIAGNOSIS. 
Genuine hypertrophy is recognized by the increased volume, great 
hardness, and especially by the increased vigor of the muscle. 
Pseudo-hypertrophy, on the other hand, shows increased volume, 
hut diminished power. This occurs in dystrophia musculorum much 
oftener than genuine hypertrophy, but it may be developed from the 
latter. 
Tonus of paralyzed muscles, active spasm, rigidity of muscles. 
An increased tonus of the muscles that are paralyzed (rigidity, active 
spasm) is a characteristic, though sometimes absent, sign of those 
paralyses which are of cerebral or spinal origin above the anterior 
horn. This tonus may be so slight that the examiner will only notice 
it as a slightly increased resistance during passive motion. But it 
may also be so strong that even when perfectly at rest a muscle is as 
hard as a board, and that motion of a joint, in which the muscle 
would be extended (that is in which the muscle would act as an 
antagonizer), is entirely impossible. Thus spasm of the quadriceps 
prevents bending of the knee, not only passive, but also active bend- 
ing, which, probably, if the flexing muscles were intact or were only 
paretic, would take place (spastic pseudo-paralysis). Patients also, 
even in slight degrees of rigidity, experience great difficulty in making 
active motions. That these spasms are not due to permanent ana- 
tomical changes in the muscles, only to muscular contraction, is 
proved by the fact that they are sometimes subject to striking change. 
If the paralyzed muscles are spastic to a high degree, often for a long 
time there does not develop any atrophy of inactivity. 
Paralyses due to affections of the cortex of the brain usually 
manifest themselves by very early spasms. In hysteria, also, very 
decidedly active spasms occur. (Regarding increased tendon reflex 
as an attendant phenomenon of spasms, see p. 497.) 
Atonic paralysis. This is characterized by diminution or loss of 
muscular tonus, in consequence of which there is abnormal passive 
mobility of the joints. This laxness is present in recent paralyses, in 
which the atrophic, acutely degenerative condition has not yet devel- 
oped (“atonic atrophic paralysis”). It is also found in cases of chronic 
and long-standing degenerative paralysis (see also under Contractures). 
Cerebral paralyses, as hemiplegia, in rare cases, may also manifest 
decided atony. There is a tolerably marked laxness of the muscle, 
without paralysis, in tabes. EXAMINATION OF THE NER VO US SYSTEM. 
495 
Contractures. In long-continued paralyses, both degenerative and 
simple, there develops in the paralyzed limbs a constant anatomical 
shortening of individual muscles, and, indeed, just the muscles that 
are chiefly spastic often shorten in spastic paralysis, but not always. 
On the other hand, in degenerative paralysis, it is more the antago- 
nizes of the paralyzed muscles, or those of the paralyzed muscles that 
are strongest. Thus, from the moment of paralysis, the prevailing 
position, the posture of the affected limb, gives the first indication of 
the development of contracture. These contractures do not change. 
The motions of the limb that oppose the contracture, and the stretch- 
ing of the affected muscles caused by this motion, are very painful. 
3. THE REFLEXES. 
1. Skin Reflex. 
By this we understand the quickly passing contractions of the 
muscles which are caused by an irritation applied to the skin. The 
stimulation of the skin usually recommended is tickling or stroking 
it with the blunt end of a pencil or the handle of the percussion 
hammer. It is well from the beginning to aim at a certain symmetry 
in the methods we employ; only in certain cases, especially if there 
is diminution of the reflex, we may endeavor to call it forth by prick- 
ing with a needle or touching it with a piece of ice. The skin 
reflexes about to be mentioned in detail are, even in health, very 
different in different individuals (the cremaster reflex relatively varies 
least); but upon the two halves of the body they are always alike. 
Therefore, where there are unilateral anomalies of it, the most cer- 
tain results of trial of the skin reflex are obtained by a comparison 
with the sound side. If we have like results upon both sides of the 
body, then it has only a doubtful diagnostic value. 
We are not to confound with skin reflexes those motions that are 
voluntarily made. With some practice they are readily distinguished. 
In the face and the upper extremities, the skin reflexes are of no 
importance; on the other hand, the three reflexes upon the legs and 
abdomen are of especial diagnostic significance: 
(a) The reflex of the sole of the foot. This is produced by irri- 
tating the skin of the sole of the foot, and in health consists either in 
a dorsal flexion of the toes or of the whole foot, or even in motion of 496 
SPECIAL DIAGNOSIS. 
the hip-joint and knee. Pathologically, the reflex may be absent 
(weakened on one side and increased upon the other). It may be 
increased with reference to the amount of the contraction, with refer- 
ence to its extent, as in simultaneous contraction of the other leg, 
motion of the pelvis or of the Avhole body, for instance, as shorter 
opisthotonus; or it may occur slowly, or only after repeated and con- 
tinued application, or summation of a strong irritation. It would be 
influenced in its form by the tonus of the muscles of the legs: in spasm 
of the extensor, for instance, often, instead of a single motion of flexion, 
there occurs repeated trembling. 
(b) The cremaster reflex in men consists of a prompt upward motion 
of the testicle from the contraction of the cremaster which follows irri- 
tation upon the inner surface of the thigh. It is not to be confounded 
with the indolent contraction of the tunica dartos of the scrotum, 
which follows somewhat later. Sometimes the cremaster reflex is 
extended to the muscles of the abdomen, causing the backward draw- 
ing-in of the abdomen. 
(c) Abdominal reflex. This is a contraction of the muscles of the 
abdomen [chiefly the rectus] from irritation of the skin of one side of 
the abdomen [stroking downward from the edge of the ribs], which 
is recognized by an unilateral or a bilateral drawing-in of the abdo- 
men ; when the irritation is weak, by a slight displacement of the 
navel toward the side irritated. 
The figure explains the mechanism of the skin reflex : the sensible 
irritation proceeding from the skin is conveyed by the motor fibres to 
the anterior horn; but the anterior horn itself is influenced by the 
reflex retarding fibres which pass in the pyramidal tract. It is clear 
that the skin reflex must be lost by an interruption of the reflex arc 
at any point, or by the unsusceptibility of the skin, or by myopathic 
paralysis; that it must be increased with any increased excitability 
of the anterior horn, or removal of the restraining reflex from the 
brain, also in hypersesthesia of the skin. Recently, an increase of the 
abdominal reflex upon one side has been observed in intercostal neu- 
ralgia (Seeligmiiller). 
We have not mentioned a number of other skin reflexes, since they 
are not important: for pupillary reflex, the reflex closure of the lids, 
see under Examination of the Eye. 
Of the reflexes of the mucous membrane, the choking reflex when 
the mucous membrane of the pharynx is tickled has diagnostic sig- EXAMINATION OF THE NERVOUS SYSTEM. 
497 
nificance: its absence is a frequent occurrence in hysteria (anaesthesia 
•of the mucous membrane), also in bulbar paralysis (nuclear paralysis). 
Of very much greater diagnostic importance are the 
These reflexes are likewise short contractions. They are produced 
by taps upon the tendons of muscles, upon the bones and fascia, also 
by sudden tension of a tendon by a quick passive movement (in which, 
however, the muscle itself is also stretched), Both the short move- 
ment of the limb and the momentary hardening of the muscle may 
be made an object of examination. In order to develop the tendon 
reflex it is necessary to have the limb perfectly relaxed, and it is well, 
to divert the attention of the patient. 
2. Tendon Reflexes (periosteal, fascial reflex). 
Fig. 152 
Diagram of the course of the cutaneous and tendon reflexes. H, skin; M, muscle; 
V, anterior horn: Hi, posterior horn; s, the tract of the tendon reflexes; h, the tract of 
the cutaneous reflexes. 
Whenever it is possible, a comparison is to be made between the 
right and left limbs, but even where this cannot be done, as when the 
disturbance is bilateral, or the two sides are disturbed in a similar 
way, the greatest importance can be attached to the result of the test, 
because here the individual variations are not prominent, as they are 498 
SPECIAL DIAGNOSIS. 
in the reflexes of the skin; hence the tendon reflexes are much more 
important aids in diagnosis than the skin reflexes. 
Tendon and skin reflexes may be confounded. In a doubtful case, 
this can be avoided by comparing irritation of the skin alone at the 
given points, by means of pinching, pricking a fold of skin, or by 
direct mechanical muscular irritation (see below, Biceps-tendon Re- 
flex); lastly, as in the skin reflexes, by having the patient take part 
in the examination by making voluntary contractions; these take 
place later, and, hence, can only deceive the inexperienced. We may 
be very easily misled into supposing that there is an absence of 
tendon reflex, if the muscles under examination are not perfectly 
relaxed. 
We enumerate the tendon reflexes according to their importance: 
(a) Patellar reflex (Erb; knee-phenomenon, Westphal), consists 
in a contraction of the quadriceps. It is caused by striking with a 
percussion hammer, with the tips of the semi-flexed fingers, or with 
the rim of the ear-plate of a stethoscope, upon the patellar tendon. 
Often we must carefully seek the most susceptible point. 
Sometimes we may first make the test with the leg covered; but if 
the result is in any way doubtful, then the knee must be uncovered. 
Whenever a very exact examination is to be made, the latter must 
always be done. In order to get the muscles completely relaxed, we 
must select certain positions: a favorable position is to have the limb 
extended at rest, with the feet resting upon the floor ; another position 
is with the leg crossed over the other in the sitting position ; a third 
is to have the patient sit upon a table with the legs hanging down; 
with the patient in bed, we pass the hand under [the thigh just above] 
the knee and gently lift it up. As a means of inducing patients to 
relax the limb, they are to be diverted by conversation, or they may 
be directed to close the fist as tightly as possible, or sometimes we 
may have them grasp the left hand of the examiner or press the hand 
of someone else. 
Hot only active contraction, but possibly also increased tonus of 
the quadriceps, disturbs the exhibition of the reflex. Even a patho- 
logically increased patellar reflex may thus be hindered by spasm, 
which must be carefully guarded against. Hence, as far as is pos- 
sible, we must prevent any active spasm by the position (particularly EXAMINATION OF THE NERVOUS SYSTEM. 
499 
by a cautious passive motion) of the knee-joint. It may also be inter- 
fered with by deformity and stiffness of the joint. 
With very rare exceptions, the patellar tendon reflex is always 
present in health, and both sides are equally strong. 
The author cannot forbear saying that he regards as impracticable 
the designation “ Westphal’s sign” for the absence of patellar reflex— 
notwithstanding his very high regard for the meritorious investigator, 
who is deserving of the honor—because this designation could easily 
be confounded with the opposite (as, that Westphal’s sign meant 
patellar reflex). 
(b) Tendo-Achillis reflex and foot-phenomenon. Striking upon 
the tendo Achillis, and often only on a very limited portion of it, in 
health, generally causes a reflex contraction of the gastrocnemius (and 
soleus) with slight plantar flexion of the foot. In doing it, it is best 
to lift up the foot by taking the malleoli with the left hand (the foot 
of course being bare). 
By foot-phenomenon we designate the contraction of the same 
muscles if there is a continuous contraction, a passive dorsal flexion 
of the foot, often best excited by a quick passive motion (stretching 
the tendons, also the muscles); a reaction then takes place in a 
series of rhythmical contractions of the plantar flexors, or a long 
series of contractions : foot clonus, foot-phenomena, dorsal clonus. 
This latter phenomenon is not really a pure tendon-reflex, rather in 
part it is dependent upon direct irritation of the muscles as a result 
of stretching. But it has exactly the same diagnostic significance as 
increased tendon-reflex, for it does not at all occur in health, or, at 
most, only temporarily, as when one is very tired. 
(<?) Tendon reflex of the upper extremities. Here they do not have 
the same diagnostic importance [as those under (a) and (J)], particularly 
because they are very often absent in health. Striking the flexor 
tendons at the wrist-joint, the biceps at the bend of the elbow, the 
triceps tendon close above the olecranon, generally causes a slight 
reflex contraction; in the two latter we must be careful not to strike 
the muscle itself. (See Mechanical Irritation.) 
(d) Periosteal and fascial reflexes are elicited by striking the latter 
and the bones—the tibia: patellar reflex; bones at the wrist-joint: 
biceps, even pectoral is reflex. We not infrequently observe them in 
health, but very particularly when there is increased tendon reflex. 500 
SPECIAL DIA GNOSIS. 
Not wholly unimportant, also, are the bone reflexes which are manifest 
in the muscles of the face from blows upon the knee—upon the nose; 
they are absent in bulbar paralysis, and are present in paralysis of 
the facial tract above the bulb. 
The mechanism of the tendon reflex is made clear by Fig. 152, p. 
497. We see that for its production it is necessary to preserve the 
integrity of the reflex arc : (a) tendons ; (b) sensitive (that is, centri- 
petal) nerve; (c) posterior root; (d) anterior horn ; (e) motor nerve; 
lastly, (/) muscle. But we take note of the influence upon these of 
restraining fibres in the pyramidal tract, which may be cut off, and 
also may possibly be temporarily irritated. Interruption of the 
pyramidal tract (which is manifest by its secondary degeneration as 
far as the anterior horn) or cutting off of the pyramidal tract by 
primary degeneration, causes increase, therefore, of tendon reflex, as 
in cerebral paralyses, spinal paralyses from disease of the pyramidal 
tract, in myelitis transversa, amyotrophic lateral sclerosis, spastic 
spinal paralysis ; but also increased irritability of the spinal cord itself, 
as in strychnia poisoning, tetanus, lyssa, neuroses, and particularly 
sometimes in hysteria. On the other hand, the tendon reflexes are 
diminished or are lost: in disease of the anterior horns, of the periph- 
eral nerves, of the posterior roots or their connection with the anterior 
horns (poliomyelitis, spinal progressive muscular atrophy ; any disease 
of the peripheral nerves; tabes dorsalis—here diagnostically very im- 
portant ; myelitis, tumors, hemorrhages, if in certain locations—that 
is, if they disturb the gray substance for the arm or leg). 
It follows from what precedes that the increase, and also in many 
respects the diminution, of the tendon reflexes, goes parallel with in- 
creased or diminished tonus of the muscles. And, in fact, tonus 
seems to be genetically related to tendon reflexes. In this sense it is 
also of interest that the predominant reflexes at the arm are the flexors, 
at the leg the extensor of the knee, the plantar flexor tendo-Achillis 
reflex for the foot, and that exactly corresponding with a recent spastic 
paralysis of the arm, we are apt to have flexor spasm of the arm and 
extensor spasm of the leg at the knee and ankle. 
Westphal’s view [p. 499] that the “tendon reflexes” are not 
reflexes, but that they are always, when elicited by the prescribed 
methods of testing, due to the direct irritation of the muscles by 
stretching and concussion, is to be regarded, especially as respects EXAMINATION OF THE NERVOUS SYSTEM. 
501 
patellar reflex, as definitely refuted. Nevertheless, we must still 
agree that the ordinary method of examination for the foot-phe- 
nomenon in this respect is not free from objection (as has been urged 
by others also, as Jendrassik): the brusque dorsal flexion of the foot 
must necessarily stretch the gastrocnemius—here it may be due to 
the effect of stretching of the muscle added to that of the tendon. 
Mixture of tendon reflex and direct muscular irritation from stretch- 
ing the muscle probably also occurs in executing “ brusque passive 
motion ” of the limb (very quickly bending it, and extending the knee- 
joint, etc.), which is very strongly to be recommended for determining 
a slight degree of increased tonus of the muscles. 
4. ELECTRICAL EXAMINATION OF THE NERVES AND MUSCLES.1 
Regarding the Physics, and the Instruments Employed. 
For the electrical examination we employ the secondary or induc- 
tion current of the faradic battery and the constant current of a gal- 
vanic battery. We graduate the strength of the faradic current by 
the extent to which we withdraw the outer coil from the inner, which 
is reckoned by centimetres and millimetres from the point where one 
coil is completely enclosed by the other, or the distance between the 
coils X cm.; the strength of the galvanic current is changed by im- 
mersing a different number of elements, sometimes more delicately by 
a rheostat. [The galvanic batteries now made in the United States 
and England usually have a rheostat as a part of the outfit. It is 
much better to use it, for two reasons: all the cells of the battery are 
drawn from alike, since all can be thrown into the current at the 
beginning of each sitting; the gradations in the strength of the 
current are made without shock to the patient.] 
The current is conveyed to the body by an electrode, previously 
moistened with warm [preferably salt] water. In making the 
examination, one of these is always the indifferent one—that is to 
say, it merely serves to close the current that is flowing through the 
body ; the other is the “ differentiating ” or examining one. The 
first must be as large as possible, in order to spread out the current 
1 Of course it is not necessary here to go into particulars. Hence we refer the reader 
to special works, particularly to Erb’s classical presentation in his Electro-Therapy. 502 
SPECIAL DIAGNOSIS. 
over as large a surface as possible at the point where there is much 
the greatest resistance, namely, at the skin. The resistance is 
inversely proportional to the cross-section. Usually, the indifferent 
electrode is placed upon the sternum. For examining nerves and 
small muscles, the examining electrode must be quite small, in order 
to convey the current as closely as possible to the structures, which 
all lie near the skin; we cannot examine those lying deeper. For 
this reason, in making the faradic examination, it is best to select 
the so-called “fine” electrode of Erb (see Fig. 153). But in em- 
ploying the galvanic current, such a small electrode would so concen- 
trate the current by its small cross-section that its passage through 
the skin would be too irritating, and hence we must select for this 
Fig. 153. 
“ Fine ” electrode of Erb (natural size). 
current one somewhat larger. The size of the electrode is, as already 
said, of important influence upon the intensity of the current in its 
transit through the skin and a short distance beyond it, hence, also, 
in that to the stimulating nerves. It is likewise not unimportant, 
for it is very desirable to know, at least approximately (why, see 
below), with how strong a current we touch the nerves beneath the 
skin. For this reason, and in order that the conditions under which 
the examinations, conducted by different persons, may be as nearly 
as possible alike, it is strongly recommended to employ a so-called 
“ normal electrode.” Unfortunately, we have several, of which we 
consider only the following: one devised by Erb, of 10 sq.cm, diameter 
(either square, 3.3 cm. on a side, or round wflth a diameter of 3.5 
cm.); and one by Stintzing, round and somewhat convex, 3 sq.cm, in 
cross-section and 2 cm. in diameter. With every record of an 
examination there should always be a statement of the size of the 
electrode employed. 
We have no absolute measure for the total strength of the faradic 
current in making examinations. Here we note the distance of the 
coils, but this, according to the construction and power of the EXAMINATION OF THE NERVOUS SYSTEM. 
503 
apparatus, may indicate different strengths of current; nevertheless, 
this has value for comparison where the examinations are made each 
time with the same apparatus (see below). For the galvanic current 
we have an absolute measure : the milliampere (M.-A.), = lQ00~ohms* 
(See text-books upon Physics.) To ascertain the number of milli- 
amperes used, w’e employ a so-called absolute galvanometer. The 
total strength of current as given by the galvanometer is then divided 
by the transverse section of the examining electrode in such a wTay 
that, for example, with a total strength of 2.5 M.-A. and an electrode of 
2.5 
12 sq.cm, transverse-section to a sq.cm , a current of py M.-A. is given 
off (N.B., to a sq.cm, of the skin); the density of the current in the 
nerves examined is not exactly proportional to that in the skin (see 
below). Hence, this fraction has no exact value as such—rather only 
as a brief expression of the two figures wdiich we have to consider. 
If we employ a normal electrode, then we can note: Norm, electrode 
2.5 
Erb (10 sq.cm.) 2.5 M.-A., or pp M.-A. (N. el. Erb). 
This comparison of the total strength of the current with the 
absolute measure is nowadays indispensable; it has, it is true, only a 
value which is, in a certain sense, circumscribed. A difficulty which 
at present is tolerably successfully overcome, consists in the fact that 
the conducting resistance of the skin, for various reasons, declines, 
and with it, although only in a slight degree, the strength of the 
current increases, while the electrodes rest upon the body, and 
hence, also, from the moment when the galvanometer is switched-in 
to the instant when the needle comes to rest. This space of time 
in the new galvanometers (especially Edelmann’s horizontal galvano- 
meter, but also with the instruments of Bottcher-Stohrer and Ilirsch- 
mann), by appropriate checks, is satisfactorily shortened. Stintzing 
is to be credited with very exact examinations regarding these 
points. 
A much more considerable difficulty, and one which probably will 
never be entirely overcome, consists in the fact that we cannot con- 
centrate our current upon the nerve (muscle) to be examined, because 
it lies in tissue which itself is a good conductor, and that from the 
total strength of the current and the cross-section of the conductor of 504 
SPECIAL DIAGNOSIS. 
the current into the skin we can only approximately determine the 
current which enters the nerve (muscle) itself. For this, there are two 
chief reasons: first, because the situation of the nerve with reference 
to the skin varies with each individual (layer of fat, anatomical 
peculiarities); and because, from the situation of the nerve, the frac- 
tion of the current which enters it is intrinsically changed. (Even 
the quality of the contractions caused by the current will be influenced 
by the relation of the nerve to the skin.—Erb.) Further, since the 
nerve offers a quite considerably stronger resistance to the current if 
it enters it at a [right] angle to its axis, than if it flows along its 
axis, the angle at which the current enters the nerve will consider- 
ably affect the strength of the current; and we cannot accurately 
measure this angle in the case of all nerves. 
There follows from the foregoing, first of all, the practical point 
that, in spite of our ability to measure the strength of the total 
current, we are taught to bear in mind the individual peculiarities of 
the nerves (muscles) to be examined, in their relation to the skin, in 
interpreting the results of the examination, so as to supply, as far as 
possible, the want of exactness in our calculation; and it follows, 
further, that it is superfluous, and even a source of error (because it 
withdraws our attention from the more important points of view), if 
we strive after exactness in electrical examination by the fineness of 
the apparatus, especially of the galvanometer—an exactness which, 
let it be said once for all, the examination cannot have. Of what use 
is it exactly to determine the strength of the total current to within 
one-tenth of a M.-A., when we do not exactly know how much of the 
total strength the real objects of our examination—the nerves— 
receive ? 
How to distinguish the poles quickly. In the faradic current the 
poles come but little into consideration, namely, only so far as to 
know that the cathode (negative pole) of the opening current of the 
secondary coil has a stronger irritating effect than the anode. In 
the galvanic current, the poles are widely different, and hence it is 
important to distinguish them quickly upon the apparatus. The 
simplest way is to employ a very mild current, and then to place the 
two electrodes upon the cheeks; upon the side of the anode we 
experience a peculiar indefinable taste upon the tongue and the 
mucous membrane of the cheek of that side; or we place the wires EXAMINATION OF THE NERVOUS SYSTEM. 
505 
of both poles about 1 cm. apart upon a piece of wet blue litmus 
paper : the anode colors it red. 
By a current-changer we are able to reverse the poles—that is, to 
quickly make the anode the cathode, and vice versa. 
Methods of Examination and their Physiological Results- 
upon the Living Human Body. 
As a foundation to what is here to be spoken of, we refer most 
urgently to the text-books upon physiology or upon electro-ther- 
apeutics, especially to what is taught regarding electrotonus and 
the laws of contraction (Pfliiger). Unfortunately, we cannot enter 
upon these subjects here; only remarking that the results of the ex- 
amination upon uninjured animals and men differ from the physio- 
logical results, and for physiological reasons, which cannot here be 
explained. [The student is referred to Landois and Stirling’s Phy- 
siology, section 336, for an excellent presentation of Electrotonus— 
law of contraction.] 
The electrical examination consists of an irritation of a nerve (indi- 
rect irritation) as well as of the muscle (direct irritation), one of 
which, indeed, takes place with both kinds of current, and in observing 
the effect of the irritation, as it is manifest by muscular contraction. 
Thus, we have to make use of an indirect faradic and galvanic and a 
direct faradic and galvanic examination. As previously stated, the 
extent of the irritation is always a matter of to us (dis- 
tance of the coils; total strength of the galvanic current in M.-A.). 
We draw our conclusions from the results of the examination : 
(a) From the degree of excitability of the nerve (muscle), by deter- 
mining with what strength of current there follows the first, small- 
est, just noticeable, or minimal contraction; or also by determining 
the extent of irritation which is necessary with the galvanic examina- 
tion to cause a tetanic contraction. The minimal contraction is 
observed at the muscle, or by the movement of the joint. The com- 
prehension of these minimal contractions (still more of galvanic teta- 
nus—see below) by the individual examiner is, to a certain extent, 
variable, and a source of inexactness. 
(b) With reference to the quality of the reaction in the direct irri- 506 
SPECIAL DIAGNOSIS. 
tation of the muscle with the galvanic current, that is, the character 
of its contractions and its “law of contraction” (see below). 
Since the electrical currents only stimulate by sudden oscillations 
in the current (except it be very strong), the faradic current, because 
it consists of a great number of opposing currents of short duration, 
causes a tetanic contraction proceeding from the nerve as well as 
from the muscle itself, which continues while the electrode remains 
with the current closed ; the galvanic current, on the other hand, 
indirect as well as direct, produces its effect only at the instant of its 
entrance: contraction from closing the current, and at the instant of 
its exit: contraction from opening the current. But while with the 
nerve exposed (Pfliiger) at the cathode [represented hereafter by Ca] 
(negative pole), only the closing of the current, and at the anode 
[represented hereafter by An], only the opening of the current occa- 
sions a contraction, we find that with the nerves and muscles of the 
living man there is another law of contraction (explained in works 
upon electro-therapy). 
G-eneral Methods, and Explanation of the Terms Employed in 
Galvanic Examinations. 
The indifferent electrode stands upon the sternum, the examining 
electrode (normal electrode) upon the nerve (muscle). With the 
current-changer we close the current so that the examining electrode 
is the cathode—that is, we make the “ cathodal closure ” CaS [S = 
Schliesung, closure] ; there results a contraction, C, thus it is CaSC ; 
then we open the current, thus making a cathodal opening, CaO: 
sometimes there is CaOC; then we reverse and close the current, 
so that the examining electrode becomes the anode, An, making 
AnS: we sometimes have AnSC, then likewise at the end AnOC. 
With a vfery strong current we have upon CaS, and with the current 
remaining closed, a tetanic contraction: CaSTe. 
Laws of normal contraction with galvanic stimulation: 
1. Nerve: 
(a) Weak current: feeble CaSC, 
CaO : negative, 
AnS : 
AnO: “ EXAMINATION OF THE NER VO US SYSTEM. 
507 
(b) Stronger current: strong CaSC, 
CaO : negative, 
AnSC, 
AnOC. 
(c) Very strong current: CaSTe, 
feeble CaOC (not always), 
strong AnSC, 
strong AnOC. 
That is, with a weak current there is only CaSC, with a strong one 
also AnSC, and about at the same time AnOC, with very strong, 
CaSTe, and sometimes CaOC. 
The contractions are, all of them, short, lightning-like. 
2. Muscle, irritated at a place where there is no nerve, or, at least, 
irritated as little as possible (at a distance from the “ motor point,” 
the place where the nerve enters, see below): 
Moderate current: CaSC, 
Only a little stronger : AnSC. 
The contractions of opening the current are subordinate, often entirely 
wanting. The contractions mentioned as occurring at the closure are, 
indeed, short, but yet not so lightning-like as those from an exposed 
nerve. 
Method of Examination in Detail. Normal Condition. 
Preliminary remarks. In examining individual nerves and muscles 
we must strive most earnestly to employ exactly similar methods. In 
the first place, in examining nerves, we should use Erb’s fine electrode 
for the faradic current, and either Erb’s or Stintzing’s normal elec- 
trode for the galvanic current. With the galvanic current, especially, 
we should always make about the same pressure upon the electrode, 
increasing the pressure only when there is a very firm layer of fat (in 
order, in this way, to equalize, to some extent, the effect of the fat 
layer). We are always to examine homonymous parts together, that 
is the right, then the left radial, the right, then the left median, or, 
when the disease is unilateral, the nerve (muscle) of the sound side 
always first. 508 
SPECIAL DIAGNOSIS. 
1. Points of Stimulation, 
In what follows we give the points of stimulation of the nerves 
and the so-called motor points of the muscles (studied by Duchenne, 
Ziemssen, Erb—the illustrations from Erb’s Electro-Therapeutics), 
which chiefly correspond to the points where the nerves enter the 
muscles, and hence are essentially also the nerve-points. In exam- 
ining the muscles themselves we place the electrode upon the fleshy 
part of the muscle, avoiding, as far as possible, both of these related 
noints. 
Fig. 154. 
Region of central 
convolution. 
Upper branch of 
facial. 
M. frontalis. 
M. corrug. supercil. 
Region of the third', 
frontal convolution. 
M. orbic. palpebr. 
M. temporalis. 
Muscles of the 1 
nose. 
Upper branch of 
facial in front of ear. 
N. facialis (Stamm). 
M. orbicul. oris. -J 
M. zygomatici. 
N. auricul. post. 
Middle branch of 
i 
Middle branch of 
facial. 
M. masseter. 
Lower hr. of facial. 
M. splenius. 
M. levator menti. - 
M. quadr. menti. 
M. triang. menti. " 
M. sterno-cleido- 
mastoideus. 
Lower branch of 
facial. 
N. hypogloss. 
N. accessorius. 
M. levator anguli 
scapul. 
M. piatysma myoid. 
Muscles of the root ( 
of tongue. ) 
M. cucullaris. 
N. dors, scapulae. 
M. omohyoideus. 
N. axillaris. 
N. thoracic, 
anter. (M. pector.) 
N. thoracic, long. 
(M. serratus antic, 
maj.) 
N. phrenicus. 
Supraclavicular 
point. (Erb’s point. 
M. deltoid., biceps, 
brachial, intern, and 
supinat. long.) 
Plexus 
brachialis. 
Points of Electrical Irritation upon the Head and Heck. (Erb.) 
The points most distinct in the figure correspond to the chief places 
for applying the stimulation. In the faradic examination, we seek EXAMINATION OF THE NERVOUS SYSTEM. 
509 
-carefully in the course of the nerve for these most excitable points 
{that is, of course, for those places where they lie nearest the skin). 
Remarks regarding Fig. 154 : We observe particularly the upper, 
Fig. 155. 
M. deltoids os 
M. triceps (caput longum) 
Nero, musculo• 
cufaneus 
M. triceps (caput intern.) 
M. biceps 
bracbii 
Nero. ulnaris 
_ M. bracb. 
internus 
M. supinator longus 
Nero. medianus 
M. flexor carpi ulnaris 
M. flex, digitor. commun., 
profund. 
M. pronator teres 
- M. flex, carpi radialis 
M. flex, digitor. snblim 
(digiti II et III) 
M. flex, digitor. sublim. 
M. flex, digit, subl. (digit, 
indicia et minimi) 
M. flex, pollicis longus 
Nero. ulnaris 
Nero, medianus 
M. palmaris brev, 
M. abductor pollic. brer. 
M. abductor digiti min. 
M. flexor digit, min 
M. opponens pollicis 
.M. opponens digit, min. 
M.-flex. poll. brev. 
Mi. lumbricales 
M. adductor pollic. brev. 
Points of Electrical Irritation upon the Arm. (Erb.) 510 
SPECIAL DIAGNOSIS. 
middle, and lower facial (the three most distinct points upon the face). 
At the brachial plexus we notice Erb’s point [the supra-clavicular 
point]. 
Fin. 156. 
SI. deltoideus 
— 51. 'triceps (caput longum) 
} SI. triceps (caputextern.) 
y. raJialis 
SI. brachial, intern. 
SI. radial, ext. long. 
SI. supinator long. 
SI. radial, ext. brer. 
M. extensor digit, communis 
- SI. ulnar, extern. 
SI. supinat. bier. 
SI. extensor indicis - 
- SI, extens. digiti minim. 
SI. abductor pollic. long. 
SI. extensor pollic. brer. 
SI. extens. indicis 
} SI. extens. poll, lpng. 
M. inteross. dorsal. I et II { 
"■ SI. abduct, digit, min. 
)SI. inteross. dorsal. 
Ill et IV. 
Points of Electrical Irritation upon the Arm. (Erb.) 
2. Examination. 
The tongue and soft palate will be best directly irritated with an 
electrode that is isolated as far as to the end (which may be done by EXAMINATION OF THE NERVOUS SYSTEM. 
511 
simply winding it with adhesive plaster). A strong galvanic current 
should never he used upon the head. 
Remarks regarding Figs. 155 and 156 : We examine the arm in 
the position of moderate flexion and slight pronation, but the muscles 
are to he relaxed (hence, the arm must rest upon something). 
The radial nerve lies deep, especially if the muscles are well 
developed. We can generally follow with the finger the ulnar nerve 
upward from the sulcus of the internal condyle of the humerus. 
Remarks upon Figs. 157, 158, 159 (pp. 511-514): It is very 
difficult to stimulate the ischiatic nerve. It can only be done by 
Fig. 157. 
N. cruralis 
> M. tensor fasciae latae 
W. obturator 
M. pectineus 
M. sartorius 
M. adductor znagnus 
M. adduct. Iongus 
U. quadriceps femoris 
M. rectus femoris 
M. cruralis 
vastus externus 
M. vastus internus J 
Points of Electrical Irritation upon the Upper Part of the Thigh. (Erb.) 
pressing the electrode in deeply and employing a strong current. 
We can easily find the peroneus nerve, if we feel for the head of the 
fibula and go inward and upward from this. 
Upon the back, since the nerves almost nowhere lie sufficiently 512 
SPECIAL DIAGNOSIS. 
near the surface to permit of the indirect examination, we have to do 
almost exclusively with direct muscular irritation. It is superfluous 
to make more exact statements regarding the simple topographical 
relations. 
We demonstrate this upon a single nerve-muscle, and for this we 
take the radial. We always begin with the faradic current, and 
this for good reasons, which have recently been made more strong 
(relations of the “resistance to conduction ”—Stintzing), which we 
cannot enter upon here. 
(a) Faradic Examination. 
(«) Nerve. The indifferent electrode is placed upon the sternum, 
the examining electrode (the fine one of Erb), held as a pen in writing, 
is placed upon the radial nerve [musculo-spiral], where it turns around 
the humerus at the middle of the arm : here tolerably deep pressure 
is necessary. The induction-coil is to be pulled out till the minimal 
•contraction is produced, and the distance to which it is removed is 
read off and noted. Thus will we feel for the nerve with the elec- 
trode: the minimal contraction takes place at the instant we pass 
over the nerve. Next, there is to be determined the “ conductive 
resistance” at that particular spot: we employ the galvanic current; 
we apply a well-moistened normal electrode; a definite number of 
•elements of the battery is inserted; we read off and note down the 
figures of the galvanometer in M.-A. The galvanometer is to be 
read when the electrode has been upon the nerve for just thirty 
seconds. 
It is necessary, in our opinion, to determine the “conductive re- 
sistance” exactly in the manner described by Erb. The fluctuations 
in the conductive resistance, and with it (in an opposite sense) the 
strength of the total current, are in fact, during the examination, very 
slight, and can ordinarily, as has been shown most accurately by 
Stintzing, be neglected. But, in some cases, it happens that at the 
point of examination the skin is very tender, or abnormally dense; in 
which case, of course, with the same separation of the coils of the 
same apparatus, we have relatively a stronger or relatively a weaker 
current; and we obtain a minimal contraction with a large, or with 
only a very slight, conductive resistance. This result we would EXAMINATION OF THE NERVOUS SYSTEM. 
513 
refer to an increased or diminished irritability of the nerve if we 
had not ascertained by the galvanic determination of the u con- 
ductive resistance ” that the skin was the cause of the variation. 
Extremely instructive examples illustrating this point are given by 
Erb in his Electro- Therapeutics. 
Fig. 158. 
M. glutaeus maximus 
Nero, ischiadicus 
H. adductor inagiius 
M. semitondinosus 
M. semimembranosus 
M. biceps fem. (cap. long.) 
M. biceps fem. (cap. brev.) 
N. peroneus 
tibialis 
M. gastrocnem. (cap. extern.} 
M. gastrocnam, (cap. int.) 
M. solaus 
M. soleus 
M. flexor digitor. comm, longus 
M. flexor hallucis longus 
N. tibialis 
Points of Electrical Irritation upon the Back of the Lower Extremity. (Erb.) 
In other words : whenever Ave are making an electrical examina- 
tion, we must know what strength of total current we are employing. 
Since we are not able to determine this directly with reference to the 514 
SPECIAL DIAGNOSIS. 
faradic current, we must endeavor to form an opinion of the total 
strength of the faradic current (with a certain definite separation of 
the coils) by bearing in mind the total strength of the galvanic current 
which is caused by a certain number of elements (always the same). 
Fig. 159. 
Jfert. peroneus 
M. gastrocnem. extern. 
M. peroneus longus 
M. extens. digit, comi 
long. 
M. tibial. antic. 
| M. solens 
[M. peroneus brevis 
M. extensor hallneis 
long. 
M. flexor, ballacis long. 
lli. interossei dorsalas 
M. extens. digit, comm, 
brevia 
M. abductQr digit! min. 
Points of Electrical Irritation upon the Leg. (Erb.) 
If we examine at the same time a number of nerves, we first de- 
termine the minimal contraction for all, and then the conductive 
resistance; and, after we have examined the nerves, we can at once 
make the faradic examination of the muscles. 
It is always well to follow the faradic examination with the galvanic, 
and in this way, with a good deal of practice, we can form an opinion 
regarding the relation of the conductive resistance at the different 
points of stimulation of the nerves, and can make a counter judgment 
regarding the faradic result by a comparison of the number of ele- EXAMINATION OF THE NERVOUS SYSTEM. 
515 
ments used each time, and the absolute strength of current that is 
obtained. But, then, there must always be given in the record of the 
galvanic examination both the number of elements and the strength 
of the current in M.-A. 
We wish that the direction given above, that the galvanometer 
should be read when the electrodes have been in place just thirty 
seconds, could be carried out in all efforts at electro-diagnosis, because 
otherwise the marked increase of the current at the beginning, just 
after the electrodes have been applied, could easily occasion great 
inequalities. 
(/S) Muscles supplied hy the radial [ nerve. We 
use a somewhat larger electrode, stimulate the fleshy part of the 
individual muscles, and, lastly, determine the minimal contraction; 
the determination of the conductive resistance is not necessary. 
Under some circumstances, there comes into consideration the 
quality of the muscular contraction in indirect and direct faradic 
stimulation. (See under Reaction of Degeneration.) 
(b) Galvanic Examination. 
(a) Nerve. Place the indifferent electrode upon the sternum and 
the examining electrode (with somewhat strong pressure) upon the 
radial [musculo-spiral] nerve where it passes around the humerus; 
close the cathode three times; if the result is negative, increase the 
number of elements; again close the cathode three times, and so on 
until the minimal contraction is found. Then switch-in the galvanom- 
eter and read off the strength of the total current. (Galvanometers 
that have a very good arrangement for damping the vibration of 
the needle can remain switched-in during the examination.) Now 
determine the minimal AnSC in the same way (but it may be 
omitted). Usually we may be satisfied with this. The next point of 
interest would be the determination of CaSTe. (Regarding varia- 
tions in the quality of the reaction, see under Reaction of Degenera- 
tion.) 
(/?) Muscles of the radial. We proceed as in the case of the nerves, 
but sometimes we may place the indifferent electrode upon the wrist, 
dorsal side, etc. It is always necessary to determine the minimal 
CaSC and minimal AnSC ; but before all, the most exact observance 516 
SPECIAL DIAGNOSIS. 
of the character of the contraction (see under Reaction of Degenera- 
tion), whether it is “ lightning-like” or “slow,” and in this direction 
we not only observe the minimal contraction, but also whether it is a 
stronger, or a strong, contraction. 
Summarized, the scheme of examination would be as follows: 
(a) Faradic examination: 
(«) nerve 
(/3) muscle 
(b) Galvanic examination : 
(«) nerve 
(/?) muscle. 
3. What to Observe in Determining the Electrical Reaction. 
We examine in two main directions: (a) the quantitative excita- 
bility, or degree of excitability of the nerves and muscles; (b) the 
qualitative excitability of the muscles under galvanic stimulation. 
(a) Quantitative excitability. Its diminution in the most marked 
degree, namely, loss of excitability, is easily recognized. To the 
record is always to be added: “ lost when the coils of the induction 
apparatus were separated to a distance x, or for a current of 
x M.-A.” On the other hand, it is difficult to define the limits be- 
tween the normal and pathological in simple diminished or increased 
excitability, particularly of the nerves. We can take different ways 
to arrive at a conclusion in this regard : 
(a) We compare the two halves of the body—very much the most 
certain way, but of course only applicable in cases of unilateral disease. 
Normally, the difference between the two halves of the body is very 
slight. The maximal differences for the nerves and with the galvanic 
current, according to Stintzing (58 healthy persons; Stintzing’s normal 
electrode of 3 sq.cm.), are : 
Ram. frontal. N. VII 0.7 M.-A. 
K. accessorius 0.15 “ 
N. medius 0.6 “ 
N. ulnaris 2" above the olecranon 0.6 “ 
N. radialis 1.1 M.-A. 
N. peroneus „ 0.5 “ 
N. tibialis l.l “ 
For faradic excitability the difference for the two sides of the body, 
at least for the four pairs of nerves that come especially into consider- 
ation, rami frontal, (facial.), N. accessorius, ulnaris, peroneus (see 
below) is, according to Erb, scarcely ever greater than 10 mm. separa- 
tion of the coils of his Dubois induction apparatus; according to EXAMINATION OF THE NER VO US SFSTEM. 
517 
Stintzing the maximal difference of all the pairs of the body that are 
accessible for examination is 15 mm. 
A difference which approaches this maximal difference must lead 
one to think of a pathological condition ; a difference that is materially 
greater is certainly pathological. But whenever a difference is found, 
we must always consider whether the two homonymous nerves are 
situated exactly alike (malformation of the bones, etc., see above). 
(/?) We are to observe the relation which exists between the irri- 
tability of the N. frontalis (facialis), accessorius, ulnaris (at the 
elbow), peroneus : according to Erb’s method. 
These nerves, but especially the ulnaris and peroneus, show only 
slight differences in health, as the following table, taken from Erb’s 
Handbook, shows: 
Faradic Current. 
1. Healthy person, mechanic, age thirty-eight years. 
Distance of coils in mm., 
minimal contractions. 
Variation of galvanom. (old one), 
10 elements. 
N. frontalis .... 
r. 165 
1. 166 
r. 18° 
1. 19° 
N. accessorius . . . 
172 
177 
16° 
15° 
N. ulnaris 
159 
158 
6° 
6° 
N. peroneus .... 
160 
163 
7° 
9° 
2. Healthy person, laborer, age twenty-four years. 
Distance of coils in mm., 
minimal contraction. 
Variations of galvanometer 
(old one), 10 elements. 
N. frontalis .... 
r. 195 
1. 192 
r. 17° 
1.17° 
N. accessorius . . . 
187 
182 
10° 
9° 
N. ulnaris 
135 
185 
6° 
10° 
N. peroneus .... 
180 
180 
5° 
5° 
G-alvanic Current. 
Healthy men, thirty-eight to twenty-four years of age. (Normal 
electrode, 10 sq.cm.) 
Occurrence of the first 
C&SE. 
Occurrence of the first 
CaSTe. 
N. frontalis .... 
r. 1.4 M.-A. 
1. 1.2 M.-A. 
r. 8.0 M.-A. 
1. 8.0 M.-A. 
N. accessorius . . . 
0.5 “ 
0.5 “ 
4.0 - 
4.0 “ 
N. ulnaris 
0.4 “ 
0.4 “ 
6.0 “ 
5.5 “ 
N. peroneus .... 
1.5 “ 
1.5 “ 
7.0 “ 
7.0 “ 518 
SPECIAL DIAGNOSIS. 
By studying these tables we ascertain from them the relation be- 
tween these four pairs of nerves as to the extent of their irritability, 
and it is possible to recognize with greater certainty a bilateral varia- 
tion, especially of the ulnar or peronous nerves. 
(y) Lastly, Stintzing has given us in a very exact way the “ limits 
of value ” for the irritability of nerves ascertained in the case of fifty- 
eight healthy persons (Edelmann’s galvanometer, normal electrode 3 
sq.cm.). But these figures are only of value for Stintzing’s normal 
electrode: 
R. front. 17. fac 0.9—2.0 M.-A. 
R. zygomat. N. fac. . . . 0.8—2.0 “ 
R. ment. N. fac 0.5—1.4 “ 
N. accessorius .... 0.1—0.44 “ 
N. medianus 0.3—1.5 “ 
N. ulnaris 0.2—0.9 M.-A. 
2" above the olecr. 
N. radialis 0.9—2.7 “ 
N. peroneus 0.2—2.0 “ 
N. tibialis 0.4—2.5 “ 
In individual cases, however, Stintzing has found still smaller or 
larger figures. These extreme values are exceptions, possibly, of a 
pathological nature. 
Except in the reaction of degeneration, the quantitative irri- 
tability of the muscles very often goes quite parallel with that of 
the nerves. We can endeavor to determine this by estimating it. 
For its relation to the reaction of degeneration, see under the latter 
heading. 
(b) Qualitative irritability of muscles from galvanic stimulation. 
Although, with respect to the nerves in general, we are only interested 
in the strength of current required to produce the first occurrence of 
CaSC and CaSTe, since the law of contraction of the nerves is that 
normally the character is almost always lightning-like, in the direct 
galvanic stimulation of the muscles, two important variations come 
into consideration : the character of the contraction (whether lightning- 
like or slow, vermiform, wave-like), and further, the law of contraction, 
and particularly the relation between CaSC and AnSC. But the 
first point of view is much the more important. 
There are two classes of pathological galvanic muscular reactions: 
1, the reaction of degeneration (EaR), the exclusive attribute of de- 
generative-atrophic paralysis; 2, the myotonic reaction, which occurs 
solely in Thomsen’s disease. EXAMINATION OF THE NERVOUS SYSTEM. 
519 
1. The Reaction of Degeneration (EaR). 
(a) Complete EaR. 
The electrical examination gives the following results: 
Faradic : 
nerves : I = 0, that is, irritability (I) lost, 
muscles : I = 0, that is, irritability lost. 
Galvanic: 
nerves : I = 0, that is, lost, 
muscles: slow, tonic, vermiform contractions : 
the quantitative irritability, about normal, or increased or diminished; 
AnSC occurs with a less strong current than the CaSC, and with a 
less strength of current from which both take place, AnSC is greater 
than CaSC : AnSC > CaSC. 
(b) Partial EaR. 
Faradic: 
nerves : diminution of I, 
muscles : diminution of I; 
Galvanic: 
nerves : diminution of I, 
muscles: EaR as above. 
For more ready comprehension we add here two curves from Kast, 
which graphically exhibit the normal muscular reaction and the EaR. 
Fig. 160. 
Diagrammatic representation of the normal galvanic muscular reaction. Healthy 
young girl. Stimulation of the muscles in the region of theperoneus. 33 cells. Ka= 
CaSC; An = AnSC. (After Kast.) 520 
SPECIAL DIAGNOSIS. 
Fig. 161. 
Diagrammatic representation of the reaction of degeneration (EaR). (After Kast ) 
Case of poliomyelitis anter. chronic. Same muscles as above. 40 cells. Contractions 
tardy, AnSC > KaSC. 
Course of EaR. EaR is the pathognomonic sign of those changes 
which take place in muscle, or motor nerves and muscle, when 
they cease to stand under the peculiar trophic influence of their 
anterior horn ganglia—those alterations we designate as degenera- 
tion of the nerves and muscles. This degeneration can he most beau- 
tifully studied by the electrical phenomena if a nerve trunk is, at 
some place, suddenly interrupted throughout its whole transverse 
section. Whenever there is such an interruption there is manifest a 
complete separation of the portion of the nerve of the muscles located 
peripherally from the anterior horn, which must inevitably lead, not 
only to paralysis, hut also degeneration of the portions cut off, and 
with it EaR. But now the case can either proceed so far that there 
is a permanent interruption at the injured spot, which results in com- 
plete atrophy of the nerves and muscular fibres, or, after a time, the 
conduction at this place may be restored; and in the latter case there 
is a return of the tissues of the nerves and muscles to the normal con- 
dition—that is, there is regeneration of them. Now, according as the 
degeneration of the nerve (muscle) results in atrophy («. e., transfor- 
mation into connective tissue), or again regenerates and returns to 
its normal condition, the EaR shows a definite result as such, and 
also in its temporary behavior with reference to the ability to use the 
muscles. This result of EaR may, of course, he made use of in 
drawing a conclusion as to the condition of the nerves and muscles. 
Erb has investigated these facts in regard to rheumatic facial paral- 
ysis, and by experimental examinations, in a classical manner. He 
has given representations for the course of rheumatic facial paralysis, 
which we here insert. 
Fig. 162 gives a representation of complete EaR with reference to 
motility, and faradic and galvanic irritability of the nerves and muscles; EXAMINATION OF THE NERVOUS SYSTEM. 
521 
and over it are given the designations of the simultaneous histological 
changes. The line of galvanic muscular irritability is wavy so long as 
the qualitative changes (slowness of contraction and preponderance of 
AnSC) continued. 
1. Paralysis with relative early return of motility. The first trace 
of motility appears at a time when there is still complete EaR. One 
week later the faradic and galvanic irritability of the nerves reappears ; 
Fig. 162. 
Degeneration 
of nerves. 
Atrophy, etc. 
of muscular fibres. 
Regeneration. 
Cirrhosis 
Weeks. 
Motility 
Muscle 
Galv. 
Nerve 
Far. 
Galv. 
& Far. 
Irrit. 
Complete EaR with reference to motion. Faradic and galvanic stimulation of the 
nerves and muscles. Paralysis with early return of motility. (Erb.) 
hence there now is partial EaR; three weeks later, the slowness of 
the contractions begins to disappear. Diminished irritability of the 
nerves and motility continues a still longer time. 
2. Paralysis with later return of motility. Temporarily the 
condition is like that in Eig. 162. Here, also, there is for some 
Degeneration of 
nerves. 
Atrophy, etc., 
of muscles. 
Fig. 163. 
Cirrhosis. 
Regeneration. 
Weeks. 
Motility 
Muscle 
Galv. 
Far. 
Nerve 
Galv. 
& Far. 
Irrit. 
Paralysis with later return of motility. (Erb.) 522 
SPECIAL DIAGNOSIS. 
time a partial EaR. All the evidences of regeneration return again 
later. 
3. Permanent paralysis. Motility, irritability of the nerves, and 
faradic muscular irritability do not return. The galvanic muscular 
Fig. 164. 
Degeneration 
of nerves. 
Atrophy; nuclear proliferation ; cirrhosis 
Total atrophy. 
Weeks. 
Motility 
Muscle 
Galv. 
Far. 
Nerve 
Galv. 
& Far. 
Irrit. 
Irremediable paralysis. (Erb.) 
irritability in the course of some months becomes nil; the contractions, 
so long as they are still possible, are slow. 
Fig. 165. 
Nerve? 
Degenerative atrophy 
of muscular fibres, s- 
Regeneration. 
Weeks. 
Motility. 
Muscle 
Galv. 
Nerve 
Far. 
f Galv. 
<fc Far. 
(_ Irrit. 
Paralysis in which there is only partial EaR. (Erb.) 
4. Paralysis in which there is only partial EaR. The faradic 
and galvanic irritability of the nerves and faradic irritability di- 
minishes only to a slight degree. Motility returns again quite early. EXAMINATION OF THE NERVOUS SYSTEM. 
523 
Varieties of EaR. 
(a) Partial EaR is necessarily accompanied with slowness of con- 
tractions (which are also indirect—Erb). Not only the contractions 
which occur with direct galvanic irritation of the muscles, but all 
contractions, including those, also, which occur with galvanic and 
faradic stimulation of the nerves and faradic stimulation of the mus- 
cles, are slow in their character. [“ The faradic excitability of the 
paralyzed muscle undergoes a diminution corresponding to that of 
the nerve, but the galvanic excitability of the muscles manifests the 
quantitative and qualitative changes which are characteristic of the 
severer forms of the reaction of degeneration.”] 
(b) The AnSC of the nerves is slow, the CaSC is not (Lowenfeld), 
or, the muscle has a slow faradic reaction, while the nerve does not 
respond at all (Stintzing); or, the muscle has a slow, the nerve a 
prompt faradic reaction, etc. 
Stintzing, with the greatest pains, has recently undertaken to bring 
order out of this confusion with remarkable, although with few, results. 
Probably it is well to allow the material to still further accumulate 
before we undertake to interpret it, diagnostically or pathologically. 
(c) Mixed Electrical Reaction. We thus designate those electrical 
reactions which occur when a muscle is partly degenerated and partly 
normal, and a corresponding portion of the nerves is also sound 
and another portion degenerated. Then we find a diminution, but 
never a loss, of faradic and galvanic excitability of the nerves and 
of faradic excitability of the muscles. But the direct galvanic 
muscular reaction causes the greatest difficulties : the contractions 
are not exactly short, not altogether slow, AnSC=CaSC, here and 
there also shorter: it is hard to discover its significance. All of this 
is not easy to understand, because normal contractions are mixed 
with EaR; especially difficult is it, if, as is almost always the case, the 
excitability is lowered. The object is sometimes attained by making 
repeated, indeed, daily tests (when it seems that EaR often becomes 
more distinct), by thorough examination of every part of the mus- 
cular system with weak as well as with moderately strong currents, 
frequently changing the location of the indifferent electrode (which 
must always be done in such a way as to avoid exciting the nerves). A 524 
SPECIAL DIAGNOSIS. 
single clearer manifestation of EaR in one muscle, or in a bundle of 
muscular fibres, will usually serve as an indication of the whole disease 
as degenerative atrophic paralysis. It is true that EaR has twice 
been found in myopathic muscular atrophy in single muscles (Schulte 
and Zimmerlin). We (with Erb) do not share the opinion of Wernicke 
that this mixture is the single cause of every case of partial EaR. 
2. Myotonic Reaction (Erb). 
Myotonia congenita occurs in the very powerful (hypertrophic) 
muscles which always exist with this disease: they show increased 
irritability and continuance of the contraction with the faradic cur- 
rent ; with the galvanic test, likewise, there is increased irritability, 
but only contractions as the current is closed, and then extremely slow 
and continuing contractions with peculiar formation of furrows and 
depressions. Stable acting currents (the stimulating electrode placed 
not upon the muscle, but on the vasti, for instance, near the patella) 
produce rhythmical, wave-like contractions from the cathode toward 
the anode. 
The relation of EaR to the so-called mechanical EaR is not unim- 
portant. (See, regarding this, on p. 526.) 
3. Diagnostic Value of the Electrical Condition. 
The reaction of degeneration (EaR) occurs: 1. In all paralyses 
produced by disease of the ganglion cells of the gray anterior columns 
of the spinal cord, or of the motor nerves of the bulb. 2. In all 
paralyses produced by disease of the anterior roots and of the periph- 
eral nerves, where the trophic influence of the anterior horn ganglia 
fails on account of the interruption of the conduction, peripherally, 
in the nerve and muscle. 
The reaction of degeneration (EaR), therefore, is closely connected 
with degenerative atrophy of the muscles. Thus, it occurs : in polio- 
myelitis acuta, chronica, spinal progressive muscular atrophy, amyo- 
trophic lateral sclerosis, lesions of a section of the gray anterior horns 
from hemorrhage, tumors, etc.; bulbar paralysis; in traumatic lesion 
of the peripheral nerves; in neuritis of all kinds; in “rheumatic” 
paralyses ; in primary multiple neuritis ; in toxic paralyses, and those 
that occur after infectious diseases. EXAMINATION OF THE NERVOUS SYSTEM. 
525 
The presence of EaR points directly in opposition to: cerebral 
paralysis, paralysis from lesion of the pyramidal tract in the spinal 
cord; further, against myopathic paralysis; lastly, against functional 
or hysterical paralysis. 
Of course, the EaR is to be regarded as contra-indicating the 
diseases last named, only with the reservation that there is no com- 
plication with the conditions first named. Of this character we, with 
others, consider also the condition of EaR found by Schulte and 
Zimmerlin with myopathic progressive muscular atrophy [see previous 
page]. 
In harmony with the above principles, partial EaR has exactly the 
same significance as complete. It occurs : 1. In slight affections (as 
slight forms of rheumatic facial paralysis, slight paralysis of the arm 
from pressure). 2. In atrophic paralysis, which only affects a portion 
of the bundles of the muscular fibres, it is disseminated (especially 
frequent in spinal progressive muscular atrophy, amyotrophic lateral 
sclerosis, multiple neuritis), and, hence, as a mixed reaction. (See 
above, p. 523.) 
When EaR is absent, sometimes it does not strictly show that there 
is no affection of the anterior horns or of the peripheral nerves—that 
is to say, it does not do so if we have to do with a disseminated 
disease (see Mixed Reaction). EaR may be wanting when there is 
an existing peripheral paralysis, if it is very slight (very slight 
pressure-paralysis of the N. radialis, which heals in three to four 
weeks). 
EaR in muscles that are not paralyzed is seen by itself in lead- 
paralysis and traumatic paralyses. 
Lessened excitability, especially of nerves, without EaR, occurs 
chiefly in myopathic muscular atrophy (dystrophia muse., Erb), in 
muscular atrophy from disease of the joints, and in lesions of the 
spinal pyramidal tracts, especially if recent and very severe. More- 
over, it is observed with multiple neuritis, arsenic-paralysis, alcohol- 
paralysis, bulbar paralysis, amyotrophic lateral sclerosis, etc., and 
here it is probably to be counted as mixed reaction. 
An intermitting general paralysis at intervals of one to four weeks, 
which lasts for twenty-four hours, with complete or almost complete 
loss of all electrical reaction, has been observed by Westphal. Its 
nature is very problematical. 526 
S PE ClA L DIAGr NOSIS. 
Increased excitability as manifested by early occurrence of CaSC 
and CaSTe, occurrence of AnOTe, is an extremely important sign 
of tetanus. Slight increase is observed in cerebral, spinal, recent 
neuritic paralyses, in progressive muscular atrophy of spinal origin 
(here a more considerable increase, and this in muscles that are still 
performing their function). 
The increase of galvanic excitability of the muscles with EaR, as 
well as of the faradic and galvanic irritability of the muscles with 
myotonic reaction, does not belong here. (For myotonic reaction, 
see above, p. 524.) 
4. Mechanical Excitability of Muscles and Nerves. 
1. Upon striking a muscle with a percussion-hammer, we see that a 
short contraction occurs, like a CaSC with a tolerably weak current. 
We find these contractions increased and usually quite decidedly slow 
in those muscles which show electrical EaR : “ mechanical EaR.” If 
distinctly present, this shows the same thing as the electrical EaR; 
but, often enough, it either fails or is not distinct, while the electrical 
examination proves the existence of EaR. 
Increased mechanical excitability with energetic, but slowly de- 
clining and prolonged contractions (to as much as thirty seconds, Erb), 
are peculiar to myotonia congenita. [See p. 524.] 
For those who are experienced, mechanical excitability is not with- 
out its value as a preliminary starting-point. But it cannot be a 
substitute for the electrical test. 
2. Idiomuscular contractions are transverse prominences which 
appear locally at the spot where the muscle is struck—thus far without 
any diagnostic significance. 
3. Mechanical excitability of the nerves (striking upon the trunk 
of the nerve at the point of electrical stimulation) has individual 
differences. In many healthy persons mechanical irritation does not 
cause any contraction at all. The mechanical excitability of the 
nerves—but not of the muscles—is very much increased in tetanus 
(especially in the branches of the N. facialis). 
4. Charcot has discovered that a peculiar form of over-excitability 
of the nerves and muscles is characteristic of the lethargic stage of 
hypnosis in very hysterical persons: pressure upon the nerve or 
muscle causes contracture. EXAMINATION OF THE NERVOUS SYSTEM. 
527 
We mention here, further, the peculiar and obscure phenomenon of 
paradoxical contractions (Westphal): In passive dorsal flexion of the 
foot there occurs a tetanic contraction of the tibialis anticus which 
lasts from a few seconds to several minutes ; the tendon of the muscle 
becomes prominent, the foot—even -when it is no longer held— 
remains dorsally flexed. It frequently occurs in connection with 
increased tendon reflex. 
5. Coordination and Ataxia. 
In all motions there is necessarily a more or less complicated 
concurrent action of a number of muscles. For example, in order 
to seize anything with the hand, not only are a series of muscles 
of the arm, hand, and finger moved, but at the same time, or a 
minimum of time before, the scapula, as a fixed point for the arm, 
must be steadied; moreover, from the free attitude of the body, the 
shifting of the centre of gravity, brought about by the motion of 
the arm, must be equallized by the contraction of the muscles of 
the trunk and legs, and the equilibrium must be maintained—a 
proceeding which, it is evident from what has just been said, cannot 
be sharply defined. Hence, in order that the hand may attain its 
object, and in order that it may attain it in the shortest way and 
with a steady motion, a very exactly defined number of muscles 
must contract at the right instant and with the finest adjustment 
of energy. This correct selection of muscles, and their regula- 
tion as to time and gradation of activity, is called coordination. It 
is acquired by practice by means of conscious and unconscious direc- 
tion of our motions; and it is preserved by an oversight which is 
continually becoming less conscious and more unconscious, and which 
all our motions acquire. 
Children at first are ataxic in grasping things as wrell as in walk- 
ing. The acquired coordination in walking can be partly lost again 
from long-continued severe sickness. 
The processes for acquiring and for maintaining cobrdination are 
certainly very diversified. Cobrdination will be acquired by the cor- 
rections which will be suggested by sensible irritations of all kinds, 
caused by the motions that are made and conducted to the central 
organs : the eye sees, the ear (as of the violinist and others) hears— 
the motion itself or its effects, the sensibility of the skin, the whole 528 
SPECIAL DIAGNOSIS. 
totality of deep sensibility furnishes information—and the correc- 
tion depends upon the sense of power of the muscles, which gives 
unconscious information regarding the intensity of the Avork accom- 
plished each time by the muscle. In this acquisition of coordi- 
nation the conscious will participates in many ways: in maintaining 
codrdination it recedes very extraordinarily, and gives place to an 
unconscious influence of the motions by centripetal influences. But, 
if necessary, it may at any moment take hold, and even with a con- 
trary effect to that intended, in that the unusual, new agent of the 
regulation of the will disturbs the codrdination which Avent on suc- 
cessfully before unconsciously. A person says, “ I will make it par- 
ticularly beautiful,” and just at that instant he becomes aAvkAvard. 
This happens, not only Avith nervous and embarrassed people, but also 
Avith those who are very calm : under the control of the will, they 
suddenly perform a motion Avhich has long been automatically made. 
Noav there is scarcely any doubt as to the nature of the centripetal 
influences, but where and how they bring their influence to bear 
upon the motor tract is very far from being clear. Voluntary 
motions certainly proceed to a certain extent from regulation derived 
from the cortex (where the complex motions, like those for speech, 
must exist), but certainly still other portions of the brain, which prob- 
ably act as reflex centres, have an influence upon this regulation 
(thus especially the cerebellum for the motions of the trunk and 
legs); and lastly, no doubt the gray anterior horns have a part in 
directing the continuity of motion : they preside over the tonus 
of the muscles, the antagonizing tension constantly in action during 
activity; they are the seat of tendon and skin reflexes. That 
all these things have an influence upon the continuity of motion 
seems to us (as Avell as to many others) cannot be doubted. But, 
likeAvise, there is no doubt that the various centripetal influences upon 
codrdination, to a very great extent, may act vicariously for one 
another: when there is the loss of the conscious skin and muscular 
sensibility, in the disappearance of centripetal stimulation, they call 
forth the muscular tonus, the more attentive regulation of the cor- 
tical innervation (Avith the assistance, for example, of the eyes) 
replaces the loss of constancy ; that, on the other hand—for instance, 
in the case of the blind—the exquisite superficial and deep sensibility 
(conscious as well as unconscious) must become prominent. But now, EXAMINATION OF THE NERVOUS SYSTEM. 
529 
if coordination can no longer be maintained, then with its disturb- 
ance there occurs ataxia. It is clear from the foregoing that ataxia 
may exist at the same time with perfectly normal vigor ; indeed, it has 
nothing whatever to do Avith native strength. 
Ataxia shows itself according to its degree only with delicate, or 
it may even with gross, functions. It usually occurs as an excess 
of innervation in the sense of directing motion, or as a want of 
restraint (tabes).: swing of the legs in walking, putting the feet down 
as if stamping, or only a clumsy way of moving the feet when turn- 
ing around (as in closing the door of one’s room); thus, on account of 
the uncertainty, the legs are spread out in standing and walking ; 
impossibility of describing a circle Avith the foot Avhen lying in bed, 
inability to exactly place the heel upon the knee of the other leg; 
when endeavoring to take hold of anything, the hand misses it, as in 
the effort to take hold of one’s own nose, in executing Avith the hand 
the finer movements of all kinds. In other kinds of ataxia there are 
other kinds of uncertainty, without this character of missing the 
mark, or the ataxia of the legs and trunk manifests itself by reeling. 
The control of the eyes sometimes diminishes the ataxia, sometimes 
not; the first is often the case in tabes. Most ataxic patients accord- 
ingly show a noticeable imvard consciousness Avith every ordinary 
voluntary motion (as walking), quite in contrast Avith persons in 
health [see p. 480]. 
Ataxia occurs: (a) In cerebral affections, and particularly those of 
the cortex; here with paresis, confined to a limb or one-half of the 
body ; Avith lesions of the vermiform process of the cerebellum, of the 
crura cerebelli, and of the pons and the corpora quadrigemina; and 
lastly, in individual cases in ordinary hemiplegia, if there is slight 
spasm. (b) Especially in tabes, where ataxia is the most impor- 
tant symptom, sometimes after disease involving the whole thickness 
of the spinal cord. (c) Rarely, and generally to a slight degree, in 
diffuse peripheral neuritides. (d) Rarely as a highly developed dis- 
turbance after acute infectious diseases. On the contrary, traces of 
ataxia after long confinement to the bed, especially after acute dis- 
eases, are not at all rare. Coordination is then temporarily and 
only partly lost. 
For details regarding the different theories of ataxia, especially those 
in regard to tabes dorsalis, see the different special works. It is our 530 
SPECIAL DIAGNOSIS. 
opinion that only one source of coordination has always been assumed, 
in a somewhat one-sided way, by the advocates of the several views. 
6. Spasms of the Voluntary Muscles. 
We gather together under this designation all those pathological 
motions existing outside of the influence of the will, so we must go 
very much beyond the popular literal idea of “spasms.” But this 
cannot very well be avoided unless we purposely wish to divide the 
subject very minutely. First, then, a few general remarks : 
Tonic spasms are those lasting some time—from minutes to days 
and weeks—and are symmetrical. Clonic spasms are contractions of 
short duration, followed by relaxation of the affected muscles. All, 
with the exception of some forms of trembling, are phenomena of irri- 
tation derived from the nervous system; and, in fact, chiefly from 
the cortex, pyramidal tracts, the anterior horns of the spinal cord, 
some probably also from the peripheral nerves (also from the muscles 
themselves: paralysis agitans, contractions of fibrillse). The patho- 
logical irritation is probably generally a direct one, but certainly also 
partly reflex; and, indeed, there is no doubt that the same kind of 
spasm may be caused by direct as well as reflex influences—as partial 
traumatic and reflex epilepsy. Many kinds of spasm consist of 
motions that are always similar—many combined from a few, and 
sometimes from a great many. 
Spasms are partly the intrinsic element of the given disease, the 
thing of which the disease consists ; partly they are a symptom; and 
then again they may be a local sign, that is, they may point directly 
to the seat, or point of origin, of the disease. Often we must deter- 
mine other phenomena (as paralysis, etc.) for the purpose of dis- 
covering the point of origin. 
With certain spasms, especially those that are paroxysmal and 
general, the condition of self-consciousness at the time of the attack 
is of great diagnostic importance. Also we often have to consider the 
general mental condition, for many cases of convulsions lead us over 
into the territory of psychiatria. 
We now only mention the different kinds of spasm : 
Trembling (tremor) consists of unproductive motions, often only to 
he seen by close observation, rapidly following one another. We EXAMINATION OF THE NERVOUS SYSTEM. 
531 
recognize them partly by observing the limb when at rest, partly 
when the hand is stretched out, or is holding a glass of water, and also 
by the handwriting. 
Graphic representation shows that the different forms of tremor differ 
in the form, frequency, and rhythm of the contractions. Trembling 
is physiological with bodily exertion, and with mental excitement, and 
it is sometimes constant, even with persons in good health. Upon 
the borders of the normal stand the tremors of the aged, tremor senilis. 
Alcoholic tremor, especially of the extremities and tongue, occurs 
with the passing away of the effects of the indulgence, or when it is 
declining; the tremor saturninus, the tremor which affects morphia- 
habitues when they abstain from it, that with morbus Basedowii 
(generally very fine, rapid movements, sometimes also coarser con- 
tractions), and the tremors of nervous individuals, are the finer kinds 
of tremors. 
The tremor of paralysis agitans (especially of the extremities, but 
also of the head) manifests itself by a symmetrical rhythm, by a very 
characteristic position of the hand and fingers (“ pill-maker ”). It 
ceases when voluntary motions are made, especially if vigorous, but 
sometimes even when writing. 
On the other hand, the intention tremor occurs only with voluntary 
motions, in that toward the end of the motion it becomes stronger; it 
stops as soon as the patient is quiet. It is an important symptom of 
multiple sclerosis ; it occurs, however, as tremor mercurialis. In many 
cases it is difficult to distinguish it from ataxia (which see). 
Between “tremor” and “clonic spasms ” it is not possible to draw 
a precise distinction. The designation shaking-spasm is used for the 
transition forms of both. The prominent transition forms of this kind 
of tremor are those shiverings which begin with fine tremors, becoming 
constantly coarser with cooling off, and with rapidly-rising fever; 
with hysteria there are conditions that resemble tremor. Likewise is 
to be mentioned the quaking which occurs with marked active spasm 
of the legs, as especially takes place sometimes after mechanical irri- 
tation ; foot clonus, particularly, often shows these transition forms 
very beautifully. 
In the foregoing we have not distinguished between the tremors of 
spasm and those of paralysis, because in regard to most kinds of 
tremors it is not yet clear to which of the two classes they belong. 532 
SPECIAL DIAGNOSIS. 
For further points regarding this subject, see the several special 
works. 
Fibrillary contractions are contractions in individual coarse or fine 
bundles of muscular fibres which do not produce motion in the limb. 
In individual cases, however, we can observe a very diminutive motor 
effect. They are easily recognized by observing the muscle. In 
health they are often excited (with great individual differences) by the 
cooling of the skin; but they also occur with atrophic paralysis, and 
very abundantly, and hence are not without diagnostic value, in 
spinal progressive muscular atrophy. 
Clonic spasms rarely occur by themselves, but they more frequently 
accompany epileptic and other attacks of convulsions (see below). We 
sometimes observe them isolated in local affections of the cortex of the 
brain (see below, Partial Epilepsy) ; but also in other localized cerebral 
diseases, and in myelitis transversa, as single brusque bending motions 
of the legs, generally both legs together—probably of reflex origin. 
Tonic spasms, by themselves, occur most frequently in the form of 
active spasms (see above, p. 494), in lesions of the pyramidal tracts, 
and with hysteria. Moreover, they occur in tetanus, and in these forms: 
as masseter spasms in trismus ; this latter also by itself; as rigidity of 
the face, risus sardonicus ; extension of the vertebrae with rigidity of 
the neck and opisthotonus, and in spasms of the legs in the state of 
■extension. Moreover, tonic spasm of the muscles occurs when first 
moving them after long rest, and as a prolonged condition after 
voluntary contractions in myotonia congenita; also, occasionally, as 
bending and adduction spasms of the arm and hands in tetanus; as 
the tonic form of writers’ cramp, although seldom purely as such, 
generally with slight contractions mixed with tremor; and in the first 
stage of epileptic attacks (see below). 
Epileptic spasms, in genuine epilepsy, generally pursue a typical 
course: after certain subjective warnings (aura), or without these, there 
is a sudden loss of consciousness, ushered in with a cry, and imme- 
diately the patient falls down. Then there is a short tonic spasm of 
all of the voluntary muscles (more especially of the extensors of the 
arms, legs, vertebrae, but the hands are closed and the thumb is grasped 
by the fingers); then there is clonic spasm, with frightful vigor, of 
all the muscles of the body, including the muscles of the eyes, 
tongue, etc.; after a few minutes there follows, either gradually or EXAMINATION OF THE NERVOUS SYSTEM. 
533 
suddenly, a period of relaxation with continued loss of consciousness 
—post-epileptic coma. During the attack, the tongue is often bitten, 
involuntary discharges take place, and, from the interference with 
respiration, marked cyanosis often occurs. 
It is very important to make a differential diagnosis between genuine 
epilepsy and symptomatic, which often very much resembles the 
former. The latter occurs in all manner of anatomical diseases of the 
brain (regarding partial epilepsy in disease of the cortex of the brain, 
see below), as traumatic and reflex epilepsy, as epileptiform spasms in 
uraemia, these latter also as eclampsia gravidarum. 
There occur in children, upon slight provocation, epileptiform or 
eclamptic attacks during dentition, from intestinal irritation from 
worms, in the beginning of acute infectious diseases, as scarlet fever, 
measles, pneumonia, and in the beginning stage of acute poliomyelitis 
and encephalitis. 
It is generally very difficult to form an opinion regarding spasms 
from the anamnesis. Here we must he very cautious in arriving at a 
diagnosis. 
Partial epilepsy (Jackson’s or cortical). In this there are epilepti- 
form convulsions which are limited to an extremity or to the facial mus- 
cles of one side. They are an almost infallible sign of disease located in 
a corresponding part of the cortex of the brain, and also are connected 
with or followed by paresis, increased tendon reflex, and sometimes by 
disturbance of the sensibility of the affected limb (monoplegia). The 
convulsions may be unilateral or even general, but they manifest 
themselves as originally partial epileptic, by beginning in the affected 
limb. 
Hysterical convulsions (attacks of hystero-epilepsy) sometimes have 
a great likeness to epilepsy; yet almost always the motions may be 
distinguished in that they are more wide-reaching [and tumultuous], 
and more than all by the fact that they partly manifest codrdinated 
motions, or remind one of them. Motions such as we see made by a 
person senselessly furious, or an unruly child, are not at all infre- 
quent ; especial manifestations are fits of laughing, shouting, weeping, 
coughing. - 
The most important mark of difference between hysterical and 
epileptic spasms, in doubtful cases, is that in the former there is almost 
never an entire loss of consciousness; very often it remains quite 534 
SPECIAL DIAGNOSIS. 
intact; and the absence of involuntary discharges (urine, stool, in 
males also of semen), as is not infrequent with genuine epilepsy; 
lastly, the tongue is not bitten, and there is reaction of the pupil 
during the attack. 
G-ross [severe] hysteria. The attack of hystero-epilepsy may pass 
into a second stage [“phase des grand mouvements ” of the French] 
of contortions, and excessive movements—among others, especially 
that of the “arc de cercle ” (head bent backward, boring into the 
pillow; the trunk bent as in opisthotonus)—which may last for hours, 
are characteristic manifestations ; then there may follow a third stage, 
which is either quiet or may be excited (delirium)—the stage of hal- 
lucinations and of emotional attitudes. The stages may occur singly. 
Besides what has already been described, it is important for diag- 
nosis that there should be present hysterical signs (stigmates hys- 
t6riques), manifested by the patient in the form of sensory anaesthesia, 
especially a concentric limitation of the field of vision; also, hemi- 
anaesthesia; hysterogenous zones—that is, hyperaesthctic regions of 
the body (ovaries, testicles, circumscribed portions of the skin), the 
irritation of which by pressure sometimes causes an attack or is asso- 
ciated with one. 
Constrained positions and motions. To the former belong the 
drawing of the head or trunk to one side, so that the patient assumes 
the side position in bed (sometimes with the eyes fixed; deviation 
conjugee occurs with the other manifestations); to the latter belong 
the involuntary forward, backward, and movement in a circle 
(manegegang). Both phenomena indicate a lesion of the vermiform 
process of the cerebellum or of the median crus cerebri. 
With the constrained motions, or the “ coordinated spasms,” are 
also to be reckoned the gross motions previously mentioned under 
hysteria, as laughing, screaming, etc. 
Chorea minor. This is the designation given to the very rapid, 
lightning-like, entirely irregular muscular contractions, which, on the 
one hand, produce restlessness of the limbs and of the face; and, on 
the other, disturb and divert the regular voluntary motions. They 
affect the head (face, tongue, masticating muscles) of the trunk, espe- 
cially of the shoulders and legs, and sometimes the glottis. They 
occur in all degrees of severity, from single weak jerks to the most 
extravagantly confused strong movements (folie musculaire). If the EXAMINATION OF THE NERVOUS SYSTEM 
535 
subject is embarrassed, especially if observed, frequently the contrac- 
tions are increased. During sleep (but there may be difficulty in 
getting to sleep), the convulsions entirely disappear, excepting in par- 
ticularly severe cases. 
Chorea minor is not often purely one-sided, or hemichorea. Hemi- 
chorea may occur either as the forerunner or as the result of hemi- 
plegia, when it indicates a lesion of the posterior section of the inner 
capsule or of the optic thalamus. Especially frequent are choreic or 
athetose motions (which see), with declining acute encephalitis in 
children (poliencephalitis, Striimpell) in the paralyzed limbs. Quite 
recently, Flechsig has found both internal segments of the lenticular 
nucleus diseased in several cases of severe general chorea with 
delirium. 
Athetosis [described by W. A. Hammond]. This designates pecu- 
liar, slow, and at the same time tolerably energetic motions, particu- 
larly of the hands, arms, shoulders, but also anywhere else. If the 
motions are somewhat quicker than, but resembling, those of chorea, 
they then form a transition to the latter. Athetosis, as well as chorea, 
is a disease in itself; hemiathetosis is observed in the same cerebral 
locations as hemichorea (which see). In the cerebral paralyses of 
children it is more frequent than hemichorea. 
Associated movements are abnormal involuntary motions, which 
take place with the performance of voluntary motions by the contrac- 
tions of muscles in regions which have nothing to do with the motions 
desired. We find them especially in cerebral, but also in spinal, and 
even in peripheral, paralyses; hence they cannot be made use of 
as an aid in diagnosis. Sometimes we see them in muscles of the 
same limb as that put in motion. Particularly frequent is a dorsal 
flexion of the foot when the leg is drawn up to the abdomen, as in 
hemiplegia, spastic spinal paralysis (Striimpell), or in unilateral 
affections, as synonymous associated movements of the sound side 
with those of the diseased side, or of the diseased side with the sound 
side. 
Catalepsy, cataleptic rigidity, Jlexibilitas cerea, is a peculiar in- 
crease of the tonus of the voluntary muscles, of such a character that 
the limbs not only offer only a very slight or feeble resistance in 
passive motion, but also remain in a given position, even when it is 
opposed to gravity, and this sometimes for an hour and more at a 536 
SPECIAL DIAGNOSIS. 
time. Catalepsy very rarely occurs in anatomical diseases, as tumors 
of the brain and meningitis; more frequently in hysteria, especially 
in hypnosis, and in certain psychoses, as in melancholia attonita. 
7. Voluntary Muscles, their Innervation, their Function, and the 
Diseases that Disturb Them. 
1. Muscles of the eye (see Examination of the Eye). 
2. Muscles of the face, supplied by the N. facialis : 
M. frontalis draws up the brow and causes wrinkles across the 
forehead. 
M. corrugator supercil. draws the skin of the forehead over the 
roots of the nose into folds. 
M. orbicularis palpebrarum closes the eyes. 
M. depressor nasi seu dilator narium dilates the nostrils. 
M. levator lab. super, (propr.) and M. levator anguli oris lift up 
the upper lip and the corner of the mouth. 
M. zygomaticus major raises up and draws out the angle of the 
mouth. 
M. buccinator makes the cheeks tense, holds open the pouch of the 
cheek when eating, prevents the distention of the cheeks when blowing 
or when whistling (to a slight extent supplied by the trigeminus ?). 
M. orbicularis closes the mouth; is the chief factor in whistling, 
pronouncing the consonants b, f, m, p, v, w, the vowels o, u (greatly 
assisted by the levator menti). 
Paralysis of the facial: The forehead is smooth and remains so upon 
the affected side when the effort is made to wrinkle it; the eye remains 
open and cannot be closed (lagophthalmus); the naso-labial furrow is 
obliterated; the angle of the mouth hangs down; the mouth, and 
often also the tip of the nose, are drawn toward the sound side; the 
effort to expose the teeth, as in cleansing the teeth, makes very 
plain the defective elevation of the upper lip and distortion of the 
mouth. When blowing, the affected cheek is distended; on attempt- 
ing to whistle, the lips are drawn to the sound side; if the paralysis 
is unilateral, the labials are generally, except in recent paralyses, pro- 
nounced distinctly; if bilateral, they cannot be. (See further, Soft 
Palate, Hearing, Taste.) 
3. Muscles of mastication, tongue, soft palate, pharynx. Mm. 
temporalis and masseter (N. trigeminus branch III.) draw up the lower EXAMINATION OF THE NERVOUS SYSTEM. 
537 
jaw and press the teeth together. Mm. pterygoidei effect the side- 
ways movement (rotation) of the lower jaw. 
Paralysis of these muscles will be recognized by the absence, upon 
one or both sides, of these motions; bilateral paralysis of the temporalis 
and masseter, by the dropping down of the lower jaw. Palpation 
below the zygoma detects possible paralysis and atrophy of the mas- 
seter ; above the zygoma, paralysis and atrophy of the temporalis by 
its laxity. 
We pass over the complicated arrangement of muscles which draw 
down the lower jaw, because their paralyses have not yet been suffi- 
ciently studied. 
The tongue is stretched out—that is, it is drawn forward by the 
two Mm. geniohyoglossi, which act somewhat convergently, and is 
drawn back chiefly by the two Mm. styloglossi; M. hypoglossus 
principally draws it down. These, and the inner lingual muscles, 
produce the changes in the form of the tongue. 
Unilateral hypoglossal paralysis : When the tongue is protruded it 
deviates toward the paralyzed side, because the genioglossus of the 
sound side pushes it that way. Bilateral paralysis (generally atrophic) 
causes diminution of all the motions, even to their complete oblitera- 
tion ; difficulty in mastication and swallowing; and in the formation 
of the consonants c, d, g, k, 1, n, r, s, sch, x, z, and of the vowels i 
[e], e [a]. Unilateral paralysis produces all these disturbances to a 
slight degree, and they become less with habit. Atrophy, seldom 
unilateral, will be recognized by diminution in the volume, by 
wrinkles, and sensible thinness. 
The soft palate derives its principal innervation from the spheno- 
palatine ganglion (N petrosus superfic. maj., and from the ganglion 
geniculi of the facial nerve. The fifth and the tenth and eleventh 
ganglia also take part). 
Examination: by inspection and phonation—i. e., by observing the 
voice and inspection, and by the swallowing of fluids. 
Unilateral paralysis of the soft palate in paralysis of the facial 
located high up, shows deviation of the uvula toward the healthy side 
and depression of the arch of the paralyzed soft palate, both more 
distinctly in phonation. In the passive state, the relaxed uvula may 
hang to one side, even when there is no paralysis. Sometimes the 
speech is nasal, and fluids may escape from the nose in attempting to 538 
SPECIAL DIAGNOSIS. 
swallow. Both symptoms are due to ineffectual closure between the 
nose and the mouth: pharyngeal space. In bilateral paralysis, espe- 
cially with bulbar paralysis and as diphtheritic paralysis, the soft 
palate hangs down without any power to contract; and nasal utter- 
ance and the difficulty in swallowing are increased. 
The pharyngeal muscles (N. X.—XI.), with the aid of the tongue, 
accomplish the act of swallowing. When they are palsied, this act 
is disturbed, and, from the lack of vigor and promptness in passing 
the food along, it easily enters the larynx: thus, there is coughing in 
connection with swallowing. But if the patient is unconscious, or 
there is at the same time disturbance of the sensibility of the larynx 
(N. laryngeus super, vagi), there may be no cough. 
4. Laryngeal muscles. The muscles supplied by the laryngeus 
super, vagi are: depressors of the epiglottis; Mm. thyreoepiglott., 
aryepiglottici (paralysis : difficulty in swallowing), and the M. crico- 
thyreoides, tensors of the vocal cords by movement of the thyroid 
cartilage toward the cricoid cartilage (paralysis: hoarse voice). 
N. laryngeus inferior (recurrent branch of the N. X—XI.): Mm. 
crico-arytaenoid. postici dilate the glottis (bilateral paralysis: inspi- 
ratory dyspnoea, sometimes of the severest kind, with the voice 
unchanged or very slightly impure). Mm. thyreo-arytaenoidei are 
the most important tensors of the vocal cords (paralysis: loss of voice 
and hoarseness). 
Musculi arytaenoidei transversi et laterales: they narrow the pos- 
terior portion of the glottis (in isolated paralysis: the voice is very 
hoarse, as in catarrh, hysteria). Mm. crico-arytaenoidei laterales : in 
connection with the preceding they narrow the glottis. 
Complete paralysis of the recurrent: (a) unilateral (compression by 
aortic aneurism, carcinoma of the oesophagus, mediastinal tumors; 
bulbar paralysis): voice hoarse, easily changing to the falsetto, or 
little or even not at all altered ; (b) bilateral (rare): complete aphonia, 
inability to cough. 
(Regarding the laryngoscopic examination, see Appendix.) 
5. Muscles of the throat and neck. M. sterno-cleido-mastoideus 
(N. XI.) draws the head and face toward the opposite side and looking 
upward; both together somewhat bend the neck and push the head 
forward: or, if the bead is the fixed point, they lift up the sternum 
or the clavicles, as in emphysema. The test of their function and EXAMINATION OF THE NER VO US SYSTEM. 
539 
recognition of their paralysis and spasm is easy. When both are 
paralyzed, the neck, and with it the head, incline backward. 
The muscles that stretch, bend, twist the neck or the head (nervi 
cervical. I.—IV.), maintain the head in the upright position. If they 
are weak or paralyzed, it is impossible to hold the head up: it falls 
forward, if it is not exactly balanced. This happens, if the head is 
too heavy (hydrocephalus). Defective mobility of the head is more 
frequently caused by spasm or inflammation (stiff-neck, caries of the 
cervical vertebrae), than by paralysis. 
6. Muscles of the trunk. Muscles that move the vertebrae (inner- 
vated by Nn. dorsales and lumbales). 
Lumbar extensors and extensors of the lower vertebrae: M. erector 
trunci (sacro-lumb. et longissim.) with bilateral action. 
Bending forward: the abdominal muscles. 
Bending of the lower vertebrae sideways : quadrati lumborum. 
Twisting the trunk: semispinalis and multifidus. 
Paralysis of the erector trunci: (a) bilateral: the body is bent 
backward (lordosis of the lumbar, kyphosis of the upper thoracic, 
vertebrae, in such a way that the latter overhangs the sacrum; a 
plumb-line held from it falls behind the sacrum); the pelvis is tilted 
up, the knees are bent, (b) Unilateral: in standing, a scoliosis of 
the lower vertebrae is convex toward the diseased side; on the other 
hand, there is a compensatory scoliosis of the thoracic vertebrae. 
Paralysis of the abdominal muscles : marked lordosis of tie lumbar 
and lower thoracic vertebrae, compensatory kyphosis of the upper 
thoracic vertebrae, but these are exactly vertical over the sacrum. 
There is marked inclination of the pelvis. 
In paralysis of the extensors, it is impossible to place the bent 
trunk in an unsupported upright position; it is accomplished by 
placing the hands upon the knees and thighs. If, in addition, there 
is paralysis of the glutei, especially of the gluteus maximus, then the 
patient can only rise from the floor by first getting down on “ all 
fours,” then pushing himself up with the hands from the floor, in order 
immediately to put them upon the knees and thus further support the 
body: this is his way of standing up. In paralysis of the flexors, it 
is impossible to sit up from the dorsal position without assistance. 
Opisthotonus is produced by spasm of the extensors, emprosthotonus 540 
SPECIAL DIAGNOSIS. 
by spasm of the flexors; unilateral spasm of the extensors causes 
scoliosis, convex toward the diseased side. 
7. Muscles of the thorax., diaphragm, and abdomen. Here belongs 
most of what has already been said upon p. 81ff. There we learn 
regarding the ordinary and the auxiliary muscles of inspiration and 
the auxiliary muscles of expiration. 
Paralysis of the diaphragm (phrenic nerve, chiefly from the fourth 
nerve of the [deep] cervical plexus) in perfect quiet, may be entirely 
compensated by the thoracic muscles of inspiration ; but otherwise every 
increased requirement for breath produces marked dyspnoea; and this 
is exactly the case with respect to the vicarious action of the dia- 
phragm when there is defective thoracic breathing. It will be under- 
stood, then, that paralysis of the auxiliary muscles of respiration has 
only a bad outlook for the breathing when it comes to such a pass that 
they must be called upon (see p. 96). 
Tonic and clonic spasm of the thoracic muscles of inspiration in 
tetanus and epilepsy at once cause severe cyanosis; in the first disease 
it may be fatal; also tonic spasm of the diaphragm interferes very 
much with breathing and may be dangerous to life. Clonic spasm of 
the diaphragm (singultus, hiccough), in a mild form, is not infre- 
quently seen ; if it continues for hours and days, as it sometimes does 
in abdominal and cerebral affections, then from the disturbance of the 
rest, and severe pain along the line of insertion of the diaphragm, it 
may bring about a serious condition. 
By the contraction of the abdominal muscles the anterior abdominal 
wall is flattened, and thus the abdominal cavity is lessened; by the 
simultaneous contraction of the diaphragm there arises “ the abdominal 
pressure,” which is important in defecation and emptying the bladder, 
and the expulsion of the child in labor. The role of the rectus and 
obliquus externus, as flexors of the vertebral column (when those of 
one side act alone, the trunk is bent laterally forward over on one side), 
has been already mentioned, as well as their function in active expi- 
ration. 
8. Muscles of the upper extremity. 
{a) Muscles which move the shoulder-blade or fix it: M. trapezius 
(N. accessorius for the most part) raises the shoulder-blades and draws 
them toward the middle line, both of these by the middle and posterior 
parts. The former chiefly lifts up the acromion, the latter the inner EXAMINATION OF THE NERVOUS SYSTEM. 
541 
upper angle. With its anterior clavicular portion it inclines the head 
obliquely backward and at the same time lifts up the acromion. Paral- 
ysis of the trapezius permits the scapula to drop down, to be drawn 
away from the middle line, and at the same time to turn round so that 
its apex moves toward the spinal column (because the levator scapulae 
holds up the upper inner angle). The shoulder sinks downward and 
forward; there is difficulty in raising the upper arm, because the 
scapula is not so perfectly fixed, and shrugging of the shoulders is 
restricted. From what has been said the test of its function is easy. 
M. levator anguli scapulae (N. dorsalis scapulae from the cervical 
plexus) lifts up the scapula by its inner upper border, with the ten- 
dency to turn the right scapula in the direction of the hands of the 
clock, and the left in the opposite direction. Its paralysis can only 
be recognized when the trapezius is paralyzed at the same time, by 
the complete inability to lift the shoulder. 
Mm. rhomboideus major et minor (N. dorsalis scapulae) draw the 
shoulder-blades toward the spinal column, and thus lift them in the 
same way as the levator scapulae and turn them in such a way that 
the lower angle of the scapula is nearest the spinal column. They 
fix the scapulae, especially in backward motions of the arms and legs, 
and when lifting weights. Paralysis [of these muscles] moves the 
scapula, and particularly its lower angle, away from the spinal column. 
Moreover, it is difficult to detect paralysis of these muscles when the 
trapezii are normal. 
M. serratus anticus (N. thoracicus longus seu posterior, Henle, from 
the brachial plexus) turns the scapula in such a way that the lower 
angle moves outward, draws it somewhat away from the spinal column, 
and presses it against the thorax : it is an important fixation-muscle 
of the scapula when the arms are lifted. When the scapula is fixed 
(by the rhomboidei) it is a muscle of inspiration. Paralysis of the 
serratus, in the condition of rest, causes a slight elevation and rotation 
of the scapula, so that the lower angle stands out a little from the 
thorax and is (slightly) drawn toward the spinal column. The arm 
can be lifted up to the horizontal sideways: this moves the inner border 
of the scapula close up to the vertebral column. It can only be raised 
higher by fixing the scapula in the same way as would be accomplished 
by the serratus. When the arm is moved forward, the inner border of 
the scapula stands out like a wing. 542 
SPECIAL DIAGNOSIS. 
(5) Muscles of the trunk and of the scapula [attached] to the upper 
arm : 
M. deltoides (N. axillaris at the infraclavicular portion of the 
brachial plexus); the middle portion extends the arm outward from the 
body, the anterior portion raises it obliquely forward, the posterior por- 
tion obliquely backward. It raises it as far as the horizontal, beyond 
which, the arm being fixed by the deltoid against the scapula, it is 
raised by the rotation of the scapula. Paralysis is easily recognized : 
If the muscle is relaxed, there is subluxation of the humerus, par- 
ticularly if at the same time the supraspinatus is paralyzed; if the 
deltoid is atrophied, the contour of the bones at the shoulder shows 
plainly. 
M. supraspinatus (N. suprascapularis from the supraclavicular por- 
tion of the brachial plexus) assists the deltoid in raising the arm out- 
ward toward the front, rolls it inward, it is also said to hold the head 
of the humerus in its socket when the arm is raised. 
Mm. infraspinatus (N. suprascapularis) and the teres minor (N. 
axillaris) roll the upper arm outward. 
M. subscapularis (N. subscapularis from the brachial plexus) is a 
rotator inward. Paralysis of a rotator allows the arm to rotate in the 
opposite course; in testing, we first make passive rotation, and letting 
the arm fall, allow it actively to do the same thing, while we oppose 
the rotation. 
M. pectoralis major (N. thoracic, anti, of the brachial plexus) ad- 
ducts the upper arm; when the arm is raised up, it moves it forward 
in the horizontal plane, draws the arm down when it is raised. Test: 
Have the upraised arm moved forward in a horizontal plane while we 
offer resistance. 
M. latissimus dorsi (N. thoracico-dorsalis from the brachial plexus) 
draws down the arm when it is raised up in exertion, [it depresses it] 
and draws it backward. When the arm hangs down it draws it back- 
ward and inward [toward the buttock]. Test: The arm is raised to 
the horizontal and the effort is made to lower it while the movement 
is opposed. The teres major materially assists the latissimus ; it is at 
the same time a rotator inward. 
Mm. coraco-brachialis (N. musculo-cutaneous of the median) and 
anconeus longus (cap. long, tricipitis; N. radial.), when the arm is EX AMIN A TION OF THE NERVOUS SYSTEM. 
543 
drawn down by the latissimus and pectoralis, hold the head of the 
humerus up and firmly in its socket. 
(c) Muscles from the upper arm to the forearm : 
M. triceps (N. radialis) is an extensor of the forearm. 
M. brachialis internus (N. musculo-cutaneus) is a simple flexor. 
M. biceps (N. musculo-cutaneus) flexes and supinates. 
M. supinator longus (N. radialis) flexes and pronates. This is 
proved by having the moderately pronated forearm flexed while the 
movement is resisted. If it is healthy, it rises up like a hard roll on 
the outer side of the elbow-joint. 
We here next mention the pronators: the pronator teres (it is at 
the same time a flexor) and quadratus, both supplied by the median 
nerve. 
(d) Muscles which extend from the condyles of the humerus and 
the bones of the forearm to the hand and fingers, and the small mus- 
cles of the hand: 
The extensor carpi radialis longus and brevis (N. rad.) + extensor 
carpi ulnar. (N. rad.) are elevators of the hand. The flexor carpi 
radialis (N. median) -j- flexor carpi ulnaris (N. ulnar.) are volar flexors 
of the hand; the palmaris longus (N. median.) assists in this action. 
The extensor carpi radialis longus flexor carpi radialis adduct 
the hand in the direction of the radius. Extensor carpi ulnaris + 
flexor carpi ulnaris adduct the hand on the ulnar side. If the exten- 
sor carp. rad. long, acts alone, it raises the hand obliquely on the 
radial side, as the ext. carp. uln. does on the ulnar side. 
Paralysis of the extensors of the hand (or especially lead-paralysis, 
also sleep-paralysis of the N. radialis) allows the hand, when the fore- 
arm is pronated, to hang loosely down. Paralysis of the abductors 
and adductors and also paralysis of the extensores c. radial, long, and 
carpi ulnaris alone, produces oblique position of the hand [paralysis 
from the former giving a position opposite to that of the latter]. We 
test the individual movements by successively opposing them. 
M. extensor digitorum (communis indicator, exte. digiti V., all from 
the N. radial) extend the first phalanges. 
M. flexor digitor. comm, sublim. (N. median.) flexes the middle 
phalanges; M. flexor digitor. comm. prof. (N. media, the two ulnar 
bellies from N. ulnar.) flexes the terminal phalanges. Mm. inteross. 
dors. + volares (N. ulnar.) and Mm. lumbricales (N. med. and ulnar.) 544 
SPECIAL DIAGNOSIS. 
flex the first phalanx and at the same time extend the middle and 
terminal phalanges. 
Mm. inteross. dors, alone abduct (spread apart), volares alone adduct 
the (middle : third) finger. 
Movements of the thumb: extensor pollic. long. (N. rad.) is essen- 
tially an extensor of both phalanges; extens. poll. brev. (N. rad.) is an 
extensor only of the first phalanx. Adductor poll. long. (N. rad.) 
abducts the metacarpus. Flexor poll. long. (N. med.) flexes the term- 
inal phalanx. At the thenar are the opposing muscles — abductor 
poll, brevis, outer head of the flexor brevis, and the opponens poll, 
(all from the N. med.). Adductors: adductor pollicis and the inner 
deep head of the flex. brev. (both N. ulnar.) These two and the 
abductor brev. flex the first and extend the terminal phalanx. 
The adductor, flexor, and opponens act at the hypothenar, their 
names indicating their action. All are innervated by the N. ulnaris. 
Characteristic positions of the hand and fingers: 1. In paralysis of 
the ulnar there is the clawing, clutching hand, main en griffe: the 
first phalanges are extended, the middle and terminal ones flexed 
(paralysis of the interossei), the thumb hangs helpless over the hand 
(paralysis of the adductor); the fingers are easily spread out (action 
of the extensores digit.). Thus the interosseal spaces on the dorsum 
are deepened, likewise the groove between I. and II. metacarpal bones 
(atrophy of the adductor pollicis, deep head of the flexor brevis and 
inteross. dorsi I.). The hypothenar is atrophic. 2. In paralysis of 
the thenar (deep median paralysis) there is the ape-hand: the thumb 
does not stand out opposing, but is parallel with, the other fingers. 
Paralysis of the extensors of the hand causes apparent Aveakness of 
the long flexors of the fingers, because the origin and insertion of the 
flexors are brought near together by the flexion of the hand at the 
wrist. Hence, we must passively extend the wrist and then test the 
flexion of the fingers. For the same reason it is necessary, when there 
is paralysis of the long extensors of the fingers, to passively extend 
the first phalanx before testing the flexion of the middle and terminal 
phalanges. 
Examination. We observe the position of the hand for possible 
atrophy. Then we test extension, flexion, abduction and adduction 
at the wrist—sometimes all of these—by resisting these motions; then 
the extension of the fingers; next the long flexors by “hooking” of EXAMINATION OF THE NERVOUS SYSTEM. 
545 
the fingers; then let the patient make the separate motions of the 
interossei muscles; flex the first phalanx with the middle and end 
phalanges extended; then spread out and close the fingers; test the 
muscles of the thenar and hypothenar by bringing the thumb and 
little finger into contact; lastly, the examiner places his own index 
finger in the saddle between the thumb and the second metacarpus, 
while the patient makes simple adduction of the thumb, thus testing 
the power that is manifested. Pressure of the hand is a very prac- 
tical way of making a general test of the long flexors and the small 
muscles of the hand. 
For such paralyses as are not wholly diffuse, but rather confined to 
individual muscles or groups of muscles, peripheral and certain spinal 
paralyses, it has value only as a preliminary examination. For various 
reasons we consider the dynamometer as an unnecessary apparatus 
and one that does not accomplish its purpose. 
It cannot be sufficiently insisted upon that in order to establish the 
diagnosis exactly in the upper extremity, and particularly in the hand, 
beside a clear conception regarding the location and physiological 
action of the muscles, there must be a knowledge of their innervation. 
We observe, especially, how the ulnar and median are distributed in 
the small muscles of the hand. The former innervates the hypothenar, 
interossei, the two ulnar lumbricales, and the adductors of the thenar, 
adductor pollicis, and the deep head of the flexor brevis; the latter, 
the remaining muscles. In the hand, the radial only supplies branches 
to the skin. 
9. Muscles of the lower extremity. 
(a) Muscles from the pelvis to the thigh : 
M. ileo-psoas (N. crural from the lumbar plexus) flexes the hip- 
joint ; it is assisted (and in the sense of pure flexion) by the action of 
tensor fasciae latae (N. gluteus super, from ischiadic plexus). In 
paralysis of the psoas, or of this and the tensor fasciae, it is not pos- 
sible to flex the thigh either in walking or in bed; paralysis of the 
tensor fasciae alone permits the pure psoas action to take place: 
flexion with rotation outward. 
M. gluteus max. (N. glut, inferior or plexus ischiad.) extends the 
thigh; when the thigh is fixed, it brings the pelvis to the horizontal 
position, and thus the trunk to the vertical (into the upright from the 
stooping posture, standing upright, etc.). When it is paralyzed, there 546 
SPECIAL DIAGNOSIS, 
is the peculiar kind of action in rising from the floor described on 
page 539, with paralysis of the extensors of the trunk. 
M. gluteus medius (N. glut. sup. from the plexus ischiad.), abduc- 
tor ; M. gluteus minim, (same nerve) rotates the thigh inward. The 
three glutei are the most important supporters of the pelvis. 
M. pyriformis (plex. ischiad.), M. obturator, int. (N. ischiad.), M. 
gemelli (N. ischiad.), M. obturator exter. (N. obturat., plex. lumbal.), 
M. quadrat, femor. (N. ischiad.), are all, in reality, out-rotators. 
M. adductor long., brev.,magn., pectineus and gracilis (N. obturat., 
plex. lurnb.), are, for the most part, adductors, at the same time partly 
flexors. The effect of their paralysis is clear. 
(b) Muscles from the pelvis and the femur to the leg: 
M. quadriceps (N. crural.) extends the leg; its long head, the 
rectus, arises from the pelvis (anter. infer, spine), and hence acts 
with more power when the thigh is in a position of extension with 
reference to the pelvis. In paresis of the quadriceps, the leg (or pos- 
sibly both legs) in walking are frequently set forward, flexed more 
markedly at the knee-joint (the leg during the forward movement of 
the limb hangs vertically down), and this is true also when it is set 
down quickly, so that there is a sort of snapping of the knee-joint 
into the position of extension. The examination is best made by 
endeavoring to flex the limb when it is actively extended. 
M. sartorius (N. crural.) is probably chiefly an inward rotator of 
the flexed leg. 
Mm. biceps fern., semitendinos., and semimembranos. (N. ischiad.) 
flex the knee-joint; the first rotates the flexed leg outward, the second 
inward. If the limb is powerfully extended by the quadriceps, then 
these flexors, as well as the gluteus max., act: they place the pelvis 
in the horizontal position (important in walking). 
(<?) Muscles from the leg (or the condyles of the femur) to the foot 
and toes: 
M. gastrocnemius, soleus, plantaris (N. tibial.) are extensors; that 
is, are plantar flexors of the foot, and, at the same time, adductors of 
the extended foot. 
Mm. peroneus long, and brev. (N. peroneus) are extensors (chiefly 
the first) and adductors of the foot, lift up the outer border of the foot. 
In paralysis of the peronei muscles (by “ peroneus-paralysis ” we mean 
paralysis of the whole peroneus nerve: see below, under M. tibialis EXAMINATION OF THE NER VO US SYSTEM. 
547 
antic.); the foot in extension, as well as flexion, stands in the position 
of adduction and the outer border of the foot is deeper; the foot 
becomes flat. It is not easy to test the activity of the peronei: we 
must first show the patient the movements of abducting and lifting 
up the outer border of the foot by passive movements, and then have 
him repeat them; besides, we have the patient extend the foot: 
in paralysis of the peroneus longus decided adduction then tabes 
place. 
M. tibial. ant. (N. peroneus) flexes; that is, dorsally flexes and 
adducts the foot; M. extensor digit, comm, and extens. halluc. long. 
(N. peron.) flexes and adducts the foot, extends the toes. Paralysis 
of the dorsal flexors causes the point of the foot to drop when the foot 
is lifted from the floor. If the peronei are likewise paralyzed (pero- 
neal paralysis; that is, paralysis of the peroneus nerve), then the foot 
is lax at the ankle-joint; the point of the foot hangs down, with 
inclination to adduction. In walking we observe that the foot, as it 
is raised from the floor, makes a peculiar shuffling motion inward, and 
it is set down in a fumbling manner. Persons with unilateral, isolated 
peroneal paralysis are always inclined to take a longer step with the 
disabled limb in order to obtain the sweeping motion required for the 
awkward placing of the foot upon the floor. 
M. tibial. postic. (N. tibial.) is an adductor. 
Mm. flexor digitor. comm. long, and brev. (N. tibial.) are flexors 
of the middle and terminal phalanges of the toes ; Mm. interossei 
externi interni (N. tib.) are flexors of the first, extensors of the 
middle and terminal phalanges—interossei externi. [The outer three 
muscles are abductors of the second, third, and fourth toes, respect- 
ively, while the first is an adductor of the second toe, and assists the 
plantar interossei.] 
Paralysis of the interossei causes a peculiar kind of claw-position 
exactly analogous to that of the fingers (see p. 544). 
M. extensor halluc. longus (N. peron.) extends the first phalanx of 
the great toe; Mm. adductor, flexor brevis, abductor hallucis (N. tib.) 
act essentially in accordance with their names: they produce simul- 
taneously flexion of the first and extension of the terminal phalanx. 
Paralysis of the flexor of the great toe hinders one in walking, but 
especially in springing. 548 
SPEC1A L D1A GNOSIS. 
Disturbances of Speech (Lalopathy). 
I. Dysarthria and Anarthria. 
By these expressions we understand those disturbances of speech in 
which we see it altered in the same way as the activity of a joint is 
distributed as to its motility: by paresis, paralysis, trembling, spasm, 
and even ataxia of the vocal muscles. 
Unilateral paralysis of the muscles of speech occurs in unilateral 
affections of the pyramidal tract above the medulla oblongata, or of 
the cortical centre of the motor speech muscles ; likewise in peripheral 
paralysis of the hypoglossus and facial nerves. At first the speech is 
decidedly disturbed; if these affections continue, there occurs a 
considerable improvement in the speech, as if it were re-acquired by 
practice. Bilateral paralyses generally occur from the bulbus of the 
oblongata (bulbar paralysis), and are then, if they are ganglion 
paralyses, degenerative-atrophic. It is rare to have bilateral speech 
paralysis from bilateral cortical or pyramidal lesion (pseudo-bulbar 
paralysis). We also rarely have a bilateral paralysis of the hypo- 
glossus or facial nerves of peripheral origin. 
For the muscles that produce speech and their innervation, see 
above, pp. 536 and 537. Depending upon which muscles are paralyzed, 
the disturbance of speech may vary with different letters, as mentioned 
at the above-named place. We recognize slight anarthritic disturb- 
ances of speech by requiring the patient to pronounce difficult words 
quickly, especially such as contain many consonants. Simultaneously 
with this disturbance of speech, the voice, from paralysis of the palate, 
is often nasal (or also a kind of “ clod-voice ”), or the voice has a 
monotone, or it is inclined to change to a falsetto. (Regarding swal- 
lowing, see p. 537.) 
Scanning speech: sounding like the speech of a rider of a horse 
that is trotting; there are sharp changes of rhythm, unnatural 
pauses, sudden, “ explosive,” and then, again, snapping pronunciation 
of words. It is particularly characteristic of multiple sclerosis. 
Hysterical dumbness is a complete loss of speech and generally also 
of the voice, which occurs suddenly, and generally after an attack of 
hysteria, which lasts anywhere from days to years, and may suddenly 
disappear. The mobility of the tongue is normal. EXAMINATION OF THE NERVOUS SYSTEM. 
549 
II. Aphasic Disturbances, Disturbance of Graphic Communication 
(of Mimicking, of Singing). 
In order to understand these conditions it is necessary to make 
some explanations regarding the acquisition and use of speech, of 
writing, etc. 
Speech and its related functions have their foundation in the culti- 
vated memory, which is acquired by much practice, and for the mother 
tongue in childhood. We acquire such a development of the memory: 
1. For speech in the narrow sense, and it comprises: 
(a) Cultivation of acoustic memory, acquaintance with the sound of 
words by hearing letters, words, and sentences spoken by others. 
(b) Cultivation of the motor memory, the complex motions used in 
speaking words, by imitating what we hear, trying to produce the 
same by correcting what the organs of speech produce until we attain 
the desired degree of perfection, and we treasure up [in the memory] 
the complex motions which are required for accomplishing what is 
desired. 
2. The memory for writing comprises the cultivation of the optic 
memory, the acquisition of writing, and the complex motor writing- 
motions—again by imitating what we see. 
Likewise, we develop the comprehension and reproduction of music, 
a very individual faculty; of mimicry, and of gestures, varying 
according to the nationality. 
Simultaneously with speech, or always somewhat later than imita- 
tion of what is heard, ideas develop—the concrete first; upon the 
foundation of the concrete, the abstract. 
Now, we suppose that the cultivation of the sound of words, and of 
their form, also the complex motions for speaking as well as writing 
them, these four to be accumulated each at its own place in the brain- 
cortex ; but that, presiding over all, yet not concentrated at one place, 
but as the result of innumerable functions, with numberless tracts 
connected with the cells of the brain-cortex, is the mind—intelli- 
gence. The representations of memory, and the complex motions 
(which are likewise representations of memory), can only functionate 
the nervous tissue—that is, can only be represented as tones, chords, 
a series of tones and chords of a violin. 
And in fact they can be innervated: 550 
SPECIAL DIAGNOSIS. 
1. From the representations of the sound of words: these come 
from the periphery through the sense of hearing. If we hear the 
mother tongue (or any other language which we know), from the con- 
ception, we inwardly pronounce the words. 
2. From the written representation : from the periphery—that is, 
from the organ of sight, if we read in a known language; and from 
.the conception, if we inwardly represent to ourselves the printed or 
written word. 
3. From the complex motions of speech : from the centre repre- 
senting the sound of words by virtue of the imitative instinct—repeti- 
tion ; and from the mental conceptions—independent utterance of 
thought. 
4. From the complex motions of writing : from written words, by 
virtue of our imitative instinct—copying ; from mental conceptions— 
writing out the thought. 
But still, this is not all: the impulse to produce the complex motions 
of speech may come from the written or printed representation—we 
read aloud. On the other hand, the impulse to make the complex 
motions of writing may come from what is heard—we write from dic- 
tation. Further, while we are speaking or writing, there comes along 
the muscular sense an innervation (going in a centripetal direction) of 
the complex motions of speech or writing. We can make this clear 
if, with the eyes closed, we have someone else move our hand, as if 
writing a word: by this means, without other assistance, we can recog- 
nize simple words. In a still higher degree, also, in the active motions 
of writing and speaking the report of what is written or spoken—that 
is, the contractions of the muscles taking part in these acts, and the 
motions produced by them, go centripetally to the brain. 
The conceptions of musical notes seem to cobrdinate those of word- 
sounds, while the complex motions for producing speech and those 
which produce music (melody and rhythm)—that is, for singing—are co- 
ordinated with the larynx and mouth. The conceptions of musical 
sounds are intimately connected with those of word-sounds, and the com- 
plex motions required in singing are connected with those required in 
speaking. The intimateness of this association appears very distinctly 
in the fact that when a melody happens to come to mind we hum the 
words belonging to it; or, if the words come first, then we hum the EXAMINATION OF THE NERVOUS SYSTEM. 
551 
melody. Sometimes this humming is a purely automatic act, for both 
the text and the melody are articulated involuntarily together. But, 
again, sometimes the internal re-sounding follows the articulation or 
act of listening, and from this internal impression the articulation is 
first produced. 
Now, to these innervations there belong tracts of communication. 
Those conducting from the periphery to the “ sensory ” centres, 
leading to the centres for conceptions of sound and writing, we under- 
stand very wTell—the acoustic and optic nerves. Further, there must 
exist very manifold combinations between the conception and the four 
different centres themselves [mentioned on p. 550], but it is very 
difficult to obtain an exact presentation of these combinations. 
For instance, Kussmaul supposes that the tract from the centre of 
ideas to that for the complex motions of speech goes through the 
portion which takes note of the sound of the word ; hence he assumes 
no direct innervation of the centre of the complex motions of speech 
from that of ideas. Likewise, there is a dispute whether there is a 
direct communication from the written representation, or whether 
there is a communication with the centre for the complex motion of 
writing, etc., only through another centre. We will only bring forward 
one instance, for the sake of illustration. The following acts, done 
without understanding by persons in health as well as by sick persons 
—repeating, reading aloud, copying, or writing from dictation—make 
it plausible that direct communication exists between the sensory and 
motor centres, which, therefore, do not go through the centre for 
ideas. But there is no doubt that, in regard to this, there are very 
considerable individual differences, particularly dependent upon the 
degree of cultivation and the intelligence. 
Of course, we also understand the tracts which peripherally lead 
from the “motor speech- and writing-centres ”—they go through the 
pyramidal tracts, the bulbar nucleus, to the individual motor nerves; 
and, finally, we have a general presentation, at least, of the tracts 
which pass centripetally from the muscles and joints. 
These very different qualities, acquired by practice, may each singly 
or several together be lost. When the organ of hearing remains per- 
fectly intact, the innervation from the periphery of the conception of 
the sound of words—that is, the ability to understand the words of one’s 
native tongue—may be lost: there is word-deafness [“ inability to 552 
SPECIAL DIAGNOSIS. 
understand spoken words, although they are heard as sounds, while 
printed or written words are understood”—Billings], loss of intellectual 
perception of sounds. Even when the muscles of speech are perfectly 
normal, the ability to employ language, to express one’s ideas through 
the innervation which results in the complex motions necessary to make 
use of the appropriate word in the native language, may be lost: motor 
or ataxic aphasia (or, as Kussmaul designates it, “ the purest form of 
ataxic aphasia ”). The arm may be in perfect condition, and yet we 
may not be able to wrrite; or the eyes may be intact, and yet we 
cannot read—agraphia, alexia. But since the different capacities 
under consideration—the understanding and formation of Avords, the 
understanding and production of writing—are in a very manifold way 
connected with each other, these disturbances almost never occur 
singly, but as a complex of disturbances. 
The expressions—u acoustic amnesia ’’ for word-deafness, “ visual 
amnesia ” for loss of intellectual perception of sounds—seem to us to 
be very useful, more so than the German designations formed upon a 
different principle. The only objection is that these expressions may 
be confounded with the idea of amnesia discussed later on (p. 554). 
The study of these things has proceeded from the observations of 
the disturbances of speech in the narrowest sense, that is, of speaking 
(Boilliaud, M. Dax, Broca). For this reason, and because all dis- 
turbances that come under consideration apply to speech in the broader 
sense (spoken and written speech, with reference to its comprehension 
and production), we class together, not at all incorrectly, all the 
conditions under consideration, by the designation of aphasia, aphasic 
disturbances. 
We only mention now those two manifestations which may be most 
sharply distinguished, while for all the details we refer to the special 
works (see, also, the “schema” of Lichtheim). 
1. Word-deafness (Kussmaul), sensory aphasia (Wernicke). The 
two ideas are not wholly identical. Special works show this more at 
length. The patient hears every word, but it sounds to him as any 
healthy person hears a word that belongs to a language which is 
wholly strange to him. The mother tongue, so far as the under- 
standing of the hearer is concerned, has become a foreign, unknown 
tongue; also, ability to repeat and to write from dictation is wanting. EXAMINATION OF THE NERVOUS SYSTEM. 
553 
But, again, sometimes the understanding of writing may fail {alexia), 
and with it the ability to read aloud (see p. 558). 
But, in opposition to this, the power of volitional writing and to 
copy written characters, and further, volitional speech, is preserved. 
Nevertheless, we generally observe a disturbance in this also: very 
often the wrong words are used, because words that are related by 
sense or sound are, from unrestrained association, pronounced and 
strung together {paraphasia); or, it may be distinctly noticed that the 
correct words are employed, but they are distorted by repetition of 
syllables, dropping of syllables, transposition of letters or syllables 
{literal aphasia, syllable-stumbling). Moreover, both conditions some- 
times have relation with amnesia (“ amnestic aphasia,” see p. 556). 
2. Atactic aphasia (Broca’s aphemia, Wernicke’s motor aphasia) 
consists in this, that the patient is unable to communicate his 
thoughts by words: he cannot name objects presented to him, 
although he promptly shows that he recognizes what they are in that 
he knows how to use them correctly; at the same time there is dim- 
inution of the power to voluntarily write, or to write down what is 
heard (or write from dictation): agraphia, with the exception of the 
ability to transcribe from copy, which is usually retained. Thus, in 
pure cases, there is perfect understanding of what is said and also of 
what is written, and hence there is neither word-blindness nor word- 
deafness. 
But in one respect the condition of most patients of this character 
is still somewhat obscure : with reference to the question whether they 
are able to produce the sound of the word mentally, to conceive of its 
sound, i.e., to mentally sound the word. According to Lichtheim, it 
is probable that in most or in all such cases this capacity has also been 
completely lost. But regarding this point it is very difficult to form a 
positive opinion with respect to these patients. 
We cannot refrain from dwelling a little upon this question. (For 
further regarding the examination of patients with aphasia, see below.) 
We must confess that, in these cases, we have found that the method 
employed by Lichtheim, though it is ingenious, is very uncertain. 
Lichtheim, in order to determine whether the word which designates 
the given object is mentally correctly sounded, requires the patient to 
tell how many syllables there are in the word, or to press the hand as 
many times as it contains syllables. It is assumed that when an object 554 
SPECIAL DIAGNOSIS. 
is presented to a patient there arises in his mind a conception of 
the sound. What designation does he think of ? I hold up a knife 
before him—does he think “a pocket-knife” or “knife?”—a drink- 
ing-glass: “a drinking-glass” ora “glass?”—“handkerchief” or a 
“sackcloth?” I admit that there are substances about which there 
is no doubt, but one would be easily inclined to hold that the number 
of syllables was wrong, and yet the patient thought he had understood 
and had spoken correctly. 
Slighter forms of atactic aphasia manifest only a slight defect in 
the command of language: single Words are omitted or single words 
are defectively pronounced: “doltor,” “dolner,” for doctor; “lit,” 
for lip; I am “benter,” for better, etc.—that is, there is a literal 
ataxia, syllable-stumbling. But often the patient dwells upon only a 
few words, or only one, or even a single syllable, which is constantly 
employed for everything, as was the case with a patient reported by 
Striimpell, and whom we have watched for years, who could only say, 
“bibi, bi-bi-bi-bi-bi.” We also have cases of paraphasia. 
An atactic-aphasic patient who, before becoming affected, was a 
good singer, may lose the power of singing as well as of speaking, and 
yet the “ear” may be retained: he hears when he himself or some 
one else sings a false note. But though the speech may be lost, he 
may still retain the powTer to sing the melody of a song, and then it 
may happen that with the melody he may automatically articulate the 
words to which it belongs, although he cannot articulate them without 
the melody. In connection with this the reader is referred to p. 550 
for what was said regarding the connection between the complex mo- 
tions of speaking and singing. 
There is another disturbance which plays an important part in all 
forms of aphasia and which presents a special group of symptoms : it 
is amnesia, amnestic aphasia. 
The patient presents a perfect picture of a person who is endeavor- 
ing to speak a foreign language which he only slightly or very imper- 
fectly understands. An object is held up before him : he is not able 
to name it; he repeats it without understanding it, or he remarks: 
“Yes, certainly, that is the word;” or he hits upon the correct word 
through association, as upon the number of fingers held up before him 
by counting—“One, two, three, four—correct: four.” This amnesis 
manifests itself only with reference to certain kinds of wrords, as for EXAMINATION OF THE NERVOUS SYSTEM. 
555 
proper names, or chiefly for those representing the most concrete ideas 
(Kussmaul). 
Amnesia can be mixed with the different forms of aphasia; the 
former may be very indistinct—even for a time, or continuously, may 
predominate over the aphasia; but it also occurs in all possible 
conditions that do not at all belong here: senile dementia, disease of 
the brain of all kinds, in convalescence from any very severe illness, 
etc. With Lichtheim we do not count these cases as aphasia. 
Localization of the aphasic disturbances. The exact localization 
of the two important centres of the understanding and use of language 
is one of the greatest attainments of recent times. 
The centre for the complex motions employed in the formation of 
words, the motor speech-centre, is located in the left third frontal con- 
volution (Broca); lesion of this point causes atactic aphasia. The 
centre for the formation of sounds, the centre for acoustic recollec- 
tions, is located in the left anterior central convolution (Wernicke). 
The right hemisphere has nothing to do with speech, except when the 
left side is mutilated, when it contains these centres instead of the 
left. 
Further, it is extremely probable, though it cannot be regarded as 
certain, that the centre for the conception of writing is to be looked 
for in the optic portion of the cortex of the occipital lobe (both sides 
or only the left ?), and the motor centre for writing in the left second 
frontal convolution. 
Hence, all these centres could lie within the given motor and sen- 
sory portions of the cortex: what relation they sustain to these we do 
not exactly know. We may always conceive of them as groups of 
cells which are brought into connection by tracts especially “smoothed” 
by repetition—that is, tracts with peculiarly slight resistance. 
Mode of Procedure in Testing for Aphasic Disturbances. 
We look for any possible aphasic symptoms whenever there is 
disease of the brain, but especially with any patient who has had 
an attack of apoplexy, and particularly when there is right-sided 
hemiplegia. 
It is evident that the examination of these patients is often inter- 
fered with, either because of their mental hebitude—dimness of 556 
SPECIAL DIAGNOSIS. 
perception—or the inability to think, and the loss of memory which 
they exhibit. Those patients can only be exactly examined in 
whom the general effect of the injury has passed off; and the most 
interesting cases are those where, after the indirect collective symp- 
toms (see, respecting this, the last section of this chapter) have 
disappeared, an aphasic assemblage of symptoms remains behind as 
a unilateral disturbance. 
In the first place, we ascertain whether there is amnesia: if the 
patient can, we have him count, but further we test him by requiring 
him to name objects placed before him. If he fails to do this, we give 
him the name of the object and have him repeat it. If he can do so 
(either with or without apparent understanding), he is not atactic- 
aphasic, but amnesic. It is to be remarked that occasionally amnesia 
may simulate all: atactic aphasia, word-deafness, word-blindness, 
agraphia. 
We now proceed to test for possible word-deafness: by conver- 
sation, by requiring the patient to do something, as to touch his nose, 
or by directing him to take something in his hand—a knife, pocket- 
handkerchief, etc. We must be careful to avoid making any kind of 
gesture, also looking in the direction of the object named. 
Hereupon we look for signs of atactic aphasia: requiring him 
to speak and to repeat; further for evidences of paraphasia, literal 
aphasia. If the patient is atactic-aphasic, then we must always make 
the effort to discover whether he has the internal sense of words (see 
above). 
After these things, we conclude the test by having him read (that 
is, read with understanding), read aloud, have him write, compose, 
write from dictation, copy. With persons who were formerly known 
to have had a musical ear, or could sing, it will he well to inquire 
whether they retain or have lost these powers, or, especially, what 
is the relation of the singing of the air and hearing the music to the 
understanding and speaking of the words that belong to it. 
The diagrams serve to display the mutual relations of the four cen- 
tres to each other and to the so-called “centre of perception.” Many 
forms have been prepared, of which we mention those of Wernicke, 
Kussmaul, Charcot, Lichtheim. 
These diagrams are very useful for studying this subject (and we 
especially recommend Lichtheim’s). They are a very excellent guide EXAMINATION OF THE NERVOUS SYSTEM. 
557 
for examination, for the clear understanding of the different functions, 
and as a stimulus to independent thought. But they do not exhibit 
the actual facts. As a rule, these can never he represented; the 
individual differences are too great. Charcot rightly distinguishes 
persons as those in whom either the conception of sound or the con- 
ception of writing, or even the mechanical representation of speech or 
of writing, whichever may he predominant, serves as a guide for 
speech and writing (and likewise for understanding as well as the 
production of them). We assume that in speaking as well as writing 
Fig. 166. 
Lichtheim’s diagram of aphasia. A, centre for conception of the formation of sound 
(a A, conducting tract); 0, centre for conception of written characters (o 0, conducting 
tract); M, centre for the motions of speech (Mm, the centrifugal motor tract); E, cen- 
tre for the motions of writing (Ee, the corresponding motor tract); B, centre for con- 
ception of ideas. The arrows indicate the direction of innervation. 
the mental conception causes an innervation of the centre for sound 
first, and then this innervates the centre for the complex motions re- 
quired in producing the effect [of speech or writing] ; and further, 
that, when writing is seen, it must first innervate the centre for sound. 
Thus there results the understanding of the writing, and hence we 
can form a conception of what is the significance, to such a person, of 
the loss of the centre for the conception of sound: a lesion of the 
temporal lobe. Hence, in our opinion, if we add to Charcot’s diagram 
the centre of cognitions, with its manifold relations, it is the most 
plausible: it includes all tracts that can possibly exist, and in most 558 
SPECIAL DIAGNOSIS. 
cases of aphasia we must assume that in each individual, while in 
health, some of the tracts did not exist. Hence, it follows that, from 
the character of the disturbance, whose location we can know nothing 
of without an autopsy, much less locate simply from the symptoms, we 
must draw a conclusion regarding the tract from that one which the 
patient has made use of in health for the purposes of speech (in its 
widest sense); and further, from this we must ascertain what centres 
or tracts are now cut off. 
It is plain from this how difficult it often is to judge of these things 
in an individual case. 
First we give Lichtheim’s and then Charcot’s diagram. After 
Lichtheim’s we add his brief summary of the possible disturbances 
and their phenomena. This summary does not by any means give an 
idea of Lichtheim’s work upon aphasia. Attention is here urgently 
called to the special works, particularly to the classical writings of 
Charcot, Wernicke, Kussmaul, or their pupils, and Lichtheim. 
1. Interruption in fff, the centre for the conceptions of motion or 
the motor speech-centre (atactic aphasia). 
Lost: (a) volitional speech ; 
(b) ability to repeat; 
(c) “ to read aloud; 
(d) “ to write volitionally ; 
(e) “ to write from dictation (e [in the figure], 
the internal conception of the word-sounds). 
Retained : (/) understanding of speech ; 
(.g) “ of writing; 
(7i) ability to write from copy. 
2. Interruption in A, the centre for the conceptions of the sounds 
of words (sensory aphasia). 
Lost: (a) understanding of speech ; 
(b) “ of writing; 
(<?) ability to repeat after one; 
(c?) “ to write from dictation ; 
(e) “ to read aloud. 
Retained : (/) “ to write volitionally ; 
(g) “ to write from copy; 
(h) “ to speak volitionally. EXAMINATION OF THE NERVOUS SYSTEM. 
559 
3. Interruption of MA. 
Intact: (a) understanding of speech ; 
(b) “ of writing; 
(c) ability to write from copy. 
But there is (a) paraphasia ; 
(6) paragraphia (the same disturbance in voluntary 
writing); 
disturbance of the same kind in— 
(/) repeating after one; 
(g) reading aloud; 
([h) writing from dictation. 
4. Interruption of MB: modification of motor aphasia. 
Lost: (a) power of voluntary speech ; 
(b) “ “ writing; 
—as in atactic aphasia. 
But intact are not only 
(c) understanding of speech; 
(cT) “ of writing; 
(g) ability to write from copy ; 
but besides (/) “ to repeat what is said; 
(g) “ to write from dictation ; 
([h) “ to read aloud. 
5. Interruption of Mm: modification of motor aphasia. 
Lost: All speech ; everything else intact. 
6. Interruption of A B. 
Lost: (a) understanding of speech; 
(b) “ of writing. 
Disturbed: (c) volitional speech : paraphasia. 
Retained: (d) “ writing; 
(e) ability to repeat what is said; 
(/) “ to read aloud; 
(g) “ to write from dictation. 
7. Interruption of A a. 
Lost: (a) understanding of speech; 
(b) ability to repeat what is said; 
(c) “ to write from dictation. 
Retained: (d) power of volitional speech ; 
(g) “ “ writing; 560 
SPECIAL DIAGNOSIS. 
(/) understanding of writing; 
(g) ability to read aloud; 
(A) “ to write from copy. 
We now introduce Charcot’s diagram without further explanation. 
Apply Lichtheim’s Case 1 to it: it will be seen that in those cases 
which show that representation of symptoms perfectly (Broca’s 
aphasia), it must be assumed that M is diseased ; but further, that in 
Fis. 167. 
Charcot’s diagram of aphasia. Drawn by Marie {Prog, med., 1888). The designa- 
tions are the same as in Lichtheim’s diagram. The centres are represented as being in 
those centres of the cortex where they are to be looked for; the light hatching around 
A and 0 indicate the general acoustic and optical field in the cortex. Notice the double 
arrows upon all connecting lines between A, 0,E, M. Also notice the arrows pointing 
centripetally toward Mm and Ee, where the stimulation going to M and E cause the 
motions of speech and writing. In our opinion there is to be added the centre for ideas* 
which should have a twofold connection with A, 0, E, M. 
health the connection had passed from E to A only through M; and 
still further, that for arbitrary innervation of E it must have previously 
gone from M, or from A through M. EXAMINATION OF THE NERVOUS SYSTEM. 
561 
As an addendum, we add here a few remarks upon the diagnostic 
value of the character of the writing : 
(a) Writing is the expression of thought, and in so far as this is 
the case it is a very fine test for recognizing psychical disturbances 
of all kinds. (See the text-books upon Psychiatria.) 
(b) As was mentioned above, agraphia belongs to the group of 
aphasic symptoms, and, in fact, it occurs in those forms which are 
completely analogous to disturbances of speech in the narrow sense: 
as total, as partial agraphia, as paragraphia, or literal agraphia. 
Likewise, it was previously stated that a sharp distinction was to be 
made between volitional writing, writing from dictation, and copying. 
Also, the loss of the capacity to form strictly grammatical sentences, 
to make a correct sequence of words (agrammatismus, akataphasia), 
shows itself in the writing also, or still better than, in speaking. 
(c) Motor disturbance of the right upper extremity manifests itself 
in many cases in a very characteristic way in the handwriting: the 
iifferent kinds of trembling, ataxia, the different varieties of writers’ 
cramp. It is also worthy of note that patients with paralysis agitans 
very frequently write naturally because, as is well known, their 
trembling ceases when making intentional motions. 
The value of the handwriting for diagnosis here consists chiefly in 
the fact that we may recognize early slight disturbances (the contour 
wavy): ataxia manifested by the strokes going beyond bounds, 
especially by the imperfections of the large letters. 
In paralytic dementia the writing, as well as the speech, is ex- 
tremely copious. This shows the psychical disturbances : delirium 
with exaltation or dementia; there is agrammatismus, akataphasia, 
paragraphia, especially literal paragraphia in an extraordinarily high 
degree ; lastly, there may be motor disturbances of the upper ex- 
tremities, trembling, ataxia. 
Sense Organs, 
The Eye.—In considering the relations of the diseases of the eye 
to internal diseases, those in connection with the diseases of the 
nervous system are of very much the greatest importance. 
We find the eyes, or the function of sight, sympathetically affected 
in diseases of the nervous system in a great variety of ways. We 562 
SPECIAL DIAGNOSIS. 
observe disturbances which exhibit the more or less direct results of 
disease of the nerves or of the brain. They are: paralyses (less 
frequently spasms) of the outer and inner muscles of the eye; dis- 
turbances of the different qualities of vision itself, from lesion of the 
sensory tract at any point from the optic nerve to the cortex ; neuritis 
optica (choked disk), which, on the other hand, may itself cause dis- 
turbance of vision. Other conditions, which are coordinate to the 
diseases in which they occur, oppose these conditions. They are of 
extremely varied character. We mention, as examples: atrophy of 
the optic nerve in tabes dorsalis, multiple sclerosis, embolus of the 
central artery of the retina with simultaneous embolus of the fossa of 
Sylvius, syphilitic iritis or retinitis in syphilis of the brain. 
Likewise, the disturbances of the apparatus of vision, occurring with 
any other internal diseases, may be either coordinated conditions or 
sequent phenomena of those diseases. Of the former category we 
name as examples : choroidal tuberculosis in acute miliary tuberculosis, 
retinal hemorrhage in general hemorrhagic diathesis (sepsis, pernicious 
anaemia), the various manifestations of syphilis, etc. As a sequent 
phenomenon we have embolus of the retinal artery in endocarditis 
aortae or mitralis, possibly cataract with diabetes mellitus, etc. 
We give these instances in order to show in how great a variety of 
ways the disturbances of vision may occur as symptoms of other dis- 
eases. In what follows we cannot classify the subject matter according 
to the points of view mentioned above. We rather proceed in accord- 
ance with the course of an examination of the eye. 
1. Movements of the eye.—As is well known, these take place, in 
part at least, in a very complicated way, by the coordinate action of 
the muscles of the eye. Paralysis or spasm of the outer muscles of 
the eye causes a defective motion of the eye and disturbs its binocular 
motion, which we designate as strabismus. If the strabismus is due 
to spasm, it is present in all positions of the eye; but if dependent 
upon paralysis, then it has a different relation. In slight paralysis 
(paresis) of a muscle, strabismus only occurs wThen a motion of the eye 
is made which is in a considerable degree dependent upon the co- 
operation of the muscle paralyzed; on the other hand, in more 
marked paralysis, strabismus may be almost always present. It is 
only absent when the eyes are brought into a position which cor- 
responds with an especially marked relaxation of the paralyzed muscle. EXAMINATION OF THE NERVOUS SYSTEM. 
563 
In long-continued paralysis of one or more muscles of the eye, con- 
tracture of the antagonizing muscles also takes place; in consequence 
of which condition, strabismus is always, or almost always, present. 
Lateral strabismus is designated as divergent or convergent, according 
as there is a divergence, or an abnormal convergence, of the axis of 
vision. 
The direct result of strabismus is double-vision, or diplopia. This 
results from the fact that, in fixing an object whose image only falls 
upon the macula of the normal eye, it falls, in the one whose muscle 
or muscles are paralyzed, to one side of the macula, and at varying 
distances from it, according to the degree of the strabismus and the 
distance of the fixed object from the eye. In consequence of the 
double image, the determination of the position of an object in space, 
and with it the judgment of the patient with reference to his own 
position, is disturbed. Hence, primarily there is difficulty in taking 
hold of objects and in walking; there is dizziness (vertigo of the eye), 
and this is most marked when there is diplopia in looking downward 
(paralysis of a rectus inferior, of an obliquus superior). But after 
long-continued strabismus double vision disappears, for the patient 
learns to voluntarily shut out the abnormal eye. 
If it happens to be a case where there is paralysis or spasm of the 
muscles of both eyes which effect the conjugate motions of the eyes 
(as the rectus internus of the right and the rectus externus of the left 
eye), then we speak of paralysis of the conjugate muscles of the eyes 
(or spasm of these muscles); for the position of the eyeball we employ 
the designation conjugate deviation. 
Paralysis of all or of almost all of the muscles of an eye results in 
protrusion of the ball—exophthalmus paralyticus. Marked or total 
paralysis of the oculomotorius produces, beside the paralysis of the 
eye (see below), also ptosis (depression of the upper lid), dilatation of 
the pupil, paralysis of accommodation (paralysis of the levator palp, 
sup., of the sphincter of the iris, of the muscle of accommodation). 
Deviation of the eye in which the paralysis or spasm is located is 
termed the primary deviation. In cases of paralysis there occurs in 
the normal eye a so-called secondary deviation, if we have the patient 
cover the normal eye and then have him look with it at an object 
which has been fixed by the diseased one. (Upon this subject, see 
works upon the Eye.) 564 
SPECIAL DIAGNOSIS. 
We employ our own individual judgment in determining a paralysis 
of the muscles of the eye, by controlling the position of the eye of 
the patient while he is looking at a distant object and from the accom- 
modation, also, especially by motions of the ball sideways, upward 
and downward ; moreover, we test the patient by having him look 
at objects in different directions, and then question him as to double 
vision and in what relation the objects stands to one another. 
Mode of procedure in determining double vision. We hold up a 
finger about a metre from the patient, move it up and down, to the 
right and then to the left, and hold the finger steadily in the position 
in which the patient has a double image, and then have that position 
described by him. Then we suddenly close one eye: the patient now 
declares which image has disappeared. In this way we determine 
to which eye each one of the double image belongs. Or, we take a 
lighted candle as the object of vision, and alternately cover an eye 
with a piece of colored glass, and then, of course, the image presented 
to this eye is colored. (For further regarding this subject see works 
upon the Eye.) 
In regard to the significance of double vision, it is first to be stated 
that when the balls diverge the images are crossed; when there is 
abnormal convergence, they are on the same side (on the side of the 
convergence). All the rest follows from what will now be said where 
we collate the function of individual muscles of the eye and the effects 
of paralysis. 
M. rectus externus (N. abducens), rolls the eye outward. Its 
paralysis, according to its degree, produces convergent strabismus, 
which is manifest either in looking straight ahead, or in looking only 
toward the side whose external rectus is affected. The double vision 
is also upon that side. 
M. rectus internus (N. oculomot.), rolls the eye inward, antagoniz- 
ing the preceding. When it is paralyzed the in-rotation of the ball 
is imperfect; there is divergent strabismus, crossed double vision. 
M. rectus super. (N. oculomot.), rolls the eye upward and at the 
same time a little inward. Rectus super. -f- obliq. infer, together 
cause upward motion of the ball. Paralysis of the rectus sup., limits 
the motion upward; the abnormal eye stares downward and a little 
outward: there is double vision when looking upward; the image 
of the paralyzed eye is superimposed upon that of the other. EXAMINATION OF THE NER VO US SYSTEM. 
565 
M. rectus inferior (N. oculomot.), rolls the ball downward and 
slightly inward; acting with the obliq. sup., there is simple down- 
ward motion. Paralysis of the rectus infer.: in looking down, the 
paralyzed eye does not move, but remains directed upward and a little 
outward; there is double vision, with one image above the other, 
the lower being that of the abnormal eye. 
M. obliq. infer. (N. oculomot.), if it is paralyzed, in looking up- 
ward we have the action of the rectus sup. alone: the eye turns some- 
what inward. There is double vision upon the same side, one image 
is above the other or they are side by side, particularly in looking 
upward. 
M. obliq. super. (N. trochlearis), if this is paralyzed, then in look- 
ing down the rectus inferior acts alone, turning the eye somewhat 
inward. There is double vision upon the affected side, especially when 
looking downward. 
Some of these paralyses, if they occur singly, can be easily recog- 
nized, and this is especially true of those of the recti. But when 
several are combined, particularly if the obliqui are involved, there is 
often the greatest difficulty in making out the exact lesion. A com- 
bination which may occur frequently is a paralysis of all the muscles 
supplied by the oculomotorius, with which we may then also have the 
internal muscles of the eye involving the levator palp. sup. With 
this total paralysis of the oculomotorius the eye is rotated outward 
(the action of the abducens), there is some exophthalmia, the pupil 
is dilated and remains so in the presence of light, and there is absence 
of power of accommodation. 
By nystagmus, or oscillation of the eyeball, we understand very 
slight clonic jerking motions of the ball. They are generally conju- 
gate. If they take place in a horizontal direction, then we speak of 
horizontal nystagmus. It is often most distinct in fixing the eyeball, 
but particularly with marked rotation movements of the balls side- 
ways or in a vertical direction. 
The diagnostic significance of paralysis of the muscles of the eye 
varies very much : paralysis of several muscles of only one eye always 
points with considerable probability to the base of the brain, or to the 
orbital fissure and orbit, and this is particularly apt to be the case if, 
at the same time, there is evidence of a lesion of the optic nerve (dis- 
turbance of vision, unilateral choked disc). Progressive paralysis of 566 
SPECIAL DIAGNOSIS. 
the muscles of both eyes, sometimes ending in total paralysis of these 
muscles, indicates a progressive nuclear paralysis (ophthalmoplegia 
externa). It is difficult to estimate the symptomatic value with refer- 
ence to the topical diagnosis of conjugate deviation. When it is 
present we should always first think of the possibility of a lesion of 
the posterior corpus quadrigeminum or its neighborhood; but aside 
from this, conjugate deviation occurs with all kinds of local disease 
of the brain, especially if recent. Hence, if the deviation is due to 
paralysis, we infer that the line of vision is toward the same side, 
but if it is a conjugate spasm, the line of vision is toward the opposite 
side. In the latter case the head is very often drawn to that side. 
Paralysis of the oculomotorius of one side and of the extremities of 
the opposite side (crossed pai'alysis) points with great certainty to a 
lesion of the crus cerebri, and this corresponds with paralysis of the 
third nerve. We can immediately understand this fact if we recollect 
that the N. oculomotorius dexter passes to the right crus cerebri at its 
base—that is, it passes alongside of the pyramidal tract belonging to 
the left side of the body. 
2. The pupils.—We do not concern ourselves with those changes 
of the pupil which belong wholly in the province of diseases of the 
eye (especially in connection with iritis). 
We are to consider the size, or the changes in the size, which 
result from certain circumstances. When the iris is normal, the 
size is regulated by the action of two antagonizing muscles : the 
sphincter pupillse (N. oculomotorius) and the dilator pupillse (N. sym- 
patheticus). 
(a) The size of the pupil. Contracted pupil, myosis, occurs in 
health during sleep, likewise in old age. Otherwise myosis is 
always a sign which must awaken suspicion, and indeed is especially 
frequent in tabes dorsalis (see below, Reflex rigid pupil); and, also, 
although more rarely, in progressive paralysis. The degree of the 
illumination also has a marked effect upon the size of the pupil (if from 
reflex action it is not rigid, see below under c). Hence, it is to be 
examined under moderate illumination. Dilatation of the pupil, 
mydriasis, occurs with marked disturbances of consciousness, severe 
pain (see below under c), with atrophy of the optic nerve, paralysis of 
the M. oculomotorius; lastly, sometimes with tabes and progressive 
paralysis. EXAMINATION OF THE NERVOUS SYSTEM. 
567 
Effect of poisons. Atropine, duboisin, cocaine, dilate the pupil; 
eserine, pilocarpin, morphia, contract it. These effects upon the pupil 
are, in connection with other symptoms, employed for diagnosis in 
cases of poisoning with any of these substances. 
(b) Inequality of the pupils sometimes occurs with persons in 
health, also in people with unequal refraction in the two eyes (with 
myopia: mydriasis; in hypermetropia: myosis) ; but, otherwise, 
inequality of the pupils is a suspicious symptom. It occurs in uni- 
lateral affections of the brain of all kinds (thus, especially with 
hsematoma of the dura), with unilateral paralysis of the oculomotorius, 
of the opticus (dilatation), and in tabes; besides, it frequently occurs 
in attacks of migraine (irritation, paralysis of the Sympathetic of the 
affected side). 
(<?) Reflex changes in the size of the pupil. The pupil contracts 
in the presence of light from the contraction of the sphincter (the 
reflex arc [composed as follows] : (a) the optic nerve; (b) optic tract; 
(c) probably the anterior corpus quadrigeminum; (c?) oculomotorius). 
The test is made either in a light room by covering the eye with the 
hand and then suddenly withdrawing it, or in a room with a dim light 
by quickly going to the light (more certain). In either case the 
patient must not employ any accommodation, hence must look at a 
distant object (see below, converging motion). It is best to test each 
eye singly by alternately closing one. Sometimes there is an indica- 
tion for testing the crossed (“ consensual”) reaction: we observe the 
changes in the pupil of the right eye, while we vary the light which 
enters the left, and vice versa. (Regarding liemiopic pupillary reaction, 
see below.) In old age the reaction of light is physiologically slow. 
Pain, as painful irritation of the skin (pinching, Faradic brush), 
dilates the pupil through the action of the dilator. The reaction is 
slower and less marked than from light. 
Absence of reaction is the term used for “reflex rigid pupil ” (Erb), 
both “to light ” and “to pain.’’ This absence of both reactions often 
goes hand-in-hand, especially in tabes, where Erb in 84 cases found 
59 instances (= 84.5 per cent.) of absolutely rigid pupils, or (more 
rarely) very feeble reaction. At the same time there was always 
reflex rigidity with reference to pain ; and, further, in 37 cases (= 52 
per cent.) simultaneous myosis. Reflex rigidity is less frequent in 
progressive paralysis; but there rarely ever occurs any other abnor- 568 
SPECIAL DIAGNOSIS. 
mality of the pupils (myosis, mydriasis, inequality, slow reaction of 
rigidity) in this condition. 
The reaction of light also fails in atrophy of the optic nerve, and 
in complete paralysis of the oculomotorius. But it does not fail in 
central blindness, hence not in cortical hemianopsia. Moreover, when 
testing in this case, the light from the side where the field of vision is 
defective must be brought nearer, so that it may only fall upon the 
half of the retina which is cut off from the centre (see p. 569). 
Reaction of light takes place in the diseased eye in unilateral optic 
atrophy when the normal eye is illuminated; on the other hand, 
reaction of light is not retained in the diseased eye in unilateral com- 
plete paralysis of the oculomotorius, as is evident from the course of 
the reflex arc. 
(d) Contraction of the pupil in convergence of the eyes, or from 
accommodation, may not take place in paralysis of accommodation 
(this most frequently after acute diseases, particularly diphtheria), 
but it may also be retained. This contraction of the pupils during 
accommodation has its chief diagnostic significance in the fact that it 
must be avoided when testing for the reaction to light or pain—that 
is, it is generally retained with reflex rigidity of the pupils. 
3. Testing for the central sharpness of vision, the color-sense, and 
the field of vision. 
{a) We test the sharpness of vision by means of Snellen’s plates, 
which contain test-letters of different sizes, the number of which is 
represented by the distance in metres at which a normal eye can read 
the type. After correcting any possible anomaly of refraction in 
either eye, they are placed at a distance at which it can read the test- 
letter X. The sharpness of vision is expressed by a fraction whose 
denominator is the number on the plate, and whose numerator is the 
distance at which it can be read. According to the above, in normal 
vision the denominator and numerator must be alike; the fraction 
then is always equal to 1 (f, J-, etc.); instead of this [the sharpness 
of vision represented by] SY. = in case the eye is diseased we 
have SV. = etc. (For particulars, see text-books on the Eye.) 
As a matter of course, if we discover a diminution in the sharpness 
of vision, before we conclude that it is due to a disease of the nervous 
system we must exclude any disease of the refractive apparatus. 
(Here, also, the reader is referred to special works upon the Eye.) EXAMINATION OF THE NERVOUS SYSTEM. 
569 
(b) Testing the field of vision, FV., the “peripheral sight.” The 
most exact way to do this is to employ a perimeter. A substitute for 
this expensive instrument, which can he recommended to one who is 
not a specialist, is the field-of-vision chart, which has six straight 
lines intersecting each other at a point making angles of 45 degrees. 
Starting from the point of intersection, these lines are divided into 
centimetres. At the point of intersection a rod of definite length 
stands perpendicular to the chart (it is screwed into the chart); upon 
this upright is a hoop into which the person to be examined places 
his head. It is used in the same way as a perimeter. The normal 
size of the field of vision for three or four healthy persons, with a 
definite length of the upright, is placed upon the chart. (It will be 
shown that on the outer side the field of vision is endless, because 
the angle is less than 90 degrees to the direction of the line of 
sight—but of this no account is taken.) The pathological result is 
drawn upon a diagram which represents the chart and the normal 
field of vision on a smaller scale. 
We recognize very decided disturbances by steadily holding a finger 
about a half metre from and in front of the eye, and then moving the 
other hand, or a light held by it, in every direction in the field of 
vision. Of course, in this case, as in all others, we are to test each 
eye singly. The great difficulty is in having the patient hold the eye 
fixed immovably. 
Concentric narrowing of the field of vision rarely occurs in organic 
diseases of the brain. It oftener occurs Avith multiple sclerosis, 
usually from atrophy of the optic nerve (see below), more frequently 
in neuroses ; and it is an especially important symptom in hysteria, 
“ traumatic hysteria,” but also in “ railroad neurosis,” which is closely 
related to this. With atrophy of the optic nerve there likewise occurs 
narrowing of the field of vision, which is concentric, more rarely 
in the form of a sector. Central scotoma occurs particularly in 
alcohol- and tobacco-amblyopia. 
The result of semi-decussation of the optic in the chiasm is the 
peculiar symptom known as homonymous hemianopsia—a defect in 
the field of vision, involving about half of it, upon the same side of the 
body in both eyes. Fig. 168 explains this condition: a complete 
interruption of the optic tract or of the path centrally from it, or, 
lastlv, a total destruction of the sight-centre in the cortex of the 570 
SPECIAL PI A GNOSIS. 
occipital lobe, from which there must result hemianopsia; and, too, 
the centripetal conduction of the half of the retina corresponding to 
the side of the lesion will be interrupted, consequently the half of the 
field of vision opposite the lesion will be defective. Thus, homonymous 
hemianopsia indicates a lesion which affects the tract of sight between 
Fig. 168. 
Schematic drawing for explaining the relation of the eyes to vision, and representing 
hemianopsia. The direction of vision of the two eyes BR is very nearly parallel (the 
eyes being fixed upon a distant object). M, macula lutea; Ch, chiasm ; Rr, Rl, right 
and left cortical field of sight (occipital cortex). Notice a kind of semi-decussation in 
the chiasm, the division of the fibres in the retinae, and the character of the images as 
they appear in the cortex. H, a local disease behind the chiasm; it causes hemianopsia. 
The portion of the field of vision which disappears, and the cortical field which does not 
perceive the object, are hatched. The corresponding tracts are represented by a wavy 
line. 
the chiasm and the cortex. Without doubt, this tract also passes 
through the posterior portion of the posterior crus of the inner capsule, 
and with equal certainty is in relation with the anterior corpus quadri- 
geminum of the affected side, for from here also hemianopsia may arise, 
or, when there is lesion of the corpora quadrigemina of both sides, 
there is blindness. Lesion of a tract as far as to the affected corpus EXAMINATION OF THE NERVOUS SYSTEM. 
571 
quadrigeminum causes hemianopsic rigidity of pupil with respect to 
light (see above, Hemianoptic reaction of the pupils—Wernicke). 
Hemianopsia is sometimes made manifest by the patient not notic- 
ing when some one comes to his bed from that side; by his not being 
startled when a light is quickly brought near him from the affected 
side; or, in writing, he does not see what he has written upon one 
side of a sheet of paper, etc. 
A bilateral dropping out of the nasal half of the retina, with bilat- 
eral temporal (hence, not homonymous) hemianopsia, may be caused 
by a tumor which is situated close in front of or behind the chiasm. 
In this case the two eyes in some degree may compensate, by mutual 
action, for the defect, though, of course, very imperfectly—for binocu- 
lar sight is no longer possible. There occur other difficulties whose 
description does not belong here. 
Subjective sensations of vision occur in severe diseases of the eyes 
of all kinds, but especially in anaemia (flimmering), with nervous sub- 
jects. Temporary partial amaurosis has great significance: a strong- 
shining, generally pronounced unilateral subjective sensation of light, 
which, in some of the cases, is markedly present in migraine {migraine 
ophthalmique), sometimes, during the attack, passing into hemianopsia. 
(c) The color-sense. The central perception of color is tested by 
means of skeins of woollen yarns of as pui’e colors as it is possible 
to obtain. The color-sense within the limits of the field of vision—in 
other words, the size of the field of vision for the individual colors—is 
ascertained in the same way as that of pure white (see above). It is 
not without importance (see text-books upon diseases of the Eye). 
(.d) The results of the ophthalmoscopic examination which are here 
of interest to us will be found in the Appendix. 
The diagnostic value of the electrical reaction of the retina cannot 
be determined, hence we pass it over here. 
Hearing.—Functional test. We ascertain the distance at which a 
whisper can be heard (a healthy person in a closed room can catch it 
at a distance of about twenty-five metres). We also employ the tick 
of a watch, which has previously been tested upon healthy persons, to 
ascertain the distance at which it can be heard. As a matter of course 
each ear is to be examined separately, and the ear not being examined 
is to be closed. To this also extends the testing of the behavior of 
the conductivity of the bones: a normal person does not at all or 572 
SPECIAL DIAGNOSIS. 
only barely bears a watch held near to the closed ear, but hears it 
distinctly when it is brought in contact with the skull in the neigh- 
borhood of the ear. Persons with disease of the outer ear-passage 
and of the middle ear are in the same condition as those with normal 
ears when more or less completely closed: at a distance they hear 
poorly or not at all, but by the conduction of the bones they can hear 
excellently well. On the other hand, when the acoustic nerve or its 
terminations in the tympanic cavity are diseased (nervous deafness), 
hearing at a distance and through the bones are both alike diminished. 
The examination with the ear-mirror cannot be described here. It 
naturally comes into consideration for the differential diagnosis of 
nervous deafness and of affections of the middle ear or of the external 
ear passages. (Regarding this and its detailed use, see the text-books 
upon diseases of the Ear.) We call especial attention, from the funda- 
mental scientific points of view, to the important electrical examination 
of the acoustic nerve (Brenner); it is true that, in its diagnostic rela- 
tions, it has no independent significance. 
Apart from the special aural point of view, the determination of a 
disease of the ear or of the sense of hearing is of importance for vari- 
ous reasons : (a) for recognizing constitutional affections (caries of the 
petrous bone in scrofula, tuberculosis, middle-ear catarrh in syphilis; 
see p. 286); (b) for recognizing any other local disease of the cranium, 
or within the cranium (at its base), or of the brain, which injures the 
acoustic nerve or the central conduction of hearing; lastly, with ref- 
erence to further resulting phenomena of a disease of the ear or the 
petrous bone, if they exist: purulent (sometimes, also, tuberculous) 
meningitis, abscess of the brain, and facial paralysis. 
It is further to be mentioned that, on the other hand, in a normal 
condition of the hearing apparatus a functional disturbance may be 
caused by a rheumatic facial paralysis, if it is located high up : 
from paralysis of the stapedius muscle, supplied by the facial, and 
predominant development of the tensor tympani, there may arise a 
morbid acuteness of hearing, especially for deep tones. 
Subjective sensibility of hearing (tingling, ringing, buzzing, roaring 
in the ear, etc.) occurs in anaemia, nervousness; further, in diseases 
of this organ of any kind; but, lastly, also in palpable nervous dis- 
eases. The latter are then generally affections of the acoustic nerve* EXAMINATION OF THE NERVOUS SYSTEM. 
573 
as compression or neuritis, or of its terminations in the labyrinth. 
Subjective auditory sensations, as signs of disease of the acoustic 
nucleus of the oblongata, or of the auditory tract in its central course, 
or of the auditory centre of the cortex in the temporal lobe, are very 
rare, if not unreliable. It is very worthy of note that tinnitus aurium 
may sometimes introduce an attack of migraine, apoplexy, or, as an 
aura, an epileptic attack. 
Tinnitus aurium may occasionally be combined with dizziness 
(nervus vestibularis); this is much the most pronounced in Meniere’s 
disease. Marked ringing in the ears majr become the source of 
psychical disturbance. 
In order to make a diagnosis of word deafness, or of sensory aphasia, 
it is, of course, necessary, as a preliminary condition, to determine 
whether the hearing is good. 
Lastly, attention must be especially called to the fact that a uni- 
lateral disturbance of the hearing may have entirely escaped the 
attention of the patient. 
Smell.— Testing its function. For this purpose we may employ 
camphor, petroleum, perfumed spirit, and, as disgusting material, 
asafoetida ; but not ammonia or acetic acid, because even a very slight 
amount of the vapor of these substances may irritate the trigeminus. 
We first test one side and then the other. We do not here describe 
the examination of the nose with the nasal speculum. 
Anosmia [loss of the sense of smell] of neuropathic origin is not 
very frequent. It occurs in processes in the anterior cranial fossa and 
the anterior portion of the brain which lead to compression of the 
olfactory, as from tumors, meningitis, hydrocephalus; and here it is 
also due to compression of the olfactory. Unilateral anosmia has been 
observed as an associated phenomenon of total hemiansesthesia in lesion 
of the posterior portion of the internal capsule—of course, on the side 
opposite to that diseased. But in exactly the same way we may have 
unilateral anosmia with hysterical hemiansesthesia. 
It is rare to have anosmia from lesion of the nerves passing off 
from the bulb in the ethmoid bone, when this bone is fractured. But 
it is always to be remembered that the most frequent cause of loss 
or diminution of the sense of smell is disease of the nasal mucous 
membrane. It is further to be noticed that in old age anosmia some- 574 
SPECIAL DIAGNOSIS. 
times occurs without any notable pathological cause (atrophy of the 
olfactory). 
In very isolated cases the disturbance is to be referred to paralysis 
of the trigeminus; that is, to the dryness of the nasal mucous mem- 
brane due to the paralysis. 
Ilyperosmia and osmic paraesthesia (parosmia) occur in hysteria and 
insanity, and as an aura in genuine epilepsy. 
Regarding the significance of the nose as a point of departure in 
disease within the cranium, compare further, pp. 358-9. 
Taste. — Testing its function. We test it for the recognition of 
salt, sugar, vinegar, and quinine. We also make a test by retaining 
the same order of succession of all these substances when suitably 
diluted. Then follows the testing of a circumscribed portion of the 
tongue, as first one and then the other half of the tongue, then the 
anterior two-thirds as compared with the posterior one-third, because 
the former portion is supplied by the chorda, the latter by the glosso- 
pharyngeus. For this purpose we wipe the tongue somewhat dry, 
apply to it a very little of the [test] fluid with a glass rod, remove any 
surplus and have the tongue simply drawn back, but without any 
further motion. Although this method is somewhat doubtful, since a 
portion of the hard and soft palate, which cannot be exactly defined, 
also possesses the sense of taste, yet it seems practicable, as follows 
from its positive results in certain cases of facial paralysis. The 
more exact method of not drawing the tongue back into the mouth 
after the test substance has been put upon it, thus to eliminate the 
assistance of the palate, has the disadvantage that then even persons 
in health can only imperfectly taste. 
Ageusis [loss of the sense of taste] on one side of the tongue is 
observed with total hemianaesthesia. Unilateral ageusis of the anterior 
portion of the tongue occurs also from peripheral chordal paralysis, 
and this is the case whether it involves injury of the branch of the 
trigeminus as far as the Gasserian ganglion, or of the second branch 
from there to the spheno-palatine ganglion, or of the facial between 
the geniculate ganglion and the point where the chorda is given off, 
or of the commisural portion between the fifth and seventh nerves, the 
N. petrosus superf. major. Total ageusis points to hysteria. 
Moreover, the fineness of the taste, as well as of smell, varies much 
with the individual. EXAMINATION OF THE NER VO US SYSTEM. 
575 
Disturbances of the Vegetative System in Nervous 
Diseases. 
We must here limit ourselves to a brief enumeration of the most 
important points. 
1. Greneral Phenomena 
The apoplectic habit (short, thick neck, red face, full chest, abun- 
dant layer of fat) decidedly predisposes to hemorrhage of the brain, 
but this also occurs very frequently even in very lean and anaemic 
subjects. In other respects the general habit does not predispose 
individuals to diseases of the nervous system. 
Nervous diseases affect the nutrition in a great variety of ways, 
sometimes, for a long time, not at all, and again very decidedly. It 
depends chiefly upon the accompanying vegetative disturbances: fever, 
decubitus (which see) and the various disturbances of individual 
internal organs to be mentioned. 
A tuberculous nature of a local disease of the brain, or of a menin- 
gitis may be suspected (aside from possible tuberculosis of the lungs, 
scrofula, hectic fever) when the nutrition is decidedly poor. The same 
thing is time with respect to carcinoma. 
Fever occurs in diseases of the nervous system: (a) if the disease 
itself is of an inflammatory or infectious nature; (6) if it causes 
vegetative disturbances, as decubitus, cystitis, etc., which in turn 
give rise to fever; (c) in many cases where the elevation of the tem- 
perature is supposed to be of a neurotic character: in progressive 
paralysis, in injury of the cervical spinal cord, which is not fatal 
(here, according to Naunyn and Quincke, the increase in the produc- 
tion of heat rises to 44 C. [=112° F.]), in tetanus, in severe epileptic 
attacks. 
Diminution of temperature is likewise seen in progressive paralysis, 
and with injuries of the cervical spinal cord. 
2. Disturbances of the Respiratory Apparatus. 
Nose. Certain affections of the nose (nasal polypi, enlargement of 
the turbinated bones, chronic catarrh) stand in a peculiar, often causal 
relation to various neuroses, especially to bronchial asthma, to nervous 
affections of the heart. The nose, through the ethmoid bone, may be 576 
SPECIAL DIAGNOSIS. 
the gate of entrance for meningitis or abscess of the brain ; also, it is 
to be mentioned that the nose comes especially under consideration in 
the diagnosis of syphilis. 
Larynx. The larynx may be paralyzed. When there is anaes- 
thesia of the larynx we investigate its nerves and their centres in the 
bulb; further, hysteria sometimes comes into consideration. See 
some additional remarks regarding the larynx in the Appendix. We 
have a nervous cough from simple nervousness, also in hysteria. 
Laryngeal spasm is an attack of nervous cough, which may occur in 
decidedly varying severity from slight irritative cough to attacks 
resembling whooping-cough of the severest character. It is produced 
by irritation of the vagus by tumors of the bronchial glands, or it 
occurs in tabes and hysteria. 
Dyspnoea: see what was said regarding asthma in connection with 
the nose. It occurs also in uraemia, and is sometimes the most promi- 
nent symptom in chronic uraemia, and in diabetes. Lastly, dyspnoea 
is caused by functional and true paralysis of the respiratory muscles. 
With the latter we take into consideration the . tracts of the nerves, 
the nerve centres, especially the respiratory centre in the bulb. Dys- 
pnoea is caused also by tonic and rapidly recurring clonic spasms of 
these muscles. In hysteria there is great disturbance of the breath- 
ing : extrerpely rapid superficial, or labored, deep, panting breathing, 
and temporary fixation of the diaphragm. (Regarding Cheyne-Stokes 
phenomenon, see p. 92.) 
The condition of the lungs and the character of the sputum are 
chiefly regarded from two points of view: the determination of a 
tuberculosis; and, because a connection between fetid bronchitis, 
abscess or gangrene of the lungs, emphysema, and purulent menin- 
gitis and abscess of the brain has recently been recognized. 
3. Disturbances in the Circulatory Apparatus. 
Heart. This has most important relations to hemorrhages and em- 
bolic softening of the brain: hypertrophy of the left ventricle favors 
the occurrence of hemorrhage (contracted kidney) and valvular endo- 
carditis. In case of weak heart, thrombi existing within the heart 
(the auricular appendix), may cause emboli. Atheroma of the vessels 
likewise may cause hemorrhage, emboli, and local thrombosis of the EXAMINATION OF THE NERVOUS SYSTEM. 
577 
vessels of the brain. But often aneurism of the minute arteries of the 
brain causes hemorrhages without there being any atheroma of the 
vessels of the body. Whenever there is loss of consciousness, but espe- 
cially in every case of apoplexy, and of paralysis, which is to be referred 
to the brain, the heart and vessels are to be most carefully examined. 
Palpitation and pain (angina pectoris) occur in organic disease of 
the heart, in simple nervousness (heart neuroses), in hysteria, in Base- 
dow’s disease, and in nicotine poisoning. Hence these phenomena 
may have great diversity of significance. 
Much has already been said (p. 237ff.) regarding the anomalies of 
frequency of the pulse. Temporary, seldom continuous, quickening 
of the pulse occurs in neuroses; but, besides, paralysis of the vagus 
or the vagus nucleus (neuritis, bulbar paralysis) quickens the pulse, 
often, also, causes a gallop-rhythm (see p. 220). 
The vasomotor disturbances are extremely manifold and interesting, 
but, according to our present knowledge, are seldom of diagnostic im- 
portance. There must be mentioned the unilateral paleness or redness 
of the head in many cases of migraine (hemicrania, sympathetica 
spastica and sympathetica paralytica); unilateral paleness in hysteri- 
cal hemiansesthesia. We observe cyanosis, coldness, oedema, especially 
frequently in cerebral, sometimes also in spinal (poliomyelitis acut.) and 
in peripheral paralyses, and in hysteria. Sensations of heat of the 
skin in Basedow’s disease—perhaps, also, in paralysis agitans—are to 
be referred to vasomotor influences. Regarding the secretion of per- 
spiration, see p. 86f. 
Local asphyxia (cyanosis, coldness) and spontaneous symmetrical 
gangrene is observed in general neuroses, peripheral neuritis, but also 
in acute infectious diseases, diabetes, and ergotism. 
4. Disturbances of the Digestive Apparatus. 
Very much has already been said upon this point, hence reference 
is made to p. 284ff. 
Anaesthesia of the pharynx may, exceptionally, he evidence of a 
palpable disease; it is a much more frequent and important symptom 
of hysteria. 
Increase in the secretion of saliva occurs in psychoses, idiotism, also 
in bulbar paralysis; in all three cases—in the first from inattention, 578 
SPECIAL DIAGNOSIS. 
in the latter from simultaneous paralysis of the lips, tongue, and mus- 
cles of deglutition—the secretion sometimes runs out of the mouth. 
But, for the same reason, in bulbar paralysis the secretion escapes 
from the mouth, although it is not increased in amount. Diminished 
secretion of saliva is seen chiefly in facial paralysis (secretory fibres in 
the chorda tympani). 
We are also to bear in mind the nervous dyspepsias, which may be 
divided into psychical disturbances, as dyspeptic difficulties with per- 
fectly normal digestion, and nervous disturbances of secretion or of 
the motor function of the stomach. The diagnosis is to be determined 
by an examination of the contents of the stomach. 
As was previously mentioned, vomiting takes place in all kinds of 
disease of the brain, especially in those that develop rapidly; further, 
very especially in the course of diseases of the cerebellum. It is also 
to be mentioned that there is vomiting with migraine and hysteria. 
Gastric crises are attacks of very severe, often widely-radiating 
cardialgia, associated with vomiting (hyperacidity); they are a pecu- 
liarity of tabes, and not infrequently they are for a long time misun- 
derstood. Intestinal crises (attacks of colic), and those involving the 
rectum (severe tenesmus), are rare occurrences in tabes. 
With a number of nervous disturbances, especially in children, wTe 
must think of intestinal parasites. They may cause nervous agitation, 
marked nervousness, attacks like migraine, and spasms. It is not 
unimportant, although very infrequent, that the taenia solium may 
infect the subject who has it with cysticercus [cellulosae] : thus, some- 
times, cysticerci may develop in the brain, in the eye. 
Habitual constipation is especially frequent in all kinds of diseases 
of the spinal cord. Marked retentio alvi is very often dependent 
upon weakness or paralysis of the abdominal muscles, perhaps from 
abdominal pressure. 
Incontinentia alvi is partly the result of inattention on the part of 
idiots, the insane, those who are unconscious; on the other hand, it is 
evidence of paralysis which either only manifests itself by the fact that 
the stool cannot be retained long after the first sense of desire, or that 
only the fluid stool cannot be held back; lastly, that solid as well as 
thin stool passes each time. This disturbance may occur from inter- 
ruption of the reflex arc centripetally from the rectum to the lumbar 
portion of the spinal cord, and thence again to the sphincter muscles, EXAMINATION OF THE NERVOUS S VST EM. 
579 
or by interruption of the tracts, centripetal and centrifugal, between 
the lumbar cord and the brain (voluntary defecation). Involuntary 
discharge of the stool likewise takes place, particularly in spinal 
diseases both of the lumbar cord and of the portion above it. In 
the latter case the discharge seems to be regulated by the absence of 
reflex, but without the influence of the will; on the other hand, in 
destruction of the lumbar cord, the reflex as well as the voluntary 
influence is annulled: the sphincter is relaxed, the scybala escape as 
they are carried down from the intestine. The same thing is also 
observed in very great prostration. 
5. Disturbances of the Urinary Apparatus. 
Oliguria, anuria, also polyuria, may temporarily affect hysterical 
patients. Polyuria (diabetes insipidus) and also glucosuria are ob- 
served temporarily or continuously with local diseases of the oblongata, 
for a very short time in tabes, and when there is considerable increase 
of the intracranial pressure. On the other hand, in genuine diabetes 
mellitus there are observed a number of nervous disturbances: neural- 
gia, neuritis, deep disturbances of the nutrition of the skin and the 
subcutaneous cellular tissue, and coma which appears either slowly or 
suddenly like apoplexy. 
Cystitis, from the slightest to the most severe form, is observed 
when there is difficulty in emptying the bladder (which see), and espe- 
cially (but not exclusively) after the use of the catheter. It is par- 
ticularly an important and frequent complication of myelitis transversa 
and of tabes. 
Further particulars regarding the condition of the urine are given 
in connection with the urinary apparatus itself. 
Involuntary passage of the urine occurs in the insane, with idiots, 
in the state of unconsciousness, in severe diseases of any sort; fur- 
ther, as a special form of disease in enuresis nocturna. 
Retentio et incontinentia urince, however, have an especial role. 
With the former, the patient, when urinating, must press or wait a 
little, when the urine gradually comes in the ordinary way, or else it 
escapes very slowly in a small stream, or the bladder cannot empty 
itself at all and the catheter must be used. Incontinence often first 
manifests itself as under reflex control, but the urine is passed inde- 580 
SPECIAL DIAGNOSIS. 
pendently of the will, or simultaneously with retention there is an 
after-trickling, or an escape of the urine while laughing, coughing, or 
in severe cases, as ischuria paradoxa: the bladder is not completely 
emptied, sometimes remains always abnormally full, but from time to 
time some of its contents escape; in the most severe cases the urine 
trickles continually from the constantly-full bladder. In the latter 
cases there is complete paralysis of the bladder (generally of the 
detrusor as well as of the sphincter). 
An involuntary passage of urine which is under reflex control re- 
quires an intact reflex arc: (a) healthy mucous membrane of the 
bladder; (b) sensitive muscle ; (e) nerves ; (d) lumbar spinal cord; 
(e) muscles of the bladder—hence it occurs with an intact lumbar 
cord, but one which is cut off from the brain: myelitis transversa 
dorsalis, cervicalis, or traumatic and other spinal transverse lesion. 
We meet with complete paralysis of the bladder chiefly in lesions of 
the lumbar cord. All kinds of bladder disturbance occur, from the 
slightest to the most severe, in tabes. Differential diagnosis comes 
chiefly into consideration from the fact that disturbances of the bladder 
are absent in multiple neuritis (as against tabes); further, in amyo- 
trophic lateral sclerosis, polio-myelitis (as against myelitis). 
We have still to mention the [frequent, but not invariable] invol- 
untary passage of urine in attacks of genuine epilepsy; it is wanting 
in hystero-epilepsy, and so it is important for differential diagnosis. 
Bladder crises (painful tenesmus) are observed in tabes. 
Lastly, it is to be cited that the most varied conditions of irritation 
of the penis (especially phimosis) may lead to enuresis, pollution, 
other nervous disturbances of various kinds. 
6. Disturbances of the Grenital Apparatus. 
The various anomalies of the male genital function may be almost 
entirely (with the exception of azoospermia and aspermatism) func- 
tional and organic, and in the latter case again may rest upon a ner- 
vous as well as some other form of disease. From the standpoint of 
diagnosis of nervous diseases the decline of the genital function is 
chiefly of importance in tabes, as against chronic multiple neuritis. 
On the other hand, differential diagnosis from neurasthenia spinalis is 
often necessary, and it is to be remembered that in the latter disease EXAMINATION OF THE NERVOUS SYSTEM. 
581 
there may also be long-continued marked functional disturbance of the 
activity of the sexual function. 
Of the female genital apparatus very little needs to be said here. 
An energetic reaction has taken place against the etiological relation, 
formerly very strongly claimed, between anatomical disturbances and 
hysteria, which reaction, in turn, is going too far. In our opinion, 
there is no doubt that in women diseases of a sexual character may 
cause hysteria, certainly more than other conditions which tend to 
weaken the nervous system do. 
The so-called painful ovary or ovarian liypei’aesthesia, sensitiveness 
of the hypogastric region, especially on the left side, to pressure upon 
this spot (which has nothing to do with the ovary) is not unimportant 
in hysteria and sometimes causes an hysterical spasm; also [pressure] 
sometimes arrests an existing attack [Charcot]. Similar hystero- 
genous zones may exist in other regions of the body in hysterical 
subjects. 
7. Disturbances of the Skin. 
A number of diseases of the skin, apart from the special province 
of dermatology, rest upon a neurotic basis, as herpes, sometimes prob- 
ably also pemphigus ; further, the so-called glassy skin ; at any rate, 
each of these may be regarded as a disease of the peripheral nerves. 
Herpes zoster, especially when it involves the intercostal nerves, has 
a special significance: it has its origin in compression of the spinal 
cord, in tabes, meningitis spinalis (here probably entirely from the 
roots of the nerves), in disease of the spinal ganglion, and in peripheral 
neuritis, in all these cases generally associated with neuralgic pains. 
But herpes also occurs in the region of any other nerves, as the tri- 
geminus. 
Regarding herpes labialis, etc., see under acute general diseases, 
p. 50. 
In all diseases of the nervous system we must search carefully for 
any evidences of syphilis, not only upon the skin but also in the other 
organs which come under consideration. 
Regarding local perspiration (see p. 38) we sometimes, although 
rarely, have local anidrosis. Among the laity the loss of perspiration 
of the feet plays an important part as the supposed cause of a 
number of diseases, particularly spinal, as tabes; it is probably a con- 
secutive, and in itself an indifferent, phenomenon of this disease. 582 
SPECIA L DIA GNOSIS. 
Hemorrhages of the skin occur spontaneously in hysteria, as curi- 
osities ; punctiform ecchymoses may be observed upon the face, chiefly 
in the neighborhood of the eyes after epileptic attacks. Here, also, 
we more frequently have hemorrhages in the conjunctiva. Hemor- 
rhages into the subcutaneous tissues take place after injuries received 
during an epileptic attack. The significance of hemorrhages into the 
skin and subcutaneous cellular tissue of the head (especially about the 
eyes, and of the nose in fracture of the base of the skull), is treated 
of in the works upon Surgery. 
jDecubitus is an ulceration of the skin, then of the subcutaneous 
tissue and sometimes of the deeper tissues, and even of the bone 
itself. It occurs in dependent portions of the body upon which the 
patient’s weight rests, and particularly where the skin covers bony 
prominences, as the sacrum, the heels, the scapulae. Want of clean- 
liness, and lying upon the sacrum, especially when there is inconti- 
nence of stool and urine, are very marked exciting causes. 
1. Decubitus acutus (malignus). It at first manifests itself as an 
erythema exudativum, then vesicles are generally formed, whose bases 
become necrotic, from which the destruction proceeds rapidly both in 
area and depth. Pressure and filth are marked causes, but pressure 
alone may produce the ominous exudative erythema, as on the inner 
sides of the knees when pressed together in cases of adduction con- 
tracture, where we once saw an enormous decubitus acutus form in a 
few days. Decubitus acutus has been seen by Charcot in hemiplegia 
upon the posterior portion of the paralyzed side two to four days after 
an attack of apoplexy. We have observed it only in severe diseases 
of the spinal cord. 
2. Ordinary decubitus occurs only when the body lies so that pres- 
sure is made upon one place and with the concurrence of uncleanness; 
it may be entirely prevented by proper care. It also begins as an 
erythema, or in the form of a few pustules, or a cutaneous hemor- 
rhage. It occurs in all organic paralyses, also in any kind of cachexia, 
if care is not taken to prevent it. 
Mai 'perfor ant [perforating disease of the foot] is a destruction of 
the skin and deeper parts of the foot, especially of the heel [sole?]. 
It occurs in tabes, in progressive paralysis, also in diabetes. Recently 
ulcerations of the skin, or subcutaneous tissues in syringo-myelitis of 
the cervical cord have been observed (Schultze). EX AMIN A TION OF THE NERVOUS SYSTEM. 
583 
Growth of hair is a very notable anomaly dependent upon a neu- 
rosis. But these changes have no independent diagnostic signifi- 
cance. 
The nails readily become claw-like, angular and brittle in long-con- 
tinued severe peripheral paralysis. 
8. Bones and Joints. 
We observe the arrest of growth of bones after severe central paral- 
ysis during the period of childhood, and, likewise, after polio-myelitis 
acuta it is generally more marked than after encephalitis. Abnormal 
brittleness of the bones is frequently seen in tabes. In severe syringo- 
myelitis of the cervical cord, there are severe trophic disturbances of 
the bones, as fractures, periosteal inflammations with separation of 
sequestrum. 
Arthropathia of all kinds are to be observed in diseases of the 
nervous system : 1. Organic arthropathia, seldom in recent hemi- 
plegia, occurring more frequently as stiffness of the joints, is easily 
confounded with stiffness and sensibility from contracture. It occurs 
in old hemiplegias, and is also to be observed as serous effusion with 
periarticular swelling or as severe deforming arthritis, also causing 
new formation ; both the latter occur in tabes. 
2. Joint neuroses occur as painful, occasionally exacerbating affec- 
tions of the joint, sometimes with points of pressure, stiffness, and 
contracture, the two latter disappearing under narcosis, but without 
any sign of organic disease. 
Under the name of acromegalia, Marie has recently described a 
peculiar disease, which consists in a giant-like enlargement of the 
feet, hands, nose, inferior maxilla, and certain parts of the skeleton, 
dependent entirely or chiefly upon hypertrophy of the bones. 
THE DIAGNOSTIC VALUE OF THE SYMPTOMS IN NERVOUS DISEASES. 
In diseases of the nervous system the individual phenomena combine 
to form complexes of symptoms in so manifold a way (much more than 
in the diseases of any other organ-system), that the representation of 
only the most important possible combinations would very much ex- 
ceed the limits of a brief work upon diagnosis. Moreover, for the 
introductory study of individual diseases, we must confess that we 584 
SPECIAL DIAGNOSIS. 
think the method of special pathology which compactly presents the 
picture of disease on the lines of etiology, anatomy and symptoms is 
far preferable to the introduction of such minutiae into a text-book 
upon diagnosis, as, if this and that phenomena is present, then the 
disease is so-and-so; but if we have this and that other phenomena, 
then it is some other disease. For this reason we add here only a few 
general remarks. 
In diseases of the nervous system much more than in those of the 
rest of the organism, the impression stands out distinctly that we in 
reality have to estimate the phenomena found in a patient in two 
ways. We must ask ourselves : 
(a) What are the portions of the nervous system Avhose disease, 
judged by their nature and location, has caused or can cause the pres- 
ent phenomena ? This proceeds upon our knowledge of the anatomy, 
physiology and pathological physiology of the nervous system, which 
we must acquire as perfectly as possible. 
(b) Does the picture formed by all the symptoms correspond with 
any disease with which we are now acquainted ? Then comes the 
further question : 
(c) What light does the etiology, development, and course of the 
disease throw upon its nature, and sometimes also upon its location ? 
The lines of thought designated by (a) and (b) closely interlock; 
generally both are employed in a single case. In certain diseases, 
indeed, we are wholly or almost wholly directed to the latter, (b), which 
is, so to speak, unscientific, particularly in certain general neuroses 
or functional diseases (regarding which, see below). On the other 
hand, we are fortunately able, in local diseases of the brain, of the 
spinal cord and of the peripheral nerves, to proceed upon an almost 
purely anatomico-physiological basis. 
In order to make a diagnosis of the location of a local disease, 
besides the special knowledge requisite for such a discrimination, 
one must have a certain amount of practice in making combinations, 
of which the ability to keep in mind the topography must form the 
basis. (Let it be here once more repeated that our preliminary 
anatomical remarks do not, by any means, contain all that has been 
positively determined and is interesting to know, but are rather for 
the purpose of instruction in topographical thinking). We advise 
the beginner, who wdshes to train himself in this department, to begin EXAMINATION OF THE NERVOUS SYSTEM. 
585 
with the study, for instance, of peripheral facial paralysis, the different 
combinations of paralysis of cranial nerves at the base of the brain, 
and then to study the group of symptoms in the cerebral centres. 
In order to arrive at a conclusion regarding the location of a local 
disease it is recommended, as the result of experience, that we should 
always attempt to trace the different phenomena back to a focus; but 
it is evident that sometimes there will be several foci. Moreover, the 
probability that there is only one focus varies with the supposed nature 
of the disease; thus, for instance, a glioma almost always occurs as a 
single tumor, while metastatic cerebral abscesses are generally, and 
thrombotic foci of softening very often, multiple. 
In regard to local diseases of the brain we are to distinguish 
between the general phenomena as respects the brain, and the local 
symptoms. The general brain symptoms are essentially those relating 
to increased intracranial pressure, and may comprise : 
(a) Psychical disturbances (affecting the clearness of consciousness, 
of intelligence, the subjective condition). 
(b) Pain in the head; dizziness; rigidity of the pupils; spasms; 
certain phenomena of organic life, as diminution of the pulse, vomit- 
ing, etc. 
Affections that develop rapidly and are of limited extent, espe- 
cially hemorrhages, also other disturbances occuring suddenly, as 
emboli, usually produce the most pronounced general phenomena. 
We call the sudden loss of consciousness, sometimes combined with 
one or other of the phenomena mentioned above, an apoplectic attack. 
The local symptoms are divided into direct and indirect: the 
former are dependent upon disturbances of the centre and the tracts 
which are regarded as irremediable, the latter are caused by all sorts 
of disturbances (commotion, “collateral oedema,” anaemia, etc.) in the 
neighborhood of the elements that are really injured—disturbances 
which may again disappear, and which, after a hemorrhage or emboli, 
always disappear in the course of months, so that only the direct local 
symptoms caused by the disturbance itself then remain. With local 
growths which develop slowly, as tumors, these indirect local symptoms 
may often change, or they may permanently remain. In the spinal 
cord, when there are local diseases, the general phenomena do not 
usually play such an important role, and we may not here be able 
sharply to separate the direct and indirect local symptoms. 586 
SPECIAL DIAGNOSIS. 
But in all diseases of the nervous system all possible disturbances 
in the rest of the organism contain diagnostic points, and come espe- 
cially under consideration in local diseases of the brain and spinal 
cord for forming a judgment as to the nature of the local trouble. We 
compare what was said upon this point in the chapter on vegetative 
disturbances; but, especially, we must never fail, in every disease of 
the brain and spinal cord, to take into consideration the possibility of 
the syphilitic nature of the disease (when there is the slightest sus- 
picion of syphilis the treatment is to conform to it). 
Under the anatomical diseases of the nervous system, in every 
respect the so-called systemic diseases have a special place. In these 
conditions the disease in the nervous substance is, with more or less 
regularity, always concerned only with certain elements, which sys- 
tematically (in Flechsig’s sense, see below) belong together, while other 
portions, even lying very close to the diseased ones, remain entirely 
healthy : the disease does not lay hold of the entire region, and thus it 
stands in sharp distinction from the inflammatory diseases and all new 
formations. But even though the systemic disease lays hold upon ele- 
ments of the same function (and indeed always the symmetrical por- 
tions of the two sides ; and these are generally, although not always, 
of the same severity upon both sides), it always produces, at least 
in its main features, a like combination of symptoms. If several 
systems are affected with disease at the same time, then we speak of 
the combined system-disease. Amyotrophic lateral sclerosis furnishes 
the most clear picture of a combined system-disease which may affect 
the whole cortico-muscular conducting tract from the cortex to the mus- 
cles, but always leaves all the rest entirely intact. We advise every 
one to begin the study of the system-diseases with this remarkable 
one. 
Recently, aside from the systematic nerve-trunk degenerations, we 
speak, also, of systematic nuclear degeneration, in that we have 
somewhat modified the idea of the system which was employed by 
Flechsig only for the bundles of fibres which showed similarity by 
the point of time when their medullary sheath was formed (and which 
“ appeared to be intercalated between apparatus having objects of 
equal value ”). Hence, and not incorrectly, we designate the disease 
itself as systematic when it involves “apparatus having objects of 
equal value.” EXAMINATION OF THE NERVOUS SYSTEM. 
587 
In conclusion, we make a few further remarks regarding the differ- 
ential diagnosis of functional and anatomical diseases of the nervous 
system ; this differential diagnosis is often so extremely easy that the 
question does not arise at all, but sometimes it us extremely difficult. 
The points of departure for the differential diagnosis are arranged in 
four categories: 
1. The first question always is whether the general picture entirely 
corresponds with a local disease, or an anatomical or functional disease. 
It is to be remarked, however, that hysteria may sometimes exactly 
simulate a local disease of the brain. 
2. There are certain symptoms of palpable disease that are entirely 
unmistakable. These are: the reaction of degeneration (or rapidly 
developed and very decided atrophy and laxness of the paralyzed 
muscles (compare, further, what was said on p. 493 regarding atrophy 
in hysterical paralysis); choked disc and reflex rigidity of pupils are 
also symptoms. Not absolutely certain, although pointing quite 
decidedly to a palpable disease, are : absence of tendon reflex ; in 
unilateral affections, the unilateral absence of abdominal reflex, and 
very marked disturbance of the bladder. 
3. There is one almost certain sign of functional disease: a sudden 
return to a perfectly normal condition after long persistence of a dis- 
eased condition, or the sudden occurrence of new and different phe- 
nomena with the disappearance of those previously existing. There 
are other signs of functional (hysterical) diseases which, in combina- 
tion, cannot mislead; these are the stigmates hysteriques (Charcot) : 
hysterical hemiansesthesia, concentric limitation of the field of vision, 
characteristic spasms, sometimes hysterogenic zones. 
4. As regards cerebral symptoms, marked development, or, on the 
other hand, the absence, of a disturbance of the sensorium and the in- 
telligence, decides the question. Also, continuous fever and rapid 
decline of strength indicates an anatomical disease. APPENDIX. 
We present here a very brief sketch regarding the examination of 
the larynx with the mirror and the revelations of the ophthalmoscope, 
so far as they are related to internal diseases, especially to the diseases 
of the nervous system. Lastly, there follows a review of the life his- 
tory of those pathogenic bacteria which have any part in the diag- 
nosis of internal diseases. 
We pass over entirely the examination, with the mirror, of the nose 
and ears, because these pertain chiefly to the diseases of these organs 
themselves, and are very rarely of significance for recognizing any 
other diseases. Besides, with reference to the latter view, we have 
already (pp. 573 and 575) referred to the diseases of the nose and ears 
which do sometimes come under consideration. 
1. Laryngoscopic Examination of the Larynx} 
Instruments and sources of light. Tiirck’s reflector with a head- 
band is most frequently recommended for illuminating the throat. As 
the laryngeal mirror we employ a round mirror, with a diameter of 20 
to 25 mm., fixed to a staff- at an angle of 120 to 125 degrees. The 
staff is fixed to a handle or it is screwed into a handle prepared for it. 
For a source of light we may employ any sufficiently powerful od- 
or gas-lamp. The lamp is placed close to the head of the person to 
be examined, so that the light from the reflector is thrown at the 
smallest possible angle into the throat of the person being examined. 
If it can be had, sunlight is better than artificial light. It is employed 
either in such a way that the patient sits, with his eyes closed, facing 
the sun, and the light is allowed to fall directly into the throat or so 
that the sunlight is thrown by the reflector into the throat. If the 
1 Let it be distinctly understood that the above only contains the most essential 
points which are of use in the examination itself. They cannot and should not take 
the place of the study of these subjects in a medical course. 
589 590 
APPENDIX. 
sunlight is glaring, we employ a special mirror with a longer focus (or 
a plane mirror), because the ordinary reflector would make a too glar- 
ing light, and sometimes even produce an uncomfortable sense of heat 
in the throat. Electric, magnesium, and other lights are at present 
too expensive to take the place of sunlight. 
In making the examination we sit directly in front of the patient, 
have him open his mouth, set the reflector at the proper angle, then 
warm the laryngeal mirror a little over a spirit-lamp (testing its tem- 
perature by placing it against the back of the hand), have the patient 
put out the tongue, seize it with a napkin or handkerchief and draw 
it out [as far as possible. It is well to have the head thrown quite 
well back.]. Holding the mirror as one would a pen, it is to be slowly 
and carefully introduced into the mouth, and then the patient required 
to distinctly pronounce “se," at the same time giving the proper direc- 
tion to the mirror as it is pushed as far back as possible into the phar- 
yngeal cavity, slightly pressing up the soft palate. The parts are now 
brought into view by elevating the mirror, depressing it, turning it 
Fig. 169. 
Laryngoscopic view of the larynx during quiet breathing (after Heitzmann), double size. 
now to the right, then to the left, and revolving it, both during quiet 
respiration and phonation. 
The mirror must be most scrupulously cleaned with every examina- 
tion. It is not necessary to employ a special mirror with patients 
who are manifestly syphilitic. 
Irritability of the pharynx (strangling, vomiting) may, with prac- APPENDIX. 
591 
tice, be avoided. In very obstinate cases we can employ cocaine. 
(See the special text-books regarding other obstacles and the ways of 
meeting them.) 
In the laryngoscopic image the parts that are anterior appear as the 
posterior; on the other hand, what is upon the right hand of the pa- 
tient remains upon the right; the examiner has, of course, the right 
vocal cord of the patient upon his left side. 
We observe (see Fig. 169): 1. The base of the tongue, the glosso- 
epiglottic ligaments, the epiglottis, lig. aryepiglottica with the carti- 
lages of Wrisberg. 2. The arytenoid cartilage, or the cartilage San- 
torini, the false vocal cords, the sinus Morgagni. 3. The ligamenta 
glottidis vera, with the vocal process of the arytenoid cartilage. 4. 
The region between the arytenoid cartilages, pars interarytsenoidea 
(the posterior wall of the larynx); the subcordal region, or the fore- 
shortened trachea. The illumination must be strong. 
It is advisable for those who have had but little experience to first 
fix the landmarks by the shining white prominent true vocal cords, 
and from thence to examine the individual parts of the laryngeal 
picture one after the other. 
The examination with the laryngeal mirror is directed to three 
things: the form and the color of the parts of the larynx, and the 
position, or motion of those that move. 
As to the form of the several portions of the inside of the larynx it 
is to be remembered that the representation given in Fig. 169 is, of 
course, only schematic. Repeated examinations of normal larynges 
will show the variations and fix them in mind. The form of the epi- 
glottis varies very much; this is also true of the arytenoid cartilage 
and the false vocal cords or the opening of the ventricle of the larynx. 
The color of the mucous membrane of the larynx, with the excep- 
tion of the true vocal cords, is tolerably uniform and corresponds some- 
what with that of the hard palate. Very often the upper border of 
the epiglottis, and sometimes its upper surface, is lighter, even yellow- 
ish-red. Above the arytenoid cartilages, the color of the mucous 
membrane varies considerably. sometimes it is exactly like the other 
parts, sometimes darker, again lighter, and then yellowish. The true 
vocal cords are shining white; in individual cases, with the function 
perfectly normal, they are slightly rosy. At the vocal process there 
is a circumscribed yellowish spot. 592 
APPENDIX. 
We must be on guard against being misled by deposits of mucus 
or of pus from the lungs. These deposits may be superficial, or may 
conceal deep ulcerations, loss of substance, croupous deposits. If 
in doubt, require the patient to cough. If still uncertain, have the 
patient inhale the vapor of steam for a few minutes, and then repeat 
the examination. 
Normally the positions and movements of the portions of the larynx 
are perfectly symmetrical, although it is to be remarked that if the 
mirror is not properly held in position, the parts may easily appear to 
be unsymmetrical. During quiet respiration, the rima glottidisis tol- 
erably widely opened—at least so that the whole breadth of the true 
vocal cords is visible; the arytenoid cartilage (cartilage of Santorini) 
can be seen between the pars interarytsenoidea (posterior wall of the 
larynx); with active deep inspiration, the vocal cords separate from 
each other still more, so that they almost or quite disappear under the 
false vocal cords (which likewise stand apart. During phonation, the 
vocal cords come so closely together that either no slit between them, 
or scarcely any, can be seen. Generally their median edges form a 
perfectly straight line. But in individual cases, only the pares liga- 
mentosae close so sharply, and posterior to the process, vocales (that 
is, the pars cartilaginea), the vocal cords remain somewhat more apart, 
leaving a triangular space between them. 
When the glottis is closed the arytenoid cartilages come near to- 
gether and the pars interarytaenoidea disappears ; on the other hand, 
the false vocal cords leave a tolerably broad space between each other, 
through which we see the true vocal cords. 
Pathological conditions. Since Ave here come upon a subject that 
has already been frequently referred to, in what follows Ave bring 
forward only those conditions Avhich have relations to other internal 
diseases, and treat of them in the briefest AVay. 
We do not meet with paleness of the mucous membrane of the 
larynx as a local condition. Also, it is no longer of importance in 
the recognition of a general anaemia, because this is much easier deter- 
mined by the paleness of the skin, lips, etc. Only one circumstance 
needs mention, that tuberculous infiltration and ulceration, in contrast 
with other kinds, as syphilitic, often accompanies a very striking gen- 
eral paleness of the mucous membrane of the larynx. Abnormal red- 
ness of the mucous membrane of the larynx, Avithout other changes, APPENDIX. 
593 
occurs in febrile hypersemia of all the mucous membranes and in gen- 
eral or local engorgement (the latter caused by pressure upon the 
larynx by tumors, from engorgement in the region of the cava supe- 
rior), Also, whenever there is any redness of the larynx it must, as 
a matter of course, lead us to examine most carefully for any possible 
other changes (ulcerations, swellings, etc.). 
Redness, swelling, and sometimes secretion, are the signs of catarrh. 
Acute, as well as chronic laryngeal catarrh may involve various loca- 
tions : for example, it may attack the upper portion of the larynx, 
leaving the glottis free ; it may also attack only the glottis. A simple 
catarrh is always symmetrical. Acute, as well as chronic catarrh may 
cause motor disturbances: on the one side this may be due either to 
the swelling of the mucous membrane (especially of the incisura inter- 
arytaenoidea, preventing the closure of the glottis), or, to paralysis of 
the tensor of the vocal cords or the adductors. 
Acute laryngitis, especially in children, may give rise to apparent 
stenosis by reason of the swelling. 
It is to be especially remembered that chronic and recurrent acute 
catarrh, and likewise, no doubt, simple catarrh, are very frequent in all 
chronic diseases of the lungs and especially in tuberculosis. It is, 
further, important to remember that behind a chronic catarrh a tuber- 
culous or syphilitic (or lupous) new formation may for some time be 
concealed. A swelling which is limited to or elects the interarytaenoid 
region is always very highly suspicious of tuberculosis. 
Laryngitis hypoglottica (von Ziemssen) is an especially severe form 
of acute, as well as chronic, catarrh. In this 
disease we see beneath the vocal cords some- 
times merely a soft rosy border, which can only 
be seen during inspiration; sometimes a firm, 
grayish-red, smooth or uneven lump (see Fig. 
170). It is almost always present upon both 
sides. These subcordal swellings appear to 
vary a good deal as to their nature : sometimes 
they are simply due to oedema; in other cases, 
to a simple catarrh; in still others, to submu- 
cous infiltration. Further, such a subcordal laryngitis may be or may 
become tuberculous in its nature; more rarely it is syphilitic. From 
the condition of the larynx alone it is extremely difficult to make the 
Fig. 170. 
Swelling below the vocal 
cords from laryngitis hy- 
poglottica chronica (after 
Ziemssen). 594 
APPENDIX. 
differential diagnosis of these specific diseases from simple catarrh, as 
well as between syphilis and tuberculosis. There may, however, be 
other alterations of the larynx present, or unquestionable signs in other 
organs, which throw light upon the matter. The serious character of 
laryngitis hypoglottica is manifested by the fact that very frequently, 
and sometimes very suddenly, it causes severe stenosis. 
Marked swelling of the whole larynx or of certain portions of it 
indicates oedema or phlegmon—that is, severe submucous inflammation 
which ends in abscess. Both of these will chiefly be distinguished by 
the color of the mucous membrane, which is pale when there is non- 
inflammatory oedema, even yellowish and often shaking like jelly, 
while in phlegmonous inflammation it is deep red. Midway between 
these two conditions stands inflammatory oedema, which pathologico- 
anatomically and genetically cannot be sharply distinguished from 
phlegmonous infiltration. Severe phlegmon may lead to decided dis- 
figurement of the larynx (see Fig. 171). This may also be true of 
oedema, as is shown in Fig. 172. Circumscribed laryngitis phleg- 
monosa usually results in the formation of abscess, or it may occasion 
a submucous or periehondrial formation of pus. 
Fig. 171. 
Fig. 172. 
Phlegmonous laryngitis, with phthisi- 
cal ulcer, a, epiglottis; b, left aryepi- 
glottic fold; c, left pyriform sinus. (From 
Ziemssen after Turck.) 
Extensive phthisical ulceration of the 
larynx, marked stenosis of the larynx 
from (Bdema. a, right aryepiglottic 
fold; b, anterior portion of the right 
cord. (From Ziemssen after Turck.) 
Both these conditions are extremely dangerous, because they very 
easily result in stenosis, and sometimes, if they are acute, with re- 
markable suddenness. Phlegmonous laryngitis sometimes results in 
the formation of pus in the larynx (especially perichondritis), or its 
neighborhood (as angina Ludovici). Laryngeal catarrh very seldom 
terminates as a phlegmon; foreign bodies, and substances that irritate 
chemically and as escharotics, may produce it; and lastly, it occurs in APPENDIX. 
595 
various acute infectious diseases, either resulting in catarrhal or ulcer- 
ative processes, or, it would seem, as independent metastatic diseases. 
Inflammatory oedema may be the result in all of these cases, besides 
or instead of phlegmon. Simple oedema is rare and chiefly occurs 
with general dropsy of all kinds, and in local obstruction (as in struma, 
mediastinal tumors). 
Ulceration seldom occurs in the larynx with simple catarrh, more 
frequently in acute infectious diseases, especially in typhus abdominalis 
[typhoid fever] and variola, but most frequently in syphilis and tuber- 
culosis. We limit ourselves to a description of the two last-named forms. 
Syphilitic ulceration in the larynx occurs almost exclusively in 
connection with pharyngeal syphilis. It, by preference, attacks the 
upper section of the larynx, but it may appear in the glottis. In the 
majority of cases a single ulcer is observed. The ulcers have reddened 
edges, with a more or less shallow, whitish deposit upon a vocal cord, or 
the epiglottis, or there is a vei’y deep crater-like cavity with a whitish 
deposit and sharp or swollen border. By the absence of knotty ele- 
vations of the border they are sharply distinguished from carcino- 
matous ulcers. On the other hand, it is often difficult to distinguish 
them from tubercular ulcerations. Here the differentiation is made 
by other signs of syphilis or tuberculosis that may be present. 
Regarding gummata of the larynx, see below. Syphilitic infiltra- 
tion without ulceration and without other associated signs of syphilis 
are very difficult to diagnose. These slighter syphilitic changes, 
moreover, very seldom come under examination, because they do not 
usually cause any inconvenience. See special works regarding them. 
Tubercular ulceration develops from tubercular infiltration. The 
principal location to be mentioned is the region of the interarytenoid 
space. The regions next most frequently attacked are the arytenoid 
cartilages and the false vocal cords. Tuberculous ulcers, with the excep- 
tion of those upon the glottis, are more frequently multiple than are 
syphilitic. They are either very superficial and yellowish in color, or 
deep with swollen edges, sometimes, especially in the interarytenoid 
space, with papillomatous mucous proliferations. Although not path- 
ognomonic (Gottstein), the latter form is in the highest degree char- 
acteristic of tuberculosis. Further, a pale oedematous condition of the 
rest of the mucous membrane points to tuberculosis. The most im- 
portant factor is the discovery of tubercle bacilli in the sputum. These 596 
APPENDIX. 
maj come from the larynx or from the lungs, which latter are always, 
or almost always, the first to be attacked. 
Deep ulcerations may lead to perichondritis laryngea. The most 
frequent form is perichondritis arytsenoidea. Perichondritis causes a 
very marked swelling and redness, generally over quite a large area. 
It very easily passes from this condition of swelling or collateral oedema 
into stenosis. If it ruptures into the larynx, then the necrotic pieces 
of cartilage will be coughed out, and sometimes, when examining with 
the laryngeal mirror, we see them lying loose. 
Scars are found in the larynx, as elsewkere, after healing from loss 
of substance. Those that chiefly interest us are the syphilitic. These, 
more than others, are inclined to retract, and hence they not infre- 
quently result in stenosis. We either find a partial adhesion of the 
vocal cords or extensive cicatricial adhesions of the true and false vocal 
cords, with a funnel-shaped narrowing downward, etc. It is generally 
impossible to form any conclusion as to the nature of the antecedent 
processes from the scar. Only this, further, is to be said, that most 
laryngologists now agree that tubercular ulcers may cicatrize. 
Excepting the syphilitic gummata, new formations in the larynx 
have only a local significance. Gummata are either solitary nodules 
or a group of individually small nodules, at first red in color, with a 
crinkled contour. They are inclined to break up rapidly, and then 
to be replaced by deep ulcers. 
Fig. 173. 
Fig. 174. 
Pedunculated fibroma upon the under 
surface of the left vocal cord; position 
during inspiration (Ziemssen). 
Epithelial carcinoma of the right vocal 
cord (Ziemssen). 
The other new formations may be divided into benign and malig- 
nant. Of the former, very much the most frequent are the papilloma; 
more rare are the fibroma. Both, but especially the latter, are gen- 
erally located upon the vocal cords. Papilloma are sometimes flat, APPENDIX. 
597 
wart-like, sometimes regular papules, often multiple, cauliflower-like. 
The fibroma are generally pedunculated; the surface is usually 
smooth, while that of the papilloma is uneven or villous. All the 
other benign new formations (lipoma, cysts, etc.) are extremely rare. 
The malignant new formations are, in the great majority of cases, 
carcinoma. They, like the papilloma, generally develop from the 
vocal cords; next in frequency, from the false vocal cords. They 
manifest great inclination to necrosis and ulceration. The differen- 
tial diagnosis of carcinoma, so long as there is no ulceration, is to be 
made from papilloma, after the occurrence of ulceration from tubercu- 
losis and syphilitic ulceration : generally this is not easy. For par- 
ticulars, we must refer to special works. Sarcoma of the larynx is 
much more rare than carcinoma. 
In reference to the more unusual diseases of the larynx, like lupus 
and lepra, we refer to special works. 
Spasms of the muscles of the larynx are, for the most part, not at 
all, or only exceptionally, observed with the laryngoscope. We here 
only mention phonic and inspiratory functional spasm of the glottis 
in adults. The former takes place at the instant when the effort at 
phonation is made, when a decided closure of the glottis takes place, 
as can be recognized with the laryngoscope; on the contrary, in the 
latter the vocal cords close at the instant of inspiration, hence, at the 
time when they ought to separate. During expiration the glottis is 
normal, or almost normally open, in opposition to paralysis of the 
[crico-arytsenoidei] postici muscles (see below), in which they are very 
close together during expiration also. 
As disturbances of coordination, both of these conditions will be 
understood from their analogy to the neuroses caused by certain occu- 
pations affecting the upper extremity (writers’ cramp, etc.), and are 
to be accounted for by over-strain. 
Paralysis of the Muscles of the Larynx. 
Paralysis of all the muscles that close the larynx (the crico-arytse- 
noideus lateralis, arytsenoideus transversus, thyreo-arytmnoideus ext. 
et internus—all supplied by the recurrent nerve): during phonation 
the vocal cords do not come close together, but remain in the position 
of inspiration. Complete aphonia is thus produced. The paralysis 598 
APPENDIX. 
is generally bilateral, and is almost always due to hysteria as a basis. 
Hence, it is often combined with anaesthesia of the larynx. 
Paralysis of the arytsenoideus transversus: during phonation the 
most posterior portion of the glottis (the pars cartilaginea) does not 
close. As a result we have hoarseness, even to complete aphonia. It 
not infrequently occurs with acute laryngitis. (See Fig. 175.) 
Paralysis of the thyreo-arytsenoideus intern., one or both sides, 
causes imperfect closure of the glottis; when both sides are paralyzed 
there is a very narrow, symmetrical oval fissure (see Fig. 176); with 
Fig. 175. 
Fig. 176. 
Paralysis of the arytaenoideus in acute 
laryngitis (after Ziemssen). The poste- 
rior portion of the glottis remains open 
during phonation. 
Paralysis of both thyreo-arytsenoidei 
interni, resulting from acute laryngitis 
(Ziemssen). Position during phonation. 
unilateral paralysis, a correspondingly narrow, unsymmetrical fissure. 
It occurs in laryngitis, but, also, often in hysteria. 
Paralysis of the crico-arytsenoidei postici muscles, the openers of 
the glottis (recurrent nerve); posticus paralysis: the vocal cords in 
bilateral paralysis, during expiration, stand near together, and during 
inspiration still closer, sometimes in apposition; phonation may be 
quite normal. Hence, there is inspiratory dyspnoea, with inspiratory 
stridor. The dyspnoea may increase until there is asphyxia. In 
unilateral posticus paralysis the paralyzed vocal cord is motionless 
and lies near the middle line, while upon the sound side there are 
normal motions. 
In its etiology, posticus paralysis is in many cases obscure. Some- 
times it forms the beginning of a bilateral recurrent paralysis; in 
other cases it seems to have a muscular origin (gumma in the muscle, 
laryngitis with atrophy, etc.). 
Recurrent paralysis—that is, paralysis of all the muscles supplied 
by the recurrent nerve—causes the vocal cords to assume the so-called APPENDIX. 
599 
cadaver position—the position with reference to each other that they 
have during quiet breathing. In severe paralysis, the vocal cords are 
entirely stationary in this position. In incomplete paralysis, they 
still make slight motions outward and also show an inclination to 
assume the position of adduction, for which there is, as yet, no undis- 
puted explanation. When the paralysis has continued for a long 
time the vocal cords become atrophied. 
Bilateral recurrent paralysis produces bilateral cadaver-position of 
the vocal cords, and thus complete aphonia, with inability to cough. 
Fig. 177. 
Fig. 178. 
Bilateral complete posticus paralysis 
(paralysis of the crico-arytsenoidei pos- 
tici, dilatation of glottis) at the moment 
of inspiration (Ziemssen). 
Position during inspiration in paral- 
ysis of the left vocal cord, or recurrent 
conduction paralysis (after Ziemssen). 
Position and immobility of the left vocal 
cord, as in the cadaver. 
This is caused by compression of both recurrent nerves from aneu- 
rism of the aorta, carcinoma of the oesophagus, and enlarged glands. 
It will be readily understood that this bilateral paralysis from periph- 
eral causes is much more rare than unilateral. Complete or incom- 
plete bilateral paralysis of the recurrent nerve has been observed with 
bulbar paralysis, tumors, softening of the medulla, and compression 
of the vagi after their exit from the medulla. 
Unilateral recurrent paralysis is much more frequent. It may be 
easily overlooked, because the voice is often clear, although weak, for 
the reason that the sound vocal cord during phonation reaches beyond 
the middle line. The paralyzed vocal cord during quiet breathing 
stands in the cadaver-position, the sound one in the position of rest— 
that is, somewhat more widely abducted than the other. During 
phonation the necessary closure of the glottis takes place, because the 
healthy vocal cord overreaches; but then the glottis is necessarily 
askew. Unilateral paralysis of the recurrent nerve is almost always due 
to compression of the nerve in the neck or as it passes into the thorax; 600 
APPENDIX. 
this will be brought about by the same causes as bilateral peripheral 
recurrent paralysis. Thus, recurrent paralysis may be an important 
corroborative symptom of aneurism, of carcinoma of the oesophagus, 
or of any other kind of mediastinal tumor. When there is a suspicion 
of one of these conditions, we may almost regard a recurrent paralysis 
as decisive; at any rate, the existence of a recurrent paralysis has 
often given the first suggestion that led to a discovery of an aneurism 
or of carcinoma of the oesophagus. 
Paralysis of the tensor of the vocal cords (crico-thyreoidei muscles, 
superior laryngeal nerve) is very seldom observed, and then it is 
always combined with anaesthesia of the mucous membrane and paral- 
ysis of the epiglottis. It is a tolerably dangerous condition, because 
of the accompanying difficulty of swallowdng and the risk of degluti- 
tion-pneumonia. The glottis is not exactly steady, but oscillating. 
In unilateral paralysis the normal vocal cord stands higher. 
Paralysis of the tensor of the vocal cords takes place most frequently 
in diphtheria, but then it is always accompanied with paralysis of 
other muscles. 
2. Examination with the Ophthalmoscope. 
This method of examination strictly belongs in the province of 
ophthalmology. Therefore we limit ourselves simply to its use for the 
purpose of diagnosis, where we observe a connection between certain 
changes of the fundus oculi and an internal disease. 
(a) Changes in the fundus oculi in nervous diseases. All diseases 
wThich lead to a general increase of the intracranial pressure may 
cause choked disc (neuritis optica). It is then always bilateral. At 
the same time choked disc may be absent in all these conditions, but 
its presence is of the highest diagnostic significance, and particularly 
in tumors and meningitis. Hydrocephalus is more rarely, and abscess 
of the brain very rarely combined with choked disc. Unilateral 
choked disc is only caused by local pressure (a tumor, etc.) upon one 
optic nerve. 
The extent to which vision is disturbed when we have choked 
disc varies very much; there may be none, or almost none. Disturb- 
ance of vision in choked disc usually occurs very early and markedly 
if the disease-process causes pressure upon the chiasm or the begin- 
ning of the optic nerve, as in tumors of the hypophysis cerebri, or if APPENDIX. 
601 
there is hydrocephalus which presses inward upon the third ventricle 
(Wernicke). There must, of course, be disturbance of vision if the 
choked disc is followed by atrophy. 
Pronounced choked disc is very easily recognized (only take care: 
neuro-retinitis Brightii is exceptionally very much like it); but the 
exact recognition of a slight neuritis optica is very difficult. When- 
ever there is such a possibility an ophthalmologist should always be 
called in. 
It seems that neuro-retinitis is particularly apt to be present in 
meningitis when there is a basilar exudation. Neuro-retinitis is said 
to occur also with encephalitis. 
Primary atrophy of the optic nerve takes place (by the intraocular 
portion of the nerve changing into a white disc with a sharp boundary) 
especially in tabes, then sometimes in multiple sclerosis, dementia 
paralytica; lastly, it occurs from pressure upon the chiasm. [The 
capillary circulation ceases, and hence the disappearance of the nor- 
mal rosy hue.] 
Finally, it is to be mentioned that retinal apoplexy has been 
observed as the forerunner of cerebral hemorrhage, emboli of the cen- 
tral retinal artery as the precursor of cerebral embolism. Regarding 
the changes of the fundus oculi in syphilis, see below. 
We hardly ever find choroidal tubercle in tubercular meningitis. 
(But with reference to acute general milliary tuberculosis, see below.) 
(b) Changes in the fundus oculi in other internal diseases. 
Retinitis or neuro-retinitis albuminurica, with white specks, often 
arranged as radiating lines around the macula, sometimes confluent, 
thickening of the walls of the vessels and hemorrhages, occurs partic- 
ularly frequently in contracted kidney, also often in subchronic and 
chronic nephritis, but very seldom in acute nephritis. The dis- 
turbance of vision is greater or less according as the macula is 
attacked or not. Uraemic amaurosis has nothing to do with this con- 
dition, but as a matter of fact this form of retinitis often occurs in 
uraemia (and this is important for the diagnosis). 
In constitutional syphilis (hence also in syphilis of the brain) we 
sometimes observe syphilitic changes in the fundus oculi: retinitis 
syphilitica, retinitis pigmentosa, choroiditis syphilitica. 
We not infrequently find tubercle of the choroid in acute general 602 
APPENDIX. 
tuberculosis, especially in the region of the macula; the tubercular 
deposits are generally very difficult to see. 
In diabetes there occurs a peculiar so-called diabetic neuro-retinitis 
and atrophy; in leucaemia, hemorrhages and whitish exudate; in per- 
nicious anaemia, but also in simple, severe anaemia, hemorrhages 
(generally easily seen). 
Further, retinal hemorrhages are not unimportant diagnostic signs 
of pyaemia, particularly pyaemic endocarditis. They are not an abso- 
lutely fatal sign, as I myself saw in one case of puerperal pyaemia: 
this undoubted case of pyaemia, where besides the hemorrhages there 
were chills and slight icterus, recovered and the effused blood disap- 
peared, leaving clear specks behind. 
We have still to mention : 
Pulsation of the retinal arteries in aortic insufficiency, embolus of 
the central artery in endocarditis (also frequently observed in chorea); 
lastly, after severe hemorrhages (particularly of the stomach, also of 
the intestine, and uterus) there occurs sudden amaurosis, not infre- 
quently at first without any ophthalmoscopic condition, afterward 
usually with distinct atrophy of the optic nerve. 
Alcoholic amblyopia shows a negative condition, or else hypersemin, 
neuritis, atrophy ; tobacco amblyopia shows a normal fundus optica, or 
atrophy; in amblyopia or amaurosis saturnina either there is nothing, 
or else there is hypersemia and neuritic atrophy. 
3. Bacteria which come under Consideration in the Diagnosis 
of Internal Diseases. 
The object of the following sections is to summarize the notable 
peculiarities of the different microdrganisms which have already been 
mentioned in different parts of the work. But this pertains not only 
to the characteristics of the different organisms and their appearances 
when stained, but also to the much more important phenomena of their 
growth in cultures and under animal experimentation. In regard to 
the methods of procedure we must refer to the text-books upon bac- 
teriology, and particularly to the instruction in the bacteriological 
courses. 
Staphylococcus pyogenes consists of small round cells which are usu- 
ally found in irregular masses, but are never arranged in chains. The APPENDIX. 
603 
spores of this, as of all other micrococci, have not yet been discovered. 
It grows upon gelatin even without much air, in the temperature of the 
room, still more rapidly and luxuriantly in a higher temperature. 
The gelatin becomes liquefied. Scratch cultures are either gold- 
yellow (Staph, pyogen. aureus), or white (Staph, pyogen. albus), or 
clear yellow (cereus), or citron yellow (citreus). Upon a surface it 
grows in round, light-brownish colonies looking like dots, which lose 
their sharp contour in the centre of the fluid. Mice, guinea-pigs, 
and rabbits die in from two to nine days after intravenous and peri- 
toneal injections. Mice are killed with certainty only after the sub- 
cutaneous injection of a large amount, but none of the other animals 
named are killed by subcutaneous inoculation. 
It can be stained by all of the aniline stains, also by Gram’s 
method. It is the most common excitor of suppuration. It is found 
in abscesses, furuncles, in many cases of empyaema, purulent perito- 
nitis ; also in ulcerative endocarditis, etc., upon the valves of the 
heart; in pyaemia and acute osteo-myelitis, in the suppuration 
which complicates typhoid fever, etc. 
Streptococcus pyogenes, resembling the first named by its round 
cells, forms chains by progressive portions pushing out in the same 
direction, which sometimes twist around each other. The separate 
ones often vary in size. It grows slowly upon gelatin, better upon 
agar, in the temperature of the room, but more rapidly in an incuba- 
tor at a temperature of 27° C. [=98.6 F.]. It does not render gelatin 
fluid. The cultures upon a plate are extremely small, J mm. diameter, 
yellowish to yellowish-brown in color. When inoculated by puncture 
it develops slowly and does not spread out upon the surface of gelatin. 
It is stained like the preceding. It is fatal to animals only when they 
have been previously weakened; it causes redness and swelling of the 
rabbit’s ear. There is frequently found a pus coccus which particu- 
larly inhabits the lymph tracts, and causes progressive phlegmon ; it 
is also found in pyaemia, especially puerperal pyaemia, likewise fre- 
quently in endocarditis. 
Streptococcus erysipelatosus, morphologically and as regards its 
staining qualities, is like the preceding, hut from the culture has thus 
far not with certainty been distinguished from it. In the rabbit’s 
ear it causes a somewhat less active and extensive inflammation than 604 
APPENDIX. 
the streptococcus pyogenes. The inflammation has the symptoms of 
erysipelas. 
Micrococcus gonorrhoeus (gonococcus, compare Fig. 131, p. 427) 
usually occurs in the form of diplococci (roll-form), which often appear 
as tetracocci in that the single coccus has a bright stripe, as the 
beginning of a new portion. It is difficult to breed, but is best done 
upon coagulated blood-serum, in a moist room at 32° C. [= 90° F.] 
(Bumm). It is stained with all of the aniline dyes, best with a con- 
centrated watery solution of methylene-blue, stained after the method 
of Gram. It seems that it is pathognomonic of gonorrhoea if found 
within the pus-corpuscles. Outside of the pus-corpuscles, and even 
in epithelial cells, there also occur other diplococci of like form and 
staining qualities. 
Bacillus anthracis (see Fig. 78, p. 280) is a rod, on an average 
about 5-10// long, 1—1.25// wide, with an abrupt end, often some- 
what concave, with the inclination to develop into threads, without 
peculiar motion. It develops upon gelatin, potatoes, in alkaline urine 
at the ordinary temperature of the room, better at 36° C. [= 97° F.]. 
Sometimes there develop spores within spores (endogenous formation 
of spores). Gelatin is rendered fluid; when the amount of air is 
limited it develops poorly. Plate-cultures, after twenty-four hours, 
can be seen, when slightly magnified, as round grayish-black spots, or 
wavy, as if curled; upon potatoes the cultures are gray-white, some- 
what elevated. It is fatal to susceptible nursing animals (mice, rabbits, 
guinea-pigs, certain kinds of sheep), even with the most minute inocu- 
lation and in a very short time. They are found in capillary blood 
and in all organs richly supplied with blood, particularly the spleen; 
with living bodies they do not develop spores, likewise usually no 
long threads. They are stained by all basic aniline coloring-matters, 
but they are easily spoiled if the covering-glass is made too hot; they 
become non-transparent if too strongly stained. They can also be 
stained by Gram’s method. 
Bacilli of malignant oedema are 3—3.5,1/ long, 1-1.1// wide (Fliigge), 
hence thinner and shorter than the anthrax bacilli, from which they 
are also distinguished by the rounded ends. They form rigid threads, 
often of considerable length. The individual bacillus forms spores, 
and these are so large that they distend the bacillus. In the 
dependent drops they manifest peculiar motions. They only grow APPENDIX. 
605 
when oxygen is excluded, hence are anaerobia. They develop in a 
reagent glass, best in gelatin to which is added a J per cent, solu- 
tion of grape sugar (Fliigge). They flourish best at the temperature 
of the body. But they only grow at the lower end of a deep, very 
fine canal formed by sticking in a needle, and this canal is to be 
again closed. It fluidizes the gelatin and forms an offensive-smelling 
gas. It is stained by all the aniline dyes, but poorly after the Gram 
method. It is found in garden soil, in muddy water, in the blood of 
asphyxiated animals, etc. A little of the soil taken up on the point 
of a penknife and put under the skin of the abdomen of a guinea-pig 
or rabbit generally kills it by the invasion of the bacilli in one to two 
days (but sometimes, during this experiment, tetanus develops). In 
man it causes oedema and sometimes emphysema of the skin (see p. 55). 
Typhus abdominalis bacilli (see Fig. 121, p. 391) are short, slender 
rods with rounded ends, thrice as long as broad, one-third as long as the 
diameter of a red blood-corpuscle. They have active motions (hanging 
drops). They form threads in cultures and hanging drops, but not in 
living animal bodies. It is questionable whether they form spores. 
They develop, at the temperature of the room, upon gelatin, agar, 
potatoes, without the character of the growth being characteristic. 
On the other hand, the potato culture is characteristic: for some days 
after the inoculation it would seem as if nothing had grown—at most 
that the surface of the potato around the inoculating scratches has a 
moist shimmer; in the whole circumference of this shimmer a very 
thick resisting turf of bacilli is present. But this peculiarity of be- 
havior is not always manifest. Upon some potatoes it is not visible. 
Only that culture in which it is visible is demonstrative. It is best 
stained with carbol-fuchsine or Ldffler’s alkaline methylene-blue solu- 
tion 51 it is be washed only with water. It is stained after Gram’s 
method. It regularly occurs in the intestine, spleen, liver, kidneys, 
also in the stools, and now and then in the blood in abdominal typhus 
[typhoid fever]. 
Tubercle bacilli (compare Fig. 40, p. 184, and Fig. 130, p. 426) 
are thin rods, 1.5-3.5/* long (Fliigge), frequently slightly curved or 
somewhat broken; they often form threads, and sometimes two or 
1 30 c.cm. of concentrated alcoholic solution of methylene-blue, 100 c.cm. of one per 
cent, solution of potassium. 606 
A PPEXDIX. 
more lie close together. Very often they contain a number of egg- 
shaped spaces (spores), and then, when stained and slightly magnified, 
they sometimes look like chain micrococci. They have no inde- 
pendent motion. They grow best in a reagent glass upon an oblique 
coagulated, sterilized blood-serum and glycerin-agar, at a tempera- 
ture of 37.5° C. (min. 30, max. 42). At best they grow very 
slowly, and hence the strictest care is necessary that it may not de- 
velop excessively. (For the technique, see special works.) In four- 
teen days there appear small, dull-white scales and specks, which, 
when slightly magnified, show an arrangement that reminds one of a 
tangled braid of hair (compare Fig. 130, p. 426). We can have it 
develop upon a covering-glass and then stain it by the method 
described on page 185. The experiment of inoculation is best made 
upon guinea-pigs, by placing some sputum, for instance, in the abdom- 
inal cavity. Generally, there is no reaction in the peritoneum. After 
two to three weeks the glands swell, and in four to eight weeks the 
animal dies. 
Lepra bacilli, resembling small tubercle bacilli, are stained with 
aniline in the usual way, but also like tubercle bacilli; hence, like the 
former, there may be a double staining. They are found in leprous 
skin, in the glands, in the tissue-juices, in the nerves, also said to be 
found in the blood, etc., mostly in small and large cells resembling 
giant-cells. Cultures have not yet been successfully made. 
Anthrax bacilli are like tubercle bacilli, only somewhat broader. 
They are stained with Loffler’s potassic methylene-blue. Stain very 
carefully, then wash with dilute acetic acid. They are often easier 
and more certainly demonstrated by culture than by animal experi- 
mentation. They develop rapidly upon slices of potato at 35° C. 
[=97° F.], as a brownish, slimy mass. It can be inoculated upon 
guinea-pigs; some maintain that puppies are better. Death follows 
after an indefinite time, and nodules occur in various organs (one of 
the first symptoms is a swelling of the testicles). 
The cholera bacillus (see Figs. 117, 118, p. 389, and Fig. 119, 
p. 390) has been very fully described upon p. 389f. It has there 
been pointed out that the certain proof is only made by culture. 
A mucous floccule from the stools or from the linen is taken, 
placed in a small glass with a fluid five to ten per cent, culture- 
gelatin, from which plate cultures are prepared. After standing APPENDIX. 
607 
one to two days in an ordinary temperature, small white points 
are seen at the bottom which gradually reach the top, and, by 
rendering the gelatin fluid, form deep, funnel-like depressions. At 
the bottom of the funnel lie the whitish cultures, not larger than a 
pin-head. By making an inoculation-puncture in the reagent glass 
there is also produced a funnel, which, from the rapid thinning of the 
fluidized gelatin, contains a large bubble of air. The lower part of 
the inoculation-puncture resembles a thin thread, which in some 
places is as clear as glass, and looks like an empty capillary tube, 
while in other places the culture, sunk together, consists of gray and 
whitish threads. In the dependent drops there is active motion, 
like a swarm of gnats, and the bacilli strive to reach the border. 
Larger plate-cultures, under a slight magnifying power, show a pecu- 
liar lustre and an arrangement; as if they were a collection of shivered 
glass. The inoculation is made upon guinea-pigs, the contents of 
whose stomach is made alkaline by 5 c.cm. of a five per cent, solu- 
tion of soda (using an oesophageal catheter); the intestine is made 
quiet by injecting into the peritoneum 1 c.cm. tinct. opium for each 
200 grammes weight [of the animal] ; then, by means of the oesopha- 
geal catheter, there is introduced 10 c.cm. of the deposit of the cholera 
bacilli in bouillon. After two days the animal dies (often without 
diarrhoea, always without vomiting): the condition of the intestine is 
found to be exactly like that in cholera. In the intestines are abun- 
dant cholera bacilli. 
Bacilli of Finkler-Prior (see Fig. 120, p. 391) resemble cholera 
bacilli, but are thicker and plumper; but in the colored preparations 
they cannot certainly be distinguished from Koch’s comma bacillus. 
Plate-cultures develop remarkably rapidly, and render gelatin fluid 
in much larger quantity than cholera bacilli. This difference in the 
rapidity of development is the best mark of distinction. When slightly 
magnified, the cultures seem to be very finely and uniformly granular, 
of a yellowish-brown color. The inoculation-puncture, likewise, shows 
a much more rapid fluidization, but not the clear threads beneath the 
upper “ air-bubble,” but an irregularly wide canal, which reminds one 
of a stocking. After a week the whole reagent glass becomes fluid. 
Also, the inoculation of animals gives a different result—stinking in- 
testinal contents, while in cholera they smell stale. INDEX. 
ABBE, reference to, 185 
Abdomen, circumscribed disten- 
tion of, from inflammatory 
exudation, 314 
distention of, causes of, 309 
drawing-in of, causes of, 309 
inspection of, 313 
sound on percussing, 109 
topography of, 297 
tumors of, dulness over, if thick, 
306 
value of measuring circumfer- 
ences of, 316 
Abdominal affections, severe hiccough 
in, 540 
breathing disappears in paralysis 
of diaphragm, 90 
contents, position of, illustrated, 
298 
diseases, headache with, 483 
distention, effect on diaphrag- 
matic breathing, 90 
inflammation, restricting action 
of the diaphragm, 90 
organs, irritative cough from, 165 
pressure, importance of, in defeca- 
tion, urination, and labor, 540 
reflex defined, 496 
increase of, in intercostal neu- 
ralgia, 496 
unilateral, absence of, 587 
swellings, solid, feeling of resist- 
ance with, 116 
typhus. See Typhoid Fever, 
wall in emphysema, 84 
Abnormal constituents of urine, sec- 
tion on, 435-442 
sounds over lungs, 125 
Abscess, deep, revealed by oedema, 54 
due to dentition, 286 
irregular enlargement of liver 
from, 322 
large, peptonuria with, 439 
of abdominal wall, pain from, 309 
case of, which simulated 
meteorism, 309 
Abscess of chest wall, weakened vocal 
fremitus with, 158 
of liver, prominences on liver 
from, 326 
tenderness with, 324 
of lung, effect of, on thorax, 87 
elastic threads in sputum of, 
177 
haematoidin in sputum in, 172 
lung tissue in sputum in, 172 
purulent sputum in, 169 
of spleen, unequal enlargement 
with, 335 
of tonsil, 290 
perinephritic, cause of pus in 
urine, 419 
retro-pharyngeal, cause of cyan- 
osis, 43 
Abscesses, staphylococcus pyogenes 
found in, 603 
Absolute deadness, 108 
Abulia defined, 472 
Accidental murmurs, 229 
Accommodation in breathing, 95 
of valvular deficiency, 195 
paralysis of, 563, 568 
Acetic acid, excess of, in stomach, 
345 
Acetone, a product of decomposition 
of albumin, 449 
diaceturia with, 447 
odor of breath in diabetes, 285 
of urine from, 414 
source of, in urine, 449 
test for, 414, 449 
when occurs, 414 
Acetonuria, test for, 448 
when occurs, 448 
Achorion Sehonleinii, in vomit, 366 
Achroodextrin, from starch, 353 
“ Acid curve ” of urine in twenty-four 
hours, 404 
intoxication in diabetic coma, 449 
reaction of urine, usual, 403 
urine, calculi found in, 433 
Acids, fatty, needles of, in sputum, 180 
609 610 
INDEX. 
Acids, salivation caused by, 289 
Acoustic amnesia, 552 
ganglion, 461 
nerve, 551 
disease of, 572 
injury of, 572 
Acromegalia, defined, 583 
Actinomyces in pleural exudation, 161 
in sputum, 175 
described, 189 
with inflammation of mouth, 290 
Acuoxylon, 140 
Acute diseases not recurrent, 22 
Adaptation in breathing, 95 
Addison’s disease described, 48 
iEgophony described, 159 
iEsthesiometers, Sieveking’s, use of, 
474 
After-sensibility, defined, 478 
Age, location of heart in, 192 
lung boundary differences due to, 
125 
old, area of heart dulness in, 205 
position of apex beat in, 198 
variations of percussion note by, 
120 
of pulse affected by, 234 
Aged, venous thrombosis in marasmus 
of the, 268 
Ageusis, with total hemiansesthesia, 
574 
Agrammatismus defined, 561 
Agraphia, 552, 553 
amnesia may simulate, 556 
an aphasic symptom, 561 
Air in peritoneal cavity, auscultation 
and percussion of, 318 
in peritoneum, a cause of dimin- 
ished area of liver-dulness, 331 
-passages, stenosis of, inspiratory 
pressure diminished in, 164 
sound of, on percussing over cavity 
containing, 109 
Akataphasia defined, 561 
Albumin, acetone a product of de- 
composition of, 449 
boiling and nitric acid test, 436 
-curve, 437 
decomposition of, leucin and tyro- 
sin products of, 432 
ferrocyanide of potassium test, 436 
Geisler’s test papers, 436 
in pleural fluid, 160 
in serous sputum, 169 
in sputum, 190 
in urine, 435, 439 
Albumin in urine after exertion, 437 
makes the bismuth test for 
sugar uncertain, 444 
significance of, according to 
amount, 420 
must be removed in determining 
nitrogen and urea, 434 
physiological, small amount in 
urine, 405 
picric acid test, 436 
qualitative tests for, 435 
quantitative tests for, 437 
rare forms of, 439 
Albuminous bodies, digestion of, 345 
Albuminuria, a cause of dropsy, 53 
casts scanty in physiological, 422 
cyclic, 435, 437 
oedema with, 54 
renal casts in urine, diagnostic 
value of, 422 
retinitis with, described, 601 
when occurs, 435 
Alcohol amblyopia, central scotoma 
in, 569 
formation of, in stomach, 345 
headache in poisoning with, 483 
paralysis, lessened excitability in, 
without EaR in, 525 
poisoning, odor of breath in, 285 
stools offensive, 371 
uses of, effect on disease, 21 
Alcoholic amblyopia, 602 
poisoning, delirium tremens from, 
471 
stools, color of, 373 
tremor, 531 
Alcoholism, trembling of tongue of, 
287 
lipaemia in, 280 
Alderton, reference to, 199 
Alexia, 552 
Alkalies, salivation caused by, 289 
Alkaline fermentation in urine, from 
micrococci and bacilli, 
425 
odor of, 404 
turbid urine from, 412 
reaction of urine, sometimes in 
health, 403 
urine, simple, distinguished from 
urine alkaline from fermenta- 
tion, 426 
Allochiria defined, 478 
Amaurosis after severe hemorrhages, 
602 
saturnina, 602 INDEX. 
611 
Amaurosis, temporary partial, signifi- 
cance of, 571 
uraemic, 601 
with albuminuria, 441 
Amblyopia, alcohol, 569 
alcoholic, and tobacco, 602 
Ammoniacal fermentation of urine, 402 
odor of stool from admixture with 
urine, 372 
Ammoniaco-magnesian phosphate in 
urine described, 431 
Ammonio-magnesian phosphates in 
urine, 402 
Amnesia, 554, 556 
acoustic and visual, 552 
may simulate atactic aphasia, 
word-deafness, word-blindness, 
agraphia, 556 
mixed with aphasia, 555 
Amnestic aphasia, 553, 554 
Amphoric breathing, 159 
corresponds with metallic 
rales, 153 
defined, 148 
with cavities in lungs, 147 
Amphoteric reaction of urine, 404 
Amyloid degeneration of intestines, 
fats poorly absorbed in, 371 
disease of spleen, 335 
kidney, albuminuria with, 435 
casts in urine of, 422 
liver, surface of, 325 
Amylolysis, disturbed in super-acidity 
of stomach, 356 
incomplete, shown by microscopi- 
cal examination of vomit, 365 
Amylolytic period of digestion, 342, 
343 
shortened, 346 
Amyotrophic lateral sclerosis, 580, 586 
EaR with, 524 
increase of tendon reflex 
in, 500 
lessened excitability 
without EaR in, 525 
partial EaR with, 525 
An, an abbreviation for anode, 506 
Antemia, absence of pulse with, 243 
a cause of dropsy, 53 
albuminuria with, 435 
alkalescence of blood diminished 
in, 283 
caused by anchylostoma duode- 
nale, 382 
color of blood in cases of severe, 
271 
Anaemia, diminished haemoglobin in, 
275 
dizziness with, 471 
due to bothriocephalus lata, 880 
to tapeworm, 377 
headache with, 483 
heart-sounds often strengthened 
in, 217 
in contrast with chlorosis as re- 
gards diminution of red cor- 
puscles, 276 
leucocytosis in, 278 
may be concealed by redness of 
face, 42 
microcytes and macrocytes in, 276 
microcythaemia with, 276 
murmurs heard in, 229 
oligocythaemia in, but not in chlo- 
rosis, 274 
peculiarities of blood in, 275 
pernicious, ieucin and tyrosin in 
urine of, 432 
retinal hemorrhages in, 562 
uric acid increased in, 434 
poikilocytosis with, 277 
polyuria in, 406 
progressive venous pulse with, 268 
red corpuscles diminished and 
paler in, 275 
retinal changes in, 602 
splenic, enlargement of spleen in, 
335 
stools to be examined for parasites 
in, 377 
subacidity of stomach in, 356 
subjective sensations of vision in, 
571 
sensibility of hearing in, 572 
tracing of pulse of, 248 
urine of, very pale, 408 
should be examined for ba- 
cillus tuberculosis, 426 
venous humming in, 269 
vertigo with, 472 
Anaemic heart-murmurs, explanation 
of, 230 
propagated from venous 
trunks in chest, 269 
murmurs, 229 
necrosis of pons and medulla, 462 
Anaesthesia, cause of, 459 
defined, 477 
important distinction with refer- 
ence to distribution of nerve, 479 
of dorsum of forearm, caution re- 
garding, 485 612 
INDEX. 
Ansesthesia of mucous membrane in 
hysteria, 497 
partial, cause of, 459 
sensory, in gross hysteria, 534 
total, rare, 479 
Analgesia defined, 479 
Anamnesis defined, 17 
mode of taking, 19 
scheme for, 26 
unreliable regarding spasms, 533 
what it comprises, 19, 20 
Anarthria defined, 548 
Anasarca. See (Edema. 
Anatomical disease, symptoms of, 587 
divisions of the chest, 76 
variations, cause of unequal pulse 
in symmetrical vessels, 257 
Anatomy of heart, 191 
of liver, 319 
Anchylostoma duodenale, described 
and illustrated,.382 
Anchylostomen in vomit, 364 
Anchylostomiasis, 382 
feces of, contains Charcot’s crys- 
tals, 388 
Aneurism, absence of pulse with, 
243 
aortic, pulsation in, 204 
blood in sputum from rupture of, 
167 
caution regarding, when making 
exploratory puncture, 162 
difficulty in distinguishing from 
apparent enlargement of heart, 
210 
effect of, upon pulse in one of two 
symmetrical vessels, 257 
increased circumference of thorax 
in, 163 
near oesophagus, caution regard- 
ing sounding oesophagus, 294 
neuralgia from pressure of, 483 
of abdominal aorta, 255 
of aorta, and other arteries, effect 
on pulse, 245 
crystals in sputum in hemor- 
rhage into lungs, 180 
cyanosis from, 43 
description of, 254 
how distinguished from em- 
pyema pulsans, 102 
pressing on the larynx, 75 
pressure by, upon recurrent 
nerve, 296, 599 
of arcb of aorta, affects vessels of 
left side, 255 
Aneurism of .ascending aorta, affects 
vessels of right side, 254 
of descending aorta, 255 
of innominate artery, 255 
of minute arteries of brain a cause 
of hemorrhage, 577 
of pulmonary artery, 255 
phenomena of, 40 
pressing heart forward, 203 
pressure on nerves from, 469 
pulsation of, near stomach, 302 
recurrent paralysis a symptom of, 
600 
simulates enlarged heart, 209 
systolic pulsations at base of heart 
in, 203 
Angina, cause of enlargement of 
tongue, 286 
hepatica, herpes with, 50 
Ludovici, 594 
cause of cyanosis, 43 
necrotica, tonsils in, 290 
pectoris, in organic disease of the 
heart, 577 
pulse in, 240 
Angle, epigastric, 82 
in emphysematous thorax, 83 
of Louis, 84 
in phthisical thorax, 84 
Angulus Ludovici defined, 76, 78, 81, 
82. 
Anhidrosis, sudamina after long-con- 
tinued, 50 
Anidrosis, 38, 581 
defined, 37 
Anilin, color of blood in poisoning by, 
270 
Animal parasites, examination of stool 
for, 377 
exotic, 21 
in sputum, 182 
in urine, section on, 424 
. section on, 377 
two found in blood, 283 
Ankylostoma, 41 
Ankylostoma-ansemia, 54 
Anodal closure, result of, 506 
Anode, at the, contraction only at the 
opening of the current, 506 
colors blue litmus red, 505 
positive pole, 504 
Anomalies of breathing, 89 
Anorexia, defined, 472 
Anosmia, when it occurs, 573 
unilateral, associated with hemi- 
ansesthesia, 573 INDEX. 
613 
AnOTe, occurrence of, important sign 
in tetanus, 526 
AnSC, 518, 519, 520, 521, 523 
minimal, determination of, 515 
Anterior column of spinal cord, 455 
cranial fossa, effect of lesion of, 
457 
gray columns, 492 
disease of, EaR with, 
524 
horn, characteristic sign of cere- 
bral and spinal paralysis 
above, 494 
excitability of, increases skin 
reflex, 496 
ganglia, 455, 456, 492 
part in skin reflex, 496 
results of disease of, 490 
horns, disease of, tendon reflex 
diminished in, 500 
effect of lesion of, 456 
gray, EaR with lesions of, 
524 
preside over muscular 
tonus, 528 
office of, 455 
pyramids, 454 
roots of spinal nerves, 455 
compression of, results of, 491 
Anthrax bacilli, cultures, 606 
described, 280, 606 
illustration of, 280 
Antifebrin, urine after taking, 451 
Antiperistalsis of stomach, 303 
Antipyrine, urine after taking, 451 
Anuria from obstruction by echino- 
coccus, 425 
in acute nephritis, 407 
in hysteria, 579 
Anxiety, effect of, on amount of urine, 
401 
pulse frequent in, 240 
subjective expression of, an dys- 
pnoea, 99 
Aorta, anatomical relations of, 254 
aneurism of, pulsation in, 204 
paralysis of recurrent nerve 
by pressure from, 538 
pressure by, upon recurrent 
nerve, 296 
relation of left carotid to, clinical 
importance of, 463 
sclerosis of, shown by stronger 
aortic second sound, 217 
stenosis of, commencement of, ab- 
sence of apex-beat in, 202 
Aorta, stenosis of, from enlarged retro- 
peritoneal glands, 341 
murmur of, where heard, 224, 
225 
pulse in, 252 
tracing of pulse in insufficiency 
and stenosis of, 249 
various phenomena of, 253 
Aortic and tricuspid insufficiency, 
combined arterial and venous 
crural sounds with, 269 
first sound, softest heart sound, 
217 
insufficiency, 194, 195 
and stenosis, effects of, 195 
opposite condition of 
pulse in, 252 
arterial liver pulse in, 257 
capillary pulse in, 256 
double sound over crural 
artery in, 259 
effect upon second sound, 258 
increased arterial pulsation 
with, 257 
murmur of, where heard, 224, 
225 
progressive venous pulse 
with, 268 
pulsating splenic tumor with, 
335 
pulsation in aorta with, 254 
of retinal arteries in, 602 
pulse in, 251 
with, 253 
tracing of pulse of, 249 
weakening of first sound at 
apex in, 219 
stenosis, 194 
absence of pulse with, 243 
paleness in, 41 
pulse with, 242, 244 
sounds with, 258 
weakening of aortic second 
sound in, 219 
valve, insufficiency of, sounds in, 
217 
valves, where best heard, 213, 214 
Ape-hand in paralysis, 544 
Apex-beat of heart, examination of, 
197 
absent in pericardial adhesion, 202 
and heart-beat not to be con- 
founded, 201, 203 
causes of, 198 
change in width and strength of, 
200 614 
INDEX. 
Apex-beat coincides with systole of 
heart, 212 
displaced by retraction of lung, 
209 
displacement of, 199 
doubling of, 202 
in determining apparent enlarge- 
ment of heart, 210 
in dislocation of heart, 211 
position of, in children, 198 
with pericardial exudation, 
202 
strength and breadth of, a sign of 
hypertrophy, 200, 201 
weakening of, causes, 201 
Apex, first sound at, strengthened in 
mitral stenosis, 218 
sounds of heart heard at, 214 
mitral murmurs at, 224 
murmur of stenosis of left 
auriculo-ventricular open- 
ing, heard at, 224 
Aphasia, with albuminuria, 441 
. atactic, 552, 553, 554,559 
cause of, 555 
phenomena of, 558 
Charcot’s diagram of, 560 
Lichtheim’s diagram of, 557 
localization of, 555 
mixed with amnesia, 555 
mode of procedure in testing for, 
555, 556 
motor, 559 
sensory, phenomena of, 558 
Aphasic disturbances, 549 
Aphonia, 74 
a result of recurrent paralysis, 
599 
how caused, 597 
in paralysis of recurrent nerve, 
538 
tone of cough in, 166 
Aphonic patients, 159 
Aphthae, in vomit, 366 
Apices of lungs, 81, 82 
boundaries, 122 
caution regarding slight dead- 
ening over, 126 
cavities in, 131 
diminished in phthisis, 137 
disease of both, comparative 
percussion in, 125 
dry rales with catarrh of, 
150 
large rales in, a sign of cavity, 
152 
Apices of lungs, percussion note over, 
120 
position of, changed by dis- 
eased condition in neck, 137 
relatively deadened sound 
over, 114 
shrunken, open tympanitic 
sound over, 110 
sometimes enlarged, 136 
systolic subclavian murmur 
at, 259 
tuberculosis of, increased 
vesicular breathing in, 
144 
deadened sound with, 
129 
pain with, 102 
prolonged expiration in, 
145 
tympanitic resonance 
over, in beginning, 127 
tympanitic sound over, in be- 
ginning tuberculosis, 112 
upper limits of, 125 
Aplasia of lung, deadened sound over, 
114 
Apnoea, 92 
contracted pupils in, 93 
jerking of muscles in, 93 
Apoplectic attack, defined, 585 
habit, 575 
Apoplexy. See Cerebral hemorrhage, 
aphasia after an attack of, 555 
decubitus after, 582 
disturbance of consciousness in, 
470 
glocosuria with, 443 
heart and vessels to be examined, 
577 
pulse in, 245 
syncope as a precursor of, 471 
tinnitus aurium sometimes a pre- 
cursor of, 573 
transitory albuminuria with, 435 
Arc de cercle, 468, 534 
Area of heart dulness, enlargement of, 
208 
Areometer, use of, in determining 
specific gravity of urine, 403 
Arm, motor centre for, 454 
nerves of, 485 
paralysis of the muscles of, 542 
points of electrical irritation upon, 
illustrated, 509, 510 
position during electrical exami- 
nation, 511 INDEX. 
615 
Arsenic, poisoning by, cause of htem- 
ato-jaundice, 47 
-paralysis, lessened excitability 
in, without EaR, 525 
Arterial liver-pulse, when liver en- 
larged, 322 
pulse, propagated through the 
capillaries, 268 
sclerosis, abnormal pulsations in 
arteries in, 256 
condition of arteries in, 256 
gallop rhythm of heart with, 
221 
pulse with, 244, 245 
Arteries, examination of, 234 
Artery, basilar, 461 
middle cerebral, 462 
hemorrhages and emboli 
most frequent in, 463 
largest and most impor- 
tant of the brain, 462 
ophthalmic, 461 
posterior cerebral, portion of brain 
it supplies, 462 
communicating, 461 
vertebral, 461 
Arthritis deformans, 467, 583 
pain in spine with, 483 
Arthropathia in nervous diseases, 583 
Articular neuralgia, 484 
Arythm of pulse, 241 
Arythmic breathing, 92 
Ascarides in ductus choledochus, a 
cause of jaundice, 47 
Ascaris lumbricoides described, and 
symptoms of, 380 
eggs of, 381 
illustrated, 381 
Ascites, abdominal veins enlarged 
with, 314 
associated with cirrhosis of liver, 
325, 326 
cause of diminished area of liver 
dulness, 331 
caused by stasis, 314 
chylous, 318 
defined, and diagnosis of, 313 
due to venous engorgement, 260 
effect on form of chest, 86 
employment of deep breathing in, 
323 
may cause venous stasis, 262 
press diaphragm up, 322 
tympanitic sound with distention 
of abdoipen from, 130 
value of tapping for diagnosis, 318 
Asiatic cholera: See Cholera Asiatica 
Aspergillus fumigatus (mould) in spu- 
tum, 175, 190 
Aspermatism, 580 
Asphyxia, local, in neuroses, 577 
Associated movements in paralysis, 
defined, 535 
Asthma, bronchial, expiratory dys- 
pnoea peculiar to, 99 
rapid breathing in, 94 
relation of Curschmann’s spi- 
rals to, 180 
casts in sputum of, 173 
cause of cyanosis, 43 
Charcot-Leyden’s crystals in, 
182 
in sputum of bronchial, 
174 
in connection with disease of the 
nose, 575 
oxalate of lime in sputum of, 
182 
simulation of, 19 
spirals in sputum of, 175 
uraemic, 440 
Asymmetry of breathing described, 
91 
of pulse, 245 
of skull, 465 
Ataxia defined, 527 
and explained, 529 
difficulty of distinguishing, from 
tremor, 531 
of upper extremity, 561 
when it occurs, 529 
Ataxic aphasia, 552, 553 
cause of, 555 
Atelectasis in children, 98 
Atelectatic crepitation, inspiratory, 
defined, 154 
Atheroma of aorta, systolic murmurs 
with, 254 
of vessels a cause of hemorrhage 
of brain, 576 
Athetosis defined, 535 
Atonia in paralysis, 489 
Atonic atrophic paralysis, 494 
paralysis, 494 
Atrophic paralysis, 490 
fibrillary contractions in, 
532 
partial EaR in, 525 
two forms of, 493 
Atrophy and paralysis, parallelism 
between, 493 
disunion of, 493 616 
INDEX. 
Atrophy defined, 35 
disturbance of vision from, 601 
of inactivity, 491, 494 
of muscles, 489 
varieties of, 490 
Atropine, effect of, on pupil, 567 
poisoning, red skin in, 41 
Auenbrugger, reference to, 104, 105 
Aura, a prelude of epileptic convul- 
sion, 532 
Auricle, its relation to venous pulse, 
264 
left, location of, 191 
right, location of, 191 
Auricular semi-lunar murmur, where 
heard, 224 
Auricularis magnus nerve illustrated, 
485 
Auriculo-temporal nerve, illustrated, 
485 
Auscultation of heart, 211 
points of election for, 213, 
214 
of intestine, 312 
of lungs, 138 
to be after percussion, 140 
of peritoneal cavity, 318 
of pulse, 257 
of stomach, 307 
of veins, 268 
of voice, 156 
when it may be omitted, 158 
of whispered voice, 159 
results of, in aneurism of aorta, 
254 
value of, when small surface of 
lung is involved, 126 
Autocthonous clots, effect on pulse, 
245 
Auto-intoxication, 
by acetonuria, 448 
by diaceturia, 448 
Auxiliary muscles of inspiration and 
expiration, 540 
named, 96 
of respiration, aid in thoracic 
breathing, 99 
Axillary lines defined, 76 
nerves illustrated, 486 
Azoospermia, 580 
BAAS, reference to, 151 
Baccilli, reference to, 159 
Bacillus of anthrax, illustrated and 
described, 280 
! Bacillus described, cultures of, 604 
distinguished from Koch’s comma 
bacillus, 607 
in sputum from mouth, 188, 289 
in urine, 425 
resembling tubercle bacillus, 
400 
of Finkler-Prior described, cul- 
tures of, 390, 607 
of glanders, found in blood, 282 
of malignant oedema described, 
604 
of tuberculosis, absence of, 187 
discovery of, made elastic 
threads in sputum less 
valuable, 177 
found in blood (rare), 281 
in sputum, 275 
in urine, sign of tuberculosis 
of urinary passages, 426 
Back, nerves of, too deep for electrical 
examination, 511 
Bacteria, casts of, in pyaemia, 424 
found in hyaline casts, 423 
intestinal, in stools, value of, 
388 
in urine, 399 
of nephritis, 427 
section on their diagnostic value, 
602 
urine made cloudy by, 402 
turbid from, 413 
Biilz, reference to, 174, 183 
Bamber, reference to, 191 
Band-box note with emphysema, 135 
Barrel-shaped chest, 83 
Bartels, reference to, 395 
Basch, reference to, 245 
Basedow’s disease, blowing murmurs 
over lymphatic glands in, 
259 
heart-heat in, 201 
hemidrosis in, 38 
increased strength of heart- 
sounds in, 216 
palpitation of heart in, 577 
pulse in, 240 
tremor of, 531 
Basilar artery, 461 
Baths, cold, value of pulse in showing 
result of, 253 
induce perspiration, 37 
Baumann, reference to, 432 
Berger, reference to, 190 
/3-oxybuteric acid in urine of diabetic 
coma, 449 INDEX, 
617 
Biceps reflex, 499 
-tendoh reflex, 498 
Biedert, reference to, 164, 186 
Bienstock, reference to, 388 
Biermer, reference to, 104, 135, 136 
Bile-acids in urine, diagnostic value 
of, 443 
small amount of, in normal 
urine, 405 
value of, in jaundice, 46 
coloring matter of, in urine, 410 
deficiency of, effect on absorption 
of fat, 371 
effect of, on color of stools, 373 
not usually found in watery stools, 
374 
-pigment in sputum in icterus, 172 
-pigments and bile-acids, section 
on tests for, in urine, 442 
vomiting of, 361 
Biliary colic, vomiting in, 358 
engorgement, tenderness with,324 
Bilirubin, 46 
Bismuth test for sugar in urine, 444 
uncertain if there is albumin, 
444 
Bizzozero, reference to, 271 
Black color of vomit, from ingestion 
of iron, and in acute lead-poisoning, 
360 
Bladder, alkaline fermentation in, 
cause of turbid urine, 412, 413 
carcinoma villosum of, particles of 
tissue in urine from, 421 
completely emptied by act of uri- 
nation, 408 
crises (painful tenesmus) in tabes, 
580 
depot of pus in the neighborhood 
of, cause of hydrothionic urine, 
415 
distended, diagnosis of, 398 
disturbance of, 587 
examination of, 398 
importance of emptying in exam- 
ing abdominal organs, 341 
paralysis of, 590 
position of, 398 
retention of urine in, a cause of 
diminution of secretion, 408 
tenesmus of, causes of, 400 
Blindness, central, 568 
result of lesion of corpora quadri- 
gemina, 570 
Blood, abnormal additions to, 280 
alkalescence of freshly drawn, 283 
Blood, arterial, brighter in color than 
venous, 270 
bacillus of typhoid fever found 
in, 281 
-casts in urine, sign of renal hema- 
turia, 424 
chemical examination of, 283 
color of, in cases of poisoning by 
various substances, 270 
coloring matter of, in urine, when 
occurs, 410, 441 
corpuscles, change in form and 
size of red, in anaemia, 275 
counting of, 274 
in stools, 387 
normal proportion of white 
to red, 278 
pathological diminution of 
red, 275 
proportion of white to red 
increased in anaemia, 275 
red, number of, in a cubic 
millimetre of blood, 275 
crystals in, in leukaemia, 279 
diseases of, cause of paleness, 40 
entire amount equals about one- 
thirteenth weight of body, 270 
examination of, 270 
from nose and throat, diagnosis 
of, 171 
in sputum from rupture of aneu- 
rism, 167 
intensity of color of, 270 
in urine, form and appearance of, 
416 
gives a small amount of albu- 
min in solution with, 435 
makes it turbid, 412 
-jaundice, 46 
large effusions of, urobilin in 
urine with, 409 
-making organs, development of 
fat in disease of, 41 
microscopical examination of, 273 
mode of examination of, for micro- 
organisms, 282 
morphological constituents of, im- 
portance of, in diagnosis, 270 
movement of, in heart, 193 
murmurs, 229 
normal structures of, 273 
pathological conditions of, as re- 
vealed by the microscope, 273 
-pressure, diminished amount of 
urine when reduced, 407 
how measured, 245 618 
INDEX. 
Blood, pure, changed by gastric juice 
in stomach, 362 
seldom vomited, 362 
spectroscopic condition of, 272 
examination of, valuable in 
three classes of cases, 272 
time it takes to coagulate after 
withdrawn, 283 
tracing of pulse after loss of, 248 
Bloody sputum described, 169 
vomit (haematemesis), 361 
Blushing, 42 
Boas’s test for free muriatic acid, 351, 
367 
Boiling and nitric acid test for albu- 
min in urine, 436 
Boilliaud, reference to, 552 
Bone reflexes, 500 
Bones and joints in nervous diseases, 
section on, 583 
arrest of growth of, in paralysis, 
583 
sound on percussion of, 109 
Borborygmi, 312 
Border of lungs, abnormal position of, 
125 
Bornhardt, reference to, 35 
Bothriocephalus lata described, 379 
illustrated, 379 
Bottcher, reference to, 503 
Boulimia defined, 472 
Boundaries of lungs changed, 136 
method of determining, 117, 
119 
parietal, of organs, 116 
of liver, spleen, and kidneys 
illustrated, 321 
Bowels, disturbance of, from venous 
engorgement, 261 
obstruction of, peculiar grass- 
green vomit with, 361 
vomiting of feces in occlusion of, 
364 
Brachial plexus, Erb’s point, 510 
paralysis of, cause of anaes- 
thesia of the region of the 
median nerve, 487 
Brachycardia, 238 
Brachycephalus, 465 
Brain, abscess of, from disease of the 
nose, 576 
hearing in, 572 
relation of, to disease of the 
lungs, 576 
sensibility of cranium to pres- 
sure with, 466 
Brain, absence of cough in disease of, 
165. 
aneurism of minute arteries of, a 
cause of hemorrhage, 577 
bloodvessels supplying, section on, 
461-463 
concussion of, glycosuria after, 443 
cysticerci in, from taenia solium, 
578 
difficulty of local examination of, 
463 
diseases of, anomalies of breath- 
ing in, 91 
dyspnoea in, 94 
headache with, 482 
inherited, 20 
disturbance of vision by lesion at 
base of, 460 
effect of local disease at base of, * 
457 
habit which predisposes to hemor- 
rhage of, 575 
hearing in local disease of, 572 
hemorrhage and softening of, re- 
lation to diseases of the heart, 
576 
inequality of pupils in unilateral 
affections of, 567 
lateral view of, 452 
lesion at base of, paralysis of mus- 
cles of one eye in, 565 
local diseases of, diagnosis of, 586 
hemidrosis in, 38 
thrombosis of vessels of, 576 
paralysis of cortex of, early spasms 
in, 494 
postures assumed in diseases of, 33 
retinitis in syphilis of, 562 
slight amount of vomit in diseases 
of, 360 
slow pulse in diseases of, 237 
symptomatic epilepsy in anatom- 
ical diseases of, 533 
symptoms, general, enumerated, 
' 585 
syncope in chronic diseases of, 471 
syphilis of, changes in fundus 
oculi in, 601 
tuberculous nature of diseases of, 
if nutrition is poor, 575 
tumors of, disturbance of con- 
sciousness with, 471 
migraine with, 483 
vertigo with, 472 
value of pulse in showing com- 
plicating disease of, 253 INDEX. 
619 
Brain, vomiting from irritation of, 358 
in rapidly developing diseases 
of, 578 
occurs suddenly in diseases of, 
359 
Breath, odor of, importance of, 285 
short, in deformity of chest, 88 
Breathing. See also under Respiration, 
abdominal, 90 
disappears in paralysis of 
diaphragm. 90 
anomalies of, 89, 91 
from C02 in blood, 92 
asymmetry of, described, 91 
costal type of, in women, 90 
deep, during auscultation, 141 
diaphragmatic, interfered with, 
86 
irregularity of, 92 
obstructed, 74 
of compression defined, 147 
painful, effect of posture upon, 
32 
thoracic, replaced by diaphrag- 
matic, 90 
transition, explained, 149 
undefined, explained, 148 
Brenner, reference to, 572 
Brick-dust sediment in urine ex- 
plained, 402, 429, 430 
Brieger, reference to, 356, 372, 432 
Bright’s disease, choked disc with, 
601 
dropsy of, explained, 440 
Broca, reference to, 552, 553, 555 
Bromine, urine after taking, 450 
Bronchi, epithelium in sputum from, 
176 
Bronchial asthma, casts in sputum of, 
173 
Charcot-Leyden’s crystals in 
sputum of, 174, 182 
relation of Curschmann’s 
spiral to, 180 
breathing, how conducted to the 
ear, 143 
difficult to distinguish from 
vesicular, 143 
normal, described, 141 
not to be confounded 
with pathological, 
141 
pathological, explained, 
164 
difficulty of, weakened in case 
of filled cavity, 147 
Bronchial catarrh, 94 
cause of diminished vesicular 
breathing, 145 
kind of rales with, 150 
tubes, closure of, weakened vocal 
fremitus with, 158 
pieces of, in sputum, 172 
rapid breathing in diseases 
of, 94 
sensitiveness of, a cause of 
cough,165 
Bronchiectasis, 131 
amount of expectoration in, 168 
friction sounds with, 156 
odor of sputum in, 171 
Bronchiectatic cavities, micrococci in 
sputum from, 189 
ringing rales with, 153 
Bronchitis, acute, mucus in first stage 
of, 168 
a ferment in sputum of, 190 
alveolar epithelium in sputum of, 
177 
amount of expectoration in, 168 
capillary in children, 98 
caused bv dust, 21 
Charcot-Leyden’s crystals in spu- 
tum of, 174, 182 
chronic, morning cough of, 165 
cyanosis in, 43 
diffused, rales with, 150 
fetid, crystals in sputum of, 181 
micrococci in sputum in, 189 
odor of sputum in, 171 
relation of, to brain disease, 
576 
sputum in three layers in, 
169,174 
fibrinous tubes in sputum of acute 
and chronic croupous, 172 
increased vesicular breathing in, 
144 
jerking, inspiration in, 145 
metallic rales with, 150 
non-ringing rales with, when 
there is a broncho-pneumonic 
deposit, 153 
prolonged expiration in, 145 
purulent, coin-shaped sputa in, 
169 
putrid, leptothrix buccalis in spu- 
tum of, 184 
tyrosin in sputum of fetid, 182 
vital capacity of lungs in, 164 
Bronchophony described, 158 
Broncho-pneumonia in children, 98 620 
INDEX. 
Bronchus, primary, when open tym- 
panitic sound is heard over, 111 
stenosis of, 98 
Bronze skin, 48 
Bruit de pot felt described, 134 
where it occurs, 134 
Bubbling rales, 154 
Buccinator nerve, illustrated, 485 
Bulb, EaR with disease of the motor 
nerves of, 524 
Bulbar paralysis, absence of bone re- 
flex in, 500 
of reflex of pharynx in, 
497 
cyanosis in, 43 
EaR with, 524 
increased secretion of saliva 
in, 577, 578 
lessened excitability in, with- 
out EaR in, 525 
paralysis of diaphragm in, 90 
of recurrent nerve with, 
538, 599 
position of the soft palate in, 
538 
power to cough lost in, 165 
quick pulse with, 577 
rigid thorax in, 91 
salivation in, 289 
speech in, 548 
pulse (bulbus jugularis), 265 
Bulbus jugularis, 263, 265 
murmur at, in tricuspid in- 
sufficiency, 268 
Bumm, reference to, 604 
Bursa omentalis, 299 
Butyric acid, formation of, in stomach, 
345 
Buzzing felt near the heart, 204 
C| abbreviation for contraction. 
y Ca, abbreviation for cathode, 506 
Cachectic conditions, chloride of so- 
dium in urine diminished in, 434 
Cachexia, chronic, disturbance of con- 
sciousness in, 471 
defined,35 
delirium in, 471 
diminished volume of abdomen 
in, 309 
general atrophy in, 491 
indican in urine of severe, 409 
leucocytosis in, 278 
malarial, 41 
oxaluria in, 430 
Cachexia, poikilocytosis in, 277 
severe, ecchymosis in, 51 
state of skin in, 36 
temperature in, 64 
urea diminished in all kinds of, 
434 
Cadaveric odor of breath, 285 
Caecum, to be examined in sudden 
obstipation, 369 
Calcifications in pericardium, friction 
sounds from, 232 
Callus, cause of pressure on nerves, 
469 
Camman, reference to, 140 
Cancer. See also Carcinoma. 
cachexia of oxaluria with, 430 
poikilocytosis in, 277 
of head of pancreas, a cause of 
jaundice, 47 
of rectum, pain at stool in, 370 
of stomach, alkaline vomit in, 366 
palpation of, 303 
use of sound in, 302 
navel on liver in carcinoma of 
liver, 325 
paleness in, 41 
Cancrum oris, description of, 288 
Cantani, reference to, 430 
Cantharides, fibrin in urine in poison- 
ing by, 439 
Capillaries, arterial pulse propagated 
through, 268 
Capillary pulse described, 256 
Capsule, inner, lesion of, with hemi- 
chorea, 535 
internal, 454, 461 
Caput Medusae defined and explained, 
262 
quadratum, 464 
| Carbolic acid, color of urine after 
taking, 411, 435, 451 
Carbonate of lime in urine, 431 
illustrated, 431 
Carbonic acid, accumulation of, a cause 
of cyanosis, 42 
diagnostic importance of, 
270 
effect of poisoning by, upon 
color of blood, 270 
in blood, cause of, 43 
increased exhalation of, in 
fever, 60 
oxide poisoning, absorption bands 
in blood in, 272 
Carcinoma. See also Cancer, 
acetonuria in, 448 INDEX 
621 
Carcinoma, delay in absorption from 
stomach in case of, 355 
disturbance of consciousness in, 
470 
effect of, on consistence of liver, 
326 
epithelial, in larynx, illustrated, 
596 
inherited, 20 
irregular enlargement of liver 
with, 322 
nutrition poor in, 575 
of gall-bladder, 326 
of kidney, palpation of, 395 
of larynx described, 597 
of liver, change in shape of, 325 
difficult to distinguish from 
that of omentum, 340 
with and without tenderness, 
324 
of lung, deadened sound over, 
127 
of oesophagus, 292, 294, 296 
affecting the larynx, 75 
of pancreas, diagnosis of, 340 
of peritoneum, 315 
of skull-wall, 465 
of spleen, unequal enlargement 
from, 335 
of stomach, absence of free muri- 
atic acid in, 356 
hypersecretion in cases of, 
357 
local increased resistance 
with, 302 
pain of, 304 
of tongue, 286 
shreds of tissue in stools in, 377 
ventriculi, hemorrhage from, 362 
peptonuria with, 439 
Carcinomatous pleuritis, cells in exu- 
dation of, 161 
ulceration of rectum, hemorrhage 
from, 375 
Cardia of stomach, position of, 298, 
299 
Cardiography of apex-beat, 202 
Caries of rib, pain in, 101 
cause of pleurisy, 102 
of vertebrae, tenderness with, 467 
Carotid artery, left, relation to aorta, 
clinical importance of. 463 
pulsation of, in health, 255 
pulse in aneurism of aorta, 254 
Carotids, internal, supply the brain, 
461 
Cartilage, sound on percussion, 109 
CaSC, 518, 519, 523 
determination of minimal, 515 
early in tetanus, 526 
Case-taking, value of, 25 
CaSTe, 518 
determination of, 515 
early in tetanus, 526 
Casts, epithelial, forms of, in urine, 
424 
in urine, the infallible signs of 
nephritis, 420 
of red blood-corpuscles, ilustrated, 
424 
renal, kinds of, 422 
preparation of, for examina- 
tion, 422 
Catalepsy defined, 535 
rarely occurs with anatomical 
diseases, 536 
Cataract with diabetes mellitus, 562 
Catarrh, acute nasal, a sign of various 
diseases, 74 
chronic nasal, cause of neuroses, 
575 
nasal, 73 
of intestine, meteorism with, 309 
of large intestine, stool of, 373 
of larynx, signs of, 593 
of stomach, delay in absorption 
in case of, 355 
hypersecretion in cases of, 
357 
pain with, 303 
Catheter, always to be used to draw 
urine in cases of unconscious- 
ness, 401 
cystitis excited by, 425 
to be used to avoid contamination 
of urine, 399 
use of, a cause of cystitis, 579 
shows residual urine, 408 
Cathodal closure, result of, 506 
Cathode (negative pole), 515 
at the, contraction at the closing 
of current, 506 
of galvanic current, use of, in test- 
ing sensibility of spinal column, 
468 
of the opening current of sec- 
ondary coil stronger than 
anode, 504 
Caudate nucleus, blood-supply of, 
462 
Causes of disease, exciting, 21 
predisposing, 21 622 
INDEX. 
Cavities, bronchiectatic, micrococci in 
sputum from, 189 
cylindrical, effect of length upon 
pitch of sound, 110 
experiment to illustrate, 110 
in apex revealed by loud rales, 
152 
in lungs, amount of expectoration 
from, 168 
bronchial breathing over, 146 
coin-shaped sputa from, 169 
containing air, closed-tvmpa- 
nitic sound from, 110 
open or closed, tympanitic 
resonance over, 131 
plegaphonia over, 159 
large parietal, noise of spun-top 
over, 134 
with smooth walls, 136 
Cavity in lung, if filled, weaker bron- 
chial breathing over, 147 
increased vocal fremitus with, 
158 
metamorphosing breathing a 
sure sign of, 148 
purulent sputum from, 169 
ringing rales with, 152 
Celli, reference to, 282 
Celsius’ thermometer, 57 
Central convolution, 459 
anterior, blood-supply of, 462 
left anterior, centre of acous- 
tic recollections, 555 
posterior and anterior, illus 
trated, 466 
blood-supply of, 462 
thread of Curschmann’s spirals 
described, 179 
Cephalalgia, significance of, 482 
Cercomonas (infusorium) in sputum, 
183 
Cerebellum ataxia in lesions of the 
vermiform process, 529 
illustrated, 466 
vermiform process of, lesion of, 
534 
vertigo with tumor of,472 
vomiting in diseases of, 578 
Cerebral abscesses, 585 
affections, ataxia in, 529 
artery, middle, hemorrhages and 
emboli most frequent 
in, 463 
largest vessel of brain, 462 
posterior, portion of brain it 
supplies, 462 
Cerebral blowing sound in children 
with systole of heart, 258 
congestion, with albuminuria, 441 
disease, absence of cough in, 165 
severe hiccough in, 540 
diseases, clonic spasms in local- 
ized, 532 
hemorrhage, Cheyne Stokes respi- 
ration in, 92 
irritation, acetonuria with, 448 
paralysis above the anterior horn, 
characteristic sign of, 494 
EaR not present in, 525 
in children, hemiathetosis in, 
535 
increase of tendon reflex in, 
500 
symptoms, significance of, 587 
tumors, Cheyne-Stokes respira- 
tion in, 92 
Cerebro-spinal meningitis, herpes 
with, 50 
Cerebrum, 461 
blood-supply of, in the region of 
fissure of Sylvius, 462 
disease of, muscular atrophy with, 
493 
relation of acostic nerve to, 461 
Cervical enlargement of cord, location 
of, 468 
nerves, illustrated, 485 
vertebrae, caries of, 589 
Chain-coccus in urine, 426 
Change of respiratory sound, Fried- 
reich’s, defined, 113 
of sound, tracheal, Williams’s, 
121, 130 
Wintrich’s, described, 111 
Charcot, reference to, 279, 493, 526, 
556, 557, 558, 560, 581, 582, 587 
Charcot’s crystals, 387 
Charcot-Leyden’s crystals, 179 
described, 181 
in asthma, 388 
in sputum, 174 
Cheek, nerve-supply of, 484 
Cheese-spirals, 391 
Chemical examination of blood, 283 
Chemistry of digestion, 348 
Chest, asymmetry of, 82 
circumference of, in relation to 
weight and height, 35 
dimensions of, 82 
form of, in relation to disease, 81 
lagging behind of, 86 
pathological form of, 82 INDEX 
623 
Chest, sides of, percussion note over, 1 
120 
-wall, affections of, which cause 
deadened sound,130 
inflammatory diseases of, 
weaken apex-beat, 201 
thickening of, a cause of 
diminished vesicular 
breathing, 145 
weakened vocal fremitus 
with, 158 
Cheyne-Stokes respiration described, 
91, 92, 93 
dyspnoea in, 94 
increased vesicular 
breathing in, 144 
with uraemia, 440 
Chiasm, pressure upon, atrophy of 
optic nerve from, 601 
Children, area of heart-dulness in, 205 
arrest of growth of bone in paral- 
ysis of, 583 
at first naturally ataxic, 527 
cancrum oris in, 288 
capillary bronchitis in, 152 
cerebral blowing sound with sys- 
tole of heart in, 258 
choreic motions in encephalitis 
in, 535 
color of stool in, 373 
cracks in lips of, a sign of heredi- 
tary syphilis, 285 
diaceturia in fever of, 447 
as an independent disease in, 
447 
ease with which they vomit, 358 
edge of liver distinct in, 323 
effect of severe diarrhcea in, upon 
amount of blood in the body, 
270 
elasticity of thorax in, effect on 
rales, 153 
epileptiform attacks from various 
causes, 533 
examination of, for eruption of 
teeth in, 285 
expansion of lungs in, after 
whooping-cough, 136 
frequency and character of stools 
in, 368 
gallop rhythm a sign of heart- 
failure in, 221 
heart-sounds in, 216 
hemiathetosis in cerebral paral- 
ysis in, 535 
how to examine mouth of, 284 
I Children, kinds of fungus spores in 
stools of, 388 
laryngitis in, 593 
lientery stools in, 372 
meat-juice stools in catarrh of 
large intestine in, 375 
nervous disturbances from intes- 
tinal parasites in, 578 
nursing, sour odor of stool nor- 
mal in, 371 
percussion note in, 120 
position of apex-beat in, 198 
of heart in, 192 
pulse in, with febrile disease, 239 
rapid breathing in fever of, 94 
reaction of stool in, 372 
relative heart-dulness in, 207 
retro-pharyngeal abscess in, 290 
round worms in, 380 
size of liver in, 320 
sounding oesophagus of, 293 
thrush in, 288 
yielding thorax of, permits pro- 
jection in enlargement of liver, 
321 
Chill described, 62 
with rise of temperature, signifi- 
cance of, 64 
Chittenden, reference to, 439 
Chlorate of potash, color of blood in 
poisoning by, 270, 271 
poisoning by, causing hsema- 
to-jaundice, 47 
Chloride of calcium, poisoning by, 
methsemoglobin in blood in, 
272 
of iron reaction, test for acetone, 
414 
of sodium, amount of, in urine 
405 
in urine, 434 
Chlorides usually diminished in fever, 
60 
Chloroform poisoning causing haema- 
to-jaundice, 47 
odor of breath in, 285 
Chlorosis, blood-corpuscles markedly 
pale in, 275 
color of blood in, 271 
dizziness with, 471 
Egyptian, 41 
heart-sounds strengthened in, 217 
murmurs heard in, 229 
no notable diminution of red cor- 
puscles in, in contrast with 
anaemia, 276 624 
INDEX. 
Chlorosis, paleness in, due to loss of 
haemoglobin, 41 
red blood-corpuscles not dimin- 
ished in, 274 
use of Fleischl’s haemometer in, 
276 
venous humming in, 269 
Choked disk, 562, 587 
absence of, in bulbar paral- 
ysis, 496 
from intra-cranial pressure, 
600 
recognition of, 601 
unilateral, 565 
Cholaemia, 47 
Cholera Asiatica, alkaline vomit in, 
366 
anuria with, 407 
bacillus, cultures of, 607 
described and illustrated, 
389 
mode of preparation of, 
389 
necessity of pure culture 
of, 390 
color of stool in, 373 
effect of discharges in, on 
amount of blood in the 
body, 270 
examination of, 606 
increased peristalsis in, 366 
indican in urine of, 409 
great quantity of stool in, 
370 
mucus in stools of, 374 
odor of stools in, 372 
peculiar vomit of, described, 
361 
saliva diminished in, 289 
severest diarrhoea with, 369 
sweat in, 38 
watery stools in, 371, 374 
morbus, mucus in stools of, 374 
Cholesterine, crystals of, in sputum,181 
Chorda tympani, 461, 484 
Chorea minor described, 534 
significance of, 535 
Choroid, tubercle of, 601 
Choroidal tuberculosis, 562 
Choroiditis syphilitica, 601 
Chronic diseases, development of, in- 
dicated by weight of body, 
35 
outbreaks of, 22 
Chyluria, fibrin in urine in, 439 
lipsemia in, 280 
Chyluria, lipuria in, 447 
produced by filaria sanguinis, 425 
rare, 412 
Ciliated epithelium, transfer of mucus 
by, 167 
Circle of Willis, 461 
Circulation, disturbance of, causing 
paleness, 40 
through lungs, 41 
Circulatory anoaratus, examination 
of, 191 
disturbances of, 576 
Circulus vitiosus, in stomach, 345 
Circumference of thorax increased in 
inspiration, 163 
where measured, 162 
Circumpolarization for determining 
presence of sugar, 447 
Cirrhosis of liver, ascites with, 314 
bloody vomit in, 361, 362 
consistence of liver in, 326 
diminished area of dulness 
with, 331 
enlargement of spleen with, 
335 
made out after tapping abdo- 
men, 318 
surface of, 325 
urine of, dark, 408 
venous engorgement caused by, 
262 
Clarke, columns of, 459 
Clavicular depressions deepened, 87 
Clavus hystericus, 482 
Clear sound defined, 106, 109 
from closed air-cavity, 110 
Clinical study, value of case-taking 
in, 25 
Clonic spasms, 530 
when occur, 532 
Closed tympanitic sound defined, 110 
heard over stomach, 111 
Clothing, effect of, on disease, 21 
C02in blood, effect of, on breathing, 93 
Coagulation of blood slower when 
nutrition is disturbed, 283 
Coal-dust in epithelial cells in sputum, 
177 
sputum, 171, 176 
Cocaine, effect of, on pupil, 567 
Cocci in urine, 425 
Cod-liver oil, lipuria when taking, 447 
Coffee-grounds-stool, in gastric hem- 
orrhage, 375 
-vomit explained, 363 
Cohnheim, reference to, 53, 54, 407 INDEX, 
625 
Cohnheim’s hypothesis regarding 
dropsy of kidney disease, 440 
Cold baths, value of pulse in showing 
result of, 253 
catching, disposition to headache 
with, 483 
Colic, abdominal, from passage of gall- 
stones, 376 
Collapse, cold sweat of, 38 
described, 63 
from hemorrhage in cases of ulcer 
of stomach, 362 
shown by fall of temperature, 65 
weakness of apex-beat in, 201 
Colon, boundary between, and small 
intestine 312 
distention of, for purposes of diag- 
nosis 311, 312 
fecal masses in, increases the area 
of dulness near the spleen, 338 
position of, illustrated, 298 
relation of, to spleen, 336 
transverse, scybala in, 303 
tumors of transverse and descend- 
ing, confounded with those of 
spleen and kidney, 311 
Color of expectoration, 168 
of skin, 38 
of tongue, 287 
of urine, 401 
-sense, testing the, 568, 571 
Columns of Clarke, 459 
of Goll, 459 
of Tiirck, 455 
Coma defined, 470 
diabetic, 579 
acetone odor of urine in, 414 
/3-oxybutyric acid in urine 
of, 449 
diaceturia in, 447 
odor of breath in, 285 
difficulties of diagnosis in, 471 
from diaceturia, 448 
post-epileptic, 533 
uraemic, 440 
with diabetes mellitus, 579 
Comma bacillus, Koch’s, distinguished 
from Finkler-Prior’sbacillus,390,607 
Communicating artery, posterior, 461 
Comparative percussion, 118, 121, 
125 
Compensation of heart disease, pulse 
in arrested, 240 
of valvular deficiency, 195 
Compensatory hypertrophy of one 
division of heart, 219 
Complementary pleural sinus, 80 
exudation into, 306 
space, 192 
Complication of disease shown by 
temperature, 65 
Complications, value of pulse in, show- 
ing beginning of, 253 
Concealment of disease, 19 
Concentrated urine, appearance of, 402 
Conception of space, how tested, 481 
Concretions in urine, 433 
Concussion of cranium, disturbance 
of consciousness in, 471 
Conduction, resistance to, 512 
Conductive resistance, 514 
variations of, due to thickness 
of skin, 513 
Confinement to bed, ataxia after, 529 
Coufluent sputa, 169 
Congenital drawing in of thorax, 89 
Conjugate deviation, 566 
of the eye, 563 
Conjunctiva, color of, 39, note. 
nerve supply of, 484 
Consciousness, change of, in Cheyne- 
Stokes’s breathing, 93 
diseases in which disturbances of 
occur, 470 
disturbances of, terms used for, 
470 
loss of, 40 
sign of, 489 
mydriasis with marked disturb- 
ance of, 566 
never an entire loss of, in hys- 
terical convulsions, 533 
obtunded, phenomena of, 471 
when there is loss of, heart and 
vessels to be examined, 577 
Consensual reaction of pupils, 567 
Consistence of expectoration, 168 
Consonance increases vocal fremitus, 
158 
Consonant rales, 152 
Constipation, 368 
alternating with diarrhoea, 369 
and severe obstruction to be 
sharply distinguished, 369 
habitual, in diseases of spinal 
cord, 578 
Constrained positions and motions de- 
fined, 534 
Constricted liver from tight lacing, 
323 
Constriction, feeling of, about thorax, 
482 626 
INDEX. 
Contagion distinguished from infec- 
tion, 22 
Continued fever, range of temperature 
of, 62 
Continuous fevers, red skin in, 41 
Contracted kidney, casts in urine of, 
422 
diminished urine with, 407 
polyuria with, 406 
retinitis in, 601 
pupil, 566 
Contraction, character of, 518 
laws of, 505 
normal, with galvanic stimu- 
lation, 506 
minimal, 505, 515, 516 
. quality of, sometimes important, 
515, 516 
tetanic, 505 
Contractions, idio-muscular, defined, 
526 
lightning-like, 507 
of fibrillae, 530 
paradoxical, defined, 527 
quality of, depends upon relation 
of the nerve to the skin, 504 
slowness of, in partial EaR, 523 
Contracture due to over-excitability 
of nerves and muscles, 526 
of muscles in paralysis, 495 
Contractures wanting, 493 
Conus aortae, 193 
arteriosus, sound caused by filling 
of, 213 
terminalis of cord, location of, 468 
Convalescence indicated by weight of 
body, 35 
perspiration in commencement of, 
38 
pulse in, 235 
temporary imbecility in, 472 
Convolution, anterior central, 454 
left anterior central, centre for 
acoustic recollection, 555 
second frontal, motor centre 
for writing, 555 
third frontal, motor speech- 
centre, 555 
posterior central, 454 
Convolutions of brain, anterior and 
posterior central, blood 
supply of, 462 
posterior and anterior cen- 
tral, illustrated, 466 
Convulsions. Also see Spasms 
clonic spasms in, 532 
Convulsions, difference between hys- 
terical and epileptic, 533 
due to eruption of teeth, 286 
epileptic and hysterical, opistho- 
tonus with, 468 
hysterical, tetanic, perspiration 
in, 37 
in children, diaceturia thought to 
be the cause of, 448 
produce cyanosis, 42 
sign of nervous disease, 22 
simulation of, 19 
with uraemia, 440 
Cooing in intestine, value of, 312 
Coordinated motions in hystero-epi- 
lepsy, 533 
spasms, 534 
Coordination defined and explained, 
527 
disturbances of, in the larynx, 597 
how acquired, 527 
of muscles, 488 
temporary loss of, 529 
Copaiva, odor of urine after taking, 
414 
Copper, condition of teeth in poison- 
ing by, 286 
Copying, power of, 550 
Cord, compression of spinal, 467 
spinal, effect of lesion of, 457 
Corona radiata, 454 
effect of lesion of, 457 
Corpora quadrigemina, ataxia in le- 
sions of, 529 
blood supply of, 462 
Corpulence, 35 
increases area of dulness near the 
spleen, 338 
Corpus quadrigeminum, lesion of pos- 
terior, 566 
Corpuscles, mucous, in sputum, 175 
Cortex of brain, clonic spasms in 
local affections of, 532 
effect of lesion of, 457 
partial epilepsy a sure sign 
of disease of, 533 
spasms from irritation of the, 
530 
Cortical centres, lesion of, results of, 
456 
where their trophic influence 
ceases, 456 
Cortico-muscular tract, 452, 456 
Corvisart, reference to, 104 
Costal breathing, absence of, how met, 
91 INDEX. 
627 
Costal breathing absent in emphy- 
sema, 84 
defined, 83 
how changed, 90 
in place of diaphragmatic, 95 
often wanting in women, 85 
Costo - abdominal breathing, how 
changed, 90 
Cough, diseases and conditions in 
which it is absent, 165 
dry, defined, 166 
frequency of, and time of day of, 
significance of, 165 
moist, described, 166 
nervous, 576 
parts of mucous membrane from 
which it arises, 165 
phenomena of, explained, 164 
power to, when lost, 165 
spontaneous, or reflex, 165 
suppression of, from pain, 165 
tones of, described, 166 
vomiting from violent, 358 
Coughing, effect on venous circula- 
tion, 263 
produced by attempts at swallow- 
ing in paralysis of pharyngeal 
muscles. 538 
removes rales, 149 
Coupland quoted, 26 
Covering of body, effect on vocal fre- 
mitus, 157 
“Cracked-pot” sound, described, 134 
where heard, 134, 135 
Cranial fossa, anterior, middle, poste- 
rior effect of lesion of, 457 
nerves, nuclei of, illustrated, 455 
points of exit from skull, illus- 
trated, 458 
walls, disease of, 465 
Cranium, diseases of, headache with, 
482 
examination of, 465 
local diseases of, hearing in, 572 
rhachitic thickening of, 464 
sensibility of, to pressure, 466 
size of, at different ages, 464 
Creasote, color of urine after taking, 
411 
Cremaster reflex, defined, 495, 495 
Crepitant rales defined, 154 
in capillary bronchitis, 152 
Crepitation, non-uniform, 154 
Crepitations in mediastinal emphy- 
sema, 233 
Cretinism defined, 472 
Cretins, skeleton of, 33 
Crisis defined, 67 
signs of, 63 
Critical sweat in various diseases, 37 
Crossed paralysis (oculomotorius) of 
one side and extremity of other, 
566 
Cross-section of chest, 163 
Croup, 75, 98 
casts in sputum of, 172 
cause of cyanosis, 43 
dyspnoea in, 93, 94 
severe cough of a cause of emphy- 
sema of skin, 56 
tone of cough in, 166 
Croupous pneumonia, one-sided ex- 
pansion of chest in, 86 
Crura cerebelli, ataxia in lesions of, 
529 
Crural arterial and venous sounds 
combined, 269 
artery, double murmurs in, 259 
nerve, illustrated, 487 
vein, double sound over, how 
distinguished from that over 
crural artery, 268 
Crus cerebri, 454, 457 
injury of, 457 
lesion of, crossed paralysis 
with, 566 
median, lesion of, 534 
Crutch paralysis, 488 
Crystals, fat, distinguished from elas- 
tic threads in sputum, 177 
in sputum, 174 
in blood in leukaemia, 279 
in feces, 387 
in sputum, kinds of, 180 
of cholesterine in sputum, 181 
of fatty acids in sputum de- 
scribed, 181 
Cubebs, odor of urine after taking, 
414 
Current-changer, 506 
use of, 505 
density of, in nerves and skin, 
503 
electric, cannot be concentrated 
on nerve, 503 
reasons why, 504 
strength of, as affected by the 
angle of entrance of, 504 
increases, while electrodes 
are on the body, 503 
of total, 512 
of total, must be known, 513 628 
INDEX. 
Curschmann, reference to, 179, 180 
Curschmann’s spirals in sputum, 178 
Curvature, greater, of stomach, ana- 
tomical relations of, 
299 
boundary of, 305 
in distention, 301 
position of, 298 
when dulness over, 306 
lesser, of stomach, anatomical 
position of, 298 
relations of, 299 
Curve, Damoiseau’s, 129 
Cutaneous nerves of lower extremity 
illustrated, 487 
of shoulder, arm, and hand, 
distribution of, illustrated, 
486 
veins, enlargement of, 262 
Cyanosis, a result of general venous 
engorgement, 261 
causes of, 43 
described, 42 
from interference with respiration 
during an attack of epilepsy, 533 
from poisons. See Examination of 
Blood. 
from severe coughing, 166 
in paralysis, 577 
in tetanus and epilepsy, 540 
of newborn, 42 
sometimes absent in tuberculosis 
pulmonum, 44 
with dyspnoea, 99 
Cyclic albuminuria, 435, 437 
Cylindrical cavities, effect of length 
of, upon pitch of sound, 110 
experiment to illustrate, 110 
Cylindroids in urine not to be con- 
founded with casts, 424 
Cystic hemorrhages, very free, charac- 
teristics of, 418 
Cystin in urine, significance of, 432 
-calculi, 432, 433 
Cystitis, alkaline urine with, 413 
caused by cystin, 432 
by ptomaines, 432 
from use of catheter, 579 
haematuria from, 417 
hydrothionic urine with, 414 
micrococci and bacilli in urine of, 
425 
mucus in urine of, 416 
odor of urine in, 415 
sediment in urine in, 419 
signs of, 400 
Cystitis, turbid urine with, 412 
with a nervous disease, 575 
Cystometer, Woillez’s, 163 
Cystopyelitis, 398 
DAMOISEAU’S curve, 129 
Dax, M., reference to, 552 
Deadened resonance, 125 
sound associated with feeling of 
strong resistance, 116 
defined, 109 
from thick skeletal covering, 
114 
relatively, where occurs, 114 
where heard, 109, 113 
Deadening, relative heart and liver,l 12 
Deadness applied to sound, 106 
area of, increased with extent of 
exudation, 128 
of sound over pleural thickening, 
3,48 
relative, of sound defined, 107 
Deafness, absolute and relative, 108 
nervous, 572 
Decomposition of intestinal contents, 
vegetable parasites in feces in, 388 
Decubitus acutus defined, 582 
described, 582 
disturbance of nutrition with, 
575 
Deep breathing, employment of, in 
examining the abdomen, 323 
lung sound,108 
sensibility, 473 
part of, in recognizing the 
form of bodies, 481 
section on, 479 
Defecation, assisted by abdominal 
pressure, 540 
Defervescence, stage of, 65 
Deformity of chest, 81 
Degeneration, character of, as deter- 
mined by location of lesion, 456 
funnel-breast a sign of, 89 
of hypertrophied heart, weak 
apex beat in, 201 
of nerves and muscles, 520 
primary and secondary, increase 
of tendon reflex in, 500 
reaction of, complete and partial, 
519 
Degenerative atrophic paralysis, 492, 
493, 518 
atrophy, 490, 493 
difficulty of diagnosis in, 491 INDEX 
629 
Degenerative atrophv, w7hen wanting, 
491 
paralysis, 495 
Deglutition-pneumonia, 600 
Dehio, reference to, 143 
Delayed sensibility, 478 
Delirium, defined, and the diseases in 
which it occurs, 471 
in gross hysteria, 534 
-muttering in typhoid fever, 471 
tremens in alcoholic poisoning 
described, 471 
with uraemia, 440 
Dementia paralytica, atrophy of optic 
nerve in, 601 
character of the writing of, 
561 
senile, mixed aphasia and amne- 
sia in, 555 
senilis, 472 
Deneke, reference to, 391 
Dentition, cause of epileptiform at- 
tacks in children, 533 
disturbances due to, 286 
Deposits, pysemic, in lungs, friction- 
sounds with, 156 
Depression, clavicular, 81, 82, 84 
Morenheim’s, defined, 76 
states of, acetonuria in, 448 
Desaga, spectroscope devised by, 272 
Descendants divided by heredity, 20 
Desquamation of renal epithelium in 
acute nephritis, 424 
Detritus in stools, 387 
Development, errors of, funnel-breast 
a sign of, 89 
Deviation, conjugate, 534 
primary, secondary, 563 
Diabetes, acetone odor of breath in, 
285 
alkalescence of blood in, dimin- 
ished in, 283 
diminished sweat in, 38 
disturbance of consciousness in, 
470 
dyspnoea in, 576 
gangrene in, 577 
insipidus, 579 
inosite in urine in, 447 
lipmmia in, 280 
mal perforant in, 582 
mellitus and insipidus, polyuria 
with, 406 
apple odor of urine in, 414 
caries of teeth in, 285 
cataract with, 562 
! Diabetes mellitus, character of urine 
in, 443 
contradictory character of 
urine in, diagnostic value 
of, 409 
diaceturia in, 447 
effect of, on weight of body, 36 
levulose in, 447 
lipuria in, 447 
oxalate of lime in urine of, 
430 
percentage of sugar in urine 
of, 443 
polyuria of, secondary to 
polydipsia, 407 
specific gravity of urine in, 
412, 413 
thirst in, 23 
various nervous disturbances 
with, 579 
neuralgia in, 483 
ocular changes in, 602 
oxalate of lime in sputum of, 182 
saliva diminished in, 289 
thrush with, 288 
Diabetic coma, acetone odor of urine 
in, 414 
/?-oxybuteric acid in urine 
of, 449 
odor of breath of, 285 
sometimes increased vesicu- 
lar breathing with, 144 
Stadelmann's observations 
on, 449 
Diaceturia, an independent disease in 
children, 447 
comparison of color of urine, with 
test for salicylic acid, 450 
in adults, when occurs, 448 
in children the cause of convul- 
sions, 448 
test for, 448 
when occurs, 447 
Diagnosis defined, 17 
Diameter of thorax, how measured, 
162 
Diaphragm, action of, in stenosis of 
upper air-passage, 98 
interfered with, 90 
tested by palpation, 103 
adjacent to fundus of stomach, 
299 
depressed by exudation, 128 
in exudative pleuritis, 330 
depression of, from emphysema, 
199 630 
INDEX. 
Diaphragm, effect of paralysis of, 540 
of position of, on relative liver 
dulness, 332 
of pressure upon, may inter- 
fere with action of heart, 40 
elevation of, causes dislocation of 
heart, 200 
fixation of, in hysteria, 576 
high position of, 87, 130 
due to abdominal disten- 
tion, 317 
diminishes area of spleen 
dulness, 339 
from paralysis, in peri- 
tonitis, 317 
increased parietal area of 
heart with, 211 
liver moves with, 320 
in inspiration, 322 
low position of, renders spleen 
accessible, 335 
paralysis of, inspiratory dyspnoea 
from, 99 
position of, 80 
aids diagnosis between pleu- 
ral exudation and thick- 
ened pleura, 130 
changed with diminished 
volume of lungs, 137 
in children, 192 
of the heart changed by de- 
pression of, 204 
pressed upon by meteorism, 309 
upward by enlarged liver, 322 
pressure upon, a cause of paleness, 
40 
pushed up by subphrenic abscess, 
322 
rapid breathing in diseases of, 94 
relation of spleen to, 332 
to liver, 320 
with other organs, 312 
spasm of, 94, 540 
trichinosis of, pain in, a cause of 
cyanosis, 44 
upward displacement of liver in 
paralysis of, 323 
pressure of, cyanosis from, 43 
vesicular breathing increased on 
account of high position of, 145 
Diaphragmatic breathing, 83 
in place of costal, 95 
friction sounds, 233 
peritonitis, simulates pleuritis,161 
pleurisy, tympanitic sound in 
lung over, 130 
Diarrhoea, alternating with constipa- 
tion, 369 
brick-dust sediment in urine of, 
430 
causes diminished sweat, 38 
color of stool in, 373 
defined, 368 
due to eruption of teeth, 286 
effect of severe, on the amount of 
blood in the body, 270 
foul-smelling stool in severe, 372 
infusoria found in stools of, 383 
less amount of urine in, 407 
quantity of stool increased in, 370 
saliva diminished in, 289 
watery stools in, 374 
Diastole of heart, sound of, what due 
to and where best 
heard, 213, 214 
sound with, 212 
venous humming louder dur- 
ing, than in systole, 269 
of ventricle, movement of blood 
in, 193 
Diastolic collapse of cervical veins, 
267 
murmur at aorta, 251 
murmurs, 222, 225 
how distinguished from sys- 
tolic, 226 
sound over larere arteries in health, 
257 
Diazo-benzol-sulphuric acid test for 
sugar, 445 
Dicrotic pulse, tracings of, 248 
Dictation, writing from, 550 
Diet, coating of tongue from articles 
pf, 287 
effect on disease, 21 
Differential diagnosis between peri- 
and endo cardial murmurs, 232 
Differentiating electrode, 501 
Difficult breating, 93 
Digestion, aided by mechanical action 
of stomach, 347 
amylolytic period of, 342 
bacteria in feces in anomalies of, 
388 
character of stools in disturbance 
of, 372 
chemical action during, 347 
duration of, 347 
examination of process of, 342 
intestinal, shown by stools, 367 
mode of procedure in examining, 
350 INDEX 
631 
Digestion, normal, te3t of, 348 
particles of food found in stools 
in disturbed, 386 
period of, prolonged, 356 
shortened, 356 
prolonged in dilated stomach, 346 
study of process of, 341 
washing out the stomach in dis- 
turbance of, 357 
Digestive apparatus, change in weight 
in diseases of, 35 
examination of, 284 
section on disturbances of, 
577 
Dilatation of heart, a cause of insuf- 
ficiency, 194 
area of dulness enlarged in, 
208, 209 
cause of projection of region 
of heart, 202 
eccentric, 195 
in anaemia, 229 
simple, 196 
of stomach, 348 
absence of free muriatic acid 
in, 356 
infrequency of the attacks of 
vomiting in, 359 
with fermentation, recog- 
nized by seething sound, 
. 308 
Diphtheria, acute nasal catarrh in, 74 
appearance of tonsils in, 290 
death after examination of throat, 
284 
examination of mouth in cases of, 
284 
gallop rhythm a sign of heart- 
failure in 221 
glands of neck enlarged in, 291 
glycosuria in, 443 
may cause cyanosis, 43 
microscope an aid in diagnosing, 
from benign necrosis, 291 
paleness from, 40 
paralysis of tensor of vocal cords 
from, 600 
sequelae of, 22 
sometimes no contraction of pupil 
after, 568 
tone of cough in, 166 
Diphtheritic paralysis, position of the 
soft palate in, 538 
Diplococci in purulent pleural exu- 
dation, 161 
Diplococcus in urine, 399 
Diplopia defined and when occurs, 
472 
mode of determining, 564 
result of strabismus, 563 
significance of, 564 
Direct percussion defined, 104 
Discharges, involuntary, during attack 
of epilepsy, 533, 534 
Disease, first appearance of, 23 
location of, sometimes indicated 
by headache, 482 
simulation of, 19 
Diseases, acute, power of resistance 
to, 33 
sometimes no contraction of 
pupil after, 568 
ataxia after acute, 529 
concealed, 19 
course of, 23 
directly inherited, 20 
exciting causes of, 21 
internal, and form of thorax, 81 
names of, misused, 19 . 
predisposing causes of, 21 
tracing of pulse in wasting, 248 
wasting, hsemic murmurs in, 229 
Displacement of apex-beat, 199 
Disposition to disease inherited, 20 
of lungs, 81 
emphysema, with full chest, 34 
tuberculosis, 34 
Distention of stomach, 300, 301 
artificial, methods of, 301, 302 
Frerich’s formula for, 301 
Ziemssen’s formula for, 302 
Distoma haematobium, cause of hsema- 
turia, 283, 425 
eggs of, in urine, 425 
illustration of, 282 
hepaticum and distoma lanceo- 
latum described, 383 
illustrated, 384 
pulmonum, eggs of, in sputum, 183 
in sputum, 174 
Disturbances of speech, 548 
Disturbed sensibility, local manifesta- 
tions of, 478 
Dizziness, also see Vertigo, from the 
eye, 563 
significance of, 471 
sometimes combined with tinnitus 
aurium, 573 
Dolichocephalus, 465 
Dorsal clonus, 499 
position for inspection and palpa- 
tion of heart, 197 632 
INDEX. 
Double murmur from pressure, 259 
vision, mode of determining, 564 
result of strabismus, 563 
significance of, 564 
Drawing-in, circular, of chest, 88 
inspiratory, 97, 98 
of abdomen, causes of, 309 
of one side, 86 
Drinks, certain ones which cause 
polyuria, 406 
Dropsy, anidrosis with, 38 
of kidney disease, cause of, 440 
orthopnoea with, 33 
three causes of, 53 
urea diminished in cachexia with, 
434 
Drunkards, lipsetnia in, 280 
Dry cough defined, 166 
rales explained, 149 
Duboisin, effect of, on pupil, 567 
Dubois’s induction coil, 476 
Duchenne, reference to, 508 
Ductus choledochus, 46 
compression of, 340 
Wirtungianus, 387 
Dull, as a term for sound, avoided, 108 
sounds, 107 
Dura mater, disease of, 465 
Duration of digestion, 347 
of lung sound, 108 
Duroziez’s double murmur, 259 
Dust, inhalation of, cause of bron- 
chitis, 21 
of pneumonia, 21 
Dwarf, skeleton of, 33 
Dynamic sense, 479 
defined, 480 
Dynamometer, uselessness of, 545 
Dysarthria defined, 548 
Dysentery, blood in stools of, 373 
catarrhal, mucous stool in, 374 
color of stool in, 373 
consistence and form of stool in, 
371 
feces of, contains Charcot’s crys- 
tals, 388 
meat-juice stools in, 375 
odor of stools in, 372 
pain and straining at stool in, 
370 
in left iliac fossa with, 308 
shreds of mucous membrane in 
stool in, 377 
watery stools in, 374 
Dyspepsia, acute, paleness in, 40 
coated tongue of, 287 
Dyspepsia due to diseased teeth, 286 
following healed ulcer of stomach, 
vomiting with, 361 
foul odor of breath in, 285 
gastric, headache with, 483 
intestinal, fungus spores in stools, 
388 
nervous, 578 
has marked subjective symp- 
toms but no physical signs, 
308 
subacidity of stomach in, 356 
watery vomit of, 361 
stools in, 372 
superacidity of stomach with, 357 
symptoms of, with displacement 
of right kidney, 396 
time when vomiting occurs in, 359 
Dyspnoea, 32, 74 
active expiration of, 97 
caused by emphysema of skin, 57 
color of blood in, 270 
described, 93 
expiratory relation to emphysema, 
85 
from drawing up of diaphragm, 86 
from uraemia, 440 
in Cheyne-Stokes breathing, 94 
in connection with nervous dis- 
eases, 576 
in diseases of the lungs, 95 
in emphysema, 84 
in heart disease, 96 
in paralysis of the diaphragm, 540 
inspiratory, 74, 598 
from paralysis of the laryn- 
geal muscles, 538 
mixed, when exists, 100 
of fever, 94 
sometimes increased vesicular 
breathing with, 144 
usually accompanied by perspira- 
tion, 37 
Dystrophia musculorum, 493, 494, 525 
EAR, affections of, in diseases of the 
nervous system, 572 
catarrh of middle, a sign of con- 
genital syphilis, 286 
importance of determining dis- 
ease of, 572 
subjective sensibility of hearing 
in diseases of, 572 
suppuration of, cause of menin- 
gitis and abscess of brain, 467 INDEX. 
633 
Ear, vertigo in diseases of, 472 
EaR (reaction of degeneration), 518 
diseases which are excluded when 
it is present, 525 
in myopathic muscular atrophv, 
524 
partial, 522, 525 
relation of, to mechanical EaR, 
524 
significance of its absence, 525 
varieties of, 523 
when wanting, 525 
with reference to motion, 521 
Ebstein quoted, 89 
reference to, 205, 208, 447 
Ecchymoses, 51 
Echinococcus bladders in sputum, 
174, 182 
change in shape of liver from, 325 
in urine, 424 
irregular enlargement of liver 
with, 322 
membranous rags of, in vomit, 364 
of kidney, palpation of, 395 
of liver a cause of jaundice, 47 
depression of liver from, 330 
no tenderness with, 324 
of omentum is rare, 340 
prominences on liver from, 326 
unequal enlargement of spleen 
from, 335 
Ecker, reference to, 452, 466 
Eclampsia gravidarum, 533 
Ectasia of stomach, 345 
Edelmann, reference to, 518 
Edelmann’s horizontal galvanometer, 
503 
Edinger, reference to, 453, 455, 458 
Effusion in abdominal cavity, 313 
into cavities a result of general 
venous engorgement, 261 
into pleural cavity, serous, puru- 
lent, ichorous, complicating 
pneumothorax, diagnosis of, 
129 
percussion of, in abdominal cavity, 
value and method of, 316 
Effusions into pleural sacs, 80 
large, in abdomen, effect of, 317 
Egyptian chlorosis, 382 
Ehrlich, reference to, 185, 279 
Eichhorst, reference to, 154, 164, 208, 
247, 248, 249, 302, 424 
Elastic fibres a sediment in sputum, 
186 
threads described, 177 
Elastic threads, how distinguished 
from leptothrix buccalis, 
184 
how to obtain, for examina- 
tion, 178 
importance of, in sputum, 177 
Electric sensibility, 476 
j Electrical condition, diagnostic value 
of, 524 
examination, details of method 
of, 507 
methods of, 505 
of nerves and muscles, 501 
what it consists of, 505 
irritation of arm, 509, 510 
points of, upon the head and 
neck, illustrated, 503 
reaction, mixed, defined, 523 
what to observe in determin- 
ing, 516 
sensibility unchanged in atrophy 
of inactivity, 490 
Electro-diagnosis, reading the gal- 
vanometer in, 515 
-motor points, 469 
Electrode always to be applied with 
the same pressure, 507 
Erb’s fine, for faradic current, 502, 
512 
examining and indifferent, 512 
for testing sensibility of skin 
illustrated, 476 
indifferent, 523 
and differentiating, 501 
where placed and size of, 502 
place of, in galvanic examination, 
515 
relation of size of, to intensity of 
current, 502 
Electrotonus, 505 
Elements, galvanic, number of, 514, 
515 
Emaciat'on cause of narrow chest, 85 
how detected, 35 
produced by disease of internal 
organs, 36 
Emboli, effect of, on pulse, 245 
region of brain where most fre- 
quent, 463 
result of atheroma of vessels, 576 
from thrombi in weak heart, 
576 
Embolism, local, low temperature in, 
71 
Embolus of the central artery of the 
retina, 562 634 
INDEX. 
Emesis, induction of, when contra- 
indicated, 342 
intentional, for diagnosis, 305 
Emotions causes of disease, 21 
Emphysema, 80, 82 
a cause of hypertrophy of right 
ventricle, 196 
action of muscles of neck in, 538 
and form of thorax, 81 
band-box note with, 135 
case of pernicious anaemia com- 
plicated by, 230 
cause of emphysema of skin, 56 
of expiratory dyspnoea, 99 
of hypertrophy of right ven- 
tricle, 210 
causes diminished parietal area of 
heart, 197 
clavicular depression in, 84 
cyanosis in, 43 
diaphragmatic breathing in, 91 
diminished amount of urine with, 
407 
expiratory pressure in, 164 
disposition to, with full chest, 34 
distinguished from oedema, 55 
disturbs circulation through the 
lungs, 44 
downward displacement of liver 
with, 322 
dyspnoea in, 95 
effect of, on relative liver-dulness, 
332 
on upper boundary of liver, 
330 
effects of, upon venous circulation, 
263 
enlargement of liver with, 322 
expiratory bulging in, 98 
extension of boundaries of lungs 
in, 136 
“gallop rhythm” of heart in, 
221 
heart-dulness diminished in, 210 
inspiratory dyspnoea with, 100 
local expansion of chest in, 86 
mediastinal, 57, 210, 233 
muscular aid in, 84 
non-ringing rales with, 153 
non-tympanitic sound with, 112 
of lungs, 204 
a cause of displacement of 
heart, 199 
conceals apex-beat, 201 
the action of pulmonary 
valve, 203 
Emphysema of lungs diminishes area 
of spleen-dulness, 339 
of skin, 55 
in connection with diseases 
of oesophagus, 296 
weakens apex-beat, 201 
peptonuria with, 439 
prolonged expiration in, 145 
rales with, 150 
sequela of whooping-cough, 22 
tough expectoration with, 166 
value of pulse in cases of, 253 
venous engorgement from, 261 
vesicular breathing diminished in, 
145 
vicarious, 85 
downward displacement of 
lung boundary in, 136 
how developed, 87 
no expiratory dyspnoea with, 
100 
on left side, difficulty in de- 
termining location of heart 
in, 211 
vital capacity of lungs in, 164 
weakening of heart-sound in, 
219 
with pleuritis, friction - sounds 
with, 156 
Emphysematous thorax, 83, 85 
Emprosthotonus, 539 
Emptying of stomach, dangers of, 357 
Empyema, amount of expectoration 
in, 168 
crystals in sputum of, 180 
haematoidin in sputum of, 172 
necessitatis, 102 
pulsans, 102, 204 
difficulty in distinguishing 
from apparent enlargement 
of heart, 210 
pulsation in, near the heart, 204 
purulent sputum in, 169 
staphylococcus pyogenes found in, 
603 
tuberculous, 161 
tyrosin in sputum of, 182 
Encapsulated pleurisy defined, 129 
Encephalitis in children, choreic 
movements with, 535 
neuro-retinitis with, 601 
ushered in by epileptiform spasm, 
533 
Encysted inflammatory exudation in 
abdomen, 317 
j Endemic diseases, 21 INDEX 
635 
Endocardial murmurs, loudness of, to 
what due, 223 
sounds felt, 204 
whizzing, 227 
Endocarditis a cause of insufficiency, 
194 
of stenosis, 194 
aortse, embolus of retinal artery 
in, 562 
embolus of central retinal artery 
in, 602 
hsematuria with, 417 
pysemic, retinal hemorrhages in, 
602 
sequela of scarlet fever, 22 
streptococcus pyogenes with, 603 
ulcerative, staphylococcus pyo- 
genes in, 603 
valvular, relation of, to disease of 
the brain, 576 
Engorgement, dropsy of, 440 
of kidney, haematuria with, 417 
of liver, surface of, 325 
of spleen, 335 
venous, effects of, 260 
thrombosis in oedema of, 268 
Enteralgia, simulation of, 19 
Enteritis, color of stool in, 373 
consistence and form of stool in, 
371 
forms of fat found in feces in, 386 
mycotic, ptomaines in intestine 
in, 432 
poor absorption of fat in, 371 
Enteroliths, from vermiform appendix, 
376 
Enuresis from phimosis, 580 
nocturnal, 400, 579 
Eosin, staining of white corpuscles of 
blood with, 279 
Eosinophile white corpuscles in leu- 
kaemia, 279 
Epigastric angle, 82 
in emphysematous thorax, 83 
in phthisical thorax, 84 
pulsation not to be confounded 
with simple aortic pulsation, 204 
Epigastrium defined, 297 
illustrated, 298 
portion of liver in, 320 
projection of, in enlargement of 
liver, 321 
protrusion of, in inspiration, 90 
pulsation in, 204 
Epilepsy, acetonuria after attacks of, 
448 
Epilepsy, albuminuria with, 435, 441 
clonic spasms in, 532 
convulsions of, 37 
cutaneous hemorrhages from at- 
tacks of, 582 
cyanosis in, 44 
differential diagnosis between 
genuine and symptomatic, 533 
disturbance of consciousness in, 
470 
dyspnoea in, 95 
fever with attacks of, 575 
glycosuria after attack of, 443 
hyperosmia and parosmia as an 
aura in, 574 
involuntary passage of semen in, 
534 
of urine in, 580 
Jackson’s (partial or cortical), 533 
described, 533 
opisthotonus with convulsions of, 
468 
(petit mal) syncope with, 471 
spasm,or convulsion,described,432 
spermatozoa in urine after at- 
tacks of, 421 
tinnitus aurium sometimes as an 
aura a precursor of, 573 
tonic and clonic spasm of thoracic 
muscles in, 540 
traumatic and reflex, 530, 533 
wounding of tongue during at- 
tacks of, 287 
Epistaxis, 73 
Epithelial casts, forms of, in urine, 
424 
illustrated, 424 
Epithelium, ciliated, transfer of mucus 
by, 167 
in sputum, 176 
in urine, kinds and significance 
of, 420 
renal, illustrated, 421 
Equilibrium, an act of coordination, 
527 
Equinia, acute nasal catarrh in, 74 
Erb, normal electrode of, 502 
reference to, 461, 469, 476, 498, 
501, 504, 508,509,510,511,512, 
514, 516, 517,520,521,523,524, 
525, 567 
Erb’s fine electrode, 507 
point in brachial plexus, 487 
supra-clavicular point, 510 
Ergotism, gangrene in, 577 
Eructation, odor of, 359 636 
INDE X. 
Erysipelas, coccus of, 161 
enlargement of spleen in, 335 
fever in, 65 
leucocytosis in, 278 
recurrence of, 22 
resembles inflammation of strep- 
tococcus ervsipelatosus, 604 
vomiting in, 358 
Erythrodextrin from starch, 353 
Esbach’s album inometer described and 
illustrated, 438 
Escherich, reference to, 388 
Eserine, effect of, on pupil, 567 
Ether poisoning, cause of hsemato- 
jaundice, 47 
Ethmoid nerve, illustrated, 485 
Etiology, value of, 20 
Ewald, reference to, 351, 354 
Exacerbation of febrile disease shown 
by temperature, 65 
Examination, electrical, details of, 507 
general, divisions of, 31 
method of, in diseases of nervous 
system, 463 
of patients 24 
of the blood, 270 
special, scheme for, 27 
Examining electrode, size of, 502 
Exanthemata from poisons, 50 
Exanthematous diseases, 49 
fevers, enlargement of spleen in, 
334 
Excesses, venereal, cause of disease, 21 
Excitability, bilateral variations of, 
518 
increased in tetanus, 526 
lessened, when it occurs, 525 
mechanical, of muscles and nerves, 
526 
of nerve (muscle), degree of, 505 
quantitative and qualitative, of 
nerves and muscles, 516 
Excitement, effect of, on amount of 
urine, 401 
on heart-sounds, 216 
on pulse in fever, 240 
upon pulse, 235 
headache after, 483 
induces perspiration, 37 
mental, effect of, on heart, 198 
heart not to be examined 
after, 201 
syncope from, 471 
Exciting causes, effects of, on chronic 
diseases, 21 
of disease, 21, 22 
Exclusion, determining limits of liver 
by, 328 
Exertion, albumin in urine after, 437 
effects of, in auscultation of heart, 
211 
on action of heart, 198 
on pulse in fever, 240 
upon pulse, 235 
headache after, 483 
heart not to be examined after, 
201 
mental, glycosuria after, 443 
muscular, a cause of idiopathic 
hypertrophy, 196 
over-, weakness of heart-sounds 
from, 218 
severe, a cause of emphysema of 
skin, 56 
Exhaustion which accompanies vomit- 
ing, 359 
Exophthalmia, 565 
Exophthalmus paralyticus, 563 
Exotic diseases, 21 
Expectoration absent when there is 
no cough,167 
defined, 167 
examination of, 167 
general characteristics of, 168 
kinds of, 168 
Experiment to illustrate effect of 
length of cylindrical cavities upon 
pitch of sound, 110 
Experimental meal, Ewald’s, 349 
Jaworski’s, 349 
Leube’s, 347 
relative merits of each, 349 
Expiration, bronchial breathing usu- 
ally most distinct with, 147 
effect of, on circulation in jugular 
vein, 262 
in emphysema, 84 
muscles of, 97 
position of liver during, 320 
pressure of respiratory air in, 164 
prolonged, in commencing tuber- 
culosis of apices an im- 
portant sign, 150 
when occurs, 145 
role of the abdominal muscles in, 
540 
sound of, bronchial in character, 
142 
Expiratory bulging, 98 
dyspncea in emphysema, 84 
relation of, to emphysema, 85 
to inspiratory, 100 INDEX. 
637 
Expiratory dyspnoea, when exists, 99 | 
pressure greater than inspiratory, ! 
164 
valvular sound in the crural vein 
in health, 269 
Exploratory puncture, directions re- 
garding, 162 
of abdomen, value of, 318 
of pleura, how performed, 160 
of the heart, 234 
use of, 130 
Exposure a cause of disease, 21 
Extra-pericardial friction sounds, 233 
Extremities, nerves of, motor tracts 
of, illustrated, 453 
Extremity, lower, muscles of, 545 
muscles of the upper, 540 
Exudation depressing the diaphragm, 
128 
diagnosis of, from transudation, 
160 
extent of, shown by area of dead- 
ness, 128 
in abdomen, value of measuring 
circumference of, 316 
increase of chloride of sodium in 
urine with, 434 
inflammatory, in abdomen, 317 
kinds of, in pleural cavity, 161 
plegaphonia over, 159 
pleural, encapsulated, 128 
measurement of thorax in, I 
163 
pleuritic, effect of, on vocal fre- 
mitus, 157 
or pericardial, conceals apex- 
beat, 201 
purulent, in sputum, 167 
Eye, affections of, in diseases of the 
nervous system, 561 
cystercerci in, from taenia solium,! 
578 
determining paralysis of muscles 
of, 564 
function of individual muscles of, 
564 
inflammation and ulceration of, 
from paralysis of nerve, 484 
movements of, paralpsis of mus- 
cles, 562 
muscles of, 536 
significance of paralysis of, ! 
564 
Eyelids, dropsy of, in kidney disease,! 
440 
Eyes, how closed, 536 
Eyes, relation of, to vision, illustrated 
570 
unequal refraction of two, 567 
FACE, motor centre for lowe- por- 
tion, 454 
muscles of, 536 
three most distinct points upon, 
510 
Facial nerve, chorda tympani nerve 
joins the, 46i 
effects of paralysis of, 536 
increased mechanical excita- 
bility of, in tetanus, 526 
lesion of, from caries of pet- 
rous portion of temporal 
bone, 469 
motor tracts of, illustrated, 
453 
paralysis of, 548 
paralysis, diminished secretion of 
saliva in, 578 
effect upon taste in, 574 
hearing in, 572 
reflex, 497, 499 
rheumatic, partial EaK in, 
525 
rheumatic paralysis, 520 
sense of taste in anterior portion 
of tongue affected in paralysis 
of, 461 
tract, paralysis of, bone reflex 
present in, 500 
Faradic battery, secondary or induced 
current, for examining nerves 
and muscles, 501 
current causes tetanic contraction, 
506 
comparative unimportance of 
the poles, 504 
Erb’s fine electrode for, 507 
relation of total strength to 
galvanic current, 514 
strength of, how measured, 
502 
examination of nerve-muscle, de- 
scribed, 512 
to be followed by galvanic, 
514 
excitability of the two sides of the 
body,516 
Farado-cutaneous sensibility, 476, 
477 
Fasting stomach, gastric secretion in, 
346 638 
INDEX. 
Fat, absence of, 34 
development of, in diseases of 
blood-making organs, 41 
drops of, in urine, significance of, 
420 
effect of, on extent of abdomen, 309 
in conjunctiva not to be con- 
founded with jaundice, 45 
in urine after fatty food, 405 
lumps, needle-shaped crystals in 
stools, significance of, 386 
people, veins of, 260 
striae produced by accumulations 
of, 52 
variations in amount of, 34 
Fatigue a cause of disease, 21 
Fatty acids, crystals of, in sputum, 
184 
in sputum of gangrene, 190 
degeneration of heart, paleness in, 
41 
of kidney, epithelium found 
in urine of, 421 
heart, Cheyne-Stokes respiration, 
92 
Fauces, vomiting from tickling of, 358 
Favus in vomit, 366 
Fear produces perspiration, 36, 37 
Febrile diseases cause change in 
weight, 36 
exacerbation shown by tem- 
perature in, 65 
haemic murmurs in, 229 
perspiration in, 37 
pulse in, 239 
subnormal temperature in, 63 
value of pulse in, 253 
weakness of heart-sounds in, 
218 
Febris hepatica, herpes with, 50 
recurrens, 37 
Fecal accumulation in stenosis of in- 
testine, 369 
odor of stool masked by other sub- 
stances in, 372 
vomiting not always fatal, 364 
when occurs, 364 
Feces, balls of, in intestine, diagnosis 
of, 310 
Charcot-Leyden’s crystals in, 181 
in urine, 315 
involuntary discharge of, in at- 
tacks of epilepsy, 534 
microscopical constituents of, il- 
lustrated, 385 
examination of, method of, 385 
Feces mixed with blood, significance 
of, 375 
physical and chemical peculiari- 
ties of, 370 
section on, 367 
Feculent exudation in pleural exuda- 
tion, 161 
odor of urine, 414 
Fehleisen, reference to, 427 
Fehling’s solution, estimating amount 
of sugar by, 446 
test for sugar, compared with 
polarizing method, 447 
Female sexual organs, headache with 
diseases of, 483 
Ferment, in gangrene of lungs and 
bronchitis, 190 
Fermentation, alkaline, in urine, from 
micrococci, 425 
ammoniacal, of urine, effect of, 402 
increased formation of lactic acids 
in subacidity of stomach, with, 
356 
in dilated stomach, 346 
in intestinal canal, acid reaction 
of stool in, 372 
alkaline reaction of stool 
in, 372 
microorganisms that excite, in 
stomach, 343 
of contents of stomach with dila- 
tation of stomach, 308 
of urine in bladder, cause of turbid 
urine, 412, 415 
test for sugar, 445 
Ferrocyanide of potassium test for 
albumin in urine, 436 
Fetor of breath, 285 
Fever. Also see Temperature, 
acetonuria in, 448 
albuminuria with, 435 
alkalescence of blood diminished 
in, 283 
anidrosis of, resists therapeutic 
measures, 38 
brick-dust sediment in urine of, 
430 
casts in, 422 
cause of increased dyspnoea, 96 
chill of, phenomena of, 40 
chloride of sodium in urine dimin- 
ished in, 434 
chlorides diminished in, 60 
coating of tongue in, 287 
continued, sweat diminished in, 
38 INDEX 
639 
Fever, continued, urine should be ex- 
amined for tubercle bacillus, 426 
continuous, significance of, 587 
critical purturbation in, 68 
curve, effect of antipyretics on, 67 
dark color of urine of, 408 
defervescence of, 67 
defined, 60 
delay in absorption from stomach 
in cases of, 355 
diaceturia in, 447 
diminished amount of urine in, 
407 
disturbed nutrition in, 575 
effect of, upon heart’s action, 201 
exacerbation of, 62 
frequent pulse characteristic of, 
238 
heart sounds strengthened in, 217 
hectic, 68 
hyaline casts in urine of, 423 
in connection with nervous dis- 
eases, 575 
increase of urea in, 433 
urobilin in urine in, 48 
increased frequency of respiration 
in, 94 
formation of C02 in, 93 
intermittent, herpes with, 50 
malarial, defined, 70 
irregular in various diseases, 71 
lips in, 285 
mucus in urine of, 416 
of pus formation in, 68 
pulse in, 240 
recurrence of, 66 
recurrent, microorganisms of, 
found in blood, 281 
red skin in, 41 
tongue in, 287 
relapsing, leucocytosis in, 278 
section on, 57 
slow pluse in critical decline of, 
237 
sound heard over crural artery in 
high, 259 
subacidity of stomach in, 356 
subnormal temperature in crisis, 
63 
three types of, 62 
thrush in, 288 
tracing of pulse of, 247 
trembling of tongue in, 287 
tremor with rapidly-rising, 531 
typical course of, 64 
uric acid increased in, 434 
Fever, urinary products increased in, 
60 
urobilin in urine in, 409 
variations of temperature in, 63 
with albuminuria, 441 
Fibres-elastic in sputum, 175 
Fibrillary contractions, 530 
defined, 532 
Fibrin, floccules of, in the fluid from 
puncture of pleura, 160 
in urine in hsematuria, 439 
Fibrinous tubes in sputum, 172 
; Fibroma of larynx described, 597 
pedunculated, in larynx, illus- 
trated, 596 
Fifth nerve illustrated, 485 
Filaria sanguinis hominis, cause of 
haematochyluria, 283 
effects upon the urine and 
urinary passages, 425 
illustration of, 282 
Filehne, reference to, 190, 198 
Finger-percussion, 105 
advantages over hammer per- 
cussion, 116 
how done, 118 
-pleximeter percussion, 105 
Fingers, characteristic positions of the 
hand and, in paralysis, 544 
distribution of nerves to, 485 
paralysis of the muscles of, 543 
Finkler and Prior’s spirals, 390, 607 
how distinguished from 
cholera bacillus, 391 
illustrated, 391 
Fischer, reference to, 478 
Fischl, reference to, 177 
Fissure of anus, pain at stool in, 370 
of Rolando illustrated, 466 
of Sylvius, artery of, 462 
effect of occlusion of, 462 
Flechsig, reference to, 452, 535, 586 
Fleischl’s hsemometer recommended, 
271, 276 
Flexibilitas cerea defined, 535 
Fluctuation in abscess of liver and 
echinococcus, 326 
sign of fluid, 315 
Fliigge, reference to, 184,289, 604, 605 
Fluid, nature of, in plural cavity, by 
puncture, 160 
Fluids, effect of drinking, on color of 
urine, 402 
Folie musculaire, 534 
Fontanelle, cerebral blowing sound 
heard while still open, 258 640 
INDEX. 
Food, albuminous, source of uric acid 
in urine, 405 
certain ones which cause polyuria, 
406 
character and amount of stool af- 
fected by, 370 
color of the vomit from kinds of, 
360 
effect of, upon color of stool, 372 
oxalate of lime in urine after cer- 
tain foods named, 430 
particles of, in stools, 386 
tests of rapidity of passage of, 
from the stomach, 354 
when in sputum, 167 
Foot clonus, 499 
quaking with, 531 
paralysis of muscles of, 547 
phenomenon, defined, tested, sig- 
nificance of, 499 
objection to ordinary method 
of examination, 501 
sole of, reflex, 495 
Foramen ovale, open, systolic venous 
pulse with, 267 
Forearm, paralysis of muscles of, 543 
Forehead, how wrinkled, 536 
Form, knowledge of, section on, 481 
of expectoration, 168 
of spinal column, 467 
Fossa infra-spinata, 77 
deadened sound over, 114 
of Sylvius, illustrated, 466 
supra-spinata, 77 
Fossae on front of thorax, 76, 81 
Fourth ventricle, 455 
Fraukel, A., pneumonia coccus of, 188 
reference to, 161 
Frankel, B., reference to, 297 
Fredricq, reference to, 286 
Fremissement cataire, 227 
Fremitus, laryngeal, 75 
vocal, palpation of, described, 156 
Frequency of breathing, anomalies of, 
91 
Frerichs, reference to, 301, 443 
Frey, reference to, 246 
Friction, sensible, how recognized, 155 
-sounds, extra-pericardial, 233 
felt near heart, 204 
not heard if fluid is present, 
156 
not to be confounded with 
moist rales, 155 
over peritoneum, 318 
pericardial, 230 
I Friction-sounds, pleuritic, described, 
155 
sometimes a favorable sign, 
indicating absorption of 
fluid, 156 
when occur, 156 
Friedlander, pneumonic coccus of, 188 
Friedreich, reference to, 180, 191, 267, 
268, 269 
Friedreich’s change of sound de- 
scribed, 113, 133 
Frontal convolution, left third, motor 
speech-centre, 555 
third, blood supply of, 462 
lobe illustrated, 466 
Frothy sputum, 169 
Fruity odor of urine, 414 
- when occurs, 414 
Fuliginous deposit on lips in fevers, 
285 
Fulness of veins increased, 260 
Functional disease of nervous system, 
sudden return to normal con- 
dition, a certain sign of, 587 
neurosis, analgesia in, 479 
Fundus oculi, changes in, in diseases 
other than nervous, 601 
changes of, in nervous dis- 
eases, 600 
of stomach, anatomical relations 
of, 299 
position of, 298 
Fungi found in urine, 425 
in sputum, 174, 183 
pathogenic, section on, 389 
spores of, in feces, when found, 388 
Funke, reference to, 429 
Funnel-breast, cause of, 89 
described, 88 
Fiirbringer, reference to, 182 
Furuncles, staphylococcus pyogenes 
found in, 603 
GABBETT, reference to, 187 
Galacturia, 412 
produced by filaria sanguinis, 
425 
Gall-bladder, distended, when felt, 322 
emptying of, by pressure, 326 
enlargement of, 331 
normal and pathological con- 
dition of, 326 
obstruction of, a cause of en- 
larged liver, 322 
position of, 320 INDEX 
Gall-bladder, suppuration of, gall- 
stones in stools from, 376 
-stones a cause of jaundice, 47 
accompanied by chill and 
fever, 64 
appearance of, described, 376 
in feces, how to find, 376 
sometimes can be felt, 326 
Gallop rhythm of heart described, 220, 
221 
Galvanic battery, constant current of, 
for examining nerves and mus- 
cles, 501 
current, a strong, should never 
be used upon head, 511 
effect of, only at closing and 
opening of current, 506 
how to distinguish the poles 
of, 504 
measure for strength of, 502 
must not have too small an 
electrode, 502 
normal electrode for, 507 
quality of reaction with, 506 
relation of, to total strength 
of faradic current, 514 
used in determining the con- 
ductive resistance, 512 
examination, how conducted, 515 
methods, and explanation of 
terms used, 506 
should always follow the fa- 
radic, 514 
muscular reaction, normal, dia 
grammatic representation of, 
519 
resistance, 476 
stimulation, qualitative irrita- 
bility of muscles, 518 
tetanus, 505 
Galvanometer, absolute, 503 
damping of vibrations of, 515 
Edelraann’s, 518 
limits of exactness of results from, 
504 
time when to be read, 512, 515 
Ganglia of anterior horn, 456 
Ganglion, acoustic, 461 
geniculate, 461 
spheno-palatine, 461 
Gangrene, infusoria in sputum of, 
183 
odorless, 171 
of lung, crystals in sputum of, 
180, 181 
effect on thorax, 87 
Gangrene of lung, elastic threads in 
sputum of, 177, 179 
fatty acids in sputum of, 190 
ferment in, 190 
fetid sputum in, described, 
174 
micrococci in sputum of, 189 
mucus in three layers in, 169 
odor of sputum in, 171 
relation of, to brain disease, 
576 
rupture into oesophagus, 296 
spontaneous, in neuroses, 577 
starch corpuscles in sputum of, 
180 
Gartner, reference to, 389 
Gas in stomach and intestines some- 
times gives a lung-sound, 113 
intestinal, effect on movements of 
diaphragm, 90 
sound on percussing over cavity 
containing, 109 
Gastric crises defined, 578 
juice, coagulating effect of, 353 
secretions, accumulation of, 346 
Gastritis, vomiting of pus in phleg- 
monous, 364 
Gastro-duodenal catarrh, 46 
Gastroxia, 361 
Gastroxynsis, 361 
Geigel, reference to, 267 
Geisler, reference to, 436 
Geniculate ganglion, 461 
Genital apparatus, disturbance of, sec- 
tion on, 580 
Gerhardt, reference to, 125, 132, 191, 
259, 414 
Gerhardt’s change of sound described, 
133 
Gestures an acquired faculty, 549 
Glanders, bacilli of, found in blood, 
282 
Glands, enlarged, compression of bron- 
chi by, 43 
Gleet, diplococcus in urine, 427 
may be due to tuberculosis, 426 
Glioma, usually single, 585 
Glossitis cause of enlargement of 
tongue, 286 
Glosso-pharyngeus nerve, 461 
Glossy skin, 581 
Glottis, dilators of, paralysis of, 99 
spasm of, cause of cyanosis, 43 
due to eruption of teeth, 286 
muscles of, 597 
vibrations of, in phonation, 157 642 
INDEX. 
Glycosuria, after poisoning with va- 
rious substances named, 443 
in disease of oblongata, 579 
when occurs, 443 
Glykaemia, polyuria due to, 407 
Gmellin’s test for bile in urine, 442 
Goll, columns of, 459 
Gonococci illustrated, 427 
in pus of gonorrhoea, 427 
stains of, 427 
Gonorrhoea, coccus of, 604 
haematuria from, 417 
Goose’s throat, a condition of arteries, 
256 
Gorges, reference to, 404 
Gottstein, reference to, 595 
Gout, neuralgia in, 483 
uric acid found in blood in, 283 
often diminished during 
attack of, 434 
Gouty diathesis, inci'ease of uric acid 
in, 434 
Gram, reference to method of staining, 
188, 189, 190, 282, 603, 604, 605 
Granular casts, generally are hyaline, 
424 
illustrated, 424 
Grape sugar in urine, when it occurs, 
443 
Graphic communication, disturbances 
of, 549 
Gray substance of spinal cord, destruc- 
tion of, results of, 491 
Greater circulation, perspiration in 
engorged condition of, 37 
slowing of, a cause of cya 
nosis, 44 
Griesinger, reference to, 382 
Guaiac, tincture of, test for bile pig- 
ment, 441 
Gummata, change in shape of liver 
from, 325 
of larynx, 595 
syphilitica, in larynx, 596 
Gums and teeth, examination of, 285 
Gvinzburg, reference to, 352 
Gutbrod, reference to, 199 
JJABITATION, a cause of disease, 
Habits, a cause of disease, 21 
Habitual headache, hereditary, 483 
Haematemesis described, 361 
diseases with which it occurs, 362 
Hsematin, absorption bands of, 272 
Haematin in solution, test for, 441 
Haematoidin, 46 
casts mixed with, in urine, 424 
crystals of, in sputum, 180 
in urine, 432 
in lungs of patients who have 
died from heart disease, 177 
in sputum, 172, 176 
Haemato-jaundice, 47 
Haematoma of dura mater, inequality 
of pupils in, 567 
Haematuria, 410, 416 
albumin with, 441 
due to strangulus gigas, 425 
fibrin in urine in, 439 
from distoma haematobium, 425 
produced by filaria sanguinis, 
425 
use of microscope in, 418 
when occurs, 417 
Haemic murmurs, 229 
Haemin, crystals of, illustrated, 363 
test for, 363, 364, 375, 442 
Haemochromometer, instrument for 
estimating number of red corpuscles 
in blood, 271 
Haemoglobin, absorption band of, 273 
amount of, diminished in anaemia 
and chlorosis, 275 
diagnostic importance of, 270 
appearance of, as a sediment in 
urine, 419 
approximative determination of 
amount of, 271 
casts of lumps of, 424 
diminished in blood in oligo- 
cythaemia, 275 
poikilocytosis with, 277 
exact quantity of, only deter- 
mined by quantitative spectrum 
analysis, 272 
in separate corpuscles may be in- 
creased, 277 
loss of, cause of paleness, 40 
scale for estimating percentage 
of, in blood, 272 
tests for, 441 
urine to be examined for, when 
no corpuscles are found, 418 
Haemoglobinaemia, 46,410 
color of blood in, 271 
examination of blood in, 271 
value of spectroscopic examina- 
tion of blood in, 272 
Haemoglobinuria, 410, 419 
albumin with, 441 INDEX 
643 
Haemometer, Fleischl’s, recommended, 
271, 276 
Hsemophile, haematuria in, 417 
Haemoptysis, caution against speaking 
in, 159 
Haeser, reference to, 412 
Hair, growth of, 583 
Half-moon-shaped space (Traube) de- 
defined, 127, 128,137, 
299, 300, 306, 329 
diminished by enlarged 
spleen, 339 
by exudation, 307 
encroached upon by en- 
larged liver, 331 
in examining the spleen, 
337 
outer boundary of, found 
by spleen, 333 
Hallervorden, reference to, 449 
Hallucinations of sight in delirium 
tremens, 471 
Hammer-pleximeter percussion, 105 
Hammond, W. A., reference to, 535 
Hand and fingers, characteristic posi- 
tions of, in paralysis, 544 
distribution of nerves to, 485 
importance of knowledge of mus- 
cles of, and their innervation, 
545 
mode of examination in paralysis, 
544 
nerves of, 485 
paralysis of muscles of, 543 
Hartnack, reference to, 175, 181, 185, 
281 
Hauser, reference to, 184 
Hawking described, 166 
Hayem’s counting chamber described, 
274 
Head and neck, points of electrical 
irritation upon, illustrated, 508 
a strong galvanic current should 
never be used upon, 511 
distribution of cutaneous sensitive 
nerves upon, illustrated, 485 
nerves of, 484 
nervous pain in, 466 
Headache, circumscribed, when dis- 
ease causing it is so, 482 
from uraemia, 440 
significance of, 482 
unilateral (migraine), 483 
Health, patellar tendon reflex always 
present in, 499 
Hearing, centre of, 460 
Heart, action of, increases perspira- 
tion, 37 
interfered with by pressure 
on diaphragm, 40 
rapidity and strength of, 212 
anatomy of, 191 
apparent enlargement of, 209 
auscultation of, 211 
-beat not to be confounded with 
apex beat, 201, 203 
boundary between, and lung illus- 
trated, 304 
caution regarding, when making 
exploratory puncture, 162 
change in form of, 196 
in systole, 198 
chronic diseases of, paleness in, 41 
subnormal temperature 
with, 64 
-deadness, boundaries of, 124 
diminished with extension of 
lung boundaries, 136 
small when lungs are ex- 
panded, 136 
degeneratian of, weakens apex- 
beat, 201 
diminished work of, weakens 
apex-beat, 201 
disease, Cheyne-Stokes breathing 
in, 92 
development of fat in, 41 
dyspnoea in, 96 
effects of, on circulation 
through lungs, 44 
haematoidin in the lungs of 
patients who have died 
from, 177 
importance of second pul- 
monary sound in, 218 
infarction of spleen from, 335 
inherited, 20 
pulse in, 239 
with effusion, 33 
with slight compensation, 
gallop rhythm with, 221 
dislocation of, 199 
displaced by exudation, 128 
displacement of, by tumors, 255 
disturbed in chronic jaundice, 47 
-dulness, absolute, 205 
area of, enlarged, 208 
diminished, 210 
displacement of, 210 
parietal area of heart, 204 
relative, defined, 205, 207, 
208 644 
INDEX. 
Heart-dulness, size and diagnostic 
value of, 207 
enlarged, larger parietal area with, 
197 
enlargement of, cause of expan- 
sion of chest, 86 
diagnosis of, 200 
effect on apex, 199 
left, makes the half-moon- 
shaped space smaller, 306 
pulsations at base of, in, 203 
simulated, 197 
examination of, 191 
excited action of, cause of blow- 
ing murmurs in Basedow’s dis- 
ease, 259 
exploratory puncture of, 234 
failure. Also see Heart, weak. 
Cheyne-Stokes breathing in, 
92 
confused sounds in, 212 
diagnostic value of heart- 
sounds in, 217 
due to disease of its muscle, 40 
dyspnoea in, 96 
gallop rhythm a sign of, 221 
pulse in, 240 
lowering of temperature in, 71 
first sound a mixed one, 214 
doubled, 216 
hsematoidin in sputum in disease 
of, 172 
hypertrophy and dilatation, area 
of dulness enlarged iu, 208 
of, pulse in, 244 
or dilatation of, not to be! 
mistaken in retraction of 
lung, 137 
other than valvular, 196 
increased labor of, measured by 
specific gravity of urine, 413 
inspection and palpation of, 197 
-liver boundary of, 329 
location of, in side position of 
patient, 193 
mechanical displacement of, 87 
method of percussing, 208 
movement of blood in, 193 
murmurs, localization of, 223 
organic distinguished from 
inorganic, 230 
endocardial, defined, 221 
relation of, to time of action 
of the heart, 224 
transmission of, 228 
when heard, 222 
Heart muscle, diminished amount of 
urine in diseases of, 407 
weakness of sounds in paral- 
ysis of, 218 
nervous affections of, in connec- 
tion with disease of the nose, 575 
neuroses, 577 
normal percussion figure of, 205 
organic disease of, palpitation 
and pain with, 577 
murmur of, 219 
paleness a symptom of disease of, 
40 
palpitation of, in mitral defects,240 
nervous, 201 
parietal area of, changed by dis- 
location of, 211 
percussion of, 204 
physical phenomena of, 193 
place of, makes asymmetry of 
sound on right or left side of 
chest, 121 
points of election for auscultating, 
213, 214 
position of, 191 
in children, 192 
powerful action of, a cause of 
thoracic pulsation, 102 
pressed upon by meteorism, 309 
projection of neighborhood of, 202 
pulsations at base of, 203 
of, palpation of, 102 
pulse in valvular disease of, 240 
relation between size and energy 
of action of, 201 
of, and area of dul- 
ness, 205 
of, and parietal por- 
tion, 196 
of, to diseases of the brain, 
576 
of, to lungs, 79 
relative deadness of sound over, 
124 
representation of action of, 215 
resistance of, 205, 208 
simple dilatation of, 196 
slow pulse in certain conditions 
of, 237 
-sound, metallic, in pneumo-peri- 
cardium, 210 
-sounds doubled, 219 
metallic, explained, 221 
normal, described, 212 
variations of, 216 
origin of, 212 INDEX 
645 
Heart-sounds, pathological changes in, 
216 
strengthened, heard over 
larger area, 217 
tone of, variations of, 216 
weakening of individual, 219 
when weakened, 218 
strength of, estimated by pulse, 240 
value of absolute dulness, 207 
of pulse in displacement of,' 
253 
in showing complicating j 
disease of, 253 
valvular disease of, enlargement 
of liver with, 324 
sequela of rheumatism, 22 | 
venous engorgement from defect 
of right, 261 
weak. Also see Heart failure. 
area of dulness enlarged in, ! 
209 
murmurs indistinct in, 223 
thrombi in, a cause of em- 
boli, 576 
with dilatation, a cause of 
insufficiency, 194 
weakness, character of pulse in, 
243, 244 
Hearing, importance of, determining 
disease of, 572 
morbidly acute, 572 
place of, in speech, 550 
subjective sensibility of, when oc- 
curs, 572 
testing of, 571 
Heat induces perspiration, 37 
sensations of, 577 
Heaving, strong apex-beat, 200, 201 
Hebetude, tongue often left protruding 
when there is, 287 
Hectic fever, 68 
in tuberculosis, 42 
Hegar, reference to, 311, 398 
Height, relation of, to weight, 35 
Heitzmann, reference to, 590 
Heller, reference to, 378, 379, 383,384 
Heller’s test for blood pigment, 441 
for haernin, 364 
Hematemesis with pulmonary hemor- 
rhage, 167 
Hemialbuminose in urine, 435, 439 
Hemialbumose, a rare constituent of 
urine, 439 
Hemiansesthesia, 460, 461 
associated with unilateral anos- 
mia, 573 
Hemiansesthesia defined, and when 
occurs, 479 
in gross hysteria, 534 
Hemianopsia, 460 
cortical, 568 
homonymous, defined, 569 
illustrated, 570 
phenomena of, 571 
Hemiathetosis occurs in same loca- 
tions as hemichorea, 535 
Hemichorea, 535 
Hemicrania, one-sided redness of face 
in, 42 
unilateral redness of head in, 
577 
Hemidrosis defined, 37 
in Basedow’s disease, 38 
Hemiopia, 460 
Hemiplegia, 457, 494 
arthropathia in old, 583 
ataxia in some cases of, 529 
cruciata, 456, 489 
decubitus in, 582- 
defined, 489 
dorsal flexion of foot with, 535 
hemichorea a forerunner or result 
of, 535 
right, illustrated, 453 
-sided, aphasia with, 555 
Hemisphere, right, has nothing to do 
with speech, 555 
Hemisystole, double positive venous 
pulse in, 267 
explained, 202 
Hemoptysis defined, 170 
Hemorrhage, bloody color of sputum 
from, 170 
cause of urobilin-icterus, 48 
cerebral, effect on breathing, 91 
most frequent in the region 
supplied by the middle 
cerebral artery, 463 
slow pulse in, 237 
cutaneous, contrasted with hyper- 
semia, 42 
effect of, on amount of blood in 
the body, 270 
internal, shown by temperature, 
65 
sudden fall of temperature 
with, 63 
long-continued, a cause of dropsy, 
53 
microcythsemia after, 276 
of lungs caused by distoma pul- 
monale, 183 646 
INDEX. 
Hemorrhage of lungs, diagnosis from 
hemorrhage of stomach,170 
starch corpuscles in sputum, 
180 
of pons or oblongata, effect of, 457 
of stomach, 40 
microscope useless in, 365 
rectal, stools of, described, 374 
retinal, in hemorrhagic diathesis, 
562 
slow pulse with, 237 
source of, in hsematuria, diag- 
nosis of, 417 
subnormal temperature with, 63 
sudden amaurosis after severe, 602 
symptoms of, 40 
Hemorrhages, cutaneous, 51 
distinguished from inflam- 
mations, 51 
in jaundice, 47 
when occur, 582 
Hemorrhagic diathesis, hemorrhage of 
stomach in, 362 
in chronic jaundice, 47 
retinal hemorrhage in, 562 
exudation with tubercle and car- 
cinoma of pleura, 161 
infarction of kidney, hsematuria 
with, 417, 418 
Hemorrhoids, hemorrhage from, 375 
pain at stool with, 370 
Henle, reference to, 421, 486, 487, 541 
Hepatic jaundice, 46 
Hepatitis cause of enlarged liver, 322 
interstitial, surface of liver in, 325 
Hepatization of lung, deadened re- 
sonance over, 126 
Hereditary disposition to headache, 
483 
taint shown by funnel-breast, 89 
Heredity, 20 
Hering, spectroscope devised by, 272 
Hernia cause of pressure on nerves, 469 
Hernial orifices to be examined in 
sudden obstipation, 369 
Herpes facialis, 50 
labialis and nasalis, 50 
zoster, relation to nerves, 581 
Herringham, reference to, 437 
Heubner, reference to, 112,135, 317 
Hiccough defined, 540 
severe in abdominal and cerebral 
affections, 540 
High lung sound, 108 
Hildebrand, reference to, 356 
Hippocrates, reference to, 138, 156 
Hippocratic succussion confounded 
with splashing from stom- 
ach or colon, 156 
described, 156 
Hirschmann, reference to, 503 
History, clinical, defined, 17 
previous, what comprises, 20 
Hoarseness, how caused, 598 
Hoffmann, reference to, 481,482 
Homonymous parts to be tested to- 
gether, 507 
Hooke, reference to, 138 
Hoppe, reference to, 190 
Horseshoe kidney, 393 
Hour-glass stomach, 302 
Huber, reference to, 428 
Hiifner, reference to, 434 
Hutchinson’s spirometer, 164 
teeth, sign of congenital syphilis, 
286 
triad, signs of syphilis, 286 
Hyaline casts described, and when oc- 
cur, 422 
granular forms, 424 
illustrated, 423 
various additions to, 423 
Hydatid vibration with echinococcus 
of kidney, 396 
of liver, 326 
Hydrsemia, albuminuria with, 435 
cause of oedema, 53, 54 
color of blood in, 271 
leucocytosis in, 278 
peculiarities of blood in, 275 
polyuria in, 406 
Hydrocephalus, anosmia with, 573 
choked disc with, 600 
head unevenly balanced in, 539 
how distinguished from rhachitis, 
464 
pressing upon third ventricle, 601 
slow pulse with, 237 
with macrocephalus, 464 
Hydrocyanic acid, color of blood in 
poisoning by, 270 
Hydronephrosis, palpation of, 395 
tenderness in inflammatory, 395 
Hvdropericardium, cause of weakened 
heart-sounds, 219 
increases area of heart-dulness, 
209 
Hydroperitoneum. See Ascites. 
Hydro-pneumothorax, splashing in, 
233 
Hydrops vesicse fellese, 326 
Hydrothionic urine, 415 INDEX. 
647 
Hydrothorax, diagnosis by explora- 
tory puncture, 129, 160 
Hypsesthesia defined, 477 
Hypacidity of gastric juice, effect of, 
344 
Hyperacidity of gastric juice shown by 
microscopical examination of vomit, 
365 
Hypersesthesia defined, 478 
Hyperidrosis defined, 37 
Hypermetropia, 567 
Hyperosmia in hysteria and insanity, 
574 
Hyperpyrexia, 61 
Hypersecretion of gastric juice with 
vomiting in nervous dyspepsia, 
361 
of stomach juices, diagnosis of, 355 
with hyperacidity of stomach, 361 
Hypertrophic liver, surface of, 325 
Hypertrophy combined with atrophy, 
493 
compensatory of one division of 
heart, 218 
idiopathic, of heart, 196 
of a ventricle shown by strength- 
ening of the sound of corre- 
sponding valve, 217 
of heart, area of dulness enlarged 
in, 208 
cause of projection of region 
of heart, 202 
compensatory, 195 
degeneration of, weak apex- 
beat in, 201 
not to be mistaken in retrac- 
tion of lung, 137 
other than valvular, 196 
right and left, 251 
(with dilatation), diagnosis 
from simple dilatation, 196 
of left ventricle, 252 
aortic second sound felt 
in, 218 
pulsation with, 253, 
254 
apex-beat, when absent 
in, 202 
capillary pulse in, 256 
heart - sounds strength- 
ened in, 217 
polyuria with, 406 
pulsations in arteries in, 
256 
pulse with, 242 
slow pulse with, 237 
Hypertrophy of muscles, 490, 493 
how recognized, 494 
of right heart, venous engorge- 
ment with, 261 
ventricle caused by emphy- 
sema of lungs, 210 
pulmonary second sound 
felt in, 218 
with emphysema of 
lungs, 204 
Hyphidrosis defined, 37 
Hypnosis, catalepsy with, 536 
over-excitability of nerves and 
muscles in, 526 
Hypochondria, oxalate of limein urine 
of, 430 
phosphaturia in, 432 
Hypochondrium defined, 297 
illustrated, 298 
left, projection of, by enlarged 
spleen, 334 
spleen lies in, 332 
projection of right, in enlarge- 
ment of liver, 321 
right, portions of liver in, 319 
Hypodermic syringe used in explora- 
tory puncture of pleura, 160 
Hypogastrium defined, 297 
illustrated, 298 
Hypoglossal paralysis, unilateral, de- 
scribed, 537 
Hypoglossus, paralysis of the, 548 
Hysteria, absence of pharyngeal reflex 
in, 497 
allochiria in, 478 
anaesthesia of larynx in, 576 
of pharynx in, 577 
aphonia in, 598 
catalepsy with, 536 
disturbance of breathing in, 576 
dumbness after an attack of, 548 
epithelium in bloody sputum of, 
176 
gross, described, 534 
headache with, 482 
hemiansesthesia with, 479 
hemidrosis in, 38 
hyperosmia and parosmia in, 574 
hypersecretion of stomach in, 357 
increased tendon reflex in, 500 
laryngeal spasm in, 576 
loss of voice in, 538 
narrowing of field of vision in, 569 
nervous cough in, 165 
opisthotonus with convulsions of, 
468 648 
INDEX. 
Hysteria, palpitation of heart with, 577 
paralysis in, 75 
of diaphragm in, 90 
peculiar bloody sputum with, 171 
polydipsia and” polyuria with, 406 
relations of, to sexual organs in 
women, 581 
sensibility of cranium to pressure 
in, 466 
spasms in, 37, 494, 581 
tenderness of vertebrae in, 467 
tonic spasms in, 532 
total ageusis points to, 574 
tremor with, 531 
unilateral elevation of tempera- 
ture in, 71 
vomiting in, 358, 361, 578 
Hysterical and epileptic spasms, dif- 
ference between, 533 
convulsions, likeness of, to epi- 
leptic, 533 
liemuinaesthesia, 587 
paralysis, EaR not present in, 525 
persons, over-excitability of, 526 
signs, 534 
Hystero-epilepsy, 533 
cyanosis in, 43 
distinguished from epilepsy, 
580 
stages of, 534 
tongue never bitten in attacks 
of, 287 
-traumatic neurosis, analgesia in, 
479 
paralysis, 493 
Hysterogenous zones, 581, 587 
in gross hysteria, 534 
ICTERUS. Also see Jaundice, 
bile pigment in sputum in, 172 
catarrhal, oxalate of lime in urine 
of, 430 
hepatogenic, color of stool in, 373 
slow pulse in, 237 
neonatorum, 47 
urobilin with, 411 
with puerperal pyaemia, a case of, 
602 
Idiocy defined, 472 
Idio-muscular contractions defined, 
526 
Idiopathic migraine, 483 
neuralgia, 483 
Idiotism, increased secretion of saliva 
in, 577 
Idiots, incontinentia alvi in, 578 
Idiots, involuntary discharge of urine 
by, 579 
skeleton of, 33 
Ileo-caecal region, cooing in, in ty- 
phoid fever, 312 
illustrated, 298 
-inguinal nerve illustrated, 487 
Ileus, when occurs, 364 
Iliac fossa, left, pain in, with dysen- 
tery, 308 
right, pain in, with typhoid 
fever, typhlitis, disease of 
vermiform appendix, 308 
regions, pain in, due to inflam- 
mation, 309 
vein, oedema of legs from com- 
pression of, 314 
pressure upon, by enlarged 
retro-peritoneal glands, 341 
Imbecility defined, 472 
Immediate percussion defined, 104 
Inacidity of gastric juice, 345, 346,356 
Inactivity, atrophy of, defined, a re- 
rult of paralysis, 490 
Inanition, acetonuria in, 448 
slow pulse in, 237 
Incisura cardiaca, 192 
and parietal relation of heart, 
197 
illustrated, 304, 327 
in deep inspiration, 125 
the lung-heart boundary, 122" 
Incompensation, difficulties in making 
diagnosis when present, 253 
of heart defined, 219 
Incontinence of urine, 400, 579 
Incontinentia alvi, when occurs, 370, 
578 
Incubation, period of, defined, 22 
Incubator, testing digestive power of 
gastric juice in, 352 
Indican, coloring pigmentin urine, 402 
in urine, 435 
described, and tests of, 409, 
435 
when occurs, 409 
Indifferent electrode, 501 
where placed, 502 
Indirect percussion defined, 104 
Inebriety concealed, 20 
Infantile paralysis, 493 
Infarction, hemorrhagic, of kidney, 
hsematuria with, 417, 418 
of lung, deadened sound over, 
127 
mucous, mucus in feces in, 387 INDEX. 
649 
Infarction of lungs, bronchial frothing 
in, 146 
dyspnoea in, 95 
friction sounds with, 156 
weak percussion over, 115 
pulmonary, bloody sputum in, 170 
Infection distinguished from conta- 
gion, 22 
Infectious diseases, 20 
acute, delirium in, 471 
headache with, 483 
leucocytosis in, 278 
ataxia after acute, 529 
disturbance of consciousness 
in, 470 
EaR with paralysis in, 524 
enlarged liver with, 322 
enlargement of spleen in, 334 
epileptiform attacks in the 
beginning of acute, 533 
gallop rhythm a sign of heart 
failure in, 221 
glycosuria in, 443 
hsemato-jaundice in, 47 
haemoglobin in urine with, 
411 
indicated by high morning 
temperature, 64 
local gangrene in acute, 577 
position of patient in, 32 
respiration in, 91 
slight amount of vomit in, 360 
ulceration of larynx with 
acute, 595 
value of pulse in beginning 
of, 253 
venous thrombosis in severe 
acute, 268 
vomiting in beginning of cer- 
tain, 358 
influence, neuralgia from, 483 
Inflammation, leucocytosis in all kinds 
of, 278 
oedema in the neighborhood of, 
54 
of chest, pain with, 101 
Infra - clavicular spaces, percussion 
note over, 119, 120 
Infra-scapular space, 77 
Infra-trochlear nerve illustrated, 485 
Infusoria found in stools of diarrhoea, 
383 
in sputum, 183 
Inguinal region defined, 297 
illustrated, 298 
pain in, from psoas abscess,309 
Inhalation of dust a cause of disease, 
21 
Inherited diseases, 20 
tendency, 20 
Injuries, scars from, important in 
nervous diseases, 52 
Inner capsule, disturbance of vision 
by lesion of, 460 
Inorganic murmurs, 229 
sediments in urine, section on, 
428-433 
most frequent forms in urine, 
428 
Inosite in urine in diabetes insipidus, 
447 
Insane, incontinentia alvi in the, 578 
involuntary discharge of urine by 
the, 579 
Insanity, hyperosmia and parosmia in, 
574 
superacidity of stomach in, 357 
Inspection of abdomen, 313 
of intestine, method of, 308 
of kidneys, 394 
of stomach, 299 
of thorax, 81 
of veins, 260 
position of patient during, 81 
Inspiration, atelectatic crepitation in, 
154 
auxiliary muscles of, 96 
causes rapid emptying of veins, 
262 
deep, effect on area of heart-dul- 
ness, 206 
forced, cause of, 100 
increased circumference of thorax 
in, 163 
in emphysema, 84 
jerking, when and where occurs, 
145 
pressure of respiratory air in, 164 
relation to pulsus paradoxus, 263 
systolic subclavian murmurs 
heard at close of, 259 
tonic and clonic spasm of thoracic 
muscles of, in tetanus, 540 
variation of pressure during, in 
pleural and subphrenic cavity, 
317 
vesicular breathing only heard in, 
142 
Inspiratory dyspnoea, relation to ex- 
piratory, 100 
when exists, 99 
with emphysema, 100 650 
INDEX. 
Inspiratory pressure, in what diseases 
diminished, 164 
Insufficiency caused by endocarditis, 
194 
mitral, systolic venous pulse with, 
267 
of aorta, cause of pulsation, 254 
255, 256 
of crural vein valve, murmur with, 
268 
of tricuspid valve, positive venous 
pulse pathognomonic 
of, 264 
pulmonarv second sound 
in, 218 * 
of valve, effect of, 194 
valvular, effects of, 193 
Intelligence, cloudiness of, in uraemia, 
440 
development of, 549 
Intensity of lung sound, 108, 112 
of sound of organs containing air 
explained, 106 
Intercostal muscles, atrophied with 
lung cavities, 98 
pain in trichinosis of, a cause 
of cyanosis, 44 
paresis of, pulsation with, 102 
nerves, neuralgia of, in tabes, 484 
neuralgia, 101 
increase Of abdominal reflex 
in, 496 
space, second, heart-sounds heard 
at, 214 
spaces, 82, 84 
in phthisical thorax, 84 
Intermittent fever, 69 
herpes with, 50 
increase of chloride of sodium 
in urine in, 434 
malarial, defined, 70 
range of temperature of, 63 
sweat in, 37 
Internal capsule, 454, 461 
blood-supply of, 462 
effect of lesion of, 457 
of local disease of, 459 
hemiansesthesia with deposits 
in, 479 
jugular veins, positive venous 
pulse in, 265 
organs, disease of, effect on weight 
of body, 36 
diseases of, effect on skin, 39 
effectof engorgement of veins 
on, 260 
Interscapular space, 77 
percussion note over, 120 
Intestinal bacteria in stools, value of, 
388 
canal, portion of, in stool, from 
sloughing, 376 
catarrh, acid or alkaline stool in, 
372 
bilious stool in, 373 
diffuse dull pain with, 308 
due to tape-worm, 377 
infusoria found in stools in, 
383 
mucus in feces in, 387 
mucous stools in, 374 
particles of food in feces in, 
386 
contents, decomposition of veget- 
able parasites from, 388 
crises defined, 578 
digestion shown by stools, 366 
discharges, frequency and char- 
acter described, 367, 368 
diseases with diminished sweat, 38 
gas hinders action of diaphragm, 
90 
hemorrhage, 65 
phenomena of, 40 
infarction defined, 374 
irritation from worms, a cause of 
epileptiform attacks in chil- 
dren, 533 
peristalsis sometimes can be seen, 
309 
Intestine, amyloid degeneration of, 
forms of fat found in feces in, 
386 
auscultation of, 312 
invagination of, character of pain 
with, 308 
percussion of, 311 
perforation of, cause of pneumo- 
thorax, 210 
resistance of fluid in, in compari- 
son with air, 315 
small, mistaken for colon. 310 
Intestines, closed tympanitic sound 
heard over, 111 
disturbance of, from venous en- 
gorgement, 261 
examination of, 308 
points in, 370 
hemorrhage from, appearances of 
blood in, 375 
importance of emptying, in ex- 
amining abdominal organs, 341 INDEX 
651 
Intestines, inflating, for purposes of 
diagnosis, 312 
lung-sound, when heard over, 113 
metallic sounds over, 112 
Invagination of intestine, character of 
pain with, 308 
Invalidism, venous thrombosis as a 
result of, 268 
Involuntary discharges during an at- 
tack of epilepsy, 533, 534 
of stool, 579 
Iodide of potassium found in saliva, 
289 
in urine after taking, 450 
Iron colors the vomit black, 360 
-dust, detection of, 177 
in epithelial cells in sputum, 
177 
in sputum, 171 
solution of chloride of, a test for 
salicylic acid in urine, 
354 
in the presence of alco- 
hol, sugar, and acid 
salts, 351 
Irrigation of rectum, 311 
Irritability, electrical and mechanical, 
of muscles, 488 
of nerves and muscles, faradic and 
galvanic, representation of, 521 
Irritation, direct, 505 
indirect, 505 
of nerves from pressure, 482 
peripheral, sensitiveness to, 472 
Ischiatic nerve, electrical examination 
of, 511 
Ischuria paradoxa, 580 
Itching in jaundice, 47 
JACKSON’S epilepsy, 533 
described, 533 
Jaffe, reference to, 190 
Jaksch, reference to, 180, 272, 279, 
282, 283, 381, 382, 384,385, 388, 423, 
424, 439, 444, 447, 448 
Jaundice, 45. Also see Icterus, 
gall-stones in stools with, 376 
itching in, 47 
sometimes caused by ascaris in 
ductus choledochus, 381 
sweat in, 38 
with engorgement from displace- 
ment of right kidney, 396 
with puerperal pvaemia, a case of, 
602 
Jaworski’s experimental meal, 349 
Jendrassik, reference to, 501 
Jerking breathing, where noticed, 143 
inspiration distinguished from in- 
terrupted inspiration, 146 
when and where occurs, 145 
Johnson, reference to, 436 
Joint neuroses, 583 
Joints, chronic disease of, atrophy 
with, 493 
muscular atrophy from diseased, 
lessened excitability without 
EaR, 525 
Jugular vein, right, shape of opening 
and its relation to venous hum- 
ming, 269 
veins, phenomena of circulation 
in, 262 
Jurasz, reference to, 258 
KAHLER, reference to, 439 
Kaltenbach, reference to, 398 
Kannenberg, reference to, 183, 427 
KaSC, 520 
Kast, reference to, 434, 519, 520 
Keratin, coating for pills, in testing 
rapidity of passage of food from the 
stomach, 354 
Keratitis, parenchymatous, a sign of 
syphilis, 286 
Kidney, amyloid, casts in urine of, 
422, 423 
contracted, casts in urine of, 422 
diminished sweat in, 38 
gallop rhythm of heartin, 221 
oedema from, is fugitive, 440 
polyuria with, 406 
relation to heart disease, 576 
disease, alkaline vomiting in, 366 
dropsy of, disease of, 440 
engorgement of, casts in urine of, 
422 
hyaline casts in urine of, 423 
lateritious sediment in urine, 
430 
epithelium from in case of dis- 
ease, 421 
fatty, fatty casts in urine of, 423 
hemorrhage of the pelvis of, diag- 
nosis of, 418 
hemorrhagic infarction of, hsema- 
turia with, 417, 418 
horseshoe, 393 
large white, adipose white cor- 
puscles in urine of, 420 652 
INDEX. 
Kidney, large white, paleness in, 41 
left, adjacent to fundus of stom- 
ach, 299 
new formations of, when can be 
felt, 395 
position and relation of right and 
left, 392 
pulse in contracted, 244 
tenderness in tumor of, 395 
of region of, when occurs, 
395 
tracing of pulse of contracted, 247 
tumors of, diagnosis of, 397 
value of percussion in, 397 
urine from only one, 400 
vicarious action of one, 408 
wandering, 395 
Kidneys,anatomical situation of, illus- 
trated, 393 
anatomy and topography of, 392 
engorgement of, albuminuria 
with, 435 
examination of, section on, 392- 
451 
injury to, hsematuria with, 417 
local examination of, 394 
location of, illustrated, 321 
pathological condition of, 394 
position of, 79 
value of pulse in showing compli- 
cating disease of, 253 
Klemperer, reference to, 354, 437 
Knee-phenomenon, synonym for pa- 
tellar reflex, 498 
Koch, reference to, 185, 390 
Koch’s cholera bacillus, described and 
illustrated, 389 
comma bacillus distinguished 
from Finkler-Prior’s bacillus, 
607 
Kosselt, reference to, 190 
Kreatinin hinders examination for 
sugar in urine, 405 
Krehl, reference to, 246 
Kronecker, reference to, 297 
Kiihne, K., reference to, 439 
Kiilz, reference to, 447 
Kussmaul, reference to, 263, 301, 303, 
551, 552, 555, 556, 558 
Kypho-scoliosis, 467 
a cause of hypertrophy of 
right ventricle, 196 
cases in which spleen can be 
felt, 334 
deadened sound over, 114 
described, 88 
Kyphoscoliosis, dyspnoea from, 95 
Kyphosis, 467 
described, 88 
from paralysis of erector trunci, 
539 
LAACHE, reference to, 275, 429, 
430, 431, 432 
Lachrymal nerve illustrated, 485 
Lacing, tight, constriction of liver 
from, 323 
Lactic acid, excess of, in stomach, 345, 
346 
fermentation, effect of, 343 
tests for, in contents of stom- 
ach, 351 
Lactose in urine, when occurs, and 
when demonstrable, 447 
Laennec, reference to, 104, 138, 142, 
191 
Laennec’s pectoriloquy described, 159 
Lagging behind in paralysis of sen- 
sation, 485 
detected by palpation, 103 
in breathing described, 87, 91 
in stenosis of a bronchus, 98 
Lagophthalmus, 536 
Lalopathy, 548 
Lameness, simulation of, 19 
Landerer, reference to, 54 
Landois, reference to, 246 
Landois & Sterling’s Physiology, re- 
ferred to, 505 
Lardosis from paralysis of erector 
trunci, 539 
Laryngeal mirror, 591 
muscles, action of, and effects of 
paralysis of, 538 
spasm defined, 576 
Laryngitis, acute, 598 
circumscribed phlegmonosa, re- 
sults in abscess, 594 
hypoglottica illustrated, 593 
serious nature of, 594 
in children, 593 
Laryngoscopic examination of the 
larynx, section on, 589 
image, reversal of parts in, 591 
Larynx, abnormal redness of mucous 
membrane of, 592 
casts of, in croup, 172 
color of mucous membrane of, 591 
evidence in, of pressure by tumors,. 
255 
examination of, 74 
for recurrent paralysis, 296 INDEX. 
653 
Larynx, inflammations near, cause of 
cyanosis, 43 
laryngoscopic examination of, sec- 
tion on,539 
view of, 590 
local examination of, 75 
nervous diseases in which it is 
affected, 576 
normal sound over, 119 
open tympanitic sound, when it 
is percussed, 110 
paralysis of various muscles of, 
and results, 598 
pathological condition of, 592 
position and movements of por- 
tions of, 592 
sensitiveness of, a cause of cough, 
165 
spasm of muscles of, 597 
stenosis of, 97 
tone of cough in ulceration and 
stenosis of, 166 
tympanitic sound over, 121 
ulceration of, a cause of emphy- 
sema of skin, 56 
what to observe in examining, 
591 
Lateral column of spinal cord, 455 
Lateritious sediment in urine, 402, 
429, 430 
Law of contraction, 518 
Lead colic, drawing in of abdominal 
wall in, 309 
pulse with, 244 
tracing of pulse of, 247 
headache in poisoning with, 483 
neuralgia from poisoning by, 483 
paralysis, 543 
EaR in, 525 
poisoning, 21 
black vomit in acute, 360 
cause of paleness, 41 
condition of teeth in, 286 
double sound heard over cru- 
ral artery in, 259 
Leanness, significance of, 34 
Leg, motor centre for, 454 
muscles of, and their paralysis, 546 
points of electrical irritation upon, 
514 
Legal, reference to, 448 
Length of Thorax, 163 
Lenticular nucleus, 454 
blood-supply of, 462 
disease of both internal seg- 
ments, with chorea, 535 
Leo, reference to, 344 
Lepra, 21 
bacillus described, staining of 
cultures of, 606 
Leptotkrix buccalis illustrated, 289 
in urine, 428 
in sputum, 175, 184 
pbarvngomycosis leptothricia, 
29 r 
Lesion, location of, in cortico-musGU- 
lar tract, effect of, 456 
Lethargy, defined, 470 
Letzerich, reference to, 190 
Leube, reference to, 302, 347.355, 426, 
434, 445, 474 
Leube’s experimental meal, 347, 348 
Leucin, form of, in urine, 431, 432 
when occurs, 432 
Leuckart, reference to, 379 
Leucocytes with large nuclei, 279 
Leucocythaemia, relative, 275 
Leucocvtosis a physiological condi- 
tion during digestion, 278 
defined, 278 
Leukaemia, 41 
albuminuria with, 435 
color of blood in, 271 
crystals in blood in, 181 
defined, 278 
greatest enlargement of spleen in, 
335 
haematuria in, 417 
red corpuscles diminished and 
paler in, 275 
retinal changes in, 602 
uric acid increased in, 434 
use of microscope in, 279 
various forms of, 279 
Levulose, in urine, when occurs, 447 
Lewis, reference to, 391 
Levden, reference to, 174, 179, 182, 
190, 202, . 267, 388 
Lichtheim, reference to, 53, 552, 553, 
555, 556, 558, 560 
Lieben, reference to, 448 
Liebermeister, reference to, 58,238,356 
Liebig, reference to, 434 
Lientery stools, 372 
Life, mode of, cause of disease, 21 
Light, source of, for laryngoscopic ex- 
aminations, 589 
Lime, oxalate of, in sputum, 182 
Linea costo-articularis, 332, 338 
Lines drawn on thorax, 76 
Lingual nerve, chorda tympani in, 461 
Lintels, 185 654 
IXDEX. 
Lintels of tubercular sputum, 177 
Lipaemia defined and when occurs, 
280 
Lipomatosis cordis, weak apex-beat 
in, 201 
Lips, color of, 285 
Lipuria, 412 
occurs in chyluria, 447 
Literal agraphia an aphasic symp- 
tom, 561 
aphasia, 553, 556 
paragraphia, 561 
Litten, reference to, 427 
Liver, acute yellow atrophy of, ecchy- 
mosis in, 51 
anatomy of, 319 
average boundary lines of, 329 
cancer-navel upon, in carcinoma, 
325 
cirrhosis of, tender at first, 324 
venous engorgement caused 
by, 262 
consistence of, in various diseases, 
326 
constricted, sometimes tender, 324 
deadness, absolute, 124 
illustrated, 304 
in right mammillary line, 108 
relative, small when lungs 
expanded, 136 
downward displacement of, 128, 
321, 322, 324 
movement of, in inspiration, 
322 
enlargement of, causes and signs 
of, 322 
displacement from, 330 
due to venous engorgement, 
260, 261 
effect on form of chest, 86 
makes half - moon - shaped 
space smaller, 306 
projection of right hypocbon- 
drium in, 321 
examination of, 319 
granulated, surface of, 325 
inspection of, 320 
-kidney angle, 393 
location of, illustrated, 321 
lower border of, rarely felt, 321 
mobility of boundaries of, 329 
mode of palpating described, 266 
motions during breathing, 323 
organs that border it, 320 
palpation and percussion of, 323 
value of, 332 
Liver, pathological conditions of, 324 
relations of its boundaries, 
329 
percussion limits of, illustrated, 
326, 327, 328 
position of, 78, 79 
and boundaries of, illustrated, 
319 
as affected by pleurisy or 
pneumothorax on right or 
left side, 331 
pressure upon, from meteorism, 
309 
proportion of, that is parietal, 320 
-pulse, 302 
arterial, 257 
venous, 266 
relative, deadness of sound over, 
124 
size and form of, 324 
in children, 320 
slight projection of, in children, 
320 
square position of, 330 
-stomach boundary, 329 
surface of, in various diseases, 325 
that is displaced downward not 
to be confounded with enlarged, 
331 
tilting of, in pleurisy, 199 
tumor of, 306 
unequal enlargement of, 331 
wandering, position of, 322 
not in contact with dia- 
phragm, 322 
Lobes of the brain, upper and lower 
parietal, temporal, and frontal, 
466 
of the lungs, boundaries of, 80 
Lobulated liver, from deep syphilitic 
scars, 325 
Lobus paracentral is, 454, 459 
Local sense, how tested, 474 
Location of thoracic contents illus- 
trated, 319 
sense of, 473 
Loftier, reference to, 605, 606 
Logwood, color of urine after, taking, 
411 
Lordosis, 467 
from weakness or paralysis of 
muscles of spine, 467 
Louis, angle of, defined, 76, 78, 81, 82, 
84 
in phthisical thorax, 84 
Lowenfeld, reference to, 523 INDEX 
655 
Lower extremity, illustration of cuta- 
neous nerves of, 487 
nerves of, 488 
points of electrical irritation 
upon the back of, illus- 
trated, 513 
Ludovici, angulus, 76, 78, 81, 82 
Ludwig, reference to, 198, 246 
Lumbar enlargement of cord, loca- 
tion of, 468 
Lumbo inguinal nerve illustrated, 487 
Lung-cavities, atrophy of intercostal 
muscles in, 98 
bronchial breathing over, 146 
metallic sounds over, 112 
tympanitic sound with, when 
communicating with air, 
131 
compression of, against thoracic 
wall increases vocal fre- 
mitus, 158 
by large exudation, 128 
from high position of dia- 
phragm, 317 
contraction of .differentiated from 
primary deformity of chest, 
88 
diminishes area of spleen- 
dulness, 339 
left, effect on heart, 203 
emphysema of cellular tissue from 
perforation of, 56 
fistula, sound of, defined, 153 
gangrene of, mucus in three layers 
in, 169 
-heart boundary, 122, 125 
-kidney boundary, 123 
left, lower border of, boundary of, 
125 
-liver boundary, 122,124,125,328, 
329 
overlaps the spleen and dimin 
ishes area of dulness over, 339 
retracted, tympanitic sound with, 
111 
sequestra, 172 
shrinking of, 197 
-sound defined, 108 
-spleen boundary, 122, 124 
-stomach boundary, 122, 124 
thickening of, ringing rales with, 
152 
tissue, decreased tension of, 135 
in sputum in abscess of lung, 
172 
no irritative cough from, 165 
Lung tissue, relaxation of tympanitic 
sound with, 130 
retracted, noise of spun-top 
over, 135 
thickening of, bronchial 
breathing in, 146 
Lungs, abnormal sounds over, 125 
abscess and gangrene of, elastic 
threads in sputum, 177 
haematoidin in sputum, 172 
active mobility of, 125, 210 
amount of expectoration from 
cavities in, 168, 169, 175 
anatomical boundaries of, 78, 79 
auscultation of, 138 
borders of, 80 
boundaries of, changed, 136, 304, 
319 
rules to be observed in deter- 
mining, 124 
brown induration of, dyspnoea in, 
96 
catarrh of larynx in disease of, 
593 
chronic diseases of, subnormal 
temperature with, 64 
consolidation of, cyanosis in, 43 
contraction of, a cause of hyper- 
trophy of right ventricle, i96 
difficulties in determining their 
boundaries, 123 
diminished volume of, how recog- 
nized, 137 
diseases of, form of thorax in, 81 
which cause dyspnoea, 95 
disposition to disease of, 81 
disturbances of the circulation 
through, 44 
dust diseases of, 21 
elasticity of, lost in emphysema, 84 
emphysema of, a cause of dis- 
placement of heart, 199 
weakens apex-beat, 201 
examination of, 76 
gangrene of. Also see Gangrene. 
odor of sputum in, 171 
hemorrhage of, in tuberculosis, 
170 
large cavity in, metallic heart- 
sounds with, 221 
lobes of, boundaries of, 80 
location of, illustrated, 321 
lower border of, in children, 192 
relatively deadened sound 
over, 114 
boundary of, 122 656 
INDEX. 
Lungs, normal percussion of, bounda- 
ries of, 121 
sound over, 119 
cedemaof, bloody sputum with, 170 
dyspnoea in, 95 
serous sputum a peculiarity 
of, 169 
percussion of, described, 118 
posterior boundaries of, illus- 
trated, 123 
pressure upon, by meteorism, 309 
rapid breathing in inflammation 
of, 94 
relation of disease of, to certain 
brain diseases, 576 
to diaphragm, 80 
retraction of, measure of thorax 
in, 163 
near the heart, 137 
upward displacement of liver 
with, 323 
shrinking of, a cause of displace- 
ment of heart, 199, 200, 211 
both pulmonary sounds 
strengthened in, 218 
pulsations at base of heart in, 
203 
starch corpuscles in the sputum 
in hemorrhage of, 180 
symptoms of hsematemesis in 
hemorrhage of, 167 
thickening of, deadened sound 
from, 114 
feeling of resistance with, 116 
metallic rales with, 150 
simulates enlarged heart, 209 
thoracic boundaries of, 77 
topographical anatomy of, 76 
tuberculosis of, see Tuberculosis 
tumor of, peculiar sputum in, 171 
tumors of, deadened sound over, 
127 
value of pulse in showing compli- 
cating disease of, 253 
vital capacity of, relation to size 
of body, 164 
wounds of, a cause of emphysema 
of skin, 56 
Lupus, may be the cause of catarrh of 
larynx, 593 
Luschka, reference to, 78, 79,192, 319, 
321 
Lustgarten, reference to, 399, 427 
Lymphatic glands, blowing murmurs 
over, 259 
leucocvtosis in swelling of, 278 
Lymphatic glands swollen in syphilis 
and diphtheria, 290 
Lympho sarcoma of spinal cord, he- 
mialbumose in, 439 
Lysis defined, 67 
Lyssa, increased tendon reflex in, 500 
M-A (milliamperes) strength of cur- 
rent measured in, 512, 515 
Macrocephalus with hydrocephalus, 
464 
Macrocytes, defined, occur in anaemia 
and in pernicious anaemia, 276 
Maixner, reference to, 439 
Malaise, from uraemia, 440 
Malaria, bacillus of, 282 
diagnostic value of temperature 
in, 64 
haemoglobin in urine of, 411 
melanaemia in, 280 
neuralgia from, 483 
spleen much enlarged in, 335 
Malarial cachexia, 41 
intermittent fever, 70 
Malignant growths cause of paleness, 
41 
pustule, 21 
examining blood for micro- 
organism of, 282 
Mai perforant, defined, 582 
Mammillary line corresponds with 
border of liver, 327 
edge of liver at, 323 
variations of, 77 
lines, 297 
defined, 76 
Manegegang, 534 
Mania, with uraemia, 440 
Manneberg, reference to, 399, 427 
Manometer, use of, in puncture of 
cavity, 318 
Marasmus defined, 35 
Marchiafava, reference to, 282 
Marching a cause of disease, 21 
Marey, reference to, 246 
Marie, reference to, 560, 583 
Martius, reference to, 199 
Masseter spasm in trismus, 532 
Mastication, difficulty of, in paralysis, 
537 
muscles of, 536 
Matterstoek, reference to, 259 
Maxilla, superior, nerve supply of 
mucous membrane of, 484 
Meals, effect upou pulse, 235 INDEX 
657 
Measles, 49 
acute nasal catarrh in, 74 
coin shaped sputa in bronchitis 
of, 169 
epileptiform convulsions in the 
beginning of, 533 
inflammation of larynx in, 75 
petechiae in, may be overlooked, 
51 
recurrence of, 22 
Measurement of thorax in aneurism 
of aorta, 254 
Measuring circumference of abdomen, 
value of, 316 
the thorax, 162 
Meat-juice stools in dysentery, 375 
Mechanical EaR, 526 
irritation, neuralgia from, 483 
Median nerve, anaesthesia in the re- 
gion of, from paralysis of 
brachial plexus, 487 
distribution to hand, 545 
illustrated, 486 
paralysis of, 544 
Mediate percussion defined, 104 
Mediastinal emphysema, crepitations 
of, 233 
pericarditis, 204 
tumor, measurement of thorax in, 
163 
producing pressure-paralysis 
of recurrent nerve, 538 
swelling of cutaneous veins 
over sternum sign of, 262 
venous engorgement from, 
261 
tumors affecting larynx, 75 
displacement of the heart by, 
199 
effect on heart, 201 
Mediastinitis, callous, diastolic col- 
lapse of cervical veins in, 267 
effect upon venous circulation, 263 
Mediastinum displaced by exudation, 
128 
displacement of, how recognized, 
137 
thickening of, simulates enlarged 
heart, 209 
tumors of, cyanosis an effect of, 
44 
Medicines, exanthem from use of, 50 
urine as affected by, 450 
Medulla, anaemic necrosis of, 462 
blood-supply of, 462 
softening of, 599 
Melsena neonatorum, hemorrhage of 
stomach with, 362 
Melanaemia defined, and connection 
with malaria, 280 
Melancholia attonita, 536 
Melanotic tumors, color of urine with, 
411 
Meltzer, reference to, 297 
Meniere’s disease, tinnitus aurium 
with, 573 
Meninges, disease of, feeling of con- 
striction about thorax in, 482 
tumors of, disturbances of con- 
sciousness from, 471 
Meningitis, anosmia from, 573 
basilar, rigidity of neck in, 468 
slow pulse in, 237 
breathing in, 91 
cerebro-spinal, herpes with, 50 
irregular temperature 
with, 71 
Cheyne-Stokes respiration in, 92 
choked disc with, 600 
consciousness may be retained in. 
471 
disturbance of consciousness in, 
470 
drawing-in of abdominal wall in, 
309 
from disease of the nose, 576 
headache with, 482 
irregular temperature in, 71 
neuro-retinitis with, 601 
pain in spine in, 483 
posture in, 33 
pulse in, 245 
purulent, affections of hearing 
with, 572 
relation of, to disease of the 
lungs, 576 
sensibility of cranium to pressure 
in, 466 
slow pulse with, 239 
spinalis, herpes zoster in, 581 
spinal, rigidity of spinal column 
in, 468 
tenderness of vertebrae in, 467 
tubercular, suspected when nu- 
trition is poor, 575 
value of pulse in showing devel- 
opment of, 253 
vomiting in, 358 
Memory, loss of, 556 
testing of, 469 
Mental condition, during spasm, 530 
disease, first traces of, 470 658 
INDEX. 
Mental diseases, hemidrosis in, 38 
disturbance due to fever, 60 
impressions produce perspira- 
tion, 36 
nerve illustrated, 485 
Mercurial poisoning, 21 
cause of paleness, 41 
Mercury, cocci in mouth in poisoning 
by, 289 
condition of teeth in poisoning 
by, 286 
headache in poisoning with, 483 
neuralgia from poisoning with, 
483 
salivation caused by, 289 
Mesenteric glands, disease of, forms of 
fat found in feces, in, 386 
Mesocardia, 211 
Mesogastrium defined, 297 
Metallic after-sounds defined, 112 
associated sound accompanies 
bronchial breathing, 148 
heart-sound, 210 
murmurs, 227 
pericardial splashing, 233 
poisons from inhalation, 21 
rales, 150 
sound defined, 112 
with pneumothorax, 135 
with various conditions, 136 
tone over large cavities with 
smooth walls, 131 
Metamorphosing breathing defined, 
148 
Meteorism cause of diminished area 
of liver-dulness, 331 
effect on extent of abdomen, 309 
on form of chest, 86 
employment of deep breathing 
in, 323 
intestinal, 313 
or peritoneal, metallic heart- 
sounds with, 221 
pressure by, upon liver, dia- 
phragm, lungs, heart, 309 
with and without pain, value of, 
in diagnosis, 314 
Meteorismus peritonei defined, 313 
value of percussion in, 317 
Methsemoglobin, absorption band of, 
273 
in the blood in poisoning by 
chloride of calcium, 272 
spectroscopic examination for, 442 
Methods of auscultation, direct and 
indirect, 138 
Methods of percussion of thorax, 118 
Methyl-violet test for free muriatic 
acid, 451 
Miasm, 21 
Microcephalus, 465 
Micrococci, casts of, in septic pro- 
cesses, 427 
in mouth, 289 
in purulent plural exudation, 161 
in sputum from mouth, 188 
Micrococcus gonorrhoeus described, 
604 
tetragenus, 184 
urese, 426 
Micro-millimetre, value of, 185, note. 
Micron, a measure, value of, 185, note. 
Microorganisms, examining blood for, 
273 
in mouth, 289 
in sputum, 167 
in stomach, destroyed by anti- 
septic action of gastric 
juice, 343 
excess of, 345 
in the blood, 280 
in urine, staining of, 415 
mode of examining blood for, 282 
that excite fermentation, 342 
Microcytes, 276 
in ansemia, 276 
in pernicious ansemia, 276 
Microcythsemia, 274 
after hemorrhages in ansemia, 27fi 
Microscope, diagnosis of thrush by aid 
of, 288 _ 
examination of contents of mouth 
by, 289 
generally useless in determining 
hemorrhage of stomach, 365 
magnifying power, use in exam- 
ining the blood, 273 
use of, in diagnosis of diseases of 
palate and pharynx, 291 
in examining for cocci and 
bacilli in urine, 426 
urinary sediments, 415, 
419 
in hsematuria, value of, 418 
Microscopic appearance of uric acid, 
428 
examination of blood, mode of 
procedure, 273 
value of, 271 
of urate of soda and lime, 429 
Micturition, difficult, a cause of dimi- 
nution in amount of urine, 407 INDEX. 
659 
Middle cranial fossa, effect of lesion 
of, 457 
Migraine defined, symptoms of, and 
when occurs, 483 
hemidrosis in, 38 
inequality of the pupils in, 567 
sometimes preceded by tinnitus 
aurium, 573 
temporary partial amaurosis in, 
571 
unilateral redness of head in, 577 
vomiting with attacks of, 578 
Miliaria, 50 
Miliary tuberculosis affecting the cho- 
roid, 562 
Milk, color of stool when the diet con- 
sists of, 373 
particles of, in sputum, 175 
Miller, reference to, 391 
Milliampere-meter, 503 
Mind, condition of, mode of examin- 
ing, 469 
Minimal contraction, 512, 514 
Minkowsky, reference to, 449 
Miserere, when occurs, 364 
Mitral disease, enlargement of liver 
with, 322 
of heart, paleness in, 41 
venous engorgement in, 261 
first sound, the loudest heart- 
sound, 217 
insufficiency, 194, 195, 196 
and stenosis, effects of, 195 
color of skin in, 41 
dyspnoea in, 96 
murmur of, 224, 225 
pulse with, 242 
systolic venous pulse with, 
267 
murmur heard at apex, 224 
stenosis, 194 
absence of pulse with, 243 
arhythm of pulse in, 241 
character of pulse with, 243 
division of second sound at 
apex in, 220 
double sound over crural ar- 
tery in, 259 
first sound strengthened at 
apex in, 218 
pulse in, 251, 253 
weakening of aortic second 
sound in, 219 
valve causes a systolic sound, 213, 
214 
where best heard, 213, 214 
Mobility of spinal column dimin- 
ished, 467 
of spleen, 335 
Mode of life, effect on complexion, 39 
Moist cough described, 166 
rales, 149 
explained ; when occur, 151 
Monoplegia, 457 
facialis, brachialis, cruralis, de- 
fined, 489 
with partial epilepsy, 533 
Monos (infusorium) in sputum, 183 
Moore’s test for sugar, 445 
Morbus Addisonii, 48 
Basedowii, apex-beat with, 201, 
216 
blowing murmur with, 259' 
tremor of, 531 
Werlhofii, hsematuria in, 417 
Morenheim’s depression defined, 76 
Morgagni, sinus, 591 
Moritz, reference to, 132 
Morphia, effect of, on pupil, 567 
induces perspiration, 37 
poisoning by, Cheyne - Stokes 
breathing in, 92 
tremor from, 531 
Mosso, reference to, 93, note. 
Motility, disturbances of, 488 
of lungs, when diminished, 137 
Motion, loss of, from paralysis and 
stiffness not to be confounded, 488 
Motor aphasia, 553 
cortical regions, location of, 466 
of occipital and temporal 
lobes, relation to cra- 
nium, 465 
cranial nerves, 455 
memory, 549 
points, 508 
stimuli, 456 
Mould in sputum, 190 
Mouth, effect of opening and closing 
of, upon the pitch of sound, 111 
examination of, 284 
microscopical examination of con- 
tents of, 289 
odor from, importance of, 285 
open, tympanitic sound when it is 
percussed, 110 
Movements, associated, defined, 535 
sensation of, defined, 474 
Mucin in urine, test for, 441 
Muco-purulent sputum described, 168 
Mucor (mould) in sputum, 190 
Mucous colic, 374 660 
INDEX. 
Mucous corpuscles in vomit, 365 
deposits upon larynx, 592 
infarction, mucus in feces in, 387 
membrane of larynx, color of, 591 
reflexes of, 496 
sputum described, 168 
stool described, and significance 
of, 373 
threads in urine not to be con- 
founded with casts, 416 
Mucus, cloud of, in normal urine, 402 
in feces, 387 
in three layers described, 169 
in urine, 416 
causes it to be jelly-like, 419 
chemical proof of, 416 
threads of, in sputum, 175 
Muguet in sputum, 175 
Mulberry tongue a sign of scarlet 
fever, 287 
Muller, reference to, 386, 387 
Muller, F., reference to, 371 
Multiple neuritis, diagnosis from tabes, 
580 
EaR with, 524 
neuralgic pain in, 484 
sclerosis, allochiria in, 478 
atrophy of the optic nerve in, 
562, 661 
narrowing of field of vision 
in, 569 
scanning speech in, 548 
tremor with, 531 
Mumps (inflammation of parotid 
gland), 288 
Muriatic acid, excess of, in stomach, 
345 
free, testing for, with phloro- 
glucin-vanillin,350 
with tropaolin paper, 
350 
when wanting, 356 
in stomach, 344 
quantitative examination, 351 
relation to pepsin, 352 
Murmurs, anaemic, 229 
blowing over lymphatic glands,259 
characters of, 227 
combination of several, differen- 
tiation of, 228 
diastolic and systolic, 228 
differential diagnosis between 
peri- and endocardial, 232 
double, described, 259 
endocardial, loudness of, to what 
due, 223 
Murmurs heard over veins, 268 
heart, when heard, 222 
metallic, 227 
pericardial, 230 
presistolic, 228, 251 
explained, 226 
normal venous pulse with, 263 
systolic and diastolic, 226 
subclavian, 259 
that can be felt, 227 
Muscles and nerves, electrical exami- 
nation of, 501 
mechanical excitability of, 
526 
auxiliary, of inspiration, 96 
of respiration, 83, 541 
behavior of, when irritated, 507 
diagram of their innervation, 454 
disturbance of nutrition and tone 
of, 489 
EaR with degenerative atrophy 
of, 524 
increased tonus of voluntary, 535 
motor points of, 508 
nutrition of, nervous influence, 456 
of arm and hand, importance of 
a knowledge of, and their in- 
nervation, 545 
of the eye, action of, and paralysis 
of, 562 
function of individual, 564 
paralysis of, 562 
of the lower extremity, 545 
of the thorax, diaphragm and 
abdomen, 540 
effects of paralysis of, 540 
of the trunk, action of, and effect 
of paralysis of, 539 
of the upper extremity, 540 
spinal, pain in, 483 
tonus of, 528 
voluntary, innervation, function, 
and the diseases that disturb 
them, 536 
Muscular atrophy from diseased joints, 
lessened excitability with- 
out EaR, 525 
spinal progressive, fibrillary 
contractions in, 532 
dystrophia, 493 
irritation, direct, on the back, 512 
rheumatism, pain in spinal mus- 
cles, 483 
sense, 474, 480 
defined, 480 
test for, 481 INDEX 
661 
Muscular sense, tract of, 459 
Musculo-spiral nerve, examination of, 
512 
muscles supplied by, ex- 
amination of, 515 
paralysis of, from com- 
pression, 487 
Music an acquired faculty, 549 
power to produce, 550 
Mydriasis, 566, 567 
Myelitis, 580 
allochiria in, 478 
diminished tendon reflex in, 500 
transversa, 492, 493 
clonic spasms in, 532 
cystitis in, 579 
increase of tendon reflex in, 
500 
involuntary passage of urine 
in, 580 
Myocarditis, arhythm of pulse in, 
241 
fibrinous, slow pulse in, 237 
pulse in, 252 
pulsus intercedens in, 241 
weak apex-beat in, 201 
Myopathic muscular atrophy, EaR in, 
524 
lessened excitability in, 
without EaR, 525 
paralysis, EaR not present in, 525 
skin reflex lost in, 496 
progressive muscular atrophy, 525 
spasm, 493 
Myopia, 567 
Myosis, 566, 567 
Myositis ossificans, a cause of rigid 
thorax, 91 
cyanosis with, 44 
Myotonia congenita, 532 
increased mechanical excita- 
bility in, 526 
Myotonic reaction, described, 524 
in Thomsen’s disease, 518 
NAILS, in peripheral paralysis, 583 
Names of diseases, misuse of, 19 
Naphthalin, color of urine after 
taking, 411,451 
Narcotics, disturbance of conscious- 
ness in poisoning by, 470 
Nasal polypi, cause of neuroses, 575 
Naunyn, reference to, 449, 478, 575 
Neck and head, points of electrical 
irritation upon, illustrated, 508 
Neck, nerves of, 485 
Neelsen, reference to, 187 
Negative venous pulse, 263 
Neisser, reference to, 427 
Nelaton’s oesophageal catheter, use of, 
to wash out stomach, 347 
sound, use of, 302, 355 
Nephritis a cause of cardiac hyper- 
trophy, 196 
of dropsy, 53 
acute and chronic, albuminuria 
with, 435 
casts of albumin in urine of, 
424 
hemorrhagic, desquamation 
of renal epithelium in, 424 
slow pulse with, 237 
amount of diminution of urine 
indicates severity of, 407 
bacteria in urine of, 427 
casts the infallible sign of, 420 
chloride of sodium in urine di- 
minished, 434 
chronic, cause of paleness, 41 
hsemorrhagica, blood-corpuscles 
in casts in urine of, 423 
mucus threads in urine of, beside 
casts, 416 
oedema with, 54 
parenchymatous, pus-corpuscles 
in urine of, 420 
renal casts in urine of, 422 
epithelium in urine of, 421 
retinitis with, 601 
saliva contains urea in, 289 
sequela of scarlet fever, 22 
sometimes phosphates in urine 
are diminished in, 435 
sweat in, 38 
tenderness in acute, not chronic, 
395 
tracing of pulse of, 247 
turbid urine in, 412 
urea diminished in, 434 
Nephrolithiasis, 433 
haematuria with, 417 
Nerve centres, vasomotor influences 
from, on pulse in symmetrical 
vessels, 257 
faradic examination of, described, 
512 
lesion of, degenerative atrophy 
from, 491 
points, 508 
sensibility to pressure in neuritis, 
468 662 
INDEX. 
Nerve trunk, examination of, its course 
must be known, 468 
Nerves and muscles, electrical exam- 
ination of, 501 
cutaneous, of the lower extremity 
illustrated, 487 
distribution of sensory cutaneous, 
484 
individual peculiarities of, in re- 
lation to the skin, 504 
irritation and pain from pressure, 
section on, 482 
mechanical excitability of, 526 
neuralgia as sequela of inflamma- 
tion of, 483 
of head, 484, 485 
of lower extremity, 488 
peripheral, and their surround- 
ings, 468 
points of tenderness in, 484 
of stimulation, 508 
shoulder, arm, and hand, 485 
Nervous cough, a dry cough, 166 
during menstruation, 165 
disease of heart, increases strength 
of heart-sounds, 216 
diseases, diagnostic value of symp- 
toms in, 583 
disturbances of the vegetative 
system in, 575 
importance of scars from in- 
juries, 52 
local sweating in, 38 
patients, rapid breathing in fever, 
94 
system, anatomical diseases of, 
586 
anatomy of, 452 
central, injuries to, glyco- 
suria afcer, 443 
chapter on examination of, 
452-587 
convulsions in disease of, 22 
differential diagnosis of func- 
tional aud anatomical dis- 
eases of, 587 
diseases of, diagnosis of, 586 
Nervousness, dizziness with, 471 
subjective sensibility of hearing 
in, 572 
Neubauer, reference to, 412 
Neukirch, reference to, 121 
Neuralgia, defined, cause of, 483 
glycosuria with, 443 
in head, 483 
intercostal, 101 
I Neuralgia, sensitive points in nerves, 
468 
simulation of, 19 
tenderness of nerves during, 484 
with diabetes mellitus, 579 
Neuralgic pain in connection with 
feeling of constriction, 482 
in herpes zoster, 581 
Neurasthenia, cerebral, with vertigo, 
472 
headache of, 482 
pain in spine in, 483 
phosphaturia in, 432 
spinalis, 580 
Neuritis, acute degenerative, 493 
acoustic, subjective sensibility of 
hearing with, 573 
ataxia in diffuse peripheral, 529 
condition of nerve in, 468 
degenerative, 491 
EaR with, 524 
herpes zoster from, 581 
multiple, lessened excitability 
without EaR in, 525 
partial EaR in, 525 
nerve sensitive to pressure in, 
484 
of phrenic nerve, effect on dia- 
phragm, 90 
optica, 652 
from intracranial pressure, 
600 
peripheral, cyanosis in, 43 
degenerative atrophy with, 
491 
gangrene in, 577 
with diabetes mellitus, 579 
Neuro-fibroma, condition of nerve in, 
468 
Neuroma, condition of nerve in, 468 
Neuro-retinitis Brightii, choked disk 
with, 601 
diabetic, 602 
when occurs, 601 
Neuroses, hypersecretion of stomach 
in, 357 
increased tendon reflex in, 500 
joint, 583 
local sweating in, 38 
narrowing of field of vision in, 
569 
phenomena of pulse in, 577 
pulse in certain, 240 
sometimes inherited, 20 
vomiting in, 358 
Neurosis, slow pulse as a, 238 INDEX 
663 
Neurotic bronchial spasm, cause of 
dyspnoea, 94 
causes for glycosuria, 443 
Newly-born, urate casts in urine of, 
424 
urine of, frequently contains 
albumin, 405 
weight of, 35 
Nicotine, headache in poisoning with, 
483 
neuralgia from poisoning with, 
483 
poisoning, effect on heart, 201 
palpitation of heart in, 577 
Niemeyer, P., reference to, 140 
Night-sweats in phthisis, 38 
Nitrate of silver, deposit of, 49 
Nitric acid test for albumin, 436 
Nitro-benzole, color of blood in poi 
soning by, 271 
poisoning by, odor of bitter 
almonds in vomit, 366 
Nocturnal enuresis, 400 
Noise of spun-top described, 134, 135 
where it occurs, 134 
Noma, description of, 288 
Non-tympanitic sound caused by ten- 
sion, 111 
defined, 108 
from closed air-cavity, 
110 
over sternum, 121 
transition to tympanitic, 
explained, 112 
where occurs, 111, 112 
Noorden, reference to, 404 
Normal boundaries of lungs, 119 
electrode, 502, 503, 506, 507, 512, 
516 
percussion boundaries of lungs, j 
121 
Nose, blood from, appears as hsemate- 
mesis, 361 
disease of, migraine with, 483 
examination of, 73 
fluids escape by, in paralysis of 
soft, pal ate, 537 
nerve-supply of mucous mem- 
brane of, 484 
relation of diseases of, to nervous 
diseases, 575 
suppuration of, cause of menin- 
gitis and abscess of brain, 467 
Nostrils, how dilated, 536 
Nothnagel, reference to, 373, 374, 387, 
388 
Nourishment, insufficient, a cause of 
drawing-in of abdomen, 309 
Nuclear paralysis, synonym for bulbar 
paralysis, 497 
Nursling. Also see Children. 
Nurslings, stomach-digestion in, 344 
Nutrition, disturbance of, cause of 
ophthalmia neuro-para- 
lytica, 484 
disturbed, blood coagulates slower 
in, 283 
how to judge of, 34 
of muscles, 488, 489 
signs of, 489 
variously affected in diseases of 
the nervous system, 575 
Nylander’s reagent, 444 
Nymphomania, 472 
Nystagmus, horizontal and rotatory, 
defined, 565 
0 abbreviation for opening of cur- 
, rent, 506 
Obermeier, reference to, 281 
Obersteiner, reference to, 478 
Oblongata, 455, 461 
diseases of, glycosuria in, 443 
effect of lesion of, 457 
glycosuria in disease of, 579 
Obstipation (constipation), 369 
increase of indican in urine in 
obstinate, 409 
large stools after prolonged, 370 
Obturator nerve, illustrated, 487 
Occipital lobe, blood supply of, 462 
centre for conception of writ- 
ing in optic portion of cor- 
tex of the, 555 
illustrated, 466 
lobes, effect on vision of lesion of, 
460 
nerves illustrated, 485 
Occupation a cause of disease, 21 
Oculomotorius, absence of pupillary 
reaction of light in paralysis 
of, 568 
inequality of pupils in unilateral 
paralysis of, 567 
muscle, dilatation of pupil in 
paralysis of, 566 
total paralysis of, 565 
Odor from mouth, importance of, 
285 
of expectoration, 168 
of sputum described, 171 664 
1NDEX. 
Odor of urine, pathological, 414 
Odors of urine, normal and adven- 
titious, 404 
(Edema: 52 
a result of general venous engorge- 
ment, 261 
cause of, explained, 54 
collateral, 54 
deceptive increase of weight, 35 
distinguished from emphysema of 
skin, 55 
due to ankylostomo-ansemia, 54 
from kidney disease, 440 
nephritis, 54 
in paralysis, 577 
may conceal venous stasis, 262 
near heart, weakens apex-beat, 
201 
of chest-wall, cause of deadened 
sound, 130 
Aveakened vocal fremitus 
with. 158 
of engorgement, venous throm- 
bosis with, 268 
of glottis, cause of cyanosis, 43 
of larynx, 594 
of legs, from compression of iliac 
veins, 314 
of lungs, albumin in sputum in, 
190 
bloody sputum with, 170 
crepitant rales with, 154 
dyspnoea in, 95 
serous sputum a peculiarity 
of, 169 
tympanitic sound with, 111, 
130 
showing deep abscess, 54 
slight, disappears between even- 
ing and morning, 54 
striae from, 52 
(Edematous skin in empyema, 86 
(Esophagoscopy, 297 
(Esophagus, anatomy of, 291, 292 
auscultation of, 297 
carcinoma of, producing pressure- 
paralysis of recurrent nerve, 538 
compression of, 296 
congenital stenosis of, 292, 296 
danger of inducing emesis when 
it is eroded, 342 
dilatation of, 296 
disease of, a‘cause of drawing-in 
of abdomen, 309 
examination of neighborhood of, 
291, 296 
(Esophagus, expectoration from, in 
hysteria, 171 
location of stricture of, 295 
obstruction of, 296 
percussion of, 296 
perforation of, cause of pneumo- 
thorax, 210 
pressure upon recurrent nerve 
from carcinoma of, 255, 599 
recurrent paralysis a symptom of 
carcinoma of, 600 
rupture of, a cause of emphysema 
of skin, 56 
sounding of, dangers of, 294 
difficulties of, 294 
method of, 293 
stenosis of, obstipation with, 369 
O'idium albicans, description 287 
Old age, anosmia in, 573 
nutrition of skin in, 36 
reaction of pupils to light, 
slow in, 567 
slow pulse in, 237 
Olfactory nerve, 461 
anosmia with compression of, 
573 
Oligocythsemia, diminution of red cor- 
puscles, 273 
haemoglobin diminished in, 275 
occurs in anaemia, 274 
Oliguria in hysteria, 579 
Omentum, dulness over, from fat, 306 
examination of, 340 
shrinking of, in tuberculosis, 340 
Onanism concealed, 20 
One-sided action of diaphragm, 90 
Open pneumothorax, tympanitic 
sound, 110, 111, 113 
Ophthalmia, neuro-paralytic, 484 
Ophthalmic artery, 461 
Ophthalmoplegia externa, 566 
Ophthalmoscope, examination with, 
600 
Opisthotonus, 496, 532, 534, 539 
defined, 468 
with meningitis and tetanus, 467 
Opium poisoning, Cheyne-Stokes 
breathing in, 92 
Optic nerve, 551 
absence of pupillary reaction 
in atrophy of, 568 
atrophy of, after severe hem- 
orrhages, 602 
in diabetes, 602 
in tabes, 562 
course of, 460 INDEX 
665 
Optic nerve, dilatation of pupil in 
atrophy of, 566 
illustrated, 460 
inequality of pupils in paral-I 
ysis of the, 567 
lesion of, 565 
narrowing of field of vision 
from atrophy of, 569 
primary atrophy of, when 
occurs, 601 
thalamus, 454 
blood supply of, 462 
hemichorea with lesion of, 535 
Organic heart murmurs explained, 221 
Orthopncea, 97 
diseases in which it occurs, 32 
effects of, 33 
in heart disease, 197 
Oscillation of the eyeball, 565 
Osmic paraesthesia in hysteria and 
insanity, 574 
Osteomyelitis, staphylococus pyogenes 
in, 603 
Ostium venosum, 218 
Ovarian hyperaesthesia, 581 
tumor, differential diagnosis from 
tumor of kidney, 396 
made out after tapping abdo- 
men, 318 
Oxalate of lime, concretions of, 433 
in sputum, 182 
in urine, forms of, described, 
429, 430 
microscopic appearance of, 
430 
when it occurs, 430 
Oxaluria defined, 430 
Oxybutyric acid interferes with cir- 
eumpolarization for sugar, 447 
Oxygen, deficiency of, a cause of cy- 
anosis, 43 
diagnostic importance of, 270 
effect of deficiency of, on color of 
blood, 270 
Oxyhaemoglobin, absorption band of, 
271, 272, 273 
effect of, upon color of blood, 270 
Oxyuris in vomit, 364 
vermicularis, described, 382 
found in urine, 425 
illustrated, 381 
PAIN, a cause of rapid breathing, 
94 
a cause of suppression of cough, 
165 
j Pain accompanies diseases of the ab- 
dominal cavity, 314 
after use of sound in cesophagus, 
significance of, 294 
cold- and heat-, test of, 475 
dilatation of pupil with severe, 
566 
effect of, on reaction of pupils, 
567 
frequent pulse with severe, 240 
from pressure on nerves, 482 
in respiration, a cause of dimin- 
ished vesicular breathing, 145 
in spine, various causes of, 483 
in swallowing, significance of, in 
diseases of oesophagus, 292 
produced by pressure on stomach, 
299, 300, 303 
produces perspiration, 37 
restricting action of diaphragm, 
90 
sensibility to, how tested, 476 
spontaneous, section on, 482 
syncope from, 471 
tenderness of spleen, when occurs, 
335 
thoracic, produced by pressure, 
101 
with movements of bowels, when 
occurs, 370 
Palate, examination of, 284 
sense of taste in, 461 
soft, electrical irritation of, 510 
examination of, 290 
innervation of, 537 
muscles of, 536 
Pale skin, 39 
Paleness due to diminished haemoglo- 
bin, 40 
unilateral, in hysterical hemi- 
ansesthesia, 577 
various causes of, 40 
Palpation above and below zygoma, 
what it shows, 537 
in disease of peritoneum, 314 
in examining throat, 285 
of arteries, 256 
of intestine, 308 
of kidney, importance of, 395 
of liver described, 266 
how performed, 323 
value of, 332 
of mouth, 288 
of cesophagus, 292, 293 
of peritoneum through vagina, 
316 
of pharynx, 290 666 
INDEX. 
Palpation of pulse, how performed, [ 
234 
of rectum described, 311 
of spleen, 334 
of stomach, 302 
of thorax, 100 
of veins, 260 
of vocal fremitus described, 156 
respiratory, how performed, 103 
use of, in heart-murmurs, 227 
Palpatory percussion of heart’s resist- 
ance, 205, 208 
Palpitation in organic disease of heart,i 
577 
nervous, causes stronger heart- 
beat, 201 
of heart in mitral defects, 240 
Pancreas, anatomical relation of, 299 
cancer of, a cause of jaundice, 47 
examination of, 340 
Pancreatic juice, deficiency of, 371 
Panizza, reference to, 177 
Papilloma of larynx described, 596 
Para-anaesthesia defined, 479 
Paradoxical contractions defined, 527 
Paraesthesia defined, and when occurs, 
482 
osmic, 574 
Paragraphia, 559 
an aphasic symptom, 561 
Parallelism between atrophy and 
paralysis, 493 
Paralyses, kinds of, in which there is 
EaR, 524 
Paralysis affecting the larynx, 75 
agitans, 530, 531 
and atrophy, parallelism be- 
tween, 493 
the writing often good, 561 
associated movements in cerebral, 
spinal, and peripheral, 535 
atonic, characteristic of, 494 
atrophic, 490 
atrophy of inactivity, a result of, 
490 
of muscles with, 491 
cerebral, EaR not present in, 525 
or spinal, above the anterior 
horn, characteristic sign of, | 
494 
contracture of muscles after, 495 
crossed, illustrated, 453 
degenerative atrophic, 492, 518 
determined by extent and location 
of lesion, 457 
extent of, 489 
Paralysis from pressure, partial EaR 
in, 525 
heart and vessels to be examined 
when there is, 577 
how produced, 456 
incontinentia alvi with, 370 
increased excitability in cerebral, 
spinal, and neuritic, 526 
intermitting, general, 525 
of arm, or one side of body, with 
albuminuria, 441 
of brachial plexus, cause of anaes- 
thesia of the region of median 
nerve, 487 
of crico-arytenoid muscles, dys- 
pnoea from, 75 
of diaphragm cause of inspiratory 
dyspnoea, 99 
cyanosis from, 43 
dislocation of heart in, 200 
of dilators of glottis, cause of in- 
spiratory dyspnoea, 99 
of extensors of the trunk, effect 
of, 539 
of extremities, cause of, 457 
illustrated, 453 
of facial nerve, effects of, 536 
tract, bone reflex present in, 
500 
of heart, pulse in, 240 
of intestine in peritonitis, 369 
of laryngeal muscles, dyspnoea 
from, 93 
of muscles concerned in cough, 
165 
of arm, 542 
of eye, significance of, 564 
of head and neck, 539 
of inspiration, effects of, on 
thorax, 91 
of mastication, tongue, soft 
palate, and pharynx, 537 
of shoulders, 541 
of speech, 548 
of the lower extremity, 545 
of pharyngeal muscles, effect of, 
538 
of phrenic nerve shown by pal- 
pation, 103 
of respiratory muscles, cyanosis 
from, 43 
dyspnoea from, 95 
of soft palate described, 537 
of various muscles of larynx, 
causes and results of, 598 
of voluntary muscle defined, 488 INDEX 
667 
Paralysis, peripheral, disturbance of 
sensation lags behind that 
of motion in, 485 
nails in, 583 
permanent, illustrated, 522 
phenomena, method of examina- 
tion, 488 
progressive, imbecility with delu- 
sions in, 472 
signs of, 23 
syncope in, 471 
radial, anaesthetic zone with, 479 
rheumatic facial, 491, 520 
section on, 488 
tremors of, distinguished from 
spasm, 531 
varieties of, determined by loca- 
tion of lesion, 456 
with partial EaR, illustrated, 522 
return of motility, illustrated, 
521 
Paralytic dementia, character of the 
writing of, 561 
thorax described, 84 
Paraphasia, 553, 559 
testing for, 556 
Paraplegia, inferior superior, 457, 
489 
Parasites, animal, 21 
in sputum, 182 
in urine, 424 
intestinal, nervous disturbances 
in children from, 578 
vegetable, 425 
in feces, significance of, 388 
Parasternal lines, defined, 76 
Paresis defined, 488 
of detrusor urinse, in tabes, 408 
of muscle of eye, 562 
of muscles of speech, 548 
of quadriceps muscle, 546 
symptoms of, 489 
with ataxia in cerebral disease, 
529 
with partial epilepsy, 533 
Parietal area of heart changed by dis- 
location of, 211 
boundaries of organs, 116 
lobes of brain, superior and infe- 
rior, blood-supply of, 
462 
upper and lower, illus- 
trated. 466 
organs defined, 113 
tumors of chest, feeling of resist- 
ance with, 116 
Parosmia in hysteria and insanity, 
574 
Parotid gland, inflammation of, 288 
Parturient patients, perspiration of, 
38 
Passive mobility of lungs, 125 
Patellar reflex, absence of, name for, 
499 
always present in health, 499 
synonyms defined, how tested, 
498 
Pathogenic fungi, found in urine, 
varieties of, 427 
section on, 389 
Pathological odor of urine, 414 
respiratory sounds, 144 
urine, section on, 406-450 
Pathognomonic sign of tricuspid in- 
sufficiency, 264 
Patient, position of, during percussion 
of thorax, 118 
Pectoralis reflex, 499 
Pectoriloquy, Laennec’s, described, 
159 
Pediculi, marks of, 51 
Pel, reference to, 180 
Peliosis rheumatica defined, 51 
Pelvis, muscles attached to, 545 
Pemphigus, 581 
Penzoldt, reference to, 143, 198, 306, 
354, 436, 445,450 
Penzoldt’s test for bile in urine, 442 
Pepsin, relation between, and muriatic 
acid in the stomach, 344, 345 
Peptone in sputum after crises in 
pneumonia, 190 
in urine, confounded with albu- 
min, 437 
when occurs, 439 
test for, 353 
Peptones, 343 
Peptonizing of milk in stomach, 344 
Peptonuria distinguished from albu- 
minuria, 435 
when occurs, 439 
Percussion, comparative, 118, 121 
for relative heart-dulness, 
207 
depth to which it reaches, 113 
difference between weak and 
strong, 107 
different results of strong and 
weak over spleen, 338 
effect of feeble, 114 
foundation of, 106 
general remarks upon, 103 668 
INDEX. 
Percussion, gentle and strong, illus- 
trated, 115 
hammer, 104, 105, 120 
used in plegaphonia, 159 
use of, 116 
in testing mechanical 
excitability of muscles 
and nerves, 526 
history and methods of, 104 
light, in pleuritic exudation, 127 
metallic sound with, 112 
note, difference by volume of tis- 
sue, 107 
variations of, in individuals, 
by age, region, and sex, 120 
of abdominal cavity, 316 
of heart, 204 
methods of, 205 
of intestine, 311 
of kidney, 394 
of liver, 326 
mode of, 328 
value of, 332 
of lungs, boundaries upon the 
back illustrated, 123 
in front illustrated, 122 
of oesophagus, 296 
of spleen, 336 
of thorax described, 118 
over thick covering, representa- 
tion of, 113 
results of, in aneurism of aorta, 
254 
rod-pleximeter described, 135 
strong, of supra-clavicular fossa, 
130 
when not to be used, 117 
value of, in locating deeply 
seated deposits, 116 
three methods of, 105 
topographical, defined, and uses 
of, 116 
value of, in tumors of kidney, 397 
Pericardial exudation, cause of weak- 
ening of heart sound, 219 
conceals apex-beat in dorsal 
position, 201, 202 
cyanosis from, 43, 44 
exudations, deadened sound over 
lung compressed by, 127 
friction sound, disappearance of, 
explained, 231, 232 233 
murmurs, 230 
changes in, in contrast with 
endocardial, 232 
sounds, felt, 204 
Pericardial splashing, metallic. 233 
Pericarditis adhesiva, a cause of sys- 
tolic drawing-in, 204 
diastolic collapse of cervical 
veins in, 267 
divided second sound in, 220 
pulse with, 243 
diagnostic importance of pulse in, 
253 
differential diagnosis from pleu- 
risy and peritonitis, 233 
downward displacement of liver 
in, 322 
escape of fluid into oesophagus, 
296 
externa, cause of diminished mo- 
tility of lungs, 137 
friction sounds with, 156 
exudativa, causes projection of 
chest-wall, 203 
decreased tension of lung 
near, 135 
effects on position of liver, 
331 
increased area of heart-dul- 
ness in, 209 
pulse in, 252 
tympanitic sound near, 130 
weak apex-beat in, 201 
friction sounds with, 231 
position of apex-beat in, 209 
pulse in, 253 
value of pulse in diagnosis of, 253 
of radial pulse in, 202 
venous engorgement from, 261 
Pericardium, diseases of, paleness of 
symptoms of, 40 
distention of, cause of expansion 
of chest, 86 
effusion into, 33 
fluid in, increases area of heart- 
dulness, 209 
tuberculosis of, friction sounds 
with, 232 
Perichondritis, 594 
laryngea, from deep ulcerations, 
596 
of trachea and bronchi, 172 
Perinephritic abscess, cause of pus in 
urine, 419 
Perinephritis, palpation of, 395 
purulent, diagnosis of, 395 
tenderness with, 395 
Perineuritis, condition of nerve in, 
468 
nerve sensitive to pressure in, 484 INDEX 
669 
Periosteal and fascial reflexes, 499 
reflex, 497 
Periostitis, neuralgia from, 483 
of ribs, pain with, 101 
Peripheral irritation, sensitiveness to, 
472 
mixed nerves, origin of, 455 
nerves, disease of, diminished 
tendon reflex in, 500 
EaR with lesion of, 524 
examination of, 468 
nutrition of, 456 
neuritis, ataxia with, 529 
sight, testing, 569 
Peripleuritis, cause of deadened sound, 
130 
effect of, on boundarv of liver, 
329 
Perisplenitis, cause of apparent en- 
largement of spleen, 335 
due to stenosis of intestine, 310 
Peristalsis, action of, in digestion, 343 
increased, character of stools with, 
372 
effect on character of stools, 
368 
of stomach, diminished, 348 
Peristaltic motions of stomach, in hy- 
pertrophy and dilatation, 302 
Peritoneal deposits, cause of apparent 
enlargement of spleen, 335 
effusion, a cause of cyanosis, 45 
alkaline urine with, 413 
exudation, diminished amount of 
urine with, 407 
fluid, encysted, 315 
friction sound, 233, 318 
sounds over spleen, 339 
Peritoneum, air in, a cause of dimin- 
ished area of liver dulness, 331 
bands in, found after tapping ab- 
domen, 318 
distention of abdomen in diseases 
of, 313 
examination of, 312 
fluid in, gives deadened sound, 
114 
pain in disease of, interfere with 
circulation, 44 
rapid breathing in diseases of, 94 
sarcoma and carcinoma of, 315 
tenderness of liver, if involved in 
carcinoma of liver, 324 
value of percussion over perito- 
neal cavity, 316 
vomiting in inflammation of, 358 
Peritonitis, acute, pain of severe, 314 
cause of cyanosis, 43 
caution against talking in, 159 
Cheyne-Stokes breathing with, 92 
chronic, diagnostic points of, 
315 
little or no pain with, 314 
diaphragmatic, interferes with 
action of diaphragm, 90 
simulates pleuritis, 161 
dislocation of heart with, 200 
effect on form of thorax, 86 
fecal vomiting in severe, 364 
general, cause of tympanitic sound 
with, 130 
grass-green bilious vomit in, 361 
indican in urine of, 409 
local, shown by palpation, 103 
meteorism with, 313 
obstipation an early sign of, 369 
pain and tenderness with, 308 
paralysis of diaphragm in, 90 
pulse in, 244, 253 
shrinking of omentum in simple, 
340 
staphylococcus pyogenes found in 
purulent, 603 
subphrenic, defined, 317 
friction sound with, 233 
tenderness of liver with, 324 
time when vomiting occurs in, 
359 
tuberculous, surface of liver in, 
325 
tympanites with, 309 
Perityphlitis, palpation of abdomen 
with, 310, 315 
Pernicious anaemia, 41 
case of, with heart complica- 
tions, 230 
microcytes and macrocytes 
in, 276 
poikilocytosis not pathogno- 
monic of, 277 
red corpuscles diminished 
and paler in, 275 
retinal changes in, 602 
size and form of red corpus- 
cles in, 276 
Peroneus nerve, electrical examina- 
tion of, 511 
• illustrated, 487 
-paralysis defined, 546 
Perspiration, 36. Also see Sweat, 
a cause of subnormal temperature, 
63 670 
INDEX. 
Perspiration alternates with amount 
of urine, 37 
contains bile in jaundice, 46 
insensible, 37 
greater at night, 37 
local, 581 
office of, 37 
relation of, to amount of urine, 
401 
sudamina after profuse, 50 
varieties of, 37 
Perverse sensibility to changes of 
temperature, 478 
Petechise, 49, 51 
Petrosal nerve, superficial, 461 
Pettenkofer’s test for bile in urine, 
442 
Petters, reference to, 414 
Pfliiger, reference to, 189, 505, 506 
Pharvngomycosis leptothricia, de- 
scription, of, 291 
Pharyngeal muscles, action of, and 
effect of paralysis of, 538 
syphilis, usually with ulceration 
of larynx, 595 
Pharynx, anaesthesia of, 577 
diseased condition of, 290 
examination of, 284 
expectoration from, in hysteria, 
171 
inflammation near, cause of cy- 
anosis, 43 
irritability of, how overcome, 590 
muscles of, 536 
reflex of, absence in hysteria and 
bulbar paralysis, 496 
sound from, confusing to begin- 
ners, 142 
Phase des grand mouvements, 534 
Phenyl-hydracin test for sugar, 444 
Phimosis, results of, 580 
Phlegmon of larynx, 594 
progressive, streptococcus pyo- 
genes in, 603 
Phlegmonous laryngitis, illustrated, 
594 
Phloroglucin-vanillin test for free mu- 
riatic acid, 350 
Phonation described, 157 
in paralysis of soft palate, 537 
position of vocal cords during, 
592 
Phosphate crystals in urine of cyst- 
itis, 419 
of lime illustrated, 430 
in urine, 402 
Phosphates, deposit of, in urine, 402 
in urine, diminished in rhachitis, 
435 
Phosphatic calculi, 433 
Phosphaturia defined, 431 
when occurs, 432 
Phosphoric acid, salt of, in urine, 431 
Phosphorus, acute poisoning by, leu- 
cin and tyrosin in urine of, 432 
lipuria in poisoning by, 447 
odor of garlic in vomit in poison- 
ing by, 366 
poisoning, a causeof jaundice, 47 
ecchymosis in, 51 
odor of breath in, 285 
peptonuria with, 439 
Phrenic nerve, paralysis of one, shown 
by palpation, 103 
Phthisical thorax described, 84 
ulcer of larynx, illustrated, 594 
Phthisis, absence of cough in, a bad 
sign, 165 
accommodation in, 96 
and form of thorax, 81 
asymmetry of breathing in, 91 
chronic, extension of area of 
heart-sounds in, 217 
cyanosis from severe cough of, 
166 
diminished apex of lungs in, 137 
dry cough in beginning of, 166 
friction sound with, 156 
fungi in cavities of, 175 
importance and value of the ex- 
amination of stomach digestion 
in, 356 
inspiratory pressure diminished 
in, 164 
lagging in, 103 
morning cough in, 165 
muco-purulent sputum in, 169 
neuralgia in, 483 
night-sweats of, 37 
orthopticea in, 32 
systolic subclavian murmurs with, 
' 259 
tenderness with, 101 
undefined breathing in beginning 
of, 149 
vital capacity of lungs in, 164 
vomiting in, 358 
Pick, E., reference to, 357 
Picric acid, color of urine after taking, 
411 
effects of, not to be con- 
founded with jaundice, 45 INDEX 
671 
Picric acid test for albumin, 436 
Pigeon-chest described, 88 
Pilocarpin, effect of, on pupil, 567 
Pio Foa, pneumonia diplococcus of, 
188 
Piorry, reference to, 104, 191 
Pitch, as affected by tension of walls, 
110 
change of, in pneumothorax with 
fluid, 136 
over lung cavity, 131 
differences of, 107 
of closed air containing cavities, 
how determined, 110 
of lung-sound depends on tension, 
112 
of open tympanitic sound, 111 
of vesicular breathing, 142 
Plantar nerve illustrated, 487 
Plasmodium malarige, 282 
Plegaphonia defined, 159 
Plethora distinguished from abnormal 
redness of skin, 41 
Pleura, diseases of, form of thorax in, 
81 
rapid breathing in, 94 
with effusion, 33 
exploratory puncture of, 160 
exudation in left, diminishes the 
half-moon-shaped space, 307 
inflamed, a cause of cough, 165 
serous exudations of, whispered 
voice with, 159 
shrinking of, cause of displace- 
ment of heart, 211 
thick, feeling of resistance with, 
116 
thickened, and pleural exudation, 
how distinguished, 129 
thickening of, deadened resonance 
with, 129 
diagnosis of, by puncture, 
160 
simulates enlarged heart, 209 
tumors of, distinguished from 
pleuritic exudate, 160 
one-sided expansion of chest 
in, 86 
weakened vocal fremitus 
with, 158 
Pleural cough, a dry cough, 166 
effusions, 80 
deadened sound over, 114 
endothelium in exudation, 161 
exudation, effect on boundary of 
liver, 329 
Pleural exudation, effect of, on circula- 
tion through lungs, 44 
encapsulated, 128 
measurement of thorax in, 
163 
exudations, a cause of diminished 
vesicular breathing, 145 
inflammations restricting the ac- 
tion of diaphragm, 90 
sacs, boundaries of, 80 
surface, growths on, conductors of 
vocal fremitus, 158 
Pleurisy, also see Pleuritis, asymmetry 
of breathing in, 91 
caused by caries of rib, 102 
differential diagnosis from peri- 
carditis and peritonitis, 233 
downward displacement of liver 
in, 322 
due to fracture of rib, 102 
effect on position of liver whether 
on right or left side, 331 
effects of, on the chest, 87 
encapsulated, defined, 129 
exploratory puncture in, 162 
exudative, complicating pneumo- 
nia, character of bronchial 
breathing with, 147 
non-tympanitic sound with, 
112 
first symptom of, 137 
lagging in, 103 
paleness a symptom of, 40 
position in bed in, 32 
shrinking after, diminishes area 
of spleen dulness, 339 
tubercular, 161 
with exudation, dyspnoea in, 95 
with oedema of chest wall, 54 
Pleuritic effusion, alkaline urine with, 
413 
exudation a cause of displacement 
of heart, 211 
conceals apex-beat, 201 
cyanosis from, 43 
deadened sound over lung 
compressed by, 127 
deadness and feeling of re- 
sistance with, 126 
diminished amount of urine 
with, 407 
displacement of liver by, 324 
expansion of chest with, 85 
pulse with, 245 
vocal fremitus increased 
above, 158 672 
INDEX. 
Pleuritic exudation, with compression 
of lungs, bronchial breathing 
from, 147 
exudations, segophony with, 159 
encapsulated, 86 
feeling of resistance with, 116 
with tumors of thorax, 129 
friction-sound, an extra-pericar- 
dial, 233 
sometimes heard when 
there is no inflamma- 
tion, 155 
-sounds described, 155 
not to be confounded with 
humming rales, 150 
where most distinctly 
heard, 155 
Pleuritis, also see Pleurisy, adhesive, 
vital capacity of lungs in, 164 
carcinomatous, 161 
diagnosis by exploratory punc- 
ture, 160 
diaphragmatica shown by palpa- 
tion, 103 
differential diagnosis from pneu- 
monia, puncture in, 160 
exudative, displacement of apex- 
beat in, 199 
effect on liver-dulness, 330 
fixation of heart in, 200 
inspiratory pressure dimin- 
ished in, 164 
tympanitic sound with, 111 
weak bronchial breathing 
with, 147 
pulse in, 253 
purulent, 102 
rupture of fluid into oesophagus, 
296 
septic, 161 
sicca, 155 
friction-sound with, 156 
tenderness due to, 101 
with emphysema, friction-sounds 
with, 156 
Pleximeter defined, 104 
double, of Seitz, 105 
finger used as, in percussing in- 
testine, 312 
hand as, how to be held, 119 
-rod, described, 135 
use in diagnosing venous pulse, 
266 
used in plegaphonia, 159 
Pneumatometer, Waldenburg’s, 164 
Pneumatometry described, 164 
Pneumonia, absence of cough a bad 
sign, 165 
acute and chronic, alveolar epi- 
thelium in sputum of, 177 
and pleurisy, differential diag- 
nosis when in left chest, 307 
asymmetry of breathing in, 91 
bloody sputum of, 169 
bronchial breathing in, 146 
caused by dust, 21 
chlorides in urine in, 434 
coccus of, 188 
staining of, 188 
course of temperature in, 67 
critical sweat of, 37 
croupous, bloody sputum in, 170 
crepitant rales in, 154 
deadened resonance with, 126 
fever in, 65 
fibrinous tubes in sputum of, 
172 
loud bronchial breathing 
with, 147 
tenderness with, 101 
tough expectoration with, 166 
tympanitic sound in stage of 
engorgement and 
resolution, 130 
with, 111 
Curschmann’s spirals sometimes 
in sputum of, 180 
decided increase of urea after 
crisis of, 434 
deglutition, 600 
differential diagnosis from pleu- 
risy, puncture in, 160 
dyspnoea in, 95 
effect on boundary of liver, 329 
extension of area of heart-sounds 
in, 217 
fibrinous tubes in sputum of 
croupous, 172 
friction-sounds with, 155 
hsemato-jaundice in, 47 
herpes facialis with, 50 
increase of urea in, 433 
increased vocal fremitus with, 158 
lobar, extent of deadening corre- 
sponds with lobe of lung in, 126 
lobular, thickening and deaden- 
ing with, 127 
lagging in, 103 
massive, deadness and feeling of 
resistance with, 116,126 
non-tympanitic sound from sur- 
rounding tissues, 112 INDEX 
673 
Pneumonia of left lower lobe, dimin- 
ished half-moon- 
shaped space, 307 
extension of dead- 
ness in, 127 
peptone in sputum of, after crisis, 
190 
peptonuria with, 439 
position in bed in, 32 
pulse in, 239 
rapid breathing with, 94 
reactive friction sounds with, 156 
recurrence of, 22 
ringing rales with, 151 
sometimes non-ringing rales with, 
153 
spirals in sputum of, 173, 175 
undefined breathing in, 149 
unilateral elevation of tempera- 
ture in, 71 
ushered in by epileptiform spasm, 
533 
vomit in, 358 
with jaundice, bile-pigment in 
sputum of, 172 
Pneumonic deposits, catarrhal, tym- 
panitic sound over, 130 
noise of spun-top over, 135 
thickening, weak percussion over, 
115 
Pneumono-koniosis [disease from in- 
halation of dust], 155 
Pneumo-pericardium, closed tympa- 
nitic sound heard over, 
111 
diminished area of heart-dul- 
ness with, 210 
metallic heart-sounds in, 221 
sounds over, 112 
Pneumo-thoracic cavity, rod-plexi- 
meter percussion over, 136 
Pneumothorax, circumscribed, 86 
complicated by effusion in pleu- 
ral cavity, 129 
cyanosis from, 43 
diminished vocal fremitus with, 
explained, 158 
displacement of the apex-beat in, 
199 
downward displacement of liver 
with, 322, 331 
dyspnoea in, 95 
effect of, on relative liver-dulness, 
332 
effect on position of liver, whether 
on right or left side, 331 
Pneumothorax, effect of, on upper 
boundary of liver, 330 
expansion of chest in, 85 
hydro-, diagnosis by exploratory 
puncture, 160 
lung-sound over, 113 
metallic heart-sounds in, 221 
rales with, 153 
sounds over, 112, 135 
non tympanitic sound with, 135 
of right side displaces mediasti- 
num, 137 
one-sided expansion of lung with, 
136 
open and closed amphoric breath- 
ing with, 148 
bronchial breathing over, 147 
tympanitic sound with, 111, 
135 
water-whistling sound with, 
153 
plegaphonia over, 159 
position in bed in, 32 
pulse with, 245 
sero- and pyo-, succussion with, 
156 
tympanitic sound with, 134 
with fluid, change of pitch in, 136 
with open fistula, noise of spun-top 
over, 134 
Poikilocytes defined, 277 
Poikilocythaemia, 274 
Poikilocytosis defined, 277 
in leukaemia, 279 
not pathognomonic of pernicious 
anmmia, 277 
Poikilo-microcythsemia, 275 
Points douloureux, 484 
Points of electrical irritation upon the 
upper part of the thigh illus- 
trated, 511 
Poisoning a cause of collapse, 40 
acute, disturbance of conscious- 
ness in, 470 
albuminuria in acute, 435 
animal, petechise, in, 50 
by atropine, red skin in, 41 
by carbonic acid gas, absence of 
cough in, 165 
weakn ess of heart-sounds 
in, 218 
oxide, absorption-bands in 
blood in, 272 
by copper, 286 
by inhalation, 21 
by lead, 286 674 
INDEX 
Poisoning, by mercury and lead, cause 
of paleness, 41 
cocci in mouth in, 289 
condition of teeth in, 286 
by nicotine, effect on heart, 201 
by opium or morphine, Cheyne- 
Stokes breathing in, 92 
color of skin in cases of, by va- 
rious substances, 271 
condition of mucous membrane 
of mouth from, 288 
lead, double sound heard over 
crural artery in, 259 
odor of breath in, value of, 285 
with carbonic acid, effect on color 
of blood, 270 
Poisons causing hsemato jaundice, 47 
corrosive, hemorrhage of stomach 
from action of, 362 
effect of, upon the pupil, 567 
exanthemata from, 50 
Polarizing method for quantitative 
determination of albumin, 438 
Poles of battery, how to distinguish 
quickly, 504 
Polioencephalitis, choreic motions in 
paralyzed limbs, 535 
Poliomyelitis, 491, 493, 580 
acuta, chronica, EaR with, 524 
ushered in by epileptiform 
spasm, 533 
anterior, chronic, 520 
arrest of growth of bone in, 583 
diminished tendon reflex in, 500 
Pollution from phimosis, 580 
Polysesthesia defined, 478 
Polydipsia, polyuria with, 406 
to make up loss of water, 407 
Polyuria (diabetes insipidus), 579 
in hysteria, 579 
when occurs, 406 
Pons, 454 
anaemic necrosis of, cause of, 
462 
ataxia in lesions of, 529 
blood supply of, 462 
effect of lesion of, 457 
lesion in, effect of, 456 
motor cranial nerves separate in, 
455 
Portal engorgement, hemorrhage of 
stomach in, 362 
vein, enlargement of spleen in 
occlusion of, 335 
obstruction of, a cause of 
ascites, 314 
| Portal vein, scars of, effect on consist- 
ence of liver, 326 
Position, dorsal, atalectatic crepitation 
in, 154 
effect of change of, on pericardial 
friction sounds, 232 
of body, effect on pulse in, 235 
in examining kidney, 395 
of patient, 31 
during inspection, 81 
percussion of thorax, 118 
effect on heart-sounds, 220 
upon area of dulness in 
hydropericardium, 209 
in auscultation of heart, 211 
in examining heart, 206 
variations of lung border with 
change of, 125 
Positive venous pulse, systolic, 264 
tracing of, 265 
Posner, reference to, 405 
Posterior cranial fossa, effect of lesion 
of, 457 
cutaneous nerve illustrated, 487 
roots of spinal nerves, 455 
Posture, change of, effect of, on apex- 
beat, 198 
effect of, on area of dulness in 
exudation, 128 
in examining spleen, 336 
Potassium, iodide of, urine after 
taking, 450 
use of, in testing rapidity of 
passage of food from the 
stomach, 354 
Poupart’s ligament, 297 
Predisposing causes, effects of, on 
chronic diseases, 21 
of disease, 21 
Pregnancy, double sound heard ever 
crural artery in, 259 
scars of, 52 
Pressure, intra-abdominal, upon liver, 
319 
intra-cranial, polyuria and gly- 
cosuria with, 579 
on head and vertebra, pain from, 
484 
partial EaR in paralysis from, 525 
sensation of, 474 
sensibility of cranium to, 466 
-sound over large arteries, 258 
-tone over large arteries, 258 
Presystolic murmur, 228, 251 
murmurs, explained, 226 
normal venous pulse in, 263 INDEX 
675 
Previous history, what it comprises, 20 
Primary myopathic atrophy, a disease 
of muscle, 493 
Prior, reference to, 390, 607 
Profession, a cause of disease, 21 
Progressive muscular atrophy, 491, 
493 
cyanosis in, 44 
spinal, EaR with, 524 . 
partial EaR in, 525 
nuclear paralysis, 566 
paralysis, contracted pupil with, 
566 
diminution of temperature 
with, 575 
fever with, 575 
mai perforant, 582 
mydriasis in, 566 
reflex rigidity of pupil not fre- 
quent in, 567 
Propeptone, rare in urine, 439 
test for, 353 
Prussic acid poisoning, odor of breath 
in, 285 
Pseudo-bulbar paralysis, 548 
-crisis of fever, 67 
-hypertrophy, 493 
of muscles, 490 
how recognized, 494 
-leukaemia, 41 
Psoas abscess, pain in inguinal region 
from, 309 
Psychical condition of patient, 31 
disturbances, 585 
of respiration, 83 
Psycho-motor tract, 452 
Psychoses, acetonuria in, 448 
catalepsy with certain, 536 
increased secretion of saliva in, 
577 
Ptomaines, connection between, and 
cystin, 432 
Ptosis, 563 
Ptyalism, 288 
Puerile breathing described, 142 
Puerperal fever, peptonuria with, 439 
patients, lactose in urine of, 447 
period, a cause of disease, 22 
pyaemia, retinal hemorrhage in, 
602 
streptococcus pyogenes in, 
603 
Pulmonary artery, aneurism of, 255 
heart-sounds, both strengthened 
from shrinking of lungs, 218 
hemorrhage described, 170 
Pulmonary insufficiency, 194, 195 
phthisis. See Tuberculosis 
semilunar murmur, where heard, 
224 
stenosis, 194 
murmur of, where heard, 225 
weakening of pulmonary 
second sound in, 219 
Pulsating affections, difficult to dis- 
tinguish from apparent enlarge- 
ment of heart, 210 
splenic tumor, with aortic insuf- 
ficiency, 335 
Pulsation, epigastric, 302 
near heart in empyema, 204 
Pulsations at base of heart, 203 
Pulse, absence of, 243 
affected by external temperature, 
235 
by position of body, 235 
a measure of the work of left ven- 
tricle, 218 
arterial, at the spleen, rare, 257 
auscultation of, 257 
bulbar, jugular sound with, in 
tricuspid insufficiency, 268 
capillary, 256 
diagnostic value of, 251 
dicrotic, tracing of, 247 
different forms of, 242 
double murmur with large and 
quick, 259 
effect of sleep upon, 235 
of meals upon, 235 
equal, 236 
felt later than heart systole, 204 
filiform trembling, 243 
frequent, when occurs, 238 
hard, not to be confounded with 
arterial sclerosis, 244 
importance of, in pericarditis, 209 
increased frequency of, in fever, 
60 
in crises, 63 
in pyaemia, 69 
intermittent, 236 
irregularity of volume of, 241 
its value in febrile diseases, 253 
method of observing, 235 
negative venous, 267 
of no value in distinguishing sys- 
tolic and diastolic murmurs, 226 
pathological frequency of, 237 
phenomena of, in neuroses, 577 
quality of, 236, 241 
quickening of, in vomiting, 359 676 
INDEX. 
Pulse, radial examination of, 234 
felt between the time of first 
and second sounds of heart, 
212 
in aneurism of aorta, 254 
value of, in pericarditis, 202 
in showing work of heart, 
202 
relation of, to temperature not 
constant, 61 
rhythm of, 236 
size of, not shown by sphygmo- 
graph, 250 
slow, in jaundice, 47 
then faster, with albuminuria, 
441 
when occurs, 237 
sphygmographic tracing of, ex- 
plained, 246 
symmetry of radial, 245 
tracing of, with temperature, 236 
unequal in symmetrical vessels, 
significance of, 257 
value of, in showing beginning 
complications, 253 
variation of its frequency with 
age, 234 
variations of, affected by sex, 
235 
venous, described, 263 
differential diagnosis of, 266 
want of rhythm of, 241 
wire, 244 
Pulsus alternans, 202, 243 
bigeminus, 241, 243, 252 
tracing of, 250 
celer, 253 
tracing of, 248 
deficiens, 241 
dicrotus, 243, 244 
durus, 244 
incidens, 252 
inequalis, tracing of, 250 
intercidens, 243, 244 
intermittens, 241 
magnus, 244 
mollis, 244 
paradoxus, 243, 263 
tardus, 244 
tracing of, 249, 250 
vacuus, 244 
Pulvinar of optic thalamus, effect of 
lesion of, on vision, 460 
Puncture, explorative, use of, 130 
exploratory, of heart, 234 
of liver, 326 
Puncture, variations of pressure dur- 
ing, in subphrenic and pleural 
cavities, 317 
Pupillary reflex, 496 
Pupils always dilated in dyspnoea, 99 
as affected by poisons, 567 
changes of, 566 
contraction of, 568 
during accommodation, diag- 
nostic significance of, 568 
dilatation and contraction of, with 
migraine, 483, 563, 566 
hemianopsic rigidity of, 571 
inequality of, and conditions in 
which it occurs, 567 
reaction of, in hysterical spasms, 
534 
reflex changes in size of, 567 
rigidity of, 567, 587 
size of, affected by degree of illu- 
mination, 566 
Purpura hemorrhagica, 51 
Purulent exudation, examination of, 
161 
in sputum, 167 
sputum described, 169 
odor of, 171 
peptone in, 190 
white blood-corpuscles in, 176 
stools, when occur, 376 
Pus in urine gives a small amount of 
albumin, 435 
makes it turbid, 412 
when occurs, 419 
vomiting of, 364 
Pustule, malignant, 21 
Pyaemia, cutaneous hemorrhage in, 51 
enlargement of spleen in, 335 
haemato-jaundice in, 47 
herpes with, 50 
intermittent fever in, 69 
pulse in, 239 
rash resembling scarlet fever in, 
50 
retinal hemorrhages in, 602 
staphylococcus pyogenes in, 603 
streptococcus pyogenes in, 603 
sweat in, 37 
Pyelitis calculosa, 398, 433 
stoppage of one ureter by, 400 
Pyelonephritis, hyaline casts, peculiar 
form with, 423 
Pyloric stenosis, 348 
a cause of diminished volume 
of abdomen, 309 
* diagnosis of, 303 INDEX 
677 
Pyloric stenosis, effects of, 345, 346 
obstipation with, 369 
Pylorus, demonstration that it does 
not close, 302 
in distention of stomach, 301 
position of, 298, 299 
scars and hypertrophy of, 303 
separation of fluid and solids at, 
343 
Pyonephrosis, lipuria in, 447 
palpation of, 395 
Pyo-pneumocardium, metallic splash- 
ing with, 233 
Pyramidal tract, 452, 454, 455, 456, 
492, 500 
above the oblongata, affec- 
tion of, 548 
injury of, 457 
in the spinal cord, EaR not 
present in lesion of, 525 
lateral, how found, 455 
lessened excitability in, with- 
out EaR, 525 
part in skin reflex, 496 
spasms from irritation of, 530 
tonic spasms in lesion of, 532 
Pyrosis hydrochlorica, 357 
Pyuria, due to strangulus gigas, 425 
Qualitative excitability of 
nerves and muscles, 516, 518 
Quality of contractions, depends upon 
the relation of the nerve to the 
skin, 504 
of pulse, 236 
of sound, terms for, 108 
Quantity of expectoration, 168 
Quineke, reference to, 161, 267, 271, 
277, 575 
Quinsy (abscess of tonsil), 290 
RACHITIS, diminution of phos- 
phates in urine in, 435 
Radial artery, abnormal course of, 242 
nerve, electrical examination of, 
511 
faradic examination of, 512 
illustrated, 486 
muscles supplied by, exami- 
nation of, 515 
paralysis of, from compres- 
sion, 487 
in axilla, 488 
Radial nerve, small cutaneous fila- 
ments to dorsum of fore- 
arm, 485 
pulse, asymmetry of, 245 
diagnostic value of, 251 
simultaneous on two sides, 
236 
sphygmographic tracing of, 
explained, 246 
Railroad neuroses, narrowing of field 
of vision in, 569 
Rales acquire a metallic tone, 148 
bubbling, 154 
crepitant, defined, 154 
sign of capillary bronchitis, 
152 
dry, explained, 149 
elasticity of thorax in children 
cause ringing, 153 
humming, hissing, whistling, so- 
norous, sibilant, 149 
loudness of, explained, 152 
metallic, 150 
moist, explained and when occur, 
151 
not to be confounded with 
friction sounds, 155 
palpation of, 100 
removed by coughing, 149 
ringing, in thickening of lungs, 
152 
sounds are rarely to be felt, 155 
the substances which cause, 165 
toneless, 146 
various sizes, 152 
Reaction of degeneration (EaR), 490, 
491, 492, 493, 518 
complete and partial, 519 
course of, 520 
diagrammatic representation 
of, 520 
diseases which are excluded 
when it is present, 525 
distinct symptoms of, 587 
mixed, 525 
partial, 525 
significance of its absence, 
525 
varieties of, 523 
when occurs, 524 
wanting, 525 
variations of, 403 
of expectoration, 168 
of urine, generally acid, 403 
quality of, with galvanic current, 
505 678 
INDEX. 
Reaumur, thermometric scale, 57 
Records of cases, keeping of, 24 
Recti muscles, intestinal peristal- 
sis seen when they are separated, 
310 
Rectum, odor of stool in ulceration of, 
372 
pain at stool, in various diseases 
of, 370 
palpation of, 311 
tumors of, examination for, 311 
Rectus abdominis muscle, dulness 
over, 328 
Recurrent fever, defined, 70 
enlargement of fever in, 324 
microorganism of, found in 
blood, 281 
nerve, compression of, 296 
effects of paralysis of, 538 
paralysis of, from pressure, 
599 
pressure upon, 255 
paralysis, results of, 598 
what a symptom of, 600 
spirals, 281 
Red blood-corpuscles, alterations in 
size and form of, 276 
changes in the number 
and character of, 273 
decomposition of a cause 
of jaundice, 46 
increase of chloride of 
sodium in urine from 
destruction of 434 
in sputum, 176 
nucleated, 279 
number of in a cubic 
millimetre of blood, 
275 
seldom found in vomit, 
365 
size of, 276 
variation in number of, 
271 
Redness, local, when physiological, 
42 
Reflector, Turck’s, for examining the 
larynx, 589 
Reflex, abdominal, increase of, in in- 
tercostal neuralgia, 496 
unilateral absence of, 587 
arc, constituents of, 500 
biceps, 499 
-tendon, 498 
bone, absence of, in bulbar paral- 
ysis, 500 
Reflex bone present in paralysis of 
facial tract, 500 
changes in size of pupils, 567 
choking, absence of, in bulbar 
paralysis, 496 
cough 165 
cremaster, defined, 495, 496 
fascial, 497, 499 
increased, 496 
manifestations of muscles, 488 
may be absent, 496 
patellar, increased tonus of quad- 
riceps disturbs the, 498 
name for absence of, 499 
synonyms, defined, how 
tested, 498 
tendon, always present in 
health, 499 
pectoralis, 499 
periosteal, 497 
pharyngeal, absence of, in hys- 
teria, 497 
and bulbar paral- 
ysis, 496 
pupillary, 496 
rigidity of pupils, 567, 587 
skin, defined, how tested, 495 
increased by excitability of 
anterior horn, 496 
mechanism of, 496 
sole of foot, 495 
spinal centres, 455 
suppression of urine, 408 
from echinococcus, 425 
tendo-Achillis, and foot-phenom- 
enon defined, how tested, sig- 
nificance of, 499 
tendon, 493 
an attendant phenomenon of 
spasm, 494 
diminished in spinal progres- 
sive muscular atrophy, 
500 
in tabes dorsalis (very 
important), 500 
illustration of mechanism of 
explained, 500 
increase and diminution of, 
goes parallel with 
tonus, 500 
of, in cerebral paralysis, 
500 
in primary degeneration, 
500 
in secondary degenera- 
tion, 500 INDEX 
679 
Reflex tendon, increase of, in spastic 
spinal paralysis, 500 
in spinal paralysis from 
disease of pyramidal 
tract, 500 
increased in hysteria, 500 
in strychnia poisoning, 
500 
in tetanus, 500 
in the phenomenon of 
paradoxical contrac- 
tions, 527 
mixture of, and direct mus- 
cular irritation, 501 
of upper extremities, 499 
when diminished or lost, 500 
when increased, 500 
Reflexes, bone, 500 
cutaneous and tendon, diagram 
of, 497 
predominant ones in arm and leg, 
500 
seat of skin and tendon, 528 
skin, not so important an aid in 
diagnosis as tendon reflexes, 498 
tendon, aid in diagnosis, 498 
and skin, seat of, 528 
importance of, 497 
section on, 495, 497 
Regional difference of thoracic sounds, 
125 
Relapsing fever, critical sweat in, 37 
hectic with, 69 
leucocytosis in, 278 
Relative deadness of sound, 108 
heart-, liver-, spleen-deadness,327 
liver dulness, 327 
variation in location of, 332 
Relaxed lung tissue, tympanitic sound 
with, 112, 130 
Remission of temperature, 62 
Remittent fever, 62, 65, 70 
in other febrile diseases, 68 
range of temperature of, 62 
vomiting, an early symptom 
of, 358 
Remittent typhus fever, hectic with, 69 
Renal calculi, 398 
accompanied by chill and 
fever, 64 
colic, vomiting in, 358 
engorgement, haematuria in, 418 
epithelium in urine, forms of, and 
diagnostic value of, 421 
sand, 433 
Rennet ferment, 343 
Rennet-zymogen test for, 353 
Residence, place of, cause of disease, 
21 
Residual urine, causes of, 408 
not normal, 408 
Resistance, electrical, as affected by 
the angle of entrance of the 
current, 504 
inversely proportional to cross 
section of electrode, 502 
of skin, important point re- 
garding its increase, 503 
feeling of, 109 
over hepatized lung, 126 
power of, 33 
sensation of, described, 116 
Resonance, deadened, when devel- 
oped, 126 
Resorcin, test for muriatic acid in 
stomach, 351 
urine after taking, 451 
Respiration. Also see Breathing, 
anomalies of, 89 
change of sound in, 113 
effect of, on apex-beat, 198 
forced, 97 
in dyspnoea, 96 
how palpated, 103 
increased, a cause of dyspnoea, 93 
frequency of, in fever, 60, 94 
in crisis, 63 
in relation to form of thorax, 81 
interference with during an at- 
tack of epilepsy, 533 
irregular, 83 
larynx during quiet, 592 
motions of, 81 
normal, 81 
described, 82, 141 
quiet, heart dulness in, 206 
relation of, to amount of urine, 401 
sighing, 92 
symmetrical, 83 
tumors of kidney do not move 
with, 395 
types of, 83 
Respirations, number of, 82 
Respiratory apparatus, disturbances 
of, in nervous diseases, 575 
centre, 457 
disturbance of, in Cheyne- 
Stokes breathing, 93 
irritation of, in fever, 94 
displacement of stomach, 303 
motions, effect upon circulation 
in jugular veins, 262 680 
INDEX. 
Respiratory movements of thorax, pal- 
pation of, 100 
palpation of, 102 
muscles, dyspnoea from paralysis 
of, 576 
organs, cough as a sign of disease 
of, 165 
disease of, perspiration in, 37 
sound, metallic, 136 
sounds, pathological, 144 
Restlessness from uraemia, 440 
Retentio alvi, 370 
from paralysis of abdominal 
muscles, 578 
Retention of urine, 400, 408, 579 
Retina, electrical reaction of, 571 
embolus of the central artery of, 
562 
Retinal apoplexy, a forerunner of cere- 
bral hemorrhage, 601 
arteries, pulsation of, when occur, 
602 
artery, emboli of the central, a 
forerunner of cerebral embolism, 
601 
Retinitis in syphilis of the brain, 562 
syphilitica, 601 
Retraction of apex of lung in tuber- 
culosis of, 127 
of lung, increases area of heart 
dulness, 209 
of lungs, measurement of thorax 
in, 163 
tympanitic sound with, 112 
Retro-peritoneal glands, enlargement 
of, 340 
confounded with aortic 
aneurism, 341 
-pharyngeal abscess, 290 
a cause of cyanosis, 43 
Reynolds, reference to, 448 
Rhachitis, 464 
forms of, 88 
how distinguished from hydro- 
cephalus, 464 
Rheumatic facial paralysis, 491 
disturbance of hearing 
with, 572 
partial EaR with, 525 
paralysis, EaR with, 524 
Rheumatism, articular, recurrence of, 
22 
chronic articular, phosphaturia 
in, 432 
pain in spine with, 483 
inherited, 20 
Rheumatism, intercostal neuralgia not 
to be confounded with, 484 
occasionally slow pulse in, 237 
of chest-muscles, pain in, 101 
of thoracic muscles, rapid breath- 
ing in, 94 
peptonuria with acute, 439 
perspiration of, 38 
sequelae of, 22 
simulation of, 19 
Rhonchi, metallic sound with, 136 
sibilant, 149 
sonorous, 151,153 
Rhubarb, color of urine after taking, 
411, 450 
Rhythm of breathing, anomalies of, 91 
of heart-sounds described, 212, 
213, 220 
of pulse, 236 
tracing of, 250 
Ribs, character of in phthisical thorax, 
84 
deformity of, 82 
form of, 81, 82 
fracture of, diagnosis of, 102 
how counted, 77 
in emphysematous thorax, 83 
markedly bowed, deadened sound 
over, 114 
pain in disease of, 101 
rapid breathing in fracture of, 94 
sharply bowed, causes deadening 
of sound over, 126 
Rice-water stools defined, 374 
vomit, in Asiatic cholera, de- 
scribed, 361 
Richardson, reference to, 246 
Riegel, reference to, 153,173,182, 246, 
250, 264, 265 
Riess, reference to, 208 
Rigidity of paralysed muscles, 494 
Rigors, in abscess of liver, 328 
Risus sardonicus, tonic spasm of face, 
532 
Rod-pleximeter percussion, 317 
described, 135 
metallic sound with, 112 
use of, 306 
Rolando, fissure of, illustrated, 466 
Romberg’s symptom, 480 
Rosenbach’s test for bile in urine, 
442 
Roseola, 49 
Round worms, described and symp- 
toms of, 380 
in vomit, 364 INDEX 
681 
S abbreviation for Schliesung, closure 
j of current, 506 
Saccharomyces in diabetic urine, 428 
Sahli, reference to, 230, 269 
Salicylic acid, urine after taking, 450 
Saliva, acidity of stomach, stimulates 
secretion of, 346 
coloring matter of bile in, 46 
diminished in facial paralysis, 
578 
increased secretion of, when oc- 
curs, 577 
nerve presiding over secretion of, 
484 
various conditions of, 287 
when diminished, 289 
Salivary glands, examination of, 288 
Salivation, description of, 288 
Salkowski, reference to, 172, 181, 434, 
445 
Salol, broken up in the intestine, made 
use of to determine rapidity of 
passage of food from stomach, 
354 
urine after taking, 451 
Salzer, reference to, 125 
Sanger, reference to, 398 
Santonin, color of urine after taking, 
411 
effects of, not to be confounded 
with jaundice, 45 
Santorini, cartilage of, 591, 592 
Sarcina in urine of alkaline fermenta- 
tion, 428 
pulmonalis, in sputum, 184 
ventriculi described, 366 
in vomit, 365 
Sarcoma of kidney, palpation of, 395 
of larynx, 597 
of lung, deadened sound over, 
127 
of peritoneum, 315 
of skull-wall, 465 
Satyriasis, 472 
Scale of Fleischl’s hsemometer, 272 
Scanning speech, 548 
Scapula, paralysis of the muscles at- 
tached to, 541 
percussion note over, 120 
position of, 82 
Scapular line, 77 
Scarlet fever, 49 
ecchymosis in, 51 
enlargement of spleen in, 334 
epileptiform convulsions in 
the beginning of, 533 
Scarlet fever, glycosuria in, 443 
haemoglobin in urine, 411 
mulberry tongue in, 287 
recurrence of, 22 
red skin of, 41 
sequelae of, 22 
slow pulse in nephritis of, 237 
value of pulse in showing 
complications of, 253 
vomiting in, 358 
Scars, 52 
in larynx, causes of, 596 
on tongue due to syphilis, 288 
Scherwald, reference to, 159, 434 
Schizomycetes in mouth, 289 
in vomit, 365 
pathogenic, section on, 389 
the only microorganism found in 
blood, 280 
Schleroderma, on thorax, effects of, 
91 
Schreiber, reference to, 346, 357 
Schulte, reference to, 524, 525, 582 
Scintillations with migraine, 483 
Sclerosis, multiple, allochiria in, 478 
vertigo in, 472 
of arteries, cause of hypertrophy 
of heart, 196 
Scoliosis, 467 
described, 88 
from paralysis of erector trunci, 
539 
Scorbutus, cocci in mouth in, 289 
condition of teeth in, 286 
cutaneous hemorrhages in, 51 
haematuria in, 417 
peptonuria with, 439 
Scotoma, central, in alcohol and to- 
bacco amblyopia, 569 
Scrofula, caries of petrous bone in, 572 
chronic catarrh a sign of, 74 
nutrition poor in, 575 
Scrofulosis indication of tuberculosis, 
22 
scars of, 52 
Scybala, diagnosis of, 310 
Sebacic acid, odor of, in vomit, 366 
of stool in infantile diar- 
rhoea, 371 
Secretion of gastric juice, threefold 
importance of knowledge of, 342 
Sediment, kinds of, in urine, and sig- 
nificance of, 402 
Sediments in urine, in inflammation 
of urinary tract, 419 
urinary, of organic bodies, 416 682 
INDEX. 
Seelegmiiller, reference to, 485, 496 
Seitz, reference to, 105 
Self-consciousness during attack of 
spasm, 530 
Semen, involuntary discharge of, in 
attacks of epilepsy, 534 
Semilunar valves cause diastolic sound, 
213 
Senator, reference to, 177, 405 
Senile dementia, mixed aphasia and 
amnesia in, 555 
Senna, color of urine after taking, 411, 
450 
Sensation of movements defined, 474 
Sense of heat and cold, how tested, 475 
of pressure, 474 
of space defined, how tested, 474 
of touch, how tested, 473 
Senses, organs of, 561 
special, centres and tracts of, 460 
Sensibility, deep, 459, 473 
part in coordination, 528 
part taken by, in recognizing 
the form of bodies, 481 
section on, 479 
disturbances of, section on, 472 
local manifestations of disturbed, 
478 
of skin, 473 
use of, in recognizing form of 
bodies, 481 
superficial, part of, in coordina- 
tion, 528 
to changes of temperature pre- 
vented, 478 
to pain, how tested, 576 
increase of, 478 
tract of, 459 
Sensitiveness of vertebral column to 
pressure, 467 
Sensory aphasia, 552 
condition of the hearing must 
be determined in, 573 
cutaneous nerves, distribution of, 
484 
tract, blood-supply of. 462 
section on, 459 
Sepsis, enlargement of spleen in, 335 
rash resembling scarlet fever in, 
50 
retinal hemorrhage in, 562 
Septic hemorrhage of kidney, hsema- 
turia with, 417 
Sequelae, 22 
Serous sputum, a peculiarity of oedema 
of the lungs, 169 
Serous sputum described, 169 
Sex, variations of pulse from, 235 
Sexual diseases concealed, 19 
Seyler, reference to, 190 
Shaking spasm, 531 
Shoemaker’s breast, cause of, 89 
Shoulder, nerves of, 485 
Shrinking of one side, 86 
Sibilant rales, 149 
Sibson’s furrow defined, 76 
Sieveking’s sesthesiometer, use of, 474 
Sighing respiration, 92 
Sight, place of, in faculty of writing, 
550 
tract of, 460 
Silver, nitrate of, deposit of, 49 
Simon, reference to, 398 
Simulation of disease, 19 
Singultus, defined, 540 
Sinus of peritoneal cavity, position of, 
299 
phrenico-costalis, 80 
Situs inversus viscerum, 193 
with reference to position 
of liver, 331 
Size of body, relation to lung capacitv, 
164 
of communicating opening, effect 
upon pitch of sound, 109 
Skeleton, deformity of, effect on chest, 
88 
Skin, appearance of, over the abdo- 
men when latter is distended, 
313 
bronze, 48 
color of, 38 
as affected by state of blood, 
271 
characteristic in some dis- 
eases, 41 
cutaneous hemorrhages in jaun- 
dice, 57 
deep disturbance of nutrition of, 
in diabetes mellitus, 579 
diagnostic value of its appearance, 
49 
disturbance of, section on nervous 
relation of, 581 
effect of thickness of, on conduc- 
tive resistance of, 512 
emphysema of, 55 
weakens apex-beat, 201 
examination of, 39 
glassy, 581 
hemorrhages of, 51 
in cases of poisoning, 271 INDEX. 
683 
Skin inspection of, with reference to 
condition of blood, 270 
nutrition of, 36 
oedema of, in perinephritis, 395 
cedematous, in empyema, 86 
of face, dropsy of kidney disease 
first in, 440 
pale, 39 
redness of, 41 
reflex, defined, how tested, 495 
increased by excitability of 
anterior horn, 496 
mechanism of, 496 
seat of, 528 
reflexes, not so important aid in 
diagnosis as tendon reflexes, 
498 
sensibility in, part in coordina- 
tion, 459, 527 
use of, in recognizing the form 
of bodies, 481 
state of, during a chill, 62 
various conditions of, 36 
Skoda, fundamental sentences from, 
109 
reference to, 104,138,152,191,199 
Skull, asymmetry of, form of, 455 
examination of, 463 
Sleep, effect of, on pulse, 235 
paralysis, 543 
Smallpox, 49. Also see Variola, 
cutaneous hemorrhage in, 51 
enlargement of spleen in, 335 
infectious in utero, 20 
larynx in, 75 
leucin and tyrosin in urine of, 432 
scars of, 52 
vomiting in, 358 
Smegma bacillus, 400 
Smell, section on sense of, 461 
testing the sense of, 573 
Smothered sound, 108 
Snellen’s plates for testing vision, 568 
Sodium, chloride of, in urine, 434 
Softening of pons or oblongata, effect 
of, 457 
Sole of the foot, reflex of, how elicited, 
495 
Sommerbrodt, reference to, 246 
Somnolence defined, 470 
from uraemia, 440 
Sopor defined, 470 
Sound, abnormally loud and deep per- 
cussion, where occurs, 135 
Biermer’s change of, described, 
136 
Sound, conditions that determine the 
quality of, 109 
dissimilarity of, on right and left 
sides of chest, 121 
Friedreich’s change of respira- 
tory, defined, 113 
described, 133 
individual differences of, 120 
metallic, defined, 112 
moist cracked-pot, 135 
normal, over lungs, trachea, and 
larynx, 119 
of falling drops, 153 
qualities of, terms for, 108 
rectal, use of, 311 
regional differences of, 120 
Williams’s tracheal change of, 121 
Wintrich’s change of described, 
111 
explained, and when oc- 
curs, 138 
Sounds, centre for conception of, 557 
intellectual perception of, 552 
qualities of, explained, 106 
Space, conception of, test for, 481 
complementary, 192 
Spasm, active, of paralyzed muscles, 
494 
of muscles of speech, 548 
of thoracic muscles, dyspnoea 
from, 95 
sensation of, of muscles, 479 
defined, 480 
Spasms. Also see Convulsions, 
defined, 530 
from intestinal parasites, 578 
hysterical, 587 
voluntary muscles, 530 
Spastic paralysis, 492 
contracture after, 495 
pseudo-paralysis, 494 
spinal paralysis, flexion of foot 
with, 535 
increase of tendon reflex 
in, 500 
Special senses, centres and tracts of, 
460 
Specific gravity of urine, diagnostic 
value of, 413 
how measured, 403 
if high, sugar probably 
present, 443 
in disease, 412 
relation of color to, 408 
Spectroscopic examination of blood, 
270 684 
INDEX. 
Spectroscopic examination, value of, 
271 
urine, for methsemoglobin, 
442 
Spectrum analysis, quantitative for 
determining amount of haemoglobin 
in blood, 272 
Speech, an acquired faculty, 549 
-centre, motor, interruption of, 
558 
location of, 555 
difficulty of in bilateral paralysis 
of the soft palate, 538 
disturbances of, 548, 549 
how acquired, 549 
in paralysis of soft palate, 537 
place of hearing in, 550 
right hemisphere has nothing to 
do with, 555 
Spheno palatine ganglion, 461 
supplies the soft palate, 
537 
Spermatic nerves, illustrated, 487 
Spermatorrhoea, 421 
Spermatozoa, in urine, diagnostic 
value of, 421 
Sphincter vesicse, spasm of, due to 
echinococcus, 425 
Sphygmograph, pathological forms of 
pulse shown by, 247 
tracing of radial pulse explained, 
246 
Sphygmomanometer, use of, 245 
Spinal column, curvature of, effects of, 
87 
diminished mobility of, 467 
section on, 467 
sensitiveness to pressure, 467 
cord, cervical, diminution of tem- 
perature in injuries of, 
575 
injury to, fever with, 
575 
difficulty of local examina- 
of, 463 
disease of, feeling of constric- 
tion about thorax in, 482 
diseases of, diagnosis of, 586 
EaR not present in paralysis 
from lesion of pyramidal 
tract in, 525 
incontinentia alvi in disease 
of, 370 
increased irritability of, in- 
creased tendon reflex with, 
500 
Spinal cord, lessened excitability in, 
without EaR, 525 
lumbar, residual urine in dis- 
eases of, 408 
lympho-sarcoma of, hemial- 
burnose in, 439 
relation of, to spinal column 
described, 468 
spasm from irritation of the 
anterior horns of, 530 
curvature, 82 
irritation, pain in spine with, 483 
tenderness of vertebrae with, 
467 
paralysis, above the anterior horn, 
characteristic sign of, 494 
from disease of pyramidal 
tract, increase of tendon 
reflex in, 500 
spastic, dorsal flexion of foot 
with, 535 
progressive muscular atrophy, di- 
minished tendon 
reflex in, 500 
fibrillary contrac- 
tions with, 532 
Spine, pain in, various causes of, 483 
Spinning-top, noise of, 128 
Spirals, Charcot-Leyden’s crystals 
upon and in, 182 
Curschmann’s, illustrated, 178 
described, 179 
Finkler-Prior’s, 390, 607 
in sputum of croupous pneumonia, 
173 
of pneumonia, 175 
Spirillum recurrens in hemorrhage of 
kidney, 427 
Spirochaeta in mouth, 188, 289 
Spirometer, Hutchinson’s, 164 
Spirometry described, 163 
Splashings in intestine, 312 
Spleen, adjacent to fundus of stomach,. 
299 
anatomy of, 332 
arterial pulse at, rare, 257 
auscultation of, 339 
boundaries of, 336 
consistence of, 335 
-deadness illustrated, 304, 337 
diseases in which it is enlarged, 334 
-dulness, enlargement of, difficul- 
ties in determining, 339 
enlarged, causes projection of left 
hypochondrium, 334 
enlargement of, diagnosis of, 339 INDEX 
685 
Spleen, enlargement of, due to venous j 
engorgement, 260 
effect of, on form of chest, 86 
from venous engorgement, 
261 
makes the half-moon-shaped 
space smaller, 306 
examination of, 332 
form and surface of, 335 
infarction of, cause of enlarge- 
ment, 335 
inspection of, 334 
-kidney angle, 393 
leucocytosis in inflammation of, 
270 
location of illustrated, 321 
-lung angle, 338 
defined,333 
measuring the, 337 
mobility of, 335 
palpation of, 334 
pathological relations of, 338 
percussion of, 336 
portion that is parietal, 333 
position of, 79 
illustrated, 333 
relation to colon, 336 
to diaphragm, 332 
to lung, 333 
size of, in various diseases, 335 
tenderness of, diseases in which it 
occurs, 335 
topography of, 332 
tumor of, 306 
not diagnosticated from per- 
cussion alone, 338 
wandering, described, 336 
differential diagnosis of, 397 
when it can be felt, 334 
Splenic anaemia, enlargement of spleen 
in, 335 
Sponge, hot, use of, in testing sensi- 
bility of spinal column, 468 
Spun-top, noise of, described, 134 
where it occurs, 134 
Sputum, character of, with reference 
to certain brain diseases, 576 
chemical examination of, 190 
crystals in, 174 
defined, 167 
fibrinous tubes in, 172 
importance of examining by naked 
eye, 171 note 
in three layers, fetid, described, 
174 
microscopical examination of, 175 
Sputum, muco-purulent, crystals in, 
181 
odor of, described, 171 
spirals in, 174 
substances visible in, by naked 
eye, 171 
Stadelmann, reference to, 443, 449 
Staphylococcus pyogenes, 602 
cultures of, 603 
Starch corpuscles in sputum, 180 
grains, in vomit, 365 
Starches, changed into erythro- and 
achroo dextrin, 353 
interference with digestion of, 344 
Stenosis, auscultatory sounds of, 297 
of air-passage, inspiratory pres- 
sure diminished in, 164 
labored respiration in, 93 
of aorta, murmur of, when heard, 
224 
pulse in, 240, 252, 255 
slow pulse with, 237 
of intestine, indicated by band- 
like, flat scybala, 371 
obstipation in, 369 
peristalsis to be seen with, 310 
tympanites with, 309 
of larynx, described, 75 
voice in, 74 
of left auriculo-ventricular open- 
ing, dyspnoea in, 96 
of oesophagus, 292 
of trachea, 97, 98 
of upper air-passages, cause of di- 
diminished vesic- 
ular breathing,145 
diminished frequency 
of respiration in, 91 
of valves and effects of, 194 
weaken the sounds of, 219 
Stereognosis, defined, and test for, 481 
Sterility, 21 
due to syphilis, 21 
Sternal lines defined, 76 
Sternum, acts as a thick pleximeter, 
121 
and ribs in emphysema, 83 
character of percussion - sound 
over, 123, 124 
heart-sounds heard over, 214 
non-tympanitic sound over, 121 
, Stethography defined, 164 
of thorax, 162 
Stethoscope, double murmur from 
pressure with, 259 
in examining heart, 220 686 
INDEX. 
Stethoscope, mode, use, and kinds of, 
139 
use of, in auscultation of heart, 
211 
of pulse, 257 
of veins, 268 
in cardiac murmurs, 232 
with venous humming, 269 
value of, in auscultating over 
spleen,340 
when to be used, 140 
Stiff-neck, 539 
Stigmates hysteriques, 534, 587 
Stimulation, points of, 508 
Stintzing, normal electrode by, 502 
reference to, 354, 502, 503, 512, 
516, 517, 518, 523 
Stohrer, reference to, 476, 503 
Stokes, reference to, 92, 142 
Stolnikow, reference to, 190 
Stomach, abscess of, circumscribed 
pain with, 314 
acute catarrh of, paleness in, 40 
alkaline urine with dilatation of, 
413 
amyloid degeneration of mucous 
membrane of, 356 
anatomy of, 297 
atrophy of mucous membrane of, 
356 
passage of oil into intestine 
in, 354 
auscultation of, 307 
blood from, in expectoration, 167 
boundary illustrated, 304 
cancer of, peptonuria with, 439 
catarrh of, absorption from, 354 
superacidity with, 357 
vomit in, 360, 361 
closed tympanitic sound heard 
over, 111 
coating of tongue in diseases of, 
287 
decomposition of contents of, 356 
digestion described at length, 342 
duration of, 344 
how studied, 341 
mode of examining, 347 
pathological disturbance of, 
344 
prolonged, 345 
value of results of examina- 
tion of, 355 
dilatation of, 348 
absorptive power in, 355 
causes of, 345 
Stomach dilatation, indicated by sar- 
cina and torulae in vomit, 
365 
infrequency of the attacks of 
vomiting in, 359 
symptoms of, with displace- 
ment of right kidney, 396 
with fermentation ofcontents, 
seething sound over, 208 
diseases of, in which there is di- 
minished or absence of free 
muriatic acid, 356 
distensibility of, 300 
disturbance of, with migraine, 
483 
examination of, 297 
extent to which it is parietal, 
299 
fasting, value of examination of, 
355 
great amount of vomit in dilata- 
tion of, 360 
-heart space, 306 
hemorrhage of, 40, 170 
acid reaction of blood in, 170 
distinguished from that from 
lungs, 362 
hour-glass, 302 
hypersecretion in ulcer of, 357 
hypertrophy of muscular coat of, 
345 
inflated, metallic heart-sounds 
with, 221 
inflation for diagnosis, 300 
inspection and palpation of, 299 
mode of, 299 
-liver space, circular, 306 
-lung sound, vrhen heard over, 113 
space, circular, tympanitic 
sound over, 306 
metallic sound over, 112 
method of examining fasting, 355 
movements of, part in digestion, 
353 
normal cannot be defined through 
, abdominal wall, 300 
percussion of, 304 
perforating ulcer of, stool of, 372 
cause of pneumothorax, 210 
position of, 78 
if dilated, 305 
illustrated, 319 
of lower border of, illus- 
trated, 327 
of, when moderately full, 
305 INDEX 
687 
Stomach-pump, use of, in washing out 
the stomach, 348 
purposes for which it is to be 
emptied, 357 
rapidity of passage of food from, 
tests for, 354 
resonance in region of heart dul 
ness, 206 
rinsing out, in studying contents 
of, 341 
section of, examination of con- 
tents of, 341 
significance of acid secretion of, 
357 
sudden amaurosis after severe 
hemorrhage of, 602 
superacidity with ulcer of, 357 
symptomatology of dilatation of, 
346 
tests of absorptive power of, 354 
ulcer of, hemorrhage from, 362 
vertigo in diseases of, 472 
vomiting in diseases of, 358 
washing out of, 347, 357 
Stomatitis, cause of enlargement of 
tongue, 286 
Stone in pelvis of kidney, tenderness 
with, 395 
Stool, alcohol, odor of, 371 
bilious, described, 373 
bloody, described, 374 
color, constituents, and admix- 
ture of, 372 
fatty, described, 374 
Stools, consistence and form of, 371 
involuntary discharge of, 579 
in attacks of epilepsy, 534 
odor of, 371 
purulent, when occur, 376 
reaction of, 372 
watery, when occur, 374 
Strabismus, defined, 562 
lateral, divergent, convergent, de- 
fined, 563 
Strangling, from irritability of larynx, 
590 
Strangury, causes of, 400 
Strength, rapid decline of, 587 
Streptococci, in purulent pleural exu- 
dation, 161 
Streptococcus erysipelatous,described, 
603 
in urine, 399 
pyogenes, 161 
description of, and when 
found, 603 
Striae, 52 
frojn ascites, 313 
on abdomen, cause of, 314 
Stricture of oesophagus, location of, 
295 
Stridor laryngeus vel trachealis, 97 
Strongylus gigas, cause of pyuria and 
hsematuria, 425 
Structure of body, 33 
Struma, blowing murmurs over lym- 
phatic glands in, 259 
Strumpell, reference to, 67, 178, 249, 
250, 440, 466, 478, 535, 554 
Strychnia poisoning, increased tendon 
reflex in, 500 
Stupor defined, 470 
Subacidity in dilated stomach, 346 
of stomach, effect of, 344, 348, 
356 
Subjective sensibility, 472 
Subphrenic abscess, downward dis- 
placement of liver from, 
322, 330 
peritonitis, diagnosis of, 317 
Succussion, Hippocratic, described, 
156 
pathognomonic of hydro-pneumo- 
thorax, 156 
Sudamina, 50 
Sugar, determination of, by circum- 
polarization, 447 
in urine, qualitative test for, 
444 
often in urine of health, 404 
qualitative test for, 445 
uric acid in urine hinders exami- 
nation for, 405 
Sulphuric acid in urine, 435 
Superacidity. Also see Hyperacidity, 
of stomach, 348 
contents, when it occurs, 351 
diseases in which it occurs, 
357 
effect of, 344 
free muriatic acid with, 346 
signs of, 356 
Supersecretion. Also see Hypersecre- 
tion. 
of gastric juice, what diseases it 
occurs with. 357 
Suppression of urine, due to venous 
engorgement, 260 
reflex, of urine, 408 
Suppuration, cause of paleness, 41 
of ear and nose, cause of menin- 
gitis and abscess of brain, 467 688 
INDEX. 
Supraclavicular depression deepened 
from contraction of apex 
of lung, 87 
percussion of, 118, 130 
Supraorbital nerve, illustrated, 485 
Suprascapular nerve, illustrated, 486 
Supratrochlear nerve, illustrated, 485 
Swallowing, difficulty of, in bilateral 
paralysis of soft palate, 538 
difficulty of, in paralysis, 537 
pain in, 75 
Sweat. Also see Perspiration. 
accompanies remission of fever, 62 
alterations of, 38 
cold, with dyspnoea, 99 
critical, in recurrent typhus, 70 
diminished, 38 
Sweating, accompanies vomiting, 359 
cause of diminution of urine, 407 
effect of, on color and amount of 
urine, 402 
local, 38 
Syllable-stumbling, 553 
Sylvius, embolus of the fossa of, 562 
fissure of, artery of, 462 
fossa of, illustrated, 466 
Sympathetic paralysis, inequality of 
pupils in, 567 
Sympathetica spastica, unilateral vaso- 
motor disturbances in, 577 
Symphysis pubis, significance of dul- 
ness above, 316 
Symptom, Romberg’s, 480 
Symptomatic, migraine may be, 483 
neuralgia, 483 
Symptomatology of diseases of ner- 
vous system, section on, 463 
value of, 20 
Symptoms, concealment of, 19 
direct and indirect, in nervous 
diseases, 585 
Syncope defined, significance of, 471 
Syphilis, affecting larynx, 75 
liver, 324 
change in shape of liver from 
scars of, 325 
changes in fundus oculi with, 601 
chronic catarrh, a sign of, 74 
cicatrices of, dyspnoea from, 93 
concealed, 19 
congenital, Hutchinson’s teeth a 
sign of, 286 
constitutional, paleness in, 41 
cracks in lips of children, a sign 
of hereditary, 285 
deformed nose from, 73 
Syphilis, diagnosis of, when brain and 
spinal cord are affected, 586 
glands of neck enlarged in, 291 
haemoglobin in urine of, 411 
hereditary, early signs of, 22 
infectious in utero, 20 
inherited, 29 
irregular enlargement of liver 
with, 322 
may be a cause of catarrh of 
larynx, 593 
middle ear catarrh in, 572 
mucous patches in mouth in, 
288 
nervous diseases from, 581 
neuralgia from poison of, 483 
nocturnal headache with, 482 
nose affected in, 576 
primary and secondary outbreaks 
of, 22 
scars of, 52 
on tongue from, 288 
sterility caused by, 21 
subcordal laryngitis from, 593 
tonsils in, 290 
ulceration of larynx with, 595 
Syphilitic formations of tongue, 286 
gummata on liver, 326 
on skull, 465 
infiltration and ulceration of 
larynx, 592 
difficulty of diagnosis of, 595 
iritis, 562 
scars in larynx, 596 
Syringo-myelitis of cervical cord, 582 
trophic disturbance of bone 
in, 583 
Systole of heart, collapse of veins with, 
264 
movement of blood in, 193 
sound with, 212 
Systolic drawing-in, 267 
near apex of heart, 202, 204, 
220 
heart-sound, what due to and 
where heard best, 213, 214 
murmur, 252 
at apex, 251 
heard with aortic stenosis, 
258 
over pulmonary artery, when, 
255 
with atheroma of aorta, 254 
murmurs, 222, 225 
how distinguished from dias- 
tolic, 226 INDEX 
689 
Systolic, positive venous pulse is, 264 
sound in health over large arte- 
ries, 257 
subclavian murmur described and 
explained, 259 
trembling and pulsation in epi- 
gastrium, 204 
true venous pulse, rare in facial 
veins, 267 
venous pulse, 266 
with mitral insufficiency, 
267 
vesicular breathing, 143 
T abbreviation for tetanic contrac- 
, tion. 
Tabes, allochiria in, 478 
arthropathia in, 583 
atrophy of optic nerve in, 601 
bladder crises (painful tenesmus) 
in, 580 
disturbance in, 580 
brittleness of bones in, 583 
cystitis with, 579 
decline of genital function in, 580 
dorsalis, ataxia the most impor- 
tant symptom of, 529 
atrophy of optic nerve in, 562 
contracted pupil with, 566 
diminished tendon reflex 
(very important), 500 
mydriasis in, 566 
feeling of constriction about tho- 
rax in, 482 
gastric crises with, 578 
herpes zoster with, 581 
hypersecretion of stomach in, 357 
inequality of the pupils in, 567 
intestinal crises with, 578 
laryngeal spasm with, 576 
laxness of muscles in, 494 
location of, 484 
mal perforant in, 582 
migraine in, 483 
neuralgia in initial stage of, 483 
pain in spine with, 483 
polyuria and glucosuria in, 579 
residual urine with, 408 
tenderness of vertebrae in, 467 
vomiting in, 361 
Tables of comparison of the two sides 
of the body, with faradic and gal- 
vanic current, 517 
Taenia cucumerina, described and illus- 
trated, 380 
Taenia mediocanellata described, 378 
illustrated, 379 
solium, cysticerci in brain from, 
578 
described, 377 
eggs of, described, 378 
parts of, illustrated, 378 
poikilocytosis in, 277 
Talma, reference to, 151 
Taste, mode of testing the sense of, 574 
sense of, location of, 461 
Teale, reference to, 62 
Teeth and gums, examination of, 285 
caries of, in diabetes mellitus, 285 
condition of, in poisoning by mer- 
cury, lead, copper, 286 
in scorbutus, 286 
diseased, a cause of dyspepsia, 286 
disturbances which accompany 
eruption of, 286 
Hutchinson’s sign of congenital 
syphilis, 286 
Temperament, effect upon pulse, 235 
Temperature. Also see Fever 
an index of severity of disease, 61 
chart, value of pulse record on, 253 
course of, 62 
daily variations of, 60 
dangerous to life, 61 
diagnostic value of, section on, 64 
diminution of, when occurs, 575 
effect of, on perspiration, 36 
exacerbation of, 62 
complication shown by, 65,67 
fall of, collapse with, 70 
sign of collapse, 67 
frequency of taking, 59 
highest observed, 62 
local, 71 
lowering of, 71 
normal, variations of, 59 
relation to pulse not constant, 61 
remission of, 62 
section on, 57 
subnormal, section on, 63 
table of, 61 
taking of, methods, 58 
‘ tracing of, with pulse, 236 
unilateral elevation of in hysteria, 
variations of pulse due to external, 
235 
Temporal artery, pulsation in, 256 
convolutions, second and third, 
blood supply of, 462 
lobe, 461 690 
INDEX 
Temporal lobe, illustrated, 466 
Tenderness of intestine, kinds of, and 
diseases with, 308 
of liver, when manifest, 324 
of nerve during neuralgia, 484 
of region of kidney, when occurs, 
395 
Tendo-Achillis reflex and foot phe- 
nomenon defined, how tested, sig- 
nificance of, 499 
Tendon reflex, 493 
an attendant phenomenon of 
spasms, 494 
increase and diminution of, 
goes parallel with tonus, 500 
increased in the phenomenon 
of paradoxical contrac- 
tions, 527 
in partial epilepsy, 533 
mechanism of, illustration 
explained, 500 
mixture of, and direct mus- 
cular irritation, 501 
of upper extremities, 499 
seat of, 528 
when increased, 500 
reflexes, aid in diagnosis, 498 
importance of, 497 
section on, 497 
when diminished or lost, 500 
Tenesmus at stool, 370 
of bladder, cause of, 400 
Tension diminished, gives deep non- 
tympanitic sound, 112 
of lung tissue diminished, 135 
effect on pitch, 112 
of wall of closed air cavity, effect 
on pitch of sound, 110 
of walls, effect upon change of 
pitch of sound, 111 
Terminal arteries, defined, 462 
Test papers, Geisler’s albumin, 436 
Testing the sensibility to irritation, 473 
Tetanus, cyanosis in, 44 
dyspnoea in, 95 
fever with, 575 
galvanic, 505 
increased excitability in, 526 
tendon reflex in, 500 
opisthotonus with, 468 
tonic and clonic spasm of tho- 
racic muscles in, 540 
spasms in, 532 
Thallin, urine after taking, 451 
Thermsesthesiometer, use of, 475 
Nothnagel’s, described, 475 
Thermometer, selection of, 58 
Thermometers, scales of, 57 
Thermometric scales, comparison of,61 
Thigh, points of electrical irritation 
of, illustrated, 511 
-sound, 109 
associated with feeling of 
strong resistance, 116 
defined, 106 
term used for dull, 108 
when heard, 113 
Third nerve, paralysis of, 566 
Thirst, in febrile diseases, 287 
Thoma-Zeiss’s apparatus for counting 
blood corpuscles, 274 
Thompson, reference to, 286 
Thomsen’s disease, 493 
myotonic reaction in, 518 
Thoracic breathing aided by auxiliary 
muscles, 99 
conditions that abolish it, 91 
replaced by diaphragmatic, 90 
diseases, position in bed in, 32 
duct, compression of, a cause of 
chylous ascites, 318 
organs and deformities of chest, 
81 
pain produced by pressure, 101 
viscera, position of, 78, 79 
Thorax, anatomical prominences of, 
76 
circumference of, increased in in- 
spiration, 163 
where measured, 162 
covering of, effect of, on heart- 
sounds, 216 
cross-section of, 163 
deformity of, a cause of disloca- 
tion of heart, 199 
larger parietal area of 
heart, 200 
effect of elasticity of, on heart- 
sounds, 216 
emphysematous, 85 
examination of, in connection 
with disease of oesophagus, 296 
flexibility of, 83 
flexible projection of, in diseases 
of the heart, 203 
form of, 81 
important, 33 
frequent measurements of, value 
of, 163 
inspection of, 81 
inspiratory enlargement of, 83 
length of, 163 INDEX 
691 
Thorax, local expansions of, 86 
measurement of, 162 
one-sided extension of, 85 
palpation of, 100 
paralytic, described, 84, 85 
pathological forms of, 83 
percussion of, described, 118 
phthisical, often absent in phthi- 
sis, 85 
right side measures more than 
left, 163 
rigid, causes of, 91 
diaphragmatic breathing 
with, 91 
prevents projection in en- 
largement of liver, 321 
short, position of apex-beat in, 
198 
tympanitic resonance in re- 
gion of heart-dulness in, 
206 
sound on percussing, 109 
tumors of, measurement of thorax 
in, 163 
value of pulse in deformity of, 253 
repeated measurement of, in 
aneurism of aorta, 254 
wall of, dulling effect on heart- 
sounds, 217 
yielding, in children, 98 
Throat and neck, muscles of, 538 
Thrombosis, effect upon pulse in one 
of two symmetrical vessels, 257 
local low temperature in, 71 
of large veins of lower extremities, 
268 
of veins a cause of cyanosis, 45 
renders deep veins accessible, 260 
venous, effects of, 262 
when and where it occurs, 
268 
Thrombus, closure of venous trunk 
by, 261 
Thrush, description of, 287 
in children, spores in feces, 388 
microscopic appearances of, 290 
stenosis of oesophagus from, 296 
Tinnitus aurium, sometimes a pre- 
cursor of migraine, apo- 
plexy, or epilepsy, 573 
with migraine, 483 
Tobacco amblyopia, 602 
central scotoma in, 569 
use of, effect on disease, 21 
Toes, paralysis of muscles of, 547 
Toluylendiamin, poisoning by, caus- 
ing hsemato-jaundice, 47 
1 Tone, as applied to heart-sounds, 212 
of heart-sounds, variations of, 216 
pitch of, how effected, 109 
; Tongue and soft palate, electrical irri- 
tation of, 510 
coating of, 287 
color of, 287 
dryness of, 287 
enlargement of, 286 
examination and conditions of,286 
in typhoid fever, 287 
motor centre for, 454 
muscles of, 536 
that move it, and effect of 
their paralysis, 537 
nerve-supply of anterior two- 
thirds of, 484 
normal mobility of, in hysterical 
dumbness, 548 
not bitten in hysterical spasms, 
534 
often bitten during attack of epi- 
lepsy, 533 
sense of taste in, 461 
anterior two-thirds from 
the chorda, and poste- 
rior one - third from 
glosso-pharyngeus,574 
taste in the anterior portion of, 
affected in paralysis of facial 
nerve, 461 
trembl ing of, in alcoholism, fevers, 
and typhus, 287 
wounds of, 287 
Tonic spasms, 530 
when occur, 532 
Tonus of muscles, 488, 496, 528 
disturbance of, 489 
method of testing when only 
slightly increased, 501 
of paralyzed muscles increased, 
494 
of quadriceps, increased, disturbs 
patellar reflex, 498 
Tonsils, condition of, in tonsillitis, 
syphilis, diphtheria, etc., 290 
crystals in sputum from inflamed, 
181 
offensive plugs from lacunae of, 
171, 174 
Tooth-mucus bacillus, like comma ba- 
cillus, 391 
Topographical percussion defined, and 
uses of, 116 
relation between surface of brain 
and skull, illustrated, 466 
Topography of abdomen, 297 INDEX. 
692 
Torula cerevisise, in fever, 388 
in vomit, 365 
with normal digestion,366 
Touch, sense of, how tested, 473 
Toxic headache, causes of, 483 
influences, neuralgia from, 483 
paralyses, EaR with, 524 
Trachea, casts of, in sputum of croup, 
172 
change of sound in, 130 
distance of bifurcation of, from 
incisor teeth, 291 
epithelium in sputum from, 176 
mucous rales in, 165 
normal sound over, 119 
open tympanitic sound, when it 
is percussed, 110 
sensitiveness of, a cause of cough, 
165 
stenosis of, 97 
inspiratory drawing-in of 
chest wall in, 98 
tympanitic sound over, 121, 130 
ulceration of, a cause of emphy- 
sema of skin, 56 
Tracheal change of sound explained, 
132 
sequestra of, in sputum, 172 
tone, Williams’s, described, 111, 
131 
Transfusion of blood, haemoglobin in 
urine after, 411 
Transition breathing, 148, 149 
corresponds to hinted rales, 
153 
Transparency of expectoration, 168 
Transudation, diagnosis of, from exu- 
dation, 160 
Transudations, effect of absorption of, 
on reaction of urine, 413 
increase of chloride of sodium in 
urine with, 434 
Trapezius muscle, paralysis of, effect 
of, 541 
Traube, reference to, 104, 151, 179, 
259, 306,440 
Traumatic hemorrhages, 51 
hysteria, narrowing of field of 
vision in, 569 
paralysis, EaR in, 525 
Traumatism, exposure of nerves to, 
468 
Treatment, value of pulse in, showing 
result of, 253 
Trembling (tremor), 530 
Tremor, graphic representation of, 531 
Tremor, mercurialis, 531 
saturninus, 531 
senilis, 531 
with hysteria, 531 
Trichina spiralis described, 383 
importance of, 383 
illustrated, 384 
Trichinae in stools, 383 
in vomit, 364 
Trichinosis, 383 
cyanosis with, 44 
Trichomonas vaginalis, found in urine, 
425 
Tricocephalus dispar, described and 
illustrated, 383 
Tricuspid insufficiency, 194, 195 
case of relative, referred to, 
266 
double sound with, over crural 
vein, 268 
murmur of, where heard, 225 
positive venous pulse pathog- 
nomonic of, 264 
relative, pulmonary second 
sound in, 218 
venous murmur with, 268 
murmur, where heard, 224 
stenosis, 194 
venous engorgement from,261 
valve, causes a systolic sound, 
213, 214 
Trigeminus nerve, 461 
anosmia due to paralysis of, 
574 
sense of taste in anterior portion 
of tongue affected in disease of, 
461 
Triple-phosphates, deposit of, in urine, 
402 
illustrated, 430 
in sputum, 182 
in urine described, 431 
Trismus, masseter spasm in, 532 
Trommer’s test for sugar, 444 
used in estimating amount of 
sugar, 446 
Tropaolin-paper, use of, in testing for 
free muriatic acid, 350 
Trophic influences of the cortical cen- 
tres, 456 
Trunk, muscles of, and effect of their 
paralysis, 539 
nerves of, 485 
Tubercle bacilli, illustration of, 184 
in sputum in tuberculosis of 
larynx, 595 INDEX. 
693 
Tubercle bacilli, mode of examina- 
tion, 185 
only present with disintegra- 
tion, 161 
staining of, 186, 187 
bacillus, cultures of, described, i 
605 
in blood, rare, 281 
in feces, presence explained, 
391 
in pleural exudation, 161 
in sputum, 175 
in urine, illustrated, 426 
sign of tuberculosis of 
urinary passages, 426 
Tubercular cachexia, 41 
deposits, small tympanitic sound 
over, 130 
peritonitis, 315 
enlargement of spleen in, 335 
surface of liver in, 325 
tenderness of the liver with, 
324 
ulceration, result of infiltration 
in larynx, 595 
Tuberculosis, 82. Also see Phthisis 
acute miliary, of lung and pleura, 
friction sounds with, 155 
pulse in, 239 
affections of ear with, 572 
cachexia of oxaluria with, 430 
catarrh of larynx in tuberculosis 
of lungs, 593 
Charcot-Leyden’s crystals in spu- 
tum of, 182 
choroidal, 562, 601 
chronic, Curschmann’s spirals in 
sputum of, 180 
remittent fever of, 68 
color of face in, 42 
crystals of cholesterin in sputum 
of, 181 
deepening of clavicular depression 
in, 87 
diagnosis of, by aid of microscope, 
291 
disposition to, with narrow chest, 
34 
dyspnoea in, 95 
effect on weight, 36 
elastic threads in the sputum of, 
177 
fever in, 65 
fibrin in urine in, 439 
forms of fat found in feces in, 
386 
Tuberculosis in apices of lungs, with 
cavities, 131 
indicated by scrofulosis, 22 
infections in utero, 21 
inherited, 20 
intestinal, feces contain Charcot’s 
crystals, 388 
infusoria found in stools of, 
384 
tenderness with, 308 
miliary, petechise in, 50 
of apex of lung, increased vascu- 
lar breathing in, 144 
prolonged expiration in, 145 
of apices, pain with, 102 
of larynx, 75 
of lungs, 22 
disturbance of the circulation 
through them, 44 
night-sweats of, 38 
shown by tubercle bacillus, 
187 
of lymphatic glands, effect on ab- 
sorption of fats, 371 
of pericardium, friction sounds 
with, 232 
of peritoneum, little or no pain 
with, 314 
of pleura, a cause of tenderness, 
101 
of tonsil, 290 
of urinary apparatus, 398, 426 
shreds of tissue in urine 
of, 421 
passages, 400 
pulmonary hemorrhage in, 170 
red border upon gum in, 286 
shrinking of omentum in, 340 
thrush with, 288 
tracing of pulse of, 248 
tympanitic sound over apices of 
lungs in beginning of, 112 
ulceration of larynx with, 595 
weight of body in, 35 
with paralytic thorax, 85 
Tuberculous and syphilitic laryngitis, 
differential diagnosis of, 593 
infiltration and ulceration of lar- 
ynx, 592 
Tumor of kidney, tenderness with, 395 
of liver or spleen, 306 
of lungs, peculiar sputum of, 171 
Tumors, abdominal, effect on form of 
thorax, 86 
tympanitic sound near, 130 
cause of venous stasis, 262 694 
INDEX 
Tumors, cause of inspiratory dyspnoea, 
99 
cerebral, slow pulse with, 237 
conceal apex-beat, 201 
glandular, cause of pressure on 
nerves, 469 
in chest cavity, dyspnoea from, 95 
in lungs, weak percussion over, 
115 
intestinal, percussion of, 312 
intra-tracheal, dyspnoea with, 93 
neuralgia from pressure of, 483 
of abdomen, dulness over, 306 
of brain, disturbance of conscious- 
ness with, 471 
sensibility of cranium to 
pressure with, 466 
of chest cavity, bronchial breath- 
ing from, 146 
diagnosis of, by punct- 
ure, 160 
wall, cause of deadened 
sound,130 
pulse in, 253 
of intestine, diagnosis of, 310 
kinds of, 310 
of kidney, described, 394 
diagnosis of, 397 
value of percussion with, 397 
of pleura, one-sided expansion of 
chest in, 86 
of stomach and spleen, respiratory 
motion of, 322 
pulsation with, 302 
of thorax, irregular boundary of, 
129 
measurement of thorax in, 
163 
of tongue, a cause of enlargement, 
286 
of transverse and descending 
colon easily confounded with 
those of spleen or kidney, 311 
of vertebrae, tenderness of, 467 
of wall of stomach, 300 
near stomach not felt, 303 
pressure of, a cause of jaundice, 
46 
Turbinated bones, enlargement of, a 
cause of neuroses, 575 
Tiirck, reference to, 594 
Tiirck’s reflector, 589 
Turpentine, odor of urine after taking, 
414 
Tympanites, effect of, upon extent of 
abdomen, 309 
Tympanitic deadened sound, 131 
resonance in region of heart-dul- 
ness, 206 
near an infiltrated lung, 126 
near heart, when, 210 
open or closed, over lung 
cavities, 131 
over lung containing scat- 
tered deposits, 127 
with high tension of lung- 
tissue, 135 
sound further defined, 109 
intensity of, 109 
just above large exudation, 
128 
musical pitch of, 109 
occurs with lack of tension 
of lung-tissue, 110 
on right side of chest over 
stomach or colon, 121 
over apices in beginning 
tuberculosis, 112 
diseased lungs, causes of, 
130 
larynx and trachea, 121 
where heard, 109 
with pneumothorax, 154 
with retracted lung, 111, 
112 
sounds, 107 
Typhlitis described, 315 
recurrence of, 22 
tenderness in iliac fossa with, 
308 
Typhoid fever, velTyphus abdominalis 
abscess of abdominal muscle 
in, 309 
of muscles in, 54 
bacillus of, cultures of, 605 
described and illustrated, 
391, 605 
found in blood in, 281 
staining of, 605 
consciousness, disturbance of, 
in, 470 
cough, absence of, 165 
feces of, contain Charcot’s 
crystals, 388 
glucosuria in, 443 
haemoglobin in urine of, 411 
headache in, 483 
hemorrhage in, shown by 
temperature, 65 
subcutaneous in, 51 
ileo-caecal cooing in, 312 
infusoria in stools of, 384 INDEX. 
695 
Typhoid fever, intestinal hemorrhage 
in,375 
tenderness in, 308 
leucin and tyrosin in urine 
of, 432 
leucocytosis in, 278 
mental condition in, 32 
paralytic chest from, 85 
peptonuria in, 439 
posture in, 32 
pulse in, 238, 239 
tracing of, 247 
rash of, resembling scarlet 
fever, 50 
recurrence of, 50 
roseola in, 49 
spleen, enlargement of, in, 
334 
spermatozoa in urine in, 
421 
staphylococcus pyogenes in 
the suppuration which ac- 
companies, 603 
stools thin in, 371 
sweat in remittent stage of, 
38 
temperature, course of, 65 
variation of, in, 66 
tongue, state of, in, 287 
tympanitis in, 309 
ulceration of the larynx in, 
595 
Typhus abdominalis. See Typhoid 
Fever 
fever, cutaneous hemorrhages 
with, 51 
eruption of, 49 
typical course of fever 
in, 65 
Tyrosin, form of, in urine, 432 
in sputum, 182 
in urine, illustrated, 431 
when occurs, 432 
UFFELMANN’S test for lactic 
acid, 351 
Ulcer of stomach, blood in stool from, 
375 
hemorrhage from, 362 
pain in, 303 
superacidity with, 357 
supersecretion of stomach 
with, 357 
Ulceration of larynx, seldom with 
catarrh, 595 
i Ulceration of larynx, voice in, 74 
of trachea and bronchi, 172 
Ulcerations, deep, of skull wall, 465 
internal, a cause of emphysema 
of skin, 56 
Ulnar nerve illustrated, 486 
distribution to hand, 545 
electrical examination of, 511 
position of the hand in par- 
alysis of, 544 
neuritis from fracture of internal 
condyle of humerus, case of, 
469 
Ultzmann, reference to, 429 
Umbilical region, illustrated, 298 
Unconsciousness, catheter always to 
be used to draw the urine, 401 
faradic test of, 476 
involuntary discharge of urine 
during, 579 
Undefined breathing explained, 148 
Unequal pulse in symmetrical vessels, 
significance of, 257 
respiration, 92 
Ungar, reference to, 182 
Unilateral convulsions in partial epi- 
lepsy, 533 
skin reflex, 495 
Unverricht, reference to, 153, 154 
Upper extremities, tendon reflex of, 
499 
Uraemia, ammoniacal odor of vomit 
in, 366 
Cheyne Stokes breathing in, 92 
coma from, 440, 470 
defined, 440 
dyspnoea in, 576 
epileptiform spasms in, 533 
headache with, 483 
slight amount of vomit with, 360 
symptoms of, 440 
urea diminished in, 434 
vomiting in, 358 
Uraemic amaurosis, 601 
Urate of ammonia, form of, in urine, 
432 
illustrated, 430 
in urine, 402 
of soda and lime, described, 429 
Urates, precipitation of, by albumin 
test-papers, 437 
Urea, amount of, in twenty-four hours, 
405 
cannot be determined from spe- 
cific gravity of urine, 412 
increase of, 433 696 
INDEX. 
Urea in saliva in nephritis, 289 
method of determining amount 
of, 434 
quantitative determination of, 
value of, 413, 434 
Ureter, obstruction in, a cause of 
diminished secretion of urine, 407 
one, stopped up in tuberculosis,400 
Ureters, examination of, 398 
Urethra, diminished amount of urine 
from stricture of, 408 
Uric acid as a urinary sediment de- 
scribed, 428 
concretions of, 433 
crystals of, illustrated, 429 
diathesis, increase of uric 
acid in, 434 
found in blood in gout, 283 
hinders examination for 
sugar, 405 
salts, separation of, from 
cooled urine, 402 
source of, in urine, 405 
when increased, 434 
Uridrosis defined, 38 
Urinary apparatus, chapter on exami- 
nation of, 392 
disturbances of, section on, 
579 
examination of, what it com- 
prises, 392 
calculi, cause of, 429 
casts, most important element in 
pathological urine, 421, 422 
constituents in solution, 433 
anomalies in amount of, 433 
diseases, sweat in, 38 
passages, deep-seated inflamma- 
tion of, fibrin in urine of, 439 
products in fever, 408, 416, 422, 
423 
sediments, 404 
examination of, 415 
of organic bodies, 416 
Urination, assisted by abdominal 
pressure, 540 
frequent causes of, 400 
Urine, acidity of, how determined, 414 
affected by medicines, 450 
always to be drawn with catheter 
when there is unconsciousness, 
401 
amphoteric reaction of, 404 
anomalies in amount of, 406 
causes of diminution of (anuria), 
407 
Urine, clear, to be tested for sugar if 
specific gravity is high, 443 
color and transparency of, in 
disease, 401, 408 
complete diminution of (anuria), 
407 
concentrated, appearance of, 402 
effects of, 400 
concretions in, 433 
contains bile in jaundice, 46 
contamination of, how to avoid, 
399 
daily average amount of, 401 
determining amount of nitrogen- 
ous material in, value of, 434 
diminution of, in fever, 60, 407 
discoloration of, causes of, 410 
examination of, section on, 399 
fermentation of, effect of, on its 
appearance and character, 402 
increase in pigments of, 409 
in uro-genital tuberculosis, 426 
involuntarily discharged in at- 
tacks of epilepsy, 534 
involuntary discharge of, when 
occurs, 579, 580 
mode of procedure in examining, 
400 
normal, section on, 401 
odor of, 404 
due to medicines, 414 
pathological odor of, 415 
section on, 406-450 
reaction of, generally acid, 403 
in disease, 413 
retention and incontinence of, 400 
rule for approximation of solid 
constituents from specific grav- 
ity, 412 
secretion of, less at night, 401 
soluble constituents of, named 
and described, 404 
specific gravity of, how measured, 
403 
when diminished, 413 
staining of, from medicines, 411 
suppression of, causes of, 407 
due to venous engorgement, 
260, 261 
table of colors of, useless, 408 
turbidness of, when passed is pa- 
thological, and when occurs, 
411 
Urobilin, coloring pigment in urine, 
402, 409 
-icterus, 48, 409 INDEX 
697 
Urobilin, tests for, 410 
origin of, 48 
Urobilinuria, 46 
Urometer, requisites of, 403 
Uterus, diseases in utero, 20, 21 
Uvse ursi, color of urine after taking, 
411 
Uvula, position of, in paralysis of soft 
palate, 537 
VAGI, compression of, 599 
Vagina, taking temperature in, 
58 
Vaginal mucus in urine, 416 
Vagus centre, 457 
slow pulse in irritation of, 
237 
irritation of, by bronchial tumors, 
576 
nerve, weakness of heart-sounds 
in paralysis of, 218 
paralysis of, pulse in, 240 
quick pulse in, 577 
Valleix’s points of tenderness, 101, 
484 
Valve, insufficiency of, effect of, 194 
stenosis of, effect of, 194 
Valves of heart, part taken by, in the 
heart-sounds, 213 
where best auscultated, 213, 
214 
Valvular defects revealed by mur- 
murs, explanation of, 221 
deficiency a cause of cyanosis, 44 
compensation for, 195 
disease of heart, hsematuria with, 
417, 418 
enlargement of liver 
with, 324 
incompensation in, a cause 
of diminished amount of 
urine, 407 
value of pulse in, 252 
insufficiency and its effects, 193 
relative, murmurs with, 230 
sound in jugular vein, 265 
Varicella, 49 
Variola. Also see Smallpox. 
ulceration of larynx with, 595 
Vasomotor centre, pulse in irritation 
of, 245 
disturbances, when occur, 577 
influences upon pulse in symmet- 
rical vessels, 257 
Vegetable parasites in urine, 425 
Vegetative system, disturbance of, 
in nervous diseases, section on, 
575 
Vein, portal, enlargement of spleen in 
occlusion of, 335 
Veins, auscultation of, 268 
examination of, 260 
of abdomen, enlarged with as- 
cites, 314 
of skin enlarged in aneurism of 
aorta, 254 
phenomena of circulation in, 267 
Vena cava inferior, pressure upon by 
enlarged retro-peritoneal glands, 
341 
Venereal excesses, cause of disease, 21 
Venous engorgement, effect on color 
of the blood, 270 
effects of, 260 
enlargement of spleen with, 
335 
of tongue, 286 
humming explained, 269 
louder on right side, 269 
synonyms for, 269 
when occurs, 269 
-liver pulse, 266 
with enlarged liver, 322 
pulse described, 263 
double positive, in hemisys- 
tole, 267 
positive, tracing of, 265 
progressive, in aortic insuf- 
ficiency, 267 
in veins of hand and 
back of foot, 268 
tracing of, 264 
stasis a cause of jaundice, 47 
a cause of oedema, 54 
ecchymosis from, 51 
thrombosis, when and where oc- 
curs, 268 
Ventricle, contraction of, causes a sys- 
tolic heart-sound, 213 
hypertrophy of, shown by streng- 
thened sound of corresponding 
valve, 217 
left, hypertrophy and dilatation 
of, shown by displacement of 
apex, 200 
Vermiform appendix, 317 
inflammation of, Cheyne- 
Stokes breathing in, 92 
tenderness in disease of, 308 
usually no tumors with in- 
flammation of, 316 698 
INDEX. 
Vertebras, spines of, sensitive to pres- 
sure, 467 
Vertebral artery, 461 
column, section on, 467 
Vertigo, also see Dizziness 
defined, and when occurs, 472 
from the eye, 563 
Vesicular breathing described, 142 
diminished, causes of, 145 
origin of, 142 
pathological changes of, 144 
special peculiarities of, 143 
Vicarious action of centripetal influ- 
ences in coordination, 528 
of diaphragm in defective 
thoracic breathing, 540 
of kidney, 408 
participation of neighboring 
nerves, 485 
of nerve, 479 
Vidian nerve, 461 
Vierordt, C., reference to, 275 
Vierordt, H., reference to, 35, 217, 283 
Vierordt, K., reference to, 246, 272 
Vierordt, O., reference to, 154,180 
Virchow, reference to, 177 
Vision, concentric limitation of, 587 
of the field of in gross 
hysteria, 534 
narrowing of field of, 569 
disturbance of, from choked disc, 
amount of, 600, 601 
disturbances of, in diseases of the 
nervous system, 562 
in uraemia, 440 
subjective sensations of, 571 
testing field of, 568, 569 
for central sharpness of, 568 
Visual amnesia, 552, 
Vocal cords, position of, during pho- 
nation, 592 
in paralysis, 599 
fremitus, aid in determining appa- 
rent enlargement of heart, 
210 
aids in diagnosis between 
pneumonia and pleuritic 
exudation, 158 
increased, when, 158 
palpation for, 100 
described, 156 
technique of, 157 
variations of, 157 
weakness or suppression of, 
when occurs, 157 
Vogel, reference to, 408 
Voice, character of, in paralysis of 
muscles of speech, 548 
effect upon, from paralysis of 
laryngeal muscles, 538 
in disease, 74 
Voit, C., reference to, 434 
Volume of air cavity, effect upon pitch 
of sound, 109 
of an extremity, measurement of, 
490 
of cavity, effect upon change of 
pitch of sound, 111 
if closed, effect on pitch, 
110 
of muscles, diminution of, 491 
Voluntary motion, 455 
muscle, spasms of, 530 
Vomicae, 131. Also see Cavities in 
Lungs. 
Vomit, chemical examination of, 359 
coffee-ground, test for haemin in, 
363 
color of, 360 
comma bacilli in, in cases of 
cholera Asiatica, 390 
microscopical appearance of, 360 
examination of, 364 
odor of, value of, 366 
quantity of, 360 
reaction of, in various conditions, 
366 
section on, 359 
watery, watery-mucous, and mu- 
cous, significance of, 360 
Vomited material illustrated, 365 
Vomiting, act of, described, 358 
central, diseases in which it oc- 
curs, 358 
due to round-worms, 380 
frequency of, 359 
from irritability of larynx, 590 
from severe coughing, 166 
from uraemia, 440 
in diseases of abdominal organs 
other than the stomach, 358 
induction of, when contra-indi- 
cated, 342 
kinds of, clinically distinguished, 
358 
of use in obtaining contents of 
stomach, 341 
phenomena associated with, 359 
reflex, 358 
section on, 358 
time when it begins, 359 
ways in which it occurs, 358 INDEX 
699 
Vomiting, when it occurs in nervous 
diseases, 578 
Vomitus matutinus potatorum, 359, 
361 
amount of vomit in, 360 
WAGNER, E., reference to, 171 
Waldenburg, reference to, 164 
Wandering kidney, 395 
diagnosis of, 396 
differential diagnosis of, 397 
liver, 331 
signs of, 324 
spleen, 335 
described, 336 
differential diagnosis of, 397 
Wasting diseases, haemic murmurs 
heard in, 229 
significance of, 34 
Water-brash of drunkards, 361 
-whistling defined, 153 
Waxy casts, a form of hyaline, 423 
illustrated, 423 
Weichselbaum, reference to, 427 
Weigert, reference to, 185 
Weight, loss of, a sign of disease, 
23 
of body, increase and diminution, 
34, 35 
relation to height, 35 
Weil, Handbook of Topographical 
Percussion, quoted, 112 
-Luschka, quoted, 78, 79 
quoted, 113, 122, 123, 125 
reference to, 116, 121, 130, 132, 
133,192, 206, 207, 259, 304, 306, 
312, 319, 321, 327, 332 (note), 
333, 336, 338, 393 
Wernicke, reference to, 552, 553, 555, 
556, 558, 601 
Westphal, reference to, 498, 499, 525, 
527 
Westphal’s view of tendon reflexes, 
500 
Whispered voice, auscultation of, 159 
White blood-corpuscles in sputum, 176 
increased proportion of, 
to red, in anaemia, 275 
in urine of cystitis, 419 
normal proportion of, to 
red, 278 
with haematoidin needles, 
432 
corpuscles, increase of, in leukae- 
mia shown by microscope, 279 
White kidney, large, fatty casts in 
urine of, 423 
dropsy with, 440 
form of epithelium in 
urine of, 421 
lipuria in, 447 
Whooping-cough, effect of, on venous 
circulation, 263 
expansion of lungs after, 136 
expiratory bulging in, 98 
microbe of, 190 
phenomena of, described, 166 
relation to emphysema, 22 
severe cough of, a cause of 
emphysema of skin, 56 
vomiting in, 358 
Will, conscious, participation in co- 
ordination, 528 
Williams’s tracheal tone described, 
111, 121, 131, 132 
Willis, circle of, 461 
Wintrich, reference to, 104 
Wintrich’s change of sound described, 
111, 132, 159 
Woillez’s cystometer, 163 
Wolff, reference to, 246 
Women apt to conceal disease, 20 
Word-blindness, testing for, 556 
-deafness, 55, 461 
defined, 552 
testing for, 556 
the condition of the hearing 
must be determined in, 573 
Worms, a cause of epileptiform attacks 
in children, 533 
Wrisberg, cartilages of, 591 
Writer’s cramp, 532, 561 
Writing, an acquired faculty, 549 
centre for, 557 
diagnostic value of the character 
of, 561 
disturbances of power of, 549 
how acquired, 549 
Wunderlich, quoted, 65, 68, 69, 70 
Wunderlich’s table of temperatures, 61 
crystals, 433 
YEAST cells in sputum, 190 
fungus in urine, important when 
there is sugar, 428 
Yellow atrophy of liver, acute, dimi- 
nution of phosphates 
in urine with, 435 700 
INDEX. 
Yellow atrophy of liver, acute, leucin 
and tyrosin in urine 
of, 432 
acute, urea diminished 
in, 434 
diminished area of dul- 
ness with, 331 
fever, hsemato-jaundice in, 47 
hemorrhage of stomach in, 
362 
ZEISS’ apparatus for polarization, 
447 
reference to, 175, 274, 281, 447 
Zenker, reference to, 179 
Ziehl, reference to, 187 
Ziemssen, reference to, 164, 302, 508, 
593, 594, 596, 598, 599 
Zimmerlin, reference to, 524, 525 
Zygoma, what palpation above and 
below shows, 537 
Zygomatic nerve illustrated, 485 CATALOGUE OF 
1EDICAL AID SURGICAL WORKS 
PUBLISHED BY 
W. B. SAUNDERS, 
JVo. 913 Walnut Street, Philadelphia, Pa. 
INDEX. 
AUTHORS AND SUBJECTS. page 
American Text-Book of Diseases of Children 6 
American Text-Book of Practice 4, 5 
American Text-Book of Surgery 2, 3 
Ashton’s Obstetrics . . 18 
Ball’s Bacteriology 22 
B rockway’s Physics 23 
Cerna’s Notes on the Newer Remedies 14 
Chapman’s Medical Jurisprudence and Toxicology . . . .13 
Cohen & Eshner’s Diagnosis 21 
Cragin’s Gynaecology 19 
Da Costa’s Manual of Surgery 14 
De Schweinitz’s Diseases of the Eye 8 
Garhigue’s Diseases of Women 15 
Gross’s Autobiography 10 
Hare’s Physiology 16 
Hampton’s Nursing : Its Principles and Practice 14 
Jackson and Gleason’s Diseases of Eye, Nose, and Throat . . 20 
Keating’s Pronouncing Dictionary of Medicine 9 
Keating’s How to Examine for Life Insurance 11 
Martin’s Surgery 17 
Martin’s Minor Surgery, Bandaging, and Venereal Diseases . . 20 
Morris’ Materia Medica and Therapeutics 18 
Morris’ Practice of Medicine 19 
Nancrede’s Anatomy and Manual of Dissection 12 
Nancrede’s Anatomy 17 
Norris’ Syllabus of Obstetrical Lectures 15 
Powell’s Diseases of Children 21 
Saunders’ Pocket Medical Formulary , 11 
Saunders’ Pocket Medical Lexicon . . . . • . . . .15 
Saunders’ Series of Manuals 12 
Saunders’ Series of Question Compends 16 
Sayre’s Practice of Pharmacy 22 
Semple’s Pathology and Morbid Anatomy 18 
Semple’s Legal Medicine, Toxology, and Hygiene . . . .20 
Senn’s Syllabus of Lectures on Surgery 14 
Shaw’s Nervous Diseases and Insanity 22 
Stelwagon’s Diseases of the Skin 19 
Stevens’ Practice of Medicine 13 
Stevens’ Materia Medica and Therapeutics 14 
Stewart and Lawrence’s Medical Electricity 23 
Thornton’s Dose-Book and Prescription Writing 23 
Transactions of the American Climatological Association . . 24 
VlERORDT AND STUART’S MEDICAL DIAGNOSIS 7 
Wolff’s Chemistry 17 
Wolff’s Examination of Urine 21 
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4 VOLUME II. (Ready Shortly) will contain: 
Urine (Chemistry and Microscopy). 
JAMES W. HOLLAND, M D., 
Professor of Medical Chemistry and Toxicology, Jefferson Medical College, Phila- 
delphia. 
Kidneys and Lungs. 
FRANCIS DELAFIELD, M.D., 
Professor of Pathology and Practice of Medicine, College of Physicians and Surgeons, 
New York City. 
Air*passages (Larynx and Bronchi) and Pleura. 
JAMES C. WILSON, M.I)., 
Professor of Practice of Medicine and of Clinical Medicine, Jefferson Medical College, 
Philadelphia. 
Pharynx, (Esophagus, Stomach, and Intestines (Including Intestinal Parasites). 
WILLIAM PEPPER, M.D., 
Provost and Professor of the Theory and Practice of Medicine and of Clinical Medicine, 
University of Pennsylvania. 
Peritoneum, Liver, and Pancreas. 
R. II. FITZ, M.D., 
Shattuck Professor of Pathological Anatomy, Harvard Medical School. 
Diathetic Diseases (Rheumatism, Rheumatoid Arthritis, Gout, Litlueuiia, and Diabetes). 
HENRY M. LYMAN, M.D., 
Professor of Principles and Practice of Medicine, Rush Medical College, Chicago, 111. 
Heart, Aorta, Arteries, and Veins. 
E. G. JANEWAY, M.I)., 
Professor of Principles and Practice of Medicine, Bellevue Hospital Medical College, 
New York City. 
Blood and Spleen. 
WILLIAM OSLER, M.D., 
Professor of Practice of Medicine, Johns Hopkins University, Baltimore, Md. 
Inflammation, Embolism, Thrombosis, Fever, and Bacteriology. 
W. H. WELCH, M.D., 
Professor of Pathology, Johns Hopkins University, Baltimore, Md. 
The articles are not written as though addressed to students in lectures, but are exhaust- 
ive descriptions of diseases with the newest facts as regards Causation, Symptomatology, 
Diagnosis, Prognosis, and Treatment, and will include a large number of approved 
Formulae. The recent advances made in the study of the bacterial origin of various 
diseases are fully described, as well as the bearing of the knowledge so gained upon 
prevention and cure. The subjects of Bacteriology as a whole and of immunity are 
fully considered in a separate section. 
Methods of diagnosis are given the most minute and careful attention, thus enabling 
the reader to learn the very latest methods of investigation without consulting works 
specially devoted to the subject. 
5 IN PREPARATION. 
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AN AMERICAN TEXT-BOOK 
OF THE 
MEDICAL AND SURGICAL 
DISEASES OF CHILDREN. 
BY 
Dr. S. S. Adams, Washington. 
John Ashhurst, Jr., Philadelphia. 
A. D. Blackador, Montreal, Can. 
Dillon Brown, New York. 
Edw. M. Buckingham, Boston. 
W. E. Casselberry, Chicago. 
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Archibald Church, Chicago. 
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John Doming, New York. 
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W. A. Hardaway, St. Louis. 
M. P. Hatfield, Chicago. 
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Dr. Henry Koplik, New York. 
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J. Hendrie Lloyd, Philadelphia. 
Henry M. Lyman, Chicago. 
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J. Madison Taylor, Philadelphia. 
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Victor C. Vaughan, Ann Arbor, 
Thompson S. Westcott, Philada. 
Henry R. Wharton, Philadelphia. 
J. Wm. White, Philadelphia. 
J. C. Wilson, Philadelphia. 
Samuel E. Woody, Louisville. 
6 For Sale by Subscription only. 
Now Heady—Second Revised Edition. 
Medical Diagnosis. 
BY 
DR. OSWALD VIERORDT, 
Professor of Medicine at the University of Heidelberg ; formerly Privat Docent at University of 
Leipzig; Professor of Medicine and Director of the Medical Polyclinic at the Univ. of Jena. 
Translated, with additions, from the Second Enlarged German Edition, 
with the Author’s Permission. 
BY 
FRANCIS H. STUART, A.M., M.D., 
Member of the Medical Society of the County of Kings, N. Y. ; Fellow of the New York Academy of 
Medicine; Member of the British Medical Association, etc. 
In one handsome royal octavo volume of 700 pages, 
178 fine wood-cuts in text, many of which are in colors. 
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“ Indispensable to both ‘ students and practitioners.’ ” 
(Signed) F. MINOT, M.D., 
Hersey Professor of Theory and Practice of Medicine, Harvard University. 
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Assistant. Professor Clinical Medicine, University of Pennsylvania. 
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Professor of Practice of Medicine and General Pathology, 
Nashville Medical College, Nashville, Tenn. 
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reference.” 
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7 For Sale by Subscription only. 
NOW READY. 
DISEASES OF THE EYE. 
A Hand-Book of Ophthalmic Practice. 
BY 
G. E. de SCHWEIN1TZ, M.D., 
Professor of Diseases of the Eye, Philadelphia Polyclinic; Professor of Clinical Ophthalmology, Jefferson 
Medical College, Philadelphia ; Ophthalmic Surgeon to Children s Hospital and to the Philadelphia 
Hospital; Ophthalmologist to the Orthopaedic Hospital and Infirmary for Nervous Diseases; 
late Lecturer on Medical Ophthalmoscopy, University of Pa., etc. 
FORMING A HANDSOME ROYAL 8vo. VOLUME OF MORE THAN 600 PAGES. 
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in the University of Pennsylvania. 
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(Signed) WILLIAM THOMSON, M.D., 
Ih'ofessor of Ophthalmology, Jefferson Medical College, Philadelphia, Pa. 
“ One of the best hand-books now extant on the subject.” 
(Signed) J. O. STILLSON, M.D., 
Professor of Eye and Ear, Central College Physicians and Surgeons, Indianapolis, Ind. 
“ Vastly superior to any book on the subject with which I am familiar.” 
(Signed) FRANCIS HART STUART, M.D., 
Brooklyn, N. Y. 
“ Contains in the most attractive and easily understood form just the sort of 
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surgery.” 
(Signed) J. WILLIAM WHITE, M.D., 
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A NEW PRONOUNCING 
DICTIONARY OF MEDICINE, 
WITH 
Phonetic Pronunciation, Accentuation, Etymology, etc. 
BY 
JOHN M. KEATING, M.D, LL.D, 
Fellow of the College of Physicians of Philadelphia; Vice-President of the American Paediatric 
Society ; Ex-President of the Association of Life Insurance Medical Directors; 
Editor “ Cyclopaedia of the Diseases of Children,” Etc. ; 
AND 
HENRY HAMILTON, 
Author of a “A new Translation of Virgil’s vEneid into English Rhyme ;” 
Co-Author of “ Saunders' Medical Lexicon,” Etc. 
WITH THE COLLABOKATION OP 
J. CHALMERS 1)a COSTA, M.D, and FREDERICK A. PACKARD, M.D. 
WITH AN APPENDIX 
CONTAIN IN Or IMPOKTANT TABLES OP BACH,LI, MICKOCOCCI, LEUCOMA1NES, 
PTOMAINES; DRUGS AND MATERIALS USED IN ANTISEPTIC SURGERY; 
POISONS AND THEIR ANTIDOTES; WEIGHTS AND MEASURES; 
THERMOMETRIC SCALES ; NEW OFFICINAL AND 
IINOPFICINAL DRUGS, ETC. ETC. 
Forming One very Attractive Volume of over 800 Pages. 
Price, Cloth, $5.00 net; Sheep, $6.00 net; Half Russia, $6.50 net, 
With Denison’s Patent Index for Ready Reference. 
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classes.5 ? 
(Signed) HENRY M. LYMAN, M.D., 
Professor of Principles and Practice of Medicine, Rusk Medical College, Chicago, III. 
“Iam convinced that it will be a very valuable adjunct to my study table, convenient in size and 
sufficiently full for ordinary use.'’ 
(Signed) C. A. LINDSLEY, M.D., 
Professor of Theory a nd Practice of Medicine, Medical Dept. Yale University, 
Secretary Connecticut State Board of Health, New Haven, Connecticut. 
“ I will point out to my classes the many good features of this book as compared with others, which 
will, I am sure, make it very popular with students.” 
I Signed) JOHN CRONYN, M.D., LL.D., 
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President, of the Faculty, Medical Dept. Niagara University, Buffalo, N. V. 
“ My examination and use of it have given me a very favorable opinion of its merit, and it will give 
me pleasure to recommend its use to my class.” 
(Signed) J. W. H. LOVEJOY, M.D., 
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Medical Dept. Georgetown University, Washington, D. C. 
9 Second Edition, for Sale by Subscription. 
AUTOBIOGRAPHY 
of 
SAMUEL 1). GROSS, M.D.. 
D. C. L. OXON., LL.D. CANTAB., EDIN., JEFF. COLL., UNIV. PA., EMERITUS PROFESSOR 
OF SURGERY IN THE JEFFERSON MEDICAL COLLEGE OF PHILADELPHIA. 
WITH REMINISCENCES OF 
HIS TIMES AND CONTEMPORARIES. 
Edited by his Sons, Samuel W. Gross, M.D., LL.D., lute Professor of Principles 
of Surgery and of Clinical Surgery in the Jefferson Medical College, 
and A. Haller Gross, A.M., of the Philadelphia Bar. 
Preceded by a Memoir of Dr. Gross by the late Austin Flint, M.D., LL.D. 
lu two handsome volumes, each containing over 400 pages, 
demy 8vo., extra cloth, gilt tops, with tine Frontispiece 
engraved on steel. 
Price . . . $5.00 net. 
THIS Autobiography, which was continued by the late eminent 
Surgeon until within three months before his death, con- 
tains a full and accurate history of his early struggles, trials, 
and subsequent successes, told in a singularly interesting and 
charming manner, and embraces short and graphic pen portraits 
of many of the most distinguished men — surgeons, physicians, 
divines, lawyers, statesmen, scientists, etc. etc.—with whom he was 
brought in contact in this country and in Europe; the whole 
forming a retrospect of more than three quarters of a century. 
10 SAUNDERS’ 
POCKET MEDICAL FORMULARY. 
By WILLIAM M. POWELL, M.D., 
Attending Physician to the Mereer House for Invalid Women, at Atlantic City. 
CONTAINING 
1750 Formulae, selected from several hundreds of the best known authorities. 
Forming a handsome and convenient Pocket Companion of nearly 300 printed pages, 
with blank leaves for additions. 
Second Edition, Revised and greatly Enlarged. 
Handsomely bound in Morocco, with side index, wallet, and flap. 
Price, $1.75 net. 
Therapeutic Gazette, January, 1892. 
“ The prescriptions have been taken from the writings or practice of Physicians whose experience 
qualities them to be worthy of trial. We heartily recommend this volume to all who desire to purchase 
such a work.” 
New York Medical Record, February 27, 1892. 
‘‘This little book, that can be conveniently carried in the pocket, contains an immense amount of 
material. It is very useful, and as the name of the author of each prescription is given, is unusually 
reliable.” 
SECOND EDITION. 
HOW TO EXAMINE EOR LIFE INSURANCE. 
By JOHN M. KEATING, M.D., 
Fellow of the College of Physicians and Surgeons of Philadelphia; Vice-President of the American 
Paediatric Society; Ex-President of the Association of Life Insurance Medical Directors. 
Royal 8vo., 211 pages, with two large Phototype Illustrations, and a 
Plate prepared by Dr. McClellan from special Dissections ; 
also, numerous Cuts to elucidate the text. 
Price, in Cloth, $2.00, 
PART I. has been carefully prepared from the best works on Physical Diagnosis, and is 
a short and succinct account of the methods used to make examinations ; a descrip- 
tion of the normal condition, and of the earliest evidences of disease. 
PART II. contains the Instructions of twenty-four Life Insurance Companies to their 
medical examiners. 
PRESS NOTICES. 
“ This is by far the most useful Dook which has yet appeared on insurance examination, a subject of 
growing interest and importance. Not the least valuable portion of the volume is Part II., which 
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"The volume is replete with information and suggestions, and is a valuable contribution to th2 
literature of the medical department of life underwriters’ work.”—The United States Review (In- 
surance Journal). 
11 S BATTUE" ID IE IRS’ 
SERIES OE 
Manuals for Students and Practitioners. 
The aim of the Publisher is to furnish, in this Series of Manuals, a number of 
high-class works by prominent teachers who are connected with the principal 
Colleges and Universities of this country; the position and experience of each 
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he writes. 
Especial care has been exercised in the choice of large, clear, readable type; a 
high grade of slightly toned paper, of a shade particularly adapted for reading 
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clear elucidation of the text; and strong, attractive, and uniform bindings. 
The prices vary greatly ($1.00 to $2.50), it not being considered desirable to 
fix an arbitrary standard and pad the volumes accordingly. 
Now Ready—Fourth Edition. 
CONTAINING 
OIST DISSECTION.” 
ESSENTIALS OF ANATOMY AND MANUAL OF PRACTICAL DISSECTION. 
By CHARLES B. NANCREDE, M.D., 
Professor of Surgery and Clinical Surgery in the University of Michigan, Ann Arbor ; Corresponding 
Member of the Royal Academy of Medicine, Rome, Italy ; late 
Surgeon Jefferson Medical College, etc. etc. 
Post 8to., nearly 500 pages, with Handsome Full-page Lithographic Plates in Colors. Over 200 Illustrations. 
Price, Extra Cloth or Oilcloth for the Dissection Room, $2.00, net. 
No pains or expense has been spared to make this work the most exhaustive 
yet concise Student’s Manual of Anatomy and Dissection ever published, either 
in this country or Europe. 
The colored plates are designed to aid the student in dissecting the muscles, 
arteries, veins, and nerves. For this edition the wood-cuts have all been speci- 
ally drawn and engraved, and an Appendix added containing 60 illustrations 
representing the structure of the entire human skeleton, the whole based on 
the eleventh edition of Gray’s Anatomy, and forming a handsome post Svo. 
volume of over 400 pages. 
12 A MANUAL OF 
PRACTICE OF MEDICINE. 
By A. A. STEVENS, A.M., M.D., 
instructor of Physical Diagnosis in the University of Pennsylvania and Demonstrator of Pathology in 
the Woman’s Medical College of Philadelphia. 
Specially Intended for Students Preparing for Graduation and 
Hospital Examinations. 
Including the following sections: General Diseases, Diseases of the Digestive Organs, Diseases of 
the Respiratory System, Diseases of the Circulatory System, Diseases of the Nervous System, Diseases 
of the Blood, Diseases of the Kidneys, and Diseases of the Skin. Each Section is prefaced by a chapter 
on General Symptomatology. 
Post 8vo., 502 pages. Numerous Illustrations and Selected Formulae. 
JPrice, $2.50. 
Contributions to the Science of Medicine have poured in so rapidly during the last quarter 
of a century that it is well-nigh impossible for the Student, with the limited time at his dis- 
posal, to master elaborate treatises or to cull from them that knowledge which is absolutely 
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redundant explanations, to bring within a comparatively small compass a complete outline 
of the Practice of Medicine. 
JUST READY. 
-A. M-A-lNTCr-A-iE-, OIF1 
Medical Jurisprudence and Toxicology. 
By HENRY C. CHAPMAN, M.D., 
Professor of Institutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of 
Philadelphia. 
WITH THIRTY-SIX ILLUSTRATIONS, SOME OF WHICH ARE IN COLORS. 
POST 8vo., 232 PAGES. 
Price, $1.25 net. 
For many years there has been a demand from members of the medical and legal profes- 
sions for a medium-sized work on this most important branch of Medicine. The necessarily 
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subject which the experience of the author as coroner’s physician of the city of Philadelphia 
for a period of six years leads him to regard as the most material for practical purposes. 
Particular attention is drawn to the illustrations, many being produced in colors, thus 
conveying to the layman a far clearer idea of the more intricate cases. The following Manuals now preparing will he issued shortly. 
NURSING: 
Its Principles and Practice 
FOR HOSPITAL AND PRIVATE USE. 
By ISABEL ADAMS HAMPTON, 
Craduate of the New York Training School for Nurses attached to Bellevue Hospital; Superintendent 
of Nurses and Principal of the Training School for Nurses, Johns Hopkins Hospital, Baltimore, 
Md.; Late Superintendent of Nurses, Illinois Training School for Nurses, Chicago, Illinois. 
This book will outline a definite, systematic course of teaching for pupil-nurses with a 
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Thoroughly tested and most approved processes are given in all the details of practical 
nursing, particularly in antiseptic surgery, and the minutest details regarding the nurse’s 
technique have been explained. 
The methods used in Johns Hopkins Hospital have in all cases been noted as the autlioritv. 
A Syllabus of Lectures on the Practice of Surgery 
ARRANGED IN CONFORMITY WITH 
THE AMERICAN TEXT-BOOK OF SURGERY. 
By NICHOLAS SENN, M.D., Ph.D., 
Professor of Surgery in Rush Medical College, Chicago, and in the Chicago Polyclinic. 
A Manual of Materia Medica and Therapeutics. 
By A. A. STEVENS, A.M., M.D., 
Instructor of Physical Diagnosis in the University of Pennsylvania and Demonstrator of Pathology in 
the Woman’s Medical College of Philadelphia. 
A Manual of Surgery—General and Operative. 
By JOHN CHALMERS I)A COSTA, M.D. 
NOW READY. 
NOTES ON THE NEWER REMEDIES. 
THEIR * 
Therapeutic Applications and Modes of Administration. 
By DAVID CERNA, M.D., Ph.D., 
Demonstrator of and Lecturer on Experimental Therapeutics in the University of Pennsylvania. 
POST OCTAVO, 175 PAGES. 
Price, $1,25. 
The work takes up in alphabetical order .all the Newer Remedies, giving their physical properties, 
solubility, therapeutic applications, administration, and chemical formula. 
It will, in this way, form a very valuable addition to the various works on Therapeutics now in existence. 
Chemists are so multiplying compounds, tliat if each compound is to be thoroughly studied, investiga- 
tions must be carried far enough to determine the practical importance of the new agents. 
Brevity and conciseness compel the omission of all biographical references. SYLLABUS OF OBSTETRICAL LECTURES 
IN THE 
MEDICAL DEPARTMENT, UNIVERSITY OF PENNSYLVANIA. 
By RICHABD C. NORRIS, A.M., M.D., 
Demonstrator of Obstetrics in the University of Pennsylvania. 
SECOND EDITION, THOROUGHLY REVISED AND ENLARGED. 
CROWN 8vo. 
Price, Cloth, Interleaved for Notes, $2.00 net. 
The New York Medical Record, of April 19, 1890, referring to this book, says: “This modest little 
work is so far superior to others on the same subject that we take pleasure in calling attention briefly 
to its excellent features. Small as it is, it covers the subject thoroughly, and will prove invaluable to 
both the student and the practitioner as a means of fixing in a clear and concise form the knowledge 
derived from a perusal of the larger text-books. The author deserves great credit for the manner in 
which he lias performed his work. He has introduced a. number of valuable hints which would only 
occur to one who was himself an experienced teacher of obstetrics. The subject-matter is clear, forcible, 
and modern. "\Ye are especially pleased with the portion devoted to the practical duties of the accoucheur, 
care of the child, etc. The paragraphs on antiseptics are admirable : there is no doubtful tone in the 
directions given. No details are regarded as unimportant; no minor matters omitted. We venture to say 
that oven the old practitioner will find useful hints in this direction which he cannot afford to despise.” 
SAUNDERS’ POCKET MEDICAL LEXICON; 
OR, 
DICTIONARY OF TERMS AND WORDS USED IN MEDICINE AND SURGERY. 
By JOHN M. KEATING, M.D., 
Editor of “Cyclopaedia of Diseases of Children,” etc. ; Author of the “New Pronouncing Dictionary of 
Medicine,” 
AND 
HENRY HAMILTON, 
Author of “A New Translation of Virgil’s JEneid into English Verse;” Co-author of a “New Pro- 
nouncing Dictionary of Medicine.” 
32mo.; 282 Pages. 
PRICE, 75 CENTS. CLOTH; $1.00, LEATHER TUCKS. 
This new and comprehensive work of reference is the outcome of a demand for a more modern hand- 
book of its class than those at present on the market, which, dating as they do from 1855 to 1884, are 
of but trifling use to the student by their not containing the hundreds of new words now used in current 
literature, especially those relating to Electricity and Bacteriology. 
IN PREPARATION. 
DISEASES OE WOME^E 
By HENRY J. GARRIGUES, A.M., M.D., 
Professor of Obstetrics in the New York Post-Graduate Medical School and Hospital; Gynaecologist to 
St Mark’s Hospital in New York City; Gynaecologist to the German Dispensary in the City of 
' ' New York - Consulting Obstetrician to the New York Infant Asylum ; Obstetric Surgeon 
to the’New York Maternity Hospital; Fellow of the American Gynaecological 
Society; Fellow of the New York Academy of Medicine; President of 
the German Medical Society of the City of New York, etc. etc. 
It is the intention of the writer to provide a practical work on Gynaecology, for the use of students 
and practitioners, in as concise a manner as is compatible with clearness. 
15 SAUNDERS' QUESTION COMPENDS. 
Now the Standard Authorities in Medical Literature 
WITH 
Students and Practitioners in every City of the United States 
and Canada. 
THE REASON WHY! 
They are the advance guard of “Student’s Helps”—that no help ; they are the leaders 
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Each book is of convenient size (5 by 7 inches), containing on an average 250 pages, pro- 
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TO SUM UP. 
Although there are numerous other Quizzes, Manuals, Aids, etc., in the market, none of 
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lowing points of excellence :— 
1. Professional standing and reputation of authors. 
2. Conciseness, clearness, and standard of text. 
3. Size of type, quality of paper and binding. 
No. 1. 
ESSENTIALS OF PHYSIOLOGY. 
By H. A. HARE, M.D., 
Professor of Therapeutics and Materia Medica in the Jefferson Medical College of Philadelphia; 
Physician to St. Agnes’ Hospital and to the Medical Dispensary of the Children's Hospital; 
Laureate of the Royal Academy of Medicine in Belgium, of the Medical Society of London, etc.; 
Secretary of the Convention for the Revision of the Pharmacopoeia, 1890. 
THIRD EDITION, 
Revised and Enlarged by the addition of a series of handsome Plate 
Illustrations taken from the celebrated “ leones Nervorum 
Capitus” of Arnold. Crown 8vo. 230 pages. Numerous 
Illustrations. 
Price, Cloth, $1.00 net. Interleaved for notes, $1.25 net 
t mverslity Medical Magazaw.—“Dr. Hare has admirably succeeded in gathering together a 
senes of questions which a,re clearly put and tersely answered.” 
Buffalo Medical and Surgical Reporter.—“The subject of Physiology is concisely and accurately 
considered.” 
Journal of American Medical Association. — “ An exceedingly useful little compend. The author has 
tone his work thoroughly and well. The plates of the cranial nerves from Arnold are superb.” 
16 No. 2. 
Essentials of Surgery. 
CONTAINING ALSO, 
Venereal Diseases, Surgical Landmarks, Minor and Operative Surgerv, and a Comnlet® 
Description, together with full Illustrations, of the 
Handkerchief and Roller Bandage. 
By EDWARD MARTIN, A.M., M.D., 
Clinical Professor of Genito-Uriuary Diseases, Instructor in Operative Surgery, and Lecturer on 
Minor Surgery, University of Pennsylvania; Surgeon to the Howard Hospital- 
Assistant Surgeon to the University Hospital, etc. etc. 
FOURTH EDITION. CROWN 8vo. 834 PAGES, PROFUSELY ILLUSTRATED. 
Considerably enlarged by an Appendix containing full directions and prescriptions for the preparation 
ot the various materials used in ANTISEPTIC SURGERY ; also several hundred 
recipes covering the medical treatment of surgical affections. 
PRICE, CLOTH, . . $1.00. INTERLEAVED FOR NOTES, . . $1.25. 
Huston Medical and Surgical Journal.—-‘-Written to assist the student, it will he of undoubted value 
to the practitioner, containing as it does the essence of surgical work.” 
Medical and Surgical Reporter.—“Contains all necessary essentials of modern surgery in a compara- 
tively small space. Its style is interesting and its illustrations admirable.” 
No. 3. 
Essentials of Anatomy, 
Including the Anatomy of the Viscera. 
By CHARLES B. NANCREDE, M.D., 
Professor of Surgery and of Clinical Surgery in the University of Michigan, Ann Arbor; Corresponding 
Member of the Koyal Academy of Medicine, Rome, Italy; Late Surgeon 
to the Jefferson Medical College, etc. etc. 
FOURTH EDITION. CROWN 8yo. 380 PAGES, 180 ILLUSTRATIONS. 
Enlarged by an Appendix containing over Sixty Illustrations of the Osteology of the 
Human Body. The whole based upon the last (eleventh) edition of 
GRAY'S AlSr^TOUVEY- 
PRICE, CLOTH, . . $1.00. INTERLEAVED FOR NOTES, . . $1.25. 
American Practitioner and News, Louisville, Kentucky.—“ Nancrede’s Anatomy.—Truly such a 
book as no student can afford to be without.” 
University Medical Magazine.—“ The questions have been wisely selected, and the answers accu- 
rately and concisely given.” 
No. 4. 
Essentials of Iedical Chemistry 
ORGANIC AND INORGANIC. 
CONTAINING ALSO, 
(Questions oo Medical Physics, Chemical Physiology, Analytical Processes, 
Urinalysis, and Toxicology. 
By LAWRENCE WOLFF, M.D., 
Demonstrator of Chemistry, Jefferson Medical College : Visiting Physician to German Hospital 
of Philadelphia; Member of Philadelphia College of Pharmacy, etc. etc. 
THIRD AM) REVISED EDITION, WITH AN APPENDIX. CROWN 8vo. 212 PAGES. 
Price, Cloth, $1.00. Interleaved for Notes, $1.25. 
Pharmaceutical Era.—“ Wolff’s Chemistry.—The scope of this work is certainly equal to that of the 
best course of lectures on Medical Chemistry.” 
Medical and Surgical Reporter. — “ We could wish that more books like this would be written, in 
order that medical students might thus early become more interested in what is often a difficult and 
uninteresting branch of medical study.” No. 5. 
ESSENTIALS OF OBSTETRICS. 
By W. EASTERLY ASHTON, M.D., 
Professor of Gynaecology in the Medico-Chirurgical College of Philadelphia ; Obstetrician to the 
Philadelphia Hospital. 
THIRD EDITION, THOROUGHLY REVISED AND ENLARGED 
Crown 8vo.; 244 Pages; 75 Illustrations. 
Price, Cloth,' $1.00. Interleaved for Notes, $1.25. 
Southern Practitioner.—“An excellent little volume containing correct and practical knowledge. 
An admirable compend, and the best condensation we have seen.” 
Chicago Medical Times.—“Of extreme value to students, and an excellent little book to freshen up 
the memory of the practitioner.” 
No. 6. 
Essentials of Pathology and Morbid Anatomy. 
BY 
C. E. ARM AND SEMPLE, B.A., M.B. Cantab., L.S.A., M.R.C.P. Lond, 
Physician to the Northeastern Hospital for Children, Harkney ; Professor of Vocal and Aural Physi- 
ology and Examiner in Acoustics at Trinity College, London, etc. etc. 
Crown 8vo.; 174 Pages; Illustrated; Sixth Thousand. 
Price, Cloth, $1.00. Interleaved for Notes, $1.25. 
Indiana Medical Journal, December, 1889. — “Semple’s Pathology and Morbid Anatomy.—An 
excellent compend of the subject from the points of view of Green and Payne.” 
Cincinnati Medical News, November, 1889.—“Semple’s Pathology and Morbid Anatomy.—A valu- 
able little volume—truly a multum in parvo." 
No. 7o 
Essentials of Materia Medica, Therapeutics, 
AND 
PRESCRIPTION WRITING. 
By HENRY MORRIS, M.D., 
Late Demonstrator, Jefferson Medical College ; Fellow College of Physicians, Philadelphia ; Co-Editor 
Biddle’s Materia Medica ; Visiting Physician to St. Joseph’s Hospital, etc. etc. 
Second Edition ; Crown 8vo. ; 250 Pages. 
Price, Cloth, $1.00. Interleaved for Notes, $1.25. 
Medical andSurgical Reporter, October, 1889.—“Morris’ Materia Medica and Therapeutics.—One of the 
best compends in this series. Concise, pithy, and clear, well suited to the purpose for which it is prepared ” 
Gaillard's Medical Journal, November, 1889.—“Morris’ Materia Medica.—The very essence of 
Materia Medica and Therapeutics boiled down and presented in a clear and readable style.” 
Buffalo Medical and Surgical Journal, January, 1890.—“Morris’ Materia Medica.—The subjects 
are treated in such a unique and attractive manner that they cannot fail to impress the mind and 
instruct in a lasting manner.” 
18 Nos. 8 and 9. 
ESSENTIALS OF PRACTICE OF MEDICINE. 
By HENRY MORRIS, M.D., 
Author of “ Essentials of Materia Medica,” etc. 
With an Appendix on the Clinical and Microscopical Examination of Urine. 
By LAWRENCE WOLFF, M.D., 
Author of “ Essentials of Medical Chemistry,” etc. 
COLORED (VOGEL) URINE SCALE AND NUMEROUS FINE ILLUSTRATIONS. 
Second Edition, Enlarged by some Three Hundred Essential Formulas, selected from the 
writings of the most eminent authorities of the Medical Profession. 
COLLECTED AND ARRANGED BY 
WILLIAM M. POWELL, M.D., 
Author of “Essentials of Diseases of Children.” 
Post 8vo., 460 pages. Price, Cloth, $2.00. Medical Sheep, $2.50. 
American Practitioner and News, Louisville, Ky.—“ The teaching is sound, the presentation graphia, 
matter as full as might be desired, and the style attractive.” 
Medical Brief, St. Louis.—“ A first-class practice of medicine boiled down, and giving the real essen- 
tials in as few words as is consistent with a thorough understanding of the subject.” 
No. 10. 
ESSENTIALS OP GYNECOLOGY. 
By EDWIN B. CRAIGIN, M.D., 
Attending Gynaecologist, Roosevelt Hospital, Out-Patients’ Department; Assistant Surgeon, New York 
Cancer Hospital, etc. etc. 
SECOND EDITION. 
Crown 8vo.; 186 Pages; 58 Fine Illustrations. 
Price, Cloth, $1.00. Interleaved for Notes, $1.25. 
Medical and Surgical Reporter.—“Craigin’s Essentials of Gynmcology.—This is a most excellent 
addition to this series of question compends, and properly used will be of great assistance to the student 
in preparing for examination. Dr. Craigin is to be congratulated upon having produced in compact 
form the Essentials of Gynaecology. The style is concise, and at the same time the sentences are well 
rounded. This renders the book far more easy to read than most compends, and adds distinctly to its 
value.” 
No. 11. 
ESSENTIALS OF DISEASES OF THE SKIN. 
By HENRY W. STEL WAGON, M.D., 
Clinical Lecturer on Dermatology in the Jefferson Medical College, Philadelphia ; Physician to the Skin 
Service of the Northern Dispensary; Dermatologist to Philadelphia Hospital; Physician to 
Skin Department of the Howard Hospital: Clinical Professor on Dermatology 
in the Woman’s Medical College, Philadelphia, etc. etc. 
SECOND EDITION. 
Crown 8vo. ; 262 Pages; 74 Illustrations, many of which are Original. 
Price, Cloth, $1.00. Interleaved for Notes, $1.25. 
Medical Record, New York.—“An immense amount of literature has been gone over and judiciously 
condensed by the writer’s skill and experience. ” . . , _ . , „ „ 
New York Medical Journal.—“The little book now before us is well entitled Essentials of 
tology, ’ and admirably answers the purpose which it is written. I he experience of the re e er 
has taught him that just such a book is needed. ’ No. 12. 
ESSENTIALS OF 
Minor Surgery, Bandaging, 
AND 
VENEREA-L DISEASES. 
By EDWAED MARTIN, A M., M.D., 
Author of “ Essentials of Surgery,” etc. 
CROWN 8vo. ; 158 PAGES; 82 ILLUSTRATIONS, 
MOSTLY SPECIALLY PKEPAliED FOK THIS WOKK. 
Price, Cloth, $1.00. Interleaved for Notes, $1.25. 
American Practitioner and News, Louisville.—“Characterized by the same literary excellence that 
has distinguished previous numbers of this series of compends. ” 
Medical News, Philadelphia, January 10, 1891.—“Martin’s Minor Surgery, Bandaging, and Vene 
real Diseases.—The best condensation of the subjects of which it treats yet placed before the profession. 
The chapter on Genito Urinary Diseases, though short, is sufficiently complete to make them thoroughly 
acquainted with the most advanced views on the subject.” 
No- 13. 
ESSENTIALS OF 
Legal Medicine, Toxicology, 
AND 
EL Y GIENE. 
By C. E. ARMAND SEMPLE, M.D., 
Author of “Essentials of Pathology and Morbid Anatomy.” 
CROWN 8vo.; 212 PAGES; 130 ILLUSTRATIONS. 
Price, Cloth, $1.00. Interleaved for Notes, $1.25. 
Southern Practitioner, Nashville.—“The leading points, the essentials of this too much neglected 
portion of medical science, are here summed up systematically and clearly.” 
No. 14. 
Essentials of Refraction and Diseases of the Eye. 
By EDWARD JACKSON, A.M., M.D., 
Professor of Diseases of the Eye in the Philadelphia Polyclinic and College for Graduates in Medicine; 
Member of the American Ophthalrnological Society; Fellow of the College of Physicians 
of Philadelphia; Fellow of the American Academy of Medicine, etc. etc. 
AND 
Essentials of Diseases of the Nose and Throat. 
By E. BALDWIN GLEASON, M.D., 
Assistant in the Nose and Throat Dispensary of the Hospital of the University of Pennsylvania; 
Assistant in the Nose and Throat Department of the Union Dispensary; Member 
of the German Medical Society. Philadelphia; Member 
of tire Polyclinic Medical Society, etc. etc. 
TWO VOLUMES IN ONE. CROWN 8vo. 268 PAGES, PROFUSELY ILLUSTRATED. 
Price, Cloth, $1.00. Interleaved for Rotes, $1,25. 
University Medical Magazine, Philadelphia, October, 1890.—“Jackson and Gleason’s Essentials of 
Diseases of the Eye, Nose, and Throat.—The subjects have been handled with skill, and the student 
who acquires all that here lays before him will have much more than a foundation for future work.” 
New York Medical Record, November 15, 1890.—“Jackson and Gleason on Diseases of the Eye, Nose, 
and Throat.—A valuable book to the beginner in these branches, to the student, to the busy practitioner, 
and as an adjunct to more thorough reading. The authors are capable men, and as successful teachers 
know what a student most needs. ’ ’ 
20 No. 15. 
Essentials of Diseases of Children. 
By WILLIAM M. POWELL, M.D. 
Attending Physician to the Mercer House for Invalid Women at Atlantic Pitv \- i t t>, • i 
to the Clinic for the Diseases of Children in the Hospital of the University 
vama and St Clement’s Hospital : Instructor in Physical DiagnosiJin the Y 
i ledical Department of the University of Pennsylvania. 
Crown 8vo.; 216 Pages. 
Price, Cloth, $1.00. Interleaved for Notes, $1.25. 
American Practitioner and News, Louisville, Ky.—“ Powell’s Diseases of Children—This work is 
gotten up in the clear and attractive style that characterizes the Saunders’ Series. It contains in 
appropriate form the gist of all the best works in the department to which it relates ” 
Annals of Gynaecology, Philadelphia.—“ Powell’s Diseases of Children.—The book contains a series 
of important questions and answers, which the student will find of great utility in the examination of 
children. 
No. 16. 
Essentials of Examination of Urine. 
By LAWRENCE WOLFF, M.D., 
Author of “ Essentials of Medical Chemistry,” etc. 
COLORED (VOGEL) URINE SCALE AND NUMEROUS ILLUSTRATIONS. 
CROWH 8vo. 
Price, Cloth, 75 Cents. 
University Medical Magazine. — “Wolff’s Examination of the Urine.—A little work of decided 
value.” 
Medical Record, New York.—“Wolff’s Examination of Urine.—A good manual for students, well 
written, and answers, categorically, many questions beginners are sure to ask. ” 
No. 17. 
Essentials of Diagnosis: 
By SOLOMON SOLIS COHEN, M.D., 
Professor of Clinical Medicine and Applied Therapeutics in the Philadelphia Polyclinic, 
AND 
AUGUSTUS A. ESHNER, M.D., 
Instructor in Clinical Medicine, Jefferson Medical College, Philadelphia. 
POST 8vo.; 382 PAGES. 
55 Illustrations, some of which are Colored, and a Frontispiece. 
Price, $1.50 net, 
Medical Record, New York.—“A good book for the student, properly written from their standpoint, 
and confines itself well to its text.” . . „ , ,. . 
American Journal of Medical Sciences.—" Concise in the treatment of the subject, terse m expression 
of fact The work is reliable, and represents the accepted views of clinicians of to-day.” 
International Medical Magazine.—" The subjects are explained in a few well-selected words, and the 
reauired eround has been thoroughly gone over. No. 18. 
ESSENTIALS OF PRACTICE OF PHARMACY, 
By LUCIUS E. SAYRE, M I)., 
Professor of Pharmacy and Materia Medica in the University of Kansas. 
Crown 8vo., 171 pages. 
Price, Cloth, $1.00. Interleaved for Notes, $1.25. 
Albany Medical Annals, Albany, N. Y.—“ Sayre’s Essentials of Pharmacy covers a great deal ot 
ground in small compass. The matter is well digested and arranged. The research questions are a 
valuable feature of the book.” 
National Drug Register, St. Louis, Mo.—‘‘Sayre’s Essentials of Pharmacy.—The best quiz on Phar- 
macy we have yet examined. ” 
No. 20. 
ESSENTIALS OP BACTERIOLOGY. 
A Concise and Systematic Introduction to the Study of 
Micro-organisms. 
By M. Y. BALL, M.D., 
Assistant in Microscopy, Niagara University, Buffalo N. Y.; late resident Physician German Hospital, 
Philadelphia, etc. 
Crown 8vo., 150 pages. 77 Illustrations. Some in Colors. 
Price, Cloth, $1.00. Interleaved for Notes, $1.25. 
Medical News, Philadelphia. —11 The amount of material condensed in this little book is so great, 
and so accurate are the formulae and methods, that it will be found useful as a laboratory hand-book.’' 
Pacific Record of Medicine and Surgery, San Francisco.—*‘ Bacteriology is the keynote of future 
medicine, and every physician who expects success must familiarize himself with a knowledge of 
Germ-life—the agents of disease. This little book, with its beautiful illustrations, will give the stu- 
dents, in brief, the results of years of study and research, unaided.” 
No. 21. 
Essentials of Nervous Diseases and Insanity, 
THEIR SYMPTOMS AND TREATMENT. 
By JOHN C. SHAW, M. D., 
Clinical Professor of Diseases of the Mind and Nervous System, Long Island College Hospital Medical 
School; Consulting Neurologist to St. Catherine’s Hospital and Long Island College Hospital; 
Formerly Medical Superintendent King’s County Insane Asylum. 
CROWN 8vo., 186 PAGES, 48 ORIGINAL ILLUSTRATIONS, 
Mostly selected from the Author’s private practice. 
Price, Cloth, $1.00. Interleaved for Notes, $1.25. 
Boston Medical and Surgical Journal—“ Clearly and intelligently written.” 
Medical Brief, Dec. 1891.—‘‘A valuable addition to this series of compends, and one that cannot 
tsul to be appreciated by all physicians and students.” 
Times and Register, New York and Philadelphia.—‘‘Dr. Shaw's Primer is excellent as far as it 
goes. The engravings are well executed and very interesting.” 
22 Uo 22 
ESSENTIALS OF PHYSICS. 
By FRED. J. BROCKWAY, M.I)., 
Assistant Demonstrator of Anatomy in the College of Physicians and Surgeons, New York. 
Crown 8vo., 820 Pages. 
155 FINE ILLUSTRATIONS. 
Price, Cloth, $1.00 net. Interleaved for Notes, $1.25 net. 
American Practitioner and News, Louisville, Ky.—” The publisher has again shown himself as fortu- 
nate in his editor as he ever has been in the attractive style and make-up of his compends. ” 
Medical Record, New York.—“Contains all that one need know of the subject, is well written, and 
is copiously illustrated.” 
Medical News, Philadelphia.—“The author has dealt with the subject in a manner that will make 
tho theme not only comparatively easy, but also of interest.” 
No. 23. 
ESSENTIALS OF MEDICAL ELECTRICITY. 
By 1). D. STEWART, M.D., 
Demonstrator of Diseases of the Nervous System and Chief of the Neurological Clinic in the Jefferson 
Medical College; Physician to St. Mary’s Hospital and to St Christopher’s Hospital for Children, etc. 
AND 
E. S. LAWRANCE, M.D., 
Chief of the Electrical Clinic and Assistant Demonstrator of Diseases of the Nervous System in the 
Jeffersou Medical College, etc. 
Crown 8vo., 148 Pages. 
SIXTY-FIVE ILLUSTRATIONS. 
Price, Cloth, .151.00. Interleaved for Notes, .$1.25. 
Med ical and Surgical Journal, Boston.—“Clearly written, and affords a safe guide to the beginner 
in this subject.” 
Medical Record, New York.—“ The subject is presented in a lucid and pleasing manner.” 
The Hospital, London, England.—” A little work on an important subject, which will prove of great 
value to medical students and trained nurses who wish to study the scientific as well as the practical 
points of electricity.” 
Annals of Surgery, Philadelphia.—” The selection and arrangement of material are done in a skilful 
manner. It gives, in a condensed form, the principles and science of electricity and their application 
in the practice of medicine.” 
In Preparation. 
A 
Dose-Book and Manual of Prescription-Writing. 
By E. Q. THORNTON, 
Demonstrator of Therapeutics, Jefferson Medical College, Philadelphia. 
23 TRANSACTIONS 
OF THE 
EIGHTH ANNUAL MEETING 
OF THE 
American Climatological Association, 
Held at "Washington, D. C.? 
September 22, 23, 24, and 25, 1892. 
Forming a handsome 8vo. volume of 276 pages, uniform 
with the remainder of the series. 
Price, $1.50. 
The following Contributions are included in the volume:— 
J. H. MUSSER, M.D., 
Whooping-cough, its Management and Treatment 
G. M. GARLAND, M.D, 
Medical Treatment of Pleurisy. 
BEVERLEY ROBINSON, M D., 
Catarrhal Inflammations of Upper Air-tract. 
E. L. SHU RLE Y, M.D., 
The Sputum in Pulmonary Consumption. 
EDWARD O. OTIS, M.D., 
Gymnastic Exercise in Chest Diseases. 
ALFRED L. LOOMIS, M.D , 
Histological Changes in Cured Phthisis. 
S. A. FISK, M D., 
Analysis of Cases of Phthisis. 
ROLAND G. CURTIN, M.D., and 
EDWARD W. WATSON, M. D , 
Epidemiology of Influenza. 
MAURICE H. RICHARDSON, MIL, 
Acute and Chronic Empyema. 
WALTER A. JAYNE, M.I)., 
Diphtheria at a High Altitude. 
W. W. JOHNSTON, M.D., 
Chronic Diarrhoea. 
T. H. BOSWORTH, M.D., 
Lymph atism. 
Etc., Etc., Eto. 
24