' ^^tf** ««* ;«Uu»« .«.■*!. «^ 1* ^if *A ** ! f 7^ CORNE LL UNIV ERSITY THE Wixsv&n Uptprmary Sltbrary FOUNDED BY ROSWELL p. FLOWER for the use of the N. Y. STATE VETERINARY COLLEGE 1897 This Volume is the Gift of 5577 _ Cornell University Library RC 76.L86 1903 Lessons in physical diagnosis, 3 1924 000 266 381 \ HOMER, - N, Y. LESSONS IN PHYSICAL DIAGNOSIS BT ALFEED L. LOOMIS, M.D., LL.D. PROFESSOR OF THE PRACTICE OF MEDICINE AND PATHOLOGY IN THE UNIVEKSITT OF THE CITY OP NEW YORK KBVISED BT ALEXANDER LAMBERT, M.D. VISITING PHYSICIAN TO EELLBVUB HOSPITAL ; PROFESSOR OF CLINICAL MEDICINE AND INSTRUCTOR IN PHYSICAL DIAGNOSIS IN CORNELL UNIVERSITY; ASSISTANT BACTERIOLOGIST, HEALTH DEPARTMENT, NEW YORK ELEVENTH EDITION— REVISED AND ENLARGED NEW YOEK WILLIAM WOOD AND COMPANY MDCCCCIII T-3 Entered according to Act of Congress, in the year 1899, by WILLIAM WOOD & COMPANY, in the OfSoe of the Librarian of Congress, at Washington. ALL BIGHTS BESERTED. PEEFATORY IJ^OTE. The eleventh edition of this volume has been thor- oughly revised, and such corrections and additions have been made as seemed necessary to make it a more com- plete guide to the student of Physical Diagnosis. The lessons on the Examination of Urine and Clinical Microscopy have been entirely rewritten. A new sec- tion on the Examination of Stomach Contents has been added. The Eeviser has endeavored to leave untouched, as far as possible, the lessons on Physical Diagnosis, de- siring that they should remain as their distinguished author wrote them. Alexander Lambert. 125 East Thirty-sixth Street, September, 1899. The original of tiiis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924000266381 OOIsTTENTSi LESSON I. tUTBODUCTION— TOPOGKAPHT OP THE WALLS OF THE CHEST— COS- XBNTS OF THE VaBIOUS KeGIONS 3 LESSON n. Inspection, Palpation, aito Mensuration , 11 LESSON III. t'BKCTJSSION. 19 LESSON rv. Auscultation .... 29 LESSON V. Abnobm al ob Adventitious Sounds «) LESSON VI. Auscultation op the Voice » ? LESSON vn. A Synopsis op Phtsical Signs in the Diagnosis of Pulmonaet Diseases. 53 LESSON vin. A Synopsis op Physical Signs in the Diagnosis of Pulmonabt Diseases— Continued 66 LESSON IX. TOPOGBAPHY OP THE HeABT AND AOETA — PhYSIOLOQICAL ACTION OP THE Heabt. 81 Vi CONTENTS. LESSON X. »AOB Methods op Cakdiao Physical Examination 89 LESSON XI. Abnormal Sounds of the Heakt ^ LESSON xn. Synopsis of the Physical Signs of Pericarditis— Htpbetbopht, Dilatation, and Patty Degeneration of Heart, and Anbu- BiSMS OF Thoracic Aorta 118 LESSON xni. Aneurism of the Thoracic Aorta and Arteria Innomtnata— Epigastric Pulsation— Sub-clavian Murmurs — Venous Pul- sations AND Murmurs. 121 LESSON xrv. Abdomen — Introduction — Topography op the Abdomen — CoH- TENTS OF the VARIOUS REGIONS— ABDOMINAL INSPECTION, PAL- PATION, Percussion, and Auscultation— Diseased Conditions OP the Peritoneum ISl LESSON XV. Physical Signs op the Abnormal Changes in the Dipperbiit Abdominal Organs — Stomach— Intestines — Liver — Spleen . 141 LESSON XVI. Physical Signs op the Abnormal Changes in the Dippebent Abdominal Organs— Continued 158 LESSON XVII. (Jbine — Introduction — Plan of Examination — Physical Charac- ters — Chemical Characters — (a) Normal Elements, (J) Ab- normal Elements 175 LESSON xvin. Clinical Microscopy— Blood, Sputum, Urinb, Vomit. P^ces. . . 311 CONTENTS. vii LESSON XIX. iSjscRASioAL Aids in the Diagnosis of the Diseases of the Resfib- ATOBT AND VASCULAR ObGANS — STETHOSCOPE — StETHOMBTEB — CyBTOMETBB — CARDIOMETER — LaRTNOOSCOPE — SPHYGMa GRAPH . - a9a LESSON XX. MsOHANICAIi An>B IK THE DIAGNOSIS OF DISEASES OF THE NeRVOUS System, asd m General Diseases— Ophthalmoscope— Ther- mometer — Microscope — Dtnamombtbr — ^sthesiometeb— iSxFLOBDIG TrOCAB— SpUCDLA . 318 LIST or ILLTJSTEATIOl!fS. FIG. PAGE 1. The anterior region of chest, the boundaries of its subdivisions, and the organs corresponding to these subdivisions, . . 5 2. The posterior region of chest, the boundaries of its subdivi- sions, and the organs corresponding to these subdivisions, 8 3. Diagram illustrating the production of rales, .... 41 4. Cavernous respiration and gurgles 44 5. Roughening of the pleurae, and slight pleuritic eflusion, . 45 6. Diagram illustrative of the physical signs of the three stages of pneumonia, 58 7. Diagram showing the pleural cavity completely filled with liquid, the lung being compressed, 68 8. Diagram illustrative of the physical signs of hydro-pneumo- thorax 73 9. Diagram showing the changes in the valves and cavities of one side of the heart during a cardiac pulsation, ... 84 10. Representation of the movements and sounds of the heart dur- ing a cardiac cycle, 86 11. Representation of the altered relations of the sounds in slowed or accelerated heart action, 87 12. Diagram illustrating the mode of production of cardiac mur- murs in the left heart, and the condition of the valves and cavities during their production, 100 13. Diagram showing the areas of cardiac murmurs, . . . 104 14. Diagram showing the pericardial sac partially filled with liquid, and plastic exudation upon the two surfaces of the pericar- dium above the level of the liquid, 114 15. Hypertrophy of left ventricle, 116 16. Hypertrophy of right ventricle, 117 17. Diagram showing the different regions of the abdomen, and the organs contained in each, wliich are visible on the re- moval of the abdominal walls 138 18. The volume of the liver in various diseases, .... 146 19. Diagram representing the different areas occupied by the spleen in its various enlargements into the abdominal cavity, 155 20. Diagram showing the gradual enlargement of a tumor of the right ovary till it fills a large portion of the abdominal cav- ity, 166 X LIST OF ILLUSTKATIONS. PAGE 21. Urinometer ^°" 23. TJreometer, ^^^ 23. Improved ureometer, 24. Albuminometer, ^^^ 35. Saccharometer, ^^5 36. Cellular elements of human blood, ^^^ 37. Thoma-Zeiss pipettes ^^^ 38 and 29. Thoma-Zeiss counting slide, . . . . • 317 30. Field of thirty -six squares in ruled disc, of Thoma-Zeiss counter, 318 31. Modified ruling of Thoma-Zeiss counting chamber, . . 220 32. Blood from case of leucocythsemia, ..... 323 33. Poikilo-, macro-, and microcytes, 336 34. Fleischl's hsemometer, 337 35. Normal blood 280 36. Blood in pernicious anaemia, ...... 330 87. Blood in chlorosis, 331 38. Blood in chronic secondary ansemia due to bleeding piles, . 331 39. Pure culture of typhoid bacilli 234 40. Typhoid bacilli — partial reaction, 234 41. Typhoid bacilli — typical clumping 234 42. Spirillum of relapsing fever, 239 43. Bacillus of anthrax, 240 44. Bacillus of typhoid fever 240 45. Parasite of tertian malaria, 243 46. Parasite of quartan malaria, 348 47. Parasite of restivo-autumnal malaria 244 48. Flagellate malarial organisms 246 49. ^stivo-autumnal parasites, crescentic forms, . . . 247 50. Filaria sanguinis hominis 247 51. Curschmann's spirals 252 52. Bronchial cast, 353 53. Elastic tissue, 353 54. Tubercle bacilli from sputum 356 55. Actinomyces, or ray fungus. , 258 56. Pneumococcus 258 57. Echinococcus booklets, . 259 58. Urate of soda 368 59. Urate of soda with spicula 363 60. Urate of ammonia, 863 61. Uric acid 365 62. Calcium oxalate , 265 63 and 64. Ammonio-magnesium, or "triple" phosphates, . . 266 65. Calcium phosphate, 267 66. Cystic, gg^ 67 Leucin • • . . 268 68. Tyrosin, 2gg LIST OF ILLUSTRATIONS. XI 70. 71. 73. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. 92. 93. 94. 95. 96. 97. 98. 99. 100. 101. 102. 103. 104. 105. 106. 107. 108. 109. 110. 111. 112. 113. 114. 115. Pus corpuscles Pus corpuscles treated with acetic acid, Epithelial cells, . Spermatozoa, Types of hyaline casts. Epithelial casts. . Granular casts, Patty casts, .... Blood casts Torula cerevisise, . Penicilium glaucum, . Sarcinffi, .... Gonococci Hremin crystals, . Spirillum choleras Asiaticse, Amoebae coli, Distoma hepaticum. Head of taenia solium, . Head and proglottides of taenia mediocanellata. Egg of bothriocephalus latus, Head and anterior end of strobile of bothriocephalus latus, Oxyuris vermicularis, . Eggs of nematode worm, Ascaris lumbricoides. Stethoscope, Phonendoscope, . Stethoraeter, Cyrtometer, . Cardiometer, Laryngeal mirror. Head mirror, Nasal speculum, . Marey's sphygmograph, Normal pulse tracing, A dicrotic pulse tracing, Pulse tracing in aortic regurgitation, Pulse tracing in aortic stenosis, . Pulse tracing from a case of atheroma. Tracing from frequent pulse, Pulse tracing in mitral obstruction. Pulse tracing in aneurism of ascending Liebreich's ophthalmoscope. Straight self-registering thermometer. Microscope, Dynamometer, JEthesiometer Dieulafoy's exhausting syringe, . aorta, PAGE 269 269 270 271 372 273 278 373 273 274 374 374 375 277 289 390 391 392 393 293 298 394 294 395 300 300 301 303 804 304 305 308 310 313 313 313 313 318 314 314 314 816 333 327 338 339 331 LUNGS. LESSON" I. INTRODUCTION — TOPOGRAPHY OF THE WALLS OF THE CHEST — CONTENTS OF THE VARIOUS REGIONS. Gentlemen . Physical Diagnosis is a term used to designate those methods which are employed for detecting disease dur- ing life by the anatomical changes which it has produced. The nature and extent of such changes can be recognized and appreciated by the deviations which they cause in the affected organs from the known physical condition of these organs when in health. The significance of physical signs in disease can be determined, not by the- ory, but only through chnical observation confirmed by examinations after death. There are five methods of ehciting these physical signs, termed "physical methods of diagnosis," viz., Inspec- tion, Palpation, Mensuration, Percussion, and Ausculta- tion. The most important of these are Auscultation and Per- cussion. The other methods are only subsidiary to these two, and can seldom be regarded as furnishing positive evidence of disease. For a complete and accurate physi- cal exploration you must sometimes employ aU these different methods, and with aU, therefore, you should become famihar. In order to locaUze physical signs, the chest has been divided into artificial regions ; but as the limits of these 4 PHYSICAL DIAGNOSIS. regions are arbitrary, the boundaries adopted by different writers vary. The following divisions, which correspond very nearly to those proposed by many authorities, you will find, I think, sufficiently small and well de- fined for practical purposes. It is important that you should be familiar, not only with the boundaries of these regions, but with the relative position of the structures and organs or portions of organs included within them. The surface of the chest may be divided into three general regions — Anterwr, Posterior, and Lateral. The Anterior region, on either side, may be subdivided into Supra-Olavicular, Clavicular, Infra- Clavicular, Mam- mary, and Infra-Mammary. Betw^een the two anterior regions we have the Supra-Sternal, Superior Sternal, and the Inferior Sternal. The Posterior region, on either side, may be subdivided into the Supra- Scapular, Scapular, and Infra- Scapular. Between these you have the Inter- Scapular. The Lateral region, on either side, may be subdivided into Axillary and Infra-Axil- lary regions. The Supra-Clavicular region is a triangle whose base corresponds to the trachea ; whose lower side, to the upper border of the clavicle ; and whose upper side, to a line drawn from the outer third of the clavicle to the upper rings of the trachea. This region contains, on either side, the apex of the lung, with portions of the subclavian and carotid arteries, and the subclavian and jugular veins. The Clavicular space is that which Hes behind the inner three-fifths of the clavicle, and has the bone for its boundary. It is occupied on both sides by lung tissue; on the right side, at its outer extremity, lies the subcla- vian artery ; at the sterno-clavicular articulation, the arteria innominata. On the left side, almost at right INFRA-CLAVICULAR REGION. angles with the bone, and deeply seated, are the carotid and subclavian arteries. The Infra-Olavtcular region has for its boundaries the clavicle above, the lower border of the third rib be- low, the edge of the sternum inside, and outside a line falling vertically from the junction of the middle and FiQ. 1.— The Anterior Eegion, the Boundaries of its Subdirislons, and the Organs cor- responding to these Subdivisions. outer thirds of the clavicle. Within these limits, on both sides, you wiU find the superior lobe of the lung and the main bronchi; the right bronchus hes behind, and the left a little below the second costal cartilage. On the right side, close to the sternal border of the re- gion, lie the superior cava and a portion of the arch of 6 PHYSICAL DIAGNOSIS. the aorta; on the left, a portion of the pulmonary artery. The aorta and pulmonary artery are immediately behind the second sterno-costal articulations; the one on the right, the other on the left side of the sternum. On the left side the lower boundary of the region very nearly corresponds to the base of the heart. The Mammary region is bounded above by the third rib; below, by the inferior margin of the sixth rib; in- side, by the edge of the sternum ; and outside, by a verti- cal line, continuous with the outer border of the infra- clavicular region. You wiU find this region to differ materially in its contents on the two sides. On the right side the lung is found extending, in front, down to the sixth rib, where its thin, sharp border very nearly corresponds to the lower boundary of the region. The right wing of the diaphragm, though not attached higher than the seventh rib, is usually pushed up by the liver as high as the fourth interspace; a portion of the right auricle of the heart, and the superior angle of the right ventricle, lie close to the sternum, between the third and fifth ribs. On the left side the lung is in front as far ks the fourth sterno-costal articulation, where its anterior border passes outward until it reaches the fifth rib (leaving an open space for the heart); then it crosses forward and downward as far as the sixth rib ; a small portion of the apex of the right ventricle is also found within this region. The Infra-Mammary region is bounded above by the lower border of the sixth rib; below, by a curved line corresponding to the edges of the false ribs; inside, by the inferior portion of the sternum ; and outside, by the continuation of the outer boundary of the mammary re- gion. This region, on the right side, contains the liver, with a portion of the lung in front, on a fuU inspiration. LOWER STERNAL REGION. 7 On the left, lying in front, near the median line, you have a portion of the left lobe of the liver and the stom- ach. The stomach usually rises to a level with the sixth rib. The Supra-Sternal region is the space which lies im- mediately above the notch of the sternum, and is bounded on either side by the sterno-mastoid muscle. It is occupied chiefly by the trachea, by the arteria inno- minata at its lower right angle, and by the arch of the aorta, which sometimes reaches to its lower border, where, on firm downward pressure with the end of the finger, you will often be able to feel it. The Upper Sternal region is the space bounded by that portion of the sternum which lies above the lower margin of the third rib. In this region the lungs he in front, but do not completely close in the space. Imme- diately behind them are the ascending and transverse portions of the aorta, and the pulmonary artery from its origin to its bifurcation. The left vena innominata crosses the sternum a httle below its upper border. Situated deeply, at the junction of the first and second bones of the sternum, is the trachea, dividing into its two bron- chi. The pulmonary valves are situated behind the left edge of the sternum, at its junction v^dth the third costal cartilage. The aortic valves are about half an inch lower down, and midway between the median Une and the left edge of the sternum. The Lower Sternal region corresponds to that por- tion of the sternum which lies below the lower margiu of the third rib. Throughout the whole extent of this region, on the right side, the lung is in front; it also ex- tends down on the left side as far as the fourth sterno- costal articulation; below this hes the greater part of the right ventricle, and a smaU portion of the left. The PHYSICAL DIAGNOSIS. Fio. 2.— The Posterior Region, tlie Boundaries of its Subdivisions, and the Organs cor- responding to these Subdivisions. CAfter SibsohO INTER- SCAPULAR REGION. 9 mitral valve, deepest of all, is situated behind the third left intei'costal space, about one inch from the sternum; the tricuspid valve is near the middle of the sternum, at the level of the fourth costal cartilage. Inferiorly is the attachment of the heart to the diaphragm; below this is a small portion of the liver, and sometimes of the stomach. The SuPRA-SoAPULAR and Scapular regions together occupy the space from the second to the seventh rib, and are identical in their outlines with the upper and lower fossae of the scapula. These regions are occupied by lung substance. The Inpra-Scapular region is bounded above by the inferior angle of the scapula and the seventh dorsal ver- tebra; below, by the twelfth rib; outside, by the poste- rior border of the lower axiUary region ; and inside, by the spinous processes of the vertebrae. Immediately un- derneath the surface, as far as the eleventh rib, this re- gion is occupied by the lungs. On the right side the liver extends downward beyond the level of the eleventh rib; on the left the intestine occupies the inner part of this region, and the spleen the outer. Close to the spine, on each side — more on the left than on the right — a small portion of the kidney is found; along the left side of the spine runs the descending aorta. The Inter-Scapular region is the space between the inner margin of the scapula and the spines of the dorsal vertebrae, from the second to the sixth. This region contains, on both sides, lung substance, the main bron- chi, and the bronchial glands. It also encloses on the left side the oesophagus, and from the upper part of the fourth dorsal vertebra downward, the descending aorta. The bifurcation of the trachea will be found opposite the third dorsal vertebra. 10 ^feffYSICAL DIAGNOSIS. The AxiLfsSCKT regioiTTias for its limits the axilla, above ; bd!^^, ^a line^krried backward from the lower boui]^^ of ""the mammary region to the inferior angle ^5^*6 scapula; in front, the outer margin of the infra- cmvieiflar and mammary regions; and behind, the exter- nal edge of the scapula. This region corresponds to the upper lobes of the lungs, with the main bronchi deeply seated. ,Th^ I Infra- Axillary region is bounded above by the p,tillary region; anteriorly, by the infra-mammary; pos- teriorly, by the infra- scapular; and below, by the edges of the false ribs. This region contains, on both sides, the lower edge of the lung sloping downward and back- ward, reaching in the mid-axillary lines to the ninth rib. On the right side from the ninth to the eleventh rib is the liver, on the left the spleen. The cardiac end of the stomach extends into this region on the left side. LESSOI^ II. INSPECTION, PALPATION, AND MENSURATION. Inspection is the ocular examination of the external surface. Though usually secondary in importance to Auscultation and Percussion, it should not be lightly re- garded, for it often furnishes you much information re- specting the condition of the thoracic and abdominal viscera. By Inspection you recognize changes in the size, form, or symmetry of the cavities in which they are contained, and in the movements of their walls dur- ing respiration, as regards their rhythm, frequency, or force. As students of anatomy you are famiUar with the form of a well-proportioned chest ; a description of it is, therefore, unnecessary. Suffice it to say that, in a nor- mal state, the two sides are symmetrical in every part ; the intercostal spaces are more or less distinct, accord- ing as the individual is more or less fat. Normal breath- ing is of two kinds, costal and diaphragmatic. In the costal the movements are chiefly thoracic ; in the dia- phragmatic they are chiefly abdominal. In quiet respi- ration you will notice the abdominal wall rise with in- spiration, and faU with expiration ; at the same time you wiU observe a lateral expansion of the lower ribs, and a slight upward movement of the upper part of the chest with inspiration, and a downward movement with expiration. The movements of respiration in these three situations are called, respectively, abdominal, 13 PHYSICAL DIAGNOSIS. inferior costal, and superior costal. In the female, the costal breathing is most marked ; in the male, the dia- phragmatic. The number of respirations to the minute varies at different periods of life ; in childhood it is about twenty-six ; from the twentieth year, about six- teen to twenty. Considerable alterations in the form and movements of the chest are compatible with a healthy condition of the thoracic viscera. You rarely meet with a perfectly symmetrical chest, even among the healthy. In my ex- amination of fifteen hundred persons I found only one weU-proportioned, symmetrical chest in seven. As you can easily recognize these healthy deviations from sym- metry, I shaU not enter into details concerning them. I would, however, mention that slight curvatures of the spine, either acquired or the result of former disease of the vertebrae, cause the majority of these deviations. We win first consider only those changes in the size, form, and movements of the thoracic cavity which are the result of disease of the thoracic organs; confining ourselves, at present, to the lungs and pleurae. The readiest way of presenting these changes to you, it seems to me, is to consider them as they occur in the different thoracic affections. First we wiU consider the signs obtained by inspection in pleurisy. In the first stage, prior to the occurrence of much liquid effusion, there is no apparent change in the size, but the move- ments of the affected side are diminished, and those of the healthy are increased ; you have what is termed a catching respiration. This sign is not distinctive of pleurisy ; it is present in intercostal neuralgia and in pleurodynia. In the stage of hquid effusion, if the hquid is sufficient to compress the lung and dilate the thoracic walls, the affected side wiU be increased in size, and, in INSPECTION. 13 proportion to the dilatation, its movements are restricted or arrested. If the cavity is completely filled Avith liquid, there will be bulging and widening of the intercostal spaces, with more or less displacement of the adjacent viscera. As the liquid is absorbed the lung expands, but not to the same volume it had before. It remains more or less contracted, and the consequence is, retraction of the affected side from atmospheric pressure. G-enerally, if the liquid effusion shall have existed a considerable length of time previous to absorption, the subsequeilt re- traction is marked, and you can determine at once by inspection that pleurisy has existed at some period more or less remote. In pulmonary emphysema, if it is a well-marked case, on inspection you wiU notice a dilatation of the upper portion of the chest, while its whole aspect ap- pears more rounded than in health, so that it has re- ceived the name "barrel-shaped" chest; the shoulders are elevated and brought forward ; the movements in respiration are limited to the lower portions of the chest and to the abdomen. On inspiration there is no out- ward expansive movement of the ribs ; the sternum and ribs seem to move up and down as if they were composed of one solid piece; in some cases of long stand- ing you will have actual falling-in instead of expansion of lower ribs during inspiration. In a well-marked case of emphysema, inspection is quite sufficient for a diagnosis ; but where the lungs are but slightly emphy- sematous, inspection furnishes no positive information. In pneumonia, the only sign furnished by inspection is that the movements of the affected side are restrained, as in the first stage of pleurisy. In pulmonary tuberculosis inspection furnishes you important information. De- pression in the infra-clavicular region on the affected 14 PHYSICAL DIAGNOSIS. side is an early sign of tubercular deposit. In advanced tuberculosis, the depression is still more marked, in some instances amounting almost to deformity. The expan- sive movements in inspiration on the affected side, in the infra-clavicular region, are diminished or entirely wanting, and this want of expansion is often noticeable at a very early period in the disease. Bulging or partial enlargement of the cliest, deter- minable by inspection, occurs in various affections. En- largement of the praecordia is observed in certain cases of hypertrophy or dilatation of the heart, or from liquid effusion in the pericardium. Bulging occurs also over aneurismal and other tumors In cases of membranous croup, acute and chronic laryngitis, and oedema glottidis, inspection will disclose to you the seat of the obstruction to the passage of air to the lung by a sinking-in during inspiration of the parts of the chest which yield most readily to atmo- spheric pressure. This sinking-in on inspiration you will notice first in the supra-clavicular spaces, then in the infra-clavicular spaces, and, as the obstruction increases, the sternum is depressed and the sides contracted. Although furnishing few positive evidences of disease, you should always employ inspection prior to the other methods of physical exploration. This is important in all cases where the evidences furnished by the other physical signs are not conclusive. Palpation, or the act of laying on the hand and feel- ing the external surface of the body, is less useful than inspection in ascertaining deformities, and the amount of general movement ; but it is more useful in deter- mining the amount of local expansion, and the charac- ter of vibration or impulses communicated to the exter- nal surface. PALPATION. 15 In order to arrive at satisfactory results from its em- ployment, you should observe the precautions already named as influencing accurate inspection ; beyond this, I need only mention that in thoracic examinations the hand or the fingers should be gently and evenly apphed to the surface of the chest, and that corresponding por- tions of the two sides of the thorax should be examined simultaneously, the one with the right hand and the other with the left. If you lay your hand lightly upon the surface of the chest of a healthy person while speak- ing, a delicate tremulous vibration will be felt, varying in intensity with the loudness and coarseness of the voice and the lowness of its pitch ; this is called normal vocal fremitus. As a rule, vocal fremitus is more marked in adults than in children, in males than in fe- males, and in thin than in fat persons. In the right in- fra-clavicular region it is more marked than in the left. Variations in the vocal fremitus are the most important evidences of disease furnished by palpation ; in fact, aU other evidences of pulmonary disease afforded by palpa- tion are better obtained by inspection. In disease, the normal vocal fremitus may be in- creased, diminished, or entirely absent. Increased vocal fremitus occurs in those affections in which lung tissue becomes more or less soUdified, as in tuberculosis, pneumonia, pulmonary apoplexy, and oedema of the lung. When the consolidation is ex- treme, involving bronchial tubes of considerable size, the vocal fremitus may be diminished or even absent ; while increase in the size of the bronchial tubes, with the shght adjacent consolidation met with in chronic bronchitis, often gives rise to increased vocal fremitus. Diminution or absence of the normal vocal fremitus occurs whenever the lung substance is separated from 16 PHYSICAL DIAGNOSIS. the chest walls by gaseous or liquid accumulations ia the pleural cavity, as in pneumothorax, serous, plastic, hgemorrhagic, or purulent pleuritic effusions, or when- ever the pleurae are thickened. In vesicular emphy- sema, owing to the dilated condition of the air cells, vocal fremitus is diminished. Besides these valuable indications furnished by vocal fremitus, you may em- ploy palpation to detect the friction caused in pleurisy by the rubbing together of the two roughened surfaces of the pleural membrane, and which is termed friction fremitus. Sibilant and sonorous rales also sometimes throw the bronchial tubes into vibration, sufficiently strong to be felt on the surface of the chest ; this is termed sonorous or rhonchial fremitus. Cavernous gurgles produced in excavations near the surface may be accompanied with a marked fremitus. Palpation may also be employed to detect points of tenderness, and to determine the density and condition of tumors. Mensuration is another method of physical explora- tion, employed for obtaining information similar to that furnished by inspection and palpation. We seldom em- ploy it in physical examinations of the lungs unless great accuracy is required, as in the record of cases. The instruments which have been devised for the mea- surement of the chest, and the different Unes of measure- ment, are numerous. The circular measurement is the only one that I have found of practical value in investi- gating pulmonary disease. The simplest and most ac- curate mode of measuring the circular dimensions of the chest is by means of the instrument devised by Dr. Hare, which consists of two pieces of tape similarly grad- uated, joined together, and padded on their inner sur- face close to the line of junction ; the saddle thus MENSURATION. 17 formed, when placed over the spine, readily adjusts it- self to the spinous processes, and becomes fixed suffi- ciently for the purpose of mensuration. For comparing the expansive movements of the two sides you will find Dr. Quain's stethometer ' very useful. The object of the circular measurement of the chest is twofold — first, to ascertain the comparative bulk of the two sides ; second, to ascertain the amount of expansion and retraction ac- companying inspiration and expiration of the two sides. The points of measurement are the spinous processes be- hind and the median Une in front, on the level of the sixth costo-sternal articulation. The average circular dimension of the chest at this point in fifteen hundred healthy persons was thirty-two and a half inches. I also found in these examinations that about four-fifths of healthy adults have irregularity of the two sides. In right-handed individuals the right side is about one-half inch larger than the left ; in left- handed, the left. This is true of both sexes. The reaUy important point of mensuration in pulmon- ary diseases is the comparison of the two sides of the chest, in rest and in motion. When a pleural cavity is distended with air or fluid, the measurement of the af- fected side may exceed that of the healthy side by two or three inches ; after the removal of the fluid there may be an equal diminution in the measurement of the affected side, as compared with the healthy one. Deficiency of expansion is also very marked in certain diseases. In empyema, for instance, you wiU often find the total difference between the fullest inspiration and the fullest expiration, on the affected side, will scarcely exceed one-sixteenth of an inch, while on the other side there may be a difference of two or three inches. ' See page 236. 3 18 PHYSICAL DIAGNOSIS. The list of affections in which variations in expansion are to be estimated by measure are the same as those re- ferred to under the head of Inspection. The measurement of the capacity of the lungs for air, by means of Dr. Hutchinson's spirometer, or of the "vital capacity of the chest," as he terms it, has been shown by experience to be very unrehable, and his in- Btrument has fallen almost entirely into disuse. LESSON III. PEKCUSSION. Peeoussion, as a means of diagnosis, is not of recent date, for we find it mentioned by Hippocrates. But as the only mode of practising it was by striking the surface itself with the tips of the fingers, or knuckles, now termed, technically, immediate percussion, its uses were very hmited. Within our time, however, M. Piorry gave it an entirely new value by introducing mediate percus- sion — the stroke being made, not on the surface, but on some intervening substance apphed to it ; and he so demonstrated, by experiments on hving and dead bodies, its superior apphcabihty for determining changes in the subjacent parts, that mediate percussion ranks now only second to auscultation among the methods of physical exploration. To estimate the value of percussion and to understand its true significance, you must first learn to appreciate correctly the elements of sound. Authors have employed a variety of terms to designate them, such as clearness, dulness, emptiness, fulness, etc.; but I think that a classification based upon analysis of the elements of sound in general, will afford us the truest and most prac- tical distinctions, especially in estimating the sounds in thoracic percussion. Those elements or acoustic proper- ties of percussion sounds which concern us cUnically are termed,- respectively. Intensity, Pitch, Quality, and Du- ration. 20 PHYSICAL DIAGNOSIS. The Intensity of a percussion sound may be increased or diminished by increasing or diminishing the force of the percussion blow. But in pulmonary percussion, you wiU find that the intensity depends not only on the force of the blow, but is further modified by the amount of air contained in the lung tissue, by the thickness of the soft parts covering the thoracic walls, and also by the elas- ticity of the costal cartilages. The Pitch of the percussion sound is always low over healthy lung substance, and, as a rule, the greater the quantity of air contained in the corresponding pulmonary tissue, the lower the pitch ; consequently, you will find the pitch of the percussion sound varying very percept- ibly in the different regions of a healthy chest. You can, however, famiharize the ear with the characters of normal pitch only by constant practice. Quality in sound is that element by which we distin- guish any given sound from every other. Thus it is by the quality that you know the sound of one musical in- strument from another. The quality of the note emitted on percussion over "healthy lung substance, and termed normal vesicular resonance, is sufficiently marked and pecuHar to be easily recognized, though it cannot be easily described, and is to be learned only by experience. The DuKATioN of a given sound, you wiU find varying according to the pitch of that sound ; the higher the pitch, the shorter the duration, and vice versd. For ex- ample, the duration of the percussion sound is percept- ibly longer in the infra-clavicular region of a healthy chest than over the heart. You wiU find that a certain definable relationship ex- ists between these respective elements of the percussion note, which has a correspondence to the different regions of the chest. Thus, after noting the intensity, pitch, PERCUSSION. 31 quality, and duration of the percussion sound in the infra-clavicular region, you wiU find that over the heart it has a higher pitch and harder quality, but a less inten- sity and a shorter duration. The substance which receives the stroke in mediate percussion is termed apleximeter, of which many varie- ties have been devised, made of wood, ivory, gutta percha, etc. They are in nowise superior, however, to the left index or middle fingers, when their palmar sur- face is apphed evenly to the chest; for these, besides be- ing the most handy, also answer best the chief requisite of a pleximeter in that they can be easily fitted with accuracy to any part of the thoracic walls. Moreover, their own proper sound, on being struck, is inappreciable, which, is not the case with ivory, wood, etc. Likewise, you wiU discover nothing better to strike with than the finger tips of the other hand, brought into Une ; while, for gentle percussion, the middle finger alone may suf- fice. Now, as the practice of percussion requires some manual dexterity, and the correctness of its indications depends in great measure upon the mode in which it is performed, you will find it useful to have recourse to the following rules as your guides : First. You should attend as carefully to the position of your patient as a photographer would, if he were going to take his likeness. Whether lying, sitting, or standing, his body should rest on the same plane, and his limbs be disposed similarly, on either side, so as to render the muscular tissue covering the thoracic waUs equally tense. In percussing particular regions, how- ever, the first aim is to make the intervening tissue as firm and thin as possible. Thus, when you percuss the front of his chest, the arms should hang loosely down. 23 PHYSICAL DIAGNOSIS. but the head be thrown back. On the contrary, the arms should be raised to the level of the head when you are percussing the lateral regions, and should be crossed in front, the patient leaning moderately forward, when you percuss the back. It is better to percuss on the naked skin, but various considerations may make this unadvisable. You should then aim to have the covering as soft, thin, and, especially, as even as possible. Second. The two sides of the chest should, for com- parison, be percussed at the same stages of the respira- tory act. You should, also, take care to compare only corresponding portions in the two sides. Thus, you should not compare a note during inspiration on the right side with one during expiration on the left, nor that over a rib with that of an interspace. Third. The finger, or pleximeter, should be appUed with equal firmness, and in the same parallel, to both sides in succession, and the force of the percussion should be exactly the same ; for the sound will vary considerably even on the same spot, whether you press hghtly or firmly with your finger, whetlier it is across a rib or along it, and, finally, whether you strike gently or forcibly. Fourth. The stroke in percussion should be made from the wi-ist alone, the arm and forearm not partici- pating in it ; and its force should be proportioned to the depth of the part to be examined — gentle if superficial, and forcible when deep seated. Percussion in Health.— The significance of the per- cussion sounds in disease depends so entirely on their variation from the sounds which are proper to the part in health, that you cannot pay too much attention to the various characters of normal thoracic percussion ; for on this almost every deduction which results from PEECUSSION. 23 your examination is based. Now, the percussion sounds differ materially in a healthy thorax, according to the re- gion percussed. Taking the percussion note of the infra- clavicular region as the standard for pulmonary percus- sion, we find each of the other regions has its own variations from it. In the right infra-mammary region you wiU get, by gentle percussion, the same note as in the infra-clavicular ; but forcible percussion, at and be- low the fourtn interspace, will raise the pitch and har- den the quality, owing to the presence of the liver be- hind the shelving border of the lung. Over the left infra-mammary region the pitch is similarly varied by the presence of the heart, until it reaches complete flat- ness at its inner border. The resonance of the right infra-mammary region has a harder quality, higher pitch, and shorter duration, from the presence of the liver immediately beneath. The left infra-mammary re- gion is similarly affected at its inner part by the left lobe of the liver, while the remaining space gives a tympan- itic resonance from the subjacent stomach. Over both clavicles you will get a mixed pulmonary and osseous resonance, while in the supra-sternal region the percus- sion sound has a distinctly tubular character. In the superior sternal region it has a bony tubular resonance down to the second rib ; below this, to the third rib, it is raised in pitch and hardened in quality. The dulness on percussion becomes complete in the next region, or inferior sternal, owing to the presence of the heart and great vessels, together with the left lobe of the liver. The Superior and Middle Axillary regions are ex- tremely resonant as far down as the fourth interspace ; the pitch is even lower than in the infra-clavicular re- gion, but below the fourth interspace the pitch rises, till 24 PHYSICAL DIAGNOSIS. complete dulness is found on a level with, and below, the seventh rib. This dulness continues through the infra- axillary regions on either side. In the Supra-Scapular and Scapular regions the percussion sound is high-pitched and hard in quality, except in the supra- spinous fossae, where it has the soft quahty characteristic of pulmonary percussion. In the infra-scapular region you have pulmonary resonance as far down as the tenth rib, and complete flatness below. In the inter-scapular region the percussion is high- pitched and tubular in quahty. Besides variations in percussion sounds dependent on difference in regions, there are stiU others ascribable to age, sex, idiosyncrasies, etc. You will find the percus- sion sound in chUdren of a softer quality and lower pitch than in adults ; while in the aged it rises in pitch, and measurably loses its pulmonary quality. In females the percussion sound is relatively more pulmonary in all its characters than in males. Marked deformity of the chest, whether congenital or acquired, also modifies the normal resonance. But it also varies materially in differ- ent individuals who are equally healthy. In some per- sons this difference may be accounted for, while in others it cannot ; but, as a rule, the thinner the chest waUs, the greater is the intensity, the lower the pitch, and the more pulmonary the quality of the percussion sound. Percussion in Disease. -It is obvious, from what precedes, that whatever modifies the density of the lung substance, and changes its proper elasticity, wiU cause a corresponding modification in the normal pulmonary resonance ; for as the lung texture is rendered more dense, or less so, than natural, the percussion sound passes through every gradation from marked resonance to complete dulness. These modifications, caused by dis- PEKCT^lON. f X 23 would classifrc^laer- the .following heads, viz.: Exaggerated Pulmq^^ ^soy^i^^ce, Dulness, Flatness, Tympanitic Besoname, msi^to-Tympanitic Besonance, Amphoric Besonance, aui^fi§fached-Pot Besonance. Exaggerated Pulmonary Besonance consists in an increase of the intensity of the sound, the pitch being slightly lower, while the quahty remains unchanged. This sign may exist to a shght degree over the whole or over a portion of a lung which is performing more than its usual share of labor. Thus, if one pleural cavity is filled with fluid, or if one lung is sohdified by the exu- dation of pneumonia, or the seat of extensive tuberculous deposit, you wiU find the resonance of percussion in- creased on the opposite unaffected side, which is now doing double duty. Extensive ansemia, by lessening the quantity of blood in the lungs, may also give rise to sUght extra resonance on percussion. Dulness. — This consists in a diminution of the pulmo- nary resonance, and may be sHght, considerable, or complete, according as more or less air enters the af- fected part. In dulness the intensity is diminished, the pitch raised, the duration shortened, and the quality hardened. Dulness always indicates a decrease in the normal proportion of air in the part, and is an impor- tant physical sign in a number of diseases, as in pneu- monia, tuberculosis, oedema of the lungs, etc. Flatness.— This indicates the total absence of air, so that there is no proper pulmonary resonance, and its sound resembles that produced by percussing the thigh. We have examples of this when we percuss over liquid contained in the pleural or pericardial serous cavities, or when tumors are developed in the thorax, etc. Tympanitic Eesonance. — This is marked by the ab- sence of proper pulmonary quality in the characters of its 26 PHYSICAL DIAGNOSIS. resonance, the type being the resonance of a tympanitic abdomen on percussion ; in intensity it exceeds normal puhnonary percussion, and is lower in pitch.' As a physical sign in thoracic affections it usually indicates the presence of air in the pleural cavity, as in pneumo- thorax. In this affection we have air contained, not in small vesicles, but in a large free space, and hence we have not the vesicular but the tympanitic quahty in the sound. Vesioulo-Tympanitio Eesonanoe. — By this term (in- troduced by Prof. A. Flint) it is meant to denote a reso- nance in which we have both the tympanitic and vesicu- lar qualities. It is lower pitched but more intense than normal pulmonary resonance, and is present when the increase of the volume of the lung, as in some cases of emphysema, is so great as to dilate and render extremely tense the thoracic walls. Amphoric Eesonance, unhke tympanitic resonance (which gives an impression of fulness), is suggestive of shallowness or emptiness ; it resembles the sound pro- duced by flapping the cheek when the mouth is closed, and fully but not forcibly inflated. It is most frequently heard over a large superficial cavity having thin, tense walls, and hence is usually indicative of phthisis. In cases of pleuro-pneumonia, a sound more or less amphoric in character is sometimes heard. Ckacked-Pot Eesonance is usually, though not in- variably, heard in connection with amphoric resonance. It resembles the sound produced by striking the hands, loosely folded across each other, against the knee, the contained air being suddenly forced out between the fin- gers. If there exists a pulmonary cavity of large size, ' Many authorities speak of the pitch as raised. I regard it lower than normal. But pitch is not an essential element. We recog- nize the tympanitic sound by its quality, not its pitch. PEKCUSSION. 27 with thin walls, communicating freely with a large bronchial tube, the chest walls being at the same time particularly yielding, forcible percussion, with the pa- tient's mouth open, will yield cracked-pot resonance. Dr. Hughes Bennett states that a cracked-pot reso- nance maybe ehcited in various diseases of the chest, and even when the chest is perfectly sound. I have never obtained true cracked-pot resonance unless over a pul- monic cavity or in pneumothorax. Auscultatory Percussion.— This is a combination of auscultation and percussion. It was first brought to the notice of the profession by Drs. Cammann and Clark in 1840. Their method of performing it was as follows : Press the objective end of a stethoscope, constructed expressly for this purpose ' (while the ear piece is accurately fitted to the ear), firmly and evenly on the surface, directly over that portion of the organ or tumor to be examined which is most superficial ; then let percussion be per- formed in the usual way, one or two inches from the point at which the stethoscope is applied. The percus- sion sound communicated to the ear in this manner far exceeds in intensity and distinctness the same sound ' This instrument is a solid cylinder of wood, shaped in the direc- tion of the woody fibres, six inches in length and ten or twelve lines in diameter ; furnished with an ear piece which will allow nearly the whole cylinder to pass through it, so that it may apply directly to the tube of the ear, without change of medium. To avoid as much as possible the sound„of the thoracic walls, as is de- sirable in some cases, this instrument has been modified by reduc- ing it at its objective extremity to a truncated wedge, leaving the other extremity as before. This is applied between the ribs so as not to touch them, and at the same time approach somewhat nearer the object under examination. — New York Journal of Medicine and Surgery, July, 1840. 38 PHYSICAL DIAGNOSIS. when communicated through the medium of tHe air. The slightest change in pitch and quahty is also readily appreciated. The benefits claimed for auscultatory percussion by its originators are : " First. That the heart can be measured in aU but its antero-posterior diameters, under most, perhaps aU circumstances of health and disease, with hardly less exactness than we should be able to do if the organ were exposed before us. " Second. That the outlines of the hver can be traced with much greater certainty than by ordinary percus- sion, in circumstances of health ; and to circumscribe it in many conditions of disease in which ordinary percus- sion is not applicable. " Third. That the dimensions of the spleen can be ascertained in circumstances that baffle ordinary per- cussion. "Fourth. That by it we can mark the superior, infe- rior, and external hmits of the kidneys. Ascites pre- sents no obstacle to the measurement of these organs ; and from enlarged spleen the left kidney is easily dis- tinguished." SuccussiON is the sudden, forcible shaking of the pa- tient while your ear is applied to the chest wall. It is employed almost exclusively in the diagnosis of one dis- ease, viz., pneumo-hydrothorax. The sound produced resembles that perceived on shaking a bottle, partly filled with water, close to the ear. It is a gurghng, splashing sound, and varies in tone according to the density of the fluid present and the relative quantities of fluid and air present. Succussion is almost always accompanied by amphoric respiration and metallic tinkling. I shall re- serve its further consideration until I detail the physical signs of pneumo-hydrothorax. LESS0T*5r TV. AUSCULTATION. Auscultation is a kind of eavesdropping, for in it you bend your ear to catch the significance of sounds that come from hidden quarters which no one may open. As in percussion, so here, auscultation may be immediate, when the ear is applied directly to the bared or thinly covered surface ; and mediate, when the sounds are conducted from the surface to the ear through a tu- bular instrument, called a stethoscope. Both of these methods have their exclusive advocates, but, as each has its own advantages, I would strongly recommend your becoming equally practised in the use of them both. Per se, immediate auscultation answers best for pulmonary examinations ; but in examining the heart, where, as in valvular murmurs, you have to analyze circumscribed sounds, your ear will often be confused by the noise of its near neighbor, the left lung, or by other cardiac sounds than the one under exami- nation, and you will find the stethoscope then assists you by measurably excluding the sounds which have their seat outside the rim of the chest piece. Besides, there are cases where the state of the surface may make you very reluctant to bring your ear into immediate contact with the patient's person, while in other cases you may not be allowed to do so, and in such, of course, you would have recourse to the stethoscope. Stethoscopes of great variety as to form and material 30 PHYSICAL DIAGNOSIS. have been recommended, each inventor claiming some superiority in principle, or shape, for his own instrument. They may all. however, be referred to two general classes, viz., flexible and sohd. I regard as the best rep- resentatives of these two classes those devised by the late Dr. Oammann, of this city. For general use I would recommend his Binaural Stethoscope. It con- sists of two tubes, the lower extremities of which are connected to a cup-shaped piece of wood or hard rubber. It requires some practice to become adepts in its use, as it indiscriminately intensifies aU sounds ; but once ac- customed to it, you will find, I think, it has no superior. In the performance of auscultation, as of percussion, certain precantions are requisite in order to insure accu- rate results. The following rules will be found of ser- vice : First. In immediate, but not in mediate auscultation, the chest should have some thin, soft covering which will not interfere with the transmission of sound, or it- self produce sound from the movements of the thoracic walls to which it is apphed. A soft towel smoothly spread over the surface will answer this purpose very well. Second. The position of the patient should be regu- lated in the same manner as for the performance of in- spection, care being taken that the parts should be in a state of perfect repose. The position of the examiner should be as unrestrained as possible, and he should by all means learn to concentrate his attention on the sounds which reach his ear. Third. The ear, or the stethoscope, should be apphed firmly, but not forcibly, to the surface ; and, when the stethoscope is used, it is important that its rim press equally and evenly on the part. AUSCULTATION. 31 Fourth. As in percussion, corresponding parts of the two sides of the chest should be compared, and the ex- amination should not be considered complete unless it has included the entire chest. In acute thoracic affec- tions auscultation should be frequently repeated. Fifth. The examination should be commenced, if pos- sible, during ordinary respiration. The patient should be directed to take a full inspiration, then to cough, and then again to breathe naturally. Some find the latter very difficult, when under examination, and they some- times seem incapable even of completing a full inspira- tion. In such instances, our object may be attained by performing the act ourselves, and requesting the patient to imitate it, or by directing him to sigh. If these expe- dients fail, direct him to cough continually for some moments, whereupon a full, clear inspiration follows, and he does involuntarily what his previous efforts have failed to accomplish. Let us now consider the important subject of the na- ture and causes of the respiratory sounds in health. If the ear be applied to a healthy chest, a soft, breezy murmur will be heard, composed of two periods — one corresponding to the movements of inspiration, and the other, both fainter and shorter, to those of expiration. They are termed, respectively, the inspiratory and the expiratory sounds of respiration. The elements of these sounds are analogous to those of percussion, and, hence, we express them by the terms Intensity, Pitch, Quality, and Duration, to which, however, we add a fifth — Bhythm—^\Ach. refers to the relative succession of the two periods in the respiratory act. As might be ex- pected, we find variations among these elements, nor- mally present in the various portions of the respiratory tract, and these constitute distinct varieties of respira- 32 PHYSICAL DIAGNOSIS. tory sounds, which are named after those portions in which they occur in health. Thus we speak of vesicu- lar, bronchial, tracheal, and laryngeal respiration, each of these sounds having its own proper intensity, quality, pitch, etc. The left infra-clavicular region in a healthy chest furnishes the purest vesicular respiration ; the inter-scapular region, the best normal bronchial respira- tion ; and by placing the stethoscope or ear over the larynx or trachea, you will hear the tracheal and laryn- geal breathing. These variations in the intensity, pitch, etc., are due to differences in the volume and velocity of the current of air, on the one hand, and, on the other, to the nature of the obstructions which it meets in its entrance to, or exit from, the pulmonary passages. Every complete respiratory sound, however, retains its division into inspiratory and expiratory murmurs. Of the normal respiratory sounds, that which stands first in importance is the Vesicular. The best represen- tative type of the normal vesicular murmur is found in the left infra-clavicular space, where you will hear dur- ing inspiration a sound of a gentle rusthng character, most marked at the end of the act. The intensity and duration of this murmur vary in healthy persons, and form the least important of its elements. Its pitch, however, should be low. The expiratory sound, when present (it being absent in four out of five healthy persons when their attention is not directed to their re- spiration), is much shorter than the inspiratory, its rela- tive duration varying in different individuals ; its in- tensity is less than in inspiration, its pitch higher, and its quahty harder ; the breezy or vesicular character of the inspiratory sound being wanting. These two sounds foUow each other so closely that they may be said to be continuous, and this fact is itself an important element AUSCULTATION. 33 of normal vesicular respiration. It should be noted here, however, that the normal respiratory sounds do not exactly correspond in the two infra-clavicular re- gions. On the right side, the pitch of the inspiratory sound is higher than on the left, and less breezy in quahty, while the expiratory is more pronounced and prolonged in duration. This disparity should be taken into account in all doubtful cases, such as in suspected small pulmonary consohdations. Age affects the char- acter of normal vesicular respiration, taking for the standard of comparison the respiratory sounds in healthy middle-aged individuals. In infancy the intensity of both the inspiratory and expiratory sounds is increased, while the other elements remain the same. In old age, on the other hand, the intensity is diminished, the du- ration of the inspiratory sound shortened, and the ex- piratory prolonged. Sex also modifies the respiratory sounds. As a rule, the inspiratory and expiratory sounds have greater intensity in the female than in the male. The greatest intensity is in the upper anterior portions of the chest in the female, while in the male it is most marked in the lower and posterior portions. If the ear or stethoscope be applied to the larynx or trachea, two sounds will be heard, one with inspiration, the other with expiration. These sounds constitute the normal laryngeal and tracheal respiration. It differs from the normal vesicular respiration in that its in- tensity is increased, its pitch raised, and its quality whoUy tubular. The inspiratory sound does not con- tinue quite to the end of the inspiratory act, so that an interval occurs between it and the expiratory sound. The characters of the next variety, or bronchial respi- ration, are very important to the auscultator from their common occurrence and significance in disease. They 3 34 PHYSICAL DIAGNOSIS. are those of tracheal respiration, only in a less marked degree, being less tubular in quahtyj while the interval between the inspiratory and expiratory sounds is shorter. Now, the more thoroughly you 'learn these varieties of healthy respiration, the better you will be prepared to understand what respiratory sounds are abnormal. Very often you wiE. hear in disease what you recognize as one of the normal sounds, but you know that this familiar sound has in this case a serious import, because it is not the natural sound of that locality. But you may also hear sounds whose character differs from any normal type. We may say, in general, that abnormal sounds consist in changes from the standard of healthy respiration as regards the three elements of intensity, rhythm, and quality, thus : _ _ ^ ., ,, . r 1. Exafffferated or increased. In Intensity the respira- „ t,- --uj x ■L.^ " ^ , \ %. Diminished or feeble, tory murmur may be . . In Rhythm, the respira- tory murmur may be In Quality the respira- tory murmur may be. 3. Absent or suppressed. 1. Interrupted. 2. The interval between inspiration and expiration be prolonged. 3. Expiration be prolonged. 1. Rude, termed rude respiration. 2. Bronchial, " bronchial " 3. Cavernous, " cavernous " , 4. Amphoric, " amphoric " Alterations in Intensity. Exaggerated Respiration differs from the normal vesicular respiration only in an increase in the intensity and duration of the respiratory sounds. It is sometimes caUed puerile respiration, from its resemblance to the respiration of children. It occurs in a part where respi- ration is more active than usual, owing to deficient ac- tion elsewhere, as in the upper part of one lung whose ALTERATIONS IN RHYTHM. 35 lower lobe is consolidated by pneumonia, or similarly where one lung does the duty of its fellow which is solid- ified by the pressure of a pleuritic effusion. Diminished or Feeble Respiration differs from nor- mal vesicular respiration only in a diminution in the in- tensity and duration of the respiratory sounds. It may arise from any cause which interferes directly or indi- rectly with the expansion of the lung, or which dimin- ishes the elasticity of the alveolar walls. Of the first condition, we have illustrations in affections which re- strain the movements of the thoracic walls, as pleuritic pain, rheumatism, paralysis, etc. ; or when there is some obstruction to the entrance of air into the lungs, such as in diseases of the larynx, trachea, or bronchial tubes ; or, again, when a pleuritic effusion or a tumor presses the lungs back from the chest walls, though not to a degree sufficient to prevent all air from entering them. Of the second condition, we have examples in pulmonary em- physema and in incipient tubercular deposits. Absent or Suppressed Eespiration occurs whenever, from some cause, the play of the lung is suspended. This may be either from external pressure, as when the lung is forced against the spinal column by the presence of fluid or air in the pleural cavity ; or when a complete obstruction of any bronchus prevents the air from either entering or leaving the lungs. Alterations in Rhythm. Interrupted Respiration. — In health the respiratory sounds are even and continuous, with a brief interval between each act. This may be altered in disease, and both sounds, especially the inspiratory, may have an interrupted or jerking character, termed by some "cog- wheel respiration." We have examples of this kind of 36 PHYSICAL DIAGNOSIS. respiration in asthma, pleurodynia, first stage of pleurisy, and incipient phthisis. It is most frequently associated with phthisis, and may be due probably to some gelati- nous mucus adhering to the walls of the finer bronchial tubes, which, though not sufficient to produce rales, still obstructs the free ingress and egress of the air. This *' cog-wheel" respiration occurs in some nervous individ- uals v?ith normal lungs, especially in young girls. A quick, full inspiration will cause it to disappear. Prolonged Interval between Inspiration and Ex- piration. — Instead of the two sounds closely succeeding one another, they may be separated by a distinct inter- val. When this occurs, either the inspiratory sound is shortened, or the expiratory delayed in its commence- ment. In the first instance, it is the result of pulmonary consolidation, as in tubercle ; in the second, the elasticity • of the pulmonary tissue is impaired, as in emphysema, no sound being heard during the first portion of the ex- piratory act. Prolonged Expiration. — Here the ratio between nor- mal inspiration and expiration is inverted. The ex- piration, at times, is twice or three times as long as the inspiration. It is always due to a want of freedom in the egress of air from the lungs. The most common, and therefore, practically speaking, the most important, cause of pro- longed expiration is tubercular deposit in the lung. Ex- cessively prolonged expiration is to be met with in vesic- ular emphysema, and this is to be distinguished from the prolonged expiration of phthisis by its pitch, which in emphysema is low, lower than the inspiration, while in phthisis it is high, higher than the inspiration, and tubu- lar in quality. ALTERATIONS IN QUALITY. 37 Alterations in Quality. RxJDE Eespiration.— This is termed by Prof. A. Flint broncho-vesicular respiration. In this variety both in- spiratory and expiratory sounds lose their natural soft- ness ; the breezy or vesicular quaUty is lost ; the sounds are higher pitched and more tubular in character, while the expiration has more intensity, higher pitch, and longer duration than the inspiration. Rude respiration always indicates more or less consoUdation of lung tissue. In normal vesicular respiration, the sounds produced by the vibrations of the air in the air cells and finer bronchi obscure that produced in the trachea and larger bronchial tubes (healthy lung substance being a poor conductor of sound) ; but so soon as any portion of lung be- comes consolidated, the vesicular element of the respi- ratory sound is diminished and the bronchial element becomes prominent ; this change constitutes rude respi- ration. It embraces every degree of modification between complete -bronchial respiration on the one hand and normal vesicular breathing on the other, the increase in bronchial characters corresponding with the degree of consolidation. Rude respiration is of practical value principally in the diagnosis of incipient phthisis. Bronchial Respiration is characterized by an entire absence of aU vesicular quahty. The inspiratory sound is high-pitched and tubular in character ; the two sounds are separated by a brief interval ; the expiratory is stiU higher pitched and more intense than the inspiratory, is as long or longer, and of the same tubular quality. Whenever this modification of the respiratory sound is present, where in health normal vesicular murmur should be heard, consoUdation of lung substance may be in- ferred. Consequently it is an important diagnostic sign 38 PHYSICAL DIAGNOSIS. in many pulmonary affections, such as pneumonia, pul- monary tuberculosis, pulmonary apoplexy, etc. Cavernous Respiration.— In some respects this re- sembles bronchial respiration, and it is often difficult to distinguish one from the other. Some distinguished auscultators declare that this sign does not exist. Its distinguishing characteristics are, on inspiration, a soft, blowing, low-pitched sound, non-vesicular in cha- racter : as a rule, the expiratory sound is lower pitched than the inspiratory, and is always prolonged and puffing. For its production, there must be a cavity of consider- able size in the lung substance, having free communica- tion with a bronchial tube. The cavity must be empty and near the surface, its walls must be sufficiently flaccid to expand with inspiration, and coUapse with expiration. This sign is most frequently met with in the advanced stage of pulmonary tuberculosis. Amphoric Respiration. — Whenever the respiratory sound has a musical intonation or metallic quality, re- sembhng that produced by blowing gently into the mouth of an empty bottle, it is called amphoric. The amphoric character accompanies both acts of res- piration, especially the expiratory. It may be due to phthisical or other excavations in the lung substance, or to an opening from the bronchial tube into the pleural cavity, giving rise to pneumothorax. In both cases the sound is produced by vibrations of air in a cavity, which are excited by a current of air from a bronchial tube. The cavity in the lung substance which gives rise to amphoric respiration must be of large size, empty, with tense, firm walls so as not to collapse with expiration, and it must communicate freely with a large bronchial tube. INTRA-THOKACIC AUSCULTATION. 39 This sign is mainly of importance in the diagnosis of advanced tuberculosis and pneumothorax. This completes the history of the most important alterations in the natural respiratory sounds produced by disease. With few exceptions they are not new sounds, but are heard in the healthy chest, and become significant of disease only when heard in unnatural locations. A new method of auscultation has recently been proposed by Dr. B. W. Eichardson (vide Lancet, November 5th, 1893). It is termed ' ' Intra-thoracic Auscultation : A New Departure in Physical Diagnosis." He employs "a good-sized [oesophageal] tube with a large lateral aperture at the extreme end. Apertures are essential in these tubes ; if they are not made, there is little or no conduction of sound." The free end of the tube is connected to an ordinary binaural stethoscope. Dr. Richardson claims that by this means an early diagnosis of stricture of the oesophagus can be made from the friction sound produced as the tube passes over the induration, and that it may be of service in the diagnosis of diseases of the stom- ach itself ; that, through the stomach, pulsating abdominal tumors could he diagnosed : "with the terminal of a full-sized oesophageal stethoscope in the stomach cavity, a loud murmur from an arterial source will be detected without the interposition of pressure, and an important difficulty in diagnosis removed" ; and that this method will prove of service in the diagnosis of diseases of the heart and aneurisms of the large thoracic arterial trunks. In concluding he says : " I assume at once that this mode of research is not called for when by the ordinary auscultation diagnosis is clear. " I have not tried this method of examination, and therefore cannot recommend it from personal experience. LESSOW Y. ABNORMAL OR ADVENTITIOUS SOUNDS. The sounds which are now to be considered are termed Adventitious, because they are not heard in health, but are found in disease, either accompanying the normal respiratory sounds, or whoUy supplanting them. They vary much in their character, according to their origin, that is, whether they are caused by changes in the lung itself or in its investments ; and, hence, in order to ap- preciate their significance you should know weU their seat and mode of production. The sounds which originate in the air passages, or in cavities abnormally communicating with them, are called rales, or rhonchi ; those which originate in the in- vestments of the lung are csiiled pleuritic friction sounds. In speaking of the former I shall use the term rale, and would classify the varieties which we meet in practice as follows ; Rales. I Dry rales. ( Sonorous rales. ( Sibilant rales. Mucous rales (large and small). Sub -crepitant rales. Moist rales. { Crepitant rales. Gurgles (large and small). Mucous click. A rale may originate in the trachea, in the bronchi, large or small, in the air cells, or in abnormal cavities situated either within or without the lung substance. KALES. 41 It may be produced within the air tubes, either by a diminution of their calibre, by the vibrations of viscid matter collected in them, or by the air bubbUng through fluid present in the bronchi and in the air vesicles, or in larger or smaller cavities. A rale may be either dry or moist in its character, and may be audible either in in- spiration or in expiration, or in both. Dry Eales are divided into sibilant, and sonorous ac- cording to the pitch and quality of the sound ; if a rale Sibilant rSles Snbcrepitant rSJes Sonorous T&lee Mucous rSIes Large sonorous rales Fio. 3.— Diagram illustrating the Physical Signs of Bronchitis. is high-pitched and whistling, it is termed sibilant ; if low-pitched and snoring in character, it is termed sono- rous. The Sibilant rale may be heard during both inspira- tion and expiration. It recurs irregularly, and some- times is so high-pitched as to become hissing in its char- acter. Its seat is the smaller bronchi, and it is caused either by the narrowing of these tubes from thickening of the mucous tissues hning them, or from the spas- modic contraction of their muscular coat ; or it may be 43 PHYSICAL DIAGNOSIS. owing to the vibrations of viscid mucus adhering to their walls. In most instances it may be temporarily- removed by violent coughing. The Sonorous rale may also be heard during both in- spiration and expiration. As above mentioned, it is a low-pitched, snoring sound, which varies, however, in intensity from a shght rale to one loud enough to be audible at a distance from the chest. It has for its seat the larger bronchial tubes, and is produced by conditions of those tubes similar to those which cause sibilant rales in the smaller bronchi, namely, lessened calibre from tumefaction of the mucous tissues, or from spasmodic contraction, or from pressure on the tube from without, by a tumor, an exudation, or a deposit ; or it may be owing to the vibrations of a thickened fold of the lining membrane, or of viscid mucus adhering to the wall. This rale is specially frequent in bronchitis and spas- modic asthma, though it may be present in almost every pulmonary disease. Moist Eales. — Under this head may be included the crepitant, sub-crepitant, and mucous rales. Crepitant rales consist of a series of minute, crackling sounds. They persist at the spot where first heard, and do not shift their position as the other moist rales. They are audible only toward the end of inspiration. There are several views as to the production of these sounds : that they are due to the bubbhng of air through a liquid in the pulmonary vesicles or terminal bronchi- oles ; that, at the end of expiration, a viscid secretion glues the walls of the vesicles together, and their sepa- ration on inspiration gives rise to the crackhng sound ; and that they are produced in the pleura independently of the pulmonary parenchyma. This rale is the charac- teristic sign of pneumonia in the first stage, though it is RALES. 43 not infrequent in some forms of pulmonary congestion, and in oedema of the lungs. The Sub-crepitant rale is a moist bronchial sound, caused by the breaking of minute air bubbles of equal size and comparatively few in number. Its seat is the smallest bronchi, and the liquid through which the air passes may be mucus, serum, pus, or blood. It differs from the crepitant rale in the larger size of the bubbles, and is heard in expiration as well as in inspiration. This rale is present in a number of affections. When heard on both sides of the chest posteriorly, it indicates capil- lary bronchitis. It is characteristic of the resolving stage of pneumonia, and is termed the "raleredux." When present only in the apex of a lung, it indicates commenc- ing tuberculosis. It accompanies the effusion of blood into the bronchial tubes, and is sometimes present in oedema of the lungs. The Mucous rale is a moist bronchial sound, produced in the same manner as the sub-crepitant. Its seat is in the larger tubes, and, according to the size of the tube in which the sound originates, it i.,: termed the fine or coarse mucous rale. Like the sub-crepitant rale, you may hear it during both inspiration and expiration, and it is modified, or entirely removed, by the act of cough- ing. Mucous rales occur in bronchitis during the stage of secretion ; in bronchial haemorrhage ; whenever pus makes its way into the air passages from an abscess — in short, whenever the bronchial tubes become partially fiUed with liquid of any kind. If these rales, whether fine or coarse, are restricted to a circumscribed space at the apex of a lung, they indicate that the bronchitis is of tubercular origin. Gurgles are produced in large or smaU cavities partly filled with liquid, below the level of which a bronchus 44 PHYSICAL DIAGNOSIS. freely opens. The sound is due to the bubbling of air up through the liquid. It is a moist sound, but has a pe- culiar hoUow, metallic quahty. Gurgles may be heard both in inspiration and expiration, and according to the size of the cavity will they be "large" or "small." Small gurgles resemble large mucous rales, but may be distinguished from them by their aboTe-mentioned hol- low, metallic character. The most frequent cause of pulmonary cavities is the """Gurgles. i=^g rr, ' —Cavernous j-P\^ • '"'^X respiration. softening and expectoration of a cheesy pneumonia, but they may be owing to abscess, gangrene, perforating empyema, and excessive dilatation of the bronchial tubes. When pulmonary cavities exist without gurgles, it may be due to the filUng of the cavity with liquid, or to its containing no Uquid, or because the level of the Kquid is below the opening of the bronchial tube. Mucous Click. — This is a single, quick, clicking sound, not removed by coughing, and which resembles an iso lated sub-crepitant rale. Authors differ as to the theory PLEURITIC FRICTION SOUNDS. 45 of its production. It appears to me to be due to the sud- den and forcible passage of air through a small bron- chus, the sides of which have been brought together at one or more points, either by external pressure or by ag- glutination from within ; as when a consohdated lobule presses unequally upon a bronchus, and excites a local inflammation of the mucous membrane with its con- sequent viscid secretion. It is therefore important as a symptom of incipient tuberculosis. Pleuritic friction sound. Flatness on percus- sion. Absence of vo- cal and respiratory £ouads. Fia. 5.— Roughening of the Pleurae, and Slight Pleuritic Effusion. Pleuritic Friction Sounds.— In health the smooth pleural surfaces, moistened by their natural secretion, play noiselessly upon each other during the respiratory movements. When an inflammation roughens one or both of these surfaces, or dries up their natural secretion, it gives rise to a friction which produces the charac- teristic sounds to which the above name is given. These sounds consist of one or of a series of abrupt, jerking, rubbing noises, manifestly superficial. 46 PHYSICAL DIAGNOSIS. and which are commonly heard over a hmiued extent of surface. They vary much in intensity, from a sound scarcely audible to one of extreme loudness ; and they usually accompany both inspiration and expiration, be- ing seldom heard with expiration alone. There are several varieties of pleuritic friction sounds, termed, respectively, grazing, rubbing, grating, creak- ing, and crackhng ; all of which belong to the clinical history of pleurisy. The grazing variety occurs at the onset of pleurisy, when dryness of the membrane is the only change yet produced. As soon as there is dulness on percussion, it is replaced by the rubbing variety, and therefore is of such short duration that it is not often heard, but may be more frequently noticed in the circumscribed pleurisy which often accompanies pulmonary tuberculosis. The other varieties are the forms in which the pleuritic fric- tion sound most commonly presents itself ; and they occur both in the stage of plastic exudation and in the stage of absorption. Sometimes the respiratory sound is attended by sounds resembling rales, which are doubtful both as to their situation and significance. They are of two kinds : First, creaking sounds not in- frequently heard at the apices of the lungs, produced either by the creaking of pleuritic adhesions or by crepi- tations in lung tissue. Second, dry crumpling sounds, resembling those produced by inflating a dried bladder, probably (as Laennec supposed) produced by the forcible distention of large air sacs in emphysematous lungs. LESSOTsT YT. AUSCULTATION OF THE VOICE. This is another method of obtaining information as to the condition of the lungs and their investing mem- branes. It is based on the fact that the vibrations of the voice are not transmitted upward only, but also down- ward, through the trachea and bronchi, to all parts of the lung. The resonance thus produced varies in cha- racter according to the situation in which it is heard. The different varieties are named after the parts where they occur in health. If the stethoscope be placed over the larynx or tra- chea of a healthy person while speaking, the voice wiU be transmitted to the ear, imperfectly articulated, and with a force, intensity, and concentration almost pain- ful. This' is called natural laryngophony or tracheo- phony. At the upper part of the sternum, and between the spines of the scapula, it is heard less intense, more dif- fused, and less distinctly articulated ; and this is termed bronchophony. But when you listen over the lung sub- stance itself, the voice sounds become distant, diffused, and without any approach to articulation. This is termed normal vocal resonance. Its intensity is usually greater on the right than on the left side, especially in the infra-clavicular region, but it varies considerably in this respect in different healthy persons. In females there is, not infrequently, no difference in the two sides. 48 PHYSICAL DIAGNOSIS. The intensity over the whole chest is greater in those who have low-pitched voices, and in thin than in fleshy persons. You cannot rely on the vocal resonance of any one region of the chest as trustworthy evidence, by itself, either of health or of disease. Its indications are fur- nished only by comparisons of corresponding parts of the two sides, after allowance is made for natural dif- ferences. In making your examination for this purpose the read- iest way is to direct the patient to count one, two, three, or repeat the numeral 99. The modifications of the vo- cal resonance which you will find indicative of disease wiU consist of changes in intensity. 1. Its intensity may be diminished ; or, 2, it may be increased ; and I would classify them as follows : 1. Diminished j a. "Vocal sounds may be weak or feeble. intensity. \h. " " " " suppressed or absent. a. Vocal sounds may be simply exaggerated. b. The resonance may be of the character termed Bronchophony . c. The resonance may be of the character termed Pectoriloquy. d. The resonance may be of the character termed Egophony. e. The resonance may be of the character termed Amphoric Voice. The varieties included under the head of diminished resonance require but little explanation. The vocal re- sonance may be faint or altogether wanting. The first of- ten occurs in bronchitis with free secretion ; in plastic pleuritic effusions, and, occasionally, when there is ex- treme pulmonary consolidation. There is absence of vo- cal resonance in pneumothorax and in copious serous pleuritic effusion. The modifications, however, which accompany increased intensity are more varied and com- plex. Increased intensity. VOCAL RESONANCE. 49 Exaggerated Vocal Eesonance differs from normal vocal resonance only in a slight increase of intensity. It denotes a moderate amount of solidification of lung tis- sue, and is chiefly of importance in the diagnosis of tu- berculosis. The characters of Bronchophony, as contrasted with normal vocal resonance, are its greater intensity, higher pitch, pecuhar vibrating quahty, and approach to articu- lation of the voice sounds. When heard in abnormal situations it has the same significance as bronchial res- piration, though more complete consoUdation is neces- sary for the production of bronchial respiration than bronchophony. The best example of bronchophony is met with in the second stage of lobar pneumonia. Pectoriloquy (so named by Laennec, its discoverer) is a complete transmission of the voice to the ear. The words spoken are heard distinctly articulated. It closely resembles the resonance heard over the larynx, and is usually limited to a small space in the chest, where it also may, or may not, have a hollow, ringing character. It was formerly believed always to indicate the presence of a pulmonary cavity, but auscultators are now agreed that this is not necessarily the case in every instance, but that it is sometimes simply an exaggerated broncho- phony ; the only distinction between these two being that bronchophony is the transmission of the voice, pec- toriloquy that of the speech. Well-defined pectoriloquy is not a common phenomenon. Egophony is the name given by Laennec to another form of vocal resonance, which is distinguished by its tremulous, nasal character, suggestive of the bleating of a goat. It also is a modification of bronchophony. Laennec considered it a sign of a limited amount of serous effusion in the pleura, over solidified lung. It 4 50 PHYSICAL DIAGNOSIS. is rarely heard, and is of not much significance when heard. Amphoric Voice is a term apphed to the vocal reso- nance whenever, in addition to its being of a hollow, metallic character, it has a distinct musical intonation. This musical sound foUows the voice, is of high pitch, and is not articulated hke pectoriloquy. It is sometimes produced in large cavities within the lung, but is more particularly a sign of hydro-pneumothorax. In addition to vocal resonance, we have a true whisper resonance, the modifications of which by disease may afford us some valuable hints (as was first pointed out by Prof. A. Fhnt). If, while practising auscultation on a person in health (as I should strongly advise you to do with one another while studying this subject), you direct him to count in a loud whisper, you wiU usually hear a soft, blowing sound, accompanying each whispered word, which varies in intensity in different persons. As a rule, it is heard only at the upper portion of the thorax, and is loudest over the primaiy bronchi. Dr. Flint calls this sound the normal bronchial whisper, and he classes its abnormal modifications into exaggerated bronchial whisper, whispering bronchophony, whispering pectoriloquy, cavernous whisper, and amphoric whisper. The exaggerated differs from the normal whisper in having greater intensity and higher pitch. It indicates slight soUdification of lung tissue. In whispering bron- chophony, the blowing sound is intense, the pitch high, and the sound seems near to the ear. When heard in situations where it is not normally present, it indicates, hke vocal bronchophony, more or less complete consoh- dation of the lung substance. The cavernous whisper is a hollow, low-pitched, blowing sound. It is a trustworthy indication of a cavity, and requires for its production RESONANCE OF COUGH. 51 conditions similar to those which give rise to cavernous respiration. In whispering pectoriloquy, the whispered words are distinctly audible at the surface of the chest, and this constitutes a more sure indication of a cavity than vocal pectoriloquy. The character and the signi- ficance of the amphoric whisper are the same as those of the amphoric voice. Another of the adventitious sounds is that which is termed metallic tinkling, its name being sufficiently de- scriptive of its character. It sounds like the dropping of a pin or a smaU shot into a metallic vessel. A single one, or a series of tinkhng sounds, may be produced by the act of speaking, or by the movements of inspiration and expiration ; but it is especially consequent on the act of coughing. This sound announces the existence either of a very large pulmonary cavity or of hydro-pneumothorax. Dr. Walsh regards it as the echo of a bubble bursting in a hquid, shut up in a spacious cavity which also contains air. Eesonance of Cough. — In a healthy individual, the act of coughing is accompanie(J by a quick, sharp, in- distinct sound, which jars through the whole chest. Over the larynx and trachea the cough is hollow, and varies in pitch and intensity with the voice of the in- dividual. The modifications of the cough sound in dis- ease are termed bronchial, cavernous, and amphoric. Bronchial cough has a quick, harsh character, attended by a marked thrill or fremitus of the chest. Cavernous cough is hollow and metallic (commonly it is termed sepulchral). It may be accompanied by gurgles, and its resonance is sometimes transmitted to the ear of the auscultator with painful intensity. Amphoric cough is a loud resounding sound, of metallic character, but not 52 PHYSICAL DIAGNOSIS. forcibly transmitted to the ear. It conveys the impres- sion of a large empty space. These varieties of cough are heard under the same conditions as the correspond- ing varieties of respiration. They are not of much utihty in diagnosis. LESSOll^r YII. A SYNOPSIS OF PHYSICAL SIGNS IN THK DIAGNOSIS OF PULMONARY DISEASES. Bronchitis. Acute and Chronic Bronchitis affecting the Larger Tubes. Infection. — The forra and movements of the chest are not visibly altered. Palpation. — Vocal fremitus is normal ; occasionally a distinct bronchial fremitus is communicated to the sur- face of the chest. Percussion. — Pulmonary resonance is normal, unless there is a very considerable accumulation of mucus in the bronchial tubes, in which case the normal resonance is diminished in the lower and posterior regions. Auscultation. — The respiratory murmur is feeble or temporarily suppressed in the lung tissue correspond- ing to the affected tubes. In the dry stage, sibilant and sonorous rales may be heard on both sides of the chest (as shown in Fig. 3). In the stage of secretion, along with the sibilant and sonorous rales, mucous rales, large and small, are heard on both sides of the chest (see Fig. 3). These rales are inconstant, coming and going, and changing their situation. When the rales are intense and abundant, they altogether mask the respiratory mur- mur. In some cases of slight bronchitis of the larger tubes, there are no distinct rales, but the respiration has a sonorous character. The Vocal Resonance is normal. 54 PHYSICAL DIAGNOSIS. Capillary Bronchitis. Capillary Bronchitis, or bronchitis affecting the ulti- mate, or capillary, bronchial tubes. Inspection and Palpation give the same signs as in simple bronchitis. Percussion is normal, or it may be slightly exag- gerated. Auscultation shows, if the disease is extensive, that the vesicular murmur is weakened or suppressed. In its stead, sub-crepitant rales are heard on both sides of the chest, accompanied by sibilant rales of a markedly hissing character. The Vocal Resonance is normal. Differential Diagnosis of Bronchitis. — The diagnosis of bronchitis of the larger tubes is readily made. Some- times, however, the gravitation of fluid from the larger to the smaller tubes may give rise to sub-crepitant rales over a circumscribed area posteriorly. Capillary bronchitis may be confounded with pneu- monia, and with acute or chronic tuberculosis. It is dis- tinguished from pneumonia by its normal or exaggerated resonance on percussion, by the existence of sub-crepitant rales on both .sides of the chest, and by the absence of bronchial breathing. The diagnosis of capillary bron- chitis from tuberculosis will be considered under the head of the latter. If the sub-crepitant rales are confined to the apex or base of one lung, and there is resonance on percussion, the bronchitis is either of a tubercular or emphysematous origin. Dilatation of Bronchi. {Bronchiectasis.) Bronchiectasis is usually associated with fibrous in- duration of the lung or with emphysematous enlarge- PULMONARY EMPHYSEMA. 55 ment, and is recognized by the following physical signs : Inspection shows defective expansive movements of the chest, and prolonged, labored expiratory movements. Palpation.— Vocal fremitus varies, rhonchial fremitus frequently present. Percussion is amphoric, unless the accumulation of thick secretion gives rise to obstruction of the tubes, and consequent local solidification of the lung ; in such cases there is temporary dulness. This dulness is to be distin- guished from the dulness of pneumonia by its tempo- rary character, and by the variations in vocal fremitus. From pneumonic consolidation it is distinguished by the presence of cavernous and amphoric breathing. Auscultation. — The results of auscultation vary ac- cording to the condition of the cavity. When it is f uU, the respiratory sounds are more or less deficient over por- tions of the chest ; when it is empty, they become harsh and loud. They are accompanied by a variety of rales, chiefly sonorous. But after profuse expectoration, large mucous rales or gurgles may be present. The sounds in any portion of the lung are constantly changing in cha- racter, altered by cough or a full inspiration. Pulmonary Emphysema. Inspection in a well-marked example of this disease reveals alterations in the shape and movements of the chest. The sternum is often abnormally prominent, as if from congenital deformity. There is bulging of the infra-clavicular and mammary regions, which gives to the upper portion of the chest a more rounded appearance than in health, or, as it is called, "barrel-shaped." The shoulders are elevated and brought forward ; there is 56 PHYSICAL DIAGNOSIS. more or less anterior curvature of the spine, and the person appears to stoop. The lower portion of the chest seems contracted, and the intercostal spaces are widened in the upper, narrowed in the lower spaces. In some instances in which the general symptoms of emphysema are well marked, the lung is atrophied instead of being abnormally dilated, and no bulging or prominence of the chest occurs, either general or local. The movements of the chest walls are also altered. At the upper portion, expansion on inspiration is dimin- ished or entirely wanting. The whole chest moves ver- tically up and down with inspiration and expitation, as if it were passively hfted from the shoulders and com- posed of one solid piece ; while below, the chest, instead of being dilated with inspiration, is contracted. "The respiratory efforts are labored, and the breathing is chiefly abdominal. Palpation. — The vocal fremitus varies ; it may faU below, it may equal, or exceed, the average of health. The apex beat of the heart is often not perceptible in the precordial space ; sometimes it is felt much lower than its normal position. Mensuration shows a marked increase in the antero- posterior diameter of the chest. Percussion. — The intensity of the percussion sound is increased, the pitch is lowered, the pulmonary quaUty of the sound is greatly diminished, and it becomes what has already been described as vesiculo-tympanitic. The per- cussion note is not materially affected either by forced inspiration or forced expiration. Auscultation.— A^ a rule, the inspiratory sound is either short and feeble, or actually suppressed, and the expiratory sound is greatly prolonged : the ratio of the two sounds being as 1 : 4 instead of 4:1. The pitch of SPASMODIC ASTHMA. 57 both inspiratory and expiratory sounds is lower than in health. In some extreme cases of emphysema, the respiratory sounds are of equal length, greatly exaggerated in inten- sity, and of a harsh, sibilant quahty, the harsh quahty, undoubtedly, being due to diminution in the cahbre of the minute bronchial tubes. Vocal Resonance varies greatly ; sometimes it is di- minished or altogether absent ; at others its intensity is greatly increased. The heart sounds are feeble, and in rare instances the organ is pushed downward toward the epigastrium. Differential Diagnosis. — The only disease with which emphysema is liable to be confounded is pneumo- thorax. The distinction, however, is not very difficult, for in emphysema the percussion sound, although tym- panitic, still retains a pulmonary quality, and there is a vesicular element to the respiratory sound ; while in pneumothorax the percussion sound has a complete tympanitic character, and the respiration, if audible, is amphoric. Besides, pneumothorax affects only one side, emphysema both. Spasmodic Asthma {during the Paroxysm). Inspection shows labored respiration. Palpation, vocal fremitus normal. Percussion is normal or exaggerated. Auscultation. — The rhythm of the respiratory mur- mur is jerking and irregular ; sometimes it is exagge- rated, at others it is suppressed. Sibilant and sonorous rales, of a high-pitched, hissing and wheezing charac- ter, are diffused over the whole chest, often loud enough to be heard at a distance. Vocal Resonance is normal. 58 PHYSsICAIi DIAGNOSIS. Acute Lobar Prieumonia. The physical signs of pneumonia vary with its dififer- ent stages. FmsT Stage, or Stage of Engorgement. Inspec- tion.— The moTements of the affected side are more or less restrained. 1st stage. ( Slight dulness. ( Crepitant rale. Complete dulness, . . , Bronchial respiration. . 2d Stage. -^ Bronchophony Increased vocal {remitus, f Diminished dulness. . . I Sub-crepitant rale. . . 3d Stage. A Broncho-vesic respiration. I Increased vocal resonance. ^ Increased vocal fremitus. FiQ. 6.— Diagram illustrative of the Physical Signs of the three stages of Pneumonia. Palpation. — ^^'^ocal fremitus is slightly increased on the affected side. Percussion. — There is shght dulness over so much of lung tissue as is involved in the pneumonic inflamma- tion, the degree of dulness depending upon the amount of exudation into the lung substance. Auscultation. — In the early period of engorgement, before the exudation takes place, the respiratory mur- mur is diminished in intensity in the affected part, and exaggerated in other portions of the affected lung, as ACUTE LOBAB PNEUMONIA, 59 well as in the healthy lung. As soon as exudation takes place into the air ceUs, or on the pleural surface, the crepitant rale may be heard toward the end of in- spiration. It is the characteristic sign of the first stage of pneumonia. In some cases, especially when pneumo- nia is developed in connection with acute articular rheu- matism, crepitation never occurs. Second Stage, or Red Hepatkation. Inspection.— The expansive movements are diminished on the af- fected side, and increased on the healthy. Palpation. — As a rule, vocal fremitus is increased; occasionally it is diminished. Percussion. — There is marked dulness over a space corresponding to the consolidated lung tissue, and in- creased resonance over the healthy portion of the af- fected lung. The relation of the resonance and dulness is not affected by a change in the position of the patient. Absolute dulness or flatness on firm percussion very rarely exists. • Auscultation. — As the air ceUs become completely filled with exudation the crepitant rales cease, and bron- chial respiration is heard over the solidified lung tissue. The more complete the consohdation the more intense and tubular is the bronchial respiration. Vocal Resonance. — There is marked bronchophony over aU that portion of lung which is the seat of pneu- monic consolidation. The heart sounds are transmitted to the surface with urmatural intensity. The character- istic physical signs of this stage are dulness on percus- sion, bronchial breathing, and bronchophony. Third Stage, or Gray Hepatization. — The physical signs in the early part of this stage are the same as those of the second stage. They are simply the signs of con- solidation. In the latter or resolving part of this stage, 60 PHYSICAL DIAGNOSIS. percussion shows progressive diminution in dulness. It is often, however, a long time before normal pulmo- nary resonance is perfectly restored. Auscultation. — The bronchial respiration of the sec- ond stage gradually gives place to rude (or broncho- vesicular) respiration, and this in turn approximates to, and at length ends in, normal vesicular breathing. As the bronchial respiration diminishes, the crepitant and sub-crepitant rales, or "rale redux," are developed, and remain audible untU resolution is complete. Bron- chophony gives place to exaggerated vocal resonance, and that in turn to normal vocal resonance. The phy- sical signs of chronic pneumonia wiU be considered in connection with tuberculosis. Lobular Pneumonia. The areas of consoUdation vary from the size of a pea to that of a hazelnut. They are usually scattered through- out both lungs, but in some instances isolated nodules may become confluent and the greater part of a lobe be consohdated. Lobular pneumonia is associated, as a rule, with a catarrh of the smaller tubes, and occurs most frequently in children and old people. Inspection.— In. the severe lobular pneumonia of chil- dren, the respirations are hurried, shallow, and imper- fect. There is only slight expansion of the chest, or in some cases there may even be retraction of its lower portion during a full inspiration. In adults inspection reveals only an increased frequency of the respiratory acts. Palpation gives negative results unless the consoh- dated areas are of considerable size and situated near the surface of the lung. PULMONARY CEDEMA. 61 Percussion.— DulneBS is present over circumscribed areas. It may be slight or complete, depending upon the extent and location of the consohdation. Dulness in children can be ehcited only by gentle per- cussion. On Auscultation small mucous rales, resembling the sub-crepitant, having a fine crackUng and metallic cha- racter, are heard over the areas of dulness. They are audible both with inspiration and expiration. The breath- ing is at first feeble, but gradually it becomes broncho- vesicular, or even bronchial. The vocal resonance is in- creased : it may be bronchophonic. -Differential Diagnosis. — Lobular pneumonia is most likely to be mistaken for capillary bronchitis. The dul- ness on percussion, the locahzation of the rales to cir- cumscribed areas, and the broncho- vesicular or bronchial breathing, will readily distinguish it. Pulmonary CEdema. In oedema of the lungs inspection and palpation fur- nish no positive information. Percussion. — There is more or less dulness on percus- sion (never, however, complete), diffused over the poste- rior surface of the chest on both sides, and marked at the most dependent portion of the lungs. Auscultation. — The respiratory murmur is feeble, sometimes almost entirely absent. With the inspiratory sound, crackling rales are heard over the seat of the oedema; the crackling resembles somewhat the crepi- tant rale of pneumonia, but is distinguished from it by its hquid character. Differential Diagnosis. — Pulmonary oedema may be confounded with the first stage of pneumonia, with hy- drothorax, and with capillary bronchitis. It is distin- 62 PHYSICAL DIAGNOSIS. guished from pneumonia, as we mentioned above, by the liquid character of the crackUng rales, and by its occur- ring on both sides, at the most dependent portions of the lungs, pneumonia usually being confined to one lung ; from hydrothorax, by the presence of rales, and by the level of the dulness not being changed by a change in the position of the patient ; from capillary bronchitis, by the slight dulness on percussion which attends it, and by the absence of the rales in the larger bronchial tubes. Pulmonary Gangrene. The physical signs of pulmonary gangrene are often obscure and never distinctive. They are those of local consohdation followed by the evidences of the breaking up of lung tissue and the formation of cavities in the lung substance. There are no special signs indicating the nature of the disorganizing process ; sometimes it is preceded by the signs of pneumonia ; generally it is ac- companied by the signs of bronchitis, and late in the disease there are physical evidences of the formation of cavities in the lung substance. Pulmonary Hcemorrhage. The physical signs of a sUght haemorrhage from the lungs are very obscure. No information as to the seat or amount of the haemorrhage is furnished by inspection, palpation, or percussion. Auscultation may, however' indicate the spot at which the hsemorrhage occurs, by the presence of moist rales. If the haemorrhage is jprofuse and accompanied by pulmonary apoplexy, abundant moist rales wiU be heard at the seat of the effusions, and they remain audible until coagulation takes place or the effusion is removed. When pulmonary apoplexy occurs. PULMONARY CANCER. 63 it is usually found in the lower and posterior portions of the lungs. If the nodules are few and small, there will be no positive physical evidences of their situation. When the nodules are large and he superficially, percus- sion will give more or less dulness over a limited space corresponding to the extent of the haemorrhage, and on auscultation there will be a diminution or absence of the respiratory murmur. When the extravasation is situ- ated near a large-sized bronchial tube, bronchial breath- ing and increased vocal resonance are heard, and there is also increase in the vocal fremitus. Pulmonary Cancer. Cancer of the lungs may be primary or secondary. In the primary form, only one lung is affected, and the growth occurs as a single mass. In the secondary, both lungs are involved, and the new growth usually takes the form of disseminated nodules of varying size. The latter variety cannot be distinguished by physical examination from simple bronchial catarrh, but pulmonary symp- toms occurring a year or so after the removal of a can- cer are very suggestive. Where the growth is single and large- Inspection shows obliteration or bulging of the inter- costal spaces. This may, however, be due to a compU- cating Uquid efEusion. Occasionally there is retraction of the chest wall. The movements of respiration are impaired. Palpation gives diminished or absent vocal fremitus. Percussion gives comparative or absolute duhiess, ac- cording as whether the mass is deep-seated or superficial. Auscultation— "Ihe respiratory and voice sounds are usuaUy absent over the affected portion of the lung. But if a large open bronchus passes through the mass. 64 PHYSICAI. DIAGNOSIS. bronchial breathing and voice will be heard. The signs on the healthy side may be exaggerated. Differential Diagnosis. — The only disease with which pulmonary cancer is likely to be confounded is pleurisy with effusion. In cancer, however, the line of dulness does not change when the position of the patient is altered; the dulness do6s not begin at the lowest portion of the thorax and extend upward ; and there may be one or more points where slight resonance on percus- sion is obtained. In cancer, the dulness is most marked in front, whereas in pleurisy it is greatest behind. Pain is present if the pleura is involved, and pressure symp- toms are sometimes seen. Pulmonary Collapse. Complete collapse of large portions of lung may be produced either by bronchitis or compression. There are no physical signs to indicate its occurrence, unless the coUapsed lung is in contact with the chest waU, and then the signs are not very distinctive. Usually there is over the space where it occurs some dulness on percussion, localized bronchial breathing, and increased vocal fremi- tus. When there is collapse of only a few vesicles, a deep inspiration may bring out a crepitant rale, audible during a few respirations, and then heard no more. Congenital atelectasis gives rise to no physical signs, unless there is marked inspiratory dyspnoea and retrac- tion of chest walls. Pulmonary Congestion. There are no recognizable physical signs of simple pulmonary congestion, unless it is associated with pul- monary oedema or bronchial haemorrhage. It may be suspected when extreme dyspnoea comes on suddenly after violent physical exertion, or during the PULMONARY CONGESTION. 65 inlialation of highly rarefied air met with in high alti- tudes, especially if, with the dy^noea, you have the physical signs of pulmonary oedema, and a watery blood- stained expectoration. Some auscultators have regarded intensification of the second sound of the heart over the pulmonary arteries as a diagnostic physical sign of pulmonary congestion ; but this evidence is fallacious, for greater intensity of the second pulmonary sound maybe merely relative, and due to weakness of the aortic sound. 6 LESSOIir YIII. A SYNOPSIS OF PHYSICAL SIGNS IN THE DIAGNOSIS OF PULMONARY DISEASES — CONTINUED. Pleurisy. There are three recognized varieties of pleurisy, Acute, Sub- Acute, and Chronic or Empyema. In acute, there is but little liquid effusion; in sub-acute, the liquid effusion is abundant, often completely filling the pleural cavity; in empyema, the effusion is purulent, comparatively smaU in quantity, and usually circumscribed. I shall consider the physical signs of the three varieties sepa- rately. Acute Pleurisy may be divided into four stages— a dry stage, a plastic stage, a stage of liquid effusion, and a stage of absorp- tion. Dry Stage. — Inspection shows a diminution in the respiratory movements, especially in expansion of the affected side. They are also quick, catching, and irreg- ular. Palpation, mensuration, and percussion yield only negative results. Auscultation. ~T!h.e respiratory murmur is feeble, jerking, and interrupted ; occasionally a grazing friction sound is heard over the seat of the pleuritic inflamma- tion. Stage op Plastic Exudation. Inspection.~The res- piratory movements of the affected side are stiU more ACUTE PLEURISY. 67 diminished, while those of the healthy side are in- creased. Palpation. — Vocal fremitus is diminished. Percussion. — There is more or less dulness over the seat of the plastic exudation. If the dulness is marked, the plastic matter is abundant. The dulness will be less at the end of a full expiration. Auscultation. — The respiratory murmur over the seat of the pleuritic inflammation is feeble or entirely absent, and a rubbing or crepitating friction sound is heard, most distinctly at the end of the inspiratory act, as shown in Fig. 5, p. 45. Vocal Resonance. — The intensity of the vocal re- sonance is diminished. Stage of Liquid Effusion. Inspection.-r-In acute pleurisy the quantity of liquid effusion is generally small, as shown in Fig. 5 ; consequently there is no dilatation of the affected side. When it appears, the jerking movements of the dry and plastic stages cease, and there is no visible motion at the seat of the Uquid accumulation. Palpation. — Vocal fremitus is absolutely suppressed over the effused liquid. Percussion. — When the patient is sitting or standing, there is flatness on percussion, from the base of the lung on the affected side to the level of the liquid, as shown in Fig. 5. The line of the flatness may be changed by changing the position of the patient. Auscultation. — The respiratory sounds below the level of the liquid are diminished or suppressed ; above, they are exaggerated. The friction sounds disappear where the effusion prevents the pleural surfaces from coming in contact with each other; but above the liquid they continue to be heard, as shown in Fig. 5. PHYSICAL DIAGNOSIS. Vocal Resonance.— Below the level of the liquid the vocal sounds are feeble or entirely abolished. Stage of Absorption.— This stage is marked by the gradual return of pulmonary resonance on percussion, and of the normal vocal and respiratory sounds. As the effusion disappears creaking friction sounds are audible for a brief period. Bub-Acute Pleurisy. In this variety of pleurisy the pleural cavity may be partly or completely fiUed with liquid. In addition, there Absence of respiratory sounds " " vocal sounds. " " vocal fremitus. Flatness on percussion. FiQ. 7. -Diagram sliowlng the Pleural Cavity completely filled with Liquid, the LuDS being compressed, is a moderate amount of plastic exudation, which thick- ens and roughens the pleural surfaces. When the cavity is partly filled, the presence and amount of the effusion are determined by the same physical signs that mark the effusive stage of acute pleurisy. When the pleural cavity is distended by accumulation of the liquid, the lung is compressed against the spinal column, and impor- tant changes in the physical signs occur. SUB-ACUTE PLEURISY. 69 Inspection shows perfect immobility of the chest walls, with general enlargement of the affected side. The inter- costal spaces bulge more or less, and the cardiac impulse is visible in an abnormal position. Mensuration shows an enlargement of the affected side, both in its circumference and in its antero-posterior diameter ; the enlargement is greatest over the false ribs, the affected side often measuring one or two inches more than the healthy. Palpation shows the vocal fremitus to be wanting. Percussion.— 1h.eve is general flatness on percussion over the affected side, the flatness extending beyond the natural hmits of the lung. Under the clavicle the per- cussion sound sometimes has a tympanitic quality. Auscultation. — There is entire absence of all respira- tory and vocal sounds over the affected side, except at the upper portion of the compressed lung ; here bron- chial respiration and bronchophony are heard. Some- times these sounds are diffused over the affected side. The respiratory sound over the healthy lung is exag- gerated. In the Stage of Absorption, inspection informs us that the enlargement of the affected side is disappear- ing, that the intercostal spaces are regaining their normal condition, and that the respiratory movements of the chest walls are returning, although restricted. Palpation shows a gradual return of vocal fremitus. Mensuration shows a gradual diminution in the mea- surement of the affected side, until it becomes even less than the opposite side. Percussion. — The percussion sound gradually recovers its normal resonance, first at the upper and then at the lower portion of the pleural cavity; sometimes in the inferior portion it never regains its normal resonance, 70 PHYSICAL DIAGIJ^OSIS. owing to the great accumulation of solid, plastic mate- rial, or condensation of lung tissue. Auscultation. — The respiratory sounds are again heard, at first weak and distant; gradually they become more distinct, and sometimes harsh in character. As the absorption of the liquid takes place, and the two surfaces of the pleura again come in contact, a friction sound, of a creaking, crepitating character, appears, and remains audible for a variable period. The vocal reso- nance is at first bronchophonic, then exaggerated, and ultimately becomes normal. The heart, with the ad- jacent abdominal viscera, returns to its normal position, sometimes with singular promptness. If, as sometimes happens, the lung remains permanently impervious to air, then there is a permanent loss of motion on the affected side, and there is no return of the respiratory or vocal sounds, while dulness on percussion is persistent. A portion of the lung (usually the upper) sometimes becomes partially pervious to air ; when this is the case, the percussion sound over it will have a tympa- nitic quahty, the vocal resonance will be exaggerated, and the respiratory sound coarse and blowing. Empyema.— The physical sighs of empyema are the Same as those of sub-acute pleurisy, when the pleural cavity is partially filled with hquid. In the majority of the cases of empyema that have come under my obser- vation, a change in the position of the patient has not caused a change in the level of the hquid, owing prob- ably to the firm adhesion that takes place above it be- tween the pleura pulmonalis and pleura costahs. Ex- cessively abundant empyematous effusions sometimes pulsate rhythmicaUy with the heart— the "pulsating empyemata. " Differential Diagnosis. —The diagnosis of pleurisy, SUB-ACUTE PLEURISY. 71 in the majority of cases, is easily made ; yet in all its different varieties there is some danger of confounding it with other diseases. In the dry stage of acute pleurisy it may be con- founded with pleurodynia and intercostal neuralgia. Tt is distinguished from them by the presence of the graz- ing friction sound, by the deep-seated character of the pain, and by the absence of tenderness on pressure over the seat of pain. It is further differentiated from inter- costal neuralgia by not having the three points of ten- derness, viz. : at the exit of the nerve from the spinal canal, over the greatest curvature of the rib, and in front. The plastic stage of pleurisy on the left side may be confounded occasionally with the plastic stage of pericarditis. It is readily distinguished from it by the cessation of the friction sound during a temporary sus- pension of the respiratory movements. The effusive stage may be confounded with con- solidation of the lung from pneumonia and tubercular infiltration, with an enlarged liver or spleen extending upward, and with cancerous deposits in the lungs. It is distinguished from pneumonia and tubercular consoh- dation by the bulging of the affected side, by the ab- sence of vocal fremitus, by the flatness of the percussion sound, by the change in the level of the liquid on change in the position of the patient, and by the absence of aU vocal and respiratory sounds. The blowing respiration that is sometimes heard over a pleural cavity filled with liquid differs from the true tubular or bronchial breath- ing of pulmonary consoUdation in being more diffused and deep-seated, and not accompanied by any moist sounds. In tubercular consoUdation, the progress of the physical signs is usually from above downward ; in ef- fusion, they advance from below upward. Besides, 73 PHYSICAL DIAGNOSIS. pulmonary tuberculosis of an entire lung does not exist without involving the opposite lung, while any amount of pleuritic effusion may exist on one side while the other remains unaffected. The physical signs of the stage of absorption will rarely be confounded with any other disease. Hyper- trophy of the liver, enlarging upward, is distinguished from effusion into the right pleural cavity by the exist- ence of pulmonary percussion and audible respiratory murmur at the posterior part of the chest. Deep in- spiration also increases the area of the normal percus- sion and normal respiratory sound at the inferior por- tion of the pleural cavity ; it exerts no such influence when the loss of resonance and respiratory murmur de- pends upon pleuritic effusion. Enlargement of the spleen affects but slightly the vo- cal or respiratory sounds at the inferior portion of the left pleural cavity. It causes no protrusion of the inter- costal spaces, and does not, like pleuritic effusion, push the heart to the right, but raises it upward. Pneumothorax. — Inspection shows distention of the affected side, widening and bulging of the intercostal spaces, and immobihty of the chest walls, contrasting forcibly with the costal movements of the healthy side. Palpation.— YocaX fremitus is diminished, or alto- gether wanting. Mensuration shows the affected side to be markedly increased in size. Percussion elicits a tympanitic resonance, of an am- phoric or metallic quahty, over the whole of the affected side. When the dilatation of the chest is excessive, the adjacent viscera are more or less displaced. The tym- panitic percussion sound assumes a muflSed character, and extends considerably beyond the normal limits of the pleura. PNEUMOTHORAX. 73 Auscultation varies according to the amount of air contained in the pleural cavity. If the cavity is dis- tended with air, so that the lung is completely com- pressed, the vocal and respiratory sounds are altogether absent, and the heart sounds are feebly transmitted through the distended pleura ; if the quantity of air is smaU, the respiratory sounds are weak and distant, and the vocal sounds indistinct. Hydeo-pneumothoeax usually results from the open- Tympanitic resonance, Amphoric respiration. Metallic tinkling. , . Sucoussion sound. . . Absent vocal fremitus. Flatness Absent voice Absent respiration. . Displaced viscera. ■ . Fio. 8.— Diagram illustrative of the Physical Signs of Hydro-pneumothorax. ing of a bronchus into the pleural cavity. The physical signs of this condition are a combination of those of pleuritic effusion and pneumothorax. As in pneumo- thorax, inspection reveals dilatation of the affected side, widening and bulging of the intercostal spaces, immo- biUty of the chest walls, and displacement of the heart and adjacent viscera. There is entire absence of vocal fremitus. Percussion. — When the patient is sitting or standing, there will be tympanitic resonance on percussion from 74 PHYSICAL DIAGNOSIS. the summit of the affected side to the level of the liquid, and flatness below ; the relation of the flatness and tym- panitic resonance changing with the change in the posi- tion of the patient. Auscultation. — Below the level of the liquid there is entire absence of all the respiratory and vocal sounds ; above its level there is usually amphoric respiration and metallic tinkling. The characteristic physical sign of this disease is the succussion sound, which is a metallic, splashing sound produced by abruptly shaking the chest while the ear is resting on its surface. The respiration on the healthy side is exaggerated. When pneumothorax is secondary to advanced tuber- culosis, the lung often remains adherent to the chest wall, and great distention of the affected side is pre- vented. Complete catarrhal obstructions in the main bronchi sometimes give signs similar to those of pneu- mothorax. Pulmonary Tuberculosis. Tuberculosis of the lungs may be divided into Acute and Chronic. The Acute occurs in two forms, Acute Miliary Tuberculous and Acute Tubercular Pneumonia. ACUTE MILIARY TUBERCULOSIS. Acute MiKary Tuberculosis, in which there is a dis- semmation of miliary tubercles throughout the lungs cannot be differentiated, by the physical signs, from a catarrh of the smaUer bronchial tubes. The diagnosis rests upon an examination of the sputum (see page 207) ^_^^;^^^^^t^^^^^n a positive result is obtained.' CHRONIC PTJLMONABY TUBERCULOSIS. 75 ACUTB TDBEBCULAR PNEUMONIA. In this form of the disease, lobules or an entire lobe may rapidly become consohdated. The physical signs are the same as those of lobular or lobar pneumonia (see pages 58 and 60). Here again the microscope is neces- sary to complete the diagnosis. CHEONIO PULMONAEY TUBERCULOSIS. (ChrOniC PMMsis.) Early Stage. — The lesion is usually situated about an inch from the apex of the lung, and nearer the pos- terior than the anterior surface ; consequently the physi- cal signs will be best marked behind. Inspection affords little information unless the con- solidation is extensive and confined to one apex, where expansion in the infra- and supra-clavicular regions of the affected side will be diminished, and there will be some flattening of the upper part of the chest waU. Palpation. — By palpation you will often detect de- ficient expansion in the infra-clavicular region of the affected side when it cannot be detected by inspection. There is also slight increase in the vocal fremitus ; this increase, however, is less significant when it occurs on the right side than on the left. Percussion. — The difference in the percussion note in the infra-clavicular region on the two sides, rather than the quality of the sound, is important. But it must be remembered that normally there exists a discrepancy in the two sides. On the right the pulmonary resonance is less marked and the. pitch of the percussion sound is Iiigher. If the consolidation is slight and superficial, the pitch tt the percussion sound on the affected side wiU be 76 PHYSICAL DIAGNOSIS. slightly raised. But if healthy or emphysematous lung tissue intervene between the consolidated lung and the chest walls, the percussion sound may be normal, or ex- tra resonant, over the affected portion. To detect pul- monary consolidation under such circumstances, the per- cussion blow must be forcible, and directed from, not toward, the trachea. If doubts exist, the percussion should be performed at the end of a fuU inspiration and at the end of a full expiration. As consohdation in- creases, the .pitch of the percussion sound rises and its clearness diminishes, until, in some cases, absolute dul- ness is reached. Auscultation. — The respiratory sound in the infra- and supra-clavicular regions of the affected side is weak or suppressed at some points, and exaggerated at others. It may be jerking, wavy, or "cogged-wheel" in its rhythm, and rude or bronchial in its quahty. The in- spiratory sound loses its soft, breezy character, and be- comes higher pitched and tubular ; while the expiratory becomes higher pitched than the inspiratory, and is pro- longed. Prolonged expiration, however, if unattended with any alteration in quality, is insignificant. The value of these states of the respiration corresponds to their position. If they exist above and are imperceptible below the second interspace, they are seriously signifi- cant. Localized mucous or sub-crepitant rales, heard over a hmited space at the apex of the lung, are always important signs of tuberculosis, and indicate the de- velopment of broncho- or catarrhal pneumonia. They are often present before any appreciable change in the respiratory murmur occurs. At first they are more or less obscure in proportion to the weakening of the res- piration ; gradually they become more distinct and nu- merous as the pulmonary consolidation increases. The CHRONIC PULMONARY TUBERCULOSIS. 77 heart sounds over the affected lung will be increased in intensity". Vocal resonance is subject to so many variations as to render it almost valueless as a means of diagnosis. Ex- aggerated vocal resonance at the left apex is of some im- portance. The Advanced Stage is marked by a greater involve- ment of lung tissue. The consolidation extends, and is attended by softening, and the formation of cavities. There is a diminution in the volume of the lung, with corresponding contraction of the chest walls. The diagnosis of a cavity demands that it be near the surface, not smaller than a walnut, and for the most part contain air. Inspection. — The respiratory acts are much increased in frequency, and marked depression will be noticed above and below the clavicles. There is deficiency in local expansion, especially during a full inspiration ; or it may be that the respiratory movements are arrested in the supra- and infra-clavicular regions. Palpation. —Hhe vocal fremitus, as a rule, is in- creased over the consoUdated area, and over a large superficial cavity when partially or completely fiUed. Sometimes a gurghng fremitus may be detected. Percussion.— Before cavities are formed there is a widespread and more intense dulness than in the Early Stage. It often assumes a wooden or a tubular charac- ter. After the formation of cavities the percussion sound varies according to the condition of the cavi- ties themselves and the lung tissue surrounding them. If the cavity is of small size and surrounded with con- sohdated lung tissue, the percussion sound wiU be ab- solutely dull or tubular in quahty ; if a layer of healthy lung tissue intervene between the chest walls and the 78 PHYSICAL DIAGNOSIS. cavity, the latter being f uU, gentle percussion will give normal resonance, while forcible percussion will elicit deep-seated diilness. Large, empty, superficial cavities with thin, tense walls yield an amphoric or "cracked- pot " resonance. Auscultation. — Oyer consolidated areas the respira- tion grows more intensely bronchial, and moist, crack- ling rales of a metallic character are heard. The rales sometimes are sticky in character, and do not change or disappear on coughing. If a cavity is empty and communicates freely with a bronchial tube, and no healthy lung tissue lies between it and the chest walls, the respiration will be either cav- ernous or amphoric (as shown in Fig. 4, page ii)— cav- ernous, when the cavity is of small size, with a flaccid wall that coUapses with expiration and expands with in- spiration ; amphoric, when the cavity is large and sur- rounded with consolidated lung, or with a thick, fibrous wall that does not collapse in expiration. If liquid has accumulated in the cavity in sufi&cient quantity tp rise above the opening into it, large or smaU-sized gurgles wiU be heard (as shown in Fig. 4, page 44). Metallic tinkling wiU sometimes be heard over cavities of large size. Vocal resonance may be amphoric, bronchophonic, weak, or entirely absent ; pectoriloquy may be present. Small cavities partially filled with liquid, and deeply seated, do not give rise to the signs characteristic of cavi- ties, but simply furnish blowing respiration and small- sized gurgles, which resemble very closely mucous rales. A cavity may be presumed to exist at the point where the bronchial breathing is most intense and the moist sounds are most metallic in quality. The difficulty with which tuberculosis is differentiated from some forms of pleurisy and pneumonia has already been indicated. HEAET AND THORACIC AORTA. LESSOI^T IX. TOPOGRA.PHY OP THE HEART AND AORTA — PHYSIOLOGICAL ACTION OF THE HEART. The diagnosis of many cardiac diseases rests upon our knowledge of the relations of the different compart- ments and orifices of the heart to the chest walls. It is therefore necessary to be famOiar with this relationship, and with the physiological acts which constitute a com- plete cardiac cycle, before we can study intelligently the physical signs involved in the diagnosis of these diseases. By referring to Mg. 1, page 6, the relations of the heart to the adjacent viscera will be readily appreciated. In the healthy chest, the auricles are on a line with the third costal cartilages. The right auricle extends across the sternum, a little beyond its right border. The left auricle hes deeply behind the pulmonary artery. The middle portion of this auricle corresponds to the cartilage of the third rib. The tip of the auricular ap- pendix appears anteriorly to the left of the root of the pulmonary artery. The right ventricle lies partly be- hind the sternum, and partly to the left of it; its in- ferior border is on a level with the sixth cartilage. The left ventricle lies for the most part to the left of the ster- num, between the third and fifth intercostal spaces. Only a narrow strip of the ventricle is visible anteriorly. The heart, then, as a whole, extends vertically from the second space to the sixth costal cartilage, and transverse- ly from about half an inch to the right of the sternum to within an inch of the left nipple Hne. Posteriorly, 6 83 PHYSICAL DIAGNOSIS. the base lies opposite the sixth and seventh dorsal ver- tebrae. The left ventricle, the greater part of the left auricle, and a large portion of the apex of the right ven- tricle, lie to the left of the sternum. Behind the ster- num he a greater portion of the right auricle and ven- tricle, and a small portion of the left. To the right of the sternum he a portion of the right auricle and the upper portion of the right ventricle. The whole of the anterior surface of the heart is overlapped by the lungs, except a triangular space corresponding to the lower portion of the right ventricle. The Surface Measurements of the heart are as fol- lows : Vertical measurement from the second interspace to the fifth interspace, five inches ; from the median hne to the left, on the third rib, two and a half to three inches ; on the fourth rib, from three and a hal£ to four inches • in the fifth interspace, from three to three and a half inches. Belative Position of the Valves. The Tricuspid Valve hes behind the middle of the sternum, at the level of the fourth costal cartilage. The Mitral Valve hes behind the third intercostal space, about one inch from the sternum. It is the deepest of aU. The Aortic Valves he behind the sternum, near its left edge, a httle below the junction of the third costal cartilage. The Pulmonary Vaxves lie behind the junction of the third left costal cartilage with the sternum. A circle of an inch in diameter with its centre at the left edge of the sternum, a httle below the junction of the third rib with the sternum, will include a portion of all these four sets of valves. PHYSIOLOGICAL ACTION OF THE HEART. 83 The AoETA arises from the left ventricle behind the sternum, opposite the third intercostal space, and passes from left to right. The ascending portion of the arch comes to the right of the sternum between the cartilages of the second and third ribs. In this part of its course it is within the pericardial sac. Thence the transverse portion of the arch crosses the trachea just above its bi- furcation (at the centre of the first bone of the ster- num), and, passing backward and downward toward the left side of the third dorsal vertebra, becomes the de- scending portion. It rests ultimately upon the left side of the bodies of the fifth and sixth dorsal vertebrae. The arch of the aorta approaches most closely to the chest waUs at the point where the arteria innominata is given off — that is, on a line with the junction of the car- tilage of the second right rib with the sternum. The Pulmonary Artery arises from the right ven- tricle, to the left and behind the sternum, on a Une with the junction of the cartilages of the third ribs with the sternum. It passes upward and backward about two inches, when it bifurcates opposite the second costal car- tilage. The Pbrioardlal Sac encloses the heart, and may be represented as a cone, extending from the second to the seventh left costal cartilage. The base of the cone rests on, and is attached to, the diaphragm, and the apex em- braces the lower two inches of the great vessels. The larger portion of the sac hes to the left of the median line, and is further from the anterior chest wall su- periorly than it is inf eriorly. Physiological Action of the Heart. A contraction of the heart begins in the great veins and proceeds as a peristaltic wave to the auricles. They 84 PHYSICAL DIAGNOSIS. rapidly contract, and are immediately followed by the ventricular contraction, or systole. After a contraction the muscular tissue relaxes, and a period of rest ensues, the diastole. A complete cardiac cycle consists of the contraction and dilatation of each of the cavities of the heart. During the ventricular systole there is a change in its form, size, and position. Auricular Diastole. — The blood is pouring from the great veins into the auricles, and through the auri- culo-ventricular openings into the ventricles below. FiQ. 9.— Diagrammatic representatioa of tlie Changes that occur in the Valves and Cavities of One Side of the Heart daring a Card.ac Cycle. The semilunar valves are closed, as seen in Fig. 9. When the auricles become distended the Auriculae Systole begins. As it progresses they become smaller, and their walls crowd toward the opening into the ventricles below, forcing a small quan- tity of blood before them. The semilunar valves stiU remain closed. Ventricular Systole.— The contraction of the au- ricles completely fiUs the ventricles with blood. At the same time, it is supposed, the flaps of the mitral and tri- cuspid valves are floated into place by reflex currents PHYSIOLOGICAL ACTION OF THE HEART. 85 along the sides of the cavities. Everything is now ready for contraction. Suddenly the ventricular walls become tense and hard, the shape of the heart becomes more distinctly conical, and it rotates on its long axis from left to right, bringing more of the left ventricle to the front. The systole is complete. The blood has been forced into the aorta and pulmonary arteries respec- tively. During its passage the cusps of the semilunar valves have been pressed toward, but not against, the arterial, walls. Any reflux of blood into the auricles, or even bulging of the auriculo-ventricular valves, is pre- vented by the contraction of the muscular papillae. They draw upon the chordae tendineae, and hold the flaps in close apposition. The cardiac impulse is synchronous with the ventricular systole, and is caused by the impact of the rigid heart against the chest wall. It is most dis- tinctly felt in the fifth intercostal space, just to the me- dian side of the mammillary line. The first sound of the heart is heard with the ventricular contraction, and is of a loud, "booming" character. It is probably of combined muscular and valvular origin. Ventricular Diastole. — After a short interval the second sound is heard. It is sharp and sudden in cha- racter, and is caused by the closure of the semflunar valves. At its occurrence the ventricles have just fin- ished their systole and are beginning to relax. Then succeeds the diastole. The ventricular walls become flaccid, the heart returns to its former position, the valves at the mitral and tricuspid orifices open, and the blood flows in from the auricles, preparatory to the com- mencement of another cycle. The semilunar valves are closed by the negative pressure produced at the end of the systole, or by the elastic recoil of the over-distended arteries. 86 PHYSICAL DIAGNOSIS. Duration of the Different Phases. — The ventricu- lar systole occupies about three-eighths of an entire cardiac cycle; the auricular systole, about one-eighth ; and the diastole of the auricles and ventricles, about one-half. But it must be remembered that the ventricles are at rest also during the auricular systole ; so it will be seen that they work less than one-half the time. Fig. 10 well illustrates the sequence of events in a Fio. lO.-Eepresentation of the Movements and Sounds of the Heart during a Car- diac Cycle —Dr. Sharpet. cardiac cycle. It is not intended that its measurements shall be exact. The normal pulse rate of the heart is T2 to the minute, though it varies considerably in different individuals, and in the same individual at different times. Thus, it is more rapid in women and children than in men, and it becomes accelerated after a full meal. A rapidly beat- ing heart differs from a slowly beating heart chiefly in the length of its diastole. As the length of the diastole increases, the greater becomes the interval between the second and first sounds of the heart. Fig. 11 is a series of circles representing the altered relations of the sounds DURATION OF THE DIFFERENT PHASES. 87 in slowed or accelerated heart action. The first and second sounds correspond, respectively, to radii 1 and 2. The larger circumference of each successive circle in- dicates the lengthening of the pause. The interval be- tween the first and second sounds becomes relatively shortened as the heart's action is slowed, and is repre- sented by a smaller arc; while the interval between the second and first sounds is lengthened. In the first and smallest circle, indicating the most rapid action, the two intervals are nearly equal, and each occupies about one-half the circumference ; in the last or largest circle the interval between the second and first sounds is about four times as long as that betvv-een the first and second. Hence it is that, when the heart is acting rapidly, it is difficult to distinguish ih.e first sound from the second, and vice versa; while with the slowly acting heart this difficulty does not occur. Attention to these varieties — physiological varieties they may be called— in the rhythm of the sounds is of very great importance in determining the attributes of a cardiac murmur, for the first step in the inquiry is to determine which is the second sound and which is the first. This, as I have said, is sometimes not an easy matter. Generally speaking, and in all cases when the action is slow and regular, there is no diffi- culty. You have only to remember that the longer interval is between the second and first sounds, and the shorter interval between the first and second. But when Fia. 11. 88 PHYSICAL DIAGNOSIS. the action is rapid or irregular, and when the first sound is indistinct at the apex, or cannot be identified with the apex beat, and also when the second sound is indistinct, or when it is audible only at the base, the first sound being audible only at the apex, as sometimes happens, the difficulty of recognition of the two sounds is very • considerable. LESSOI^T X, METHODS OP CARDIAC PHYSICAL EXAMINATION. The methods of physical examination of the heart in- clude inspection, palpation, mensuration, percussion, and auscultation. By Inspection you note the exact point of the heart's impulse against the chest wall, whether there is any un- usual pulsation, or any change in the form of the cardiac region. In a perfectly normal chest, the infra-mam- mary regions on either side are very nearly symmetrical ; but in disease the precordial region may be depressed, or arched forward, and the intercostal spaces may be widened. The most important information furnished by inspection relates to the cardiac impulse. This, in the majority of persons, is visible only in the fifth inter- space, midway between the left nipple and the sternum, and its area does not exceed a square inch. You will find it most distinct in thin persons, while in fleshy per- sons it is sometimes not discernible. You will find also that it may be displaced by a change of position, by dis- tention of the subjacent stomach, and by the movements of respiration. Thus, during a full inspiration you may see the impulse lowered an intercostal space, and then during a forced expiration see it elevated and more diffused. Change in the situation of the impulse may result from disease of the heart itself, disease of the pericar- dium or of the adjacent viscera. In cardiac hyper- 90 PHYSICAL DIAGNOSIS. trophy it is displaced downward and to the left, while in pericardial effusion it is displaced upward. It may be carried upward and to the left by enlargement of the left lobe of the liver, or downward and to the right by simple pleuritic effusion or emphysema. I have seen the impulse even external to the right nipple. Not in- frequently in cases of pericardial agglutination, or dila- tation of the ventricles, an undulating impulse wiU be visible. When from any cause the impulse cannot be seen, its position must be determined by palpation. Palpation.— This is of much greater clinical impor- tance than inspection. By it we determine the force of the cardiac pulsation, the frequency or slowness of the heart's action, and the regularity or irregularity of its movements. By it, also, we detect the presence of the friction fremitus, and what is termed the "purring thrill." The force of the cardiac impulse may be diminished or increased. Diminution in the force of the impulse may be due to degeneration of the heart wall, or to prostration of the whole system, as in collapse. It is also diminished when the apex is prevented from impinging against the waU of the chest with its customary force, as happens in dis- ease of the lungs or pericardium. Increase in the force of the impulse. — In the ma- jority of instances, this is caused by hypertrophy of the walls of the left ventricle. A slow, progressive impulse can be produced by no other cause. In such cases, the area over which the cardiac impulse can be felt is much increased. In the early stage of endocarditis and pericarditis, and in palpitations from functional disor- ders, the impulse is slightly increased. PERCUSSION. 91 The frequency and regularity of the heart's action is of great importance in the diagnosis of cardiac disease. It can often be most accurately determined by palpation. The Purring Thrill {tlie " fremissement cataire" of Laennec) is a peculiar vibratory sensation perceptible on making pressure at the precordium. In some the pres- sure need be but slight, while in others it should be firm. It may also be communicated by the large arteries, etc. Percussion. — By percussion we aim to determine the exact outline of the heart and of its investing membrane, to see whether it exceeds its normal area. In perform- ing cardiac percussion you wiU find both care and pa- tience necessary to obtain accurate results. The patient should be in a recumbent posture. You need tap but hghtly over the part where the heart is not covered by lung tissue, to obtain a flat sound ; but where the lungs overlap the organ, you must percuss more forcibly to elicit cardiac dulness, and this sound will of necessity have more or less of a pulmonary quality. We have, therefore, two degrees of cardiac dulness— the super- ficial and the deep-seated. In health the area of the superficial dulness does not exceed two inches in any di- rection. It is triangular in form, with the apex imme- diately below the junction of the left third rib with the sternum, while the base is on a line with the cartilage of the sixth rib. The area of the deep-seated dulness in health extends transversely from the left nipple to half an inch to the right of the sternum, and vertically from the second to the sixth interspace. The area of the heart's superficial dulness may be in- creased or diminished : increased, when the ventricles are hypertrophied, or when their cavities are dilated, and also when the pericardium contains hquid ; dimin- ished, at the end of a full inspiration, and in pulmonary 92 PHYSICAL DIAGNOSIS. emphysema where there is a general distention of the air cells, causing the lingula of the left lung to cover the otherwise exposed portion of the heart. The area of the deep-seated dulness is increased by enlargement of the heart, whether this be due to ventricular dilatation or to hypertrophy of its walls. It is apparently it- creased by consolidation of the anterior border of the investing lung, and by liquid in the left pleural cavity. We are often, in certain cases, much assisted in deter- mining the limits of the deep-seated dulness by auscul- tatory percussion. Auscultation. — For reasons already stated I prefer mediate to immediate auscultation in examining the heart, and in practising it you will find the following simple rules of service : 1. The posture of the patient should be recumbent when you begin your examination. Then, having care- fully elicited all the auscultatory signs which, this pos- ture affords, repeat your examination with him sitting or standing, and note whether any variations in the sounds heard have occurred from, the change in his position. 2. You should first listen to the heart sounds while the patient is breathing naturally ; having done so, then direct him to hold his breath for a moment ; and finally tell him to take three or four forced inspirations. All of these means are often requisite before we can correctly discriminate between the different signs of cardiac aus- cultation. 3. You should not confine your examination to the precordial region alone, but should explore the whole thoracic cavity, and endeavor to locaUze the points at which the heart sounds, both normal and abnormal, are heard with the greatest intensity. To this end proceed INTENSITY OF HEART SOUNDS. 93 in your examination from below upward, and from left to right. As in the case of pulmonary auscultation, so here, the normal characters must be the starting-point or standard to which every sound in cardiac auscultation is to be compared. You cannot, therefore, pay itoo much atten- tion to acquiring a familiarity with the elements of the heart sounds in health. These elements are as follows : When the ear or stethoscope is applied to the precordial region, two successive sounds are heard, followed by an interval of silence. The first sound is softer, lower in pitch, and more prolonged than the second ; as has al- ready been shown in Fig. 10, it coincides with the sys- tole of the ventricles and with the apex beat. It imme- diately -precedes the radial pulse, and has its maximum of intensity in the fifth interspace, a little to the right of the left nipple line. The second sound is sharper, or higher pitched, shorter and more superficial than the first. It marks the beginning of the ventricular dias- tole, occurs after the pulsation of the arteries, and has its maximum of intensity at the junction of the third left rib with the sternum. The period of silence immediately following the sec- ond sound varies in length with the rapidity of the heart's action. The order and duration of the sounds, and the silence, you will be able to appreciate best by re- ferring to diagrams Nos. 10 and 11 (pages 86 and 87). The intensity of the heart sounds varies in health ac- cording to the force of the heart's action, or according to the conformation of the chest, or according to indi- vidual idiosyncrasies. These sounds are less intense in fleshy or musciilar persons with capacious chests than in thin, narrow-chested, and nervous individuals. The extent of surface over which the heart sounds are 94 PHYSICAL DIAGNOSIS. heard varies with the adaptation of the adjacent organs for transmitting sounds. Generally speaking, the sounds produced on the right side of the heart are more audible on the right side of the precordial region, while those produced on the left are more pronounced on the cor- responding side. Pathological Modifications of the Normal Sounds.— In disease the normal sounds of the heart present various alterations as regards their intensity, quality, pitch, seat, and rhythm. They may also be accompanied, preceded, or followed by adventitious sounds or murmurs. An increase of intensity may be noted in cases of hypertrophy and dilatation of the ventricles, in cases of nervous irritability of the heart, or where there is con- solidation of the adjacent lung tissue. A diminution in intensity may be found depending either upon dilata- tion of the ventricles without hypertrophy of their walls ; upon fatty degeneration of the muscular tissue of the heart ; upon the granular or hyaline changes occurring in infectious fevers ; or it may be owing to a muffling of the heart sounds by pericardial effusion, or by emphysematous distention of the anterior border of the lung. Alterations in Quality and Pitch. — The heart sounds in disease may become dull and low-pitched, or sharp and high-pitched. The first sound is dull, muffled, and low-pitched when hypertrophy is conjoined with a thickened condition of the auriculo- ventricular valves. On the other hand, where the ventricular waUs are thin and the valves natural, the first sound becomes sharp and clicking in character, and the pitch is raised. The second sound is rendered dull and low-pitched by diminished elasticity of the arterial walls, and by thick- IRREGULARITY IN THE HEART SOUNDS. 95 ening of the aortic valves, without regurgitation. Some- times the heart sounds have a metallic or tinkling qual- ity, which depends either upon an irritable action of the heart or on a gaseous distention of the stomach. Alterations in Seat.— This refers to the points of maximum intensity of the respective sounds. They may be displaced upward by certain changes in the ab- dominal viscera ; or downward by tumors in the me- diastinum, and by hypertrophy with dilatation of the auricles ; or laterally by the accumulation of air or hquid in the pleural cavities. Malformations of the thorax may hkewise displace them in different directions. Alterations in Rhythm. — It not infrequently happens that a distinct intermission occurs in the heart's action. After a certain number of regular beats, a sudden pause or silence occurs ; the heart's action seems to be sus- pended for an instant, and then to go on regularly. This intermission is often observed in individuals who are in perfect health. It also occurs in diseased states of the valves or orifices of the heart. It is difficult to ex- plain its cause, and it has no precise pathological signifi- cance. Irregularity in the Heart Sounds, however, constitutes another and different alteration in rhythm. The sounds become confused and tumultuous ; they are alternately loud and feeble ; at one time slow for two or three beats, and then they foUow each other in rapid succession. When the irregularity is permanent, it is almost positive evidence of organic disease of the heart, the most fre- quent form being contraction of the mitral valves. One or both of the heart sounds, as well as the period of rest, may be prolonged or shortened. In hypertrophy of the ventricular walls the first sound is prolonged, in dilatation of the cavities of the ventricles it is shortened. 96 PHYSICAL DIAGNOSIS. The first sound is also prolonged when the two sur- faces of the pericardium are adherent. An obstacle to the flow of the blood into the ventricles prolongs the period of repose. Another alteration in the rhythm of the heart sounds is named reduplication. Each systolic sound may be repeated twice for one diastolic, or the diastolic may occur twice for one systolic. Sometimes only one sound is audible. The essential cause of the various reduplications seems to be a want of synchronism between the action of the two sides of the heart. It may occur at aU ages, and is as common with one sound as with the other. Intermit- tence is an arniost constant character of reduplication, the sound being doubled with some beats of the heart, and not with others. This intermittence in some in- stances is undoubtedly connected with the movements of respiration. In laborious respiration the first sound may be doubled at the end of inspiration and the begin- ning of expiration, and the second sound at the end of expiration and the beginning of inspiration. Clinically, it is important to distinguish true doubling of the sounds from those false reduplications which are in reality com- pounded of a sound and a murmur. LESSOl^ XI. ABNOKMAL SOUNDS OP THE HEART. Pericardial and Endocardial Murmurs. The term murmurs has been applied to those adven- titious sounds which accompany or replace the normal sounds of the heart, and which are not heard in health. Their seat may be either within the heart at the orifices of the ventricles, when they are called endocardial or valvular murmurs ; or they may be external and in the pericardium, when they are termed exocardial or peri- cardial friction sounds. Pericardial Friction Sounds. — The pericardium is a serous membrane investing the heart, as the pleura in- vests the adjacent lung. We have, therefore, when it is inflamed, results analogous to those which we de- scribed as appertaining to pleurisy — namely, dryness, and then plastic exudation, with the different friction sounds which are caused by the rubbing of the rough- ened surfaces upon one another during the movements of the heart, and, lastly, the serous effusion. This simi- larity sometimes makes it a nice point in diagnosis to distinguish a pericarditis from a pleurisy. In pericardi- tis the sounds are limited to the precordial area ; they are synchronous with the cardiac rather than the respi- ratory movements, and do not cease when the patient holds his breath. The different forms of the pericardial friction sounds have been named, like those in pleurisy, grazing, rub- bing, creaking, rasping, etc. Clinical experience, however, does not always show any definite connection between 98 PHYSICAL DIAGNOSIS. the state of the serous surfaces and the quality of a fric- tion sound. The grazing variety belongs to the initial stage of the inflammation ; the other varieties occur after the plastic effusion, and while it is undergoing or-' ganization. These sounds vary in intensity from the slight rustling which can be heard only by close atten- tion, to a loud rasping sound audible before your ear is applied to the chest. As a rule, they become more dis- ' tinct during expiration than inspiration, and while the patient is sitting rather than while recumbent, owing to the greater approximation of the pericardium to the chest wall during these states. Pericardial friction sounds may be single or double — that is, accompanying both the systohc and the diastolic movements, or either one singly. Not uncommonly the murmur is triple, caused by the systolic movement of the auricle and the systolic and diastolic movements of the ventricle. They may accompany the valvular sounds, or he independent of them. They usually con- vey the impression of being superficial in comparison with the endocardial murmurs. They are generally re- stricted to the pericardial space, the point of maximum intensity being usually at the junction of the fourth rib with the sternum. They do not often last long, disap- pearing frequently after a few hours, or at most in a few days. A pericardial murmur is distinguished from an endo- cardial by its rubbing quahty, by its superficial charac- ter, and by its not being transmitted beyond the limits of the heart, either along the arteries or round the left side to the back. It may also be distinguished from a val- vular murmur by its intensity varying with a change in the position of the patient, and by its independence of the heart sounds. PHYSICAL DIAGNOSIS. 99 Endocardial or Valvular Murmurs. In endocardial murmurs the elements of quality and intensity hold but a subordinate place as regards either diagnosis or prognosis. The same murmur may be, at different times, blowing, grating, rubbing, or musical in character, without its significance altering in the least through all these changes in its quality. "The mere fact that a murmur exists, and has a certain acoustic quality, teUs very little as regards the true character of a case." Practically speaking, endocardial murmurs may be regarded as "audible announcements" that something has occurred to roughen the surfaces of the endocardium, or to constrict the orifices of the heart, or to render the valves insufficient sq that they aUow the blood to regurgitate, or to diminish the elasticity of the great vessels, or, finally, that some change has taken place in the natural constituents of the blood itself. Anomalous chordae tendinese, when crossing the cavity of the heart near its base, sometimes give rise to a musi- cal murmur. Having ascertained the existence of a cardiac mur- mur, the first question then is. What is its pathological significance, or in what w-ay has it been produced ? To determine this it is necessary to observe particularly two points : 1st, The rhythm ; and, 2d, The seat of the murmur. The Ehythm of a Murmur.— By rhythm we mean the relation of a murmur to the different phases of the cardiac cycle. We speak of the murmur as occurring with the auricular or ventricular systole, or during the rest which intervenes between the periods of activity. To determine its rhythm you must carefully note its re- lation to the normal sounds, the impulse, and the caro- tid pulse. 100 PHYSICAL DIAGNOSIS. Evidently, the first step is to determine which is the first and which is the second sound of the heart. When the heart's action is slow and regular, this is an easy matter, but when it is rapid it is always difficult, and sometimes impossible, to distinguish the one sound from the other. It is important, therefore, not only to know theoretically all the appreciable phenomena of the phy- siological action of the heart, but to have a practical familiarity with them. Having identified the two sounds, and noted their rela- tion to the apex beat and carotid pulse, the rhythm of a murmur is readily determined; for all valvular mur- Fio. 12— Diagram illustrating the mode of production of Cardiac Murmurs in the Left Heart, and the condition of the Valves and Cavities during their production. By substitutingthe words "tricuspid" and " pulmonary " for "mitral" and "aortic," the diagram -will similarly illustrate murmurs occurring in the right heart. murs either jprecede, or take the place of, or immediately follow one of the heart sounds. First. A murmur may precede and run up to the first sound, ending at the commencement of the sound, and with the apex beat. In this case, as shown by Fig. 12, the murmur is simultaneous with the contraction of the auricles, and is either a mitral or tricuspid obstructive murmur, according as it is produced on the right or left THE RHYTHM OF A MURMUR. 101 side of the heart while the blood is passing from the auricles to the ventricles. Such murmurs, therefore, de- pend upon contraction of the mitral or tricuspid orifices, or upon deposits on the auricular surface of these valves, causing obstruction to the outflovj^ of blood from the auricle. Second. A murmur may take the place of, or follow, the first sound, ending somewhere between the first and second sounds. In this case the murmur is coincident with the contraction and emptying of the ventricles, and must be caused, as is shown in Fig. 12, either by obstruc- tion to the current of blood as it flows outward from the ventricles, in its natural direction into the aorta and pul- monary artery ; or backward, by regurgitation, through the mitral or tricuspid valves. If it occur on the left side of the heart, it is either an aortic obstructive or a mitral regurgitant murmur ; if it occur on the right side of the heart, it is either a pulmonic obstructive or a tricuspid regurgitant murmur. Third. A murmur may take the place of, or follow, the second sound, ending somewhere during the interval between the second and first sounds : in some instances it may be prolonged through the whole period of rest. This murmur is simultaneous with the dilatation of the ventricles (Fig. 12), and is produced by regurgitation of blood through the aortic or pulmonary valves, and is either an aortic regurgitant or a pulmonic regurgitant murmur. We may have, therefore, eight distinct endocardial murmurs, four systoUc and four diastolic. Not infre- quently we find in practice various combinations of these different murmurs in the same case. For instance, it is not unusual to have a mitral obstructive and mi- tral regurgitant murmur combined, so as to appear to constitute one murmur; the first sound of the heart 102 PHYSICAL DIAGNOSIS. will, however, enable you to separate the two mur- murs. In like manner, an aortic obstructive and re- gurgitant murmur are frequently combined ; here also the sound intervenes, and makes the rhythm quite plain. The greatest dif&culty is when the normal sound is merged into the murmur, as is often the case when the mitral obstructive and regurgitant are combined. The precise pathological significance of endocardial murmurs is apparent from the following table ; Table of Cardiac Murmurs.' Periods of Heart's Action. Seat of Murmur. Systolic, Left side of heart. Aortic . Mitral.. Bight side of heart. Pulmonary. ^ Tricuspid. Caiise of Murmiu'. Obstruction to the onward flow of blood through the aortic orifice, or through the aorta. Eegurgitation of blood through the mitral valve into the left auricle. Obstruction to the onward flow of blood through pulmonary orifice, or through pulmonary artery. Regurgitation of blood through the tricuspid orifice into right auricle. Diastolic. ' Aortic. ' Left side of heart. Right side of heart. Mitral., Pulmonary. Tricuspid . . ' Regurgitation of blood through the aortic orifice into left ven- tricle. Obstruction to the flow of blood from left auricle to left ven- tricle. ' Eegurgitation of blood through the pulmonary orifice into right ventricle. Obstruction to fiow of blood from right auricle into right ventricle. ' After Fuller. SEAT OF MURMURS. 103 Although eight distinct valvular murmurs may occur in the heart, those on the right side are of such rare occurrence that they are of httle clinical importance. If a murmur is heard with the first sound of the heart, it is almost certainly aortic obstructive or mitral regur- gitant ; if with the second sound, it is probably aortic regurgitant. An obstructive mitral murmur is also of comparatively rare occurrence : the force with which the blood passes from the auricle into the ventricle is ordinarily insuffi- cient to excite sonorous vibrations. Seat of Murmurs. — Having determined the rhythm of a murmur, the next step in the investigation is to find, within as narrow limits as possible, the place of its ori- gin. The points at which endocardial murmurs are produced being in the majority of cases one of the four valvular orifices, the first question to be settled under this head is, at which one of these valvular orifices it is produced. At the commencement of the examination, every means should be taken to determine in each particular case the actual size and position of the heart, together with its relation to the thoracic walls and to the sur- rounding organs, the exact point of the apex beat, and the character of the impulse. We must endeavor by careful stethoscopic examina- tion to determine the exact seat, and the hmits of diffu- sion, of the murmur under observation. If the murmiu- is very loud or diffused, or if there are several murmurs present in the same case, it may give rise to some diffi- culty ; but in the large majority of cases the observer will be able to fix on a few points, or a few restricted spaces, over which each murmur is heard, there being 104 PHYSICAL DIAGNOSIS. no murmur elsewhere ; or, if not so, areas within which each murmur is heard with greatest intensity. As there are four valvular orifices at which the major ity of endocardial murmurs are produced, so there are four distinct areas over which murmurs arising at these orifices may be diffused. FiQ. 13.— Diagram showing tlie Areas of Cardiac Murmurs. These several Areas cor- respond to the Different Spaces marked by the Dotted Lines, and a Capital Letter de- signates each Area. ^, the Area of Mitral Murmurs; B, of Aortic ; C, of Tricuspid ; and D, of Pulmonic— Gaibdnkb. The following rules will be found useful in recognizing these areas in actual practice: I. Area of Mitral Murmurs.— The maximum of in- tensity of mitral murmurs corresponds generally with the apex of the left ventricle, represented in Fig. 13 by AREA OF PULMONIC MURMURS. 105 the circle A. If it is produced by regurgitation of blood through the mitral orifice, it is transmitted to the left and backward on the line of the apex beat. The area of diffusion in front corresponds very nearly to the circle A, Fig. 13, but it is heard with nearly the same intensity behind, between the lower border of the fifth and upper border of the eighth vertebrae, at the left of the spines, as in front. The area of diffusion of mitral obstructive murmurs is usually limited to a circumscribed space (circle A) around the apex of the heart. In some instances these mur- murs are heard with equal intensity over the whole su- perficial cardiac region. To the left of the apex beat, they are always indistinct, and are never heard behind. II. Area of Tricuspid Murmurs. — The area of tricus- pid murmurs corresponds to that portion of the right ventricle which is uncovered by lung tissue, indicated in the diagram by the triangular space C. This murmur is distinct and superficial in character, rarely audible above the third rib, and thus readily distinguished from the aortic and pulmonic murmurs. It is heard loudest near the xiphoid cartilage, and along the margins of the sixth and seventh costal cartilages. In cases of hyper- trophy and dilatation of the right side of the heart, usually its point of maximum intensity is at the junc- tion of the fourth rib with the sternum. III. Area of Pulmonic Murmurs. — A murmur in the pulmonary artery, or at the pulmonary valves, is carried to the ear nearly over the seat of the valves, as indicated by the circle D in the diagram. Fig. 13. Not infrequently its point of maximum intensity is an inch, or even an inch and a half, lower down. It is usually very super- ficial, and consequently very distinct. It is limited in its diffusion, being inaudible at the apex, and also along 106 PHYSICAL DIAGNOSIS. the sternum. It is never heard in the neck, nor in the course of the great vessels. IV. Area of Aortic Murmurs. — The law of diffusion of aortic murmurs is not easily explained: not only are they heard with great intensity over the base of the heart, at the junction of the third rib with the sternum on the left side, but frequently, and not less distinctly, along the whole length of the sternum, as is indicated by the dotted lines along the edge of the sternum, in the irregu- lar space B, Fig. 13. Sometimes they are louder close to the xiphoid cartilage than at any other point. An aortic murmur is distinguished from all other cardiac murmurs by its propagation into the arteries of the neck. It is the most widely diffused of aU cardiac murmurs, and can sometimes be traced to a very great distance from the heart. It may be heard behind near the lower angle of the scapula. To complete the diagnosis of endocardial murmurs, it is necessary to consider their rhythm in connection with their area. First. A murmur which immediately precedes the first sound of the heart may be either a mitral or tri- cuspid obstructive murmur, and is produced by obstruc- tion to the current of blood as it passes from the auricles into the ventricles. If it is a mitral obstructive murmur, its maximum of intensity will correspond to the circle A, Fig. 13 ; if, on the contrary, it is a tricuspid obstruc- tive murmur, its maximum of intensity will be within the triangle C. Second. Murmurs accompanying or following the first sound, and occurring between the first and second sounds, may be produced either in the auriculo-ventricu- lar or in the arterial orifices, and they have four distinct solutions. RHYTHM OP ENDOCARDIAL MURMURS. 107 a. If it has its origin at the mitral orifice, it is a mitral regurgitant murmur, and is produced by regurgitation of the blood backward from the left ventricle into the left auricle. Its maximum of intensity in front will corre- spond to the circle A, Fig. 13, and it will be heard behind. 6. If its origin is at the tricuspid orifice, it is a tri- cuspid regurgitant murmur, and is produced by regurgi- tation of the blood backward from the right ventricle into the right auricle. Its maximum of intensity wiU correspond to the triangle C, Fig. 13. c. If its origin is at the aortic orifice, it is an aortic obstructive murmur, and is produced by obstruction to the current of blood as it passes from the left ventricle into the aorta. Its maximum of intensity will corre- spond to the irregular space B, Fig. 13. d. If its origin is at the pulmonic orifice, it is a pul- monic obstructive murmur, and is produced by obstruc- tion to the current of blood as it passes from the right ventricle into the pulmonary artery. Its maximum of intensity will correspond to the circle D, Fig. 13. Again, murmurs accompanying or following the sec- ond sound of the heart may be produced at the aortic or pulmonic orifice, and in either case coincide with the dilatation of the ventricles. a. If the murmur has its origin at the aortic orifice, it is an aortic regurgitant murmur, and is produced by the regurgitation of the blood from the aorta backward into the left ventricle. Its maximum of intensity corre- sponds to the space B, Fig. 13. 6. If a murmur following the second sound has its origin at the pulmonic orifice, it is a pulmonic regurgi- tant murmur, and is produced by the regurgitation of blood from the pulmonary artery into the right ventricle. 108 PHYSICAL DIAGNOSIS. Its maximum of intensity corresponds to the space D, Pig. 13. One, two, three, and even four of the murmurs we have been considering, may occur in combination in the same case. The most frequent combinations are the aortic obstructive and reg-urgitant, heard over the area B, Fig. 13 ; next, the mitral obstructive and regurgitant, heard over the area A ; then we have various combina- tions of these, the aortic and mitral valves being both diseased. Murmurs occurring on the right side of the heart are comparatively of rare occurrence. The tricuspid regurgitant is the only one that is of practical im- portance. Anoimic and Functional Murmurs are soft and blowing in character, are always systolic, and almost always aortic. As regards their area, they are generally dif- fused, not only over the base of the heart, but along the course of the aorta and the vessels of the neck. An anaemic is distinguished from an organic murmur by its blowing character, by always accompanying the first sound of the heart, by being audible in sever-al of the arteries at the same time, by not being constantly present, occasionally disappearing when the circulation is tranquil and returning when it is accelerated, by the presence of the general signs of anaemia, by the absence of the physical or general signs of organic disease of the heart, by entirely disappearing under treatment for relief of the anaemic state of the system. Venous Murmurs aU come under the class of inorganic murmurs. The so-called venous hum is a continuous humming sound, having frequently a musical intonation. It is best heard over the jugular just above the clavicles, with the patient in a sitting or standing position. It is CAMMANX'S RULES. 109 characteristic of anaemia, and is almost always associ- ated with an arterial anaemic murmur. Before leaving the subject of cardiac murmurs, I win give you some rules in relation to them, copied from the unpublished writings of the late Dr. Cammann; they are the result of long and careful observation, and, although they differ in some respects from the teachings of many auscultators, I have found them of great service in dia- gnosis. Cardiac Murmurs. AORTIC OBSTRUCTIVE : SYSTOLIC. " When it reaches the apex it is with diminished in- tensity. "When heard behind, it is most distinct at left of third and fourth vertebrae, close to their spines, and fre- quently extends downward along the spine in the course of the aorta, but with diminished intensity. Although the heart only extends as high as the fifth vertebra, the murmur is heard above that point, because here the aorta approaches the surface. AORTIC REGURGITANT : DIASTOLIC. " The intensity of the murmur from valve to right of apex may or may not increase downward, depending on the proximity of heart to parietes, the position of lungs, etc. ; it may decrease downward, however, from emphy- sema, supine recumbency, etc., or may perchance be loudest at apex, depending on proximity of heart to the parietes, position of the parts, condition of the mitral valve, etc. "Generally it is not heard behind, but may, toward inner side of lower angle of scapula, in thin subjects 110 PHYSICAL DIAGNOSIS. especially, be heard in the same place where is heard the non-mitral regurgitant; this non-mitral regurgitant be- ing the mitral regurgitant of Bellingham and others. " It is sometimes conveyed to left axilla. " The patient when recumbent may sometimes hear it himself. MITRAL REGURGITANT : SYSTOLIC. " To indicate regurgitation, the murmur must be heard between lower border of fifth and upper border of eighth vertebra, at left of spine, provided the transmission of the sound be not interfered with by thickness of integu- ments, or other conditions of the parts. ''When not heard in this place, but in 'left axiUa and in the region of the left scapula,' regurgitation is not indicated ; or, in other words, it is a non-regurgitant murmur, contrary to the teaching of Bellingham and others. " If there be a systolic murmur with a maximum of intensity between fifth and eighth vertebrae, at left of spine, it indicates regurgitation. "An aneurismal murmur, however, may be heard within the said limits, but it follows the aorta down- ward, gradually decreasing in intensity, without the abrupt termination of the regurgitant murmur. "We occasionally meet with mitral regurgitant mur- mur posteriorly, yet absent anteriorly. " The mitral regurgitant murmur may sometimes cease entirely, from such a change in the structural condition of the diseased valve, or from such contraction of the auriculo-ventricular opening, as will allow the valve to close so as to prevent regurgitation, there being actually in this case increased mechanical obstruction. "The following complication may exist, viz., aortic VARIOUS HEART SOUNDS. HI obstructive systolic, with aortic regurgitant diastolic ex- tending to the apex, with the mitral regurgitant behind, without a corresponding murmur in front. "All these murmurs are not infrequently heard to right of apex, and even over the whole chest. "A mitral diastohc murmur we have not heard. If ever present, as stated by distinguished auscultators, it must depend upon physical condition external to the heart. Thus, pleuritic effusions or the hke, in certain positions, by pressing suddenly and strongly upon the left auricle, may possibly force the blood with sufficient rapidity through an obstructed auriculo-ventricular ori- fice to cause an abnormal sound. " Some auscultators, however, deny the possibihty of the occurrence of this murmur under any contingency whatever." Ventricular Murmurs. Not infrequently during the active progress of endo- carditis, as well as after the acute stage is passed, a mur- mur is heard taking the place of, or following, the first sound of the heart. These murmurs are not conveyed to the left of the apex, nor heard along the course of the aorta. They are undoubtedly produced within the cav- ity of the left ventricle, either by the roughening of the chordae tendineae or the ventricular surface of the mitral valves, or perhaps by an abnormal direction to the cur- rent of blood as it passes through the ventricle. They may properly be called ventricular murmurs, and may be distinguished from other murmurs by the time of their occurrence and by their limited area of diffusion. Sounds produced by the Action of the Heart which are neither Endocardial nor Pericardial. Sounds sometimes are heard in the precordial region, 112 PHYSICAL DIAGNOSIS. produced by the action of the heart on the lungs. These sounds are mostly systolic and inspiratory: they usually cease when the respiratory movements are arrested. A blowing sound resembling a cardiac murmur may be produced in the lung tissue covering the heart, during a cardiac systole. A pulmonary cavity near enough to the heart to be influenced by it sometimes affords a loud systolic murmur. Sounds resembling rales may be pro- duced by the movements of the heart upon the bronchial tubes. Friction sounds generated in the pleura, of a crackling, rasping character, synchronous with the car- diac systole, are not infrequently heard. A friction sound heard behind and along the edge of the sternum from the second to the sixth rib is always pericardial; but when a friction sound is heard at other parts of the precordia, the diagnosis is often difacult. Pleuritic fric- tion sound usually ceases when the breath is held, but this is not always the case. LESSOR XII. SYNOPSIS OF THE PHYSICAL SIGNS OF PERICARDITIS- HYPERTROPHY, DILATATION, AND FATTY DEGENE- RATION OP HEART, AND ANEURISMS OF THORACIC AORTA. Synopsis of the Physical Signs of Pericarditis. The physical signs of pericarditis vary with the dif- ferent stages of the disease. In the early period of the attack, the only sign furnished by inspection and palpa- tion is an irritable and forcible action of the heart, and there is no change in the area of the precordial dulness on percussion.. For some time the only characteristic sign of its presence is the pericardial friction sound. After a time, as the inflammation progresses, effusions take place into the pericardial sac, and we have the sec- ond stage, or stage of effusion. Inspection no^w discloses a prominence, or arching for- ward, of the precordial region, and a diminution in the respiratory movements of the left side. Palpation shows the point of the apex beat to be raised and carried to the left of its normal position ; or, if the quantity of the effusion be large, it is entirely suppressed. Sometimes, in extensive pericardial effu- sions, an undulatory impulse is felt. The position of the impulse will often be noticed to change with a change in the position of the patient. If the cardiac impulse is entirely absent when the patient is in the 114 PHYSICAL DIAGNOSIS. recumbent posture, and becomes perceptible when he is placed in a sitting posture, you have strong presumptive evidence in favor of pericardial effusion. Sometimes when the pericardium is very greatly distended, the dia- phragm is depressed, and bulging can be detected in the epigastrium. Percussion. — The area of the precordial dulness is enlarged vertically and laterally. At the beginning, the Fio. 14.— Diagram showing the Pericardial Sac partially filled with Liquid, and Plas- tic Exudation upon the two Surfaces of the Pericardium above the level of the Liquid. dulness is principally increased upward, but any con- siderable amount of effusion is denoted by an increase in the width of the area of dulness at the lower portion of the precordial region. As the effusion increases, the shape of the enlarged area corresponds to the pyramidal form of the pericardial sac, as is represented in Fig. 14. When the pericardial sac is distended with liquid, the dulness will reach as high as the first rib : not infre- PHYSICAL SIGNS OP CARDIAC HYPEETEOPHY. 115 quently it reaches an inch or more to the right of the sternum, and occasionally it extends from nipple to nipple. Auscultation. — The friction sound of the plastic stage becomes more and more indistinct until it ceases alto- gether. The heart sounds become feeble or are entirely lost, and the respiratory murmur and the vocal reso- nance are absent over the area of precordial dulness. When recovery takes place and the liquid effusion is absorbed, the bulging of the precordial region, which was present in the stage of effusion, subsides, and the area of dulness on percussion decreases, the friction sound reappears, the heart sounds become distinct, the apex beat resumes its normal position, the impulse re- gains its natural force, and the respiratory and vocal sounds are again heard over the space formerly occu- pied by the distended pericardium. Adhesion of the heart to the pericardium does not ad- mit of diagnosis, unless firm adhesions have formed be- tween the external surface of the pericardium and the adjacent tissues, which afterward cause dilatation and hypertrophy of the heart, accompanied by recession of the apex beat, retraction of the epigastrium, and diminished motion of the pericardial portion of the diaphragm during a full inspiration. Synopsis of the Physical Signs of Cardiac Hypertrophy. The physical signs of hypertrophy of the heart vary with the seat and extent of the hypertrophy. When the hypertrophy is general, inspection shows the action of the heart to be regular, and the visible impulse to be increased in extent and in force. In children there is a visible prominence of the precordial region. 116 PHYSICAL DIAGNOSIS. Palpation. — The area greatly exceeds that within which the normal apex beat is felt, and the impulse has a heaving, lifting character. When the right ventricle is hypertrophied, the conducted epigastric impulse is strong. When the left ventricle is hypertrophied, the apex beat reaches further to the left than natural, some- times three inches below and three or four inches to the left of the normal position. Fio. 15.— Hypertrophy of Left Ventricle. Heart in situ, a, the Mammary Line. 6, Vena Cava Superior, c, Aorta, d. Pulmonary Artery, e. Bight Auricle. /, Eight Ventricle, g, Lett Auricle, h, Left Ventricle (normal outline), u, Hypertrophied Ventricle.— RiNDFLEisCH. Percussion.— The area of both the superficial and deep-seated dulness increases laterally and downward. If the hypertrophy is confined to the left ventricle, the area of dulness on percussion may extend beyond the left nipple, as is shown in Fig. 15. If, on the other hand, the hypertrophy is confined to the right ventricle, the area of dulness may extend CAKDIAC HYPERTROPHY, 117 considerably to the right of the sternum, as is shown in Fig. 16. Auscultation. — The first sound is dull, mufiled, and prolonged, and in some cases greatly increased in in- tensity. The second sound is also increased in intensity and more diffused than in health, and there is a dimi- nution or an entire absence of the respiratory murmur over the normal precordial region. I K ^ 1' \ N y , » ^ ^-, ^;^C") '/, A ' V K^-'^ '' C:-// Fi8. 16— Hypertrophy of Right Ventr.cle. Heart in situ. Description as in the pre- ceding figure. The contour of the Hypertrophied Eight Ventricle is indicated by dots.— ElNDFUffilSCH. When hypertrophy of the walls of the heart is at- tended with extensive dilatation of its cavities, the action of the heart is still regular, but the extent of the visible impulse is greatly increased, extending sometimes from the third intercostal space to the epigastrium. The apex beat may be felt as low as the ninth rib, and to the left of the nipple, and has a pecuhar heaving character, so as sometimes to shake the bed of the patient. 118 PHYSICAL DIAGNOSIS. The area of dulness may extend vertically from the third to the eighth rib, and, laterally, an inch to the right of the sternum and two or three inches to the left of the left nipple. Both sounds of the heart are pro- longed, and are often audible over the whole chest, even to the right of the spine. Dilatation of the Heart. Inspection. — The visible area of the apex beat is greatly increased, but it is difficult to determine its point of maximum intensity. Sometimes there is an undulating motion over the whole precordial space. Palpation. — By palpation you readily distinguish di- latation from hypertrophy by the feebleness of the car- diac impulse ; and although it sometimes can be felt as far to the left as the axillary line, there is an entire ab- sence of the lifting, forcible impulse which attends car- diac hypertrophy. Sometimes a purring thrill attends cardiac dilatation, especially when mitral regurgitation is present. Percussion shows a lateral increase in the area of pre- cordial dulness ; to the right when the right cavities are involved, and to the left when the left cavities are di- lated. The shape of the dull space remains oval. This point is of importance in the diagnosis between cardiac dilatation and pericardial effusion. Auscultation. — The sounds of a dilated heart are al- ways short, abrupt, and feeble. The second sound is often inaudible at the apex, and the two sounds seem to be of equal duration. If endocardial murmurs have been present, as the dilatation becomes extreme, no- thing is heard but a kind of swimming sound. The respiratory murmur is often feeble over the whole of the upper portion of the left lung. FIBROID HEAKT. 119 Asystolism. Asystolism is a term " employed to designate that re- markable group of symptoms which is characteristic of an enduring inability in the right ventricle to empty it- self." ' The physical signs are those of dilatation of the right side of the heart. A short time before death addi- tional signs occur, viz. : On palpation the cardiac im- pulse is feeble ; on auscultation the heart sounds, or any endocardial murmurs which may have been present, be- come gradually more and more feeble, until nothing is heard except a humming sound. A tricuspid regur- gitant murmur frequently develops when asystoUsm be- comes urgent, but before the heart is so weakened that it is not able to produce a murmur. If the symptoms of asystolism are moderate, the murmur disappears. Fatty Heart. The physical signs of fatty degeneration of the heart in many respects are identical with those of cardiac di- latation. The area of the precordial dulness is normal, the impulse weak or imperceptible, the- apex beat indis- tinct and often invisible. The action of the heart is irregular, the first sound is short and feeble and some- times inaudible, the second sound prolonged and inten- sified. Fibroid Heart. The physical signs of cardiac fibrosis are feeble, rapid, irregular, intermittent heart action ; a diffused, feeble cardiac impulse ; weak but sharp heart sounds. The first sound is like the second in tone and duration. They closely resemble the foetal heart sounds. On per- ' Beau, "Considerations generales sur les Maladies duCcBur," Arch. Gen. de Med., 1853. 120 PHYSICAL DIAGNOSIS. cussion we find the area of dulness increased, chiefly to the left. The diagnosis of a fibroid heart cannot be made by the physical signs alone ; we must take them in connection with the symptoms and condition of the arterial system. By the physical signs we determine that the heart is chronically weak. If, then, we find evidence of a weak heart in one who has a strong fibroid history, and who gives signs of a general arte- rial fibrosis, the diagnosis is readily made. LESSOE" XIII. ANEUKISM OP THE THORACIC AORTA AND ARTERIA INNOMINATA — EPIGASTRIC PULSATION — SUB-CLAVIAN MURMURS — VENOUS PULSATIONS AND MURMURS. Aneurisms of the Thoracic Aorta. — The thoracic aorta is affected by aneurism with varying degrees of frequency in the different parts of its course. Accord- ing to Sibson, who has collected the statistics of Y03 cases, 8T were at the commencement of the aorta in the sinuses of Valsalva ; 193 of the ascending arch, extra- pericardial'; 14 of the ascending and transverse arch ; 12 of the transverse arch ; T2 of the descending arch ; and Tl of the descending aorta. The physical methods employed in ascertaining the existence of aneurisms are inspection, palpation, per- cussion, and auscultation. Inspection. — If the aneurism presses on the superior vena cava, you will find the face, neck, and upper extremities swollen, livid, and occasionally oedematous, and the large veins of these regions turgid and vari- cose. But if the pressure is on an innominate vein, these effects will be observed only on the corresponding side. In some instances there is a thick, fleshy collar sur- rounding the lower part of the neck, due to capillary turgescence. As you inspect the chest, a more or less 133 PHYSICAL DIAGNOSIS. extensive bulging may be observed at some point along the course of the aorta. The bulging may in some cases attain the size of a cocoanut, while in others it may be perceptible only on close examination. The non-exist- ence of a tumor does not, however, prove that there is no aneurism, for if the aneurismal enlargement springs from the posterior wall of the arch, or from the descend- ing arch or descending aorta, parts which are deeply seated, there may be no visible anterior bulging. When the bulging portion is of large size, it is gene- rally conical in shape, the surface is smooth, and the skin looks tense and glazed. In most cases you will observe a pulsation of the tumor synchronous with the heart's systole; where this occurs in the anterior portion of the chest, there seem to be two beats within the thorax at the same time. Sometimes you can only de- tect the pulsation by bringing the eye to a level with, and looking across, the chest. If the aneurism is full of fibrin, there may be no visible pulsation. The position of the bulging affords a clue to the seat of the aneurism. Aneurism of the ascending arch pro- duces bulging to the right of the sternum, near the sec- ond costal cartilage; though when large it may extend into both mammary and infra-clavicular regions. Aneu- rism of the transverse arch causes protrusion of the upper part of the sternum. Aneurism of the descending arch protrudes to the left side of the sternum, though often, from the deep position of the artery in this part of its course, no tumor may be felt. Aneurism of the descending aorta shows itself on the left side of the spine, very rarely on the right. Palpation.— By the apphcation of the hand you can appreciate better the size of the tumor, the nature of its contents (whether mostly Uquid or sohd), the condition ANEURISMS OF THK THORACIC AORTA. 133 of the walls as regards perforation of the sternum or ribs, and the character of the pulsation, which is usually that of a blow equally diffused in all directions. Besides the systohc impulse, a diastohc one sometimes occurs; generally it is shght, sometimes, however, it is quite forcible. In some cases you will obtain the impulse by pressing with one hand on the sternum, and the other on the back, when by ordinary palpation you would not detect it. Again, if the aneurism is at the upper portion of the arch, by pressing the fingers down behind the sternum a distinct impulse will be felt. You may also ascertain by palpation whether there is a cessation or diminution of the expansive movement over the whole or part of one lung, and whether the vocal fremitus is lost over that side and over the tumor. The non-expansion and loss of vocal fremitus over the lung is due generally to the pressure of the aneurism on the air passages, or on the lung itself. When the aneurism presses on the carotid arteries, or when they are obstructed by coagula, a difference between the pulse of these arteries and their branches on the two sides will be noticed. Percussion. — There will be dulness over the promi- nence, or over a circumscribed space, in the neighbor- hood of the course of the aorta, not, however, corre- sponding to the size of the aneurism, unless more forcible percussion be made than is safe. The resist- ance is increased in proportion to the amount of the fibrin in the sac. When the lung is condensed by inflammation, or collapsed by obstruction of the bron- chus, there will be a greater area of dulness. Auscultation. — There are usually certain sounds or murmurs connected with an aneurism. In some cases neither are audible, owing either to the position of the 124 PHYSICAL DIAGNOSIS. aneurism, to the solidity of its contents, or to the na- ture of its orifice. These sounds resemble those of the heart, and are similarly called systolic and diastolic ; they may be either equal to, or weaker, or louder than, those of the heart ; the systolic may exist alone ; either or both sounds may be replaced by a murmur — for in- stance, there may be a systolic murmur only, or you may have both a systoUc and a diastolic sound. The character of the murmur varies. It is usually short, abrupt, of low pitch, and as loud or louder than the loudest heart murmur. It may be rasping, sawing, filing, etc. The diastohc murmur is rarer than the sys- tolic, and is usually of a softer quality. Where the aneurism compresses a large bronchus, the respiratory murmur over the whole or a part of one side will be weak or suppressed ; on the opposite side it wiU be ex- aggerated. There is also loss of vocal resonance over the aneurism, and over the lung whose bronchus is obstructed. Where the lung is condensed from pres- sure, the breathing will be bronchial ; where there is pressure over the trachea or bronchi, the breathing may be stridulous, and be rightly referred to a lower point of production than the larynx. Where there is irritation of the recurrent laryngeal nerve, this type of breathing may come from spasm of the glottis. Differential Diagnosis.— You will find that the prin- cipal difficulties in diagnosis are between aneurisms and intra-thoracic tumors. The latter are rare. They rarely pulsate, or, if they should, they will communicate to the hand a mere hft- ing pulsation ; in some instances malignant tumors have, however, a true expansive impulse. Again, in- tra-thoracic tumors are not usually developed entirely in the track of the aorta. Their area of dulness is large, EPIGASTRIC PULSATION. 125 and the resistance communicated to the finger on per- cussion is usually great. As a rule, there are no sounds or murmurs connected with them, though in some cases where a tumor is placed over the aorta a murmur may occur. Tumors are more apt to produce persistent swelling and oedema of the upper extremities, neck, and face. In a case of aneurism, this latter sign may develop, and then disappear owing to a change in the direction of the pressure. Tubercular consolidation of one apex, if associated with a murmur in the sub- clavian or pulmonary artery, might be mistaken for an aneurism. In the former we have the physical signs of tuberculosis. The murmur is heard in the course of the pulmonary or sub-clavian artery. The dulness is not circumscribed, and extends outward, and not across the median line. Pulsatile Empyema, it seems to me, could hardly be mistaken for aneurism, although such instances are on record, for it does not occupy the position of an aneu- rism. Then you have the physical signs of effusion into the pleural sac, and it is attended by no sounds or murmurs. Aneurism of the Artbria Innominata is distin- guished from aneurism of the thoracic aorta by the fact that the tumor appears early on the right of the sternum. As it increases, it pushes forward the inner part of the clavicle, or extends upward into the neck. Its pulsation is diminished or suspended by pressure on the carotid or sub-clavian artery, while an aneurism of the aorta will not be affected by such pressure. Epigastric Pulsation may be produced by an aneu- rism of the abdominal aorta involving the coeliac axis, by tumors seated on the abdominal aorta, by displace- ment of the heart to the right, by regurgitation of blood 126 PHYSICAL DIAGNOSIS. into the hepatic veins consequent upon dilatation of the right side of the heart, and by pulsation of the ab- dominal aorta. Not infrequently the impulse of the apex beat, the heart being normal and in its normal position, is com- municated to the epigastrium, and is mistaken for epi- gastric pulsation of a dilated heart. The right ventricle, in such cases, wiU usually be found lower than its normal position, and may even beat against the xiphoid cartilage. SuB-CLAviAN Murmurs. — Not infrequently just below the clavicles, especially on the left side, a systohc mur- mur is heard directly over or along the course of the sub-clavian artery. These murmurs resemble those produced by pressure on arteries. It is reasonable, therefore, to infer that they are produced in the same way — the exact anatomical condition, however, which causes them is stiU unsettled. Adhesions at the apex of the lung have been suggested, also pressure from pul- monary consohdation at the apex. One thing is cer- tain, that they are more frequently met with in those persons who are tubercular than in others. They are often most intense during expiration. I have known the presence of a sub-clavian murmur to be taken as an evidence of aneurism. Veins. — A state of permanent turgescence or disten- tion of the jugular veins, as weU as of the superficial veins of the upper part of the chest and neck, with or without pulsation, is frequently met with in the ad- vanced stage of many forms of cardiac disease, in tho- racic aneurism, and in any change in the thoracic organs which causes obstruction to the free passage of blood through the right side of the heart. Permanent turgescence of the jugular veins is usually VENOUS MURMURS. 137 due to the distention of the right auricle ; any obstruc- tion, however, to the superior vena cava or innominata, such as compression, thrombosis, or stricture, will have the same effect. If the turgescence is temporary, a full inspiration will empty and collapse the distended veins, while a full expiration will increase their distention. On the other hand, if the turgescence is permanent, the condition of the veins is not affected by the respiratory acts. Venous Pulsations may be presystolic or systolic. They are most marked in the jugular veins immediately above the clavicles. Presystolic jugular pulsations are due to the contrac- tions of the right auricle, but they can seldom be appre- ciated except when the intra-thoracic veins are distended. Sometimes in a perfectly healthy person, when in a recumbent position, presystolic pulsation in the jugular veins can be seen. Systolic jugular pulsation occurs with the systole of the ventricles and indicates regurgitation into the right auricle with the ventricular systole. Friedreich states that sudden collapse of the jugular veins occurs in some cases of pericardial adhesions. Pulsations in the carotid arteries often communicate systolic pulsations to the jugulars. Venous Murmurs. — In auscultating the veins of the neck, besides the venous hum already referred to in Lesson ^11., presystolic, systolic, and diastolic murmurs are sometimes heard over the jugulars. Presystolic venous murmurs are only heard when the patient is in the recumbent posture, and are due to the passage of blood backward through the mouth of the internal jugular. Systolic venous murmurs are sometimes heard just 138 PHYSICAL DIAGNOSIS. above the clavicles, especially on the right side, in cases of tricuspid regurgitation. Diastolic venous murmurs are only occasionally heard, and require for their production cardiac hypertrophy and dilatation with aneurism. ABDOMEK LESSOI^ XIY. INTRODUCTION — TOPOGRAPHY OF THE ABDOMEN — CON- TENTS OP THE VARIOUS REGIONS — ABDOMINAL INSPECTION, PALPATION, PERCUSSION, AND AUSCULTATION — DISEASED CON- DITIONS OF THE PERITONEUM. There are difficulties in the physical exploration of the abdomen which are not met with in. similar exami- nations of the thorax. First. Thoracic diseases involve in their diagnosis the examination of only one or two organs, or their cov- erings, while an abdominal affection may require for its diagnosis the examination of ten or twelve organs. Thus a tumor in the left side may be either an enlarged mesenteric gland, or it may be connected with the stom- ach, spleen, kidneys, ovaries, or uterus ; or it may be a hernia, an abscess, an hydatid cyst, an aneurism, or, lastly, only a lump of faeces. Second. The action of the thoracic organs is regular and rhythmical, and their contents unvarying, while the action of the abdominal viscera is often irregular and in- termittent. An abdominal organ may also at one time be greatly distended and soon after be empty ; when filled, its contents may be solid, liquid, or gaseous, or aU these together. The lungs and heart contain respec- tively the same quantities of air and blood during every five minutes of ordinary life, but the stomach and blad- der can never remain long in one condition, either fuU or empty. 133 PHYSICAL DIAGNOSIS. Third. The abdominal organs are packed loosely in a cavity with loose walls. They therefore can be increased or decreased in size, so as to alter wholly their relations to their fellow-organs. Thus the uterus, usually the smallest, will, in fulfilling its natural function, become much the largest of all, crowding even the thoracic organs. In disease, a single ovary may swell into a sac which will fill entirely the abdominal cavity. These constitute the chief difficulties in the physical exami- nation of the abdomen, and they must always throw a certain degree of doubt upon all physical diagnoses di- rected to this part of the body. To facihtate our examinations, and to render our in- ferences more certain, it is well to divide the abdomen into regions by passing imaginary planes through the body. The divisions which have been proposed by different observers vary somewhat. The following, proposed by Dr. Bright, wiU, I think, be found most useful : The abdomen may be divided into three general zones — ^the epigastric, the umbilical, and the hypogastric. The Epigastric zone is bounded above by the dia- phragm, and below by a horizontal plane passing through the anterior extremities of the tenth rib on either side; carried backward, this plane wiU pass between the bodies of the first and second lumbar vertebrae. In a well- formed chest the cartilage of the tenth rib on either side offers a projection at its lower convex border, which can be felt without difficulty. This zone is subdivided into the epigastric and the right and left hypochon- driac regions, which correspond to the spaces bounded by the false ribs. The Umbilical zone is bounded above by the lower boundary of the epigastric, and below by a liorizontal THE HYPOGASTRIC ZONE. 133 plane passing through the anterior and superior spinous processes of the iUa ; this plane, if carried backward, will pass between the second and third sacral spines. The Hypogastric zone is bounded above by the lower boundary of the umbilical zone, below, in the centre, by the upper margin of the pubes, on either side by Poupart's ligament. This zone occupies the whole cavity Fis. 17.— Diagram showing the different Regions of the Abdomen, and the Organs contained in each, which are visible on the remoral of the Abdominal Walls. of the true pelvis. The umbilical and hypogastric zones have each three subdivisions, made by two vertical planes passing backward through the spinous processes of the pubes and the points on the tenth ribs already aUuded to. The subdivisions of the umbilical zone thus pro- duced are termed the central or umbilical, and two lateral, or the right and left lumbar. The subdivisions 134 PHYSICAL DIAGNOSIS. of the hypogastric thus produced consist of the middle or pubic, and the lateral or right and left iliac. The organs contained in these regions in health are as follows : The Epigastric region contains the -whole of the left and a part of the right lobe of the liver, the gaU. bladder, the pyloric orifice of the stomach, the commencement of the duodenum, a portion of the colon, the pancreas, the abdominal aorta, and the coeliac axis. It is very neces- sary to understand the relative positions of these organs. The Eight Hypochondriac region contains nearly the whole of tlie right lobe of the liver, the angle of the as- cending and a portion of the transverse colon, the greater part of the duodenum, the renal capsule, and the upper portion of the right kidney. The Left Hypochondriac region contains the rounded cardiac portion of the stomach, at all times, and a very large portion of the organ when distended, the left angle of the colon, the spleen, and a small portion of the left kidney with its renal capsule. The Umbilical region is chiefly occupied by a portion of the transverse colon, the omentum, and the small intestines. It contains, likewise, the mesentery and its glands, the aorta, and the inferior vena cava. The Eight Lumbar region contains the ceecum, the ascending colon, the lower and middle portions of the kidney, and a portion of the ureter. The Left Lumbar region is occupied by the descend- ing colon, the left kidney, and the ureter. A portion of the small intestine also occupies the lumbar region on each side. The Pubio or Hypogastric region, in children, con- tains the urinary bladder, with portions of the ureters (if they be distended, also in adults), the convolutions of PHYSICAL EXAMINATION OF THE ABDOMEN. 135 the small intestine, and, in the female, the uterus and its appendages. The Eight Iuac region contains the "cul-de-sac" of the caput coh, the vermiform process, and the ihac vessels. The Left Iliac region contains the sigmoid flexure of the colon and the iliac vessels of that side. Methods Employed in the Physical Examinations of the Abdomen. They are the same, with, the exception of succussion, as those practised in exploration of the thorax, but they differ in their relative importance. In thoracic exami- nations, auscultation is the most important method, while in abdominal examinations auscultation is only employed in determining the existence of aneurisms and of pregnancy. Percussion and palpation are the means by which we gain the most useful information concern- ing the contents of the abdominal cavity. Before considering the signs which indicate the changes occurring in the different affections of the abdominal organs, I will briefly notice the different methods of exploration. Inspection. — By it we note alterations in the shape and movements of the abdomen. It is most satisfacto- rily performed with the patient lying on the back and the thighs sHghtly flexed. In health, the abdomen is of an oval form, marked by elevations and depressions cor- responding to the abdominal muscles, the umbilicus, and in some degree by the form of the subjacent viscera ; it is larger, relatively to the size of the chest, in children than in adults ; more rotund, and broader inf eriorly, in females than in males. Alterations in its shape due to disease are, first, en- 136 PHYSICAL DIAGNOSIS. largement, which may be general and symmetrical, as in ascites ; or partial and irregular, from tumors, hyper- trophy of organs, as the liver and spleen, or from tym- panitic distention of portions of the intestines by gas, as of the colon in typhoid fever ; second, retraction, as in extreme emaciation, and in several forms of cerebral disease ; especially is this noticeable in the tubercular meningitis of children. The respiratory movements of the abdominal walls bear a certain relation to the movements of the thorax. They are often increased when the latter are arrested, and vice versa. Thus, abdominal movements are in- creased in pleurisy, pneumonia, pericarditis, etc.; but decreased, or wholly suspended, when disease causes abdominal pain, or in peritonitis. Not infrequently, when inspecting the abdomen, a dis- tinct pulsation will be visible in the epigastric region, which frequently is mistaken for aneurism. The super- ficial abdominal veins are also at times visibly enlarged, indicating an obstruction to the current of blood either in the portal system, as in cirrhosis, or in the inferior vena cava. Mensuration is mainly useful in determining the ex- act increase or decrease of abdominal dropsies, visceral enlargements, and tumors. It is performed by means of a graduated tape. Palpation.— This method of exploration often fur- nishes important information. It may be performed with the tips of the fingers, with the whole handj or with both hands, and the pressure may be sUght or for- cible, continuous or intermitting. In order to obtain the greatest amount of information by palpation, the patient should be placed in a horizontal position, with the head shghtly raised and the thighs flexed; some- PHYSICAL EXAMINATION OF THE ABDOMEN. 137 times it is necessary to place him in a standing position or leaning forward. Indications furnished by Palpation. — By it we can determine the size and position of the viscera, the exist- ence of tumors and swellings, whether they are super- ficial or deep, large or small, hard or soft, smooth or nodulated, movable or fixed, solid' or liquid, and whether or not they possess a motion of their own. We can also ascertain if tenderness exist in any portion of the ab- dominal cavity, and if pain is increased or reUeved by firm pressure. Peecussiox. — In the performance of abdominal per- cussion, the patient should be placed in the same posi- tion as for palpation, and the percussion should be for the most part mediate. In exploring the abdomen by means of percussion, the pleximeter (the finger being the best) should first be placed immediately below the xiphoid cartilage, pressed firmly down and carried along the median line toward the pubes, striking it aU the way, now forcibly, now gently. The different tones which the stomach, colon, and small intestine furnish wiU be distinctly heard. The percussion should then be made laterally, alternately to one side and then to the other, until the whole surface is percussed (Bennet). In this manner the different percussion sounds of the sto- mach, large intestine, small intestine, and the soUd vis- cera will be readily distinguished. Thus, the percussion sound elicited over a healthy abdomen may be dull, flat, or tympanitic. Over the central portion of the liver, spleen, and kidneys the percussion sound is flat; over that portion of either of these organs where they overlap the intestines or stomach it is dull, with a tympanitic quaUty. Over the stomach and intestines it is tympa- nitic, more so over the former than the latter. When 138 PHYSICAL DIAGNOSIS. liquid occupies the abdominal cavity, over the hquid the percussion sound will be flat. A distended bladder or uterus, an enlarged liver, spleen, kidney, or mesenteric gland, ovarian, aneurismal, and other tumors, are recog- nized and their limits determined by the unnatural and increased area of the percussion flatness ; while, on the other hand, gaseous distention of the stomach or intes- tines is recognized by the increased area of tympanitic percussion. Auscultation. — For the physical exploration of the abdomen, auscultation is only of service, as we have said before, in the diagnosis of aneurisms, in detecting the foetal heart sounds and the utero-placental murmur in the pregnant state. Our examinations of the abdominal viscera are some- times interfered with and rendered uncertain by changes that occur in the abdomiaal walls. Generally the ab- dominal walls are sufficiently thin, soft, and movable for us to determine with considerable accuracy the situation and condition of the contained organs ; if, however, everything is masked by layer upon layer of fat, as in some cases of obesity, abdominal examinations will be unsatisfactory. An (edematous condition of the abdomi- nal walls, as in Bright's disease, may also prevent us from ascertaining the condition of the viscera. When this occurs, the surface of the abdomen presents a smooth, even, shiny, waxy appearance, and pits on firm pressure. Superficial abscess of the abdominal waUs also occurs occasionally, and interferes greatly with the exploration of the abdominal cavity. You can recog- nize this by the circumscribed bulging, by tenderness on slight pressure, by the redness of the surface, and by the characteristic fluctuation of a superficial abscess. The abdominal muscles are sometimes abnormally de- ASCITES. 139 veloped, or unnaturally rigid as in tetanus, rheumatic inflammation, and in the early stage of peritonitis, and this somewhat interferes with our examinations. Diseased Conditions of the Peritoneum. Under this head may be included the various results of inflammatory action, ascites, etc. They ah. give rise to more or less abdominal enlargement. Acute Peritonitis. — By inspection we recognize in acute peritonitis either a diminution or an entire suspen- sion of abdominal respiration, the breathing becoming entirely thoracic. The abdomen enlarges, becomes un- naturally tympanitic, and there is marked tenderness on firm pressure. The comparative results of firm and slight pressure is one of the strong diagnostic marks of peritoneal inflammation. Chronic Peritonitis is almost always connected with tubercular or cancerous deposits in the substance and over the free surface of the peritoneum ; and in addition to the tympanitic distention of the abdomen, and the tenderness on firm pressure, noticed in acute peritonitis, liquid accumulations take place in the peritoneal cavity. Ascites. — A collection of liquid from any cause in the peritoneal cavity is termed ascites. Inspection. — The abdomen is always, uniformly en- larged, and the movements of the abdomen in respi- ration are either suspended or limited to the epigastric region. The superficial abdominal veins, if the ascites depend upon disease of the liver, will often be found enlarged. Palpation.— U. the palmar surface of the hand be ap- plied to the side of the abdomen at the level of the liquid, and light percussion be performed on the oppo- 140 PHYSICAL DIAGNOSIS site side, a sense of fluctuation will be communicated to the hand. Percussion gives flatness at the lower and most de- pending portion of the abdomen, while at the upper por- tion, above the level of the liquid, there is a drum-hke, tympanitic resonance. When the patient is in the erect posture, the tympanitic resonance is conflned to the epi- gastrium, and upper portion of the umbihcal region. If in a recumbent posture, the tympanitic resonance wiH extend into the hypogastrium ; if placed on either side, the lumbar region of the opposite side becomes tym- panitic. Other diseases that occur in the peritoneum consist of enlargements, and may be classed under the head of ab- dominal tumors. LESSOI^ XT. PHYSICAL SIGNS OF THE ABNORMAL CHANGES IN THE DIFFERENT ABDOMINAL ORGANS— STOMACH — INTESTINES — LIVER — SPLEEN. Stomach. When this viscus is empty, or not distended, with gas or food, there is on inspection no visible prominence to indicate its position, nor does palpation furnish us any information as to its condition. Percussion gives a metallic or tympanitic resonance which enables us to distinguish it from the surrounding viscera. The Hne of dulness which marks the lower border of the liver and the inner border of the spleen determines the upper and lateral boundaries of the stomach. To ascertain the lower border, percuss gently downward from this hne of dulness, until a slight change in the percussion sound indicates that you have reached the transverse colon (see Fig. IT, page 133). Opposite the inner border of the seventh rib, on the left side, the cardiac orifice of the organ is situated. At a point a little below the lower border of the liver, within a hne drawn from the right nipple to the umbihcus, the pyloric orifice of the organ is situated. The lower mar- gin of the great " cul-de-sac " is found, generally, near the umbihcus. Diminution in the size of the stomach cannot be rec- ognized by physical exploration. An increase in size or distention of the stomach may occur from an accumu- 143 PHYSICAL DIAGNOSIS. lation of gas, from large quantities of liquids or solids taken into the stomach ; or it may be enlarged within circumscribed spaces from cancerous deposit in its walls. Gaseous or Tympanitic distention of the stomach is recognized by an increase in the area of the characteris- tic tympanitic resonance of the organ. A distended con- dition of the stomach from food or drink is recognized by an absence of the normal resonance, and by a contin- uation of the dull percussion of the liver and spleen downward to the umbilicus. A moderate amount of Hquid or sohd in the stomach can be determined by a hmited area of dulness corresponding to the " cul-de-sac " of the organ. Cancer op the Stomach most frequently has its seat at the pyloric extremity of the organ ; but in whatever portion of the organ it may be developed, it can be rec- ognized by circumscribed dulness on percussion, where in health, when the stomach is empty, we should have tympanitic resonance. The percussion dulness elicited over the cancerous mass, however, has a hoUow charac- ter which is readily distinguished from the flat percussion sound of a sohd organ. By palpation a nodulated mass is readily detected, cor- responding to the area of percussion dulness, which is movable, easily grasped, and readily separated from the surrounding viscera. These signs, taken in connection with the attendant symptoms, are almost always suffi- cient for a positive diagnosis. Intestines. In a normal condition the large intestine furnishes a more amphoric percussion sound than the stomach. When, however, it is filled with hquid or sohd accumula- tions, the situation of these accumulations can be marked out on the surface by the dulness on percussion. INTESTINES. 143 The peculiar feel of such enlargements wiU generally enable you to decide as to their true character : they feel like no other tumors. On examining them through the abdominal walls, they are felt to be hard and resist- ant ; but if one finger be pressed steadily upon them for one or two minutes, they wiU at last indent like a hard snowball. There is not the slightest elasticity about them, and the indentation remains after the pressure is removed (Simpson). As these accumulations most fre- quently collect in the descending colon, the percussion sound over this portion is usually less resonant than over the ascending or transverse colon. According to Dr. Bennet, in a practical point of view it is often useful to determine whether a purgative by the mouth or an enema is likely to open the bowels most rapidly. If there is dulness in the left iliac fossa in the track of the descending colon, that portion of the intestine must be fuU of faeces, and an enema is indicated. If, on the other hand, the sound in the left iliac fossa is tympa- nitic, and in the right dull, an enema is of little service, as it will not extend to the ceecum, and purgatives by the mouth are indicated. Sometimes the whole colon, or the transverse portion, or, what is more common, the sigmoid flexure of the large intestine, becomes distended with faecal accumulations, giving rise to circumscribed abdominal enlargement and to flatness on percussion over that portion of the abdomen which corresponds to the situation of the intestines. Care must be taken not to confound this condition with an enlarged hver, spleen, tumors, etc. The percussion sound over the small intes- tine, unless it is distended with gas, is higher pitched and less amphoric than that of the surrounding large intestine. There are no physical signs to indicate the abnormal changes which occur in this portion of the ah- 144 PHYSICAL DIAGNOSIS. mentary canal, except an increase in the tympanitic resonance which exists when it is distended with gas. Liver. Our diagnosis in any case of hepatic disease rests mainly on the size, form, and position of the liver as de- termined by percussion and palpation. The first step, then, in studying the physical signs indicative of disease of this organ, is to become familiar with its normal boundaries. In its healthy state, the right lobe of the liver occupies the right hypochondrium, lying completely in the hollow formed by the diaphragm, rarely descend- ing below the free border of the ribs, or extending up- ward above the fifth intercostal space ; the left lobe reaches across to the left of the median line an inch or more (see Fig. 17, page 133). The upper boundary of the organ is determined by per- cussing with moderate force from the right nipple down- ward until the fiatness of the percussion sound indicates that a solid organ has been reached. Indicate this point with an aniline pencil. Then percuss downward from the axiUa, and also from a point a little to the right of the median line in front, in the same manner, until a change occurs in the percussion sound. Indicate these points on the chest wall with the penciL A line drawn through the three points marks the upper boundary of the liver. GreneraUy it will be found to correspond to the base of the ensif orm cartilage on the median line in front, to the fifth intercostal space on the line of the right nipple, to the seventh rib in the axillary region, and to the ninth rib in the dorsal region. The lower boun- daiy of the organ is determined by percussing downward from the line of flatness already determined, and noting the points where the tympanitic sounds of the stomach NORMAL. BOUNDARIES OF LIVER. 145 and large intestine occur. Usnally it will be found to correspond, anteriorly, to the free border of the ribs, and to a point three inches below the ensif orm cartilage on the median line ; laterally, in the axillary region, to the tenth intercostal space ; and posteriorly, in the dorsal region, to the twelfth rib. The flatness of the left lobe usually reaches two inches to the left of the median hne. The whole margin of the liver, except where it comes in contact with the apex of the heart through the medium of the diaphragm, may thus be determined and marked out on the surface. The vertical measurements will be found very nearly as follows : On the right of the me- dian line in front, three inches ; on a line with the right nipple, four inches ; in the axillary region, four and one-half inches ; and in the dorsal region, four inches. The smooth edge of the lower margin of the liver in health, especially in thin subjects, can be dis- tinctly felt behind the free border of the ribs. The healthy liver in its normal position influences very little the percussion sound over the soft portion of the abdomen. As already stated, the soimd is tympanitic from the free borders of the ribs to the pubes when the abdominal organs are normal and empty. If, therefore, the percussion sound is flat, and the flatness is uninter- rupted upward to the margin of the ribs on the right side, we have good reason for believing that the liver is the organ diseased. The gall bladder is found where the lower border of . the liver passes under the ribs on the right side, at the tip of the ninth rib. The normal boundaries of the liver, already defined, may be greatly altered without any abnormal change occurring in the organ itself. These normal changes, un- less remembered, may lead to errors in diagnosis. Thus, 10 146 PHYSICAL DIAGNOSIS. congenital malformations may give rise to an increase in the area of hepatic dulness. An accurate history of the patient, however, will keep ns from error in such cases. In the examination of children, also, it should be remembered that the liver is proportionately larger than in adults. The practice of tight lacing may cause displacement Fio 18.— The Tolume of the Liver in Various Diseases. 5-10, Bibs. I, Position of the diaphragm in the highest degree of tumefaction of the liver (carcinoma) . II, n, Nor- mal position of the diaphragm, n. III, Relative dulness. Id, Position of the dia- phragm at the anterior wall of the chest, at the same time the line of dulness of the normal liver. IV, Edge of liver in cirrhosis. V, In the normal liver. VI, Fatty liver. Vn, Amyloid liver. VIII, Cancer, leukeemia, adenoma. All of proportional size.— After BniDi'LEisca. and malformation of the liver, and thus give rise to ap- parent hepatic enlargement. The marks which this practice leaves on the chest walls wiU be sufficient to at- tract our attention and so prevent mistake. Diseases of the thoracic organs and abnormal condi- tions of the other abdominal viscera sometimes cause WAXY LIVER. 147 displacement of the liver, simulating very closely hepat- ic enlargement : these we will consider under the head of differential diagnosis of diseases of the liver. VARIATIONS IN THE SIZE OP THE LIVER IN HEPATIC DISEASES. Variations in the size of the liver occur in almost every disease to which it is subject. It is increased in size in fatty liver, in waxy liver, in abscess of liver, in congestion, in acute hepatitis, in 06- strutition of the bile ducts, in cancer, in hydatid cyst and other tumors. It is diminished in size in atrophic cirrhosis and in acute yellow atrophy. Enlargements of the liver were divided by Dr. Bright into smooth and irregular. Dr. Murchison has divided them into painless and painful enlargements. Both of these divisions, it seems to me, have their objections, and in giving the physical signs of the various diseases accompanied by enlargement of the organ, it is hardly practicable to adopt either of them exclusively. Fatty Liver. — In fatty infiltration of the liver the organ is uniformly enlarged, there are no circumscribed bulgings, its normal shape is unaltered, there is no ex- pansion of the lower ribs, it never gives rise to ascites, and it is not attended by any visible enlargement of the superficial veins. On palpation a soft, cushion-hke en- largement is readily detected below the margin of the ribs on the right side, and in the epigastrium, extending not infrequently as low as the umbihcus ; its outer sur- face is smooth, and its lower margin is rounded and not weU defined ; it is never tender on pressure. On percus- sion there is flatness over the surface of the abdomen corresponding to the enlargement. Waxy Liver. — In waxy or amyloid degeneration, the organ undergoes greater enlargement than in fatty in- 148 PHYSICAL DIAGNOSIS. filtration ; it often becomes so large as to fill the whole abdominal cavity ; its growth is slow, usually extending over a period of two or three years. The enlargement is uniform, and the area of hepatic dulness is conse- quently increased on percussion in every direction — more, however, in front than behind. There is often a visible tumor below the margin of the ribs, but there is no bulging of the ribs themselves. On palpation that portion of the organ below the ribs is dense, firm, and resistant ; the outer surface is smooth ; the lower mar- gin is at times sharp and well defined, at other times rounded and blunt. Pain and tenderness are rarely present, so that the portion of the organ below the ribs, as in fatty infiltration, can be manipulated without giv- ing the patient any inconvenience. When excessive, it is almost always accompanied by ascites. Abscess of the Liver. — An abscess may occur in any part of the liver. It depends entirely upon its situation whether an external tumor is produced or not. If the abscess occupies the posterior portion of the right lobe, the hver is pushed down so that its margin is perceptible below the free border of the ribs, and the flatness on the right side, posteriorly, extends higher than normal. If the abscess is superficial and is pointing externally, a distinct tumor is felt, and there is always more or less bulging of the ribs if the right lobe is affected. Some- times the organ is enormously enlarged, its free border extending below the umbiUcus ; the surface of the en- largement is smooth, and it is usually tender on pres- sure. The sensation to the examiner on making light pressure wiU be soft and fluctuating, or that of elastic tenseness. In some rare instances abscesses produce an uneven or lobulated condition of the surface • under guch circumstances they may be mistaken for cancer, unless the rational symptoms and history of the case be CANCER OF THE LIVER. 149 included in the elements of diagnosis. The enlargement goes on rapidly. With a correct history of the case, the diagnosis is easily made. Congestion of the Liver. — The most simple form of hepatic enlargement is that which results from con- gestion. When the hver is thus loaded with blood, a slight fuhiess is perceptible on the right side. On pal- pation the space immediately below the ribs is occu- pied by a smooth, hard, resisting enlargement corre- sponding to the natural shape of the liver. Usually it is not tender on pressure. There is no weU-defined tumor. On percussion a flat sound is elicited an inch or two below the margin of the ribs, on the right side. Obstruction of the Bile Ducts wiU produce an en- largement of the hver, similar to the one just noticed, by preventing the outflow of bile. Sometimes, in addition to the general enlargement detected by the slight uni- form increase in the area of hepatic dulness, a globu- lar projection is found at a point corresponding to the transverse fissure. It has the elastic feel of deep- seated fluid. This tumor is the distended gaU bladder. Acute Hepatitis. — The physical signs of acute hepa- titis do not differ materially from those of simple con- gestion, except in the excessive tenderness that exists on pressure over that portion of the organ which de- scends below the ribs. Cancer op the Liver. — In most cases of cancer the diagnosis is easily made. On Percussion the area of the hepatic dulness is al- ways increased, sometimes extremely so. The organ is found to occupy the greater portion of the epigastrium, extending beyond the median Hne into the left hypo- chondrium, pushing the diaphragm upward, and often descending below the ribs to the crest of the ilium. 150 PHYSICAL DIAGNOSIS. On Palpation irregular nodules of various sizes are distinctly felt through the abdominal walls, projecting from that portion of the enlarged organ which is below the free border of the ribs. These prominences are usually harder than the surrounding hepatic tissue, and there is more or less tenderness on pressure over them. Cancer of the liver may, or may not, be accompanied by ascites. Occasionally the surface of the liver in cancer is per- fectly smooth, and in such cases you will be unable to detect the disease by the physical signs. Hydatid Tumors of the Liver. — Hydatid cysts, when small or deep-seated, cannot be detected by physical examination; but, when large or superficially seated, they are recognized by abnormal increase in the area of hepatic dulness, and by the globular form of the enlargement on the surface of the organ. Sometimes these cysts are so large as to cause the organ to flU a large portion of the abdominal, and encroach on the right pleural, cavity. The natural form of the organ is greatly altered, the enlargement taking place more in one direction than in another. Sometimes percussion over a large hydatid cyst wiU give rise to a characteristic vibration known as hydatid fremitus. This vibration is produced by the impulse of the smaller cysts that are contained in a large one. A hydatid hver encroaching on the thoracic cavity gives rise to flatness on percus- sion, and absence of respiratory sound, from the base of the chest upward as far as the tumor extends : the upper boundary of the flatness is arched. It is distin- guished from pleuritic effusion in that a change in the position of the body does not change the hne of percus- sion dulness. On palpation, sometimes the enlarged portion below the ribs has an elastic or even fluctuating CIRRHOSIS OF THE LIVER. 151 feel, and if a large cyst be near the surface it may give rise to a sense of fluctuation. The surface over these enlargements is smooth, the organ is not tender on pres- sure, and its growth is slow. DECREASE IN THE SIZE OF THE LIVER. The hver is diminished in size in atrophic cirrhosis and in acute yellow atrophy. Cirrhosis of the Liver.— In fully developed cases of atrophic cirrhosis of the liver, the organ is always di- minished in size, and there is more or less abdominal dropsy. The only evidence of this disease furnished by inspection is a visible enlargement of the superficial veins. Percussion. — The normal area of the hepatic dulness is diminished. Its limits are determined as foUows : if the abdominal cavity is distended with dropsical accu- mulations, the patient should be placed partly on the left side, so that the hquid will gravitate from the hepatic region ; the percussion dulness then, instead of extend- ing to the free border of the ribs, wiU often give place to tympanitic resonance an inch or more above their free margin, and instead, also, of extending across the me- dian line into the left hypochondrium, will rarely reach that Une; while the vertical measurement of hepatic dulness on a line with the right nipple often does not exceed two and a half inches. Palpation. — Little nodules will often be felt on the under surface of the liver, by making firm pressure with the ends of the fingers under the free border of the ribs. Sometimes, when the distention of the abdomen from dropsical accumulation has been very great, we can get no information by palpation until after the performance of paracentesis. 152 PHYSICAL DIAGNOSIS. Atrophy of the Liver. — The only physical sign of atrophy of the liver is the rapid diminution in size, de- termined by percussion. Its surface remains smooth. The diminution in size is never accompanied by ascites. DIFFERENTIAL DIAGNOSIS OF DISEASES OF THE LIVER. Conditions which may lead to the erroneous diagnosis that the liver is diseased are faecal accumulations in the ascending and transverse colon, enlargement of the right kidney, diseases of the stomach, displacement of the liver by disease in the right side of the chest, enlarge- ment of the spleen, tumors of the omentum, and ovarian tumors. F^CAL Accumulations. — To distinguish these accu- mulations from enlargement of the hver, by physical examination, is always difficult and sometimes impossi- ble. They give rise to a distinct tumor, below the border of the ribs, which by percussion and palpation seems to be continuous and connected with the Hver. The feel of these faecal enlargements, already referred to, is charac- teristic. The differential diagnosis sometimes, however, can only be made after the trial of remedies which, acting freely on the bowels, remove the accumulations and cause the disappearance of the supposed hepatic enlargement. Disease of the Eight Kidney. — The right kidney sometimes enlarges in such a manner as to present itself as a tumor extending from the under surface of the right lobe of the hver. It may be distinguished from an hepatic tumor by carefully examining its relation to the ribs. As the patient lies on his back, the enlargement, instead of passing up under the ribs, dips down, so as to aUow the finger to pass vertically between the ribs and the tumor. Furthermore, the position of an enlarged kidney is not altered by a deep inspiration. DISEASES OP THE LIVEE. 153 1^ Hi I W Eh b O DO < 03 1^ o as O O .2 „-;:^ s u gS-.-go ■gS'=||.S§ ■--^ E>,'^ rt O ^ - ^ ii 2 * CO o .SO. faO<1 U CO CC >^ • 3 " is >. 2 SI'S u „ _, S «fl I u r .£ s « g 10.2 S -■=£«■£ ■g ^ .3 = 'a M >.'3 ,gg«s«.sas OgH ,a) 6 oS o " i^aS'u .aoSftSf.ag.'^.oa ■Oh ° o,t.a S:SM'B H OgUHMi- « u.£o ..SosS li^l'^l.li-a t2 ■<1 <1 03 fe t, aj3 «jT3 EO g^ oa-o k-d CO V -<3 t> m o 2 cc «t; ci 9r— o JO'S a rt-d ft Tt d & ^ 5 ^ ? ^ 1-H 1 a a H a =1 A iz; 154 PHYSICAL DIAGNOSIS. Diseases of the Stomach. — The only disease of the stomach which we are Ukely to confound with enlarge- ment of the liver is cancer, Usually, however, it can be readily distinguished from hepatic enlargement by the tympanitic quahty of the percussion sound over the cancerous mass, and by the mobility of the mass. Displacements op the Liver downward from ex- tensive pleuritic effusion, and from pneumothorax, are recognized by the presence of the physical signs which indicate these thoracic diseases. Enlargement op the Spleen and Ovarian Tumors are distinguished from enlargements of the liver by the shape of the tumor, and by the continuous and increas- ing flatness of the percussion sound as we pass toward the normal position of these organs. Spleen. The obscurity which surrounds the normal physiologi- cal action of the spleen is so great that its affections usu- ally give rise to but negative general symptoms ; and be- cause of its relation to the surrounding organs, it often presents greater difficulties in the diagnosis of its mor- bid conditions than is the case with any other abdominal organ. In health this organ occupies the upper portion of the left hypochondriac region, its lower border touches the left kidney, while its convex surface occupies the concavity of the diaphragm. It is bounded posteriorly above by the lower border of the ninth rib ; anteriorly by the stomach and left colon ; and inf eriorly by the free margins of the ribs. It is about four inches long and three wide. In its healthy condition, inspection and palpation furnish only negative results. Percussion. — To determine the boundaries of the spleen by percussion, it is necessary that the patient SPLEEN. 155 should lie on the right side. Its anterior border is readily determined because of its relation to the stomach and intestine. Inferiorly, where the organ comes in contact with the kidney, it is difficult and often impos- sible to determine its boundary. Its superior border corresponds to the hne which marks the change from dulness to pulmonary resonance. In disease the spleen may be increased or diminished Fio. 19.— Diagram representing the different Areas occupied by the Spleen in its Tarious Enlargements into the Abdominal Cavity.— Bright. in size ; but we are rarely, if ever, able to recognize dimi- nution in its size during Uf e. In most cases of splenic disease there is neither pain nor tenderness. The only reliable physical signs are those of enlargement. The tumor produced can scarcely be overlooked. Its charac- teristics are a smooth, oblong, sohd mass, felt immedi- ately beneath the integuments, extending from under the ribs on the left side, a little behind the origin of the 156 PHYSICAL DIAGNOSIS. cartilages ; often advancing to the median line in one direction, and descending to the crest of the ilium in the other, filling the left lumbar region at its upper part. This tumor is usually movable, rounded at its upper por- tion, and presenting an edge more or less sharp in front, where it is often notched and fissured. The principal tumors which may be mistaken for an enlarged spleen are, chronic abscess of the integuments, cancer of the stomach, enlargement of the left lobe of the liver, cancer of the omentum, faecal accumulation in the colon, disease of the left kidney, and ovarian disease. Chronic Abscess in the Abdominal Wall sometimes occurs precisely in the situation of an enlarged spleen, but it is easily distinguished from it by the superficial character of the swelling, and by its being too soft to belong to an internal viscus. Cancerous Deposit in the cardiac extremity of the stomach sometimes gives rise to a tumor, which, descend- ing from the margin of the ribs, might be mistaken for an enlarged spleen. One of the best distinctive marks wiU be found in the sound elicited by forcible percus- sion : it has more or less of a tympanitic resonance, while the tumor is harder to the feel than an enlarged spleen. Enlarged Left Lobe of the Liver is easily distin- guished from enlarged spleen ; for the margin of the tumor can be traced running toward the right, and not toward the left as is the case with enlarged spleen. Cancerous and Tubercular Enlargements of the omentum are distinguished from an enlarged spleen by the fact that they extend across the abdomen, and can- not be traced backward ; they do not ascend behind the ribs, and are rough, hard, and uneven. SPLEEN. 157 F^OAL Accumulation in the intestine is a source of very ^reat difficulty in this diagnosis, for when it takes place in the descending colon, at the sigmoid flexure, the enlargement assumes very nearly the situation of an en- larged spleen, and is scarcely to be distinguished from it except by its peculiar feel, by its history, and by the results of cathartics ; nor must we conclude that the intestines have been emptied, without the most persever- ing employment of purgatives and enemata. The Left Kidney sometimes enlarges toward the left hypochondrium, and presents a tumor very nearly in the situation of an enlarged spleen ; but by tracing it back toward the loins, we shaU find that its chief bulk is situ- ated posteriorly. It is much more fixed ; is not forced downward by a full inspiration ; and if the patient is placed on his hands and knees, it does not fall forward. In enlargements of the kidney, the intestine is always pushed forward ; this is never the case with the spleen. By observing the -rules for the diagnosis of ovarian tumors, we shaU easily distinguish them from enlarged spleen (Bright). LESSOIsT XYI. PHYSICAL SIGNS OF THE ABNORMAL CHANGES IN THE DIFFERENT ABDOMINAL ORGANS — CONTINUED. Kidneys, Bladder, Uterus, Ovaries, Aneurisms, Omentum, Mesentery. Kidneys. The kidneys in health are situated in the lumbar re- gions, as shown in Fig. 2, in the space corresponding to the two lower dorsal and the two upper lumbar vertebrae. The right is a Httle lower than the left. Superficially, they extend from the eleventh rib to the crest of the ihum. The right is bounded above, by the posterior and inferior portion of the right lobe of the liver ; below, by the caecum ; anteriorly, by the descending portion of the duodenum and the ascending colon ; and posteriorly, by the diaphragm and quadratus lumborum. The left is bounded above, by the spleen ; anteriorly, by the stom- ach and descending colon ; inf eriorly, by the descending colon ; and posteriorly, by the diaphragm and quadra- tus lumborum. In disease the kidneys may be increased or diminished in size. Diminution in the size of the kidneys can rarely be determined by physical examination, so that enlarge- ments are the only conditions to which physical ex- ploration is appUcable. The kidneys may be enlarged from pyelitis, which sometimes converts them into a sac of pus ; cancerous and tubercular deposits, hydatid cysts, and simple distention, the result of an obstructed KIDNEYS. 159 ureter. A tumor is sometimes developed at the upper border of a kidney, from disease of the suprarenal capsule. Inspection rarely furnishes any evidence of enlarge- ment of a kidney. Palpation of the kidney is to be practised as foUows : The patient is placed in the dorsal position, with the thighs flexed. One hand is placed over the seat of the kidney in the lumbar region, and firm pressure is made. The fingers of the other hand are placed below the free border of the ribs, on a line running through the middle of Poupart's ligament. With each expiration the fingers are pressed deeper and deeper until the renal tumor is reached. The part of the abdomen in which the enlarged kidney is felt will vary according to the nature of the disease and the portion of the kidney involved. Percussion. — Unless the kidney is much enlarged, the results of percussion are uncertain. In performing per- cussion, the patient should be placed on the abdomen and chest, which posture will allow hquid accumula- tions in the abdominal cavity to gravitate forward, and the intestines to float upward. The external margin of the kidney is determined when the tympanitic note of the intestine is reached. Any enlargement will be ac- companied by a corresponding increase in the area of renal dulness. We can rarely estabhsh by a physical examination the exact nature of the disease to which the increase in size is due. The sources of error in the diagnosis of enlargements of the kidneys vary, according as the right or left kidney is the seat of disease. Enlargement of the right kidney may be mistaken for a tumor of the right lobe of the liver, for cancer of the pyloric extremity of the stomach, for faecal distention of the colon, and for enlargement of the right ovary. The 160 THYSICAL DIAGNOSIS. rules for distinguishing it from each of these have been already given in the previous section, as likewise for distinguishing enlargements of the left kidney from en- largement of the spleen, the left ovary, and from faecal distention of the descending colon. Movable Kidney.— This is not properly a disease, but a structural pecuharity in certain individuals. The right kidney is more often affected than the left. The attachments of the kidney are so loose that the organ can be displaced, either vertically or laterally, to a con- siderable degree, and may so approach the anterior ab- dominal walls as to be readily felt through them. It may be found in the umbihcal region, or even across the median hue. It can be detected best by drawing up the feet to retract the abdomen, then grasping the tumor with the palm of the hand. It has a smooth, rounded feel, and differs from mesenteric tumors or faecal ac- cumulations in disappearing, on gentle pressure, into the abdominal cavity, so that it cannot be felt. When the kidney is displaced, the corresponding lumbar region gives a tympanitic sound on percussion. Bladder. When the bladder is empty, its position cannot be determined by physical exploration. It can only be de- tected when it is distended and rises above the pubes. It then appears as a tumor in the hypogastric region, which on palpation is smooth and oval. Its rounded margin is easily made out by observing the tympanitic sound of the intestines on the one hand, and the dull sound of the bladder on the other. In infants, the blad- der is not as deep in the pelvis as in adults, consequently a smaller quantity of urine in the bladder can be recog- nized. A distended bladder can only be mistaken in UTBEUS. 161 the female for a gravid uterus or a uterine tumor: the use of a catheter removes all doubts. Uterus. The unimpregnated uterus in its normal state is situ- ated in the lower part of the hypogastrium, and is inaccessible to the touch, externally, or to percussion ; but when normally enlarged by impregnation, or abnor- mally by disease, palpation, percussion, and ausculta- tion furnish us with important information. In pregnancy, at the end of the second month, a duU sound on percussion, just above the pubes, indicates the enlarging uterus ; later, as the uterus increases in vol- ume and rises into the abdomen, we are able, by the oval tumor felt in the hypogastrium, and by the circum- scribed area of dulness corresponding to the situation of the tumor, to estabhsh strong presumptive evidence of pregnancy. The presumption becomes strengthened if the area of the dulness increases with the regularity proper to gestation. But palpation and percussion are not sufficient to determine whether the enlargement of the uterus is due to pregnancy, or to some morbid deposit in its walls or cavity, as fibrous tumors, etc. After the end of the fifth month, the evidence fur- nished by both these methods is inferior to auscultation. Etjles for Perfobming Uterine Auscultation. — The female should be placed on her back, with her thighs sHghtly flexed so as to relax the abdominal muscles ; sometimes it is well to incline the body from one side to the other, or forward so as to withdraw the pressure of the uterus from the pelvic arteries. The abdomen should be uncovered, as the sounds to be examined are of shght intensity and their area is very circumscribed. Their study demands close attention and perfect silence, n 162 PHYSICAL DIAGNOSIS. The stethoscope is always to be preferred, and the ute- rine tumor should be auscultated successively at different points. After the fourth month of gestation,, if the uterus con- tains a living foetus, we may hear three distinct sounds — the Uterine Bruit, which is evidently connected with the circulation of the mother ; the Foetal Heart Sound, and the Funic Souffle, which are connected with the circulation of the foetus. Uterine Bruit.— This sound is single, intermitting, and in character is a combination of the blowing and hissing sounds. It increases in intensity up to the period of labor. It is beUeved to depend upon the rapid passage of blood from the arteries into the distended venous sinuses of the uterus. It is synchronous with the maternal pulse, is subject to the same variations, and is always heard before the pulsation of the foetal heart. The Area over which it is audible varies. In some in- stances it is limited to a single point, in others it is aud- ible over a surface of three or four inches, and in a few it is heard over the whole uterine tumor, although there will always be one spot of greatest intensity, correspond- ing to the placental attachment. It is also intensified by uterine contractions, though at the height of the pain it may cease altogether. It may be modified or arrested by pressure on the stethoscope. During the first half of pregnancy it is usually heard with greatest intensity in the median line, a httle above the pubes ; after the fifth month, at the lateral and in- ferior borders of the uterus ; and next, in order of time, it will be heard at the fundus. This sound may be confounded with the respiratory murmur of the mother, and with intestinal murmurs : FCETAL HEART SOUNDS. 163 these murmurs, however, are not synchronous with the pulse of the mother, and if this fact is remembered there will be httle difficulty in distinguishing them. As a proof of pregnancy, uterine bruit is not positive, as it is sometimes heard in connection with uterine and ova- rian tumors. It does not prove that the foetus is alive, for it is heard for a long time after its death. Its nega- tive evidence is of less value, for if the placenta is attached posteriorly we may not be able to hear it, although pregnancy exist. Funic Souffle. — This sound is usually heard at a point quite remote from the uterine bruit. It is short, fee- ble, and blowing in character, and corresponds in preg- nancy with the foetal pulsation. It is supposed to depend upon obstruction to the transmission of blood through the umbilical arteries, as from twirUng or knotting of the funis, or from external pressure. It is not a con- stant, nor even a frequent sound, the conditions of its production being rarely met with. Fcetal Heart Sound. — This sound consists of a suc- cession of short, rapid, double pulsations, varying in frequency from 120 to 140 per minute. The first sound is short, feeble, and obscure, while the second, the one we usually hear, is loud and distinct, and may be heard generally over the body of the child. This sound has been aptly compared to the ticking of a watch wrapped in a napkin, and usually is first heard at the middle of the fourth month. The frequency of the pulsations does not vary with the age of the foetus. The extent over which the foetal heart sound is aud- ible varies ; usually it is transmitted over a space three or four inches square. The location of the sound is determined by the position of the foetus. It has been stated that whenever the maximum intensity of this 164 PHYSICAL DIAGNOSIS. sound is below a horizontal line dividing the uterus into equal parts, it is a vertex presentation ; when above, it is a breech ; also, when the foetal pulsations are heard low down in front on the left side, that the foetus is in the first position ; if heard below and in front, on the right side, it is in the second position. Twin pregnancy may sometimes be determined by the presence of heart sounds heard at distant points over the uterine tumor, and by the absence of synchronism in the two pulsations. The sources of deception in ex- ploring for the foetal heart sound are the Uabihty of confounding the pulsation of the ihac arteries or abdom- inal aorta of the mother with it. In most cases their situation, comparative frequency, and absence of double pulsation wiU determine their character. But a diffi- culty wiU sometimes occur in discriminating between them when the natural pulse is very much increased in frequency and the foetal diminished. Under such cir- cumstances we must be guided by the character of the sound, and whether it is, or is not, synchronous with the radial pulse. Again, in the early stage of pregnancy, the intensity and impulse of the maternal pulsation may render the feeble foetal sound inaudible. This difficulty may be overcome by removing the pressure of the uterine tumor upon the subjacent arteries, by changing the posture of the mother. During labor our examinations should be made in the interval between uterine contractions. In protracted labors, auscultation is of value in indi- cating to us the time for manual or instrumental inter- ference to save the life of the child. The indications of danger to the child are feebleness or excessive frequency of the foetal pulsation ; irregularity in its rhythm ; ab- OVARIES. 165 sence of the second sound ; its complete cessation during uterine contraction, and the slowness of its return in the interval. Irregularity and feebleness are the most threat- ening to the Ufe of the child. When the sound of the foetal heart is heard it is a positive proof of pregnancy ; but its absence is not always proof that pregnancy does not exist, for the foetus may be dead, and in some rare cases the sounds may exist and be quite inaudible for a time, and then appear. This phenomenon is not easily accounted for. Tumors of the Uterus, whether developed on its sur- face, in its walls, or within its cavity, give rise to en- largement of the organ, which causes it to occupy a position corresponding to that occupied by a gravid uterus. The position and extent of these enlargements are determined in the same manner as we determine the size and position of the uterus in pregnancy. Deposits in its walls or on its surface give rise to nodules, which feel through the abdominal walls like hard balls, vary- ing in size and shape, seldom occurring singly. The whole mass can usually be moved from one side to the other. The conniection of these tumors with the uterus, as determined by the bimanual method of examination, leaves little doubt as to their true character, and by this means we readily distinguish them from all other abdominal tumors. Ovaries. The ovaries in a normal state lie in the pelvic cavity, and their position cannot be determined by physical ex- ploration ; but when they become the seat of tumors, and have attained such dimensions that there is no long- er room for them in the pelvic cavity, they ascend above its brim and occupy more or less space among the ab- dominal organs. As they pass out of the pelvis, they 166 PHYSICAL DIAGNOSIS. are first noticed in the right or left ihac region, accord- ing as the right or left ovary is affected, and they are then recognized as ovarian tumors. Before these ovarian enlargements have attained sufficient size to attract the attention of the patient, they wiU have reached a cen- tral position in the abdominal cavity. They are of more . frequent occurrence than any other forms of abdominal Fig. 20.— Diagram showing the Gradual Enlargement of a Tumor of the Right Ovary till it fills a large portion of the Abdominal Cavity.— Bright. tumor, and their existence is determined almost exclu- sively by the physical signs which they furnish. Inspection. — In the early part of their development, an uneven projection or prominence of one part of the abdomen wiU disclose the seat of the tumor, occupying usually the iliac or lumbar region of one side, and ex- tending upward to or beyond the umbiUcus ; while in more advanced cases no inequality wiU be visible, but OVARIAN TUMORS. 167 the rounded form of the abdomen, while the patient Ues on her back, offers a strong contrast to the flattened oval appearance of ascites, or the central rounded form of a uterus distended by pregnancy. Palpation. — Ovarian tumors, when small, have a firm, elastic feel ; but when large, they are soft and fluctuat- ing. In some cases, by passing the hand gen,tly over the abdomen, the extent of the tumor wiU be readily appre- ciated. At other times, the limits of the tumor cannot be ascertained by gentle palpation, for it occupies the whole of the abdomen except the concavity of the dia- phragm. In such cases, by making firm, but not forci- ble, pressure on various parts of the abdomen, we often detect at once a general sense of fluctuation, and ascer- tain inequalities which neither the eye nor the hand when passed gently over the surface wiU enable us to detect ; sometimes, if the abdomen is not tense, we can feel masses which convey the impression of more or less flattened or spherical bodies attached to the inside of a fluctuating tumor. In some cases the sense of fluctu- ation is very indistinct ; in others it is even more evi- dent than in cases of extensive ascites. Percussion. — The sound ehcited on percussion is flat over that portion of the abdomen where the tumor comes in contact with the inner surface of the ab- doininal wall ; while at the sides and above, where the intestines have been pushed aside and upward by the tumor, the percussion sound will be tympanitic ; by this change in the percussion sound we are enabled to mark out the boundaries of the tumor. Differential Diagnosis. — Ovarian tumors may be con- founded in their diagnosis with uterine enlargements, as pregnancy, flbroid tumors of the uterus, etc., ascites, hydatids of the omentum, faecal accumulations in the 168 PHYSICAL DIAGNOSIS. intestines, and enlargements of the liver, spleen, and hid- neys. They are distinguished from pregnancy by a stethosco- pic examination of the tumor, which reveals in the one case the sounds of the foetal heart, and in the other their absence. They are distinguished from uterine tumors by their consistence, by their outUne, by the difference in their connection and relative position to the uterus, and by the fact that in uterine tumors the cavity of the uterus, as determined by the uterine sound, is always elongated. The diagnosis between ovarian and abdom- inal dropsy is made : First. By observing the difference in the shape of the abdomen when the patient lies on her back. Ovarian tumors project forward in the centre, while in ascites the abdominal enlargement is uniform. Second. In ovarian tumors, the percussion sound is dull as high as the tumor extends, while at the same time there wiU be tympanitic resonance in the most depend- ing portion of the abdominal cavity ; in ascites, the most depending portion of the abdomen is always flat, the percussion resonance being confined to the epigastric and umbihcal regions. Third. In ovarian dropsy, the rela- tive line of flatness and resonance is not altered by change in the posture of the patient, which is not the case in ascites. Hydatids of the omentum form a class of tumors which you wiU be unable to distinguish from ovarian tumors by the physical signs. The fact, however, that these omental enlargements are first noticed above the umbilicus and gradually enlarge downward, while ovarian are first noticed low down in the abdomen and gradually enlarge upward, wiU in most cases be suffi- cient for a diagnosis. Faecal accumulations in the large intestine may be ABDOMINAL ANEUKISM. 169 mistaken for ovarian tumors. The peculiar feel of such enlargements, already described, wiU enable you to dis- tinguish them from ovarian tumors. Abdominal Aneurism. Aneurism of the abdominal aorta usually occurs at or near that portion of the vessel from which the coeliac axis is given off, and the rupture is usually in the poste- rior wall of the artery. Aneurism of the ccsliac axis, of the renal, hepatic, superior mesenteric, or splenic arte- ries, is of very rare occurrence, and there are no means by which, if they do occur, they can be distinguished from aneurism of the abdominal aorta. Inspection. — On inspecting the abdomen in a case of abdominal aneurism, a tumor in the epigastrium, with an expansive impulse, usually is discovered ; in some cases, however, the closest inspection reveals nothing abnormal. When a tumor is present, the surface of the abdomen over it will be rounded and smooth. When the aneurism is of large size, abdominal respiration may be diminished and thoracic increased. Enlargement of the superficial veins of the abdomen, and oedema of the lower extremities, are very rare phenomena. Palpation.— Bj T^al-psition we can determine approxi- mately the size of the tumor, its position, and its im- pulse. Aneurisms of the abdominal aorta are usually felt in the median hne, or to the left of it, on the right side, or on both sides. They are immovable. The impulse, if one exist, is systolic and expansive, although when it is situated high up there also may be a slight diastohc movement. A thrill is rarely perceptible. By compar- ing the pulsation in the arteries of the lower extremities with that of the upper, a feebleness of pulsation may be 170 PHYSICAL DIAGNOSIS. detected. The surface of the tumor, when not ruptured, is rounded and smooth. Effusions of blood into the sur- rounding tissues may produce lobulations. Percussion.— Buhiess or flatness will exist over the tumor, unless a distended intestine lie above it. Auscultation. — A systolic murmur, resembling that produced in aneurisms of the thoracic, aorta (page 123), is usually heard directly over the tumor in front, or op- posite to it along the lumbar spine ; rarely, if ever, is a diastolic murmur heard, though a prolonged second sound often exists. In some cases, the murmur is aud- ible when the patient is in the recumbent posture, but disappears when he assumes the erect posture. ' In other cases, aU the physical signs of aneurism are absent, and still we are led to suspect its existence from the rational symptoms, the most prominent of which is a continuous, deep-seated, and at times paroxysmal pain in the lum- bar region, which shoots down the thighs and around the abdomen. Abdominal aneurism may be mistaken : First. For enlargement of various organs which by its size it has displaced, as the liver, kidney (especially the left), and the spleen. The presence, however, of the physical signs of aneurism in such cases will enable us to refer the apparent enlargement to its- right source. Second. For neuralgia, rheumatism, renal coHc, etc. The steady, persistent, long-continued, paroxysmal pain in the lumbar region, especially in male subjects, is strong presumptive evidence of aneurism ; and if we have connected with this an immovable, although per- haps Aot pulsatile, tumor along the course of the artery, the diagnosis of aneurism becomes almost positive. ' See Intra-thoracic Auscultation, p. 39. OMENTAL TUMORS. 171 Third. For disease of the spine. Here the pain, and. possibly a curvature produced by an aneurism, may mis- lead, but the physical signs of aneurism in most cases will correct the mistake. Fourth. For psoas or lumbar abscess. In this the shape of the tumor is elongated, and there is neither impxilse nor murmur perceptible. Fifth. For aortic pulsation. In aortic pulsation there is, however, absence of a murmur, or a thrill, or percus- sion dulness, and the impulse is quick and jerking, and not expansive as in aneurism. Sixth. For abdominal tumors. The tumors which are apt to be mistaken for aneurism are enlarged left lobe of liver, cancer of the py- lorus, enlarged mesenteric glands, faecal accumulations, and hydro- or pyo-nephritic kidney. In tumors the feel is usually harder, the impulse lifting, rarely expansive, and ;hey may be accompanied by ascites, oedema, or en- larged abdominal veins, the infrequency of which in aneurism has already been alluded to. If a murmur oc- cur with a non-aneurismal tumor, it may be made to disappear in most instances by causing the patient to assume a posture on his hands and knees ; the impulse may be diminished or cease at the same time. Tumors are also usually movable, aneurisms immovable. In many cases of abdominal aneurism the diagnosis is un- certain. Omental Tumors. The omentum may be the seat of a hydatid cyst, of cancer, or of tubercular deposits. These deposits or growths give rise to tumors which are readily detected through the abdominal walls, both by percussion and palpation. They are first recognized high up in the ab- dominal cavity, above the umbilicus, and gradually ex- tend downward. If there are no adhesions, you can push the tumors upward and from right to left. They 172 PHYSICAL DIAGNOSIS. are superficial, and their uneven surface is readily de- tected by passing the hand lightly over the surface of the abdomen. They are always more or less tender on firm pressure. They do not move on deep inspira- tion, and ascites is usually an accompanying symptom. The percussion sound elicited over these tumors is never flat, but has a tympanitic quality, caused by the subja- cent intestines. Mesenteric Enlargements. Mesenteric enlargements occupy a position correspond- ing to that of the small intestine. They are beyond the reach of physical diagnosis, except as they occur in children in the last stage of tabes mesenterica ; then their diagnosis is of Uttle practical use, their cure being hopeless. EXAMIISrATION^ OF TJRIJSTE. LESSOE" XYII. INTRODUCTION— PLAN OF EXAMINATION — PHYSICAL CHARACTERS — CHEMICAL CHARACTERS — (a) NOR- MAL ELEMENTS, (&) ABNORMAL ELEMENTS. Gentlemen :^You will find that the examination of the urine is of great service in the diagnosis of disease. In order that it shall be complete, the urine should be examined both chemically and microscopically. I shall first direct your attention to the chemical ex- amination. (For the microscopical examination, see the lesson on Clinical Microscopy.) This involves both qualitative and quantitative analyses — the former to ascertain the presence or absence of particular sub- stances ; the latter to determine the quantity or propor- tion in which they exist when present. The specimen to be examined should be taken from the urine passed a- few hours after a meal or should be a specimen of the mixed twenty-four hours' urine, and should be collected in a perfectly clean bottle holding from four to six ounces. The examination should be conducted after the follow- ing plan: Physical Characters. 1. Quantity passed in twenty-four hours. 2. Condition (transparent or turbid). 3. Color. 4. Odor. 5. Eeaction. 6. Specific gravity. f . Character of deposit. 17G PHYSICAL DIAGNOSIS. Chemical Characters. NORMAL ELEMENTS. 1. Urea. 2. Uric acid and the urates. 3. Phosphates. 4. Chlorides. 5. Sulphates. 6. Hippuric acid and kreatinin. 1. Xanthin bases. ABNORMAL ELEMENTS. 1. Albumin. 2. Sugar. 3. Bile. 4. Blood. 5. Pus. The examination should be made within twelve hours after the urine is voided ; in warm weather, even earlier. Physical Characters. Quantity Passed in Twenty-four Hours. — The amount of urine voided by a healthy person in twenty- four hours greatly varies. The mean daily discharge ranges between forty and fifty fluid ounces — it may rise as high as eighty ounces, and faU as low as twenty-five ounces, and still be within the limits of health, the variation depending in a great degree upon the quantity of fluid drunk. In order accurately to determine the quantity passed in twenty-four hours, it should be carefully measured in a graduated urine glass. Before determining the clinical significance of any de- viation from the usual quantity of urine passed by an CONDITION. 177 individual, Dr. Roberts states that the following points should be borne in mind : When the urine is unusually scanty, it should be ascertained, before pronouncing it a morbid phenomenon, whether the patient has abstained from liquids above his habit, or whether water has been eliminated in excess by some other channel, as the skin or bowels. The urine is always scanty in fevers, cirrhosis of the liver, and in some forms of Bright's disease through their entire course. In the early stage of acute Bright's disease it is very scanty, sometimes approaching or reaching total suppression. It is also scanty in any condition of the heart which directly or indirectly causes passive congestion of the renal veins, whereby the circulation through the kidneys is impeded. It becomes scanty, or is suppressed, in the collapse stage of cholera. Any diminution of the urinary secretion which ap- proaches suppression is of most serious import. The flow of urine is abundant when the surface of the body is cool, or when large quantities of fluid have been taken. In disease it is discharged in excessive quantity in two special maladies — diabetes and chronic interstitial nephritis. Temporary excess of urine occurs after hys- terical paroxysms, certain other conviilsive attacks in both males and females, and after mental worry or anxiety. An increased tension in the arterial system, as in some cases of hypertrophy of the left ventricle, is associated with increased secretion of urine. Condition. — Normal urine is clear when first voided, but on standing a slight cloud of mucus forms. It comes from the urinary passages, generally the bladder. Urine is rendered cloudy by deposits of phosphates or urates, and by contamination with blood or pus. Alka- line fermentation produces a turbidity of the urine by 13 178 PHYSICAL DIAGNOSIS. bringing about the decomposition of urea and the pre- cipitation of the earthy phosphates. The presence of fat in the urine as an emulsion (chyluria) gives it a milky appearance. Color.— In health the color of the urine varies from a pale-straw to a brownish-yellow tint. This is due to the presence of urobilin, a normal pigment of the urinary secretion. But the color may be altered and yet indicate no morbid condition. Certain drugs impart an abnormal color to the urine. Khubarb and senna give it a brown or reddish color ; logwood, a reddish or violet color ; while creosote, carbolic acid, and tar color it black. Santonin gives a distinct yellow color to it. Again, in cases of melanotic tumor the urine is dark. As a rule, the larger the quantity of urine passed the lighter the color, and vice versa. The darker color of the diminished amount is due to a relative excess of urobilin, as after great exertion which is attended by profuse perspiration. High-colored urine, when a nor- mal amount is passed, is an indication of disease. Bile communicates a dark olive-green tint to the urine. An admixture of blood gives the urine a smoky or distinctly reddish appearance. The red color of rheumatic urine is due to a special pigment, uroerythrin. Indoxyl potassium sulphate is a salt normally found in the urine. Sometimes, when in excess, it breaks down and by oxidation forms indigo-blue, which imparts its color to the urine. This may occur in Asiatic cholera and in typhus fever. Odor. — Healthy human urine, immediately after void- ing, has a sweetish, aromatic odor. But the odor may be changed by the ingestion of certain kinds of food and SPBCIPIC GRAVITY. 179 the admiaistratiou of certain medicines. Asparagus gives the urine a disagreeable stench, due to methyl meacaptan; cubebs, copaiba, sandal- wood oil, and garlic impart their odors. Turpentine produces the odor of violets. After alkaline fermentation the pungent odor of ammonia is perceptible. A fruity, apple odor is pres- ent in diabetes mellitus, due to the presence of acetone. Reaction. — When first passed, healthy urine is sUghtly acid in reaction. This is due to the presence of acid sodium phosphate. The degree of acidity varies in the twenty-four hours. After each meal it declines for about two hours until the urine is neutral or even alkaUne, and then returns to the normal. The reaction is affected by the kind of food eaten : thus an animal diet makes the urine acid ; a vegetable diet, alkaUne. Fasting is marked by a decided increase in acidity. After standing for some time, all urine becomes alka- line from the decomposition of urea and the formation of ammonium carbonate. The rapidity with which this takes place varies with the state of the temperature. In warm weather the fermentation begins a few hours after voiding. In febrile and inflammatory affections, especially of the hver, heart, and lungs, the urine is strongly acid ; while in affections of the brain and spinal cord, and cer- tain diseases of the genito-urinary organs, it is often strongly alkaline. Urine that is ammoniacal when voided indicates chronic vesical catarrh or obstructive disease of the bladder or ureters. When the urine is mixed with blood or pus ' the re- action is generally alkaline. The administration of mineral acids gives the urine a strongly acid reaction. Specific Gravity. — The specific gravity of urine in ' In. pyelitis and pyelonephritis the reaction is acid. 180 PHYSICAL DIAGNOSIS. health varies from 1015 to 1025. Wheu the quantity of urine is large the specific gravity is lovsr, except in diabetes mellitus ; and when the quantity is small the specific gravity is high. The most convenient method of estimating the spe- cific gravity is by means of the urinometer. It consists of a blown-glass float, weighted with mercury, and a graduated stem upon which the readings are to be made. A cylinder of convenient size is nearly filled with the urine and the instrument floated in it. The reading should be made at the lowest point of the con- cave surface of the urine. From the specific gravity of urine a rough estimate may be made of the amount of sohd matter contained in solution. The method was proposed by Trapp. If the reading is below 1018 the last two figures are to be multi- plied by 2 ; if above, by 2.33. This vvdU give the amount per thousand volumes. For example, in 1, 500 grammes of urine whose specific gravity is 1030 there wiU be 104.85 grammes of sohd mat- ter. If, then, the quantity of urine voided in the twenty-four hours be known, the daily excretion of sohds can be approximately ascertained. In disease the average specific . gravity of the urine may be increased or diminished. It is highest in dia- betes, and lowest in hysteria. In inflammations, as pneumonia, pleurisy, etc>, and in fevers, it often rises as high as 1035. On the other hand, when the average specific gravity is abnormally low you may suspect some exhausting, non -inflammatory complaint, as Bright's disease, in which it may fall so low as 1002. As a rule, Fio. 21.— Urinometer. UREA. 181 the lower the average specific gravity of the urine in chronic Bright's disease, the more unfavorable the prog- nosis. Character op Deposit. — The deposit may be scant or heavy, amorphous or crystallized, white or colored. Deposits of urates are pink, reddish (brick-dust), brown, or white in color. Uric acid crystals form a scant red- dish-brown sediment resembling grains of red pepper. When pus is present the sediment is heavy and of a yel- lowish-white color. Deposits of blood are reddish in color. Mucus, when present in large amount, forms a heavy, gelatinous deposit. The naked-eye inspection is not to be relied upon. The deposit should always be examined chemically and microscopically. Chemical Characters. NORMAL ELEMENTS. Urea is a product of tissue metabolism. It is the chief form in which nitrogen leaves the system. The urea which passes off in urine is brought to the kidneys as such in the blood, being formed chiefly in the liver It is not probable that the kidneys have the power of forming urea by a special function. The excretion is subject to great variation, being dependent upon the amount and kind of food eaten, the amount of mental and physical exercise taken, etc. An animal diet in- creases the daily excretion, while a vegetable diet di- minishes it. The amount excreted in twenty -four hours by healthy adults varies from twenty to forty grammes (308.6 to 61T.2 grains), or 1.5 to 2.5 per cent. Quantitative Estimation of Urea.— A convenient ureometer has been devised by Dr. Charles Doremus for the rapid estimation of urea. It consists of a closed glass tube bent into two arms ; the long arm is gradu- 183 PHYSICAL DIAGNOSIS. ated, the short arm is dilated into a bulb (see Fig. 22). Sodium hypobromite is the reagent employed. When urea is brought in contact with sodium hypobromite, it is decomposed and nitrogen gas is given off. The solu- tion is made by adding one cubic centimetre of bromine to ten cubic centimetres of a solution of sodium hydrate (one hundred grammes to two hundred and fifty cubic centimetres of water), and diluting with ten cubic centimetres of water. It should be freshly prepared for each examination, as it de- Fig. 23.— Ureometer. teriorates on keeping. The method of using the instrument is as fol- lows : Fill the ureometer to the mark = with the sodium hydrate solution, add one cubic centimetre of , bromine by means of the pipette, and pour in sufficient water to fill the long arm and bend. Wash the pipette, and then draw up one cubic centimetre of the urine to be tested. Introduce the tip of the pipette well into the bend, and force the urine out gradually. As it passes into the hy- pobromite solution, nitrogen gas is evolved and collects at the top of the tube. The reading is made after twenty minutes. Each division of the scale indicates 0.001 gramme of urea for one cubic centimetre of urine. If, then, the number of milligrammes to the cubic cen- fowler's method. 183 timetre be multiplied by the number of cubic centime- tres of urine passed, the result will be the amount of urea excreted in twenty-four hours. If the percentage by volume be desired, multiply the number of milli- grammes found by one hundred. An improvement on the Doremus apparatus is shown in Fig 23. The urine Fio. 23. is placed in the smaller tube instead of in the pipette, and the small stop-cock between the tubes is turned, and the desired amount of urine is quickly run into the large tube. This prevents the greater or smaller loss of gas so apt to occur when endeavoring to fit the tip of the pipette into the bend of the large tube, or when the urine is forced out too quickly from the pipette. Fowler'' s Method. — This method, devised by Dr. George B. Fowler, of New York, is based on the fact 184 PHYSICAL DIAGNOSIS. that the specific gravity of urine bears a definite ratio to the amount of urea present. After the decomposition of the urea by the hypochlorites, every degree of density lost corresponds to 0.Y7 per cent, or about 3.5 grains to the ounce. The hypochlorite solution used is Squibb's solution of chlorinated soda (Labarraque's solution) seven parts of which will destroy the urea in one part of urine, unless the amount be very large, in which case the urine should be diluted with an equal volume of water and the result multiplied by two. Mix seven volumes of Labarraque's solution with one volume of urine; allow the mixture to stand for two hours with occasional shak- ing. Stand some of the original urine and some of Labarraque's solution beside the mixture, in order that when the specific gravity is taken the density and vol- ume of each will be equally affected by the temperature in which they have stood. Take the specific gravity of all three solutions to obtain the specific gravity of the mixture before decomposition took place ; take the specific gravity of Labarraque's solution, multiply by seven, add the specific gravity of the urine, and divide by eight. Subtract from this result the specific gravity of the mixture in which the urea has been decomposed, and multiply the difference by 3.5 to obtain the number of grains of urea per ounce, or by 0.77 to obtain the per- centage of urea. This is an accurate method, and is not interfered with by the presence of albumin or sugar. As the amount of urea excreted at different times of the day varies, being greater during the waking than sleeping hours, the specimen to be examined should be taken from the mixed urine of twenty-four hours. URIC ACID. 185 Clinical Significance. — In disease, the quantity of urea contained in the urine may be abnormally increased or strikingly diminished. It is abnormally increased in all febrile affections (except yellow fever, in which it is diminished), in all nervous affections (especially in epi- lepsy), in pyaemia, in diabetes, and, as a rule, in acute inflammation of the thoracic viscera. It is abnormally diminished in cholera, in some cases falling as low as four grammes in twenty-four hours. In BrighVs disease, the diminution in the quantity of urea in the urine is marked and significant. As a rule, the more albumin in the urine the less the amount of urea, and vice versa. But not infrequentlj', in pa- tients with waxy or cirrhotic kidneys, the quantity of albumin may be slight, or for a time entirely absent (the urine being of low specific gravity), and still the quantity of urea daily excreted falls far below the normal stand- ard. In all forms and stages of those kidney changes included under the term Bright's disease, it is important to determine accurately the quantity of urea contained in each day's urine — it is an important element not only in diagnosis, but also in prognosis. Uric Acid is a normal constituent of the urine. It is not present as the free acid, but in combination as urates. The daily excretion of uric acid varies from 0.5 to 1 gramme. Like urea, it is a product of tissue meta- morphosis, and is increased by an animal diet. Its pro- portion to urea is as 1 : 45. The presence of free uric acid is detected by the murex- ide test. Place the suspected deposit in a small cruci- ble with a few drops of nitric acid, and evaporate nearly to dryness. On the addition of a drop of ammonia a 186 PHYSICAL DIAGNOSIS. rich purple color is produced. (For the microscopical examination see page 262.) To estimate the quantity of uric acid in a specimen of urine, add one part of hydrochloric acid to twenty parts of the urine, and set it aside for a day or two. The uric acid in the bases is replaced by the hydrochloric, and thrown down as yellowish or brownish crystals. These should be carefully separated, dried, and weighed. The calculation is then made for the urine of twenty-four hours. Urates.— The urates found in the urine are chiefly those of potassium, sodium, and ammonium; those of cal- cium and magnesium may also be present. In perfectly healthy urine they are held in solution. Sometimes, however, when the amount of water is diminished, as after excessive perspiration, they are precipitated as the urine cools. The deposition of urates usually occurs in strongly acid urine of high specific gravity. They form a heavy deposit, of a pink, reddish brown, or even white color. These deposits are composed principally of acid urates. Uric acid, being a dibasic acid, can combine with one or two atoms of a monad metal. Two atoms of these metals in combination with uric acid give the neutral urates, and one atom gives the acid urates. The acid urates are much less soluble than the neutral urates, and are thus more easily thrown down. Urates are readily dissolved by heat. Clinical Significance. — Uric acid is not always in excess when it is readily precipitated. If the urine is very acid, it may be separated from its bases and thrown down. Purdy gives the conditions of the urine which tend to precipitation of uric acid as follows: 1. High PHOSPHATES. 187 grade of acidity of the urine; 2. Poverty in mineral salts; 3. Low percentage of pigmentation; 4. High per- centage of uric acid; 5. Long standing. Any urine upon standing sufficiently long will deposit uric acid crystals in consequence of the changes culminating in ammoniacal decomposition. This may occur before the urine is voided, and be the basis of the formation of calculi. The amount of uric acid excreted is diminished in anajmia, chlorosis, and the advanced stages of Bright's disease. It is increased in those diseases of the heart and lungs in which there is deficient aeration of the blood, in many diseases of the liver, in fevers, and in acute rheumatism. The urates are frequently deposited with the uric acid. Persons who habitually pass urine containing deposits of urates and uric acid are generally the sub- jects of gastric and hepatic disorders. They are usually large eaters and drinkers, and take little exercise. De- ficient oxidation is the chief cause of the uric acid diathesis. Phosphates. — The normal quantity of phosphates excreted in twenty-four hours has been found to be sbout 2.5 grammes. They are derived in part from the food, and in part from tissue metabolism — some have supposed, principally the nervous tissues. Phosphates of sodium, calcium, and magnesium are the salts pres- ent in largest amount. The calcium and magnesium salts constitute the earthy phosphates, the sodium and potassium the alkaline phosphates. As long as the urine is acid in reaction, the phosphates are held in solution. Sometimes, however, calcium phosphate is precipitated 188 PHYSICAL DIAGNOSIS. upon the application of heat. In aliialine fermentation, urea is decomposed by a special bacterium, the micro- coccus urese, with the formation of ammonium carbon- ate ; the earthy phosphates are precipitated, and in the presence of ammonia the triple phosphate crystals are formed (see page 267). Deposits of phosphates are readily dissolved by a few drops of nitric acid. The phosphates are not always in excess when they are readily precipitated; and, on the other hand, they may be in excess and yet remain in solution. They are increased in amount by, a proteid diet and by mental or bodily exercise. Estimation. — TJltzmann gives a good approximate test for the earthy phosphates. A test tube eight inches in diameter is filled with urine to a depth of three inches, then a few drops of a solution of ammonia or potash are added, and the urine is heated gently till the phosphates separate out in flakes. The tube is then allowed to stand for ten minutes for the phosphates to settle. If the deposit equals four-tenths of an inch in depth the phosphates are normal ; if two or three times that depth they are increased ; if the deposit is only one- or two-tenths of an inch they are diminished. The test for the alkaline phosphates is made after the earthy phosphates are precipitated as above by acidify- ing the clear filtrate with acetic acid, and a few drops of a solution of ferric chloride (one part of the official solution to ten of water) are added ; a yellowish white precipitate will indicate the presence of phosphates. Or after the earthy phosphates are filtered off the ammoni- acal filtrate is treated with ammonio-magnesium mixture (one part crystallized magnesium sulphate, two parts PHOSPHATES. 189 ammonium chloride, four parts ammonium hydrate, and eight parts distilled water) ; the alkaline phosphates are thrown down in a white cloud— a milky turbidity being considered the normal amount, a thick creamy precipi- tate showing excess of phosphates, while a slight turbid- ity shows a diminution. Estimation of Total Phosphates (Halliburton). — The following reagents are necessary: 1. A standard solu- tion of uranic nitrate. The uranic nitrate solution contains 35.5 grammes In one thousand cubic centi- metres of distilled water; one cubic centimetre corre- sponds to 0.005 gramme of phosphoric acid (PjO^). 2. An acid solution of sodium acetate. Dissolve one hundred grammes of sodic acetate in nine hundred cubic centimetres of water; add to this one hundred cubic cen- timetres of glacial acetic acid. 3. A solution of potassium ferrocyanide. Method : Take fifty cubic centimetres of urine ; add five cubic centimetres of the acid solution of sodium acetate; heat the mixture to boiling; run into it while hot the uranic nitrate solution from a burette until a drop of the mixture gives a distinct brown color with a drop of the potassium ferrocyanide solution placed on a porcelain slab. Read off the amount of solution used, and calculate therefrom the percentage amount of phos- phoric acid in the urine. Estimation of the Earthy Phosphates. — Take two hun- dred cubic centimetres of urine. Bender it alkaline with ammonia. Set the mixture aside for twelve hours. Collect the precipitated earthy phosphates on a filter; wash with dilute ammonia (1 : 3). Perforate the filter, and wash the precipitate into a beaker with water acidi- 190 PHYSICAL DIAGNOSIS. fied with a few drops of acetic acid. Dissolve with the aid of heat, adding a little more acetic acid if necessary. Add five cubic centimetres of the acid sodium acetate solution. Dilute the mixture to fifty cubic centimetres with water, and estimate the phosphates with the uranic nitrate solution. The amount of earthy phosphates sub- tracted from the total phosphates will give the amount of alkaline phosphates. Clmiaal Sigmficance.—Uke most urinary ingredi- ents, the quantity of phosphates eliminated in the urine undergoes a marked change in disease. It has been found to be abnormally increased in all inflammatory diseases of the nervous system, in paralysis, or in any se- vere nerve lesion, in acute mania, in delirium tremens, and in rickets. It is diminished in most febrile and inflammatory affections, especially pneumonia (unless nerves or nerve centres are involved), in Bright's dis- ease, in gout, and in rheumatism. Chlorides. — Sodium chloride is the only chloride present in the urine in sufficient amount to claim atten- tion. The mean daily excretion has been computed at 11.5 grammes. But as it is derived chiefly from the food, it is subject to great change. The test for sodium chloride consists in acidulating the urine with a drop or two of nitric acid and the addi- tion of a little silver nitrate solution. The chloride of silver is formed, which is insoluble in nitric acid, but readily soluble in ammonia. The quantitative estimate of the chlorides is best made by Sutton's modification of Mohr's testo Ten cubic centimetres of urine are measured into a thin porcelain dish, and one gramme of pure ammonium nitrate is CHLORIDES. 191 added; the whole is then evaporated to dryness, and gradually heated over a small flame to dull redness till all vapors are dissipated and the residue becomes white. It is then dissolved in a small quantity of water, and the carbonates produced by the combustion of the organic matter neutralized by dilute acetic acid; a few grains of pure calcium carbonate to remove all free acid are then added, and one or two drops of a saturated solu- tion of neutral potassium chromate. The mixture is then' titrated with decinormal silver solution (16.966 grammes of pure nitrate of silver to one thousand cubic centimetres of distilled water) until the end reaction, a pink color, appears. Each cubic centimetre of silver solution represents 0.005837 gramme of sodium chlo- ride. If 5.9 cubic centimetres of urine are taken for titration, the number of cubic centimetres of silver solu- tion used will represent the number of parts of sodium chloride per one thousand parts of urine. Clinical Significance of Chloride of Sodium. — The absence of chlorides in the urine is marked and constant in the exudative stage of acute inflammation, especially in pneumonia during the stage of hepatization, when they may be absent for two or three days, and return as soon as resolution commences. They are absent in p, greater or less degree in most acute febrile diseases, as scarlatina, variola typhus and typhoid fevers, and re- current and acute yellow atrophy. Intermittent fever seems to be an exception to this. The chlorides are diminished in all acute and chronic renal diseases as- sociated with albuminuria, due to some extent to a di- minished secretion of water. They are also diminished in anaemic conditions and in rickets, as well as in melan- 192 PHYSICAL DIAGNOSIS. cholia and in idiocy. In acute rheumatism, as soon as the endocardium and pericardium become implicated they generally suddenly disappear. Chloride of sodium is absent or diminished in cholera, and its increase or return is regarded as a very favorable symptom. On the other hand, an increased amount of chlorides is found in all conditions in which retention has previ- ously been present, as in the acute fevers, and in cases in which resorption of exudates and transudates with increased diuresis is taking place. In diabetes insipi- dus and in prurigo a great increase has been observed in some cases. In the acute fevers the diminution seems to be in ratio to the severity of the attack, while a continued increase, seems to indicate an improvement in the condition of the patient. The Sulphates are present in the urine in consider- able amounts, the average amount excreted by a nor- mal individual being between two and three grammes in twenty-four hours. They are derived from the al- buminous material which is constantly broken down, only a small portion of the inorganic sulphate being derived from the food. The larger portion of the sul- phates excreted is in the form of inorganic salts of sodi- um and potassium, the former predominating. About one-tenth, however, is in combination with organic com- pounds, the most important of these being the indoxyl and skatoxyl potassium sulphates and compounds of phenol, which are formed from the indol, skatol, and phenol produced by the putrefactive processes in the large intestine. The inorganic sulphates are the preformed sulphates, while the organic are the ethereal or com- bined sulphates; the ratio between the two is 10: 1. PHOSPHATES. 193 The test for the sulphates consists in adding a drop or two of nitric acid and a few drops of a saturated solu- tion of barium chloride to some of the urine. A white precipitate insoluble in acids is formed. ■QUANTITATIVE ESTIMATES OP THE SULPHATES. (HALLIBURTON). Volumetric Determination. — The following solutions are necessary: Standard barium chloride solution — 30.5 grammes of crystallized barium chloride in a litre of dis- tilled water. One cubic centimetre of this solution corre- sponds to 0.01 gramme of sulphuric acid (SO^). Solution of sulphate of potassium, twenty per cent. Pure hydrochloric acid. One hundred cubic centimetres of urine are taken in a beaker acidified by five cubic centimetres of hydro- chloric acid, and boiled. The cortibined sulphates are thus converted into ordinary sulphates, and like them give a precipitate with barium chloride. The solution is run from a burette into the mixture as long as a precipitate occurs, the mixture being heated before ■every addition of barium chloride to it. After adding fiive to eight cubic centimeti'es of the standard solution, allow the precipitate te settle. Place a drop of the clear, supernatant solution on a watch-glass; add to it a drop of the barium chlorido solution ; if a precipitate ■occurs, add more barium chloride to the solution, and proceed until no more barium sulphate, is formed on the addition of the barium chloride. Excess of the barmm chloride must also be avoided. When only a trace of excess is present, a drop of the clear fiuid from the beaker gives a cloudiness with a drop of the potassium .sulphate solution placed on a watch-glass against a 13 194 PHYSICAL DIAGNOSIS. black ground. If more than a cloudiness appears, too large a quantity of barium chloride has been added, and the operation must be repeated. From the quantity of barium- chloride used the percentage of sulphuric acid in the urine is calculated. Qravimetric Determination. — This method consists in weighing the precipitate of barium sulphate by adding barium chloride to a known volume of urine. One hun- dred parts of suphate of barium correspond to 34.33 parts of suphuric acid (SOJ. Method (Salkowski): One hundred cubic centimetres of urine are taken in a beaker; this is acidified with five cubic centimetres of hydrochloric acid, and boiled. Chlor- ide of barium is then added till no more precipitate occurs. The precipitate is collected on a small filter of known ash and washed with hot distilled water till no more barium chloride occurs in the filtrate; i.e., until the filtrate remains clear after the addition of a few drops of hydric sulphate. Then wash with hot alcohol, and afterward with ether. Eemove the filter and place it with its con- tents in a platinum crucible. Heat to redness. Allow it to cool, then add a few drops of concentrated sulphuric acid to convert the small amount of barium sulphide formed into sulphate. Heat again to redness to drive off excess of sulphuric acid. Cool over sulphuric acid in an exsiccator ; weigh, and deduct the weight of the cru- cible, and filter ash ; the remainder is the weight of barium sulphate formed. Estimation of the Combined Sulphates (Salkowski). — One hundred cubic centimetres of urine are mixed with one hundred cubic centimetres of alkaline barium chlo- ride solution (two volumes of solution of barium hydrate PHOSPHATES. 195 with one of barium chloride, both saturated in the cold). The mixture is stirred, and after a few minutes filtered; one hundred cubic centimetres of the filtrate {i.e., fifty cubic centimetres of urine) are acidified with ten cubic centimetres of hydrochloric acid boiled, kept at 100° C. on a water bath for an hour, and then allowed, to stand till the precipitate has completely settled; if possible, twenty-four hours. The further treatment of this pre- cipitate (equals combined sulphates) is then carried out as in the last case. To calculate the H,SO„ multiply the weight of barium sulphate by 0.4206; to calculate the S0„ multiply by 0.34335; to calculate the S, multiply by 0.13734. This method of calculation applies to the gravimetric estimation both of total sulphates and of combined sulphates. To obtain the amount of pre- formed sulphuric acid, subtract the amount of combined SO3 from the total amount of SO.j. The difference is the preformed SO^. Clinical Significance of the Sulphates. — An increase in the excretion of total sulphates in the urine takes place whenever there is an increased tissue destruction in the bodj", as in the acute febrile affections. The high- est amounts have been observed in the febrile stages of pneumonia and acute myelitis. They are also incrsased in leucaemia, diabetes mellitus, and insipidus oesopha- geal carcinoma, progressive muscular atrophy, pseudo- hypertrophic paralysis, and as a rule in chronic nephritis. An increased elimination seems to be caused by large doses of morphine, potassium bromide, sodium salicy- late, and antifebrin, while alcohol shghtly diminishes the excretion. A protoid diet increases and a vegetable diet diminishes the amount of total sulphates excreted. 196 PHYSICAL DIAGNOSIS. Of the greatest clinical importance is the elimination of the combined sulphates and their ratio to the preformed sulphates. The ethereal sulphates are increased in all cases of increased intestinal putrefaction, and may be used to measure directly the degree of this putrefaction; while the normal ratio of ten to one may be greatly diminished. As has been shown by Drs. Herter and Smith, this becomes of great importance in the treat- ment of epileptics, when the seizures are due to the reflex irritation caused by the putrefactive changes occurring in the intestines. The ethereal sulphates are dimin- ished by the ingestion of the terpenes and camphor, and by the Carlsbad and Marienbad waters; these mineral waters, however, at first cause an increase. Other substances occurring normally in the human urine are hippuric acid, kreatinin, and the xanthin bases — xanthin, heteroxanthin, paraxanthin, hypoxan- thin, guanin, adenin, and carnin. Hippuric acid is benzoyl-araido-acetic acid, and is formed from benzoic acid and glycocoU; it is normally excreted in amounts varying from 0. 1 to 1 gramme, and is increased by the ingestion of fruits containing benzoic acid, such as prunes, coffee-beans, etc. Kreatinin is derived from the kreatin of the muscles and the kreatin in the muscle tissue ingested as food. About one gramme is daily ex- creted by a healthy adult. The xanthin bases are un- doubtedly derived like uric acid from the nucleins. Their relation to uric acid and to each other is seen by the fol- lowing formulae : Uric acid, CbHiNjOs. Paraxanthin, C6Hj(CHs)N40a. Xantliin, CsHiNiOs. Adenin, CsH^Ns. Hypoxanthin, C5H4N4O. Guanin, CbHbNbO. Heteroxanthin, 06H3(CHa)N402. Carnin, C7H8N4O,. ALBUMIN, 197 The clinical significance of these substances is un- known. Their excretion varies in disease, but too little is known to justify any clinical deductions. Abnormal Elements. ALBUMIN. Of the different forms of albumin which have been found in urine, serum-albumin is the one which at pres- ent has most clinical significance. Numerous tests have been proposed for its detection, but only a few of them will be considered here. Before applying a test the urine should be rendered clear by filtration. When the turbidity is due to a de- posit of urates, a gentle heat will suffice to remove it. Qualitative Tests. 1. Heat and Nitric Acid Test. — Pour the urine into a test tube until it is about three- quarters full, and boil the upper portion of it — the lower portion is used for comparison. If a precipitate forms, it may be due to the presence of albumin or to an ex- cess of phosphates — the addition of a few drops of nitric acid will decide which. A precipitate of phosphates is readily dissolved, while the albumin is not affected or in- creased in amount. 2. Heller's Test. — Pour a small quantity of nitric acid into a narrow test tube ; draw some of the urine into a pipette and float it on the surface of the acid. If albumin is present, a clearly defined white band is formed at the junction of the two liquids. An excess of urates will likewise give a white band, but the upper border is not clearly defined, and it disappears on the ap- plication of a gentle heat. Dr. Charles E. Simon recom- mends as a great improvement on this test the using of 198 PHYSICAL DIAGNOSIS. a " conical glass of about two ounces capacity instead of the test tube. About twenty cubic centimetres of urine are placed in the glass, and six to ten cubic centimetres of nitric acid are added by means of a pipette which is carried to the bottom of the vessel, when the acid is slowly allowed to escape." This test is very accurate. But a color band formed at the junction of the two liquids must not be mistaken for albumin. 3. Potassium Ferrocyanide and Acetic Acid Test. — Mix some of the urine in a test tube with an excess of acetic acid, and add a few drops of a ten-per-cent solu- tion of potassium ferrocyanide. In the presence of albu- min a precipitate will form, or, if the amount be small, only a slight turbidity will appear. It is especially necessary, in applying this test, to have the urine clear; otherwise the presence of a small quantity of albumin may be overlooked. 4. Purdy''s Test. — "Fill a clean test tube about two- thirds full of the filtered urine, and add to this about one-sixth of its volume of a saturated sodium chloride solution. Next add five to ten drops of acetic acid (fifty per cent), and gently boil the upper inch or so of the contents of the test tube for about half a minute. If albumin be present, even in the minutest traces, it will appear in the upper boiled portion of the test if exam- ined in a good light. This test possesses all the sensi- tiveness of the heat-and-acid reaction with albumin, while it avoids faulty reactions." Albumin will be found in urine that is contaminated with blood, pus, or the menstrual discharge. Quantitative Estimation. — The albuminometer gives ALBUMIN. 199 m only an approximate result, but it is suflQciently accurate for clinical purposes. It consists of a thick glass cylin- der the shape of a test tube (see Fig. 24). At its upper portion is the mark E ; about midway down, the mark (J; and below this, a graduated scale. The reagent used is made by dissolv- ing one gramme of picric acid and two grammes of citric acid in one hundred cubic centimetres of distilled water. The urine is poured in to the mark U, and the reagent added to the mark E. The mouth of the instrument is closed with a rubber stopper, and the two liquids thor- oughly mixed by inverting the tube several times. It is then set aside in the upright position for twenty-four hours. The albumin is coagulated and falls to the bottom. The quantity present is read off on the scale, each division of which cor- responds to 0.1 per cent.' The Clinical Significance of Albumin in the Urine. — When albumin is found in the urine, the first and important question to decide is, whether it indicates the existence of organic disease of the kidneys. This question, however, is one which is not al- Ka. m. ways easy of solution. When the symp- toms of acute nephritis, such as dropsy, headache, high- tension pulse, and anaemia, are present together with a ' When the exact amount is desired, the albumin must be coagu- lated, separated by filtration, and the precipitate dried and weighed. 200 PHYSICAL, DIAGNOSIS. diminished quantity of urine of high specific gravity containing albumin and granular and epithelial casts, the inference is plain that we are dealing with a renal lesion. Or if with the symptoms of chronic nephri- tis, such as high-tension pulse, cardiac hypertrophy, oedema of the extremities, with urine of normal spe- cific gravity, containing albumin and casts ; or if with- out the oedema, and large amounts of pale urine of low specific gravity, with or without Jayaline casts, and only a small quantity of albumin, the inference is equally plain. In the acute infectious diseases the albuminuria occurring in the early stages is not usu- ally due to a permanent lesion of the kidneys, while that occurring in the later weeks — the second or third — or during convalescence more often indicates a more serious lesion. When there is a venous con- gestion due to cardiac disease or due to pressure from any cause, the albuminuria may result from the changes in the renal circulation, and does not necessarily indicate a concomitant nephritis. Injuries to any part of the genito-urinary tract may cause albuminuria. Calculi in the bladder or in the pelves of the kidneys may also cause it. The albuminuria resulting from these condi- tions must be differentiated by clinical examination from that resulting from nephritis. The "functional albuminurias" occurring with anaemic conditions, or with errors in diet or errors in the mode of living, or after severe muscular exertion are apt to be transitory, with urine of normal specific gravity, and usually appear at certain times in the twenty-four hours, only to disap- pear completely at other times. Albumin in the urine, therefore, appears when from any cause the blood serum SUGAK. 201 becomes mixed with the urine during secretion or excre- tion, and the true significance must be judged by a care- ful scrutiny of the general systemic symptoms. SUGAE. Various forms of sugar have been found in the urine, but grape sugar is the only one which possesses clinical interest. It is not present in normal urine in suflBcient quantity to respond to the ordinary tests. Urine containing sugar is usually light in color, of peculiar odor, and with a specific gravity varying from 1025 to 1045, or even higher. If albumin is present, it must be coagulated and removed by filtration before examining for sugar. The qualitative tests most conveniently applied are Trommer's, FehHng's, and the Fermentation Test. Trommer^s Test. — Pour a small quantity of the urine into a test tube and add about one-third its volume of liquor potassse. A ten-per-cent solution of copper sul- phate is now added, drop by drop, until no more will dissolve. The mixture is then heated. If the urine contains sugar, a reddish-brown precipitate of copper suboxide is thrown down. This test is not always reliable, for chloral, uric acid, and bile. pigment give the same reaction. Fehling''s Test. — The reagent employed consists of two solutions — a copper solution and an alkali solution — which should be kept separate in well-stoppered bot- tles, and mixed when required. The copper solution is made by dissolving 34.64 grammes of pure crystallized copper sulphate in one hundred cubic centimetres of water and diluting to five hundred cubic centimetres ; 203 PHYSICAL DIAGNOSIS. the alkali solution, by dissolving one hundred and sev- enty-three grammes of sodium tartrate and one hundred grammes of caustic soda, of a specific gravity of 1034, in five hundred cubic centimetres of water. Equal parts of these solutions should be mixed when required for use. In applying the test, pour two or three cubic centime- tres of the reagent into a test tube, and heat to the boil- ing point. (If a precipitate occurs, the reagent is use- less.) A.dd an equal volume of urine, and warm but not boil again. If sugar is present, a reddish-brown precipitate is formed. If the solution becomes green and turbid it is due to other reducing agents not sugar. Fermentation Test. — Fill a large test tube with the suspected urine, then add a small quantity of yeast; close the mouth of the tube with the finger, and invert it in a tumbler containing a considerable quantity of the same urine; remove the finger without permitting air to enter the tube, and support it in an upright position by means of a small wire triangle. Set the apparatus in a warm place for twenty-four hours. If sugar be present, it will be decomposed by fermentation into alcohol and carbon dioxide, the gas rising to the top of the tube and displacing the urine; if sugar be absent, no displace- ment will occur. This test is reliable, provided the yeast is good and the temperature suitable. Phenyl-hydrazin Test. — This is the most reliable and delicate of all the tests for glucose in the urine. Two parts of phenyl-hydrazin hydrochloride and three parts of sodium acetate are placed in a test tube with six to eight cubic centimetres of urine. If the salts do not dissolve on warming, a little water is added and the SUGAR. 203 test tube placed in boiling water. After twenty min- utes it is plunged suddenly into cold water, and if sugar is present the characteristic yellow crystals of phenyl- glucosazone are thrown down. These are bright yellow needle-shaped crystals, single or in sheaves or stars. When in small amounts they must be searched for mi- croscopically. Quantitative Estimation.— The urine used should be taken from that of the twenty-four hours. Five centigrammes of sugar will reduce ten cubic cen- timetres of Fehling's fluid prepared as above. . In mak- ing the estimate, proceed as follows: Ten cubic centimetres of the fluid are diluted with forty cubic centimetres of water, and placed in a floren- tine flask. A burette is filled with some of the urine, diluted with nine parts of water. The flask is put upon a tripod, and the fluid boiled. A little of the urine is added from time to time until the light blue color is lost. It is well to remove the flask after each addition of urine, and examine it. Just when the color disappears is a nice point to decide, and upon it depends the accu- racy of the test. The amount of diluted urine used is now read off. Suppose that the quantity is ten cubic centimetres. Now, if ten cubic centimetres of dilute urine contain 0.05 gramme of sugar, then one hundred cubic centimetres would contain 0.5 gramme, and one hundred cubic centimetres of the undiluted urine would contain five grammes, or five per cent of sugar. Purdy^s Method. — This method has the advantages over Fehling's that no precipitate is formed, the end reaction is a colorless fluid, and the standard solution is permanent. Dissolve 4.762 grammes of pure cupric 204 ^ PHYSICAL. DIAGNOSIS. sulphate and thirty-eight cubic centimetres of glycerin in two hundred Subic centimetres of distilled water with the aid of gentle heat; dissolve 23.50 grammes of potas- sium hydroxide in two hundred cubic centimetres of dis- tilled water, mix the solutions, and when cool add three hundred and fifty cubic centimetres of strong ammonia (U. S. Pharmacopoeia, specific gravity 0.9). Bring the solution up to one thousand cubic centimetres with dis- tilled water. Thirty-five cubic centimetres of this solu- tion correspond to 0.02 gramme of glucose. Measure ac- curately thirty-five cubic centimetres of the solution into a flask of one hundred and fifty to two hundred cubic centimetre capacity, and dilute with distilled water till the flask is half filled, then boil. Eun the urine slowly from a burette into the boiling fiuid, drop by drop, -till the color begins to fade ; then still more slowly, three to five seconds elapsing after each drop, until the blue color completely disappears and leaves the test solution per- fectly transparent and colorless. The amount of urine used contains 0.02 gramme of sugar. Th© best results are obtained by first diluting the urine before titration. Any dilution may be employed, and the result multiplied by the number. of dilutions. In diabetes mellitus the percentage of sugar varies from a minimum of one-half per cent to a maximum of ten per cent. The fermentation saccharometer of Max Einhorn gives approximately the amount of sugar contained in a specimen of urine. It is based on the principle that, in alcoholic fermentation, for a given quantity of sugar so much carbon dioxide is evolved. The apparatus is shown in the accompanying cut. The method of using SUGAR. 205 it is as follows : Shake one gramme of commercial com- pressed yeast with ten cubic centimetres of the urine to be examined in a test tube, and fill the long arm of the instrument with the mixture. Set it aside for twenty- four hours in a room of ordinary temperature. As the carbon dioxide is given off it rises to the top and dis- places the urine, giving the percentage of sugar present. If the urine contains more than one per cent of sugar. Fig. 25.— Saccharometer. it must be diluted with water and again tested. The degree of dilution must be taken into account in making the reading. In applying this test, it is well to perform a control experiment with normal urine in order to prove the purity of the yeast. Fill a test tube with the urine and thoroughly mix a little of the yeast with it. Then invert the tube in a tumbler containing some of the same urine. If the yeast is pure, after twenty-four 206 PHYSICAL DIAGNOSES. hours there will be no accumulation of gas at the top of the tube, but perhaps a small bubble of air may be seen. Clinical Significance. — The presence of sugar in the urine indicates that there is an excess in the blood. It may occur temporarily and in small quantity (glyco- suria), or continually and in large quantity (diabetes mellitus.) Persons who confine themselves largely to a carbohydrate diet may occasionally have sugar in their urine. It is almost constantly present during convales- cence from acute infectious diseases, such as typhus fever, diphtheria, pneumonia, etc. In lesions of certain parts of the central nervous sys- tem, sugar is found in the urine: injury to the medulla gives rise to a diabetes which may last for a considerable time. Glycosuria follows poisoning by carbon dioxide and the administration of ether or chloroform. Gouty pa- tients are subject to glycosuria at intervals. When bile is present in the blood it is excreted by the kidneys. It imparts a dark olive-green tint to the urine. Gmelin's test for the bile pigments consists in placing a drop of the urine on a white surface and a drop of fuming nitric acid alongside of it. As the two come in contact a beautiful play of colors is observed, commencing with green and blue, changing rapidly to violet and red, and finally to yellow or brown. Rosin^s Modification of Smith's Test. — Five to ten cubic centimetres of urine are placed in a test tube, and two to three cubic centimetres of tincture of iodine diluted with alcohol (1 : 10) are run down the side of BLOOD. 207 the tube so as to form a layer over the urine. If bili- rubin be present a distinct emerald-green ring appears at the point of contact. This test is extremely delicate. The presence of biliary acids can be demonstrated by Pettenkofer's test. Add a few drops of a weak solution of cane sugar to a little of the urine in a porcelain cap- sule. Place the capsule in cold water. Now add an excess of concentrated sulphuric acid, drop by drop, tak- ing care that the temperature is not raised above 70° C. A beautiful violet color indicates the presence of the bile acids. In cases of jaundice the bile coloring matter or the biliary acids are present in the urine in greater or less abundance. BLOOD. The blood cells may be present in the urine (haematu- ria), or only their coloring matter in solution (hsemoglo- binuria). Blood may be intimately blended with the urine, and form little or no sediment. Urine contain- ing blood is generally alkaline in reaction, and of a light smoky to a deep-red color. The most reliable test for blood is that furnished by the spectroscope. -(For the microscopical examination, see lesson on Clinical Micro- scopy.) Hsemoglobin produces two characteristic ab- sorption bands in the yellow and green between the lines D and E. If it is reduced haemoglobin, only one broad band is seen. The guaiacum test consists in adding a drop of the tincture of guaiacum and a few drops of ozonic ether to a little of the urine in a test tube. The mixture is shaken, and then the ether allowed to collect at the top. If blood be present, the ether will have a blue color. 308 PHYSICAL DIAGNOSIS. The test cannot be relied upon in the presence of saliva or the salts of iodine, or unless the tincture is freshly prepared. Blood occurs in the urine after injury to any part of the genito-urinary tract, in acute congestion and inflam- mation of the kidneys, as a result of poisoning by car- bolic acid, in cancer of the bladder, and in acute infec- tious diseases, such as small-pox, yellow fever, etc. It is present in malaria, scurvy, purpura, and haemophilia. PUS. Pus in the urine (pyuria) forms a heavy white or yel- lowish sediment, and the hquid above is generally tur- bid. The urine is alkaline in reaction, except in cases of pyelitis and pyelonephritis, where it is acid. Owing to the alkalinity, the phosphates are quickly thrown down. It is common to find the earthy phosphates and crystals of ammonio-magnesium phosphate associated with the pus ceUs (see page 221), in which case the urine has an ammoniacal odor. When sodium hydrate is added to a deposit of pus, a thick, gelatinous mass is formed. But the test is not accurate.. The presence of pus cells should always be demonstrated by a microscopical examination. In cystitis an abundance of mucus is usually mixed with the pus. Pyuria indicates suppuration somewhere in the genito- urinary tract. It occurs iu pyelonephritis, pyelitis, in cystitis, and in gonorrhoea. Leucorrhoeal discharges often contaminate urine. If an abscess opens into the urinary passages, pus suddenly appears in the urine in large quantity, and after a few days diminishes in amount or ceases altogether. . CLIJS^IOAL MICROSCOPY. LESSOl^T XYIII. CLINICAL MICROSCOPY — BLOOD, SPUTUM, UKINE, VOMIT, F^CES. Examination of the Blood. Fob clinical purposes the microscopical examination of the blood is restricted to determining the number and condition of its cellular elements, their hsemoglobin con- tent, thereaction of the serum on certain bacteria, and to searching for pathogenic bacteria and animal parasites. To obtain a specimen of blood for examination, the tip of the finger, or, better, the edge of the lobe of the ear, after being thoroughly cleansed, is pricked with a triangular- pointed needle, a slide is lightly touched to the apex of the drop of blood — which is allowed to run out, not pressed out — a cover glass is inmaediately placed over the drop, and slight pressure made so as to have a thin layer for examination. If the specimen cannot be examined im- mediately after its removal, a small amount of melted paraffin or flexible collodion, run around the ;edge of the cover glass, will keep the blood unchanged for several days. To prepare a dried specimen, instead of covering with a coyer glass, the end of another slide is lightly drawn across the first one, spreading out the drop in a thin layer, which is allowed to dry spontaneously. For cover-glass specimens, one cover glass is touched to the apex of the drop and another cover glass is laid on the first at such an angle that the corners do not coincide. 212 PHYSICAL DIAGNOSIS. The two cover slips are then drawn apart in the same plane, not lifted apart. In a specimen so prepared the corpuscles may lose their true form. These artefact dis- tortions, however, all point in the same direction, which differentiates them from pathological malformations. When normal blood is examined under the microscope, three varieties of cells are noted. Eed Blood Coepuscles (Fig. 26). — These appear as Flo. 26.— Cellular Elements of Human Blood. A, red blood cells forming rouleaux; B, red blood cells crenated ; D and E, rod blood cells having absorbed water; F and G, red blood cells with surface in focus ; H, white blood cells. flattened, bi-concave discs with an average diameter of 0.00Y5 millimetre. Between 6 /^ and 9 A^is within normal limits. When the centre of the cell is in focus the outer rim appears dark; when the edge is in focus then the centre appears dark. The cells show a tendency to adhere to each other, forming rouleaux or coin heaps. BLOOD. 213 After exposure to the air for a short time they lose their normal smooth contour, and the periphery becomes uneven or crenated. Blood Plates. — These are small, colorless, ovoid bodies, about one-quarter or one-half the size of a red blood corpuscle. They are usually seen cohering to- gether in masses. The number of blood plates under normal conditions is given as from 400,000 to TOO, 000 per cubic millimetre. White Corpuscles or Leucocytes (Fig. 26). — These appear as transparent cells with a granular pro- toplasm. They are mono- or multinucleated. Their size varies from that of the red blood corpuscle to twice its size. The classification, at present, of the various kinds of leucocytes depends on the character of their nuclei, the reaction of their protoplasm to staining agents, and the place of their origin in the body. The aniline dyes used for staining are chemically basic or acid, or a com- bination of the two forming a neutral compound. The basic dyes, such as hematoxylin, methylene blue, etc., have a selective action on the acid principles of the cells, while the acid dyes, such as eosin and fuchsin, unite with the basic principles. There are thus basopMle and acidophile granules in the leucocytes, while a compound of a basic and acid dye unites with certain elements in the cells which are called neutrophile. The leucocytes of normal blood are described as follows : (1) Small mono- nuclear leucocyte or small lymphocyte. These, supposed to arise in the lymphatic tissue, have a single compact nucleus and basophile granules, with but a thin layer of protoplasm surrounding the nucleus. (2) The large mono- nuclear leucocyte, with a large vesicular nucleus and 214 PHYSICAL DIAGNOSIS. basophile reticulum. Their nuclei are oval or elliptical in shape, and are surrounded by a larger zone of cell pro- toplasm which is apparently non-granular. At times the nuclei appear bent like a horseshoe, or indented ; they are then called transitional forms. (3) The polynuclear or j)olymorphonuclear neutrophile leucocyte, with a nucleus of two or more lobes united by delicate threads, having the appearance of several nuclei, and with many neutro- phile granules. (4) The eosinophile leucocyte, with a nu- cleus of several separated lobes and with many eosino- phile granules. Two other forms of leucocytes appear in pathological blood which are not present under normal conditions: (1) Myelocytes, mononuclear cells with neutrophile or eosinophile granules. They are so named because they are probably derived exclusively from the bone marrow. They occur chiefly in leucaemia. (2) Mast cells. These are mono- or polj^nuclear with large basophile granules which must be demonstrated with a special stain (Ehr- lich's dahlia). They occur almost exclusively in mye- logenous leucaemia. The normal number of leucocytes varies, according to Cabot, from 3,000 to 10,500, prob- ably averaging from 5,000 to 7,000. The proportion of the different varieties is given as follows : Small mononuclear leucocytes, 20-30 per cent. Large " " 4-8 " Polymorphonuclear " 60-75 " Eosinophile " -1-4 " Changes in Numbers op Ked Blood Corpuscles.— Normal blood contains from 4,500,000 to 5,000 000 red blood corpuscles to the cubic millimetre, at sea level BLOOD. 215 3 •womeu having normally a smaller number than men. This number is frequently surpassed in vigorous, healthy persons; 6,000,000 is not infrequent in healthy young men. Altitude above sea level raises the count in direct ratio to the height attained. Concentration of the blood from any cause, such as profuse sweating, temporarily raises the count of red cells. In the new-born for the first ten days of life the number of red cells is very high, Y, 000, 000-8, 800, 000. In diseased conditions the number may fall to 2,000,000, and in extreme cases to less than 500, 000. Mark- ed decrease in number is readily detected with the aid of the microscope; the field is more trans- parent, the color of the corpuscles is paler, ' they show their bi-concave form less characteristi- cally, and the rouleaux are not as marked. The above appearances are generally sufficient for rough diagnostic pur- poses. When the exact number is desired, the Thoma - Zeiss or some other counting apparatus FiQ. 27.— Thoma-Zeiss Pipettes. A, For red IS required. corpuscles; B, for wUte corpuscles. ! 1 ' Oligocythemia is usually associated with deficiency of coloring matter. 216 PHYSICAL DIAGNOSIS. The Thoma-Zeiss instrument consists of a pipette by means of which a measured amount of blood is diluted in a known proportion (see Fig. 27). The tube of the pipette is graduated in such a manner that when it is filled with blood up to the mark 1, and then with a diluting fluid up to the mark 101, the dilution of the bloo(^ is 1: 100. If the pipette is filled to the mark 0.5 the dilution of the blood is 1 : 200. Within the bulb of the pipette there is a glass ball to aid in mixing the blood. The diluting fluids used are (1) a six-per-cent. solution of common salt deeply tinged with gentian violet; (2) Toisson's solution, which also stains the white cells so that they can be easily distinguished from the red. The formula is as follows: Methyl violet 5 B 025 gm. Sodium chloride 1.000 " Sodium sulphate 8.000 " Neutral glycerin 30.000 cm. Distilled water 160.000 " (3) Gowers' solution: Sodii sulphatis gr. 112 Acidi acetici 3 i. Aquae i iv. The counting chamber consists of a large glass slide with a central excavation. In this excavation a shelf has been cemented, and on its surface a square millime- tre is ruled off and divided by fine lines into four hun- dred squares. Every fifth square is divided by an addi- tional line. The surface of the shelf is 0.1 millimetre below the level of the surface of the slide. If therefore BLOOD. 217 a drop of the diluted blood be placed on the shelf and covered with a cover glass the number of cells seen in each small square vpill be the number contained in -^^ ^ ^~ tdVt cubic millimetre. The method of procedure fJJWJJJJM m Fio. 88.— Thoma-Zeiss Counting Slide. A., Buled disc; B, cover-glass; C, moat. is described by Dr. Ewing as follov^s : The cleaned fin- ger tip or ear is punctured and a drop of blood is allowed to flow. The pipette is filled to the mark (1) or (0.6) ; if the blood be drawn a little above the mark gentle tap- ping on the point will bring it down to the mark. The tip is then cleaned of adherent blood. The mixing fluid is then quickly drawn into the pipette to the mark 101, and thoroughly shaken. The counting-chamber and cover A Pig. 29.— Thoma-Zeiss Counting Slide. A, Euled disc. glass having been thoroughly cleaned, two drops of the diluted fluid are expelled from the pipette, and a small drop is then placed on the centre of the shelf. As quickly as possible the cover glass is adjusted and firmly 218 PHYSICAL DIAGNOSIS. pressed down. If Newton's color-rings appear at the corners of the cover glass the preparation is successful. Dust particles may prevent intimate contact of the slide and cover glass and the formation of these rings, and must in every case be avoided. The rapid and successful ad- justment of the cover glass is the most important detail in the process of counting red cells. The size of the drop to be deposited on the shelf can only be learned by experi- ence. When the cover glass is in place the blood must at least cover all, or nearly all, the shelf. It may project into the moat, but if it runs out underneath the cover glass the specimen must be discarded. The preparation ap- pearing thus far successful, it is examined in the light to see that the red cells are evenly distributed. If the cover glass has not been rapidly adjusted it will be found that the central portions of the blood contain more cells than the peripheral, in which case the specimen must \)e rejected. After the cells have settled for a moment, counting may proceed, using a mechanical stage and Leitz No. Y lens. One hundred small squares at least must be counted over. To avoid counting the same cells twice it is customary to include in any square those cells lying on the lines below and to the right of 0° 00 o °°1 jO O o a o o n O o O o a o QOO o °n QOO n . °a o o OoO o o o O*^ o o o o o o o o o o °o° o o o o o o O o o o o O o o c o o o o °o:° o o Q o Oo O >o o o o oo OO o o o o oo o o o o O O O O ooo o o o o o o OOo J oo O o o ,ooo = o O°o Oo o o o o o '0 o oo o a o ' °0 o o 00 O O OOO Oo o o o o o O o i i o o a o°° Oo. , oO o o ) "o °,"o o o >° o° 0° "o- ^0 o o o O P O °0° o o < k o Fig. 30— Field of Thirty-Six Squares on Buled Disc o£ Thoma-Zeiss Counter Covered with Normal Blood Diluted Two Hundred Times. BLOOD. 319 the square, omitting such as lie on the lines above and to the left of the square. Computation. — Having counted all the cells in one hundred small squares, the number per cubic millimetre may be estimated as follows : One hundred small squares comprise an area of ^^ square millimetre, or a cubic contents of HuX^V (depth) = -}^ cubic millimetre. The dilution of the blood being 1:100, the number of cells counted is therefore to be multiplied by 40X100 =4,000. If 400 small squares are counted for complete accuracy, the multiplier is 1,000. Cleaning the Instrument. — After every use of the pipette it is absolutely essential that both chamber and tube be thoroughly and properly cleaned and dried. The counting chamber is to be wiped with a cloth moist- ened with water. Alcohol and ether dissolve the cement under the shelf. The mixing pipette is first emptied of blood, the last particles of which are to be dissolved by reiilling with water. The bulb is then filled with alcohol and then with ether, and after this fluid has been expelled the tube must be thoroughly dried before using again (blowing dry air from a rubber bulb will soon dry it). Minute particles of water remaining in the tube cause the partial or complete solution of red cells in the subsequent speci- men, and the appearance of faint "shadow corpuscles." Enumeration of Leucocytes. Leucocytes are best counted in the same specimen and chamber with the red cells. A special chamber has been constructed for this purpose, in which nine square milli- metres can readily be recognized by examining the 220 PHYSICAL DIAGNOSIS. chamber with the low power of the microscope. , In order to enumerate a sufficient number of leucocytes for accurate results, it is necessary to count all the white cells appearing in three, six, or nine square millimetres, according to their abundance. Only eight to ten leuco- cytes are found in one cubic millimetre of diluted nor- mal blood, but at least fifty must be counted to secure Fio. 31.— Modified Euling of Thoma-Zeiss Counting-cliamber. any reliable indication of their numbers, while at least one hundred or more must be counted when minor vari- ations in number are being followed. For the purpose of counting over this larger area, a mechanical stage is almost essential. The leucocytes are readily identified in salt solution, after a little practice, by their refractive appearance, and usually also from their bluish stain from gentian violet. The small lymphocytes are the only ones that are liable to be overlooked with ordinary care. WHITE BLOOD CORPUSCLES. 331 Computation. — If fifty-four loucocytes are found in six square millimetres the average is nine per square millimetre, or (9X1,000) nine thousand per cubic milli- metre. Increase in the Number of White Blood Corpus- cles {Leucocytosis) . — The proportion of white to red corpuscles in the blood varies from 1 : 400-700. In dis- eased conditions this ratio is often diminished ; in leukae- mia it may even become 1:1. The varying ratio be- tween the number of red and white cells is not the essential point in leucocytosis, but it is the actual in- crease in white cells above the normal for the individual, the kind of leucocytes present, and their ratio to the total number of leucocytes. All leucocytoses are not evi- dences of disease, as there are physiological leucocytoses, viz. : Leucocytosis of the new-born, of digestion, of pregnancy, post partum, and after violent exercise, massage, and cold baths. Those of the new-born and post partum may be as high as 36,000 per cubic milli- metre, while those of the other physiological conditions do not usually go above 13,000-15,000. The relative percentage of the different kinds of leucocytes remains unchanged. In considering the leucocytosis of disease several fac- tors must be taken into consideration. Certain diseases do not cause a leucocytosis at all, and in the diseases in which it is present it varies in intensity in ratio to the severity of the infection and the resistance of the indi- vidual affected. A mild infection against a good resist- ance gives but a slight leucocytosis, A more severe infection against a good resistance gives a marked leu- cocytosis. An overwhelming infection, breaking down 223 PHYSICAL DIAGNOSIS. all resistance, gives no leucocytosis. The absence of leucocytosis, therefore, may indicate a very favorable or a fatal prognosis, while the presence of a marked leuco- cytosis indicates a strong reaction against an infection, but does not indicate the final result. Leucocytosis is regularly absent in typhoid fever, malaria, in most cases of grippe, measles, and tuberculosis (except in some cases of tubercular meningitis and peritonitis, and pul- ; monary tuberculosis with mix«d infection). It is pres- ent in the other acute infectious fevers and in all pyaemic and septicsemic conditions, in the secondary stage of syphilis, in carcinoma and sarcoma (some cases), actino- mycosis, trichinosis, and following the ingestion of cer- tain substances as salicylates, in illuminating gas poi- soning, during and after etherization, and after severe hemorrhages. In the majority of these diseases it is the polymorphonuclear leucocytes which are increased, but in trichinosis the eosinophiles are the ones affected. The largest leucocytosis is present in the bubonic plague, in which 200,000 per cubic millimetre have leen seen. Next to this pneumonia and sepsis show the greatest number. The blood in leukaemia is peculiar to the disease. While the ratio of red to white cells is much diminished, becoming as low as 1:1, or even, as in some cases on record, the white cells have been actually more numer- ous than the red, the characteristic features of leukemic blood are the presence of abnormal cells and the abnor- mal proportions in which the leucocytes occur. In the majority of cases there are two distinct types, splenic- myelogenous or myelocythsemia, with great hypertrophy of the spleen and marrow changes, with but little or no WHITE BLOOD CORPUSCLES. 223 involvement of other lymphatic tissues, and lymphatic leukaemia or lymphsemia with some group of lymphatic glands enlarged. Myelocythsemia usually runs a chronic course, while lymphsemia is more often an acute disease. The characteristics of myelocythsemia are : a moderate decrease in the red cells, usually to about 3,000,000 per cubic centimetre ; the haemoglobin a little more than pro- Fia. 38.— Blood from Case of LeucocythBsmia. A A, white corpuscles; B B, red blood corpuscles. X 300. portionately decreased ; nucleated red cells, both normo- blasts and megaloblasts, are very numerous (see Blood of Anaemia for a description of these cells), the former usually predominating. The total number of white cells averages about 450,000 per cubic millimetre. Mye- locytes are present in large numbers and basophile cells are also numerous. The percentage of polymorphonu- clear neutrophiles and small and large mononuclear cells is diminished from the normal, while that of the eosino- philes is often shghtly increased. Of course the actual 324 PHYSICAL DIAGNOSIS. number of all leucocytes is enormously increased, but the percentage present of each variety varies greatly from the normal. In acute lymphaemia the red cells are much diminished, with a rapidly progressing anaemia. The nucleated red cells may be as abundant as in myelocythsemia, though usually they are not so numerous. The actual number of leucocytes is not, as a rule, so great as in myelocythse- mia, and the lymphocytes form about ninety per cent of all leucocytes present. The large mononuclear forms usually predominate. The polymorphonuclear neutro- philes and eosinophiles are few in number. In chronic lymphsemia the red cells are not so much diminished as in the acute form, and the nucleated forms are not common. The small lymphocytes are the predominating form of leucocytes. As in acute lymph- semia, they form over ninety per cent of the total number. The myelocytes and eosinophiles are scanty, and the neutrophiles are present in but a small percentage. In estimating the percentages of leucocytes a stained preparation must be used. The specimen of blood must be prepared in a thin layer, as already described in the preparation of a dried specimen. After the specimen has dried spontaneonsly it is hardened by heat or im- mersion in equal parts of absolute alcohol and ether. If the leucocytes are to be studied, heat fixation is the best. The specimens should be heated in a hot-air oven to 140°-155° C, and as soon as the temperature reaches the required point the specimens should be taken out and allowed to cool. If the red cells are the ones to be studied for malarial organisms or nucleated red corpus- cles, the alcohol and ether method is sufBcient, and the RED BLOOD COKPUSCLBS. 235 specimens should be immersed for one-half hour, though a twenty-four-hour immersion is much better. The best stain is Ehrlich's triacid mixture It is made as follows (Cabot) : Saturated watery solution of orange G. . . 6 c.c " " " acid fuchsin . . 4 " Add to these, a few drops at a time, shaking between each addition : Saturated watery solution of methyl green 6.6 c.c. Then add : Glycerin 5 c.c. Absolute alcohol 10 " Water 15 " Shake thoroughly for a few minutes and allow it to stand for twenty-four hours. Do not filter. A drop of this stain is spread over the specimen and allowed to stain for at least three minutes. It can be left longer if desired, as it will not overstain. It is then ■washed off with water, the specimen dried between filter paper and mounted with balsam, and is then ready for examination. In estimating the differential percent- ages of leucocytes, from five hundred to one thousand leucocytes must be counted, and the percentage of each form present must be reckoned. Changes in Size, Form, and Color of Eed Blood Corpuscles. — At times the blood contains cells that are smaller than the normal red blood corpuscles, but which have the same shape and contain haemoglobin. These cells are called microcytes, and the condition micro- cythcemia. It occurs in all forms of anaemia, and has no diagnostic significance. 15 226 PHYSICAL DIAGNOSIS. Colored corpuscles that are larger than normal {ma- crocytes) are also found, and, while they may be presenn in all ansemias, they are most common in the pernicious type. Closely associated with variation in size is that of form. The red blood corpuscle may assume a variety of shapes, as club, dumb-bell, anvil, flask, etc., when they are called poikilocytes (Fig. 33), and the condition poihilocytosis. These cells are found in varying num- f d Fig. 33.— Poikilo-, Macro-, and Mici-ocytes (d, ft, c). a, normal red blood cell; e, broken-down red blood cell; /, nucleated red blood cell (marked anaemia). (After Quincke.) hers in all anaemic conditions, but are most marked in pernicious anaemia. These degenerations are called ne- crobiosis. Another evidence of necrobiosis is the change in color certain red cells take with the triacid stains. Instead of the orange color they are brownish, purple, or gray. This is called polychromatophilia. Besides these necrobiotic changes in anaemia we find three forms of nucleated red cells : normoblasts, megalo- blasts, and microblasts. The normoblasts are found in the bone marrow of healthy individuals. They are of the same size and color as a normal red cell, but contain RED BLOOD CORPUSCLES. 237 a round rucleus, which usually lies to one side in'the cell and equals about one-half the diameter of the whole cell. The nucleus may project over the edge of the corpuscle or even half out of it. With Ehrlich's tri-color stain the nucleus is stained blue-black or light blue-gray with a dark blue rim. Occasionally the nucleus is not single and round, but may be double or many-shaped. The megaloblast is a very large cell from 11 to 20/* in diameter. It frequently shows polychromatophilia. Its large nucleus fills most of the cell, and stains pale green with Ehrlich's tri-color stain. There are often purplish granules scattered through the nucleus. Microblasts are rarer than either of the other nucleated Fig. 34.— FleiscU's Hsemometer. a, Partition into which the blood is put; a', par- tition' into which water is put; (?, mixing cell; K, K, colored glass slip; P, P, metal frame on which scale is marked; B, S, reflector; T, screw which moves the frame, P, P. red cells. The cell body is smaller than the normal red cell and contains a nucleus like that of the normoblast. As the color of the red blood corpuscles depends upon 228 PHYSICAL DIAGNOSIS. the amount of coloring matter they contain, a pale color of the blood may be due to a deficiency of haemoglobin, as well as to a diminution in the number of cells. Both conditions may be appreciated under the microscope with little practice. To estimate accurately the amount of hsemoglobin in the blood. Von Fleischl's haemometer or Henocque's haematoscope is required. The method of estimating the haemoglobin with Von Fleischl's instrument consists in comparing a certain amount of blood dissolved in distilled water with the colors of a graduated glass wedge. A metallic cell di- vided into two compartments is placed on the stand of the instrument in such a manner that the compartment containing clear water rests over the colored glass wedge, while that containing the blood rests so that the light penetrates directly. The wedge is then moved up or down the scale till the colors in the two compart- ments seem to correspond. The number is then read off on the scale, which gives the percentage of haemoglobin. The scale reads from zero to 120. The color of normal blood for men is 100, for women 80-90. The method of procedure is as follows: One compartment of the me- tallic cell is partially filled with water, and one of the capillary tubes in metal handles accompanying the in- strument is touched to the drop of blood flowing from the punctured ear or finger, when it will fill instantly with blood; any blood on the outside of the tube is rapidly wiped off, and the tube is quickly put in the water in the cell and rattled to and fro. The capillary tube is then washed out by forcing water through it from a medicine dropper. Both sides of the cell are filled up with water, using the medicine dropper and BLOOD CHANGES. 229 stirring the blood mixture with the metal handle of the pipette. Great care must be taken that the fluid in one side does not run into the other. The examination is made in a dark room by yellow candle-light or lamp- light and the colors seen in the two cells are matched by moving the glass wedge to and fro. It is important to see that the glass pipette is clean and dry before using ; passing a thread wet with alcohol and ether through it will clean it. When filled the tube must be level full, with neither a convex nor concave meniscus. To prevent oxidation a glass cover may be placed over the filled cell. Care must be used not to enclose air bubbles or expel any of the blood solution. Do not sit facing the light, but always sideways to it. Use as little light as possible. A yellow or black paper tube fitted over the cell is of great assistance. Alter- nate the eyes, and rest them from time to time. As Cabot points out, sudden color changes affect the retina more than gradual ones. The thumb-screw should be moved with quick, short turns rather than slowly and gradually. Clinical Significanck of Blood Changes. — The diagnostic value of changes in the number of white blood corpuscles has already been noted. In simple ansemia, due to hemorrhage, or dependent upon diseased conditions associated with diminution in the number of red blood corpuscles, there is a corre- sponding decrease in the amount of haamoglobin. In the severer forms there is necrobiosis of the red cells and normoblasts, and often a leucocytosis. In chlorosis, although the number of red blood cor- puscles is not notably reduced, usually not below 4,000,- 230 PHYSICAL DIAGNOSIS. Fio. 35.— Normal Blood. Magnified 360 diameters. Via. 36.— Pernicious Anaemia. Magnified 350 diameters. Note the relatively large jze and well-stained centers of the cells. BLOOD CHANGES. 231 Pig. 37.— Chlorosis. Magnified 350 diameters. Note small size and pale centers. Fig. 38. —Chronic Secondary Anaemia Due to Bleeding Piles. Magnified 350 diame ters. Note the similarity ot chlorotic blood (Tig. 37). 232 PHYSICAL DIAGNOSIS. 000, the loss of haemoglobin is excessive, and the indi- vidual cells appear pale and "washed out." Microcytes, macrocytes, and poikilocytes may he found in small number. Normoblasts are rare even in severe cases. Blood plaques are usually increased. There is not usu- ally a leucocytosis ; sometimes there is an increase of lymphocytes, and a few myelocytes have at times been observed. Pernicious anaemia is attended with a great diminu- tion in number of all the cellular elements. The red cells are diminished to about one million per cubic millimetre. The haemoglobin content of individual cells is often relatively high. There is an increase in average size of the red cells. Poikilocytosis and polychromato- philia are common. Nucleated red cells are often abun- dant, and the megalohlasts are more numerous than the normoblasts. The white cells are diminished, and there is often a lymphocytosis with a small number of myelocytes. Free pigment, and white blood corpuscles containing pigment granules, are found in the melanaemia of ma- larial disease. 8erum Diagnosis.— A ievr years ago Pfeiffer dis- covered that the serum of the blood of animals immun- ized against a given infection would cause a definite reaction when mixed with the culture of the germ causing the infection. Widal applied this clinically to typhoid fever. The reaction consists in the aggluti- nation of the scattered and actively motile bacilli into clumps of motionless bacilli, with the spaces between these clumps clear or nearly clear of bacteria. The methods of procedure are as follows : (1) After careful SEKUM AND DRIED BLOOD. 233 disinfection of arm and syringe, about five cubic centi- metres of blood are drawn from a superficial vein, and immediately expelled into a sterile test-tube and set aside until the serum has separated from the blood clot. Eight drops of the serum are then placed in four cubic centimetres of neutral broth, and the mixture is inocu- lated with a loopful of a twenty-four-hour old bouillon culture of typhoid culture. This culture is allowed to stand twenty-four hours at 37° C. At the end of this time, perhaps earlier, the culture will be clear, and there will be flakes of bacilli as a sediment at the bottom of the tube or adhering to the sides if the case be one of typhoid fever. Otherwise the broth will be evenly tur- bid and a true sediment does not occur. (2) Nine drops of culture are measured with a medi- cine dropper into a small test-tube, and then one drop of fresh blood from the punctured ear or finger is dropped from the same dropper into the test-tube. A loopful of this mixture is then examined on a cover-glass on a hol- low slide, or simply between cover-glass and slide, to see if a typical reaction occurs. This gives the usual 1 : 10 dilution. " The following are the methods and technique recom- mended by the New York Health Department : ' " Technique of Obtaining Serum and Dried Blood. — Blood may be easily obtained by pricking the tip of the finger or the ear. Two or three large drops should be collected on a glass slide and allowed to dry. Paper is not as good a receiver for the blood as glass, for the blood soaks more or less into it, and later, when it is ' Biggs and Park, The American Journal of the Medical Sciences, March, 1897. 234 PHYSICAL DIAGNOSIS*; dissolved, some of the paper-fibre is apt to be rubbed off witJi it. "In preparing the specimen for examination the dried blood is brought into solution by mixing it with about five times the quantity of water. Then a drop of this decidedly reddish mixture is placed on a cover-glass and Fig. 39.— Pure Culture. Fio. 40.— Partial Reaction. Fig. 41.— Typical Clumping. to it is added a drop of a fifteen- to twenty -hour bouillon culture of the typhoid bacillus. The two drops, after bemg mixed, should have a faint reddish tinge. The cover-glass, with the mixture on the surface, is inverted over a hollow slide (the edges about the concavity hav- mg been smeared with oil or fluid vaseline so as to make PSEUDO-SEACTIONS WITH DRIED BLOOD. 335 a closed chamber) and the hanging drop then examined under the microscope (preferablj' by gaslight), a high- power dry lens (about | inch) being used. " If the reaction takes place rapidly, the first glance through the microscope reveals the completed reaction, all the bacilli being in loose clumps and nearly or alto- gether motionless. Between the clumps are clear spaces containing few or no isolated bacilli. " If the reaction is a little less complete, a few bacilli may be found moving slowly between the clumps, in an aimless way, while others attached to the clumps by one end are apparently trying to pull away, much as a fly caught on fly-paper struggles for freedom. "If the agglutinating substances are still less abun- dant, the reaction may be watched through the whole course of its development. Immediately after mixing the blood and culture together it will be noticed that many of the bacilli move more slowly than before the addition of the serum. Some of these soon cease all progressive movement, and it will be seen that they are gathering together in small groups of two or more, the individual bacilli being still somewhat separated from each other. Gradually they close up the spaces between them, and clumps are formed. According to the com- pleteness of the reaction, either all the bacilli may finally become clumped and immobilized or only a small portion of them, the rest remaining freely motile, and even those clumped may appear to be struggling for freedom. With blood, containing a large amount of the aggluti- nating substances all gradations in the intensity of the reaction may be observed, from those shown in a marked and immediate reaction to those appearing in a late and indefinite one, by simply varying the proportion of blood added to the culture fluid. " Pseudo -reactions with Dried Blood. — If too con- centrated a solution of dried blood from a healthy person is employed, there will be an immobilization of the 236 PHYSICAL DIAGNOSIS. bacilli, but no true clumping. This is sometimes mis- taken for a reaction. Again, dissolved blood always shows a varying amount of detritus, partly in the form of fibrinous clumps, and prolonged microscopical exam- ination of the mixture of dissolved blood with a culture fluid shows that the bacilli often become more or less entangled in these clumps, and in the course of one-half to one hour very few isolated motile bacteria are seen. The fibrinous clumps, especially if examined with a poor light, may be very easily mistaken for clumps of bacilli. This pseudo-reaction is regarded by many inexperienced observers as a true typhoid reaction, but it occurs as readily with non-typhoid as with typhoid blood. [An- other form of pseudo-reaction may occur in which there will be distinct clumping, the clumps, however, are not motionless, but there is a noticeable heaving of the clumps and a greater or smaller number of freely motile bacilli are seen moving between the clumps. J " The Use of Serum Obtained from Blisters or the Blood. — Fluid serum can be easily obtained in two ways : 1st. The serum may be obtained directly from the blood thus : the tip of the finger or ear is pricked with a lancet-shaped needle, and the blood as it issues is al- lowed to fill by gravity a capillary tube having a central bulb. The ends of the tube are then sealed by heat or wax, and as the blood clots a few drops of serum sepa- rate. This method of obtaining blood-serum has the advantage of rapidity; but also this disadvantage, namely, that the serum thus separated is apt to contain more or less blood-cells, which somewhat obscure the field when the liquid serum is immediately mixed with the culture, and which cause clumps of detritus (resem- bling, though less marked, those found with the dried blood), if the serum is allowed to dry. 2d. The serum may be obtained from a blister. In" the examinations thus far made this has given far more satisfactory re- sults. The method is as follows: a piece of cantharides SERUM AND DRIED BLOOD. 237 plaster the size of a five-cent piece is applied to the skin at some spot on the chest or abdomen. A blister forms in from six to eighteen hours. This should be protected from injury by a vaccine shield or bunion plaster. The serum from the blister is collected in a capillary tube, the ends of which are then sealed. Several drops of the serum can be easily obtained from a blister so small that it is practically painless and harmless. The serum ob- tained is clear and admirably suited for the test. " The Advantages and Disadvantages of Serum and Dried Blood for the Serum Test. — The dried blood is easily and quickly obtained and does not deteriorate or become contaminated by bacterial growth. It is readily transported, and seems to be of nearly equal strength with the serum in its agglutinating properties. It must, however, in use, be diluted with at least five times its bulk of water, otherwise it is too viscid to be properly employed. The amount of dilution can only be determined roughly by the color of the resulting mixture, for it is impossible to estimate accurately the amount of dried blood from the size of the drop. "Serum, on the other hand, can be used in any dilu- tion desired, varying from a mixture which contains equal parts of serum and broth culture to that contain- ing 1 part of serum to 100 parts of culture. It can be measured roughly by the platinum loop, or more care- fully by a graduated capillary pipette. The disadvan- tages in the use of serum are entirely due to the slight difficulty in collecting and transporting it, and the delay in obtaining it when a blister is employed. If the serum is obtained from blood after clotting has occurred, a greater quantity of blood must be drawn than is necessary when the dried blood method is used. If it is obtained from a blister, a delay of eight to eighteen hours is re- quired . The transportation of the serum in capillary tubes presents no difficulties if tubes of sufficiently thick and tough glass are employed and a proper case is supplied." 238 PHYSICAL. DIAGNOSIS. In testing any specimen of dried blood or serum with a dilution of 1 : 10 or 1 : 20, if a typical reaction does not occur in fifteen to twenty minutes the result should be considered as "no reaction." Clinical Significance of WidaVs Tes^.— When pres- ent the Widal test is one of the surest single symp- toms of typhoid fever. But as a few cases have been reported in which the blood of other diseases has given a reaction in 1:10 dilution, we must consider a 1 : 10 reac- tion as indicating that the case is probably one of ty- phoid. A 1 : 20 reaction, however, may be considered as indicating that the patient in all probability has had or has typhoid. Eeactions in dilutions of 1:40-60-100 may be considered as positive. The reaction appears in the majority of cases by the tenth day. It may appear as early as the third or fourth day, or as late as the thirty-fifth. It sometimes does not appear until during convalescence or not at all during the attack, but does appear during a relapse. In from two to five per cent of all cases it does not appear at any time. The blood may retain the power of giving the reaction for weeks, months, or even years after recovery from typhoid. The presence of the Widal test may be positive proof of typhoid, but its absence in any given case at any time of the disease does not disprove typhoid fever. At the present time a few micro-organisms are recog- nized in the blood as diagnostic of existing diseased con- ditions. Spirillum of Eelapsing Fever. — To examine for spirilla a drop of blood is placed on a slide under a cover glass. They appear as fine, delicate spiral threads. Their length is about six times the diameter of a red SPIRILLUM OF RELAPSING FEVER. 239 blood corpuscle (Fig. 42). Attention is often called to their presence in blood by the disturbance their motion causes in the red blood corpuscles. They should be sought for with an oil- immersion lens and Abbe's con- denser. It is almost impossible to stain them, as they are destroyed by most staining solutions. The pneumococcus is sometimes found in the blood in cases of pneumonia or in malignant endocarditis due to Fig. 42.— Spirillum of Relapsing Fever. (Drawn by J. M. Byron, M.D., Loomis Laboratory. this organism. The method of Sittmann is the best procedure. Five or six cubic centimetres are drawn from an arm vein after careful sterilization of syringe and skin, and the blood is then expelled into sterile bouil- lon or into fluid agar, the temperature of which is 45° C, and the agar and blood mixture is plated and grown in the thermostat at 37° C. The pneumococci appear in the blood about twenty-four to forty-eight hours before death. All cases in which the pneumococci have been found have not proved fatal; but it is in either fatal 240 PHYSICAL DIAGNOSIS. cases or in severe cases which often show metastatic infections from the germ. (For staining see Sputum.) In general septicsemia and in mahgnant endocarditis Fig. 43.— Bacillus of Authrax. CDrawn by J. M. Byron, M.D., Loomis Laboratory.) and in pulmonar}' tuberculosis with cavities streptococci and staphylococcus aureus and albus are often found in "^>"'' Fig. 44. -Bacillus ot Typhoid Fever, x 700. (Drawn by J. M. Byron, M.D . Loomia Laboratory.) the circulating blood. To prove their presence Sitt- mann's method of procedure, as above described, should be employed. BACILLUS OP ANTHRAX. 241 Bacillus of Anthrax. — This bacillus appears as a rod, straight or but slightly curved ; its length is from one to two diameters of a red blood corpuscle, and its breadth about one-sixth its length (Fig. 43). They may be joined so as to form chains. They can be seen with- out staining, or can be stained with a watery solution of methyl blue (two parts to the hundred). Mice and guinea-pigs are ver}' susceptible to this disease. If blood from a case of anthrax (wool-sorter's disease) be injected into one of these animals, it shows immense numbers of bacilli in the blood in a short time. Bacillus of Typhoid Fever (Fig. 44). — This bacillus has been found in blood aspirated from the spleen. (See also Faeces.) Aspiration of the spleen is not justifiable, as it has caused death. Tubercle Bacillus. — In general miliary tuberculo- sis, tubercle bacilli are sometimes found in the blood. (For methods of staining, etc., see Sputum.) Plasmodium Malaria. — Amoeboid bodies have been found in the blood during a malarial paroxysm, by Lav- eran and other observers. Three varieties are now recog- nized : the tertian, quartan, and sestivo-autumnal. The youngest form of all of these types is an amoeboid body, which is a small, nonpigmented, hyaline spheroid. Just after a malarial paroxysm, or during the later part of it, these bodies are found free in the blood and in the red cells. In the tertian parasite these young forms appear in the red cells as highly refractive spheres showing slight but active changes in shape and position. They are from one-fifth to one-fourth the size of the red cell. Usually but a single parasite is present in a red cell, 16 243 PHYSICAL DIAGNOSIS. though at times two or more may be seen in the same corpuscle. In twelve to eighteen hours after the chill the parasite occupies about one-third of the corpuscle, and the destroyed haemoglobin is seen as fine, nearly black pigment granules. In this stage the amoeboid movements of the parasite are very active, so that its form varies greatly. The pigment granules are also 10 Fig. 45.— a Parasite of Tertian Malaria Cafter Thayer). 1, Normal red cells; 2 and 3, hyaline parasites ; 4, 5, 6, 7, pigmented forms ; 8, 9, 10, 11, segmentation. actively motile. The pseudopodia can be seen pervading the whole corpuscle ; by the union of two pseudopodia a ring shape is formed enclosing a bit of the corpuscular substance. This ring is coarser, larger, and more irreg- ular than the signet-ring form of the sestivo-autumnal parasite. The red cell is usually distinctly swollen. On the day of apyrexia the amoeboid movements are slug- gish but still present, while the pigment is actively motile. The full-grown parasite is larger or about the size of the swollen corpuscle around it. About the end of PLASMODIUM MALARIA. 243 forty-eight hours the amoeboid movement practically ceases, and pigment collects in a mass at the centre, and fine radiation appears from periphery to centre, dividing . the parasite into from fourteen to twenty segments or spores. Each spore contains a fine central point sup- posed to be the nucleus. The cycle is tjompleted by the dis- charge of the spores into the blood, and is coincident with 10 U U 13 i£ 15- Fig. 46.— Parasite of Quartan Malaria (after Thayer). 1, Normal red cell; 2, hyaline parasite; 3 to 11, pigmented forms; 12 to IS, segmenting forma. the chill. The pigment freed is taken up by the leucocytes or deposited in the liver, spleen, and lymphatic organs. The segmentation of the tertian forms occurs mostly in the internal organs, and is not very common in the peripheral circulation. The quartan parasite completes its cycle of develop- ment in seventy-two hours and entirely within the circu- lating blood. The youngest forms are not distinguish- able from the young tertian. In a short time, however, they become more refractive and of sharper outline, and 244 PHYSICAL DIAGNOSIS. the amoeboid movements more sluggish and restricted. The pigment granules are coarser and darker than in the tertian. The red cell gradually loses its color, but does not swell as with the tertian, or become green or coppery-colored, as with the sestivo-autumnal. It is slightly decolorized and shrunken. The full-developed parasite is smaller than the red cell. After forty-eight 1 2 3 * J JO It 13 14 iS 16 Fia. 4r.— Parasite of ^stivo-Autumnal Malaria (after Thayer). 1 to 6, young forms; 7 to 13, mature forms; 14 to 16, segmenting forms. hours the amoeboid movements cease and the pigment is quiescent. From six to ten hours before the return of the paroxysm the first phases of reproduction appear. The pigment gradually moves from the periphery toward the centre, often in definite radial striae. These regular striae of pigment are rarely if ever seen in the tertian form. The pigment finally concentrates in one or more coalesced masses of pigment at the centre. The segmenting strisB appear and divide the parasite into from six to twelve pyrif orm segments, which rapidly become round or ovoid PLASMODIUM MALARIA. ^45 and separate from each other and the central mass. The red cell membrane ruptures, and the spores are free. The segmenting forms sometimes appear from six to eight hours before the chill, but most of them occur just before or during its onset. Of course all parasites do not ma- ture at the same instant, but each paroxysm corresponds with the maturation of one generation of parasites. The cycle of the cestivo-autumnal parasite is not definitely known. Welch gives it as from twenty-four hours or less to forty-eight hours or more. They develop mainly in the internal organs, spleen, and bone marrow, intestinal mucosa, and sometimes in the brain capillaries. The youngest forms closely resemble those of the ter- tian, but are readily distinguished when seen in the plasma or soon after entering the red cell. Ewing de scribes them thus: "In the plasma they move rapidly about with a peculiar rolling and darting motion, and exhibit three or four slightly projecting knobs, so that their shape is often that of a minute star with blunt points. In the cell they are slightly refractive, sphe- roidal, or ring-shaped bodies, showing rather active changes in form. In stained specimens, the earhest intracellular bodies are usually of the typical signet-ring form, but may be quite minute in size." It is not un- common to find two or more hyaline bodies in a single corpuscle. As they develop they show amoeboid move- ments and contain a few pigment granules. After from twelve to eighteen hours the characteristic signet-ring formation occupies about one-quarter to one-third of the red cell. The red cell may remain normal. It does not swell or become decolorized, but often is shrunken, creased, or otherwise deformed, and of a brassy color. 246 PHYSICAL DIAGNOSIS. Sometimes a necrobiotic change occurs in which the haemoglobin separates from a part or whole of the outer part of the stroma and collects around the hyaline body. After twenty-four hours the parasites tend to disappear from the peripheral circulation, and the segmentation takes place in the internal organs. The pre-segmenta- tion forms become more refractive and homogeneous, and the pigment fuses into a single small block situated at the centre or near the periphery. The sporulation occu- pies a longer time than in the tertian or quartan, and takes place in groups; hence the long duration of the gestivo-autumnal paroxysm. Sporulation is in general like the tertian but more irregular, and the spores are much smaller. The number of spores in each parasite varies from six to ten or less, to even thirty to fifty. The pigmented spheroidal body of this parasite, besides the regular sporulation, develops into the crescentic form. The young crescents appear in the general circulation on the third or fourth day, and the full-developed crescents by the fifth to seventh. The crescents measure from 9 to 12 /^ in length, and contain in the centre large, brown- i Fie. 48.— Flagellate Malarial Organisms (after Thayer). ish-yellow pigment granules. The remnant of the red cell membrane is often seen stretching across the concav- ity. These crescents are very resistant to quinine, and appear and last in the circulation for weeks whether or PLASMODIUM MALARIA. 247 not quinine has been given and the paroxysms have ceased. The crescents are supposed to be sterile forms of the parasites. Under certain unknown conditions flagellated forms develop from adult parasites. The flagellse are very mo- tile, and at times break off the parasite and move free. % Z ^ Fig. 49. They are nearly transparent and difficult to see. They are bulbous on the ends and sometimes contain pigment granules. They develop in fresh specimens after the blood has been spread under the cover .glass for a few minutes. Their biological significance is unknown. Fra. eo.-Filaria Sanguinis Hominis. cinbtantaneous photograph by J. M. Byron,M.D.) In studying these organisms a fresh specimen is ob- tained by allowing a drop of blood on a cover glass to 248 PHYSICAL DIAGNOSIS. spread out thin as the cover glass is dropped on to a slide. The amceboid movements and motility of the pigment can be seen in such specimens. Stained specimens must be thinly spread and instantly dried, and then are best fixed in equal parts of alcohol and ether for a half-hour or longer. A very light stain with eosin is necessary ; otherwise the early ring forms may be overlooked. The best stains are : Ozenzyenski's fluid — Saturated aqueous solution methylene blue 20 c.c. One-half-per-cent solution of eosin in seventy-five-per-cent alcohol 10 " Water 20 " Stain from ten to fifteen minutes, wash in water, and mount in balsam. Plehn's solution — Concentrated watery solution methylene blue 60 c.c. One-half-per-cent solution eosin in sev- enty-five-per-cent alcohol 20 " Distilled water 40 " Twenty -per-cent NaOH 12 drops For this solution the specimens are hardened by im- mersion for three or four minutes in absolute alcohol and then stained for five or six minutes in the solution. FiLARiA Sanguinis Hominis (Fig. 50). — The filaria is found in the blood of people living in the tropics, or who have become infected there. The worm may give no symptoms beyond the urinary. Formerly it was believed that there was but one spe- FILAEIA SANGUINIS HOMINIS. 349 cies of Filaria, but it is now recognized that there are at least four if not five such hsematozoal embryos, each be- longing to a separate and distinct species, and each prob- ably having its own special pathological relations. The filarise sanguinis are described by Manson as long, slen- der, transparent, gracefully formed, snake-like organ- isms, which, when seen under the microscope in newly drawn blood, exhibit a remarkable activity in coiling and uncoiling themselves, in wriggling and lashing about in incessant and rapid movement among the corpuscles. They remain alive — their movements gradually slowing down, however — for days on the slide, provided the blood be kept from drying up and at an ordinary temperature. One species, Filaria diurna, appears during the day, dis- appearing during the night ; another, Filaria nocturna, appears during the night, disappearing during the day ; whilst two species, Filaria Demarquaii and perstans, are constantly present both by day and by night. The first three species named are enclosed in long trailing sheaths, whereas Filaria perstans is unsheathed or naked. The best method of ascertaining the presence or absence of filariee in the blood is to make a deep puncture in the finger, and, when a large drop has welled up, transfer the whole drop to the centre of a glass slide by dabbing the slide against the blood. Spread the blood with a needle evenly over the slide for an area of about an inch and a half and allow it to dry. Stain by immersing the slide for about an hour in very weak watery solution of fuchsin, one or two drops of a saturated alcoholic solution of.fuchsin to an ounce of water; or more quickly in a two-per-cent solution of methylene blue. If it be found too deeply stained, it can be decolorized by washing for 250 PHYSICAL DIAGNOSIS. a few seconds in a weak solution of acetic acid, three or four drops to an ounce of water. The specimen may be examined wet or dry and with or without a cover glass. Sixty or eighty diameters is a sufficient magnifying power. With the fuchsin solution the filarise and leuco- cytes are the only stained objects on the slide. To study tho anatomy or movements fresh specimens must be used. Filaria diurna begins to appear in the peripheral circulation about 8 A.M., increasing in numbers till 12 or 1 P.M., and decreasing from that time till about 9 p.m., when it disappears for the night, Filaria nocturna be- gins to appear in the peripheral circulation at about five, six, or seven in the evening, increasing up to midnight, then gradually disappearing, till by seven or eight in the morning all have disappeared save perhaps an occasional straggler, which may be found at any hour of the day. This filarial periodicity is constant and depends on the sleeping habits of the host, for if the host sleep during the day and keep awake during the night the periodicity is reversed. The filariae are probably taken into the human body in drinking-water. In the case of the Fila- ria nocturna the female mosquito is the intermediary host. [For further details see Hanson's article in vol. iii., Allbutt's "System of Medicine,"] Examination of the Sputum. CELLULAR ELEMENTS. To examine for cells, a small portion of sputum may be put on a slide and covered, without staining, or the specimen may be double stained for tubercle bacilli, when all the cellular elements except red blood corpuscles retain their form. SPUTUM. 251 Epithelium.— Squamous cells from the mouth or vocal cords appear as large, flat cells, more or less granular. They may show fissures or folds. Columnar epithelium from trachea, bronchi, and nose is less often present; rarely are the cilia seen. From a clinical point the " alveolar " cells are the most important variety found in sputum. They are polygonal, with a granular protoplasm, and often show granules of pigment (carbon, blood pigment, iron, etc.) or fat glob- ules ; their nuclei are made more distinct by the addition of acetic acid. The statement that they are the true alveolar cells is now questioned. Their presence indi- cates that the specimen of sputum is from deeper por- tions of the respiratory tract, whatever may be their origin. White Blood Cells or Pus Cells. — These are al- ways present in sputum. When an abscess ruptures into the lung, or in purulent bronchitis, they may consti- tute the entire cellular element. Thej' give the charac- teristic reaction to acetic acid. They often contain par- ticles of pigment. Liver cells may be found in sputum. They indicate the opening of an hepatic abscess into a bronchus. Eed Blood Corpuscles. — A few are always found. They show their characteristic appearance (see Blood), except when retained in the bronchi for some time, when hsematoidin crystals may be present. CuRSGHMANTST's SPIRALS (Fig. 51). — These can often be seen by the naked eye. When magnified they are found to consist of a white central thread covered by fine fibres spirally arranged. They occur most often during asthmatic paroxysms and in capillary bronchitis. 353 PHYSICAL DIAGNOSIS. Bronchial Casts or Fibrinous Coagula (Fig. 62). —When the casts are of large size they are readily de- tected by the naked eye. Microscopic forms occur in pneumonia. In plastic bronchitis "they are long, and Fie. 51. Fig. 52. Fie. 51.— Cursehmann's Spirals, a, central thread. (After Curschmann.) Fig. 53.— Bronchial Cast. the terminal filaments may form a fine network in which epithelium and blood corpuscles are enclosed." Elastic Tissue. — Elastic fibres occur generally in bun- FiG. 53.— Elastic Tissue. CAfter vonjaksch.) dies, but they may retain the form of the alveoli (Fig. 53). They vary considerably in length and thickness^ SPUTUM. 353 are curled, and have dark borders. To obtain these fibres free from mucus^ etc., the sputum is put into a test tube, diluted with an equal bulk of water, and ten or fifteen drops of liquor potassse added. The mixture is then heated below the boiling point for a few minutes, and thoroughly shaken. By this process all the cellular elements are destroyed, but elastic tissue and micro- organisms are not affected. After standing for one or two hours, a small portion of the sediment is placed on a slide, covered, and examined. The presence of elastic fibres merely shows that destruction of lung tissue is taking place. They are found in tuberculosis, bronchi- ectasis, pulmonary abscess, and occasionally in pneu- monia. In pulmonary gangrene the fibres are generally destroyed in the lung by the ferments that are formed in that disease. PATHOGENIC BACTEKIA. Tubercle Bacillus. — In collecting the sputum it is necessary to instruct the patient to expectorate into a clean cup or wide-mouthed bottle, being careful to save that portion which is raised after coughing. Frequently specimens are sent for examination that contain only the secretion from the pharynx and posterior nares. The diagnostic value of such sputum is of course nil, unless there is tubercular ulceration of these parts also. Staining Solutions.— A number of solutions have been proposed, and special advantages claimed for each. The following give satisfactory results and are the most stable : 254 PHYSICAL DIAGNOSIS. No. 1. Ziehl-Neelson Fuchsin Solution— Fuchsin' 1 Pa^*- Alcohol, ninety-five per cent 10 parts. Carbolic acid '^ Water (distilled) 100 " Filter and keep in a well-stoppered bottle. No. 2. For Decolorizing — Nitric acid 1 pa^t. Water 3 parts. Or a better solution is 0.3 per cent hydrochloric acid in ninety-five-per-cent alcohol. No. 3. For Double Staining — Methyl green or methyl blue 2 parts. Water 100 " Filter and keep in a dark bottle. Preparation and Staining of Specimen. — The por- tions of sputum most likely to contain the tubercle bacilli are the small, whitish, opaque masses. One of these is picked up with a clean platinum needle or steel pen in a holder, and transferred to a cover glass. Another cover glass is placed over it, and, after pressing out the excess of sputum, the two glasses are separated by quickly slid- ing one from the other. A thin film remains on each glass, and is allowed to dry spontaneously. When dry, the cover glass is passed slowly through the flame of a Bunsen burner or alcohol lamp three or four times to fix the film, so that it will not be washed off during the nec- ' Two kinds of fuchsin are in the market, the basic an< ojsid. As tubercle bacilli only stain with the aniline dyes in alhadne solu- tions, the acid fuchsin is worthless. The bright crystalline fuchsin is for the most part basic. Acid alcohol also destroys the solution. PATHOGENIC BACTERIA. 355 essary manipulations. Care must be taken that the cover glass is not heated too hot, as then the bacilli lose their affinity for the dye. Either of the following meth- ods may be employed for staining the specimen, but the second will be found more convenient : I. A small amount of solution No. 1 is put into a watch crystal, and the cover glass floated on it with the film down. The crystal is held over a flame until steam arises (do not allow the solution to boil). After a few minutes the cover glass is removed, and the excess of dye rinsed off in clean water. It is then submerged in solution No. 2 for a few seconds, and immediately rinsed in another vessel of water. If the film still retains a bright-red color, it must be dipped again in No. 2 and immediately rinsed. This can be repeated until it shows only a slight pink or rose tint. If this step is carried too far, then even tubercle bacilli will be decolorized and the distinctive test destroyed. The cover glass is now floated for about a minute, film down, on solution No. 3, in another watch crystal, and the excess of dye washed off in clean water. It is then ready to be placed on a slide and examined. II. The cover glass, ' film up, is seized in forceps ; ^ with a medicine dropper a few drops of solution No. 1 are poured upon it, and heated, by slowly passing through ' Instead of using cover glasses to make the preparation, a number of specimens from different portions of the sputum can be placed on a slide, which is then treated as a cover glass, except that the cedar oil is placed directly on tke film, no cover glass being used. ^ Self -retaining forceps, made especially for this purpose, can be obtained from dealers m microscopes and supplies. 256 PHYSICAL DIAGNOSIS. the flame of a lamp or burner several times, until steam arises. After a few minutes the dye is washed off, as in I., and solution No. 2 added. This is allowed to remain for a few seconds only. If the specimen is still too deeply stained, the process can be repeated uptil the desired rose tint is obtained. Lastly, a few drops of solution No. 3 are allowed to remain on the glass for about a minute. This should be washed off in clean water. The prepara- Fio. B4.— Tubercle Bacilli from Sputum, X 900. (Drawn by J. M Byron M D Loomis Laboratory.) tion can be dried and permanently mounted in Canada balsam. The tubercle bacilli can be detected with good No. 1 objective, but it is better to use an- oil-immersion lens and Abbe's condenser. The tubercle bacilli, stained red, appear as small, rod- like bodies, slightly curved. While individually they are about one-quarter the diameter of a red blood, cor- puscle in length, two or three may be so grouped as to appear much longer. Portions of the protoplasm con- ACTINOMYCES. 357 tained in them do not stain, but are seen as clear spots, giving the bacilli a beaded appearance (Fig. 64). It is unknown whether or not these clear spots are spores. The presence of bacilli in the sputum indicates tuber- culosis of the lungs or larynx. But absence of the bacilli does not indicate that there is no tuberculosis, unless repeated examinations have been made. In acute miliary tuberculosis they are rarely found. Actinomyces, or Ray Fungus. — These appear as bunches of pear-shaped bodies (Fig. 55). They are easily detected without staining. To facilitate the ex- amination, the suspected sputum may be treated with liquor potassse (see Elastic Fibres above), and the actino- myces looked for in the sediment; or they may be stained by Gramas method. Their presence in the sputum indicates the involvement of the lungs by this disease, whose symptoms and early physical signs are similar to those of tuberculosis. In examinations of sputum suspected of containing tubercle bacilli it is of the greatest importance to disin- fect the hands if they become soiled. Also to prevent the sputum from becoming dried and disseminated in the air. When a platinum loop is used to spread the sputum on a cover glass, great care must be observed not to allow portions to snap off from the loop when brought near a flame. Carelessness in these details may have most serious consequences. Pneumococcus (Fig. 56).— The pneumococci of Fran- kel are found in the sputum in croupous pneumonia. Friedlander's method of staining them is to make cover- glass preparations of the sputum, as in the examination for tubercle bacilli. Treat the film for a minute with a 17 258 PHYSICAL DIAGNOSIS. one-per-cent solution of acetic acid, after which the specimen is allowed to dry in the air; it is then placed for a few seconds in a saturated aniline-water-and-gen- FiG. 65.— Actinomyces, or Bay Fungus. X 860. (Drawn by J. M. Byron, M.D. Loom] s Laboratory. ) tian-violet solution ; finally the dye is washed off with water and the cover glass mounted on a slide. Frankel Fig 56.— Pneumococeus. (After von Jaksoh.) treats the cover-glass preparation with a weak, watery solution of methyl blue. The pneumococeus has been BCHINOCOCCTJS. 359 found in the saliva of healthy persons and in the sputum of cases of bronchitis. The bacillus of influenza is often present in large numbers in the sputum of patients suffering from a grippe bronchitis or pneumonia, and also in cases of tuberculosis in which an influenza infection has occurred some time previously. The bacilli are minute rods 0.2-0.3 iJ- broad by 0.5 /^ long, occurring singly, rarely in chains of three or four members. They do not stain very easily with the aniline colors, and are decolorized by Gram's solution. At times they show a bipolar staining, when they may appear as cocci. A very dilute solution of Ziehl's solu- tion and water, in which the speci- men is stained for fifteen minutes, gives very good results. In recent cases the bacilli are found free in enormous numbers in the sputum, but after the bronchitis has lasted „^'«; w.-Eohi«ococcus Hooklets. some time they are found only inside the cells. When found in the leucocytes they often stain poorly, as they are apt to be degenerated. They are often found in pure cultures inside the thick green pellets occurring in influenza sputum. EcHiNOCOCCUS. — Hooklets and portions of the cyst wall (Fig. 57) are found in the sputum when hydatid cysts in the lungs, pleura, or liver have ruptured into a bronchus. Amceb^ coli may be found in the sputum if an hepatic abscess has opened up through the lungs. (See Fig. 84.) 260 PHYSICAL DIAGNOSIS. The Examination of Diphtheritic Exudates. The early diagnosis of diphtheria is always of the greatest importance. Clinically it cannot always be differentiated from other inflammations of the fauces and tonsils. A direct examination may be made by rabbing off a portion of the exudate with a sterile plati- num loop or with a sterile cotton swab on a steel wire. The exudate thus obtained is then smeared with a drop of water on a cover glass, allowed to dry, and then fixed in a flame as with sputum slips, and stained for ten minutes with Loeffler's methylene-blue solution. For one accustomed to the appearance of diphtheria bacilli this is a fairly good method in some cases. But if no diphtheria bacilli are found, or if any doubt exists as to the nature of the bacilli present, a culture on Loeffler's blood serum must be made. The exudate is obtained with a loop or swab as before, and then rubbed over the inclined surface of the blood serum. The serum tube is placed in a thermostat at 37° C. for from twelve to twenty-four hours. At the end of this time a platinum needle is swept over the various kind of colonies seen on the serum, and then smeared with a drop of water on a cover glass. This is allowed to dry, fixed in the flame, stained for ten minutes with Loeffler's blue and mounted in balsam. The colonies of the diphtheria ba- ^cillus on blood serum at the end of ten or twelve hours appear as pearl gray or whitish-gray, slightly raised points, and are about equal in size with the colonies of streptococci; but by twenty-four hours the diphtheria colonies are larger than those of the streptococci and nearly equal in size those of the staphylococci. The diphtheria on the blood serum outstrip in their growth in the first twenty-four hours most of the other bacteria THE EXAMINATION OF DIPHTHERITIC EXUDATES. 261 which may be present. In the cover-glass preparations made from the blood-serum tubes the diphtheria bacilH are found to possess the following characteristics, and are best described by Dr. W. H. Park: "The diameter of the bacilli varies from 0.3 to 0.8 a and the length from 1.5to6.6/<. They occur singly and in pairs, and very infrequently in chains of three or four. The rods are straight or slightly curved, and usually are not uni- formly cylindrical throughout their entire length, but are swollen at the end, or pointed at the ends and swollen in the middle portion. Even from the same culture dif- ferent bacilli differ greatly in their size and shape. The two bacilli of a pair may lie with their long diameter in the same axis, or at an obtuse or an acute angle. The bacilli possess no spores, but have in them highly refrac- tile bodies. They stain readily with the ordinary aniline dyes, and retain their color after staining by Gram's method. "With an alkaline solution of methyl blue the bacilli, from blood serum especially, and from other media less constantly, stain in an irregular and extremely characteristic way. The bacilli do not stain uniformly. Certain oval bodies situated in the ends or in the central portion stain much more intensely than the rest of the bacillus. Sometimes these highly stained bodies are thicker than the rest of the bacillus; again, they are thinner and surrounded by a more slightly stained por- tion. The bacilli seem to stain in this peculiar way at a certain period in their growth, so that only a portion of the organisms taken from a culture at one time will show the characteristic staining. In old cultures it is often difficult to stain the bacilli, and the staining, when it does occur, is frequently not at all characteristic. It is important in making cultures from exudates that no 362 PHYSICAL DIAGNOSIS. antiseptic, especially no mercurial solution, has lately been applied." Diphtheria bacilli persist in the. throat for a longer or shorter time after all membrane has dis- appeared. Cultures should therefore be made from time to time until their disappearance is assured. Fig. 27a.— Bacillus Diphtherise. The formula for Loffler's methylene blue is as follows: Saturated alcoholic solution methylene blue 30 c.c. Aqueous solution of KOH (1 : 10,000) 100 c.c. Loeffler's blood serum is composed of ordinary neutral bouillon of one litre of meat infusion, 1 per cent pep- tone, 0.5 per cent salt, and 1 per cent glucose. Three parts of serum are mixed with one of broth, and the mix- ture is run into small sterile tubes plugged with cot- ton. The tubes are inclined at an angle in a sterilizer and slowly brought up to' a temperature just below the boiling point, and kept at this temperature, 90°-95°C., for two hours. Prepared in this manner they can be kept ready for use for months. Urine. The microscopical examination of the urine deals al- most exclusively with those elements that form the sedi- ment. The urine is allowed to settle in a conical glass ; after a few hours a drop of the sediment is removed with a pipette and placed on a slide, under a cover glass, URINE. 363 for examination. The constituents of the sediment may be divided into two groups: 1. Non-organized. 2. Organized. I. (a) AMOEPHOUS DEPOSITS. Urates.— These usually appear as pale-pink, brown, or dark-red granular masses (Fig. 58), although at times the urate of soda has a globular form from which sharp spikes of uric acid project (Fig. 59}. Urate of ammonia also at times assumes a spherical form, with or without small projecting spicula (Fig. 60). The urates are held in solution in normal urine at or w o @ *^%1^ Fio. 58. Fig. 59. Fig. 60. Fig. 68. — Urate of Soda. A, amorphous granules in clusters; B, granules in strings, sometimes mistaken for granular casts. X 250. Fig. 59.— Urate of Soda with Spicula. Fig. 60.— Urate of Ammonia. A, clusters of brown spherules; B, isolated spherule with spicula—" the chestnut-burr " crystals. X 850. slightly below the body temperature. Their precipita- tion is favored by (a) acidity, (6) concentration, and (c) cooling of the urine. They appear in the urine in dis- orders of the digestive tract, and when the ingestion of nitrogenous food is beyond the needs of the body; in febrile conditions ; and in diseases of the heart and lungs that prevent proper oxygenation. Too little exercise, close rooms, and excessive use of wine and malt liquors predispose to their appearance in the urine. Their per- 264 PHYSICAL DIAGNOSIS. sistent presence without adequate cause is one of the diagnostic points of urinary calculi. Calcium Phosphate and Calcium Carbonate.— These are found in alkaline urine only. Calcium phos- phate occurs as minute granules and small spherical masses, or as angular particles. Calcium carbonate is almost always amorphous. Both are usually associated with the triple phosphates. Fat. — When fat occurs in the urine in small quan- tity, the condition is termed lipuria. The urine is tur- bid, but clears up on shaking with ether. The micro- scope discloses globules of varying size which strongly refract light. In chyluria, fat is present in large quantity and in a state of molecular subdivision. The urine has a milky appearance. Chylous urine most frequently depends on invasion of the urinary tract by the Filaria sanguinis hominis. (b) CRYSTALLINE DEPOSITS. Uric Acm. — Crystals of uric acid assume a great variety of forms, but as a rule they can be recognized by their color; the lozenge-shaped crystal is the com- monest form. If doubt exists as to the nature of an un- usual form, dissolve the crystals by adding a drop of caustic potash to the specimen, and then acidulate with a little hydrochloric acid ; if they are uric acid, they will recrystallize in one of the commoner forms (Fig. 61). All crystals of uric acid, as they appear in the urine, have the characteristic yellowish-red color. Uric acid appears in the urine under the same condi- tions that were mentioned for urates, with which it is URINE. 365 usually associated. Deficient action of the skin, from any cause, produces an excess of uric acid in the urine. It has a strong tendency to form around any small con- cretions in the urinary tract, giving rise to uric-acid calculi. 'Q Q Ftq. 61. FiQ. 62. Fis. 61.— Uric Acid. A, the most common forms; B, disintegrated crystals; C formation of stellate masses. Fig. 62.— Calcium Oxalate. X 250. Calcium Oxalate. — This is generally deposited as small octahedra which strongly refract light, and more rarely in the hour-glass or dumbbell form (Fig. 62). " The prism of the triple phosphates sometimes appears octahedral, and the diamond-shaped crystals of uric acid are occasionally so small as to simulate the oxalates. Acetic acid dissolves the crystals of triple phosphates, and caustic potash causes the uric acid to disappear, while oxalate of lime resists both reagents." Crystals of oxalate of lime appear in the urine after eating ap- ples, pears, cauliflower, and the different varieties of sorrel, and after the administration of rhubarb; it is 266 PHYSICAL DIAGNOSIS. often present in diabetes mellitus, catarrhal icterus, gout, hypochondria, and after epileptic seizures. It is common in cases of mental exhaustion from overwork and excitement. The term oxaluria has been applied to that condition which, in addition to the abundant and persistent presence of calcium oxalate crystals, has a well-marked train of nervous and dyspeptic symptoms with a tendency to hypochondriasis. The mere finding of a few oxalate of lime crystals is not sufficient for this diagnosis. Ammonio-Magnesium or " Triple " Phosphates. — These crystals are found only in alkaline urine. During Fig. 63. Fio. 84. Figs. 63 and 64. — Ammonio-Magnesium, or " Triple " Pliosphates. X 250. alkaline fermentation, urea is decomposed with the for- mation of ammonium carbonate ; this combines with the magnesium phosphate present to form the so-called triple phosphate crystals. When slowly formed the crystals assume the shape of triangular prisms with bevelled edges (Fig. 64 A), but when produced rapidly they have a feathery outline (Figs. 63 and 64 B). UKINE. 5J67 Fio. 65.— Calcium Phosphate. Calcium Phosphate, although usually amorphous, may be deposited as angular crystals (Fig. 65). The precipitation of these salts in crystalline form does not necessarily indicate that they are excreted in excessive quantities, but shows that there has been some change in the reaction of the urine, due to alteration in some of its constituents which ordinarily retain these salts in solution. Excessive mental work or anxiety, and certain forms of dyspepsia, reduce the acidity of the urine and favor the precipitation of the earthy phosphates. Alkaline fermentation of the urine in the urinary tract causes their deposition on the mucous membrane and the subsequent formation of calculi. Oystin. — This body is occasionally found in the urine in crystalline form ; it occurs as six-sided plates (Fig. Q&). According to Baumann it is a normal constituent of urine, but the quantity eliminated in twenty-four hours is very small, amounting to 0.01 gramme or less per litre. Little is known of the conditions that cause its elimination by the kidneys. It is often hereditary. Brieger has called attention to the relation of certain pto- maines in the intestinal tract and the appearance of cystin in the urine. It is also sometimes present in excess in the urine of tea tasters. It may lead to the formation of calculi. Leucin, Tyrosin. — The urine may contain large quan- tities of these substances. Leucin appears in the form of spheres, resembling globules of fat (Fig. Q^). When Fis. 66.— Cystin. X 850. 268 PHYSICAL DIAGNOSIS. these spheres are large they may show radiating lines and concentric rings. Tyrosin crystallizes in the form of fine needles ar- ranged as sheaves (Fig. 68). These bodies appear in those diseases in which oxidation is impaired, such as acute yellow atrophy of the liver, typhoid fever, small- pox, and in hepatic diseases generally. Fio. 67.— lieuoin. X 250. Fia. 68. -Tyrosin. X 260. Xanthin rarely occurs in the urine. It is of interest clinically only as it may form calculi. II. OEGANIZED. Mucus. — In healthy urine it is almost impossible to detect, microscopically, the small amount of mucus that is present, as its refractive power is the same as that of the urine. When it holds cells or crystals its presence may be inferred from the arrangement of these bodies. When excessive in amount it is often seen as trans- parent threads or cylindroids. Pus is changed by alka- line fermentation to a condition that resembles mucus. If small mucus threads are found in markedly alkaline urine with an ammoniacal odor, this fact must be con- sidered. URINE. 269 Pus.— In acid urine pus cells have a distinct, circular outline, the protoplasm is granular, and the nuclei are more or less apparent. If acetic acid is allowed to flow under the cover glass, the corpuscles become slightly enlarged, they lose their granular appearance, and the nuclei become more prominent (Figs. 69 and TO). If the urine has undergone marked alkaline fermentation, the pus cells are destroyed (see Mucus, above). Pus' in the urine may come from any part of the urinary tract, or from the rupture of an abscess into it. When its origin is in the kidney, the normal reaction of i^m: ,?: V ^?-i /ft "■.'.w; -^ \ "* „ .i**^ lt)^3f¥-i ■ — ■' ^■-...•■' Fig. 69.— Pus Corpuscles. Fio. 70.— Pus Corpuscles treated with Acetic Acid. the urine is retained, while in suppurative inflamma- tion of the bladder the reaction is alkaline when voided, or it soon becomes so. The epithelial elements associ- ated with the pus cells often decide what portion of the tract is involved. In women the accidental contamina- tion of the urine with pus from the vagina and uterus naust be considered. Vaginal epithelium is then usually 'Frequently in examining urine a very few corpuscles, having all the appearances of pus cells, are found. These are claimed to be mucus corpuscles. Some observers affirm that while they react to acetic acid the same as pus cells, still if they exhibit only one or two nuclei they are mucus corpuscles. Their true character has an important financial bearing to persons under examination for life insurance. 370 PHYSICAL DIAGNOSIS. present. The distinctive features of gonorrhceal pus will be considered under Micro-organisms (page 2T4). Blood. — Eed blood corpuscles are recognized by their size, color, and the peculiar change of light and shade in focussing. Frequently they become globular and pale, or their edges become crenated and the protoplasm granular (Fig. 26). They are rapidly destroyed by ammoniacal changes in the urine. Their presence indi- cates hemorrhage into the genito-urinary tract. The diseases of the kidney in which they most frequently occur are congestion, acute nephritis, calculus, cancer, and embolism. They may be found also in certain blood states, as purpura, scurvy, etc. In women the menstrual discharge may contaminate the urine. The other organic constituents (epithelium, casts, etc.) which may be associated with the blood corpuscles aid in deter- mining their origin. Epithelium (Fig. 11). — Three principal varieties of epithelial cells are found in the urine : squamous cells, from the bladder, vagina, or orifice of the urethra ; co- lumnar cells, from the deeper layers of the pelvis of the kidney, or from the uterus— they may be ciliated when from the uterus ; and spherical cells, which have their Fis. 71.— B, superficial layers of blad- der; B^, deeper layers of bladder: V, cells from vagina; U, ciliated cells from cervix uteri; C, from uterine mucosa; P, from pelvis of kidney; T, from tu- bules of kidney ; G, from prostatic por- tion of urethra. URINE. 371 origin in the tubules of the kidney, or from the deeper layers of the mucous membrane of the pelvis of the kid- ney, of the ureter, bladder, or ure- thra. Eenal epithelium has a poly- gonal, well-defined outline, is slightly larger than a pus cell, and has a large oval nucleus. The presence of such cells in a cast at once deter- mines their origin. Tailed cells from the superficial layer of the pelvis of ^"'- '^^- - spermatozoa. the kidney are sometimes found. Spermatozoa. — When found in urine, these bodies have the characteristic tadpole appearance (Fig. Y2), but they no longer possess any power of motion.' They are present immediately after all seminal emissions; often after defecation, especially if constipation is extreme; and after epileptic seizures. They have been found in the urine of women after coitus. They are occasionally found in typhus and typhoid fevers. Oasts. — These are moulds of the tubules of the kid- ney, formed by the effusion of materials that coagulate spontaneously. They often enclose formed elements. Their diameter varies from -5-^^ to ygVu ™ch, or even smaller. Hyaline. — Hyaline casts are transparent, structure- less cylinders, often invisible with strong illumination. Their extremities are generally rounded or slightly »In medico-legal cases (rape) the vaginal discharge should be examined for spermatozoa. Pieces of clothmg supposed to be stained with seminal fluid are macerated with distilled water in a test tube, for a short time ; after shaking thoroughly, the pieces are removed, the sediment allowed to settle and examined. 273 PHYSICAL DIAGNOSIS. clubbed, but, from a tendency to fracture transversely^ fragments are often found with straight ends (Fig. '73). Small hyaline oasts are found in the acute (inflamma- tory) stage of nephritis, when they are generally associ- ated with other varieties, and the urine is markedly albuminous. Large hyaline casts are found in the atro- phic stages of all forms of Bright's disease. Hyaline casts may have pus cells or renal epithelium adhering to their surface. At times a few hyaline casts are Fig. 73.— Types of Hyaline Casts. found in urine that is non-albuminous and contains no other evidence of kidney disease. This is most apt to occur in the atrophic form of chronic nephritis. Waxy casts are a variety of hyaline. Generally they are of yellowish color. At times they give the amyloid reaction with iodine and iodide of potash, but this is not pathognomonic. Epithelial. — These show the characteristic epithelium of the tubules of the kidney. The cells may have a normal appearance, or are more or less broken down and degenerated. The casts may be composed entirely of renal epithelium., or a few cells only may be entrapped in a hyaline cast (Fig. 74). Epithelial casts are present in desquamative nephritis. When pus cells are mingled with renal epithelium in UKINE. 373 casts, the inflammatory changes in kidney are exten- sive. Granular.—Granular casts vary greatly in size, color, and appearance. Their outline is vyell marked, and one Fio. 74.— Epithelial Casts. Fig. re.-Granular Casts. or both ends generally rounded (Fig. 75). The granular matter may be composed of the debris of epithelium, pus, or blood. In the early stages of nephritis they are associated with epithelial casts. When granular casts Fio. 76.— Fatty Casts. Fig. 77.- BloodCasts. only are present, they indicate the large, white kidney, or that extensive destruction of the parenchyma of the kidney is taking place. Fatty. — The oil globules may be in degenerated epi- thelium (a variety of granular casts), or may themselves constitute the cast (Fig. 76). This variety is indicative 18 374 PHYSICAL DIAGNOSIS. of the large white kidney, or the contracted kidney with marked fatty degeneration. Blood (Fig. 11). — The presence of a few red hlood cor- puscles in an epithelial cast indicates the acute stage of kidney disease. When they constitute the entire cellu- lar element they are diagnostic of renal hsBmaturia. When they appear without other evidences of acute con- gestion of the kidney, or traumatism, disease of the renal blood-vessels, especially amyloid or fatty degenera- tion of the Malpighian tuft, must be considered. Oasts composed of micrococci are often present in septic embolism of the kidney.' MICEO-OEGANISMS. Non-pathogenic. — These include those forms found in urine that has undergone fermentation. When pres- et ^m Fio. 78.— TorulaCerevisisB, Fig. 79.— Penicilium Olaucum. X 300. Fia. 80.— SarcinsB. X 800. ent in freshly voided urine they indicate that this proc- ess is going on in the urinary tract. The most common forms are : Torula cerevisise (Fig. Y8), found in diabetic urine; Penicilium glaucum (Fig. 'The microscopical appearance of extraneous matter, as hair, fibres of silk, linen, cotton, etc., should be so well known as not to be mistaken for casts. URINE. 275 79) ; a small form of Sarcina (Fig. 80) ; and Micrococcus urese. Pathogenic Gonococci. — These are spheroidal bodies, occurring in pairs (diplococci) or groups of pairs. Be- tween the associated cocci there is a slight space. Their opposing sides are somewhat flattened, giving the char- acteristic coflEee-bean appearance. They must be stained to be demonstrated. A drop of pus from the urine, or direct from the meatus urinarius, is smeared upon a cover glass, which, Fio, 81.— Gonococci after it has dried, is passed slowly through a flame to fix the film. A few drops of a solution of methyl blue (see Sputum) are placed on the specimen for a few min- utes, the excess of dye is washed off, and the specimen examined with an oil-immersion lens or a No. T objec- tive. Gonococci, stained blue, appear free on the epi- thelium and in the pus cells (Fig. 81). The diagnostic feature is the presence of the gonococci in the pus cells, and that the gonococci are decolorized by Gram's stain. In the urethra non-pathogenic diplococci are sometimes 276 PHYSICAL DIAGNOSIS. found. They are slightlj' larger than gonocococi, and may exist free or in the epithelial cells, but are not found in the pus cells. Gonococci in pus, whether urethral, vaginal, or con- junctival, are diagnostic of gonorrhoeal infection. Tubercle Bacilli are indicative of tubercular ulcera- tion somewhere along the genito-urinary tract. (For method of staining, etc., see Sputum.) Actinomyces may appear in the urine when the genito- urinary tract is primarily or secondarily involved. PARASITES. Filaria Sanguinis Hominis (Fig. 50, page 247). — These bodies often appear in the chylous urine of pa- tients whose blood is infected. In addition to the oil globules, pus and blood may be found in the urine. Echinococci, hooklets, and portions of cysts may ap- pear in the urine when a hydatid cyst has formed in the genito-urinary tract or ruptured into it from neighbor- ing organs (Fig. 67, page 259). Vomit. The vomit may contain elements from the oesophagus and respiratory tract besides the contents of the stom- ach. The microscopical examination may show tho presence of food masses, such as muscle fibres, with well-marked striations, oil globules, needle-shaped fat crystals, connective-tissue fibres, starch granules more or less altered, and vegetable cells. These, of them- selves, are of no diagnostic value, but may give a hint as to the rapidity of the digestive process. Eed Blood Corpuscles, showing their characteristic VOMIT. 271J' appearance, may be found in the vomit where hemor- rhage into the stomach has been so great and its expul- sion so rapid as not to allow the gastric juice to act upon them, or when blood is added to the vomited mat- ter above the stomach. When acted on by gastric juice the corpuscles are destroyed, and their contents appear as masses of reddish-brown pigment (coffee-grounds). To determine the presence of blood in such cases, some of the suspected matter is dried, ground into a powder, and placed on a slide. A few crystals of common salt are added, and a cover glass put on. A little glacial acetic acid is allowed to flow under the cover glass, and the slide is heated (not to boiling) for a few minutes. The salt is dissolved out in a little water. If the specimen contains blood, small, dark, rhombic crystals of hsemin will be seen (Fig. 82). Ptrs Cells are also destroyed by gastric juice. They only ap- ^ „„ „ •' ° •' J J f Fio. 82.— Hsemin Crystals. pear in the vomit when there is a suppurative inflammation of the stomach walls, or when a large abscess has ruptured into the stomach. The EPITHELL4.L Cells found in the vomit are of the squamous or columnar type. Squamous cells come from the CBSophagus or mouth ; columnar cells from the gas- tric mucous membrane. SARcm^ VENTRICULI, having the characteristic "wool pack " appearance (Fig. 80, page 274), are often found. They are present when the stomach retains its contents for a long time, especially in dilatation of the organ. 278 PHYSICAL DIAGNOSIS. Tubercle Bacilli, when found in the vomit, indicate a tubercular ulceration in the food passages or contam- ination of the vomit by sputum. The chemical analysis of the gastric contents is often of great assistance in diagnosis. For accurate deter- minations of the digestive powers of the stomach we must have known contents for digestion secured at defi- nite periods during the digestive process. Test meals therefore are employed. The test breakfast of Ewald consists of thirty-five to seventy grammes of wheat bread and three hundred to four hundred cubic centimetres of water or weak tea without sugar. As traces of lactic acid are formed dur- ing the early stages of the digestion of this meal, Boas' test meal should be used when especial importance is attached to the presence of this acid. This meal con- sists of one tablespoonful of rolled oats and one quart of water boiled down to one pint. The contents of the stomach are obtained one hour later. The double test meal of Salzer consists of thirty grammes of lean cold beef hashed fine so as not to obstruct the stomach tube, two hundred and fifty cubic centimetres of milk, sixty grammes of rice, and one soft-boiled egg. Exactly four hours after the ingestion of this meal Ewald 's test meal is taken, and one hour later the stomach contents with- drawn. The gastric juice is thus obtained at the height of digestion, and some idea of the motor power of the stomach may also be formed. Under normal conditions no remains of the first meal should be found in the stomach at the time of examination. Test meals must be given in the morning on an empty stomach. If there be retention of food the stomach must be washed out on VOMIT. 379 the previous evening. The stomach contents are ex- pressed by means of a stomach tube, and the amount obtained after Ewald's meal is usually from fifteen to sixty cubic centimetres. The tube is like a large soft rubber catheter with a hole in the end and two on the sides near the tip. It should be about thirty-six inches long and should be introduced for twenty-four to twenty-six inches of its length. The tube is introduced to the posterior wall of the pharynx ; the patient then bending the head slightly forward, the tube is pushed down till resistance is felt when it touches the floor of the stomach. The pa- tient may be told to swallow during the process. If the gastric contents do not flow out readily the patient should bear down with the abdominal muscles or cough a little. If this is insufficient aspiration may be used. Simon recommends suction with the mouth, with the fingers slightly compressing the tube near the patient's mouth to feel the contents as they flow by the fingers. The normal gastric juice is acid from free hydrochloric acid and acid combined with proteids and salts. The secretion of hydrochloric acid begins immediately after the ingestion of food ; the time of appearance of free HOI in the gastric contents depends on the amount and kind of food taken. After an Ewald meal it appears free in from fifteen to thirty minutes. It gradually in- creases in amount, and after a light meal reaches in one and one-half to two hours from .05 to .19 per cent, and after a full meal in two to three hours from .2 to .33 per cent. Lactic acid, when present, is the result of abnormal fermentation of the food or has been in- gested. 280 PHYSICAL DIAGNOSIS. Tests for free HCl. — With Gunzberg's reagent, ■which consists of : Phloroglucin 2. gm. Vanilin 1- Absolute alcohol 30. cc. This solution must be kept from the light, in a dark- colored bottle. A few drops of the gastric juice or un- filtered gastric contents are placed in a clean porcelain dish and an equal number of drops of the reagent added ; the mixture is then slowly evaporated by gentle heat- boiling or rapid evaporation are to be avoided. In the presence of free HCl a rose tint or fine rose-colored lines develop, the depth of color varying with the amount of acid present. A brown, brownish-yellow or brownish- red color indicates that excessive heat has been applied or that free HCl is absent. Topfer''s Test. — The reagent is a 0.5-per-cent alcoholic solution of dimethyl-amido-azo-benzol. One or two drops of this solution are added to a trace of gastric contents, which need not be filtered. If free HCl be pres- ent a beautiful cherry red develops, varying in intensity with the amount of HCl present. Loosely combined HCl and acid salts do not produce this color. In the absence of free HCl a yellow color results, the fluid be- coming cloudy and fluorescent. This test is more than twice as delicate as that with the Gunzberg reagent. It is important to obtain the total acidity of the stom- ach contents in order to calculate the total production of HCl, free and combined, and the amount of organic acids and acid salts present. To obtain these results a decinormal sodium hydrate solution must be titrated against the filtered gastric juice, using as indicators cer- VOMIT. 381 tain coloring agents which react to the various acid principles as found iu the gastric contents. The decinormal sodium hydrate solution is made and standardized, the method given by Simon being the easiest of application. " One-tenth gramme of pure crystalhzed oxalic acid is dissolved in distilled water, and the solution •titrated with the decinormal sodium hydrate solution purposely made too strong by adding four grammes NaOH to a little less than one thousand cubic centime- tres distilled water, which is to be corrected, using two or three drops of a one-per-cent alcohohc solution of phenolphthalein as an indicator, until the rose color does not disappear on stirring; 15.9 cubic centimetres should bring about this result. As the NaOH solution, how- ever, has been purposely made too strong, less will be re- quired. The amount of water that must be added in order to bring the solution to its proper strength is de- termined by the formula C = '^, in which represents the number of cubic centimetres of water which must be added to the remaining solution, N the total number of cubic centimetres remaining after one titration, n the number of cubic centimetres consumed in one titration, and d the difference between the number of cubic centi- metres theoretically required (15.9 c.c.) and that actu- ally used in one titration. The solution having thus been properly diluted, the correctness of its strength is again tested and a further correction made if necessary, until absolute accuracy has been obtained." The indicators used are a!s follows: (1) 0.6 per cent alcoholic solution of dimethyl-amido-azo-benzol (amido- benzol) which reacts only to free acids such as free HCl. (2) A one-per-cent aqueous solution of alizarin mono- 282 THYSICAL DIAGNOSIS. sulphonate of sodium (alizarin) which reacts to organic acids, acid salts, free HCl, but not to loosely combined HCl. (3) Phenolphthalein which reacts to organic acids, acid salts, free HCl, and combined HCl. One cubic centimetre of decinormal soda solution neu- tralizes .00365 gramme HCl. Into each of three small porcelain dishes are measured five cubic centimetres of filtered gastric contents and diluted with equal amounts of distilled water. Into No. 1 one to two drops of amido-benzol are added, which if free HCl be present, turns bright red. From a gradu- ated burette the decinormal soda solution is added, drop by drop, until on stirring the last traces of red have dis- appeared and the fluid is of bright lemon-yellow color, indicating the end of the reaction. The quantity of soda solution used is noted and the free HCl computed. Into No. 2 one to two drops of alizarin are added and the solution titrated. A deep violet color indicates the end reaction. From the quantity of soda solution used may be computed the acidity due to all acid principles excepting loosely combined HCl. Into No. 3 add one to two drops of phenolphthalein and titrate as before. The end reaction is reached when the red color obtained no longer darkens on further ad- dition of the alkali. From the quantity of soda solution used compute the total acidity of the specimen. To determine the combined HCl subtract the result of No. 3 from that of No. 3. To determine the total HCl, free and combined, add the result of No. 1 to the difference between Nos. 2 and 3. Where free HCl is present all the combined acid is HCl. VOMIT. 283 To determine the acidity due to organic acids and acid salts subtract the result of No. 1 from that of No. 2. The sources of error with this method are: (a) the diffi- culty of determining accurately the end reaction, espe- cially with alizarin. To obviate this Topf er recommends the following controls: (1) To five cubic centimetres of distilled water add one to two drops of alizarin; a clear yellow color is obtained. (2) To five cubic centi- metres of a one-per-cent solution of disodium phosphate add one to two drops of alizarin, when a red or slightly violet color will result. (3) To five cubic centimetres of a one-per-cent solution of sodium carbonate add the one or two drops of alizarin, and the clear violet color to be obtained as the end reaction will appear. (&) Amido-benzol reacts to the organic acids, lactic, acetic, and butyric, as well as to free HCl. But these acids are not usually present when the stomach contains free HCl, and besides the dissolved albumins practically nullify their disturbing effects. The presence of lactic acid in the gastric contents may be shown by Kelling's test: Dilute five to ten cubic centimetres of filtered gastric juice with ten to twenty parts of water, and add one or two drops of a five-per- cent aqueous solution of sesquichloride of iron. If lactic acid be present a distinct green color is seen when the test tube is held to the light. This reaction occurs only in the presence of lactic acid ; the test is, therefore, more reliable than that of Uffelmann. For a quantitative estimation of lactic acid Boas' rapid test is sufficiently accurate for clinical purposes: A few drops of dilute H,SO, are added to ten cubic cen- timetres of filtered gastric juice, and the albumin present 284 PHYSICAL DIAGNOSIS. is removed by heat. The filtrate is evaporated to a syrup on a water bath. Ten cubic centimetres of water are added, and the solution is again evaporated to a small vol- ume ; this eliminates the fatty acids. The fluid is shaken with two hundred cubic centimetres of ether, allowed to settle, and the ether decanted. The ether is then evapo- rated by placing the evaporating dish in hot water {keep all flames away) . The residue is taken up with water and titrated with decinormal sodium hydrate solution, using phenolphthalein as an indicator. The number of cubic centimetres of decinormal soda solution used mul- tiplied by 0.009 gives the amount of lactic acid in the ten cubic centimetres of gastric juice. Butyric acid may be recognized by Boas' test: Ten cubic centimetres of gastric juice are extracted with fifty cubic centimetres of ether; the ether is then evapo- rated and the residue taken up with a little water, and a few crystals of calcium chloride are added. Butyric acid, if present, will separate out in oily drops, and can be recognized by its rancid odor. Boas also recommends the following test for acetic acid : Ten cubic centimetres of filtered gastric juice are extracted with ether. After the evaporation of the ether the residue is taken up with a few drops of the water, and the solution carefully neutrahzed with dilute NaOH. A few drops of dilute ferric-chloride solution are added, when a deep blood-red color will be obtained if acetic acid be present. Quantitative Estimation of the Fatty Acids. — McNaught's modification of Cahn-Mehring's method. Ascertain the total acidity of ten cubic centimetres of gastric juice. Evaporate another ten cubic centimetres VOMIT. 2S5 to a syrup, take up with water, and obtain the total acidity. The difference between the results equals the acidity due to the fatty acids. To prove the presence of chymosin or rennet ferment Leo's method is to be preferred : To five or ten cubic centimetres of raw milk in a test tube three to five drops of gastric juice are added and placed in the thermostat at 37° C. If in ten to fifteen minutes coagulation takes place the chymosin is present. To test for the chymosinogen ten cubic centimetres of filtered and faintly alkaline gastric juice are mixed with two to three cubic centimetres of a one-per-cent calcium chloride solution, or the gastric juice is rendered faintly alkaline with lirne water and mixed with five to ten cubic centimetres of milk; the mixture is then kept at 37° 0. If the chymosinogen is present a thick casein coag- ulum is formed in a few minutes. When it is desirable to prove definitely the absence of pepsin and pepsingen in the stomach the method of Jaworski is to be preferred. Two hundred cubic centi- metres of decinormal hydrochloric acid are poured into the stomach through a stomach tube and siphoned out after half an hour. Ten to twenty cubic centimetres of this fluid are placed in test tubes, and small pieces of coagulated egg albumen being dropped into the tubes, they are placed in a thermostat at 37°-40° C. If no solution of the albumin takes place there is no pepsin nor pepsinogen in the fluid. The clinical estimation of the products of the diges- tion of the carbohydrates may be disregarded. The digestion of the albumins in the stomach is de- pendent on the HCl and pepsin present. They are 286 PHYSICAL DIAGNOSIS. broken down into their various proteoses and either pass as such into the intestines or are further changed into peptones. Casein, however, is first coagulated by the chymosin, and then broken up into the caseoses and nuclein by the HCl and pepsin. The time required for this digestion is of clinical importance, and may be esti- mated by examining the gastric contents at stated inter- vals. But the estimation of the various proteoses is not clinically important. As stated above, five hours after the ingestion of the Salzer test meal all remnants of the albuminous ingredients should have disappeared. This may also be used as an estimate of the motility of the stomach. The absorptive power of the stomach may be roughly indicated by Penzoldt's test: When five grains of potassium iodide are taken in a gelatin capsule iodine appears in the urine and saliva of the normal subject within six to fifteen minutes, while with deficient ab- sorptive powers its appearance is much later. The iod- ine may be detected by applying a few drops of urine or saliva, and one drop of strong nitric acid, to starch paper, which in the presence of iodine turns blue or violet. The Clinical Significance of the Examination of the Gastric Contents. SIGNIFICANCE OP HYDEOCHLOEIC ACID. A normal percentage of .2 to .3 per cent of HCl in the gastric contents argues strongly against organic dis- ease of the stomach. When, however, all symptoms point to disease of the stomach, a normal percentage of HCl points to a nervous dyspepsia or atony of the mus- cular wall. VOMIT. 287 With a constant subacidity (HCl below .1 per cent) one must think of a subacute or chronic gastritis. It also occurs with ulcer of the stomach or duodenum, with incipient carcinoma and atony of the stomach. A constant hyperacidity (HCl over .2 per cent) occurs most frequently in nervous dyspepsia. It may he pres- ent in the early stages of chronic gastritis. It is not uncommon with simple ulcer; it points strongly against carcinoma, but may indicate a neoplasm developing in the cicatrix of a former ulcer. Anacidity is the most frequent symptom of the later stages of chronic gastritis; it is not an uncommon symp- tom in nervous dyspepsia, especially in the form follow- ing eye strain from astigmatism. In gastritis pepsin also is usually absent, while it is present in nervous dyspepsia. It is strong evidence of carcinoma when confirmatory symptoms are likewise present. A variable acidity indicates in all probability a ner- vous dyspepsia. Lactic acid is not formed in appreciable amounts during normal digestion even after the ingestion of car- bohydrates. When found under these conditions it has been taken as such with the food. Boas found only traces in chronic gastritis, atony and dilatation of the stomach, and in nervous dyspepsia. It may be present in larger amounts in dilatation of the stomach with stagnation of its contents. The production of lactic acid points strongly to carcinoma, and if accompanied with stagnation in the stomach and a diminution of HCl, the presence of carcinoma, even in the absence of a tumor, is extremely probable. On the other hand, the absence of lactic acid does not exclude carcinoma. 288 PHYSICAL. DIAGNOSIS. The occurrence and significance of butyric and acetic acids are, in' general, the same as of lactic acid. Before drawing any deductions from their presence, however, the previous ingestion of butter and fats as a source of butyric acid and alcohol of acetic acid must be ex- cluded. Fmces. The number and character of food residues found in the f^ces depend upon the diet. In a general mixed diet there will be found vegetable cells, starch granules, muscle fibres, elastic and white fibrous tissue, and fat: globules ; while in the stools of children and adults fed exclusively upon milk large quantities of fat and crys- tals of fatty acids will be found. Eed Blood Corpuscles do not present their charac- teristic form unless a large quantity of blood has been thrown into the intestines and rapidly voided, or its ori- gin is in the lower portion of the large intestine, as from hsemorrhoids (in women contamination with the menstrual flow must be considered). When blood has been retained for some time, no corpuscles can be de- tected, but it is changed to a " tarry " or dark -brown mass (see Vomit). Pus Cells are rarely present in healthy stools. In simple intestinal catarrh only a few are present. When found in large numbers they are due to ulceration of some portion of the intestinal tract. Pure purulent dis- charges take place onlj' when an abscess has ruptured into the intestines, and occasionally in dysentery. Epithelium, in small amount and more or less al- tered, is always found in healthy faeces and has no diag- F^CES. 289 uostic significance. When found in large quantity it is indicative of intestinal catarrh. MICEO-OBGANISMS. Large numbers of micro-organisms are found in the faeces ; most of them are non-pathogenic. Some which are found in unhealthy stools are also present in the healthy — they seem to be concomitants, and not ex- citants, of the diseased condition. The pathogenic bacteria are the — Fio. 83.— Spirillum Cholerce Asiaticse. From a culture. Cholera Bacillus (Comma Bacillus). — This appears as a short, curved rod that is thicker than the tubercle bacillus (Fig. 83). Two bacilli may be so placed as to give the peculiar S-iike appearance. They are found most abundantly in the free mucous fiocculi of the rice- water discharges. A cover-glass preparation may be made and stained with methyl blue, as for gonococci. Bacillus of Typhoid Teyek {Bacillus of Eberth). — This appears as a rod with rounded extremities; its length is about one-third the diameter of red blood cor- puscles, and its width one-third its length (Fig. 44, page 240). Vacuoles are sometimes seen in the rods. They stain with a watery solution of methyl blue. The bacilli of cholera and typhoid fever as they appear in the faeces cannot be differentiated by their appear- ance, or by their reaction with the staining solutions, 19 290 PHYSICAL DIAGNOSIS. from other bacteria having similar form. To decide their true nature it is necessary to make cultures. The best mediiim for the differentiation of typhoid bacilli is that of His and Capaldi. This requires such special bac- teriological knowledge and technique that the student is referred to special works on bacteriology. Tubercle Bacilli may be found in the stool when there is tubercular ulceration of the intestine, or when tubercular sputum has been swallowed. ANIMAL PARASITES. Amceb^ Coli. — These are cellular bodies, three to four times as large as a pus cell, from 25 to 35fi in diam- eter, having a vesicular nucleus and often fine nucleo- Fio. 84. — Amoebas Coli. From the Intestinal wall near an ulcer. Drawn from a specimen prepared by Prof. W. J. Councilman. lus, both apt to be centrally placed. Their protoplasm is finely granular and may contain vacuoles, coarser gran- ules, bacteria, and red blood cells. When seen imme- diately after voiding, they often show amoeboid move- ments (Fig. 84). They have important diagnostic significance in relation to dysentery and abscess of the liver. P^CBS. 291 Only certain intestinal worms and their ova will be considered. Von Jaksch describes them as follows : DiSTOMA Hepaticum.— This is a leaf -shaped worm measuring twenty -eight millimetres by twelve millime- tres. The head is short, and furnished with a sucker. There is another sucker on the ventral aspect, and be- twen the two the genital pore is situated. The latter leads to a uterus which is convoluted like a ball of wool. Fio. 85.— Distoma Hepaticum. About natural size. The eggs are oval, 0.13 millimetre long by 0.08 milli- metre broad. One extremity is broader than the other and opens with a lid ; the shell is brown and is composed of two layers. T^NiA Solium. — The taenia solium is not a common parasite in America. It may measure upwards of three to six feet. Its head is quadrilateral, about as large as a pin's head {■jt~'st°^ ^^ inch), and dark in color. This is succeeded by a delicate, thread-like neck about an inch in length and unjointed. The segments or proglottides, which form the rest of the body, are short and relatively broad near the neck; but as they increase in size this relation ceases, and, still growing in both dimensions, their quadrilateral form becomes evident about three feet from the head. Their average length is from nine to ten millimetres and their breadth six to seven milli- metres. Under the microscope the head is seen to pre- sent four prominent suctorial discs, usually pigmented, and between them a rounded elevation or rostellum. 292 PHYSICAL DIAGNOSIS. ■which is surrounded with about twenty-six booklets of different sizes. The sexual apparatus first becomes visi- ble about a foot from the head. The uterus is but little branched, and the genital pores are situated somewhat behind the middle of each segment. The eggs are Fig. 86. Fig. 87. Fig. 86,— Head of Taenia Solium, x About 40. Fig. 87. — Head and Proglottides of Taenia Mediocanellata. A, head, X about 15; B, mature proglottid, showing general apparatus; C, head and fragments of immature proglottides, showing gradual tapering of the neck. Natural size. nearly spherical, 0.036 millimetre long by 0.03 milli- metre wide. The outer covering or shell has radiating lines. When fully formed, booklets can be demon- strated on the embryo. T^NiA Mediocanellata or Saginata. — This para- site is longer than the taenia solium, attaining to twelve or fifteen feet, and its segments are also longer. The head is surrounded with four large and usually black F^CES. 293 pigmented suckers, but it is not provided with a rostel- lum and is without a circle of hooklets. The segments increase in length more gradually than the t^nia solium and are commonly pigmented. The uterus is very much branched, and the genital pore is situated at the side of the proglottis. The eggs are slightly more oblong than those of the solium, and exhibit a primordial yolk mem- brane. The embryo does not show hooklets. BOTHEIOCEPHALUS Latus. — This worm attains a length of fifteen to twenty-four feet. The head is ovoid and two millimetres long by one millimetre broad. It is cleft and provided with two lateral suckers, placed on either side of the middle line. It has no hooklets. The pro- glottides are at first short and small. They increase Fig. &s.-Egg Jq breadth as they proceed, of Bothriooepli- aius Latus i, and towards the end of the Lid. (After summe.r, in parasite approach the " Keal Encycl.") „ mi ^ square form. The uterus of mature proglottides containing eggs exhibits a retiform arrangement and appears superficially as a small rosette. This uterine rosette is characteristic of this parasite. The eggs are oval, O.Y millimetre long by 0.045 milli- metres broad; the shell is brown, and cjhaius^.atas;B,i.ead one end is small, opening with a lid. ^^^^^^f^JZ. The protoplasm of the egg is divided of Bothriocephaius 1^ ^ ° latus. (After Summer, into small masses of uniform size. in-'EeaiEncyci." Fig. 89.—^, Head and anterior end of strobile of Bothrio- 294 PHYSICAL DIAGNOSIS. OxYURis Veemicularis {Common Thread Worm or Teat Worm). — The female is ten millimetres in length, and exhibits two fully developed uteri which extend symmetrically backwards from the vaginal orifice. The male is rather less than half the length of the female, and its tail is provided with six pairs of papillae. The heads of both sexes are similar. It displays a remarkable Fio. 90. Fig. 91. Fig. 90.— Oxyurfs Vermicularis. A, Female ; B. male. FiQ. 91.— Eggs of Nematode Worm. A, Eggs of Ascaris lumbricoides, X about 300. B, eggs of Oxyuiis Termicularis, X about 250. cuticular enlargement and small prominent lips. The eggs are irregularly oval, and measure 0.05 millimetre by 0.02-0.03 millimetre. The shell is membranous and consists of two or three laminae. Their contents are coarsely granular. The eggs often contain an embryo with an indistinct alimentary canal and a tail equal to half the entire length. Ascaris Lumbricoides {Common Round Worm). — This is a cylindrical worm of some size^ with a body that tapers from before backwards. The male is two hun- dred and fifty millimetres and the female four hundred millimetres long. The head, which is distinct from the body, consists of three conical prominences (lips) furnished with tactile papillae and minute teeth. The caudal process of the male is folded hook-like on the F^CES. S95 abdominal surface, and is provided with papillae. In the female the vulva lies deeply behind the anterior third of the body. The eggs are nearly round and brownish-yellow in color. Their diameter is 0.06-0.07 Fi&. 92. — Ascaris Lumbricotdes. (After Peris.) About half natural size. A male; B, female. millimetre. In the fresh state they are covered ex- ternally with an albuminous layer, and beneath this is a tough shell, which in turn encloses the very granular contents. MECHANICAL AIDS TO DIAGNOSIS. LESSOl^ XIX. MECHANICAL AIDS IN THE DIAGNOSIS OF THE DISEASES OF THE RESPIRATORY AND VASCULAR ORGANS- STETHOSCOPE — STETHOMETER— CYRTOMETER — CARDIOMETER — LARYNGOSCOPE — SPHYGMOGRAPH. I WILL now briefly describe the different instruments which may be employed as aids in physical diagnosis, and give some rules to guide you in their use. Stethoscope. In the diagnosis of diseases of the respiratory and vas- cular organs, a stethoscope is not only often convenient, but at times absolutely essential. A great variety of stethoscopes has been devised, each inventor claiming for his own instrument some superiority in principle or shape. They may all be referred to two general classes, viz., flexible and solid. For general use I would recommend the binaural stethoscope devised by the late Dr. Cammann, of this city. It has two flexible tubes fitted into the cup that is applied to the surface. These are continuous with two metal tubes so curved that they fit into each ear, and are connected with each other by means of a metal bar with a toggle joint in its cen- tre. An elastic band holds them in position (see Fig. 93). It requires some practice to become adepts in its use. But, once accustomed to it, you will find it has 300 PHYSICAL DIAGNOSIS. no superior. It closes both ears to all but the desired sounds. In selecting a stethoscope you should be careful that the ear pieces exactly fit your ears. If they are too large, they will cause pain; and if too small, they will J-i. Fig. 93.— Stethoscope. FiQ. 94.— Phonendoscope. produce a roaring noise which will obscure the sounds you desire to examine. In cardiac auscultation, and in determining abnor- malities of the blood-vessels, this instrument will be found almost indispensable ; for pulmonary auscultation it is only occasionally of service. STETHOMETEE. 301 The phonendoscope as invented by Bianchi and Bazzi is an instrument devised for the same purposes as the stethoscope. It increases the intensity of the sounds, but gives them a metallic character. It can be used over clothing where a stethoscope is useless. It consists of a drum or cylinder (B),pne surface of which, covered with a thin sheet of hard rubber is applied to the surface to be examined. The rubber tubes and ear pieces are at- tached to the opposite sides. A second rubber disk fits over the first, and is for the attachment of the rod (A) used when small areas are to be auscultated. This di- minishes the intensity of the sound, but is necessary for small areas. Stethometer. The simplest way to ascertain the circular measure- ment or amount of motion of the chest or abdomen is by means of an ordinary pocket tape. But Dr. Quaih has devised an instru- ment for this purpose, called the stethometer. It consists of a brass box with a dial, and an index which is moved by a rack attached to a silken cord. One revolution of the index indicates an inch of motion, the intervening space being graduated, as shown m ^.^^ 95.._stetiiometer. rig. 95. It may be employed when the patient is in a standing, sitting, or recumbent posture. The mode of its appli- cation is as follows: Place the box on the sternum with the index pointing to the median line; carry the silken 302 PHYSICAL DIAGNOSIS. cord around the chest to the spines of the vertebrae, where it should be held firmly with the thumb or finger. The amount of motion of the side under examination, from the end of an expiration to the end of a full inspi- ration, wiU be accurately shown by the index. This instrument is of great utility in determining the exact amount of difference in the expansion of the two sides of the chest, as weU as for determining the amount of local expansion in any region. Fio. 96.— Cyrtometer. Cyrtometer. It frequently happens that the exact shape of the chest or abdomen is far more important than the amount of motion. An instrument to determine this was made in 1860 by G. Tiemann & Co. from suggestions given them by Prof. Austin Flint. It resembles in principle the cyrtometer of WoiUer, invented in 1857.' ' Vide Gazette des H6pitaux, 1857, p. 134. CARDIOMETEB. 303 It consists of an ordinary compass with short arms ; slits are made in the ends of these arms to receive nar- row strips of lead, which are made long enough to en- circle the chest and meet in the median Kne in front ; they are fastened into the arms of the compass by means of thumb screws. An indicator is attached to the centre of one arm, and sUdes through the other ; this is arrested at any point by means of a thumb screw (Fig. 96). When apphed, the arms of the compass are pressed on each side of the vertebral column and fastened by means of the thumb screw pressing on the indicator ; the strips of lead are moulded so as to fit any depression or elevation of the chest ; the thumb screw is then loos- ened and the instrument removed. After its removal, bring the arms of the compass together until they reach the same notch in the indicator as when the instrument was applied to the chest ; fasten it with the thumb screw, place it upon paper, and you can easily trace the exact shape of the chest. Cardiometer. The cardiometer was devised by the late Dr. Cam- mann to determine accurately the distance of the apex beat from the median line. It resembles a pocket knife in shape, with one extremity rounded and the other slightly pointed. On its handle is a scale of inches which may be used as an ordinary rule. Enclosed in the handle is a graduated blade, which runs its whole length and is attached by a pivot to the rounded ex- tremity. This blade is pointed at its free extremity and has a sht through its centre. A small arm is con- nected to one side of the handle, by means of a pivot, near its rounded extremity ; the free end shdes along 304 PHYSICAL DIAGNOSIS. the slit in the blade and has a small indicator attached to it. As the instrument is opened the indicator marks the number of inches between the extremity of the blade and the extremity of the handle (see Fig. 97). In using this instrument, place the pointed extremity of the handle on the median Une and open the blade to Fig. 97. — Cardiometer. a point corresponding to the apex beat. By reading the scale, the distance of the apex beat from the median hne is determined. In recording cases, and in accurately determining slight changes in the position of the apex beat, this instrument will be found of service. Laryngoscope. The apparatus consists of three parts — the throat mirror, the head or reflecting mirror, and the source of G.TIEMANN = CO . FiQ. 98,— Laryngeal Mirror. illumination. It is used to examine the nose and upper air passages. The throat or laryngeal mirror is a small mirror LARYNGOSCOPE. 305 mounted in a G-erman-silver frame and attached to a delicate handle from six to seven inches long. It is made in six sizes, Tarying from three-eighths of an inch to one inch in diameter. There are several different shapes, but the round mirror is best adapted to general purposes. For laryngoscopic work the mirror is attached to the handle at an angle of 135° ; for rhinoscopic, at an angle of 105°. The reflecting mirror is a large concave mirror, perfo- rated in its centre so that the iUuininating and visual rays will be in the same axis. It should not be too large, or its weight will become objection- able. The mirror is attached to a head band by means of a baU-and-socket joint, to give perfect freedom of motion. Source of Illumination. — Sunlight is to be preferred because of its whiteness, but the Argand burner or a coal- oil lamp may be used. Sajous states that a small piece of camphor dissolved in the oil -will make the light whiter. A condenser may be used to increase the intensity of the hght. Method of Examining the Larynx.— So adjust the reflecting mirror that the opening in its centre corre- sponds to the hne of vision, and that the Ught is thrown into the patient's mouth. Then direct the patient to catch the tip of his tongue in a napkin and draw it weU forward. Take the throat mirror, previously warmed over the lamp (to prevent the condensation of moisture 20 Fig. 99. —Head Mirror. 306 PHYSICAL DIAGNOSIS. on its surface), lightly in the right hand, and introduce it into the back of the throat with its face directed down- ward. It should not touch the base of the tongue, or retching may be excited. Let the posterior surface of the mirror rest against the base of the uvula, and push it upward and backward toward the vault of the pha- rynx. The plane of the mirror should form an angle of about 45° with the horizon. If the throat is irritable, the mirror should be removed and the patient allowed to rest a few minutes before another attempt at examination is made. It may be necessary to produce local anaesthesia by means of a ten- per-cent solution of cocaine ; but this procedure is to be avoided, as a sense of choking is thereby produced. The administration of a smaU dose of potassium bromide a few hours previous to the examination wiU be found of service in rendering the parts less irritable. Laryngoscopical, View of the Larynx in a Nor- mal Condition. — In the laryngeal mirror, when it has been introduced into the pharynx as already directed, the^rs^ thing that comes into view is the back of the tongue with its large f oUicles, then the hoUow space be- tween it and the anterior or glossal surface of the epi- glottis, which is of a dark-pink color. Next, the apex and laryngeal surface of the epiglottis, the free surface being of a yeUow color, while the laryn- geal or under surface is invariably of a bright-red color. Next, the ary-epiglottic folds, which are of about the same color as the mucous membranes of the gums. Next, the ventricular hands, having about the same color as the mucous Hning of the hps. Next, the vocal cords, which are pearly white, hke the sclerotic coat of the eye. Next, the tracheal rings, which are of a decidedly RHINOSCOPY. 307 yellow color, the mucous membrane between them being of a bright red. Lastly, the bifurcation of the trachea and the bronchi. In making your laryngeal observations, as soon as the posterior wall of the larynx is brought into view, note carefully the form, size, color, position, and mobility of the true and false vocal cords, as well as all their rela- tions and form of motion, also the appearance of the anterior wall of the larynx from the free border of the epiglottis down to the trachea. For the purpose of investigating the action of the vocal cords, the patient should be directed to inspire deeply or to produce a vocal sound, as ah or eh. You must remember that the objects seen in the laryn- geal rairror are reversed : the anterior part of the larynx becomes the posterior ; but the right side remains the right, and the left remains the left. This reversed pic- ture is somewhat troublesome to the beginner. By fre- quently examining the different parts in the order al- ready given, you will become familiar with their normal appearance and motions, and be prepared to recognize abnormalities. The laryngeal diseases in which the laryngoscope is of special service as an aid in diagnosis, are thickening, induration, and ulcerations of the vocal cords, paralysis of the vocal cords, polypi or malignant growths spring- ing from any portion of the larynx, exudation on the mucous surface of the epiglottis or larynx, follicular en- largements, and ulcerations of the larynx, as well as other changes which may occur in the course of chronic laryngitis or tracheitis. Bhinoscopy. The examination may be made through the anterior 308 PHYSICAL DIAGNOSIS. or posterior nares, and is called, accordingly, anterior or posterior rhinoscopy. The anterior examination is by far the more satisfactory. Anterior Ehinoscopy. — Dilate the nostril by means of a nasal speculum (Fig. 100), and throw the Ught from the reflecting mirror into the cavity. By placing the fingers of the left hand on the forehead of the patient, and pressing the tip of the nose upward with the thumb, the opening is much en- larged. The head of the patient should be' on a level with that of the examiner. Inspect the infe- rior meatus first. Then, by turn- ing the head of the patient slightly from side to side, the surface of the septum and that of the inferior turbinated body wiU be brought successively into view. Now tilt the head backward until the mid- dle turbinated body is seen, and examine its surface and that of the septum opposite. By further tilting, the anterior end of this body and the vestibule of the nose can be seen. A ten- or twenty-per-cent solution of cocaine is now thrown into the cavity, and, after allowing sufficient time for the contraction of the blood vessels, the same pro- cedure is repeated. Posterior Ehinoscopy.— Pass the tongue depressor well over the arch of the tongue and puU its base for- ward, depressing it at the same time. You must be care- ful not to crowd it back into the throat, or retching may Fia. 100.— Nasal Speculum. SPHYGMOGEAPH. 309 thereby be excited. Warm the rhinoscopic mirror and introduce it sidewise between the uvula and left pillar of the fauces. When it is well in the pharynx, with its face directed forward and slightly upward, turn it gently until the posterior nares are brought into view. The septum is seen in the median line separating the oval openings of the nares. On each side of the sep- tum the nasal passages appear as dark cavities. The superior turbinated body is visible in the upper part of each cavity as a faint reddish band ; below it is the middle turbinated body, appearing as an elongated mass of a yellowish-red color ; while between the two posteri- orly is a dark line— the superior meatus. Passing further ■ downward you come to the middle meatus and the in- ferior turbinated body, only the upper half of which can be seen. It appears to rest on the floor of the nose. The inferior meatus cannot be brought into view. By turning the mirror to the side, the opening of the Eustachian tube may be seen as a dark slit. If the handle of the mirror be raised, the vault of the pharynx is brought into view. It presents an irregular surface, indicating the site of the pharyngeal tonsil. These various parts making up the complete image can be seen only in detail. This examination discloses the condition of the nasal mucous membrane, and such morbid alterations as may exist there, as necrosis, ulceration, polypi, etc. In the vault of the pharynx one can see the condition of the pharyngeal tonsil, and such hypertrophy, as may be present. Sphygmograph. Various modifications of the sphygmograph have been devised by different experimenters, but the one which seems to me to be the best is that which was invented 310 PHYSICAL DIAGNOSIS. by M. Marey, of Paris, to determine various points in the physiology of the circulation of the blood. This instrument consists of a brass frame with a wing fastened to each side by hinges, so as to spread out upon the arm when the instrument is appUed. Enclosed in this frame is a flexible steel spring, covered on the under surface of its free extremity with an ivory button, which rests upon the artery or vein to be examined, and is con- nected by means of a bar of metal, which has a vertical plate attached to it, with a very hght lever moving upon a pivot ; the vertical plate is brought in contact with the lever by means of a screw. The free extremity of the lever registers its movement up a blackened strip of Fig. 101.— Marey 'sSphygmograph. paper that covers the brass plate. This plate is moved at a uniform rate by means of watchwork placed in the small box beneath. Ten seconds are occupied in the passage of the plate. A thumb screw winds up the watchwork, and a small lever starts the plate or stops it, as desired. Silk bands embrace the arm and hook on to projecting points on each wing, as seen in Fig. 101. The sphygmograph was proposed as an aid in the diagnosis of diseases of the heart, arteries, and veins. When properly adjusted, it is claimed that it gives an exact representation of the pulse curve, the frequency and regularity of the pulsations, and any peculiarity of the pulsation. But it has not fulfilled the expectations that were entertained of it, for it has been found that SPHYQMOGEAPH. 311 the characters of a sphygmogram may be entirely changed by merely altering the amount of pressure on the arterial wall. During the excitement, too, which is sometimes brought on by adjusting the instrument, the tracing obtained is very different from that taken when the heart is beating tranquilly. Sphygmograms are of more importance in the record- ing of cases and clinical teaching than in diagnosis. By means of them we can demonstrate elements of the pulse that would otherwise escape detection. Care must be used in adjusting the instrument, for if too much pressure is made the arterial wall Avill be so compressed as to interfere with its free movement ; and if the pressure be too slight the full movement of the wall will not be registered. In taking a tracing from the radial artery, the instrument should be applied to the arm with the ivory button resting on the artery just beyond the lower extremity of the radius. The pulse is a wave of increased arterial pressure, started by the systole of the heart, and passing over the arteries of the body. A graphic record of this wave, taken at any point of an artery, is caUed a pulse curve. It consists of three parts — the upstroke or anacrotic limb, the crest, and the down-stroke or katacrotic limb. The upstroke represents the flow of blood into the arteries and the consequent distention of their walls. It is nearly synchronous with the ventricular systole. The crest of the pulse curve designates the period dur- ing which the artery reaches its greatest degree of dis- tention and begins to recoil. It is usuaUy pointed, but may be rounded, as in certain aneurisms and aortic stenosis (see Figs. 105 and 109). The down-stroke represents the return of the artery 3ia PHYSICAL DIAGNOSIS. to its original calibre. Its descent to the base line is gradual. It is broken by one or more undulations, the most prominent of which is the dicrotic crest. This crest is sometimes so marked as to be perceptible to the finger, giving rise to the dicrotic or " double " pulse. Fig. 102.— Normal tracing. (After BramweU.) The up-stroke is from a to &. Tlie crest is at b. Tlie down-stroke is from !> to a', with o the prediorotic, and d the dicrotic crest. In a normal pulse curve the up-stroke is nearly or quite vertical, the crest is pointed, and the dovra-stroke slopes gradually to the base line. The predicrotic and dicrotic crests are visible on the down-stroke (see Fig. 102). V\\ ti i^"^V,U^^^ Fig. 103.— a Dicrotic Pulse Tracing. CAfter Eichhorst.) Dicrotism is favored by a low ai-terial tension, a suf- ficiently powerful heart, elasticity of the vessel walls, and a diminished resistance in the smaU arteries. It occurs in cases where there is loss of vaso-motor tone, and in typhus and typhoid fevers. The prominent features of the tracing of aortic re- gurgitation are the suddenness of the down-stroke and • the almost complete absence of the dicrotic crest (Fig. 104). 8PHYGM0GEAPH. 313 _ In aortic stenosis (Fig. 105) the blood is not propeUed mto the artery suddenly, owing to the resistance it meets, Fie. 104. —Pulse Tracing in Aortic Regurgitation. (After Strumpell.) and hence the up-stroke is gradual. The crest in this instance is rounded. If atheroma is sufficiently advanced to cause much impairment in the elasticity of the arterial waUs, the Fig. 105.— Aortic Stenosis. (After Bramwell.) tracing wiU be as represented in Fig. 106. Owing to slowness of expansion the up-stroke is gradual. The crest is rounded in this case, though it may sometimes FiQ. 106.— Tracing from a Case of Atheroma. (After Eichhorst.) be pointed. The loss in elasticity prevents the occur- rence of secondary crests. The frequency of the pulse may also be studied by 314 PHYSICAL DIAGNOSIS. means of the sphygmograph. As the plate moves at a given rate of speed, the number of pulse curves traced during its passage indicates the number of heart beats in a given number of seconds.' Fig: 107 is a tracing from a case of mitral regurgita- tion with a rapid pulse. It wiU be seen that the pulse curves foUow each other in quick succession. ji-ll Fig. lOT.— Frequent Pulse (120 to 130). (After Bramwell.) The pulse may be irregular in time or volume, or in both. Irregularities in volume are usually associated with irregularity in time. VaJ\^ \j^\^^ Fig. 108.— Mitral Obstruction. (From a patient in Bellerue Hospital.) In Fig. 108, from a case of mitral obstruction, irregu- larity both in time and volume is represented. Bight Arm. Left Arm. Fia. 109.— Aneurism of Ascending Aorta. (From a patient in Bellevue Hospital.) The passage of the blood through an aneurismal sac; usually leads to a flattening of the pulse curves (see Fig. 109) and a retardation of the pulse on the corre- sponding side. ' Mahomed's modification of Marey's sphygmograph is so con- structed that four inches of the plate pass hy the point of the pen in ten seconds. LESSOlsr XX. MECHANICAL AIDS IN THE DIAGNOSIS OP DISEASES OF THE NERVOUS SYSTEM, AND IN GENERAL DISEASES— OPH- THALMOSCOPE — THERMOMETER— MICROSCOPE- DYNAMOMETER — ^STHESIOMETER — EX- PLORING TROCAR— SPECULA. Ophthalmoscope. The simplest and least expensive ophthalmoscope is Liebreich's. ' It consists of a concave circular mirror about one and one-half inches in diameter, and from ten to twelve inches focal distance, perforated in the centre by a small circular aperture. Behind the mirror is a hinged clip, into which eye pieces may be adapted, three of wMch are concave and two are convex, from six to twelve inches focal distance. On the side of the mirror is a shank which fits into a handle about six inches in length, by which the mirror can be held in any position desired. In addition to these there is a convex object lens of two and one-half inches focu& (shown in Fig. 110). The examination is best made in a darkened room, the examiner and patient sitting or standing face to face. ' The best instrument for the direct method of examination is that of Dr. Loring, of this city. The refraction of the eye examined may be determined by its use, it having' a complete series of convex and concave glasses, which, by an ingenious revolving disc ar- rangement in the mirror, may be placed before the eye of the ob- server. The student who desires to give much attention to ophthal- moscopy will probably prefer this instrument, although it is more expensive than that of Liebreich. 316 PHYSICAL DIAGNOSIS. There are two methods of examining the eye with this instrument, the direct and indirect. In both a lamp is placed at the side and a little behind the patient's head, the flame being on a level with his eyes. The handle of the mirror is held between the thumb and forefinger, and the eye piece at the aperture of the mirror is brought close to one of your own eyes in such a manner that the Ught from the lamp is reflected into the eye under observation. If you desire to make a direct ex- amination, bring your eye which is armed with the mir- ror very close to the patient's eye, at the same time ad- justing your eye for objects at an infinite distance, that is to say, having the accommodation at rest. The ex- TIEMANN &Cff- Fie. 110.— Liebreich's Ophthalmoscope. aminer should use the corresponding eye in examination with the one being examined. If the eye of the observer and that of the patient be of normal length, a clear image wiU be obtained ; if not, the proper correcting glass, convex or concave, may be used. The patient should turn his eye a little outward and across the room upon some object. In indirect examinations the lamp and mirror are ar- ranged the same as for the direct, but the mirror is only brought sufficiently near the eye to be examined to bring the focus of the reflection upon the optic disc ; having done this, take the convex lens between the thumb and first finger of the hand not engaged with the mirror ; rest the second and third fingers of this hand OPHTHALMOSCOPE. 317 on the patient's forehead, so as to steady the lens, and move it to and fro directly in front of the eye under examination untH you find the focus— your little finger remains free to raise the lid, if necessary, or to press upon the eyeball. When by practice you have acquired dexterity in manipulating this instrument, and by repeated examina- tions of the normal eye have become familiar with the appearance of the normal retina, optic disc, and choroid, you will be able readily to recognize many of the patho- logical changes in those structures which are now be- coming important elements in the diagnosis of diseases of the brain, spinal cord, and other vital organs. The importance of this instrument in the diagnosis of diseases of the eye is universally admitted, so that no ophthalmic surgeon of the present day regards the ex- amination of an eye complete without an ophthalmo- scopic examination. I shall not attempt to detail its diagnostic uses in this branch of surgery, but wiU briefly state its uses in medical diagnosis, as it is com- ing to be regarded of no little importance. An ophthalmoscopic examination of an eye may show the optic disc to be the seat of simple hypercemia, anae- mia, ischcemia, or congestion and effusion within and around it ; of inflammation of its sheath or of its sub- stance ; and, lastly, of atrophy. It may show the retina to be the seat of hypercemia, ancemia, ot fatty exudation patches, or of hcemorrhages. It may show the choroid to have partially or alto- gether' Zos^ its pigment and to be the seat of hcemor- rhages, to have undergone atrophy, etc. It may show the blood vessels within the eye di- minished, obstructed, dilated, tortuous, varicose, pulsat- ing, or to be the seat of embolism, thrombosis, or rupture. 318 PHYSICAL DIAGNOSIS. Hyperemia of the Disc may occur in the vessels of the disc, in the retinal veins, or in both retina and pa- pillae together. The larger vessels, and chiefly the ret- inal veins, are seen dilated, darker in color than natu- ral, slightly tortuous, or even varicose. To pronounce upon slight hyperaemia of the disc or retina is a delicate and difficult task ; generally the hyperaemia is to be first seen on the inner half of the disc. In states of hyperaemia, when pressure is made on the baU of the eye, pulsations in the veins are more marked than in the normal condition. Direct exami- nation is important in these cases. Clinical Significance of Hypercemia of the Disc or Retina. — Its causes are many. First, it is frequent in the first stage of ischaemia, of neuritis, or of an atrophic process. It may be due to orbital disease, to choroi- ditis, to Bright's disease, to alcoholismus, to cerebral tumors, to acute or chronic meningitis, and to active cerebral hyperaemia ; transient hyperaemia may be seen in forms of cardiac disease which obstruct the venous circulation, and in Grave's disease. Anemia of the Disc and Retina is the opposite of hyperaemia. It is always accompanied by anaemia of the retina and choroid. It is liable to be mistaken for atrophy of the disc ; but the edges of the disc are not so sharp and well defined as in atrophy, and it is pos- sible to distinguish the arteries from the veins ; again, anaemia is equal in both eyes, atrophy is not ; besides, atrophy rarely involves a whole disc equally, as does anaemia. Clinical Significance.— The causes of anaemia of the disc or retina are the same as those of general or local anaemia. Ischemia op the Disc is a mechanical venous conges- OPHTHALMOSCOPE. 319 tion, oedema, and punctate extravasation of the disc ; the disc is swollen, rising abruptly on one side and sink- ing gradually on the other ; its color varies from a bright transparent gray to a dirty red ; the margin of the disc is wholly concealed by infiltration and excessive vascu- larity, which gives it a mossy appearance ; the veins of the retina are tortuous — they may be very tortuous. It is difficult and sometimes impossible to distinguish this condition from optic neuritis ; the two are fre- quently associated. Clinical Significance. — The causes of ischsemia of the disc are all those changes within the skull which more or less directly distend the ophthalmic veins. The three main causes are, chronic meningitis, hydrocephalus, and tumors. The lesions of the optic disc which seem to have the closest connection with cerebral, spinal, and general diseases are hyperoe,mia and ancemia of disc and retina, optic neuritis with its consecutive atrophy, and primary or progressive atrophy. In Optic Neuritis the disc becomes larger than usual, its edges indistinct, irregular, and puffy, the infiltration casting a veil over it, so as to change its color into a lilac gray, and more or less to conceal the vessels as they pass within its margin. The veins increase in size, become tortuous or even varicose ; they darken in color and seem to be gorged with blood. The capilla- ries, which in their normal state ought not to be seen, also become evident, and give a mossy or woolly ap- pearance to the disc (Von Graefe). Clinical Significance.— Optic neuritis is very gene- rally coexistent with meningitis at the base of the brain, with cerebral tumors and large cerebral hmmor- rhages. 330 PHYSICAL DIAGNOSIS. It can only be distinguished from the retino-neuritis of albuminuria, and from the retino-choroiditis of syphilis, by the history of the case, by its limitation for the most part to the papillae and the conveying vessels. Its resemblance to ischaemia has already been stated. In the consecutive atrophy of optic neuritis, the in- tense vascularity in and about the disc subsides, the in- filtrations are absorbed, the nerve whitens, and the capillaries slowly shrivel and vanish. The edges of the disc become distinct but are deformed, and patches of organized lymph are to be seen upon and about them. In progressive atrophy of the optic, disc, the fine ca- pillaries which give the rose tint to the healthy disc slowly disappear, and a dead or pearly white is left. The border of the disc is sharp, clearly defined, flat, and even. This lesion generally depends upon some disease of the cerebrum, cerebellum, or spinal cord. The most important indications of organic disease ca- pable of being recognized by an ophthalmoscopic exami- nation of the eye have been summed up by Dr. T. C. Allbutt as follows : In the first stage of meningitis there is dilatation of the veins of the retina, peripapillary congestion, and often external effusion. In the second stage the veins become tortuous, thrombotic, and sometimes rupture.' In basilar meningitis optic neuritis is present, but not in meningitis of the convexity. Intercranial affections which directly distend the ophthalmic veins, as hydrocephalus and intracranial tumors, cause ischaemia of the discs, and, if the pres- sure is extreme, atrophy of the optic nerves. Acute and chronic cerebral softening causes acute or chronic optic neuritis and atrophy. Cerebral haemor- THERMOMETER. 331 rhage, when large, by its obstruction causes stasis in the vessels and effusion in and about the optic disc. In diseases of the spinal cord, as progressive atrophy, sclerosis, and chronic myelitis, simple progressive atro- phy of the optic disc is not uncommon. In Bright' s disease the nutrition of the optic nerve, as well as that of the retina, is interfered with ; upon the retina extravasations are seen in the course of the vessels ; these extravasations are slowly effused and pass into degenerative states, forming white patches or striations along the margins of the veins ; most of these patches have evidently been clots ; some may be due to "the degeneration of retina. In syphilis the choroid is the cmef seat of lesion, and patches of many colors are to he seen at the back of the eye ; some q^ brilliant white and others of darker tints, as red or brown. We also have intense neuro- retinitis in syphihs, but its appearances cannot positively , be distinguished from those of any other forms of neuro- retinitis. Thermometer. The thermometer is now regarded an indispensable aaiechanical aid in the diagnosis of disease. I prefer (and would recommend to you) the straight, self-registering ■clinical thermometer represented in Fig. 111. This thermometer consists of a glass stem, having on it a graduated scale varying from 95° to 112° F., ex- hibiting .2° F. The upper extremity of the stem is closed. At the lower end there is a bulb of mercury as thick as the diameter of the stem. Within the stem is a bit of mercury, detached from that in the bulb, called the index ; this index is set by taking the bulb and stem of the instrument firmly in the hand, when, by repeated 31 322 PHYSICAL DIAGNOSIS. sudden blows of the wrist upon the knee, the index is brought down the stem to a point just below the lines ^^ which indicate the degrees. After the in- dex has thus been set, the bulb of the instru- ment may be applied to the axilla, between the thighs, in the mouth, rectum, or vagina, or to any part where it can be completelif covered^ When the instrument has been in perfect contact with the parts for five or seven minutes, gently remove it, and the top of the index will denote the maximum tem- perature of the part. (Thermometers are now made with very small bulbs requiring but a minute's contact.) If the axillary temperature is to be taken, the axilla should first be thoroughly dried, and the bulb of the instrument placed directly beneath the fold of the pectoralis major mus- cle, the forearm on that side being carried across the chest, and the elbow held by the other hand of the patient or by an assistant. If the rectal or vaginal temperature is to be taken, the parts should first be thoroughly cleansed with warm water, and the patient placed on the side. The mouth is the usual place at which the temperature is taken, and is sufficiently accurate for relative values. Fie. 111.— . Straight, Self Registering Thermometer. ' Dr. E. Seguin, of this city, has devised a thermometer for de- termining localized surface temperatures. The peculiarity of this instrument is that the mercurial bulb is flattened, so as to furnish a large surface at its base. Dr. Seguin claims for this instrument facility and accuracy in determining the surface temperature of different parts of the body. THERMOMETER. 333 Thermometrical observations, if possible, should be continuous, and be taken at least twice in the twenty- four hours— from T to 9 a.m. and from 4 to T p.m. In cases of doubtful diagnosis, and in very active dis- ease, they also should be taken at noon and at midnight. The pulse and number of respirations should be noted at the time the temperature is taken. The rate of rise in the temperature indicates the degree of heat, and should be noted. Eange op Temperature in Health.— The normal temperature, taken in any of the above-mentioned local- ities, varies from 97.5° F. to 98.4° F. Any rise above 99.5° F., or depression below 97.3° F., if persistent, is a sure index of disease. A temporary elevation takes place after meals and after violent exercise. But there is a diurnal variation of temperature amounting to one degree usually, sometimes two. The minimum occurs between 2 and 6 in the morning, and from that time there is a rise until the maximum is reached between 5 and 8 in the evening. Eanges op Temperature in Disease. — The greatest range of temperature in disease is 1 7. 0° F. ; the minimum of 91.8° F. has been recorded with recovery of the pa- tient, and the maximum 117.8° F. The highest recorded temperature was observed in the New York Hospital in a patient with sunstroke. The highest temperature ordi- narily met with in severe and fatal cases rarely exceeds 108° F., except in sunstroke, in which 115° F. has oc- curred with recovery. , A single thermometrical observation is an important element in differential diagnosis when taken in connec- tion with other symptoms, but it has no independent diagnostic value. 324 PHYSICAL, DIAGNOSIS. Axillary temperature below 100° F. excludes the ex- istence of fever ; above 101° F., leads to the probability of fever; when it exceeds 108° F., you may probably exclude fever. A temperature of 107° F. indicates malignancy, and when met with for two consecutive days in typhus, scarlatina, measles, jjueumonia, pyaemia, meningitis, or rheumatic affections, death is almost certain to foUow. In relapsing and in pernicious intermittent fevers, the temperature may rise to 107° without indicating great danger. In many diseases, during the last few hours of Uf e, the temperature suddenly rises as high as 109° F., or even 112° F. ; especially is this true in tetanus, sunstroke, typhus, pyaemia, etc. A temperature below 98° does not necessarily indicate collapse, but is more likely to be met with in the aged and feeble when subjects of grave disease. Thus it is evident that a given temperature without its antecedents is apt to mislead in diagnosis. When isolated, the highest temperature only portends danger, and with a temperature of 95° F. coUapse is not cer- tain. Daily Variation of Temperature in Disease. — Daily thermometrical variations in disease depend upon the elements which constitute the morbid processes, the intensity of these processes, and the stage they have reached; also somewhat on the idiosyncrasy of the patient. A single day's variations may determine the severity and stage of a disease ; but you must compare the vari- ations of a number of days before (in a large proportion of cases) you can reach a diagnosis. High average temperature, above 104° F., is met with THERMOMETER. 325 in remittent, typhus, typhoid, and relapsing fevers, in severe pneumonia, etc. A moderately high average temperature above 102° F. IS met with in catarrhs, cerebro-spinal meningitis, diph- theria, dysentery, pleurisy, pericarditis, acute rheuma- tism, peritonitis, etc. A slight average rise in temperature above 100° F. has a varied significance, and is met with in a large class of chronic affections, and at the commencement of acute inflammations and mild types of fever. When your thermometrical observations foUow regu- lar diurnal variations, with a rise each day of one de- gree — as, first day, morning 99.5° F., evening 101.5° F.; second day, morning 100.5° F., evening 102.5° F. ; third day, morning 101.5° F., evening 103.5° F. — you have almost certain evidence of typhoid fever. If the temperature does not exceed on any evening 103.5° F., the fever will probably have a mild course ; if it reaches 105° F. in the evening, it shows that the attack is a se- vere one, and forebodes danger. A sudden and marked reduction of temperature to 95° F. during the third week of typhoid fever, denotes hgemorrhage from the sloughs of Peyer's patches. If a patient with measles retain a high temperature af- ter the eruption has faded, it indicates sonie complication. Whatever differences of opinion may exist in regard to the importance and reliability of thermometrical ob- servations as elements of diagnosis, the following propo- sitions, it seems to me, may be regarded as established : 1. An abnormal temperature denotes the presence of some disturbance in the animal economy. 2. Certain degrees of temperature indicate fever. 3. The height of the temperature decides the severity and danger of a disease. 336 PHYSICAL, DIAGNOSIS. 4. Therniometrical observations aid us in discovering the laws which regulate the course of certain diseases. 6. When the normal therniometrical course of a dis- ease has been determined, its diagnosis ^is simplified. 6. The thermometer indicates quickly and certainly any deviation in the regular course of many diseases, the transition from one stage to another, and the com- mencement of convalescence. 7. It reveals the occurrence of compUcations. 8. It often reveals the imminence of a fatal termi- nation. 9. It sometimes shows the impossibihty of the con- tinuance of life. 10. It is an important guide as regards the effects of remedial agents. Microscope. The compound microscope consists essentially of a tube (T) having a system of lenses at each end ; the up- per system is called the ocular (Oc), the lower the ob- jective (Obj). Within this is a smaller or draw tube. The whole is attached to the stand (S). At St is the stage on which the object to be examined is placed. In its centre is a diaphragm for the purpose of regulating the amount of light. Below the stage a mirror (M), with a plane and concave surface, is suspended. It is for the purpose of illuminating the specimen, and is so adjusted as to admit of movement in any direction. The lenses are focussed by means of the coarse (C. adj) and fine (F. adj) adjustments. The coarse adjustment has a rack-and- pinion movement ; the fine adjustment consists of a finely cut screw acting against a spring. There should be at least two objectives — a low power having a focal distance of half an inch, and a high power with a focal MICROSCOPE. 327 distance of one-sixth of an inch. For bacteriological work a homogeneous oil-immersion lens (one-twelfth) is required. A good microscope should magnify from fifty to four hundred linear diameters. Method of Using the Mi- croscope. — For the exami- nation of blood, pus, urine,' etc. (for sputum see page 260), all that is necessary is to place a drop of the speci- men in the centre of a slide, cover it with a cover glass, and put it under the micro- scope. Small pieces of tumors, and curettings from the ute- rus and cervix uteri, may be teased out on a shde with fine needles and examined for their component cells. But when it is remembered that a diagnosis is based in many instances upon the arrangement as well as the appearance of the ceUs, it will be seen that this method is open to serious objections. Tissues should always be hard- ened, embedded, and cut into thin sections. The sec- tions should then be stained and mounted. For the methods of hardening, staining, etc., the student is re- ferred to Stirling's Practical Histology." ' For obtaining tlie sediment from urine, it is convenient to close the upper end of a pipette with the finger, pass its tip down through the urine, and then remove the finger. Fig. 112.— The Microscope. 328 PHYSICAL DIAGNOSIS.. Dynamometer. The best dynamometer is that of M. Mathieu, an in- stx'ument maker of Paris. It is very simple, and for measuring the strength of the hands leaves nothing to be desired. It consists (as shown in Fig. 113) of an elliptical steel spring, to which is attached a semicircle of brass upon which a scale is marked. The indicator termi- nates at its central end in a cogwheel which works upon a steel arm. When it points to zero of the scale, the lower end of the arm touches the elliptical spring, A brass sheath upon the under side of the scale keeps Fig. 113.— Dynamometer. this arm in place, at the same time allowing it to move freely. When the dynamometer is grasped in the hand, and the two sides of the spring approximated, the indicator is turned by the upward movement of the arm. One great advantage of this instrument is that, when the pressure is taken off, the indicator does not return to zero, but remains at the point to which it has been car- ried by the muscular power of the individual. Clinically, you are able to measure the strength of partially paralyzed muscles of the upper extremities, to determine the shghtest difference in the muscular power of the two hands, as well as to determine any changes that may occur from time to time in the course of a case of parg,lysis. iKSTHESIOMETEE . 339 ^sthesiometer. This iustrument was invented by Dr. Sieveking in 1858 for the purpose of determining the degree of tac- tile sensibihty of any part of the body. It consists of a graduated bar of metal four or five inches in length. At one end is a fixed steel point. Another steel point is made to slide upon the bar, and can be fixed at any distance from the first by a screAv which works at the top of the slide (Fig. 114). It wiU be found that in a perfectly healthy person, when two impressions are simultaneously made upon the skin, the power of distinguishing them varies greatly in different parts of the body. i lo g|° ' 1 ° "1° ^!° 3 Fis. 114.— ^sthesiometer. The following table of Weber gives the distances at which the two points of the sesthesiometer are normally felt in the different regions of the body : Tip of the tongue 1-1 Palm of distal phalanx of finger 2.2 Palm of second phalanx of finger -i-i Tip of nose 6-® White portion of the lips 8.8 Back of second phalanx of finger 11.1 Skin over the malar bone 15-4 Back of the hand 29.8 On the forearm ^^-^ On the sternum 4*-^ On the back 66.0 330 PHYSICAL DIAGNOSIS. In using the instrument, first fix the two points at the distance which is normal for the part of the skin to be inquired into. The points must be apphed simulta- neously.' If the patient feels only one point when' both points touch the skin, the two points must be gradually separated from each other, and reapplied to the part until both points are felt ; in this way you will determine the amount of ancesthesia present. If, on the other hand, the two points are each distinctly felt at the normal distance limit, they must be brought gradu- ally toward each other until one point is felt ; thus you determine the amount of hypercesthesia present. The patient ought not to see the instrument, or know for what purpose it is apphed. This instrument aids you in determining the amount and extent of sensational impairment in cases of paraly- sis, as well as for determining if the loss of sensation is progressive. In the record of cases it is also of service. Exploring Trocar. This instrument is an aid to positive diagnosis, as it enables you to determine the character of fluid contained in a distended pleural, pericardial, or abdominal cavity, or of that contained in any fluctuating tumor or deep- seated abscess. There are three instruments which may be used as exploring trocars, viz. : the ordinary Hypodermic Sy- ringe, Dieulafoy^s Aspirator, and Dieulafoy^s Exhaust- ing Syringe. The objection to the hypodermic syringe is that the needles are so smaU, and the exhausting power of the ' Care must be taken not to press too heavily, or the sensation of two points will be converted into the sensation of one. EXPLORING TROCAR. 331 syringe so slight, that you are not always able to draw the fluid through them. The Aspirator is the best instrument for the purpose, but its price places it beyond the reach of many. The Exhausting Syringe is much larger than the hypo- dermic syringe. It consists of a glass cylinder encased in a metal mounting, which is fenestrated so that the fluid can be seen as it is drawn into the syringe. There are two branches upon which the needles may be fitted. A valve is placed at their junction, and connected, by means of small bars and joints, with a handle running along the Fio. 115.— Dieulafoy's Exhausting Syringe side of the cylinder. When the handle is depressed, the valve rotates, closing one of the branches ; when the pressure is taken off, a spring returns the handle to its former position, the valve closing the branch previously opened (see Fig. 115). By this means the entrance of air into the needle is prevented. Two needles accompany the instrument— a large and a smaller one ; the former to be used when pus is sus- pected, the latter when you expect to find serum. The needles are first introduced into the part to be examined, and then connected with the syringe, either directly or by means of a small rubber tube. 332 PHYSICAL DIAGNOSIS. Dr. Dieulafoy, of Paris, the inventor of this instru- ment, says that it is always possible to introduce the needle without danger in searching for fluid, no matter where it is situated or what its nature, and that he has never met with an accident in using it. If, after obtaining the fluid, any doubt remains as to its character, a drop should be placed on a slide and ex- amined under the microscope. The diagnostic value of such an instrument is so readily appreciated that it is not necessary to enter into the details of its application. 'Ihe X-Ray in Diagnosis. Professor Eoentgen in 1895 discovered the peculiar ray to which his name has been given. At first it seemed to promise great assistance in the diagnosis of obscure con- ditions. The rays are the cathodal rays of an electric current passed through a vacuum tube (Crookes' tube). It is probable that such rays, but less powerful ones, emanate from the anode. The X-rays have the power of passing through solid objects. They are not subject to reflection or refraction, and produce fluorescence and phosphorescence. Their usefulness is at present greatest in surgery, in examining the diseases of the bones and in locating foreign bodies. In medical diagnosis they have been successful in showing enlargements of the heart, pericarditis, aneurisms, and calcareous deposits in the blood-vessels. Emphysema of the lungs, tumors, cal- careous nodules and cavities in their substance and pleuritic effusions can be recognized. They have been disappointing in mapping out stones « in the gall bladder, kidneys, or urinary bladder. To one SPECULA. 333 ■who has made a special study of the shadows produced in examining the body with these rays, they are often of great assistance, but it needs long practice and a trained eye to obtain from them much assistance. Specula. Various specula have been devised for exploring the nose, the ear, the vagina, the rectum, and the urethra, and, in the hands of those accustomed to their use, are of material aid in arriving at a more positive diagnosis than could otherwise be obtained. The endoscope, an instrument constructed for the pur- pose of exploring and making applications to the urethra, bladder, and rectum, has a series of dark-lined metallic tubes, which are employed as specula, and may be used with solar or artificial light. The uses of this instru- ment are almost exclusively confined to the domain of surgery ; I shall not, therefore, include it in the list of mechanical aids to medical diagnosis. INDEX. A.bdomeu, auscultation of, 138 difficulties of physical explora- , tion of, 131 inspection of, 135 mensuration of, 136 methods of physical examina- tion, 135 palpation of, 136 percussion of, 137 topography of, 131 zones of, 133 Abdominal aneurism, 169 wall, chronic abscess of, 156 Abscess of liver, 148 Acetic acid, test for, 384 Acidophile, 313 Actinomyces in sputum, 357 in urine, 376 ^sthesiometer, 339 Albumin, Heller's test for, 197 in urine, 197 significance of, 199 tests for, 197 Albu;iiinometer, 198 Ammonio - magnesium phosphate crystals in urine, 366 Amoebaa coli in faeces, 390 in sputum, 359 Amphoric cough, 51 resonance, 36 respiration, 38 whisper, 50 voice, 50 Aneemia, pernicious, blood in, 333 simple, blood in, 339 Aneurism, abdominal, 169 of the arteria innominata, 135 of thoracic aorta, 131 diagnosis of, 134 physical signs of, 131 Anthrax, bacillus of, 341 Aorta, 83 aneurism of thoracic, 131 Aortic valves, position of, 83 Ascaris lumbricoides, 394 Ascites, 139 Aspirator, 331 Asthma, spasmodic, 57 physical signs of, 57 Asystolism, 119 Atelectasis, 64 Auricular diastole, 84 systole, 84 Auscultation, 39 immediate, 39 intra-thoracic, 39 mediate, 39 of the voice, 47 rules for performing, 30 Auscultatory percussion, 37 Axillary region, 10 Bacillus of anthrax. 341 typhoid fever, 341 Bacteria in the blood, 339 "Barrel-shaped" chest, 55 Basophile, 313 Bile ducts, obstruction of, 149 Bile, Gmelin's test for, 306 in urine, 306 Pettenkofer's test for, 307 Rosin's test for, 306 Bladder. 160 Blood, bacteria in, 339 changes, significance of, 339 examination of, 311 guaiacum test for, 307 in fEeces, 388 in uriue, 307. 370 in vomit, 376 plates, 313 pneumococci in, 339 red corpuscles, 313 changes in number, 814 enumeration of, 315 staphylococci in, 340 white corpuscles, 313 enumeration of, 319 Bothriocephalus latus, 393 Breathing, costal, 11 836 INDEX. Breathing, diaphragmatic, 11 normal, 11 Bronchi, dilatation of, 54 Bronchial casts, 253 cough, 51 respiration, 33, 37 ■whisper, 50 abnormal modifications of, 50 Bronchiectasis, 54 physical signs of, 55 Bronchitis, 53 capillary. 54 physical signs of, 54 differential diagnosis of, 54 physical signs of, 53 Bronchophony, 47, 49 whispering, 50 Broncho- vesicular respiration, 37 Butyric acid, test for, 284 Calcium oxalate in urine, 265 Cancer of liver, 149 pulmonary, 63 diagnosis of, 64 physical signs In, 63 Cardiac hypertrophy, physical signs of, 115 Cardiac impulse, 89 murmurs, 109 table of, 103 Cardiometer, 303 Casts in urine, 271 Cavernous cough, 51 respiration, 38 ■whisper, 50 Chest, average circumference of, 17 regions of, 4 topography of. 3 vital capacity of, 18 Chlorides in urine, 190 Chlorosis, blood in, 339 Cholera bacillus, 389 Chyluria, 264 Cirrhosis of the liver, 151 Clavicular region, 4 " Cog-wheel " respiration, 35 Comma bacillus, 389 Congestion, pulmonary, 64 Cracked-pot resonance, 36 Crepitant rSles, 43 Curschmann's spirals, 351 Cyrtometer, 303 Cystin in urine, 267 Czenzyenskl's fluid, 248 D Dicrotism, 312 Dilatation of the heart, 116 Diphtheritic exudates, examination of, 360 Distoraa hepaticum, 291 Double pulse, 812 Dry rSles, 40, 41 Dulness, pulmonary, 25 Dynamometer, 338 E Eberth's bacillus, 289 Echinococcus in sputum, 259 in urine, 376 Egophony, 49 Ehrlich's triacid stain, 335 Elastic tissue in sputum, 352 Emphysema, pulmonary, 55 diagnosis of, 57 physical signs of, 55 Empyema, 70 pulsating, 135 Endocardial murmurs, 99 Endoscope, 333 Eosinophile, 314 Epigastric pulsation, 135 region, 134 zone, 133 Epithelium in fseces, 388 in urine, 270 in vomit, 377 Exhausting syringe, 331 Expiration, prolonged, 36 Psecal accumulations, 153, 157 Fseces, 288 amoebae coli in, 290 animal parasites in, 390 ascaris lumbricoides in, 294 blood in. 388 bothriocephalus latus in, 398 cholera bacillus in, 389 distoma hepaticum in, 391 epithelium Id. 288 micro-organisms in, 289 oxyuris vermicularis in, 294 tenia mediocanellata in, 292 tenia solium in, 291 tubercle bacilli in, 290 typhoid bacillus in, 289 Fat in urine. 264 Fatty heart, 119 liver, 147 Fehling's test, 301 Fermentation saccharometer, 304 Fibroid heart, 119 Filaria Demarquaii, 349 diurna, 349 nocturna, 349 INDEX. 337 Filaria perstans, 249 sanguinis liominis, 248 in urine, 276 Flatuess, pulmonary, 25 Foetal heart sound, 163 Fremissement cataire, 91 Fremitus, friction, 16 rhonchial, 16 sonorous. 16 vocal, 15 Friction fremitus, 16 sounds, pericardial, 97 pleuritic, 40, 45 Funic souffle, 163 Gangrene, pulmonary, 62 Gastric contents, chemical analysis of. 278 significance of examination, 286 Gmelin's test, 206 Gonococci, 275 Gower's solution, 216 Giinzberg's test, 380 Gurgles, 43 fisematoscope. 228 Hsemometer, 227 Heart, abnormal sounds of, 97 auscultation of, 92 dilatation of, 116 duration of phases of contrac- tion, 86 fatty, 119 fibroid, 110 foetal sound, 163 hypertrophy of. 115 inspection of, 89 murmurs, 97 palpation of, 90 percussion of, 91 physical examination of, 89 et seq. physiological action of, 88 relative position of valves, 82 sounds of. 93 modifications of normal, 94 reduplication of, 96 surface measurements of, 82 topography of, 81 Heller's test, 197 Hemorrhage, pulmonary, 62 Hepatitis, acute, 149 Hydatids of liver, 150 Hydrochloric acid, tests for free, 280 Hydro-pneumothorax, 73 22 Hydro - pneumothorax, physical signs of, 73 Hypertrophy, cardiac, physical signs of, 115 Hypochondriac regions, 134 Hypogastric region, 134 zone, 133 Iliac regions, 135 Infra-axillary region, 10 Infra-clavicular region, 5 Inframammary region, 6 Infra-scapular region, 9 Inspection, 11 in pleurisy, 12 in pulmonary emphysema, 13 Interrupted respiration, 35 Inter-scapular region, 9 Intestines, physical signs of, 142 Jugular pulsation, 127 K Kelling's test, 283 Kidney, movable, 160 Kidneys, location of, 158 physical examination of, 159 Lactic acid, Kelling's test for, 283 Laryngeal mirror, 304 • respiration, 33 Laryngophony, 47 Laryngoscope, 304 Larynx, abnormal appearances, 807 method of examining, 305 normal appearance, 306 Leucin in urine, 267 Leucocytes, 213 enumeration of, 219 Leucocytosis, 221 Leukssmia. blood in, 222 Lipuria, 264 Liver, abscess of, 148 cancer of, 149 cirrhosis of, 151 congestion of, 149 diagnosis of diseases, 158 table of. 153 displacements of, 154 fatty. 147 hydatids of, 150 normal boundaries, 144 variations in size, 147 838 INDEX. Liver, waxy, 147 Lobar pneumonia, 58 Lobular pneumonia, 60 Loeffler's methylene blue, 263 Lower sternal region, 7 Lumbar regions, 134 Lymphaemia, 223 Lymphocytes, 213 ISI Macrocytes, 226 Mammary region, 6 Mast cells, 214 Megaloblast, 227 Mensuration, 16 in disease, 17 Mesenteric enlargements, 173 Metallic tinkling, 51 Microcytes, 325 Microcythaemia, 225 Micro-organisms in urine, 374 Microscope, 826 method of using, 337 Miliary tuberculosis, acute, 74 Mitral valve, position of, 83 Moist rSles, 40, 42 Movable kidney, 160 Mucous click, 44 rales, 43 Mucus in urine, 268 Murexide test, 185 Murmur, aortic obstructive, 109 regurgitant 109 mitral regurgitant 110 rhythm of, 99 Murmurs, ansemic and functional, 108 area and rhythm, 106 aortic, 106 mitral, 104 pulmonic, 105 tricuspid, 105 cardiac, 109 table of, 103 endocardial, 99 seat of, 103 subclavian, 136 valvular. 99 venous, 108, 137 ventricular, 111 Myelocytes, 214 Myelocythsemia, 233 N Nasal speculum, : Neutrophile, 213 (Edema, pulmonary, 61 diagnosis of, 61 physical signs of, 61 Oligocythaemia, 315 Omental tumors, 171 Omentum, cancer of, 156 tuberculosis of, 156 Ophthalmoscope, 315 Optic disc, appearances of, 317, 318 atrophy of, 320 Optic neuritis, 319 Ovaries, 165 diagnosis of tumors, 167 physical examination of tu- mors, 166 Oxyuris vermicularis, 294 Palpation, 14 Pectoriloqujr, 49 whispering, 50 Percussion, 19 auscultatory, 37 immediate, 19 in disease, 24 in health, 22 mediate, 19 rules for performing, 31 sound, duration of, 30 intensity of, 30 pitch of, 20 quality of, 20 Pericardial friction sounds, 97 sac, 83 Pericarditis, physical signs of, 113 Peritonitis, acute, 139 chronic, 139 Pettenkofer's test, 207 Phenyl-hydrasin test for sugar, 303 Phonendoscope, 301 Phosphates in urine, 187 Phthisis, chronic, 75 Physical diagnosis, definition of, 3 methods of, 3 Plasmodium malarise, 341 sestivo-autumnal parasite, 345 crescents, 246 flagellated bodies, 247 tertian parasite, 341 Plehn's solution, 348 Pleurisy, 66 acute, 66 physical signs of, 66 stages of rf) et seq classification of, 66 diagnosis of. 70 subacute, 68 INDEX. 339 Pleurisy, subacute, physical signs of, 69 Pleurodynia, diagnosis from pleur- isy, 71 Pleximeter, 21 Pneumococci in sputum, 257 Pneumo-hydrothorax. succussion in, 28 Pneumonia, acute tubercular, 75 lobar, 58 gray hepatization in, 59 physical signs of, 58 red hepatization in, 59 lobular, 60 diagnosis of, 61 physical signs in, 60 Pneumothorax, 73 physical signs of, 73 Poikilocytes, 226 Poikilocytosis. 326 Pubic region, 134 Pulmonary artery, 83 congestion. 64 tuberculosis, 74 et aeq valves, position of, 83 Pulsating empyema, 70, 125 Pulse curve, 311 Pulse-rate, normal, 86 Purdy's test for altjumin, 198 for sugar, 203 Purring thrill, 91 Pus cells in vomit, 277 in ^seces, 288 in urine, 208, 269 Pyuria, 208 R Eaie redux, 60 RSles. 40 classification of, 40 Ray fungus in sputum, 257 Relapsing fever, spirillum of, 338 Resonance, amphoric, 26 cracked-pot, 36 exaggerated pulmonary, 35 normal vocal, 47 of cough, 51 tympanitic pulmonary, 35 vesiculo-tympanitic, 36 Respiration, absent or suppressed, 35 amphoric, 38 bronchial, 33, 37 broncho- vesicular, 37 cavernous, 38 "cog wheel, " 35 diminished or feeble, 35 exaggerated, 34 in disease, 34 in health, 31 Respiration, interrupted, 35 laryngeal, 33 rude, 37 table of abnormal, 34 tracheal, 33 vesicular, 33 Respiratory sounds, abnormal, 40 normal, 31 Retina, appearances of, 317, 818 Rhinoscopy, 307 Rhonchi, 40 Rhonchial fremitus, 16 Rosin's test, 206 Rouleaux, 212 Round worm, 394 Rude respiration, 37 S Saccharometer, 204 SarcinsB ventriculi in vomit, 277 Scapular region, 9 Sepulchral cough, 51 Serum diagnosis, 232 Sibilant rSles, 41 Sonorous fremitus, 16 Sonorous rSles, 43 Sound, elements of. 19 Spasmodic asthma, 57 Specula. 333 Speculum, nasal, 308 Spermatozoa in urine, 271 Sphygmograms, 311 Sphygmograph, 809 Spirometer, 18 Spleen, physical signs of, 154 Sputum, actinomyces in, 257 alveolar cells in, 251 amoebae coli in. 259 cellular elements of, 250 Curschmann's spirals in, 251 echinococcus in, 259 elastic tissue in, 353 epithelium in, 351 examination of, 350 fibrinous coagula in, 353 liver cells in, 351 method of staining for tubercle bacilli, 354 pneumococci in, 357 pus cells in, 251 red blood cells in, 351 staining solutions for. 353 tubercle bacilli in, 253 white blood cells in, 251 Stethometer, 17, 301 Stethoscope, 30, 399 Stomach, cancer of, 143, 156 distention of, 143 physical signs of, 141 340 INDEX. Subclavian murmurs, 136 Bubcrepitant rSles, 43 Succussion. 28 Sugar in urine, 301 significance of, 306 tests for, 301 Sulpliates in urine, 193 Supra-clavicular region, 4 Supra-scapular region, 9 Supra-sternal region, 7 Tffinia mediocanellata, 293 saginata, 393 solium, 391 Temperature, diurnal variation in disease, 324 normal, 333 range in disease, 333 in health, 333 Test-breakfast, Ewald's, 378 Thermometer, 331 Thread worm, 294 Toisson's solution, 316 Topfer's test, 280 Tracheal respiration, 38 Tracheophony, 47 Tricuspid valve, position of, 83 Triple phosphate crystals in urine, 366 Trocar, 330 Trommer's test, 301 Tubercle bacilli, 341 in faeces, 390 in sputum, 253 in urine. 276 in vomit, 278 stains for, 253 Tubercular pneumonia, acute, 75 Tuberculosis, pulmonary, 74 et seg. acute miliary, 74 chronic pulmonary, 75 advanced stage, 77 early stage, 75 Typhoid bacillus in faeces, 289 fever and Widal 's reaction, 338 bacillus of, 241 Tyrosin in urine, 267 V Umbilical region, 134 zone, 133 Upper sternal region, 7 Urates in urine, 186, 263 Urea in urine, 181 Ureometer, 181 Uric acid crystals in urine, 364 in urine, 185 Uric acid, murexide test for, 185 Urine. 175 abnormal elements in, 197 actinomyces in, 376 albumin in, 197 signiflcance of, 199 ammonio - magnesium p h o S- phate crystals in, 266 bile in. 306 blood in, 307. 370 calcium carbonate in, 364 oxalate in, 265 phosphate crystals in, 367 phosphate in, 364 casts in, 371 chemical characters, 181 chlorides in, 190 color of, 178 cystin in. 367 deposits in, 181 echinococcus in. 276 epithelium in, 370 fat in, 364 fllaria sanguinis hominis in, 276 leucin in, 367 microorganisms in, 374 microscopic examination of, 363 mucus in, 268 odor of, 178 phosphates in, 187 physical characters. 176 plan of examination, 175 pus in. 308, 269 quantity in twenty-four hours, 176 reaction of, 179 specific gravity of, 179 spermatozoa in, 371 sugar in, 301 significance of, 306 sulphates in, 192 triple phosphate crystals in. 366 tubercle bacilli in, 276 tyrosin in, 367 urates in. 186, 263 urea in, 181 variations in quantity, 185 uric acid in. 185 crystals in. 364 variations in quantity, 186 xanthin in, 268 Uterine bruit, 163 Uterus, 161 auscultation of, 161 tumors of, 165 Valvular murmurs, 99 INDEX. 341 Veins, 126 turgescence of, 136 Venous hum, 108 murmurs, 108, 137 pulsations, 127 Ventricular diastole, 85 systole, 84 Vesicular murmur, 33 respiration, 33 Vocal fremitus in disease, 15 normal, 15 resonance, exaggerated, 49 normal, 47 table of variations in, 48 Vomit, blood in, 27G coffee-grounds, 277 epithelium in, 277 pus cells in, 277 Vomit, sarcince ventriculi in, 377 th". 376 tubercle bp illi in, 378 W Waxy liver, 147 Widal'stest, 338 Xanthin in urine, 268 X-ray in diagnosis, 333 Ziehl-Neelson solution, 354 Prescription Dr-'X'L. HO MEi N, V,