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SENIOR ASSISTANT-PHYSICIAN TO THE MANCHESTER ROYAL INFIRMARY, FORMERLY ASSISTANT-PHYSICIAN TO THE CLINICAL HOSPITAL FOR CHILDF.EN. Mitfj &ttmw0tts EIta0trati0tt0 antu plate in Colours. LONDON: CHARLES GRIFFIN AND COMPANY, LIMITED. PHILADELPHIA : J. B. LIPPINCOTT COMPANY. 1894. WB (41 I S"rq. TO THOMAS BARLOW, M.D. (LOND.\ F.R.C.P., I'HYSICIAN TO UNIVERSITY COLLEGE HOSPITAL, AND TO THE CHILDREN'S HOSPITAL, . I GREAT ORMOND STREET, THIS WORK IS DEDICATED 3n admiration of HIS POWERS OF OBSERVATION, HIS CLINICAL ACUMEN, AND HIS SOUND JUDGMENT ; 5n (SratttuDe for HIS TRUE-HEARTED FRIENDSHIP, WHICH THE AUTHOR HAS ENJOYED FOR MANY YEARS. PREFACE. THE chief aim of the present manual is to assist the student and junior practitioner in the Examination of Medical Cases. For this reason, symptoms and signs are treated of rather than diseases, and much thought and labour have been devoted to the arrangement of symptoms in the order in which they are usually considered in practice. No arrangement can be perfect in this respect, for no two cases are examined in pre- cisely the same way. Nevertheless, it is hoped that the method adopted will impress upon the student the necessity of eliciting facts, and of recording them in a correct and orderly manner, and that it will also be successful in giving him a firm grasp of the subject of Clinical Medicine. A large number of the illustrations are from photographs or drawings of cases under my own care ; for others I am indebted to the kindness of some of my colleagues, while the remaining illustrations have been collected from various sources, which in all cases are duly acknowledged. In the preparation of this volume I have received help from Dr. Williamson in the sections relating to the blood, sputum and puncture fluids, and from Dr. Kelynack in those on the pulse and temperature. I am also greatly indebted to my friend and colleague, Dr. Harris, for his kindness in writing the section on Laryngoscopy, and to Dr. Wild for that on skin eruptions ; while to my friends Dr. Barlow, Dr. Dixon Mann, and Dr. Steell, I owe thanks for a number of valuable suggestions and corrections. X PREFACE. My warmest thanks, too, are due to Dr. George Lang, of Bromley, for the Index and Table of Contents which he has so fully prepared, and for the great assistance he has given me in proof-reading. Dr. Lang has read and criticised every page of the proofs, and it is to his ability and care that many omissions have been supplied and many mistakes and inaccuracies corrected or avoided. Finally, I must express my acknowledgments to the publishers for their kind assistance in many ways, and especially for the liberality with which they have met my wishes in regard to the illustrations. JUDSON S. BURY. 10 ST. JOHN STREET, MANCHESTER, April, 1894 CHAPTER I. INTRODUCTORY. PAGE SYMPTOMS AND PHYSICAL SIGNS IMPORTANCE OF INSPECTION METHOD OF EXAMINING A PATIENT CASE-TAKING i CHAPTER IL SYMPTOMS FOR THE MOST PART SUBJECTIVE IN CHARACTER. SYMPTOMS INDICATING DISTURBANCE OF THE FUNCTIONS OF THE NERVOUS SYSTEM 9 SYMPTOMS INDICATING DISTURBANCE OF THE FUNCTIONS OF THE RESPIRATORY AND CIRCULATORY ORGANS 18 SYMPTOMS INDICATING DISTURBANCE OF THE FUNCTIONS OF THE DIGESTIVE ORGANS 20 SYMPTOMS INDICATING DISTURBANCE OF THE URINARY ORGANS . . 24 CHAPTER IIL EXAMINATION OF THE SURFACE OF THE BODY. CHANGES IN SIZE AND SHAPE 27 EXPRESSION EXPRESSION OF FACE 53 ATTITUDE 58 WALKING ' ' 7& Xll CONTENTS. CHAPTER IV. TEMPERATURE. PAGE TEMPERATURE IN HEALTH 79 TEMPERATURE IN DISEASE 79 CHAPTER V. EXAMINATION OF THE SKIN AND ITS APPENDAGES. CHANGES IN THE COLOUR OF THE SKIN 91 THE MOISTURE OF THE SKIN 92 CUTANEOUS ERUPTIONS 94 CLASS I. GENERAL DISEASES WITH CUTANEOUS LESIONS . . 97 CLASS II. DISEASES OF THE SKIN DUE TO PARASITES . . 101 CLASS III. LOCAL DISEASES OF THE SKIN NOT DUE TO CUTANEOUS PARASITES 115 ABNORMAL CONDITIONS OF THE NAILS 126 CHAPTER VI. EXAMINATION OP THE RESPIRATORY SYSTEM. ARTIFICIAL DIVISIONS OF THE CHEST 127 INSPECTION 128 PALPATION 141 PERCUSSION 144 AUSCULTATION 154 THE SPUTUM 164 THE EXAMINATION OF THE LARYNX 172 CHAPTER VII. EXAMINATION OF THE CIRCULATORY SYSTEM. ANATOMICAL RELATIONS OF THE HEART 191 INSPECTION AND PALPATION 193 PERCUSSION 203 AUSCULTATION 209 THE PULSE 220 CONTENTS. Xlll CHAPTER VIII. PAGE EXAMINATION OF THE BLOOD ....... 232 CHAPTER IX. EXAMINATION OF THE DIGESTIVE SYSTEM AND OF THE ABDOMINAL ORGANS. THE TONGUE 240 THE TEETH 244 THE GUMS . . 247 THE Mucous MEMBRANE OF THE MOUTH 247 SALIVA ............. 249 THE SOFT PALATE, FAUCES AND PHARYNX 250 THE (ESOPHAGUS 253 THE ABDOMEN . . . 255 THE STOMACH 263 EXAMINATION OF VOMITED MATTERS 268 INVESTIGATION OF THE CONTENTS OF THE STOMACH AND OF ITS ACTIVITY DURING DIGESTION 272 THE INTESTINES 275 EXAMINATION OF THE FAECES 279 THE LIVER AND GALL BLADDER . . 284 THE SPLEEN 295 THE PANCREAS 299 THE OMENTUM 300 THE MESENTERY AND RETROPERITONEAL GLANDS .... 300 THE KIDNEYS 300 CHAPTER X. EXAMINATION OF THE URINE. VARIATIONS IN THE QUANTITY OF THE URINE 307 VARIATIONS IN THE COLOUR OF THE URINE 308 VARIATIONS IN THE ODOUR OF THE URINE 309 VARIATIONS IN THE CONSISTENCE OF THE URINE .... 309 VARIATIONS IN THE TRANSLUCENCY OF THE URINE .... 309 VARIATIONS IN THE SPECIFIC GRAVITY OF THE URINE . . .310 VARIATIONS IN THE KEACTION OF THE URINE 311 CHEMICAL EXAMINATION OF THE URINE 312 SEDIMENTS AND MICROSCOPICAL EXAMINATION OF THE URINE . . 332 UNORGANISED SEDIMENTS 332 ORGANIC DEPOSITS 339 XIV CONTENTS. CHAPTEK XL EXAMINATION OF PUNCTURE FLUIDS. PAGE EXUDATIONS 345 TRANSUDATIONS 346 CONTENTS OF CYSTS 348 CHAPTER XII. EXAMINATION OF THE NERVOUS SYSTEM. ANATOMICAL AND PHYSIOLOGICAL INTRODUCTION 350 INVESTIGATION OF THE SYMPTOMS PRODUCED BY DISEASES OF THE NERVOUS SYSTEM 369 DISORDERS OF MUSCULAR ACTION 369 DISORDERS OF SENSATION 410 DISORDERS OF REFLEX ACTION 418 DISORDERS OF LANGUAGE 425 DISORDERS OF VISION, &c 433 DISORDERS OF HEARING 454 DISORDERS OF TASTE 455 DISORDERS OF SMELL 455 INDEX . 457 LIST OF ILLUSTEATIONS. no. PAGE 1. Face of large white kidney 31 2. Face of myxoedema 31 3. Acromegaly 32 4. Rickets . . 34 5. Cretinism 36 6. Hereditary syphilis 37 7. Chronic hydrocephalus 37 8. Skull of case figured in No. 7 38 9. Brain of case figured in No. 7 38 10. Microcephalus 39 11. Brain of case figured in No. 10 39 12. Atrophy of right half of tongue * . . .40 13. Hemiatrophy of face 41 14. Subcutaneous rheumatic nodules 45 15. Hands in rheumatoid arthritis 45 1 6. Dislocation of knee in locomotor ataxia 48 17. Exophthalmic goitre in a child 52 1 8. Paralysis of superior recti muscles 55 19. Paralysis agitans 56 20. Retraction of head 57 21. Osteitis deformans 60 22. 23. Attitudes in sciatica 62 24. Attitude in sciatica with lumbo-sacral neuralgia 63 25. Attitude in carrying bucket - . 63 26. Tetany 64 27. Attitude in paralysis agitans 65 28. Position of foot and great toe in spastic paraplegia .... 66 29. Spasm of face and hands in hysteria 67 30. Position of upper limbs when all the muscles are paralysed, with the exception of those supplied by the fifth root 68 31. Dropped hands from a case of lead paralysis 69 32. Severe alcoholic paralysis (complete) 70 33. Hands in slight alcoholic paralysis 70 34. Showing metacarpal bone of thumb on nearly the same plane as the corresponding bones of the fingers, &c 70 35. Showing normal action of thumb and little finger 71 36. Showing action of thumb and little finger when the flexor brevis, abductor and adductor pollicis and opponens minimi digiti are feeble 7 1 37. First degree of paralysis in multiple neuritis 71 38. Second degree of paralysis in multiple neuritis 71 XV XVI LIST OF ILLUSTRATIONS. FIO. PAGE 39. Third degree of paralysis in multiple neuritis 72 40. Fourth degree of paralysis in multiple neuritis 72 41. Showing adduction of first metacarpal as well as slight flexion of thumb at both joints, from a case of chorea . . . . .72 42. Claw hand, result of neuritis of ulnar and median nerves, following scarlet fever 73 43. Slight degree of claw-hand, rheumatic neuritis 73 44. Infantile paralysis, extreme talipes equinus ...... 74 45. Attitude of feet in Friedreich's disease 75 46. Extreme atrophy of hand muscles, probably from rheumatic neuritis . 75 47. Chronic rheumatic arthritis, showing muscular atrophy and distortion 76 48. Temperature chart, showing remittent type of temperature : leuco- cythaemia So 49. Temperature chart, showing intermittent type of temperature in the different varieties of ague 81 50. Temperature chart, moderate attack of scarlet fever . . . .81 51. Temperature chart, pneumonia during convalescence from scarlet fever 82 52. Temperature chart, pneumonia 82 53. Temperature chart, tubercular peritonitis 83 54. Temperature chart, pneumonia showing "pseudo-crisis" and defer- vescence by crisis 84 55. Temperature chart, acute rheumatism 85 56. Temperature chart, typhoid fever (death) 86 57. Temperature chart, relapse of typhoid fever (perforation) ... 86 58. Temperature chart, apical pneumonia (fatal) 87 59. Temperature chart, tubercular meningitis 88 60. Temperature chart, tubercular meningitis 88 61. Temperature chart, pneumonia in marasmic infant .... 89 62. Hair with f avus fungus 1 09 63. Hair from case of tinea tonsurans 109 64. Microsporon furfur no 65. Burrow containing acarus and eggs 1 1 1 66. Female acarus 112 67. Pediculus capitis 113 68. Pediculus corporis 1 14 69. Pediculus pubis 114 70. Acarus folliculorum 114 71. Chest and abdomen of young, rickety child 130 72. Tracing of rickety thorax 130 73. Tracing of rickety thorax, extreme deformity 131 74. Excessive arching of right ribs in a case of syringo-myelia . . . 132 75. Tracing of thorax in fibroid phthisis affecting right lung . . .133 76. Retraction of left side of chest following empyema . . . .134 77. Shows scar of abscess, below left scapula, and spinal curvature . . 135 78. Tracing of chest wall of Figs. 76 and 77 135 79. Boy the subject of phthisis at right apex 136 80. Retraction of epigastrium in paralysis of diaphragm . . . .138 81. Tracing from a case of Cheyne-Stokes breathing 141 82. Relations of thoracic organs 147 83. Limits of lower margins of lungs and pleural sacs behind . . .148 LIST OF ILLUSTRATIONS. xvii 84. Displacement of mediastinum, heart and liver in left pleuritic effusion 152 85. Fibrinous coagula from a case of plastic bronchitis . . . .166 86. Tubercle bacilli, Ziehl-Neelson method 170 87. Laryngoscopic lamp and bracket 175 88. Portable oil lamp 176 89. Position of patient, examiner, and lamp when making a laryngoscopic examination 177 90. Laryngeal reflectors and mirrors 178 91. Larynx during normal breathing 179 92. Larynx during deep inspiration 179 93. Paralysis of crico-arytsenoidei postici, position of cords during inspira- tion ............. 179 94. Healthy laryngeal image during phonation 179 95. Imperfect view of larynx 180 96. Position of parts in laryngoscopic image 180 97. Names of the different parts of the laryngoscopic image . . .182 98. Larynx with its muscles from behind 183 99. Muscles and nerves of the larynx 183 100. Solitary papilloma growing from left, true vocal cord . . . .185 101. A. Laryngeal polypus springing from the right vocal cord; B. ditto during phonation 185 1 02. Tubercular larynx, thickening of epiglottis and ary-epiglottidean folds 187 103. Tubercular larynx, more advanced 187 104. Extensive tubercular ulceration of the larynx 187 105. Paralysis of left recurrent laryngeal nerve image during inspiration . 188 106. Same as 105, image during phonation 188 107. Paralysis of both thyro-arytaenoidei interni 188 108. Paralysis of both arytsenoidei postici 188 109. Paralysis of both thyro-arytsenoidei interni and arytsenoidei postici . 189 no. The trachea and the opening of the main bronchi 189 in. The chambers of the heart and the great vessels in their relations to the front of the chest 192 112. Sphygmographic tracing, showing venous pulse 196 113. Sphygmographic tracing, showing venous pulse 197 1 14. Displacement of mediastinum, heart and liver from right-sided pneu- mothorax 200 115. Dr. Ewart's plan of eliciting tracheal tugging 203 1 1 6. Showing normal and abnormal areas of cardiac dulness . . . 204 117. Mitral and tricuspid regurgitation, with cardiac and hepatic enlarge- ment 205 118. Forms of pericardial sac when containing (A.) 16 ounces, and (B.) 52 ounces of fluid ........... 206 119. The method of percussion described in the text 207 T2o. Showing extent of dulness in a case of aneurysm of thoracic aorta . 209 121. Diagram of cardiac cycle 210 122. The normal position of the cardiac orifices, with the areas employed in isolating murmurs generated at these orifices . . . .211 123. Represents the different rhythms of murmurs as described in the text 213 124. Congenital contraction of orifice of pulmonary artery from fusion of the valves ; foramen ovale open 215 I) XV111 LIST OF ILLUSTRATIONS. no. HAOE 125. Representing the directions of currents generating murmurs . . 216 126. Dudgeon's sphygmograph 221 127. Normal pulse-trace magnified 222 128. Pulse-tracing : " tachycardia " 223 129. Pulse-tracing : mitral stenosis 223 130. Pulse-tracing : mitral, low tension 223 131. Pulse-tracing: mitral, abortive beats 223 132. Pulse-tracing : before recovery from disturbed circulation . . . 224 133. Pulse-tracing : after recovery from disturbed circulation . . . 224 134. Pu'se-tracing : " delirium cordis" 224 135. Pulse-tracing : aortic incompetence 225 136. Pulse-tracing : showing " missed beat " 225 137. Pulse-tracing : bigeminal pulse 225 138. Pulse-tracing : bigeminal pulse 226 139. Pulse-tracing : bigeminal pulse 226 140. Pulse-tracing : trigeminal pulse 226 141. Pulse-tracing: " pulsus paradoxus " 226 142. Pulse-tracing : aortic incompetence 227 143. Pul.-e-t racing : aortic incompetence 227 144. Pulse-tracing : dilatation of aorta 227 145. Pulse-tracing : anacrotic pulse 228 146-148. Pulse-tracing: changes in pulse during convalescence from cardiac failure 228 149. Pulse-tracing : cardiac failure, bigeminal pulse 228 150. Pulse-tracing : acute Bright's disease 229 151. Pulse-tracing : pernicious anaemia 229 152. Pulse-tracing : chlorosis. 229 153-159. Pulse-tracing: heart-failure in chronic Bright's disease; pro- gressive increase of pulse-tension . 230 160. Pulse-tracing: low-tension pulse 231 161. Pulse-tracing : hyperdicrotic pulse ....... 231 162. Pulse-tracing: rare form of anacrotic curve 231 163. Pulse-tracing: " pulsus bisferiens " 231 164-167. Pulse-tracings: intra-thoracic aneurysm .... 231,232 168. Poikilocytosis 233 169. Leukaemic blood 234 170. Gower's ha3macytometer . . . 237 171. Gower's haemoglobinometer 238 1 72. Fissuring of tongue in tertiary syphilis . . . . . . . 243 173. Notched teeth in hereditary syphilis 246 1 74. Anatomical regions of the abdomen 256 175. Taenia saginata 282 176. Tsenia solium 283 177. Bothriocephalus latus 283 178. Cancer of the liver 289 1 79. Hydatid tumour of the liver 290 1 80. Enlargement of liver and spleen in a case of cardiac dilatation . . 293 181. Enlargement of spleen in leucocythfemia 296 182. Enlargement of spleen in a case of anremia 298 1 83. Relations of spleen and left kidney 304 LIST OF ILLUSTRATIONS. XIX FIG. PAGE 184. Esbach's albuminimeter 316 185. Phenyl-Glucosazon crystals 329 1 86. Ureometer 3^2 187. Forms of uric acid 333 188. Urate of sodium 335 189. Urate of ammonium . 335 190. Oxalate of lime ........... 336 191. Triple phosphate crystals 337 192. Stellar phosphates 337 193. Tyrosin, cystin, leucin ..."... ... 338 194. Casts of urates ... ........ 340 195. Epithelial cast 341 196. Blood cast 341 197. Granular cast 341 198. Fatty casts 342 199. Left side of brain 350 200. Median aspect of brain . 351 201. Cortical centres 352 202. Cortical centres .... 352 203. Course of motor fibres 353 204. Degeneration : tracts in the spinal cord 358 205. The nervous apparatus of vision 357 206. Diagram of the fourth ventricle 361 207. The nuclei of origin of the cranial nerves 362 208. 209. Areas of cortex supplied by branches of cerebral arteries . . 363 210. Transverse section of cerebral hemisphere, showing lenticulo-striate artery, &c 364 211. Diagram and table of reflex actions . 366 212. Spasm of interossei in a case of alcoholic paralysis .... 370 213. Convulsive tic ............ 372 214. Facial spasm from cortical irritation 375 215. Muscular atrophy in chorea 379 216. Hand in athetosis 380 217. Dynamometer 382 218. Atrophy of hand muscles in a case of disseminated sclerosis .. . 385 219. Double wrist-drop 386 220. Idiopathic muscular atrophy (side view) 387 221. Idiopathic muscular atrophy (front view) ...... 388 222. Motor points of face .......... 389 223. Motor points of upper limb (anterior surface) 390 224. Motor points of upper limb (posterior surface) 391 225. Motor points of lower limb (front and outer aspect) .... 392 226. Motor points of lower limb (posterior aspect) ..... 393 227. Deformity of foot in hemiplegia ........ 398 228. Congenital spastic paraplegia 401 229. Congenital spastic paraplegia 402 230. Effects of unilateral lesion of the spinal cord in the dorsal region . 405 231. Friedreich's disease . . . 409 232. ^sthesiometer 411 233. Sensory nerves and motor points of head and neck .... 412 XX LIST OF ILLUSTRATIONS. FIO. I' AGE 234. Distribution of the cutaneous nerves of the upper limb . . -413 235. Distribution of the cutaneous nerves of the lower limb . . .415 236. Method of obtaining the knee-jerk .421 237. The cortical mechanism for speech-processes 428 238. Scheme of the nerves of the iris 438 239. The muscles of the eyeball 439 240. Diagrams showing relations of true to false image in different varieties of squint 441 241. Total ophthalmoplegia 442 242. Field of vision of left eye, showing boundary lines for different colours 444 243. Field of vision, from a case of poisoning by carbon bisulphide . . 446 244. 245. Fields of vision, from a case of hysterical amblyopia . . . 447 246, 247. Fields of vision, from a case of hemianopsia ..... 449 248. Fundus of the normal eye 450 249. Syphilitic choroiditis . . . .. . . . . .451 250. Retinitis in renal disease 452 251. Recent papillitis 453 252. Scheme of organ of hearing 454 Plate (I and II.) Diagrammatic View of the sensory distribution of Spinal Nerve-roots - .To face page 367 CHAPTER I. INTRODUCTORY. IT is difficult or perhaps impossible to give an accurate definition of either health or disease, for there is no sharp boundary-line between them. Disease implies a derangement of the healthy functions or structure of the body, and it may exist for some time before leading to recognisable manifestations of its presence. The actual onset of diseased change in function or structure is indeed for the most part unknown to us during life, for its manifestations only appear at a variable period of its develop- ment : these are called symptoms, and must be regarded as integral parts of the disease. Recognisable departures from health, which are perceived only by the patient, are called subjective symptoms, and these frequently he endeavours to express by words or gestures. Recognisable departures from, health, which can be detected by the senses of the observer, are called objective symptoms. Some writers call the former simply " symptoms," and the latter " physical signs." Others give the term " symptoms " a wider application, and " physical signs " a narrower one. Thus under " symptoms " they include not only the subjective manifes- tations of disease, but certain objective symptoms, such as pyrexia, emaciation and vomiting, while they restrict the use of the term " physical signs " mainly to the results obtained by an examination of the chest and abdomen and nervous system. Certainly such a distinction is of considerable importance in the study of disease. For example, two patients present identical physical signs of phthisis impaired resonance, harsh breath sounds, and a few moist rales at the apex but while one of them is very ill, the other is comparatively well. The former patient suffers from pyrexia, emaciation and much weakness, whereas the latter is quite free from any general manifestations of disease. Moreover, the symptoms just referred to may all subside, while the physical signs remain much as before. Another example is mitral disease how varied are the symptoms in different cases in which the physical signs, so far as palpation, percussion and auscultation go, are almost identical. Similar observations might be made in respect to many other diseases. Symptoms, indeed, have a cyclical history of their own, and their A 2 INTRODUCTORY. relation to the few coarse physical signs which we are able to make out is often much too subtle for our ken. At the outset, then, let the student fully realise that symptoms really follow a course of their own, apparently quite apart from the. signs which are revealed to him by the various methods of physical examination. Further, it is to be noted that the severity and significance of sub- jective symptoms vary greatly in different individuals. A man of strong constitution may become the subject of grave disease without knowing that anything is amiss, while a delicate person with susceptible nervous system may feel the slightest departure from health. In the latter case, subjective symptoms are of great value and require careful study, although, at the same time, their importance may easily be exaggerated. For the investigation of objective symptoms, the unaided senses in many cases are sufficient, while in other cases the employment of certain instruments, such as the stethoscope or ophthalmoscope, or of chemical tests, is necessary to complete the examination. Of the various methods of examination, which will be explained in due course, a thorough inspection of the patient is of very great importance. It is necessary to emphasise this fact, because this mode of inquiry is so often neglected by the student. It is remarkable how much valuable information may be obtained by the trained eye from a careful general inspection of the surface of the body; indeed, many diseases can be diagnosed by this method alone ; and although it would be foolish to neglect making a thorough examination of the patient by every other means at our disposal, we would insist on the great importance of subject- ing to careful analysis and consideration not only the more obvious signs of disease, but also those more subtle signs which may be revealed by the expression of the features, the posture of a limb, or the gait in walking. These signs convey impressions to our minds which it behoves us to sift and weigh, for they often have an important bearing on the diagnosis and prognosis of the case. Indeed, it is not a rare experience to hear of the death of some one in whom the physical signs were never marked or of serious moment, and afterwards one says, " Ah ! I remember how ill he looked." If this impression, unconsciously received at the time of examination, had been recognised and its meaning sifted, it would have led to more repeated examinations ; possibly we should have been able to place the patient under more favourable conditions, or at any rate could have warned the friends as to the probably dangerous nature of the malady. The method of conducting the examination of a patient will obviously vary to some extent with the nature and severity of the illness, but in all cases it is necessary to take into consideration : INTRODUCTORY. 3 (i.) The symptoms for which the patient seeks or is brought to us for advice. (2.) The account of his illness as given by the patient or his friends, together with facts relating to his previous health, habits, place of residence, occupation and family history. (3.) The symptoms observed in making a physical examination of the case. Some physicians prefer to examine a patient before giving ear to the history of his complaint, but the author believes that it is much better to take the latter first and to listen attentively, and as far as possible Avithout interruption, to the patient's own statement of his case. When the patient is unconscious, very young, or otherwise incapable of giving an account of himself, then we have to depend on the statements of his friends. While listening to the account of the illness, we often unconsciously receive impressions from the attitude, general aspect and psychical con- dition of the patient, which subsequently may prove to be of great help to us in forming an opinion with regard to the diagnosis, prognosis, and treatment of the case. In reporting cases, special prominence should always be given to the symptom or symptoms for which the patient seeks advice. The com- plaints of the patient form the text of the case, and should be referred to again and again during the examination. Sometimes they appear to have no connection with the results of a physical examination, but often there is a direct relation between the two, and it is certainly of the greatest importance never to lose sight of the patient's own words with regard to his trouble. These should be given in inverted commas, and the order in which the symptoms are related should be preserved as far as possible, and on no account must the words of the patient be trans- lated into scientific terms. His version as to the cause of his illness, and any evidence that he has to give in support of his view, should be recorded. Gaps in the history may be filled up by inquiries as to different symptoms. The first sign of ill-health and the date at which it occurred should be especially noted, also the date at which the patient left off work and the date when he took to bed. But the information obtained by more or less leading questions should be distinguished from that which is volunteered by the patient. With regard to the former, there is an occasional danger of fallacy owing to the patient wishing to make his case out worse than it really is. Inquiries should also be made as to previous attacks of the same kind of illness, and as to the previous health generally. In recording past illnesses, corroborative evidence of their existence should always be asked 4 INTRODUCTORY. for. For example, it is not enough to say that a patient had syphilis or rheumatism. But statements should be made, in the case of supposed syphilis, as to the presence of a sore followed by bad throat and " break- ing out " on the skin so many weeks afterwards, and by pain and swelling of the shins so many months afterwards ; while in the case of supposed rheumatism, inquiries should be made as to the length of time in bed, the presence and duration of sweating, and the number of joints affected with pain and swelling. Questions should then be asked as to the existence of any similar or allied diseases amongst the patient's relatives. But it is necessary to observe that with hospital patients there is a great risk of fallacy in these family details. Having obtained a full account of the previous history of the patient, the next step is to make an examination of his present condition, " to take the present state " as it is sometimes called. At the outset we should ask ourselves is there any striking dominant symptom 1 If there is, we should begin with the system to which that symptom belongs ; thus if the patient is paralysed, we begin with the nervous system ; if he suffers from shortness of breath and dropsy, we begin with the circulatory system, and so on. If there is no striking dominant symptom, it is well to return to the patient's own complaint, and investigate that and the system with which it is connected. But with whatever system we begin, it is necessary to make a thorough examination of the whole body, and to draw up a report as to the condition of its various tissues and organs. As a guide to the principal subjects of inquiry, the following form, which is now in use at the Manchester Royal Infirmary, is appended : DIRECTIONS FOR REPORTING MEDICAL CASES. PRINCIPAL SUBJECTS OF INQUIRY. PREVIOUS HISTORY. 1. History of Present Illness. Mode of Onset. The first sign of ill-health the date of month when patient left off work, and date when he took to bed. Course of Symptoms. Give order of occurrence, with date of commence- ment and cessation. The condition of the patient at the time of admission, and the course of the case to the time at which the notes are taken should be stated. Supposed Cause of Illness. Give patient's version, treatment before admis- sion, and its effects (briefly). 2. Previous Health. Nature and character of previous illnesses, their dates and duration (ailments of infancy in special cases) previous admis- sions into hospital indications of gout, rheumatism, venereal diseases (gonorrhoea, soft chancre, hard chancre, sore throat, pains in bones, &c., symptoms of infantile syphilis, if necessary) cough haemoptysis. INTRODUCTORY. 5 Sexual disorders catamenia leucorrhcea. Inquire specially for previous hemorrhages or discharges, if there be anaemia. Previous general nutrition and weight. 3. Social History. Particulars concerning residence, coldness, dampness, salubrity prevalence of special diseases changes of residence residence abroad. Occupation peculiarities of occupation, as exposure to heat, cold, noxious gases, dust, &c. changes in occupation. Food and clothing excess or defect, &c. stimulants, character and amount tobacco drugs. General or special habits and mode of life. If married, date of marriage issue still-born children miscarriages and times at which they have occurred. 4. Family History. Father, \ > Ages, health, or cause of death. Sisters, / Brothers, / Diseases and causes of death in other relatives, especially consumption, insanity, gout : specify whether relative affected was on side of father or mother. PKESENT STATE. GIVE DATE. (a.) External Surface. Posture temperature general appearance form of head colour and expression of face, worn, languid, sallow, excited, stupid, livid in any part, flushed, anaemic wrinkles nostrils lips arcus senilis conjunctiva; pupils eyelids eyeballs ears. Relation of appearance to age. Nutrition well nourished, stout, spare or emaciated, weight. Peculiarities of external configuration, tumours, swellings, deformities. Skin oedema, face, body, ankles, &c. Perspiration face, head, body odour, if any cutis anserina roughness softness cicatrices rashes (maculae, stains, erythemata, wheals, papules, vesicles, pustules, scaliness, tubercles), ulcers discolourations and superficial vessels. Hair on head, body. Nails curving clubbing of fingers onychia structural alterations. Glands superficial, back of neck, along sterno-mastoid, in axilla, groin parotid. Joints form redness tenderness pain stiffness deposits around deformities. (b.) Nervous System. I. Motor Disorders. Spasm. Tonic, clonic, distribution of, whether general, unilateral, or local, distortions resulting from spasm. Tremor and its relation to voluntary movement. Paralysis. Spastic or atrophic, and distribution of, whether in the form of hemiplegia, paraplegia, hemiparaplegia, or local, distortions of paralysed limbs. Station. With and without closed eyes. Gait. Whether ataxic, spastic, paralytic, shuffling, staggering. Strength. As tested by ability to move in bed, by power of grasp, and of resistance to passive movements at the various articulations. Disorders of special movements, caused by paralysis of the ocular motor muscles, the facial, lingual, and masticatory muscles. INTRODUCTORY. 2. Sensory Disorders. Acuteness of cutaneous sensibility, as tested by prick- ing, pinching, touch, double points, hot and cold bodies, faradism and different weights ; change of position on the eyes being closed ; touching prescribed spot on face : pain sense of constriction, &c., paraesthesia, such as numbness, tingling, &c. Spine. Tenderness, hyperassthesia to pinch or to faradism. Distribution of anaesthesia, whether hemiansesthesia, paransesthesia, local anaesthesia. 3. Reflexes. Superficial, deep. 4. Vaso-motor and trophic disorders redness or pallor of surface, tempera- ture of surface, cutaneous eruptions, glossy skin, deformities and cracking of nails, abnormal dryness or premature greyness or falling off of the hair. 5. Electrical Reactions. Faradic, galvanic. 6. Psychical Disorders. Emotional condition, irritability, insomnia, vertigo, incoherence, depression or exaltation of spirits, hallucinations or illusions of the senses, delusions. (c.) Circulatory System. Palpitation dyspnoea syncope pain, its char- acter. Heart. Cardiac region, general appearance, normal or bulging ; impulse, its area, strength and character (normal, heaving, weak), apex beat note the intercostal space, distance from left vertical nipple-line, or especially in women, distance from mid-sternum if thrill or friction fremitus note its site and rhythm. Percussion. Map out superficial cardiac dulness give upper limit, right limit, left limit of deep dulness. Note any prominence or dulness of mediastinal region. Auscultation. Note character of sounds at apex, over ensiform cartilage, at aortic and pulmonary cartilages, accentuation, loudness, redupli- cation, or other special characters. If murmurs or friction, give rhythm, situation of maximum intensity, and the direction in which they are conducted. Arteries. Undue pulsation of carotids and brachials any abnormal pulsation above manubrium or above clavicles or elsewhere. If a tumour be present, note if pulsation is expansile, any thrill tor- tuosity of arteries at elbows and over temples. Radial Pulse. Compressibility, regularity, frequency, size. Are the two radial pulses alike ? Sphygmographic tracing. Veins. Undue visibility on chest wall pulsation in neck. Do jugulars fill from below ? Varicose veins and venules in different parts of body. Capillary Pulsation. Examination of Blood. Numeration of corpuscles by hsemacytometer, estimation of haemoglobin. (d.) Digestive System. "Lips teeth gums tongue fauces and pharynx deglutition thirst appetite abdominal pain or discomfort, its rela- tion to the taking of food, to defsecation, to movement, micturition, &c., flatulence or acidity nausea, vomiting, SEE vomited material and describe frequency of defecation character of stools, SEE stools, if possible, and describe haemorrhage piles pruritus ani, &c. Physical Examination of Abdomen shape, measurement at epigastrium and at umbilicus condition of umbilicus aortic pulsation super- ficial veins palpation, thrill, amount of resistance, feel for edge INTRODUCTORY. 7 of liver, for edge of spleen, for mesenteric glands, for kidneys, for enlarged pelvic organs or tumours, and define percussion, define upper limit of liver dulness in right nipple-line, in mid-axillary line, in line of angle of scapula ; define splenic dulness, any dulness in Sanks, give limits and note change with change of position. If tumour, note percussion limits, also its position, alteration of position with respiration, its mobility, the character of its surface, its con- sistence, &c. Presence of hernia. (e.) Respiratory System. Cough, character of; expectoration, character of, presence of blood, microscopic examination elastic fibres, tubercle bacilli. Pain, tenderness, decubitus, number of respirations, character of, easy, laboured dyspnoea, inspiratory, expiratory. Give ratio of pulse to respiration. Is there any movement of extraordinary muscles of respiration ? Is there any retraction of chest wall during inspiration ? Stridor. Voice examination of larynx. Physical Examination of Chest. Inspection. Shape of chest, depressions or bulgings, want of symmetry, muscular wasting, immobility of inter-spaces ; direction of ribs, costal angles. Movements, character and amount, want of sym- metry, whether abdominal or thoracic. Palpation. Again note difference of movement on the two sides, &c., also vocal fremitus and relative intensity on the two sides rhonchal fremitus friction fremitus. Percussion. Relative resonance, deficiency or excess of resonance. Note pitch high or low; duration long or short; quality hard, tubular, &c. ; resistance normal, diminished, increased. Auscultation. Changes in character of breath sounds in regard to the duration and intensity of the inspiratory and expiratory portions, especially noting the quality, whether of the vesicular or bron- chial type, &c. New sounds dry or rhonchi, moist rhonchi or rales simple, or with special character friction sounds, metallic tinkling, &c. Vocal Resonance. Increase or diminution of, bronchophony, pectori- loquy, aegophony. Succussion. Splashing sounds, &c. (/.) Special Sense Disorders. Smell hyperosmia, anosmia, hallucinations of smell. Vision. Acuteness of, colour vision, hemiopia, polyopia, field of vision, ophthalmoscopic examination. Hearing. Acuteness of, as tested by watch and by tuning-fork. Physical examination of meatus and of throat. Air entering middle ear by blowing nose. Taste. Acuteness of, as tested by salt, sugar, bitters, &c. Speech. Anarthria or dysarthria, stammering, motor aphasia, word deafness, word blindness, verbal amnesia. (g.) Genito-urinary System. Frequency of micturition difficulty, pain, its character and locality. {frint. Quantity in twenty-four hours, colour, reaction, specific gravity, clearness or turbidity, test for albumin, sugar, and bile amount of chlorides, of albumin and sugar, if present percentage of urea in twenty-four hours' urine. Deposits. Their general appearance. Microscopic examination ascer- tain presence or absence of epithelium, pus, blood, casts of the uriniferous tubes their character, number, and variety fatty 8 INTRODUCTORY. particles, renal cells, amorphous lithates and phosphates, crystals of uric acid, oxalate of lime, triple phosphates, &c. Male. Scrotum testes gonorrhoea stricture syphilis. Female. Menstruation, natural, excessive in quantity, too frequent, accompanied with much pain leucorrhcea condition of uterus. Note condition of breasts. After recording the condition of the various organs, the treatment and diet should be entered, the prescription for any medicine ordered being given in full. The reporter should endeavour to form some idea as to the diagnosis and prog- nosis of the case, but should make no entries on these points, except by direction of the physician in charge. In recording the subsequent progress of the case, the reporter should enter the letter of the alphabet at the commencement of each paragraph relating to it. The prescription should be copied, and any alteration in the method of administration must be entered. The frequency of the pulse and of the respiration must be entered on the chart daily. Changes of diet must be recorded, and the amount of stimulants, if any are ordered. When the case is completed, the reporter must make out a Summary of the nature, course, and treatment of the case, and give it, together with the notes, to the Medical Registrar. Should the patient die, and an inspection be obtained, a copy of the post- mortem appearances, abstracted from the post-mortem register, must be added. The reporter should, if possible, attend the post-mortem. The arrangement adopted in the preceding tabular statement does not strictly correspond to that in which the symptoms of disease are described in the ensuing chapters. An attempt has rather been made to separate symptoms complained of by the patient from those which can be observed and investigated by the physician. But neither this classification nor one in which symptoms are separated into subjective and objective can be rigidly followed without certain modifications. Sometimes a patient when asked " what is the matter," answers that he has dropsy, is para- lysed, or has a swelling or tumour somewhere. These are objective signs of disease which can be investigated by the physician himself, and are therefore more properly relegated to the chapters dealing with physical examination. More frequently, however, the patient complains of pain, sickness, palpitation, giddiness, &c., and a discussion of these and other subjective symptoms rightly comes under our first group. But there are other symptoms, such as vomiting and shortness of breath, which, although in the main of an objective character, it is useful to consider along with more purely subjective phenomena. The various subjective and objective symptoms of disease might be discussed in connection with the various organs or systems disturbance of which most commonly produces them. Such an arrangement, however, appears to us more artificial than the one here adopted. Moreover, the latter plan has the advantage of drawing attention to the wide significance of certain symptoms. For example, vomiting, while commonly the result of a disordered stomach, may be set up by disease of the brain or kidneys, hence from a clinical DISTURBANCE OF THE NERVOUS SYSTEM. 9 point of view it is better to discuss its possible causes and to study it in all its bearings before proceeding to make a physical examination of the stomach and other organs of the body. Some symptoms are mentioned in this section, because it would be inconvenient to separate them from others which strictly belong to it. Thus coma and delirium can be observed by the physician, but for an account of other disorders of consciousness, such as loss of memory or attention, illusions or hallucinations, we have largely to depend on statements made by the patient or his friends. CHAPTEE II. SYMPTOMS, FOB THE MOST PART SUBJECTIVE IN CHARACTER, FOR WHICH THE PATIENT SEEKS OR IS BROUGHT TO THE PHYSICIAN FOR ADVICE. IT is convenient to group these symptoms according to the system with which they are most closely related, it being clearly understood that such an arrangement does not necessarily imply disease of the particular system. I. SYMPTOMS INDICATING DISTURBANCE OF THE FUNCTIONS OF THE NERVOUS SYSTEM. Pain is probably the most frequent symptom for which a patient seeks advice. Its significance varies greatly, partly according to its locality, but chiefly in consequence of the varying susceptibilities of the nervous system in different individuals. As a rule, the information to be derived from a study of pain by itself is trifling as compared with that to be obtained by a consideration of its associations. It must also be borne in mind that the position of pain does not by any means always correspond with that of the disease ; frequently, indeed, it is situated at some distance from it. Pain may be generalised all over the body, or limited to a very small area of its surface. General pains occur sometimes at the onset of febrile conditions, as in influenza, typhoid, acute rheumatism. Localised pains also in some cases may appear to depend on a general blood change, while in other cases they are obviously produced by local disease. Whenever possible, it is desirable to ascertain the exact position of pain, its chief characters, I O SYMPTOMS SUBJECTIVE IN CHARACTER. whether aching, throbbing, shooting, &c., and its relation to time and movement. The term neuralgia implies a severe paroxysmal pain in the course of a sensory nerve or its branches. By many authorities the word is restricted to cases where the nerve disturbance is of (so-called) functional origin ; by others it is made to embrace cases of organic origin, as well as those where no definite lesion can be discovered. Neuralgic pain is shooting, throbbing, gnawing, or boring in char- acter, and of very variable duration. Associated with the spontaneous pain there is usually superficial tenderness of the neuralgic area. This may be diffuse, or more commonly is localised to certain points in the course of the nerve or its branches. These " tender points " usually correspond to places where the nerve emerges from beneath bone or fascia. Sometimes there is tenderness over a vertebral spine, usually at a spot which corresponds to the origin of the affected neive. In seeking for a cause of any neuralgia, the possibility of irritation at a distance from, as well as along the course of the affected nerve must be debated. 1 Pain in the Head. In asking ourselves what may be the cause of any particular headache, it is well to regard the subject both setiologically and clinically. The chief causes of headache may be grouped as follows : (i.) Dis- turbance of the intra-cranial circulation, as in heart disease ; (2.) Changes in the blood, as anaemia, or a toxic condition produced by alcohol, kidney disease, rheumatism, gout, or the inhalation of certain gases, especially in connection with overcrowded rooms; (3.) Pyrexia; (4.) Disease of the thoracic and abdominal viscera, especially of the stomach and sexual organs ; (5.) Diseases of the head, the scalp, the cranium, the brain or its nerves; (6.) Disorders of the special sense- organs, especially the ear and eye. Such a classification must of necessity be artificial to some extent, for often the causes enumerated act in combination. Thus the headache of pyrexia, while doubtless partly due to elevation of tem- perature and to vascular congestion, is mainly due to a toxaemic blood state. Also the headache of gastric disturbance may be partly the result of anaemia, partly reflex, and partly toxic in origin. 1 The importance of studying the situation of pain in visceral disease was insisted on by the late Dr. Ross in his valuable paper " On the Segmental Distribution of Sensory Disorders," Brain, 1888. Since then the subject has been further investi- gated, especially by Head and Mackenzie. Dr. Head in particxilar has demonstrated that certain definite and constant areas of cutaneous tenderness each area having a maximal region in which there is pain may be found in association with various visceral diseases, and that these maximal areas coincide with areas that are marked out by attacks of herpes zoster. DISTURBANCE OF THE NERVOUS SYSTEM. I I Clinically pain in the head may be studied in relation to its locality, character, time and other circumstances. Locality. Headache may be diffused and general, or localised to a particular spot. A general headache is sometimes the result of intra- cranial disease, as meningitis or cerebral tumour, but more commonly it may be traced to some morbid condition of the blood, as that of rheumatism or gout, or to nervous exhaustion. A frontal headache is common in pyrexia, and the temperature should always be taken when the headache is not obviously related to functional visceral disturbance. Apart from pyrexia, frontal headache is most frequently associated with stomach derangement, while occa- sionally it accompanies lung disease. Occipital headache may be caused by constipation, hepatic disorders, ovarian diseases, and sometimes by gastric derangement. The deep-seated pnin of neurasthenia is often attended by a sensation of tension about the occiput, and by tenderness to touch in that region. Pain in the temples is met with in anemia, hysteria, and neuralgia. In anaemia the pain is usually bilateral, and is accompanied by a sense of. bursting of the temples. In hysteria pain may shoot from one temple to the top of the head. In migraine pain usually begins on, and may be limited to, one side of the head, but sometimes the headache is general ; hence the term " hemicrania " often given to this disease is inaccurate. The condition of the ear requires careful investigation when there is persistent aching or attacks of neuralgic pain in the neighbourhood, while the bones, especially the mastoid, should be palpated for spots of local tenderness. Vertical headache also is often neuralgic in character. In hysteria the sensation of a nail being driven into the skull, called "clavus," is sometimes experienced. A feeling of weight or pressure on the vertex, often accompanied by a dull diffuse headache, suggests an overtaxed brain, but it is also complained of by hypochondriacal persons. The Kind of Headache. Sharp violent pains occur in neuralgia from any cause. Sometimes they are present during the growth of a tumour, or mark the early period of a meningitis. Dull heavy headaches suggest a toxsemic state, as in uraemia, jaundice, chronic alcoholism, lead poisoning. A throbbing headache increased by move- ment is characteristic of anaemia ; it also often occurs in cases of cardiac hypertrophy, especially when this is associated with gastric disturbance. A pulsating constant headache may be due to an intra- cranial aneurysm. Relation of Headache to Time, Taking of Food and other Circum- stances. The headache of exhaustion and inanition is most marked on 12 SYMPTOMS SUBJECT EVE IN CHARACTER. waking in the morning, and is relieved by food ; that of anaemia comes on in the day, and is worse at bedtime. The syphilitic headache, often very severe, intense and persistent, is particularly characterised by nocturnal exacerbations, which deprive the patient of sleep (but be it noted that sleeplessness in syphilitic subjects cannot always be accounted for by pain in the head). This headache is often accompanied by much irritability and mental depression, while in the severest cases the head is too sensitive to lay on the pillow, and the patient sits up in bed holding his head between his hands. Excitement and movement improve the headache of hysteria ; they aggravate that produced by organic brain disease, also the pain of migraine. The pain of organic brain disease is characterised by its constancy, but it is liable to paroxysmal exacerbations, often of great severity. It varies in character and in position. It may be dull, boring, or rending ; it may be general or local. When local, the seat of pain sometimes corresponds to that of the tumour, and there may be local tenderness. Tumours of the cerebellum frequently give rise to occipital pain, but occasionally pain is limited to the frontal region. Hence the locality of a brain tumour cannot be diagnosed with any confidence merely from the position of the pain. An aneurysm of the basilar artery usually produces occipital headache. It will be gathered from the above observations on headache, that while this symptom may be caused by disease of almost every organ of the body, it appears to be most closely related to alimentary disturb- ances, to anaemia, or to some toxic condition of the blood. Whenever its aetiology is doubtful, the temperature should be taken, the optic discs examined, and the condition of the nervous system carefully investigated. Pain in the Neck may be due to caries of the spine, to disorders of the windpipe, pharynx, or oesophagus, or to muscular rheumatism, the sterno-mastoid being not uncommonly affected. Pain in the Back. This may be general or local, and may be caused by disease of the vertebra, the cord or its membranes, or the spinal muscles. Sometimes it is a referred pain in consequence of visceral disease. Thus an aching pain in the mid-dorsal region is common in dyspepsia, one at a lower level may be due to a loaded colon, pains in the lumbar region sometimes result from kidney or ovarian disease, while pain over the sacrum is often associated with disorders of the bladder or uterus. Muscular pains are very common in the lumbar region. Aching of the back occurs in the early stages of many of the specific fevers, particularly in influenza and smallpox. It is also common at puberty in conditions when the ligaments are lax, and when there is a proneness to lateral curvature. Aching or DISTURBANCE OF THE NERVOUS SYSTEM. I 3 burning pains in the dorsal spine occur in hysteria, together with local tenderness both superficial and deep. Aneurysms of the thoracic or abdominal aorta are often attended by some pain along the vertebral column or in the course of the spinal roots. Spontaneous pain and radiating bands of local tenderness are also met with in many diseases of the spine and its membranes. Probably neurasthenia and " spinal irritation," as a result of former injury, are the commonest causes of severe spinal pain. Pain in the Chest. Here we have to think mainly of the inter- costal muscles and nerves, the pleura, the heart and aorta, and the stomach. In disease of the lungs a dull pain may be complained of over the affected area, but unless the pleura is involved, it is perhaps rare for pain to be a prominent feature. At the same time it must be freely admitted that distension of an organ with blood, as of the lung in the early stage of a pneumonia, will give rise to local discomfort, and even to actual pain. A sharp stitch-like pain in the lower axillary region, increased by breathing, is due to pleurodynia or pleurisy : in the latter disease the temperature is raised, and the pain is succeeded or accompanied by friction sound. A general soreness of the inter- costal muscles may be the result of severe coughing ; it occurs also in rheumatism and in dyspepsia, but the common pain in stomach dis- turbance is one of aching or gnawing character, situated across the front of the chest below mid-sternum, and felt also behind in the mid- dorsal region. Severe unilateral neuralgic pain may precede, accompany, or succeed an attack of shingles, and in elderly persons it is very often persistent. Pains varying in character and severity also occur as a result of pericarditis, valvular disease, dilatation of the heart from muscle failure, and aneurysm of the aorta. They reach their greatest intensity in angina pectoris. In this disease the paroxysm of pain is combined with a sense of impending death. The pain is usually most prominent in the left side of the chest ; it shoots back between the shoulders and down the inner side of the left arm to the elbow ; sometimes it extends down the inner sides of both arms, and it may be to the tips of the ring and little fingers. Pain in the Abdomen. In seeking for an explanation of pain in the abdomen, the condition of its walls and contents requires to be investigated. It may be set up by disease of the liver, kidney, or other organ, by a strangulated hernia, or other source of intestinal obstruction. It may be caused by aneurysm, by tubercular or cancerous growths in the mesenteric glands. Pain and tenderness are common in hysteria, and the diagnosis from peritonitis may present difficulties. The pain of spinal disease or of pleurisy is sometimes referred to the 14 SYMPTOMS SUBJECTIVE IN CHARACTER. side or front of the abdomen. Intense paroxysms of epigastric pain are not uncommon in locomotor ataxy, and are generally associated with disturbed action of the heart and incessant painful vomiting. These attacks of gastralgia, or gastric crises, as they are called, along with lancinating pains in the limbs, chest and back, may occur for many years before ataxic symptoms make their appearance. Colic is a term applied to spasmodic abdominal pain, of which three chief varieties are distinguished, namely, intestinal, renal and biliary, which are produced by irritation of the intestine, ureter and bile-ducts respectively. Intestinal colic, due usually to some irritant in the bowel or to lead poisoning, is referred as a rule to the neighbourhood of the umbilicus. Renal colic, usually produced by the passage or disturbance of a calculus in the ureter, is a severe pain which is felt in one loin and flank, and darts down to the groin and testicle, and sometimes to the thigh or to the chest and back. Sometimes there is an associated disturbance of the colon, especially of the caecum, which becomes paralytically distended, and there may be attacks simulating the beginning of typhlitis. Biliary colic, commonly caused by the escape of gall-stones into the cystic and common bile ducts, is an agonising pain which is situated in the right hypochondrium, and shoots up to the right shoulder and back. All forms of colic may be ushered in by shivering or rigors, and be accompanied by nausea and vomiting, clammy sweat, and other symp- toms of collapse. Pain in the Limbs. This may be the result of syphilis, rheuma- tism, gout, or other cause which leads to disease of the bones, joints, muscles, or nerves. It is also to be noted that a pain in the tip of the shoulder sometimes occurs in pleurisy and pericarditis ; that shooting pains down the arms are sometimes the result of aneurysm, heart disease, angina pectoris, disease of the posterior roots or peripheral nerves ; and that lightning-like pains in the lower limbs constitute one of the earliest and most striking features of locomotor ataxy. Numbness and Tingling of the extremities often attend the onset of acute affections of the nerves, spinal-cord, or brain. They are particu- larly common initial symptoms in the various forms of multiple peri- pheral neuritis, and may exist for some time before objective changes in the cutaneous sensibility can be detected. At the onset of peripheral neuritis, numbness and tingling are frequently combined with alternat- ing attacks of burning sensations in the hands and feet, and coldness and deadness of these parts, together with actual paroxysmal pains in the limbs. In the alcoholic variety severe cramps in the muscles of DISTURBANCE OF THE NERVOUS SYSTEM. I 5 the calves and other parts of the limbs, morning retching and vomiting, as well as shortness of breath from cardiac weakness, are also frequent symptoms complained of by the patient. Vertigo. Vertigo, called by the patient "giddiness," "dizziness," or " swimming in the head," is a disturbance of the sense of equilibrium. The patient feels as if going to stagger or fall, or that surrounding objects are oscillating or moving in a particular direction. The sub- jective sensation of movement is sometimes accompanied by actual reeling or falling to the ground. The symptom is a common one, and according to its associations the following varieties may be distinguished : Ocular Vertigo. This is usually due to weakness of one of the ocular muscles, as the external or internal rectus. Often there is some error of refraction ; for example, the strain on the internal recti in myopia may be followed by weakness of these muscles, and then near objects become indistinct, and a sense of confusion and vertigo ensues. Auditory or Aural Vertigo. Giddiness may be caused by disease of any part of the auditory apparatus, the meatus, tympanum, Eustachian tube, the labyrinth, auditory nerve or its central connections. When associated with tinnitus and deafness, there is probably an affection of the labyrinth, especially of the semicircular canals, and the condition is called Meniere's disease or labyrinthine vertigo. The deafness is central, that is, does not depend on impaired conduction through the middle or external ear ; the vertigo, which varies in intensity, may be severe enough to hurl the patient to the ground ; it is usually par- oxysmal, while the tinnitus and deafness are persistent. The attack may be attended by temporary unconsciousness, and in bad cases is followed by nausea, vomiting and symptoms of collapse. Whenever vertigo is accompanied by other indications of ear disease, a careful otoscopic examination should be made, and a normal con- dition of the meatus, membrana tympani and Eustachian tube proved before admitting the existence of primary disease of the labyrinth. Gastric Vertigo. Giddiness is often complained of by the subjects of gastric or hepatic derangements, and is commoner in ordinary dyspepsia than in serious organic disease of the stomach. It is frequently accom- panied by buzzing in the ears, and may be followed by nausea, vomiting, pallor and faintness. There is no deafness, but it is highly probable that a large number of cases of gastric vertigo are really due to disturbance of the semicircular canals. Still in some cases, as, for example, in gout, there often appears to be a close relation between the taking of food and vertigo. Vertigo depending on Disorders of the Nervous System. Giddiness occurs in depression or exhaustion of the brain from any cause, such as 1 6 SYMPTOMS SUBJECTIVE IN CHARACTER. excessive smoking, drinking, anaemia, or mental strain. It is usually slight or moderate in degree, while it is frequently accompanied by emotional disturbance, gastric derangement, palpitation and sleep- lessness. Vertigo also occurs in connection with neurasthenia, epilepsy and migraine. When present in epilepsy, either as the aura of a major attack or as one of the chief symptoms of a minor attack, vertigo is almost always attended by loss of consciousness. Sometimes it is a symptom of intra-cranial lesion, being especially related to disease of the cerebellum and its peduncles. In persons past middle life, with signs of arterial degeneration, an attack of vertigo should suggest the possibility of an apoplectic seizure ; indeed, temporary vertigo and slight confusion of intellect may be caused by a small cerebral haemor- rhage. In such cases vertigo usually appears with headache, nausea, or vomiting, and often there is a sense of unilateral numbness or weakness. Disorders of Consciousness. Exaltation of the Mental Powers occurs as a premonitory symptom of some forms of insanity or delirium. In chronic alcoholism a stage of mental exaltation frequently ushers in the development of other psychical disorders, and is attended by hallucinations of the special senses. The patient imagines himself to be very rich, or fancies that he hears music, while when he closes his eyes he sees bright clouds or other pictures. But it is noticeable that while the patient is becom- ing more absorbed in contemplating his own thoughts and feelings, his powers of observation and of attention to business are on the wane. The mental excitement, extravagant acts and elation so often seen in the early stage of chronic alcoholism closely resemble the early symptoms of general paralysis. Perversions of Consciousness are met with in the various forms of insanity, in the delirium of fever, in poisoning by narcotic drugs, and in many diseases of the brain or its membranes. An illusion is a false perception of some sensorial impression received from an actual object, but the error can be detected by the mind and corrected. A hallu- cination is a false perception which occurs without the action of any external stimulus ; thus voices are declared to be heard or objects seen in the absence of external realities. Hallucinations of hearing are very common in cases of melancholia and delusional insanity. A delusion is a false belief, a perversion of judgment, and always implies a disordered intellect. Illusions, hallucinations and delusions are the chief factors of delirium. The mental state in delirium is similar to that in insanity, but the term is commonly restricted to the acute mental derangement which occurs in many fevers, in organic- DISTURBANCE OF THE NERVOUS SYSTEM. 1 7 brain disease, in toxaemic conditions, or in certain low states of the system. Three distinct types of delirium may be recognised : (i.) Low twittering delirium, in which the patient lies still, mutters to him- self in a rambling fashion, and picks at the bed-clothes. This variety is common in typhoid fever. (2.) Delirium tremens, in which the patient is restless and sleepless and troubled with illusions and hallucinations. He sees all kinds of horrid animals creeping on his bed or running about the room ; he is very suspicious, his movements are tremulous, and there is a tendency to violent outbursts of raving delirium. (3.) Raving delirium, characterised by great intensity of both mental and bodily activity, is a feature of acute mania ; it occurs also in meningitis, and occasionally in some fevers. Of poisons producing delirium, alcohol is the commonest. A pro- longed debauch may be followed by delirium tremens, while a chronic delirious state is very common in the subjects of severe alcoholic paralysis. The paralysed patient may speak distinctly at first, but his talk soon becomes incoherent, and it will be observed that his memory is very defective, and that he has erroneous ideas especially as regards time and locality. Frequently he is very suspicious of his attendants, and often accuses the nurse of poisoning his food. A morose depressed state is often interrupted by periods of great excitement, and the patient may exhibit suicidal or homicidal impulses. Pyrexia is the commonest cause of delirium, but there is sometimes a difficulty in distinguishing between this variety and the delirium caused by organic brain disease for example, a case of pneumonia has often been diagnosed as one of tubercular meningitis, while acute brain disease has been mistaken for a specific fever. The error is avoided (i) by considering whether the degree of pyrexia is sufficient by itself to account for the delirium ; and (2) by making a thorough examination of the patient, in order to see whether there are symptoms, such as persistent vomiting, optic neuritis, local spasms, or paralysis, which are indicative of an intra-cranial lesion. The association of headache with delirium is also suggestive of brain disease, for the headache of fever usually ceases when delirium begins. This important distinction was first pointed out by Sir William Jenner. Loss of Consciousness. This may be partial or complete. A partial loss may affect all forms of mental activity, as in trance, catalepsy, hysteria, idiocy, or dementia, or the defect may be more or less limited to a single faculty. Thus loss of memory is particularly noticeable in some cases of anaemia, and in advanced forms of chronic alcoholism, while lack of attention is often a feature of hypochondriasis or neura- sthenia. A complete loss of consciousness may be produced by a great variety of causes, the chief of which are : Certain poisons, as opium, B I 8 SYMPTOMS SUBJECTIVE IN CHARACTER. alcohol, chloroform ; uraemia, diabetes ; syncope, from failure of the heart's action ; head injuries ; functional and organic diseases of the brain ; hysteria ; epilepsy ; multiple sclerosis ; general paralysis of the insane ; meningitis ; cerebral haemorrhage, embolism, thrombosis, tumour, or abscess ; hyperpyrexia and sunstroke. When a person is deeply unconscious, it is sometimes difficult to arrive at a diagnosis of the cause of his condition. In such a case, let the student observe the following points : The condition of the heart and other organs ; the temperature ; the urine ; the odour of the breath ; the pupils ; the results of an ophthalmoscopic examination ; the presence or absence of convulsions, of unilateral spasm or paralysis ; and the condition of the reflexes. An important indica- tion of the depth of coma is stertor, or the snoring noise made by the patient in breathing. This depends on obstruction to the entrance of air into the chest, and is usually produced by the falling back of the tongue or of a relaxed soft palate. II. SYMPTOMS INDICATING DISTURBANCE OF THE FUNCTIONS OF THE RESPIRATORY OR CIRCULATORY ORGANS. Cough. Coughing is a reflex act excited by irritation of the terminal fibres of the superior laryngeal or some other branch of the vagus nerve. After taking a deep inspiration the glottis is closed and then forced open by a sudden expiratory effort. As a rule, cough is a result of a morbid condition of some portion of the respiratory tract, but if not obviously produced by disease of the respiratory organs, the possibility of the existence of irritation elsewhere must be entertained, and it is especially important to make a careful examination of the throat the influence of an elongated uvula, post- nasal catarrh, adenoids, or enlarged tonsils being weighed with the results of a physical examination of the chest. The condition of the ear, of the stomach, and other abdominal organs, may also require investigation. Without attempting to enumerate all the causes and varieties of cough, we would draw attention to the modifications of its tone pro- duced by local changes in the larynx, by pressure on the trachea, and by functional and organic disease of the brain. Any impairment of the proper vibration of the vocal cords, as that produced by the presence of false membranes, ulceration or paralysis of the cords, tends to make the cough hoarse and croupy, and may diminish or abolish its tone. Here, too, may be mentioned the peculiar empty ineffective cough of diphtheria and of alcoholic paralysis. When there is pressure on the trachea, as from an aortic aneurysm or a mediastinal DISTURBANCE OF RESPIRATORY ORGANS. 19 tumour, the cough is hard and metallic in quality, and is associated with stridulous inspiration. The cough also occurs in paroxysms, sometimes much resembling those of whooping-cough, but unaccompanied by the characteristic inspiratory noise of the latter disease. Fits of harass- ing coughing, if not due to advanced phthisis or to whooping-cough, should always make us think of thoracic aneurysm and mediastinal tumour. As regards morbid brain conditions, we may note the barking cough of hysteria, and the influence of profound apoplectic attacks and of bulbar paralysis in diminishing or abolishing the act of coughing, and thereby tending to cause a dangerous accumulation of secretion in the air passages. Shortness Of Breath. When a patient complains that he easily gets out of breath, or that he is short of breath when he moves quickly, it is most likely that he is suffering from anaemia or from heart-disease. Shortness of breath is particularly significant of cardiac insufficiency, of weakness of cardiac muscle ; thus it is perhaps the commonest symptom complained of by patients suffering from alcoholic dilatation of the heart. The symptom is largely subjective ; the patient feels a need for more air, and objective signs of difficult or hurried breathing may be inconspicuous. But, as a rule, a slightly increased frequency of the respiratory movements is observable. The leading respiratory feature, then, in anaemic and cardiac disease is the patient's own consciousness of disturbed breathing. The opposite condition, in which increased frequency and difficulty in breathing are apparent to the observer, but scarcely noticed by the patient, occurs in chronic disorders of the respiratory organs, as emphy- sema and chronic bronchitis, especially when the disease has lasted for many years, and the patient has become accustomed to the hindrance to his breathing. The chief causes of dyspnoea or difficult breathing, and of alterations in the frequency of respiration, are given in the section on the respira- tory system. But we may here point out the importance of regarding these symptoms from a wide standpoint, of taking into account not only the state of the lungs and heart, but also that of the blood and nervous system. If, after a careful investigation, no obvious signs of organic disease can be discovered to explain the occurrence of repeated attacks of severe dyspnoea, it is worth while remembering that the latter may be due to pressure on the trachea, or a large bronchus from an aneurysm, or a deep-seated tumour, and sometimes to a stricture of the windpipe. Nor must it be forgotten that laryngeal spasm, with severe paroxysms of dyspnoea laryngeal crises may constitute very early symptoms of locomotor ataxia. The attacks often closely resemble 20 SYMPTOMS SUBJECTIVE IN CHARACTER. those of laryngismus stridulus, while occasionally noisy breathing is accompanied by a spasmodic cough like that of whooping-cough. Palpitation. This means that the patient feels the beatings of his heart, and the consciousness is usually attended by a certain amount of distress or actual pain. When the heart is examined, its action may be found to be quite normal, but generally some change in its force, frequency, or regularity accompanies the subjective sensation. The commonest cause of palpitation is dyspepsia. The symptom is also frequently associated with hysteria, neurasthenia, or other functional nervous disorder. Other causes are anaemia, gout, exophthalmic goitre and organic cardiac disease. In heart disease palpitation is usually much aggravated by exertion and excitement. In Graves' disease, palpitation, combined with throb- bing of the larger arteries and breathlessness, may exist for a long time before the other symptoms, prominence of the eyeballs and enlarge- ment of the thyroid gland, become developed. But, in whatever way palpitation is started, its degree is much influenced by the condition of the stomach ; hence an investigation of the functions of this organ is of the first importance. m. SYMPTOMS INDICATING DISTUEBANCE OF THE FUNC- TIONS OF THE DIGESTIVE ORGANS. The Appetite is diminished or lost (anorexia) in many diseases, especially when there is pyrexia or disorder of the alimentary canaK But although loss of appetite is a common symptom when inquiry is made with regard to it, it is not often a prominent complaint made by the patient, for it is usually overshadowed in his mind by the existence of other symptoms. Thus a patient attacked with a febrile disorder complains that he feels ill, cold, or weak, or that he has been shivering, or of some symptom peculiar to the particular disease from which he is suffering, such as sore throat in scarlet fever, joint-pain in rheuma- tism, &c. Perhaps certain forms of dyspepsia and early phthisis are the commonest conditions in which a patient consults a doctor for loss of appetite. In chronic disease, mental depression always requires con- sideration as a factor leading to anorexia. Excessive Appetite (bulimia} occurs in certain nervous diseases, in diabetes and in some varieties of indigestion. Children suffering from worms or gastro-enteric catarrh are often stated by their mothers to "eat all before them." An unnatural appetite (pica} for the most peculiar articles is sometimes observed in hysteria, pregnancy, and insanity. Thirst. When great thirst and an intense feeling of weakness are DISTURBANCE OF DIGESTIVE ORGANS. 2 I complained of, the most likely disease is diabetes, and the patient may say, " The more I drink the thirstier I get." Thirst is also present in all febrile diseases, in gastric derangements, and whenever there has been great loss of liquid from the system, as by diarrhoea, vomiting, or haemorrhage from any part. Attention may be especially drawn to the distressing thirst which follows the vomiting associated with acute peritonitis. Dysphagia means pain or difficulty in swallowing, and occurs as a symptom in many diseases affecting the throat, pharynx, larynx and esophagus. Thus it is a striking feature of acute tonsillitis and of ulceration of the throat, while it is often prominent in glossitis and in tubercular disease of the larynx, especially when the upper orifice and the epiglottis are implicated. Much difficulty in swallowing may result from pressure on the pharynx, as by a retro-pharyngeal abscess, or on the oesophagus, as by aneurysm of the thoracic aorta. It is also present when there is spasm or paralysis of the pharynx ; the former occurs in hysteria and hydrophobia, the latter in diphtheria and bulbar paralysis. When the soft palate is paralysed, an early symptom in diphtheritic paralysis, liquids regurgitate through the nose during the act of deglutition. Dysphagia is a common result of O3sophageal disease. The patient first notices that he cannot get down solid food as well as formerly that it seems to stop at a particular point, to indicate which he points sometimes to the upper and sometimes to the lower end of the sternum. He may also state that food comes up soon after it is swallowed. This regurgitation is quite different from vomiting food, not much altered, comes up easily without any conscious effort and with little or no pain. If the obstruction is due to an organic lesion as a malignant ulcera- tion of the wall of the oesophagus the dysphagia increases until there is great difficulty or inability to swallow the softest food or liquids. But even in such a case the degree of difficulty is not constant ; on some days the patient can scarcely swallow anything, while on others he can get down food, even solids, with comparative ease. In cancer of the ossophagus, the inability to get food down is asso- ciated with great weakness and extreme emaciation. Dysphagia is also met with in cases of fibroid thickening of the oesophagus as a result of chronic alcoholism. A temporary difficulty in swallowing accompanied by regurgitation is sometimes met with in elderly persons the complete recovery in a day or two suggests spasm rather than organic disease of the oesophagus. Vomiting 1 . In the act of vomiting we have to consider the centre in the medulla, the nerves to and from the stomach, and other afferent 22 SYMPTOMS SUBJECTIVE IN CHARACTER. nerves to the medulla. The stimulus may be started at any of these places. First, the centre may be directly affected by a growth, haemor- rhage, or local disease. Poisoned blood may act on the centre, as in acute fevers, uraemia, or from poisons or medicines absorbed into the blood ; for example, the vomiting produced by a hypodermic injection of apomorphia. Secondly, vomiting may be started by irritation of the afferent nerve endings to the fauces, pharynx, oesophagus, stomach, uterus, or other abdominal organ. Thirdly, by brain irritation. Vomiting is an initial symptom of many acute diseases, and this is particularly the case in early life. It is especially noticeable at the onset of scarlet fever, pneumonia and tubercular meningitis, of which diseases it may be a symptom of great diagnostic value. Thus, a young child is taken suddenly ill, the temperature is raised, the fauces are congested and swollen, and there is a slight eruption of uncertain character over the upper part of the chest. Now the occurrence of vomiting on the first day of such an illness is highly suggestive of scarlet fever, but in the absence of vomiting the case may turn out to be one of ordinary sore throat, or of a general catarrh with subsequent localisation in the bronchial or gastro-intestinal mucous membrane. Vomiting is one of the earliest symptoms of acute peritonitis, and also occasionally of pleurisy, pericarditis and phthisis. In elderly persons it often marks the onset of cerebral haemorrhage ; and at all ages it frequently occurs as an early symptom of brain disease, and even when the lesion is one of limited extent. Vomiting is a striking feature of the paroxysms of whooping-cough, occurring sometimes with such severity and frequency as to place the patient in great danger. During the convalescence of typhoid fever both vomiting and diarrhoea are easily excited by even slight additions to the diet. Vomiting is also not uncommon during the course of phthisis, heart disease, Addison's and Bright's diseases. It is often a prominent symptom in both functional and organic disorders of the stomach and bowels. It occurs frequently in the catarrhs of the alimentary tract that are so common during the period of infancy and early childhood, and may be associated with either obstinate con- stipation or severe diarrhoea. Sometimes there is a difficulty in deciding whether a patient is suffering from atonic dyspepsia or gastric ulcer : the occurrence of vomiting in such a case would of itself be in favour of ulcer. But when the ulcer is situated on the anterior surface of the stomach, vomiting and other symptoms may be absent from first to last, or till the onset of perforative peritonitis. In cancer of the stomach, vomiting is most common when the orifices are obstructed, or when there is an ulcerated surface. When new growth is limited to the walls of the stomach, the DISTURBANCE OF DIGESTIVE ORGANS. 23 orifices being not materially implicated, vomiting may never occur. In such cases, however, the subjective feeling of nausea is often very con- spicuous. In intestinal obstruction vomiting occurs more severely and more constantly the nearer the seat of obstruction is to the stomach ; and in obstruction of the large intestine it may never become prominent. In hepatic, renal and lead colic, vomiting, which frequently occurs, is not necessarily related to the pain. Occurring early in the morning, and associated with a tremulous furred tongue, having a pale red glistening tip and edge, it is significant of alcoholic propensities. Vomiting is a common symptom in tumours of the brain, especially when they are situated in the medulla, corpora quadrigemina, or in the middle lobe of the cerebellum. It is distinguished by its persistency and by its association with constant headache and optic neuritis. It also occurs in abscess of the brain and during the course of a meningitis. Vomiting from cerebral causes is usually unattended by local gastric symptoms, and is not commonly preceded by nausea. In these respects it closely resembles the vomiting met with in hysteria, and in what are known as the ''nervous dyspepsias." In hysteria it is sometimes associated with a voracious appetite, and may last for months or years. In Meniere's disease it is found in conjunction with vertigo, faintness and aural disorders ; in megrim, with periods of intense headache. DiarrhCBa that is, undue frequency and looseness of the bowels is symptomatic of many diseases. Thus it is prominent in cholera and typhoid fever. It is sometimes met with in scarlet fever, particularly the malignant variety, measles, Bright's disease, leucocythaemia and exophthalmic goitre. Some of its chief causes are : Irritation of the intestines by improper food, purgative medicines, poisons, worms, retained faeces ; defective hygienic conditions, as exposure to excessive cold or heat, bad air, excessive fatigue, &c. ; mechanical congestion of the intestinal vessels from obstruction of the portal circulation, as by diseases of the heart, lungs, or liver ; organic lesions of the intestines, as inflammation, ulceration, albuminoid disease. Diarrhoaa is easily induced during the period of infancy, and has a definite relation to the temperature of the subsoil, being often very prevalent during the later summer months. The diagnosis of any case of diarrhoea is largely based on a consideration of associated symptoms, and on the results of an examination of the abdomen and the condition of the stools. In all obstinate forms of chi-onic diarrhoea of obscure origin, the condition of the rectum should be carefully investigated, especially with regard to the presence of signs indicating malignant disease. Great 24 SYMPTOMS SUBJECTIVE IN CHARACTER. stress, too, may be laid on the need of examining the fseces, in order to avoid the risk of overlooking malignant disease, and of remembering that a thin discharge associated with "weeping" often occurs near a partial obstruction. Constipation is a prominent symptom in many disorders of the heart, liver, stomach and nervous system. It occurs in anaemia, in diabetes and at the commencement of many febrile diseases ; it consti- tutes an early sign of peritonitis and is an important symptom of intestinal obstruction. In the acute varieties of obstruction, constipation is usually complete and absolute, and is associated with severe colicky pains, vomiting and symptoms of collapse. But in acute intussusception there is oozing of blood mixed with mucus from the anus. In chronic obstruction the condition of the bowels varies from time to time ; thus when the obstruction is due to cancer of the rectum or sigmoid flexure, diarrhrea and constipation may alternate, but in obstruction from faecal accumu- lation, constipation is pronounced, and tends to become absolute. In order to differentiate the various forms of intestinal obstruction, it is necessary to make a careful examination of the abdomen and its parietes, to consider the sex, age and previous history of the patient, and to study the mode of onset and the character of the pain, vomiting, and other symptoms that may be present. These points will be found discussed in text-books on medicine or surgery. A digital examination of the rectum should be made when pain is referred to the rectum or to the lower part of the abdomen. Pain and straining at stool (tenesmus) occur in dysentery and other inflammatory affections of the descending colon, also in connection with piles, fistula, stricture, or other lesions affecting the rectum. The rectal crises, which sometimes occur in locomotor ataxia, are characterised by paroxysms of severe pain and tenesmus, and the patient may complain that he feels as if there were a foreign body in the rectum which he has a strong desire to evacuate. IV. SYMPTOMS INDICATING DISTURBANCE OF THE URINARY ORGANS. The symptoms to which a patient may call attention are : Changes in the appearance or quantity of urine (see Examination of Urine, Chap. X.); alterations in the frequency of micturition ; inability to pass water or to hold it properly ; pain or difficulty in micturition. Increased Frequency of Micturition must be distinguished from alterations in the quantity of urine passed. Thus in stricture of the urethra, prostatic disease, cystitis, tumour or calculus of the bladder or DISTURBANCE OF URINARY ORGANS. 2$ kidney, urine is passed with abnormal frequency, but not necessarily in increased quantity. Whereas in diabetes, granular kidney, tubercular, albuminoid and cystic disease of the kidney, there is increased flow of urine, as well as abnormal frequency of micturition. Frequent micturition at night is sometimes met with in gouty subjects, and is an early sign of granular kidney and of senile enlarge- ment of the prostate. Diminished Frequency of Micturition, with diminution in the total amount of urine passed in the twenty-four hours, occurs in the final stages of albuminoid and granular kidney disease, and in other conditions which, when very aggravated, lead to total suppression. Diminished frequency of micturition, without diminution in the total amount of urine passed, may be observed in many cases of retention of urine. Inability to Pass Water. This may be due to retention or to suppression of urine. In the latter condition the secreting action of the kidney is impaired or lost, whereas in the former urine is secreted more or less normally, but cannot be voided properly, owing to obstruc- tion in some part of the urinary passages. Retention of urine occurs sometimes in states of unconsciousness and in lesions of the spinal cord, as dorsal myelitis, which cause paralysis of the detrusor vesicse. It is also not uncommon after operations for piles, after injury to the genital organs or neighbouring parts. In the male, common causes of retention are stricture of the urethra, enlarged prostate, impacted calculus, or other source of mechanical obstruction. In the female, a retroverted gravid uterus, or any tumour pressing upon the urethra, bruising or swelling of the urethra or perineum after labour, and hysteria, may be mentioned as frequent causes of retention. It is worthy of note, too, that retention of urine is sometimes the only symptom of commencing peritonitis in women. Suppression of Urine may be a result of mechanical obstruction to the passage of urine, as by congenital malformation, disease, or blocking of the ureters, or it may occur independently of obstruction, as during the course of a specific fever, in the algide stage of Asiatic cholera and in cases of acute inflammation of the kidneys. The symptoms of non-obstructive suppression resemble those of uraemia, but in cases of obstructive suppression, convulsions, coma, and dropsy are of rare occurrence, the chief symptoms being great weakness, twitchings of the muscles, contracted pupils, panting, laborious breathing and general restlessness. Inability to Hold Water. In a large proportion of cases of incontinence, the symptom really depends on retention. The bladder, in consequence of some obstruction, as an enlarged prostate, is unable 26 SYMPTOMS SUBJECTIVE IN CHARACTER. to empty itself properly. It is therefore always partially and often completely filled; hence urine is discharged frequently, and often " incontinently." The association of incontinence with retention occurs also in females as a result of prolonged labour, and in girls from vulvitis or other variety of genital irritation. Retention with "overflow incontinence " is also an important symptom in many cases of loco- motor ataxia and other diseases of the spinal cord. It is common, too, in conditions of mental impairment from whatever cause. True incon- tinence of urine from paralysis of the sphincter is produced by lesions of the cord which implicate the bladder centre in the lumbar enlarge- ment. Wetting the bed or the clothes is sometimes a valuable indica- tion of the occurrence of an epileptic fit. Nocturnal incontinence of urine apart from epilepsy or any local lesion is not uncommon in children ; the urine is usually voided during the early hours of sleep. The symptom is to be regarded as a sign of nerve weakness, of undue tendency to reflex action. Sometimes the affected child exhibits rheumatic proclivities ; but careful search should always be made for any sign of local irritation, such as phimosis, worms, or vulvitis. Pain, with or without Difficulty, in Micturition, occurs in a number of morbid conditions affecting the urethra or bladder. It is common in pelvic inflammation, especially in women, and in cases of enlargement or displacement of the uterus. Pain and a frequent desire to pass water are prominent symptoms in cystitis, and in cases of stone in the bladder. The pain in calculus is usually referred to the end of the penis, and is much increased by sudden movements of the body. In cystitis, pain is situated over the pubis and sacrum, and in the perineum ; there is also a very urgent desire to pass water, which is experienced even after all the urine has been voided. Pain referred to the bladder and frequent painful micturition requires especial emphasis in relation to peritonitis which has spread down to Douglas's pouch. This is common in disease of the vermiform appendix and in latent peritonitis from typhoid fever. Here, too, may be men- tioned the nephralgic, vesical, and urethral crises, which occasionally manifest themselves during the course of locomotor ataxia. In nephralgic crises the paroxysmal pains closely resemble attacks of renal colic, while in bladder and urethral crises the patient suffers from painful and frequent micturition, which very rarely is accompanied by the passing of a little blood. CHANGES IN SIZE AND SHAPE. 2? CHAPTER III. EXAMINATION OF THE SURFACE OF THE BODY. UNDER this heading may be included the examination of the skin and its appendages, that of the subcutaneous tissues, of the contour of the muscles, glands, bones and joints, together with a brief notice of tumours and deformities. The deviations from normal are extremely numerous, and it is only possible, with the space at our disposal, to give a brief account of the more important ones ; of these many will be dealt with in the chapters devoted to diseases of the skin and of the nervous system, while others are referred to in the sections relating to inspection of the chest and abdomen. In the present chapter the chief objective signs noticeable in making an examination (T) of the body generally, and (2) of the head, limbs and spine, are more particularly considered, and they may be con- veniently arranged under the headings, Size, Shape and Expression. The term "expression" is taken to include not only the expression of the face, but also that of the body and limbs, as exemplified by posture, station and gait. CHANGES IN SIZE AND SHAPE. I. The Body Generally. In a large number of diseases the general bulk or weight of the body becomes diminished ; in compara- tively few does it become increased. When the whole body is wasted, we speak of emaciation or general atrophy ; while wasting of a portion of the body is called local atrophy. In general atrophy the most obvious sign is wasting of the sub- cutaneous fat. In progressive muscular atrophy, which may also produce great thinness of limb and body, there is not, strictly speaking, general atrophy, but general atrophy of one tissue, namely, the mus- cular. Local atrophy commonly depends on loss of muscular tissue, but the bones and other tissues may also be involved. In muscular atrophy the strength of individual movements is im- paired, and the rapidity with which the weakness progresses varies with the position and nature of the lesion ; but in cases of adipose atrophy, voluntary power is not necessarily affected. At the same 28 EXAMINATION OF THE SURFACE OF THE BODY. time the two varieties cannot be abruptly separated, for whenever wasting of adipose tissue occurs as a result of disease, the muscles also suffer, if only to a slight extent. Emaciation (chiefly Adipose Atrophy) is roughly estimated by the ease with which a fold of skin is pinched up from the underlying parts ; but in order to obtain accurate indications the scales are necessary, and in all serious diseases the patient should be weighed, if practicable, at regular intervals, for then useful information is obtained as to the progress of the malady. Emaciation is a prominent feature in all acute febrile diseases, and is also present in varying degree in the majority of chronic maladies. It is especially noticeable in typhoid fever, where it progresses with greater rapidity than can be accounted for by the degree of pyrexia, the scanty diet, or the loss by the evacuations. Emaciation is fre- quently one of the earliest indications of phthisis, also of tubercular meningitis in children, in whom it may occur for some time before the onset of more characteristic symptoms. In pulmonary phthisis or in general tuberculosis the chest and limbs are the most affected, while the face is often spared till the malady is far advanced ; but in malignant disease, and especially when the abdominal organs are involved, the face wastes as much and as rapidly as other parts of the body. In infancy, unsuitable food or catarrh of the stomach and bowels are the commonest causes of general atrophy. It is sometimes present in rickets and congenital syphilis, but in both these diseases the infant may be plump and well nourished, and indeed "fat rickets" is commoner than "lean rickets." Occasion- ally cases of infantile atrophy are met with to which no clue can be found : a proper quantity of suitable food is taken, the digestive and other functions appear to be normal, there is no pyrexia, and no lesion is discovered on post-mortem examination. It should be observed that in children weight is more readily lost, more quickly regained, and that its loss is less frequently a sign of serious disease than in adults. In the latter, however, and especially in females, extreme emaciation may occur in association with hysteria, but this no doubt is mainly the result of fasting ; and in all cases of emaciation the question of starva- tion, whether voluntary or enforced by necessity or disease, must be carefully considered. Local Atrophy. In local atrophy the skin, fat, muscles and bones may be separately or collectively involved. Thus atrophy of the skin may result from undue stretching of a part, witness the "linese albicantes " on the abdomen of women as a result of pregnancy, or on the breasts as a result of lactation. Atrophy of the hand muscles may be produced by destructive lesions CHANGES IN SIZE AND SHAPE. 29 of the median and ulnar nerves ; progressive wasting of a limb from destruction of cells in the anterior horns of the spinal cord. In the latter condition the bones are affected as well as the muscles, but the wasting of the osseous tissue bears no proportion to that of the muscular, for the bones may be found of normal length and thickness when the greater part of the muscles of a limb is lost, and conversely a limb may be shortened and thinned when its muscles are free from obvious wasting. The condition of a limb in which a retrograde change has taken place in parts originally well developed must be distinguished from a limb in which there has been arrest of growth. Thus a destructive lesion of the motor part of the cortex on one side of the brain in early infancy will hinder the growth of the limbs on the opposite side of the body, and hence at a later period of life they will be shorter and thinner than their fellows, the bones as well as the soft tissues being more or less arrested in their development. The affected limbs, indeed, in some cases may be perfect in shape and correspond to those of a healthy child, while the opposite limbs have the size and vigour of adult life. The presence or absence of local muscular atrophy is determined first by inspection and palpation, a muscular prominence on one side being compared as to bulk and consistence with the same part on the other side of the body ; second, by measurement ; third, by testing the strength of the part supposed to be affected. The conditions under which atrophy of muscle occurs may be arranged in four classes: Atrophy from disuse: thus a moderate degree of wasting affects the muscles of a paralysed limb, or of a limb that has been kept in splints for a length of time. Atrophy from disease of the muscular tissue itself: the so-called "myopathic atrophy." Atrophy from disease of the nervous system. Examples : infantile paralysis, the muscular atrophy depending on destruction of the cells in the anterior horns of the cord; wasting of the extensor muscles of the forearm from disease or injury of the musculo-spiral nerve. Arthritic Atrophy: When a joint is inflamed, either from injury or disease, the muscles moving it frequently undergo rapid wasting : thus wasting of the thigh muscles follows severe injury to the knee-joint ; atrophy of the interosseous muscles of the hands attends rheumatic swellings of the knuckles. The distinctions between these varieties of muscular atrophy are given in the section on the Nervous System. Obesity, or an excessive quantity of fat throughout the body, is of frequent occurrence in women at or about the climacteric period ; also in persons who habitually indulge too freely in malt liquors. It is common, too, in idiots, and in some cases of chronic cerebral disease, e.g., cerebral tumour. 30 EXAMINATION OF THE SURFACE OF THE BODY. By Dropsy is meant an accumulation of serous fluid in the areolar spaces of the connective tissue, or in the serous cavities of the body. In the former position, dropsy, when extensive, is termed Anasarca ; when more or less localised, (Edema. Dropsy increases the size of the affected part, and the swelling is distinguished by the pit which is produced on pressing with the finger. The degree of enlargement varies much : it may be so great as to render the skin tense and shin- ing, or so slight as to be scarcely perceptible. In doubtful cases, as, for example, when examining the leg, steady continuous pressure with the finger over the shin for a few seconds may produce slight pitting when more sudden pressure has been unsuccessful ; also even in minor degrees of oedema, a feeling of dough iness or want of elasticity is usually experienced. As a rule, the pit begins to gradually fill up directly the finger is removed, but in extreme oedema it may persist for a considerable time. Dropsy is most marked in dependent parts, and in regions where there is much loose cellular tissue, as the eyelids or scrotum ; it should always be looked for over the sacrum, even when undetectable elsewhere. Dropsy may result from any cause which interferes with the circula- tion of the blood, or which leads to deterioration of this fluid itself. (Edema limited to the legs, slight or moderate in degree, occurring in middle life, and especially in females, is frequently due to varicose veins ; in such cases, even if there be no obvious varicosity of the superflcial veins, the possibility that the deep veins may be affected should not be forgotten. (Edema of the lower limbs may also be caused by any undue pressure within the abdomen, as from tumours or ascites. (Edema beginning about the ankles, and then slowly progress- ing to other parts of the body, occurs usually as a result of mitral regurgitation or of mitral stenosis ; it is also produced by dilatation of the right side of the heart, due either to obstruction to the pulmonary circulation, as from emphysema and bronchitis, or to weakness of the cardiac muscle. Slight pufnness about the ankles, becoming a genuine oedema after standing or walking, is significant of anaemia ; and the amount of dropsy, originally started by mechanical obstruction to the circulation, is largely influenced by the degree of anaemia present. Puflfiness beneath the eyes may be noticed in whooping-cough, and is an early sign of renal dropsy. In acute nephritis the spread of oedema is often very rapid ; in a few hours the features may be almost obliterated and the whole body greatly swollen ; the subsidence of the swelling may be equally rapid. In some forms of chronic Bright's disease there is considerable and persistent anasarca, but in the red granular kidney, oedema may be absent or quite insignificant. Apart from kidney disease, oedema of CHANGES IN SIZE AND SHAPE. 3 I the legs and considerable puffiness of the backs of the hands is not uncommon in marasmic infants. Dropsy limited to the arms and upper part of the body points to FIG. i. Face of Large White Kidney (Dr. Dreschfeld's Case). The left eye is nearly closed by cedematous swelling. The raised eyebrows and wrinkled forehead indicate the difficulty in opening the eyes. mechanical obstruction within the thorax, as from a mediastinal tumour pressing on the superior vena cava. Dropsy limited to one limb indicates obstruction of a venous trunk, as, for example, the swollen lower limb of phlegmasia dolens. Local FIG. 2. Face of Woman, aged 45, showing moderate degree of Myxcedema. oedema may also result from active congestion ; thus the inflammatory swelling of gout pits on pressure. Myxoedema. In this disease there is an increase in the general 32 EXAMINATION OF THE SURFACE OF THE BODY. bulk of the body, the whole surface is swollen, but does not pit on pressure, and the skin tends to be dry and scaly. The face becomes broad, puffy, and expressionless, and glistening pear-shaped swellings are sometimes to be seen below the eyes. The nostrils are swollen and the lower lip is thickened and everted. The hands and feet are large Flo. 3. Dr. Dreschfeld's Case of Acromegaly. Duration of the disease five years. The enlarge- ment of the lower jaw and of the hands and feet were conspicuous features. The thyroid could not be felt, but on each side of the neck there was a well-defined swelling, which dipped down into the thorax, and was continuous with an area of dulness over the upper part of the sternum.--^, if. J., January 1894. and spade-like. The tongue too is enlarged. There is usually torpor of both mind and body, together with some impairment of the special senses, and the utterance is thick, slow, and guttural. The tempera- ture of the body is usually subnormal and the urine contains a deficient quantity of urea. CHANGES IN SIZE AND SHAPE. 33 Acromegaly, a rare disease, resembles myxoedema in many respects, but presents many notable differences. Thus the skin is but rarely hard and dry, and the bodily and mental functions are not impaired. Also the hands and feet are greatly hypertrophied ; the face, too, is elongated, and certain parts, especially the nose and lower jaw, become much increased in size. Frequently the ends of the long bones are hypertrophied, but the shafts are unaffected. Sometimes temporal hemianopsia is present. Mediastinal dulness in consequence of enlarge- ment of the thymus gland has also been detected. Subcutaneous Emphysema, a condition caused by the escape of air or gas into the subcutaneous tissue, produces a swelling somewhat similar in appearance to that of oedema. On pressure with the finger, a characteristic feeling of crackling is experienced ; a pit is also pro- duced, which fills up more quickly than that of redema. Variable and, as a rule, limited in its distribution, emphysema may extend over nearly the whole body. Apart from surgical cases, it is usually set up : (i.) By rupture of some of the pulmonary air cells in consequence of great intra-thoracic pressure, as in whooping-cough ; the air is driven into the inter-lobular septa, and then finds its way through the mediastinum into the cellular tissue of the neck. (2.) By ulceration over a pulmonary cavity, which has become adherent to the chest wall. (3.) By perforation from ulcer of the larynx, trachea, oesophagus, stomach, or intestine. In the case of the stomach and intestine, it is necessary for the affected part to be glued to the abdominal wall, otherwise the gas will escape into the peritoneal cavity. Local increase in size, other than that caused by obesity, dropsy, subcutaneous emphysema, the presence of a new growth, aneurysm, or other tumour, may be caused by true or false hypertrophy of the muscular tissue. True hypertrophy of muscle, as a result of disease, is exceedingly rare. It occurs in Thomson's disease, the characteristic symptom of which is rigidity of muscles when put into action after a period of rest. Here the hypertrophy is often accompanied by increased strength ; but in a still rarer affection a partial or wide-spread hyper- trophy of muscle is found in association with diminished power. False Hypertrophy of muscle is a leading feature in the disease known as pseud o-hypertrophic paralysis, where the increased size of the calves and other muscular masses is due to a growth of fatty or fibrous interstitial tissue. Enlarged hard muscles also occur in cretinism, and may supervene on muscular atrophy, as, for example, sometimes in infantile paralysis and in hemiplegia. II. The Head and Face. Variations in size and shape, within the limits of health, and apart from mental impairment, are innumerable, C 34 EXAMINATION OF THE SURFACE OF THE BODY. and will be found discussed in works on Anthropology. Variations depending on pathological changes are chiefly met with in early life. The cranium of even the youngest healthy infant is firm and un- yielding to ordinary pressure, except over the anterior and posterior fontanelles ; the two halves are almost, if not quite, symmetrical ; the shape of the head in the antero-posterior plane is that of an irregular pentagon with curved sides, and this form is maintained throughout life. The size is variable, but the following may be taken as normal limits below the age of five years : The circumference at the level of the occipital protuberance, from 15 to 20 inches; the transverse diameter, Fio. 4. Child the subject of Rickets. Head shows bossy frontal eminences. Thorax shows anterior convexity (sternum and costal cartilages), lateral grooves, and transverse constric- tion. Abdomen large. taken with the calipers between the parietal eminences, from 4 to 6 inches ; and the antero-posterior diameter from 6 to 8 inches. Ample illustration of changes in the form of the head and face will be afforded by a brief reference to rickets, cretinism and a few other familiar diseases. Rickets. In infants a few months old the free margins of the flat bones of the skull may be unduly soft, and the occiput and the parietals may yield to the pressure of the finger like parchment ; also round spots of local thinning may be detected on these bones, and even exceptionally CHANGES IN SIZE AND SHAPE. 35 on the frontal. To this abnormal flexibility the term Craniotabes is applied. Associated with craniotabes, bossy swellings may form on the frontal and parietal bones in front of and behind the anterior fontanelle respectively; they shine through the thin pale scalp, and sometimes cause a characteristic pale bluish prominence. There is no local heat or tenderness over these areas, but it is probable that the irritability displayed by infants so affected, the throwing about of the head and the boring into the pillow, bear a direct relation to these hyperplastic changes. In aggravated cases the bosses increase in size, and other swellings arise around the parietal eminences, on the upper part of the occiput, on the temporal regions and in the neighbourhood of the sutures. All these new superposed osseous growths, if not absorbed, gradually become more or less diffused and organised, and thus give rise to the various forms of the rickety skull. Of these there are two principal shapes to be noticed : the commonest shape presents a broad, square forehead, strongly-developed frontal and parietal eminences and occipital protuberance ; the crown is flat- tened, but still shows some indications of the original four bosses, with a broad median groove and a ridge on each side of it. The second type of rickety skull is elongated fore and aft, or markedly dolichocephalic. Other rickety heads show the whole occipital region flattened so as to appear nearly vertical on side view ; some show marked asymmetry, especially in the posterior part, and this is occasionally accompanied by compensation in the fore part ; the frontal region being prominent on the same side as the flattened parieto-occipital region, and vice versa. Delay in closure of fontanelles and sutures is also to be noticed. The anterior fontanelle, which in a healthy child is usually closed at about eighteen months of age, may be unduly wide long after this period. Grooves may also be felt in the cranial bones for the distended veins which course over the scalp. The face in rickets often looks small in contrast to the massive frontal region ; the alveolar border of the upper jaw tends to assume a beak-like shape, while the lower jaw is somewhat polygonal, with its anterior part turned slightly inwards. Cretinism. In this disease the head is large, and in many cases brachycephalic that is, contracted from before back and expanded at the sides and sometimes measures more from ear to ear than from the root of the nose to the occipital spine. The top and back of the head are usually flattened. The face is square and large, especially in the upper third ; the nose is short, depressed at its root, and spreads out enormously towards the alae ; the eyes are wide apart, the mouth large and gaping, and the lips thick. 36 EXAMINATION OF THE SURFACE OF THE BODY. Enlargement and thickening of the bones of the cranium may also be due to injury, syphilis, ostitis deformans, or leontiasis ossea. In Hereditary Syphilis, after the period of infancy, the forehead is often square and upright, and is prominent at and within the frontal eminences ; a somewhat characteristic feature of the prominence is a FIG. 5. Dr. Shuttleworth's Case of Cretinism. "Sarah,' awl 21. Height, iifiivly jjfeet ; weight, 49 Ibs. Features characteristic. Frontal suture and anterior fontanelle not completely closed. Speech slow, and limited to a few words. ridge placed transversely between the frontal eminences. But this is not constant, and skull changes due to syphilis are apt to be associated with skull changes due to rickets. Occasionally necrosis and exfoliation of bone take place, and may leave a large gap in the frontal or parietal region. ' In young infants asymmetry of the skull is sometimes present. CHANGES IN SIZE AND SHAPE. 37 In association with the above phenoirena characteristic changes may be observed in the face. The cornese present opacities, the bridge of Fia. 5. Child the subject of late Hereditary Syphilis. 10. 7 ._ Chronic Hydrocephalus in a young child. the nose is thickened and depressed, and radiating linear scars are to be seen about the nose and mouth. Hydrocephalus. The pentagonal shape of health tends to become a 30 EXAMINATION OF THE SURFACE OF THE BODY. circle. The head is round, increased in height out of proportion to its length, and usually bulges more in front than behind. The circum- ference may measure as much as thirty inches. The fontanelles and sutures are widened out and unduly prominent, and frequently fluctua- tion can be obtained. The cranial bones become very thin, either Skull and Brain from Case Fig. 7. The skull shows large fontanelle and numerous tabetic spots. The hrain shows great enlargement of the lateral and fourth ventricles. generally, when sometimes a crackling sensation may be yielded on pressure; or in limited areas, craniotabes. In comparison with the big cranium the lower part of the face looks abnormally small. The eyeballs are prominent, and are depressed so that the sclerotic above CHANGES IN SIZE AND SHAPE. 39 the cornea is often exposed while the pupils may be partly covered by the lower lids. In young children, especially during the latter half of the first year, it is often difficult to decide whether hydrocephalus is present or not. . - . . .' .... - FIG. io. Boy with small conical head, internal squint, defective intelligence, and spastic^limbs. Almost daily convulsions from age of six months till death at age of two years. The child's head enlarges quickly, the fontanelle is full, and perhaps a fit occurs ; in such a case it is useful to compare cyrtometrical tracings made at monthly intervals. FIG. ii. Brain from Case Fig. 10, shows a deep suclus behind the frontal lobe, and imperfectly formed convolutions behind the sulcus. The cerebellum was uncovered as in Fig. Microcephalus. The head may be smaller than natural and yet maintain a normal shape ; in some cases, however, the diminution in 40 EXAMINATION OF THE SURFACE OF THE BODY. size is due chiefly to great narrowing of the transverse diameter of the frontal region, while the antero- posterior plane remains of normal length ; in other cases the head tapers towards the top and presents a triangular shape in the coronal section. The sutures and fontanelles are prematurely closed. A microcephalic child is more or less idiotic, is subject to fits, and frequently has rigid flexed limbs (Fig. 10). Asymmetry of Skull has already been mentioned as occasionally present in rickety and in syphilitic infants. It also occurs in associa- tion with defects in one of the cerebral hemispheres, when there may be a condition of crossed atrophy. Thus if some of the convolutions on the left side of the brain are wasted or wanting, the left parietal bone may feel flatter than the right, and the left side of the forehead shore FIG. 12. Girl, aged 9. Eight limbs, right half of chest, and right cheek smaller than corre- sponding parts on left side. Marked atrophy of right half of tongue. Above the cheek, however, the left side of the head was a little smaller than the right side. off more than the right side ; but below the eyes the arrested growth will affect -the right cheek and the right limbs, the latter frequently presenting a spastic hemiplegia. Slighter degrees of this asymmetry are by no means uncommon ; indeed, it is perhaps rare to see perfect equality between the two sides of the face, and it may be that there is a corresponding asymmetry between the cerebral motor areas. A still rarer form of facial asymmetry is seen in the affection known as "unilateral atrophy of the face; " in this disease the skin, connective tissue, and fat are thinned and wasted whilst the muscles are spared ; the bones too, if the atrophy begins in early life, may be arrested in their development, and then the two halves of the face look as if they belonged to different individuals ; one side having the fulness of youth, the other the wrinkles of old age (Fig. 13). CHANGES IN SIZE AND SHAPE. 4 I Local Depressions in any part of the surface of the cranium should be carefully looked for in cases of unilateral convulsions. A depres- sion in the bone may be the result of old syphilitic disease or of an injury which occurred months, or even years, before the development of brain symptoms. III. The Eyes. Undue prominence of the eyes occurs in Graves' disease, also to a slight degree in cases of myopia, and may depend on the presence of an intra-ocular tumour. Alterations in the size of the pupils and palpebral fissures are often of great aid in diagnosis. FIG. 13. Dr. Dreschf eld's Case of Facial Hemiatrophy. Girl aged 9 J. The atrophy, first noticed four years ago, involves the skin, subcutaneous tissue, and upper and lower jaws. The muscles are healthy, but the left half of the tongue is wasted. Contraction of the Pupils (Myosis). Contraction of the pupils with marked diminution of the reaction to light is an important symptom of locomotor ataxia and of general paralysis of the insane. Narrowing of the palpebral fissure on one side, with contraction of the corresponding pupil, points to a lesion of sympathetic nerve fibres in some part of their course from the medullary centres through the cervical portion of the spinal cord, along the rarni communicantes of the eighth cervical and first dorsal nerves, and upwards in the cervical sympathetic till they reach the muscles of the eye. Now this symptom namely, sinking in of the eyeball, with approximation of the eyelids and a small pupil is most frequently observed in locomotor ataxy, in aneurysm of 42 EXAMINATION OF THE SURFACE OF THE BODY. the thoracic aorta or other mediastinal tumour, and in injury or disease of. the cervical portion of the spinal cord, and a diagnosis between these conditions may often be instantly made by a general inspection of the body ; for in the case of aneurysm we should probably at once notice some pulsation of the upper part of the chest wall ; and in affections of the cervical cord, muscular atrophy in the upper limbs and the position of the hands and the spastic attitude of the feet would attract our attention ; while in locomotor ataxy there would be an absence of all these signs, but both pupils, besides being small, would be inactive to light. They are also diminished in size in mitral regurgitation, in typhus fever, and whenever the iris is congested either from general or local causes. Great contraction of the pupils, in association with profound coma, if not due to opium poisoning, suggests haemorrhage into the pons Varolii. Dilatation of the Pupils (Mydriasis). The pupils are larger in childhood than in adult life. They are often dilated in hysteria, in anaemia, in typhoid fever, and in many cases of apoplexy. Inequality of the Pupils may be due to unequal refraction of the two eyes, myopia being associated with mydriasis, hypermetropia with myosis. A destructive lesion of one third nerve produces dilatation of the corresponding pupil. Inequality of the pupils is often a pro- minent symptom in general paralysis of the insane ; it occurs some- times in locomotor ataxy, also in migraine. The effect of poisons on the size of the pupil must be remembered atropine, duboisin, and cocaine dilate, while opium, eserine, and pilocarpine contract the pupil. Irregularities in Shape suggest iritis ; they are also frequently met with as a result of iridectomy. Coloboma of the iris is a congenital cleft in the iris, which is always directed downwards or slightly down and in. It may affect one or both eyes, and may occur with or without coloboma of the choroid. IV. The Limbs. In addition to wasting or overgrowth of the soft tissues of a limb, which have been already referred to, its size and shape may be considerably altered in consequence of disease of the bones or joints ; and the following are some of the more important deformities which result from such changes. In Rickets the earliest naked-eye changes in the upper limbs are observed at the wrists, the lower ends of the radius and ulna being larger than normal. This enlargement is usually most obvious between three months and two years of age, a period when beads at the junction of the ribs with their costal cartilages are also prominent. The lower ends of the tibiae, and, to a less degree, the ends of the other long bones, also show enlargement. CHANGES IN SIZE AND SHAPE. 43 The chief changes in the shafts of the long bones are as follows : The arms become convex outwards about the insertion of the deltoid ; the forearms convex backwards ; the thighs convex forwards, and some- times outwards as well ; while the tibiae present a slight concavity on the inner surface, or a marked forward convexity in their lower thirds. Mollities ossium, a rare disease, chiefly affecting the female sex, is characterised by fractures and extreme flexibility of the long bones, together with distortions of the spine, sternum and pelvis. In Cretinism the ends of the bones are frequently abnormally large ; the hands are spade-like, and the fingers and toes shorter than normal. (See Fig. 5.) In infants of about three months old who are the subjects of Inherited Syphilis, slight swelling may occur in the neighbourhood of the wrists, elbows, shoulders, or knees, together with a " pseudo-paralysis " of these parts. Tenderness and powerlessness are usually more marked than swelling. The enlargement at the wrist is just above the junction of the epiphysis of the radius with its shaft, and is therefore a little higher than that of rickets ; it may also extend for a short distance along the shaft. Occasionally suppuration or partial dislocation of the epiphysis occurs, which subsequently becomes welded with some displacement to the shaft. Older children, just as the subjects of acquired syphilis, may present nodose or diffuse enlargement of the bones, especially the ulnae, lower ends of humeri, clavicles and tibiae ; and there may be overgrowth in length as well as in thickness. Nodose bony swellings occasionally develop during the convalescent period of Typhoid Fever. They are usually very painful to pressure, and are accompanied by pyrexia, and some spontaneous pain in the affected limb. In Infantile Scurvy, at from sixteen to eighteen months of age, there may be noticed extreme tenderness, swelling and immobility of the lower limbs, and sometimes of the upper limbs. The affected part, commonly the thigh, is swollen and cylindrical in shape, tense and shining. The swelling, which is deep-seated, begins near the junction of shaft with epiphysis, and extends for a varying distance along the shaft. The child is somewhat wasted, pale, sallow and fretful. Its gums are frequently spongy, and liable to bleed. The urine may contain albumen or blood. Thickening and Spontaneous Fractures of Bones are occasionally produced by injuries or diseases of the nervous system. Thus injuries of nerve trunks have been followed by swelling and thickening of the bones ; and if the injury occur in early life, the development of the affected bones may be arrested. Deformities and fractures of the 44 EXAMINATION OF THE SURFACE OF THE BODY. bones occur in the insane, and particularly in general paralytics ; also in locomotor ataxy, in which disease the period of swelling and fracture is usually preceded by paroxysms of lancinating pains. Very rarely spontaneous fractures occur in young infants, and probably as a result of rickets. They occur in the middle of the shaft, as well as near the epiphysis ; they may be single or multiple, partial or complete. Clubbing of Fingers and Toes. By this is meant an enlargement of the ungual phalanges of the fingers or toes. Clubbing may be regarded as an indication of impeded circulation within the thorax. Its com- monest causes are phthisis, empyema, and congenital heart disease. The thickening in phthisis is mainly from before back ; in empyema, from side to side. In phthisis the nails are often filbert shaped and incurved. Incurvation of the nails that is, a marked turning down of the tip of the nail is occasionally met with in healthy persons, but, as a rule, the normal direction of the nail is a gradual upward slant from matrix to tip. The Joints In medical practice articular swellings are most com- monly due to rheumatism, gout, or rheumatoid arthritis. They also occur in connection with gonorrhea, syphilis, pyaemia, the puerperal state, some of the acute specifics, especially scarlet fever, purpura hsemorrhagica, haemophilia, and during the course of certain diseases of the nervous system. In Acute or Subacute Rheumatism, while any joint may be attacked, it is the larger and medium-sized ones which are principally affected. There is some tenderness and usually great pain on movement. The skin over the joint is natural in appearance or presents a pinkish blush. The arthritis is transitory and shifting in character and symmetry is usually displayed in the order of succession. Thus while the swelling of one knee is subsiding, the other knee is the most likely joint to be next attacked. Pyrexia and profuse acid sweats accompany the arthritis, and appear to vary in severity with its intensity and extent. At all ages rheu- matism exhibits migratory and relapsing tendencies, but in other respects certain differences are to be noticed at different ages. Thus rheumatism in the child is characterised by the frequency with which erythematous eruptions, subcutaneous nodules, endocarditis, pericar- ditis and chorea occur ; while sweating, articular pain and swelling, and pyrexia are more marked in the adult. With regard to the nodules, they are small firm bodies, varying in size from a pin's head to an almond, which are situated over the tendon sheaths or fasciae, and also over bony prominences, and are most commonly found about the elbows, and over the extensor tendons of CHANGES IN SIZE AND SHAPE. 45 the hands. Other sites are the margins of the patella, the malleoli, the vertebral spines, the parietal and occipital bones, and the bony prominences of the shoulders and hips. FIG. 14. Subcutaneous Rheumatic Xodules on the elbow of a lad aged sixteen. (After A. Garrod.) Rheumatoid Arthritis may follow an attack of rheumatism, gout, or gonorrheal rheumatism ; or be developed independently of any previous FIG. 15. Chronic Polyarticular Rheumatoid Arthritis. disease. Three more or less distinct types can be distinguished, which, however, are not very rarely found in association. 46 EXAMINATION OF THE SURFACE OF THE BODY. The most important variety is poly articular rheumatoid arthritis. It occurs chiefly in women about the climacteric period, but is also met with in both sexes, and at the two extremes of life. In the child it is rare and assumes a rapidly progressive form, while in advanced life it is usually extremely chronic. The small joints of the hands and feet are the first to be attacked, then the disease steadily progresses towards the trunk ; in the upper limbs, for example, involving in order of succession the wrists, elbows and shoulders. Great symmetry is exhibited in the distribution of the lesions. The temp oro-m axillary articulation, rarely affected in acute rheu- matism, is often involved in rheumatoid arthritis. The neck frequently becomes stiff in consequence of " spoudylitis deformans " of the cervical spine. With regard to the hands, all the phalangeal joints may be enlarged, the enlargement being partly due to thickening of the arti- cular ends of the bones, and partly to an increase of fluid in the synovial membrane. When the elbow is involved, the bursa over the olecranon is frequently distended with fluid. In advanced cases movements of the bony surfaces against one another produce a char- acteristic grating. The skin over the enlarged joints is sometimes glossy and pigmented, while the nails are brittle and longitudinally ridged. Atrophy of the neighbouring muscles is a striking feature, but visceral complications are rare. Heberden's Nodes. These are due to an osteophytic enlargement of the ends of the bones which enter into the formation of the terminal phalangeal joints. This variety often occurs alone, but also in associa- tion with the polyarticular variety. The Monarticular Variety affects men oftener than women. The joint, usually the hip or shoulder, becomes stiff and painful, and the neighbouring muscles undergo marked atrophy. It may here be mentioned that enlargement of the ends of the bones, a distinctive feature of the diseased joints in rheumatoid arthritis, is also occasionally present in acute or subacute rheumatism ; for example, the author has observed thickening of the styloid and coronoid processes of the ulna, of the ends of the radius, and in one case, of the ribs near their anterior ends. There is sometimes, too, great tenderness over the thickened portion of bone, suggesting periostitis, and sometimes a fibrous nodule may be felt adhering to the presumably inflamed periosteum. Gout. The gouty joint, which is usually one of the small articula- tions, and most commonly the metacarpo-phalangeal joint of the great toe, is the seat of great pain and tenderness ; the part is red, swollen and cedematous, and the skin desquamates towards the end of the attack. In chronic cases tophi or chalk stones may be found around CHANGES IN SIZE AND SHAPE. 47 the joints and in the cartilages of the ears. The creamy juice obtained by pricking one of these deposits, when placed on a glass slide with a drop of liq. potassse, shows under the microscope innumerable deli- cate needle-shaped crystals, which are chiefly composed of biurate of sodium. When many joints are affected, and no tophi can be discovered, there is often a difficulty in deciding between rheumatoid arthritis and gout. The former often attacks more joints, and shows a greater tendency to symmetry than the latter disease. The history of the case is also of help in forming a diagnosis. Gonorrhoeal Arthritis. This name is given to joint lesions which sometimes occur in connection with a purulent discharge from a mucous membrane, especially that of the urethra. The knees and feet are most commonly attacked. The feet become swollen, and the soles are often excessively tender. The temporo-maxillary joints are liable to be affected. The arthritis is of an intractable character ; it may be progressive, and result in ankylosis of many joints, including spondy- litis deformans. But, as a rule, the disease is limited to a few joints ; while constitutional disturbance is slight. Conjunctivitis and iritis are not uncommon, but endocarditis is rare, and, when present, is nearly always of the ulcerative or septic variety. In Scarlet Fever two types of joint affection may be distin- guished. One variety occurs towards the end of the first week, and is usually transitory. The sheaths of the tendons at the back of the wrists, as well as the wrists themselves and other joints, become tender, red and swollen. The other variety comes on during the period of desquamation, and is frequently indistinguishable from ordinary rheumatism. In Haemophilia the knees sometimes become swollen in consequence of haemorrhage into the joint, or from an effusion of serum into the tissues around it. In Congenital Syphilis a passive synovitis is not uncommon as one of the later manifestations. A child walks into the out-patient room, and, on examination, one of the knees is enlarged, perhaps distended with fluid, but pain and tenderness are usually absent. Diseases of the Nervous System. Painful swelling of joints some- times follows injuries or diseases of the spinal cord or peripheral nerves ; also redness and swelling of the larger joints may be found on the paralysed side in hemiplegia, and oftener in cases of softening from thrombosis than in cases of hsemorrhage. A form of chronic arthritis sometimes develops very suddenly in locomotor ataxy ; the joint, usually the knee, hip, shoulder, or elbow, may be considerably swollen within twenty-four hours from the com- 4 8 EXAMINATION OF THE SURFACE OF THE BODY. mencement, and generally without pain or febrile reaction. Sometimes the joint recovers completely, but in severe cases the heads of the bones gradually become atrophied, and then, owing to relaxation of the liga- ments and feebleness of the surrounding muscles, spontaneous luxations frequently occur. The joints of the foot are sometimes attacked and a characteristic deformity the "tabetic foot " is produced. V. Th6 Spine. The various antero-posterior curves of the healthy spine are less marked in childhood than at a later period of life. FIG. 16. Extreme backward dislocation of left knee in a man ;ige in diameter, placed end to end ; nucleated spores are also present of comparatively large size, 7 fj, in diameter, and either in rows or in groups. Ringworm. Tinea tonsurans, ringworm of the scalp Tinea circi- nata, ringworm of the body Tinea sycosis vel T. barbae, ringworm of the beard. The hairy scalp is most commonly affected. The disease commences as a red papule round a hair ; this spreads at the periphery to form a red, slightly raised patch covered with greyish-white scales, through which project the stumps of broken hairs ; the patch enlarges up to 2-5 cm. in diameter, and may coalesce with others to form an irregular area, or may involve the whole scalp. The hairs are dull in colour, very brittle, and broken off about 4 mm. from the skin; the stumps are often bent or twisted, and the extremities frayed out like a brush. CUTANEOUS ERUPTIONS. IO9 Examined under the microscope in liquor potassse, the hair shafts are seen to be infiltrated with spores and mycelial threads of the Trico- phyton tonsurans ; the former are about half the size of favus spores, and the latter are less jointed and run longitudinally in the hair. Flo. 6-2. Hair with Favus fungus. A, A, chains of spores projecting beyond the edges of the hair ; B, spores between the fibres of the hair ; C, D, broken-up root end of the hair, with masses of spores between the laminse. (Kiichenmeister. ) FIG. 63. Hair from a case of Tinea ton- surans, loaded with spores, a, a, broken ends of hair ; b, rupture of longitudinal fibres ; c, c, ragged edges of hair. (M'Call Anderson.) In some cases the condition known as Tcerion is produced, in which there is suppuration of the hair follicles in the affected area, which forms a red, raised patch, soft and boggy to the touch, and discharging I I O EXAMINATION OF THE SKIN AND ITS APPENDAGES. pus from several points ; the hair follicles are usually destroyed by the suppurative process and permanent baldness results. Ringworm of the body appears as a circular patch 10-25 mm< or more in diameter, with well-defined slightly raised edges of a reddish colour and covered with branny scales ; as the periphery spreads, the centre gradually fades and clears up, so that a ring is formed which may coalesce with neighbouring rings to form gyrate figures covering a large area. Scrapings of the epithelium show the same fungus as ringworm of the scalp. FIG. 64. Shows the clusters of spores and the tubes of the Microsporon Furfur. (M'Call Anderson.) The so-called Eczema marginatum is ringworm affecting the fork and neighbouring parts of the trunk and thighs. Ringworm of the beard is the result of inoculation of the Tricophyton into the hairy parts of the face ; it begins as a red itching spot, which may form a scaly patch or ring, but in most cases a suppurative in- flammation is set up in the hair follicles, which become swollen, forming tender, red, prominent nodules, in which points of suppuration are seen with loosened hairs ; the follicles may be destroyed and bald patches result. Tinea versicolor or Chloasma is found almost entirely on the trunk as yellowish-brown or buff patches of various shapes and sizes. These are scarcely raised above the surface and very slightly scaly at CUTANEOUS ERUPTIONS. I I I the margin : neighbouring spots enlarge and coalesce to form large areas, which may cover the greater part of the trunk. A scraping of the epithelial scales from the edge of a patch, when examined in liquor potassae under the microscope, shows a network of mycelium studded with collections of round spores, the Microsporon furfur. Erythrasma, a somewhat rare disease, similar to Tinea versicolor, but of darker colour, occurs in the folds of the axilla, or the fork and neighbouring parts; it is due to a small fungus, the Microsporon minutissimum. Alopecia areata appears in the form of localised bald spots on normally hairy parts, most commonly the scalp ; they vary in number, FIG. 65. A burrow containing a female acarus with the head directed to the blind end of the burrow. Within the acarus is an egg. Behind the acarus and in a row one after the other, with their long axis placed transversely to the long axis of the burrow, there are ten ova in various stages of development. Between the ova are black irregularly-shaped faecal masses. (After Neumann.) size, and shape, but all present a smooth, glistening surface. Around the border of the patch scattered among the healthy hairs are found short stumps of hair-shafts, thicker at their free extremity, and often compared to a point of exclamation (!). The patches spread peri- pherally, and during recovery the broken hairs are no longer found, but a fine downy growth of hair appears on the smooth glistening skin. The etiology of the disease is still doubtful ; probably both neurotic and parasitic cases are at present included under the same name. (d.) Diseases due to Animal Parasites. Scabies. Itch is a contagious disease characterised by intense itch- ing of the skin from the presence of the Acarus Scabiei, the so-called itch insect. The lesions in the skin are multiform, and are either due I I 2 EXAMINATION OF THE SKIN AND ITS APPENDAGES. to the actual presence of the parasite or to the friction or scratching of the skin of the patient. The characteristic lesion is the bwrow (see Fig. 65), a tunnel formed in the skin by the female acarus, and in which the eggs are laid and hatched ; on the surface it appears as a white or dark line (usually the latter, from particles adherent to the slightly roughened epidermis forming the roof of the burrow), 3- 1 7 mm. in length, and often more or less curved. At the deeper end the parasite is to be found, while the eggs in various stages of develop- ment occupy the remainder of the burrow. The parts most frequently affected are the interdigital webs and dorsal aspect of the fingers, flexor surface of the wrist, penis, and neighbouring parts. The para- \ FIG. 66. Female Acarus. site may be obtained for examination by carefully scraping the epider- mis over the deeper end of a burrow with a pin until the roof is broken through, the acarus can then be picked out by the pin, to the point of which it usually clings. It forms a minute, oval white speck, .3-. 4 mm. in length ; under the microscope it is seen to possess four pairs of legs, the two anterior pairs having suckers at the extremities, the two posterior ending in bristles or setae. The male is smaller than the female, and the fourth pair of legs are also furnished with suckers; it does not burrow, but wanders over the surface of the skin. The site of a burrow is often marked by a papule, vesicle, or pustule, the result of inflammation set up by the presence of the parasite. CUTANEOUS ERUPTIONS. I I 3 The lesions due to scratching consist of linear wheals, excoriated papules, vesicles and pustules, with crusts of dried blood, pus, or serum. The eruption is chiefly on the front of the body and limbs, and is almost confined to the area bounded above by a transverse line across the chest and arms at the level of the nipples, and below by a transverse line at the level of the knees. In patients who sit much on hard seats, the region of the buttocks is much affected, and so are the lines of pressure from belts or tight clothing. The characteristic feature of scabies is the variety of the inflammatory lesions and their distribution, while the presence of a burrow is con- clusive. Pediculosis Phthiriasis, occurs in three forms, according to the three species of lice which are found as human parasites. These are named, from their habitat, Pediculus capitis, Pediculus corporis vel vestimentorum, and Pediculus pubis. Pediculus capitis. The head-louse lives and breeds in the hair of the scalp ; it is about 2 mm. long, and half as much broad, of a dirty white colour, and consists of a triangular head, a thorax, to which are attached six legs, and an abdomen, which comprises the bulk of the body of the animal. The lice are found wandering about the roots of the hairs, while the ova (" nits ") are found as small white specks glued laterally to the hair shafts. The presence of the parasites excites intense itching and scratching, especially in the occipital region. Ex- coriations are formed, which become inoculated by pus FIG. 6 7 . Pediculus cocci, and pustules are produced. This process spreads capitis. (if'Caii until the back of the head becomes covered with a thick mass of matted hair, crusts and dried secretions, concealing a sup- purating surface. To this condition the name Eczema Impetiginodes is often applied. The sub-occipital glands are enlarged and may suppurate. Pediculus corporis, or body-louse, is larger than the head- louse, and wanders over the surface of the trunk for the purpose of feeding ; it inhabits the clothes of old and dirty people, especially about the neck and shoulders. The characteristic lesion is a minute haemorrhagic speck, just visible to the naked eye, and not raised above the surface of the skin. The itching is most intense, and the skin of the affected area is covered with a typical scratch eruption, made up of linear wheals and excoria- tions, small papules with a dried blood crust on the summit, occasional pustules and, in chronic cases, much pigmentation of the skin. Pediculus pubis. The crab-louse is broader, smaller and flatter H I 14 EXAMINATION OF THE SKIN AND ITS APPENDAGES. than the others. It is found in the pubic hair and occasionally on the hair of the face. Its presence leads to great irritation and scratching, with similar results to those produced by the Pediculus capitis on the head. Pulex irritans, the common flea, produces a slightly raised red spot, with a central puncture, often marked by a speck of blood, which persists as a petechia after the hypersemic papule has disappeared. Cimex lectularius, the bed-bug, produces a raised red spot, similar to but larger than that caused by a flea, and more persistent and irritating ; a purpuric spot remains for some time and undergoes the usual changes in colour. ^i FIG. 68. Pediculus cor- poris, female. (M'Call Anderson.)- FIG. 69. Pediculus pubis. (M'Call Anderson.) Fia. 70. Acarusfolliculorum, fully matured specimen, dorsal view. (Nayler.) Leptus autumnalis, the harvest-bug, bores into the skin and causes a papular eruption, which itches and leads to scratching and the con- sequences thereof. The lower parts of the legs are usually first affected. Q-nats, mosquitoes, bees, wasps and some caterpillars cause papules and wheals, with much itching and irritation, and sometimes consider- able swelling. Acarus folliculorum is a parasite not unfrequently found in the sebaceous glands; it is of elongated shape, one-sixth to one-third mm. in length, and consists of a head, a thorax, with four pairs of rudi- mentary legs, and a tapering abdomen, which forms about one-half CUTANEOUS ERUPTIONS. I I 5 of the entire length of the animal. It gives rise to no symptoms in man. Elephantiasis Elephantiasis Arabum, consists in great hypertrophy of the skin and subcutaneous tissues from obstruction of lymphatics by parasites (Filiaria sanguinis hominis) or other causes. The affected part, often the leg (Barbadoes leg) or scrotum, is enormously swollen, but does not pit on pressure. The skin is thickened, hard, smooth, or irregular from dilated lymphatic vessels. The latter often rupture and discharge clear or milky fluid ; pigmentation is often present and varies in character. CLASS III. LOCAL DISEASES OP THE SKIN NOT DUE TO CUTANEOUS PARASITES. (a.) The changes in the skin are alterations of colour or consistence, or both combined. There is no elevation of the affected surface, no formation of vesicles, pustules, or secondary lesions. Erythema simplex is a patchy redness of the skin from the action of some irritant, such as friction, heat, the rays of the sun, or chemical irritants. Erythema intertrigo is a redness of the skin due to friction of contiguous surfaces, such as the groins and thighs of children, or beneath the mammae in obese females. Erythema lave is a more or less diffuse redness, often seen on skin affected with rederna. Erythema pernio Chilblains, are red patches on the fingers, toes, or other exposed parts of the body where the circulation is feeble, caused by exposure to cold, and especially occurring in persons of feeble circulation. If exposed to friction, inflammation and ulceration of the skin may take place. Erythema paratrimma is the redness of the skin which is exposed to pressure when patients are confined to bed ; it is especially liable to form when there is any disease of the spinal cord ; if not relieved, ulceration takes place, and the well-known bedsore (Decubitus) is formed. Purpura is a name given to haemorrhage into the skin from various diseases ; it sometimes appears without obvious cause, and is then described as a separate disease ; the skin presents numerous purple spots of all sizes, from petechiae up to large irregular patches ; these do not disappear on pressure, and undergo the usual changes in colour seen in a bruise. The legs are usually first affected, but in severe cases, Purpura hcemorrliagica, the greater part of the body may I 1 6 EXAMINATION OF THE SKIN AND ITS APPENDAGES. be involved, and also the mucous membranes, so that haemorrhage may occur from nose, mouth, respiratory tract, stomach, or rectum. Cutaneous naevus is a vascular growth in the skin made up of dilated capillaries or veins ; it is found as a red or purple patch of variable size and shape, often on the face as a " port-wine stain " or " mother's mark." Pressure empties the blood-vessels, which gra- dually refill when the pressure is removed. Ksevi are often present at birth, or appear soon after, but may occasionally appear in adults ; they may either remain stationary or gradually increase in size. Dilated blood-vessels are also found on the face in Acne rosacea (q.v.), and may be the only lesion in the early stages. Lentigo, Ephelides, Freckles, are small spots of brown or yellow pigment, occurring on those parts of the body exposed to the light, most commonly the face and backs of the hands. Albinismus is a congenital absence of pigment from the body ; when complete, the skin is white or pinkish, the hair white, and the eye appears pink owing to absence of pigment in the iris and choroid. Leucoderma Vitiligo, consists in a deficiency of pigment over limited areas of skin, with excessive pigmentation in the parts im- mediately surrounding the diseased areas ; it appears in the form of white patches, i-io cm. or more in diameter, of irregular shape, but having well-defined convex borders, which sharply contrast with the deeper colour of the surrounding skin. The patches enlarge peri- pherally, coalesce, and may spread over nearly all the body ; the hair on the affected skin becomes white ; recovery rarely takes place. Sclerodenna Hide-bound Disease, occurs in two distinct forms : (a.) Diffuse scleroderma is very rare, and begins about the face or neck as a hardening of the skin without change of colour ; there is usually no swelling of the skin ; the affected area does not pit on pressure, and the skin cannot be pinched up from the subcutaneous tissues. The movements of the joints are stiff, and finally completely lost. In other cases oedema is an early symptom, and later gives place to induration and shrinking. The affected skin after some time often shows reddish patches, and yellow or brown pigmentation. The greater part of the body may be affected, and the disease may last for years. (/?.) Circumscribed Sclerodenna Morphcea Keloid of Addison, presents itself as an irregular -shaped patch of a pale yellow or ivory colour surrounded by a zone of purplish hypersemia ; the patch is neither raised nor depressed ; the skin feels like parchment or leather, is smooth, dry, and can often be pinched up. Several patches are often present at once, and are usually 3-8 cm. in diameter; they persist for years. Striae atrophicae Lineae albicantes, are white lines on the skin of CUTANEOUS ERUPTIONS. I I 7 the abdomen, due to localised atrophy of the skin following previous over-stretching, as in pregnancy or ascites ; other parts of the body are sometimes affected with similar or more extensive atrophic patches. Glossy Skin is a condition usually seen in the hands as the result of injury or disease of the nerves supplying the affected part. The skin is thin, smooth, glossy and without furrows, and redder than normal, or mottled red and white. Neuralgic pain is often present. (b.) The lesions in the skin are localised elevations of the surface; vesicles, pustules or secondary lesions are only produced as the result of scratching or other irritation. Callositas Tylosis is a localised thickening of the epidermis, usually found on the palms and soles, and due to intermittent pres- sure from the use of tools, from much walking, or similar cause. Clavus Corn, is a similar localised thickening of epidermis, but it grows downwards into the skin, causing atrophy of the papillae and the formation of a pit, which is filled by the epidermic plug ; pres- sure on the elevated horny surface causes acute pain. The toes are the parts chiefly affected ; when the corn is between adjacent surfaces the epidermis is macerated by the moisture and soft corns are pro- duced. Verruca Wart, is a small projecting growth composed of one or more hypertrophied papillae covered by a thick layer of horny epider- mis ; warts may be pointed or flattened, single or in enormous numbers. When recent they are pink in colour ; when old, yellowish brown. The hands of children are the most common sites. Venereal Warts Condylomata, occur on the perineum, penis, vulva, or other moist situations, as the result of irritating discharges ; they are pink or red in colour, and usually covered by a foul white secretion. Naevus pigmentosus Pigmentary Mole, is a small collection of brown or black pigment in the skin, which is usually more or less elevated above the surface ; many are covered by hair (Nuevus pilosus). Moles vary much in size and number ; the face, neck and back are the most common sites. Xanthoma Xanthelasma. consists of small buff-coloured, slightly raised spots on the skin. The commonest situation is the upper eye- lid near the inner canthus. They are formed in association with " sick headache " and with jaundice. Keloid Keloid of Alibert, is a nodular growth of fibrous tissue occurring on scars (so-called false keloid) or spontaneously. It forms smooth, white or pink, elevated masses of various shapes, the most common being a flat rod with lateral processes, situated over the sternum. Contraction of the new-formed tissue may cause deformity of the surrounding skin. I I 8 EXAMINATION OF THE SKIN AND ITS APPENDAGES. Melanotic Sarcoma appears as one or more raised, brown, or bluish- black spots, which enlarge to form distinct tumours. They often originate from a pigmented mole. Molluscum fibrosum is a soft growth projecting from the surface of the skin, often pedunctilated, and varying in size from a pin's head to an orange ; the skin of the tumour is normal in character and often flaccid and wrinkled. The tumours may be present in very large numbers. Molluscum contagiosum consists of small growths on the skin, 2-12 mm. in diameter, sessile or pedunculated, of a yellowish colour and firm consistence. The top is usually pitted with a small central hole, from which a little milky semi-fluid material can often be squeezed. Two or three may be present on the face, hands, arms, mamma?, or genitals, or the growths may be scattered all over the body. Prurigo is a rare disease, which usually begins in early infancy and persists through life. It must be carefully distinguished from pruritus, i.e., the symptom of itching, which is common in many forms of skin disease. In prurigo, the lesion consists of minute papules, more easily felt than seen, as they are of the colour of the skin. They chiefly occur on the extensor surfaces, and are attended by intense itching and scratching, with the usual effects of the latter upon the skin. Urticaria Nettlerash, is characterised by the evanescent char- acter of the eruption and by the intense itching of the skin. The lesion consists of wheals, slightly raised red or white elevations above the surface, of various shapes and sizes, but always very broad in pro- portion to their height ; they may disappear within an hour, or may last several days ; successive crops of wheals may continue the disease for an indefinite time. In children, persistent papules (Lichen urticatus) are often left after the wheals have disappeared. Disturbance of the alimentary canal by ingesta is often associated with the disease. Erythema multiforme occurs, as already mentioned, with rheumatic symptoms, but also independently. The lesion consist of red papules (Erythema papulatuni) of varying size ; these may remain discrete, or run together to form slightly elevated red patches of irregular shape. The swelling and redness often disappear from the centre of the patch, so that a ring (Erythema annulure) is formed, and, by the coalescence of neighbouring rings, gyrate figures (Erythema gyratuni) are produced. (c.) There is persistent scaly desquamation from the skin, either general or local. Ichthyosis Xeroderma, is a congenital condition of the skin due to thickening of the epidermis and deficient secretion of the cutaneous glands. In the mild forms (Xeroderma) the skin is dry, rough, and looks CUTANEOUS ERUPTIONS. 119 dirty, especially over the elbows, knees and extensor surfaces of the limbs. In more advanced cases the dry skin is covered by thin polygonal scales of epidermis. On their removal the skin beneath is seen to be of normal colour. The worst cases (Ichthyosis hystrix) are characterised by the formation of horn-like polygonal masses of epidermis, 10-15 mm - ^ n height, and of a dark greenish colour. The intermediate skin is generally xerodermatous, but may be healthy. Lichen scrofulosomm is an uncommon disease which occurs in scrofulous patients; it consists of minute papules of a red or pale colour, each papule being covered by a minute scale. The trunk is the part affected. Lichen planus is a somewhat rare disease, characterised by discrete papules, 2-4 mm. in diameter, of a bluish-red colour and angular outline. The apex is smooth and flattened, and presents a central depression ; the papules, when once formed, do not enlarge, but fresh papules appear between those already present until confluent patches are produced of various size and shape ; these are of a purplish colour, raised, firm and covered with scales. The front of the wrist and forearm and inner aspect of the knees are chiefly affected, but it may appear on any part of the body. Psoriasis is a common disease, which usually commences over the patellae and olecranon processes as small, raised, red spots covered by silvery grey adherent scales. On completely removing the scales, the red surface exhibits to the lens a number of bright red dots. The patches increase in size, and coalesce to form larger patches of varied outline. Different names are applied to the different appearances pre- sented, such as punctata, when the spots are small ; guttata, when they are about 5-6 mm. in diameter, and look like drops of mortar on the skin ; nummularis, when larger ; circinata and gyrata, when rings or gyrate figures are formed by involution of the central part of each patch and coalescence of neighbouring rings; unioersalis, when the whole of the body is involved. The eruption is dry throughout the whole course of the disease. The extensor surfaces of the limbs are the most common sites ; the scalp is often involved, then the trunk, less frequently the face and flexor surfaces of the limbs ; the eruption is usually symmetrical, and may spread over the whole of the skin. The general health is hardly affected, and recurrence commonly takes place. Pityriasis rubra, Exfoliative dermatitis, is rare, and begins as a red patch on the chest or arms; this rapidly spreads, and other patches form and coalesce, so that in a few days the whole surface of the body is involved, and presents a surface of bright red colour, covered by thin scales, small on the face, but forming large flakes I 20 EXAMINATION OF THE SKIN AND ITS APPENDAGES. on the trunk and limbs. The scales are shed copiously. There is often burning and tingling, but not much itching. The skin is very little thickened, discharge is usually absent, and if present does not stiffen linen. The patient is often in good health, but constitutional disturbance may be severe, and even fatal in elderly people, among whom an epidemic form of the disease has recently been described. Seborrhcea and Seborrhoeic dermatitis. (a) Seborrhcea sicca affects chiefly the scalp and other hairy parts ; it consists in accumulation of the dried fatty secretions of the cutaneous glands to form dried scales (scurf or dandriff) covering the skin at the roots of the hairs. On removal of the scales, the skin is white and apparently normal. The disease leads to atrophy of the hair and baldness. (/3) Seborrhcea oleasa is seen chiefly on the face as an oily secretion, giving a shining, greasy look to a skin which is usually dirty from adherent dust. It also occurs on hairy parts, when a greasy crust of fat and epithelium is formed, instead of the dry scales of Seborrhcea sicca. (7) Seborrhoeic dermatitis is an inflammation of the skin due to, or associated with, the disorder of the cutaneous glands causing seborrhcea ; the lesions of the skin closely resemble those of the less acute forms of eczema (q.v.), less frequently those of psoriasis, while a peculiar form affecting the trunk is known as Lichen circinatus, and consists of red spots spreading peripherally, and healing in the centre to form rings ; the central portion is of a light yellow-brown colour, and the red borders are scaly. Neighbouring rings coalesce to form gyrate figures, which may cover the greater part of the trunk ; the limbs are not involved. In the various forms of seborrhceic dermatitis the scales and crusts are greasy, and seborrhcea is present on the scalp or other parts. Lupus erythematosus is not very common ; it occurs chiefly on the face, but is also found on the scalp and other parts of the body ; the cheeks and bridge of the nose are often affected together, giving the so-called "butterfly" patch. It commences as a red spot, covered by a yellow, adherent, greasy scale ; if this be carefully removed, a pro- cess from its under surface is seen to project, like a plug, into the orifice of a sebaceous gland. The spots spread peripherally, and coal- esce to form red patches of varied size covered with similar scales and plugs ; the margin of the patch is sharply defined and slightly raised above the surface. After an indefinite time the centre of the patch becomes depressed, scales no longer form, and a white superficial scar is left ; when hairy parts are involved, permanent baldness results. Ulceration never takes place. The duration is very prolonged, progress CUTANEOUS ERUPTIONS. I 2 1 is slow and often intermittent, periods of long quiescence being inter- rupted by acute exacerbations and rapid extension of the disease. (d.) Vesicles OP bullse are present on the skin at some stage of the disease; either absorption, or rupture and discharge of contents takes place, with formation of crusts, or desquamation of epithelium. Miliaria, sudamina, are minute vesicles, filled with clear, slightly acid fluid. They are due to the accumulation of sweat beneath the epidermis, as a result of profuse perspiration. They may become inflamed and form papules, the so-called red gum or stropliulus of infants. Cheiro-pompholyx. A disease limited to the hands and feet ; it consists of vesicles situated beneath the horny epidermis, through which they appear as small translucent spots ; when numerous and closely set, they coalesce into irregular bullse. The skin is not red- dened, but there is often burning or tingling. After seven to ten days the contents are absorbed, and the epidermis peels off, leaving normal skin beneath. Erythema iris Herpes iris, is closely allied to Erythema multiforme, and occurs as a red papule, soon becoming a vesicle ; this enlarges, the centre is absorbed, and a vesicular ring is left surrounded by a red areola ; in other cases a ring is absorbed leaving a central vesicle sur- rounded by a depressed purplish-red ring ; this is again surrounded by a white vesicular ring, and finally a red areola. Occasionally the number of rings may be increased or irregular figures formed by coalescence. Herpes facialis occurs in association with acute pneumonia, bron- chitis and ordinary catarrh, as one or more groups of vesicles on an inflamed base. The contents dry up into a scab, which soon falls off. The lips, nose and adjacent parts are usually affected. Herpes preputialis occurs on the prepuce and neighbouring parts, and occasionally on the vulva in females. One or more vesicles are found on an inflamed base ; rupture usually occurs and shallow ulcers are formed, which must be distinguished from venereal sores. Herpes zoster Zona Shingles, consists of an eruption of papules, which rapidly become vesicles on an inflamed base ; the vesicles are arranged in groups, which correspond in distribution to the branches of some cutaneous nerve ; one of the intercostal nerves is most commonly affected, the eruption forming a girdle (zond) round half the trunk from spine to sternum. The branches of the fifth cranial nerve or the nerves of the limbs may also be involved. There is often neuralgic pain along the course of the affected nerve, which may persist for some time. In most cases, if not in all, the lesion is a trophic one, due to 122 EXAMINATION OF THE SKIN AND ITS APPENDAGES. disease in the ganglion on a posterior root, or its homologue in the case of the cranial nerves. Pemphigus presents an eruption of bullse which gradually increase to 3 cm. or more in diameter ; each is surrounded by a red areola. Any part of the body may be affected ; the number of bullse varies, and they come out in successive crops. Each crop lasts a few days, when the fluid is absorbed or discharged, and the epidermic covering dries and falls off leaving a red stain. Pemphigus foliaceus is a rare and fatal form, in which the whole body may be involved. The eruption consists of flaccid bullse, which rupture and form foliaceous crusts covering a raw inflamed surface. Dermatitis herpetiformis is a rare disease, which affects chiefly the limbs and abdomen ; it presents itself as red, flat patches with a raised margin and a depressed livid centre ; these gradually enlarge, and when 2-3 cm. in diameter, vesicles of various size develop on the raised red margin ; bullae also form, both on the raised patches and independently. Fresh patches form during the course of the disease, so that all stages are found present at the same time. Eczema is the most common of all diseases of the skin, and mani- fests itself by a great variety of lesions, according to the stage of inflammation reached in each particular case, and the nature and extent of the secondary lesions. The essential feature is the superficial inflammation of the skin. This shows itself in various ways, so that different names are applied to the different stages. (a.) Eczema erythematosum usually occurs on the face as diffuse red patches, with much heat and some swelling of the cellular tissue, the superficial epidermis is shed as fine scales, and the inflammation either subsides or passes on to a more intense degree. (6.) Eczema papulosum Lichen simplex, is characterised by the for- mation of red papules on the trunk, limbs, or other parts ; the papules vary in number, and may coalesce to form raised red patches ; vesicles may be formed and discharge serum which stiffens linen, or the epidermis be shed in the form of scales. There is much itching and irritation, which often leads to scratching and excoriations. (c.) Eczema vesiculosum occurs most frequently on the flexor surfaces of joints, behind the ears, or anywhere where the skin is thin ; it appears as a red patch, which burns or itches, and soon presents a number of minute vesicles containing clear serum ; the vesicles rupture and the serum forms a discharge, which is often copious, and stiffens linen on drying ; if scanty, the discharge dries up to form yellow crusts, on removal of which the red, moist, exuding surface is seen. CUTANEOUS ERUPTIONS. 123 This, the classical type of eczema, may develop from either of the preceding forms. (f.L) Eczema rubrum is a still more intense degree of inflammation, and often affects large tracts of skin, especially on the lower ex- tremities ; the inflamed surface is bright red and moist, discharging large quantities of serum, which dries np into yellow crusts, not infrequently mixed with a little blood from rupture of the distended capillaries. (e.) Eczema squamosum is a much less intense inflammation, and is often a later stage of any of the more acute conditions ; it occurs as irregular patches of a red colour covered by scales of epidermis. On pinching up the skin, it is felt to be thickened and indurated. (/) Eczema pustulosum Eczema impetiginodes, is due to secondary inoculation of the inflamed skin by pus cocci, so that pustules form with greenish crusts of dried pus ; this is not uncommon, and is dis- tinguished from Impetigo contagiosa by the fact that the pustules in the latter disease occur on healthy skin, and not on an already inflamed surface. (g.) Eczema rimosum occurs most frequently on the hands of people who work in irritating material, such as sugar, chemicals, or soap and water ; there is much thickening of the epidermis, which interferes with the movements of the joints, and cracks take place in the lines of flexure, exposing the red surface of the papillae and forming painful fissures. In a typical case of eczema, several of these varieties are present together, the skin presenting papules, vesicles and red patches, crusts and weeping surfaces, or thickened skin covered with scales, according to the stage and degree of the inflammation. Eczema may persist for years, but usually by successive outbreaks of a more or less acute character, each of which leaves behind an increase of inflammatory infiltration, so that the affected skin becomes thick and hard in proportion to the chronicity of the disease. (e.) The affected skin presents suppuration of the seba- ceous glands, combined with other lesions which vary in character. Acne vulgaris commences by a blocking of the ducts of the seba- ceous glands and retention of the secretion ; this gives rise to a pro- minent white papule, the opening of which presents a black dot, due to accumulated dirt in the orifice of the duct. Such a papule is called a " Comedo," and the retained secretion can be expelled by pressure. Comedones are most commonly found on the face, and may persist indefinitely ; usually, however, suppuration takes place, the papule increases in size, becomes red and painful, the summit soon presents a I 24 EXAMINATION OF THE SKIN AND ITS APPENDAGES. yellow spot due to the formation of pus, the minute abscess ruptures, the contents are evacuated, and healing takes place either with or without scar according to the depth to which the suppuration has extended. The face, neck, shoulders and chest of young adults are the parts particularly affected. Acne rosacea Gutta rosea, is a condition of hypertrophy of the vessels of the face often associated with disorder of the alimentary canal, abuse of alcoholic stimulants, or uterine derangements. The nose is usually first affected, and is red, with distinct tortuous blood-vessels on the affected part ; at a later stage nodular thickening of the nose (so-called "grog blossoms") present themselves, and may increase in size so as to cause considerable deformity. After the nose, the condition spreads to the cheeks, chin and forehead. Combined with the vascular hypertrophy there is usually inflammation of the sebaceous glands of the affected area, leading to suppuration and the formation of pustules. (f.) The skin presents irregular uleeration, with indurated edges, spreading deeply, and showing- no signs of healing. Epithelioma frequently affects the skin of the lower lip or genitals, but may occur on any part of the body. It begins as a small hard wart or nodule, which gradually enlarges and becomes adherent to the deeper tissues. The surface ulcerates, and a constantly spreading ulcer is produced, with raised, indurated, everted, or undermined edges, and an irregular base, with more or less foul discharge. The disease spreads so as to destroy the whole structure of the affected part. The nearest lymphatic glands are usually enlarged and indurated. Rodent ulcer occurs chiefly on the eyelid, nose, or cheek as a soft, wart-like growth, which breaks down in the centre to form an irregular ulcer, with hard sinuous edges, not everted, undermined, or nodular, and of a yellowish-red colour. The surface presents few granulations and little discharge. Pain is absent or slight, duration prolonged, and the neighbouring lymphatic glands are not affected. (g.) There is gangrene of the skin. Acute decubitus Bedsore, is gangrene of that part of the skin which is compressed by the weight of the body when the patient is confined to bed from disease or injury, more especially of the central nervous system. The gangrene is moist in character. Oancrum oris is gangrene of the substance . of the cheek, com- mencing in the mouth and spreading to the skin. It occurs in weakly children, especially after various specific fevers. Noma is a similar condition, affecting the external genital organs of female children. CUTANEOUS ERUPTIONS. I 2 5 Senile gangrene occurs chiefly on the lower extremities of old people ; it commences as a black spot on the toes or foot, and spreads to a variable extent, the affected area becoming dried up, shrivelled- looking and black. Eaynaud's Disease is a rare disease, affecting the extremities in a symmetrical manner; the fingers or toes are cold and numb, then blue and congested, and finally black gangrene occurs, and the affected parts are separated in the usual way. Drug" Eruptions. (Abridged from Dr. JR. Crocker, "Diseases of the Skin.") Antipyrin sometimes causes a red papular eruption, not unlike measles, more rarely an urticaria, Arsenious Acid and its preparations cause occasionally urticarial or papular eruptions, and, if long continued, a brown pigmentation of the skin. Belladonna and Atropin cause a general red rash resembling that of scarlatina. Bromides, when given for some time, cause pustular eruptions on the face, chest and back, the so-called "Bromide Acne." A number of spots may coalesce to form larger patches. Chloral Hydrate, in large doses, occasionally produces a dark red papular rash, affecting chiefly the face, neck and limbs. Copaiba often causes a profuse rash, consisting of red, slightly raised spots, discrete or confluent, and affecting the trunk, limbs and face. Iodides cause rashes of various kinds ; the most important is the "Iodide Acne" a crop of pustules very like those produced by the bromides, but usually smaller and more pointed. In rare cases papules, wheals, or purpuric spots are produced. Mercurial preparations, in rare cases, give rise to a red papular erup- tion or a diffuse redness with swelling. Opium and Morphia sometimes cause a red papular eruption resem- bling measles or scarlet fever. Quinine may produce a rash like scarlet fever, or a papular one like measles. Silver Nitrate, after prolonged administration, causes a peculiar slaty- grey colour of the skin ; this may be so dark as to be nearly black ; it is of general distribution, but deeper on parts exposed to light. Once produced, the discoloration is a permanent condition. Sulphonal has occasionally been followed by a red macular eruption. Tuberculin, injected hypodermically, causes, with the constitutional reaction, a red eruption on the skin, either papular round the hair follicles, or red spots of varying size and distribution. Turpentine and Terebene are occasionally followed by redness, papules, or even vesicles, with intense itching. 126 EXAMINATION OF THE RESPIRATORY SYSTEM. ABNORMAL CONDITIONS OF THE NAILS. Onychauxis, or hypertrophy of the nail, is not uncommon ; there is much thickening and irregularity, and the nail may form a horn-like growth several inches in length and of various shapes. Onychomycosis is due to affection of the nail by fevers or ring- worm ; the affected nail is dry, lustreless, discoloured, opaque, furrowed, fissured, and raised from its bed ; the parasite can usually be found by microscopic examination. Onychia is a general term used for inflammation affecting the matrix of the nail. Ingrowing toe-nail is an inflammation of the skin and matrix set up by the pressure of the tissues against a sharp edge of nail ; it is usually found on the great toe. Transverse Furrows in the nails occur as the result of acute diseases, such as specific fevers ; the position of the furrow affords some infor- mation as to the occurrence of recent illness, and the breadth and depth correspond roughly to its duration and severity. Curved Nails occur often with clubbing of the fingers in patients suffering from phthisis or chronic heart disease. CHAPTER VI EXAMINATION OF THE RESPIRATORY SYSTEM. THE symptoms usually complained of by patients suffering from disease of the respiratory organs are : Pain, cough, spitting of phlegm or blood, changes in the voice, shortness of breath, loss of appetite, or more general symptoms, such as weakness, loss of flesh, &c. Changes in the strength or quality of the voice, in association often with cough, suggest disease of the larynx ; cough, expectoration, haemop- tysis, difficulty in breathing, and loss of flesh and strength, together with a varying degree of pyrexia, suggest disease of the lungs, while acute thoracic pain and shallow breathing characterise the onset of pleurisy. The pain of pleurisy is often stabbing in character, and makes the patient afraid to breathe. Its severity is a measure to some extent of the severity of the attack of pleurisy. The pain is usually most severe before friction-sound can be heard, and often passes away as the rub becomes audible. The pain of pleurisy may be referred to the anterior ARTIFICIAL DIVISIONS OF THE CHEST. 127 part of the abdomen, and sometimes to the groin or hip ; also severe pain may be present over the tip of the shoulder and outer third of the clavicle. It is well to remember that an attack of pneumonia is frequently ushered in, especially in children, by symptoms closely resembling those of acute gastric catarrh ; thus there may be severe vomiting, belching of wind, palpitation of the heart, together with pain at mid- sternum and between the shoulders, while occasionally the patient suffers from rumbling of the bowels and diarrhoea. AETIFICIAL DIVISIONS OF THE CHEST. For purposes of accurate description, it has been found convenient to mark the surface of the chest with certain imaginary vertical lines and to divide it into certain regions. The lines are : 1. The median line, drawn through the middle of the sternum. 2. The mammary line, drawn through the nipple. 3. The parasternal line, drawn midway between the preceding and the edge of the sternum. 4. The anterior axillary line, drawn from the anterior fold of the axilla. 5. The axillary line, drawn downwards from the apex of the axilla. 6. The posterior axillary line, drawn downwards from the posterior fold of the axilla. 7. The scapular or dorsal line, drawn through the angle of the scapula. The regions are : Anteriorly. i. The supra-sternal region or notch. 2. The superior sternal region or notch, separated from 3. The inferior sternal region or notch by a line joining the lower border of the third costal cartilages. 4. The supra-clavicular. 5. The clavicular, corresponding to the inner half of the clavicle. 6. The infra-clavicular, from the clavicle down to the lower border of the third rib. 7. The mammary, from the third to the sixth rib. 8. The infra-mammary, from the sixth rib to the costal margin. Laterally. i. The axillary, from the apex of the axilla down to the sixth rib. 2. The infra-axillary, from the sixth rib to the costal margin. Posteriorly. i. The supra-scapular region or fossa. 2. The supra-spinous region or fossa. 3. The infra-spinous region or fossa. 4. The interscapular, lying between the scapula and the middle line. 5. The infra-scapular. In recording the locality of morbid phenomena, it is, however, often necessary, in order to ensure perfect accuracy of description, to state not only the region, but the particular rib or intercostal space where the physical signs are situated. 128 EXAMINATION OF THE RESPIRATORY SYSTEM. Methods. The methods employed in making a physical examination of the lungs are : Inspection, including mensuration; palpation; percussion; ausculta- tion ; succussion. INSPECTION. Much valuable information is obtained by a careful inspection of the chest, and, whenever practicable, this should always precede other methods of investigation. It is not unnecessary to lay stress on the importance of this mode of procedure, for many students are too apt to begin their examination with percussion and auscultation, and thereby omit to notice facts which are frequently of great aid in diagnosis. The patient should be placed in a good light, with the surface of the chest fully exposed to view, but with the back protected by some covering. If not too ill, he should either sit or stand, in an un- constrained position, near the fire. The observer should view the chest from the front, from the back, and from either side. He should first examine the condition of the skin as well as the nature of any eruption present ; then take note of any undue visibility or distension of the superficial vessels ; and finally direct his attention to the size, shape and movements of the thorax. Variations in the condition of the skin are described in Chapter V. ; those relating to the vessels in Chapter VII. Size and Shape. In surveying the chest with the eye, the follow- ing points require special consideration : Its length or height ; the relation between the antero-posterior and transverse diameters ; the size of the costal angle (that formed by the convergence of the rib cartilages at the xiphoid cartilage) ; the direction of the ribs ; the width of the intercostal spaces ; the arching of the sternum and spine ; the height of the shoulders ; and the projection of the scapulae. The circumferential shape is accurately determined by means of the cyrtometer, an instrument readily made by uniting two long pieces of soft metal, such as lead, by a leather hinge ; the hinge is placed over the spine, the metal arms are moulded to a given circumference of the chest-wall, and are then removed without alteration in their shape by means of the hinge. When laid on a sheet of paper, an accurate tracing of the contour of the chest at the required level may be obtained. The length of the diameter of the chest is determined by calipers, and thus the cyrtometer tracing may be checked and rendered more accurate. The Normal Chest. In new-born children the antero-posterior and transverse diameters are nearly equal, and a tracing of the circum- INSPECTION. 129 ference is almost a perfect circle. This shape is maintained till towards the end of the second year, after which it gradually passes into the elliptical shape of the adult chest, in which the transverse exceeds the an tero- posterior diameter, and the front of the chest is flattened instead of being rounded, as in infancy. As old age comes on, the chest tends to acquire the same rounded figure that it had at the beginning of life. In a well-formed chest, the right half is slightly larger than the left half, but otherwise the two sides are perfectly symmetrical ; the nipples are seated on the fourth ribs, or on the fourth interspaces, and the costal angle is nearly 90 in size. The supra- and infra- clavicular regions are nearly on the same level with the clavicles, and the outline of the ribs is usually only apparent in the lower part of the lateral regions. Deviations from a perfectly shaped chest are exceed- ingly common, and are compatible with the soundest health. The more marked departures from normal, either general or local, require a special description, and may be grouped as follows : I. Bilateral and symmetrical changes A. Natural deformities The alar chest. The flat chest. B. Accidental deformities Transverse constriction of the chest. The rickety chest. The pigeon chest. Enlargement of the chest. Diminution of the chest. II. Unilateral changes Enlargement. Diminution. III. Local changes Bulging. Depression. The Alar or Pterygoid Chest. This form is characterised by an undue obliquity of the ribs, in consequence of which the thorax is elongated vertically, the shoulders droop, and the angles of the scapulae project from the trunk like wings, hence the name "pterygoid." The antero-posterior diameter is shorter than normal, but the transverse contour of the chest is not materially altered in shape. The Flat Chest. In this variety there is flattening from before back, the cartilages of the true ribs are straight instead of curved, and the sternum may even be depressed below the level of the cartilages. The flat and the alar types of chest are natural deformities : they I 130 EXAMINATION OF THE RESPIRATORY SYSTEM. indicate deficient capacity for lung-tissue, and have been called phthinoid chests, because persons possessing such chests frequently exhibit tuber- cular tendencies. Transverse Constriction of the Chest, or Harrison's Sulcus. This is Fia. 71. Chest and Abdomen of Young Child the subject of Rickets. On the right side a row of beads with a groove in front of it is seen. The projection of the sternum and costal cartilages and the enlargement of the abdomen are also shown. a sulcus or depression which extends from the base of the xiphoid cartilage on either side, outwards and slightly downwards, and ceases at about the mid-axillary line. It is very common, is produced in childhood, and persists during later life. Frequently it accompanies Fia. 72. Tracing of Rickety Thorax of Boy aged 13 months. The bead (at a distance of 5 inches from the spine) and the grooves in front of and behind it are indicated. other deformities, such as the alar, flat, rickety, or pigeon chest, but it may exist alone. The Eickety Chest. A typical rickety thorax is characterised (i.) By a row of beads at the junction of ribs with the costal INSPECTION. I 3 I cartilages; collectively they form the "rickety rosary." These beads are most manifest about the fifth and sixth ribs ; they are generally symmetrical on the two sides ; they are usually distinct at the age of three months, and may increase in size up to the end of the second year, but are rarely found in children over five years of age, and no vestige of them remains in adult life. (2.) By the presence of two grooves, one in front of the beads, the other behind them. The former is a slight groove, and is usually more easily felt than seen (see Fig. 72); the latter is a broad shallow de- pression, which begins outside the nipples on each side, and extends obliquely from above downwards and outwards (see Fig. 71, also Fig. 4, p. 34). Thus the contour of the rickety chest tends to resemble that of a guitar (see Fig. 73). (3.) By increased convexity of the costal cartilages, which, with the FIG. 73. Tracing of a Rickety Thorax of Young Child, showing extreme deformity. sternum, form a broad rounded projection. This convexity, as well as the lateral grooves, is shown by a cyrtometer tracing taken a little below the level of the nipples. (4.) By the presence of Harrison's sulcus. The Pigeon Chest. The essential feature of the pigeon chest is that the outline of a horizontal section approximates to the triangle, the true ribs being straightened in front of their angles and the sternum carried forward. This type of thorax may be found without any beads or other signs of rickets. It occurs most commonly in children over two years of age who have suffered from some chronic respiratory trouble which interferes with the entrance of air; and, unlike the rickety, the pigeon chest often persists in adult life. Bilateral Enlargement of the Chest. This is nearly always the I 3 2 EXAMINATION OF THE RESPIRATORY SYSTEM. result of emphysema of the lungs. It may be called the inspiratory chest, but in a well-marked case the enlargement is much greater than can be produced with healthy lungs by the deepest inspiration. The antero-posterior diameter is increased, and may even exceed the trans- verse diameter. The sternum is projected forwards and the spine is arched backwards ; sometimes the former predominates, sometimes the latter. The projection backwards is constituted by the spine and the angles of the ribs ; immediately in front of it, and involving the scapular and infra-scapular regions, the chest- wall is flattened, or even slightly depressed. Hence a horizontal outline is not truly circular, and the term " barrel-shaped " scarcely gives an accurate idea of the emphysematous thorax. Sometimes the enlargement is limited to the upper part, but more commonly it involves the whole length of the chest ; in the latter case FIG. 74. Excessive Arching of Right Ribs iu a case of Syriugo-myelia. The increase in size <>f the right side of the chest has slowly developed during the last fifteen years, and has been accom- panied by overgrowth of the bones of the right limbs. the costal angle and the lower intercostal spaces are much wider than normal, and the cartilages of the false ribs are everted. Paralysis of the diaphragm is another occasional cause of general enlargement of the chest. A chest closely resembling that of emphysema sometimes occurs as a consequence of habitual stooping; also in association with marked stooping and permanent alteration in the shape of the spine spondy- litis deformans of the vertebrae and rib articulations due to ankylosis. Lengthening of the antero-posterior diameter of the chest may also result from caries of the vertebrae. Bilateral Diminution, in which the capacity of the thorax is less than that of a healthy one in a condition of deepest expiration, may result from (i) phthisis or (2) from paralysis of the intercostal muscles. INSPECTION. 133 Unilateral Enlargement. This is most commonly caused by the presence of serum or pus in the pleural cavity, but is also met with as a result of pneumothorax, of extensive hsemothorax, of a tumour affecting the greater part of one lung, or of compensatory hypertrophy in consequence of chronic disease of the other lung. Enlargement of the affected side is indicated by : elevation of the shoulder and ribs ; widening of the intercostal spaces and of one half of the costal angle, and deviation of the spine towards the opposite side. The side looks rounder than its fellow; there is a tendency, e.g., in pleural effusion, for the affected side to assume the semicircular form, and the vertebro-mammary diameter is increased in length. A peri- pheral measurement, however, may not be greater than that of the healthy side, which is also enlarged to a slight degree, for it must be FIG. 75. Tracing of Thorax in a Case of Fibroid Phthisis affecting the right lung. The figures indicate the distance in inches from the spine ; the dotted line indicates the probable normal shape of the right side. The greatest flattening was in the axilla. The cardiac impulse in this case was in the fourth right intercostal space a little outside the nipple line. remembered that any centrifugal pressure on one side will affect the chest as a whole, there being no unyielding partition between the two halves. The cyrtometer is of value in showing a localised rather than a general effusion. Unilateral Diminution. The common causes of retraction of one half of the chest are (i) pleurisy, the fluid having been absorbed and the lung not in a condition to expand; and (2) fibroid phthisis. Rarely an infiltrating cancer of the lung leads to retraction of the chest-wall. Occasionally, and especially in children, a rapid shrinking of one side follows collapse of the lung due to obstruction of the main bronchus. On viewing such a chest from before or behind, the affected side looks flat, the shoulder and ribs are depressed, and the nipple is on a EXAMINATION OF THE RESPIRATORY SYSTEM. lower level than its fellow ; the intercostal spaces are narrowed, and the inferior angle of the scapula is lower and nearer to the spine than that on the healthy side. The spine too is curved towards the healthy side. The distortion due to pleurisy with retraction is usually more marked than that produced by cirrhosis or collapse of lung. An apparent unilateral diminution may be produced by lateral curvature of the spine. In such a case, however, a flattening in front of the chest is ' FIG. 76. Retraction of Left Side of Chest following an Empyema wliich perforated the chest- wall below left scapula fifteen years ago. Now the left side is dull from apex to base ; the extent of dulness to the right is indicated by the dotted line. compensated for by a protuberance of the chest-wall behind or vice versa. Local Bulging of the chest-wall may be the result of one of the following conditions : Tumours, &c., of chest-wall ; a circumscribed pleural effusion; a pointing empyema; pericardial effusion; hyper- trophy and dilatation of the heart ; an aneurysm ; a hernia of the lung ; very rarely a large phthisical cavity or an intrathoracic growth. A bulging of the lower part of the chest-wall on the right side may be caused by an enlarged liver ; on the left side by an enlarged spleen. INSPECTION. 135 Local Shrinking. The most familiar example is the depression of the supra- or infra-clavicular region which follows shrinking of the FIG. 77. Shows scar of old abscess below left scapula, and ink line drawn over spinal column to show the curvature. FIG. 78. Tracing of Chest- Wall of man photographed in Figs. 76 and 77. apex of the lung in phthisis ; and in inspecting the chest- wall, particular attention should always be directed to these regions, a slight flattening 136 EXAMINATION OF THE RESPIRATORY SYSTEM. below the clavicle or a slight depression above it being significant signs of early phthisis. Rarely, flattening may be simulated by atrophy or congenital absence of part of the pectoral muscles. A cup-shaped depression, involving the lower part of the sternum and attached cartilages, and varying in height and depth, is of frequent It may follow some chronic form of obstruction to the occurrence. FIG. 79. Photograph of Boy the subject of Phthisis at the right apex, to show the hollows above and below the clavicle, the dropping of the right shoulder and the slight lowering of the right nipple as compared with the left. The shaded area indicates the extent of impaired resonance, the darkest shading indicating where impairment was greatest. entrance of air into the chest, such as adenoids, enlarged tonsils, hooping-cough, pericardial adhesion, or, according to Gee, a unilateral pleurisy. Sometimes it is produced by pressure, as in shoemakers. In many cases it is difficult to find a satisfactory explanation for this deformity. Movement. Changes in the respiratory movements of the chest- wall may be considered under the following headings : INSPECTION. 137 Increase of respiratory movement. Decrease of respiratory movement. Respiratory retraction of chest-wall. Alterations in rhythm and rate. Increase of Respiratory Movement affecting the whole chest is observed along with accelerated breathing in the pyrexial state, also in hysteria. Unilateral or local increase occurs when the opposite lung is incapacitated by reason of changes in its tissue, fluid in its pleural cavity, or obstruction of its bronchus. The movement of the diseased side being usually less than normal, renders the asymmetry of the two sides still more striking. In phthisis, when both apices are diseased, the respiratory move- ment of the lower part of the chest is exaggerated. Conversely, when air does not freely enter the lower parts of the lungs, the upper part of the chest shows increased movement. Decrease of Respiratory Movement occurs 1. When there is any hindrance to the entry of air into the respiratory passages. This may be caused by laryngeal disease ; by compression of the trachea or bronchi ; by imperfect expansion, col- lapse, or consolidation of the pulmonary vesicles, as from phthisis, pleural effusion, or any painful affection of the chest-wall. 2. When the air-cells are unduly and permanently distended, render- ing them incapable of much further enlargement by an inspiratory effort. This condition characterises emphysema, in which, as Jenner puts it, " the patient tries to take in his breath at the top of his breath." 3. When the muscles of respiration are weakened or paralysed. In hemiplegia feebleness of chest movement on the affected side may not be visible during easy breathing, but it usually becomes apparent when the patient draws a deep breath. It is to be observed that, associated with lessened extent of move- ment, there is usually delay in time. On watching, for example, the infra-clavicular regions in a case of phthisis at one apex, it may frequently be noticed that the diseased side not only expands to a less degree than the healthy side, but lags behind it, and takes a longer time to complete its excursion. Indeed, the alteration in relation to time may sometimes catch the eye before that in relation to space. In paralysis of the intercostal muscles, respiration is carried on by the diaphragm, and by the extraneous muscles which elevate without expanding the upper part of the chest. In paralysis of the diaphragm the epigastrium is hollowed, and is drawn in instead of being protruded during each inspiration, while during expiration it may be slightly 138 EXAMINATION OF THE RESPIRATORY SYSTEM. protruded instead of falling in, as in normal breathing. There is also overaction of the lower intercostals, so that in quite a remarkable way the margin of the thorax moves with respiration far more than in ordinary breathing. This may be well seen in some cases of alcoholic and diphtheritic paralysis. Respiratory Retraction of the Chest- Wall. Severe obstruction to the entrance of air into the respiratory passages may lead to more than mere abolition of respiratory movement ; there may be movement in a direction opposite to normal that is, certain parts of the chest-wall become drawn in with each inspiration. Thus, when the apex of the lung is solidified and excavated, the supra- and infra-clavicular regions may sink in during inspiration ; and in severe laryngeal obstruction, recession of the front and sides of the thorax below the level of the nipples is usually conspicuous (see Inspiratory Dyspnoea). Normally, FIG. 80. From a Fatal Case of Alcoholic Paralysis a few hours before death, showing the retrac- tion of the epigastrium which occurs in paralysis of the diaphragm. (/Jews.) there is indrawing of the intercostal spaces during inspiration. In pleurisy this feature is often absent : the part remains immobile, if not actually bulged. Rhythm and Rate. The average rate of breathing in the adult male is from sixteen to twenty per minute. It is somewhat quicker in females and in children. The new-born infant takes about forty- four respirations per minute, a child three years old about twenty-five per minute, one of fifteen about twenty. Both rhythm and rate are much more easily disturbed in the child than in the adult, and hence, relatively, are of less value. They are apt to be disturbed if the patient's attention be directed to the respira- tory act, hence it is better to determine the frequency of respiration by inspection than by palpation ; and it is convenient to watch the move- ments of the chest after counting the pulse, and while the finger still remains upon it. INSPECTION. 139 Dyspnoea is a term somewhat loosely applied to all instances of diffi- cult breathing, in which, as a rule, there is increased frequency of respiration. Orthopncea signifies very great difficulty in breathing, causing the patient to assume a sitting or standing posture. It is seen during the paroxysm of asthma, and is often present in the severer forms of heart disease. In investigating a case of disordered breathing, it is necessary to observe the frequency, the depth or shallowness, and any peculiarity in the rhythm of the respiratory act. Diminished Rapidity of Breathing may be met with in all severe affections of the brain or its membranes, as tumours, extensive haemorr- hage, and any variety of meningitis. As a rule, stupor or coma is present, and the respirations, although slower, are deeper than normal. Frequently, in such cases, the breathing tends to assume the Cheyne- Stokes type (see p. 141). In diabetic coma respiration is often slow, deep and sighing in character. Where slowness of breathing is accom- panied by obvious effort or discomfort to the patient, the term dyspnoea may correctly be given to it. This laboured respiration is especially marked in stenosis of the larynx or trachea, from tumour, inflamma- tion, compression, or other cause. Increased Rapidity of Breathing occurs 1. In pyrexial conditions. The degree of acceleration varies with the nature of the febrile disease, and to some extent in different indi- viduals. Nervous persons and children breathe more quickly than others suffering from the same degree of pyrexia. Any great increase in the frequency of respiration during the course of a fever should lead to a careful examination of the lungs and heart. 2. Whenever breathing is attended by pain. This is the case in disease of the pleura ; in inflammation of the diaphragm or of the peritoneum, especially that portion covering the diaphragm ; and in painful affections of the thoracic walls, such as pleurodynia, or injury to the ribs. In this class of cases the chest movement, although accelerated, is shallower than normal. 3. In diseases of the bronchial tubes, whether obstructed by secre- tion as in bronchitis, or narrowed as in asthma. 4. In all conditions which either diminish the breathing surface of the lungs or hinder their proper expansion. This includes all diseases of the lungs, pleuritic effusion, pneumothorax, mediastinal tumours, abdominal affections which raise or hinder the descent of the diaphragm, deformities of the thorax which lessen its capacity ? paralysis or spasm of the inspiratory muscles, as in tetanus or epilepsy. 5. In diseases of the heart or great vessels which lead to congestion 1 40 EXAMINATION OF THE RESPIRATORY SYSTEM. of the pulmonary circulation. Of these, mitral disease and a clot in the pulmonary artery may be specially mentioned. 6. In diseases of the nervous system. The slow laboured breathing of many brain affections has been already mentioned. In other cases great rapidity of breathing may be observed, as in the terminal period of many forms of meningitis. In hysteria, acceleration without any real difficulty in breathing may be observed ; but when there is laryngeal spasm, violent paroxysms of dyspnoea occur and respiratory distress is often extreme. 7. In abnormal conditions of the blood. Hurried respiration occurs in uraemia, and recurrent attacks of dyspnoea in cases of Bright's disease suggest the onset of unemic coma or convulsions. Accelerated breathing occurs sometimes in diabetic coma. Quickened breathing after slight exertion, often called shortness of breath, is a marked feature of anaemia, Inspiratory Dyspnoea signifies that there is a hindrance to the free ingress of air. It is a striking phenomenon in obstructive laryngeal disease, as from inflammation, diphtheria, or the paroxysm of whooping- cough, or of laryngismus stridulus, and occurs perhaps in its purest form in paralysis of the posterior crico-arytaenoid muscles (the dilators of the glottis). Sometimes, too, it is present in hydrothorax and in acute oedema of the lungs. Drs. Barlow and Lees have also described inspiratory dyspnoea with stridor in cases which they suggest are caused by driving in of the arytaeno-epiglottidian folds, owing to relaxation of tissue about these folds. The chief sign of this condition is recession of the more yielding portions of the thoracic parietes. This is best seen in the pliable chests of young children, and when the natural pliability is increased, as by rickets, a very slight obstacle to breathing, such as that produced by a mild attack of bronchitis, is often sufficient to induce recession of the chest-wall. With each inspiration the lower end of the sternum and the epigastrium, together with the lower lateral regions, are sucked in, and when the obstruction is in the larynx or upper portion of the trachea, the supra-sternal notch and the supra-clavicular regions are also depressed. At the same time the sternum is pushed forward, and, by watching such a case, the mode of production of the pigeon chest and of Harrison's sulcus is easily appreciated. With respect to rhythm, inspiration begins abruptly and is prolonged, while expira- tion is shorter than natural, but the pause relatively to the respiratory act is longer than natural. Expiratory Dyspnoea signifies that there is a hindrance to the free egress of air. This may be due either to a diminution in the ex- PALPATION. 1 4 I piratory power of the lungs or to a lesion obstructing in a certain way the upper air passages. The former condition holds in emphysema and asthma; the latter is illustrated by a movable tumour situated immediately below the glottis, which is forced against the glottis by the expiratory current, but pushed away from it by the inspiratory current of air. In emphysema, especially when complicated by bron- chitis, the diaphragm descends powerfully during inspiration, but thoracic movement is almost limited to elevation, there being little or no expansion, while expiration is slow, laboured, and prolonged. Cheyne-Stokes Breathing. This designation is given to a peculiar alteration of rhythm, in which respiration occurs in repeating cycles ; each cycle is composed of an ascending and a descending phase, and is succeeded by a period of complete cessation of respiration. The ascending phase begins with the shallowest possible inspiration, this is succeeded by a number of inspirations of gradually increasing depth till the acme is reached, when the descending phase commences, which FIG. 81. Tracing from a Case of Cheyne-Stokes Breathing. (Gibson.) comprises a number of respirations of gradually decreasing depth till breathing stops. The pause may last for from five to forty seconds, the cycle from fifteen to seventy-five seconds. During the pause the pupils often contract, the pulse becomes slower, and twitching move- ments of the limbs may be observed. This phenomenon is met with in meningitis, apoplexy, heart disease, uraemia, and in some acute diseases, as typhoid fever. Occasionally it passes away and the patient recovers for a time, or even completely, but, as a rule, the prognosis is unfavourable, and indeed the symptom usually appears only a short time before death. PALPATION. By palpation, or the application of the hand to the surface of the chest, the results obtained by inspection with regard to the shape, size and movements of the chest may be checked and amplified, and the following points may also be investigated : The nature and situation of any sensory disturbance ; the presence or absence of 142 EXAMINATION OF THE RESPIRATORY SYSTEM. fremitus, whether vocal, tussive, rhonchal, or friction ; of fluctuation and of pulsation. Movements. The palms of the hands or fingers must be applied evenly and on symmetrical portions of the chest-wall ; in this way the anterior, posterior and lateral movements may be examined. The movements of the upper part of the chest are best felt (i) by placing the hands on the surface below the clavicles, so that they diverge from one another with the tips of the fingers touching the outer part of the clavicles; (2) by standing behind the patient and placing the hands over the shoulders, so that the fingers lie on the infra-clavicular regions. To investigate the posterior movements the hands should be laid over the interscapular and scapular regions, while the lateral movements may be felt by grasping the sides of the chest from before or behind. The strength of the diaphragm, as well as the relative strength of its two halves, may be tested by applying the hands to the abdomen, so that the finger-tips cross the epigastrium. The conditions in which deficient or excessive movement occurs have been already enumerated under " Inspection," but attention may here be drawn to the importance of distinguishing between elevation and expansion of the thoracic parietes. To the eye the thorax of severe emphysema may appear to move sufiiciently well, but to the hand it is evident that, while it is raised as a whole, there is little or no filling out of its walls that is, no real expansion. Sensory Disturbance. Indications of disease affecting the parietes or contents of the thorax are frequently afforded by touching or press- ing the surface. Thus it may be found on touching or pinching the skin that certain parts of the surface are less sensitive or more sensi- tive than normal ; for example, diminution or loss of cutaneous sensi- bility over one half of the chest points to disease in the central nervous system a band of increased sensibility or hypersesthesia extending across and around the chest suggests irritation of the posterior roots of some of the spinal nerves. Localised spots of tenderness may be due to obvious lesions of the skin or bone, or to an affection of muscular tissue. Tender spots are present along the course of one or other of the intercostal nerves in neuralgia, as, for example, that associated with shingles ; they occur also in hysteria. A. more localised tenderness, situated in an intercostal space, especially in the axillary region, may be observed in early pleu- risy ; sometimes, too, during the stage of effusion, particularly if the fluid be purulent. In examining the chests of children suffering from pneumonia, it often happens that they shrink or cry during percussion or auscultation of the affected side ; the same thing may be observed to a less degree at the apex in phthisis. PALPATION. 143 FremitUS. Vocal Fremitus in Health. The vibrations of the vocal cords produced by the voice in speaking, singing, or screaming, are communicated to the chest-wall, where they are distinctly felt by the hand in the vast majority of healthy persons. The intensity of vocal fremitus depends on the following conditions : (i.) On the strength and pitch of the voice, loud and low-pitched voices yielding more marked fremitus than weak and high-pitched ones. Hence this sign is comparatively of less value in women and children than in men. (2.) On the size of the bronchus and its position relatively to the chest-wall. Yocal fremitus is therefore usually more intense on the right than the left side, the right bronchus being wider and nearer to the back than the left one. The difference between the two sides is best marked below the clavicle, below the scapula, and between the scapula and the spine, and it is in these regions that deviations from normal are best appreciated. (3.) On the distance of the examined spot from the larynx ; fremitus being strongest over the larynx, and more marked over the upper than the lower regions of the thorax. (4.) On the thickness of the chest- walls ; thus the vocal thrill is less perceptible over fat, muscular, or cedematous chests than over thin ones. Vocal Fremitus in Disease. In examining the vocal thrill, all patients should be asked to repeat the same sound, the words " ninety-nine," pronounced in as deep a tone as possible, being convenient ones for the purpose ; and in comparing the two halves of the chest, care should be taken to place the hands or the tips of the fingers on symmetrical spots. Under certain morbid conditions the vocal fremitus may be diminished, abolished, or increased. Vocal Fremitus is Diminished or Abolished (i.) When there is an effusion of liquid or gas in the pleural cavity. In pleurisy the presence of effusion may be determined and its extent mapped out by the alteration in vocal fremitus; above the effusion the fremitus is normal or increased, the increase being often marked in the infra-clavicular region ; more fluid is required to annul fremitus over the right than over the left infra-scapular region. The return of fremitus to a part is often the first indication that absorption of pleuritic exudation has commenced. (2.) In very dense consolidation of lung tissue, whether the result of inflammation or of new growth, unless the solid mass be intimately connected with a large open bronchus. (3.) Over lung tissue, either healthy or diseased, when its bronchial tubes are narrowed by secretion, external pressure, or other causes. 144 EXAMINATION OF THE RESPIRATORY SYSTEM. Thus the vocal thrill is sometimes feeble in chronic bronchitis and in asthma ; occasionally it is diminished, or even completely absent, over a pneumonic lobe or a phthisical apex. Vocal Fremitus is Increased (i.) In all forms of lung consolidation, provided the solidification is not too dense and is traversed by air tubes, the large ones at least being unobstructed. (2.) Over pulmonary cavities which are near the surface, have thick walls, and communicate with open bronchi. The question of vocarfremitus is largely one of comparison between the two sides of the chest, and it is a valuable aid to diagnosis between pleuritic effusion and pneumonia of the inferior lobe of the lung. It cannot, however, for reasons already indicated, be relied on alone. In a child the cry is a valuable means for testing fremitus, but it must be admitted that the thrill produced by voice or cry is often so mis- leading that the exploring syringe has to be used before a certain diagnosis can be made. The vibration produced by coughing tussive fremitus is less marked than that of the voice. Rhonchal or Bronchial Fremitus. Narrowing of the bronchial tubes produces sounds known as rhonchi (see p. 161). Their vibrations are often readily felt, and are particularly common in children. Friction Fremitus. The vibration produced by the rubbing together of inflamed pleural surfaces is sometimes transmitted to the chest- wall, where it may be felt as a vibratile rubbing or grating sensa- tion. It is commoner during the later than the earlier periods of pleurisy. Fluctuation. The sensation of ordinary fluctuation may occasion- ally be detected in cases of empyema which lead to bulging of the intercostal spaces. Fluctuation by percussion of the surface may also in rare cases be of diagnostic aid, as when a large pleural effusion is found in association with an intrathoracic tumour. Pulsation. Rarely in cases of left empyema pulsation of cardiac rhythm may be perceptible, and is usually situated somewhere between the left clavicle and the sixth rib ; the heart is always much displaced to the right. Aneurysm may be simulated by a pulsating empyema ; very rarely it may be necessary and justifiable to use a fine hypodermic syringe in order to make a diagnosis. PERCUSSION. Percussion is the art of striking the external surface of the body chiefly of the chest and abdomen in order to ascertain the physical condition of the underlying parts. To this end the nature of the PERCUSSION. 1 4 5 sound emitted by the percussed part, and the degree of resistance offered by it and felt by the observer, must both be carefully studied. There are two methods of percussion the immediate and the mediate. Immediate Percussion is performed by striking the chest with the palmar surface of the fingers, or with the tips of two or three brought together in the form of a hammer. It is sometimes used to obtain a rough preliminary notion of the limits of the intrathoracic organs, or of the presence and extent of pathological changes. Thus in effusion into one pleural cavity, the broad contrast between the sounds on the two sides may be easily and quickly demonstrated. Its main use, however, is in the percussion of certain bony prominences, as the clavicle or spine of the scapula, the bone being lightly tapped with one finger. Mediate Percussion may be performed either (i) by means of a small hammer with its striking end tipped with india-rubber, and a pleximeter consisting either of a thin piece of ivory or of one of the fingers ; or (2) by the fingers only. The latter is by far the most convenient and precise method, for not only does it satisfactorily discriminate between the finer gradations of sound, but also supplies information by the sense of touch with regard to degrees of resis- tance and elasticity. In its employment one finger of the left hand usually the first or second, or sometimes, as in percussing above the clavicles, the little finger must be placed with the palmar surface of the last two phalanges accurately and firmly applied to the part. This pleximeter finger is then struck with the semi flexed first or second finger of the right hand. Observe also (i.) that when comparing the sides of the chest or two parts of the same side, the pleximeter finger must be applied precisely in the same manner as regards pressure and direction, and over similar structures ; thus if placed vertically over one spot, it must be placed vertically over the compared spot ; rib must be compared with rib, intercostal space with intercostal space. (2.) The percussion stroke must spring from the wrist only ; thus the force of the blow may be regulated with nicety, and so made equal in any two compared spots. (3.) The blow should be delivered quite vertical to the surface percussed ; as a rule, it should be light, for if too strong the vibration of the neighbouring parts may confuse the true sound. This is especially the case in children, owing to their yielding thoracic walls. Theory Of Percussion. All sounds are divided into noises and musical sounds or tones. The vibrations that constitute the latter are repeated at regular intervals, are periodical, each has the same wave- length ; those of the former succeed one another irregularly, without K 146 EXAMINATION OF THE RESPIRATORY SYSTEM. periodicity, the consecutive vibrations are unlike. Between a pure musical sound and a harsh noise there is, however, no abrupt separa- tion ; many intermediate sounds bridge over the gap between them. Thus the sound emitted by the healthy chest is neither a noise nor a perfect musical note ; it possesses tone, but this is made up of a series of tones which do not completely harmonise ; the musical quality is therefore impaired. The various percussion sounds, normal and abnor- mal, might also be divided into tones and noises : the former possess the common properties of loudness, duration, pitch and tone ; in the latter, tone is absent and pitch for the most part is indistinguishable. But in clinical reports we are in the habit of describing percussion sounds not as "tones" or "noises," but as possessing varying degrees of resonance or of dulness. For resonance is the production of tone by rhythmical reflection, and since, as Dr. Gee points out, " the only tones which percussion knows (those of bone and cartilage excepted) are produced by resonance " (that is, by the rhythmical vibrations in the cavities formed by the lungs or by the alimentary canal), it has come about that " the words tone and resonance as applied to percus- sion sounds mean the same thing." The important points to be observed in percussion are 1. The degree of clearness of the tone or resonance. 2. Next to tone, pitch is the most important quality ; and of the two remaining qualities duration is of more practical value than loud- ness. Pitch and duration bear an inverse relation to one another ; thus the shorter the duration the higher the pitch. 3. The resistance felt. To become familiar with simple standards, and with the chief varia- tions in the sounds and the tactile sensations of percussion, the student may profitably go through the following exercise, practising on himself or on a fellow- student : (i.) Let him percuss the fleshy part of his own thigh and note its resistance and tonelessness ; this is the best example of dulness. (2.) Percuss his stomach, this gives clear, as distinct from muffled, resonance. Contrast the stomach with the colon as regards pitch. (3.) Percuss the right front, and observe the normal muffled quality of the thoracic resonance. In percussing downwards over the mammary region, observe the rise in pitch and the shortening of the duration of the note, also the increase in resistance on coming to the liver. (4.) Percuss out the cardiac dulness, carefully noting how much of the third and fourth spaces are impaired, reckoning from the left margin of the sternum outwards to the left. (5.) Fillip or percuss over the pomum Adami with the mouth open, PERCUSSION. 147 and note the pure tubular sound ; contrast its pitch and duration with those of the right mammary region. (6.) Percuss a fellow-student's back close to the spine, then pass out- wards, noting the increase of resistance when over the muscles. (7.) Percuss the clavicle or the back of the second phalanx; observe that the pitch of this osteal note is higher than the note over the trachea, and that the latter is higher than that over the thorax (8.) Percuss a lung in the post-mortem room, and observe the clear tubular character of the note. Limits of the Lung's. Each lung, somewhat conical in shape, has three surfaces, an outer convex, an inner concave, and a lower or basal FIG. 82. Relations of Thoracic Organs. (Weil and Luxchka.) a, b, edge of right, c, d, edge of left pleural sac ; e, f, margin of right, g, h, margin of left lung ; i, upper, and k, lower fissure of right lung ; I, fissure of left lung ; in, n, right ; n, o, lower ; p, o, left margin of heart. concave surface which rests upon the diaphragm ; and three borders, namely, a thin anterior or median, a thick posterior, and an inferior border, consisting of an outer convex part and a smaller inner concave part. In Health the apices rise anteriorly from i^ to 2 inches above the clavicles, but posteriorly they do not project above the limits of the bony thorax. Starting behind, the upper limit of each lung is marked by a line, curved with its convexity downwards from the spine of the seventh cervical vertebra to the outer edge of the trapezius, thence with a slight inward curve to the outer edge of the sterno-mastoid, and then downwards to end at the sterno-clavicular articulation. The anterior 148 EXAMINATION OF THE RESPIRATORY SYSTEM. margins lying deeply behind the sterno-clavicular articulations, descend to meet at the level of the second costal cartilages, they run parallel as far as the fourth cartilages, the right lung slightly overstepping the middle line, the left keeping near the left edge of the sternum ; at the fourth cartilage the left curves outward across the fourth space to the fifth cartilage, thence it inclines towards the sternum, nearly reaching the inner third of the sixth cartilage, where it joins the lower edge to form a tongue-shaped process of lung. The position of the lower margin of the right lung during quiet respiration is as follows : It reaches the sixth rib near the sternum, the seventh rib in the mammary line, the FIG. 83 Limits of Lower Margins of Lungs and of Pleural Sacs behind. (Weil and Luschka.) a, b, lower margins of lungs ; c, d, lower edges of pleural sacs ; e,f, g, fissures between lobes ; i, lower edge of liver. seventh space in the axillary line, the ninth rib in the scapular line, and is opposite the tenth or eleventh dorsal spine, near the vertebral column. The left lung reaches the eighth rib in the axillary line, and the same places behind as the right lung. The fissure between the upper and lower lobes begins opposite the third dorsal vertebra or the spine of the scapula ; it passes downwards and forwards over the scapula to reach the sixth space, and terminates usually at the anterior end of the seventh rib. On the right side a second or upper fissure leaves the lower one at the posterior axillary edge about 2^ inches above the angle of the scapula, and passes horizontally forwards at the level of the third space to reach the PERCUSSION. 1 49 anterior edge of the lung near the sternal end of the fourth cartilage. Behind, then, we percuss over the upper lobes down to the third ribs, and over the lower lobes below them. In front on the left side we percuss over the upper lobe only, on the right side mainly over the upper and middle lobes, and in the right axilla over the three lobes. In Disease. A difference in the height of the two lungs is so excep- tional in health that it almost always suggests disease ; shrinking of an apex is an early physical sign of phthisis ; undue size points to emphy- sema, when the apices may reach as high as z\ inches above the clavicles. The position of the lower and other boundaries of the lungs is also similarly affected by disease. The site of the middle lobe shows the importance, when there is chest disease, of percussing the right axilla, for in pneumonia it may be the only lobe affected. A knowledge, too, of the position of the fissure between the upper and lower lobes enables one to judge how far pneumonic consolidation is limited to one of them ; but it is to be observed : - (i.) That the anatomical limits of the affected lobe may be over- stepped without its fellow being necessarily involved (a lobe in the condition of red hepatisation being larger than a healthy one). (2.) That the upper portion of the lower, and the lower portion of the upper lobe, may be picked out and glued together by a typical croupous pneumonia. Respiratory Movement. In quiet breathing the position of the margins varies but little, but between a full inspiration and a full expiration the difference is considerable ; in the lateral regions as much as 3 to 4 inches. A diminution of the respiratory excursion to per- cussion is observed in emphysema, in commencing pleurisy, and in adhesion of the pleura. The Normal Pulmonary Sound, called " sub-tympanitic," is sui generis, and is only to be learnt by experience. It is short, rather low in pitch, and its tone is muffled. Its nature is complex, but it is mainly made up of the vibrations of the thoracic parietes and those of the air columns in the lungs. Dr. Bristowe considers that the sound is almost entirely due to the former ; other authors believe the latter to be the essential cause, and some refer the sound yielded by percussion to vibrations produced in the pulmonary vesicles and the smallest bronchioles, while others, as Dr. Gee, refer it to the vibrations of the air in the larger bronchial tubes, the sound being muffled by the intervening lung substance. The quality varies considerably in different individuals, and to a slight degree in different parts of the chest. Hence the importance of DRS. TASKIK TEOPATHIC PHYSICIANS 526-529 Auditorium Bldg, Ls Anf $l^i)Cal. EXAMINATION OF THE RESPIRATORY SYSTEM. comparing the percussion sounds emitted by corresponding points of the two sides of the same chest. The note is clearer in thin than in fat people ; it is prolonged, low in pitch, and its resonance increased over the elastic chest-walls of the child, whereas over the rigid chest of old age the resonance is dimi- nished and the pitch is raised. It is also less muffled that is, clearer and purer in the child than in the adult. Regional PePCUSSion. The sound is clearer in quiet than in forced breathing. It is clearer in front and at the sides than behind, clearer above than below the clavicles, clearer below than over the scapulae. It is shorter and higher pitched over the clavicles, ribs, sternum and scapular spines than over the soft parts. There is also a alight difference between the two apices, percussion close to the clavicle giving a less resonant note on the right than on the left side. The reverse obtains, however, below the second rib. Certain viscera encroaching on the lower pulmonary regions modify or lessen the extent of the normal sound. Thus on the right side the liver dulness is detected in the fifth space in front, the seventh in the axilla, and the eleventh posteriorly, and with hard percussion even a space higher, the lung resonance being muffled and higher in pitch in the fourth, sixth, and tenth spaces. On the left front the cardiac dulness is obtained in the fourth and fifth spaces, and it modifies the pulmonary sound to deep percussion in the third space. In the sixth space we get the tympanitic stomach note, which, about the margin of the thorax, passes into that of the colon. In the left lateral region the splenic dulness is encountered between the eighth and eleventh ribs. It is important to observe that a normal pulmonary sound does not necessarily exclude disease of the respiratory organs ; tlms it may accompany a severe bronchitis, a dry pleurisy, a circumscribed lesion of the lung deeply seated, or a disseminated tuberculosis in the early stage. Increased Resonance. 1. Hyper-Resonance or Tympanitic Re- sonance. The loudness and duration of the typical pulmonary sound is increased, and its pitch is usually lowered, while the degree of clear- ness varies. In emphysema the sound tends to become clearer, but it is rare to get Skodaic resonance. Its extent is often much increased ; thus resonance may be obtained down to the costal margin in front, and to the twelfth rib behind. A local emphysema around tubercular nodules at the apex may completely mask any dulness which would otherwise result from their presence. In pneumothorax the resonance becomes tympanitic, but in cases of extreme distension it is muffled or almost abolished ; when liquid is present as well as air, the position of the dulness will vary to some extent with that of the body. Occasionally the sound is amphoric. PERCUSSION. I 5 I 2. Tracheal Resonance, or the so-called tympanitisch of Skoda, hence sometimes called " Skodaic resonance." The note is short, the pitch raised, and the tone clear. It is heard (i.) Over relaxed lung. (a.) In the neighbourhood of extensive infiltration of the lung, or of effusion into the pleura or pericardium. Thus in pneumonia of the lower lobe, or when there is effusion into the pleural cavity, a clear and sometimes quite a tubular or even amphoric sound may be obtained over the apex on the same side. (J.) Over a portion of lung which is only partially infiltrated, solid or liquid being mingled with air-containing tissue. Examples : the first and third stages of a croupous pneumonia, especially in children ; oedema of the lung ; catarrhal pneumonia. (2.) Over air spaces, (a.) Smooth-walled cavities, which are either close to the surface or are separated from it by dense solid tissue. Examples : bronchiectasis ; tuberculosis. If the cavity communicates freely with a bronchus, the pitch rises when the mouth is open, falls when it is shut. (&.) When the bronchus or natural air spaces are directly connected with the surface by solid masses. Examples : pulmonary tumours ; pneumonia of the upper lobes. (3.) Sometimes when the diaphragm is pushed up in consequence of abdominal distension, the increased clearness of the pulmonary re- sonance being probably due to relaxation of the lung-tissue. In other cases, however, the pulmonary resonance becomes impaired. This may be sometimes observed on the left front when the heart is enlarged and also raised by ascites. Here probably a portion of the left lung has, through collapse, become completely airless. Diminished Resonance. The note is shorter, more muffled, and its pitch is usually raised. The various degrees in which the normal pulmonary resonance may be impaired or muffled are often spoken of as (i) slight impairment or slight dulness; (2) moderate impair- ment or moderate dulness ; (3) absolute dulness. Diminished resonance is met with under the following conditions, passing from without inwards : 1. In thickening of the superficial tissues, as from great muscular development, an excess of fat, or redematous swelling. 2. When the ribs are strongly arched, as in kyphosis. A familiar instance is offered by percussing the back of a well-marked emphyse- matous thorax ; the projecting angles of the ribs often give a mode- rately dull note, while the shallow depression over the infraspinous region furnishes increased or even tympanitic resonance. 3. When there are fluids or solid masses between the lung and the chest-wall. (a.) In hydrothorax or dropsy of the pleura the effusion is usually 152 EXAMINATION OF THE RESPIRATORY SYSTEM. bilateral ; hence there is dulness at both bases, which is commonly limited to the posterior aspect of the chest, but is not always at the same level on the two sides. (b.) In pleuritic effusion the dulness is usually unilateral. It may be limited to the lowest part of the chest behind, or extend over the whole of one side from apex to base. When a moderate quantity of fluid is present, the dulness is always higher posteriorly than anteriorly, and, if the patient has not been confined to bed, there may be impaired KlG. 84. Displacement of Mediastinum, Heart, and Liver in a case of Pleuritic Effusion on the left side. The shading indicates the extent of dulness to percussion. resonance over the greater part of the back, while the lateral and front parts of the chest are quite resonant. As a rule, when there is copious effusion, but not enough to completely fill the chest, the upper line of dulness is a curved one and its shape approximates to that of the letter S, the highest part of the curve being over the scapula and in the axilla, the lowest part near the spine. Behind, then, there is com- monly a band of resonance, more or less impaired, in the interscapular region, and over the adjacent portion of the scapula, including the suprascapular fossa. PERCUSSION. I 5 3 In front, whenever effusion is considerable in amount, the upper line of dulness crosses the middle line, descending from the neighbourhood of the apex of the lung to join the dulness yielded by the more or less displaced heart (see Fig. 84). After removal of the fluid, either by paracentesis or by absorption, the infra-axillary region is usually the last place where dulness may be obtained. It is important to remember that the extent and degree of dulness is not a measure of the quantity of fluid present ; a small empyema, for example, may coexist with extensive and absolute dulness ; or, on the other hand, resonance may be only slightly or moderately impaired when there is a considerable amount of effusion ; also, after removal of serum or pus, the dulness sometimes remains as great as ever. (c.) In pneumothorax when the pleural cavity is greatly distended. (d.) Over tumours or thick false membranes. 4. Rarely in extreme emphysema. 5. When the lung adjacent to the chest-wall is partially or com- pletely impermeable to air, as when collapsed from any cause, or when it is the seat of inflammatory or tubercular infiltrations, of hsemorr- hagic infarcts, of abscesses or new growths. The most common causes of impaired resonance are, solidification of lung tissue and liquid in the pleural cavity. Metallic Ring 1 or Amphoric Resonance. A high-pitched hollow metallic sound, whose fundamental tone is accompanied by overtones which give it a prolonged metallic echo, is met with over large super- ficial air spaces with smooth walls, either completely closed or com- municating with a bronchial tube by means of a small opening. Examples : pneumothorax ; large pulmonary cavities. Cracked-pot Sound (Bruit de pot fele). This may be roughly imitated by clasping the hands loosely together and striking the back of one of them upon the knee, the enclosed air being suddenly expelled through a small opening. It is produced in health sometimes over the yielding chest of a healthy screaming infant; in disease (i.) over a superficial cavity connected with a bronchus by a narrow opening, as at a phthisical apex or in pneumothorax. (2.) Sometimes over relaxed lung-tissue, as at the upper limit of a pleuritic effusion or over a par- tially consolidated lung. In children especially it is by no means uncommon to obtain a cracked-pot sound below the clavicle on the side of a pleural effusion. As a rule, a heavy percussion stroke is necessary to bring out the sound ; it should be delivered during expiration, after the patient has taken a full inspiration, and while his mouth is open. Resistance. The feeling of resistance varies inversely with the I 54 EXAMINATION OF THE RESPIRATORY SYSTEM. compressibility of the part percussed ; for example, it is much less over the yielding thorax of the child than over the rigid chest of advanced life. It is greater over solids and liquids than over air-containing tissues ; thus resistance is increased in solidification of the lung, still more so over a liquid pleural effusion, and most of all over an intra- thoracic tumour. It is diminished in moderate distension of the lung or pleura, as in pneumothorax and emphysema, but if the distension is extreme, there is an increase of resistance to percussion. The value of this sign is very great ; it enters largely, though often unconsciously, into our conception of the differences observed between the results of percussion over a healthy and a diseased part of the chest. AUSCULTATION. Auscultation is the act of listening to the sounds produced in the body by means of the application of the ear directly or indirectly to the body surface. It implies the voluntary effort of bringing the ear into some sort of contact with the surface, and includes everything heard whether the sounds be produced in the respiratory organs, in the heart and large vessels, in the alimentary canal, or in connection with any other organ. In auscultating the respiratory organs, we listen for the normal and abnormal sounds produced by breathing, speaking and coughing. In immediate auscultation the ear is applied directly to the chest, in mediate auscultation through the medium of the stethoscope. Both methods have their advantages. By listening directly to the chest, a rapid estimation can be made of the condition of a large portion of lung, and for the dorsal region this is the only method permissible when the patient is too feeble to be held up for more than a few seconds ; the method is also especially suitable for the examination of the back of a young child. The breath sounds are heard louder than with a stethoscope, but many delicate sounds may be lost. The accurate localisation of sounds, too, is difficult, and examination of the apices is obviously unsatisfactory. Rules to be Observed in Stethoscopic Examination. i. In all cases, when practicable, the stethoscope should be applied directly to the skin. 2. Great care should be taken that every part of the circumference of the conical end is in accurate contact with the skin ; this is best ensured by first grasping the lower end of the stethoscope with the finger and thumb (usually of the left hand), and holding it evenly, gently, but with sufficient firmness against the chest-wall, until the ear has been carefully adjusted to the other end. When this is accom- AUSCULTATION. I 5 5 plished, and the observer feels that the stethoscope is well balanced, and that both ends are accurately adjusted, the finger and thumb should be removed from the stethoscope, and used with the other fingers to separate the clothes (if the chest is not stripped), and so prevent rustling noises through contact with the stethoscope. 3. Each part of the chest front, axillae, back is to be carefully examined and compared. In comparing the two sides of the chest, the stethoscope should be placed on symmetrical spots. Auscultation of the Healthy Chest. It is most important that the student, before listening to diseased chests, should become perfectly familiar with the normal sounds heard on listening over the respiratory organs. They are those of respiration, of phonation (pro- duced at the rima glottidis by the vocal cords), and of articulation (produced only in the cavity of the mouth). The student should there- fore listen while the person breathes, while he speaks in his natural voice, and while he whispers (which gives the simple articulatory sound). And the following exercise may be usefully undertaken at home with the help of a fellow-student : Exercise 1. Apply the stethoscope to one side of the larynx, and observe the inspiratory and expiratory sound during quiet and during forced breathing, noting the length of each, and comparing it with that of each respiratory movement ; the interval between the sounds ; their pitch and peculiar hollow quality. 2. Apply the stethoscope or the ear directly to the left infra-scapular region, and carefully observe the marked difference between the breath sounds here and over the larynx. It is very desirable that the student should auscultate the places mentioned daily during the first week or two of his beginning the study of auscultation, and it is well to write out, and more than once, his own description of what he hears, and compare it with that of a fellow-student, and afterwards with the details given below. Too much stress cannot be laid on the importance of this exercise, for the breath sounds as heard over the windpipe and over the spongy lung-tissue form two great types under which all morbid breath sounds may be classed. Once mastered and retained as standards in the mind, there are but few future auscultatory troubles for the student. 3. Having studied these types, he should listen to other parts of the chest, and observe any minor modification of the breath sounds, espe- cially comparing the right with the left apex, and the sounds heard over the manubrium and in the inter-scapular region with those heard in other parts of the chest. 4. The normal sounds of vocalisation and articulation should now be studied by listening over the larynx and over the infra- scapular I 56 EXAMINATION OF THE RESPIRATORY SYSTEM. region on the left side (i) when the person speaks in his natural voice, and (2) when he whispers. Breath Sounds in Health. On auscultating the respiratory organs, two sounds or murmurs are heard, one accompanying the act of inspiration, the other that of expiration. A marked contrast exists between the breath sounds heard over the larynx and trachea, and those heard over the chest-wall covering the vesicular tissue of the lung. The Laryngeal or Tracheal sounds are blowing and harsh, begin and end abruptly, are of about the same duration, and are separated by a very short but distinct pause. The expiratory is softer than the inspiratory murmur, and during exaggerated breathing exceeds it in length. Each lasts as long as the inspiratory and expiratory move- ment that produces it. They may be imitated by breathing in and out through the lips, pushed forwards as in pronouncing " chur." On listening over the manubrium, and in the inter-scapular region at the level of the bifurcation of the trachea, weaker sounds, but sounds identical in quality, are heard in many persons ; hence this type of breathing is called "bronchial." The sounds heard over the healthy lung, called " vesicular," are softer and lower in pitch than the laryngeal, and lack its hollow reverberating character. There is no interval between them ; they form a continuous breezy murmur, like the sighing of wind through the leaves of a tree. The expiratory part of the murmur is feebler, lower in pitch, and one- fourth to one- fifth shorter than the inspiratory, and is often quite inaudible. The inspiratory begins and ends with the inspiratory move- ment of the chest ; the expiratory is only heard at the very commence- ment of the expiratory act. A careful distinction should be drawn between the sound of ordinary tranquil respiration and that of forced or deep breathing. The latter tends to lose the vesicular character, and often approximates to harsh breathing. Healthy Varieties. The qualities of the vesicular murmur vary slightly in different parts of the chest. Generally speaking, it is louder over the more resonant parts thus in front than behind, above than below. At the apices the vesicular quality is less marked, the pitch is higher, and the expiratory sound is longer than over the infra- scapular region; and these peculiarities are more noticeable at the right than at the left apex, the breath sound in the right infra- clavicular region being somewhat higher in pitch, and expiration longer than in the left infra-clavicular region, whereas the inspiratory murmur is nearly always louder at the left apex. In infancy the respiratory murmur is louder and less breezy, and is called "puerile ; " in old age it is feebler than in the adult. The expiratory sound is also longer at the two extremes of life. AUSCULTATION. I 5 / Mechanism. The laryngeal breath sounds are caused by fluid veins produced at the glottis by the passage of the air through the narrow space between the vocal cords into the wider spaces above and below. The vesicular murmur has a double mechanism ; it is mainly produced (and its expiratory portion probably entirely) at the rima glottidis, the laryngeal character being lost by conduction through the spongy texture of the lung. Its inspiratory portion is also made up of the innumerable minute murmurs evoked by the passage of air from the end of each bronchiole into its infundibulum. Auscultation Of the Voice in Health. The voice in health is made up of two elements, namely, phonation and articulation ; the former is produced by the vibrations of the vocal cords, the latter in the mouth by the movements of the tongue, lips, and palate. Phonation. On listening with a stethoscope to the larynx of a healthy person during the act of singing or speaking aloud, the musical part of the voice is heard with almost painful intensity ; a similar but less distinct voice sound is heard over the first piece of the sternum or behind between the scapular spines ; but over the rest of the chest- wall which covers healthy lung-tissue a mere humming or buzzing is audible. Articulation. The articulate voice, best heard when the patient whispers, is distinct on listening over the larynx ; also often over the situation of the chief bronchi, although there it is usually difficult to identify the words whispered. But over the chief part of the pul- monary surface articulation is completely lost. Auscultation in Disease. We meet with (i) modifications of the normal breath sounds; (2) modifications of the normal sounds of phonation and of articulation ; (3) adventitious sounds. Most of the phenomena enumerated below may be studied by the examination of a case of pleuritic effusion and a case of chronic phthisis. In the former, let the student note the feebleness of the breath sounds over the effusion, with their loudness over the opposite lung. In the latter, let him compare the hollow bronchial breath sound with the normal laryngeal breathing. In both let him examine carefully for broncho- phony and pectoriloquy, and for adventitious sounds. Modifications of the Vesicular Type. 1. Weakening or Sup- pression of the Vesicular Murmur. This may occur: (i.) From feebleness of the movements of the thorax, as on the side of a pleuritic stitch. (2.) From obstruction of the air passages, either (a) from within, as in stricture of the trachea, in bronchitis, and sometimes in cases of pulmonary consolidation, owing to blocking of the bronchi with secretion ; or (&) from without, as when a bronchus is compressed by an aneurysm or a new growth. (3.) When there are fluids or solids between the lung and chest- wall; thus in pleuritic effusion, or when I 5 8 EXAMINATION OF THE RESPIRATORY SYSTEM. there are massive adhesions, also sometimes in pneumo-thorax, when no open communication exists between the lung and pleural cavity. 2. Harsh, Exaggerated, or Puerile Breathing. This type of breath- ing is heard over the chest of a healthy child. Both inspiration and expiration are louder and of harsher quality than in the adult. When the result of thoracic disease, sometimes inspiration, sometimes expira- tion, is the harsher of the two, and expiration may be prolonged slightly, but there is no lengthening of the pause. The lengthening of expiration in harsh breathing is usually more apparent than real that is, the ordinary expiratory sound of normal respiration becomes louder, and is therefore more manifest. Harsh breathing may be heard over healthy lung when another portion of the lung or when its fellow is compressed, solidified, or otherwise disabled ; thus, in a case of pleuritic effusion, harsh breath sounds are usually audible over the unaffected side. It is also very common over minor or moderate degrees of consolidation, as at the apex in phthisis. 3. Prolongation of Expiration. This is a feature of bronchial breathing, but sometimes it is the chief or the only modification, as when the elasticity of the lung is diminished in emphysema, or when there is an obstruction to the exit of air, as occurs in bronchitis. It is often one of the first indications of a commencing consolidation at the apex. 4. Jerky or Wavy Breathing, in which inspiration is interrupted two or three times, is heard over the whole lung: (i) sometimes in hysteria; (2) in painful affections of the respiratory muscles, causing them to act irregularly. Locally it is of more importance, as when met with at the apex, when inspiration has sometimes a " cogged-wheel rhythm," a sign often of incipient phthisis. It is thought to be produced by obstructions in the finer bronchioles, and is probably of the nature of a rhonchus. 5. Deferred Inspiration. Inspiration is said to be deferred when the inspiratory movement of the chest is felt before any sound is heard. This occurs in emphysema and in laryngeal obstruction. 6. Broncho- Vesicular or Transitional Breathing. Sometimes it is very difficult to say whether the breath sounds belong to the vesicular or to the bronchial type ; for example, at a phthisical apex, and in some cases of emphysema, the breath sounds are harsh, divided, and expiration is as long as inspiration ; they thus approach the bronchial type, but the peculiar " ch " quality of true glottic breathing is either absent or doubtful. Skoda classed such sounds as " indeterminate," but it is better for the student, when in doubt as to their nature, to describe them as accurately as he can the quality, the pause, and the relative AUSCULTATION. I 5 9 length of the inspiratory and expiratory portions, rather than to merely give them a definite name. Modifications of the Normal Laryng-eal OP "Bronchial" Type. Bronchial breathing, similar to healthy laryngeal or tracheal breathing, is heard over the chest, where normally the vesicular is audible, when the lung-tissue has ceased to contain air, being consoli- dated as in pneumonia, collapsed or compressed as in cases of pleuritic effusion. In these cases the bronchial tubes are surrounded by solid tissue, and hence the glottic sounds are well conducted, while any sounds which originate in the parenchyma are suppressed. According to the character of the sounds heard, bronchial breathing is described as tubular, blowing, or cavernous. Tubular most nearly approaches to the normal breathing heard over the larynx. It is, however, higher in pitch, it conveys the sensation of air being drawn into and puffed out of a narrow metallic tubular space, which appears to be immediately beneath the part examined. It is heard to perfection over a hepatised lobe in pneumonia, and its metallic quality is highly developed. In blowing breathing there is less concentration, the sounds appear to be produced at a distance and in a wider tube. In cavernous breathing the ear gets the impression of a still larger space, the inspiratory and expiratory sounds are both of a hollow whiffing character, and are lower pitched, especially the expira- tory, than in tubular breathing. Mostly heard over cavities in the lung, it may also be produced when there is solid tissue between the root of the lung and the surface. These modifications of the normal glottic breath sounds are produced by varying degrees of solidification or excavation of lung-tissue. The precise amount of change in the lung structure cannot be determined by these variations. The important information derived from the pre- sence of the bronchial type, whether of tubular, blowing, or cavernous quality, is that the lung parenchyma no longer admits air. The bron- chial breath sound is recognised, it cannot be too often repeated, by its peculiar quality, and not because it is louder than the vesicular mur- mur ; indeed, perfect tubular breathing of extreme weakness may often be distinguished over an effusion into the pleural cavity. Auscultation of the Voice in Disease. Vocal Resonance may be defined to be the voice as it is heard on applying the ear, directly or indirectly, by means of a stethoscope, to the surface of the chest. Weakness or Absence of Vocal Resonance is met with in cases of obstruction or compression of the bronchial tubes, or when fluid or morbid tissue intervenes between the lung and the thoracic wall ; thus it is found in pleuritic effusion, in pneumothorax, and in cases where the pleural cavity is obliterated by dense false membranes. I 60 EXAMINATION OF THE RESPIRATORY SYSTEM. Intensification of the Vocal Resonance or Bronchophony. It is impossible to distinguish between a simple increase of the vocal reso- nance and brouchophony ; hence they are here classed together, and bronchophony is defined as an increased distinctness or clearness of vocal resonance at the surface of the chest. The musical tones formed at the glottis reach the ear not as a vague humming, but with distinct- ness and clearness, and in these respects are similar to the sounds heard over the windpipe in the neck. Bronchophony, as already mentioned, may often be heard over the bifurcation of the bronchi, and sometimes beneath the right clavicle, especially in women and children. When present at other parts of the chest, it is pathological and has a similar significance, speaking broadly, to bronchial breathing. Thus it occurs (i) in consolidation of the lung, as from collapse, pneumonia, phthisis, haemorrhagic infarct and tumours ; (2) over excavations in the lung or dilatations of the bronchi, provided that the tissue around such cavities is solid ; (3) sometimes in cases of extreme emphysema. But it is to be noted that if in cases of consolidation or of excavation of the lung, the bronchial channel be obstructed between the larynx and the conducting part of the lung, as from a plug of secretion, the production of bronchophony is interfered with, and the voice sound is enfeebled or annulled. Pectoriloquy is a term best restricted to the transmission of the arti- culate utterance of a patient directly to the ear or along the stethoscope of the auscultator. It refers to articulation, bronchophony to phona- tion. A pure articulatory sound is best obtained by getting the patient to whisper. Then if each syllable sounds distinctly, and as if produced in the tube of the stethoscope, pectoriloquy is said to be present. Pec- toriloquy is most frequently met with over superficial cavities, which freely communicate with bronchial tubes. Like bronchophony, it is sometimes present over solid portions of lung, and is therefore not a cer- tain sign of a cavity. This physical sign is also often to be recognised over a pleuritic effusion, and perhaps more frequently when the effu- sion is serous than when it is purulent. JEgophony is a peculiar modification of bronchophony, in which the voice resembles the squeaking of a Punch and Judy exhibitor or the bleating of a goat. The voice is higher pitched and shriller than that coming from the patient's mouth, and has often a tremulous or jerky character. It is best heard in cases of moderate pleural effusion on applying the ear near the angle of the scapula ; but true segophony is not a common phenomenon. The name, however, is often given to ordinary bronchophony possessing a slightly nasal twang ; this might be termed nasal bronchophony. Resonance of the cough or cry may be of value in the absence of AUSCULTATION. 1 6 1 other signs. Thus in auscultating the chest of a restless screaming infant, when the breath sounds, for obvious reasons, are difficult to appreciate, a ringing bronchophonic cry is suggestive of hepatisation of the underlying lobe. Adventitious Sounds. In most diseases of the lungs and pleurae, at some part of their course, the respiratory murmur is accompanied by certain adventitious sounds, which are known as rhonchi, rales and friction sounds. These may be grouped as follows : Rhonchi or dry sounds. 1. Sonorous or low-pitched rhonchi. 2. Sibilant or high-pitched rhonchi. Rales or moist sounds. 1. Crepitation. 2. Bubbling riles. i Small bubbling or subcrepitant rales, (i.) Simple. -J Medium bubbling or submucous rales. ( Large bubbling or mucous rales. (2.) Metallic or con- sonating. Small metallic or crackling rales. ) Called also " dry Medium > and moist Large ,, ) crackling." " Laennec's dry crepitant rales with large bubbles." Pleuritic friction. Rhonchi, sometimes called dry rales, are musical continuous sounds, which accompany inspiration and expiration. They may completely obscure both breath sounds, and may be audible away from the patient. They are classed as sonorous and sibilant. The former are low-pitched, cooing or snoring sounds ; the latter are high-pitched, and of whistling or hissing character. They are produced by the passage of air through a bronchial tube which is narrowed at some point, the constriction being due (i) usually to the presence of viscid mucus; (2) to swelling of the bronchial mucous membrane; or (3) to contraction or compres- sion of a bronchial tube, the first occurring in asthma, the last some- times in aortic aneurysm. Crepitation. This term is applied to very fine sharp moist sounds heard during inspiration, usually towards its termination, but not during expiration. They may be imitated by rubbing a lock of hair between the fingers close to the ear, or by rubbing the moistened thumb against the forefinger. Crepitations are uniform in size, and are unaffected by coughing. They are typically met with in the first stage of pneumonia ; also over redematous or collapsed lung (see "Collapse rale," p. 164). The last condition indicates their nature, namely, that they are due to the sudden expansion of alveolar walls glued together by viscid secretion. L I 62 EXAMINATION OF THE RESPIRATORY SYSTEM. This rale has been called " vesicular," and it gives us the important information that air can still enter the air cells. Sometimes the bursting of innumerable small bubbles produces sounds identical with those of true crepitation. Simple Bubbling, or mucous rales, of various size, are produced in bronchial tubes or in cavities in the lung, by the passage of air through mucus, serum, blood, or other liquid. They are irregular in size, and are modified by coughing and by expectoration, differing in these respects from the crepitant rales as just described. Their size depends on the quantity and quality of the fluid, and to some extent on the capacity of the space in which they originate, although it must be borne in mind that small bubbles may be formed in large tubes. The smallest sized bubbling, sometimes called the subcrepitant rale, occurs in capillary bronchitis; the largest is produced in the trachea and bronchi, and indicates an accumulation of fluid owing to failure of vital powers; hence it is popularly known as the "death rattle." It is especially noticeable when death takes place during coma, as in apoplexy, and the last stage of many pulmonary affections. Metallic Biles. These are bubbling rales of various sizes, which have a peculiar metallic character. They are sometimes called " con- sonating," owing to their clearness and resonance, and the term may be taken to include the "dry and moist crackling " spoken of by some writers, and which are so frequently met with at a phthisical apex. Besides indicating the presence of liquid in bronchial tubes or in pulmonary cavities, they also suggest that the latter are surrounded by solid tissue. A variety called " clicking," from the character of the sound, is produced during inspiration only, and is common at the apex in phthisis. Dry Crepitant Rale with Large Bubbles. This term was given by Laennec to a sound which conveys "the sensation of air distending dry and very unequally dilated pulmonary vesicles." It is a rare phenomenon, and is practically limited to extreme cases of emphysema. It resembles a high-pitched bubbling sound, is persistent, accompanies inspiration, and is best heard in the infra-axillary regions. Dr. Steell has drawn attention to a crackling sound closely related to the above rale, and " audible in the neighbourhood of the pulmonary artery over the border of the left lung. Usually it is heard only during inspiration, but it may be present to some degree during expi- ration, and may temporarily assume cardiac rhythm." He thinks that the sound is produced by an emphysematous state of the edge of the left lung, and that its " intermittence and variableness may be ex- plained by varying conditions of lung compression by the heart," the heart in these cases being usually enlarged. AUSCULTATION. 163 Friction Sounds. In health the gliding of one pleural surface over the other is silently performed, but any unevenness of the opposed surfaces, or the deposit of morbid material between them, is liable to produce friction sounds. These vary from the slightest grazing sound to loud creaking or crackling. They are commonly restricted to a small area of the lower half of the chest in the lateral region, or near the lower angle of the scapula. They may accompany both inspiration and expiration, but as a rule they are present only towards the end of inspiration. They are less continuous than rales, often occur in a series of jerks, are uninfluenced by coughing, and are strengthened by a deep inspiration, and sometimes by pressure of the stethoscope on the intercostal space. They are usually associated with a stitch-like pain, with enfeebled breath sounds, and with diminished movement of the affected side. The friction sound disappears before the advancing fluid, but is again audible, and often with greater intensity, during its subsidence. The loudness of the sound bears no relation to the amount or condition of the exuded lymph. Besides lymph, the sound may be caused by the presence of miliary tubercles, of false membranes, and even by increased vascularity and dryness of the pleural surfaces. Friction sounds are occasionally produced by the movements of the heart, and are then audible when the patient holds his breath. Ex- tensive friction sound over the right side may occasionally be produced by inflammatory products between the liver and diaphragm (perihepa- titis), and more rarely also on the left side from perisplenitis. Amphoric Echo. This is a peculiar metallic sound, similar to that produced by blowing into an empty bottle or jug. For its production a large air-containing cavity is necessary, but the presence of liquid is not essential. It may accompany the breath sounds, the voice, cough and rales, or even the cardiac sounds. It occurs in cases of large cavities in the lungs, and in pneumothorax ; in the latter case the amphoric quality is given to the bronchial breath sounds by their passage from the collapsed lung through the pleural air cavity, which may be quite closed. This echo too sometimes accompanies the car- diac sounds, and in such a case may be generated by a gas-distended stomach. Metallic Tinkling is a clear, ringing, highly metallic single sound, which is best imitated by letting drops of water fall on the surface of a little water in a decanter. It occurs along with or alternates with amphoric echo, and its explanation and associations are the same. The Bell Sound. If the stethoscope be applied over a pneumo- thorax or other large air-containing cavity while the side is percussed by two coins, a sound is produced which closely resembles that heard at a distance from an anvil struck with a hammer. When this bell or I 64 EXAMINATION OF THE RESPIRATORY SYSTEM. anvil-like sound is present, the limits of the air-containing cavity may sometimes be accurately mapped out by percussion of the coins in different places while the stethoscope is stationary ; for the bell sound is lost when the coins are percussed outside the boundaries of the air space. Fallacious Auscultatory Sounds. i. A dry rubbing sound, confined usually to inspiration, is occasionally heard in the supraspinous fossa near the shoulder-joint, where it doubtless originates. 2. A rumbling sound is not uncommon. It is produced by muscular contraction, and is usually continuous. 3. Conduction of rales across the spine. This may be observed in pneumonia of the lower lobe, the crepitations being heard on the pos- terior aspect of the unaffected side. 4. Collapse Rdle. Fine crepitant sounds are sometimes heard at the base of the lung posteriorly, when a person with healthy lungs sits up in bed and takes a deep inspiration, but they readily disappear after a few inspirations. It is necessary for the young student to be on his guard against confusing this collapse rale at the bases of a bed-ridden patient with crepitation on the one hand and friction on the other. Occasionally, too, this rale occurs at the apex in cases of typhoid fever, and, if not recognised as a " collapse rale," might lead the observer to regard the case as one of tuberculosis. Succussion The Hippoeratic Suecussion Sound. A distinct splashing sound may be produced in a large cavity containing air and liquid by giving the patient a smart shake, while the ear is applied to the surface of the trunk ; sometimes the succussion sound is loud enough to be audible to attentive bystanders, or even to the patient himself. As a rule, the sign indicates the existence of a hydro-pneumo- thorax. If heard on the left side of the chest, the possibility of the sound being generated by a dilated stomach must be considered. A feeble succussion sound is sometimes audible over a cavity in the lung during the act of coughing, the cough propelling air into the cavity and thus setting up gurgling or splashing rales, and in cases where a cavity furnishes no characteristic bronchial breath sound, a succussion sound or succussion rales may be of value in diagnosis. THE SPUTUM. In health the expectoration is very small in amount ; it consists of a colourless transparent sticky fluid. In various diseased conditions the amount is greatly increased and the character altered. Sputum may be divided into the following varieties : 1. Mucous. The expectoration is clear, viscid, tenacious and trans- THE SPUTUM. 165 parent This is the variety met with in the early stage of bronchitis. It consists chiefly of mucus and a few cells. Mucous expectoration is generally followed by a more opaque variety at a later stage of the illness. 2. Purulent. The expectoration consists chiefly of pus, and is green- ish-yellow in colour. This variety is met with in cases of empyema bursting into the lung, in pulmonary abscess and in tubercular cavities. 3. Muco-pumlent. This is the most common variety. Its characters are intermediate between mucous and purulent expectoration ; it is really a mixture of transparent mucous and greenish-opaque purulent sputum. Mucous, muco-purulent and purulent sputa are met with in the successive stages of bronchitis ; mucous during the acute stage, muco- purulent and purulent in the advanced stages, or at the commencement of convalescence. 4. Serous. The expectoration is a thin frothy-looking fluid, which consists principally of serum. This variety occurs in oedema of the lungs, and sometimes during or after the operation of paracentesis of the chest. In the latter case the sero-albuminous expectoration may be very copious, and the associated cough very troublesome. 5. Sanguineous. Blood may be expectorated in the form of streaks or clots, or it may be intimately mixed with the sputum. When sudden and profuse haemorrhage into the air passages takes place, large quan- tities of pure blood may be coughed up. The Quantity of sputum is sometimes very great. Thus in bronchi- ectasis large quantities may be brought up at one time. Pus passing suddenly into the bronchial tubes gives rise to profuse purulent expec- toration, as in cases of empyema bursting into the lung, or in cases of pulmonary abscess, tubercular cavity, abscess of the liver or medi- astinum discharging their contents into the bronchial tubes. The Odour. In gangrene of the lung the expectoration and breath have a peculiar, intensely pungent and foetid smell. The sputum is usually very foetid in bronchiectasis, bronchorrhcea, and often when derived from pulmonary cavities or abscesses. Casts. In plastic bronchitis, and occasionally in acute croupous pneumonia, fibrinous casts of the small bronchial tubes are found in the sputum. In diphtheria fibrinous shreds or pieces of membrane are sometimes expectorated. In hydatid of the lung and in hydatid of the liver, which has burst into the bronchial tubes, daughter cysts, not unlike empty gooseberry skins, are sometimes coughed up, while scolices and hydatid booklets may be found in the sputum on microscopical examination. 1 66 EXAMINATION OF THE RESPIRATORY SYSTEM. Persons who live in large towns, where the atmosphere is loaded with suspended carbon particles, frequently expectorate a small amount of black sputum in the early morning. In the form of pneumo- noconiosis, known as anthracosis (coal-miner's phthisis), the sputum is dark brown or black. Under the microscope free carbon particles are detected. These particles are not affected by acids or alkalies. The leucocytes and alveolar cells in the sputum contain carbon pigment granules. The sputum in siderosis is brownish-black, and the cells present (leucocytes and alveolar epithelium) contain pigment granules, which give the reaction for iron blue coloration with hydrochloric acid and ferrocyanide of potassium black coloration with sulphide of ammonia. FIG. 85. Fibrinous Coagula from a case of Plastic Bronchitis (). (v. Jaksch.) The sputum, in cases of silicosis, may contain a large amount of silicious or calcareous matter. The expectoration of blood haemoptysis is a point of great im- portance, and its primary source must be clearly made out if possible. The following are the chief causes of haemoptysis : 1. Tubercular lung disease. In these cases haemorrhage is frequently due to the rupture of a small aneurysm of a branch of the pulmonary artery ; at other times to erosion of a small arterial branch. 2. Haemoptysis often occurs in heart disease, especially in mitral cases. It may also be due to haemorrhagic infarcts in the lungs. 3. Aneurysm of the aorta rupturing into the lung. THE SPUTUM. 167 4. Ulcerative affections of the larynx, trachea, or bronchi. 5. In pneumonia the expectoration at first may be scanty and colour- less, but it soon assumes a rusty colour, which is characteristic of the disease. At this stage the sputum is almost airless and very tenacious, and adheres firmly to the vessel. The colour is due to dissolved hemo- globin, and to the presence of a small number of red corpuscles. Sometimes the sputum is grass green, probably owing to the conversion of haemoglobin into bilirubin, and afterwards into biliverdin. At a later stage the expectoration increases in amount ; it becomes more watery and yellowish or greenish in colour. 6. Haemoptysis sometimes occurs in blood diseases, as purpura, or in diseases in which there is a marked haemorrhagic tendency, such as haemorrhagic small-pox. 7. In young healthy persons, haemoptysis occasionally occurs, and the patient may recover completely without the appearance of any subsequent symptoms of lung disease. 8. Since the days of Hippocrates, a relation has been supposed to exist between haemoptysis and menstruation, and a few rare cases have been recorded on good authority of vicarious menstruation in this form. 9. Sir Andrew Clark has called attention to a form of recurring haemoptysis in arthritic subjects. The patients are over fifty years of age ; the disease is not followed by pulmonary changes, and rarely ends fatally. 10. Blood from the nose may trickle down the throat and be ex- pectorated, and so simulate haemoptysis. Also blood in the expectora- tion is sometimes due to haemorrhage from the gums. In chronic pneumonia with destruction of lung-tissue, and in certain cases of aneurysm, the intimate admixture of blood and sputum gives rise to a dark expectoration resembling prune juice. Sometimes there is considerable difficulty in deciding whether blood, especially if large in amount, is coughed up or vomited, i.e., whether the case is one of haemoptysis or hsematemesis. Blood from the lungs is usually brighter red and more frothy than that from the stomach. The latter is often mixed up with partially digested food, and is usually acid in reaction, whereas expectorated blood is alkaline. But an exa- mination of the chest and abdomen, as well as a careful consideration of the history and other aspects of the case, are often necessary before a diagnosis can be established. Tubercle Bacilli. The examination of the sputum for the tubercle bacillus in cases of suspected tubercular disease is of the greatest importance in practical medicine. By the presence of these bacilli in the sputum, the diagnosis of tubercular disease can be definitely settled in an early stage of the disease, when the physical signs and symptoms I 68 EXAMINATION OF THE RESPIRATORY SYSTEM. would not justify a positive diagnosis i.e., at a time when the pros- pects of a cure by treatment are the greatest. Hence the student should become thoroughly well acquainted with the method of examina- tion for tubercle bacilli. Frankel-Gabbett's is one of the most convenient and reliable methods. By means of a pair of forceps, a small piece of sputum is taken from a vessel containing the expectoration and placed on a cover- glass, which has previously been well cleaned. It is best to take a bit of the thickest and most purulent portion of the sputum. The sputum is spread over the cover-glass, and then a second well-cleaned cover- glass is placed on the first. The two are rubbed together so as to obtain a thin uniform layer of sputum, spread out between the cover- glasses. They are then separated, and a thin layer of sputum is thus obtained on each cover-glass. The cover- glasses are then dried over the flame of a spirit-lamp or Bunsen's burner, the surface on which the sputum is spread being kept upwards. When quite dry they are passed rapidly three times through the flame of a Bunsen's burner or spirit-lamp. They are then floated on a magenta solution in a watch- glass or capsule, the side on which the sputum is fixed being in contact with the fluid. The strength of the solution is as follows : Magenta ........ i gramme. Absolute alcohol . . . . . .10 cc. 5 per cent, solution of carbolic acid . . 90 cc. The solution is warmed until vapour is given off freely, but it must not be heated to the boiling-point. The cover-glasses should remain in this solution for about four minutes, and should then be washed in water for a second or two. They are then floated (the surface on which the sputum is spread being downwards) in a solution of methyl-blue and sulphuric acid, or a little of this solution may be dropped on to the sputum-covered surface of the glass slip. The methyl-blue and acid solution has the following composition : Methyl-blue 2 grammes. 25 per cent, solution of sulphuric acid . 100 cc. After staining for one minute, the blue solution is washed away thoroughly with water ; the cover-glass is dried and mounted in Canada balsam. Precautions. i. It is desirable not to place too large a piece of sputum between the cover-glasses ; otherwise almost the whole of the sputum is squeezed out when the cover-glasses are rubbed together. 2. In drying the cover- glasses, it is well to hold them in the fingers, for if held by forceps there is a danger of the specimens getting too hot and becoming charred. THE SPUTUM. 169 3. When the cover-glasses are placed on the carbol-magenta solution, it is well to see that they either float perfectly or sink to the bottom. If floating with half the cover-glass above the surface and half below, a line of deep red stain is formed on the cover-glass, which is difficult to remove. 4. After staining in the methyl- blue solution, the cover-glasses should be thoroughly well washed in water ; but before mounting in Canada balsam they must be perfectly dry. 5. In mounting the specimen, it is well to avoid using too much Canada balsam, for an excess of balsam surrounds the cover-glass as a raised rim, and is liable to be smeared on the objective of the micro- scope. Xylol balsam is very useful for mounting the specimen. This method of staining is exceedingly convenient, and can be carried out in a few minutes. In order to avoid any risk of self-infection from the tubercular sputum, the fingers should be thoroughly cleansed as soon as the specimens are prepared ; also it is advisable to burn the sputum when it is no longer required for examination. By this method of staining, at first all parts of the cover-glass pre- paration are stained red with the carbol-magenta. The acid in the second solution removes the red stain from everything except the tubercle bacilli, other structures being blue from the action of the methylene blue. No other bacilli stain red in this way except those of leprosy. Under the microscope, tubercle bacilli appear as small slender rods 1.5 tJs- 3.5 n in length, they are slightly curved, and sometimes con- tain clear spaces which do not stain in the same manner as the rest of the bacillus ; hence tubercle bacilli often have a beaded appearance. Their presence is a certain indication of tubercular disease. Their ab- sence, however, does not prove the absence of tubercular disease. It sometimes happens that tubercle bacilli are only discovered in the sputum after repeated, prolonged and careful examinations. It is well to remember that the presence of tubercle bacilli does not necessarily indicate a fatal termination of the disease. Cases of com- plete recovery sometimes occur, even after tubercle bacilli have been found in the sputum in great numbers. Moreover, the number of bacilli present in any specimen cannot be regarded as an indication of the degree of severity of the disease. Tubercle bacilli are present in all forms of acute and chronic pul- monary tuberculosis, but in miliary tuberculosis of the lungs, accord- ing to von Jaksch, they are always absent from the sputum, which resembles that of acute catarrh. Another method much in use is that of Ziehl-Neelsen. In this method the specimens are prepared and stained in the carbol-magenta 170 EXAMINATION OF THE RESPIRATORY SYSTEM. solution, as described above, but the cover-glasses are then placed in a 25 per cent, solution of sulphuric acid for a few seconds, until the red colour is changed to a brownish-yellow, which occurs very rapidly. They are then washed well in water, and stained with a watery solution of methyl-blue. Nitric acid, i of strong acid to 3 parts of water, or hydrochloric acid 33 per cent, solution, is used, in place of sulphuric acid in other methods. Biedert's Method. A useful method is described by Biedert for detecting tubercle bacilli when these organisms are present only in small numbers in the sputum. [The method is of great service in examining urine for tubercle bacilli.] One tablespoonful of the sputum is mixed thoroughly with two tablespoon fuls of water and four drops of caustic soda solution added. If the mixture is very thick, eight drops may be added, but too much caustic soda must be avoided, otherwise ^ " r *!/' V S | f -^--^'v L ^ ^ o/ v -v /, V ^ v -^ > L j. N 4. vsvvv _-_*. Wf ?' AT APEX. FIG. 125. The arrows represent the direction of the current generating systolic and diastolic murmurs, according as these are formed at the base or apex of the heart. Thus a systolic murmur at the base is of obstruction mechanism, at the apex of regurgitation mechanism. A diastolic murmur at the base, again, is of regurgitation, at the apex of obstruction mechanism. The long vertical lines represent the first sound, the short the second sound, as in Fig. 123. (Steell.) systolic murmur occurs very rarely in aortic regurgitation when the left ventricle is enlarged. (2.) A reduplicated first sound in Bright's disease may occasionally present a close resemblance to a pre-systolic murmur and first sound. (3.) Sometimes in mitral stenosis the second sound is absent, when the accentuated first sound following a long pre- systolic may be mistaken by a careless observer for the second sound following a systolic murmur. A diastolic murmur is very often found in association with the pre- systolic in mitral stenosis; it is less harsh, however, and has a diminuendo character that is, the intensity of the murmur lessens towards its end, whereas the pre-systolic is of crescendo character. The diastolic murmur, heard in the mitral area, may occur alone ; or it may alternate with the pre-systolic; or both being present one predominates ; or both may be absent for a time. The auscultatory AUSCULTATION. 217 phenomena of mitral stenosis are indeed remarkable for their change- able character. 2. The diastolic murmur of aortic incompetence is often conducted to the apex, rarely it is limited to that spot; in the latter case a difficulty in diagnosis may arise, but the associated symptoms of aortic regurgitation are usually present. In the Aortic Area, a diastolic murmur heard at the sternal end of the second right cartilage, and usually still better below this, especially along the left edge of the sternum, is indicative of regurgitation through the aortic aperture into the left ventricle ; if feeble, it is liable to be missed, especially when, as so often happens, it is limited to an area near the lower end of the sternum. Its quality is usually soft and blowing and its pitch high, though occasionally it is harsh or musical and very loud. It may be audible and have its maximum intensity at the apex beat. The lesion in a large number of cases is dilatation of the aortic orifice as a part of general dilatation of the vessel ; in other cases there is or has been rheumatic or septic endocarditis, or chronic thickening and shrinking of the semi-lunar cusps, as a result of frequent physical strain ; or rupture of a valve ; or deformity of the valves in consequence of atheroma. The second sound is very often present, and then the murmur runs off from it. When there is accentuation of the second sound, the in- competence often depends on dilatation of the aorta. Sometimes an accentuated second sound exists for a time without a murmur, and by itself should always suggest repeated careful examinations in anticipa- tion of a diastolic murmur. This miu-mur is commonly associated with an aortic systolic one, which, however, indicates relative rather than real constriction of the aortic orifice. The two murmurs sometimes produce a to and-fro sound like that of the sawing of wood hence called bruit de scie. In the Pulmonary Area. In mitral stenosis, and sometimes in other conditions leading to obstruction of the pulmonary circulation, there is occasionally heard at the sternal end of the third left cartilage, and for a short distance below it, a soft blowing diastolic murmur which runs off from an accentuated second sound, and when the second sound is reduplicated it runs off from the latter portion. This Dr. Steell calls the murmur of high pressure in the pulmonary artery, and considers that it is due to real regurgitation through the pulmonary aperture. Being situated near the left border of the sternum, the condition can only be distinguished from aortic incompetence by collateral evidence such as the absence of an aortic pulse, and of enlargement of the left ventricle. Pericardial Friction. The smooth surfaces of the healthy peri- 218 EXAMINATION" OF THK CIRCULATORY SYSTEM. cardium glide upon each other without the production of any sound ; but when they are roughened by disease, certain rubbing, creaking, or grating noises may be heard which are called pericardial friction sounds. These adventitious sounds occur in pericarditis, being due at the com- mencement to increased vascularisation or to dryness of the membrane, at a later period to exuded lymph. Pericardial friction is usually limited in extent, but it may be heard over the whole of the prsecordial region, and even to some extent beyond it. As a rule it is heard first at the base of the heart, and is also usually well heard to the left of the lower part of the sternum. It accompanies the movements of the heart, and hence has a to-and- fro character, but it is usually loudest during systole. Unlike pleuritic friction, which disappears during the stage of effusion, pericardial friction is often well heard when there is a great deal of fluid in the pericardial sac. Occasionally friction is absent during the whole course of pericar- ditis. This is especially apt to occur when the exudation is purulent, probably because the vigour of the heart-muscle is depressed. The intensity of friction depends upon the vigour of the heart's action, upon the condition of the inflammatory exudation, and to some extent upon the position of the patient. The following additional characters serve to distinguish pericardial friction sounds from endocardial murmurs : 1. They have a distinctly superficial character. 2. Pressure with the stethoscope may modify their quality, and render them more intense. 1 3. They usually maintain the same tone and pitch throughout, and do not begin with an accent or shock, as is the case with endocardial murmurs ; nor are they transmitted in definite directions. 4. They are associated with the movements rather than with the sounds of the heart. 5. They may shift their position or undergo changes in strength or character within a few hours. Pericardial friction usually disappears gradually. Its cessation may be due to enfeeblement of the heart. It is important to remember that friction may be produced by very slight changes in the pericardium, which are unaccompanied by effusion or by symptoms of any kind. Auscultation Of the Arteries In Health. If the stethoscope be placed very lightly over the carotid or subclavian artery, two sounds resembling the heart sounds are audible. On listening over the femoral 1 According to Ringer and Phear the character of an etidocardiaf murmur is much altered by pressure with the stethoscope the murmur becomes feebler and its pitch is raised. (Lancet, Feb. 10 1894.) AUSCULTATION. 2 1 9 artery a single sound almost toneless, a sort of dull thud, systolic in rhythm, is alone audible. If pressure be made with the stethoscope, the first sound is usually at once transformed into a soft murmur, but the second sound heard in the carotids and subclavians remains unchanged. Traube has described a double sound in cases of great aortic regurgitation. In Disease. -A systolic murmur is heard over the carotid and sub- cla vian arteries, in anaemia, in Graves's disease, and in aortic regurgita- tion ; and in the last condition usually whether a systolic murmur is audible over the aortic cartilage or not. On listening over the femoral artery in cases of aortic regurgitation, the normal dull thud is replaced by a more distinct sound, which may closely resemble a cardiac sound. When pressure with the stethoscope is made over the large arteries in aortic incompetence, a systolic and a less loud diastolic murmur are usually developed. Auscultation of Thoracic Aneurysms. On listening over aneurysms of the aortic arch, it is more common to find altered sounds than murmurs. The first sound tends to lose tone, and may be repre- sented by a dull thud or a mere jog or push. The second sound is often accentuated, and this sign, when the diagnosis of aneurysm, based on other signs and symptoms, is doubtful, should be regarded as one of considerable significance. This is especially the case if the accentua- tion is heard where normally the cardiac sounds are not distinct. Ac- centuation of the second sound over a circumscribed dull area in the upper part of the chest is strongly suggestive of aneurysm. The pre-. sence of murmurs may be explained by the co-existence of valvular disease of the heart, sometimes, however, they are undoubtedly pro- duced at the mouth of a saccular aneurysm, and may be systolic or diastolic ; the former being the commoner and usually the harsher, the latter the more prolonged of the two. A systolic murmur heard to the left of the spine, apart from evidence of valvular disease, may be an important sign in the diagnosis of aneurysm of the descending portion of the aorta. Auscultation Of the Veins. On listening over the internal jugular veins at the root of the neck in anaemic subjects, a humming sound bruit de diable is frequently heard. The murmur is continuous, and so differs from a murmur heard in connection with an artery. It is usually better heard on the right than the left side of the neck ; it is louder when the patient is standing than when he is lying down, and becomes intensified whenever the blood-current through the jugulars is accelerated. The significance of this murmur is not great, for it is occasionally present, although feebly marked, in healthy persons, while it is absent in many cases of anaemia. 220 EXAMINATION OF THE CIRCULATORY SYSTEM. THE PULSE. By the term pulse we indicate that alteration in the calibre of a blood- vessel which results from variations of pressure exerted by its contained blood, the pressure being regulated by the action of the heart, the elasti- city of the larger blood-vessels, and the resistance in the arterioles and capillaries. A pulse may be obtained in almost any superficial artery, but as a matter of custom and convenience, we make use of the radial artery at the wrist, and, when simply the pulse is spoken of, it is under- stood to mean the radial pulse. Methods Of Examination. The pulse may be investigated by (i) digital and (2) instrumental examination. Digital Examination. This method is still the most accurate and generally useful, but skill in the detection and interpretation of varia- tions in the pulse can only be acquired by long practice and careful observation. The first two or three fingers are to be lightly placed over the radial artery. On moving them laterally or from side to side across the artery, and then upwards and downwards along it, its direction, calibre, and the condition of its walls may be determined. Pressure of varying degree on the vessel may now be made, usually with one finger, and first that nearest to the heart, which should be the forefinger. By this means variations due to alteration in the force or character of the ventricular systole will be evidenced by the frequency, the rhythm and the force of the pulse. The condition of the vessel between the beats should then be noted as to whether it is relatively empty or full. The degree of compressibility should also be determined by ascertaining the force required to obliterate the pulse. Further still, the general character of each pulsation must be examined as to its rise, duration and fall. And, lastly, the pulse on one side of the body must be compared with that on the opposite side. Thus, in a systematic examination of the pulse, the following points require investigation : 1. The state of the coats of the artery. 2. The character of the pulse when considered as a sequence of events or series of beats. 3. The characters of the pulse when considered as a single event or individual beat. 4. The symmetry of the two pulses. Instrumental Examination. The sphygmograph has been intro- duced as a ready and convenient means of graphically recording the THE PULSE. 221 general characters of the pulse. Several forms of the instrument have been devised. Those most frequently used are either a modification of Marey's or else the smaller ones of Dudgeon, Pond, or Richardson. However they may vary in general form, each essentially consists of (i) receiving part, usually a spring or button resting on the vessel; (2) lever, whereby the movements of the receiving button are trans- mitted and amplified ; (3) recording apparatus, a smoked paper moved by clockwork, on which the distal end of the lever records the curves which constitute the graphic representation of the pulse. Most sphygmographs have also some means of varying the degree of pressure exerted by the receiving button on the artery. In the case of the compact and convenient instrument introduced by Dudgeon, this is brought about by means of an " eccentric," the dial of which is FIG. 126. Dudgeon's Sphygmograph. marked in ounces. While some such means of altering the pressure is most convenient, it must be clearly understood that the sphygmo- graph will not afford accurate measurement of the amount of pressure used. On the same pulse most different forms of tracing may be obtained by varying the amount of pressure. Hence several tracings should always be taken under varying -degrees of pressure ; then by a study of the series the true characters of the pulse may be determined, and the tracing or tracings in which these characters are best brought out should be kept for comparison with the results of subsequent examinations. The chief " events " in a normal pulse tracing, together with the terms usually given to them, are indicated in Fig. 127. The percussion wave is due partly to the contraction of the muscles EXAMINATION OF THK CIRCULATORY SYSTEM. of the ventricular wall and partly to that of the papillary muscles. Roy and Adami believe that the elevation is mainly due to the action of the musculi papillares ; hence they suggest the term "papillary wave" instead of "percussion icave" and they call the "tidal wave," the " outflow remainder wave." The dicrotic or recoil wave is believed to be caused by the reflection of an impulse from the closed aortic valves. Condition of Arterial Walls. In patients the subjects of exten- sive arterial degeneration the radial artery often participates. Some- times there is a general thickening of the vessel, in other cases irre- gular patches of induration can be felt, while occasionally the normal elastic artery is converted into a calcified tube. Characters of the Pulse as a Series of Beats Frequency. This varies in health according to age, sex, posture, time of day and other circumstances. It is also influenced by mental emotion, by exercise, and by the administration of certain drugs. In disease the pulse is FIG. 127. The Normal Pulse-trace magnified, a , b, percussion up-stroke ; a, b, c, percussion wave ; c, d, e, tidal wave ; e, f, a, dicrotic wave ; r i - ' FIG. 189. Urate of Ammonium, Sediment in Alkaline Fermentation. (. Jaksch.) bells, are seen. Being opaque, they appear dark coloured by trans- mitted light. An Oxalate Of Lime deposit, usually very scanty, can be recognised by the naked eye as a fine powder or a silvery line on the top of a delicate cloud of mucus the " powdered-wig " looking sediment. If a specimen of urine which yields a deposit of oxalate of lime is allowed 336 EXAMINATION OF THE URINE. to stand in a urine glass, white lines appear on the sides of the glass, as though it were scratched ; the lines are due to linear deposition of crystals. Most frequently met with in acid urines, the crystals are sometimes seen in neutral or faintly alkaline urine, and occasionally alongside crystals of the triple phosphate. Recognition. Oxalate of lime crystals occur in two forms : (i.) The commoner are octahedra, looking like a square-folded envelope ; more rarely they appear as quadrilateral columns with pyramidal ends. (2.) Occasionally dumb-bell shapes are seen, which much more closely resemble real dumb-bells than the "dumb-bell" shaped crystals of uric acid. Oxalate of lime crystals often show a tendency to form micro- scopic concretions. Tests. (i.) Oxalate of lime is insoluble in acetic acid and in alkalies, but is soluble in hydrochloric acid, (2.) The form of the crystals is characteristic, so that only exceptionally can they be mistaken for other crystals. Sometimes very small crystals of the triple phosphate resemble the octahedra of oxalate of lime ; a drop of acetic acid quickly FIG. 190. Oxalate of Lime from Sediment in a Case of Cystitis and Pyelonephritis, (. Jaksch.) dissolves the former, but leaves the latter unchanged. Sometimes, when of large size and bile-stained, they present a superficial likeness to uric acid crystals. Clinical Import. Deposits of oxalate of lime are often found in the urine of healthy persons, especially after a meal containing rhubarb, tomatoes, &c. When constant and ' large, they point to impaired digestion, to debility or a depressed condition of the nervous system. The crystals are also met with in catarrhal jaundice, in diabetes mellitus, in convalescence from some diseases, especially typhus, and in paroxysmal hsemoglobinuria. Earthy Phosphates form the ordinary bulky white sediment of ammoniacal urine, being often mixed with mucus and pus. Urine which deposits phosphates is not always alkaline, it may be neutral or even feebly acid. On gently heating in a test-tube the urine becomes turbid and clears again on cooling, but if boiled a chemical change occurs, and the turbidity does not vanish on cooling. A drop of acetic acid at once dissipates the turbidity, showing the absence of albumin. UNORGANISED SEDIMENTS. 337 The earthy phosphates are the triple phosphates and the phosphate of lime. 1. The Triple or the Ammonio-Magnesian phosphate forms a white sparkling crystalline deposit ; the crystals stud the sides of the urine glass and make an iridescent scum on the surface. The ordinary FIG. 191. Triple Phosphate Crystals from Sediment in a case of Chlorosis. (. Jaksch.) form is a triangular prism with bevelled ends, presenting, however, many modifications ; they are the largest of urinary crystals. Star- shaped feathery crystals are also sometimes seen. 2. Phosphate Of Lime occurs in two forms : (a.) An amorphous white flocculent deposit, showing under the microscope small pale FIG. 192. Stellar Phosphates. granules associated with crystals of the triple phosphate. The urine, always alkaline, often has an iridescent film on its surface. The amorphous phosphate may be present in the alkaline urine passed shortly after a meal (&.) Crystalline Phosphate of Lime or Stellar Phosphate. The Y 338 EXAMINATION OF THE URINE. crystals appear as rods, wedge-shaped or conical ; they may be grouped together so as to form circular rosettes or sheaf-like bundles. Such a deposit is rare, and generally accompanies some grave disorder, though exceptionally it is met with in health. Cystine. This rare pathological crystalline deposit is met with when a cystine calculus is present in the urinary passages, and also occasionally independently. The urine is pale, oily in appearance, and has a sweetbriar odour ; it is usually faintly acid and liable to alkaline decomposition, evolving sulphuretted hydrogen, and turning from yellow to green. It is turbid when voided, and deposits a light- coloured sediment, which, under the microscope, exhibits six-sided tablets of various sizes, also some irregular masses. Tests. (i.) The crystals are soluble in strong hydrochloric acid, and are thus distinguished from six-sided crystals of uric acid ; moreover, they yield a negative result with the murexide test. (2.) A deposit of cystine is not dissolved by heating the urine, but it is soluble in ammonia. FIG. 193. a, Tyrosin ; b, Cystin ; c, Leucin. (v. Jaksch.) When mixed with the triple phosphate crystals, the latter may be dissolved out by acetic acid, the plates of cystine remaining. Leucin and Tyrosin have been detected in the urine in acute yellow atrophy of the liver and in poisoning by phosphorus, also still more rarely in small-pox and in typhoid fever. They usually remain dissolved in the urine, but are deposited on slight evaporation. Tyrosin, however, sometimes deposits spontaneously. Under the microscope tyrosin appears as delicate needles arranged in tufts or sheaf -like bundles. Leucin appears in yellowish spheres, distinguished from oil-drops by their insolubility in ether, and by the presence of radiating and con- centric striae. From spheres of sodium urate they are distinguished by the solubility of the latter on heating. Carbonate Of Lime is a very rare deposit in human urine. It occurs in small spheres or dumb-bell shapes, and very rarely in stars, made up of thin acicular prisms. It effervesces with and dissolves in acetic acid ORGANIC DEPOSITS. 339 ORGANIC DEPOSITS. Blood Corpuscles. Their appearance and the duration of their visibility varies with the density and the reaction of the urine. In an acid urine of normal specific gravity, the red discs are easily recognised by their characteristic biconcave shape, and by their colour which, however, is paler than in pure blood ; they may remain unaltered for several days. In a urine of low density they lose their central depres- sion and become spherical ; and when the specific gravity is very low, or if the urine be ammoniacal, they often disappear very speedily. In highly concentrated urine the concavity is marked, the corpuscle shrinks and assumes a crenate or horse-chestnut shape. Sometimes (especially, it is said, when the bleeding is from the kidneys) the corpuscles exhibit amoeboid movements throwing out and drawing in processes. They are only exceptionally, as when there is a con- siderable haemorrhage from the bladder, seen in rouleaux ; as a rule they are discrete. They are distinguished from other bodies by their feeble refractive power, their fine delicate outline, and by the absence of a nucleus. MUCOUS and PUS Corpuscles are spherical cells slightly larger than a red blood disc ; they closely resemble white blood corpuscles. The Mucous corpuscle, usually ill-defined and granular, often contains a simple nucleus : every grade is seen between it and an epithelial cell. The Pus corpuscle exhibits a multiple, usually a tripartite, nucleus after the addition of a drop of acetic acid. Both mucous and pus corpuscles are rapidly dissolved by caustic alkalies ; hence if a portion of the glairy mass found in ammoniacal urine be put under the microscope, no pus cells are visible, or only a few black dots, the remnants of their nuclei. To distinguish pus from round epithelial cells, add a few drops of a solution of iodine in iodide of potassium, when they turn a mahogany brown ; epithelial cells turn a pale yellow colour. Epithelium. From the healthy genito- urinary passages of the male but few epithelial cells can be detected in the urine, but in the female squamous cells from the vagina are almost constantly present. In disease, epithelium from all parts of the passages may be seen. The slight differences which normally exist between the cells from different parts of the renal tubules, or between those of the pelvis, ureter and bladder, can rarely be made out after the cells have soaked in the urine ; the source is determined by the prevailing type of cell, by the presence or absence of casts, and by the accompanying symptoms. It is impossible to say whether a particular renal cell comes from a 340 EXAMINATION OF THE URINE. convoluted or from a collecting tubule ; this, however, is of little practical importance, for it is rare for an inflammatory process to be limited to such a restricted portion of kidney. The following three varieties of epithelium may be easily distinguished. 1. Bound Cells with a well-defined single nucleus may come from (a) the urinary tubules, especially their convoluted portions ; or (6) from the lower layers of the mucous membrane of the pelvis, ureter and bladder. They are larger than leucocytes, and the nucleus is usually visible without reagents, and is thus distinguished from the multiple nucleus of a pus cell, which requires acetic acid before it appears. In diseased conditions the renal epithelial cells may be wasted or broken up into amorphous granular matter, or they may contain oil globules, &c. 2. Columnar Epithelium. Cylindrical, tailed and spindle cells, with well-defined nuclei, are mainly derived from the pelvis, ureter, or urethra. Epithelium from the pelvis of the kidney is never found in FIG. 194. Casts of Urates, from a Case of Emphysema, (v. Jaksch.) healthy urine ; its presence always indicates irritation of that part. Many of the pelvic cells closely resemble cancer cells, but the latter are usually more numerous, larger, and more perfect than the former. The diagnosis, however, between cancer and calculous disease of the kidney is more reliably based on other symptoms. 3. Squamous Epithelium comes from the bladder or vagina ; it con- sists of large irregular-shaped cells containing a simple nucleus. Those from the vagina are larger and more apt to occur in flakes than the cells from tho bladder. Casts. Inorganic Casts, or cylindrical forms composed of an aggre- gation of amorphous urates, amorphous phosphates, or of hsematoidin crystals, &c., are occasionally met with in adults as well as in children, but especially in the urine of new-born babes. Organic casts form by far the more important group; these are moulds of the tubules, for the most part composed of an albuminous material which has escaped from the capillaries, and solidifies in the tubules, entangling any loose ORGANIC DEPOSITS. 341 cells or other elements that may be present ; it then contracts, passes along the tubule to the pelvis, and thus escapes with the urine. The size of the casts, and the presence or absence in them of various elements, are points by which they are classified. 1. Epithelial Casts. Sometimes, as in scarlet fever, the renal cells are simply heaped together in the form of a cylinder ; but more commonly the cast is composed of coagulable material containing epithelial cells. 2. Blood Casts. Here also red or white corpuscles may amalgamate to form a cast, but more frequently they are found irregularly studding a fibrinous mould. When composed of white blood corpuscles they re- semble pus casts ; the latter are occasionally seen in abscess of the kidney. The presence of the above cell-formed casts (i and 2) in the urine points to acute nephritis or to an acute exacerbation of a long-existing nephritis. 3. Granular Casts arise mostly from the destruction of epithelial and blood cells. Their colour varies from a yellowish- white to a brownish-red; their size and contour also vary, and they often occur in broken pieces with sharp edges ; they are studded with granules, sometimes very fine, sometimes very coarse. When there are FIG. 195. Epithelial Cast. FIG. 196. Blood Cast. FIG. 197. Granular Cast with a few Fat Drops on Surface. but few and very fine granules the transparent hyaline mould is visible, but when the granules are numerous the cast looks dark and opaque. The dark coarsely granular casts are generally about T ^ inch in dia- meter. Sometimes blood discs or fat drops are seen on their surface. 342 EXAMINATION OF THE URINE. These casts are significant of an inflammatory process going on in the kidney. They are, however, found, though very rarely, in the urine of cyanotic induration of the kidney. 4. Hyaline Casts are glassy-looking, often with ill-defined contour, and are sometimes too transparent to be seen without the addition of a coloured fluid, such as a watery solution of iodine, or of magenta, or aniline violet, &c. They vary much in length ; they are from ^V?r to ^^ of an inch in width. Sometimes they show a tendency to branch at their ends ; occasionally their contour, instead of being straight, is wavy. Sometimes homogeneous throughout and free from deposits, they more commonly have (i) a few epithelial cells, normal, con- taining oil drops, or converted into granules, on their surface ; or (2) a few red blood discs or leucocytes; or (3) possibly a few crystals, as of oxalate of lime, are seen studding their surface. Darker looking hyaline casts are sometimes called " waxy ; " they are solid-looking and highly refractive ; some are very long, others are represented by short and broad fragments, which are often cleft and broken. They may be quite homogeneous or covered with various elements. Occasionally they react to the albuminoid test, but often do not even when the kidneys are lardaceous ; they may give the albuminoid reaction through changes pro- duced by a long duration in the urinary pas- sages. The above casts, hyaline and waxy, are found in every variety of nephritis. 5. Fatty Casts are transparent or dark granular casts, which are dotted over with minute oil drops. Sometimes the oil particles are collected into dark cylindrical masses, and from their surface radiating needles (composed of salts of the higher fatty acids) are occasionally seen to project. 6. " Cylindroids " are long, ribbon-shaped forms, of variable breadth and contour, which have been found in the urine of scarlet fever, also sometimes in other cases of nephritis. They are probably mucoid in nature, and are of no diagnostic importance. The Clinical Significance of Casts. Normal urine is free from casts, though very exceptionally a few small hyaline ones may be found ; the presence of many hyaline casts points to a severe disturbance of the general circulation or to some kidney irritation. It is difficult to form an accurate estimation of the condition of the kidneys from a study Fio. 198. Fatty Casts. ORGANIC DEPOSITS. 343 merely of the casts passed in the urine ; still a knowledge of the pre- vailing type whether granular or fatty, for example is of consider- able assistance in making a diagnosis. Specimens of urine passed on different days must be repeatedly examined before a correct judg- ment can be formed as to the prevailing types. Epithelial and blood casts with a plentiful desquamation of renal epithelium point to an acute inflammation of kidney structure ; oil drops in the epithelium or scattered over hyaline casts indicate that a fatty change is going on in the kidney. Hyaline casts are met with in both recent and old cases of nephritis ; large hyaline casts suggest that the renal tubules have become widened through loss of their epithelium ; they are found in association with granular casts in chronic cases, also in the terminal period of acute scarlatinal nephritis. Tube casts are abundant in acute parenchymatous nephritis, less abundant in chronic parenchymatous nephritis, and are usually scanty in lardaceous disease ; in congestion of the kidney also there are very few. In obscure cases of bloody or purulent urine the presence of casts suggests a renal element in the causation of the blood or pus. In the large majority of cases when casts are found, the urine con- tains albumin ; exceptionally, it cannot be detected by the most delicate tests. Thus, sometimes in passive renal congestion from mitral disease, small hyaline casts, with or without granules, are found when albumin is absent. In chronic Bright's disease albumin may temporarily disappear, and yet casts may be found in the deposit, just as in the convalescence from acute Bright's disease after the disappearance of albumin. In icterus, too, as already stated (see p. 324), casts are frequently present ; a trace of albumin is often also present. Diagnosis. As a rule, casts are easily recognised ; occasionally one of the following forms may be mistaken for a cast. (i.) Mucous coagula studded with urates may resemble granular or fatty hyaline casts (see Fig. 194). (2.) In spermatorrhoea, &c., hyaline cylindrical forms (which enter the prostatic part of the urethra from the vasa deferentia and seminal tubes) may be present. They are distinguished by their greater size (being twenty or thirty times wider than kidney casts), and by the absence of albuminuria, and of other renal symptoms. (3.) Cylindrical collections of micrococci, found when a septic pyelitis affects the kidney substance, may resemble granular casts, but the micrococci resist reagents, such as liq. potassae or nitric acid. The dotting also is very fine and evenly distributed ; it is much more regular than in the granular cast. (4.) In new-born children, and occasionally in adults, cylindrical masses of urate of ammonia may be seen in the urine. They are soon 344 EXAMINATION OF PUNCTURE FLUIDS. dissolved by a drop of acetic or hydrochloric acid, and are replaced by crystals of uric acid. Search for Casts. The specimen of urine should be fresh, for if twenty-four hours old, all the casts may have been dissolved. When it has stood for a few hours in a conical vessel, the sediment may be examined. In order to exclude the action of air in the sediment, the conical glasses in which the urine is put to settle should have ground-glass covers to fit their own ground upper edges. The urine should be decanted, and the deposit dropped on to a slide, or, without decanting, a little of the deposit may be withdrawn by a pipette; it is very important that the pipette should be quite clean. Sometimes, owing to the density of the urine, casts are deposited slowly ; in such a case dilution of the urine will facilitate their descent. If no casts, or only a few, are seen, it will be well to obtain a specimen of the deposit from the whole twenty-four hours urine; or, if the urine tends to become alkaline (in which case casts are soon dissolved), successive portions of the urine as passed are allowed to stand a short time and then examined. In this way in doubtful cases the whole of the twenty-four hours deposit may be investigated without running the risk of solution of the casts through long standing. Casts may be present when there is little or even no deposit appreci- able to the naked eye, and rarely in the absence of albumen. In rare cases albumen may be present in large quantity, and yet no casts can be found. CHAPTER XI. EXAMINATION OP PUNCTURE FLUIDS. IN diseased conditions, fluids may accumulate in the various cavities of the body, in the subcutaneous tissues, or in cystic new formations. Again, collections of purulent fluid may be formed in various organs and cavities. The presence and character of a collection of fluid may be determined by puncturing the affected region with the needle of a hypodermic syringe, and, if fluid is present, drawing off a small quantity of it for examina- tion. If strict antiseptic precautions have been used, no bad results will follow, even should no fluid be present. EXUDATIONS. 345 The collection of fluid may be the result of inflammation, in which case it is termed an exudation ; or it may be due to abnormal or to obstructed circulation in the parts affected ; the fluid would then be termed a transudation. Although the character of the two classes of fluid differs, it is sometimes very difficult to say to which class a given specimen belongs. EXUDATIONS. Exudations may be serous, haemorrhagic, putrid, sero-purulent, or purulent. Serous Exudations are yellowish, and more or less turbid, the tur- bidity being due to the presence of cell elements; when allowed to stand, a clot forms which contains much fibrin. The clotting occurs sometimes directly the fluid is withdrawn, sometimes a little later, but, in any case, within twenty-four hours. Such fluids contain a few scattered red blood corpuscles, leucocytes and endothelium cells; their reaction is alkaline, and their specific gravity is gene- rally above 1018. They are rich in serum albumin and serum globulin ; small quantities of uric acid and of sugar are present. Serous exudations are met with in the pleural cavity after pleurisy, in the pericardium after pericarditis, in the abdominal cavity after peritonitis. In appearance serous exudations strongly resemble transudations, but they differ in the following points : In serous exudations the fluid is more turbid and the cell elements are more numerous ; there is a greater tendency to coagulate ; the specific gravity is higher, and the amount of albumin greater. Exudations are sometimes Haemorrhagic ; they then contain blood corpuscles along with haemoglobin in solution. This variety of exuda- tion may be due to carcinoma, to tubercle, or to scurvy. Another variety of exudation is the Sero-pumlent, in which the fluid is more turbid and the cell elements are more numerous than in the serous form. In a more advanced stage of inflammation the effusion may be Puru- lent, as in empyema, purulent pericarditis and peritonitis. Pus has a yellowish or greenish-yellow colour ; it is turbid, and of varying consistence ; the reaction is alkaline, and the specific gravity high. The colour may be altered by admixture with blood. Micro- scopical examination reveals enormous numbers of pus corpuscles, with a few red corpuscles, epithelial cells, and various forms of micro- organisms. 346 EXAMINATION OF PUNCTURE FLUIDS. TRANSUDATIONS. These are fluids which do not form as the result of inflammation, but as the result of altered or of obstructed circulation. They may be serous, hsemorrhagic, or, in a few very rare cases, chylous. The fluid may collect in the subcutaneous tissue (oedema or anasarca), in the pleural cavity (hydrothorax), in the pericardium (hydro- pericardium), in the abdominal cavity (ascites), in the ventricles of the brain (hydrocephalus), in the tunica vaginalis (hydrocele). Serous transudations are yellowish or greenish-yellow, clear fluids. Hsernorrhagic transudations are more or less reddish in colour, gene- rally, however, only of a faint red colour. Chylous transudations have a milky appearance. The reaction of transudations is alkaline. The specific gravity is lower than in inflammatory effusions. They contain fewer cell elements than serous exudations, but these are of the same nature leucocytes, red corpuscles and endothelial cells. As a rule, transudations do not coagu- late spontaneously. Sometimes, when allowed to stand for a long time, coagulation occurs, and a fibrinous clot is formed, especially if the fluid contains blood. If coagulation should occur, it is only after a much longer time, and in a less degree, than is the case with exudations. Chemically, transudations consist of water and the elements of blood plasma serum albumin, serum globulin, fibrinogen, blood salts, ex- tractives, and generally sugar, but no peptones. The salts are almost the same as those of the blood. The percentage of albumin is less than in blood serum ; it varies in amount hence the variation in specific gravity. An important difference between transudations and exuda- tions consists in their relative specific gravities, and in the amount of albumin they respectively contain. The Specific Gravity of transudations varies according to their loca- lity ; it is highest in hydrocele fluid, then follow transudations into the pleura, peritoneum, subcutaneous tissues, and ventricles of the brain. Exudations have a higher specific gravity than transudations, but the specific gravity of the fluid has no constant relation to its source. There is no sharp and constant difference between the specific gravity of transudations and exudations ; but, as a rule, the specific gravity of a pure exudation is rarely below 1018, while that of a pure transuda- tion is rarely above 1012. Thus, if the specific gravity of a fluid obtained from the peritoneal cavity is higher than 1018, it is almost certainly due to peritonitis (exudation); if lower than 1012, to ascites (transudation). If the specific gravity is between 1012 and 1018, the fluid may be either a transudation or an exudation. TRANSUDATIONS. 347 The following figures show the difference in the amount of albumin in transudations and exudations : In Pure Exudations. In Pure Transudations. Pleura higher than . 40 per cent. Pleura lower than . 25 per cent. Peritoneum . . 40-45 Peritoneum . . 15-20 Skin .... 40 ,, Subcutaneous tissue . 10-15 Cerebral meninges . ? Cerebral meninges . 5-10 Cerebro-Spinal Fluid. In spina bifida and in cases of chronic hydro- cephalus, large quantities of fluid collect in the former in the sac of the swelling, in the latter in the distended brain ventricles. This fluid closely resembles normal cerebro-spinal fluid. It is clear, the specific gravity is low, and the solids amount to 10 to 13 parts per 1000. When boiled it becomes opalescent, and on the addition of acetic acid a flocculent precipitate separates. Sugar or some other reducing agent possibly pyro-catechin is also present. The fluid differs from other transudations in containing as a rule no fibrinogen ; no clot of fibrin is formed when the fluid is treated with fibrin ferment. Examination of the Puncture Fluid for Micro-Organisms is of some value. The results of recent observations show that the majority of exudations, serous or purulent, which contain no bacteria are tuber- cular in origin. Most of the primary, idiopathic, non-tuberculous inflammations of the pleura are said to be due to Frankel's pneumonococcus. Next in importance to this organism are the various pyogenic micrococci, espe- cially the streptococcus pyogenes. Serous exudations in primary pleurisies, in which pyogenic micro-organisms are discovered, have a greater tendency to become purulent than those containing pneumono- cocci. Pleurisies accompanying or following pneumonia owe their origin mainly to pneumonococci. Pleuritic effusions due to these micro-organisms run a much less severe course than those dependent on pyogenic bacteria, or than those due to the presence of both kinds of organisms. Pus or other puncture fluid may be examined for the micro-organisms of tubercle, glanders, malignant pustule, actinomycosis, or leprosy (according to the methods described in pathological text-books), when these diseases are suspected. Tubercle bacilli are rarely found in puncture fluids, though the disease may be undoubtedly tubercular. In tropical abscess of the liver peculiar amoeboid organisms are found the Amoebae coli. 348 EXAMINATION OF PUNCTURE FLUIDS. CONTENTS OF CYSTS. Hydatid Cysts. The puncture fluid obtained from these cysts is opalescent, or clear and colourless, and is therefore at once distinguish- able from ascitic fluid. The reaction is alkaline and the specific gravity low 1006 to 1010. The fluid contains no albumin, or only a very small amount, together with a trace of sugar or some substance which reduces Fehling's solution. A large quantity of inorganic salts, espe- cially sodium chloride, and frequently succinic acid, are present. To detect succinic acid, evaporate the fluid to the consistence of a syrup, acidify with hydrochloric acid, and shake up with ether. Pour off the ether, evaporate, and dissolve the residue in water. This solution gives, with perchloride of iron, a rust-coloured floccular or gelatinous precipitate if succinic acid be present (Wesener). Microscopical examination is of the greatest diagnostic importance. Minute white specks (scolices) can often be detected in the fluid with the unaided eye ; under the microscope they present the well-known appearances of the scolices of the Taenia ecchinococcus. The scolices are round or oval bodies with a somewhat constricted neck, bearing a crown of booklets and four suckers ; sometimes the neck and booklets are retracted into the body of the scolex. Not infrequently no scolices can be detected, but the deposit at the bottom of a glass in which the puncture fluid is allowed to stand is found to contain the characteristic booklets. Sometimes portions of hydatid membrane (i.e., cyst wall) are found in the fluid, the membrane being distinguished by its transverse striation or laminated appearance and by its granular inner surface. If suppuration or haemorrhage into the sac have occurred, the chemical composition of the fluid is altered accordingly. Only the presence of scolices, booklets, or the laminated membrane is diagnostic. Hydronephrosis. The fluid of a hydronephrotic cyst is generally clear and watery in appearance, with a sp. gr, between 1008-1020. It contains traces of albumin, and usually of urea and uric acid, but in old cysts the urinary constituents may be absent, having been absorbed. As urea and uric acid sometimes occur in other cysts, they are only characteristic of hydronephrosis when present in large amount. To test for urea : Evaporate the puncture fluid on a water-bath to the consistence of a syrup. Extract with alcohol; filter the extract and again evaporate to a syrup. A little of the residue dis- solved in a small quantity of water is placed on a slide and a drop of nitric acid added. Six-sided plates of nitrate of urea crystallise out, and can be easily recognised with the aid of the microscope. To test for uric acid : Add a quantity of hydrochloric acid to the CONTENTS OF CYSTS. 349 puncture fluid ; allow it to stand twelve to twenty-four hours. Crystals of uric acid are deposited, which may be recognised by the naked eye, by microscopical examination, and by the murexide test (see p. 333). Ovarian Cysts. The fluid obtained from these cysts is very variable in character. In colour it may be clear yellow, yellowish-green, dark brown, chocolate-coloured, or almost black. It may be watery and clear, or thick, turbid and slimy, or ropy. The sp. gr. varies from 1002-1055 j it is generally between 1010-1025. The fluid has little tendency to coagulate ; its reaction is alkaline. Microscopical examination reveals the presence of red blood cor- puscles, leucocytes, and epithelial cells of various forms squamous, columnar, and ciliated, together with cholestrine crystals ; colloid masses are sometimes present. The chemical character of the fluid varies considerably, according to the changes which have taken place in the cyst, such as those caused by haemorrhage or inflammation. The chief chemical constituents are water, serum albumin, serum globulin, salts and metalbumin. To test for the presence of metalbu- min, the fluid is feebly acidified with acetic acid, boiled, and then filtered. Other forms of albumin are thereby removed. To the filtrate an excess of alcohol is added, which produces a white flocculent precipitate. The fluid is allowed to stand for twenty-four hours. It is then filtered, and the precipitate, after being squeezed in linen, is suspended in water. The solution is again filtered, and ought to give the following reactions (v. Jaksch) : 1. On boiling it becomes turbid, but does not form a precipitate. 2. Acetic acid gives no precipitate. 3. Acetic acid and ferrocyanide of potassium render the fluid thick, and impart to it a yellow tint. 4. On boiling with Millon's reagent the fluid yields a bluish-red colour. 5. With concentrated sulphuric and glacial acetic acids it yields a violet colour. In Dermoid Cysts, hairs, squamous epithelium, fatty matter, cholesterin crystals, and hsematoidin are found. If the fluid be purulent on the first tapping, the cyst is probably a dermoid cyst. A low sp. gr. and the presence of only a small amount of albumin is said to point to a cyst of the broad ligament. Pancreatic Cysts. The fluid from these cysts has a low sp. gr. It contains serum albumin, but no metalbumin, and rarely mucin. Cholesterin is always present, and frequently blood pigment also- (according to v. Jaksch, in the form of metheemoglobin). Fluid from a pancreatic cyst will digest albumin without the addition of an acid, i.e., in an alkaline solution. No other cystic fluid possesses this property. In old and large cysts, however, this power may be very feeble. 350 EXAMINATION OF THE NERVOUS SYSTEM. CHAPTER XII. EXAMINATION OF THE NERVOUS SYSTEM. ANATOMICAL AND PHYSIOLOGICAL INTRODUCTION. THEKE is no other class of diseases the study of which requires such an intimate knowledge of anatomy and physiology as that of diseases of the nervous system. Again and again the student is baffled when attempting to make a diagnosis, not so much through inability to in- FIG. 199. Left Side of the Human Brain. F, frontal lobe ; p, parietal lobe ; o, occipital lobe ; T, temporo-sphenoidal lobe ; A, ascending frontal, and B, ascending parietal convolution ; 8, fissure of Sylvius ; s', horizontal, s", ascending ramus of s ; c, fissure of Rolando ; the other convolutions and fissures are marked with capitals and small letters respectively. (Ecker.) vestigate a nervous case, but because he forgets the function of a particular centre, or the origin and relations of a particular cranial or spinal nerve. It is, therefore, desirable, before entering upon the investigation of symptoms, to briefly review some of the more essential facts relating to the structure and functions of the nervous system, ANATOMICAL AND PHYSIOLOGICAL INTRODUCTION. 3 5 I giving special prominence to those which most commonly call for con- sideration in the diagnosis of nervous diseases. Cerebral Convolutions and Fissures. These are shown and designated in the accompanying diagrams. The three most important fissures are: (i.) The fissure of Sylvius, which divides into a short anterior and a long posterior limb; (2.) the fissure of Rolando or the central sulcus, which extends from just above the Sylvian fissure to the upper edge of the hemisphere, and separates the frontal from the parietal lobe ; (3.) the parieto-occipital fissure, which occupies chiefly the median surface, and marks the boundary between the parietal and occipital lobes. On the median aspect it joins the calcarine fissure, J?IG. 200. Median Aspect of the Eight Hemisphere. CC, corpus callosum ; Gf, gyrus fomicatus ; H, gyrus hippocampi ; h, sulcus hippocampi ; U, uncinate gyrus ; cm, calloso-ruarginal fissure ; F Jt first frontal convolution ; c, terminal portion of fissure of Rolando ; A, ascending frontal, and B, ascending parietal convolution ; Pi', quadrate lobule ; Oz, cuneus ; po, parieto-occipital fissure ; oc, calcarine fissure. (Ecker.) enclosing a wedge-shaped area called the cuneus. On the inner surface is also seen the long calloso-marginal fissure, the posterior end of which reaches the edge of the hemisphere a little behind the fissure of Rolando. The precuneus or quadrate lobule lies between the colloso- marginal and the parieto-occipital fissures. The ascending frontal and ascending parietal convolutions, sometimes called the anterior and posterior central convolutions, unite below the lower end of the fissure of Rolando, and their lower ends, together with the posterior end of the third frontal convolution, constitute what is known as the oper- culum, which overlies the island of Reil. The upper part of the ascending parietal convolution blends with the superior parietal lobule. 352 EXAMINATION OF THE NERVOUS SYSTEM. To the prolongations of the two central convolutions on the median surface of the hemisphere the term paracentral lobule is applied. In front of the ascending frontal convolution are the three antero- posterior frontal convolutions, which, together with the corresponding FIG. 201. Lateral Surface of Right Cerebral Hemisphere, showing the approximate positions of the Cortical Centres. Speech, however, is represented mainly in the left hemisphere. inner surface, constitute the prefrontal lobe. The marginal gyms is mainly constituted by the median aspect of the superior frontal convolution. MotOF Centres and Motor Path. The psychomotor region of FIQ. 202. The Inner Aspect of the Right Hemisphere, showing the probable positions of the Cortical Centres. the cortex consists of the two central convolutions with the adjacent portion of the superior parietal lobule, together with the paracentral lobule and part of the quadrate lobule or precuneus. The leg centre occupies chiefly the upper third, the arm the middle third of these ANATOMICAL AND PHYSIOLOGICAL INTRODUCTION. 353 convolutions, while the face, lips and tongue are represented in the lowest third of the ascending frontal convolution. The motor centre for speech occupies the posterior end of the third frontal convolution, together with the lowest portion of the ascending frontal in the left hemisphere, and also in all probability the underlying island of Reil. It is probable that the centre for the movements of the head and eyes >A.R FIG. 203. Course of the Fibres for Voluntary Movement. a, b, path for the motor fibres for the limbs and trunk ; c, fibres for the facial nerve ; A'c, nucleus caudatus ; Gi, internal capsule ; Nl, lenticular nucleus ; P, pons ; Nf, origin of the facial ; Py, pyramids and their decussa- tion; 01, olive; Gr, restiform body; P.R, posterior root; A.R, anterior root; x, crossed, and z, direct pyramidal tracts. (Stirling.) occupies part of the first and second frontal ; that the trunk muscles are represented in the median aspect of the ascending frontal; and that in the lower parietal lobule that is, the lower portion of the parietal lobe is a centre for the movements of the upper eyelid. Nerve fibres pass down from these motor centres to connect them with the spinal cord. Passing through the white substance of the Z 354 EXAMINATION OF THE NERVOUS SYSTEM. hemisphere, they converge to the internal capsule occupying its " knee," and the anterior two-thirds of its posterior segment ; the leg fibres are the furthest back, and are next to the sensory fibres. In the crus the motor fibres occupy the middle two-fifths of the crusta. The fibres for the face, and those destined for the tongue, part from the other motor fibres in the pons, and cross the middle line to reach the nuclei of the facial and hypoglossal nerves. In the pons the limb and trunk fibres lie between the superficial and deep transverse fibres, in the medulla they constitute the anterior pyramid, the greater proportion of the fibres of which crosses over at the decussation to run in the KIG. 204. Scheme showing the Degeneration-Tracts, and the Paths that do not undergo Degeneration in the Cord. AMF, anterior median fissure ; DPT and CPT, direct and crossed pyramidal tracts ; AR and PR, anterior and posterior roots ; AAL and DAL, ascending and descending antero-lateral tracts ; CT, cerebellar tract ; D, comma-shaped tract ; PJiz, posterior marginal zone ; PEC, postero-external column. The parts left white do not undergo degenera- tion. (Stirling.) lateral column, forming the crossed pyramidal tract. A small though variable proportion of fibres is continued into the anterior column of the same side of the spinal cord, and probably also a few into the lateral tract of the same side. The relative positions of the face and limb centres and fibres are indicated in the diagrams. In the cord the lateral or crossed pyramidal tract is situated in the posterior half of the lateral column, and extends down, gradually diminishing in size, to the end of the cord. The anterior or direct pyramidal tract ("column of Tiirck ") descends in the part of the an- terior column adjacent to the median fissure, and usually ceases about the middle of the dorsal region. ANATOMICAL AND PHYSIOLOGICAL INTRODUCTION. 355 The fibres of the pyramidal tract end in grey matter near the motor cells in the anterior horns. From these ganglionic cells spring the anterior roots, which are composed of motor fibres destined for the muscles. In a similar manner the tracts for the motor cranial nerves separate from the pyramidal tract in the crus, pons and medulla, and cross to end near the ganglionic cells, which constitute their nuclei in the floor of the fourth ventricle ; and from these cells issue fibres which are collected together to form the motor cranial nerves. The cortical motor areas are the centres for voluntary movement. The anterior horns of the cord and the corresponding nuclei in the medulla and pons transmit voluntary motor impulses to the peripheral nerves ; they are also centres for reflex action. The cortical centres preside over the nutrition of the pyramidal tract, the bulbar and spinal nuclei over that of the motor fibres in the peripheral nerves. A divi- sion of the motor path into two parts, an upper and a lower part, is therefore a natural one from a physiological point of view, and is very convenient clinically. The upper division extends from the cortical centres along the pyramidal tract to the bulbar nuclei and to the anterior horns of the spinal cord ; while the lower includes the bulbar nuclei and the anterior horns, together with the motor fibres which extend from them to the muscles. Affections Of the Upper Segment. A destructive lesion of any part of the upper segment gives rise to a spastic paralysis, that is, to a loss of muscular power associated with rigidity or spasm of muscles ; the pyramidal fibres below the lesion undergo degeneration, but the grey nuclei of the medulla and pons, the anterior horns, motor nerves and muscles do not degenerate. The situation of the lesion is indicated more or less definitely by peculiarities in the distribution of the paralysis, of which the follow- ing are the chief : i. If the lesion is above the decussation of the pyramids, the limbs and trunk muscles are paralysed on the opposite side of the body, (a.) If it is situated above the middle of the pons, the opposite side of the face may be also paralysed. (&.) If below the middle of the pons, the face is paralysed on the same side as, but the limbs on the opposite side to, the lesion; this is called "crossed paralysis" or alternate hemi- plegia. (c.) When the lesion involves the anterior pyramid of the medulla, the face remains unaffected, (d.) Irritative lesions of the cortical centres cause convulsions, destructive lesions paralysis on the opposite side ; and owing to the divergence of the motor fibres as they approach the cortex, and the consequent separation of those belonging to the face, arm and leg respectively, the paralysis is often limited to the face or to one limb ; it is then called monoplegia. The convulsions, 356 EXAMINATION OF THE NERVOUS SYSTEM. too, of an irritative lesion are usually at first limited to a few muscles of the opposite side of the face or of the opposite limb. 2. If the lesion is below the decussation of the pyramids, that is, is situated in some part of the pyramidal tract in the spinal cord, the limbs and trunk muscles are paralysed on the same side. As a rule, in the cord both tracts are affected, and hence both sides of the body are paralysed ; in such cases the grey matter rarely escapes injury, and so modifications of sensation or of the reflexes usually accompany a spastic paralysis of spinal origin. Affections Of the Lower Segment, that is, the bulbar or spinal motor nerve-cells or the motor nerve-fibres, produce atrophic paralysis ; the cells and the fibres below the lesion degenerate, the muscles, sup- plied by the affected nerves, also undergo a rapid atrophy, and give degenerative reactions to electricity (see p. 395). Sensory Or Centripetal Path. Cutaneous sensations, received by the terminal apparatus in the skin of the trunk and extremities and from the mucous membranes, are conveyed along sensory nerve-fibres to the posterior roots of the spinal nerves. The position of the sen- sory path, however, between the posterior roots and the cortex of the brain is for the most part uncertain. Gowers believes that sensibility to pain (and with it possibly also that to temperature) is conducted by the antero-lateral ascending tract, while sensibility to touch ascends the posterior column. Passing through the posterior half of the medulla and pons, where the path from the fifth nerve joins it, the sensory path goes through the crus cerebri and enters the posterior third of the hinder limb of the internal capsule ; this part, which re- ceives also fibres conveying sensory impulses of taste, hearing, smell and vision from the opposite side, is called the " sensory crossway." Higher, the sensory fibres pass into the white substance of the hemi- sphere, and those conveying impulses from the cutaneous surface of the body end, in all probability, in the cortex of the central convolu- tions and of the parietal lobe. Gowers considers it probable that muscular sensibility is transmitted upward along the same side of the cord, possibly in the posterior median column, whereas all other forms of sensibility immediately cross to the opposite side of the cord. Ferrier, however, says " the evidence is in favour of the view that the lohole of the sensory paths pass up the opposite side of the spinal cord, and that they are not contained either in the posterior median columns or in the direct cerebellar tract, or in the antero-lateral tract ; . . . and we are led to suppose that the sensory tracts ascend in immediate relation with the central grey matter." A destructive lesion of the parietal portion of the cortex, or of the ANATOMICAL AND PHYSIOLOGICAL INTRODUCTION. 357 hindmost part of the internal capsule, will produce loss of sensation in the skin and mucous membranes of the whole of the opposite half of the body. Also it must be remembered that lesions of the so-called motor area are sometimes attended by sensory disturbance. For example, the extremity of a paralysed limb may have its sensibility blunted or" perverted as regards locality; and motor spasms from irri- tation of this cortical area are often preceded by a sensory aura. Destruction by injury or disease of one side of the cord produces loss of cutaneous sensibility on the opposite side below the level of the lesion, but according to Gowers, loss of muscular sensibility on the same side. The Visual Path. The optic tracts pass from the retinae along the optic nerves to the chiasma ; here there is a partial decussation, the fibres from the inner half of each retina crossing to enter the optic tract of the opposite side, while the fibres derived from the outer half of each retina run along the optic tract on the same side (see Fig. 205). The visual path passes in the optic tract to the anterior pair of the corpora quadrigemina, thence in the posterior segment of the internal capsule by the corpora geniculata, through the white substance of the hemisphere to the cortex of the occipital lobe. But, in addition to this half-vision centre in the occipital lobe, there is, in all probability, a higher visual centre situated in the angular gyrus, in which the whole of the opposite field of vision is represented, and to a less degree the whole field of the eye of the same side. Destruction of the occipital cortex, especially of the cuneus, or of any portion of the optic tract between the occipital lobe and the chiasma, renders the outer half of the retina on the same side and the inner half of the opposite retina blind to visual impressions ; thus if the left optic tract is the seat of a lesion (see B, Fig. 205), the patient, when looking straight before him, cannot see objects situated to his right. It is probable that a lesion of the left angular gyrus leads to extreme concentric diminution of the field of vision of the right eye, and to a moderate diminution of the field of the left eye. The Auditory Path. The auditory nerve, directed inwards from the temporal bone, passes between the pons and medulla to its nucleus in the floor of the fourth ventricle. This has important central connec- tions with the cerebellum, and also, by means of the opposite internal capsule at its posterior part, with the auditory centre in the first temporo-sphenoidal convolution. The Olfactory Path. Some of the fibres of the olfactory nerve enter the uncinate gyrus of the same side; others cross, perhaps by means of the anterior commissure, to the opposite hemisphere, reaching the cortex through the posterior end of the internal capsule. 358 EXAMINATION OF THE NERVOUS SYSTEM. The Path fOF Taste, according to Gowers, reaches the brain solely by the roots of the fifth nerve, the fibres connecting the nucleus of the latter with the opposite hemisphere, passing also through the " sensory cross way." FIG. 205. Diagram to Illustrate the Nervous Apparatus of Vision in Man. (After Sherrington, modified.) The right optic tract (shaded) supplies the temporal side of the retina of the right eye and the nasal side of the retina of the left eye ; excitation of these parts of the retina; produces vision in the shaded portions of the fields of vision. The right opt'e tract is represented as ending in GL, the lateral corpus geniculatum ; in K, the pulvinar ; and in AQ, the anterior corpus quadrigeminum. Connecting these bodies with the right occipital lobe, R.oc., is the optic radiation, represented by dotted lines ; NC, the nucleus caudatus ; LN, the nucleus lenticularis ; and TH, the optic thalamus. A lesion B or a lesion A would produce right hemianopsia; a lesion N would produce temporal hemianopsia; while the lesions T, T, would produce nasal hemianopsia (see p. 448). Si Psychical Centres. It is believed that the seat of the highest mental processes is located in that portion of the cortex which lies in front of the motor areas. Lesions of this part, that is, of the pre- frontal lobes, may produce considerable mental changes ; but it is no ANATOMICAL AND PHYSIOLOGICAL INTRODUCTION. 359 less true that wide-spread disease of other portions of the cortex leads to dulness of the higher faculties, and it is probable that mental opera- tions are subserved by very extensive areas of the cortical grey matter. The Centre and Paths for the Co-ordination of Movements. The paths in the nervous system which appear to be related to the accurate adjustment of muscular action are closely connected, and as it were interwoven with, those which conduct certain sensory impulses ; it was therefore fitting to consider the latter first. The subject is a complex one, and few, if any, positive assertions can yet be made with regard to it. There are, however, a few facts relating to the cerebellum and to certain tracts in the spinal cord which require a brief notice. The Cerebellum consists of two lateral hemispheres and a middle lobe, and by means of its peduncles it is intimately connected with the cere- brum, pons and medulla oblongata. Its connection with the cerebral hemispheres is mainly a crossed one, fibres passing from the prefrontal, temporal and occipital lobes to the oerebellar hemisphere of the oppo- site side. The middle lobe of the cerebellum is largely concerned with the maintenance of equilibrium, and may be regarded as the centre for the co-ordination of muscular contractions. It acts, however, in strict subordination to the cerebrum, and may be said to regulate muscular contractions, which are initiated, and are subject to constant changes, by the action of the higher centres in the cerebrum. Lesions of the middle lobe produce a staggering gait ; when situated in its upper part, there is a tendency to fall forwards ; when in its lower part, to fall backwards. Lesions limited to one of the cerebellar hemi- spheres are frequently unattended by definite symptoms, but the patient may exhibit a tendency to fall towards the affected side, or there may be a forced rotatory movement towards this side. But the latter symp- tom is usually due to active disease of the middle peduncle of the cerebellum The middle lobe of the cerebellum is connected with the periphery of the body by several important tracts. Two are situated in the spinal cord, namely, the posterior median or Goll's column, and the direct cerebellar tract. Both undergo an ascending degeneration, when the fibres of which they are composed are interrupted. The fibres of each tract are derived from the posterior roots, those of the direct cerebellar tract chiefly from the posterior roots of the upper dorsal and cervical regions, and not from those of the lower extremities ; this tract has an intimate connection with the posterior vesicular column. It is probable that both the columns of Goll and the direct cerebellar tracts consist of cerebello-afferent fibres, and it may be pretty confi- dently stated that they conduct sensory impressions from the muscles to the cerebellum. 360 EXAMINATION OF THE NERVOUS SYSTEM. Interruption or disease of these tracts, or of the posterior roots from which they are derived, appears to be one of the principal factors in the production of incoordination of movement a characteristic feature of locomotor ataxia. A third centripetal path is constituted by the auditory nerve, espe- cially that part of it which receives impressions from the semicircular canals, these impressions being conveyed to the auditory nuclei, and thence to the cerebellum. Irritation of the nerve-fibres to the canals produces a feeling of giddiness and incoordination of muscular move- ments, so great sometimes that the patient finds it difficult or impos- sible to stand. These, together with aural symptoms, are the chief phenomena in Meniere's disease or auditory vertigo. It is also highly probable that the cerebellum is indirectly connected with the periphery by a fourth tract, namely, the visual ; for our rela- tions to external objects are largely estimated by sight and by the position of the eyes. It may indeed be assumed that centripetal fibres pass from the centres for the movements of the eyeballs to the middle lobe of the cerebellum, which regulates the attitudes of the body, so far as they relate to the maintenance of equilibrium. The Central Ganglia. The optic thalamus is connected by fibres with the tegmentum of the crus, with the superior peduncle of the cerebellum, in all probability with the optic nerves, and with all parts of the cerebral cortex. It is probable that the thalamus has to do with some of the higher reflex processes, but lesions limited to it, and not involving the adjacent internal capsule, do not produce any symptoms, with the exception possibly of tremors or clonic spasms, involving movements on the opposite side of the body. The nuclei of the corpus striatum have no connection with the cortex, nor with the pyramidal motor path ; but both the caudate and the len- ticular nuclei have extensive connections with the cerebellar hemisphere of the opposite side. Destruction of the corpus striatum may be un- attended by symptoms. The Relative Position of the Nerve Nuclei beneath the floor of the fourth ventricle and the Sylvian aqueduct is shown in the accom- panying diagrams. It is important to observe: (i) that the nuclei of the hypoglossal and spinal accessory nerves are close together, and that injury to their roots paralyses the tongue, palate and vocal cord on the same side. Such paralysis is also caused by degeneration of the nuclei; then the lips also suffer, probably because the fibres of the facial nerve which supply the orbicularis oris dip down to the hypo- glossal nucleus, and thus we have "bulbar" or " labio-glosso-laryngeal- paralysis." (2.) That although the facial nerve winds round the nucleus of the sixth nerve, it has no real connection with it. ANATOMICAL AND PHYSIOLOGICAL INTRODUCTION. 361 (3.) That the nucleus of the third nerve is made up of three parts an anterior centre for accommodation, another for the light reflex of the iris, and a third, the largest, representing all the other eye muscles supplied by the third nerve. (4.) That the nucleus of the fourth nerve is continuous with that of the lowest part of the third. Some fibres, Corpus quadri- < geminum ( post icun Conarium or pineal gland. Brachium coujunctivum auticun Brachium conjunct! vum posticum. Pedunculus cerebri ad corpora qua pemina, or uperior cerebellar peduncle. ad medullam oblon- gatam, or inferior cerebellar peduncle. Funiculus cuneatus (Part of restiform body). Funiculusgracilis (Posterior pyramid). FIG. 206. Diagram of the Fourth Ventricle. The numbers IV. -XII. indicate the superficial origins of the cranial nerves, while 3-12 indicate their deep origin, i.e., the positions of their central nuclei ; t, funiculus teres. (Landois and Stirli-ng.) however, probably come from the nucleus of the sixth. Indeed, the connection between the nuclei of these three nerves, which govern the complex movements of the eyes, is a very close one. (5.) That the deep origin of the fifth nerve is a very extensive one : it reaches from be- neath the corpora quaclrigemina down to the grey matter of the spinal 362 EXAMINATION OF THE NERVOUS SYSTEM. cord, being close to the visual path above, and to the origin of the cervical nerves below. (6.) Thatthesixthnerveshavingalongercour.se than any of the cranial nerves before they enter the dura mater, are most exposed to injury, and are especially liable to be damaged as they pass beneath the pons by anything pressing upon it. Lesions at the Base Of the Brain are liable to injure some of the cranial nerves as they pass to their respective foramina. Thus a.tumour situated in the anterior fossa of the skull is apt to affect the olfactory nerves, and by backward extension to damage the optic or the oculo-motor nerves. If situated in the middle fossa, the second, third, fourth, fifth and sixth nerves are likely to suffer : of these, the in- volvement of the fifth nerve or of the Gasserian ganglion is usually the most prominent feature. If situated in the posterior fossa, the fourth FIG. 207. Scheme of the Disposition of the Nuclei of Origin of the Cranial Nerves in the Region of the Bulb and Pons. (JSdinger.) or any nerve below it may be involved, and, at a later period, the motor tract may become affected. Blood- Vessels Of the Brain. The arteries are derived from the internal carotid and vertebral arteries ; on the left side the current of blood is much more direct than on the right side ; hence solid particles more readily enter the left internal carotid and the left vertebral than the corresponding vessels on the right side. Each internal carotid divides into an anterior and a middle cerebral artery ; these, together with the posterior cerebral and the communi- cating arteries, form the circle of Willis. Cortical Branches. The anterior cerebral arteries curve round the corpus callosum, and supply on the outer surface the first and second frontal and the top of the ascending frontal convolutions, also the inner surfaces of the hemispheres in front of the parieto-occipital fissures, together with portions of the orbital lobules. The posterior /a. ANATOMICAL AND PHYSIOLOGICAL INTRODUCTION. 363 cerebral arteries supply the lower aspect of the temporal and the occi- pital lobes. The middle cerebral supply the rest of the cortex, and hence all the motor region, with the exception of portions of the leg centres, which receive blood from the anterior cerebral vessels. The middle cerebral also supply the sensory portions of the "cortex, together with the auditory and speech centres, and probably the higher visual centres, the half-vision centres receiving blood from the posterior cerebrals, which supply also the sensory part of the internal capsule and the corpora quadrigemina. FIG. 208. FIG. 209. FIGS. 208 and 209. Areas of the Cortex supplied by Branches of the Cerebral Arteries. The areas shaded with horizontal lines represent the distribution of the anterior cerebral artery; the areas shaded with vertical lines the distribution of the posterior cerebral artery. The unshaded area in Fig. 208 represents the distribution of the middle cerebral artery. Central Arteries arise from the three cerebrals near their origins, and also from the circle of Willis. There are six groups, two mesial and four lateral, two on each side. The small anterior mesial group from the anterior cerebrals supplies the head of the caudate nucleus; the small posterior mesial group from the posterior cerebrals supplies the inner part of the optic thalamus and the walls of the third ventricle. Haemorrhage from rupture of these small branches of the anterior and posterior cerebral arteries is 364 EXAMINATION OF THE NERVOUS SYSTEM. apt to burst into the ventricles. The internal capsule and the central ganglia are mainly supplied by the antero-lateral groups, which consist of small arteries derived from the commencement of the middle cere- brals. There are internal branches which penetrate the inner portions of the lenticular nucleus and internal capsule, and external branches, which are larger, and are divisible into two sets an anterior set, named lenticulo-striate arteries, and a posterior set, the lenticulo- optic arteries. Both these sets, but especially certain branches of the former set, are particularly liable to rupture. The arteries of the C A FIG., 210. Transverse Section of a Cerebral Hemisphere, cca, corpus callosum ; NC, caudate nucleus ; NL, lenticular nucleus ; 1C, internal capsule ; CA, internal carotid artery ; aSL, lenticulo-striate artery ("artery of hemorrhage"); F, A, L, T, position of motor areas governing the movements of the face, arm, leg and trunk muscles of the opposite side. (Uorsley.) posterior lateral groups which spring from the posterior cerebrals supply the posterior ends of the optic thalami, and their rupture usually damages the posterior third or sensory portion of the internal capsule. The crura and corpora quadrigemina are also supplied by the posterior cerebrals. Between the central and cortical systems there are no anastomoses, nor do the central branches communicate with one another ; but anastomoses often exist between the cortical branches. The pons and medulla receive median and lateral branches from the vertebral, basilar and cerebellar arteries. There is no communication ANATOMICAL AND PHYSIOLOGICAL INTRODUCTION. 365 between them, and hence softening is not uncommon ; but it is rare in the cerebellum, because the superior, middle and inferior cerebellar arteries freely communicate with one another. The Veins. The leading anatomical points to be remembered in connection with the venous circulation of the brain are : 1. That the veins from the greater part of the cortex pass upwards and forwards into the superior longitudinal sinus, the direction of the current of blood being opposed to that in the sinus. This is one of the chief reasons why clots are readily formed in the sinuses and cortical veins. 2. That the veins of Galen, which receive blood from the lateral ventricles, empty themselves into the straight sinus. Any obstruction of these veins, as by a tumour of the middle lobe of the cerebellum, causes effusion into the ventricles, and constitutes a factor in the production of hydrocephalus ; at the same time it is doubtful whether much hydrocephalus can be present unless the communication between the ventricular cavity and the subarachnoid space (by means of the foramen of Magendie) is completely occluded. 3. That nearly all the blood from the cerebrum and cerebellum is conveyed directly or indirectly into the lateral sinuses, and thence to the internal jugular veins. 4. That there are several important communications between the intra- and extra-cranial veins. Thus the veins of the nose and most of those of the scalp communicate with the superior longitudinal sinus ; the occipital veins with the lateral sinus by means of the mastoid veins ; the deep cervical veins with the inferior petrosal sinus ; while a communication is established between the facial vein and the cavernous sinus by means of the ophthalmic vein. Blood-Vessels of the Spinal Cord. Two points of practical importance in connection with the distribution of the arteries may be mentioned. 1. Owing to their tortuous course before entering the cord, they are much less exposed to pressure than those going to the brain, and hence haemorrhage into the cord, from degeneration and rupture of the arterial wall, is a rare event. 2. The arteries which supply the cervical and upper dorsal regions pass almost horizontally to the cord, but many of those which nourish the lower end of the cord have a long ascending course, the arteries accompanying the nerves of the cauda equina being often several inches in length. This, together with the smallness of their calibre, offers much resistance to the blood-stream, and may possibly explain to some extent the proneness of the lower part of the cord to become diseased. 3 66 EXAMINATION OF THE NERVOUS SYSTEM. Relations of the Spinal Cord and of the Spinal Nerves tO the Vertebral Spines. At birth the lower end of the cord Vertebral Vertebral Spine. Body, jg^j^^ r / fy 1 c. r Pupil-Accommodation; Jaw. Jye-Muscles. Conjunctival. Respiratory '(Coughing, Sneering). Cardio-Innibilory. vaso-Moior Sucking Vnntitinar. 5 (7 * { f f A I / Z> 7t 7> ,5 fi Epigaglrie. y 8 .9 tO yjlbdom inccl. 77 9 7) 1f) // i T) 11 n 11 r. 1 \ V 9 \ \ LremasteMc. \ 1? \ * \ \Knee-Jer7c. '* \ /, \\ 2? /^ , 3 st Gluteat. T ! } K * vN tinkle- \ Veneal. L J \ 9 s * Clonus. \Mcctal. T I * ^^~~^^ ' Plantar?) tiexual. JL J v 4 FIG. 21 1. Diagram and Table of Reflex Actions, showing the Plane in the Cord through which the Reflex occurs, and its level with regard to both the Bodies and the Spines of the Vertebne. (Hill.) reaches as low as the third lumbar vertebra, but in the adult it is opposite the lower border of the first lumbar vertebra. The cervical enlargement extends from the upper end of the cord to the first or second dorsal vertebra, and corresponds to the bodies and 02 PI ate I. Plate II. Diagrammatic view of the sensory distribution of spinal nerve - roots . ANATOMICAL AND PHYSIOLOGICAL INTRODUCTION. 367 spines of the cervical vertebrae. The lumbar enlargement corresponds to the lowest three dorsal and the first lumbar spines. The spinal nerves do not leave the cord at the vertebrae corresponding to them in number ; and inasmuch as disease of the cord or its roots is frequently produced by lesions of the vertebrae or of the spinal mem- branes, it is impossible to make an accurate diagnosis of the seat of the lesion without a knowledge of the relations between the roots and the vertebral spines. These relations, as well as the various levels at which the reflexes occur, are shown in Fig. 211. Distribution of the Spinal Roots. This, so far as it has been ascertained by the labo'urs of Ferrier, Thorburn and others, is in- dicated in the following table. The facts given in the column relating to the sensory distribution of the spinal nerve roots are also shown, diagrammatically, in Plates I. and II. (modified from Thorburn, "Brain," 1893). "It must, however, be fully understood that the boundaries of the areas represented are not to be taken as absolutely defined ; they are merely general delineations of the usual distribution of each root ; " for example, in the case of the sole of the foot, there is no satisfactory evidence as to the true boundary between the first sacral and the fifth lumbar. Relation of Motor and Sensory Functions to Spinal Roots. Xerve Roots. Motor. Sensory. C. 1-3 Small rotators of head. Sterno- mastoid. Trapezius (upper part). Levator anguli- scapulas. Scaleni. Depressors of hyoid bone. Supra- and infra-spinatus. Dia- phragm. Teres minor (?). Scalp and neck. In Plate I., CP represents the area supplied by the descend- ing branches of the cervical plexus. Neck and upper part of chest. Biceps and brachialis anticus. Deltoid. Supinators longus and brevis. Over deltoid and outer aspect of arm and forearm, as far as styloid process of radius. Subscapularis. Pronators. Teres major. Latissimus dorsi. Pec- toralis major. Triceps. Ser- ratus magnus. Extensors of wrist, sors of fingers. Long exten- Central portions of anterior and posterior aspects of arm and forearm. 368 EXAMINATION OF THE NERVOUS SYSTEM. RELATION OF MOTOR AND SENSORY FUNCTIONS TO SPIXAL ROOTS continued. SSEL Sensory. C. 8 Flexors of wrist. Long flexors of fingers. (Inner side of little finger, of hand, forearm and arm. D. i Interossei. Other intrinsic mus- cles of hand. 2-12 Lower part of trapezius. Muscles of chest and abdomen. Erec- tor spinse. Chest and abdomen, and upper part of buttock. L. I Ilio-hypogastric and ilio-iu- guinal. 2 Cremaster. Outer and upper part of thigh. The areas are represented differently on the two sides in Plate I., in order to illus- trate probable variations in the distribution of the second lumbar. 3 Sartorius. Adductor and flexors of thigh. Anterior aspect of thigh. 4 Extensor of knee. Abductors of thigh. Anterior and inner part of leg ; also inner and outer portions of thigh. 5 Hamstring muscles. Outer aspect of leg and foot ; also probably part of back of thigh. Mi 2) Calf muscles and glutei. ^ Intrinsic muscles of foot. ] -g al | sis 3 fcfl 7J o _o proportion to atrophy ; atrophy affects muscles as a No sensory disturbance* Crura . cerebri j Ophthalmo- ! plegiaexterna t or interna. ll whole ; presence of terior roots or RD. (see p. 395); . motor nerves _ fibrillation of sj 6 "rt S " 'ft 02 muscle a variable element ; tendon reactions dimi- nished or lost, oc- casionally exagge- . rated at the onset. [Single Usually some| Mid rf fa nerves disturbance V , of sensation/ ^nerves | Multiple \ neuritis /"Idiopathic. Lead, 1 alcohol, (diphtheria, gout, and rheumatism, diabetes, &c. DISORDERS OF MUSCULAR ACTION. 385 'Weakness in proportion to , atrophy ; atrophy invades Atrophy associated wi0 Pseu do-hy P ertro P hic muscle bit by bit ; no I increase in bulk or j- raivala RD. ; fibrillation absent! muscles or present in slight degree;] Enlargement of muscles^ wi thic progressive tendon reactions normal, may be present but V m ^ scu i ar . a ^ r0 phy. diminished or lost, never I oftener absent ) exaggerated Mode of Investigating a Case of Atrophic Paralysis. In examin- ing a part affected with weakness and wasting of muscular tissue, the following points require investigation : 1. The distribution of the weakness or wasting. 2. The proportion that the atrophy of a muscle bears to its weakness. 3. The presence or absence of sensory disturbance. 4. The electrical reactions of the muscles. 5. The condition of the reflexes (see pp. 418-425). 6. The presence or absence of fibrillary tremors (see p. 371). FIG. 218. Marked Atrophy of the Small Muscles of the Hand of a Boy, the subject of Disseminated Sclerosis. I. Distribution. Atrophic paralysis may be limited in extent, or widespread over the muscles of the body. Limited Paralysis. When weakness and atrophy affect a single muscle, or a group of muscles supplied by one nerve, the lesion is situated in the motor fibres of this nerve, or in its nucleus of origin. Examples: Paralysis of the deltoid from disease of the circumflex nerve ; paralysis of the serratus magnus from disease of the posterior thoracic ; paralysis of the facial muscles from disease of the facial nerve or its nucleus ; paralysis of the extensor muscles of the forearm from disease of the posterior interosseus branch of the musculo-spiral nerve, as in the ordinary form of lead paralysis. 2 B 386 EXAMINATION OF THE NERVOUS SYSTEM. When a group of muscles which act in functional association, but yet are supplied by different nerves, becomes paralysed, there is a lesion of a particular group of cells in the anterior horns, or of certain of the anterior roots, or possibly of the nerve plexus which supplies the affected limb. Examples: Paralysis of the deltoid, biceps, brachialis anticus and supinator longus from disease of the fifth cervical root, or of the upper portion of the cervical enlargement of the spinal cord ; paralysis of the small muscles of the hand from disease of the first dorsal root, or of the lowest portion of the cervical enlargement (see Fig. 218) ; paralysis of the peronei and tibialis anticus muscles from disease of the anterior horn, as in infantile paralysis. Limited atrophic paralysis may have a symmetrical or an irregular distribution. Most of the above examples of paralysis are asymme- trical. A random distribution of weakness and wasting also occurs in FIG. 219. Double Wrist Drop, from a Case of Alcoholic Neuritis. diffuse forms of chronic myelitis. An example of symmetry is afforded by the double wrist drop of lead palsy affecting the extensor muscles of both forearms. Widespread Paralysis. This may be due to a chronic degeneration of the anterior horns or to a multiple neuritis. In both cases a symmetrical distribution of the paralysis may be observed, although symmetry is far less common in disease of the cord than in disease of the nerves. The diagnosis, however, is occasionally very difficult. Thus a patient may have double wrist drop and marked atrophy of the thenar and hypothenar eminences, as a result either of peripheral neuritis or of chronic anterior poliomyelitis. In the former case, as a rule, both arms are simultaneously and symmetrically affected; but in the latter the paralysis is commonly unilateral in onset, and even at a late period of the affection is more marked on one side than the other ; further, there are usually signs of muscular irritability in the DISORDERS OF MUSCULAR ACTION. lower limbs, either spasm of the muscles or exaggeration of the knee- jerks indications that the fibres of the pyramidal tracts are also implicated. Moreover, the diagnosis is usually cleared up in process of time, for a multiple neuritis may be curable, a chronic anterior polio- myelitis is incurable. A widespread, or even a universal, paralysis sometimes occurs at the onset of acute anterior poliomyelitis, but then certain parts quickly begin to recover, while others run on to permanent paralysis and atrophy. The wasting in the myopathic group is usually widespread, but is FIG. 220. Photograph of Woman the Subject of Idiopathic Muscular Atrophy, showing Marked Atrophy of Trapezii, and Projection of Scapulae owing to Atrophy of Serrati. distinguished from the preceding affections by striking peculiarities in regard to distribution. In well-marked examples, the upper arm, the shoulder, and the thigh are the seats of election ; occasionally the face is affected. The thinness of the arm contrasts strongly with the normal-sized forearm, the muscles of which are usually spared with one exception, namely, the supinator longus ; this muscle is commonly much atrophied. The lower portions of the pectoralis major and the latissimus dorsi, the serratus magnus, and the lower portion of the 388 EXAMINATION OF THE NERVOUS SYSTEM. trapezius are also frequently involved. The hands nearly always escape, but both they and sometimes the shoulders are attacked in chronic anterior poliomyelitis, while the face is spared. Furthermore, it is to be noticed in the myopathic group that the atrophy may be found in association with enlargement and increased firmness of certain muscles. Two classes of cases may be distinguished. In the one class, pseudo-hypertrophic paralysis, enlargement of muscles is a conspicuous feature. The muscles of the calf and the infra spinati are most frequently affected. In this disease, then, certain FIG. 221. The same Case as Fig. 220, showing wasting of Pectorales, and the drawing up of the Upper*Angles of the Scapulae (owing to the absence of opposition) by the Levator Anguli Scapulae and upper portion of the Trapezius. muscles are wasted, others are abnormally large, but whether large or small, the diseased muscles are weak. In the other class, idiopathic muscular atrophy, wasting of muscles is conspicuous, while enlarge- ment of muscles is said to be absent, or, if present, is not a striking feature of the disease. But it is difficult to make an absolute distinction between the two classes on these grounds, for if cases of idiopathic muscular atrophy be carefully examined, enlargement and hardness of certain muscles, or DISORDERS OF MUSCULAR ACTION. 389 parts of them, will often be discovered. Thus, it is common to find the upper portion of the deltoid atrophied, while the lower portion is firm and hard, and to find firmness of some of the forearm muscles in association with atrophy of the supinator longus. Arthritic Muscular Atrophy. The atrophic weakness which follows injury or disease of a joint is usually limited to the muscles that move the joint, and is most prominent in the extensor muscles. Thus, if the shoulder is affected, the deltoid chiefly wastes ; if the hip, the glutei ; if the elbow, the extensor muscles of the forearm ; if the knee, the Upper branches of the facial. Trunk of the facial. Mm. retrahen. et attolens. aurtcnl. Muse, occipitalis. Middle branches of the facial. M. styloliyoideus. M. digastricus. Lower branches of the facial. M. corrugator supercilii. M. orbicular palpebr. M. compressor nasi et pyram. nasi. M. levator lab. sup. alaeque nasi. M. levator lab. sup. propr. M. zygomatic minor. M. dilat. nariura. M. zygomatic major. M. orbicularis oris. M. levator menti. M. quadratiis menti. M. triangularis menti. FIG. 222. Motor Points of the Facial Xerve, and the Facial Muscles supplied by it. (Eichhorst.) muscles in front of the thigh. The interossei muscles are strikingly wasted in rheumatic affections of the finger-joints. 2. The Relation between Wasting and Weakness of Muscle. In acute lesions of the anterior horns or of the peripheral nerves, weak- ness is always in excess of atrophy, at least during the active period of the disease. Thus, in infantile paralysis certain groups of muscles may be markedly paralysed before their atrophy is apparent, but at a late period of the affection, atrophy of a limb will be just as con- spicuous as its paralysis. In chronic disease of the anterior horns, 390 EXAMINATION OF THE NERVOUS SYSTEM. weakness and wasting proceed side by side. But the cases in which paralysis is directly dependent on, and proportional to, atrophy of muscular tissue are those already mentioned of idiopathic muscular atrophy. Here muscles waste bit by bit, and their atrophy always precedes and produces their weakness. 3. Sensory Disturbance. The presence of decided sensory disturb- ance, such as pain, hypersesthesia or anaesthesia, in cases of atrophic paralysis is sufficient evidence that disease is not limited to the anterior horns, to the motor nerve-fibres or to the muscles, but that it also involves sensory nerve-fibres, or some portion of the sensory tract. Local tenderness or swelling of a nerve-trunk, or limitation of sensory M. deltoidenB (ant. half) N. axillaris. I N. musculo-cutaneus. M. biceps brachii. M. brach. anticns. N. medianus >I. pronator tores. | M. flex, digitor. commun. profund II. flex, carpi radialis. ' 31. flex, digitor. sublim. M. flex dig 8Ul,l. (dig. ind etinin.) M. flex poll. longus. >. medl- M. abductor pt>lllc. | M opponeiw polIlcU. poll. brev. ibductor polllc- Mm. lumhricalct , let II. M. fle N. ulnariB. 31. flexor carpi ulnaria. Mm. luuilirl- ilesIIIetlV. M. opponens digit uiiu. M. flexor digit, min. M. abductor digit, min. M. pal marls bre. N. ulnaris. FIG. 223. Motor Points of the Median and Ulnar Nerves, with the Muscles supplied by them. (Eichhorst.) disturbance and paralysis to the territory supplied by a particular nerve are certain indications of a peripheral nerve affection. Hyper- sesthesia of the skin or muscles points to a lesion of peripheral nerves or of the posterior roots. A certain amount of pain and hypersesthesia of the limbs may be observed in cases where the lesion affects the posterior and anterior horns, and is limited to the cord. There may also be a more or less persistent zone of hypersesthesia at the upper level of the lesion, but anaesthesia of parts below the lesion is the main sensory phenomenon that is found in association with atrophic paralysis of the muscles when the cord is the seat of disease. It must, however, be borne in mind that pains like those of rheu- DISORDERS OF MUSCULAR ACTION. 391 matism may be present at the onset of cases which turn out to be examples of disease limited to the anterior horns. 4. Electrical Examination. In order to make a satisfactory elec- trical examination it is necessary to have i. A faradic battery, such as the sledge induction coil of Du Bois-Reymond, in which the strength of the current (varying inversely with the distance between the primary and secondary coils) may be read on a scale. 2. A galvanic battery provided with (i) apparatus, either a dial collector of cells or a rheostat, by means of which the strength of the current may be altered, and (2) a current reverser or commutator, which is also commonly employed as an interrupter, although it is more con- N. radialia. M. brachiaL intern M. snpinator long. M. radial, ext. b M. extens M. triceps icaptst ext.) M. triceps (caput long.) M. deltoirleus \ (post. hair. . axillaris). 1 / M. abdnct. digit, min. (N. nlnaria.) Mm. inteross. dorsal. I. II, III, et IV. IN. ulnaris.) FlO. 224. Motor Points of the Radial (or Musculo-Spiral) Xerve, and the iluscles supplied by it (Eichhm-st.) venient to have the interrupter in the handle of the electrode ; (3) a galvanometer graduated in milliamperes ; (4) conducting cords or rheophores; and (5) electrodes of various sizes. Method of Examination. The patient should be placed in a good light, and in such a position that symmetrical parts to be tested may be equally accessible to the operator. Both electrodes, as well as the skin to which they are applied, must be thoroughly moistened with a solution of salt in hot water. One electrode of large size should be fixed over the upper part of the sternum, the other, of smaller size, is held in the operator's hand, and is successively applied (i) over the trunk of a motor nerve, stimulation of which will cause contraction of 392 EXAMINATION OF THE NERVOUS SYSTEM. all the muscles it supplies, and (2) directly over the individual muscles. To* act on the muscle itself the electrode may be placed either over the point where the motor nerve-branch enters the muscle the so-called " motor point " or over some other part of the muscle ;* in the former case the whole muscle will contract, in the latter only the portion irri- Cruralji. Tensor vaginae femoris. Obturator n. Pectineus. Adductor magnus. Adductor longua. Quadriceps. Kectus. Crureus. Vastus externus. Vastus internus. Gastrocnem. Soleus. Flexor long, pollicis. Abductor minim, digit Ext. poplit. n. Tibialis auticus. Ext. digitorum. Peroneus longus. Peroneus brevis. Ext. long. poll. Ext. brev. digit. Dorsal interossei. FIG. 225. Motor Points of Front and Outer Side of Lower Limb. tated. The position of the motor points and the superficial position of the chief motor nerves are indicated in Figs. 222-226 and in Fig. 233. It is best to begin the examination with the faradic or induced current, and then take the reactions at each pole of the galvanic (called also voltaic or constant) battery ; in each case a feeble current should 1 In health, identical effects are obtained by applying the electrodes over the sub- stance of the muscle and over the motor point, but this is not the case in many diseased conditions. DISORDERS OF MUSCULAR ACTION. 393 be first employed, and then gradually increased till a slight contraction is obtained, when the strength of this minimum current, indicated by the deflection of the galvanometer, should be recorded. Sometimes considerable difficulty is experienced in obtaining a reaction, probably owing to an unusual degree of resistance to conduction in the epidermis ; it is then advantageous, after thoroughly moistening the skin, to pass a moderately strong current through the part. We are then more likely to obtain accurate results when the muscles are tested with Gluteus maximus. Biceps (long head). Biceps (short head) Ext. poplit. n Sciatic n. Adductor magnus. Semitendinosus. Semimembranosus. Int. poplit. n. Gastrocnem. (ext. head). Gastrocnem. (int. head). Soleus. Flexor digit, comm. Flexor long. poll. Tibial n. FIG. 226. Motor Points of Back of Lower Limb. (Eichhorst.) feebler currents. In testing with the galvanic battery, the kathodal or negative electrode should first be placed over the nerve or muscle to be examined, a few cells put in circuit, and the current gradually made stronger, till a slight contraction occurs on its closure. With each addition to the strength of the current the "make" or closure should be tried three times with the commutator or hand interrupter electrode ; this is called the kathodal closure contraction (KSC). Then, without removing the electrode, the current is reversed by the commutator ; the 394 EXAMINATION OF THE NERVOUS SYSTEM. exciting electrode is now the positive pole, and in the same way the minimal closure contraction (ASC) is recorded in milliamperes by the galvanometer; finally, the contraction at the opening or "breaking" of the current at the anodal pole (AOC), and, if possible, also the kathodal opening contraction (KOC) should be recorded. Laic of normal contraction : a. Weak currents produce KSc. b. Medium KSC', ASc, AOc. c. Strong KSTe, AOC', ASC, KOC. A = anode. K = kathode. c = feeble contraction. C = medium contraction. C' = strong contraction. Te = tetanic contraction. O = opening or breaking of current. S = closure or making of current. It is seen that ASc is obtained before AOC, but sometimes, as in the case of the musculo-spiral nerve, AOC occurs more readily than ASc. When the belly of a muscle is directly stimulated, we usually only get the closure contractions, and, as a rule, KSc before ASc ;. but not very rarely, especially in testing large muscles, like the quadriceps femoris or the deltoid, ASc is obtained more readily than KSc. Pathological Alterations. The electrical excitability of the nerves and muscles may exhibit changes either as regards quantity or quality, the former being of much less diagnostic importance than the latter. Quantitative Changes. A simple increase or decrease in the excita- bility is determined, in the case of unilateral affections, by comparison with the healthy side of the body ; in bilateral affections by comparison with healthy parts which are known to react to currents of nearly the same strength. This is the case with the ulnar, facial, spinal accessory and peroneal nerves; so that if in disease, e.g., of the muscles supplied by the ulnar nerves, a weaker or stronger current were required than that necessary to excite the peroneal (external popliteal) nerve, it would be fair to assume that the ulnar nerves pre- sented quantitative changes. But in coming to such a conclusion the utmost caution is necessary, owing to the various degrees of resistance, not only of different parts of the surface, but also of the same parts in different individuals. It is, therefore, always essential to appeal to the galvanometer, to repeat the observations at least three times, and to ignore differences that are but slight between the healthy and diseased parts. If a quantitative change is present, it points to an abnormal condition of the motor path, and is of value in discriminating between organic and functional affections. DISORDERS OF MUSCULAR ACTION. 395 A simple increase has been observed in tetany, KSC being readily obtained by a weak galvanic current. It has also occasionally been observed in hemiplegia, in tabes, and in the early stage of peripheral neuritis. A Simple Diminution of electric excitability is met with in cases of simple muscular atrophy, as in pseudo-hypertrophic paralysis, and in the other so-called myopathic atrophies, also in the muscular atrophy asso- ciated with joint affections and with chorea ; also in many of the muscles in cases of amyotrophic lateral sclerosis, and of chronic anterior polio- myelitis, while other muscles give the reaction of degeneration (RD.). In high degrees of lessened excitability it may be necessary, in order to obtain a muscular contraction, to quickly reverse a strong voltaic current from positive to negative ("voltaic alternation"). If with the strongest current no contraction results, then the galvanic irritability is said to be lost. Quantitative and Qualitative Changes. The Reaction of Degene- ration. Complete RD. Unlike the simple quantitative alterations, the nerve and muscle reactions do not run a parallel course, and must therefore be considered separately. Nerves. If a peripheral motor nerve is injured or diseased, or in any way cut off from its trophic centre, or if the trophic centre itself is more or less destroyed, motor paralysis is produced, the nerve degenerates, and the degenerative atrophy spreads to the muscles supplied by the nerve. Sometimes for one to two days after the lesion the nerve excitability increases, but then always begins to diminish, and equally to both currents, and the rapidity of diminution varies with the severity of the lesion. In a case of moderate severity the nerve loses its irrita- bility to both faradism and galvanism by the end of the second week, and the loss continues till about the end of the second month, when slight reactions to strong currents begin to appear, and the irritability gradually increases, but remains for a long time below normal, even after the complete restoration of voluntary power. In an incurable case the non-excitability is persistent. The Muscles behave in a similar way to the faradic current, although the return of faradic irritability is somewhat slower and more gradual. They differ, however, widely from the nerves in their behaviour to galvanism. The galvanic irritability sinks at first, but during the second week begins to rise above normal, and sometimes to increase during the third and fourth weeks, when muscular twitchings may be excited by only a few cells. Instead, however, of the lightning-like contraction seen in healthy muscles, the movement is slow, delayed and prolonged, and if the current is continued is apt to become tetanic- 39 6 EXAMINATION OF THE NERVOUS SYSTEM. Also ASC increases till it equals or surpasses in intensity KSC, and opening contractions may also be obtained, when KOC may be equal to or greater than AOC. The galvanic muscular irritability continues above normal for one to two months, then sinks, while the qualitative changes remain. In incurable cases the galvanic irritability falls lower and lower, till finally a weak sluggish response to ASC is the only evidence that muscular tissue still exists, and in a year or two even this slight reaction may vanish. Partial RD. Here nerve excitability to both currents is preserved, and sometimes the muscles act normally to faradism ; but they pre- sent the same changes to galvanism as in the complete RD. Between the complete and the "partial" type of the RD here described, and between the latter and healthy reactions, there are many varieties, and it is often difficult, when the departure from normal is not great, to say whether or not degenerative atrophy has commenced. The increased excitability of the muscles to galvanism, perhaps only of short duration, may have disappeared before the patient comes for examination, or the undue response at the positive pole may not be distinct, especially in the later stages ; it may indeed be found that KSC is equal to or greater than ASC. There is one sign, however, th#t is never wanting namely, sluggishness of muscular contraction. If the movement is distinctly slower and less lively than in health, the pre- sence of some degree of degenerative atrophy may safely be inferred. The RD occurs in peripheral lesions of the motor nerves, whether of traumatic, rheumatic, alcoholic, or diphtheritic origin ; and in diseases affecting the anterior horns of the spinal cord and the nuclei of the medulla oblongata, as in infantile paralysis, diffuse myelitis, bulbar paralysis and amyotrophic lateral sclerosis. In some cases of lead poisoning the RD has been proved to exist in muscles which appeared to have complete voluntary power. It is of importance to remember (i) that there is no necessary rela- tion between paralysis and the reaction of degeneration, and (2) that no direct information as to the nature of the lesion whether inflam- matory, toxic, or traumatic is afforded by an electrical exploration of the nerves and muscles. Group Of Spastic Paralyses. In this variety of paralysis the muscles maintain their normal bulk, but their tonicity is increased and the affected limbs present varying degrees of rigidity. The increase of tonus may be so slight that it only shows itself by a very slight increase of resistance to passive movements, or so great that the muscles feel as hard as boards even when the limb is at rest, and render movements by their antagonists totally impossible. DISORDERS OF MUSCULAR ACTION. 397 Another peculiarity of spastic paralysis is that the paralysis is diffuse, that is, all the muscles of a limb or of a portion of a limb are para- lysed, and although some muscles are weaker than others, as, for example, the extensors than the flexors, it is rare for any muscle situ- ated within the affected territory to escape some degree of paralysis. In this respect it differs from the atrophic paralyses, which for the most part pick out particular muscles or groups of muscles. Spastic paralysis is evidence that some part of the upper segment of the motor path has its functions impaired or abolished. The condition of the affected part will be the same whether the lesion be situated in the motor cells of the cortex, in the pyramidal fibres, or in their ter- minal ramifications in the grey matter of the spinal cord. The Localisation of the Lesion in a case of spastic paralysis is mainly determined by a consideration of the distribution of paralysis, together with the presence or absence of sensory and other associated symptoms. Spastic paralysis may be hemiplegic, monoplegic, or paraplegic in distribution. Hemiplegia. In the ordinary type some muscles on the affected side are completely paralysed, whilst others are merely weakened or remain entirely unaffected. Thus the limbs and the lower half of the face are paralysed, and the tongue, when protruded, deviates towards the para- lysed side ; but the muscles of the upper part of the face, those of mastication and the muscles of the trunk, present varying degrees of immunity. And, speaking broadly, the degree of paralysis of a part varies directly with the degree of its unilateral use ; for example, the arm, which is habitually used without its fellow, is more paralysed than the leg, while the muscles of the eyes, neck and trunk, which are nearly always bilaterally combined, escape. Weakness of the latter may, however, often be detected when the patient makes a strong effort ; thus, during a deep inspiration, the affected side of the thorax will be found to expand to a less extent than the healthy side ; and when the patient tries to keep his eyes tightly closed, the observer will often be able to detect a diminished resistance of the orbicularis palpebrarum on the hemiplegic side. It should also be noticed that an emotion may cause a muscle to contract when a voluntary effort is unable to do so ; for example, the paralysis of the lower facial muscles may pass unnoticed when the patient smiles, but is at once apparent when he tries to show his teeth. After an attack of hemiplegia the paralysed limbs are affected with tonic spasms, which, according to the time at which they come on, are named as follows : There may be an " initial rigidity," lasting for a few hours ; then an " early rigidity " of a few weeks' duration, to be succeeded by a " late rigidity" which persists as long as the paralysis. 398 EXAMINATION OF THE NERVOUS SYSTEM. In the upper liinb there is usually adduction of the shoulder and pro- nation of the forearm, with flexion of the elbow, wrist and fingers, especially of the distal phalanges. In the lower limb extension predo- minates, while the foot usually presents talipes equino-varus. Such late rigidity lessens during sleep, is partly overcome by placing the limb in warm water, or by faradising the antagonistic muscles ; pro- longed passive extension and friction of the muscles also tend to pro- mote their relaxation. Eventually the active contraction passes into a " structural rigidity," which is necessarily irreducible. The varieties of tonic spasm to which a hemiplegic limb is subject vary very greatly in regard to the degree of rigidity, and sometimes (espe- Fio. 227. Extreme Talipes Equino-Varus in a case of Hemiplegia dating from infancy. cially, perhaps, in cases of syphilitic thrombosis) there is a considerable degree of weakness without any appreciable spasm. When recovery takes place in hemiplegia, the least paralysed move- ments are the first to regain power, while the specialised movements of the hand and fingers, which suffer most, are the last to recover. Recovery is commonly more complete in children than in adults, but the affected limbs are often arrested in their groicth, and the mind may be defective. The above description applies to the ordinary type of hemiplegia, sometimes called "total hemiplegia." This, when persistent, is due to a lesion of the cortex or of any part of the pyramidal tract above the middle of the pons ; when transient, to disease in the neighbourhood of the motor path or centres, injuring or compressing them. Total DISORDERS OF MUSCULAR ACTION. 399 hemiplegia is rare from disease of the cortex or the centrum ovale, and usually depends on a lesion of the internal capsule, affecting the anterior two-thirds of its posterior segment. Hemianaesthesia and hemianopsia in association with hemiplegia indicate disease of the posterior end of the internal capsule, and then, too, the functions of the other special senses may be impaired on the same side as the hemiplegia : in such cases the leg is more paralysed than the arm, and indeed motor weakness is rarely permanent, and may be only slight in degree. Right-sided hemiplegia is usually associated with some degree of motor aphasia, which, however, soon passes away unless the lesion involve the speech-centre in the cortex, or be situated imme- diately beneath it. Slight ptosis on the hemiplegic side suggests disease in or near the cortex, probably of the parietal lobe. Paralysis limited to the limbs on one side, the face and tongue escaping, depends in all probability on a lesion of the upper portion of the motor cortex; but in rare cases the lesion involves one of the anterior pyramids of the medulla or the pyramidal tract in the cord. In the latter case the lesion will be on the same side as the paralysis. When a lesion is so situated that one of the motor cranial nerves is involved as well as the motor path, the muscles supplied by the cranial nerves are in a state of atrophic paralysis, whereas those of the limbs are affected with spastic paralysis. Such combinations will be referred to when the mixed paralyses are considered. Hysterical Hemiplegia differs from hemiplegia of organic origin in the following particulars: The paralysis is rarely complete in both limbs, and the face and tongue almost always escape ; occasionally they are affected by a hemispasm which curls the protruded tongue towards the paralysed side, and then the paralytic deviation of organic hemiplegia is closely imitated. The paralysed limbs may be flaccid, but not infrequently are the seat of contractures, which are character- ised by the varying degrees of resistance they present to attempts made to overcome them at different times. In hemiplegic contraction of some standing, the whole limb cannot be straightened out at once : if, for example, the fingers are straight- ened, the wrist remains rigidly flexed ; but in the hysterical contraction the fingers and wrist may be extended at the same time. The super- ficial reflexes are often lost on the affected side in organic, but fre- quently remain normal in hysterical hemiplegia. The latter is also distinguished by its association with hemiansesthesia, impairment of the special senses, and with various emotional disturbances. Monoplegia. Some writers apply this term to limited forms of paralysis, whether of spinal or cerebral origin, in which all or almost all the muscles of one side of the face or of a single limb are involved ; 400 EXAMINATION OF THE NERVOUS SYSTEM. and hence they speak of a spinal and of a cerebral monoplegia. But the term is more commonly restricted to partial varieties of hemiplegia, which depend on lesions situated either in or immediately beneath the motor convolutions, so that, according to the seat of the lesion, there may be a crural, a brachial, a facial, a brachio-crural, or a brachio-facial monoplegia. These monoplegias are distinguished by the frequency with which the paralysed parts or some part of the affected side are subject to attacks of partial epilepsy. The clonic spasms, as we have already seen (see p. 374), always begin locally, then may spread to the whole of the side paralysed, and ultimately, in some cases, to the opposite side. As a rule, in crural or brachial monoplegia the paralysis is not absolute ; the lowest part of the limb is most affected, and fre- quently presents some impairment of tactile sensibility or of muscular sense. When the leg alone is paralysed, the lesion is usually situated on the mesial aspect that is, in the paracentral lobule or extends but a little on to the outer surface of the hemisphere ; for unless disease of the cortex be close to the longitudinal fissure, the arm becomes involved, and then there is a brachio-crural monoplegia. In a facial monoplegia the muscles on one side of the face are affected in the same relative proportion as in ordinary hemiplegia. As a rule, facial paralysis of cortical origin is complicated by paralysis of the arm, and, when the left hemisphere is the seat of the lesion, by aphasia also. Pseudo-bulbar paralysis, a condition characterised by symptoms closely simulating those of a progressive labio-glosso-laryngeal paralysis, is sometimes produced by bilateral lesions in the lowest portion of the motor region, or by a lesion in the lenticular nucleus of both hemispheres. The general history of such cases is, that the patient has an attack of right hemiplegia, from which he slowly recovers ; this is followed in a few weeks by an attack of left hemi- plegia and aphasia, the symptoms of which also slowly abate in severity, and then it is found that there is paralysis of the muscles of mastication, of articulation, and to some extent of deglutition. Hysterical Monoplegia. Paresis of one limb with marked contrac- tures may follow severe emotional disturbance. It is usually associated with manifestations of the hysterical condition. Paraplegia. A spastic paraplegia indicates disease at the top of each motor area in the cortex, or in some portion of the pyramidal tract between these areas and the centres in the lumbar portion of the cord which preside over the muscles of the lower limbs. For the production of a pure example of spastic paraplegia, that is, spastic paralysis of the lower limbs, unattended by any other symptoms, there must be disease affecting both pyramidal tracts, and restricted to them. It is still doubtful whether such a condition, which has been called primary DISORDERS OF MUSCULAR ACTION. 401 lateral sclerosis, really exists ; certainly in the majority of cases which appear to be of this nature, a careful examination will reveal some impairment of the superficial abdominal reflexes, or other indications that the grey matter of the cord is also implicated. The cases referred to are usually examples of a chronic myelitis, in which the main stress of the disease is on the lateral columns ; or a disseminated sclerosis, in which the other symptoms of this disease, such as nystagmus, scanning speech, and tremors on voluntary movement, are not conspicuous, or have not yet developed. Perhaps the purest examples of spasmodic paraplegia are to be found FIG. 228. Case of Congenital Spastic Paraplegia, associated with mental impairment in birth-palsies, which occur as a result of meningeal haemorrhage at birth, leading to atrophy of the central convolutions. Such con- genital spastic paraplegia may exist alone, but generally it is found associated with difficulties of articulation, mental defect, or other evidence of cerebral disturbance ; it is rare, also, not to be able to detect spasm or other derangement in the movements of the hand. It is worthy of note that in all cases of spastic paraplegia, whether produced by brain or cord disease, the relation between spasm and paralysis of muscle is very variable. They may be associated together 2 C 402 EXAMINATION OF THE NERVOUS SYSTEM. in almost equal proportion, but frequently it will be found that while a limb may exhibit a fair amount of power, each movement is in- terrupted by violent spasm, and the tendon reflexes are greatly exaggerated. In other cases slight spasm is associated with con- siderable weakness. Hysterical or Functional Paraplegia. Paralysis of the lower limbs may develop suddenly in consequence of some emotional disturbance, or occur in anaemic subjects apart from definite symptoms of hysteria. The limbs may be flaccid or present marked contractures. In either FIG. 229. Spasm of Gastrocnemii and of Adductors of Thighs the Spastic Paraplegia following convulsions which occurred immediately after birth. (/Joss.) case the knee-jerks are active or exaggerated, there may be ankle clonus, which usually consists of a few jerks slowly evolved, and often somewhat difficult to develop. Sometimes, however, ankle clonus is well marked, and its characters may be indistinguishable from those which constitute the typical ankle clonus of organic disease. The plantar reflex is frequently absent. Commonly there is spinal tender- ness, and when the patient can stand she complains of an aching back, and frequently that her legs suddenly give way under her. When a patient suffering from spastic paralysis of organic origin places her back against a wall, and tries to raise the anterior part of the foot DISORDERS OF MUSCULAR ACTION. 403 from the ground, spasm of the calf muscles ensues, which fixes the toes still more firmly on the ground ; but in hysterical paralysis the patient is able, and may be induced at times, to raise the anterior part of the foot from the ground. Sometimes in hysteria there is a spastic weakness of all the limbs associated with tremor of more or less changeable type. This con- dition may present a close similarity to disseminated sclerosis, especially in the early stages of this disease ; and when tremor or voluntary movement, nystagmus and scanning speech are absent, the differential diagnosis may be very difficult. As regards disseminated sclerosis, it is useful to remember (i) that a temporary paresis of one limb may be replaced by a temporary paresis of another limb; (2) that obscurity of vision of one eye may be re- covered from, and then be followed by obscure vision in the other eye ; (3) that pallor or atrophy of the optic disc is not uncommon. In hysteria, on the other hand, a shifting of powerlessness from one side to the other rarely occurs, and the characteristic affection of the vision is blindness on one side, the optic discs, however, being perfectly normal. (Buzzard.) Mixed Paralyses. This heading comprises a large number of cerebral and spinal affections, in which spastic and atrophic paralyses are combined in various proportions, and are found associated with sensory, vaso-motor and nutritive disorders. In order to unravel the complicated symptoms of such cases, it is essential to have an accurate knowledge of the two simple classes of paralysis just described ; to be acquainted with the anatomy of the brain and cord, and to know the functions of the cord at different levels, as well as of its roots and principal nerves. A few examples will suffice to illustrate the general principles upon which a diagnosis is to be made. Crossed Paralysis. When hemiplegia is found in association with paralysis of a cranial nerve on the opposite side of the body, the lesion is in or near the origin of that cranial nerve. Thus simulta- neous paralysis of the right limbs and the left third nerve indicates a lesion of the left crus cerebri ; right hemiplegia with paralysis of the left fifth, a lesion in the middle of the left side of the pons ; right hemiplegia with paralysis of the left sixth or seventh nerve, a lesion in the lower part of the pons ; right hemiplegia with paralysis of the left side of the tongue, a lesion on the left side of the medulla. Diseases of the Cord and its Membranes afford many examples of mixed paralysis. The commonest feature of cord disease is paralysis of the lower limbs, which, as we have seen, is of the atrophic or spastic variety, according as the lesion is in or above the lumbar enlargement. 404 EXAMINATION OF THE NERVOUS SYSTEM. In the latter case the muscles of the trunk or arms may also be impli- cated. The various disorders of sensation, of the reflexes, and of the functions of the bladder and rectum which may accompany the para- lysis, and which are described in another place, are also of great help in determining the situation and extent of lesion. Thus the upward extent of paralysis and of the impaired sensation, together with the position of any pain or zone of hypersesthesia around the body, supply important information as to the height of a transverse lesion of the cord, while the condition of the reflexes, the nutrition and tonicity of the muscles, give indications with regard to the vertical downward extent of the lesion. The following groups are given as illustrations of some of the prin- cipal types of spinal disease. Group I. Cervical Pacliymeningitis with Transverse Myelitis. Here disease of the anterior roots gives rise to an atrophic paralysis in the upper limbs ; disease of the posterior roots to sensory disturbance at the level of the lesion, whilst interference with the conducting paths in the cord produces a spastic paraplegia together with anaesthesia of parts supplied below the level of the lesion. The exact height of the lesion may be determined by a knowledge of the functions of the anterior and posterior roots of the cervical nerves (see tables in anato- mical introduction). Thus in pachymeningitis on a level with the eighth cervical and first dorsal roots, the flexors of the wrist and the small muscles of the hand are weak and wasted, hence there is a tendency to extension of the wrist, and the fingers are held like claws, there is also a band of anaesthesia along the inner side of the hand, forearm and arm. Whereas anaesthesia along the outer side of the arm and shoulder with paralysis of the deltoid, biceps and supinator longus are indications that the fifth cervical root is involved. The symptoms of amyotrophic lateral sclerosis at certain periods of the disease may resemble those of pachymeningitis of the cervical region. But in the former disease the atrophy of the upper limb muscles is less random in distribution than in the latter, and is associated with muscular tension and contractures ; and there is an absence of severe pain, of hyperaesthesia and anaesthesia. Group II. Transverse Myelitis in lower part of mid-dorsal region. Spastic paraplegia with anaesthesia of the lower limbs and lower part of the abdomen ; weakness with degenerative atrophy of some of the muscles of the lower part of back and abdomen. Ankle clonus and exaggerated knee-jerks. Disturbance of the vesical, rectal and sexual functions. Epigastric reflex present, but abdominal and cremastric reflexes absent. Plantar reflex exaggerated. Group III. Transverse Myelitis implicating middle and lower por- DISORDERS OF MUSCULAR ACTION. 405 tions of the lumbar enlargement. Atrophic paralysis affecting to vary- ing degree the majority of the muscles in lower limbs. Anaesthesia in territory of nerves supplied by sacral plexus, and in portions of terri- tory supplied by lumbar plexus knee-jerks lost. The plantar reflexes also abolished, but the cremasteric present. Paralysis of the bladder and rectal sphincters, with impaired sexual power. Group IV. Disseminated Myelitis : one focus of inflammation in right portion of cervical enlargement ; another in left side of lumbar enlarge- ment. Atrophic paralysis of some groups of muscles in right arm and in left leg; spastic paralysis of right leg anaesthesia of certain parts of left arm and right leg other symptoms according to number and posi- tion of other inflammatory foci in the cord. FIG. 230. Diagrammatic representation of a Lesion of the Left Half of the Spinal Cord in the Dorsal Region, a, oblique lines motor and vaso-motor paralysis ; b, d, vertical lines com- plete anaesthesia ; c, hypersesthesia, which affects also the left lower limb, as represented by dots. (Erb.) Group V. Unilateral Lesion of the Cord ; the left half of the mid- dorsal region being destroyed. Anaesthesia of the right leg and right half of the abdomen nearly up to the level of the lesion, where there is a band of hypersesthesia. Paralysis of the left leg, the skin of which is hypersesthetic ; above the hypersesthetic area of skin there is usually an anaesthetic zone, which corresponds with the level and vertical extent of the cord lesion ; above this zone a narrow hyperaesthetic belt may sometimes be detected, which joins that on the opposite side (see Fig. 230). Loss of muscular sense in the paralysed leg; also vaso-motor disturbance on the side of the lesion, usually declared by an elevation of temperature of the paralysed limb. 406 EXAMINATION OF THE NERVOUS SYSTEM. The reflex actions on the side of the lesion are usually increased, but are not materially altered on the other side. PARALYSIS OF THE BLADDER AND RECTUM. The wall of each viscus contains muscular fibres to expel the con- tents, while the presence of a sphincter at the mouth of each prevents continuous evacuation. These muscles are under the control of centres in the lumbar enlargement of the spinal cord, which are themselves partially governed and brought under voluntary control by means of fibres passing between them and centres in the cerebral cortex. The lumbar centre is connected with the periphery by means of afferent and efferent fibres, the former passing from the mucous membrane lining the viscus to the lumbar centre, the efferent from this centre to the sphincters and muscular walls of the viscus. Complete and permanent relaxation of the sphincters only occurs when the lumbar centres are destroyed. Thus, in cases of myelitis implicating the lower portion of the lumbar enlargement, there is fre- quently "paralytic incontinence" of urine and faeces that is, urine dribbles away continuously, and fa?ces escape as soon as they enter the rectum. Intermittent incontinence of urine may occur when the voluntary path above the lumbar centre is interrupted. Then any sudden move- ment or pressure on the bladder will cause the urine to be expelled. But loss of voluntary power leads to weakness of the detrusor muscle ; hence the bladder is never thoroughly emptied, and when the detrusor is completely paralysed there is retention of urine. Associated with retention there is " overflow incontinence," because there is enough pressure in the bladder to force urine out when the sphincter relaxes. Overflow incontinence is a more serious condition than paralytic incon- tinence of urine, because it indicates incomplete emptying of the bladder, the too frequent results of which are decomposition of urine, cystitis and serious kidney disease. Retention of urine and overflow incontinence occur not only when the voluntary path is interrupted as, for example, by a myelitis in the dorsal portion of the cord but also from disease of the cerebral cortex, especially when this entails lowering of the mental functions. Im- perfect emptying of the bladder, and a tendency to retention and incontinence of urine, are met with in locomotor ataxia. As Dr. Growers has pointed out, the condition of the sphincter ani is best tested by introducing the finger into the rectum. When the lumbar centre is destroyed, the finger feels a momentary contraction, due to local stimulation of the sphincter, but this is followed by com- DISORDERS OF MUSCULAR ACTION. 407 plete and permanent relaxation. But when the centre is intact, and disease is situated at a higher level as, for example, in cases of transverse myelitis of the dorsal cord then the initial relaxation of the sphincter which follows introduction of the finger is succeeded by firm tonic contraction. v Perversion of Muscular Action, there being no necessary alteration in Strength Incoordination of Movement Ataxia. In every voluntary movement several muscles are brought into play, and if the movement is to be successful, each muscle used must contract in such a way and to such a degree that its strength is accurately proportioned to that of its fellows. Thus, when the hand is stretched out, and a small object, such as a pin, picked up from the table, the contractions of the many muscles employed, from those of the scapula to those of the finger and thumb, must be exceedingly accurately adjusted, for if there is the slightest irregularity in the balance, either of individual or of associated activity, then the object is missed. The power of selecting the right muscles and of correctly regulating their activities is called coordination ; and a movement executed in the manner prescribed is called a coordinated movement. But when there are errors in the balance or equilibrium of the con- tractions of the different muscles then the movement is incob'rdinated. and the condition is called incoordination or ataxia. Accurate adjustment of muscular action is necessarily impaired by weakness, or by spasm of any muscle employed in a particular move- ment ; but such imperfections of movement are not included under the term "ataxia." And although paralysis or spasm may be found in association with ataxia, the latter frequently exists without either. But while it is true that a want of proportion may be found between the actions of individual muscles, apart from detectable alteration in their strength, it is nevertheless sometimes difficult to discriminate between cases of ataxia and cases where certain muscles are weak or the seat of spasm. For example, in many cases of writer's cramp there is spasm, and sometimes weakness of the special muscles used in writing, but in other cases there is no obvious spasm or weakness, and it may be difficult to give a mechanical explanation of the muscular irregularities displayed in the attempt to write, such muscular irregu- larities often closely resembling the disorderly movements of ataxia. The difficulty referred to, however, is mainly limited to minor defects in muscular action ; for, as a rule, a careful examination will enable us to decide whether certain defects in the movement of a part are due to incoordination or to paralysis. Also, when the two conditions are combined, as in ataxic paraplegia, the incoordination of movement is 40 8 EXAMINATION OF THE NERVOUS SYSTEM. still recognisable unless paralysis is profound. Similar remarks might be made with regard to the motor defects met with in multiple peripheral neuritis, especially when caused by alcohol. The gait in alcoholic paralysis has indeed frequently been called ataxic, but in the majority of cases its peculiarities are clearly due to weakness of certain groups of muscles; in rare cases, however, of peripheral neuritis true ataxia does occur. The actions of a child learning to walk have sometimes been quoted as an illustration of incob'rdination occurring in health. But the peculiarity of the gait of a young child is the want of dorsal flexion of the foot, and the consequent marked flexion of the thigh on the body in order to clear the foot from the ground. This is imperfect voluntary control over the flexors of the foot on the leg, and not ataxia. Incob'rdination of movement is most conspicuous in tabes dorsalis or locomotor ataxia. In this disease it is usually earliest and most strikingly seen in the lower limbs. If a patient, while lying on his back, be told to touch the knee of one leg with the toe of the other foot, or to describe a circle in the air with his foot, the ineffectual efforts of the disorderly movements of the limbs are well brought out. The incoordination is always increased by closure of the eyes (Romberg's symptom). Thus at an early period of the disease the patient, when standing with his feet close together and his eyes shut, totters and sways, and may even fall to the ground. Curiously enough, closure of the eyes often increases the unsteadiness of an ataxic patient who is quite blind. Romberg's symptom is most marked when sensation is lost in the soles of the feet, but it also occurs ichen the cutaneous sensibility is quite normal. It must also be observed that great mus- cular power, as exhibited in resistance to passive movements, may be associated with the most marked ataxia. When tabes dorsalis is fully developed, the patient can only stand securely, even with his eyes open, when the feet are wide apart, and the great effort to maintain equilibrium is evinced by the irregular movements of the tendons on the backs of the feet. The disorderly movements of the legs in walking also testify to the presence of in- coordination (see ataxic gait, p. 78). In Friedreich's disease the upper limbs may be affected at the same time as the lower, but in ordinary tabes their movements become disorderly at a later period of the disease. At first there is inability to execute delicate movements, such as writing ; the patient is also unable, when his eyes are closed, to touch a prescribed spot, such as the tip of his' nose : when the ataxia of the hand is well marked, the fingers fumble in buttoning and unbuttoning the clothes, an object is reached and grasped in a roundabout and uncertain fashion ; and at DISORDERS OF MUSCULAR ACTION. 409 an advanced stage of the disease the patient may be totally unable to dress himself or to convey food to his mouth. Ataxia may occasionally affect the muscles of the trunk. Thus, Dr. Gowers mentions a case of locomotor ataxia in which the patient " could sit steadily on a chair when his eyes were open, but if he closed them would at once fall off." In severe ataxia involuntary movements, sometimes indistinguish- able from tremor, may affect an outstretched limb. This has been called static ataxia. Incoordination of movement, closely resembling that of locomotor ataxia, occasionally occurs in diphtheria and as a sequela to the acute FIG. 231. Two Brothers presenting the characteristic Symptoms of Friedreich's Disease, viz. : Incoordination of movement, absence of knee jerks, jerky tremor, lateral nystagmus, slurred hesitating speech, and curvature of the spine. (Brain, 1886.) For a description of the foot deformity and the gait, see pp. 74, 79. specific fevers. It may also be observed in some cases of hysteria; the patient may be unable to stand steadily when the eyes are closed, and all voluntary movements may exhibit a jerky unsteadiness. Ataxic Paraplegia. In this disease ataxia is combined with a spastic weakness of the lower limbs. The knee-jerk is exaggerated, not lost, as in locomotor ataxia, and sensory disturbances are rarely present. Reeling Movements, in which the patient sways from side to side or from front to back, occur in cerebellar disease, and chiefly when the middle lobe is involved. The gait in such cases is very like that due to alcoholic intoxication. The unsteadiness occasionally resembles that of locomotor ataxia, but, as a rule, the irregular jerky movements of 410 EXAMINATION OF THE NERVOUS SYSTEM. the legs are not present ; the staggering is due rather to a swaying of the whole body than to disorderly movements of the lower limbs. This " cerebellar ataxia " rarely involves the upper extremities. It is often associated with vertigo, severe headache, and optic neuritis, and there may be indications of motor paralysis from pressure on the pons or medulla. Similar derangements of coordination occur in Meniere's disease, in combination with vertigo, noises in the ears and deafness on one side. Sometimes there is vomiting, but in uncomplicated cases marked headache, optic neuritis and paralysis of the limbs are absent. DISORDERS OF SENSATION. Disorders of sensation may result from injury or disease of any portion of the sensory apparatus, whether it be a peripheral end organ, as the eye, or a tactile corpuscle ; a sensory nerve- fibre or a ganglionic nerve-centre. They comprise : (i.) An excess of the normal sensibility of a part, hypercesthesia. (2.) A diminution or loss of the normal sensibility of a part, anaesthesia. The terms liy per algesia and analgesia are some- times employed when excess or diminution of sensibility is limited to the application of painful stimuli. (3.) The presence of pain in the absence of an external stimulus. (4.) The presence of abnormal sensa- tions, such as tingling, numbness, crawling, itching, " pins and needles," feelings of cold or heat. These may occur apart from any external stimulation, and are called par&sthesice. (5.) Acceleration and retardation of sensory perception. In the present section attention will be given to the chief disorders of cutaneous and muscular sensations. The examination of the cutaneous sensibility is often attended with difficulty, and requires much patience on the part of the investigator. He has to rely on the intelligence, honesty and goodwill of the patient, and must be constantly on his guard against erroneous statements, whether intentional or unintentional. The patient may complain of numbness in certain parts, which, when examined, appear to be normally sensitive, or he may be totally unaware that the sensibility of a part is increased or diminished until it is objectively tested. Again, when the loss is only partial, the boundaries of the affected part may vary with each examination, and it may require much skill and judg- ment to strike an average. In applying the tests, the following rules should be observed : 1. The patient's eyes must be closed. 2. Direct him to say " Yes " immediately he feels the skin touched, and let him then indicate the part touched. DISORDERS OF SENSATION. 411 3. Compare corresponding points on the two sides of the body. Tactile Sensibility may be tested by means of the observer's finger, or by a light touch with a feather. The Sense of Locality is tested by asking the patient to indicate with closed eyes the part touched, and in health the error is small. A more accurate test is to be found in the minimal distance at which two points touching the skin are recognised as two. This test may be applied by means of a pair of compasses, or by an sesthesiometer, such as that devised by Sieveking. The distance at which the points are recognised as separate varies in health according to the part of the body touched, being, for example, 1.5 mm. at the tip of the tongue, 2.3 mm. at the tips of the fingers, and as much as 70 mm. on the upper arms and thighs. The power of discrimination varies, too, with the intelligence of the patient, and may be increased by practice. The Sense of Pressure is tested by applying different weights to the FIG. 232. ^Esthesiometer of Sieveking. parts to be examined, which should be properly supported, in order to exclude the sense of muscular contraction. Also, it is desirable to interpose a disc of wood, or other non-conducting substance, to exclude the sense of temperature. The maximum variation recognisable in health is about one-twentieth of the total pressure. Sensibility to Pain is best tested by pinching a fold of skin, or by pricking the skin with a pin or point of a quill pen. The faradic current is a delicate method of comparing the sensitiveness of corre- sponding regions on the two sides. Faradic sensibility may be diminished when all other forms of cutaneous sensibility are normal. This is frequently observed in cases of sciatica ; it occurs also in cases such as lead paralysis where there is well-marked motor paralysis. The Rapidity of Sensory Conduction is determined by noting the interval between a prick and the signal given by the patient directly he feels it. In health the interval is much less than a second, but in locomotor ataxia there may be a long delay, even several seconds. 412 EXAMINATION OF THE NERVOUS SYSTEM. Sensibility to Temperature, often affected with the sensibility to pain, is most conveniently examined by applying hot and cold spoons to the part, or two test-tubes, one tube being filled with hot, the other with cold water. Muscular Sense. In addition to common sensibility, as illustrated by the pain of cramp, or that produced by squeezing the muscles, the Hose, temporal!*!. Muse, masseter N. hypoglown*. Muse, sternothyreoldeus. Muse, omohyoideus. No. thoracic! anteriorea. Unsc. splentus. Muse, steniocleiilomastoidens. N. accessorius NUM. levator anguli scapulae. Muse, cucullarla or t rapeziua. N. dorsalis scapulae. >". axillarls. N. thoracicus longus N. phrenlcu*. Erb's Supraclavicular- Fio. 233. Distribution of the Sensory Nerves on .the Head, as well as the Position of the Motor Points on the Neck. SO, area of distribution of supraorbital nerve ; ST, supratrochlear ; IT, infratrochlear ; L, lacrintal; JV, ethmoidal; JO, infraorbital ; B, buccinator; SM, subcutaneus malte ; AT, auriculo-temporal ; AM, great auricular ; 03fj, great occipital ; OMi, lesser occipital ; C 3 , three cervical nerves ; CS, cutaneous branches of the cervical nerves ; C, W, region of the central convolutions ; SC, region of the speech centre. degree of contraction of the muscles is appreciated by the mind. This sense of muscular effort may be tested by placing various weights in a bag and suspending it to the part to be examined. In health, a differ- ence of one-fortieth of the whole weight can be recognised. Recognition of Posture may also be regarded as a part of muscular sense. It is tested by asking the patient, whose eyes are covered, to DISORDERS OF SENSATION. 413 move a liinb into certain prescribed positions, thus to touch the tip of the nose with his index finger, to describe an imaginary circle with his great toe, or a limb is firmly grasped by the observer, and moved about in various directions, the patient being asked to indicate its position after it has been brought to rest. The muscular sense is often strik- ingly impaired in locomotor ataxia, also sometimes in hysteria and in cortical lesions. Modifications of Cutaneous and Muscular Sensations, with their Diagnostic Value. Anaesthesia. The degree of ansesthesia, me FIG. 234. Distribution of the Cutaneous Nerves of the Upper Limb (after Henle). Sc, supra clavicular ; ax, circumflex ; cmd, area supplied by nerve of Wrisberg and intercosto-humeral cps and cpi, branches of musculo-spiral ; cm, internal cutaneous ; el, musculo-cutaneous ; me, median ; ra, radial ; t, ulnar. whether partial or complete, its variety, whether limited to touch or pain, afford, as a rule, but little help in the localisation of a lesion. Complete anaesthesia of a part is more common in hysterical than in organic affections of the nervous system. In hysteria, too, the anses- thesia is often remarkable for the abruptness of its limitation and its want of correspondence to the anatomical distribution of the cutaneous nerves or spinal roots ; thus it may affect one upper limb below the level 4 I 4 EXAMINATION OF THE NERVOUS SYSTEM. of a line drawn round the middle of the arm, or the whole of one side of the body, with the exception of the leg below the level of the patella. In syringo-myelia a disease characterised by the association of muscular atrophy and anaesthesia in the upper part of the body the loss of cutaneous sensibility is mainly confined to pain and temperature; occa- sionally, however, tactile sensibility is also involved. But in other diseases as, for example, peripheral neuritis the most frequent form of partial diminution of cutaneous sensibility is analgesia, with pre- servation of the tactile sense. " Anaesthesia dolorosa," in which an anaesthetic part is the seat of violent pains, if not of functional origin, is usually limited to affections of the posterior roots or peripheral nerves. The most important feature to be investigated is that of distribution. When sensation is impaired over the lower half of the body and the lower limbs, the condition is called paranaesthesia ; when over the lateral half of the body, including half the face and the extremities, it is called hemiancesthesia. In other cases, anaesthesia is limited to the area of distribution of particular nerves, or it is distributed in limited bands or patches. Paraiisestliesia testifies to a lesion of the spinal cord or of the cauda equina ; and is usually associated with paralysis of the lower limbs. The distribution and variety of the paralysis is then the best indication as to the nature and position of the lesion ; but the exact height on the limbs or body to which the anaesthesia extends furnishes a reliable guide to the upper level of the lesion. Hemiansesthesia. Loss of sensation involving the whole of one side of the body points to a lesion in the opposite side of the brain. When the loss of sensation is combined with impairment of the special senses, the lesion is situated in the opposite cerebral hemisphere, and most frequently at the hinder end of the internal capsule. This condition of unilateral anaesthesia, affecting the special senses as well as the skin and mucous membrane as far as the middle line of the body, occurs also in extensive organic lesions of the cortex, but more commonly in hysteria (functional lesion of the cortex). In hysterical hemiansesthesia, every form of cutaneous sensibility, as well as common sensation in the accessible mucous membranes, muscles, bones, and other deep structures, is more or less completely lost on the affected side, and even the muscular sense is often impaired or abolished. The special senses are likewise implicated ; the senses of taste and smell are generally lost on the affected side, while hearing on that side is only impaired, and the affection of sight consists of a restriction of the fields of vision for form, and especially for colour, affecting to some extent both eyes, but most markedly the eye on the anaesthetic side. DISORDERS OF SENSATION. 415 Sometimes, in hysteria, anaesthesia of one side of the body is associated with hypersesthesia and paralysis of the opposite side. Hemiansesthesia of organic origin is usually less profound than that produced by hysteria, and when dependent on disease of the internal mj FIG. 235. Distribution of the Cutaneous Nerves of the Lower Limb (after Henle). A. Anterior surface i, anterior crural, middle and internal cutaneous branches ; 2, external cutaneous ; 3, ilio-hypogastric ; 4, genito-crural ; 5, ilio-inguinal ; 6, posterior cutaneous and other branches of small sciatic ; 7, obturator ; 8, greater saphenous ; 9, external posterior cutaneous; 10, musculo-cutaneous ; n, anterior tibial; 12, communicans tibialis. B. Posterior surface i, posterior cutaneous; 2, external cutaneous; 3, obturator; 4, posterior cutaneous with filaments of tibial communicating; 5, posterior cutaneous branches of peroneal ; 6, long saphenous ; 7, communicans tibialis ; 8, calcanean of posterior tibial ; 9, internal plantar ; 10, external plantar. capsule, is found associated with hemianopsia instead of the visual defect just described as characteristic of hysteria. Hemiansesthesia without disturbance of smell or sight may result from damage to the sensory tract between the pons and internal capsule. Hemianeesthesia with normal sensibility of the face, or a 4 1 6 EXAMINATION OF THE NERVOUS SYSTEM. crossed anaesthesia in which the face is affected on one side and the limbs on the other side, occur in lesions of the pons and medulla. Slight impairment of sensation on one side is not uncommon in hemiplegia of the ordinary type, but as a rule it is transient ; whereas, when hemianaesthesia is distinct and permanent, there may be but little motor weakness, and this usually affects the leg more than the arm. Limited Anaesthesia. Examples: i. The slight blunting of tactile sensibility at the extremity of a limb which is paralysed by disease of the cerebral cortex. 2. Patches of anaesthesia along the course of nerves whose roots are damaged by spinal caries or by tumours of the cord. A knowledge of the functions of the spinal roots (see tables and plates) is then essential in order to determine the locality of the lesion. 3. Areas of anaesthesia in affections of the peripheral nerves. Here it must be borne in mind that the conduction of sensory fibres in a mixed nerve is much less readily impaired than that of the motor fibres. Thus a lesion of the ulnar nerve may be unattended by any anaesthesia of the skin when the muscles supplied by it are more or less completely paralysed, or the muscles supplied by the fifth cranial nerve may be weak and wasted while the cutaneous sensibility of the face is unaffected, and yet post-mortem a tumour is found which compresses and flattens out apparently to an equal degree all the fibres of the nerve. Hyperaesthesia. This may be widely distributed, or limited to certain spots. It may affect the skin, the organs of special sense, the muscles, or other deep structures. A general hyperaesthesia of the surface of the body is a prominent feature of hydrophobia, and occurs also in hysteria. Hyperaesthesia of one side of the body is a rare phenomenon, and, apart from hysteria, is chiefly met with in disease of the pons. Of local varieties of hyperaesthesia, the narrow band of over- sensitive skin at the upper level of spinal lesions is one of the most common. It is most marked in cancer of the vertebrae, but is also usually well developed in caries of the spine, and in the various forms of spinal meningitis. The position of this zone is readily ascertained by pinch- ing the skin along the sides of the trunk. It frequently encircles the body, extending forwards and a little downwards from one or more tender vertebral spines. When the spinal tenderness is not very obvious, it may be brought out by passing a hot sponge down the spine, or by the application of the kathode of a galvanic battery. When the posterior roots of the cervical or lumbar enlargement are implicated in a meningitis, bands of hyperaesthesia will be found on DISORDERS OF SENSATION. 417 those parts of the surface which are supplied by the irritated roots. Thus increased sensitiveness along the outer side of the upper limbs from shoulder to thumb points to irritation of the fifth cervical root. Hyperaesthesia of the skin and muscles is prominent in cases of neuritis ; and an accessible nerve-trunk like the ulnar may be swollen as well as tender to pressure. In alcoholic multiple neuritis the muscles are often extremely sensitive, great pain, for example, being caused by slightly squeezing the calves or fleshy parts of the arms. The pain of neuralgia is frequently accompanied by increased sensi- tiveness of the skin, more marked usually to tactile than to thermal impressions. The hyperaesthesia is commonly most intense at certain spots; these "points douloureux" usually correspond to a superficial part of the nerve, to its divisions, or to its union with another nerve- trunk. Hypersesthetic spots are also common in hysteria. Thus there may be tenderness of the spine or of the infra-mammary or hypochondriac regions, or over certain areas of the thorax or abdomen. Of the latter, the most frequent and characteristic are the ovarian regions, where tenderness may be superficial or deep. Pressure over the ovarian regions, or indeed sometimes over hyperaesthetic spots in any part of the body, may cause great distress and give rise to fainting, to globus, or even to convulsive attacks ; hence these hyperaesthetic areas have been called "hysterogenic." The local tenderness of the dorsal spine in hysteria may be contrasted with that around the sides of the body in vertebral caries. Parsesthesia. This term includes : 1. The presence of abnormal sensations in the absence of any out- ward stimulus. Thus (a.) subjective tactile sensations, as formication, a feeling of creeping, as if ants were crawling over the skin ; itch- ing and the like. (b.) Subjective painful sensations, such as stinging, pricking, or smarting, (c.) Subjective sensations of heat and cold. 2. Perversion of the cutaneous sensibility that is, the production by an external stimulus of a feeling different from that experienced in health. Thus a touch of the finger may give rise to pain, a prick to a burning sensation, the application of cold to a stinging sensation. Sometimes a single touch is felt as two, three, or even five points ; this is called polyaesthesia. In other cases a patient is unable to tell what part is touched, and he may refer an impression on one side to a correspond- ing place on the opposite side of the body then the condition is named allocheiria. The above modifications of normal sensation may occur from disease 2 D 4 1 8 EXAMINATION OF THE NERVOUS SYSTEM. of any part of the sensory tract. The varieties of perverted sensibility are especially common in locomotor ataxia. Numbness, tingling, creep- ing and cold sensations are frequently complained of during the early stages of peripheral neuritis ; they also occur at the onset of acute brain lesions, especially when the hinder end of the internal capsule is directly or indirectly implicated. In disease of the cerebral cortex the cutaneous sensibility may give normal results to the ordinary tests, and yet the patient be unable to recognise the nature of objects placed in his hand, or to tell accurately the position of the affected limb. DISORDERS OF REFLEX ACTION. The mechanism necessary for a reflex action consists of a sentient surface connected by an afferent sensory nerve with a ganglonic centre, which is in relation by means of afferent nerve fibres with muscular or other irritable tissue. Disorders of reflex action will occur when any part of this machinery is irritated or destroyed, or when it is cut off from the controlling influence of higher centres ; and the disorders will be manifest in parts, chiefly glands and muscles, to which the efferent nerves are distributed. Hence abnormal reflex phenomena may show themselves either (i) in the modification of some secretion, a striking example of which is afforded by the complete suppression of urine which occurs as a result of severe injuries to the abdominal viscera, or (2) by changes in the nutrition or action of certain muscles. A third group of cases, closely allied in their nature to ordinary reflex actions, is constituted by examples of reflex neuralgias and of reflex or referred pains. Thus a neuralgia limited to the fifth cranial nerve has been known to follow injury to the ulnar nerve. Refeired pains, such as pain in the testicle from renal colic, in the shoulder from pleurisy, are of much interest and importance. Here also may be mentioned the transient blindness called "reflex amblyopia" which in rare cases follows irritation of the fifth cranial nerve by a diseased molar tooth. The present section is, however, mainly devoted to the second group, viz., to Reflex Disorders of Muscles. Irritation of a sentient surface may cause an alteration in the strength of a normal reflex movement, or it may lead to changes, temporary or permanent, in the tone or nutrition of muscles. Reflex movements may be produced in health either by stimulation of the skin or accessible mucous membranes, or by excita- tion of tendons, fasciae, or periosteum. The former are called super- ficial, the latter deep reflexes. The Superficial Reflexes include the cutaneous and the cranial DISORDERS OF REFLEX ACTION. 419 reflexes. The cutaneous reflexes consist of quick muscular contrac- tions, caused by tickling the skin with a feather or the finger, or by scratching or tapping it sharply. The following (tabulated after Gowers) may be readily obtained in health, especially in young chil- dren, and alterations of their natural vigour are often of great signi- ficance in disease : Name of Reflex. Mode of Excitation. Nature of Result. Level of Cord upon which Reflex Depends. Plantar. Stroking sole of foot. Movements of toes ; Second sacral nerve of these and foot ; (lower part of lum- or of these and bar enlargement). leg. Gluteal. Stroking skin of Contraction of glu- Fourth and fifth lum- buttock. tei. bar nerves. Cremasteric. Stimulation of skin Retraction of tes- First and second lum- at upper and in- ticle. bar nerves. ner part of thigh. Abdominal. Stroking abdominal Contraction of up- Eighth to twelfth walls downwards per or of lower dorsal nerves. from costal mar- part of abdominal gin to nipple-line. muscles. Epigastric. Stroking side of A dimpling of cor- Fourth to sixth or chest downwards responding side of seventh dorsal from nipple. epigastrium. nerves. Scapular. Irritation of inter- Contraction of sca- Sixth cervical to se- scapular region. pular muscles and cond dorsal nerve. of portion of axil- lary fold. Clinical Value. In forming an opinion of the vigour or feebleness of the cutaneous reflexes, it should be borne in mind (i) that they vary much in different normal individuals; (2) that they are usually more marked in children than in adults, and in women than in men ; (3) that it is often difficult to elicit the abdominal reflex when the belly is large and flaccid, and that the cremasteric reflex is often absent in elderly men ; and (4) that occasionally repeated trials fail to produce some of the reflexes, as the gluteal and scapular, even when there is no reason to suspect disease of the nervous system. Keeping in view these precautions, the following conclusions may be drawn : The presence in average strength of a cutaneous reflex indicates that the reflex arc upon which it depends is intact and probably healthy. Exaggeration of a cutaneous reflex suggests either that some part of the arc is irritated or that it is separated from the control of a higher centre. Thus the reflexes are increased when the grey matter is un- duly stimulated, as in tetanus and strychnine poisoning, or in conse- 420 EXAMINATION OF THE NERVOUS SYSTEM. quence of irritation of the posterior and anterior roots (the afferent and efferent portions of the reflex arc respectively), as in cases of pachymenin- gitis. Commonly, too. they are exaggerated when there is disease of the cord above their level ; sometimes there is an initial inhibition of reflexes, which subsequently are found to be increased. A lasting diminution or absence of cutaneous reflexes below the level of the ori- ginal lesion is usually attributed to downward extension of the disease in the cord, but Bastian holds that a complete transverse myelitis, say of the cervical region, will of itself sometimes cause abolition instead of exaggeration of the reflexes at a lower level. Diminution or absence of a cutaneous reflex points to a defect at some part of the reflex arc. 1 Thus, in infantile paralysis affecting one of the lower limbs, the cremasteric reflex may be lost while the plantar is retained, because the upper but not the lower part of the lumbar enlargement is diseased. In dorsal myelitis the condition of the reflexes often affords valuable information as to the seat of disease; thus, if the epigastric reflex is normal and the abdominal absent, we may assume that the cord is affected between the sixth and tenth dorsal nerves. As a rule, in myelitis, and also in locomotor ataxia, the degree of enfeeblement of the reflexes varies with that of tactile sensibility, although sometimes it will be found that the reflexes are lost above the line of anaesthesia. In disseminated sclerosis loss of the abdominal reflexes is sometimes a valuable indication that the grey matter of the cord has become involved. In hemiplegia of organic origin the superficial reflexes are usually enfeebled or lost on the para- lysed side, but in hysterical hemiplegia they are generally normal, with the exception of the plantar reflex, which is frequently lost. Loss of the plantar reflex is also a characteristic feature of damage to the cauda equina. The chief cranial reflexes are : 1. The closure of the eyelids caused by irritation of the conjunctive. 2. The contraction of the pupil to light, or its dilation by irritation of the skin of the neck. 3. Spasm of the facial muscles by irritation of the fifth nerve. 4. Sneezing and lacrimation by irritation of the nasal mucous membrane. 5. The contraction of the palate by irritation of the fauces. The palate reflex is enfeebled or lost in hysteria, also in bulbar paralysis. The pupil reflexes are considered under the examination of the eye. 1 Diminution of a reflex is shown not only by its weakness and by the difficulty in obtaining it, but also by the slowness of the movement. DISORDERS OF REFLEX ACTION. 421 The Deep Reflexes. The Knee- Jerk or Patellar Tendon Reflex is the forward jerk of the foot and leg, which is produced by tapping the ligamentum patellae with the tips of the fingers, the inner border of the hand, a percussion hammer, or the edge of the ear-piece of the stethoscope. If a doubtful result is obtained, the knee should be laid bare. The jerk is caused by sudden contraction of the quadriceps, and it is essential that this muscle should be stretched to a certain extent. This is usually obtained by crossing the leg to be tested over the other ; the knee of the supporting leg being at a right angle. Another FIG. 236. Method of obtaining the Knee-jerk. convenient posture is to get the patient to sit on the edge of a table, or, if a child, on the edge of a chair. In stout persons who cannot cross one knee over the other except in a stiff fashion, the operator may support the limb to be examined by passing his hand beneath the patient's thigh and grasping the opposite knee. Some patients appear to have great difficulty in keeping the knee loose ; in such cases the muscular tension may often be overcome by getting the patient to hold up his head, open his mouth, or put out his tongue ; and it is also helpful for him to interlock the bent fingers 422 EXAMINATION OF THE NERVOUS SYSTEM. of each hand, and to pull strongly while the ligamentum patellae is being struck (see Fig. 236). When the patient is confined to bed, the knee should be slightly flexed and the thigh supported just above it. It is also frequently useful to push down the patella with one hand, while the patellar tendon is struck with the other. In health, the facility with which the knee-jerk may be obtained varies in different persons, but to a less extent than the cutaneous reflexes. It is commonly more sluggish in the child than in the adult, but is more active in infancy, and is readily obtained at birth. It is often difficult to elicit in elderly persons. Exaggeration of the knee-jerk occurs: (i.) In phthisis and other exhausting or febrile diseases. (2.) In hysteria and in chronic rheu- matism. (3.) In tetanus and in poisoning by strychnine. (4.) It is a marked feature of all forms of spastic paralysis ; thus, in hemiplegia the knee-jerk is increased on the paralysed side, and often, too, on the other side ; in lateral sclerosis, whether primary or as a part of disseminated sclerosis, or of amyotrophic lateral sclerosis. In the last-mentioned disease exaggeration of the reflex is found in association with muscular atrophy. Occasionally muscular spasm is so extreme that the knee phenomenon cannot be properly elicited ; this is sometimes the case in the spastic hemiplegias of infancy. (5.) It is not uncom- mon in the early stage of peripheral neuritis. Enfeeblement or absence of the knee-jerk occurs whenever any portion of the reflex arc is interrupted, thus : (i.) In locomotor ataxia, of which disease it is an early and important sign. (2.) In atrophic paralyses, whether of spinal or neural origin, as infantile paralysis, alcoholic neuritis; often, too, in diabetes and diphtheria. In descending myelitis it sometimes constitutes a valu- able premonitory symptom of approaching bladder disturbance, for if it be noticed that the muscles on the front of the thigh are getting weak and wasted, and that the knee-jerk is lost, it is highly probable that paralytic incontinence of urine will soon appear. (3.) In pseudo- hypertrophic paralysis. (4.) In some cases of cerebellar tumour, pro- bably when one of the lateral lobes is affected. (5.) During and for a short time after the convulsive stage of an epileptic attack; also in coma from any cause. When the knee-jerk is absent, a slight hollow over the patellar tendon may often be observed ; the percussing fingers do not feel that sense of resistance which is always experienced when the knee-jerk is present, and which is a valuable sign in cases where, from obesity or other causes, there is little or no movement of the leg ; we feel con- vinced from the sense of resistance that the reflex exists, but are unable to demonstrate its presence, and that our opinion is correct is DISORDERS OF REFLEX ACTION. 423 often proved by the fact that a satisfactory knee-jerk is obtained on the next examination. Wrist and Elbow Jerks. A tap with the edge of a stethoscope over the lower end of the radius produces flexion of the elbow in many healthy persons. The movement is usually due to contraction of the supinator longus, but if the reflex is exaggerated the other flexors of the elbow are brought into action. Flexion of the fingers may also occur, but as a rule this movement is better produced by tapping over the front of the wrist. Contraction of the triceps is caused by tapping over its tendon just above the olecranon, and sometimes by tapping over the lower end of the ulna. These reflexes at the wrist and elbow are due to stimulation of afferent nerve fibres in connection usually with tendons, but some- times with fasciae or periosteum. In the latter case they are called periosteal or fascial reactions. Sometimes it is difficult to say whether a movement is due to tapping over periosteum or over tendon. For example, a tap over the lower end of the radius affects in some cases the periosteum, in others the tendons passing over it. In the former case flexion of the elbow is commoner than flexion of the wrist or fingers, but in the latter the reverse holds. The reflexes referred to have a like pathology to that of the knee- jerk; thus, they are increased in cases of spastic paralysis, e.g., in hemiplegia and in lateral sclerosis ; they are diminished or abolished in cases of atrophic paralysis, e.g., in peripheral neuritis. Curiously enough, however, the wrist-jerk is exaggerated in many cases of wrist- drop from lead poisoning. But it must be noted that the intensity of the reflex movements obtained at the wrist and elbow vary in health much more than the intensity of the knee-jerk ; thus in many per- sons the wrist-jerk is completely absent, while in others it is present in great excess. Occasionally their diagnostic value is great. For example, a patient suffers from paresis, in association with some slight sensory disturb- ance, of the distal portion of one upper limb. The condition may be due to peripheral neuritis, or to a lesion in the cortical centre for the arm. Now in such a case, exaggeration of the wrist and elbow jerks as compared with the other arm would be strong evidence in favour of a cortical lesion, while their absence would point to peripheral neuritis. Precaution. Irritability of muscular tissue, as shown by a marked contraction produced by tapping over the belly of a muscle, must be carefully distinguished from exaggeration of the deep reflexes. The pathological significance of the former condition is not clearly made 424 EXAMINATION OF THE NERVOUS SYSTEM. out. Sometimes it is present when the deep reflexes are in excess, as in advanced phthisis ; in other cases muscular irritability is associated with loss of the deep reflexes, thus in locomotor ataxia, tapping over the quadriceps femoris may cause its vigorous contraction in cases where the knee-jerk is entirely absent. In all probability the condi- tion referred to is more commonly met with in cases of atrophic than of spastic paralysis. Ankle Clonus or Foot Clonus is usually found in association with marked exaggeration of the knee-jerk ; it is but rarely present in health, and then only in a modified form, thus tapping on the tendo Achillis may cause contraction of the calf muscles, together with sudden extension of the ankle. To elicit ankle clonus, the knee should be slightly flexed ; the fore part of the foot is then lightly grasped and suddenly and forcibly pressed upwards towards the tibia. Immediately the calf muscles con- tract and depress the foot ; the muscles now relax, and the pressure of the hand being continued, the foot is once more dorsally flexed, when the calf muscles again contract and extend the foot a second time, and the clonic series of spasmodic contractions continues so long as the tension of the tendo Achillis is maintained. The movements are uniform, and occur from six to nine times every second. Ankle clonus may be produced by any of the conditions which lead to increase of the knee-jerk. Occasionally, as in some cases of dis- seminated sclerosis, it may be developed when the patellar reflex is not in excess, or even when this is absent, but a converse condition is more frequent ; and in children, even when the knee-jerk is greatly increased, it is rare to obtain ankle clonus. Both ankle clonus and exaggerated tendon reactions may be found in typhoid and other febrile disorders. A loose kind of ankle clonus, consisting of a few imperfect move- ments, and differing from the typical clonus met with in spastic paralysis, may often be developed in cases of hysteria and neuras- thenia, but it is commoner to find irritable knee-jerks and no ankle clonus. Occasionally well-marked ankle clonus is obtained in hysteria. Toe Clonus. When there is increased tension of the foot muscles, sudden passive extension of the first phalanx of the great toe may produce rhythmical flexion of the toe by the contractions of the abductor and flexor brevis. Wrist Clonus. Pressing the hand backwards into a hyper-extended position will, in certain conditions, as the late rigidity of hemiplegia, excite movements like those of ankle clonus. Spinal Epilepsy is a term applied by Brown-Sequard to paroxysms LANGUAGE AND ITS DISORDERS. 425 of violent tremors which sometimes affect the lower limbs in cases of spasmodic paralysis. The clonic spasms may often be arrested by grasping the toes of one foot and bringing them suddenly and forcibly into plantar flexion. Paradoxical Contraction is a name which was given by Westphal to a slow tonic contraction occurring in a muscle when suddenly relaxed or shortened. This phenomenon is best seen in the tibialis anticus, which, under certain ill- ascertained circumstances, contracts when the foot is grasped and dorsally flexed ; the tendon of the muscle stands out, and the foot may remain stiffly flexed for some minutes. This anomalous reaction has been observed in the early stage of loco- motor ataxia and in some other nervous affections, but appears to have no affinity with exaltation of the deep reflexes. Alterations in the Strength, Tone, or Nutrition of Mus- cles Of Reflex Origin. Transient paralysis sometimes appears to be due to peripheral irritation. Examples ; Inability to pass urine after an operation on the anus, such as the removal of piles or the division of a fistula ; transient weakness of one arm after opening the chest for empyema ; transient ptosis, which very rarely follows irrita- tion of the fifth nerve, as from extraction of a tooth. Muscular Spasm. The spasmodic condition of the muscles in cases of spastic paralysis probably largely depends on external stimulation of the sensory nerves ; and the author believes that, very rarely, intense spasm of the legs may be started by peripheral irritation, and may become a permanent condition apart from any evidence of paralysis or other indication of disease of the nervous system. Of examples of spasm affecting the involuntary muscles may be mentioned intestinal colic from irritation of the mucous membrane of the bowel, and attacks of asthma following irritation of the nasal mucous membrane. General convulsions, too, are frequently induced in young children by peripheral irritation, as by the presence of a worm in the intestines. Muscular Wasting. This, as already pointed out, frequently super- venes on injury or disease of a joint, and there is some evidence in favour of its being a reflex phenomenon. LANGUAGE AND ITS DISORDERS. Communication between human beings by means of language is effected by an outgoing and an ingoing mechanism, with their con- necting links. The Outgoing Mechanism is constituted by cortical centres, the cells of which are connected by nerve-fibres with similar groups of cells or nuclei in the medulla or spinal cord, whence nerve-fibres proceed to 426 EXAMINATION OF THE NERVOUS SYSTEM. supply the muscles used in articulation, vocalisation, writing, and various gestures. The Ingoing Mechanism, constituted by the eye and ear, and in the blind by the sense of touch, together with their sensory paths and centres, is made use of when we try to comprehend the language of another by listening to his utterances, by reading his writing, or by watching his gestures. Disorders of language, therefore, may be classed into motor and sensory varieties. Thus, just as a limb may be paralysed either as regards motion or sensation, so speech may be affected by a motor or a sensory paralysis. Vocal Speech is composed of two elements, phonation and articula- tion. Phonation is produced in the larynx, and its defects are referred to in the section on the larynx. Articulation is produced in the cavity of the mouth by the muscles of the lips, tongue and palate, and these, just like the muscles of a limb, may be affected by spasm, tremor, in- cobrdination, or paralysis : and it is of great importance to recognise that the movements concerned in articulate speech are dependent, just as much as those of a limb, on a motor mechanism composed of cere- bral centre, conducting path, nuclei of origin in the medulla and cord, motor nerves and muscles, and that the spasm, tremor, inco- ordination or paralysis which may affect alike speech or a limb are produced by damage to some part or parts of the motor mechanism. A thorough comprehension of this fact will alone give the student an adequate conception of impaired speech processes, especially of those that result from damage to the higher or cerebral mechanism. Disorders of the Outgoing- Mechanism Articulate Speech. Stammering or stuttering is a spasmodic disorder of speech, which chiefly and most commonly affects the muscles of articulation, but may involve those of the glottis, or even those of respiration. The check in enunciation usually manifests itself in the pronunciation of the explosive consonants, 5, p, d, t, hard g, and 7r, but may occur during the production of other consonants, and even of vowel sounds, and, in exceptional cases, the sufferer stammers while whispering or singing. The check is followed by a painful pause, during or after which the sound at which the hitch occurs is rapidly repeated, until the complete word is uttered. Sometimes the patient is quite unintelligible. There is a tendency for other groups of muscles to become involved, so that in severe cases the mouth may remain open, while the muscles of expres- sion are convulsed, the glottis is contracted, respiration is arrested and violent spasms affect the limbs and trunk. The defect usually appears between the age of four years and puberty, but it may come on at any age. Sometimes it follows febrile or func- LANGUAGE AND ITS DISORDERS. 427 tional nervous disorders ; sometimes it is the result merely of tempo- rary debility. Aphthongia is a term applied to temporary spasms affecting the muscles supplied by the hypoglossal nerves, the spasms being brought on by any attempt to speak. The difficulty of speech in chorea also depends on spasmodic move- ments of the tongue and mouth, and sometimes also on spasm of the respiratory and laryngeal muscles. Thus a sudden, deep, or jerky inspiration will often cut off the last syllable of a word ; words are uttered too quickly, or with a drawl or hesitation. Tremor of the muscles of articulation is seen in general paralysis of the insane, in meningitis, in disseminated sclerosis, and in delirium tremens. Scanning, Staccato, Syllabic Speech. This is characteristic of dis- seminated sclerosis. In a typical case a pause occurs after each syllable, the syllables are slowly evolved and are unduly accented. The patient appears to speak with effort, and tremor of the lips and tongue is often present. A somewhat similar defect may accompany locomotor ataxia. Slurred or Clipped Speech occurs in general paralysis of the insane. Words are slurred over and uncompleted, or " clipped : " there is tremor, and often a peculiar pouting of the upper lip, which seems to be stiff and as if glued to the lower lip, while the effort to articulate brings into prominence the want of control over the lower facial muscles. Other Defects in Articulation, comprised under the terms anarthria or dysarthria, are most prominent in affections of the medulla and lower part of the pons. The tongue usually suffers first, and hence I, r, n, t, are imperfectly pronounced ; when the lips become paralysed, the letters o, p, b, m, are indistinct; paralysis of the palate gives a nasal quality to the voice, p and b, for example, being sounded like m and v. Finally, in some cases of bulbar paralysis, there is total inability to articulate a single word, a condition called alalia ; then, too, the power of swallowing is lost, and saliva cannot be retained in the mouth. Paralalia is sometimes used to express an inability to pronounce words correctly ; thus, in ordinary hemiplegia or in paralysis of the facial nerve, the utterance is often thick, and difficulties of articulation may also be present in abnormalities affecting the larynx, nose, palate, teeth, or lips. The defects of speech alluded to above depend for the most part on imperfect action of the muscles of articulation, due either to disease of the muscles, their nerves, or nuclei of origin. But under the name Aphasia, we refer to disorders of speech which result from lesions of 428 EXAMINATION OF THE NERVOUS SYSTEM. the cerebral hemispheres, and which are due either (i) to paralysis of the special movements of articulation, or of the special movements of the hand used in writing; or (2) to paralysis of the receptive sensory centres. The former class constitutes motor aphasia, the latter sensory aphasia. There are also mixed cases, which form a class of combined motor and sensory aphasias. MotOP Aphasia. In complete motor aphasia there is inability to Fi<3. 237. The Co-ordinated Cortical Mechanism for Speech Processes. (After Young anil HUM.) From the eye and ear centripetal fibres (v and a) ascend to terminate in the angular gyrus (V) and first temporo-sphenoidal convolutions (A) respectively, but in reality these fibres are directly connected with a much larger area of the cortex than is here indicated. In addition to these, fibres of muscular sense (*, s', and "), indicated by dotted lines, ascend from the muscles of articulation, from those of the hand and from those of the eyeball to reach the cortex. The centres of vocal and written expression are represented at E and w, and these are connected by means of centrifugal fibres, m and m', with the vocal apparatus and hand respectively. ("Aphasia," by Ross.) speak, called aphemia, to write, agraphia, and there may be loss of power to express thoughts by signs or pantomime, amimia. The essential peculiarity is the loss of voluntary speech, the patient, while understanding everything that is said to him, and while retaining more or less his previous powers of understanding written words, is completely incapable of repeating a single word spoken to him. But, although speechless, he is not always wordless that is, he often articulates LANGUAGE AND ITS DISORDERS. 429 certain words, which are usually the same for the same patient, and have therefore been called "recurring utterances;" they are commonly either the words actually spoken, or those about to be spoken, when the damage to the brain occurred. Thus the recurring utterance of a woman who was taken ill in a cab after telling the cabman to drive her to Mrs. Waters was "Misses" (Gowers); that of a librarian was "List complete " (Russell) ; that of a girl attacked when riding on a donkey, " Gee, gee " (H. Jackson). Words or phrases of this kind must be regarded as of an inter- jectional or emotional character rather than as expressions of an intellectual state. It is also to be observed that the patient may be aware of his errors in speaking, that what utterance he has is usually clear and distinct, and that in singing he may be able to utter every word of a song although unable to speak it. Every gradation may be met with between the most severe degree of aphemia, in which the patient replies to questions by grunting noises or meaningless syllables, being practically wordless as well as speechless, and very slight defects, where the paralysis of speech is only indicated by a hesitating slow utterance or by slight mistakes in the use of words. The chief varieties of aphemia are represented in the following table, taken from Dr. Ross's book on " Aphasia " : APHEMIA. Varieties. The Faculties of Spoken Speech. ist deg. 2nd deg. 3rd deg. 4th deg. sthdeg. i. Spontaneous vocal ) speech in sen- > tences. . \ Impaired. Lost. Lost. Lost. Lost. 2. Repetition of ) words and read- > Retained. Retained. Lost. Lost. Lost. ing aloud. ) 3. A few intelligent replies to ques- tions in single words. Retained. Retained. Retained. Lost. Lost. 4. Occasional and re- curring utter- ances of no Retained. Retained. Retained. Retained. Lost. speech value. 5. Grunting sounds'^ and syllabic ut- terances, not V forming any 1 word. i Retained. Retained. Retained. Retained. Impaired. 430 EXAMINATION OF THE NERVOUS SYSTEM. Permanent motor aphasia results most frequently from a lesion in the posterior part of the third left frontal convolution, but it may depend on a lesion in the centrum ovale underlying this convolution, although, if the motor path is involved some distance below the cortex, the defect of speech is transient and soon recovered from. It must be remem- bered, too, that most cases of ordinary, right-sided hemiplegia, due to damage to the posterior half of the internal capsule, are accompanied by a temporary motor aphasia. It is probable that the centre for writing occupies the posterior part of the second left frontal convolution. There are also many degrees of motor agraphia. The patient, if his hand is not paralysed, may be able to copy words or sign his name when he has lost the power of expressing his thoughts in writing, but even when the disability is slight the spontaneous writing of simple sentences presents egregious blunders in spelling and diction. Rarely agraphia may exist without aphemia. MOTOR AGRAPHIA. Varieties. The Faculties of Written Speech. ist deg. 2nd deg. 3rd deg. 4th deg. sth deg. i. Spontaneous writ- ) ing in sentences. \ 2. Writing to dicta- } tion and copying > sentences. ) Impaired. Retained. Lost. Retained. Lost. Lost. Lost. Lost. Lost. Lost. 3. Writing and copy- J ing imperfectly f a few single f words. ) Retained. Retained. Retained. Lost. Lost. 4. Writing letters of ) the alphabet. j 5. Copying geometri- j cal figures. \ Retained. Retained. Retained. Retained. Retained. Retained. Retained. Retained. Lost. Impaired. Disorders of the Ingoing- Mechanism. 1. Damage to the Ingoing Current Deaf -mutism, in which a person cannot speak because he cannot hear, is an example of damage to the ingoing current along the auditory nerve. Thus a child born deaf never learns to talk, and if a child under seven years loses its hearing in consequence of disease as from a lesion of the labyrinth its speech gradually deteriorates, and it may become completely dumb. 2. Damage to Sensory Centres Sensory Aphasia. The LANGUAGE AND ITS DISORDERS. 431 simplest varieties, though rare, are afforded by uncomplicated cases of word-blindness and of word-deafness. Word-Blindness. A patient suffering from this disorder is unable to read printed or written words, and in some cases he cannot recognise a single letter. He sees the letters and words, and may read aloud, after making elaborate preparations, but there is no correspondence between the actual and the spoken words. He may, however, be able to recognise portraits and simple geometrical figures, to tell the time by a watch correctly, and often he correctly names all objects pre- sented to him. His power of writing, if not entirely lost, is usually limited to short words, written either spontaneously or to dictation, and he often writes better when his eyes are closed than when they are open. In an example of pure word-blindness there is no defect in spoken speech, the patient can repeat correctly all words uttered in his hear- ing, he also understands all that is said to him, and answers questions correctly. In association with word-blindness there is almost invariably some degree of right bilateral hemianopsia. The lesion most commonly implicates the lower and hinder part of the left parietal lobe (in- cluding the angular gyrus), together with the adjacent portion of the occipital lobe. Word-Deafness. In uncomplicated cases of word-deafness the patient can speak, and, if an educated person, may be able to read intelligibly ; he hears sounds as well as before his seizure, but he fails to understand spoken language. An uttered request to close his eyes or to hold out his hand, when unaccompanied by expressive gesture, is not attended to : he hears that some one is speaking, but the words do not revive corresponding ideas. Objects presented to him are also named in- correctly (this is called the aphasia of recollection). There is also inability to write from dictation, and in some cases to repeat words. Strangely enough, sometimes a complicated sentence is better under- stood than a simple one. Examples of pure word-deafness are rare, for language being first developed in connection with the auditory mechanism, any damage to the auditory speech-centre (the first and second temporo-sphenoidal convolutions) is likely to interfere with the other departments of speech. Thus, not only is some degree of word blindness usually present, but motor speech processes are also affected ; to these dis- orders, in cases of sensory aphasia, the term paraphasia was applied by Kussmaul. A slight degree of paraphasia may be temporarily evinced by a nervous or an exhausted person, as when on meeting a friend he calls him by a wrong name. A worse degree is observed in cases 432 EXAMINATION OF THE NERVOUS SYSTEM. of word deafness, when all objects are named wrongly, as worm powder for cough medicine, parasol for castor oil. In still worse cases all objects are called by the same name ; thus a patient under the cai-e of Dr. Ross, who previous to his attack had been a heavy drinker, called his finger, or any other object presented to him, a public-house. In the worst variety of paraphasia, speech is mere inarticulate jargon, and the condition is called gibberish aphasia. Such an aggravated condition, occurring either in connection with word blindness or word deafness, is nearly always associated with hemiplegia, and cases pre- senting such marked motor defects are to be regarded as examples of a mixed motor and sensory aphasia. In sensory aphasia mistakes in writing corresponding to those made in speaking are also frequent, and are classed under the term " paragraphia." The patient writes wrong words, makes errors in spelling simple words, is perhaps unable to complete a sentence in writing, and if severely affected he cannot form a single intelligible word. Disorders of the Connecting Links. The cortical centres for speech are assumed to be healthy, but the fibres connecting them are diseased. Verbal Amnesia, or the Aphasia of Recollection, the third simple variety of sensory aphasia, is always present to some extent in cases of word blindness or word deafness, but may exist alone. In this condition there is a loss of memory for words. Most persons have experienced a slight degree of this in temporarily forgetting the name of a friend, or of some familiar object ; in worse cases there is an inability to name most of the objects by which the patient is sur- rounded, although, if the name of an object is wiutten down or uttered in his hearing, he immediately associates the name with the particular object in question. It will be gathered from the above necessarily brief account of aphasia : (i.) That cases of sensory aphasia usually present a combination of the three simple varieties in varying proportions pure examples of word blindness, or of word deafness or verbal amnesia being rare. (2.) That some motor disorder of speech is of necessity associated with every sensory disorder. It is therefore essential, in the investigation of any form of aphasia, to first ascertain whether it is the motor or the sensory nervous mechanism of speech that is chiefly affected ; and if the aphasia is mainly sensory, to determine to which variety it mainly belongs, ignoring for the time any peculiaiity in motor disorder. To this end the following tests may be employed : i. Ask the patient to perform some simple action, such as "Hold DISORDERS OF VISION. 433 out your hand," "Close your eyes," being careful not to convey in- formation by facial expression or gesture. If he does not carry out the request, and if he does not appear to understand any simple question, he has word deafness. It is also useful to ask him some ridiculous question, such as "Are you a hundred years old?" If the question is not emphatically denied by speech or gesture (the patient giving evidence that he hears ordinary sounds), we may be quite sure that he is word deaf, and that there is disease of the first temporal convolution, or immediately beneath it. 2. If word deafness is excluded, try him with similar requests in writing ; ascertain, also, whether he can read short words. Before, however, deciding that the patient is unable to understand written language it is desirable to write down the name of some simple object, such as pen or key, and then bring before him several objects, including those written, and see whether he is able to associate the written name with the actual object. If he cannot do this, and if it be also found that there is hemianopsia, the patient is suffering from word blindness. 3. The presence of motor aphasia is established by finding that the patient, while giving prompt obedience to written or spoken request, is unable to give pertinent replies to questions, and generally also to repeat words uttered in his hearing, or presented to him in writing. DISORDERS OF VISION, INCLUDING CHANGES IN THE EX- TERNAL APPEARANCE AND MOVEMENTS OF THE EYE. In addition to a description of disorders of vision, which depend upon disease of the nervous system, it is convenient to include a brief summary of other morbid conditions of the eye, in so far at least as they form part of or are caused by general diseases. Both classes may be grouped together and considered in the following order : 1. Affections of the Conjunctiva. 2. Affections of the Cornea and Iris. 3. Disorders of Muscular Action. (i.) Of Internal Muscles. (2.) Of External Muscles. 4. Amblyopia and Functional Disorders of Sight. 5. Changes detected by means of the Ophthalmoscope. Affections Of the Conjunctiva. The chief changes to be noticed are yellowness, oedema, signs of congestion or inflammation, subcon- junctival haemorrhage. 2 E 434 EXAMINATION OF THE NERVOUS SYSTEM. Yellowness. Yellowness of the conjunctiva is one of the earliest and most constant signs of jaundice. Care must be taken to distinguish it from the yellowish appearance due to other causes ; thus the conjunctiva often appears yellow in pernicious anaemia, owing to the shining through of the subconjunc- tival fat. A yellowish discoloration, with enlargement of the conjunctival vessels, is common in chronic alcoholism and in other cases when venous congestion is present. The brownish discoloration caused by long-continued application of nitrate of silver may here be mentioned. (Edema. Slight oedema of the conjunctiva causes the watery and glisten- ing eye which is frequently observed in Bright's disease. When oedema is very great, it constitutes chemosis. This is noticed in purulent ophthalmia and accompanies severe inflammation of surrounding parts. Congestion. Apart from local conditions, congestion of the conjunctiva may occur in several general diseases, of which may be specially mentioned : common catarrh, measles, typhus, heart disease, rheumatic fever. Frequently, too, it is the result of severe coughing. Inflammation. Acute forms of conjunctivitis, of varying intensity, and characterised by redness, swelling, and more or less muco-purulent discharge, are met with in small-pox, measles, hay-fever and gonorrhoea. The condition occurs also as a result of direct irritation. Membranous (" Diphtheritic ") Ophthalmia. The ophthalmia of measles, and sometimes of other infantile diseases, occasionally takes on a membranous type, the membrane being limited almost invariably to the palpebral conjunctiva. A very severe form, in which the whole thickness of the conjunctiva is involved, and the lids are much swollen, has been observed as an effect of the true diphtheritic poison in a few cases. {: Subconjunctival Ecchymosis. This is of a purplish hue, and occurs as a result of straining efforts, as in severe coughing or vomiting. Ecchymotic patches in the conjunctiva are also sometimes met with in severe forms of acute ophthalmia. Affections Of the Cornea. For clinical purposes, these may be divided into Opacities and Ulcers. They not infrequently coexist ; in fact, a certain amount of opacity, due to infiltration with inflammatory products, is nearly invariably found round an ulcer. Many of these affections, especially when acute, are accompanied by " ciliary conges- tion." This is indicated by a ring surrounding the cornea, composed of closely set, straight, radiating vessels. It is of a pink colour, duller than the bright red of conjunctival congestion and inflammation. This is also a prominent symptom of iritis. The chief opacities of the cornea are : Arcus Senilis and Inflammatory Arcus. Nebula and Leucoma. Steamy Cornea. Opacity from Lead. Calcareous Film. Pannus. Ground-Glass Cornea. Dotted Opacity. Onyx and Hypopyon. DISORDERS OF VISION. 435 The last three of these are associated with, more or less, " ciliary congestion." Arcus Senilis. This is a white or yellowish opacity at the junction of the cornea and sclerotic. It commences under the upper lid in the form of a crescent ; then it affects the lower margin of the cornea and, at a later period, may encircle the whole cornea. True arcus is rarely met with before the age of forty years, but opacities bearing a superficial resemblance to it, but whiter and of more irregular outline, may occur at an earlier age, as a result of inflammation in the neighbourhood. Nebula and Leucoma. These are names given to opacities of the cornea the result of injuries or of inflammatory processes. They are often valuable indications of previous disease, especially of interstitial keratitis and strumous ulceration. When faint, and forming a mere cloud, the opacity is called a nebula ; when dense and opaque white, it is called a leucoma. A leucoma to which the iris has become adherent is called Leucoma adherens. It indi- cates that there has been an ulcer which has perforated into the anterior chamber. It is to be remembered that a nebula so faint as to be very difficult to detect may cause a very serious defect of vision. Steamy Cornea. A slight degree of superficial opacity, so that the cornea presents the appearance of glass which has been breathed upon, is common in the earlier stages of corneal inflammations. A uniform steaminess is one of the prominent symptoms of glaucoma. A characteristic opacity sometimes follows the application of lead lotion to a cornea the surface of which is abraded. This is a sharply defined, opaque, pure white spot, due to the deposition of lead salts in the corneal tissue. Calcareous Film of the cornea is a transverse band of a greyish colour, containing white calcareous deposits. It occurs chiefly in eyes that have long been lost from some severe inflammatory process. Pannus is an opacity with vessels extending into it from the conjunctiva. It occupies the part of the cornea covered by the upper lid, or sometimes all the cornea. It is a concomitant of trachoma. Ground Glass Opacity (Interstitial Keratitis) Here the whole thick- ness of the cornea becomes hazy and the surface steamy, so that the cornea bears some resemblance to ground glass. The opacity differs in intensity at different parts, so that it looks patchy on close inspection. It may be so dense that the iris can with difficulty be discerned. Straight vessels branching at acute angles run into it at various parts, giving a salmon colour in the more acute stages. Some of these vessels remain after the affection has subsided, and form a valuable sign of its previous existence. Ciliary con- gestion accompanies this disease, and may be very intense. In most cases patients thus affected are the subjects of hereditary syphilis. Dotted Opacity of the cornea (Keratitis Punctata) is found in many cases of serous iritis, serous cyclitis, and sympathetic ophthalmitis. The lower part of the cornea becomes hazy, and the seat of small dotted opacities, generally of greyish colour, but they may be white or pigmented. They are of ten' arranged in the form of a triangle with the apex upwards. They are formed by the deposition of lymph on the posterior surface of the cornea. The anterior chamber is often increased in depth. Onyx and Hypopyon sometimes accompany ulcers of the cornea and iritis. Onyx denotes a deposit of pus in the substance of the cornea. Hypo- pyon is an accumulation of pus in the anterior chamber. The pus lies at the 43 6 EXAMINATION OF THE NERVOUS SYSTEM. lowest part of the chamber, and its upper limit is horizontal and straight, or nearly so. Ulceration of the Cornea is recognised by the loss of substance which it occasions. With this are generally associated more or less ciliary congestion, loss of transparency of the cornea, due to infiltration with inflammatory products, pain, blepharospasm, and contraction of the pupil. The chief points to be noticed are the position, size, shape, number, amount and colour of the surrounding infiltration, the amount of ciliary congestion, and the presence or absence of vessels running to the iilcer. A large propor- tion of corneal ulcers is of merely local origin, and occurs as the result of slight injury, with or without subsequent infection. They often indicate a condition of impaired general health. The following are the principal ulcers : The Simple Ulcer, occurring as a small shallow depression with greyish floor and but little infiltration of the edges. The Crescentic or Ring Ulcer, which appears in the situation of or on the arcus senilis, and may entirely surround the cornea. The Suppurating Ulcer, a deep ulcer, situated near the centre of the cornea, with a yellow purulent deposit on its floor, and often accom- panied by purulent infiltration of the cornea and hypopyon. The Ser- piginous Ulcer also occurs near the centre of the cornea. The floor of this ulcer is greyish, and deeper towards the advancing edge, which is curved, raised, and of a yellowish-white colour. It is often complicated by hypo- pyon. The Dendriform Ulcer, which appears as a fine groove, throwing off lateral branches and having hardly any infiltration. One very definite form of ulcer is due to exposure of the cornea to drying, dust and other irritants, owing to insufficient closure of the eyelids. It occurs as a dry -looking, grey depression on the lower part of the cornea, where it is not covered by the upper lid, and consequently has the shape of a crescent or of the segment of a circle. The chief diseases in which it occurs are : Paralysis of the facial nerve, extreme cases of exophthalmic goitre, and in the last stages of exhausting diseases, such as infantile diarrhoea, cholera, malignant disease and meningitis. In meningitis, ulceration may perhaps be of neuropathic origin. Neuropathic Ulceration of the cornea is characterised by rapid and general infiltration, giving it the appearance of moist wash-leather, the accompanying ciliary injection and other signs of inflammation being only slightly marked. It may be observed in paralysis of the ophthalmic division of the fifth nerve ; in herpes zoster affecting the region supplied by this division, especially if the nasal branch is implicated, or even in the absence of any skin affection. Phlyctenular Ophthalmia occurs in persons of the tubercular diathesis. In this affection small, greyish or yellowish elevations, accompanied by local congestion, appear at or near the margin of the cornea. These burst, leaving small round ulcers with yellow, infiltrated bases and edges, which show a tendency to advance towards the centre of the cornea, their track being marked by a leash of vessels from the conjunctiva. They often make their first appearance after an attack of measles or whooping-cough. Ulcers are also left as a result of herpes of the cornea. This may occur in the course of herpes febrilis or of other diseases accompanied by herpes, such as pneumonia, typhoid fever and intermittent fever. Clear elevated vesicles appear, without vascularisation of the cornea. These burst, leaving a shallow irregular abrasion with a festooned edge. The corneal ulceration DISORDERS OF VISION. 437 of small-pox perhaps deserves separate mention. It appears about the tenth to the fourteenth day of the disease, after the secondary fever. It results from the spreading of an ulcer from a conjunctival pustule. Small-pox pustules do not present themselves on the cornea itself. Affections Of the Iris. In examining the iris the chief points to be noticed are its colour and the size, shape and mobility of the pupil as compared with that of the opposite side. The depth of the anterior chamber and the ocular tension are also of importance in this connection. This subject will be dealt with under the following heads : Iritis. The results of Iritis. Deformities of the Iris. New growths of the Iris are so rare that they need not be described in this book. Iritis. There are two chief varieties of iritis, the plastic and the serous. In both the colour of the iris is altered, its lustre diminished, and its pattern obscured, so that it looks muddy. A blue eye becomes greenish and a brown one rusty. The pupil is more or less contracted, and its movements are slug- gish. Ciliary injection (see p. 434) and a certain amount of conjunctival congestion, with blepharospasm and lacrimation, are generally present. Plastic Iritis is characterised by the formation of lymph on the surface or in the substance of the iris and in the pupil. This gives rise to adhesions between the iris and the anterior capsule of the lens (posterior synechise). The presence of these is detected by the irregularity of pupil which they cause. This is rendered more obvious by dilating the pupil either by shading the eye or the use of atropine. The lymph may form yellowish or reddish nodules on the surface of the iris, especially in the later stages of secondary- syphilis. In Serous Iritis the exudation is chiefly fluid, slightly turbid from the presence of small particles of lymph. The accumulation of the fluid causes deepening of the anterior chamber and increase of ocular tension. Lymph is deposited as fine yellowish or greyish dots on a triangular area at the lower part of the cornea, keratitis punctata (see p. 435). Contraction of the pupil and ciliary congestion are only slightly marked. Iritis may be of purely local origin, but the commonest cause of this affec- tion is syphilis in its secondary stage. Many cases of chronic iritis are due to the rheumatic and some to the gouty diathesis. Iritis also occurs in small- pox (in the desquamative stage), typhoid fever, pneumonia, diabetes and septicaemia. Results of Iritis. As a result of inflammation the iris may be left of a lighter colour than natural, or a patch of dark pigment may make its appear- ance, or portions of the iris may be left pale, thinned and atrophic. The presence of synechise, or of the spots of lymph and pigment which they leave on the lens-capsule, is proof of a past iritis. Synechise cause the pupil to be of irregular shape. It may become oval or notched, or have a crenated outline. If the whole of the posterior surface of the iris is adherent the condition is called total posterior synechia. If it is adherent throughout the circumfer- ence of the pupil only, circular synechia results and causes exclusion of the 438 EXAMINATION OF THE NERVOUS SYSTEM. pupil. Sometimes the pupillary area is covered with lymph which becomes organised ; the pupil is then said to be occluded. The pupil, if excluded or occluded, may be round, but cannot be dilated by means of midriatics. Under these circumstances aqueous humour accumulates behind the iris, bulging it forward and making it funnel-shaped, at the same time making the anterior chamber shallow. Secondary glaucoma may result. Deformities of the Iris and Pupil The iris and pupil may be of ab- normal shape from other causes than those mentioned in the preceding para- graph. As an effect of injury the iris may be separated from its attachment to the ciliary body for part of its circumference (irido-dialysis), or a portion of it may be folded back on itself (retroflexion of the iris). Occasionally the pupil is eccentric in position congenitally. Coloboma is a deficiency of the iris, generally at its lower and inner part, due to imperfect closure of the FIG. 238. Scheme of the Nerves of the Iris. A, psychical impression ; B, centrum optici ; c, oculomotor centre ; l>, dilator centre (spinal) ; E, iris ; a, optic nerve ; H, oculomotor (sphincter) roots ; I, sympathetic (dilator) ; K, L, anterior roots ; M, N, 0, posterior roots ; A, seat of lesion causing reflex pupillary immobility ; *, probable seat of lesion causing myosis. (After Erb.) choroidal fissure in the foetus. Fine threads attached to the anterior surface of the iris sometimes run across the pupil. They are remains of the fatal pupillary membrane. Disorders of Muscular Action. (i.) Paralysis of the Internal Muscles. The internal muscles of the eye are the ciliary muscle, the sphincter of the iris, and the dilator of the iris. (a.) Cycloplegia. Paralysis of the ciliary muscle, loss of accommoda- tion. In this condition distant vision is good, but near vision is defec- tive. Bilateral cycloplegia is one of the earliest and most common DISORDERS OF VISION. 439 symptoms of diphtheritic paralysis ; it occurs also in locomotor ataxia and in cases of poisoning by belladonna. It may be due to disease of the anterior parts of the nuclei of the third nerves, or of the nerves themselves. (&.) Iridoplegia, or paralysis of the iris. There are three varieties of paralysis. i. Loss of the reflex to light, called reflex iridoplegia. In examining this reflex each eye must be tested separately, the other eye being covered. The patient should look at a distant object, while a bright light is brought suddenly in front of the eye. ii. Loss of the sMn reflex. Dilatation of the pupil may be produced yj^fs**^ " FIG. 239.- Lateral View of the Muscles of the Eyeball. 5, Trochlea or pulley of the superior oblique muscle, 12 ; 6, optic nerve ; 8, superior ; 9, inferior ; and 12, external rectus ; 13, inferior oblique. inferior oblique, in most healthy persons by stimulation of the cervical sympathetic by pinching or faradising the skin of the neck. This reflex is lost in some cases of damage to the cervical spinal cord or the cervical sympathetic. The skin reflex and the light reflex are often lost together, as in tabes, and in general paralysis of the insane. The light reflex is lost when there is atrophy of the optic nerves, or com- plete paralysis of the third nerves. It is maintained in blindness of central origin and in unilateral optic atrophy. iii. Accommodation iridoplegia. The pupil does not contract when the patient looks from a distant to a near object. The condition is usually associated with cycloplegia, as in diphtheritic paralysis, but may exist alone. Loss of the reflex to light, but contraction of the 440 EXAMINATION OF THE NERVOUS SYSTEM. pupil in accommodation (the Argyll Robertson pupil), is a common symptom of locomotor ataxia. iv. Paralysis of the dilator. This is generally one-sided, and is caused by pressure or disease of the cervical sympathetic (see p. 41). The affected pupil is smaller than the other, and does not dilate when shaded. The condition is associated with retraction of the eyeball, and slight narrowing of the palpebral fissure, but the movements of the upper eyelid remain normal (2.) Paralysis of the External Muscles of the Eyeball. Paralysis of any of these muscles is mainly recognised by the following symptoms : Defect of ocular movement, strabismus and diplopia or double vision. The limitation of movement is brought out when the patient tries to follow with his eyes an object moved in various directions in front of him. It constitutes what is called the " primary deviation ; " it is always in the direction of action of the paralysed muscle, and varies with the amount of paralysis. The term "secondary deviation" is given to the excessive movement of the sound eye when this is covered, and an object is fixed by the affected eye. Strabismus, or the want of correspondence between the visual axes, is called convergent when the prolonged axes of the eyeballs would cross, divergent when the axes diverge from one another. Thus paralysis of one external rectus produces a convergent squint, paralysis of one internal rectus a divergent squint. Paralytic strabismus is distinguished from strabismus due to muscular spasm by the following points : Paralytic squint is only present when the position of the object necessitates action of the affected muscle, whereas spasmodic squint is present in all positions, and secondary deviation of the sound eye does not occur. Diplopia, common in paralytic squint, is usually absent in the spasmodic variety. Of the two images of an object looked at by a patient suffering from diplopia, the true one is seen by the sound eye, and is sharper in outline and more distinct than the false image, which is seen by the affected eye. Diplopia is said to be simple or homony- mous when the false image is displaced towards the side of the paralysed eye ; crossed when it is displaced towards the side of the non-paralysed eye. The former occurs with convergent, the latter with divergent strabismus. In testing the eyes for diplopia, it is best to place a coloured glass before one of them while the patient looks at a candle-flame held in different parts of the field of vision. The following is a summary of the chief symptoms which would result from paralysis of each muscle of the left eye : DISORDERS OF VISION. 441 Sixth Nerve. External Rectus. Defect of movement outwards with convergent strabismus and diplopia on looking to the left. The images are vertical and parallel, the false image being to the left of the true one, and not tilted, unless the eyes look at an object above or below the horizontal level. The head is turned towards the left side. Third Nerve. Internal Rectus. Defect of inward movement, divergent strabismus and crossed diplopia on looking to the right ; the images are side by side, the false image being displaced in a horizontal line to the patient's right. Superior Rectus. Defect of movement upwards, and on trying to look upwards the left eye is rotated upwards and to the left by the action of the inferior oblique. The diplopia is crossed ; the false image is higher than the true one, and is tilted towards the right. Inferior Rectus. Downward movement of the eyeball defective. On looking downwards, there is crossed diplopia, the false image being lower than the true one, and tilted to the patient's left. Inferior Oblique. On looking up, the left eye shows defective move- internal rectus. External rectus. Superior oblique. FIG. 240. The Black Cross represents the True Image, the Thin Cross the False Image. The.left eye.is affected in all cases. (After Bristowe.) ment, and its pupil is directed towards the right. The diplopia is simple ; the false image is higher than the true one, and is tilted towards the left. The head is inclined backwards, and the chin turned a little towards the right side. Fourth Nerve. Superior Oblique. On looking down, the left eye shows defective movement, and its pupil is directed towards the right. The diplopia is simple ; the false image is below the true one, and is tilted towards the right. Isolated paralysis of the external rectus is not uncommon, that of the superior oblique is occasionally met with, but the other muscles which are all supplied by the third nerve are usually paralysed together. In complete paralysis of the third nerve there is loss of the inward, upward, and, to some extent, of the downward movement of the eye- ball ; there is external squint, and the eye can only be moved outwards by the external rectus, and downwards and outwards by the superior oblique. There is also ptosis, or drooping of the upper lid from paralysis of the levator palpebrae ; the pupil is moderately dilated, and 44 2 EXAMINATION OF THE NERVOUS SYSTEM. does not contract to light, and the power of accommodation is lost in consequence of paralysis of the ciliary muscle. Paralysis of the third, fourth, or sixth nerve suggests disease at the base of the brain, in the sphenoidal fissure, or in the orbit. Paralysis of one third nerve may also be due to a lesion of the cms, and then there is hemiplegia on the opposite side of the body. Paralysis of the sixth in association with paralysis of the fifth or seventh nerve indicates disease of the pons. Paralysis of both third nerves suggests a tumour in the interpeduncular space, but this is a very rare condition. Sometimes the movements of the eye rather than its individual FIG. 241. Total Ophthalmoplegia ; Double Ptosis ; Partial Paralysis of Face and Tongue ; Optic Discs normal, and Fields of Vision unimpaired, so far as could be ascertained. muscles are paralysed. Thus there may be loss of the upward movement of the eyes, in association with drooping of the upper lids (see Fig. 18, page 55); loss of convergence, either by itself or in combination with loss of accommodation ; paralysis of lateral movement causing what is called conjugate deviation of the eyes. These conditions are due to lesions of the nerve nuclei, or of higher centres in the cerebrum. Conjugate Deviation of the Eyes with Turning of the Head may be due to paralysis or spasm. When due to paralysis, the head and eyes turn towards the side of the lesion if this is situated in a cerebral DISORDERS OF VISION. 443 hemisphere, but away from it when the lesion involves one side of the pons. The reverse is the case when conjugate deviation is produced by spasm in consequence of an irritative lesion in the pons or cerebrum. Total Ophthalmoplegia means paralysis of all the ocular muscles ; when this is complete the eyes are motionless, and, as partial ptosis is also frequently present, the patient has a peculiar sleepy expression (see Fig. 241). External ophthalmoplegia means paralysis of the external muscles, internal ophthalmoplegia paralysis of the pupil and ciliary muscle. Each form is usually due to syphilis, and may occur alone or in association with hemiplegia, or with symptoms of locomotor ataxia. As a rule the lesion consists of a chronic degeneration of the oculo- motor nuclei. It is of great interest to observe the weakness of the orbicularis palpebrarum which frequently accompanies ophthalmoplegia, the association being analogous to that between paralysis of the lower facial muscles and the tongue in cases of bulbar paralysis. Nystagmus. This term is applied to involuntary rhythmical move- ments of the eyes, which are generally bilateral and symmetrical. The movements may be constant during waking hours, or may occur only when the eyes are moved in a particular direction. In the latter case weakness of certain muscles is indicated ; for example, if horizontal twitching movements of the left eye are observed when a patient tries to look as far as possible to the left, it is probable that there is partial paralysis of the left external rectus. Nystagmus occurs in many diseases of the nervous system, and is common in disseminated sclerosis, in Friedreich's disease, and in cases of tumours of the cerebellum. It is frequently found in association with local affections of the eye opacities of the cornea, diseases of the retina or choroid, &c. which cause serious defect of sight. It is common in albinism. Sometimes it develops in adult life, apart from other evidence of disease, as in coal-minera Amblyopia and Functional Disorders of Sight. The defects of vision to be considered here are Amblyopia and amaurosis. Night-blindness. Day-blindness. Hemiariopsia. Coloured vision. Micropsia. Diplopia, not due to muscular derangement. Colour-blindness. The clinical examination of these affections involves the testing of 444 EXAMINATION OF THE NERVOUS SYSTEM. the acuteness of vision, the extent of the visual field, and the colour- sense. Acuteness of vision is estimated by the patient's ability to recognise certain standard letters at a given distance. (For details, refer to text-books on diseases of the eye.) If vision is very defective, it is sufficient to note whether the outspread fingers can be counted at a short distance. The extent of the visual field can be measured with sufficient accuracy for most clinical purposes, as follows : Stand about two feet in front of the patient, tell him to cover one eye, and to look FIG. 242. Field of Vision of Left Eye, showing Boundary Lines for Different Colours. (Meyer. ) steadily with the other at your nose. Then hold up a finger in a plane with your face and at some distance from it. Gradually bring this finger nearer to your nose and note the distance at which he begins to see it. Do this from various sides, and from above and below. Con- traction of the field from one or from all sides may thus be detected ; as also may central scotomata for red and green, if small pieces of paper of these colours be used in place of the finger-tip. In order to obtain a correct map of the field of vision it is necessary to use the " Perimeter," an instrument in which an arm shaped like a quadrant of a circle, and graduated in degrees, moves round a central DISORDERS OF VISION. 445 pivot on which the patient's eye is fixed. Then a white or coloured object is moved along the arm, which is placed at various angles, and the points at which the object ceases to be seen mark the limits of the field. The results are recorded on prepared charts. In a normal eye the field for the object is larger than that for colour, while the fields for colour diminish in the following order : White, blue, yellow, red, green, violet (see Fig. 242). As a rule, it is sufficient to test the visual field for red and green. Colour perception is best tested by getting the patient to match a skein of wool of a certain colour with all the skeins of a similar colour which are present in a collection of skeins of every colour and shade. It is also useful to ask the patient to identify and name certain colours, but it must be remembered that a patient may not know the names of certain colours, or, while unable to perceive them, he may give the correct names. Amblyopia means diminished acuity of vision, accompanied by no abnormal ophthalmoscopic appearances, or only by slight signs of optic neuritis or atrophy. When the dulness of sight amounts to actual blindness it is called amaurosis. It may be due to disease or func- tional disturbance of the retina, optic nerve, optic tract, or visual centre. It may be symmetrical or asymmetrical. (i.) Amblyopia from suppression of image ("congenital amblyopia") is the defect of vision often present in the squinting eye of children, with convergent strabismus associated with error of refraction (hyper- metropia). The defect is chiefly noticeable in that part of the field of vision which is common to both eyes. (2.) Amblyopia from defective retinal images ("amblyopia ex anopsia "). In cases of very high hypermetropia, or astigmatism, where clear images have never been formed on the retina, full optical correction of the error of refraction may fail to raise the vision to the normal standard. (3.) A rarer form of asymmetrical amblyopia, coming on somewhat rapidly, and involving chiefly the central region, and perhaps associated with slight haziness and congestion of the optic disc, may be due to exposure to cold, or may be of reflex origin from irritation of the fifth nerve, as by carious teeth. (4.) Toxic amblyopia is generally caused by the abuse of tobacco. It is progressive and symmetrical. The discs are slightly congested and hazy in the early stages, pale and somewhat atrophied in the later. The defect is most marked in the central part of the field. Yery often there is a central scotoma for red and green. In diabetes mellitus a central or peripheral defect of vision may be present, and sometimes optic atrophy is found. Ursemic amblyopia, or, more commonly, amaurosis, occurs suddenly in some cases of puer- peral eclampsia and scarlatinal nephritis. 446 EXAMINATION OF THE NERVOUS SYSTEM. (5.) Severe haemorrhage, as from the stomach, bowels, or uterus, may cause blindness either immediately, from defective blood-supply to the retina and visual centre, or later possibly from optic neuritis. (6.) Concentric restriction of the field occurs in atrophy of the optic nerves ; it is also a frequent symptom in cases of hysteria. In hysterical amblyopia the contraction of the field is most extreme on the anaesthetic side of the body, and affects colour vision ; the other eye may also have its field reduced in size to a variable extent, but colour vision is unaffected. Associated with the amblyopia there is 60 105 120 150 165 180 FIG. 243. Perimetric Tracing of the Field of Vision for Colours in the Right Eye, from a Case of Paralysis (multiple neuritis) due to poisoning by Carbon Bisulphide. The fields of vision were much contracted in each eye for white and blue, while those for red and green were absent. The optic discs were paler than natural. Almost complete recovery a month later, (ftoss and Bury, p. 192.) often some degree of asthenopia, in which there is weakness of the ciliary muscle, and of the internal recti, together with photophobia, and it will sometimes be found that owing to speedy weariness of the eye the first perimetric chart shows a larger field than a second one taken immediately afterwards. A similar " crossed amblyopia " is occasionally met with as a symptom of cortical disease, probably from damage to the supramarginal and angular convolutions; the dimness of sight affects the eye on the side opposite to the cerebral lesion. DISORDERS OF VISION. 447 Night-blindness (nyctalopia) signifies much diminished acuity of vision in dim light. It is a symptom of retinitis pigmentosa, and is frequently prominent in cases of syphilitic retinitis. It may also be congenital, and 105 135 LEFT. 105 135' FIG. 245. Extreme Concentric Contraction of the Fields of Vision in a Case of "hysterical amblyopia," and right hemianaesthesia. quite unaccompanied by ophthalmoscopic changes. Acute nyctalopia occurs after exposure to very bright lights, and is often associated with scurvy. Day-blindness occurs in some cases of congenital amblyopia. 44 8 EXAMINATION OF THE NERVOUS SYSTEM. Hemianopsia means loss of one-half of the visual field, not due to intra-ocular disease. The line separating the lost from the retained half-field is generally vertical, and deviates in the middle, so as not to interfere with the fixation point : it may, however, be oblique, or only a sector of the field may be lost. Hemianopsia is absolute when all three visual sensations (colour, form, and light) are lost. If only one (colour) or two (colour and form) are lost, it is " relative. " Most cases are absolute. Homonymous or lateral hemianopsia is the commonest variety, the right or left half of the fields of both eyes being lost. Loss of the right half-fields implies loss of function of the left halves of the retinae, and vice versa. Homonymous hemianopsia may occur as a functional disturbance in migraine, but as a rule it depends on organic disease, and the lesion implicates either (i) some part of the visual path behind the chiasma, viz., the optic tract, the hinder end of the internal cap- sule, or the white fibres of the occipital lobe ; or (2) the visual centre itself, viz., the cortex of the occipital lobe. Temporal hemianopsia, due to blindness of the nasal half of each retina, is a rare affection, and may be unnoticed by the patient. It is produced by damage to the middle of the chiasma, which involves the crossed fibres, as from the pressure of a tumour or a distended third ventricle, or a localised meningitis. The symptom is met with in some cases of acromegaly (see p. 33). Nasal hemianopsia, a still rarer affection, is due to injury of the uncrossed fibres, and may be caused by pressure on or inflammation involving the sides of the chiasma. Altitudinal hemianopsia means loss of the upper or lower halves of the visual fields, and would indicate a lesion of the upper or the lower part of the chiasma Coloured Vision (chromatopsia) is not uncommon after extraction of senile cataract, and in exhausted states of the system. It is also an effect of the administration of santonin. Eed vision is most commonly complained of. Micropsia. Objects appear smaller than they really are in cases where accommodation is only effected by excessive effort. This disorder of vision is sometimes the aura of an epileptic attack. It is a common symptom in syphi- litic retinitis. Diplopia (double vision) is generally due to squint, and has already been considered (see p. 440). This is binocular diplopia. Uniocular (or monocular) diplopia is an occasional symptom in hysteria, disloca- tion of the lens, irido-dialysis, commencing cataract and astigmatism, and may occur as a result of the instillation of eserine or atropine. Colour-blindness (achromatopsia) may be observed in tobacco- ambly- opia, in optic atrophy after neuritis, and in optic atrophy associated 449 105 LEFT. 135 Fields of Vision in a case of left-sided Hemianopsia. The black areas represent the blind parts. The patient also suffers from slight left hemiplegia and partial left hemianresthesia and the lesion probably softening from syphilitic thrombosis of the lenticulo-optic artery most likely involves the hinder end of the right internal capsule. Note (i) that the line of sepa- ration between the blind and seeing halves deviates at the fixation point, leaving central vision intact ; and (2) that there is a slight restriction of the right halves of the fields of vision. 2 F 450 EXAMINATION OF THE NERVOUS SYSTEM. with diseases of the spinal cord, especially locomotor ataxia. It occurs also in hysterical amblyopia, and in some diseases of the retina. Changes detected by means of the Ophthalmoscope. A knowledge of the use of the ophthalmoscope should be acquired at an early period of the student's career, so that he may soon become fami- liar with the leading aspects of the fundus in health and disease ; for a detailed account of these we must refer him to special works, it is only possible in the present manual to give a brief summary of some of the chief morbid changes. Disease of the Choroid. The common changes met with are of an atrophic character, that is, pale or white patches with rings or spots of brown or black pigment in the neighbourhood. FIG. 248. The Entrance of the Optic Nerve, with the adjacent parts of the Fundus of the Normal Eye. a, ring of connective tissue ; b, choroidal ring ; c, arteries ; d, veins ; g, division of the central artery ; h, division of the central vein ; L, lamina cribrosa ; t , temporal (outer) side ; n, nasal (inner) side. (Landois and Stirling.) In Choroiditis dissemivata discrete or confluent atrophic areas are found scattered over the fundus. The condition occurs most frequently in syphilis, and in both the hereditary and acquired forms at a period varying from six months to three years from the commencement. It may be limited to one eye, but usually both eyes are affected. The change is commonly most marked at the periphery. White patches in the central region also occur in myopia, and in elderly persons, often as a result of haemorrhages. Large atrophic patches are sometimes seen in hydrocephalus, arjd may follow the absorption of tubercular masses in the choroid. Tubercles in the Choroid must be carefully distinguished from the white spots of atrophy ; they are more yellowish in tint, have a rounded DISORDERS OF VISION. 451 form, and pigmentary distuibance is usually absent. They are often present in cases of tubercular meningitis, but may exist in acute miliary tuberculosis, apart from meningitis. Diseases of the Retina. When inflamed (retinitis) the retina loses its transparency and appears hazy or smoky ; the opacity is either diffuse or it occurs in spots and patches. Pigmentary deposits in the retina are arranged in a lace-like or reticulated form, or in sharply defined lines, and not in blotches and rings, as in the choroid. They are superficial to the vessels. Syphilitic Retinitis, in which there are diffuse hazy opacities, a blurred disc, and tortuous vessels, occurs as a secondary symptom in both con- genital and acquired syphilis. Its onset is commonly rapid, its course FIG. 249. Atrophy after Syphilitic Choroiditis, showing various degrees of wasting, a, atrophy of pigment epithelium ; b, atrophy of epithelium and chorio-capillaris, the large vessels exposed ; c, spots of complete atrophy, many with pigment accumulation. (After Hutchin- non and Nettleship.) chronic, and failure of sight is a conspicuous feature. As a rule it is secondary to choroiditis. Albuminuric Retinitis is characterised by the presence of (i) a grey- ish haze, (2) sharply defined opaque white dots or patches, (3) haemor- rhages, and (4) inflammation of the disc (papillitis). One or other of these changes predominates, and they are variously combined in different cases. The condition is nearly always significant of a chronic nephritis, and occurs most commonly in granular kidney ; it is often a marked feature in the albuminnria of pregnancy. Hcemorrhages in the retina, of various shapes and sizes, are frequently met with in leucocythasmia and pernicious anaemia ; they are also some- times present in cases of scurvy, purpura, ague, septicaemia, and ulcer- ative endocarditis ; and they usually form a part of every severe retinitis 452 EXAMINATION OF THE NERVOUS SYSTEM. or papillitis. Retinitis haemorrhagica, a condition in which numerous small linear or flame-shaped haemorrhages are scattered over the f undus, is occasionally seen in gouty persons, and in the subjects of arterial degeneration. Retinitis pigmentosa is a chronic symmetrical disease which tends to atrophy of the retina, with much pigmentary deposit and secondary atrophy of the disc. The disease is hereditary, and begins in early life ; contraction of the visual fields soon occurs, and blindness ultimately results. Embolism of the Central Artery of the retina produces instantaneous blindness of the affected eye. The central region looks misty, and the opacity is greatest around the yellow spot ; the vessels, especially the arteries, are diminished in size ; white atrophy of the disc supervenes, FIG. 250. Recent severe Retinitis in Renal Disease. (After Goivers and Nettleship.) and sight becomes impaired or is completely lost. Embolism of this artery may take place at the same time as embolism of a cerebral artery. Optic Neuritis or Papillitis consists in swelling and increased vas- cularity of the optic papilla or disc. The edge of the disc becomes blurred, and the retinal veins enlarged ; the swelling of the disc renders it unduly prominent, and the vessels bend down abruptly at its edge ; the opacity extends, and appears to enlarge the disc ; the veins become broader and the arteries narrower, and blood patches may be visible on the surface or margins of the swollen area. Such changes may dis- appear almost entirely, but commonly the disc passes into a state of "consecutive" atrophy, presenting a staring white colour and sharply cut edges. Care must be taken not to mistake haziness of the disc, often seen in cases of hypermetropia, for true neuritis. Double Papillitis, not always equally marked in the two eyes, is DISORDERS OF VISION. 453 strongly suggestive of intracranial disease, and especially of tumours of the brain. It is also frequently met with in tubercular basal meningitis, but only very rarely in cases of cerebral haemorrhage or of thrombotic softening. It has sometimes been observed in cases of embolic softening, and occasionally in diffuse cerebritis; also in multiple sclerosis, and rarely in chronic myelitis. Papillitis with or without retinitis also occurs in albuminuria, lead poisoning, simple anaemia, and after the various exanthemata, especially scarlet fever and typhoid. Unilateral Papillitis is usually due to disease at the back of the orbit or near the optic foramen, as from the local pressure of a tumour. Disturbance of sight may be absent even when there is considerable swelling of the discs, and when present is often more marked during FIG. 251. Severe recent Papillitis ; several elongated patches of blood near the border of the disc. {After Hughlings Jackson and Settleship.) the subsidence than during the active period of the inflammation. Failure of vision, occurring early and soon becoming extreme, points to local pressure on the chiasma, as from a distended third ventricle in hydrocephalus, a new growth, or a local meningitis. In such cases the pupils are dilated and immovable, whereas in neuritis from a central lesion they usually preserve their reaction to light. Atrophy of the Optic Nerve is either secondary, following a severe papillitis or embolism of the central artery of the retina; or primary, when it results either from pressure on some part of the nerve or chiasma, or in consequence of a chronic sclerosis of the nerve fibres. The most frequent cause of such sclerosis is locomotor ataxia, and after this multiple sclerosis. In locomotor ataxia, optic atrophy may precede all other symptoms by several years. 454 EXAMINATION OF THE NERVOUS SYSTEM. DISORDERS OF HEARING. Tests. i. "Air conduction" is conveniently tested by means of a watch held at varying distances from one ear, while the other is closed by the finger. The distance at which the ticking just ceases to be audible is measured and compared with that of the opposite ear, or, if this is diseased, with an ear of average acuteness. 2. "Bone conduction." Normally a watch held close to but not touching the closed ear is nearly or quite inaudible, while if it be applied to the skull near the ear, the ticking is loudly heard. Disease FIG. 252. Scheme of Organ of Hearing. AG, outer ear meatus ; T, membrana tympani ; A', malleus, with its head (h], short process (kf), and handle (in) a, incus; x, its short leg; , stapes ; z, Sylvian ossicle ; P, middle ear ; o, fenestra ovalis ; r, fenestra rotunda ; x, beginning of cochlea ; pt, scala tympani ; vt, scala vestibuli ; V, vestibule ; S, saccule ; U, utricle ; //, semicircular canals ; TE, Eustachian tube. The long arrow shows the line of traction of the tensor tympani ; the short curved arrow that of the stapedius. (Sfacalister.) of the external or middle ear produces the same result as closure of the passage with the finger ; but in disease of the auditory nerve or of the labyrinth, both air and bone conduction are impaired. Deafness. (i.) Apart from local changes in the external auditory meatus, in the Eustachian tube, or in the tympanum, the most frequent cause of deafness is disease of the labyrinth, or of the nerve endings themselves. These parts are affected in old age, in some of the acute specific fevers, especially mumps, and in congenital syphilis. In Meniere's disease, deafness is associated with vertigo and vomiting. (2.) Deafness from intracranial disease is commonly caused by a lesion of the auditory nerve at the base of the brain, as from syphilitic DISORDERS OF TASTE. 455 meningitis. It may also result from damage to the auditory nuclei within the pons, or from a lesion above the nuclei, affecting the teg- mentum, or the internal capsule, or the upper part of the temporo- sphenoidal lobe. (3.) Loss of hearing may occur in hysteria or in anaemia. Sometimes it follows the administration of quinine or the salicylates. Subjective Noises, Tinnitus Aurium, may be produced by obstruc- tions or disease in any part of the ear, and rarely by lesions affecting the nerve, its nucleus, or the auditory path in some part of its central course. "Buzzing" or "roaring" sounds are common in anaemia. Sounds like bells or music are generally of central origin, and occasionally constitute an epileptic aura. A pulsating sound may be due to in- tracranial aneurysm, and in rare cases a murmur may be heard on applying the stethoscope to the posterior part of the skull. DISORDERS OF TASTE. Tests. The front of the tongue, the back of the tongue, and the palate should be separately tested with sugar, quinine, salt and dilute acetic acid ; the two first- named substances are best appreciated at the back, the two latter at the tip and edges of the tongue. Ageusis, loss or diminution of the sense of taste, affects one half of the tongue in cases of hemianaesthesia, whether of organic or of functional origin. Unilateral ageusis of the anterior portion of the tongue may occur from damage to the chorda tympani, to the facial nerve between the chorda tympani and the geniculate ganglion, to the second branch of the fifth, to its roots, or to the Gasserian ganglion. The path of taste from the palate and back of the tongue, according to Gowers, is along the glossopharyngeal nerve, tympanic nerve, and small petrosal to the otic ganglion, and thence along the third division of the fifth nerve to its root. Lesions of the root of the fifth nerve have abolished taste on the corresponding side of the tongue and palate. Perversion of the sense of taste parageusia, or increased sensa- tion of taste hypergeusia or subjective taste sensations, may each occur in hysteria and in insanity, may result from ear disease, or constitute the aura of an epileptic attack. DISORDERS OF SMELL. Tests. i. Such substances as camphor, musk, oil of cloves, valerian, assafcetida, which affect the olfactory nerves alone, should be applied first to one nostril, then to the other ; but bodies like ammonia or acetic 456 EXAMINATION OF THE NERVOUS SYSTEM. acid, which irritate the branches of the fifth nerve, should not be employed. 2. Flavour may be tested by holding in the mouth cheese or wine. Anosmia, loss or diminution of the sense of smell, is most com- monly due to local disease of the nose, as from polypi. It may also occur : As a congenital affection ; in old age ; in paralysis of the fifth nerve, and sometimes in paralysis of the seventh nerve ; from injury or disease of the olfactory nerves, bulbs, or tracts ; in thrombosis or embolism of the anterior cerebral artery ; sometimes in locomotor ataxia ; also in association with, and on the same side as hemi- anaesthesia, whether of functional or organic origin. Hyperosmia, or increased sensitiveness of the olfactory nerves, is occasionally present in cases of hysteria and insanity. More frequently in hysteria, certain odours produce great disgust, headache, or fainting. Hallucinations and illusions of smell, such as subjective odours of sulphur, or of putrid bodies, are met with in the insane : they may occur as aurse of epileptic fits ; and are occasional symptoms of an intracranial tumour. INDEX ABDOMEN, anatomy of, 255 enlargement, of, 257, 277 fluctuation in, 260 - fluid in, 261 gas in, 261 inspection of, 256. 257 movements of, 257 palpation of, 259 retraction of, 257 superficial veins, 258 tumours of, 200, 260 Abscess of liver, 165 of lung, 165, 171 of mediastinum, 165 subdiaphragmatic, 294 Absence of expression, 57 Absolute cardiac dulness, 204 Acarus folliculorum, 114 scabiei, in Accentuation of heart sounds, 212 Accommodation, 439 Acetonuria, 329 Achorion Schb'nleini, 108 Achromatopsia, 448 Acnerosacea, 124 vulgaris, 123 Acromegaly, 33 Actinomycosis, 108 Addison's disease, 22, 97, 235, 258 Adenoids of pharynx, 251 Adventitious sounds, 161 .Sgophony, 160 Ageusis, 455 Agraphia, 428, 430 Alalia, 427 Albinism, 116, 443 Albumin, estimation of, 315 Albuminoid degeneration, 234 Albuminuria, 313, 317 Albuminuric retinitis, 302 Alcohol, 16, 17, 18, 23, 70,244, 373 Allocheiria, 417 Alopecia areata, 1 1 1 Alteration of voice, 173 Alternate hemiplegia, 355 Ainblyopia, 418, 443, 445 " Amblyopia crossed," 446 Amimia, 428 Ammonio-magnesian phosphate, 337 Amnesia, 432 Amphoric echo, 163 Amyotrophic lateral sclerosis, 422 Anaemia, 10, 19, 24, 30, 219, 247, 318 Anaesthesia, 410, 413 dolorosa, 414 Analgesia, 410 Anarthria, 427 Anasarca, 30 Anchylostomnm duodenale, 284 Aneurysm, abdominal, 257, 260, 302 aortic, 13, 19, 21, 42, 59, 161, 166, 174, 201, 202, 208, 219, 226 auscultation of, 319 intracranial, n, 12, 455 of innominate, 199 Angina Ludovici, 53 pectoris, 13 Anidrosis, 93 Ankle-clonus, 424 Ankle-drop, 69 Anorexia, 20 Anosmia, 456 Anthrax, 103 bacilli, 235 Antimony, 285 Anus, 278 Aortic aneurysm, see Aneurysm, aortic. disease, 199, 203, 212, 214, 217, 219, 223, 227, 240 Apex-beat, 199, 200, 201 Aphasia, 399, 427, 430 Aphemia, 428 Aphthongia, 427 Apoplexy, 16, 42 Appendix vermiformis, 276 Appetite, 20 "Arc de cercle," 377 Arcus senilis, 435 Argyll- Robertson pupil, 440 Arrest of growth, 29 Arsenic, 285 Arterial wave, 196 Arteries, 198 auscultation of, 218 Arthritic muscular atrophy, 389 Arthritis, 47 Ascaris lumbricoides, 284 Ascites, 200, 257, 258, 260, 261, 262, 286, 293 Asthenopia, 446 458 INDEX. Asthma, 59, 161, 171 Astigmatism, 445, 448 Astonishment, 55 Asymmetry of skull, 40 Ataxia, 407 Ataxic paraplegia, 409 Atheroma of arteries, 199 Athetosis, 380 Atrophic paralysis, 383, 384 paralysis, investigation of, 385 Atrophy, 28 arthritic, 29 myopathic, 29 of face, unilateral, 40 Atropine, 42, 249, 448 Attitude, 58 Attitudes associated with normal mus- cular action, 58 due to abnormal muscular action, 62 due to muscular rigidity, 64 due to muscular weakness, 68 in Friedreich's disease, 74 in locomotor ataxy, 74 in peripheral neuritis, 70 in sciatica, 62 of hand in rheumatism, 75 " Attitudes passionelles," 378 Auditory path, 357 vertigo, 360 Aura, 376 Auricular depression, 196 wave, 196 Auscultation, exercise in, 155 of aneurysms, 219 of arteries, 218 of heart, 209 of veins, 219 of voice, 157, 159 Auscultatory areas of heart, 210 BACILLI, tubercle, 167, 236 Bacillus anthracis, 236 Barbadoes leg, 115 Base of brain, lesions at, 362 Basedow's disease, see Graves's disease. Bedsore, 115, 124 Bell-sound, 163 Biedert's stain, 170 Bilharzia haematobia, 323 Birth-palsies, 401 Bizzozero's corpuscles, 323. Bladder, disease of, 12 paralysis of, 406 tumour of, 24 Blebs, 95 Blindness, 301 Blood, examination of, 232 in malaria, 236 in urine, 339 micro-organisms in, 235 spectroscopy of, 239 uric acid in, 240 Blood-corpuscles, counting, 237 Blood-vessels of brain, 362 of spinal cord, 365 Boil, 102 Bones, spontaneous fracture of, 43 thickening of, 36, 45 Bothriocephalus latus, 283 Bradycardia, 223 Breath, shortness of, 19 Breath-sounds in health, 156 laryngeal or tracheal, 156 Breathing, bronchial, 156 cavernous, 15.} Cheyne-Stokes, 141 " cogged- wheel," 158 rate of, 138, 139 varieties of, 156, 159 Bright's disease, 22, 23, 223, 229, 241 301, 308, 317, 322, 329, 434 Bronchiectasis, 165 Bronchitis, 19, 30, 165, 194 capillary, 162 Bronchophony, 160 " Bronze-skin," 97 Bruit de diable, 219 de pot fe\6, 153 de scie, 217 Bubbling rales, 162 Bug, 114 Bulbar paralysis, 21 Bulging of praecordium, 199 Bulimia, 20 Bullas, 95 Burrow, scabies, 112 "Butterfly-patch," 120 CJECUM, 276 cancer of, 278 Calculus of kidney, 59 urinary, 24, 26 Callositas, 117 Cancer of stomach, 22 Cancrum oris, 124 Cantharides, 323 Capillary bronchitis, 162 Carbon-monoxide poisoning, 239 Carbuncle, 102 Cardiac dulness, 204 dulness diminished, 207 dulness increased, 205 failure, 191, 224, 225 murmurs, 213 pulsation, 201 valves, position of, 210 Cartilage, aortic, 193 pulmonary, 193 Cases, examination of, 2 reporting, 3 Case-taking form, 4 Casts, 340 in sputum, 165 significance of, 343 Cataract, 246, 448 Cavity in lung, 163 Cerebellum, 359, 409 INDEX. 459 Cerebellum, tumours of, 12, 422 Cerebral convolutions, 351 disease, 18, 23, 139, 325 fissures, 351 haemorrhage, 18, 22, 307, 317 tumour, 453 Cerebro-spinal fluid, 347 Cervical pachymeningitis, 404 Chalk-stones, 46 Chancre, 105 Charbon, 103 Charcot's crystals, 235 Charcot-Leyden crystals, 171 Cheiro-pompholyx, 121 Chemosis, 434 Chest, auscultation of, 154 bulging of, 134 deformities of, 129, 130 diminution of, 132, 133 enlargement of, 131, 133 inspection of, 128 movements of, 136, 142 palpation of, 141 regions of, 127 retraction of, 138, 140 Cheyne-Stokes breathing, 141, 191 Chicken-pox, 100 Chilblains, 115 Chloasma, no uterinum, 97 Chloroform, 18, 285, 325 Cholera, 23, 25, 68, 281, 308, 325 Chorea, 378 Choroid, 450 Choroiditis, 450 Chromatopsia, 448 Chyluria, 235, 308, 321 Cicatrices, 95 Ciliary congestion, 434, 436, 437 Cimex lectularius, 114 Circulatory system, 189 Cirrhosis of liver, see Liver, cirrhosis of. Clavus, 117 Claw-foot, 73 Claw-hand, 73 Clicking rales, 162 Clipped speech, 427 Clonic spasm, 371 Clubbing of fingers, 44 of toes, 44 Club-foot, 74 Cocaine, 42 Collapse of lung, 133, 161 Coloboma of iris, 42 Colour-blindness, 448 Colour-perception, 445 Coloured vision, 448 Coma, 18, 25, 139 Comedo, 123 Condyloma, icr, 117 Congestion of liver, 191 Congo red, 274 Conjugate deviation, 442 Conjunctiva, 433 Consciousness, disorders of, 16 loss of, 17 perversions of, 16 Consonating rales, 162 Constipation, n, 12, 24 Contraction of pupil, 41 Contracture, 369 Convulsions, 355, 374 of brain, 351 of infants, 65 Coordination, 359 Corn, 117 Cornea, 434 ulceration of, 436 Corpus striatum, 360 Cough, 13, 18, 174 " Cracked-pot "' sound, 153 Cramp, 370 Craniotabes, 35 Cranium, thickening of, 36 Crepitation, 161 Cretinism, 33,35, 43, 51 Crises, gastric, 14 laryngeal, 19 nephralgic, 26 rectal, 24 urethra!, 26 vesical, 26 Crisis, 85 " Crossed amblyopia," 446 Crossed paralysis, 355, 382, 403 Crusts, 95 Crystals, Charcot-Leyden, 171 Curschmann's spirals, 171 Curvature of spine, 48 Cyanosis, 51, 194, 247 Cycloplegia, 438 " Cylindroids," 342 Cyst, hydatid, 262 ovarian, 262 renal, 262 Cystine, 338 Cystitis, 24, 26, 320 Cysts, contents of, 348 DAY-BLINDNESS, 447 Deafness, 454 "Death-rattle," 162 Deep cardiac dulness, 204 Defervescence, 81, 85 Deformities in congenital syphilis, 43 in fractured spine, 69 in Friedreich's disease, 74 in mollities ossium, 43 in rheumatoid arthritis, 46 in rickets, 42 in typhoid, 43 Degeneration, reaction of, 395 Delirium, 16, 17 tremens, 17, 317, 374 Delusion, 16 Dementia, 17 Deposits in urine, 339 Depression, auricular, 196 460 INDEX. Depression of praecordium, 199 systolic, 202 Dermatitis, exfoliative, 119 herpetiformis, 122 Dermoid cysts, 349 Diabetes, 18, 21, 24, 25, 241, 307, 310, 325, 329, 422, 437, 445 Diacetic acid, 330 Diarrhoea, 23, 301 Diastolic murmur, 216, 217 shock, 202 thrill, 203 Diazo reaction, 330 Dicrotic wave, 222 Difficult micturition, 26 Digestion, 272, 273 Digitalis, 226, 308 Dilatation of pupil, 42 of right ventricle, 194, 201 Diphtheria, 18, 21, 53, 165, 251, 252, 422 Diplegia, 382 Diplopia, 440, 448 "Dipping for liver," 28? Disease, Addison's, 97 Graves's, 97 Raynaud's, 125. Disorders of consciousness, 1 6 Displacement of apex-beat, 201 Disseminated sclerosis, 18, 373, 443 Distension of right heart, 202 of veins, 194 Diverticulum, Meckel's, 275 Dizziness, 15 Doremus, method of, 331 Dorsal posture, 59, 68 Dropsy, 30, 191 Drug-eruptions, 125 "Drunkard's arm," 69 Dry crepitant rale, with large bubbles, 162 Dulness above third cartilage, 208 cardiac, 204. Duodenum, 275 Dysentery, 24 Dyspepsia, n, 12, 13, 14, 20, 22, 23, 224, 264, 265 Dysphagia, 21 Dyspnoea, 19, 51, 139, 140, 173, 191 EAR disease, n, 454 Early rigidity, 397 Ecchymoses, 94 Echo, amphoric, 163 metallic, 212 Eclampsia, 376 of infants, 65 Ecthyma, 102 Eczema, 122 Ehrlich's reaction, 330 Elastic tissue in sputum, 171 Elbow -jerk, 423 Electrical examination, 391 Elephantiasis Arabum, 115 Grtecorum, 104 Emaciation, 28 Emphysema, 19, 30, 61, 132, 137, 153, 162, 201, 207, 212, 288 subcutaneous, 33 Emprosthotonus, 64 Empyema, 44, 49, 165 Enamel, pitted and rocky, 246 Endocardial murmurs, 213 Enlargement of cranial bones, 36 local, 33 Ephelides, 116 Epigastric pulsation, 201, 258 Epigastrium, 255 Epilepsy, 16, 18, 307, 317, 375, 422 Epithelioma of skin, 124 Equinia, 103 Eruptions from drugs, 125 Erysipelas, 53, 101, 250 Erythema, 99, 115 Erythrasma, m Esbach's process, 316 Eserine, 42, 448 Eustachian tube, 454 Exaltation, 16 Examination of blood, 232, 235 of cases, 2 of circulatory system, 189 of larynx, 172 Excoriations, 95 Exophthalmic goitre, see Graves's disease. Expression, 53, 54, 55 absence of, 57 Expiration, prolonged, 158 Extension of great-toe, 66 Exudations, 345 FACE, expression of, 53 hemiatrophy of, 40 movements of, 55 prognosis from, 57 Fajcal accumulation, 277 Fffices, examination of, 279 Fallacious auscultatory sounds, 164 Farcy, 103 Fascial reactions, 423 Fastigium, 81, 83 Fauces, 250 Favus, 108 Fehling's solution, 326 Fermentation test, 328 Fever, 80, 222, 334 types of, 80 Fibrillary contractions, 371 Filaria sanguinis hominis, 115, 235 Fingers, clubbing of, 44 Fissures, 95 Flea, 114 Fluctuation, 114 in abdomen, 260 Foot-clonus, 424 " Foot, the tabetic," 46 Forced movements, 380 Fractures, spontaneous, 43 INDEX. 461 Friinkel-Gabbet stain, 168 Freckles, 116 Fremitus, 143, 144 friction, 144, 203, 290, 298 Friction fremitus, 144, 203, 290, 298 pericardia!, 217 pleuritic, 144, 203 Friedreich's disease, 74, 79, 408, 443 Functional murmurs, 213 Furunculus, 102 GAIT, 77, 78, 79 Gall-bladder, 284, 290, 294 Gall-stones, 291 Galloping rhythm, 212 Gangrene, 125 Gastric crisis, 14 ulcer, 22, 23, 259, 264, 265, 270 General convulsions, 376 paralysis of insane, 18, 41, 42, 44, 244 Giddiness, 15, 301 Gland, thyroid, 51 Glanders, 103 Glands, enlargement of, 49 lymphatic, table of, 50 salivary, 52 scrofulous, 51 Glaucoma, 435, 438 Glossitis, 21, 240 Glossy skin, 117 Glycosuria, 325 Gmelin's test, 324 Gonorrhoea, 320, 434 Gonorrhceal arthritis, 47 Gout, 10, 46, 100, 303, 334 " Grandes mouvements," 377 Granular kidney, 212 Graves's disease, 20, 23, 41, 51, 97, 198, 211, 219, 222, 227, 373 Great-toe, extension of, 66 "Griffe des orteils," 73 "Grog-blossom," 124 Ground-glass opacity, 435 Gummata, 106, 107 Gums, 247 Gutta rosea, 124 HALLUCINATION, 16 Hand in hemiplegia, 67 Hard chancre, 105 Harrison's sulcus, 130, 140 Hsemacytometer, 237 Haematemesis, 270 Hsematuria, 322 Hasmic murmurs, 213 Haemoglobinjemia, 240 Haemoglobinometer, 238 Haemoglobinuria, 323 paroxysmal, 323 Haemophilia, 47 Haemoptysis, 166 Haemorrhage into pons, 42 Haemorrhoids, see Piles. Haemothorax, 133 Head in rickets, 34 Headache, 10, 264, 301 Head-injuries, 18 Hearing, 454 Heart, enlarged, 199 fatty degeneration of, 223^ Heart-disease, 10, 13, 19, 59, 134, 296, 434 congenital, 44 Heart-sounds, accentuation of, 212 enfeeblement of, 212 intensification of, 211 modifications of, 210 normal, 209 - reduplication of, 212 Heberden's nodes, 46 Heel, drawn up, 66 Heller's test, 325 Hemiamesthesia, 399, 414 Hemianopsia, 33, 399, 433, 448 Hemiatrophy of face, 40 Hemicrania, 1 1 Hemiplegia, 67, 77, 379, 382, 397, 422 hand in, 67 Hepatic pain, 284 Herpes, 121, 436 iris, 121 Hip-disease, 49 History, previous, 4 Hodgkin's disease, 51, 256 "Horse-shoe" kidney, 305 Hydatid thrill, 289 Hydatids, 165, 285 in sputum, 167 Hydrocephalus, 37, 347 Hydrochloric acid, 274 Hydronephrosis, 306, 348 Hydro-pericardium, 206, 212 Hydrophobia, 21. 64 Hydro-pneumothorax, 164 Hydrothorax, 51 Hyperaesthesia, 410, 416 Hyperalgesia, 410 Hyperidrosis, 92 local, 93 Hyperosmia, 456 Hyperpyrexia, 18, 85 Hyper-resonance, 150 Hypertrophy of left auricle, 205 of left ventricle, 201, 205, 212 Hypochondrium, left, 256 right, 255 Hypogastrium, 256 Hypopyon, 435 Hysteria, u, 13, 17, 18, 19, 20, 21, 23, 25, 28, 56, 67, 78, 307 major, 377 minor, 377 Hystero-epilepsy, 377 ICHTHYOSIS, 118 linguae, 242 Idiocy, 17, 29 462 INDEX. Iliac region, 256 Impetigo contagiosa, 102 Incontinence of urine, 25, 406 Incoordination, 407 Infantile convulsions, 65 paralysis, 372 Influenza, 9, 12 Initial rigidity, 397 Insanity, 16, 20 Inspection of chest, 128 circulatory system, 193 of patient, 2 Inspiration deferred, 158 Internal capsule, 354 Intestinal obstruction, 23, 24, 258, 270 Intussusception, 24, 260, 278 Invasion of pyrexia, 81 Iodide of potassium, 246 Iridoplegia, 439 Iris, coloboma of, 42 Iritis, 42, 437 JACKSONIAN epilepsy, 375 Jaundice, n, 92, 223, 247, 285, 291, 299, 309, 434 Joints in acute rheumatism, 44 in congenital syphilis, 47 in gonorrhoea, 47 in gout, 46 in haemophilia, 47 in nervous diseases, 47 in rheumatoid arthritis, 46 in scarlet fever, 47 swelling of, 44 KELOID of Addison, 116 of Alibert, 1 1 7 Keratitis, 435 Kerion, 109 Kidney, amyloid, 307 enlarged, 305 floating, 305 granular, 307 "horse-shoe," 305 sarcoma of, 322 scrofulous, 303, 322 Kidney disease, 10, 12, 25 Kidneys, 300 Knee-jerk, 421 LACTIC acid, 274 Lasnnec's rale, 162 Language, 425 Large intestine, 276 Laryngeal crisis, 19 image, position of parts in, 181 mirrors, 177 obstruction, 139 paralyses, 1 88 reflectors, 177 stridor, 173 Laryngitis, 174, 184, 227 Laryngoscopy, 173, 179 difficulties in, 181 Laryngoscopy, illumination in, 175 position of patient in, 176 Larynx, morbid conditions of, 184 thickening and tumours of, 185 tubercle of, 184 ulcers of, 21, 186 Late rigidity, 397 Lateral sclerosis, 422 Lead, 23, 69, 247, 257, 259, 318, 373, 38s Leaning forwards, 61 to one side, 61 Lentigo, 116 Leontiasis, 104 Leprosy, 104 Leptothrix buccalis, 249 Leptus autumnalis, 114 Leucin, 338 Leucocythaemia, 234, 296, 297 Leucocytosis, 234 Leucoderma, 116 Leucoma, 435 Leucorrhoea, 320 Leukaemia, 234, 318 Leukoplakia, 243 Lichen planus, 119 scrofulosorum, 119 Lineae albicantes, 28, 116, 285 Liver, 284 abscess of, 288, 289 acute yellow atrophy of, 285, 293 amyloid, 288, 289 anatomy of, 286 cirrhosis of, 258, 270, 285, 288, 289, 293, 308 congested, 191, 288, 289 enlarged, 294 fatty, 288, 289 hydatid of, 288, 289 new growths of, 288 pulsating, 198 Liver-dulness, 291 Local convulsions, 374 enlargement, 33 Locality, sense of, 411 Locomotive pulse, 199 Locomotor ataxy, 14, 19, 26, 41, 42, 74, 78, 408, 422, 450, 453 Lordosis. 68 Loss of consciousness, 17 Louse, body, 113 crab, 113 head, 113 Lumbar region, 256 Lung, abscess of, 165, 171 cavity in, 163 collapse of, 161 consolidation of, 143, 144 Lung, gangrene of, 165 hernia of, 134 oedema of, 165 solidification of, 211 Lungs, limits of, 147 Lupus erythematosus, 120 INDEX. 463 Lupus vnlgaris, 103 Lymphadenoma, 296 " MAIN en griffe," 73 Malaria, 235, 236, 296 blood in, 235 Malignant pustule, 103 Marechalt's test, 324 Measles, 98, 250, 434 German, 98 Measurements of head, 34 Meckel's diverticulum, 258, 275 Mediastinal tumours, 18, 207, 208 Mediastinitis, 226 Megaloblasts, 234 Melasna, 280 Melana?mia, 235 Melanotic sarcoma of skin, 118 Meniere's disease, 15, 23, 360, 454 Meningitis, II, 18, 22, 23, 64, 223, 257, 274 Mercury, 243, 244, 246, 285, 373 Mesentery, tumours of, 300 Metallic echo, 212 rale, 162 ring, 133 tinkling, 168 Meteorism, 257 Methyl-violet, 274 Microcephalus, 39 Micrococcus ureaj, 312 Micro-organisms in blood, 235 Micropsia, 448 Microsporon furfur, 1 1 1 minutissimum, 1 1 1 Micturition, frequency of, 24 painful, 26 Microcytes, 234 Migraine, n, 16, 23 Miliaria, 121 Mitral stenosis, 30, 166, 194, 203, 211, 212, 214, 216, 217, 224, 225, 240 Mixed paralyses, 403 Mole, 117 Mollities ossium, 43 Molluscum contagiosum, 118 fibrosum, 118 Monoplegia, 355, 399 Moore's test, 325 Morphia, 325 Morphcea, 116 Mother's mark, 116 Motor centres, 352 path, 352 path, lower segment of, 355 path, upper segment of, 355 Mouth, bleeding from, 248 microscopical examination of contents of, 249 mucous membrane of, 247 ulceration of, 248 Movements of face, 55 Mucin, 321 Multiple sclerosis, 18, 453 Mumps, 52, 454 Murmurs, cardiac, 213 diastolic, 216 functional, 213 hremic, 213 presystolic, 216 systolic, 213, 214, 215, 216 Muscles, enlargement of, 33, 388 Muscular sense, 412 Mydriasis, 42 Myelitis, 25, 401, 404, 405, 422 Myopathic atrophy, 29 paralysis, 384 Myosis, 41 Myxoedema, 31, 51, 223 Ksvus, 116 pigmentosus, 1 1 7 Nails, curved, 44, 126 furrowed, 126 Narcotic poisoning, 16 Nasal bronchophony, 160 Nebula, 435 Nephralgic crisis, 26 Nephritis, acute, 30, 341 Nerves and vertebrae, relations of, 366 Nettlerash, 118 Neuralgia, 10 Neurasthenia, n, 16, 17, 20 Neuritis, 14, 57, 68, 77, 371, 386, 417, 422 Night-blindness, 447 Nits, 113 Nodes, Heberden's, 46 Nodules in skin, 95 rheumatic, 44 Noma, 124 Nuclei, position of, in medulla, 360 Nystagmus, 401, 443 OBESITY, 29 Obstruction of bile-duct, 285 Odour of sputum, 165 (Edema, 30 QEsophageal bougie, 253, 254 disease, 21 (Esophagus, examination of, 253 relations of, 253 Oi'dium albicans, 248 Old age, 373 Olfactory path, 357 Oliguria, 308 Omental tumours, 293, 294, 300 Onychauxis, 126 Onychia, 126 Onychomycosis, 126 Onyx, 435 Ophthalmia, 434 Ophthalmoplegia, 443 Ophthalmoscope, 450 Opium, 17, 42 Optic atrophy, 448, 453 neuritis, 40, 452 thalamus, 360 464 INDEX. Orthopncea, 139, 191 Osteo-arthritis, 223 Ostitis deformans, 36, 61 Outflow-remainder wave, 222 Ovarian disease, 12 tumour, 262, 293, 349 Oxalate of lime, 335 Oxyuris vermicularis, 284 PACHYMENINGITIS, 259, 404 Pain, 9 hepatic, 284 in abdomen, 13, 259, 264 in back, 12, 302 in chest, 13 in disease of stomach, 264 in head, 10 in limbs, 14 in micturition, 26 in neck, 1 2 in testicle, 302 Pallor of skin, 91 Palpebral fissure, narrowing of, 41 Palpitation, 20 Pancreas, 299 Pancreatic cysts, 349 Pannus, 435 Papillary wave, 222 Papillitis, 452 Papules, 95 Paradoxical contraction, 224 temperatures, 87 Paraesthesia, 410, 417 Paralalia, 427 Paralysis agitans, 66, 77, 244, 372 bulbar, 244 infantile, 49, 68 of bladder, 406 of diaphragm, 132, 138 of eye-muscles, 438, 440 of fifth cervical root, 386 of intercostals, 132 of larynx,- 188 of rectum, 406 pseudo-bulbar, 400 pseudo-hypertrophic, 33, 68, 78, 388, 422 spastic, 66, 77 Paranaesthesia, 414 Paraplegia, 382, 400, 402 Parotid bubo, 52 Paroxysmal hasmoglobinuria, 323 Pavy's solution, 327 "Pea-soup" stools, 281 Pectoriloquy, 160 Pediculosis, 113 Pediculus, 113 Pelvic inflammation, 26 Pemphigus, 121, 240 Peptonuria, 319 Percussion, 145, 203 of stomach, 266 regional, 150 resistance on, 153 Percussion- wave, 221 Pericarditis, 13, 14, 201, 202, 206, 208, 217 Perihepatitis, 163, 285 Perimeter, 444 Perinephritis, Periosteal reactions, 423 Peritonitis, 22, 29, 59 Petechiae, 94 " Phantom tumours," 259 Pharyngeal exudation, 251 Pharynx, 250 ulcers of, 252 Phenyl-hydrazin, 329 Phloroglucin-vanillin, 274 Phlyctenular ophthalmia, 436 Phosphate of lime, 337 stellate, 337 - triple, 337 Phosphorus, 285 Phthinoid chest, 130 Phthiriasis, 113 Phthisis, 22, 28, 44, 59, 132, 133, 137, 162, 165, 171, 422 Physical signs, i .Pica, 20 Picric acid, 328 Pigeon-chest, 131 Piles, 24 Pilocarpine, 42 Pimples, 95 Pityriasis rubra, 119 Plasmodium malarite, 236 Pleura, fluid in, 133, 134, 137, 152, 201, 288, 294, 296, 299, 347 Pleurisy, 13, 14, 48, 59, 61, 133, 143, 163, 226, 259 Pleurodynia, 13 Pleurosthotonos, 64 Pneumonia, 22, 161, 165, 167, 226, 285 Pneumonoconiosis, 166 Pneumo-pericardium, 212 Pneumo-thorax, 133, 153, 163, "01 Poikilocytes, 234 " Points doloureux," 417 Poliomyelitis, 387 Polyaesthesia, 417 Polygraph, 195 Polypi, nasal, 456 Polyuria, 307 Pomphi, 95 " Port-wine stain," 116 Post-nasal catarrh, 18, 251 Posture, 59 Postures due to muscular rigidity, 64 in spastic paralysis, 66 Precordia, 199 Pregnancy, 317 Present state, 5 Presystolic thrill, 203 Prognosis from face, 57 Progressive muscular atrophy, 372 Prostate, bleeding from, 323 enlarged, 25 INDEX. 465 Prurigo, 118 Pseudo-bulbar paralysis, 400 Pseudo-crisis, 85 Pseudo-hypertrophic paralysis, see Paralysis, pseudo-hypertrophic. Psoriasis, 119 Psychical centres, 358 Ptosis, 441 Pulex irritans, 1 14 Pulsating empyema, 144 Pulsation, aneurysmal, 202 epigastric, 201 venous, 194 visible, 198 Pulse, 221 frequency of, 222 intermittent, 225 irregular, 224 "locomotive," 199 tension of, 228 varieties of, 227, 228, 229, 230 "water-hammer," 227 Pulses, want of symmetry of, 199, 232, 253 Pulsus alternans, 224, 228 bigeminus, 226 bisferiens, 231 celer, 227 paradoxus, 226 tardus, 227 trigeminus, 226 Puerperal state, 317 Puncture fluids, 344 Pupil, contraction of, 41 excluded, 437 occluded, 438 Pupil-reflex, 439 Pupils, dilatation of, 42 inequality of, 42 irregularity of, 42 Purpura, 115, 167, 247, 248, 323 Pus, 321 in faeces, 282 in urine, 338 Pustules, 95 Pyaemia, 285 Pyelitis, 320 Pylorus, cancer of, 265 stricture of, 258, 268 Pyramidal tract, 354 Pyrexia, 10, 20, 28, 80, 139 course of, 81 Pyrogenetic stage, 81 Pyrosis, 269 QUININE, 455 Quinsy, 250 RALES, 162, 164 Eashes, 97, 98, 99, 100, 101 Raynaud's disease, 125, 323 Reaction of degeneration, 395 , Rectal crises, 24 Rectum, 278 Rectum, paralysis of, 406 Redness of skin, 91 Reflex action, 418 amblyopia, 418 Reflexes, cranial, 420 deep, 421 superficial, 419 Regurgitation, 21 Relapsing fever, 98 Relations of heart, 191 Renal calculus, see Calculus in kidney. Reporting cases, 3 Resistance on percussion, 153 Resonance, amphoric, 153 diminished, 151 increased, 150 of cough, 1 60 of cry, 160 Skoda'ic, 151 tracheal, 151 tympanitic, 150 vocal, 159 Respiration, abdominal movements in, 258 Cheyne- Stokes, 191 Restlessness, 59 Retention of urine, 406 Retinitis, 302, 447, 451 Retraction of chest, 138, 140 Retropharyngeal abscess, 21 Rhagades, 95 Rheumatic nodules, 44 Rheumatism, 9, 10, 12, 13, 14, 44, 75, 99, 434 acute, 212, 241, 308 Rheumatoid arthritis, 45, 46, 75 Rhonchi, 161 Rickets, 34, 40, 42, 48, 49, 130, 245, 288, 295 chest, in, 130 " Rickety rosary," 131 Rigidity, 65, 66, 67, 369, 397 Ringworm, 108 Rodent ulcer, 124 Romberg's symptom, 408 Rotheln, 98, 250 Round worms, 284 Rupia, 106 Rupture of air-cells, 33 SALICYLATES, 309, 455 Saliva, 249 Salivary glands, 52 Sarcina ventriculi, 272 Scabies, in Scabs, 95 Scales, 95 Scanning speech, 427 Scarlet fever, 21, 47, 97, 241, 247, 250, 285, 31? Scars, 95 Sciatica, 49, 61 Scleroderma, 57, 116 Scoliosis, 49 2 G 466 INDEX. Scotoma, 445 Scrofuloderma, 104 Scurvy, 246, 248, 323 infantile, 43 Scybala, 281 Seborrhcea, 120 Semilunar space, Traube's, 267 " Sensory crossway," 356 disturbance, 390 path, 356 Septicaemia, 98 Shingles, 13, 121 Shortness of breath, 19 " Shoulder growing out," 49 Siderosis, 166 Signs, physical, i Silicosis, 166 Silver, 434 Sitting posture, 59 Skin, examination of, 94 lesions of, 94 redness of, 91 pallor of, 91 yellow, 92 Skin-diseases, diagnosis of, 95 Skodaic resonance, 151 Skull, asymmetry of, 40 Small -pox, 12, 100, 252, 434 Smell, 455 Soft palate, 250 Sordes, 247 Sound, bell, 163 succussion, 164 Sounds, adventitious, 161 fallacious, auscultatory, 164 friction, 163 Spade-like hands, 32 Spasm, 369, 425 Spastic paralysis, 66, 355, 383, 396, 422 Spermatorrhoea, 343 Sphygmograph, 221 Spina bifida, 49, 347 " Spina bifida occulta," 49 Spinal caries, 12, 49, 61, 259 cord, disease of, 12, 25 epilepsy, 224 roots, distribution of, 367 Spine, curvature of, 48 fracture of, 69 Spino-neural paralysis, 384 Spirals, Curschmann's, 171 Spirillum Obermeieri, 235 Spleen, 295 amyloid, 296 congested, 296 embolism of, 296 enlarged, 296 movable, 296 palpation of, 297 pulsating, 298 Sputum, 164 black, 1 66 casts in, 165 crystals and spirals in, 171 Sputum, elastic tissue in, 171 hydatids in, 165 muco-purulent, 165 mucous, 164 odour of, 165 purulent, 165 quantity of, 165 rusty, 167 sanguineous, 165, 166 serous, 165 Squamae, 95 Staccato speech, 427 Stammering, 426 Standing, 60 Static ataxia, 409 Station, 60 Status epilepticus, 376, 378 hystericus, 378 Stertor, 18 Stomach, acute distension of, 268 anatomy of, 263 auscultation of, 268 dilatation of, 264, 267 fungi in, 27 1 inflation of, 264 motor power of, 275 pain, 264 percussion of, 266 symptoms, 263 tenderness, 265 tube, 272 tumours of, 265 Strabismus, 440 Striae atrophicae, 116 Stricture of rectum, 24 of urethra, 24, 25 Stridor, laryngeal, 173 Structural rigidity, 398 Strychnine, 64, 422 Subcrepitant rale, 162 Subcutaneous emphysema, 33 Subdiaphragmatic abscess, 294 " Sub-tympanitic " note, 149 Succussion sound, 164 Sudamina, 121 Sulcus, Harrison's, 130 Sunstroke, 18 Suppression of urine, 25, 418 Sweating, 92 Swelling of joints, 44 Sycosis, 1 02 coccogenic, 102 Symptoms, i digestive, 20 respiratory and circulatory, 18 urinary, 24 Syncope, 18 Synechiae, 437 Syphilis, 12, 14, 36, 105, 296, 450 congenital, 28, 40, 43, 47, 107, 246, 252, 297, 454 hereditary, see Syphilis, congenital. Syphilides, 105, 106 Systolic depression, 202 INDEX. Systolic murmurs, aortic, 214 murmurs, mitral, 213 murmurs, pulmonary, 215 murmurs, tricuspid, 216 thrill, 203 TABES dorsalis, 408 " Tabetic foot," 48 Tachycardia, 223 Taenia echinococcus, 348 mediocanellata, 282 saginata, 282 solium, 283 Talipes, 74, 398 Tape-worms, 282 Taste, 455 path for, 358 Teeth, carious, 245 eruption of, 245 grinding of, 246 loosening of, 246 notched, 245 Teething, 245 Temperature, 79 effect of idiosyncrasy on, 89 in acute rheumatism, 85 in ague, 81 in leucocythaemia, 80 in pneumonia, 82, 84, 87 in scarlet fever, 81 in tubercular meningitis, 88 in tubercular peritonitis, 83 in typhoid fever, 86 influence of age on, 88 influence of complications on, 89 paradoxical, 87 subnormal, 90 " Tender points," 10 Tenesmus, 24 Terror, 55 Tetanus, 64, 317, 422 Tetany, 64 Thickening of cranial bones, 36 of larynx, 185 of limb bones, 43 of cranial bones, 36 Thirst, 20 Thomson's disease, 33 "Thorn-apple" spherules, 335 Thrills, 203 Thrush, 247, 251 Thyroid gland, 51 Tidal wave, 222 Tinea favosa, 108 tonsurans, 108 versicolor, 109 Tingling, 14 Tinkling, metallic, 163 Tinnitus aurium, 455 Toe-clonus, 424 Toes, clubbing of, 44 Tone of muscles, 383 Tongue, 240, 241 dry, 242 Tongue, furred, 241, 242 " mapped," 242 spasm of, 244 "strawberry," 241 tremor of, 244 nlceration of, 243 "Tongue-tie," 244 Tonic spasm, 369 Tonsillitis, 21, 250, 251 Tonsils, enlarged, 18 Tophi, 46, 100 Torula cerevisiae, 271 Trachea, pressure on, 174 Tracheal tugging, 203 Trance, 17 Transudations, 346 Traube's space, 267 Tremor, 371, 427 Trichina spiralis, 284 Trichocephalus dispar, 208 Trichophyton tonsurans, 109 Triple phosphate, 337 Trismus, 246 Trommer's test, 326 Troposolin, 274 Tubercle bacilli, 167 bacilli in urine, 170 bacilli, staining, 168 Tubercular ulceration, 104 Tumours of larynx, 185 Turpentine, 323 Tylosis, 117 Tympanites, 292 Typhlitis, 59, 276 Typhoid fever, 9, 22, 23, 28, 43, 99, 241, 242, 250, 276, 281, 285, 296, 297, 330, 437 Typhus fever, 68, 98, 285. 307, 434 Tyrosin, 338 ULCER of stomach, 33 rodent, 124 Ulcers, 95 of larynx, 33, 186 of pharynx, 252 Umbilicus, 258 Unconsciousness, see Coma. Uraemia, n, 18, 301, 445 Urates, 334 Urea, 330, 348 Ureter, obstruction of, 308, 317 Urethral crises, 26 Uric acid, 332, 348 acid in blood, 240 Urinary deposits, 339 Urine, 307 albumin in, 312 albnmoses in, 320 ammoniacal, 312 bile in, 323 blood in, 321 chlorides in, 330 colour of, 308 estimation of solids, 310 468 INDEX. Urine, examination of, 312 globulin in, 318 incontinence of, 25 odour of, 309 peptones in, 319 phosphates in, 336 pus in, 320, 321 reaction of, 311 retention of, 25 sediments in, 332 specific gravity of, 310 sugar in, 325 sulphates in, 330 suppression of, 25, 418 tubercle bacilli in, 170 Urinometer, 310 Urticse, 95 Urticaria, 118, 240 Uterus, disease of, 12, 25 Uvula, 1 8 VACCINATION vesicle, 101 Vaccinia, 100 Valves, cardiac, position of, 210 Varicella, 100 Varicose veins, 30 Variola, 100 Veins, auscultation of, 219 obstruction of, 3 1 Venous distension, 194 pulsation, 194 Ventral posture, 59 Ventricular wave, 196 Verbal amnesia, 432 Vermiform appendix, 276 Verruca, 117 necrogenica, 104 Vertigo, 15, 16, 454 Vesical crises, 26 Vesicles, 95 Visual field, 444 Visual path, 357 Vitiligo, 116 Vocal resonance, 159, 160 Voice, alteration of, 173 Vomit, 268, 269, 270 "coffee-ground," 270 examination of, 268 microscopy of, 27 1 stercoraceous, 270 Vomiting, 21, 264, 301 WALKING, 76 dragging toes in, 77 exposing soles in, 77 Wart, 117 post-mortem, 105 venereal, 117 "Water- brash," 269 Wave, arterial, 196 auricular, 196 dicrotic, 222 outflow-remainder, 222 papillary, 222 percussion, 221 tidal, 222 ventricular, 196 Wheals, 95 Whip-worm, 284 Wooping-cough, 22, 30 Wrist-drop, 69 Wrist-jerk, 423 XANTHELASMA, 117 Xanthoma, 117 Xeroderma, 118 YEAST, 271 Yellow skin, 92 ZIEHL-NEELSON stain, 169 I Zona, 121 THE END. PRINTED BV BALLANTVNE. HANSON AND CO. EDINBURGH AND LONDON Date Due CAT. NO. 23 233 PRINTED IN U.S.A. WBlUl B975c 189 1 * Bury, Judson S Clinical medicine; a manual for the use of students and junior practitioners WBllU ' B975c Bury, Judson S Clinical medicine; a manual for the use of students and junior practitioners