CORNE LL UNIV ERSITY
THE
FOUNDED BY
ROSWELL P. FLOWER
for the use of the
N. Y. State veterinary College
1897
This Volume is the Gift of
Dr. K. M. Wiegand,
5577
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HC 71.K56
The signs of internal disease, with a bri
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FRONTISPIECE.
Surface Topography During Moderate Expiration.
THE SIGNS OF
INTERNAL DISEASE
With a Brief Consideration of
the Principal Symptoms thereof
BY
Pearce Kintzing, B. Sc, M. D.
Professor of Physical Diagnosis and Diseases of
tlie Heart, Maryland Medical College; Physician
to the Franklin Square Hospital, Baltimore, Md.
ILLUSTRATED
CLEVELAND PRESS
CHICAGO
To
Kicl^arb Armstrong, A. IH., ITl. D.
In remembrance of kindly help and sympathy
during my earliest efforts to acquire
the science of medicine, "
and as a tribute to his f ifty-f our fruitful years of practice,
this book is respectfully dedicated.
PREFACE.
This volume is the outgrowth of my lecture notes. First in-
tended for the students of my classes at the college and hospital, it has
grown gradually to its present proportions, wh,en it seemed worthy of
wider circulation.
While little that is new or original can he said upon certain of
the subjects which have been so well worked over by Da Costa, Loomis
and Gairdner, who stand in their relation to physical diagnosis in the
position occupied by the old masters in the field of art, yet the value
of putting one's ideas and knowledge of a subject into concrete form
for teaching so far surpasses the endeavor to teach from the abstract,
that I offer no other excuse for being chargeable with the offense
implied in Cadmon 's — ' ' Of the making of books there is no end. ' '
Most books upon technical subjects are written by the men of the
schools and the laboratories, who, with the endless resources at their
command, are apt to give small consideration and less preference to
methods better suited to the class of the general profession which
might almost be called its lay-members.
I have strongly endeavored to keep these in mind and to chQOse
always the simpler way when it sufficed.
I am much indebted to Miss Margery Comegys for artistic work
and help on the plates and illustrations and to Dr. F. W. Hachtel for
assistance in proofreading and indexing.
PEARCE KINTZING.
TABLE OF CONTENTS
Section I. Diseases of the Chest
Introduction.
Methods.
Symptom.s and Physical Signs.
Case Taking
History.
Classification of Symptoms.
Stethoscopes.
Phonendoscope.
Section II. Medical Anatomy.
Shapes and Types of T+iorax.
Divisions of the Chest a^d Abdomen.
Description of their Con-tents.
Landmarks.
Thoracic Regions.
Section III. Physical Examinations.
Inspection.
Types of Respiration.
Mensuration.
Palpation.
Fremitus.
The Pulse.
Thrill.
Vascular Phenomena.
Arterial and Venous Bruits.
The Sphygmograph.
The Sphygmometer.
Percussion.
Percussion Scale.
Changes in Percussion Produced by Disease.
Auscultation.
Normal Respiratory Sounds.
I
10 TABLE OP CONTENTS
Altered Respiratory Sounds;
Changes in Respiratory Sounds Produced by Disease.
Adventitious Sounds.
Auscultation of the Voice Spiinds.
Crepitation.
Aids to Diagnosis.
The Laryngoscope.
The Ophthalmoscope.
Section TV. Symptom. =; of Pathologic Conditions of the Chest.
Cough.
Expectoration.
Haemoptysis.
Dyspnoea, Classification of.
Cyanosis.
Clubbing of Fingers and Toes.
Section V. Bronchitis.
Acute.
Chronic.
Emphysema.
Spasmodic or Bronchial Asthma.
Bronchiectasis.
Bronchial Stenosis.
Bronchial Obstructions.
Section VI. Pleurisy.
Varieties.
Dry Pleurisy.
Pleurisies with Effusion.
Small Effusion.
Medium Effusion.
Large Effusion.
Diagnosis from Pericarditis.
Pneumothorax.
Section VIT. Lorak Pneumonia.
Stage of Congestion.
Stage of Red Hepatization.
Stage of Gray Hepatization.
Expectoration.
Bacteriology.
TABLE OP CONTENTS 11
Blood Changes.
Urine.
Differential Diagnosis.
Broncho- Pneumonia,
Bacteriology.
Embolism of the Pulmonary Artery.
Pulmonary CEdema.
Section VIII. Pulmonary Tuberculosis.
Classification.
Stages.
Incipient Phthisis.
Consolidation.
Softening.
Cavities.
Cough.
Expectoration.
Tubercle Bacilli.
Hcemoptysis.
Urine in Tuberculosis.
Blood.
Section IX. The Heart.
Physiology.
Anatomy.
Methods of Examining.
Changes in Position.
Inspection.
Palpation.
Percussion.
Percussion Areas.
Changes in Areas Produced by Disease.
Auscultation.
Sounds of the Heart.
Physiology.
Position of the Valves.
Isolation of the Sounds.
Alteration of the Sounds.
Conditions Affecting Intensity of Sounds.
Adventitious Sounds.
12 TABLE OF CONTENTS
Causes.
Results of Valvular Impairment.
Time of Murmurs.
Location and Areas.
Mitral Murmurs.
Tricuspid Murmurs.
Aortic Murmurs.
Pulmonary Murmurs.
False Murmurs.
Diagnosis from Organic Murmurs.
Section X. Diseases of the Heart.
Pericarditis.
Pericarditis with Effusion.
Diagnosis from Dilatation.
Chronic Pericarditis.
Adherent Pericardium.
Hydropericardium.
Pneumopericardium.
Organic Valvular Diseases.
Signs and Symptoms.
Mitral Insufficiency.
Stenosis.
Insufficiency and Stenosis.
Aortic Incompetency.
Associated Murmurs.
Stenosis.
Aortic Stenosis and Incompetency.
Tricuspid Regurgitation.
Stenosis.
Pulmonary Valve Lesions.
Insufficiency.
Stenosis.
Order of Frequency of Simple and Combined Cardiac
Lesions.
Congenital Cardiac Lesions and Diseases.
Myocardium.
Hypertrophy and Dilatation.
Myositis.
TABLE OP CONTENTS ^^'i
Aneurysm of the Heart.
Acute Endocarditis.
"^Section XI. Thoracic Aneurysm.
Special Signs.
Pressure Symptoms.
Pulse.
Section XII. Examination of the Blood.
Classification of Cells.
Leucocytes.
Blood Counting.
Red Cells.
White Cells.
Hematocrit.
Dried and Stained Films.
Dyes.
Malarial Organisms.
Haemoglobin.
Estimation of,
Blood Changes in Disease.
Anasmias.
Leukaemias.
Other Diseases.
Section XIII. Diseases of the Abdomen.
Introduction.
Anatomy.
Regions and Contents.
Methods of Examining.
Diseases of the Peritoneum.
The Stomach.
Cancer of the Stomach.
Diseases of the Intestines
The Small Intestine.
Examination.
Ulcer of the Duodenum.
Acute and Chronic Catarrh.
Colitis.
Intestinal Obstruction.
Physical Signs.
^
14 TABLE OF CONTENTS
Gall Stone Disease.
Appendicitis.
Physical Signs.
Differential Diagnosis.
The Large Intestine.
Dysentery.
Cancer.
The Liver.
Changes in its Size.
Diseases of the Liver.
Spleen.
Kidney.
Bladder.
Uterus.
Placental Bruit.
Foetal Heart Sounds.
Ovarian Tumors.
Dropsy.
Diseases of the Omentum.
Ascites.
Forms and Diagnosis.
Section XIV. Examination of the Stomach Contents.
Gastric Juice.
Composition.
Methods.
Test Meals.
Acidity.
Free Acids.
Organic Acids.
Digestion Products.
Starch.
Pepsin.
Rennin.
Motor Function.
Residue.
Macroscopic Examination of.
Microscopic Examination of.
TABLE OP CONTENTS 15
Section XV. IixAMi?)ATioN or the Urine.
Normal Urine.
Composition.
Changes on Standing.
Color.
Odor.
Reaction.
Specific Gravity.
Solids.
Urea.
Uric Acid.
Ethereal Sulphates.
Inorganic Constituents.
Chlorides.
Phosphates.
Abnormal Constituents.
Albumin.
Tests.
Pus.
Tests.
Carbohydrates.
Qualitative Tests.
Quantitative Tests.
Bile.
Diazo Reaction.
Diaceturia.
Urinary Sediment.
Chemic.
Histologic.
Casts.
Bacteria.
Section XVI. Examination of the F-eces.
Constipation.
Fetor.
Physiology.
Quantity.
Consistency.
Reaction.
16 ' TABLE OF CONTENTS
Composition.
Meconium.
Diarrhceal Stools.
Acholia.
Typhoid Stools.
Dysentery.
Gall Stones.
Detection of.
Enteroliths.
Pus.
Microscopic Examination.
Section XVII. The Roentgen Ray in Diagnosis.
The Thorax.
The Abdomen.
SECTION I.
DISEASES OF THE CHEST
INTRODUCTION.
It is in diseases of the chest that physical research has reached its
highest development and has been most prolific of results. It may
be claimed that the science of physical diagnosis cannot be learned
from books. For reply, we ask, — what science can? Nevertheless,
the orderly setting forth of the groundwork, and a clear description
of the phenomena on which are based the inferences and conclusions
of physical diagnosis are as necessary and h^pful to the students as
is the same work in any other department of science.
Yet, withal, that the ability to make correct application of these
principles and more especially the acquisition of capacity to interpret
their import and significance, must be gained by bedside practice, is
freely admitted.
The manner of investigating disease of the chest should be taken
^}y the student as a type of the methods used to investigate disease
in other parts of the body. It is absolutely necessary for the student
first to make himself thoroughly familiar with the normal sounds and
normal properties connected with the functions of the thoracic organs,
.and to fix firmly in mind their exact location and natural anatomical
•outlines. Experience has taught me that these deficiencies are the
great stumbling blocks of the student. This knowledge can be ac-
quired by painstaking study upon the living, subject, combined with
the practise of the same methods upon the healthy individual that
would be used were he diseased, until these normal properties are a
part of our consciousness, and departures therefrom as quickly recog-
nized as is a false note by the maestro.
It must be remembered that departures from normal sounds and
changes in normal areas are caused by alterations in the physical
properties of the organs or parts affected, and in no other way. As
■often as we strike the key of an organ we elicit a certain invariable
Jiote, and it is only by altering the physical conditions or the mechan-
18 DISEASES OF THE CHEST
ism at some point between key and pipe that we can change the char-
acter of the sound. So the principal thoracic organs, in the accom-
plishment of their functions, produce certain fixed sounds which are
altered only by changes in their physical projierties or in the mechan-
ism of the sound production. To determine the extent and significance
of these alterations is a part of the ofllee of the diagnostician.
Further than this, all matter is endowed with certain individual
properties, and to make manifest the different degrees in which vari-
ous organs may possess one or another of these, is also a part of physical
diagnosis. Thus, the capability of producing resonance, of transmit-
ting or conducting sound, of vibrating when struck, varies materially
with the different tissues of the body, and all of these properties are
profoundly affected by disease, by alteration's in their structure, or
by changes in their surroundings. Yet disease' must, indeed, be exten-
sive ere a structure loses entirely its normal properties. It is manifest,
that as long as any of the normal structure remains unaltered, that
far will it retain its normal properties. On the other hand, these will
be appreciably or materially altered in some cases by even slight dis-
ease; hence diagnosis becomes, broadly speaking, a question of esti-
mating differences or departures from the normal. Just as the ear of
the better trained musician is able to recognize even the finest shading
of a note, so the person more skilled in recognizing minute differences,
in the physical signs which it is possible to elicit from the human body
will be, other things being equal, the better diagnostician. But the
work does not stop here. It is the ability to correlate, to judge the
relative importance of the facts brought to light, and to draw rational
inferences therefrom, which marks the true diagnostician.
These refinements can be learned only by practice and perse-
verance. No description sufiices. Only by comparisons, by compre-
hensive knowledge drawn from wide sources, can anything resembling
perfection be reached.
Gairdner truly says, "The popular, and to a certain extent the
half -educated, medical mind is always looking for a pathognomonic
sign, or a broad, striking, easy generalization from a few facts;
whereas it is only by ripened experience that we come to know grad-
ually the real value of common and obvious, still more of uneommoa
and not obvious, facts ivhen seen in combination, so as to form con-
jointly a basis for large inferences."
DISEASES OF THE CHEST". 19
METHODS.
To the end that we may attain the objective point as above set
down, it is of the highest importance that we proee(?d along orderly
lines. The various steps of the examintion bear a certain relation to
each other, as to sequence, and this law of harmony should not be
violated heedlessly. Again, I emphasize the dictum that it is only
by minute, painstaking repetitions, by careful comparisons of sus-
pected with healthy structures, that we may hope to arrive at reason-
able certainty. A hasty conclusion, jumped at in one step of the
examination, unconsciously may pervert the judgment as to other
palpable signs, that these may bear out the false conclusion. It is
generally agreed among workers in this field that the most orderly
progression is the one here to be followed.
First, a clear, succinct history of the case should be obtained,
keeping before the mind the leading factors of what constitutes useful
and necessary information, never approaching the ease with a precon-
ceived idea of what ought to be found. Nothing, perhaps, better illus-
trates the comparative tact and talent of different examiners than
their ability or inability to obtain leading facts. Much care is neces-
sary not to suggest the answer. It is well established that the com-
plaisance of a large class of patients prompts them to give the answer
which they believe is expected. This is especially true of hospital
and dispensary habitues. Too much cannot^ be said of the present
and future value of correct ease records. 'That doctor's life must
indeed be busy, who has not the time to devote to this work. In
examining cases, a physician is necessarily guided by the circum-
stances in which he finds the patient, as well as by his knowledge
and experience of the condition with which he is called upon to deal ,-
hence, no single method is applicable to all cases. We begin our
inquiry by ascertaining what the patient feels to be wrong. This
usually refers us to some one organ or part, and the local investigation
is followed by a general survey of allied functions or organs, with
inquiries into the manner in which the present illness began, the
previous health and kindred questions, the family history, the pre-
vious history and the present state of the patient.
It is well to separate the manifestations X>i the disorder into two
divisions: subjective, or those of which the patient is conscious, and
objective, those of which the examiner gains knowledge by his own
senses. The former are classed as symptoms, and the latter as signs
20 DISEASES OF THE CHEST
or physical signs, a useful but often disregarded classification. Fur-
ther, it is simple and natural to combine to a certain extent anatomic
and physiologic facts in related organs. Thus the respiratory and
circulatory systems are not only, closely allied, but have their seat in
the thorax; while the genito-urinary system and the various organs
lof digestion are situated in the abdominal ca'vity, and may be con-
veniently grouped consecutively.
We begin with that system which, from the general aspect of
the case, seems to be the chief defaulter, and give it the fullest con-
sideration. Thus, as suggested by Sir Williara Roberts, "If we find
orthojjnoja, general anasarca, and distended jugular veins, we begin
wilh the circulatory system. If we find purulent expectoration, ema-
ciation, and clubbed finger-ends, we begin with the respiratory sys-
tem. If we find albuminous urine and pale, puffy countenance, we
begin with the urinary system," etc.
Few writers on medical diagnosis, and fewer still of the sys-
tematic writers upon medical practice, offer the student any sub-
stantial aid upon this important subject of case investigation. Apart
from hospital internes, the great body of students is left to work
out its own salvation, and devise a method as the result of experience.
Experience means waste. Hence we append a short synopsis, modified
to suit our present purposes, derived chiefly from the plans proposed
by Sir William Roberts in his work on Practice, and the form pro-
posed by Leach, as elaborated by Finlayson, from which source also
;some of the preceding suggestions were obtained.
Name. Sex. Age. Address. Occupation. Date. Preliminary
inspection; general information; definite inquiry as to what has
brought the patient to seek advice; (incorporating the patient's own
statements in so far as they are relevant.)
Previous History. Present Condition. Diagnosis.
1.
Social.
1.
External.
2.
Previous Health.
2.
Special Organs.
3.
Present Illness.
3.
Circulatory System.
4.
Family History.
4.
Respiratory System.
5.
Digestive System.
f>.
Genito-Urinary Sys
tem.
DISEASES OF THE CHEST 21
Under the first division we place the leading facts in ordei-
named :
1. Social. Residence — cZima/e^prevalence of special diseases —
occupation — exposure (heat, cold, chemical products, dust,) — food —
stimulants — ^tobacco — drugs. Mode of life — facts about marriage —
children — parents.
2. Previous Health. Nature and character of previous illnesses,
(confined to bed — hospital — interruption of occupation) — Indica-
tions pointing to special aiSections — especially rheumatism — syphilis
(adult and infantile) — cough — haamoptysis — anemia (probable
cause) — sexual disorders — gain or loss of weight.
3. History of Present Attack. Onset — cause of symptoms —
treatment if any.
4. Family History. Age and causes of death — special diseases,
which have shown themselves.
Under the second division, PRESENT CONDITION, are noted
most of the signs observed or ascertained by the examiner, which we
have classified as objective. Of necessity some of these signs fall into
both categories, but are classed here owing to their greater signifi-
cance. These points, in so far as they have special reference to our
own subject are fully dwelt upon under the sections on Inspection,
Ausculation, etc,
1. External Surface. Posture, — temperature — appearance —
color of skin — expression (languid, sallow, worn, wasted, flush,
anamic) — nostrils — lips — arcus senilis — conjunctivEe — state of nutri-
tion — senility — presenilty. Peculiarities of development — deformi-
ties- — joints — tumors — swellings. Skin — oedema (where) — perspira-
tion — rough — dry — cicatrices — rashes — discolorations — superficial ves-
sels (especially of neck, abdomen and extremities). Hair — nails — ■
finger-tips. Glandular enlargements (where):
2. Special Organs. Disorders of vision — of hearing — (ear dis-
charges) — other senses — with special details as they bear upon the,
case.
3. Circulatory System. Palpation — Cardiac pain — dyspnoea —
pulse — location of apex impact — area of impact — character — local
bulging — neck — pulsation. Other regions. Venous engorgement — pul-
sations — cyanosis — thrill (where) — area of percussion — dullness. Re-
sults of auscultation at four cardinal points. Murmurs. Blood exam-
ination.
22 DISEASES OF THE CHEST.
4. Respiratory System. Number and character of respirations
— dyspnoea (inspiratory or expiratory) — orthopncea — effect of exer-
tion — pain — cough — sputa — voice — larynx — throat. Results of inspec-
tion, palpation, percussion, auscultation and= mensuration, with due
attention to details mentioned hereafter in the special sections, care-
fully describing and exactly locating all alterations — the conduction of
heart sounds — the resistance. New sounds.
5. Digestive System. Lips — teeth — gums (red or blue lines) —
tongue. Fauces. Thirst — appetite — pain or discomfort after eating
— flatulency — acidity — hiccough — vomiting ( character ) .
Abdomen — walls — pain — tenderness — colic^— ascites — Estate of bow-
els — character of motions — abnormal constituents (worms, blood,
pus,) — piles.
Liver — size — feel. Spleen — size — feel. Hernia — other regions.
6. Genito-TJrinary System. Frequency of micturition — pain —
difficulty. Special examination of urine — quantity in 24 hours — color
— reaction — specific gravity — clearness — albumen — sugar — urea — de-
posits. Microscopic examination and results..
Males, strictures — specific diseases.
Females, menstruation — its disorders — leucorrhoea — pregnancy —
specific diseases.
For detailed methods pursued in the examination of the nervous
system the reader is referred to special works on that subject, in
which they are usually fully exploited. Such notes as bear upon the
special case may be inserted conveniently at the end of the above
scheme.
The order in which the steps of the physical examination should
follow each other has alreadj^ been intimated in the above plan.
Definitely stated they are :
(a) Inspection;
\h) Palpation;
(c) Mensuration;
(d) Percussion; and
(e) Auscultation.
These complete the case record and bring us face-to-face with the
momentous conclusion for which our work has been undertaken, — the
Diagnosis.
In all cases in which a justifiable diagnosis can he reached it
should he recorded, as it engenders greater pare on the part of the
DISEASES OF THE CHEST
23
examiner and carries a certain weight of respopsibility. Such a record
does not preclude a subsequent revision of opinion, and certainly it
more definitely shapes the last step, — the Treatment.
The first requisite of diagnostic science- is a good stethoscope.
While almost any instrument can be made to answer, yet comfort in
Fig. I — Camman's Stethoscope.
the use of the instrument, as well as satisfaction and refinements in
the results of its use, vary widely with the choice. Avoid cheap, badly-
made instruments, as well as heavy, cumbersome ones. See that the
ear tubes fit naturally and easily into the ears,, and that they perfectly
close the canals. A large ear-bulb is more satisfactory than a small
one, especially for protracted use. A metal spring is more satisfac-
24 DISEASES OF THE CHEST
tory than gum elastic, for retaining the instrument in position. A too
weak spring is annoying ; a too strong one fatiguing. The conducting
pipes should be of the same caliber throughout, and not too small.
The abrupt shoulder of the jointed stethoscope is an objection. The
bell should not be too large, since a large bell does not admit of being
evenly placed against the tissues, especially in the intercostal spaces,
and thus extraneous sounds are admitted, which, being conducted to
Fig. 2 — Bowie's Stethoscope, Compound Form.
the ear of the auscultator, cause confusion. The soft rubber supple-
mentary bell, devised to correct this defect, is; not wholly a success.
The binaural stethoscope has replaced entirely the single instru-
ment. That devised by Dr. H. K. Valentine, of Brooklyn,* is one of
the best types with which I am familiar, and possesses the requisites
named. The Bowles instrument is very satisfactory. The ear pieces
do not differ from those in ordinary use ; two pieces of rubber tubing
*E)escribed m the NeTt: York Medical Record of Tiily i6, 1892.
DISEASES OP THE CHEST 25
attach them to a hard rubl^er Y, which is again joined by rubber
tubing to the drum. The drum is a steel disc somewhat larger than a
silver dollar and about twice as thick. It is pierced in the center by
a small hole into which fits the elbow-joint pipe which connects it tO'
the T-piece. The face of the drum is slightly cupped, and over thia
concave face fits a thin, hard rubber disc which receives the sound
Fig. 3 — The Bowie's Stethoscope.
vibrations. The sounds are conducted with extraordinary clearness,
and intensity, and its use is especially commended to those whose sense-
of hearing is less acute than normal. The flat disc admits of its being
slipped under the back without disturbing the position of the patient,,
and thus may be employed when his condition forbids the use of th&
common type, as during or immediately after severe haemoptysis, in
which a recent experience of my own was instructive. With its use,.
26
DISEASES OF THE CHEST
breath sound's may be heard in areas where otherwise they are in-
audible, as in the subscapular region. The drum may be removed and
1 lie ordinary bell be substituted when desired.
Fig. 4 — Phonendoscope.
The phonendoscope, of Bazzi and Bianchi, is cumbersome, ex-
pensive and possesses few, if any, advantages over the one described.
Tt is excellent for auscultatory percussion, whereby the outlines of the
various organs may be mapped out with great certainty.
SECTION II.
MEDICAL ANATOMY.
SHAPES AND TYPES OF THE CHEST.
The shape of the thorax and its general capacity as well as its
expansile powers, are influenced by age, sex, occiipation, heredity and
disease. Heredity impresses its most striking as well as its strongest
peculiarities upon those structures which earliest develop and earliest
reach maturity, hence the bony skeleton is strongly influenced thereby.
At birth the contour of the chest is almost circular and the thorax
cylindrical, but as development proceeds the expansion and growth of
Fig. S — Thorax of Infant, Sb.owing Conical Shape.
the lungs pTish out the ribs in the lower lateral areas, the chest flat-
tens and at the same time becomes conical. As depicted by Morris,
the axillary border of the chest at the eighth month shows little or no
vertical curvature. The relative shapes of mesial transverse vertical
sections of the infant and adult chest are illustrated by the accom-
panying figure.
In old age the shape of the chest by slow retrogression approaches
28
MEDICAL ANATOMY
once more the cylindrical type. Here again the most marked changes,
take place in the inferior areas ; the lower circumference showing con-
siderable recedence while the middle zone changes least. Atrophy of
the muscles of the shoulder girdle occurs with age, and the resulting
Fig. 6 — Vertical Mesial Sections Adult Chest and Infantile Chest. The lines
AB and CD are parallel.
Stooping posture gives rise to a seeming contraction of the upper chest
zone which in reality is very slight.
Types of Thorax. — Defective development combined with inher-
ited tendencies aided by malnutrition and imperfect expansion pro^
duce the most common of thj vicious types of chest. Such are the
MEDICAL ANATOMY 29
rickety chest and the variations thereof known as the ' ' pigeon-breast ' '
and the phthisical or paralytic chest. In its most modified degree the
rickety deformity consists simply of a flattening of the lateral areas
of the chest with corresponding decrease in the transverse diameter.
This results in a degree of forward bulging of the chondral area, which
is spoken of as transverse constriction. This and the succeeding forms
originate when the bones are still soft and pliable, and in general are
associated with deficient expansion, which is not only a cause but a
permanent result of the condition.
In true rickets the chest is flattened laterally and its contour is
trapezoidal, with the wide border posteriorly. Just outside the junc-
tion of the ribs with the cartilages there is an oblique shallow depres-
sion extending downwards and outwards, which transverse constriction
makes the sternal portion of the chest unduly prominent. A shallow
groove or curve passing outward from, the level of the ensiform car-
tilage towards the axilla is known as Harrison's sulcus, or curve. It
corresponds with the attachment of the diajJhragm to the cartilages
and is more prominent and deeper during inspiration. Posteriorly
the spine shows vertical curvature. The line of junction of the ribs
with the costal cartilages presents small, nodular enlargements, gen-
erally visible, always palpable, which appear as early as the third
month and disappear about the fifth year. They are fantastically
called the "rickety rosary." The bones are spongy and increased in
size. Expansion is impaired.
This deformity is not peculiar to rickets. Other conditions which
interfere ^vith free respiration produce the same deformity, particu-
larly enlarged tonsils, as pointed out by Dupuytren in 1828. This
type of chest is particularly interesting owing to the predilection
which its possessor has for respiratorj disease.
Laryngismus stridulus and other spasmodic affections of the
larynx are also of frequent occurrence.
The pigeon or chicken breast is an exaggefated type of the above.
The antero-lateral constriction reaches such a degree that the sternum,
especially the lower half, is pushed far forward and a transverse sec-
tion of the thorax appears nearly triangular. The curvature of the
ribs lies almost entirely at their angle, wh^ee'they project nearly
straight forward to the sternum. The lower ribs are flared out by
the liver and Harrison 's sulcus is well marked. The lower and lateral
regions of the chest retract with inspiration. The causes which pro-
30
MEDICAL ANATOMY
duce the rickety chest are responsible for the chicken breast and the
tendencies are the same.
The Funnel Breast. This name has, been bestowed by the Ger-
mans ("trichter brust") upon cases which present marked recession
of the ensiform cartilage. The name does not apply to cases in which
the cartilage has been bent inward the result of occupation, but to
those in which respiratory obstruction has resulted in its permanent
Fig. 7 — Types and shapes of chest. .A.cqiiired (occupational) deformity. The
interspaces on left side are much wider than on the right.
retraction by the act of breathing. In such eases the lower sternal re-
gion and intercostal angle is distinctly excavated and retracts during
inspiration. Enlarged tonsils, whooping cough and many respiratory
affections are assigned as caiises.
The Barrel Chest. This deformity i? also called the emphysema-
tous chest. It may occur as early as the tenth year, but is generally
seen only in adult life. The chest becomes rounded and barrel-shaped,
the intercostal spaces are widened, the neck is short and the back
bowed, the shoulders arj bent forward, the arms hang lax, giving a
MBDI0AL ANATOMY 31
stooping appearance to the possessor. The circumference as taken by
the cyrtometer shows a close approach to a circle. In early life the
change is often due to asthma, the result of naso-pharyngeal disease ;
in later life to emphysema, the causes of which are discussed there-
under.
The Phthisical Chest. While Hippocrates recognized a form of
chest as predisposing to this ailment, yet a disease so universal is no
Fig. 8 — A normal adult male chest outline. 6th costal cartilage.
respecter of types and it can scarce be said that the description holds
good.
The form of chest usually described as phthisical is the result of
the disease rather than one of its causes. Such a chest is long, nar-
row and flat with depressed sternum. The lung capacity is generally
stated as being below normal, but Benneke asserts that this is a mis-
taken belief. The ribs slope downward abnormally, making an acute
angle at the ensif orm junction. All the fossse. are deep, especially the
clavicular and suprasternal, and the scapulte project wing-like from
behind, hence the name- — ^the "alar chest."
DIVISIONS OF THE CHEST AND ABDOMEN.
Diagnosticians divide the chest and abdomen into regions by
imaginary lines and name the various sub-divisions for the most part
in accordance with the underlying organs. Such sub-divisions are
necessary for convenience in describing and locating the various or-
gans as well as the lesions to which the parts are subject. Uniformity
in this regard among systematic writers is most conspicuous by its
32
MEDICAL ANATOMY
absence, these usually making their sub-divisions in accordance with
fancied convenience.
The diaphragm separates the chest or thoracic cavity from the
abdominal cavity. The diaphragm is attached anteriorly in the cen-
tral line to the ensiform cartilage, to the lower border and inner
surfaces of the cartilages of the six lower ribs. While posteriorly its
<3rura are continued down over the bodies of the lumbar vertebra
the diaphragm as a partition extends only as far as the lower border
of the ribs. It forms a vaulted roof to the abdominal cavity, arching
on either side higher than in the middle portion where the pericar-
dium is attached. It rises on the right side as high as the upper bor-
Fig. 9 — Emphysematous chest of practically the same circumference as Fig. 8.
Note approach to circle.
•der of the fifth rib, and on the left as high, as the top of the fifth
interspace. Viewed from in front its line presents two domes, with a
slight fall or "sag" in the middle.
MEDICAL ANATOMY.
Regions or Spaces of the Chest. While it is presumed that the
student of physical diagnosis is thoroughly familiar with both the
topographical and the relational anatomy of the parts studied, yet by
reason of the aids to description which such anatomic depictions
furnish to the writer, as well as for the ease of comparison and refer-
ence which they afford the reader, no work on the subject is complete
which omits them.
MEDICAL ANATOMt 33
The exterior of the trunk offers some well recognized landmarks
which serve as cardinal points both for description and for location.
Such are the clavicles, the nipples, the umbilicus and the ensiform
cartilage in plain view anteriorly; and the rfiedian furrow or spinal
gutter, the apex of the vertebra prominens, tlie spine of the scapulse
and the crests of the ilia behind.
The space above the clavicle is known as the supraclavicular fossa.
The infraclavicular space lies below each clavicle, and while its upper
border is sharply defined by that bone its lower border is separated
from the adjacent mammary region only by ^n arbitrary line. This
space extends inward to the sternum, outward to the shoulder, being
bounded here by a vertical line bisecting the clavicle at its outer
fourth. Emaciation throws the clavicles into strong relief and makes
both the fossa and the space appear deeper and better marked. At
the top of the sternum is the suprasternal notch. The mammary region
extends outward from the edge of the sternum to the vertical line just
located, and from the upper edge of the third to the upper margin of
the sixth rib. The nipple occupies the center of the area, being either
in the fourth interspace or, as I have more often observed it, over the
fourth rib. The mummary line passes vertically through it and bisects
the clavicle at its middle point. In mature females the nipple is dis-
placed through many causes and even in the male it lacks constancy,
hence the line is better named the midclavicular line. A second ver-
tical line parallel with the mammary line and lying within that line is
useful for descriptive purposes, it is called the parasternal line and
divides the space between the nipple or midclavicular line and the
edge of the sternum into^ equal parts. The inframammary region ex-
tends from the sixth rib to the lower costal margin. The sternal re-
gion is bounded by that bone. It should be noted that the length of
the sternum is subject to considerable variation and is relatively
shorter in women than in men. The transverse projection which marks
the union of its first and second parts always can be felt and corre-
sponds with the cartilage of the second rib. The sternal region is
divided into upper and lower by the line which separates the infra-
clavicular space from the mammary region (third rib).
The axillary regions meet the mammary= and inframammary re-
gions in front; behind they are limited by a vertical line dropped
from the posterior axillary fold. The same circumferential line (sixth
I'ib) which divides the mammary regions separates the superior axil-
^4 MEDICAL ANATOMY
lary area from the inferior, which last region extends downward to
the edge of the ribs. It is convenient to divide these regions by a
vertical line, the midaxillary line, into equal' parts, the anterior axil-
lary region and the posterior region.
The posterior aspect of the chest presents above, the scapular
regions which are anatomically divided into the supraspinous fossa
and the infraspinous fossa. The parts included between the inner
edges of these bones when the arms are pendant is the interscapular
region. The scapulae lie on the ribs from the second to the seventh,
inclusive. The portion of the chest included between the lower edge
of the ribs and a line joining the inferior angles of the scapulae is
the infrascapular or subscapular region. As an aid to description the
regions are bisected by a vertical line called the midscapular line,
which name indicates clearly its location.
Landmarks. The top of the sternum is on a level with the second
■dorsal vertebra. There is little or no lung behind the first bone of
the sternum. The highest part of the aortic arch lies one inch below
the suprasternal notch. The innominate artery lies behind and rises
as high as the right ster no-clavicular joint. When either the aorta or
the innominate is higher than normal its pulsations can be felt in
the sternal notch.
No little difficulty may be experienced in counting the ribs in fat
persons, hence it is useful to know that :
1. — The transverse projection on the sternum, above referred to,
corresponds to the center of the cartilage of the second rib.
2. — The nipple in the male is placed either over the fourth rib,
or between the fourth and the fifth ribs thre_e-fourths of an inch out-
;side of their cartilage.
3. — When the arm hangs at the side the lower external border of
the pectoralis major corresponds with the position and direction of
the fifth rib.
4. — A horizontal line drawn around the chest through the nipples
cuts the sixth intercostal space midway between the sternum and the
: spine, i. e., in the midaxillary line, which point is often selected for
tapping pleuritic effusions.
5. — When the arm is raised the highest visible digitation of the
:serratus magnus corresponds with the sixth rib. The digitations be-
low correspond respectively with the seventh and eighth ribs.
MEDICAL ANATOMY 35
6. — The lower angle of the scapula, corresponds to the seventh
rib, which is the longest rib in the bo^y.
7. — The eleventh and twelfth ribs can be felt even in corpulent
persons.
(These seven points are taken with modifications from Keene's
surgical landmarks.)
The tips of the spinous processes of the vertebrae may be made to
show readily as red dots by making slight friction over their points.
THORACIC REGIONS AND THEIR CONTENTS.
The supraclavicular region contains two structures of importance
to the medical man, the apex of the lung and the subclavian vessels.
The apex projects above the clavicle behind the sterno-cleido-mastoid
and between the scalenii muscles for a distance varying from
one-half an inch to an inch and three-quarters, (Holden). In extreme
cases it projects above the rib as much as two inches, especially the
left apex which is generally the higher of the two. The artery crosses
the first rib at the outer border of the sterno-mastoid muscle where it
arches over the lung apex. By elevating the shoulder to relax the tis-
sues the beating of the artery can be felt easily in the subclavian
fossa. Just in front of it empties the external jugular vein; behind
it the internal jugular.
The Clavicular region lies behind the clavicle. Owing to the slant
of the ribs the inner third of the clavicle overlies the first rib, the mid-
dle third overlies the first and the second ribs. The bone is so sepa-
rated from the lung that no typical lung note is obtainable, yet direct
percussion upon the clavicle, as explained further on, often elicits the
first signs of apical change.
The innominate artery extends upwards as=high as the upper limit
of the right sterno-clavicular joint where it bifurcates into the right
common carotid and right subclavian arteries (Morris). The right
innominate vein lies immediately outside of the artery. The left
common carotid artery lies behind the left sterno-clavicular articula-
tion and the left innominate vein passes in front of both innominate
and carotid arteries as it traverses the space behind the manubrium
to reach the right vein behind the first rib. Between the sterno-
clavicular articulations lies the Suprasternal region, or Interclavicular
notch, whose lower border is the top of the sternum. It contains tne
trachea in the center. The vessels lying behind its joints have been
36
MEDICAL ANATOMY
named. In case of dilatation of the aorta or upward displacement of
the heart, the vessel may be elevated above the notch where its pulsar
tions can be felt or even, seen. In these cases backward displacement
of the trachea is usual.
Fig. 10 — The normal Thorax. (Male adult.) Showing reference lines.
Midclavicular line. PA Parasternal line. IE Inframammary line.
Infracostal line.
MC
IC
The infraclavicular spaces overlie the lung substance and as no
other structures are in contact with the chest wall within their areas,
we !.;et here the typical lung sounds. The superior vena cava lies
t
PLATE II.
RELATION OF LUNGS TO THE THORAX
The lobes are outlined in red. The pleural reflection in
black. Note tlie continuation of pleura below lung border.
MEDICAL ANATOMY 37
partly behind the chondfo-sternal junction on the right side and be-
hind the first and second intercostal spaces, reaching the right auricle
behind the third cartilage (Morris). It is covered by the edge of the
lung. The right auricle lies behind the third cartilage ai^d in the
third interspace beyond the sternum, but is well covered by the lappet
of the right lung.
The Mammary regions differ on the two sides. On the right side
are lung, liver and heart. The entire right surface area is covered by
lung. Beneath it lies the right border of the heart which projects be-
yond the sternum more than one inch, almost reaching the parasternal
line. This border lies behind the third and fourth ribs and their in-
terspaces, covered by the edge of the lung (Luschka). A minute
portion of the right ventricle lies in the fifth interspace close to the
sternum, which, during forced expiration is uncovered. The liver
rises beneath the dome of the diaphragm as high as the fourth inter-
space, receding farther from the chest wall as it rises.
On the left side the mammary region contains heart and lung.
From the left edge of the sternum outward are the right and left
ventricles. The left auricular appendix, at the base of the pulmonary
artery is quite superficial in the third interspace. The external boun-
dary of the heart on the left side is a line drawn from the point where
the parasternal line cuts the third interspace, to a point slightly out-
side the apex in the fifth interspace, the line curving outward and
downward in its direction.
All of this area is covered by lung except the tongue-shaped por-
tion of the ventricle which is known as the area of absolute cardiac
dullness, a small triangle whose sides are drawn through these three
points, (a) the apex, (b) the base of the xiphoid, and {c) the junc-
tion of the fourth rib with the sternum.
The Inframammary region, right side. The lower edge of the
right lung follows closely the sixth rib as far out as the nipple line,
thence it passes slightly downward and outward to the seventh rib.
The diaphragm rises to its highest point just inside the right nipple
(midclavicular) line which is as high as the top of the fifth rib (Mor-
ris), and separates the lung from the liver. The liver in this same
line extends downward to the edge of the ribs where it can be felt on
inspiration. On deep inspiration its border projects still lower. This
border may be traced upwards towards the umbilicus on an oblique
line. In front in the' middle line the' lower border of the liver extends
38 MEDICAL, ATiTATOMY
downward to a point about half way' between the xiphoid cartilage
and the navel (Quain). My observation is that this distance is' too
great, probably one-third being more nearly accurate than one-half,
but the distance from the navel" to the xiphoid varies- greatly. For
women the measurement given by Quain is much more flearly corteet.
Here the line of liver border is from the ninth right tb the eighth
left costal cartilage, ' ' crossing the middle line about a hand 's breadth
below the sterno-xiphoid articulation (Godlee).
In order to complete the description of the liver it is only neces-
sary to add that posteriorly it is opposite the ninth, tenth and eleventh
dorsal vertebra, and that on the right side, it extends between the
seventh and eleventh ribs, and in the mammary line from the fifth
t6 the ninth costal cartilage.
The Left Inframammary region differs Materially from the right.
The left lobe of the liver extends aci-oss the sternum. Its extreme
left point is about an inch and a half beyond the left margin of the
bone (Quain), The lower lobe of the Ifeft'lung covers the area,
reaching from the fifth to the seventh Costal cartilage, then passing
outward and downward. The cardiac half of the stomach rises un-
der the left dome of the diaphragm to the tqp of the fifth rib and ex-
tends outward as far as the anterior axillary line. The degree of dis-
tention and the nature of the stomach contents influence materially its
position.
The Sternal region is divided into uppel- and lower areas. In in-
spiration the top of the sternum corresponds to the fibro-cartilage be-
tween the second and third thoracic vertebra and is distant about two
and a half inches from the spine (Holden). There is little or no lung
behind the first borie of the sternum. The, trachea' continues down-
ward in the central line and bifurcates behind the joint formed by
the manubrium and the gladiolus. Lying on this bifurcation is the
aorta, reaching within one inch of the sternal notch! Behind the
trachea is the oesophagus. The left innohiinate vein crosses imme-
diately behind the upper border of the manubrium to ireach the supe-
rior cava on the' right side' in the first intep-spaee. Behind the vein
ascend the great branches from the aOrta. The lower sternal region
is the part fcovered by the gladiolus, or second piece of the bone. Be-
hind its upper area the thin edges of the lungs meet on full inspira-
tion as far down as the fourth rib where the left Iting diverges to
uncover the heart ; the right sometimes extends just beyond the mid-
MEDICAL ANATOMY-
39
rig. II — The Thorax. Posterior Reference Lines. Scapulas drawn outward.
A Line of division between the lobes of the lung. B Lower limit of lung.
CC Interscapular lines. D Suprascapular line. E Infrascapular line.
MEDICAL ANATOMY 41
die line (Holden). The bronchi subdivide outside the edge of the
sternum, deep in the mediastinum. The primary bronchi diverge
opposite the second rib cartilage. The right is more horizontal than
the left and slopes down to the level of the fourth dorsal vertebra.
The left is smaller than the right but longer and more inclined, reach-
ing the level of the fifth vertebra. The beginning of the aorta, the
FIRST MB
StCOjilO RIB
THIRH RIB -
CLftVrCLL
SCRPUt/1
Fig. 12 — The relation of the clavicle to the ribs.
inner portion of the right auricle and the central portion of the right
ventricle lie to the front in this region. The lower extremity of the
sternum is marked by the junction of the ensiform cartilage. It
usually recedes from the surface presenting the depression known as
the scrobiculus cordis, or pit of the stomach, lying opposite the sev-
enth cartilage.
Immediately below the sternal region between the :inf ramammary
regions lies a portion of the Epigastric region.. It is chiefly occupied
by stomach and liver. The quadrate lobe of the liver lies immediately
to the right of the umbilical ,line^ and adjoining it still further to, the
right is the gall bladder, opposite the ninth costal cartilage, close to
42
MEDICAL ANATOMY
the outer edge of the ijectus muscle. When full the bladder is pal-
pable ; when- distended its position is often marked by a spherical swell-
ing of the parietes.
NOTCH
Fig. 13 — The diaphragm. Relation to thorax. The cayal opening is seen on the
left', the oesophageal opening 011 the right of the ensi-forra ; above it the aorta.
The Axillary regions are occupied by lung substance and are
alike on the two sides. The lower, or infra-axillary, regions differ as
to their contents. On the right side in the posterior axillary line the
MEDICAL ANATOMY
43
STERNUM
UPPE.R MAMMARY LINt
'^^P«ft- MAMMARY 1||Je.
0/APHRA6M.
Fig. 14 — The normal thorax, with reference lines an-d position of diaphragm.
Lateral view.
MEDICAL ANATOMY 45
lung reaches the eighth rib (Morris). This margin of the lung de-
scends about an inch and a half on full inspiration (Godlee). Hence
the numerous discrepancies met with in description. The liver ex-
tends below the lower lung margin to the free border of the ribs. On
the left side the lung has the game relations as on the right. The
spleen lies a little behind the mid-axillary line, its long axis corre-
sponding with the tenth rib, the viseus reaching from the ninth to the
lower border of the eleventh rib, Its anterior border is marked by a
line drawn from the left sterno-elavicular joint to the tip of the elev-
enth rib. The cardiac end of the dilated stomach projects into the left
infra-axillary region.
The Scapular regions do not differ on the two sides. They con-
tain lung tissue. The incisura of upper and middle lobes cuts the
fifth rib from above downward on a long diagonal.
The Interscapular region is chiefly occupied by the dorsal ver-
tebrae, in front of which is the oesophagus. Still more anteriorly is
the trachea with its subdivisions as noted. The point of tracheal
division corresponds to the fourth or fifth thoracic vertebrae (Morris).
The Subscapular region, from the seventh rib to the inferior mar-
gin of the thorax, for the most part covers the lungs. Holden says,
' ' Opposite the angles of the scapulae, the arms being close to the sides,
the lungs extend to the tenth ribs. ' '
It should be emphasized that the pleural sac extends lower down
than the lung all along the lower margin of the thorax. Thus, near
the sternum the lower margin of the sac stretches along the seventh
rib cartilage; in the axillary line it reaches the lower margin of the
ninth rib; posteriorly it reaches as low as thg twelfth rib, which cor-
responds to the tip of the eleventh thoracic spine.
Holden calls attention to the ease with which tapping of the
pleural sac may be performed between the eleventh and twelfth ribs,
"but not with a trochar, since a trochar would penetrate both layers
of the pleura and go through the diaphragm into the abdominal cav-
ity. The operation should be done cautiously by an incision begin-
ning about two inches from the spine, on the outer border of the erec-
tor spinae on a level between the spines of the eleventh and twelfth
thoracic vertebrae. The intercostal artery will not be injured if the
opening be made below the middle of the space, which is very wide."
The vertical field of the kidneys corresponds to the last thoracic
and the two upper lumbar vertebra, the right lying in most cases
46 MEDICAL ANATOMY
from a third to a half inch lower than the left, but exceptions to this
rule are frequent. They extend inward far enough to overlap the
tips of the transverse processes of the vertebrae named.
The spleen slightly overlaps the left kidney opposite the upper
half of the kidney's outer border. If the hiatus diaphragmaticus is
well marked the kidneys come into relation with the pleura, the dia-
phragm intervening.
The cardiac orifice of the stomach lies to the left of the body of
the ninth dorsal vertebra (Holden).
SECTION III.
PHYSICAL EXAMINATION.
INSPECTION.
Inspection is the art of observation. Minute differences which
the novice utterly overlooks may be detected readily by the trained
eye, and valuable information gained thereby. Indeed, it is often
possible merely by inspecting the chest to maike a near approach to a
correct diagnosis. By inspection we recognize changes in size, form
and symmetry. In order to give full weight to inspection it is nec-
essary that the chest be uncovered to as great an extent as may be
possible without undue risk to the patient by reason of exposure, or
Tinduly wounding the modesty of young females. Place the patient
in the best obtainable light ; when the condition of the patient admits
it is preferable that he stand or sit, since the recumbent posture is not
so favorable for observation.
The first point to be observed is the type of the chest, whether
long and narrow, flat and shallow, or deep. The normal chest is
symmetrical and the diameters well-proportioned. The interspaces
are equal and the clavicles none too prominent. Note especially the
antero-posterior diameter and compare it with the transverse diam-
eter; carefully compare the two sides as to ^mmetry or asymmetry,
giving especial attention to the anterior, upper surface. Depression
here may indicate tuberculous deposits; local bulging in this region
may be indicative of aneurysm. Bulging in one lateral area may be
caused by a pleural effusion, while retraction: of some part may have
resulted from previous disease of the lung or pleura. Note anteriorly
the outlines of clavicle, sternum and rib, giving attention to inequali-
ties of the interspaces and the degree of obliquity of the ribs; note
whether the type of respiration be costal or abdominal; whether ex-
piration is longer than inspiration ; whether the intercostal spaces are
equal and well-marked; whether the impact of the apex of the heart
is perceptible. . (Displacement of the heart from various causes is dis-
cussed under diseases of that organ. Uncovering of its anterior sur-
48 PHYSICAL EXAMINATION
face by retraction of the upper lobe of the left lung is referred to
under Tuberculosis.) Being familiar with the movements of the
healthy chest, you will note changes in the rhythm, frequency and
force of both heart and lung movement. All the above observations
should be made during quiet, natural breathing; whereupon the pa-
tient should be instructed to essay forcible inspiration and expiration,
during which the entire category should be • repeated, and careful
comparison made with the former set of observations. During the
period of forced inspiration note carefully the expansion of the tho-
racic walls, whether it be a uniform, expansile effort, or shows irregu-
larities, as occur in phthisis and after pleurisies; or whether it be a
cage-like rise and fall of the entire chest structure, with little or no
true expansion, as in emphysema. On the posterior aspect of the
chest note whether there are any deviations from the straight line of
the vertebral spines; the distance of the inner borders of the scapula
from the spine ; whether the lower angles are on corresponding levels
on the two sides ; and whether both or either of these bones project un-
duly from the body. A valuable sign of pneumonia in children is the
lack of expansion just beneath the clavicle on tie affected side.
Three types of breathing are recognized: abdominal, superior
costal, and inferior costal. In women, as the heritage of the corset,
superior costal breathing is the usual type. In men, abdominal. In
the normal chest the expansion is equal on the two sides, and all the
thoracic diameters increase with inspiration. In disease the expan-
sion may be unequal. If the thoracic walls become fixed, the expan-
sion is chiefly affected by the descent of the diaphragm. It is to be
remembered that few persons are perfectly symmetrical; usually in
right-handed persons the right side is more developed than the left,
while in left-handed persons the opposite obtains. A corresponding
slight deviation of the spine is very common and cannot be considered
as unnatural. A considerable degree of alteration in the form, move-
ments and size of the chest may occur without serious embarrassment
to the contained organs and without interfering with their healthy
functions. Few of us have not been struck by the extent to which
the ravages of disease may affect an organ, and yet it be able to per-
form its allotted duty.
Alterations in Chest Walls Produced hy. Various Diseases. By
inspection alone we may detect the presence of , various diseases, or con-
clude that the patient has been affected by them at some more or less
PHYSICAL BXAMINATIO^T
49
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PHYSICAL EXAMINATION 51
remote period. Thus, pleurisy often leaves an indelible stamp upon
its victim. In the pre-effusion stage, and even when only slight effu-
sion is present, there is no apparent change in the size of the chest,
but the movements on the affected side will be somewhat restricted
and those of the sound side proportionately increased. In the lesser
degrees it is difficult to detect this change by the unaided eye. The
respirations are not full and free but terminate abruptly, with a catch,
as it were, by reason of the pain which develops when a certain de-
gree of expansion is reached. This sign is not distinctive of pleurisy,
as it is often present in herpes zoster and intercostal neuralgias.
Irregularities and contractions show the ravages of previous at-
tacks of pleurisy. Old sinuses may exist. Flattened areas, exaggerated
interspaces and over prominent fossae may be the result of tuberculosis.
A conical sweling in the upper area may be the first intimation of an
aneurysm of the aorta.
Mensuration. Mensuration, as applied to diseases of the chest,
furnishes certain data as to shape, size and c&paeity. By its means
the actual outline of the chest is ascertained; the relative measure-
ment of the two sides, a comparison of its various diameters, and the
amount of expansion are determined and may be recorded.
The instrument used for determining the outlines of the thorax
is the stethometer of Quam, or the cyrtometer. The latter consists of
two thin flat strips of lead, each about twenty-four inches in length,
joined together at one end by a piece of rubber tubing. The joint is
applied over the spine of a vertebra at the desired height, and the
flexible strip accurately molded to the chest walls, noting the points
where they overlap by a scratch on the bands made over the middle of
the sternum. The pieces are removed without disjointing, and a trac-
ing made on a large sheet of paper. The antero-posterior diameter is
marked from the joint to the line of overlapping, or may be meas-
ured by calipers. The semi-circumferences, the transverse diameters,
and other measurements are made from the tracing. Deviations in
the two sides are strikingly brought out by superimposing the trac-
ings, which may be done by folding the paper and holding it towards
the light. The semi-circumference increases in cases of intra-thoracic
growths, or during the accumulation of pleuritic effusion. It de-
creases in the course of pulmonary tuberculosis, in the deformity fol-
lowing the removal of fluid, and from many other causes.
52 PHYSICAL, EXAMINATION
For ascertaining the relative expansion of the two sides, tapes
joined at the back serve an excellent purpose.
Gain or loss of flesh and muscle affect the chest measurements,
a fact which is to be taken into account duringtreatment to re-estab-
lish pulmonary expansion, and it must not be forgotten that in right-
handed individuals the right semi-circumference of the thorax may-
exceed the left by as much as an inch.
For ascertaining the comparative outlines of the two anterior
surfaces of the thorax, and for making records of the same, I have
used with much satisfaction thin, narrow lead strips. The strip is
applied vertically so that one end projects over the clavicle, and ex-
tends downward to the edge of the thorax. Its relation to the nipple
being noted, it is carefully molded over the clavicle and ribs. A trac-
ing of each side is then made. Differences imperceptible to the naked
eye are brought out, but what is more important, future changes are
detected. The method is especially valuable in .incipient phthisis.
Palpation. Palpation is an endeavor to obtain information of the
physical condition through the medium of the sense of touch. It con-
sists of laying on the hands, or in bringing the finger tips into con-
tact with various regions of the body. In localized diseased conditions
the tips of the fingers should be applied, as the larger area of the
palmar surface is not so suitable for differentiating between circum-
scribed localities, and is less sensitive than the tips. As a means of
palpation between the ribs, the ulnar surface of the hand affords an
excellent means, owing to its high sensitiveness- and the readiness with
which it fits into the intercostal depressions.
When the hands are brought in contact with the thoracic wall
overlying the lung, and the patient made to speak, a distinct succes-
sion of vibrations is communicated to the hand. This is known as
tactile fremitus* The strength of the vibratioiis varies in both health
and disease from the faintest tremulousness to strong well-
marked, separated vibrations. In health the character of the voice
materially influences their strength, the vibrations being better
marked in low-pitched, deep-voiced men than in higher voices;
stronger in men generally than in women, and weakest in children.
The amount of tissue overlying the lungs influences this fremitus,
and the vibrations are more appreciable in thin persons than in fat
*The phenomenon is indiscriminately called by some writers tactile fremitus
And vocal fremitus.
PHYSICAL EXaMINATION
53
ones. Any form of disease which increases the density of the pul-
monary tissue or increases its conduction power augments the fremi-
tus, provided that the bronchi are open, arid that the air column
from the larynx to the pulmonary tissue is uninterrupted. The sen-
sation is due to vibration communicated to thfe thoracic walls, through
the medium of the tissues, from the air in the trachea set in motion
by the act of speaking. Hence, fremitus is increased in pneumonia
Fig. i6 — Ulnar palpation.
and tubercular deposits. On the other hand, conditions which sepa-
rate the pulmonary tissues from the chest wall, or diseases accom-
panied by a diminution of the normal pulmonary density, lessen the
fremitus, or even obliterate it. Thus, when a layer of air or fluid in-
tervenes between the periphery of the lung and the parietal wall, as
occurs in pleuritic effusions, plastic pleuritic thickening, pneumo-
thorax and in solid tumors the fremitus is decidedly lessened or is
totally absent. In health the fremitus is most marked on the right
side just below the clavicle where it is stronger than in the corre-
54
PHYSICAL EXAMINATION
spending left area, probably due to the anatomical fact that the right
bronchus is of larger caliber, is straighter and enters the lung on a
somewhat higher level than its fellow. Posteriorly, in the right supra-
scapular fossa the fremitus is greater than on the opposite side, for
the same reason. From this fact it may be deduced that if the tactile
fremitus is well-marked and equal on the two sides in the areas named,
then it is increased on the left side, and further evidences of disease
should be sought for at the left apex. If fremitus is weakened but
equal on the two sides it would indicate diminution on the right side.
Fig. 17 — Differential palpation of apices of lungs.
When the bronchial tubes are more or less occluded by the ad-
herence of tenacious secretions or by stenosis, vibrations similar in
character to the voice vibrations, produced by the passage of the air
through the bronchi, are communicated to the hand. This is called
rhonchial fremitus. It is often present in bronchitis, and is particu-
larly frequent in children suffering with the disease. The conditions
necessary for its production are the same as those which produce the
rales heard on auscultation.
Fremitus produced by coughing is called tussile. Advantage may
sometimes be conveniently taken of crying spells in young children
to determine the presence or absence of crying and tussile fremitus.
Friction fremitus results when two inflamed surfaces of the
pleura are rubbed together, and is often present during the dry stage
of pleurisy. More rarely it is due to pericardial or peritoneal fric-
tion, which however may sometimes be felt.
Next in importance to fremitus as a contribution to our know!-
PHYSICAL EXAMINATION 55
•edge by palpation ranks the location of the cardiac apex, as indicated
by the position of the impulse. Even when visible on inspec-
tion it may be more accurately located by palpation, and a considera-
tion of the many diseases which affect its character and location will
impress on one's mind the extreme importance attached thereto.
Fowler says : ' ' The position of the cardiac impulse is the key to the
diagnosis of many affections of the chest. ' '
Other information gained by palpation is a recognition of the
degrees of resistance offered by various organs, and especially re-
sistance due to increased density of an organ. The finger-tips may
detect the presence of pulsation or vascular thrill, as of an aneurysm,
crepitation caused by air under the skin, or crepitus, such as results
from a broken rib.
The relative length of the expansile excursion on breathing may
be appreciated by many better by palpation than by inspection. Hy-
persesthesia and tenderness are revealed by palpation. ,
THE PULSE. -- - -
Much valuable information is gained by a careful study of the
pulse, which with many becomes such a routine procedure that the
gains are minimized. Intelligent palpation of the pulse enables us to
recognize the febrile state, to estimate the general strength of the
patient during the course of disease, as well as to suspect solely from
its character the presence of various conditions and complications.
The three chief factors which are to be noticed in examining the pulse
are the frequency, the quality, the rhythm.
The frequency of the pulse is easily ascertained in general
although it is possible for it to attain a rate so rapid as to be uncount-
able. The right radial artery is chosen for convenience and the ex-
aminer 's left finger tips are lightly superimposed. The count is made
during fifteen or thirty seconds, unless great accuracy is desired, when
the beats are counted during one or two minutes. The normal pulse
rate for healthy adults is usually stated as being seventy-two per min-
ute, but the rate is sometimes higher and often much lower. The
pulse is more rapid both in childhood and in old age, and varies much
in different individuals of the same age. Eichhorst 's figures are given
thus, slightly modified for ease in memorizing : — first year, 135 per
minute ; second year 110, falling to 100 at the fifth year ; then fall-
ing two beats per year for the next five years, giving us 90 at the
56 PHYSICAL EXAMINATION
tenth year; reaching 72 between the fifteenth and twentieth year,
where the rate remains stationary until the sixtieth year, rising slowly
year by year thereafter.
Many conditions aside from disease influence the pulse rate,
either increasing or diminishing it. Thus alcoholic stimulants in-
crease it and their persistent use brings about a maintained high pulse
rate. Tea and coffee increase both the force and frequency of the
pulse, as does the taking of food, while fasting diminishes both. The
effects of exercise, excitement and emotions of ail exhilarating nature
are well known, while depressing emotions, fear and shock diminish its
rate, as do rest and sleep. Quiet sleep, recumbency, sitting, standing
and moving each successively augment the pulse in the order named.
High temperatures and high atmospheric pressure increase, while the
opposite conditions diminish the rate. Deep breathing and coughing
increase the volume as well as the number of beats. The pulse is in-
fluenced by drugs, and it is wise to ask what medicines have been taken
before estimating the pulse value. Digitalis is the commonest drug
used to slow the heart; belladonna has an opposite effect.
The pulse during the twenty-four hours describes two well-defined
■cycles which vary greatly in different persons, although showing
considerable constancy in the individual. These show a morning and
an evening maximum, and an afternoon and a night minimum rate.
In incipient phthisis the day cycle is often reversed.
Morbid changes which influence the pulse rate are too many to
be enumerated fully, but a few may be mentioned with profit. All
inflammatory conditions and fevers raise the rate, and in uncompli-
cated fevers the pulse rate increases about 8 to 10 beats for each de-
gree F. above the normal. This rule is not applicable to persons who
were the subjects of disease prior to the onset of the fever. In such
the rate rises in a much higher ratio. The various infective processes,
pyaemia, septicsmia, tuberculosis and the like are all attended by rapid
pulse. Increased intra-thoracic pressure from almost any cause ac-
celerates the pulse, apart from the inflammatory action which may
be the cause of the pressure; thus effusions, obstructions caused by
disease of lung or pleura, enlarged glands, so act. In incipient
phthisis the pulse constantly augments long before the temperature
curve shows its characteristic rise. Pain increases the rate; so also
does pneumogastrie paralysis, as from glandular or aneurysmal pres-
sure. The rapid pulse of exophthalmos is one of the three classic
PHYSICAL EXAMINATION 57
symptoms of that malady. Most anemias areiattended by rapid pulse.
The technical title is pulsus frequens.
A diminished pulse rate, while less frequently a manifestation
of morbid processes, is perhaps more significant than its opposite.
The absorption or presence in the blood of certain substances manu-
factured within the organism, as urea, bile, bile pigment, etc., slow
the pulse. Cardiac degeneration, especially if accompanied by dis-
ease of the coronary arteries, some forms of valvular disease and affec-
tions of the myocardium, very generally slow the pulse. Of the valve
lesions, aortic stenosis stands first in this relation, followed by mitral
■stenosis. All forms of weakness,' especially post-febrile and post-
hsemorrhagic debility, influence the rate in the same manner. A large
percentage of epileptics, as pointed out by Craig, are the subjects
■of valvular heart diseases; but aside from tliis they furnish a pulse
rate most striking for its slowness. Wood records a rate of 8 to 10
per minute. All forms of disease of the brain and meninges accom-
panied by increased intercerebral pressure, retard the pulse. Lead
intoxication slows the pulse. Many other eonditions will also fall
within the experience of the practitioner. The condition is spoken of
as pulsus rarus, but in extreme slowness the precaution of counting
the systolic contractions of the heart always shduld be observed, as the
■wave may not reach the extremity.
The quality of the pulse depends upon the balance maintained
between its size, its strength and its fullness. The amount of expan-
sion which the artery undergoes depends upon the strength and the
fullness. The strength varies with the strength of the cardiac con-
traction, and the fullness with the amount of fluid pumped into the
■channels. The latter is much influenced by the state of the venous
system. Without material difference in the rate the artery may swell
gradually under the finger, or the vessel may fill with unwonted sud-
denness, to subside as quickly as it arose. Such conditions often point
to organic diseases of the valves.
The last described of these conditions, spoken of as the pulse of
unfilled arteries, the recedent pulse, or pulsus celer, often enables us
■definitely to recognize aortic incompetency. The peculiarity is made
more strikingly manifest if the patient's arms are raised vertically
above his head while examining the radials. With this pulse is often
seen marked pulsations in the vessels of the neck and elsewhere. It
58 PHYSICAL EXAMINATION
is called Corrigan's pulse, from its deseriber. Its sudden, slapping,
jerky character has given it the name, "water-hammer pulse."
States of high arterial tension give us a hard, full pulse. The
vessel walls are not hard, yet the pulse may have a cord-like feel. The
radial pulse may be misleading, as it is sometimes anomalous, and is
easily pressed upon by clothing.
We estimate the strength of the pulse by the amount of pressure
of the fingers necessary to obliterate it. A really weak pulse is ac-
companied by a diminution in intensity of the first sound of the heart,
without much change in the intensity of the second sound. Obstruc-
tion in front as well as increase of the vis-a-tergo give us a hard pulse,
hence mitral stenosis, aortic insufficiency, contracted kidneys, hepatic
cirrhosis and many other conditions produce it. The distinction be-
tween a hard pulse and hardness of the arterial coats due to sclerosis,
.should be borne in mind. The differentiation is simple.
Pulse Ehythm. In health the pulse is perfectly regular. How-
ever, during sleep, especially in children, intermissions may occur
which are in no wise due to deleterious influences. The study of the
pulse often shows a distinct intermission recurring at regular inter-
vals, as the loss of a beat at every fourth, sixth or eighth contraction ;
or the Intermission may be irregular. The pulse may be affected
without the heart being correspondingly involved, or the heart beat
also may be abortive. Sometimes several slow pulse beats are fol-
lowed by two or three rapid ones. The significance varies greatly.
Excessive use of tobacco is one of the most common causes of arythmie
pulse. Arhythmia is sometimes a premonition of oncoming cerebral
disturbances. It is common in pericarditis, especially of children, and
in many forms of heart disease, particularly fatty heart, of which it
is, perhaps, the most pronounced sign, of mitral disease and various
functional disturbances, as flatulency or dyspepsia. It is prone ta
occur during convalescence from debilitating diseases, where its sig-
aifieance is less ominous than its occurrence during the height of the
ailment, when it often portends heart failure;
The pulse of the two sides may show want of symmetry, as often
occurs in aneurysm of the arch of the aorta causing obstruction of
some of the branches. Owing to the same cause the two pulses may
not be perfectly synchronous. Embolism may cause diminution or
obliteration of the pulse, but in such cases a careful search for anoma-
lies should be made.
PHYSICAL EXAMINATION 59
THRILL.
In mitral and aortic disease a distinct thrill is sometimes imparted
to the pulse, and should always suggest the causative factor.
Dicrotous Pulse and Pulsus Bigeminous. Sometimes a curious
double beat may be felt by applying the fingers very lightly over the
artery. It is not uncommon during convalescence from fevers, espe-
cially typhoid. When the two beats follow each other closely, it is
called "bigeminous"-; generally the second beat is weaker. The
sphygmograph more clearly shows these peculiarities. Its significance
is not particularly important.
VASCULAR PHENOMEINA.
A study of the various phenomena exhibited by the veins and
arteries is both intei-esting and profitable although much neglected by
the student in general.
The veins from the examination of which may be gained most
information are those of the neck, especially the internal and external
jugulars, although the superficial veins of the chest, abdomen, lega
and other parts are capable of imparting many supplemental facts.
The phenomena presented are studied by inspection, palpation, and
auscultation.
I. Venous Pulsation. On inspection there is often present a
visible throbbing in the veins of the neck, the internal and external
jugulars being especially the seat of pulsation. By reason of the
direct connection with the superior vena cava,^ the right internal jugu-
lar is more apt to show pulsation than its fellow. The significance of
the venous throb in the neck has been referred to under cardiac in-
spection. The venffi innominatse or brachio-cephalic sinuses at the
root of the neck, just behind the clavicle, should be carefully exam-
ined. Palpation may reveal pulsations which are invisible.
II. Enlargement of the veins is of common occurrence and may
be temporary, permanent, variable or intermittent. Kinking, knotting
and varicosities are present. They are far more common in women
than in men, and become more apparent with the advance of age.
Permanent enlargement of the veins results from dilatation or con-
tinued engorgement of the right heart, from tricuspid regurgitation,
from obstruction affecting a large venous channel as the cava. Such
obstruction may be caused by extreme pressure from an enlarged
organ, as occurs in hepatic cirrhosis, by a new growth, such as a tumor
60 PHYSICAL EXAMINATION
or an aneurysm, or from occlusion of the vasculai? lumen by a throm-
bus or an embolus. The enlargement may be due to the communica-
tion of an aneurysm with the superior cava, of which accident Pepper
and Griffith have collected twenty-nine cases. ' ' Cyanosis, csdema and
great distention of the veins of the upper part of the body, being the
most frequent symptoms."
Thrombosis of the portal vein may occur as a sequence of cirrhosis
or syphilis of the liver, or be caused by cancer or by sclerosis of the vein
itself. The condition is known as adhesive pylephlebitis. Intense
engorgement of the entire portal system rapidly follows. The super-
ficial abdominal veins are distended and tortuous. Hsematemesis,
melaena, ascites and enlargement of liver and spleen give intimations
of the condition. A definite diagnosis is rarely reached during life.
The distention of the cervical veins during cough is a familiar spec-
tacle, but during the course of diseases which permanently enlarge the
veins, and thus produce insufficiency of the valves^ the swelling is much
increased during the act and even may be alarming, as in a recent case
of my own of a patient in the terminal stages of phthisis. In extreme
cases the pulsation can be both seen and felt. An easy method of de-
termining whether the pulsation is transmitted or is due to filling
from below is to make just sufficient pressure on the vein to obliterate
its lumen at its lowest palpable point in the neck, then to slide the
fi.nger upwards for a short distance with only sufficient force to empty
the vessel. If the vessel fills from below it does so with a jerk which
is synchronous with systole and the carotid pulse„ The external jugu-
lar ofl^ers the best opportunity for the trial.
Venous distention increases during expiration and diminishes
during inspiration. As already mentioned, tricuspid regurgitation
and right-sided engorgement and hypertrophy are the most potent
causes of the phenomena. Insufficiency of the valves within the veins
has been discussed. Friedreich's diastolic collapse as a sign of pericar-
dial adhesion is described elsewhere. Venous pulsation is often seen in
chorea and chlorosis. The venous engorgement, particularly of the
small veins of the thorax, in emphysema is mentioned thereunder.
Most cardiac valvular diseases, especially when accompanied by
lack of compensation, produce venons engorgement, of which local and
general oedemas are the sequels.
The enlargement of the veins around the umbilicus, known as the
PHYSICAL EXAMINATION 61
caput medusw, is due to thrombosis or obliteration of the portal vein,
as occurs in cirrhosis of the liver.
In phthisis venous pulsations are common, an occasional situation
being the back of the hand.
VENOUS MURMURS.
Auscultation. The "bruit de diable" of French writers, the venous
hum of American authors, is often present in health, but is generally
accepted as significant of anaemia wherein its intensity furnishes an
index of the grade of the anaemia for the particular case ; that is to say,
that while it varies widely in the different forms of anaemia, and in
different individuals, yet in general its intensity lessens with improve-
ment and increases with increase in the malady..
The bruit is best heard at the junction of the right subclavian
with the jugular vein, the head being twisted slightly to the opposite
side. The murmur is not interrupted as is the arterial murmur, but is
continuous. Its quality varies and the names descriptive thereof are
as numerous as those chosen to describe valvular lesions. It is usually
humming or buzzing, or rustling, but may be musical, singing, piping
or whistling. Pressure of the stethoscope produces it in health and
pressure intensifies it when otherwise present. It is strongest during
inspiration and during cardiac systole. It diminishes and may disap-
pear on lying down and is loudest when the patient is erect. Some-
times a venous thrill is felt in the vessels of the neck in cases of
extreme anaemia, but is quite rare.
Time of Venous Pulsations. The venous pulse as observed in the
external jugular is either presystolic or systolic. It may be timed
by the carotid pulse. The presystolic pulsation is spoken of as the
negative pulse. The vein collapses with the heart's systole and refills
before the next systole. The collapse is synchronous with the apex
beat, hence the refilling is synchronous with the auricular contraction
which closes diastole and is presystolic.
The systolic venous pulse, spoken of as the positive pulse, is
synchronous with the apex beat. It is most apparent in the right
internal jugular vein and is a very important and positive sign nf
tricuspid regurgitation. To a lesser degree other veins are affeuiod
and show throbbing. In the form of valvular deficiency just men-
tioned this pulsation is produced by the systole of the right ventriek'.
projecting a current of blood through the insufficient tricuspid valvii
62 PHYSICAL EXAMINATION
at each contraction, over-distending the already filling auricle tod
projecting the blood still farther into the' ascending cava whose open
mouth is unguarded by valves.
A similar blood wave traverses the inferior cava and gives rise
to pulsations in the liver produced and explained in the same manner
and having the same time as the jugular pulsations. The change in
the volume of the organ which occurs with expansion and contraction
of the heart may sometimes be distinctly felt and even seen. Of ttimes
the throbbings are painful.
The phenomenon is best appreciated by placing one hand over the
fifth and sixth interspaces at the junction of the costal cartilages and
the other over the liver in the mid-axillary line, when the rhythmic,
systolic expansile pulsation is felt easily and can be distinguished
readily from the systolic depression of the: liver caused by communi-
cated pulsations from the hypertrophied right ventricle, which is non-
expansile.
ARTERIAL MURMURS.
Through the large arteries the sounds of the heart are transmitted
for a considerable distance by the blood current and have the quali-
ties of the sounds as heard at the aortic valves. The intensity dimin-
ishes as would be supposed as we recede from the point of origin. In
the neck over the seat of the common carotids or the subclavian artery
both heart sounds are distinct, but the sound made by the closure of
the aortic valve, the cardiac second sound, is the more evident. The
first heart sound is here faint and of low pitch.
Over the exit of the femoral arteries from under Poupart's liga-
ment the aortic valve sound may often be distinguished in health, but
disappears before Hunter's canal is reached. At the ligament the
first heart sound can not be heard.
Arterial Murmurs due to Disease. Just as pressure with a steth-
oscope upon the trunk of an artery causes a murmur to appear, so
pressure arising from various causes as tubercular deposits, new
growths, enlarged glands, thyroid tumors or aneurysms occasion
arterial murmurs.
Diseases of the vessels which change their caliber or destroy the
resiliency of their coverings produce murmurs, hence the aneurysmal
bruit and the murmur associated with extensive atheroma. This dis-
ease is prone to attack the aorta just beyond the sinuses of Valsalva,
PHYSICAL EXAMINATION 63
and many a case of supposed aortic valvular disease is in reality due
to the bruit or the thrill caused by the calcification plates. Congenital
narrowing of the vessels operates in the same way as external pressure
to produce bruits. Thrombosis may also cause a murmur. The uter-
ine bruit which accompanies the formation of the placental sinuses
during pregnancy is a familiar example of vascular murmur.
In aortic insufficiency the vascular phenomena are characteristic
and it is possible to make a diagnosis of the disease by inspection
and palpation alone. Thus :
On Inspection a visible pulsation is seen in the peripheral vessels,
arteries, veins and capillaries, and often the= face or hands are seen
to alternately suffuse and pale with the heart action. The capillary
pulse is seen in the finger nails or along the margins of a light scratch,
or by pressing a microscopic slide against the everted mucous mem-
brane of the lower lips, as suggested by Shattuek. The arteries pul-
sate forcibly, the carotids swell and throb, the aorta behind the supra-
sternal notch rises and suggests aneurysm, the abdominal aorta lifts
the epigastrium with each beat. The temporals and radials fill with a
vermicular twist and jerk, followed by instant collapse. The ophthal-
moscope shows the same phenomena in the retinals.
Palpation. The finger feels a short, quicX hammer-like stroke,
followed by rapid recedence. When timed with the apex beat the
radial pulse shows a distinct retardation.
Auscultation. In the carotids and subclavians a double murmur
is heard, and the second aortic sound may be audible here, even when
absent at the aortic cartilage. Duroziez calls attention to the double
murmur heard in the femorals.
Tyson mentions a vascular sign described by Traube, occurring in
aortic regurgitation as the result of the sudden change of pressure.
' ' This is usually a double sound, of which the' first element is ascribed
to the rapid distention of the artery by a blood wave which throws its
walls into vibration. A second sound occurs with a cessation of the
pressure."
Intermittent venous murmurs are spoken of by some authors;
they must be of rare occurrence.
THE SPHTGMOGRAPH.
Numerous instruments have been devised for the graphic repre-
sentation of the pulse in the human being. Marey's sphygmograph
64 PHYSICAL EXAMINATION
is one of the oldest, but is still most used. Richardson's or Dudgeon's
modification of Ponds' American sphygmograph is the simplest form
for the clinician. By means of the instrument a graphic record of
the pulse is made in the form of a tracing, which shows a saw-like
series of elevations and depressions corresponding to the vibrations in
the pulse wave.
The elevations correspond to the onset of the wave, the depres-
sions to its recedence. Hence variations in the tracing graphically
show differences in the temporary rise and fall of arterial pressure,
the rate at which successive waves pass a given point, as well as varia-
Fig. i8 — Dudgeon's Sphygmograph.
tions in their rhythm. The primary blood wave, caused by the cardial
systole is followed by several succeeding waves of lesser degree, called
secondary waves. The chief of these is the rebound in the blood cur-
rent caused by the sudden check, produced by the closure of the aortic
valves, named the dicrotic wave. A lesser wave, supposed to be due
to the stoppage of the backward flow towards the heart of the aortic
current, by the closure of the valves, is called the predicroUc wave.
Perhaps the following explanation will render clear the difference in
the two waves. The systole forces the current up hill into the aorta.
A portion of the fluid obeys the impulse to return. The gates close.
The first influence felt by the column in the arteries is the stoppage —
the predicrotic wave. The second effect is the rebound — the dicrotic
wa\c. This dicrotic wave is increased by the natural resilient recoil
of the elastic aortic walls, dilated by the primary current, which
occurs just in time to catch the second wave. Lesser waves due to
this resiliency follow the dicrotic wave but are of less moment.
PHYSICAL EXAMINATION
65
The dicrotic notch is due to the cessation of the inflow with each
isystole, causing a momentary falling off of the pressure, the fall being
modified by the influences just named.
When the arterioles are constricted, the dicrotic notch is lessened
and we have the curve of high tension, pulse such as occurs in Bright 's
disease. When the arterioles are widely dilated, the dicrotic notch is
exaggerated and we have the low tension characteristic curve. Before
making the tracing it is well to measure the varying degrees of pulse
tension by the sphygmometer. The pressure of the instrument is ad-
justed accordingly. In pulse of low tension, slight pressure gives the
ANACROTIC
CATACRoT«C
SIDE.
a b c -a
Fig. 19 — Normal pulse tracing.
best results and too much pressure extinguisbes the tracing. In high
tension pulse, rather strong pressure of the Spring button gives the
best results. ,
Ax, entrance of the stream into the aorta. This up-stroke is called
the anacrotic stroke, or percussion stroke, and ia due to the sudden
■dilatation of the artery by the primary blood wave. The hypersensi-
tive lever is carried too high, and in reality should have stopped at .r.
The lever begins to fall but is overtaken by the predicrotic wave on
the catacrotic side of the tracing and carried, to y — , the real summit
■of the pulse wave. Hence omitting the false movement of the lever,
axy, represents the real upward or anacrotic curve, ky, represents the
predicrotic notch, y, represents the point at which the ventricular
streanl ceases, when the positive pressure remits and the negative
66 PHYSICAL EXAMINATION
wave, caused by the sudden cessation of inflowing blood, and the first
slight reflux begins. This cessation of pressure allows the lever to fall
to w., W, is the point of closure of the aortic valves and is synchronous
with the second sound of the heart. Wz, is the positive wave or re-
bound due to the closure of the aortic valves and corresponds to th.e
true dicrotic wave, hence ywz, is the dicrotic notch, sometimes called
the aortic notch, owing to the manner of its production. The slight
curve at m, is due to the resilient waves which succeed the aortic or
A
Fig. 20 — Pulse of constricted arterioles. High tension pulse.
dicrotic wave. Since this curve m, is produced during diastole, it is;
sometimes caled the diastolic notch.
The Pulse of High Arterial Tension. The pulse of constricted
arterioles, the high tension arterial pulse, called by Sansom the pulse
of prolonged arterial tension, differs from the normal pulse in that a
notch is formed at the top of the curve and the maximum altitude of
the lever may be reached after the notch. Yeo explains this phenom-
enon on the ground that the first reflected wave is positive instead of
negative, in the case of constricted arterioles, and is therefore added,
to the percussion stroke, reaching it just as the lever begins to fall at k
'lud carrying it to y, thus broadening the top of the primary
•nirve, and this pulse is named the a,nacrotie pulse. The aortic or
dicrotic notch, wz. is lessened as the dicrotic w^ave is lessened in these
conditions and the post-dicrotic wave m, is nnt discernible. Such a
pulse is the result of resistance encountered by the blood current
PHYSICAL EXAMINATION* 67
through the arterioles and capillaries, as stated, and is found in con-
tracted kidneys, in all diseases which cause atheroma of the arterial
walls, gout, lead-poisoning, and aortic stenosis!
Lead-poisoning is prone to produce three. of the chief disease-fac-
tors just mentioned, siacs lead' workers are notoriously subject t<>
arterio-sclerosis, contracted kidneys and hypertrophy of the heart. In
this state the fullness of the vessels is felt to be maintained for a con-
siderable period and the collapse is gradual. Pressure of the finger
obliterates the pulse with difficulty.
The Pulse of Low Arterial Tension. In this case the arterioles are
widely dilated, the negative wave is reflected and is subtracted from
the primary wave instead of being added to it. The vessels collapse
A
Fig. 21 — Pulse of low arterial tension.
quickly after the primary filling and pressure of the finger easily oblit-
erates-the pulse. Such a pulse is said to be soft. The tracing shows a
vertical up-stroke, ak, followed by a quick fal^ ky. so that the apex, k,
is sharp and pointed. The predicrotic notch, y;, is insignificant, but the
dicrotic notch, wz, and aortic wave, 2, caused by the valve closure are
exaggerated, also the post-aortic curve, m, is marked. When present
in even a moderate degree the wave, z, may be appreciated by palpa-
tion and the pulse is said to be dicrotic. Such dicrotism may reach an
extreme degree and the point, w, may fall to the base line or below, in
which case the pulse is said to be hyperdicrotie.
Low tension pulse occurs with conditions which cause dilatation
of the capillaries, as the inhalation of chloroform, the administration
of nitro-glyeerine or nitrite of amyl. Turkish baths are followed by
the low tension pulse. In diseases producing serous diarrhreas, colli-
quative sweats and diuresis it follows, owing to the emptying of th(f
vessels. It often marks the course of febrile diseases. Aortic regiuvi-
m
PHYSICAL EXAMINATION
tation furnishes the best examples. When the dicrotic wave ap-
proaches in force to equality with the primary wave, to the finger it
appears as though there were two closely associated beats followed by
a pause. Such a pulse is called pulsus bigeminus. (See section on
Pulse.)
Sometimes three such beats are separated by a pause when the
name pulsus trigeminus is used to designate the condition,
THE SPHYGMOMETER.
This is an instrument intended to measure the degree of tension in
the peripheral arteries with greater accuracy than the time honored
Pig. 22 — The Riva Rocci Sphygmomanometer.
-viue of simple palpation. By its use records can be made of daily
variations during the course of disease and 'operations, as well as the
^ascertaining of immediate results from taking medicine, food, and
drink.
A number of these instruments have been devised, some supposed
to measure the systolic pressure of the artery, by recording the amount
of foi-ee required to obliterate the pulse, others to measure diastolic
pressure. The recorders are of two kinds, manometers, or mercurial
columns, and aneroid instruments, fitted with dials, like the barometer.
The latter are objectionable owing to the readiness with which their
PHYSICAL EXAMINATION 69
mechanism is disordered. The objection to the instruments in general
is that they are provided with rubber tubing which inflates to vary-
ing degrees under pressure and changes much in this respect with age.
The Riva-Roeei instrument, is, all things considered, the most
serviceable, Stanton, of the University of Pennsylvania, has modified
Fig. 23 — The Riva-Rocci Sphygmometer — Stanton modification. A Air pump.
B Manometer. C Cuff.
this by fitting it with rigid connections. The essential parts are an
air pump, a manometer, a rubber armlet which fits around the upper
arm, and tubing connections. Stanton advises that the width of the
armlet be not less than three and a-quarter inches. To use the instru-
ment the armlet is adjus.'ed, air is pumped ini until the radial pulse is
exactly extinguished, and the height of the mercury noted at the same
moment. Experiments have shown that the pressure within the arm-
let and that within the manometer are at all times the same. The
accuracy of the instrument is .shown by applying it to the thigh, when
70 PHYSICAL EXAMINATION
it will be found that the difference in the index does not vary over
four or five millimeters.
The slight oscillations noticed are caused by the varying degree of
interarterial pressure and the inflneuce of respiration on blood pres-
sure. During the course of protracted operations the instrument fur-
nishes valuable -information, likewise in the: study of the state of
arterial tension in kidney and heart diseasea, and the effect of drugs.
It is difficult to transport, is fragile and, like many other devices, has
so far found its field of greatrst usefulness in the hospital.
PERCUSSION.
Percussion elicits certain sounds by tapping over the areas occu-
pied by the thoracic and abdominal organs. The tapping may be
Fig. 24 — Percussion Hammfer.
directly upon the overlying tissues, called mediate, or upon an im-
posed substance, immediate. While the rubber-headed hammer named
a plessor, and an ivory plate called a pleximeter, are useful for class
'demonstrations, nothing in actual practice ecj^uals the fingers of the
two hands, as thereby we not only quite as' satisfactorily elicit the
sounds sought for, but further gain valuable information by noting the
amount of resistance which the finger encounters, and likewise the
amount and length of the vibrations communicated to the super-
imposed digit. Percussion is the most diificult to acquire of the arts
used in physical diagnosis, and the maxim that "practice makes per-
fect" is peculiarly applicable here. The strt)ke should be delivered
from the wrist, as in piano-playing ; never from the elbow. The ham-
mer fingers should fall perpendicularly and strike the finger which is
used as pleximeter at a right angle to its surface, while the latter is
applied as firmly and as evenly to the chest wall as possible. For per-
cussing, the middle and third fingers arc superior to the index and
middle fingers. The nails should be kept short, that they do not pro-
duce sounds by impact. In percussing over the thorax the fingers
should be applied to the intercostal spaces parallel with the ribs, never
across the rib and interspace, since this gives two notes differing in
PHYSICAL EXAMINATIOSr 71
quality. Over the clavicle, mediate percussion gives the best result
and often gives the earliest indication of disease by a variation from
the normal note. Owing to varying conditions, such as thickness of
the overlying muscular tissues, quantity of fat present, etc., the sounds
elicited by percussion over the lungs vary greatly not only in differ-
ent areas upon the individual, but likewise over corresponding areas
in different individuals; so much so that we are not far wrong in
saying that every lung has its own normal note.
PERCUSSION SCALE.
In spite of these variations, we may constt'uct a roush scale which
is generally applicable, although the notes lack the fixedness of musi-
cal tones. The note of highest pitch is obtained by direct percussion
over a bone, as the sternum or clavicle, and is called osteal pitch.
Fig. 25 — Pleximeter.
Next is the tone produced by percussion over the trachea during quiet
inspiration. This is called tubular pitch. The note produced by per-
cussion over the second anterior interspace or the axilary region of a
healthy, well-developed individual falls next in the scale, and this
note is called the vesicular note or the norm:il pulmonary note. Flint's
comparison of this note to that produced by tapping a large loaf of
bread is classic. The note produced by percussion over an air-con-
taining cavity of considerable size, as th? stomach and intestine, is
called tympanitic. It is lower in pitch than the vesicular note. It is
not difficult to divide tympanitic resonance into two tones, small
tympany, the note of the small intestine furnishing the standard
therefore, and large tympany, the latter being the note obtained by
percussion over the empty sto^raeh or the colon. The note which
Flint called vesiculo-tympanitic occurs in disease, but in the scale of
pitch assumes a place between the normal ve'^isular resonance and
small tympany.
Two other sounds remain to be considered, dullness and flatness.
Gee defines dullness as the absence of tone, tone being that succession
of sound impulses which characterizes a musical tone, but which 7S
72
l^llYSICAL EXAMINATION
absent in a mere noise. Ea Costa* defines a dull ^ound as one dsuoting
the absence of air. "It is the sound of both fluids and solids. It is
thus the sound sent forth by the airless viscera ; from the liver, spleen
and heart." We believe, however, that a profitable distinction can be
n-ade between dullness and flatness by calling the sound possessing
the above qualities flat, and calling a sound which approaches flatness
Eig. 26 — Percussion of dorsal regions. Patient astride of chair with arms folded
across the back. Intercostal spaces widened, scapulae rotated outward.
in pitch, but which still retains some resonance, dull. In the scale of
pitch, the terms would fall above osteo-pitch, flatness being the highest
possible in the scale. Writers who desire to avoid this distinction use
instead of dullness the term impaired resonance, modified by the
adjectives "slight," "considerable," and "marked" Their incon-
sistence is made apparent by the terms "relativi? dullness," "dullness
*6th Edition, Medical Diagnosis, p. 24G.
PHYSICAL EXAMINATION 73
more marked", etc., which are used by mdst systemic writers on
practice.
A protracted discussion of the theories of percussion sounds would
be profitless. Two only have received extensive recognition, that oi
Gee, who believes that the vibrations originate in the bronchi, and.
that of Bristow, who advocates that the tones are produced solely by
vibrations of the chest walls, hence, any interference with these vibra-
tions changes the note.
Scale of Pitch. Arranging the notes on a descending scale, be-
ginning with the apex note, or note of theoretically highest pitch,,
we have :
Flatness
Dullness
Osteal
Tubular
Vesicular
Vesieulo-tympanitie
Small tympany
Large tympany
It may assist the student somewhat in his conception if we com-
pare these eight variations with the notes in* the musical scale from-
high C to low C, with this reservation, that the resemblance ends with_
the fact that each of the percussion notes is lojver than its predecessor.
While the above subdivision of the percussion notes might seem
at first glance to be an unnecessary refinement, the terms are all met
with in the works of various standard write'rs, hence a clear classi-
fication of them for the benefit of the student cannot be amiss.
It is to be prefaced that the percussion seunds produced over the
pulmonary areas can vary in health only in regard to pitch, intensity
and duration. Pitch changes with the number of vibrations per sec-
ond, the greater the number of vibrations the higher ths pitch ; while
the intensity varies with the amplitude of the vibrations, the law
being, the greater the amplitude the louder the sound. Duration
varies inversely with pitch, the higher the pitch the shorter the dura-
tion of the sound. The pitch also varies with the degree of tension,,
both of the covering of the lungs and of the organ itself. The rule
above given applying again, viz., the greater the tension the higher
the pitch, just as in musical instruments, the tighter the string is.
74 PHYSICAL EXAMINATION
tuned up the higher the note. The pitch of the pulmonary percussion
sounds is altered by disease either in the direction of dullness or of
tympany. Changes in the sounds are best^ appreciated by careOul com-
parison between corresponding areas of the two lung surfaces, ignoring
for the moment the very slight differences which normally exist.
■CHANGES IN THE PULMONARY PERCUSSION NOTE PRO-
DUCED BY MORBID PROCESSES.
Increased resonance is frequently met with. It is called hyper-
resonance. Its quality is that of the normal percussion note more or
less exaggerated, that is to say, the volume of sound, the intensity
and duration are increased, while its pitch is lowered. It means in-
creased volume in the air vesicles without increase in the tension. Tem-
porary over-distension produces this note in its slightest degree, while
■emphysema produces a more marked example.
Skoda 's resonance is a note of higher pitch than true tympany,
yet with a tympanitic quality. It occurs in connection with two con-
ditions, pleuritic effusion and pneumonia of the lower lobe. It is
most strikingly manifest in the infra-clavicular region in a case of
moderate effusion. Osier says, ' ' In the subclavicular region the atten-
tion often is aroused at once by a tympanitic note, the so-called Skoda 's
resonance, which is heard perhaps more commonly in this situation
with pleural effusion than in any other coBdition. It shades insensibly
-into a flat note in the lower mammary and axillary regions. Skoda 's
resonance may be obtained also behind, just above the limit of effu-
sion." Tyson maintains that Skoda 's resonance and Flint's vesiculo-
tympanitic note are identical.
Tympanitic Resonance. Lower in pitch than the preceding and
produced by percussion over a quantity of air, "enclosed in walls
which are yielding, but neither tense nor very thick." (Da Costa,)
The sound is somewhat musical, and the-pitch varies with the size of
the cavity. It is abnormally present in pneumo-thorax, or over large
pulmonary cavities.
Diminished Resonance. Impaired resonance, which in our scale
we have denominated dullness, is a note of higher pitch than the nor-
mal vesicular sound, but the duration of the note is shorter and
sharper. The note closely resembles that produced by percussion over
a thin board ; hence its quality is described as wooden. It is noticeable
in partially consolidated lung, in compression or displacement by
PLATE III.
RELATIVE AND ABSOLUTE PERCUSSION AREAS.
The shaded area represents the area of flatness of heart and liver,
fusing into one.
The dotted area marks out the area of heart and liver dullness
obtained by deep percussion.
The lower dotted line represents the descent of the liver with forced
inspiration.
T. Traube's tympanitic or semi-lunar space=.
PHYSICAL EXAMINATION 75
morbid growths. Increased resistance generally accompanies it. Even
over wholly consolidated lung the note is not entirely flat so long as
any vesicular substance remains.
Flatness is the abssnce of tone, absence of resonance, and is the
height of pitch. Such a" sound is heard when percussion is made over
the thigh or over a large pleuritic effusion.
Amplioric resonance is metallic in quality, while tympanitic in
pitch. It indicates a large hollow space witli firm elastic walls, as a
•cavity which communicates with the bronchus. Percussion over tht
trachea with the patient's mouth partly open furnishes a fair imita-
tion of the amphoric quality.
The Cracked-Pot Sound. Bruit-de-pot-fele of the French writers.
Its quality is indicated by the name. This sound is closely associated
with amphoric resonance. The condition Usually occasioning this
sound is a cavity freely communicating with Jhe bronchus, the caviti
having yielding walls. To produce the sound" it is necessary to strilie
a strong, sharp percussion blow while the patient holds the mouth
open. It may be imitated by striking the loosely folded hands across
the knee. Da Costa says the sound is met with independent of exca-
vations in "pleurisy above the seat of the effusion; in bronchitis of
children; near a pericardial exudation; in emphysema and certain
instances of pneumothorax. Indeed, any disorder in which the chest
wall remains very yielding, and in which a certain amount of air
contained in the lung or pleura and in uninterrupted connection with
the external air is, by sudden percussion, forced into a bronchial tube,
will occasion this cracked-metal sound. ' '
We briefly indicate again the outlines of the lungs, (see also
.section on Divisions of the Chest). On the back the lungs extend from
the seventh cervical vertebra (vertebra prominens) to the level of the
bottom of the tenth dorsal. In front the apices extend for varying
distances above the cla^/icle, from a half inch fo one and a half inches
in extreme cases. On the right side we enequnter hepatic dullness
about one and a half inches below the nipple. On the left side cardiac
■dullness begins at the lower border of the third rib. In the left
lateral region we encounter stomach tympany and a little in front of
the mid-axillary line splenic dullness begins at the ninth rib. An-
teriorly, along the right side of the sternum, the right lung extends as
low as the sixth costo-sternal cartilage. The left overlaps the heart as
far as the fourth cartilage. In the mid-axillary line the edge of th'?
76 PHYSICAL EXAMINATION,
lung reaches the lower border of the seventh rib. The liver dullness
is therefore indicated by a line beginning at the junction of the fifth
cartilage with the right side of the sternum, and passing over the
seventh rib in mid-axilla, the lower body of the tenth posteriorly
to the eleventh vertebra. It should be remembered that in the erect
position the spine of the tenth vertebra is on a level with the middle
of the body of the eleventh. The bifurcation of the trachea is behind
the sternum, opposite the second costosternal cartilage and the arch
of the aorta curves from right to left and from before backwards
over this division.
AUSCULTATION.
Auscultation is the recognition by the ear and the determination
of the significance of sounds emanating from normal or diseased struc-
tures. It is, therefore, almost necessarily limited to the respiratory
and circulatory systems. The late Professor Flint picturesquely de-
scribed it as a kind of eaves-dropping.
Auscultation may be mediate, by means of the stethoscope, or
immediate, by the direct application of the ear. In practice, auscul-
tation should follow percussion. In using the instrument care should
be taken to avoid pressing the bell too firmly against the tissues as
false sounds, resembling friction sounds, thus may be easily ijroduced.
In the case of children the premature exhibition of the stethoscope
may cause fright, and, as sounds of all kinds are readily transmitted
through the thin chest walls of the young, often its use may be dis-
pensed with. In the examination of the lungs the stethoscope is
sometimes of doubtful advantage as compared with immediate auscul-
tation, and as the practitioner frequently may be caught minus this
portion of his armamentarium, it is wise to. practise both forms of
auscultation. One sometimes encounters cases, especially in hospital
and dispensary routine, in which he is loath to apply the ear, even
with towel or napkin intervening, and occasionally over-modest female
clients make objection to the procedure. It is to be observed that in
the ease of females the configuration of the breasts renders immediate
auscultation more difficult and less accurate than mediate; likewise in
the examination of the heart in both ma.les and females, by reason of
the circumscribed areas of the valvular sounds, the stethoscope is
almost a necessity not only for their accurate location and differen-
tial ion but also that sounds emanating from neighboring organs, as.
PHYSIC.VL EXAMINATION 77
-tlie lungs and pleura, may be excluded more i-eadily. If it is desirable
to cover the chest during' the examination, spe that the covering be of
such nature as not to interfere with the transmission of sound nor of
.A material of itself to originate sounds. The best covering for the
purpose is a thin, gauze undervest ; in the absence of which, a thin,
soft towel is a fair substitute. Starched, garments are especially to
be avoided. The author has known the soft creaking of a starched
•chemise, freshly donned in anticipation of the examination, to be mis-
taken for the friction sound of beginning pleurisy.
The most reliable evidence is gathered by repeated exammatious
of corresponding areas, causing the patient alternately to breathe nat-
urally, deeply, to cough and to count, as occasion requires. I have
found that repeating the number "nine hundred and ninety nine,"
by reason of its ringing character, to be especially suitable in testing
vocal and tactile fremitus.
NORMAL AND' ALTERED RESPIRATORY SOUNDS.
It is manifestly impossible to recognize alterations in the pulmonic
or cardiac sounds unless we are thoroughly familiar with the normal
ones. Constant study of healthy respiratory and heart sounds is the
only way in which the ear can be kept in accord with the demands
made upon it. Just as the musician attunes his instrument before
playing, so the diagnostician should constantly attune his ear.
The varieties of respiratory sounds which are recognized in health
are of three types, but the unfortunate lack of uniformity in nomen-
clature is not only most confusing, but would lead the student to con-
clude that there are half a dozen varieties.
It must be emphasized that the sounds about to be described are
natural, and only have a pathologic significance when heard outside
of their own proper spheres, or when one which should be heard in
a certain locality is replaced by another.
As a starting point, we begin with the air sounds heard over the
glottis or larynx. Here the ear recognizes a harsh, blowing sound of
high pitch and great intensity, heard both on inspiration and expira-
tion, which acts are separated from each other by a distinct silenl
interval. The quality of this sound is unmistakably blowing, tubular,
and somewhat hollow. As we descend from the larynx to the top of
the sternum, the sound undergoes a very slignt modification. This
sound is known as tracheal, bronchial, or tuhid ir breathing; the vari-
78 PHYSICAL EXAMINATION
ous terms being used by different authors as having the same sigTiifi-
cance and being interchangeable.
If next we apply the instrument over the second interspace, an-
teriorly, we hear a much softer sound. Its pitch is decidedly lower,
the blowing character has been replaced by a gtentle breezy rustling
of short duration, heard best with inspiration, followed without any
appreciable interval by a still softer expiratory murmur of yet lower
pitch, shorter duration, but with a faint suggestion of blowing. As this,
murmur is supposed to originate in the alveoli, it is called vesicular
breathing. It is best heard as well as most ehareieteristie at the point
indicated. At the apices and low down posteriorly its intensity dimin-
ishes, but its quality remains unaltered. This is what is meant by the
normal breath sound, or the normal respiratory murmur, and the
student will do well to fix indelibly in his mind its qualities.
The third recognizable type falls between the two just described,
and shares the qualities of each. It is a sound Heard over the subdi-
visions of the trachea, that is to say the roots of the lungs; hence is
heard normally over the manubrium in front and in the interscapular
region behind as far down as the top of the fifth dorsal vertebra.
With inspiration the vesicular element is diminished but not absent.
Inspiration is separated from expiration by a distinct interval, shorter
than in the first variety. Pitch and intensity likewise fall between
the two varieties above described. This form of respiration is known
as broncho-vesicular breathing.
CHANGES IN THE BREATHING SOUNDS PRODUCED BY
DISEASE.
I. The vesicular murmur may be altered in intensity, by being
increased or diminished, or the murmur may be suppressed.
Increase in the intensity of the vesicular murmur is called puerile
breathing, on account of its likeness to the breath sounds normally
heard in children. It denotes increased activity and follows violent
exercise. It is not necessarily a sign of disease. Inspiration and
expiration are equally affected. When heard in adults it indicates
that an increase of function in the unaffected portion of the lungs
is compensating for diminished activity elsewhere. It is often called
suuple mental breathing or exaggerated breathing. One of the best
examples of its occurrence in disease is the respiratory murmur hoaivt,
over the sound side in cases of pleuritic effusion.
PHYSICAL EXAMINATION 79'
II. Diminished Breathing. Diminished or feeble respiration is
the opposite condition to puerile breathing. It is dne to diminished
functional activity, caused by obstruebion to the entrance of air into
the vesicles ; by partial obliteration of the cells by deposits within, or
from pressure upon them. The character of the normal breath sounds
is unaltered, but the intensity is diminished. It may arise in the
course of a variety of affections, as paralysis or pleurodynia. Feeble
respiration at the apex combined with impaired percussion resonance
is a strong indication of the early stage of tuberculosis,
III. Absence of the Respiratory Murmur. Large pleural effu-
sions, massive pneumonia in which the secretion totally occludes the
bronchi, and collapse of the lung, are the only conditions likely to
cause entire absence of the breath sounds.
IV. The respiratory rhythm may be so changed that the relative
length of inspiration to expiration is altered ; or tho respirations may
become uneven and .jerky, exhibiting the so-called wave or cog-wheel
character. In the first instance it is the expiration which is most
affected and the change is usually in the nature of a prolongation of
that act. The prolongation is generally accompanied by a change of
pitch. If the pitch be elevated it means consolidation, deposits within
the air cells or in the nearby bronchi. Here the quality of the sound
gradiially ascends to bronchial or tubular. If the pitch is low and
the quality unchanged, it indicates emphysema. In the one case the
bronchial deposits mechanically dam back the air; in the other the
loss of elasticity causes the expiratory prolongation.
Cogwheel Respiration. The inspiration is disconnected, broken
into two or three parts due to the uneven expansion. Affections of
the muscles of respiration or previous disease of the lungs or pleura,
especially old adhesions, or diseases of the bronchi offering an impedi-
ment to the entrance of air are the causes. It has been met with in
hysteria, in intercostal neuralgia and other spasmodic affections, as
well as in pulmonary tubercular deposits of which it was once con-
sidered a pathognomonic sign. Here its favorite seat is near the
apices.
Bronchial Breathing. The character of this respiration has been
already described. When heard over the vesicular areas of the lungs
as the result of disease the qualities above attributed to it are little
altered but the intensity is diminished. The tracheal sound as heard
at the root of the neck posteriorly is the prototype of bronchial respira-
-80 PHYSICAL EXAMINATION
tion and should be used as the standard of comparison. Bronchial
breathing is higher in pitch than the vesicular inspiratory sound and
retains more of its tracheal qualities. Its expiratory quality is af-
fected in the same way, its intensity increased, its duration equal to or
longer than inspiration, its pitch elevated, and inspiration and expira-
tion separated by a distinct interval. Bronchial breathing signifies
the consolidation of the vesicular structure from deposits within, or
air-cell obliteration from pressure from without. The sounds of the
still patent, large-caliber bronchi are then conducted through the
-denser tissue to the ear, replacing the vesicular murmur and causing
it to appear as though the sohnds originated immediately under
the ear.
Sometimes adventitious growths, as solid tumors or aneurysms,
intervening between the chest wall and the trachea or a large bronchus,
will cause obliteration of the air cells and the bronchial bruit is then
ieard over the tumor area.
As indicating consolidation, bronchial breathing is heard in pneu-
monia and in the infiltrated areas of phthisis. As the result of intra-
thoracic pressure it is heard over the compressed lung above moderate
.and large effusions.
Broncho-vesicular Breathing. When heard peripherally in dis-
eased conditions it portends partial consolidation, but less in degree
than that indicated by bronchial respiration. It is subject to varia-
tions in quality, especially intensity, and may pa§s into the bronchial
type by exacerbation of the conditions which cause it. As the change
•occurs, more and more of the vesicular element is lost and the tracheal
quality assumed, as indicated by an ascent of both intensity and pitch.
Tubular Breathing, as the term is generally used, is synonymous
Tvith bronchial breathing. It indicates the breathing of complete con-
isolidation, as does the latter, but the former term is more limited in
its application. Its quality is described as whiffling, and its pitch as
higher thanthe bronchial pitch. Like the latter tubular breathing is
present in pneumonic consolidation and in the complete consolidations
sometimes met with in the superficial areas of phthisis.
Cavernous Breathing, as its name indicates, is produced by the
entrance and exit of air from a cavity. The cavity may be within the
lung substance or external to it, without causing alteration of the cav-
•ernous sound, provided it be entirely or partially empty and that it
PHYSICAL EXAMINATION 81
<3oramunieateo with an open bronchus. It is asserted that a cavity must
be as large as a wahiut to produce the phenomena attributed to it.
The inspiration is low-pitched, hollow and blowing, as is the ex-
piratory sound. Often, but not invariably, expiration is still lower in
pitch than inspiration, which is the reverse of bronchial breathing.
The pitch is never raised on expiration and expiration is longer than
inspiration. It requires for its production yielding walls. As a stand-
ard of comparison for cavernous breathing, we compare it with the
sound heard at the lower end of the trachea. The sound is often asso-
ciated with gurgling, due to fluids confined in the vomics, which may
disappear when the cavity is entirely filled, to reappear after expec-
toration. It is significant of the third stage of phthisis, of bron-
chiectasis or of pulmonary abscess.
Amphoric Breathing, like cavernous, requires a cavity with resil-
ient walls communicating with a bronchus. It is a high-pitched, blow-
ing sound, the qualities being those of cavernolis breathing in an exag-
gerated degree. But in addition thereto it Has an echoing, metallic
character, as has the corresponding percussion note. It may be imi-
tated by blowing across the mouth of a bottle or jug (Amphora). Its
intensity varies. It indicates a lai^e- cavity and usually means pneu-
mothorax. Rarely a pulmonary cavity may afford the necessary con-
ditions for its production.
NEW OR ADVENTITIOUS ^OUNDS.
In addition to the changes and modifications of the respiratory
rhythm already described, auscultation reveals certain sounds which
are in no wise related to or analogous to the normal sounds. Such are
rales, rhonchi, friction sounds, echoes and the like.
Kales are peculiar sounds generated in the air tubes by the pass-
age of air through exudates contained therein, or by the forcible sep-
aration of agglutinated surfaces, as the swollen lining of the small
bronchi or the collapsed alveoli. When they originate in a portion of
the lung which has undergone consolidation, or when due to the forma-
tion of a thick, viscid and not easily displaced exudate into the cells,
the character of the sound is sharp, crackling, dry, or even explosive.
These sounds are described as crepitant or crackling rales, and are
■gauged according to size and intensity into small, medium and large
•crepitant rales. As already stated, they mean consolidation of the
-vesicular portions of the lungs. The small, sharp crackle, heard often-
82 PHYSICAL EXAMINATION
est with inspiration, originates in the alveoli, and is heard in the early
stages of tubercular formation, or may be accepted as the earliest sign,
of the softening stage of' the pneumonic process. This rale is not
limited to inspiration, but may also be heard during expiration. The
larger crackling rales are in character the same as the small rales
and indicate an extension of the associated processes. Hence they are
heard in the softening stage of pneumonia and of tubercular deposits.
They also occur in broncho-pneumonia. The largest crepitant rales,
are confined almost entirely to minute cavities, surrounded by areas
of consolidation which form during tubercular softening.
Sounds produced in the manner just described, particularly when
they emanate from lungs whose structure is little altered, and in which
the lesions are confined principally to the lining membrane of the
tubes, vary in character with the amount and natiire of the secretion.
They may originate in any portion of the bronchial tract, including
the trachea, but usually are confined to the lesser bronchi. When
these sounds are dry and have somewhat of a musical character, they
are termed rJionchi. When their nature indicates the presence of
liquid in the tubes, they are denominated moist j liquid, or mucous
rales. Sometimes the sounds suggest the breaking of small bubbles.
Such sounds originate in the smallest bronchioles and are heard in
capillary bronchitis. Others are larger and have a, gurgling character.
All of these sounds are extremely evanescent, changing their loca-
tion, appearing or disappearing with forced respiration, coughing, or
change in the position of the patient. They may be so turbulent
as to entirely obscure the normal respiratory murmur. These rales
are named small, medium and large bubbling or mucous rales, and
the names are sufficiently descriptive of their location and character.
The large rales occur in cases involving the trachea or largest bronchi,
and are common in chronic conditions, such as feacheitis and bron-
chitis. They are the cause of the "death rattle" sometimes heard in
expiring persons. These rales are heard in all pulmonary diseases in
which inflammation of the bronchi is the essential element of the dis-
ease or occurs as a complication. Pure, large gurgling rales, having
the character of liquid poured from a bottle, are (Confined to partially
filled cavities, and are heard on coughing.
fihonchi are dry sounds, and like wet rales are confined to the
bronchi. They vary in both character and pitch according to their
location and the amount of obstruction or narrowing produced by the
PHYSICAL EXAMINATION 83
causative condition. The narrower the tube, the higher the pitch of
the sound. Such narrowing may result from swelling of the membrane,
as is apt to be the case in inflammations of the finer divisions, or from
secretions, which is the usual cause of their occurrence in the large
tubes ; or the two causes may operate together, as in bronchitic asthma.
The low-pitched rhonchi are called sonorous, owing to their reverber-
ating character; the high-pitched are called sibilant by reason of their
hissing nature. Others have a whistliDg sound.
They may be heard on either inspiration or expiration, or both,
and accompany acute and chronic inflammations of the bronchi. The
finer, higher-pitched rhonchi are heard in aciite conditions and when
exacerbations or extensions of chronic forms take place. They are
very variable and large rhonchi may suddenly disappear. The finer
varieties, indicating obstruction, are somewhat more stable. a\s has
been said under Cough, they often indicate the first stage of a condi-
tion in which moist rales are the second stage. Bronchitis and asthma
and emphysema give us the best examples.
Stridor' is the name given to the harsh, rough, vibrating sound
imparted to the breathing by certain conditions. It might be called
respiratory tremor. The breathing is noisy and labored, inspiration
is prolonged and the voice is often raucous. Direct pressure on the
larynx, trachea or a large bronchus produces: it, hence the most fre-
quent cause is thoracic aneurysm or a mediastinal growth. Xext in
frequency is syphilitic stenosis. If due to local conditions as inter-
laryngeal growth or paralysis of the vocal cords, an examination of
the larynx will reveal the cause.
Friction Sounds. These sounds result from the rubbing together
of two inflamed pleural or pericardial surfaces. In older cases the
surfaces are roughened from the deposit of exudate, or fine fibrous
union may have formed.
Friction sounds consist of a number of sHort, repeated sounds of
a crackling, rubbing or crepitant nature. They are often compared
with the creaking of new leather. They are usually heard over a very
limited area, possibly never exceeding in size a half dollar. They are
unilateral and oftenest confined to the lower thoracic areas.
Pleural friction sounds are generally heard on both inspiration
and expiration, but may appear only at the ewl of forced inspiration.
The sounds are frequently referred to as "come and go" sounds. It is
84 PHYSICAL EXAMINATION-
often difficult to decide whether the sound arises from altetation of
the pericardial sac or of the pleural membranei
The following points will aid in the distinction: —
The location; the evident superficial situation of the pleural
sounds.
The relation of the two sounds to respiration above mentioned;
pericardial sounds do not disappear when rtspiration is suspended.
From the crepitant rale it is distinguished by the fact that pleural
.sounds are influenced by neither cough nor by respiration.
That deep respiration increases the pairf in the case of friction.
That friction areas are more circumscribed and that the rale is
heard only on inspiration.
AUSCULTATION OP THE VOICE SOUNDS.
When the ear is applied to the normal chest while the patient
speaks a distant, muffled, humming, vibratoi^y sound is heard. The
spoken words are inarticulate. The sound is strongest in deep-chested
adult males and weakens by gradations in wonjen and children. What-
ever the character of the sound may be, it is=pretty constant in pitch
and intensity over the entire pulmonary periphery of the individual.
The sound is called normal vocal resonance. It is more intense in
the vicinity of the trachea and large bronchi and is slightly more
intense in the right infraclavicular region than in the corresponding
region on the left. Conditions which increase .conductivity increase the
intensity of the sound and vice versa. Hence consolidation of the
lung of any degree whatsoever increases it.
The pitch is unaltered in this case but th|i sounds are louder. On
the other hand emphysema, in which the lung is, so to speak, rarefied,
diminishes the vocal resonance, as does also pneumothorax, by separ-
ating the conducting substance from the chest wall. Thickened pleura
similarly affects it by offering a barrier, and over pleural effusions it
is totally absent.
Occlusion of the bronchi by mediastinal growths, aneurysm or
other causes, prevents the sound waves from reaching the periphery,
hence vocal resonance is also absent in these conditions.
This absence will be understood readily when it is considered that
the vibrations set up by the act of speaking must reach the surface by
traversing the intervening air column. If the column is interrupted by
bronchial obliteration, the sound waves will be absent over the lung
PHYSICAL EXAMINATION 85
surface so supplied and likewise over the corresponding area of lung
covering.
Bronchophony. Over the large bronchi the voice sounds heard
in health are of greater intensity, more sonorous, more concentrated
and of higher pitch than those sounds heard over the vesicular regions.
This is called the bronchial voice and is the" type of bronchophony.
The sound seems to be near the ear. The terha bronchophony means,
therefore, increased or augmented vocal resonance. It bears the same
relation to normal vocal resonance as does bronchial breathing to^
the normal vesicular breath sounds, and when heard in localities other
than over the roots of the lungs means increased conductivity, hence
consolidation. The sounds are inarticulate.
Pectoriloquy is the name given by Laennec to the distinct trans-
mission of articulate words through the chest to the ear. By some
it is regarded simply as exaggerated bronchophony. In character the
sound closely resembles the sound of the voice heard over the larynx.
In bronchophony, as stated, the sounds are inarticulate, while in pec-
toriloquy not only is sound of like quality transmitted to the ear, but
the articulate words are audible. In a few cases the sounds not only
seem to arise under the ear, but are much intensified and the pitch
elevated. This is a union of bronchophony and pectoriloquy and is
named bronchophonic pectoriloquy.
In other instances the character of the voice sounds, although
articulate, are distant, hollow and even may be slightly ringing. Here
the pitch is not elevated, the area is limitecl and the words do not
seem to arise under the stethoscope. This Flint named cavernous pec-
toriloquy. He says that the former means solidification, the latter
a cavity.
Amphoric Voice is so named when in addition to being ringing
and hollow it has also a musical, a metallic 6v a tinkling character.
The sounds are not articulate as in pectoriloquy. It is generally taken
to mean pueumo-hydrothorax, but may occur in large cavities offering
similar conditions, especially large vomica whose walls are formed by
limiting membrane.
JSgophony is bleating bronchophony, caftsed by a thin layer of
fluid set into vibration by the voice. It is of very rare occurrence,
but has been found in eases of moderate pleur&l effusion, its usual seat
being at the lower angle of the scapula.
The Whispered Voice changes or is modified by disease as well as
86 PHYSICAL EXAMINATIOlJ
the spoken voice. Normally the whisper resonance is not heard ex-
cept over the large bronchi which form the roots of the lungs, and
the adjacent areas in the upper thorax. Here is it a soft, blowing
sound which accompanies each word. Increased or exaggerated whis-
pered reso)ta)ice and wliispering bronchophonymay be said to be pres-
ent when the normal whisper just described is heard over the vesicular
areas of the chest, where they are never normally present. The whis-
pered sounds then have the characteristics of their spoken congeners.
The second of these two is higher in pitch, more intense and nearer
the ear than the first. It indicates consolidation.
Also may we have whispering pectoriloquy, amphoric whisper,
and cavernous whisper. Whispering pectoriloquy is a surer indica-
tion of cavity than its spoken equivalent. The whispered voice is some-
times transmitted in pleurisy when the spoken voice is not. Bacelli
considers this sign as diagnostic between serous and purulent effusions,
but clinical experience does not bear him out.. It is however perpet-
uated as Bacelli 's sign.
There still remain to be considered a few adventitious sounds of
somewhat rarer occurrence than those already described.
Crepitation. A fine, crackling sound exactly' imitated by rubbing
the hair between the fingers, close to the ear. It has long been accepted
as the earliest sign of fibrinous deposit within the air cells in pneu-
monia. It may also occur when air enters the collapsed air vesicles
and is due to the separation of their walls, hence is heard at the end
of inspiration (see Pneumonia). It may be present also in hypostatic
pneumonia, oedema of the lungs or in areas of lobular collapse.
}^uccussion Splash. This was described by Hippocrates, and is a
peculiar splashing sound produced by violent coughing or a sudden
shaking of the body. A large cavity containing both air and fluid is
necessary for its production. It may be exactly imitated by splashing
an uncorked earthenware jug containing a small quantity of water. It
is present in hydro- or pyo-pneumothorax (q. v.).
Coi7i Ring or Bell Sound may be produced in pneumothorax or
in very large pulmonary cavities. A coin is placed flat against the
chest and is struck with the edge of another coin ; with the stethoscope
applied over the affected area, is heard a clear ^ bell-like tinkle.
Metallic Tinkling is a sound which Loomis likened to dropping
pins or small shot into a metallic vase. The sound is echo-like, clear,
high-pitched and ringing. It may be single or a series of sounds, maj'
PHYSICAL EXAMINATION 87
be produced by the movements of respiration, by coughing or even by
speaking. A large, dense-walled pulmonary or pleural cavity and a
communicating bronchus are necessary for its production. It is often-
est heard in pneumo-hydrothorax. Dr. Walsh regards it as due to
the echo of bursting bubbles shut up in the cavity. It is also attrib-
uted to dripping fluid striking upon a liquid' surface. The term am-
Fig. 27 — Laryngeal mirror with electrical connections.
phoric echo is used in the same connection to describe the above sound,
or one very similar.
Post-tussive Suction, a rare but valuable sign of cavity. When an
excavation is so conditioned as to be compressed by the act of cough-
ing, the air is expelled therefrom during that act with a slight hissing
noise. The dilatation of the cavity after compression is sometimes fol-
lowed by an audible, air-suction sound, varying in intensity with the
size of the cavity. The name is sufficiently descriptive of its quality.
A sound similar to the above, also produced by air entering a cavity
Fig. 28 — Laryngeal Mirror.
with inspiration, has been described by Laerinec, Skoda and others,
and called "the puff"
THE LARYNGOSCOPE.
This well-known instrument enables us to view the interior of the
larynx, the vocal cords and a portion of the trachea.
Acute and chronic laryngitis cause hyperaimia, erosions of the
cords and occasionally a slight exudate. In the chronic form the mem-
brane is thickened. CEdema and pseudo-membranous formations give
names to their respective varieties.
Tuberculous Inflammation. The vocal clirds a:t t".i;c"::ijnc(V.and
eroded, the movements restricted; infiltration, superf.cial ar_d deep, i:s
88 PHYSICAL, EXAMINATION
seen. Thickening of the arytenoids is the earliest sign. Other symp-
toms of tuberculosis coexist.
Laryngeal Syphilis. Symmetrical superiicial ulcers occur early.
Gumma, deep ulceration and necrosis of the cartilages are tertiary.
Paralysis of the laryngeal muscles arises from various central
lesions, medullary syphilis, multiple sclerosis, locomotor ataxia and
hysteria. In another group of paralyses the lesion affects the fibres of
the recurrent laryngeal in their tortuous course, or the laryngeal fibres,
in the vagus or accessory nerve, or the direct laryngeal nerve is subject
to pressure. Xew-growths are the principal cause of such paralysis.
Fig. 2g — Laryngeal Headlight.
The left nerve is most exposed to injury ovs^ing to its course around the
aorta. Mention is made of the condition under Aneurysm.
Causes. Aneurysm, pleural thickening, mediastinal tumors, en-
larged bronchial glands, carcinoma of the oesophagus, enlarged thyroid
and even pericardial effusions are assigned as peripheral causes of
the lesion.
THE 0PHTHALi\I0SC(5PE.
The examination of the eye-ground by means of this instrument
adds greatly to our diagnostic knowledge. Much information is within
reach of the general observer even though he has not received special
training in technic.
Besides diseases strictly pertaining to the eye, the following con-
ditions are worthy of attention.
Choroiditis. Syphilis, rheumatism and gout often originate the
disease. Typhoid and piierperal fevers, septicemia and conditions
causing thrombosis are sometimes complicated by it.
TuhcnJp of Ihe choroid is observable in miliary tuberculosis;.
PHYSICAL EXAMINATION,
89
gumma in syphilis. Sarcoma of the choroid is met with oeeasionally,
the subjects being usually above thirty-five ye^rs of age.
Ptdsation of the retinal veins occurs during cardiac diastole but
is physiologic. Pulsation of the arteries is generally pathologic. It is
seen in states of increased or diminished arterial tension and occurs in
aortic regurgitation with hypertrophy, in Basedow's disease, in syn-
cope after heemorrhage.
Papillitis is most frequently caused by intracranial diseases, es-
pecially cerebral tumors or meningitis, but glycosuria, albuminuria.
Fig. 30 — Laryngeal Reflectar.
lead-poisoning, anaemia, amenorrhoea and syghilis also are recognized
causes.
Alrophu of the optic nerve occurs in spinal diseases as tabes dor-
salis, in syphilis, diabetes and malaria. Toxic agents, alcohol, tobacco
and lead are designated as causative.
Cardiac valvular diseases may cause embolism of the retmal
artery, as may also albuminuria and pregnancy.
Retinal hemorrhage may result from numerous derangements of
the vascular system, as arterial sclerosis, valvular diseases, especially
mitral disease, embolism and thrombosis, miliary aneurysm and the
90
PUYSICAI. KXAMINATIUN
following general conditions: Diabetes, albuminuria, pernicious ante-
mia, purpura, scurvy and k-ukivmia.
Betinitis is caused by albuminuria, glycostiria or syphilis. The
Fig. 31 — Morton's Ophthalmoscqpe.
Tvhite patches upon the retina — albuminuric retinitis — which are seen
in Bright 's disease have often revealed the malady when entirely un-
suspected.
Cataract. Diabetes is a well established cause o£ cataract.
SECTION IV.
SYMPTOMS OF PATHOLOGIC CONDITIONS
OF THE CHEST.
COUGH.
Among the adventitious sounds one which plays a most prominent
jole is cough, and while its presence does not always indicate de-
rangements of the respiratory apparatus yet by reason of its para-
mount importance as a physical sign, and its almost universal asso-
ciation with all pathologic changes, however slight, in the breathing
and vocal apparatus, it is best considered along with the pulmonary
adventitious sounds.
Cough is a sudden, single or multiple violent expiratory effort,
spasmodic in origin, with the object of expelling some irritating sub-
■stanee from the air passages. Each cough is accompanied by a sudden
opening and closure of the glottis so that the air is expelled in forcible
•blasts.
The character of a cough varies greatly, not only during the
course of any single disease, but varies likewise with the multifarious
pathologic conditions which originate it. In. the beginning of some
■diseases it is so characteristic that the nature of the affection may be
foretold by the cough alone. With the progress of the disease this dis-
tinctiveness is often lost, as in phthisis, while in other maladies, as
wrhooping cough, it develops as the disease progresses.
Coughs are dry or moist as to whether they are or are not accom-
panied by expectoration. According to the location of the disease
which originates it cough is spoken of as laryngeal, tracheal, bronchial,
■cardiac or sympathetic. The possibility of stomach cough in the sense
used by the older writers is now generally denied.
Dry coughs are indicative of the primarj^ stage of almost all in-
flammatory affections of the larynx and pulmonary system. In pleu-
risy and the early stage of phthisis, dry cough is significant.
Coughs due to pressure of various growths upon nerve trunks
92 DIAGNOSIS OB PATHOLOGIC CONDITIONS OF THE CHEST
associated with the respiratory tract, particularly such as involve the
recurrent laryngeal nerve, the coughs of cardiac affections, thoracic
aneurysms and some other conditions, remains dry throughout its
course or is accompanied by so little expectoration as to merit that
distinction. Irritation of the air passages, whether inflammatory or
non-inflammatory, will likewise cause dry cougji, as nasal polypi, rhin-
itis, acute and chronic inflammation of the fauces or tonsils, elongated
uvula and hypertrophied tonsils. A similar cough is caused by many
ailments the seat of which is entirely removed from the air tracts, and
while the relation of cause and effect is indubitable, yet from the man-
ner of their production they must be classified as sympathetic. Thus,
dentition, intestinal parasites, various organic diseases of the brain,,
the stomach, the intestines, the heart or the blood vessels number
cough among their symptoms. Diseases productive of dropsies, such
as changes in the peritoneum, kidneys, liver and valvular diseases of
the heart likewise manifest this physical sign. It is a common mani-
festation of hysteria and states of high nervous excitement.
Dry cough is of a peculiar irritant character, affecting alike both
possessor and listener. I have sometimes attributed this impression on
^he listener to the undefined sense of wasted effort.
A careful study of the varying character of cough in its many
phases is instructive. Laryngeal cough is ringing and brassy, although
the voice is husky; nasal and pharyngeal coughs are "hawking and
hemming" in character. The cough of croup -is so characteristic as to
originate the ad.iective "croupy. " That of false croup is husky,
1 aueous, stridulous and brassy. The most noticeable quality of chronic
laryngeal cough is hoarseness. Likewise vocal hoarseness accompanies
most other laryngeal disorders. The cough of emphysema is loud,
harsh, wheezing and paroxysmal. The characteristic spasmodic cough
of whooping-cough is so well known as scarcely to need description.
It consists of a violent, protracted series of abrupt, forcible expiratory
efforts, followed by a long-drawn inspiration which is accompanied by
a hoarse noise called the whoop, from the similarity of the sound to
the syllable. The cough usually continues with brief interruptions
until expectoration or vomiting supervenes, only to be repeated again
after varying brief intervals. Prior to the development of the whoop,
which appears at the end of the first week, the disease presents no
signs which distinguish it from ordinary catarrhal bronchitis, more or
less of which is associated with it throughout its course.
DIAGNOSIS UJ' PATHOLOGIC CONDITIONS OF THE CHEST 93
Commonly associated with certain coughs is an annoying tickling
sensation in the throat, the patient frequently observing that if the
tickling were stopped, the cough would disappear.
Cough is atfected by position, being usually worse during the
recumbent posture; by time, being usually worse at night, or, as in
chronic bronchitis and phthisis, worse in the early morning.
EXPBCTORATION.C
Expectoration is the consummation of such coughs as progress
through an orderly sequence or which belong to the series that we have
designated as mcist coughs. The matter expfectorated often possesses
such physical, chemic or microscopic characteristics as positively to
identify the source and character of the disease, as in phthisis, pneu-
monia, bronchitis, abscess of the lung and a few others.
The amount of sputum expectorated varies largely with the dis-
ease and may reach 1000 cc. in twenty-four hours. The consistency of
the sputum varies greatly, as a rule it is less When the amount is great.
The consistency is extreme in the first stage of acute pneumonia,
bronchitis and phthisis. In these cases, especially in pneumonia, it is
a familiar fact that the sputum cup may be inverted without loss of
the jelly-like contents. Sputum containing air floats, while denser,
airless masses sink. Very dense sputum assumes round or flat, disc-
like shapes, and when such masses float in thinner expectoration, we
have the coin-like or nummular sputum, of which the cavities of tuber- -
culosis give us the best examples. Small, cheesy particles which sink to
the bottom of the cup are likewise indicative of phthisis and usually
contain large numbers of tubercle bacilli. In cases of pulmonary
oedema the fluid expectorated is thin, serurii-like and covered with
froth. The sputa of pulmonary gangrene, of perforated empyema
and of pulmonary abscess may be composed almost entirely of pus,
which may possess a strong, distinctive odor. The color of the sputa
varies from the transparency of mucoid exp,ectoration to the dark-
brown or red of admixed blood. The white color indicates leucocytes,
yellow and green sputa are purulent, bile pigment also gives a green
color to the expectoration. Red denotes blood. Pulmonary gangrene
gives rise to a fetid, chocolate-colored sputum. This form of sputum
contains various elements deserving of more particular mention^ such
as elastic tissue fibers, the presence of which always denotes some de-
structive process in the pulmonary tissue. Such destruction occurs in
94 DIAGNOSIS OF PATHOLOGIC OONDITIONS OP THE CHEST
phthisis and abscess as well as in gangrene. In former days the recog-
nition of these fibers was, taken in connection with other physical signs,
the surest indication of phthisis at the command of the diagnostician.
Fibrinous easts are found in the sputa in the course of pneumonias
and sometimes in bronchitis. They may be recognized by the eye and
beautifully demonstrated by shaking them with a little water in a
large test tube.
The sputum of bronchial asthma is very distinctive and finds no
counterpart in any other affection. It contains small, translucent
pellets or gelatinous masses, named by LaenneC, "perles". These ball-
like masses, when unfolded, are found to be mucous moulds of the
smaller tubes. The entire sputum may consist of these bodies floating
in thin mucus. If a portion of the sputum be spread on glass and
held over a dark background, it will be found that among these masses
are some which have a twisted or spiral shape recognizable by the
naked eye, others, when unravelled and viewed under the microscope
present the same structure. They assume one of two forms. In the
first a few mucin fibrils are twisted upon each other and enclosed
in their meshes are entangled a small number of leucocytes, generally
eosinophiles of large size and containing numerous fine granules stain-
able with eosin. In the second form the mucin fibrils are much more
numerous and are tightly twisted around a crooked central fiber. En-
closed within the skein are a few cells. Curschmann views the threads
as transformed mucin formed in the finest tubes as the result of a
bronchiolitis. It has been stated that these bodies have been fo"und in
the sputa of chronic bronchitis and of croupous pneumonia, but Osier
says he has never found them therein.
The above-described sputa often contain pointed octahedral crys-
tals first described by Leyden and called Charcot-Leyden crystals.
They occur later in the attack, while the spirals are found early. If,
however, the sputum containing the spirals be kept for several daj^s it
is said that the crystals will develop from the spirals. These crystals
are found very occasionally in acute and chronic bronchitis and
phthisis. Under the microscope they appear either as small, straight
hexagonal prisms or as granules of varying size ; they are quite gener-
ally associated with free eosinophilic leucocytes as already stated. The
crystals are found in the blood in myelogenous leukaemia.
The boiled sago-like grains which often appear in the sputum arc-
due to the presence of alveolar cells which have undergone myelin
DIAGNOSIS OF PATHOLOGIC CONDITIONS OP THE CHEST 9&
degeneration and are merely indicative of a catarrhal process without
other distinctiveness, although they are ol;t(|n encountered in early
phthisis.
The presence of tubercle bacilli and the diplococcus pneumoniffi^
and the methods of demonstrating them by stains, are discussed under
their appropriate headings.
HEMOPTYSIS.
Definition. Haemoptysis is the expectoration of blood which has.
escaped into the air passages. Oecasionaly blood escapes into a cavity
which is not in communication with a bronchus, in which ease there
is no expectoration of blood. Thus there may be extravasation of
blood into the pleural sac or a pulmonary aneurysm may rupture into
a cavity which has no communication with the air tubes.
Causes. The most common causes of hmm'optysis are :
(a) The rupture of an aneurysm on some branch of the pul-
monary artery.
(b) Erosion of a branch of the pulmonary artery due to disease
of whatever nature. Such hasmorrhages occur during the advanced
stages of phthisis, bronchiectasis, cancer and oecasionaly in gangrene
of the lung.
(c) Active or passive hypertemia of either the bronchial or pul-
monary capillaries. In this case the quantity of blood is small com-
pared with the other lesions. Such haemoptysis occurs at the outset
of phthisis, in acute broncho-pneumonic phthisis, in acute miliary
tuberculosis, bronchiectasis, cirrhosis of the lung, emphysema, in the
initial stages of pneumonia and bronchitis; in pulmonary gangrene,
cancer, abscess, in short, all inflammatory diseases of the lung. In
these cases the quantity is often only sufficient to streak the sputa.
(d) Injuries to the lungs and pleura, tumors and parasitic in-
vasions and all forms of pleurisy may give rise to haemorrhage.
(e) In young, healthy persons haemoptysis may arise without any
assignable cause, without warning, continue a few days and pass
away without leaving any subsequent token of its visitation, and the
attack may never be repeated.
(f) Hfemoptysis occurring with lesions of the cardiac valves,
particularly in mitral insufficiency and mitral- stenosis and in aortic
insufficiency. Here it may be profuse and reeur at regular intervals
for years.
96 DIAGNOSIS OF PATHOLOGIC CONDITIONS OF THE CHEST
(g) Hemoptysis accompanying certain impoverishments of the
blood, particularly rickets, scurvy, purpura, hemophilia and occasion-
ally leueoeythffimia. Under this head may be included the haemoptysis
of malignant fevers.
Ulcerative affections of the larynx, trachea and bronchi give rise
to hemorrhages which may be profuse and rapidly fatal. Such ulcer-
ation may occur even in bronchitis. Aneurysm of the aorta may ulcer-
ate into a bronchus or the trachea. Vicarious hemoptysis replacing
menstr^iation is too well established to be denied. A recurrent
hemoptysis of arthritic subjects is described by Sir Andrew Clark.
In these cases the patient is beyond fifty years of age, the hemorrhages
recur without any serious disease of the lungs being present or devel-
oping after the attack.
Character of the expectorated blood. The quantity varies from
a mere show to a litre, the rupture of an aortic aneurysm into a
bronchus may amount to the latter quantity. The blood is bright-red
when moderate in amount, but if enormous may be dark or venous-
colored. It is mixed with the bronchial secretions formed in the vari-
ous diseases with which it occurs. When in any considerable amount
it is frothy from admixture of air. The blood of hemoptysis is alkaline
in reaction, a point which serves to distinguish it from blood derived
from the stomach. If it is retained for some time within the lungs
it coagulates and its color is dark-brown or black. It is then often
coughed up in strings or moulds of the bronchioles. For several days
after a hemorrhage the secretions will be stained with brownish
streaks.
Symptoms. These vary with the gravity of the attack. When
large quantities of blood are suddenly lost the symptoms are more
grave than when a like quantity of blood is more slowly lost. In the
graver cases blood may pour out of the nose and, mouth or it may be
coughed up in gulps. Blood which has been swallowed may be after-
wards vomited or be passed by the bowels.
The symptoms are great pallor and anxious expression of face,
cold, clammy skin, small feeble pulse, faintness and coldness of the
extremities. During the attack there is a decided fall of temperature,
but subsequently a febrile reaction sets in, the temperature rapidly
rising to 102° or 104° F., then falling by gradations for several suc-
cessive days. This fever will continue, especially in tuberculous cases,
for several days to a week, even in patients where there was little ele-
DIAGNOSIS OF PATHOLOGIC CONDITIONS OF THE CHEST 97
vation prior to the accident. The hremorrhages of pulmonary tuber-
culosis may be separated by wide intervals and some tuberculous cases
terminate without any distinct hasmoptysis, while other cases are
marked by periodical recurrences.
If haemorrhage comes from a ruptured pulmonary aneurysm the
quantity is apt to be large, but if the termination is not fatal, the
opening closes and the danger passes. If a vessel erodes the closure is
by clot, which may be dislodged, allowing a repetition of the haem-
orrhage at intervals of a day or two, as is often observed.
Diagnosis. Inspection of the front of the chest and auscultation
with a stethoscope may be made during the= continuance or imme-
diately after the haemorrhage, but no attempt at percussion nor
change in the position of the patient is permissible, neither should ho
be allowed to speak, cough or even breathe deeply. A few moist rales
may be heard towards the apex. A previous knowledge of the presence
or absence of tuberculous signs is most useful. The heart may be
examined early, in order to ascertain whether or not the valves of
that organ be diseased.
Difficulty is often encountered in determining from the history
of a case whether a previous attack has been one of hsemoptysis or of
hsematemesis. If the patient is seen during the attack the differen-
tiation is easy. In case of a previous seizure, it should be ascertained
whether the patient had suffered from cough, expectoration, shortness
of breath and other symptoms referable to the lungs, or whether he
had previous to the attack dyspepsia, vomiting or other gastric symp-
toms, or gives a history of hepatic disease, particularly cirrhosis. Per-
haps splenic enlargement may be made out. These three organs are
the chief malefactors in hsematemesis, while the lungs, the heart and
the vessels assume the same roles in haemoptysis. The history may
show whether previous or subsequent to the attack the sputum was
.streaked with blood, and whether faintness preceded it. Sometimes
.also, in the case of intelligent patients, one can- ascertain other valuable
facts, as to whether the attack came on during a fit of coughing or of
vomiting, and whether or not the blood came all at once or in successive
mouthfuls.
The common recital of the patient in the case of heemoptj^sis is
that he "felt a tickling in the throat," or "had a salty taste in the
mouth, followed by the blood." Such a description does not apply
to hffimatemesis.
S8 DIAGNOSIS OF PATHOLOGIC CONDITIONS OV THE CHEST
In htematemesis the blood is dark in color, acid in reaction ; if it
has remained long enough in the stomach to be acted on by the gastric
juice it resembles coffee-grounds. It may be= mixed with food. It is
generally clotted. Vomiting is often preceded by a sense of faintness.
The passages subsequent to the attack are tarry, but it must not be
forgotten that during an attack of haemoptysis blood is frequently
swallowed, to be afterwards vomited or passed from the bowels. For
convenience we arrange the above symptom^ in parallel columns, as
an aid to differentiation.
Hcemoptysis. Hcemat erne sis.
1. History and symptoms of 1. History of disease of stom-
pulmonary disease. Cough, moist ach, liver or spleen; enlargement,
rales. Signs of cardiac valvular No physical signs of valve dis-
disease. ease.
2. Sputa blood-streaked before 2. Attack comes on during
and after the attack. Attack vomiting, often preceded by
comes on during coughing. If faintness. Blood comes en masse.
vomiting, it is subsequent to
seizure.
3. Blood aerated, alkaline in 3. Blood dark-brown or black
reaction, frothy, bright-red in in color, acid in reaction, mixed
color, clots readily; mixed with with food, usually in coarse clots
pulmonary secretions, pus. or coffee-grounds.
4. Local physical signs. 4. Melsena and nausea subse-
quent. Local physical signs.
The following signs of all severe internal haemorrhages are com-
mon to both conditions, viz., restlessness, extreme pallor, a quick,,
feeble pulse, syncope, subnormal temperature, skin clammy or bedewed
with cold perspiration, breathing shallow and feeble but hurried, great
thirst. In fatal cases consciousness is apt to be retained longer in
hsemoptysis than in h^matemesis, since the stomach loses its power to
expel the blood earlier than do the lungs.
In cases not presenting the ordinary physical signs the larynx
should be examined for a ruptured vessel or ulceration, as mentioned
under causes.
Syphilis of the trachea and bronchi is also an occasional cause of
haemorrhage, likely to be overlooked.
DIAGNOSIS OP PATHOLOGIC CONDITIONS OF THE CHEST 99'
DYSPNCEA.
Difficult breathing accompanies a variety of disorders of very
diverse character. Sometimes it is the direct' result of gross lesions
of the respiratory or circulatory systems, at others it is due to the
presence within the organism of toxic materials and occurs wholly
apart from discernible lesions. In still other cases subjective causes,
as pain or even hysteria, are responsible for its presence. Certain
constitutional vices, as rickets, while not wholly accounting for its
oncoming, are yet contributory and augment it when present.
Among, diseases of which dyspnoea is a well recognized symptom,,
asthma, of either the bronchial or cardiac type, stands in the front
rank. Of the former variety it is the leading symptom. Further-
more it is seen in all inflammations of the respiratory tract from the
Schneiderian membrane to the ultimate air cells. It occurs with
coryza, with nasal polypi, hypertrophy of the tonsils, retro-pharyn-
geal, oesophageal, or fauceal abscess, and quinsy. It is characteristic
of obstructive inflammations of the larynx, as diphtheria, of new-
growths or paralysis of the organ, and of the spasmodic condition
known as laryngismus stridulus. In catarrhal inflammations of the
larynx it plara a less prominent role. The diseases of the trachea, the
bronchi and the lungs of which it is a symptom are more particularly
described in this work. It may be said to be associated in varying
degree with the entire list, as well as with those of the pleura. Ad-
mission of air into the pleural sac, as from ulceration, may cause its
sudden onset, as does also perforation from without. Cancer of the
respiratory- tract, and especially cicatrices cesulting from previous
ulceration, are included in the etiology.
Its intimate association with all forms of heart disease is well,
linown, and here it often forms a safe barometer indicating plainly,,
by its rise and fall, not only the state and progress of the disease, but .
likewise the eiScacy of the treatment. It accompanies endocardial and
pericardial inflammations. Intrathoracic growths are causes, both
directly, through the obstruction which they produce, and indirectly,
by their influence upon the respiratory nerve mechanism (see Aneur-
ysm). Acute mediastinal lymphadenitis gives rise to paroxysmal
dyspnoea ; de Mussy holds that the dyspnoea of whooping cough is due
to this cause. Thrombosis and embolism of the pulmonary vessels,
as well as cerebral embolism, are occasional but grave causes. Any
condition which materially alters the intrathoracic pressure, operating.
100 DIAGNOSIS OF PATHOLOGIC CONDITIONS OP THE CHEST
either from within, as emphysema or effusions into the pleural or
pericardial sacs, or operating from without, as tumors, hypertrophies
and dropsies below the diaphragm, may likewise cause dyspnoea. Kid-
ney diseases, unaccompanied by dropsy, owing to faulty elimination
manifest it, and in ursemia it assumes a peculiar type. Its intercur-
rence during the course of, or during convalescence from scarlet fever
should suggest scarlatinal nephritis. It is present in apoplexy, cere-
bral tumors and other diseases of both brain* and cord. Alcohol and
toxic substances absorbed into the blood, as well as changes in the
blood itself, are known factors, hence its share in the symptom-group
of the anffimias. In progressive pernicious anaemia it progresses with
the case and is the type of the so-named ansmic dyspnoea. In large
goitres and in Ludwig's angina dyspnoea results from tracheal com-
pression.
The dyspnoea of obesity is a matter of daily observation.
Classificatimi. Dyspnoeas may be classified as machanical, chem-
ical, and nervous. The first includes all those forms which arise from
pressure and obstruction, thereby causing a reduction of the air cur-
rent; from deformities and from lesions which result in hypostasis.
Chemical causes are toxicity, imperfect aeration and the accumu-
lation of COj, as occurs in febrile diseases and faulty elimination.
Nervous and reflex causes include spasmodic cases, affections of
the respiratory center, peripheral irritations, and palsies.
In many cases two of these factors unite to produce the dyspncea.
According to its relation to respiratory rhythm we classify dyspnoea
as inspiratory or expiratory.
Appearances and Physical Signs. The dyspnoea may be plainly
manifested by the expression and attitude of the sufferer, the marked
evidences of pain, the appearance of labored breathing, the cyanosis
or the pallor of the skin, or the noises which accompany the respira-
tory acts. The respirations may be lessened in number, but are much
oftener increased. Normally the number of respirations is 18 to 20
per minute for men, and 20 for women. In children the number va-
ries with age, being 45 per minute at birth, 25 at the fifth year, decreas-
ing to 18 at the fifteenth year. The number, of respirations is influ-
enced in health by the same causes which increase or diminish the
pulse rate (see Pulse). The relation of the breathing rate to the pulse
rate is one to four, or one to four-and-a-half, in health. The num-
ber should be reckoned without unduly attracting the attention of the
DIAGNOSIS OF PATHOLOGIC CONDITIONS OF THE CHEST 101
patient, since this consciousness involuntarily increases the number.
Oft times the movement of the bed-clothes suffices for ascertaining the
number. If the breath-pulse ratio above given is much exceeded, we
may suspect that the disorder has to do with the respiratory function,
while if the pulse-breath ratio is altered materially, the probability is.
that the circulation is at fault. A previous knowledge of the con-
dition of the patient substantially aids in the appreciation of the
situation, since in aggravated cases a complete examination may be
impossible. Yet even here valuable information is afforded by vis-
ible signs, as pulsation, the presence of cedema, anasarca, signs of
pressure, of spasm or obstruction, collections of fluids, or even of exu-
dation into the air cells. Perhaps the heart-sounds may be listened to
without greatly adding to the discomfort of the patient. Careful
attention to the neck, throat and abdomen is recommended. Dilata-
tion of the nares accompanies inspiratory dyspnoea. The accompany-
ing sounds may aid in locating the seat of the disease, as well as inti-
mating its nature. In obstruction of the larynx or trachea, or spasm'
of the cords, the sounds are loud, rough, vibrating or snoring, and
the auxiliary muscles of respiration are brought into play. Some-
times the sounds suggest a valve-like obstruction to inspiration, and
the act ends in an abrupt croak or squeak, as in laryngeal diphtheria.
Abscess about the fauces or inflammation of the tonsils imparts a pe-
culiar hoarseness and choking, and is accompanied by incessant efforts
to expel the viscid secretions. Affections of the- glottis, ulcerations and
tumors of the larynx, give to respiration a crowing sound or a stridu-
lous character. Bronchial obstruction, when sufficient to cause con-
siderable disability, imparts a whistling or wheezing note to the respir-
ation, which may be heard only on inspiration, or on both inspiration
and expiration. Fluids give rise to rales or gurgling sounds. Pneu-
mothorax sometimes is accompanied by a sighing or gasping breath.
Cough occurs in no inconsiderable proportion of dyspnoeas, as
readily would be concluded from scanning the list of causes. Fits of
coughing, as a rule, increase the dyspnoea, or the dyspnoea may occur
only during and after coughing, as in pertussis. In almost all con-
solidations of pulmonary substance the same observation holds good.
Expectoration generally brings relief, as in bronchiectasis.
The term dyspnoea is not, however, confined to the phenomena
above described, in which the breathing is manifestly labored, and in
which auxiliary aid is sought. The term is quite as applicable to those
102 DIAGNOSIS OP PATHOLOGIC CONDITIONS OF THE CHEST
•diseases in which a decided increase in the number of respirations oc-
curs without particular effort as is seen in pneumonia, in which the
rate may rise to 60 or even 80 per minute. This form belongs properly
to the second division of our classification, viz., Chemical Form.
Allied to the latter form is the dyspnoea which occurs upon ex-
<3rtion The patient may be quite comfortable so long as he remains
■quiet or recumbent, but the exertion of sitting^up brings on an attack.
Such dyspnoea, occurs frequently in convalescence, but is not con-
fined within its boundaries. In another variety the patient may be
free from discomfort so long as he walks on a level or walks at a
moderate pace, but should he attempt a slight ascent, or should the
necessity to quicken his pace arise, the attacTi sets in. This may be
ihe first admonition to the patient that his mechanism is deranged.
Dyspnoea in young children often shows itself in the inability
■of the child to nurse, although obviously anxious to do so. The neces-
sity for breath causes it quickly to relinquish the effort. This is espe-
cially marked in nasal and laryngeal aft'eetidns, either obstructive or
spasinodic.
Cardiac dyspnoea may come on suddenly or gradually, after ex-
ertion or when the subject has been perfectly quiet. It is often ac-
companied by excessive pain. The resemblance of this affection to
bronchitic asthma has given it the name of cardiac asthma. The
spasmodic nature and the absence of mechanical causes point to the
nerve influence as an etiological factor. It not infrequently comes on
suddenly during the night. Its causes have been already listed.
The peculiar sudden dyspncea of pulmonary embolism is described
in that section.
Nervous dyspnoea, the third class, has already been touched upon
by reason of the impossibility of completely separating the three
classes. It is apt to be combined with mechanical causes, since pres-
sure and peripheral irritations of nerve terminals are potent factors
in exciting spasm and other evidences of reflex action. Hence, in diph-
theria, in all forms of laryngeal inflammation^ irritations the result of
of growths or foreign bodies in larynx or trachea, and, as already
stated, the influence of an aneurysm, may cause alarming and even
fatal spasm of the glottis. The nervous influence in the production
•of bronchial asthma, is described in the section devoted to that malady.
That it is the result of transient spasm is indicated by the suddenness
with which it comes and goes, the manner in which it is influenced bv
DIAGNOSIS OF PATHOLOGIC CONDITION^ OP THE CHEST 103
nervines, and the influence which certain odors or irritants ^vhen in-
haled exercise in the development of the attack.
Hysterical dyspnoea belongs to this category, and the dyspnoea
of pregnancy sometimes seen early in the case, apart from any albu-
minuria, cardiac or kidney lesions, is partly mechanical and partly
nervous. The dyspnoea of the later stages is almost purely mechan-
ical.
Reual dyspnoea shows itself in two forms, the earlier form usu-
ally appears after exertion and in this respect closely resembles the
corresponding form of cardiac dyspnoea. The second form is probably
of nervous origin, and markedly resembles spasmodic bronchial
asthma. The differential diagnosis between the two forms should be
based upon evidence pointing to disease of the one or the other organ.
In sooth, the various forms are all differentiated by signs and evi-
dence confirmatory of pathologic changes sufficient to account for the
attack having occurred in the organs and tissues involved, and by the
careful exclusion of similar changes in the otjier organs which might
give rise to corresponding symptoms.
OrtliopnoBa is inability to breathe while lying down; it is a grade
of dyspnoea. In some eases it is so severe that the patient must sleep
with the head resting on the arms or on a table. While the patient
may be able to bend forward, yet the slighest backward tilt brings
a sense of impending suffocation. Orthopneea sometimes occurs in
oedema of the lungs, in high grades of pulmonary congestion and in
pleural effusion, but usually it is associated with some cardiac lesion
or with an advanced aneurysm. In the absence of signs of pulmonary
involvement the probability of the cardiac origin is increased. Peri-
carditis may cause it, particularly when adhesions form. Increased
strain thrown upon the heart in the course of other diseases which
cause lesser grades of dyspnoea, and intercurrent cardiac complica-
tions may produce it; hence it may be paroxysmal. The assumption
of the erect posture is explained by the fact that the organs are less
hampered in this position, the auxiliary muscles are more easily fixed,
and fluids, gravitate to levels where they interfere less with the air
interchange. In some eases a satisfactory explanation is not apparent.
CYANOSIS.
Cyanosis is closely related to dyspnoea, ^nd great dyspnoea usu-
ally presents a considerable degree of cyanosis, yet each may occur
without the other; thus, in that group of congenital cardiac defects
104 DIAGNOSIS OP PATHOLOGIC CONDITIONS OP THE CHEST
known as congenital cyanosis, or morbus coeruleus, while cyanosis is
the most evident sign, dyspnoea may be wholly lacking. On the other
hand, severe attacks of tachycardia may bej attended with marked
dyspnoea, yet cyanosis be lacking.
Cyanosis may affect the entire body, or only the extremities may
show signs of it. The face is affected in all except the lighter grades.
The lips and the finger-tips are the first to give evidence of it. All
diseases interfering with the entrance of air into the lungs cause
cyanosis directly proportional to the degree of interference. Dis-
eases and conditions interfering with the ndrmal exchange of gases
which occurs in respiration, and which permit the retention of COj
within the body, naturally produce cyanosis. Hence, diminution of
the cell areas of the lung, such as occurs gradually in the course of
consolidations, or quickly, as in compressions and exudations, is fol-
lowed by this result. Even in severe bronchitis, especially of children,
a considerable degree of cyanosis is manifest. Pneumothorax exer-
cises a similar influence. In pleurisy it increases with the amount of
the fluid.
In cardiac diseases, it is one of the general manifestations, and
increases with the dyspnoea. Diseases involving the right heart mani-
fest it to a greater degree than those of the opposite side. It is marked
in tricuspid disease.
Conditions of the blood which diminish the oxygen-carrying
power cause lividity and cyanosis. Thus, it is seen during the admin-
istration of angesthetics, in many forms of poisoning, as by nitrous
oxide, after a dose of morphia, the inhalation of irrespirable gases,
especially COg, and coal-gas. Diseases and neuroses of the larynx
which cause dyspnoea, also cause cyanosis ; as paralysis, and laryngis-
mus stridulus of children. In the chronic infantile stridor of Taylor
and Lee, dyspnoea is without cyanosis. Acute laryngitis produces
lividity of lips and finger-tips. Laryngeal diphtheria may produce a
high grade of general cyanosis.
The chronic cyanosis of heart diseases is followed by permanent
changes of an indurative nature, as pigmentation and sclerosis. Cyan-
otic induration is described in connection with diseases of the heart.
CLUBBING OF FINGERS AND TOES.
In various chronic disease of the chest there occurs a thickening
and curving of the finger ends and to a less degree of the toes and
the nose, to which the name of clubbing is given.
DIAGNOSIS OF PATHOLOGIC CONDITIONS. OF THE CHEST 105
It was mentioned by Hippocrates and is called "Digiti Hippo-
eratici." Trousseau describes it as follows:
"The deformity consists in a contraetiod of the ungual phalanx
with enlargement and thickening of the digital pulp. While the nail
curves towards the palm, the extremity of the finger assumes the form
of the large end of a club and sometimes in enlarging it flattens so
as to resemble the head of a serpent. This deformity generally comes
on by slow degrees but at other times it is produced with great rapid-
ity, the patient suffering pain during the process. In some persons,
the toes are the seat of a similar deformity, bpt when it occurs in the
toes it is generally in a much less degree than in the fingers. ' '
Trousseau does not mention the change as affecting the nose, but
other writers call attention to this fact, and I have seen it occasionally.
It has also been stated that in the digital afffection the nail is raised
from its bed and that by bearing down on its proximal end, the hard,
elevated margin of the root of the nail may be felt. While in most
eases this is true, and the stretched, shining^ atrophic skin over the
root indicates the hyperplasia beneath, yet, quite frequently in my ex-
perience, the nail has been sunken and the hyperplasia seemed to sur-
round it as a wall. Particularly is this the case in the flat clubbing,
likened by Trousseau to the head of a serpeijt. The enlarged digits
often show cyanosis. The disease is general arfd bi-lateral although all
fingers are not eqiially affected. In a recently reported case of sub-
clavian aneurysm it occurred only upon one side. It has been known
to appear and disappear without any known disease being associated.
Its progress is generally slow but it may attg,in considerable propor-
tions in two or three weeks. In the order of the frequency of its asso-
ciation it occurs in bronchiectasis, chronic pulmonary tuberculosis,,
especially in conjunction with cavity, emphysema, chronic bronchitis,.
chronic asthma, empyema, congenital heart affections accompanied by
cyanosis, and certain valvular lesions. In the first mentioned, its oc-
currence is so frequent as to be of some diagnostic value and is apt to
be associated with changes in the nose and toes. In mitral insuffi-
ciency it occurs especially when a child is the subject of the attack.
Its association with pulmonary tuberculosis is well-illustrated in dis-
pensary practice.
SECTION V.
BRONCHITIS.
Definition. An acute or chronic iriflammation of the bronchial
lubes occurring primarily or in the course o£ various diseases. When
the finest ramifications of the bronchi are the seat of the disease it
is Called capillary bronchitis.
ACUTE BRONCHITIS.
Inspection shows only slight increase in the number of respira-
tions, which occurs in the febrile stage of the acute attack. The res-
pirations have a somewhat hurried character.
Palpation. Vocal fremitus normal. Occasionally a distinct bron-
chial fremitus is transmitted to the chest surface.
Percussion. The resonance is clear over the entire area. It may
be slightly diminished in the lower and posterior regions when large
-amounts of mucus have accumulated in the bronchial tubes.
Auscultation. The respiratory murmur changes, becoming more-
bronchial and harsher in character. Expiration is usually quite no-
ticeable, which is not generally the case in health. New sounds are
present, called rales. These may at first be dry and afterwards be-
come moist, more usually both exist at the same time and are heard
in different areas. Sometimes they are go harsh in character and so
-widely diffused as to mask the breathing sounds. The larger tubes
give rise to large bubbling or sonorous rales, the finer ones to small,
hissing or sibilant rales. In a very few cases, accompanied by an
extremely viscid exudate, there may be some fremitus. In these cases
the respiration may be broncho-vesicular and the symptoms mislead-
ing. Ordinarily the vocal resonance is normal.
The cardinal symptoms of acute bronchitis are cough, expectora-
tion and dyspnoea, although children below the age of five years do
not expectorate, and the dyspnoea caused, by a slight catarrhal inflam-
mation of the smaller tubes may be inappreciable.
The disease generally begins as a catarrh of the nasal, pharyngeal
BRONCHITIS 107
•or laryngeal regions, with hoarseness and tickling in the throat, soon
succeeded by a sense of rawness behind the sternum, and in severer
cases, or in emphysematous subjects a sense of tightness in the chest.
The principal characteristics of the disease are that it is bilateral,
that percussion and voice sounds are normal, that the adventi-
tious sounds change in character and location with great rapidity,
that it is accompanied by a cough that is at first short, dry, hacking,
painful and which recurs in severe paroxysms. "When the hyperemia
of the bronchial mucous membrane subsides and free secretion inter-
venes the cough loses these characteristics and becomes loose and pain-
less, but is still paroxysmal.
The sputum of bronchitis is at first scanty, viscid and tenacious,
■expelled with much difficulty and adheres to the vessel. It may be
blood-streaked. Later it is more mixed with saliva, less viscid, is
frothy from admixed air and resembles partially-beaten white of egg.
It is now scantily mixed with leucocytes. In the third stage it con-
sists largely of an admixture of leucocytes and mucus, becomes again
■denser, its color changed to yellow or dirty green and the separate
mouthfiils do not agglutinate. The amount may be eight to ten ounces
in twenty-four hours. The microscope shows mucous corpuscles and
epithelium floating in clear fluid. The epithelium is cylindrical and
ciliated. In the second stage hyaline cells, leucocytes, epithelium, oil
globules and a few blood corpuscles may be observed. Pulmonary
phthisis is the only disease that resembles bronchitis in any of its
physical signs, but the course of the disease and the absence of tubercle
bacilli, soon clear up the doubt.
Capillary Bronchitis. On inspection no differences from the
■above signs are noted, but in advanced cases marked lividity due to
lack of blood aeration is present.
Mensuration, no change.
Percussion. Note normal or slightly exaggerated.
Vocal resonance normal.
Auscultation. Vesicular murmur is weakened and in some cases
■suppressed. Siiberepitant reles are heard on- both sides of the chest.
If heard over considerable areas they indicate' positive and extensive
inflammation of the capillary tubes. These |iue rales may be heard
•only in the dependent and posterior portions= of the lung, in which
(case they are due to the gravitation of fluid from the larger into the
108 BRONCHITIS
smaller tubes. Above these areas the large moist rales may be abund-
ant or mixed with finer ones.
Differential Diagnosis. This disease might be mistaken for pneu-
monia, but the normal or exaggerated percussion resonance, its bilat-
eral character with suberepitant rales heard on both sides, and the
absence of bronchial breathing, should set the physician right. The
disease attacks the aged and young children. While clinically it is
distinguished from catarrhal pneumonia, in practice it is often im-
possible to determine which disease has attacked the patient.
CHRONIC BRONCHITIS.
Presents no distinctive features, except in cases. due to mechanical
irritation, the so-called artisan's bronchitis. This type may be
accompanied by wasting, due to induration of the lung, thus resem-
bling phthisis, but differs from it in its essential "chronicity and the
absence of tubercle bacilli
EMPHYSEMA.
Definition. A chronic interstitial inflammation of the lungs,
causing obliteration of the capillaries, associated with dilatation of
the air spaces.
A compensatory emphysma is- recognized when one lung, or a.
portion thereof, by reason of disease being unable to„ perform its func-
tions the remainder increases in bulk and the air spaces dilate. This;
condition is not, however, pathologic.
Physical Signs. Inspection. The patient is cyanotic, especially
after exertion. The breathing is rapid. In advanced cases the upper
part of the thorax is dilated and prominent, especially the sternum
and clavicles. The muscles of respiration and the elevators of the'
chest are hypertrophied, especially the scaleni and the sterno-cleido-
mastoids. If both lungs are affected the chest is barrel-shaped, the
spinal column bent forward, the shoulders rounded so that the patient,
seems to stoop. The middle and sometimes the upper intercostal
spaces are widened, the lower ones narrowed, and the lower ribs drawn
in. The above picture depicts the hypertrophic type of the disease.
There is, however, a form of the disease in which the lungs are-
atrophied instead of hypertrophied, but in which the symptoms do-
not radically differ from those of the above type. Atrophic em-
physema is generally found in the aged, and may be looked upon as.
a part of the physiologic process of decay.
BRONCHITIS 109
The chest movements are altered. Instead of the rhythmical ex-
pansion and contraction seen in normal respiration, the chest is lifted
as though it were an inflexible piece, and, owing to calcification this
is indeed often the case. The lower ribs and abdominal muscles are
drawn in with inspiration, the breathing is labored and of the abdom-
inal type ; the diaphragm being brought little into action.
Palpation. Fremitus varies, sometimes it is increased, at others
diminished. The apex beat is generally lowered and pushed to the
right.
Radioscopy shows that in emphysema the diaphragm occupies a
lower plane and does not rise during expiration to the normal level,
and that the heart assumes a much more vertical position in this disease
than it occupies in the healthy chest.
Mensuration. Both the circumference of the chest and the antero-
posterior diameter are increased. The antero-posterior diameter often
equals the transverse.
Percussion. The percussion note is clear and ringing, the pitch
being lowered but the intensity of the sound increased. It is in this
disease that we get the typical vesiculo-tympanitic note. The note is
not changed either by forced inspiration or forced expiration. The
finger feels increased resistance. The area of cardiac dullness may be
absent. Although there is very generally present hypertrophy of the
right ventricle, it cannot be demonstrated during life.
Auscultation. The inspiratory sound is short, feeble and even
suppressed. Expiration is greatly prolonged and may be three or four
times as long as inspiration. The pitch of both is lowered. Rales
of all sizes and qualities may be heard. In those cases where narrow-
ing of the bronchi has resulted from chronic inflammation, both in-
spiration and expiratn^n are prolonged, nearer equal in length, harsh,
sibilant, high-pitched and may be accompanied by rales, especially if,
as is usually the case, bronchitis coexists. Theoretically, vocal reso-
nance should be always diminished, owing to the lessened vibration
in the air columns. As a matter of fact it varies as does fremitus, be-
ing occasionally normal or even increased without any satisfactory
reason being evident.
Differential Diagnosis. Emphysema might be mistaken for pneu-
mothorax or pleural effusion. Prom the tirst it differs in that the per-
cussion sound is always pulmonic, even if tynjpanitic, and the breath-
ing is still vesicular, while in pneumothorax both are amphoric. Em-
110 BKONCHITIS
physema is bilateral, pneumothorax is unilateral and raetallic tinkliuji-
is diagnostic. Percussion dullness over effusion contrasts strongly
with the vesiculo-tympanitic note of emphyseina. The malady is most
frequently the. sequel to bronchitis.
Ilffimoptysis, although a rare occurrence in emphysema, may take
place and has been known to prove fatal. In fatal cases it is prob-
ably due to rupture of the aorta, since extensive atheroma of this ves-
sel occurs in the disease. The ordinary hjembptysis of emphysema is
small and unimportant.
SPASMODIC OR BRONCHIAL ASTHMA.
Defimtion. A spasmodic, paroxysmal panting for breath due to
contraction of the caliber of the bronchial tubes. The seizures are
probably of nervous origin.
Physical Signs. Inspection. Breathing is labored, the muscles
of respiration stand out prominently, the abdominal muscles are con-
tracted and hard. Inspiration is prolonged and labored, as is also ex-
piration. The patient sits up, leans forward and grasps some object
to aid in the fixation of the shoulder muscles. The face is cyanotic,
the expression anxious. The chest is in a permanent state of infla-
tion, hence shows little expansion with inspiration.
Palpation. Rhonchial fremitus Ls recognizable, vocal fremitus is
lessened and often covered by the rhonchi.
Percussion is unchanged in true asthma", In associated emphy-
sema it is exaggerated.
Auscultation. The rhythm of the respiratory murmur is .ierky
and irregular, now exaggerated, now suppressed. The vesicular mur-
mur is inaudible owing to lessened vesicular interchange. All over
the chest are heard sonorous and sibilant rales with both inspiration
and expiration, and expiration is noticeably prolonged. The dry
rales change to moist as the attack progresses and the change brings
relief.
Differential Diagnosis. There are attacks of renal asthma
which closely resemble the above form, but in these the dyspncea is
less marked, and the kidney lesions are manifest on examination of
the urine. Rhonchi and rhonchial fremitus are less pronounced and
may be absent, but the expiratory character of the dyspnoea is apparent
in both forms. Spasm or paralysis of the glottis produces a dyspnoea
BRONCHITIS
111
which resembles asthma, but in these the difficulty is wholly inspira-
tory and the rales are not present.
BRONCHIECTASIS.
Definition. An acute or chronic affection characterized by dilata-
tion of the. bronchial tubes, cough and characteristic expectoration.
The dilatations may be cylindrical or sacculated. In the acute cases
the former are generally found, while in the chronic cases the sacs are
gradually formed. Occasionally the acute cases give rise to saccula-
tions. There is also an acute and chronic form of enlargement of the
bronchioles (bronchiolitis) but the physical signs are not sufficiently
distinctive to allow the disease to be -described apart from bronchiecta-
Fig. 32 — Curschmaii's Spirals. A Natural size. B Enlarged.
sis. This latter form follows acute infectiohs diseases, especially
measles and whooping cough. It may become chronic.
Clinically we recognize three forms of the disease :
(a) Ptwe bronchiectasis which follows after bronchitis, espe-
cially chronic bronchitis, pneumonia, pleurisy, empyema. Its associa-
tion with the first is well known, but it is also especially prone to be-
present in lobar or broncho-pneumonia, where it is limited to the
bronchi within the affected area. Influenza is responsible for not a
few eases, and bronchiectasis which may be.classified as acute, has suc-
ceeded its attacks.
(b) Tuberculous bronchiectasis. Few cases of pulmonary tiiber-
culosis progress to the end without the formation of bronchiectasis-
Sometimes the large cavities so formed are mistaken for vomica. In,
112 BRONCHITIS
•one of my cases enormous dilatations were present in a lung riddled
with tuberculous cavities.
Both the saccular dilatations and the cylindrical enlargements are
found.
(c) Traumatic bronchiectasis, caused by the pressure of a for-
eign body within the bronchi or external pressure exerted' on a bron-
chus, causing kinking or stenosis of the tube and subsequent dilata-
tion.
In the three forms enumerated the disease is essentially chronic,
■cases sometimes lasting ten to twenty years. A case seen by me began
with pneumonia which was followed by empyema and then by bron-
chiectasis.
The physical signs vary with the location, size of the sac and the
amount of its contents, giving rise to wholly different signs when full,
partly full or empty. The sacculated cases are unilateral. The cavi-
ties most often form in the lower lobe. They are rarely single, some-
times two communicate by a narrow passageway. Oft times there are
two large ones and one or two of lesser size. The size of the dilatations
varies greatly.
Inspection shows deficient expansion over the affected area.
Breathing is labored, expiration prolonged. The expression is anxious,
varying degrees of cyanosis are not uncommon. In chronic cases
the fingers are clubbed, the nails incurved. In eases following chronic
lung diseases, especially an old empyema, a pneumonia, or a pleu-
risy where, as is so often the case, adhesions have followed, the re-
tracted side, the compensatory bulging opposite to it, the shoulder
■droop on the affected side, and the forward curve of the spine form
a most impressive image. If upon these is engrafted, as is occasionally
the case, a hyperostosis of the extremities, hands, fore-arms, feet and
legs, the picture is ineffaceable. This proliferating hyperostosis, de-
scribed by Marie and named osteo-arthropathie pneumique, occurs in
other chronic lung diseases, and differs from acromegaly in that it
affects only the parts mentioned and is a true proliferation.
Palpation. Vocal fremitus is usually increased by reason of the
associated induration resulting from the causative disease, such as
broncho-pneumonia. Rhonchial fremitus is also present. The fremi-
tus may not be manifest unless the voice is considerably raised.
Percussion. There is very generally a considerable area of dull
percussion resonance, even of flatness, in the, region affected, which is
BRONCHITIS 113
more often the lower lobes. Dullness will be found posteriorly and
laterallj' oftener than anteriorly.
With a full sac surrounded by induration flatness prevails. With
a large, completely empty sac the note is tympanitic. With smaller
sacs and with cylindrical enlargements the note is tubular.
Auscultatiuii. The breath sounds are absent with a full sac. They
are bronchial, cavernous or amphoric when the sac is empty. When
half-full splashiugs, succussions and bubblings are heard with both
inspiration and expiration. With an empty' sac, bronchophony and
pectoriloquy may be heard.
When the cavities are full breathing may' be deficient over the en-
tire affected half of the thorax, but is subject to rapid changes. A
full inspiration, a cough or even a change of position renders it
audible.
Rales. Extensive rales are heard par- tout, large, loud, sonorous,
gurgling, mucous, rapidly changing. They are especially manifest
and characteristic when the cavity is partially filled.
Cough. The patient may have considerable intervals of freedom
from cough, days or weeks. This and the character of the cough ren-
der it distinctive. It is always paroxysmal, iisually matinal, the pa-
tient generally having a premonition of its oncoming. Each paroxysm
may exhibit a descending scale both as to the intensity and
the force of the succeeding notes. Thus, a sipgle paroxysm may con-
sist of six notes, the first loud, hard, expulsive, with each successive
note a little less intense than its predecessor.. After a brief pause a
repetition of the effort occurs, until with some chokings and gaspings,
the cavity is emptied.
Sputa. This varies in amount with the size of the cavity and the
frequency with which it is emptied. Povir drams to half-a-cupful is
an ordinary amount. Its color varies; white, gray, yellow, green,
brown. It is exceedingly offensive, the odor being foetid or cheesy,
■' ' as of the ripe Camembert cheese. ' '
When placed in a tall glass the sputum separates into three lay-
ers. An upper, frothy layer which may be colored, a middle layer of
watery mucoid fluid; the third, a thick sediment of granular matter,
■cells, casts of the tubes, bacteria, crystals of fatty acids, and, if ulcera-
tion of the walls be present, elastic fibers are found. Sections of the
■casts show peculiar alternate layers of inspissated secretion and bae-
114 BRONCHITIS
teria. lu no disease is the sputum more charagteristic, and its appear-
ance to the naked eye is sufficient to establish the diagnosis.
Bacteria. The influenza bacillus in pure, cultures has been found
present so frequently in these cases as to raise the question of its
causative relation. Lord, of Boston, relates thirty-five cases of bron-
chitis and bronchiectasis in which it was foilnd, and other observers
have met with it almost as frequently, but the ubiquitousness of this
germ and its association with conditions so varied and diverse, throw
doubt upon the relation of cause and effect.
Hemoptysis. Hsemorrhage frequently occurs in the course of the
disease and is often profuse, due to the rupture of small aneurysms
formed within the dilatations, or to tears in = the enlarge'd capillaries
and venules.
Differential Diagnosis. The rapid changes in the respiratory
murmur, becoming loud and harsh where a moment before it was in-
audible, the character of the rales, and especially the physical proper-
ties of the sputum and the absence of tubercle bacilli therefrom, serve
to distinguish the disease from phthisis. Further, the cavities of
bronchiectasis are usually at the base, while thp excavations of phthisis
begin at the apex of the lung.
Dull percussion and induration are signs of pneumonia, with
which the disease is not infrequently associated, but the temporary
character of the one, the varied fremitus, the cavernous or amphoric
breathing of the other, should prevent the mistake.
Rupture of an empyema into the bronchus comes on suddenly
and has been preceded by a pleurisy. Nevertbeless these dilatations.
exist with chronic phthisis, pleurisy and empyema.
BRONCHIAL STENOSIS AND OBSTRUCTION OF THE LARGE
BRONCHI.
Narrowing of a large bronchus may arise from a variety of
causes. Complete obstruction is rarer. The] principal factors caus-
ing stenosis are: External compression, most frequently by an
aneurysm, less frequently by other mediastinal growths; syphilitic
disease; cicatrization following ulceration and constriction; oblitera-
tion by a foreign body.
Complete obstruction "is followed by collapse of the part of the-
lung supplied by the tube. In time, compensatory changes take place-
in other portions of the affected lung and in it's fellow.
BRONCHITIS US''
Dyspnoea is the most characteristic symptom and varies with the
completeness of the obstruction, the suddenness of its' production and
the degree of compensation which follows. As said under aneurysm,
this cause is productive of the most intense dyspnoea, which may be
continuous or paroxysmal.
Physical Signs are : Impaired expansidh on the affected side,
which may be local or general. If a main bronchus is involved, the
entire side of the thorax is affected. The suprasternal and supra-
clavicular fossae are drawn inwards with inspiration, the intercostal
spaces recede as does the epigastrium at the xiphoid angle.
Later, retraction of the chest walls follows over the collapsed area.
Palpation shows diminished expansion and enfeebled tactile fre-
mitus over the defective area. As secondary changes occur rhon-
chial fremitus develops.
Percussion. The note rises in proportion to the amount of col-
lapse and becomes dull in total obliteration. In old cases where con-
densation of lung tissue is followed by fibrous and pleural thickening
the note is dull or flat.
Auscultation. , The peripheral breath sounds are feeble or absent.
Stridor may be present and heard near the seat of constriction. It
should be sought for posteriorly outside of the vertebrse, along the
inner edge of the everted scapulse. Vocal resonance is proportionally
diminished. Later, rales develop from retained secretions, and as
stenosis is one of the chief causes of bronchiectasis, signs of that dis-
ease may follow.
Cough is present and varies with the cause and the degree of ob-
struction. The sputum has no especial characteristic unless bronchial'
dilatation follows, (q. v.)
SECTION VI.
PLEURISY.
Definition. Pleurisy is an inflammation, of one or both pleural
sacs. Varieties. Primary, secondary: Acute, chronic: Circum-
scribed or diffused: Dry pleurisy, pleurisy with effusion.
Because this disease so often passes unrecognized by the physi-
cian, in spite of its pronounced physical signs, as evinced by the fact
that extensive adhesions are often found post-mortem without any his-
tory of pleurisy being elicited, it deserves a minute description.
The various stages of the malady present different signs, and will
therefore be considered separately. Inspection, palpation, mensura-
tion, percussion and auscultation all give intelligent answers when
applied as interrogatives to this disease.
In the beginning of an attack, whatever form it may afterwards
assume, the lesion is that of a dry pleurisy, in which the two con-
tiguous layers,first the visceral and then the parietal, become inflamed.
Following this an exudate of thick, soft gray or yellow lymph is de-
posited upon the two surfaces, sometimes in distinct layers. At first
this lightly adherent lymph may be easily rubbed off, after a time it
is sticky, rough, shaggy and quite adherent. The two surfaces may
now become agglutinated and the attack thus terminate (Pleuritis
sicca).
In the beginning and at its height such a condition presents the
following signs:
Inspection. IncBeased frequency of breathing but with restric-
tion of the respiratory movements. Enfeebled respiration which is
made manifest by comparison with the sound side. The limitations of
the respiratory excursion vary with the severity of the pain.
Palpation. Touch will sometimes reveal a peculiar fremitus
caused by the friction of the two surfaces (pleural fremitus of Da-
Costa) over the region corresponding to the arSa of inflammation. Vo-
cal fremitus during the inflammatory stage remains unaltered or is
even increased over the inflamed area. Absent vocal fremitus is one
PLEURISY 117
of the early signs of effusion. The reader is again reminded that vocal
fremitus is normally more marked on the rigjit side than on the left.
Mensuration. Previous to the exudate, no change. (Right side
normally the larger.)
Percussion. Prior to the effusion percussion elicits little or no
information.
Auscultation. In the presence of severe pain the respiratory
rhythm changes and becomes irregular and jerky. Likewise pain
causes the respirations to become shallow or enfeebled, in which case
the normal vesicular murmur is diminished — thus confirming the signs
elicited by inspection. Friction sounds are audible especially on deep
breathing. They are superficial and have a sandpaper quality. Gen-
erally they are heard on both expiration and inspiration; sometimes
they are limited to expiration. They may be limited to a single spot in
the inframammary or infraaxillary space, and hence be easily over-
looked. Usually the area is more extensive. The sound resembles the
crepitant rale, but this rale is an inspiration rale.
PHYSICAL SIGNS OP EFFUSION.
Inspection. With moderate effusions insspeotion shows lessened
chest movements, due to inability of the lung to expand to its full
capacity. Pain may or may not be present. When present it is usu-
ally accompanied by an increase in the number of the respirations,
which may even amount to dyspnoea. In the absence of pain, respira-
tions may be even lessened in number. The interspaces above the
diaphragm may be widened. A moderate effusion is one in which
the level of the fluid does not rise above the nipple in front.
Palpation in moderate effusions. Confirrpation of signs revealed
by inspection, as diminished respiratory rhythm and widening of the
lower interspaces. The friction fremitus will have disappeared. In
small effusions the tactile fremitus is generallj'' diminished. This sign
is more valuable in men than in women and children. It must be re-
membered that fremitus is usually stronger on the surface of the
right chest than on the left; stronger in men than in women.
Mensuration shows little if any variation in small and moderate
effusions. In right-handed individuals, especially men of the labor-
ing class, the circumference of the right chest is normally greater than
that of the opposite side.
Percussion. Dullness increasing to flatness over the area of the
118
PLEURISY
effusion is the most important sign of the exudate. In adults it is
difficult if not impossible to demonstrate effusions of less than five
hundred cubic centimeters. The dullness is usually most marked and
first obtainable posteriorly, then in the axillary region, lastly in front.
Fig- 33 — Physical signs in effusion into left pleura (Patton). A Skodiac per-
cussion resonance, exaggerated vocal resonance, tubular quality of breath-
ing. B Complete dullness, absence of vocal fremitus, no respiratory sounds.
C Purile respiration, prolonged expiration, exaggerated percussion reson-
ance. D More or less well marked pulsation. F Displaced area of cardiac
dullness. Upper limit of shading indicates anterior line of Ellis' curve.
Along the upper border of the effusion percussion dullness is ob-
tained and increases to flatness as we percuss from above downward.
Total absence of vibration, coupled with an increased sense of re-
PLEUEISY 119
sistance under the pleximeter finger, much grieater than that observed
in cases of lung consolidation, are most noteworthy and significant
symptoms.
The prevalent, in fact almost universally accepted, belief that the
level of pleural effusions changes with alterations in the position of the
patient is almost wholly erroneous, and is the probable reason why
such effusions frequently are overlooked. Only occasionally does such
change of level occur, and I wish to lay special stress upon this fact.
As pointed out by Flint, Da Costa, and others since, we get in-
creased percussion resonance, even amounting to tympany, above the
level of the fluid. This peculiarity is due to= disturbance of norma]
tension in the pulmonary tissue, which is more or less condensed. The
change of quality is variously known as Flint's vesiculo-tympany,
Skoda 's resonance, etc. In moderate transudations the upper level
of the effusion, and hence of percussion dullness, is not a straight line
but a horizontal curve with the convexity upwards. The curve reaches
its greatest height in the mid-axilla, whence it descends to the
sternum, where, however, the level is higher than at the vertebra. In
order to demonstrate this curve the patient should be in the upright
position. In a moderate effusion this line may extend from the junc-
tion of the sixth rib with the sternum, which point is one inch above
the xiphoid junction, to the lower border of the fourth rib in the an-
terior axillary line, thence slope gently backwards. This line of dull-
ness does not change with inspiration or expiration but may change
with changes of position.
Auscultatw7i. Moderate eff'nsious. The breath sounds become
feebler and more distant as the amount of fluid increases. As has
been stated, the vesicular portions of the lung^ are pressed upon and
egress of air is prevented, hence vesicular respiration is absent and
is replaced, first, by broncho-vesicular and then by bronchial breath-
ing. In children this occurs very early and with comparatively small
effusions. Sometimes the breathing is amphoric. On the opposite side
the lung is doing increased work and the breath sounds are therefore
intensified or puerile.
Vocal resonance varies. When the effusion is small in amount
the voice is still conveyed via the chest walls to the ear. With in-
creased effusion the voice sounds are absent over the liquid. If lis-
tened to at the upper border of the fluid a^ peculiar quavering or
bleating, called egophony, may be heard. It i^ not often present, but
120
PLEURISY
when heard is decisive. In typical forms egophony is uncommon,
although much insisted on by the older writers, hut it is by no means
rare to hear a curious iiasal, twaug-like quality in the voice, particu-
larly at the outer angle of the scapula.
Moderate effusions, while they compress the air cells do not affect
Fig. 34 — Di.splaccnicnt nf organs in a considerable effusion into right pleura
( Patton ) . A Slight enlargement of side, with effacement of intercostal
spaces. B Compressed lung. C Displaced heart. D Displaced li\'cr.
the bronchi. Bearing this fact in mind aids in comprehending many
of the observed phenomena.
LARGE EFl^^'SIOXS.
I iispccl iun. The I'espiratoi'y movements are much diminished or
entirely absent on the affected side, and increased on the sound side.
The intercostal spaces are widened, especially m the lower segment.
Even bulging may be noted. The affected side looks inflated, the
PLATE IV.
P. Point where Pericardial Friction is most often heard. PL.F.
Point where Pleuritic Friction is most apt to be heard. The
Inner Circle represents the most frequently affected Dorsal
Area.
PLEURISY 121
scapula stands out more prominently than its fellow, the shoulder is
elevated.
The heart impulse is moved to the left in right-sided pleurisies
and is found outside the nipple line. It is sometimes elevated slightly.
In left-sided pleurisies the apparent displacement is much greater,
and the apex impact may be found a considerable distance to the right
of the sternum, even in the right nipple line. <
Palpation in large effusions confirms inspection as to lessened
mo'vement on breathing, widening of the interspaces and abnormal
position of the apex. The impact of the heart apex in disease, as in
health, often may be felt when it cannot be seen. Tactile fremitus
is absent over large infusions, but in childreja even with a consider-
able transudate, both vocal and tactile fremitus may be present, a
point not to be forgotten. In these cases the sound probably reaches
the ear through the medium of the chest wall.
Mensuration. The affected side is larger than the sound side.
The difference seldom exceeds an inch or an inch-and-a-half . A cyrto-
meter tracing of the two sides shows marked differences in the con-
tour.
Percussion. As the level of the fluid rises it is followed by the
dull percussion note, which changes to flatness from above downward.
Flatness is generally first demonstrable posteriorly at the base of the
lung. Resistance under the finger and absence' of communicated vibra-
tions which only occurs in the presence of confined fluids in the
chest, are signs whose value have been previously emphasized. Except
in effusions which absolutely compress (carnify) the lung, tympanitic
resonance may be obtained in front, beneath the clavicle and above
the spine of the scapula posteriorly. The cracked-pot sound may be
elicited by percussion below the clavicle, while»the patient expires with
the mouth held open. Below the fluid level absolute flatness extend-
ing to points lower than the normal limits o| the lung is present.
Auscultation. Vocal fremitus is absent, but Baccelli has noted
that the whispered voice sometimes may be transmitted to the ear
when the spoken sounds are inaudible. He states that this is not the
case if the fluid be purulent, hence this sign, if present, denotes serous
effusion. If the effusion is sufficiently large to squeeze the lung up-
ward and backward into the spinal gutter, then the breath sounds
wholly disappear. Usually, however, some breath sounds, feeble and
distant, but of a bronchial character, may still be heard over the spinal
122
PLEUEISY
gutter when the patient folds the arms tightly over the chest, so as
to widely separate the scapulae. Bronchophony is heard in the same
region.
Sometimes auscultation will enable us to locate the apex of the
Fig- 35-^Physical signs (posterior regions) in effusion into left pleura (Patton).
A Diminished respiratory sounds. B Very faint or absent voice sounds, ab-
sent breath sounds, dullness, no vocal fremitirs. C Dullness, no vocal
fremiitus, no voice or respiratory sounds. D Voice sound is tubular or
nasal in quality, sometimes approaching segophony. Upper limit of light
shading indicates the posterior line of Ellis' curve.
heart when it can neither be seen nor felt. On the opposite side the
respiratory sounds are exaggerated.
Absorption Stage. Inspection shows that, the enlargement of the
affected side is disappearing, that the widening interspaces are re-
PLEURISY 123
turning to their normal condition. The absent* respiratory movements
return, and the obscured apex may now be seen.
Unfortunately the process does not generally stop here, but con-
tinues by reason of contractions and adhesions until various deformi-
ties plainly show the ravages of the disease. The organs may be per-
manently displaced. Owing to adhesions thci slow contraction of the
■connective tissue thus formed, and the orgaiiization of the exudate,
the resulting deformity appears gradually, after a considerable in-
terval, and is progressive. In children it may entirely disappear
with growth. In adults it is permanent and varies from a hollow de-
pression in the ensiform region to antero-posterior flattening of the
chest, flattening and retraction of its lateral areas, the lower ribs be-
ing in contact or overlapping, and spinal curvature of greater or
less degree.
Palpation shows a gradual return of fremitus, vocal and pleural,
.and a return of the organs to their normal position.
Percussion. The return of normal percussion resonance is grad-
ual, returning first above and extending downward. At the base reso-
nance may remain permanently absent owing to accumulations of
solidified plastic material or to solidification pf lung tissue.
Auscultation. Respiratory sounds return.- At first they are weak
.and distant but increase in distinctness until' they have even a harsh
quality. With disappearance of the effusion, a return of the friction
sound is noted. At the base of the lung all sounds may be feeble and
obscured for a long time. As the vesicles gradually distend a peculiar
•creaking or crackling sound is heard. Bronchophony reappears and
in some cases egophony.
In cases where a portion of the lung remains permanently imper-
vious, there is permanent loss of respiratory motion and of vocal and
respiratory sounds over such areas.
DIAGNOSIS.
As said in the beginning of the section,: pleurisy passes unrec-
ognized perhaps oftener than any other disease occurring within the
thorax. In the early stage the friction sounds may be absent and
this absence is one of the chief misleading factors. The disease is not
to be mistaken in the first stage for pleurodynia or intercostal neural-
gia. Both of these disorders are unattended with pyrexia, the ten-
■derness is superficial and excited by irritation of the skin. Pain in
pleurisy is deeper-seated. The pain of pleurisy may however be re-
124 PLEURISY
ferred to points distant from the seat of the lesion. Thus, the seventh^
eighth, ninth, tenth and eleventh thoracic nerves after passing through,
the intercostal muscles at the side of the thorax, so as to lie against
the pleural sac, afterwards pass between the obliquus internus and
transversalis muscles and ultimately reach the skin of the anterior
abdominal wall. Hence the frequency with which pain is referred to
these terminals, a fact which should be borne in mind, and an examina-
tion made along the entire course of the nerves ^seemingly involved.
In double pleurisy the pain is referred to symmetrical points on the
thorax or abdomen, but in general symmetrical pains are more prob-
able indications of spinal disease. The pleural friction sound is gen-
erally audible with the beginning of expansion, differing in this re-
spect from the fine crepitant rales of pneumonia.
Left-sided pleurisy may be mistaken for peritjardial effusion and.
vice versa. In addition to the description given under pericarditis,.
the following points should aid in the differentiation :
Pericarditis. Left-Sided Pleurisy.
Apex impact usually cannot be Heart ape;s: is displaced to
seen nor felt. Heart sounds fee- right. If much displaced, prob-
ble and distant. ability of effusion is increased. If
not displaced effusion is improb-
able. Apex impact visible but
displaced. Sounds not changed
in intensity.
Dullness extends upward in Dullness follows around the
pear-shaped area. axilla in usual'line.
Vocal fremitus present. Tubu- Vocal fremitus absent. Breath-
lar breathing when great com- ing sounds absent; if tubular,,
pression of the lung. strongly marked.
Orthopnoea. Faint cyanosis of Xo cyanosis, no orthopnoea.
face and extremities.
Eotch's sign, absence of reso- Roteh's sign absent,
nance in right fifth intercostal
space.
In the pre-exudate stage the location of the friction sound, its-
superficial character and its relation to the systole and diastole of
the heart, differentiate the two conditions.
The effusion may be mistaken for pulmonary consolidation, either
PLEURISY 125
of pueumonia or tuberculosis. It is possible also to confound cancer
of the lung and various enlargements of the spleen with the effusion
of pleurisy. From pneumonia and tuberculosis it is distinguished
by the increase in size of the affected side, widening of the intercostal
spaces, absence of voeal resonance and of fremitus. In the former dis-
ease the percussion sound is dull, in pleurisy it is flat, and in neither
,of the former does the dullness follow Ellis's curve. The bronchial
breathing of a lung partially compressed by pleural effusion is much
deeper-seated, more diffused and usually unaccompanied by rales.
In pulmonary tuberculosis the disease generally progresses from above
downward, while in pleurisy, as pointed out, the reverse obtains.
Pleurisy is unilateral. Tuberculosis sufficiently extensive to simulate
it would be bi-lateral. The history further aids the diagnosis.
Enlarged spleen, if :-t disturbs the position of the heart, raises
it instead of pushing the heart to the right. It does not interfere with
the respiratory sounds of the left side, nor cause bulging of the in-
tercostal spaces. Posteriorly the percussion sounds are normal at the
pulmonary base, where they should be first affected in pleurisy. (See
also Pneumonia for further differences.)
The urine in pleurisy presents a marked contrast to that of pneu-
monia. While the organic solids are increased and the volume dimin-
ished, yet the chlorides, sulphates and phosphates are but little
changed and albumin is very rare. Peptone is often present during
resolution and indicates absorption of the exudate.
PNEUMOTHORAX.
Definition. The presence of air in the pleural sac. Since air is
almost never present unassoeiated with an effusion, either serous or
purulent, we therefore have hydro-pneumothorax or pyo-pneumo-
thorax, as the case may be.
Air may find entrance into the sac from perforation of the pa-
rietal layer of the pleura or from perforation of the visceral layer.
The latter is much the more common and the largest majority of all
cases results from tuberculous ulceration. Emphysema probably stands
second as a cause. The left side is more often affected than the right.
The organs are then displaced to the right and the lung may be col-
lapsed arid pressed against the spine as in pleurisy.
The amount of associated effusion varies. Some cases are not
discovered until post-mortem examination is made.
126 PLEURISY
The Physical Signs vary considerably according as to whether
air alone is present or whether it is associated with effusion.
Inspection reveals asymmetry with enlargement and immobility
of the injured side, this half of the chest being in the position as-
sumed in full voluntary expansion. This is easily demonstrated by
noting the resulting symmetry on causing the patient to forcibly in-
spire, the asymmetry returning on forcible expiration. Bulging of
the intercostals may be present and it is to be noted that there is no
recession of the spaces on inspiration. This^ is especially the case
if the opening into the pleura is valve-like so that there is actually in-
creased inter-thoracic air pressure, as is often the case. The heart im-
pulse is generally displaced to the right. Tfie costal movements of
the opposite side are increased. Vocal frenaitus is diminished or
absent.
Mensuration. The tape shows marked increase in the measure-
ments of the affected side, and little or no change with expiration.
Percussion elicits a tympanitic resonance over the whole of the
expanded side. The note varies with the amount of air imprisoned
within the cavity and the degree of tension under which it exists. It
may be vesiculo-tympanitic if little or no pressure is exerted or it
may be purely tympanitic, indicating tension and pulmonary com-
pression. Often it is amphoric with a rich metallic quality. The
pitch varies with the conditions named and deserves especial mention.
If the ingress and egress of air are free the pitch is low, and may be
raised by causing the patient to inspire deeply and hold the mouth
closed. From this pitch the note rises with the pressure until flatness
is reached. When the air is confined under such extreme pressure
that vibration from percussion is impossible, the resulting note must
be flat and toneless. A lesser tension elicits a very high-pitched per-
cussion note. Percussion of the lower areas of the chest yields dull-
ness owing to the presence of fluid, but it is to be noticed that the
tympanitic areas often extend much beyond their normal fields. When
fluids are present the flatness elicited by percussion changes with
changes in the position of the patient. This variation of the percus-
sion level occurs much more readily and frequently than in pleurisy,
where it is often impossible to demonstrate any such change.
Auscultation. Absence of all vesicular murmur is noticed. Such
breath sounds as may be occasionally heard ai:e feeble, indistinct and
distant and are never vesicular, but rather amphoric in character, or,.
PLEURISY
127
as occurs iu pleurisy when the pressure is sueh that the vesicles are
obliterated, we get bronchial breathing. The vesicular murmur on
the sound side is iuteusilied and approaches puerile breathing. The
vocal resonance is amphoric and may be imitated by spealcing softly
into a large bottle. Kales are generally present and assume peculiar
Fig. z^ — Physical signs in pneumothorax (Patten"). A Tympanitic percussion
note, breathing suppressed, tultular or amplioric. voice sounds metalhc or
amphoric ; metallic tinkling. B Dullness, absence of all sounds. C Harsh
breathing (upper portion), increased percussion note rnd increase in pitch
of voice and respiratory sounds (lower portion). D Displaced area of
cardiac dullness. E Displaced spleen.
characters. One very characteristic sound is known as metallic tink-
ling and may be likened to drops of water falling against a very thin
wine goblet, or to striking the goblet with a delicate wire. These
phenomena were first described by Laeiuiec, but his explanation of
the manner of their production is of doubtful correctness.
128 PLEURISY
Trousseau describes a valuable sign. Place a coin over the affect-
ed side and strike it sharply with the edge of another coin while the
ear is held against the chest of the patient. A bell-like ringing or
tinkling is heard which is pathognomonic, and may be obtained even
when intrapleural tension is so high as to yield percussion dullness.
Succussion splash may be elicited by violent oscillation of the pa-
tient while the ear is applied to the chest wall. The patient should
be in a sitting posture. Sometimes the patient himself is aware of
this phenomenon. It even may be felt by superimposing the hands
over the ribs, one on either side, while the patient quickly moves the
body. This sign, which is known as Hippocratic succussion, is fully
described under Auscviltation in the introduction. It requires for its
production the presence of both air and fluid in a cavity. When pres-
ent its diagnostic significance is absolute. No one should be misled
by the possible splash of a stomach partially filled with liquid eon-
tents.
In pneumothorax the organs are often displaced, especially the
heart and liver. The first may be pushed either to the right or to the
left; the latter displaced downward.
SECTION VII.
PNEUMONIA.
LOBAR PNEUMONIA.
Definition. An inflammation of the lung "substance accompanied
by exudation from the blood vessels and the growth of pathogenic
bacteria, being due to a specific infection.
The lower lobe of the right lung is most often the seat of the dis-
ease, and, next, it most frequently attacks the lower left lobe. The
lower lobes are affected nearly three times as often as the upper lobes.
The physical signs vary with the stages of *the disease, which are
called, respectively, stage of congestion, stage of red hepatization,
and stage of gray hepatization.
FIRST STAGE.
No consolidation has yet taken place although there is some exu-
dation into the aii- vesicles.
Physic.al Signs. Inspection. The patient may lie on the affected
side, or be propped up, leaning toward, or "favoring," that side.
Dyspnoea at this stage is not marked, orthopnoea is not frequent. The
movements of the affected side are more or less restrained.
Palpation. On touch the fremitus is normal.
Percussion. The percussion note is at first unchanged but as the
air spaces are trespassed upon the note becomes higher in pitch, its
duration shorter and its approaches to dulln'ess in direct proportion
to the amount of exudate into the air spaces.
Auscultation. Very early in the diseastj, even before exudation
has taken place, the respiratory murmur diminishes in intensity over
the affected area and becomes correspondingly exaggerated in other
parts. This quiet, suppressed breathing in one part of the lung with
exaggeration in other parts, especially on the opposite side, is quite
marked even in the preliminary stages and should always suggest
pneumonia. Likewise during this stage of enfeebled respiration, after
exudation occurs, on drawing a long breath the sounds over the in-
180 PNEUMONIA
disposed area will be observed, to have that harshness of quality and
elevation of pitch to which the name broncho-vesicular breathing is.
applied. As soon as exiidation takes place the crepitant rale is heard^
the distinctive sound of the first stage of pneumonia. This rale is
a fine, crackling sound heard close to the ear,. occurring at the end of
inspiration and may not be audible until a full breath is drawn.
Opinion differs as to whether this crepitus is due to a fine exudate-
upon the pleura or is caused by infiltration into the air cells and finer
bronchioles, due to the separation of the sticky exudation with in-
flation of the cells. While a priori the latter view seems more rea-
sonable, yet it is probable that the former is correct. Coarser rales,
may be present in the large bronchi and may mask the more delicate
crepitant sound. Moist rales are seldom present at this stage.
An examination of the urine will show diminution of the chlo-
rides and perhaps albumin will be found.
SECOND STAGE.
Inspection. The restricted movement of the affected side is now
marked and the compensatory or exaggerated breathing on the oppo-
site side may attract attention even before the patient is uncovered.
The respirations are increased in frequency and are of a labored:
character, as indicated by calling into play the accessory respiratory
muscles. The nostrils dilate on inspiration, always a sign of inspira-
tory dyspnoea. The area of the cardiac impact may be much larger
than normal, as pointed out by Graves, especially in pneumonias of'
the left upper lobe. The cardiac impulse may be transmitted through,
the solidified lung so as to cause marked movement of the chest wall.
Mensuration. The affected side is increased in volume though,
the increase is slight and not sufficient to obliterate the intercostal,
spaces. (Contrast with pleurisy.)
Palpation. Vocal fremitus is generally increased over the con-
solidated area, as is to be expected. Yet for some unexplained reason
it is sometimes diminished or absent. This diminution may be due to-
the closure of the larger bronchi by the exudation, thus preventing
the voice sounds from reaching the periphery. In such cases a vig-
orous cough may clear away the obstruction and restore the fremitus.
Lack of expansion may be more apparent to touch than to sight, espe-
cially by a comparison of the two sides. Friction fremitus often may-
be felt. (See pleural fremitus.) >
PNEUMONIA 131
Percussion. There is marked percussion dullness over the area
of infiltration. The note varies with the degree o£ distention of the
air spaces. Sometimes the note is almost tympanitic, or at least sug-
gests that quality, and varies therefrom to marked dullness, but never
reaches that absolute flatness which has beep described as the distinc-
tive quality of effusion. Where consolidation is central and surround-
ed by distended, pervious tissue, we get the tympanitic note, and here
even deep percussion may not elicit dullness. In the aged especially
must we be on our guard against variations and irregularities. Dur-
ing this stage sometimes percussion elicits the cracked-pot sound. (See
Phthisis.)
Auscultation. The crepitant rale appears with the exudation
upon the pleura. It may persist through the second stage, but some-
times is absent altogether.
The respiratory sounds are propagated from the large bronchi
through the consolidated tissue and have therefore the quality of the
tubes which remain pervious. The breathing is therefore tubular,
much intensified and is similar in quality to that heard when in health
the stethoscope is placed over the roots of the lungs or over the large
bronchi. Breathing may be more intense and bronchial in this dis-
ease than in any other prilmonary condition. Rales may or may not
accompany this blowing respiration.
From the above explanation it follows that in cases where the
large bronchi are closed by exudate, the broiichial respiration is also
absent. Bronchophony is generally heard when bronchial breathing
is heard, but if consolidation is imperfect it may be absent. It may
have the bleating or ■ nasal quality to which the name egophony is
applied.
THIRD STAGE.
Gray Hepatization. Movements gradually return and respira-
tory harmony is established. Respirations become less labored and
less frequent as permeability returns. If there has been enlargement,
of the affected side, it disappears. With increased motion of the lung
the crepitant rale may be manifest.
As softening progresses air enters the vesicles, but the tubes are
loaded with the softened products and rales are heard over all parts,
coarse and bubbling as well as finer, dryer sounds, crepitant and sub-
crepitant. The name rales redux has been given to this process.
132 PNEUMONIA
Bronchial breathing and bronchophony disaj)pear and are replaced
by the gentle vesicular rustle. Last of all to disappear is the dull per-
cussion note and the cracked-pot sound. Impaired resonance over
certain areas may permanently remain.
It will be seen that the third stage repeats largely the inspection,
palpation and auscultation signs of the first stage in inverse order.
The third stage, which is the stage of resolution, occupies ten or twelve
days. The last sign oP this stage is the crepitant rale, the return of
which is known as "crepitans redux." When it is replaced by nor-
mal vesicular breathing, dullness should have disappeared.
Besides recovery and death, two other terminations should be
noticed, abscess and gangrene. Osier asserts that ordinary fibrinous
pneumonia never terminates in tuberculosis, that such supposed cases
were tuberculous from the outset.
Abscess results from pneumonia in about three or four per cent,
of the eases. Small cavities may unite into one involving a consid-
erable portion of the lobe. The sputum becomes abundant, purulent,
contains elastic tissue and may contain crystals of cholesterin or of
liEematoidin.
The cough comes on in sevei'e paroxysms, with profuse expec-
toration. The fever is at first remittent, then intermittent- and hectic.
The signs of cavity are not usually present.
Gangrene occurs about as often as abscess, but may present no
signs except post-mortem. It may occur with abscess. If the sputum
becomes foetid and exhibits the characteristics of gangrene, the diag-
nosis is clear.
Special Syinploms. Herpes develops in about one-third of all
cases. Coming on early it is of decided diagnpstic value as it appears
in scarcely any other respiratory disease, although it occurs about as
frequently in malaria and cerebro-spinal meningitis as it does in
pneumonia. The commonest seat of development is about the angle
of the mouth and nose. Less usual seats are about the eye, ear, the
genitals or the anus. The vesicles appear in a«crop of half a score to a
score, disappearing in a few days, leaving behind dry scabs.
Chill. In no other disease except malaria is chill so apt to be an
initial symptom. Often it comes on at night and is always severe,
lasting fifteen to forty-five minutes. It is followed by rapidly rising
fever which runs a course between 100° and 105°, F., most frequently
falling by crisis between the third and the eleventh day.
PNEUMONIA 133
Pain. Most cases are ushered in by ^arp, lancinating pain,
which is due to the accompanying pleurisy and therefore has its usual
seat over the affected side, yet the pain o:£*1,en appears before the
pleuritic friction is observable and may be referred to some distant
point. Pain is generally most marked in the mammary or the axillary
region. In old persons it is less distinct or absent. In central pneu-
monias it is absent. It is often referred to the abdomen in children.
Pulse varies with the fever but rises to 100° or 120°.
Dyspnaa occurs early and is severe. The respirations quickly
reach thirty ; later fifty or sixty in the adult ife not uncommon ; eighty
is not extraordinary, especially if both lunga are involved. In chil-
dren one hundred is not unknown. The movements are restrained
on account of pain, hence are shallow, often ending in an expiratory
grunt. Deep breathing elicits exquisite pain.^ The respiration-pulse
ratio is more significant in pneumonia than in any other disease,
reaching one to two or one to one-and-a-half in some cases, instead
of the customary ratio of one to four. Thus", a pulse rate of 100 or
110 may coincide with a respiration rate of 50.
The cough, is very painful and therefore restrained. It is at first
short, frequent but single, dry and hard. Later it is accompanied
by characteristic expectoration. In children and in old people the
cough may be slight and attract little attention.
EXPECTORATION.
The first expectoration consists of small, glairy mucus, arising
from the concurrent bronchitis. Within twenty-foiir hours after the
initial chill the sputum assumes distinctive characters, becoming ex-
ceedingly tenacious, viscid and gelatinous or gluey, then tinged with
blood. The cup may now be inverted without spilling the contents.
The mass trembles like jelly. The patient has difficulty in expelling
the sticky ^ masses. From being blood-tinged, it becomes decidedly
colored and the designation "prune-juice sputum" is sometimes ap-
plicable, though, in my experience, infrequently in frank pneumonias.
In cases of the asthenic type it is common. The term ' ' rusty ' ' better
describes the secretion in the majority of instances. The amount
varies from one to four ounces in the twenty-four hoiirs. After the
crisis the color changes to greenish, then yetlowish purulent masses
are expectorated and gradually it fades away., Sometiines after crisii^
it ceases suddenly.
134 PNEUMONIA
Microscopically the sputum is found to contain degenerated
bronchial and alveolar epithelium, mucus, leucocytes, blood corpuscles
changed and unchanged, minute fibrinous casts of the capillary
bronchi and alveoli, hajmatoidin crystals, the micrococcus laneeolatus
and sometimes other organisms, such as Friedlanders bacillus pneu-
moniae, staphylococcus and streptococcus pyogenes and various others.
BACTERIOLOGY.
Owing to the confusion which is apt to exist in the mind of the
student with regard to the bacteriology of pnSumonia the following
statements are made :
Friedlander in 1882 described capsulated bacilli as being of
constant occurrence in the alveolar exudate. They were named
" Friedlander 's bacillus pneumoniaj. " He believed they were path-
ogenic. Frankel and others subsequently showed that this bacillus
was of comparatively rare occurrence in pneumonia, and that an-
other, discovered by Sternberg, was present in the sputa of nearly all
cases. Friedlander 's bacillis is now named, "The pneumo-bacillus. "
This second organism has been known by various and confusing
names and is still called the diplococcus pneumoniEe and also the
pneumococcus of Frankel.
In 1888, Klein described yet another bacillus, known as Klein's
bacillus pneumonise.
In some cases of the disease only streptococci are found. Fran-
kel 's pneumococcus has been found in the saliva and bronchial secre-
tions of healthy individuals. In some eases of pneumonia none of
the above organisms is present.
The diplococcus pneumonias, also called the micrococcus laneeo-
latus, and pneumococcus, is oftenest found in the sputum, but in the
absence of physical signs and clinical symptoms does not indicate
the presence of the disease, since it may be found in healthy persons.
Method. Smear two cover glasses with the, sputum, rub together
into a thin layer, separate, dry in the air and fix by passing a few
times through the flame of an alcohol lamp. Immerse in a one per
cent, solution of acetic acid for two minutes, draw off: the excess of
acid with a pipette and stain, first in a saturated solution of anilin
water, then in gentian violet. Wash in water and examine. The
organism is a rod-shaped diplococcus surrounded by a capsule
( Simon ) .
PNEUMONIA 135
BLOOD CHANGES.
The most common and characteristic blood phenomenon is leu-
tjocytosis. The normal number of leucocytes per cubic millimeter does
not exceed ten thousand. In pneumonia it may increase to 30,000
or 40,000. Osier has seen 63,000. Leucoeytosis increases with tem-
perature and disappears with crisis. Its absence portends grave con-
sequences. Its persistence means delayed resolution. Since leucoey-
tosis does not occur in influenza, its presence is of diagnostic value.
THE URINE IN PNEUMONIA.
The quantity is diminished to one-third or one-half. Uric acid
•and urea are increased and large deposits of* pigmented urates occur
at critical stages. They are stained brown or red. The specific grav-
ity is 1025 to 1035. Excess of mucus causes the fluid to become
quickly alkaline. The chlorides are greatly diminished or even absent
during the first and second stage, or even until convalescence sets in.
Their return is a favorable indication. The sulphates increase.
Nearly fifty per cent, of all the cases show albumin during consolida-
tion and its presence is distinctly unfavorable. Diminution of the
"total solids is also unfavorable. Sometimes nephritis is intercurrent or
is a sequel of pneumonia.
DIFFERENTIAL DIAGNOSIS.
Pneumonia in the first stage resembles pulmonary oedema. The
latter differs by the presence of liquid cractling rales occurring at
the most depending portions of the lungs and on both sides, while
pneumonia is usually confined to one lung. Further, the frothy
sputum, the general distribution of the rales, ^ their coarser character,
the cyanotic lips, the noisy breathing, the absence of fever, in csdema,
prevent error. When not the immediate precursor of death, cedema is
not an acute condition.
In the consolidation stage it may be confounded with pleural
effusion. ,It differs from the latter in that boalging is absent, vocal
fremitus instead of being absent is increased, by the fact that the
percussion note is never wooden or absolutely fiat and that its area
does not move with changes in the position of the patient, that the
respiration sounds are intensified and tubular instead of absent in
pneumonia, and that when occasionally present in effusion they are
indistinct, distant or deep-seated. Pleurisy is often without rales
136 PNEUMONIA
and the sputum is frothy. Pneumonia does not displace any of the
organs.
From phthisis it differs both in the history and in the course and
progress of the disease. Tuberculosis advance's from the apex down-
ward. Pneumonia is confined oftenest to one lobe and that the lower
lobe, is much more acute, the hectic flush is absent as are the night
sweats. The character of the cough and sputum is different, there
are no tubercle bacilli present. The pulse-respiration I'atio is inverted,
that is to say, in pneumonia the pulse is slower than called for by the
respiration rate, while in phthisis it is faster. The dyspnoea of pneu-
monia is much more striking than that of phthisis. It is only in those
cases of acute phthisis that appear after pneumonia, that the physi-
cian must be on his guard.
BRONCHO-PNEUMONIA.
Synonyms : Capillary Bronchitis, Lobular Pneumonia, sometimes
Catarrhal Pneumonia.
Definition. An inflammation of the terminal bronchus and the
vesicles which constitute a pulmonary lobule, due to the invasion of
the lung by various kinds of microbes. It is lobular, in contradistinc-
tion to lobar, pneumonia.
Holt's statistics give a proportion of two cases out of every three
as secondary to some other disease.
Bacteriology. The organisms most comnlonly found in broncho-
pneumonia are bacillus influenza, micrococcus lanceolatus, streptococ-
cus pyogenes, staphylococcus pyogenes aureus et albus, Friedlander 's
bacillus pneumonia?, also the organisms of the associated disease when
the process is secondary, as the bacillus of diphtheria. The infection is
almost always mixed.
In typical form broncho-pneumonia is a disease of childhood,
usually attacking children under two years. It is either a primary
disease or is secondary to bronchitis, measles, whooping cough, diph-
theria, ileo-colitis, scarlet fever or influenza, in the order named
(Holt). It also follows other diseases but less frequently. Wilkes
mentions it as occurring after extensive burns of the skin. It occurs
in the course of typhoid fever. It follows the inhalation of foreign
substances, giving a distinct type, the so-called inhalation or degluti-
tion type, due to benumbing of the larynx, as after apoplexy, in
uripmia, and post-operative pneumonia.
PNEUMONIA 137
Rickets and malnutrition are predisposing causes and furnish a
fruitful mortality. In the aged it often terminates a chronic bron-
chitis.
The disease is bi-lateral but one side usually bears the brunt of
the attack. The lesions are small areas of consolidation, often sur-
rounded by areas of over-distended cells alternating with small areas
of collapsed lobules, which are depressed below the surface. The con-
solidated spheres change from brown to gray, and then to yellow
with age. They may be separate and remain fairly scattered, but
some aggregate and by their confluence form large racemose bunches
of consolidation, with interspersed air cells, so that an entire lobe is
never solidified. The lower lobes are affected oftenest and collapsed
lobules are found near the base of the lungs. The small bronchi, the
alveoli, and occasionaly even the large bronchi are filled with inflam-
matory products and proliferated cells. When pressed they exude
puriilent mucus.
The cases terminate by softening, abscess, gangrene (bronchiec-
tasis often so terminates), return to normal or become chronic
(chronic pneumonia). So much of the morbid anatomy is absolutely
necessary for a proper understanding of the various signs and symp-
toms encountered.
Associated Lesions. The bronchial glands enlarge but do not
undergo softening. The right heart dilates, due to the obstruction
encountered in the lungs, and this leads to venous engorgement of the
organs connected with the systemic circulation, as the spleen, liver,
and kidneys. Intestinal catarrh is for this reason often associated.
Course and Symptoms. The primary attack often sets in with a
convulsion, sometimes with a chill, the temperature rises rapidly to
103° and varies between 103° and 105°, but is fairly constant. Cere-
bral symptoms may mask the pulmonary lesion, or what is more likely,
the disease may be mistaken for lobar pneumonia.
The secondary form begins as does the primary with accession of
fever, cough and dyspnoea, rarely with chill. The fever is more irreg-
ular and ranges between 102° and 104° Mprning temperature may
be higher than evening. The cerebral symptoms if they occur, come
on early and go quickly. Breathing is from fifty or sixty to eighty
per minute. (Compare lobar pneumonia.)
Physical Signs. Inspection. Patient rests propped up in bed
with the head high, respirations are short aad shallow, ala? nasi are
138 PNEUMONIA
widely dilated. The face, at first pale, soon becomes livid and then
cyanotic. The expression is anxious. The breathing is labored, the
inspirations are short, the expirations are prolonged, there is little
true expansion. The sternum rises, but there is recession of the lower
interspaces, the submammary and epigastric regions, with inspiration.
The tongue is dry, the skin hot and dry or alternates with perspira-
tion. The pulse is small, quick, rapid and may be uncountable. The
■dyspncEa is painful, but the efforts to breathe "Subside somewhat under
the influence of the non-oxygenated blood. In cases which survive
■dyspnoea gradually fades. Emaciation is rapid.
Palpation. Fremitus increases with the atmount of consolidation.
Percussion. The note is normal as long as the areas affected are
few and scattered. As coalescence occurs the resonance becomes im-
paired. This usually develops after forty-eight hours. The asso-
ciation of coalescence and collapse gives flatness, but in the most
common form of the disease the patches are' scattered and much of
the lobe remains crepitant. Early in the disease the note may be
hyper-resonant in front and along the over-distended edges.
Auscultation. Breath sounds are harsh in the upper lobes, feeble,
absent or bronchial at the base, depending on the relative amount of
the three factors which influence them, viz: consolidation, collapse
and hyper-distention. As the bronchioles fill with exudate, blowing
breathing predominates and expiration may be jerky and grunting.
The rales, at first fine and subcrepitant, soon Ijecome higher and whist-
ling and the fine crackling rales are not limited to inspiration.
If bronchiolitis occurs rales become metallic and high-pitched,
associated with bronchial breathing and bronchophony. Rhonchi,
sibilant rales and other signs of bronchitis vary with the extent to
which the tubes are involved. Vocal resonance increases with con-
solidation.
Collapse is indicated by retraction of the side, absent breathing
sounds, absent vocal resonance and fremitus. The percussion note of
collapse is not as dull as that of consolidation.
The cough is hard, distressing and even painful. Occurring
secondarily to bronchitis, the fr-ee secretion ceases. A cough which
was loose and painless now becomes short, frequent, dry and painful.
The secretion becomes viscid and is coughed up with difficulty. It
may be blood-tinged but is never rust-colored as in pneumonia. In
■children expectoration is absent.
PNEUMONIA 139
Diagnosis. The secondary forms are easiest diagnosed. If, dur-
ing convalescence from one of the diseases mentioned, a child 'has an
accession of fever with cough, a rapid pulse, decided increase in the
respiration rate and if, on auscultation fine crackling rales scattered
about the base of the lungs are heard, one may safely expect broncho-
pneumonia to intervene.
The disease closely resembles pneumonia if the lobules coalesce
into large masses. Broncho-pneumonia occurs ofteuest before the
second year, while lobar pneumonia is rare- before the third year.
Pneumonia is unilateral; broncho-pneumonia is bilateral. The first
is primary, the second is oftenest secondary. Pneumonia shows fewer
remissions in temperature and the crisis occurs about the eighth day.
From tuberculosis the diagnosis is often made by postponement.
It is an aid to know that acute miliary tuberculosis, without softening,
is more common in children of this age than the caseous form, but
both occur. In tuberculosis the upper lobes suffer oftenest, in the
pneumonias, the lower ones, and typical signs may be detected in
the vomited matter, shreds and tubercle bacilli may be found. From
TQeningitis it is differentiated by recalling that brain symptoms ac-
company the onset of many diseases of childhood, and the dyspnoea
and the cough soon draw attention to the lungs.
EMBOLISM OF THE PULMONAEY ARTERY.
Sometimes called Embolic Pneumonia, Haemorrhagic Infarct or
Pulmonary Apoplexy.
Definition. A conical extravasation of blood into the lung sub-
stance resulting from the lodgment of an embolus in a branch of the
pulmonary artery. The embolus must arise from a thrombus which
has formed somewhere in the venous system, and which, becoming
detached and passing through the cavities of the right heart, ulti-
mately blockades a branch of the pulmonary artery. During preg-
nancy such a thrombus may form in the venous system of the pelvis
or in the femoral vein (phlegmasia alba dolens). During typhoid
fever it may arise from thrombus of the saphenous or femoral vein.
So also in the course of septic diseases, of pleurisy or phthisis, thrombi
are apt to form in the veins mentioned or ill the jugular vein. In
middle ear disease they may form in the lateral sinus. Further,
emboli may result from clots formed within the heart itself, in dis-
140 PNEUMONIA
eases of that organ. Pat emboli are sometimes found after death
from diabetes.
Symptoms. A small embolus may cause only a transitory oedema,
or hypersemia which soon passes away.
Septic emboli cause inflammation, and gray hepatization follows
the wedge-shaped infarct. This may be succeeded by abscess or gan-
grene. The typical lesion following pulmonary embolus is infarct,
which is a form of pulmonary hemorrhage. The area is cone-shaped,
the base reaching the surface, the apex corresponding to the point of
obstruction. If small, they give rise to few symptoms. If, however,
a large area is involved, the attack comes on in a moment, the patient
is seized with agonizing pain and the most intense dsypnoea, the heart
is irregular and tumultuous, or weak and imperceptible, and death,
may result within a few minutes.
In severe but not fatal eases the symptoms are somewhat as
follows :
Inspection. Patient is anxious, breathing is rapid and panting,,
but is unob.structed. Sometimes the Cheyne-Stokes type supervenes^
lips are blue, skin cold and moist. Heart becomes gradually quiet
and feeble.
Palpation shows increased fremitus.
Permission reveals impaired resonance over the limits of the
infarct.
Auscultation shows harsh inspiration, somewhat lengthened ex-
piration, crepitant and suberepitant rales, and even bronchial
breathing.
Blood appears in the expectoration after twenty-four to thirty-
six hours. In some cases involving large areas the signs are those of
croupous pneumionia, but the outline of the lobe is not followed; the
disease is unaccompanied by pyrexia, and comes on much more rapidly
than is possible with pneumonia.
Occurring in the course of mitral disease the symptoms are : pain
in the side, dyspnoea and possibly hemoptysis, with the expectoration
of dark, blood-stained sputum. A local pleural friction sound may
mark the site of the infarct. Deep percussion may reveal tender-
ness (Head).
Diagnosis. The suddenness of the onset, the character of the
dyspnoea — the patient breathing deeply, yet conscious of a lack of
PNEUMONIA 141
air — the agony, the absence of signs of obstruction, should suggest
the nature of the disease.
Asthma is accompanied by sonorous and sibilant rhonehi.
Laryngeal obstruction shows signs of impeded air entrance.
Qi^dema shows fine crackling rales over the bases of both lungs
and is painless.
Infarct is unilateral.
The knowledge of a coexisting phlebitis, or of heart disease, aids
materially the diagnosis. If seen after the onset and without a knowl-
edge of the history of the case, the disease may be mistaken for pneu-
monia. Xon-septic cases are afebrile. Septic cases are followed by
•chill, rigor, hectic, and the familiar chain of septic symptoms.
PULMONARY (EDEMA.
DefinHiun. An effusion of serous fluid into the air vesicles and
interstitial tissues of the lung substance. It occurs in the lungs, as
elsewhere, by reason of disturbances of the circulation and changes
in the vessel walls, hence is associated to a more or less extent with all
diseases producing pulmonary congestion. It gives rise to few symp-
toms except an aggravation of the existing, symptoms of the asso-
ciated disease.
As an independent entity we consider the pulmonary oedema
which frequently terminates a variety of acute or chronic diseases,
and is therefor spoken of as terminal oedema. Such diseases are acute
and chronic nephritis, cardiac diseases, various antemias and diseases
of nutrition and cerebral diseases. It is prdne to occur in maladies
in which general dropsy exists. Acute osdema may follow the embolic
obstruction of the pulmonary artery just described. Sometimes it
follows the rapid removal of large quantities of fluid from the pleural
cavity by thoracentesis. The transudate may be watery serum or
blood-stained. Very acute oedemas are almost entirely serous.
Except in the case of the rapidly produced oedema just men-
tioned, the symptoms come on slowly. They are an increasing sense
of suffocation, increasing difficulty of breathing, some cyanosis, a weak
pulse and a cough which is short and dry. The oedema here begins
at the base of the lungs and mounts, the symptoms increasing there-
with. If suddenly developed, the above symptoms are much aggra-
vated, the dyspnoea is severe and there is expectoration of abundant
frothy sputa, which may be blood-stained or hsemorrhagic. The
142 PNEUMONIA
dyspnoea depends on the number of air cells occupied. The malady is
afebrile, bilateral.
Percussion gives areas of impaired resonance,' amounting to dull-
ness over the bases and dependent portions of the lungs. Large effu-
sions give marked dullness.
Auscultation. The vesicular murmur is feebje or absent. Rales
are fine or coarse, moist or liquid, according to the extent of the in-
volvement. In extreme cases the breathing is bronchial, and coarse,
rattling rales are audible at a distance.
Broncho-pneumonia intervening as a secondary disease is the
only affection likely to be confounded with pulmonary oedema, but
the mode of onset, the age, the fever, the glairy, tenacious expectora-
tion and the scattered areas of dullness . in the latter will clear up
the doubt.
SECTION Vlll.
PULMONARY TUBERCULOSIS OR CON-
SUMPTION.
Definition. An acute or chronic febrile infective disease of th&
lungs, caused by the bacillus tuberculosis, characterized by diffused
tuberculous infiltration, the formation of tubercles which undergo
caseation or sclerosis and which may ulcerate or calcify.
VARIETIES.
A. Acute phthisis. 1. Tubereulo-pneumonie phthisis (Osier).
2. Acute tuberculous broncho-pneumonia.
B. Chronic ulcerative phthisis.
C. Fibroid phthisis.
D. Miliary tuberculosis of the lungs.
The first form, acute pneumonic tuberculosis of the lungs, known
also by the name of "galloping" consumption, phthisis florida, is
characterized both by its diffuseness and its rapidity. It occurs in
both children and adults. Many eases occurring in children are mis-
taken for simple lobar-pneumonia. Since an entire lobe or even an
entire lung is affected, and inasmuch as physical signs are identical
with those of pneumonic hepatization, in which condition the lung is
found to be post-mortem, the mistake is excusable. The upper, then
the lower lobe, then the entire lung, is the order of frequency of
involvement.
The physical signs are those of consolidation ; increased frequency
of respiration, dyspnoea, percussion dullness, marked increase in
fremitus, feeble, vesicular murmur followed by suppression and then
bronchial breathing. This tubular breathing becomes very intense
and is marked as early as the fourth day. The characteristic crisis
does not occur by the tenth day and the sputum becomes muco-pura-
lent and changes to green color (Traube). Tubercle bacilli are now
found in the sputum, which settles the diagnosis.
144 PULMONARY TUBERCULOSIS OB CONSUMPTION
In the second form, which Osier denominates acute tuberculous
broncho-pneumonia, which form he states constitutes the majority of
cases of phthisis florida, especially in children, the lesion is a blocking-
up of the small tubes with cheesy matter, while the air cells of the
lobule are filled with the products of catarrhal pneumonia. These
areas are separated by areas of crepitant tissue, but by their fusion
an entire lobe may be rendered nearly solid. Owing to the inter-
spersed islets of crepitant tissue the physical signs are indefinite. The
first positive signs are usually those of deposits at one or the other
apex.
The respirations are markedly increased in number, the sub-
clavicular expansion is diminished. Areas of diminished resonance
are found, more generally at the apices. Over these areas the vocal
resonance and fremitus are increased, percussion sounds impaired,
pitch raised, and the approach to flatness is flireetly in proportion to
the volume and density of the involved tracts. Auscultation shows
the absent vesicular sounds, replaced by rude or harsh tubular breath-
ing, associated with rales, numerous and varied in character. The
cough, hacking, troublesome and almost continuous, at first dry, soon
is accompanied by expectoration which very early shows the presence
of tubercle bacilli and elastic fibers. The tongue is dry and brown,
the fever high. A few of these cases survive the acute stage only to
become chronic. This form is especially prone to follow measles and
whooping cough.
Chronic Phthisis. Ulcerative Tuberculosis of the Lungs. As
first pointed out by Laennec, and more recently in the admirable
analysis of J. Kingston Fowler, 1888, the primary lesion is most often
situated from an inch to an inch-and-a-half below one or the other
apex, nearer the external and posterior than to the anterior surface,
whence it spreads downward. As has been pointed out in the section
on topography, the lung projects from one to one-and-a-half inches
above the clavicle, hence this point of infection would lie anteriorly
under the center of that bone. The situation of the focus towards
the posterior surface accounts for the occasional presence of demon-
strable dullness in the supra-spinous fossa, 'S^hen it cannot be made
out anteriorly. The right apex is the seat of the primary lesion more
frequently than the left. Fowler further calls attention to the fact
that the lower lobe is usually affected when the physical signs of dis-
ease at the apex are sufficiently definite to alow of the diagnosis of
PULMONARY TUBERCULOSIS OR CONSUMPTION 145
phthisis being made. The point of involvement is again from an inch
to an inch-and-a-half below its apex, which corresponds on the chest
wall to a point opposite the spine of the fifth dorsal vertebra. Have
the patient reach the arm of the affected side around his opposite
shoulder and place his fingers upon the spine of that scapula. The
point in question is marked by the inner edge of the abducted scapula
and the spine named. Cavities are usually first formed where the
lesions are oldest, and must be as large as walnuts before they may
be positively diagnosed by the signs. Henee patient and repeated
examinations of the points indicated should be made.
The next most common seat of cavity after the localities described
is in the second or third interspace, anteriorly, outside the mid-
clavicular line.
It is of extreme importance in examining a suspected case of
phthisis that the orderly sequence laid down in the preliminary chap-
ter be followed carefiilly, and it may be said to the credit of the diag-
nostician that in the vast majority of the cases a correct conclusion
may be arrived at by the intelligent interpretation of the physical
signs, before it may be reached by a bacteriological examination, and
with no less certainty. Before attempting to explain the physical
signs which accompany the tuberculous invasion of the lungs in the
chronic variety of the disease, it is necessary to name the lesions pro-
duced. These are:
a. Scattered and disseminated tubercles. These so long as they
are few and separated give rise to no positive signs.
b. Caseous tubercular masses due to the union and breaking
■down of neighboring tubercular particles. The localities in which
these masses are prone to occur earliest have been pointed out in this
•section. The signs to which they give rise vary with their situation
.and extent, and are considered below.
c. Tuberculous cavities (situation noted y. These may have soft
walls undergoing ulceration and extending their areas by breaking
down, or the walls may be composed of the so-called pyogenic mem-
brane, in which case extension is slower. The formation of the cavity
wall, the size, the situation (superficial or deep), the nature of the
opening into it, whether full or empty, all modify materially the signs.
d. Cavities formed by dilatation of the- bronchi, called bronchi-
ectasis (q. v.). The form of such cavities may be cylindrical (small
bronchi) or globular (large bronchi).
146 PULMONARY TUBERCULOSIS OR CONSUMPTION
c. The various forms of pleurisy, some of which are invariable
accompanists of phthisis during some part of its course. Three com-
mon variations are worth naming. 1. i^dhesive, over the infiltration
area, which results in a local glueing together of the two layers.
2. Perforative, into the pleural sac, resulting in empyema and pneu-
mothorax. 3. The entire pleura may become the seat of tubercular
infiltration, be studded with tubercles, thickened and may cement the
lobes into a single mass.
f. Pulmonary concretions. These may not be differentiated by
the physical signs, but are often coughed up, as are also bronchial
concretions found in chronic bronchitis^ with dilatations. Those of
phthisis differ from those of bronchitis by being more irregular, non-
uniform masses instead of pebble-like.
The physical signs are best considered under three stages ;
The incipient stage; the stage of Gomplete consolidation; the stage-
of softening and formation of cavities.
THE INCIPIENT STAGE.
Pulmonary tuberculosis is met with in chests of all shapes and
capacities but the long, narrow chest is the prevailing type. Here
the intercostal spaces are wide, the costal angle narrowed and the-
vertical direction of the ribs increased. The scapulae project like
wings, often one more than the other. In another type the antero-
posterior diameter of the chest is lessened, the sternum is sunken, the
subclavian spaces flat and the clavicles prominent.
Inspection may be negative. A few scattered tubercles give rise
to no phenomena appreciable by our coarse senses, but as soon as they
are sufficient in number to interfere with the elasticity or to increase-
the conductility of the lung tissue, they |)roduce objective signs. On
the other hand, if any wasting has occurred the clavicles are rendered
more prominent and there may be slight flattening below one or the
other collar bone. Expansion may be slightly diminished in the same
region. Deficient apical expansion is an early and impoi'tant sign.
It may best be estimated by taking a position behind the patient, who
should be seated, and looking downward over the shoulders. The
breathing will be somewhat accelerated but shallower than in health,
and the apex beat may show acceleration with marked quickening of
the impact.
The wavelike shadow caused by the rhythmical rise and fall of the
PULMONARY TUBERCULOSIS OR CONSUMPTION 147
diaphragm, known as Litten's sign, whicli is more fully described in
the section upon adherent pericarditis, is seen to be altered early in
pulmonary tuberculosis. The change, for the, most part, consists in a
limiting or shortening of the normal shadow on the affected side. The
sign is important and always should be searched for in suspected cases.
Palpation. Deficient expansion may best be gauged by standing
behind the patient and alternately placing the fingers in the sub-
clavicular spaces and the lateral regions of the chest and noting the
relative motility. So also, by placing the thumbs in the supraclavic-
ular spaces, while the fingers are placed in the upper intercostal
spaces, one may estimate the relative expansion of the apices with
fair accuracy. (See Fig. 17.) Vocal fremitus is increased wherever
the condensation is of sufficient degree to assist sound conduction
In the early stages it is difficult to estimate sMght increase in conduc-
tion, especially when it is recalled that deposits are more apt to occur
on the right side, and that normal fremitus is somewhat greater on
this side. If, however, fremitus is greater on the left side than on the
right, the fact is significant. Pleuritic thickening causes diminution
instead of increase of the touch fremitus.
Mensuration. The tape may show deficient expansion on one
side, or, what is more general, the tape encircling the body imme-
diately under the arm-pits does not show the amount of expansion
which is to be expected. This obtains early in the disease.
Percussion. Changes may be recognized on percussion which are
not made manifest by palpation. The first positive sign of infiltration
is dullness and its most usual seat is immediately underlying the clav-
icle. It is most surely discovered by direct percussion on that bone,
without intermediation of the pleximeter, although it may require a
cultivated ear to detect the change. Its note is higher and shorter
than normal, and is the note of impaired respnance. The difference
in the two sides may be marked, or both may be affected. The impair-
ment when not at the apex, is oftenest just below the clavicle. The
note should be elicited during natural breathing, on forced expiration,
on forced inspiration and with the mouth held open, as directed by
Flint. A comparison made between corresponding areas while the
breath is held after forced inspiration, most surely detects defective
resonance, when present.
Auscultation. When positive percussion changes can be elicited
148 PULMONARY TUBERCULOSIS OE CON^MPTION
abnormalities on auscultation are invariably present, and in some
eases even precede impaired resonance. The earliest auscultatory sign
is, generally speaking, feeble breathing, owing "to a lessening of the
tidal air entering the vesicles of the affected area. Make careful com-
parison between the two sides during quiet breathing. Inspiration on
the diseased side may be inaudible. Next in order of sequence is a
prolongation of the expiratory murmur. About the same time, or a
little later, the inspiratory sound grows harsher. The type of breath-
ing now becomes broncho-vesicular. Vocal resonance is increased in
direct proportion to the amount of consolidation, yet in not a few
cases it will be found absent by reason of early pleurisy having thick-
ened the intervening membranes, thereby masking its effect, as noted
under touch fremitus. Bronchitis, when present, is manifested by
rales. A soft bruit heard in the pulmonary or subclavian artery is
often present, and Da Costa states: "A murmur is, indeed, at times
present in the pulmonary artery long before any other physical indi-
cation of tubercle is discernible." Also interesting is the so-called
eardio-respiratory murmur met with in phthisis, caused by the pro-
pulsion of air from the tubes by the impulse of the heart. It is best
heard during inspiration, in the anterolateral regions of the chest.
In time the murmur is systolic, and is described' as a whiffling bruit.
(See heart murmurs.) To sum up the signs already elaborated, which
allow of the diagnosis of beginning tuberculosis with almost as great
certainty as does the finding of tubercle bacilli in the sputum, and
often long before their occurrence therein, we append the following:
, Modification of vesicular murmur at apex.
/ Adventitious sounds, arterial or respiratory,
limited to the apex.
Percussion dullness in clavicular area or
supra-spinous fossa.
bigns of y Increased fremitus.
, Impaired expansion or flattening of anterior
incipient < ^-u • £
^ \ thoracic surface.
phthisis. 1 Cough.
Shortness of breath.
Sustained rise of temperature with probable
morning maxima.
Modification of Litten's' diaphragm sign.
Failing health.
PULMONARY TUBERCUIjOSIS OR CONSUMPTION
149
STAGE OF CONSOLIDATION.
The second stage gives rise to signs more positive and more pro-
nounced than the first.
Inspection plainly shows loss of flesh, prominence of clavicles,
ribs and interspaces. A hectic flnsh may be noted. Flattening is
Fig- 37 — Extension of tuberculous lesion (Patton).^ Dark shade — primary le-
sion; light shade — extension of primary lesion; X — secondary lesion of op-
posite apex.
most apparent anteriorly and the breathing excursion is lessened both
with quiet breathing and during forced inspiration, when lack of
expansion is striking. Expansile efforts may be painful.
150
PULMONARY TUBERCULOSIS OR CONSUMPTION
Palpation shows increased fremitus except, as noted in first stage,
where pleurisy has resulted in thickening. The skin is hot and dry.
Percussion shows positive dullness over the affected areas, which
contrasts markedly with the unaffected parts where the respiration is
augmented and the note preternatural^ clear. Both apices may be
Fig. 38 — Showing relation of lobes to posterior chest wall, also extension of
tuberculous lesion (Fatten). A Frimary lesion. B Extension of primary
lesion. CC Secondary deposits.
affected. The plexor finger notes increased resistance. Pain on per-
cussion is often complained of. Hard, board-like tympany is not
encountered in recent cases but is found in old chronic cases with
extensive fibroid changes. Caseous consolidation, as noted under
pneumonic phthisis, has a tubular or bronchial quality. Percussion
should be practised in the supraspinous fossiE and in the intrascapular
regions, for reasons already given. In mu.scular and fleshy people not
much information may be gained thereby, but in thin, and especially
PULMONARY TUBERCULOSIS OR CONSUMPTION 151
in emaciated individuals, the returns are of great value. Myoidema
is the name given to the local contraction and bulging of the muscles,
when subject to irritation, such as occurs in direct percussion of the
pectorals. It is encountered in thin, nervous individuals, and, al-
though often seen in phthisis, is not of any special significance.
Auscultation. Vocal resonance is increased. The breath sounds
are harsh.
The disappearance of the vesicular elements and the approach
toward pure bronchial breathing are in direct proportion to the
amount of consolidation. The inspiratory portion of the sound is
shortened and the expiratory part is prolonged and blowing. When
consolidation surrounds a bronchial tube, typical blowing respiration
obtains. The signs are apparent in the supraspinous fossffi as well
as in front. Bronchophony, a high degree of vocal resonance, may
be present. It denotes consolidation. The presence of pleurisies may
give rise to fine superficial friction sounds or cracklings, and extensive
bronchitis may, by its noisy signs, interfere With auscultation.
Acquired lesions of the cardiac valves are certainly rarely encoun-
tered in the subjects of pulmonary tuberculosis, especially in the
chronic forms of the disease ; so rarely, indeed, that the late Henry
Formad denied their existence.
As pointed out, however, under the caption Congenital Cardiac
Defects, the subjects of congenital valvular lesions are very prone to
acquire pulmonary tuberculosis.
THIRD STAGE. SOFTENING STAGE. CAVITY FORMATION.
During this stage a portion of the lung is undergoing softening
while in other portions consolidation is proceeding by reason of con-
tinued infiltration. Hence the signs vary. The persistence of moist
rales and cracklings in areas previously consolidated indicates soft-
ening.
Inspection. Hectic has increased. Alternate, hot, dry skin and
cold, clammy perspiration are noted. Emaciation has made marked
encroachments. The limitations of movement during respiration are
still more restricted and the flattening under the clavicles more pro-
nounced than in the earlier stages. The superficial veins over the
thorax attract attention by their prominence, and fullness. Tyson
draws attention to upward retraction of the heart in cases involving
the left upper lobe. It must be rare. He also notes that the area of
152 PULMONARY TUBERCULOSIS OB CONSUMPTION
cardiac impulse enlarges upwards and pulsation may be visible in the
third and fourth left interspaces.
Palpation. Vocal fremitus is still increased in spite of cavity,
since cavities form in the midst of consolidated areas and are sur-
rounded by compact substance which increases conduction. Osier
remarks, ' ' In the later stages, when cavities form, the tactile fremitus
is usually much exaggerated over them. ' ' But considerable thick-
ening of the pleura diminishes this fremitus. If air cannot get into
a cavity by reason of its bronchus being closed, the fremitus is not
increased. Ehonehial fremitus may be present.
Percussion over cavities gives neither as positive nor as unvary-
ing results as over consolidation. If the cavity wall be thick and the
substance between it and the surface dense, the percussion note will
be dull as in consolidation, though heavier percussion may elicit
tympany. If dense, but thinner walls intervene, the sound is a mix-
ture of dullness and tympany, difficult to describe. Very thin walls
yield sounds which are truly tympanitic or metallic. Amphoric and
cracked-pot sounds often may be elicited. To demonstrate the cracked-
pot sound, percuss with a firm, quick stroke, while the patient with
suspended respiration, holds the mouth open. If a cavity underlies a
layer of healthy tissue, which would be a seemingly rare condition,
the note is clear, especially on light percussion. Percussion sounds
are much modified in the presence of ckvities by the act being per-
formed with the ijiouth alternately opened or closed. With the mouth
closed, the pitch is lowered and the vibrations longer. This is known
as Wintrich's changed note. Da Costa points out that over cavities
the heart sounds are heard with extraordinary clearness and that
there is often seen a "wavering impulse" in the second intercostal
space.
Auscultation. The breathing sounds vary with the relative de-
gree of consolidation and excavation. Over the hardened areas we
still have bronchial sounds, and if these are mixed with small bub-
blings and cracklings, subcrepitant rales, it indicates liquefaction or
beginning excavation. Cavities give rise- to new sounds. It is worthy
of note that numerous small, isolated cavities without much fibroid
deposit or pleural thickening, may exist at the apex and yet the per-
cussion note remain unaltered, although the auscultatory sounds will
be greatly modified and out of harmony with the percussion findings.
Cavernous breathing describes the tidal- air entering and leaving an
PULMONARY TUBEECULOSIS OR CONSUMPTION 153-
excavation. When the walls of the cavity are firm and unyielding,,
the note of respiratory rhythm is higher pitched, metallic and echo-
like. This is amphoric breathing. Large bubbling sounds occur when
air passes into a cavity partially filled with liquid, termed gurgling
rales. Cavities which give forth the amphoric respiratory sounds will,
when they contain liquid, produce metallic tinkling.
The voice sounds as modified by cavities, are interesting and dis-
tinctive. Cavernous voice, like cavernous breathing, is the hollow,,
resonant quality imparted to the sound by reason of its traversing
an excavation. Amphoric voice has added thereto an echoing, metal lie
or musical quality, and is higher in pitch than the cavernous voice.
Pectoriloquy, both spoken and whispered, when present is a distinctive
sign of cavity. The term has already been defined. In apical cavities
the heart sounds are often distinctly heard and occasionally an in-
tense systolic murmur is transmitted into the cavity. Over left apical
cavities, gurgling sounds or crackling sounds, synchronous with the-
heart impulse, may be heard. They are caused by an impact com-
municated to a cavity partially filled with fluid. Walsh describes a
case in which the suceussion splash was obtainable, as described under
pneumothorax.
AUXILIARY SIG-NS OF PHTHISIS.
Fever. The deposition of tubercles is accompanied by elevation
of temperature, hence fever is an early and characteristic sign. The-
maximum is between two and six P. M. Early fever is generally
remittent. Later both intermittent and remittent types occur.
Hectic, which is in reality septic fever, due to the absorption of tuber-
culous products, is a more or less regular rise and fall of temperature-
varying between wide ranges, rising to 102° — '104° and falling to sub-
normal, even 96° being not unusual. This type prevails in the soft-
ening and cavity formation stage.
Cough. This symptom has already been touched upon. At first
so slight that the patient will deny its existence, it often grows to be-
the most distressing and intolerable of the symptoms, causing the
patient to lose sleep or, as is sometimes the case, exciting intractable-
vomiting, thus contributing to the rapid emaciation of the afflicted.
Its early characteristic is hacking, unaccompanied by expectoration;
technically, unproductive. Then a glairy mucus is coughed up. If
the larynx is involved early the cough as well as the voice is husky..
154 PULMONARY TUBEECULQSIS OB CONSUMPTION
Spells of coughing followed by copious expectoration denote cavities
or bronchiectasis. Oftenest such paroxysms occur on waking. Some
cases progress to solidification or even to cavities with very little
cough.
Expectoration follows cough, although the cough may have re-
mained dry for a long period. At first scanty, it increases rapidly
and may be as much as 250 c. c. in twenty-four hours. Sometimes
distinct apical manifestations or extensive consolidation are accom-
panied with insufficient expectoration to alloW "of an examination. The
early expectoration is glairy, mucoid, containing sago-like grains, alve-
olar cells which have undergone myelin degeneration. (Thudichum.)
Presently grayish or greenish masses are observed and are the first
differential constituents of the sputum. They should be examined
microscopically. After this the expectoration becomes more muco-
purulent, may be blood-tinged. The nummular masses already
■described are of frequent occurrence, and are distinctive of cavity
formation. Each mass is separate, greenish or gray-green in color,
airless and sinks to the bottom of the cup when thrown into water.
The odor of the sputum is sweetish, mawkish, unpleasant but not
offensive. The sputum contains pus corpuscles, and epithelium from
the entire tract traversed by the air — the mouth to the alveoli. The
latter cells are most numerous. Blood discs, particles of food, oil
drops, elastic tissue fibers and bacilli are other constituents.
Elastic fibers are derived from the blood vessels, the bronchi, the
alveoli or from particles of ingested food. Rinsing the mouth before
collecting the sputa will obviate a mistake as to food tissue. It is to
be remembered that such tissue may be retained in the mouth for
several days. Boiling the picked-out masses with liquor potassa or
soda in a test tube allows the elastic tissue to fall to the bottom of the
tube, when it may be examined microscopically. Osier states that a
method quite as efficient is to spread the njasses into a thin layer
between two glass plates, which are then held against a black back-
ground. The elastic tissue shows against the background as opaque,
grayish-yellow spots, M'hich may be immediately examined by the low
power, or by sliding the glasses apart may be picked out for examina-
tion on a slide. He states that milk globules and fragments of bread
are similar in appearance, but that the eye soon learns to distinguish
these. Fibers from the alveolar walls are branched or wreath-like
interlacements and show the arrangement of the air-cells. Those from
PULMONARY TUBERCULOSIS OR CONSUMPTION 155
the bronchi are elongated fibers, two or three together and form
reticuli. Those from the artery may be sheet-like or fenestrated mem-
brane, as though it were the intima of a vessel. Generally they resem-
ble the fibers derived from the bronchi. Alveqlar fibers indicate exten-
sive erosion, softening and destruction. Epithelial cells from the
alveoli are also found. These are large, oval or round non-nucleated
■cells about twice the size of a pus corpuscle.
The tubercle bacilli are the unfailing sign of tuberculosis. They
.are made apparent only by special staining methods, and microscopic
■examination. The simplest method is perhaps the following: Shake
up commercial aniline oil in water until the solution is saturated.
Filter out 100 c. c. of this solution. Next add fuchsin to absolute
alcohol until the alcohol is saturated. Add 11 c. c. of the second
•solution to the 100 c. c. of the first, for the stain.
Pick out a small, cheesy-looking particle of sputum with a needle
.and spread on a cover-glass by rubbing against a second glass. Dry
these slowly by holding a foot above a Bunsen burner (or alcohol
flame). Cover the slide liberally with the staining fluid a,nd hold
near the flame until the fluid boils, after which it is washed in run-
ning water. It is now put in a 30 per cent, solution of nitric acid
until decolorized, when it is again washed, mounted and examined.
The bacilli are colored red and appear as elongated, slightly-
■curved, sometimes beaded rods. In doubtfjil cases the covers are
-allowed to remain twenty-four hours in the stain. The number varies
from a full field to one or two found only on repeated examination.
In disputed cases, where the symptoms are not confirmed by the
microscopic findings, it is recommended to make cultures from the
sputum. Directions therefor may be found in works on Bacteriology.
Hmmoptysis. By reason of the frequency with which it occurs
and the serious results which attend it hasmoptysis has a specially im-
portant relationship to pulmonary tuberculosis. Blood may simply
•occasionally tinge the expectoration or it may be present in the sputa
in considerable quantity. It occurs early and late in the disease and
is more frequent in males than in females. It may be the first
premonition of the invasion of the dread destroyer, or it may close
the drama. The onset of the attack may be sudden or a premonition
■of its oncoming may be gathered from the staining of the sputa which
often precedes it for two or three days. It may come on during
quiescence, after exercise, after a fall or a blow upon the chest. The
156 PULMONARY TUBERCULOSIS OR CONStjMPTION
idea that it follows sudden exertion, strain or excitement is not borne
out by clinical experience. In many eases it comes on during sleep.
In a proportion of the subjects both physical signs of the disease
and bacilli are absent. In another proportion bacilli are found subse-
quent to hemorrhage. In the third class, evidences of the disease are
positive and bacilli found in the expectoration confirm the signs.
Haemoptysis should, however, always excite a strong suspicion of
tubercle and the cases subsequently should be carefully watched.
Haemoptysis occurs in sixty or eighty per cent, of all eases of
pulmonary tuberculosis. The amount varies from a teaspoonful to a
pint, being smaller when it occurs early in the disease. Even large
haemorrhages are seldom immediately fatal. In character, blood from
the lungs is frothy, mixed with mucus, bright-red in color, unless it
has been retained in a cavity, when it is darker. After hasmorrhage
the sputa may contain dark masses of blood or may be blood-streaked
for several days. A careful examination of the hsemorrhagie mass
often reveals small raucous nodules in which bajcilli or elastic tissue
may be found.
The general symptoms accompanying the loss of blood are noted
under haemoptysis. Some of the special symptoms are the great dis-
turbance of mental balance and the febrile reaction, lasting from
several days to two weeks, which succeeds every considerable hgemor-
rhage. This is attributed to the foci of broncho-pneumonia arising
from the lung substance derived from the hemorrhagic cavity which
have been drawn into the pulmonary alveoli. The bleedings may be
widely separated from each other or may recur at frequent intervals.
Dyspricea is not increased in proportion to the acceleration of
respiration, and is not marked even when respirations are very fre-
quent. Dyspncea may be cardiac by reason of. enlargement of the
right heart.
Perspiration. Drenching perspirations are a common symptom.
These come on after cavity formation. They occur after the fever
drop which takes place towards morning, hence the familiar term
"night sweats" They may occur during the day. Sometimes they
occur in the early stages and are the cause of the pa.tient seeking
the doctor.
The pulse is soft and compressible, though quick and frequent.
Venous pulsation and capillary pulsation are often seen. With the
progress of the disease the pulse weakens. Vomiting, excited by
PULMONARY TUBERCULOSIS OB CONSUMPTION 157
coughing, is an unpleasant symptom coming on late in the disease.
Pain either is due to coughing, when it is located at the base of the
sternum, or it is due to pleurisy, when it is located over the lesion.
Diarrhoea is one of the late symptoms. When once established it
is apt to prove intractable.
The clubbing of the fingers, as noted by Hippocrates, comes with
the advance of the disease, but occurs also in chronic asthma, bron-
chitis, and more rarely in chronic cardiac diseases. It has been noted
in cases of aneurysm. The finger-tips become bulbous and the nails
curve over the finger tips. All of the fingers are not equally affected.
(See Clubbing.)
The Urine in Tuberculosis. The quantity of urine voided is influ-
enced by the diaphoresis, diarrhoea, pyrexia and even the quantity of
expectoration. Thirst, which accompanies the febrile stage, increases
the amount; the other conditions diminish it. It may be as little as
500 e. c. Uric acid and the sulphates change but little. Urea dimin-
ishes markedly during the daily febrile period, and increases in the
same proportion during the sweating period. It often settles down as
a pink sediment. Diarrhosa diminishes the urates here as in other
diarrhneal diseases, The amount of chlorides varies with the quantity
of food ingested and the incidental complications.
Ehrlich's diazo-reaction is sometimes obtainable. Its presence
may be regarded as unfavorable. It is apt to be found in cases which
are rapidly-progressing, and chronic cases which are nearing the end.
A trace of albumin is frequent, but casts, blood and epithelium are
exceptional. When present they indicate amyloid changes. If pus
occurs in the urine it should be examined for bacilli.
The method of obtaining the diazo-reaction is described in the
section on Urine.
State of the Blood in Pulmonary Tuberculosis. Cabot* makes
the following statements:
1. The red corpuscles are usually normal, but the hagmoglobin
is diminished. In some cases both are diminished.
2. The leucocytes do not change in character.
3. In the early stages of the disease the white corpuscles are
normal, after an attack of hffimoptysis they show an increase.
*Ycar-Book of Treatment, 1897.
158 PULMONARY TUBERCULOSIS OR CONSUMPTION
4. If cavities are present there is no leucocytosis. If the
leucocytes are increased, there are no cavities.
5. Pneumonic tuberculosis (extensive infiltration) may show
marked leucocytosis, not invariably.
6. Fibroid tuberculosis shows no leucocytosis.
7. Pyrexia, due to the presence of pyogenic organisms, shows
leucocyte increase. If not, there is no leucocytosis. If fever is absent
there is no leucocytosis.
In contradiction to the fourth statement, which would be most
important if confirmed, Stein and Erbmann state that one of the
conditions of leucocytosis in pulmonary tuberculosis is the presence
of cavities in the lungs, hence at present no definite conclusions can
be i-eached on this point.
SECTION IX.
THE HEART.
Physiology. The heart is a double-cylinder muscular pump. Be-
tween the two cylinders no communication exists after birth. One side-
serves for the low service or pulmonary circulation, the other for the-
high service or systemic circulation. Each pump consists of two cham-
bers, the receiving chamber or auricle, and the pumping chamber or
ventricle. As soon as the auricles are filled they contract, forcing the
blood into the ventricles, the contraction of which immediately follows.
After the ventricular contraction a period of rest succeeds.
The contraction of the cavities of the hea-rt is called the, cardiac
systole, the period of rest is called the diastole, the two periods make
up the cardiac cycle.
The systole of the corresponding cavities of the two aides of the
heart is exactly synchronous, that is to say, the two auricles contract
simultaneously; and the simultaneous contraction of the ventricles
immediately follows that of the auricles. While the auricles are con-
tracting the ventricles are in a state of relaxation, and the relaxation
of the auricles commences directly after the ventricular contraction
begins.
The rate of the heart beat depends upon the duration of the dias-
tolic pause, which lessens proportionally as the heart beats more
rapidly.
Anatomic Relations. Encased in the pericardial sac, suspended
apex downward from the great vessels, the he'art largely occupies the
middle mediastinum or interpleural space. It hangs obliquely behind-
thie lower two-thirds of the sternum, projecting slightly to the right
and considerably to the left of that bone.
That the heart is suspended by its vessels and not supported by
the diaphragm is proved by the fact that the diaphragm separates from
the heart during deep inspiration, as shown by the Rontgen rays.
Furthermore, the rays show that the heart chambers are not en^
160 THE HEART
tirely emptied at each systole, as \^'as formerly assumed by physiolo-
gists (Beck).
Behind, its base corresponds to the sixth, seventh and eighth
thoracic vertebrs, from which it is separated by the oesophagus and
the aorta. In front, the base corresponds to a line drawn across the
sternum at the lower border of the second costal cartilage, extending
one-half inch to the right and one inch to the left of the sternum. Its
lower border, made up of the right ventricle, is nearly horizontal. It
rests lightly on the central tendon of the diaphragm, which separates
it from the convex surface of the liver. The apex-, which possesses a
-certain freedom of motion, strikes the chest wall at a point between the
cartilages of the fifth and sixth ribs, at a point two inches below, one
inch to the sternal side of the nipple, which point is 314 to 3^/2 inches
from the midsternum in the fifth interspace. The right ventricle is
anterior and lies directly under the sternum. Its lower segment occu-
pies the fifth interspace, its lower border is on a level with the sixth
cartilage. The organ projects slightly to the right, but considerably to
the left of the breast bone.
The left ventricle lies chiefly behind the right, but its left border,
which includes the apex, comes to the front in systole. This border lies
wholly within the nipple line.
Perhaps DaCosta was the first to say that the heart of an individ-
ual is about the size of his fist. Eoughly speaking, the comparison is
fairly correct and useful. Cunningham gives the average weight of
the heart in adult males as eleven ounces (310 grams), in females nine
ounces (250 grams).
The Valves of the Heart. Each side of the heart is equipped with
two valves. One guards the opening between the two chambers, the
auricle and its corresponding ventricle, the other, placed within the
ventricle, closes the aperture of the great vessel which springs there-
from, viz : — the aorta on the left and the pulmonary artery on the right
side. Three of these valves are made up of three cusps, or leaflets,
each, while the remaining one consists of only two cusps. This latter,
named the mitral valve, closes the orifice between the left ventricle and
its auricle. To the free edges of its leaflets are attached the chordce
iendinece.
The corresponding opening on the right side, that between the
right ventricle and its auricle, is closed by the tricuspid valve, com-
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THE HEART 161
ptised of three leaflets as its name indicates. Its movements are also
limited by the chordaj tendine^.
The aortic and the pulmonary valves close each their respective
■openings. Each is composed of three cusps or concave pockets whose
edges are free. They are named respectively, the aorlic semilunar- and
the pulmonary semilunar valves.
The PrcBCordium. That portion of the thoracic wall which covers
the heart is called the precordial region. It is roughly quadrilateral,
and its boundaries are a vertical line drawn %ths of an inch to the
right of the sternum, another parallel thereto passing just out-
side the apex, two horizontal lines, the first drawn through the junc-
tion of the manubrium with the gladiolus of the sternum (second rib),
the second passing through the ensiform cartilage.
THE EXAMINATION OF THE" HEART.
The method adopted for the examination of the lungs applies
•equally to the heart, and the same order should be observed, namely,
the history of the ease should be follovred by inspection, palpation,
mensuration, percussion and auscultation.
History. Much diagnostic aid is derived from the history of the
case, since many symptoms point unmistakably to cardiac lesions. Es-
pecially the date of previous diseases, which may have stood in a causa-
tive relation, should be fixed and their nature .carefully inquired into.
When the condition of the patient admits the standing position is
the most advantageous for the examiner, who may himself either stand
or be seated on a rather high chair. He thus avoids the humming
noise arising from his own circulation, which is a fruitful source of
annoyance to the examiner when he is obliged to assume a stooping
posture.
Even bearing in mind the possibility of being accused of prolixity
we urge upon the student the desirability of taking advantage of every
reasonable opportunity to examine the normal heart with all the com-
pleteness of detail which would be used were the organ diseased.
While percussion and auscultation are relatively the most important
steps, the others are by no means to be neglected.
Inspection. We begin our inspection by noting the contour of
the chest wall. In health the two sides arc symmetrical or nearlj' so,
but this symmetry may be gravely altered by disease. Occasionally
we may detect a slight prominence or even protrusion over the seat of
162 THE HEAET
the heart in perfectly healthy persons, especially those who practise-
habitually great physical exertion. Hypertrophy, or the accumula-
tion of fluid within the pericardium, markedly emphasizes this prom-
inence. Pericardial inflammation may leave as a sequence a very
evident precordial depression. We note the condition of the circu-
lation, as manifested by the capillaries, the presence or absence of
oedema about the eyes or ankles as evinced by pitting, the presence
and character of the cough, the number and character of the respira-
tions and the amount of dyspnoea. One often notes a peculiar anx-
ious expression of the countenance accompanying certain heart lesions,
which is most impressive, and not without significance.
The most important particular of inspection is the location of
the apex. It is usually possible to recognize the apex beat by inspec-
tion, except in stout persons or in cases where the organ is retracted
from the chest wall. Sometimes its absence' is accounted for by its.
striking against a rib, instead of in an interspace. The impact is less
apparent in women than in men, even when "the mamma is retracted.
It is more pronounced in spare individuals ai^d in cases in which the
organ is hypertrophied.
The location of the impulse has been given already as lying be-
tween the fifth and sixth ribs at an average distance of three inches
to the left of the mesial line. In narrow-chested individuals it may
be lower and in children it is often an interspace higher. In case the
impulse is invisible it may be brought into view by causing the patient
to walk briskly a score of paces, by bending* him forward, or, if re-
cumbent, by turning him well towards his left; front.
Inspection should note not only the position of the apex beat, but
its area, whether it be diffused or concentrated and the regularity of
the succession. In health the area should not exceed one square inch.
The location of the impact changes only slightly in the different posi-
tions assumed by the patient, but is less pronoujiced when the person is
supine, and it moves slightly to the left when he lies on that side. It
is somewhat altered by distention of the stomach and by flatulence. It
is more influenced by breathing. During deiep inspiration the heart
descends, the forward movement of the expanding left lung pushes it
backwards and to the right, causing the apex to move towards the
epigastrium. During forced expiration the heart descends and ap-
proaches the chest wall, a larger portion of its anterior surface is un-
covered, the impact is more 'diffused and weightier ; hence expiration
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-Tig. 39 — Auscultation of normal heart- sounds. Relative length of normal heart
sounds drawn to a scale of i-io. Each division below the line represents
i-io second.
While the normal heart rate for adults is upwards of seventy
per minute, yet for convenience we may assume a rate of sixty beats
per minute, since this rate greatly facilitates the description. Then one
beat or complete heart cycle will occupy one second. If now we
divide the complete cycle occupying one second into tenths of a second,
the relative length of the factors which make up the cycle will be,
first sound, 4-lOths, short pause, 1-10, second sound, 2-lOths, long
pause, 3-lOths ; total, 10-lOths. This is indicated by the accompanying
simple diagram.
A — Ventricular systole.
B — Short pause.
C — Closure of aortic and pulmonary valves.
D — Ventricular diastole.
172 THE HEART
As said, the long pause or period of rest varies with the heart's:
rate. When the heart's pulsations follow each other with great rapid-
ity, the period of rest is reduced to the mininium, and when the
heart's action is slow the period of rest is lengthened and becomes
longer than the period of action. On the other hand, when beating
rapidly the long pause so lessens as to be shorter than the period of
action, hence the normal sounds of the heart may seemingly change
their relationship to one another, and, when the action becomes very
rapid, to the listener the first sound seems to follow the second sounds
since the interval betwen the second sound and the recurrent first
■lllllllll
Very Hapid Heart.
■Illlllll
Moderately Kapid.
■Illlllll
Slow Heart.
II II nil I
Very Slow.
Fig. 40 — Diagram illustrating the relationship in time of the first and second
heart sounds in different rhythms.
sound is now longer than the interval between the first sound and
the second; a state of aifairs which may be embarrassing to the
student.
In the slowly-acting heart the distinction is easy, since it is only
necessary to remember that the long silence follows the second sound,
but in cases of rapid, irregular action accompanied by a change in
the qualities of the two sounds which makes them resemble each other,
or when only the first sound is audible at the base and the second only
audible at the apex, the difficulty of separation is considerable.
The accompanying diagram may aid in comprehending the rela-
tionship.
PLATE IX.
The cardinal points of tiie valve areas. Points at which valve
sounds are best isolated?
THE HEART 173
POSITION OF THE VALVES OF THE HEART.
The valves are all located within such a narrow radius that a
.silver quarter may be so placed as to cover a jJtortion of each. Indeed,
the aortic and the pulmonary semi-lunar valves are separated from
each other only by the thickness of the aortic wall. The two auriculo-
ventricular valves and th|e aortic valve are in one plane, which forms
a diagonal of the thorax. As described in the various text-books,
much variation in the location of these valves' will be found to exist.
Most recent anatomical research as to their ejcact topographical posi-
tion locates them as follows : The pulmonary valve lies beneath the
third left costal cartilage, but close to its junction with the sternvim,
and is the most superficial as well as the highest up of all the valves.
"Were the position of the heart vertical the aortic valve would lie
almost exactly behind the pulmonary valve, but, viewed from in
front, the heart is the subject of a double tilt. The vertical axis
points from right to left and the anteroposterior axis points from
above downward. For this reason the aortic valve occupies a lower
level than the pulmonary valve, at the same time being deeper-
seated, lying behind the left edge of the sternum, opposite the upper
part of the third interspace.
The mitral valve, the most deeply placed of the four, lies beneath
the left half of the sternum, opposite its jutiction with the fourth
cartilage. The right auriculo-ventricular, or tricuspid valve, is more
superficial than either the mitral or the aortic valves; its aperture is
almost vertical, and it lies under the middle of the sternum, opposite
the fourth interspace. The upper, inner segrAent of its opening over-
laps the lower inner segment of the mitral orifice. It will be seen,
therefore, that all of the valves lie under the middle and left half of
the sternum, between the upper border of the third cartilage and a
short distance below the fourth.
ISOLATION OF THE VALVE SOUNDS.
It might strike the student as a difficult, if not an insurmount-
able, task to isolate the sounds arising from four structures so nearly
superimposed. Such, indeed, would be the ease were it not that the
points of isolation, the point at which each separate sound is best
heard, does not correspond to the surface area above given, nor even
to the superficial point nearest to the actual seat of the valve. This is
due to the fact that the sounds emanating from the valves, made by
174 THE HEART
the impinging of the blood current against their leaflets and from
their closure, is best propagated in the direction of the blood current;
hence the apparent discrepancy. The locality in which the mitral
sound is best heard is over the apex area. The tricuspid is best heard
close to the left border of the sternum, at the' fifth interspace, or over
the xiphoid cartilage. The aortic valve sound is loudest and clear-
est, and should therefore be listened to, on the right of the sternum in
the second interspace, where the aorta approaches closest to the chest
wall, for which reason the second right costal cartilage is named the
aortic cartilage. On the opposite side of the sternum (left), in the
same interspace, is best heard the pulmonary valve. This gives us
four cardinal points at which the four sourfds are best isolated, at
which their individual qualities are strongest and easiest to difEer-
entiate.
INFLUENCES "WHICH CAUSE ALTERATIONS IN NORMAL
SOUNDS.
Since inflation of the lungs increases the thickness of the heart
cover, diminishes its exposed area, as well as causes recession of the
organ, all the sounds are better heard during forced expiration. Ad-
vantage should therefore be taken of expiration to differentiate sounds
which are otherwise inaudible or only feebly heard. The normal
sounds of the heart are best heard with the patient sitting or stand-
ing, although its areas are best mapped out with the patient lying
on his back. But in case of suspected disease of the organ it is abso-
lutely essential to percuss and to auscultate the patient both while
standing and while lying down. The diagnosis may be materially in-
fluenced by this precaution, and doubtful cases may be removed to
the realm of certainty by the procedure. Thus, a murmur may en-
tirely disappear when the patient lies down, and reappear when he
rises. It may confidently be stated that such a murmur is not organic.
On the other hand, a murmur which is only audible when the patient
is in the recumbent posture is probably organic.
CONDITIONS WHICH AFFECT THE INTENSITY OP THE
SOUNDS.
The normal heart sounds are heard with greater intensity, as well
as over a larger area, in persons whose chest walls are thin ; also as the
result of excitement ; in cardiac hypertrophy ; during the sthenic stage
THE HEART ITS
of fevers; as the result of certain cardiac stim^^laIlts ; and as the result
of increased density of adjacent pulmonary tissue. As a result of the
last-named, they may be conducted to very djistant points. The full
significance of this sign is considered under the section on Phthisis.
Conversely, the heart sounds are rendered weaker even in health
by abnormal causes. Fear or fright so acts, as do debility, wasting
diseases, and the anaemias. Many drugs have the power to depress,
the heart, and careful inquiry should be made as to whether the
patient is addicted to drug habits. Diseases such as fatty degeneration
of the muscles ; mechanical causes interfering with cardiac action, — as
effusion into the sac of either the lung or the heart, — produce like
results. Not infrequently one encounters a heart whose sounds are
abnormally weak and inaudible without any assignable cause, the
subjects being generally women.
Except in eases of cardiac hypertrophy, or when consolidation of
tissue has taken place, the extent of the area over which the sounds,
are audible has no special significance. Full inspiration obscures
certain of the sounds. This is particularly true of the pulmonary
valve sound heard on the left side in the second interspace. Likewise
during full inspiration the aortic sound is lightened in intensity. The
apex seund is now best heard nearer the median line, as the apex is.
moved in that direction by the lung expansion. Nervous excitement
and exercise temporarily increase the intensity of both the heart's
action and its sounds. Such action is named palpitation. Advantage
may be taken of exercise to temporarily intensify the sounds when
auscultating a heart whose action is feeble. Softening of the walls
diminishes the intensity of both the sounds, particularly the first. This
is observed in many acute febrile and infectious diseases, and in the
degenerations. Thickening of the walls changes the (Quality of the
tone, especially of the first sound, lengthening it and rendering it-
more heavy and booming, thus lowering the pitch of its note. This is.
the result of hypertrophy, however brought about.
The quality of the second sound is more constant, and changes
materially only in disease of the valves or in grave alterations in the
composition of the blood. Increased back pressure on the 'valves
causes a forcible, snap-like closure, which augments the second sound'
both in clearness and intensity. This is especially the case with the
pulmonary second sound, and ija lung consolidation is an important-
176 THE HEART
sign of beginning of pulmonary infiltration. Anfeurysm of the aorta
will cause accentuation of the second sound of that valve.
In case of fluid in the pericardial sac both sounds seem to come
from a distance and to have a feeble, muffled character. Other changes
worthy of notice are the reduplication of one or the other sound and
the lengthening or shortening of either interval, t|ie long or the short,
between the sounds.
Be duplication. Generally it is the second sound which is re-
peated. This curious phenomenon can be explained only on the
hypothesis that the corresponding valves, the aortic and the pul-
monary on the one hand, and the mitral and tbe tricuspid on the
other, fail to close synchronously; or else on the assumption that the
two allied chambers of the heart fail to contract in unison. Such a
theory as the first is very plausible and could be btrought about by any
relatively important change in the blood pressurg of the two circula-
tions, the pulmonary and the systemic. Prom the nature of the case,
the former more often will be at fault, and pulmonary engorgement by
increasing the back pressure on the doors of the pulmonary artery will
cause that valve to anticipate slightly its time of closure, and, indeed,
such reduplication often occurs after running, as is seen in sprinters.
In the same way narrowing of the blood channels, the effect of sclerosis
of large organs, particularly the liver or the kidneys, would produce
.similar results on the aortic valve.
Retardation in the closure of the tricuspid valve causes redupli-
cation of the first sound.
Reduplications are sometimes intermittent, sometimes rhythmical,
that is, they skip a certain number of beats, recur at stated intervals,
skip and recur almost melodiously.
Shortening of the silent intervals in relation to pulse rapidity has
already been referred to.
ADVENTITIOUS SOUNDS..
The normal sounds of the heart may be replaced by or be inter-
mingled with other sounds adventitious in their nature, totally differ-
ent in quality from the normal sounds. The recognition of these
sounds and the correct interpretation of their relation to the heart's
mechanism, are of prime importance in the diagnosis of the many
.ailments to which the structure is liable. These new sounds are classi-
fied as pericardial or endoca/rdial.
CAVITY ?•=
RIGHT
LEFT Vf.NTRlCLt
PLATE X.
THE TRICUSPID AND PULMONARY VALVES.
From Cunningham's Anatomy
by permission of Wm. Wood & Co.
THE HEART , 177
Those sounds which are due to alterations in the structure or
changes in the condition of the adjacent layers of the pericardial sac,
namely, the visceral and the parietal layers, are termed exocardial
or pericardial murmurs. Such' changes are usually the result of in-
flammation, but may be caused by external pressure. From their
character they are called friction sounds. The manner of their pro-
duction will be considered hereafter.
Those sounds that originate from changes occurring within the
■organ, which are essentially changes aifecting those reduplications of
its serous lining which form the valves, are classified as endocardial.
In contradistinction to the friction sounds they are termed murmurs.
Endocardial murmurs vary extremely in character, pitch, tone,
duration, location, time, and in the distance and direction in which
they are transmitted. They often receive their names from a fancied
resemblance to some sound in nature; hence, we read of blowing,
•cooing, rustling, clacking, rasping, grating or filing murmurs. Such
terms are useful since they generally roughly indicate the pitch. The
majority of murmurs are soft and blowing, yet occasionally they are
so harsh and noisy as to be audible to the bystanders.
CAUSES WHICH PRODUCE MURMURS.
As to the exact physical or mechanical causes which operate to
produce the above-described sounds we have no positive knowledge,
but a plausible theory may be formed by reasoning from existing
pathologic conditions. We know that murmurs accompany grave
•changes in the composition of the blood without any recognizable
structural alterations of the heart, the valves, or the vessels. Such
murmurs are called hcemic murmurs, and are described as functional
•or accidental. They are associated with most of the grave ansemias,
but occur in other diseases as well. By sonje writers the term inor-
ganic murmurs is applied to sounds so arising; both this term and the
name nonorganic are objectionable in this sense.
On the other hand, murmurs are associated with certain path-
ologic alterations of structure which can stand only in a causative
relation thereto. Enumerated they are:
(a.) Narrowing of the orifices through which the blood finds exit.
(b.) Widening oif the orifices.
(c.) Narrowing or widening of the bloodvessels or lieart chambers.
(Changes under a. and b. are in effect changes in the valves, such
178 THE HEAKT
as roughening, thickening, or puckering; of the leaflets, — deformities
resulting from sclerosis. Inflammatory deposits or vegetations result
in perforations or contractions of the leaflets.)
(d.) Imperfect opening or closure of the valves due to causes
mentioned and to shortening of the chordJce tendinece.
It were profitless to discuss the laws of hydraulics and hydro-
statics which might seem to apply. Suffice it to say that the noises
are produced by the vibrations set up in both liquids and solids by
the circulation of the blood over the altered structures. It is also
conceivable that blood alterations may' influence these murmurs,
especially by increasing or diminishing their intensity.
■ Organic murmurs may be produced at any of the four valves of
the heart, but by far the most common' valve to be affected is the
mitral; next in order of frequency is the aortic, then the tricuspid,
with the pulmonary a bad fourth. The aortic and mitral valves
together are affected four-fifths as often as the aortic valve alone.
RESULTS OF VALVULAR IMPAIEMENT.
Inability of a valve to close so as to render itself "water-tight" is
called insufficiency, and the return flow of blood through the orifice is
called regurgitation. The causes have bfeen enumerated. It is, how-
ever, well established that the phenomenon of regurgitation may
occur during excited and violent-acting states of the heart, when both
valve and muscle are perfectly healthy. Such inefficiency can be
explained only as a temporary expansion of the valvular ring or by
imperfect closure, just as other automatic acts are disturbed by over-
stimulation. So, also, altered states of the blood may be accompanied
by all the audible signs of regurgitation without organic change being
present. No doubt in many of these cases the insufficiency is actually
present, only to pass away with the improvement in the general
condition.
Contraction, puckering or thickening of the valve leaflets, or
deposits upon their surface, shortening and thickening of the chordce
tendinea, and deposits into the valvular fibrous ring, operate to pro-
duce such a narrowing of the valve opening as to interfere with the
outflow of the blood. Such interference is called valvular stenosis.
The aortic and the left auriculo-ventricular • orifices are of tenest
affected.
THE HEAKT
ITS'
TIME OF CARDIAC MUEl'IURS.
Having considered the physiologic action of the heart and the
mechanism of the murmurs we are prepared to discuss the relation-
ship of the latter to the former in point of time; in other words, to
fix the rhythm of the murmur as regards those acts which constitute
the complete heart cycle, viz., the systole, the' diastole and the period
of rest.
A murmur which accompanies only a single act of the heart, the
filling or emptying of a chamber, the opening or closure of a valve.
a
R
R
A PRESYSTOLIC MURMUR
R
R
R
R
R
A SYSTOLIC MURMUR
r
E
A DIASTOLIC KIURMUR.
Fig. 41 — Diagram illustrating the single or simple murmurs.
is classified as a simple or single murmur. Murmurs which arise in
connection with two of these acts, constituting a union of the simple
murmurs, are called compound miirmurs. Compound murmurs aris-
ing at one orifice or valve are called double murmurs, when originating
at different orifices they are called combined or associated murmurs.
Every simple valvular murmur has one of three relations to the
sounds of the heart, on6 of three places in the cardiac cycle.
First, the murmur may be synchronous with the contraction of
the auricles, in which ease it is auriculo-sysiolic. In time such a
murmur precedes the first sound, running up to that sound but ending
180 THE HEART
at the moment of its production. The relation which any murmui*
bears to systoie or diastole may best be asceftained by placing the
stethoscope over the seat of the murmur, and, while the tip of the
tlnger records each systole, the attentive ear consigns the murmur to
its proper period in the heart cycle.
Second, the murmur may be synchronous with the contraction
of the ventricles, in which case it is veniricular-systolic. In point of
time such a murmur follows the first sound of the heart and ends
somewhere between the first and the second sound. Sometimes the
inurmur is so prolonged as to almost touch the second sound. It is
quite apparent that in this case the murmur may actually begin with .
the beginning of systole, but will not be apparent until the cessation
of the true systolic sound, hence will follow immediately upon that
sound as though it were a prolongation of systole.
Third, the murmur may be synchronous with the dilatation of the
ventricles, in which case it is ventricular-diasthlic. In point of tirhe
such a murmur follows the secoitd, sound and ends during the interval
betwen'the second sound and the recurrence of the first sound.
Briefly recapitulated the simple murmurS: are, therefore, presys-
tolic, systolic, or diastolic in relation to the functions of the heart.
In accordance with the simple scheme adopted for representation
of the heart sounds we may, by a slight modification, represent also
the simple endocardial murmurs and their relations to the normal
sounds :
Various combinations of the simple murmurs, constituting the
(Compound or double murmurs, are not of rare occurrence, and greatly
increase the perplexity of correctly timing them. They are illustrated
in Diagram.
The most common of these associated or combined conditions, as
we shall see, is the co-existence of a ventricular-systolic and a ven-
itricular-diastolic murmur; then, of an auricular-systolic ■ with a ven-
tricular systolic murmur. In certain cases of long standing, in which
two or more valves are affected, four or even six murmurs might
possibly be present in the same heart.
LOCATION OF CARDIAC MURMURS. VALVULAR AREAS.
The point of origin of a murmur, the direction and the limit of
its diffusion, are pretty constant quantities, and clinical experience
combined with post-mortem confirmation have established certain fields
THE HEART
181
which are called the areas of the murmurs. The location or seat of
the murmur is determined by finding its point of greatest intensity;
by mapping out the field over which the sound is audible, the direction
and extent of its transmission, in conjunction with the associated
symptoms. Even when all these elements &re weighed there is a
possibility of error, and experience rather thkn precept must teach
the student that the presence of an adventitiotis sound does not neces-
sarily mean organic disease,^ nor does its .absence indicate freedom
from such a malady.
We examine successively the four cardinal points already named,
at which normally the four valve-sounds attain their maximum in-
WW
AS ■+ VS
AS +Vi
AS +VS+V D
a
£
V6 + VO
■lllpilJl
r
Fig. 42 — The combined murmurs. AS Auricular systole. VS Ventricular sys-
tole. VD Ventricular diastole.
tensity (see plate) . If a murmur is clearest aftd most distinctly heard
at the apex, it is strong presumptive evidence that it concerns the
mitral valve and the left ventricle. The mitml area is a small circle
surrounding the apex of the left ventricle, as ilhistrated in the accom-
panying plate. Its location, therefore, changes with changes in the
position of the apex, and enlarges with enlargement of the ventricle ;
hence the necessity of accurately locating the apical point. Mitral
murmurs are more generally propagated to the left than to the right
of the apex. Especially is this true of regurgitant murmurs. The
obstructive mitral murmur is apt to keep within bounds, and its point
of greatest intensity corresponds pretty acci\rately with the center
flf our circle — that is, it is a little to the right of the apex point.
182 THE HEART
A corresponding circle on the back, of which the inferior angle
of the left scapula is the center, will often enclose a field in which are
distinctly heard the mitral murmurs, especially in emaciated persons,
and this field should not be overlooked. This is admirably shown in
the photograph of the patient with mitral insufficiency, on page 209,
in which case the murmur was transmitted directly to the area shown,
without following around the axillary space.
Both DaCosta and Naunyn draw attention to the fact that some
mitral murmurs have their seat of greatest intensity, not in the above
area, but in the second or third interspace, an inch-and-a-half or two
inches outside the left border of the sternum,'^that is, just beyond
the pulmonary area, for lesions of which valve they might possibly be
mistaken. The murmurs thus centering are usually regurgitant, and
the explanation lies in the fact that at the point indicated the auricle
is most superficial, and that it crops out still further when dilated by
the regurgitated fluid. Some of the murmurs assigned incorrectly to
the pulmonary valve, are, according to Balfour, in reality mitral mur-
murs so caused. While the center of intensity is higher up in these
cases than the usual mitral center, yet this should not deceive the
cautious observer. Their area is outside the pulmonary area, and they
are heard, but with less distinctness, in the mitral circle.
Tricuspid Area. If the murmur is best heard over or at the left
margin of the ensiform cartilage where the right ventricle is exposed,
it is highly probable that it emanates therefrom, and that the tricuspid
valve is the malefactor. In case of considerable dilatation or hyper-
trophy of the right ventricle the valve moves towards the left, and the
sound is heard along the sixth interspace, (sixth and seventh ribs)
to the left of the sternum.
The tricuspid area is triangular in shape, larger in its bounds
than the preceding area, since it lies more to the front. Its limitations
are a line crossing the sternum from the lo\^er border of the fifth
right costal cartilage to the upper border of tie third left cartilage,
thence downward to the center of the mitral area above described,
thence across the ensiform cartilage to the point of beginning. The
diagram gives a clearer idea of the area than can be given by descrip-
tion. The left boundary coincides with the left interventricular
cardiac groove.
Pulmonary Area. If a lesion of the pulmonary valve exists the
auditory area is limited to a small circle over the origin of that artery
THE HEART 183
in the second and upper third left interspaces. The inner border of
the circle touches the left edge of the sternuira. These murmurs are
superficial, hence distinct. The sound disappears when searched for
across the right sternal border, but may be indistinctly transmitted
upward toward the left sterno-elavicular articulation. It is not con-
ducted into the great vessels of the neck, nor is it audible in the apex
area. These limitations serve to separate it from both mitral and
aortic murmurs. Organic pulmonary murmurs never arise in inter-
current diseases, although functional murmui-s are often credited to
this role.
Aortic Area. If the region in which centers the intensity of the
adventitious sound be the upper sternal, especially if the region lie
to the right of the bone, the murmur in all probability arises from
3. defective aortic valve. These murmurs are- heard with little varia-
tion of their intensity beneath the manubrium,: and on both sides of the
sternum, in the third left and in the second right interspaces, which
latter is just below the aortic cartilage, at which point aortic murmurs
.attain their maximum intensity, as a rule ; but owing to the position
of the aorta and the direction of its current they are audible, ofttimes,
the entire length of the breast-bone, and in cases of regurgitation the
center of intensity is not infrequently over the ensiform cartilage,
-and even extends over to the mitral area.
Aortic obstructive murmurs are transmitted into the vessels of
the neck with considerable clearness and intensity, which fact distin-
guishes them easily from all other murmurs. Even regurgitant aortic
murmurs may be heard faintly in the cervical vessels. The obstructive
murmur is sometimes heard in the course of= the great vessels- down
the spine and even in the extremities. The diagram shows the area
■of these murmurs as it appears on the anterior aspect of the chest.
MITRAL MURMURS:
When during the long cardiac pause the" blood returns from the
lungs to the left auricle, the inflow causes that chamber to dilate
(auricular diastole). As soon as this auricle is filled, the chamber
contracts, (auricular systole) and forces the blood through the _left
auriculo-ventricular orifice into the left ventricle. If now the mitral
valve has been affected by disease in one of the ways set down, so that
the orifice is narrowed and the flow obstructed, the current no longer
passes, silently and swiftly, through the gateway to its ventricle.
184 THE HEART
The obstruction causes the emptying process to be impeded and there-
fore prolonged, and the passage of the blood is accompanied by a
murmur, which has its greatest intensity in the apex region and which,
in point of time, occurs during the auricular systole, that is, before
the apex impact. Such a murmur denotes mitral stenosis, and is so
named. It begins when auricular systole begins and, ends with or
before the completion of that act. It occurs while the blood is being
expelled from the auricle and while the ventricle is still passive, but
it frequently results in a prolongation of the auricular contraction.
Being produced by the blood flowing in its natural direction it is
spoken of as a direct murmur, in contradistinction to murmurs arising
when the blood flow is in a direction contrary to its natural course,
such murmurs being named indirect murmurs. Special attention is
directed to the fact that this murmur may be distinctly audible only
when the patient is lying down, disappearing, when he sits or stands.
Although this murmur occurs during ventricular diastole, it is not
to be understood that it is audible during the entire period of the
ventricular dilatation, although blood is flowing passively into the
cavity during the whole of that act. Ventricular diastole closes with
auricular systole, and the added impetus given to the current by this,
contraction of the auricle may be necessary to. impart sufficient force
to the stream to produce the murmur. The auricular contraction ia
inaudible, but is immediately followed by the ventricular contraction,
which produces the first sound of the heart.; Since the murmur is
generated immediately before this latter contraction or systole, it is
called presystolic, which distinguishes it from those murmurs whose
duration is that of the entire diastolic period. The special point re-
garding its tempo is that it is not heard immediately after the second
sound of the heart, but immediately before the. first sound.
With or without encountering obstacles in its path the blood from
the left auricle now reaches and distends the left ventricle (ventric-
ular diastole), whose contraction immediately- succeeds its distention
(ventricular systole). In the healthy heart the only escape for the
current imprisoned by the closure of the mitral gate is through the
open aortic valve. If, however, disease has wrought changes which
inhibit the perfect closure of the mitral leaflets, when the blood surges
against them during the ventricular contraction they will not suffice-
to stop its flow, but will permit a portion, of the fluid to pass back-
wards and re-enter the left auricle. This back-flow is further aided hy
PLATE XI.
THE VALVULAR AREAS.
Red Circle, Mitral Area.
Triangle, Tricuspid Area. P- P^l-^nary Area.
The Aortic Area in black dots.
THE HEART
185
the slight negative pressure existing in the auricle during that period
of the cardiac cycle. The valve permitting this return flow just
described is said to be incompetent, or insiifficient , and the reverse
current is called regurgitation. In this case it is mitral regurgitation.
This phenomenon is indicated also by an aeeom'panying murmur, which^
in its beginning, is synchronous with ventricular systole, — that is to
say, the apex impact and the carotid pulse, and accords with the first
sound of the heart; or it immediately succeeds that sound and pro-
longs it, ending between the first and second heart sounds. It is
the most common of the valvular defects. The preceding murmur may
exist as an independent entity, but is more -often associated with the
present one.
TRICUSPID MURMURS.
The right ventricle acts in unison with the left, its systole and
diastole are at one with its fellow. The tricuspid valve bears the same
physiologic relation to the right heart that the mitral valve does tO'
the left. Except for the number of its leaflets, its anatomic construc-
tion is similar, that is, the edges are joined to the delicate chordee
tendineaj which limit its motions; hence it is subject to the same ail-
ments as its fellows, but for some unknown cause is less often visited
by these afflictions. The tempo of the mui'murs which arise in con-
nection with disorders of this valve will coincide in all respects with
those of the mitral. Hence tricuspid stenosis will be presystolic
(auricular-systolic), and tricuspid insufficiency will be accompanied by
a regurgutation which takes place during' ritiht ventricular sys-
tole (v. s.)
Tricuspid regurgitation seldom exists as an independent disease,,
except as the result of a congenital defect. It is prone to be one of
the later complications of mitral disease.
The stenosis is still rarer than the incon\petency.
Tricuspid murmurs are quite distinct find superficial, almost
never heard higher than the third rib, hence are not easily overlooked,
nor are they apt to be misinterpreted.
AORTIC VALVE MURMURS.
The outflow of blood through the aortic semilunar or sigmoid
valve takes place during the systole of the ventricles. Alterations,
occurring at this orifice of such a nature as; to offer an impediment
to the outward current, such as narrowing of the passage, give rise
186 THE HEART
■to a murmur which is synchronous with the apex beat and follows
the first sound of the heart as a prolongation of that sound. The
murmur will then be' ventricular-systolic (v. %), and the character of
the obstruction will be stenosis.
If, by reason of enlargement of the aortic ring or owing to defects
already expounded, the valves are unable to prevent the reflux of the
current which closes them back into the ventricular chamber, then
this backward flow or regurgitation of blood will also engender a
murmur which succeeds immediately upon tjie ineffectual closure of
the valves, that is to say during the period of diastole of the ven-
tricles (v. d.) The murmur so produced is usualy a long-drawn,
soft souffle which, as an index of disease, is the most trustworthy of
all the adventitious heart sounds.' Such a^ sound may replace or
obscure the second aortic heart sound, since in some cases the stiffened
segments majje little or no efforts at closure; and the backward flow
begins with the beginning of diastole.
A consideration of what is taking place
The mechanism of the disease is as follows :
210
DISEASES OF THE HEART
The insufficient semilunar valves permit a portion of the blood
pumped into the aorta to regurgitate into the left ventricle. The
regurgitation occurring at the time when that chamber is filling from
its auricle, the effect of the double supply of blood, is to cause dilata-
tion of the ventricle, which is ultimately followed by its hypertrophy.
As the two processes act continuously the necessity for ever-increasing
Fig. S5 — Mitral systolic murmur — seat of greatest intensity and direction of
propagation with diminishing intensity.
hypertrophy is manifest. The muscular endowment of the ventricle
walls allows it to attain a degree of hypertrophy which surpasses that
possible in the case of any other portion of the heart. Cases have been
recorded in which a heart weight of forty-eight ounces was reached.
As long as the two processes go on harmoniously equilibrium is main-
tained ; no eyil results follow, and the discovery of the condition may
be accidental.
PLATE XIV.
Aortic Diastolic Murmur, seat of greatest intensity and direction of
propagation. AP. Position of Apex,
DISEASES OF THE HEART
211
The difficulty experienced by the left auricle in ridding itself
of its contents, owing to the raised pressure in the ventricalar chamber^
causes it to dilate and then to hypertrophy, and to increase the length
of its systole. The raised pressure within thd veins of the lungs thus-
produced must be counter-balanced by increased pump-work on the'
part of the right ventricle, hence inevitably, after a longer or shorter
time, the right heart shows secondary dilatation and hypertrophy, in
which the dilatation is finally paramount. The student will under-
stand that pathologic results are not always ea'sily distinguished from
Fig. s6 — Pulse of aortic regurgitation. Apex acute. The height to which the
lever rises is materially influenced by the amount of pressure made upon
the button. D Aortic valve closure. Dicrotic notch marked. Predicrotic
notch absent.
causes, and that the mechanism and order of sequence above given may
be diversified on quite as reasonable grounds as those here assumed..
PHYSICAL SIGNS.
Inspection. The apex is seen in the sixth or seventh interspace,,
as far to the left as the anterior axillary line. The impulse is dif-
fused and undulatory during the dilatation period, wide and forcible
during hypertrophy. Bulging is seen in children; the entire pra-
eordia is raised. Occasionally during systole there is a depression of
the prfficordia between the sternum and the nipple, due to atmospheric
pressure.
Palpation. The character of the impact is wavy and undulatory,
or strong and heaving.
Percussion. The area of dullness is enormous in advanced cases,,
attaining here its greatest limits. The transverse area extends to the
left beyond the anterior axillary line and downward as far as the
seventh interspace.
Auscultation. A murmur is heard with maximum intensity in
the second right interspace (aortic cartilage). It is transmitted down-
212 DISEASES OP THE HEAET
ward along both borders of the sternum towards the apex and the
ensiform cartilage.
Since it is produced by the reflux of blood during the filling of
the ventricle the murmur occurs during diastole, and therefore re-
places the second sound of the heart, or is intermingled therewith
in cases where the leaflets are still capable of closure. In these cases
both the murmur and the valve-sound may be distinct. The quality of
the murmur varies greatly. Oftenest it is a long, soft, souffle, but
may be harsh and rasping. Osier says it is the most trustworthy of all
cardiac murmurs. We think it is not more indicative than the pre-
systolic mitral thrill.
Associated Murmurs. In many cases of aortic incompetency the
arch of the aorta has become roughened by atheromatous deposits.
This roughening gives rise to a systolic murmur which is present in
about one-third of all cases. The roughened semilunar valve segments
also are wont to originate a murmur by the passage of out-bound blood
over their surfaces. The presence of these murmurs is often inter-
preted to mean aortic stenosis, although only a small proportion of the
cases show any real narrowing of the aortic orifice. Both sounds are
systolic and may be heard beyond the aortic area. In most cases of
aortic incompetency the ventricular dilatation and hypertrophy en-
large the mitral ring, causing relative insufficiency of its valves, giving
rise to the systolic murmur of mitral incompetency. That this mur-
mur arises at the mitral valve and is not a conducted miirmur is shown
by the fact that its quality is often materially different from the
systolic murmur just described as arising from the aortic valve. This
.aortic murmur is rough, high-pitched; the mitral soft and blowing.
Flint Murmur. Yet another murmur is heard in the mitral or
:apical area, but is less common than the systolic bruit. This second
jnurrtiur is known from its describer as the Flint murmur. Its quality
IS rumbling, its area limited and its time presystolic or diastolic.
Whether it is due to the inflowing blood from the left auricle, or to
the reflux current from the aorta producing: vibration of the mitral
leaflets, is uncertain. Flint believed that the dilatation of the ven-
tricle prevented the mitral leaflets from folding completely backwards
against the chamber walls and, thus acting as an impediment, produced
the bruit.
The pulse is described elsewhere. The delayed radial pulse which
follows the apex beat after a distinct interval is characteristic, and the
DISEASES OF THE HEABt
213
length of the interval increases with the increase of the incompetency.
In the carotids, especially the right, the systolic murmur may be quite
as apparent as at the cartilage, and the second aortic sound may be
u
(>^>w ^
Fig- 57— Enlargement of the heart in aortic regurgitation (Patton). A Area
of greatest intensity of murmur, somewhat depressed. B Direction of
transmission of murmur.
perfectly distinct here, even when absent ovefthe valve. Broadbent
considers this a favorable sign, indicating that the amount of regurgi-
tation is small.
214 DISEASES OP THE HEABT
titer Symptoms. Cardiac palpitation, distress and faintness on
sudden exertion or rising, are very early features, due to arterial
anfemia. Pain and even angina are frequent. Headaches, dizziness
and attacks of syncope from disturbed cerebral circulation are not
uncommon and likewise may be early manifestations.
Nocturnal dyspncsa and oedema of the ankles and under the eyes
indicate failing compensation. The patient sleeps at first with the
head elevated, then in a chair, lastly at a table. The sleep is fitful
and disturbed by a sense of impending suffocation. General dropsy is
not a terminal complication unless mitral disease is associated. Endo-
carditis, emboli, paralysis and hematuria may each play its part.
It is in aortic incompetency that sudden death frequently occurs,
due in many cases to sudden over-distention of the left ventricle. In
others, the case progresses through the stages of venous congestion and
pulmonary engorgement to general dissolutien.
AORTIC STENOSIS:
Pure aortic stenosis is the least frequent of the valvidar affections
of the left side of the heart. In almost every case of stenosis there is
some incompetency. The majority of the cases are found in old men,
associated with extensive atheromatous changes of the arteries, and the
older the subject the greater the likelihood of there being calcareous
deposits within the aortic ring. Uncombiiied aortic stenosis is the
least dangerous of the various forms of valvular disease.
The first effect of the stenosis is hypertrophy of the left venti'icle.
Since there is no over-filling or backward flow in this lesion, simply a
demand for increased power of propulsion, the hypertrophy comes
about with little or no dilatation. The cavity walls thicken enor-
mously without enlargement of the chamber. As long as compensa-
tion is perfect the change is confined to the left ventricle. With failure
of compensation dilatation occurs, then its auricle suffers and involves
the right heart in the same order as was involved the left. With the
left ventricular dilatation comes enlargement of the mitral ring, and
relative incompetency of that valve.
InspecMon. Even when considerable hypertrophy is present the
apex impulse may be invisible, or if visible, may be feel^le. More
often, however, it is slow, forceful and heaving. It is displaced down-
ward and outward into the sixth or seventh interspace.
In old men considerable emphysema of the lungs is present and
DISEASES OF THE HEAi^T
215
serves to obscure the impact as well as to diminish the area of dullness.
Palpation. The impulse may be impalpable and feeble, or force-
ful owing to causes given. The chief diagnostic symptom is the pres-
ence of a well-marked thrill felt over the base of the heart, and cen-
tering over the aortic region. It occurs with systole and may be of
great intensity. In some cases it may be felt with diminished inten-
sity over the apex. (Anders.)
Fig. 58 — Mitral presystolic murmur, arsa and direction.
Percussion. The area of dullness is increased transversely, b\it
never to the extent found in aortic insufficiency. Usually the area
as marked out by percussion falls much within the true cardiac
boundaries, owing to the masking of the dulljiess by the emphysema.
AuscuUation. A_harsh, loud, prolonged murmur is heard, syn-
chronous with each systole. Its point of greatest intensity is either the
second right or the second left interspace close to the sternum. The
second sound is obscured or more generally absent, since the lesion so
216
DISEASES OF THE HEART
thickens and stiffens the valve leaflets as to prevent their closure. As
the ventricle loses power with dilatation, the murmur softens in tone
and late in the disease may disappear.
Associated leakage and roughening are manifested by the some-
times present diastolic murmur causing a see-saw sound. Although
the conditions necessary for the production of this see-saw murmur
are very frequently present, yet it is so often masked by the systolic
thrill that it is inaudible. The systolic thrill is propagated into the
great vessels. When mitral incompetency supervenes, it is indicated
by a murmur, also systolic, sometimes musical, which is heard at the
apex. Tricuspid involvement manifests itself in the usual way.
The pulse is the pulsus tardus; small, well-maintained in tension
but slower than normal. The accompanying tracing shows its
character.
Pulse curve of aortic stenosis — note absence of aortic notch.
Curve of mitral stenosis.
Fig. 59-
Diagnosis. These findings point to aortic stenosis : —
A rough, loud, musical systolic murmur of maximum intensity at
the aortic cartilage.
A thrill felt at the base.
Signs of hypertrophy of the left ventricle.
The pulsus tardus.
The mistakes are due to anemic murmurs which are much softer,
more apt to be found in the young, often intermittent, unaccompanied
by thrill, and disappear under treatment.- In ansemias, the second
aortic sound is accentuated.
Bright 's disease produces cardiac enlargement with which arterio-
sclerosis is commonly associated, but the urinary symptoms point to
the disease, and in the aortic calcification of this condition the second
sound is not absent, as it is in stenosis.
Other Symptoms. Cerebral anemia during the failing stage
brings on attacks of syncope or dizziness, often of the most distressing
PLATE XV.
Aortic Stenosis. Seat of Greatest Intensity. T, Tlirill. Ttiis Murmur
may be Audible all over the Chest and in the Great Vessels.
DISEASES OP THE HEART
217
character. In a case under observation the dizziness is centripetal,
that is the patient always describes an ambulatory circle to the right
and falls towards its center.
General oedema and dropsy are rare. CBdema of the feet occurs.
The other symptoms are due to associated lesions.
AORTIC STENOSIS AND INSUFFICIBNCT.
As stated by Broadbent, there are few if any cases of aortic
stenosis without some insufficiency and the double aortic lesion is by
many writers ranked next in frequency to mitral incompetency, hence
a double aortic lesion is more frequent thai a single one. Hyper-
trophy of the left ventricle reaches the same mammoth proportions
as in the single lesion and the vascular phenomena are little modified.
Mitral disease. Compensation fairly well maintained. Inequality of force of
successive beats shown — insufficiency slight.
Combined aortic and mitral disease, hypertrophy marked, pulsus alternans.
Fig. 60.
The double aortic lesion is evinced by a double murmur, systolic
and diastolic, best heard over the base, on both sides of the sternum,
and named, from its striking similarity to the sound of that vessel
when afar off, the steam-tug murmur.
The combination of aortic stenosis and mitral insufficiency gives
rise to synchronous systolic murmurs, one qentering in the apical
region, conducted across the axillary space toward the scapular angle,
the other best heard at the aortic cartilage, conducted into the vessels
of the neck.
TRICUSPID REGURGITATION.
The causes may be grouped under three heads :
I. Inflammatory. Acute or chronic endocarditis with resulting
218 DISEASES OF THE HEART
deformity — occasional. Foetal endocarditis is more prone to attack the
right than the left side. According to Eauchfuss endocarditis is more
common on the right side of the foetal heart only because the valves
are there most often the seat of developmental errors.
II. Valvular lesions of the left heart producing relative insuffi-
ciency by the ensuing obstruction to the pulmonary circulation — more
common.
III. Obstruction to the pulmonary circulation occasioned by
cirrhosis, fibroid phthisis, emphysema and chronic bronchitis — most
frequent.
The ventricle first hypertrophies and then dilates. The blood is
projected into the right auricle and thence into the veins of the neck.
The strength of the venous pulsation indicates the force of the regurgi-
tation. When the dilatation and insufficiency are great the pulsation
is strong. The right external jugular best- displays the throb, but the
subclavian and axillary veins may also show it. It is best seen when
the patient is semi-recumbent. It is greatly intensified by coughing
and is an important physical sign.
Inspection. In addition to the signs of overloaded veins and
venous pulsation an impulse is seen in the epigastric region, or on one
■or other side of the ensiform cartilage, which is caused by the hyper-
trophied ventricle. Holding the breath, coughing or blowing increase
its force as well as that of the venous throb. As already explained,
hypertrophy of the right ventricle lifts the left ventricle away from
the chest wall, so that the apex beat on the left is invisible. The pul-
sating liver may be visible.
Falpation. The above-mentioned signs are confirmed. Liver pul-
sation is less often seen than felt.
Percussion. The area of dullness is increased to the right of the
sternum. If the disease is secondary the increase is also to the left.
Auscultation. A systolic murmur having its greatest intensity in
the lower sternal region is heard. The murmur is soft, blowing and
of low pitch, and while less widely transmitted than the corresponding
mitral murmur, is often heard in the rigljt axilla. Even when asso-
ciated with a mitral systolic murmur the softer quality and lower pitch
of the tricuspid bruit enables one to separate the two sounds. The
co-existence of venous pulsation with this jbruit may be taken as posi-
tive indications of the lesion.
False murmurs seldom attach themselves to the tricuspid valve
DISEASES OF THE HEAET 219
and physiologic venous pulsation is not systolic. It corresponds with
auricular and not ventricular contraction.
Diagnosis. The diagnosis of tricuspid insufficiency presents no
■difficulties, and with these three points in mind a positive opinion may
be given.
Increased area of dullness to the right of sternum.
Systolic murmur centering at xiphoid.
Venous pulsation in external jugulars.
The tricuspid murmur which develops secondarily to a mitral
:systolic murmur, owing to its softer quality and lower pitch, may be
inaudible. In that case the venous pulsation may be taken to indicate
the lesion, especially if hepatic pulsation co-exists. Asystole sometimes
-develops and portends evil.
Other Symptoms. The symptoms are those of the allied heart
lesions or of the co-existent bronchitis, empjiysema and pulmonary
cirrhosis. General venous engorgement and universal anasarca pre-
vail. The kidney and liver engorgement are followed by a complex
-symptom train.
TRICUSPID STENOSIS.
The disease seldom exists as an isolated affection. Congenital
■eases die young. Women are afflicted four ti^nes as often as men. It
is secondary to lesions of the left heart. The ipechanism is exactly like
that of mitral stenosis with which lesion it is oftenest associated.
The physical signs are not always well-defined.
Inspection. Cyanosis, especially of the face and lips, is generally
present.
Palpation. Even when present the thrill can rarely be felt.
Percussion. Slight change in cardiac area, a little increase to the
right of the sternum.
Auscultation. Thrill may be present and is presystolic. A pre-
systolic murmur is often to be made out in the costal angle at the right
of the ensif orm cartilage, sometimes in the foiirth or sixth right inter-
spaces. Either the murmur is often absent or the murmur of the
associated mitral stenosis, of which it forms one of the most serious
-complications, so obscures it that it is indiscernible. General anasarca,
•extreme and obstinate, is an end symptom.
Diagnosis is difficult owing to the masking of the bruit. It is
220 DISEASES OF THE HEART
seldom made. The presence of the thrill is convincing. Venous reple-
tion and dropsy suggest it.
PULMONARY VALVE DISEA1SES.
These lesions are rare. Under the caption False Murmurs are
mentioned some of the conditions which are mistaken for pulmonary
valvular diseases. Care must be taken not to mistake the transmitted
mitral murmur mentioned under that disease, which occasionally cen-
ters around the root of the pulmonary artery, for disease of this valve.
Pulmonary insufficiency is the rarest of all valvular defects. It
is generally congenital.
Inspection. Constant cyanosis, great venous congestion and
dyspncea are marked symptoms. Jugular pulsation is mentioned by
Thompson.
Palpation — negative .
Percussion. Hypertrophy of the right heart, of moderate degree.
Auscultation. The lesion should be evidenced by a diastolic mur-
mur of maximum intensity in the second left intercostal space. The
corresponding murmur of aortic insufficiency theoreticaly centers on
the opposite side of the sternum, but in fact the differentiation by
position is impracticable and in any case is extremely difficult. The
rarity of the one contrasted with the frequency of the other affords
ample grounds for error if not for excuse.
The strongest differential point is that the vascular phenomena
accompanying aortic insufficiency, are absent in the pulmonary disease.
Pulmonary stenosis, also congenital, is caused by union of the
valve segments. Cases are occasionally encountered in which vegeta-
tions are the cause of both insufficiency and stenosis (Shattuck). The
congenital cases are associated with compensatory lesions of the for-
amen ovale or ductus Botalli, or imperfect ventricular septum due
to arrest of development.
Inspection : Negative.
Palpation. There may be a thrill in the second left intercostal
space. ^
Percussion. Slight enlargement of right heart.
Auscultation. There should be a systolic murmur with point of
greatest intensity to the left of the sternum in the second interspace.
This murmur is not transmitted into the vessels of the neck. The-
PIvATB XVI.
Mitral and Tricuspid Systolic Murmurs. The "Hour-Glass" Murmer.
DISEASES OF THE HEARIJ 221
pulmonary second sound would be absent or replaced by a diastolic
murmur, since incompetency is necessarily associated.
The differentiation from the murmur of" aortic stenosis presents
difficulties. The left-sided hypertrophy is absent in the pulmonary
form.
ORDER OF FREQUENCY OF THE SIMPLE AND THE COM-
BINED CARDIAC LESIONS.
Statistics differ materially as to the order of frequency of both
simple and combined lesions. The following order is as nearly correct
as available figures permit:
1. Mitral incompetency.
2. Aortic incompetency.
3. Mitral stenosis.
4. Aortic stenosis.
5. Tricuspid stenosis.
The claim of mitral incompetency to supremacy is undisputed.
Aortic incompetency and mitral stenosis are practically equal in fre-
quency, and the same may be said of the two forms of tricuspid disease.
Of double murmurs, heard at the same orifice, the mitral lesions are
more frequent than the double aortic murmurs.
The combined lesions occur in the following order of frequency:
The mitral and aortic segments are mosi; often affected together.
Next in frequency is the combination of mitral and tricuspid
lesions; then of aortic, mitral and tricuspid.
In children the most common combination is mitral insufficiency
with aortic insufficiency. In adults mitral insufficiency with aortic
stenosis and insufficiency is perhaps the- oftenest found combination.
The following order is taken from the statistics of F. J. Smith:
1. Aortic incompetency and stenosis : Mitral incompetency.
2. Aortic stenosis and mitral incompetency.
Aortic incompetency and mitral incompetency.
Equal.
4. Aortic incompetency and stenosis; mitral stenosis and in-
competency.
5. Mitral incompetency and tricuspid incompetency.
6. Aortic incompetency and stenosis ; mitral, incompetency; tri-
cuspid incompetency.
222 DISEASES OF THE HBABT
CONGENITAL CARDIAC DEFECTS.
Two causes are recognized: arrested development and foetal
endocarditis.
Acardia, double heart, dextro-cardia and malposition of the heart
are pathologic curiosities. Defective auricular or ventricular septum
is more common. When the opening is very small or slit-like little
harm seems to result. Patent foramen ovale, imperfect septum and
persistence of the ductus arteriosus Botalli each exists alone or com-
bined with stenosis of the pulmonary valve. Patent foramen ovale is
sometimes found post-mortem when the defect has been unsuspected.
Peacock states that the most frequent conditions are :
1. Stenosis and atresia of the pulmonary valve, the pulmonary
artery and the right conus arteriosus. In 181 congenital cases he
found one or the other in 119.
2. Defective auricular septum.
3. Defective ventricular septum.
These may exist alone, but are more frequently associated with
pulmonary stenosis, perforate foramen ovale, and patulous ductus
Botalli, in the order named.
4. Congenital lesions of the tricuspid orifice, pure or associated.
5. Persistency of the ductus arteriosus.
"When existing alone, may be found at an advanced age.
6. Congenital narrowing of the aortic orifice.
7. Congenital narrowing of the mitral orifice.
The number of valve segments is sometimes increased or dimin-
ished. Increased pulmonary and deficient aortic leaflets occur oftenest.
Two segments may be fused, in which case thickening as a rule co-
exists. Bicuspid aortic valve has been oftenest noted. The tendency
to valvular disease later in life is increased by these defects.
Foetal endocarditis leads to sclerosis and thickening of the edges
and to shortening of the chordce tendines. In some cases the results
resemble a perforate diaphragm, especially in stenosis of the pul-
monary valve. The valve may be rough or perfectly smooth. Smooth-
ness is taken to indicate imperfect development. Roughness indicates
endocarditis. The subjects often die of tuberculosis. Defective sep-
tum may be associated. Congenital aortic defects are less frequent
than pulmonary lesions.
Symptoms. The most striking symptom of congenital defect of
DISEASES OF THE HEART 223-
the heart is cyanosis, which appears soon after birth and is permanent.
It may be of slight grade, affecting only the lips and finger tips, ears-
and toes, and only come on after crying; or it may be of high grade,
the entire body exhibiting a bluish or purplish lividity. Clubbing of
the fingers and toes is usual and extreme and the nails sharply curve.
Cough and dyspnoea, both increased by slight exertion, are generally
present. A systolic murmur heard over the auricles and absent at the-
base indicates the lesion. In congenital pulmonary stenosis the second
pulmonary sound is abnormally weak or, absent.
DISEASES OP THE MYOCARDIUM.
Atrophy of the heart is the reverse of hypertrophy. Diminution
in the size of the heart keeps pace with diminished need. It is con-
genital or acquired. Wasting diseases and old age are causes of the^
acquired form. The wasting which accompanies phthisis is a well-
known example.
Physical Signs. Weakened impact, usually invisible, small weak
pulse, diminished cardiac area. In estimating the latter the influence
of emphysema, so often present in old age, must be kept in mind. The
sounds are generally weak but may be otherwise normal. In phthisis
the second pulmonary sound is accentuated despite the atrophy.
HYPERTROPHY AND DILATATION.
Cardiac enlargement occurs in three forms :
1. Simple hypertrophy, in which the walls are thickened without,
any change in the size of the cavities.
2. Hypertrophy with dilatation; dilatation with hypertrophy or
excentric hypertrophy, in which both dilatation of the cavities and'
thickening of the walls are present.
3. Simple dilatation, or dilatation of the cavities with thinning
of the walls. It is manifest that if the walls are stretched, they must
thin.
The weight of the heart has been given. The normal thickness of
the left ventricle is from one-third to one-half inch ; the right ventricle
from one-sixth to one-fourth of an inch; the auricles are about a line
in thickness.
The thickness of the left ventricle has been known to reach an inch
and a-half, the right, three-fourths of an inch in thickness. The-
auricles may double their normal thickness in extreme cases.
224 DISEASES OF THE HEART
The weight of the heart in these cases varies from fifteen to
twenty-five ounces, except in such extreme cases as follows: Stokes
reports a heart of sixty-four ounces ; Alonzo Clark, one of fifty-seven
ounces ; Beverly Kobinson, one of fifty-three ounces.
Independently of cardiac valvular lesions there is a small group
of hypertrophies and dilatations which deserves notice. They are
sometimes designated as idiopathic, as opposed to the hypertrophy
•caused by valvular diseases. Either the hypertrophy or the dilatation
may be primary, but eventually the one condition brings about the
other, hence ultimately they co-exist.
Causes. Increased labor and increased intracardial pressure.
The part affected depends on the part called upon to bear the strain.
Mechanical obstruction to the circulation, if produced suddenly, brings
dilatation, if brought about gradually, hypertrophy supervenes. The
left ventricle is primarily affected in those conditions in which the
impediment is in the general arterial circulation. Such are arterio-
sclerosis, increased intra-thoraeic pressure. A moderate degree of
hypertrophy exists during pregnancy, according to Larcher. Immod-
erate athletic exercise, continued use of alcohol, particularly beer
(Striimpell), and all forms of Bright 's disease. The right ventricle
is primarily affected when the causes are chiefly the outcome of im-
peded pulmonic circulation, and is affected secondarily in diseases
which have produced the same condition in the left heart. We are
of the opinion that also associated action and nerve supply is responsi-
ble for a considerable amount of concurrent hypertrophy in these easea
as well as in valvular diseases. Nerve and muscle fibers are in large
part common to both hearts and ability to disassociate their work must
needs be an acquired function.
Right hypertrophy is seen as a result of undue muscular exercise
in athletes and soldiers (Da Costa).
The lung group embraces emphysema, cirrhosis, phthisis with
consolidation, and pleuritic adhesions. Yet left hypertrophy quite as
often as right exists in these eases.
Hypertrophy of the heart as a Whole is due to associated causes,
those which call for increased work of both sides: Exophthalmic
goitre, certain diseases of the nervous system, excessive use of cardiac
■stimulants, — ^tea, coffee, and alcohol, — pericardial adhesions, as as-
serted by Quain, independent of valvular diseases. Sometimes
pericarditis is the cause of extreme dilatation without hypertrophy.
DISEASES OF THE HEART' 225
In cases where dilatation exceeds hypertrophy, some form of myocar-
dial degeneration generally will be found to co-exist.
Sudden death with acute dilatation in- infective diseases, and
death occurring after slight exertion during convalesenee, are probably
so caused. The dilatation found in old alcoholics and in cases of wide-
spread arterio-sclerosis is associated with fatty infiltration, fatty
degeneration or fibroid overgrowth. Dilatation which supervenes
upon hypertrophy in valvular diseases is probably due to the prone-
ness of the hypertrophied muscle to undergo degeneration.
Simple dilatation is most often observed in the auricle and the
right ventricle.
Symptoms and Physical Signs. As long, as the balance is main-
tained between the two conditions few symptoms present themselves.
There may be some dyspnoea, and vascular throb may be present in
the neck. In failing compensation the vascular phenomena described
under cardiac lesions supervene, venous repletion and congestion of
the various organs. Headache, giddiness and palpitation are frequent.
Inspection. Precordial bulging, especially in children, cardiac
impulse displaced outward and lowered to the sixth or seventh inter-
space. Dilatation is indicated by the diffused, wavy, uncertain stroke.
Palpation. The impulse may be double, one systolic, one diastolic.
Pulse regular, full, tense in hypertrophy; weak, irregular and more
frequent in dilatation.
Percussion shows area of increase.
Auscultation. In hypertrophy the first sound is dull, heavy,
prolonged and sometimes reduplicated. Laennee called attention to a
click, sometimes heard in the young.
In dilatation the quality of the first sound approaches that of the
second, the pause shortens and we have a simulation of the foetal heart
sounds, called by the French, embryocardia. Frequently the canter
rhythm, or bruit de galop, is present. Murmurs are absent unless the
condition results in valvular incompetency.
Diagnosis. Four points are insisted upon :
Increased area.
The heaving or diffused impulse.
Absence of murmur.
Character of the sounds.
Acute myositis, abscess of the heart, aneurysm of its walls, fatty
226 DISEASES OF THE HBAET
changes, acute myocarditis, give rise to no distinctive signs in them-
selves, but may bring about results which are recognizable.
Fibroid heart (myocarditis) is followed by a train of symptoms
due to the resulting dilatation and venous congestion. It is usually a.
part of endocarditis. Its physical signs are those of dilatation. A
variable and unstable mitral murmur may be present without accentu-
ation of the second pulmonic sound.
ACUTE ENDOCARDITIS.
Definition. Inflammation of the lining membrane of the heart.
The valves are usually involved, though the lining membrane of the
cavities and the chordse tendineffi may b"e affected alone. That the
latter condition is not as rare as might be supposed is proved by the
statistics of the Royal College of Physicitos, in which series of cases-
the walls were affected 33 times in 209 cases.
It is usual to distinguish two varieties of the disease, a simple
and a malignant form, but in reality the distinction is one of degree
rather than of anatomical difference.
Simple or benign endocarditis always arises in the course of some
other disease. Rheumatism plays the chief role, with pneumonia
second. Tonsillitis and scarlet fever are liable to the complication. ,
Other infectious diseases less frequently show it, but the possibility
of its occurrence as a late complication must not be forgotten. Attacks-
during the course of phthisis are not rare. The causal relationship of
chorea to endocarditis in early life can not be denied, and a large
proportion of patients who have been afflicted with the former carry
the lesions of the latter malady.
The malignant type may exist as an independent disease, but
secondary forms are more usual. In infective diseases, pneumonia and
kidney diseases the malignant variety is prone to occur.
While in rheumatism, as in pneumonia, the benign type is oftenest
met with, yet the malignant form is not rafe in either disease.
Septic infective diseases furnish a proportion of the cases.
Symptoms. Simple endocarditis gives rise to no distinctive symp-
toms or physical signs. In the course of inflammatory diseases in-
creased rapidity and irregularity of the heart's action and increased
fever without assignable cause are suspicious.
A murmur at the apex may develop but its presence does not
indicate the disease, nor does its absence m,ean exem,ption. The stu-
DISEASES OP THE HEART 227
dent must free his mind of the widespread fallacy that heart affections
must needs be attested by murmurs.
The malignant form is manifested by rigors, sweats, irregular or
intermittent fever, delirium and signs of septic infection, which are
in no way distinctive of heart involvement. Another type is the
typhoid, which is self-explanatory.
In persons known to have chronic valvular lesions, symptoms sim-
ilar to the above should excite grave apprehensions of a recurrent
endocarditis. Embolic symptoms often occur and aid the diagnosis.
The disease is perhaps most often mistaken for typhoid fever. Widal's
reaction excludes the latter.
SECTION XI.
THORACIC ANEURYSM.
An aneurysm is a more or less circumscribed dilation of an
artery. The dilation may include all the coats of the artery, or it
may be that one or two coats having yielded or ruptured, the remaining
part dilating thus forms a blood sac which communicates with the
parent vessel.
A convenient division of these lesions is into internal, or medical,
and external, or surgical, aneurysms, which classification is self-
explanatory.
Aneurysm of the thoracic portion of the aorta is by far the most
frequently met with among aneurysms, since aneurysms of the
aorta follow the same law as does sclerosis with regard to situation,
viz., the nearer the heart the greater the pressure, hence the greater
the liability to aneurysm. For this reason they are oftenest found in
the ascending portion of the arch, which is the subject of attack five
times as frequently as the abdominal aorta; then in the transverse
and descending portions, where they occur three times as often as in
the abdominal vessel. For the same reason they are found on the
•convexity of the arch, rarely on the concave side.
Anatomy. The aorta lies in the middle mediastinum. It arises
;from the base of the left ventricle, behind' the left margin of the
!Sternum, opposite the lower border of the third left costal cartilage.
'This point corresponds to the body of the fifth dorsal vertebra. It
passes upwards, forwards and to the right, between the superior vena
cava and the pulmonary artery, as far as the right border of the
sternum, beyond which it does not project, and as high as the second
costal cartilage. Its breadth is 28 m. m. At the point given it arches
upwards, backwards and to the left, winding around the trachea to
reach its left side, whence it passes to the left side of the lower border
R
Eoii;aopH\LlC lEl/CoeVTES,
PLATE XVII.
EXAMINATION OF THE BLOOD 237
A material increase of any particular cell-element is spoken of as
— 'osis, hence the term leucocytosis, microcytosis, etc. Microcythsemia,
megalocythsemia, etc., have the same significance.
To give a detailed description of the various cells found in the
blood in disease were impossible within the limits of this brief treatise,
and would serve a less useful purpose than the accompanying classi-
fication with attached nomenclature.
The Bed Corpuscles. The red cells are circular, bi-concave discs
of greenish-yellow color and non-nucleated. The average diameter is
7.5 IX. The center being thinner than the rim is therefore lighter
colored. Abnormal pallor can be detected by practice. There is less
variation in the size and shape of the red than of the white cor-
puscles. Moving cells are seen to change their shape, like elastic bags.
Macrocytes are probably regenerative cells; microcytes, degenerative.
The name poikilocytes was given by Quincke to irregular forms
sometimes seen elongated, balloon-shaped, rod-like, which occur in
severe anaemias and in chlorosis. Crenation, which occurs upon the
slide, is the ameboid motion with change of shape, and is outside
poikilocytosis. The absence of the rouleau tendency is sometimes
noticeable, and is seen in pneumonia, hepatic diseases and nephritis.
Polycythsemia is an actual increase in the number of red blood cor-
puscles. It is relative when due to a diminution of the plasma, as in
diarrhceas and ascites. The opposite condition is known as oligocy-
thsemia and occurs in the anemias, septicaemia and all wasting diseases.
Normal red cells show little affinity for dyes, differing in this
respect from the white cells. In disease, red cells which accept stains
are met with, also cells not normally present in health but seen in dis-
ease, as the microcytes and the megalocytes which stain readily.
Staining with methylene blue shows the granular nature of diseased
and degenerated red cells. Cells containing such granules occur in
pernicious anaemia, malaria, the leukaemias, and lead poisoning. In
the last they are very constant, and, in the absence of the other condi-
tions, saturnism should be suspected.
Nucleated red cells are found in the foetus and immediately after
birth, and at all times in the bone-marrow. Three varieties are
described :
( a ) Normoblasts,
(b) Megaloblasts and
(c) Microblasts.
238 EXAMINATION OF THE BLOOD
The first is a developmental form of the normocyte. In other
words it is an immature red blood corpuscle: Megaloblasts, cells of
10 ju or over, occur only in disease. They are not found in healthy
marrow. They are seen in ansemias due to intestinal parasites, in
grave anaemias, especially when pernicious. Ehrlich considers their
occurrence as prognosticating death, except in parasitic anemia.
Microblasts are rarer than the above, they are of small size,
imperfect form and their import equally serious. Both forms seem to
indicate a return to the foetal type of blood.
The following terms are used to describe the behavior of all cells
towards the various dyes employed :
Basophilic, having an affinity for basic dyes.
Achromatophilie, no affinity for dyes.
Oxyphilic, having an affinity for acid dyes.
Polychromatophilic, an affinity for both bksic and acid dyes.
Neutrophilic, having an affinity for neutral dyes.
Eosinophilic, having an affinity for eosin stain.
Chromotrophic elements are stained a ditlerent color from that of
the dye, as when violet dyes stain red.
The White Corpuscles, or leucocytes, are colorless cells. They
are generally larger than the red bodies, more irregular in shape, are
nucleated and much fewer in number than the red cells. From their
composition they are divided into granular and non-granular varie-
ties, or may be classified as mono-nuclear and poly-nuclear forms. The
larger varieties, especially the coarse granular cells, are actively ame-
boid, the small mono-nuclear variety is devoid of ameboid move-
ment.
Classified in accordance with their origin, two groups may be
distinguished :
I. Those from the bone-marrow, the myelogenous group, and
II. Those from the adenoid tissue, the lymphogenous group. This
second group comprises the lymphocytes of all sizes.
The first group includes the following:
(a) Polymorphonuclear neutrophiles.
(b) Eosinophiles,
(c) Mast cells,
(d) Large mononuclear cells of Ehrlich.
The forms of group I are not transitional*
LftRGE LYMPHOCYTES
SMALL
pOL-fMoPxPHOt^ocLEnK
ritUTPOPHILt
EOSlSOPHlLf-
ff EiOSlftOfHILlt
M>fELOCYTe.
ONHUTROpMILlC.
LtUCOCfTE.
StUTRDPHlLlC
M'iE.LOCYTE.
I- Z -b .SMdLt.
LTMPHOCYTE
RED CELLS AND POLYMORPHONUCLEAR NEUTROPHILES
PLATE XVIII.
VARIETIES OF LEUCOCtTES.
EXAMINATION OF THE BLOOD
23^
♦LEUCOCYTES.
Classification according to structure
and behavior towards dyes,
f Mononuclear.
A.
NoN- Granular ■
Varieties.
Granular
Varieties.
Little or no
ameboid move-
ment; many
contain one or
two peripheral
granules.
Poly nuclear,
polymorpho-
nuclear.
Phagocytes,
active, ameboid
motion.
Neutrop hi lie,
basophilic, oxy-
philic.
Mononuclear.
Granular cells.
i. Small lymphocytes derived from adenoid tissue. Vary
in size from smaller than a red blood corpuscle to
considerably larger, Mononuclearj both nucleus,
and protoplasm JDasophilic. Outline smooth or
irregular. In adults, 20 to 30 per cent, of total nuinber
of leucocytes; in infants, 40 to 60 per cent.
Laryre lymphocytes, large mononuclear leucocytes,
derived from bonfrmarrow and spleen. Two to three
times the size oi red blood corpuscle. Large, single
nucleus; both nudeus and protoplasm basophilic-
Outline irregular, oval. Surrounded by broad zone
of protoplasm. Form from 4 to 8 per cent, of total
number.
Polynuclear nutrophilic leucocytes.
Polymorphonuclear neutrophilic leucocytes or
phagocytes, About same size as No. 2. Nucleus
elongated, twisted, broken. Granules embedded in
protoplasm stain with neutral dyes (neutrophilic)..
Protoplasm proper stains with acid dyes. Most com-
mon of all lejjcocytes. 62 to 70 per cent, of total
Derived from neutrophilic myelocyte
leucocytes.
(Ehrlich).
Polynuclear oxyphilic*leucocytes, same as No. 3, except
embedded protoplasm stains with acid dyes, or eosin,.
hence also called polynuclear eosinophilic leuco-
cytes. I to 4 per cent, of total or about 50 to 200 per
c. c. of blood.
. Polynuclear basophilic leucocytes, mast cells, size
about same as Nos, 3 and 4- fn disease size may
reach 22 micro-millimeters. Embedded grains of
protoplasm,difierent sizes, stain only with basic dyes.
Nucleus polymorphous. Rare. Never exceed 0.5
per cent.
, Myelocytes. Mononuclear neutrophiles, granular cells
of the bone marrow, " Intruders ^''^ occasional occur-
rence, border cell between physiologic and patho-
logic conditions. (Starvations and various intoxica-
tions.) Are derived from large lymphocytes (2) and
develop into the polynuclear leucocytes (3) are never
normally found in the circulation. According to action
with dyes', are neutrophilic, eosinophilic or baso-
philic, all with single, large nucleus, surrounded with
protoplasm. Diameters 10-20 micro-millimeters.
The protoplasm of normal leucocytes is stained uniformly bright-
yellow by iodine. In diseases in which pus is a product of the disease,
or in which the infection or intoxication is due to some form of bac-
terial invasion, as in typhoid fever and pneumonia, the granular pro-
toplasm is stained brown by the reagent. This was announced a few
years ago by Kaminer. Later, Wolff announceii that the reaction was
due to the presence of glycogen and occurred irrespective of disease.
Hirschberg has confirmed Wolff's work and the staining can no longer
be regarded as significant. The polymorphonuclear neutrophiles best
show the reaction, while the eosinophiles are exempt. It was pre-
viously taught that the reaction served to demonstrate sepsis and also-
to distinguish between a serous and a purulent effusion.
The number of leucocytes per cubic millimetre of blood varies
much both in health and disease. The average may be stated to be
5,000 to 6,000, but may faU anywhere between 3,000 and 10,000
within strictly physiologic limits. An increase above normal is called
240 EXAMINATION OF THE BLOOD
liyperlencocytosis, or simply leucocytosis ; a diminution below normal
is hypoleucocytosis. The increase or diminution may affect all the
varieties above mentioned but more generally it will be found that a
particular variety suffers much out of proportion to the remaining
cells. The most common form of leucocytosis is an increase of the
polymorphonuclear neutrophilic cells (3). In the new-born these
exist physiologically to as high as 20,000, which number decreases to
10,000 by the end of the first year. The eosinophiles may reach 2,200
(Taylor). Pregnancy and labor, severe exercise, bathing, and even
digestion increase the number of leucocytes above normal. They vary
from day to day, and from day to night. Such variations are physio-
logic and temporary. The number is below normal in the ill-nour-
ished, the sickly and in those who have fasted; If a deficient amount
■of food has been eaten, as is often asserted by patients, the count will
verify the statement. Such conditions of ill-nourishment and unhy-
gienic surroundings must be given proper weight before conclviding
that a count of, say, 3,000 is pathologic.
Cabot gives the following classes of pathologic leucocytosis :
Post hffimorrhagic leucocytosis.
Inflammatory leucocytosis.
Toxic leucocytosis.
Leucocytosis in malignant disease.
Leucocytosis due to experimental and therapeutic influences.
Among inflammatory conditions in the above classification are in-
cluded infectious diseases.
In septic conditions leucocytosis increases with the severity of the
attack, at least, so long as resistance is normal. Where the resistance is
greatly diminished, leucocytosis diminishes therewith, and may fall to
a low point. In pneumonia, its absence forebodes a fatal termination.
In many of these conditions, while the nefUtrophiles are increased,
the eosinophiles are correspondingly diminished.
Leucocytosis is absent in the following diseases : Typhoid fever,
malaria, grip, measles, rotheln, mumps, cystitis, all forms of tubercu-
losis and tubercular processes except the meningeal form.
Bloodgood* states that in appendicitis the' leucocytosis is a pretty
safe index of the severity and extent of the disease. A count of 15,000
falls rapidly to 10,000 with the amelioration of the disease. A count
*Americaii Medicine, ipoi, page 306-7.
EXAMINATION OF THE BLOOD 241
of 20,000 observed within forty-eight hours of the beginning of the
attack demands operation. In gangrenous eases the count reached
25,000 to 30,000. Very high leucocytosis observed within the first
forty-eight hours points to peritonitis.
In intestinal obstruction the increase is of especial value, rising
rapidly to 20,000 within twenty-four hours, and still higher in gan-
grene or associated peritonitis. Later in the disease a low count with
persistence of the symptoms is unfavorable.
Fevers with leucocytosis are not typhoid; since it does not occur
in uncomplicated cases. Its occurrence, therefore, in undoubted cases
points to complications. It is stated that in articular rheumatism
complicated with endocarditis, the count doe's not rise much if any
above that for the uncomplicated joint affection, viz : 10,000 to 12,000,
^^'
(---SLIhp
Fig. 6l — The Thoma-Zeiss Counting Chamber.
but that when complicated with pericarditis the average rises to 20,000
or over, and that such rise foretells the complication.
Tuberculosis is only attended by leucocytosis when secondary pus
infection occurs.
The eosinophiles and the mast cells are increased in myelogenous
leukaemia, while in the lymphatic forms of the disease the lymphocytes
are increased, numbering 40,000 to 200,000. Increase of eosinophiles
is found in bronchitic asthma, in scarlet fever, in hydatid disease of
the liver, as noted in one of my cases, in intestinal parasites, gon-
orrhoea and in inflammatory skin disease.
Blood Counting. The most suitable apparatus for enumerating
the blood corpuscles is the cytometer of Thoma-Zeiss, manufactured
by Zeiss. It consists of a diluting pipette for the red corpuscles,
another for the white, a specially ground cover-glass and a counting
■242
EXAMINATION OF THE BLOOD
chamber in the bottom of which is placed a disc ^ ruled into squares
whose sides measure 1-20 mm. and whose areas are therefore 1-400
of a square millimetre. The depth of the chamber when the cover-
glass is in position is 1-10 mm. When the chamber is filled the con-
tents overlying each square will be a column 1-400 ^^- ^ase by 1-10
mm. in height or 1-4000 cu. mm.
Hence the number of corpuscles overlying an.y one square X by
4,000 would equal the number of corpuscles in a. cubic millimetre of
blood, if the blood examined were undiluted. Since it is impossible to
make the count without diluting the blood to 100 or 200 times its own
volume, the above product must be multiplied by the dilution mul-
tiple. Furthermore, since great variations occur in the number of
Fig. 62 — Thoma-Zeiss Hemacytometer Pipette, and Chamber.
corpuscles found in the various squares, in practice it is actually
necessary to count the corpuscles overlying a largQ number of squares,
divide by the number of squares counted in order to obtain an average,
then multiply by the other factors. By reason of the ruling presently
to be described, it is found convenient to count a field 16X16 or 256
squares. Suppose the number therein totals 1,792, giving an average
of 7 for each square, the dilution being 200. Then 7X4000X200=
5,600,000 cells per cu. mm. of blood. Countimg; chambers with the
rulings of Turck enable the enumeration of both red and white cells,
to be made in the same specimen. In this apparatus the small 1-20
mm. squares are fenced off into blocks of 4X4 or 16 of the smaller
squares, separated by interspaces or ' ' alleys, ' ' the width of the small
squares. For enumerating the red discs, the 16 central blocks are
EXAMINATION OF THE BLOOD 243
eouBted, thus giving 256 of the small squares, which is sufficient for
a fairly accurate average. To count this nvimbef of squares after
some practice requires about half an hour ancl the result is generally
between 1,200 and 1,500 corpuscles. Much nfust be learned by prac-
tice, and accuracy comes only with experience. After having made
the count the instrument should be washed with water and the whole
process repeated with a second drop of blood, and in cases of wide
variation, a third count should be made.
Enumeration of the Bed Blood Corpuscles. The blood is most
easily obtained from the ear-lobe, which may be first washed with
soap and water. Disinfection is not necessary. Punctures made with
a three-sided surgical needle furnish a free iiow of blood and obviate
the necessity of squeezing, which dilutes the drop. Wipe away the
first drops, then draw the blood directly into the capillary tube of the
mixing, pipette to the 0.5 mark, if a dilution of 1 :200 is desired, or to
the 1.0 mark for a 1 :100 dilution. In cases of anjemia the latter is
preferable, while for practice upon normal blood the former suffices
and the cells are more quickly counted, with less strain upon the
the eyes. Great care is necessary in drawing' blood into the tube not
to pass the desired mark. In case such accid'ent happens the pipette-
must be cleansed immediately, and the attempt repeated. The mark-
reached, the blood adherent to the point of the tube is carefully
wiped away and the. tube plunged directly into the diluting fluid
which is drawn up until the 101 mark above the bulb is reached. The-
two fluids are intimately mixed by shaking and rotating. The portion
which has remained in the capillary tube and not mixed must be ex-
pelled, and a portion of the remaining fluid transferred to the count-
ing chamber. . The cover-glass is placed over it and the slide is put
on the horizontal stage of the microscope where it should be allowed
to stand for several minutes in order that the corpuscles may settle
evenly. Much care and practice are necessary that neither too much
nor too little of the fluid be placed in the chamber. If too much, it
will overflow into the rim or moat which surrounds the graduated
plate, or overflow between the cell-rim and the cover-glass. If too
little, the count will be inaccurate.
If the drop has been accurately gauged, Newton's rings will ap-
pear at the edge of the cover-glass as far as it rests on the underlying
cell wall, when the glass has been pressed into place.
244 EXAMINATION OF THE BLOOD
Diluting Fluids. The simplest is a 0.8 per cent, salt solution, or
one of MgSO^ of 20 per cent, strength. Gowers' fluid consists of:
Sodium sulphate gms. 6.3.
Acetic acid, gms. 3.6.
Distilled water gms. 117.0.
Toison's fluid is convenient as it stains the leucocytes and facili-
tates their enumeration. Its composition is as follows :
Sodium chloride, purif 1.0 < gm.
Sodium sulphate, purif 8.0 gm.
Neutral glycerine 30.0 c. c.
Methyl violet, 5B 0.025 gm.
Distilled water 160.0 e. e.
Diluting solutions containing mercuric chloride, as Pacini's and
Hayem's, are advantageous since they do not stain the tube as does
Toison 's.
Counting the leucocytes. The same chamber is used for count-
ing the white cells that is used for the red discs. Turck's ruling
greatly facilitates the work. For countings the white cells a dilution of
1 :100 is sufficiently accurate. If a dilution of 1 :200 has been used for
the red cells, the second or large bore pipette may be used for this
■enumeration. The blood being drawn up to the 1.0 mark, Toison's
fluid is added until the 101 mark is reached, when the steps described
in the ease of the red corpuscles are repeated. The leucocytes are
stained blue by the fluid and the corpuscles overlying the entire set
of large blocks, 144 in number, are counted, beginning at one corner,
going across the field and back until all are counted. Corpuscles lying
in the interspaces or "alleys" between the blocks must not be in-
cluded in the count. A rule of procedure must be adopted in regard
to counting bodies partially within and partially without the boun-
daries. Perhaps the safest plan is to count in all that lie on two ad-
jacent sides of the square and ignore all that impinge upon the two
remaining sides. The rule is equally applicable to the enumeration
of both the red and the white cells. Divide the total by 144 to ascertain
the average for one square. Since these blocks are composed of 16
small blocks, each of which is 1-4000 cu. mm. in contents, it follows
that one of these columns is 16-4000 cu. mm. or 1-250 cu. mm., hence
EXAMINATION OF THE BLClOD 245
multiplying the average obtained by 250, by the degree of dilution
100, equals the number of leucocytes per cu. mm. in the blood ex-
amined. Thus, if 65 leucocytes are countad on 144 squares, the
average per square is 0.45X250X100=11.250 leucocytes in one cubic
millimetre of blood. This method has the advantage of being much
simpler than that of finding the cubic contents of the microscopic field
and should be more accurate.
If for special reasons a dilution of 1 :10 or 1:20 be desirable, it
becomes necessary to destroy the red bodies, since their preponderance
would obscure the white cells. In this case a 0.5 per cent solution of
acetic acid to which has been added a little gentian or methyl violet,
renders the red cells invisible while it makes p'rominent the leucocytes.
The apparatus may be cleaned by first washing out the pipette
with the diluting fluid, then with water, afterwards with absolute
alcohol, lastly with ether. The counting chamber should be washed
with water only as alcohol and ether destroy the cement. Explicit
directions usually accompany the apparatus.
A magnifying power of three hundred diameters will suffice for the
count.
The hfematocrit, as proposed by Blix and modified by Daland, has
the advantages of celerity and ease of management. It consists of two
graduated glass tubes, 50 mm. long and 0.5 mjn, in diameter, that fit
accurately into a carrying frame which revolves in the ordinary cen-
trifuge. The tubes are graduated from 1 to liOO. The blood is drawn
directly into the tube from the puncture by means of a rubber tube,
or it may be diluted with an equal volume of a 2.5 per cent, solution
of bi-ehromate of potash. For diluting, the* pipette of the Thoma-
Zeiss apparatus may be used, the blood being drawn to the 1.0 mark,
then an equal quantity of the diluent drawn in. The process must
be repeated some four times in order to obtain sufficient of the mixed
fluid to fill both tubes of the hajmatocrit, to w|iich it may be directly
transferred. As a speed of 10,000 revolutions^ per minute is necessary
for good results, an electric current is desirable. The result as indi-
cated by the scale gives the number of corpuscles per cu. mm. by
adding five cyphers to the reading, thus, 50 on the scale indicates
5,000,000 red cells. Doubling the scale gives the volume percentage
of corpiiscles to the normal ; thus, 45 on the index equals 90 per cent.
If the blood has been diluted, the indicator readings must be multi-
plied by the degree of dilution.
246 EXAMINATION OF THE BLOOD
Much criticism has been bestowed upon the results of Daland's
method. It is especially claimed that it is inefScient in cases in which
there exists much variation in the size o:^ the corpuscles, or in which
the leucocytes are considerably increased; but Daland claims good re-
sults in these cases as well as in the othars. In a large series of com-
parative counts made with both the haematoerit and the Zeiss instru-
ment, I obtained quite as uniform results as when two different per-
sons counted the corpuscles in separate specimens of blood from the
same individual, by means of the Zeiss counter.
Preparation of Dried and Stained Films. Wet preparations can
be utilized only when the microscope aild proper materials are near
at hand. When the examination must be deferred it is necessary to
make use of dried .specimens. They are prepared by pricking the
cleansed finger or ear-lobe, wiping away* the first drops, catching the
next drop, as it emerges from the punctiire, upon a clean cover-glass
without touching the glass to the skin, spreading the drop into a
capillar\- layer by covering the one disc; with another then carefully
sliding them apart, and drying the two Jjlms thus obtained in the air.
The dry films will keep indefinitely, especially if placed in closed jars.
Simon recommends the use of slides instead of cover-glasses,
spreading the drop with the edge of a second slide held at an angle
with the first. The superiority of his piethod rests on the lessened
difficulty of gauging the drop to the size of the cover-slip and the more
uniform thickness of the smear. I\Iy own preference is to bring the
edge of the slip even with the edge of the slide and to catch the drop
directly in the capillary space thus fonijed.
Fixation is accomplished by exposing the specimen to a tempera-
ture of 140° C. for half a minute, but requires special apparatus.
Longer exposure at lower temperatures, as one hour at 110° will
accomplish the same end. Fixation by: immersion in a mixture of
e(iual parts of absolute alcohol and ether, or in the alcohol alone, is
satisfactory for most purposes. For the first, the immersion should
last from one-half to one hour; for the second, five minutes suffices.
The following solution is more satisfactory than either of the
above :
Commercial formalin, 40 per cent. . . 1 c. c.
Water 9 c. e.
Mix, add alcohol 80 e. c.
EXAMINATION OP THE BLOOD 247
Fix by covering with a few drops of this solution, allow it to
remain one minute, then drain off and immediately replace by the
staining mixture desired.
With practice one can make perfectly satisfactory stains by sim-
ply passing the cover-glass through the flame about twenty times in
rapid succession, learned by noting the effect on the red discs. If the
heating has been sufficient they will be stained bright yellow by the
tri-acid stain.
Ehrlich 's tri-acid stain is the most satisfactory for diagnostic pur-
poses and is all that is necessary for the clinician. Gruber's colors
are used. The dye is made by mixing the following :
Saturated watery solutions of orange G-, methyl green and acid
fuchsiu are prepared and allowed to stand for several days, after
which the clear fluids are decanted. The dye is compounded as
follows :
Orange G-. sol 6 c. c.
Acid fuehsin sol 4 c. c.
Add the one to the other drop by drop, while shaking. When
thoroughly incorporated add
Methyl green sol 6 c. c.
Glycerine : ... 5 c. c.
Absolute alcohol , 10 c. c.
Water 15 c. e.
Shake well, let stand for twenty-four hours.
The specimens are stained with the above compound for about
five minutes, drained, dried with bibulous paper and examined with
the one-twelfth oil immersion lens, with the wide diaphragm.
Ehrlich 's triple stain dyes the
Red corpuscles, orange or bright yellow.
Nuclei of leucocytes, green.
Nuclei of nucleated red cells, green.
Neutrophiles, violet.
Mast cells, uncolored.
.Eosinophiles, red or copper-red.
The definition of the nuclei is improved by counter-staining with
248 EXAMINATION OF THE BLOOD
a saturated solution of methylene blue. After washing off the triple
stain the blue solution is poured over the film and washed ofl: after
one or two seconds (Hewes). The blue counter-stain brings out
clearly also the malarial parasites, which do not show in the films
stained only with the triple stain.
Jenner's stain, the eosinate of methylene blue, gives satisfactory
differential pictures. No previous fixing is necessary, as this is ac-
complished by the methyl alcohol of the stain. The dye consists of a
0.5 per cent, solution of the powder in absolute methyl alcohol. The
films are well-covered for five minutes, washed with water, dried and
examined.
The red cells are stained terra-cotta.
Nuclei of both red cells and leucocytes, blue.
Neutrophiles, purple-red.
Eosinophiles, bright-red.
Granules of mast cells, dark-violet.
Ehrlieh's hfematoxylin-eosin solution is also known as Gollaseh's
dye. It is frequently used.
Preparation : Dissolve 2 gm. hematoxylin in a mixture of 100
c. e. each of alcohol, glycerine and distilled water. Add 10 gm. gla-
cial acetic acid and a slight excess of alum. The solution must ripen
for four to six weeks, after which 0.5 gm. eosin, or, if preferred,
orange G., is added. The smears are fixed either by heat or by alcohol
(five minutes) and stained for varying times from five minutes to
two hours, according to the intensity desired. The method requires
less skill of technique than either of the others.
The nuclei Of the leucocytes are stained dark-blue.
Bodies of leucocytes, light-blue.
Bed corpuscles, bright-red.
Eosinophiles, red-granular.
Nuclei of normoblasts and megaloblasts, dark-blue.
Neutrophiles, unstained.
As said, the triple-stain is the only one really necessary for the
practitioner, and familiarity with one stain and the ready recogni-
tion of the bodies differentiated by it is far more useful than doubtful
versatility or questionable proficiency.
Malarial Organisms. These parasites are readily recognized in
wet specimens by careful focusing, or th4y may be stained for per-
manent preparations. The causative factor of malaria is a protozoon
LtUCOCYTE
Reo C6ULS
LYMPHocyres
€W •
i5-/^^&i
SMALL
LYMPHOCYTES
PLATE XIX.
CHRONIC LYMPH/EMIA
Small Lymphocytes in various stages of transition.
EXAMINATION OP THE BLOOD 249'
of the class which grows in the blood and is therefore called h£ema-
tozoon. This particular species is named in honor of its discoverer,
Plasmodium malarice of Lavaran. The most- common form of the
Plasmodium is found enclosed in the red blood corpuscle. It is a pale,
segmented, mulberry-like body, surrounding a mass of pigment. If
a little solution of gentian violet or fuehsin be added to the wet
preparation, the stain will impart itself to each of the fifteen or
twenty separate segments, differentiating a Seep-tinted, central nu-
cleolus from the surrounding protoplasm of lighter stain. Some of
these same bodies may be found apparently free from the corpuscle
which encapsulated them. The free bodies may be entire or in various
stages of disintegration, or exist as small, pale, spherules floating free
in the liquor sanguinis, or attached to the outside of the red corpuscle,
where they exhibit ameboid movement. Staining here shows
also a central nucleolus and a nucleus.
These forms are found previous to, or during, the chill and dis-
appear a few hours after that event, when they are replaced by active
ameboid, inter-corpuscular bodies, constantly changing shape and
throwing out pseudopodia into the substance of the corpuscle. These
undergo successive changes, until the pale spherules again fill the cor-
puscle, and, at the time of the next chill the rosettes and radiating
pigment bodies reappear. The crescents which are found in the blood
associated with irregular and severe eases, according to Thayer appear
in most of the cases of Eestivo-autiimnal fever during the second and
third week. The crescent develops within the red corpuscle from the
small hyaline bodies which gradually increase in size, collect pigment
in their centers, assume a crescentic shape, while the outline of the
corpuscle disappears. The last to disappear is a line connecting the
two horns of the crescent. The dried preijarations, after fixing, are
best stained by the eosinate of methylene blue, as advised by Roman-
owsky. The dye may be purchased ready prepared.
Hcemocjlahin. The relative values of the htemoglobin to the cor-
puscular elements are mentioned in the discussion of the various
subjects. It is to be noted that slight alterations in the amount of
hemoglobin are constantly occurring as the result of diet, weather
and habits. It is influenced by age, climate, country, sex and disease.
The hsemoglobin reaches its lowest value in chlorosis where as low as
15 per cent, has been observed. In this disease the fall in the per;-
centage of hsemoglobin is below the fall in the percentage number of"
■250 EXAMINATTON OF THE BLOOD
the red corpuscles, although these also indicate a marked decrease.
The corpuscles look pale. In Thayer's series the average for the red
iDodies was 4,096,000, while the percentage of hsemoglobin for the
total number was 42 per cent. In one case the corpuscles were 85 per
cent, while the hgemoglobin was only 35 per eeftt. He calls attention
to the fact that there may be, however, well r&^rked actual anemia.
In typhoid fever the haemoglobin often diminishes more rapidly
than the corpuscles.
In septic infections, especially in general septictemia, the same
phenomena may be observed, but generally th'e two keep pace with
•each other.
Blood changes in pernicious ancemia. In progressive pernicious
ansemia, the corpuscular loss exceeds the loss of hsemoglobin, although
the latter may decrease to as low as 20 or 25 per cent, of the normal.
The ratio is important as a diagnostic feature. A fall of red corpus-
cles to half a million is not uncommon and 315,000 has been recorded
by F. P. Henry (Ansemia, Phila., 1887). Megalocytes abound; their
diameter ranging from 10 to 15 micromillimeters as compared with 6.5
to 9.5 for normal cells. Microcytes and poikilocytes are also abundant
in most cases, yet none of these features are pathognomonic.
Minute, highly colored spherical bodies, known as Eichhorst's
corpuscles may abound. Eichhorst regarded them as pathognomonic,
but they are sometimes absent.
Two kinds of nucleated red corpuscles seen in pernicious ancemia
are described by Ehrlich. First, small normal sized corpuscles with
deeply stained nuclei. Second, large forms with pale nuclei which he
calls gigantoblasts. Leucocytes are usually slightly diminished in
number, although the mononuclear white cells may show slight ■ in-
crease. Henry remarks that the red corpuscles in this disease re-
semble the blood of the lower animals in numb^% shape and size, and
amount of haemoglobin.
In the latter stages of leuksemia the same ratio as the above is
frequently noted.
Blood changes in gastric carcinoma. In carcinoma of the stom-
ach the blood changes ofttimes so nearly coincide with those of per-
nicious auEemia a,s to lead to error.
In Osier's series the average of corpuscles in 59 cases was
3,700,000, and the average hsemoglobin in the same series was 45 per
•cent. The corpuscles varied between 1,000,000 and 6,000,000 while
PLATE XX.
PERNICIOUS AN-^MIA.
EXAMINATION OP THE BLOOD 251
the hemoglobin only fell as low as 30 per cent. The leucocytes ex-
■ceeded 20,000 per cu. mm. in three cases, and exceeded 12,000 per cu.
mm. in eighteen cases.
Blood changes in leuktnnia. (a) Spleno-medullary form. In
■all forms of leuksemia the diagnosis must be made by the examina-
tion of the blood, as it alone offers distinctive features. The blood
pictures are most striking and significant. In the commoner form,
the lieno-myelogenic, the change is the increase in colorless corpuscles.
The normal average of white cells per cu. mm. of blood during health
has been stated. Their ratio to the red cells is set down as 1 to 500
or 1 to 1,000. In leukeemia the proportion may be 1 to 10 or less.
One to 1 is not unknown. The eosinophiles maintain their proper pro-
portion to the other white cells, hence their^ total increase is very
large and their presence in the stained field is striking. Their sizes
vary greatly. The polynuclear neutrophiles may maintain normal
proportions early in the disease, but frequently diminish in the later
stages. The greatest increase is in those cells not normally found in
the blood, the myelocytes of Ehrlich. They are marrow cells and are
much larger than the large mononuclear leueqcytes, from which they
further differ by having their protoplasms filled with fine neutro-
philic granules. (See classification, 6a.) Eosinophilic myelocytes are
.also plentiful. (Classif. 6b.)
Mast cells (polynuclear cells with coarse basophilic granules, 5b)
are always present in considerable number and may be even more
plentiful than the eosinophiles (Osier).
Red cells. The normal red cells are only moderately reduced in
spleno-medullary leukffimia, seldom falling below 2,000,000, but nor-
moblasts or nucleated red cells are present, some with large pale
nuclei, some showing evidence of mitosis, and gigantoblasts are
present. The hemoglobin value is usually reduced. Ameboid move-
ment is feeble. Charcot's crystals separate out from the leukemic
blood which is kept for a short time.
(b) Lymphatic Leukemia. As the name indicates in this form
the principal changes occur in the lymph apparatus, and in the blood
those cells which are derived from the lymph gland predominate, viz :
Lymphocytes. The proportion of colorless cells to red cells is less
pronounced, seldom if ever reaching 1 to 10; the increase consisting
-almost solely of lymphocytes, which may be either the small forms or
.the large cell lymphocytes (2-a) which approa,ch in size the poly-
252 EXAMINATION OF THE BLOOD
nuclear leucoctyes (3-b). In the purely lymphatic form of the dis-
ease, myelocytes are not present and eosinophiles and nucleated red
corpuscles are rare, but in the mixed forms, which occasionally occur
the blood picture is a union of the two described.
The diagnosis presents only one difficulty ; to- distinguish it from
ordinary leucocytosis. This, however, should present no great obstacle
since in all ordinary leucocytoses the increase take's place solely in the
polynuclear neutrophilic cells (3-b).
Estimation of Hwmoglobin in Blood. The simplest method of
estimating the percentage of hb. is by Tallquists's>color scale. {Nofh-
nayel's Handhuch . Bhrlich and Lazarus.) This scale is a series of
lithographed tints resembling the color of bloody containing various,
percentages of hb. ranging by tens from 100 to 10. The blood-drop
is caught on a piece of filter paper and compared directly to the color
scale by daylight. Little books of suitable filter paper are sold with
the scale. While great accuracy is not attained by this method yet
valuable conclusions may be drawn. As normal blood varies between
100 and 90 per cent it cannot be said that a decrease below the nor-
mal percentage has occurred until the latter degree has been passed.
Tallquist noticed that in stains of blood taken from patients suffer-
ing with pernicious anaemia the colored center was surrounded by a
zone of varying width, u.ncolored in some cases, or colored a faint yel-
low. He observed the same thing in various other anaamias includ-
ing chlorosis, and concludes that when the nimbus is entirely uncol-
ored, as viewed by transmitted light, the corpuscles have fallen to one-
half the normal number or less, and that the greater the decimination,
the broader the zone.
A very suitable instrument for the general practitioner for esti-
mating hb. is Growers' hfemoglobinometer, to be recommended by rea-
son of its low cost and the ease with which it may be used. Results
obtained from the better grades of this instrument, will probably prove
more reliable and accurate to the general worker than would those of
the more complicated instruments of Dare, Oliver or von Fleischl
which are better suited to the skilled laboratory technician than to
the needs of the general practitioner. The apparatus consists of two
small tubes of equal height and diameter, which stand upright in a
wooden base. One is closed and contains a colored solution which cor-
responds in color to a 1 per cent, solution of normal blood in water.
The other, open at the top, is graduated into cu. mm. by a number
m
^tf^
# • ^
§
PLATE XXI.
LEUKAEMIA.
EXAMINATION OF THE BLOOD
253
scale. A laueet, a dropper and a capillary pipette marked at 20 cu.
mm., with suction tube, complete the apparatus. A few drops of
water are placed in the open tube, the finger is punctured, the blood
drawn into the pipette to the mark and immediately discharged into
the graduated tube, refilled with water to recover all remaining blood,
and this added to the graduate. The tube is now well-shaken and com-
pared with the scale by standing at such an angle that the edges join
each other in the line of sight, Water is added little by little, shaking
the tube after each addition. The percentage is indicated on the scale
when the colors exactly correspond.
es' New I [remoglobinometer and Colorimetei'.
Description.
The blood pipette is .shown at W. It consists of two small glass plates, one
transparent, one white, with a capillary space between, into which the blood to be
examined is automatically drawn, undihited. The plates fit into the detach-
able clamp, X, and are held evenly in position by the thumbscrew. After filling
the capillary tube, the clamp and tube are placed in clamp holder, white glass
outwards, as shown in the drawing, where they are held in place by grooved
guides in the fixed bracket.
Fig. A shows the color scale. It consists of a prism of colored glass, E,
a semicircle of white glass, F, on the edge^ H, of which is etched the percentage
index of haemoglobin. G is hole or hub by which the scale is fixed in case, S,
allowing rotation. I is a white glass disc which serves as background for the
colors.
Fig. B shows instrument ready for use with candle illumination, Y. The
color scale has been placed in the metal case, S, and is rotated by milled wheel,
R, The li,ght falls equally upon the exposed white .glass discs, V and W. The
observer views them through the detachable camera tube, U. T, is a movable
screen to shade the observer's eye. When the colors exactly correspond, the
percentage indicated is read at; the scale opening, Z. Th drawings are one-half
actual size.
254 EXAMINATION OF THE BLOOD
Eodgkin's Disease. . The blood shows little that is characteristic-
apart from simple anaemia of varying grades. The red corpuscles may
sink to 2,000,000. They show only moderate poikilocytosis. The white
corpuscles may show a moderate increase, with abundant lymphocytes.
Occasionally the white cells increase inordinately and resemble the
characters found in lymphatic leukemia.
Purpura. The blood changes are those of ansemia with the hb.
line below the corpuscular line.
Addison's Disease. Anaemia is generally present according to
Addison, but sometimes is wanting. In Wilson's case the blood re-
sembled pernicious antemia.
Splenic Ancemia. This is described as a profound anemia with-
out leucocytosis, and often without marked poikilocytosis.
Pulmonary Tuberculosis. References to the blood changes are
included in the general description of the malady. Recent investi-
gations by UUom and Craig show that when a cavity is present there
is a constant mild ansmia, associated with a decrease of the htemo-
globin. They find that an increase of the erythrocytes in cases with-
out cavity is a favorable symptom. A decrease of leucocytes in ad-
vanced cases is unfavorable. They regard an actual increase of
lymphocytes as indicating an increase in the resistance on the part
of the organism against the tuberculous infection, hence su^ch increase
as well as augmentation of the transitional forms, is to be regarded
as favorable.
SECTION X-III.
DISEASES OF THE ABDOMEN.
The abdominal cavity contains many and varied organs whose
physiologic offices, while they differ exceedingly are yet closely re-
lated to one another in that they contribute to a common end. Yet
in spite of this relationship it may be said that disease of one or the-
other, whatever may be its nature, gives rise to no symptom group or
correlated phenomena in any way comparable to those associated with,
disease above the diaphragm. Secretion or excretion may be altered,,
function may be changed or even abrogated as the result of disease,
yet inter-dependent symptoms and inferential physical signs are not
a consequence. Perhaps the one exception to this statement is that
changes in the blood are apt to be associated with alteration and dis-
ease of each of these organs.
For these reasons physical exploration of the abdomen presents
many more difficulties and yields less fruitful and less satisfactory
results than when the same methods are applied to the thoracic organs.
Nor is the reason therefor far to seek. The abdominal organs are
many, the thoracic few; the abdominal organs are packed in a loose
cavity with distensible walls, and their size constantly changes with,
their functions. The thoracic walls are almost unyielding, the posi-
tion of the organs is fixed and their capacity but little changed even
in severe disease. The contents of the abdominal organs may be solids,
liquids or gases, or an admixture of all of these ; some may be greatly
distended or totally collapsed, as the stomach, intestines, urinary
bladder, gall bladder and uterus ; while heart and lungs are subject to
but little variation. Lastly the action of the thorax and its organs is
regular and rhythmical ; that of the abdomen and its viscera irregular
and intermittent.
The same methods are used which we have seen applied to the
thorax but their relative importance changes. Inspection and palpa-
tion yield most valuable information here, while auscultation, the most
important in thoracic exploration, is of relatively little importance
256 DISEASES OP THE ABDOMEN
when applied to the abdomen. The most favorable position for ex-
amination of the abdomen is in many cases the erect posture, although
recumbency is often necessitated by the form of sickness, or in order
to secure complete relaxation. The knee-breast or knee-elbow posi-
tions furnishes most information in cases of movable organs, tumors
and dropsies. Not only should the front, but alSo the sides and the
back, be examined. Eelaxation is secured by elevating the shoulders
and gently flexing the thighs. Anassthesia must sometimes be re-
sorted to.
Anatomy. Whether the segmentation of the abdomen into nine
areas has survived the test of time because it is of practical value, or
whether it is due to innate conservatism is questionable. Certain it is
that the divisions are based neither on substantial anatomic grounds
nor warranted by convenience. Variations in the descriptions as found
in existing text-books are innumerable and the hope of uniformity is
remote. Anderson's suggestion that the boundary lines be converted
into planes, defined on the dorsal as well as on the ventral surfaces is
here adopted. The plan, however, was originally suggested many
years ago by Dr. Bright. The abdominal organs vary widely in their
positions within physiologic limits, hence their positions and relations
can be described only with approximate correctness.
Two horizontal planes are passed through the .abdomen, the upper
at the lowest point of the tenth costal cartilage. This_ plane lies about
two inches above the umbilicus, marks the lowest anterior point of the
costal border and cuts the second lumbar vertebra posteriorly. It cuts
through the transverse colon, the stomach, ascending and descending
colon, the lower curvature of the duodenum, the small intestines and
the kidneys.
The second plane passes horizontally backward through the an-
terior superior iliac spines into the pelvis.
A third plane carried across the true pelvis at the upper level of
the symphysis cuts the distended bladder, the fundus uteri, the ova-
ries and Fallopian tubes, the small intestines, the cfficum or lower
part of the ascending colon, the sigmoid flexure and the upper end of
the rectum.
For the longitudinal planes as pointed out by Anderson the outer
borders of the recti muscles — extending from the infra-costal furrow
above to the spine of the pubis below — ^have the advantage of easy
location and of giving much greater symmetry to the regions de-
DISEASES OF THE AbOOMEN
257
Fig. 64 — The abdominal organs viewed from behind. The diaphragm partly re-
moved. From Cunningham's Anatomy, by permission of Wm. Wood & Co.
DISEASES OE THE ABDOMEIN 259
limited, than the old vertical lines bisecting Poupart's iio'aments.
The rectal lines, furthermore, bring the inguinal region entirely into-
one division. The vertical planes cut the transverse colon, the small
intestine and kidneys. The ovaries lie at the intersection with the
pubic plane. Further, the right plane cuts the gall bladder, the
cfficum ; the left cuts the stomach, the pancreas, the spleen and the
sigmoid flexure.
METHODS OF EXAMINATION.
Inspection. The shape of the ideal abdomen is flatly elliptical
with a slight depression marking the umbilicus, a shallow central
groove and two vertical lines delineating the inner and outer edges^
of the recti muscles, and three transverse lines marking the muscle
Fig. 6s — A convenient position for palpation of the= abdominal organs, whichi
may be used in home or office. Especially useful in searching for small,
growths of pylorus.
into zones. It is seldom seen except in well-developed, muscular young
men. I have never observed the transverse lines in women. They are-
absent in the very young and those past fifty years.
The size and shape of the abdomen vary greatlj' in health and^
its appearance is measurably modified by eettain physiologic condi-
tions. The abdomen of the child is considerably larger in proportion,
to the size of the chest than is that of the adult. Again in old age-
the abdomen is apt to increase in its volume while the thorax shrinks,
thus renewing the disproportion. It is more apt to become voluminous
with advancing years in women than in men, and repeated preg-
nancies leave an indelible stamp. A full meal distends its upper-
portion.
260 DISEASES OF THE ABDOMEN
Probably as an inherited tendency the waist circumference varies
more in women than in men. Its disproportion to the girth of the
thorax is greater, and in the higher orders of^society where lacing has
been longer and more strenuously practised the effects are much more
marked than in the lower orders, as evinced by our immigrants. It
tends to displace the liver and the free end of the stomach downward,
as well as to unduly contract the lower ribs which are greatly in-
creased in their inclination, lessening the costal angle and diminishing
the lower intercostal spaces.
The pelvic portion of the abdomen is proportionally longer in
women and the distance from the xyphoid cartilage to the sj^mphysis
pubis varies more than in men, thus giving the female more "waist"
and less chest length. We note the size and shape of the abdomen
and observe its movements, and look for changes which may result
from such alterations. Alterations in the shape of the abdomen due
to disease consist in enlargements or retractions of its walls.
Enlargements of the abdomen may be general and symmetrical,
or local and irregular. General enlargements are caused by accumu-
lations of gas within the intestinal canal, particularly within the
colon (tympanites) as occurs in typhoid fever; by fluid accumula-
tions within the peritoneal cavity (ascites) or in the parietal tissues
(oedema) ; by tumors or new-growths, in which ease the enlargement
ma,y be local or general.
Local enlargements are in the main due to hypertrophy of some
special organ as the liver, the spleen, the kidney or the ovary, to
hernias or rarely to enlargements of the mesenteric glands, or accumu-
lations of fteces. Local inflammations such as appendicitis often show
local swelling. The descent of the diaphragm and the bulging in the
epigastrium due to fluids in the thoracic cavity has been mentioned.
Retraction of the walls is seen in all forms of acute febrile and
wasting diseases as typhoid fever, tuberculosis and cancer. It occurs
and is progressive in intestinal strictures and in stenosis of the gastric
orifices. Infective and catarrhal diseases of the bowels accompanied
by diarrhoea, tuberculosis, meningitis and some other cerebral diseases
rapidly produce it. It is extreme in lead colic.
Alterations in the movements of the abdomen indicate change in
the respiratory rhythm or in the peristalsis. In the unrestricted
belly the walls rise and fall with the excursions of the diaphragm. In
disease they may increase with the latter or vice versa. Thus in suprn-
UPPER MAMARV
LOWER MAMMARt
PLATE XXII.
ANTERIOR SURFACE TOPOGRAPHY AND REGIONAL LINES.
A. Aorta.
LV. Left Ventricle.
RV. Right Ventricle.
P. Pulmonary valve.
A' Aortic valve.
M. Mitral valve.
T. Tricuspid valve.
G. Bl, Gall Bladder.
DISEASES OF THE ABDOMEN 261
diaphragmatic inflammation, as pleurisy and pericarditis, the muscles
are increased in their play, while in inflammations below the partition,
as peritonitis or intra-peritoneal growths or colic, their movements are
held in abeyance and the costal type of respiration prevails. In
thin-walled individuals the outlines of some of the organs and the
movements of peristalsis are frequently apparent, and with the loss
of , adipose in the course of wasting diseases they become so. Semi-
rhythmical, contractions and relaxations of the abdominal muscles are
not unusual, especially in the sick, and the shifting of gaseous accumu-
lation, accompanied by noise, is a common event. The great curvature
of a well-inflated stomach may be easily traced.
We examine the state of the skin, whether soft, rough or smooth ;.
moist or dry and branny. Its color, whetheri it indicates jaundice or
impeded circulation. We note distention of veins and capillaries, es-
pecially in the umbilical zone already described, and the frequently
transmitted epigastric pulsation which is sometimes mistaken for
aneurysm-.
Palpation. In order to secure the best results from palpation,
the comj)lete relaxation of the parietal walls is necessary. To accom-
plish this, place the patient upon a hard mattress with the legs and
thighs partially flexed. It is necessary to change the position from
the back to the side, or to the knee-breast posture in detecting the-
presence of fluids, movable tumors or fluctuation.
The hand should be well-warmed so as not to cause involuntary
shrinking and contraction. The side of the hand or the tips of all
the fingers used together is preferable to the single finger. Punching-
and poking are to be avoided. The pressure must vary with the end
sought; slight, forcible, continuous or interrupted, being singly or
alternately used; care being exercised not t^ cause useless pain by
unnecessary repetition.
Note whether the skin is hot, indicating= fever or inflammation,,
or cold, indicating chill or deficient circulation; whether the tissues;
are unusually relaxed or resisting and elastic and whether any oedema
exists.
The examination of the contained organs determines their size
and position, whether fixed or movable and whether pulsation is
present ; their consistency and outline, whether smooth, nodular, tense,
tender, softened or hardened.
262 DISEASES OF THE ABDOMEN
Fremitus due to eularged spleen or liver may occasionally be
detected.
Fluctuation means the presence of fluid. Jn order to detect it
the examiner places one hand at the distal part of the collection, and
laps upon the overlying surface. The peculiar Stroke communicated
to the hand hy the fluid set into vibration is called fluctuation. Cir-
cumscribed fluctuation is distinguished from fluctuation due to fluids
free in the cavity by its area and position and by not gravitating
freely with changes in the posture of the patient. Such collections
■occur in ovarian cvsts, ligamentous cysts, hydatids of the liver ami
po,ssibly in cy.stic kidney. Encysted collections of pus or other fluids
limited by peritoneal adhesions, fluids distending the fallopian tubes,
and abscess of the abdominal vails, may also give rise to localized
fluctuation. /
Pain may be superficial or deep and the amount and kind o)'
pressure necessary to produce it determine this fact. The charactei-
of the pain and the manner in which it is influenced by . palpation
have no little significance. Pains due to inflammation of the bowels
or other miicous membranes are dull, heavy and continuous and
require considerable pressure to manifest them; Pain arising from
inflammation of the serous coverings, the peritoneum, is sharp and
cutting, subject to exacerbations and increased by slight pressure.
Colicky pains, nerve pains or neuralgias are often relieved by firjn
pressure, although a touch may cause a painful- spasm, which distin-
guishes them from the tenderness resulting from inflammatory
troubles.
Palpation includes vaginal and rectal examinations, for fuUei-
details upon which subjects the reader is referred to special works.
Pcrcussioit. By percussion we determine the size and position of
the various organs, their relations to each other atod even gain consid-
erable information as to their conteTits, siTice the note varies unmis-
takably therewith. The position of the patient best suited for per-
cussion is recumbency upon the back, as for palpation. The fingers
furnish the best plexor and pleximeter, and the variations in the
note elicited are so manifest and so readily recognized that the student
will do well to familiarize himself with their qualities before essaying
thoracic adventures. These notes are dull, flat and tympanitic ac-
cording to the point chosen and the organ per6ussed. The body of
the liver, the spleen and the kidneys give forth a perfectly flat note,
DISEASES OF THE ABDOMEN 263
while their edges which overlap the stomach, colon or intestines give
a varying dull note. The small intestines, the colon and the stomach
give a full tympanitic note, \s'hich may be characterized as small,
medium and large for the three viscera in .the order named. The
separation of the three organs nevertheless reSquires considerable deli-
cacy of discrimination, by reason of the variations of the note which
arise from different conditions of these viscera. Thus, each may be
distended to its fullest capacity by gaseous or solid contents, or may be
in a state of collapse, or they may be partly filled. In each condition
the note for the same organ will differ. The quality of the note varies
hut little, being tympanitic in all cases except when the viscus is
filled with solid matter, but the pitch varies widely. As stated in our
preliminary considerations, pitch rises with the tension but diminishes
as the enclosed air volume increases, provided the tension remains
the same.
From the foregoing it will be seen that the note of large tympany,
or stomach tympany gotten by percussing a moderately distended
stomach which is normally the lowest pitched sound obtainable from
the human body, rises in pitch if the gas so distends the stomach as
to increase its tension, when the note may become metallic or amphoric.
The intestines, being smaller cavities, give a higher pitched note
than the stomach; the tension being equal, this note is higher for the
small intestine than for the colon.
Increase in size of the solid organs, as well as new solid growths,
are recognizable by the extension of their area of flatness; thus, en-
larged liver, kidneys, spleen, uterus, tumors of ovary, womb or
mesenteric glands or aneurysm of the great vessel may be recognized
and their limits determined. A full bladder gives us an area of
dullness above the symphysis, where intestinal tympany replaces it
v/hen emptied. So too, distentions of the hollow viscera manifest
themselves by a change in the percussion note,, the tympany increasing
with the distention.
It will thus be seen that intelligent percussion furnishes valuable
results. In order to obtain the full benefits the areas must be care-
fully gone over from side to side and from above downward with a
stroke of varying strength ; now light, to elicit superficial resonance ;
now medium, to determine relative dullness; and strong, to demon-
strate deep-seated, covered-in flatness.
264 DISEASES OF THE ABDOMEN
The percussion areas of the various organs will be given in . detail
along with the consideration of their diseases.
The state of the abdominal walls rfiay interfere with the satis-
factory examination of the organs ; thus accumulation of fat seriously
influences palpation and the percussion note. Contraction and spasm
of the parietal muscles, as occurs in beginning peritonitis, or the uni-
lateral contraction of the rectus as seen in appendicitis, may retard
the examination yet contribute to its diagnosis. CEdema of the walls,
such as occurs in chronic Bright 's disease, seriously interferes with
the examination.
Auscultation. Over the abdominal tract no sounds are heard in
health save the whirr of the blood through the aorta, the shifting of
gas in the intestines known as "borborygmi" and, certain churning
sounds of a somewhat metallic character which arise from the mixed
contents, solids, liquids and gases, of the" stomach.
In disease the bruit of an aneurysm may be present. A friction
fremitus due to two inflamed surfaces of peritoneum rubbing together
is much rarer than friction sounds in the region above. A blowing
thrill or murmur is sometimes heard over the spleen when that organ
is enlarged.
The placental bruit and the sounds of the foetal heart belong
mote properly to the field of obstetrics, but are pathognomonic of
the pregnant state,
DISEASES OF THE PERITONEUM.
The peritoneum lines the entire abdominal cavity and as so re-
fleeted as to enclose wholly or partly all the contained viscera, vessels
and structures.
PERITONITIS. INFLAMMATION OF THE PERITONEUM.
Classification: Acute, chronic; primary, secondary; local, gen-
eral; simple, septic.
Morbid varieties: Fibrinous, serous, purulent.
Symptoms: Pain; severe, cutting, piercing, griping. In puer-
peral cases less severe. Tenderness. Seat of pain and seat of tender-
ness may not coincide. Chill; vomiting, early and severe. Vomited
matter ; food, bile and even fasces.
Fever: Generally 101° to 103°; evening rise.
Pulse : Rapid, increases with disease, 130 to 140.
DISEASES OF THE ABDOMEN 265-'
Eespirations : Superficial, painful, shallow. May be 30 to iO
per minute.
Physical signs : Patient lies on the back with the knees flexed.
Abdominal walls at first tense and retracted, resistant. Diminution
or suppression of abdominal breathing; thoracic breathing increased.
Later abdomen sweUs and becomes tympanitic, resistance passes.
Disappearance of liver dullness points to presence of gas free-
in the peritoneal cavity, but previous adhesions may hold the liver
against the parietal wall or a coil of distended intestine may inter-
vene and replace the dullness. Pain is manifest on slight touch, but
actual seat of tenderness is only determined by firm pressure. Fluid,
indicated by fluctuation, gravitates into the cavity while the intestines
float on top. Dull area shifts with the changes of position. Hiccough
may indicate involvement of the diaphragm, covering. Friction or
crepitation is often heard. Heart is displaced upwards or outwards,
apex may be in the fourth interspace and heart and liver dullness be
found in the third interspace.
Urine scanty, dark, heavy, contains alburtiin and indican in large
quantity. Simple test: Shake together eqilal parts of HCl and
urine, then add three drops of a freshly-made, saturated solution of
chlorinated lime. Indican is indicated by the dark blue color which
immediately succeeds.
In the chronic variety the chief manifestation is a collection of
fluid in the peritoneal cavity. The collection occurs independently of
tuberculosis, cancer and causes of ascites.
THE STOMACH.
When the stomach is empty, or not distended with gas, its out-
line and position are not indicated by any prominences on the outer
wall, and palpation as well as inspection fails to furnish any informa-
tion as to its location. Since, however, the viscus is seldom if ever in
a state of collapse, percussion gives us a tympanitic resonance so
distinctive and drum-like as to enable us to differentiate it from the
neighboring organs. The flatness of the percussion note which marks
the liver area limits the stomach above and easily determines its
upper boundary. The inner border of the spleen limits the fundus on
the left. The degree of obliquity of the stomach is still a matter of
dispute, the merits of which we will ignore at present, stating what
we consider the most accurate views. When the stomach is distended
266 DISEASES OF THE ABDOMEN
the fundus and greater curvature rotate to th^ front, and come in
immediate contact with the abdominal wall. This portion is trian-
gular in shape, bounded on the right and above by the liver, on the
left by the costal edge as low as the ninth. The free border or greater
curvature can be determined by percussion. Begin above at the edge
of the liver and percuss gently downwards from this line of dullness
until a slight alteration in the pitch of the tympanitic percussion note
indicates that the transverse colon has been reached. This line, which
marks the greater curvature of the stomach, bows downward from the
free end of the tenth rib on the left, crosses the" middle line a little
Fig. 66 — Normal position of the stomach, according to Rosenheim (solid line).
Dotted line, normal position according to ]i.ichhorst.
above the umbilicus (1" to 2"), thence curves upward to the edge of
the thorax where it meets the right parasternal line. ^
The cardiac end or fundus reaches as high as the sixth cartilage
being behind the heart apex. The cardiac orifice is opposite the
seventh left costal cartilage about one inch from the sternum
(Treves).
The pylorus varies, but its most frequent position is to the right
of the middle line two to three inches below the sterno-xyphoid articu-
lation. This point corresponds with the level of the twelfth thoracic
spine,
DISEASES OF THE ABDOMEN 267
For diagnostic purposes the stomach may be distended either by
inflating it with air or by means of an effervescing- powder. Air may
be introduced through the stomach tube by means of a hand bulb.
The powder consists of a teaspoonful of tartaric acid dissolved in a
half-tumberful of water and swallowed, '.-^ be immediately followed
by a teaspoonful of sodium bi-earbonate also dissolved in a half-
tumblerful of water and the gas retained. The' resulting distention is
usually visible and the outline may be thus determined.
Knapp describes a simple method for locating the lower border of
the stomach, which I have found useful.
The patient, standing erect with the abdomen covered, drinks a
glass of cold water. After the lapse of half a minute the examiner
places his hand, which must not be cold, against the bare abdomen.
The lower limit of the cold region is quite definite, and denotes the
position of the fundus and greater curvature of the organ.
Lincoln, by a method of transillumination of the stomach by the
use of fluorescin, gives results bparing upon the position of the lower
border of the viscus in thirty cases. In four he found it above the
umbilicus, in four at the level of the umbilicus, in twenty-two below
that level. He leads us to infer that only eleven of those examined
had gastroptosis ; and concludes that the stomacL* lies much lower in
the healthy individual, male and female, than generally has been
described.
Enlargements of the stomach may be recognized by palpation and
percussion; diminution in its size cannot be told by physical
-exploration.
Increase in the size of the stomach may be temporary or per-
manent. Temporary distentions are of daily occurrence and cannot
be regarded as pathologic. They are caused by accumulations of gas
or the ingestion of large quantities of liquids or solids. Treves gives
the average capacity of the stomach as about five pints (two to three
litres). This is certainly too great, three points (1% litres) being
more nearly correct. The elder Leidy used to say that stomachs
which have never been over-distended were filled Jjy a pint but couJd
be stretched to two quarts (two litres).
Gaseous distention of the stomach is recognized by the note of
large tympany heard over an extended area. It should not be difE-
cult to separate this sound from the note of the colon, unless the
latter is also greatly distended. When the stomach is distended by
268 DISEASES OF THE ABDOMEN
liquid or solid contents the normal tympanitic note is wanting, a ail
the dull area which replaces it will extend from the liver edge down
to the umbilicus, and outward on the left until it fuses with the
splenic dullness. When the stomach is partly filled, as some time
after a meal, the contents gravitate to the dependent part or cul-de-
sac and the dullness is limited to that portion of the organ. For the
purpose of detecting these conditions percussion should be made with.
Fig. i)^ — Position of stomach in moderate gastroptosis (Rosenheim's description). .
the patient standing. In case the viscus is empty this is sufficient,
but if partially filled the percussion should first be made with the
patient erect, noting the dull area, then ret)eated with the patient
lying upon his back, when the dull area will he replaced by the char-
acteristic tympany.
Almost all forms of dyspepsia and conditions in which stasis of
the gastric contents occurs are associated with gas formation and tem-
porary distention. The stomachs of beer-drinkers are apt to be dis-
tended. The increase in size may be permanent, as in gastrectasia,
which is a permanent increase in the volume and capacity of the-
stomach, arising from muscular atony, or in pyloric obstruction, in;.
DISEASES OF THE ABDOMEN 269
which the condition is brought about by the gradual stretching of the
Tv'alls by the retained contents.
Physical signs of Gastrectasia. Inspection may reveal the out-
lines of the organ, especially the greater curvature, which extends as
low as the navel and even lower. As these cases are very generally
accompanied by descent of the organ, the upper curvature may some-
times show itself circling beneath the ensiform cartilage.
Palpation. The air cushion sensation is often recognizable by
the touch.
Percussion furnishes trustworthy evidences of dilatation. We
begin above and percuss downward to the colon, observing the pre-
cautions mentioned as to the change of position of the patient. If
the viscus is empty the ingestion of a large glass of water will cause
the lower tympanitic border to be replaced by dullness when the
patient is erect. The double percussion is conclusive. If doubt re-
mains a stiff sound may be passed and the end felt through the
abdominal wall, or the sound may be pushed along the great curvature
until it encounters the resistance of the pylorus and the abnormal
■distance noted. If the lower limit of the stomach reaches below the
navel the conclusion that the organ is dilated is justifiable. The
stomach tube may be used for filling the organ with water in order to
■displace the tympanitic note, but is seldom necessary.
CANCER OF THE STOMACH.
One in five of all primary cancers attacks the stomach, about
two-thirds of the cases attack the pylorus.
Inspection. In the early stages, negative. After cachexia and
emaciation set in the tumor may be visible.
Palpation. Tenderness may be present long before a tumor can
be felt. When palpable, tumor of the pylorus is generally situated
near the umbilicus, owing to the displacement caused by dilatation,
and is freely movable, changing its position with varying conditions
of the organ and the body.
Percussion gives an area of dullness — not flatness — over the tumor
wherever it may be situated. The percussion should be performed
when the stomach is empty or has been washed out, when the contrast
•of tympany and muffled dullness is more manifest. Pyloric stenosis,
which results in most cases, causes gastric dilatation with the physical
270 DISEASES OF THE ABDOMEN
signs of that condition. Sometimes peristalsis, stopping short at the
pylorus, may be seen.
Other symptoms are those of dyspepsia and debility ; vomit which
contains blood ("coffee grounds"); diminished or absence of HCl
and the presence of lactic acid in the stomach contents.
■ DISEASES OF THE SMALL ll^TESTINE.
Anatomy. The small intestine extends from the pylorus to its
junction with the large intestine in the right iliac fossa and has an
average length of seven meters. It is divided into the duodenum,
30 centimeters long; three-fifths of the remainder constitutes the
jejunum, the balance forming the ileum. There is little histologic
distinction between the two structures. T^o kinds of glands are
found in the walls, secretory — the glands of Brunner and Lieber-
kiihn — and the agminated glands or Peyer's patches and the solitary
follicles.
Peristalsis. During digestion the gut is subject to certain move-
ments designed to propel forward its' contents, called peristalsis.
These movements are wave-like — peristalsis proper — pendular and
rolling. Violent painful peristalsis is called tormina.
The functions of the intestines are absorption and excretion. A
considerable quantity of gas is always found within the lumen, derived
from the stomach, the blood or formed within the canal (see Faeces).
Previous diseases, habits, occupation, diet and the use of special
substances as alcohol, tobacco or drugs should be the subject of careful
inquiry in intestinal affections.
The principal facts to be elicited are as to the existence of
(a) Pain; its seat, character, duration, relation to digestion,
evacuations, eructations and food ingestion; how influenced by rest,
motion or pressure.
(b) Tympanites. Sudden tympanites should suggest obstruc-
tion, especially if inability to pass gas co-exists.
(c) Constipation, its duration and nature.
(d) Diarrhoea, the character of the stools (see Section XVI),
(e) Tenesmus. This usually indicates an affection of the large
intestine.
The maladies of the small intestine individually considered do
not give rise to definite correlated groups of distinctive physical signs,
hence these manifestations may be considered together, afterwards
DISEASES OP THE ABDOMEN 271.
pointing out the differential characters along with the special,
symptoms.
Inspection is not limited to the abdomen; but the chest, the back
and the anal region should be carefully viewed. The examination is.
best made upon a hard bed or couch with as perfect relaxation as.
possible. The import of various superficial vascular conditions is.
referred to elsewhere. Irregularities of contour, the condition of the
skin, the presence of ascites or oedema are especially to be noted.
Ewalt says small new-growths are often easier to recognize by in-
spection than by palpation. Wasting diseases, cancer, the cachexias,,
lead-colic and meningitis give rise to ^depressed or scaphoid abdomen.
The contour and outline should be inspected with the eyes on a level
with the surface, viewed during full inspiration and forced expira-
tion. Irregularities are sometimes revealed by voluntaryv muscular-
contraction of the walls.
In nervous and emaciated persons, particularly the convalescent,,
and in those with relaxed abdominal walls peristalsis is visible. If
general and confined to the small intestine it is not especially signifi-
cant. Stopping short at a given point it indicates obstruction. Vis-
ible peristalsis of the large intestine is pathologic and not infrequently
points to stenosis. It is also found in neurotics. During attacks of
colic sudden forceful peristaltic discharges — tormina — (accompanied;
by shifting gaseous contents) are often visible.
Palpation. The desirability of a warm room and warm hands-
has been mentioned. Palpate first the superficial parts, then the
deeper regions, examining first with the patient on the back, then
on either side, lastly in the knee-elbow position. A number of writers,
advise palpation in a warm bath.
After a careful examination of the parietes, the deep palpation-
beat proceeds from above downward, not omitting the inguinal and
femoral canals. The course of the large intestine should be separately
followed. The sigmoid flexure is easily palpated. An increasing
number of observers, since Edebohls, claim ability to palpate the-
appendix — certainly a difficult task.
We note by palpation irregularities of distention, pain, sensitive-
ness, tenderness, succussion, adhesions, new-growths, faecal accumu-
lations. As to the last, differentiation has been sufficiently dwelt on.
New-growths are much oftener malignant than benign. The size,,
mobility, consistency, contour and location are noteworthy..
272 DISEASES OP THE ABDOMEN
Cancer, sarcoma and tubercular growths are the most frequent.
The first are irregular, hard, nodular ancj seldom attain large size.
The second smooth, hard and may be large.
The third vary in consistency, are diffused, occur in young sub-
jects and are often associated with tuberculosis elsewhere. Diarrhoea
accompanies these while the former are associated with constipation.
Percussion. General directions upon abdominal percussion and
the results obtained by percussing different areas have been given.
We search for departures from the normal note. Successive examina-
tions, especially after freely evacuating the biowels, are recommended.
The character and differences in the soutods elicited have been
described.
Auscultation reveals intestinal sounds such as succussion, bor-
borygmi and gurglings. Little of practical value is educed from
their presence. Their absence is significant of paralysis of the bowel,
as in appendicitis, or of perforation, in which case there is total
absence of all bowel sounds. In stenosis the sounds are increased.
Gurgling in the right iliac fossa, formerly considered a diagnostic
feature of typhoid fever, has no clinical value.
ULCER OF THE DUODENUM.
These occur at any age, even in the new-born, but are most fre-
quent between the ages of thirty and fifty. Men are more frequently
affected than women. The symptoms are similar to those of gastric
ulcer, for which the disease is apt to be mistaken. The special symp-
tom is pain which appears several hours after eating. The situation
of this pain is on the right parasternal line just below the gall bladder.
It has been found that diminishing the acidity of the gastric juice or
temporarily suppressing its flow through the pylorus relieves this
pain, a feature which distinguishes the disease from gastric ulcer.
Administering acid wines or food accomplishes the purpose. Tender-
ness, reflex vomiting, hsematemesis and blood in the stools summarize
the symptoms. The gastric contents give no definite indications. Per-
foration or fatal haemorrhage may occur.
ACUTE AND CHRONIC INTESTINAL CATARRH.
These may be classed as infectious, alimentary, climatic, medicinal
ajid toxic catarrhs. The first is primary or a complica.tion of existing
•disease ; the second includes the larger ma;jarity of aU eases.
DISEASES OP THE ABDOMEN 273
The general symptoms are pain, nausea, diarrhoea with much or
little mucus. The presence of green bile in the dejecta indicates that
the disease is in the upper intestine. General lassitude and weakness
supervene. 'The stomach is often involved. Fever is slight or absent.
The urine is scanty and not seldom albuminous.
The diagnosis is easy. Large masses of mucus and an admixture
of blood with the faces point to the large intestine as the seat of the
disease. Local tenderness aids in locating it. The main symptom is
the altered condition of the fseces.
The symptoms of the chronic form are similar but less acute.
Constipation is not incompatible with this form, a fact to be remem-
bered. Constipation and diarrhoea may alternate in chronic catarrh.
Membranous colitis is a form of catarrh accompanied by painful
spasm of the intestine, alteration of function and the occurrence in
the stools of mucus which assumes the form^ of membrane or casts.
Females are usually the subjects of the disease and constipation marks
the preponderance of the cases.
Intestinal obstruction or stenosis may affect the small or the large
bowel. The causes are formation of ligamentous bands, the occur-
rence of hernia, impaction by gall stones, foreign bodies (food, fsecal
impactions), intestinal concretions, compression from organs or
growths and intussusception. Band or slit strangulation and intus-
susception account for ninety per cent, of the cases. Dilatation
develops above the obstruction and is greater the nearer the difficulty
is to the rectum. For this reason when the jejunum is the seat,
involvement and over-distention of the stomach quickly intervene.
Constipation comes on as soon as obstruction is complete but may have
been preceded by diarrhoea. The peristalsis is augmented and is visible,
occurring in intermittent painful spasms. The character of the stool
is not significant. In certain cases bile is constantly found in the
stomach. The subjective symptoms are loss of appetite and strength,
nausea, fullness and a peculiar distress. Eructations and vomiting
mark most cases. Visible peristalsis and intestinal rigidity are the
most important physical signs. Suddenly developed constipation,
resistant to cathartics, occurring in one of re^lar habits shoiild excite
grave suspicion, particularly if the patient is of advanced age.
Complete, rapidly-developed obstruction involving one or more
intestinal coils, is called ileus. The symptoms are great pain, nausea,
vomiting and suppression of fteces and gas. The vomiting if con-
274 DISEASES OF THE ABDOMEN
tinned becomes stercoraeeous. Incarcerated hernia is the most fre-
(jiient and potent cause. Tympanites develops, bnt spasmodic peris-
talsis is generally absent. The distended and, resistant portion of the
intestine before the obstruction can generally be recognized by pal-
pation and inspection. In hernia, palpation, recognizes the incar-
cerated bowel by the impulse communicated on coughing.
Obstruction may be mistaken for biliary or renal colic, but the
history, the presence of jaundice, enlarged, tender liver or kidney,
bile, blood or other foreign substance in the urine aid in recognizing
these while marked indicanuria points to obstruction. The symptoms
tending to exclude peritonitis are given therejinder.
Volvulus is a twist of the intestine upon its mesentery, or a
knotting of two or more intestinal coils. The sigmoid flexure is
oftenest involved, next the ascending colon.
As a rule it is an accident of late or middle life.
Pain, absence of fajces and flatus, local tympanites and vomiting
are present. Tenesmus is inconstant. The faeces below the twist,
when evacuated, may contain blood. Constipation resistant to cathar-
tics follows.
Palpation. Sometimes the flexion can be palpated, or we may
discover in the lower abdomen near the median line a resistant, air-
cushion tumor of varying size.
Percussion evolves dullness or tympany according as the sigmoid
is full or empty. Metallic tinkling is occasionally heard. The imme-
diate return of water injected into the rectum and the ability to inject
only small quantities aid in the diagnosis.
Intussusception is the invagination of one portion of the intestine
within the lumen of another portion. It may occur at any age, but is
especially prone to affect infants and young; children, and appears
suddenly.
Symptoms. Spasmodic pain, tenesmus, blood in the stools, which
continue until the distal portion of the bowel is evacuated, and the
presence of a palpable tumor, hard and sausage-like, over the ascend-
ing or transverse colon make certain the diagnosis. Blood in the stool
is found in over eighty per cent, of the cases. Intussusception oc-
curring during the death agony is not to be mistaken, when found
post-mortem, for the above.
DISEASES OP THE ABDOMEN 275
GALL STONE DISEASE.
Synonyms: Cholelithiasis, Hepatic Colic, Lithogenous Biliary
Catarrh.
Defiiiitio)i. An acute or chronic affection of the gall bladder
and duets, generally inflammatory, resultin*g in the formation of
calculi.
Bacterial invasion is a potent, if not the sole, cause.
The sufferers are generally women who have borne children ;■
persons between the ages of thirty-five and fifty. In many cases
stones exist without causing inconvenience. Stones are single and
large, or multiple and small. Permanent obstruction of the cystic
duct results in dropsical enlargement of the bladder — hydrops vesicm
fellece — which results in a cystic tumor discernible in the upper
abdomen, and easily recognized.
The general symptoms of the colic are produced by the passage
of the stone through the duct or by its lodgment therein. The former
is the cause of ordinary biliary colic.
Symptoms. Pain, severe, even agonizing, which comes on sud-
denly. Generally centering in the right hypochondriac region it
radiates over the epigastrium, lower thoracic region and into the right
.shoulder and arm.
Palpation. Tenderness which centers oyer the gall bladder is'
manifest and the bladder may be palpable. "With relaxed abdominat
walls gall 'stone crepitus is occasionally felt when the bladder is not
over-filled with stones and its walls are not tbo tense. Occasionally
the muscles of the right side are rigid. Enlargement and tenderness
of the liver, and enlargement of the spleen, are discoverable by palpa-
tion and percussion. When the, stone reaches and blockades the com-
mon duct it produces jaundice, which may bet slight and transient, or
intense and protracted. The colic lasts hours or days, ending sud-
denly with the discharge of the calculus into the bowel. (For recov-
ery and recognition of gall stones, see Section XVI,) Rigor and
chill are occasional. Fever is generally present; temperatures of
102° — 103° are common, 105° is exceptional. Vomiting and pro-
tracted nausea are usual. The urine contains bile when jaundice
occurs, and bile in the urine frequently precedes its manifestation in
other localities. Albumin and red blood eprpuscles are found in
most cases.
276 DISEASES OF THE ABDOMEN
Differential Diagnosis. The location of" the excruciating pain
and tenderness are almost sufficient. If jaundice occurs the diagnosis
is sure. Stone should always be sought for in the stools. History
of previous attacks greatly aids. ,
From renal colic it differs in the location and character of the
pain. There the pain is in the lower abdomen, radiates to groin and
testicle; icterus is not present, nor is bile found in the urine. Gas-
tralgia is without chill, fever or jaundice ; voiniting is rare. Pressure
and food ingestion afford relief. The attacks are periodical and asso-
ciated with general nervous manifestations.
APPENDICITIS.
Definition. An inflammation of the vermiform appendix caused
by the invasion of micro-organisms. The disease may be acuts or
chronic.
The recognized varieties are : Catarrhal, Interstitial, Ulcerative,
Gangrenous.
The effects of extension of the inflammation beyond its original
bounds are circumscribed or diffuse abscess, and peritonitis which
may be limited or general. These results are brought about by exten-
sion of inflammation, by perforation or by gangrene.
Catarrhal appendicitis may result in immunity from further
attacks by adhesion of the contiguous surfaces producing obliteration
OMEN
Cancel- and tuberculosis of the omentum: give rise to ascites and
the general symptoms of the diseases. In a case of cancer occurring in
my own practice, small, hard nodules were early detected in the omen-
tum, which gave the sensation on palpation of small chips of wood
laid upon the intestines.
Percussion in cancer is woodlike, overlying tympany, until the
fluid accumulates.
ASCITES.
An accumulation of serous fluid free within the abdominal cavity
is termed ascites.
The causes are local and general.
Local ca.nses are : Inflammations of the peritoneum, simple or
tubercular; cancer of the peritoneum.
Obstruction of the portal circulation within the liver, as in
cirrhosis and chronic passive congestion, or, in the branches of the
gastro-hepatic omentum by new-growths, peritonitis or aneurysm.
Pressure upon other vessels, as in the ascites associated with
ovarian dropsy, due to pressure exerted by the growth.
Ascites accompanying enlargements of the spleen.
General causes are those which producd general anasarca, and
include organic heart and lung diseases, chronic Bright 's disease, and
hydrsemia. Here the cause may operate directly or mechanically. In
heart disease, when ascites occurs without general oedema, secondary
changes in the liver should be sought for. Pulmonary emphysema
and cirrhosis of the lung exhibit ascites as terminal symptoms. The
various kidney lesions associated with ascites have been mentioned.
Inspection. The abdomen is imiformly enlarged, and when the
patient lies on the back the flanks flare outward. The umbilicus is
prominent and protrvxdes on standing. In old and recurrent cases the
linese albicantes show. In cirrhosis, the superficial veins are prom-
inent and the caput Medusae may be present (see Liver Diseases).
Palpatiem. Fluctuation is easily felt by placing one hand over
the lateral area and smartly tapping on the opposite side. The fluctu-
ation is more apparent if the patient sharply- depresses the linea alba
with a thin book or cardboard.
Small effusions are palpable by placing the patient in the knee-
Ijreast position when the fluid gravitates to the dependent part and
floats the intestines away. In case of large effusions difficulty may
DISEASES OP THE ABDOMEN 295
«
be experienced in palpating the abdominal organs. This may be over-
come by suddenly deeply indenting the walls with the linger-tips in
the desired locality, in order to displace the flliid. In cases of consid-
erable tension even this fails.
Percussion. The area of dullness surrounds the tympanitic area
of floating intestines when the patient is in the dorsal position, hence
the lateral areas are dull, and the height of the dullness rises as the
fluid increases. The line separating dullness and tympany is sharply-
defined, and when marked out is ovoid in shape.
The dullness is movable. When the patient is placed on the side
the region of the upper flank, previously dull, becomes tympanitic.
Effusions too small to give rise to dullness with the patient on the
back are' easily discovered by placing him in the knee-breast position.
The diagnosis of ovarian ascites from free peritoneal ascites has
been given. The principal diagnostic point is the recognition of the
causative condition. The heart and lungs show positive signs of oih-
ease when the dropsical stage is reached, and the dyspnoea is out of
proportion to the pressure caused by the fluid. The liver shows
enlargement and the superficial veins are its sign-board. The urine
gives evidence of Bright 's disease. Cancer of the omentum can be
felt as lumpy enlargements directly under the skin. Fever, hectic,
wasting and night-sweats point to tuberculosis. Percussion shows en-
larged spleen. Blood examination demonstrates its relationship to
the condition.
SECTION XIV.
EXAMINATION OF THE STOMACH
CONTENTS.
Introduction. The gastric fluid is a thin, almost colorless liquid,
acid in reaction, with a sp. gr. of 1001 to 1010. The analysis varies
greatly with different conditions and different observers. The fol-
lowing is approximate (Schmidt) :
Water 994.4
Organic substances, pepsin 3.2
Hydrochloric acid 0.2
Sodium chloride 1.5
Potassium chloride 0.5
Other inorganic salts 0.2
1000.
The total acidity varies between 0.10 and 0.30. The free acid
varies between 0.10 and 0.30, normally only reaching the latter point
on a carbo-hydrate diet. Ordinarily on nitrogenous diet it does not
exceed the minimal figure.
The secretion of gastric juice begins immediately upon the inges-
tion of food but the hydrochloric acid ' conta:ined in the first portions
secreted combines rapidly with the ingested proteids and their con-
tained inorganic salts, the product being acid proteids and acid salts.
The chief mineral salts are the di-sodic and di-potassic phosphates,
which are converted into the corresponding acid phosphates. For this
reason free hydrochloric acid is not found in the stomach contents
■> until a varying time after eating, depending upon the character and
amount of food ingested. After an ordinary meal, free acid appears
in healthy stomachs in from forty-five minutes to one hour, and the
amount gradually increases as digestion proceeds, reaching its height
towards the conclusion of gastric conversion.
EXAMINATION OF THE STOMACH CONTENTS 29T
Fats and starches in superabundance delay its appearance. After
the Ewald test-meal free acid should appear in twenty minutes.
. , With ordinary diet lactic acid is very generally found in the
stomach contents in small amounts, and under certain circumstances,
butyric and other organic acids may appear, without being manifesta-
tions of disease. In gastric catarrh, ansemia, during the course of
fevers, pepsin and hydrochloric acid are considerably reduced. Hydro-
chloric acid is increased in gastric ulcer and in nervous dyspepsia
(hyperchlorhydria), and in those queer cases of super-secretion of
Reichmann and Rossbach (gastroxynsis).
Fermentative changes may cause lactic and butyric acid to ap-^
pear in large amounts in the fluid, aeeoihpanied by gaseous distention
and sour, gaseous eructations. Excessive mucus accompanies catarrhal
inflammations. Blood, bile, fragrants of growths, albumin, ammoniunn
carbonate and urea occur in special conditions.
The clinical examination of the gastric fluid is practically limited
to the determination of: ,,
(a) The reaction.
(b) Total acidity.
(c) Presence of free acid and of acid salts.
(d) Presence of free hydrochloric acid.
(e) Organic acids.
(f ) Presence of syntonin, peptone and the pepsin strength.
The volumetric analysis can be performed readily by those pos-
sessing even slight skill in laboratory maniptilations. The necessary
apparatus is simple and inexpensive. The standard or volumetric-
solutions are easily prepared or may be purchased from competent,
pharmacists.
The necessary apparatus is :
A 50 e. c. burette, graduated to 0.1 c. c.
A graduated pipette, and one or two graduated cylinders ; one or
two flasks, capacity 500 c.c. ; or a litre, and necessary test tubes.
EXAMINATION OF THE GASTRIC CONTENTS.
The examination of the gastric contents for clinical purposes, such
as ascertaining the state of the secretion, the motor function of the
stomach, the presence or absence of abnormal substances and the-
products of gastric digestion, has approached almost to a routine pro-
cedure. After fasting all night, or, better, after washing out the
-298 EXAMINATION OF THE STOMACH CONTENTS
stomach, the patient is given a test-breakfast. Ewald's is simplest
and most used, consisting of an ordinary baker's roll eaten dry, and
300 c.c. of weak tea, without milk or sugar, or a like quantity of warm
water. Such a "meal" contains little or no lactic acid, the presence
of which is the objection to most proposed test-meals. The Boas' test-
meal, consisting of a gruel made of a tablespoonful of oatmeal boiled
in a litre of water, may be used for estimating lactic acid. One hour
after ingestion the residue is removed with the stomach tube and
examined. The residue should be about 40 c. e. After noting the
quantity, odor, color, consistence, and amount of mucus, a small por-
tion is examined with the microscope to determine the nature of the
Fig. 70 — Stomach Tube with Syphon Bulb.
".residue and the presence of anatomic elements. The remainder is well-
shaken, filtered, and the clear filtrate tested as;soon as possible.
Reaction. The normal reaction of the gastric juice is decidedly
-acid, due to hydrochloric acid, acid salts (NaH^PO^), occasionally to
organic acids and carbonic acid. During digestion free organic acids,
acid albumins, consisting of combinations of hydrochloric acid and
organic acids with the proteids of the food, and the acid salts (acid
iSodiXim and acid potassium phosphates) also add to the acidity.
Lactic acid should not be present after the oatmeal breakfast. Its
-sources are, fermentation of the stomach contents due to retention —
^deficiency of the motor function and to pyloric obstruction — and to
the introduction of sarcolaetic acid into the stomach with foods.
'Butyric and acetic acid are fermentation products. In gastric carci-
.noma, lactic acid is found after the test-breakfast. The reaction is
EXAMINATION OF THE STOMACH CONTENTS
299
■determined with litmus paper which acids turn red. Other substances
used as acid indicators are :
NAME OF Dye
Phenolphthalein
Congo- red
Tropeolin
Litmus
Dimethyl-amido-azo benzol
Alizarin-sulphonate of sodium —
Boas' resorcin sol., Resorin, 5 gm.
cane sugar, 3 gm.; alcoliol, {95-* )
100 c. c ,
Gunzburg's Solution. Phloro
gkicin, 2 gm.; vanillin, i gm.
Alcoliol (%^i, 100 c. c
i4 in
Alcohol
Water
1+ Sol.
Water
Water
0.5 ' in
Alcohol
Water
i« Sol.
Alcohol
Alcohol
Color
WITH
Acids
Colorless
Blue
Red
Red
Cherry
Yellow
Pink
Pink
Color
WITH
Alkalies
Pink or
Red
Claret
Yellow
Blue
Yellow
Violet
Colorless
Light
Brown
Reacts
WITH
All. Acids
Free Acids
Only
All Acids
All Acids
Free
Mineral
Acids
Free Acids
and
Acid Salts
Free
Mineral
Acids
Free
Mineral
Acids
Sensitiveness
Extreme
H CI — 0.1 in 1000
Lactic--o.2 in 1000
H CI = 0.3 in 1000
Extreme
H CI ^ 0.2 in 1000
H CI =0.2 in 1000
H CI =0.5 in 1000
H C 1 = 0.5 in 1000
Dried papers colored with the above solutions are convenient for
testing. By testing the filtered gastric contents successively with
three papers colored with the above dyes, we may determine whether it
is acid (litmus) ; whether the acidity is from free acid (congo-red) ;
and whether free hydrochloric acid is present (azobenzol). If the
congo-red paper, blued by free acid, is gently warmed the blue color
is discharged when it is due solely to organic acids, but remains if pro-
-duced by hydrochloric acid. Boas' resorcin- solution is more stable
than Gunzburg 's solution, and equally sensitive. It is used thus :
A few drops of the reagent are spread= upon a porcelain dish,
which is gently heated ; a glass rod dipped in the gastric fluid is drawn
across the field. Free hydrochloric acid causes a scarlet streak to ap-
pear. If the acid is present in small quantity the streak appears only
on complete evaporation. Previous filtration is not necessary. Pro-
teids, acid salts and organic acids do not interfere with the test. One
part of hydrochloric acid in 20,000 parts of water is detected by the
method.
Organic Acids. — The sources of lactic, acetic and butyric acid
-have been mentioned. The presence of more than a trace of organic
300 EXAMINATION OF THE STOMXCH CONTENTS
acid in the stomach after the test-meal should be regarded as patho-
logic. Butyric acid has an odor like that of rancid butter and can
generally be detected by the smell. Acetic acid has a vinegar-like
odor, which is emphasized by boiling.
The tests may be applied to the mixed fluid or the organic acids
may be extracted with ether.
Method : 5 c, c. of the gastric fluid are boiled with three drops of
hydrochloric acid until syrupy in consistence. After cooling add a
small quantity of ether, shake well, decant into a basin, add ether
again and repeat. The ether is evaporated, the residue redissolved in
a few drops of water and tested.
The most important of the organic acids is lactic acid and it
occurs in larger amount and more frequently than the others. As
stated, the presence of organic acids results whenever the food is too
long retained in the stomach, and occurs when hydrocholoric acid is
deficient, in dilation of the stomach, deficiency of its motor func-
tion, in cancer and in stenosis of the pylorus.
The breakfast of oatmeal-gruel contains no lactates, and is supe-
rior to the Ewald meal.
Tests : Dilute solutions of ferric chloride turn canary-yellow on
contact with lactic acid (Uifelmann's test). A few drops of dilute
neutral solution of ferric chloride are mixed with a fourth the
quantity of carbolic acid, and water added until a clear amethyst
color is obtained. Lactic acid in the proportion of 1 to 2,000 instantly
changes the blue color to yellow. Lactates produce the same result,
but as their clinical significance is the same, it does not interfere with
the test. Sugar, alcohol and certain salts, as phosphates, are capable
of changing the color. Butyric acid, 5 parts in 1,000, changes Uffel-,
mann's reagent to a tawny-red color. The quantitative determination
of organic acids is rarely necessary for clinical purposes.
(a) Quantitative estimation of the total acidity.
Method ; 10 c. c. of the filtered fluid are accurately measured into
a beaker and three drops of the phenolphthalein solution are added.
The burette is filled with =^ NaOH solution* which is added until
*Which means a decinormal solution. A nprmal solution is made by dis-
solving the molecular weight in grams of this substance in a litre of water. A
decinormal solution is cue-tenth of that strength. In the case of NaOH, 40
grams to the litre constitutes a normal solution, but owing to the impossibility
of obtaining pure sodium hydroxide, the solution must be standardized by titra-
tion against a normal sokition of oxalic acid and corrected as follows : 50 grams
EXAMINATIONi OF THE STOMACH CONTENTS 301
a permanent pink color is produced in the beaker. Near the comple-
tion of the test, each drop produces a pink cloud which disappears
on stirring with the glass rod, until neutralization occurs, when a sin-
gle drop produces a permanent shade. The= number of c. c. of the
deeinormal alkaline solution used multiplied by .00364 equals the
weight in grams of hydrochloric acid in ten c. e. of gastric fluid. This
multiplied by ten gives the percentage.
The decimal .00364 represents the weight of HCl. neutralized by
1 c. c. of the NaOH. solution.
(b) The estimation of free hydrochloric acid.
Topfers method : To 10 c. c. of gastric fluid add three or four drops
of a 0.5 per cent, alcoholic solution of dimethyl-amido-azobenzol.
The deeinormal solution of NaOH is run from the burette until the
red color changes to a pure yellow. This reaction is not affected by
combined hydrochloric acid nor organic acids, unless 0.2 per cent, of
lactic acid be present. The calculation is made by multiplication as
before.
The test may be made by using Boas' resorcin solution if pre-
ferred. A few drops of this solution are spread on a piece of ground
glass and dried. The ^ NaOH soluiion is added from the burette
to the 10 c. c. of Altered gastric fluid minus the indicator, as before,
until a drop of the solution removed with the rod fails to react by giv-
ing a pink color when drawn across the warmed plate. Blowing upon
the plate intensifies and hastens the color production.
(c) Estimation of combined hydrochloric acid. Here alizarin-
sulphonate of sodium in 1 per cent, aqueous solution is used as an in-
dicator, which reacts with all acid elements except acid albuminates.
The alkali is added as before to 10 c. c. of gastric fluid, colored
with three drops of the indicator, until a clear reddish-violet color is
attained, which is not reached until free acid^ acid salts and orgastic
acids have been neutralized. As the color produced in the alizarin
test is not easily recognized by the inexperienced, a 1 per cent, solii-
of best NaOH are dissolved in a litre of water. loc.c. of this solution are placed
in a beaker and 3 drops of the l per cent, alcoholic solution of phenolphthalein
are added for an indicator. From the burette is dropped sufficient of the normal
oxalic acid solution (63 grams to i litre) to just discharge the pink color. If
each solution were normal equal volumes would exactly neutralize each other.
Suppose I2C.C. of the acid were required, then the NaOH solution is 12-10
strength instead of 10-10, hence must be weakened by additions of the difference
in c.c. of water, which is in this case 2-10. In other words 20 c.c. of water
must be added to every looc.c. of the hydroxide solution to render it normal.
302 EXAMINATION OF THE STOMACH CONTENTS
tion of sodium phosphate or sodium carbonate may be colored with the
indicator and used for comparison. It wdll be seen that the difference
between the number of c. c. used in this titration and that used in
the estimation of total acidity by the (a) phenolphthalein method
equals the number of c. c. necessary to neutralize the combined hydro-
chloric acid. Hence by these three tests we get the total acidity (a),
the free acid (b), the combined acidity by subtracting (c) from (a).
The organic acids and acid salts together are found by adding (b) to
(a) minus (c) and subtracting the sum from (a).
Free acids and acid salts. A simple method of determining
whether acidity is due to free acid or to acid salts is by the addititm
of calcium carbonate, CaCO,. Free hydrochloric acid decomposes the
carbonate and is neutralized, while acid sodium phosphate, NaPL
PO4, is unaffected. If therefore the acidity disappears it was due to
hydrochloric acid, if diminished, as shoVn by the color reaction to
test-paper, the remaining acidity is due to acid salts. The test may
also be used quantitatively by determining the total acidity before and
after the addition of the carbonate (Leo]s test).
Significance of hydrochloric acid. In the acute stages of fevers,
hydrochloric acid is temporarily diminished. In dilatation of the
stomach, atrophic gastritis, amyloid degeneration, some forms of nerv-
ous dyspepsia, ansemias, cachexias, and, Addison's disease hydro-
chloric acid is permanently diminished. It is generally absent in can-
cer, especially if accompanied by extensive gastritis, and may be ab-
sent in chronic gastric catarrh and extensive degeneration.
DIGESTION PRODUCTS,
To determine the efficacy of the digestive function we may ex-
amine the products formed in the stomach during the conversion of
proteids into peptones. When the albuminous compounds named
proteids are submitted to the^digestive action of pepsin, trypsin, ren-
nin and certain other enzymes, intermediate products are produced in
the course of the conversion, which finally become peptones. These
intermediates are termed albumoses or proteoses and the process is
named proteolysis. When pepsin in the presence of hydrochloric acid
is the proteolytic agent a small proportion of the proteid is first con-
verted into acid-albumin, which may be precipitated by neutralizing
the fluid during the early stages of digestion. At a later stage it dis-
appears and other albumoses appear a§ the result of hydrolysis.
EXAMINATION OF THE STOMACH; CONTENTS 303-
Some of these substances should be present in the residue of the test-
meal removed at the end of an hour, others do not appear until a
much longer period. Native proteids, albumin and globulin are pre-
cipitated by slightly acidulating and boiling.
Acid albumin is precipitated by exactly neutralizing the solu-
tion. The ^ NaOH may be used with phenolphthalein as the in-
dicator.
Primary albumoses, which may be taken to represent the next
step, are obtained by first removing the native proteids and acid:
albumin as above, then saturating the filtrate with MgSO^.
Secondary albumoses/ Filter out the above primary albumoses
and saturate the filtrate with (NH^)2 SO^. Filter and test the filtrate
for peptone. Peptones are tested for by the biuret reaction, viz : To ■
the above filtrate add one c. c. of KOH or NaOH and two drops of
CuSO^ solution, a rose or red color indicates peptone.
Little peptone is found in the stomach at: any time as the result
of gastric proteolysis. Whether this is due to the fact that the pro-
cess stops short of its formation, as is held by Ewald and Gumlich,.
or to the immediate absorption when formed, is undecided. Even
from the small intestine it rapidly disappears.
Starch. The salivary diastase continues the conversion of starch
into dextrin and maltose until free hydrochloric acid appears, which-
after an ordinary meal may be delayed forty minutes to one hour,
when the conversion should be complete. The process is called
amylolysis. At the end of this time iodine should give no blue color.
Brythrodextrin gives a reddish- violet color with aqueous solution of
iodine. The blue or purple reaction indicates faulty or deficient dias-
tase in the saliva or excessive acidity of the gastric juice.
Pepsin. The efficacy of the pepsin is tested by noting its action-
on discs of coagulated albumin — ^the white of boiled eggs. When
hydrochloric acid is present pepsin is rarely absent from the gastric
juice. In its absence pepsinogen may be present and is converted into-
pepsin by the hydrochloric acid. Two tests should be made ; one with
5 e. e. of the filtered fluid, the other with the -fluid plus two drops of
hydrochloric acid, using discs of equal size and thickness, cut from
the egg. The test tubes are kept at a temperature of 100 F., and ex-
amined occcasionally to ascertain the effects. If no liquefaction oc-
curs, pepsin is absent. If liquefaction occurs only in the tube to whiclt
acid has been added, this substance is needed to develop the ferment..
:30'4 EXAMINATION OF THE STOMACH CONTENTS
Bennin. Carefully neutralize 5 c. c. of gastric fluid and also 5
"C. c. of milk. Mix: if rennin is present coagulation occurs in ten to
fifteen minutes.
The rapidity with which stomachic absorption takes place is as-
•certained by noting the time at which the iodine reaction occurs in
the saliva after administration of potassium iodide. A capsule, care-
fully wiped, containing three grains of KI is administered and at the
end of five minutes and each succeeding minute, the saliva is tested
with strips of bibulous paper which have been previously soaked in
starch paste and dried. The papers are moistened" on the tongue, then
touched with a drop of commercial nitric acid, which always contains
traces of nitrous acid. Iodine is liberated and a blue spot is produced.
The reaction should occur in ten to fifteen minutes. When the reac-
tion is delayed twenty minutes or more absorption is abnormally de-
layed and indicates disease of the mucosa.
The motor function of the stomach is conveniently determined
by Ewald's salol test or by Fleischer's method.
Qastric peristalsis pumps the portions of prepared food products
which are not directly absorbed from the stomach, through the
jjylorus. The stomach peristalsis begins about fifteen minutes after
food ingestion, and gradually becomes more and more energetic until
the end of stomach digestion, which lasts four or five hours. Dila-
4;ation of the stomach, weakening or degeneration of its muscular
■coats and pyloric stenosis interfere with the food transfer, and the
-contents are retained abnormally long in the stomach. On the other
hand I have frequently found that in persons suffering from intes-
tinal indigestion of the catarrhal order, with the production of
■diarrhoea, the stomach peristalsis is abnormally active. Fleischer ad-
ministers a capsule containing about two grains of iodoform, which
is not decomposed in the stomach but which is converted into iodide .of
; sodium in the duodenum. The capsule is administered with the test-
breakfast and iodine should appear in the saliva in from 55 to 100
minutes.
Both the motor and absorption powers are determined by remov-
ing the residue of the test-breakfast after the lapse of stated times,
.-and noting the amount. After two and a half hours, there should be
nO residue.
Klemperer introduces 100 c. c. olive oil into the washed-out
EXAMINATION OF THE STOMACH CONTENTS 305
stomach and removes the unabsorbed portion after two hours, to de-
termine the amount.
Bwald administers a capsule containing ten grains of salol, which
is not absorbed in the stomach, but which splits into phenol and sali-
cylic acid in the duodenum. Salicylic acid should appear in the urine
in one hour or one hour and a quarter after administration. A drop
of urine is caught on a piece of filter paper. On touching the middle
of the drop with a drop of 10 per cent, solution of ferric chloride a
violet rim appears around the spot.-
Mucus. "When not apparent to the eye = in the vomit or in the
residue, mucus is not in excess. It is increased in all catarrhal and
inflammatory conditions and then occurs in ropy, stringy masses. In
■chronic alcoholics and drug habitues it reaches excessive proportions.
Mucus is recognized by shaking the sediment with dilute NaOH, fil-
tering and precipitating the dissolved mucus by the addition of acetic
acid.
MACROSOPIC EXAMINATION OF THE RESIDUE.
The quantity, character, amount, color, odor and proportion of
mucus are noted. The residue removed five or six hours after an ordi-
nary meal furnishes us more information upon these points than does
the test-meal. Particles of food from preceding meals may be found.
In cases of acute summer gastritis it is not rare to find in the vomit
remnants of food ingested twenty-four to forty-eight hours previously.
Excess of proteids indicates deficient acidity. Excess of starch indi-
cates excess of acidity.
Bile and blood are visible to the eye when present in any quan-
tity.
MICROSCOPIC EXAMINATION.
Food particles may be identified, blood and pus cells, bacteria,
yeast-cells, sarcinas, bile stains and sometimes particles of new-
growths may be recognized. Staining with methyl-blue best demon-
-strates bacteria, which are always present in the stomach and are un-
doubtedly necessary to the digestive function. Only when in excess
or when specific forms, the product of specific disease, are present
can they be considered pathologic. The Boas-Oppler bacillus is
found in carcinoma, and its absence is generally said to indicate the
absence of the growth, although Osier lays more stress upon the pres-
•«nce of lactic acid, which the bacillus is thought by its discoverer to
306 EXAMINATION OF THE STOMACH CONTENTS
be the chief instrument in producing, than' upon the bacillus itself.
Sarcina3 are in excess in pyloric obstruction and dilatation. Fermen-
tation is due to bacterial activity and produces the well-known train
of symptoms named dyspepsia.
SECTION XV.
EXAMINATION OF THE URINE.
The advances made in physiologic chemistry, combined with the
advances made in microscopic technique, have enhanced the ability to
interpret the changes and variations Avhich (*cur in the urine both
with the physiologic and metabolic processes of the body, as well as
in the pathologic digressions to which it is subject, to a degree little
short of certainty. The uninterrupted constancy of the secretion and
the ease ■\^•ith which it may at any time be obtained, offer us an un-
excelled index of the metabolic changes going, on within the economy,.
for it may be said that no pathologic process dan seriously disturb the
normal cell metabolism without producing a change of some charac-
ter in the urine, which preeminently repi'esents the result of that,
process, and more quickly than any other product indicates a dis-
turbance of normal function. Hence the application of urinalysis to
the recognition of disease.
THE UKINE.
Quauiity. The average quantity of urine^ f or healthy individuals
is 1500 c.c, or about fifty ounces, for the twenty-four hours. In order
to determine the per diem amount the patient should be provided with
a clean receptacle Avhich can be tightly covex-ed, capable of holding
the entire quantity. He must be instructed to pass the urine directly
into the container and to void it before each visit to stool. A half-
gallon bottle is a convenient receptacle. The quantity is diminished
by perspiration and exhalations of moistur& and increased activity
of the bowels. Cold and dampness increase it; hence it is somewhat
greater in winter. Great muscular activity, imbibition of large quan-
tities of liquids and over-eating increase the amount; while fasting
and abstemiousness diminish it.
The amount secreted is greatest after mid-day and least during
sleep. The urine is increased in disease — in diabetes, chronic inter-
stitial nephritis and amyloid degeneration of the kidney, and in those
308 EXAMINATION OP THE URINE
forms of cardiac hypertrophy which are accompanied by increased
intratascular pressure. Temporary abundance succeeds attacks of
hysteria and other forms of convulsions.
The urine is decreased in acute Bright 's disease, parenchymatous
nephritis, cirrhosis of the liver, all acute fevers and inflammations
and in active and passive hypersemia of the kidney, as in early
Bright 's disease. The urine may be decidedly lessened or even sup-
pressed in very acute inflammations of the kidneys, by obstruction of
the ureters, by great internal injuries, and in profound shock or col-
lapse, in the algid stage of cholera and in cases of pronounced poison
of infective disease. Complete suppression can not long exist without
being followed by urjemia and death.
Before deciding upon the clinical significance of increase or
diminution of the volume of urine voided, careful inquiry covering
the above points referable to diet and habits should be made.
Composition of the urine. The normal urinary constituents are
derived from the waste products of the liquids and solids ingested and
from the result of retrograde tissue metamorphosis. The urine is
chiefly a solution of urea and certain organic and inorganic salts, hold-
ing in suspension epithelial cells and mucus. Their relative amounts
are given in the following table taken from Parke 's schedule :
Amount of urinary constituents passed in twenty-four hours.
Constituents. Weight 66 kilos.
Grammes.
Water 1500.00
Total solids 72.00
Urea 33.18
Uric acid 0.55
TTippuric acid 0.40
Creatinin 0.91
Pigment and other organic matters 10.00
Sulphuric acid 2.01
Phosphoric acid 3.16
Chlorine ■ 7-8.00
Ammonia 0.77
Potassium .... 2.50
Sodium 11.09
Calcium 0.26
Magnesium 0.21
EXAMINATION OP THE URINE 309
Each 1,000 grains of urine contain about 33 grains of solids, of
which amount 25 grains are organic and 8 to XO grains inorganic.
Changes produced by standing. On standing certain changes are
brought about in the composition of the urine. The rapidity of these^
changes depends on the temperature (being produced much quicker
at high temperatures), the accessibility of micro-organisms and the
composition of the urine as voided, highly-acid urine withstanding the
changes longest. When normal acid urine is allowed to stand in a
tall, conical glass, there appears after some hours a floating cloud
which settles near the bottom, composed of mucus in which is en-
tangled a few bladder epithelial cells. In d cold room this occurs
within two hours. It is named the nubecula. The next substance tO'
be deposited is the reddish or yellowish alkaline urates, sodium, potas-
sium and ammonium, and in cold urine the urates of the alkaline
earths, calcium and magnesium. The latter are held in solution in
warm urine. The next deposit to occur is lific acid, which crystals-
are dark-red or brown in color and which in part replaces the urates,
j^t the same time or a little later form octahedral or envelope crystals
of calcium oxalate. Still later normal urine deposits a sediment com-
posed of phosphates of the alkaline earths — granular, amorphous cal-
cium, phosphate and triangular prismatic crystals of triple phosphate
(ammonio-magnesium phosphate) — often interspersed with dark spicu-
lated spherules of ammonium urate (Purdy);. Upon standing for a
few days all urines become turbid, owing to the swarms of bacteria
which appear in the solution. Such turbidity cannot be removed by
simple filtration, but may be cleared by repeated shakings with pow-
dered charcoal and refiltering.
After a varying time, depending on the factors named, the urea,
is transformed into carbonate of ammonia and the normal acid re-
action is changed to alkaline. The change may come about in forty-
eight hours or not until after the lapse of several days. This change is
spoken of as ammoniacal decomposition and is due to the activity of
certain micro-fungi, as first pointed out by Wormley. By the same
process amorphous urates are transformed into ammonium urate, uric
acid is transposed into triple phosphate, and calcium phosphate is
deposited.
Acid fermentation with the production of acetic and lactic acid
is due to the action of contained mucus. Uric acid and the lu'ates are
310 EXAMINATION OP THE URInI]
precipitated by the process and the acidity diminished. It is not
common.
Color. The normal color of the urine is 'clear-amber or straAV-
eolor, due to the presence of urobilin or urochrom and uroxanthin.
Abnormal coloring is due to blood, bile, melanin, hsemoglobin, vege-
table colorings and those derived from medieiijal sources. Imbibing
large quantities of water renders it paler, and abstinence and strong
diet by concentration increase the color. As a rule both the depth
of color and the acidity increase with the specific gravity and the
increase of the solid constituents, and vice versa.
In disease the urine is deficient in coloring matter when abundant,
as in diabetes, hysteria, interstitial nephritis and amyloid kidney.
In the first it may have a pale-green cast when viewed with trans-
mitted light. Fevers and diseases which concentrate the secretion in-
crease both relatively and absolutely the ameiint of coloring sub-
stances. The presence of blood and hsmoglobip products produces a
red or brown color. Bile pigment gives the i,irine a dirty-greenish
tint. Diabetic urine may also show a faint-greenish tinge. Carbolic
acid and creosote color the fluid dark-brown or black, santonin im-
parts a yellow color.
Odor. The odor of fresh urine varies with' the degree of concen-
tration ; sweetish, aromatic, characteristic, it Jias given rise to the
adjective "urinous." The odor is due to acid derivatives of the
phenyl group. Stale urine is ammoniacal. Putrid urine is due to
the decomposition of mucus and other organic i^ubstances. Poods and
=drugs influence the odor. Asparagus, garlic, cabbage, impart a well-
recognized odor, and the essential and aromatic oils and turpentine
give character to the odor of the urine. Cystitis gives rise to ammo-
niacal urine (Nothnagel says acid). Pyuria lias the odor of pus or
of decompo-sition. The odor of acetone is often noticeable in the
urine of eclampsia and of diabetes.
Reaction. The reaction of fresh normal urine is acid, due to acid
sodium phosphate. The acidity increases for several hours after be-
ing voided, due to the so-called acid fermentation. During this period
a whitish deposit, sometimes pink or red, of acid urate of sodium or
uric acid is deposited, which disappears on warming. The acidity is
least between meals ; early morning urine may be alkaline. Alkalinity
cme to ammonia (inflammatory alkalinity) causes red litmus to turn
blue when moistened therewith, but to resume its original color when
Pate Yellow.
Liqht Yellow-
3
Yellow.
-f.
Reddish Yel lotv.
Yellowish Red.
Brot^nish. Red.
Reddish Brown.
Brvtmish Black,
PLATE XXIV.
VOGEL'S SCALE OP URINE TINTS.
EXAMINATION OP THE UKINE
311
dry. The urine is rendered alkaline by the administration of alkalies,
as soda or potash, the alkaline carbonates or the salts of the vegetable
acids, hence a vegetable diet reduces acidity. Acidity is increased hy
administration of acids, by a meat-diet and by concentration.
Specific Gravity. The normal specific gravity of urine varies
from 1018 to 1022, the average may be placed at 1020, but varies with
food and drink. Meat-diet, active exercise, copious sweating raise it
above this figure. Fluids imbibed lower it. Those forms of Bright 's
Fig. 7t — Squibb's Urinometer.
disease with increased urine are accompanied by diminished specific
gravity, while the acute variety and diseases which diminish or con-
centrate the secretion raise the figures. When in disease the volume
of the urine remains unchanged and the specific gravity falls, it means
faulty elimination and its import is unfavorable. The presence of
sugar raises the specific gravity,- a,nd urine of a specific gravity of 1028
or over should be examined therefor. Squibb's urinometer is recom-
mended for office use. Corrections for temperature in taking the spe-
cific gravity are sometimes necessary in VerJ? hot or cold weather.
The rule is to add one degree of specific gravity for every 10° F. of
the urine above the degree at which your urinometer is standardiz:ed
312 EXAMINATION OP THE URINE
(Squibb 's at 77° F.) and to subtract one degree for each 10° F. be-
low standard.
In using the instrument the bulb of the urinoraeter should be
first completely immersed and care should be taken that it does not
rest in contact with the side of the container.
Transparency. Fresh healthy urine is clear. If urine is turbid
when passed it is pathologic. Mucus renders it cloudy. This cloudi-
ness is unaffected by heat, mineral acids or alkalies, but is increased
by the addition of acetic acid. Precipitates of urates, carbonates and
phosphates render it cloudy. Urates redissolve on the application of
heat, phosphates disappear on the addition of mineral acids. In
fevers, the quantity of urine is occasionally sp small tha.t the urates
separate out before the urine leaves the bladder. This is not infre-
quently the case in pneumonias and in capillary bronchitis of chil-
dren, owing to deficient oxydation. Increase bf turbidity on the ap-
plication of heat is due to organic substances, albumin, pus or blood, or
to earthy phosphates. Increased turbidity on the addition of mineral
acids is due to organic elements.
The amount of solids in the urine is obtained approximately by
multiplying the last two figures of the specific gravity by 2.33. The'
product equals the number of grams per 1,000 c. c. of urine. This,
number is known as Haser's coefficient. By multiplying by 0.233 the
percentage of total solids is at once obtained. For children the-
coefficient is too high, 1.80 should be used.
The average excretion of solids in health for adults is sixty grams
per diem, but decreases about 10 per cent, for each decade after
forty. Decided decrease points to renal insufficiency, and in ne-
phritis portends ursemia. In the course of any acute disease, the elim-
ination of solids should vary with the tempera'ture, since high temper-
ature means active tissue metamorphosis, hence in these conditions-
decrease in solids means faulty elimination.
Of the urinary solids, urea constitutes the greatest proportion,,
being normally from twenty to forty grams in the 1500 c. c. per diem
urine, with an average of thirty-three grams. Urea represents the-
ultimate oxydation of nitrogen in the organism.
Acute sthenic conditions, mental and muscular activity and nitro-
genous foods increase the output of urea. Chronic diseases, asthenic
diseases. Bright 's disease, and diseases of the liver retard the elimina-
tion of urea.
EXAMINATION OF THE URINE
313-
Detection of Urea. Place a few drops of the urine on a glass
slide and add half as many drops of nitric acid. On warming, rhombic
and hexagonal crystals of nitrate of urea are formed and recognized
under the microscope. Fluids which do not give this reaction are not
urine, — a noteworthy point.
Quantitative detenu iuation of urea requires practice. The ure-
ometer of Doremus is sufficiently accurate. The reaction is due to
the fact that when a solution of urea is brought into contact with a
solution of sodium hypobromite, the urea undergoes decomposition.
Fig. 72 — Doremus' Ureometer and Pipette.
with the freeing of all its nitrogen. Thus : CON.J-I^+3NaBrO=CO,+
3NaBr+2H„0+N,.
The long arm of the tube is filled to the bend with the sodium
hypobromite solution liy inverting, and the instrument righted.
Then, with a graduated pipette one c. c. of urine is introduced and
slowly discharged beneath the surface of the solution. The nitrogen
set free rises and the displaced mixture flows into the bulb. After
ten minutes the reading is taken. The scale reads in milligrams,
which indicates the amount per c. c. of urine. Normal urine gives
.02 gm. per c. c. which is two per cent. Another form of scale gives
the percentage or grains per fluid ounce.
The hj^pobromite solution must be freshly prepared as follows :
Dissolve 100 grams of sodium hydroxid iu 250 c. c. water. For use,
814
EXAMINATION OF THE URINE
take 10 c. c. of this solution and add 1 c. c. of. bromine, mix and
■dilute with 10 c. c. water. This amount is sufficient for one test.
Owing to the dangers, the instability and the disagreeable proper-
ties of bromine, I prefer the method of Bartley. A straight tube,
-closed at one end, graduated so as to give the number of grains per
fluid ounce, a pipette holding one c. c. and the ordinary urine pipette
are required. The tube is filled to the fifth division with a twenty
per cent, solution of KBr. Chlorinated soda solution, NaClO (Labar-
raque's), to the fifteenth or twentieth division is added. A small
Fig. 12! — Urea from aqueous solution.
-quantity of pure water is now floated upon the top of these reagents
by inclining the tube and adding the water from the pipette. One
c. c. of urine is now carefully floated upon the water by the same
method. Tightly closing the open end with the thumb the tube is
inverted and shaken. After effervescence ceases the surface reading
of the fluid is noted. Still closed, the tube is pliinged into a pail of
water and the thumb removed. The imprisoned liquid falls and the
tube is immersed until the outer and inner liquids are at the same
level, and the reading again noted. The difference in the two read-
ings is the number of grains of urea in one fluid ounce of urine, which,
multiplied by the number of ounces passed in twenty-four hours,
gives the number of grains per day. A quantity of less than 350
grains per day should be regarded as pathologic.
EXAMINATION OF THE UKINE 315
Uric acid is readily recognized by the microscope. Its various
-crystals are shown in the figure. If urine b'e, kept until ammoniaeal
■decomposition occurs, uric acid crystals deposit. In general, condi-
tions which increase urea increase uric acid.
Dyspnoea and impeded respiration increase it. Bright 's disease
and gout diminish its excretion. The normal amount is 0.6 to 0.8
gms. per day. It is determined by filtering a known quantity of urine
and adding 5 c- e. of HCl to each 100 c. c. After twenty-tour hours
-collect the precipitate on a jjreviously-weighed filter paper, wash, dry,
weigh and deduct the weight of paper. The result is the weight of
uric acid in the amount of urine employed.
Ethereal sulphates in excess in the urine indicate putrefactive
-changes of grave order, within or outside the digestive tract, and the
increase is proportional to the severity of the process.
Phenol potassium sulphate and indican are representatives of this
group. Both indoxyl-potassium sulphate and indolyl-sulphuric acid
are known as indican, and respond to the same tests. Excess of this
substance indicates putrefaction of albtimin with absorption of indol.
It especially points to obstruction of the small intestine. In purulent
pleurisy and peritonitis it occurs in abundance. It is increased in
wasting diseases .and starvation, hence is found in phthisis and cancer,
likewise in dysentery, typhoid fever and acute brain diseases. In
bealth the urine contains a mere trace of the ethereal sulphates.
Detection. ]Mix equal quantities of urine and strong HCl in a
test tube, add drop by drop a freshly made saturated solution of
chlorinated lime (bleaching powder) or chloriile water, until the solu-
tion fails to darken on further addition. Shake the blue solution
with chloroform which takes up the indican and indicates by the
■depth of its color, the amount present.
Inorganic Constituents. The chlorides are the principal inor-
ganic constituent of the urine and the quantity excreted averages
10 to 15 grams daily, thus ranking next to urea. The excretion of the
■chlorides is lessened in all acute febrile diseases, in dropsies and serous
■exudations. In grave cases of pneumonia they may disappear from
the urine. In rheumatism their sudden disappearance should arouse
the suspicion of endocarditis or pericarditis. Their reappearance or
'increase is favorable from a prognostic point in all these conditions.
The chlorides are precipitated by solutions of nitrate of silver.
316 EXAMINATION OF THE URINif
In most cases an approximate estimate of their quantity is all that
is necessary to the clinician. I have used the following :
Add to a volume of urine a few drops of nitric acid, then a solu-
tion of AgNOj (1 to 20) . The chloride of silver falls as a white, curdy
precipitate which should occupy one-fourth of the volume of the
urine taken. If the precipitate, after standing, occupies much mor&
or less than this volume the chlorides are increased or diminished. A
counter-test with normal urine always should be made for comparison.
The silver nitrate solution should be added, drop by drop, until its.
further addition fails to produce a precipitate.
Ultzmann's method: A standard solution of nitrate of silver,
one drachm to the ounce, is prepared. To half-arglass of urine add a
few drops of nitric acid, then one or two drops of the silver solution.
"If a white, flaky precipitate occurs, quickly sinking to the bottom
without diffusing, the chlorides are undiminished. If simple cloud-
iness, without curdy flakes, appears and readily diffuses, the chlorides-
are diminished to 0.1 per cent, (normal, 0.5 to 1.0' per cent.). Should
no precipitate Occur the chlorides are absent. ' '
Phosphates. The amount of phosphoric acid in the day's urine
varies between 2.5 and 3.5 grams, excreted as alkaline and earthy
phosphates.
The earthy phosphates are insoluble in alkaline urine and on
heating the precipitate is increased and may be mistaken for albumin.
They disappear on the addition of acid, while albumin remains.
Triple phosphates are not present in normal urine when voided, but
form on standing. In cystitic urine they are found. The acidity of
the urine depends upon the presence of acid sodium phosphate. Acute
fevers, gout, most kidney diseases and pregnancy diminish the phos-
phates. Wastings, especially osteo-malacia and rickets increase their
excretion.
The earthy phosphates are precipitated by rendering the urine
alkaline and heating.
The alkaline phosphates are precipitated by magnesium mixture,
which is composed of MgSOj^ and NH^Cl, each one part ; aq. ammonia,,
one part ; water, eight parts.
The sulphates in the urine increase or diminish in general with,
the urea.
~ r^'- ...■.■■'Mi''-- r < M, i^J'::. T- ^ ."■/"
PLATE XXV.
Triple phosphate; ammonium urate; bacteria.
Alkaline fermentation.
EXAMINATION OF THE UBINE 3] 7
ABNORMAL CONSTITUENTS QP THE URINE.
Albumin. Of all the abnormal constituents of the urine, from a
clinical standpoint, the greatest interest centers upon albumin and
its significance. Briefly summarized, its presence means alteration in
the structure of the kidney, alteration in the composition of the blood
or of blood pressure.
1. Albuminuria without coarse renal lesions is a matter of dis-
pute. After cold-bathing, muscular exercise, dyspepsia, hysteria and
violent emotions, it is found in the urine ocpasionally, and the changes
which permit the transudate are certainly not permanent. Cyclic or
adolescent albuminuria is interesting. Boys are oftenest the subjects
and recovery follows after a varying period.
After sixty, it is not uncommon to encounter small quantities of
albumin in the urine, associated with mucin, and the tendency in-
creases with each decade thereafter.
2. Albuminuria of pyrexia. Albumin may be present in fevers
of almost any degree, the lesions which cause it generally passing
away with the disappearance of the primary disease. It is seen in
tonsillitis, typhoid . fever, pneumonia, malaria, the entire group of
specific infectious diseases which used to be called zymotic, cholera,
yellow fever and other infections.
3. Albuminuria due to blood changes. All profound anaemias,
leuksemia, purpura, syphilis, scurvy, rickets, poisoning by metallic
substances as arsenic, lead, mercury or phosphorus, are followed by
albuminuria which in some cases is transient, in others leads to per-
manent lesions. The administration of anassthetics is followed in rare
cases by albumin. Certain states and conditions also manifest tran-
sient albuminuria, as the puerperal state, exophthalmic goitre, tetanic
seizures, after apoplexy and epileptic fils, purpura and hospital
gangrene.
4. Albuminuria with kidney lesions. Here the transudate oc-
curs in states of active congestion, as in inflammations of the kidneys ;
in passive congestion due to obstruction or pressure, or such as occurs
in organic heart and lung diseases. Organic lesions of the kidneys,
constituting the entire group of Bright 's diseases, the degenerations
and suppurative processes of the organs and growths within their
structure, constitute the chief causes of albuminuria.
5. Pus-producing inflammations of any part of the urinary tract
are accompanied by albumin in the urine.
318 EXAMINATION OF THE URINE
6. Albuminuria accompanying impediments to the circulation,
in which the kidneys are not primarily involved, as tumors, abdominal
growths, cirrhosis and other changes in the liver.-
The amount of albumin cannot be taken as indicative of- the
gravity of the lesion, since in some serious alterations, such as inter-
stitial nephritis, the amount is small and intermittent ; nor can albu-
min without other evidences of renal alteration be accepted as indica-
tive of organic disease, but in general, its increase or decrease in estab-
lished recognized conditions, indicates the gravity of the causative
disease.
Tests for Albumin. Typical albuminous urine is of low specific
gravity, pale greenish- j^el low in color, and forms a permanent froth
when shaken. Soon after being passed a sediment is deposited.
The potassium ferro-cyanide test is one of; the easiest and most
reliable tests at command. I have found it most satisfactory. It may
be applied as follows : A quantity of urine is placed in a test tube,
half as much of a solution of potassium ferro-cyanide of a strength
of 1 to 10 is added and the tube shaken. On the addition of a few
drops of acetic acid, albumin, if present in any form, is precipitated
in a flocculent cloud. The test gives no reaction with mucin if the
acetic acid be added last, and no reaction with phosphates or urates,
hence any precipitate which occurs is albumin,, albumose or nucleo-
albumin.
Another method of applying the test is to' add acetic acid first
and filter out the precipitated mucin, then float the clear acidified
urine upon the top of the ferro-cyanide solution. A white zone form-
ing at the point of contact indicates albumin.
Heller's test. This test is probably more Universally used than
any other test and is reliable to those familiar with its variations. A
test tube is filled to the depth of one inch with- pure nitric acid. A
long pipette is filled with urine, which is fioated upon the surface of
the acid by considerably inclining the tube and slowly discharging the.
urine against its side. The presence of albumin of any kind is indi-
cated by a white zone at the point of contact. The width varies with
the amount of albumin present.
The amorphous urates when precipitated by this method appear
as a brown cloud or zone in the urine, above, and not at the point of
contact, and can hardly be mistaken for albilmin. Their density
diminishes upwards. Mucin may show as a clo4d towards the top of
EXAMINATION OF THE UKINE 319'
the tube. The only probable error is in patients who have been
taking balsams, in which case the precipitat^e resembles albumin, but
is cleared by addition of a small quantity o^ alcohol. While the pre-
cipitate generally appears immediately, yet when very scanty may
require a few minutes to form, hence the tube should be re-examined-
at the end of half an hour.
Boiling the urine in a tube coagulates albumin, and also pre-
cipitates the earth phosphates. The latter redissolve on the addition
of nitric acid, which should be added drop-by-drop as the urine is
reboiled. Albumin in small quantity is apt to escape detection by
this test and excess of phosphates may deceive the observer. The test
is reliable for albumin in considerable quantity, but is inferior to
either of the other tests given and less easy of manipulation.
Mucin. Mucin is the secretion of the mucous cells. It is a
gluco-proteid, i. e. a compound of a proteid and a carbo-hydrate and
is closely related to the albumins, hence coijstitutes a fruitful source
of error in searching for small quantities of albumin, especially if the
amount of mucin is increased. It is present in all urine and in inflam-
matory conditions of the urinary tract is increased. In catarrhal
inflammations of the pelvis, of the kidney oV the bladder the amount
may be enormous. Mucin is increased in febrile processes and is-
sometimes the forerunner of albumin in these cases.
It is not coagulable by heat and is soluble in strong mineral acids
and in alkalies, but is precipitated by acetic 'acid, alum and very
dilute mineral acids, which latter property gives rise to the propensity
to mistake it for albumin. Mucin is insoluble in alcohol, ether, or
chloroform. Owing to its solutions dissolving oxide of copper, the
presence of mucin in abundance hinders the„ test for sugar.
Detection : Dilute the urine to double its volume and add excess
of acetic acid. The mucin is precipitated.
Pus. Pus renders the urine turbid to I^Ee naked eye. It quickly
deposits as a whitish or greenish sediment. The supernatant liquid
contains albumin and globulin. Heat does Hot dissipate the sediment,
hence distinguishes it from urates. Acids do not dissolve it as they
do the earthy phosphates. The addition o£ strong alkaline solutions
dissolves it with the production of viscid or ropy masses (Donne's-
test) . The addition of hydrogen dioxide causes rapid effervescence, —
a valuable test for pus in any fluid.
The microscope shows characteristic cells.
■320
EXAMINATION OF THE UEINE
CARBOHYDRATES.
While glucose, levulose, inosite and lactose may occur in the urine,
the most important clinically is glucose. Whether or not glucose is a
constituent of normal urine is still disputed. ¥ery delicate tests fre-
quently demonstrate it in urine otherwise normal. When glucose
appears in the urine in appreciable amount it is- known as glycosuria.
Glycosuria may appear as a temporary condition in various dis-
eases of the brain and cord, lungs, liver, heart, during pregnancy and
Fig. 74 — Lipogenic Glycosuria. Urine also contains albumin.
in certain infectious diseases, as diphtheria, influenza, rheumatism,
typhoid fever, syphilis, scarlet fever, cholera and cerebro-spinal
meningitis.
It is often encountered in obese persons, particularly Hebrews,
and is known as lipogenic glycosuria. Certain drugs and toSie mate-
rials produce a substance which gives to the urine a similar reaction,
as morphia, chloral, hydrocyanic acid and amyl nitrite. Both tem-
porary and permanent glycosuria have followed the inhalation of
nitrous oxide. The internal use of turpentine, of salicylic acid, mer-
cury, alcohol and a few other substances is sometimes followed by
the reaction. Phloridzin, and some of the other substances mentioned,
produce glycosuria by directly attacking the renal epithelium and
■destroying its power to keep back glucose. The ingestion of a larger
EXAMINATION OF THE URINE 321
quantity of carbo-hydrates and peptones than the' liver can take eare
of, causes a temporary glycosviria.
Persistent glycosuria is known as diabetes. It is not a disL^ase
but a symptom and the causative lesion must be looked for in the
liver; the pancreas — which shows lesions in fifty per cent; the nervous
system — where several lesions have been found in connection with
cases, but none typical; or in the kidneys. The heart, the lungs and
other organs show frequent lesions which are all probably secondary.
Diabetic urine is generally pale straw-color, often with a greenish
tint, has a characteristic, sweetish odor and ta'ste, and a specific
gravity varying between 1030 and 1050. The amount of sugar present
varies from two to twelve per cent. The quantity of urine is much
increased, being seldom less than 1600 c. c. and may reach 8000 c. c.
per diem. The gravity of the disease increases with the polyuria.
Glycosuria without polyuria is seldom fatal, especially in advanced
life. The severity of the disease in all cases beais a relationship to
age. In the young it is progressive and almost uniformly fatal, run-
ning its course in a few months to a few years. After thirty-five the
disease progresses slowly and the prognosis is better. After fifty, it is
often amenable to treatment.
Teats for glucose. The methods of detection most often used are
by means of the copper tests, which depend upon the fact that solu-
tions of grape sugar in the presence of an alkali reduce cupric oxide
to lower oxides. The presence of albumin interferes more or less with
the tests and, as it is easily removed by boiling and filtering, it is
wise to do so.
Trommer's test. Add to a quantity of urine in a test tube about
half its volume of sodium or potassium hydroxifie. Then add, drop
by drop, a solution of copper sulphate (1 to 8) until a slight bluish-
white precipitate is formed. The precipitate is cupric hydroxide.
In the presence of glucose it is dissolved on shakjng and a dark-blue
color results. On heating, if glucose be present, red cuprous oxide and
yellow cuprous hydroxide fall, just as the boiling point is reached.
If, instead of boiling, the tube is allowed to stand for half an hour the
same reduction occurs. With heat the test is extremely delicate. If
no precipitate occurs, sugar is absent.
Precautions. If sugar is present in considerable quantity, the pre-
cipitate forms without boiling. The urine should not be kept boiling,
but merely brought to the boiling point, since continued boiling causes
322 EXAMINATION OF THE UR'INB
other substances to reduce the copper, as uric acid, creatin, mucus,,
albumin, peptones, hypoxanthin, creatinin, giycuronic acid, carbolic
acid, certain alkaloids and excess of coloring qiatter. As a rule, these
give a greenish or greenish-yellow, not a red,; deposit.
Precipitate of phosphates may occur on the addition of the
hydroxide, but is white and flocculent and bears no resemblance to the
red, granular cuprous oxide. A yellow precipitate, which falls on
cooling, is cuprous oxide and is not due to glucose. A red granular
precipitate is very probably sugar.
Haine's test. This is a modification of Pehling's test. Formula:
Pure copper sulphate, 30 grains; distilled water, V2 ounce, dissolve;
add pure glycerine, % ounce; mix and add 5 ounces liquor potass^e.
The solution is somewhat more stable than F^hling's solution.
Method : Boil one drachm of the test fluid in a tube and note
whether it remains clear. Add six to eight' drops of urine and reboil.
A copious red or yellow precipitate indicates sugar. If no precipitate
occurs, sugar is absent. Here again the alkali may pi-ecipitate the-
earthy phosphates, but they should not be mistaken for sugar. The
precautions given under Trommer'stest should he' observed.
Fehling's test is applied in the same manner as Haine's. The
quantity of urine added should never exceed, the volume of the test
solution used. Fehling's solution is best prepared in two parts.
I. — Dissolve 3-4.64 grams of crystallized CuSO^ in water ana
dilute to .500 c. c.
II. — 173 grams Roehelle salt and 60 grams NaOH are dissolved
in water and diluted to 500 c. c.
For use, mix equal volumes. This solution* is also used for quanti-
tative examination, 10 c. c. of the mixed solution equals 0.05 grams
glucose.
Phenylhydrazin test. When this substance is boiled with grape
sugar a characteristic crystalline compound results.
Test : To 50 c. c. of suspected urine add? 2 gms. phenylhydrazin
hydrochloride, and 2 gms. sodium acetate, 10 c. c. of water may be
added to promote solution. Dissolve, and heat on water-bath for one
hour. On cooling, a yellow deposit forms, a few drops of which is
placed on a glass slide. Bright, needle-like crystals of phenyl glueosa-
zone are formed, rarely invisible to the naked eye. Scales and brown
granules are not indications of sugar. The microscope shows radiat-
ing acieular structure. The crystals indicate that the urine contained
EXAMINATION OP THE UEINE 323-
a carbo-hydrate and the test is therefore reliable. None of the sab-
stances meTitioned under Trommer's test is capable of producing the
reaction.
Quantitative Determination of Sitgar. The amount of sugar in
the urine indicates the severity of the disease and is the basis of prog-
nosis. Its increase or diminution is the best- evidence of the result of
treatment.
Roberts' differential test is accurate and simple, but requires:
twenty-four hours for its determination.
Method : Place 4 ounces urine in a large bottle, add % cake of
compressed yeast and cork with, a perforated cork. The same quan-
tity of urine is placed in another bottle and corked. Both are allowed
to stand twenty-four' hours. The alcohol and carbonic anhydride
formed by the fermentation reduce the specific gravity one degree for
each grain of sugar per fl. oz. of urine. Thu'fe, if the sp. gr. is reduced
from 1040 to 1030, the urine contains ten grains of sugar per ounce.
When fermentation is completed the urines are decanted and the
sp. gr. of each separately obtained. The number of degrees of den-
sity lost in the fermented urine indicates the amount of sugar per
ounce, or, the number of degrees lost mu.ltiplied by 0.23 gives the
percentage of gluco.se. The results are approximately accurate.
Fehling's test is the most satisfactory yet devised. The only
objection that can be urged is that practice is necessary to determine
the precise point of reduction.
Method: 10 c. c. of Fehling's solution" and 30 c. c. water are
measured into a porcelain dish and kept a.t the boiling point over a.
Bunsen burner or alcohol lamp. The uriner is added, drop by drop,,
from a burette until the blue color of the, Fehling's solution has en--
tirely disappeared. The number of c. c. of urine required to produce
this result is noted and the sugar calculated thus : It requires 0.05.
gm. of sugar to remove the coloration of the ten c. c. of solution used^,
hence the number of c. c. of urine dropped contained 0.05 gm. of'
sugar. Say 2 c. c. of urine were used, then 100 c. c. which is 50X2'
contained 50X0.05 or 2.5 grams per 100 c. c. By dividing 5 by the
number of e. c. of urine used the result is the same, and the per cent,
thus easily obtained.
When considerable sugar is present the urine should be diluted
with a known volume of water, as one to five, and the result corrected;
in accordance with the dilution.
324 EXAMINATION OF THE URINE
Acctonuria. Whether acetone occurs in healthy urine or not is
disputed. It occurs after alcoholic indulgence, over-eating of proteids
and in the urine of children. It occurs in fevers and rises and falls
with the temperature curve. It is often associated with carcinoma
and should be sought for in suspected cases. In diabetes its appear-
ance often precedes diaceturia. It is capable of producing a species
of auto-intoxieation, and often occurs in the insanities.
Cliautard's test is the simplest. An aqueous solution of magenta
is decolorized with sulphurous acid. A drop of this solution added to
fluids containing acetone gives a violet color. When the amount of
■acetone is very minute, the color develops after five minutes.
Diaccturut. Ethyl-diacetie acid in the urine is of serious im-
port. It occurs under the same febrile conditions as acetone. In
diabetes it is the premonitor of coma and signifies death.. It occnr.s
oftenest in young subjects. jVccording to von Jaksch, the cause of
coma in diabetes is diacetie acid.
Detection : Boil a sample of the urine and add a few drops of
ferric chloride. A deep-red color is produced. If the phosphates are
precipitated, add the chloride until precipitation ceases, filter and re-
peat the test. No other substance gives rise tOj the red color in the
boiled urine. ,
' . , BILE.
Bile acids and bile salts appear in the uriWe during attacks of
jaundice. Increase of bile salts occurs with the termination of "bilious
attacks." They are increased in many forms of organic dis-
ease of the liver, in splenic leucoeythiemia ancf anieniia. Bile pig-
ments are found in the urine in phosphorous pqigoning, in grave dis-
orders of the liver, in obstructive jaundice, where the coloring matter
reaches the urine through the circulation, and- precedes its appear-
ance on the skin. Both may appear during excessive summer heat
and after the use of alcohol. The color of the urine is yellow, green,
brown or black. On shaking it yields a yellow froth which is charac-
teristic and in the absence of ingested drugs snch as rhubarb, chrys-
orobin and the like, is distinctive.
Gmelhi's test fur Bile Pi'jiiieiii. A small quantity of commercial
nitric acid (yellow nitrous acid) is placed in a test tube and the urine
is floated upon it. A rainbow coloration appears at the point of con-
tact. Or the urine may be passed through filter paper, and a drop of
EXAMINATION OP THE UBINE 825
the acid placed in the center of the wet paper, when the colored rings,
appear.
THE DIAZO-REACTION OF EHRLICIi.
This test was proposed by Ehrlieh in. 1882 as a valuable diagnos-
tic sign of typhoid fever. Although the reaction occurs in a few other
jdiseases, as pulmonary tuberculosis, yet in the cases most often mis-
taken for typhoid fever the reaction does not occur, viz., malaria. I
studied the urine in 36 cases of typhoid fever in soldiers returned
from Tampa. The reaction was pronounced in 35. It was absent in
all cases of malaria when typhoid was absent.
It occurs from the fourth to the severfth day and thereafter. The
intensity of the reaction varies with the gravity of the case. When
absent, the diagnosis is doubtfiil. It occwrs in ra.pidly fatal cases of
phthisis, sometimes in measles, miliary tpberculosis, pyaamia, scarlet
fever and erysipelas. It is absent in apyrexial disease (Ehrlieh). Two
solutions are prepared:
I. — 2 grams of sulphanilic acid; 50 e. e. HCl; 1,000 c. c. water.
Mix.
II. — A 0.5 per cent, solution of sodiutn nitrite.
Method : 50 parts of No. I and one part of No. II are placed in
a test tube, an equal (piantity of urine added, and the solutions well
mixed. About % of the volume of ammonia is then added. If the
reaction is po.sitive a carmine or cherry-red color develops, and on
shaking the color extends to the foam. Von Jaksch thinks the re-
action due to acetone and not especially significant of typhoid.
URINARY SEDI.MENT,
When urine is allowed to stand for some hours gravity causes it
to separate into two layers, the solid poiftions or sediment and the
supernatant liquid. The solids consist of insoluble materials contained
in the fluid and soluble substances which by chemical activity or
crystallization have been separated from the solution, iluch time is
saved and many difficulties are overcome by separating the urinary
sediment immediately by means of the centrifuge, instead of wait-
ing for gravity to accomplish the same end."
We have already noted some of the changes which take place in
normal urine on standing. Changes more rapid and more radical
occur in pathologic urine. Much more information is therefore
326
EXAMINATION OF THE UfelNE
gained by an immediate examination of such urine, before easts have
macerated and soluble substances which may have been passed as
solids have had time to dissolve, and before pernicious bacterial ac-
tivity has had time to destroy contained elements or to form new
ones. In the same way crystalline substances which are passed in a
state of crystallization may be distinguished from those which form
upon standing. By the centrifuge the elements are more completely
separated and concentrated, hence such as occur in only minute quan-
tity are less likely to escape detection than when collected by gravity.
Fig- 75 — Hand Centrifuge.
It is difficult to satisfactorily classify! the two groups, of sub-
stances which make up the urinary sediment. Organized and unor-
ganized are terms frequently used, but unorganized does not in this
case mean non-organic and is misleading. Perhaps the division into
chcmic and histologic sediments is as useful as any.
The chcmic substances are u.rie acid, the urates, phosphates, cal-
cium iixalate, cystin, leucin, tyrosin, melanin.
The sediments of acid and alkaline urine difEer markedly. Acid
iirine may deposit: (a) uric acid; (b) acid- urates of sodium, potas-
sium, ammonium and calcium; (c) calcium oxalate; and occasionally,
(d) hippuric acid; (e) calcium sulphate, cystine, leucin, tyrosin.
PLATE XXVI.
URIC-ACID CRYSTALS. fNatural color.)
EXAMINATION OP THE UEINE 327
In such urine the uric acid and the calcium oxalate are crystalline, the
urates amorphous or granular, except sodium urate which is sometimes
crystalline.
Alkaline urine may deposit: (a) amorphous phosphate and car-
bonate of calcium ; (b) crystalline urate of ammonium ; (c) phosphate
of calcium and magnesium; (d) triple phosphates.
The most important constituent of the alkaline sediment is the
amorphous earthy phosphates which are regularly precipitated in
urine that is alkaline when voided, as well as in urine that has under-
gone fermentation. The crystalline forms are^ the triple phosphates,
ammonium urate, calcium phoophate and carbonate, and, under path-
ologic conditions, leucin, tyrosin and cystin.
TJric acid crystals occur as a deposit only- in acid urine. They
are deep-red or yellow in color, prone to cling to the sides of the ves-
sel and can be recognized by the trained eye. Cubes, plates and
rhombic crystals, alone or coalesced into beautiful stellates and ribbon
bow-knots, are found and are easily recognized under the lens by
flolor and form. Threads suspended in urine attract the crystals and
their tendency to aggregate around any suitable nucleus explains the
formation of uric acid calculi, the most frequent of all forms of
gravel. Uric acid may be said to be pathologic when it is deposited
shortly after the urine is passed. Occurring in urine which has stood
ten hours or more, it has little clinical significance. Excess of uric
acid, high acidity, diminished mineral salts and pigments, favor its
deposit. CJver-indulgence in animal food produces the first two of
these factors. Fever favors its production by diminution of the liquid
elements aid raising the acidity of the urine.
Acid urates of sodium, potassium and ammonium, sometimes of
calcium, occur as amorphous or crystalline deposits. The sodium salt
occurs in the brick-dust sediment so often seen in winter urine. It
occurs as amorphous granules or stellate or fan-like crystalline clus-
ters. Its color is from pink to brown, according to the amount of
urinary pigment present. The calcium and potassium forms are amor-
phous.
Ammonium urate occurs as coarse, spherical masses studded with
spicules. The colors are yellow to deep-browh and the crystals are
known as "hedge-hog" or "thorn apple" crystals, easily recognized.
They are more apt to be found in alkaline urine.
The above form the mixed urate sediment so often seen on
328 EXAMINATION OF THE URINE
the sides and bottom of the vessel. The deposit is increased by fever,
wasting disease, organic disease of the liver, dyspepsia and gout. It
is recognized by its disappearance on the application of heat.
Oxalate of lime occurs in either acid or alkalin;' urine. It is often-
est seen associated with triple phosphates. The crystals are small,
highly refracting octahedra or envelope crystals or ' ' dumb-bell ' ' crys-
tals and are unmistakable under the microscope. They disappear on
the addition of HCl. Calcium oxalate is a constituent of certain
Fig. 75 — Oxalate of Calciifiji.
vegetables and their use increases greatly the amount in normal urine.
Tomatoes, rhubarb, asparagus and grapes coatain excess of the salt;
"greens," cabbage, turnips and apples contain' smaller amounts. Ex-
cessive meat ingestion causes excretion of large amounts of the salt.
Hipp'uric acid excreted in large amounts hy the herbivora. is
found only as a trace in normal urine. After taking benzoic acid or
eating certain fruits, the crystals are seen, but have no clinical signifi-
cance. They occur as colorless prisms with sharply-defined ends and
as needles. They do not respond to the mul-exide test as does uric
acid.
Calcium sulphate crystals occur as radiating needles and are of
little importance.
Phosphates. The alkaline phosphates are not found in urinary
EXAMINATION OF THE URINE
329
sediment. The earthy phosphates are the ammonio-magnesium phos-
phate, known as triple phosphate, and calcium phosphate.
The first occurs in various forms, the beveled triangular prism,
or "coffin lids" being the most characteristic. These may be square
or oblong, are glassy or light-green in color and easily recognized.
They disappear on the addition of acetic acid. Stellate feathery
forms are less frequent but easily distinguished.
Calcium phosphate is usually an amorphous, granular, white
deposit which, as said, is precipitated by heat and may be mistaken for
Fig. 77 — Triple Phosphates. Pine Branch Crystals, R'apid precipitation.
albumin. The crystalline form, rarely seen, consists of rods, separate-
or grouped into wedges, or of stellate, colorless rosettes.
The deposit of triple phosphate in freshly voided urine means
ammoniacal decomposition in the urinary passages,. as pyelitis and cys-
titis. The deposit of phosphates in other urine occurs in convalescence,
in dyspepsia, particularly nervous dyspepsia, phthisis and as pointed
out by Sir William Roberts, in cancer.
Cystine is rarely seen. It may occur in diminished bile secre-
tion. It occurs as opalescent hexagonal tablets wh^ch sometimes over-
lap each other. It aids in forming calculi. A drop of HCl or of am-
monia on the slide causes its disappearance. With the latter it re-
appears on evaporating the reagent.
Leucin is rare. It appears as white lamella? or as yellow spherules
230
EXAMINATION OF THE URINE
like drops of oil. It resembles sodium urate, but unlike it is not dis-
solved by heat. From oil drops they are distinguished by not being
dissolved by ether.
Tyrosin occurs with leucin in small-pox, typhus, typhoid, in acute
atrophy of the liver, leucocythasmia and in phosphorus-poisoning.
It occurs in yellow-green globules or as fine needle-like ,radiating
■crystals.
HISTOLOGIC SEDIMENT.
The histologic sediment found in the urine includes pus, blood,
epithelium, casts, spermatozoa and bacteria. More rarely are found
fragments of tissue, of new-growths, parasites or their eggs.
Fig. 78 — Triple Phosphates — Slow Precipitate. Amorphous Urates. A Stellate
Forms. B Coffin lids.
Pus is the most frequent histologic constituent of the urine and
may come from any part of the urinary tract. Pus-coutaining urine
is turbid when voided and responds to the tests for albumin. Pus
corpuscles are easily recognized by the microscope as pale, circular
cells containing finely granular protoplasm and one to three distinct
nuclei. Treatment with acetic acid causes them to lose their granular
appearance and the nuclei to become distinctly visible. Their size
is nearly double that of the red blood corpuscle. When a quantity
of pus is treated with potassic hydrate it dissolves into a homogeneous.
EXAMINATION OF THE URINE
331
sticky mass which will not flow (Donne's test). In testing allow the
pus to settle, then pour off the supernatant liquid befoi'e adding the
hydrate.
Pus is frequently mixed with micro-organisms and with epithe-
lium or other tissue elements derived from the locality of its origin.
Pus derived from the kidney is intimately mixed with the urine
when passed, the reaction is acid and the kidney epithelium is found,
and bladder symptoms are absent. Renal epithelial cells are small,
round or polygonal with a single large nucleus. Their size distin-
guishes them from pus cells.
Pus-urine from the bladder is alkaline when voided or quickly
I'lg- 79 — Tyrosin Crystals.
becomes so, contains liberal quantities of mucus, triple phosphates and
flat, large epithelial cells from the bladder.
Pus from the urethra may be squeezed out, qr flushed out with
the first drops of urine. In cases of doubt, washing the urethra before
micturition frees the urine from pus. In prostatic disease the pus
often appears as long threads bound together with" mucus.
Blood. Blood corpuscles appear in the urine, under a number
of pathologic conditions. Their bi-concave characteV and the alternate
change from dark to light of rim and center, whi'ch takes place on
focusing, owing to this formation, aid in their recognition. After
having been soaked for some time in the urine they lose their sharp
332 EXAMINx\.TION OF THE URINE
uutline, swell, pucker and resemble the pus corpuscles, but can be dis-
tinguished by the absence of nuclei. If in doubt, a small quantity of
the suspected sediment may be evaporated on a watch-glass and tested
for hffimin, when small, dark characteristic crystals are formed, shaped
like little rhombic plates or rods with sharp an'gular ends. The hsemin
test is simply made and is proof positive of bipod. To the dried res-
idue is added a few crystals of common salt, a drop of glacial acetic
acid, and the mixture boiled. The crystals are- seen under the micro-
scope.
The color of the urine depends upon the* amount of contained
blood and the reaction of the fluid. Acid urine darkens the color,
alkaline urine brightens it. If in any quantity, the urine is markedly
albuminous and cloudy. When blood is deiived from the bladder
it usually forms clots, while blood coming from the kidney is apt to
be diffused homogeneously, to be of dark-red Or brown color and acid
in reaction. On standing a brownish sediment is deposited. Some-
times thread-like clots are found. Blood-castS when associated, show
the source of the hajmaturia to be the kidney. Acute Bright 's disease,
chronic interstitial nephritis, malignant growths, tuberculosis, can-
tharides, oil of turpentine and other powerful, diuretics are causes of
hfematuria. Injuries are often followed bj^ blood. In renal abscess
and renal calculus the blood is mixed with pus. I reported a case a
few years ago of death from purpura hasmorthagica of the kidneys.
BJood from the bladder is occasioned by diphth&ritie and acute cystitis,
calculi, carcinoma, congestion, injuries, fibroids, polypi and varicose
veins about the neck of the bladder.
The urine is usually alkaline in reaction and if the hiemorrhage
is occa'^-ioned by cystitis, pus, mucus and triple phosphates are found.
Irregular clots occur, and the color is bright-red. Blood occurring
in large quantities may coagulate within the bladder.
Epithelium exists in small quantities in normjj urine, and is cast
oif from the urinary tract as from the body surface, the intestines
and the respiratory tract. It is increased in disease of the genito-
urinary system, as in disease of the other surfaces named. The
sources from which the epithelium is derived can not in all cases be
told by the form of the cell. The large, flat, irregular squamous cells,
with prominent nuclei, are derived from the bladder and the vagina
and are the most distinctive cells met with in the urine The columnar
cells, elongated spindle, cylindrical, or caudate cells, with a well-
EXAMINATION OF THE UKINE 333
marked nucleus are derivable from any part of the urinary tract,
from the pelvis of the kidneys to the urethra inclusive. Lastly, small,
round or spheroidal granular epithelial cells with nucleus and nucleo-
lus occur singly or in groups. Such cells are derived from the kidney
tubules but are also found beneath the superficial, layers of all the
rest of urinary tract, hence in inflammations causing denudation or
exfoliations are not distinctive. They occur in quantity in acute
Bright 's disease and often are associated with casts. Sometimes the
cells adhere to the casts. In cystitis the flat, squamous cells predom-
Fig. 80 — Hyaline Casts.
i-'jate over the other varieties, while in inflammation.s of the tubes they
occur very sparsely.
CASTS.
Casts are moulds of the uriniferous tubules. 'The mode of their
production and the rcateiial of which they are composed are not yet
ascertained. From their appearance they may be separated into three
classes.
(a) Clear or hyaline casts.
(b) Casts composed of histologic elements, rb: blood corpuscles,
epithelium and pus cells.
(c) Those consisting of waste-products, the resijlt of tissue change.
The urinary sediment having been separated by the centrifuge, a
334
EXAMINATION OF THE UKINE
few drops are placed upon a glass slide or in a shallow cell and well
djstributed. With a low power and concentrated light the iield is
carefully searched. Sometimes hyalinie casts which are exceedingly
transparent, hence liable to escape detection, are best seen in a sub-
dued light or in shadow. They may be Stained with iodine or magenta,
which facilitates the search, but alters the appearance and may thus
lead to wrong inferences.
Hyaline casts may be perfectly clear and homogeneous or they
may show slight granular structure in parts. Sometimes a fragment
Fig. 8i — Epithelial Casts.
of epithelium adheres and renders them. more visible. They are very
pale and transparent, of varying widths and lengths, extending in
some cases clear across the field. They are only found in albuminous
urine and disappear from alkaline urine on standing. Wide hyaline
casts, more refracting than the above are found, which exhibit the
amyloid reaction. They were formerly called waxy casts and sup-
posed to indicate amyloid degeneration of the kidney. Sir William
Roberts refutes this, and says the reaction is due to degenerative
changes in the casts themselves.
Blood casts occur in cases of congestion or hemorrhage of the
kidney, hence are often associated with blood in the urine. They con-
sist of cylindrical moulds, generally short and rounded at the ends,
composed of tessellated blood corpuscles.
EXAMINATION OF THE UEINE
335
Epithelial casts are usually hyaline moulds to which the epithe-
lium is adherent, sparsely, in clusters, or clumps. Sometimes, how-
ever, the entire epithelial lining of a portion, of the tubule seems tO'
be exfoliated intact, giving rise to cylinders composed of intact epithe-
lial cells. They intimate clearly a catarrhal or desquamative inflam-
mation of the tubules and are highly important from a diagnostic
standpoint.
Pus c^i^sts are rare, pus corpuscles adherent to hyaline, granular
or epithelial casts are often seen.
Granular casts are frequently met with. Tliey are moderately
broad and as generally found one or both ends, present a broken-off
Fig. 82 — Granular Casts.
appearance. Sometimes one end is rounded, very rarely both ends.
The granules vary from fine to coarse, and the colors are white, yel-
low and dark. The tissue elements frequently cling to their surfaces,
epithelium, fat, pus corpuscles or leucocytes. They indicate chronic
degenerative changes and are found in chronic parenchymatous and
chronic interstitial nephritis.
Fatty casts indicate extreme chronicity and corresponding de-
generative changes. They are commonly attributed to the large white
kidney. The fat globules are studded over the surface of the cast in
such a way as almost completely to cover it. The globules vary in
size and sometimes small fatty crystals co-exist.
336 EXAMINATION OF THE UUlNE
Bacterial casts composed of masses of micrococci indicate grave
infective processes. Under the microscope they appear granular, dark
in color. They do not disappear upon the addition of alkali or acid
and when examined under high power their nature is apparent.
With regard to the diagnosis of the forms of kidney lesions from
the variety of the cast Osier remarks : ' ' The character of the cast is
of use in the diagnosis of the form of Bright 's disease, but scarcely of
such extreme value as has been stated. Thus, the hyaline and gran-
ular casts are common to all varieties, the blood and epithelial casts,
particularly those made up of leucocytes are most common in the acute
eases."
CyUndroids, described by Thomas, occasionally occur in the urine.
These are long, ribbon-like structures with branching ends, trans-
parent, colorless and hyaline. Their exact nature and significance is
undecided.
Spermatozoa are readily recognized by their shapes. The head is
oblong or oval and the thin tail is directly attached. When alive they
exhibit active cilia-movements. They are ahvays found in the urine
succeeding ejaculation, and are persistent in s|)ermatorrhoea and in the
urine of confirmed 'masturbators. They are occasionally found in
acute infections and in post-epileptic states.
Bacteria. Yeast fungi and fission-fungi are found in stale urine.
The latter in habitual catheter users. Ammckniacal bacteriuria is the
name given to the condition resulting from ammoniacal bacterial fer-
mentation within the bladder. It is common" in catheter users. The
principal agent in its production is the micrococcus ureaj.
The pus-producing organisms, as well as the bacteria of all in-
fective diseases, may be found in the urine. Bacillus tuberculosis is
found in tubercular infection of any part of the tract, and the gon-
ococcus in urethral infection. The first is seaj*ched for in the concen-
trated sediment, after treating it just as sputum is treated.
Gronococci lie in pairs (diplococci) within.. the pus-cells. In recent
infection they are abundant and easily found in the purulent
secretion.
SECTION XVI.
THE F/ECbS.
A complete examination of the fasces includes macroscopic, micro-
scopic and chemie examination, and is of importance principally as a
guide to the state of assimilation or mal-assimilation of the food.
Such research is not always necessary for diagnostic purposes. The
number and character of the movements should be inquired into and
whether they are easy and natural or produced by effort and strain-
ing, whether they are followed by pain, descent of the mucous mem-
brane, hemorrhoids, bleeding or other unusual phenomena. In the
inspection of the stool, the color, odor, quantity, eonsisteacy, form and
appearance are noted.
Both the frequency of the discharges and the amouht of the de-
jecta vary with the individual, as well as with the amount, kind and
quality of the food ingested. It is influenced bj* age, sex, habit and
occupation. While normally the bowels should move once in twenty-
four hours in adults, departures in either direction cannot be pro-
nounced unnatural. Many individuals habitually have two or three
movements per day ; others, a movement each forty-eight hours.
Regularity and the resultant effect on the health of the individual
are more to be considered than physiologic rule. It is wiser and safer
not to disturb the established order and habit of the bowels, provided
the health equation remains unaffected, than to attempt to establish
new habits, especially in adults, but the inculcating of correctness and
regularity in the child and the beneficent effects^ thereof, cannot be
■over-estimated.
In nurslings and milk-fed infants the number of stools varies
from three to five in twenty-four hours, decreasing with age and mixed
diet.
Constipation is a bodily condition or habit in which the amount
of the faeces and the number of the movements are less than normal.
Obstipation is the temporary or permanent absence of movement?
•
lactic and butyric acid fermentation, but sometimes acetic and pro-
pionic acids are found. Vegetable diet assists in their production.
Much mucus renders the stools alkaline. The' acid reaction of
nurslings and milk-fed infants is due to lactic and free fatty acids.
Composition. The faeces are composed of the undigested jJarts
of the food, the useless and injurious portions of the various secre-
tions, decomposition and microbic products and gases.
Among the first are found yellow elastic tissue, tendons, nuclein,
epidermic and horny substances, vegetable fiber, chlorophyll, gums,,
resins, cellulose from vegetable sources, particles of food which, from
imperfect mastication have not been acted upon, by the digestive
juices, alimentary substances which are assimilable, .but of which an
excess has been taken, especially fats and starches, insoluble salts, as
silicates, sulphates and phosphates of calcium and anmioniLini-mag-.
nesium phosphate.
340 THE FiECES
In mixed diet the waste secretions exceed the residue derived from
the ingesta, and consist of intestinal mucus, epithelial cells, sub-
stances which failed of absorption, as decomposed bile, coloring mat-
ters and inorganic salts; free fatty acids froin acetic up to palmitic
acid, butyric, lactic, cholalic acid and cholesterin ; indol, skatol, cresol,
phenol, leucin, tyrosin, each may appear under certain conditions.
The gases expelled are CO,, CH^, H, N, HjS. The N is derived from
swallowed air, the rest arise in the course of decomposition.
The meconium is the name given to the contents of the intestine
which accumulate during fcetal life. It is usually evacuated soon
after birth. Its color is dark-green or brown and, its consistency salve-
like or tarry. It is acid in reaction and devoid of fascal odor. It
consists of epithelial cells in abundance, chole'sterin, fats, fatty^ acids,
mucin and bile-coloring matters.
The stools of milk-fed infants contain fats, fatty acids, casein,
epithelial cells, lactate of calcium, mucin, coloring matters and bac-
teria. In infants fed on cow's milk, the caseiif is much increased over
that of breast-fed infants.
Acholic stools are wanting in bile. The color is blue-clay or
chalk-paste. They are very fcEtid and contain: large quantities of fat.
Suppression of the pancreatic secretion is foUowed by fatty stools,
and their persistence should be viewed with grave suspicion.
Diarrhoeal stools contain excess of water. When due to catarrhal
conditions they contain epithelium and much mucus. In acute cases
the latter imparts character to the passages, which are named mucous
istools. Medicines which hasten peristalsis produce the same water}'
levacuations. Further, the activity of the peristalsis prevents absorp-
tion, hence hurries down much \inassimilated food substance.
The characteristic typhoid stool is offensive, abundant, thin, gray-
ish-yellow, granular, and in appearance and consistency resembles
pea-soup. The reaction is alkaline. They sometimes contain blood,
shreds of necrotic tissue, and, generally, ammonium-magnesium phos-
phate. On standing they separate into two Ictyers, an upper, serous
layer containing albumin, and a lower layer containing the residue,
food and epithelium. After the end of the first week is found the
Eberth bacillus and a poisonous base known as typhotoxin. Blood
and necrotic. shreds are recognized by the microscope.
Cholera stools are ever likened to rice water; thin, turbid or
translucent. Koch's spirillum or coma bacillus abounds, especially
THE F/ECBS 841
early in the disease. Epithelial cells in abundance are seen under the
microscope. The discharges contain nitrites which, with the indol of
the stool, gives a blood-red color on the addition" of dilute sulphuric
acid. The reaction is diagnostic.
The discharges of dysentery are peculiarly fcetid, voided with
great tenesmus, tinged with blood, contain muchs mucus, and, in old
cases, fragments or sloughs of mucovis membrane and pus. Amoeba
coli characterize the form known as tropical dysentery. Fresh dejecta
miist be examined upon a warm stage ' in order to demonstrate their
presence. The fibrinous casts and shreds of mucus should be examined
by floating in water.
Gall-stones and enteroliths are sometimes found. When gall-
stones are suspected, the stools should be passed into a cheese-cloth,
"crab-net" over a wire frame, placed in the closet, then washed in
running water. The stones are recognized by their hardness, shiny
appearance, color and facets, giving them an uncut crystal appearance.
Enteroliths are solidified food concretions of varying, usually
small, size. Seeds, animal parasites, eggs and larvffi are often found
in the fffices.
Pus occiirs in cases of abscess rupturing into the tract or in
destructive inflammations of the bowel itself, as in dysentery.
In cases of tuberculous, syphilitic or cancerous ulceration pus is
mixed with tissue shreds and blood.
Microscopic Examination. When very thin the faeces can be ex-
amined without dilution, or a small portion may be thinned with
water, spread on a cover glass, dried, fixed and stained in the usual
way. Bacteria, pus, blood, epithelial cells, crystals, and detritus are
thus recognized.] In conditions of intestinal suppuration, leucocytes
are found. The crystalline substances encountered are fat crystals,
phosphatic crystals, oxalate of lime, sulphate of calcium and occa-
sionally others.
SECTION XVII.
THE ROENTGEN RAY IN DIAGNOSIS.
The X-ray contributes very considerably to the science of diag-
nosis and in some eases, at least, affords aid at just the point where
other methods are imperfect or totally inadequate. Hence it is to be
regretted that the system is not of more universal applicability: In
private practice its use is not yet extensive, but at present all large
hospitals and most smaller institutions, as well as many physicians'
•offices, are equipped with the necessary apparatus.
Since, however, for a long time to come the greater number of
examinations for ascertaining the physical condition of patients must
be conducted without its aid, practitioners will do well to eultivatie
and practise the older methods of diagnosis, even in the instances to
be described in which its use affords us most comfort by reason of its
certainty.
The static machines constructed for office use are equipped with
the necessary X-ray apparatus. They are expensive, bulky, station-
ary, but efficient. At present the work is generally confined to men
■of special training, but experience is the only requisite.
For purposes of diagnosis in diseases of the chest a high pene-
trating power is unnecessary and less efficient than one of lower power
since the latter renders less transparent the organs which we most
wish to examine, by reason of such solid organs obstructing the softer,
less penetrating rays. This is brought ■about„by using Crooke's tubes
of less perfect vacuum than those necessary for viewing the bones
and large joints. Such tubes are technically called soft tubes.
The Examination. The examination may be direct, by the use
■of the fluoroscope, to which proceeding the name radioscopy, or Ront-
goscopy, is given; or the examination may be indirect, by making
radiographs or plates from which prints are made. The latter process
is called radiography.
A fluoroscope is simply a piece of card-board coated with a fluor-
THE ROENTGEN RAY IN DIAGNOSIS 343
escent salt — platinocyanide of barium is the best— and fitted into a
frame like the stereoscope.
In general hospital work the examinations are made almost
entirely with the flnoroscope as the results are immediate, and in the
hand of a practised examiner much more inforrtiation upon certain
necessary points is vouchsafed than by the pictures. But the direct
Fig. 83 — Normal Chest. The natural bulge in aorta referred to in text is seen
at B.
examination requires that the patient be submitted to the ordeal Tor
a much longer time than is necessary to secure the photographic
picture, and is tiresome likewise to the examiner.' In cases of severe
illness this is a point worthy of consideration. On the other hand it
is the only way in which pulsations, the movements of organs, and
•changes in the position of fluids may be appreciated.
As intimated, experience and good judgments play no small part
in forming correct conclusions by this method, since only by practice
and experience the relative position, size and qnjilities of the organs
344 THE ROENTGEN BAY IN DIAGNOSIS
in the shadow pictures can be learned, as all these vary with the
distance between patient and light, and other factors.
Radiography is most useful in doubtful and disputed eases; the-
prints have a certain medico-legal value, can be used for measure-
ments and comparisons, and when successive pictures are obtained
show positive results of treatment or of the advance of disease, and
furnish us with permanent records.
Since the improvements in apparatus and technique, the neces-
sary exposure has been so shortened that' at present satisfactory pic-
tures are obtained by exposures of less than a second (von Ziemssen).
Fluoroscopic Examination; Radioscopy. The examination is con-
ducted in a dark room and is simplest and most satisfactory with the
patient erect, as in this position only are the normal relations pre-
served. The Crooke 's tube is placed behind the patient in the median
line at a distance of about two feet, on a level with the part to be-
examined. A fenestrated, adjustable metallic screen, or a Beck's
diaphragm, placed between the tube and the patient is useful for
concentrating the light on a particular point and for cutting off
extraneous rays. In case the patient is unable to stand, the tube is
adjusted under a canvas cot on which he rests. The fiuoroscope is'.
placed directly in front of the chest walls.
Rontgen ray burns are the result of too long or too oft-repeated
exposures. Restricting the single exposures to five minutes, and not
repeating these oftener than at intervals of every three days, is said
to be a safe limit.
THE THORAX.
The healthy lungs do not perceptibly intercept the rays hence-
their image appears only as a faint shadow. The vertebral column,
the ribs, clavicles and sternum are plainly seen. The pericardium,
the outlines of the heart and its movements are distinct. The great-
ly vessels are less distinct, but visible. The movements of the diaphragm
are distinct and when restrained the limitation may be detected by
the practised observer. In children, and generally in adults, the bifur-
cation of the trachea may be seen.
The apex of the heart shows sharply during deep inspiration. A
bend or protuberance upon the left of the aorta, above the pericardial
sac, resembling an aneurysm is often seen and might be mistaken
readily for such a growth.
THE ROENTGEN RAY IN DIAGNOSIS
345
Fig. 84 — Small Aenurysm of Aorta. Johns Hopkins Hpsp., Dr. Baetjer.
THE ROENTGEN RAY IN DIAGNOSIS
Ml
Fig. 8s— Disseminated Pulmonary Tuberculosis, both lungs. Johns Hopkins
Hospital, F. H. Baetjer.
THE ROENTGEN RAY IN DIAGNOSIS 349
The unequal heights of the two sides of the diaphragm is strik-
ingly seen, the right side being always the higher. This shows best
during deep inspiration. In case of hypertrophy of the heart the left
diaphragm is sunken below the normal plane, while in early tubercu-
losis Williams finds the structure abnormally high*.
Diseases, injuries or malformations of the vertebra, supernumer-
ary ribs, or foreign bodies within the thorax are easily recognized.
Cardiac hypertrophies and dilatations not only can be recognized
but differentiated (von Ziemssen). Displacements, effusions into the
pericardium and aneurysms of the organ are made out, as are also
mediastinal tumors.
While the healthy lungs give almost no image, yet diseased con-
ditions are fairly well brought out by the rays. Pulmonic solidifica-
tions, especially deep-seated foci of pneumonia almost impossible to
demonstrate otherwise, appear, as do tuberculous solidifications,
vomicse, abscesses, bronchiectasis, atelectasis and calcifications.
Cavities with thickened walls are seen as shadows surrounded by
lighter areas. Incipient tubercular lesions show but little, and it is
doubtful if they can be recognized by the rays before they are demon-
strable by other means.
Effusions into the pleural cavities are markedly opaque, and the
movements to which they are subject are strikingly shown. Serous
effusions appear more opaque than do those of pus. Th^ boundary
line between effusion and air in hydropneumothorax is distinct. Pul-
monary retraction resulting from old pleurisy, as well as thickening
and deposits upon the pleural membrane, all show in the plates.
Irregular movements of the diaphragm and restrictions of its
excursions are easily studied. The diaphragm separates from the
heart during deep inspiration.
During forced inspiration the lung shadow is diminished. In
emphysema the lung shadow is fainter still than in normal lungs.
The heart obstructs the shadow of that portion of the lungs which it
covers.
Sclerosis of the deep vessels can be recognized only by the x-ray
picture. The position, size, shape and type of intrathoracic aneurysms
are better told by the skiagraph than by percussion and auscultation,
and repeated instances are recorded in which they have been discov-
ered by this means when their presence was unsuspected. Pulsation
distinguishes them from solid tumors of the same area.
350 THE ROENTGEN RAY IN DIAGNOSIS
THE ABDOMEN.
In diseases of the abdomen a somewhat harder tube than that
used in chest work is desirable. Skiagraph;^ gives the best results.
The solid liver shows best; the intestines are discernible only occa-
sionally, but their contents show. The triangular psoas muscle can
be seen. The outline of the stomach is shown by coating its walls
with a substance impenetrable by the rays, as subnitrate of bismuth,
or by the introduction of a flexible steel wire covered with rubber.
Tumors of the stomach show only when of considerable density.
Eadiographs of the intestines are obtain'fed in the same manner
as has been suggested for taking skiagraphy of the stomach. One
ounce of bismuth subnitrate is suspended in" a quart of milk. The
skiagraph of the stomach may be taken immediately after its inges-
tion. Six hours later the picture of the small intestine is taken ;
twelve to twenty-four hours later the colon shpws best in the print.
Recent examiners are all in accord in stating that the position of
the stomach as described in the text-books is incorrect. The vertical
position, as referred to in the description of the organ in the section
on anatomy, and the jjosition which has usually been considered and
described as ptosis or moderate prolapse, are most often observed.
The same may be said of the intestines; what formerly has been re-
garded as prolapse of the colon is more commonly found than the so-
called normal position.
The examinations show that dilatation and prolapse are fre-
quently met with, especially in women.
More extended research will probably change many of our preva-
lent ideas on these topics.
The spleen appears indistinctly, as do also the kidneys. They
appear in the radiographs but are seldom seen by the fluoroscope.
Diseases, fractures and displacements of the lumbar vertebr£e;
calculi of kidneys, ureter, bladder and prostate, and those of the
hepatic duct and gall bladder are demonstrable.
The size, shape and position of the liver are easily studied by the
rays, and abscess, when present, is revealed.
Biliary calculi are difficult to show in the picture and much de-
pends on their composition, but in recent years the difficulties have
been successfully overcome.
Hydronephrosis and cysts of the kidney fiave been demonstrated.
THE ROENTGEN BAY IN DIAGNOSIS 351
Fig. 86— Aneurysm. Johns Hopkins Hospital, Dr. Baetjer.
THE ROENTGEN RAY IN DIAGNOSIS
•A5'S
Fig. 87 — Aneurysm of Aorta. Johns Hopkins Hospital, F. H. Baetjer.
THE ROENTGEN RAY IN DIAGNOSIS. 355
but it is in calculi of these organs that the pictures are of paramount
usefulness, since the absence from a good plate of indications of their
existence justifies a negative diagnosis in most cas'es. Ureteral and
vesical calculi also can be skiagraphed.
The Rontgen ray diagnosis of renal calculi is more satisfactory in
children than in adults. The most important factors are the size and
composition of the stone, the size of the subject tinder examination,
and the condition of the kidney, according to Smart. He says that
pure uric acid stones are the most difficult to detect ; pure phosphatic
stones ranking next. A combination of uric acid with phosphate or
oxalate of calcium is more easily detected, while pure oxalate stones
are the most opaque to the rays. Occasionally a collection of pus or
induration of the organ may obscure the shadow. I'he intestines of
the subject should be well emptied by enemas and purgatives, and all:
clothing removed from the parts of the body which are to appear in;
the negative.
Breathing should be restricted by an abdominal binder in the case
of children, as the movements of the kidneys interfere with the sharp-
ness of the pictures. Adults may be placed face downwards on a
canvas cot, the weight of the body being sufficient to limit the respira-
tory excursions. In this case the tube is placed under the cot, and the
plate on the patient's back, as before described. Both kidneys and
both ureters should be included in the picture. In case of doubt, the
exposure should be repeated a few days later, the conditions being as
nearly similar as possible.
Foreign bodies in any part of the abdomen are easily located,
especially if metallic, as nails, tacks, coins and the Murphy button..
INDEX
Abdomen, 255
alterations of, 255
anatomy of, 256
auscultation, 256, 264
enlargements, 260
causes of, 260
general considerations, 255
inspection, 259, 280
methods of examining, 259
palpation, 261
percussion, 262, 280
planes of reference, 256
shape of, 239, 271
topography, 256
tumors of, 275, 277
retraction of, 260
Abdomina'l pain, 262
Abscess of fauces, loi
of liver, 281, 283
of lung, 132, 140
Absorption, gastric, 304
Acetic acid, 298
detection of, 301
Acetonuria, 324
Achromatophilic, 238
Acids in gastric contents, 300
acetic, 245
detection of, 300
butyric, 300
hydrochloric, 296
estimation of, 301
lactic, 298
detection of, 300
Acidity, total gastric, 300
Addison's disease, 254, 302
Adherent pericardium, 195
Adventitious sounds, 81, 176
Alar chest, 31
Albumin, 317
coagulation test, 319
Heller's test for, 318
Potassium ferro-cyanide test for,
318
Albuminuria, 199, 317
cyclic, 317
lesions causing, 317
Albumoses, 303
test for, 303
Amylolysis, 303
Amoeba coli, 341
Anacrotic pulse, 65
Anaemia —
in Addison's disease, 254
dyspnoea of, 100
in .gastric carcinoma, 250
m Hodgkin's disease, 254
pernicious, 250
in purpura, 254
splenic, 251
Anatomy of aorta, 228
of chest, 27
of heart, 159-
Anasarca, cardiac, 211, 294
general, 294
Aneurysm, 228
of ascending aorta, 230
Bramwell's classification, 230
of descending arch, 231
differential diagnosis, 232
of innominate, 232
physical signs, 229
pressure symptoms, 230
special diagnostic symptoms, 232,
23s
Smith's sign, 232
thoracic, 228, 231
of transverse arch, 231
tracheal tug, 232
x-ray diagnosis of, 49, 349
Aneurysmal bruit, 230
thrill, 230
Amphoric breathing, 8t
resonance, 75
voice, 8s
Aorta, anatomy of, 36
Aorta area, 183
associated murmurs, 212
358
INDEX
Aorta—
incompetency, 183, 186
mechanism of, 210
murmurs of, 185
physical sign, 211
notch, 66
obstruction, 183
stenosis, 186, 214
diagnosis of, 216
stenosis and incompetency, 217
mechanism of, 217
physical signs of, 217
thrill, 215
Apex of heart, 160
method of locating, 55, 162
Area of absolute cardiac dullness, 37,
167
Arhythmia, 58
Apoplexy, pulmonary, 139
Appendicitis, 260, 276
palpation in, 271
diagnosis of, 278
physical signs of, 276, 378
leucocytosis in, 240
tumor in, 279
varieties, 276
Arterial murmurs, 62
Ascites, 294
causes, 294
hepatic cirrhosis, 285
in hepatic cancer, 285
diagnosis of, 295
Associated cardiac murmurs, 179, 212
Asthma — ■
bronchial, no
cardiac, 214
renal, no
Atrophy of optic nerve, 89
Auscultation, 76
of heart, 170
immediate, 76
mediate, 76
of voice, 84
Auscultatory percussion, 26
Axillary regions, 33, 42
boundaries, 33
contents, 42
divisions, 34
B
Bacelli's sign, 86, 121
Bacteria of bronchiectasis, 113
of broncho-pneumonia, 136
in gastric carcinoma, 305
of pneumonia, 134
in urine, T 336
Barirel chest, 30
causes of, 30
Basophiles, 238
Bell sound, 86
in pneumothorax, 86
Bellows murmur, 291
Bile pigment in urine, 324
Gmelin'S: test for, 324
Bizzozero's plaques, 236
Bladder, 290
Boas-Oppler bacillus, 305
Boas' test meal, 298
test for HCl, 299
Blood, exarnination of, 236
in abdominal diseases, 255
in Addison's disease, 254
in chlorosis, 249, 252
corpuscles of, 237, 238
counting'' apparatus, 241
diluting fluids, 244
films, 246
fixation of, 246
in gastric carcinoma, 305
haemoglobin of, 249
in Hodgkin's disease, 254
in intestinal obstruction, 274
in lobar pneumonia, 135
in lymphatic leukaemia, 251
malarial organism of, 248
normal elements of, 236
nucleated red cells of, 237
in pericarditis, 241
in pernicious anaemia, 252
in phthisis, 157, 254
plaques of, 236
in pneumonia, 135
preparations, 246
in purpura, 254
in splenic leukaemia, 251
in spleno-meduUary leukaemia, 241,
251
staining,: 247
in stool, 274
technique; 246
test for presence of, 331
INDEX
359
"Blood-
in urine, 331
color imparted to, 332
Breathing —
(see also Respiration)
absent, 79
amphoric, 81, 153
bronchial, "J"}, 79, 119, 151
broncho- vesicular, 49, 78, 80, 119,
130, 148
cavernous, 80, 152
diminished, 79
in pneumonia, 130
in phthisis, I48
ptierile, 78
supplemental, 78, 1 30
tracheal, TJ
tubular, 49, 77, 131
types, 48
vesicular, 78
Broadbent's sign, 195
Bronchi, division of, 41
Bronchial stenosis, 114
asthm.a, no
Bronchiectasis, ill, 145
ditiferential diagnosis, 114
physical signs, 112 v
varieties, in, 145
Bronchitis, 106
acute, 106
capillary, 107
chronic, 108
physical signs of, 106, 107
sputum of, 107
Broncho-pneumonia, 136
diagnosis of, 139
from acute tuberculosis, 139
physical signs, 138
terminations, 137
tuberculous, 143
physical signs of, 144
Bronchophony, 85
in bronchiectasis, 113
in broncho-pneumonia, 138
in pleurisy, 122
in pneumonia, 131
in pulmonary tuberculosis, 151
whispered, 86
Bruit, aneurysmal, 230
de cuir neuf, 191
de diable, 61
Bruit—
de galop, 191, 225
in phthisis; 148
de souffle, 212, 291
Butyric acid, detection of, 300
Cancer, gastrici 250, 269
diagnosis from liver enlargement,
286
hepatic, 284"
of rectum, 282, 338
Canter rhythm, 191, 225
Calculi, diagnosis by x-ray, 355
intestinal, 272, 282
Capillary pulse, 63
Caput Medusffi,: 60, 294
in atrophic cirrhosis, 285
Carbohydrates, 320
in urine, 326
Carcinoma, gastric, 250, 269
acetone in, 324
of liver, 284
rectal, 282, 338
urine in, 325
Cardiac cycle, 159
changes in,^ 189
defects, congenital, 222
diastole, 159
dullness, Z7t 167
impulse, displaced, 168
normal, i6g
lesions, ordier of frequency, 178, 221
in tuberculosis, 151
murmurs, 177 (see Murmurs)
systole, 159-
valves, location of, 160, 174
reduplication, 176
sounds of, 174
Cardiac orifice of stomach, 46, 266
Cardio-respiratory murmur, 187
Case —
records, 19
value of, 19
taking, 20
Casts, 333
bacterial, 336:
blood, 332, 334
epithelial, 335
fatty, 335
fibrinous, 94
360
INDEX
Casts —
granular, 335
hyaline, 334
P"S, 335
urinary, 333
Cataract, go
Catarrh, intestinal, 272
Cavities, 145
Cells, behavior to dyes, 238
mast, 238
Chemical dyspnoea, 100
Chest, adult, 28
alar, 31
alterations produced by disease, 48
anatomy, 32
barrel, 30
emphysematous, 30
infant, 27
funnel breast, 30
landmarks of, 34
normal, description of, 47
pigeon breast, 29
paralytic, 31, 116
phthisical, 31
rhachitic, 29
regions of, 32
transverse constriction of, 29
types of, 29
Chautard's acetone test, 324
Chill, 132
Chlorosis, 60
Cholelithiasis, 67
Cholera, stools of, 341
Cholesterin in pneumonia, 135
Choroiditis; 88
Clavicle, relation to ribs, 41
Clubbing of fingers, toes, 104, 112, 157,
223
causes of, 105
Coin ring, 86, 128
Colic, abdominal, 274
hepatic, 276
intestinal, 279
renal, 276, 279
Colitis, membranous, 273
Coloptosis, 280
Concretions, bronchial, 146
pulmonic, 146
Congenital heart diseases, 222
Constipation, 84, 270, 337
Consumption, 143
(see Tuberculosis)
Cor Bovinum, 163
Corpuscles, fed, 237
counting, 243
■white, 238
Corrigan pulse, 58
Corset wearing, effects of. 260
Cough, 91
in aneurysm, 230, 234
in bronchiectasis, 24
causes of, 91
characteristics of, 92, 133
dry, 91
moist, glj 93
paroxysmal, 107
stomach,, 91
sympathetic, 92
varieties, 91
whooping, 92
Cracked pot sound, 75, 121, 131, 132,
152
Crenation, 237
Crepitans reflux, 132
Crepitation, 86
gall stone, 27s
Crepitus, 86.
Crescents, 249
Crook's tubes, 342
Croupous pneumonia, 129
Crystals, Charcot-Leyden, 94
in leuksfemia, 251
Curschmann's spirals, 94, 11 1
Cyanosis, IS3, 223
causes, 104
chronic,* 104
congenital, 103
relation, to dyspnoea, 104
Cyrtometer, gi
Cystin, 329
Cytometer, Thoma-Zeiss, 241
D
Daland's hsematocrit, 245
Dare's h^emoglobinometcr. 253
Deglutition pneumonia, 136
Dexiocardia, 164
Diabetes mellitus, 321
Diaceturia, 324
significance, 324
INDEX
1
361
Diaceturia —
test for, 324
Diagnosis defined, iS
importance of, 22
methods, 17, 19
x-ray in, 342
Diaphragm, 32
anatomy of, 32, 42
in emphysema, 109
height of domes, 32, 37
openings in, 42
Diarrhoea, 338
Diastolic murmurs, 206
Diazo reaction of Ehrlich, 325
Dicrotic notch, 65
wave, 64
Digestion products, 302
Digiti Hippocratici, 104, 112
Dilatation, cardiac, 223
Diplococcus pneumonise, 134
examining for, 134
Direct murmurs, 184
Divisions of bronchi, 41
Donne's test for pus, 315
Doremus' ureometer, 313
Dropsy, (see Ascites)
Dry pericarditis, 190
Ductus arteriosis, patent, 222
in heart diseases, 222
Dullness, definition of, 72
Dysentery, 280
agglutination test for, 281
bacteriology, 280
differential diagnosis, 281
stools of, 341
varieties, 280
Dyspncea, 99
anaemic, 100
aneurysmal, 230, 233
of bronchial stenosis, 115
causes of, 99
cardiac, 99, 214
chemical, 100
classification, 100
expiratory, lOo
\ inspiratory, 100, iii, 130
laryngeal, 99, 1 10
mechanical, 100
.nervous, loi
of pulmonary embolus, 140
pai-oxysmal, 103, 115
Dyspnoea — ■
of pneumonia, loi, 130, 133
physical signs of, 100
renal, 103
of tuberculosis, 156
Eberth's bacillus, 340
Echo, amphoric, 87
Echinococcus, 285
Effusion, pleuritic, 117
point for tapping, 34
Egophony, 85, 119, 131
Ehrlich's diazo reaction, 157, 325
triacid stain, 247
Eichhorst's pulse scale, 55
corpuscles, 250
Elastic tissue, test for, 154
Ellis' curve, 118
Embolism of pulmonary artery, 139.
diagnosis of, r40
physical signs of, 140
Embryocardia, 225
Emphysema, 108
compensatory, 108
diagnosis of, 109
physical signs of, 108
varieties, 108
Emphysematous chest, 30, 108
causes of, 30
Endocarditis, acufe, 226
malignant, causes of, 226
symptoms of, 227
simple, causes of, 226
symptoms, 226
Endocardial murmurs, 176
Ensiform cartilage, 41
variations in, 41, 260
Enteroliths, 341
Enteroptosis, 280
Eosinophiles, 238
in leukaemia, 251
Epigastric pulsation, 163, 206
significance of, 163
region, 41
Epileptics, pulse rite of, 57
Erythrocytes, 236
Ethereal sulphates, 31S
Ewald's test meal, 297
salol test, 305
Ewart's sign, 193
362
INDEX
-Exocardial murmurs, "n
.Expectoration, 93
amount, 93
of bronchitis, 107
of pneumonia, 133
of phthisis, 154
varieties, 93
(see also Sputum)
J^'ecccs, 337
acholic, 340
blood in, 274, 338
in cholera, 340
in colitis, 273
composition, 337
consistency, 338
in diarrhoea, 340
in dysentery, 341
gall stones in, 341
gases of, 340
inspection, 337
in intestinal catarrh, 273
odor, 338
palpation for accumulations, 280
reaction, 339
quantity, 339
in typhoid, 340
.Taecal accumlilations, 280
signs of, 2S0
False murmurs, 187
Fehling's glucose test, 322
Fever in broncho-pneumonia, 137
in hsemoptysis, 96
hectic, 153
in phthisis, 153
in pneumonia, 132
in pulmonary abscess, 132
pulse rise in, 56
Fixation of blood films, 246
Flatness defined, 72, 75
Fleischer's gastric motor test, 304
Flint's murmur, 212
vesiculo-tympany, 119
Fluctuation, 262
circumscribed, 262
Fluoroscope, 342
FcEtal heart sounds, 291
Possa, 34
infraspinous, 34
supraclavicular, 33
Fossa — ■
supraspinous, 34
Friction sounds, 83, 177, 190, 194, 262
diagnosis of, 84
Friedreich's sign, 195
Fremitus, ^2
abdominal, 262, 264
cardiac,- 166
diminished, 53
factors of, 52
friction, 54, 130
normal,! 54
pericardial, 190
pleural, 116
in pneumonia, 53, 130
rhonchikl, 54, no, 112, 152
tactile, 52
tussile, 54
variations, S3
vocal, 84
Funnel breast, 30
causes, 30
Q
Gall bladder, 41, 275
enlargements of, 42
palpation of, 42, 275
Gall stone disease, 275, 341
differential diagnosis, 276
Galloping consumption, 143
rhythm, 191, 208
Gangrene, intestinal, 281
pulmonary, 132
Gastrectasia, 269
Gastric carcinoma, 250, 269
lactic acid in, 305
Gastric contents, examination of, 296
absorption, 304
test for, 304
acetic acid in, 298, 300
acid salts of, 302
Boas' test for, 299
Boas-Oppler bacillus in, 305
butyric acid in, 298, 300
smell of, 300
test for, 300
chemical examination of, 300
digestion products, 302
free acid, 296
free HGl, 296
estimation of, 301
juice, 296
INDEX
363
'Gastric contents —
lactic acid in, 297
after test breakfast, 298
test for, 300
microscopic examination, 305
motor function, 304
mucus, 305
organic acids, 299
test for, 300
pepsin, 303
reaction, 29S
rennin, 304
sarcinse, 305
total acidity, 300
Gastroxynsis, 297
•Gigantoblasts, Ehrlich's, 250
Glucose, 320
Fehling's test for, 322
Maine's test for, 322
Phenylhydrazin test, 322
Robert's test for, 323
Trommer's test for, 321
precautions, 321
Gmelin's test, bile pigment, 324
Gollash's dye, 248
Gonococcus, 336
■Gower's fluid, 244
haemoglobinometer, 252
Glycosuria, 320
qualitative test for, 322
quantitative test, 321
significance, 320
(see also Glucose)
H
Hsematemesis, 60, 272
Haematocrit, Daland's, 245
Hematuria, 332
Hasmic mu'rmurs, 177
Haemocytometer, 241
Turck's rulings, 244
Haemoglobin, 249
in chlorosis, 249
estimation of, 252
in gastric carcinoma, 250
in leukaemia, 251
in pernicious anaemia, 250
in septic infections, 250
, Haemoglobinometer, Dare's, 253
Gower's, 252
Tallquist's, 252
Haemopericardium, 198
Haemoptysis, 95
in bronchiectasis, 114
causes, 95
character of, 96
diagnosis, 97
from haematemesis, 97, 9
in embolus, 140
in emphysema, no
in gastric carcinoma, 270
in mitral diseases, 199
in phthisis, 155
recurrent, 96, 97
symptoms, ^6
vicarious, 96
Haemorrhage, intestinal, 98
retinal, 89
Haine's glucose test, 322
Harrison's sulcus, 29
Hazer's coefficient, 312
Heart, diseases of —
absolute dullness of, 37, 169
anatomy of, 159
apex impact, 160
areas, 162, 167, 168
dilatation, 199, 223
physical signs of, 225
displacements: of, 164
causes of, 164
in emphysema, 109
fatty, 225
fibroid, 226
hypertrophy, 223
causes, 224
pseudo, 163
murmurs, 177
causes of, 177
location of, 180
time of, 179
percussion areas, 166
decreased, 169
displaced, 169
increased, 169
physical examination of, 161
physiology, IS9
rate, IS9
reduplication, 176
sounds, 170
altered, 174
adventitfous, 176
element^ of, 171
364
INDEX
Heart — ■
normal, 170
over cavities, 152
reduplication of, 166, 176, 207
(see also Cardiac)
Heaving, aneurysmal, 229
Hectic, 153
Heller's albumin test, 318
Hepatization of lung, 129, 131
Herpes in pneumonia, 132
Hiatus diaphragmaticus, 46
Histologic sediment of urine, 330
History taking, 21
Hippocratic succussion, 86, 128
in pneumothorax, 128
Hodgkin's disease, 254
Hydrochloric acid, 296
in gastric contents, 298
qualitative test for, 299
quantitative test for, 301
significance, 302
tests for, 299
Flydropericardium, 197
Hydropneumothorax, 125
Hyperchlorhydria, 297
Hyperleucocytosis, 240
Hyperresonance, 74
Hypertrophy, cardiac, 223
causes, 224
Hypobromite solution, 313
Hypoleucytosis, 240
Hyperostosis of Marie, 112
Inframammary —
right, 38
Infrascapjjilar region, 34
contents, 45
Infraspinous fossa, 34
Inorganic murmurs, 177
Inspection, 47
rules for, 47
in intestinal diseases, 271
Insufficiency, aortic, 183, 186
mitral, 198
pulmonary, 220
tricuspid, 217, 219
Intermittent venous murmurs, 63
Interscapular region, 34, 45
boundaries, 45
contents, 45
Intestine, : 270
catarrh of, 272
glands of, 270
large,: anatomy of, 279
diseases of, 270
obstruction of, 273
perforation, signs of, 278
small, 270
anatomy of, 270
diseases of, 270
special symptoms, 270
ulcer of, 276
Intussusception, 274
Iodoform test, Fleischer's, 304
lodophilia, 239
Ileus, 273
Incisura of lung, 45
Indirect murmurs, 184
Indol, 315
in intestinal obstruction, 315
in peritonitis, 315
Indican in urine, 274
significance of, 315
test for, 265, 315
Inferior axillary region, 34
contents, 45
Infraclavicular space, 33, ;}6
boundaries, 33
contents, 36
Inframammary region, ^;i
boundaries, 33
contents, left, 37
Jenner's stain, 24S
K
Kidneys, 43, 289
anatohiy, 45, 289
enlargements of, 289
movable, 290
palpatixin, 289
percussion areas, 289
physical examination of, 289
tumors of, 290
Klemperer's gastro-motor test, 304
Koch's CQma bacillus, 340
L
Lactic acid, 300
in gastric contents, 300
Ufflerfiann's test for, 300
INDEX
365
Laennec's purring tremor, i66
perles, 94
Landmarks of thorax, 33, 34
of ribs, 34
Laryngoscope, 87
diagnosis by, 88
Larynx, ulcer of, 88
hsemorrhage from, 98
Laryngeal breath sounds, loi
stenosis, 99
dyspnoea, 99
Laryngismus stridulus, 104
Lavaran's Plasmodium, 248
Leadworker's pulse, 57, 67
Leo's test for acidity, 302
Leucocytes, 236
basophilic, 239
classification, 239 '
counting, 244
eosinophilic, 239
large mononuclear, 239
neutrophiles, 239
normal number, 239
polynuclear, 239
in pernicious anaemia, 250
in pulmonary tuberculosis, 254
reaction to iodine, 239
'small mononuclear, 239
Leucocytosis, 237, 240
absence of, 240
basophilic, 240
causes of, 240
eosinophilic, 240
experimental, 240
inflammatory, 240
in malignant disease, 240
pathologic, 240
pneumonic, 135
post hjemorrhagic, 240
physiologic, 240
therapeutic, 240
toxic, 240
Leucin in urine, 329
Leukaemia, 251
diagnosis of, 252
lymphatic, 251
splenomedullary, 251
Line —
mammary, 33
midaxillary, 34
midclavicular, 33
Line —
midscapular, 34
parasternal, 33
Lithogenous biliary catarrh, 27s
Litten's phenomenon, 147, 195
Liver, 282
abscess, 281
symptoms of, 283
acute yellowr atrophy, 285
alterations of position, 283
anatomy of, 37, 76
amyloid, 284
borders of, 38, 76, 282
in atrophy, 285
cancer of, 284
changes in size, 2^3
in amyloid, 284
cirrhosis, atrophic, 285
hypertrophic, 284, 294, 318
cysts of, 295
displacements, 283, 286
enlargements, 275
echinococcus* 285
fatty infiltration, 284
hyperaemia of, 283
lymphadenomata, 285
normal boundaries, 38, 76, 282
nodules, 284
pulsation, 62| 164, igp, 218, 283
syphilis of, 285
Lobar pneumonia, 129
bacteriology, 134
blood changes in, 135
diagnosis, 13-5
special sympfoms, 132
terminations, 132
Lungs —
abscess of, 95, 132
altered sounds, 78
anatomy of, 45
apex areas, 35
auscultation, 76
blood from, 96
borders of, 45, 7s
cirrhosis, 294
collapse of, 114
conditions causing cough, 91
causing clubbing, 105
consolidation, 149
expansion, types of, 48
in embolism, 139
366
INDEX
Lungs —
gangrene of, 132
hepatization of, 131, 140, 143
inspection, 47
lobes of, 39
outlines of, 75
oedema of, 135, 141
diagnosis, 135
palpation, 52
percussion, 70
percussion note, 71
changes in, 73
in pericarditis, 193
in pleurisy, 121
compression of, 121
in pneumothorax, 125
relation to clavicle, 35, 75
to pleura, 45
to sternum, 38
to thorax, 75
retractions, 151
symptoms pointing to, 20
Ludwig's angina, 100
Lymphocytes, 238
in Hodgkin's disease, 254
in leukemia, 252
M
McBurney's point, 277
Macroblasts, 236
Macrocytes, 236
Malarial organism, 248
Mast cells, 238, 252
in leukaemia, 252
Mammary region, 31
boundary, 31
contents, 37
line, 31
Mechanical aids to diagnosis, 63,
Mechanical dyspnoea, lOO
Meconium, 340
Mediastinal growths, 99, 235
diagnosis from aneurysm, 169,
from cardiac hypertrophy,
Megaloblasts, 237
Medical anatomy, 32
Megalocytes, 236
in pernicious anaemia, 250
Meningeal disease, influence on
57
Mensuration, 51
Metallic tiflkle, 86, 127. 153
in intestinal obstruction, 274
Microblasts, 237
Microcytes, 236, 250
Microscope —
findings in faeces, 341
in' stomach, 305
in urine, 330
Midaxillary line, 34
Midclavicular line, 33
Midscapur3r line, 34
Mitral area, 181
incompetency, 198
diagnosis of, 203
rrffechanism of, 198
physical signs of. 198
incompetency and stenosis, 20,. 305
336 solids of, 312
significance of
diminution, 312
specific gravity; 311
spermatozoa in, 336
sugar in, 320
374
INDEX
Urine — ■
sulphuric acid in, 315
sulphates in, 315
transparency, 312
in typhoid, 247
tyrosin in, 330
in tuberculosis, 157
urates in, 327
urea in, 313
Hartley's method, 314
uric acid in, 315
uric acid calculi, 327
Urinometer, 311
Uterus, 290
enlargements of, 291
impregnated, 291
physical examination of, 293
tumors of, 292
V
Valentine's stethoscope, 24
Valves, cardiac, 160
areas, 174
aortic, insufficiency of, 183, 186
stenosis of, 186, 214
cardinal points for, 174
congenital diseases of, 222
differentiation of sounds, 174
insufficiency, 178
isolation of, 173
location of, 173
mitral, insufficiency of, 19S
stenosis of, 184, 204
names of, 160
pulmonary, insufficiency of, 220
stenosis of, 220
tricuspid, insufficiency, 185, 217
stenosis, 178
Valvular lesions of tuberculosis, 151
Vascular phenomena, 59
of aortic insufficiency, 63
venous, 59
Veins, enlargement of, 59, 165
conditions causing, 59
significance of, 59, 165
Venous engorgement, 60, 192
murmurs,; 61
pulsatior;s, 59, 165, 100. 218
in phthisis, 61
time of, 61
transmitted, diagnosis of, 60
as sign of tricuspid reglirgita-
tion, 61
Ventricles, thickness of, 223
Vesicular breathing, 78
percussion note, 71
Vesicnlo-tympany, 71, T09
Vocal resonance, altered, 84
normal, 84
Voice, amphoric, 85
auscultation, 84
cavernous, 153
in pneumothorax, 127
in phthisis, 153
whispered, 85
Volvulus, 274
Vomit, stercoraceous, 274
W
Water hammer pulse, 58
Whisper resonance, 86
Whooping cough, 92
dyspncea of, 99
Wintrich's changed note, 152
Xiphoid cartilage, 41
m