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OF rilVSIdANS OF 1-!llLAt)EL|-HlA. Bit;.; AITHUR OF A 





Eotere'l acrordini; li> i\ie Act of CongrtM iD the Jear I8W7, bv 


In tlin Oflii-n of Itic lilhrBriHn o( Cnngrou. All righU rnerved. 

j> o R > A N , !■ I: ] s r E h 

1-1 - 


The first edition of tliis book, which was published in August, 
1896, waa so rapidly exhausted tliat the author has liad an early 
opportunity to present a second editiou, from which the unavoid- 
able faults of a first edition have been expunjred and to which 
oiauy new facts have been added. The autiior desires to reiterate 
the fact that the book was written with the hope that it would 
prove useful as a guide in bedside practice. That the profusion 
needed a book dealing with diagnosis from the standpoint of the 
symptoms manifested by tiie |>ntient seems to be evidenced by the 
rapid sale of the first edition. 

In this edition the two indexes of the first edition have been 
combined in one to avoid confusion aud aid the reader. 

pRlL*DU.FHii. 222 South Fifteknth Strert. 
September, IH97. 

59 1 er, 


The object of this volume U tu place before the pliyBician and 
student the subject of me<:Iical diagnosis as it is met at the bedside. 
To accomplish tliis the symptoms used in diagut^is are discussed 
first, and their application to determine the character of the disease 
followa. Thus, instead of describing locomotor ataxia or myelitis, 
there will be found in the chapter on tiie Feet and I^ga a discus- 
sion of the various forms of and causes of paraplegia, so that a 
physioian who is (consulted by a [Miraplegic patient can in a few 
moments find the various causes of this condition and the differen- 
tia! diagnosis between eac;li. So, in the chapter on the Tongue, its 
app(?arance in disease, Iwath local and remote, is discussed. In other 
words, this hnok is written upon a plan quite the reverse of that 
commonly followed, for in the ordinary ircatises on diagnosis the 
physician is forced to make a supposititious diagnosis, and, having 
done this, turn to his reference book and read the article dealing 
with the disease sup|Hi8ed to ))e jircsent, when if the description 
fails to coincide with tlie symptoms of his case he must make 
another guess and read another article. In this book, however, the 
discovery of any marketl symptom will lead directly to the diag- 
nosis. Thus, if the patient is vomiting, in the chapter on Vom- 
iting will l>e found its various causes and its <liagnostic signiDcnnce, 
and the differentiation of each form of this atfection from another. 

The value of the lx)ok is increased by the prei>aration of two 
indexes: one of symptoms and the other of diseases, 

Ba.iing his efforts \i\Htn the experience which he has had in l>oth 
di<laetic and clinical teaching of lai^e classes of .students during 


the last twelve years, the author hopes tliat the work may in some 
degree lighten the labors of the general practitioner and student, 
and relieve the all-imiwrtant subject of diagnosis of some of the 
difRe 111 ties which surround it. He has also endeavored to make 
the text serve as an aid to the rational use of his Text-Book oj 
Practical TheiapeuUcst. 

Philadelphia, 222 Soctu FirtEEKTii Street, 
August, IHM. 








The ezpresmioD and crilor of the luva — Fitcial piiralyKiH, uniluteral find 
bilateral — Ptwia —Facial spasm —The shape of the head — The 
uiovemeDta and position of the head ...... 2i^ 



The general appearance at the hiuidrt und arms— The sliopc of the 
hands in disease — Spamns of the fingers — Tremore of the hands- 
Paralysis til' the hands -tnd aniig 54 



The general appearance nf the feet ami le;p when clothed— The gait — 
Spastic paraplegia — Parajilcgia without spastic eontniction — Crural 
monoplegia— Deformities of the feet— The joinljj — Alterations in 
the nutrition of the feet and legs aside from a change in the 
muscles ............ 85 







The general appearance of the tongue—Its coating— Its appearance 
in poisoning— FiBBures and ulcere of the tongue — Eruptions of the 
tongue— A trojihy and hypertrophy of the tongue — Paralysis — 
Tremor and spasm of the tongue 140 



The general diagnostic indications afforded by the eye — Diplopia — Dis- 
order of the extemai ocular muNcles — Disorder of the internal ocular 
muscles— Strabismus and squint — The pupil — HemiaDopsia — The 
visual fields — Color-vision — The optic nerve and its lesions — Re- 
tinitis — Amblyopia and blindness 158 



The color of the stin — Eruptions of the skin — Gangrene, ulcers, and 
sloughs — Scars, sweating, dryness, tedema, hardness — Autesthcsia, 
and hemianiestheHia — Parte!>thot«ia, hyperiesthesiu, itching . . 195 



The inspection of the normal anil abnormal chest— Their topography- 
Alterations in the shape nf the thorax — The rhythm of the respira- 
tions—The results of using inspeitinn, palpation, percussion, and 
auscultation in health und disi^ase — The characlcristic signs and 
symptoms of the various^ diseases of the thoracic organs . . 263 



The surface of the abdomen— Changes in the iippeiiranee anci shape 
of the abdominal wall — The signs ami symptoms of disease of the 
abdominal organs 320 



The condition of the blooilvessels on palpjition— Fci'ling ami counting 
the pulse — The quality, force, iitid volume of tin' pulse in lieiillh 
and disease ^-I') 





The various forms of red and white corpuscles — Their proportionate 
number in health and disease — AlteratioitB in their form and 
character — The hsemoglobin of the bkiod in health and disease 
— The various forms of ancemia — Lcucocythoemia and pseudo-leuco- 
cythwmia — Parasites of the blood 353 



Disorders and diseases of the urinary bladder — Betentiou of urine — 
IncontioeDce of urine— The eharacteristicH of normal and abnor- 
mal urine — The normal and abnormal contents of the urine— 
Their significance — Tents for the contents of the urine . . . 377 



Constipation and diarrhcea — The causes of these two symptoms and 
their diagnosis — The diaeaaes in which these symptoms occur — 
Choleraic diarrhcea — Dysentery — The color of the feces— Intestinal 
parasites ...,.,....,. 418 




The methods of taking the temjierature — Tlic Hignificance of fever — 

The febrile moveuiento of various diseases 433 



The causes of headache — Digestive iicadache — KeailiicheH <lue to the 
eyes— Headaches due to cerebral tumor ami alwi-ens^HeudaclicM 
due to syphilis — Headaches coinplicHtiiig acuto diseases . . . 4i'if5 







The convulsionB of epile|>sy in its various forms — Of infancy — Of hys- 
teria — Tetanic conTulsioQa — Spusnis — Chorea 480 



Due to urfflmia — Cerebral ieaion>i — Intestinal obstruction — Peritonitis 
— Cholera — Gastric disease — Hepatic disease — Poisons — The ap- 
pearance of vomit 504 



The varieties of and indiciitions of cough — The causes of cough — The 

sputum — Its pathohigical signiiicaucc 522 



The Itinds of pain — The significance of it.-^ locality — Colic . . . 535 



The knee-jerk and ankle-clonus — Tli« arm-jerk — Tiio signilicttncc of 

decrea-ted and incTcascd reflexes . , 547 



The changes in the speech ami vi'ii'e — Their significance — Aphasia — 

Apraxia — Alexia — Paraphasia rj52 







A CLEAR nnderstwuliii}; by tlic |>hy^i(-iati of tlie value of Uic 
iiyni[>tnnii4of di.s(-A;>e tvliicli Im «^*, nud of ttioi^o defloribed by tlic 
]iaticiit H of vibil iai])iirtfiiioi' for the purptiscs nf dingnmi.* mid 
Ircaliitoiil, iitid on«i of tliv tidviiiitiignw of older plivMi-iuii'i over ilicir 
yoimger brethn.'ii U llio altility which thoy btivc gniiieil timiiigh limg 
tmimn)f to ^n\n\\ tlie tvwvutiiil drtuil* of a («!*« almut^t at llicir (in<t 
gliiiK-v ut thi- |mtient. Mueli of this »t>ility is unconsciously [)o»- 
MMetl bowisu it if fpiiiied by a graduiil prooL-w-, yrt it in nimv thi- 
Iww viiliiabliL', mid \\s \n^i^a^i\on often impmssei! the {mlient with 
tim insight which his physician hns into his case. At lirst it ix 
inipoiwibltt for tlie novioe to cast aside tlie minor Hyuiptouu, wliieti 
till- pnticnt ctDplta^iiEea as his major ones, and to pcrt-eive clearly 
tluit i>iii> or two facts Uiat have been belittled in the tuirnttion of 
tlie (ftorj- of the illtKaa are in reality the stalk about wliicli every- 
tltiilK else in tlie case must be made to clu>iter. 

Let Us Mippine the patient before the physician is one wlio \\\\» 
been able to walk into the oiliee or disj>ensary. Tlic attentive 
lihyMcian v&xy at once ^ihcr mm-li information about the case from 
lio clothing, tlio gait, the build, the voice, the expression, anil th« 
nniT. The chin man, with a peak(J Hen and pnivided «itli au 
(iniisnally warm overcoat, and alill further wrapiK-d up with » 
iQuDler ftlmost to his eyes, is in all pi-obability a sufferer from some 
pulmonnry or throat difficulty, while tlie heavily built, pble^mutic 
tiidivldiuil, with a large head and well-tilleil |)auncli, is much inon.- 
a]it to fmffer fmrn giMn^ intestinal or bilinri' catarrhs. Such a per- 
will prr)biibly lie one who habitually vrears hi^ coat ojien on th« 




coldest clay!*, Aginin, clii'oiiic (iriiiikards, or jtei-aons whotw men 
poweri arc failing, ufieii are exceedingly careles,* about llieir elotiiJ 
iag, butUiiiing tlie ooat or the trow^en* with the wrong buttons, and 
keeping the flotlung rtirty anil ^jxitled. Home mses of diabetea 
have tlrst lx.-en by the wliitc sikjU on the trowMr8,a8 the 
result of hnving athnvvd u few tlntpn of urine to fall ou the cloth, 
where tliey linve dri^tl. Old men who have inenntineticc of urine 
ofti.^n w(«r trtiwser» which arc »1nined in front, iind tlicy often huvc 
an mil moil iaeiil mlur nbont tJiem from th'ix «)ii»<.-, 

Tliu various forini' of g«it which intlicstc fti.-timl di«*u*»> will lie 
foniiil (lii>oii!v«;il in the chapter on the lej^s uml feet, bnl it may be 
mentioneil in piii^ing thnt in mlilitiun to thc^i diungvH, which lire 
iK'|K-ii(lent upon Hctiial diM-OM^' of the te^ or the nervous »yi^t«m 
«ii]>plyiiig them, thnt the genenil beiiriii); iind striilc of a {uttieiit 
will often give us h clear iiUii of his geiieml tone. The oeiim*- 
thenie ]>atieiit wnlks feebly or Mith a, Atep that might bo culled 
atftxie, while the strong, heiirly iiinn of good pliyslijue strides along 
with a gait <]uite different from this, or that of au individual who 18 
delicate an<l feeble. 

f^iniihirly, tlie ]>ntient's build betokens diiiense or health. The 
thin, tall, and hoUow-t^he^ted jwrnou U reeogui^ed as a fair mark 
for the tuberole')>aril1ii!i, and the heavy, closely knit, ]>lilogmatie 
cuan aa one who may .iiiffer from he{)atio disorders. Again, the 
bearing of a person posaeatiiing a highly organized nervous .tyfltem 
shows iti^elf in the oODstanC activity of hiit mind and body. ?{o 
part is tjuivt for more than n moment, and drugit are more apt to 
produce exlraonlinary ^ymptonii' w tlie nw-iilt of idi<'fsyoerH«i«'s in 
ihio ty|K; of imtient tiiun in any other. 

When the pliy.siciun hn:^ gatliert^ m much information a* pomilde 
as lo the age and gencnil rN>n<lition of his [jutient, by a careful w-tu- 
tiity nf hi* fiww and extrx;njilie*, of which iwruliny, however, th^ 
]uitient should be un(v>nscioUH, be should luk him to tell what bring9!| 
him for nilviee, and an a rule this wit! be tlie op[M>rtuiiity the suf- 
ferer nKvkn to [Klur out the slorv of his ailment as In- hcch or feels 
it. Often the btory will seem wearisome, and, to the educated mind 
of the physician, wandering or unncenwarv; but to the patient every 
word eeoms of the greatest imiwrtance, and to show any lack of in- 
terest may give the impression of curelessoeae, or it may interrupt 
the story just as a must important symptom is about to be described. 
Even if the patient la unable to convey a very clear idea of hU con- 





ditiou, tlie mni)iK>r in wliich his story is tnW, itic dianicler of liia 
8pwo)i, ami thf expreit^iou of UU face wliile upeuking may give 
UMufill infomutiou as lo his ailment or (it<>nernl state. 

If, instmd of the patient bi*ing au offire or (iis|>eusary case, he b 
one who is being visitecl at home, the fact that the patient meeta 
the pliyaictSD in one of the living roomi ratlier than in a hedroom 
indicates Hther that there ia little immediate danger in the caiie, or, 
at least, that the difKcnItv in not aeiite, hut chronic in ty[>e, as 80Hie 
slowly progrc-wing form of pulmonary, cnixltai-, or renal di^vo^ie. 
Of course, there are exoeplinns tn this rule, a* in iIki ea.te of a 
iwtieat who, liaving cungtic a heavy cold, i^ remaining! iniloors, hut 
not in l>e<l, for prudence' aake. Or, agiiiu, if on seeing thr? jiatlent 
we find him liitting in a rhnir only |Kirtly dr<><4ed ami jiropped up 
with pillow.-i, or in.->tead leaning foruranl \\[H>n thr bavk of a uhair 
placed in front of him, tve know that he i^ the tuthjcct nio^ prob- 
ably of ail acute or chronic h*«irt discaw, mio*1 likely nil acute CJcae* 
crhution of till- latter. A glamx- nt the hw of iMidi » {Mitienl, revel- 
ing a tn-mhliiig mwlril, blue lip% or an antioiis fn<rir*. will nid still 
further ti) dirtvting ntb-ntion Ut the heart or lungs "nd the hand« 
if examirHil will appi^nr n-lax<fl and liviil or darkened in hue, in- 
dicating capillary stasia and deticicnt oxidation. In other uues, 
however, the patient found sitting propped up with pillows may be 
a convule^cnt from Home long illness; but if i^t, the general atmos- 
phere of the patient is bettor, and tlie surroundings are apt to he 
nnint lidy, 

If we tind the patient in bed, he may he lying abnormally <juiet 
as the result of fuintncss or acute nausea, or, perhaps, from {lartial 
or Di>inplete coma due to pcrebral or renal disease, or from the effects 
of some drtig; or, again, he may he rolling about the bed from tlie 
pain of acute belly-ache, or be keeping his legs and body very still 
while hia haniU and head are ever on tJio move to prevent anytliing 
from suddenly ap|>rrmching or touching his abdomiaal wall, as iu 
peritonitis The striking difference ln-tween the activity of the 
head and the lixation of the lower part of the body, in peritonitis, 
ia nntflble. Sometimes, however, anxious restlessness indii^tcs acute 
internal or exlernnl hemorrliage; but here the movements are minute 
thixigh wiive, and the patient doftt not ex|>end much sta-nglb as he 
doci when oulTering (ruin jKlin. Usually a patient wIh) is lying on 
hit Midi* turni on hi« bat'k m* tlie pliyHtcian or niirtc approarheM, in 
order to faojt his %*iaitor; but if ho pcrdiiitviitly reinnin-i on the nido 



u'itlioiit moving vx«?l>t to ]»artly turn Iiifi lieail. we iiiny Mis]»ect 
that in tluit posture he is nmst comfortable, iiiitJ that the pi^itioii is 
atwiamed for its oonifort op to relieve pain or dyttpnoea. Thus, in 
acute pU'iiriBV the patient lies willi the afTeotecI side upjH-rniost 
becsiuse it is too eore to permit him to toneh it lo the bed ; whei-ea-s, 
if the stage of effusiou has arrived, \u: Vies on the affected Mile in 
order to give the side whieh is lit^lthy free play in goin]>eii.iatory 
respirator)' movements, and to remove llu! ])rc^ure of tht^ cfTii^iou 
from ihe heaUhy hmg. If the patient lying in this posture in not 
snfFerin^ fnim pli^urisy, \ih pmsitiun may he ns.-^iini(Kl to !>(■ diiv to 
an effort to relieve tiw diac-omfort c-aiiiw<l by an cnlnrfrnl livCT. 
TIk- foot that th« piitieiit lies cunritantly un the hack is also » char- 
nvtori^tio of );mvo and advanced disease in some instaneeM. Very 
ill pcitions uhiiost never lie on the side, nnd the fact that a desper- 
ately ill oa*' of yestenhiy i» found lyin^^ on the side to-<ltty is an 
eneniiraj^ing sign. I'crsons tvith severe heart disease uro rarely, if 
ever, able to lie prone in Ixtl, and have to be more or less proppwl 
up with iKil-rents and pillows. Larg^ growtlis in the abdoniiuiil 
cavity prodiiein;^ pressure on the diaphragm also ueceasltato tliis 
scnii-prone posture, nnd double pleural efFusionH, or pulmonary eou- 
aolidation, or oedema, pmdutv the upright or half-riH<lining attitude 
in order that the upjier jtarta of the lung may he u^ted to advantage. 

Again, if the patient wakes when sjxiken to, and tlien droiw off 
to sleep at once, some form of poisoning may he ]m\s(?nt, il-> from 
opium, or the poison of ad\'anced he|>atie or renal cirrhosis may he 
present. (I-'or the signifieanee of pieking at the bed-ctotbca, see 
chapter on the Hands nnd .\rms. ) 

We can next pass to a couNiilemtion of the objects to be sought 
in <)Ut^stioning n patient an to the illness from which he is sufTering, 
Often much information ram be gained by u welliUrcete*! questiou, 
and a hivonihle liU|ii'cs^Kion can be made upon the jiatient by the 
manner in which it is put and the Ix^nnj; which it has on his case. 
Thus, if n man is eviili-ntly much eniueiiited, and his clothes lit him 
loosely, a ipiestion in regard to his loss of llesh is very a]ipropriate; 
but if he is manifestly too stout for eomforl such a quei^ion will be 
most nnfortumite. Or, agnin, if a young married woman comes 
complaining of constant sickness of tlio stomach and a fnaoifnl 
appetite, anil the physieiim directs all his questions to the condition 
of the stoinneli without an eye to a slight increase in size about the 
waist or below it, his professional acumen is in grave danger of 




^ lilH'McH )>)' that >>anic woman, who knows, or won findB out, 
that h*.T (liMx>iiifort ii< due to prof^nnncy. 

If chv noiium \i immunitsl ami th^rt- i« tio evidence of gnetrk 
()i«or<lcr on Itor toii|;uo, it i» weU to rvinouibcr wluit Biitt«y, of 
OcorRJa, Mid in regard to this corKlition: "Always Ix-hcv*.- u yonnjt 
uiuiunrif^ol woinim with abtlotuinul ttimor, of high Bociiil position 
and tio impeachable virtue, if sho )ins be^n watched over by a 
platonic and alistctuious young cousin of the male permtaeion whik 
th« mother went out, to be pregnant." 

A^in, it a married woman of sitnie years tells her physician that 
'r\w has no children, the jthvi^ician nittiii-nlly naks some quei^ilions 
which elicit the fact th«l she has ha<l fre<iuent miscarriages. He 
in this way finds quite as muob about probable syphilitic infection 
lis if the question had be*n put t "' Have you #ver had a wore on 
yotir pri^'ales," which would embarrass the patient, produce 
domestic troublEs, and probably be lied about if she was forced 
to answer the ([uestion. 

Again, when asking a woman aixiut the hndth of the living 
jtarc-nts, or the cause of death of llid dead, cure should l>e taken 
not to ask a direct t^uestion, as, (or cx«mj>le, whether the motlicr 
lias dieil of ouxwr, for the jxttient may be iilnwly greatly worrictl 
iMt she has that diitenso. It is better to ask the cause of rlt^th, or 
of tlie iliiMt«» stie it) suffering from. If the story '\e that the parents 
<lic<] of " bronehiti^," in all hnninn probability the real cause of 
tlcatli H-as tubcrculoisis of the lungs. 

If the patient oomphiins of pain, past or present, tlte best way in 
which b> discover its true seat is to ask him to ptacs Iiis baud on 
lh« Jiffcctwi i»rt, as iu this way errors in his description of his 
untofny will not be committe«l, and false impressions will not be 
oonveyetl to the physician's mind. Even this direct metlxNl of 
allowing tlic area of pain is not to be absolutely relied upon, for 
oft«n paias are refcrreil to jiarts in which tliere is no dise&M. 
Thus, the pain of coxalgia is apt U* be felt iu the knee and ankle, 
awl in children the pain of acute pulmonary di;>eHw i.t oft«ii de- 
scribed by the patient as felt in the aMomen. If the pain hiw been 
really alidominal, there will, in many <iihr«, liave l>e<>ii dtnrrh(i<« or 
fiw passage of Hatiis. It is not to be forgotten, on the other hand, 
that a <)ne9lion whieli di!«x)vers the fact of several movements of 
the bowels <l(>es not prove the prv^wjiw of true (liarrh<ni, fM-mnsu 
a purgative may have Itccn taken by llic (wtient. 


Id asking questioDs as to couatipation the physician must not 
forget timt the opinion of the patient as to wliat constitutes regu- 
larity of bowel-movement is of ver}- little value in many instances. 
A daily movement is not known to many patients, and a movement 
every few days may be quite sufficient to justify the statement, in 
their opinion, tliat no constipation is present. 

The young physician, in particular, in asking questions of women 
patients of the better class, should not hesitate to ask direct ques- 
tions as to the state of tlie bowels or of tlie menstrual function. To 
hesitate or ask indirect questions about such matters simply pro- 
duces embarrassment, which otherwise would not exist, and inti- 
mates tbat t}ie question is one of doubtful propriety, when in reality 
it is most important and proper. 

If the patient to be examiued is a child, it is well for the physi- 
cian to remember that his mere presence as a stranger may be a 
source of alarm, and that the association in the child's mind of 
sickness and the doctor, and badly tasting medicines, is sufficient to 
render him a much -to-be-dreaded individual. Generally it is best, 
on entering the room where the child is, to pretend to jiay no atten- 
tion to it whatever, but to engage in conversation with the mother 
or other person, speaking of the case in a way which the child will 
not understand. Very often this very lack of attention will result 
in the child forcing the recognition of his presence upon the physi- 
cian by making the first adv:inccs toward frieudsbip, and this is 
imrticularly apt to be the case if the child is already spoiled by 
over-attention by the fiimily and friends. Time should always be 
given the child to grow accustomed to the jieculiarities of the vis- 
itor, and if any instrument for diagnosis is to !m; employed, it is 
best to bold it in tbc hand as if it were a plaything; before attempt- 
ing to put it into actual use. The t:iet wliicli tlic )>liysiciau must 
exercise in diverting a sick child is an cs.scntial to the successful 
treatment of children. Some |>]iysici:tns are welcomed to a house 
by the sick and well as a Simtii Clani nould be, and otber.s, devoid 
of the trait of amusing children, are fled from as if they were dragons. 

During the time that the physician is allowing the child to get 
accustomed to his presence he should be gaining much useful infor- 
mation about the cawe by observing the movements and expi-essiou 
of the child; its color, size, nutrition, breathing; the shape and size 
of its head; the condition of tiie lii»s, wlietbcr moist or dry; and, if 
the child is speaking, the tone of its voice, or, if crying, the char- 



er of iti* oiy. It is iii-cJk-tus lo stutc that « cbilJ may im*}' fruiii 
fright, from puiti, aitgcr, or Imager. CouBtant screaniiug crying is, 
liowvviT, n«irly always due to the pain of earache or hunger, for 
alxloiiiiiiiil oolif is uttiially intermittent. If there be {)ain iii thf 
«»r, thv luind will often Iw ruhhcil over the affected side of the 
nl, and tlie child will not be paeiHed by tJie offer ot the breast. 
Tf ihv child coiijetis, mid tlien begins to cry, pneumonia nr pleurisy 
may be present; or iu other cases the pain ii^ sn great that the child 
ia m'lcss. A fharp, pierciug shriek of crying indicates the pain of 
4-aniclie or of meningitis in many casef^ 

If the crying cliild be placed at the breast, which il take!) with 
avidity only to drop the nipple in a moment with a cry of pniu or 
anger, one of several enndiliontt is present : either tlie child lus 
stomalitifl or the breast U empty; or, again, if it icixen the breast 
awl then letit go witli a gas]), il jin^lKibly haj* corvKD or ttyphilitic 
0UUfHes, which prevents it fnim bn^ntliing (bi-on^h the imw while 
Slicking. Simitiir sign.-" nuiy be present in any other ooudttion pro- 
ihicing i^tiirtne^-i of breath. 

If n child over four ninntlis of ng« crivM and i^hcd^ no tears in tlw 
oourM* of 111! illuevM, this i« an tinfuvurablc ^ign. 

Il is important to notice whether there is languor or a tendeucy 
to play. A healthy infant, when awake and wdl-fed, is always 
kiokiog or cooing ami moving its arms about, and has a happy 
expression on its face; whei'ess if any cerebral trouble is present, 
it often has an anxious frown, or its hands are placed to the side (rf 
its bead or rubbed over the vertex. 

Iu a perfectly healthy child which U sleeping tlie respiration 
should be practically inaudible, and it is a good practice to note 
tlie regularity of the breathing in all patients while they are a.s1eep, 
t%n il li then nnaffet-ted by voluntary effort. In children a sighing 
breathing, or one disturbed in rhythm, often indicates a disturbed 
(ligwtion or fever. 

The brentJi of the bealthv child is inx-ariablv odorle^A and .sweet, 
lint is apt to become heavy and iotir in ffver and gastric (liwinlers, 
and in fonsilliti:< and diphtheria it is apt to have a {x-culiar aick- 
eaing odor of u wwoet clmmrter. In ojl*ps of empyema ojwnlng 
tntn a bniiichn^ or in gangrenous »ti>matili.t the bn.'Atli i» very 

TIm- physicuin «liould alwa\'s, by careful questioning of the nur«e 
or uiotlicr, tind out how long the illncKM Uak lasted, the manner in 


which it began, the fact as to whether a similar attack has occarred 
before in this or other children of the family, and the state of the 
temper, appetite, bowels, and urine of the patient, for an irritable 
temper in a child means ill-health, as does alao a poor appetite, 
constipation, diarrbcea, or abnormal urine. 

The expression of the face, shape of the head, and similar note- 
worthy points in the diagnosis of the case will be more thoronghly 
discussed in the chapter devoted to these parts. 

When it comes to a close examination of the child, great care 
must be exercised. The character and rapidity of the respirations 
are best studied at a distance before excitement has disturbed them, 
and the best time for listening to a young child's chest is when it 
is held over the shoulder of the mother as if she were carrying it 
for a walk, or, if the child can be taken in the physician's arms, 
its buttocks should rest on one hand, while its cheat leans against 
the other. In this way the physician can listen to the back of the 
chest without ditficulty, keeping the child amused by walking up 
and down the room while it is in his arms. 

If it is not possible by any bribe to cause the child to protrude 
the tongue for examination, the physician will often be able to see 
this organ when the mouth is widely opened in crying. 

In taking a child's pulse it is best to take it while it is asleep, if 
possible, as the excitement of the physician's visit or the crying on 
awakening will greatly increase the pulse-rate. 





Th« ecpnnian and color ot ili« face— Fiuuii] paral^ti*, uniluicinl uid biloicrnl-- 
Pton^FacioJ ipiwDi— Tho *h«pff of the liffnil— The iiioTeiiieni* mid {loritlon 
of the head anil neok. 

S<> niiK'Ii can be learned by the i>hyaician from the expression and 
g<riicm) nppoamncc of a ]>aticnt"B face ami the rarriaj^ and .ihapo of 
hi» lii>ad, that a <nrefi)l ini<|K'etion of thedc parti^ nhmild always be 
nuule. For this reason, in the eonsultiiig-rnorn and at tlic becljiidt', 
the pbv'aieian aliouM aln-ayti arran^^ hi.'* chair in such a way that 
the li^t fallti ii|>on the face of bin palioiit, wbib' bit) own is in the 
Window, and this is of ini|iiirtatic'' tiot only hccaiisi* tb<! fnoinl expres- 
sion of the (intient ciin rbii^ bu well mtii, Ixil aUi> Ix^iiisv !t prevcnb< 
the |>aticm from making a too citmf .scrutiny of tbt; jibysicinn's turn 
with tlie <^j<.!Rt of dotet^ting enuoiimf^inent, bu^k of syniimthy, or 

The F»c«. 

The Bxpression i* procbu-cd by the formntion ^>f itcaw*, or 
alteratioiiii in tlic contour of tht^ »kiii and v^tibrntAiHtmo tiiwu<^« by 
tro])hic and musoular action, and iIicm; cliangoi* ar<> in t'lnu; bnnif^bl 
■ImhH by tlt<> ini-tiEitl K-iidi-noicM mid babila of tin* piitivnt, hi« tcni- 
|»orainent. Ids intcllii-tual <IcvitlopN»'Ht, \m exptwnrc to outdoor or 
indoor influences, and tinally, ituil ibi^- arc vory ini|>or1»nt, by 
pntlloloKicid prrnyMMes which may l>o p>!iig on Koinuwherc in bi» 
body. Tlio l<'m]KT of the man alw nffci-t;* bi.s cxpn-H^ion, jxirttcu- 
brly lu he nppniachf« niiddb- lifv, and be looks umiuble, c»iHd>l« of 
midden ungor, or 4ullen, an tJiu cnac- uiny Iw. 


The intellectual face is easily recognized. Sometimes it is 
deeply thoughtful and placid, at otliera eager or keenly alive to 
the surrouDdiogs or the conversation, and it separates the man 
descended from several generations of men who have lived as 
thinkers from him whose ancestors have been but recently wage- 
earners by physical labor, iuvolving only ordinary human intelli- 

Fulness of the lips, imrticularly of the lower lip, is supposed to 
be present in persons of strong sexual appetite, and often indicates 
a phlegmatic temperament, whereas the thin, mobile lip is typical 
of the high-strung, nervous iudi\'idna1. 

The expression of the lips as a whole is also to be regarded in 
connection with the expression of smiling. The risus sardonicus 
of strychnine-poisoning or tetanus is quite characteristic, and the 
simple smile of hysteria is equally notorious. 

The skin of the face and the expression about the eyes of one 
who has been e-vposed for years to the weather are so characteristic 
as to need no description, while the face of the clerk, whose life is 
almost entirely spent indoors, is pale and wan. 

Similarly, the face of a person who vtses alcohol to excess is gen- 
erally flushed, heavy, and niitre or less expressionless. The eyelids 
are reddened more than niirmal, und the skin is apt to be puffy and 
unhealtliy-looking. Women at the menstrual period, or when suf- 
fering from menstrual disorders, often have dark areas under the 
eyes, aud pigmentation of the eyelids is often seen very early in 
pregnancy. In women, and sometimes in men, excessive fatigue 
and loss of sleep cause marked infra-orbital discol orations. A 
puffiness under the eyes, most noticeable in the morning, may indi- 
cate renal lesions or the excessive use of arsenic, and if it is uuilat- 
erat it probably depciuls upon sunif.' local inflammation of the eye 
or rarely ujwn disea.-se of ime of the cerebral sinuses. So, too, an 
ecchymotic spot under tlie eye ni:iy Ih? due to a bruise, to some one 
of the forms of purpura or to st-urvy. 

The color of the face is discusswl in the chapter on the Skin, but 
it is not out of place to note at this point the pallor of the face in 
fright, faintness from hemorrhage, acute or chnmic, that due to lack 
of proper fooi.1, and the peculiar pallor of chlorosis. In the latter 
disease the faint, yellowish-green tinge of the skin in some ]>arts of 
the face, which still ri'tulns its plumpness, is ijultc typical. A parch- 
ment-like skin stretcheil over the face so that it appears as if dried 


over tlic lUKlvi^HtriK'tiircst ■» vcvn iti mnuz yming per^nui^ ituffering 
from ^yptiilig, ami in »ome uiMS of alcoholic lieimtic rirrtio^i:*. 

Tbft color of tliu faei; oiay Ihj remWred gmy ur bliiirili by the 
iuftcetioii of uvi'Mows of tliu oual-ttir protlncts, i«iicli »» ucotatiilidc, 
aottpyrin, uiiil iilR'nn'ftiii, ami it \» ciiriuiDf timt thin cfTvct i» bt^t 
BOCti wlii-ii t\w [Kiti'-nt L<i vic^rtxl ut u litllt- dii^tiitivf. 

(For tlio indiciitioiis of fuoiul (.-vuuo^tH, nee chnptvr ou tliv Skin.) 

Ill view lit tlif extraordinary vfinations swn in the oxpri'Mion of 
the fiicv in the hi'ultliy it is not mirprisio^ that thi)- piirt of the IxhIv 
should give the physicinn, when i-tudying disease, *o tutivti uMrful 
tiifonniitiuu. It iii un interesting fact, too, and one not unworthy 
of note, that the true facial expn:si>ion of a diseaHc is rarely u|>ed 
by a malingerer, and in all dUeosea is uurecognincd by the imtient 
even though he sees himself several times daily in the looking-gluss. 
Ttms it is by no means uncommon to see a person who is suffering 
from tile onset of some sudden and grave disease, ))earing njxin his 
face what we call "an expression of anxiety," when he himself aa 
yd has no conception of the gravity of his illness. This expres- 
sion is very characteristic of serious illnes.-i, and, though diflicnlt to 
dmoribe, when r^oognir^^ beooni«9 quite vnhiable n8 a diagno^tio 
factor, [mrticuliirly as it rarely, if cvitr, 'm oMiggerat^ by tlie 
iwtienl who b«ir» it. It is w-en mo.*t niurkcdly in cusui* of severe 
ftcnlf otvu|K>u.i pncitmonin or ]K"ritoniti^, <ir after severe injuries. 

Wb<-n [K-rKonN liavr hiid i-ontinnotiTi pnlti for n long time, n» in 
IHi(icDt> wboluivegmwtbsof a ninlignnnt charm-lvr or oilier i>rgnnie 
Aiteoae, the i-xpre»^ion of the face, naturally gentle, often l)ec<Hnes 
lianl and Mtnny, or, if the p:iin be in Uif bead, the expnsmion i.* not 
only that of |>ain, hnt of profound nicntjd dejircsMon. In com^ uf 
csroirKima the face becomes thin, ibt skin yellow and slniw-culurcd, 
and oftentiniw grewy and thick, and there in often a marked look 
of anxiety. On lh« other liand, the {xUient M(>mctini<->< hoH a doggwl 
(■xprm«ion on hiit tnce m if he had ))L-en told of the true raui'e of 
his itinots, anil wiu rctiellin;; against the inevitable jtrogrcittt of the 

In the cuso of ddldren, mnoli information ean be gained m to 
the Klate of the body by the facial expri^i^ion. giarticnhtrly while the 
child «lce]is. If it is asleep and licaltiiy and well, the cyclitU are 
cltm-d, the lips arc ever t-a slightly |>arlL-d, the noMriU art^' ])nictic- 
ally immobile, and the general expression is very {>eaoeful. If, on 
the iriher bond, the eyelids of a nleepin;^ child arv slightly ]Mtrled 

M ^ 


SO as to show the wititfs of tlie eyes, there is present s»orae dige^vc 
or nenr'oiK clietnrbatiL-t.-, pcrlmps aoeompanied by moderate pain. If 
tlie (lisi'iwf U grave and the eyelids remain far enoitgli apart to reside 
in gliixing of the eonjuni-tiva from dryness, this is a sign of grave 
import Agiiin, twitching of the eyelids often indii-atcs nervous 
irritation or the early stages of the oonvidsive state, and it is not 
uncommon for an expression to pass over the faee of a ohitd wlio, 
while sleeping, is suffering from pain, which tiegini* as a smile and 
ends with a drawing-ia of the cornerH nf the month, an vxpreeiaion 
■Bnewhftt like that seen on the faee of a waking child when it 
wems to he in doubt as lo whether to hiiigh or to ery. Whether 
■sleep or awake a (-hild in juiiii, if not crying, has a pim-ht-d look 
about its nose and month, and sometinit-Jt 8onit? idea of tJie seat of 
the pain may be gained by the ]iart "f the fju'f which is drawn. 
When jwia is in the head, the forehetul i« apt to be wriukUtd into a 
frown; if llie nose is pinched and drawn, it i» «iid to ithow tliat the 
pain is in tlio ohcst; and if the up|K-r lip is niisod, [Kiiit k probaldy 
felt in tlie belly. 

Aaide from these syuiptoinatie manif stations, however, wo And 
in the fucc of a child several evidences of important diathetic 
tendencies, op even hereditary diseases. Thus we see the light 
Baxen-liaired, slimly built child with a refined, spirituede face and 
transparent skin, whose temiwral veins ean be easily traced and 
whose expi'ession is often thoujfhtful and deeji, Su<'h a child often 
eomes of tubercular parents, and is frwpiently a vietini of tuber- 
culosis, in one of its rapid forms, as it appfoaches pnberty. Or, 
again, the child is "stneky" and cheesy-lwiking, apparently solid 
and sttinly, but its features nnr liesivy or |M>rha{is even coarse, while 
its Deolc is thick and short. Such a child is often a victim of tuber- 
cular bone discnjte. In other instanr«s, a sijuare projecting forehead 
with faulty bonc-developmcnt elscwhen- indii-atisn rickets, or an 
iinmcnM.', bulging forelKwl with n wixenetl, puny faoe beneath 
shows hydr(HTphalii' tondcnciw. SoniL-timtif a broadnc«4 of the 
brid)^- of the nose or marked tIalnciA of it indicates congenital 
syphilis. Such it child is often much wasted, itt f^^uturcs pindied, 
iU lips thin, whik- the flaltcned naail bridj^ is bhiisli and \t» faoe 
is often tliat of a little old man, shrivelled and wrinkled. Mucous 
patches at the corners of the mouth or around the anus are often 
found in such cases, and soon confirm the diagnosis of infiintile 
aypbilis. Finally, in respect to fecial expression in childhood. 




altcntwn must I>e cnllecl to the " tish niuntli," vtiftioiii*, ninl " iioiwv 
piDc-tiMl " expression of tliiJ«o vhililrfu wliu »re *' tuoiitli-bn.ul]K'r« " 
from tiafial obfitriictiun. (Fig- 1.) Oniat immobilttv uf tlif li|w and 
cliL>cks may lie cluv to mucuut; patcbes or otiu-r nk't.-nttion» uf tliv 
buccal muoouK membrane, and if higb fi-ver is present the pro-ence 
4tf beqietie hlUters alwmt tbe lips points to croupous pueiinionia id 
the child or adult. 

In adults tbe facial expression of many diseases is even more 
obaraoterUlie than it b in children. Tliiis we see in acute pul- 
OMinary phtbiaiit tlie widely o|H>ned e^'e, the bunted expretwion, tJie 
i|iitvering nostrils, ibe i"ed fliiih over tbe malar l>i>nes, ibe wasting 
and dr%'n«ss of the hair and skin, and the euger, or a^uilbetic, 
glance of the eye. 

Fw. 1. 

Dor. M*i wna. >l«uui*bnaliin. (ram obttniolltin ut lli« ptinrrni : opvn muulh : vaMni 
•xprcMiou: finobM niaitili; dull (Jtm: ^ratplnc cycUdt i luaKcn eluMi : rouad «liouli1«n. 

In twvoro pneumonia tbe lliishot fare, with a dc^']>er red on one 
chock thiui the other, the unxioiM expn.-)«ion, and the dilated nostril 
are iKilPwortliy; and in the dyifpniwi of liwirt dist-sw the dilated 
nurttril and <itn:<tant opening of the mouth, as if seeking for air, 
with the fanial pallor or n-nnudi^, arc chanii-UTislic. Often, too, 
in chronic »irdiae or pntuionan' disease pniducing ilij^Ul ditlictiliy 
in nwpirQtion, the putieiit's lips are sc^'n tu Ih- slightly |>»ruil and 
■Iry, and ohi.t\ appear somewhat evunotie. lu children suffering 
from lections of the mitral valve of tliu heart it i'- vcr^' coniinoii for 
•unit' blnrrini; or indistinc-lucsv of the features to l)o prevent. 

One of the must cburueteristic facial expressions that wo meet 
witli in lluit of typhoid fever or fevers of a typhoid tj'pe. The 
he« is dwil aud expresiuoul&w; the teeth are covered by sordes, 

30 THE .VAytFEsrArtoy of disease ly organs. 

wlikrh fwcvmo liniwn and bUckisli bv expoeiirv or by iliwolanitioo 
fiiHii mc'lk-inc^ iim) foods; tIlL> Xl^s uro nitea moveil in n low Dltlt- 
IcrinfT dcliriniu; and tlii.' whole apiicnmnoe is that of apathy. £v0n 
wlii-n ^]ii>kcii to, the fuct- of u patient suffering from enteric fever 
nirely li];htB up in respon;^ to the greeting. 

Kqnally, if not more, charaotpristic is t!ie facial expret«iioii of 
acute perilonitifi. The upper Up Im drawn up in such a n-ay as to 
show the teetli, and the expression of nusiely and nervous unrest 
ia well devclojKKl. Similarly iu alxloniinal luiiii due to othvr 
causes than {teritonitis there is often a twitchiiij; uf the muscles of 
the Up and almul the eye whioli is ijuiic tyjm-al. This twit<'h is 
said by Fnthergill to be |Hunili:ir Ln [diIii below tlK? diaphmgm, and 
he is also res]>nusible for the statement timt it \i \)V»\, «eea in \Xxf. ixx 
of the t>arturient woman in the si'cond sta^^ of labor. 

The fadal expresMon of liy»tiTiti may Ih> ii]iailietiu, or it U tliat 
of devotion, mgt>, or grief, and thcso cxprvw^ion^ arc fixed if the 
patient Ih* cataleptic. If «hc iji not rntidcplir, not infrcciuciitly ono 
expi'cs'.iou nmy succpwl the olhcr, nr in thuir jilace ther« com«« tliat 
curious sinili! or vaoiiotts expression of the face whieh i* «o churoc- 
tori*lic. It should he rcmtrnihenil, however, that tliitf vacant, fat- 
uous look may oecur in women suffering from the early stages of 
dis»eniimit»l sclerosis and in children with chorea. Then we have 
the cluU-d faL-inl expr(^«sioQ of general paralysis of the insane, tile 
cxcittil look of acntc mania, the beuten, weary, careworn look or 
apathetic ghitiev of nervous exhaustion, and the hopeless expression 
of melancholia. 

The face of paralysis agitans, sometimes calletl the ' ' Parkinso- 
nian visage," is distress and jialhelio, and yet somewhat intense. 
(See chapter on tlie Hands aud Arms, nud part of on Tremor.) 

\ pale, puffy face, generally looking worn and M^cary, may be 
.leen in eases of ehronic or subacute niial ilis<!a.-ie. In children there 
t!) often in this condition a ^x'cnliar traiisjuireut or pearly look in 
the lower eyelid, so that it seems nomewhnt pelbu'id. Great swell* 
ing or <edenia of the face is seen in €-rv!>i]>clHs, dropsy (Fig. 2), 
and intlammatory swelling (see chapter on the Skin). In tricliln- 
iosis the eyelids are often swollen enrty in the dismsc, and then 
recover their normal appearance only to become swollen again iat*r 
in the malady. 

When the faw bears a sleepy, listlcw exprewion, the forehead 
being devoid of wrinkle*, and there are pre.*enl faulty moveiuents 




of the lip^ which cannot he upproximak^d, as in wliistling, and ut 
the «irae lime the patient is nnable to floee the ej'oa entirely, 
altltoiigh the liik droop, the physician should think of the yiom- 
bility of thew lieing the early sytnptoiu» of «'hat has been called 

Flo. 2. 

nmM ■ pulvnc Willi w^Ofv' nnuiirn 'Iii>' '<> i Immlc puvuclixmabju* Iia[dii1dt- 
IFrom ft |»Unil to llie ■uthru'i iraMi-Jcilenon McdInI Cbllfite lli)*|ilul,) 

the '* fi»rio-humero-sra]»ular" type of nuiseuUr atrophy (Ijandonxy 
and IK'ji'rine). The disease, aft its name implies, speedily involves 
the iwapnlro and arras after affecting the face, and exophthalmoH is 
often present. Thia form of muscular atrophy lacks the fibrillary 
twitchings seen in spinal progressive nuiscnlar atrophy; there are 
no changes in electrical excitability, except that owing lo the loiw 
of mtt«-'Ie-6bn' the reaction is feeble. The facts that more than one 
member of the family is iiffected, and that the disease is of long 
dumtJoD, 8<lded to tlie# »igi>S render the diagnosis easy. It h a 
rare discaw. 

Ao ap(»earance of the faoe alinnst identical with that jni«t described 
ia seen in Frieilreich's ataxia, and in often one of the earlier mani- 
feslaliona of the di:sea!»e; but tite presence in Friedreich's ataxia uf 
tbe ataxic gait, the jerky arlicniation, ny.tlagmns, lo« of knee-jerkn, 



aiid absence of luii.irular atrophy ^'itiimlv it from tlic Laiidouzy- 
I>^ji>riiJo tj'ix" rtf ii)ii!t<-iil»r alixi[iliy jufit tlewriboil &» f«vir>-liuiiii'ni- 
spajmlar atni|iliy, (See Ataxia in cliftpt«r ou Fret uikI lA-g«.) 

'rill' faoiut i-xjtre«ii)iJ nf <rn'tiiii''ni w cxwiMlingly flmviu'lcrititict 
Tin- nnsi- i.i bi'<in<) and llai, tin.* I'vi'liils wwiiilui, tlic li|>s iirv jjruatly 
tliicki^uM, nud the eiilargcti t^Hijria- luIU out o{ (lie idouUi, from 
which .■•aliva i»)ii«t»iitly driblilf;^, whili* thi- wttxy wkiii mid siibnor- 
iiiul t(rm|ii!raliir>' nf tin- Itoiiy, with a poor firculution, slow rcfipim- 
tlon, aad mtiiitJil lii'lu'tiidL-, cumpleb.- tlio syniptuiii-gronp. There is 


CiwUm. iDmcvk.i 

Doarlr always in wi'll-developnl case» marked liiml>ar 1oi<()o»i«^ 
(Hg. 3.) The facial esprc&iioti of niyxcedetua i» h<«vy and list- 
less, aa a rule, (Sft- [m^o rt4 a»d oha(>ti*r on Skin,) 

la certain forms of leprosy the face ofti-u ItecomiM leoiitiiie, or 
Hoii-like in appearance. 

The faoies of exhausting discasi^ alioiit In pnwliiw dmtli w very 
eharactcristio, and is seen freiiuenlly in rliok-ro and in InhcmiluiHS 




oC -ilic laDgB. (i i^ mllwl tUv " Hi|>pncrHtio bux," ami U pocutinr 
(ho Blaking-in of tlt« tcni|>I(;» mIiltt- the jnw'niiD^c-Icii ure iiiM-rtci) ; 
tht eyes arc minken, and nroiiiii) them an fpx-»t Imllon-tt, »o that the- 
infra- iind ^itpni -orbital ridgvit befomi> grcutly accentuutetl, Tlw 
«ycli(lH iin.' lilightly |mrt»i, the cornea somi-'wliat glax»l; tlic nuec 
Ijinotiiil, its skin dmnii; and the lower jaw somewhat dropped. 
Such n fiuxf, if typical, is a sure foreruimer of diiMolation. 

FaoibI Deformity. Facial asymmetry is -tnmetime-i seen as a 
congenital defe<?t, awl cnrioualy eDwigh in often devehiped in cliil- 

Fm. t. 

Acntnatkljr. ibowlns the )«[X« tao* *li>I lundt. (DlBtKULI 

dren who suffer from congenital wry-neck. This Im not to be oon- 
fiiHcd with that extraordinary- affection culled facial hvmiatrophy, 
which uHually Iwgins in childhood in one spot, and shiwty proceeds 
nntil one side of the face, sharply outlined from tlie other, becomes 
wasted iit Its nkin, muscles, bones, color, and hair. Even the eye 
tuny t>e sunken and shrunken. Itarely this wasting is bilateral. 




Siiinotinies iii ^uil lii^miiiii-(i|>l)y (he wn-Hlii))! in a«coiii|>iuii<fl by 
imiiifii) twitchingfl, u'hi<')i iiicnwM' with rii<-iitiil <'X<;it«'mfi)l. Mari' 
mrciy Uieiv U dwixawe in tlic nwiity «f UwU' nnd hvariug un ill* 
a[Tc('t«(1 Mile, whili; myo^i.i, .'•ivi-iitiii^, or i-xiTjtKivt* iIryiio«f of tin; *Vm 
may \n' fuiiii<l mi tiii:« hiiK-. Suvli i^yniiitoiiiH iw the Iiwt jtliow involvc- 
(iK-nt of tho ftyiiiimtlift ir ncrv«-(ibn>». Tlit ctuiiigvs iirc prolmbly due 
to iliwu»c of tli« (iftii (tririn'ial) iierv**. 

As to wliot)i<;r ciiviiiiML-riWd sck-rodcrma (nioq)hu») nnd faeiiil 
hctnintrogihy urc id(^>nl!ral, lliiil U, wliHher tliv tiret \* ■ wcll-dvvvl- 
opu) form of tlu- Utter, if not ilccukti. Ilyili? appun-ntly iVRiinU 
them ae iilontiiiil. (8w chciptor oii Skin, Scli'i-odtTina.) 

Cvcii murt' niri; llinn fiu^ial hvmiatrujihy is facial hcmiliypt-rtroiihy, 
ono side rfiDiiuing iionniil in mkc nad tb« othttr becoming gigantic. 

Fio. i. 

MjswUma. lUiLnxa.t 

The niassive Uvx "f a pereon siifTcring from acromegaly is very 
oharacteristic. (Fig. A.) The face has a full-moon broatlncse in 
cnyxtEdema. (Soe Fig. 5.) The enlargement of tlie liony jurtt) of 
tiie skeletoD, th« iqrphosis, aud the com|iai«tivc muscular feeble- 



i( ucnx>me^ly aid in the dia^Doeiii of tliat diseasp, for hi 

rxoedema there is no true bouy cDiapgement, Tfic face io oetvitiii 
deforioana i» filmped like a triangle with the base upward. In 
osteitis deformans tlie sJiafu of llie long hones become weakene<1, 
and their snrfaoefl roughened from periosteal dejwaitis. (See chapter 
on Hands and Arms.) 

Unilateral Facial Paralysis. Very nofible changes in llie face 
are pmJueed by jiaralysis, the former being, as a rule, unilateral and 
dupL'iiding upon central or j>eri|>heral nerve Wious fur its cause. 
Smiling, when unilateral [Kiralyiiiit is present, results in the drawing 
back of only ono corner of ihtt inotith (on the well side), and whist- 
ling or the pnmnnciaLion of labial sounds is diflicult or impossible. 
The cheek of the {mralyzed i^Ule tit ntu\n piiffiK] out with each expi- 
ration, but the wrinkliiig of the ^kiii is on the side of the face 
which Ls not pitnilvKcd, itwirig to contraction of the ninaeles which 
are unoppo^. 

(For it tl«*cription of the p-nt-ml nimtomy and physiology of tbe 
nervons tmris IiivoIvckI in pumlytiis of the face and cl»ewhore, see 
chapter on Hemi)ilcgi«.) 

tniilnu-ral piinily8i!» is tlip form of fiicial paralysis most (.ixninonly 
seen, aitd \t li^cneraUy dnc to injury of the faciul ncrvc-iniuk. Tbc 
lesion protlticing the panilyiiiH may be peripheral — that ii<, in the 
nerve itself — or central, as in the pons or the ccrt-briil cortex. The 
former vuriety ih thi; most common, pnividc<l Ihc paralysis is purely 
facial, and tt is ni>inillyduG to inllnmmiition of tbc ncrvc-sbcutb us it 
pattM-s tiiTUtigh tli« etylo>mastoid foruiucn, tbir loI^»uf fnuetiou being 
duo to pri-s»nrc on the uxis-cylindcr!^ owing to the pn-»cncc of swell- 
ing in so limttw) » canal, 8ucb an attack will genomtly be found 
iisMciate<l witli a history of exposure to cold or injury by a blow, 
or with (tint of middle-ear disease with caries of tbe petrous portjon 
4tf tlu- tcmpoml bone following otiti-i, which inllaiuiiiatory procea9 
eauscrt prcesure oa tlie nerve. It is not necessary for tbe otitis to 
Iw luppunitive or for caries Io exist in all cases, for it seems prob- 
able tbnt by tbe extension of iiillaiumation along the chonla tympani 
such n pnnilyais may result. Still more rarely facial puralysis re- 
sults foHn swelling of tl»e parotid gland, or tumor in its neighbor- 
hood, and it may occur as the result of pressure by growths at the 
haw of ibe.bniitt, syphilitic or otherwUe, from fracture of the base 
of the skull involving tlie petrous portion of the temporal lione, 
and very rurely, when the dit«ea»e occurs iu the uewlmm, from hem- 


oniiMge from the i-crebfllmn durinj* birtli, or fiwin pre^uK nf 
forceps. Fiiiallv, (mralyoU due to u j)L'n])fitrmI Iwjmoii of th« uervt* 
mny result from neuritis, ami from priumry iK-iiiorrlm^ into tlie 
n(!rve-«lieatji or into tlie »tvlu-n)ii«ti<)i! i»iii»l. Fu'i'itl pitnily'^iH iiiiiy 
also ariso from lommotor ataxia, tlii^ I<7<ioii iK-i'iig In tliv [>dii)(, niH) 
from hysteria. All tht-se foriiii; are very rare, coniiMmitivt-ly «[K?ik- 
ing. The cerebral or m<Kliilliirv Icfiiuns wIir-Ii pniiliiiie niiilatomi 
facial paralysis usually consist iu hemorrhugc and tumor. 

The (letemiiuatinn that facial paraK'sis is due to n peripbenil 
neuritis, or pressure, may be impus§ible at the first visit of tb(- 
patient, if this visit la mode, as it iLsually is, mtliin a few liours 
of tlie onset of the malady; but it seimrates itself from facial paral- 
ysis of cerebral origin in the course of ten days or two weeks, for, 
if the nerve is inHametl or pressed upon in the foramen, the muscles 
of the face s[)eedily undergo degeneration, because they are cut oBF 
from their trophic centres. In the cerebral form, on the other hand, 
the trophic changes do not occur, and the reactions of degeneration 
fail to ap|«'ar, InHanse trophic impulses can slill reach the facial 
»crve>trunk and the ninscl«s. In other words, electrical renpon-w 
iu the paralyxe^l side remains normal in centric Wions and is loAt 
iu pcripbentl Wions. The oidy othur cinidition in whii'b llivrc can 
be developed the reaction of degeneration, nnd the Wion not be in 
the ucr\'iMrunk or (onimen, i" wIk-ii tbeiv i» it tumor M the Ixww of 
the bratu luvolviug the faetul fibres below the facial luieleus or 
destruyiug tlie uiicleUM itself. 

Ven" rarely in eerel>n>l facial |«irnly»i» is the losi of j)ower as 
mmpletc as it is in tlie periphend form. Af^iu, iu cerebral facial 
paralysis the eye on the paralyzi"^ side cuu usually be closed and 
the forehead wrinklol, wheri'^i^ in the periphend form it cannot. 
^Vby this should be so is not clear, uuk-ss it is that iu the muscles 
used commonly in jiair^^ a« in those of the foreheatl, then- is an 
nde<piate nerve-supply tbroui;h direct nou-decu»iatin^ tracts which 
innervate the muscles. When facial paralysis has associated with 
it none of the sigiis of ]K'ripberaI wattting, and none of the remote 
CAUses of hemorrhage, embolism or thrombosis, such as result from 
impaired bloodvessels or a diseased heart, aud when the pnraly^H 
coine« on gradually (though it may be sudden fr<mi surroiuiding 
intlauimalinn), the condition is prol>ably due to cerebral tiiuior. 
Tlli^ diagnosifi is confirmeil by the gradual spread of the )ianily:;iti 
to other jturu, as the arm and tlieu the leg on the same side of the 



body, and by the d«veIo[>nient, often bftfore ea«h sjircad of the paral- 
ysU, of a fonvulsion. The fadal paralyitU resultinj; from tumor at 
the baw of tlie brain iliffent fmni that due t<> oeri^Virnl tumor or 
hemorrhage by the f»i-t, iilivady ^tat<-<l, thut the n'mrtion of rleg^euera- 
tion <itiickly develojis in tlio jvaraly/inl {inrt; tlmt tin- ]>nrtA Kiipjilied 
by the frontal branch of the ftti'inl nri^- <>ri«-n <jiiJtf ii8 mnrh |>ant1y/.ecl 
as are those wi|i]ili«l by the lower hmnoh, which in nirf in the oere- 
bral In'ion, iind tiiore will t'onunonlv \w found other evicloiic^*!* of a 
growth whic'h, in a ri'nioii so ({■■ui'^-ly fillwl with importitnt wntres, 
sjioMlily nffoct* other fnnc-tioni<.. Thn*, there will nearly always be 
found in luwocintion with thii< form of fnoinl parnlyw" iiarnlyi-I" "f 
the oriilo-niotor ami alxltiwii!:, umsinj; jitosii^, ii moderately dilated 
pupil, and intertuil or external uMiiiInt. Thu optic nerve may show 
rltokw) disk, and them may he di-lurbancG of vision. (See eliapter 
r>n Kye.) If thb ttimor growit hirj^- enough, or \s to placed an to 
involve tlie fiieial Bhn-s for both sidc<> »& wi-11 lui those of the ot-ulo- 
motor, ab<liieens, and optic nerves on both side«, nil these symptunia 
become, of coum-, bilateral. 

Piu'ial iialsy aswetateil with dcnfncat! may indicnte cerebellar 
tumor, the dii^plotus of this cutisc being decided liy the other eere- 
bellar symptoms, such as the iieonliar gait. (See c-hapter on Feet 
and Irfgs,} Such growths are not uncommon in ehildrcn. 

Somelimea vcr>- Hhortly after birth the ehild is seen to have a 
facial jjaralyftiH resulting from pressure by the forceps, which liave 
slipiieil and injured the facial nerve, or hnve cuu.-xhI an extrava- 
mtion of blood into the neigblxfrhood of the {mrolitl gland, thereby 
iTiu.-iing preawiire on the nerve. The proguosi.s i.« usually favorable 
if due to nueh causes; but if the fonvps have can.-wd fai-ial jialay 
by prtMlneii^^ a eerehral hemorrhnire, the outlook i.t l»ad. 

The possibility of facial iianilvnirt being due to hyteria should 
tint l>e foi^itten. TIk- 1ii.-<s of )>OM'er ULidtir these eotidilioii.-* nuty 
W unilateral or biUtcral, generally the former. Its niv<ociation 
with the symptom.tof hysteria dttseribtrd in the chiipti-r on tiie skin, 
niul clm'wltere, in this htMik will aid in lunking the d!ugno:<ii!i. 

Then! yet momin to be cou^idereil seveml forms nf facial panl- 
yaU unilatcml in chanu'ter yet Hi!i<iMciuteil with purnlyitis else- 

('nilateml facial paralysis very mrely ooeant in aiMOcinlion with 
DKitiopU-gia in aoulc anterior [toliomyelitis. 80 M'ldooi ihxw it ovriir 
in this eonneetton that it has Imi-u denied an existence. Often il ia 



but temporary, while the monoplegia of the arm is permanent It 
occurs more commonly in the disease id adults than in children. 

Facial paralysis with arm paralysis of the same side, followed in 
a short time by paralysis of the leg of the opposite side, is quite a 
characteristic symptom of syphilitic arteritis at the base of the brain. 

FiO. 6. 

nopffffia [ ftraehiol ) 


Zaton <tferoa» pamlanii 
{fact of MatR* miitt leilh 

A laion caiirli>.g j-niMfilefftii. 

CorlU-al er lire for op- 
ptaite aitli/ of fact 

Jitfffial capanlt (pof- 

-ilnrni- 4f P'rv lofaet 


C"ina^l tif^midal tract 


■Crvnttil mro-Mtdal tract 

mnif u/TiT mtrti 

X'^tor nfftH to loirer 

Dlagnm lo show tbe gi^neral arrausenient of Lhe Tnotor Itscl anil llie eflfect 
of lesions Hi viirloua poEnla. LOicMEROPr) 

Cn.>ssed paralysi;^ — that is, paralysis of the face on out' side, and 
of the arm and leg on the other — is due to a lesion in the pons 
above the decussation of the pyramids and below that of the facial 
fibres- (Fig. (!.) Thus it is seen in thisfi^nn.', on the left side, third 



tiwcriptinn, thnt the lesion in t\w pune cuts •>? tlio motor fibre« in 
the place iudicatol, thereby musing the (llstribution of the {mmlysis 
jitflt named. (See also chapters on IIemij>legia and on Arms an<] 

Sometimes the muHclee supplied b}- th« faeial nerve esra|>e paral- 
ysiiS biit those of the jaw, nanieiy, the maiisetera and temporals, 
iM^rome |>aralyzed either hilnterally or more ri>mmonly unilaterally. 
This i.H a rarc affection, and depends upon [Kiralysis of the inferior 
ituixillnry branch of tlie trifacial nerre. This may be due to prea- 
stirc prodnewl by growths or infliin^matory processes at the base of 
thi- nkull. It may also ixictir as the result of hemorrhage into th« 
oicdiilln, or from pmgresi^ive bulbar paraly^tis. 

pToecs. Iti eonnection with the subject of facial iMimlysii* tliAt 
of ptoeiit or drooping of the iipjx'r eyelid nnnt Ik* wnisidcrcd. It 
depends U|>on loon of function of ttic orulo-uiolor nerve or itn ventre 
or nuclei. (Fig. 7.) It is a stymptom of the gnntcst imjiortauoe, 
first, hecau<T)_' it iM »o rvfulily recognized ; itccond, bcoittM- it i^ a source 
of great unnuyancc mid alarm to tho [ntticut; and thinl, and more 
■mjiortattt, it nft«n gives lu very clwir idciw uf the condition of the 
Lm^eut. The presence of thii> «ymptoiii should call to the physi- 
Ku'it mind the various causes which prudare it. 

Piu. T. 

PUtl*l«fteM*<>rBl(Wuile liuis)i<lv|lii or >niTillltlc utIeId. IHimcK.) 

In the fintt pbiti', it somtjtinica occurs as a congenital defect, and 
' \a MUch n uiw: the lii4tor\' of the [uitieut renders the diagnosis ea«y, 
Si-oond, it de|M>nds ujwn a lodiun of the oculo-niotor iwrve or it* 
L aucl«uit. If tliis nerve be entirely destroyed so far as it8 function 


^B is cnnc«mo(), there will be, in additinn to ptosis, paralysis of all the 

^1 cxtttnml niiiiicles of tli4> eyo except the superior obIi(|iie and ext«r- 

^H iiul r(^N)tti;*, niid in uddition tiicre will be a nxideraiely dilated pupil, 

^H which will not otmiruct, and pnralysi?! of the eiliary muHote — >that 

^M IS, loss of aoconiiiuxlAtiun. Thf ryo ran be moved outward by the 

^B action of the external ri-(rtu», and n little downward and inward Uy 

^H t]ie tfiiperior nbliqiK-. Oiplopln i^ pn^eiil, ucxl a littli! exophihitbmiii 

^H may be pr^-sent owing to the iictioii uf tlu' ."iipcrriur ublitjiic, which 

^M proMHW on the bitll. If tliv IcMion be in tlie nculi>-motor iitielcus, 

^H thu near pwitiun of (he itiii-k-t >if the fourth iind iMXth nerves will 

^H prubiibly cause them to be ufFeete*! aUo, thcn>by oaiiinng: a gvticml 

^M opiitlmlmoplegia. If the lesion is not nuclear, it nuty bo due to 

^H diseufie in the uerve itself, ns already poinletl out. If tliU U the 

^H COHC, the leiiioti is probably due to prestture in the euveruoiis siniw 

^H or to periostitis of the bone« forming the sphenoidal fi^^nre through 

^H which tlie nerve pn&seii. Sometimes, however, the paralysis of the 

^H nerve may be oidy partial, so tlmt the external muscles of tiiu eye- 

^M hall eM»pe, and only ptosis and a dilated pupil are present. Veiy 

^m nrt-\y ptosis results from a cerebral hemorrhage, without the other 

^B iiifcas of oeiilo-motor jtaralyais being present. That is to say, tlje 

^H branch of the oculo-motor which suppliers the levator pal|)cbrari« 

^M in «fFecti.>d, while the bninehet^ supplying the external and internal 

^M ocular miM'Kst e^cjipe. 

^m If there is a history of a cerebnil attack rotembliog a mild ajHt- 

^M plexy, and a unilateral ptosis is present, the KHion is probably in 

^M the c<)rtical centre fur (he oculo-inntor nerve in tlie anf^nlnr gyrus 

^M just below the inter- parietal li-««iire. The lesiun is, of ooursi*, npon 

^m the ojipositc side of the cort«x from the ptosis. Sudi a cose ts very 

I rare 

I A fourth cause of ptosis is due to an affection of the sympLthetio 

nerve, and is sometimes called pseudo-ptusis. There are associated 

symptoms of vascular ditutation, with redness and swelling of the 

skin of the aflfected side, eleviition of temperature in that part, <>on- 

1 traction of the pupil on the affected side, and apparent shriulcuge 

[ of the eye into the orbit. This form of ptosis results from the 

i [Kimlysiit of the unstriped muscular fibres of MuUer which exist in 

( the orbital fasi^ia, for as these niuseiilar fibres aid in Imlding open 

I Hit lid their paralvMi* results in partial gitoeje. Notbnagel asserts 

, that ftuch ttymptomn occur with lesions in the corpus striatum. 

A fifth cause of pttxi."* in reflex irritation usually throiiji^h llie liftli 




hmtp. ThU ie probably due to an inliihitiou of the nculo-motor 
ceutre. It is iisuslly only tran.iieiit. 

Sixthly, it is Dot uncommon in cases of nervous sypliilU for »o- 
ciilleit alternate ptoais to develop. First, one eye in affecled by 
plnsis, and then the other jtist ok tlie first l>eginti to improve or 

Ptosis ha.4 been known to complicate tetanus, jtrolmbly an tlie 
rastilt of reflex irritation of the fiftli ner\-e. 

Ptosis, eithitr unilateral or bilateral, niav arise from hv.stcrin and 
iilio]iathic mui^ular atrnjiliy. If from Iiv»[ena, the diai^nosii? van 
be made from ihv a^', xex, and liistory of the juiticnl, from iltc 
prewfKV of hyi^tfriyiil »pii»ory diangcj* dvsorilMii in tbc ehaplor oh 
tlie rtkin, ant) from the fact tliat \Xwk \* a tt'JuWncy to spoem of tlw 
orbitrtibiH:* miisi'Ic when tJie ])a(icnt is nindo In iout( up. This wn- 
Inictioti of tJtc orbicularis proves likat there is no true pimilv-xix of 
the levators. If tlic ptoi^it U bilateml and hy»t«riejil, the bend Is 
tipIHil Imrk wlK-n the patient is told to look up. 

•Single or double plui«i» \<i by no mmoit a rare Myniploiu of loct^ 

lOtor ataxia, and is often iif>^KMat«-cl with other evidences of ooulo- 
laolor |Hilsy. Sometimes diplopia <liic to these changes in the 
first eyuiptom oomplalned of, and the patient may state that the 
diplopia oumes and ^es. 

\ Bilatfiml ptosis may arise from tubercular or syphilitic changes 
about the base of the brain, or it may be congenital, or if tmnsicut 
be caused by poisoning by gelsemium or conimn. It is also seen 
in A\^\il degree in feeble, overworked women, particularly in the 
early morning on awakening. 

Again, it is nut very rare to see slight drooping of both lids in 
all the membcre of a family, in which case the condition is usually 

Kwl marketl in the women, and Ls to some ext<mt combated by the 

>nLtl luttseles, which, in contracting, make the patient frcwn and 
draw up the eyebmws. Ptosis may also Ite doe to tubercular or 
ivphilitio diseaw of the <«>r|M>ra ijnadrigemina, and the reason for 
liis will be riear when tJie dfwp origin of tlie oculo-uiotor ner%'eB 
their nuclei is remembered. (Fig. 8.) Sometimes there will 
,t&\ with ttie ptosis internal sfpiint due to paralysis of the 
itorve (tiixth), which arisas from the nearby nucleus, and 

eimmvlvd with thai of iIk oculo-molor. (Fig. 9.) (See also diap- 

roo ilie Kye.) 

If tlH> eotxlitioti is due to a Rerions congenital fault, we usually 



find »iw<K*ittt«<l wilti it ftiiliire li> oltvatc the cvebalU, and the faihirc 
IH probably dtiiMti ti mioli-jir defeol. If due tn g«lHemtum or cuuium, 
thv otliLT sym[>toriiH uf ]K)i^ni»}; hy llioae driig8 will l>e present. 

Flo. a 


Oujitt I iinUnnii. 
fun-trV- •' 

Umininlia rrtt 

Afnionui HurlnuL' 



UtdallkoldMiiaMwItliUiacutpaiaqiuarlfaiiiliia Tb*Dumb*nIV-XIt Indli-kUilwiupW' 
a«l•larl■lneftb«0Isnul^vn(n.^rllll•UuMI>-13ltnlll0ll•Ul•l^■l«aparlflD— ( (.. LlivpMlloa 
«rib«iro«ntmliuielali Saboin ilMde*poriBiiiotUi«aculi>-motor(wrreoroiio*14«^ IQftAy.) 

Ptosis, with hciuipli'^ift of faw and Wmbu nii the ajiposit^ side 
of the bixlv, asrti.K'iatcd it tnnv l><- with hutuiaiitesthasiii, i-i due to u 
teaioi) ill the oriis oen'bri. providiil ilic two t^vts* of tmralyses occur 
sitnitltnneotu^ly, otlicrwi*c they muy Iw due to two sc]iamlc lesions. 
(Uughlingif JnukiuMi. ) 

A vrry rare condition, of which tlicrc tm but twenty-seven cams 
on reoont Dcvordiiig to Durcjuicr, itf rccurn-nt piirulyais uf the oculo- 
motor nervt; on unv aitlo. The attiick begins with violent juio on 
unv side uf tJic heiid, nausMi, nml vomiting, nnd l\n^^^ symptoms art 
folIowMl by pt<)!iis, exTi^^rnal strubittmus, mydriasis, piiralyeii) of nccoin- 
iDodation, an<l crosACd diplopia. It '}» seen most frequently in womoD, 



but may date from as early a [leriod of life as eleven months. The 
attacks may last for a few weeks, and occur often or only after a 
lapse of many years. As already stated, alternate ptosis sometimes 
develops in syphilitic persons. 

FlO. 9. 

DUgnm of ibe connections of the auoleua ot Ibe ilitb nerve. (Bruce.) 

Bilateral Facial Paralysis is a rare condition, and wlien it occurs 
can only be due to a bilateral lesion in the cerebrum, to acute bulbar 
paralysis, to pn^ressive bulbar paralysis, to a lesion in the (Kins just 
where the facial fibres decus.sate, to bilateral disease of the pons 
owing to disease of tlie basilar artery, syphilis at the base of the 
bruin producing a tumor or inHammatory thickening, very rarely to 
bilateral inflammation of the mastoid foramina, resulting from cold 
or double otitis, from toxic multiple neuritis, but not from tliat 
toxic neuritis due to alcohol. Very rarely bilateral facial paralysis 
results from multiple neuritis in its diphtheritic form. 

The development of bilateral facial [Kiralysis due to a double 
cerebral cortical lesion never occurs without evidences of paralysis 
elsewhere in the body, such as monoplegia or hemiplegia. 

The bilateral paralysis of the facial nerve in acut*^ bulbar paral- 
ysis is characterized by ittt limitation, as a rule, to the noigbborlnxMl 


of the lips, by dysphagia, liDgual paralysis, affected speech, paralysis 
of the ocidar muscles, and a rapid pulse. This disease is very rare, 
and depends for its existence upon an acute inflamniatioa or myelitis 
of the medulla oblongata. 

When due to prt^ressive bidbar paralysis (gloaso-Iabio-pharyngeal 
paralysis) the paralysis is confined chiefly to the Hps, and is associ- 
ated with alterations in the tongue (see chapter on the Tongue) and 
speech, with tremor of the tongue and stiffness of the lips. The 
mouth stands half-open, the lower lip is pendulous, and the patient's 
expression is that of a person about to burst into tears. The symp- 
toms of glosso-Iabio- pharyngeal paralysis may, however, be exactly 
reproduced by diphtheritic paralysis, with this difference in prog- 
nosis: the first die and the second class got well. 

In making a diagnosis nf bulbar paralysis it should be remem- 
bered that another condition exists In rare instances in which no 
definite patholo^cal changes can be found in the nuclei in the 
medulla oblongata, and yet many of the symptoms manifested by 
the patient are identical with those of glosso-lahio-pharyngeal 
paralysis (true bulbar paralysis). This condition has been called 
" asthenic bull>ar paralysis," and in it we find, as early symptoms, 
that the muscles of swaJlowirifj and of speech become easily tired 
on exertion, showing failure of the nuclei of the fifth nerve; that 
defects in articulation and speei-h arc developed, indicating disorder 
of the nuclei of the ninth and tcntli nerves; and clumsy movements 
of the tongue are present, whicli is a -iign that the nuclei of the 
hypo-glossal and twelfth jjiiir are involved. These symptoms are 
practically identical with those of true bulbar paralysis. What 
are the symptoms which by their presence in the true disease and 
their absence in asthenic bulbar paralysis aid us in separating the 
two affections ? The answer to this (|uestiim is that the drooling of 
saliva, the atrophy of tlie tongue, lips, and extremities, the fibrillary 
twitching of theaffecteil muscles, and the loss of electrical irritability 
in these muscles, all of which symptoms belong to true degenerative 
bulbar paralysis, arc not to be found in the so-called asthenic form. 
There is, however, in the latter tUseasc a cimditiou nirely found in 
the degenerative form, namely, paralysis of the o<.'ulo-motor, the 
lower facial, and the inferior division of the fifth or trifacial nerve, 
causing dilated pupils, diplopia (which, however. Is not aeeonipanied 
by strabismus), and ptosis (from tlic oeuhnmotor failure), facial 
paralysis about the mouth (from facial nerve failure), and loss of 



sxpfession about the eyplirnws aiitt foi-eheail (due to factnl and tri- 
' facial failure). Whether ihe diagnaiia lie true liegeiierative buUmr 
paralviiii) or the a.>«theuio form juM dt.'teiL'Med, \a both the progn<isiH 
ift nio^t tmfavnrablc Iiideed, tJie aiitii^iiic form is often the more 
m|itdly fatal of tlie two. In the latter the nuclei in the pons are 
prTitjahly atwayit involved, hut, as already stated, no ]iathological 
oh«ug«ii liavtt tMK^n dttmoni>trati>d in any of tlie7« ner^nuit centres. 

I A very rare iilTwtion is oculo-faeinl [wralyaiH, which i» oongeii- 
llal or dev«lo])» in cbildhood, nml ia diiiinic. There arc present 
pnmlym of the oi;idur iiinm-leif and pliwis. 
F«ota3 Spasm. Spiu-'Ui of tlio faoinl mu»clei< may result from 
funcUoDftl and organic diMXtM', ami iKM-urs far mon.- rnKpiently in 
wnmvn tlMD ill m«u. The vxuwif of the fiinirtioiial inrim we do not 
undcrstnud, a* t)iey awnr in neuropathic (wrMus aii<l about the 
climacteric perio*!. Rarely the ><pasm aritw fnim Tvi\v\ irritnlion 
^P'tlirouf;)) the trifacial, resuUitifr from a decayed tooth or a cuiL«e io 
~ tile eye or iu the skin. I [abi{-s|iai^ni anwi^i from a trick learnwl by 
a child, or it) acquired in taking t^IUlfiF or iu sniping. The organic 
caiiM« nni many. Thiu, there may l>e an irritative k'rgion of the 
facial nerve-trunk or one in the cortical centre for the &ice, a tumor 
prehsiog ou the ner^'e at it« point of origin, or an aneurism of the 
veitehral artery, Tlie B|)aflm may be ooufined to one side or dis- 
tribnted over twth sides, and may be clonic or bjnic in type. Some- 
time.') it only iKs;uTH on attempted movement, in otiier casoi it is 
coiintaut. The clonic fonu is the more eomraon. Spasm of the 
face is seen in chores, convutsive tie, blepharo-facial s)iasm, in 
tetanus, meningitis, and epilepsy. AA'hen due to chorea it nearly 
always is clonic or twitehiug, as it is also in (Convulsive tic and 
habit-spasm, bat in tetantLs, meningitis, and epilepsy it is generally 
rigid or tonic. In blepharo<facial s|Ni.'un tlie rnntraetlons may be 
^^tfuic or clonic. In ehon»t the s]tasm i.n must market) nl>ont the 
^■poruer of the mouth and the cyeltrow or eyelid.'^. Tli« moveineots 
^■of convulsive tic are exceo<Iin)^ly siiddcn, diirting Across the face 
^kukI involving all the mnitclc.t Diippliol by tin' facial uervc. As a 
nile, tliis atfci-tion is unilateral. TIicmc i^ptinmodio movenientit of 
noDvulsive tie may !)»■ almo-<t constiuif or iippcar in pnroxyt>i&8, 
^and nrely tlic muwlc« of the jaw, the neck, and the tongue are 
iBectnl. The dtwiu^c depi^^nd* upon a disorder of the facial nerve, 
ilM centres, whii<h ih not umler>tood. The jiroKiio^is lit l>ad mi 
a^ curv if) oinvartietl. Spiwn of the Iflvntur paljK-bne Huperioriit 


muscle is sometimes seen as a symptom of exophthalmic goitre. It 
is called "Abadie's sign." 

In blepharo-facial spasm there are paroxysmal spastic contrac- 
tions of the orbicularis palpebrarum and other facial muscles. The 
spasm often tightly closes the lids. Generally in children there is 
also photophobia with the spasm of the eyelids, which is often tonic 
in character and generally bilateral. This condition has associated 
with it what have been calletl " Graefe'a spots,'" namely, the pres- 
ence of spots near the supraorbital foramen or over the vertehrte, 
which when pressed on cause sudden relaxation of the spasm. 
These should always t>e sought for, as tliey aid us in giving relief 
to the patient. 

Spasmodic niovemeobi about the eyes such as have just been de- 
scribed are sometimes parallelwl by what is called nictitating or clonic 
spasm, which is probably due to some undiscovered cause of reflex 

The development of facial spasmodic twitching accompanied by 
a sudden burst of explosi\c speecli, repeating the last word heard or 
said by the patient in conversation (called ecliolalia), or the sudden 
bursting out with some blasiihcmoiis or filthy word (called copro- 
lalia), sometimes is seen in neurotic adult females or children, and 
is often associated with pcrversiou of moral sense. It is called by 
Gilles de la Tourette "Maladies des tic convulsifs," but this is 
aa unfortunate term, bcnmse it is ;ipt to be confused with ordinary 
convulsive tic of children or adults, (See Electric Chorea and 
Myoclonus Multiplex iu the chapter on tlie Hands and Arms.) 

In tetanus the mu.-k.Ues of the jaw, the miisseters, and temporals 
are first involved in the touic contractions, nud these are followed 
by rigidity of the muscles of the neck and body. Often the rUiis 
sardonicus is nmrkcil fnmi the first, and the face soon looks like 
that of a very old niaii nwinfj to the muscular contractions. 

In meningitis the chanicteristic sym]>toms which label the malady 
render facial sjxism a (wn pa ni lively uuimportant .-iymptom, and in 
epile|Jsy the convulsive seizure soon makes easy the diagnosis of the 
cause of the facial si>asm unless the epilepsy is limited in its char- 
acter, when the history of the presence of an aura, or of uncon- 
sciousness, or biting of the tongue may be disciAcred. 

I This Is nol to be confined with ih» more coniniciii aaeoT iheltrm ■■ r:r4i;fi^s-,igii " tolnrjl- 
Cale Ihc conilllloii In e]ni>ht1ialmlc goiin:, !□ which Iht; IIiIh (ti> w follow the ervliails wben 
tbe TiBllen' looks down. 



S[KL>itu or contmctures of the niU!U-I<>s of th<; faoc MiinHltiiOH follow 
hu'ial iiamlvfiis a.s rcpovpry begins, and tlii^ lonlracliin?:* iiivolvt> tli(r 
formerly pnraly^ced inuticles, wh«rea-'« in |>arnlyMi) in tli<^ litnlw die 
oontrsctureA generally take place in the muwlf-j" wliioli ttn not 
pumlyiied. Souietiines theiw oontraoturc^ in the fat.'e aru pt-rinNnrnt, 
and ar«du€ to ineomplelo rexluratian of tlie fiiiintioiii« of tlic mius- 
cleB affected, fare should Ix- taken lo n'liii-mlii-r that not very 
tiiieomiuonly cnntraeturos la (he niiisi'les of tlio fticc n^iilt from 
liyM^ria, and that they are oftwi ou llw side o|>)ionit<; ihe fueial 
]taraly.>i.'4 if the latter exitibi. 

Active !>fi\»m of the muscles of tlit; faoe may follow ex]»o«ire to 
eold, aud if M>iiietimoi* folIowR the paraKviU due to tliis rau»c, or, 
, in other words, I* a w^jneiice of Bell'?i iiuUv. 

The Head and Neck. 

lu exHiiiiiiiiij; (he htiid we l>x>k for vnriatiuii» rn>tn the normal 
in itrt i^hit|H', Hr- foiKiiDelhis, the po^^itioii in which it is held, and its 
movctncntM n» govcrucl by [lie cvrvical iuohc-Ici-. O! the last we 
tthall )t|H'nk (iret, although it hnf heeii ox-nliutK'il iimler the head- 
ing of wn,--ueck. We find that the head h moved almornially in 
nodding Kpasm, chorea, and in letanns and etrychuine-]x>l'ionin^. It 
is also thrown back<vard and forwani or from si<1e to side in ejiilepay, 
ntu] iu hysteria or in the couvultus'eseizui'cs occurring in young chil- 

JVbdtft'njr Bpa»m of the head, depending upon somewhat rhyth- 

'iDteal contractions of the sterno-ma.itoid aud tra[>eKins niunicles, in 
^imetimes seen in half-fed or rickety children. It also (KXMir* in 
hysteriral women, and in men who are not hysterical. The nod- 
ding may he slow and infret^ncnt, only coming on with excitement, 

[or it may be practically coosuint. It always Iteeonies worse when 
ibe intient is examiuetl, and may be so rajiid and forcible as to 

^ teem altnoiit severe enough to ^hake the head i>(T (he iihouhlers. 
Often the mi»eles involvnl will Ix- found vi-ry rigid. 

If till' R]ia.tiHiM]ie movement be not rhylhwieal, as it nstially 
is in nodding :<[msni, and yet it is more or lesn oonslant and 
irregular, thi' raitM- h prolmbly elunva minor if it is pn^^nt in n 
child, or it may belong (o the irregiilBr movements of adults cla-<sed 

I tinder the varionH forms of tie or choreiform sjnum. (See clmplen 

lua Hatulit uitd Aniii and on CoDVuUiouB and S]iia><mti.) 



Wri/-nfck coDsUts in a drawing of the Iiead to ouc sidi- l)_v tli* 
sterao'inatiUtid inUAcle in a Atale of ojiniim, and at t]ie same time tlif 
head niav be tilted io the E>ack or front nooordin^ to tlie soceason' 
nmsiilos which are involved in the i«|KiHni. 

Somi'tiriies a tunic R|>ii.sRi of the stenio-niast<iid mtiscle, produced 
by exjMiaure to oi^ld or due to a diMiuct ncrvoii» lesion, caui^Gs the 
head to he drawn down over tlic .-houldcr, or hilateral 8paMii of thie 
muscilc miiM-t^ lixation of the head. If the came be exjxi^ure, with 
rcNiillinf; niyo.fitift, the history of ex|>o»iire, combined with (hat of 
a ifinhh'n oiiHi-t, will ])i-rmit a enrri^t dingnoitipi and a favorable prof^j 
no^i^, it hcin;; r(^niitniheri-(t, however, if th<> patient in a female, tliati 
hysterical 8|m»in may he the caii^c. If liyt)t<;ria h tlie cause, the 
history of the ]>aiiciit mid the prericiirc of tiltfnilion in her color- 
fieldif and thtr other signj* of hy«Urria can prohaltly he elicited (see 
chapters on the Kyc mid on Uie Skin.) Oo the otliitr hand, if the 
contraction has cwme on ):riidiiHlly, after wiinc injury or in a.*socift- 
tion with Honie nervouit afTet^tiun elm.'where, it ii^ vvidvnt that A tniv 
nervous hwion niidorlies the di»onler. 

If it is a tonic spasm, the involved niii«-le is on the Hide towarctj 
which the huid is drawn, whereas the mu«L-le on the opposite sidc^ 
ia Bcetl to he prominent owiu); to its being stretched hy its opponent. 
The chin is, however, directed upward and away fram the affected 
«de. Rarely the tia|H'i'.ius it* the only muscle involved, in which casaj 
the head is drawn liackwani and towani the diseased side, or, if thai 
aterno'niasti>id and trapezius muscles are both involved, the head is 
tilted laterally and liackward until the jintient lookii np in the air.. 
Pain in tlie Dtnsch>s only occurs from fatigue. Thi.s tonic s]taflia 
affecting the head can be seiniratdl from tlint iKcnrring in tctaiiuR 
by the fact that in tetanm there is n gi^m-ral difTii^ion of the it]) 
to other miLsctes, alihoiijih in thai form of t(rtanu.s called *' heftd 
or cephalic ictanm" thi' din^iiosts h more difficult. This form 
of tetanus usually has with it the following diai^nostic jioints: thetv^ 
is a history of infi-ction, the churacUT of the onset is Mi<lden, there ' 
ftrc trismus, difficult »wallowiu^, re»piraIor>' distiii-lmni'«, and facial 
paraly^s with rar** involvemcnl of the ocular niuscics. Tlw »])asn^ 
in cephalic tctaniiis is al*» often increased by uiovenient or the nt 
tempt to take food, Strychniiu^ixitsoning is also to be thoiii^ht of. 

Shoiihl the tuiiscles be iifTeeted by » clonic spusin, the head IsJ 
jerked about instead of remninin^ fixed. 

Uetrantion of the heiwl iu ehildreu is ud indication in mnuv cnsesj 




twnotL-' Ikrain Hi^ca^f, aixl ■■'>inmoi)ly anw^ fnmi a Uaaal mcniii- 
gitb, jirobably a^ the re.->iilt <>f an ulTit^iuii itif^ l\w vi-ntriftlra. It 
i» to bo remembered tlut some of t)ie»e ciim.^ rewver, though »i)eh 
ft i¥*ii!l ii» raiv. Ag;aiii, wo ahnukl iiM forj^ct thnt ojiric« nf tlws 
cervuail verti-lirtc may 0111*1; thU position, or that loiiik-r and i'lilnrgcd 
glands ill thv iic-ck may »o ncsiill. Soinotiiiic», loo, it ocnuK after 
fnlirt wittioiit then- Im-iii^ iiny iiiiliciiiirxi nf tiu-tiin^uitl irritation. 
Kartriy in iH'Hnttir liabiiw n,-ti-iictioii of Uif lnwl, n» 11 U'liipornrj- 
8ym[>tom, ac<?om]iaiiii'# iitlaclcs uf iii(ligc:<tioi). 

Siinilftrly, in adults nufffring frum ccrcbro^piiinl fcvor tltc Iioad 
io often hvld in n rctnu-k'd jm^itUR-. 

Thi^ IKwturt; of tiw IkwI iduv nUo aid u» 111 diii<;aosi8 when no 

of it« guverning miiwleit oxi^to. ThuH, chrouic denfness ia 

ant ear may cniM; the putiviit to hold one i;!do of his head further 

forwuitl than ihv other, in ordi.-r to oat^'h tho Huiiiids hi? Hccks and 

(Ivunoed strabiMiiiis inny cause a child to so carry Its huad as to 

improve h» 6i;;ht and avoid diplnjiia. 

Ou tht> utiicr hand, pi-rsou; siiffcriag from great mental depreaaiou 
witli n tendency to melancholia often sit for hours with the head 
bowed fortt'ard witli llie eliin resting on the ehesl. 

The changes from the normal in the Miajte of the head are to a wr- 
tain extent contiidcnKl in that guirt of tlii^ ehnptrr dealing with Ilie 
nymmetri' ami a])pearaneo of thi^ face, but ihcrv Ntill mninin to l>c 
diflotinwd the change.') in tlie rtha]>e of the head «» a whoh-. TheM: 
occur in acromegaly, oAt«itiit deformans nnd iu hydroeeplmliiH, 
micn>ci'plialii4, ricki^ts, idJot^y, niyxo^lema, and cn^iniitm. Tlie 
cbaitge» in wveral of llicsc Ktatca have already been deneribcd iti 
the |Mirt of ihi.'i ehajiler de%'ole<l to the Faee. 

Tlie hea<l of liydrooephatus i^ greatly enlai^ed alxivo tlie level of 
the ears, and thb «yinse!< the fat*, already ha\'iiig a teinleiioy to 
fatitty developmeni, to l<iok !<niall and wizf-nini. The eyi^i* mwmi 
iumewhat bnlging, the orhilal platen are oblique, and the liaek of 
the h(^ flattened. Smiiotimi-!* the foiitanelle remains ptiLtating In 
Irne hydnioephahiA for a long jieriod. Attain, in ihe true hydiYt- 
_ Ins clioketl disk !» t^omettnien manife^u-d quite early. (Set- 
OivoftH-k'tt and Trousseau's sign^) In miernecpiialiifl, on the other 
luuid, the braid is ^mall and ofli-n nari-otv. Technically, iW term 
inieroeephaiU)> ts appli<<d to idiots whose liead^ are lewt than iwven- 
ItU'lieH in (lireuinference. Nearly alwaytt tlie head of an i<)iot 



li iibiiortnally forniotl. Tlic ctvtiiiuid head ih large, bouvy, unt] 

Wliea 11 yiiting (.-liilil has uniiHtially pruminent p:irit'tal aud frontal 
boiiM, whioli seem ImlpiDtr, ami there U a ^nenil reeembUiice \q 

yio. 1(1 

Aeiom«f&I]r wltbKoltniiiul vio|ilittulialoi, (U. Ii. Mciiitiv.) 

the shape of the skull to that of hycIrooephaliD^, we su»|)fct the pree- 
enoc ot rickets. Aa a rule, the forehead is broad and high, the top 
of tho head flat, and the slinpe of the head more miind than in the 
^nuinu disease. Sometimes in such a eliild ue 6nd, in addition to 


' tfa<'w choi^en from the normal, ^pobi ot tliiuned bone in the oociphnl 
Hiul )uirielftl regions. Thone mny Ik^ altu) winowhatMifteDcd, and thiH 
, citiutition, nill^l "' i;ranio-tal>e>," w tirinally a wgii of rickets which 
^B exiaW io iiAwtctatton wilh infantile Avjihili.t. Ftickets is seen nearly 
^^ twice AS <»ft«ii in Itny a» in (:irl«, ami iIktu is tHually to be found 
I <l4>fio!<^iit dcv«li)j>ai<.-nt of thv boiiet* everywheiv, [lartitmlarly in the 
ribn nnd IrgH. 

Fm. II. 

SsopbdMtnloiiiKrc. (Mei.tiu.1 

Th<; <iiii<liti(in of the fontam-lleit in young children in of impor- 

in (liagnodi^. In the lii-iiltliy child all the fontanelles save 

; Ute iint''ri<)r friiilniu'llf <'lo.<<* duriii); the i«rly wrt-k.< of life, hut tlie 

liitttT <>)M-nin); <lix-'< imt rUiHc i^ntirt-ly till the infant \» ahonl (>ne 

'fair and u luilf old. Dnrln^ tht> (imt few months thlit fontanelle 

chiewt \"erv slowly indcod, Imt after thir* time ha.-* elnjx^'d iti* wlges 

lb«.i>nio n|iidly ii|>|> The [>r(-*>nee of ntlier fontanel let) 

jn a ditld'!) okull after it !» wveral months nld iadicMt4>9 rieketx, 

9V|>hili)i, liydroce|ihidti», or some inlmeniniid prowlh producing pro.*- 



sure on tlic craniiil l)oi)i.^i«, prt-voiuiiig tln'ir n|i]>riiximntioii. Gpikt- 
nlly. however, iIu'k- iniiinr ruiitnii«lU-M nrc tiol fwvnul oi)eii, but 
cIowkI, uu(I the a^iiditioti of thv niitorior foiitniicllv U ttio gtiitlf in 
diiiKfio^iH. In Bcvi-re ww".-* of rickMs thi- iiiilfrior fonliitieltc- iTiiiiiiita 
optin u)> till the thini or foiirtli vuiir, iinil ^^lioiild tl)v iiiohilic ten- 
diinej- bo <iov(.'loi>cd wirlv ni life thf «l{p* of tin- fonlniirlle nmy uot 
onlv fuil to bf upproximnt^<I, bnt npluully rcM-<li? from one itiiotlicr. 
Soinctiruo)' if t)i« inlgcii of tlio funtimclle fin; fotintl to l)C softor ihnn 
ti^unl the (liugDo^is of rickets cnn be so cotilimieil. If Mr[)hili« he 
the cuuae of the deficient boiiL> di'velupniciit, evidi'i)c«^ of this dis- 
ease ill muooiie pntvhes about the month and nnns niiiy be found, 
or a history of licredity addneeti; while if tlic ooudttion lie Iiydr«-J 
c-cplinlns the fonlunelle will be mnrUcdly hiilging. 

ExophtholinlE tf^ln in h iiinliv Tliv |ili"(iiHra|'h clim unl I'lnulf thrm ibe eDUiBimuil et 

tUu Ihyralil. irniin « inlltnt In Uienulhor'i wanlL) 

If the itkin over the foutunolle be found to l>e bulging teinpom- 
rlly ti^ H slight extent, the eau;^ pml>nhly lies in some iiciitf disesiMJ 
with fevvr, )inidtipiiig cerebral congestion; wiierea.', if jx-rmuiient, 
uiid the ^'n<!ml diiuonfiionH of the akull are not iiinivuMtl, mi intnt- 
cniniiil (growth may be the cause, or a cerebral hoiiiorrliii);e, n puru- 
lent nieninjfiti*. or ftome cystic formation mm" be present, or 


sometimes a thrombosis of a cerebral sinus produces hydrocephalus 
and bulging. This difference in the tensiou of skin over the fonta- 
nellc aids us in separating the meniogeal symptoms of pneumonia 
from those of true meninptis, for in the true form the scalp is tense 
and in paeumonia it is often retracted. 

Marked sinking-in or collapse of the fontanelle always indicates a 
grave condition arising from some disease which seriously weakens 
the heart and general circulatory system, particularly marasmus and 
cholera iofantum. Sometimes it appears as a result of thrombosis 
of the cerebral sinuses. Sometimes in rachitic babies auscultation 
of the fontanelle will reveal a murmur, hiemic in origin. This is 
most frequently heard in this clasH of patients, but can occasionally 
be heard when no stich distiirtiance of nutrition exists. 

Excessive sweating of the head, producing a wet pillow, is often 
an indication of rickets when it occurs in a child. 

A swelling in the neck in the median line, or on both sides of the 
median line, antfiriorly, is probably due to goitre. (See Fig. 10.) 
If it is associated with cardiac [lalpitation and distress, exophthal- 
mos, tremor, nervousness, and depression of spiritn, it is called ex- 
ophthalmic goitre. (See Figs, 11 and 12.) If these symptoms are 
absent, the condition is simply one of overgrowth of the thyroid 
gland. (For the movements of the head in epilepsy and hysteria, 
see the chapter on Convulsions.) 



Tbo gcnornl npiionmnrc of ihc linadi and arois— The alupe or tlic hands in di*- 
««M— 8pMii]a or tli« nnK«t«— Tivcaon of the hands— PttralyaU of tho handi { 

nnd Mm*. 

Thr up[)nininu> of ttii' liaml iiml iinii ofh'ii gives us valuable 
hiiiw ill tlif (lingno^iif of «Ii«-nw, oliicily liy renaon of variatinn in 
tlieiri«lia]io, tunnricrof iiiovomi'iit, iimi gciii>ml wjnsisteucy ; but as 
all thoMu iwiidilioii!- viin- widdy in nuniiiil iiidividiialw, we oan only 
regard diMtiiiot iiiiil wcll-miirkiil iiltL-nitiuii'f frtmi the iiorinal type 
IS ioiticutivL- of n definite disctiw. ^^■l■ ciiii, however, oEtfn gather 
general informution a« to the- patient from the linnd^, [mrtloularly 
«8 to his oc-viipution; tliUB we see tlie Hinoi^>tli, *uft hand of the pro- 
fes^ionul inan or elerk, the lionty hand of the laborer, the blaekeaed 
nails and skin of the mneliiniBl, or the Wue-baek dollings of the 
hand of the miner; and Hirt as-serts that atrophy of the iintiUienar 
erainenoe often ensues in cabinet-makers, perhupii from th« exooa- 
«ve use of the plane. Even when no |>atbnlog!cal condition t'xist 
we are wont to regard the heavy and homewhat tliick and vlumity' 
hand as. an evidence of a phlegmatic temperament, and the thin, 
wiry, dexterous hand an indicative of the nervoiia temperament. 
Similarly, we reoogiii;:e as tlie hand of the .ttrumnii.i that one in 
which the fingers nn* idender hi-tween the joints and tlie joints 
themselvi>^ thiek and ebinm', or, again, in pervms with tubercular 
teudenitiej*, we we u slendijr, delicate hand, eimily oompi-essed and 
aomcwhal efTeminalo in ly|H-. Very commmily, too, in children 
who have develope<l heart <lis«i«' in early life the hand becomes 
Mliure-liNikin);, and the fingiTrs are ebib-idiupcti through thickening, 
at the tips. A similar clubbing alw> nianife^lif it^H-lf in many euiwaj 
of emphysema and ehrunie phthiM4 in adu1t«. 

From the aiip^-uninw of tbe nails we can ofti^'U gitin important' 
information; thu^, whenever the color of the blomi in the capillu- 
riefl tinder the uuile is du»ky we know that a deficient pulmonary j 
function exiBtfi or tliat the circulation i« impairetl, it may lie from 
foebleue8» or from cold. In auiemia the uails arc often very pole, 




plion Mattkenzie \\m a-tsortt^l that if prewure ou the tip of 

sfli^r mnipleUrly <>iii|)lic--^ tliu (npiUni-iuri under the nails 9a that 
thfi a|>)>caniiice U pale tli« tt<\ (■orpiisiK'^ are jir^ncnt in only half 
the ui'iml iitiinlH>r. 

Whiu- if]Kil* in th« nuil miiy Ik' flur to injury of tho matrix hy 
picking lit the Imw of tho nnil, "ir be ilne to aunt* fevers producing 
tr»phi<: Hmnj^M. 

When iht* nails aw «triut«<l and in lun);itudiii»l ridf^vi the [latient 
ia <ift«n of the gonty diathesis, while tmnisveree ridges may indicat« 
mm!«t of iiuil-grow'th through local injury tu the matrix nr th« 
ImiMiirment of the general nutrition as the re.sult of some .severe 
oysteinie shock, such a« a severe surgiral operation or prolonged 
illness. Sometimes these marks result from a severe atta<tk of gmit, 
and Fothergill tells us that it took iiWit seven months for »ucli 
u nuirk to grow out of his nails. Ordinarily, this mark will he 
found about half-way up tlie nail three months after the attitclc. 
In h<-miple^ia or acute infantile pal»v the growth of ihi- nail of the 
pamlyu'd |Hirt is generally arresled, us ean be determined hy stain- 
ing it and wati^iing it fi'om day to day to see !f the stained put 
gmdually inovca away from the base. When the nails arc distortcil 
and tiiickened the eaune may be Ineiil injur\' or {leriphoi-al neuritis, 
or any condition of the nervou-t .tysteni reuniting in deeided tropbic 
inRnencoK, ax in that rare condition syringomyelia. 

I^ypt^rtrophy of llie naiU m> that they are abnormally elongated 
is (uually aModatett with tiiickcning and the development of great 
fragility. The nail may even lie .«j>tral1y twlnted (onyehogyropho- 
mh), or, if very wide, may cut into the .'^kin and produce paronychia. 
Tluwe oondilioriA may n?xult from »kin UsionK, aucb as ecKeroa, or 
lietHi) ntber, at or nojir the matrix, or be due to sypbilLi, and Vogl 
asM.'rtM tliai mere thickcoiiig inuy a,r\i^ from severe fevers. They 
may »Im» Im? iw*n in itv*!--* of Kikynnud's diiM-AM^, or in solerodactyle, 
■ud ia aiiH» of pulmonary osleo-arthni|iatlty. 

.\trophy of the nuil>« may itppiirenlly ari-'te from idmtical eauaes 
with tiKMW which jirodncc hyiKrtropliy, ami ICa]>08i liaa seen the 
DttlU soft Mid raenibninivlike, with ati«ceMMts under them, from 
]iwmnt>i)t of the (ingi-r*. 

.\ diagn()'<tic indiejition giveu its by tlic fingent is itcen in dactyl- 
itis (Iitu to syphiliH (Fig. 13). Similar defurmity, often multiple, 
aluo oocunt in MTrufnlovis or tnbcrenWiiiL. In other c«m-ji thiii is 
rcplaoed by iin cniplioi) on the <Wn of tJie hand clmntrteriiitic of 



syphilis. Another indication is seen io tlie ulcers at the bases of 
the linger-nsiU, with epchymotic Mpots on the skin, [HXKlncetl by the 

Fl«. 1!. 

liiclTtltlt >rptill>li» In the In hill. kTAi lvh.) 

ohloral-habil; and alill aiiotlier is tlie sores seen at the bases of the 
finger-uails in persons who handle irritating drugs, such as elate- 
rium. (See chapter on the Skin.) 

C'oiigested veins on the itaii<i iiuiy intlieato ob^ttrnctinn to tlie 
v«non8 droulation nf the arm, or )ren<>ral lack of vnsculnr tone and 
a ft^blc lioiirt. 

When the hand is cold and i-lnmniy th^ coiulition may l>e due 
to iironiidrtwi^, or a liK-al di:>tHrbain'« in innervation of thl^ »weat- 
glaude. It \» often n.'cn in eaw» of wwalled ^pinnl irritittion and 
nervous exhaustion. Exrciwive Tiwcating ■■( tlic linnd 'm hI«o ofteo 
st;cn in eases of progressive miiicuhii' atrophy. 

There arc two sots of movement* Oiwx'iated with the ma-^les of 
the wrL-l and luuid which pofisess grave prognoi<tio and diut^nostio 
imixjrtancc. The first of these is twitching of llic niiHcIcfi of the 
forearm (I'ubMiltns ti'ndinum). It indi«-nt<.-s •^ccre, cxImiiNting dts- 
eaee. The second Is pickinp nt the iK-dcIittlies. The di-Hcriixion 
of the grave import of this dangerous symptom, " picking at the 
bedclothes," or carphologio, is giv«i by Shakcspwirc in hi9 deacrtp- 
tjon of the death of Falstaff : "After I saw him fumble with the 
«h«ctit, and play with flowers, and smile uiwn hi'- fingcn^' ends, I 
knew tliat there waa but one way; for his nose was as shnrp as a 
pen." And a^in, Hippcrcrates has well empliasiired the gravity of 
this «ynipt»>m, for he pays : " In acute fevers, in pcripneumoniiw, 




!B [tlcuritM, iind iu )ieacl»clK-i<, tin- Immls iirc niovt-t] to niwl fro about 
ttie fac«, seeking iii tlic vuid, u» if (^tlieriug bits of\v, piokii^ 
at the covering)*, or dctiidiiu); objects from the wiillit of tli« room, 
oonHtitiitiitj: m many i<if^)« of a fntiil ivrminBlioo." 

Pra. u. 


A IbvlRU nr plalur* ibovtni U>* amUUcni or lh« hikixl iii ■ <*te of rtmadBfaoL n )• 
•moUmI thatapbiwa coupkMlrslir tniMranat to the rartk*tl<jiu. tuo cha^iitoMHM 
ta (ft* bona an unpbr^rMloa and illslMaUon ; iIm (liumli tiu tnifii c<iiDtit««tlr dldooMed, 
lb* |>ti>lanc«i Mns allofvUiar illii'liuvi] : (hare hu b«en aiirhyloii) of ibo proximal phalant 
«f Uw nm Oacir wlUi It* EnoUMrM'- ^U'] • lanpi «ta1oii l> (botrn oa Iha ulnar iliItL Smallvr 
■n^MB an ibown on Ui« motuiarval of U* flRh fliistr ai IU bon«, and alio la the phal*ng«B 
af Uw«aM nnc«r. irniai lti« MrHleal Onmlflttnt April. IKM,) 

Tli« Hng«rD arr- oflen ittstortcd und ivriHlcd out of their normal 
|M«itioii from the trophio chanpii) whirh take place in gotit and 
artliritiit dofonnai^ (rlic(imatui<l nrtUritix). In gotit die deformity 
iiivmU^ tlio rtnmll jointu in |i»rlioiiIiir, and in many inataiioe:) ap]>earii 
Di'Mt iiuirkiNl in tUv forctinjcer. Fixation nnd deformity of Uic 
fingnnt occur tliroiigli tlie deposit of urate of itoditini in lar^e 
amoiinlA lUxiiit (ho )»iiitn in their tciidnnx nnd nheaths, so that thr 

lUdlovmi'l' oT ' 1*^ or EDUi In nblob the gaaiy dcinlM aSMted all (ba JoInM ol IiMb 
lianda, grMllT dtfonnins (bum. Tli* outline at Iba bMid ihom tba ^afannllr. bui In Ifau 
«Me It I* ln(*mUne to mile llinl the gnotir clepeMli du not [■rtrvnl Ita* i«uc* «f th* my*. 
lUrkbd coutr Doilultn npM pfncat In ihlt nuc. froni wblch ebBltf tnBiflrlil sai nadllr 




liiiKcnt are as in spliiiU. Tb<! kDoliti tif nraUf of Hodiiini apjtear as 
hunl, white inaaw.% aod, if ven* sii)>ortioiii], a:* i^lintening roaASis, 
Hie svirfaces of wliit-ti often iirrak down and allow tlio eHcapti of 
material looking like wet, powdered chalk. Tin* joint-siirfa<«» 
theiniwlveit are not primarily nmcli nitcred, titit .-iK^^oudurily gnive 
chnogea oatir in tlicm. (Figs. H, 1.5, and 16.) 



pMlant'* haiiikiMla Flf, 14. >bciiilni[ <t>c ■|>|<iiaTmui'ii aiid ci plaining lo •ome ciunl 
Hit Mpn-iodUon ot (b« bona^ but trma tliln plclitr* ■l<>»u uiiu would Ukk11> «ip«cl «icb 
WilOM bOM lartau, 

Verjf oommonly in prat the only jointfi of the baud which are 
iuvolvwl un> till' liret joiotK of tlic fingi'nt, a knol) <l«vvlopint£ on 
either iiidv nf thi' knm^klv. (Fig. 17.) The little finger in gout is 
often t)eiit at an neute angle ul the middle kniii'kle, au tluit it i.t held 
ill an awkward hoohol position. (l*>g- 1^.) Thti; i» moxt com- 
monly seen in women, while in men it u euiumon to ect^ forced 
fli'xion uf the Hrst phalanx of tlie middle fiogi-r into the piilm of 
the hand even when very little >f any deposit of urates hw taken 
pliiec. This drnwiug down of the fingers is eonsideretl hy Paget to 
be imtJiognomoflic of gout, although the patient will elaiin that it ia 
Jiie to the use of a cane, a hammer, or other extraneous cnuse. 
(Fig. 1».) 

Distortion of the hand with dniwing of the finger or fiiigere into 
th« palm may Ite due to Dupuytren's eontmotion, which rwulti* 
from burns or other injury to the jialmar faacua. 

While the history of lite patient, Uie localization of the mani- 
fattationa of the dlsfase, and it^ cliarai^r render ii difforcntinl diag- 
nosis between the hand of gMit and tlmt of artliriti!) dcformuns a 
poAttihility, it should not l>e forgotten that the dcfomiitie« of gout 
may take cvetT.- position assumwl ^>y those of arthritis deformuiiK. 

In arthritis deformanii the distortion of the hand may bo fur more 


Klo. IT, 

Setwrdsn'i soucjr nodw. Illnitntlm ooai- 
nOB Ibrnn «f lanniiul phalaiifatl daflceuon. 
Fondnsm >u<) lllll* Aagtr nt ■ wvoutn aged 
WTvnty TW*> "Crab'pajr* "otM* onr iln 
JMnif «• Kin dojdoMd. (DucKwotcnt.) 

NoduUr norfimngttllabtrdm'inodMlflM 
(otoatr oitbTitlion ib« bradDgti and UK1#'1 
nngwr al a wouiaa a(ed UV ycu*. (Ddck> 



Ti>pbaoniiii covl or rttlit hand. IMleclioDofitlilti loalnaratpMI. OiiiIi« wridtaicator* 
a laiGV. ctiiilkr iltpmll, whtob bad bwii IfMWil hr Invltlon, <l>lvi,uuniH.i 

TtlK BAA'DS A^ifi ASMS. 


\ marked tiinn in ^ut, for Iimv ihi-rc U iK>t ii n*|>Iint-likc dt-ixMit nlxKtt 

I tilt.- joint, but in its skwl tlic (Uvi-lupiuL-nt uf (.■xustoncw on l\w vdfrtM 

[of llifl nrliculnr Aiirfitivit, wtiieli iit uuoc Wk utid di-ijuitit tlif finj^n, 

whilt' ut tht! Mtint* tinif tliv u{)))OHiti- siOi- uf llio joint niny Iw jm^ 

tinlly ali»orix-<i, fo ttitit dislucutioii !» reiulily pm'luc'ud. (Fi^. 2<>.) 

As II rv^iilt ttiort- iH liuiuelimes (levclo{)«l wlist i» uillt-<1 tin- " woul-fin 

baad" (ul»a «i>ca iu amen of gout), a hand iu wliirli the digits are 

(IvHmukI cliicHy towuni the iilnii, through th<.' aotiuii of the ext^^ii^r 

muscles, which are &up|iliG(i with nervei- whioh are retU-xly Irrilatwl 

[bv the coiulitioti of the- joiotx, and thcrebv ckuso m(uii^iii (Clmreot). 

(Fig. 19.) 

m. IV. 


TvpnaoMiut pciiit nr hkniU, tlloMnUiiK ilaflwUon aod lonldii uf •11^11* >■>'■ liliBlkiivf*. 
Tat Hgtin lotbc leRabowitbe"i(al'fln" (Tpc iDuokvokth-j 

Chronic rhi-iirnati^ini inny ]>n>diiee };nidiial eliaii^t^ in the nhujM? 
of thi- hand rhit^lly ihronff h di>iii.-«*> and the alteratinnn which it ca»»C6 
in thv miK)iiU<A and li^nimt^ The ehit^ alteration ii* inimoliility 

I or HlifFne^H, Siitnc |>i'rsiin» believe that when the hand wastes it 
dout Ao nirt from diMi'>i-, but tJinHiifh ivlk'x nervim.4 iiifluen<^s. It 
nrt'ly, if KVi>r, mxitm in the ltiiud.-< nione, hnt when it dite.- the joints 

|An' oft«n NWollen and Homvwhul tvndtr, but never hani ax in gout. 
Tilt; finfi^r-inintM iire- not ronimouly involved in amite arlienlar 
rhcuiuiitiikm. certainly very mrdy m the oidy inanife.'-lation of the 
diwMMT. The intlainnmtoi^' proiWtH in more apt to h« almiit the 
ball of tbe thumb, or iu tl>e wriot and enqial jninti*. The hand is 



sepn iimU-r iUvhk- cirOHmntniicfi^ ns ii Hufusy, swollen inoas, jmffy, nml 
Mniii.TiitL'ly U-mliT hikI hot. SoiiiftimeH it is ^iiUe retl at the joints, 
but otiicnvise quite iHilli<I, pttrticiilarly in the puffy, (edematous area 
on till- Imck of tlic hiitid, Thu preseni'e af intense local iiiHaninia- 
tion, tho history of sudden iiDsft, and tho intense piiin on niovcmiriit , 
readily separate rheumatism from gout and arthritis deformans, and^ 
\imve it to be se|)amtcd from sprain, septic arthritU, aii<l ilixrp-wcjiU'd 

A Bunigcn ttypiciuNaliOHinc iiic iMuiiiioaal Ui«t>>>awaf ib« bMid In t. mm of ehroDio 
ThaiiniBluir] ■nlirlllk It will Ixwcu (Uni Ih* prriilUr oiilllna or ili« piDximal pbaJKURCskr* 
dmtn lhcIrp»IIlont^-u l«loni we tmy nolv tnobxloilt uf tnv mninnnriinl a( the tnldillcnnd 
Miif nii(vn ulUi Uio at unitimin tiid iiiicirotiQ ilcpoilii In I be buailiol tbt pliaUncM Uid 

«lt1>Hiitl<i»>. (Fniin Iliv Slfliml itnnilrlf, Avrll. IKKVi 

inHammation of tlif Iiaiid ]>ri>]HT. Tlii' lir«t is exclndifil by th« 
history, tlit- siwond by tin: history and p-ivi-Hl look of evidonw of 
goDorrbiea or scjMis or purpuni, and tin- third by the lack of aciwn)' 
panying ^-noral systemic disturbance and tiu' absteniK- of a bi^toiyJ 
of tivumatisni or infection. In this connection it >ilioiild not l>o| 
fbt^otten that synovitis of thi.' joints of the liandii, wrii't's uu*' ellwwVTl 



~«m»Mimes ocoon diirinp On- fall uf Urmiic nil, lire id aoM'lct fovw omi 
ifl often not ttmi>ctiiU-(l with any mu uf u-iii|t(.-ruUire 08 a Tvm\l uf itit 

Bdevelopnieat. Tlic condition is siiildvu in oii^-t aiid ti^imlly rapid 
in ite pourw. TW wimft sWU" miiy oxist in tin- joint" of tin? lower 
Itnibs, but Mitr^Hvii found it in tlit- liunii» nnil wristji in si.-vvnly-lwo 
out of one huiulrvtl noses nml twi-nty-fivi- tiim-s out of u linndnnl in 

^Ltliv tnr^i^r joints. Thv oumlition iisnnlly iiiipfure, liowi-vcr, in 

^" riieiimiitic vltilHrvn umi thoso witli \\ rlii-mnatio Iiurrdtty, iind is 
{TPtH'nilty n'licvwl liy Kalicyliitiw, eo it is not n pun- sL-ptic artliriti^. 

^H Ttio iwrvoiis di«turbiiiiLi-i« wliicli chiin)^> the appinimnco of llie 
hwufU nrc very iiumerotis. 

A nf^ioiiouroltc cedems is not peculiar to the hand, althuugli frc- 
qiHiotly involving; tliis {mrt of tho body. It consiatii of a swelling 
V)ir>'ing in »i» from a dituo to a silver dollar, which i» not a>JetnatouB 
in tile MGSC tliat it uin he pitted on presnure. This swcllii));, whicll 
may \m multiple, a-d iu color, or |>ale and waxy in appearance, lasts 
but n few hoiini or days, disappears, and often speedily returns. 
Somculmt allied to angioneurotic o^denia is that condition of the 
hand (or toes} characterized by a white and waxy or slate color of 
tJ>e fingers, associated with cnldue.'«4, swelling, and mottling of the 
skin, Cenaed '"' Itaynaiid'H di.Hi'ju*e." Often this is a passing condi- 
tion, but in its aever(> fornix then- is Knnlly (leveloi>ed drj' gangrene 
of the fingers involv«<l. The iimditions of the hand resembling it, 
from which it muKt hv. MqMmili'd, an* oenilc j^m^rene, in which the 
BilvamW a^ of the patient and the prc^nue of diseased and thick- 
«i bloodveiwils will enable lis to decide on the Intter i\» the cause; 
it-bit«, in whidi the hii<.tory of exitosiin- will Ir- <3f valne, although 
:pmuru to <!ol<f often prveipitati'» an attack of Raynaud's disease; 
vrgoliwm, which can Iw disooverwl by the history of the patient 
having taken fou<l for a lonj; time which may have contained bad 
rj'«; k>]iro>ty, whieh will probably be seen monr mark^l in other 
|mrtfi, and in tbo patelK'i< of which enu be funiid the leprous bacillus; 
and ali-oholie netiritiis, of which wc jsball sia^k Inter (see eltapler 
iin the .Skin). In that state known as Morvan's diK-]ir>e or " paiu- 
annmlliiwui with whitlow/' tliero is a slowly pmgrei>ftive loss of 
power in the hand, with atrophy and ulcers about the bas«s of the 
nail*. Sometimes the temiinul phahmtico undergo necnKtia, and en* 
latltement of the fini^rs, tlirough swelling, may be very marked. It 
prolNible tliiit thisuonditiou represents two «c[>arate Unions, namely, 
uritift and syringioniyelia, and it is an excee<din|>ly ratv dtseaiv. 




Swdlitift of tlic Imml, folli»w«I iii sonio nioiitlin by riii>t«rc of the 
skiu, may, in ii (kt^u from the tropica, uiiuiii mywloiiia, which is,lH)w- 
evcp, seen more coDimunly in tlie lowtrextn-miiy a» "Miulura foot" 

In nddition to tiitwe tmphic chmitrr's in tin- liand wt; have tlie 
Eo-pnllctl " spade-likf" hiiml sf^n in myxntlunm, 8crom«^ly, iiik) 
tlie pulmonary oetfo-arthrupathy of Marie. In myx<rdcmn the 
deformity dirpi-nds upon thi.- alti-rations Jn lliu siihcntaiiewii)' tii.'«it(«,i 
nithcr than on changes in thi- bi>n(S, su that the hund is «woUc4i oi^' 
hoggy-looking, but does not ])it on prvesurt- an in true oiU'inn. In 
acromegaly the L>ulai'gement !•> ehirtly os^eoits, us it in nl«u in |>til- 
uionary Ohteo-arthri>(Mithy, the fornintiou being on a gigantic settle, i 
In the latter diiiense, however, the hands and feet are nione affected^ 
Eind ihe enlargeniont tB not symmetrical. Fnrlher, this condition \» 
nearly always HSf>ociated with changes ui tlio lungs, i-nch as emphy- 
sema, tumors, and old lii-oncliial troubles. The hands are not only 
grently enlarged, but deformed, so that a side-view of the finger-tip* 
reminds one of the sha|>e of a jtarrot's beak, the nail Iwin^ turned 
over the end of the linger. Thi;! is even more marked in the thumb, 

The differeuliatioo of pulmonary osteo-arthropathy from acro- 
megaly is to bo found in the fact that in the first-named disease tiiere 
are no ehangf-i in the face, tlio .skin, li[>.>« or orbital ridgas. Neither 
is there .ipinal kyphnsl:* in the cervical r^ioii, tihhnugh it may be 
present lower down. .Again, in pulinoiiary osteo-arthropiithy the 
long tiones of the ujipi-r exIremiliC'S are gri'atly i-nlarged in llieir 
epiphyses, while in actomegaly they are not no enhirged. 

Alteration.- in the lontinir of tin- hand are, however, far more 
freipiently prodm^ed by atiitphic prowfwc* than by those which result 
in hyjiertrophy. 'I'licv ari»i^ in ciisv:* of piiraly.'<i.'S not only from 
wasting of the mii.-«eular tissues', m that hollows or ouuken pluoex 
oocur, htii alio from the dlatorliun>^ caused by the coulractiona of 
healthy muscli's, whleh, having no op]>osicioii h« in heallh, KjKTdily 
draw the honeKof the hand into nhnurmal ])osition«. In other com 
the disea-sed miiiwulnr fibre" nniy l>e H[MiMn oil leal ly contrnctotlfOVCP-' 
coming the ro-Utance of the healthy musi.JeT(. 

The W);:>ting of the haiid sct^'u in old iige, jiartienlarly in women,] 
and in advnncitl phthisis, iliabel^t^ mcllttu>, and other conditions in 
which the tissues of the IhhIv in general lose their plumpness, is 00 
unlvvrKally distributed that :t diagnosis of wasting from old age is 
not ilifRcult. On the other hand, the waiting due to nervous leuons 
ii) generally not universal, but liuite<i to single muscles or groups o£ 

THE UAyjfS J.ViV A it MS. 


mtiselca, die remaining imrlinti of ilit- Iimul 
appeatance or Xxiag only indirectly iiitttuiircd. 

hnving ite normal 


CUU'liaud, lOiiav.) 

^H Under the iinnu' of •' clnw-hand," or " mavi-fn'ijrifff," we liiid 

^|« deformity of tlie hawl n-liich i» in il««lf very rliarHi^leristi*], 

oltliCHigli indiwilive of wvemi <uiii<k<4 whiuli ull oiwrBti- in an ideu- 

5 tied mantwr. The hm-k of ttn? Imnd Ux-w* \U noriniil wHivexity 
Mid boconvfi somewlml eoiinivc. iln- ti'iidonn on ihc cxlenitiir .inrfare 
stutid uul ill ridgv«, (he [trnxinDil {)liukin);e» are dmwn backward 
Uxrard the wrist, while the second and thini plmlanj^i^ are dniwn 
toward llic palm of the hand (Fig. '21). 80 tne timet;, however, the 
tips of the fingers an- drawn toward the tmck of the hand. This 
defomiity results from atrophy and pamlyr^ii- of the interoiMe! 
tnU!wle» and lumhrical«?«, which are stippliiil hy the median and 
ulnar nervc», The extensor eommiinis digitoruni and Hcvor dtgi- 
tonnn pnxluce a dorsal Rexion of the first phalatigi'f^ and a roinpletc 
^^ paimar tiexiun of tlie second and third phalanges. A certain amount 
^B ol immotnlity vi also umsetl by the faet that flexion of the hand is 
^H impfitsible in the fingent and almost lo«t at the wrist. 
^^ Tltu claw-tumd having l»een reengnized, it remainn to he decided 
what are ita ea«se». It may be dne to diseafw of the peripheral 
nerves (the oinar and nit'dian), of thf i^elU in the spinal oord, and 
^_ of the cells ill the cerebral cortex !u the hand-area. 
^1 Taking up for oonsideration paralysis of the metlian and ulnar 
nerves aa a cause of elaw-hand, we find tliat the most common oause 
iaa neuritis prodnoed by some mechauieul injury resulting from an 
aoeideat, or from the following of .some oi'cujKilion in which, for 
example, tJte artisan pre»ies his elliow oonstantly on some hard sar- 
fnve. The deformity may he, therefore, either unilateml or bilateral 


(getwrally th<t fornu-rj, iiml then- will lie cviiU'iioi's nf IdcuI iojury, 
or a history wliicli will iiulii'jtb^ that llu- Ie»ii>ii i» pi'iipliontl. Fii^ 
tlier llinu tlii«, tlicrc will iinrly rIwavh be foitml, iii ulnar luid 
iHpdinii injury, »ien»ory il* well a« niotur impalv^i-i; utiil Hirt luwiTtH 
t\w rciiiiirluiblv fiict ihut tin- okw-lmiiil ruHv ili>volop in m**» in 
whioli tion)M)ry tlii^turbiuic'cs arc thv only evidence uf nicdiiiii nnd 
ulnar dillii'iilly; in otiier worrla, before motility Is lost tlinjiij;Ii 
jiHralysi". (Sw clmjiter on the Skin, AuIL'KllH'!^ia of the Skin.) 
Toxic nenritiri very rarely, if cvor, eaii^e« clavr-hand, us the miiHculo- 
»l>inil nervf is more ooiiniiurily iitFcetecI in tins condition and llie 
cxti-nwrn- beeouie jjaralyzcd. 

There ure i^veral spinal eaiisfs uf elaw-Iiund, the tuot^t important 
of thcni beiiijT i>rogrewtivf mtiscnlar atrophy, tlisit disease in which 
thert- an? atrophy and abuornial chanjje in tlie anterior horns of tlie 
gray mutter of thu i;pinal cord, ]mr(icu]arly in th« cervieal region. 
(Fig. 22.) It will Ik' remembered, ton, that the anterior nerve- 
nmts and motor nerves become involved in thij* proceas. As a 
result of tlieHo chaugvM, we have developed loss of jMiwer in the band 
and arm followed by the develo[>ment of a claw-liand from wasting 
of tile same muscles, as already described, the discase-proi-ess being 
generally bilat^^ral, bnt alTt-cling the rigtil Imuil mid iirm more lliuit 
the leit as a rule. As progrcssix-e mn.'tiTular (itro|>liy ofU*» nnikeit its 
Hrst manifestation in iIu-hi- niiiH>'lei<, the haml utToiiU iiiiicli diag- 
noHtie inforuiiiiion in siisiu'eici vum*-, and if the |Kttient with thi« 
disease he mitvhed a^i he unbutton* hi« coal, it will be found that 
h« doe8 not usi> liis ihnudi and fimt fbigi-r, but iiu^lie* the bnttuiM 
or ihtt edg*- of the builonhr)!.-:* wiih ihe baek of Ins fing<,T8. (Figs. 
23, 24, and 25.) The additinnitl symptoniH arc eome pain or pur- 
lesthewa in the nffi'eUHl piirl» prior to the wusling, and that the 
paralysis spn-ads, un iin mime indicates, from muscle to muscle. 
Thus, Ifcginniiig in the ball of the thumb it passes to the interossei, 
iitid thence up the forearm iiitd urm. Sometimes, however, (be fore- 
iirm iniiaeles eM-a|K-, and the shoulder muscles are attacked sccon- 
(larily. Very rarely are the shoulder muscles first affected. Soon 
after this the dor^d muscles fail aud lordosis begins, or the head 
falU forwmil on tbe chest. Fiually, the respirator.* musclts are 
altavkeil. The irritability of the muscles is increased, so that they 
ooutract if tapped, and fibrillary tremors constantly affe<'^ tliem in 
many iuMinnoes. Xo vasomotor changes take place in the affected 
part, but. linidly, the reactions of degcueralion devch>)>. The di»- 
eaee may last fur many years. 


Soia4!(iiiu« in t-ttroniu jioltomyvlilLit in tliv iidult » ilcfuriuity mmO' 
wlint likr tlmi of rUw-lmnd may cxUl, but ihis is a wry ntrc con- 
«litiii(i, cutupunittvcly f'pt.-ukiiig, ami U 6c[Kinit<.tI with <llf!ic4tlty from 

nu. JO. 

Ana*at (pUwIranl tuTolrtdla piogrcmlvo muMuUr •troiiU)', lb* at«M lavolvtil ara ilu 
■ntcne«h«flnaf Um Rtar omuc* eliMartibAdlas b«v]r>»itl lliu kniarlor lateral inicli and 
wimliir MM WIN Utakdlnt Itstil). 

FM. a. 



ProcroMTs raiucnUi alKqihr. Suakaii-la 
laMroMMl (iiMa* no iho btek of Ih« hud. 

Uie rlitw-Iinnd of iKTiiilR-ral iionritiB of » goin'ml and severe type. 
An the rvHuIt of tliv aciito polioinyulitiit of infaiiry, we muy also 



have the himil tli^tornil l>_v roiitrat-tupi!)^, I'lirh iis forwii cxtm-iiim 
in |)aml}'sii« uf thv tlvxuns, fonx't) tloxiun iii iMimlyisiM of Uil* cx-, 
tODson, mill (^iHw-hiiicl in iiunilyxis of tho hitommei. hut iii mot 
fuswt «f this ihwnisc the foot it^ the piirt iiivolv<'<I in (ho tliisonW. 
In progreiwivo iiiutciilnr atmphy the utropliy often pruTr^Ie* the 
puralyiiii!, whcrtnis in poliomyelitis the [Htralyt-ii^ prei;e<l('8 the ntruphy, 
BO thiit in tile former the reaction of degeneration ticvelojw late, and 
in tile latter «levelopi< early. A t^oniewhiit elau-ijha{>v(] hiinit is nlsOj 
somclimeii seen in that vorv nire eoiidition nilletl Morvan'sdipe!iae,f 
hut it hiitt not the ehurncteristie apjKiiraiice of mam-en-jriffr, lh«re 
being n slow Hymnietrieiil wastin;; of the nuiseles with a dmvrini; of 
the tiu^er^i into llexiou. There are alf^ analgesia aud painlMw whit- 
lows. It usually oceurs in yoring or middle-a^ed mules. Morvaii's 
discaM) of the fiii^cni, us already slated, may arise from a syrinjE^J- 
myolui and neuritis, or neuritis alone. 

Fio. 35 

tlkiid niiil fanutnu Incbmulo tiilual ojiiBOiilu iilni|>ti>'. thouiiiii (npvclally wuiIdk dI Uwdw 
and hjfpolhoDBr BmlacncoL lt>inn.*K.) 

AnotJicr spinal leeion producing great alterations in the apjicar- 
ance of the hand and arm, tlirmigh wa>iting of tin- thenar and anli- 
tlienar and into^<)^st'i and tht- niu.ieleJ« of the arm, i^ aniyntniphiv 
lateral sclGroHiii. Here ajptin the hand often !ihow8 the flr^t numi- 
featations of the dineaHc in the Iok^ of powttr of which tlie patient 
oom])lains. The early Ayulp^>InA nf amyotrophie lateral Heterosis 
may clawly resemhie those nf |m)gTe*ttve mnKoular almpliy io the 
loHSof power iu the thnmh niu^elex, hut in thi» disa'a^e the reflexes 
are markedly increasMl in tJie affei-tf^l luuseles, wheren" in pro* 
gressive mu^nlar atrophy they are Intti, although filirillnry muscular 
twitehings may he i^nt^ml hy tapping. A^iin. the jintieiit Is usually 
mnuifeMting some of the «ymptonii« of laterut seli-rotsis wlien he wmee , 



Flu. », 

Ton- the physipian, aitoli a.-« wmriHi--ts, ftlifTin'-'W, imt! Ic«^ of [wwor 
in Uie legs. (Hw simpler on Legs, I'araplitpa. ) Tlii-w ore »l»o 
texog^raletl knce-jiTk.- aik) »iikliscloii(iM, nnd wriKt-jurk h marked. 
Wantiag of the niiiHcloit nf ilie iinnd, caui^in)^ dintoninii, muy »]i» 
Ihe <lHe to ityriiigomyrliii, Iml gfiifnilly ilicro will lie with tliii loss 
I of [lower and dintiirtuiiiit; of ^unotitioit, siicli a» fliiivstlu-sia. Ofteu 
in syrittgumyi-liB tinrri'will be (iovvIii[»«i mi nrtlmiiiiithyof (1m! iiriiiB 
rviicli (IS H jiccn in lliv U'jjs in tiibc«. 

Wnnting nf llic liaml, witti llcxioii ittid rigidity nnd >H>nictiiiics 
I cnntRutim-s, \» ».fB nin.'ly in titlviiiioi-il |Minily!^ii^ iiK^itani^ iii pliiiv of 
i tbr flmnwU'Piittitf Ircmor, 

III tlif " <vM)ni1 [Hilsy of childi-en," Mi)ni(.>tinK-« cull««I " spaMic 
infiintik' liviaiplf^iu," the hand nmy be floxcd on tlu* foniirm, und 
the fuTvarui on the iirni, the thumb 
drawn into tin- juilni uf the liiiiid 
and the finf^rs flexed ae in Fig. 26. 
Tlicse deformities are in)t nei^asarily 
cunfiai'd to one arm alone, but are 
sometimes bilateral. A iwoiilinritj' 
of these ca-rei^ is lliat tlic musclcft 
I Waste very rtlighlly, and do not de- 
velop iJie rea<Hioiis of ile^enenitinn, 
\fo thai tlie t^uM; ^■jiamtcs it'Jrlf rri>ii) 
i»myelitii«. Tin' fing('n> in the 
liral luiloy (»f children mn i)ften 
in eurioiii* po«itionif wit^i 
p, and, if tho limh Ih- i^oddenly 
flfxnl, CI lo<:k-likc Meniwitinn \vill Ik- 
[imparted to the pliysieinnV hutid. 
Ciiii%'illHive w.'ixiirv» of an epilepti- 

ft)mi ty]»e Jin.* very frtM^uent in eiue-i 

^'l I I •'■■II /-< I Hlthl licmlplcxlt. Willi cnnlnrturM 

oerehral [Mil.'y iti ehihlren. Cohn „^a „„rt«i Kr«»ii, «t .»» ..,,«• m 

n»iert(t ihiit iheR- aiv on reoml eight '"**■ " '^■''t run of tvt. toilowing 

,, , , . , Ij-pliiniuilnrliil fcver. tSirn».1 

i3iM.-« in wliieli intent ion -tremor has 

taken l)io place of the ti|»wtic rl^dity just dc^Tihed, and he reportt) 
a ninth. Similar lesion* may follow infantile cerebral hnmorrlmge, 
llimmboeia, or embolism. 

Agaiu, in persons wlio have had apoplexy it is not iiiiei.)mnion a» 

' time iirwfl oil for the lemjMiniry s]Mu«m seen in the ransdes of tlio 

hnod and arm to be replaeed by permanent oonlraetions reitnlting 



in (lefriniiity. These coiitractioiii%, if thi'v occur early, nro mi cvi- 
ili'DOi* of irritiitiuii of tlio |iyrami<lnl tmct or the librL>^ jiisl IH-Iiimi 
tliu Iciivc of the internal c-iip&ule, iind arc of Hcrtous import, uk tlicy 
■lulirntv thv cxtvtiHioi) uf murkoil iiifliinimiilnrv proccfises. Wltoii 
ttivy vomv uD latLT they .show tliut » di-gi-Heraiive prucLtte is Av- 
HOCiidinfr thfi pyramidal tmcts. Wasting finally cHim«ii on. (For 
riirtlit-r <li:4fti>Kiion of the NigiiiRtnoci- of paralysis in tlie ann and 
hand, see suw^eoding p:igca and chapter on Hemiplegia.) 

A vt-ry imjMrtant point always to be rememlieretl in examining 
cwntruettinMi of the h»n<l and urm, or of the lower limlHi, is the fact 
that ihoy often are due to hyeteria, in whieh <!ase the history is that 
th«y set in suddenly, and they are generally aeeoniftanied by otJier 
hystcriral manifestations, which can be discovered if sought for. 
jVb a rule, the niiiscleit <lo not waate or develop degenerative reac- 
tions, biit rarely such wasting may occur. ^Figs, '11 and 28.) Care 

no_ n. 

Kio. at 


IIjtwclGklktJDpbi'odlietmiit with Oeslnn oi Miik ti»n<l iiii)iiolii«rtl«w. 

Iho lut two phriMHi* Inio Ue pain, larllcu- 
Imrif iholut plUkluifOoT lholDd«zui<l mlddlii 
nngvm. <G'IUA pr u Tdl'kettk.I 

must be taken a pnngiiosis for cases of hysterical contruo 
ture, since organic lesion.4 sometimes supervene. Charcot states | 
that if the contractures persUt when the patient is under anaesthesiu, 
and the muscles are atrophied, organic disease esUts, It is impor- 
tant to rememlter this, for the^ contractions may be practically 
permanent when onoe induced, and as injuries may produce a true 
orgauic or a false hysterical contracture, much medieo-Iegal inttint^t 
centres about llii.t dilTt-rcntiHl diagiiosis. ('losely allied to thfiea; 
cn.te.- »re tho-r of hy.->tcri«»l coniractun^ in which after grasping 
an olijtH't the [Kiticnt cnnnot lot go until the mum-ten are .xtroked. 
Putting an li^nuireh haudagv un »i)uh a forearm will usually pro- 
dm^' the Hpii-m. 

When in the course of aii acute illnc^rH in a child the tingers are- 




«niwn cTown iiiio the |iiiltn uf tin- Imnd, wltli iln' tij)^ ti)iii-iiiii|^ \)w 
]ta\m anil tlio tliitmb tiirtK-il in Ix-iK.otl) liinii wiili its li]i prt-'wiiig 
(he palm, the pnticnr mny Imvu inuninKrnl cnn^lion ur inflaniRiii- 
tlon, or hydroi-ephnlii'*, iitkI ii i^-iutiiI rcinviilxiDii iniiy be iitiiiiiiiont. 

When iIm? liti^ifi* an- txjtit tnwunl lln- imlm, but tin- lips v.x Cviidtil 
ftwl the ttiuiuh turned in (" tlio iici-uui'Ik-uv's ImTuI"), l\w puKitiurt 
is ty|>icnl 11/ tflony, Imt in lliH (vnxlitioii tlic i\-st of the ln>rly will 
oviilcriiT of iiivolvt'ini'nl. Thf ruTvoiw irrilahility in this 
ition is ^ntilly iiit'iviD^cil, nnd {iruKsiirc- un n hrgc blucNlvcHscI 
tin rvv- trunk will oftt-ii pnHiiire tin- spiMm. Cnrioiuly vnuuf;h, 
gmtrie itiliilatiun <ir tliyruitl wuHting wilt often 1r- funnd » ith lL*tuny. 
In (tthiT Knws it uppt'urs to be due to profonnd debility, iia nfter 
pn>lon^i>d niiretng. [Sen THuny in eliupter on ConvnlMOns itnd 
(jvneral S[Miifiii!i.) Caro miiiit l>e tnken to sepmikte the siwalltid 
mr|K>|H.-(Iiil itpiism of rickety, hydrueephalnid diildreu from tnio 
U>tnayi in wlueh the body is nsunlly involved, and from spiistJc 
]Hinily«iM dne to infiintile een-brul piilsy. 

Sjuwtiv rigidity of tlie arinii is often one of the earliest ntjios of 

chnmic hydnwcphaltts, even before the skull bej;ins to enUrge, and 

viilsiouK may be pret^nt from time to time. In congenital 

'^^Mstie rigidity due to w^li'rosii* nr defcetive <levolopment of the 

oortex cerebri the Ajiantte condition i^ usnully ooiilinecl to the legs. 

(See ohapter on l-wgs and Feet.) 

!:^|ia^ni of the fingers of a rigid ty]>e on attempting to make cer- 
tain movement.-* i» nl.-<o xeen na the reetull of exoeewive use nf the 
jiort involved, and oeeur« in jieam.*tre3i»cw, eigarette-roUere, eigar- 
ixillen), tyjwwrilers (nm>ly), telegraphers, mllkeni (rarely), persons 
who tific 11 pen to uxeiwi, and in piano, Ante, elarionet, ami violin 
playrrs. or In )>ersoiis eiigngetl in any OLvnjHition requiring oonatant 
nnt] comparatively minnu* nnd wi-ll co-ordinatefl effort. It seems 
III be more i<oDini»n in men than vrnnien bv a large pro|>orti»u (3!) 
to 4). 

S(iiiie|[mi>n iKiralvHU^ tremor, or vnHomotor disturbnnees take the 
pliiiv of •M-(rn)i(itii>n-f<paMn. 

The MiKUtiii ri^iilting from oc^:ii]iiilion inu«l l>e ttcpai-ated fn>ra tliat 
waictinnTf well in the hand in ]w«t-hemipK'gic eborea, progressive 
iiiu*<enhir ntrophy, the vnrioii)< fontw of toxie peripheral neuritis, 
mmI tlint duv tu irrilntivv curebral foei, ench m tnmon of the braiD. 
TIm' hixtor}' ttmrly itlwayv clinn* up the ilijignosi". .S[)aKm of the 
niOMJea uf ihv liaixl nnd ann, rhythmiud or uthvm'im.-, inay also 



be (Iiie to Iiysteriii, ntwl may ro<«mbl«, when i\av to this caiire, tnte 
U^tniiy (not U-Iiitiiiis). 

Oliurcic nioVenicQtK arv hcl-ti uhicfty in ohiUIivii n» u inanif(«tntioti 
of chorfa miimr. They iirt- iixiially ficuii in rhi-iimutii- m»l nciintlic 
diildrcii, ami hi!art-uitirmiii'Mari>i;L-ui>nilty UiV-limixl in thu4K> vumi'. 
Tlii.^ dnst »vidL-iii»3 of spasm tiiay be dt'vclopcfj in llio humi, an<1 be 
limited to that nii-mber in rare viwt'B, and the hand often dnLi|H( tiling 
thitt an- plnLMxl in it. Th<.> hand ibwlf is rarely involved alone, snd 
th» miiscloB of the arm tofls tlic entire arm und bnnd from »|K>t to spot 
with a fidgety, jerking movement whieh is verj- eharacteristic. A 
furm uf eliorcA minor, usu:illy limited to the arm, is called {uiral.vtic 
chorea. It eomee on suddenly, and is eliaroeteriiHKl by loss of power 
with a few feeble twitelies. It affects only children. 

Sometimes choreic movements come on in the latter lialf of life, 
often preceded by enmtiunal disturbances. These movements are 
not true chorea. They are often cidled senile chorea. 

In some c.-isi's of adult chorea the [uitient tends to become maniacal, 
particularly toward night. .Snch cases usually ocour in women, and 
the prognosis as to life is bud. There is often iu these onsen great 
mental heaviness. 

Sc-venil other alTeetion.s wliieh Aiiniowliat re»cmhlc true chore* arc 
sometimes met with, but all ■>f them luck, with one ex«-vi>tioii, tlw 
pcunliarityof !(.'• mnvumonttt. One of these is what hu" bwn cillcd 
habit-chorpji, or, more correctly, haliit-t^iMLiim, in whidi condition 
the patient af<|iiirft* a nervouji trick of jerking a muscle or a set of 
muttcles. tlnliki^ true ehon-a, it is more frei|tii;ntly *-i'n in adults 
than children. lU limitation, i» n rule, to a single not of muscles 
and tile histtory of the ciwe uwially Ne|>anite it fnini chorea minor, 
and till- nitiwiilar nmvenieiit;) consii^t in siiddrn twitohinga rather 
than jerking, irn^giilar iniiseular movement)^. 

In |>am myoclonus multtplc:( (lie dist^isi', as the name implies, 
usually involves symmelricji! ptirt**, the (Tuntractions of tiic muscles 
u])|)enr in pnroxy.tms, and llic miiiek'* involved iirc usually the 
l)ice|>H, delliMil, and irieep? in the arm», and the (lUiulriceps femorie 
•lul »ilf niuM-lcs of the lower limbs. Myoclonus mulliplex ts ■ 
discOM- of adult life, and chorea is usually si-en iu ehildlioiHl. Some- 
times the museUs* in niyoeloniis are exceedingly irritJible. 

Under tlic nnme uf electric chorea, or " Dubini's disease,' ' Dnbini 
dew'-ribwl a diwasc, affecting both sexes and all ages, in which sudden 
idiui^k-likc cuntnuttonf of tlie muscles take place, as if they were 




Ii.'iiijj KtiiniiliiUtI by a i=luwing inU.Tru|>te(! farfidic rurrpnt. The 
<lti>ic^i»«' iLvimlly l)L>giii» in the upper cxtremitii?)^ und graUtixillv in- 
volvt-it the rmt of lh« ImmIv, and progressively puiieeB to a fatal issue. 
Tlii<t rt> a very rare iliwuHc, amt the sudden contraction of the muscles 
Jii tonic ^pasni sejiiiniteH It from chorea. 

Still another form of electric chorea is that of Itergeron, which is 
prolubly identical with vrliut has ttcen <!aned hysterical chorea. 
Hvre, u^uin, the shock-like muscular contractions are manifested 
chiefly alM>iit the Hhouldcrs. The patient is usually a female, and 
has the stigmata, sensory and otherwise, of hysteria. (See chapters 
on Skin, Kye, and Feet and Leg^.j 

Again, the physician may meet, exceedingly rarely (almast never, 
ta the United States or Kujiland), with a condition tnlletl convulsive 
tic or {talmtis, which lias al-^o been calleil " the jum]H'r«," in whieh 
the movements an> not in the sli^ht«!St like tnu' i-horcji, lint are 
sudden muscular movements, nmially imilalivc of the act of some 
other jtennm or animal. TIuh !• oft*-ii a^t'ticiatiHl with twliolalia— 
tltat is, reiieativi or <i'hiHii I'pwu'h — or cuprotalin or filihy sgieeeh. 

Finally, anothir very ran.' diwa^c \s tluit known uif Huntin)rton'» 
or hen-ditiiry chon-ii, n iinulition in wliicli tlia.- twitching n>ually 
i>c^in» in the knHy and extends to the arms and Ic^. Thi» ailment 
is Itenxlilar^', rarvly begins lioforo thirty yam of »ii*:, is iicvumpunied 
by |mi^n^vc mental deteriorations, a teudeniy to melancholia, and 
may laifl ten or twenty years. 

Mercurial puisunit^; producing tremor may cnuse so eoanw a 
movement in advanced cases that the case may bo ihout;lit choreic 
(For a <lc«cri])tion of tremors, see latter part of this chapter.) 

n " Thomscu's disease " the hand is placwl in touic spasm as 
us voluntary movement is attempted. Closely resembling 

lOm^cn's disease, or myotonia congenita, is what is culled para- 
myotonia, which exists in three forms: first, a [tutient suffering 
from pamlysis n^tibms ou attemptin}|r to move is seized with rigidity 
of tlie muscles, which holds htm lixed; second, a patient is suffering 
from ataxia ami muscular weakness, and is seixc<) with an attack of 
tniMnilar rigidity; and, third, a patient may have the muscular 
8X8tion cKMMirring jost as it does in Thomsen's disease, save tliiit it 
la produced by cold or exposure, and not hy intention-movement, 
ami may last for hnan. This is called paramyotonia congenita. 
(See also Athetosis.) 

Tlte position of the hand may be very various. Thus the hand 



may drop edgewise from the radius towani the ulna from panilysis 
of llif extensors on the radial side of tlie forearm resulting from 
ueuritis or acute infantile poliomyelitis, while marked drop-wriat 
may occur from {mralysis uf the extensors in chronic lead-poisoning, 
or in any form of neuritis, toxic or otherwise, involving the ner\'e- 
supply of these muscles (musculo-spiral nerA-e), (Fig. 29.) Wrist- 
drop may also be developed by pressure upon the musculo-spiral 

Fio. !9. 

Boy with muliiple iifiiriilH. niih iliiulile «rM-.iriiii.iiiii ^llshi ffMjNlrop, (Sachs.) 

nerve, as in crutfli-]>iilsy. If ilir \vrisl-<lri>p is bilatenil, it may be 
diu! to toxic utniritiw; but if miiIat*, it is |)robai>ly but not posi- 
tively due to pressiirc-punilvsis from sleopiufr with tlic head resting 
on that arm, iir from pressure by a i-rutrh, or siune similar pri'ssure 
i-apable of injuring the nerve. Vi^ry iiinly wrist-drop 
is seen in lcad-|Miisiuiing, When lead is the e:iiisi' tlie su])inator 
lungns usually (.■.■T<'apes, as does alsntlie slmrl extensor i)f the thumb, 
sii that the foiiann ciin lie flise<l and llie thiimh exteiuli'd. Pain 





I* mwly |irv>wnt in |irfwitin> or luml wn»t-<Irop, l»ul in prcwiit in 
U'riet-Oi\>[> duo tu uk-uliolio iuk] uiImt furmii uf toxic ticuritis. 
,Oft«ti, too. ill tlicei- 1»'^'« tin; Hcxors nru coiisidvraltly in\'oIv«tl (km 
{Kirt of this chiiptt^r on Itnichiiil Moi)upl(<}pa). 

Tremors of tbe Hiuid and Arm. The iiinvements of the hand 
should iilwuye be curcfully wak'heil in cases of auapcoted nvrvuuB 
di4>U!ic. Thu inofit cuiiimon nllcration will be fnitnd to be tremor, 
•which may indicalo jHinilyeiM agitans, general paresis, clironic mer- 
«iirinl, lilumbic, or uloohotic poii^oning, hysteria, senility, Graves's 
disease, and dissciniiiaietl sclerosis. Sometimes a tremor may he 
found in luittirally nervous women who are drinkers of tea to excess. 

In jKimlysis sgitsns the whole hand is involved, and generally 
both bands are equally affected. The tremor is rh%*tlimii-al and 
Bne or niinnte in chanicter at lirsl, but later may bo (jiiite coarse. 
It is a slow tremor of about five vibration;* per rtecond, wbich is 
move or less oonstant, and worse when attention is called to it, but 
it IB nut greatly increawMl, and, jierhaps, Is even decreased, by a 
vohiutarj' act, such as an attempt to raise a glass of vrater, Verj* 
rarely, however, the reverne holds true, and the tremor is incrcaseil 
by voluntary effort. The fingers ar« (generally fteuii-estcnded and 
the tJntmh h addueted, i^> that it cousumlly ruin the index finger 
wild its |MiIp, MA if it were ntteuiptiii)^ to nih off the xkin of tJiat 
mcniWr. Froptcntly then* nro pain mid nching of the irxtensor 
miiiH-lcii of th<; fori,iirnt and wrist from the constant exertion. (See 
<-ha|>ter on Fwl and I-c^, piirt tm (init.) 

TIk' tri'inont of diw«eminHt<Hl »ck>n»is an- »Uu i>low, but connw in 
chunuiter. They are not (Minxlant, hnt lire develo[K'd upon iut«ii- 
tioiHil movement, and have n gn^uk-r amjililiide than Uiohc of Park- 
innon'M dtM>*Mi {{mmlyi^i^ agitnns). Often threading a net^dle will 
be |Mi4«it)If for a jwrton with thi<* tlimniM*, bc<.niu!«c it is a Khort act, 
white lifting n gliuw of water will he impufwiblc. The other symp- 
tumaof iliMeniinateif m-Ierusis hwi<lc intcntion-trcinor are fttnoeato 
or smnniiig Hjicvoh, exiiggi^riitt^Hl kiK-c-jerlcs imklc-elonue, jnw-jeric, 
Slid wrtp>l-]i'rk, ilisonlcnil xpccch, iiysbigmi)»^, mii>«euhir wcnkneiM, 
with rigidity and (Mralysis of grou]nt of iniiwlcp, cauaiiig mono- 
plitiia. |m^lpll^il^ or pnmlynift uf the cninlal innvIcT'. 

Thv tn-iiKir of mercurial, pltimhic, niid uk-uholic poisoning rv- 
*tmh\c* lluit of iianilysis iigiliiuis Hive that it it< more rapid, roaehing 
nine or ten vibration^ [)cr soeond, and in the eiiKi^ uf alcoholic tremor 

ilciTrutHxl by n large drink of liquor, while thuHi due to lend and 



mt'iN'iirv may be rapidly rolieved liy potasainni ioclldp. Further 
tlmii ttiin, the ti-emnrnf alwjbolinui if* (^enerallr worse in tlie nioniinj;. 

A point nf litMne im|inr(anc« in jiliinibic npiiritiH jmxliiciiig tremor 
nnd w riHt~(]r(i|i itt thi; fact that [ininfiil ^itriMitinnn are rarely present; 
ill ar^tiiml iieurilJ.«, on itiv other Imiiil, ihf^y are often the most 
pn^iiiinvnt symptom, even |>rcee<ntig the niotar (lie^tiirbaaoe. In 
mt-rciiriul neuritis, on )lie other hand, trfiiior preeedes all evideti** 
of ii>Hs of [Hiwiir, and, linnlly, may lici-ome ito coarse a.t to resemble 
chorwi. The tremor of peiienil [Xirr-sH is aUo rapid, eight or nine ! 
jwr »o<v>nd, and ic it very fine tremor, vrhieii may !«• folt only when 
tlie arm is extvmUil and tlie finp^r rf!<tcil on thi? hand of tli« jihyai- 
ctan. In otiior word*, the tremor of the hand in gcnoral imrwis i.4 
gcimmlly not a preilominant syniptuni, but \i idieitod when tlK 
miiicU* arc put upon n struiii. In repird to the fltiftneiw of iJie 
tremor of ^eiR-ral pare«i», it should be remembered that it ehweiy 
n'si-mblci^ that of BriK^luw'ii or UrHVV^s diaoiwe (vxophtJiiilmic 
goitre) (eijrht or nine per second), sitiee the tn-mor of this (tuiilitton 
U not only eijually line, but (jenertilty im«et'ti except when the srtu 
is i:xtonde<l and tips uf the lin^erK rtstfsl upon ttie Jinjifcrs uf the 
doctor. This tremor has been ejillinl the " railroad brld;^ tremor." 
berauiae of its fineness and vibratory eharaRter. The individual 
liiiger» do not separately tremble in Graves's disease. 

In post-hcmipleijic tremor the trouble is unilalenil, there is a 
liistoi^- of cerebral injury, and paralysis is present, 

TpBTOor of a very marked character may be due to hysteria, and 
ariaes roost freciuently in those who have been expose<l to tthocks or 
ao^dents. The tremors may occur constantly or only with inten- 
tion-movements, or be increased in amplitude Inn not in rhythm on 
■novemcnt. The latter form is known as the "tyjie Rendu," and 
has a rhythm of spven to nine per swiond, while tin- slower hysteri- 
cal tremor may be four or five per second. 

Beyond tlw 9iaU> of tremor should be recalled the movenieiits of 
ohorcji, which may be limiUtl to one arm or hand, and which in 
their miMcr form-> may be coiifuvd with the pronoiitiii'd inovemeubt 
pn}diiee<l by effort in iliMcminnted wilcrosis. Tliv latter «re often 
very arhythniicnl. and so the cboiTie inovcmciu the inon: closely 
resembles them; but lliosc of sclcnwis an; puriiosivc, while tlinse 
of ohoren are not, ninoe the movement contemplated in chorea is 
opp'isiii by a iHiiiimilictury eontniction. 

Movuments of tho Hnnd and Arm. Aside from the movemcots 



of tremor, cnreful tioU's Eliuul<t be maile of the movemeDtti of the 
luiml us a whole, and of the <;o-ordi nation of its fiugers and of t)ie 
arm governing it. Thiie, tremlilin^ conlractjons of tlie eitenmr 
IcDcIons (•uibsiiltuti tendiuum) arc a sign of grave and advanocd fonns 

kof l\*[)lti>id fever, and picking at tlie bedolothea (carpUologia) is <A 
6till graver import (»ee lieginning of thi.t chapter). Inahilttv to 
write, to play musical ini^truait-ntci re<juiring the as^e of tlie lingers, 
or to »ew, may indicate tlie rare form of lotionjotor ataxia involving 
the np|>i>r extremities, so tJiat if the [tatient in a^ked to dotw- hi^ 
eyes aitd fm^l hiin.ielf the fork or i>|>oon mi.s'^a \\\» mouth tliroiigh 
lock of eo-trnli nation, although lo«i of power may not l>e pre^nit. 

Sometimes in toeomolor ataxia a."* t)ie diHi-a.-?e beeonie^ advaniy^l 
|iaroxy.'«ui»l Iwitohiug of the lingers may eotue on, or involuntiLiy 
movomenti* of the fingvnt oeeur in a.'Moeiation with voluntary movc- 

fmctitM cliwwherc. 
In locomotor and Friwlreich's ninxin alw) the nic>venietit.-< of the 
band mn- often lueking in co-fvrdi nation. Thi' hcmd may U- ad- 
vanced jKMt Uie object which llie ]>nticnt di-^ire^ Ut gnwp, or else 
falk xhort uf it. On endeavoring to pii^k up an ubj<'et llie Ungi-rs 
are s|)n?ad over it like a wideitprt-ud oluw. (iencrully iIii^m^ ataxic 
eymptum^ will bi> moiv marked in the other parte of tlie body and 
be bilateral, but Onneixxl lias reported nn instance in which only 
one hand (the left) was involved. This faulty movement of the 
han<l may, however, be due to the fact tbnt the ocular muscles are 
affected, ami the " erroneuus projection" due to this t^use leads 
the imtient to pass the hand beyon<l the object rGiLche<l for. 

When fibrillan." Iwiicbingt of the muscles arc present and topping 
^^ the miischw prodnees idiojKithic muscular contraction progreasive 
^H muscular atrophy may be present. 

^H S-imeUniPs, as tlie resnlt of infantile cerebral (raralysis or from 
I^Vlesions developing in later life, the muscles of the hand are affected 
by a slow, etmstant movement, so that the fingers assume ourioaa 
eniiHtraiiHHl and umisual postures, being moved into extreme or 
foreed extension, Hexion or pix)natiou, or supination. (Fig. 'tO.) 
Thin <K)nditinn !.« called athetosis, and is se|ittrable from chorea in 
tJint the movvmenti* arc slower and limited lo the lingers and wrinLs, 
tlie ami citcnping. 

In thi« eonordion mention shotitd be made of " mirror* writing," 
a cttriou* oondiliou in wliioh ihi' piilicnt writes from right to left 
ln»t««(l of left to lighu It occurs in wme eases of mental fenble- 



iiesa, liereditary or actjiiired, and rarely in hysteria. " Mirror- 
writing " may also Ix; present in cases of cerebral paralysis. The 

Fia. 30. 

Exauiplesuf Die jHsltloiKii itw t'Lii::frs in Ihu iiic>vuiiii.'iit- iii hiIieI'ms. iSiiiCMrei.L.) 

above example of tliis, tiiki'ii frmii tlio ciisc rcpDrli'il by Clapliaiu, 
illustrates tlie cliarat-ter of t!ie liiimlwritinii:. The [liitivnt, :i girl of 



twenty-four years, oould wriu- all three ways', but mirntr'Writing 
was easiest to Iter, {Fig- -tl.) 

Veiy rarely atlietoid tiiovcnicnts of Uie liiigvn« occur in AdvHnctKl 
(ipinal labnt, ]m»liably n» tlie rcstilt of a ivlnti'd Wion, and not fM:>iii 
tiilH« ititelf. 

KM. n. 

ParBlfBlB of On« Arm, or Brachial Monopls^a. AliMiliitc l<»w 
iif jiiiwiT in imii Imiid aud iinii vritlxnil ilif mt-ciwiiry di>v(^lu|)iiH-nt of 
su1>M?(|tM-iii dffonnity nwulti> frofli octvliral or |icri|)lK'ral kiiioiM, i» n 
rtde, tx-iiig nu-i>ly xpinal in nrigin, nml jhiiiIIi'iI iinu'lual iiionojili^a. 
"I'Ijp <nu.-«H iif tliin Iiw» of i>»wcr wht-n itj" origin is f^-n-hnil iiiuy 1« 
vnriouH. Tbui^ th« lMi»n inny tx' curtit^al nr Hubcnrlioal; lliat i^ iu 
the Niirfaiw iif thi< l)niiii<ir in lliif internal cii|Hnlc, orlx-twi.'oi) tln'oir- 
Vfk luid Uk- tutjMuli: ill the (tirunx nidiiitn. Am » niK', however, niiniu- 



plegiA i» cortical io origin, for hdow th<^ uort«x tlie motor fibres run 
so cWely togrthvr that only n vci-y miuiII U-!<tiiii i-nii involve one witli- 
oiit irivulviii)^ (ill, mi<) »o pnxtiKring a )i<-tiiipti.'f;ia. Tlxvu^ mrtital 
It'.'iiiiiiH whi«i llicy lid oi-cur ari' pMicmlly, but not alwiiy;*, assorialetl 
with »miiv(ilsiv<-«i-ixiiri' ill tile |iiiruiyw<i limb, iiixt Si^uiii huni-iillcd 
this omviilsion tbf " eigniil-Hyiii|>toiii " iiiitimting ti roriinil IcHtoii. 
Brnctiiiil m>iiioplit<;iii not iIul- to liyt^ti-riH or iii-iiriti", iirLvwI^tl aitil 
acooniptinivil by ii convulsion utiJ Ioi<» of cun»i-ioiii>iiu»'. lUiil lurking 
in signs of iDvuIvvnient of lowiT nervous centres, is, tin-n-fore, tv)T- 
liuil, and is pfntriilly flat- to tin- formiition of ii clol in lln' luind 
and iirni cvntri- ivsuttin); from injury or from tlic- ordiniiry viwi-iilur 
caii^'s of upopli;xy. In utiior cases it is duv to c^^^rcbrul cmUilism 
or tbrouibosis, or to the growth of some neuplnsm, spittilic or olh<;iv 
wise, or to » louilirxd meningitis. 

Tlic proluibiHty of tlio lesion being un embolism or thrombosis i« 
deereased by the reeollection of the fact that tho cortex is so vrell 
supplied by vessels from the pia matcp that paralysis of a eontrc 
from lack of blfMxl-stipply from such a cause is rare, unli-as the 
lesion is subcortiuil, or, in other words, not deep enough to involve 
fibre-- fn>m other centres as they appmacli each otiier, and yet suffi- 
ciently deep to prevent the tii^ines fnim [tartitkin^ of the nutrient 
blood-supply from the pia muti^r an jiLst mentioned. Aside from 
the discovery nf a •■mditlon of the inlerniil oipm.-*, Htirli as cnrdiac 
valvular di.wa>(- "i- icpsiif, wliifti might eansi; eniholUni, the diag- 
noeiis lietweon paraly^Ls fwin licniorrhape and embolism in prao- 
tioilly im|>os^ihle, and this in al»o true of tlie para1y«i» due to 
thrombosi.4, except that in rnsct of thrombo!'!.'' wc often lind the 
presence of ^nend endnrtcrili*, and Uic jiarnlysiH of thromlKwis 
may lie stow and f^naliial in it« onset. If the pamlysic rapidly 
iiprea(U, the lesion is proljably due to a hcmorrhngc. 

The history of there having been some sudden ciiii-te for oil in- 
crea^i in arterial u-n]<ion, as by niusi-nlar effort, and the prcBcnw of 
atheromatous vessels niil us in deciding iis to the probability of Ihe 
letiiun la'ing due to u hemorrhage, and the sudden onset, COlipltxl 
with the symptom? namcti, makes the diagnosis clear in a certain 
pro|»>rtion of iiiMtt, 

Neoplasms or tumors of the bruin proilnciug mono]ilegii( are 
gradual in their development, acconi[Kinie<l generally by heudavhe, 
by cluingCK in the optic disks, and sometimes by mental disturbnnocs 
or pressurt^vsymptoma, A s|H.>eitic history [Minting to the formation 


THU HJ-Vi>S ASD Anif& 


ol H Dyptiilitjv tumor h of value in tlie cliagnoais. (See chaiiter on 
Ht^dachc. ) 

If brac-hinl moDoplE^a retmlts from a lesion in the internal mp- 
8ulf. tile legion tnuiiit be v*rrv ltiuiti>d, or, in oilier woit!.-*, tmly liirg<e 
fiituufih to cut off tlie hand and arnt tibreit. 'rutiioi'.4 and l«.siou0 
from trail mil tiaia-i in tliis area are veiy rare, and lietuoi-rljngcs*, wliitih 
frci)Uentlv caiiHo |»araI_vsi.-« hy nffeniing ilii^ area, an* gciiiTally ]iro- 
fiise (rnodgli to (?aiu-ii- henii])logta — tluii is, injury of tin." mof )r lilinw 
mtpplyin^ tlte le^ tntisolefl act well. Sometimes, howex'er, xiiddca 
indamnintory iirocoasi^ are set tip in the ti.-vin^ surroiiiidin}; ti tumor 
which may iiredpitate sudden paraiyrti^ 

i Although the onset of a monoplegia due to eortituil, MilxTortioil, 
or cajisiilar eaiises is iiid<!en, the rc-ac-tioiis of degenemtimi do not 
oome <»ii for a loii^ j>eriod of tinn- in surli i-jisits, lii^'imsi' tlit- inuselcd 
ill the |iaralyx«d area are Htill ooiiiui'U'd with the trophic centroi' in 
the (xird, and thin atfonls uii a x'aluablt; point in dirferentiiil diii|7noi*iii, 
Somi-times a stul<lenly tlevclo|<ed monoplegia iifleetiu^ tlte arm 

^coni» on as a manifestation <>( hy.«ti.^ria, niid follow-s Lli*- ty]M- of 
true cerebral heniorrlia^ 8o clo^^ty w almost to defy diagoosiit. 
Thi.s oondition may be al^eolll[Klnied liy hystericjil ledenin, the hand 
lHt'oinin){ jiiilTy and nwolleu. The pre»eniu- of ii nvtirotic tem{H'ra- 
ment mid other hyetvnml eiguH, ouuplod with tlte prompt develop- 
ItMtiit of oontracturu, and tlte fuel that the miim^le^ do not nipidly 
wwtt% point to the onoMof the lo«4<)f powor in nonie otui^<, and thin 
ia fmpliaetjced if the presence of liysti'rieal utiii^the^in of the itkin 
can be dl»covere"l. Knrthcr, if iIm- hiiiid w afToeti'd, Pittnek tie»crtti 
tliut in making hu attempt to ^^r^i^p an object the lltnmb and forc- 
fin)i;pr are chii'fly u«od; but if the object i» placed sudiWnly in lite 
ulnar part of ttw luind, the remiiiniii>; lingers can gniHp it easily. 
(8oe ejiaptcr on the Skin fur addilioniil hysterical i«ympt^»n'^. ) 

In all ca«e« of binchiid nionopk-f^ia dtie to periphvml IcHioiiq wc 
fin<t tJiat atrophy of the mti»cles comes on very rujiidly from cutting 
off of thv nm»eli» from their lro])hic oi*ntrw in the spinal cord. 

Bmehial mouoplt-giu i^ very ofti'it the nvult of injury to tJie 
bncbiail plcxuH or to Mome of it« imjiorinnt brniichat. The synip- 
tonif eonsist in hmvimiM or nunibneiM of the nnn with uortr <ir iena 
loas of power. Tht- motions of the unit which nrv [lanietilarly 
affected are usually abdnetioii and elevntiim, which movements 
depend upon llie eirrmnllex nerve. If ihe power of extending the 
arm is lust, the Iom depends upm [Minlyfis of tht* mtiwtilo-tripinti, 



which 8tipi))ie» tlic triin-iw : whfrais if titv power to *!tfx tUv fon*- 
aroi i« lost, ttitire !» juinilvHin uf tim ii)tiiK:ii1o^uluiicotl<>, whicti i» 
the 8ii))|)l3' of Ihf bnicliinli» nntieiif unci hicvps. If thv mipinator 
]on(fii!< U involvH, tiie tuuHciilo-«p'trHl i« niso nffLTk'il. 

Wticii bnu^hiul moiiopl€gi;k (IcpcDtlH for it» exi^tviK-u ii]k>u priiuitrv' 
lii-ai:liiiil neuritis th(!rp is pain in the wri^l and hand ut first, or oil 
the suupnln unil in tlir axilla, thenci' raiUutin^ down tin- urm. This 
pain in t^>netuDt und dull, and uoif ami then 4.>xcnicintiii|^, and m 
matte worse by movement, even whon the loss of power in t<oni|«im- 
tively eli^lit. Simetimes, on the other hoild, when the nenriti:< is 
flcptio in orij^in, it may start in the ulnar nerve and ^mdnallr 
extend u|i to the plexus. In still other cases brachial mono- 
plegia may depend upon fracture or dii^locsition of the head of t)ic 
humerus, and in ^uch a ease the paralytic Kvmptoniii are apt to be 
ver^' well ilevelnjied. The mtiacnlo-spiral nerve is often paralyzed 
by fracture of the humerus, and this resiUt;' in paralysU of the 
rauHcles of the Iwick of the arm and forearm and Itaek of the hand, 
and of the skin oovering these parts. Sometimes in locomotor ataxia 
the peripheral nerves seem ijuite a^ much involved as the spinal 
cord, and symptoms precisely like the paralysis of a toxic neuritis 
dcv(tlo]i. Thu.s, Striimpoll ha;* rv|ii>rti'<l oases of miisculo-sinriil 
])iiraly,<ijt from this muse, and Kc^mak and Hirl record cases in 
wliicli th<- nii^iim uorvi' tuut het'n ufTect^ii, no thnt not only loxs of 
power but watting "f tim niu«clw luw rwdiltitl. Thi? is portitailarly 
the aue if the nuiitcle^ are much used in the daily pun«uit«. The 
tilniir ncrvo may nlwj V' affi-ctcd. Such casw ar*' separated from 
pseudo-tabes by the pupillary rcHexos and other patho|;uomonic 
ataxic symptoms. (See chapter on the Feet and Legs and thnt 
on the I'Ve.) Wideiipread muscular atrophy of the arm somi.^ 
tinic; takes place in locomotor ataxia as a result of a coincident 
neuritis. There are still two comparatively rare forms of brachial 
monoplegia of the plexus iy|>e, namely, that due to pressure of 
growths in the neek, or axilla, and brachial (uirulysis of the upper 
arm type, sometimes called Erb's ^mralysis. This latter form occurs 
frjm paralysis of the fifth and sixth cervical nerves or their roots. 
In adults this eommonly results from blows or heavy weights 
strikin)^' on the shoulder, and in infants from pulling on the neck 
in difficult labor. As already said, it is an upjier arm palsy, and Ls 
due to the lo^s of nerve-supply to the deltoid, biceps, hmchialis 
anlicuA, and supinator longus and hr«vis, and the supra- and infra- 



tipiiiutufi miisclcw. Thi' ii'lult fonn U ofl<.-ii iis^icJiitfil witti aniVNdK'- 
oiii and U punkU'iit. In infinite it b often IviiipDniry niiil mtDM>r}' 
sv-niptoms arc coniinunly absout. 

Wh^n Uie lower arm it- paralyzed an the rvKult of trouble in (he 
bnteliinl pk'Xtis tlie legion k in the iierve)^ ariein^ from lliv i^evonth 
and eighth cervical and lirrtt dnn^al rootii, and the muscle? ufFectei) 
■re the triceps, the llesi>rs of the wrist and fingers, the pnmtitont of 
the hund, the extensors of the fingerH, and the muscles of the hiind. 
The ana can still he raised by the deltoid and the foreann Hexed 
on tlie arm. 

When there is H-aetinit "illi panily»>i'< of the thenar, lij-pothenur, 
and interufiiiei musele.s, nut due to piii^ressive niUftcular atrophy, 
with an»it]iesia in Ihe arm and forearm In the part supplied by the 
ulnar Derve, and in addition myosis on the side of the Ici^ioii, witli 
sluggish pupil, retraction of the eyeball, and partial closure of the 
lids, there is probably a lesion of the Qr»t dorsal root of the hmehijit 
plexus and the (■oronionicating branch of the second dorsal. The 
cause may he neuritis or pressure by a tumor. This form Ls some- 
tiiaea called *' Klumpke's pm-alytiis," 

The presence of bihilerttl brachial nionojiIeKia should always 
make tJH- physician KuspiciouH of Icad-poixonin;; or cruteb-paralysii^. 

(Kor II description of the arcat; iuvolvcil in the spiuiil ooni, which 
uutsc loM of power in the arms and IcgH, hcc chapter on Feet and 
Loga, part on Paraple<;ia, and tables of localimtion in that ehnpler, 
also plates in chapter on Skin.) 

Apparent brachial monoplegia, in reality a syphilitic pseudo-palsy, 
baa tjecn ilcscril)etl particularly hy I'ari-oc A child apjiarcntly per- 
fectly well, and Init a few weeks old, suddenly loses the power of its 
am, ao that the member liangs like a Hail. Xo wasting takc^ 
plat^v, no degenerative reactions occur, there mny be some pain, and 
crepitation on moving the arm. The eause of these symptoms lie* 
in the fad that there has been a sepamtion of the epiphyses from the 
ahafts of the bones with eonsei|Uent helplessness. Sometimes gen- 
eral iiaralysifl of the extremities arises from the extension of the 
diacaae to other limbs. The prognosis as to life is bad. 

It yet remains for iis to discuss the paralysis of several important 
grau|)s of the mu.scles of the arm. If the forearm cannot he flexed, 
tliere is loss of power in the hi(«pi and brachinlis anticus, and to 
■ome extent in the supinator longoH; and a» the Hi'st in'o muscles 



nrv HiippliMi liy thv imiHt'iiIo-c-iitiuK'OUM nn<l tliv tliird In* t)w muiwulo' ' 
M|>inil, ftmU u fniliiiv in tU-xioii kIiuws jmriiKt^is of tlii'«v flbrcs. 

Parulysts of (he vxt*.Mi»or» of tlie fon'nrni, wrist, niiil Itaixl, uii<) 'iF 
fixIoiiHion of tlic flbow with wrist-dmp in (wtiBiKjucncL', ami flexion 
of tlio tips of the ftii}|Ct''>^f i^ iUk! to disease afFcetiog the inuHcnlo- 
6|iinil nervv, but thu Hugers can still be partly extended thruu);li 
the uetiun of the intcrossci and Inmbrii-nleif, providtil the ti|i8 are 
flexed. The linck of the hand and wri^t become unduly prominent 
after a short time beiTauso of the forced flexion of tlie hand and 
rapid waatiog of the extensor^-. In niutit cases the supinator lotigus, 
whieh siipinales the forearm aflur it is pronated, isparaly/ed. When 
tile ability to pronate tlie forearm is grentty impaired, uud the thnmh 
is exlcndctl and ab<lueted, so that it cannot l>e brouglit in contact 
with the tips of tlie fingers, the trouble is probably pamlysis of the 
median nerve, and this is contlnncd if all the phalanges are paral- 
yzed except the first. 

If the arm cannot be moved outward, away from ihe body, 
there is paralysis of the deiloid supplied by the circumflex uen-e. 
In this connection attention should be called to the loss of jmwer 
with wasting of the muscles seen after iliroet blows on the muscle 
or ufUT injiH'if-K to thi- joint, sometimes called "joint^palsies." 

Brachial Partesthesta. Distiirlmnnes of seiiHiition in the bnnd 
and arm vunsii^t in ann-HtheKia, aiial^'sia and ninnhnesn, tiii^linf;, 
and pain. The arwi of tlnse sensations deiHiiuln upon ilu- nerve- 
trunks involved, and to Mime ext«nl upon thedi^reeof involvement. 
Thus, if the function of the nerve is men-ly iiiipain'd, the xenMtion 
may be that of tingling or pain ; if »lill further imjuintd, the ocnsa- 
don imiy be that of ntimbncwt ; and if the sensory lilirei* W totally 
destroyed or piirnly/*il, absoUne aniesthesia and aualge^ia may be 
present. (See Anuvtliivtiu, ehnptcr on Skin.) 



I |[«nf nl appntrnnn nf (ho (**t nod legv when dollied —The guii — Siuutic pan- 
pIcipa—I'luvplvgiA without iimitif coDlruclion — Cniml monoplegin— n«rorniU 
li«a of tha r«v(— Tha JninU— All*rn(lnii» In tho ntitrltlun of (h« livl and lep 
uid« rrom a chaug« in ihc luuiictiia. 

As the pliy.iician see» a piiliuiit apprniinliiiig luiii^ lio cnii oiUfO 
^iii inforiniili'iii iti \n liii- ailmcnl fnini wlui-ii tliv iniiii ih HiifTmn); 
by noticing liU i^iiit aii<] tlie a))|ii.>iii-iiiifi> of tliu lags mid ft^i-t, for, 
while die gait varies gi*iitiy in mipinu! individiinU, in »omu diisfiuics 
it in -w typioal that lie wlio runs iimy road tlic diii};iio»i». A ^litiiro 
at tlie feet revwiling ouo fwrt iiiuri' l«yi;ly w>v(!ri'd Uiiiu the "ther, 

I ur a slit in the »lioc, or a vi>ry locuv lacing, will point to th« proa- 
eiine of .tome inllnninnitory or dnijwiwil iwolling, which forces tlie 
(lotient tn give It romn; luid if ttit- ]o|{h of a mim of ordinury build 
look kwoIImi iiikI Itil the trviwiwre ti^flitly, whik- a ^hiiice at his face 
rcvoib timt it i.'< iMifTy, nitliLT thsn one which is obese, dropsy, still 
more wid<«prvttd, is probably the eaiise. 

Gait. A>^di; froru locjil injuries causing a lame ^\t. which will 
be found dip«c'ii««i-<l in a boi>k on iturgicul diuguosis by the writer's 
friend, Dr. Munin, we fiud that gout, rheumatism, and Amti^n an- 
the common cjiuses of a limping g:iit, arising from tmnhle in one 
leg, iinil tJnit in uncii ea»c« there is n pained exprt-seion of the fii(* 
Ht cnch movement, whicli shows the i^ufFering that \^'alktng ean»«M, 
The gait of >4neh n jiaticnt is slow and cautious, and he i^ apt to rest 

. ever)' few Klop», beuring his weight at i^uch times chiefly on the welt 
1<%, or, by uK-ams of Ins hands, upon chairs or tables that may be 
iwnr. Aside from the ulterations of ^il produced by thene i^annA), 

I we wo very lypieal gaits produced Iiy locomotor ataxia, piwudo- 
lueonwitor iitnxia {peri|iheral uetiritiH) due to alcoholic or lead-jxii^ 
oning, syphilid, or |)eriphcral neuritis arising from othor <tiUHe«, 
Frieilrcich's atuxia, general paresis, chronic myelitia, Uteml solo- 
roMM, nenu- poliomyelitis, pseii do- muscular hyiiertrophy, eerebml 
in^iliie ixdsy, multiple eclerosis, jKiralyBis agitan^, eenilwllar di^ 
oute, orgsnic and hysterical hemiplegia, and oetconialactn, and the 
gail^ rnuHetl by rickets or otlier bony defeeta, 

in locomotor ataxia the gait ia unsteady and wavcrinply nncer- 
luiu, resembling that of u blindfolded person who !.« told that he in 



nppruiu'Jiiu^ sum<.' inctiimlity In t1ii.- floor. Tlie juttiviit rontinually 
Kevins to Ik- fpL-linj; for the Kmunil wiili bU feet, and «n*fully pM-kt* 
his wTiy uloiig ii perfectly Kiiiootli titirf&fx- in a lalwn^d fashion, uifiiig 
a cane to Itclp lilm both in tlit; wiiy uf siipfxirl nml of fcoUn^ i\m 
groiiiul. If lie luokis lip from the ground while walking, lie kwuvk 
sitddctily and muy full; iind if prevented from returning hU cyc« to 
the pavement, ulraoat surely fulU if no aid is ^ivcn him. (Fig. 32.) 

Fii„ s; 

tisll la • mM ol luoomuIoTtlkxIii. I'^iim luniiiriuiipotit x-rlnl iiliotognr-hi oT ft piilt«DtOf 
Dr. DoKtuo, DuulBiUnulUiicoiMlTnoui tiTodinCKDipoiiiUorvlowbr Mn^bridm. 

Thfi ^it of p8endo-t8be8 is .wmHiniet identical with that just 
described, in usually asiiociated with ii hiKtory of nhioholic- execs*, 
And is due to multiple neurili.-<. In n iiiajority uf the eases, how- 
ever, it is distinctive, and has bwn enllcd the "stepimfje" gait. 
The fwt i* thrown forwaril niid the (oc is nii*il to that the heel 
first strikes tlie ground in miicli tlic manner tuhiplcd wlicn one 
attempts U> step over some ohstavle. SonictinnH ihtu ciiic is found 
iu c»jies of ariteitiral neuritis and ihitt due l>i h-iid, hut in alcoholic 
tabes tliere arc j^nendly menial "ynipti'inn ass^K'inled with this gait, 
while in lead-|Kiisoniii}^ the pathot^nnmoniir signs of tliis cnnditioii, 
Hueh as the bine line on the gums nu<) wriHt-dnip, when t'umbined 
with tlic liistorj', clear up tlic diagnosis. It muj>t not be forgott«n, 
however, that tlie difTerentinl diognopiis of tabes from pseudo-ta)>e« 



ia i*(»mi*tinnit si'Tv ilifliciill, imd n» Dana hiw well swd: " When 
ZMj^rini- ilv^icrilMtl vi» loconiutur utDxin ii viisu which nuw ap{K<ars to 
iwvc becD on« of ulooholir pGri[>lipniI iiourotiibt-s, whva Btixzanl has 
diflguoaltcutv<I as ti'u« spinal tiibos it cnse of post-diphtheritic ataxia, 
whon Seligmuellcr mistiikvs a, cast- of \viill-piii>er-puisunin^ for one 
of tnu- epinal tabes, wc amy onsily bii]>[»)sl- t!uit (.-rront have been 
madu by many others." 

Tilt! important symptoms which ]ioiiit to true locomotor ataxia 
uru the swaying of the IknIv when the eyes are closest (Romberg' i< 
eymplom), the loss of knee-jerk (Westiihal's sign), the history of 
gastric, laryngeal, or vesical crises, tlie presence of numbnese in tlic 
feet, the &low onset of the disease, and the abiieuce of any history 
of exposure to the causes nf neuritis jnst named. If all thaw signs 
are present, and are combined with tliat most important symptom, 
tlio Argyll-ltnliert'wn pupil, the diagiinsis is practically certain. 

(.rrube has, however, reported recently three caiies of diabetes 
m«)liturt producing a psewlo-talies Aw- to neuritis who had tht* 
Argyll- Kobe rtson pupil, and in luldition atta^^ks of abdominal imin 
likv the <-ris«s of true ataxia. 

The following table from Peterson's article in Dercnm's ^errout 
Diataaa sliovrs very ehurly luid cumimrutively the symptoms of th<- 
Ant, second, ami thinl stage.'* uf tnie kH^nnotor ataxia : 





bMn^oMMiMn. but noahanvo 

Oitalpr lniN>«r<1tnkU0D, and 
maiKal aiailo itali. 

Cannot mlkbenuM of itaxU. 


Mora markvil aomthaiuii. 

ISUiHin uuKilinlt. 

SfaoMliit'Fklat lu Oit Le«k 

Ptiju wont. 


tXmtaUbcd n IcM kiin*]*rlu, 

Lni hnw-i«rkt. 

LMt kM»-]«rlci. 

MmMmIom puplUitiTranii Lmi init>lll«ry nllox to llgbt . Ixm nllaz to llflit. lajroaU, 
IoukM. mill injiHiK. ' * 

WwkiMM of MUiwl fUDCtlap. ImpMencc. 

lanlnii of aoouoimodklteu. 

tHDMoiii diplopia ; insdeDt , Ocolu ■■Mmnn^oriurkud OtibibaJinopUflB. 

aoHtoa MleWRUon. 


tMfikla obaaiw In Uia )»■>■■•> 

BaMatMfkytf im(Dcl 


tnerMMd vwImI vaaluMM. 

opile atfopb]! nnijr denlopa. 

Tnipbic clnuigw mil no c»at- 


larrnvi and Tl»«*al ortMi. 

Oltdlt muadol. 

OubaiBiiiaUoa naadad. 


MneaioarlHd If ilMy began Ui 


3fct K> ooDmon. 



In neuritis causing pseudo-tabes we have a hiBtorv of rapid onset 
of the symptoms, paralysis and wasting of the muscles, and an 
absence of vesical symptoms and the Ai^-11-Robertson pupils. 

From a prognostic and therapeutic standpoint it is interesting to 
note that about 80 per cent, of all cases of tabes dorsalis are syph- 
ilitic. (Duckworth.) 

Reflex action is decreased and the gait altered in locomotor ataxia, 
because, though the motor tracts are open, the sensory tracts in the 
nerves, the posterior nerve-roots, and the posterior columns of the 
cord are diseased. For those reasons the reflex arc is destroyed and 
the co-ordination of the muscles lost. The patient cannot tell how 
to use his muscles unless he can see them and co-ordinate tiiem by 
the aid of the eye. The sensations of formitation or numbness are 
also due t« these sensory lesions, (Fig. 33.) (For description of 
motor and sensory tracts of the spinal cord, see early part of chapter 
on Hemiplegia, and chapter on the Skin.) 

Fla. 33. 

SbowLng the areui of the con) involvv-l In likt^omoiur HtaxlB. Tfie ^hadln^ Include both 
the oolutnn of Goll, Ibe Inner, iiml ilial of lliir<laeli, itiL- aiiU'r, li Is to be rcmembeied tLat 
the leilona of locomolor ataxia arc rutmtl In tlw ]Kri|ihvrn1 ne^^'e^• as ucll. 

Sometimes not only the gtiit, but the entire s^et of the ordinary 
symptoms of locomotor ataxia iiif ape<l by hystiTia so closely that 
a diiignosis may be almurt iinpas,-iil)lt', htit the Arjryll-Roberlsou 
pupil, the lost knee-jerks, and the optic atrophy will not be present 
if hysteria be the cause of the sympti>ms. t )ii the other hand, Rom- 

bcrffs flvmploin may ha niiirke)! to un «xtrat>n1in»ry d^nc. The 
IMtkiit wiin U [lyM'-ricn], in fallln;: rirarly alwuy.'i fnlli) tli<! wunt* 
wiiy, k<f [tiii^ Wr frnmc !<lilT like a liniinl. (See dinpur on Ky« for 
(lilTcrvntial <XTii1»r syiiiptoms.) 

In FriMln-ii'h'n ninxia the gatt is pei^iilinr. The Ifp? iiiv widely 
■efianiti.'d and mover] in an uiH;eitain, hoitutin^ n)tinii<!r, iin<t if llie 
feet arc pla^wd oIof^ tu^;etli(^r and the jiatient ttdd tx» autnA t^till, 
Hw-aying at once develoj>-(. [f ilie eytf be closed, lh« ownvitif; iiiay 
greatly iuoreoHe, and the mnveminitti of the arms nru inc(>>untiiiHt<Hl. 
The*' !«yin|rtoni#, which to a (lortiiin extent :«itnul»tc tnie loooniotor 
Ataxia, are n^eiocinled, as a mle, with othent whicli iwjxinttv the two 
«ff(!elion8, for in tliiA di»ieaM> tlie «yniptoms wften wnj« on in very 
e*rly lifr, then- is tuimetime* »yriliL);nins, ii^tinlly u httttory of heredity, 
Uienr IN a «1ow iind jvrkyartiouUitioii, M»lio<4Ur (jiliiH-M npiino-varuK, 
bnt there is mi Ar]^vll-Kol>ort«>u pupil. (Fig. 3-1.) 

Plo. M. 

Moaliw Um fplnal wcu chkflT inTolred In rrtnlrcklt'i niaxU. Tbo Krcu an U» oolumn 
at RuidMbn): UutUlvnl tftmiBlda) Uaoumi tb# daliimnt of Uoll (V; Um |iaiarU« iicrT»- 

Friedreicb's ataxia ruuHt be §c|Miruted from iinolher rare diMOSM* 
in whieli the j^it h ataxic iind the disieasp heretlitary, mimoly, 
hcrwlilary (wreljellar ataxia, in which we linve the followin" synip- 
lota» not Hoeii in Frinlreich's diseaee, ttatnely, normal or exato^-niled 
knue-jurkn, Aij^vU-ltobertson pitpiU, atnl a be);rinnin);of the niahidy 



after twenty yi'«r> (if itfje. The following wide roinpilwl by Collins, 
of New York, givw tJie tli(Tvreiiti»l poinU hetweoii theae <)i«(!iu<eft: 

UnBEriTJLHT SriMi. Ataxu. 
/HalnicA'i tUiHue. 

1. GndiMl liDvalrmml of coonlindloii. , 
Dm tn iett. kfterwinl Iti nrmiL Ijilct in Ihc 
dlMKM Ibo 1«U>iIi( uw] nvl. a> If iliiilcr the 
tnOiMnm afulrvliol. ,^ quick tMckmnl Mrd 
torwtnl balnnclni moTumcnl. 

2. auuioa : rltiaiini oT rrn, u ■ lUlu. In* 
OlMKW Uip iiniwaillniw , itili mtiy bcfttwol. 

>. TltubatloH or upper cilniinlUa Tcrjr uD' 
ooniiiioii, IrtCKiilurliy lu rolnntary nior*- 
mttw* i-l armt ninl Hnsvn. 

4. PrrquonU)' Jtrliy, Imvular mnvvuitnl* of 
hwd Mill iH>ak. Somstlnw* like kn Irrcjciilar 


6, Mtmellr niiucli* 4o 'lut nbow nnllnarlly 

d. AULilB » not logKHil wbsn Itui imUoiiclB 
IjrUi) dowii. 

7. AlfocUoD of *pMob may be alanl : wb«n 
11 dot* oecui liB !■!« tyiiiiiioin, nnd OomlHiar 

an «t1<lln| uf tytUbln uiil nn occiuloa&l b»i> 

*. N)-aii4pniu li B mrx rainmun tynirUiiiD. 

^i It mty be Ucklnii. 

^. Myoutlc IrrtUbllllr I* lo*L Kii*fr'>>rkt 
ma; b« unMiit In ih* MiilnnliiK nf ihe<llw>M, 
but Ihcf B»n •Huppoat. Ankk-donui 1* 
Deter prcwDl. 

in, M«iiUII]> iionnal. Vtij mrsljr ftnjr dt- 


II. IMItnwillM or (be nipnolllH. mcb u 
pUd Ant mnd >|dai.l cumcun. rcrr common. 


l.fUlt: nnnrtoln. iMllnB:pll nfima )it- 
EbrlBlocl. IllLcni ftw|Uenllr vrslkf wllb bodT 
bom r<ir<viinl aud haul tlin>« n bacKiirarll. (nd 
lliu ftiDl irldg aiarl- J>oM Uit liar) lo nUb 
(he fesl. 

2. SUUvii : Kombcm (ymptnnu tlaenl. 

3. lltiibdIOQ kntl ItiTo-otdlDBUon anil Ida 
of dMuniy In the iiiipvr oxltcmiUca. nui4«l> 
form ni^rtniunu fc^mvnilfd on tnluniarf 
«abrt; " Intenlloniil.'' 

i. X«t iDlYcquciitly OKlIUtloiu or ]ci>T 
lamwniRilii ol lb* bcail. J«a oflKii of 111* 

fi. Euititer«i*t1 ««nlncUoa of cbe tnlBicUO 
nitm'Ii> ttu ijwiktiig, 

4. Alalia Ii nry mutb lea. or dliaptain 
»h«ii Iho patient it Ijitif down, but tbo liio»- 
i.inll nail oil pcralTls. 

7. Speech : hciltailiic. abrupt, uploll*, 
atutk, dtTsuUv.i. 

K Kywr Iwllcbint of tlin *y*halli nij 
cninmon. biu not nrUacmiu. optica atfopby, 
|in<t{r«al>v vbiirQliIlUi. panlyda m |«t«>lii ol 
Ibecilcraal nwtl ■omeUnin, 

8. M)-aMtlo IrrtUblUiv inorcucd: MDuMa 
vxlllOIe'■t'^d, auali u kneo-Jork* : oRwi anklv- 


10. M«nul •honcvmluRnvacyliigftotnallfbt 
piyeblaal dlitutbnai'n up lo ■ ocmiKlarabl* 
dactM of demeatlo. 

11, lierormlllModlittilrtniillMaodiplM. 
lueb M pud M or anoUealii do nol ooour or 
am muat rar*. 

The feebleiiew of ihe limh;*, ihc vt-ttcx irldo]>1egin(ArgylUlioberU 
Bon |)U[>il), and tlit> nliixin gait Homotiniet* ^>een n-s the ohief iiiaaifefi- 
tatioiitt of general pariniM niiiy ontirH' an error in ditifcnoiui) in favor of 
locomotor ataxia, hut earefiil cxnminution will ruvml mental feeble- 
new in tiie imretie cjiw or nt Iciurt evidences of delations, and if the 
di.'^pAw is at ail IIkti^! will bv n history of the patient having 
[ia<l i?oiivnl»ioii« or »jHi|iti.'etiform iittuclu. Sometiiiiw tlwn- will be 
fouml |irej4ent in pnrotie dcinctitia incrcaMx) knix-jerlut and inimy of 
tlic Kytnpliitii^ iif ntuxic ]uinipl<^Ki"> btit the iitwodntt-il mental fniliirc 
nad fine iiitontioti -tremor of the handa (W-idi* the diaguosis in hvor 
of parotic (teniontia. 

In chronic myelitis in tLe early Hiagoa, while motion in atill pro> 



red tbc guit is typically that of FeebleneMt, aiiil tlic 1c^ re^jMnd 
lowly to the c*ppbral <I«sireB, beiiijjf tlrapgpd iilotij; afti-i" the ]iati<-tit, 
who loaos fopwanl, ^upjwrting «niie of liia weight im iTtitcIu-!t or 
canea. If the letuona of th«dieiea»e involve tlie lateral pynimidii) 
tracts to a considerable extent, the gnit \n MMtu-wital .'i}».->iic, wliilc if 
tlie aenBory fibres are rrnieh involved il may lie lik<- Uint of lUtixiiu 
lender the-te ciroumstanoei) the atutude and gait of a [laticnt arc 
sometiniea a combination of ihoM^ of hitirnl ^]iinal M-lenK<ii!i {iiguuitio 
[Mfapl^ia) and locomotor ataxia. In some instaiiMts the )>]uwlic 
[ ayniptoms arc more marked, in othera clio t^ignit of locomotor ataxia 
are more prominenL Thi^i oonditioii is i-nlled ataxic [K)rit))Iei;iii, 
in it we find the exaggerated kn(M--jerk.H of luleral selvrosiit 
uiatt^d witJt the swaying of the body (Horn berg;' it «yiitj)tuiii) of 
ataxia. Ankle^loau8 in also prei«ctit. The criseit of loroniutor 
ataxia do not occur, and the Ai^yll-Iiubcrtson i>ii]>il U iifiinlly not 

iiri'M-iil. (Fig. ;15.) 

no. S.V 

MmlKf UMB of iiinal oonl IDioliid iDanilr [antilcclt. wblpb !■ pckcllOKllT ■ DOmblDS- 
UM Of iMtoMOc ftUila and UwmI Klanxlt 1. lAlamt at eramad prnisldaE UacU. X 
hMMtM ecdunoi of Ooll and Durdaah. I. DlR(tlprr*mlclalti*oUorTiirak*ia(iliuooa 

In lateral sotoroms the guil lit tyjiiejilly s]wstie, the legs being 
rigiil from llie hip-joint down, and the to« Iwing dragged in a »eiiti- 
cin*l<- from Whind forward. 

When ilicT gait of n ymng ohild in xttimbling, or the leg or l(^ 
tire draggvd after it, or tbc ankb-s bond mi that loeoniotion ia im|>on- 
cibW, Uk' proUdde dingnoMH ii* that tbc niii^^ U iwuUr [>olioniyelitia. 
(iSfO Paniiyain of l,*g.) 



Vlu. >A 

In i)8«ii<l()<mii4cii1itr liyin!rtm]>tiy llunv is ii pc-iruliur vt-udillint; jniil, 
A temlcDiry tft stinnlilf, llit- Ivniy is iisuiilly bent forward, ami tlien.' 
'm iliflinilty in getting up fr>>iii tlu- tlitor find on going up nnd dowa 
tdati's. The patient in ull lii« inovvm^iits show^ a marked loss ofj 

power in tliG legs witli a great ap- 
jKirc-nt iiiercaiie in tlic size <if the 
nuiweles in the legs. (Fig. 36.) 

Tlie gait of phendo- muscular hy- 
]iprtropliy is somciimps (-losely re- 
l>roiIiK'i-d in cliildreu HiitTcring from 
-I'vere ricketo. and tlio other f^-a- 
mres of the ea»e whieh may nna- 
li-ad the physieiaii are that the child, 
if fat, will have Imlging legs, ae if 
ilie mii.-icW were hyiiertrophiod, and 
lonJoiiis due to $ipiual tvealsneHe. In 
ihe rickety ease, however, the knee- 
jerk Is preserved, and in thepseudo- 
tnitni-ubr hypertrophy it is lost. 

The gait of a ehild -inffpring frutra 
iiifjinlile eereWnil )iaraty.-<i.'' in quite 
ehMnu'HTi^tic. In the (irsl jihicO; 
it 18 spustie, uud thv ptilient wa 
ou the twM or in foiuc onscs oIdIv 
f iM)t devtdops. The hi-elsiircftverted 
and the toes turneil inward, tlw 
knees being suclosoly appntxtliiated 
that the elothes niny heouinc worn 
tivtween them from the rubbing. So 
giviit ib the extension of ihu legs 
that the toes are very apt to drag, 
and, tinally, the adduetiun spasm 
may be so great that tlie lu^ overlap 
Kii'h other as walking is attempted. 
(Kig. :J7.) 

The gait in multiple Bclerosis is 
iiflMi markedly spastic and paretic 
— tlml is, stiff and feeble, nml may 
in the early stages of the disease 
closely rOM-mhlc thnt of s))tMtio paraplegia due to lateral tn-Ierosia. 
Wht-n thv patient attempts to piek up a small object with 


rUE FEUt Ayj) LEOS. 


flngcnt there nrc ln>[nor and osnllalioti of the huiid. Tlioru iiro 
nlitu Hmnning h]>cou)i and uystu);niu«. 

Ill [xirHlyHU ii}nttt>i« tlic pntiviit's gait is liiirritxl Ik'Cuusl-, tvoia 
ihi- li'iit-j.ivfr [Mx^itiuii of hU IkhIj", liii- centiv cf griivity i-- too f«r 
fiirwiinl aati bt- run§ tu keeji up wilti it. TbU is caliiii fL-»tin:ition, 
Tt» gail is also §(>iiiewhnt trottiug or tiHldling. (Fig. 38.) (See 
chnptcr on Flaoct^ mid Anns, part of on Tremor.) 

Fin, J7. 

na. Ki. 

(iMMna. (Krain ■ |«llsiil sf IMnMim'i In 
lfc» J >«Wion McdlMl (MItge tbM|4UI.I 

31il» tI«« «( ■ vnM ot parmlytli ks)lai» ihavr- 
Irif iDrvranl lacllnailon oT iniuk, TenilenoiP M 
pFDpalRlaD. tDxaccM I 

Iti ii'D-lx'lldr diio.'a.-u' llic gnit nmy HuHoly riT^'mMc that of a 
ilriiuk(.-ii limn, and tlit; [mlii'iit litii> the f^rratt-Ht diflimiiy iu k«e[>iiig 
fnint ttlievring ofT tu oov mh aa hti walk-, ttwaying, too, from side 
to aidr (<-<^n-lM-IIiir titiiliatioii). Tlic middlo lobe uf (be 4-oiY-1ii>lt(im 
ID u»ually afTwtvd; but Nothnaj^cl a«»ei-l:« tbat, if tbcM i4ymi>loiiui 



arc aasociaU'd with pnraty.'^iA of the ooiilomotor oerves an(t other 
8>-n)])tnin^ of hruii)-t(iiiii>i', then- ii< a gitiwlh in thi; iKjrpuni qiiadri- 

Ill hi>iiii])1i>|;in th« (jail i* (KTiilinr in tlif Orajfj'infj uluii); (if tlie 
[Kirulv/A-il liiiih by n ]>i'Ciiliiir i>iitwarfl swiiif;, which noun wuars 
Awnv the Kok' of tlic shoe- uii the imiLT sidt; tieitr thv ball of tlio 
font. It i^ «iinn-iiiiii"« cnlUtl H rnowiii;; H!'it. huwinso the Ic^ (-wwji* 
aroiiml in ii tmlf-circlc. Very often the shoulder opjiOBitf the 
puraly/ed side i* raiM.-it in order to tilt thu jwlvis on tho parnly^'d 
side, »ii (IS to muke cirvnmdiictioii eiwy. Tiii» put is to be clwirlj'J 
8eiiiiriito«l from tlint due to hyHlericuI punilysis. for in this condition ' 
the k]! is drii|efe<l after the ho<]y without this outward swln^. It 
is dragged nlong like the broken hind Itiiib of one of the lower 
aninialfi, or le shoved forwai-d and the well foot drawn nflor, the 
reverse of what Iiniipeiis in or^nie panily>iis. The footsteps of the 
hysterical jjamplogii.' an-, moreover, apt to be earefiil and mincing. 
Furllier, the loss of power is usually lcft-sidL<d, and ns^ociated with 
characteristic hysterieal aun-atliuiia (sec chapter ou Skin), and often 
with areas of hyperiesthesiu. Again, in the gait of hysterical |)«ral- 
ysis tlie patient is apt to be excessively laborious in her progress, 
and will e.xhauHt her uiusi-les in her strained movenientti. An 
altered gait due to irregularly distributed [mralysis of groupi* of 
miiseli-j* is nearly always hysterical, and sometimes the patient who 
linii hysterical loss of power will suddenly fall through giving vray 
of her knees. 

A I'ondition of the gait nm) station of the {Kttient varying from 
normal, which occurs most aminionly in hysteria, coiisuHtft in an 
inability lo eo-ordinate the movements of the muscJe^ of looomolimi 
or thi»>e n!<eil in slandini;. This is ea11e«l " a^tasia-abasia." It M 
in reality u form of auixia often developing only when the patirat 
allvmptf to walk. There m no loss of power in the Icgis, but uu 
inability to use them n^ularly or with power while walking, 
although if the patient be made ti> lie ilowu the movemenlji of the 
limheafl made in walking nm Ih- perfornK^l ]H.'rfe<'tly. The kiictN 
jerks are rarely lost, and in addition the general »yniptom^ of hy^- 
tcria can nearlv alwavif be found. The ImkIv often rw\» to and fm, 
and iMrcusionally tiie muscles seem to be Homewlmt epaMie. Thi* 
symptom generally fotlowa scMne sevens' shock, and is most coui- 
ni'inly seen in young jiei'sons, usually female eliildren. 

In nsteiimalaeia there IB increasing difficulty of walking, jiartlj 



dm- U> iwia iukI |«irtly to iniiwulai- w<uikiK-:<s. Tin- (jnit is hobbling, 
lotb^riiiK, and iii iimiti- (i|> of !<liort mid cvi<lL-iilh' painful &ti'pM, " tlic 
pclvi« iittd I(^ boitif^ ji-rkcd forwiml iw if in one piece." Tlic 
kyphotic dofurniity of tlii.' »]>iiio. nmsciilur t«ndvnies6, nucl lati-ml 
comjtivflMoii of till- diwc imd pL-Ivis, wltli distortions of Uie liinlw, 
aid in miilcin); the <litt|;noAiB. 

no. SB 

AlllMD'aeawof otHriTnitliida. (CdJoIwrv* ytdfralAurnal.) 

Tlir gait of rickotn is only |>»'idiur wlion curvatun- of the limbs 
or Mpinc dwtn)yji tho normal posture of the l»ody or iuterfertii* with 
iiw movitnviite tif the Iinilx^, hut it U nearly always inorv or losw 

Clu(H>ly ;iMmwted wit h]altenit ions iu power in ihe I«ga, prodiictitg 



changes in tlic gnit, we have \o>^ of jMiver or paraljrsis affedit^ the 
muscles of the lower cxtremitieB : cither on both sides, in whicJi 
Otee we have n eondition uilled paraple^; of one lower limb, mA 
condition «dled crural monoplegia; and of groups of diuaoIc9, re-' 
suiting in locaiizc<I palsies. Tlieae pamlvEes often produce deform- 
ities, as will be sliown sbortly. 

Paraplegia. Given a case of paraplegia, what niay he its cause? 
It inav aril* from a cerebral lesion, wliicb is very rare, except in 
children, when it U common,' and it must depend upon a lesion on 
both sides of the cerebral cortex or in each capsule; that \t- tn f«jr^ 
there must lie present a le.iion in the leg-centres on both sides of ^ 
the eortex or in the fibres going to tlie legs through the internal 
nijwuli's. Much more commoidy the It^ions causing paraplciriii nn- 
iu tiie spinal cord, very rarely tliis symptom It dui> to in vol wnicnl 
of tlie nerve>tninl(H on botb sides after they have left Uie eonl, nnd 
somcUmes it is ojin.^ed by liysteria and retlex irritation. 

When [Mirnpli^ia on^urs in a young child it is due in a great, 
uiitjority of tJic <awo>t to caries of tlie verteline, an<l tbe pi-cMmirs i 
pnidiicLt<l dot^'H uiit uiHM-ssiirily depend upon compre.'^iou by tlic 
boni'i<, Imt by ihi; iiiflnuimulory exudate. 

The Sjiimd Icsiooe giving ri«- tu pEini|>l(.'gia of tlic lower extremi-j 
tics arc unmcnnis, and are jH-rbnp!^ best grou|>ud in the following; 
tabic of Bram«Tll : 

1. Ont»ni« <llMwv 

2. raaciioa*! 

tliflBmm«Uaii or cord 
SoltcniQK " " 

Uvninrrhai^ ■■ ■' 
Tumort ■' " 

Moii!iinlU» ■■ ■' 

Men In ([put hitniaiTfutKv 



Ckria oT bone 

Tumon tit bOQO 



Malurtil wid ■nuimlc. 

iMpeniletil nti Idta. 




SPAsnr PAnAPMOUiA. The fmraplegia of cerebral infantile 
pnmlyHS is spiistic, and follows difficult labors or iujuries to the 
eliilU before or after hirtli. Contractures nearly always ensue, and 
exist chiefly in tbe adductors of the thighs, ao that tlie attitude u 

■ Sucti Bii oFcDtrmm Insilulii linry rarr. but it l> qui to pommoD in rauni clilldreli, i 
iu*a<r M H praMQl. of Uicuuairf InAuinUDenibnl pibf lielim ^nfteglu. t^uMt.) 


very cliaRu.-tvri6tic. (Fig. 40,) Epileptic coiivitlniows very often 
ooniplicntt? thcBc casee. Ott<m tlicse parnpk^iiis are not ruanifestcd 
few Bomt' months, or eveu longer, after birth. In raany oases they an? 
first ttotioed when the child attempts to walk. Cerebral spastic 
pamptf^ia in infante also sometimes conies on in (Mfles of no-called 
arrested development. Such cases present uo al>normality for the 
first few mouths of life, then cease to develop in mental hrifchtnewt, 
fail to reiH^nize the nurse or mother, iviise to play, gradually lose 
iheir vision, and develop nystagmus. Death usually takes place 
in one or two yean at the IntesL Convulsions do not oeoiir iti this 
state, hut t^niora are often ))resent in the amii*. There i^ no his- 
tory' iu such vaaea of difficult labor or premature delivery. In both 

flpuUo dl|iltBM, oontmllkl. pmrnllDK vhorvUonu an<1 alliplolil norEinouli. jDtnttUM.) 

thiH and the ijifantile eereliral form of sjuuitic panipK-[:ia the py- 
ramidal tracts are de^eneratixl. It la important to renieinlH-r that 
oerebrsi )iarapl(^la in not a.saixtiated with the tlevetu|>mciit of tlie 
reatrtionsof de)ji^neratinn in the jmralyxed [>art, and is a»'StKriutcd 
witli eompanttivelv little wasting, thereby dilTerin^ from the de- 
formities of tlte lower extremities re:«ulliug from poliomyelitis or 
Bcule infnntilt- patsy. . 

Cnrv sliould be tnlo^n tlial the >ipiuli<- paniplcgia of riokets is uot 
mi'^Liknn for a birtli-pnUy. 

A n;n*biM-!<piniil i-iui^e of niwslii' |Kmi))K-j;;ti in adults is multiple 
ovri'bro-Hpinal Hclrrotii-", in which o>tidit ion the loMuf power amounts 
to « iMiresis nither than an absolute jwrntyitiit. The pre#cnue of 
intmitlon-tremorn, cxacp-rnted kfioe-jerkti and nnkle-clonui^ nyslag- 



mus, and vertiginoue, epileptiform, or apoplectiform seizures, with 
staccato Bi>eech, and local areas of loss of power elsewhere, associ- 
ated with spastic paraplegia, readers the diagnosis easy. 

The natural sequence is to pass on to a coDsideration of the other 
forms of spastic spinal paraplegia, and to take up first of all its mani- 
festation in children. This occurs in what is known aa liereditary 
spastic paralysis, which is to be separated from infantile cerebral 
paralysis by the absence of a historj- of injury to the head at birth, and 
the absence of convulsions and defective mental development, all of 
which appear in the cerebral form, and this absence of convulsions 
and defective mental power in this form of si>astic paraplegia almost 
certainly separates it from the cerebral infantile type of paralysis. 
It is to be separated from the spastic paraplegia of lateral sclerosis 
by the facts that it occurs in early life, and that there is a history of 
heredity, or of several members of the family being affected by the 
disease. There are usually rigidities and contractures, but the 
bladder and rectum escape the paralysis, and tliere are no trophic 
changes. The reflexes are increased. This disease ia rare. 

Fiu. 11. 

SbDwIntf Bhadod nrvas Involve In Uieral si-luri^is, vl£.,ilju i^m^^^-il pymml'ltiL tract*^ 

In transverse myelitis there is often in tlie liiior stjigi's of the 
malady spiistic piimplonia as a result of the irriUiliility of the spinal 
centres below tlic scat i>f the lesion, and this niiiy caiisi- a spastic 
gait. In distinction from latend wlero-is wc- find in myelitis that 



t)it>n- jirr n f>ir<ll)--)iaiu, invi)lvetucnt cif tlie bliulilcr nnd RCtuin, and 

Ill iiin mlitll, when tlivrc in lo<u uf |N>wvr in the lower liuttis witli 
itpoMic nxilrnflivii of tlit- imiM'U-« wIk'm ihe {xilii^-iit uttcDijits tu move 
them, so lliiit tiwy btTumc rijptl, or if iK-forc tJic elu^- of rigidity 
develops tlic f^iit 't» spuHtiv nod stiff nnd ttic rutlfxc^ urc grvady 
ejciggvntlwl, thv (U^utSB is ^-iicnilty Ntenil f>|>inal sclerosis, (Fig. 
41.) Then- L4 also in lateral N|>iDnl sclerosis it(>sc»ce of I lotli sensory 
ilisordera mid nxtal u»d bluddcr troubles, but sometimes there is 
jirescut excessively hasty urination. The reasou wliy the reflexes 
are increased 111 laterul sclei'osts, and similnr ailmenta associuted 
with spiistic imriiplegin, is that the inbibitonr' tibrei- which des(>pnd 
fniin Sctedienow's reflex inhibitory eectre in the medulla oblongata 
are destroyed in the lateral [lyramidal tracts. In amyotrophic lat- 
(^ral MtlerotiitiMWilar svmptonisansix' witli wasting of the muscles 
are present in the later stages, but in llie early stages the arms are 
ohicrty afTwti-d by the wasting and pamlysis, (Fig. 4'2.) (See 
i^hapter on ilaiid.4 and Arms.) 

Fin. <2. 

Umotai «r(B til tglnui ^ir) Intalirerl la un^vlniphi" imi-ml wlcnoln 1. Craaiil |>nwii(4a 
tract*. 1. AiitolvlKmtotsnjr DKliHronlkliiJiiR llin liv|>)ile(vlla. 

Spafitic paraplegia may aWi he due to spinal |iachymvningitij!i, nnd 
lh« axHociated symptoms may so closely rtrscuible tiiwc of niyclilis 
llint a diagnoiiis is impossible; but thu s|Mi»tie eluimrtcr of ihc juira- 
plegia, the early ap]M>arance and severity of the |»in, and the com- 


pamiivdy t^low development nf the HVinptnms U) pacjiyroetiin^lii;, 
will iii<1 in .■M-|>iiniliii)r tli<; two nfTwlitniK, a.t will alsotiie jiresoni?^ uf 
pcrxistviitly iiivri'ustH) rcHex<« from tlie Kist. Scnftory dititurbaiioee, 
libido fr'im piiiii.ui-f i-tiinmini in tiiyolili!', but rare in this cxindi- 
tjoii. If iIk- iiiUudiiniitory jtroii-H:) lii'ramt'it wideiipread, there may 
be iwnsnry tliwmlcrs iLiid ti'ophir i^loti^hA owing to invasion of the 
[Ktrliniii^ i}i i\w cord ooiineelt'*! uiih the HeDtation and nutrition iiy 
n tRvundurv myclilii^. Tlie devi'l»pinent of -tignii of iipinal caries in 
such luwL^M at ODoe show:* tlifi eondilion lo be meningeal in origin, 
niiit t\w hit^tory of tniunutlixm will point to lueningitiH rather than 

Si«wtii5 pttnipli'giii, grwitly ini-ntiM'd u-ndon-reflexw*, low muHcIe- 
ttiueiuu, v<?ii™l diwDitlijr, tiiid slight seiwury distuHwMW.s in au 
udiilt, should mnke the physit.-iiin think of »jiiniil i>yphili«. 

8pii»tic piimplegiit in oiiriy cliiMhuud, whwi not due to eerrbral 
lesions, as airwidy dismissed, i* nsiiiilly dne to F<itt'» disuitse. The 
reflexes art- exuggeruted, the bunds iire dniwn nj), and the feet 
are extended.. Jf the liiinlHir ei^ird is disejised, the rellexe« urt^ lust. 
Impiirv will perhaps revojil a history thut the ehild hns litvn entity 
tired IjL'forL- the paralysis omie on, sincl tiiis eomplnined of beily-nrhe, 
whieh hiLs nriilly boen due to pain aloii^ the inten?uiitid nerves from 
the irritatioD at their roots. Thus, pain in the region of the navel 
suggests intlamiiinliou at the eighth donul vertebra, or at the enxi- 
form oirtitage at tiie fonrtli or fifth dorsal vertebra. Early in die 
disejifie pressure on the spinal column may increofio tlie reflexes. 
The area of the eord involved tim Ite determined bv tile symptoms 
as detailed <hi pp. Itl6 and 10". The prognosis is not always un- 
favorable, as extraordinary recoveries take place. 

NoN-*ii-.\8Tif pAUAfl-KdU. Passing from n past ie paraplegia we 
ooiiie to thow fornix of paraplegia lacking this iKs-iiliarity. They 
are quite numerous and inijiortanL If the pampli'gia cornea ou 
suddenly, the cause may be hemorrhage into the substance of the 
eonl or into the spinal mrmbmne^ or be due to eompres^ion or 
destruction i>f the «?ord by injuries of the Itack, whereby there is 
lne«mtion of the nofl [Kirls or fmcttire or dietoeution of tlic vcrtebrie. 

When the ]mniplegift is slower in on*et ihe spinal cniisi-?' are 
iicute ast-onding pandyitis or Ijsiiidry's ixiritlyMH. aeiiu- eentnd mye- 
litic, and acnle tmusver^e myelitis. On the othi.'r bund, the slowly 
onouraing paraplegias are due lo chronie myelitis, lo lixwmotor 
ataxia, amyotrophic lateral selei'osis, lateral soluiiisis, [loliomyelilU, 


nciirttU, nnd prciHiirr itud to disense nf the verl^bne or to spiniil 
tumors. Kiniilly, we hiivr whut arc cnlted rcflos and hysteririit 

Ht^'morrimge Into the spinal cord is an exceedingly rare condition 
unless pPMeded bv gravp diaeaw nf its ti^iieit. Indeed, the esist- 
en<» of Biic'h a condition in man lias been denied. The jtatienl, 
previouftiy in good health, is stricken i^iiddenly to the ground, and 
there may be almoHt a^ miieh eerebral distiirbanee a.i in nerebral 
apoplexy, but ciin!teiousne.-« U generally preserved. The total 
smount of jiaraplegia may be instant, or not )>e omipletfi for 
twenty-four hours. Bedsores speedily <levelo|i, and death ensues 
from exhaustion or from extension of the hemorrhage upward to 
the vital oeatrei). Practically idcntieat symptoinit ensue when the 
hemorrhai^ takes plai-e between tht- membranes euveriuj; tlie eunl, 
lu both instances (he reHexe:^ are lost if ttie hemorrhage hv sulli- 
eient to pniduci' tjtial panilysii*. 

If, on thi- other hand, aft^r n prodiMmal period of ^hort diiiiktioii, 
during which then- is soino fever, ihi- jmtieiit is -iiiddenly uttiickcd 
Willi [Miniplogin, llie cause may be llie amtc iwivudtng luyoIitiK of 
Landry, and tlic rapid cxteu^iun to Uil* trunlu, tliv arms, and the 
respiratory inusele^, with the rouHocjuent early death of the jmtient, 
will oonlirm the diagnosis. There it) usually no involvement of 
aonsatiuD or trophic paralysis, and the Bphincterit of the bladder 
null r^-etum escape the ]iamlysii4. Simihir symptiinis afrSoHnted with 
•u>n«<irv disturbanoes are probably due to a polyneiiritiH. 

l>iller and Meyer st-ite that the cardinal jioiutD for the difFerenliat 
diai^noeii; are : 

1. Flaccid paralyaii^ of the muscles, spreading rapidly from one 
])oiiit over the rest of the body, generally Iwgiuning iti the legs, but 
eottietimex following the reverse order, as in the French zoologist 

2. Absence of miiscniar atrophy and of electrical reaction of 

'A. Tendon and sujieriieial reflexes absent. 

4. Sensibility not, or only slightly, impaired. 

5. Sptiinetcrs, a.s a rule, intact (exceptions nithor frequent). 

By far the most common catise of partkplegia is aiyoliti^ in one 
t>f itt* forms, hut, whether the onset be rapid or slow, it must bo 
renietnlKTcd that the sympttMna of myelitis depend, lirst, upon the 
h'vt'l III which the spinal cord is involved, and, second, as to 



wtu>I.)i4^r tlic lifioii involvon ttir whit<- iimttiT or tin; gniy. If the 
l(^-4!uii i? an ui'iiN- (MMitml luyelilii' of tin- gray iiiitttiT, il tiMiinlly 
jirodunoi ninny of th<- «ym])t»m» iiboiit tn bo di-tnik>cl iiinkT fivtitc 
troiisvertte myelitis, but tin- nnsct i« nnili^niitil iiiiil tlie nivus iri- 
volvotl iin> uhiiaIIv witli-sprt-ail. It is attfiiiiwi by fowr of u niarkvd 
type, thoii)>b t)io tvinpcrnturc oF tin- jjurnlyzc^ purbt in bolovr noruuil, 
and by curly cviJcnops of trophic Icaioiis. Multiple artlirltiit may 
coino on. Tbt; bladder siiid rectum are paralyzed, and, liiwiUy, deli- 
rium may develop. The pro^oeia is nofavorable. Acute central 
myelitiii is to be Kepamted from Liindry'-i piLralyBi!) by tbe facts that 
in it sensation in lost, and tliere are rectal and vesical itaralysis, fever, 
and rapid troplae clianges. From polyneuritis it is separated by 
the facts that there are no great trophic changes in thU form of 
neuritis, and the rectum and bladder are rarely paralyzed. 

The ayraptonjs of acute transvei-sc myelitis are capable of lieing 
divided into three groups, in the firat of which the onwt is as sudden 
as is that <if n|mplexy, in ihe second the symptoms come on t^uickly, 
and in the third more snhacutely. In the acute forms, however, 
tlie history will be tlial after a )>eriod of numbness, heaviness, and 
wenkiii'Tts of tin- U-^n, with more or 1i'H'< |iaiM in the back, the jiatient 
luL<^ found it impossible to move hi< le^, lioa lost control of hii> 
blnd<]er nnil rectum, or ttiilTers fi-om n'tcntioii of the urine and fecw 
iiMteiul, and at the same time has dcvelopi-d nnatnthi-sin of hiif lowi-r 
extremities and the ginllc-«cnsatiou, or. if the kviun be situated 
hi^h np in tlio currl, tingling iu his arms (sec eJiupter on Skiu), 
The reflexes miiy be abolished at tirst, and then return in un I'XS^ 
geralcd form in the segments of the cord l>elow tlic nrcn affected. 
In other eases the reflexes do not return if the lesion is completely 
transverse. The guitient is s])eedily bed-ridden, and to these symp- 
toms just detailed is soon ad<lcd the development of beilsores and 
sloughs on de]»endent imrts of the legs or on the buttocks, followed, 
it may be, by deatli from exhaustion, although the case may sttrvlve 
for months and cvi-n bei><irae somewhat better. If improvement 
takes )>laiie, si-nsation returns in the course of from one to six months, 
gome motion jii from six tn eighteen months, and, ilnally, sjiasms and 
contmcturej* may result from dei4cending degeneration of the lut«nil 

The following dii^mni from Taylor's fmla of Mr^eint #hou-« 
tbo eifcot of II lesion in the spinal cord in transverse myelitic. 



STHprows \s TiiAXsvKitfiE MvEurie. 
"nt iluktiioil p»nian n>i>ra>aou ihe imi of InUn 

BcdcuB Domut 


B»n4 of hypgnMbMi* .... 

MnMlM p»td«d. wMte. aad low 
ibrtr et«oiilckl rMcuona . . 

UuMlM pkUad . 

VfMmVt *l«BWlfl TfOtLiMU . 

Bijtoii IsomMol 


B HiB W i 

T«mp*ainu« ftbo** N«l «r bodjr 

ReflcMa Dorrul. 

BkDd of bnvastbad*. 

MumMi paU«d. muir. kuil Iom 
lb«U alaatrinl rocOoiu. 

SenmUm loii. 
Uiuctat iwUM 
Donot waiM. 

No lim of •ItoHim raaeOuH. 

BaOfOM iDonaicd. 

Tnnpamtiire atiOTD roi o( body. 

In CAffiflin whiMi [Mi-nplej^iu ivsulu fmni tin- iinH-e Mibacrtite form 
of tnuHvcnto tiiyvIitU th« symptoniti ure u»uiilly not ijuite *o nipici 
in tlioir o»w>t lu* in lliu n-pe just oanipd. Tliu putiviit llivt nntioos 
Uint liiM blndrtiT iitid tvctutu art- unduly irrituMc. and in his liralw 
Uierv tnur In; miltjcctivp sensory disturbnuci.-.^ (wo FutwKtiKvtit in 
cliii)>U>r ■>» tlic Skin). The motor symptoms Iw^^iii by it fooliti); of 
lufUvinOK" or innliility to <juickty move tlic lowvr limlinf, fa that 
tJie [Miticut frak tired on nlight exertion. Stwin thvHC symptoms 
d«i.'|tcD into ubsolnt^? unfesthesia :tnd motor j>amlyei«. and tlie ^inlk-.^ 
M>n«ition on the tnink becomes well develo]>cd (see ohaptcr on Skin). 
Tile blatldcr, which at dm was irritable, may now l>e b>neto.i«, paral- 
vt»\, and retentive or incontineoU Itetwitive, if the lesion is above 
thti lumliur oord; incontinent, when tlie lower part of the lumlmr 
iMibr^ivinent is disca^-^d. The reflexes may at first be abolished, 
bnl vwry mmhi some <)f iliein return, only those reflexcB the centres 
for whieli are desiroye<l by the transveisc lesion being abolished; 
ihni is, (he relle.^es ivoover after the first sliock of the attack, and 


those niuMrlet* and tciidnii^ liAving spinal centres below th« lesion 
liavo their reflexe:^ iiioreiuiod l>ecmii«e tliey are cut ofT fmiu ilie in- 
hibiting eentro higb<-r up in the cnrd nr tnediilla. 'I'hc niu^icli^ of 
the K-)p<, whieh nt ihi^- t'lTfl i^hiielc nf the ^nm-t of the iiiitlndy were all 
llaccid and pimtly/i^l, now dividir tln'inm.'! vim> into two (rlnHM.-?', (Iiottc 
tliiit iiri- rDiiiicetc-d with thi'difra-x-d |(urt of tliu mnl, whieh rt'muins 
pHralvKw!, ami thosv whidi airo conneel^ii wltli tJiP lower contw*, 
whioli rceoviT some puwer; but us the lexion in iki plaeot) uh to cut 
thfrin nil off fn)ni cerebnil infliK'iii-c», voluntary motion is lost lU 
w>n)plctcly fiK if all were d^-prived of Hpitinl itiKtienci-. The truly 
])urHly;:ed uiu«elei4 wa^te, but the otherii which huve uuiin|Hiirv<] 
ripitisl centres do not, except very slowly from disuse. On tJie 
coutriiry, they often become ^i»astirally coutraeted. Other tropliic 
vbau;;e>i, eneh as U-dfiore?) and bullnr, devehtp in the skin eonneetts^l 
with the dieeuHC)! focus, but not in that connected with centres below 
the lesion. .Vme^the.tia is present l>ecause tllo lesion prevents tJie 
sensory impulse from reaching the braiu (see chapter on Skin). 
When the entire cord is not evenly involved in the transverse lesion 
certain (iroups of muscles partly escape. It is anscrted that the ex- 
ten-->ors eseaj>e oftener tlian the llexnrs. The height of the [laralyeia 
abo de|X.-ndn upon the situation of the liv<ion In the iv^rtl, and if high 
enough tit involve the cervical region, and yet not high I'nough to 
linralyxe tin- diiiphragni and cimim- dmth (third or funrtli iiTvienl), 
thertt may be eonti-aclinn of the pnpil by involvement of the libn.'* 
from the nuelcux of the third nerve, which runs down tlic cord to 
the Ui»t wrvieiil vcrtcbrw before joining ilie sympiilhi'tie. When 
the legs become »f«wtie late in trinsverw; myelitis tlie "siiiw i» »up- 
(HMcd to be M deSLH^'iiding <l(xencvHtion in the pyiiimidnl tracts. 

The symptoms of elironie Inmsverse myelitic producing )uimpl(^ia 
are practically identind with tJic more urnite form just dcncribedf 
except ttuit they are vcrj- slow in tlioir development. 

Having discussed the various forms of myelitis, we have still to 
Btudy the ((Ueation as to the scat of the lesion iti each form. Let 
US suppose that a patient presents himself with the following con- 
dition: there is complete paralysis of his arms and tegs, with par- 
alysis of the muscles of the trunk, and total aniesthe«ia of the same 
areas. The legs are in a state of spastic paralysis, tlieir reflexea are 
increased, and their nutrition is naimpaired; while the arms ore 
found relaxed and Baoeid, devoid of reflex excitability, and under- 
going degenerative atrophy. The bladder and rectum arc not 




iPDtive. All ttiew svmptc 


probably bctw 

crw 1 


if (he 


cervical rep 
vical aud fiist (liiraat vertebiw. 

I If, on the other liand, tbt- upi«-r pxtivDiUies are not affyoti-d 
(except, pcrba))!9, th^- small muscles of the Iiand), but there is th« 
same loss of pi>H'tr in the lejipt, ivith spastic contmetinu of thfl 
oacles, and the other iiyniptoms jiuit iiameil are present, ontnbiit«d 
ilh (ie^nenlion of the muselei tit the trunk, the Irsiott is prob- 
ably somewhere between the second and twelfth dorsal vertebne. 

Again, if the iwralysiii of motion and sen!«atinn be only in the 
lower limlw, nnd iIht"* be tlacridity of (lie niii!*i>Ier( (where before 
we di»covcrc(l npii^tic ooiitmt^iori), with ninnoiilnr degeneration, 
la** <i( reRexcit, and {wnilyMi* of thi; blndder and reetnni, tlie lesion 
in the lumbar oonl. 


^M DtrFBaEXTiAL DiAovosta op Ldubab, DoiuAt. 
^1 Mysutis.' 


ttaml Bj«lllli^ 


ConrlOkl tajtUtit. 


1, Onrwl. aMonls&l. nd MtO^niMlM, ffla- 

<»nl Inf M lMd|bl of Ifldnn . 
J. Uii*. 



tUBnMVniiii'l lolnii: mi* 
I of ICEi, umiiletc 
IKDtbu ' 

BtOMUOu. Paliuiiiloei.DrclrdlP'pKlii* nintle-islD uid hTpcni» Hn^rxilhealii and 

tMouodMni; biwranlbv 
tUBnMVniiii'l loll 

«( an«<«n dimtbution- 


IL II. lu «tru|ihM nHMln: 
I orln mllil ouM qtuutiu- 
I iliEdinanucloO- 

0( (lomi •ad •bdcoulnkl 

[and iuurconai aunlM 
not tubjwit 10 eunfiM HDD) 
«omipoiidlii« U htlgtMafl 
Iwlon ; wnwtliiiM nlU 
■04 aloiT of Isga. | 

It. t*. la donal uicl iiMaiDl- 
n>l miucleaiillsbliiiukntl- 
MUvc obancH OQlr In Icri 

puni la MTUln 
iMiMHllitrlbi. Hum 
ol anoi; bflnw Ibli 
MrMsibM* ol ■tmi. 

body, •n'l l«c>' 

Alnphr of iiMk-nio*- 

elM (TMC' or more 
«ainiiioiily of nrrai. 

IL tl. Ill ItTOplllOd 


«bMi inuud. 

IneonUnoimfrem pmljridi Relcndon, or lDl*niittl«nl fUtDeuluilonil is)re> 
or ((ihlncter. InounUDCooe ttvm ivllax IIUil 

■nloii : Ulor fniio oirri^ 
Bow. OMIUs oomnian. 

lonmllnaioe&Dmpaimtiiu lofofaiDUry vtMiullDa 
of )»UacUr i li i^ttl^rt by Inta nnu tpMU or oon- 
«oiMlf«Uoil, itlpallon. 


Timpanuy lOH. ibon ispid aiiiiauliido(«l u)^ 
lotnM*. inu. 

l^iDponfjp loM^ Uten tloi* Bamooiludofwlnjr*- 
Incitwr. IIU*. 

I OfWn pnwol. 

>ft*ii prtwiit. 

■ From PiliKW't anlol* la IWrvuin'a Kvnoua PlinM*. 



Still fiirtluT, if then' Iw In** of jwwur witli ik'Ki'iiorntion of tlio 
small mii!«ik'» «f tin- fi^rt, iind Xa^ of wn^tioii of tin- oiitei<l4- of the 
feet utul toos, itud of tliL- xkin nbuut tlie naus, with prGM>n'«tioii of 
power in tlio tliighs nnJ of tlic ]intfl)iir reHex, the Ivsiou is in the 
sacral L-ord. 

Finully, it !» possible! for disoiso of the uitidu tM[uItiii to produce 
8yni{itoin» of a luRibar-sucral U>t-ioii owiitK to tlic facrt that tliiu juirt 
of the oord is coiupo«ed of tibrcK derivwl from tUc«i> two urcav^. The 
patolkr reflex mav be prc8cr\'ed as tile lesion is below the reflex 
arc, and all the fibres mtiy not bu involved. 

In this ennnectiou the re-.ider should study that part of the 
chapter on the skin whicJi deuk with ntucsthcsin. 

This subject is stiU further subdivided and elucidated bv the 
following table and by the illustration (Fig. 43). 


COHu. (Acoordiog taSTAHk.) 





n. KU'l II. SMTno-nunlold. 
C. Tnpnliu. 

s«aiuni iiiii naek. 

ly. C. Dlnphnunn, 

GoMm lira«hl>11i. 
iupliiitlor lonsui. 

Sapn- tnd In/n^plmtlu*. 

V. C DfllmM. 

AiMblitlB (iiilciii 
SuiMtiatoi li-iiiKU* 
SnpLiiAlor t>r«Tb. 

1^rT« RUjmr. 

PcolOMlli (vlnitliinliit part). 

Samliu iQiutDai. 

VL C. BlmiH. 

Pei'Uinlli IcUtIcuUi put). 
, f«mlii> inaituiit. 

BiuDun of wfUt and 


m. c iTnaet«(ioiit bMdi, 

I KilMuan ot MM aod 

I rraiulan of wrtM. 
Flcxonof vrliL 
rMtnnlUIMMil pkti). 

TtNB IMjOt, 

HjrpacliMidHiua. (?) ' Back ot bead to vsrtei. 

8add*ntDtiplialtonpradDa»d Nppk, 

tiT (udden pronira banaalb 

the lower Iwnlor o( flbi. 

I'Hpll. «li WTlhri-rvtoil. S»tk, 

Otutatlon at \be iiuplt pin- tlpiicr ibonldtr, 

duvol by irrlutldii ot Uio Oumt atln. 


■lack of dliciuldar and 

OiiMT (Ida nr ana bii>1 

(OMBjm. fninl and 



Etb nrfieal U> in donal. 

Iifluuon «f >klD over lUo 

•eapula pratuMa eontiac- 

tlon of tbe wapular mui' 

HapInaMr lonitu. 
Taping lla undon In wriM 

prnluoei Box Ion nf fore< 


Trtrepa. Outar aldaaf ftmn fc ' 

.MIKollhecrvloal. frantaodbMCi 

Tapplnn elbow leiidnn pro- oiiwrbalf of bHH. 
duoM*xMD>lon of (braarm 
Itetarior wriM. 
Iktiplnfl iBodont (aOKa *x- 
Miulonar band. 

AnniloT irruc 
Tapplnt aatorlor icndoiu 

(KUaM OsxlOD or vrriKi, 
Palmar. T(b earrlcai to lii 

ill niHInf pal m canaoa doa urc 

Innn (Ida and bMk ( 

arm aad tuearo. 

Radial UalT of UM 





vm. c 

t. o. 

II. to XII. 

I. I. 

tl. u 

tV. L. 

V. I. 

t. lo II. 




, FI«nnof«TKaa4llii|«n>, 
tutriDil« amelaa aS band. 

Kxtnnon or thumb. 
: Inirlnio UMtd mutki. 
TMnar uul hypOUNiiar 


Miuelca of tack and ftbdo- 

Knetana (fliuFL 


>CaMiei«f kbdoDum, 

nio-iaoiu (Mrlorliu). 
Klaxnn c.r knee (KMntli>. 
Qii*drle«i» Iciooni. 

QoBdllMIM Ikowli. 

iMwr totawn of mtsli. 
AbducuHiof Ihlcb. 

' Addudonof ihigb. 
Klaxitn or kiim fwr t t w l. 
TlbUttlt antloiu. 

Outoanl mtatoN ot Ihlgb, 

riBiunoI ankle. 
Ktuouon Of loca^ 


l^mt t.*aat at tow. 


iDiitmlc miuelMof lonL 

l>cfi&«al muaela. 

Kl>tnulrtC. tititnltll-lonul, 

TftfkllnR nuiiimnry rvgloii 

aUK> Rlracllnn of the 

AMonlnal Itblii lllh llo^ 

atMkInt )Mc as abdomen 
«auMa ramotlon ol belly. 

Cmnautolii. w to M lain- 

' fWMnt iDDor Ihlirh oauKa 
I nmouoii ot i«rni>mi. 

Palollar ".cndon. 

HirlkliiK IniKinn caiuo cx- 
, tcnitull ot Ice. 


(ih 111 Mil lumbar, 
iiiroklrtK iKiilnrk oaii-r* 
•lliujilliilt in fold or boll -irk 


TlrkllQff loto of fool caii'ei 

flriloii iir Ion anil nlnti'- 

tliia ol io€- 


FOnarm laiA band. 
Iiimir ball. 

Fonsm. luner tialf. 
I'Inu dlitrlbDIlon to 

9k In al ohvii and 

■lidciniiHi, In iDiiiIi 
runnlDK acouuri and 
downwaM «aiT(- 
•pnndlnK to iplDa) 
I'ppcr cliileal nfloii. 

Skin ov«r groin and 
rtonl or •ccnliim. 

Uulcr iIiIk at thl|[b. 

Fntiil *i»l liinM lld» 
of ihlgb. 

lec bi auklc. 
Iiiiior Mda uf Ibot. 

Backoritalfh, back of 
i*t, and oiiHC I>atl nI 


liaok or iblab. 
Let and vxA. outer 

Fonl'Nrflvx. AcblUa lendon, fkln ortr nrnim, 
: OvMutaadanorfboinuuHi , Anat. 
\ nMOMtoniatikla^lnniu I nrlnaum. OeDllala. 

ttladdtrud r«oUl omtrra. I 

I'araplttgia when dne to locomotor itaxta is nearly alwaya so nur* 
rtiuDth^l t>y lillivr ty]>tra1 i4yiii|itj>ti).'i of Ltii» iliw^^e lut to render its 
i«e|i»nition frum the iHtraplegia of myelitic en.-^y, and, furtlier, it is 
rurrly n tnie 1(W8 at jHiwer, Tlie .xtahbUi^ ant] darltn); )u>ins of 
ataxia {wf HinpLcr on I'Hiii), the [in-sitiioe nf the Arifvll-Robcrtson 
{lupil, tJif RhM-Di<4' nf the (Kitollnr reflex, and the atrophy of ttift 
opUi' txTvc are all dmritoleriitfii' of ataxia, and absent in myelitis 
(fw>- nLwi fnrty )nirl nf tlil-* cliniXer on f^ail). 

Tlwi i(ymi»Un«t> nf Inti-nil iwierosis and amyotn)pi)ie lateral bcIo- 
pwia liiivf iilrtiidy lni-n ill-i u--ict nnder Oait and Spaatic Pam- 
ph'tjtn, l>nl in thv p;tn«iii'-;;'H i illifl " iitaxio |tarap1e);ia, '' alwi 
already tlisruivKsl, there are in iwwK'intion liiteml M?1croii<i)i and pnii- 
torinr w>lvMais, and for thii> rea^m sume of the ityniprnni!* «>f liotli 



are found to hit pn'setit. Tliiiis in nililition tn los» of |h>wit tht-n^ 
is a A|Kiiitic rDixIItiiin i>f iln; k-jj^ with I'Ximgi'ratcd rcflcxtw, ulitMMiif 
of tiifi Argyll-Kill icrtj^it II |m(>il ami of crlsi-s of jHiiti, bnt tin? 
R(»iiibt;rji :<yni)iti>ni, (ir xwiiyinn wlit-n tliu eyes are closetl, t-i prcsenl. 
Tin- i\)i)ilitiuti wliicli iiiii*t closely resembles ataxie parapleg'ia Is 
tliHt i>f tnnior nf tlie mutille lobe of the cerebellum, but in aiieh 
i'wu-t we Iinvo, in uddition, hi>a<lac)ie, vertigo, optie neuritis, titii- 
Iiation, and sunictimcs vomitiii);. 

Fro. \t 

M Ui T(b Mrvlc&l MVmeul 

in to mb dona) MfaianL 

tit (o MU liiiiilivr o-gRicnl- 

Mb M«ml MgiRvnC 

HboKlnt tbc mtTiim-areM '>l i<< i << i. < rr. .{.iiniini appnHiiiiikialjr in uiu aniM nr tb« 
•ftulrvnt tiip[-I]rlii|[ lliv Hunk aDit Uinbfti 

Tile onset of paraplegia id n young ehiU!, preeeded by nn nttaclt 
of fever, vomiliog, peMtlessiH'ss, add general illness, lasting but a 
few liotin) or days, and ivhieb may bp enmplicated by coavuUiona, 
all point to tbe cauiw being piiliomyolitis of a severe iyi>e. The 
legs nre, however, a.-* a rnle, oniitpletoly [MralyKi-d for but a brief 
^leriod after tbe attack. Kveiitiinlly the ^torni elears off, ami only 
the muscles directly onitiieeted with the diAnused cells in tlie cord 
(anterior oornmi) remain pnnilyx(»l. There 14 no Iom^ of scusatioti, 



reflflx a<'lion is alinlUIiw] !i) tlic |iiiral_vwM^I [xirt^. Far ami 
away the m(>74 iiiijiorlanl point in tlie diii^nuM^ iti lIii> svni])Ioni of 
rapid wiisiiiig of tii« iuim-Ich in tliv [uinily)tp<] jmrtn anil t])i> rajtiil 
<l<!Vclo)>nH'iit ii( n(>lcliK'S:> in tlu-^e ari-a-t, whicli is due lo the d«ittnio 
tioii of tlir Irojiliic (»iitn^»i in tlic K|Miinl cord. 

PnmpIcKm nviiltiit); fiMin tmiior of tlie vonl or ite tui'mbrnn*^ 
only cnxiii!* when tlio {^iwlli i» *><• )>liici-d as t«i cut off all tin" iimtor 
travtH (tiipplyint; 1>utl) limlw, whic^li in niri'ly iui'uni])liNhi'<) until 
after a long \\\ntAfTy of riion- or li-s.* wcll-ik-velopwl niutor and BL-nsorv 
failure. Tlip pnruly»i» !» di'vi.-Io|)ed in tlic uixiib siipplii'd by tho 
oi'ntrcs in tlie conl bdow or at llio level of tlic prowtli, and the 
viulent |iain nwirly always pn-.vent in casus of tumor puint>^ to the 
diajfuoeis. Very painful pariipk-jfia, tlKTufurc-, indii-atoe spinal 
tumor 08 itot uinsc. Tht.- arui of anir^thcsia and tlie muHcloi^ 
involved may also f^ive deljnito information as to the ^eat of the 
growth (see chapter on the Skin, and Starr's table jiiet cpioted). 

If the puraplet^a he due to compres-iion from fmrrtiire or diHlo<«- 
tion of the verlebne or to other dire<'t injury, the history of the 
patient and the evidences of external loeal mischief will deeitlo the 

Sometimes during the course of M-vtre diHt-iui-, pruducin^ irriia- 
tim) of till! bladder, kidney, botvel.-*, or rertnin, a.i in violent cytttitiK, 
Muiic in the kidney, and dysenbrry, jNiraplc^^ia i-imu':' on, dnt* in 
some nuxn to an infeetiourt inyclitii>, hut in ntlierH to what i^ npjuir- 
ently only a retlex pamiy^'i*, il< it often [MLv>en away witli the re- 
moval of the source of irritntjon. Kven wona» in the intestine 
have prmlnoecl mieli a pamlyniit, and thi-ir n-moval haw iM-n fol- 
lowed hy ciirt'. Generally iten«ntio» in the limbs i!< iminiiKiired 
waA the bladder and reettini ael nornmlly. Sonietiniei^, hnwevor, 
in thi- pwwnir of wvere renal ili«ejwe, fu« ninal wIcdIiim. lher«> may 
Im- all Mtrti> of disturbance of Ken«ition and puin, \\» well a» f;rait 
motor [KiralyiUA, witJi total low of reflexes, followio); an exaffgera- 
tion of the reflexe*. Probably these -revervr (awt orcr always due 

a ooineidvnt myelitis ratlier tiian U> retle\ irrilativc cause, 

No form of (uiraplegia pn-sent^ so many types or repn-senu so 
many ortfanie rliscuHeii as does that <lue to liyKleria, for there amy 
l>e Dot only (ireat loss of motion, bat exa^tferated or lost retli-xus, 
relaxation or spusUc contruetion of the nins^lei«, anieistliesia and 
hyp:- nest hesia, pain <>r no p«in. The very oecurretiee of such 
irrqipilar manifesiattons in a young, nvarotio girl, the faets that the 

110 Tilt: ilAyiPESTATIOy of DI.SEASE IX ORGAyS. 

nuRsthetic areas oonstaiitly tend to shift their |Ktsitimi, and, finally, 
that the cuntracliim.'i, if jirciK'iit from liynteria, disnj)|H'nr on udiiiiit- 
isteriiig an aiiiestliotic to a sta^ in whinh mnwiitar relaxalioii i* 
prodiieed in the nrdinnry imlivtiliiHl, Hid ii!< in innkin^ what it* in 
man: ainfin au ahuoi^t im|Hi»i«ihle diagiui^u (m-v that (inrt of this 
chapter on Cantmnlurcs). 

A yifiirudo-paniysiin of tlm k-gji with inimubility wmi'timi-'* occnr» 
a» II symptom of »i'orlnitiiM in infunry. Thf iwircut'ii notico that the 
child llinoh<;K when pii-kitl up or hamlk-^l, und spciuk an if tt-ndt-r 
froDi rhenmntiisni. Often the tpim« are ewullcti nnd l)lL-Mliti)r, und 
purpuric eriiptiui)« Hppeur on the likin. The shafts uf the bones 
of the leg* or of the arms may be enhirged, and btematuria or 
bloody stools may appear. 

I*«cndo-pnriiple^ia may occur in rickety children from faulty 
musL'ular and bony ilevelopmenl. It is to he sepnnttetl from the 
ordinary piiraple^las of childhood hy the state of the boues, the 
presence of kneo-jerks, and the ahsenoe of local wastinu or spasm, 
but general spaiini, or «irpo-[>edal spasm, i.w often seen in rickety 

Not nnoommonly a partial paraplejiia m-cnrs as a result or sequel 
of diphth<^ria. The i^iiditkm, however, \» more ataxic thmi jnini- 
plc^ic, anri Boiir^^ :ix?ierl» that lliere \» no nnmc-ular atrophy micb 
n» o('i'Ui>< in true (inmplegia diic to netiritie, or in some apinnt 

Wlu-n neiiritiH ])ro(Iuces jianipk-gia it mny present symptonu very 
cloKely allied to tlio-ti.' of acute myelitiit, if the symptoms comfl OD 
Kuddcidy, or of locomotor ataxia; that is, neuritis miiycimsc pecitdo- 
tabcft if itjt onset be slow. The neuritis Is always multiple and 
involvM thi' arms and the body after affecting the legs; thcro in 
well-ilvvcluped ann^thcsia (see chapter on .Skin), pn^cedcd by sensory 
disturbanoes and marked muscular and nerve-trunk tendurue«s; but 
there is no ginlle-sensatiou, as there Is in myelitis and talws. There 
are often trophic changes in the skin in neuritis (see chapter on Skin), 
but no bedsores as in myelitis. Toxie agents producing a neuritis 
may sometimes cause a paraplegia of the lower extremities. !)& Custa 
states tliat malarial neuritis may cause such a symptom, but, as a 
rule, a toxic neuritis prodm>?* loss of ]»wer in the arms. Very 
rarely paraplegia of the lower extremities results from diabetes 
mellitus, the lesiim lieing in all i)roliahility a multiple neuritis. 

Monoplegia of a lower extremity may be due to cerebral 



)e»<i(>»fl or U> tipinal or nervti-lninlc li-^i(in>. Tin- wrdirnl li->iou 
producing iii<>iio[>1egia in ono \v^ ir' wry mn-, iiikI if tt ot'i'iits, itt 
any »g^ iiMUmt4;i> ii legion in iIk- rviivoliilimiN nt tliv U[>|H'r rnd of 
th« fiwun- of Koliindo. mid tliv cmitiixiiition of tlii^ iiR-a in Ihv |>ani- 
centntl IitliuU- of ihi> niiir^innl oonvolntion. U iilike thu [Mirai»k-giA» 
of infnntilir if'rt'l)^! pimilv:.!^, tiiunoplo^^iH of tlii- k't; v«ry riin-Iy 
BrU';< fnun Uii:' c«ii»r. If tlicre nrtMio ?iigii^ of ocrcl)nil trutibk-, 
till' |in'-*<'n<'e of ii virtnplctw U-jj iiionopk'giii oftii niran one of nfvural 
tiiin)^ nuiiivly, ii lofton limited to one "iilc of the ford, tis, for 
cxiirnplff H hvmiliitvnil niyeliti", liyti'riciil paralysis, iu wbi<ib 
iIhti' will be irrf^tilar uiiip-tliwiu (txo ykin), and tlio otlicT hys- 
ti'riml ^^ij^K, or a tumor ]}rv>-'-iiig on iIk' (;niriil nt'rvf iu the pelviir, 
or sM.'tion of the Dfln'e by injury*. Apparent monoplegia may, 
however, be due to mui-euhir pain or u painful phlebitis producing 
niiip^-uliir fixation. 

DiAosAM sBowiKo Symftoms IX Hkmilatbkai, Mtelitir. 

(ttx dark mas rapmcnu lUc lUc u! tbc IcMon.l 

Hpin*! mnl 

ftid«mi twnnft) . . . 
tanil of nrimmiliAia 
■•n4 of auiCTiI]«dB , 

Hirtor tmlXT 

llri«(B<tkMla ..... 

hflsm lactcMtd .... 

Ttniamiiiie ata*a the ml 
Of Ik* boat 


Keflcm iiurmii!. 
Band ur bj'pormUKSIit. 
■tend of uimlhnlB. 

HoloT ptnTCr unafliiPMd. 


B«acxcs anaflccMil . 

Timtwrnu'* Miue u Uie nut 
el (ho body. 

If the eoudition i» dlle to .i li-xioti on one side of the cord, the 
Aymptonu ure quite vhnni(.'teri<'liv. Tlit-n- i» imralyiiis of all the 
muscln; of the leg which are 4tip)ilifd hy the part of the cord 
uffi-ctMl or below it. The muttolcs, the uervi>-snpply of which 
ouiiMs directly from the affected i«irt, i;v«itunlly wiutte and undergo 
dcgeacniUve changes. The most typiwd KVinptoni of this lesion h, 
hnwirt'or, the crossed character of the sensory imnilysis. That is to 
MV, there ia loss of seimatiou in the op|>o«ite limb from that in which 
, niotioa is lost, and in the tiuilt in whieh motion in ]<i'>t there in hy)>er- 
^ KatheMa, w tliat tho lightest toneh may be very ptiinful. The cause of 


this is obscure, for the studies of Mott have proved that tlic seni^ori' 
tracts in the cord do not decussate od entering it, as has been sup- 
posed heretofore. There is, however, a symmetrical band of anes- 
thesia round the body at t!>e level of the lesions, and a similar band 
of hypcrfestheaia above tlie lesioQB. The reflexes of the ]>arts sup- 
plied by the diseased area are lost, but those supplied by the area 
below the lesions are increased as in ordinary myelitis. 'Very com- 
monly the paralyzed limb is over-warm from vasomotor palsy. 

Fig. U. 

Areu tnvDlred In acute aiiJ chronic |>ollr>myclllls. In cblldrcn It l« BomeUme) called *cate 
Inrautlle ptralyale. Sbadlng ghciHSBreu nf ixiif In aiilerlor cornunor gny null«r wblcbare 

Paralysis of certain jrroiips of mustdos or a single muscle in tlie 
l^s is most <liic to antt-rior poliomyelitis or neuritis. 
(Fig. 44.) In poliomyelitis the <'Iiilii will be found to have loss of 
jMtwer in certain muscles in oni- or both legs (sL-e aW Paraplegia), 
so that there is a dnigginj; of tlie toe or " foot-drop," the shoe 
becomes irregiilarlv worn thnuigh, being dnigged on oue edge along 
the ground, the involved niusch's being pciuliarly relaxed and 
flaccid, so that the leg may \\obblc, In use a crude t(!rm. This is 
sometimes called a " Puiicliinclln leg." There is no tendency to 
spastic contrai'tiiin, the reflexes arc rapidly lost in the afEected part, 
and the muscles speedily waste and develop the reaction of degen- 
eration. (Fig. 4(i.) When mntraetnres take pliiee they are not 
siHistic, and are due to hwiltliy muscles being nn<ip|H>sed by the 


diseased ones. The tciiiix-n(tiir*'of the psinilyzod pait U Inwer than 
normal. Th« hi:«u>ry in pulioinyHiUM is tliat of siulden onaet with 
fev«r, vomiting, and rcstltrtwiii-tte. Thf two fonditioita of soiite 
cerebral (Kimly^i^ and anterior poliomyolitis are so cU-arly s^ejiaratiy] 
in vrell-nuirkiil 4?aiti<« that no «rror turn bi- mad^, particularly if tlio 

yn. «. riu. Vk 

cam ot MUM inteilll* «M«bml iKlar fsi t^^ixc »( inmaillc tH"*! I'*!*}' - panJ^il* *nA 

tamtatlMin Klih rii M. (8*aK.| aftoiitij'ol leAlivohhRjr. (i(«ai&) 

history of tJie attaok tx- borne in Tnin<l, unloM it 1h> in th« ubscur« 
forms of corcbml infaiititi- yaUy in the cnrly stujiiofi. The above 
fignrn hIiow thv tno (li(T<-n?ut typcm of ])]inily<iiH n'§ultiiig from tinsne 
mrrbral and spinal di.-*i>a^ivi in the ehild, (Figs. 45 and 4(1.) In 
scuU' infantili? |HraIyc<i.-i of s|»inal origin the right lower oxtremiry 
is most fre<[tienlly affw;t«l, after this, a close eecwnd. the left ivg. 
.Soniettmcs muHcnlar atniphy pjay Iw niar^kci) in yonng children by 
flip alHindance of Aniieiitaneons fat. A point of some importanee 
in examining the reflexes is that prceenoe of kneo-jerk should not 



(■XfliKle the (lis^no^is of polioDiyolitis, Ixjcaiu*' tlio rvllcx :i' t i« niily 
(Jpctrrtved if the feotrt* whidi (^uiic this jerk iirc liiBi-ii^"'! ; t!i;it is, 
if the difiC-aHe has only affected ihal part of the coni siip))1yin<!; the 
foot, a tap on the knee may readily piwUiee a reepoiise, whereas if 
the disease be hij;her up iu tlie cord the reflex will l>e lost. The 
ohrouio aoterior {mlioniyeliti!) of atlult life presents very similar 
8ymi>loins to the acute form of iufancy, Imi is a very rare disease. 

('are niuiit he taken that [laraly^is of the leg reaultiag from an 
injuiy to the )>eroneal nerve with resulting neiirtlia is not mistaken 
for aeiite polinrayelitiw. The historj- of an accident, of pain, swell- 
ing, and the presence of a hruiw aid iif in niakUig a diagnosii^ If 
tlio--<e ?<ymptom.4 ocenr in an adult, a jioHsihle cause is [uiralyiiLs of 
the peronral nerve o4!onrring in the course of tabes. (In connection 
with this i-hapter see that on the si^iBcanoe of annstlieeia of tho 

DefortnitleB of the Feet and Le^. Much of what hni^ kecu 
8iLid in tiic pn-aHlinir ihaptcr aj< In the diseases whieii pniditoc altern- 
liun.s ill the shiipc nf ihi- hiiinl niid arm applies cipiHlly to tin- cliangvti 
from the iiurmiil si-cn in the apjieanuioi^ and niovenicntK of the feet 
and lege. The foH are finally enlarged syninietrii-ally in nero- 
nicguly and in Marie' )s pnlniiiuury oF^tcti-nrthropalliy, Iu tlie latter 
diBcaxc the ejilni^^'nicnt iif piirticiilnrly noticeable bvounac it is the 
extremities wliiirh jire <:hifHy hypertrophicd, wlicreas in acromegaly 
there is simnltjuieuiis cnhtr>;i-inenl of thi; shafts of the long bones. 
(See chapter on Handi« and Arms.) It is to be remenihercd that in 
both acromegaly un<I piiltnonury ustco-)irthr<>[inthy the enlai^nient 
(teems to be due to hypiTtrophy uf nil tlu- tissiii.')- compo<iing the foot, 
whereas, on the other liand, in myxutlenia the foot, though enlargetl, 
is puffed and swollen lu appcunincc throngh hypertrophy of the 
subcutaneous tissues idune. Often the foot appears to l>e a ^■aoA 
deal enlarged as the result of deformity, particularly that whieh 
oon»st8 in partial displacement of the artieubir surfaces of the meta- 
tarsal and phalangeal bones through the wearing of badly fitting 
shoes, or joini-t roubles, of which we sliall sjieak later. 

Uikder the name of "sciopedy" Power had reported a cnw nf 
congenital symmetrical enlargement of the anterior part oC the foot 
not involving tiie heel. Any enlargement of the legs a«woiated 
vith tliis condition, he states, only rottuIlK from hy]tertrophy of tbo 
musclee^ resulting fiv)m the effort to lift the ft-i-l. 

The claw-liand s[x>ken of in tJie chajiter on lliul part uf the body 



is peprcsciited by a similar tipfarniity ia the foot which may ariae 
fnini tJie sinic rause^, in rejjaixl to tho norvotiH h'MionH, ajw) (li'j»rnd 
ujwQ airwphy of (he interossei ami irther intrinsic mnsi:lM of (he 
foot (Fig. 47); but progretsive muwular atm])hy rarely involves 
tlii! foot, aUhoiigh it may Iiejtin there. ^V'ben progrcfwive intiiwular 
Btmphy di>e!i l>egia iu the lower extretnitief, it nmy fnll luto tlie 
claae <«l)cd pn^renaive netirul niuc<oiitar ntn>|tliy, or the |)eroiiea1 
or leg-form of progrewtive mttnciilar atmpliy, affwljs the h-g chiefly, 
aixl rarely involvei* the foot ]iro|)er tiritt. Tliv «xtcii»ur iiitii4cle:i of 

Pio. i;. 

no. (8. 

■■Cbv-Kni" trtmi urvptit i>l hii(>roii*oi 
•sd eUm loldiuto muKlm ot tool, ilir- 

I'nci'iiii<i<rniibov*<vr«>nul t««, (row 
itropbTor ubttllonUoiu. (Sunu.) 

tin- loiw low their jmwr, the ttilcro>>{>ei wa8(c, (h« fiH>t niny lie flat- 
tftiied iir <'luw-jilui|Kil, or, in olhi-r iii»t»iiooi(, uny one of ih* foroM 
of olub-foot may develop. If the defomiity is tiihitcnil, it in a 
■itniiig evirh'iicc of tl« ln-ing the leg-type of prognwwve mtHr-ulnr 
ntrophy, ami »oi iliie to infuiitili- pnruly»i>=. There will proluibly 
W H hi«tory of liercdity in siieh caH.'«. It must Ih* ctirt-fiilly m.>]hi- 
mtcd from tlie pes equimw wen a» a rtwiilt of progir'wiive mitl Bont«^ 
infiititih- s|Hn»l puralvHis involving the tibinliH nnti4-n« ux »«■» in 
Fig. 48. The toot an- byper-extendcd, tind the foot is very broad 
wIhii vivwetl from sido (o ludc nt the mi-tmar^l joiittiii. It in sU(<->l 


tlial tliir* sign i« ftiniHidered ttliai-aL-terHlk- of the early development 
of thfi diwuLHt! ill families whli tlu- heredity. St»nietiiues in plaoi! 
of tlilit dpfonnity the foot beenmei* alinoat jiarallel with the tibia in 
cxoei^ive extension, with evei^inn as the re-<iilt of ttliortejiing of 
llie jwroiiou.-* longns*. (i''ig. 4il.J In other in.ttanceri the deformities 
itiidertrt) uuirkctl oimnges a.'* llie dii^ifA^- progre^i-ii, no that tJiey not 

Flu. tv 

no. u 

rijuilmr •uilbM aiblWUng otanMiiIiia tooantctelmaorpMCiDoiu Iuuru*. ■bortanlug al 
Iniurrarw illuneMT. A C. ■ml loitfon of (hot. I> (SACKa.J 

only gmvf woDte, hut are altered in type. (Figs. 49, 50, 51, and 
52.^ In diMinftion from ordinary pro^fi-esaive muscular atrophy 
this leg-type often liji.-* niarl<fd di.Hlurbancc of sensation aatmciated 
with it (Dana.) It generally occunt in males. Aceording to 
Marie, anollier form of olaw-foot is tteen in Friedreich's ataxia, 
there being iL-^wciutod witli it elnl><foot. 

Progre.'Mivc neural niniurulnr ntni)>liy in a rare di.sea.'^e whieh ntnst 
be scpnmted from mnltiph- iieiiritii« by the (xiin of the latter afTee- 
tion and the fiiot that neuritis nir»dy prodiiivji double dub-fiMH, and. 
further, tliat in neuritiit tliero is no history of herwiity. From ixilio- 
myelitiK we «cpiimti^ it by the fiu-t that in ihic jteivneal type of piir- 
iily»ie the oniwt i" nion- [flow and by the fuel thiit then- \« ii lost of 



tilt' reflexes in t*(?vere jwliomyoIilU, though they ai* preserved for 
a Imijr lime in the iwrniical lyi>e. I'miii Fru^lri'-icli's titaxia it is 
iieparated by the fad tlint in ttint tho retlcxrui are IoaI, there 
i.i n |HH-iiliar ii>isu-ii>linu(<iif in wtilking, nn<) »n ahiieuce nf clectneal 
cbanp-s in \Xu- miim-lc^. 

In MMiki' iikifw of IixtiiHotur Hlnxiii tlnt^f^tot fr«ni loi^inf tin* plantar 
urrh in soeti, and vuTioii» dyntrophics* nf thir joints take pirn-* as the 
diMOSv progri'MCH. 

na. «. 


I al t'rasftiBlTe oiiuOiiUr Kimiiliy In aclillit wUh ■ *[>lii4l iMlDn. Tbatout flgarailM. M^ 
M. UidUllUuMrmMthit prafnMtniinutldaoriliaiiiuvlasnd tboileltondtlUanmltlof t^r^ 
Bwn. In fit. U brPwntMiwtMi or tba fluxen *n<l or iha bis toe I* vttj ttilUnf . (THOOMur 

Th« iwroncttl Icfc-type of progre^ive muwular atrophy may so 
oloMclr rceemble the so^iilled Aran-Dticheaoe type of prt:^i;;Tea6ive 
muMnlur atrupUy as In defy <Iiagn<»l'>, hut a§ a rule tlie latter tbV 
oue nfTuctft tlio artos tirsi, and ^eni^tion is aot iDVolved. (See 
diaptvr «n IIuDd»i and Aruii.) 

Waiting of the niiiscloi nf tlie inner i^iirfaoe of the foot affeetiiig 



the l)i|j; toe, and tho-ic oD the oiiKr side involving tlie inovementH 
of th« littlo toe, the interuflset and th(- flexor brevis ooniinunis, may 
occur from the neuritis due to locomotor abixi», and an tlie plantar 
aponeurosis retn^its the toes are remlcn'd iinmovahh- llexMl; in 
other caaos in place of flexion wc )£ot ntroiig i'xtitii:<ii)ii, «jt iii Llii^ 
figure. (Fig. 53.) 

rio. u. 

TBbniio lb«L (Saittaunos SKtm.) 

A shrivelled, tin(l4>v<>ln[)ed foot and le;; with dniwin^ np and 
deformitv arc si'«i iiinsl vomuKniIy n» tlie ulrimatv rwuU of the 
aoutc oeivbra! paralyHix uf infancy. (Fig. S4,) 

Anutc crn-liml piintlysis of irifaiii.'y is to Ik- »epiinitc<l from epinal 
pitralysiA of iiciiti- or Htibiuuitc poliouiyHitis iint«r!or of infanoy, or 
tliv mre puliuyini'litis of later life. In thefe there may be hilateml 
punilvKiit, alUiutigh only one leg and foot ure more often involved. 
Like the iMimlyMiH from i-crrbnil (Iih'-iihc.-, Hpiiiul piimlysiK c^niot on 
Bud(U-uly, hill there is this miirked differenec, viz., that in old wsrp- 
bnil parnly«i)« there are epniftic rigidity aud spastic eontRtctitniw, no 
atrophy of the muscles, until by ilisiiine or secondary <'hatigeH in the 
(M>nl the muscles loso their nutrition, there is marked increase of 
the refiexes, and the eleotiical renctions remain normal for a lung 
period of tiiui>; wltercsLs in the early st.igcs of aeute spinal pinilyius 
tliere ia an entire absenre of ■•[lastio contraction, tlie mti>«elcs being 



^-r-; M 

p^Qiiarly lax, flaliSv, ami lifole^*; contractJoDs with nwiiltinf; de- 
formity only urUIiig from the aoliou of hoiUhy muscles rubbM) of 
their natural antagiiniAtA. Tho contractures 
of the leg which 'KHsiir ia a<!iite infantile par- 
aly^b iif tvjiinal origin art' not fljm.'jtic, and are 
often only develo{)cd upon intcntioii-move- 
menlfl or by the Hnop(»osed hoaltliy miisclesi. 

A vpry important form of oontraetiirc fol- 
lowing (araly-tiii or ocenrritig without it, 
which it< apt U> l(wd ton mistake in diagnnitit^, 
M thai «WM in hj-Mii-rin (Fig:*. •V) and flfit, 
Afl a nile, llio ciontmMitrM (s>nw im in t»**o- 
oiiition with [Mmph'^iii. Si)miHiinrts how- 
ever. tl»cy affii-t thi- iirimor an arm. It i" ii 
i.'liiini«rb'rii!>lic of Uiiwo titninu-tiin-^ ilm- to 
hyslcria th«t thvy KVt in Hiiddcnly, am) art- 

wajrs Rooonipainod by snch hyHtc-riinl 

mptomit as borl>on,'^ui, ovarian ti-ndcr- 
ams^ and oftL-n mvus of anii^lhesia. Weir 
Mitchdll has divided t)ii.'Kr uiftei; into two 
forms. The first only involves single |«rt« 
or limited mu9Gle-^rou|», and, though tlie 
contiarturea may last fi)r years, joint- or 
romtcI&i^hangeA do not ocour. In the 900- 
imd dasrt, one limb after another i.s at- 
taeked until all means of locomotion, or 
evea moving the trunk, are Iwt, and tlic 
mtUNiltn, joiniM, ami areolar tiMiie nudergo 
ufgnnic ohaiigcti. The tvtle«4-j« an* lo»t in 
•iioh etwot in tlie tiit<' 8tiig(»4, and the eli»> 
trinal rnction c»f th<! nitiHrh-7< i* itn|uiin^il. 
reui'hwl by the mx, the |>er«onaI history, the history of the illii«8a, 
th<' po'icnm of anin«tlm!a (wi- f^hapter on Skin), and hyiR'ni-stho- 
siiif, L'ftiiiilly the eoiitractnn- foniL-* on middenly: it is very riKid, 
ami thv m<isi'lm on bi>th mdes of tlm limb are fixed; (lint is, the 
oODtracturo involve* antugonistie mu«.-li.-». Sh-i'|] does not always 
oatlH a rolaxutioQ of hysterical contraction, bnt ether or chlorr*forni 
Dwially ilws M>. (Sec chapter on Hands aiid Arms.) 

Dfformityor distortion of llie lep< may n-su1t from the secondary 
iniisiCQUir atrophy followiac upon chrouic inflamiaation in a joint or 

I'll 'ii iiiAtnilla 
Nil. (Uini-i 

The iliagnosis is to bv 

^^^^^^^^^ THE AUD 121 ^H 

joinit, Tlie niusculiir wiuttiiii; iiwlcr tliesn dminihtan(M>s arises from f 

■iiMiritis, whiuli is iu^«ociiitL-(l ^vttli 

1I10 arthritis. 1 

The Jointe. Tlie joiuti- of tliv luwor ltiiitK< inaj' he swolleu itnm J 

an Arthritis urising from mnny 


catK^es, suohftslocomoturatHxia, 

Fto. M. ^^H 

hemiplegia, rheiimatou) iirtliri- 

^^^^ ^H 

\\f, (arthritU deformanii), acute 

^^^^K ^^1 

iii>'(!litt», rerebro-ttpinal menin- 

^^^^^m ^^M 

gitis, Morvan'sdisea.-ie, septiew- 

^^^^^K ^H 

mia, or th« infections proceaaes, 

^^^39 ^H 

bikK a> acute articular rheuma- 

^ ^H 

^—^ tittui uiul tvpli»til fevf^r. 

^H I1te modt marked alterations 

/^ Im. ^H 

in iIm* joint-" are thosi' pnxluced 

/^M ^M^m. ^H 

by luK'KiK'i-d Ii^icoiiiiitor ataxia. 

1 ^^ ■ 

anil arc »i1IhI art)iriipttthio.«. 

^9 ^H 

Often iIm-v nt* iiwucintcii witli 

/ ^H 

K]>ontara!0(u fnifinnv of tht> 

/ 1 ^H 

bonnt. Thv kni-i-« nra mo«t 

1 M ^^1 

rominonly involved, tlieii the 

■ ■ ^^1 

H ankles and hips. A joint or 

K t * ^H 

^V several joints may Itecome sud- 

^^ t ^^1 

denly swollen with or without 

\ 1 / ^^^H 

{tain, and M'ithout ap|inn-nt 

\ A 1 ^^^1 

c&xti*- until the swelling iHn^oines 

^^^^i ^^^H 

(liiile massive. There are then 

l^H ^^1 

dcveli)|>e<l osseous hy|>erpla<>in 

i^w^^l ^^1 

and n teDdeiiey Ui dislocation 

/ T\ 1 ^1 

witli t-rt*piliiiion nn niovcnient. 

B ^^^^^1 

U)d t)w end* of the boni- be- 

■M' hv ^^1 

cfimc worn away and a)(«i>rhe<). 

^r ^V ^1 

DiMlocation and fnurtuivs arv 

^v ^V ^^1 

(iiinmon, and the hones are 

^m V ^1 


j^w ,^^w^^ ^1 

In rheumatoid artliritis then- 

fl y. -"^^^^^^ ^^1 

ie a gradual enlarj^ement of tla- 

^^" ^^1 

joints from accumulation of 

UyitrrlHl ifiaiin aiKl oonlnrlur*. >tiiowlns ^^^H 

llioalllluilcliiUicelMI rulUun. (Bkj»i«ki.u] ^^H 

61114I, which in tnm Is iiWirlMKl, 


lenving the artieiilalinfc surrao(>t< 

mufflicniKl, uttcvrn, and riefonned, ^^^ 

bill there are no deposits of unite 

of Mxliuin wi in gout, th« deform- ^^| 


ides b^ing du« to altf-raUoiia in tliearliculaling Rurfncx^ thctnm^'lvi'is 
ami tlie jwriflriitiilar dcvt^lopmerit nf lion«t. Th«* iliiM-u^- iilwnj-s n*- 
maiiia in the jaiat ori^nallv att-ickec), nitliougli new joiitt>i iirc in- 
volved. Pain is often seven-, iliiilocatii)>ii> «u<l fractures art- rnrc^J 
and tlie small joiiiLi are uft^'n involved. (Sec cim]ittr on Hnodi^ and' 

Rlicnnmtoid iirtliritis when ii |>r(>^n<»<(;)f to an iiilvniif«it slu^^ 
catiitex great deformity liv the lot-king of tJic joints ihrougli the ■ 
development of mti-ophyteii. By the drstniotioii of the L-nrtilagi-v, 
wnj*tJng of the nxisoles and thiekening or contntelion of the Ugii- 
mentdi^, it may cuuhc diiilomtion of all «urt», and fiiUe poitttions. la 
the greal mnjurity of i-iweji it orciinf in women between twenty audi 
thirty ytar* of age, but it may ilevcloji in eiirly eliildhoiKl. Pain is 
Bftvure in r'uine fiwi-«, iilMent in othent. Tlie thighs become llexml 
upon thealxlomen, and the leg on tliethtgli. The number of jointi- in- 
volve) variut greatly, but tlie involvement is generally synimetrieHl. 

Sometimes thii^ diceUHe, whieli \s genendly griidiml in 'ibi odm-I, 
becomes veryaente, i^peedily invoh-ing many joints, eniising Welling 
of tlie synovial sheathi* and bur»e, and iK'ing aoi-ompanie>d by samv 
febrile movement. The suddenness of its on»«-t, the fel>rile move- 
ment when the onset U sudden, and the juaJn may cause it to 
reeenible aeiite articular rheumatism, but Ute abt<enee of redui 
in the joints and of the migmtion of the swelling from one joint to 
another aids In the differentiation. The arthritis of aeuti- ivntrul 
myelitis is sudden in iti« om^ei, generally ninlu]ile, and kcoomjiiinied 
by the other symjuonis of tlmt disease [ace Pamplegiu and Anivs-j 
thfitiu of the Skin). 

The arlhritiii of oercbro-spinnl meningitis \» really to be diissed'! 
as un infections itrthritis, anil the preseuee of the ehuracteristjc signs 
of the disease renders its cause evident. The joints are many of 
tliem affected simultaneously with swelling, pain, and serous ur 
purulent effusions. In eases of septic urtlirilis the joints become 
awollen iind often suppurate, so th:it the articular surfaces become 
more or less deslroyed. This may occur after infeeliou during the 
puer|>erium or in any <-ase of pyieraia. In Morx'an's diseiue or 
syringomyelia the small joints are usually affeote<I. 

The onset of an inflamnialion in the lower end of the femur or in 
tlie np[>er end of the tibia, producing what, at first glance, »eems to 
be an arthritis and sometimes simidlnneously involving other an-ns 
near joints, should niute a suapieioii of aeutv tulcomyelilis, wliivli is 



rlueaiie in dibdv co^ph imk'AA •iiin;ica1 aid ooraest to the )k»tioiit. 
fj^miitoing conitUt of lioriii^ [laiii in the pnrt, ^rcat tenderne&i 
■nil KWM.Iliiig, aurl llic i^kiu itwii hrrak? down n^ x |mnil(>nt and offen> 
Hive dinclwrgi* miiki-i its way to tin; surfiicc. 

ClofH'l^v itUiiil li^) tliii> i» tlivmriitu t;i)li>]n-:>itiM nf iiirmicy, in which 
Uifrt i» fuiddenly tlcvplopod a chill foll<jwi-d by ^rpjit |>»in nnd »vtK\l~ 
ins of ihf ji>int« or tlit-ir nci|;hl]orh(NHl. The «kiii hfconn-« «np>r)rw(l 
witli hloixl nnd th« joint filk with pus. Can- mutit hf taken to w|)u- 
ralu this condition from rhi'iinuitiiiiii and the joint-swvHinix some- 
times seen after typhoid fever. This state is practieiillr ideuticsl 
witli the acute arlliritis of childliood. 

Wlien arttiritiH in due to gonorrheal infwtion it is generally seen 
in the kne«<i or ankl», and nccnm in men, as a nile. It is an infec- 
tious arthritis and Iil-*!.-* very ]ierHi-*teiilly, often attackinj: at the liame 
time joiiibi so rurfily involvi-d by rhenmali.-<ni ai the jaw, the vcrte- 
IhsI joint*, nnd tltn Hterni>-chtviRul«r urtiiiuUtion. Accordinj^ to 
the late Dr. How^nl, of Monti\-»l, it oiviirs in tive fornix : 

a. Artlinilific, in whioh then; iin.' wandering; ))iiinii ahout the joints, 
witltoai redncsit or swelling. Thew pcr<iKl for n lon>; lime. 

A. IMtciimatic, in which wveral joints heeonie nffeetiil, just an in 
subacute nrtlcular rheuniatiKm. The fever is sli;;ht: the IiK-nl 
influmiiiation may lix itself in one joint, but more eonimoiily 
severul Iteeome swollen and tender. In this form cerebral and 
cardial complications may occur. 

r. Aente goiiorrbiml artliritis, in which a single articulation Ih*- 
comes Auddenly involved. The pain i^ severe, the swelling exten- 
sive and due chiefly to periarticular ledema. The ^nepal fever is not 
at all p rx>|Kirti 'mate lo the intensity of the hteal sign-i. The affection 
lly resolves, though suppuration oeettMonally supervenes. 

tl. <'hninif hydrarthrosis This is usually monoarticular, and is 
j»rtictihiriy apt to iuvolvc (hi' knee. ]l come!* on often without 
'|iun, rediM^ or swelUn);. Kormntion of pun is rare. It occurred 
only twill- in ninety-mx niM'H tnliulate<l by Nolen. 

f. Burrcal and synnviiil form. Thin altaoks chiefly the tendoiLs 
and tli<>ir t<limtli>i. and tlie bur^e ami the p(rrio»t4rum. The nrticula- 
tionv may not !«■ urri-<-u><l. The burwe of the pnti-lhi, llic olecranon, 
mnd tJie fitdo Achiliis nru nioHt apt to be iuvolviHl. 

Acute arlicuUr rbeiunatiKui in the knee or ankle produnu nwell- 
tif ibe joint, retlnt-JW, heat. e3c'tHi»iti- teiiderm'Hn, inmiobility from 

in, swrlliiig of the MirrxMitidiug t4«H)es. It duct* not rvuuun for a 



I nnlv 


loiip period iinclintiKetl in one joint, and is a ppoccas Sfoompeiiiied 
hy ffver. 

Altboiigh gout is capable of cnuHing fJeforrnity in the lower ex- 
tremitieH, it has ooe fact about it which is of praotioal imjwrtance, 
oatucly, that it iiivolv«^ the small joinUt of the fiM»t, u-hik rlieuma- 
tiiiO) attacks tlie large jiKiitri, niirh n-« the kn(v, hy [tn-fcretioe. ( intit 
involves the foet iiiohI ooiimiDiily, \vliiU> rhciimntisui is iiior<! fre- 
quently aavn In tho haii<l, if ^nmll joiiit<< arc afFcvtcd, nixl the big 
toe is the favoritf [>liu-c for ^otity inikni fixation. Asi<)4> from tlio 
swellin|2, rcduiHse, and exijiiiifitt' t«niUTneH)t of pttuty joints, ail of 
which symptoniH cxcc-cd in anit«nc«« «milar nianifcdatiorw in iwute 
rheumatism, tlicri- i^ oft«n au ndditioual :iinl p(!miancnt cnu.*«' of 
tli-formity in the cimlk-ittones whtoh arc ik-jxMitt-d ulxmt the joints, 
and which an- ncvor wen in rhvtimatism. The hiKtory of fro<)iicntly 
recurriiif{ attavlt!^ la^tinf; but a few days, ait'ompnnictl by i-nlarp'- 
nient of the veinm abotit the joint and shedding of tliv skin locally, 
]K)inti4, when adddl to the liyraptoins nameil, to a typii^il caw^ of 
gout. It nmy !»■ almost ini|»)S!iiblc to determine whether a (.-ate be 
one of chronic rhcumatii^m or ^ut iinlo»ia chalk-deposite can be found, 

.Sometimes in chrouie lead-poisoning wo ha%"0 developiil wluit is 
known as plumbio gout, owing to tlie deposition of urate of lead and 

Acute synovitis is generally the result of an injury, is confined 
to one joint, is often aeeompaniH by n far greater effusion into the 
joint than is seen in rlieunintisni, anrl there is no systemic distiirb- 
au<;e. Should a single joint Iw apinrently effaced by an aberrant 
attack of acute rheninatisni or synovitis, the physician should never 
forget the jiossibility of its bi-ing a giinorrhitial arthritis. 

The ouflet of « multiple arthritis, with wliioh there are headwhe, 
chills, inten.'u- aching in tlkc bom^, joints, and mnHcIes, and a fever 
rising as high us 106* or 107°, and rarely iiti crythcmatoiw rasli, 
may indicnti' the prcsenw- of (Ien<;uc. The joint* are swollen and 
jminfnl, and often butli the large and small o»o» iir<- involved. 
Another arthritis, probably infections, is sometimes seen in epidemic 
dysentery and in scarlet fever. Rarely immediately after or 8oni« 
months after typhoi<] fever a hyjiertrophic osteoarthritis ctHDCS on 
Ms a result of a local diilicolty produoed by tlic hHcIllmi of Ebertl). 
This is to be separated from ordiuary septic artbntis following 
typhoid fever. 

In .Schonlein's disease, which is a form of very severe pnr^mra. 



i[)le anliritiH, with great ]iaiii, and piirimrii- pnijrtions oociir, aiid 
tlir |>re^iii:(; of tlie .■MiliciilanfK>ii.'i exudnh' with cHJeiua and gloiigliiiig 
the mtwotu Dienibmiu' nf th<; nimitli addit to the piotuiv. Th« 
il jtwms vm- ill, Imi di^lli pan>l_v fftllow.*. Such oiaeA are 
irp, but liiv wrilur miw tyiw in oori^ultniion witli ])r. Wilful, of 
V'iH*iII>iir}', Nvw Jvr^y, in which iihirming shniglis of t)iv ton^JU 
•ml i>iiC43il mucoU!4 mcmlmmc (H'l'urn-d. (Su- nhap(4;r wt Skin.) 
Vm' n«irl_v nlliw) ti> this nix- the joint-invnlvcincnts of hcnto- 
(philiK, which in thvir eiiddvii uiiiM-t' iiinl )Kitn o1o«cly rcM'intth^ rhcu- 
nulisni, |xirticu1arl}- lut thv Inrgu juiiitK arc commonly iuvoKx-d. 
Thi' litHlory of the jkuttuiil biin-; u hlt'ttk-r, or of his bi-iug n-latvd 
(o one, may vtt-ur up thv <liEi^iiu»ii>. 

IntviiHC Bwvlling of the leg, uiiidc fram that due to ordinnry 

Fcpderua, may be dnc to milk-k-i;, which is a condition oF swvlliii); 

of tliL- entire limb, gonorally limited to one mdv, aud seen dui-itig 

the pucrperium or after any ouc of the iofcctioiis fevore, such n« 

typhoid. The joiutK are not psirticnhirly affectt-d. On the <wn- 

ttary, the calf of the log is the j>art moel affected, it being whiu*, 

[firm, hot, but slightly, if at all, ledemutoiiit. Pain \r> axces&wv, 

[there is entire loss of power in the affected limb, and iln temjicra- 

|tur« \» niueh higher than normal. 

If tlie Hwelling of the leg in bilateral and pita oD pre^ure, it is 
[practically always the reiiult of anasurca from mnal or eaixliac difi- 
s; but if uuilaieral, it may be, an just fltated, due to thromlMiitiH 
Ittie femoral vein (»ee citapter on the Skin; Ctxlema.) 
Time very im|>ortanl senoii.t alcerationn in the nutrition of the 
'foot ri'iimin to lie noted, namely, jKrrforating ulcer due to tabett 
dorMtlin, dialH-tic gangreniA, and m'liile gangrene, Perforating ulcer 
uiually RpiH.'ur^ in one foot, beginning with the formation of a blel>, 
whieh chiini^!> tn nn alntcTKit, whi(rli in turn In fullotreil by necra»i.'i of 
all (he ti^-iK'" "f tli>' foot inutiediiitely undi-rlying the destroyed jkin. 
Willi it :>!!' as-.." I It'll the tiigiw of ataxia. Soineiinieit prfornting 
iilni-r of the foot oirunt during the wumc of dinbi-tps mcllilun, but 
it i^ proi«ble in mnny such i-asiK tbut locomotor ataxia i» a«Mwiat<,><l 
witli diaU-te». {V'tfi^ &7.) la diabotie gangrene the tucH nr« 
nearly always affected iu prefcrcner to other partp of iIh- Iiody. 
An analysie of the urine will aid the diaguoHis (mw chapter on 
SkEo). In senile gangrene the age of the iinticnl, biu) bloodvew^vU, 
and the atxwiice of a miflictent caniw for g»ngn-ne. \w from trauma, 
iMt|amtu the case from any otlier condition, while the fact that Knile 



Fia. a. 

gangrene generally affects tlie inner side of the foot, esi)«njiUy the 
big tm, and is a dry gangrene, renders tbe diagnoniii v&ny. 

Oangirene of the extremi- 
ties HometimeH follows tbe 
infectioiiH diiWiiAe^, »ucli as 
ararlet and tvplioid fevera, 
from tlin>nih<wifl of tlie fcm- 
ornl artery. Ii may also 
occur in the emirM! nf ex- 
oplilhaltuio goitn\ 

Miin* riircly gnngrciiv of 
itu- foci iiiiil iiiiinl:- follows 
eiuboliT^m lUw to vuivular 
cuntiiti^ dip^nisv. It is usu- 
ally a ntoi«t gtiii);n'm-, vx- 
tr(.'in<.-ly ])ainful, and septic 
ffver may ensuo, 

lu this oonnoL-tion men- 
tion maybe made of " Ma- 
dnra Font," or niyi-ctonia, 
n flinniif Io«d iILhiisc of 
Iropinil elimntiit and culled 
" fnngHB f<M)t diiirsm;" in 
India. .\ xmiitl tumor do- 
vHot» un the fcxtt or hand, which, after the lapse of twelve to twenty- 
four months, bursts an<l leaves several siixisee from which escape 
blaek jiartiek-s or whitisli-red bodies like iish-roe. The diseuse miiy 
spreiid all the way up the leg. The [aile particles in th« disclmirgo 
look like actinomyoeH. 

Altenitionii in the ap)teAranoe of tlie tihiie or shins often fpve uft 
a clear iilea of the pn-seins- of ljit« sypliilin, t-ilher l)ecause <if gum- 
matous •fwelliugs in tliis neighborhood or owing to the development 
of peno»4teal thickening and exoiflnscK, 

TabtUd ulDvr. ninHai.Bi«:i Humi.) 


FIG. I. 


Cnil o) LocnIliMloi «* CS'tieal C*rtrat ••rMmi^M o<i Eilam«i $url«cr c' CBrfbrwn. (BrflU'* 

FM5 2 

Cnart 0* l.c<al'i*l>a>i ol Cot^ll C*"inn Mipf^ -4^ »-. W*d<>i 5uH>e« ol CsfMin^ (0'*|h) 



Uavixo oon^iiderix) the raanifestaliotis of tliAease lui seeu in the 
Anas aii<l Ie^h in citnaection with mnnofilr^ia and paraplegia, 
h|>a.iiu Slid contracture, we iniiat now hliidy tlie diagnnittii'r meaning 
of hemiplegia, or that form of juiralyain which involveo the arm and 
h^ itiiil liead on one itide of the body. Thi^ form of paraly^^i^, 
when n>m|>lete, is tilways ilne to a lesion arising above tl>e npinal 
(.'onrl — tlinl is it lit cortical or dne to legions in tlif? Uiwer Imctt of 
till' brain; and the dinracter of the paralysis, the asMociatioii of 
othvr *ym[>l»m» with it, and the hiittory of tlitt |uitient itud hit* ill- 
neM, will rt-iiiliT n ilittpumi* ca^y us to the iipprojcimulv Mte nf the 
loftifMi in miMt nif«(«. The mtutt ivinimun eaus^ nrv hcmorrhuge 
into till- (i-n-hral ttsriiK'ii from u rii(itiir('d hloodvcK^ol, or cmholiHiii 

»or throinbofiis of some vuskl'I •iiipplyiiijj; importmit artiis. 8tUI 
btiier cutuies of hemipl^ia arv bruin-tumors, meningeal hemorrhage, 
dcgi-nenitivf proc-cwcK, aud hysteria, 

BefonL- wo unter into cousideration of the various symptoms re- 
Mitting from central nervous lesions it ia well to stop for a moment 
for the purpose of clearly understanding the aLiatomy and physi- 
ology of tlic iMrtfi involved, in order that we can properly study the 
resultft of lesions in tlie nerve-centres or nervous tracts, 
^ft It is not ueccssary to remind the render that the brain is divided 
^*inio thpH! areas, the frontal areo being concerned with intellection, 
the middle arm witb motion, and the posterior area with sonsalioit 
id special senae. These areas are again divided into rtiiliareas, 
"■each of which governs or is eounectM with several fnuctioiis, and 

|6till further sulxli vis ions exist, in which reside the venires govern- 
bg siiudi arena, as, for example, a sitigle muscle or group of muscIcM, 
[I'ig^. I and 2, Plate I.) Dts^nM' of nny \inn of the hmiii surface, 
Ibertifore, mwliHcs more or Ipjw the fuurliou of tlinl |«rt and the 
part of tlie body tribniary to it. Itenoath the Hurfatr^^', tlmntgh the 
siM-nlled whiti' miUtcr, variniw libres \mh^«, which carry to or fmno 
tio cvulrvfi in the oerebnd cortex the impnlsun couuucI«d with their 



functiou, aud these fibres approximate one another more and more 
closely in the lower {)art of the hrain until tliey form a bundle 

DlaKniin ghowlne the flbres from tlie cunei nirmini; Ihc caruiia mdiHla, whlcb after ihej' are 
appmilmaieil puw inio Ilie liilonial oa|nitle. Ii alto sliowa Ibe dociiiuHtloD n( the pyramid of 
the ktlBidf. B-hlrh i«mi- lo ihi; rijfhl riileof thu spinal wiM, and Ibe dlrucl or uncnmed tract. 
Filially U alM »howA tht? Bccoiutnry lU-gfiierutlnn whJcli iiccurv after cerebral liemorrhagc or 
Bollening^ and which folio we' Ihi' coiineof flit- motor lra«^I^ hi to I tie t<pln>il cord, tJ- Silo of 
Iculon. The eontliiumiM tines are llUrea giiing lo the Jegt. Ihc dutled ate ihowpilng lolhe 
arms ami motor cranial nerves- iM^xlied from Van liEHiTHTKN.t 



Outline or b«rftwiiW Mtckm «f bniD, lo Mi>ur ihe IdMrmI o^nd*. Ktiunl fixe, Tba 
inijr ■MWroT UwoMlex MndtlaiMriiw !■ leR iiii>UidBd.billUi>toribiFRort>iu •irlaluin kud 
e(«l« IbatooMt to *h«d«4. () r. opUo ihuMmuMliiiirlng itiv nirdlaii, litrrvl. and anMrlOi 
hqkUI'. XL. Dudeau IraUcuUiii. ilioiilnE Ibe I'oisnipn laic*. iDd i1>f iim«r dlTirioD ofth* 
glatiM |i*IU4(u TarTBD»U; .V C. Dai-leua cauilaivu. Ibc 1*fke lioad in fKmlo/. and llw dlmln- 
Mint Uil n«u iiM ihalantii : <; <b*liii«ror iTiviiiiMiial miniii*. Fnao••e|tr^'io•^B^e^l*" 
tmtktUie psHUonoI theraniiuldal inci aii nhok. aod Ihe Kvsral fcilen indicate blMdlf 
lh*nlall<t«pa4llcmof tbonnnil (»nii<ll'ii-uLa nt itin (nfl. iiaiuuS ai-con1lii|i tu ibamovo- 
Maalaaltll ■faloti ll>«7 an eonotrnfii : Ihii* A'lW, moTrTnirtiliol ihc (jm: Und. of llie bead ; 
Awm: vf th« lOOpw ; Jfaa>«. or (he mouth : SHuhJ. of Iho ihouMor : Bbwt. at ilia clboir . 
, JMflti, af til* ImiiiI ; Jiikit t4 Ilia aUomtii ; ntp, of the Iilp : A'lirr. iif Iho feim i Tbo, o( Iba 
I: 9. Um MnipM'fr«otn|iltal Intel ^ ot. Obn* lo ihc «edtilial loho: <>p, oi-iic mllaUon. jU 
IniileMl UiatbtMof the Iranial mo, in the foi* timbor the raiaaletu nunlof (beppun- 
fldal Uact, ran abnoM bocUoD tally, vamivl null lbs iilanoetf the MrUoii. o^lhatiMtnixn 
pat Ika enniM callaama : 9fl. Ibe aplcnluni of the •anie. bolh out aonaa horlaoDlalljr. Tbe 
Ikiek darli Une IwUrataa Ihe lioundary of Ibc OaTlll«a or Ibo antcflOf ami dcaoandlng bonu of 
Unlaurat tvntrieln aii-l at iiir !ti]M nniriol*. tba iw« mitrielea btlo) laid opan lata ana tqr 
UiataaiOTalaf IbeTeluin and (bonU plaiuik tig. Tba oral nutllna lu Iht ton parlortlili 
MTlty tMttmim tta Ibwix. IammI toibantwlaui l«iilieiiUiiiat«a«tn in outline iheolaii*- 
tma, Iba •onu «r ib« liland of IMt, and Ihi opoKulam or oonTotuihin brvtlapiiinc Iba 
luT Hall. riilaatrtadMdio* which In iboblad part of tlWMcUon. 

130 rH£ NAytFESTATtOh' OF t>lS£AS£ IS OROAyS. 

(oortmo rafliiita). Tluis we sw in Piute II. Iidw tbo fibiw! arising 
from the mi'ldlv area of ttie eortex een-brl paws ilown tbroii^jh the 
leotJcular aiiclcufi into the tncu ur angle of what k ealletl the iater- 
□al cnptnile. This is a ktoral view. In Fig. 58, which also shows 

fVaHMl 1(4*. 


of rff/telan 





the resiilta of a ItMion in the oajK^ule, we get an antepo-|H>sterior view. 
Thes« fihrea are arruiged in iiuoh a wny that tho!<e arising from the 
lower juart of the eorlex, n.s la the faoe-ecnlre, lie nearest tht.< knee 
of the na[ toil le, and tlio:«e higher, fnrtheftl from this point. {Pig. 
69.) After the motor fihrtw have jiaMsetl tliroiigli the internal ««]>- 


ll>*or*M WKMino OnurM «* Wats' F*m Inm m* C*f«Vrw« •W C*ra 
U VM ^'inMrU' (FlMait.) 



^bdIc lliey {Mm into the cnia cerebri of that iiide, which (the cr»» 
aercltri) comiectH the hemiopbere of the Mine sicie with tlie ettv- 
bellum bebiud it, and the potm and mediiUa below it. Tli« ontm 
cerebri are two tbick, cvlindripal bundles of wbiu* mutter whirh 
emei^ froiu the anterior bonier of the |>on.s (Pig, liO), ilivvr^ lut 
they {xtiiit upward and oiitn'ard to enter Uin under )Mkrt of ejieh bonii- 


JOnrttut mf rv/arap< 

l^it'iit arm 

rM>fu«>li*«lnsUia|aDer*larmii(«uictital ibomoiof (r«aiftiKlibo*mciarle*Mi*»t 

sjibfrt-, »■ if ■.tratobin^ out to receive tlie motor fibre* from tlio 
iiici-nml <'a]i<ulv. From the eriini <>er('bri the mutur fibres pam 
downwiml into tlio |iuns Varolii. Here tlie fibrM whi<rh linve 
bitlicrlij tntvollwt together divide iuto two purto, namely, thoM 


from tlic face and tong;iic ociitrc, whicli pRUH to ihc oiipu^lte micI 
and iKfoiiic oonneetcd M'ith tlio iiuL-li-i ot (Ik- facinl nn<l liyi'ugli 
nervm, whicli act iis minor ceDtrtt) i^wriiiDg tlio fu<.-c an<) tongtui, 
and the fibres for the iimi, leg, aud trunk of th« Ixxiy whk'h pon- 
tinue on down tn the niediilln oblungutn, whvrc tliev form ihv Ht- 
called pj-ramids, and having done so most of the libros cross to the 

PlO «2. 

Slicivrinf iho nwcbanlini a( dlfDiNut liomlplislH. A hMlon >( A caiuM Coniplaw li«ml> 
Ii1«Bla hj dntroiins llio iiiulor tiscu Otic Bl U mum* iianl]nli a( Ihlfd cnnia) narM (mo 
ocull I hf dwlrcrluK 1<* Duclcui oi rail »u mme Mq. ■Dd i>u«l)nli a( •cm Mill ]ts on oppiMlll 
ride. AI*ilouUFwuM*I>>cliil|*1i)'oiiuinoRid«, hvnil|>l«|liion oppoalle tid*. Ina) 
•t B tho hffOcloMui would bt allteiod on one ildc. with hMotpLecli on ilw olber. (HodUM 
(tnm £i>ijiaxii,1 

oppiK^itr side of tlM> »|ii»iil (■■ml (tti« crotwmg of tlu^ pyiiimidA), Htid 
so form the oruc^notl or liiu-ral pymmliial tracto. (I'')g. 58.) A 
smiillor niiiiibur of tibrc«, howuviT, )mis« (UrcK^tly down to tho 8[Hnal 
conl from thv riK-<hillii oblmiji^itii, :iiid form whut i» cnllod thv dirvet 
or anterior pyramidal tnicl. l>irect, bccauiio it dove not cruse; ante* . 


nor, boo»u»e it West atotig llie «<lp; of tliv nnU'rior fissiin- of tLc oortl; 
pyrainiclat, licmutw il KQn\f« down frotu tlw; pynuakl. TIiU is mmv 
timc-'i uilk-d Tiin^k's c-oliimn. (Fig. 68.) It w hy mvime of th«eo 
two traces io the «pinftl oonJ tliat motor impulses jmm down to tlte 
ttervfr-trunlu miil mu-idlpit. 

We can iiti<U-r'liin<l, thorcfoiv, timt if u flniall lesioa occurs ut the 
peripheral ctuliii^ of the oufuda niduita — that is, on the (.■ercbml 
«ir1rx — it will ouly prmiuw ii limitc\1 punilvsis. Thus, as wen in 
Fig. 61, II clot at tliL' unii-cttntre would only involve tli« artn-fibres. 

Flit. (9. 

; mcU Id wtbui tori. U Xawim hum* of (i«r mattar wblab «nUlii Itao Mil* 
tD*«diD|tli«na*riiliinor lh«nuu«l«utdtl*i>riMU>tIieDw(or raott. 1. PoMoitarlionwM 
(Mr mmHt whleb no*ln Itia taiotj toou S. Cmweil l»ui«l prrunliUl at ehlaT tuoMt 
IMeu (RiD oanai cf bnln. 4. Oolumiu of Runlacb n Un oiiUr nunry truu nrrrlni 
iBpolM* ocrafl), *. ColumuofaotlorlniierHiuorT KBcUouTrkncloipuImiipwanl. Tsc- 
OtaMnilMIIlir. (. DiKel OMOteUu mot. wlileb eanle) ImpiilMS uf a Miwaty cliaraelu up- 
wud. TT»jt ot miwcilt iiwt T. AaMro-UtUnl UmU, irbleh ooTulHof flbtMconiluotlns Uie 
tKjrnMtHOrtbccovdlnlotbMor theoMdiilla. Tbojr niDUIo anHrlof ngivv-tixiU atid ai« 
IbacfeMiMllftcnBM tfltocM. Thare an aln Uarin lu Utt> root tu pain aiid lantpuMurt 
MHt. K CWwon of Taitk. nr dtnd aiMrtor pjnaMal traol, iibloh uxrlca Imimlaaa ol 
iitommfd. 0. t^Mial mind tncu BOW hT. 

If. howflver, the Icoton l>e hnvtir down whi-rc tho flhnst of the corona 
nidiiiiH iiH' gi-tting chMcr nnd oloscr, ns, for eiciiniple, in the intenisl 
OMptuh', then I'vcn n small lesion will produce w><Wpniid pamlyiuSf 
fliaup it will involve a larf;i: »iimlx.'r of Hbrti! ninnin^: uhimali^ly to 
ridety M'lumtJ.'d areas in the hoily, and, if large enough, prodtice 
liptegiii. (Figs, 61 ami 62 lesion A.) If the lesion Iw situated 


ill the \toni* on one sidfl, it will cau^e fncJal imntlvKiit on tltiit side 
nnd hpmi|)1egia on tho o|>pci'«it« sulfi of the body, bMUiiMV, r» sliown 
ill the dtii^rram (l-'igs. 61 nnd 1)2 M), it will, under thtg» circum- 
:^tniioi>4, diT*iniy thr- fiicinl tilin.'x iifu?r thi>y have pros»i-d, niid the 
I'vinninin^ motor tiling* hrfoiv thi-y crow. The vuriutts tTurti> motor 
nnd »cn»or}', in tliv is|iiniil uunl nrc i«howu in Fig. 63. 

FIG. fli. 

DlagramotUicuterlMCf ItebucuriBcbnlii. uliaHiiig £.0,.thaluiUaular optic, and LAj 
laDllMiUrMiUMtMttf uiarlML Oiipof itiv Uiivc it rtlM tbviinciyaf Mrabml bvn 
r..l. ToHtibmiiL Si. eplnaUi uitvrlDt &^. 8tiliuiUt|«ilo[lor. a.A. ISunuttwUhm»4UM^ 
bniwlMB. CAj. a. CanbraUi npcrlar. ei. OtnlMlU Intorlo*. Cp. A. OwAmlb pcMaiUt 
(pnftindK tanbri), Ont. p. A . CnmniitnlnDlai fvMetloni, Ca.<. CaroUilnwin. «.A.Opb- 
liwlmlck. Cm. A. CTretimlU media lA. TauM SylTll). f. A. [Onilul*. en. A. OMp. KMatl. 
Co. A. CoFClumlli iBUrlui. Om. A OaBinualoiai klileilot, Ccnjt. A. CMp, MlloM. 

Hemiplegia from hetooirliage ts chanotenawd by sudden on<«t 
in most outes, by more ot Iom) mental iliHtiirbanoe and dworder* of 
motion, sonsntion, ntid of ilie spL-oinl iteiiiHM Rooording to the ftlto of 
the leaking v«)«cl. The 8kin-reflvxe!< nre apt to be iiuirkitlly dc< 
oraisetl nnd the d<H>[> r('Hexe-« inor(»i<e<l, but ttiv bladder nnd rectum 
arc not usmilly |iiimly»^l. iilttioiigli in the first tiluwk of the nocidcnt 
there miiy Ik' ve«i4!itl ntid rectal incontinence. The mental disturb- 
anoe umuilly nmonnte to a rapidly oneoming nnenniM^iouftiieiss iu 
hemorrht^ic hemi|)tegia. 



The fjuestjon of the loontion of the lesion is very imiwrtAnt. In 
the giTAt niiijority of tSSOS it is situated ubovo the jiotnt at uliich 

Idle (loctiKsatioD of tlie motor fibres tukes pluct* in the lueddUa, and 
ie, tlicreforc, on the opposite Hide of tlie body frutu thiit on whicli 
the hemiplegia exists. If, however, the le^jion be below the deeus* 
Mition, the |>urnlyHi<i and lesion are on tile aami> side, as just described. 

■ The most eoinmou site for the lesion in hemiplegia is in tlie knee or 
]>oHterior limb of the internal capsule, owing to the tact that the 
middle cerebral artery in one of its leoticulo-striate bnuicbee per- 
forates the internal capsule, and ends in tlie caudate nucleus, and 
—^ tliia artery is so commonly ruptured that Cluireot has called it the 
^ "artery of cerebral bemorrliage." (Fig. C4,) If the hemorrhage 
does Dot involve tlie jmsterior tbirU of the internal capsule, tliere 
are no sensory symptoms lutsoeiated with thp motor los«, bat the par- 
alysis will be practically universal on that side, involving the leg and 
arm, and the lower |nrt of the face, mo that the mouth \n drawn 
^toward the healthy side. (Kxpliiined by Fig. ">!•.) The symptom!* 
ciated with hemiplegia due to lliis eau^^ often become very 
severe becauite the heniorrlingv ii^ mi liiat the lateral vea- 
tricle> lMii>ini' R\]fd with lilciod, and from tliein the blood po^wM to 
tlie thinl, and from thcix- to the fourth ventricle, where, by pressure 
^fc ou the vital centres, il speedily pmdmvs dciitli. In such euses deep 
utKoiiBciousiie!$s, stertorous bn^itliing. a slow, full pulse, and a flushed 

»Bldn, becoming eomewlmt oyanotie, may be present. Kecovcn' never 
oociiDS for the secoiidar)' inflammation, or softening, following the 
outflow of blood proiliiees fatal results, even if the patient survives 

»for some days. 
In casra in wluch the hemorrhage is ver\' limited consciousneas 
nay be l<»t for only a brief perioti, and at most there may be only 
mental confusion. Often in mild uises there is a slight return of 
power in the affected side within a few days, and the temperature of 
the affected part, which has been rai!«<l, approaches the normal. 
Pinally, after six to eight weeks the dominant symptoms consist in 
partial loss of power of the arm and leg, and tlio faiunl [>aralysis Iiils 
H.pcrhaps entirely disappenre^l, altltough the tongue when protruded 
may tend to go over to one side. If Uie case does not ]MS9 to such 
favorable results, in.ittwd of recoverj' of |M>wer al tliici time tJiere are 
I'develojicdeontraetionnaiH] senondan* rigidity from degenerative {hih 
I exlending u> the pyramidal tracts. (See Fig, •iS.) Kltzig Iuim 
tliat thcM! roiidition.-> art- apt to be leaH inarkt^l in iliu mom- 


iiig, Wastiiif; <if the ixiruly^xl niiisolett only vnsiKtt from llic disuw^ 
and not from tnipUu- clmiiKc 

A\'livti ttiu ciiAc t» not of thv vor}' «;vi>re typo which caiiws deatli 
in II few himri^, and yt't thv k-siontt are sucli tliat recovery is not 
gitiiig to tnke iiliK'c, llie psitivut at the third or fourth diiy ))ct.'omcs 
uncoD»ciou« a si-cond time, hU temjienittire rise^ be mutters, and 
gruwi< restlv^^, Rnully becomes coiuHtii«>, then devolupt- respimtorj' 
fuilnre, or a hypoittutic conj^Gstion of the luu^, and dies. 

When a patient Is seized with headache, dizxmeee, vertigo, and 
vomiting, and rapidly oneoming hemiplegia and bemianfestheiiia, 
attended at fiist with no loss of coiueioHsuerw, but in a dav bv 
uiKonaciousneHfl andeoma, he b »ulTering from what has been called 
*' ingravescent a]>nplexy." The hemorrhage, nnder these circnm- 
stanoes, begins in the knee nf tlie int4-rual cap!<ule, [trm-eocli) Imck- 
ward till it involves the oeotKirv fibres in the internal cajMuU-, and, 
finally, breaks into the lateral ventricle, won after wliioh d<nth 

When a hemiplegia is followed by rigidity very early, with jwniwry 
involvement and convulsions, the lesion Is prolmbly cnrtioal, or, 
more eorrectly, is secondarily eortical to a dwper hemorrhage, nod 
i(pn.-ii(U over the i^entRw for the lace, arm, nmi leg, ^[ost turn- 
uionly, Iiowvver, cortical hoinorrhugcs arv due to injuries, or they 
may arise from uupn>voked vaw;ulur rupture. In any case, tfaey 
are nsuully nsherL'd in by oonvuUiouit. 

Where, on tlic other lumd, tlicre \n {Hindy§is of tlio arm, trunk, 
and leg on one side, with facial ]Hiraly»if- nnd anaesthesia on tlie 
opposite aide of a well-murketl typ, associated with early rigidity 
of the paralyzed lude, conjugate deviation of the eyehalla, very 
marked rise in bodily tempenitnrc, a contracted pupil, atid convul- 
sions, with difficulty in ^wallowiiig and iti speech, tlie lesion is to lie 
found in the pons Varolii on the side opposite the paralysis. This 
is due to the fact that the injnry is below the deeiissatiou of tlie 
^ial nerve, (Figs, (Jl and 02.) If botli sides of the face are 
paralyzetl with hemiplegia elsewheiv, the lesion is in the pons where 
tlie facial fibres cross. Pons paralysis is nearly always associated 
with giddiness, vomiting, eonjngate spasm with nyslagnius, albu- 
minuria, glyoa-iurin, and marked dii^lurbances in the rer^piration and 
beart. Pontile hemorrhages are, however, very rare, an<l n«itally 
are rapidly fatal. 

Finally, if there la liemi|>l^a involving the lower [wrt of the 




fnce, Uic nrin, niid the U-g, nnd in aiklition |Miiraly»i)< uf tli« U|>por 
{■art of tho fiive, aii^J plueis (rum pumlysiif of the fuciul aii<l vctilo- 
motor nerves OD the oppiMitv «id«, iiad iii aswciution im]uiirv(] !K-ii7>i> 
bilitr And vasomotor changes in tli*^ limbs, the lutlon is probubl}' in 
th« cms ccrtltri on thv side of tlio upper fHcliiI panilvsiti— -thnt '\», 
(ID Ihi' tiailie akie as the ptmiB; but thig is only true if thi- tno p»r- 
alysed have been simultaneoHs in occurrence, as it is possible for 
one lei^ion in one place to jtriiduee jinralvBis of the face and another 
elsewhere to produce ilie beniiplej^ia (^see Ptosis in chapters on Face 
\tiA on the Eye). 

If in the development of symptoms of cerebral hemorrlia^ there 
be little hemipleg'ia and tenijiorary uticonsciou-iiK-ss, folloned in some 
faoim by a sudden agj^ruvation of the iiymptoms, it may be tluit in 
tlif ttoginning of the atlaok the le-iion has Wen in the frontal lobes, 
but lias gntduaily oxtondt^l lim^kwnnl until it has ruptured into the 
lati-nd ventricle. So, too, ii liemitrrhafit- iutu the iM-apilal lob*' or 
the posterior giart of the jiarietnl Inbc is rarely ninrki^ by much 
Itentipk-^ia. and, if ])rcs«'iit, tiic leg i» mon? jinmlyzed tlmn the arm. 
The 4:liiirn<'t*'risli<; symptom, however, is well-markul heminntvs- 
thesiu (sci- ehnplcr on 8kiii), and heni ianopsia (ecc ulmpter on £yi>). 
Geiiernlly, however, such changes result from a thrombosis. 

Wlien there is devela]H>d, in caset- of hemiplegia, aphasia or dis- 
ordered speech, there is probably a lesion in the neighborhood of 
the thini frontal convolution, or the island of Beil (see chapter on 

Hemiplegia may l)e due to cerebellar hemorrhage, in wliich case 
there are loss of consciousness dei'pening into profound coma, cou- 
trai^iLtl [Hipils, vomiting iu many of the cases, and liiially deatli 
when bemorrh^e breaks into the lateral ventricle. The diagnosis 
of cereliellar hemorrhage is very diPfiotilt. 

Of the irregular forms of hemiplegia there an- several. Sometime» 
the \e^ is from the I>cginning more affected ttian the arm, and 
remains pinilyzed long after the fa<-e and arm have recovered. 
Tlic leg may become rtgi<l and distorti-d by oontrnetures, and tlieru 
will (iflen l>e found pra-«itnt marked aniesthesia of the .'^kin of the 
purnly/fd leg and arm, with liemiauo|isi^ atul aphasia. Such .symp- 
lo<o» indicaLo a losiim of oompanitively tunall sixe involving the 
tegi^bn-- and M>nie of tJie i«nsory fibres in the internal ca[inule, and 
n-Anlts from nipturv of tito leittlciih^-optic artery. When tlie arm 
•uffent muft the Hyniptoms jiuit d«Hrnl>ed tm in th« leg are »e<>n in 


it, Hiiil motor npltitHiii, !f thp lesion is oD the ri^lit side, is often* 
very niHrkoi], as is also fapial paralysis. This is suppofted lo be 
duo to llic aiitvrior fn>ntat artery, a liranob of the inferior anterior 
ocrtrbral artery, becoming diseased. 

WIr'u post-licmiplegic chorea attacks the paralyzed limbs Uiere is 
often a focal lesion in the iiosterior extremity of the internal capsule. 

Th<? symptoms we have just detailwl may also ari?«, as we have 
already siud, from embolism or thmmbosi.t of the eereliral vessels 
as well as from hemorrhage from them. How are we to sejianite 
the hemiplegias of hemorrhage and ocolu-^ion ? In many ca.^*c« this 
is impn^ible, but there ai« xonie difFei'ontial jmint^i which may aid 
us. In tJie first place, thrombosis is a condition of ad\-nnocd age, 
while hemorrhage may occur at any tim« from tliirty yimra of age 
on. The prcflenee of lii>mi|>l(>gi» in it young man, tliervfore, 'n^ proh- 
ably not due to a thr{>uil)nsis. A^iin, hemorrhage occurs oftvn afiej 
e.\ertion or the drinking of 8tiniiilimt>, nod ououn* rarely t» steep, 
wliercTs ihnmiboHi't not rari-ly comc-i «u under tliow <-ircunwtniicp*, 
nnd oftt-n dfvelo]i!> during tlie night, ho (hut the juilient awakes 
paralyxed, but n patient may have both thrombosis and itjioplcxy. 
In hemorrhage, coiiM-ioimni»M is gem-rally lost, whcrciis in throm- 
bosis it is often only dimmed. Vomiting and coutnictod pupilH 
from pressure on the lower centres indicate hemorrhage, while their 
absence may point to thrombosis. Finally, the general systemic 
shock and febrile movement are apt to lie greater in hemorrhage 
than in thrombosis. The history of syphilitic infection, pivKlucin^ 
an endarteritis, also points to chrnmb<.tsii^ although hemorrhage may 
arine from this cause also. 

The diagnosis of eml)oltsm producing hemiplegia from tlie panil- 
yw9 due to hemorrhage is always more or less dillioult, but the 
pro-^ncc of chiiinic or iilrcratave endiHrarditis or their results, or 
otbi-r oaune for the formation of emboli, iiiiU the diagnosis. Where 
the cau8C ii* embolism the onset is Kiidden, whi^rcas in tliromho^vis it 
18 Hometimes nmrc gmilnnl. The [wiraly^ii from embolL^m is more 
oummonly ou the right )>iilc uf the hudy, owing to the fact that it 
is more easy for an embolus to pass into the left middle oervbnil 
artery than into the right. 

Spitr^tic hemiplegia may be due to cerebral tumor, and i» often 
associub^^l with oonvulsious, particularly if the growth be eortjcnl. 
Very often the paralysis uf oerobral tumor will be found, fmm the 
history, to have come on gradually. Thus, the history may be that 


I at Br^t tbe )>ide of the ftu-Q liot Ih-vii paralyzHl, llivn thtf ami and 
then tli«^ leg, and thai tliv fompl(.-to lo»< of ]>owcr ha^ nut )>een 



I 1 

■Ddd«ii Iitit gnidiiul in the purt ittTL-ctcd, or that a ouiiviiUiun lia> 
left thnt sifle, which wa» previously unlj* ini|)»irtitl in Mrctigtli, 
tiilnlly |KimlyM'4l. 

H^'tniplcgiu niso conicH ou as a result of cen-bral (typhili^, nd<I, 
aside from a hiitturj' uf specific iiifeetion tiud n%ponse to H[)cdfio 
liM-clir«t>oii, presents few characteristie si;;os. The presence of in- 
tense htisdache, oonvulBious of an epileptiform type, and tJic faet that 
the psmlysis oocutb in eome caaes in early youth, point to its origiu. 

Another auine of heniiplc^a ui diffune cerebral sclerosis of one 
hemisphere (not multiple wierosia), in wbicli the rnogt constant 
symptoms are, in addition to the paralvriii*, evidencai of motor irri- 
brtion, Mich as epileptoid cniivuLiions of a bilateral or nnilateml 
character, rhythmical or arhythnii<-al twit«hiagR of the muscles like 
dmren, and dementia. 

Hemiplegia may also arise from liK-niatonia of the dura mater. 
The symptoms, aside fniui the |KiralysiH, arc licadache, stupor, 
irregular pulses, vomiting, and coiitmrt«<l pupils, or, in other words, 
symptoms of oerebral eoiupressiun, Suiuetimcs Iwitdiings of the 
laralyxod smIc owitr. and if tlw clot l>e near the thJixi frontal ctm- 
volution or the island of Rcii, iiphtisia may be pn-sent. SemQition 
il usually not involvtxl. The diagnosis of this form from that due 
to h<rinorrliage is often impossible. Similar symptoms, too, may 
sriee in the course of Itaynaud's disease, 

Hemipl^a arising from acute inhntile cerebral paralysis has 
many of the distinctive features already described when discussing 
the paraplegia due to this diseased state. The a^v of the patient, 
the occurrence of epileptiform convulsions and of allieboius in the 
affected parts, and the [>atientV history are the important |k>!uIs to 
be recalle«l in making a diagnosis, Tlie li'<4ion is altvays due to a 
cerebral hemorrhage or to embolio softening. 

Wlien hemiplegia oocuni in lo<?omotor ataxia, it dejiends not upon 
tite disoasir, bat upon a oon)])liniting hcmorrluLge, endmlism, or 

A slowly devclo|>eil hcmiplvgm iDtiKtinicn rvKiiltn from midtiple 

lorwiii, (Ih- |Kithol(igical pnxi'T^ involving the side of the poiitt 

1(1 s[Hnal cor<l, but the intention-tn-mor, the |H>culiur sjH't^^h, llio 
nyittngnitui, and the very excessive reflexes aid us in the diagnosis 
of thi* cniiNe of the lum of power. 



A fomi of hemiplegia whicb is often very misleiidinje: is that 
oocurriijg in general paralysis of the innaae or paretie dcmetitiu. 
In this disease the patient often has attacks of vertigo, uncooacioiis- 
nesa, and more or less marked hemiplegia or monoplegia, sometimes 
with apha'iia if the rij^ht side is paralvr^rl. This form is also liable 
to l)c wnmgly diitgnitswd l>y reason of tiie epileptiform convulsioas, 
which frecjuently ooeur, and which in eonnention with the pamlviiis 
give the irapi-ession in the first attai^k that there is a hemorrhnge o£ 
the eerehml (tfrtex. Tin- prer^inoe of tlie iiltvntl di.ipi>.Mti<iii of the 
patient, the loss of mftmory mid iii(i,>llif;";"fi!, the [Hicnliar stumbling 
speech, and tlie iMirioiw tliiin(;w in tlir hantlwriting are *>ine of tlie 
ftymptom? which complete tlnj dingniMlic pictiir*-. 

In tliis otmdition we should not furf^t the poAttbility of ht'ini- 
plejria or monopk^gin occnrrtng with Middcnnuwi in the crniirw of 
renal diwjasc with tincmiu. Tlic paraly^iiii may be poriujineut or 
only trun«ti-nt, but the urine will be found to be albuminutie, ai>d 
the other siffna of renal disorder may be nmnifci^t. 

UemijtIcKia sometimes comes on in purulent meningitis. The 
history uf ii head-injurj' or of a pywmic or infective jtrocesi;, the 
ocrebml Bymptomts the stiffness of the back of the neirk, the impair- 
ment of the normal movements of the eyeball, and the optic neuritis, 
associated with the mnvul^lons, make the diagnosis possible. 

A very rare form of paralysiii, in which tlie arm on one side and 
the leg on the other side are involveil, is due tn a bnlhar lesion jnsl 
where the deeiLssation of the pyramids lakm place. This in callc«l 
orogsed paralysis, and is due to euttiu}^ off of one t<et of fibres before 
they ont;*.*, and the others after tliey have erotisal. (See chiipt<T» 
on Hands anil Anns, Keet and I<cg*, and Knco and Ht^ad for further 
information as to croised punily»i«.) 



Thif ^Mnil k|>|)Mir3nc« of the uingiiii— lu coating— luaiifiOArjni^ iii iioiaoniiij; — 

yinrc* Bod ulcen of the tnngu« — Eruptioni on ihe longu^— Atrophy luiil 
i^rtraphy of (he toof ii* — PsralyxlB — Tnmor tmd Rpann of i)if inngne. 
: •|>pcumiioc of tlitr tongiiv it r«iwgn'm^ va indimtiw of tlie 
t ootidilinu of UiiT piititftit, and !>> n viiliinlil<- diu^no^tic- aid in 
iiseiisw otiior than tliO!«L' m^iWfiftMd willi diwiilcr of tin- (tHxtro- 
tnt<-Hl!niLl n)tiii>iiM membninc. In vxnnitiiin^ ttilf^ ur^un the phvKi- 
dan ehoiilil Inke note uf the wndition uf it« surface, its «hiipc mn it 
liitf in thi- m')iith ur is protnidud, niid tlic diiimeter of its inove- 
mi'nt& Hi- tilioiilil also ew Unit it in well protrudud, uikI c.\anii»« 
the b>ck of it more thun thc> ti|>, »» the latter i* the part frivixK ^i<-' 
k-;L>it infonnntion, 

Befcine diMmiwiiig tlio precise a|>petti-aiice of the tonjjiie in the 

varioufl disorders in which it becomes altered iu appearance it is 

well to retneailier tlmt its anrface is covered bv iniiooua membrane, 

which differs in varioiu parts. The epitJieliiin] is ■tcalj- and rests 

upon the eorintn or mucosa. The mucosa also supports many 

papillw, which are thickly distributed over the anterior two-third« 

of Ihe tongue on its upper surface. These papilhe give the peculiar 

rtKighneas which is so characteristic of this surfane, and occur in 

three formi, namely, llie eircw nival late or large ^Mptlbe, tlie fungi- 

^^forni or mediate, and the fitifomi. The oi renin vallate are only 

B'Mght or twelve in nnmhi-r, and art' arranged at the hack of the 

tongue in the sliapi> of Ihe letter V, with the paint towarrl the ix>ot 

of the organ. The fungiform papilla- are scattered freely over the 

I tongue, mwlly m tlte sidi-y and tip, ami appear a.sdeep-n-d eminence)*, 

^■be luiu« of which are smaller tiiati t)ii-ir fren extremities. Their 

^Mpilfii'lial <y>V('ring i* very thin. Th<- filifurni piipilltr, uhich cuvor 

HtiiA anterior surfuor of tlie timguc, arc vi-ry minuu-, and iirniiigi-<l in 

n UflM oorn-jtpiiiKling in dinvtion with the two mwit of the ciircum* 

vallnte inpilhe. Krom their npiccs ]>rojeft many fiiip, fdiforni jiro- 

ifisuKa, wliich are of a whitii^h tint owing tti the density oi the cpi- 


iheliutii of wIiIHi th«yiin> oomposcct. There are, in addition, many 
8iin|ilo ]iH[nllit! which oovcr the siirfaw belweeii the peoulinr ones 
nlrvjuly <l(;scritiecl. It U the fungiform jiaplllte which are i«een most 
ciinimimlv in lusc.^ of discji^, fur they In-enme Urge and |>n)iui- 
noat, iiikI Ixicausc nf their rwl oolwr show through the ctaling as 
n-<l <h)te. 

The npiwimnc'e of the Mirfacc of the tongue vuios greatly even 
iu licitlth iK'uui\Iiii); to thi: condition of its tunoous m«fnbniue nod 
the i-pithelitini wvurinf; it. The most common nlUTutioiu in tU 
apiH'iinuiw nrr due tn mere snix-rliciiil cuuttn)^ or fnr, whii'h ron- 
i^ii^t of duul (rpithcliul ei-lls, micro-orgnuii>imH of muny kindn, imd 
tlinormnlly sha]tu<l living epithelium. Small jxtrtidM of food niny 
.nUo \k present, nutlin lielit-vcs tluit tho ooiitint; Iti chiefly dite to 
oiicru-ur^miiiimit. The question as to how elmractcristic of n ]«ir- 
ticular disease any one i-oating or fur iniiy be h«« keen wurnily dis* 
cus»ed. Some have gone su fur us to assert thiit the coaling of tliv 
tongue \a nut indicative of any state in particular, while others, of 
whom the author is one, are M>nvlne«d that while an absolnte diag- 
nosis of diftease in other organs cannot be basetl npon the appear- 
ance of tlie tongue, great aid can be gainetl by it* Study. 

Tin-re aro, hi>wcv4>i', very few (^ondition^ of th*" coating of the 
tougue whicli an- patliri^u»nionio of any one dnea-'W, .linco the coat- 
ing ii* produ(!o<l hy the lo(;al eonditionti of the mouth rather than by 
the dirtcii--ic it»<'lf. 

Taking up for eonsidcmtion the- various forms of coating, we find 
that (he nn-a at the Ikisi- between tlx' eln-mn vallate papilhe is always 
somuwhat <vi*twl even in llio best of ln-nltli, and tlint in di.wjL-^e the 
hoavieitt <»nting \* generally found in thi:> region, while tJie tip and 
Bide*, even in thoBe diwiwi-s in which the mating U heaviest, are 
generally fairly elenr. This is In part due to the chnmct»T of the 
epithelium in different parts, an<l to Uv fuot that the tip and sldedi 
are generally scraiH-d cltrui hy the ntovrnients of llie tongue. Kur- 
ther, it should be rcmeMiberetl that the ilevclopniont of <K)llting, OKlde 
from digestive arrangenienls. depends chiefly on thn-e factor* : tinul, 
immobility of the tongue, so that it is not kept clean by rid>bing; 
second, mouth -breathing, whereby the surface becomes dr}' and les« 
ea.>iily oleanse«l; and, ihiid, fever, which not only dries the Srurfat'c 
of the tongue by mouth-breathing, but Interferes with salix'nry seere- 
lion. Additional local cannee are a demyed or ragged tooth or follic- 
ular tonsillitis, which infeota the lingual epithelium, lack of clean- 


¥iO- t- 





Ty|.»hot<l Tongu« 

BlllouJi Ton^uo, Willi V-<ii'>w Coniinil. 

Fifl. 8- 

Flg. * 

T»ni|»« Of Miimjiia OiHissa cir Chronic 
Cntarrh of Slumiinli. 

Tonou« of Ciroitir Oiisina CniorrK 
wrilli Anemia. 




., nn<l Iiahits, siiHi as nmnkinjr. In tlie last class of jtatienlti, 
lykci^, a lioivily onatecl tongue in the DioruiDg is very i-umiiloii. 

Thti tongiw ot the typhoid slate, aiicl of typhoid fever in [mrticu- 
tar, i* '(iiitf (•lunwterUlio, Iwcjiuse the prolong:ed' illness, the gr«at 
cxhnustiuu, and lliti gcnonil a|iaLliy of tlie patient all tHinapire to 
produce a p«viilinr (.-oating on thiit organ. Early in tJie di.'«ea8e 
the aurfiwx- of tlic tongiie may he more or leas fuiil, rc^mhling 
llie coating awociat«<l with hiliou.'tiicats in that the Iwck (mrt ia 
coatol evunly and with n |w«l«, hul very !*oon a chara«t«risti(! sign 
appear<i, namfly, that tlie tiji of thv tongue and it« edgot hocotu« 
red, atHl tlio uwting becomes most niarUod on oiich xidi; of t[u> 
median fiwure, which in<.-n-a»o» in depth from Wfun- backward. 
The tongue aim bc«om<.it narruiv insti-ad of brnnd and flabby, an it 
u in biliousness and is drier. If the attntrk be mild, thJH eonditiou 
may remain till conval<%cenec i» e«tal>lii^lKil; but if the diHcasc runs 
a severe counae, the continji; Ix-comc^ very heavy, more dry, rough 
and browu from expi>surc lu air and medieiue. The furred ap]iear- 
ance becomes almost shaggy at the buck jMirtion, and the dr^'ing 
procoedii until the underlying epithelial hiyer is craeked and tissured, 
M) that tiny exudations of bl<HHl adil to the lingual discoloration. 
The reddened <^dges become dusky in hue, and may be cracked and 
ftwnred alao. (Fig. 1, Plate III.) The tongue is very slowly pro- 
tnidetl on refjuest, partly from mental apathy, jiartly from fecblentva 
ukI Imvaiuw it^ iiiirface is >w stiffened that to move it i^ dilticult. 
It is e<iually slowly withdrawn for similar reasons, and wliile piti- 

iHlod is often markedly tremulous. Totrard the close of llie attack 
tlu* tongnc eleaiLs off througli exfoliation of the dead epithelial accn- 
niulalion, and this is a favorable or unfavorable sign aocording to 
whetlier the remaining surface is red and moist or thisky and dry. 
SiHiirlinHra theHe ehara<Heristie e.iatinjr> do not appt^nr, tlie tongue 
being brown and rough all thrimgh lhedi>tltlM^ 

A Miiall, triangular {Hileh devoid of conting iit often wen at the 
lip of the Imigtie in nthi|)ning fever. 

In bilicKi^ne^H tlie t<ingm- it eoat<<d nlmoi^l uniformly bya whitiah- 
\'ellofv, |M»ty otiat, extending from back to tip and ddv to side. 
The tongue in bnuul and- flabby, and sometimes indented by the 
teetli, while the bmith i^ foul and heavy. (Fig. 2, Plate III.) A 

milar tongue it aaea in severe tonsillitis, except that it seems even 
DioD- foul and hvs yellow in tint. Similarly in jaundice of tlie 
•cute catarrhal tyjtc we have a coating still more yellow in some 



cases, because, as Fothcrgill asserts, the coat lias becu stained by the 
Uiuro-cholic ackl eliniinatcci by the sali\"ary jflands. llie circuin- 
vallate pnpillie are often promioent and stand above the coating, 
which if. eaaily removed on scraping. 

A bniail, white, heavily cuated moist tongue is often seen in acute 
articular rheuiiiatism, bet^miug dry if the fever is high and tlic 
nltnok pnilongetl. 

The white loiijrue of persons who take large araonntt* of luitk m 
{^(.■Derally not smooth and pasty, but rather rough in ap]>enraiice. 
If the tongue be suffering from an atlnek of thrush (sawliar«imy«« 
albiuini'). tlx- whiti! eoating will eimsist of irregular while innssM 
of tlic gruwlli, which, if in great ininilwr, often coalcsiv ant) make 
a fairly cwn siirfaec. The sorcneM of the inoutli, tlic IihyiI Ik-iii, 
the salivHtiun, and tlii^ age of the person — geiieniUy a young child 
— render the diugnoKJ? wi^y. 

A grayish diphtheritic-looking eymting of the tongue owrurring in 
adultfi may bf due to the gmwtli of various furnuf of niycoMes. 
Thus, a fine network of Icptrtthrix in threu'U and tufte often i^pread* 
over the tongue, particuhirly in the n^on of the cirounivallalo 
papillie. The growth may be ipiite dark in cx>Ior, hut it is sepu- 
nited from the exudate of diphtheria by microscopic study and tUe 
nb»enee of systemic disturbiince. 

Sometimes on examining the tongue of a child we find that it is 
bniud and Habby and covered by a gray coating, which is smooth 
and fairly moisL Scattered throughoat this coating are patches in 
which the coating and epitiielium have lieen shed, leaving red sjmts 
with sharply defined edges, >vhicli s[>otA are said to be " worm-eaten ' ' 
in th«ir apjiearanee; that is, to have tlie irnq;nhir outline of the 
marks on n worm-eaten leaf. In these areits are to lie ."leen eulai^ed 
And reddened fungiform papillie. Such u tongue iji typical of what 
ha» been called, by Ivnslncti Smith, " mnei>n» diiWiwe," a condition 
in which there exists n more or h« marked chronic <ntan'hal pnicvss 
in all the mucous membmne. (Fig. 3, Plate III.) If. on tlie other 
hand, there is a oi^imjNinitively light coating, dotteil irrt^ularly by 
bright-n.Ml spots, which aro not raised above the surfucc, but ure 
very numerous, ami tlic ptticnt Is a child, the diagnosis may be 
made of acute or subacute gastric catarrh. (Fig. 4, Plate III.) 

The so-called strawberry tongue is one in which the organ is at 
first covered by a thick whitish coat, through which prt>ject the 
fungiform juapillie, which have been depriveil of their epithelial 




«!Ov«riug, and being swolleti or 4^ii)argvtl stand oitt [tmniitii-iillv. 
The edgeii of the b>ngu« are ii.->iia1ly rctl and bare wf <.'uittii)>;, and 
Id tbese odgea the fiingifonn |iii)iill:i' are alMi viituivvd. Ait the 
disease progreeaes the coating i.-< Ioj<t fnmi nil over the entire oif^ui. 
This appeamnce of iJie tougiiii i* .-hm-ii (ronmionly in wciirlet fever, 
lit U not, ns l)u.<) been thought, [Mithogiioinoniv of that diiteaw. 
The fungifonn ]in|>illic in tin- Mrftwb«rrj" tongue of scurlet fever 
are, l»ow«ver, ]iiirtienliirly pruininent and erect, 

Whvn the timgnt* ii> «;xc«>»»ivelj- fiim-d nr rou^h in apgxrunince, 

c ixiiitiiig h due to abnurninlly ]ong and projueting pnpillie ouv- 
by an exwiw nf living iin<l deiid ^'pilhelinl cells; it may denote 

iTe diM'.ase nf t\w vinceni, but in nin^- in^tuneeti po^esw^ no diag- 
|jM)»t)c inipurtiitKi'^ tmlew cuuple<l with other xyniptonts. This 
tuugiiv in >M>tiietimiM eecii in «<^r(>ftilou(t cliildrcn tu vrhoiu strumous 
nianife^littiuiii* arc marked. 

Should th« tongue be denuded not only of eouting, but, !n addi- 
tion, of iti^ uorniid i-iiittielium, ho Unit it »p]H-iir« dry, lL»r<), iiud harsh 
to the touch, it deiiutt^^, n» a rule, ^nive and advimecd disease of an 
cxhatuftiog nature, siicli a» rennl, heptilie, or gastric disorder about 
to cnni^- tin- death of the |mtient. Soinetiini.'!' thi« (^undition Ib seen 
in advaneed phthisis or gastric carcinoma, and is of evil omen. 
When the tongue is bereft of epithelium, bee^ and red-looking, 
elon^tled and narrowed, and shows a jieculiar roundne*i when 
protruded, severe visneral diseai^ of the abdominal organ.s siieJi a.i 
dysentery, or hepatic abscess, or carcinoiua, will often tie found, 
or, in aome cases, tliis eonditlon develops to add to the diwoinfort 
of cases nf advanced pulmonary luberculosiit or acute jteritunitia. 
This tongue is «>metiraes called the '■ parrot tongue." 

thii< connection the jmint should l>c noted that dn'nei^ of th4> 

igiie in the presence of grave disease is alums an evil omen, au<l 
Ittumiitg mmsture of the tongue a favorable one. 

iiilnteral c»ating of the tongue may l)« due to a decayed or 
I tooth, or to hemiplegia, whioh |ir<^vt-nt» that side of the 
If! from being cleaned thmngh mnvemem. ilillow and Fairlie 
Clark ImhJi aMwrt llint morhid conditioas of the neoond divUiou of 
the trifacial nerve nuii*e unilateral eoating, nml that abnonnalitioH 
of tile third diviHioti do not produce ihe^ cliaoged 09 we would 


The Mttting nf the tongue i* often (w HiaitKil by extmnooui> 8«lv- 
iManoM as to be eutiraly changed in ajijKiirann). If the cuiiting be 




bluck, llic color tiiiiy be due to tli« ingestion of irun, of bUtiiiith, 
obarc»!iI, ink, or bluckberries, mnlberrieB, cherries, or n.-d wtiic, . 
In very rare cases it ia black, not from tlic growth of n fiinuiiif. 
bos been thought, but from over^^wlh of thv epilheliuin with lli« 
deposit of a black pigment of iiuknown origio. Usually tliiit 
brown isli- black discoloration is eon lined Ir» tlte middle of the 
tongue. The affected surface b often rough, due to the cnlar^wl 
papillie, and the edges of the spot are less black tlian the centre. 
In professional tea-tasters the tongue may be orange-tinted. 

The coating may be stained brown from the ohewiig of tobacco, 
licorice, nufc*, and prunes, or chocolate, and yellow from the ingcs-j 
tion of jaudaniini or rhubarb. 

The color ttt the tongue itwlf, aside from discoloration of ila 
epithelium, is an important diajrnoslie aid. It is e.i(ceedingly |«de 
in all fiiniis of atiiemia, particularly ihntie due to lack of haiiio- 
globin, such as ohlorosis or acalc aiiuniia from hemorrhage, and in 
pernicious anwmia, wlieii well ndvanooil, it has a remarkable {tailor. 
It is livid and cyanotic in ciim-s of jmlmoimrv disease interfering 
with oxidntion of the bloixl^ or in wrdiac disease with similar diffi- 

Purple spotii, wliicli miiy be almost btuck, may be prciH^nl on the 
tongue in .Xddison'H diseiise. Sometimes they arc bluisli -black, and 
always well defined and even willi the surface. Very rarely tli* 
tongue is discolored by infarcts, I >1oimI- stains, and bruises. When 
the tongue has its edges dotted with yellowish (Hitches of a slightly 
elevated clmntctcr the condition is xanthelasma, and the liver will 
often be found to be tlisordercd. 

In casts of poisoning by corrosive sublimate the tongue presents 
a most oharactcrUtie appearance, for it ii* white and shrivelled, and 
the papillte at the base are unu.-<ually lai^\ 

When sulphuric acid ha-> hwu swallowed the tongue has a purcb- 
ment-like a]t))ear:tncc, ia st fJrst ivhitc^ and then gray or brownish- 
gray, and finally is covered by a black ^ilutif^li, which as it se]>arot«fl 
leaves a .swollen, excoriaU'd [uttch. In nitric- and chrooiio-acid- 
poisoning the tongue is i»iirivrllcd iin<I kinon-ycllow In color, as it 
is when hydnx-ldoric aciii htw bc<rn dWiillowcd. The tongue of 
earl>i>lio-iteid-|>oi^>uing t* very cbamctcriiflic iniltHid, for the mucous 
membntue in shrivdled and puckcitil into foliU. The spotti where 
the acid lia-'* touclicil arc bruwnish if inipuri' :wid hif* been swal- 
lowitd, or white if the pure acid has been taken. In tlte (Htuiw; of 



H ft'w liourt< tlu8»put bccomcH stirruiinded by u n>cl xoiie, aikI finull}- 
ItctirtDics tiiirk l>ri)wn ur Itlack in tW ifiitrc. After o,\nlic noid is 
ukiti tlif UHigiiL- iniiy bo invvivfl by ii tliick whiu- ciml iind looks 
n» if it h««l Ummi h^uMoc). CmiKlic polmh miH mxla Kofton lliu 
loiiciiim mi^mbnuio, so that it iu p'llpy and oiwily ik-taclKtl, iiml lookd 
IM'arly nil oryollowin hiii-. Wht-iiiimniuniii ir^ swallowod tlic color 
it> white, but Hii[i«rfic'inl rcilcniH may make it pearly in app<.-untiic«, 
nti'l lu-itl nttratcof iiierciirv rfiidfre it vi-ry r«l. Cantluiridal poison- 
ing prodiicvi! lur^' liii)^ml bltstvn- and sores. 

Aaklc from tlie ouiting and color of tlie tongue, it« surfaee slioiitd 
he fxiimincd to disoover fissures, cmcks, ulcers, sloughs, and swell- 
ings, Tlitf tongue IB often seen to be superficially and irregularly 
fiflsnrrtl in old persons, particidarly in those who have useil large 
(pisntittes of strong alcoholic drinks or strong tea, or who have 
clit'Wetl tobaoeo incessantly for many years. The liss>ures eross 
«flch olhvr in every direction, although the <M!ntr:d fissure which 
runs longitudinally is generally deepest and longest. If the fur- 
rows arc very (Jeep, they may indicate the early stages of what Wud- 
derlich hits mllcd dissecting-gl(»#iilis, which in turn may be due to 
syphilis,' altliniigh, as a rule, the fi»surc.'i of the tnngtie due u» sypli- 
ilis are dee|»€st at the edges of llu* organ, and are due to pn>!«ure 
by ami from trrilntinn from the t<-eth or to ulccrnlion, and ^^uhite- 
quent cicatrixalton of iimall .svjihilttic m>du)«!) or gnmmata. The 
wrviifll glnndft arf mndy involvtrd in such wixr*. [f only oni' uWr 
jo pn^-nl, it inay he chanrre, which will tinve the |H-cnliur Huntcrian 
banl Ikwo, aiMl, in »uch n i:n.*f, th« cervieal glands will jirobably bo 
MiUrgrd, An epitltclioina muy kItu) have an indiinili-d Ihm' with 
wcoiKhiry ghindnlar enlargement. I^ingtml nleern may aUo be 
pmont n« tlte niti(^>u« piit<-lKi< of syphilis, or be due to wound* 
from ihw twth, u bmkcii piiHVsIem, or a fork. When tlic«f l)«wHn« 
chrunii- their M'jviration from those due to syphilis and tuberculiMis 
in pntctieally iui|Hi)>i>ible tm »iiperlk'ud cnuinination. Soioctitnci an 
utocr of i)h! tongiu- i>> due to epithelioma; but if thin is the etiw, the 
patiffnt will pniimhly be |Kist thirty yenrv of age. Ah deep syph- 
ilitii- iilecrs heal selenjsi* i>f the tongue may develop. 

Multiple iiWnition of the tonguv may be due u> tttlKimiW di»- 
which if verj' nirely primary, but rat!n'r imimdary to iUi pres- 

elsv where. 

■ TM* ti dniM br lMiiuti|<ia|r ui doubwd br BuDln. 

8ore« are often ftellate in nhape, anil iltere 


IB alway.-i Hwellitig nf the ocrvinal lymplialiKA, whtrenA iit miilli[>li' 
syphilitic iilocrntioii nf iIir tonjcue tlie ^1iin<)9 ^oiicnilly viteujio. 'I'lic 
diagnoiuii between tubcrcTiitiir iitrer and tlmt diiii to cpitliclimiia !s 
more difli<^iilt, ^ince in l>ntli (li.><enftCH tlie a^rvii-al ^lititdit tiix> involvwl. 
Both are mom eonimon Jii nu>n tliaii in women. The ngv of lliv 
patient, the jtresenov of tiil>ervnliir iliiwiisu cluewliffrc, ,«»<! thi- sibsenw 
of indumtiou jioint to tubercle. The tHlwrnilonn iilwr u not mr- 
rounded by nmoli intintnmntion, is oovonrd by gmyi.«h purulent 
muiii)^, find niiiy conlain Imeilli of tulierele, iind i» oflvu muwciiiu-d 
with tiibfrciilnr nodulra wliieh huve not broken down. 

UUhir of tho toiigne niny nl»o bi- due very, very rarely to liipuH. 
A very tumihir tongue i- stwii in a tro|it'-al <li4eit»e with intestinal 
disorder called by Thin " p«ilo:^i«." An herpetic eruption appears 
on the tongue, wliicli lenvei" lurpe urea* devoid of epitliolium, while 
BinuuiiH furrowif or lis«iire« develop. These IiMures thun hcalf the 
patchvM become pul]i<l, and recovery takes place. 

The various ulceratiil surfaces so far described nn);ht Ix- eonfo 
with ulcerative slomntitis, but their chronic diameter and insens 
tiveness tis compared tu acute olc<rrs of the lonf*ue, associated witk I 
a Bpecifie histonr or manifestations of tubcrcnlosis or syphilis else- 
where, render the diagna^In clear. 

An ulcer on the fnenuni may be due to whooping-cou^h, in which 
diseti-se the edge of the lower inoiiiors may injure the tonguo in the^ 
paro3ty!«in of cough, or it may indicate the prcience of a ni|;ge<l 
tooth, which produces iwn>>lant irritation, or, if the patient is ad- 
vanced io years, repro:«ent the early stagea of epithelioma, or that n 
broken pipe-sUitn ha-'' produced a wound. 

Very rarely the l>uigiic pnrtakt^ of the ulceration of the tonsils' 
«ud roof of the motitli whi<Th h seen in caaeo of Schcinldn's disease, 
tocompanied by ]iuq]uric eruptions on the skin and evidences of 

Should the tongue be marked by bites from the teeth the psticnl 
may be im epileptic. Even if l;c denios that he is alTectctl by the 
disoaso, the attacks may bt; unknown to him, liccau«u they are noc- 
turnal. If the tongue is fre()uently bitten, the patient may be 
sulTering from the early stages of glosso-labio- pharyngeal pamlyiti^.' 

The surface of the tongue may be attacked by variour. eniptionis 
suck as measles, variob, eczema, horpiis, erysipelas, pemphigiL^, 

> Itncfbc pointed out lu pM*Lii( tbal It (here b* nu. ADd no bitlns of ibe loofM tT«t 
ooonn. ftad ibo latlent b a fisoulo. tils i^iuob am probtbtr lifMcri««L 






•, or hydpoa, ant! from (he riiiUure of the vesicles or biiUio ao 
led tiloere may ariite. 

If the sore is herpetic, de Mussy asaerls that the eruption will 
found iu the diatrihution nf the linffual brauch of the chorda 
'mpaui along the under border nt the tilde. 

Sometiniei* the Kiirfaoe of the lonj^iie i* here and there devoid of 
epithelium, aud iti ^ome of the.-te patt^hei* excoriated. I'ain way or 
may not be present. The eDiiditlon In eall<-<l chmiiio tiiiperficial 
|{l<wsitia by Hack, and \» et^nsiderod by Aomo to hr- ilie Ranie dineaAe 
dc«oril)ccl by Kn|HH>t tw (;la«!>u<Iyuia exfoliativa. It w more i-ommoii 
in men, and hwU many yeant. 

(JrtJcnria of the tongue lia< been reported by Luvoran and xeru- 
demia pi);ineiitosuiii by Iveutiug, 

The presL-mf of a pla<{i]e on tht- anterior portion of the dorsum 
of the toii^e to one (<idc of the median line, which If: raided, not 
ulcerated, but red and irritated-looking, may be due to exce^isive 
emokuig, (h« smoke irritating the local epithelium. It ia always 
Teiy amootli, later covered by a yellowish-brown ooat, and is 
eomeiinies tnlled "smokers' patch." It may extend over the 
whole longiie and \&st for years, 

When the lon^^ie ha^ on its dorsum and e<I^es dull-white or nlate- 
oolonnl dots, ]Kiti'lies, or lini:>, whii:li arr- elovnted, hard and horny lo 
thv toitoh, but not |>ninful, the condition in known as leueokeratosis 
buoculU, or Irucoma or ichthyosis and this may arise from smoking 
or gl>if>»-bh)wing, [t mrcty iic^ins in pvt-Moiit nnder twenty or in 
lOM over aixty ymrs. Tt i» often n ^.tronR pre«lisi>o«ing agent 
towani <'(»rni'r of the tonfriie. Tlni*»^ "[wt* are arranged on the 
toitt;iio in lonfjitndinal lines. Hy<lc a8M.-rt« that tiK-y arc due to 
exoeaKiv« kemliniuttion of tlic epithelium ooxa-rvd by an adherent 
ukI Atawt [(oUiolr, The historj- in chronic, and nlliinatoly by the 
•tiffiHiM of the N|)ot<t tlie ton^^ue may bcooinc rnurlo.'d, an<l tliif in 

rn, {fcrluip^ ^vu ri«c to carcinoma. When the toiif^ue ii« covered 
by omooth, dcn>4> plifiuiv and diitc- or rin^, the tundition may h& 
lichen planno, hut tlic diiignot-in of lichen planus from loneukenitogtis 
huocall!) is diflieult, if not impo«(.«ihlc. The pla'jues nre most com- 
Sionly scftn in mule!> between twenty »w\ forty ycnr><. Closely 
allii'd lo this is the rare condition of hardening of the tongue due 
to st^leroderma, as doscribctl by Kajmsi, 

A very rare eoodition of the tongue is one in which its surface is 

rked by rings or areas on the dorsum, which gradually enlarge 


until tlii\v n-ai'li lln- <t(I>^' wp conlcw.'e. In »p{>i-jinitioc lliev nre rvi 
aiiil KUiiintli, tli>|iriv<><l i>f lilifonn impillw, but not of tlic futiKiform 
vnrivty. Often l\ic liurdcr of tlic (•iivtlv is niorv red timii tbe cttntrc, 
Aiiil llio vcrv eAgc is often yollowisli. This condition is liomrttmeo 
calliTil wanilcriDx null, t^ogrupliicitl toii;;iii.% or ;tnnulus Dtigraos. 
liittic if unytliin^ \» known of ittt (uu^f, save that dvUcato children 
nre most ofti-ii iiftctrtvd. 

Feeble, Kiekly cliildrctn KoniHimit- develop upon the tongue, as 
well an on tile lips and vlieek^, a condition in nOiioh a tcnaetous 
cxudiitiun i« tlirown out, the miieotis memhrane becnmiii); figured 
and Kore. Guston and Seliestre have called this stomatitis iin|)eti' 
gin OWL 

t^deniu of (he toiiKnc, with the development ujma it <if veflicl<-«, 
and, Jinally, slow^hs, may oocur. and U probably identical witli the 
foot-and-mouth (lIsea'^e of domealio aiiiiiiaU. 

Riluteml atrophy of the tongue is dae to diseaw a^eeiing the 
hypoglo'isal nerves in 8f>me part of their eoiirse in or IkIow ihe 
nuclei (see Paralysis of the Tongue). It otvurs aa a iiyniptoni o(l 
glaiso-lahio ■pharyngeal paralysis, in which case the tongue is shriv- 
elled and atro|)hieil in juilches, and in the later ntnges of the lU^eagfJ 
tlie organ hiw a ennutwl apjKfiranw. In other citsoi it is present' 
in progre^ive muscular atmphy, and rarely in locomotor ataxia. 
It has nli^> bt-eii 8Cen in ttem-nil imntlvMs of the insane. Unilateral 
•tro])hy may also oei-nr from lhe«.' cuiisi.>s, and Hemak assorts that 
it sometimes arises frum elirunic lend -poisonint;. Any disease itn 
volviug the hypoglossal nerve« may mo result (see Paralysis of the 

In rases whure tlie tongue is much enlarged the increase in siaa^ 
may be due to maliguunt growth, to maoroglossia, whicJi U a form 
of congenital lymphan<;ionia, inflammatory hypertrophy, and syph- 
ilis, or aeute inllaiiimatioii from irritant poisons or foods, it may 
also be due to dermoid e)-st<i, fibroma, lipoma, papilloma, angioma, 
myxoma, oeteoma, and enehondroma. When it is due to aeute glos- 
sitis the organ is seen to be several times its normal size, is pro- 
truded from the moutli. and marked by the pressure of tlie teeth. 
The organ is also clumsy and stiff, and heavily coaled on the IwcIcJ 
jKirtion. There is a profuse tlow of saliva, and swallowing and 
speeeh are almoi^t im]><^ssible. Glo^itis may abto be due to inercu- 
rialisiu, to septic infection, and may be citlier unilateral or bilateral. 
The tougiie may be greatly enlarged by aelinomyoosin, tliis <'«»ndition 




in otd«n tinM^ being called angina Ludnvici. Or«at enkr^ment 
of Uie tonjfue roav alao an^e in aortimegnlv and in myxoedeina. \a 
th« tatter diitenw tlie organ i» bniad. Hat, and iH>ft. 

The inoTements of the tiin^jm- dc|iciid upon it.'« innervation and 
itti rnii->cl(^^, and nfToid valunl)lo iiifurniaiion in diii)rniK<i.«. Tliv 
raftidily of itri protrnsion in oer\'miit and exc-ifftblo |icn<on8 wh«n 
tliin* anf a.-«k(d to »how tiic tonjriie is noU'Wurtliy. nnd \t» mniitiint 
nilting in oftt-n stvn in |>ur«niis wiio mi; foeliU^nuniKd, In all di:^ 
vant» n««wri»tfid witli nivntnl lioltctndc iti* pmtni'^ion on r«tiuoi«t i>> 
very clow, altliouj;)) tlie jMitiont will ofk-n do this iwX wlien all 
oilier ordvre fail to protliiuc a nvponM-. In tht; \'ariuu« forms of 
ramn dim to ajtoplexy. <liub<.'t(^^, niu-mia. and ci'iTlira) oongestioD, 
tlitD condition obtains, iind it ie vi'ry cbanu-teristii! of typhoid fever. 
Often (he tonjrue which ha« bwn |):irtiiilly protrtiilcd is k-ft «>, t'vcn 
wlicn till- putivnt is told to draw it in. WIk-ii tin.- patit^'nt tindtt it 
diRicnIt or tinpovKibti? to reinovo food from bctWLi-ii the teutli and 
chfck by nicnns of hi« tonfuif, ami <'<implains tliiit the power of 
(speech is interfered willi. Iwrause tlif lon^jiie w cliinifv in iX/^ move- 
mento, he may be suffering from the disease known lu ^loHso-labio- 
pliaryngenl paralysis or progressive bidhitr piimlysi^. Theiw lingual 
disorders are often the earliest signs of the disease. More rarely 
titia disability of the tongue may arise from paeudo-hulbar paral\'sia, 
or what has been ealled gUw^i-labio-pharyngeal wrebral paralysis, a 
discAse in which fot-i of softening ooetir in that portion of the eordoo- 
milwular tract in whir.h are the libres which supply the muscles used 
tn swallowing and speaking. This false type is sejuratod from the 
true hidliar palsy by its sudden onset, an apoplectiform seixiire, and 
otliffr evidences of cortical disease. The tongue affords the most 
imiuirtunt points for differential diagnosis when a differential diag- 
DiMi^ lit to be made under those ciroumHtances, for in the false 
<ltiietLm< it does not waste or d<>veIo|> the reactions of degeneration, 
wh'trcjis in true bulbar paralysis these changeit always speedily 

Paralysis of Uie Tonfrue, In apoplexy the tongue is protruded 
toward die ]iiiraly»)d side as it is also in tlx; o*>nd)tion already do- 
aoribed of hcniintrophy. The Irriions of tlic liypn^Inssns whit'h pro- 
duce paralysis imiy be of oortieul origin (niiilntiM-iil), in which cam^ 
tlie hemorrluigi- or oilier injury may be iiitiiitted where Ilic middle 
and inferior frontal oonvolittion« fonn the anterior central convo- 


liitiou/ or in the- ttiipnt-iiiioloir tnict b«twe<-ii ttic oirtox and lite 
mi»ltilla, ur ttt tin* liypu^loMWtl utu'lviis, or^ l^^in, in tlio infm^nudeor 
tnct within the mediillu. Insulmr sc-lertisis may wry rapidly tnnnei 
linguul purttlystM. PitralysiM uf tiiv tong(i« may iiliu) ix»ult frnm 
injury Xo thi- hy|Migluss(il libm oiiteide tliu mitliillii tlirungh iiif-ii- 
iDgitis or syphilitic or other i^rowlhs. In still uth«r fSi»» prc^uaire 
upon tlio ncrvo in its foriimcn muy cnn^ uniintcml |i»n(ly:4i>s or ' 
wounds of till? neck, <»rivf> of the fii*t ceiA'icsil vcrtcbnr, or ixT^'ical ^ 
tumors may so result. Often in such u nue the spitiiil lux^wwory 
nerve is also involved. A'ery rarely, ludce«l, thu toiij^^iiG iiiny Iw 
paralyzed by a hypogloMnl neuritis (Erb). In rare instunci-s iK'ini- 
atrophy of the tongue is associated with hcmlatropliy of tlur faoc 
witliout hypoglossal injury (Gowers). Giniif I aiwfrts that the vcntmxy 
part of the trifacial coutains trophic tiliiuieuts for the toufpii*, uud 
that tlie unilateral wasting may be due to disease of this nerve. In 
paralysis of the facial nerve the tongue inay Iw partially [mralyMd 
through the fact that the lingualis muscle is supplier! by means of 
the chorda tympani nerve. When a tongue whidi is paralysed 
imilateraUy is retained iu the month, it is seen that its root on tlto 
parolyzetl side is higher tlian the other, owing to the paralysis of 
the posterior fibres of the hy]>oglosstid, bin when it is protruded the 
tongue goea toward the paralyzed aide beeause it it) puslied oat by 
tlie fibres of the genio-gtossus muscle on the well side. Finally, 
let ne remember lliiit if the tongue is paralysed on one side the 
lesioD is in the cortex or the jwns on the opposite side of the lx>dy, 
or in tile nueleus in the niediillti on the same side of the body, or in 
the nerve after it has Icfl the meilidlu. If it is bilateral paralysis 
the lesion is probably nuclear, benmse the nuclei are so eloaely situ- 
ated that even a ><mall Wion involves both of (hem, or it may he 
due to sytnmetrioiil ilitciiJW uf both sides of the cortex, the so-oalled 
peetido-bullMir pamlyMit already 8{>okcn uf. 

It should not l)c forg»tti>ii that {Hiralvi^is of the tongue may occur 
as the result of <liphtheria. 

Uirt asscriit llint the reaction of d<^-ncmtiou may be found in 
the tongue wh<ttlier the lesion l>e cortit^l or in the lUicleus. If tlie 
lesion is only wrebral, this reaction will probably nppi-ar very late 

A tromor »een ia the tongue may iudicnte a vnricty of nervous 

1 Thti !• probUtr ■ fut. bai nui rcc mnilrniMl by buioikt. uulc* utti mnflc]«r Kdingari 
cm of bAc&Idk Udder 1 hi* ftrca, ■ nidi«(cd tnc lonxue anlr, ut ijpical one. 



ailment* or severe aoiite disease, as in tvplioid and othpr severe 
inffwlious diEwaties, but tlie freednm from exivssive coating and the 
absence of the ordinary tugn* of nnitc illness wilt sepnmte tlie eitse 
of biDgiie tremor of tumte disearie from the tremor reprr^ieiiting 

^ncrvcMis uiltnenw. 

^ft An ini]Mirlniit point ta \k r(>giirdu<l in noting linj^iiil trvmnr is 
wln-ttK'r tliv Iromor or lUirilliiry muvemenl i^ (<on^(unt, or xvhetlicr 
it ]i[>j>car« only when Ihi- tunt^iii- ii* moved to luid fm or profriid*-*!. 
In ty|>liiiiit fcv«r thi- tn-mor (xfcnr* on ^lllv^■ln^■nt. wlierea* in 
gluw<:Kli(l>i<>>pluiryn^-u] ptiriily^iF' when thi- nioulli i>^ ogx-ii fihrilliiry 
tuovrnicnbt of the or^in lire often iimrked. wlitle the ori^nn lies in 
tliu tloor of tlic month powerlevt iukI hcyond the eontrol of itio 
pntieut. Tremor of the tonj^uo in uIko #i-en in n marked form in 
many ciuux of ateoholism, and a«soaiild with this tremor it will be 
D(>te<l thiit the {H'otruHiun of the orj^n !« unuertnin or in jerks. 

B Spaem of the tongue may be nuihiteral or bilateral, most com- 
monly the hitter. It is wen very commonly in cases of eliorea, 
partieiilarly i>f ihc pofit-lieiiiiplegic tyjif, and in hysteria. In the 
first ilisea^ the movements are elmmeteristically choreic. In tlie 
InMer the spasm may be tonic or clonic or alternately tetanic and 

Often the eipoiun in hyiiteria is unilateml. Sometimes it m olonio 
in puuqteml melancholia. Spasm of the tongue is a common symp- 
tom in uKWciation with the twitching of tlie lips of general [laralyius 
of the itiMne. Jerky movements of the tongue may alii^o iH'etir in 
tiixitar ^>ch!msis, hut thi^i is not tlie oaiiAe of the pceulinr speeeh of 
that n<Tir4!tioii. 

Very nircly the eoiiditinii of lingual spaitm ii^ due to irnlntion of 
lie hy)>(>f;lo«sU)i by winie cHiiw as yet unknown. The tongue is 
<h1 in or out or thrown from st<lc to mh and often injured by 
f tlie teeth. The n|iii»iiu^, ns a rule, »re nut eom^tunt, but >romc on in 
attacks which clo«ely rc'M^iiblc epi]e[>Hy, and in that they arc pro 
c>-<)e)l by an auni (Itcnmk jiihI IlL-rgcr). A very rare ufTti^lion 

•termed aphlhoiigiii (.Flenry^ i* ehiirai-terixci) by T^pa«m of the tongue 
Dn altem|»tiii); tu Hpuik, Itombcrg )iiu> reoonhnl a ouw of lingual 
S|Kifim due to irnlntion of the fifth nerve from lingiuil neuralgia. 
^^ In that very rare condition eulk-d " Thomwn's ili(M.'««t," " eliai^ 
^■■eterir.ed by tonic spnsmM in tlie muwdes during voluntary inove- 
^ tnents," the torigiie may W involved, but in this i-nse the otlier 
..vnluutar\- miutclce will f^ltan■ in the ulTection, 



Having oousideretl llip diagnofttic Htgiiilicauce of chaug*B in ihe 
a|)]>eanince of the tongue io lliis chapter, and of the apjieamtioe of 
the Wpa in the eUapter on the Faoe and Head, there is yet to lie 
discussed the condition of tlie buccal mui-ons memlirane, the ton^U, 
tile soft palati.', the tiwth, the tipper jmrt of the pharynx, ainl the 
poAt-nawi) ftjiaeei*. As almost all the conditions found in the latter 
regions are of interest to the rhinologjst i-atlier than the general 
practitioner, onlji- one or two alTeetioiis of these purls will l)e included 
in tht9 wnrtc. 

Swelling and relncM of the hitociil miiroti* memhrfini' oo-ur in 
the variuiw mild forniN of stomatitis, nnd in the ultvmtivi,' typi,- of 
this disease tlie more severe lesions are often found in this iin.*a. 
In tliemiilignaiit iileerutivestijinatili* enllcd noma llwslouj;ii which 
rteptii-uli-s from the inside of tJtc elieuk leaves n larp; exravation 
which may heeoiue «o deep as liimlly to perforate the cheek. 

It is int^^re^ting t<i note that swelling of tlie cheek with great 
inlliirnmation of the bui^oal nineous mcmbnme Is somctimo^ t>eeii as 
the result of tlie furmutiun of a ttalivarr onh^iilus lu the duet of 
Steno, and it is aliio stated that obstruction from iiithtmmntioii of 
this dtiet often oucurs a* a result of poisoning by sulpliurie arid. 

An[aiu, in that rare disease called Schonlein's disease, or true 
peliosis rheuinatica, tlie writer has seen a case in which, in addition 
to the multiple arthritis, purpuric eruption, and great iwiema, the 
formation of a large ulcer or slough threatened to perforate the 
check, and in healiug produced a cicatrix which interfered with 
the patient's ability to open the mouth. This patient was an adult. 

If a patient presents himself to the physician with the statement 
that he Is suffering from general pains all over the body, particularly 
in the small of the hack, <iuite high fever it may be, with much sore 
throat and ditKcnlty in swallowing, the trouble in the majority of 
cases nnll be, in the a<ln1t, tonsillitis of the follicular form. If Hie 
symptoms are exceedingly severe, the inflammation may result in 
suppuration — suppurative tonsillitis. It is to he remembered in all 
oases that the systemic or onnstitntioual disturbance is out of all 
proportion to the severity of the lonal lesions. If it i.s tonsillitis, 
the glands can be felt in the majority of caws a little Wnejith and 
forward of the angle of tin- jaw, and pressure upon them may pro- 
ducc considerable pain. If the mouth is well opened and the tongue 
depressed, tliere will be found on each side of the throut a more or 
\i»! projecting and inllamed niasi*, in the depre^ioiis or folltcular 





iing« of which will be found a whiu- or yollowlsh v.xuduto, which 
in ^■.■vcrtt cnscs may spread over the surfaw of Uio gluod till it eli^litly 
re*eiiibl«s tlic membrane of diphtiicria. Pressure on tlie tonsil may 
OBit«c tho farther projection of these chcesy-loakiDg masses. 

In ihe suppurative form of the disease the surface of the gland 
may b« smooth and reddened, and in a day or two beeome soft and 
fluctuating, and if laaeed pus will esca|3e. 

The severe ron^titiitional disturbance, tlie ftorene.ta of the ihroat, 
difficulty in swallowing;, and tln^ follionlar exudate eall to mind in 
all such cases the possibility of the disease biding diphthc-ria; but in 
tonsillitis the exudate can bi> easily removed without lejivinj; a bill- 
ing surface behind it, and it ha.t not the du»ky, dirty look of diph- 
tlieritie moiubran<>. Afruin, in tonsillitis the exudate ii< >>cen un the 
tonsils only, whi^mv* in ilrphtberia it spn^ads ovor the Imlf-artdiea 
and uvula. The k>'ihtiiI ttynjploin* ni:iy make one Mi;«pcct tliv onset 
of Mttrlct fever, purtjeularly if the |>ittient be « child; but the ex' 
amioMtion of ihi- thnuit in searlct fever nhow." the int^-nse n.'tintw* of 
the pharyngeal mucous niembmne with com |hi rati vidy slight enlui^ge- 
atent of the tonsils. The intense rcdnetw of the throut in eearhitjna 
and thedevclopmr'nt of the ru^h on thu ^kiu aid in making .1 difFur- 

^— cntial diagnosis. The lymphatic glands of the neck may be enlai^ged 

^■in scarlet fever, but are rarely so in t«msill!tU. 

^H If the (latjcnt lirst complains of dysphagia, and, on examination, 

^'tlje pharnyx is red and the tonsils are covered with jKitches whtcli 
speedily spread, as just described, so that bv forty-eight or seventy- 
two hoars the tonsils, pillare, and soft palate are covered by a gray 
membrane, the ease should always be diagnosed as diphtheria and 
treated as siR-h unless a l>acteriological examination of the exudate 
shows the infection to be due to a atreptoraeons and not to the Kleba- 
Loeder bacillus. Even if the patient has not true di|>htheriH, he 

^ may be exceedingly ill. Again, it Ls to be remeralu'ri^l that while 
many of the eases of .tearlet fever which in tJieir early stage.s present 
a membranous phart'ngttis or tonsillitis an- due to the streptooocms 
and not lo the [joetller l>a<'ilhis, in the later stages of the diMiue 
tlie Lofrffler bacillus is tlie oa««e of the local lesion. The differ- 
niliatioD is lobe made chiefly by baeteriologieal tests, but it i» worthy 
of Duie that th« early formci sti'C|)tooocoic membrane doe* not 
sprawl M» docH tlie dijihtheritie membrane, unri do«<it not return so 
rapidly when n^nioved. The two diseases, diphtheria and sicArlet 
, fm-or, oxifit Mimultnnvo4i«ly. Uarely a false membrane due to str«>|>- 


tocfxwua infection, or stilt more mrcly to the diphtheria bacilliiH, 
oomplictttott thu cviirw of typhoid fever, aii<J a\»n oooiirs as a grave 
<!■ I in pi illation of moulcK. 

If in liny aiac of ()iphth<-riii the faW meinhmue oxteDcl* to (he 
ntti*ul clijimbcn*, thu pro;;ni>si* is very iiiifavoruliUv 

Ortliiiiiry iorv throat or aotito p)mryit)ritis i* f^nemlly nivuiujm- 
nii'd witli little MysU-mie disturlitinci.', (he local piiin nml «orcnc»8 
beiu)^ tliu must uhiimeteristie symptoms. Infi|H'elion will aliow the 
pharyii^ical wall rod aud atign'-lookiii^, nnd very likely unduly dry. 
Oaru should nlwayo he tukoo, in the case of vhildn-n particularly, 
that the airly eoro thruut of metiffli^s and Muirk-t fever is nut uikeii 
for !«imp1e phur^'agitlH. Oft«D the rasll of iiilik-Il-k eun be seen ou 
the pharj'ngenl iv-all some Iioure before the rash appear* on the skin. 

Koplik asserts that this eruption on the pharyngeal mueous mem- 
brane is uot charaeteristic. With this we cnnnot agree. He ulso 
asserts tliat an eruption ap|»ears on tlie buccal mucous nienibrane 
which pi-eeedes the eruption on the skin, and is eharacteristic before 
the skill eruption appears. It loses its peculiarities as the skin lie- 
coines involved aud merges into a more diffuse redncLss, which entirely 
dltappears before the skin has returned to its normal state. The 
buceul eruption coimiv^ts in Kinall, i t'i-i-(;uliir red »jiot» with u blinish' 
whitir centre-, and sliuuld be looked for in n good li^ht. Kojilik 
believe- timt tln'xe Hpiit> arc alMulutely chn rooter i«tie. Tliey arc to 
he Hi'piimteil from llic re(hlenc<l niueous mcmbrunc of scjirlct fever, 
the large, white spots of thrufih,aml the Horc mouth of stoimititis. 
They do not appear in riitlieln. 

Pigmentation of the buccal mucous mcmbntnc often occurs iu 
Addison's disease, 

Sometimes coses arc seun in which there arc toneillar pain and 
irritation, and iu which careful examination proves the discomfort to 
be due to the presence of a small calculus in a follicle of the tonsil. 

When swelling of the tonsils is chronic the enUirgeroeot of the.'w 
bodies may prodiiw moiith-brenthing, with the peculiar faeies 
of that habit, deficient thoracic and general systemic development, 
and a peculiar oou^h, constant in cliaraeler and worse at night. 
Often the .-■wolleu or enlar>re<l glands extending across the pharynx 
Actually toiieti one aiiothiu' (see illustration in chapter on Face). 

Finally, we eun sometimes gain iwme information from the teeth 
•8 to tile 8tAle of the juitient. In children who are siifferent from 
rickets the toetli dcuiy very curly luid mpidl;, >vnd if they be »uf- 


fereri) from inlierited syphiiia, the teeth are often cut id the early 
months of extrauterine life. 

Caries of the teeth to ao undue extent is also seen in many preg- 
nant women and in cases of diabetes mellitus. 

If the permanent upper incisors are notched or pegged-shnped 
with notches in the free edge, as if cut out with a small gouge, 
they are a fairly sure indication of syphilis of a hereditary character 
(Hutchinson teeth), and if in association with this deformity of the 
teeth we find middle-ear catarrh and keratitis, we have the " syph- 
ilitic triad," which is infollihle as a sign of hereditary syphilis. 
The^e notches are not found in the so-called milk-teeth. 

FlQ. 6j. 


BulcblDwn (eeUi. 

The staining of teeth by tobacco or other materials held in the 
mouth may reveal certain habits of the patient, and a blue-line 
on the gums where they join the teeth is an indication of the 
presence of chronic lead-poisoning. Ijoosening of tlie teeth with 
bleeding, spongy gums sliould call tn the physician's mind the pos- 
sibility of scurvy or scorbutus, and the spongy gums are particularly 
indicative of this affection in bottle-fed babies. Jf loosening of the 
teeth oc-curs in adults, it may be due to mercurial salivation. 



1'li« jcfTiural iliaitiiOKlIc InJiratlnnn ntlbnli>d by the «ro — Diplopia uul diKiHer of 
■ lie extcmul (wiilar miitck* — l^ltnbinna* nnd Kiumt — lliaardor at (]i« inUtnal 
(icalftr oiiM'le*— Th« i)u|)ll— I lorn latin i>tiii — Tb« Ti«uiil lielda— CoIor-riMon— 
Tlio optic nerrc nral its [(BioLis — Kelinilin — Amblvopu mid blindnmK. 

Thk eye affords more iuformntioii for diugiiMiilie pur|KM<es omi- 
corning the condition of other orguns of the ImmIv than any ttingk 
jmrt which can be examined. We gather from it not only u <:I«ir 
idea as to it« own state, and the state of the nervous uentn>^ mure 
or leas intimaitely connected with the government of its roDVoments 
and its B|M>cial functions, bnt in addition we often gain jiositive ia- 
fonuation as to the condition of organs more remotely sittiat^, ii^ 
for example, the kidneys. The very fact that so many difTiTcnt 
tia*ues nnr foniid in this organ rendi'i-s it »us(Tplitilc to tlic uiuny 
dismac;) affeotiiig simihir liMueft cUewhert- in the I>ody. The jmrt* 
of tlie eyi^ which give im the grc«te*t anionnt of knowledge nh<nit 
ctinngiw ill other tissues are llic optic nerve imd retina, and tliv 
oc-nlar mtwclei*. Tlie ervstniliiK! lens, the eonjnnetivu, and eomca 
oft«*u give additional evi<k'nee indioiting the geDi-ra! Bytttemio oou- 
(lilion. Outunu^ should make the phytiioian Hiupevt diahetv);, even 
if it apiwiir in ]>enM)nii in yoant. Tlic cyelid», if puffy in 
apjiearuiiee, tnay indieate rennl dr^uv^e, i^mliav lesions, or tho ovei^ 
use of arKtoie (Mce clmplor on the Faee). Au examination of tbe^ 
inner side of the lidv niiiy reveal a judlor due to nnicmin. ^^ligh' 
conjunctival heniorrliage may remnlt from violent (»ughiug. In old 
persons Hiieli a licmntThage, if not due to iiijnry, may indicate degon- 
omtivc viucidar •rliang'.'*. 

Promiueuee of the eyeball or exophthalmos is seen as au almost 
oonstunt eymptom of true pHtrc, which for this reason is trailed 
exophthalmic goitre. (See Figs. 11 and 12.) ^Vssociated witJi the 
bulging eyeball we find more or less enlargement of tJie thyroid 
gland, an irritable heart, and a very rapid pulse, throbbing carotid 
■rt«ries, marked general nervomtnes?, often mt-nlat ih-pn.-itsion, and 

TUB Ere 


-niarkitl or ndviinocil cn8v« of exoplithnliiiic 
_ coiiilitioii in wliicli the iipjwr cyolid docs not 

follow till; cyelxill in itit downwnril niovt'iiioiit. Tliiit is somi'linttM 
called *'Gnvte'« symptom." Agiiin. tlirrc nmy be alnxwl total 
atMcnce uf winkiii):; at »n involunljirv net, " Stcllwsg's symptom." 
Or, ngaiii, there ii* institlicifiicv of cnu vct^nco, so tliut u neur point 
cnnnot bv gccn willi both vyvs ut otiuu (M<H.>l>iu:^'s sign). 

On (■xitniining thf exterior of the eyebnll wc uftcii Dotiee n prayish 
riuji; along the jiinclioti of tliv eorueu and selem. It possesses when 
u cumplct« rtn^ but little eigni&-anee, except age; but if it is but 
the segment of a ring or in two segments, one above and tlie other 
bcluw tlie coniea, it is n true amm aeiii/in, and In sold to indicate in 
Home eases fatty degeneration of the tissues of the body. The one is 
nn iinnulus senilis, the other an arens senilis, and the areus is the 
change worthy of nolo, although many cliaiciaiis, including the 
author, deny that either has any siguifieanee. 

An examination of tlie pupil may reveal that it i:^ immobile from 
ail old plaMic iritis, due to syphilis or rheumalisiii, but it is not to 
be forgotten tltat this condition mav arise from iritis due to purely 
looU <aii.«eii. A widely dilated pupil may indicate the use of jioiiie 
uydriatiH or the iiigeritinn of atropine. It ii« al^u) M?cn in fright, in 
■one hysuriml Hcixurt^, and in glnncoma and whenever the virion 
u loitt, tmlcM* it lie oontniot«d by disfviM uf the iris. A rontructcd 
pupil iiKlirau;^ the ««.• of n niywtie or the fxisttiire of ci>ntnil nerv- 
oiM di»«'a)H% 4Ueh a» ataxia, whieh eaii^c« the .-Vi^'l I- Robert s<^n pupil 
u well. Sometimes eonieul iutlammotion by (fusing photophobia 
nuiyiniiM; exw-wive myiMi-i, ['in-iwlnt pupiU miiviil*) result fmra . 
tli« USD of opium or it« alkaloi<l)-, and s^rve to diiTerentiate the eondi- f I 
tion from true coma, in which the pupils are usually dilaliil. If, how- 
ever, the euma be due to cercbnil iuflammiition or meiiin^itiT>, the / 
pupils may be contracted; or If it be due to intnicRtiital pressure, ' 
they are usually dilated. (Hee Paralysis of the Inlntociilnr Miimi'1««,) 

In addition to these objective symptoms we have also a vcrj- im- 
purtaai set of sign^ connected with tlic ot;ular muscles, external and 
internal, as manifested by tlio various forms of strabismus or changes 
in the pupil and in the accommodation of the eye. by the ptosis 
already discussed in the chapter on the fuw, and in nystagmus and 
ucidar spasm. Deyoml this, too, we Imve two other ocular symptoms 

bjoclive in natJire, namely, diplopin or double vision and partial 

oumplete bliudncea. 


Diplopia di-iH-ii*!". ii]i(iii lln- fact tliai in an eye in whicli the 
miisdui urc ftlmoi'iiiul in ilii-ir funclinn tlic image which falls upon 
th<.> fov(% or vii^iml iictiUy i<]>ot of tlie rotltm, in the well eyt- hits 
lo fall upon llu- i»a«iii s|hii in tin- woak eye. Tu tlie well eye the 
object nppcitra to l)C ill llio diri-otiou in whiHi the eye it* Uinied, 
wlierou* u> tin; wwik cy<' it nppoarii to he in another direction. As 
a result, tli<' iiiinri p;lii the imprcHMoii of two olijei'-t» inMeud of one. 
The inipn-woii inmlo mi the well eye ii" the " Into image," as it is 
callc<l, »nii thiit in the diseitmnl eye is e<illeil the " fnlM^ image." 
Aay cause which interfen-j* with the lixiition of eaeli eyo on the 
same ]>oint prodnoes diplopia, nnd, as the eyes ure normally dirceted 
to the ohjwt lixud by the ueiilur niti^-le», ]>araly«i^ of any one of th»»e 
muijcles pixKliiccs diplopia when the uxls of one eye is deviated from 
the point of fi\aliiin. bewmse the eye on one side is not pntpcrly 
move<I by reason of the fuel that one musele has failed. Piplopiji 
is ordinarily a constant »ign of oeiilar muHeulnr pnmlysis; but if 
only wwikness ur insuflicleiicy of a mnscle is preseni, iliplopiii may 
never be a symptom reTOj!;ni/,e<l by the patient. The fiirins of dip- 
lopia — that is, the ])o«ition of the false ima^s in respect to llic true 
images — \-ary with the niuseles uffecled, and will be Btudied in a 
moment when paralysis of the mnseles is te.sted for and their diag- 
noiiis discussed. It only remains at tWir< plaee, therefore, to ]>oInt 
out tlie probable signitieanoe if a patient with diplopia prei*ents 
himself U> a physician. 

Thus, a ^Kilient with dip1o]>ia may be suffering from n Icsioit io 
the cerebral cortex, sueli a.s hemorrhage, sclvroiti^ or i<<»ftciiing; or 
from a lesion in the ernnial nerve nuetci, in the pons or corpora 
ijuadrigemina, or in the fascieiilar fd>res. Agiiin, diplopiti may arise 
from lesions al the linse of the brain, as meningitii>, tnbercukr or 
syphilitic, or from injnry to tlie nerves in the orbit or in their 
pripberal endings. .\i. a result, we find di]ilopia as a symptom of 
any whieh may alfift these gmrls, and it is <]uite a common 
.symptom in locomotor nliixlii, in Fricdreieh's ataxia, and in puretie 
dementia. I'rohahly it is seen must eommonly in ataxia, and with 
it, as tlie oculomotor nerve in it« bmneh supjilying the le\'3tor 
palpebiw i:^ purtiirulnrly apt to be panilyjEed in this disease, wo may 
And pto«isi. 

Diplopia is also found in tnses of ptomaine-poisuniiig, and in 
poisoning by belladonna, spigclia, eoohim, and gelBemium, owing 
to iJivir efTvt^ on the ooular ocrves. 



betu'ooii tiio vitnuiiB 
le othvr eymiitoniH ai 


rh*" difTcmnUn) <lui^< 
diplopia it) to bo oiadi; 1 

Paralysis of Ooulur Muecles. As something has already )M>en 
mid in the clijipttT on the File- and H^ad of the diajfunstio inij>ort 
of pandvfii)) of thc> ooiiliir mni«cl<:s in cauiieetioa with thn ^uliJL'Ct iif 
ploftis, a further couriidi>rati»u of the abnormal cIiangeA in their 
functions will he discussed first in the jirejtent chapter.' Before 
doin;; m, however, it ia neoes.-ar_v tn descrilie the methrKls re-'iort«d 
to for the purpose of deraoDAtnttlng nr determining dejinrturcA from 
the normal in n)us>-h-.s. In the flr^t place, it niitt*t he cktirly 
aoderM/^Kxl that the function of tlie C3ctrin»ie niu^^loi* of the cveball 
b to direct the ball tovmrd the object at which the jnticut desires to 
look, and they alwi evenly halanw one iinnther to keep the oye sbosdy 
in '\U axia. Thus, the external and internal rectuH mnscles mnin- 
tain thi> hori/oi)ti\l oqnililirinm of Uie eyeball. If the iiitcriinl rectus 
ifl completely piiralyjtwl in one eye. we have developed ii uullnteral 
ext4>rnal ^[uinl, the eye l'x>kinff toward the outer side of the orbit; 
and if the external rectus fiiiU, iIk- eyeball is turned toward the nobe. 
If tJlwe muscln are affected in both eyes, we have a divergent squint 
in the fir«t ca^ie and a cous-ergent squint in the second. Not only 
do the mitscles of each eyeball govern the eye-movements of tliat 
(We, but by the nervous centres governing the eye-niusclea the two 
Mitaof eye-ninscles are oo-ordinated, so tliat they move as one organ 
io health. 

Just hero it is well for the reader to make ii clenr distinction 
between eoneomitnnt and piimlyti<^ «qnint, for they an- two very 
different things in origin, symptoms, eonr!*^-, and prDgnonis. A 
eoneoinitant squint int n wrong relation in the vinual axes, so that 
they do not intenicct in the [loint looked at; btit there is no marked 
limitation of the movements of either eye in any din-elion. lie the 
direction of the eyes what it may, the scjiitnt remains pructitvlly 
ilDchanged. Further, if the lixing eye is etivere<l, the other eye 
promptly fixes, and the covered eye deviates without the patient 
altering the position of the eye (Jackson). On the other hand, 
paralytic squint is the deviation which takes place when the attempt 
is made to torn the eyes in certain direelious by means of tlie muscles 
which are jiaralyzed in whole or in part. When ihe attempt is 

> UUm pr«faruu«>*f Mil eli*|mr traeoN tuu been luito of Uie artUlle oT >D]r Mood. Dr. 
4« Rehwalnllf. «n " Wiih or lh« Cnntal Vtrnt," In DtNam'i Nor*oiu tlMuoi. 



made, the eye with the sound miiHcles turns us it should, while tlie 
eye with the jraralyxed luiiscle hangH back, beginning to deviate as 
the eye» are turned, so that thin miiHole is retjuiretl to perform its 
fuuciian, and deviates more at* cnsiti^r effitrt is required. The de- 
gree of twjnint and of »eiiaration of the double images it causes xmries 
with the (iirootion in wliioh tlie «ye» nre turned, tiiere being none at 
all in oertnin diroctioni>. 

Wc examine t\w futictional airtivity uf tint oculiir muaclee hy tlie 
following nieaKiire^ : 

The iiaticnt \n told to look at lhi> tij) of a iwncil or the ti)> of the 
lingt-r of the physician, hold atwut thn-t- firt fn>ni his fiioo. This 
object is tJicn gradually bRtught nenrcr and nourer to liiiti, itnd tJie 
vjVi of the patient iiccecKurily cuiivergc more and more as it n|>- 
prooobes the misi;. Normally the eyes will be co-ordinulely con- 
verged when the object is only three and n Iiiilf ineliM from thein; 
but if any weakness or insuRiciency of one internus is present, the 
ej-e on that side will deviate or fail to converge before this point \» 

Again, a fine point like a pin-point is held at alwut oij;ht to ten 
inches from the eyes and below the horizontal, and one eye is oov- 
ered by a card or the hand. If the eye which is wparated from 
the object by the cani dfviHiet inward, it indi<'ates inHiifficienoy of 
the external reotus. If, on thi- otiu-r hand, it deviiiUa outward, it 
iihow» insiiffioienoy of the inlernat rt-cTtus. On Hutldon removal of 
the nani the eye at onec springs back into plaw for the purjMj^ of 
fixing upon liie objctrt, and " in fpjncral terms wieh millimetre of 
movement deviating from the Gxntion-paint corresponds to what Li 
called two <k'grco» of insniliciency, as measureil by prisms" ^Itan- 
dnll). If llie internus is insuiUcient, and the covem) eye movi'^ in 
to fix in sevcnil distinct impulses, each impulse ehouhl be multiplied 
into the foregoing result. 

A veiy usL'ful, anil the simplest, apparatus for testing the funo- 
tiunal balance of the ocular muscles is ihe rod-test of Maddox, 

A ci^Il in which is mounted a tiansj>arent glaas rod is placed in a 
trial frame, which is then placed in front of the eyee. If the hori- 
zontal deviation is In be determined, the physician must " seal tlur 
patient at six metres from a !in)all tinme, and place the rod horizon* 
tally before one ej'c, a colored glaK* before the otlier. If the line 
passes through the flame, iJiere 18 orthophoria (equipoise), as far as 
the horizontal movements of the eyes are concerned. Should the 


line lii* to either sidf of ilic flume, a* in most ijcnplo it will, llicre i,» 

IcitlHT Intent ccHivergvm;!! or lnt«iit tliviTguuct;: ttie forrmrr, i( llic 
line h th« same Bid« an the rod (honioiiyniuus diplv()ia); tliv klter, 
If l4j tlic (>t)i«r Mde (cro«^ •li[>lopiii)." (Msiddox.) (F'ig. 60.) 
Fab c 


Maililox'* rad-UM for bnrisHiUI <lPvlktlon. rti t.-, i r.-fon ibi.' rlirlil eye. a. The lino 
|WM> tbtoogb lb* Uame— anbDph0i1k, S. Tlie liui: iu^-j.! 1i> llii; tight uf Itio lliini*^Uii«iii 
IIMUMHIHIW III ■■nitiiii1» C. TtM llB* piuMn In llw Mn of Uia flams-'laMail illTcccvnce, or 

When the vertical devintion i^ to be eiftitontofl tliu roil is* {ilncctl 
LTtically ill the flame. IT the jiationl ?ttAtrf« llint iiw horixoiittil 
liiif of UkIu jHiirKS* (UreiTlk throiiffh th(> llmiic, tin- verlicjil hnluiti-u 
of the vyvK U tiorniitl; if, on the otlier hiiiid, the line ic ubovc tlio 
fliune, thi^iv is a l4.'nik>nrv to ii)iwiinl <li;vi»cion of thv nakvil oyv; 
t if the liov ID bt^hiw the flume, Uicrc- is tipwiinl devintion of the 
covered by the rtHl-test. (FifT- *'"■) 
ting of this kind refers to tlie in^utliciencies nnd not to Uie 
of tlie ouuUr mtL§eloK. 
Ttii^ im|)ortnnee of being nble to denion«tmtc these minor fniUirOtl 
Ju the oenlnr musL-lt* by ihew meiUH lies in the faet that in this 
tiiwlachea cine to miisele eyo-stmin may bo remedied by 
iving their eaiisfl by j>roperly fitted glasses, or by gymnastic 
ses witli prisma, or in some casea by tenotomy. 
Where there ure marked paUiea of tlie oenlnr museles tliere is 
lly some |)oiMm exereising it.-' cffecta u|ion their nervous centres 
tliG nerves th«maelvea, or tliere is some central nervous lesion 



affpotlng tlie eeiilrea govnriiing: these ninsples in the cortex, or llicre 
U a lentoii in the nuclei or faitcieuli, »r, again, there may be leuons 
In the ha.sal gniigltn, or in tlie cflurae uf the fibres of tliv nerve 
between tlie iiitoleus and the eve, or in the orbit or iierve-eDtliii^, 

no. ST. 


Maddoi'imd-Icit foTTorUcaldCTltiiciii. TbcrodliU-Gircllio rlalitcTi- ■^- Tbc lliic]ia>«< 
tbrooKh llii- Itmaii— uribuiiliurit, D. Tb« Hat ptuae* b#loir tb( flmiit. Tlis utipor ln»«ii te- 
lonn Hi Ibo lort eye— ilibi hnwrpboila- C. The Uqc immn Bbon tbt iUin«, Ilio ujipcr 
IiUKKO bi'lDtipi (u ttw rlghl txu^luR hjrpflrpnntlB. (tjii^URWUviti.] 

The i«i};na of panityMiK of the ocular musolcit con»iat in the follow 
ing symptoms : Di|itopia, whieh i« due to the failure »f the images 
to fall on the vorrur-pondin;; points in eueh retina. TIuh diplopia 
bocomus more and more murked us the object is moved toward the 
side on which the paralyzed iiiu«'le lie*. Strabismus, whieh may 
or may not be eonatunt, usually develops when the patient endeavors 
to turn his eyes in the direction of tlio paralyzed musdv. Vertigo, 
which is due to the diplopia, or, if the well eye is closed, to an erro- 
ueoUB localixutionof the objects in the field of vision. Altered car- 
riage of the head, due to tlie fuct that the patient Iries to tnni his 
head in the direction in whii'li he is least troubled by double imngeH; 
that is, he obtains the natural lixfttton-|K)int of the weak eye, and 
then adjusts the well eye accordingly. 

If the jiaralyflis of the oenlar niti^-le bo complete, the Mjuint and 
the loss of movement of the muAcle which is paralyned will usually 
enable the physician to lind out tlie ]>aralyKed miincle; but if there 
be only a partial paralyiti^ or paresis of an ocular muitele, tlien jkiuIiiI 
ianot necessarily present, and the diagnosis of the pari aff«!te<I must 



Liniiil** bv n Titudy of the tloiible imugiri!. This is niude by placing 
ibi- pnticiit, nt a ilittlniicQ uf from tbrct to five yards, a candle 
on tlic Mitiii: Ivvvl a» liix v^'es. One «ro U cuvered by a piece of red 
glR>>«, w tbat iIk- pa(i<;nt om n^iulily distinguish bt^twcen tho images. 
The lif;biv<] randle is then iiiovttl from the middle of the patient 
ti) tliL' ri^ht itnd left, and the relative positions of the red and white 
iiiin^t^ iiotfd. Thi-n t)ie cuudlo is moved np and down. an<l the 
nwultd rworrlod. Thtwe operations having been recordetl, it is to 
be remeinburAd tliut diplopia is most marked and sometimes only 
appears when the patient turns hia eyes in that direction which 
calls into play the affected muscles, no diplopia being present if 

Flo, M. 

r Uft ftMuMni In * («>wflb«Dit))Irsliior»rpbllluaoiigia. iDKinntn.) 

mu<4'les are used. Again, tbe imiigt; which ludongs to (hv 
allvctwi eye is prujeeted in the direction towanl which the pnnilymHl 
utiAck'' normally turns the eye, an<l, finally, tim diHtnncK; of the double 
inagv inorrases when the eye6 are tiinicd in the din-ction of the 
■etion of the paralyzed muscle, or, in other word;^ tliut irnap.- la 
faW and belongs to tlie affected eye which in the ref^ion of diplopia 
[0)0708 taeier than tbe moving teat-object — that is, the <:undle-flnn)0. 
If we place a candle several yards (say thn>e to five) in front 
a patient suffering from paralysis of tbe external rectus and 
level of hw eye^, die double images of two eamlles will 
as in Fig. Ijy, if he baa complete panilysis of the external 
reetua or internal sqnint of the left eye; while if the right external 
3i \» paralyzed, tJie iniiijre^ wilt appear as in Tig. 70. Further^ 
tbv object lit moved to tlte ri^ht in tlie firnt condition, the UAbr 



aud till! tniL> canJle separaie further aud furllier; wh«reas if th* left 
extvrnus is inv<ilvc«l and the object is moved to the left, the same 
«epan\tion takes place. This condition is called homoiiymoiis diplo- 
pia, bticause the word homon>ino[i<< indicates that the false image 
is seen ou the same side a.^ the eje ofFectiKl. 

Fra. SO. 

Fm. n 



If, on the other hand, the false imago U found to the riRht of the 
true one, as in Fig. 71, the intvnial ret-tus of the left eye is paral- 
yzed, and causes an external squint if the paralysis is complete ; 
and if the same mnsele of the right eye is affected, the false image 
will ahw he to the left side of the true one, (Fig. 72.) Further, 
if the object is moved to the right in the fii-st rase, the two images 
separate more and more widely ; or if the right internus is involved, 
and the «>bject in iiinved to the left, the same thing occurs. This iflj 
railed crossed diplu|Mu, honiiiiH^ the image of lUc right eye apftcai 
on the left nlde, and the imngc of tlic left eye apjioars ou tlie right 

Fm, 11. 

Fw. w. 






Ttlthbclnu^liilllOiKllIi*. (oiS'iHi'ilMnt.) 

Supposing, again, that tlie images are seen as in Fig, 73, then the 
Irft siipurior rectus is involved (downward squint); while if they 
nppcar as in Pig. 74, the right superior rectus is afTerted. This 
diplopiii (ir-eurs chiefly in the upper field, because, accnriiing to a 
rnlv nh'ividy ^iven, diplopia is most manifest iu that [tortlun nf tlie 
fleld of fixation Wward n-hieh the paralyxed muscle commonly rotatai| 
the eye. 

If the imnges ftp[ieiir n» iu Fig. 75, the left inferior reotua is 



nfFMted ; or if as in Pi(r. Tfi, the right inforiyr nwtu-j miiaole. This 
is also croHHcd dii)lo))ia, oliietly in tln^ lowor lieltJ, Wiaiise tlie inferior 
rectm muscle rotau^i* tlie evflbitll downward. 

VM. ffi. 


Tb* Mm links* i> In oatlln*. [it* ScnwuKm.) 

A^iD, if the i[na$!;G£ itppciir as in Fig. 77. th« left inferior obliijuc 
muscle i>i paralyzed, iind thor<.- will be inward and downward sijuint; 
if tiie right inferior oblique is uffeotod. the irhugos will be oa iu Fig. 
78. There is a homonvmous diplopia most marked in the np]>er 

If title to luimlysiA of the left riUjterior oblique, the images ap])eer 
P>H ■» Fi^. 79: and if, as in Fig. 80, the right U alTcnt«d. Thcnt U 
'■ Ml upwnni and inward wjuiut, and tJiere is a homoayinous di])lopiit 
chicflv In thi': lower fiehl. 

rta. n. 

Pig. 7S. 


Tto. aa. 


I i 

ThetiUHlmBcetiUiOQtUae. (uHHvuviliim-j 

Finiilly, if there in divergent wgiiint with failure of movement in 
all dircetiottit, except outwanl and slightly downwanl, aii<l there are 
ptneiH, mmlemte mydrinsrs and piimly^iH of aueomuuHtatinn, tlierc 
■TO oculomotor lanilysis iind i-nwii^il diplopia. 

Tlie following twbli- of UmI/ \ /\!-rnalional ()linir», vo\. iii., 4t]i 
Mries) wimiiiariwn th<r fiicUt iw to the diagnosU of the eundition« 
ptTHltidng HtrabiMiiiim; 

I. Lat^nil diplujiia itHliciitef piindysiU of an internal or external 

1. Homonymousdiplopiu indiait<,'«|Hinily»iiiof au exteruul roottui. 



a. Imnp^-i>«-|mrntiiij{b>Uicri^li( iiiilU-HU^jianilyeUof theextenim 
of tlic riglit fj'c. 

ii. Ituii^c^ Hci^Hiratiiig to th« k-ft iiidiratc juimlyHis of Uw RXterntw 
of till! left eve. 
'2. Crossed ima^t'S inilioutv pnrnlyeiis of au iiittTutLS, 

a. ImagiM se]inrntiiig to the ri^ht ladicatf punilysis of tlie iittvrnus 
of the left eye, 

h. Imagei; (U.>puruting to the left indicate pan>1>'«s of tlie intcrniis 
of the right eye. 

II. VertimI diplopia In the upper field iiidioatea paralysis of (be 
superior rectus or inferior olilii|He. 

1. Homonymous images indicate paralysis of the inferior oblique. 

a. Image of right eye higher means [iaralyM.t of the inferior ol^ 
liqiie of the right eye. 

b. Image of right eye lower means ]iandy:<i^ of tlie inferior ohliijue 
of the left eye. 

2. Cros-ied imager indimt^* pHmly<>i)^ of the siiiH-rior rudtu*. 

a. Image of right eye higher meanM ]uimlyt(i« of the superior revtiw 
of the right eye. 

b. Image of right eye lower meumi paralysis of thl^ superior ructiis 
of the left eye. 

III. Vertical diplopia in the lower field indieatcs pamlyeis of tJio 
inferior rectus or BUperior oblique. 

1. Ilumoiiymous images indieate pnralyftis of the superior ob- 

a. Image of the right eye higher meant* paraly^!^ of tlie «ii>erior 
oblique of the left eye, 

2. Cro»»ed image:* indimto guimlyttis of the inferior rcctii». 

a. fmiige of thir right eye lower means jianth-sis of tlic inferior 
rectus of the right eye. 

A. Image of the riglit eye higher meims paralysis of the inferior 
rectus of the Ictl eye. 

' It is exceeilingly difficult, however, always to localize exactly tbc 
affected muscle, a iliffioiilty which is mueh iiici-eased when more 
than one is parotic, the paresis being of different degrees. 

Having now canaidered the means of determining that die musclee 
are defective, we must determine the diagnostic indications pi-eaeatfid 
bjr this examination. lu otlicr words, vre must seek tite oatue of 
the paralysis or lata of iwwer. 

Paralysis of the ocular musuJes may bu due to u lesion in one of 

sevoial plao«8. Thus it may ariae in hemorrliage, sclerosU, and 
eoftenio]^ of tlie cerebral cortex, in which caec the other symptoms 
of leHons in tlioee larta will bo present as in apoplexy, disitemiuated 
wleposis, or meningeal diHease, Or it may depc-nd n]Mtn lesions in 
the fa^iculi between the cortex and the nuclear origin of the nerves, 
as in the crns. (This is rare.) Or, again, it may he due to legions 
in the nuclei. If this be tlie ca^e, we have developed ophtltalmo- 
ple^ia,' or paralysUof all the ocuinr miiscW siippliod by the third, 
fourth, and itixth nerves. This inideur [laralysi^ is divisible into 
two clatwvfs t)i« acute and chronic. Sometimi^ it i^^i called acute and 
dironic nuclear ]mUy. The acute form is sudden in iti< Mm>et, nil 
ihw wiilur muficlv» li)»ing power. With the onset of tlic nttjick there 
may bu fes'er, vomiting, and even eonvuUionit, Suoh an attack 
rcKuItt' from nilnutv hcmorrha);cK umouK the nuclei, or from an acute 
itemorrhogic jmltocncephalitis in tlie fourth ventricle, arising from 
syphilis, tuberculusie, ptomainc-poi»oning, alcoholic and salphurio- 
acid-|M>i Honing. Such coses are usually ra]>idly fatal. A 1cm fatal 
form follows injuries, and tlie effectH of nicotine, lead, carbonic acid, 
or such diseases as diabete.s, .syphilis, ami epidemic iafluenxa. Soroe- 
timea acute ophthalmopl^ia oomee on with acute poliomyelitis or 
«cut« bullmr paral\-8i^ 

Climiiie ntich-jir jiaralyiiis is gradual in itit onitef, muscle after 
muoelc failing, and even ptosis coming on. Sometimes after a er-i^ 
tain degrv* of panilysift is reechecl the <lis<'ii8c romes to a standstill. 
Tile trouble may be unilnlemi nr biliitunil, mid is often unsymmel- 
rical, and it oocurs after acute ophthulniopkf^ia, lus ft eon^-nital 
defect prodiioing bilatornl pto»i» («ee chapt4.'r on Face), as an at^nired 
disease In childhood an<l sidult life, ami in conjunction with loco- 
motor ataxia, paretic dementia, disfwrninate^I sclerosis, pro^roMive 
iAoscular atrophy, clironic buli>iir paralysis, and in connection with 
^Ualysis of the frontiilis and orbi<'ularis ]Kit]>ebnirum, which are 
innervale«l by the facial nerve. The cause may Iw tuberculosis or 
^pllilis, but in some cases no cause can be found. 

If the oause of the paralysis of one or two muscles be basiUir 
lesions, these may arise from hemorrli^e, pachymeningitis, raviiin- 
giti«, botJi simple and tubercular, chiefly the latter; purulent men- 
in^tJa, alKwess as the result of iniddle-car disease, and aneemia. It 

> OphUialnp|il«ila h hvr* iiipllvil In It* (Irlcl Mnw THc aonl fR nftdn iiwi) U> ultiiUy loM 
•Tiwcrln liidlTldiulcjV'inuicln: uid while iu lue In botli wiifi li i^Drrvcl. II la talitT to 
MoSn* lit w«c* to nuislw aod ooniileu lulonn. 


may also arise a& tlie result of obliterating arteriHs, ]UirtiiMi1nr1y In 
syphiliticA, and fruai tumnn^. In children sinltlea c-onvcrgvrit stra- 
btsmuB and di]>tiipia are often among the earliest symptoms of tuber- 
ciilar meningiti.'i at the bn*e. 

If the he in the nerve-tninks tliemselvee, the lesion will 
probably be cellulitis, tenonitis, hemorrhagai in th« orbit, or fr&c- 
tara-i of the orbit; or, iiffain, there may be disease of the frontal 
iituus. If the leniou i.s dii^ttiiftlr ])eri{>henil, it may he due to rheu- 
matism (when the external rcf-tus is uoramonly affected), ueuraBthe- 
nia, or it may ari!*e from iiric-acid diathesis and gimt. Further, 
»ni?h leftioii'i mity he due to intUienxa, dinhet^, diphtlieria, lend and 
ah«hol, or any one of the drop* whirh pamlyxe the oeiilar nerves. 

So much for f^encnil MatemiyntH u* t<i the eomnion and jiassihle 
Bites of t\w IcHionn priTdnrint; [iiimlvitiji of the oenlar muiielej*. We 
ean now fju further than tlii» and locate the lejtiou more ftciMini»*ly 
from the kuowlcdj^c wc have gained ai< to the partiviilnr miiit<-l« 
«ffci!t«l and tlip ottivr symptoms proiwntod by the «iw;. 

Let iu§ i-iippuse that n patient !<nfFeriiig from paralytic internal 
squint, or a diplopia which iitdieutes pamlyMis of th« cxt^Tnal itNHiu, 
prei^enls himself to the plix'tiician, what diagnostic vigiiilicanct- has 
tliLa eympl()m?' 

In the tirst place, it is to be rememliered that the external rediu 
receives iw nerve-supply from the abducens, or sixth nerve, which 
arii«e» from the pyramidal body close to the pons. (Fig. 81.) Its 
deep oi'igtn it» a iinolcus under the floor of the fourth ventricle. 
Thi' nerve pierces the dura miit'T on the basilar surface of the 
sphenoid bone, pa;M;s through the elinoid pnx-ess, enters the < 
eniou« cinuit, ami, finally, enters tiie orliit through the spheitoiilal 
fiwnrw between the head)* of ihi^ external rectus. If thi:t form of 
squint is luwuciatcd with hemipli.-^in of the opposite »ido of the body, 
the Icjtion is in the pons on the *nme side iw the nffi-et^-fl eye and 
the opposite from tlic hemiplegia, betMnsc the eye-fibres have crossed 
higher up, hut the motor traet« for the liml>« cross louvr down. 

On the other liimd, if there is no monoplegia and nbdncens palsy 
(internal st^nlnt) on the same side of tlie body, the lesion is in their 
point of origin in the cortex, or, in other words, the lesion had taken 
place above the point where the tracts cross. .Such a puntlyius is, 
therefore, cortical. 

1 ThU Mtbn lo [«Ml]rtle km) not to conoomluut iqulDL 



If, agftin, tliere is oomplct« iinilatoral paralysis of the sIhIhwps 
(iutemal Mjiiint), with loss of the a.'wuciateii m-timi of the ialermiH, 
tile lesion i» in the nuolei under the tloor of the fourth ventricle, 

pm. u. 

Tim bMO «< Uw tmla 411 J IbanmiMl ti«rr«ii, cnm. pniu. aiiil iduiIuHk, lAi.tKH TBOMnoOI.) 
I V> Xtl, TtW OmnUI n«rrca /H, upllv Ihalftmun h. rilulUT) bttlf. IC TobM cUitnDin. 
•. corpora altlMHtia P. tvi poiUDciiU. t. iiitarlor. «. Bil«rii>r(tiilsalau body. p\i. roii* 
VaraBI. ^ AniarlM t>r">i'><<> "l tuwtiilla. a. ollio. if. D*cuNMl«a or anUHor jirnrnti. 
m. AnMftat mIuibii of tplaai tord. et. t^tctal oolumn of tplnal oonl. Or. Ccnbcllum. 
jt nwenlnorMMtanuni. VI. The iixtb or aMuconi norrc- 

lUM! tlic itii«let uf thi^ ihirft iiml itixtli enininl tu'rv«'» un^ vloMly 

irti->l, m ihnl a Inioii iuvolviii]; lUv .tixth linoleum wrakoiM the 

iitcU'UK of till- third lu'rve. (Fip. 82.) Coniplelc [xiralysts of iho 

'«xt«n)itH may, HxrvtoTf, 1»e due tu » inicloitr Iomud; for if tliv loi^ion 


were above tlio nnoli'tis, Urn nucleus mij^lit obtnin collateral impale 
sa seen in fU'in din^rHtii, iind, tlivnTuix-, the panilvf-ig would b« on) 
partial. It iiinv uI«o be due to u pi'ri]iiR'nil lesion, Soiudime^^ 
ho\vev<tr, nn iiilliiiiinint<<ry process i>n?ssiiif: iipon tlie basilar surface 
of thft ft]ilii'i)iji(l, iiixl tlifii'by tuvulving the nerve, may cause a 
similar efFevt. Loss of power of the external rectus tuay also uri<« 

no. ft. 


■Mixninof ili« oouDootlooior tlia nuolvu* <ir UiBiliih aom. <Biivci.| 

from ncurasthvnLa, uric-acid diathesis, gout nod rlieumatism, and 
in tubercular or syphilitic ineninp^tis at the bcwo, us alraidy stated. 
It also comes on in some cases of dinbetc«, la ffi'ippf, and in ohronio 
poisoning by lead and alcohol, or the acute poisoning of gelsfiiuiuin,. 
ptomaine-puisoning, oonium- and spigelia-poisooiDg. 

Again, let ns suppose that the internal rectus is paralysed, cau^n^f 
external squint. We remember tliat it is supplied by the outdo* 
motor nerve, wbieh arises from a nucleus in front of the corpora 
quadrigemina, which extends from the level of the )K)»terior com-. 
missare to » p^int near the nucleus of the fourtli neri'e or pathetJona. 
(Fig. 81 .) LaiidoiH .'^tate.'i that tlie two uuetei (the third and fourtli) 
are united. The nuclcu-i of the oenlomoior nerve ha-n bei-n divided i 
into aeveml group-s, as .thown in Fig. 83, after Kruoe, wli^re, how- ' 

ever, It i« Micii that tlic tliirtl ami ronrtli niicloi arv not uiiitiil. The 
Borvc iliscif pwni« lUe <liirn niator W-Iuw tliu pi»t<;riyr cliuukl pri>- 
«**, jMi»«>f' iilon^ Uic wiittT Willi i>f tlif t'HvornouB ^iiiu^, and after 
dividiiip; into tvru bniuelivM •.■utcn titi; orbit tUruufrh tbv eplicnui'lul 
fisaore. Tlie upper bmncb iitippli«<i the superior rectus and the 
levator palpebral, and the lower one after dividing into tliree 
branchvtt tuippliw the liitemul rectos, the inferior rectus, and the 
inferior obliqnc musclee. The oculomotor nerve receives filaments 

Fra. K 

SAHWOf Uw HiBuati (if th* niietauiof UMtlilnl neri«Kn>l ibeli nlaUon* (o tacti olli«r 
*a«tlOlk*«Ml«ai«fUiCfMinbMrv«. iiMi. Tbicd iiacv*. )i. UullHQ nuclciu *. AiiWrlor 
OMlm*, IMtitar p«H. A|. AQlerlof nuclcm. lomr psrt of nuiii iiiiolvuit A,, AnMrlur 
BWlvD^ IMWmMUMa p«ftloii. *>. AiiMtlnr nuvlcui, npp«r pocUcm, r.i. I\ialcn>-lui«ni«l 
UolxM. r. ■. |idUani«xUnuJ nucl«<w. t. Eaiarnal tiucJaiu, ■- Auparior nooleiUL !)ein« 
«f lb* raot-nbrti IHM tiM tomt mhI Inlcrmcdlftio |«'t> of th# K<i(«rior mialam u« rvpn* 
MBtod br doOal Unas m eranliMt to Um oppoaiM ild*. it. T1i« ducIcd* or ib« C»DrUk ntm. 
IT.*.,, t*.*.^ iT.M.i. Ttwflnl.Mcoii't.aDdlblnt poMIoiDOf lberuHr<v[«cUTclr. <Biiccit.1 

froni tlio onvemoos plexua of the sympathetic^ nnd frixn thi' fintt 
division of the fifth nerve. In addition tu divcreviit »qiiint there 
L-, as already pointed nnt in the last few f>at^-s, in ocnlomotur paral- 
ftie, aa additional ayniptoins, ptosis, luyilrtiwis, mid iKinilysis of 
imodatiun. The l&tion producing uuilatoral ptix^is inny be 
in tlie cerebral cortex on the oppw-ito »idc from tlw nffwted 


eye in the aiigiilar gyms just below the interparietal fissiire. AjiHiin, 
tubercular nr other de^neratlve diiiease of the eorpora ijiiadri^iiiina 
may caiuie double plo^iiH. 

If the patient Iih.4 ptosis vt'ith preAervncifiti uf the function of tlw 
intmoi'ular musoles ^that is, juirtial onihtcuntjir paralysis), witJt 
iiemiplegia of the nppusite sld4> nf tiic Ixxly, tbt- li-sion, scrurding to 
Maiithner, prolwbly nfftwtc the fa^ciciilnr fibres — tliat i*, tl«»i*e hv 
tween the oorlex mid ihr nuclei, Thero inny be iw»oci«t«[ with 
thi« form of ooitlomoUir imralysic loss of power in ibe bypogIi>>«l 
und fueiul iRirves. Ou tlic other h»nt), if lliv ooiiloiuolor |mraly«i« 
is oompliite, the IcsioD iif ulmi»^t (H^rtuinly nt tJio busu of tim brain. 
And this djjignosifl bGComtw prurtimlly certain if there '\» n««UL'taied 1 
with it paralysis of other cnmiul nerves. Pandysio of the oc»t<>- 
motor nerve on one ^idc with hemiplegia on the opjiosite side of tlie 
boily is not positively ii erns or fascicular lesion unless the purolysit) 
occure simultuneoualy. (Hugblin^ Jackson.) 

If, however, there be double ocidnmotor paralysis, the lesion is 
bilutcral and probably due to a leaioii at the base, aa meningitis or 
arteritis; or to an inflammatory exudate involving both nuclei; or, 
again, to diphtheritic poison or the legions of tabee donuilis. 

If that very rare form of oeular niusete [tarnlysls, namely, iaotated 
palsy of the fourth ttin^blcar nerve, is present, we will probably lind 
Uiat the paralyms is due to a lesion at the ba.sfl of the bruin, due to 
moninK'''"' '"" ^''<' pi'essure of a g-rowth. 

SupiKirtiuj;, however, llml u putii-nt pi-esenlj* himself with swelling 
of the eyelids, cxopbtbnlmos, a eoutraetcd, followed by a dilated, 
pupil, nnivstliesia of tliu i^kin of the upp<T eyelid and of the teni|)le, 
or the urea itupjiliod by tlie lii-^t divisioa (ophthalniie) of the fifth 
nerve, and ophthixlmo])1ej;ia — that !s. pnnilysi^of the extrinsic ocular 
museles ou one side — where will be the lesion ]>roductivc of tJlEs 
tiuiu of iutercatiug symptoms? It will be sueu at once tltnt Kuch a 
condition tstJie result of paralysis of the oculomotor (third), pathetic 
(fourth), and abdneens (sixth) nerves, and (hat as iu all probability 
only one lesion has produced tbi'se symptoms it must exist at some 
point where all these uorve-fibrt's are so closely approximated that 
tboy arc readily involved t*>gether. It will be recalled that the 
oourse of tliese nervos is as follows: the oculomotor ncr\'e having 
arisen from the mucIciih in the corpora quadrigcmlua pierces the 
dura mater below the jiosterior olinoid pi-oceas, pusses along the 
outer wall of the cavernous stniLs and there divides into two 

THE m'£. 


iranclieii. Tiie pathetic n«rve passes near the clinaid process &]ang 
the outer wall of the cavemoiui sious ami with the oculomotor nerve 
euters the orbit through the sphenoidal (ismi-e. The sixtli nerve 
pierces tlie dura mater on the basilar surface of the sphenoid boue, 
paj«w^ thruugli the dinoid process, and ente!^ llie cavernous sinus, 
liikally readiing the orbit through the sphenoidal 6ssure. It i--< tliU'* 
seen tliat a lesion at the sphenoid fiiwiure and pressure in the ciiv 
eruous niniis would cause all the synijitonis descril>ed alxivv. Thiit 
ovcur^ in caiwtn of [hroinboitis of Uie eavcrnon.-! sinus. Where there 
i* nil »rtvrio-vcDons aneurism of this sinus there will he pulMtting 
vxnphlhaliiKis. Injury or inflammntion, if in this nn-n, may nUo 
product! n scriw of nyinptJims. 

The siguiriimniN! of coiijnKate l»tcml parnlyxis iirudticin^ a devia- 
tiuo of ijotU eyw to the rijihl or left, a» the ciisi' may \k: is that 
M>me imiun cxistjt in the cerebral cortex, the corona mdiatu, or the 
inteniul mjmuIc, or in the ponit before the fibres have crufised. The 
Itttou, if in the cortex, however, docs nut have to be lotnlizcd lu one 
tp(A, for any ituurcc of irritation in the cortex may apparently oniise 
etmjugate deviation, [f the Iciuon is the result of an apoplexy, the 
eyes are turned toward the Bide opposite to the puralysie {I'rcvost's 
wtnptom) — that is, the " patient looks at his lesion." The reason 
that a unilateral lasion can cause a bilateral deviation is that the 
lateral movements of the eye are governed by an impulse which 
paaiei} down from the cortex to the sixth-nerve nucleus and thetice 
■orow the |>oi<lerior longitudinal fascriculus to the opposite side, 
wborc it piks^cs to Uie onoleitsof the tliird nerve. A* oonjugntc 
latern) dcvtiition is musecl by contrAction of the internal n-ctiii< on 
OM (tide (thinl nerve) ami the external ni^tus on the other (sixth 
uervc), the mechaniHni of the deviation is clear. Thus if lite legion 
be a diirtiftctivi- one on the left side of the brain, cjiusing right hemi- 
plegia, the eyee will be turned to the left by the action of the unaf- 
foctvd loft external roetna and the right internal n-ctiiiK; white if ihc 
hwiiHi bt; on tlio right side of the bruin, tin- r<>vcr>w will occur. If, 
however, tlic lesion be irritative (as a tumor), thin deviation ia 
nvenoxl, because in this case the i>entres are irrilalcil un<l euiise 
upcwm of the musclm rcoeivioi; their nervc-s4ipply frum the affected 
iii\t of tlic ecrebnim. In other words, the eyes are turned toward 
tile side of the body which is convuW-d. 

hi tiiu ltn4 instance th<> eyes arc tunieil away from tJie aftei^ted 
•itle beause llie muscles of the eyes ou that side are a\m ]ianilyxcd, 


itn(] thf vvcs arc tliorcfore turned l)y tiip'lfw wliictli n'liiiiin In* 
tact. In the afcond iostaane tJie eves mo turned tnwiin! tlu- cuu- 
vuttfod side becnuHe the internal and oxt^riml pcrtiw ■w s{«iflmodk* 
itlly eoutnictcd and eo overoonie tlie houldiy mu^cilc-.*. 

Wc find, however, that, if the liwiou be in the jwiut nithtr tlinn 
in (he cortex, three canditioii-' »r<r ix-verswl, for now n destructive 
lesion causes the eyes to he turned to the pnrnlyzed wde, and an 
irritative lesion direct>i tiicni nwuy from the pnralv/ed side. 

This i» heitt explained \ty l\w following diuj;ram and descriptioo 
from Hwanxv'fi wi'll-known book. (Fig. 84.) 

Flo. w. 

1. Left CXI. ROl 111. 1 UniDL riKliii. 3. IU|kt bU. NaUK 
4. Rliflit Bit. mtun ^ Xucltiulonihlrilnvrr*. 11. triMllH 
nglil IIiIrI ncrv«, ; anil *. VoU.. lonillurllDal l«Dili Itam 
nViih Dcrvo to Dpp«rie (hint nori«. •>. Snrleia IHl itxtH 
itomt. to, NUL-tuiii riylil ulilli ii*rv«, II anil 12. I.(A and 
rigU rraiilcnl cvDln". A» IminilH ilanluf ftam li malil 
iTBvcI down \o V. anil produce bb aaoclalMl moTcmMii ctf tb« 

A destructive le»iou at 12, the right cortical centre, involving 
«li«» motor eentre* of the body, would cause left hemiplegia; bim), 
since the external rcctuj* of the left eye and internal reetUK <»f the 
right eye vruuld be jmrulyzed, the aulagoni^lA woidd turn the cyce 
to the right — I'.r., away from the [mnvly/ed side. A dewlnidive 
lesion of the right i^idc of the |Hiti^, iil^u prudix'tiif^ left hemiplegia, 
if it involves the sixth niivleuri, will produce pnralyi^ia of ihc cxterual 
rectus of the right eye unduf the internal rectus of the left eye, ai>d 
tlien the antagonists would turn the tyva to the left — i. r., toward ihe 
paralyzed side. Et is easy to i^ee bow irritutive leitlons would pro- 
dtiiie exactly tlie opposite effects. 

Sijuint which is due to hysteria is always cauM'd by siiusmodic 
eontmetjon of the eye-muacle and is never duo to paralysis, m 
It oft4'n i» in organic di.tease. Very often there is n syiasax of 
the eyelid or eyebrow ai«Aoeiated with it. The administration 
of a reluxant, ttuoli n^ ohloruforin, will at onoe overcome such a 

Ky»tAginn», or tlie rapid uscillation of the eyeA from «de lo aide 



or in a vertical or rotarv ninvoineiit, is uftiiaily liilateral.' When 
not con^nital it i^ » fiHKiuoiit sym|it'>ni uf <li.'<'«emliukt(^l solerofli^ 
Prieiln-iuh's ataxia, and adviuioi.'d Imxtinotor ataxia, and while it 
doos nnt locnliiw the lasion it iiidimt*'..-' very piMtitivcly that on« ig 
prcwQt and timt th*r cn.-w \a not oin- of hystorin or fnnntioiiiil dis- 
Muw. NywlafriiiiH na-iimny in cliihlrvii i« wxy often iLwociaUrd 
witli im|>crfi'ut vision of grmt defiree or witti Windnctw iw a wm\i 
of opacity of thi« W)rn4'8, (wigenital cttlarn>-t, or utrophy of the norvc. 
In oUkt ioHtanccis linvrvvcr. it arlM-!* from umwUi* in the Pi!rel>dhiin 
or |K>iis, and it \* minttlimiM seen in liyilivxvphuliiB and very rarely 
in arnt"' miiiin^iti* iind in upilt-iwy. Vt-ry nirely lateral DyKiaj^mus 
ift *«<rn ill ■■hildrcn who M^m othi-nviiw iiomiiil, ami it thi-n poetwxMCS 
no pnrtioular ilij4rim«tir inipurtunoe. 

Paralysia or DL-wrder of thn Intraooular Miisolea. FTavinf; 
diH^lt^s<-l| ili<- dia^niMtii- iiitliciiliunH of c-lumgvs \a i\\v fniK-tion of 
the cxtraiKuIar niiuwlfw, wc next proctiid to a consideration of thcao 
fa"'(« in oomiwtion with the iniRuwnlnr inii>>tclcs. Tht-se conHist, it 
will be IV in em be red, in the muscular fibres of the iris, circular and 
radiutiii]*, iiud the ciliary mtiHele. The nervoMipply of the iris 
consists in fibres from the oculomotor or thinl nerve, tko uppur or 
ophthalmic division of the fifth, and the sympnthetie. It will be 
remembered that in the posterior part of the orbit there ia situated 
a ganglion called the ciliary or ophthalmic ganglion. Ry iis tihort 
or motor root this ganglion is conneeted with the third nerve, by 
its sympathetic root with the cavernous syiiijiathelie plexus and tlie 
oervical sympathetic plexus, while by its long or sensory root it is 
oaanecteil with the nasal branch of the ophthalmic or iip|>er branch 
of the tiftJi nerve. Prom this gimglion extend forward two .tets of 
nerves, one short (tJie short ciliary nerve), which supplies the iris 
and the ciliary muscle, and one itet long (lon^f ciliary nerves), whieli 
aUo go to the iris. The filaments which go to the ganglion by 
neatut of its flliort or motor root (fnim the oculomotor nerve) poaa 
hirwan] to ilie cin-ular film^N of the iris, white thus*' which have 
arL-«en in th" synipnthetie pli'\iin piK" furwaii! to the radiating lihnu), 
TIksm liL*t ftl)nr-t are in part derived from the oervii-al ^ym|)at])etic 
ganfrliiiii, run through the cirotid plexii", and are oonlrolted to w>itie 

Itent by the cilio-KpinHl centre of Itiingr in the :*piiiul <<onI nt alKMit 

bo levcuth oervieal or iirst dorsal x-ertebra. 

> n* fkivclaii ihuuli] laTDvinbur ihm •»iii« oc«ii|i&tli>D(. ■uch at taliila(. tiroduM tn ttaa* 
I II J Mil mm wKboul lli« | ir B W »n» of llif illHdo aboiit U> b* lumMl. 



The ciliary muscle is supplied by the fibres of the short eiliar}' 
nerves, which have arisen in the floor of the third ventricle and 
which is connected with tlio nucleus of the third nerve. 

Testing the Pupil. The size of the aorma! pupil is about 4 
millimetres in diameter, but this varies according to the degree of 
light to which the patient is exposed. It ought always to be mca.'^ured 
by a millimetre measure, which gives its approximate diameter. 

The pupil to be tested must be free from any abnormal couditions 
produced by new or old inflammation of the iris, and the light used 
should not be excessively bright, but about that usual to tlie eye. 

The patient is to be placed facing the light and told to look 
at some distant object. Tlie hands of the physician are then 
placed one over each eye, the patient being told to keep his eyes 
open and to endeavor to see the objtfct seen before the eyes were 
covered. One hand is now quickly removed from one eye and 
the pupil observed. This observation must lie acute or the pupillary 
contraction will occur before it is seen. This reflex is due to the 
fact that we have an irritation of the optic nerve by light, and 
this sends a reflex wave to th«? centres governing the pupil and 
causes it to contract. Xot only does tlie uncovered pupil react in 
this manner, but the covered one does the same thing. The first 
is called a direct reflex, the scmnd is called the indirect or consen- 
sual reflex. The exact p:itbw!iy of this reflex is unknown, but we 
know that the li^lit-impiilsc jmissc:^ along the optic nerve, and, 
arriving at its semi-dcciiss:ition in the chiasm, passes along each of 
the tracts to the corpora ijuadrigeinina, and thence by the commu- 
nicating libreri (.Nrcvncrt's libros) between these bodies and the oculo- 
motor (centres to the centre for the sphincter pupillte or circular 
musclo-ccntre, and from tiierc to the ciliary ganglion, the ciliary 
nerves, and the mnsclcs of tlic iriri. (I'^ig- So.) 

Xot only docs the pupil change its size by reason of the ordinarv 
light-rcrtcx, but it also contr.ict-i or dilates in association with the 
other muscles fjovcriiing acconimndation and convergence, namciv, 
the (iiliary muscle and internal recti. Tliis is the associated reac- 
tion of the pupils, and is tested by causing tlie patient to direct his 
eyes tti a near object — for example, the |)oint of a iieneil. If the 
sight is intiict, c-()utractioii of fjie pupil will occur. 

The pupil-dilatinj; centre Is in the medulla and is very sensitive 
to reflex irritation. 

."Supposing that the pupillary niovenieut is abnormal, wc should 



recollect before Htudyiog the case further what the causes of its^jior- 
verriioa may be. Thus its size is altered by drugs, by local disease 
of the Iris, by spinal disease and disease of the sympathetic, by 
localized cerebral lesions, by abeyance of the cerebral functions, 
and by irritation of the brain. Let ua suppose, however, that on 
testing the ocular reflexes in the manner already described we find 
that the pupil of one eye when uncovered does not contract, and 
immediately does so as soon as the other eye is uncovered, what is 
the indication? It indicates that there is disease of the optic nerve 
of that eye which does not convey tlie impulse of light from the 

Ki.i. A-. 

3N 1 3N 

!l.s. cemreof Ihlrd nerre: 1, connection betvecn nuclei or tblrd nerrea; 2, Mefnert's llbre* ; 
Q. coriHira cjuulrigemLnH : c, chlunu: o. optic nerve ^ r. myotic fibrea of third neive; L, leal 
U letlon : Brroiri show p>tb of ImpiilK In leilan of right Iract U L, (Swahzv.) 

nttina; whereas if it contracte when the other eye ii^ unciovered, it 
shows that the rest of tlie mwihaniara involve"! in the reflex is in- 
tact. Accommodative reaction of the pupil is intact also. Again. 
Rup{M)sing that irides fail to react to light, but do to acconuuodation 
and convergence, wo have the "Argyll-Unbertson pupil," so called, 
which indicates that a lesion exists in the communicating fibres 
(Steynert's fibres) which convey the Impulses from the <rorpora 
<ju:idrigcmina to the oculomotor nuclei. (Sw Fig. 80.) 

This condition is seen in locomotor ataxia, general paralysis of tlie 
insane, sometimes in cerebral syphilis and as the result of jmisoning 




by tlio l)UiiI](liide of i^rtxiii. Koc-iitly Onilio Iioa ro{>ort<Kl Uikv 
oaj^CH in wliu^li llio Arg^'lI-KolxTlsoii jitipil Uovi,'1o[kh1 in thv (XHinw 
of (lml>vt<-.-s riH'lUtni*, It w wortliy of iiute, Imwwver, tliHl \\\Xv in nil 
tlieM- alTcctionH Un; rvaclion tu ncwuminoiliitioii iiiiiy iilso b« luM. 
Rarftly ilic ii*\i*r»i? of tlie Argyll-Roljcrtt^on pupil oociirs via tJ» 
rottiiU of n loHioii in the :^>oon(l nml Uiirc) giiirte of tiie omilomolor 
niinlciiK. If the cyt« fni) to resot to li);ht and to iii^tomiuuiliiliun, 
thi'Pt! is probiiljly blimhu-TW diiv to optitviifrvt iliN>n>4r. 

If on throwing light into the right fryo thwtv \>- no n.-j(rtiou of the 
jiiipil of thut oyc, iind on tlirowiuj; it into the left vye thfrc ie still 
no runction in the piipil of the- right eye, there must Iw a lesion of 
the uijclens of tlie right oculomotor iiervv or puUy of the coDducting 
fihrcd of each optic nerve. 

Di/nlafioH of the pupil occurs in cii»es of jcl^ui^tna, optio-ncrve 
atrophy, in iliseui^i! of the orbit, and under the effect of drtigH poe- 
»e(;sing a mydriatic itctioD, as, for example, atropine. It also 
occurs in pcraous Buffering from fright, neurasthenia, aortic regurgi- 
tation, and irritation of tlie cervical sympathetic, as hy aneurism. 
A dilated pupil is al.-M often seen in idiotic children. 

Dilatation of the pupil remitts from two rauwA, opposite in clinr* 
aot«r: the finit Ih irritation due to tumor, meningiiie^ or other irri- 
tating le.sinn of tlx- iijiper [Ktrt of the splnid i-ord; the iH>coiid to 
])«raly»i.-< of the cercbnil eenUv of the oonloniotur nerve, resulting 
from oerehml heimirrhiige, tlinunhu^M, tnmoitt, or <kli«<?Oj«M of the 

Contraction of the pupil is aI»o due to leHion »imilurly tutuated 
and result.* fi\>m w^urees of irritation in the cerebrum, resulting 
from meningitii* and ecrcbrul tumor, and Ilertltold usscrte tliat a 
eontraetod pupil shows tluit a sudden attack of parulysls is due to 
emboltem and a dilated pn])il showD hemorrhage, Myosis {enntrao-J 
tion of the pupil) resuttfi from paralyzing lesions of the spinal oord* 
situated in the rE^iou of the cervical vertebra;, and ocnurs notably 
in locomotor ataxiit. It is also seen in general ^mralysis of the 
inatiue (paretic dementia), the false paretic dementia of eyphilis, and 
in bulbar puralysis witli progressive muscular atrophy. It is alw 
one of ihe most notable signs of opium-|M}isoning. 

Under the name of " hemiopic pupillary inaction " or " Weroicke's'j 
pupil " we aoraetiraes, though rai-ely, meet with a condidoti 
ated with hemiaiio]>sia or blindne.'M in o)ie>lialf of the eye, which is 
demon^raliHl in the following manner: the ^lalient h seated in a 



oarR mom and one eye U covere*!. Tlie other eye i« iio>v illiimi- j 
na[«--(l by juttt Miffioient light from a Hut mirror to enable ttic phviti- I 
ctan to ae« the eye:. By meanA of the concave mirror of !Ui uphthaU I 
itU)aco|)e the physician now directs into ilie uncovered eye a bright 
beam of light, taking care tJiat it falla upon one side of the retittu, 
or, in otJier wonii), entire the eye oblitjuely and strikes on the side 
of the retiim which is Wind, If when the light falls on the blind 
side of the retina tiiere is no pupillary reaction, it is cousidereJ 
that tlie h^ion exUtt« in the ai-c between the optic chiasm and the 
oor[iora (|UHclrigetniim; liiit if there is a pupillary reaction, the 
lesion must be furilier imcli in the visual eentre-s, hack of the reflex 
an;. Wh«n tlie Ii-sion is fcuind linck of the reflex arc it may indi- 
mte n Icmuii of the optii' trai't, thi! pustcrior segment of tlie thalamus, 
the [msti^rior part of the ohiastn, or rarely it may lie caused by a 
legion of tlie optic n<Tve if the hi'niinnojMia be monocular, which is 
mrely the hikc. ■ 

Filially, a rhythmiual ivmtraclinn and dihitation of the pupil, 
aiUiit *' hiftpiu," nr<^ t^een in Ix-alth fur n moment on snddi-ii fX]>o- 
win; ti) li|;iit; but when (M>n»tant i» u sign of di.sseminat«d sclerose, ^~ 
ep<h-p!>y, or the uirly itta^i^ of acute meningititt. It is wmctimcif 

r'o in hysteria. * 

The presence of a recurrent, unequal dilatation of the pupils of a 
transitory character is said to be by liampuldi »n early and almoet 
constant sign of pulmonary tuhorculoais. Tie chums that this is 
dtte to a reflex irritation of the nerves governing the pu|)il through 
the sympathetic system. Probably in these cases enlarged glands 
in the client ai^ the cause of the ])upillary phenomenon, just as an 
aneurisfn may be, Destree claims that 'J7 per cent, of his cases of 
phlhiais present this pupillary symptom. 

Koies points out that pupillary contraction and dilatation take 
|d»oe in ai«>ociation with Cheyne->Stokes breathing. Dilatation 
usually exists with tlie inspiratory movements, and myoais occurs 
during the interx'al of apnu?a. j 

Changes in the Acuity of Vision, Having disou.tsed the di«g> ' 
nostic value of alterations from the normal in tiie function of tlie 
extra- and inlraociilar musoUw of the eye, we can pnx-et-d In a tim- 
sideration of the value of changes in the acuity of vision. 'II10 
qoesdona of tlie aciiity of vision in relation to errors in the rafmo- 
tive media of the eye will not, of course, be includnl in thU hook. 

Failure uf vision in (lart or in toto depend.-* upon a leaion vrhidi 


deHtrovii the peripheral wuUr sense-organ (tlio ej-o), tlie optio iwrvce, 
the optic tracts, or tJie receptive unci jjcrreptive wntrws oi sigliU It 

m. «. 

TIi«tIiiuk1 UkM, Ttw moll or ■ Icilan wirirlicr* btlwnn Ih* ehtum ui'l tli» canralCW, 
pnatno* honionruioui bemluioiiila. ii. I-caloa >t cblauD ouutnB blUlonl Icmpoisl : 
■iMfila. li^ L««lni> >( vUliuui c4u*lHg iinlUwnl iiawl liaii>liiiK>|»U. r. I.alnii M obll 
OMMtDf unllu*nil («in|«ml ImnUnopslft. «.«. Mutnuiatlkl niKra nf cnw. I.. Lmitilaoai I 
otn*. V. Kott nucieoL ni. Tblrd none*, r, q. n. >. tr, Loloiu Id ihs oodplMI lobB i 
' B Atml of II iirodiicini l*n haauoTinoiu IMonl bemlMOrvU. 






slw ID t^iiftodeut nptin UilnU-nil Ii^ionti tri tfn> prystallinc lens, «a in 
ntUnift, ur in the oonim, am in i^c-von; kvnttitis. 

Before wtt (IIm'IIS^ tiwao vuriouif ciiuiwm of lilindntaw it is neocsstin,' 
thitt we TtvaW tliv nvrvuiiit nnatuniy of tbi; urt^auB of sight Thvisn 
nervo-Iibrm sbii'lii))^ with iIil- nxU and cuiiee of tht rotiDn nnd tlic 
fibrw from till' iiiaviilii ptisd bock along tlie optiv nen'c imtil thi'y 
oume to wbnt i» linowii mt the clniistn, wlii-n? tlic viirions til}n.>s from 
tin' cyr dcctis«»le, in tliut ih^ iibiii; from the inner half of <^iicli vre 
Ctom to the o|)]M«ito Hiilc, whereas tlio«e of the out«r biilf of VAc\i 
eye pus to the *axae side, aa is shown iu Fig. 80, Aft«r the optic 
tncts Havc boeu formed by this (partial) decugaation caoh one winds 
around tlic corr<^spondin;; crus cerebri, and terminates in two roots 
ipoa tltc corpora geiiiculatii externa and int(.-riia and ujwn (he pos- 
terior part of the optic thalaniiiii. The pupillary fibres ako branch 
hei« to tlio corpora qnadrigeniina. The><e parts are known as the 
primaiT optic centime. After leaving them the fibres pass hnekward 
into tJie posterior part of the posterior limb of the internal capsule 
and tlienoe to the cortex, rise in a fan-.iha|te, pass onteidc the tip of 
the lateral ventricle, and reach the si-condary or true optioal centre 
in the tovrer part of the median aspect of tlie ocicipital loiw. (See 
Fig. 86.) 

Hkmia^idpsi'A. Ax lesions of the ncrvons (■entros frequently pro- 
duce piirtiul or I'lnnpleic blindiH^tif, it i« of impurttinix-, (Irsl, tluit the 
preneuoc nf |>artiiil blindm^ shuidil btr iliiti^ovcntl, nnd, second, (Jmt 
thn lesion musing it should bit hNittcd. Aside from general faiiurc 

viuon due to cliatige.-> in the rotitm or optio nerve wo Imvc in 

ny caws of nervous dist-nsc a condition mllwl hemiiino|>sin or 
pnrtinl or w«nplrte bltmhH'ss of onc-lmlf of the ri-tina. L'snnlly 
beminnopiiii is bihit<-nil — that ia, in both cye#; and it is usually 
bomonyniouH — tluit \>t, on the snmc side of each vyc; or, in otlicr 
words, if it is (he outer luilf of tlic left eye, it will lH^ in the inner 
half of the right eye. If this is the <uise, it is eidlcd left bilatiral 
homunymoiis licroiauopsin. If, on the other band, the outer half 

each eye t» blind, this is mllcd biloniporal hemiiinopsia; or if 
i« blindness w found in the nusnl side of both cyca, it is Hdlctl 
ioasal licmianopvin. It must be rcmenibcns], however, that the 
ap^Mircut blindness of the out«r side of the eye is n-ally due to dis- 
ouo of the tibrus supplying the op|Kisitc side of the rolinu, no is 

own in Fig. 87. The prL->>cuoc of lieminnopsia in any form is 

tcrniined by tlie following nictliod of examination: the patient 


is placed with the back to tlie light and one eye is covered, while 
the otlier is fixed upon the centre of the physician's face, whicli 
should be two feet away. The finger of the physician is now moved 
to the left and right as far as the patient can see it, the head and 
the eyeball of the patient remaining fixed. If the eye failn to see 
the finger when but a little distance to one side or the other of the 
fixation-point, hemianopsia is present. 

FlO. S7. 

Fixation PoOtl. Rxation fbaif. 


We mcitsiire the licKl of vision more uccunitely by means of what 
is known as a jierimeter, wliicli is a semicircular metal band which 
revolves n[>on its middle point, boinjr capable therefore of describing 
a hemis|)herc in s|micc. This arc is divided into degrees marked 
on it from 0° to !)0°, and at tlie centre of it is placed the eye which 
i.s to be examined, whicli eye finds it" fisatioo-poiut in the centre of 
the semicircle. A small piece of white pa|)er is now moved along 
the metal arc on its inner surface, from the extremity and toward 
the centre, until it comes intii view, when the [thysician notes the 
number of degrees at which the object is seen and notes it on a chart. 



(See Fig. 88.) The area of the normal field is well seen iu thia 

Let us suppose that on using the tests just described we find left 
lateral homonymous hemianopsia — that is, blindness in the visual 

rifi. St. 

i::ii»rl of F. V. of right eye. 
Fro. US. 

Left homonymous bemitnopsla fram a case of guns hot- nound, wLlh nuspected lesloii of the 
light cnneui. (m Schweimtz.) 


field, aa jihowii in Fig. 89. This signifies ttmt tlio patioot liii« « 
lesion somewhere in the \-iaiial trai^t hack of the ohiasm, eitlier in 
the cuneiia, in the occipital lobe, in the optic radiations, in tJii> 
internal capsule, in tlie primary optic centrfts, or in the optic tnict. 
Fijj. 8(i !*hii\vri l.lie ftilc.-* of lhe.'*e lesions and wliy tliey cause left 
honiojiyniuiiit li«niiaiiu|)»ift. Siipptining, on the other liand, tliat in 
plaiX! of lefl liomonynioiw liemianopsia we find bitt'niporal hemian- 
o\^a (Fig. tKi), tlii» iiKlIintes that tite |>ationt has a lesion of tlie optic 
InMjri* ill ihw erosniiig fibres in the middle of the ehiasm (see " H ** 
in Fig. 86); or if hiniiKal Iienilano[tsia, that he has a IciOou on both 
sidiM of tJie chia-sm or onv on the outer side of each optic nerve. 
Thi* is a very rare legion. 

Re. so. 


uso 3G0 





Bliuaporal bciulniioiiila (Kuna nucoi lUcnnnutsljr ndilmlljr undor tba a»i« uf I>r, U. C 
Woitu kiM 1a»r tliulliiil liy I>R I'M^AKih K^Bi •lAialtieil lu INUbjttift.Q. KDlScHKiiNm, 
■ndkbon Heidi louiKl. im; Sciiwti!<m.l 

I[emiano)isia of the honionymous forni is very mruly found in 
hysteria, geoenilly in oasociation with hysterit^l hcniiuife^heHia, in 
which condition the eonjuncdv-a is iisually ana^sthetio, therehy differ- 
ing from the condition of the oonjnuctiva of {lertnons !<iifferiiig from 
hemianiEsllicaia of an organic origin. 

In some caiies in place of henttanop'^in we have tumply an altera- 
tion in the visual fields for «ilor. It will \». reniemben?*! that iho 
boundaries at the power of the clear jteroeption of oolors nn not 
identical with tlie boundary for white light, iHir arc they identical 
with one another. Passing from the periphery towutxl tliv ccutre 



he vbiial field in optliiwrv <]ayli^ht we fimi that blue is the 
color firrt aeen, ite boundarj- beiog almnst as great a^ that of white. 
After blire Pome yellow, orauge, re<!, aud linally preen. The blue, 
red, and green Ijeiny the mo^t inijioriant colors, their boundaries arc 
shown in Fig, 91. These fields are deteniiineil by mean^ of small 
pieces of colored paper ))aw)ed around the perimeter in tlie manner 
ualresdv deserilH^. 

ch4rtnr p. V. or icAir*. >i.ijiDnLr.} 

The nlieration of (he viminl Held fur c^lurK ii> (^lled, if xo ohangetl, 
bomonymoits lieinidywlironiiitop^in, and tiie lesion producing it is 
§)tiuited in the cKitex of the ompitnl lobe : while if tho oolorv arc 
iii<lii<liuf;tiiH)uible, it ii< cAlleil heuiiiicbrunrntopHin. Thii^ site of the 
hlnion iuw rcecntly been denied. The tr»nM|iotfi(iun of tlic viitunl 
' fields for <>olor i>^ nfiially n symptom of liysterift, uiid an u nile the rvd 
field takes the pliici- of th'.- bhie, and nWrrrnr. ThcGohlHforidl the 
colors arc ul»o markedly narMwod in hysteria. This tmnspooition, 
nither than lowi of eolor-^-iiM', helps us uonietimes to a diKtinrtion \x- 
twecn tbc ocuUr 5yroptom£ of hj'steina and those of true tabeedorsalis, 


a dtBtinction which is of great iraportaDoe. vet oni" which is often 
oxceedingly difficult, save for thpse afld two other symptoms, uaniely, 
that ID hysteria the knee-jerks are nsoally presen'eil aud the Argyll- 
Rohertsou pupil is not seen. The following table from ('huroot'^ 
locturoa for 18S(t-'8y fiumDiari/en ihofii- diffoivntial jwiate: 



Uolor appatklun uf lh« 

rapUUir dlMarbd nee*. 


Qfmptoau diM la BOtMi- 
or vlviiitl uvrilm 

{'■tml)Ml> (rum Ifolun Ota malor 1, mmollmin Mvidftleil i«r»lTiU. 
ncm:oriIiecTO(bDltwrot pc^ 1. Ulepbanapun. 
Iplienl): uanMiquoatdiiilapla. i. MonocoUr illplaiilii i inloro|«l> , 
■nil uwRMpila. 

ArsTll-RobertMiii |nipU. 


1 lTrosii1«r miicHnlnR Miiitru- 

CilD oC Ibt Tlnlial flollll. 

Z Tabale »climai»ii>i»lk 01 Oyt- 
obniniRloiwIa, alAioUng EAntl 
Rmin and led. rello* >n4 bluo 
bcliiH iiRMivod U> (he UuL 

1. rmciwlvu tillndnOKi 

I. Itacnlar MoraDtrlc oQiilrulMa 

flt ibevtnwl ngld*. 
'.'. Iij'icbKnaatnpd* tnau lUapla] 

aoaincllon ol tho vlraat tImlM 

Ibrenlon. Fmiucadr iwi^pUon 

or T«d ainnv p«r«l»u. 
8. TruuHiUT unbljropla or anuu- 

The Optic Nerve and the Ophthalmoeoope. There still rem 
U» \n: tnmAdf.rM the disgiionlic indicjition^ iiffordtvi im hy the opti^ 
nerve. Before taking upthtR suhject mention mn»( bu made of tlie 
manner of uxing the i>])hthiiimcHeo]><^ 

The pHti<.-nt in to \>Q Hail<Hl in a (hirkcovil room, and by his side, 
at tlie level nf tho eye to be examine*] im<) far vnoiifih hnok of him 
for bin fai'i- to be in wbrtdow, iihouhl be plucwl u lamp, or, if ^^li c«« 
be liad, nti Argimd biiriiei-. The phyaiaiin now suAtit liiniwif, if 
the rij^ht eye i« to l>o obiierved, at tho rii^ht tide of hiif patient, nnil 
takes II ehair rili^htly l)it;)>er than thtit of the jmtiont. The ophthitl-. 
moiwopc iit now taken in the ri;{ht Imnd and held in snch a position 
that chfi concavity of the phvsiciun's bruw fib; over the convexity 
of the inHtruinent. The eye of the physician is wi plnecd that he 
can readily see throti^h the iiperturc in the centre of the ophtlml- 
moscope, uikI by mcuiw of tlie ouncuve mirror on the face of the 
inetriiment he reflects thL> li^lit into the eye through the pupil. The 
putient must not Wk directly into the ophthalmosco|>c, but to one 
side, and his vision should ho distant and accommodation as far as 
posMblo relaxed. If the examiner is not skilled in the use of the 
ophthalmoscope and the result of tlie ouiminntioQ is of great im- 
portance in the diagno&is of the case, it is justifiable to use homatro- 



pine to dilate Uie pupil aud preveut Uie nlteratioiui of uocoog^ 
by jKiralyziug tliis function. The oplulialmnswipe and the bead of 
the pliysicinD are now approachwl as closely a■^ [MiHsihIe to tlie eye 
of tlie patient, the angle of the two hoads tieing as nearly an ])oi«iible 
iilentioal tis shown in Fig. !'2, If tlie light Ik? iiowilii-eclfd slightly 
b>»'anl the nasal side of the eye, the optic nerve will be m-vu, or iu 
jits stead a retinal bloodvesaet will he secii aorohu the Held of viiilon, 
and this should he traced along itA oouifte to its origiu in tlicjiapilln. 

BrtMlTC pMlUcnof phjrMplMi aM (Mlcnt wthllM (mptOTlnc (Ha direct ni«llioi1. 
(NUUU and OLIt'ER.I 

If IImf |>nti<>iit nr the pliyiiieian i^ Hhort^.tiglit^nl (inyi>j)ir), the ophltial- 

niiwrifn- intisi Im> ndjiisled to correct this rritir by plncitig over ttie 

raiHTtiirc n wm-jive h-ii^; but if itrdiiuiry ilegn-w of fiir-siglite«bi««9 

[(liypcnnrtmpis) nn> prcw-ul, the iLte nf n eonve.v hnw !.■* not ncec*- 

r, ImxiiiM.' lh« neciiiiiinoiliition of the eye innkow up for tliv error 

rcfractinn. If the hy|iermetmpin i)«»o great that ai-ootnmo<1nt)t)0 

laot »vcftx>mc it, then a (Xfnvex len« inu»t be iimhI. The view 

tlie (tyv which t» obtaineil onltnurily by a beginner i« clouded, 


not because of myopia or hypermetropia, but because the pliysiciaii 
haa not as yet learned to relax his accommodation in making tlio 
examinatioQ. A concave glass usually remedies this. 

In health the optic nerve appears as a nearly round or slightly 
oval disk, situated somewhat to the nasal side of the eye, and vary- 
ing in color from grayish-pink to red, the centre being whiter and 
the nasal half the darkest part. Around the papilla are seen two 
rings, the outer one darker and generally incomplete or absent, 
while the inner one is a faint white stripe, which becomes more 
marked as the })aticnt grows older. The first is called the choroidal 
ring, and represents the edge of the choroidal coat of the eye wlifre 
it is pierced by the nerve. Tlie second is the scleral ring, whirli is 
the edge of the sclerotic coat. The centre of the optic papilla may 
be even with the snrface or cupped, and may be stippletl or dotted 
in appearance. The retinal arteries emerge from this centnd sjwt 
and the chief venons trunks empty into it Generally one arterial 
and one venous stream pass nii and a similar one downward, and 
botli soon bifurcate, aften^'a^d still further dividing. The arteries 
are distinguished from the veins by their bright-red hue, while the 
veins are darker ii] color. Tlic veins are about one-third larger 
tlian the arteries. A briglit stripe due to an optical delusion seem> 
to divide ojieh vessel longitudinally into two jtarts. The arteries 
of the normal eye do not pulsiite, but pulsation of the veins is quite 
common. It must be rememberiKl that tlie appearance of the papilla 
and of the bloixlvessels as tliey leave it \'aries very greatly within 
l>erfcctly physiological limits. As already stated, the cupping of 
the ])apilla may be i[iiite deep or quite hliallow, and the bloodvessels 
may divide as alreatly dcsi rilieil, <ir divide in the papilla into four 
bninches. Tlie veins aiv usually mure tortuous than the arteries. 
(Plate IV., Fig. 1.) Tlic retina is priictically transparent, so tiiat 
the unilerlying choroid is seou. In persons with a dark skin the 
retina hiu-^ a gniyish line in tlie neiglil»)Hioi>d of the papilla, which 
is most marked on its nas;d side and is sliglitlv streaked. 

To the outer side of the iiajiillu, slightly below the horizontal 
meridian, is the macula lutca or yellow spot, which is about the 
size of the end of the optic mrve, lint darker in color, somewhat 
granular, and dev()id of any retinal vessel. It i^ the point of the 
cyc-groimd in wliicli direct vision is best <lcveloiMtl. In its centre 
is a briglit spot, the fovea centralis. As a person grows older these 
clear distini'tioiis vanish anil the mavuhi liitea is to Iks di.stinguished 

>»«»■ Mnwhil a) OM'o Nanw (Sii-*ti 
Mrai^l. MoiVKw ■•o>- Hub 



iroin titc Hiirroiindinf; (>yv~trruuii(t oiily l»y Mt durkcr liiio rdcI tlic 
Kbwfiira* iif v«aecU. Tliu nuioulii i» dillimll tu iwv, hixsmtK u^ the 
ligiil fulls oa it Utc ]mpil nt ouue cmitnioi^. If tlii; ttyc is dilated 
liy a iiivilriutir. however, and t)i<.- pitiont luuks directly intu tlti- 
o[>httialn]a;ky)[Mi, tin* uiioula is n-jidily seen. 

Tlie rcti glare ppoducwl by tlirowing the light into the eye \>y the 
opIitluilriKMoupe b due to reflection from the bloodvessels of the 
elioroid coat. 

The patholngi<!al Mgnifimnoe of alterations in them? normal appear- 
aaces ia very great. Let us suppose that oa examining tJie eye- 
gnHin<) we find tJie end of the optic nerve red and its edges irregular 
and obscure, or, if the morbid condition is further advanced, that the 
nerve-l»ead looks protruding or niouiid-like and the arterien going to 
it are smaller than normal and partly cnnowiled, while the veins 
are enlarged aud tortuous. Hemorrhages may be seen in the papil- 
lary region or near it, occurring in flame-like shapes. These are the 
ngas of optic netiritis, and uptii^ neuritis dejiends upon intraorbital 
or intraeranial di»eaae, although, if tht- proMew^ is not marked, it may 
be doe to hypermetropic atitigniatiAm. Vision is often unaffected, 
but it the leaion be in the cerebellum sudden blindness may come on. 

As itonic diffijri'uctw itf opinion vxiist a;* to tin- various forms of 
oenritinof the optto nerve tlic term ]uipillitix i^ often ut«cd to signify 
all thi> forms of njitic u<-nritis whirl) wr nn^t with, or in other casciK 
is npoken of us clioki-d diik. Hnpillitin is nioro ciimnionly tlic rejtutt 
nX brain-tumor than of any other intmemniftl h«ion, and, again, it 
ID much more (H>minou in leiioiis uf the cerebelliini than in tiiinon 
eWwhen- in tJie bruin. Another fairly common entwe of [nipillitii^ 
t« moningud intlainniution, pnrlicidurly about the huso of tJic brain, 
and tubercular nirnini^itis is very yinma to pru<hie« it, Ccrtrbnil 
ubocnu may also cimi>v thif change in the optic ner\'e. 

'Id addition to theeranud ciiris»sof papillitis wu have acute febrile 
dI«oHer», ^philii!, toxtcmiaa from lead and alcohol, rheumatism 
And auivmia. Sometimes, however, tliey produce an acute or chronic 

trobnlbar ueuntis. There is nearly always id snclt csbl-h a tui^ 

ntml MMtoma, which c:iuses a failure to reoognii!« oolur, «a, tur 
p!e, green or red. 8<»metinies the patient reaIi7X.-s the failure 

'jiU vision, which may W impain^ otherwise than by disorder of 

lie cohir-seniie. In other ca^^s he fails to do so until hb eyes arc 

Txnminnl. The chnmic form of retrobulbar neuritis is generally 

reault of the exceaaive use of tobacco aud alcohol, and produces 


wliat IS called tobacco-am blyopi a or toxic amblyopia, with failure of 
visiou from these causes. Id euch caaea there is a central scotoma 
between tlie macula and the optic nerve where the senses of red and 
green are lost. Tlie ophthalmoscope may reveal in such cases discol- 
oration of the disk and a triangular spot of atrophy in the outer and 
lower part of it. Supposing, however, on using the o]fhthalmosco[>e 
we lind in place of a papillitis an atrophied state of the nerve, in 
which, if the disease be young, the nerve-M?nding looks gray and 
the outline of the disk is sharp (Plate IV,, Fig. 2), or if it be well 

Fia. 93. 

Upper curven frequency of taber^. >E1ditle t'lirve, frequency of Hevere ocatar symptoms. 
Lower eurve. fre<|ncney of atrophy of the opllc nerve. iBkkqcK-) 

advan(;etl the edges appcai- hazy, the arteries contracted, and the 
veins large and tortiions, wliile the disk is quite white. (Plate V.) 
This primary or gniy form of atrophy is most typically seen in 
the optic-nerve le.siou of locomotor ataxia, and so is often called 

tiihc'tic atrophy. About ;S4 per cent, of all tabetics suffer from 
this change. Again, it is act'Q in eases of paretic dementia 
somewhat less frequently. Optic atrophy is often seen in cases of 
disseminated sulerositi. Hei-ausc of the fact that gray atrophy of the 
nerve is one of the earliest signs of locomotor ataxia, in some cases 


■vMiiK AlFu[t-« C irr DtAn: NeiM. rrc" * '-'■■^ i" '■■ jatlOM" MM>ca' Co»ao* HoW'Ui. 

|M SclTM>«'l.-'l 



it is u viiliialilt.- one in tbi? tluLK>iofliii of thifi grave dimrder, flcjmmtiiig 
it from pseiido-tiiljes due to ordinarv peripheral neuritis. The dia- 
gram (Fig. 9:1) on pa«e 192, taken from de Sehweiuitz'a article on 
this subject, shows the relation hetween age, severe ocular Hymji- 
toms, and atrophy of the optie nerve. 

The more advam^eal foriu-H of optic atropliv with a hajiy outline of 
the diiik UAUally result fmm diseases in the optie oentreH or in the 
nerve itaelf. Thiis there may lie present a tumor pres-iing on the 
vhioaD] or optio tracts. 

I Again, if on the m^e of the ophthalnio9ri>]>e we lin<I that tliere !& 
a faint hazine^-i of tin* rt-tinx, that whititih ^tivAks are found in it 
wlkieh may he hliikTih-gnty or vcllowiiih in line, ihiil the hloodvettaeln 
tn lortiioilK and minute ve.4<M.>l>4 aiv easily seen because of their 
enlargitiient, that hciunrrhagio exndalionK of a flnme-like ehnracter 
anr pn-.'vent, and that ihirk pi^mimtetl i*\Mtn rejni'Heni where previous 
hvuiorrlia};eM have hi!cn, and, finally, tliat the head of Uie optic nerve 
\n not nicarly outlined, wi- have tlio pieture of reliniti;'. Generally, 
in nNtuxnation with thew sifim, we titKl lut Mihjt*i.!tive symptoms 
cluingi's in tlie vixiiul field, n divtorteil viiiion, so that straight linM 
■ppmr bem inward or outward, ami there are pain and fear of light. 
If the vitreous humor ii^ opufgne, in addition to tliese syiuptoinj^, 
syphilis may \k prraeiit, and the iris may give evirlennt of iritis. 
Where the hemorrhages arc very manifest and profuse (hemorrhagic 
retinitis) the cause may he disease of the heart and bloodvessels. 

By 6ir the most important of these forms of retinitis from n diuf;- 
lUMrtta Btandpotnt is what is known as nihuminurie retinitis, or that 
due to Bright's diseise. Here, in addition U> the Hame-like hemor- 
rhagic areas, wo find irregular spatterings of white which may be 
stsr-iihaped. The importance of the discovery of such changes is 
that by it is tlte liri>t suspicion of renal trouble iin>uscil. This si;fti is 
of (he greateHt value in pregnancy. Ketiuitis also sometimes results 
from diabetes. 

Hemorrhages into the retina without retinitis usually arc the result 
of AO|)li««cmia, ulcerative eudocarditii^, hiemophilia, diabetes, gout, 
and malarial fever of a severe ty|>e. Tliey arc also seen in coses of 
great eardiae liy|iertn>phy witli stenosis, and after suffocation. 
I The irU indicate)* disease in other organs more rarely tlian the 
FVetina and opiict nerve and the mnscles, hut an irregular pupil indi- 
mting an oM iritis xhouhl nti.sic a question a-t to a history of injury 

I or rheuniatixm. 




Finally, it should not be forgotten tliut <«tArnct soiuctimoit occurs 
as ttii- n-«ult of (liiilK-Uw DiGllitiw uii'l tliiit conKtil iiloemt!on h oftiMi 
an evidpnct- i>f scrofulonif tcnik'nckt, while ii dUtort«'(i pupil diic to 
an old iritie should raise u suspicion of syphiltii. 

It must not be forgotten tiiat patients often hnve, in distinction 
from distorted inmgea, visions or Samcs of light or brij^ht sparks 
before the eyes, or in their place dark spots called muecw volituntes. 
Often the vImohs are Uid prodromes of an attack of migniine or of 
an epileptic seizure. In the caite of spots of light or stars we usu- 
ally liud them as a result of severe indigestion, and ihe dark spots 
may arise from the same caiises, Musne volitantes may also be 
due to small particles of mucus floating over the cornea or to small 
floating bodies in the vitreous, 

Partial or complete bliudneim is sometimes seen in cases whicli 
are under the influence of a drug, as, for example, ([uiniiie or other 
drugs; and sometimes partial or complete blindness results from 
iinemia (unemie amanrosis). As a rule, it does not occur aa a 
single symptom, but follows an attack of acute unemic manifesta- 
tions; that is, it is found after a coiiviiUion or period of coma has 
passed by. As a rule, nothing nbuormal is foimd in the eye to 
aoeouut for it, ami the piipilliiry reflexes im- iiitiict. Th*- fffect of 
tJie poison in the blood is tiicrtrfon- fxcrvisttl n|>on the optii^inl «ont««, 
probably in the oceipitjil lobe. Siffht !><: usually regained in these 
CUMM in a few days. 



t*kln — Rri<|>tl<itw on (he Ma — Ctkiigraiw, oloon, and ilouulis — 
BMtf MM^BUfc drvnoH, 'I'doBA, liudncM — AiuntbeiU and hemunHsthwia — 
PitfMilbedit, hn>t>nnnh<MiK, Itcblos. 

Mltcii infurmiition cnn Ik- ubtutnL'<l bv mrcful cxumiii»tiDti of Uil> 
Bkin in tnaoy cases of (liH^ase. Tlio fxuoiincr should make a noto 
of Uiv <.-oIor of the int«guinent,of its^tienil nutrition, of its pliubilt^ 
nnil its ticn>(ibihly. Xiiturnlly ihu eye at uncp takes in iiny vruption 
or erars wliivli nuiy tuar its naturally smooth surface, aud, as erup- 
tions and scnrs nrc often the ntantfestations of more or less uetire 
sjTBtcmic disorders, an iniupbt into the presence of internal disease 
nuiy be obtained from them, 

Th« color of the skin in health in tlie white race depends upon 
th4! presence of pigment in the ocIIa of tlie mucous layer of the 
epadermi)!, and in the corinm In ihoae |>art« of the body where pig- 
mentation is niarke<i, or tn the eonditinii of the .lutK-utaneouii cireu- 
lalion or of the blond in the 8ul>e[itaneous veasela. Thufl vre often 
find the skin of the ]M<rineum, tmrotum, axillte, and of the lower 
abdomen much darker than ol.-iewhere in |>enionA in jierfert health. 
Similarly we see a marked reddish or yollowi.'-b-bmwn hue in those 
parti of the skin wlitch have been oxporied to sun and weather, as a 
rasult of a de|H)iiition of ptgnn^nt and an inereo.'ted capillary uireula- 
tiuD. With th«ie iiormiil nlti'rationit in color, however, w« have little 
to dii, for it U [Jie nbnorninl vnlonitiouN which interest ns from a 
(liuguoatto iilandpiitnt. Thi^ mottt coiumoti of thft^e changes in color 
dite to pigment h jaundice; the next (he vhloattmn of pregnam^nr or 
nterine dixease, a oonditimi uinmlly liinit^nl to thi< faec. AlKlnminal 
gmwtJiM due to iiiturrt-nhiHii^, iviniN'r or lymphonui, and tiitHToulottis 
of tliv prrilonetini aloii »ium' piifinenlaiion of tin- rikin, and in melau- 
ntic cnueer tlivrf i'^ olu-n very dark diwroloratloti. ho mnrked as to be 
Dunfuj»ed with tliut of Adiliion'H diveiiM-, .Vi^ntit, it 'm not unoom- 
moR for [>er»iin)< who huve hepatic torjtur wiih(-oni<ti|>ittion to develop 
what iirf cnlhit )ivrr->ipot4, in which the nkin haj* rather a dirty hue. 
Under the nkme of vat^tlHmd'it *' pit;men(ittion " we t^omclimefl itee 




discolumtimi iiidiKVii by t\w irriuilioii (rf llie jikin i>potliiowl by Iioe 
nnd cxiHwun; U> dirt mid Wfutln.-r, ami this is cit]Mil)le of beJng min- 
tukcii fiir tin- pi(;iiiiMitnl40ii nf Aildi^oii's di«ou)>c. Finally, wp see 
the- yellowish-brown \\KW of ihe akin due to tine* ventioolor, lh« 
hrouzinf; of tlic akin in Addinon'tt disL-attc, nml Uio slab^hhip liiut of 
nrgym or ebroiiti; wlvur-poisoniiif;. (See fiirtlwr o« in cliisi (rliiii>- 
tflr.) Thi; chanj^s in color drpendiu); upon diHtiirbanoe of tlii.- 
8abcut»iie'>iis circiilntion or uu nlt^'nilions iii (lie blood uii- i-itlier 
local or general. In extTcnio norvoinnese fliisbiiijf or liluslijiig, 
due to n local viu^oniotor relnxtition witb increnaed blood-vtipply, 
may reddvii tli« face nnd nwk, or in hectic fever n liypcrwiniii iif 
tbc i^kin over the nialiir bones niiiy give rise to »n increusc in color, 
which mity be du«ky rod, due to imperfi>ct oxidiition of the blood. 
ConBidcmMe cviuiuwis of tlie fjice and bunds in h ca)M.M>f tuberciilu^ii^ 
of tile liin;^ is n very gnive symptom. Again, we sec in pneuinonin 
a jieculiur diuky n-A fluMbing of one cheek or of the vntirL- fncc, iind 
in cry^tipeluH the zonv of liyperu<niio redneiifi iti chikracterized by its 
sharp line of denmraition and \t& ruificti edge. In the nltenitioos in 
color due to changer's in the qiiiility of the blood we have, as causes, 
aniemiii due to lack of curpusclea or of li^njoglobin, arUinj; fnim the 
\'arioiin etiologi<»l faetors producing such fttau-s, 

.lArsDlcK. Tnkinjt "p the color-cbango due to pigment, we find 
thitt in jaundice the depoaitjon of the biliary ooloring-niatler varicA 
in degree from a slight tinge or almo^it tni|>eroeptible yellowing to 
a dark citron or olive-green hue. 

lu examining the skin for jaundice f^are nhould l>e taken not to 
do so by gas or candle-light, for the yellow Ilanie ma»kH the biliary 
color. If the tinge is very slight, it may be made more marked 
by stretching the skin on the palm of tlie hand or by preying upon 
the iikin n glass slide so that the yellow hue shows thn>ngh it. 

Having discovered that biliary coloring- matter Ims been dejiusitcd 
in tJie rete mueosum, it reuutins for the pbysivJun to decide what 
the cntise of the jaundice may be. In the first place, it must \w 
remembered that jsnndice may be hepatogitnoits — that its nrisi- from 
disorder in the liver, or be heniiitogenoiiB from disordcrji of the 
bloiHl with the setting free of li1otMl-j)igracnt. The hcpatogi>nou» 
jaundice is by far the more wmmon of the two conditions, unil the 
mo«t common eutisc of Uii.-< form of jiuindit« is eatjirrhal iiifhimma- 
tion of llic ^niiiller duct« niic] eomnion bilixluct which gvncnilly 
oocunt in UKHjcintion with gnstro^ltiodonal catarrh. 

THE SKiy. 

.\f n re«iilt of this catarrhal prourss the bilcMiiict boconiex blockiil 
liv tlio HWolloD mucous niviubmnv iind the muvtiD which is 8ecret«<t; 
tlR' hilixry ml on n;;- matter h iib»orl)iHj iuto the hvpatic rimilatiuii 
■ltd giMiL-nil ciruulattnn, anil is by tliiH tn<!ua<) di»tribut«l i>v«r tlit- 
body. Auottior oommuu uiuso of heputogi'nmis jaundice is the 
ob«tnictioa otfcrL-d tu the flow of bite bv tJie prespuoo of a jjiiU-titunu 
or gull-stones in the dorts; and a third cause of obstmctive jaundice 
so called U prvc&ure on the ducts bv growths or inflammatory pr«- 
diiote in the Immediately iidjatvnt organs, or of adherent inflamma- 
tiou in tho durtx tlicmfwlvcs, or by the prescnoe of a round worm In 
the duc^ Ven- nirply the jiLundi<^> may arise from tile pressure on 
tlM.- CMumon duct prodiicetl bv floating kidti«y. 

The followin); table from Taylor's Index 0/ yMidne summariites 
tllD I'siiises of hcputiigeuou-t jauudioe : 


' r of ll»r Itwir. 

' •oooiulBry [nilllmtian ofilkiHl* 
Inlmiinana (iManL 
oJ nrlonw- 
of dueil*nuiii. 
at pancrmt. 
of kldDvir. 

ytram eliiy- * 


tlait>nwllcnui( | ijrnipbailMuai)*. 

t Cklarrli of tumucti and duadcnum. 

4- AbdolulDal aiKUFliiii. 

h. HrdMldOTMiL 

I. AwomulMlontf Iww. 

7. OtmUd at matlna (umon. 

^ PMlliapaaua. 

Oatarrlinl ]»undi<T- of thv acutt> typ<^^ \a gcncmlly prtMlueivl by 
int)it*or«tiotw in diet a-wociat4xl with expocurv. The |uiiieiit after 
mon or lots marked symptoms of gastric ruid iiit»>tiual di^ittirbnnoc 
and indigmtioD feels wretchedly. Thi'rv la a prvinonitory mental 
iMaviDuaH, with lan;;iior and muluiw, and witliiii forty-<.-tght honre 
or iem llui yellowing of the eoiijunetivii ami skin appears. Tlio 
(«ni|M-niltiiv is generally subnonnul to a flight degrue. The tuiigui: 
i« lienvtly ooatod and often somewhat tlry. There an* Riarkc<l losa 
of npiM'tttv, great distmss, liendaclie, and depression of sjiirits. Ex- 
uiuinalion of llie hypochondrium may reveid sumc local tondernctui 


and slight Iiepntio cnlaPRement, while the alxlomen will bi> in soia« 
iui^tancoB markedly tympanitic as a result of intestinal fornieutative 
prooesees in the ahsence of antiseplic bile. Thp howels are oonsti- 
patod, often refiitting: to move except with powerful pui^tiveA. 
There ii< littJe )iain, except headache. ThU condition hft** for n 
few days or a week, when the color of the skin and conjimotivii 
UHualty lie^iiiA to fade nii<l (Jie iiarmal hufi is reached in the oonrk* 
of a week or mure. 

The pri'seiKw of pemii^tont jiiiindiw should raise tlie .'tnitpicion tlint 
it is due to more serious disorder thiiu simpli; cntorrhal infliiinmutioii. 

The jaundiiv due to ohstnii-tion hy stime may )>c duo to hlockiiig 
uf the biliary <l«rt, wlicrehy llicn; is n !<Ingimti(Hi of the flow with 
realisorption of the bite, or to stoppKgc of th« flow by tlie prcM^nee 
of II .ttoiie in Uifcoummoii diirt jiwt i»» it enter* th« bowoL A rliffcr- 
ential diagnoisiii u# to wlirtJicr the »tuiic is in one or tJic otitcr of 
the^ plnccj* \» often imjMMsiblc, but in the variety in which tlic 
ob.«trii(!ti'»n it liclow the o|K>ninK of the eyrtic dnct it may he |km- 
»ihle Mimetinics to iliimaver hy abdominal {Ktl{Hitiou a pear-like 
swellin)i[ due to a distended ^lU-hladder. 

The jaundice of ^U-stonc ohtttriiciion may be auddcn or gnwlual 
in onset. If sudden, it is often, but not always, preceded by a 
violeiit attack of jiain in the liypo<'hondriniii, or, in other words, 
hepatic colic, in which tlie agony is excruciadng and is aooompanied 
by nausea and vomiting. The area of the jialn is, however, dis- 
tinctly hepatic, and it doc» not radiate down the inside of tlie tliigh 
and into tlie testicle or penis »s does that due to renal calculus. In 
place of the subnormal ti>ni)>eralunr so often seen in catjirrhal jaun- 
dice we Hnd in obslniclive jauiwlii'<> timt the ti*n]jM*rmun? is often 
oon^idenibly misud, and this is ]wrticnlurly apt to be the caw ia 
those inwtanww in which tin* f>ni«et is f^nidual and the jaundine jwr- 
tdflteut, hcin{^ due to retlex irritjition, or septic absorption, pro<)u<M.xl 
by tlie inipactcil stone, whi<-h may be senitching or uloemting the 
liuing meinbtauc of the duct. The history of repeated attncks of 
gull-stonc colic, the presence of gall-i^toDcs now An<l then in tlw 
stools, the Hwolleii gall-bladder in wliich, in very thin persons, the 
stones may sometimes be felt, the age of the piticnt, who is gener- 
ally in or past middle life, and the fact tlmt the patient is a female, 
all ]>oint to gall-stone as a cause of the jaundice. As a rule, there 
u great loss of flesli in all forms of jaundice; but if the local damage 
done hy the stone is great and septic absorption is marked and the 


rna sff/.v. 


fever higli, tlw failtin- in .iiptiigtli may U> 1110*1 nlnnniii^, wliilc tlie 
rcprat«d ng»» tint] iiwoaU itK-ntOM ttiv iliKtm-tf of tlu- luitivnt. 

Jmindific vcr>' ninily aviww (mm ]}Tvii»nrv 011 Uic due)8 by an 
•iwuriMn of tilt; iiUluiiiinnl Hurtit, or fruiu tin(Miri«m iuvulvtiij; t}i« 
licpAti<! iirlvry, Tiirec »iioli vauvs lire r«wnl«I by Frcriclis, Jiitiu- 
dioc lias Also bcvii seen in uuourisms of the mipcriur nic^outvric 
•rb^ry lu thn result of pn««urc nml in iw^cs in wliidi tlicru haa 
\Kvti, or i^ pert 111.' jwiiti^, with displiiocnieiit of tlio liver in i^iiuh a 
wity tlmt tJie utUiiMioitfl uiuse Iwistiui; or drugging on the diieto. 

TIk- jnimilicL- of innligimnt diseaso prei^ing u]>on the gHll-ducts 
is tuiiully iiot iiitoiisi', und is eliunicterized by the physiuit <ii^8 of 
4 tumor, by tin- ninrkeil iva»ling of the patient, and, us a rule, by 
tlie Viry gnidtml onset of tlie pigmentation of tlie $;kin. Generally 
tbo iMion in sucli citi-es ii< enreinomn of the head of the punercais. 

Jauitdiec is also seen in h«[mtic hypertrophic cdrrbostH to n sliglit 
extent iu a small progwrtion of eiiseH, and it is to be remembered 
tlmt in those Mises of this disciise in whieh delirium and muscular 
Iwitdiing oeciir that the symptoms may resemble iioiite yellow 
atrophy of the liver, and that all forms of jaundice produce headacdte 
and may cause delirium. Tn ai'nite yellow atrophy of the liver (sm 
below) the liver is greatly reduoed in si/e, whereas in hypertrophy 
it ia greatly incn^ied in .^iite; and in at.n»phy the temperature 19 
aahnormal, wheroa.') in tJie jaundice due to hypertrophic eirrhoHt.* it 
ifl apt Lo be alH>ve normal. Jaiindiee ali<«) may l>e a iimnifeHtatioii 
of acute iKiiiKMiing by phimphorus, which cimdilion in generally 
feCDOtn [luniMl by hepatie swelling and tendernftitt and witli coffee- 
grouwl vitmiliug. 

■tHiiiidine iii pre.sent in all f:ital eiL'te.i of yellow fever and often in 
cucH whieh ultimutelv i-eoover. It attut i^t a constant nvniiitoin iu 
Weil'n dit*«K«?, which it prifbably in reality « septic ictj.'riis, but it 
i» wry rarely seeii in itupputnljve hciwlitiit. A flvntiiig and light 
liae of )aiiiidiee U wmetimvtt seen in uuh^ti of chronio x-alvulur lyii^ 
diac' (liwnM! in which i»mpensiition \» grudiitilly failing, llurely 
thin hue iMwomm ileeper tut the heart- failure inrre(u>o». Tbi« jaun- 
dice in duo to engorgtrment of tlie liver (nutmeg-liver), whicJi in 
tine niMiltK in vatnrrh of tlu; biloiliiet«, with ooiise<|uent obstrun- 
tiim to till* flow of bile. 

In amyloid ili»eaM- of the liver Bartholow states that jaumlice 
oocuni in al>oiit oiu-leiith of tlie oums us a reault of enlargement of 
tiw lymphatics in the hilus with pmsiint on tlio hepatic duct. In 


]ftiiii(lic« rostiltiiig from i-aiuvr uf Uic liver Uii; giwvth must l>e so 
flituitietl m lo .■'^mpn-^s tlic AiutU, coiiw-cnn-nlly juuiidiw w-ciirs in 
nljoiu only onv-lliinl of ihc awe». Similnrly jnuiidici; may n>siilt 
from tile pn-sc'tuT! of cdtiuoootwi, Imt ttiis i* not ft o<i(umoii .'^ym{tt<>m 
of ttic Kfowtli of tlii'Ko purusitvii, mid tlio tli^citM- is vcr;,- nirc iii lUe 
United Stnk-». 
^ Juundici- soiiictinm compUcntes diat]ct«». Under tlie^ic rirmim- 
ows it may be rcgiirdwl aa a ooineidi'iuH! or a vuliiiililc diii);n<ii^tit! 
aid, for, ax we have itlnuuly xtatt'd, lumorsof the imnrrt-ns by pres>j 
int; uti tlio common duct mity »ui«! juni)ilii.v, iinti, u» i» now vridl 
known, widespruid disLiisc of tlic gitincn'Ait miiy cuiisi.* diiibftts. 
Jaundict! in a casts of ditibctcs (i)ioid<l tlicreforL- <]inTt attention to 
the pituereiU-. 

lu tliis cotincctiou it is well to rcmembor that Hanot, under the 
aamv of diub&te hroni>^, hax de«i:r!hcd u piffmeutation of tlifl skis 
whieli e'liilaiiiri iron (that of Addition's dinease and rac1an:vmiit do 
not), and «-hich is associated with dialjctcs, liypertrophic cirrhosis 
of the liver, and enlatgement of the spleen. The eolomtion oeeuni 
most markeiHy \\\xm rhe face, linihs, aud genital organs; the gly- 
cosuriii is ahimdant aud slight ascites may he prefletit, tlie lower 
limbs may be <cdenmtou.->, th« lost) of weifflit and atrenglli ts rapid, 
and dentil won en>i)i--i fnun pneiiniouia or coma. ITanot and Miiriti 
hotli ref^rd it a.s a distinct di.'M'iL'<e fiinn untinnry diabetic mi<llit4i». 

Other not^'Worlhy.'iymptonin of hegmtngenouA jiiiuidiec- ari! int^-liM 
itehing of tJie skin; a very slow jmlsc when the imtieut is at mtt, 
due to ittimulntioii of the vugtis by Uie bile in the blood; and ;(tain- 
iog of the swejit doe to tlio bih^iMgiumit may aUi be prcwnt. 
Should the j»iindt<<c be due to gnll-^lono! impact^ in the diicto, 
and prmltioing irritation or uleemtinti of iheir lining w) that «eptic 
abHurption or " Chupcot's fever" develops, the pulse may bcooroc 
more rapid and running, from the general feebleness which rapidly 
asserts it«'lf. Itigors of extreme severity, followctl by Kweatings 
Olid marked febrile movement, develop in such en8e», tlio ehilU 
occurring daily or pcriodit«lly iu a tuanner clonely retutmbUng 
tho»e of iutermittent fever. As these symptoms sometimes de- 
velop in oases in which tlie post-mortem discovers no sign of pus, 
it has been thought that tlie dtsttirbauoes were due to reflex causes; 
but the opimoQ of Charcot that there is present in all such eases a 
Irne infection si^enis the more probable. When the gull-stone pro- 
duces active t>nppu ration the fever Iweomes more like remitteat 


(fvi-r nnd lln' jutient rapidly cinamtrs mid jiir^nti* all tli« siffii^ 
of aclivv 3U[»)>unt(ion. 

The iirin« iu nil <ai»w of liciHiKigvituii^ jmmdiort U hwivily liiltr- 
{jtainiTt! (jwi- (j'rimO, iiml tin; iKtooU (rencmlly oJay-oolwrod owing Ut 
aInmiiicm.- of WiU: t» tlif fcm<. 

A very run' onii«c <>f jiiiiii<Iic«^ ii^ mtit* yellow «lri»[»hy of the livt-r, 
n ditWBMO wliicli in m'cd wiiiowlutt mure frviiui'iitly iii women Uiaii 
ill men, iind lairtivtilHrly In us^ocintioi) with jin-inxtncy. The ng4> 
nf (M'curivntv ii> usiuiily lictwcvn the twi-iitiet)i mid thirtieth yuin*. 
The syniptMiu bc^in with giietro-iiitestinRl diitordvr, followed by 
hmduchv, deliriiim, miuKmlar twiUrhiii);, und pi-rhnp-t fonvuleions. 
SiiiiiiltitiH'uiisly witli the unset of the hi^duehe the jnimdive Hppvnn*, 
tiie juntient becomo« typhoidal and dies from exhiiiistion, allhuURh 
recovw- hna bt-en liDown to occur. The stwds dnnn^ the attuck 
are cliiy-fdored and the tiriue cuntuins luuein in diHcs and tyro«in 
in aeedlo-like cryfttnlii. 

IJrTniiloitfnnuK jinmhce in <lne, lut its name implies, to hirjiking 
down of the hlood to so great an extent that the liver cannot deal 
with ibe waste material with suflieient rapidity, and as a roault 
altered hiemoglohiii is dcposiletl in the tissues. Any poison which 
prudueee exoeasivo hemolynu, aiieh as picrie aoid and the coal-tar 
products, chlorate of polasAiitm, glyeerine, and poisonous mushrooma, 
may caiLse this i.x>DJitioii to develop, and in extreme malarial dii^easc 
(n-iiiittent and j)criiieioti)t nmlanal fever|, ilfiifrue, n'la[Miiii); fever, 
j>ontii'iou.'< atui-mtii, pneumonia, and in other infei^tioiiit maladies 
jaiindity iiuiy tx- prixlutHtl in thJJH manner. It i« jiiirtienlurly apt 
toooisiir in oa.«!* of marked »ep»i!». 

Jta onuMiH are shown in the rolh>win^ table fmni Taylor's Index : 

OAV«nt or llKUATORRKOrs jAt'XItlO. 

I Vellow km, 
! Typhm fi!^TT. 
1 S<sil*( (uvrr 

\ KalarvUifl ftvw. 

(teem nmiyl { 
hi com 





rbu*|>hanu. < 
wmvarj, KiitloHiiijr, 
ehlani(bnii, Mhor. 

Mriaatraiphjrot UvcT. 
I Clnbnili or Hv*r lii ll> later ittigm. 



■Tiitiiidioc sometimes occurs after severe heraorrliage of a j>rolonjjpJ 
character and in prolonged exhausting fevem, and is then due not 
to any local hG[)atic trouble, bnt to blood-diiuigeA, with the pmduo- 
tion of urobilin in excessive aniounts. The urine fitils to earry off 
all the urobilin whicli U ]>nMhi(x<d froni hicniatoidin or bilirubin. 
This condition is ealhtl " urobilin ititerus," 

In nearly all tascu* of hcniatiigeJioui^ jautidioi> tlte discoloration of 
the skin i^ very slight, and the important faet is to \tf. remembered 
that the sto<its are not light or clay-colori^l as ii> hejiatic ^auudioe, 
hut contain a normal or cxoc9t*ivo ninonnt of pigment. Again, the 
systemic syniptrimn of mtiirrhiil or oltstrtirtive lic[Mitic jaundice itre 
practically iilisoiw in tlic licmnlogi-nous variety, and tin- jaiiiidiiw U 
simply a minor nvmptom ni^iwiatiL'd with more gmv« mnnifolatioiu 
which clianictcrizc tli<' individual infectious proi-i-At. If Uk? (Hiuon- 
ing is very uiiirki^^l, iMinvulsion*, coma, or niTtive delirium may oome 
on, but it i» probable that thtwc i^ymptomi« art- thtv inorv to the 
pitison of the diwa^c than to the brokoiwlown bl'KKl. 

Vierortlt Btatcs tliut a very small *inotuit of hilinrj* cidorinj»-niattcr 
is otUin found in tlio urine of jiatiGnte miffcring from pyieinic jaun- 
dicv, and re^ird^ this us an impurbuit ei<!^ that the discoloration of 
the skin is due in a given case to blood-changw* and not to biliary 
obHtruction, whereas an excessive amount of bitian.- nutter in the 
urine indicates hejHitic trouble. 

Thrre renuunato be considered tlie jaundice seen In the new- 
born, usually within the first or second day of life (icterus neona- 
torum), which some believe to be due to a decrease in the lilood- 
pntssiire in ihi; portal vessels subsequent to the arrest of the placental 
circuhiti<m, with coiise-fjiienl absorption of bile into the blood, owing 
to the nomjwimtively high tension of this fluid in the bile capillaries. 
Others think thi:' jaundice is due bo breaking down of iJie blood- 
enrpuMrk-)^ uliortly aft«r birth as tlie result of some mild infection. 
Probably both niiiws act in aome (sises. If the cause be alb>r«(l 
bIood-prc<if!ure, the progiKwii* is favorable, ao<l reeovery takes plorc 
in about ten dayn or two wwks; but if the cause be aii infe<-liou, 
the condition ofti.>u prov<» nipidly fatal. Siioidd this jaundioc of 
the newborn be very markiil the pniicnt may be sufTering from 
congenital stenosis, or absence of ihv common or he]Mtic duct (wliich 
C8use is mrc); from septitwrnia, through infcotiou by way of the 
umbilicus; from pblobitis of thu umbilical vein, or from a hepalttL'4 
due to hereditary syphilis. In any of these latter causes death 



will pnitwlily occur, wlivnitA in tbc mild form of ictvruB iicunii- 
t<>riiin |)m> prugiiusw Je ven,- favorable, pvph llimi^li the diHculom- 
lion lamls (or wM'k«. TIk- mild form of icterus neonatorum, if due 
Ui )>t'MKl-«lum);i«, i« niivly nvoomittoied by preat discolomtinn of the 
orinfi, ami the feom nrc usually no lighter than normal in color; 
but if hc|ntic dUuiHe be present, the urine \9 bile-»tained and the 
fcoes are light in hue. 

Jiiundioe sumctimea comes on in the oourae of acute ulcerative 
vudocanliti^ and haa been miHtakeu for that of acute yellow atrophy 
of the liver, and it often ajipears as a symptoni of pemieiotiB mala- 
rial fever, with vomiting, diarrttraa, and grave nervous nymptoRis. 

Rarely jaundice follows severe fright or extreme anger, and 
Da Coetu states that it sometimes ensues after ooneuseion of the 

Oriiett CllANorM ix thk CoejOK ok tiik Skin. .\ condition of 
tl»e sliin characterized by yellow, more or lew elevatwl giatches is 
xanthoma, which Murehison states often complioaten he|>atic trouble, 
and which in itn nodular form may po.4ttib1y attack the liver and so 
produce jaundice. Itti favorite <li.'4lributioii is about the eyelida, 
bttt it may ap]>ear eluewhere. lA-^iouci i^imilar to xanthoma riome- 
timeN apfiear in tlie <'Oiime of dial>etc-> (Hulcliin.ton, Ik-!^nier), and 
nnder the«e cin-umiitanccn ^(•ncrnlly develop !<uddenly, and spon- 
taiKtHi'ity diMp]H.-ur aft^-r booh:! wvck^ or nionttiA. 

When the itkin of iht- entire IkhIv, th'- ftic^? being particularly 
iiHi'ctcd, ifl of a livid or bli]i»h-slato color, n-^itiibliiig HHUcwIiiit th« 
ftp|>Ouninn) of u pcnton cxpiifcd to riiy^ of llglil [Kisfin)^ throu|;h blue 
^MH,tliccoiK]iti(>ii ijithat of iirgyriaorc)ininic!filvcr-pot»uiiing. This 
dJsoolomttun IS HO charactenHttc »s to admit of no diHtculty in dinf^ 
OOMs, siiK-c the abscni'e of any circiiljiturj' or respinittiry cnilmrraM- 
nent excludes the possibility of its bein^ due to cyanosis. Owing 
to tile decrease in the amount of silver given internnlly by physi- 
miis chronic argyria is becoming more au<l more rare. The 
discoloration is due to a deposit of oxide of silver iu the rete 

Discoloration of the nkin of the entire body of a rallovr, lemon- 
yellow tint, soractiroes called a "muddy-yellow" hue, is seen in 
jwrsious who are stifFerers from prolonged malarial poisoning, and 
ill MMiti* msei the subjeda of prolonged suppurative praoeeses not 
tuticroulnr in clmmcter. ,V greasy, yellowish skin does, however, 
■■x)ur a» oil iiomm|>itnimeiit of some camts of pulmonary phthisis 


ami tlii'sc txisim liiivc tis a rule a gloomy proguosia. Oftun ofaroDW 
hepatic tlifMiust-, micli iis cirrlioiiis, ]>rodiiooti thi« mIIow a])p<>ftrnn<w. 

Olliur changi'^ Ui Uil< cwlor of tlic skin, whioli (noiiut lie «ikI to 
be (Iiiu to (li-poeition of pigment, nithoiigli thoy ««.'iii to Ik- miltmkI 
by this, arc seen mo5t inarkwlly iti tht- pLi-uliar yellowish, Hiocsy 
luillor of carcinomu, the grc-enii^h-ydlow tiiigo of true chlorosii^ tlie 
curious cadaveric hue of advancoil pyaemia, and the y«llow skin 
with u groiuy feeling in §oine caacH nf pnretii? dcmentiik. 

Local pigmentations of the skin result from m:iny cauiMis, Lotll 
local and sj-stemic, direct and indirect. When brownish-yellow 
spobi or streaks apjiear on the faee, w> that rhloaama is deve1(i|)e"I, 
we i-houhl Imik for uterine or hepatic clistiirlwnoe or pregnancy; 
they are practicnlly lai^ freekles nf a more or less distinct brown 
hue. In other in>4tanees ehloasniio spots or localised ditnolonticHi 
of the skin results fi-om injury to tlie skin, as prnsEfure by clothes, 
chafing, or after constant severe scratehing in the eourw of eccema 
or pediculosis or soahies. If the pigment is found in the nuchal 
and sacral regions, it is proliably from the scratcliiiig caused by 
pedieuli; if on the bo<ty in irregular diittribution, it may have been 
canscd by prurigo. Again, the presence of a brown pigmentation 
of tho »kin in I'iwirly oullim^l |Mitchi>9 may indimt*; tin- larlier use 
of a lly-hliMcr, a iniist^rd i>liv<l*r, or other wvunter-irritaiils, and n 
brown diiiiwhimtion of tlie skin, wIiU^li might pojsibly !» oonfuwd 
with llmt of Addison's discii!4(>, U producitl by tho five iisir exter- 
nally of oil of <!ftde. .Sometimes \h\'^r -.pui,* nn- jirodixi^l by the 
prolongrd um of ansi-nie, and the wriu-r lias it^ported a ini>« in whivh 
the iHiuloj'wiK'e of the r'jmts produced a euriuui* grayish-brown hue 
of the- culin^ lK>i1y, so that the man looked nomewhat like a niulatui. 

Sumptiinut bruwu pigmentation of the skin of thu neek and fact 
appear:; as a i^ymptom in exophthalmic goltn-, and this disoam; may 
also produce similar l<%iom> on tho chest and wrists. 

Very closely resembling these spots is the bronzing of tlic skial 
in patches which is seen iu persons suffering from Addison's dis- 
ease; but although bronzing of the skin is u somewJiat eoustant 
symptom of vYddison's disease, its presonM- is neither a positive Dor 
negative sign in diagnosis, for bruniiing is sometimes seen in caseaj 
in which the suprarenal capsules are normal, In some instanoGS 
the bronze color deepens into a dark gray or even a black hue, and 
although the disoolomtion is generally in patches, it may exteod 
over the entire surface of the skin, even to iho edges of the finger- 


naib. The oaiU, however, ftwaipe, lu does also the mucous mi.-ni- 
bmne of the ti|e, aUhough tho Iiduii! of the tnotilh itself laay he 
<l<ilt<-d with pigmentation. The color Ih duo to pigmvntiitioD of the 
rcte Malpighii, and pre-Ksuro has no effeet on it. The aymptoms of 
Addition's di-*ease to lie found associated with thceu skin-cthaiigeA 
are '* aniemia, general laoijiior or debility, remarkable feeblenej» of 
the heart's action, aod irritability of Uie etoniach." (Addiiiion.) 

The slate-colored .-ikin of ar>;yria or chronic silver-poisoninji; can 
be readily distinguiahed from the bronze eolor of A<ldiaon's dLseaiu- ; 
hill if a furllier test is needed, it will lie found timt wasliiug the skin 
of Ni^yria with a solution of iodine changes its color, while ttiat of 
Addison's disease remains unaltered. 

While patches, or leueoderniii, are also sometimes seen in mM.-» 
of tnic i^itre, and brown oiu^s in tuberculosis. 

In auvii>oma of one of the internal oi^ns, or of tiie broo.'St, of an 
odvanoed stage, the apjicamnce of the skin is drawn and iiDHMiiiiIly 
•itUK»tli,nft(!n shiny or gr<tt.'iy-hH>ktug, somewhat gnni my and li-»th<.TV 
to tlie tnueh, |<arttciilarly where the integument is nnttinilly dense. 
Although it i.-olifTicull todcsi^ribv, this skin is almost jMithognoniouic 
of ivirciiiotiia, although it may al^o htt present to some «xtcnt in (ur- 
■ilvniiised fiat's of ]M>rnieious iinieinia or sarcoma. 

Pallor of (lie -ikin i>i due to nbsemi- of the UDrnml pi|;nicut, to 
<)efluit;iit blood, to dHilml or \iKa.\ vasomotor ilisturlKiiDH; M is typi- 
6(k1 by fnintint;, and far more rarely by liayiinud's (liuaBe. As a 
type of the pallor <hK' to lack of piffment in the skin we see vitiligo, 
nitllc lh(! [Killor due to )H-rntcTioU!i amcmin or pscudo-letikiemia and 
DiiiLiria ii^ owiu^ t*> lack of red corpuscles. Similarly, a juillor due 
III lock of hicmo^lobin is typified by chlorosis. (See Ulood.) In 
all of these diseases the skin may be of ghastly whiteness or tinged 
with yellow. The skin is apt nlso to l>e ver}' white, and even 
rhnlky in appcaranee, in chronic contracted kidney and chronic 
(Hin^nchynuitouH nephritis. 

In fhlorosis the entire surfa<i' of the Iwdy It expeedingly i«le, 
and the skin of the face, particularly about the mouth and now and 
eves, is somewhat greenish in hue. 

A very important diagnoi^tic {wint to be remembered is tlint re<I 
'-Iteeks often cause the physician to overlook well-advaixwd nnieniia 
in yonng women. (See chapter on the Bhx>d.) 

In tlinse cases in which tlte skin is pale from alteration of the 
sulieutaneoua circulation there is usually incomjietenoe of tlie heart 


or vii80tiioior diiitiirtMinco, l)Ut the ramt imorkcd form of gcnernl 
luillor IK thttt tliic to myxoHlciDit. 

CycriWx or t]lii(>iio»i< uf tilt- itkiii ilqwixU u])on tli« (rirciibtiuti in 
l[i« HulH-iitimooiiM vc««'Ik of imporfwrtly i>xtili/.i'il l)loo«). Tin- wnmll 
vein* 1I11- uftori swii to Ix' »wollvii, imrticiiUrly tlmiw wf Un- fncL- nml 
till- haiidH and fcft. The iu<Mt uuirktHl form of vvunosis with vriii<!h 
WL- mi'ft h thf cyiinoeis of thi- newborn ohiUl, BiifftTiiin fn>m n [wtii- 
)on!^ fommoit oviile, iint) in this condition the color iniiy \siry from 
a s1at«-bluc to bu alnioiit block hue. Th« lobes of thv t^ars, 
the tongue, the a?r<itiim, iind tlit- toM sliow the color most deeply. 
It is impurtniit (o rumembi>r thut this form of vyaiioeiti is greatly 
decn^isetl iLs n rule by placing the cliild on its right aiile. Any- 
thing fvhieh {in>duce)i excitement inertflsce the cyanosis greally, 
wbercni- cyanuisi^ duo to other cfiu^es is not subject to great varia- 
tjone. In the cyanosis of the newly born, males are far njorc fre- 
quently affeiHiiI th:iii fciiiule.'i, in the proportion of about 2 to 1 or 
3 to 1, and it is a noteworthy fact tlmt even when the eyanoisis is 
due to a niaifunnation of the heart it may not be proKt'nt from the 
time of birth, hut may develop eeveml days afterward. J. Lewis 
Sniitli records forty-one cases in which the cyanosis due to a con- 
genital timrt- lesion oanie on at jM-riodi« niuging from two weeks lo 
forty ymnt afUT birth. 

About 'Sri ]M-r ot^iit. (»r the cowit of eyuunMN due to otmgenital 
dt>fi'(-t.-< die in the llr^it yi.'ur. The following table from •!. I^cwls 
Sniitli fthowirt the character and n.'I«tive frei[m'ncy of these lesJon^j: 


1. Fiilmonarir krttrjr ibMiil. tuilfniciilnrir. Impervlmu. or p4rtl>II]r obMnicwd n 

IL ttlchtaartcaloTaolrlcaUt Drin(« lm|«(vli»i><ir cuiilmriui] . . . . • 
X. OrillMoritiapiiliniKikrj'Krtvrritnildiurtfliiit'iniiiilo-ivmrtciilmraptrtun 

liu|i«r«luu«ot«DtitneloJ 9 

i- Itlclit Te&incLcdlndnt tnea two caTlUta by « turtriiuiDMUjr MptuiD . . U 

& OnaM>»leJ« Mill mi> raiiirlrla 13 

a. TvDUinolfsuulolM vsiiirlple 4 

*. A (iDKlo-uheotovonUtcuIju <ii|«iilDKi laMnDrtculai and InliaTcnlrtmlBr 

^[>lum lnooD)|ilaU , . I 

S. Hltnl orinw cltavd or ooalrMlad .8 

9. AortaalHDnl. ruillawnljujr. Impcrrloui^oc parUaUjobalrnvMil . . . S 

10, Aollla alid (liu 1*11 aurlculo-irnitrloulur orrllc* liii|i«rv1niH or cnnuaoud I 

IL Aonaaiul piiimaiuir umj' tniMpoicd - ■ ,■ . . . . M 

I'l. ThoamanUrluc iba laR aurlclo 1 

It I'ulmoiiuT ninioiiwiliiji liiw Uia rivhl auricle ralutnth* oanioracirfM 

tvlu > 

14. .iorla liaixnlnu* nr eontnutcl atuv* lu iKdat uf uutan witb lb« ■tootua 
arlKrtraiu; pulmonary *n«ni wlially or in part MlppljInK blood (o Ibf 

•lotcDdlnc uwia tbivogli Uie ducMi ancrlmu 9 

Total ... ... .IS 



The chancos aiv nhnnt ten to nne that in cvftWiiiiU of the iiewl)om 
the legion i.t ahseiKM^ of n projicrly devolofXHl ii)t«^raiiriiuilar or inter* 
ventricular wall. 

In tint adult or chihi iij-aiioci* miiv Ik- pnxiiicwl by serious uinliac 
di»e(i^, hy pnlmoimrv iliw»jic, wioh ai- ixicuinoniii, pulmuiiiiry wm- 
ge«ition, aiid bronehi(i-ta;<ii? with «-mj>liy»cni« nml ,T)«o<;ijilcd uirtliuu 
(lilaluljoii. It alKo oocnra in hir}'ngeul ulratruction arising from 
extvriml prtfssuiv or intnilarynjiciil ilifliciilty. luiil in «im» of asthma 
of a «-voiv form, (St-e t;'ha(»t«r on tin- Thorax and ib* Viscera.) 

In some cases uf purctic dementia the skin of the forehead i§ dull 
imd ilnsfcy-looking. In other instanees a grayisli-blue or cyanotic 
appwiranee may arise from the ingealion of dru>^ which reduce the 
htemogilobin of the blood, sucli as antipyrine or acetanilid, and id 
such instances the discoloration ia first seen about the haae of the 
thumb-nail or in the skin of the face, particularly if the poticnt be 
examined from a little dLitaucc. 

The condition of tht- skin, ■m far as its nutrition is concerned, is 
of great importamw in diagnmi!<. In profound failure of the vital 
forcci* continuing over a ^n-at length of time it becomes abnoimally 
dry aiid ncaly, the hair becomes etragtrlinj; and liiatrelen^ and fi«> 
ipicntly fall*. In younp |)cnK)ii8 unffcriug from gmva di*eM!*e of the 
Inngn or heart of a chrouio type there is often not only an undue 
dryness of the cuticle, hut an abnonTinl growth of tlowny hair all 
over th<- body sm! limbs, and more partieiiliirly down the spine and 
ovirr the bii-iist-bone. 

Eruptions on the Skin. The inHucnoe of age upon the devel- 
opoivnt of skin lesions is very great, and Slejibcn Xtiicken/ie ha« 
summt^ up the relationship of skin disease to age in Ihc Following 
amusing manner: " The seven stages of man could be well illus- 
tmtrd by disease of the ekin, though we lack a Sbakcspeiirc to do 
justice to the theme. In the 'mewling and puking' infant wc 
meet with sclerenia and cedenia neonatorum, the ' red gum ' or 
stropbiiluB of the older writers, intertrigo, ecxema, urlirartii papil- 
losa (liclK-n nriicatus), iirtiearia pigmentosa, xerodi-mia pigmen- 
tosum, and imjietigo; the " schiwlboy,' with his chilblains and 
ringworm, alopecia an-abi, rosea, ecthyma, and ' foot- 
liall diM>JUie;' and tbi-n the ' lover,* with his acne and ayooais, 
and, a.^ a I'e.ttilt of inv-gnlar .^exna) eieursions, IiLi ayphilides; ' and 
thon the ju.'^tioe, in fair ntntid belly' witli aone roHaona, dial>etic 
b«>ila, and pniritii^ a»t; lli« sixth »tagc shifUi into the ' lr«n and 


slippered pantaloon,' with rodent nicer and 'gonty* ecxema; ' last 
scene of all, sans teeth, aans eves, aaim taste, rfaofi everytJiiiig' — 
except an iuoo»<aaiil and intolerahle itching of the lUcin which ve 
call senile prurigo." 

Then- are two eimilitions of the Hkiii in which valuable evidence 
18 given tliat tiie pntJent is ^ulTRrini; from rhentnatisin. One u^ tlie 
prt^enoe of orvlhenia in one of it^ many forms, tlie otli<-r in (he 
appcarnnw uf pnrpnrn, or, as it lias liccn <uiIlod, peli<>^i> rh(:iimali<'n. 
That tlic prt^wnoe nf erytlionm ]>oint« in many ca»C8 to rhviiinatic 
trouble is provi-d bcyon<:l nil doubt, eitlu-r i>rythciim p»|inl»ti)m, 
annnluiro, nmrgiimtiiin, or iKnliMiim being indieHtivc of tlit- ^ystiMuic 
tiiint: bill it in worthy of note that the erythoniu mHrgiiiatiim iii tno«t 
din^rnustic and iTvllienia niHloMini (he least <liagno»(4C of rhcninatic 
[toisoning. Sonietiuim thiH eruption may be the only muni ri.-sta( ion 
otlier than (.-urtlim- involvement, ami when the murginatv ernptiou 
\i present severe cardiac involvement in commonly seen. The pupu- 
tatc eruption i» most eomnionly fuum) on the huek of the wrtstn, the 
hand«, and the fi-et when it ooi-iini as a rlienmatic sign, while the 
Dodose variety is generally eorifined to the front aspect of the legs 
or the extensor surfaeL-s of the arms. It mast be remembered that 
these forms of erythcuia may be distributed anywhere over the bo«ly 
in rheuinatiHm, but that they become especially diagnostic if limited 
lo tlie areas minied. 

Purpuric discolorations of the skin, somewhat resembling multiple 
bniiaes in ap[)earance, are due to a number of causes and {>os^ieiss ■ 
varied signilicauce. In the first place, tliey are due to the dieoutc 
known as purpura hiemorrhagica, which may be divideil iu(o the 
aeuCe aud subacute forms, and that M'liich i? secondary na the residt 
ot severe infet-tlons and certain j)oisoning!<. T)ie acute funii of pur- 
pura runs a rapid course and reaches a fatal result in nuxsl caM-s id 
a ^horl lime. It is a comparatively rare disi-ai^e and u.sitally attaeks 
young adultfi, chiefly males, up to tM-enty-oight years of age. It is 
sometime)* seen in young girls and more nm^ly in young prc^iinnt 
women. Tile chief symptoms ooiL4i?il in hemorrliag«» from tlie 
mucous mcmbmiieti, purpuric spow. High fever, and a genenil class 
of symptoms resembling thoi« of sepsis, as diilts, pyrexia, and vx- 
tuiiistinii. In other instaiieus active hemorrhages take place into 
the viw^era, and if into the meninges of the biain cause cerebral 
ayiap(onis at once. The liver and spleen an^^ nearly always enlarged. 

The subaeiitc typo, while seven-, runs u fur more favonble counie 



_ ^ostutiuui- and results, II tuuully attacks children or 
a!t mnl<>)> fruiii twenty to thirty ypars of age. Tiie patient, 
•ftvr u fwliiiff of wr«tclictlD(.-M, aiul )H.>rliap!> a chill, followei] hy t)ie 
purpuric vrapliou, ih attacked by sweltinp of tlie jointa and perhaps 
hcmorrluijiic:!; from tlic kiihK-vH, bowels, and niucoii-i membranes. If 
till" lietnorrhagc be from the giinis, the teeth are not loosened, as in 
»c«r\-y. I'roBtration may be great ami the ^tatient may appear as if 
HufTering from typhoid fever. The prognosis is good for idttmate 
recovery. It is sometimes calletl pelioais rheiimatica or Sohiinlein's 
disease. This subacute form, however, oeotirji in a more severe man- 
ner, aa" Henoch's flisease," in the persons of children between nine 
sad twelve years, and is mtich more common in males than female:* 
(five to one). lo this form we have aa additional .tyraptoms marked 
pUD and tenderness in the helly and bloody stoolsi, with tene-smiiH 
and active vomiting. The illne-ss may last a long lime, but n^over^' 
often oficnrs, about 25 per tent, dying. The joint^ymptoms of the 
other fornui of purpura may he flight or absent. OAen, too, tlie 
{Mirpara ia accompanied or replaced by erythema. 

The development of polymorphic -iki)! U-sions, oon^tUting of hyper- 
emia, wlema, aiid hemorrhage, n'ith artiiriti^ oomsionatly and viit- 
ooral di#tnrlxuic«», con^i-ntiiig in atuttrkt of vomiting or <liarrhcea, 
eodocun litis, pi^ricurdiii^, noiite ncpitritiii, and hemorrhagOH from th« 
mncoiut mi>mbnm<'«, indicuu-s ihr preai'nce of n condition culled cn-- 
th<-in»exiid»livum miiltifnrine. Tlieattacksure apt to be recurrent. 
Sometimes the »kiti-m:itiIfe)station!t arc aliaent. 

SubeiitarKixis tibroid uo<bili's«omctimc8 ucetir in ciise»uf rhcunui- 
llim iind vary in <^i/.e from a liemp-soed to a walnut. Tliey arc 
lutudly sitiint>.'d in the rfubeiitaneons connective tU»ue, but may be 
>ttach«d to the dwp fascia or muscular sheaths, 

Tile qneiftioD as to whether purpurit; eruptions are ever truly 
indiealive of rheuniatisni lias been much discussed and their diog^ 
tie valne denied, but the author believes that in some cases of 
riienmatism purpura i;^ a symptom, apjK-ann^ oft'Mi in the neighbor- 
houd of the involved joints, nearly always on the lower limbs, and 
oft«n bnnking out before any evidcRce of articular trouble exists. 
In other instance... the development of the purpura is simultaneous 
with the disappearance of joint-trouble. The eruption usrwUy fades 
in a few days, but frequent relapses or new crops of it often occur. 

Purpuric eruptions may be producetl by cimnine in prsons who 

I'e an idiosyncrasy to this drug, and by iodide of potas«um, chloral, 


^ indi 


I J.,.. 



ami snlicylic acid. They may also accotniMuy any severe infevlioua 
disease and follow the entrance into tlie Ixidy of any poison whicli 
destroys the blooti, such as the poison of enake-bite. They also 
result frum severe jaundice, from profound aua<mia, from congenital 
mrphilis nitli va-^ciilar changes, f i-oni endocarditis (a form of sepsis), •. 
and in ca,ses of multiple sarcomata. Rarely purpura has followed! 
fright and severe grief. 

Urticaria may occur as a iiiunifeslation of rheumatism, but it hai) 
no diagnostic value. Sometimes it easue.s upon the use of salicylic 
acid, or turpentine, and (juite commonly follows the ingestion of 
iodide of jHitassium. The w-hi'aU prmlucetl by tlie latter drug differ 
from those of urlicarla in l^-ing iitiduly rtKl. 

Hemorrhages of the skin occur s|)oiilaneously in M>me cases nf 
hy-iteria and pan^iu dementia arid iiftor epileptic ntlnoks, (icirticM- 
larly aWut tlie t;yc.f, and oftvii fri)ni injiirii-s rei-i-iveil iti otlicr |uirt/t 
of the bi>dy during the oonvuli^ion. .Minute hemorrhages umy nVto 
oofur in the a)iirs(- of severe wh"uping.<\iugh, und, in llie furni <if 
peteehiie, n'siill from snake- jwiwuing, !<t-pticiemi«, eercbn)-«piital 
meningitis, iutlism, ergotism, and aft4>r inhaling the vupor of Wn- 
xine. They are also seen in scurvy ami in i>ome «n»bi of profound 
wasting, as in the course of phthisis and cnrcinonui. 

Petechial rashes closely resembling those of inalignuut snuilliwx, 
typhoid fever, or cerebro-spinal fever may be due to the presenoe 
of acute ulcenitive endocarditis. 

Hemorrhages sometimes appear in the skin covering a part which 
has been affected by a severe pain iu a crisis of loi^omotor ataxia. 

A very extiwordinary manifestation of spoulaQcotia subcutaneous 
hemorrhage is seen in what is known as hiematoma aurls, a conditiou 
in which a free extravasation of blood takes placi> into and Iteneatli 
the skin of llie ear. The color of the swoUeu ear is quite re«J iu 
color if ihe hemorrhage has been recent, or dark blue if it is an old 
ociHirrence. The left ear is more commonly aflectetl than the right, 
and it i* .-teen more cttrainonly iu males thfin females. 

luti' redne** of the skin is s('en iu ai-ute inflammation.s of 
the i^kin or the subcutaneous tissues, and as the result of hot apjili- 
mtion^, the n^lncju being mon> ami more marked as the heat ■» 
prolonged and is gn«t. Often the prolonged use of high h«t 
will pmcUu'e u peculiar mottling of the Hkin like that of uu old 

A«irle from the n-dne88 of tlic clioek^ and forehejul from blusliiog;, 

THE SA'/.V. 


^na dbouUl remember the ^'onci'al tliL^hing seen »o onmnioiily in [ler- 

' mMl sufTeriog from phlliUi-i, jiariictiliirK' when tliey are excited, 

whieli differs from the more dtiiiky mlneaa »een over the inalnr 

•bont^ in hectii" fever. 
Another interesting diagnnstic itign in the ^ktn im what la known}ie"lache oeitbralf," a condition of vaMmotor dUnnler in whioh 
wht-n ihf! finger is gently drawn over the skia of Uk- fwrrh(;n*l ii r«l 
]>nl<')i ^|)e(-iliiy develojw. It in seen in moningrtil irritation, hniin 
tiliBweiut, epilepsy, in some wL^es of exoplithnlmic goitre, luid in panMic 
dcincntiu. .Somotitues it i« willeil ^'lach>- meningttUe." 

Krythi'mii or rosc-nwli, »*Mnetinu;:i cnlleil roseola, ia a rcdncB* of 
the skia nm) occurs in ninoy piilliologioiil i-onditioti;!. It niuy bo 
locKlixcl or diffiii^. In a nmnlK-r of iIith-h*!'^ it iiid;^ ns very 
greatly in retu<hing n diiigDo^is, hut tito [ihysiciun should iilwnys be 
iiaiitioii^ in (lc{>L-nding mnch upon it, »inev it may miidead, owing 
to tliv fiurt thiit it oft«n np|K-ani wht-n devoid of dingnostic impor- 

^P The development of » diffuse, ptinetiitcd rusoni»h on the ekin 
of n person who is snITeriiig from miilutse, fever, nervous disturb- 
uoee, and sore throat should direii the physidan's attention to the 
possible presence of two infections dii^euses, namely, scarlet fever, 
which ii) more eommon in ehildhood, ami syphilis, whioh is more 
fnijuent in aduttci. Tlie rash of scarlet fever is of a very hright- 
rcl color, and shows itself at the end of the first or on tlie second 
■Bay of the diseuM^, first appears on the chest and neck, and then 
^I^Mdily involves nearly the whole surface of the body, altliougli 
Ae forehead often e.-nsipes and the skin about the oorneiv. of the 
moulh remains nearly aln'ays white and free from eruption. On 
the rrther hand, the sol«s of the feet and palms of the liand.s are 
very markedly affected. So intensely reddened is the [tatient's 
Mirfnee that it may have the color of a boiled loUstcr. Tliis n^^l- 
iMws <le|>ends u|Hin an acute hypeneraia of the skin, which lliniigli 
removed l>y prctsure instantly returns when the linger is willi- 
drtiwn. A noteworthy point is its punctate and mottled a]i|H.-flr> 
iniM-, for, while the entire rdcin may l>e red, there are jmint^ which 
are nion* rc^l thuu tlic rwt of che skin, and also certain areas which 
an.- |uirti<'nliirly so. The :<kin is often slightly swollen and feels 
teiM-, niid itching U commonly present. The rush nhnally Insta 
three or fotir diiy^ and then fiides, <les(|uamntion of the eiiticln 
lily setting in, which 'm complete in about two weeks. Some- 


titniw, howcvvr, it rr>niaiu^ for tea dnys to tlircc weekit. Often 
when the niati win ecarcch- be «ecii on tin- *kiii it?' ftill devnloiiiiwiit , 
will be found on the pliiirvtit^vil u-all. In thv initligiinnt tyiH-^ of] 
suurlct fever |H!tc-ditFc ami subilvrniul humorrhafrw miour. 

Soiuftiitii!*, too, in those ciisra of ircarlct ft-vc-r which hnvc wjvcre 
aymptoiu'! of uW-ratiit); sore ihroHt with air or UOM cuii)pli<ittioiM 
there dvvelop^ about lh« thin! week of the diiiOLsr, « <liirk<rc(l |>it|» 
ular or mnctilur erythema on the extensor aspects of the liirgc jointc. 
It ia a grave syDiptoni. 

An erythemu reoembling geurlH fever, not only in its »ppcamiic«, 
but al^o by its asuicuition with sM-elling of tlic lymplintie ^lunds 
and reddening of the mucous membranes of the mouth, soinetinie^ 
develops about tiic second or third day in cases of dengue or bimk- 
bone fever. 

In children there are several other conditions than scarlet fever 
which are aaaooiated with rose-rash, and tliese are more apt to lead 
to errors in diagnosiii than is the rash of syphilis. The most fr&- 
c(uent of these is erj'thema roseola, or roseola of acute indigestion, 
or that following the use of a food to which the patient has an idio- 
tyacnsy. It U generally, but not always, widely diffused ami is 
often a.'Mnciated with auiitw and .■^ovinv febrile mnvt'nicnt and vnniit- 
ing, but it can be si'paratiKl from »i^rli*t fever by llu- faoti* that there 
ifl an absence of severe constitutional and nervoux nyniptomA (except 
in neurotic children), thert* is no I'ore tiiroat or enlarged cervical, 
glands, and tlie nu-Ji does not conic out on the clavicles and gradiiallr 
travel down the body. Koi^colous eruptions also a))pear iit |>eriM>n» 
with delicate skins after coming in cuntui-t with irriuml ptimtit, ami 
Duk«s ii«K!rts tluit it may dcvvlup from hiiudliiig aitcri>illar». 

Aiioiher oondition cloitely rMembling wyirlflt fever i» mrely etxa^ 
namely, acute exfoliating iIcrmatitiH, calle^l, in its mild form, era 
thema Mcarlalinij'irm, which has n sudden onset with fcbriU- move-' 
moot and a rash whirh mpidty spreads over tlic entire bo<ly and 
lasts four or Ave day*., finally ending in deniunmation. So cloeoly 
may tliis disease resemble scarlet fever that a diagnosis during the 
first attack may be impossiijle for the first few days, but the comli- 
tion of the throat and tongue doc« not resemble th« comlition seen 
in scarbttiia. Destiunmation is often eveu more complete than in 
scarlatina, and tlie hair and nails are frequently shed. Relapses 
are very common and give rise to the reported cases of repeated 
attacks of scarlet fever. 




The rafli of rultellu or rubcobi ur mtlicia (Gcrnuin niensk'^) !x a 
rmteola, am] moru cl<»ely rcsemblvx Uiat of scarlet fover in some 
GftaCM tltnti il (Iocs tlint of iiiua!tU-)>, Ijiit it Ik nt^vcr as scarlet, is dis- 
tinctly iiuK'tilfttvcl, an<) oiilynt a distaoce Umka liomogeneoiiit. Close 
cmmiiiiitioii iilwu}'s n^vciils the nuh io oval patches, aud it lacks 
die (UfTiiwd duinivtor of the nuh, the puuctation of the skin, the 
grnvi! syMcniic (listorhuiicc, ao<l tho throat-symptoma of si^rlet 
fever. FurtlM.'r, the febrile inovement is comparatively )ilighc, and 
ruh lasts ouly two or three days. Slight desquarantion may, 
however, occur. 

Gtrman measles is separated from true measles in many cases by 
tht murke<l glandular enlargements, chiefly tlie posterior, cervical, 
AxilUry, and inguinal. 

The eruption of measles (morbilli) is very characteriBtic, aud can 
be in most cases easily 6e|»anited from the other exanthemata by 
close examination. It is a roseofii in character, but more dtisky 
than that "f scarlet fever. It appears about the fourth Jay of the 
iltneee in association with catarrh of the mucous membrane of the 
ejres and respiratory tract. Unliko scarlet fever it appears iu 
maiculea first upon the forelieail or fai'e, ilien on the neck, trunk, 
ltd liinlx*. Ttu! niifulo^, which nfr^'ii coalesce, are arranged in 
iitti* which an^ red, l>iit braoiu'^ H'liiu'wliiit yelliiwitOi on prex- 
II*, 'ftiey are slightly nii.*cHi, Tln-n; h n«irly always Ui lie «fou 
BOOM uninvolvod skin, ihc cntin- surfmrit not being covcn-tl iw in 
■niHtti fever. Iti samv instanws iu which the eruption is Aberrant 
II diagnosis of measles from scarlet fever in mloiitt^Hlly inipoti«tihle 
antil tlie cns^ has Ik-cu wuti^^hiu) for some ihiys: hut the »iow onwt 
meuslcM, in which the eruption uppcnra on the fourth day as 
the firet day in scarlet fever, the swollen eyes and no«', the 
losfl of tlie face, tho caUirrlial <!onditiou of the nuivmis mcm- 
brunes, tJie curious fall of tcni|ieraturc after the preliminary rise on 
the first day, the short duration of the rash, all aid in the diagnosis 
of measles. The dusky eruption of meusle^ can ncnrly always be 
and on the pharyngeal mucous membrane. (For the mouth and 
throat symptoms of scarlet fever and mwislcs, see chapter on the 
Houth and Tongue.) 

An erythema or roseola sometimes np[iears over the skin of chil- 
a who have been vaccinated, genendly about eight to ten days 
the o|)eralion. It mix-ly lasts more than two days, and on ita 
i.tapitcarance Iliere it) slight des(|uamation. 



It al^o nppcnr* soin(>tinift< in casien at Hiualljmx iirovious to ihe 
oiitl>nitk of tlio true eru|)(i(>n. I'uder the latter fircumsUncee it 
i^ fomiil most oommuiily nboiit lh<^ gmia and inner surfan! of lli<.' 
tliigli!^ aii<] uD thi.> liy|>iigik<trliiin, \n\n^, clnvioles, and the <.>xtvii»>r 
aurfuvL*^ Sij t'losHv mny t]w iwrly nish i>f !«inall[>rts simulate the 
Abormnt tyiw of nii'UsW an to Iwid to gnivt- nuHtakoi in diagnosis 
6onii)liino» nn imnicdiati.- diannosii* is inii»HHil»U', fvcn l>y tho most 
expi'rifiii'Lil, but the nwh of inwutlop ohuiikiiiIy apixMiM on the face, 
theivforc this dilTorenw;, coupled with » history of exjioaure, the 
gniduul ilcvi'lopmeiit uf the peculiar " nhol iindi-r ihi- (skin " sensa- 
tion of viiriohi, unil tJie ultimate diiftinel j)n]>nlalion, veMculalino, 
and piintulatiuu uf smallpux ttoon remove the doubt from the physi- 



Day or Eruptiov or thr Vjtiuous Exahtbeuata. 



Am. { 

KDtbcIn «ri U«nnui mculca. 
VlrlocUa wcblcluDiiax. 


Solrld ttrtr. 


>l*iul« or miirbllllor rubcoliL 
VartolH ur imalJpox, 

rorehMd. IM*. klld WtlMk 

Typhut or (Up fiirar. 


e«vantbi«DlDtl]d4r . . ■ . 

Trpboid or «DHrio fever. 


The reraembranee that the iunibatinn period of \*BrioIa Is twelve 
days, that of varicella seventeen days, of measles ten days, of rubolEa 
twenty-one days, and scarlet fever four days, will aid the diagnosis 
if A hintory of ex|>osure can lie obtained. 

A diagnosta between tlie eruption of measlm and variola often can 
l)c made hy stretehing Ihe skin between the lingers, when, if it be 
measles, the papule cAniiut \u: felt, whereas, if it be variola, it per- 
sist. This i* mlled ilie " grisolle sign." 

Among otiiur dinpiL'St!!* in which rownwh fliipi-ai-s we find diph- 
thcrin, »(>])ticii!niia, ohulem, ly)>bi>id fever, ni;il)irial poisoning, and 
Bri^ht's di*!ii!*c. lu diphtlima it may h>ad tin* phvtucian u> a 
diu;;nii«i:« of MtiHct ft^vcr witli Acvert- faui-iiil niaiitfestationa, aiid 
only a curcfiil I'xn mi nation of tlic tliront, flu- rapi'l subsidence of 
the nii^h, and the biieti.Tiulogirnl oxumtimtion of the false nu-nibniiie 
will BCttle llio <lia;i;noM!<^. SoniL'limes, however, ft rosi'ola a]>|>e»r8 
laU) in the oonrsu of diphthoria, probably as u reitiilt of septic ub* 

mrfttlmi. Tho )>rci*pnoc dt n wry lilph tcmiwnUiire, of nervous 
irri lability, iiix) the predomiimnco of t^R^ tlinjiHt-lcjiiioD* of rwurlct 
fever ought to decide tbe diai^DOBis iu fiivor of scurk't frver. 

Til* mscota of wirly syphilis resembles tliat <if wjirlct fever in 

► tliti( it lirtit Hppmrf< '>n the trunk; but it is not bright liciirlet, but 
ntlier dii^ky red. It apiK-nrs to pau^his nud i» not diffuse, nnd U 
tMiMii.<« tilwut ax weeks or three mouths after the uppeiimnec of iin 
ioitial lesion, ocour« in »n w.lult a« a. rule, is not nw«oct»te<l witll 
llif^li fever, mid soon involves the face and forehead. These symp- 
wnt'^ ai<i Ufl in M-punttin); it from scarlet fever, although the rasfi often 
uppunrs iu full blast in the palms of the hands and soles of the feet; 
but a nitwoluus rash in the^> areas in an adult is always suspicions 
Bnf »]wcifie trouble. These patehes speedily change from rose-rush 
^to of her mure marked Wions in eases of syphilis, and one of the 
firet changes that they undergo is to heeome circinatP. They fade 
and reappear, tsst an indefinite time, fade in the centre, and bo 

■ ehnnge into marinate or circinate erytlieiiui. 
When roseola develo|>s after a surgical oi»>ration or after delivery 
in u puerperal female, it is not a manifestation of Hcarlet fever, hut 
is due to sepsis, although it is of ronrn^e (xiHttihle for scarlet fever to 
atlai^k ^ueli casvi at any time. 1'he ra^h h uriually fi:iiin<1 over the 
abdomen and inner 4tdi?» of the tliigln. The alu^nee of mre tlimal, 
the pn-si-iKie of a ■>c])tie pn>i><-*«, iiod the absence of a slrawlierry- 
, tongue all help to exclude Kcarlatiim. Somctimci^ late in an attack 
af cholera u raith like surgical rix^^-ola appears in the ^me an»», or 
iu t)»e perifw] of naiction comet out on the forearms, Uu-ks of (lie 
bandft, and mrc-Iy on the Imck. 
Tlie roMiolons rush of typhoid \t «onivtinien widely dixtnhtited 
I aUnotM like incaslen in appuirancc; but, iw a rule, it 'm limited 
I a few or many rose-spot« on the nlMlunieu, chest, or Imck, These 
I roM>-e|x>t« dtHippiur on light pressure, but inmicdiat^^'ly return when 
^■tltc prcMiire i« removed, and are most mai'kcd in typhoid fever 
^bbout the si.-venlli to the U-ntli day of the disi-ase. They may bc- 
^HjSBe I'lii^htly papular. In tins eonucction it shi)uld uut be forgotten 
^■tltat the rose-rash of t^'pfaoid fever may be so profuse, particiilarty 
tn |M-rkons with a dclieute skin, as to resemble scarlet fever; and, 
further, it is to he borne in mind tliat very rarely searlel fever and 
[typhoid may complicate one anotlior. The abdotuiual symptoms 
typhoid fever and the throat synipttmis of scarlet fever aid in 
differcatial diagnosiij. It should be remotubcred, however, 


■ Tl 


tlint llie oxIiaiiKticiii following an attack of :icarlel fever may reoder 
tlie ^nentl ii[)p<>amii(% citrrciiiely like tyjihoid. In the rela|»e of 
ty|>lioi(l fcvisr the rosfr-spote ofton npiwnr a.i early an ihe Uiirtl or 
foiirtli dny. In typhiiti fe%'er they ftr« much more plentifnl and 
often form petcohwe. 

In iiriffht's <lii*ciwc a roticoUi often nppeartt over xiw feet and 
ntikW, wristti and liandH, am! fjinetimcTi ^pren(l:< t<» the »kin of 
tliti che«l am) ubduiiK-n. l\tH)iitiniiitiun may take plaee, but aIh 
8cno« of febrile muvumcnt and tho prvectiee of renal trouble render 
the diagnosis ttuy. This manifestation lin« not n dimfpTon^ imjinrl. 

A dunky rod rash rapidly spreading uwr the nvi^hhorin^ «kin, 
above the level of which the affected area is raiaetl, and which is 
rtopanited from the §onnd skin by a sharp line of demarcation wliioli 
can be both seen and felt, h characteristic of erysipelas. The 
skin soon becomes brawny to the sight and touch, ami llie Hue of 
demarcation feeU markedly indurated. Moat commonly the disease 
appears on the face, starting from the inner <'anthtiii of the eye, the 
nostril, or the corner of the mouUi. Verj* rarely does erysipelas 
affect the skin of the trunk. The fever tuay l>e ijuite marked, 
even in mild eascj*, and iiHtially fnllit by crisis on the sixtJi <lay. 
In Mcvere ca«(M( with fulal tendencies there may develop in place nt 
011818 a typhoid state with low fever and delirium . If th» disease be 
severe, blehs and bulla- form, tJie <etlenui of the skin Ixfcomes very 
profi^'iiiid, and linally suppuration may occur, forming wluit is known 
as phlet<;monous erysipelas (see also Glanders), 

ErysiiK-Iatons intlamniatioii of the skin without systemic disturb*' 
nnce may follow the application of arnica. A conditioa also closely 
resembling erysipelas in its raised surface is urticaria, which, bow- 
ever, differs so materially in other resiM^ct-* that a diagnosis is readily 
made. Aside fmm the absence of systemic di.'^tiirbnnce in urticaria 
the swelling of the skin is not i^, but ]>ale and jiearly in hoe, 
although it may he surrounded by nn erythcinntouft blush ; the onset 
is extraonlinarily sudden, so tlint a skin i«i>ruiiiigly normal at one 
moment, nft^r a liilifrlit bruiting by the finder or nibbing by the 
clothes develops the complete eruption in a moment. 

A marked ni«Cf>lii or dermatitis involving the ini<idc« of the thighs 
or the scrotum or vulva should give rise to the belief that the patient 
is suE^Ting from a failure to properly pass or retniu the urine, 
which, on escaping, irritates the skin. This is particularly apt to 
rvsult if the urine is tliat of a dialietic. Again, it is an interesting 



mntoiiti rasJi 

that in ^ome ca^es nf tiihi?rnilar [M^ritniiitis an enrt 
irs on tlio atidi > 111 ilia 1 wall nrouiid t\u' navel. 

Tile pre.4eDoe of a roseola or «rvt)it;ttiatoii>t msli oftrii iiidicatei^ the 
ODUiwanI ill Hill' lira of iomei drii^, f^illowiitt; itf cxti-riial or iutenial 
use. \Vc find timt it wry ommioiily follows the iugcntion of 
coiMiilm, mid, tu many pvrauuH »uCFiTiiig frum venereal dii't-noc take 
tliiH dnig, tlic p)iy><imii niii'st uno cure nut to be U-tl intu adil^^ 
aim» of sypltililie ruscolu. It ul^o follown the uae of quinine, 
opiiim, aiitipyrine, niid mauy other drii)^, such an dij^ibtlw nnd 

TIic roMOlu caused by th« use of copstibn appestrs by preference 
on tlio upper and lower extremitiea, and particularly on the backs 
of llie hnndH, about the kneee, the anklea, and on the chest, and it 
is often ocootnpaaled by fever. Indeed, tlie eruption enticed by 
copuibn may closely re«tmble a papular syphilide; but its sudden 
oDSiet, itching, and disappearance when the drug is stopped separate 
^t diagnosticully from the -ijiecitic disease. 

The mseola following the use of bromide of potasHium i.-i, aeoord- 
ing to Veicl, very rare, and b distributed over the lower limbs. In 
children it may closely resemble measles. 

The roseola or erythema caused by (jutDine is to be sepctrated from 
tliat of scarlet fever by the absence of fever, of the scarlet tongue 
iiiul sore throat, and by the fact that there are no prodromes or oir- 
otilator}- dL>4Uirbauce except tliv ehariiolf riwic evideuwof ciuclionii^u. 
In doubtful «i.'*cit thii^ in Mill further ooiilirmcd by nnalysiif of tJiu 
uriiw or by the ate of the following simple tc»t. Observe the dis- 
apiHvranc*^ of lliv fluorvscenoe of the urine caused In* i|uinine. after 
tite Mxliuiu ehluridc 1ms been n;mDV4^d by procipitittiuii by nitrut« of 
mercury, or after ecpaniting the ([uininc as an iodide by the addition 
to the urine of a solution of two parts iodine, one part uf iodide of 
potiLssium, aud forty piirt« of water. The i<Mlide of ciuiniiie cau be 
Afrain di«!)olvCfl by the application of heat. 

.V distinct diffuse nt^eola sometimes follows the use of arseute. 

Itd-reohi mny l>e caused by the use of salicvlie aciil aud strvch- 
nin<', and a scarlatiniform rash sometime.s appears iu blotches over 
the faiv and body in jiersona who are taking tuqientine. 

Roseola also ensues in some persons after the application of sur- 
gical ilressingx containing iodoform, corrosive sublimate, and oarbolio 
■rid, t>ciog due either ti> a hx^al effeot of these drugs or to their 
ib^qition from tlie dressings, .\rnica tincture applied for sprains 


or briibos may prodtK-o markud ruseula, or even erythematous an<l 
erysipelatous swelling of tlie skin, as already stated. 

By far the most important drug-exanthem is tJint caused by alnn 
pioe, the nish producetl hy it bfing very like that of scarlet fever, 
except that it larks the red pmictntions of that disease. This rash 
may be associated with a slight rise in temperature and be followed, 
rarely, by deaquamntion. The face of a child suffering from an 
overdose of athtpiue is very charaoteristic. The eyes are bright, 
the pupils widely dilated, and the skin over tlie iiialar bones is red, 
but striking lines of pallor reach from the corners of the mouth lo 
the nose. There may he aetivf, talkative delirium and very mild 
convulsion.^ fnjni overdofleii of atropine, thno making the resem- 
blance to the onset of scarlet fever very striking. The brief dura- 
tion of the riL-ih, it? lack of [mnclntion, ilie ab^enoe of high fever, 
and llie lii.'^tory of the patient having tokcni atropine or bellHdomia, 
all help to mnke Uie difTi-i-inliitl dingno»i^. 

[iiMCula, followed by ih-.'Mpiiiiiiation, has been known In follow tba 
hyitodermic iiije^^ioiiof menniry, Simictimen the niwof blue oint- 
ment prodiiivsn widi^sprt-^ni lu-li i<-^<-tnhling me.islc>*, and ihii' resem- 
blaiKi; nuiy Ik- incn.'«i«wl by lli.* •ii'vvlopmcut of a febrile movement. 
A similar eruption may ensuu from the ingestion of opium. 

Erythematous raslics, too, frequently follow slight irritation of 
the skin in persons who use chloral. 

Acne of the skin, particularly on the face, is often produced by 
the use of bromide or iodide of jiotassium, or of any preinration 
containing bromine or iotline. That producott by iodine ia gener- 
ally sudden in its onset and profuse in its distribution. The base 
of the pimple is bright red, the top speedily becomes pustular, and 
Fournier states that il may be hemorrhagic. Sbipping the inges- 
tion of the drug speedily relieves, or at least decreases, the cruptinn. 
The acne due to bromine is often very profuse, and the pimples in 
severe csaaes may conIcs(v. making sloughs of oonsiderable sixe nnth 
an indurated l»i:4e. 

In some persons, generally females, there is d«vclope<l an aone on 
the faoe, bre««t, and back, as the result of taking iron as n tonic. 

In luldition to the acne i>an.-«ed by dnig^i, or ihi-ir cimimiiiidiii, we 
should also montion the acne and furuncles appearing in ]K<rscnn 
working in [xmitlin, which U due to blocking of the iicbncivui> glumlit. 

Closely a8Sociatv<) with iim form of eruption \* that which is 
oharactcristtcof smallpox and ohickcnpux. The eruption of small- 




apjieni^ on the Bwnnil or tliird day in tlie form of tiny S]K-ck8, 
n-wnibling flca-bitt^. Theite rapidly become (tapulre, wliirli hnve 

Flc M. 






y^Ti "^ 



^^i *i 





ifnullpux iTiiiittuu ou lliv wvBiilli Avf. 

an ioduret^ base, so ibat they feel as if shot were under the skin. 
(Fig. IM. ) After about thirty-six hours these jMipiiU-s bocoine vesi- 
cles, containing a turbid fluid, whieh sjKedily beeomen purulent, 

Fia. U. 

B [Mi«ulc. (Fin*. ''•'> ■Tid 90.) Generally this piwew of 
Ion liitcoM tlinx- duys uimI, with the development of the pun, 

HiuaU|>.'i i-iui>ilnn cai lliodithin ritjr. 


tliv no-oji11(hI M'cuti<liiry fvvvr, which nuiy be oven higher tLiui th« 
primnry fovor of invasion, nets in. ^Vftcr a period of eighteen lo 
tw^^'iity-onc (layH the ]>iistii1i>H drop off, having become dried up, 
leiiving, if the attack him been severe, or the skio delicate, deeply 
pitted scars. Although the eriiptioD of smallpox apitears on the 

Fid. M. 

Smulipoi ernpllcMiou tbotliTanUi lUtj. Tlwpaok liiMuco bt umblUcoUO. 

forehead, which i» the favorite seat of acne in many i-asfs, a diffi-r- 
eotial diagnosis is not difficidt, since tlio grave syatemic disturb&noc, 
febrile movement, and rapid InvolvenicDt of the whole surface of 
the body speedily indiiwte the true nature of the disease. Thw 
early appeanince of the rash on the bands in varioU is also a diag- 
notdic sign, as aene in this part of tlie skin iH practically unknown. 
Then the sudden development of the erujitton in smallpox is entirely 
different froni the gradual on»et oven of the must intense aoiie. 


iCMMBpunilviit acnfof the forc-heiut develops iii sypliiliH. 
Tilt S^arntioD of variola from meo-Htes U^n already Iweti ili)reuis«c<1, 
and it i» only in the papular htage that the former diiwase can l>e 
cuiifiiiK-(l with tile latter, while the reddened roueous membranes and 
swollen fucv of the eaise of mmeile-s soon determine the diagnosis. 
The rapid formation of vesicles and tin; ithotdike ^ni^alioii i,f the 
eniption "how that tJie eruption U not nicni^les, 


Tjrplckl vicoliia v«d*l«b TtaOi dajr. 

The appearanoc of the eruption of viit-oinia fonowind viu-rintition 

lust lie next described. Tliree or four dayc after the \ii<.vinHttoii 

single or several papulej* arise on the scarified surface, which hy 

the .xixth day are ebaui^d into nmhtlieated vesieles, which hooii 

l^niiitc anil form one vesicle the size of a five-cent piece. This vesicle 

tially forma a neab which falls off after the expiration of nlwjnt 

1TW wifks from the inoculation. A " (PxkI take" is alvniys sur- 



rmuKkti by no nrt-olii of rosy red of i*evi-nil im-tu-s in width. Rarely 
itevore iiiflniiiinulioii nml »lo(if^liii)g <?iHiie. (Fig. !'".) 

In oliiokenpox tlie eru|)tio[i «p|K«r» on Uw (irst or second day 
nnd kwpH coming ont for «;vi>ral duys. It is nwe-cwlorcd luid oocim 
M jwpiiK"*. wliieli imni<Hli»k-ly Ix-coiue vesicles. Tiipy last Imt fo*ir 
or five tlivys, niKl arc iisuully u^uciaUH) with very mild febrile dii*- 
tiirbiiQce, ttio child rcmniiiiug Itnt little indisposed if well nred for 
nud iiiirseil. Unlike Bmiillpox, vuriecllu doi-» not beeotne ttn]i)iliniti.Nl, 
anil ruri'ly loaves pit'^ in llic skin unk-HS tlii' veitielos are picked ut 
by tlie fingi^'r-nuiltf. Xeilhor do tlie voti!cl<»t become pustules tinteM 
infceted by pieking or the child U in si eondiUoii of debility or siifTertt 
from otrtimu. Vuricella is scpiirat^d from viinulu by the nb(H.'m>; of 
severe sy^tcmie distil rbitnco, by the rush first uppearin); on tlie ehest 
iind iie«k instead of tlie forcliead and bands, by the presence of 
otber e»ses of tbe disease in nn cpidt'iuie, and, finally, by tlie faet tiiat 
it attacks eliildren who have been wvll vaccinated, whereas small- 
pox does not. The hi<4tory of exposure is, of ouursc, an im}iortttiit 
point to be iavesti||rate<l. 

An eruption closely resembling cliickeupox or smallpox is that 
called im[>ctigo contagiosa, in wbioh there are found multiple, Bat- 
tened or !>liglitly timbilieatiKl roiindi.->b or oval voitiolcs, piistuleti, or 
bleb*, which furni after siiiiie duys dry yellowt^h enwu. It txvurs 
in childlir«>il, or early adult life, and i» often aiisoemted with some 
degree of fever. The area.* involved iire the faee, neck, buttook.i, 
hands, and feet. The leninn-i of the .ikin are Iitrger than in ohieken- 
pox, but often follow this dLtease. As its immv indicates, tlie 
disease is oontagious, and the oeeurrence of a scries of t^aws in close 
proximity to one another should not mislead the physician iuto a 
dtflgnoais of variola or vuricella. The eruption \uMt» about two 
weeks, and Kajvwi iwserts tluit swelling of the submaxillary glands 
Is always preiient. We a%u further separute impetigo contagiosa 
from vurieelln by the locolixution of its eruption to one area, m a 
rule, by the fiiet that the eruption betNjmes bullous or purulent, am) 
by the Inrj^-r si/e of tbe vehicle. From smalljKix we can separate 
it by the absence of severe pain in the back, tlie grave systemic dts- 
tiirbimce, and the secondary fever of that disease, accoinpdiniccl as 
they are by the smallness of the pox, the pc-culiar odor of the 
patient, and the history of ex{)OHure to variola. 

In the presence of a pa]>nlar, ptisUilar, or vesicular eruption of 
the skin it must be renicmliervd thni i|iiinine sometimes develops 



Ihcvo k-^ious ill siiitceptiltio pLTsoiie. In soiui- iii^taiKt'r^ wlit-re it 
involve titf lmii<is it niuy iadiciitc that a local vf^L-ct Urn bi>c>ii pro- 
diiowl bv working with the drug. 

Eciema in its vnriom forma may a|)pi>ar aa the result of the lue 
of rjuiniou int«n>»Ily or locsilly, or of the employmetit of mercurv 
iutcmully or externally. When it arises from the iiae of iotlide of 
potatteium, which is v-erj- rare, it ciiiefly affects the scalp and scro- 
tum. The development of an ecKematoiia irritation of tlie skiu 
sometimes follows the use of chloral. 

Herpes labialis is a very constant lesion associated with croupous 
pneumonia, ami ita development is said to he a fa*-orahIe sign. It 
is also an important sign for the sejiaration of epidemic oerchro- 
»ptRal meningitis from raeniagitis dn« to otlier causes, as it is not 
<»mmoidy present in the »on-q)ideraio form. It sometimes arises 
a» a result of using salicylic ai^id. 

The development of rocurring crops of Imils in persons not ex- 
posed to paraRin or tar :4hould cati>ie the phy.'<iciaa to suA]ieet the 
presence of diabetes mcllituii, or at Iciwt timt there i.'* general de- 
bility, and particularly im abwiuoe of limr i»»U.* from the system in 
the proper qiiuntity. Wheu the onlinary boil pusses into a condition 
of mark«<l iminnition about its huse, with sloii;;Iiiog of tlie Kub- 
Mitaaeons tissue and necrosis of the skin, which l)ccomc» pcrforatetl 
bj till* openings of several sinuses, we have to deal with a curbuudo 
or nnthnix simplex. The din^se iif'Ually appears on the back of 
the net-k, on the back, or the lip. The sy^tennc disturbance is vory 
groftt ftnd the exhaustion profound. The skin covering the area 
involvol )>eoonicd grayish or bluisli-black, and then separates ux a 
Uir\iV mass, while the aubcutiiiieous tissue comes away in shreds. It 
i* a dangt^rous disease in all persons, but particularly so in those who 
«r already weakene<l by other diseases or excesa. 

The development of a painless macule on the skin of the hand 
or foot, followed by an acutely inflame«l [>a])ule which itches and is 
soon changed into a relaxed vesicle containing bloody serum, in 
which there is a IinnI nuclciH wbidi resis upon an indurated base, 
is the initial m.iuif<siu(ion of anthrax nialtgiia or muligiiant pustule. 
The lynipliatics m>oii lie<'omi- swollen, and nicta^tatie abseessett 
speedily fonn clm-wkfirr, na in the nxillar^' glands. The systemic 
symptomR are seven;, Minn-umoj* being miiuife^t^^Hl in high fever, in 
other ctisi.> by a typhoid -itule. Dcatli isvur^* c<.>niiui>nly tlie s««juel 
(flj) |M-r cent.), even if promj)t siiT);i(»l interference takes place. 


There is gvnorally a lii.-«tr)ry of ■•xpmitre ti> iiifcRted animaJii or tlioir 
hides. Muligiiiiiit puittuli- iK to he Nejiarated from oarblincle by ita 
fulmiDUtiti}; ohiimctcr nnd {MViilinr npfMuimiiw. 

WheD iin i>ryHi]K-hktiiiil ranh u-ith !*wi-lliiig nf the okin and the 
dovclopmcnt of papiilbs, vt^iuUw, ])ii«cuk«, «iid biiUip appears in 
asAociutiori with inihinition uf Hk-- Mkiii, with sloughing ttventiially 
taking; plaw, ihi? diMiiwi' iiiuy powiiblv not Iw vrysipeliw of a phlpg- 
monaufi form, hut i;l»mi(.T« or eijiiiim. Xiiiucrc>ii» inthinimatory 
foL'i nppeikr iu ihu skin in p;hiiid(!n< which c-iid in lociil ultsce^^x itnd 
hemorrhagic nodules, and profound systvRiiv infection is always 
piuwiit. Tilt' prtsfiifp of « suniotis discharge from th« nos<? aids in 
oi>nliruiiu<; the diagnosis. Deuth usually comes in a fvw diiys in 
this acute form. Should the course of glnudois be chronic, ptistiiles 
somewhat like thoKc of smallpox, excL-pt thiit they are not unibilt- 
oated, lie ou nu indurated base, and in them 'm formed a viseid or 
BaiiioDA piifl of offensix'c odor. Tliis dixense is rare, Botli fonne fri>m infection from -a horse suffering from the malady. Glan- 
der;4 may be confused with x-ariola or the pustular and gummatous 
eA&ftcti of HVphilig. 

The development of pea-siaad or larger bullie npon the skin may 
indii-jite the proAcnoe of pemphigus, or if there i^ central nervous 
disease involving the spinal cord and reuniting in trophic lc:«ion9 
similar htilhin-t eruption.'^ may take plaee. The bultw, if they eon- 
tjiin A dark hhimly fluid and are c^ituuted upon a Itrnb in which Uivrc 
is an nhnnrmnlly high temperature, are |K:cuIiiirly indicative of cen- 
tral ncrvyiiH leninnit, jiartieularly If there is a tendency to ililiitation 
of the eapillarii,'^ of the i<kin on ttlight irritation; but if the tein< 
peratnn; of the entire body he mi^ed, the physician should rtmu-m- 
her that pvniphigiH is a disease in which there is often marked 
febrile movement. Sometimes thci^ bullous manifestations are fol- 
lowed by gangrene in ciises of neuritis or otiier diTtcase causing 
trophic lesions, such as myelitis and ]mnrtic dementia. 

Itullie on the face may follovr the iiigostion uf antipyrinc or iodine 
com pounds. 

The development of a pemphigus-Hke eruption in the skin may 
follow the use of salicylic acid or copniha. 

In the cas«aof herpes xoster the skin \eamo often has itfi origin in 
oompre^don of the spinal cord, or in such diiteases as tabes, spinal 
meningeal irritation, and peripheral neuritis. 

Glossiness of the akin, in which iL>i minute creasea liecome 



^and it up])c.'iireuiKlu1y itliiny, often rcetilb^ f i-om ohrouic 
rii^ some portiou of tlic ihtvoib sVBtem conupi-led with 
t(i« (favvrnmeot of niitritioii. Vorv commonly it reaulttt from 
pi-ripbcnil nviiritiH. In iul<litioD to glo^tsiuess tliere nn> oftoii rtnl- 
iii~^ uud murkeil thinning or thickening of the cutiole and aubcuta- 
nvotu tiB^es. 

tjJangrene of the skin may follow nei^-e injuries or central nvr- 
voos le^ions^ Thiw it may follow iigion divi^ii>n rrf a nrrve-triiiik, 
or l>e due to cerebral ahttoess, in wliii-h cai^i- ihir gim^rvui* m-iII Iki 
with the other ItKaliKiiig :«yniptom^ nu Uic o|)|H)»itc ifidv of thv liody. 
The wrehnil form d<?velo[»i Hnd<k<nly iind wittitHil the prodromul 
rednetts of hed-'ion-.-* a-* ^wn in prolungvil iihiis^fe. Simllrtr ni|iid]y 
di>\-oIii|>inf; sloui^hs imd ulwrntiuns of the skin are m-ou in coms of 
wnite mvelilUi nnd in the »C(;ihkI nm\ third <«tji^v> of [Mirctic dementia. 

A very interesting; eoiiilition is the so-culktl spontniieuus gimgreue 
of livAtrrtu. On the skin, generally of the breai^i of a young girl, 
a spot develops which f«t*U to her to Ik- hut uml burning. The i^kia 
HOon becooMM very while, then in a few hours very re<l and forms a 
whual. This rupidly be<wmi>s dark and bluish-hlat^k, looking like 
a burn of snlphunc acid, and a slough finally eomeo awny, leaving 
a permanent cicatrix. 

Gangrene of the skin followi^ U|mn diaheleM melIitnR,and may 
involve the ticrotum or vulva if tlie irritation nf tliese |Kirti« hy the 
urine is constant. More iMmmonly the toea are afTetTled, and tlit;r« 
b tbU im|x>r1iint differential point that in the gangrene of ol<| 
ago witli Iwid ve.-iwU the legion is tisiially at tlie tip of the toe, 
whcnxt» in diabirtic gangriMir it i^ fn^ijuently about tiiv bull of th« 
big tot^ or on the wilo <ir dorsiun of llit* foot.. FrcviuuH Ut the devel- 
opment of gMngrt'ne thcrt^ iiiv devehippd bulhe and nlher iiillamnia- 
lory eliunge* in the sk!ii wliieh is iiIhmK to l»> arfeclj-d. Kii|K)si 
desoribea ii ecqiiginons form of giingreiie :iITi'i;tiug tin- leg tii di4d<etiea 
and a variety of tinue bn.nk down, in wliicli a tiernintitis, followed 
by nlcvK and a lii]in»-Iike forinntion, iiIao f)wmrs in dinlK-tcs, 
Perforating uh>er of the fool iHX'urs in lo4»motor ntjtxta nnd in 
paretie dcmeuluL 

Cliiseiy related, yet cgiiile distinct fn>m nngionenrutic (edetm, tB 
that condition eulletl lljiyniin<rs diocase, symmetrical gnngrmtc, or 
loiail naphyxia, according to ita severity. The fingers nni) loea or 
• the noM*, with or without ex|>osure to cold, arc fouwl to be pale 
ltd livid, looking like a hand fmui which nil tl>c blood has boen 




removed by ihe use of an E^raarcli bau(1ag:e. The part ofwu feels 
us if " mleep," and is ni»re or less numb and without seuiiatioB. 
To the touch the part lii oold and waxv, and it does not bleed when 
pricked. With tlie ouaet of thenc ni^ns there are often general 
ehillina^H and malaise. Often thin manifestation speedily disap- 
pL'nrs leaving the skin apparently normal ; but if it penii^i^, tlie 
.-kin heroini>!< i^lo^^'y. i<hrivelled, and looks lui if it had been -uiak^d 
in hot water for hours, Wlion the di.wasc is more severe tlie jmle 
waxinc^ h supplnnti^ by cvtuxHis tjll the lin|rer'ti)>r(, for ejtnmple, 
look »K if dipped in blue ink; tiii'n; i^ ofl<>n hicml Kwvlliu)^; the nkin 
18 fre(|U«ntiy found to be Kweuting frwiy nml is di!rtcn<li-d with binod. 
The skin muy mpi<Uy MOjmmte from the deeper ti?i^uu* iniil Itefonic 
uettrutie in putvhes or ai mngw, and tlie entire- tip of the tinf^er, afwr 
becuniiii); bhiek, shrivuU up into a condition ro^-mblin); dry gAa- 
greuc, which Is M-panittx) from the found ukin by a sharp line of 
deumrwition. Hometlmeti small necrotic jintcheti hIuuj^Ii out, which 
leave cicatrices telling of the iittiick. The proguoHis is not biul. 
The moet interesting com plication of the disease is paroxysmal 

The development nf gangrene of the tiiigers and inee sometimes 
follows tlie pmlonged use of bread made from rye wbicJi le infected 
by ergot. 

Sometimes gangrene of tJie flkiu follows severe atlaok.s of t)ie 
cxanthoinfttA in children who afc strumous or very feeble, or who 
arc sypliilitiV. 

Ulcers about the biwe of the finger-nails should miiso the suspi- 
cion of the cxcedtuve use of chloral, 

BetUores may develop whenever by long-coutinuwl pnwwnre upon 
any part of the boily the local circulntiou is dii^tnrbed, particularly 
if in addition there is general systemic debility from some exhaust- 
ing disease, such as (y|)hoid fever. They also develop very speedily, 
and apparently almost spontaDeoiisly, in the course of acute tran»- 
verse myelitis, Under these circnmstam-es the sacrum is tJie area 
most Beverely affected. Sometimes theae sloughs liave been known 
to develop as early as six hours after the beginning oS the attack. 
AwLooiated with the involvement of the .''oft tJsouea the bones may 
bri<ak down, and cellulitis about the re>Ttum and bladder phu<c the 
patient's life in immediate jiiijinrdy. In heniiph^ia, |uirtioiilnrIy in 
tfuit wliiiJi is due to w^reliiilhir hi'iiinprhagw, Itedson."* often form on 
tlie bnttonks, and in inrnplcgia, from other causes than tnimtverM' 



litU, upon tin- «»cnmi. Tlicv tt]m> upiH^mr on rln- Iiivl)'. iii^ide 
1^ Uk' IvDMi!, ami about ilic hips in sumc v(wt.-)t uf jiiiniplvgiH. 
SoddfiD sloughiug uf th^ »kiii of the- nntcs 8omrLinie« occunt in 
of iiitrucrnnial Iieiiiorrliage, :ui'[ is said by Joffroy to be POd- 
eted with Iciiiou of tlic occipital lobttK. 

The value of roseola and rupini eruptions in the diagnons of 

e)i)hiliH has already boon dwolt iijion. When the rueoola bocotues 

tmogformcd into slightly ele\'atod or bean-shaped spots, irregularly 

ficattorod, but sumetimos forming groups which are apt to bo oircn- 

^ysr, sod these circles become marginated and then scaly on the 

^edges, reirembling lepra or psimaais, or even go f urtlier than this and 

develop bnlli« and bleliH, and when the Jtores which form are filled 

with a clear liquid nhich may become sauioun or turbid and on 

drying leave crttntA, tho remo\id of whioli reveals deeply excavated 

^IfMi^Ii.t, the area of the slough often being an large an a t^ilver dollar, 

Bbut often irregular in outline, ^ypliilitie ru|>ia i.s probably the legion. 

Then- is, however, this im]MirtJitit <li(T< point, niinx-ly, tliat 

in s|Hi'ific riipin there is an tissentini feutnn;, n jwriplicnil ring of 

indtimtion, wh<trcaL> in tlie iion-«pccifiR form lhi« indtimtion itt 


V If, in adilition to tbc»c variations, tiio eruptions arc dusky red 
and leave liehiud them on healing cupper ish- looking discolonitiou 
of tlie skin, and upjieiir on areas, sueii as the tiexor surfaces, where 
ordinary skin eruptions are rarely seen, the diagnosis of s^'philis Li 
highly probable. If the eruption is chiefly tiilwivrulated and the 
tubentlc^ are large and more marked than usual, and if they ulcer- 
ate ai>d become «Ieep sores, an<l Rnnlly form on healing well-marked 
cicatrice^ tertiarj- syjihilis is U' bi- considered the probable caumi. 
H If, again, we And siiuill nodules under dusky red skin, which 
finally breaks down ami diseliargc.s bloody serum, or j>us M'hieh ju 
Imnxiwing forms discharging sinuse:^, syphilis of tlie tiiird stage 
■may Iw nf^rtled as a likely eauw. 

The »p|Hiir»iu-e of h:inl, dnrk-bruwn iufiltraUHl nn-as in the skin 
may Ix? du<r tu tin- exiviutive tiw of bromine, and an tliey giiKtnalty 
b«oomo depressed in the centre clotM.-Iy rwtcpible in some aufvs tlie 
oodulcs of nyphiltn. 

Tho i«kin of the abdominal walU in «we« of iwcitcs in apt tu be 
»t only thinner than normal, but len«i' awl slightly idiiny, while its 
p(Hiirnin-e when view<H| in ji irood light may be iflif^itly blue like 
Jir iri<lef(iciM.-c of eertiiin kind<tur gIlW4Wun>. 



SCAKs ov TiiK SKIN often give us mucl) ui^^ful infonnatjoa. 
Early tenitfiiiiicA to Htninm oi' Liilx-rr-ulosLi niny bt- faniKl ia tiie scars 
resulting from liiippiimtiiig oervii'sl ^IsncU. In tlic groin <mch 
Hcai^ may be an evidence of venereal infection, although it should 
be remMiibercc] tlint .'^n]i|>ui-nli<>n of these. (flantU usually takes p\&ee 
tkti a n»ulc of channroicLs anil not from tnic chanore. It has already 
bt>eii flhowi) tlint My|>liilitt<- Hkin k^iionH often leave wan to mark 
their >»{«, ti>ca.n njton tlio heiul ti'll m of potMihle injnriefi to the 
limin in HiW{ifcU-<] tnnnnatic qiilcfMy, or of falls in eiHlvpUcii. 
Siniilurly, utiivr traiinmtii^nu in the- history of tlie pnticnt may Ite 
diwwvercd by soirs clscwhi'vrc. 

Tho pn-mrncv of itiinicroiis ref^pilnrly arranged flnv Mnrx mi the 
chfMtt or elsewhere mny develop the fuet that the patient luut at Hunic 
timu bei-ti wct-euppcd for some pulmonary or other dis>.iB)te; or if tho 
ptx'tiltar tkrce-|H>int<.Hl Mtir of tho Itech is seen, another good e\'i- 
denee of :t bleeding ih presented. 

When the i^kin of the abdominal wall exhibits strin- or sfurs 
arrangetl in parallel series, it iudicuteH tliat it has beeu stretehed 
very eonsiderahly by ptvgiiuncy, ascites, or, more rarely, by e-vees- 
sive eorpiilonce. Sitmtrtimes these strise appear on the lower limlut 
in pittgnnnt women or in jK-r^ma willi droj»y. Very rarely thcjr 
may develop on the arms or legs or elsewhere during oonvnle^ 
eeneir from some grave disojwe, r*ne,h an typhoid fever. 

SwEATfNVi Of THK SKi.v, iwido ffoHi tlic iioniud and almo^ im- 
pcrtwptible exhalation of moisture, tnke^ ))lacc in heahh as a result 
of sevens musenlar exertion, wheri-by the periiilieml eiir-uialion k 
iiiereosiHl .-uid the botlily temiHrrtttun; ni!»ed, or when tlie body is 
very heavily elud or cx[k)m,h| to vxteriml hejit in exccm, In all 
th«ise ca*c» the itwenting in to be n^rded iw u pbysiologtml effort 
ou the pttrl of the iKkly lo reduec its temperature by inereo&ed eva|>- 
omtion from the surfatH,-. In disease Hweadng provides us with verj' 
important information in many conditions. 

During the eoiirne of fevers, whieh natumlly end by eriMa, itw 
occnrrenee of a profuse sweat (generally ai^aoeiated with a fall of 
tempetsture) gives us the first sign of beginning eonvaleswnee, im<l 
ill irritative fevers, or those due to cold and eougestion, the ariificiid 
pntductiou of a sweat is decidedly a good omen. The .-iweiil of 
crisui is perhaps most marked in ci-oii]>ous pneumonia. Frofiuc 
sweating is abo a characteristic symptom of relapsing fever, pyir- 
lutii, acute ulcerative endocarditis, phthisis, malarial fever of the 

M k. 



dUtinctly pi^riiMlic type, nnd of typlioid fevt-r zind <?olliipso. Cun- 
stont profuM! Bwuitio); is inarkixl iii Bonn- casus 4>f oeute nrticiilar 
rU-iimatkni, and it U worthy of note that while §weating generally 
oocurs in febrile diseases at a time when the teni]>erature is falling, 
in rheumatism the febrile movement may even increaae during the 
8Wiiit rather than decrease. 

Pntfase so-called colliquative sweabt often accar at night id debtl- 
itatMl jiersons wi£hoat the preitenct.* of any fehrite movement, and 
are »n evidence of profound nervotiii tind va^wniotor relaxatioii. 
Modemte sweating iuimottmeit is acen from ximil&r oanM« iu feeble 
jienonn after taking unytbing in the food or drink wbicb produeCit 
Nrcubitory or nervoiiN «'xi;it*rment. Lotali/t.'d ^wvaiings occur 
almott twicly in subjects of »«rvoiii> di»cn«o, whieli \* oftMi organic, 
u En paretic dtinifiilin. an<i •M>mctiim;» fnnctionni, a* in liyrteria 
or Rnynand'tt <)is<^'itfir. They dejK-nd upon (vcrvcrted vasomotor 
iDfliioncc« sunt to ihi- gliiniU and their supplying vcmhcIb iu |)nrtio- 
tilnr nrvuM. Locnlixi-d t^wwitin); of one side of the hoe or n^'k or 
clM>»t is often a must importunt sign of n thoracic aneiiririm pressing 
on tile eerviod sympatlietic. Ilromidrosis may occur in hysteria, 
w ihv \\iitA may be the only part affected in Graves's disease im<l 
in migraine. Profuse sweating of the hejiil of an infant wh«n 
Hh<eping may be indientive of rickets. 

In OOMS of the unemia of cholera or of renal di-ten^' th<-ro may 
bv profme Hweating, whii-li Inki-H the pliicc of tlic dry mid hot i*kin 
8Mn more oommouly in tliii< (i>iiilitii>ii. The surface of llie entire 
hotiy is U"imIIy involved in tlie iswwii. 

The i|niitity of the sweat varies greatly in many person*. Tn 
cnsc« of deficient renal activity it often contains urinary elements, 
inulls urinifcrons, uni] may even deposit particles on the ^iii in 
BRuUl white smJM, iinrtictilarly on the furehcnd and nose. This is 
ralluil iiridrusts. In jaundice the sweat may be bile-stainod. 

ExcBB8t\'i: imvNEHS OP TIIK8KIN IS Seen in gntve fomu of renal 
diflensL', in nearly all acute fevers witli a high lemperatuR>, am) in 
oholcru and diabeten, in which diseji«es the dryness is largely the 
n-AuU of tlie drainage of liqi]id§ from tlie body. 

.Sometimes after a prolonged dryness of the skin during high 
fnvor, as soon a§ sweating begins hundreds of little blisters develop, 
duo to retained sweat under the epidcrm. These are called miliaria 
or sudumina. 

When the skin is dry and lm»h, and the uaturally thickened jiot^ 


tions have in lhr>ir fftliln n |K<ou]Iar wliitc apju-aniin'i- tm if lillet) with 
meal, <liabeU'» tihoiiid be ^nu^lit fm-. litin^ly Uic |t}ivsid(iii miiy he 
deceived by pmfMae wwvatiiij: in diahcUr*. 

Dropsy and Swelling of the Skin. Swclliii^ of llir nkin and 
mtWiiUiiii»)ii>i tiwfHi-» iwcurs iiio*t frwjiicntly as ii rtwiilt nf (Impsv, in 
whirh ix>n(liti(in ihu Iy[ii[>h-«})acc8 bcoooic lillcil In* lii|iiiil. ThL- !>kiu 
In the tiraa involveil in not only itn'olloii but duut^hy, or if thfl effu- 
sion is vcn>' great tho skiu may be of almotit board-likv liardiiciw, 
KO tciiM^ly is it distended. Prcstiure with tJie tip of the Gnger npon 
such uu arcii will rusult in pitting;, and thi^ is one of the more !m- 
purtant signs sepnnitin;; dropsy ur true cedemn from the swetlint; of 
ueute inSnmnmttun, whieh, while it may he very tensL', doe^ not pit. 
Further, the swi-lUng of iDflammutioa la ususlly loi-alized, reddeoed, 
and feela hot to the touch, whereas the diH>pi4ieaI swelling is more 
diffuse, is pale, and ttie temperature of the i>art is lower lliaD 

When the effusion of litjiitd is limited to one portion of the bo<ly 
it is uHUally callod iwleraa or lotaili/tHi dropsy, wheny*:* if the entire 
body is boggy it is designated general aiiiL^in-a. Divjpsy is to I"? differ- 
eutiiited from niyxtt<<|i;ma by the fnet:* that in the hitter disen^ tlic 
on Bi;t is very slow, thi-ifwellingiloei* not pit on prcssnrc andisiiniver- 
wil and fairly eipiidly distributed over the body, thi- thyroid gland 
will oft«*n bo found diseased, the subcutaneous tissues arc nut boggt' 
but re^stant, and there is anfcsthe.sitt of tlio skin. When tlio snb- 
cutuueoiis tissues are distended by air, instead of liquid, they are 
even less resistant tian in dropsy, the swelling is usually very local- 
ized mid <loes not pit, and the part crackles or crepitates on g«itlo 

The presence of droptiv is indioative of many widely separated 
diwAsea. In the tirst plare, It may indicate a deficient eirvnlalion 
of blood, eitlier by reorton of a feeble or disea'ted heart or because 
of ob»truetion by the preiHure of growths, thrombi or emboli. 

It may lie due to disease of the walls of bluodvcsnel^ and lym- 
plintic.->, K* is genernlly the cnae in renal discane, or it may ari»e from 
diM.ta-'e of the blood it<«clf. Again, in some cmc* it is due to (lis- 
onlereil nervoui* eoutrol of the vessel*, by mumii of centric or 
penphcml changes which may be orgunic or functional. 

The signifieumy^' of a wi<lety <liffus04l general dnipey or (uosarca 
IS generally that there is well-marked renal disease, and this proba- 
bility is greatly strenj^thened if the oidema of the face be well 

TUE SKIX. 231 

1, parlicnlarlv In the morning on ariwing, liiwipjtearing as tfic 
BjgOM oil. Tlie skin in siieli i:a.4f!!i will usuallr be ijuitc pule, 
■nd AD examination nf the urine will reveni the jtreaenee of the 
sigD.s of iit;^|>liriti». Tli<! next tatmi oomnKin cause of general una- 
sarca nftvr rpiinl dt^ciuio in heart disea-ii'. When due to thi^ cause 
it will \w fonnil lluit the gliuHtly [tallur of renal aua-^ami Li replaced 
hy cymimiK, and oft«n hy engorgement uf some of the aupertiDial 

Ivt-iits, while the physical si^^n.'* nf nanlini; di.seiL'^e will eonfjrra the 
diti|rniisi». Genend luiaiarca m>iy rnri;ly arise iv« n rci^ult of a mul* 
tiplv iHTiphcntI n(Hiritii>, mid it til»u occitrx as a ityni|)toni of l>eri- 
U-ri and from th« «xee;i»iv<> use uf Inrp; anKiuriLs of uT»i'nii'. This 
arM-nioal afiiuarca may In* due to tho n<-)iritis prodinttl hy the drug, 
■ nltlionj^h Wood thinks it is due tu a oeltulitiK. Uurely wi^ tiiid gen* 
enti uttamrea in vnne^ of adviuicnl oatii'iToii'! eaehexin, and i-iire 
' mtiM he i-xorrised that the ha-mio murmur due to aniemin doi-!< not 
^m niiHluiul the plivHicinn into a diaffnosls of hoart diac&iw. 

Dropsy widely tliSii»ed or localised in the feet and IC|rt aleo oouura 
iu sourvy. 

The miKt eommon neat of loealixed dropsy or (edema U the feet 
and legs, particularly ab[>ut tJie in»te|). the ankles, and the tibtie, 

»When it is bilateral it is generally indicative of cardtae failure or 
more mroly of n;nal disease. Xearly nlwiiya, if it l>e renal, a care- 
ful examination will disi-over the iiHleniii in other parts of ttie Imdy, 
alllioiigh it may l)e m<»l marked in the fi^et nnd legs. In many 
eascii the various neniiis siww, »utrh a;! the jtcrimrdiiun, peritoneum, 
and plinine, will be found t^i eonuin more liijiiiil than nonnul, eind 
tlie li^Ufw geiH'mlly will lie foinul inlitlmUtl. 
Other ran»ie» of aideina of llie fei;t and h-^ are aniiMitta, aiid 

PobMtnictimi to tlie return of blood from the lower linibn by tvt\gon of 
(trowtiii in iho abdomen pn-^nin^ iipmi the iliar veinx or inferior 
vemt cava. Thiiit cancer of the jHinereiL^ troniutimut chumm <odetn» 
of tlie feet and iugs in thu manner. Very rarely todenia of lJi« 
lower extrcniiliefl follows hepatitis or eirrhosi« of the liver as a 
^_ primary symptom. Usually such leriions produce ascites alone, or 
^P if the legs arc involved ihcy bocx>me so by reason of the pressure ot 
the fluid in the pelvis during the time tliat the patient is sittinj; np 
or stamling. Ttiis latter eausc of bilateral tedcnui of tlie lowur 
linib't ipf. however, mre. Sometimes fetleina of both le^ and feet 
iconics on in persona who, tlimigh feeble and relaxetl, remain stand- 
ing witli little muacular movement during many hours in tlie par- 


silit uf llieir ocmiiuitioii, an in tygietietterii and i^alejimt^ii. In nth^^r 
iiislaiioE», very mticli nioro frei{ueiit1y, anleRui of ttie feet and hgs 
oomett on in the cnui-se of ]>mf(>uiirl aiiiKuia reHulting from i<low, 
hemnrrliiiiroF> or other miiM^. It i^ also i<eeii in tlie oncttei-tic stagt \ 
of gastrin (yin<*r, owiiii; to tlic nnicniid xrhii-li t!* jirrseiil. Gmenil 
Dwelling of n leg in n piierpi-nil womati ic [HN>bnIiIy due t«) plilcg- 
mtiNJii nihil (loU-tH, nnil thii< iifTt-ction miiy nlw he bilntitnil. Both 
Heniiiin nml Cutiieron KiiM liiivc eat'Ii it- purlvt) it cukc of bilnterul 
{ihlej^niasin itlbii Ooleii); ooeiimn); in ii vir);in witJi iiiiieiuiu. Wlivn 
it oooiu'ii in muk-it it is [uo«t commouly unilateral un<) ii i<»mpliaitiun 
of eonvniesconce In typhoid fover. It is du« to tJironiboeiB of tJie 
left femoral v«>in, as a rule. 

Wlien tlio fa«o i« <edenialotis the swelling is most market] under 
ttie eyt«, tlic lower Uds of whieli are psiticuhirly puffy iti the morn- 
ing and nearly normal lu ajipparanee at night. This form of u-ilema 
is most marked in, and ix almo>4i juithoguomonio of, renal diseatu!. ' 
Its only other uau§efl are the excessive taking of arsenic and angio- 
neurotic (edema. Mure alarm should be felt at a slight swclliug of 
the Eaoe of this charaoter tliait if the feet arc mnrkedly puffed. 
Sometimes cedematous hwoIHu^ of the side of the face and sralp 
whioh ha.'* been iiivolvwl in u severe alluek of neuralgia Inketi 

When iiHlemit of one or both eynlids occurs, with pr^)lru>iion of 
tlie eyeball, the swelling extending to the re»t of the f<ww iw time 
goex on, it formt^ ua important symptom in obscurv ctuws of su»- 
pcotod corebml tlirombo§is, and is caused by the intimate asMociatioa J 
between the intracninial vessels and those of tlie face, I 

Sometimes (edema of the eyelids comes on in neurotic subjects ' 
and may extend to the forehead. This may be seen in cliildreu, 
most commonly about puberty, and is probably the result of a 

Cinema of the np]H>r extremities alonfi only results from causes 
inti-rfering with the Jlow of blood, sueh a'*are produced by morliid 
growtli-i in the ch<Mt, an me<lia^tinal growths, and in ooites uf an«u- 
Tl»m. When tliu swelling h limited to one arm or leg it w » ttign 
that there i« inti^rference with tlie locml <'ircHliition, «», for example, 
the obstruetion of the femond vein by thrombus', us in phlegmiwin 
allui doIcuH following labor or enteric fever, or, when tlie unlema is 
in the left leg, by caneor of the »i|>muid flexuru. If llie ifwclling 
of the arm>i and head is mautfosted suddenly, it may be due to 

TBF SKry. 


thnt ran.- uoiiditioii in whii-li lui nortic iui«itrinni hipturM into tbe 
von« ravH; whttrcn.'^ if it <k>v«Io|)8 slowly, it ix <)uc to prr^^un- by 
B growtii. 

Theni remsin three fornix of local cmU-mn of t^omo (liugiiostic Hig- 
nilintim.-, tuinicly, tliat occiirrinn in ii liniitotl area uver some <Jc«])- 
sfati:*! DupptinitivL' proci-tie, ub in the skin buck of the ear in chscii 
of iniLstoid ab«ce^ or thromboeis of tbe lati-nil Kitiufrcs, that ovor 
tho ribs in cases of purulent exudation into the pleura, and tbut 
OD tbe tliigb in the deep muscular abscesses whicli sometimes follow 
typhoid fever. 

tlCdenui of tiie le^ and wrists sometimes complicates relapsing 
fex-er, and is evidence of profound feebleness, without necessarily 
indi<»l!ug renal or canliHc disease. Sueb a linjited oedema, or even 
gonernl anasarea, may occur during convalesoenoe from typhoid 
fever from similar <-aiiwft. Unletci tlii-t eHiision i^ nAsnciated with 
sigiu of )fmve n>iml or cardial mischief the prognasis, lurcnrding to 
I^mlel, i^ fnvomble. 

When tbe fkia i:* jwle and nrfi'ctt'd by an ntlematoid i*we1ling, 
with tbickfiiing, hardening, and low* of oliwtieily, particiiliirly nbout 
tbr fn<y, and al«o in tho trunk and extremities, and if tliis swelling, 
wbiH) rr»i.-mblc); redemx, faiU to pit on pressiire. the physician should 
nmembur Unit mrxietlcmu, or the vrctiaoid oedema of Gull, may be 
present. If in a<ldition to these signs there is a bslf-idiotjc or 
heavy expression of tbe facv, a slow and Inliored manner of speech, 
will) tiiivkened, clumsy fingers, tbe diitgnosis is made practically 
certuin. The brain in this disease perceives or )^rasps ideas veiy 
slowly, and all tlie functions of the body seem torjiiil. 

Tberv are several other diseases in whteh great thickening of the 
skin takes place, which cannot, however, lie confounded with myx- 
cedentB. In elepliautiasis there is a hypertrophy of akin and subcu- 
taneous tts.'4ues which is conlineil to some )uirtioiilar region of tlie 
IxmIv and arises from loeal cirrubtory diiilurtxiut'C in tin? blo<x) and 
lympb- vessels. Tbe skin is very bard, so that the leg, if n(Tcct«d, 
fiwb like ■ solid maw of wcnhI, The dlsraw nioftt cummnnly nfTcctn 
one of the legs, rarely both, nnd thr ^;n>tnm. In Ifotli myxntlenia 
and eIo|>haDtJnsis tbe ]iroc-<»w de\'Hopft very t«lowly, 

Wh>-n the skin in diribt] with irn-giilitr |iiifbi-4 or ntniikrt, which 
may be dcpre^wMl, eluyutt^-d, or tightly Hin-ttrhed, or if thi- ciitiro 
»kln is thickvitwl, oovoreil with thin si-nli-o, or puitHCM<e« a plasti^r- 
likv nppmrancK!, tho jib>'4ieiaii should rcuugniu tliojto Hyiuptomn bi> 


iDdiuktive of scleroderniii. If in atldilioii to these signs tbi-re is a 
flectiuB pitting of the skin oo pressure, ami it «anuot bt- pttichin] 
into :i fold, the dia^no!ti» ia eonfirmed. Sometimes the skin in 
wieroderma seems liound down by tense cords or bands of rrtnictwl 
connective tiasiie. 

If diii-in]; the first months of life tlie skin of au infant heonraes 
cedematou3, hard, ten^te, and glossy, varying in color from a white 
to a reddish or dirty yellowish-brown, and if this rapidly involves 
the entire siirfnoe so that the integument l»eoomes «>ol, immovable, 
and resistant, tlic child apjiearing ai* if fnixen into stiffness, it is 
probably ^"nlTering from solei'oriia neonatorum, a disease entirely 
different from the scleroderma of the adult. As a nile, death 
^iieedily ensues; but iK^fora thi« take pla<re the parts first affected 
become thin and Io»c thuir swelling and may develop eyaiiot^is uim] 

The affection jii»t d«seribe<l i« to be sepunited from nxleinii tt«oiui- 
tonim,a, oonditiiiri arising in pn-mntnrely born children. Within 
n few d»y» after birth (here iis discwverml u pallid, eold eoiiditiou of 
tlio butlxK'k», thiglis, legs, and iirm<i. The |Hirt« spi^edily becoiuo 
cedemutoUH and livid blue. Finally tlic (edema may bceume very 
marked and the skin tense in eonseqiiencc. Intense drowsiness is a 
ehiiraeteristic of the disease. Death oommonly endues, but recovery 
may oocnr. While the color of the skin may be identical in <^ema 
neonatorum and s(;lercnia neonatornni, the former afteetion lacks the 
stiffness of the jaws and other joints, and the pitting on pressure is 
marked. As scleroderma does not occur before the first year it can 
be excluded from the diagnosis. 

Very cla'«ely allied in its causes and appearance vitli urticaria of 
the severe type is angioneurotic oedema. In tliis uondition there 
appear ujmn the skin numeroas patches or pla^pK^ of circnmscrilicd 
puffy swellings, which have a rnl ap|>eaninw and vary from tlte MM) 
of a nickel to a silver dollar or larger. There is an absence of iteli- 
ing, an imixirbint difference from true iirtimriti, hut the |Mirl affected 
may In; tense or hot to the patient. These atttiekn arc genemlly 
recurrcDl, and take ])hic« in neurotic pi'r»onH. They may cause loss 
of sight through swelling of the eyelids and, where the muoous 
nienibmneM of the pharynx and larynx are involved, )H.'rious inter- 
ference with breutiiiug. The swelling of angioneurotic cedema 
does not pit, and it is to be sepnntted fix>m the blue oedema ai>d 
white wdeina of hysteria. True angioneurotic tedema is rare in 

Iijfrteriii, and il 1<Huilizv<] swolUiig» do rosiilt from tliis oondition the 
pbmouin will ^i^ncrally Sd*) marked bystcriml ^i^uh mnniF<!)it«d, 
Hiurli SM, (li»onkT§ of M-nimtioii or Undc-niivs over tliu ovaru-H. 

Tbp ocolur uppouniiice and toucli of tlm skin having hcea 
sttMlinl in so fi:ir Iu^ ite surface affords evidence! of tnorv deeply 
wutetl dtireaso or fuDctionnl diHtiirbance, w« nest pa»- to s 
study at its sensibilily, having the eanie diagnostic objects in 

8«aaation in the Skin. Before ooiiaidering tlie \'arioua jierver- 
siouii of ita sense it Li imjKirtADt to remeuil)er that the sensibility of 
the akin may lie divided into four jiartfi, namely, its tartile sense, 
ili4 [xtin !«!iLse, its ilicrmic spn.^, and its seiisi? of pressure. .\uy 
one of these ttenses may be ]>ervertfH) or iu iibeyatice without the 
others b«ng afFci^ed in a l^iulilar manner, and it is noteworthy tliat 
while corresponding smuts of the »Icin in all individuals have prao- 
timlly identJcnl sensibilities, <'«cli jmrt of tint Mi\ iw.-- u tM.nisjtiven<»8 
of its own, so that while in >>oni(> ])nrts the slight>>Dt timiih is felt, in 
other* seven- irritation niiirt be pix>ditce<l to auisi! inu<'li of a rostilt. 
These <liff<rrcnre.-( have been iiirc-fully »tndie<l by many olwprvcrs, 
tile moMt thoroitgli licinj; >Vobcr, who has found that the avertiKC 
ability to turpanito points brmight in contact with the skin 'in about 
as follows: at the fingeMipH puintti eiin be st'[inrat<^tl ut from 2 
to D millimetres, on the lips 4 to <> millimetres, on the tip of tJic 
noM' 6 millimetres, on the cheeks and backs of lingers 12 millimetres, 
and on tlic forehead 22 millimetres. The skin on the neck separates 
points at .'U millimetres; thai on the forearm, on the lower leg, and 
baek of foot at 4ll millimetres; on the chest at i^ millimetres, on tlie 
back at Git millimetres, and on tlie arm and thigh iit To millimetres. 
If tests be frequently repeated in a single individual, the ability to 
separate the points increases with training, f'jire should always be 
taken that the pressure on iioth points is e<{iial, applied simulta- 
neously, and that the {Kiints are ixjuidty sharp. 

In testing taetile sensibility, not only sliould point* be nsed, but 
also objeotit. Often sinirlc points may be applie<l wi(lH)ut any 
abnormnl nianife-'iljition, iiiid. In :*i>nK^ ciiik;^ of dE»<4se, the skin, 
which seenLs devoid of senMi? on ordinary touch, is found to bo exccs- 
eiwly hy|MTic>rbetic if tlif haml iw dniwn lightly over it. 

The b<i>t appuratuit for li.'Kting tactile M-imbilily in the ivsthftoi- 
»mot«r of OuTolI, which is n pair of double-pointetl compoasce con- 
necU>(] by a giwluate<] scale. (Fig. 08,) 


The ability to distinguish pain^iving and thermal applications 
IS most acute in the normal skin of the hands, in which tactile sense 
is also most acute. 

Fig. 98. 

Cnrroll'a (tsltacelometer. 

The methods by which we test the pain sense are several, but 
chiefly by pricking tlic skin, more or loss deeply, with some sharj*- 
pointcd iDStrunicnt, such as a pin, or liy pinching the integu- 
ment. The thermal sense h studied by applying bodies which are 
hot or culd against the skin, suc-h as a cold knife, a small piece 
of ice, or a test^twbe which contains very cold or hot water. I» 
all such tests the physician should use both hands simultaneously. 
With one he sliould apply his instrument to the suspected area, 
and with the other a similar instrnment to an area known ti> be 
healthy, in order that an actual corajMirison as to the sensations 
may he noted by the patient. Thus the face may be used as the 
normal area in a spinal losiou, and tlie skin of the arms as a control- 
surface in a lesion involving the legs. The eyes of the patient 
should be blindfolded, and if tactile sense is being tested the instni- 
mcut must be of the same temperature as tlie body. 

Disturbances in the sensation of tlic skin may arise from func- 
tional iir oi^.mic disease involving the peripheral nerves, the sen- 
sory tracts in the spinal cord, similar tracts in tlie lower part of the 
brain, and, tinally, the subcortical or cortical parts of the cerebrum 

The sensory patliway or tlic afferent fibres pass upward, starting 
with the jxTiphcnd seuse-oi^n in the skin, or elsewhere, and after 
forniiuff pari ui tlie ncrvt'-lnmk and entering the ganglion on the 
posterior rout, enter the spinal cord by what is railed the (wsterior 



mot, whw-h 19 ghoun in the Gpuro near tin- worJs " Lisesucr's 
zone." (See Figs. St* and 100.) 

Tlw posterior root enters tli« winl in tlircf sotn of Itbnw; one of 
these, the one lyiog nearest the iwstorior tnciliiiu fissiin-. is composed 
of «oar»c llbreAund U railed ihe mediuii bundto, and passes obliquely 
into the lateral part of tJie column of Burdacb. 

FlO. 9». 

DliinDi Ol IM raUUou <tr Lbo nerra-nKrc* tn iba ipdial coKl. A. AnMrior root; 9, pcatarfor 
toM; I), naiorpMt; K, MuarT pan i F. mlicd nirro- (BDiMinLj 

Some i.if thosf fibn.* uI»o ^-nt'T tlic oolniim of Ciotl. An won as 
tliey have cutcrctl thiH oilumn they tiiru at right iiii);li*f* and run 
upward for sumo distuiKw, tliercbv helping to form the column of 
Biinbich, Some of tlieni also nm dowiin-nrd a nhort dietuni.'e. 

Tim st-cond M.-t, n<.-Hr the side of tlic <ronl, goes directly into the 
gray matter of tlie pu§terior lioru through tho substAnco of Rotaado, 
and llie third set, nearest the side of the cord, enters the cord ver^' 
sujH-rficiidly, and, tjiniing at once at a right nngle, goes upvrard to 
form Lissnncr's zone. The longiitudinal course of these fibn» is 
shown in Plata VI. Here It is seen that they jtass upward chiefly 
ill tJie column of (ioll (|H>8terior median) to the medulla oblongata. 
Bi'forp rracbiog tlie medulla, however, the ooliimn of tioll endtt in 
the ^nutile nucleus and the column of nurdach in the cupeatc 

These anclei which have received the Kbres of tlie two »oitsory 
columns give origin to fibres which paea to the brain. They sweep 
forwartl to tlie front of the central canal of tlie medulla and <]<<<ni8- 



sate at a higher level than the motor ^tmct8. A great majority of 
these fibres pass upward to the brain, but some pass forward, and 

Fig. 100. 

^LMwfwfr'a sone or 
jitt't-margiuat tone. 

---'-AHhriiir i-ooli. 

Cbirt allow lii^ the svuwry IravLi lii tliu sjiinal oonl nilli entrance of the seusorj neive-rootl. 

TBK SKiy. 


L'AiMlly jiiio tliR nwtifonn body oa t\w ])iiAt<^rii>r a.><[M«t ot the intiliitla. 

'Those ffliicfa piuw Hpw»rd from div »u-i'iilU'<) fillet pa«« into tin; orun 
cerebri, io Uuit p»rt of it called tlic tiyiiR'iitiitii, niid ttivitra into 
ihu puHterior pnrt of tin- [lo^UTior lunli of tliv iiiu-nitti iiipmile, 
whvncc (Ikv spread out in tliv coroii:i i'u<tiut» to tliv occipitul lolic 
and tcmpor(>-«plK-noi(iiil lubiw. 

The duty of the physicinn in all cases is to delermini* first wlietJier 
the <li8ea6e is Functional or organic, aud tbea wherv the lesion pro- 
dacing thv Kyniptoms is situated. 

The two fhi«f manifestations of perverted sensibility in the skin 
are aiiirsthesia and hypenesthesia, and the minor ones are [tarces- 
theiia or numbness, tingling and forraicration, and analgesia, or the 
failure to feel pain. Whatever tlie isiiuie nf these symptoms may 
be, the liislory of the patient and his general .tymptoms should he 
OBTefuUy studied when examining these sign^, a^ frequently a dlag- 
noiiis is impossible with them alone as guides. 

Aasesthesia. .-\ mtiHtbi^ia of tlic skin is indioative of s \'ery 
Urge number of oonditiotts nriiiing anywhere in the scnM>ry apjia- 
latu-s In other words, unythinj!; which interfn-es witli the trans* 
missiou of an impulse to the |)i.'n-cptivceentn.-!( in the briiiu may be 
it« cautte. Of (he functionnl vunses, the mo«t frequent is hysteria, 
and the preeonee of cutaneous anicsthesin in a female i^hould 
nlways arou^ a suspidon of iti> being due to Lliis cause, llarely 
it is seen in hystericail males. The organic causes of amesthcMa 
of the skin are cerebnd hemorrhage, cerebral tumor, hemorrlmge 
Id the poos or tumor of the jjoub, hemorrhage in the cord, tumor of 
the cord, myelitis (transverse), locomotor ataxia, cerebro-spinal men- 
ti^tis, spinal meningitis; cctmpreasion of the cord by vertebral 
cartes, by fractures, by dish>cations; and hemorrhage into its mem- 
branes. Additional cfiusis are pressure on the jmsterior nerve- 
root» by reason of cariee and growtJut, inflammation of the nerves 
(neuritis), injuries to the nerves by blows, pressure, or cutting, 
Iwid, finally, by |>anily»is of the nerve-emlitigs from ty>M or tJie 
)toUon of drugs. 

Ann«tJiiMiii, iK-Pording to its *n& nf <Ii-ttributiiin, may be divided 
into heinianiMthe«ia, cmMM^l aituMtlK^iiii, bilatvnkl niiicHtbcsiu, irreg- 
ular but ocHnp1«ti; uniMtlieMtt, and jHirtinl nni(«tlif>«iii. 

HKMtA.v.F'.s'rit»:si.v occurs niomt firxpicntly ae a result of hyttwrin, 
Ui>xt eoinniiMily from Imion of the |Mstenur part of the intenul 

240 rj/fi iiAyiFicsTATioy of diskasj; ix onoAXS. 

capsule, niid lunn; rart-ly from spinal injuries or gpjwtli.t in tli« •.'ord 
of a miilatcml (•imracttT. 

Tlio )ie]nianii,'!tllic!<i» of hy.->t«ria iin'oK'i«, m tto tutmv tfn|>liti>, 
oite side of tlti^ tmdy, mid h luiinlly uiiiwrMil on Unit side, cxcrpt 
thai hi-n- nnd tUvm iiiity lie putvln-s of liy[x;m-.stlio»iu or iviidcniuM, 
dotted like otucd in the midst of tliu Rii«MK>v of »trnmtion. This 
ftiiiDsthi-xiii i» ofti'ii uiiitccuru[tau !<.■(] by motor |i:inilyH(i^, ,ii)d it« an-a 
IK separattil front iht^ uppi>&itv tiitk- of ihi- buily liy u sliurji liutt of 
demurcstioD, whioh runs aluD); the middle of the trunk and face. 
Th« ppesenco of such a well-dcfiin-tl line of i^psinttioii in a young 
woman is of great eigniScance. Tlie ant^lheaia la generally 
absolute, and severe injury may be clone to tlie ttkin in aome oase-s 
without tlie patient feeling it; but, notwithstanding its intensity, it 
is a noteworthy fact tliat the nnseatbesia may transfer itself to tlie 
opposite aide of the body with great suddeiineiia, and equally nad- 
denly return to its former tiite. In a-great majority of cnse^ for t«mi« 
unexplained reason, tJie left side is the ouo affvctctl by imH^Athi-sia, 
and hyjipiiesthesia of the opposite »ide incrcnws t]i« cotitniMl whicli 
exiAttt between it and thai tii whioh «»UMition U lost. (Sec Hy]wrw-»- 
tliesin.) In some i-am'-n of hyi^terictil hcmiauii-stlM'Kia tlie [Mimlyi^is 
of si-UHittion involvvs the nerves of special sense, and loss of limell, 
tust4.', and hearing, and impuirmont of sight may ensue on the same 
side. The visual changes arc so cbaravterislic that tliey prat^tit-ally 
dfjcide the cliaracter of the case when they are discovei'etl in anv 
instance of doubtful diagnosis; tliey consist in a Ifiss of the eolor- 
vision (first, violet is lost, then blue, and then red), and there is n 
l^reat limitation of the visual field, whereas in tlie hominuirstlic^ia 
due to an oi^nio leaion in the internal <»|isule, 30 .situated iiti lo 
involve the nerve-fibres oimneeted with vii^iou, tlicre 'ii< hemiopia. 
Hemiinio|M4ia due lo hyt<tcriA in *" niri^ ilb lo Iw denied an vxiat-j 
cncc by mo^l atitli<iritia'<, but Moyd niid de Schwcinitz have nutt 
a CAM. (ieiiiTHlly tho losa of vi.sion on the unie«thvtic itide is a 
total oiw for both sitle^ of tlio eye in hyt^terii'iil blindneiM. (8«o 
chapter on Eyv.) Ncnrly always in hysteriral lK'niianHi<tliMia a 
»pot urn be found over the shoulder which iit not aniesthvttc 
The ago of the )Hitient. Iier sex, th«! geneml expr<-ssion of tlie face,, 
and the history of her illness, iiswciutcii, as Is freipicntly the t^use,^ 
with some, or all, of the hysterical symptoms dt-tailcd furtht^r on 
in ttiis chapter, will gttiierully dooide the diagnosis in favor of 

TBB SKty. 


A form uf liysti-nuil hemiiiii(e^tli<.'siii wry apt to Imil to an crrur 
in ciiagtKMiis is thnt uvea \a per^xis uha hiive suffen-d from iufnntiie 
cerebral panilyiuii witli the resulting dL-furmity (a dispose not diar- 
scterizcd wiUi seusory dUturbancee), but who have in later lif«, 
Riiporim posed ui^tn the old picture of disease, tliat of bystcria with 
tliU 9en»>ry manifestation. 

Aoieiithesia irregular in its ilistributiou, or absolute heniianies- 
tlieaia, may tJCflur in tlie cfiarjto of dioi-e-a. The presence of chorea 
in i\» motor manifencationa olearii up the diagnosis as to the cau»ie of 
the losa of Aensalion. 

I lemiamcittheflia when not hysterical Is nearly alway.s due to an 
ur^nie Wion in the jia-^terior [tarl of the iiinder limb of llie internal 
capnuh- on tiv: oppiMile .sid<^ of the bniiii fnim the aiiiesthatia, and 
tlw lulditiotial nymptoniH winch Miinetinir^ iLcconipany it de|>en(l for 
tht'ir 4!xint(niii! ii|)oii wliHlicr Uk^ legion is large enough to involve, 
not only the tlhrcH fmni the cutuneou» Hn-JL>, hut aUo tJiose of i^peotal 
Hcnsc, Bitdi as night, lniariiig, or lastc Ni>arly al'n-aya the area 
ili!)>tn>yod i» xufTiciciitly large to n-^iill not only in h<.'niiniiie^tho'<ta, 
hut aUo Ions of niociiiii on the saim? »idc-. Tin.* \i>!<!^ of sensation in 
euoh u vunc in mrcly ati eorn|>lvti> od in hyMoria, aud the m\c of the 
footand palm of the hand a ro often nut affected. In nirc iustuncvo, 
bovrever, the hemianaKthet-ia of c^^ipsular diiMjaML' may be absolute 
and univenuil, or, more rarely still, occur tn patehc», thereby eloeely 
reecmbliu); the auiu^thettc areas seen in hy^^teriu. 

HemiimK-:«the»ia may also be produced by a large Wion of the 
«OTtex in the occipital, temjmral, and parietal lobes, in which ease it 
wilt involve tlic side of the head as vvell as tile trunk, and will be 
aseociiited with such delinite evidences of apoplexy or injury that 
the diagnosis will be readily made. If it is widespread, all thv 
special scuses will be involved. 

Senaory dLsturbaares of tlio skin are more fre<iuent in softening 
of tlie bniiu than in hemorrliage into the brain, and most commooly 
are assodatcd witli subcortical, rather than cortical lesions. 

Id this connection it should be renioinl)eii?d that the irregularity 
of distribution of tlie leMonn in dirtni-minated siderosis may cause a 
liemianinstJiesia, jianiai or coRiplele. 

Anawthesia renulling from tnmor of the brain ocenrs in aWit 20 
per cent, of the easi-.'4, and may be unilateral and <nintiued to (h« 
iralvMid side, or ajiprar na an isolated ityniptom without motor 
fsifi. When of the latter form it t» often associated with 


lv<noi)8 ill tW Di'igliborLood of the fissure uf Rolando, attd in 
ttirnun iDvolving th« posterior ]jarietal regiou and the jioeierior 
port of tli» internal capsule, 

Antopidies and (.■x|>erinient8 bHow that hemiameftthesia may arise 
fruni a leeion in the optic thalamoa, but such an oocum-noe is very 

A ver^ important and ea^ntia! factor in making the diagnoHia 
that the anresthesia is eei-el>ral in origin is (he history of the begin-, 
niiig of the attack, which lias been rtndJeu if due to Iicuiorrhage^ J 
embolus, or thrombiia (see Hemiplegia), and ohameleristie of the] 
condition wliii^h we call ajmplexy. 

Unilateral anwfttheiiia afuoeiati^ with motor [wmlytits, botli lidng 
somewhat irregular in tlieir dii«trihution, may be diiu to a Wiou, 1 
9uoh a» a tumor in the jions or mediilln ohlongatN, but doflth so cvmi- 
moiily endues aoon after the apoplexy that the »yiii])t()ii) is often 
overlooked or cannot Iw develo]>ed. Furtlier, tin- discovery of such 
auii!:<lhe«La does not jiositively IocuHki.- th« lesion in the pons, for we 
do not know much alx>ut the oours« of the «;n*ory Bbri'M in tliis 
part. If, however, the «re«supplie<l by the trifacial nerve, namely, 
the fuce, is nuoisthetie, and these symptoms aro uasociatod with it, 
then it is fair to assume tJiat the trouble lies in tht! pons and has 
involveil the nucleus of the fifth nerve. (See Anesthesia of Face,) 

AntGetliesiA of irregular distrilMitiou or fwnfined to one limb may 
result from eerebml or spinal lesions, or be due to a neuritis, of 
which we shiill sjwak furllier on. If it is a mom>-anwsthe8ia from 
eerebral disease, which is very rare, the umesthesla ie most marked 
at the distal part, and gradually fiiJes off as ilie trunk is approachnl. 
(t i.s evenly distributed, so far as oircumfereucc is coneemed, and 
hai« no tOiarp line of demarcation. 

When such an anfeslhesia is due to spinal disease the cause may 
be tumor of the spinal C4>rd, the symptoms depending in their char- 
acter on the area in%*olved; but in any event the upper border of 
the area involved is sJiarply outlined and a constriction-band sensa- 
tion i* often jiresent. 

Tlio irregularly distributed form of aniesthosia due to fa\'steria 
has iJic same genend jieculiarities of migration aa are .seen in heroi- 
annsthcMin from tliis cause, and in its symmetrical form it clottely 
neembles the anie.sthc.'^iB clue to niuliiple nenritui. Thus, in the 
hjiDd ttie area of amei'thi^ia may be that eovered by ii gauntlet 
glove, ID the fool that covered ordinarily by a sock, the line of 



nonu»l seiLsiition bt'iiig prcireiit junt iibove Uie place to which these 
prcil«:tioDs usually cxtcml. 

(_'ii<M.sEi> AN.(>rriiK-stA. WhoD H^nwiry iiuralysia of one side, 
Msoeiated with piirtlnl paralysis uf motion or paresis ou the name 
si<l«, comes <m, and with it tlii-re U hypenemia of the skin on that 
side from vasomotor paralyais, there is a strong prohability that 
^ere is a lesion in die cerebral peduncle of the oppaiite )u<lc. If 
there is at the same time jiaralysift of the muscles supplied by the 
oculomotor nerve on the opposite nide from the aiiae-itheiiia — -that !», 
OD (he^inesideaA the lesion, this diajinoiiisUfltill fitrth«rei>nfirracd; 
and if the tongue and half of the ftioc on the anteiithctii; ^idc of the 
bo<ly an; paralyzed, tilill further confirniatury evidcntn^ uf a pediin- 
cuWv IcMon ii4 obtained. Thus there niitfhl be heminnwathe^ia and 
piinilysit of the right side of the body, including tlie faee and right 
half of longiie, and ptosis, from otiuloniotor pal:«y, on the left ["ide 
of the fiMX!. Thi! pantlysin of the ImhIv, faw, and tongue would be 
on the nidc oppo^te to the lesion, but the twiilonuhtor paralysis would 
bo oo the Himc nide ok the h-sion. 

Crmiwl anKHthc^iia of ttie linibii and faoe — that ir, aua'sthenfia of 
one ride of the body with ani^«tti(sin of the opposite Mide of the 
hoe — can only ow-iir iu le^'ions involving the upjKT piirt of the pon« 
in such a way that the tihre* of the trifaeial are diseuM-*! on one 
aide, and the jiath for tteuHory impulsnt of the otlior side of the body 
is also destroyed. (Soe ehuptere on Face and Head, luid on Hemi- 

An important point to be noted in the diagnosis of ix-rebnil autcs- 
tbesia is the faet that tlie reflexe« are pn.-?*CTVed, tliough the {wtiont 
may not feel the touch or painful impn^'ssion; that is to niv, irrita- 
tion of tile skin causes movement in the arm or leg, not by any 
intention of the patient, but owing to tlie faet that the »en>ory cen- 
tres iu tl>e cord receiving an impuli^- cuuix! the eorreepondiog motor 
centres to send out iraput>'e!^ which contnittt tlie muwics. 

Partial bemiantesthesia, with partial hemiplegia on the opposite 
fide iu ciTissetl jiaralysis, may occur frotn Ic^ionv on onv side of the 
spimd voni, and. if high up, involve a large ]iiirt of the trunk and 
lower limbu, (Sec chapter ou Fwt and Legv, part on Myelitis.) 
These eeaes have been ex]ilaiued by a theory of Rrown-S^iqnaid, 
whMl has recently been doubted owing to the *>tiKlie<: of Mott 
and others. Thus, until recently, it was eoni-idercd a» provt-d that 
Kensory impulses enterittg the oord crOH-u^^l to tin* opposite side 



almost at once, at least in great«r jKirt, |Kmei«g tn the lateml col- 
utnus in front of the pyraniiJa) tract, and tliat a vciy snuill number 
entered the posterior ooluniiiit, while a few ascended in tiie gray 
matter. The recent studies of >Iott, in confirmation and oriticiaia 
of atill other invert I igators, seem to prove that the reverse U the case, 
and that the greater pari of the sensorj* impulses do not (-ross the 
oord, only a few litres jiofising to the opposite side on entrance. 
He believes that ihe main )>alliway for heat and cold sensatlonit in 
in the ^ray matter, while tiie tactile pathways are in the imsterior 
columns, althotigli it i» jiossible that some few isolated fibrils nia^ 
exist in the latoral eolnmns and that these cross in the cord about 
tlie level of entrance. 

Bii.ATKRAr, A.v.i^»TKi'»iA. Antesthesia of hy.'tteriml orifrjo in- 
volving both le^ and sometimes the tower part of the trunk on 
both j^idi.!*, may ouour, and, iisiile from the typiittl i*ig»9 of hy^ilem 
in ^neral which diHliiiguish it, may be disnovi>rcrl by the faet that 
in hy^t4-r!n tlxr failure of si>n.'<itioit diKv* not involve tlic ^V\i\ of the 
genitnla. an it doi-.i in oi^uiiii- legions produeiiij^ somewhat similar 
symptoniH. (n addition it will lie found tlmt in hysteria a V-shaped 
piece of skin over the wicrum is not anitstlietie. AnieHtheiua of this 
variety, eorrt>Di>ouding in the OL-n»urv' orgnnn to what we call jiara- 
plegia in the motur apparatus, id pmctically never produced by a 
oerebi-al lesion, and, it not hysterieal in cause, must he spinalj but 
it is much more rare tlian is motor paralysis in these pariA fmm 
lesions in the spine, Wlien it dues ensue from spinal causes motor 
](aral\'sis will in the great majority of cases be found aasociated with 
it at least to some extent. To express it eoucisely, the diaraeteriftic 
of a typical spinal aniesthesia is that it is bilateral and unually 
involves botli sides quite symmetrically; that motor ]uimly»is Is 
generally associated with it; that the reflexes are gn^tly perverted; 
and lliat tn>phie trbanges may be present as a result of an involve- 
ment of the trophie oelLs in the anterior cornua coineidently with 
the disease of the sensory parts of the oord. 

The diseased condition.^ of the oord which result in synimetrieal 
aoaMthesia of the skin of the legs and trunk are, Br^t aiu) must 
prominent, locomotor ataxia ; iteennd, myelitis; and, finally, hcmor- 
rhagt-*, tumor of the cord or itA membmues, moningitin, or injuries 
which cati^e pri';<.'*iire on the sensory tracts by producing fracture of 
the vcrtebne or disloeation. Very rarely, luiwcx-cr, a IvsioD of tlie 
puHK may ho r^wnit. 




Lnn^sthe^iii of the Inwer [mrtioiH of ttio IkkIv mid legs ort-iirs in 
lh« later I'tagc^Mf liK»nioI>ir.itAxia, luul in ii>uiiUv pnH'C'ltHl by forms 
of ]mr;i-Titlteiin. {Sw Par(e«lhL>sitt. > Thi; aun^tliftln nmw ftre moot 
market) in tti<> !<it\c* of the fiv-t iiiid alKiiit tliu miillt^oli, according to 
Belmont. In othi*r wunlH, blnntinj; of iu-iiMhility tit m;mi in nearly 
all rasftt of I«i>o» dorwili* lute in tin? disi-jwo. In wnw imwos lh»« 
teme of tou«h i* prtsterviA und tJic KOmti; of puin lo»t (nnnlgcitia), 
wliil<> in ollicm the opp(i»ite condition i» j>rei§cnt. Attain, we And 
]o»i of Uietilc scnfH.> and of pain-aenw without loi<« of heiil und euld 
SCUM, and vict rerwi. A very ehanictcristic sensory symptom of 
tabca is tliu delay in the recognition of an irritation of the sensory 
oervcK, eo thnt if the pnticnt be blindfolded and then pricked with 
■ |>in hi> will not make au cxclumatiou or draw hi^ fool awny for 
iVwnil secoudH. In other instiinccH the (latient complains of re- 
) pricks when only one has been fpven, or when aske<l llic 
numlier of pointx pricking him, states that there arc four or fivo 
in^teail of the one milly present. If, in addition to these scntKtry 
di»turbanc«(i, wo find Itombcrg's eymplom (see Legs), Argyll-Kob- 
ert«m pupiU^soe Eye), and loas of patellar teflox (see Reflexes), aod 
a number of other dia^io^tic peculiarities of tabee, the decision as 
to the i^u.-w of the aniciitlieHia h easily made. 

Slight amt^tlienia, rptar<lation of the tmnsmiHr^ion of ^nsor)' im- 
pul'ia* from the i^kin, and |K-rvenion of tcmj)eratnre>Aense may be 
rarely dvvelo|M>d lati: in the conr^ of Kncdreich'ti ataxia. 

Bilateral aine^thesia of the rhanicl«r jnst diiti<u.«*<-d, an eau^ted by 
locomotor ataxia, may nl«) occur •» a result of aeute or chronio 
myelilui. Tlie fir4t ohange under thttitt einMtmstam-eH i^ a more 
olitiiixlingiif itttniiitivene^'', which gr»thiullydi^v|>)-iin till li>uof jrain- 
Beiiw, |)n>«.*ur(H«;n»(', and, Iiwtly,eompK*tc anie^thfHii) in develojK-d, 
Tlic developnivnt of th«^iu; riymptoiiut in<lieat4i> involvement of the 
poAturior oolunms. L'lw of reflex activity in the legs i> (leveloped 
in <lirect ppjportion ft the d««inintioa of tlie motor and iu^nsory 
nerve-Inu't" in the eonl. The pn^hMiiinnnci' of motor [tamlytii^ the 
(ai't that the lower limlM* urv* Ixith involvi-d, un<l llie absence of the 
i:luinirt«ri8tiu nyniptoniH of looomotor ntitxiii nil tend to make the 
diagntMiN nirtnin, while the »b««-niic of Ilic pains of l«l>e» and of tlie 
otlier signi* of tliat diM-AMc Mtill further vxcln<les itt pre.»euo(- from tike 
cue. Further titan thi-i, tlic niyctitis crcviw up the oord, involving 
Anas, oi^l t*^"^" luiM of the skin beoooM otueirtlietic. An im- 
porUDt [wiitt, loo, in rv^inl to the ntumthcHn of acute myelitic is 


thtfl, namely, that while in tho upper rxtremitien the Icku of !«iii<ation 
and rantioD is uHsoniated, ho that Ixith fuurtionA are lo»t in tJie inami* 
area, in the lower extremitiox these two fiinctionii sro not lcK<t in the 
wme an-as. TIiih myelitis of the liimlmr enlargement in ilx lnwi-r 
part is am()ni|iiiiiit>il hy ante-itlK-Hin of tho gltitotl urt-a and motor 
]uiraly»tiA of the anal muscles; and, again, anii>MlK>si» of the gluteal 
region, the iHK^k of the thigh, nnd the ImcIc of the ailf k iiiuH)ctntMl 
with los* of power in the inns<^k->i thiu move the foot, while in lesiuns 
of tlip upi>er ptirt of tim Itiinlxir Hiegmcnt the nntcHthe«in involves the 
thigh, tin- inner side of the leg, und tlie foot, in nssonution with 
pnmlvjiiM of the (jiindriiie|w extensor and deepi^r tnueeleii of the tliigh. 
(See ehiiptiir on Keet and Legs, jwirt on Myelitic.) 

M-. 101 


B3 3^"^"'* Anaitattla, ami artu In nblch Ihv |«ll«nt't aniwtr lo tnb of Inuiwnlur* 
■Iwwad nrtnal 

IC'Mllat; (Doicni.t 

The development nf sudden bilaterul uaicsthiwiu, which ii^ acci>ni> 
jianied by severe gtainx of a tearing or burning churactvr, eroepiu^ 
rapidly iip the body, is indicative of aeute hetnorrhiige into the 
spinal nienibnmes, or it may be dne to tliat very rare lesion, hemor- 
rhage in the eord. In either case motor paralysi'i is present. Anws- 

ThB SKiy. 


thesiii, iir thi' milder pervereiuDS of ourmul sunsibility uf Uk- i^kio, 
muv lie presietit in cases of compression of tlic conl by utricM, uud 
by spinit] curt-ature, tumors, or aoeurisms produciDg «rosiuu. Somc- 
timee, while tactile aniestiieaia U comjilete !u these cases, eevore 
pttin is oonatantly liuffered (aiuet^iha'^iii dolornea), uad thit; ie often 
the case, according to Wood, in canc&r of the apioe. 

Partial aosesthesia of the skiu of the trnnk and arms of a bilat- 
eral oharacter, a--«ociat«l with progres^ve muscular atrophy, scolio- 
sia, and trophic lesions in the skin, {minU) strongly to syringomyelia. 
Tho Io*» of poiu and temperature spiise h UMinlly the first symptom. 
The areas of anaesthesia are best shown in Fig, 101. 

Pin. ita. 

IM lo -Hi ourvlcal hvidvcii 

l«l to tlb lUmlMU NflDMlL 

IM to ttb *B«t»l Kcment. 

■niwttl Mrlko»*reu nr th« lack oorrwpondJnc •iiprozliiuMly 10 Ui> *Tm* of Um 
)pln»l wnl luppljliut >iH irunK nod Itrnb*. 

Having r>on*iden'() the gi-ncral spinal canses of anaesthesia of the 
itkiu, it yi't rtmiainH to dHcroiiiH^ what part of the uitrd is involved 
by the patiiological prui'i-v.; and this is fortiimit<>Iy possible, ebiefly 
throii);h tJii* vnry atM-iinitc mid notrwurthy Htndie;* of M. Alhrn Starr, 
Thurtmni, iLn<t Hea<]. nut to uitmtion Aillutvrnl ones of groat value 



by Horsley aiiJ many othera; but the field Is only partly covered, 
and Bome of our uncertaintice depend upon lack of knowledije ai^ 
to the course of tJie sensory fibres in the cord. 

Roughly, we may state that disease of the cervical cord geueralty 
prmliiccii^ dintiirbanoes of sensation in the arms, hands, and fingers; 
disease of the tloKal cord, disturbances in the sensation of the luck 
and trunk, which may radiate into the tliighs; and disease of the 
lumlmr cord gives rise to these symptoms in the legs and feet. 

Again, it is to be rememl)erfd that, as a rule, in a transverse lesion 
of (he spinal «ird the aiiiestliesia begins at a level which is three or 
four inclie.-* 1>clow the lesion in thi- cord (Hnrsley ami Oowers); this 
being due, an proved by Sherringtoii, to the fact that each area of 
skin is supplied by three nerve-roots whose peripheral filamenta 
overlap one another. 

Fio. in. 

Accuoi uunUiH^iii li:tl«ii>ftlnilouil«rcIii<ir ttivi|ilniilrunl tnmMcml V. to ImiBar u. 

r SiCKl V. 

//. Muni IV. 

IIL Bum 111. 

< After SiAii.l 

YII. Lomkat n. 

IV. 9Mml I. 
f. Lambu v. 
VI. Lnnbuili. 

For the ready study of thv subject tlie conl bus licen .ie|»nit«<l 
into segments curreHpondint; with the vertt^brnc coverin); it. Thv 
areas of anfesthcsin produced by spinal injury or dittcue urc 



best <1e9cril>e<) In Starr's well-knoivn artii-lp ami dingrams, from 



ralization of tiie fuDO- 
(Hee chapter od Leg;s 

coimeotioii the n-atior should refer to tJie 
tiiblus on pngei) 106 and 107, showioj^ tbe 
tions of the Ht^mentA of the spinal oord. 
aiid Feet.) 

The ftiiiut^tlH'tiu areas iiiehide<t In zones I. am) IT. in Fi^. 10:) are 
(liw to n Inion luvolving the i'onn.s modiillarii) and tlie fimrth and 
llfth snctiil 8CgnienM iif the <^nl. Thci^o xoiio^ incbide the peri- 
neum, tlie poHlvrior part of Um MTotiim in males, the vagina in 
remnU-8, ami tlie iniiconit menibmni' of the rt^'irtiim, Aniei*theiia in 
nine 1 1 1, is due to tutiun vf the third, fourth, and liflh ^ai^rol M>g- 
iiu-iil«, and ini-hides a liir^ jHirt of the buttock and the u|)jN'r [mrt 
of the thigib, po»teriorU-, in n lriani;ular '^pave. Zone IV. in pniv- 
(ically an enlnrgemont of zone III. in every direction, jmrtiwilorly 
townn) tlic popliti.'nl f^paee«, and is prolMbly dtie to a legion in tlio 
tirtt and seound sacral segments; but this neeils conBrmatioii by 
Kutoptty, as Starr ])oint» ont. Zone V. inchidcs ull the first four 
xoatia just named, and extends down through tho popliteal space iu 
a baml-like sliajw; after it passes this apaee it doseondK the outer 
side of the leg and foot, isnmetimes ending at the ankle, sometimes 
at tlie .wle or the tlirire outer loen and lialf the next toe. Such an 
aren indicnt«A a lettioii involving all the Ae^meJit8 of the sacral cord, 
and extending into the linnlmr i-ortt to tho fifth hiinhar ne^ment. 
Zone VI. !.■« mi>.wd by a h-:iion cxleudin); t^o the third lundtar mg- 
nwat, awl when it i^* prv^iint thi> auicvthisiiu covers the hack of the 
tbighit and h-^ and nW the froul of the thif^bi*, except in an area 
which extemU from above downward nloiig the tfhin, "ometitnew to 
the foot, n» in Fig. IDS. If tlxt foot is invoIve<l, the lesion in tlie 
lumbar core] is probably above the thint liinilmr segment. Zone 
VII., which is larger than all, follows a h-sion in one of the four 
liiinlmr •^gmvMs — that is, all lint the lirst. The line of ana-sthesin, 
Starr telU iw, is lower in front than behiml. When the nlMtoniinal 
tfall is involved in the anu'^lhe^ia the tint lumbar segment is prob- 
ably dis^viMtl. 

The area of the aniestliesin from the level of the abdomen ourrc- 
■pMids very closely to tJic levels in the eonl if we allow for tlie sjiuoe 
alrmdy mentioned, of two to three inehes for the intcrlaciug auasto- 
inoals of tlie norvo-6bres of the posterior roots. 

Tlu'^' are nlwtit iw follows, oeoording to Thoriium: when the 
ftDmUicsia is as high as tlio auterior inferior spine of the ilium, the 



Wion U at the twclftli (inrjiiil wrli-bni; iT »t ttip tiiiibili(-iis,uc tiiv 
eleventh awA Hvclftti li.n-sil vi.Tt«l)rir; if ii]) to tlic lowwt flontititr 
rib, the whoic elcvonlh ilorsal vrrU'l»ra; if to one to four iiu-)K'« 
almve th« uinljilicu», tiio tiiitth uiid tt;nth dursal, and [K-rlin|).-< [Mi-t 
of the eightli dorsal vi-rt^bni; if iis hi^h ax the utppliv«, the fourth 
dor^iil vorti^bru; iiml if to tliL- thini rib, the Imion is as hi|;li iis tha 
sefionil (lin-stil vertebra. 

Flo. 101. 

Anu of soiivUtMla (ton krioo* aod vkrlou* Isvati of iho iplnat rnnt from ilw 
MSoaddoiwlioIhsnfttioarTmL (An«rSr4R&.) 

Stnrr hu also |;iveii ii#, in another [Hi[H-r thiin tlint nlready qiiotvil, 
equally good ideas of the ureiu of tmnvthe.-'iA (x^ciirriiijr iibovc tlion 
jiuit described. (Fig. 1U4.) Wlwri the aiiK--ithesiu extL-nds to tlie 
arms aod is found apon the inner side of tiip arm und foreann, reach- 
ing to the wrist, bat not to the hand, and also involvew a small zone 
on the extensor and flexor fttirfaces of the arm and forearm, the acc- 
Dod dor»al region is the fite of the lesion. If the ansftthetic area 
ineludes tiie ulnar .tide of the hand, th(- palmar and dorsal surfaoes 
of the »anie, and the little linger, and extendi in a narrow strip 

CaW'idl Amu tm isurcurnM t>u I'M '*IMr C DofHl RboU by t>w iMM> IX. •«) 

PLATE V)ll. 



up U> tbf. axilla on lioth the anterior and po»<berior siirfaoeH of the 
arm and forearm, the legion h prohably at tlie level of the eighth 
cervical vertebni. When the zone involved entend^ to tlie mid<lle 
of the central flnjrer nn the palmar ;iiiil doi>ni tisjicctit, and riinii up 
the ceutn* of tlie fon^trni and arm, tlii; :<(^'Vi.-iith cervi»il Hn» is dis- 
eased. Again, n-licn Ui« renmining skin of tti« hand up to th« wrUt 
and a narrow .itrip of iilciu iij) tUo fon^iriii and arm on Iwtli niii^ 
facoi 10 the axillu i» affccrtetl, the U'j^ion i» at the sixth ccrviml vor- 
telini, while auif«thosi» of tho fon^'Anii and arm on the outer nnrfacc 
an hifrh as Ilie deltoid insertion indirat*^^ that the fifth oervieal vei^ 
tvljrtil urea is in tronblc. Lesions higher than this nsually produce 
deatli liefore it is jwssible to tt^'st sensibility. 

Id order that the reader may ipiin a still beit«.>r idea of the prub- 
able.or rather approximate, area of distribution of die spinal nerves, 
the three ehartsof Thorbnm, Starr, and Head are here reproduced, 
as prepared in ooloni, witli significant lettering by Thorburn, for the 
Jnlrrnathnal Jfedical Annual for 181)0. (Plates VII., VIII., and 

Neuritia as a Cause of Anteatheeia. Ans^theaia of the skin in 
any part of the bi>dy may not only be due to eerebral or spinal 
lesion-t, hut aUn to neuritis or inflammation of the nervc-tnnik, or 
to Bome injury which im[>MirM its funotioiial activity by prensure, 
bruising, or cutting. A.s a rnle, liis.t uf sciisatiim from neuritia 
ocurii late in the diiimiie, hypeniutthexin or paneJtthesia being the 
earlier roanifestation»; but in Konie vmh^ these are absent, and anfc^* 
thetiin begins at oii<-e. The eharm^ttrristic of sm-h an nnnwtbo^ia h 
tliat it in conflned to the area .-iupplied by the u(Twt*id nerve, atthough 
the pnw^nec of a midtiple netirilis may prodiiec such a univ«r?al 
Rnii'!«ilii'«in by involving all the nerves tliat this ingn is ma«kcd. 
While a luono-aiuesthesia nniy lie due to otliur vausi-s, it is in thv 
great ntajorily of (iisc« due to neuritis. The ^igns of an auiestliesiu 
duv to neuritis arc loss of motion nnd sensation, tenderness on .pre«- 
Mire over Uie iwrve-tninks nupplying tJie affected area, trophic 
changes in tJie tissues of tin- jiart, with the development of n-aetions 
of degenemtion and pain in the involved nerves nr jmrtfi supplied 
by them. Somewhat similar symptoms occur in anterior poliomye- 
lilts, but pain is not ctmimnuly present in this di-'-ease, and there is 
no anicsthesia, eitlicr in children or adults. (.See chapters on ITands 
and Arms, and on Feet and Legs.) 

Toxic peripheral neuritis producing aiiiBslhesta may arise from 


poisoning by artwnio, li^d, hIcoIidI, or mcn>nr\', from septic ttlates 
of tho body, ami fram iiifci^lioiiA di.suA-'^^ [mrticuUrly diphtheria, 
inHiienun, and typlioid fvvcr. 

Tlint <h\c u^ tlie ininoml poisons has in each enac certain differen- 
tial point--* [>f iriipurtniicc. The anonthtsia of arscnieal poiiMining 
iii more marlttid timn in lend •poisoning, in wliich condition it is often 
almost alK«ent, and tlic luwi-r cxtTOniiticii. nn> vt-ry iipt |o W involved, 
whorenA in h^<l-|>oi:ii>tiiii];, an iM wl-U known, tii<^ nl■r^■rA of itie arm 
are partioiilnrly ^itDwvptiblo. (Soc Arms and HnntU. ) Arwnical 
nenriti--< may aWi produce prf^ncntJitiun of the nl<iri. In ali'oholie 
noiiriti." tlie tciHpumtnn' of the ana»thetir ari'iw i* ofton -<ul>nonniil 
and there aru ncnrly nlwuyn mental di»tiirbaiiM-s rcpn>scnt«d by 
deltiMoiLH. In men-iinal poisonint>:, islinkinj; like |Kiml>'8i!> agiliins 
may be j)n«ent. An uualysis of the motor Myni])tomM in atl tbt»c 
cases is imjiortant, and the di^mvery of any one of thi-M^ poiiton^ io 
till,* nritic, with the history of the pattent, K^nenilly makes the 
diagnosis jiuseibio. 

Diphtlicrilic neuritis Is quite eommun, and in -H) per oent. of the 
easos in which it <xM;urs sensibility Is lost or disturbod in the areas 
snppli<^<l by the involvwl nen'es. 

Groat care is needetl in all cases of neuritis lest the mistake be 
made of diagnosing the condition as one of lociomotor ataxia, when 
in reality it is psendtvtabeji. 

It has already been staled that in neuritis the area of amesthesin 
is that supplied by tlie affected nerve. For this reason nre can 
determine what ncrv(^-trllnk iit affected by studying the area of 
anffisthesia, always n.^N)otiihering, however, that tlio sensory fibres of 
the nervea, partienlarly in tlic hands and feet, aiiaxtonutse so freely 
with tliose of iidjafenl ncrvw that the area nf tlie anwilliesia may 
not lie exactly that »iipplie<l by the nerve involved; or, in otiiwr 
words, the presence of loss of power in a region supjilietl in health 
by a nerve which hiu' been divt<lcd ts constant, but very often scni«- 
tiun 18 nut <)istiirb<Kt, even though the divided nerve he tlw sensor}' 
Wt well as the motor supply to the part. 

It is well to remember also tliat sensory disturbances of the skin 
following injuries of nerves are often not nearly s<i great as the 
motor disturbunoe, even where tliere is no sensory tnirtsmission by 
anastomosis, and where they are present they usually disu]i|K'iir, 
moiv rapidly than llie motor loss, as recovery takes place. 

The following facts are, therefore, of diagnastie interest. If tlie 

THE SKty. 


i is fotiD<l to l)D due to a uciiriti^ and to involve tlie pulinur 
surtioe oif the llitinil), fiirc and niiddie fingera, the mcdlitn nen'i- is 

rw. 101 

rto. IOC 

Bbnnlng ii«u of loiunrr l(Mtn ln)<itlinof III* innitlin awn. IBowtny.) 
Pfj. 107. Fie. lOR: 


or loiiKnTlciMloInlurtvorihi uliiat narr*. tlinwuv.) 

)>n)liiLl)ly tJie one at fault (Fi^. 10'^ mid lOO), nnd tliL- urun inn^ 
even indudo in rare m.«tnii<M>B tho baokit of thuM' fingers at ih<-tr 



bases and the half of the third finger nearest the thumb. When 
there is disturbance of sensatiou in the ulnar side of the ring-finger 
and in the akin of the little finger there may be ulnar neuritis 
(Figs. 107 and 108). (See also chapter on Hands.) The nerve- 
supply of the skin of the entire upper extremity is well seen in 
Fig. 109. 

FIG. 1D». 

Cutaneous nerve-nupply ft the trunk aii<1 upper exiremlLy. iFoitler.I m. BupnctsTlculHr 
nerve. IID. Secuiid dureal. pa. Ponierior branches of the hplnKl oerven. Li. Literal branches 
of the iniercOHtnl nervea. ai. Anterior brancbea of the IntercoALAl nerrei. c. ClicuintlejL nerve. 
[R, Intercosl&l humeral, w. Nerve of VVriiberg. I'CB. Inlernul cutaneoui branch of musculo- 
gplral nerve, ecb. Eilflrnal cutaneous branch of muaculo-splml nerve. ICB. Inuniil ciH»- 
neoUH nerve. MC. Uueculo-cntaneous nerve, n. Itadls] nerve. V. Ulnar nerve, m. MedlHD 

Tlie devolopraent of sensory disturbances in the feet, resulting 
from neuritis, arc as follows: When there is perverted sensation of 
the inner side of the foot from the tip of the l)ig toe to the heel, and 
thence up tlio irisi(!e of the calf ti) tJie knee, the nerve involved Is 
the long or internal saplietious. When the dorsal surface of the 

THE SKiy. 


foot haa its cutaneous sense disturbed the nerve involved is the 
musculo-cutaneouB, a branch of the external popliteal. Disturbance 
of sensation on the outer side of the foot and calf indicates failure 
of function in the external saphenous, which is composed of the 
cntaneous branches of the external and internal popliteal nerves. 

Fia. 110. 


I'ulaneoiu nerve-iupplj' of the lower e it remlly. (Fowler,) LuiDb»r jileiu", IH. Illo-brpo- 
gulilc DerT«. II. lUo-lngulDal. IlL. Second lumbar nerve. iX. (ien1I(H;mnl. EC. External 
ciiiAaeoui. He. Middle cnuneoiu. ic. IixenuO cutaneoiu. is. Internal lapbenoua. pr. 
I'leiin pKlellie. Sacnl |>lezui. dp. Donalla penis uf pudlc. ir. Inferior beinorrholdal of 
podlc. p. SuparflcUl perineal of pudlc aad Inferior pudendal of ■mill iclallc. in. Inferior 
flulcal of noiU idatlc. n. Bioall iclatlc. Er. Hrancbes fmra eitcmal popUleal, is. £z- 
t«nial aapbenoui. %ct, Miuculo-cuuneoiu. at. Brancbea of anterior tibial, ft. Bnjicbes 
of poiurlor tibial. 

Disturbed sensation on the posterior surface of tlic <iilf also indi- 
cates trouble in the external supheniiiis nerve and cummunicans per- 
oiiei, while when the sensation of the skin uf the heel is distiirbe<l 


the plautiir cutaneaus ucrve, a branch of the {losterior tibial, in 

In the skin of tho thigh the aotorior eurface h i^uppliod liv tlii.' 
middle critaDCou? nerve, whiclt is a bmiich of the anterior criinil; 
on the inner side by the iuleroal cutaneous, also u branch of the 
anterior cniral ; and on the outer side by tho external cutaneous, 
which arises from tho eecond and tliird himbar nervi-s. Laterally 
the external cutaneous gives the supply. Posteriorly the small 
Bciatic gives the nerve-supply to the'skin. 

Antesthesia of the greater portion of the skin of the thigh, except 
in a narrow strip on tho hack part and In the area supplied by the 
internal naphouons nerve, often occnrs as the result of paralysis of 
tlie anterior crural nerve, arising from pelvic tumors, psoaa ahsecss, 
and vfrtehral disease, 

Faoial ansestbeBia and itt diagnostic meaning are still to 1m 
oonitidercd. When it occurs it indicates that the Bfth nerve, or 
its nucleus, is involved. 

Jf tlie area be that nf the forehead, upper eyelid, the conjunctiva 
and the nostril, the ophthalmic branch of the tifth nerve is at fniilt, 
and the lesion is probably at the sphenoidal figure or within the 
orbit, nud reflex winking of tlie eye no lunger takes place bi-oiuso 
the conjunctiva Is ann»tbetic. 

If the skin of the upj»i*r jiiirt of tho face is anBe«lheti^r, the »upi-- 
rior miixillary branch is involved; and If the »kin of tlic temporal 
region and that of the jaw and the undi-r lip is ana-sthetjc, tJic in- 
ferior mnxillar^' branch i« disi!a«id. When both of these bnuiches 
are pamly»t) thore i« probably a Liuuor uf thcsn|K>rior uuixillan' 
hone; and if the entire area of the three bnmehcs is auiesthetlc, 
the Gftsserian ganglion may he the part affected, and tliis will be 
aoDompanh'd by trophic change* in the antcsthetit; [)art«. The 
most common caum; uf anuMtlieeia uf the trifacial is, however, 

Itoniberg rusiki.-.^ the following <II(ferentia1 statemeDts: 

a. The morv the aniusthcaia is confined to single filaments of the 
tngeminuy, the more peripheral the seat of the cause wilt be found 
to be. 

6. If the lose of sensation affects a |)ortion at the facial surface, 
together with the corresponding faueial membrane, the diseatie may 
be assumed to involve the sensory fibres of the fifth p;iir before they 
separate to be dUtributcil to their respective d»ttiuiilion.ii; in other 




ironls, II muin ilivisiuQ must be ajfrnrted before or after its paa»age 
thn)tii;'> ^^*^ cTHiiium, 
I 0. When tbv entire senHoiy tract of the liftb nerve haa Wt ita 
piiwer, and there arc at the same time derangement!) of the nutritive 
fuDotions in tlie affected jiart^, (he Gasserian ganglion, or Llie nerve 
in itA immediate vicinity, ia the seat of the diTieaAe. 
k d. If the antesthesin of the fiftli nerve ia eomplinated vrith dl;^ 
■turhed functions of adjacent cerebral nerves, it may be atunntcd 
diat the cause is iieated at the ba»e of the brain. 
■ AmeAthetic patchai on the »kin may be dtie to leprosy or 8yrin- 
^>myelia, but in the fomier disease the iiiaiiiilar |Mtolie:i are proiwnt, 
ur there may l)e found evidences of tlieir |in-vtotis existcnoc in 
Utu of skin, cttpeoially on tlie baek, thighs, and calves, wliich 
an> paler tlian nomml and in which the acn.'«ation int partially 

Rarely llxs ana>»tbei«ia of leprosy may lie confused with tluil of 
[orvnnV diseaw, and it may retiulrt! a search for the lepra bacillus 
»c[Mmte them. 

OroER DiarrBBANcES <>►* Sknsation than An-btthesia. The 

"other disturbancttt of seiixation of the skin than anicsthtviiit, whi<-Ii 

•re UHualty subjective nitber tluiii objective, are pcuteftthcsia, Jiypor- 

lestliesia, and aunlgonia. 

K I'aneiitbesia, or numbne^, tin^liu);, and burning, is seen in nearly 

'all rases in which nnfc»tbcHiu ultimjitcly develops na a result of 

organic lesions. When a jintient coiuplaiiiH that lie cannot fed the 

jbnontact of clothing abrtiit his feet and lcg8, or that the feet when he 

^wnlks feel as if iTrapi>ed in some thick material, or as if he nvre 

n'lilkii^ on m(M», or that the soles of his feet feel as if they were 

numb ami at the same time tickled by ants milking over them, the 

(iltaracterifitic sensory disturbance of the skin seen in locomotor 

, ataxia is present. 

^b Often there is iJugling or numbness of the lingers, imrticularly of 
^HM ring and little lingers, and a sensation as if a girdle is about tlie 
H^Mfent in »>u)inon. These are the subjeciive disturbances of sensa- 
tion in tabes dursulis, an<l, as they are often the earliest manifeittationa 
of the di«easc, pnH.-«c«n great diagnostic im[»>i'lanrc. The objective 
M-n«ory perversions coiii^Ut in the discov<-ry by the physician, tvhdii 
sttMlying tiic wnxibilily of the iikin, of anrat of aninrthesio, aiial- 
gnia, and bypi-neilheiia. which art? usually bilat^'ral. Belmont 
has Hinted that via al>ui fin<l tbcju? arms in iipimil syj^iilix, either oii 



one or bi^tli Hideii. NumlinoM, tin^lin^, aurl forinicationfl affeottng 
the skill art! ali*r> often early symiHoms of lirain-tumor iu iUp area 
i«ii|>[)lving the aifect«(I [>nr(,ai]<) thU pna^ilinity is iocreased if there 
h assofintal !ijwi'*in. The actual objortivp stfiitihility of the skin 
may lii^ pri'Mervwl fnr wme titne afte.i' tlii'se nymptoras a|i]>ear, <ir it 
may be imjuiircd almitttt at the outant, owing to the involvenietit of. 
nil i>r [Kirt of (lie wiimry tnu'b* in the «)rd. Similar «yriii>titm» are 
uftvii !i«;uii ill the early Mtat^>i of myditiii. Tiioy an- v«y frctjiittntly 
seen ufttir iiijnries to ncrvft*, and severe tingling iu it*t acuto vnrioty 
ooounwfaon the? " funny bono" of the i:;1Ih(w h knocked ngiiiiiM nn 
objcf-t, ovrin^ to bniimng the ni>rvc. It i» t^M> seen id cum-* of 
iiouiiite-i)oi«oniiig, and when the liandti have been exposed to curbulio 
acid. P)irii'»i]ii-i<iti» lire tiir>i) frvtiuvntly m>(M1 in m8c:« *yt iieurastheniB. 

IVrvi-ntioiiM of sunsition in the i<kin Mimctime» tske u curions 
form, lui, for examjile, tliiit known u» nlldcbiriu, in which a si-asuty 
impulse in one butid w referred by tJic ]iiitient to the opposito hand. 
This is )^?en in titbes dortnlis, myelitiif, multiple utelerotiiK. iind hys- 
teriu. Ill othi-r eases, ns in paralysis iij^itans, this pcrvci-fiioii takes 
phice in the form of failure to distinguish heat and cold, and sub- 
jective st^usations of extreme heat are felt. The part affected may 
actually have its temperature raised several degrees, 

Magnan aaacrtA that a senaatiou as if a worm or bug were emwl* 
ing under the skin Is indicative of oocaine-intoxication. 

Very closely associated with the numbness of hysteria or neutit:^ 
t]ienia,and lying between fniiciional and organic disease of the ncrvM, 
is that condition called aeropanestbesia or waking numbnest^ Thia 
slate is usually seen in women [Ktst middle life, hut may oeniT in 
men. On waking in the morning marked formteation and numb' 
neiui of the fingers are jiresent, which usually {mi.«s off ns the day 
progresses, but as the condition betMinies more inarkcil they may last 
all day. While thi-re i* no ai)if.'<tho«ia, strictly s])eakin(;, the dis- 
turbed .nense of touch rentier* sewing or ]icrforminf; any small act 
with the fingcrfi «lmiwt iiii])ix''ihle. Thes<^' sensations may be cun- 
fineil to tlic area of one lurve, um the ulnar, or involve all the skiu 
of the handi), or more mrcly of the feoU General nervous excita 
biltty is iMiially ii»ioeiated with the local manifestations. 8om' 
tinier the xealp may be the aren involved, 

Aerojuirimthcsia is to be separated from th© sensory dUturbaiKM 
of hysteria by itjs irre;;nlur oiuliuc, for geuerally in the latter di»- 
eoM tlve areas aiv dtstjnetly outlined, by the fact that the hyaleriml 




is iioiLally uiiiliileml, ami by the absoiiw uf Uie chaniclcp- 
'lutic goDcrul hyetoriiitl ^vrnptoco^. From organit^ Jisea<M? it ia er|)a- 
rated by tlic ulwcnoe of the i^igns of Dvuritis about t<> he Aetvri^vH, and 
by till! ubaencc uf tciiJei'Deiss, p:iin, ami loain of power. From cere- 
bral or spinal disease it in separated by (lie abaeiice of symptoms 
produced by lesious in the«e part*, and by tbe facu that iu both 
these ]«6)0«B them is paralysis of motion iu association with the 
sensory disturbance, and in the case of spinal lesions the symptoms 
are usually in the legs, wlule a(;ropariestht»ia generally manifeots 
itself in the hands. 

Closely AHsneiated with |>ara>stliesia, if not an attual fonn of it, 
13 tlie "girdle sensation;" that is, thi^ piitient feels as tf a tight belt 
was strapped aroimd a limb or the trunk. This is seen as a prom- 
inent symptom in locomotor ataxia, nmlttis, and tumors of the cord 
or its eovfilopi-:^ When tlic liTrtion is in the lower cervical or dorsal 
region Lite Hi-UMtion i" in Uii- clii^t or alidomen; but this relation- 
ship be(w(MM) the );r«>wth and tbe sensation of constriction is not 
always tvin.->r)int. t-Sn- chapter on the I'eel and I^egs.) 

UifpriirMlirjiin of the :<kin is an imjyoi'Canl symptom of both 
byHteria uud noiinu'lhonin, and ite diitcovery in o^ocintion with the 
pticuliiir symptomH wlii(-h ocrtir in the former morbid i^UiUi conllrms 
a diafjno^U) most positively. The must important and inirious of 
tli«M> hyponrsthuifias arv th<- so-oallcd hyxterugenoiu koocs, or, in 
other wonls, an-a* involvini* the Hkin and »ulxHitnneous portis whieh 
pu9s<»s great seusitivencMW and wlnvb, when pressed iiptm, <»nst; iu 
many cum convulsive scizureit of the hysterical type. Not only i» 
tills true, but in addition it is a uuteworlhy f»el that after the ner- 
vous disturlxincc prodtiecd by this uHiini! is set in motion^ a M^cond 
prpMure on the hystero^nous zoae may anrst tbe tw-ixure. TtieMi 
n>nes coniniunly exist o%'er tbe ovaries, in the ^roin, nl>uiit the 
pGripher\' of tlie mammary glands, or upon the spine in the hinibur 
ordoi^sal region. (8ee chapter on Pain.) 

Tbe bypeneethesiu due to neurasthenia is to a gn»t extent spinal 
ia cliaractcr, but the skin of ihc test of the back, [uirticnlarly over 
tlie great mu.-«les on each side of the spitK>, may also bo involved. 
Often the neurasthenic patient or one who has phoi^phuturia will 
complain that in brushing or LMimbing her tiair pain or extreme 
neDstliveiHss is developed upon tbe SL-alp, and there may be tender 
areas on tJie nheet These areas in neurasthenics can hardly be 
cnnfus«d, eveo by the careless, with the hypencsthetie zones of 


liVHtc-riu, utid tho pentonal history uiid diitracUrristiw uf tlw indi- 
vidual iiid Htill further in tH-puratiii); ttie twu contlitionii. 

llypurfvtithiiiia of the i>kiti, usldc from tlial r^ecn in hysU-ris und 
uuuraHtlicnia, occure in periplicral neuritis and locomotor ataxia, the 
skin of the haek being particularly teiider in the lutter diseaae. and 
the exeessivf ^wiisitivenei^ h frequently »teen in u mne extending a 
litlJe above the aniesthetic areas of transverse myelitis, this hyper- 
lestlielie area being six>ii rendered anwstlietie by the progress of the 
diseaae. Ilypenesthesia in llie skin of the limbs is also rarely f«eu 
in myelitis, and when there is motor paralysis of one side and seo- 
snry paralysis of the other it is eoramonly found on the aide on 
which motion is lost. A condition of excessive dermal Iiypenes- 
theaia is also present in oerebro-spinal meningitis, in which disease 
it is often a very early symptom. It usually ap{K!ars first in the 
legs, then in the hands and arms, and, finally, the nkin of Uie face 
and head become involved. 

Hypenesthesia of the skin ofcurs, often associated wilh akin eni|H 
tiona, in that very rare condition called chronic leptomeningitis. 
Mot<)r symptoin-a are nearly always present if the cord t>econio 

HypiTie'ithma of the i«kin i* coneiilcrcd by iwnic authors to be, 
when found in fn^-'wcitition with otht,■r1^hllrltl.■tcri^tic Hyn)ptoni!<, almost 
piillRigiioinonic of brain> tumor. It may be found on the scidp, 
over It lar)jc part of the Ixxly, or in thi* part which U panilyjEed. It 
i» nL?M) found during the convalescence of typhoid fever, und in 
rvlajisiiig fevor. It also appears in the ]HinilyzeJ side of pereoos 
suffering from hemiplegia, in the area supplied by a nerve suffering 
from neuralgia, particularly that of a migraine tyi>e, in the scalp of 
persons suffering from gout, and in tlie same area in women about 
the time of the menopause. 

General tenderness of the skin or deeper tissuea is quite frequently 
seen in cases of rickets, the child crying whenever it is moved, as if 
sore and tender, and tender spots often ap]>eur over the ribs in oases 
of pleurisy. 

Sometimes in a neurotic girl about the time of puberty, or in a 
woman, one breast becomes exceedingly piiinful and tender, and the 
skin of the breast becomes ih) hy{)crieitth<:tic that tlie ulightest touch 
eauMs iHiin. Thu whole brvnift is, moreover, tcn<ler, and move- 
ment of the arm may h(Mni]>(>ffiible, owing to puin thereby enuAcd 
in the ghuid. This hystericul bmst can be sepuralcd from the 




painful kreaat due to a tumor by the genoral diffas^ i-haracler of 
the dwelling, th<- failiiiv Ui i)iitlin« any diMinot nmn-s, the neurotic 
character of the patient and her ag«. 

The hyixTa'sthe-iia of chronic alw)ioli.«in may 1)e liotli derinni and 
deep, and i.t well marked along the <x>nn*« of tlio iieriplioml nvrve)*, 
particularly whore they emer^ from deeper Htructiin'a^ It is alM 
seen in iJie ueuritiit of lejid- anil nrM^nitnl itoli^minf^. 

ImTeased seiHihility of the itkin nuiy follow the iimc of opium or 
eripot, and is met with ia the course of, i»r lu a ^ticl of, influenxu, 
and ill 9<>me cttse« of profound aiumiin. 

In sonic CAMCM hyjK'rirMlhcsin is »ii mrly sx^n of tliv onset of nun- 
tttbvrcuhitvd leprosy, nud will generally bo found in the coiirsv of 
tlic ulnar or wiatic nerve« in mioli cases. 

A wry intercEting faet fn>ni a pliysioloj^cal and diaf^iostic point 
of X'icw is tliat disetisu of the ialernal organs or vi!H.-eni often pn> 
duoes areas of hyiienestbesia or tooderaeas u|>on the skin, which 
may in future be uHed to aid in the loeali/atlun of the lesions. 
This subject has I>ecn well studied by Head {Brain, If^K.'t and 1804), 
from whose researi-hes much infonnatioa may be derived, but the 
TOMills of which will have to be oonlirmed in many wises before 
diejr can be used a.« diagnostic guides. (See article on Pain.) 

Pam ill tlie ektii is very various in it^ manifestation!!, and 
nearly always is due to fniictinnal nervous (roubles, Diilirini; hiu 
noted a Ixiriug si-iisutiou i« ^omecftjuw. It uliould direct the physt- 
daii'a atlofltion to the [xiMibility of hysteria or tal>cs dor«alis. 

PrwHta or intetiM^ itching of the pkin may be due to contact 
with Home irritnnl, but its presence, if )>cr>>i»lent, luirticiilnrly if 
widemprend or near the gi-nitjils, shoulil always ntise a susjiicion of 
dialicte^ mcilitus, or chronic letvl-poisoning, or t;uut, or chronic coii- 
tnic4e<l kidney. Very rarely opium may p roil uce a pruritus, and 
jaundice is nearly always accompanied by some itching, I'rnritus 
about t)ic nnue is often due to piles. 

l''iinilly, one important point is to be remembered, viz., we cannot 
nt4empt to make n geiieml diugiiosis merely from a study of the 
an^ns of annBtlieeia or other pi-rvcrted scn-^ibility of the skin in any 
case. The results obtained fnun rtudiei nf the seiinatinn of the 
skin are onlv to be usetl at* adilition.* to the motor and other MVinu- 

r % 

toms which will be found disciL-iscd under tlie chapters on the limlis. 



TUe inqwction of the norniil and aliiiortnal chest — Their lopographv — Allvn- 
lloM in th« iihAlX) of th« tliorai^Tlie rhythm of chn r«|iinitionii — The t«> 
»ulu of upiug inspeoliuo, palpMiuii. iKTciiMii'm, nnd Htuculbilioii lu h«allli Kficl 
dineoM— The chuactcrLttic signs iiud gymptooii of the TU-iou* diicwcs of the 
Uioraeio orjtsoa, 

Tub chief ootilents of the thoracic cnvitj- cnnsist of vital organs, 
which are mifortiiiiately only too often subject to diseano. A care- 
fat stmlv of the signs associated with the normal functions of these 
parts is, therefore, of importance, as is also that of che symptotnB 
indicating pathological changes. While it is true that in many 
instances patients present themselves to the physician with well- 
marked objective and snbjective symptoms [minting to abnormalities 
in tlie organs of tlie trhest, it is «!*> a fact, that in many others none 
of tht-jse nifptti vx'ivt, or at h-m^t in nuoh iin imh-tinito manner that 
tlio phyMciao'v nttvntion in not attruetud tu them, nnd as n result 
im]torIant tlionicie eliHugCH from the nonuul arv overluoki-il ur made 
li^fht of. \Vc biiHC otir <)iagno<(Is of the character of a case by the 
chan^^ whidi we liml in the snrfacc of the thorax us to it« contour 
nnd !i^ to itK niovcnicut», by the ri'iipiratory nnd ciinltac sounds and 
tht' other phyitical signs about to be described. 

Before wo attempt to study the altvnitjons protlneed by diK-use in 
this portion of the body we must have a clear conception ()f tlie 
ooniiul appearance of tlie chest and of tlie normal sounds which 
are produced M-ithin it. 

IxsPEciiox ov TiiK XoKUAi. CutST whcii free from clothing 
will reveal the fact that it Is eonical in form, the hnuder part of the 
cone being in the nppr portion. Above the clavicles there is 
usually a slight dejiression (tlie supra-clavicular fossa), and below 
the clavicles, which may be someivhat prominent, there is a flight 
convexity which extemU as far down as the fourth rib. This 
convexity varies considerably aa'ordiiig to the roiiscnlar develoji- 
mcnt of the individual, tho formation of the hony portion of the 
chcAt-wall, and the dvjxi-it of fat in the subeiitiineons tiiiitu«a of the 



FenT^t. Tho nipjili- is bv iiu mraiin iin tU-fiiiito « Iniultnnrlc n» i.* Monic- 

LliuiL> llKiught, ui> its position, in rcspt'ct tu ihi; riljH iiii<k-r it, varies 
Jy in difforcrnt individuals; und it is still fiirtlivr iiltcrcd in its 
pmitiun by tlt« prcecnci.- of niiu'li fut under it, or, ii<^iin, in iinilti- 
piinMis women owing t<> thi- ii-l»\ation of t)i(.> bn-ast. In the- iiver- 
ago adult male or virgin fenialo tlie nipplo is on » IovpI witli lliu 

[fourth rib or fourtli interspace. The ribs in a well-developed per- 
son are not prominent in the Hp|>er two-thirds of the cbest, but in 
die lower tliinl are more readily seen, partieulariy at the sides, 

IbecauM of their thin eoveriiig by rouitcteR and the subeutiuieous 
tisAues and ilie skin. The i<lernun] in front and the spine behind 
are normally in the middle line. Over the top of the sternum '\ft a 
deprewion called tlie epi--<t(.-mnt notch. 

Pra. 111. 

Tli«r«Btaiii«(iheuit«i»rupMtorilieelien. TheKniii*nnum«nliIadl>:«ioIluill». (TrNMi.t 

The rvMilt of luleml exainination of the nonnni ekiitt when ouni- 
pMred with tin- front view will Jmw llwit the aiitero-poeterior diaui- 
I cirr in li-*» than the Intend ilinmeu-r. 

The Kiirfare of the 4'lnrst :interiorly, posteriorly, and laterally, has 
been arbitrnrily divided by tnincinary linu« into Hi>aces, as shown in 
[till- lUHYMiiiiMiyinf; fii;ui\-. Tlic lines running from the middle of the 


clavicles (lowtin-nrd ttiroiigti the iiipplo ure called (be mam mil Ian* 
lines. (Fig. 111.) The paniiiternal tine, not shon-n iti the figiire, 
Id b vorticul Hue half-way Setweou the middle of the eterauni and 
the mummillary line; and a line mniiing down the side from the 
axill* iH called the mid-axillary line. These iirlifieia) diviAion.'i 
enable ub to describe the locality of svmptoniH. 

If wc could see through the cheHt-wall, we would find lluit tlie 
lungs extend above the olavicW. Immediately back of the inner 
end of the ckiWcle is the liegionin^ of the innominate vein, oik] 

Fra. 111. 

PmIeIoii of boart In ralnilun loilbond nwrnnm. (TTtoN.) 

back of tbib ui^tiii the common carotid :irtery un tlic left idde. On 
tlie right side tJie innominate artery bifurcates just behind tlie junc- 
tion of tlie sternum and clavicle. The figure given above uliows 
the relation of the cavitiee of the heart and its great vessels to the 
chest-wall. (Fig. 112.) 

Antetiorly the lung exteuds as far as the sixth rib on the right, 
but the dome of the liver reaches to the level of the fourti] inter- 
BiMoe. On the left side the lung extends a little lovrer than on the 

thk thorax axd its viscera. 



ri^ht Mtto. LalemUy the lung on Imtli smI^h extendi «> l)ie ninth 
rib in die mid-ax it la ry line. PiKtlcriorly on tl)<> right nide the hiiig 
extencU Of luw n» tJie tentli rib and on the left side ati low a.4 lh« 

Marked vnrialions in tUw itha[>e of \hv i-iiest owMir in liinltliy 
individimU witiumt jiowcwing any dirc^ poUiolngical ^ipiifioance. 
Tluw, it i» vi-ry imnmon to bc-c one shotiUU-r "lightly hijihor than 
Utc otln-r, mul, in th<! ww of clerks or jwi-eonn! who work much Ht n 
(liMk, Uic left Hhoulder is very iipt to be iwinovrhiit vlvvnt«d. Oucu- 
jKitions M'hich cnuiM.- tlii; individuul to luwunie eertuiii posilioiis, or 
to uiv OL-rtiiin muffcles cuutinuuUy, ulso ouii.'M' x'anntions in the 
contour of tlii? thorax. 

IsspBCTios OF THE AlixORMAL CllEST. Till! conBgiiriitions of 
the cbeet which sliow a tendency to disease or the reeulte of attacks 
of disease ure uumcrous. 

Fw. w. 



TtMr inont rnmilinriif ihi-.M- U UivhchmIIwI plithimnil <-hv8t, whidi 

liAH bt*Mi mllt^) ihc " nhir i-)ii'i<t," t>««ui*e the wn)uilic ntand out 

[from tltp I«idc like winpt. (Fig. 1 13.) Thi> untcro-poeterior diHin- 


etcr, jKirticuInrlr in the ii])per twn-t^iirdii, in very slight, nml iuHtew) 
of i<i>iivoxi[y ill this [inn thi;ro iimy ht: ttnlUiti'iuj^ or liollowneit!*. 
(Fig. 1 H.) This api-ft swirvely moves on inK|>iratloii, but tlip lower 
third, which 'k^ liiil^jin^, niovt* miir]<c<]ly «itli th« rettpinilory 
elTorlfl, aiiduuiiitl^o thvcjiig»str!iim. Thu shoiiJiloi'K arc very ;4li>|>iii^, 
tliG neck, BiiU.-riurly, rct'i.'ileH at the cpisbiriiiil notch, Imt ^jiringa 
forward towanl tht- Ailiim's fipple ami thv chiu. Tlir rilw in tlift 
nlur uhest fall downtrard toward the belly (voto thvir jiuiuttt of 
Drigtn, instead of cnming forward ia a normal ourve. (Fig. 116.) 

Fni. 11& 

I-htbUlcal cHM. 

If, on tlic other tuind, the eltrat bulgtv antc-riurly and posteriorly 
to Mv\i nn extent tlint the luiteru-posti'rior diameter is greater tJian, 
or I'lgiiul to, ihv latcml dinrnt-tor, and if this Imlging is fairly uni- 
form, the i^liouldorv beini; olevatcd, the back rounded, and the 
neck «hurl iu sppuirunoe from ihe raised shoulders, the patient ta 
probably a suffi-rer from Piiiphyscnm of the Inngs. Thia eheet ta 
often oalktl tlic •' barrel -slxapetl chest." {Fig. Mfi.) The cliest- 



wall ni<ive-i very liiile or not at at) with tlie respiratory ini,>%'enient!i, 
wliicli are cliiefly cli:i|>hra^nintii!. 

Ijocalixed bulging of the clieitt roiilt^, In itt* mo»l tlilTtiTwd ty)H.', 
from the prp9en<» nt ohronio ptr-iiral i-fTii8t<>ii ; I'lilfjini^ nf n limited 
arwi iilwt ariiM>n from cardJat- liy[Hrriri)|iliy, iinrti<ruliirly timt w^riir- 
riii^ in rhildliood; from aortic ttiie(iri»ni, cuiimiii; Inilging liy pn-s- 
f*uiv(Fig. 117); from pcrioartlial olTiLsioii ; iiiul, liiiiilly fruni medias- 
tinal growtlis. Miirk<^ Imlginfr over Iho lowor (Hirt of tlio clicsl 
on th« right side :<himlil luiiiiit u>t tu luuk fur wine- hi-putio affuctiuii 
tuf wvll AM to oxamiiio tin; lung, ami, if the bulging is low down on 
thv U-ft fM(lc-, to i-Miuine tli« xploci). 

Vv: tio. 

no. III. 

Jk>t fcanmi fsui ulii irltli cmphjMukW 

Ilulcloi at Ui« <lkMI-H«)l. Willi pnuiiii at tita 
trom HOtlG *ni| liiiii'iiiliiiiU miuuriMn. 

Ridging or jirolniHiun of tlic eteniiira, and the carliluginoiis por- 
tions of tlio rilM atdu-'Iictl to it, is calli^l " pig«on brtuet/' and in 
diie citlier to rickeW nr to the prwuiici? of s.>rne oli-itniction to 
respiration of a inoro or less olironir I'baractor iluriiig tlie tim« 
lh«! ulieKt-wall vnu soft and capiibli' of Ix-ing inotilded. Somv- 
tinics on (-aoh side of the sternum, over the <twt«l cartilages, thero 
in •««'fn n gpoovi* or depression a« tlic n-Hiill of rickt't^. In otber 



easm n depressio'i or |;roDrc extends from the tnsiform i-artilogr 
back on fiilior Bide towiirJ the si}!!!^. This is mlled " II«rTi«>ii'» 
groove," uod in dovelopod iu childrcii witli i)our bony syeums, tn 
tlio . result of repeated attacks of ostbioa or otb«r obstnicrivt' 
respirtttory diffieiilty, 

M'hon pxamiiiing: the cheet^ of children the physimii will often 
notice swelling of the tii^sues at the etisto-cartilaginous jtinctiniis, 
which look and feel to the touch like large beads under the skin. 
These beaded rihs are indicative of rickets, and arc a montfcfitatiou 
of the general tendency to egiiphyneal enlargement. This beading 
is usually mmt marked on the lower rihfl. 

Flo. lis. 

Flo. lie. 

abowliiRitinukiiiii^iiiiii iniLUloullapwof lonildeorcbe>l«ndai«IMtlDiio{i|>lBal luaiuda 
daa to Rlifunli' lutH'n'ulnrvloiirlii)' Ins iKrf ulftltMa yt»t», (Pram IM •tiUiar'' vtnir In Ilia 
ftOknuit M«i]l«al L'-illftte tloipltal.l 

Finally, unilateral Imltring of tlie chest may he due to curvalare 
of the spine, which part of the body should always be exaniini * 
before a diagnaii!! a.^ to deformity of the chest is attempted. I 

Shrinkage of the che^t in one jmrt may l>e dne to the oontnctioD 
of old pleural adhesions (Fig». IIK and 111*}. It UaoDietimesMeti 



t)Vcr the <Iiacasefl urea in {lulmonar)' tiiberculosiii, imd mny be agipdr- 
ently preeeni, but in reality due to wnstiug of tlie Uskuw covering 
die port. 

While inapecting the snr&oc of the chest Ihe phy^cian should 
also note the prtncnre or aWncenf enlar^Kl or pulsating hltHxI- 
vesaeU <m it« aurfaee or alniut the liase of the neck. The cervical 
v«awls are commonly neen ta he distended in eases of advanced 
emphysema of the lungs and in chn>nic hrouchitie, and systolic pnl- 
pution of the jugular vein^ indicates tricnspid regnrgiUition. Again, 
in cows of thoracis aneurism pressing ujtoii the sui>erior vetia cava 
and Innominate veins we find sjMingy venous musses above the 
clavii-le.t, nnd the veins of the trunk and arms are apt to be en- 
Bi>rged. Intrathonnio growths pnwiuce similar symptoms.' Pul- 
iation in tlie otrvicnl vessels is also sometimes* se«n In easeflof severe 

Ttu.' nhitpn and surfatro of the client having been studied, we can 
go furttMT iind h'Jini inudi from its movements in ro^jiiration : flntt, 
from tiic rapidity of rospiralioii; serond, from the nytpimtorj' 
rhythm; thini, from Uic charact«rof ihir hrt-iitliing ; nn<l, fourth, 
from tJte iuovi>mciit8 of the ribs. 

\Vb(Fii counting the rofpinition.^ the phyfiiciun should always 
endeavor tu do so without letting the ptiticnt know whiit he h doing, 
wnoe it is djffii-ult for muny persons not to control their breath- 
ing whcQ tlioir atleiilion it ciilkxl to it. (ienerally the eye can 
detect the fretjuency of the breathing by simply watching the move- 
ment of the chest, or the information can be gained by resting the 
liand on the abdomen or thorax, while the wrist is also held and 
the doctor is apparently taking the pulse. In the newly born child 
ID perfect Iieaith the respirations are often as high as forty-four, but 
in the adult main at rest they are iistially about fourteen to sixteen 
per minute. During sleep the number may fall to eight or ten. 
The ratio of pulse to respiration is usually four to one, but in disease 
it nuiy be one to one. 

Hiipid nspiration? not duo to any re<<ent sudden exertion are 
always indimtive of rcipimtniy trouble, primiiry or sooondary. If 
tin.' primarj' trouble be in the lung, it will pndmbly be due to cpou- 
poiui pneumouin, «itnrrlial pnnimoiiin, wvere bronehitii*, iisthma, 
tul>4TC!ulo>>iM, pubnoiiHry nlimx-m. or tuinon« of the lun^. tf il Im> 

■ W»-*M*dluUiwllJ«MMt,''bjrmt«utlior. mM(|llUHrrt«eIkuy«i]t«llliMllhx«ityut 

370 r//A- MAyjFfSTATIOy OF OtSBASE /.V OttOASS. ■ 

due to seoondarv Ir-'ioti:" in tlie liiiig, it mny ritic from pulmonflrr 
cedenia duu tn tiophritiM, frum c-onjjitMtioQ or hvpostutic cxudutioii an 
the result uf a weak Ix-itrt, from pulniuiinn,' cnibolism, from a pleiinti 
effiisioii which .'•(•ri<)u»iy intcrfon.'s with the action of tl»p lung or 
lungs, fn^m gniwlhs in ihu nitHUiuitinuni pruu^tu); u[>od bloo<Ivp8.4els 
and »i ciiiir>In)>; cxudiiuoii iiitvj Uir lungH or pk-ura, ami from ascites 
or ahdoininiil growths pri.>ru<iiig iijHin tho diaphragm. If the luDg« 
he clear or tronbh-, then the diffit-ulty may ho pn.<seDt hi the tradiea 
or hirvnx, citlicr n^ tht- result of s|>asmoiii(' contraelion of ih<»e 
pib<8agG8 or heoaume llioy an- ouohuled by growths, such as papillotna 
or nialignnnt growlli, in^iitlL- or outside, which may act by pre»mre, 
thcri'by narrowing tin- tube. Any agency which interferes with the 
jintionl n'ueiving the full uniuuiit of air ustially inhaled cait-^e^ rapid 
btvnthiiig in order that t)ic loius of air may be compensated for by 
iiK^rewnil frt'ijni-ncy of respiration. 

There ure, moreover, several other tauses which affool Uie cliar- 
•ct«r of the rei^piriitiun without affedtng the larynx or Inng-ii^nne 
directly or in<tircctly. These arc fever, which acts aa a respiralori- 
etimuhint, and exc!l«moDt, nervous or mental, jtartiiidarly tlmt of 
hvsterieal putientfi. Again, ajMpIeeiic !*ei7ureji, unemin, and dialietic 
ooma may be aecnmitanied by rapid bn^thing. 

The respirations are slowi-d or df>cr(«j<ed in number by great 
obstructioii to the entrance of air into the lungs from any cauw; 
by the action of ]ioiM>nH made in the IkkIv, n» the [X)ison of unvmiii 
or diabetf»; by the effect of pot»oris swallowed orubwrbed iu otlier 
wavi*, notably opium, elihira), neonite, elilorofomi, or antimony. 

The rhythm or rtdilive time of iuspirution, expiration, and the 
paiue iit in health tn the mouth and tnicht.'a as follows; If 10 rcp- 
rt«ent8 a coinplet*: reapimtory cycle, inspiration is represents] by o, 
<-\piriition by 4, and the [Miu«e by 1, If it is difficult for air to 
enti.-r the chest, as in spsismiKlic croup, the inspiration in much 
prolongeil. This prolongation is also sometimes very marked ia 
eases of |iaralysis of tlic jKisteriur crico-arytennid muscles. If 
there is difficulty in expelling tlie air, the expiration is prolonged, 
as in astlima and in emphysema. 

Sometimes when the cheat Li flexible, as h) tliat of a child, tiic 
insfHfation b jerking when there is obstruction to breatliing. This 
is due to the fact that the client i» fon<e<l into ex])nn8ion by nitucuhir 
effort, and at the same time is subjected to the external atmospheric 
(ire^ure, while tlie air enters the lung slowly owing to the obstruction. 


Th* most remarkable clianpi- in rliytUiu in the smj-wiIUiI Ch<>yll<^- 
Stoke-; breuthing, id nhk-li thu pntivat iiftt-r u |>uus(* uf Huvorul »co 
oudri b^ins to bn-atlie with gniduully iucroa«ing ntpidity iiik) (le|>t}i, 
and then after n^aohin^ an acme of hurritKl n-spinitiuns gmdniilly 
d»;reases their rapitlity nnd depth till tlicr faiU' to nottiing, when, 
after a pan^e, Hie same proce>v§ i.H repiSiited, Tltix breathing is seen 
oommonlj in aiwpluxy, in urtemia, in brain-tumor, in cvrebro-epinal 
fever, io meninseal tiibercii!i>*iii, in some rare tases of canlinc val- 
vular di-wose, probably t\s the result of emboliem, and in ha>maturio 
malarial fever. Rarely it occurs iti cases of acute febrile disease, 
as lyplioid fever, i*carlet fever, pneunnmia, whooping-««igh, and 
puerjieral ^pttoiemia. It also may be met with in the course of 
diabetes. Its preiiencc is on exceedingly liad prognostic sign, bnt 
ease^ of recovery after its onset have been observed, and Miirri lias 
rejwrted a case in which < 'heyne-Sioke-s breathing la-^ted forty days, 
and Sanson) one in which it lasted one hnndred and eight days. 
If tJie oaus^ be an acnie disease, recovery is more (K>niRion after this 
symptom than if it be due to some chronic process with an acute 

The fiiiietioii uf brcathini; and tlio movcmcitt^ of the tihest arc 
doMly ntwooialcd. In men the respinitory movements vlitefly affect 
11h' lower rib« am) the abdominal walls, owlnj; to the faet ttuit iis the 
diaphnif^m dew%»dn it pushes the abdominal contents downward, so 
causing alKloniinal ixilgin;;. In women, however, this is not so 
marked, and the bruUhing is chieHy costid, the tipper ]uirt of the 
ohfttt movin)> more than the lower (coital breathing). If al>dom- 
inal bniilhing is absent in a man and is replaced by breathing of 
the ci>st«l type, we can be asaureii that the movements of his dia- 
phragm are impaired by the pressure of fluid in the abdomen 
(a»cit«8) ; by peritonitis, causing lixallon of tlie diaphragm, owing 
to pain; by tlie presence of large growthit in the abdomen or by 
great eiilurgeniont of the liver and spleen. Other possible causes 
would be u subphrenic absocss or a greatly enlargeil cystic kidney, 
or hydronephrosis. 

If the coetal breathing of a woman 'm, there Ls nearly 
always some pulmonary cause for it, such wa faulty developmejit, or, 
if due to disease, its abaeniH' arises moMt oommonly from tnbercidosis 
or pleurisy, or old pleural adheniooH which bind down the cbt^l-wnll. 

Ixibored breathing (dysiiiniui) is geeii in all «i«m in whiih the 
btood eannot be provided with sufficient oxygrn owing to otmtriiotion 


to tliL- eittninuv of nir into the chest, to spiuiiu uf tlio bronchioles, or 
to thf occltidiog of the iiir-vesicW by any form of exudate, croo- 
pous, catarrhal, or serous. Theso coutUtione may bo primary or 
sc(»ndary to disease elsewhere, aa in unvmia or cardiac disease. 
Inspection of the chest in such a case hliows great activity of the 
accessory respiratory muscles, such as the steriio-tnastoid, tlje scaleni, 
the pectorals, and the abdominal recti. Thu nostrils are dilated and 
die face anxious. The posture of the patient is that of silting up 
in lied. 

Finally, we liave to noticM! the extent of the ehe^'t-nioveraenls. 
Tlieae are very slight in the charaeteri.*tic che-st of n ]>prji>n tuiviug 
a tendency to tuherc^ulosU, and in the hnnvl-t^liiipiHl nud rigid clH-i«t 
of emphysema of the lung:^. Deticieiit es^puUHJcui on inttpinition i» 
not only a predis|K)sing cau.'te for lunjr di:«i-iLS«', but au importnnt 
diaf^nostio sign. When ana wdc of the chc*l [niiv<'» nioi-c than ihe 
other to a considerable extent, we mispect, in the nide which moves 
slightly, a piienunitiia, n ]>l<-iirilii^, a plvnntii- (fTiiHon oradhcMon, or 
tul>ereulnr<x>n^)li<1atii>n, provide*! that the patient has not naturally 
a greater de^'elopincut on one side tluin the other, or has not pursued 
a trade' or oecupntiou ean^iiiji ntiilatcnil hypertrophy. 

In thi* connection should bo mentioned the " wney brtathin^' 
seen most commonly iu pneumonia, a condition in which inspiration 
and cxpinition do not seem to occur regularly or evenly all over tlie 
chcKt, one jmrt filling or emptying a moment before the other. This 
usually indicates a grave pulmonary conilitiou. 

Pai-patio.v of the chest ia usually performed by placing the 
finger-tips or tho whole hand, palm downward, on the cheat. This 
reveals alterations iu its contour and in its elanticlly. Itwillaliui 
reveal the ability of the thoracic viscera and the ch«ttl-wall to 
transmit vibrations prodm^ by the voii* (vocal fremilui*). This 
so-calletl voeal fremitus de[>ends upon the fact (hat below the vrniil 
bands lieH a column of air whieii reaches to the ves^iculur portions 
of the long, and when an indivi<hial spc-nk.^ thi< ooUinm of air is 
put into vibration, and thi-ac vibmtiouH arc in turn Iransniittcd to 
tlie clie»t-wall. Of counw, n che*t-wall gn>iitly thickened by txi 
or by highly develope^l nui^eles will not ttnu^ijiiit these vibrations 
act rt-adily a» a thin chest-wall; but aitide fnim ihew clauses of 
variations i» fremitus in health we have n uimiber uf causes ia 
disease which greativ modify vm-al fremitus. It must be remeni- 
burod, too, that this vibnitiou is more marked in men than in 



wniueii and cliililroii, beimiiiM^ the voice of a iitnn in «o niii<;li loiid^yr 
and hiiii );Tvatci' volittiK'. Vocal fn-mitiis 'in nho gn-atttr mi the 
right aide. Utnii on the left Ix'iraiist; tli*^ j>Fiiioi|i»l broiicliiM .'ii]]>|ily- 
ii>^ thU lung iii Inrgvr than that uf thiy li>.ft »ide, U jtiined to the 
tmrlien at a lc»4 acute angle, and in ni-an;r the vcrli^hral coliinin; 
and, ngiiin, a* pwienlk emphiwi/.i'd by Ciiry, thv Itronclius. going to 
the right upper lube is given ofF at ii point vorj- ncnr the origin of 
the right brmichim, und in miiiiy a\iKs " Tnlly two and n half inche.s 
alxivi^ the corn-iipomling left hmnchial tube." .SoineUmei* thU 
iipiier lube «iime» ofT the trtiHieu directly. 

Tlie iTonditiitn^ o( dij«ouw which can«e a dcerea^ie in voeul fremitus 
arc plciiml efTiwion* nf any kind, wliieh not only ent ofT lint trttn»< 
mlwioii uf ftoimd, but by their cuntaet prevent vibrtitiuri uf the eliott- 
wntl; pneumothorax, which eaiincM eollapic uf tlic transmitting 
medhitn, tJ>e lung; iiny conditiun which cutucit oe^tliiHion of a krgc 
broitchus, i^tich it:! tumor or it largv inaiw uf niiicui<, and j^ntil ph-nral 
tliiekening. When thtt vocal fremitus is increased it is an indica- 
tion uf pni'iimunifl, of tubercular tliiekeninir ur consulidatiou of the 
lung, uf (he presence of (itvities or uf tumor in the thonix touching 
the cliest-wall. Freniiliia h incr«iH«l in these conditions "becauM 
the omsulidateil lung transmits the vibrations of the air in the hron- 
chiid tubes to the chest-wall, or, in the ea-w of a cavity, the eoutid 
is tmnsmitted dire.-t]y to it, and it there eauiWH so great a vibration 
of the air in ihe hulluw ii|iaee tliat the vibration of the chent-wail 
la marked. (In ihi.-i connection, Aec part of this chapter on Auscul- 

Palpation of the chest-wall will al!H> give infomiatjon a« to the 
position and character of the cardiac pii Isalionii. Thus, the apex- 
beat uf the heart in [MTi^unn Maiidiug iivci will iiHually lie felt, in 
persons not inordinately fat and whu an> h*>altliy, between the fifth 
and aixtJi ribs, almiit twu inches to tin? left of the .sternum. (See 
Kig. i'2ti.) If t)ie n]>ex-beat !> )>elow thi^ level, it» depre.-wion may 
be duo to enlargement uf the heart (hyjKTtrojdiy or dilatation), to 
effunion in tht* [K-riciinlinl siic ur pli-imd cavity on the left side, to 
pulmonary vuijibysi-ma miiiiing abnormal descent of the diaphragm, 
and with it I'linllae hy{M'rtn>[diy. Sometimes tumors in the cheeit 
jinHlnce a similar dcpn^wion. On the other Imuil, if the a)>ex-beal 
of the heart is felt above the Hftli inli-rspa<'i', the heart may l>e raised 
by iM'rieartlial adlteiuoiM following inflammnlion, by plenral adh«- 
doiu or dTuitioiii*, by abdominal cITiiHioii (lueileii), by tumors, disten- 




tion of die oolon hy f^n.'s ami t>y ^n-at cii)ai>;iMncnt of tlic T'plceo..] 
DU|>lnor>inr>iit of the ujwx-lHait to tlio left w ^j^'iiL-mlly nwociatcd 
witli iIiiH'iiw«nl ilUp1iioi;nK'iit, iiml is Kciiinillj' due to livi«.'rti\iji!iy 
of the left vc'iitriclo, to |>lc-tir»I iidlieKiuiiB, nnd jMirticiilurly to jilviiml 
i-ffiwioii nil tin- riijlit isitlf. I*i»-i»lttcfiiiL'iit« to tin- right art: iluf to 
hyiKTinipliy nii<I ililntutioii of the ri^ht wntrk-k-, eu that the apex- 
beat U folt in tlie epigu^tnum or aguinst the edg« of the Ktornuni. 
Floiintl flTii!>i»ri uti the left side timy iilsu euiisc this diitplaeeinont. 
(Si^c figiirwf Mhuwiog <-hiingii?s in cardiac area on [KXgvs 'Haii mid 2M.) ' 

Tlic ureu of the iiormul upex-beut is about one square inuli. In 
diMsiM this area often extendi over sevenil Bt|iiaro ineJies, genorally 
as the result of hypertrophy mid dilutAtion of the vcntrieles. 

The strength of the beat in health de|)eud5 largely upon the depth 
of the elie»t ami the thickness of its walls. In dieease it is 
inercu«ed in hypertrophy of the heart and decreased in eases of fee- 
bleuuM of the hearl-muscle, by effusions into the perieardium and 
the presence of pulmonary emphysema, which cause tlie projecliou 
of a part of the enlai^-d lung between the heart and the ohest-w«ll. 

Thrills felt in the eliest-wall over the heart may be dne to abnnr- 
malitias in the bI(iod-<^iirreiit when valvular dl^ea^e or aiwitmin iftj 
present. We Uiid thrills in the pneennliiim, or the neighborhood 
of the apes, in disease of tlie mitriil valve, both rt^irgilant and 
obstJ'uclivc; and thrills in tho neighborhood of the M-cond right 
ooHtal curtilage indii-me an aortic legion, genenilly that of aortic 
stenosis, of aortitis, or of nortie nncurisiu. When thrills are felt in 
the tricuspid ai'ea, niiniely, iu the midfitcrnal region ora little to the 
right of it. the lesion is probably tricuspid regurgitation, us trionspid 
obstruction is quite rare, or to aneuri&ni of the desceudlug part of 
tlie aorUt. 

In tliis eonuectiou we should remember the pulsation felt in lh« 
chcftt-wall in some cases of empyema. In nearly every instance 
tliis pulsation, when it occurs, is found on the left side. It is pro- 
duced by the impulse of the heart against the effusion, and occurs in 
two forms: the internal, in which the effusion transmits a heaving 
impulse to the chest; and the external, in which there is a |mlsating 
tumor external to the chest-wall. Sometimes this ia called '* pul- 
sating pleurisy." 

I'EKL'LTrMiON of the oh«st IS oomiQoiily ]>erformed by placing one 
finger, generally the middle one at the left tiand, on the eliest-wal) 
and tapping it on the Itaek with the tip of th« bent finger nf the 



ri^ht Itnnil, thu niovi^mcat of the ^triklii^ hand bcin;; entirely a 
wriaHnovcmt'ot. Somrtimes pcrcuBsiun Is nisule hy ilirectly Btrik- 
iii^ till' c)iL<&t witli tlie (ingcrs or [kiIiu uf the haiul (direct porcus- 
stmi). Mmny iiliygicians also employ a pert-useioii-Iiammer with a 
ruhbcr h«u(l and a [)lvxitDot«r, ur cliest-piecc, of Ivory, colliiloid, or 
glas«. GIaf« if- hy far thu hcst tnatorial for tiic chest-pitcv, us it 
(loM uot pnxluce a note of its own when struck by the haimuer, as 
<)o thv othor miitc>rials. The dis:ulvant:i|;f of this meano of pprcar-- 
eioii ii; that tlie physician cannot determine the degree of resistance 
offered by the surface |>crcitHsed, which is of the greatest service in 
many ciises of doubtful clianicler, ag, for example, in a case in which 
pneumonia is susi>ecteil, and the results of the percus^on will decide 
the diagnosis. Care sliould be taken in jwrforroiDg pennissioD : 
first, that similar points on the cheat-wall on each side are carefully 
compared; second, that the finj^er which is applie<l to the chest in 
placed ia the same n^Iation to the ribs, or iiiter^imce^, on each side 
when it is struck; and, finally, in studying the effects of jtcrcussion 
the physician should nlways employ it both during fnroed inspiration 
and forced expiration, in order to determine the rewnance of Uie 
chest with its fnll i]uota of air and when it has only residual air. 

The rwtonnnci.' produi-cd on pen'U*eion is due to thn* things : 
fire*, to tJie vibniti(iui» of tlm air in the lungi^; second, to lUv vibru- 
tiufiH uf thi- chcnt-widl when it i« struck ; tliinl, to the vibrations in 
thi- pK-ximt'ter plaocd on the diwil. The Iiut »e«l only be ciin!«id- 
erwl as a fimtor when a ]»v*m of «H^'lluloid or ivory takes the pl«<\; 
ot tlw finger, for tlic finger itself docs not vibrate enough tu alter 
the note dcvelopwi. Tlif note prtMlnced by vibration of the chftrt- 
wall can al»u be exvUideil as of little iinportaneo unless tihe che»t is 
' pliable ami rciulieut, as in a thin child, and tJie blow be deliv- 
very luird. The iDost inijKirtant factor in the piwhiction of 
j)crentwion-notc is tliat fintt named, viz., the vibration of the uir 
in the dimt «iu»e<l by the blow delivered ou Uic cheat-wall. A 
large )Mirt of the ]K-nni6sion-note depcnils, thcrefon', upon the amount 
of air in tlie chest; thv tension of the chest-wiill ; and the condition 
of the pulmonary tisnues. The sound prmlunil when the healthy 
cliest is percussed is calletl the normiil jndmonury resonance. 

On percussing the n'glit side of the che§t unteriorly in the mam- 
millary line we find in health normal pulmonary' resonance as low 
as the fourth interspace or fifth rib, at which point the resonance 
biyins to be im)Miired, so that at the sixth intcrspaov or seventh rib 



we tiinl this iliiliiOM. Tlii; niv« nf (Hirtiul iiiid iibsoliitc lio[iiatic dul- 
nejts irt itlmwii in Fig, loO, iii llw; chapter on the Alxlomeii, 

Posteriorly wo find on pcrcuMion tliut tbv nurnia) pultuonaiy 
reiK>nan(!C b^ius iis hi^h n» thv suprascapular artra, and ends as luvr 
lis l)i« tciilh or L-k-vvnth rib. It is much letss r^aonaat as compara] 
tvilli the ]}orc'ti8siou-nut(% obbiiiiL-d frnu the anterior a.i]ieiTt of the 
che»t liy roiuMiii of tlu- thiokncw; of the i^hest-wall and the pivsencei 
of the ttmpula.'. l-'or this rtusoo pulmonary rcttimnnce is l>est tltrt-el- 
opcd posteriorly at tlic biist-s of the liiii^ Itelnw the srnjiitlw. 
Before pcreuseiii]; the bui'k tliv patient should be made lu loiti for- 
ward and fold tliu arniH iii order to ativtch llio UAAiie.t ai»d iiial(« 
llu<m tuDsc and aa thin as poiisiblc. 

Plo. i». 

'Skoflaic [uauuic* on pvicuBlan. 

Compreavd lung. 

Tfrniany mil dollar tnuiiancv. 


Succmalon on ibaUsK. 


<Flu an poTCiutfon- 

t JM* nr Tooil ninnitiica anrl fMBltili. 

Tli« dondltlon nf i«rli In bF<1to|inciiuiotbotsx fri>ui a pcrftBvtlnn lu ibe pUim. IMdUe* 
UnkUnv I* nii>[«<cutAl by dmm fttlinR on i be ■iitlhce or tlio lliild. (Qimok ami Rc««U.) 

We oan divide the abnormal mundti protliiix'd by [Wpcnssion into 
Uie tympanitic, the dull, and thi" flat. We can aI*o dovebip by 
[»er«iissioii of th« rhis-t in di^^eAAe what is known as a " cracked-put 

A tynipanitie sound itt best produced in its most typical form by ' 
pcrrusHing the epiguslriiim when the st4>mach and colon contain 
sonic go*. \V't> obtain this .sonnd when the chest is percuswd if 
there is pD'scnt in the Inng a large cavity, and also in pneumothorax 
(mjc Fig. 120), in oi^msolidal ion nf the lung in Home eases, and in 
some Instance!* of adhesions or wlla(<^ of the lung-tissue. 

If the cavity be in the Iuuk it*'lf, it must he of some size and be 
n«ir the surface, and, if it coniiuuuiuttos with a bronchus, ihc obar- 



act«r of cImi notv w!!! dumge when the nioulh is oloited or n[)oiitH]. 
(Fig. 121.) If the caBO be one of pucutuothorax, with Hiiicl in Uie 

Fna. 12L 

OdonlUMd ftiM. 
ftMninw inoMMd. 

V««al TMDBUIMlllOnHOd. 

Onlnaoa pcranMloiL 

ItinvUMvl Tool iMeoHIM 

■nil mmltuEL 
ciiTiir "lih e«voniw» 

bnathliig Hid nirBltiiB 

Hypu-raoiuiiioD os par- 

CoiuoUrlailon — btonobUt 

IiirroNd fMallu* nuit 
IncB ea pcrcuMJou. 

Tubcieulit mnUmion. 

IinialrMl nwiiianw on 

Cniiroxion— Froidiuil iui<l 
■uiicr*]iiiiiiii rniM. 

PbtbUk kt Tkrloui itaft* la mm Innc. itic phrasal itciu deptoidlnc on Ib« lUcii. 
fOnnnx nml Rin«i.i..i 

chest, chAiigE« in llie posture of ttie [Hitiont will gn-ully ulltr tlie 
cliantct«r of tlir not«. Connolidalloii of tbv Iting, ns in i)iiciiniuiiia 

rw. us 

XfcMrlag U t taoAtnM dulpewgrtr tubtrenUt InniiraUan. <UtBio?c and RnULUl 

and tuberculoabt (Pigs. 122 and t2i{), generally gives a dull rattior 
than a trmpanitin ante, but if the (imnolidated aK-u Biirruunila a 
vory su|ier(inally plaepd bronrbiiii, the perous^iion-struke may |iro- 
dnn> vibration in tlie iiir in tliin tiiW, and tbis will cauKe a note, 


^mpAoitio in character, wliicli rario* as the mouth is oloMd oc 
opeDcd. CoI1h[>sc of the Itiiig twuses K tyiii[>»nitir not^^ licmiwe 
com pitnitivcly little air in the lung vibrntc^a mi n whole, il« vihrn- 
tion« not beittg stopped 110 in lienltli by the t«i)«c «eptA nnd vc«i<!ulirj 

Fn. im 

SUonUK bdghwnliiKnf pixel) Kiiteriorlgr Inm (»iiKillil*ltoii |<«U'cloil]'' Theiti*d«<li«t1 
li tbB ooDmlldaiWd pail; x IiiillaaMi iho potftlon wb«ra Ui« pcnrunlon-amind I* mboa la 
pitch. (Uinonand Kimui.) 

wail-i. It U best heartl in vmh-s of ph-urul ufTiision ov«r th« apex 
of tlie oht^t, into wliioli the eo11fi|}(io<] lung hns been piiiOied by the 
efrii!>ioii, Tlii:^ ill somotimcH allied ''ekodaic rMonaitce." If tlie 
eiunpn^SMoii in :«utliuieiit ti> ix>n»ulidutc tlie lung, the tyni]>KDit!e note 
in lost.. Thiis »ot4,' \a not altered by opening and closing th4> mouth. 

The " craeked-put sound " is prodiiecti by the sudden expulsion 
of thcnir from u euvtty through a ftaaW opening by the fonniof the 
percii«i*ion -stroke. It uccura on [)erciid9ing n healthy child wltoii its 
mouth i« open, the uir being forced by the blow from tlic hmg 
through the glottis. In diFwose the rracked-pot sound niot-t eoni- 
mouly results from the presence of a cavity in the lung. It m«y 
also be heard in cases of pneumothorax witli a fintnlouB tract open- 
ing externally or into a bronohiis; in a few losen of pleural effuiiion 
in thiu-<^'lieflt«d peraonH ; and in rare iiuitanceii before consolidation 
has occurred in pneumonia. 

In eases oE pleural (-ffusion a flat note on percussion is hwrd over 
the effusion, and it ii^ of very much the sanie chiiructcr as the wuitd . 
elicited by percu.*Hou of the solid tissues of tlic thigh. (Fig. 12<>.)J 

CtrtUac Hulnet». f>ii pcrcu«sing tJie chest anteriorly on the left 
side it will be found that the nurniul resonance is decreased bv tho 



]irewn«c of the h<«rt. At tlic n|icx of tlie chott on tins 9i<le per- 
ou^ioti (le^iilo]!!) normal itsoiiuiim;, but as we d«Mon(1 in the line 
itititiitttl hnlf>wny bt'twceii tliL' iiumimitn- line awl tho midnttrnal 
Viae wt- finil iiii impuirEuont of rvsounncc' nt tlic thini rib, which 
brcumiti, ill the iioxt inch of descent, » vorv markL'<I dutiieiM, whJvli 
i* prucluced by the )>rp8encc of a solid organ, tho heart'. Thr im- 
painnuntof resonance Is not cotnfilete at the up|)er border of the 
heart bcmuiiu of the fuel that the edge of the lung iulervotio» 

Pm. m. 

«( tmn uncurana bjr tniic*. A ibam tiM an* of •HptrOobil owdUe dnlOMt. 

betw«eD th« heart and the diesl-wall, and so tlic not« which reHulta 
»n penaHHioD h neither the normal resonance of the lung iinr the 
dulm-«» produced by the presence of the heart. (Fig. 124.) The 
mitliiMis of the oornial cardifto diilnofts on ]>er(Mt!«iinu are ithown bjr 
the diagnini whloh ih appended, and tliey fonu wliat twve been 
nkllitl (he " ninliac triangle;*." (Fig. 12ft.) 

The hirge triangle )>eginjt at tlie level of the Aeeond left ooAtal 
f-Artilage and i-xtcndH dnwn the mid.sC4^rnnl lint- to tlx' level of tliR 
MSth eoiMa) eiirtiluge. The ba^ then (>.\tt;ndn U^ the apex-beat, 


normally nitiiaU'd in tlie fifth intet-iipacc jusl inside of the clavicular 
lloe. Tho hyjifltheiiUAe of the triau^le joias the»e pointa. In this 
arfia wi> havo included the jmrtial and total cardiac duliic^. The 
^iiiall i-ardiao liiangle, which includcM tlie ahsoluie cardiac duliiens, 
bcgin.<4 at. the third cattal cartilage and tixleiKb lo the sixth. The 
bi80-line <'xtenilii to within one and one-half inches of the iii|i]tli-, 
and tlif IiypothentLse joins thiH point with the tiiini nxital cnrlilage 

IMtgnm ahowliig nrdUci IrlRnilm. Cun)|«r« 


at the midsteriial line. An vnW be Kocn from the dtagrani tlie Itor- 
ders of the heart really extend further than this, but arc not near 
the obest-walt and are partly covered by lung-tissue. (Compare 
Fig. 124.) 

The greater jiart of tlie cardiac dulness od percussion is due in 
health to the presence of the right ventricle, which is nearest the 
ohest-wall. 'I'he right auricle al-io is well forward, while die left 
ventricle only fringes the eilge of dulnesit to the left. This Ls well 
shown in the accompanying diagram. (Kig. 136.) 

When li_vpertroj>hy or dilatation of tlie heart occum it will be 
found that the area of cardiac dulne^ extend.'* u> the right of tlift 
sternal line and to the left of the long »ide of the triangle, while 


Fii. IW. 


talHon or hMn In nlulon to tlla ind clornum. 
Flo. m. 

OMNmcI pMvaMWii-itulim* tn a t*w «f oxMulvi (wrlMrtUI oOUiiou. 
(BtliAW Ba^Hwltl. Bfler tiMoir.l 



tlie npox-bfat » ttpl to lie <li't|>tuiHKl ilowuwunl »n<) to the tpfl. 
Grcut ilUturtioii ^>f tlit; triiuif^lva oocura »» thv rt^ult of periounlial 
dTtiition (Fig. 127), but id tJiii vam tim licfirt-iM)und» will be distant 
on nu«ciiltation and tbv npcx-bi-at vury ivablt: or IohI, wliursi^ in 
hypertrophy llicy arc nxa^gonited ami tlw ujiex-bfat foreiblo. The 
diagnosis of pcricardittti, uftcr tlu! stage of dryiiMs and friction- 
sound has pnaMHl by, is by no means its oaeily made us some of tlie 
toxt-books tvoidtl niakf it appear. One of ttic most reliable sij^s 
of pericardial cfFuston is that of Rotch, namely, that any consider^ 
able dulness id the fifth right intercostal space means pericardial 
effusion, provided pulmonary consolidation and pleurul effusions or 
adhesions are excluded. In dilatation of the heart the area of the 
apex-beat is usually diffuse, and the heart-sounds, while feeble, are 
clearly heord. 

In this ooiinectioR the foUotving aumnian,', prejured by San.'ioni, 
of the differential diaguoAJs between dulnes.1 due to [terioarditii) and 
that due to dilatation of ihe heart miiv be of intere^it : 

OuUlna of duln«M 

j Dulnia |Iea^•b■Il«l. and on- 

lt«l« at dtrdopuKnl ( often nptcl. »n,\ thBn obanid- .' 
ar dnlnoi ....'' MrlaUc I 

Th« Impultc. wben fmiBt, !■ 
In Uia Ihlnl or lOunb laior- 


I Duln«a laiir *il4ud lo (bo l(fl 
i of til* »pet-bta*. 

Impultc and Bpex- 

Relation ot dulnm 
to l«n ftt>«i-b(al 

Fain ont placard Im 
aud undaraM lii 
Uie«pl|aMTtaDi. . 

nilttir^nlniboTvlii* r Ubx be intNDt If endOMidltli 
of iliu naek . . . •. compUaiic*. 

rwuIlT iu?iit«. In Mun« ol 
•CDic TbcanuUim. olrrboUo 



Fenr t Often proonL 

Ullnlauan nf (An limit. 

j DulncB Dot pc*r4hi>|>wl- >■>■) <ll-j 
I IftrjTtineiit ohleHr dowDvuiL 

f QiiuUy (orir (In*. lhou||li ■ npM ' 

dllalallutl <ll Ilw tiNCt HHBtUOM* 

ImpulM MO unMlljr te Ortl M IM 
UR of llio lomr end at lh» M^ 
nun or Id ibai(4a>Kfliim. 

' Diilue* doea not exleod to tta* left 
of tboMtapex-bcaL 

Uiualli abWDL 

' Olten pit*«Dl ttMn rigM heart 


riuallr cbninlc; otten 
will) obranio vai Hilar te 

fatlf and bbrolil ilcgv norallML 


AbKnt utile 

rtom uau ' 

The same author also tabulates the fncl.t in tho dtffcretilint diAf^ 
nosis between increased dulne-ts due lo jieritnrditl^ atnl hyitertrophy 
of the heart as follows : 



nkiH of tiavclapmmt 

Inpote : tpcx-bou . 

rrrlmntmi mM ^ffatlon . 
L!iull]r rapid. 

f ImpnlM. vhon i>r«wnt. U In 
* the Iblnl or t-iunh 1«R Inwr- 
■[■HIV, mid It fMblo; kpex 
lilted upwaM and outmtd, 
or twat oOkoad. 


WMk and qalclE : mif b* Ir- 

r«aa]l]r iloiir. 

ImimlM iiovvcnil ; It left ronlrl4l* 
lirpcriNiphl»]. apDi dliplBccd 
^nnttMi] «url out Irani ; If djilit 
rratrlulf hyi^rinipbiel. aimt 
dlipliicnl don mvanl anil Inimril; 
lioal mnj Ix In lliu vplcultlum. 

CtMlaoMt Of the pulu) dppendi oa 
Ui« dija of Iho livari whloh )• 
h7p«rtRipblMl and me oaoM uf 
Ibtt hjperltophy. When left 
ventrloln bvpfrtrnpt'lwl. *<hI no 
aotUo nbnnictlnii or mllral fr- 
guTElutlon, tlie pulv U larfo 
anil powerful. 

ipliyeema of the \aagn the cardiac triangles may bo oliUter- 
■ the exteDstoi) of the lung betwucii the chest-wiill iimi heart, 
Tliey may also be diatorltid by reason of pleural effusions [)n>s»iiig 
the heart upward and to the rifritt, or in the cose of riglit-'<id«il 
pleural effusion the heart inny he pii»hi:-d unduly to tlie left. Pueu- 
miUhora.x may cause simihir r««(ilb4, or, again, old pleural adht'sions 
mail oonditions tnay m diqilaiw tliu \aag« or heart that the triangles 
bcaonot be found. 

n*. iul 

Pio. iw. 


Mtcntn <tf Uw Donnal heart. Ib« continueui UagraiD oi Uia iMWt lit aotUe obatmcltoii 
ll» iMUculat (^ ouUlao of iho ifKhk and and rotutStlaU™ Thv rlottol llticalBdioaU 
tkctneonrMiarilialoncaTltlia. [Sjunom.) enlarcemant of Uie len eavlUca, Mpcalatlr 

tha Ttotilcl*. Tha UverHtPoi oiur illilittir 
IneruMit (SaMoH.) 

Tti« vnriuus valvular and other lesions of the heart result in altor- 
ntion iu the siae of the variouii cavitiea without the entire viscns 
beiii^ ef|ualK" affected, Tims aortic regurgilation (.'aiises enormous 
rnlargemejit of tlie left ventriole (dilatation and hy{>ortro{)hy}, aud 



aortio stenosis also causes the eamc eiihirjtcTiifiit as a nilo ui 1<^ 
degree. Mitral rogurgilation caiiees hy]M?rtroplij- ami diUlatioii of 
the left ventride and ttomi- cnlai^ement of the li-ft aiiridc, an dw8 
nt»o mitml .stenosis. Tricuspid regurgilation causes hyprtropliv 
and ditatatiuri of (he right auricle and hypertrophy of the right 
veutrioli*, and mitral stennsis often has a similar influvnct- over ihe 
right cide of ttii? In-Jirt Uy clamming hark the blood inlo the lun^ 
and rislit isidc of tlie lu'art. The following figures from Sansom 
will ilhiHtrato the deformity of the cardiac triaugrles nndcr these 
various conditions. (See Kigs. 128, 12D, 130, and 131.) 

ftO. 130. 

Via. IKI. 


DUgnm ot Hit h«ri In recantluii"n U t>i« t>la«nia a( tbe taut la otelraeUon M IM 

nlusl orirlH. The ilotim lnim liulicaie «ii- mltnl orlfln. Th* dMMd lln* loduaU* «»■ 

ttrgomoiii iif ilif Ipnniirloivanililis loRven. laiBcmoai ortli« Itft ftnrtnle. TtjeonnUnoMii^ 

trlpt*, ths watlduoiK lln« (■ii1«rs*m«nt Of asM (bow xiiliiixaiuenl of iti« rlsht <b>~1IM. ' 

Ibc rtcht vcnlrlcla mii] rfglii suiioli!. The Tbf hver^m la miioli oulu^dd. I&tNK)M.] 
llveT-«i«aUmuel]«utftn«il. iSik«h,i 

Fimilly, it is to be remembered that much information aa to tlw 
thonioio organs may be gained by the sensation of resistance offi^rcdJ 
to the lingers on p^rcu^iou. It is slight over eavities, greater ovcf ' 
healthy lung-tjssue, atill greater over eonsolidatioua, and very givat 
over effuBions. 

Ausci'i.TATios of the eliMt reveals in health two ehief varieties 
of breath -sounds, namely, vesicular hn^tUing and bronchial breath- 
ing. The first type is heanl iu it» most typical form over the apices-J 
of the lungs anteriorly, the latter at the angles of the Hi^apulie jkw- 
teriorly. We may listen to thoAc sounds by placing tlie ear direi-tly 
against the ehest, or by the use of a single or a hinniinil stethoscope. 
The |>alient must be in an nocunstrained position, a> ithonld l>e that 
of the jihyiMcian, and if tlie ear is placed against ttie ehest, or a 



single stcthosooiie U used, the face of the jihysician should alwiija 
bo turned away fnim that of the patient, Itecniiec th<-> breath of a 
w«k person It often very tlisagreeahlv and the breath of tlie doctor 
tnajr be equally annoying to the imtient. Care should be taken in 
tlte use of the McthoAoope to see that the edge of the bell la in close 
contact with tlie ohest-wall on its entire ciroumfereuce. 

The ^oumb which are heani in health in the ohest on atiitcultation 
(ire re^|Hratory and oanliai?. The roftpiratory soiindj" eonsist, as 
aln'sidy ittalml, in the ve-^icular intirninr and the bronohtal or blow 
ing WKitid^^ whiuh arc ftomvtimes eallcd tubular hreathin^. In tlie 
vviiicleit thtt air in Ntilxlividril into many minute [nins, wherea.s in 
titc bronchial uibi« it moves atunjr in a <'oliimn. Whatever niay 
be tJie ac-tnul i-aiiwof the produtrtiun of normal vmeular breathing, 
w(> know that wh<rn it !:• prv^nt it aiguille:' a heiiltliy imlmniinry 
(Nin-m-hymii. and whon tibscnt om- moro or k-m discAM-d. 

Bronchial hrutlhing, norriml in the liroiiehinl lubex, bomnu-s an 
ibnonnal sigti when it is heunl in an aveu in which vMicnlar bn'Ulit- 
in^ should be pmsent. a» will he shown whortly, 

Aftvr iletvnnining llic fact that thi' sonnds of normal vehicular 
breathing aiv prcst-nt in the nntcrior parts of the chut, or tltut those 
of .bronchial breathing can be hcunl between the shoiihlerii, we nest 
like note as to the relative diiratitin of the inspiratory and expira- 
tory sounds. Xornially in the [wrfectly healthy chest the ratio of 
the expiratorv -uiiind t'l the in-tpiratorv sound is as one to three, 
although if the volume of air itself he measured tlie duration of 
expiration is six to live. In other words, so br as auscnltation of 
the vmicnlar portion of the lung is concerned, inspiratioii is far 
longer tlian expiration. Juat at this point we learn ont* of lh« 
most important points in the physical examination of tJie chrat, 
namely, tltat while the expiratory sound may he entirely ahst-nt in 
hi^alth, any marked iner(» in its length and loudness, ^i> that it 
ei|tiaU or excocda the ini4]timtory :ii>uiid, is a sign indicative of some 
ULsense^l state whi<rh impairs tlio elasticity of the lung, sneh as early 
tubemilosis, pneumonia, and emphysema. 

The otlier \'ariations in the vesicular respiratory sounds dilTering 
from thflise of health are har^h, or, an it Ik anrnetimes called, puerile 
breathing, and irregular breathing. In chihlrv-n, as the t«rm '' puerile 
bn-alliing" iudicateK, the normal vesicular bi-oatbiug i* loud, clear, 
anil Itarsh, b«vutL«e of tlic gmit elasticity of the lung and the thin- 
nc«) of tiie chc«t-wnll. If It is rxuggcnitcd in a child or prt«cnt 



ill till' tiTcn of nurnitt) vcAiciiliir liri'iithing in luliilt^, it ii^timlly imli- 
coti-H Homu irritntiui) uf thi; liruEicliinl niiii-DUS tuumUraDv. If it it> 
found ill tlie upious uf l\w liiii^)! tit a marked degrvc iind expinitioii 
is pralotigcd, it \x itit imijurtntit iin<] fairly sun' sign of (.iirly )>ul- 
moiiary tuburculoHis. 

Sometimes physicians spoak of " brondio-vesioiilar breathing," 
meaning a breath-sound consisting of both bronchial and v^icular 
sounds. It is Bonictinics heard in a healthy pcr«tm when he breatlieA 
sujtei-flciaUy, and in disease usually indirates early pneumonic 
changes or early tiibcrciilosis of the lung. It ta only of value as a 
diajiiirtstic sign if lo«ili/pd in one part of the lung. This harsh 
lircatliing of exudation and tltickening differs from normal pm>rile 
breathing in this important particular, namely, that in tlie former 
expimlinn holds its normal ratio to inspiration, wheirias in tht! laller 
it i» greatly prolonged. 

Irregular breathing or^nrs in the chest of a healthy sobbing ohild 
and in that of an hysterical woman, but it posscKsi^ jmtiiolt^igi 
eigniticnnce if it ui^onrs when a full hrt^tli in tak<!n, »:< it ia often' 
prt^sent lu an early sign of ineipient pulmoimrv phthisis. 

Br(^>nt-tiii>I hnyilhiiig in IntiUh itt bi-st heurd in the posterior |«rt 
of the chcfit, :is iilrcady >itHtcd, bi.-twccu the siiapiiite and the eeventli 
eervical to the fourth dorsal vcrtobra. When this broncbiul or 
tubular bnonthing is licurd iu othor jHirts of the chest it is n sign of 
<liseose, for while tin- bronchial tubi-s are distributed to all jiurts of 
tlie lung, the breath-soiiud which is in them is masked bv the sounds 
of vesicular breathing and muffled by tlie Inng-tissue surrounding 
them. If tliis veacular tissue becomes consolidated by disease, the 
Vf!<i<-ular murmur is lost and the solid lung transmits the bronchial 
luiunds directly to the car of the examiner. Bronchial or tubular 
breathing, or, as it is sometimes called, " blowing breathing," heard 
in the jiart of the lung in which vesicular breathing is normally 
hciird, h therefore a sign of tubercular or pneumonic oonsolidatiou 
(Kig. I-S2) or of compression or collapse of tlie lung above a pleural 
cffuiiiuu. Bronchial brentlting is also heanl in the area of tliL* chi'Sti 
in which vesioular sounds normally pre^loniiiinte, and in tTt^t» of 
«^9ivity of the lung, Itccause in such a hing the broiiehiat Mtuiid is 
tranHinittt*d directly to tlie cavity, and lliencfi to the ojir without 
being imjuiired by the inter^'cntion of healthy bmg-tiasuc. In 
otlicr words, couKolidatetl tii>«u(vi and aivities tniiitmit soum) better 
than tlic normal vehicular portion of the lung, which U n combina* 



tion of air and vesicular usll. If the cavity l>e lai^, we have » 
IoihI .toiind (li>voIn]>i3(l hy l)i(> trnii.iniiimioit of tlio limiioliial iwui>d 
into iu« open !i]ia(H> aiitl by thtr |)a».tagf of a!r tliroitgli it. This is 
called t»vernoti» l>r(Mtliiii(r. If lh« cavity \n not very itiv^, or i» 
peculinrly litimtt-d in rclntioii to Ui<- ^ii|iplyii)^ liroiiHiii», wc have 
what M rallwl " miipliiirii! bi-eulliiiij^" — timt ii", ii nomid like that 
l»mdiio«l by blowing over thi; month of nn empty bottle. Thi« 
Ntiii)<) ii> lUwt rarely bninl in ciiw?^ of pnonrnothomx in ivIikIi tlic 
bi\>iioliiul tiiixt', niiiniii^ iH-iir to tin.* pleural »ivity, traueiiiit their 
sonm) to tlie uir in the plcurul »pucL-. 

Ik. U2. 

■not «A MMOvltuioB and pti- 

pUlOD. llUlDCH on I«ttU^OD. 

BroDcbUI littkihlnK- 

tiievmonlaor the InJkrlot labs vlibibepLirUcalaJaiiiclwnuuiiiUcoC comoUdatloii. 
(OiMOX uid RmRi.i.) 

^M It is never to bo fort|:ott(.-ii thiit in exnnuiiin); the ctierf ihc two 
^^WlB roitst hv eooi pared, since the well Hide often ^ivc»i u Htandnrd 
^'for thilt uffecti.'<l by dlscQKe, itiid in doinj; so it must be renienitiered 
tluU disGiiM' not oidy modilies the ^ij^us in the Inn^ in whieh the 
morbid proocM is situated, but also ehan^rea tlie normal ^ptB. Thus 
piMMimonia, or |dc<irii;y or plenral efFiision, ratmea a louder vofiioular 
and bmnchini bn^mhiug on the healthy side than in nomial bemnite 
this lung has to take in more air to make up for the loss of activity 
nu the discaaed si'le. Grnit i-are shoul<I. therefore, be exercised that 
the bind harsh breathing of the healthy part in nueh a ronditton is 
not mistaken for the harsh hrenlhin)^ of di-teaae. 

Tfiere an- a number of other lumnds heard in the chest in cases 


i>f diM'iUM: of i\\K uir-poseagi'tf. Tliotu ooiisUt in rales of various 
kind», voici>»jiimIs (voml n.-M)uuuc(!), frictioD-Motituli!, nod stiocuH- 
luun notes or sountU. 

RlUe* aro divided into two c)ii«( cluiisoH, moist and dry. Tb« moist 
are subdivided intotliccrepidiil, orcmcktin^, the fiDehiibbliD^. and 
the coarse bubbling. The dry are ealleil sonorotus, or sibilant and 
hissing. Sometimes the sonorous n'lles are called rbondii. The 
line crepitant n'lle is beiit imitated by pressing; tlie thumb and fin^iT- 
tip tightly together and then separating them while lliey are held 
near the mr. This rille is dne to the separation of the vesicular 
walla, which have beeome adherent because of esmlate. It occurs, 
of oourac, during the latter part of inspiration, anil is an impor- 
tant sign of croojKius pneumonia in its early stages before con- 
solidation has occurred. It also is heard in caflee of pulmonary 
collapse and rwlema, but not always in any of these diseased condi- 
tions. Care fthould be taken that the line rales sometimes heard in 
tho chevt at tln^ bases, [)osteriorly, in a person who has been long in 
one ])otiitioii in iH^d, are not thought to be indicative of pneumonia. 

Kinc bubbling rali-s occur chic-fly in the smaller bronchioles and 
tlio cjoiirse bubbling i-Sles iu the larger bronchiole^*, and tliey are 
caused by the imussokc of air thmugli llipiid or niticus. Thc>^ are 
commonly hciinl in bronchitis and in pulmonary urdcnia in the luw^r 
parts of the che«t, chiefly postr riurly. If »uch r^les are hennl luiti*- 
riorly or in the area for vctticnhir bn.-atliin(;, ihcy indi'^ate the sia, 
of resolution of a pneumonia, or if this discu^ie has not been ])rc«cnt, 
or is long gone by, they pos^oAt the serious import of breaking down 
of tissue from tubcrL-uluttis in the lung. Homctimiw these ritlesare 
limited to inspiration or expiration. In eunvHiesccoce from an 
tiltai-k of asthma thoy occur with a to-^md-fro chametor, and are 
often musical or tinkling in character, 

If a cavity has formed and liquid is in it, we nuiy hear in the 
rliest a peculiar hollow tinkling, culled by Laennec " metallic tink- 
ling." These sounds are sometimes heard over tlie stomach when 
tliii* vi(H'iis in in motion and contains a Utile liquid and air. 

Thi-i'c is another condition in which metallic tinkling is beard 
\'ery olearly, and tliat is tit bydro-pneumothorax. In this condition 
tlicni i« a uonlinual dropping of liquid from the apex of the chest, 
or, more corrci'tly, from the i-ompressed lung in the ajiex of the 
chest, am) a» the dru|)3 fall througli the air in the uhest tliey strike 
tlic surface of the watery effu-tion with atiukltng sound. (Fig. 120.) 



Ritles are often remuviKl or altered in diameter, \i not crepitum, 
by i-oughinR, 

It h«fi altwwly beeii pointed out tliat drv rules may be divitb-d 
into tlte ooarBe and sonorous and the small or line sibilant rales. 
They are produeed by tbo pusw^e of the air, in the large or &iiialier 
bronehial tubes, through partly in.i|>ifl«iled and sticky muous. If 
tliey are sonorous, ibe larger tubes are the part involved; if sibi- 
lant, the aniall bronchioles are affected. 

It shouhl not be forgotten that hai-^h brealh-soimds nia^le in the 
mouth or in (he nose may cause the (ranr^mission of rough sounds or 
r£les into the lunj^ whioh will mislead the phvHieian in his diag- 
nosis if he thinks they itnse In the piibnormry tissues. 

Fflction-»oitn*ht in the eliest dejtend upon disease of the pleura 
or of Uie pt^ricardium, neiii'rally the former. Noriimlly the visreral 
and |i»rietiil liiyvrn of tlitr Hi-i-<iti-< mi'niliraiii.-^, whieh fumi ihi; jx-ri- 
cnrdium and pleitne, pri.-Tii.tnt itmwrth Hurfaces which glide over one 
Hiiotlier noJAele^ly, but when they bt^iome roughened by dittro^e a 
wmixl of friction \n dcvclopeil. S(>nielimei> the frlr-tion-suuud is so 
•light u» to lie almo.'it iuuiidible, and again hio harsh as to sound tike 
a loud eixuking, which inn be not only heard, but will convey n 
eennlion to the baud when it is placed on the ohu«th. As u rule, 
friction -•wtmda due to plviiritis arv be«t heard toward Iho close of 
inspiration and occur only in tliL- early Htnj^es of the dixmsc, ceasing 
witli the development uf tlic cffiHion and pcrhu|)s rL-iippc»rin|; as 
the effnfiton is absorbed. The place where the sound is must audi- 
ble is (lie axilla. If a frictjon-sound is heard at the a|)e\ of tlie 
chest, tuWrculosis will often be the cause of its esisteuoc in this 
locality. Care should always l>e taken that line rules arc not mis- 
taken for friction-sounds. They can be separated one from the 
other by the recollection of the facts that rales are modilied by 
coughing, not affe(!ted iiy deep pressure on the ehest-wall, and are 
usually well diffused, while the friction-sound is not modilied by 
coughing, is intensifiiKl by pressure on the chest-wall, and is usiuilly 
limited to a narrow area, 

IVritanlial f notion -sound is, of course, hoard best in the pneoor- 
dinm III the ba.te of the honri — 'that is, at about the tliird rib. tt 
is si'[Kim(i'<l from pleuml frieiion by tlie faet tliat it continues wheo 
the patient \\n\An \\ii breath. 

Ijaennen likened this frictii>n-«>»nnd to the noin^ made by the 

Jithur of a new sadiUc when ridden fur the liml lime. Sumetiinca 




it soauds lik« the vrunobing of anow uuder the shoe. It is usually 
u to-and-fro sound. 

Voeal rtmnanee is closely allied to the .leufuitioD called vocal fre- 
Oiitos which is felt on pal[k:tti»ii, as alraidy dcscribwl in this dmpter. 
It is due to the transmission of the votoe-soundatiown the tmcheji into 
the bronchial tul)efl and lii-om-hioloft, and thence through lln- vartouii 
portions of the UingH. If a iil(-tho»copc in placed iii the episteninl 
notch while the |>atient spt-aks, and the eJir of tho examiner wliieli 
is not closed liy thi^ instrument ii« cluitml hv tho pn-vmiire of hU 
finger, the voi<» of th« potivnt will he very ch-nrly heard. If the 
stethoscope be plat-ed lietween the vertebral column and the .^-aputa 
posteriorly — in other word*, ovvt llie hmiKrhial lubes — the voice 
also will be clearly hutnl, hut not ns I'lenrly ■« over tlie tneltea, for 
two rea.sons : lirHt, htri'iim^L* the wniud Iiils nlniuly hoim divide>c) into 
tiie differt-nt bronc-hiiil tiibut, and, suconil, lKvaui«e the ihirkiitaw of 
the ch«st-wnll miitHe8 it. If the elcthoeeope he ptaoiil ovvr tlie 
nnleriiir part of the elieKt lowiird the sides in the area of typical 
ve^irulnr breathing, thi- sound uf the voice will bo Atill more mod- 
ific<t, Itcitinw the sound, like the air that conveys it, is now minutely 
subdivldctl.und the vlbnuions arc decrenH^d hy the multitude of 
vesicular \vaJU. Of course, the d(^roe of timismission of vocal 
resonance is governed largely by the elmracter of the voice, and for 
this reason it is more di.'itlnct in men than in women. 

If the patient being examined !.■< a man and haa a well-developed 
voice, it ia usually liest to have him sj)eak in a whi^iier, beeauAe tlie 
full volume of his voioe h m> great that it will he heard all over 
the ohest and the nice differences between the InuHmis.^inn of the 
:«ound in the healthy hing and the disi.'aiMed area cnnnot 1m- distin- 
guished. UiituiUy we get the patient to speak by asking him to 
repeat hU name or to count " one, two. tlim-." The uneuiployeil 
ear of the physician should always he ehmtHi, ,-ind the cunnting or 
«penki»g only be oontimied while the physician ia actually listening 
to the ehwt. 

In diseased states uf the liiug we iind the resumtuee 'at incrvuscd 
by those changes which aid in the tmnsLmission of tlio aoimd and 
decreased by ihuso changes which obrtruct its tninf^mission. A» 
point«^'d out when apeaking of vocal fremitus, a aoUdilied lung and 
the opposite state, namely, a cavity, transmit sound better than 
bwdthy tissue, which is partly air and partly lnng-tissiK>. We find, 
therefore, Uwt the vocal resonanee, or the sound of the voice of the 




pttiCDt when lie i<]H<flks, U iiicrvaiKtl in piioitmomji. in tiiWnriilsr 
oonsolidutiun, »ii(l !ii <:avity, tiiid doLTca^otl in ljuh-s of <.-inpliy(iemu, 
or in cucH in which u plt^iinil (.■ffngiuu separatee the lung from the 
c)i<^«t niiil <loiitk>ufl»<)tia(). (Fi^. 115.) Voenl rewnaiicc, however, 
mny be incrc-iucU over pleiiml cffasions, particuhirly tlie resonance 
of the wlm]ioretl voice. This is called ■' Baccelli'i^ sigu." "nd 
Banx^Ui claims that it serves to separate serous effuHions from piini- 
lent effusion-*, because in his psiwrience it Li absent in the latter 
class of cases and present in llie former.' 

When a i^avity is sitnatetl near the surface <if the lun^ so that the 
fioiind of the voire is trannniitlcci U> it and from it thron^h the 
rJiest-wall with itniutnal clitiii-iK'.'<:>, tin- Hixind .lo clearly heard is 
(Dlleil " pectorilociuy." It in tiTiiiiilly very niarlte*) over a cavity 
oonneetid with a Iiroiichiiil tnlw. 

Sometime-s wln^n lhi> voice ifrmmtn lhri>ugh the chevt-wnll m if it 
were of a bWiing clmniiitcr it is rallii) " le^ophoiiy." It \* iwiially 
hrard at iho anjjle of the '^^pnlii, nitir tlio margin wf « ])leiinil 
eSttxionf and ix Mippuscd to be catise<l by compn-^aiun and partial 
oocltwinn of a hrouchiitt. 

Finully, in pyo- or liydro-pneitmothonix, if the ear be placed 
against tiie chest and the patient in -ihaken, we have developed a 
splashing or slopping sonnd, eallcd •' llip|ioeratio snceiiaaion," It 
is not alvrai s heard in these case^^, and may lie develojted when a 
lar^ cavity in the lunjt i^ partly tillinl with lifpiid. 

The healthy phynieal Hit^nn, and the vnriatio».-< from the normal 
mgiiA nii-t with in diKcnsed omditioitH of the liii);rs, have luiw ln'cn 
diHctiHwed. TIk- next ^tep i- to unnip thi-w various ■•igiw with other 
rhanicteriittie ■ymptoint in onler that wc mny obtnin n complete 
jiii'lnre in the iliat'i">«'« of » giveri di<<ea>e. 

Ia-i II? i><ippoM- lliat u patient. previoUfsly in health or without luiy 
seWoiM pulmonary complaint, \* fnumi, after a phvHical examination 
of his ehrat, to have mptd bn^athing, a somewlint anxiotis ex]in-»- 
sion, a bright eye, and a du^^ky (lush on one or both dieelcM. I'al- 
paiinn diwovcn a hot, feverett ^ikin, which in dry or more nrely 
moist, and increased voeal f rt-mitns over hiilh sidca of the chest, 
rooire marked on one side llian the other. I'ereutwinn reveals im- 
ininncnt of i-esoiiuncc over iheun-a where fremitus was found most 

> TMt<iCi>taiDaaUcD«il hen for Blmt l> U trarUi. ThetrrtiKt hMtierrr Imn able is km It 


i»ri>«a»H, uiitl nn^i'iilt-'ilion in \\\\» nri>a »]iuw» bntncliiiil bn^ithini;, 
fiue cn-pitiviit rdlcsiiinl iiifniisiil voojil rf.*>nniioe. Umler titcso 
circum8UiDCi}i< we liuvc Itcfurc m llic jiliysicnl iif^an of acuU eroupow 
pni'umani'i. 'V\u' puIsc ijf npt to be nipid, but, not iw fast iis the 
rcspinitiun wmiM k-uil ua tu <.-xj)i-ol, for it U a c-luinioturirftic of 
thi» (liiM.'AH(^ lliat tliv rcvtpi rati OIK are out of proportioa to tbu pulse. 
Tb(! (liiii^noi^is i» coiifiriiii-<I by ttic pro^i^'tioe of pniD in tlit.- side 
iifTi-titi^d, by t}ic oonj^h, tlir ni!!ty, sticky i^jiutuin, uikI tbo liiittory 
tbut tliu illn(;)» wok 8Ut)<leii in onttet hikI wtts imliutcd by u chill 
whicli luny or ?iiay not linvc followed exposure. After a few dax's 
tJic ritlcs dimppctir lut eonsoUdntJon biy.-oini?fi coniplett^ in the affected 
part, und the urcu whieli pLVe impuirol resoniinoe on (tercueiiioM now 
gives a dull nute, while the bronchini breathing in the affected part 
lieconics more marked. Tlic lips are apt to be attacked by herpen. 
With the fall of tcmpcniturc, or crisiB, which may be resehed by the 
tliitxl to the ninth dny, the rales return (i-(i/u redvx) and become 
mure and more louse, couree, and moiHt as refiolution progreiuies^.j 
until the hing becomes entirely clear, and only a slight muglieniog 
of the breath^sounds is tu be heard. Bad Hymptotun in such a mm 
are delirium, a feeble pulse, a feeble heart with ditttant heart-iMninds, 
or one in which the aotinu h Ubonnl and irn<^iihir. I'rtme-juim 
sputum, or, as the disease progreasfw, jiurulent ttputum, are bad signs i 
aIso. If the b^mjierature falU to nontial about tJic tifth day, and 
then ri:*es agiiin, forming a ]k»eudo-cri«i>*, the attnck will probably be 
prolongeil. When a child in affeiled by croupous pueiimonia it is 
very common for ns to find nil the onlluary objective symptoms 
witliont any of Uie phy.'^iejil Kignn jUHt named. The dulnese on 
percussion is diftieiilt of dcvelopiueut becnuso the chest is so reeiU 
ieut, tliut the j>crcui«t>ion blow makes the wholo chest resound, aud 
it is notewnrtby that percii».fion of ttio chest on the diseased sidi* 
quite commuuly dcvelojis a high-pitched tym]Hinitic note such as we 
often lind above a pleural effusion. 

The condition of cruujwus pneumouia cannot readily be ciMifti^-d 
with any other disnise because of its eharaeterislic symptoms, but 
oatarrhal pneumonia and tuberculosis of the lung often are oou- 
fnsed. In ettlniThat pntiimnnia the patient usually presentH a hijitory 
of some previous illness. The disease rarely begins with the markid 
and startling symptoms of the croupou.t form, but is inwdioiisnml 
aeeom]>anied by a milder but more prolonged and eon:<tJint fovcr. 
t'crcussion often will not give the positively dull note which can be 



vlit-itiil in vron|>iiuH piieiiiiioiim, anil only impairment nf resonance 
Riav bi- tI«vclo[>cd. There is Infreascd vocal frcuiitiis oil {lalpation 
and iiien>&ife<I vocal resni]:in<% nn aiiBCultatino ; there are abo 
in(T<.ii««4] bronchinl hreathii)^ and mnre hntneliial riiles tliao in the 
i-ruii[>utiH form, for tin: tiinease is a hn>iioho-|kiieumnnia involving 
the bronchial tubes and vc-siolfls. The Mgna are generally diffuse, 
very often heard at the bn^H jioaieriorly, and olear tubular 
breathini:, sueh as In heard in ihu <rrMii)iiiii;t form, is rarely to be 
found. The spnlum is not stiuky or riitity; the fever doe^ not end 
by crisi^ but rather by ly.iin; arid the \»"ff returns ta it» normal 
state verj- slowly, iU [>i-i^ri?«8 toward hridlli oft«n remaioiiig almost 
Ktationary fur week>i nt a lime. 

The »e[)arati(iii uf tlK«e itrn)|>tums of cmtarrhnl pnetimonin fnun 
those of early ]inInionarv tiibi-ri'iilosi* is jtnictiwilly inipos^ibh- by 
the |)hyjj<«l .■«ij'iw until the tiisi' hiw progressed to a well-n<iv«need 
[Nisitinn. Often cainrrhal pneumonia merger into the tuhereular 
<-i>ndit!iin, niui very often the diiigrio^i^ of t-atnrrhal pneumonia 
pr»VL-9 to have been made in a caiBc in whicli the disease is really 
tjdtentilwis. We have to rest the diagnosis of tuberculosis ehtefly 
on the family history, the personal history, the fact that reeovery 
dfies not take plan-, and, more important ihau all, the presence of 
tuliorcle bacilli in the sputum, or yellow elaslie libres which indicate 
ft breaking doun of the Uing-i IniiUeM. 

If the malady lie liitiercuhir and progressive, we simn tind in the 
chest and sputum signs which make the diagiiosii* clear. The cheat 
on iaapeetiiiii docs not move with en^tnl breitlhing an much as is 
normal; the hand p1neo<l upon it fivls, when the [xiiient sjieaks, tliat 
there in not mily ineniimil fremitus but » bubbling fet'ling from 
i-oitr^' rith^, and anteullatiou uU) rifveuls tlte digits of the breaking 
down of Iuii;^-ti'>«ue. Finally, when n cavity it develojwd the per- 
euwion-fMiund over it bfcomet high-piteluil, and, if the cavity be 
Urge, almost tyni[>antti'-, although all around it dulinttti may be 
pfe*A'nt. The bniithiug now beooiuo' mure tubnlar or nniphorir, 
and vockI reatmanee may be im'reii^etl to -tiieh nn extent that bron- 
ohopliony or pcetorilocpiy becomes marked even iti tluit jiart of the 
lung in which in health the vc<<icnlnr !u^iind» are heard moHt typi<^ 
ally. (Fig. i'-^-i.) I'roluugutiou of expiration 'm nW pn-i^cnt, and 
!>vmtB, irr^ular hectic fever, and gnat hiss of tiesh enHiie. 

The history of the eai>c an<I its symptoms are our chief nKiins uf 
iie))«rating pulmonary abseess from pulmonary tuberculosis with the 


(levolojtmrnl of cnvltv, for tlio plnw-Jil sinus iir*; ftbimt tlio Nim*". 
Ill «tTK-i< uf iil)»<-i-K« wv tind that tlie putk'iil !)»» HiifTcrtHl fruiti piicu- 
tnuiiia ur frum pyicmia, willi embolic iufarctiun. In otlior c*b«-s 
disfrlmiTjoe from tlio n(*o and tlin»at f iiU'ring the Iniigs ]»rTMliim siirh 
le^iotu. TliL' rivrnpttims of altsniss, uhiHi sppiirute it from i.iiv'it_v 
duo to tuberculosis, arc afi follows: in abscpss the lesion I'xists in 
the lower lobt" os u rule, while the tubercular cax-ity i* nsuallj 

Fw. 131 

CtMoT (OltiMmty tavRjr dut lo luberatiloui rur tvuun nnx t* i|>p nnt. f Irtnit tb«i 
0*1 dfiworMiltr. wU&MTtRiou* bnuUnt >nd v niiprmx pHiortiaiuj-. ftnd tb« oumt Hog \ 
tbktot ooiMoUilRCloaidulneMi. withnpu bnaklnR down oT the lunftlMiia (molai rtlaal. 

found at th« ap«x or in the uppiT lobe. The coa:<tttiitioiiiil dU[url» 
»nw; iu abscess is <iUeu vtry atiglit, wherciw in tulK-rcuIosis it i^ 
iisuAlly Hcvcrc. In ahnceits the ^putiini U oupioius ai>d puruleut, 
uml often i'oii|;li«l ii|i in ga^liss, «vhcre«i> ill tnbcrculoM* it is often 
scuuty, uml not m«rl<c<lh' ]iiindcnl, us n rule. Afraiu, in tlie last- 
nampd <lisui>TC tiibvix'lc bacilli nmy he found, but tiioynrc absent in 

If tlie patient hiin ihi- siguf of cavity of the lunj;, and in addition 
an exceedingly fetid brc-alli, with groat tt-asting, the case is probably 
one of pulmonary gnugrcno. Gangrene in UiOially fonitd at tli« 
base of one luug, as is abiioess. The <ipiit«in] is usually browuiah. 



BroupliiecUius with fotid breath b occaaionnlly met with, but tht- 
f«tor after cout'biDg is never so horribly strung as it is in cases uf 
H gnn}!;reno. 

There arc twn areas in the Inng often affected very early in jmeu- 
oioata, ^rticuliirly of the erou|i<iu.i type, and in [uilmonary tulter- 
culnsis, which are apt to be overlooked, namely, (lie axilla and the 
.septum l>ctween the upper and middle U)be un tlie riglit side, an 

Pta. IM. 

I of dXlllMBI foUDd lO nUIIT CA" 
(■1M4 inltinl llii 

r^ i-<ilinon»)' tutwrcnloab. wUca the arm tt 

ar«tt only exputHM) to percussion nud au«iniltation when ibv right 
band of the pnttent i-^ ]>1 i i- 1 <iii top of hU heuiJ in »ucb ii way tliat 
the angle of the wcjipuia i= drawn away from the verlebnil Unc. 
(Fig. 184.) If this is done, tlie inner border of the soapuU will 
approximate the line uf the septum, and along tiiis line there will 
I often be found in Uihereuli»is of ihis ]>i>rtinn of tlie lung marked 


(lulnei^ oil porvuseioii or, on mtHriiltatloii, nilw, and llic othor pliy»- 
ioal ttignB of ooneolidatioii, evpn tli'iugli tliu pliysicinn is tinabk- lo 
find eWwIietv any evidence of loeal disease to aorannt for the gen- 
eral syeteniie svtnptoms. Very often eareful auHcultation of the 
iDiillary urea will alr^o reveal Hgim not In be found elsowlien^ wliidi 
aecouot for the illuesa, auch as those of pneumonia or pleurisy, tor 
here, m^ a rule, the £ri<^tion-soimdij of the latter affection are be^t 

The pbviiical .-signs of pulmonary cedema may develop suddenly 
BB a re-iilt of an iiijupy to the vaijii;^, or in aeiite di.tease of the 
lungA. Generally, however, their onset is alow and insidious, but the 
rapid breathing, crepitant rales, the limitations of these si^ns to the 
jjpwer part of the chest, combined with dnlness on iwiwaiHion, tlie 
wtsenoc of fi:\'er, the fi-otiiy aputum, and, it may be, the Itii^tory of 
renal dineiise all point to the tnio state of nfTaii*!*. 

Thore in niinther stalo that givcit diilne?ui on ]>ercti,^ion, crepitant 
rdle!^, and the nther pliy.-«iciil si^iu of pm-umunia, namely, pulmon- 
ary con^e»tion dqiendi-iit iijxm thi- ai-tton of a fechte li<-art i» the 
oouT!W of prijlonju-d exhausting fevcn*; but the hiittory of the ill- 
ness, the fwhle heart, and llic development of their (figii» in the 
dependent purle of (ho clieiit cffedtuilly preclude the idea of any 
acute indnmniatory proceiw !u the lung. 

Finally, we frequently have after a pulmonary apoplexy an area 
of consolidation in the lung; but if this be the «we, we also have, 
as a rule, a histo^^' of hromoptysia. Thia condition is, liowevor, 
comimratively rare. 

To <-Ite another form of thuranic dinease, let us aupjHise that s-1 
hi-iilthy man is selitcd with pain in the tlionix and a chill fcdlowcd 
by fevor. An examiitiitinn of liIs thorax will reveal on inH[(0(!(ion 
dt'Kcifrnt brciithiiig on the ufTitiUd side, which is tixed be^ctatiec of 
pain priMluoc^ by the itillamod pleural surfnci*s mnviufr over one 
another on in.->piration. Kxa^i't-atnl breathing will be found on 
tlic oppoi^itf^ Hid«^ to coinpcnsat4> foi- tliitt fixation, iind niMciiltation 
on the painful i<idewill reveal a frtetion-noiind, probably bc^t hcanl 
in the axilla. After tlicasc x!gn« have existed some lionn the M-cond 
Mtnge develops and an effusion tnl<e^ place wc flo<I that tJie frietiun- 
aound disijipcant and that the afrc<'t(^-<1 >^tdc, previuuily altnost Dor> 
mally resonant, is bc^inntn); to become dull, and, Jiually, is flat UD 
percussion at the most dcptrndcnt part of the pleural sue, oamelv, 
at the base of the tun^ posteriorly. This area of flatneaa OD per- 


^r.uUinlly r'mv* higlier iiniJ 1ii(;)ier until tlu- t.-ffusioii w coin- 
It L-xtvniU aiiU-riortv, ami iii:ty he ilcmonslmtcc] us well 
- here a-* it can l*e po«t«riorly atiil laterally, altlioti^li, if the patiiiit 
liM OQ his back or is partly recuinbi'iit, tlic entire anterior sarfacc 

•of the cli««t may bo reeoiiant, owiii); to the SuiJ Imviug tlie froat 
Af llie ciimt aa<\ going to the more ilept'iidpnt parte. In otiier 
words, in cases of nDti-aaeculated Beroiis pleural effusion eluiD^^ in 
tile pugitina of the patient eanse alterations in the urea of flatness 
on [icrfUS»ioii, unless tlie efFiision is larjie enou^^h to (ill the chest 
entirely, when, uf course, it is immovable. TnspcotioD will show 
an increase in the size of tlie chest on the diseased side, with bulg- 

»ing of the intercostal siwce-*. 
A curioiia yet important jralnt In this connection is the fact that 
the line where flatnesa on percussion ceases at the top of the effusion 
pontcriorly is waw or nigraoid (S-Hliajwd). Aliove tlio level of the 
effusion percnesion over the coia])ressed liiiig gives a .toniewhat hol- 
low note or hyper-resonanoe, called " skwlaic resonance," and the 
senw of resistance to the percu^Mol fin^i^r i.-< les« at thi.-< i>oint than 
over the effusion, wherir the ri.-4ist»niv; is grvat. In nusmltiiig the 
cliett ill th^ area in which flatn&u has been (Icvcloprd by iicrcu^iion 
vm* distant hrcalh-sounils ar<! audible, oxvcpt in tlie Wck nr^r thf 
vertebral column, where there may Iw marked blowing brunt hiiif'. 
If the |>aticnt s)>eaks, there will be found Iohs of vocnl R-'-onancc 
and of fremitus over the efFuHion, but along the margin of the ifpino 
on the dtseaiwil side there iiiuy be henr<l in some ciLses bron- 
ohopliony, or even the bleating voice-sound cnlletl iegopbony. In- 
spection and pnl{>ation will ^how the apes-beat of the heart displaci^'d 
to the right and downward In cases of effueion into the left pleura, 
and to the left in cases of right-eided effusion. Again, if the effu- 

tlion be on tile left side, it will he found on percussing " Tiaube's 
seuiilunar siwce," a space din?ctly in the nipple-line and a little 
below the nipple, that the usual tympanitic resonance normally 
found in this area is extinguished through the downward pressure 

^ruf the fluid. 

^P If the effusion be aecomjiiLuii'd by pneumothorax, we will 6nd 
tbr(>u sets of physical signs, namely, tlinse of effuMon, which will 
Iw nt the lowest [>art of tlie chest; next above this an area in which 
percoaaioii giveji a cli>xir tyiufNinitic note due to the air in the pleural 
oavlty; and almve thii* the physimi i^igii>i of the compressed lung in 
the n|)ex of itie chest cavity. In this condition wt> may also hear 


tmcr^tisiUiia or syi\as\iing ^nitndi', if the patient is tihaken while' tbt 
ph\'iticiaii'.4 (!ur ii< again i^l the (^hei^l-wall.and tlio meliillii' tinkli 
or timppiiig :«i>iiii(Ih, n^ the fluid falU fnmi iht* top of the chest- 
ciivily into xhv cfTiiNinii. .V^in, W(> may ti»c wtiiit Uta l>ceii call«l 
" ilullitr iiercnssiiHi." Tliii* ocHwi't* in hftviii); an iii<(«l«tn»i pliwe 
u >(ilv(.T ilullur iLt;iiin»t Uic chost-wull ua the- dist.-uM'il siiU' untcriurly, 
siiil tlic^n the phvfticinQ listeiiH at the posterior iwpevt of th^! chvnt, 
his unused fiir beint; chj4ii] by Li» finger. l*lio aMistiiit now Btriktt> 
the Hilvcr dollar with the vdge of another silver dolliir. If tli« 
dollars be struck together betow the sur^cv of the cfFiisiw, very 
Utile of the metullic sound will be traUFiiiiitteil through the rhcst. 
If the dollars are stritok together at the level of the layer of iiir, 
the sounds come through the chest-cavity with startling eleurnese; 
but if at the level of the hing, they are Ism clearly heard than at 
the level nf the air, hut more so than at the level of the effusion. 

The rea-wnn for this are obvious, fur the li(|uid prevents the tniit»- 
miiMion of tlie metallio .sotmd.s an does also to some extent the coiu- 
preaiHHl lung at the apex of tin- ehesi, wherniH the space filled with 
air convoys ih*^ Miundn diret-tly to tlie ear. 

Finally, if the effusion ii absorbed by unnidcd nature, the area of 
flatness on pcrcu^^ion bi^^jome* less and Ics'* great from above down- 
ward, the cx|musion of the chest on irispirutiou increases, tliv int«r- 
spucus cca«e to bulge, and the frictiou-sound» may return for a brief 

If the effusion does not disappear, the |diyaiejil signs of its vxis^ 
enoe persist; and if it becomes purulent, the patient is apt to lose 
flesh and strength, to have chillB. fevers, and sweats, and to pre^tit 
all the evidenees of an aei-timulation of pus in some part of the 
body. l*articularly U this re-dult apt to follow a pleurisy compli- 
cating one of the acuts infmtious diseases, such as scarlet fever, 
typhoid fever, some instances of pneumonia, and in many caies iu 
which tiiberoulnsis is responsible for tite illneas. 

Particular attention should be called to the podsibili^ at pleural 
effusions coming on in^idiDiMly, Thei'e is probably no other nios- 
mvc pathological changi- any where in the bodyi^o often nnstLS|>ected 
or overlooked, nii<I it '\* nott'worthy that when pleural cfTnsinn is insid- 
ious in lit unset and devoid of ))roilroino>, that it is often dim to an 
undiscovered tuberunlu-iis, whcthL-r iht* exudate be found to be serous 
or purulent. Again, the fact that tubercle bacilli cannot be found 
in the effusion when it U a«pi™tcd In no way proves that tJte cffu- 


Bvm is Dot tabercniiir hi on^it, since tlie; are rarely fouud in ttie 
fluid even vfhvu tubcrciilur plctiriev in most active. 

Serous pleural effusion single or <loul>le mav result from throm- 
bosis of the vena ozii'goB. It is partioulnrly apt to come on in 
patients snlTerins; frnnj ivphoid fever or i)tlier eKliaiiftinj; di^t«iM«. 
Such a tmiHiiiUlioii van l>e separatwl from ihpefTiiHion due to in- 
flammation by the method of I'ohl and Ro^nbaci]. This oousi^ta 
in withdrawing some of the fluid by an aspi rating-needle after the 
patient has received a dose of iodide of jKiuiBsiuni. A few dmps 
of fuming nitric acid are added to the fluid, and it in then agitatetl 
with rhlnmforni, when, if tlic effusion be n transudation^ the imiine 
will be s«en of a red color iiinkiu); to the hnttt>ni of the t«st-tul>c 
with the eliloroforni . If it be an intlammiitory exudate, the iodiue 
will be pn^^ed int4> the ■•(fuitidii. 

If on i)Mpiratin)T the fluid in the ehcjtt it in found to be hemor- 
rhot^ic in rhiimct^T, the aiuw may be one of the disease* which pro- 
duce markc<) aMlhcnin, notJibly carcinoma, Dophritis, one of the 
acute infectious diseases in a niaIi)Tnant form, or tuberculosis. 
The canoer may or may not he in the vUvtit. Ituroly such an cfTti- 
eion occurs lu otherwise healthy men without these causes. The 
possibility of the hemorrhagic effusion being due to a leaking aneu- 
rism, or to leakage fn>m an ulcerated bloodvessel in tnlten-ular dis- 
ease of the lun^, is to be remembered. 

If after esposiire to eold there i^ a sense of w>reness in tlie ehest, 
with more or Iciu oppn>rision and a liard ooitgh, which seems to tear 
the bronchial ttibos, the oough beiug without nHsooiiited expeetora- 
tion and the febrile ni<>v«meut but modvrat's we susi>M;t the prewnee 
of an aeutf! ImmrhitiK, n diagno^ii* which will be uonllniicd if w« 
find the following phy^inil i>ijrn»: 
^^ There Lh marked rout^hcning of thv breath -soundn ull over lh« 
|HbHt, particularly ovit the bronehial tubes at the luick, between tlie 
f n^nln.', without any increiLst^ in vocal n^'sonuiur and fremitus or 
any impairment of resonaniw on jwreuMion. Ah the disusM pro- 
givKKn these rouj^h sounds of harsh breathing give way to mW, 
which are at lirst fine »ud moist, then course aud sonorous, as the 
second stage, or stage of secretion, develops; and, Anally, iJie^' 
deorauo little by little, as health is iippniHchi-d and the muens is 
oxpelloi] by coughing. Care should always be taken lodetcrmiitc in 
examining a cajw of i%ns]>cctcd bronchitis that the Bym]>toms are not 
dne to a hroncho-pitennionia. 



Siioulcl the uu4e brcDmo tihrunii^ th« «uumi« of oonntc, «ntl more 
or lesift -ionoi-oii!*, rSlc* ivill {KTi<i:4t iitid will Ih-^ohh? ciinstniit. Such 
oaiH-s ti.«utillv biH^ime worse in wiiitur, mid tlic itpiitiiin U AtmcliiiHW 
very profuse (Uroiicliorrli<i-a). The physiciiin ahoiild ahvny* be 
cari'ftil III l)io«<.> niHCa Ijj "t-o to it tliat ronal iliswisf ur u fcoble hwirl 
U iii>t the- utii-ie of ttiL- hroiichiii) disortlL-r. TIr- lii-ulth »ufFiT4 hut 
little in simple chroDle bronchitis; but iF'hronchiectneis duvclope, it 
muy hi* miR'li uiijinirfil. 

Umk-r thi- itiiiiiB " putrid bronchitis " we have a stale in which 
tlie sputum is foul and cxpc-llod in a liquid form, in whieli float 
littU- yollow plugs (Dittrich's plugs). This condition may end in 
piilmoiiiiry gaugreno or l^iiisc metastatic abscess. 

Tbf prcsL-iiL'c of a barnd-sbaped diost, with almost immovable 
walls and marked abdominal breathing, points to the preseuoe of 
cniphysiimii of the lungs, and this opinion is oonlirmcd if on ansetil- 
tatiuii of the chest we tind mnrkud ftrolonfialion of e^pirntion, dimin- 
ished vocal resonance and fremitus, and increased resonanee on 
percussion. The face is often ijuite evanntio, the superficiul veins 
of the neck turgescent, the abdominal R-spiratory movements abnor- 
niully great, and the superlicial veins in the e|iigastriuni enlai^d. 
If l)r'iiir'biti!t or bniiidiioi-liwis is aifiH^inted with the iHnphy^mii, as 
i& fn'ipii-utly the ca^ie, we lind more or lf*i nmiki-il riiles all oviT 
the ohest, pnrtieiilnrly posteriorly. SonicliiiiiM n -(y^lolle mtirmur 
con bi' liciinl over tlie tricuspid uri-n. iliu- to iVKiirfritation on the 
right sidi' nf tliv lionrl. Ciinliiic dulues« is geiicmlty oblitentnl 
by tlie cnlnrgcil lung, and theupctx-beatennnot be felt except i» the 
neighborhood of the ciniform cartilage or in the epigiittriiiin. Until 
the liepntieaii'l splenic dulneas are found to begin and exteud lower 
than noruiul, owing to the expsusion of the Inog. We may also 
flntl niventuiition of the second sound in the pulmonary artery. 
The tricuspid regurgitation usually develops from a damming up 
of the blood In llie right ventricle. 

When a patient is seized with a violent attack of dyspn<ea its 
cause may lie asthma, a foreign body in the air-imssagc^ or larjTi- 
gcul sjiasm. 

If it is asthma, there will lie Uhnrcd breathing in whieh all the 
aoceasory muscles of respiration in the neck and trunk aid the onii- 
nary respiratory miisi^tes. The piwtim- of tlie patient will usually 
be tliat of flitting up in bed and somewhat leaning forward. Tho 
face will be flii^ied, the veniielH of tlie and neck tui^d, and tlw 



li]*- miiy Ip« uynnotic. Often tin- jmtit-itl, ivliik- ititliii); up, ii'U]i|n>rt'? 
hiiiiM-lf \)y resUDg oii lii» IhiikIti, which urt* pliuH^^l »t his miIi* in 
order to nu'w his shuul(lci« iiud fix tho cliest-walli; for contrnt'tion 
nf tliL- iuii«-k-* whioh art- fn<ii-»vorinji to ^irivf out the air, for it i* 
to Ik! n-'mi-mlK-ivd that tJic rc&pimtury difficulty in ii^thimi dcpcudB 
iiiorc upon the fact thut the puciL-iit tnonot empty the lungs thao 
upon the fact that he cannot fill theni. As u matter of fact, they 
an- too full of air which hiu^ heeu used. 

Inspection not only sliows lliPBe signs in aslhina, hut also reveals, 
in cases in which emphysema has not developed to such an extent 
na to cover the heiirt with the Inng, that the apex-beat is diffused 
and (tie heart lahorinif. Palpation reveals little, except when cnar»e 
mies are present in large numherij, when .tome buhhling may he felt. 
IVreiLi-iiiin aiually gives an increased resonanoe hecan.'to the ehet>t is 
inordinately full of air, and aiismiltation reveals very loud htoM ing 
breathing, niiuiical notes, or .ti^ucaking or creaking noises, both on 
inspinilionand expiration. Finally, a» sccn^tiou begins to lu-i-.stab- 
li.-h(Hl musieal and cooin)^ r;'ilf8 nmy be heard in woll-nmrkt-il cii.-*C3 
»]l over the ch<»t l)erore the ear ht placed against the patient. At 
ttrst tlie*' rSlpM arc heard chii^Hy on expinttiun, but very shortly 
ihcy iisxxxT eipially loudly on both inspirution and cxpimlioD. 
Tuwnnl the end of the nltjick cunghing bringn up a limited amount 
of sputum, which coiilainB CurHchnmnn's spirals nnd Charcut- 
Lvydvo erystale. (Sec chapter on Cough and Expectoration.) 

As wtliina is a symptom, not u disease !n itself, the physician 
fllionld always examine the nose, with the object of discovering some 
Boiirue of reflex irritation in the nasal mucous membrane, or the 
urine to discover whether renal disease is present, or tlie heart to 
dtsmvcr if n canliac lesion accounts for the symptoms. Sometimes 
piotric disorrler is responsible for the attack. 

Cure should be taken that a catarrhal pneumonia developing after 
■u attack of asthma is not overlooked until tlie patient is danger- 
utisly ill. 

IF on iniseul ting the diest we tind it filled with musical and cooing 
riilea heard in every jtart, though most marked in the bronchial tuhe^, 
we can l^e fairly sure that an attack of n-tthma is about passing away ; 
hut if, on the other lund, tJie attack is beginning, the prolongid ex- 
piration, with eomiKtratively few r^les, the harsh bronehial breath- 
ing, and the gi-neral ohjoetive symjitonis of the case will explain 
lie cause of tJie pulmonary ooudilinn. 


The (lyspnctn due to n forci^ body in tho air<pasHiK^, whcth«r 
it be II piecD tit nifjit or a fiiUe mi-mbniiK-, 'm mule diffcmil from 
lliut of iistUmu, for in this cn»e tin- difficulty in tviamoiily tti Uii- 
eiitnmctf of nir. The onset of thi- atlm-k is ueiiiilly sii<)(Ifn, htit 
iDBjicctioLi nil! filiuw thiit on iuspiintioii the costal iuU-rsjiu>^-K iirv 
greatly druwa in, as U also thu epigastrium. There will be pmc- 
tically uo aigRH in the which are not evidently due to the 
efforts at forced breathing, and a history of having had a foreign 
body in the mnutb or of Bome laryngeal disease will uiuially be 
obtainable. Obstruction may, however, be present and this history 
be absent, in ea»es in which an ahsoes^ has biir-'^t into the air-()a»^«ges 
from the mediastinum or through tlie posterior pharyngeal nail. 
In such a case, however, there would lie, in all probabilily purulent 

Laryngeal spa^int, prcKlucIng difficult brt-utliing, causes symptoms 
precisely like those of foreign body in Llie larynx, except that in 
spasm the cough in often eon.stimt nnd is very brafr-y or ringing. The 
[wtient will »l)ow by a gesture wltlt his hand that tlio obsiruction 19 
in th» larynx, if unable tn s|>eak. Such obntruction when »c«ii In 
children is due to sptmmodic oronp, as a rule, and, if so, pnibahly 
dcpL-niU uiK)n one of three etiiiM-«, namely, laryngeal catarrli, ricketo, 
or digestive diHtiirbaneo. If in an older person, it in prob«hly due 
to aneuriHiii pressing on the recurrent laryngcnl nerve, to lueomolor 
ntnxi*, or growths in the mediastinum producing pressure on tlie 
nerve-trunks going to the laryngcnl muscles. iSomctiroce great 
enlargement of the retro-bronchial glands will oause laryngeal 
spasm, or obstruction by pressure. 

Tnmora occur in the chest generally as mediastinal growths, and 
•re most commonly sarcomata or lymphadenomata. There will be 
found, if the growth be targe, evidences of its pressure upon the 
ohest-wnll such as bulging and dulneas on percussion over tlie swell- 
inj^. This level of dulness ia nnaltered by changing the posture, 
as it would be in pleural eBtusion. (ienerally tliere will be cvidenoe 
of preitsure on the bronchial tubes, which causes dyspncea, and of 
jiresMure on the thoracic vessels, which produe^jH signs of ini|iaired 
ciri-uln(ii)n lu shown by cyanosis, venous engorgement, and flushing 
of tlie skin of the fuoe and neck. 4 )fti!n siioh growths i^iu^ |denmt 
effusions by pn^ure on the bloodvoswU, or produce pulmonary 
consolidation by causing an cxud»tioii into the lung-tiMUO. 

The diseased conditions from which it Is neceswiry we should di^- 



tingtiiiJi n)4Hltii«tin«l nn)wtlii« <Iiiriii}i lifr nriL- «* follows: I. Frx>in 
iinr-iiriT>tn. 2. From nlj8c<.i». •% Fruni pluural t-fTusiou. Ami 4. 
From (ilinmit^ piiviimonin. Thirro lire sevenil HiilxlivUioDS at tl)c«c 
dif'i.'Ut).'!^ that mi);l)t W- iiuulo, but tu nil tiitcotH anil ptirpoir<>s tlii'so 
are tuiffivicnt. I'vriovrditif) may, pi-rtuips, be named as tliv fifth 
k>«ioii to 1>e ttiotiglit of. 

AtH'tirism in tlie thorax is sometimes so extremely difficult of 
absolute diagnosis tliat but few rules ran be laid down fnr its differ- 
ential diagnosis from growths in the mediastinum, for deeply seated 
aoeurisra in this region cannot be said to possess any pathc^omoDic 
symptoms. The variou.-i jxiriions of the aorta in whieh aneurtflm 
ot'ciirs make its symptoms diffoivnt in alnio-tt every («se, and vre 
are forved to rely more u]>on general eonditions than absolute signs. 
Thus, if a patient has no direct symptoms of aneuri^in, and none of 
those conditions present which wo know [in^llMpom; to MH'b a lesion, 
Budi as atheroma of tht; bioodveHst'U, due to Brij^it':* diMAxe or any 
otb*T simitar mnu:, or syphilid, rlK'tiTuutii^im, or n history of violent 
exvilion ur severe toil, we niny witli n wrtnin decree of n»»uruno» 
look furtlior for nymptomi^ of »K-<liii5tinnl trouble of another sort 
than HucuriKm. (See Anetirism in this chapter.) 

Unfortuiuitely, the most common age of aneurism is much the 
oame as that for mediastinal disease, although mediastinal disease 
seems to occur more freiinently in youths than does aneurism, or, 
in other words, is scatleri'd over a wider range of years. The [xtin 
of aneurism is generally considered to be more violent than that of 
any other thoracic Ictiion, but tliere exists ffasonahle doubt whether 
the lancinating pain of a grnwtli in this position does not exceed it. 
This donbt rests on sufficient basis to prevent one using this symp- 
tom as an aid of any value in diMguosis, If the aneunsmal sac be 
large enough to give us a wide an-a of dnlni-.v> on |K'n>nss!on, an 
Dr. (iravet* lias staled, ther^ ought to bi: nii ex|utusile tuovcnient. 
IliemopmiH is not in any way a dilTi-rei)liiil sign, since in the one 
ciLic it uuiy l>e due to aneurisitiiil b-akti^i', and ill luiothcr to uloera- 
tloii of small bloodviywi-|i by pn-.siiirc c-xerd»ed by u tumor, be It 
aneurismal or nuiligtuiot, or eveti benign. 

tVim abwi'SH tlic <liagtionis of nus]ia*>tin»l tuni»r< t* much nioro 
mdily UMide. In tht' Iu-hi pbuv, in idrai-*- we t;'""t'™lly have a 
history of tmunintiMii, or, if tbw caw be one of ould aiHtcvtut, it is 
ntnimonly aKnooialc^I with a bii^lury of i>itninin. If l)ic alHwew be 
l«cuii>, then? in p.'nerally tl>v history of j«in, followed by a chill more 


or Ift^K severe, aii<l fever; nr, if <u>lil, ihcii we fiv>|ii(-iitly liavc irrvji- 
ular febrile innvt^ineiitri, with lnn^r-eDntiinictl nimivxin und l<>v< »( 
flesh. Cold abHresA, too, in geiientlly in tJie poetcrior mediant! unit), 
while a"iite abseess generally occurs iti tin- iinltrriiir uptiW. 

I'ulwition may fi-c<|iipntly occur, nniiig Ut the tmnsitiissrun of th* 
uortir or rardiae im|t(iUea, and afTordit no better diagnostic ijoiiit here 
than el-ic'wherc. In snme i-ji»e» wlicre the tJieory of iineuriHiii is 
extremdy doubtful and (he likdiliuod of ahw^i'is' extremely prob- 
iibli: nn ox|>lorati>ry nceiUe inny Ik'^ uxcd, cither lbrxHi)fb a hole 
■ Irilled in the Btunuim or [)U]ij>ih) between the ribs; but u «'urefiil 
review uf tlic liiittury of the oaiw »}ioiilii certuiiily iilwnys be uuulu 
und ii(H;ii 118 It bi»fi« from wliieh to draw eoiiehii'ions. 

By far tlie grcntrst dilEciilty may be expcrietKx>d when we ultetuj't 
to dingtioAti<nto between piciind effusion ]>ro<luee<l by pleurisy and 
pleund cffunion jiroditei'd by luedtustinal diseime, pnivided thd cute 
be not seen from tlie first und the history be obecure. If tlte effu- 
sion be not Rreal, we may be able to diseern friction-suundi? pnidueed 
by the nibbing of the tumor agninst the eiiest-walls; but if ihe 
effusion be large, this sign niuy not be reoogoixable. All other 
methods failing, it would be advisable to tap the chest, uml, if (he 
fluid drawn he fibrinous, we know it to be inflammatory; while if 
it he clojir and limpid, nr at \mM tlnn and not viseid, it i» probftlrly 
due III pn-ssiire. This is not, howc-vor, a positive sign, since very 
fre<iiicntly in caaca of a^theniu inlliinunation we have an e.viidatv 
hiekin^ etitindy in tlie flbriiious tron.-tLiluentd. 

Tumors nf the mediastinum in\'ading the Uiugn hnva fretpieiitly 
btfen mistaken for chronic and even aeutc pnennionia, puMiug, ao 
they do, along the larger brunchiiil tube;< and bIoodve^«H*U. 

Wilhiiiit doubt, in « oerbkiti numU'r uf co-scis either liypostatie 
pneumoniu, or pneinnonin due to prert^urt^ on the brtnichial vc«hcIs, 
develops iw the tumor iiivitdivt the lung, uiul in 8ucU aisvs it it 
absolutely imjiussible to miike any diuvnusis unless by symptoms of 
pressure in the mediu^tiiuim, or some history pointing to such 
result. Walsh has stated that if the lei<ion be due to a tumor, tlie 
affected side will iucrejvse in bulk rather than diminish, and that 
dyspniEU out of proportion to the ilegree of eousolidation points to 
a mediaatjmit disorder rather tli:in oue eonfined to the lungs. If 
the heart bo displaced in cither diroetion, the odds point lu medius- 
tinat tumor; but the pretfcnee or abscn<^e of a haemoptysis, as ha.t 
just been stated, influenees tlic diagnosis not at nit. 




e <1ia^iiiMU nf jH'rimrditift from tiiHliuHtinal Ii-si(iti!< \n iimnh 
idore n-ii<lity iiinilu. 'V\w libtor^' of ^miileii |iru-c<iriliiil puiii mv\ 
til'- limitvtl umi of diilnc^w on jx>rctisi<ioii iiiil its very mntcriiilly in 
d«ci<liii)r lis tn wliut tint diwink-r jji, whilir iht; <U-eori[ttio» of tho 
onsit of till' iittuck, with ii few pointed qiictttioiis iis to syMti-tnic 
taintM, etc., mny (to much to uunivel tlic mystery. Ttu; tli^tcntion 
of the pvrioitnliitl hic from vfFuftion iiiiiy i^ivv iis a ix-fjiilar outline 
oa pcrcuiutiuii, vrliilo tlie iliiliiewi of midiuHtiiml diseuM: itiuy bti trreg- 
nlftruid varying. 

Heart-aounds and Si^ns, 

On sltempling to study the heart-Hoiinds we usually aiiscult tlie 
neighborhood of the apex-beat and expert to find, if the heart be 
healthy, two rounds, occurring one inmiedialely after the other, 
which resemble the sounds of the wimis " liib du|i;" the"Iul)" 
being the so-called lirr*t sound of the heart piixlnccd by tlie eontrae- 
tion of the heart-muscle and the tense valven, and the "dup" 
being raused by the slapping to nf the aortic valves. After listen- 
ing in this region vre next plaee the ear over the sectjnd right caMal 
cartilage in order to eoine ns near an [mssible to the point of origin 
of the fwooiid sontid produowl by ihe uortit.- valviit. If the heart is 
normal, we find only tliew sounds, " lub dup," and nothing olw. 
If it t» feeble from cxhaiifiting diseiise, from fainting, or by reiwon 
of fatty di-genentliori, we find that the sound " lub" i» feebb-, and 
the " dup " »otmd is also fpt-ble, bteimsi- the vnivcs do not slup buek 
into pliH-e with an much force us is normal. If, on tlic other hand, 
tlift heart is hypertrfiphied nr stimulatetl, we find tlu-se Koundit accvnt- 
lUUod, and it t» uf imporlanee to remember that marked ueccntuiitiuu 
of the aortic twi-ond sound, showing foreiltle closure of the uortic 
valves, indit-alos a condition of hi^h arterial jircsstirc, <iften the 
result of vascular spiisni arising from I'lironic contracted kidney. 
On the other hand, if the pnlmoniiry second sound at the second 
left intorcustal space is accentuated, it indicates an increase in pul- 
roonnn,- pressure dne to impediment to tho flow of b1oo«l in the 
hings. It is markedly acrentualed in both mitral obstruction and 
regurfplation and in some cases of pneumonia. 

The Boundi) produced at the vurious orilioes of the heart are heard 
best at the following points (Pig. l^t^): The mitral valve is heard 
best at the apev-beitt; the norlie valve at the second right costal 
cartilage, the tricuspid vnlvv over the stornnm on a line drawn from 



tlic third loft intoriiOstiil npuM* tu the liftli n'glit co6(iil vurlilugv, iiikI 
t\w ])iil[iioimrv viilvi' ut tlio !M.-«uikI htt intvrcostul s|ni(x'. All tht' 
Iicitrt-itotindH miiv be rcdiiplicated ill health aod in dlscoee as the 
rvsull of contractiDii iu an imequsl manuer of the papillan* tuusclet. 

Fia. Its. 

BbowIUK llic arvu lii wlilclt llie tarLoiu liuatl •(iiiiiili >tv tml livunl in licallti. A U Uic 
ftnd Itor ihnBiiriia Valve: F. tbal Ibribc [julaioiiarjr iralre: T, tbrtlii! incutpld lalrt: ami V. 
Car tbcmlinl valve. 

If difiea»e of the valvcju be jircsfiit, wr ur- apt 1o fiud rediiplicatioo 
of the second sound in cajH^ of mitral nIetiiMS and lung dii«eaBe 
producing nil alnionnally high tfiiaion in ihc palniimarv ciroulalion. 
HukU n^uplicHtiun iit also spL-n in mmv iiidividiiiils ^uffvrii^ froiu 
aortic stenosis. 

8up]>osing that on Imteiiing to thi.> heart in tlii- mitral are* theiv 
is hcafil ill place of tht^ normal sounds (" lub dup"), or with t)u>m, 
a niunnnr, wiiut docs it mean? It meant; tliut, friclion-«oiiU(U 
bcJDfi; excluded, eit3ier valvular disease of the heart, iinetirisni of 
the iioria, or marketl amcmia is present. Partieiilarly if> the ann-mic 
murmur apt to l)c heard in the isse of feeltle children suffering fr'>ai 
choral, and it will generally be found most marked at the left 
margin of the sternum.' 

I 11 DiiDi noi iHi fiirpiTUii thKi mannun i1u« ta «iii]a«ti]IU* alM an haqtmitl)' found in 
vucnrlc citililivii. 



favirif; found timt tliorc- i^ n murmur, atx), from tho abiioiice of 
[vnivmia, ttuit it m dtic to organic cardincdisoatte, it iii now neceaHniy 
to ik-tL-niiitif at wliut orifice nf tli? hrart it is prodtioed, and the 
[riilc is to be romembGn-d ihtit a murmur is alwavii heard loudest at 
>ut it* point of origin, \Vc therefore place ihe ear over the 
>rt4e curtilage (second right). If the murmur be mitral in origin, 
[it will not bo heard nt this plane, unless it he »n loud »» to be trans- 
emitted. If it is nortle in origin, it will he louder liere than nt the 
ex. If it is triciisiiid, it will he loudet^t in tlic Irieii.->pid ari^a; IE 

PJO ISfl. 

rl«|itl Ji III* MpgK-bMl whrrv Ihi- miirniannf mitral nfuTvlUiUou »■») obMngIMm Wi 
I bcvil. Tuc niroii inUilluii In lUo lUllls Uidlcnlia Die <Iiitt:I1i>ii In tvlildi Uw ncURfl* 
'bal ■uruiBt it inniunllml, ana] ihn HrrMW iwliiiliiH Ui Ilir mrmuxi th« dirwtlou of Itaiiiml*- 
•ion ofllM oti«tcuGtlT« miinniir. 

Hpulmounrj-, loudest at the pulmonary area. As niunnurs at the 
Httrimupid and pulmonary valves are rare, we nearly always have to 
^^fl«] with aortic or mitral murmurs, or hotJi. In this way, there- 
fore, we call determine the origin of the murniiir, aw) that it is a 
mitral or an aortie murmur. Lf^t ns suppose that it is mitral. We 
must determine whether it is that of mitral regurgitation or o)»- 
stmction, or, as they are also called, iuoomjietence and stenosis. The 
[trohabilities are that it is the rcgur^tnnt murmur, because this 
l(«ioD is by far the moAtcoinnnii) niiinmir lifitnl in the heart; and if 


to this ppobitbility we ad'l thp fiict that it is transmitted well it 
the axilla, and even lieiiixl at ttie auglt- of the siajiula, oiirdia^ntiU 
ill greatly aided, for this in the area of tran:inii!»inn of the mtimiiir 
of mitral regiirg;itatton. The mo^t importaiit diujriKHlic jxiint, 
however, is the di^icovery that the murmur uci^ur^i ^iiitilt>i niton sly 
nnth the Brst sound of the heart, or with iiystole— that U, with the 
a|ie\-heat or the carotid pnUe. If itdoe.4, and the uth^r Kigtvi »{ 
mi[ral disease are |>resent, it 1.4 almost nertaiiily otie of ivgur- 
^tation. This murmur oeeui:ri with the first sound, or tiy^tole, 
beeause the ventrivle in rvmtrttclinir drlvoK m<Ht of the Mood in lh« 
normal dlreetioii into the anrlii, ntid iiUo forot-s soinc of it Ixick 
through tile atirieiilo-vontriciiliir orifice Into thi* uuride, mii^ng a 
rc};urgitaiit murmur. Then? will be found very often in wwh xsate* 
n very marked aeeentimtion of the iwrond aoiind at the pulnionnry 
orifice. The area of gnyitest intensity of the mitml n^urgituut 
munniir \* ^howo in Fig. 1^6. 

In udultf^ inspection and ]iiil]intioii will mndy revoiil ranch of a 
thrill over tlie pneoordium in mitnil regit rgitution, but in chihlrvn 
thi« thrill !» mivly ab<(cnt and \j- tiMnnlly well marked. I'ereussiou 
will Mhow that the uitia of eatxliue dulness (see earlier ]Kirt of this 
chapter) ia broadened, extending beyond the rig)it edge of the ster- 
num and to the left of the tnammillary line. 

If, on the other hand, it is found that the murmur doeit not ocouu^^H 
with systole, but just Iwfore it, and is not transmitted into tl>e axil bj^^ 
but to llie right, over to the midsternal line, it is proliably that of 
mitral stenosis — tiiat is, the presystolic mitral murmur {see Figs. IS"! 
and 137). This murmur can often be exaggerated by plai>ing tlic 
patient in a prone jMisition, and occurs liefore systole, or the first 
sound, because it i^ made by the blood pa.ving through an ol)r<trueted 
Kuriculo-veutricular orifiw, and, as the veutricle does not oontract 
(eyst')le) till it is tilled, the murmur must be made while it is filling, 
and so \» presystolic in time. I'alpation of the pneoordium in 
smh R case will lutnally reveal a marked thrill in tlie fourth or 
fifth inter«]>ace. If the compensation of the heart in n nue of 
mitral stenosis 'n broken, ttieae signs are aci'iimjianied by a very 
irregulur action of tlie henrt, the firH sound Is-ooming nw-entttated 
and the murmur diMi)>pi-jiring. In some cji^i-^ wlinl in calkil a 
" gallop rhythm " develops, ihc hiiirl-sounds l)eitig reduplicated in 
such a mnuncr ns to make u gnllnping sound. 

If, however, we have found the murmur to Iw aortic, wv must 



Andudo uiwuriBni and then determine whether it w thiit uf ituHic 
n^ifritation or ubstnictioo. The I'haracteristjc HvmjitoDis of 

or angiy murmur, Kvstolic Id 

aortic aneurUiD are a "bruit' 

point of time, and heard best in tlic aron between the third ril> and 
the o1avict« on the right tude, aoconipanied by pulsation, which i« 

Kto. in. 

KUnbOiitiinaaf Kn.-iiai liittmll; uf x inlirmi iiUlnivlI*« murmur, f r thowi krM 01 
CraaUBl InwuilU' of i lilourplrl ncumltkal miimiUT. 

ofteii expaoMle; by nn angry thrill; by bulKing of the chest-wall 
(Ki^. 117 aud \%n) if thvdtMnttc \* ndvant.'cd und preasea forward; 
by glotwiiiiem of the skin over Uie bulgiu);: by unilateral sweating 
of the faec and neck fntin pn-«8uro on th« (xrvital sympathelio; by 
iai^piality of the pnpiU fn^m tho wimc aiUM.-; and by inetjuiility of 
the radial pulses, owing to thi> arrest of ihc blood in the aac, so that 
it diM4 not enter the veML'l!) on both livXcs i^ynclirtiiioUHlv. Again, 
wc n^u&lly have a very considerublf degree of dyspnoea, and home- 
times dyHpha^ia from prettsurc ou the (ntopbagus. There may also 
be hiHtort' of syphilis and of severe strain or injurj- in many eases. 
Although these are the t^'uenil symptoms of aortir aucunMni, 


them are otliprs which depend upon the seat of the aneurism and 
which niBtftriallv modify the iHiiiitr^ ttn far named in diagnosis. Let 
m »uppoi<(^ thnt a [laticiit preseuts himself with great. engorgement 
of the ve*clrt of the head and neck and arm uf the rijfht side, with 
j>crhnp)t aHleina of the arm. The heart inav he pushed downward 
and to Uif left, nnd the voice muy Ik- lost or partially impaired by 

Fia. lis. 

cue 01 aorlk aiid liuio: . i:i>m. wllli umtou af lliu rlntlclii and iflx. frnn llw 

■nthar-iiwanlB ill ihu jciTi I .. i . ^ii iL*cilIcic« ll»plul. Ttali cue 1* u( eztnonUa«iy In- 
tcnat hKMiw ihu |iletuiv nu nJuaix llilrlj-'flvc monlbi UMi Dt. D. D. etmrait haA taiued 
Ui ■rml ottbe month or iIm aimiiriiiin by elrcilcoljiili 

prrseurc on the recurrent laryugenl nerve of tlie right side. Gon- 
«ni1ly euoh symptuuiH will be due to au aneunsm »f th« greater 
curvature of the ascending aorta, although they may he due to a 
tumor in the iinterior or middle mediastinum; hut the espausile 
pulsation, die bruit, and tlio history of the case will often make the 
differeutiution {msaible. Such a growth will probably eause bulg- 
ing of the si'cond or third intersjwwe on the right side. Again, let 
IIS suppose that tite chief symptoms manifesteii by the patient are 
a brassy, ringing, and con.itant couf^h, with difboulty in Dwiillowing, 
and an examination of the vocal eordx ^hows that the left ix>rd is 
jmralysetl rather than tli« right, thervby cnut*ing hoar»eim«, utd 



I inon* or Ii>«« biil^ii); »n<) diKtciition of tlitt innmniiiute or 

Ilfift CftroiUI urtvrk-H, wliilc ttit- niduil piiIsL- is dcliiyc-d, tlii-n up may 
cniittider tliut tlip iineiirii'm U prububly uf the trntimwree purtiou of 
Mv- aivh. Still ftirtlicr, if wn irirgtilar iictimi of tlie heart, willi 
great {HiiD in the hack, is found, in addiiion to the oi-diimry sign? of 
■uourUni, it is possible timt the aneuriem may he in the dcsL-emling 
morta and he eroding the vertebra. If the aueurLtm be of the first 
two formii named, there may he found, on perciiatiion, diilD«»i over 
the flwelling or over the area of cxpannile thrill and bruit. Thus 
thfl anenrUmh of the ascending part of the arch which project for- 
ward and to ihe right cause dulness nii the right side of the sternum, 
while those of the transverse |iar[ of the arch cattse dulness on |>er- 
^Lous^on nit the left tude or in the middle line. On the other hand, 
the lestiou of the de-scending aorta often oati»es dnhiess and bulging 
between tlic vert^^bnil column and [\v: .'<capiila on the left side. 

There are otlier 8ym])tomi4 cunneot«<l with nncuri.4ni which iihonid 

'uot be overlookt'd. The lint of theiw ix " tmcheiil tugging," a 

»)gii which i.s found in immc cnws of aneuri:iini. The [Htticnt In^ir^ 

■ iu ihc erect (xwition the fingers of the |>hysiciiin gntsp tlu! ericoid 

iiirtitnge and gi-ntti- tipwiinl tmction \* pro«tuccd. TF nnenriiim la 

»pTt«cnt, ti distinct ttig will he felt with «iLch hciit of the heart. 
Anot)K>r sign ment4onod by Osier is the lorn of pulsation in lh« 
pi-riplicral vessels, the result of the lost) uf thd heart's iiopulsr in 

^- the ancurismat sw. 

^ If the B)-mptoms of aortic aneurism are excluded, we proceed to 
determine the queslion ns to whether the murmur is that of aortio 
stenosis or obstruction or incomjwtence or regui^tation. Aortio 
ob«bruct4oii is the more common Iraion of the two. This murmur 

^^oceurs with the sviitole of the ventricles, or the carotid pulse or 

^'npex-heat; it is liareh as a rule, and is traiumitted up int<) the car^ 
utid and it may he into other arteries of less im|iortance. (See Kig. 
139.) It iii produced by Ihe eontraction of the ventricle driving 
the bIo»»d through a narmwed or roughe»e<l niirtio orifice. Con.<)id- 
erablc hy|tertrophy of die left ventrieU; i.i usually present^and tlie 

Ia|)ox-beal is strong and foreil)le. 
If, on the iJilicr hand, tli<- mnrnuir oci-nra iifu-r the svKtole or 
a|i^x>heat, anil in aortic, the nuiniiur i» that of uurlic rcj^urgttation, 
and '\» cmllcd tbu dit»tolio aortic murmur. It \^ licanl loudest at 
the aortio ciirtilnge, bnt i" tnmi>mittcd down along the ^tvrnum very 
dearly nwl into the left ventricle, ^u tliat it is heard at tlie apex. 


(See Fig. 140.) In this coudition wo have iiHuaUy marked dilata- 
tion of)tlic heart with liypertmpliy (the !*o-caIIed " nx-beart"), oimI 
a ]>eculiar trip-hanjmer jmliie (see chapter on Poise), sometimes 
trailed the " walei^hammer " or Corrij.'an pulse. This murmur U 
due to iocorapetence of the aortic valve, which allows the blocHl to 
regurgitate into tJie heart after it h driven out into the aorla. 

Fis. isa. 

Pia. tto. 

dlreoUon <<r ' 

-111. inio luiirlnt-liin 1.B1I 

nrotUliiiK'iui. .It Ttir.-i.irik'atBinicilTDinuraiat. bcanL 

lihovliin IIU' nv* 111 iitllPli tliu Iiiiinnur 
ofuirllc nxurrliAlloii can bcmcnl clnrly 

If the examination lini; shown that the tricuspid valve is disensed, 
it is to be reiuemberetl that in the vast majority of cases the mui^ 
mur is due to trieuspid regurgitation, for tricu.4iiid stenosiei ia an 
exceedingly rare condition. The Ume of tJie raurmur of the tri- 
cuspid le^on is identical with that of tlie mitral rejiurgilant (sys- 
tolio), liecause this valve is the counterpart in tin- right side of iJie 
heart of the mitral \'alve. .Vctual diseajie of the pulmonary valves 
i.<« exceedingly rar<-, and tlie regurgitnnt form of lo.'iion 1^ almost 
never m<-l with, '['he mnrmiirH aometime* licjini, and tlie thrilU 
Mmetimefl felt, in thij> area are generally due to nniemia, lh« jnvfr- 
peral ntute, or snme neuroftitt; or to eonj^-nital imrrowing of tlie 
pultnonary urtert'; or to eoniprcsuon of the vcsmel by the licarl. If 




the last two causes are i)re§ent, the ventricular septum is usuully 
deficient aad cvanoaLs U noticeable. 

In the diagnoMH of all inurmurB in the heart we must remtfinbcr 
that Heveral valves may be diseased, producing Bssi>ciated murniure. 
Some diReUfuion as to the relative frequency of these associations 
ha.1 arLsoii, but tlio re&nlu of II. J. Smith in the I^ondon hospitals 
are Ortiiftlly acee[>ted aa correct. Uis results are as Follows, in the 
order of frenm-ncy and aK^ofiation : 

I. Aortic rejfurgilalinu and Htennsis and mitral regui^tatioa. 
'2. Mitral Htenoaifl and reg;u imitation. 

3. Aortic HlenoMH and mitral reg invitation. 

4. Aortic regurgitation and mitral Meiiosiu. 
&. Aortic re^irgitatiiin ntid ((tonoaiif. 

6. .\ortic rcjrurfritation and st^uonis: mitral oteuo^a and regur- 

7. Mitral ret;tir|ritntion and tricUKpid ro^urfriiation. 

8. Aortic regurf^iljitioi) and Htenosis; mitral regurgitation; tricu.s- 
pid regiirgilnlion. 

9. Mitral elenosia and n-gurfptation ; tricuspid regu imitation. 

10. Aortic Mti-no«i«; mitral Ktcjioets and nrgurgit&tion. 

II. Aortic i^urgitation ; mitral stenosis and regurgitation. 

12. Aortic stenosis; mitral regurgitation; tricuspid regurgitation. 

13. Aortic regurgitation and stenoois; mitral regurgitation; pul- 
monary regurgitatiou. 

14. Aortic stenosis and regurgitation; mitral stenosis. 

15. Aortic regiirgitatinn ; mitral stenosis. 
J8. Aortic regurgitation; mitral n^gurgitation; tricuspid regit rgi- 

17. Mitral 8t«no«iK; trictnpid regurgitation. 

18. Aortic MetiOMs ; mitral Mt«no<u.<4 and regurgitation; tricuspid 
regit rgilatiou. 

19. Aortic 8teiioHi»: mitnil 8tciio««. 
ISO. Aortic regurgitation and ]>tcno«iii: mitral aUooab and tricti»> 

pid regurgitation. 

21. Aortic regur^ilation ; mitral liteuMix and regut^tation; tri- 
a regnigitation. 

22. Aortic regut^itation and stenosis; mitnU uteootna and regur- 
gitation: tri<iispid regurgitation. 

28. Aortic regurgitatiou and stoOiV'^is: mitral stenosis and regur- 
gitation; tricuspid steuosis and regurgitation. 



24. Aortic stenosis; pulmonary stenosis. 

25. Aortic stenosis; mitral stenosis and regurgttutioD ; tricuspid 
stenosis and r^urgitatioo. 

2fi. Mitral steno^i-s and tricnspid stennsia. 

The reiativf? gravity of hearl-lesionci is, according to \Vnl6li,ad 
folliiwii, the least dangerous lieiiig placed last and the most danger- 
i>n» lirnt: 

Triuii^jiid n^iirf^ilatiiin. 

Mittnl ohntriK-tion and regiii-fritation. 

Aortic n*giirgitjition. 

Pulmonar}' ohtttnictlon. 

Aortic obstniution. 

The gi^nenil symptom'*, »iib}ectivo or objective^ whicli it jmticnt 
suScriDg frum the v»rioii« forms of vnlviiliir lesioo pmR-'nbt, in xonic 
inritunciw, have not 1h-uu sjiokun of up to this point, beouso it is tu 
bu distinctly undcretoud thai murmurs produc«d by any form of 
valviiliir Iciiou may exist with great inlensitT without there (jt-iii^ 
any systemic disttirbiinoe or tlic patient bciug conscious of their 
presonoe. On the other himd, the murmur may be so bint am to be 
almost indistinguishable, and yet the goneml symptoms uf heart 
disease be very marked. This is hecau-se the development of gcu- 
ernl symptoms depends entirely upon the ijuetition of com|>eui<alioa 
by hy|>ertr(iphy. If tliere is a leak in a valve or a oonstrielinn of 
an oritfce, this leak or ob.ttruction must bi^ ovemoine by com]>ensa- 
tory liy I wr trophy of the heart-mujwie. If the hrart-oins^'le can 
mnkc up for the regurgitation or ohstriietion by increased HTort, tlie 
oircuhitioii is uniuipair<.>d ; but if it enniiot do so, we have dcve1o|>ed 
more or les.* n>i«dly,tuvording to the U«ion present and the ii»ndi- 
tion of the hairt-mu»cle, clinnu>lcristiR symptoms. I^t u» Mip[>«(te 
that the valvular lesion if that of mitml regurfritalion with fiiihirc 
of compenstttion. The first and one of tlie mo«l proniiiieiit syni|»- 
tonia is short ntws of breath on exertion; the lijis and ears do not 
possess their norntal itnl hue, but are a Utile bluish ; and if (he con- 
gestion of the auricle and pulmonary veins is great, bmnchilis may 
be constant or attacks of harmoptysis may develop. Palpitation of 
the heart will also he complained of; and if the patient has deveU 
o(>e<l the le^on in early life, the 6nger-tips are apt to be clubbed. 
If the rupture or failure of compensation is more complete, all tlifM 
symptoms Income more marked, and the shortness of brmth, even 
when lying down, becj>mes most distressing; indeed, tlie patient may 



comforlabk only when .littiiig up. Drop»y of the lower 
extremities now comes on and the liver becomes enlar^:e(I from 
[Ktrtal eoDgeiiilton, while tiie urine becomes nlbuminous, not from 
any tnie renal lesion, but ait the result of engorgement of tJie 
kitln«yi' with blocKl. 

The gciiurnl ^yinptoms nf initml obAlruution are tdvDtioal with 
tbwtc juH dntcrilicd. 

TIic geiisml »ymptonin nf nortir nliHtriu'tinn nri' nK) mueh like 
ttiOM dcMribwl us rcj^iillin^ from miiml rcj^iir^itation, hut in 
addition Xhen orv iipt to be pre-wnt, ttirly in the procw^ of failing 
cumpcnsHtiui), «oiue ltghtnc«Tt of the huul, (iijQiine.-u^ or vertigo, or 
fniiitncsK, owing to u dcfit^iont bloo<i-»upply tu the brain. Very 
cORiuiimly, too, it will be fouud thut in atMociation with the aortic 
)^t(-niHti); there iil»r> exists mitnil re^fii if^tation, which spwiHIy pro- 

CiXawi in its tnru welUmarkeii pnlinunar)' symptoniit. DrupMV is 
very rarely sceu in patients with uurtie st«-tiosi«. On the eonlrury, 
they pivscnl, 9» a rule, the lenu aod jmoi'Iy nourished appearance tto 
aft^n found in the adult, well udvaneeil in years, with uthcrumatoug 
tendencies in hiri vessels. 
The luisnr.iation of ruptured uom{>enaatinn with aortic regurgita- 
tion presents more typieat general systeuiio ^ynip1om.-< than any of 
thi' onlinary valvular leniou-i of the heart. In lulditioii to head- 
nohe, vertigo, and a tcndenuy to syncopi*, lus^oeinted with palpiLitioD 
and a wu'^- of ■■aniiiie oppn-nsioo, \w nfti'n have u grunt deal of 
cardiae |«itn, nf ii dull, ru-hiu}^ c-linnufler in rure inslnnceit, but more 
ofttni intetuwly Khurp and laudoitting, uft<'n darting down tlie left 
ariu, juirtieuliirly iit night, Thr (lyHpn<ra ii« ofli-n extnmc, the 
|Niliciit MiCTvring from (■■rrihie attneki> of KhurtiieM of brcutli and 
oft4Ni Hitting day and night in ii eliuir with his head resting on the 
bock of u chair plaecd in frvut of him. As lime goeH on the oon- 
etnnt struggling for breiith cxhauHtu him and he falls asleep, only 
to wnke in u few moments gasping fur air, Long before any of 
the*egn»ve>iyuiptom((ari*i-wo may, however, find a number of iuter- 
Mtiug Htgus of (his heart-lesion, ohiof among which is the " water- 
mer" or " trip-hunmier " or " Corrigan pulse," the throbbing 
eafotid artt-ries, and cupillarv pulsation iu the tikin and mucous 
ineiubrantts ts to be seen. The last is bent developed hy drawing the 
thunib-nail sharply across tlio forehead, thereby causing a red mark, 
which cun Ik) s«'en pnlinj|> and flushing with each beat of the heart, 
or by pressing a glass slide on the inner part of the lower lip, when 


thesimcmpilliin- piiUntion will In- fimnH, OpIitinitmoMiupiiivicftin- 
innttuu will ofU'^ii rowul ))iilHutu>ii of tliu ntiiiul urti-ri(». 

BL'vonc) vnlvular li-«onH, producing hvurl-syniptoitiit, va hnvc ii 
□uiub(>r uf utiicr cuuM-s wKiclt «iTio<isly (listtirb ttio iiction of lb« 
heurt nnil tKt- ^CDural oirculRtury condition. The first of tliuw U 
(lilittatioii of tlip liuart. Lot us suppose that u man prveonts liimwlf 
witli a history of shortness of Lroath on exertion e<i gn^it tliiit hi« 
aotivities art' ^i^mtly ivdiiL-ed and liis usefulness impaiivd. Hv 
gives a hislor)' that lie was well until he made some vxtnionli- 
nary exertion, generally of a prolonged character, rather than a 
brief and sudden effort, whieh would perlin}<s cause aiietiriifin. 
Since that time liis symptoms of hearl-failure liave been marked. 
He may perhap-i have attacks of syncope. Esamioation of liia 
heart reveaU on inspection a diffuse thrill in the region of the apex ; 
but this thrill is too feeble to be felt, (hough well marked to the eye 
if his chest is thin. I'ereussinii shows that tlie area of canliac dul- 
neas is increased vertically and laterally, and auscultation will dis- 
cover feeble heart-so tinds; and if the dilatation of the muscuhu' 
portion of the heart is associated with dilatation of the urilices, a 
raiirmnr may be present, most eoranionly that of mitral regurgita- 
tion. Hometinitvt tricuspid n^iirgitation is also found. The first 
i^ouixl bcfon; it becomes very foebUr may he short and flapping 
like tlie oniinary sooond M>iind. Marked arhytlimia of the h««rt 
is often present. 

Af^iu, wv have hy|K'rtrophy of the hmrt occurring in pcrwini 
without valvular Icxions, aometimea aa the rmult of exc«8HVv aim) 
severe toil. It is iwen most commonly by the author in luedical 
students, who, during their holidays, devote their time to severe 
athletic sports, or lo much manual labor, and who, on leading seden- 
tary lives in the winter, develop irregular cardiac action, palpitation, 
and some shortness of breath. Examination of the pnecordium in 
such cases shows a forcible impulse of the apex of the heart against 
the chest-wall, some bulging of the chest-wall if the hypertrophy 
be very great, and no murmurs, but in their place heart-sounds 
very much louder than normal. TalpatioD shows the apex-heat 
to he lower than normal, aud on percussion an increase in the area 
of cardiac dulncss is found. 

Again, let tin suppo.'ie tliat a patient presents himself with the 
statement timt he ha.-< attacks in which he suffi-rs fmni a verr rapidly 
Ixnting heart. 1 lis ^ktn i» alternntoly red and }i.ile, and .'^wcats with- 



tvai <.-auiie, but a careful «saminatii>n ot tlic lieart fuils to rovcnl uny 

muraiurs or orgauic abnormality. There urc eansiJcmble abortneas 

uf breatb on esertlon and marketl palpitation and arh^thmia. Such 

a case may be suffering from a condition in which there is some 

deficient action of the pQciimngastric nerve, whereby tbe heart la 

not properly controlled, or tbe irregular cardiac action may be due 

to sudden vaaomotor relaxations, which by dilating tbe blixxl-paths 

reduce the normal arterial resistance. This is a condition seen in 

I association with some neuroses and very commonly seen in |ierson.« 

^m who utie tobaoco to excess. The symptoms of the so-called " lobacco- 

^^nUftn " are indeed ehiefty those of nrhvthmia due to pneuuiogantric 


^B Rarely l>ecaui»o of irritation of the vagus «crA-es or ovntnw a irtnte 
^^ of bradycnrdia develops, in which the heart U-ate vvn.' j-ilowly, pgr- 
1 hitju* only thirty or even ni slowly a» Iwolvc times u minute 
^K JIni(ly<wrdiu or j^ntit 8lowiie»> of the heart may not only be duo to 
^■a DOunwis of the vap, but (o ty])Uuid fever or other infi-t-tious dis- 
^VwuOB. It is alik> 8L-CU iu jaiimlicu. 

Oo« of the most common cattscn uf lacliycardia.or nipid heart, 
is exophthalmic goitre, in which coitdition wc huve nut unly cxoph- 
thnlmus and enlargement of the thytx>id gland, but, in addition to 
tJie taci»y(?ardia, a marked thrill over the carotid arteries, in which 
vessels a purring murmur of mnsiderable inteosi^ can abn be 
heard. The patient often suffers fn>m considerable nervous excite- 
ment or mental degire-ssion. It is an interesting fact that in ihiit 
disease the electrical resistance of the body is often diminished. 

An exceedingly invgulnr arhytlimieal iirtioii of the hejirl ciimiug 
on in the eoumf- of an acute infirctiotis disi-ase, or in any stnt^^ pro- 
'dnctive of sepsis, point-t to the po!t!>tbility of the [tatieiK havinf; an 
ibolism or tlirombuN of («ic of tlie coronary iirlcri<r!i. If the 
h suddenly pliiggiKi, death speedily occiinf; bnt if the pro- 
ceiu) to gndiuil, an anivmii; nuerrwia or white infarct iu produced. 

»Stidden attJicIc -if <Mri!iaii fecblcneiw i<<mielinicH come on as car- 
diac crtsi-D in gluaau luLiio-pliurj'ngcul [naralyitiK and in locomotor 


Before diHcuwing the i(ign< of so-called fatty heart wc must decide 
wlint U meant by this term. True fatty henrt — that ts, the condi- 
tioD of tlie heart in which this urgnn lias undergone true fatty 
d«gea€ratioD — ^lins no pathognomonic signs, so far us the heart itself 
1§ ooneeroed. In tl>tse instanoea wc base our diagnosis upon llio 


pn^j^fiiw* of ftttty depone III lion wf the nion> siijxrfii'ial or^as, siirli 
us tlic iirciis Bciiilitt in tin; cy*.-,' tin; ppescnw of fttlK'ntmaloiis bloixl- 
vcMBi-ls, thv fi-cblc hcan-simiiilH ut hU iiitwuy and the evident feeble- 
ness uf tlif hwirt on exertion. Tlie lii*tory of poiMininj! by any 
one of tlic poiiutn^ viiiiHiiig fattv <)e);eneni(ioii i» iilso to Ih- tKHiglit 
after in some »isc's. Mnrkinl fatty degt-Doration is often prcjtcnt in 
caseti of peniicions uriiemia. It is not possible to Di»ke « (lilTereii- 
tial diagnosis from the physical signs iK'tween fatty an<) fibroid be«rt. 

Aaothcr state quite distinct from true fatty hiurt, Ixit with some-i 
what »milar Hymptonis, is seen in cases in which an cx<H<wivc 
amonut of fat ha^ been deposited roiiiid the heart as well as in or 
nroum) the other organs of the l>ody. Here tliere is little or notlt- 
ing the matter witli tlie heart-miiscle, except that it is overlouded.i 
with a weight of fat. 

Where a man shows signs of general degenerative changes, has I ' 
feeble heart, i)om<> dyspmea, and i>erhaps some cedema of the lower 
extn-mitie^), we may eonelnde that he has, unless valvular disease is 
disi^overed, degenerative rayoc^rditii*, Suoh eass make up die 
greater number of eiudden denthi*, oalled [H>pularly "death l>y 
sudden mrdiac failtin-." 

Great fceblem— ^ "f liie licjirt and general "Vtftein, lo*> of fleiJi (or 
sometimes miiirii< ii.itk i' uf weight), pignientiition of thft likia uttd 
biieoal mui-ous nienibrane^ jnnnt strongly to .\ddi]iion'M di:i>etmc(>^ 
chapter on Skin). 

Finally, let us suppose that a young child is seen wlui i8,and luu 
been since birth, more or lc«s cyanotic. In all probability sneli a 
child is the subject of congenital malformation of the heart. The 
following rules, laid down hy Ilochsinger, may Ire usc<l for their 
diagnosis : 

1. In childhood lond, rough, musical heart-murmnrs, with normal 
or flight inerease in the heart-duhicss, ocmr only in congenital 
heart-diseatie. The ancjulred defects with loud heart-murmurs in 
young children are almost always associated with great increase In 
tlic heart-dtilnes-s, 

2. In young children heart-murmnn<, with great increa-te in the 
canliae diihu's* and feeble apex-beat, i*uggest congenital changes. 
The increased duhu-iw U chiefly of the right hcJirt, where*:* the left 
it only ttlightly altered. On the other hand, in the acfpiired eudo- 

> OpbthaLmoloaliO kud viAUT cllaleUni d«ar Uwt ftiviu wullla bM my (Itiitdmiot tit l&li 


carditis in children, the left heart is chiefly affected and the apex- 
beat is visible; the dilatation of the right heart comes late and does 
not materially change the increased strength of the apex-beat. 

•3. The entire abseuce of murmttrs at the apex, with their evident 
presence in the r^ion of the auricles and over the pulmonary orifice, 
is always an important element in differential diagnosis, and points 
rather to septum defect or pulmonary stenosis than to endocarditis. 

4. An abnormally weak second pulmonic sound associated with 
a distinct aystolic murmur is a sympt»m which, in early chtldhooil, 
is only to be explained by the assumption of a congenital pulmonary 
stenosis, and possesses, therefore, an importance from a poiut of dif- 
ferential diagnosis which is not to be uuderesd mated. 

5. Absence of a palpable thrill, despite loud murmurs which 
are heard over the whole prsecordial region, is rare, except with 
congenital defects in the septum, and it 3[>eaks therefore against an 
acquired cardiac affection. 

6. Loud, especially vibratory, systolic murmurs, with the point 
of maximum intensity over the upper third of the sternum, associ- 
ated with a lack of marked symptoms of hypertrophy of the left 
ventricle, are very important, for the diagnosis of a persistence of 
the ductus Botalli, and cannot be explained by the assumption of 
an endocarditis of the aortic v-alve. 



The Barfac« of the abdomen— Changes ia the appeantDce andahape of ibe 
abdominal wall — The Bigne and eyiDptome of dieease of the abdominal orgvni. 

The condition of the abdominal surface and abdominal oontcnte 
is best studied by meaoa of inspection, palpation, percuaaion, and 

Fro. 141. 

Tbe legions of Ibc alu lumen mid their <-onli.'nl>. iI.rav.I ^Ei3ge of costal can IJages In 

(toueil oullini'.l 


auBcuitation. For the purpiMeii of inspeetinn the surfa«? of the 
»\Ainaea has beeii iirbitrarily divided by diagnostioianti into a mitn- 
b«r of 'iimio!^ which arc be»l tdittwn in the aC'Cmnpanring figun.- 
([■"i^T. 141), mid which get their names from the n-'gions In which 
thtty ar«^ liM'at^Kl, or from the organ immediately iinderneatli the 
iiUt'>iniri:il wall. By mean.-* of these arbitrary ontlineo we ran 
rmdily dcMrribu tho exact i)]>ot in whit-h a ]>h\'si<»l sign or sym|)tom 
ii* foinict. 

Th«! following tabic, from Gmy's Aiuitomy, clearly allows tiie 
viMwra to be found under cnch of llir nrttuf named : 

kXfM llfpaesomtnat. 
Tttt rlRbl lobe «f Ui( IKer 
uiA Iht «dl-«Uddar, tumUv 
Bnoracf tba colon, and lurt 
of UK rnibl kldncT' 

Htchl iMmbar. 

A<«n<llDi«iilnn, ["lot llio 

rtcbl kldnoj. and tame cod- 

(CtaUo<>* of Ibo muUI luiA- 

UaU fiwUMi UNoc). 
Ttw MMun, «pp«iidlx cad. 

Sp0alMt AqrfWI. 
Tb« |iftoiI< end or I he 
•IniDKcb. laRloboortbD tint. 
■cid 1nln;ln>8pl(*1ll. tliu |>ii' 
cmiB, IbedQOdeauiD, |«rliar 
Ibe klducf* UHl Ihc •iii>ni- 
i«mtl oiiauliiH. 

Tlip imitvpTH; colon, p»rl of 

the gtFBt Dinciiliiin ■lu] na- 

uiiMry, tmnii-cn* put aflb* 

diiodvniim, and naif vonio- 

I InthiM of Un JeJaDiin uid i 

' Una, pnx of bo(h kldn»j>. 

llfpofnil'tr Rtfflim, 

Conviiliiilniit or l>ii^ Hniill 
Intallne, ibc blnddci in cbil- 
«nn. and In aiSiittii If dlt- 
iviidvd. unO Ui« iiMni>durln( . 

/<n lIvpoelUnvtHae. 
The s|ilt<nl« (Dd of [be itiim- 
acb. Ibo tniccn ■od exlremUjr 
of Ibv lUhiiorvM, Ihti H|dcnlc 
Uciiirc of tbe colon, and iiut 
of Uie loft kldnof. 

tifl Uimbar. 

tiVMwndtus tal'in, p«rt i>f lh» 
omcQlum. pan of tlic Left kid- 
iie-i. and Kime vuavoliiUaiii of 
the tmall InlMttDV; 

flKnidld Heiuraoribovoloii. 

INSPECTION. The general al>dominal wall is |>ii»hed outward or 
protrudes] by many |>erfectly normal cauMiH, siicli an an iinuaua) 
Mffloiint of fat in the omentum, pregiianciy, and an a<%umulation of 
li<)ui(l and food in the Htomaeh after a hcjivy menl. It ia aim con- 
vex to an abnormal degree in eai«ci4 in whitrli lu-t'lti^ in preiwnt, when 
llic otoroach and bowelit are (ivi>r-<Us1endod with f^s (tyiii)>anileH), 
and when any of the oi^mn found in tin? (((.Tilotiriil iiivity are the 
Heat of tiwellingA or tniiiorH of large size. In childn-» u |ir(itnnling 
|K>t-belly, " the frog-belly" of the seen incases of wrof- 
iihi or lulierctilosi-. of ibi- mcscnicrie ^InndH, and in thoM; c-ai^"* whieli 
eufler from ehronii- giLMCru-iul(Mtinal catarrh. It im elaimiHl in a 
rwenlly pubUiihe<l jxiper by n Frtneh clinician that the Juteftinal 
oanal in not only diluted, but of greater length than ii« normal in 
these caHi'S. (f, nu tlic ntlier Imiid, the l>olly-\vall !» rrtnieted^ vuii- 

322 r///; itAxiFusTAi'ioy of disease ly oroass. m 

cave, or " scaphoid," as it is aomrtimes calleti, we look fortheostitte 
in abtftiiieiicc from food, or reniomlier the iMiwihility tluil exc«!Viiv» 
vomiting or purging mny have emptied tlie gastro-iDtcstinal trac-t (if 
its usual <'iiotenU. Thus ejcce^sive summer diarrhtpa may |>nMlun< 
BUob a refliilt. Wo also find a retracted l>elly-wull in nojirly nil 
eaaes of advanced wasting dt.seas«^ »iich as oaivinonia or tiilivrcu* 
losis of the lungs; and if tlu^ retraction w a9so<.<jat«d witli luiiMtiliir 
rigidity of tiic helly-wall and ]iain, we sugpeet the early atuf^ of 
peritonilin or llie presence of some ucntely ]ininful ■ffwtion, «ii<-h iw 
renal or hejmtic eolie or lead oolie. Murkod coneavity and retrac- 
tion of the Iwlly-wall are nl«o seen somctimeit in enscM of tubercular 

The ahdumen in <)iirteiidc-d very grently by giut in iminy cases of 
peritonitis, typhoid fwer, and in persons isufToring from flatulent 
eolie. If tliiK be tho oause of the di^tt^'rition, pen^ussion uf tlic 
imtL'rior itclly'wnll when the patient is lying on the back will give 
n tymjumitie note. We separate, diagnostieully, the swollen abdo- 
meu due to wind from that due to ascites by the fact tliat in the 
latter condition the epigastrium is moderately flat when the patient 
is lying down, while when tympanites is present it is more protrud- 
ing. Again, in ascites the greatest bulging is generally to lie found 
in the Hanks, or, if the ]iatient sits or stands ereet, the liyjiugnalric 
region bulges from the ehange in the position of the fluid. If (be 
swelling be due to a modemt4>-siiuHl ovarian c%'st, this variation in 
form will not oceur, as the cyst is not readily movable. If the 
o\'arian tumor lie lai^-, the difTenuitial diagnosis mny be most diflb- 
cult and almojit im|H>s^iblc, exeejit by the history or by examining 
the li<iiiitl uithdntwii liy tupping. 

In en»es of uwHte^due to free liquid in the abdominal eavity per- 
eunion will elieil flatness over the flanks and resonanvo only where 
the int^^'stines eoiitjiining gas an- floated up against the iinterior 
belIy-^^'alI above tlie effusion, I'aljmtion unit also reveal fluctua- 
tion in asuites, but none in tympanitic distention. To develoji this 
fluctuutioD the patient is placed on hia back and the flnger-tips of 
the left band of the phyeieiao are placed against the skin of the 
flank. By means of the finger-tips of the right hand the op[ioeittc 
llauk of the patient is struck a blon- as in ])erforming ordinar)' |H>r- 
oitB^ioQ, when the impulse if fluid is present will be tntnnmitted to 
the lingers of the left hand. An the result of gradually ini^reasing 
intra-abdominal pn-ssui-e the floating ribs become pn;sj>e<l outward, 


apes-1>eat nf llic henrl is* oftt'ii displawd iijiwnrd an<) outward, 

Biid Ihe iiRiltiliniR Iteoometi )initriid<t:l iii.iiead of rvtraeted. The 

I lAua of the bclly^wnll tx^oonuTi tliin and Hhinii));, and tJie recti mua- 

. becoming ^jmratixl ciiiihlcH i\\v ])ei-intnllio niovt^m'iib) of the 

Jg to be ruadily felt throU);li llic interveuiug dluu. 

riu. lu. 

nkUthomarMor mirvmiK lli*r (ulviiillni fkr twjrond lit norinal uM. OrtrtlM 
I MHbcf ol thin TOW oniiiit rv iiit huH noilnlar inus«, iFnim ihc knUior^ nnU, 
^JMRhm UMtlMl CnllsRa II.a|<1u1 I 

Having dec'idetl that thv dttitvntiuii in due to im nccumuhitioii of 

[ free fluid in tJii^ iit>di>inei), it nrmains for tlio iiliysiviun to dutcnnine 

what till- (iitUH- "f thf iDsciK'* miiy Ik-, ]i» mosl fivi|U«iit ottiw.- in 

cirrh<Mii> nf the livvr, wliirh n-^ults in ciigur^f-mvut uf tlio abtlooi- 

llnal vcmwIh with M'<ijndnry iniiuudution of fluid (Fip. 151). If 

it Ih> not dui* to i-irrhiHift. it m:ty uriee from iin iil>dominal tnmor, 

nliii-h by preiuMng on liir|^- vi>»N:la results in an effusion uf liquid 

I tlmiiiiih their wuUis or to tubercular perifonilia, to obetruction uf 

[tlip thomrio duct, vniviilar diwaBe of the hoart rausing an obiatnto- 

ttioD to Uie How uf blood in tlie venu eava, aud, finally, to acute 


diffuse nr dimnic parouchymatous ne)>lintii>. If the ImI two 
canset) be [ti-eMint, there- will tiHiially \u^ muih: cedtinm of tlie lower 
extremiti(!» or {roiierul amiMiiia with dytipntcii and nllHitninuria. 
For lliH typittil i4ytn|ilam'< nmi ]»liy«iail sijjiw of tlicj*i3 vnriotw 
affection? tin* ri'iuli-r is rcftTn-^I ty lliosc parts uf thix Iwok in whidi 
they nrc dixi^iuMM-d (sue Iiidvx); but tlieru it iid additioiud eouroe 
of infoniiatiuD us to the cuiih- of the nHcilue to be utiUnc^l, uAmvly, 
thv i^hnraL-tvr of tho efTu^ioii. 

If ttiu tluid wUtidrawu on tupinitioti hnsu specific gruvity of l.OOtt 
iind contuins but a tnirc of albumin (about 0.!)7 [wr cvut. ), it is prob- 
ably dui- to liejuitic L'irrhosig, when.-as if due to the preesure "f a 
tumor the upecilic gravity is usually about l.Ul^ and the slbutniii 
iicnrly 2 per cent. Such a specific gravity and pmiMrtion of albu- 
min also result when the aseites is due to heart disease or pressure 
on the thoracic duct. When tlie effusion is tlie result of Brighl's dis- 
ease tile specific gravity is apt to be only 1.00<> and the proportion 
of albumin only a trace. In ca.te.t in whiHi the ascites arises from 
some disease dircetly afTeeting tlie cells lining the gieriloiieal cavity, 
as carcinoma of tlie)KTltoneiimorof the abdominal viscera, ortiiWr- 
oular jieritonitis with ov witliout pii;*, the speciiio gravity is much 
higluT than just »t«tc<l, niimcly, from 1.0I>< to 1.027 nj> a rule, and 
the [troportion of albumin ranges from 8,80 in the case of growtiis 
to 5. 76 ill the tst»c of tiiU'rcIc, ami 7. 10 when there is pus. Further 
tluin thi^, it ii« iisecrted by I'ohl and Uoseubach tliut the effusions due 
to venous engorgement, heart disease^ and renut lesions cau be scp- 
niiiti'd from those due to disease in the peritoneum affecting this 
mcuibnine directly by a test following the ad m in ist ration of iodide 
of potuMsium. When this drug is given to the first class of cases it 
Bpccdily npiiciirw in the effused fluid; but should effusion he due to 
the organic diseases of the [>eritoneum which liave Iteen named, it 
will not appear. The fluid to he tested is ])laced in a test-tube 
and some oitm acid and chloroform added, when if iodine is 
present its characteristic color will ap)>eni-. Stionld tlie cause of 
the ascites he a ruptured ovarian cy<tt the dingnos^i^ of ita raiuw 
except from the history of a previous loculiiccd swelling \g exceed- 
ingly diffieiilt. The tluid under those ('i^eunll<tnno(^r' i« usually of 
a spwilic gravity of I.Olifi. but itjt specilic gravity may be miicli 
lower, ft {» a.'tserlcd that tJie instauoee in which the s^pectBo 
gmvity of th(^ fluid is very low are due to a vyst of tho bPHwl 


Very often ihei* i« (Icv<.'1ii])<h1 in aise« of iiHcit<», p«rti<ruliirly 
wliim lluit rt>n<liUoii iirincii froni iu'p«tu' cirrliwiis, u moK or k-ss 
wi'llHlfliiiiil biindi wf vcinn on ttic untvrior bolly-wall, \vliich is 
MinetiiDCK rnllitt) tlio Oipui Mfdtufr, as thv result of an attempt at 
oltiiU-nil oirt'iilntioD to ootupen»it« for the obBtriictod flow «iu«e«l 
by the chuu}|^-H id the liver. SonietJDiPs a lueiliiutinal gmnth ^nll 
cauM) a som«what similar development. When the obstruction is 
lower liovro than the liver (he veiiip of the lower part of the a)>do- 
men (hypogastrium) will be found dialendeil. 

Fi-i. IIX- 

A MM cf obraalo »Dltiv*ininil ot iliD ■I'lotii A-ll'iwtnK >rr)iiil'l fKvcr. Tin dkrk Ilnv ■hnn* 
a» nM|ln «r Uw tfgan oa pklisUan. while (be rctnctlon In Uio IIim and Ibo dottnl lino 
IniUcal* tb* poiUloii of the ■fliaU noidi. (Fmm (hv ■iiilioi'i warti in tba JgPttva M*i11cbI 

I»calix«<l biilpn^ uf the nlKlominal wnlli*, ehielly on t\w rif!;ltt 
aide, is fmmd in uhjhm in wlii<:h tin; liver '» oiiIiirgv<l by hypertrophic 
virrliuiiis or by iMtK'cr or otlinr morliid ^[t)wth, sucli an f^iinimii or 
Mircoina, and by nb->e<>u. The hivoIUiii;. if ibt origin be in the liver, 


will ai-irii- iiDdiT tlie floaliu^ ribs on the right side, and will vtU'Iii] 
diiwittvai'd and forward Inward the umbilical area. If the enlarKf- 
mciit \w i^rtMt, it will oxti^iut far holow tht> nmhiHous and acro&- tin- 
iimhilicjd iirt-a to th(? i)|i]KMito miIo of the nhdomeu aa id Fig. I4'i. 
In t-rilnr^ctiK-nt of tbv >pl(Vii ^iniilnr niga.'i, .ipriii^ing from Uie 
flouliii)^ rihs well over to tlic left *ldii, may he developed (aee Flga. 
143 and Nl), luid liir^' i-vt>tii^ ktdnov oti either side may cuub 
aitilnmiiiiil hiili:in>;, [mrllndarly if it Iw tlouttng. (See Ploatin; 
KidiK-y and Splwii.) 

rio. ui 

A tiiw of prvfuuuil &nmul' ivlLb jpi^" 'ir .'( iin' ■ |iLi h m, m fhown Jo tlic Iftripi onl' 

llncdKHK. Thii uunllvr uulllnw liiilkiaL lui iu:iu >i( uu.j uki; ujuimun iiaM ths )■** of Ui 
hMrt&nd lo (bacaroUil arteiT. iFWm (b« tiubor'i wftrdi In Iti* jKfTciwn Uedl»l CViUt^g* 

Marked swelling »f Uir cpigaHtritini iwlt<ntai diftt«iitioii of the 
stoiiuu'li hy gaa or fiKKl, or that thi.-« organ is the seat of niorhid 
growUi. SomHimcA a i^imilar di^^lviitiim results from <-iiliirg«>mi-iit 
of the [Mxterior mt^slJJkditinl und retro-|>cnI(»nc*l ghinds. Agiitn, 
dii^tvutioii of the ujiigu^lriitm it a|)t to ho mii»cd by cnlargfiurnt of 
the li?ft lobe nf thi* livor. In ovarian tumors the ijrvwth often 
({nidually di»toiviU the t!rltirl^ belly Mjuiilly; biit, as ain.'ady stated, 



the hlslni-y \» iii^iially that of >4welliiig, low down, and of itti being 
I'hiedy unilateral :tt lir^t. 

It flhould bo reoiemberetl that the discnvery of a prrifonn aw«]l- 
iiig in the h_V|>o?a'*[riiira may jm^^bly he due to a pr«gii»iit uterus, 
ur to rct<!tition of urine, with con.'tequent distention of the bladder. 
Vitm» of diliitatiou of the ntoniaeh nflen show very great btilginj^of 
tlic umhilieal area of the abdominal wall when tliat viiwu.-* i.t dis- 
tended hy lt(|tud mid gas. (Soe I'erciiiwioii in tliiA ehnpter.) 

Wv dinuovcr tJie condition of the stomach an to itc' siiw and »lia]ie 
by uK-aiiH of wasliiiig it elwin with Uic Mtotunoh-tiihe mid tht-ii filling 
it willi » kiiuwn qiiuntity of w«t*'r, wliiyli ciiii In- i»iphoiitil mil and 
measured. Or wo «m uselhcsn-iiallc*! g;i9truilin|)liiuieuf Kinhuru, 
which coniuetii of a suuill cluctrio lani[), protected by strong ght^s 
and attached to a rubber tulw which (y>nt»ini« the necessary wiring 
for the electric current, and which i>i swallowed just lis is the onli- 
nary .itnmacli-tube. The stomach having; been thoroii)rhly clcnusod 
by lax-age t.i then filled with pure wat^^r nml tlic lamp swnlluwcd. 
If the patient be modemtcly thin and the Inspection is made in a 
<lark room, the outline of the lighted stomach can he eeen through 
the abdominal wall, and wome idea of its dimensions obtained. 
Xormally, the gnnlMr part of tlie stomach will be found lo tJie 
right of the middle line and about one to two inches above the 
umbilicus. (Sit Pcrciittwinn.) 

KM, 1«1, 


a i^fMMUU ■ Ibia iMI>i«nMl.ear«nd on on* ilda tij «n. uniuUntieil ruliliM. hMiMi 
mtt*« on • tBulin wboi by McUoii. 

1 b tka MoUonaiT niMr tiibt held bj Uiu biittoD or (pool A. At tb* ml of Ibv tub«, 
wMtli NMhoi la um <a(4la onlr. I* a boartuR iTlUiln Un tobc U> nalM lbs eabl« ran mort 


■ ItUwoUct wUOh UBuMiwd li> the ntolrlni ipraniiiif by UwrnavOi 
llalbacpoas*. nbtcblliiialoaauokeiiir ibo n>l>lo d, iiiil mij-lwranMnd M wIlL 

Another uiteful nxuitut of diagnosing dilatation of the »tomaok is 
by m«n« of llie " gvTomcIc" of Tiirek, which in it» improved 
fonn ooa»i«t)i of four {Hirt», namely : a rcvolvin); oppttrntUM; a stn- 


tionury outer Uihe; a mble mv^roil with tight-6ttiti); rubber tube; 
and a 6|)onjje-spiral attached to Uio mbli-. 

TtiRik saye : " To ahow the outline of tli« gnuitcr vurvutiirc, a 
tube containing & cable with a etpotip; at its extremity if intnMlu<<<-cl 
intn the ritoniach. An apimratus for producing n-vulutiuns is 
attacbecl to the outer end of the eable. The ruble is pastfcd unwartl 
ami it glidej* along the gr«it (uirvaturc, pluinly showing thi- outline 
uf thu fttomouh. I^Ioving imwurd, the tuiilv [kmsl-s upward ton-ard 
the pylorus, and then tunii< and piuseti alonfc the leiwcr curvature. 
When rapid n-viilntions arc pmduced the sponge and <.-ab)e mn 
bo felt in thrir rcwpw-tive situations. To det«nninc the distcnsibitity 
of the sCouiaoh, »ibli»( of difTorcat degn-es of flexibility are used. 
A very flexible cable (No. 1) k used flrsi. It i« iutmducod uutil it 
meets with re^iiitanoi' at the le^^er curvature, and itu leugth is uoted. 
At the same time the revolving sponge is examined by palpation 
through the abdominal wall. A stiffer cable (No. 2) is then used, 
and pushed onward uutil it meets with rosislanee at t!»e Ie(«fr cur- 
vature, and itn length is noted. The lengths are Ciimjjanid, and 
their difference shows the degree of distensibility. The degree of 
dixt^ntinu ahn is found by ])al|uitiriu through tlic abdominal wall." 

(Kor the lyraiitonw of giwtric dilatation, s'-ms the ehapler on Vom- 
iting, and that part of tbl* ehapter on tli« Diagnosis of dutric 
Careinunia with Dilatntion.) 

In inspecting abdomiuul swellings the phy^cian should watdi 
to see if they move up aud down with respiration. If they do, 
they arc probably eounected with the diaphragm and depend upon 
disease of the Uver and spleen, as tumors of the pancreas, stomach, 
and kidney are usually not attached to tlie diaphragm, and there- 
fore generally do not move. Inspection of the abdominal wall will 
aUo show possible venereal infection if the glands in the groia are 
enlarged, or if io suppurating they have left puckered sears. If 
HJlvery lines extend across the belly, they may indicate pregnancy 
potit or present, or any state of the al>dominal cavity causing great 
atretohing of the akin. Great bulging in the neighborhiMM) of the 
umbiliou.s will naturally snggeflt umbilical hernia, and swelling in 
the groin, not due to pn^ inguinal hernia, or perha|>s an appen- 
dienhir alwoe-se. 

PAI.PATIOK ASD I*BRCL18SI0N. More important than any other 
external metliwl of ri.iidyiug tlie oondition of UiealMlotniiml content* 
IS the use of gentle patpaiian, the flnger» being gniduully worked 


down inbk the alMli>n)iiia1 cavity iu aach a way aa iiot to <!ause jiaiii 
or excite the ruiiAdex of th« alMloiniruil Mali tn resistanoe. The 
tiaud Khould always bi> <!arerii1ly uariiKMl 1>i>fur(> |>alpation itt 
attemplefl.aiid the object of the examiner iii to dUoover, flr:«t, tlie 
hanln«iwor ivjtiMtamw lo piVKSiire; iteooiidly, th<- coiisixleiicy and form 
of \\w or^ns whioli ho cnu tonch; and, thirdly, wliothi-rany nwell- 
inff^ whirh he feehi are movable, bound down and immovahh?, piil- 
mtin^, Kofl or bnrd, nodiihtr or smooth. The |Kitii-nt whimi' iibdomcii 
w tobe j>al[NiUHl must lie placeil fl«lou lii.% hark with tlu-kui^iwdniwn 
up tu n;hix thi; uhdointnnl niuoi^h'.'^, tlio tieud nnd luwk ishoiild he 
miwd, and, if possible, thr nttoiition of the pittient pihoiilil In- ilivcrti^l 
by convL'i'sation ub'nit some Hym])tom wbicli oxisls cli^i-whi-rt- lliiin 
ill th*- holly, while tin- examination is made, n» in thtu way voliin- 
lury muscular resuitanoc- is rvmoved to wme extent. He i^honld l>u 
taatXe to breathe easily throiif^h his opened month; and if the belly- 
wall remains so rigid that u jterfect examination ix imiKweible, and 
yet the rceulte of »uch an examination are very imporlant, ether or 
chloroform should he given to relax the muHoles. 

Great reiiiataiiee of the rigid uhdoiniiiul niii.4cles is found whenever 
I>eritonitit) U pr&ient in an acute form, in ^me ean?» of renal and 
he|Mi(tc eolie, and more eoninionly in lejid i-olie nnd in liVMtenn. 
In peritonitis greut tcuderness lo the i«liglite!«t f^iiieb \^ nl»o present. 
Auothur sympti.>m of avtitc ])eritoniti», aside from the cxipiisit« teu- 
dcruess of the nbdomen. the dmwn lip, the thirst, nnd the ilisiention 
or ripdity of the belly-wall, is |uiin of a sevei-e uharaeter; nulcss it 
bo septic peritonitis, when pain may be absent. There are also the 
drawing up of the limbs to relieve abdominal tension; obstinate 
oon^tipution, moderate fever, and a very rapid, quiek pulse. The 
tonj^nc s|>ee<lily beeomee dry aud |ianrhed, and collapse may s|)eedily 
ensue in severe cases. It is not to be forgotten that looalixed peri- 
tonitis may result from many ean-W!!, uituatty from dLiease of the 
appendix vermifovmis or the genilo- urinary traet iu women, and 
that the loeal symjitonLi and loitionH may be limited by a wall of 
lymph to a ver.' xmall area of the abdominal eavity. 

It muflt l>e reiaemlM!re<l, however, tlial the anterior alxlominal 
wall, jarlieularly that of nervomt penwtn«, i.'^ often very setiftitive or 
" tieklitih," and the more exposure of the ^kiu to the air nf the 
room, <i)uphKl with the fear of tlic examiimlion, may miU'M' f^'nt 
rigidity of tlie l»irlly-wall vrithimt tlien* ln;ing any abnormal eoitdi- 
tiou pTOHiii, Tliis mu generally be ovemome by gentlettesM in )«il- 


piitiuii mid by resting tlii' palm of the band oa the belly and pertly 
tU?xiiij^ tlie fingers, rather tban by attempting tn inwrt the finger- 
tips between the abdominal muscles. The writer has recently seen 
a ea^e of rliylhmical hysterical apaiun of the recti muwlett in a male, 
which a1 lirtit gave the i^ensatinn of an enoriuouH diffuse paLsaling 
aneurism of tlie abdominal aorta. 

Let IIS suppose that on placing the hand upon the cjiigaRtrium and 
the iipjH'r pari of thi- iimbili<-al urea that wo find n swelling. In 
the lirst ptaci-, wi> must divide as to wht-th<-r it !i* in the nSdimiinal 
wall or in tli« abdominal cavity. If it i» in tho wall, it will Iw 
movable with itii' tiwiiioii of iIk^ wall and r<<iidny f;niK)M'<l by ile«p 
pnljmtiori- l)ul if in tlit; abdominal nivity, tbo abdominal wall may 
be made to move owr it unU-sx it lie attached to tlic imrivliil |K-rit«>- 
neuni. LH us i»ip]Kitte it lo in tho wall of the nbdoriK-ii, what tiat 
tla- vwcUinfr be? It may Im a fatty tnmor; in wbioh cwm it* »tir< 
face will b(> dimpled aiu) rci^iHtant, probably nut painful, iinl<t» tli« 
gmrl Imif U-cn inriaiiiL-d by nibbing or au injury, and it will wA 
tlnctiiale. Tht-ri' will gi.-ni;nilly be a history that tlie ])cnion liu:^ 
exercised eoiHtaiit preMure on the part, as in leaning agiiin»t n bendi 
or table. ^Vgaiu, it may be un uliHcesx; but a»ide from tliv niriljr 
of this eondition, we can exclude liiicb a possibility by the abeencc 
of pain and Hii<-tiiation,nnd the history of a severe injury. 

Very much more commonly a swelling in the epigastrium, or 
upper umbilical ai-ca, is due to an intra-abdominal eaiise. In adulta 
the most comnioij ejiuse is probably a growth (gem-nil ly a carcinoma) 
of the pyloric end of the stomach. In other inslances it is due, 
particularly in children, to enlai^ed lymphatic (rlands, as in tuWr- 
cnlar disease of the mest^ntery. This is alw> sumcttnics »ecn in 
adults. Sometimes by reason of tiibenmlar |ieritonitis a nodular 
moA* is not only felt in ihts area, Imt an abrwess containing tubercu- 
lar pns may be formtKl and bci-omc ^iirmundod by walls formed by 
the gluing together of the oi-giins by lynijdi. f^reinoina of the 
)iancr<!a.H may also a swelling in this iittigbborliood, or » cyst 
of the )uiiiereat« may be present. .ViieiiriMii of thv abdominal aorta 
i» also not to be forgotton. Sometimes, too, a diMondcd or mrcino- 
niatoiid gall-bladder may project into ihin area. 

If the growth be giwtrie carcinoma, the [Mlient will be in or pa*t 
middle life (proluibly between the fortieth and se\'entieth year); 
will have a history of constantly inereasiiig ]utiu and discomfort in 
the <«tumaeh; ihi-rc will have been much HHir beieliiDg, and perhajM 



Toniitiug of <H)fFee-gmimd-Wking material; roarkeil loaa of ileith 
and .4oni« rnehcxin will Iw prc-ieiit. According to Wcloh'a slatiBtice, 
out of 1300 oawjt of ^-^trio <««i-itr, 7!ll wore in the pylorus, 148 iit 
the toMfcr oiirvutnro, 104 in lhi> ■'ai'dia, RK in the poRlerior wall, aud 
61 involvml tin; whole :<loinudi. The romaimler were tn the fiinduti, 
thf ^rwiltT <mrvaHin', «r \\w imHrrior wiill. The gmwth, if tn the 
pylorus, w usunlly frt-uly iur)vsbl<-, and fur ihU ren-ton ««» lie readily 
fflt, and then if- often momentarily lurt to piilpaiion. lis positioii 
X6 ipt t« cluinf^e with the ]io*turc of the |iiitivnt iinil the iirc-teiK-e or 
not) of food in tlu- »tomiieh. Pain w u^iuilly vlieitcd on deep 
preesnrv, and, if thv urowth be larj^- mid at tin- pylorus, the symji- 
(oiuii of dilat^ition of the stoiniich will Ik- prcMcnt, betAUiK^ that 
visctts is dilated through the obittruclittn of the pyloric opi^iiing, 
n-liieh results in retention nf the gastric t-untcntit. Under thr^e 
c'iretimAtaaueH, whatever the cause of the obstruction luay W, or if 
the gastric dilatation simply results from inherent fceblenc«« of the 
stnmach-walL'), tlie entire upper {mrt of the uhdomen will be found 
distended, tense, but yieidinp, ami the history will show that Uie 
patient is attacked now and a^rnin by vomiting, during which a 
most extraordinary iiuanlity of fnixl and li<)Uid, which has gradually 
a'vuniulnti-d, will hi- expelled. The probable dia^iiosis of giistrie 
riiHcvr iiiid of gii.->lrie dilatation ma u.'^ually be coiilirmed by pcrciis- 
nioD, after dti^tvntion of thv sloniaoh,and Aonietimen by the use of 
the gaMtro-dinphaiie. (See i«rly \k\tI of thi^ chapter.) 

Kveii before the stomach it* artiliciiilty distended witli gas ]>ercuH- 
itioa will give us valunhlo infunnnlion in this connection, for, if 
obMruciiou of the ])ylitriii' <-xi.'iln, thei^ will be found either a lai^ 
•r«« of giutric tyn)|iany thruugh the acnnnuhition of gas fn>m fer- 
mentation, or, if no vomiting luii« taken plaoe for some time, an 
equally gn«t ari'a of giwtric duhiesM ihi« tu tin accumulation of food 
and liquid. If in such a caK- we fimt wa-^h out tlie stomach by 
means of a i<tomach-tulK- iiix) then lill it with gas by giving tlte 
patient to drink, lirst, a half-glai^^of water with siHlium bicnrlxniatc 
in it, aiid then another half-glass with tartaric aeid diasulvt^ in it, 
, M thtt gas will distend the viseu», wo eliall be abl« by means of 
^B penrussion to outline tlie stomach with ease. It is best to mark tlia 
^ndgeof putrio reAonanoe by means of a blue pencil, and thus map 
^BtHtt tbo gastric ana. If there is a growth at the pylorus causing 
^H ohstnictioa, there will be impairment of rcsonanoo wherever tbe 
f pylonis may he situated. While this is a somewhat indefinite state- 




iiit'iit, it it! to bv rctmembcred that a mure Jofioitc on« is liitbti- to 
ini»l(9id the titudcnt, for eveD in bealtli the j}o§itioD of the jivlorus 
ohau]^ greatly when the litoniacli in empty or is filled with food. 
Thus when empty the viscus bangs with the pytortiB very low, but 
when it is filled the pylorus is raised. Fig. I4(j )4iow» the nornul 

Fio. lU. 

OoUlaa of norouil poiitlanBUil uln of mucukvIi in do uIuU wbtn dliunded wlUi (■>, 

(Aller Mxi9iK>T.I 

gaatrio ami wlieii tJie stomach in disteiiclod with gns. The fol- 
lowing Hgurex, taktiii from Otder*!* Lfetuirn on Altdominnl Tumon, 
Ultutrate the exiraordinnry de»oniit of the utomiu-h madv in sonic 
onses of guftlric dilatation in the adult. (Fig». 147, 1-18, am) 149.) 
Many of these onws of gitotrie dilatation are also luwooiiitvd with 
atrophy of the gtutric tiibidw, or nt Ica«t an nbMi;ncc of any seeretioa 
of normal gastric juice. Tlic miitlcrw vomitwl, or wwshed out of 
tlie (ttomiich, are often devoid of hydrochloric a<Tid, but londcd with 
au excess of bictic acid. Lactic ncid iif teeted for as followH, the 
hydrochloric-acid teat buiit); pven birlow : a few drops of neutral ferric 


chloride salution are mix^ with one or two dropei of pur« carliolic 
nuid, or 10 cc. of il 'y jht cent, M>liitioii of carbolic acid, anil water 
iMld««l until RD ametjiyst hue develops. A few dropa of the filtrate 
derive*) frotn the fllomac)i-coiitcnt(< ai'e now added, and if lactic acid 
or lactates are present the amethyst -blue will liecome yellow in color. 
This is a very delicate test for lactic acid. 

Homelimea iu cases of chronic ffastric nicer the area involved 
becomes so indurated as to be felt as a hard mass throiij^h the 

Pin. t«7. 

Praflk Tlaw of Uic ■bdomeii "f * Honun ngvl ilily live ftaim. iliciwliw Uic liimcir 

alxliiniinal vrall. In mich in>rtHU<-t'» the points which aid a» in iw)>- 
arnting the n>ndition from ^r^triu •.wnoor nrc the facts that the putJcut 
is young and usually u woman; that the vomiting oevnrsimnitilialely 
after taktn); food, for in |j;astric uiuocr it 'n^ only seen iu most cases 
iwveral houn after food has hceu taken ; tJiut there is no sign of gas- 
trie ohtttruction ; tliai there is an excess of Itvdrochlorit: acid in the 
gwtrie contents in eases of ulcer, and an absence of this add in eases 
ruf nuieer; and, tinally, tJiat there is uo eachexin in cases of gastric 


nevliiR ItM f«*IU{in unil llM of llio (liimMh. (MLn.) 

no. it). 

TiiiMroribeBbliMneneaiifRlVatlbtedMomiiota. lOtun.) 



UI1.-X.T. lliuugh tlitirc ninv lie luiii'min. Tliciv U ii.siiii11y in ati^> uf 
ulixT t)o great luss of wviglil, iiiiIvm tJiv syni|>tuiiiK liiivti been pn-Miit 
a IcHii; time. 

In C5i5«t of frtwtric wicer {;rc«I imin is nfteii protlmtHl I>y ilocji or 
cvvQ siiperlicLal pniwuiv ovor the vpigti^triiim, aiirl n pitinfiil »])ot 
can geaorally bo found on the Imck, about tlie angle uf tlio riglit 

Tlivre is 110 btrttcr placv than the prvscnt to «j>eftk uf tlu- uiuiiikt 
of bestmg the Btotuach>i:»)iitcat« for bydruchlurie iicid. Tliu pHlivnt 
is directed to talce no food for ut leant twelve hotirs livfort; prcscittiog 
liimwif to the pliymcinn. On hi^ urrivai fur exnniluution \w in 
given what ie Ituown as " Ewuld's todt-brcnkfa»t," whidi consists 
of an ordinary dry roll and u littlo ovvr half u pint of wnt«r which 
has been warmeil, and \\^ u directed, uftL-r swallowing tlicet* mate- 
rials, I0 M'ait for an hour. Tlii^ Htomaeli i.s now onipticd by the 
intniduetiou uf th« bulbed stumacli-tiibc, and tht.- gastric contents 
filtered. A few minims of a solution of plitorogludn and vanillin 
are next placed in a i>orcelaiii ilish and a. few drops of the ga^trie 
liquid are allowed to trickle down to the edge of the solution. The 
disli is gently heated over a spirit-lamp or Buosen burner, and if 
hydrxH'hlorio arid i» present there will ap]H'ar a red tingi-. This 
hi an abcMilute proof of the [ynwenec of bydroehlnrie aeid. 

The ftulutiou of pliloroghicin and vanillin U made a.<< followx : 

rblomf liwln ir. izx. 

Vanillin .._.,.. gl.XT, 

AtMituM alcuhol O] 

tMinlullon I* |ikl( ^llaw lu hns. It miiM In kvpt Indaik IntllM. Mon •ipoaurclo llie 
alriAdllfhtUbeeoinestwDvrnuu] HarUiloK. 

1 If th« eainv of the swelling of the abdomen lie tiiberruUr ginnds, 
tliey will be found, in all proluibility, on deep and general palpa- 
tion, to bv scattered all tlirttiigU the abdominal eavily; tliorc will 
be a history of alternate constipation and diarrha?a, of fever, of 
geueml loos of Btr(>ngth, of loss of appetite, and an examination 
of other parts of the body may reveal the signs of a widely dis- 
tributed tuberculosis. 

I The presence of a resisting mass, deeply silnated iti the epigas- 
trium, or the upper part <tf the uiubiltiml area, and felt only on deep 
|>al|)«t)on, and then often tndintincily, should bring before the mind 
the poesibtlity of tlie presence of carcinoma of the |)anereas, a diag- 
nosis which will be larifely contirmed if caehexia lie asserting itt«elf, 
if tliere bo great |>ain iu this iieighburhuod, and if there arc oily 



fitouls u(t«r fats ufe tiikeu, as a result of tlio aliHeuoe of panorvatii' 
jniTO. Still further confirmatiDTi of thia.<liagnnsi8«-i]l be present if 
diabcUM rDellitiia be devoloped by tbe imtient (pancrcatk diabeten). 
Such u growtb in the imnoreas is usually scirrhuA canwr, and may 
be primary or secondary. Segrfi found ihat of *J27 €«.■«* of car«- 
noraa of tlie upper abdotuiual ot^ne (tancer of llie jianfrena <>coiirri-<l 
in 1:^7, but only in 12 of tUeae primarily. Stiller a-'viort^ Uiat (lit; 
following (ivinptoras are fairly ftiire sigan of patwrealii^ Aiic-rr, 
namely, niarki»I dy:ipe|>^ia, rapid omai-iatiiin and aichcxiii, Milinur- 
raal temperature, persi;«t«i)t and progressive jnuudiiv wllltnut lii'|Ktiic 
enlargement, but aiu-u with surelling of thv giill-bladder fi\>in 
ob4tniotini) to its dtict. 'I'lie*.' nign* iire, of eotirsc, only of valiK 
if tbl^ evidenot; of nmligntLiil i^rowth elmvhon; enn Imi ex<-lud<-d. 
Very nirely swelling of iIiIk rt^jiou, cither nipid or slow in ooiwl, 
fullow'K n|>on the formation of oy«t« in the p»n(^r«iii,n9 u rmtill of 
obiitnietion of the dimt of the ghind. Whun they occur tlic*e oy*l« 
may quiti; fill the abdominal cavity, nlthoiigh, w* a rnlc, tlicy are 
f|mt« BmtU. Aft pointed ont, however, by Jordan, (he real enuec of 
swelling in the puncrcHtic region miiy be liemorrha^ into the lesser 
poritonml envity. He Hummuri«w »nme of hit) viewM in rvgnn) to 
this matter as follows : 

" Coutnaiona of the iii>per part of the abdomen may be followed 
by the development of a tunmr in the epigastric, umbilical, and left 
hypochondriac regioni*. Siu-li tumors may be due to fluid accumu- 
lating in the lesser jteritoneal cAvity, and when the contents are 
foun<) (on aspiration) to Iiave the ]iower of converting starch into 
sugar we may assume tliat the pancreas has been injured." Finally, 
Jordan states that " many sucli tumors have been regarded as true 
retention-cysts of the panei-eas," 

In other in.4tuniHM n swelling in thi>f nciijhborhood may be duo to , 
what i^tnlleil piio-jmritmoOiortixiinfiiihfriii'^ut, ft eondition of ; 
in tlic peritoneal ciivity below the diuphnigm, pnxlm-cd by perfora- 
tion of tlio stoniueh or tninsventc oulun. The nbwH'ss so pruduoc<l 
may contain ga.s and fur this mwon the swelling may Iw quite 
resonant on pereutwion. Abscess in thi<) region nUu folluwi(nl>sovM| 
of the puncreuH, or fat-ncerosis of tliis orc^nn in rare instunit^. 

Sometimes, too, we have marked enlargement of (he huwl of the 
iwncreas, due to u malignant pancrcatiti)^ This is partii-ularly »|»t 
to he aasodaled with elioldithiasis. 

Th« appearance of sudden swelling in the neighborliood of th« 


|Hin<'ri<nn, AKtKK'uih'd wiUi iiili.*iim; |Kkiii, i)aiiH<.'u, iiiit] vocnitiiig, niiiy 
tx- iliK- i-ith(.>r c<> iioiilc lii;mi>rrlm);i<: ptinuruititi!), to ii)k>»tiiinl obittrtio- 
tion, or to neiite peritouilis n^ulting from [wrfontion. The last 
two lire thf more i^iimtiion. An I'xplorntor^- opiTJition is tlic only 
wuy of dwidiiiK t\v: dtugno^Iis positivt-ly. (Sci; cliuplur on Vomit- 
ing for tfymptoms of inu-ittinnl obstruction.) 

Aortit^ puliattoi) is oft«ii tnin^niitU'r) to tlie Imnd l>y enlarged 
abdominul ({lunds or tiinior-mn««c«. If tliu puliation of tlii> aortii 
ii> not tmu4iDittiHl by glands or tnniors, it miiy bi' due to unciiriiuii 
of till.- ubdominal aorta, the <]iagiiosis of wlilelt in p^-tubli^hod, if, in 
addition to ii piilmtlog sensation, wc also find on palpation a marked 
thrill, au I'xpiinsilo movement of tlie tumor, and on nusoultation we 
bear a bruit Pain due to presfiuro of the aneuriamal sac upon 
6om« of the nerves of the abdominal cavity may also be a promi- 
nent symptom. 

Localised swelling due to other causes than those already dis- 
cussed are due to im[»iction of fei^s, volvulus, and intestinal obstruc- 
tion from other causes, aa, for exam[>le, eaneer of the bowel, which 
o<«tirs moet freitueiitly in the cwcum, when the Rrowth will be found 
ill the ri^ht groin, or in the sigmoid flexure, when it will he found 
in thf> left groin. 

TumorM or foreign bodi<4 in the bowel can m-arly always l>c 
moved about utdcM ttoiind down by inflammatory ndhi'i^ion^ so 
diflering fn»nj growttm whinh involve lliw immovabk- part*, nuch v* 
tlic rrtn>pcritoaal ghuidit. N'ery ranrly wo find mncitriHW tumor of 
tlic omentum, which iiKiiitlly btiroiiK.'? n-trai-tod and !iidunitv<l m that 
ita hardeiml odgi« nm be felt exlviiding aerutw tbv abdominal cavity. 
Mon.^ ouninionly multipU- notluK^ in tho omentum, or Ktndded over 
tJte (Hirfo^.'o of the bowels, arc- due to peritoneal tnbereuloBis. Nut 
nirely the»e nodular mnMHCK are ittiiddetl over the mesentery. 

Floating kidney may also cause a iDarked movable swelling or 
tiiinor-liko uium in the upjier zone r»f the alNlomcn. If tlie belly- 
wallsui' thin, the kidney-shajMM-au sumetiniei^ lieoutlineil by pidpa- 
tioo, vaA oven the pulsation of the it-nal arter\' can be fell; bnt, as a 
rule, this cannot be done, and the dilatation of the pelvis of tlie 
kidncv br the oltBtruction of the ureter, which has become twisted, 
may distort the shape of the organ. Beep pal{ntion of the flank, 
if the kidney haa floated away from its normal sent, may reveal 
lessened resUtanoc in this area, and bimanual [talpalion, one Imnd 
lieiog placed at the back and tbe otlier in front, may reveal the slin)>e 



of till? oiynn clsowhi-n.'. Fiirtl»'r, if Un- ]iatiottt be iniidw ti> Ii« ou 
the sid^.*, the (lieluuiU'd kidiK-v mity «i>iiii>UiiiiM Ix* eloarly (MiUiri«<l by 
biinmiiinl palptitiun. 

W'v »l)uul<l nut for^-t tin- t>o««il)nity of a flontini? »plcea, a mre 
cundilioti, but one more ovtaiiiun tbuii is ^■iitrally lbuti<;iit. The 
sliapi- uf the organ, if it cun be palpHtMl, will iiid tho duif^nuKJ^ niid 
thf prfseiicf of ifsoiiiinoc on pcrcuHHJon over the ari« of normal 
splenic diilneiis will cimjiriu the diiignoais thst (lie i-pWn biiti be- 
oome displaced. As the spleen in thb emidition may fall na low 
tka the virgin uterus, it may i^imulatc any jirowlh from a uterine 
myoma to a tumor of the bowel or panoreas. By reason of twist- 
ing of itH p<:(Iiole and seooodar}' engorgement ita siiie may be enor- 
mouH; but if thin continues, atrophy finally takes plaee. As sueb 
a diifloeated i^jih^n drags on the i^tomach and pan<>reaa, it mayeauae 
a lonjf tmiu of eurioun ^vmiitomK, and oven intostiual o)>!itnietion, 
Sutton Hjisertii that by prc^vinre it may naitite diiiplaeementa of the 


When the kidni^y is enl«rg(«i from cyrtic dcgeiiemtioii, from ordi- 
nary hydroiH'phroi^ii', and from enliinoeocwuB ey8t«, it may I)c rvadily 
felt in the mnbilitml nn^ in many inMnneM. HydroiM'phnMi^ liaa 
been mletitkcn, in ebildrcn ptirticuliirly, for sarcoma of the kidney, 
and in lulult fenudes for ovnrian tumor. The diagnosis can only 
be made in some of these cases by tapping;. The fluid obtained) in 
hydronephrosiB will usually be somewhat turbid and contain epi- 
thelial cells. It should not be forgotten Uiat the condition of 
hydrooephrosiB may be intermittent, for, if this is not remembered, 
the phyttieian may be misled into thinking that the disappearance 
of the HWelling is due to a floating kidney slipping back into its 

Bulging of the flank, with |uiin, fever, and perhaps fiuetnation, 
indi(-al4M |>erinopliriticabi*o»»oroarieiiof llie spine with cold abHci-sw. 

Perinttittio niovemenltt of the inteiitine^ van immetimes be felt 
through the t>elly-wallH, and, if tlie oontiaetion of the muscular 
librCH i» excessive, nodular ma.««c^ (if momentary exicitenee may be 
caused. CliMely awtociated witli tliiii »enMtiu» on |>aI|«tton ih what 
is ddlcd '■ phantom tinwir." Such a formation i« gt-nerally found 
in hysteriuil women, and often leads to ludicrouH errors in ding* 
noeis. It ia duo to pen^istont dilatation of a knuckle of iotMlini 
by gas, tliereby forming a moderately hard and nn>re or lw« eon- ' 
stant mass, which may n-semble a real tumor. Examination of iho 



]iRtieiit umlor ellicr will iiKimlh' reveal its triK' i-lmnicU^r. IjIWiI- 
i»-il HUjiortif^iii) luid iiicourdnut tuDiors iimy arise tliruti^li bjmsiuocUo 
l)lit Iwiilininl truotnictititis of the i\<cti iiiti«clcs. 

Fiiutlly, « );Wi'lliilg in the riei^hburiiood of the tinibiltc(i« i^boiiM 
alwnyK iirouM the mmpieion of an iimbilieiil licmlu, imii tlii: «itnit- 
tion uf the Hwellin^ ul the itmbiliciis, the fact thnt percussion over 
it givej* a highly tympaDitic note, owing to the gus Id the prota|Me(l 
gui, iind the possibility of redueing its size by taxis, will rvntler n 
diiignu4i<« of umbilical hernia pot»ihle. 

If on palpating the epigastrium and umbilical area nothing ubnor- 
RWl hH!> been found, we next seek to diiicover If there is anything 
ftbnormal in the right liypochondrium, or, in other wonis, whether 
tliere is any dit«ease of the liver. 

Normally, in the adult, this ^land cannot be felt below the ribs, 
except part of the h^ft IoIk- in the epigastrium occasionally. Some- 
tiroes, on deep inspiration, the diitphragm pushes the liver tow 
enough to be felt. In ohildron thu liver !■* naturally large enough 
to be felt below the ribit. 

When the normal liver is pennis^^d we find that it lies in the 
area .iliown in Fig. 1*)0, and that as we percuss above it on the 
ribs- ill the miinimiiry line we first gfl pulmormry rw^onance, then a 
litthr l><<Iow this impuirctl resonant^, due to the fact that thi- lower 
*^\'fy of the lung is interposed between the chest-wall and the liver; 
and still lower we Iind ab>H)1ute dulness or fintuess, due to the «oIid 
liver itself. Below this area, which ceases just lielow the lnwi-ft 
rib, we usually find tym{niiiy on percussion, due to the gtus-tlistended 
bowel. If we percUM in the midi^ternal line, we get the same signs; 
but they begin as high as llie nipple, or above it, and then cease at 
a line drawn across the abdomen almiit midway Itetween tlie eusi- 
form cartilage and nmbilieiit. To the left of the middle line of the 
steruum the liver-dulness merges into the cardiac duliiess. (See 
Fig. l/iO.) Id the mammary line liver^ulness begins at the fifth 
rib, Literally it beginit at the seventh and eighth, posteriorly at the 
tvnih, owing t» the sloping position of the diaphragm. 

When u ban) and firm miLts, with a smooth nurface, can be felt 
in tiie right liy[MK>hondrium or right nnibilicjil area, which is mov- 
able, and which has an edge whii'h can be readily felt on deep pal- 
jiation, Ihe ma-ttt in proltahly an cnlargiil liver or one putthed down 
into the abdominal mvity by a large jileuml effniuon or a stibphrenic 
abwens, or ?MMitettmcH by an eniphy^'niatouN lung. Tlie «at»ea of 



eiilai'f^uiiK^tii ai't; amyloiil dej^nomtion, ooiigeHtion, hy|>er(r<>pliie 
oirrliiiitis atu] iibsoes!!, «urciQOinit, sHrnamn^ and lynipliailcitoma. 
WIk'ii tlio Murfaov in found to be smooth the con<ii(ii)ti ii* pn>hal>]j' 
iiinyloid or fatty t!«j;i;ucratioii, or (Mnj^tion. If U»e sMirfaoe is 
ruiigli, it wilt proliably be due to I'irrhcKtis, wliit'li pvi» n gmtiular 

no. IM. 

9b«vrtii| alualaM anil r«kUve pcmtutfan-dDlittM of Hiw and hMTt. I. IMUtlTe 4«luen at 
llitr. I AbtaiutadulawB. s. K*laUvodiiliiai«<if hutrt. «. AbMiluuduliMM. 

twtiniation b) the liiuid when tlxr ubdomtanl witll i^ moved ovor tiio 
organ. In tiiiiU^imi)t f^wtli Intvc im'l i^iimll iindiiloi* mny often 
bj^' fuimd, and di^prcw^iuns or iinibiUiatioiu of itA durfncc may Iw 
mnrkf.1. (I^>. 142.) 

When, uti piiljuitiiiR thv livor, we tiixl miirkcd t^-mlcmess and 
some fiwelliiiff, and, awuK-iatvd with tlxwe isym|)(oni8, fi-vor, rigors, 
sweats, and Mnietimm vomiting, and, in aililition. a hiriton* tJiHt 
the patient has hud dys<.-ntery or has had exposure) to tropical brat 
or has stvalluwod much bad irnter, wc arc forced to the belief that 


an nfascew of tlic liver i-xisu«. Thii^ may be ^ii^lc or multiple. 
tf the Utter, it ii< probably du<* to pytPtnia, ao<] no sput of Btictiia- 
tiun will bv found a& a rule; whcreiu, if it is lai^e and siugle, 
flu ■■twit ion w sonii.*tim(»( felt, Fiirtlior, the enlargement of the 
livor in tin; pyu-Diit' form i» uoiforii), wliereaii in the siugle ab^ceaa 
there U often one spot which \» swollen or enlarged. If a single 
larjrc pyriform swelling, »'hich is yielding and somewhat jiaiDfal 
on pnlpiititiii, be found, nnd there is Home fluciuatlon pivaent, abM-eSfl 
DHirtt be tltotighl of, or in its place im|raction of the gall-bladder 
with ^nll-»ton«ti or its disipntion by obtttruotiou to ita ducL Th« 
bistorA' of the case will usually se|)arate tlie cntiditiouti, one from 
tlio otlior, for diagnostic jiurposefl, for tn the ease of absoess tlie 
hiatory will probably I>e that of a person expoaed to tropieal liont 
or one who has had an injury, au acute infwtion, or an aiim-bic 
dysentery; while if gall-stones he the lau^e of tlie Bwelllng, there 
will b« a history of gall-«t<.)ne cotic, of jaundice, or of liepatic fever. 
More rarely a single Ijepalii' swelling may be due tn hydatid cyst, 
but the history and pn-semv of fl net nation, roRibiix'*) with the result 

Bi>f examining the fluid aspinktwl from lite swelling, will decide the 


B The cuimitftviicy of the liver is ii^^uully very liarrl in iMWf» of 

Hcirrlio«i», curcinunui, and amyloid degpnemtion, In cirrlioifis there 
will be some ascttos in mutiy oa.<cs, some swelling of the legs |X'rhn|Mt, 
and dull pain in the hepatic region. The digestion Will be iIi>>or- 
dered, there will be marked loss of fiesh and often h tenia tcnies is. 
Sometimes coma comes on. In malignant disease of the livor there 
^ will be pain, marked emaeiation, and cachexia; ntxliiles will be felt in 
[the liver-auhstan«?, and the organ be found much enlarged. Tendor- 
I on pressure will be markwl. Sometimes ascites will be present 
a growtli may \w found, usually as the primary lesion, in the 
stomach or bowel. In tlie nasi- of amyUiid liver tJiere will be a 
history of prolonged xuppunitioii elsewhere, and there will l>e present 
dutordered tligp,ition, irn'gnhir howel-movements, and little pain. 

Marked tendernew of the liyiwchoii'lrium ii* usually found tn 
oongcwtion of tlie liver, in inllamnintiun of it8 ti'vuK-n, ^nch ils tlmt 
muNol by an infection or by gnll-st<me« in ib* i<>ubstutict!, and in 
malignant growth. Tenderness is pnteticnlly aliM^nt in waxy Uvor 
and in fatty degeiK-rution. 

In eafiTH of (-irrhusisof the liver, whether it be in the liy)M;rtr(>phic 
atrophic form, tlie organ presents no symptoms in itself save 



tbat in the hypertrophic state its size is JQcreaaed so that it can be 
felt below the ribs, whereas in the atrophic state it cannot be felt 
except by pushing the fingers well up under the ribs. The symp- 
toms accom pa Dying cirrhosis are chiefly connected with diaonlere 
of the alimentary canal, either through direct failure in the diges- 
tion and assimilation of food, or from cbaoges in the blood-siipply 
of the abdominal contentR. The following excellent diagram from 
Taylor's Index of Medicine shows what these symptoms are, and 
discovers their cause at a glance, the cirrhotic process, of course, 
obstructing the flow of blood in the liver. (Fig. lol.) 

Fio. l&l. 


\S|^lrcn\ mid 


J^ Hirmojrhiiidi 
To lIluiitialG Hi'mptoms of ulrrboalu uC llTer, 

Finally, the ])hystcian who finds the lower umi^in of the liver 
abnormally low down in the abdominal cavity ^honld not make a 
diagnosis of enlurgemont of tliis organ until he has assnred himself 
that the extension of the margin of the liver is not due to an effu- 
sion in the right pleural cavity wliicli presses upon this organ. So, 
too, if the patient is a woinan, the lower border of the liver may 
have I>een pushed ilowa l)y tight lacing, and careful palpation may 
reveal a furrow across its snrfaci; produced by the constat. 

A sniiill |H?!ir-sli(HKHl mass protrniling from nnder the liver is 
usually dui! to an enlarged gal l-b ladder, di'^tcndcd by bile or calculi. 
If it is the former, pressure niiiv ciuise it ti> disappwir, owing to the 
bile l>eiug pressed out into the int<'stiue. 

In the left hy|iiK'honilriuni the spleen mm be very readily ontliuL-d 


rm. IJrJ, 


Sy pemtAHioii in iierwins not iiii)r<Ii»ntol_v fat. lt« normal position 
in best shown in the lut^mpanyinK tiffurc (lo2). 

Hie ii{>[K'r Itonlor uf tliu aplwii id on a level with lh« tontli «Ioml 
vertfthni un*i thi* Iow<>r Iwnlcr on ii U-vd with the pnd of the elffventli 
rih. \\t n|i[><.T vA^ or limit U on a level with the ninth rib. In 
))emiMHin)i; the Kpleeii hunvy penMi»>ion i>i to be avoided, lunce tliis 
nuy develop the resununne of Uie »totn- 
neh or bowels. Tiie Bpleeii wmiiot be 
palpated unletw greiitly enliirgetl, but 
it iiuiy be found bulging from beneath 
the lowi-%t rib in typhoid fever; in 
t»carlel fever; as the result of acute or 
chrunie oiaWinl fex'er; in louoocjlhas- 
mia of the spleno-medullai'v varietv; 
in amyloid disease, as that after long 
Bnppuraiiou; in early syphilitie infee- 
lion; and in any disea^ which i-aiines 
venous engorgement of the alidomiual 
viscera, auiJi as cardiac disease or he- 
patic eirrhosJH, Sometimes diWplaoe- 
menl of the spleen downwnrd uriMt) 
from eii)pby<^nin of the Uinfjs or left- 
md«(l pleural efTiuion. 

Acute splenic swelling i*onietimt^« 
oomos on in oueti of general »eptie«- 

Xfwiy always tlie splenic surface is 
smooth, except for the notch in its siir- 
fiioo (mc Fig. 143), unless tlie disen«e be the rare oondiriou of 
hydatid disMSO or wrcinoma. (For FloHting Spleen, stv p. .tSH.) 

There yet remains for discussion the •<i};nitii.-auee of iiivrea»cd 
mistance on palpation, and percussion-dulncss, in the gruinx. In 
the riglil ilia*- region tlie presence of swelling, infreasetl rtwstnncc, 
impaired resonance, or tympanites, particularly if pain nud tender- 
ness are present, point strongly to appendicitis or to inflammation 
about the t^pvi cod. Sometimes, however, the presence of a dis- 
tinct lump in this region in a person advanced in life may mean a 
malignant growth, for carcinoma of the caput coli is not rare. 

If the left groin is affected in a person well advanced in years, 
nanniionm is aliw to 1>e regarded as |>a»eihle, for the sigmoid flexure 

Nnnnat ;ii»tnuii at ill* ii|il(i;ii. 


is a frequent seat of such growths. In a young person, or a child, 
impaction of feces, a foreign body, or intestinal obstruction is to be 
considered. (See chapters on Vomiting and on the Bowels.) 

For the diagnosis of renal diseases reference is to be made to the 
chapters on the Bladder and Urine, the Blood, the Bloodvessels 
and the Pulse, and upon the Thorax (that part on the Heart), to 
the chapters on Vomiting and on Headache, and to those on Corns 
and Unconsciousness, and Convulsions and Spasms. 

For further information in r^ard to the di^nosis of diseases of 
the abdominal viscera, the reader is referred to the chapter on tlie 
Skin (that part on Jaundice), the chapter on Vomiting (part on 
Intestinal Obstruction), that on the Bladder and Urine, and that 
on the Bowels and Feces. 

! cnndilinn a( the blmdvcMoU on palpation— Fmling and coiintinjc ilic paU 
T)ie ({uuliiv, for««, &nd volume of tbe puW iu Iivalth and diwnsp. 

<>SK of tliir tint tiling thut tlie plivi^k-ian docs whca he is study- 
ing tliv condition of a patient in u> f«:l the pulst!, l-vco if the Bymp- 
Uitni* wliich aw present do not indiciitv circulatory diKtiirbniiov, 
Immium' the pnW is nn index of the vonditioii of the hcurt im to lU 
power, its valvuhir action, and its ncrvoim state. The pulse very 
often i^ves ns information of the prescnee of renal di^^easc, and it 
will frei|Uciitly give us a gt^'ncral idea of the tone or degree of de~ 
bilitj- of the patient. By feeling the ptilse we also gathtT valuable 
iaformatiou as to the condition of the arteries, and tint) U a very 
impuflant part of the diagnosis, for, to nse an old raying, " a man 
M only w* old a^ hU artitrii^;" and if he i.t riixty yearn of age and 
han ^)(id vf9!M.'l^, lie i^, 0.-* a rule, b» young in hciiith an another man 
of tliirtv witli Imd v<-Ni<>lM, litmiiM.' it it< bv the hloodvcwclH that lh« 
tiwiues of the hiidy are nutiriithitl, and, us life dctwud^i uihui tlm 
pnKcm of nnlrition, the better the vejisele the better the vitality. 

When exaniinin); the pnlne of a ]Nitient who is well enouf^h to i» 
up and about tlio physician should nait until suflieient time liuti 
elapsed after exerdnc for the ptilso to beeome steady, and the patjcnt 
•ihould l>e in a sitting or reclining pofitnrc in order to pi-event ovei^ 
action of tlio heart. Particularly in it im[>orlaiit in Uie case of 
nervous individuals to wait for nedntion to follow the excitement 
of meeting the physician. 

Often when called to »ee a i«iok cliihl or u ni<irvou.<4 woman, who 
may l>e !ileej)ing at the inomeul of iJie phyNitriatt'x arrival, a true 
(Kttiiuit« of tlic pulse can In- miule without disturbing tltv patieiit by 
gently potting the tip of the linger on tlic temporal artery where it 
pBiiKM over tJie zygotnatie process. This artery may also bo ns«l 
for this purpose in casa; of tremor, chorea, delirium, or munta, 
wliere (he hand is eon«(antly moved almnt »o that the radial artery 
rangot be felt. 

346 riifi MAytfBSTATtOS OF DISEASE ly OJtOAys. 

In countiDg tlie jiulso U is best to count it for tho entire minute, 
or to oouDt it for SfU'pn secondii and tliPH multi|kly the result by 
four. If the \>uUe is irregular, it is always be^it to count it for a 
minute. If the pulse he very irregular and riirinlni;, and so difB- 
oiilt of eoiiiitinjj:, the eounl .4iiiulil lie nude Uy Iir*l('(iin(; at the ()rie- 
corditini for the ajiox-beat. 

Before ooiiHidcrinj; thp ijimlitJPA of (lie piil^ie in hi'iilth or disi'-iL-av 
it U well to nndttnstiLtut what it )8 due lo mid tht> muiiiier in whiidi 
the circulation i^ nirricd on. Tiie UhioilvcimdA ctmaitat of the arlR- 
ries, arli-rioli-A, [yipillnrio-*, virnul(«, and vi-inii, Thpse v«wi>l!* alvriiy-* 
GOiilain lilmid during life, and llio function of the h^nrt t* to |tm(>id 
t)n> blood tlu'iiti};h ihitni, Th« flow of bloixl i" niaintnineil, fit^x, 
by tlie forw ex [tcndi-d by the Ih-hM, and, tMScond, by tli« tonicity of 
the blowlvt-swU. If Uk; bhvidvcwwls of the body hcoomi* n-iaxdl, 
M in dtnitl), all the bloix) i* rtwiily held by the ones inont rulaxcd, 
namely, the abdumiunl, thonicie, and other veins. We find thcr^- 
forL- that thf vcswU art- only filled with blood when their walls are 
to a ocrtnin extent oiiistritrtitl by the <^H)Htractiun of their musoiilar 
fibre!!; and tiiat this eontnu'tioa is maintained by the uetton of the 
vn<mniotor eentre in the- Mi>?<1nlhi oblonj^ta, whieb also controls 
many minor contres gover»in(f small areiw of vessels. The arteries 
are ver\' elastiu in health, and when tilled with Mood are fllif^htly 
dlf<t<>nded. Behind the eoliimn of blood, which bein^ a fluid ci>n- 
fim^ laterally is prat-lioally a i^cilid, for t1nid.« are incompressible, is 
the heart, and in the arteriolef are mnst^uhir fibres which by their 
onntraetion n'gulaf the How of blood into the eajiillnric^ fr»m 
which the nnlritioiml prmfHses an- carried on. The bloixl in the 
arteries is, thei-cfon-, siibjoct to thn-e chief pressures, namely, that 
of the heart hi'liind the cobnnn, that of the daMin and distendc<l 
arterial walls oti the sidcjs of the eoliimn, and the rvMstanee of the 
ooutracK^l artenohv in front of the indinnu. By these means bloud- 
pressun; or tension is maintaincil. If the heart beats more strongly 
or the arterioles eontruet mnre tightly than normal, the blood-«trcaiu 
is iiuder a greater pressure tlian IxYore. If the heiirl i^ feeble or 
tlic arterioles lux, tlic pressure falls, because the blouti is not preaaetl 
upon bi^hind or obstriietwl in its fli>w in front. If the tension is 
above or below normal, the iiiterebauge of food and oxygen and 
carlionte acid between the tissues and the blood in the eapillariett U 
jwrverted, for the rate of flow in the capillaries dependK br^ly 
upon the blood-pressure in the arteries. As the capacity of the 



<n[>ilhiri' syi^tcm of vesat^ls i» tuauy timeH gralrr tluin iltul of fliv 
itrh-'rius, »o, if thv nrtmoles relax, th« opilUriL-s suvi vvim* n-ill 
retain all the blood, anil lo them it will etagoate and b«ooue UMkn. 

The manner in wliirh arterial tension is chiefly miiintaincd luiviitf; 
Ijeeo deacribed, we ran now consider the (Milse-lieat itiwlf. The in- 
dividual paU»e-beat b not a wave of blood sent oat by tlie heart, but 
it is the traaimiisiou of tlie force of the heart-beat sent alon^r the 
blood -ocilu ran, and the eliaraeter of the bent trivet ns, therefun.', on 
itiea of how forcibly the heart la driving anotlier <{U&ntitT of blood 
into tlte nurta, and aUo how mndt bhxK] is being iteot out at each 

HiippoiUDg, Uien-lorc, that on ftrling tli« radial jhiIiw we find that 
tlie nrUry in tenw and ban), ami thiit the individual Iwat xit Rtrong 
and itx %-oliinii- );n.tit: ibiii ifij^iitii.-* ibiit Ibvre if an fxnlv'l vasninotor 
oeiitnr, vanning vuntnivtion of the voirscl^ iirKl that an e\'-it«-<l, uver- 
iictii);{ heart is forcing; the blood into tJie already tense ve^^cvla. If 
thtfi <roiiditiun increaiws, one of three things can happen: either the 
Iienrt will l>e unable to pump the blood out into the arteries aguinot 
tlie pressure and consequently berame distended and paralyzed, or 
the bloodveaseU will biirst in the weakest spot, or the spasm of tlto 
arterioles will have to give way. It U the flr^t n-j4ult whieh we 
meet in eases of true angina [leolnri^, for in this imitate we find great 
arterial tension, with dii«tentioii and vngorgomcnl of the l«ft side o( 
the heart, and the moment nitro>;lyni'rin or nitrite of amy! relaxes 
tlie i^pOKiii of the arterioleii tliv symptoms are relieved. It in the 
800on<l rmult wliich oft«n produoeM apoplexy by rnptnrp of the 
woakoxt vu<»«l, usually the middle ocrebntl artery. It is the tbirti 
nvnlt wbicli we try to bring about for tlie reliei of the |>ationt, 
Htlwr by dntgs or by bleediii;,;. Where we have atheroma or hard- 
ening uf the hloodvettM'ls ns the result of old ago, syphilis, or chronic 
vemel-«hiiugeB tlic very inelasticity of the vessel, aasooiated, por- 
bap«, in some cases, with some irritability of the vasomotor centre, 
causes a high arterial tension, with a laboring heart, a congested 
head, and a feeling of fulness of the head, of which the patient will 
seriously complain. The second sound of the heart will also be 
much accentuated. 

The dUeovery of a high arterial tension in a young penion, or in 
an older one who has not atheroniau>u» ve««MU, will generally mean 
the presence of an excitett circulation, in conncctitm with w>nic acutt* 
inllamnintory diaco^'e ia its early ^itageti, and, !f high fever i» prcm-nt 


in ft [trevimiHly hcwltliy persMn, the pulae will be found to be <)uick 
and lianl. 

A ciitiililiuit of iiitMiHC viii>oulnr ntlnxHtiuii, due to fuiliirv of tJie 
heart or the iirU'rioW lo mnintitin hlowl-piT^iiiv, is -it^n in caec* 
of fainting iiiu) tsyueope on llic urn- haixl, or of collapse uml «liock 
on the otiier. Horu wo find a soft, easily extinguished blood-Ktimm, 
wliifh I'liii, h_v [iri-M-Hiire on tlie iirtcrv, be readily ent off from the 
di»t«I vewds. The urtery feels reliixetl to the phyeiciuti's tingcr 
and iJic skin may he bedewed with sweat. 

We eun euuelude, therefore, thiit hi);h arterial tension indicatee 
in the yonn^, w » rule, un excited eirculation, due to liome acute 
nilnient in its early 8taf^-«, or, if in an older jierson not Ruffering from 
an acute malady, it is dtie u> atheroma of the bloodvessels, renal 
disease of a ehronic interstitial type, or hypertrophy of the heart: 
provided, of eourse, in all cases that there is no hiHtory of the reoeot 
in>;estioii of powerful stimuUnta to the eirculattoa. 

A very low arterial tension indicateB a feeble oondilion of the 
system, I'ueh a^ is seen in all exh:iiHtin^ di^ases, acute or ehrtinio, 
or, if no disease bo pre-ient, in the sense of an acute malady, it indi- 
cates general nervous debility, with or without the presenoe of ii 
feeble and dilatt^d heart. 

The pulse itself varies ti* to volume, dinnioter, nipidity, hihI 
force, and does ao within nonniil limit«, and jitill more »o under ttic 
effecta of disease. It viirJos grealJy acconiing to uge. Thns, llie 
pulse of the newborn ehild itt usually about 13o to I'lO, at one year 
120 to 1:I0, at two yean* 105, at four year* !I7, at ten years about 
i)0, at fifteen yeors 78, and from tw«nty to fifty ynire at 70 per 
minute. At eighty yenrs of n^e it is usually nboiit 80 beat« [>er 
minute. The rate is also inerut8e4l by tulcing food, by fxeriTise, 
norvou.-<iie.t8, and by pain and fever, as will Iw stated again In a 

The volume of the pulse-wave depends chiefly ii|»n the quantity 
of bloud expelled from the heart at each systole, and also U|>on the 
eundition of the aortic valves of the heart, in so far as their ability 
to prevent regurgitation is ooneerned. Stimulation of the v^aa 
nerves usually results m a large pulse-wave, as alnaidy pointed out, 
as does also t^rdiac hypertrophy with dilatation. If, on the otiier 
hand, part of the blood thrown out of the heart into the aorta falU 
hack into the ventricle, we have a ptiW of «>n)all netual volume, 
and diis i^i oalled, of the peculiar nottsation whidi it givpit 



ti) ihr finger, tlic " U'it>-I»iinmer," " waWr-Iiamiiior," or " Corri- 
gHii'M [HiW," In !»in'ii a <;iw<-, liwMusi' (if th«? [xiwi-r of Uif vpnlrictc, 
tilt! l>lix)(] i» forctfd out into tlit* anrbi with grvM force, biit a^ tlie 
last purt of thtr wjive re^iirgiuiti's the jnttw !-«> foutid t«> Ih* slmn 

land ttharp. In iniintl regiirgilatiou or in mitral fitcn<;u->H tlie ikiIm; 

. ia u»iiiilly itniMll in votiiinc, iMmin^ tlie li;ft ventricle Itaii nu(, or 
ntanot (^et, viiuu^h li1uo<l at uich htM to »eD(l uiit a volnmiuoiu 

So far 08 tli« cliuniftiir uf tin- piiW is n>n<.><'rnv<l, wv reoognixc one 
which in kIuw and full, as thiit eovii uftvr di|;!l»li! i;^ used; tlint 
which U ithurt nnd sharp, as in uurtic rrgtir^tJition; thai which is 
email and hanl, lis ts often ^-cn in aortic olnstruvtion ; and tlic ^^mall, 
wiry jmUe of acute peritonitis. 

Via. ua. 

1 iphiTKniOKfapb. iIh'DOHiS'ii.) ('*(UIii luitparlliic lani im "inllWil mthlttbe in<illt|>lr- 
InC lonn mny bo itl*|i|iir*d. a I* ft mull inplal iitMi' wlilc^ti ti kept pr e— il oa tbn win? bj 
(h«*p(tO|t. Tht r«fttral movcmenlt of n canir lixind-fro momniinl* •>{ Itit larn e aboill 
tbe BMd KHitd. Tbcw *rv oammunlnuil I'l kflil magoldcd by Ihn lorct t. which nmps 
ranBd Uw null polnl /. ftw bM •nd ot ihia tnor rurlai • Ugbl iMal nutrkcr wblrli rtili 
raafUipoT mnkcd ispar.A Tb* iBptr u p1«Md btowlh iwoandl whMl* uml loin mi « 
Nilltt wbicli na b* totMad br mcaui <4 clack-Hork cnnulnMl In Ui« bm t. Tbc paptt I* 
Ihim MUMd ta iniTbl at ■ imlltann nir- Tb* trrvw itrndUBWd In ounca (Traill* Imiiglil 
In lia*r on (h« •prlos b b)- in«uii of ■ am. ■u'l by tbl> Uit (ocwiira |>ul on th* tJttrj can be 
fcfuUlad. The \Brtn auifnltf Itie pulK'tnorrrociou flnr UnK*. 

Various imnioA nrv H)>plin<) to a piil*^- [HM.ti'riMin^ certain [XTiiliaH- 

.tiea. Thus, wo huvc under iho uamc jiuinui fniradoj-iw a puliM; whicJi 

3|M!aK) with V9c\i dpi']i iiispinilion. It !« iMiuillydiic to indun- 

vf nit><liiii(in<>-pcrit%trdit(B, whcrr-bv influinniutorv bamU prciis on 

the l)lo»dv(MfN?U or thv heart. If the ))vat« of the heart arc irrejtulnr 


in force, but regular in rhythm, we liave developed what is called a 
pulsua alterant. 

A dicrotic poise is one which in characterized by a reduplication, 
which feels like a second beat following the first before the latter is 
over. It is found in many cases of exhaueting fever, and depends 
upon an undue elasticity of the bloodvessels, with relaxation of tlie 
arteriolejj, so that the blood first unduly disteods the arteries, which 
then contract upon it, and thus produce the second wave or apex to 
the pulse-curve. 

We can study tiie pulse either hy the touch or by the sphygnio- 
graph. If by the latter means, the instrument of Dudgeon is the 
best. (Fig. lo:i.) 

The normal pulse-wave Ls shown in Pig, lo4. 

a br Fercuaaloa np-stroke. abc^ Porcunion'waTe. cd i Tidal wave- f/ff- DEcrolIc 
wave. iJ c/. Aortic nalcb. fg. Dluiollc period. 

It will be sei'n that thero Is a distinct upstroke pi-oduced, which 
is ciillctl the line of ascont. Tliis is due to the disteotion of the 
artery priMlnced by tlio ventricle fi>rcing blood out into the norm. 
There in after tliis a lini; of dt'siwnt interrupted hy two separate 
seoonditiT waves, wiiich arc called catacrotic waves. The second 
or lower of these is culled tlie dicrotic wave, and is the one which 
heiwnes marki^l enough to bi' felt in some eases of disease. The 
dtiRition of the pcriixl of dcsocnt corresponds to the time the bliMid 
is flowing out of the arteries into the uipitlarie.s, and, if this flow is 
rendered ilillicalt by vascular spasm, the line of descent will Iw 
jjraihial; if easy fr()ni vasi'ular relaxation, it will be short. If the 
drop i.s very sudiicii, it is pulse of " empty arteries," so calle<l, as 
after .seven' hetiiorrhage in i.iises iif acute regurgitsition. 

Very Huall iri-cgiihirities of the line of dencent arc due to the 
elastic btiHKlvcssel bein^; thrown into vibnitions by a forcible pulse- 

Ill Kij^, lo~} is sliriwn tjie tvpical pulso-wave of aortic reguigita- 



tioo; and in Fig. 156 that of mitral stenosis, which is iir^ular in 
time and voludie. 

The rapidity and force of the pulse also depend largely on the con- 
dition of the bloodvessel -walls, particularly the rapidity. The latter 
also is influenced by the activity of the pneum<^astric nerves in r^;u- 
lating the beat of the heart. Thus, if the arterial pressure be very 
high, through spasm of the arterioles, the difBcuity experienced by the 
heart in forcing blood into the arteries will be so great that pulsation 
will be very alow; whereas if the normal resistance to the actjon 
of the heart be removed by vasomotor relaxation, the beat will be 
rapid, just as the wheels of a locomotive fly around on a slippery 
track when the friction or resistance is removed. If the vessels are 
relaxed, the impetus communicated to the column of blood in the 
vessels by the heart is lost, and so the pulse is not forcible; or if 
the resistance is excessive, the force ii^ di^ipated. 

Fill. 155. 

TnclDg fnnu > caseoC aortic reKurgllatioii. iMl'sher.) 
FlO. l.W. 

Tndng from • cane ot nillnl ilentiaJa, showing iocreued lenslou mod khdg IrTesutarit)'. 


The vagus or pneumugastric nerves are coDtioually holding the 
heart in check, and by causing full diastole enable it to send out a 
large wave of blood at each contraction. If they are greatly stimu- 
lated, we have a very slow pulse and a full wave of blood with each 
heart-beat; but as the heart now beats very slowly the blood-pressure 
may fall for lack of blood in the vessels, unless there is an increased 
force of the heart at each contraction to make up for the number of 
beats in the minute which liave been lost, or unless there is also a 
great increase in arterial tension by contraction of the vessels. A 
very slow pulse depends in the great majority of utses upon a high 
arterial tension from vascular spasm — i.e., resistance to the flow of 
blood; more rarely it is due to irritability of the vagus nerves, pro- 
duced by pressure or disease, or by drugs, such iis <ligitaljs. 


The term bradycardia is applied to a very slow pulse. Tbe piilse 
may be as slow as twelve a minute. 

A rapid pulse is seen most commonly as tlic result of stimulation 
of the heart by drugs, by fever, or by fear. Fear causes the vagus 
to lose control of the heart, and fever acts by reason of the etimulanl 
effect of heat upon this viscua. In other words, the quick pulse of 
fever is not a mere coincident symptom of fever, but the result of 
it. When the heart's action becomes exceedingly rapid it is called 
tachycardia. It is due in the majority of instances to relaxation 
of the bloodvessels, or more rarely t« depression of the pnetimogag- 
tric nerves. Often in this condition the pulse becomes so fast that 
it cannot be counted. 

Great force of the pulse is due to hypertrophy, or over-action of 
the heart because of stimulation; and great feebleness generally iit 
caused by marked dilatation not associated with hypertrophy, or in 
acute disease to exhaustion of the heart^muscle. 




Th« vuiouv tonm of nd uid wht(« oorpoadw — Thalr proporUoiuM osiabtr la 
bcalth Mid diMMe — Altcralionn in their forni aixl cfaancUr — Tbe hanDglotmi 
of the blood la bMllh Mid diwaHr— Tb» v:irbu> laiiatot MMmm* — L — OOey- 
IhKOiis and [Meiiili>>1«iKDC7lb»mi> — I'anntw ot the blood. 

An already |)omt«tl out in Uic cliapu-r dwotiil to tlic fJcin^ 
markal cliatigis in tlic blowl siKt-dily prwiiioi- raaiitft'st nltcnitions 
ill tbe ap|x<amncx- of the juitioiit. Ttu; pivMint clmpU'r will be 
devoted to a oonsi deration of the changws in the blood vbpo w« 
exaiuiiio it hv mt.>aiis of tiio naked aye or by meana of variouH forma 
of ilelitate apparatlL-i deeigned bi give lis aociirate n«iilts. Before 
studying the eoDdition.i of tlie btootl which are fouod in ditieaae, it 
i* well to briefiy rehearse the eiiarscterietics of normal blooil when 
it ie I'xnniined outride tlie Uxly. 

The blood nmsi.^tM of a li()uid') (»r pta.'iina, in which an> fotiad 
tnro ^rmt vnrietlei* of oell.-^ — the rc<l bIniMlH-ell.4 an<) the whiu: hlood- 
ooIIb. The red oellx an: ealled cryihrocytes, the white velU louoo- 
cytcs. Hid nil ct-IU are hieonrav<! dixkii, dark at tlie odgei and 
with a ch'ar or brij^ht Hjiot in the nentrc, dne t'» their bieoncavity. 
They do not voutain n ntiehtM. The rc<l color of the b1oo«l is due 
to the l^^n.>^ltion of luimenw iiiimlient of thejt<- bodiitM, tlie ouloriog- 
matter of which is cnlletl biDmoi;[obin; hut if a few eorpuseles be 
plared in a bright li);ht on the »tn^ of the micraeoope, they look 
bright and yellow. The number of red hlood-cellH is ahoitt 5,<KK),000 
to tlie cubic milUtnetre of blood iii a healtliy adult male, and nbont 
4,.')nO,(MW in the healthy fcniule. If thii; number ih ex<'ec-iiiid, which 
in very rare, tlie condition is »illed polycy tliemia ; if decn-tuKil, t]ie 
condition in called oligocytha-min. One of the niotri marked in- 
Htonoca of {folvi-ythiemia which 'xvors h ttii* very vxtniordinary 
incmw of rol hIrHMl-eeltH which in ufun met with in canat of congcn- 
itid rardiac diKcaiw in ehildren, aniountjnjr to r» many aa B,000,000 
to ll«- cubic millinictre. lt<^de the ordinary red blotxl-eelU we 
find in liMltJi umall red oelU supposed Ut Ik.- immature ted eelU and 



oallt^l [iii<;ro(!yU'i«. (iiul sometjincs, tlioii|r1i nipcly, iDCgklwytc)^ or vrn- 
lurgt; rt^il (X-IU. Nut uiily nitty the rvd MooA'txWa cliange in ninii- 
lier^ but the quantity of thoir liiiMnD^lobin may niso vury. Xorrnal 
blood mIk'iiKI ■■ontiiiii 100 jier cont. of Iiicaiofj^lubiii, but often wir ItDil 
purfiwt liciiltb wliuii t)K' hccmoglobiD i^ only vstinuitct] lit 85 |HTOcut. 
If tbu proportion of hicmuglobin is dcurcnaed, vtv call tliis condition 
onf of oli|;ocliromiDmiu. 

In tliHL'osu wc lind more or Ices marked alterations in the rod c«lU 
thom^clves and in tlioir ooloring-tncitt^r. Tlie microcytvs and mi^- 
locytcs alrt'ady named may become abaorraallv prcat in number. 
Red cell.-i which are deformed are found in great number and are 
called poikiloL-ytes. Other retl eells which, unlike ordinary healthy 
cells, possess a nuoleiisand are capable of am<eboid movement, are 
found aud are called by the unfortunate and confusing name of 
*' norm o blasts," aud finally \vc. find other red oells pigmented or 
vacuolixed; or, again, so dim in appearauoe a» lobe called " Bhadow 
oarpUHcles.'* The disease in whioh these changeH are found will 
be discussed further on. 

The proportion of the wliite to the red celU in healtli is about 
1 to o(>0, but very great variations ooi'ur. Thus, aftor meals (Jie 
whit« istrpiiBcle* an; alwnyit inunuised, w tliat the proportion may 
be 1 to IdO of the red celln. On the other hand, aftvr this primuni- 
incruo^e, titey may be decrwiwd. and the proportion may be 1 t«j 
800. Time of day i» also a factor in producing a variation. Hirt 
found l)cfore brt>akfaHt the proportion to be 1 to 716: one hour 
after brt-«kfft»t, 1 to rt47; thi-w hours aftpr limikfnst, 1 to 1514; 
ten minutea after dinner, 1 to lo!)2; half an hour after dinner, 1 
to 429; two and a half hours after, 1 to 1481 : lialf an hour after, 
before supper, 1 to 544; and two hours after supper, 1 to 1227. 
In frequency, the proportion is about 1 in 280. 

The white cells appear in the blood of healthy individuaU in 6ve 

1. They occur as white oells as smalt as, or smaller than, the ordi- 
nary red cells. This small white cell coutalus a nucleus sn large 
that it almost completely fills its body and prevents us from seeing 
any surrounding protupiaiim. It is called a lymphocyte. It Forms 
about 20 per cent, of tlie tnL-d number of whiU' cells in health. 

2. They occur m what arc cathni large mnnuuuelear lea«Ktyt«a 
cells, much larger than the rod cells, pos«ei«»ing a mtidi-nitely largi' 
single iiueleun, whicli i» surrounded by n xone of pale, uou-granular 



protoplnnn. Sometintes thcsv celU show u vJiaiigc in tiio shnix; of 
Uiv niivlciis, »n<) iiro tliCD nllud traiiHitioaxl Ifucocytrs. Tliesu 
monoiiiicluir ouIU makv nbuut 10 per ceiit. of tli*> white bIooJ-«i.-lb. 

•). Tltcy occur us Ini^', whito cwlU with a oticleus of irnf^iUr 
ribapG (poIymoqihouH nuvl^iu), <>r a nucleus split up intu scvenil 
SBUillcr nuclei (polynucletir). They are often called for tJiie rea^n 
polvEuorplions or polynnclear lettcocyteo. Ttmr protoplasm oon- 
taine fine granuleis, which stain when brought in contact with neutral 
(lyee, and for this reofwn these cells are often called iieutrophiles. 
A neutropbtle, a polymorphous leucocyte or polynnclear leucocyte, 
are therefore one and the same thinj;- They t^qital about 60 per 
cent, of the white hlood-i>ells. 

4. We find very large {lolyinorpboui* leuoooytfs containing very 
coatrse granule^, which Htain when brought in contact with ncid 
dyeei, of \t-hicb the ehii^f ii« vnnm. Tlicy are called o^ainophtlic, and 
are very lioiitad in number or vntirety nlMcnt in many ntves. In 
diseaiie we find variations from tliwH* ty])i*s ai« lo proportional and 
actual nnmber, and in addition oUier wliit« *x\\» an- ])rc«<M)t. 

In mnrly all infoetiotM discoM^ of inodcmtv m-verity w« 6nd an 
increase in the number of white cvlla. TWa condition is called 
leucocii'to^is. The particular form of white cell which is incrcaM^ 
in number in these states is the polymoqihoua or polynnclear cells. 
On the other band, the eosinophilee are almost never found. Per- 
hapti the acute infectious disease which illustrates leticocytoeia most 
typically is croupous pneumonia. 

In kukivmia of the spleno-mednllary type, which is by far the 
most common form, we find that an entirely different white bl<Kxl-ccll 
from those already described is present, namely, ii large white cell, 
aeveral times larger than the ordinary cells, with a single lar^e 
nucleus, usually situated to one side, and the protoplasm of which 
contains granules which stain with neutral dyes. In so far as tltv 
granules are concerned, this cell resembles, then, the ordinary- poly- 
morphous leucocyte, but it is separated from it by its large size and 
by the fact that the nucleus is single. Rarely these granules take luHd 
{ensinopliilea) or basic stains (basophiles). The large mononuclear 
leucocytes are also slightly increased in leiikwmia as to niimlxT, as 
may be the traii.iitional forms, l-'osinnphiles, as described above, 
are often present in considerable uunilier, and though at one time 
tJiought to b« (Mthognoinonic of Icukn'mia, arc not ao considerol »t 
thif time. 


Ill iGiikfcmin of the- lym|ihiitic type tbc lynipliocytcs arc tlic cells 
greatly inercaBotl. 

Id order that the various forms of whito wlls that n-v have niuiiml 
may Ijg readily sejiaratfil from one another w« liavv to n»ort to wr- 
tain stains-, it ha\'iDg been shown by Elirlieh and many others that 
the nuclei of these cells are siisoeptihic todifferont stains, as are also 
th« grannies found in their protoplasm. These stains differ as to 
their eolor and rewtion. We have basic stains, acid stains, and 
neutral stains. If the white cell is readily ataioetl by an acid stain, 
it 13 called an eosinopbile; if by a basic stain, a basophlle; if by a 
neutral rttaiu, a nfutropliile. Further, these stains render tlu- nucleus 
one eolor and thi> gnmnles amrther, as in Plate X., in several of the 
figures of which will l)e found oells with red granules and blue nuclei. 

Th»> hettt solution for Htaining-]>urposeis is that of Ehrllch, whieh 
la etilU-iI a triple stain. It i» oninpufed as follows: saturated watei^- 
sottition of orange " g," 125 ao. ; natiirated bydro-alooholic (20 |>er 
cent, of ali-ohol) riolntinn of aeid fiiseliin, \ih o.o. These ingredieiit't 
having bec-ii mixed gradually and thoroughly shaken, the following 
constituentit arc added, the shaking l>eing eontinned: salnntcd 
wati-ry isolutioM of nictliyl-j^ecn, 12o e.c; absolute ah^oliol, 7o c.c 

Witliin the hu^ year EhrliHi ha« suggc«teil the following in place 
of this formula, vi^e. : sutiiratcd watery solntion of orange "g," 
135 parts; saturated watery solution uf nicthyl-grecn, 110 (laita; 
saturated watery solutiou of iioi<l fuohsin, 100 parts. 

To these are added );lyccrin, 100 parts; absolute aloohol, 200 
parts; and water, 8(X> jHirts. 

This solution should stand for several weeks to alluwof sti-dimeii- 
tation; it improves witli age; and when it is use'l the BQpt'mataut 
liquid U to he drawn off by a pipette in order to avoid the seditnenu 
Thii* stain acts in a few minutes. 

Sonu' wver-gla'wes having first l»een well cleansed with alci>linl 
and wnt«r, the i*urfaee of one is touohod to a drop of freshly drawn 
blood, and then another eover-gla!*» pres-ned on its surfaoe until the 
blood is evenly di.-itributed. The gltL'Wc^ are tlien separated and 
allovreil to dry. After they Iiave dried th«y are still furtlier hard- 
ened over an alcohol Hame or on a hot Mngc made of sheet coppt'r, 
and kept at 21*2° F, for tifleen minuter to two hour^. After thii^ tliry 
are placed in tlie staining- Itiiid for from one to four minutes, then 
washed in pure water, dried, and mounted in C"ana<hi haliani or 
cedar oil. The Canuthi bal^uiin should not Iw preiured with chli>> 



reform, aa it will <Ie«>Iorize the siwrimcn. The (tIbw in then ready 
for RiicixMoopic examination widi ouv-twclfUi iiil -immersion Ifrns. 
The eoHiuo[>lii1<> grmiiiilm in tiiv o»riMi«cle» will br i^ned « nildiiah 
hue, the nciitrophile gnmultni pnqile, and the nuclei hluiidi-gtven or 
Unc. (Plntc X.) 

We examine the 1>1(hhI not only by thv micnwoopc, b(it by color* 
teMa, The "bjwt o( the mictxMcopic exsmiiuition is bolli to d«l4.'r- 
mini! the (jiuility and churaet«r of the rvti and whit« curpiM-W, their 
number nixl the presence of juinuitcs. The oolor'loKb* ure for thv 
|>nr|K>^ of di'terminin'^ Utc pro[t»rtions of hteroofjiobin, or, in other 
wordit, the nbilily uf tbe corpii«ieI«s to carry oxyfri.>n to thv ti^HUes, 
To Mtidy the bluml mioro^topiuilly wu ntwl a c|utirtor>inch objcdivft 
for ortlittary e»rpit»eiilar work, or, as they say on llu.- Coutinent of 
Kunipe, It Number 7 Hartnuetc or a D. Ze'tse; and for cxsminnlions 
for parasites a 1-12 oti-im mention Ien§ for use w-itlt a oondcntier. 
The eyp-pieoefi used are usually Noe. 2 and 4. 


TlxraiA-Xaln btood^oaatlns appuvtui. A lienr glwiaUpla*. in llii nidilto of afalfh It k 
o«U {Bi oucUy I'Ul tnUUnicln la doplb. Tbe c«U h Umlwd «t Uiu iitrtpbcry by * cltrolu 
fulMr M pi«Ttul Ruld plMi*d uion Uiecall (ramtoalnsbBJondltlJMwaea Uic aUp >iu] ocnw* 
■buK Tb> floor or IbeocJI li niled Into tquRnB irboM (Idm ini 1,'J) mm. Duk ttnM nuk 
QUI IMS* •qiiaia oonulnlnc meatT-llTV inuU ■qtmw. Ttilek, rarrrulljr (iwiod oprar-fhan 
(0) H* pratldM InthB rua. Th> urtUurr n)Uin JMaupmrtai U and to nHanan and sUs 
thAbload. llcoDdiBof •MplllkrrlubttlMuiipwparUoBaf irhloliUbla*nliiIo4«&aBbM 
<S)hal>llniil(ae'iiun. TIxiHiuof lbelubol*Rn>1nkiedftllU*niIat t e.ia«. 

The flngcr-tip or ihf^olie of liie ear of the patient having been 
washed etran, n iduirp middle or the tip of a tenotome in ii«ed to 
puiieUin^ thu xkin, and tite drop of blood which OKapcs U pta«<d 
upon a glum i«lid« and cx>vcr«d with a oover-glaM. so that tlic film 
of btoo<I w very thin intlecd. Exaniiucd under the luicmsoope tliut 



wilt i;ivv II rriidc i<k-a uf tbc prO|)ortiDn of whit« to r^ corpust-lM, 
ftiid of tiK'ircolor nnd shape; but more aocurate meUiods arc advi^ 
nblc, and for their iiso we rwort to what \b called a hsematocytoro- 
ctLT. uf wliich tlic best !h tho Thomn-Xeiwt upparatitD, wliioh con^M-i 
iu part of a ^\aas capillary IiiIk-, about 10 cm. long, with an expau- 
sion near thi- middle, which expansion ciiDtains a iunatl glsi^d ball, 
which is movable. On tlie tube ai-e three mark». Part way tip it 
is markcti O.o, l>elow thu expansion 1, and above the fx))ani*i<m 101, 



I , 




. L- 

■ /'(■• - ' 






■ -J I- ■ ■ 


I • 



". ■ 






' ; ' ■- 

'. ' '. 


■ ■ ■ 

• •^ 

-"", " 

*; .'-■-' 




a > 

-'' ," 



--. . 


L :_il 




;;• ; : \. 

•■ ; .- 
-1 -ZX . 

AppMntDoeof blood III the Tboin«-2«liaMll- 

The flwoiid pi«w of apparatus is a stnall cell 1-10 millitiH'trc id 
depth, and llti^ Ruor of the cell ih divided by fiuely dniwii lin(^i> into 
wpiiire.'*. KiiHi Hjiiure erpials l-4<K)0 cubic mm., and tliciM.- ^luarra 
arc wpuraU-d into grouf).s of It! by plainer lines. (Figs. 15" i"«l 

The finjier having been freslily prieked, the blood is dmwn up 
to the mark 0.5 in thi^ fiajiillary tiibi\utiil tlii; tip of the tube 16 then 
wiped eleau. A throe pur oviit. nolutioti of coinmcin oalt is drawn 
up after it, until the tulxr and bulb iirv lillrd to tb<- jioint mnrked 
)01. The lip of the tube h now wipud <try by tnt-uiis of a clean 
clotJ]. By shaking the glas« ball in the (tibt; the blood and salt 
Holutinn beeniiK' wi-ll mixi>d in the projiortion of 1 to 200. After 
tlie salt solution in the lower part of the ■'apillary tiilie ha.s l)ecn 
forced out by gviitly blowing into the up|K.>r end of tW pipctto 
and the Mood-mi xtiiiv hitH reaelicd iti^ tip. a drop of ibis huniogctmMts 
fltiid in forcj^l out into tiic evil just described and a oover^lntnij 
gviitly ptacml over it, all air Iteing excluded. Tho eull should no* 
be allowed to ntaud for several minutes to allow the eorputvle^ lo 
Hittle and become sbatiooary. The oorpiiHcles in each of the sixteen 



Bqoares in tlif ui-II are dow cuunted, ad(](Hl tujrctlier, and the 
Rvenige niiraWr In a cell obtaiued by dividing the number of 
corpuscles by tlie number of stjuares. ThiB number in turn is mul- 
tiplied bv 800,000, and thLt result ia tlie number of cwrpusples in a 
cubic millimetre of blood; or multiply the number of «^o^p^)wlefl 
counted in all the aquar&t by 4000 (40l>0 beiu): the cubic 4M)ntGnts 
overlying a n^nare), and the result by 200 or 100, according to tlie 
dilution; after thi.t divide tlio prixluct by tlic number of fKjiuireH, 
and tilt! r<;:iult will etiual the uiinibt^i' uf oolU in a cubic millimetre 
of blood. 

If tlie blood in drawn up to the puiut mitrkod 1 in the pipette 
before the tiViw sulution i» added, vrc multiply by 400,000 instead 
of fM)0,000r Mini% the bluod »ulut!on is twiec as strong. In nuiking 
tU« <^mnt it will be found that ^onic of the vurpue<.'U-» overlap tJie 
line of n )rivi-n squarv, »nd may therefore be counted Iwii-e or left 
out altogctlier. For thia rcawn it is ctuttumury bu include these 
«*>rpuwle» which overlap the up))cr and left-hand border*. Fur- 
ther, it is bevt to put down the number of cells found in cneh ^luare 
IM they are ouunted, and not to attempt to carry the addition in the 
memory, sinw the lose of one corpuscle makc^ a great difference in 
the ultimate rei^nU, iitid for tlii.-> r^LKon tlie nion> MjUareA included tn 
the original eoiint the nion? ititHimle the I'esult. For careful Htudy 
of the blood several «ount«> of several different tilling^ of the ghu» 
cell ftliotdd be made unrl the retiult obtained by taking tite avemge 

of th^tlM-. 

In making tlic eount of the rwl bIood-<vrj)Uwlc* care should 
h1m> lie ukeu Ui evtiinatv the wliit<- TOrpuwIet^ niuw tlie pnijMirlion 
of wliiti; to ntl often giveit uk very valuable information in dii^eaAe. 
Tlitx may Im done by tminf^ as a diluent for the blood in the pijiette 
what In culled Toifson'a solution, iuHteiul of the wihilioii of wilt already 
lUiDod. This has the itdvanta^- that it Mtains the white cells blue, 
and M Kfldotw them moru readily eDtint«d. Toison's solution is 
oomiMMcd of: 

HeU>tl-*loUi . . 

iHMUled wttst . 

C>il0ria*or nUnm . 
•ilpbiUaof ndlom . 
hlnUMmiar . 


1.0 (IS (iHau 
&0 rt<l«M*ua« 


IM* !• then aiwrot ; It itHatNi aboul dcirm nUnutw hr lb* wblu owphmIh lu h» (Ulnwl 



When we desire to Miint the white corpiuaclvH alone we employ a 
{ii|H-tt«, whtob mnkM the dilution of the blood iu the )>m]M)nina t>f 
1 to 10, and we use iii place of s«\i M>Uitioi> m a dUm^nt a O.rt per 
wnt. solution of glacial noetic actd in wnler. Thi.4 iK-i<) Koliittou 
diiisolvcA ttiu reel corpiiwles, but makcw th<- whiu^oii&imon.' readily 
8CCU. The iiietliod of culculating tfie tiuralter of white oorptuelM 
in « cubic millimctro in tht- sume im thn( ^won lot thv rod oorptuelea, 
«xoopt that 11.^ the ililutiun is 1 to 10, inetttul of 1 to 100, we multiply 
by 40,000 iustcnil of 400,000. 

no. IK). 

Another very useful and rapid method of obtmiuin^ ud approxt- 
mate estimate of tlie nunil>er of the rml and white blootl-oelU ib by 
tlie use of the centrifuge, witl] the hematocrit attachment (Fig. IfiO), 
which takea tlie place of tlie te»t-tubc holders Khawu in Fig. 139. 



ras Btoott. 


T1t!« infttruRiiMit i* on impiwroiMnl Bpoa At BEto-Hflfa ksMK- 
tocrit, uit'l i» ii8««t for Uiir %-olaowCric' cadaatisa of ch» nJ ^li 
wtiili' )ilno<l-0(>r]>tisd<» without prerMMw fihtiaa of tk» falaol. Ok 
turn of tlif hnmllc uf the ciMitrirn^ will ntam tW ^k^^ afcaik C5 
tioMM, unil 77 rotations of the handle will csan tfcc h^aaiKiit to 
flUlkv-'K)OOrovolutiuas|M!r minnte. ThisannMaBipaidwattnBad 
with odIv modvrato cxertioD on the part of tbe mMialor. Tht 
hiemaliN-rit atburhmcDt 4»n«ist« of a winllii ftmmim, urr; ia^ tw» 
gnduatM capillary gins; tubis, SO nus. lonfg j miK. boRi id wUcfc 
IB placvd the fivshly drawn blood. Tbcer a cCTir a l rfy gradoBtMl 
glaM tiiUrtt, sMtol in rubber-«ujhioacd enp» at I aad 3. wc bid !■ 
portion scciirGly by eprini^ caps, AA« so ihBl then ■• a» poaAtk 
danger of losing the tubes during mtrntioa. Bjr drswia^ back thm 
milled heads BB tin- tul>e» arv inrtantlj reltaMd awl ■• t^mekfy 
clamped again into position, (Fig. 160.) "Oua 

Fm. Ml. 

■ ■ * 




be nude of aluniimim, in onW that it nwy Im* rtruni; and U^t 
The advantage guine<I by thv hh^ of thin metal i* that it i« poeribU 
to greatly increase the lengtli of the arma of the twmelrNjrU; therebjr 
takiiiff advantage of the wcll-kiinwn law of nHf-tumioi thai " tha 
ceulrifugal fnrctpa of two ecjiial l>tHli(«, movin^r with i.i(ual velocil^ 
at different dititaoees froui centre, are invenwly an llieir distanat 
from the centre/' In order, thenrfon-, !■> obtain any <t<-oin-<I aninuot 
of centrifugal force it is not neccMary to in'-mM tJie spet^l of the 
ina<'hine, but simply to incr*n»c the disliitxM; from tlie nentr^, or, iu 
the ok^e of the centrifuge, the length of the lurmal'M.Tit 

The fio^r of the patient !•) thor»ii|^hly elcsnited wilti watvr, aod 
then piiitctureJ by means of a spcar-pointcd nei-dle. The flntt 
drop of blood is rejected, and a itecood (Imp b M?a:tircil by very 
•ill^ht presaure. The blood is then drawn, by Nui-ti'in, bv ini«iia 
of a eoiMtriried dropper (Fig. ]t>I)with ntblHT-biilb e<>in>i-<-ti»n, 
ami by ihii* meanti [ilaeed in the liMKuati^Tit, whieli iii rnpidlv 
revolved for at leaxt one minute. 


Tlie rapidity nii<] Hlmpliclly of thi!- procesci ura npparent nt uoce. 
Tlie Itlitoil <ltK-» nut liavH Ume to uuuj^lntv, anO by Uie centrifugal 
forve tlic rvtl rorpuiwItiB, having tlic gnntert specific gravity, ans 
tlirowii III tin- ilistal extremity of tho tube, aud will occupy about 
oae-hslf iif lliL' tube, or to about llic mark 50. 


The white oorpUBclRs, uext in speciKc gravity, will occupy a |>oai- 
tioii between the red coqiiBcle? an<l tlie Uqoor iiangiiiniit, which u 
found ill the jimxinial cmi of the tulw, quilc clear and free fmm 

ri«, 111. 

Voa Flclichl'a tuomomout. 

When the column of red bluod-carpuitcle« extends to mark 50 we 
have, a» a rule, about five million red eorpusulea per cubic milli- 
mettcj hut if the prwiipitatc^i eorptuwlM reach only nurk 30, tliere 



[art- uiily about tlir<.i> iiiilliun |ht vnlnv millimetre, or ifixty volimic 
piT Wilt. If tlicy rcacli odIv mitrk 20, there are uboiit tw« million 
per cubic millimetre, or fnrtv volume per eent. 

Uuvifl); diseuvenKi tlic ntiiiilicr and the 4|imlity of tl>e coqiiiMilex, 
nn (Hjiuitly importune nieuiiiire ii; to discover the <{i)iintiL\' of hicniu- 
glubin whieli they eontain. We do this best by tlie use uf the 
Ihemoglobitiometer of v. FleischI, although that uf Goiveni is some- 
times used. Fleischl'e apparatii^ consists of a smull table, iti the 
centre of which is a hole inio which litt a round cylinder with a 
glass bottom, divided perpendicularly in the middle by a metal 
diaphragm, and both side-^ of which are filled with pure water. 
Under the stand is a fnirae in which is set a piece of colored glass 
aa near th4> hue of diluted blood as possible, and this glass is 
lajK-red off (iradiiiilly, so as to (rive a lighter shade of red at one 
end than the oilier. The frauie carrying; the ^liL-ks is markett hy a 
graduated flcale, and ia mnviHl from nide to side iu a Irarlc under 
the half of the eyiinder, wliteh i^ to contnin only pure wator, hy a 
thuml>-M!rew. L'uder (lie gla.-w and <-ylind('r is a while reflector 
to din-ct the myit of light throiif;!! them. (Fig. 1«2.) The ixwt of 
the appiimtiM coiuistit in a little i-apillnry tube attached to u tiny 
wire handle. This tube will hold just euough pure and healthy 
btiMKl to color the wat«r on one side of the cylinder to the hue shown 
in tlie colored glass when it is opposite the nonnid mark " 100." 
The finger being punctured, the end of the capillan>' tube is tightly 
touched til the drop of blood, which runs np the napilhvry tube. 
Tlio blood is now washed from the capillary tube into one of the 
seclioDs of the hteninmeter container, by directing thr>>ugh the tube 
a stream of distilled water from a fine-pointed pipette. Bolli oom- 
partmentit are then lillM to the brim with dii'tilUHl water. The 
ini^ide of the aipillary tiiln- shouM be jH'rfeilly dry bcfon' lilHug it 
with IiIoihI, and, when lilK^d, no 1>1iiimI mimt hi- nllowcd to eling to 
tlie outside. Neglect of thejic pryivtutioiM invitee niTiuns ina<'cura- 
cies in tlie n!Hull<t ohtninol. The ajiparatun in then ex|K>"«l to gajt- 
li};ht or lamplight, Ihiiiuw with ihiylight the hut' of the ghuw doei* not 
match li](Hid-eolor, and the fninu- lit moved bnckwan) and fontard 
nntil the color of the glaiw, under the aide of th« cylinder which 
ooutainii i.idy pun- water, w_i-ms lo the eye to match the fluid wn- 
tjiiuing iJie bh>od on the side through which the pure li);ht streams. 
Tf the ghiM iiiHtcltw (he blood-color when the murk on the frame 
if at 50, it ftlmwtt that the hiemoglobin equals only SO per cent, of 

364 3''f£' 3lAyiIliSTATI0X OK DtSHASE IN OSGAyS. 

normal; or if it is at 85, !t si^uificH 85 per cent. An a matter 
of faL't, an Rxaiiiiiiation of perfectly healthy tilood will often give 
not more tlian SH to 1)0 per cent, of hemoglobin with lliia appi- 

Care ttliould be taken in regsnl to three pointti: finrf, to l»e »ni<e 
that all the blixx] i.4 wajihed out of the <npillary tube into Hie water; 
second, to Ih> nun^ that the two halves of the cylinder are filled lo 
the brim with watvr, iio tliat tliere i>i neither u positive nor a ne^- 
live ineiiisen!* ; unil, third, to be careful to clcniisc tlie entire ajipa- 
rattis tlniniiigliiy after cocli tise of it before putting it away. 

Ansemia. Haviiifr Kttidiet] tlie mothorU uf oxnmining the bloud, 
we oome next to the luiiriideratiun of the (Iiu);ni)!>tic vnhtc of \ht 
conc]ilioni< whidi we find in it. Wc find, fintt, that anwrniii, or blood- 
dcfieieiioy, is reprewttit^^l by two (Mnditionit, in one of whieli the 
piillor and other syuiptunus an- due to a diminution in the number 
of red bloud-oorpnMckit, while iu llic other there in « dcemwc in the 
amount of lifcmoglobin in each corpuscle. In regard tu the wluto 
vurpiutelui we find even mure viiluuble dia^iuHtic dnta, t^lneu tliinr 
vnriatiuu in number, form, and elisrscter i^ nuirkt<d in wjnie dis- 
|Ha&. I'nictioilly all coiiditionii of the blood which arc |Kithidiiiji;i<^il 
fl^nent diwa.'ie^ in organs connected with the blood direetly or 
indirectly, and do not de{>end upon primary ohangci in this liquid, 
except in mre Instances. ^H 

A patient's blood having l)een found lacking in the pn>]>er nnm- V 
ber of red blood-corpuscles, the question naturally iirwes f%n to what 
eonditions underlie thix vnrinti<m from the norniiil. The mont roni- 
mon cansi's of tliis detmijjM.' an- the iiife<aiou^ di*eaw», which all 
renult in prodtieing a degree of anivmia nio»t marketl during early 
oonvaleaccnee, and the history uf such an attack xhonlil always bo 
sought for, and, if fouml, rc^^iirded nn an iniportanl jKiiut for eoii- 
siderution in reaeiiiug a diagnosi<;. If there be no hi^tor}* of aent« 
illne«». the most natural couditJou to be thought of ix tliat known 
lis ifimpic unieiniu, prutluccd by no apparent diitcaBc of the organs uf 
the ixMly, but due tu lack of gotxl food, pure air, proper Iiy^eoie 
aurroundingis, and (UEorcise. If this is excluded frum the dia};;nn6i«, 
we must not forget that if food is tiiken and not abirorbcd projicrly 
the corpuscular nclmeMi of the blood is decreased, and therefore 
dirouio indigestion, notably that condition called atrophy of die 
gastric tiibnies, may be the cause of the difticulty. Again, pnifouiHl 
atuemia, as to the number of the red bload-corpuscles, may he 



present and seem inex]ilicabli% iititil it U discuvoixtl ilmt Uio jMiti^nt 
f^ufTi'rs fiviiii bl^tnlitig hciiKii-rln^iilH, »»il iIk- ilaWy Ium uf lilood, even 
though it be flmall, i.4 siiHivifiil to ])ro(ltii.'c tum'iuiu. Siuiilitrly re- 
]wat(>cl attat^k.s «if nns^'-lileal nr of oxwssivf uit-iiKtruatiuti may so 
rciiiilt. Xatiinilly tUf. pliyiiuinn will huvc <^'xolu(li-<l the possibility 
of tlie aiin-tiiin lieitig iliip to ti pivfiiM: hcmorrh)i|;u from iiny cause 
before »earchiug an far tut thin fur n i]i(^^iuHi». 

There still remain:* to he <Hii»i(lerL-U the nnivmi* vrhtdi is culled 
penticiou», in tlint it pni); restively gets worm.- until (l«uth oocur« in 
the mnjiirity of ca>u.^, nitlioiigh n few may rwover. At present we 
<lo not uii<ler<tii»il the piiUiolog>' uf this iIIt^liiir-. It is vliunictcrixed 
hy inarkrd |Millor without low uf flefili, or, tu speuk more oorreclly, 
tlic »u1>cutjiui-oU8 tii^suea are uilded tu nither than robbcii of fat. 
Tlieru i» gradual inertniHing dyi^n'eu, fuihin^ of etreu^h, cunljnc pul- 
pilation,vrnouitinurinun),»ume vertigo, ami ruuring in the ears. The 
blood 4iuw«ainu0t extraordinary iinil rontiniially dimiui»liing uuin- 
ber of retl blond-curpuecles, luitil tla- number may amutint to only 
1 ■13,000 to thecubiemillimetn-. In uilditiou, the following ptiints of 
grviit diagnostic importAUM^ are to be noted. I'irBt. the individuul red 
«tr(mm;l(7» arc richer tliau uunnul in hivmoglobin; weond, many of 
tfaem are larger than normal (mej^loeytes); thinl, the nnl eorpuwle^ 
are deformed, some lieiug ovoid, others irrp^lar in shape f«>ni pro- 
jections aud con strict ions on their siirfaetw (poikilocytes); fourth, 
tliere arc present mierocytes or red hluud-cells, whiuh are .■•inaller 
than normal; fifth, nueleated red blood-cells (normublo-Hta); and 
sixth, and quite constantly, there arc other large celU like the mega- 
locyteii, named megaloblails, whieh liave a plain staining nucleus. 
TheAe hist arc often larger than the megalocytcs, and are sometimes 
oalled the " eorpuiwles of Klirlich,'" since lie regnnU them as patli- 
ogDomonie of pernicious antemia. The white bluud-oorpiiseles ar« 
nornwl in number, or slightly decreased, although the great dimiiiu- 
tjon in lh« red cells renders the profmrtion of while to red greater 
than normal , 

AiiH'nitii itependitig u|«>n laek of hemoglobin in the oorpuseleB, 
nttiier tluin a detrpeiwe in their actual number, is (»een most typically 
in Ilmt (audition eulletl cMonm*. In this state the oorpusewlar 
diniiuiition is so i«light lliai it may be ignore<l; but iJie dccmwc in 
hnitnoglutiin is extraordiimry, sometimes falling tut low as 2t» jkt 

TMNan DM loM «oii/iiMd wiin uw MyalocrtMot Kbrll«li, whlob tn l»nf "klu caU*. 


cent, of the Dnrnial or below it. The red corpuscles are, hovrevei^" 
very commonly irregular in form; thai U, there is more or tear 
IMikilooyloHb, hut the wliite corpuscles remain aormal in niuaber 
or slightly increase. Xormohlast« are (jiiite coDslantly found in 
cliloro9es of a severe type, liut tlie larger varieties of nucleated 
eiythrocytes are not seen. The dia^ostic points, in addition Ut tiione 
of chloroKi.'f just named, are the fact timt the inti<!iit i:« gt-iu-rglly a 
young girl of from fourteen to twciity-llv<> yocin^, tJtat tlin akin m 
peculiar in iti< ]Mllor (sun iihai)t«r on Skin), and tli«rw i* often little 
if any menstriial R<iw, which is ii»)imlly only faintly pink in Imc. 
Dyxpnitik, citnliuc iriv^iilarity, oun»tij»ilit>n, and u way wani ap|>etite 
arts ofCvn prtwi^nt. AiuoitltJition of the nook on the right Hide over 
tlio jugular vein will rcv(^«I u [lecnliar miirinur callvd a " humiiiiiig- 
top" murmur. Febrile movement of slight degree may itlso be 

lo addition to these causes of antemia we find autemia doe to a 
decrease in both the corpusclej^ and hemoglobin, A large prn|>or- 
tion of these eases have already Wen mentioned when sjieaking of 
the anemias of convalescence and hemorrhage, but a far more im- 
portant cause of this condition, yet one often overlooked, to the 
gnait n'grctt of the physician in later yMirs, !» the poi^ibitity Qf tli« 
cauHc Inking tiiberouloHis. Still other oausfut of such ana;mia an- 
cnnner, Hiircouia, nn<l renal diacow.*, |»irtieiilnrly gofitric vaitoer, in 
which CLinditiou thr bliHid may n.-«emble that of pt-rnioiouM anicmia, 
und gastric ulcer, in wliiirh the lo48 of corpuscles may iil»o l>c extn- 
ordinury, even if no licmorrhugc occurs. Chronic lead -poisoning, 
arsenical poisoning, und nra-mic poisoning may <»usg it, and it artites 
from the jire^-niH; of numerous forms of paraMtcs in tJte bowels, 
Buoh as tapeworm, nnchylostomuni dnodenale, and last, but by do 
means least, from mahtriid infection, eitlier as manifested by acute 
attai'ks, freciucntly repL-wtetl, or by slow poisoning witli tlic devcloji- 
raent of cachexia. (See further on in tliis chapter.) 

Leukfemia. Thei-e yet remain to be considered those conditions 
in which we find not only thosi' states already describci, but, in 
wlditiun, marked alterations in the white hlood-oorpuscles as well 
us the red, nlteratiorL^ of such moment that they become the salient 
features of the blood when it is examined, and they are of great 
diatfnoslic tmportnnoe. The pointa of importanoe in exaniiniog 
blond in r^>g»rd to thi' wliiii- cnriniMle^ nn* thi-ir number nnd their 
peculiarities nnd kindi^. The discovery that the proportion of whito 





FKL 2. 

'■ "'1 .. n 

A 4 A 


ft ij ■ 



ftUllBCd Vlfh 1liCtnu[<illMI UfthllHT. M joa 

t l»oi BlobUri*^ . TJ»c luiTcnv in Ihc while «Hn 

t^plriil^MyeloEvnitf Ixukiciiil*- 

Uirtlii h^nijitl.Mti'lhi.K Jen. ifnKvimti ■«-[(*• mfrw 
loLuf »«--irly nuilorm •irr. roi>ia'l. T-i Hit' Itfl « 

diiil (hfer fiHiiiin|>lii](>h«i^rii, i Kiclcr j 

fIG. 3. 

r»G -I 



qlC* ■ilt'ir\TiL|, T- ir Ir^JrwUf ■"'I n^br lH)r 
%imrytv i: ' >' ' i lliku Uahi T^r Uirvr 

hIh* ■ - ' '.f*'llr4, thf AinuUrr iiiir 

V}rvliM7lc. XnmfioUDht. UrfjJnltld'4 . 

THpltalrilik. r.,iiiyt'lut^vlrBhuwlniencu4iup1ilHr 
ir>.iik<ikfe n iiii.iniHiilmi l-ti}i fTiMH M >rt*«' of 

Nfklcutv Mi^- li<L< I. iiLjKiiiiH, t Mri:4 iiikHmt^l 

K^-Ir^iTi-M*-'!' Ill* riiliililPi»i I ffiMikrt <M-*<"I |jrnilc- 




r^rpiiBclwi is far too Kreut, varyin)|r from the iiornuil (1 Ui 450, 
ap|iroximately), should cniisc t\w physima, first, to exclude ull pos- 
mliility of transient caus^ uf variation bv making an examiuation at 
various timee of day, or by excluding the presence of acute infevtione 
dittea^e characterized by leucocytmi!^ — that is, the prescnw! of an 
unnflually large number of white corpuscles of the polymorphonu- 
clear variety. This can be done, not only by ejcchiding the pres- 
ence of infection, but also by the fact that in loncocytosiH in 
infectious diHeaneH the increa!»c is solely in the polynuclear neutro- 
phite cnrpwtole^. Again, it in well known ihuC the taking of meals 
inorcit»r» tin; white eorpuiiclcfl during digestion, and that exercise 
and niaititagic do the Mtme ihinj;, nt least ko far as tlie pro|Mirtion in 
tlic |>criphcral vessels from whicth we dmw tlie blood is I'onoemed. 
If, however, these caMsc» are exrludeil. mid wv (Ind a [wtient of 
from Iwcnty-five to forty years of age and u niulir (in \\n: propurlion 
of 3 to 1), {mllid and puffy-louking, dy»j)na'!ir, and fcebli.-, with a 
tDarkeal and ooniftutit incrcaiw in the prupurtion of his white cor- 
pusck-^, what ilm-f it mt-aii-' It probably mvans that Um luitivnt 
\a sufferiufi; from loukiemiu (leii(X)0}'thirmiu) in one of its two forms, 
namely, Kplvno-mcdiillary Ictikiemia or lymphatie leuko-mia, of 
which the former is by far the most common. 

When die disease lenktemia is present in its spleno-medullary 
form the typical change in the blood is the increase in large mono- 
nuclear leucocytes and in the presence of the so-oalled myelocyte 
of Rhrlich, a large white oorpusi-le with a pale-staining nucleus of 
even outline, and neutrophilic fine granules. The myelocyte is 
fretjuenlly of the same sixe as the large mononuc1t«r leuivHTVtc, and 
nan be distinguished from this cell only by the fact tlint it contain*) 
neutrophilic granules, while the prolophura of tlie mononiiolear 
leiieuc^'te is clear. The ordinary largi- miinnnuclciir oclla are not 
grmtJy inereased, and the [)olynnirphi>iis or jtolynnehiir cell?' are 
rather decreased, tkwinophile celU may or may not be present. 
Ttw myeloeyti? of Khrlieh is » giniil-t'cll, without amiptmi<l move- 
ment. When HtJiiiii-<) with Khrli<'h'8 tri-aeid stain tin- ^mnulen of 
tiie MMinophilic leuciKytr appear as coarse rcddi»h-bronw grunulcfl 
MMitti-riHJ thron'^Hi the protoplasm of thv cell, and often euperim- 
ponol u[>on the nuelcuK. 

The other changes fotmd in leukaemia are that the rc<l blood-cella 
an ynatly dccreaaed in numlier, and a large number of nucleated 
red oolU may be »ecn. The hwmoglobln is decreased. The pro- 


portion of one to three red cells is often met with. Tlie additional 
symptora of this form of luuka?mia is grvut und (gradual enlai^'- 
ment of the spleen, with marked splenic tendcmeaa. Auwultation 
over this organ may reveal a murmur and palpation a cn^pitn.''. 
Hemorrhage, generally from the nose, is common, and dynprnea 
and diarrhrea are often present. Often retinitiixlevclopti, and slight 
fever may oocnr. 

In advanced aniemia when the proportion of while to red cells 
jg one to ten, the white corpusol&-« all remaining nonunl in numlier, 
except the lymphocytes (that i», the mononuclear, deejter nluining 
oclU, with a rim of non-grannlar protoplasm), which are grt-iitly 
increased in iiuiiiber, we Hus|>ect lynphafic latkmnia. Mye](>(!ytR«, 
xo typintl of the npleiio-mediillary form, do not a|i|>eiir in this i^ui- 
ditiun, iiud splcub (■nlnrgeinent U absent, hul in its plaint- th»nr it* 
often vnhirgcmtnit of the sujierlicial lymph-glands, hut tht>M> never 
grow su Inrgt! a* in Ilddf^ktit'.s di.'<ea.-«e, or pttc(idi»>leukteiuui. 

PsL'udo-Unikit'niin, or Hod^kin'ri di-tfasc, i:< »uppoi< tu he diffcr- 
entiutt^^l froiu tiui' Icuktutnia hy th't l>|iH>d exnmiuutiou, it being 
6tatud that in tliiH uuiludy thor« i» usually only n i^light Uern-^asc in 
the rvA eelU nml no trtlu-r uiiirkwi chttngott. Ki-iWiitly, however,^ 
Martin and Malthewson huve empiiiuizcd the fact thut In some 
oases of pseudo-leukiemia the lymphocytes have increitse^l as greatly 
as in many instances of true loukaimiu. As a general rule, how- 
ever, the hlood condition separates the affections. (See cliapter on 

Parasites of the Blood. We still have for consideration the 
paiiL^itii- dt.seafle.1 of the blood. These uonsist in the malarial germs 
of I^vorau, or, as it is more properly called, the " hwrnatozoon 
nudnriin" of Marchtafa\'a and Cclli, and the tilaria .sanguinis 

MAt.ARtAL Oroanihmi^. Xo more im|Mirlaiit ndditiuii to the 
study of di^'iuc, from a diagno^ttic stand{>rilnt, lui--* been iua<li> that) 
the disoovery of the pptiwnoe of a parasite iii the hlood of pi>r^iu« 
suffering from malaruil f-jver, which is always pnytent umler titvsc 
circuni«tancei<, and in all pnthaliility ac(» ai* the muiwof nil uwla- 
rial miioifestatioiM. Thc^u parasites are vnrictie^t of Nimroxoa, which 
live inside the red bluod<oi>q)iu«dc« of tlio individual ntta>-ked.' 

' In tbla coantry Um ahlef latMUvnuin iiitci ilM liar-Muorr ot lb* nuluid |«nU>« luta 
bMn Oilsr. OouDcltmul. ■nil, mofs retenUl', TMjvr And llewMNiD. from whoM mbaluUira 
•nd »Uo nmiiutfniiti oik "Tlit >(alan»l F«Kni<i( D4liimi>n]" mucb ■■( ibo laFDcinaUoD In Uig 
lut or ibli book UilcrlTVd. 

TheParasiie of leriian Ttvtr 

m m 9 ® 9 


'< V* 










,/■ ^ 

The Parasite of Quarlan Fever 

• • a o 

O Q @ O 

e m .t> 

rUh- BLOOD. 


The pamaite of malnrUI fcvpr occurs in three forms, namely, aa 
that of tertian fever, that of qiiartau fever, and ah the {Ktm-iile of 
the BO-called iestivo-autiimnal fever. The tertian imraslte ix n small 
hyaline, colorless hody, whiih ot-cnjiiea but a slight extent of the 
interior of the red blootl-coqinsde. (Plate XI., Fig«. 2, 3, and 4,)' 
When quiet they are round like the eorpuwcle in whifli they lie; 
hut if tlie specimen examined Iw fresh, they may be i^eeii to po^tM'wt 
active amteboid roovenientn, thentby rhniigirig their «ha|>c. 

Soon thirt iimcehikid bixly grows in »\/.v and bi-ginK to develop rrd- 
diah-brown pigmunt-granulcsll'Iate XI.,Fig!«. '1, (>, and 7) in itxctf, 
'IlieM- pigment-gran II ten an> mpidly moving hiHlie>, and na tlwy iire 
often found in the iiroji-otion.tof (Ik- |>»re^ite, it nmy look, until l\u» 
fact is corrw^tftd by fUiv fiviuwing, as if «rvi>ral [wrasitiM wcr« in one 
oorpitsclc-. An tin- pigniont-iuaAM-H incn-a^-, the i-orpiwle whiHi 
oooniD» the jMinisile becumci< mure uud murt- pule, and at tlie «ime 
timo «wcll8 lip or expaods, aitd the uma-boid muveinuDlM grow less 
Mid leM, while the pigment t^'ndf' to arrange ilsclf towani the 
periphery. (See Plate XI., Fig». 7 and 8.) Finally, only a »hell 
of oorputwle k left (Plate XI., Fig. 9), the pigment aft«r eulleettng 
in tliv eontre Wcomes motiouI(i>u«, and then the parasite uudei^iKV 
^ntpotation ; and, liiwlly, we have developed 10 to 20 segments, 
arninged about the central clunip of pigment like a rosette. ICaeli 
segment has a spot looking like a nucleus, and soon the matar« 
bodiefi so formed break out of their host and attack new and pre- 
viously healthy blood-cells. Sometimes the parasite becomes so large 
that it entirely destroys tlie eoqtn.icle and Hoats free in the blood, 
in which mse the pi gment-gnt utiles (|Utet down and tlie mass l>e- 
conies mi^ha|>en and iipjiarently deaf], breaking uji into .imaller 
masses, and give« rise to aeveral small bodies, which, however, soon 
Deem to hise life (Plate XI., Fig. 21), or it becomes filled with 
vacuoles [Plate XI., Kig«. 2;t, 24), or, tinally, we have springing 
from ttieoe extm-etd hilar bodies llagella or waving arms, extending 
from the mai^in of tin- ]uinLAil«-. (Plate XI., I**ig. .'l.'i.) Tho* 
tlagella Im^k off now and again and keep waving through the 
blood, looking like Mpirilla. The eiitin' proeens jnst des^^ritMHl 
seemq ti> oMiMitnc niMmt forty-viglil hours, iiinl it is of inten*Ht to 
note tlukt the iwMue of the paroxyotn of the <liM!ii>« occurs witli tJto 
segmentation uf the full-grown |tanv>ite, so that the pn-«vn«o of 

' So. L h • DOnBAl Md rolpuwla. rUlo* \L UHl XIL arv i>Mn [rum TUrw •ti4 U«wM- 



segmttatinii borllcA i»dioat«#) tho noar a|)proa<-b of an attack. If, 
on the other haud, w-e liavc a <)oul)t<- tortiaii inftM-tioii — tltat is nu 
attank daily — or a quotidinti form, we liave two »rt« of panuiten, 
raeli one of whi<rh r^^clu^s itM period of rtcg'niotitntinii on iilri-riuite 
da,V!«, and ^o a dtiiiv attack is (laUi^tHl. In siirh hloiid during a 
paroxysm will he fonnd two »ctj« of |>itrn)uti«: uiic «Dt iti-irnii-titiii); 
or fanning (In- )wii-o.xyw", luid the other not half-^Jcvcloint), w[ii«h 
produce llie ttlUirk of the niorrww. 

Tiic ([iiarUtii jiiinisite, or the one aiusing an attack every tliinl 
day in it» earlier i^ta^es of development, looks very nincli like thut 
of the tertian form, for it occnn lu a email hyaline amcpbuicl liody 
filling It fraetiun of the corpiiselp. They soon, however, dcvolop 
the followini;; diGTercncei^; first, they develop a sliarper oullioe; 
second, tlicy are more refractive; thini, the amieboid ntovetneuts 
arc slower (Plate XI., Fig. 2(>); fourth, the pigment-^ranuW an 
coarser and darker (t'late XI., Fig. 27), and, more important slill, 
they lie verj- quietly around the edge of the parasite; fifth, the »»r- 
puscle acting as host does not increase in si/e, and finally di.tippear, 
as it does wheu affeet«l hy the tertian type, but grows smaller at»d 
darker, more refractive and metalliolooking (Plate XI., rigi*. 2>t 
to -U). Keaching their <t>mplete development in about nixty-foiir 
to 9e\'enty-two hours, they appear att small, niund Imdiesi., taking up 
nearly :ill ihi- sjwi' in the wirpn*rl(T» in whieJi thcj' live, or ihey 
np]>e(ir free in tlie blooil-seruiii (Plat*- XL, P'ig. .15). .Vn Uio lime 
for the iHiroxynm approachett the pigmcnt-gninuW whieJi lui\-i; 
been »e«ttere<l bt'gin to collect at tliP eentre (Plate XI., Figs. ."Hi 
to -W) in a '■tclhte form, and the protoplasm of tlie mass then 
divides by segriKiitalion Into from six to twelve sinnll [Kiir-likv 
bodies, escfi of which has a rcfructive centre. The»f iMxlics l>e- 
uirae more and mon^ separaled from one another, and simtiltJiM^ 
ously we find new corpuscles infected by the orljiinal small round 
bodies which we first saw. 

Sometimes these jiarafutea expand and beoonw very tntuE]i>ftrent, 
their pigment-graDules become very active, bat ftnally become quiet, 
and the body of the paraoite grows more and more indistinct. They 
become dead parasites. (Plate XI., Fig. 40.) 

Again, tlie parasite may undergo a breaking up into smaller 
bodies, which ant badly forniod and indi.'ttinct ; also a degenerative 
form, and vacuoles may develo]). (I*Inte XI., Pig. 42.) Finally, 
flflgella may develop, »» in the tertian orgnnii^m (Phite XI., Fig. 

Itte f^ruite of Kamn Autum) 

• • • e o 

• 9 • o • 

« • • • 

^ • • ^ € 











41), and Umr dilTrr Troni thv tertian fonu in being Bmaller, and 
tlieir fn^nilles arc i-imnti'r. 

Ill tlio Uiinl form of tDftwtion (lOKtivo-autiimiial fever) we find Rt 
tir:<t tliv icmiill hynlinc botlivs, but thcv haw a ringi-d appearance, 
iiml iitv )^>ra(!ti nitre vtrv aoiull. (Plate XII., Flpi. ■'{ lo H.) Sud- 
ib'iilv this body becomes lar^r and tlii' riuj; \a lo^t, the edge becom- 
ing wavy, and amceboid moveraenta occttp, tJie psemlopodia oft«n 
juiiitng to form a true ring, Pigment-granules fiually (te%-eIop after 
a vuriablt.' length of time, but tliey ape few, rarely more than two in 
a piini^icc, near the edge (Plate XII., Figs. 7 to 12), and quite still. 
Th« GurpU8cle»i are not deeolorixea), but often are shnvelled and ven* 

The ]K>ripheral circulation during the pnroxyam of testivo autnmital 
fever oontainft very few, if any, pai-anites, but blood drawn fioiii tlie 
oplenn may t<liow iutracorpuaetilar [>ura»ites, with bloeks of pi^aiem 
and wme trw [inm»itcft. Ad fwg^nientalion goet> on the paraAilc may 
look like the tertian form, but it is far smaller. (I'latc X 1 1., Figs. 
21 ui "iH.) Aft«r this |h-ira.sitv has Ixron preseui for some linys we 
find in the b]'H>d larger piiraNitcn, of an egg'sha{ie, or (-rirM^cut-Mhape, 
the remain!* of the biood-oell, looking like a smtUI qimrter of an 
apple glued to tho side of the ('n-soent. (Piatt' XII., Fig. 29.) 
Vacuolixation and flagdiattun may <levtflop in llii» form as in 
othentf and tito use of (|uinin« in the lint wtH'k may prevent tlic 
<l«vplopment of the orescent*. 

The foUowing table Depurates eoeli of these malarial forms from 
the others : 


n«ir«to|Bin t* boon. 
Fal« and IndUtlact. 

AotlTtlr anueWd. 


PtfCMDt Mlln In iiiav«m«nL 

Pull lim at ttte cntpunla. 
PUBMkBtc loriu UW m 

Iwc* H oMpnaol*. 
eiCDieiila U u> 3). 

Irtqtnlat miwaiMi «flan. 
Oorpiiurl* bvriinw Mlorlan 
■Dd •nulUu ^ uHi 

<l<tatU,H Panulli. 
IMVTinpi til 72 lirjnn. 
Hbatpljr o(itUii«d ind icflao- 


Mlffhllf amirbald Kiiil laUr 

ricmcnt •low In morenwDl, 
PlROiDiit auV.. 
Smallar thin th* iior)<i»c]*, 
Dcffcnormavcliniiit vtrj miich 

tnuUtct Uixi III ivrllmi 
Unui ciili eqiMl ina\'t. 

BouKlfUl nactUa. 
UotroMla btoaawa hrasLjr' 
lookliiB and Mini alien. 

. IMrv«iUaiBaal. 
ttoTtlopa Id M la 4< boar*. 
■lav* a wINfltd afimraim. 

A«u**lr aawbold. 


ngstae^iaauiai quit* um. 

Vcrj' niuh •uuJMrthaBaeM- 

Tba pcDcna of ncinenlUlan 
■KM an la iba Inianial m- 
nam, ao aatmaDUnf fciM 
la oMtbniid In tba blood. 

nauia crcaoi dCb. 

CMpUMla ■• >brlTelli!d aud 
TBT Mmt. but uot dci»tor> 


The blu'Ml it iiKiiiilly examiiitil fitr iJio tiiitlarial ]iiini.'<ib' bv what 
U rallfil the iliriM^t or '* witlimil .■•taiiiiiig" metliod. The cover- 
I*hi8«-rt whuOi are to be employed are cleoiMcH very careftilly by 
washing in alcohol iiml ilhcr. The IciIk* of tlie ciir, tiftrr [nt'tug 
«ir«fiilty flwinwtd, is tliuii sliililiri] with a iiceitlc or inimll utnotouie, 
and thf firet few ilroiwiT] wiiwd nw«y. A ixTfw-tly x-lciui 
cov^r-ftlttw i» now jnr-Uoil up liy iiii-(in» nf ii jKiir of foroein* and 
touched tu thc^' tip L>f th(^' drop of hlixid luid then ptiicL-d hluod-Mdv 
down upon n cluiui ^liiss *\'nic. The hlood in i^a%\ly ditttrihtiiccl 
belwtin th(! );hu!sc«, and only tlio incrcst lotioh of tht- oovpr-uLisB 
shoidd ix' tuttdc to iIr' 4ln>p of hlooti, us otherwise too Dittcli hloo<l 
will be tahcn up. 

The microHcope should be fitted with a ^ ail-immvrsiuii lens 
and a No, 4 eye-pieco. 

W}ieii it is desired tn keep the specinicQ and to stxiii !t, the beet 
stain is that of methylcne-bluf and eoaine, whieh is prepared as fol- 
lows : a t'oncentraled watery solution of mcthylene-hlne is diluted 
one-half witli water and ni!\ed with an e<inal volume of a J per 
cent, solution of eo»iie in GO per cent, alct^ol 

In onler to pre|iare blood-spceimens for staining, two eover-^Iaasen 
nrt^ i-e<[uired. After a small drop of blood has been allowed to 
full on the centre of one cover-glass the aeoond eover^lim i» 
plai<ed upon it, and as soon as the hlood Uan spread out between 
the two in » thin film the glaitses are drawn a[)art> the snrftuT of 
eaeh Iwuriiij^ a thin, even layer of corpiiHales. Tlie eover-f;l«*tcB 
arc now mpidly driod in Uk- air, an<] immer.vd in a mixtitn* of 
equal part* of absolute aleohiil and ether for half an hour, to "fix" 
the pruparntions. Tlie speeitneiis are then dricil and stained. 

We can uae another inetliod, in which we ftjiin by placing tho 
dried cover-glass in CheiiKynski's sohilton and ^'ntly hoatini; it 
for fifteen minutes. This solution is made as follows : methylene- 
blue in satunitcd watery solution^ (0 e.e ; cosine in } per cent, solu- 
tion in 70 per er-nt. alcohol, 70 e.e.; distilhil water, 10 e.c Tli« 
luematozoa are stained blue, the rixl cells lake the «-oIor of eosine, 
the nuclei of the lencot^'tes arc staim-d blue, and the eosinophile 
granules of the oells bright red. 

We have already stated that the [Kiroxysm of the malarial disease 
takea place at the time when the parasite is breaking up into s^ 
ments. In other words, the attacks occur «-henever the cycle of 
growth of a .set of parasites is completcil, which in tertian fever is 



every forty-oiptit liouns, iiud in quurtjin fevur every seventy-two 
Iiuurv. If tlicn.' be iww sets of panuitcs In the blood, however, of 
the tertian type, the attacks nuiy be daily, or quotidlao, liince each 
set nuituro oa altcrnato days. This is often called double t«rtiun. 
This iii the moi^t eommon form of the disea-te iu the United f^tatea. 
If there Iw a double tjuartaii infection, the attacks eome on two suc- 
ceasive days, then a day of intermistuon ensues. If three sets of 
panuiites of ihis tj-pe are ]ireaent, the attaoks may lie ilaily for three 
days — triple (juartun infection. (See chapter on Fever.) 

The pamnite of lestivo-autumnal fever ia irregular in its develop- 
ment, and is often the eatise of the irregular malarial fever fteen in 
the fall of the year. It yiel<lA le^ia readily to quinine than others. 

WidaPa lent /or typhoid or fnterie fever de{>endtt upon the fact 
that tlie blood -(*e rum of a patient suffering from tyjihotd fever exer- 
cii>eflaj| aniagoiilstie effeet u]ton the typhoid barilluH, The method 
of Widal,ai< moditied by Johnston, of Montrenl, ia n^ rollowii: the 
]<^>e of iht: (Kitleiit'iii ear hiiviii^ liei-n pricked, the dmp of hlood is 
placed uit n rhsui ^\aj& .«lidc uiidnllowiHl In dry. A lonjiof bouillon 
culuire of the typhoid bacilhiri iii now placed on nn nbitolutoly clran 
covcr-);laf«, and to tliiit is added u lurtre luupful of u vmtery mIuUo» 
of the dried blood. From the mixture of hlood and typhoid 
bouillon u "hanging-drop" pn-piiRition is made, and cxamin^id 
with a 1 or jj dr>' objective, when it will Ik? noticed, if the patient 
ifi suffering from typhoid fever, timt the typhoid bacilli rapidly form 
clumpci. If the patient has not typhoid fever, this cbimping and 
enunglement of the bacilli witli arrest of their movements do not 
take place, unless he has liuil the disease within several montlw, 
when the reaction may oecur without signifying tlie onset of a uew 

Ftu\ltlA. The (ilaria sanguinis hominis ap]>car« in the blood in 
its embryonal form, aii<l is fonn<l fully developixl only in the lym- 
pliatics. It ociHirs in three forms, and lias been well de-seribi?d by F. 
P. Henry, of Philadelphia, in a recent pa|H>r. Tl>ese forms are: 
1, Filnrin diurnn : '1. hllitiin i\aftt<ma ; 'A, fllarin prtttlan*. These 
tuum^ are indicative of the habits of the anitnnl, th« filaria diwaa 
bdia}; fotttid tn llie smpnrfieial veswi-U .solely or chieHy dnring tlie 
day; tUvfilnria twcturnn :w>lely or chiefly during tJic night; while 
the flliiyin firrttmu) i» coiiatantly prwutnt in the cnpillariet of the 
int«rgumenl. The A/""'* (fiunirt and t\tr* filaria jxridawt arc oon- 
finetl, thn& far, to the wort ixmmI uf Africn and adjoining districts; 



while tin- fitiria nodunui U pand^tnic- in llic lm[>i''!> mid <;iiilrmio 'm 
uertaia .scctioua of tlic Uiiit«<l Stab». Tlic Euiiilt« of jfi/arw ttoduma 

fm. u*. 

Pllftrik lilts III lb* blood. InatantaiicDiM pbowrnlcrafnph. Four bondnd dlUMIan 
iiiMmUI«alIon. PourmllllnietnaMaRpoobnHUtlo. fHust'aoHi.l 

have t)eeu frequently fouuil ; that of fUarla pertiaiu never, no tar as 
Iluiiry hne been able to awwrtaiu. In the opiuivn uf Muibou, tJie 

f^r,. 1^1 


■7 — n 

niarla 111 itw IiIooiL 

niPtBn. <IlimiiT> (Mas.1 

filaria loa of the eye of the negro of Old Oilabar Is probably tho 
adult form of the^am rfiuma. If it is ii«t, ho arguet*, then there 
must lie another bloodworm yet to be diwwvered, for the embryon 

Till-: BLOOD. ^^^ 376 

of the ton Hiiiat ewjt]Ht from the tiixly of thrir li(Wt thmugli the 
uiixliiiiii i»f llio cirrulAtauti. 'V\wjil<tria /jcntftow \m» U«ii pnicti- 
lally [trovcd hy Mauwii to kv tlie niti.-^< of ttif futii) " Alcc|>inK-4U<.-k> 
iK-je»" of tlir Congo rtgion. 

The 4<'Oond i» tJie one orHioarily «ei-ii in blood obtained from the 
peri[)henil vin!iilnlion«liiriof;ek-<^'P or at night. (Figs. IS^'iiind 164.) 
'n>c tnmlv lilaria iDfOMunv Sii niiUimctn-H long by 0,407 inilliiiictrc 
brood, and tlit- Uitl is twisted into a Mpinil form. Thi; fvmiilu nh-a»- 
iinu> Im milliinvtrra long hy O.Vlo millitnctn> wid«, and the vulvii 
is 2.36 mivromilli metres from tli« auttrior cxli-emity, Thi* L»mbryo 
lil«a8iir&4 3(0 to -'UO mioromillimptrt>s long by 7 to II mlcmmilli- 
metiffi widr, and has a ijointw! tail. This eiubpyo U in an almost 
impen«ptiblo shell, whicli does not impede ita movements, and aa 
it is about the size of a red blood-eorpnsele it jnsses through the 
cspilkries in extraordinary nnrabers, Ita active movements and 
t%'pical appeanmce render it readily e<een in the blood. The dia- 
eovery of thia panmilt' in the blor)d renders a dJagn^icfia certain, ami 
it shoold alwayt) l»e sought for if chyluria or elepliantiaHis ia present. 
If the )>atient remHtnn avrake at nights and fl]e<-]M during the day- 
time, tli« orgnni.Hrn will )>o foiitiil in the blood during tlie itteeping- 

Tim fitnria diiirna is found in the blwMt during waking-lioiin, 
Nnd the iinbryo« of the fitaria |H-rstans are tlie only form of ihla 
par»sit4.' known. 

SiroAK IN THE BuMD. Thv blood in penwnii sufTviing from 
diabi-ti-i( contains sugar in excess, and R. T. Williamson has siig- 
geetctl its disiL«very by the followini; prooess. The nunuai bluiMl 
nil! not give this reaetion. A small, narrow tnit-tube is well 
eleaned, and at the bottom of the tube arc pUced 40 cmm. of 
water. To measure this the mpillary tulie uf a Gower's hiemo- 
globinometer i-i u-hwI, whidi is graduated for 20 The tip of 
one of the |i»tient'i> fingera li cleaned and dried, then pricked, suti 
when a large drop of blood ha^ escaped it is s»icke«l «p into the 
small capillary hiemoglobinonietcr tube. Twenty* of blood 
are taken up from tlic linger. The bIoo<l is tlien blown gently into 
tl>e water at the Imttom of the small test-tobe. If it should adhere 
tji the Mde nf the tnl>i', it mnnt be <nrefully shaken to the Itottom. 
Then 1 ceui. of a I in l>()(K> watery solution of methyl-blue id 
addiil. Finally, to the mixlun^ 10 of litjnnr imtassa are 
■ddeil. The oontt^nlA 'pf tlte tube are llien well mixeat hy shaking. 


As a. control-ex pe rime at a second t«tit-tube of aimilar size U taken, 
and into this is placed the same quantity of non-diabetic blood, with 
the same proportion of water, methyl-blue, and liquor potassa. 

The fluid in eaoh tube has a fairly deep-blue color. Both tubes 
are theu placed in a beaker or capsule containing water. This is 
heated over a spirit lamp until the water boilft; it is allowed to con- 
tinue boiling for about four minutes. By the end of this time the 
fluid in the tube containing the diabetic blood has changed its color 
from fairly deep blue to a dirty pale yellow (almost the color of 
normal uriae). While the fluid in the tube containing the non- 
diabetic blood remains blue, occasionally it becomes bluish-greon, 
sometimes pale violet, but it is never decolorized — that is, it never 
loses its blue color. The tubes should be ke])t quite still while in 
the water-bath, as by shaking tlie decolorized methyl-blue is oxidized 
by the oxygen of the atmospliere, and a blue tint may then return 
to the fluid. This is the reason why it is necessary to use a water- 
hath, since if the test-tubes be heated directly over the spirit lam]i 
it is difficult to avoid sliaking the fluid. 

If the assertions of Freund arc correct, the testing for sugar in 
the blood is of value as a means of sejmrating carcinoma and sar- 
coma in diagnosis. Tlius he asserts that in carcinoma there is an 
increase in the sugar in the blood, whereas in sanroma no sucli 
increase faikes ]jlacc'. 

For tliis purpose the te«t just named is scarcely delicate euough, 
and it is wi«e to remove the proteida by boiling with sodium sul- 
pliate, and theu after filtering to apply the ordinary urinary tests 
for sugar. 



DMonlor* nail diMMC* nf th* Dfinnty blndder— Iktienlion of urine— lncootb«nre 
rif urlui- — The I'loraut^riMUcs of DOmiiil and nbnormal urine — The normul Hud 
kboormnl coolonis or the urine— Their oigQillcnotw— Ttsis for the conleDU of 
ill* iirlns. 

TiiK iiriniuy seorrtjan i» one wludi is loo frifiiRiilU- if^iurcd by 
tlir MikIciiI nnd phyiuc-iuii in iftudyiii;; tlu- dint^nosis uf di»uuM>. Id 
tDMiiy itiHtiiiiMV it will, if prujK'rly ti-Ktol, pvc such (ratdtivL' cvIdciiL>o 
in repird to ulisiMirc affoctiona that a oorivct diagnoiuH is nt once 
powihlo, and in othc-r cuoi'^ itH cxnminution, u-t n matter of routine, 
will di^-nvor important fui-t« (lie exi)^tol)(<e of which h:u lieeii iinBHs- 
poL-tvd. Again and t^in will a diagnn-iis prove erroneous if tJie 
importance of urinary examinations is igriiorwl, anti cx«tly errors 
for iht? (xilienl and the repotatioii of llic pIiyAi<-tHn eiii^ne. 

In a.tkin){ i|ueiitionA nhoiit the chnnu-t^-r of tti« uritii> giuMted and 
its ([nantity, the plmidBii should In- son' tlmt the ]iatii.-nt clonrly 
uuilerniawbi \m (picwtionn. Oftcu wc will In- told that niiich iirini; 
i« ))(i«w(l, when, in reality, it in only in umall muount, hut |iatwe<l 
oftvn; or (hat it it bliMMj-rcd, wln-n Himply rtd fn»ra iinit<it and 
uric acid. ]n iiKpiirin^ alxnit its color, wc should rememlK-r tluit 
if lai^ amuiinU of liijuid liave l>ccn i«wullow<.tl it will probably bo 
li^ht in huf, or, if small amountK of drink taken, dark in hue. 

Anonuilics conncetcit with the urine may Ik' divided into tlioec 
whicll involve the organs which secrete, retain, and expel the Huid, 
ami those which arc manifested iu the iiritH* itself by alterations in 
it« quantity, ixlor, njK'cifie gravity, and in its naked-eye appearance, 
its mierosoopical apprtiranee, and, tiiially, by those changes which 
are discovered by means of testa which poeeae no initiienoe of note 
on the urine of the healthy. 

The objeetive Hymptoms of many esfca of diflcasc of the kidneys 
have already been di^ui^ued. (See chapter on the Skin, .inch as 
onlenia and (X>lor of ihu !«kin, and chapter on Faoc, e.^pm^tion.) 
Ajtide from tluwo cvidvnws uf rvnal disease no altcntioti van luuallv 



be noted iinl«s.-« it be !<»■« of \vi'ij;lit. Thi> siibjciriivi- !"yiii|iu>ms of 
tlie patiunt <xiiiimiinly miijiUl in Imw of ninliitioii. in»lai^% dUturlKxl 
(UgCi«tio», auit shortuo88 of bniitli. Kurcty 18 there putn in tlie 
liimbur region, iinkt^t ])yditi«i, Htonc in tlio kiiln«y or ur«t<rr, <ir 
IK-ri-ncplirititi truiiblcs iirc present, when psila bccuuiva an iiiijwrtiiut 

Flu. UL 

I>t to Till carlotl w(bhbi« 

I >l to inh donal wanioDd. 

til r II mil Imiiihti mumiii 

IM 10 Ub MKMl MaWMM*. 

3lia<niis Uis iDlfitco>iin»> "i ii. i. <»>(n>pnn>llti|[ aiipraxliiwulj lo Um 

kllllMl mill miyplflug tlis tniDk and IlnlKi 


The Bladder. TIic oltjectivD symptoms of blodilcr diflieiildcs 
lire gi'tifmlly IihmiI, unk-ss th(?y arc very clironic, when tin* face m».j 
ap]>ear worn am! weary, and, if a purulent cystitis bo pn<seiit, septic 
fever may occur. The suhjertive symptoms are tenderness, tenes- 
mus, and pain (see chapter on I'ain and eltapter on Abdomen), and 
retention or inrontinenoe of (irine. Retention of urine, so far aa 
the bladder ilaelf is ronreniiHl, is rare, the canse of the retention 
generally Inting outride tl)i» visetu. It may, however, ariiw from 
ilii*Mi.-«<> or injury which destroy* or lempurarily impnin* the func- 
tion of the <ri'll» in the spinal eord whicli tjiiverii tin- oonirnctinn of 
the muwdvs involved in cx]Hrlliiig urine from the bliuhler. TIkvh! 



r^jnqtrei are Hitiinted at oi- abnut ttit- hvc] nt n-liich arr given off the 
secohd, thinl, nrid fmmh wi-riI nerves. (Fig. ISO.) 

I'anilyM^ nf ilic Ulmidi-r will) rrti-ntton may, therefore, follow 
severe injiiriei* to tlie xpiiml eord pnidueecl hy a fnll, bloWA, or other 
tmiiniHtii<ti).«, or l>c <liii! tn n iiiyolitin w)iirli (if-ili-ovA ftiieli eentrcs. 
(Sif i'lm]>t<T OI) Ia'p;* jukI I'Vet, [HiM o(i I'HrajiU^ia.) .Vgain, re- 
tentiun of urine niay nrisc from jiantlysi^ of tlie iiuu«Tiilar jiatt of 
tiw vi-siwil wtilU liy (ins^iire protliioeil in severe lal>»r (ohildliirth). 

Kiti'iJtiun "onifliriK'i' coinw an in locymol^M" ataxia, in whidi dis- 
eftjw the impiiL^'i! from Un* bladder arc not recofiiiiiwd, or are |>er- 
verU'il, *w dial llit- ciihimitcr wliidi ilrfwes tin- liliuldcr diNS not relax 
t'l permit the vHoupc of urine, or the oord or bruin fuiU tn nx'uguizc 
timt the bladder ih fiitl, ami so sends no impuW' for it» relief. 
Finally, we sw* ea#es in which the bladder «inn<)t be eDijitied, 
becunse the walls of the bludder have Iweu pamlyxed by over- 
distcntiou with nriiie. 

Un tlio oilier band, ineonlineiice results from low uf power in 
tlie »])hinetor, due to injury or discnso Ju the eord ut the level uf the 
Moond, tliinl, and fourth aacral nerves; and thiu, by the way, i» a 
fir more frefjueiit oc^ciirrence tlmn is al)8oliite retention. Tbc real 
eondilion under these einnmii^raneea is that die expelling-mueelea 
and rvienliiin>inii»ele» an- Imlh finralyiteil, sn that the urine aeenmu- 
lates in the bladder and llien drihlilcA thn>ugh tlie unguarded neck 
»f the bhidder. Si^metimeH, too, tliin iiiejintinenee t:* eau)«<l by the 
urethra being i«o in^Mi-sitive tliat it fail^ l" reeogniiie the pre.'wncv 
of tlie tirine, and so iiw<i not »end an impnlw to the tijihincter to 
tighten itH hold. Enennfinenei' nUo ri'HultK from exccHMtve reflex 
irritability of the wall* nf the bhulder, wi that the nriw no «»oner 
trieldee into ibinvlm'us than an inipuW Ih sent to the spinal centres 
u'hieh M;nd a motor iiiipnW- In the n)nf>ele« of exjintsion. Thi't is 
often the (^vnditioti in the noi^turnal tneontineiKe of ehildren, for as 
Mon ns the ehild Kleep« its witl-puwer i>ver the blndth-r (Tam'M, and 
reflex activity iu alone in control. Irritating, eonrcntrate*! uriuc 
may p<>n'ert the rvllexiv of the bladder awl mi cauKc incoulinciKV. 

The bla(tder-«ymplonis iv.-vn in myelitis— tmnsverse, trauinatio, 
or otherwise — usually come ou in the acute form witliii) it few 
liours after the wnaiiry and motor diBturbane«s have been noticed 
by the ]HiUent, and eitlier incontinence or retention, or botli, may 

If, however, ttie myelitb is not complete, tlte bhulder may eecB]H^ 


On ttn> utlitT iiiiii<l, if the portion of tho oonl which h involvorf tiiip- 
puns to bi; liuil piirt govcruiti^; tlic bladder, wtuciil syiDptomi; may 
duvvlop befon^ the oiutor Bympb>in8 arv cl«iLi'ly niark«il. iVgniii, it 
18 a notuwortliy fui-t that wboii rpnovcry takt-s place vesical rontiiil 
mfty be n-i^inod btfore any marked improvomeDt can be found eUe- 
wliere. Often tlie Iohh of eoiitrol of t)ie bWlder in suvb titiit tin- 
patient eannot voluntarily expel tlie urine and eannot retain it, and 
it dribblei; awny n-itliont his knowledge. Under sncb cii-eumstaiiocs 
tliere is pi-obably a myelitis involving the lower part of Uie dorsal 
cord and the upper and lower parts of the lumbar cord; in other 
words, all that portion in whioh the \'esieal eeiitres are !iituate<l. If 
the dribbling of urine take^ place without dirxontinn of the bladder, 
the fluid patHing directly from the uret^Rt through the uretlira, the 
lower part of the lumbar enlargement nf the eord is affei-led, owing 
to the paralysis of the sphinet<-r. < >n th« ntber hand, diiatt-ntion of 
tlie bladder, due to retention of nrinti, oo(nir» when the myelitis ift 
in the lower dorviil and npjifr Itunbar ennl, and i> due to gniralyiUA 
of the dtilrn^iir muscle^ whiuh tnuke no effort to expel thi^ urine, 
while the sphincter, the oditn:* of which arc intact, maintains a 
tightly eioMei! orilici*. Sneh cbbcs may empty tint bladder .i<|Ki«mo<l- 
ieally at long int^jrvals (overflow inoontinenee) — that is, sphinoter- 
[utrnlysis from dietention may ensue. In such a condition tlin 
bladder should be emptied by the catheter to avoi4i ]iaralysis and 
vi^sieal disease. To put tlie oaae in another way, we can say that 
tJio spinal centre for the control of the walls of the bladder is situ- 
ated at a higher point in the con) than is tliat for control nf the 
sphincter, and, therefore, relentjon of urine indicates s lesion higher 
up in tlie oord than dne-* ineontinence without retention. Precisely 
similar vesical symptom.'^ occur in casen of s|)inal tumor producing 
ti-an.-iverse lesloTis of the cord («>e chapw'r on Feet and L^s, I^ra- 
plegia), or may ariM^ friMu itpiiial apoplexy. 

The bladder-eymptoms of locomotor ataxia are ofu-n quite ohat^ 
actcrintic, and are to be ifepamt«-d from those of myelili*, itpiiial 
tumor, and the v«-«iicnl troublot due to trail mat ii^ni^ of tlie <<onl. 
Tho liisorder depends cntJndy upon interferencts with tlic reflexes 
of thv viscus. and so presents %'arying symptoms which ar«> motor 
and sensory. The patient sometimes complains of tho fact that be 
has to strain for a long time before he can start a stream, which, 
even after it is started, is often jerking or internipt^«d; or, again, 
lie must sit down and bend over in order lo have the atd of his 



abiJomiiiiil miucW bi-furu he van oviuriinU- tho bliiiUk-r. As » result 
oi lliiH, rividuu) iiriiiL- in I'xcutM i» nlwavs |)ri-»ent, niid ovsUIim or 
mildor (lugrccs of vvsiuil irrilubility dc^t-loii. In ot)ii<r inHtnnws 
till- (k-»in.' to iirinato conicft npoii tliu ptitit'iit kj 6ii<lik-ii1y and forci- 
bly that the urine ia vuulod before he i-nii, with hirt imgmiroil gait, 
rvach a place to [toss it in a pro[>er maniK'r; un the othvr hiind, 
it may bo retained and can only be romoved by a catheter. Still 
others find that urine escapca on laiighing, coughing, or xiiccziDg, 
OwinfT to lack of complete control of tiie bladder and ita sphincter; 
or, again, after many attempts to urinate, the patient gi%'cs up tlie 
effort, only to be humillateil by »» involinitiirv ptif^^fige of urine 
immediately upon his penis Iwing withdmwn into hia clothes. 

These symptoms differ so materially from myelitis at* to iiinkc u 
diagnasia as to llieir eanse nearly always possible. 

In obflcnre cases of ataxia the vosieal symptomH may aid the 
iliagno^ifl qnito markedly; thuit the presence of bIitdder-^ymptom» 
would conlirni ii dia^nosii* of ataxia as against fisoniin-Cahcs due to 
|>eri|>hemi neuritis*. Again, in myelili."* the prestfin^ of vesical 
synip[om!< [H>iuti« to tliiit dtMi>n^, and exoludcs fmm the diii^ioais 
SQCh iffcction« tut poliomyelitis and lutcinl st^lcrusi^ arTcetiotis in 
whMi vesical jHiralyHiii nkrely, if over, ocvure. Prcciiwiy similar 
VCsImI symptoms are sometimes seen in cases of general pamlyftis 
(^ the insaoe, but the delusions of gi-andeur or melancholia and 
oth«r duiracleristic signs of this disease separate it at once from 

The soosorydislurbanws of the bladder will be found discui^ied in 
the chapter on I*ain, but it is worth noting here that accompanying 
the symptoms alivady named ai cliaracterislic of loooiiiotor ataxia 
vesicnl criaeii of spasm and pain frequently occur. 

When ther»> is pain in the blmldcr, made worse by the nttem[»ted 
act of mieturitiun, and tenesmus, with darting |)uin into ihi^ urvthni, 
then is probably ])resent a cystitis; but the physician shoidd niuoni- 
ber that cystitis may he pret«nt witli almost no painful manifi^tn- 
tioiis, even when in i(n netite form. In other eason thin cundiltoit 
arisGit from eoneputiation of urine, whch product?' irrilntiou of tho 
visca<«, such as is seen in ftim:* of ai-ulc nephritis or renal oongi-Ktion. 
In children this mru>>ntmtion of the urine i^ the moHt ouniinon 
cause of nocturnal urinary iniv)ntineiK-i-. 

Involuntary (icLiMgc of the urine Momctimri- ooctire in idiots, in 
some mM-4 of iniHmity, in Httackit of apoplexy, or any condition of 




sbitormal iiiiL-oii«i-ioiiKiu-»«, and KoinctinR-s in very Hcveiv inftK-tiuiis 
dis(!iL»i¥, MUch, for f.\niuplu, as diplithcri:i. Oft<.-uliin«!S it reeulu in 
children from irrltatioD of the (orwkiD or vagina, or from rectal 
irrilntioii prodiici'd by i>(?at-wi>rms, since all these causes dislurhtJie 
reflex airtivity of lli<? spinal centres. 

Interference with the passage of nrine may also arise from two 
nanses which are xui^'ical in character, iiaruely, stone in the blailder 
and tumors of the bhidder, which are oftt^n situated near its neck 
and so produce obstruction. Finally, tliat most oonimonly met with 
catiae of difficult micturition, enlargement of the prostate, is tv be 

Aside from tliese causes of iiiterferonoe with tlie passage of iiriito, 
we mtijtt not forget the |>ossihitity of ita oK'ttruclion by stricture of 
till' urethra, nor should the physician ignore the ttu-.i thnt sotno 
pcifDii.t havo " nervous bladders," which will not n-?<|K>nd to an 
effort of the will if any persiHi is uenr by, although the uriiiit ia 
inftbuitly jnuwcd as soon as thp )iaticiit is alone. 

The Oo.sorTioN op tiik UmsE it!«'lf u determined, first, by it» 
gttncml apjteamnce, quantity, odor, xpi'citic gravity; wcoiid, by its 
microscopical ii|jpi-aninr'i'; and, tliinl, by it* ch*'mical rmctioiw and 
responses to tests. Any (rliaiigcs in this duid of an ahnortnal char- 
acter are solely symptomatic, and ]ioint with more or less distiocl- 
ness to disorders of bmlily mctidiolisni, disease or disorder of the 
kidneys, ureters, bladder, or urethra, and sometimes of Uie prostate, 
tetlieli*, vagina, or uterns. 

The urine which is to be tested should always l)e passed direetly 
into the vessel in which it Ls brought to the physician, and this bottle 
itliiiiihl be M^rupiilously clean; or, if the urine is j>assed into any 
otiier vcMwl, care muxt be taken that it is perfectly clean. Mlieo 
it ifl thought thai urethral disease may obNcnn^ the iuvmtigation ■ 
catheter aluiuld be jmsstnl, all urine in the bladder drawn off, and 
then the calhi^ter allovred to remain in place, so thnt the urine will 
tritrklc directly fnim the ureters to the mihdiT, and no to a receiv- 
ing; vcf-sel, Tliia i» very inipitrtaut when the urine i» void*^! in%'oI- 
nntarily. If the condition of thi- hlnthk-r is bad, this viacns should 
be washed out by boric-ai-iii irijrctiiiim, in onler tn prevent it front 
contaminating the urine wliii.'li i^^ Ui he tcrfted. 

The quantity of urinr passed by a healthy adult varies' from two to 
four pints in the twenty-four hours, according to the amount of liquid 
ingested, tJie freedom of perspiration, and the amount of excreisc. 




Th« Mifriiitictintw of any ^rv»\ niid ■'OiiftAiit Ii)ci-cu>h< in tUv nmutiiit 
i>r iiriiif )iiMscd ill it f^vcii <m»v ik ititilli[ik>. Tlui^, wu tind it ^nntly 
immiiiMMl ill miy dtMnuM^ of tin* tliubctic cciitri-, ur of tiie Itvvr, ur 
puiim>aH, w'liich rcitulls indiiibetminvllitus; iii dinbclcs insipidus, in 
mmc oifiCD of iioiinwtlK'iiiii, and in somf cases of hystcrin. It XB 
tXto incnnsod in nmiiy rcTL'bi-nl lesiurts. 11 y[>cr trophy of tlio limrt, 
parlicntartif if oMwialetl with chronic conlraelrd kidney, causes an 
incraue in ilip nrino; ami, therefore, if a patient han to urinate 
frequently or has to arise at night to empty tlie bladder, we e<iis[}ect 
this trouble if dialMtc-i la excluded. The same result eitsucs tf the 
heart and kidaey are stimulated to inereased effort by tin? neliim of 
drugs, .inch as digita]i><, i<affein, or ahN>liol. We al^w find an in- 
crease in urinary flccrctioii, without iu jxisiM^-Uiig any j^rave itigniti- 
canco, in cnnvnlciu^entM from iiucli dijiejuic:* tm typhoid fever mid 

The ijimMtity of tlie urin« )>« dtininitdied in uuH'si in wliiiih the 
heart fnil» to do it« pru[)er niiiotint of work, with rcHultinK Ktnsis of 
tlw bloml in the kidneys, and whenever any Iiir(;e amount of liijuid 
is taken away from tlie body, a» in dtarrhnii. It irt al:«o deereaeed 
bjr fevers and by the sweats following febrile movement, i*ei^ 
sistent vomiting also has a similar effect. I'arenchynialous neph- 
ritis, both acute and chronic, greatly diminishes the urine, and in 
grave, fatal il]n&«u>H iirinaiy suppression alt«n takes place. 

The odor of freshly pa!tsed urine is faint, hut rharacterisli«. 
What is often nailed a " urine odor " is really due to the deveIo]>- 
tnent of ammonia In urin<! whieh has dd'omposed. The odor in 
altered) by many dni^ and f<MMl!>, notably by cojiaiha, turpentine, 
eucalyptiiit, valerian, muitk, ii7«irirlidn, and by aitparaguji, and dia- 
betic urine posiWf^es a heavy, sweet wlor. 

The spenlic f;mvily of the urine varies from lOO.'i to 1010 at 
60** Knhr; hut a pi-rsistentiy low sptwific gravity indimtoit ehroiiic 
oontnicted kidney if no dietctie eaiisc can be found, while a porHtst- 
ently hijfh ^[vecilic Ki^vity cither sliows coiie«nt ration of the urine 
a.4 the result of fever, or, if tiio urine is lit;ht in color, the caH>>e is 
prolMbly iluilK'tes luellilus, the high H[>ccific gravity b«^'ing due to 
the sugar which it contains. 

The tiiiked-cye appearance of the urine often f>>ves very important 
information, if its cJearneas, opacity, and color ar? studied. Its 
clearness and color are nimiiRed by the presence of blood or other 
pigiueuta derived from outeide sources, tuieli as the edu<-ts of car- 



bolto acid or nnlicylii- nt/id, of si-iina nr liiHuntoxyloii, mid liilc, iim- 
biUn, and many .-MiliHtaiK^iK mmiug frurii int<id« ^iiruva. Many 
of tliCHO RHUiif« uiuy rt-ndcr it opo'iuc, iiut then '}» one c-oiiditioii, 
ftbovc fill otlioi-it, wliic'h ri-iidcrs tliv iiriiio i-londy vvyn whwi fn>(.lily 
)»i«si-<l, iiumvly, iTvstiti" wiili ])lii)*j>liiitiirin. AftiT iinuo Iin» siotnJ 
for !*ome lunin and iimlc>i-|;oiK- olii-iiik«l (ilmnKW it often Iwconio* 

W'licn nrint- is dark ml in nilor mid «f)mfwtwil "[MHjiie clic dis- 
oolomtion inny Ix- duL> tu blowl, liicintiglubin, xniilunin, rliiitiarl), 
scuna, lu^woud, and tht? prciwaou of ud uxc>cs8 of iirBtc^ Agiun, 
it limy be R-tidLTi-d ulmust bliu-k, instead of ml, bv an vxcO(« of 
biliary ^.-oloring-niHtt^T, utid u blm-k urine is oflvn seen in uimw of 
melanotic caiicur, the color bring due tu mclauin. 

If the color be due to blood or lt(rmcr(urin, the nriiie will l>e of u 
moll! or less bright red, according to the frcahDeiiis of the «um)ik' 
brought to the physician and the seat of tlie hemorrhage. If ihv 
urine hnfi t)ecn voldeil several huurs, it will be of a din^y ret) or 
emoky hue, and on standing will cause a ooffee-ground or reddisli 
sediment of a somewhat Hocculeut appeanuioe. If, on (he other 
band, the urine is seen as soon as pusfled, it may be a brij^ht rwl or 
a dingy nvi, nccording tt> tJie ^'at of tiic lu-ni»rrlmge and tti« time 
whioh hiu* clitp^Hl wiuoo the bloedinp U'^wn; if it biw nri^on in ihe 
kidney or nreler or bladder, unci ha* Iwcn gnidual, the luixturo of 
bloinl and urine u-ill hnvc bi-rn «> intimate (lint <'biu>)^-<« iii the 
bloud will have taken place, when-tts if the hemorrhaj^'e liii< iiceuried, 
simultaneously with urination, from the neck of tlie bladder or the 
urethra, the blood will be almost unchanged when it esca|»»; from 
the urethra. The presence of clot^ in recently [>as.-^d urine in- 
dicates a not very recent fiemorrbBge, and yet one of such siire that 
the urine oonld not by dilution completely prevent clotting. 

Blood from the kidney usually piKwesse!! the following oharacter- 
iatios: it is well mixed witli the urine, and in generally altered in 
appearance to the naked eye and under the niiciiiwcope, both as lo 
color and the shape of the enrpuHclefi. The rails and i-aMn whieh 
may be pr(M<iit are eLniigcrt in color by the liitTuoglobin which Li 
free in tin* iirini\ Again, blood-eoitts or Tv<l lilmid-cnrpHseles eling- 
iiig to ctkst« indicate' renal hemorrhagt^. Wiien the blooti c»m(« 
from the kidney pelvis it may appear in the urine in loiig, worm- 
like clot* (moulds nf the «r«tcr), and their cxtrii«on from the ureter 
prrKliiees ifyniptoiun of colic. Under such oireUHLetimocs there may 



RtttTntitioDit uf lm-[imlurm niid riornial iiriiif.-, iliio to tlic l>l<x-kiii^ 
uf tlio urcU'i* on llie tliMrrwGtl ifidc bv ti oiot, >^<i timt M llio iiriii); 
oDniCM from the- healthy kiiiiit-y. A i^uiUlfti profuse liviiiorrIuif{<! in 
thi> iiritw, «iiflieiL-iitIy litrgv to endunt^or life, uiny ooinu from cystic 
tumor of tho kulnuy. 

Wlieii the hluod <K>mc« from the blndder it is gcm^rally du« to 
some capillary growth or to injury. Karely in n^rtuin caws of 
locomotor :itji\ia, hfcmaturia develops aftor tliL- vesical erLirOj; which 
we hiive already doiterilxH) (see Bladder iu this chapter). Tlie 
origin is capillary hemorrhage from the bladder-walls. 

When the blood eoineis in the lirst part of the urine |ML8sc<I and 
not in the ]a.«t part, it almoet certaiidy (vmos from the urethra. 
The urine, when not discolored by blood, may be discolorcil by the 
presence of liie coloring-matter of the blood. This is called hienio- 
globinuria. Microscopical examination of the urine in such cases 
will i»how no corpuscle.'), altlioiigh the urine will be coagulated by 
the acid tcAt; but thi^ coagulation does not settle iu Hakes as it 
usually doc-^ in albuiuiiimm urine, hut floats on the surface in a 
brownitih mass. Tlii> unked<eye jipjH'arano' of the urine is that of 
clear [kuI wine. If a few drops of urine be placed on a wrateh- 
glas", and n drop of stnmg acetic acid be added, the blood-crystals 
of Teidimauu will Ix' found, sliuwin^ that the coloring- matter is 

[f ilic diKcuIoraiiou of the urine Ik> duo to blood, a microscopinil 
caaminatiou will reveal red hlond-citrpuftclw, white blootl-titrpiiwlw, 
and jK-rhaps fine lihinicntsof clots; but the corpusclea will not be 
foand in nmlcaux, as in oi-diniiry blow! uutMtle the body, and they 
may be crenated and distorted in shape, jKirticiilarly if the uriue is 

The lest which can be moat easily applied to determine the pres- 
ence of blood, if the microscope cannot be used, is Heller's test, 
which consists in adding to a few c.o. of urine u little caustic soda, 
so as to render the liijiiid strongly ulkaliue. The urine is now 
heated to boiling, and if bloinl is present a bottle-green color is pro- 
duced, and the pho^pliates fall to the bottom of the test-tube in fine 
flakes, tinged brownish-red by tlio coloring-matter of the blood. 

The fligiiilicance of hiematuria is various, since any solution of 

itinuity in the bloodveisels of the genito-urinary tract may pm- 
duoc it. Wlien the blood comes from the kidney mme of tfae pos- 
sible eaiBcs are noute jtarencliymatoUH nephritis, resulting from any 




one of tlie soverf iitf^otinti.4 disea.'Wi*, such aa »cai-1et f«ver or mi 
riftl fever; from fiulxiliittn, n.-^iiUiii^ fi-ont ulcerative or other fo 
of eudix'Jkrditis; reiinl iiifHrcti'>n, from ttefMis of tlte kiilney; from 
i\\v \i\ff»X\on i)f irrltitliii)! ilrii);:!, mmll a^ rniillinridi.^ or ttir|>ciitine; 
hihI ftum .'tlruiii^ or lilown on tlic back, prodiK^Iii)^ rupture or otlier 
disori^iii/atioa of the kidney. Alt those ooiiditions produce what 
iitny tie cnlliil m-iitJ' hii'iiuituria. If the cause be acute nephritic 
from the prcHi^uui: uf mi iufei.aiuus malndy, 8ueh as scarlet fever, tlie 
pain ill tlic loins, the prcMcucw of iilbumin in the urine, and die erujv- 
ti()n will runder the diagnosis ea«_v. 

liioiiiiituriu due to muhirial poisoning may iipptiir with the flntt 
loahiriiii piiroxyKtn, of thi' iiitennittcnt type, which the pmtjent liiig 
ever had, and at a time when tlie history of the caae rendon it wr- 
Ifiin tliiit II hidden miilarial ounditiun tvnid uut hiive previoui^Iy 
damiLgod the rvnal tifisueii »r thoac uF other organs in thu budy. la 
olJior words, there are ca^es in which a free hemorrhage from th« 
kidney takes place, by rciLsoa of the chill, lu much the same mauuer 
iu which hemorrhage takes place in acute nephritis due to exposure 
to cold or to irritants. Under these cireumstances there may or 
may not be developetl a true organic lesion of the kidney lu the 
sense of permanent disease. 

Secondly, we have eaKCS in wbieh bloody urine apjwarif, not iu 
the Hrst malarinl paroxysm of the int'-nnitteiit type, but in assiK'in- 
tiiiri with the kter attacks, which may Imve followi-d the first eitJier 
rapidly or slowly. In thesK.- c-iues there may be no further cause 
for the hemorrhage than exuiwjtive eonseislion, but in all ppolwhility 
the vast miijority of such jiatients prosent distinct renal elmnges, 
u'hii'h permit such » syni|itoni to develop when the pitroxysio^ 
assirrts itself. 

Thinlly, we pass from those cases of bloody urine due t*" inter- 
mittent forms b) those due to remitteat attacks, which, iu many 
coses, have jj^radtially mergctl from the first into the n'mittuiit In 
these patients the prodeiss by which a bloody-oolored urtuu is rievel- 1 
oped may he very complicated, since it may hv. due to renal incou-' 
tinence, functioual or organic, or to a true hieinoglobinuria, arisiug 
from dissolution of the red blnod-oclU in the bloodvessels or blood-^ 
making organs. 

Fioatly, tliere is a type of malarial hiematiiria whioli tA only pro- 
duced by the admini^tr.ition of i|uinini* (Kiinunitsiis ff at.). 

All theae forms of hitmatnria can be diugnoscd by tlie preneoce 



of tfic mttlnriiil f^rru in thu IjIo<k] (sou BIuckI) and tlio chanu-ten^tic 
niiilitrial symptoms, oxcvpt tlmt nhicti occurs in persons who have 
a dyscnwiu from old ninlurml jmifiouing. 

If lh« liHimaturin be due to embolic infarction of tlie kidney, an 
exuminiition of the heart will probaldy reveal si^us of x-alvular dig- 
ease, from which source the embolism will have resulted, or, iu 
other (Mses, the phywcal li^is, combined with the hietorj', will 
show maliKtiant eudocurditis with renal seji^-ifi therefrom. Some- 
times thrombosis of a renal vein occurs in feeble, wasted iiifailts, 
and so lAuses hiematuria. If heart-dieease is not present, the bla- 
tory of the in^e^tion of an irritating drug will be the diagnostic 
guide, or, if injimea be the cauM?, a history of traumatism Is all 
that is needed to elucidate the case. 

The causes of chronic or persistent hemorrhage from the kidney 
are dirunic hemorrhagic nephritih. cancer of tlie kidney, calculus in 
the pelvis of the kidney producing nlceration, injury of the kidney 
by jarring of a stone, tubercnloAis of the kidneys, and cystic degen- 

If the ohronio hiematuria arifie. from chronic heniorrhagit- neph- 
ritis, Um diagno^.s 19 made iiy Uie jmllor of tlie skin, anorexia, 
nauMU, h<nuliiobo, (H)ema, dvcrviutrd amount of urine, and albumin- 

If tliv cauw bi- rcuiil eanrwr, the cAehoxia, jxiin, and the mixture 
of pUK, blood, and iliMni-tninin-d rt-nid tJiMiiR in tlie urine will n>nder 
the diikgiiosi!^ p(>,<v(ibli-. If due to calculus, there miiy Ih' n pnrvioUH 
history of iittucks of runal ooliu or uf violent jmin in tlic kidney; 
urn) if nlcMnilion of the ri-niil pclvi< haK occurred, tliert? will be di— 
turlxinvcs of the boily-lcnipeniturc, |Kiin in the lumbar area, and 
piM in tlie urine. The prusenm of tubercle tjocilli in tlie tirine 
decides tlie presence of n-nai luben;uIo»it. If i-yttie degeneration 
t« present, it ran only be determined if the cy»t in hirge cnou^i 10 
be felt. 

There art; other viirieticK of hH-iuaturia which must not be for- 
gotten, allliough comparatively rare, namely, that due to tlie ])res- 
Mioe in the blood of the filaria sungtiinii!> liominia, which \t a 
ouuditiun in which the presence of chyle in tJte ninne so inuMkft tluit 
of the blood that the urine hai^ the apiK-arance of pinkiith ercani or 
tnilk, but mieroscnpieal e.xaniinutiou will iiliow blmMl-oorpnscle)) and 
fat-glohules, as well ae the embryos of the filario. (See Chylnria 
in this ctuipter.) Another still more rare cnuMi of hicmiitnriii is the 


(listniim hwnmtobiiini of Egypt and Abyssinia, (Fi)r. 16(i.) These 
prodiiue what h>i» hecn Lvllecl tropical hiemuturia. The thini caune 
is cveu luoro niro in nmii, namely, the AtrotigrliiH ^gaa, which alwl 
caiMCil pyclitiH und miml I'niic. A fonrih form nf hwniatiiria i^ tliat 
nwn ill «>me tnscs of *curvy, |utrticidarty of tht? infantile tyi)e, and, 
loMtly, hiftnuturiii may a\*o np(X-nr at a symptom uf piirpiim hemor- 
rhagic, hi'inopliilia, and very mrely in Icuku-niia. 

fm. m. 

DIMoma biGiiiftioliliioi, nialcand han&lc Tbe iwa mnUl liodlnarcihe*n<. 

Hi'rmoi/MihiHria wiaen fit>it\ a ninnberof <tau.sei<, Michafl infectiotu 
diiM.'a.-^^, poiiwiiing hy mtuhriHimii and oertaiii lyial-Iar deriMittvcSy 
dilomti? of |K>ta.7U'itim, niid glyeerln. Malarial poinniiiii); nometiniM 
VA11W.-S it instead of hienmluria. One form of malarial hwinoglo- 
biniiriu ijt intermit tcnf, the iinnc In-inj; at one hour limpid, the next 
hour bloody, and the third hour ck'ar apiin. 

The poHsIbility of confusing; the hiciiio^lobiniiriii of tdioiiyticrusy 
about to be ritraerlbed, when lu u aevtre form, with true and severe 
malarial poisoning, is very great. The entire history of paroxyamal 
hsemojjlobinuria teems witli reports of caecA in which the chief maiii- 
fetitationa of a malarial attack were present, such as chillti, fever, 
and sweata, Tvicbtheim and Ponfick hax'e showu that the iiijeHion 
of lamb'A blood into the vessels of man resulta in violent shivering, 
fever, aweat^, and pain in the lumbar region over llie kidneys. 

I'hi.t condition aim follows severe burns and tlie traniifn«ion of 
blood, and oecnrs in paroxysmal htemoglobiniiria, a condititui which 
8een» to lie produced by mere uhilling of tlie aurfaoe of the bo<)y or 
hy immersing the hands of a ftuiwreptible person in loed water. It 
miiy alHii be produced either by t-xpo^ure to the cold and thimp, 
which are generally prei^nt in malarial loenlitJos, or to tlie chill of 
the milder form.4of malarial iKiroxynra. It may aim l>e u symptom 
of Knynaiid'it diw^a^e. 

If till.' urine be red from other canM« than blood, this may be due 
to ^ iogostion of logwood. The lii!<Iory of the ing<«tiou of tliis 
BUbstanoe will clear up the diagiio^». If it l)c due to eeuna, it will 



bc'cnrminc, daf to tlic chrvsophuu in tlui^tlrii^^lmt tliifitUiicoluratioii 
only upprant if tht^ uHiig is alkiiliui?. Precisely similnr olmrifi^rs nrc 
due to the taking of rliubarb. So in santonin-po!>>oning a blood-red 
urio« is sometimes seen, but it usually attains this iip)>eni-uiice after 
being at first yellow, then aaffpon, and then piirple-red. (^ne of tlie 
<M>ndit!on» of the urine, due to a {toison, which <sin ho rendily con- 
fused with hemoglobinuria or hfemntiiria, is that produced by car- 
Imlic ai'id. Thi* imlor is not due to blood, but to oTiidixed educts 
of the acid. The same edncls pnHluco a similar discoloration after 
naphllialin, creosote, and uva ursi have been taken in overdose. 

Kill urine, due In none of the enasos which have been ennmer- 
Kted, may Ix: owing to an excess of nrat*^ (cxc<-iit urate of sodium, 
which is usually white). If the urine bcoometi brown on the addi- 
tion of nitric iicid wlien^ the fltiiiU join, it ik due to unites; hut if 
all tilt' tliiiil is brown, the patient 1ms proliably been Inking iodine 
or iodine (!<ini pound" freely. 

Finally, the urine i« often diirk reddi»h-browu or porter^iolored 
in jaundice, owing to the presence in it of biliary oluring-miittcrM. 
Under Uicmc cireiiin«luiiccK it may be clear or upu(|Ue, anil the flui<l 
is apt to be frothy on sliuking and tu Imve un incronsed surface- 
tension, so that powdered sulphur does uot sink to the bottom of 
the vessel when the sulphur is dropped on the nrine. These biliary 
colors are at onee reco^iized by the reaction with nitric acid in 
Gmelin's test, for if a little of the urine be placed on a white plate 
and nitric acid lie allowed to tou<^h the margin of the wet place, a 
play of eolow from green to blue, blue tn violet, and violet to red 
oopiirs. The green color is the only one eharaott-ristio of the biliary 
reaction, for indJcnn gives with nitric acid the other colors. T)ie 
aanie te>t ean be uitoil by wetting hihnlous [tO|)er with urine, and 
the aeid, if hntuglit to the edge, will stain the |Ki]>er in tUe colors 
named. (Kor llic sympUtms of jauudii^', nix tlie chapter on tlte 

.\ greenlsliH-ohinil urine in seen in cAiiWttof poisoning by siilicylh' 
aetd, due to the imiican and pyrocnte^'hin; nn<l from the iiso of 
aaffron. 11ie nrine is yvlluw in santonin-poisoning , and when 
riinlMrh has boi'n taken, if it is alknline. 

When through diM'iise-jm>c«ss«M indienn is formed and excreted 
in the nrine, it nuiy he by oxidation tmiisfornietl into a blue <-oIor 
(indigolin), or into a red hue (imiinibin). If ehmmugen is present 
in hirge nniouni, shaking the nrine with air will develop a violet- 



liliK- (Htlt>r, or tliiM rhnnctt iiiny tnlce \Aacc in the Madder. If iinrie 
eontnining indioiiD lie tivtttvil willi iwu or tliree titncs iW voiuiiie of 
hydnwiilorir iwiA, il will turn a violet line, 

Inilifmniiria is |iri'^-nt in iiiU-Hitiiil nbstriiolion, j^iicral jwrlt 
itititf, i;liuluni, uuikxt uf tl^r liver or »turii(i«h, mi<t [wrnii-ioiH imic-niiti. ' 
It iniiy, liowuvor, be pn'wiiit in licaltli Hif n n.>9ult of noiiHtijntioa. 
Blue iirinu ih iiIik) fniiMtl liy iIk' ii)g;OHtion of mctliyl-viulct w it ilnig. 

\ hluok uHdo is NoiiiL-tliiici^ tixn in a vmw of mi-lniiutio cnitixT, or 
after tin* hroniiisli iiritie produced bv vurboliti acid or uvu tirsi liai* 
beet) i'X|x)6ctl to tile air. 

White or milkv-looklng urine is seen in that ooiulition e»II«1 
cliyUiriii, due to the |)re»c>noe of the filana §aii|;ninti; IiomiuiK in llic 
blood. This urine on standing forms a creamy layer on ite siir- 
fiaoe^and, if it is shaken with ether, some of the fat can be removed, 
rendering the urine elear. The diagnosis can unly be oonfuiied by 
urine becoming niiscl with railk nr cream, ami can always be made 
if the embryos of the lilaria can be found in the urine. They lie 
in verv delicate flheaths, and show a constant vibratorv movement. 
The diagnosis is still further confirmed if they are found in tlie 
blood, where ihey an? present in lai^ numbers at night. (See 
diuplui- (111 tiie BIotKl.) 

Urine may have a Homewhat milky-white ap|>cumnce from an 
exGotM of [>hoi<pIiatcH, mixed with more or It«« miieii^ u» in catarrh 
of the bladder. 

When the nnne is jxiHted in large tiuuntitieM, and ii* of a very 
pale straw color or ha« a slightly greenish tinge, it will often con- 
tain sugar; or, in other words, be the urine of diul}et(« mullitus, ui 
of glycosuria from utlier eaufres. The fact that it n'lnutns mark-i 
edly acid for a long time after it is passed, aiitl that it lins a liigli 
specific gravity, point still more to it« being diabetic, and the dil 
Dosia is confirmetl if tbe <;h3raeteristic reaction witli lIaine6's,Wbit 
ney's, or Feliling's solution is obtained. (See Tests in this chapter.) 

Mi<;i{(i«coric Ai'PKAKA.\(;t>i of thk Uki.nk and rre CoNTKyr^ 
Having considered tlie macrosoopical appeai'ance of the urine, we 
may turn to its micmsimpical appe-arance, and this part of the sub- 
ject is of even greater inij>ortance than the study of the grosa 
ap|)CHrane(: of thi:^ liccretion, for, very ex>mmonly, a sample of urine 
whicli liK>k^ (piiltt nonimt to tin- naked eye is loaded with mierc^ 
people objects of the greatest )>atiiologienl signiBeance. Tlie nunt 
im]wrtanl of tJiese ohjwtn are wluit are called "'casts " — that U, 



nioiiUIti of tUe iii'iniC«n>us tiibulen, formal a» a reAiitl of the <)iH<aai>- 
jn-ooef*^ pie^iit in itie kidney. Tlievip tn^'tn noDslst of «]iil)i«lial 
celU, IiIdchI- ami piiii-rDrjxiwle.n, iiiiii«<ci) nf u)ioi-»-i>rgaiiiMiis, or of 
bmkco-dowii or^nio matur, as iii fatty uists, 11114] iti liynline or 
traii.t|)an?iit liiHlieK, or iiioiilil^ which art- mmlo up of unknown niati^ 
rial, but often ooveretl hy oorpii!M-kv«, ]Hin-(^oi'[iiiscle», or cjiillK-lial 
cells. In midition to th«w bodivs we ti»<l n Inr^- ntinibcr of 
orgtnic hiHlic?! or Jorivntivivt of orgKnir niatt«r, and inorgimio sub* 
fltancci' iWivxHl from Uk* tiiwini-it or fnini food. 

llic rwi(I(?r who dwir** to cxAniin*; nrino nuwwjwfnlly by iho aid 
of the fuicrowx>|if must biwr in mind that it luin only he cxnminod 
Miti»fnctorily nfti^r it ha- »fxn\ "till in 11 glawt or other vv^fsvi for a 
loDg enough tinii.- to iillow iMHlinitnilutJon to tiike pluct; — that i«, 
until the- objects floating in thii lliiid hnvc had time to settle. 

Kio, li!7. 


adUa Itar unne-lub». 

By far the best methiKl of obtniniug tlie sediment, however, is 
by th« use of the centrifuge, an apjmralua liy means of which the 
•uilidi^ in a fluid are se|«raled by (centrifugal fonw. In this appa- 
ratus n sediment ean be obtnint^d in a few minutes after urine ia 
juuMed. (See i''ig. 1<»7 and chapter on Riood.) 

This sediment is to be drawn up into a pijwtte which hai* been 
iutnidiiced into tlie urine and a few dn){)s placed upon a glass slide, 
after which tJie dro|is are to be covered by n oover^glastt and the 
slide placed under the niirmseope. 

C'a.->tH comjwsed of epithelial celU present an appearance similar 
to ttuit seen in Fig. Km, and are due to prolifi-ration or exfoliation 
the epithelium lining tlu' nrintfi'rraiii tnbulrs. The cells look 
^ffwollvn and granulitr and tnny contain globulM of fnt. Thew 


epIUiclial oiste occur in tLrei' fonui): (irMi, tlioy tttay a|)|>ear at« 
hollow cask of i\w ruhiiU- wlu'ii ilxt fjHtlK-liimi lirn^ <.-xf<i1i«t«U or 
laamf. (that i.«, the lining of Uiu tube t8 <-n»t ofT in onv [lieoc); nca^ml, 
tliev aj>i>car as oast.* math' up of rpitlu'liiil ii-Ils glin-fl to one another; 
ant), tliinl, dm wWa itrc attnc-hml tu thi' Miirfaci- of ii olt'ur, tmnHjwruat 
ba^s, tonkiu); like a lij'nliiiv <nst. All these vaiietivH nrv liiglily 
refractive of light nnd uru nut alti'rol bv i.-homi<-al snlwuincvs iw 
cosily Aa arc the other ututH iiboiit to l)u (li»cri bvil. 

QutaconaiiiliiRaidlbBllilMllK, irsTRaJ 

Ilaviii]; found bodiei* of thi« »ort in tli« urinnry Mwlituent, whit 
16 their itit^nilicnnofi ? They arc n posili^-e »ifrii of an iiitliiniinatuiy 
process in tht' iiunint'Iiynitt of the hidncy, or, in other wontti, of 
parenehyniatoue nephritic. 

BIootl-casiB cunHiet of mor« or k-ss wtfll-proserved blootW-orpuwlee, 
attuphetl to one another in u mould of the tiibo in wttich they have 
nwagted. They are nirtly seen and are tnaslcud by freely llontiu); 
eellfl. The signiticancc of these blood-casts is great, as they indi- 
cate an acute iiiUnmmation of the kidney, neiite con^«tion of this 
organ, or a renal infaretion. They are of importance, too, in sepu- 
rntiug hietniituria nrJiiuig from other sources tliau the kiduoy from 
hcrnorrha^' of this oi^n, bema»e they arc not found unless tl» 
«Mupe of blood has been into the uriniferoue tuhuleH. 


Casts nom|HMed of pus-corinifwles are rrtill more rarely seen, liiit, 
if constantly presenl, may indicate niuHipte ab^eefu of the kidjieys. 

When Ria.«*e8 of inicnuiocoi Ijeoome grouped toother in die tubules 
tliey may be exj)elled in castA, and under a low {wwer look ftoine- 
what like grouiilnr i-anl^ (.hw tiolow). They «in l>e seen to ooiisist 
of mionxvKu-i if a liiglier ]H)wi-r j^ used, and they are not (juiekly 
(')tiiii}ri.-d by noid^ an arc ca-ttti eoiii|vii>cd of other tuaterial.4. 

Tlio nigiiilimnce of ilieir dlicovery \x tluil .toptic infeetion of the 
kidney iii present, tw the rwult, it iiwy l»e, of scpUe emholns brought 
fW>m n di»timt infeeted part. Tbi.?}* arc noon in suppurative renal 
hiflunmatiiitt and in easut of pyelonephritiK in which the true ix'iial 
tiMUCean: being involved by an u\teusiuii uf tlie discaae. 

PtU. iw. 

a B. K|>l(b«U»t ouu. b b. 0)iBi)U( imiuUr t»Mt. fram k mm oT uui* Brlfbl'i <1Imm». 


Outs, oompi>wd of hnilten-dowD ot^nie matter, are foDiid as 
gnmilar and fatly bodies; that is, they repreAent broken-down 
blood-eorpuiielefi and epithelial cells, and their apjiearanee \'aries 
gfi'ally a«;ordinj5 to the Htage of the proee.-ts and tJie origin of the 
materials uoniiwning tlieni. Thua, the granular appearani« may be 
very fine, as shown in Fig. MiM, or ligiit and refractive, dark or 
rijiiujuo. V«ry often the vf\^'v> of iheM' easts an- irregular and the 
eud« fniye<l and uneven. The eolor of these bodiejt may be yellow, 
bmwn, or grayish. 

The Mgiiillcwnue of graniitnr cnst^ is not as itositive as tltoso ttanHHl 


so i«t, but they often indicate a slow de^Derstive process in the 
renal pareachTma. 

Fatty casts, composed of minute globolee of oil, cohering to one 
another or attached to a central core of epitheliam or fat-cryatals, 
are found in cases of widespread fatty d^eneratioa, as the resalt of 
disease or poisoning, as in the case of large white kidney, on the 
one hand, or phosphoroa, arsenical, aniimonial, or iodoform-poiaon- 
ing, on the other. They show the presence of a very slow process 
if due to disease, but have not the same significaoce if caused by 
poison. (PUte XIII., Fig. 1.) 

Hyaline casts are long, worm-like, transparent bodies, with very 
fine granulation, particularly along the edges, and because they are 
transparent they are often hard to find. These bodies are supposed 
to be composed of albnmin which has been exuded into the tubules. 
Their significance is exceedingly grave, as they point very strongly 
to that incurable malady, chronic interstitial nephritis. If these 
casts are very large, they may show amyloid degeneration of the 
kidney. They have often been wrongly called "waxy" casts. 
(PUte XTTT., Fig. 1.) 

Fie. ITO. 

CyllQdrolds (torn albumlnnw niiae. a;b, ind c RIbbon-Uke farms, rf. CUt-Uks fbnD, 
wltbcelliupon ■urftice. t. PlUmemoua foniu in Bclnmp. 


Cnst.s are not to lie confused with cylindroids or streamers. These 
cylindniids appear in .several forms. Most commonly they look 


FiG. I 

Fia 7. 

Cuts, mty, Vuiy, II)«lliic nnil Cntnular, 

Cry<AalB of I'rir AcU, 

KIG. 3. 

FIG. 4, 

AmiiiaiilMn Cnlc CryirinU. 

K|.ilhclMt t'eai. 

A. MUaUHHH pi>lllMH»nl, II, liladdpi niKlid- 
lijNii C. kMiifr*^>>rtl<»; U.kldiivyFplllHlllinl 


like threads or filameats wliich are transparent and often somewhat 
striated or hyaline in appearance. They are often long enough to 
extend completely across the microscopic field, and if followed out 
to the end will be found to taper off or gradually become more and 
more transparent until they cannot be outlined. For this reason 
tix) much light should not be used in searching for them, nor should 
too high a power lens be used. These cylindroids often are grouped 
in bunches. In other instant-es we find cylindroids in the form of 

Fig. 172. 



^\ .^-:/ ■■' 



Non-ftlbiimlnoiu urine. >ion-H)bumlniiiia urine. 

Cul-llke fonn«, irllh depiiallorunitefl. n miil A. Cmi-llke Ibmu. e. FllsmBDUiua. 

Fiu. i;». 

"^'v.r;:-"---^ -■■"■■■"' 

FtUmenloiu «iul rtlihon-lilie cyllurlroliln. 

riblHins, or, in otlier words, they art; wider than the thread-like 
masses just de»cril>Gd. In still other instances the reseniblam^s to 
tnie tube-oast» are so niiLrlced that n differentiation is scarcely pos- 
Miblc, except that they are sometimes found to have a filiform tait- 
like ending. (See Figs. 170, 171, 172,aiid 173.) The significance 
of cylindroids is not definitely known, but tliny may bo taken as 



tin indicntiun of irritation of tbc ki<]]Ieyt^ even if nlbumin :iik1 trn« 
ciistfi cannot be foiiDcI in tin.- urine. They nro often set-n in tJif 
renal irritation following or, rather, nccomiianyiog the couililioni^ 
cullet] lithwmia or uricremia, ami in that condition in which wc liad 
uxaUirin. (For further information mnceming cylindroids, set- 
Stengel's paper in The Mfdical A'nr* of July 15, 1893.) 

According to Itramwell, the following i» th« beat method of 
staining and mounting tiibe-caflta and other urinary de|io^tH. He 
naes pieiXK-araiinf : 

" 1. An ordinary conii^al iirliio glsiu^ is tilled with mjiial jiarts of 
urine and an a'jiiooiiH solution of hori<: acid, and set a.tide until the 
deposit !*i»ttles. 

" 2, Tiie deposit is tti«ii drawn off hy mennn of ii ]ii|H>1t«, and 
tnuisferre<l In an ordinary tis«t-uiIio, in whiHi a !-innll i|imntity (half 
a draehm ix i]uitv sutliuiuat) uf picroearminc Holutinn luis bwn pru- 
viou.'tly placed. 

" 3. TIio urine and fttiiiriinK-*'""'* i*"^' tl""' thoroii(rhly mixed hy 
inverting; the tovt-tube two or tliix'c tinie«, thu und being diwed, uf 
douriic, by the thumb. 

" 4. The t»!Mt-tiibL' eoutuiaing the urine and etaining-fluid ix then 
Bet nflido to stand for twenty -four hours, 

" 5. The deposit, which lias by that time settled at the bottom 
of the tcHt-tube, is then drawn off by a fine-mouthed pijtette, placed 
on n slide, covered, and examined under a low power. 

" If any tiibe-caatt) are preneut, they are very eaiiily detected by 
this method. 

" Wlieu a cast is detet-ted, it should be carefully bmught to the 
ventre of the Held and i^icamim-d with a higher power. If amyloid 
degeneration is suspected, methyl-violet may be used, for in s<.>mc 
oases of waxy disease of the kidney the lube-ciastf ^ve tlie ohamotvr- 
Lstic rose-pink reaction with mtthyl-violet. For permanent |>re|«- 
nittnn llie deposit is drawn off im in No. 6, above, and tmii8(«rrcd 
to a small tube of Farmnt's medium,' in which it n.-nuiinH until 
the organic deposit ha» settled, when it ik again drawn off and 
transferred to elcar Farranl's solution, whence it is mounte<l in thL< 
iiMiuil manner. All organic deposits arc tlius stained and mounted 

■ n>nut-i lolulloii U niBtlc u fallmn : dliwilTo 1 (no. of kimiloiu acid in V» r.c «r lUi. 
tUlcd wklcr. tnUilidlnalvB IMttiiK oTtumiiauit wlUi fn<|uiMil KInlni. ■■■■lidit IVox. 
e( glfotrln. Filter lti» wludon Ibioogb tUa ewliali jiirvi upon vbloh hu btuii deixMinl a 

a: h. 



ta K perfectly Hear iiiik1>uiii. Tlieir minute cliHraotem <!»n be hUkIU!c1 
witli tl)« bigUeM ]>ow(rrH of tlio micniiioo|>e. " 

Th« most iiiipurtitnt •♦(••iiiin'iitnry suhstaiHt* for diagn<wlic piir- 
jMjsPK, otiivr Until cjwt", 111* Uu' prixjiicto of tis»ii<!-chnii]^, or am 
tlfrivwl from urtick'S of find. TIkwl- siib(*lJiii<!i-» »rv <'liioHy th« 
uvid iirutn of tfudkiin line] [Mttnt^'iiitn iiud iilkiilinu iimif of lunnio- 
uiuiii and potiisHiiim^ urio ucid, oxiilutv nf linK% thf* pho^ipbuU.-, vur- 
l>otiutc mill tiiilpltiiu- of liino, and thi.' so-nttU^ triple plioephiito 
(ummoniu-mH(;n(;fiic phutfphutc). 

Tli« discovery in a urinary Mxliiuont of tine i«lin|)cb-«s grauulee, 
wbich may be crytibkllinc and »bii|x-d like » fun, ubich itrc gviiumlly 
brown or. pinkish in biic, indioittc^ noid wHliiim iinitv. Urine con- 
taining sucb d«.>pO(iit« is found to become avtd on titiniding, and will 
form a bnck-dusl deposit ns ooon as it is cooled. Acid potassium 
iiRite and add L-aleiiim urate, whicb occur in itn amorphous form, 
are mixed witb it in wnallpr quantities. 

The uratM tliem.telves have no particular importance except tliat 
they are often present in esoesa iu fever, Vi'sBting diseases, gastric 
diaonlent, and iu attacks of gout. 

When in a highly acid urine the student finds rhombic or dianumd- 
8ltnp<yl ])Iiitvs(Platv XI M., Fig. 2), or plaU^oF a similar Mhiijx- with 
the liit^'itil aiigint rounded off, or ipindratv crystals or ^innri' pinion, 
or plntvA likedoiibk'-lu-ftdHl arrows, or rosettes of crystaUi, or bnodleM 
of crvi'ltdT' lik<^ l>undl(» of kindling-wood, the^e fornm are uric acid. 
Any urine will <Ii-|Ki»it such eryituiU if it huiuU for mnuy hours (siy 
ten hount), su it« acidity increases, and tiiorufore the discovtuy of 
tbeee cryetuln only jioiwcwtoit ^Ignilimnce if ihey are found in from 
four to BIX hours, as this shows an cxecM of uriu ucid, which in turn 
is found in gouty, rheumatic pcrsc^us or those who uit to excess ai>d 
lake no exercise. Often an cxee»s of uric acid !n the urine aut«- 
dutes tile development of ciirontu contraet«-d kidney. L'ric acid 
also apiiears to excess in cases sulToring from fever and acute in- 
flammations. It is also eliminated iu excess in leukaemia, sjilenic 
enlargemeni, hepatic cirrhosis, and gastro-intestinal catarrh. The 
rosette crystals just named arc often found in diabetic uriue. 

!^raall sqnaiv, brilliant octahedral crj'stals which are perfectly 
transparent and refract light strongly, looking somewhat like the 
back of a Mjtiare enveloijc at times, are those of oxalate of lime. (See 
Fig. 171.) The siguilicanoe of oxaluria is ()uite important, for it 
if) often n eoneomitant nvmptom of melancholia, depending u]>on 



defective metabolism. The finding of oxaluria separates this class 
of cases from those of the true disease melancholia, and indicates 
the use of nitrohydrochloric acid. These crystals are, however, 
found in the urine of persons who have eaten pears, cabbage, or 
tomatoes, and in that of persons suffering from spermntorrht^a. 
If not due to the ingestion of the foods named, oxaluria indicates 
deficient oxidation of nitri^nous tissues. 

Fio. 174. 

Oxalate of lime crystals, 

Creatiu in the uriue occurs iu very brilliant prisms of a rhomboid 
form, the end of which is often split into a fruyod end. (See Fig. 
175, «.) It is not present in normal nrine. 

Orcatinin also exists in normal urine iu small amounts in pris- 
matic, colorless, brilliant crystals of the shape shown in Fig. 175, h. 

When (liirk-browii spherical masses covered with thorn-like <'rys- 
tals or sharp spicules are formed in alkaline urine they are composed 
of ammonium urate (Plate XHI,, Fig. 3), and they will be found 
assf>ciated with crystals which are flat or shaped like coffin-lids, or 
more rarely arc fe;itbery, st;ir-filiapcd masses which are large in size. 
These are the crystals of the triple phosphate. (See Fig. 176.) In 
addition, such urine will contain amorphous calcic phosphate. 

The crystals of tiie trij>le piiosjihato are of some diagnostic im- 
portance, as they do not exist in the mirnial urine, but are formed 
when ammonia is set free by the decomposition of the urea. If 
.•iuch crystals are fouuil in freshly passed urine, they indicate that 



ammoniacal fermentation is taking place in the bladder, a (<on<]i< 
tioD often i^eeu in <?[ininic cvcttitiii anil in .some coAes of paraplE^a 
arising frou injury- tii the cord or myelitis. A dejMiflit of lli« 

CnVlalt Ol GIMlln N1»I OIBOlllllTI (Ckiku*.) 

0. Crjttiitor ereailD. b. OiriuJior ctMilnUi. e. C^ulicif ehlorlitsnrilnoiini) crwtlnlu. 

triplt^ pluj^phatc and aniorphoua calcium phosphate, luakiof; a 
tMLtlimont like thitt of piiriilcmt iirinc, \» MttuftinK^ M«n in persoun 

no. ITS. 

Tilple plMMplMtt«rraUb 

wifTvring from over-wurk of tlie iier\'0U8 sn'atem and in aisi>s of 
griivral dclitlity. 


In acMkiou to these aaiorphoii^ and cn'stallme bodies found in 
the urine there are a numlwr of others derived from the l)ody, or 
due to extraneoiiH contamination. Theac ai-c e|)ithelia1 cells derived 
from the kidney.-i, ureters, bladder, or urethra (Plate XIII., Fig. 4). 
Ejy^s nr bodies of several jiarasitctt, tubercle bacilli, )^ococci and 
Atreplocoeci, or Htiiphy1oc(X'<>i arc alsn t^oroetimea seen under (he 
microst»)pe. In addition, M'e lind itpermntuzna in cenain oaHCA. 
(See Fig. !7!t.) 

Tliiii), we may lind llie embryos of filarin, echinococcufl hoi^lets 
(Fig. 177), and tlie «gg» of ditttunm luematobinm, wliHi are very 
rarely seen. 

FtO. IT7. 

EchUlaDoMiu. with two houlili'ti. and wclton ol o'MIc nambnna. crmUir numUM- 

Tubercle bncilli aro to be found by the same elaining-proeescies 
aii when they art) sought for in the sputum (see chapter on Cough 
and Expoctonition), and, if fouud in the urine, indicate renal or 
vesical tid>erculous infection, provided that the patient has not 
coniaminaled the vc^el holding the urine by sputum infectdl uilh 
the organism. They are not to be confuaed with the liacJIIi found 
in preputial smegma, which look like tuherele hadll) and take thi^ 
same stains. 

Gonooocci indicate the presence of a ^pecilio urethritis or vngi» 
uitjs, an<l arc fciun<l by Htnining i»nd iixitig « ^j humogi'itcoii^ ininicr* 
won lens with u No. 2 ey^pivct*. The prucew uf sinitiing i» by thi* 



Pn. 17*. 

DBS of eiisin nat) im-tliyk-m^blui', TIm^ mnUrial on the cover-glaes 
is statiied for it ft-w !uix>rj(lH in an atcoliolii^ noltittDii of eoRii), Uten 
tb« extxiss of 0taiii is w»«1k-<1 ulT, nii<l tlie Hiide 
IB placed fur U-ii minulc« in an n<)iiuoui« solution 
of mothj'l«np-bUii'. StjvptopotTi nppivir in cimini* 
and ape stuiiiL-d liv tliv «mi<; phxi-w, Tlicy 
show infection from pue iiml iin- found in com* 
of erysipelas. (See Fij;. 178.) Stiij>!iyloi'(»oi'i 
&\»o indicate pii§-fortontion in tlii.' uriiiiirv tiiiot. 
The presence of spiTriiulonO!! i» more rare 
tlian is geoenilly ttiouf^lit. Tlioy niny Iw in the 
urine either as the rcnult of » inw (fiKTmator- 
rhon, which is rare, or from some of the tsemcn remaining in the 
nn'thra aft<>r an ejiiculatioo in coitus, or from ail emiasioii at night 
without inlercourao. Thoy appear as small, transparent bodiea 
having a head and lait, and, if alive, i>a<§sess very active move- 
ments. (Fig. 17».) 


8|>«m>lo«iM. wkb cwUot ••rolMkI t<t<jalMaiul<i|»niilueorr>UI*. 

Fermentation n>ulting from the presence of a numl)cr of H|weiat 
fungi taki-H pluco in both hi-allhy and diseased urinex after they are 
paiMxI. [n normal urine the auidity, whioh la (fenenilly present to 
n Kli|;ht de^n-e, iK-come^ still more acid through the growth of a 
Rpecittl fungus. This process is aerompaoied by the ckpoiu'tioii of 
llrio aekl, acid soilium umte, and calcium oxalate, and also amor- 



phoiiit urnb^ti. AfU;r tlio iirliie ii< expowd atiW lon^r it iiixlergoes 
au alkaline ft^nneutatioii, uml tlkure devdoji in i\w tlniil tin- micro- 
«oocii8 tirew and Iwcturiuin urcm. A« a rrsiilt the urea ta.\te» u|> 
water ami c]ecoinpi)^.s witli tlie dcvcloijini'iit of CO, and iiniinonia. 
Ni> i^ooncr !:* n positive nlkalinc n.-action v»uil»ll^hod tluin tiii>»e in* 
grwiicnbt t)i tlic nrine wliicli are ia)«oInbl« iu an alkalim! wtlutiou 
are proctjniattrd. nnini.-ly, iimorplioiti* mk-ic pluiHjitntb-, ammonium 
urate, ami umnioiiio-ma^iiOifio plio^pliutv. Tlic Jir^t in uti)urpliuu», 
but tli« umnimitutu unttv it|>pi.nn> uuiier tlic Diicru^(:u[>e in thv form 
of tiinall i^rauuk-K of u diirk oolor wliidi arc (xivcntl witli MpiiivA. 
Thu (rryntals uf ammonio-mujirneiiio pliuHphatu aru ^luipi-d like n 
coffiu-lid, and arc larfi^. 

Tlif third form of fermentation takini; pluoe in the urine ix that 
which occurs in diahotto urine, and is due to the snooliurumrcvK 
albicaiiri, the micro-organism which proditecs fennentatiou in ordi- 
narr soUittonH of glucose. 

Chemical Tests. The cliemicul te«ls of the urine give us much 
imporUiiit ill for ma I ion. We oommonly test it for albumin and for 
sugar, and, if we wish still further information, we examine it for 
its pert^entage of urea, uric acid, and for its )K>pton«H, or, to use a 
bettor term, its alhunioiicit. 

Al.nLTMt.'JtiRiA. Thei'e are a great number of t«tit^ for albumin 
and nugar. Many <if tlx-ni ure i}\n:n to fullai'ics, and tliey are there- 
furt- to bu avoiiliKl by t\n- busy piiirtitiiiui'r, who can rc^Mt a.'«:^ure<) 
that if he finds no albumin by llio beat and nitrii>a«id te*l, if pri>p- 
crly ciirri«l out, that he ran piil albumiiniria out of the piissibilities 
of the eiuw provided he U-j'U «iiiiipb-K tjikcn iit <lifrcreHt time* and 
on Several different dny*, fur nometimrj* albnniinuriii i» intermitti'Ut. 

The be»t t«»t eont^i^ts in takin;; filtererl urine and pouring enougli 
of it into a perfectly clear lc«l-tube to lill it about tw(^-third». To 
this arc now ail<Ied a few drupH of uectio aeid to render it acitl; for, 
if neutnil, the iilbuniin will not be (Nui^^uliiteil by heat. The upjtcr 
|)»rt of this uriue ih now buiknl by holdiu); tt over an alcohol tamp, 
niid if albumin ie present a Rne cloud will appear in the boilii) [uirl 
of tile urine, while tlie lower part remains clear. This clotid may 
be due to albumin or to earthy pboHphatcs, Tf a drop or two of nitric 
acid ia allowed to trickle down the side of the tube, the cloud Is 
diftaipated if due to phosphates, but not changed if due to albumin. 

If the urine be turbid before the test by reason of au exoeaa of 
uivte*, the fluid can be reudered clear by gently healing all of it. 



Heller's tǤt of adding a few dropti of urine to HNO, in a twt- 
tube is too fallacious to be used, although coniinonly employt-d. 

The (|iiaiitilative teats for alhumin are many of them impnurtical 
for the busy doctor. The best method is by means of percentage- 
tubes plaeed in a centrifugp-maehinp. By this means all the allHi- 
min is thrown down. The tubes are tilled to the 10 l-.c. mark with 
urine and 2} co. of potassium ferrocyanide solution (one pnrt to 
ten) are added. Next we add 1. J e.c. acetic acid and thoroughly 
mix all these liquifh), and the lube bdiig placed in the centrifuge 
the mai.ihin« is worke^l till all the albiiniiii has settled. Ea^h -^ 
n.c. mark on the tube represents 1 per eent. by bulk of albumin; 
that is, if thi* albumin extends up to thL- :}( etibic eeiittmetn' mark 
Ute albumin amounts to -t-'> per cent. 

Thi^ niiinilicsiiKv of albuniiii is not as grave in nil cowiti t» it was 
coa;tid<!n-<) at one iIuk-, nor m its ([uautily uf great import ummuw- 
rily, for in some of the gravcat cjuck of nmal diseiuw, ha chronic 
iTcimnuTtvd kidney, it is cxcrct«^l in very itniull iimount, and it occurs 
in tliv urine i^omctiiuca in Urge (|Uantitie« without iiny kidney Wion 
Ix-ing present. A» « nilir, however, it indiniti^v n-md diMeaite in one 
uf iut inflarumutory forms, provided it is a^^ueinted with other renul 
HvmptomD. It inay depend on changes in the blood in which the 
diffiifiibility uf ite albumin is incrctisetl (Semmola), and we sec albu- 
miDuria in cases of anicmia and in convalescence from prolnicteil itl- 
iM*& or from the cITcvts of [loisons. Again, circulatory changes may 
cause albuminuria by causing congesliou of the kidney, as in cases 
of ^liug heart from its various causes. Thet^ is an intermittent, 
little UDdenituod form of albuminuria, called cyclic albuminuria, 
or the albuminuria of adolescence, in which the albumin is absent 
on rising from bed in the morning, but appears if exercise is 
taken. An excess of albumin in the diet may cause albuminuria, 
which is not necessarily indicative of renal dbease, 

SuoAB !>■ TiiK UKi.\t~ The presence of sugar is determined 
by a large Dumber of <]ualitativc and quantitative tests, of which 
the iliroplest and most reliable are Haines's test and the test of 
Whitney. Ilaines's test eoiLsists in making a solution as follows: 
pure cop|>er sulphate, thirty grains; distilled water, half an oune«; 
thoroughly di^B^>lve tlte copper salt in tlie water; add pure gly< 
eerin, on(^'half iin nunc<:% which is to be thoroughly mixe<]; and tlten 
add liquor |Kitai««i, five ounces. One drachm of this is to i>e plac*.**! 
in a fest-lubv and grntly boiled, oimI to this an- nddol mx to 


eight drniM of the urine, ami the liquid a^in gently boiled. If 
tnigar la. present, a copious yellow precipibile i^ formec). Thiii h 
better than Fehliug'n test, Iwoaujie it ii* a jiernianeut fluid. 

WhitJiey'H t«8t i» a solution of nmnionio-cuprie salphatc, of wlii<-h 
one drnohm m d<>coloriK<Hl by j'^g grain of glucose. The .solution to 
the nmoiint of one draclmi i^ )>bi«ed in a tc:*t^tnbe and ht-iit<-d to llie 
hoiliti^jioint. Tho urine 'la nuw addnt drop )>y drop. If do sufrnr 
ii« prtvtcnt, no (-tiiiti^i- will iH^rur; but if it is, tlie bhti; <?ulor will 
bL'jrin U< fiide, and linally tlit- liquid will btreonic perfectly tviIorlcM. 
A.* tlie fading pro(^e.t<i^ l>pginp tliv itrino .should be n<ldeil tnure »]owly, 
tlircc to live tu>coi)iU of boiling intervening betwittti eiieb droji. If 
there i* any *lmde of blue or griKm left in the Milution, rwluetion 
hiM not tnkcti plae<^ Tlie following titblc dhow« how this toft m»y ] 
be umkI for tlic i]uantjtniivu egtimiition of sugar: J 

1/ rfilueiii iv ir onilnf ni ((I M( Maw ftramAii)*. 

1 cinip ........ ID or DMiic anlnfti Ml 

IdiofB . . e IM I 

1 "... . . . . &.m Ul I 

1 -' 4 ft« 

h - UO MT 

6 " £07 0.H 

7 ■• US 0L4S 

• •■ a Cl*I 

« " i.n an I 

10 ■■ IjW iui *■ 

If the urine eontuiiiM more than U.33 per c«Dt. of xugar, it is h> 
be diluted by from oue (u t«n part« of water, and the amount found 
in tlie tiible multiplied by the amount of diliitioa.^ Usually dia- 
betic urine eutiUiiiA nut less tlian half of I per cent, and rarely 
more tlijin 1 per cent. 

As Fchliug's test i» so widely useil it must he meniioited. 
Wickham Ixigge thus dc^eribca it: 

This solution may be prejmred in the following way: 666J graitw 
of ctystaUiised pottis«io-tartmte of sodium are dissolved in five fliiid- 
ounees of a solution of caustic potash, Bp. gr, 1. 120. Into this ulku- 
line solution is poured a lliiid pre[Mired by dissolving I.13J gniiiw 
of eulphate of ooppor in ten fluidmclims of water. The solution i» 
exceedingly apt to decompose, iin*! raufit always be kept in smi*- 
pered bottles and in a cool place. It is usually, tlien^fore, more 
convenient not to mis the alkali and copper until the goliitloD i« 

< Thin toil, under ihs wuao oT Jmtm Sappbliliu, c&n bt tuul «t tb* I>«itl* CliMiiiHkl Ok, oC 
Htw York. 



ited for use, lii tliw fate a flnidi'ai-hni i>f the sulphate of copper 
iutltitiou may be added to lialf a Hiiid'Oiince of the alkaline solution 
prepared a» above. 

AlHKit a I'mip!*" of dniflims of thi« tiist-stoliition are poured into an 
onltiiary t<4l-tiibe, and the fluid boihd over a tamp and set aside 
for twelve hoiira. If no di'po^il foniLs, the Holiitioii may lie ii^mhI 
fur aiialyHix; Inil if a n-d precipitate b<r thniwii down, the liquid ban 
(ltT(>n)piK«c<l, and a frcsli supply mur.t !»• bud. 

While thi> i4oltitiii[i in lioiitiig ii) the tcutt-tulie the uriu« tnaaC be 
a(ld«d to it drop by drop, and llii* cPfi'i-t wntoia-d. A few drops of 
u jwniplcof iirint- which oontains u large pi;iwiitag« of supir will at 
onni- f^w a prmpittttu of yellow or rwl ^iilioxtdc of cwpper; but if 
no pn.-cipitjit« ucc'ur, thv uriiK* i^bonld be added to the fluid drop by 
drop, any de[>08it beinj; iwrefully I<H>keil for, until a ipiaiitity I'lpial 
to that of the Fchlinj^'s solution rmployiii bcun ailded. If no 
pr«i?ipitate be found aft^-r setting the tc«t-tube lutide for an Itour, thv 
urine may be considered free from sujjnr. 

C^ution^: 1. The tP«t-6olution Hlioiild never bi^ used nHthout boil- 
ing beforeliand for a few seconds, the tartrate being exceedingly apt 
to decompose, and the solution then reduces copper as efifectually as 
would ^rajMssugar. 

'1, The (piantitynf urine ui«ed in the t«st nliould never be g^reater 
tlian tltc ipiantity of te^l-^^olutioii employed. 

'A. Aftvr a<lding urine In volume eijuat lo the Fehling*? nolution, 
till- boiling of the inlxtuK^ not be mntinued, u.« oilier biM)ic« 
pn»ent in ihu urine, Ite8id«tt :«ugar, will nnliiw copper at a high 

If the uxamiiiution for «»gnr is to Iw rnnile with th<' grtiit4i4 can;, 
the urine should .-iIwuvh be tillered, at leiu^t tliret; timtw, through 
animal charet^nil. Tbim remove!' id! uniUw and uric add, which 
often jiartly reduce thv Fvlitiiig'H solution, but the sugar goes 
tlirongh the filtur. 

■Sir William Rnlierts illni-ts that the Fehling'* <«oIution l>e placed 
in a test-tube to the depth of about ouc-<p)urler inch ami the filtered 
urinfi addml to the depth of two inelics, and the two fluids well 
mixed. The flame of the lamgi i» then applied t4> the upper ]iart 
of tbe urine, as in tcNtiiig for albumin, and this Is briskly boile<l 
for a Few kcoihU. The lest-tut)e iit now held up to the light, and, 
if sugar is present, the upper part ha« a yelloM'ii^U ting<?, while th« 
eart]iy phiwpbates are (hmwii down in gulden-eolonxl floceuli. 


The (luanlitatiiv cDfimation of aigar is bt'et made bv the Wlilliioy 
UmX, atreatty deftL-ribpt], or by the fprmcntatton-mfthod of KulM.-rt8, 
which depemU upnn the principle tfiat grape-sugar ia dcootuposed 
into alcohol, carbou dioside, etc., bv the fertnentatioD set up by 
yeast. As a result of this the urine htscw its specific gravity, and 
each degree of 8|XKnlio gravity has been found to equal one grain 
of sugar iu the flnidounee. In other wortis, if the §]>ecific gravity 
1>efore the te^t was 1.035 and after tliti test l.Oio, the amount of 
ftugar present would l>e twenty grains per ounce. Four ounces of 
urine are placed in a twelve-ounce bottle and :i lump of (iemtan 
veBiit added. The hotttc is then nnrked with a perforated oork to 
]>erniit tW gns to tv^mpc, and plaM>d in a warm place for twenty- 
four houfii. Ky it;i sid<- is plmxid a lightly vorkiKl Iwttle of the 
tiame siir.f, hohling four ouniw^ of urine and no ycjutt. Thv s|>eeiflc 
gravity of both MjimmL-n* is taken ifimidtAiivounly, and the difference 
in dogrc<M represents tlic number of grains of sugar in each on»w. 
The loss in degrtH'i* of s;>ocifio gruvity muttiplictl by 0.23 will give 
the pcrewntngc of sugnr. 

The itiynijivancr of sugar iu the uriue is various. If it w persistent 
and aceoinpanicd by w iiNtiug, {Ktlydipsta, unil |Kilyphiigia, it is a sign 
of dialietcs mellitus, due to a lesion in the medulla, to morbid func- 
tional activity of the liver, or to changes in the jNUicreas. If dia- 
betes mellitus occurs in a young |)erson, the prognosis as to life is 
nearly always fatal; if in middle age, it b hopeful; if in peisous 
after fifty, it is quite favorable. 

Sugar is sometimes found in small amounts in the urine of very 
obette [Mtrsons, and its presence under tlie^ cirounistances does not 
necessarily indicate a grave prognosis ; but, on the other hand, there 
are oases of so-called diabetogenous ol>esily in whioh the prognosis 
is very grave. Tlicy are to be sejiarated from tlie class first named 
hy tile fuot tliat tlie systeuiio symptoms of wasting, depraved nutri- 
tion, itching, funuiculosis, and profuse diiinwis arc present. Then, 
too, in the latter form, the diseaae is uwunlly «9»oeiate<I witli obesity 
in early life, whcrciw in the inihlcr form it oc^cnrs in Uic oboiity of 
ndvanecd life. Diabetes occurring in old age, or after sixty years 
of age, has not the grave prognosis iittnehHl to it that exist« iu con- 
ncctiou with the disuiMi in earlier life. The younger the {Mtient 
tlie graver the mahidy. (See also end of this chapter.) 

The other iiidicjilions of glycosuria are of Htllc imiK>rtnnw, Oly- 
cwuriu occurs in the coiuvc of ordinary eon\'ale«M!ucc, nuiny uifev- 



tious cliecastrt), [Hirticularly in ty|)liDu1 fover, Dteasli.>s, K-arlet tvver, 
diphtlieria, iortuenzH, and malarial disease, ho<1 after cerebral an- 
eurism and nervous injiirios, and after the ingestion <>f Bome poisouH, 
notably phloridzin, chlomi, arsenic, alcohol, and curare. It also 
sometimes occurs us a result of the ingestion of large amounts of 
sugar and starchy foods in persons who are inixtmpetont to digest 
and assimilati^ carbohydrate fiKwls in excess. Unless the glycosuria 
is associated with the other symptoms of diabetes mellitns, it is not 
a positive sign of the disease, for glycaiuria is a symptom of a num- 
ber of stab'A other than diitt>Ke.-> inellitu^, as jui^t pointed nut. 

Ai.Bt;MOKK i.v THK I'rink. AllMinioAe^, or pqitonet, in tlic urine 
may be t&iled for and their presence rt'cufinixcd by saturating 
altg^itly ncidiKed urine with ammoninm sulphate, liltmng out all 
precipitaU;, and adding to the flltrntr very ^ntly it little lohition 
of picrio acid, !*even grains to the ounce of wuwr. Any prwripiuite 
i« pfptom<. 

A Ill-tier niethoil than tliis, Imwover, is that described by Hiirri*, 
in whioh dik jxirt of albnmusc lu .!i'iO() parts of urine can lie r»^n>jf- 
nlxed. Before ttn- tent is made vivery truce of ooagulablc albuminoid 
mutter miHl Ik- removed from the urino to bo tested. Thi« is done, 
to use Harris's woixls, as follows: 

To 20 ccm. of (acid) urine' in a test-tube are added six or eight 
drops of a satumte«l solution of sal icy l-siil phonic acid in distilled 
water, and 1 grm. of chloride of lead, ^hake well and boil about 
thirty seconds. Cool by shaking in running wat«r from tlie oold- 
water tap. 

Kilter through ordinary clean, white Hlter-pajter until the urine 
is clear. \ow add a few drop^ of a elcar, i>n(iintted ^tolucion of 
eoditim itnlpliale in dinUlled water, in order to precipitate wliul lend 
i« held in .-tobuion; raise to the boiling-]>oiul, and cool under the 
cold-wutur tup ns Ix'fore. 

Filter iL^in until elmr. We should now have a perfectly oIc«r 
uritw, aliMitulely free from every tnnv of conguhible albuminoida, 
Iniilnding nuchNk-nlbumin, in which we nuiy mnreh for albnmose or 
p«ptoiiv. This cleJir liltnite is divided into three eipisl (lortions and 
phiced in te«t-tiibeM, one of which it Itqit for comparison, the other 
two for further mwIvaIk. 

■ 1k( Milu niM> In riMli. ir II iniwt niaml aaniml boun imtan H cm M n«inlind. n 
ihoVtdtoprtMmdfioatUieBtDvtiiaf bMMtAlii ubrib* 4diUUcia ot lomc untiHt'O'. pn- 

MtUr* Ikwdrnpor rora«lln, vlilcbwlllkM|»U wranldayKaDa ilixii noi Inwrftfv wtUi 


To WW of these arc iioir added thren or four dropn of a Ratu- 
mtLtl wliitioii of suliiyl-ifiilphu-tiing^tiitv "f Hixliiiiii in diMilled 

If tibumosc or pcjitoiMi bo prvseiit, » I'limdinvs^ will apiwar, vnrr- 
iag >D (legruo act'unJiii;; to tfio miioimt of tlii-^* |>riiti-i<lN |irc»ent. 
As the »moiint of iilhuniOMo prc^oiit is often very minute, it nisy 
be iK'<M.'ssiirv to compare tlit- tiilx- witli the oontn>l-liilic in onlcr to 
detect the cloud ineee. The cloudiuces disappt-'iin^ cntirvly on gviitlj" 
heating the test-tube, to reappear on cooling. 

In the third tube tlie test is xncial by sllowinj; about o of 
a dilute liuluiioii of the salicyl-aiilpho-tungrfate of Bodium (miulc by 
adding about ten drojw of the strong solution to 5 com. of distilled 
water) to flow gently down tlie side of the tube, so as to rest on tJie 
uriue as a separate layer. 

This -ihonld bo veiy carefully done so the line of contact will 
be sliarp and clear-out, not diffiiite. A cloudy line appeam at 
tlie jjoint of contact of tlie tvro ti(|tiidi4 if alhumose or peptone lie 

When the amount prcstcnt is very »mnl! it may take two or tJiree 
Diinute« for tlie lino tn develop, and idiows bc^t, th« two liquids 
beiofT oluur, when held in front of a dnrk backjjrouud. 

As boforo 8tate<i, this test is extremely delicate, 1 port in 5000 
being nndily detected; it Is simple, and can be easily applied in 
fifteen to twenty minutes. 

Owing to the delicacy of the reactions it is necessary that all test- 
tubes l)e absolutely clean and the testrsolutions perfectly clear, utbvr- 
wise a slight reaction may be easily overlooked. 

The sodium sulphate solution must be mided In slight excess in 
order lo insure the precipitation of all load, as any lead left in solu- 
tion would be precipitated by the salioyl-siilpho-tiingstate of sodium, 
and tlius interfere witli the test. This would be easily recognized, 
as the cloudiness in that case would not disappear on heating, but 
would become more marked. 

The boiling during the application of the t«st, while not abso- 
lutely necessary, very materially facilitates tlie reaoUons, and should 

■ Bftllc^l-dilpba-tiDKiilaW oT uillum l> praiuml u follom : 

To ■ boUliif wlunlvil Kilulloii nt Iimgtlal* or mlluiD In •IliUUvd mWc MU«rl-«il|>lMal« 
MIdlifiadiiBUjr iildad, nii'lcr i?r>n>iuni Bilmnf. uniLI thg aolutloo no lancer raniartd IUmus 
btoe; ot.ia ottivr wonli. unill lUv itikalino luafiuie or Milliiiii U oampUMty nouinUMd. 
U;onooolInKib«MllO]'l4iil|'ii»*iiiii(i>iaU'iir h^IIiiri cryiulllML AMluUon In now oiftd« of 
Ihli Id oQid. dUUlled micr aiKl ditcnd. A pvrt«cU)r elttt. Mioriwi fluid rtiulla. 



alwnvfi l»p ilone. The ■■oolitif;, iiftwr lioiliii^ nnti bc-fon; filtering, 
must iK!%*«r bi; uiiiUuhI. 

If th«sc few ttiiuplc [loinU he oirL-fiilly uWrvi-d, do diffiitiltive 
will be ex |KTioii(vil in (i|i|)lyiii)r the lw.t. 

The mi/nijioanix of nlbumu«uriu is various. It is present in 
croiipniu piKsiiiDoiiiit, nil suppurative processos, empyetoa, tubercu- 
lo«is, sinnllpox, mtiiiipf>. en'sipL-lus, e^ioccr of the viscera, jatiiulice, 
aiid a]>opiexy, uuti in typhoid fever and jihoephorus-poisoQititr. 
Von Jalueh assorCe thitt it is present lu epidemic cerebro-epina) 
iueiiin(;i(is and absent in tnbereular meninpds, and that it is a posi- 
tive differential siirii of the former disease if no ulceration of the 
lung is present, Harris, on the other baud, asaerts that albuuio- 
suria is simply a manifestation of the action of mioro-oi^ntsmti, and 
is thus only an indieation of an iufwitive jironesa. 

It ought not to l>e forgotten tliat albiimaiuria oooiiis lu tlie nor- 
mal pncr)>erinm. 

Thk IJitK\ IN Till: ITiti.NK. Th<> nmoiiot nf nrra U to b« ««tt- 
matt^l by tiie process of Lyon*, us follow* (Fig. ISO);' 

Pl«. IS). 


Abottlfl is provide-"! with pt-rfonitwl rubber o^rk un<] ilclivcry 
tube; iu this the decompo«itiun of the urea i» cITectcd, 

S. A small (est-tubo to vontuin the urine, gntduated to bold 
4 C.C., the (jiuintily cmp]ov<.fl in eairh i-x|M-riiuent. 

3. A graduated jar for mcusiiriuK the gas evolvod. The jar is 
provided at the bottom with au " overflow" tube, and at the top 
witli a vent-tube closed with a rubber eaip, to secure accurate adjust- 
ment of the level of the fluid in the jar at tbe commeucemeni of the 

> Tt<li»n<w*M*.<'l*lilW.liUr«clloa*rat UMaKtibv«t>tolo«drMiinrlie,IXirtiAOoai|aD)>, 
II. Mlob..Aren«dallu-, 


Tlir [>n>cc«M U US fullowB; put into tiw iHiuttrG bottle 30 c.c of 
a ^[K'l-iul suliitiuii of clitorinftted soda (for furmuln sew In-low), and 
luld 5 c.c. of a 20 per ovnt. sttUition of potaesiiiDi brumulL'; Gil 
tin* twt-tiibe pxaptly to the tuiirk (4 cc) witli the urine to be vxnm- 
iiied, aod lower it into the bottle by tncaiiM of u thread or by the 
lud (^ a pair of dressing-foroepe, taking care that none of ita con- 
tents is epilled in the operation. Fill the graduated jar with 
water, which must be of the same temperature as the air of tbu 
room, to a point a little above the 0° of the scale, supimrting the 
extremity of the overflow-tube so that no water can escape. Re- 
move the rubber cap from the vent^tube and connect the apparatus, 
pressing in the rubber eotlcs firmly so as to make the joints air- 
tight. Finally, put on the rubl>er cap, drawing it down so ati to 
foroe a little water out of the overflow tube, and bring tlie level of 
the water remaining cxaetly to the 0° mark, tlieorificti of tiie over- 
flow-tnbe being on the same I«vel. A little praHioe will make 
thiA easy. 

To make sure tliat th« ix>iiiii»tion8 are all {tcrfoetly air-tjglit, 
lower tli« end of the overilow tube a few inclica; a few dropet of 
wnt*r will tw-iiin' frum dimini^'hcil proMiire; but if the jointtt arc 
perfect there will be no further dropping. If there iB any lonkaj^*, 
the defective joint muat be found and the difficulty correctc^l before 
proceeding further with the exi»erimeiit. Ilavin); made aure ttuit 
the connections are perfect, catch the curved end of the overflow- 
tube over the edge of a measuring graduate, as shown iu the illus- 
tration (an ortlinary bottle or any other receiver may be used in 
place of the graduate). Now, by canting the bottle, cause the urine 
to flow out of tlie tcsit-tnbe and mix with tlie testrsoliitiou. Effer- 
vescent* 19 at once produced, and the gas evolved for«s a oorre- 
spnndiiig volume of water out of the overflow-lube. Shake the 
bottle iHK'tiAioually to promote the eseafie of the gas. When the 
action appears to be at an end ]>our into tlie meaau ring-graduate 
enough water to ronch above tlie nix-ning of the overflow-tube, in 
onler that cooling of the gas evolvini, which at liiyt l-* qnit*" warm, 
may not draw air into tlic apporatu#. Let the apjKkmtuH -itnnd 
fifteen or twenty iniuutc« to cool, then shake tin- Imttle contaiuing 
the urine once more and profw-d to n-ad off the result. To do this, 
it is necessary' to bring the opening at the end of thu overflow-tube 
jtist to the same level as tliat of the fliii<l remaining in the gmdnnted 
cylinder, since raising or lowering iIil- tube sUghtly offectd the 


volnnif <if the k»» to be meaBHrvil, The i>ercentap' of urea i« «'ii(l 
off without need of any culcuUitiou from Uie acsile of ilie in^truincoL 
The accoDipanvin^ table will enalile the physician to iK-i'i-iniii from 
the percentage-amoiint of urpa in the ajM'oimeii i-xnmimil what 1^ 
the absolute amount of that onmpouixl i-xc-ret^-d clurint; Uiu day, 
provide*!, of eoiirHe, the whole of the urine jui^st-il ilurin^ tin? twrnly- 
four hnnn haa been collected together nnd curofulh' niotiMurcd. 

I^r rvnl of (Jtiitnut]- ft li^t (vnc ol QuanUlT of 

art* b]r area la rnlni urmbj unaliipiUna 

nroxniUt. in 1 niildciuiiro, iitMniaWr. In 1 BuMouTim. 

O.I 0.4U> K«M 

0.J . . , . 0.(111 SO . . li,lH 

u» , I 11 . . , ft.vw 

0.1 . ijxa XI . . ... 

0.b . 2.1)l> 23 U.U1 

0.6 . I.T« I H . , . . . lO-OT 

0.1 . . . S.IW IS. . . . . iijn 

0.9 . . . X.SU 1« . .... ILMt 

O-V . . . LlOl )^1 . .... USOt 

1.0 . . . . un I IK ..... . lino 

i.i . . . . »ai9 to U.tL« 

1.: . . . t.*u J t.0 . . . . . u.<)i 

14 . kau I 1,1 .... - U.W 

1.4 . . CIM ' t3 . . M.»U 

1.K . CtW '(.£,. . IDlOU 

L« . J.a>l 1.4 IMM 

I.T . :.T« gj 1M» 

U. . ... C2PS 

Eui(n«.--Ttl* rotluit hu pmilM noldouncw of urint. ttiuml to coDlalnXI perWDl. of 
onk, Tbe Mai orw oicretvl nil) thotefort be laosl IfMm iba nblo) >; 34 — 3n.4SS cmtm. 

Kor oxiirl ii^tiinutioi)» the tcmjiemtiirp of ihc room in which th« 
cxiM'rinirnt iit nmdc mui^t be about 70" F. (21* ('.), A variiilion 
from tliitf toinj>erature of 20° will, however, mnke a difference in 
the result of only about 0.2 |wr i-ent., ho that the temperature 
correction may be regarded as unim]H)rtant. 

In the prooesH given for the manufacture of the te»t-solution the 
hypochlorite is changed into hyiiobromite. 

Thia mixture gives more iinifonn and trustworthy resnltA than 
those obtained with the chlnrinate^l soda alone, which is recom- 
uendt^ by Dr. Si|uibh. It i» in fat-t idenlioni in iitt action with 
the hy])obromit« solution, without tin^ grvul inoonvenicnov of liand- 
ling bromine. A few niinuti^ niitst >m' allowctl to eliipw after the 
mixture is math* before mixing the nritiv with it; luit thio ncc<l occa- 
sion no delay, sinoe tJie mixture vaa U^ put into tin' bottle iK'foro 
filling the i-ylindi-r nnd making; the connections. 

TIh' uftivity of the solution of chlorinatetl mdn ran l>o ennily te«iu-d 
by tutding to ft little of it in a test-tube a few dru]» of tlie BolutiMi 


of pollBttiiim britiiiiil*-, iim) tlivn n littlu lunrinlc of iiminotiitioi, wlik-)i 
should anise \>rU\(. ofl'orvi'.*<H^'iiw. If this in not tli« vase, it is f>u 
munh cleloriiimtiHl tor »«>. 

In siinic niR- iriMtitiK>c« il will liuppi>n tliiit ttie iiriue tnutuiiif » 
Ifti^T [)rui>ortion uf urm than the iireoinet«r is capable of indi- 
CAtiiig. Whvii UiiH is the CAse, aiiit io general when tJie speoiG<: 
pnivitv of the urine cxcccila 1,030, siigar being absent, it will be 
biat to dilute the urine witJi an equal volume of water before making 
tli« tmU Four c.c. of the diluted urine will then be used m imual 
in tliL" fX]iL'riment, but the percentage given by the reading of tbe 
inttniment mtiat be multiplied bj two. 

ft will be found in prantiee that au eittiniation of urea by this 
apgianitiis consumes very little time, and the results for all prac- 
ticul purposes are as accurate as t^oukl be wished for. 

Forviufa /or Special So/atlon of Gihiimitrrl Sothi. SImke chlo- 
rinated lime (beiit <]uality) 12 gnuiimei^ with wat«r 100 e.o.; let 
S4!ttle and liller into n 250 c.c bottle. Wiish the* ru^idue with 
enough water to ulitain MtO cc. of clear IJllrutL*. 

Diasolve nodium eiirbonnle 2-1 jrrammefl in water 45 e.v. A(M 
this aolulion (i) Ur' above lii(rat<;, mix tlioroiiglily, luid, when roi»<- 
tion is oonipli'U>, filter, parsing, if necessan-, cuougb water tbrmigh 
re«iduo ou filter to obtain 165 c.a of filtrate. 

The idiniuil value of estimating the urea is great in eitsor^ of rcruil 
di»eiii^>, and it is alsn of viilue in diabetes mcllitus and duriug preg- 
nancy or in the puerperium and before surgical operations. The 
qunntity of urea excreted in twenty-four hours is increased in mtirly 
all fevers and influnimationa, and is decreased in any cachectic state 
in which tlie metabolic changes in the tissues are impaired. U i^ 
also decreased in diseases wliieh greatly modify the activity of the 
liver, the gland which maki-s nrea. The particular value of esti- 
mating the an'a in Ilri^ht'.-< di»«ea.'«e and in pregnancy lies in this, 
namely, that the renal dl^irder in tliese ooudili(>iL'> results in an iu- 
perfcet eliminatiiin of nrea, and ii.« a result it, or elonety allte<) pni- 
ducta, an: retained in tlie blcioi). If, therefore, in a pi^-gitant woman 
or n pentou i^uffering frimi Bright'^ diseai^e, aimlvMs flhowit a con- 
stant diminution in the amount of cxereted urea, tlie phy^idan is 
wanietl that a iinemic eouvulsion or other manife^taUon of urwiuio 
disorder is imminent, and cnii take netivo rae««iirei4 to relieve titc 
IHttienl, for, after the urn.-miH iB di*veIo]icd, treatment i» of ooni|Nira- 
tively little value. 



Altlioiij^li llic i|imiitily t>f »rw> vHriw vi-rv fjrwitly in perfect 
lifiiltli, till' iiiitiii uniounc vxcrutvil in twcQty-four Itount by u healthy 
tiiBn (rf twenty to forty yean is about 512 proine. Women excrete 
u littlf \vf« than iiicii, ami children still 1^^ in actiiul quantity, but 
more in pnjportioii to their weight, 

It i« nl»»t>hitfly nt-cossary in estitnatlng the amount of urea ex- 
crvtt-cl it) twenty-four hours to test a mmple of the urine obtainMl 
from all the quantity paH^ed in that time, as a test of tlie urine 
pa^tsetl on one occasion h no guide for the total daily ({unutity. 

Cuix>BIDf>i IN TiiK TJriSB. The urint- in health ('oiilain* chlo- 
rides of sodium and potassium, and these are lo Im! discovered hy 
placing a tluidrachm of urine in a tcst-tuhe and then iiddiiig n drop 
of oitric acid, and finally a few clrop«» of a solution of nitnite of 
silver. If chlorides are present in considerable <)uaiitily, u white 
precipitate of ehloride of silver is thrown down, which can *iwily 
be dUtingui shell from alhumin; but if )K>nic ikuibt in felt lu to ittt 
charuiter, the addition of a iittlt; cauiitic amnioiiiiiui will niliiurolve 
it if comiKWod of chloride!^ and it will bt- rcpn-oipitnU'd if 
nitric Add i» again added. If the same qunnlitto of urine and 
reagents arc taken daily ami pinocti in a test-tube of fc|nnl <]imen- 
Monsaud the precipitate allowed to settle for twenty-four hours, 
we can gain an approximate estimate of the relative quantity of the 
chlorides. The amount ordinarily pnsaed in twenty-four Iiottrs hy 
a healthy man is 250 grains. 

The clinicnl Mgnificancc of a decrease in tlie chlorides is not 
great. They are dccroasetl in tlie acute stages of erou]wus pneu- 
monia, acute articular rheumatism, ami some other fevere; and if 
tliey gradually increase, they indicate the development of convaUit- 

TiiK Total Qiiastitv op Sfn.iDB escretMl hy the kidneys in 
twenty-four hours can Im? roughly estimated by what is km>uii m 
Haines's niodilication of Ilaeser's method. If the solids are mufh 
deerea.sed, more aii'iirate methods of testing shonM hi- n-surtwl to. 
The method just refi-rnxl to is mrri(rt| out as follows i the last two 
figures of the speeiRe gravity of the urini! arc multiplied by the 
number of ouncm voided in twenty-fotir hours, and the product n 
multiplied by one and om^f^nth. Thus, if a patient passes 32 
ounces, and the si>ecillc gravity of tlie urine is 1.012, we multiply 
32 by 1!2, which opmls .'ffl, and thiH is multiplied by 1,1, which 
«|uaU -122, which wouhl he uiiieh \ir» limn the tuirmal for n ]>cr»on 


iif, ftnv, 150 ))nUD<!)s who should paas about llfiO grains of mlids in 
twvtily-fdiir lioiim. 

Khrlicli has olaimt-d that a diHtiiii't aid to the diagnotiis of euteric 
fi'vcr «m he ohtaitKKl by the flo-callod diai«>- react ion of the wrine, 
ulthiHigh it i^ to \>a remembered that thi^ lakes place iu sevcnil 
other ooiidilioiH of the body, notably pulmonary tuberculotiis, 
nira*l<M, pyicniia, wvrlet fever, and erysijieian. It Li usually present 
only in »cvvrc ca.'uui of those ailments. Further than this, EhrlicJi 
(buHM-t« that liic rcftclion h usually to bo ohtalne<l about tlie fourth 
to seventh d«y of thu disea*'. A fnirit roaotion bt indicative of a 
mild uUhcIc. 

Tin- wnt is 09 follow* : 

1. Take 2 gmmmB* (30 gmuiit) of «ulplmnilir aridj 50 c.e. of 
liydrwhiorio arid, and 1000 e.r, of di^titliil wat«r. 2. Take a 
solution of Hodiinn nitritd in watvr of the strt^'ntilli of 0.^> jier c«nt. 
Fifty ])&rt« of Xo. 1 and one part of No. 2 solution nn' imw placed 
iu a (i.-¥l-tii)i<' and an »pml iimniint of urine addctl, and tiii^ niixtiin> 
is then n-niici-eil strongly alkaline by struufi nnimonia-wnter. If tin* 
diazo-n.-nrt>ion is present, the liquid beconn-e c&rmine-rv<l in color; 
and if tliu te»l-tnl)e is nlmken, this ivlor \t *txa in the foam. Thi:* 
coloration of tJio foam is the point iu tlie reaction, for, if the 
liquid only la red, the test ift not potuUve. After standing u day a 
green precipitate will form in the tube. 

The Qeneral Srmptome Associated with Urinary Disorders. 

Having oousiden^d the puthological changes found tu tlio urine 
and their ^gnificance, we now pass on to a consideration of the gen- 
eral -lymptoms which will usually be found associated with tlieee 
variationi) from the oormal functional activity of the urinary organs. 

Li'l tiA supiM»e that a patient presents himself complaining that 
he ha'* been seized with pain in the small of liie back, and per- 
haps liv nannea and ehilly sensations, followed by » marked decrease 
in tlu! ipmniity of urine secreted, which dc<irenst* may actually 
amount to 8Upprejb>ion of the urine. The urine that t-i jmssed ii* 
hiKh-<:olor<Hl or smoky in hue, sonu'timest look.« like porter, and 
fornift a very li«itvy sedimi'nt on ^binding. If it in I'llt^retl and 
tuMvtl for albumin, it will Iw found to oonUiin this abnormal ingro- 
dient in Urge amount, and a mirrosi^opical vxamiiiation of ttir mtli- 
menl will rewul a large uumber of blutHl-corpuedcs, epithelial cell*, 



and AMts fbyfttiDc) mode up of bIood-oell«, i>|>ithi>Iiii[ti, niv) nlbumiti. 
Si-aiXTly will tlieec stgns linvc been iiot«<l wiwti the imtiutit will W 
Bovt) to be uiiiL>iiitr, iiiul jiiilliiuw of the fncv nboiit the eyiss will be 
L-vidviiL Thin {>ii(rnK>^--> will tlii-D |iiii^ on to a ^uiK-rnl nnnMUTa, 
but it i« to be rL-mi'iiihunil thiit tin* moHt violiiiit acute dlffusr neph- 
rUU may exist vi'itliout dcvc-Iopiug aaaarui. If the tUtMuisv be io 
H cliili] uiiil it M due ti) suurk't fwer, xnusurcn i» c-omruon, as ie aUo 
urwtniii. The piiUi.- Jii pat4ctit« with thi!^ form »f DOphritiH '\.» usu- 
ally harJ and teitw, iind tlu> sharp und cleiir sound of the heart, as 
heanl at the second right roslul ('itrtiln^, will indicate the high arte- 
rial tension, Thi-- skin ie generally ilry, and, it nrny Iw, harsh to 
the touch. Should the symptoms persist for over a month the 
posriibility of the disease hecominjir chronic renders the pro^otiid 
doubtful; but, as a rule, parlicularly in young persons, the prognosis 
of acute diffuse nephritis is favorable. In the acnt*? diffuse nt-ph- 
ritLs of pregnancy the progno»a is, of course, grave. The history 
of the tawe prior lo thi? attack of this ailment will usually he that 
the jKitient lias been ex(>i)se<i Io cold or wet, has been or is a suffen-r 
from an acute inf«ctiou4 dism^e, has swallowed or inhaled .some 
irritant poison, or has .suffered from some severe bum of the surface 
of tlur bdiy. 

If, instead of an uciitc attack of illiH<«K, the symptoms just d«- 
ftrribed come on gradually nnd !n>^diously, and tlic t<-ndeiiey to 
atuiMirca ii< niarkiid and perei«tunt, we have lH>fore ue n uwe of 
ehronie /tarrnc/ii/mnlowi ncphritU, in which the prognuoB is niMt 
grave. Uramio vomiting and odihii may oe<;ur iu this class of 
psticntK (sec cJiuptcr uii Vomiting). RIood-celU arc also found iu 
the Hcdimeut of the urine in tliw-c cases, but are nut so numerous us 
in Hi-iite diffuse nephritis. 

A group of symjitoms which differ very markedly from those just 
(Inturihed occur in casen of ehranlc contracted kiilnry (chronic inter- 
stitial nephritis). The following description of the symptoms may 
lie taken as representing a typical case : the patient, who is usiuilly 
past middle life, finds tliat he or she tiriiiates more frequently and 
paasee a greater amount of urine than heretofore. Often the slevp 
is disturbed by the ni'ce*aly of arising to urinate. Instead of the 
urine being heavy and clouded, it is unusually clear and limpid; 
and in place of the high s[)eoific gnivi^ of diffuse parencliymalous 
nephritis, we find it uuiiHually low (only 1.010 to l.U15>. Albu- 
min is only found incunstantly and in tracer, and is generally to 


bo sought fur in tlici uriiii.' pnssed by tlic patloot n'licn fiT9t nridinf; 
from \kiI. The piiW' i^ iimiiilly much iiicmuMl in tviitiion, iim) 
ntlicrutufi of the blotxlvesscls is raurv or K-ss iiturkitl. ThU liigt)- 
t«nsion pulse h a vitluablo diugnostlc ugii. The h«urt, whtcli in 
acutp ditfuiie uc])hritia may he i^lightly dilated, or in chronic {Kiivn- 
cliymatoiis nephritis somewhat hypertrophied, is in this dia^iLse 
usiiiilly markcilly hype rtrop hied, and the set^ond sound at the sit-utid 
right cofltal <:artilage is comnionly accentuated. lu addition to tht-si; 
E^mptoms vrc &ud that chronic bronchitis is not rare, and that 
piiliiioniiry 'edema and attacks of sliortness of breath are ofteu 
present, the latter being most marked at night, friemic synip- 
totus arc more commonly seen in this class of cases tlian in any 
other, and violent vomiting difficult of control should alwrays make 
tlie phvMcian test the urine to duwern renal mischief. I'nlike 
parenchymamus nephritis, drojuty is a rare complication of chronic 
ooutrairted kidney. Micrascopin examination of the urine will only 
rt've&l n few hyaline and granular cast-s. 

Thi.1 pruguu^iH a^ U> cure i.-< biul, hut life may be proloi^ed in<lcl>- 

A cupiou.* flow of urine of a low spi-ciftr gnivity and of ii [wlo,: 
clciir uppearunco, containing futty, hyaline, and finely giuuul 
casts, is often seen in cases of amyloid tiUtaee of the kiiloey, and 
the presence of syphilis, of pmlongMl suppuration, or extccksivo Ixuie 
disease, due, it may bo, to tuberculosis, n'ith concomitant enlarge- 
ment of the liver and spleen, separates it from any other ailmenL^ 
Albuminuria may be a marked or an absent symptom. 

Ivet us supjKisc, however, that a [uiticnt comes to us with a hi»- 
toiyof exceedingly copious urination, of great thirst, of loss of fleeh, 
and has a dry, harsh skin, we immetliateir recognize that a test of 
the urine will probably reveal the case to be one of diabelet meilUun. 
This will lie to if a high specific gravity is found present 
in a clear limpid urine, and confirmed if the tests for sugar already 
given produce a reaction. The other prominent symptoms of dia- 
betes mellituit an' furuuculo.«i.4, intense itching and ei^'thenia (see 
chapter on the Skin), an exoowive appetite, and, in severe cases, 
gangi-ene of the extrcmitiiw or diabetic noma (see chapter on ('unui 
and L'nconsoiousne**). If the urine lia* a constant low r;[Hvilic 
^vity and contains no albumin or sugar, the vtaa \% prolwbly oiin 
of dtabetCTf insipidus. 

Should much pus be present in the urine, it is probably dcri%-cd 


From a pyelitis or a suppurative inflamoiatioii of the pelvis of tlie 
kidney. The symptoms of this state are, briefly, a constant or in- 
termittent pyuria, usually an acid reaction of the urine, chills and 
fever, which may mislead the physician into a diagnosis of malarial 
poisoning, or, in other cases, if the pyelitis be tubercular, hectic 
fever may be present. Sometimes violent attacks ot pain resem- 
bling renal colic are passing symptoms, and not uncommonly an 
antemia and loss of strength are notable. There is often pain in 
the back, which is made worse by pressure with the hand, and, 
rarely, if the suppurative process be marked, typhoid symptoms 
may be present. 

If the pyelitis be tubercular, tubercle bacilli may be found in the 
uriue. If due to a calculus, there may be a history of gravel and 
renal colic. Pyelitis is to be separated from cystitis by the fact 
that in it the urine is acid, in cystitis it is ammoniacal; by the pain 
in the renal region, often unilateral; and by the use of the cysto- 
scope. The prc^nosis varies. If due to an infectious fever, re- 
covery usually occurs. Tuberculous pyelitis may also recover. 



Con*l!pntion nn'IilUrrlnfji— ThnmOMit nf ihcun tvo »iiipl4m* nnd ibcir dlagWMll 
— The diaeanea ill wliicli tbe*« «riiipuiiii!i occur —Oliol«niu ilLurbiaa — D]rwn-1 
Urjr^The color or the reoo— luicitinni pariullM. 

The Bonsideration of the eondition of Uic IwwoU and feces as 
iudicjitive of (li-H'n.-u,' iifTttrliiig tlic irito-ttinr^ tli<'ni:«rlvi.>:« and utiwr 
oi^n.'^ clo«<>ly ns-^i'-iiitiil willi tlkuir fuDclioti^ van he hcM divided 
into 8cv4!ml jwi-K. ii.ini.-lv, t\w fiiucUoiml dtvurden of Uiv inb'ntinm 
and till- i>r^mi<! iliM-a-i-. froni wliii'li thoy may nufTrr, nti tUv <>»« 
hand, and tlii^ ii]i|it-iimiio<' nf lliu tcwit in both fuiidtiDiul ui>d 
orgnnio distuiM.-^ of the nli<lt>iniiinl vii<i-i'i-n in |r«iiiM«l, on tin; oilier. 
Tilt tuoni i-oniiiiuii foniut of intcMinal di)ftnrbinr« arc raD!^i|mtiou 
and diarrliiiMt. 

Constipation may be dnis to tucro 8lug(rishnt's§ of bowol-movo- 
mcDt bccniiM' of both nervous uud mti«cular utouy, or to deficient 
secretion of llie intestinal jiiiee>-, or, u^ain, to the too mpid ubsorji- 
tioii of tile liijuldK from tlie fecal matter while it 'm pugHiiij; through 
the colon. It \» uW iiiSNiictflt'ed with all those conditionH which 
[in-vent the pi-oper «cerction of bile, which liquid ven- maCeriallr 
iiicreii«L'!( iierintaUis. Tlitu-, we see ob^^tiuate coiiDlipation In most 
caK» of jaundice, catarrhal or obbtrnctive; in cases of hejutic iie- 
Ctuic, prtHliictn;; a deficient bilinrv flow; and in phosphorns-jmisiiti- 
ing, iu which the fatly dc;{caeratioii and hepatitis prevent biliary' 
Beention. Further than thiii, tlic cunstutit iu^stion of foods which 
are ab^rbed neurly i» foio, or, iti other words, leave little residue, 
particularly niw or boiled milk, protJucea const i pat ion. Again, the 
luo of wines containing largo amounts of taimie acid may produce 
aimilar results bci'aiLW of the astringency of this subetaoec, and] 
chronic constipation from the use of large quantitits of badly in- 
fused or boiled tea made with hart! water is frapiently met with. 
When too rapid absorption of the liquids takes place from tJie feivjt 
the cause may be laek of litjtiid ingested, atui the remedy be full 
draughts of pure water; or, agiiiii, eoiiMijuition nittur^ sh a n)uuifit>- 




tntioi) of iliuliuU-H in^ijiKlus or (Iiiibi;tcs mellitus, because the {>i>Iyiiri» 
of llie^if HlTtxrtioiK^ dniius tin- biKly of liquid. Obstitmte voiistipation 
slioiild llivrufore iilwiiys rail tlie ptiysician'fl atteatian to tlie&e affotv 
tion^ mill to two other possibiHticti, namely, that tlie coDtlition <le- 
PoikIh ii]>on wilful disrcgnixl by the putacnt of the calls nf nature, 
so tlint thv bowel is foreetl to redin fecnl matter until It becomes 
hunl ami dry: or, quite as iiuporlant, that the constipation may be 
due to some reflex utuse, which, as the result of irritation, I'csults 
iu an arrest of iK.Ti8laItie movement. Thus, a woman with ovarian 
and other peKHu trouble may have obstinate oon^tiimlion which 
yields little, if at all, to ptiri^tives, but reiiJily to nervoufi ttedatives 
or even to an opiiite. Or, again, in chmiiii; Icad-poLsoning the in- 
hibitory fibres of the splanchnic nerves may he so irritated tliat 
peristalsis is impossible. Here a hyptxlerinic injeotiou of morjihiae 
may make a movement ]>oasihle. 

The oi^anic diseases of the bowel prodiieinj; con^ijiatioii are many 
and of great imjmrtance. They eimai»t in inlestinal oWtruetion hi 
all its forms, as by bands, by growths, by the procw^ of iiitussns- 
ceptjon, by volvulus, by cicatricial <i.»itmctiun», and \>y imjucted 
foreign IxMlies or fecal matter. The pri-sriice of n :«.uilden atlnck of 
cMiMtipation, or the pnssenwr of thin ouiiilition in a dcKi**! which 
fniU I» yield to mild laxatives, should alwayit put the physidnu on 
\m guard lent some sudi grave eomliliitn is pr(>H«ut. A* severe and, 
finally, ntcrroraiwoun voniitiii); i* a fairly constant anil more umrkctl 
ttymptom of intestinal obKtructiou than is eonHtiputton, a disciuwtun 
of tile various symplotuiii of inlestinal ol>8tnietion will be foiui<l 
in the chapter on Vomiting, nml the <I)agno.sis of growtlis of t!ic 
iniMline will he fotind in llte chapter on the Abilomen. 

Aitidc from tlie»e mii.-«.», it is manifestly im|)ossiblc to discuii.r- all 
the ooiiditii>ii>i of the syMlciii in which <-on.stip!ition miiy be present. 
The p)iyi>iciai) miti«i always in-ar in mind tliat oonsli]iatiou often 
mtulttf in the altsurption of all H>rt» of jH)isonou» msteriaU from the 
bowelif, which in turn niiiy priHlnce all sorts of symptoms, ner\'oiiH 
or otherwiMi, fniiii epileptifurm itllacks, In rare cusco, to severe 
liendaelie and vcrligo, with vomitinf*, in othen. 

DiAitRiKKA of an iinttc type de|H-iiiU, ns a rule, u]>on one of four 
causes, luiniely, the prescniv of irritant material in the bowel, 
whioli tile intestines ulteinpt to ^et rid of by increased secretion 
ituil exeeHtlvc peristaUis; to relaxation of the bliHHivcsscU of the 
intestine, with profuse serous leakage and (wnsetjueot watery puT^- 


iog; to ffl«uto iudamniatioii, witli exi-«(«.iivc fl«crvtion of mucus; and 
to the cndeuvor uf the- .'«yitt«m to uliminuto poimiM in tJiU nuuiner, 
U8 in HBM* of fltidden profiiw; diarrlia'a, iu cams of ohrunic renal 
disea>«>, in whicli t)ic |iur|riiig !» nn I'fTort ut «litni nation. TIm> but . 
Dam«d fi.inu4 of (litiiTliciit aru iisimllji' Hiidden iu otiitct nntl s)>»dily 
get well of thcituwlvps, mid it is a mistake to nlieck tliom too 

It i» iinpcx^ible to »\xxi\(. of all tli« postibli! <«u«c)t of diarrliom, 
or of nil the- disc-iisi;!* in wliivh it 'm met with. Only tliOM^ in which 
it !i< a {iromineiit :<ym]>toin, or imc of iiti[iortiuirf, ciiii be di«<UHMxl. 

One uf tJicwr i» diulcm morliiiM, u distuim: which iiiHnifei<4» it«ulf 
in profiiM- wutcry piirgin^^, iu«oiii]iaaicd by violent ptun tn tho belly, 
niid, »fttT Mevontl !<lools hiivc iiiuMed, in li ooiii<id(.'mble iiinoiint of 
tvntwmiKf. MiUMiit m nlmu»t entirely absent from the ik'jivta, but 
|Mrtivl(.>s of iuidi^oift<.ii food mny be found in them. \'i>initiii^ i» 
ofb.'n 11 severe and i^iniultjincoiis manifesbitioii of the ^^tro-inte^ 
tinal disorder which results in these symptoms, and, if the attack 
W vory severe, it is pnictieully impossible to si-paruto it from true 
cholera Asiatien if an epidemic of that disi-ase is present. The 
patient >iiKi-<lily i>eeomcs etild mid pinehtHl'lookin];, i-WfedinRly 
weak, and liiiiilly passes into collapse. The pulse liceomes feeble, 
rapid, and running; tlie face livid, and tinuUy tlie patient may 
develop the/«c(M Itippocratica, The urine is greatly decreased or 
entirely nuppresaed, beoauae of the watery purging, and poeisibty by 
reason of the effects of certain poisons upon tlie kidneya. In the 
great majority of cases the symptoms are not so st^vere as this, 
and complete recovery en.-iues as soon a8 (he offending niateriaU are 
parsed out of the boweUi and tlie patient has time to coo%'al&«e. 

When an attack of diarrhrea, such as lias jnM been described, 
comt^ on in a young child it is u-iually called cholera infantum, or 
aunitner complaint, and it is nearly always dne to improper ft>eding 
or to the tin intentional use of bad food or had milk. The Ht'x^U of 
the child are usually at tirst lill<-<i with curds of milk and grc«u 
mii8.^tC8, looking as if the curds had bi«n staitieil with gr.i.-vi~ juice or 
i^pinach. The child often (Kisses witli extraordinary rapidity into h 
stnt^- of tNillapw, and may die in a few hours or dny^. The ten«A- 
mti» often liccome-s cnuRtanl and \n a distressing ityinptom, and the 
tieeucM l»crome itliniuken to a marked degree. The child manifrat« 
not only tlie evidence of the result.^ "f profuse purgatiim, but, in 
addition, is evidently intoxicated by the toxiiu atworbi-d (rum the 



tiiat it ItM on the lafi nf tlio wnr^^ in ii roUxod twA torjiul 
8tak>. The surface of its body i.« oficti nlinormully ould, nnc) \%n 
ttxti«niitie& may be )>ino[iec) ivaA bitie; Imt tho tetnpcnitiire of the 
iutcrtuil or^ne is geiiemlly abi)nrmally liigli, 9a that while thv nxil- 
liiiy ti'mpemtupe may be below iinrma), llif thiTmo meter will n'veiil 
a teDi]H>rature of from 11):!° to lO'i" in the rectum. SuniotinK^ llii- 
lit'ad hecomea retracted, as if meningitis wax [)re<4<>i)t. The re«[Hm- 
tious inay l»e milling or of the Cheynv-SlokM type. 

If the child or adtitt !« Aeixed with nynipt^mM nuch ii^ tliu«e 
described under eJialtra morbiia or cliolunt iufnntuni, and a »ut(|>ieiou 
of the (iresenoe of true cholera 13 raiitwl, are there any fnets which 
will point U) the correct decit^ion in n com, even if, as ulrwuly iftutcd, 
a pnsitive differential diagna-iiii cannot l>c made? In the finit place, 
a train of Hym|itu»H nf n niiili^imi)t ty|)e |>i>int to the true cliolera, 
ralher than cliulcni iiiorlitL' nr chol<'r» iio^trus, as it is sometimes 
called. Again, ilic eviilcnci-H of inficlion or poncral systemic dis- 
ease indil^ate the epidemic miiliidy ralher than does a profuse diar- 
rhaa alone. Thus the svali'mic sipii^ of iiifcclion may be so great 
that death from infection in true cholera occurs before diarrhwa 
even I>egiu4. A^ain, it would be putbghlctudctL'rmiue the presence 
nf tme cholera if the comma-bacillus tTOuld be dcmon^trnte^l ; but 
this re«]uires the examination of the fecal matter to be nin<le by lui 
expert who is familiar with the teclinique of examining fnid 
mattt-r for tlic germs and with the necessary meaaareo for llK-ir arti- 
ficial culture. 

Syiiiptonis t<letitical with the more violent forms of diolera iiod* 
tnw or true eholcrii niity bo produced by acttle polaoninff fii/ ttrithnnnj/, 
exoept tliat in tliis case we often have profuse sweating iukI wiliva- 
tjoii early in tlie attuek. The same symptoms of vomiting, purging 
of rii"e-wuter 8t"')ls, collapse, cramps in the calves of ihe b-pt, and 
violent pain in tlie abdomen may be pretwnt A difffrfntial diiig- 
uasii, without the history of the patient having taken jiot»on is 
impiwible, except by a chemical analysis of the vomited matter, 
which with the stools, and the urine, will contain anlinnmy. The 
utmost cam should be used that (he v&<ui>la which reeeive tln-Jtc matis 
tiaU »Tv chomically clean, tiiat they are hermetiimlly «ralrt) until 
ready for the expprt analysis, and that they are in (lie haiida of 
thoroughly responsible parties up to tJie itate of analysiit. 

While artenic may cause somewhat Ainiilar ftyiuploiiii>i to those 
due to nnlimony, ihe alools are generally bluiKly fnmi drvtmrtioa of 


the gm^tro-inti'T^tiniil niucoiis nitmbraiic l>y the "Irtij^. Riirely oertain 
pwmnmw tund^tooU produce Koini-u-hat similar Hym|)toni«>. 

If All iidtilt who bus not cnten anything which oould have produns] 
a (linrr)i(pn. an lUv twtilt uf irritatiun from h»(\ foud, U N-izol with 
pnjfiiw watury purging, with very little or no piiin, am) withoiic 
naiiMB or vomiting, it is prubablc tlmt he is eufTcring from thv ocu/f 
nerpoiM dhrrhiea which Hometim<.'8 rpnalts from rxpcwturc to wven.' 
n«rvoii« (itrain. To illustratr tho character of tlicse cas(« lh<: aiilhor 
niuy mention the fact that it t8 quite common for htm to mv nHxIintI 
8tiidenta, pxhaneted by a long wint«r'H work and anxious aboui ihcir 
oxaminutionif, seined hy an attack of profnse watery piirpn^; in lh<- 
middle of the night preceding the examination of which tW-y stand 
mnttt in dread. 

Care loii^t be taken by the physician in nil ca^es of sudden and 
profu«' dlarrha?a to which he in <-allrtl to exclude the pir-seni-i' of 
rvnal disease, for purging rnay be an effort at diminution of «fffte 
muterinls, and its sudden arrest by drugs may induce urwmic convul- 
sions or coma. 

Sudden attacks of profufe watery diarrhcea in wliich Ihc patient 
pauses great quantities of liqnid from tlie bowel, with or without 
[laiii in aei^xiation therewith, may ho duo to locomotor ataxia, mani- 
festing itself in an " intefittnal cri^ii^." 

In cases of persiistf nt or ob)*tinatc dinrrlxi'n, w>roii» or catarrhal, in 
whicli there Li an exceiuuve ]>eritttali>i.'* which liurriitA the iultMtinal 
contents along oo faat that the fond omnol he ]iru]>erly digc^tod, tlie 
phvHieian sliould remember tlmt fijimu-e oj tlir- anu» or some oth«r 
source of irritation miiy h*- present in the lower bowel wliich pro- 
dnoes ivflex excitabitity of llie nerves governing the boweUmove- 
ments. In other v*tt% a stricture in a feeble, ditat^tl n-cttim will 
cuti«e rctetitioD of fetes iiutil irritation, tenesmus, and oveo loose 
mucmts uiuvciiKnts are produeeil. 

If, insttnd of watery or serous movementit, the patient is attacked 
by a more or less acute diarrhtra, nccotnpanied by great pain and 
distention of tlie belly, and if tliere is marked tenderness on jirea- 
snre over the transverse colon and mucus in the feces, which are uot 
in vory large quantities after the first few movements, there is prot)- 
ably present the condition known as cnlero-eoiili*, or inflaraniatioii 
of the ileum and colon. It is met with in both children ar>d adulta, 
atid differs in '\X» oourae from cholera morbu^t and cholem infantnm 
very markedly. The [tain is usually more oon^limt, more aching. 



aud Itm gi-i[>iiig in diaraotftr. VotutHo); is not a conataot featurv, 
a» it in in liit! waU'ry diol^raio diarrha-a.s tiD<l the ocniree is niorv 
»ubeeii(v, tlie dtirutinn of llie illna^^ tituially bein^^ imta oiiv to tlirre 
wvcka. If f'KMl wliii'li i.« ilitticult of dij^tion has been eak-n, it is 
(M^fietl, still tniilij^iuLfil, fmni the bowel and is apt to b<^ otnti-d with 
nitious. Suoli A diarrhiea i* called lienleric <!iarrkaia. 

Not far niniiivcd frimi tliin tv|>it of casmi are those of a nioi* 
chi>>iii(' chamctor d(.-}>i-iidin(; upon more grave and la>iting alterations 
in tJic )^i»tro-iiitvHtiiinl ninciiwi. An a rule, the greater part of th« 
tnHi1iI<- rxiKtK in tbt; i-olon, mid mon- or lew griping pain in the 
ncitfhborhoix), naniuly, in th« nj)pnr umbilical area and left groin, 
niav tw present bt-foivr «ich movcnwnt. Tlic aljdomen is apt to be 
diitt«-ndvd and (jwitc t^-ndcr on ppi'*tnre, piirticiilarly in oertaiti vari- 
able g\>o\», and oi)iwi<lLTftblc 1(ms of bodily weight is apt tn ensue, 
ohieHy from faihire on ihv jiart of the di^^-jritivo tube to alisorb tUo 
fowl that is eaten. T\w. inovementn are not markedly watery, but 
are uttnally nnforrnwl and alwjiit itto 4xinsii*t^ni;j' of oatmeal grwel or 
a little thioker. Flnkw of nim-iw are oft«ii found in lar^c amounts 
in the feeal matter, and the fiwe* may Iw frothy or flaky aa the renult 
of fermentation. Blooil and |ni» nre very rarely seen in (he movc- 
tuentH of tlicse caiies, unles8 the blood eseapex frimt an inllamed 
hetnorrlioid. Sotnetimea, when these eases arc very severe in cliai^ 
aeter, the mueiu lakes the shft|ie of long cor(l-like or worm-like 
strings, or even seems to be membrunous in eharacter. In other 
itislaiioes the feoea, when formed, are passed in ribbon-sluiped ma««e, 
eitJier dne to spa;»ni of the muacular lilires of part of the lower 
bowel or to eieatrioial eontraetions, due to tJie healing of oM iihwni- 
tionft. In ver%- aevere eanen the eandition of the intestine gnulnally 
advances from a miid JolUctUw enltm-cotitU to one of aelital deep 
uleeration, ant) under tlie»<e cireum»tanees blood and pus may l>c 
prewnt in the movements. At such times the [tain produced by tfi« 
patient having a movement of the bnwelfi, or by the pasaap- of fecal 
tuatter over the nloerated snrfaee, may be intense, aud tJie invalid 
will often !ttnt4- tikat the pain feels as if one spot in t)ie gnt were 
mwlc mofit painful by the feces nibbing over it. Such cases often 
continue for ymrs, while some of them ultimately got well, others 
Ijcoonie elinitiii: invalids from tiie shiw cltaagCH in tlte intestinal 
walli^ In tliis ennnectton tlie diarrh<ea of (u&erci</<wM is not tit bo 
forgotten, depcndiuir, i» it does, either upon the nceneral infection or 
■ipt>n the di'velopimut of ulcerations in the iolcstinal eaital. 


In «om<.- cu«L« ill wliioli tin* piitifiil iiflcr vxjiuHuri- tn M>ld or wvt 
is Bcizitl vritli violi-iit pitiu in the (>|NgtU(trium, un<l ii fotOiti)* uf 
w(ii);lit ill the ntctuiii. k few himc muvciiiunt^. aii<I thoii iiilcnao 
tvnmmiis iukI bcurin({-<luwii, with only n few dntp* nf mtictis in llit* 
WHv of a itiuvfuiuiit, tho coiiditiuii iit onv of nvuttt rctc'Iitl «iinrrh »r 

The auGs jutit nnniod iu tlic prMioHing pnntf;rnp1iit nrc to be ^'[ni- 
ratod from thosv in wliioli Uktc is 'itic itiigfilfrt). Dvsotitery i» a 
term v«ry IrKtst-ly appliLtl, by tin- Inity in piirtinilur, to »ny fonn of 
Bevvro iliiirrh'vn, ))iirticulHi'ly if tht-ro arc liloud im<l niuiruit in tl>i- 
ini>V(.-nu.-tit, In ratlity tlii.- lorin ilvHcutcry stionU] hv liiniu>cl to 
caees diit to an iufoctioii and vcrj- apt to occur tn tpidtmiw, As 
Oeler suye. true dyvK-ntcry is one of tlie four greut opidvmic disL-uee 
of the world. 

Ijet us suppose tiiat a patient is seized with dturrhoa and some 
pain in the belly, and with only u sli);ht chill, or in other case* uo 
chill may be prcf^ent. The pain soon becomes more and more col- 
icky anil the alools are pa&wd with evei^lncreasiug bcuring-down or 
tenesmus. The effort to empty liie bowel, after it is in reiilily tJior- 
oughly emptied, results in agonizing bearing-down pains. Fever to 
the RxtKnt of from one to thrw? degrees may he pre.-ient. Tliirsl \» 
exc&«iive, the nlomach iri nnually retentive, and the iitools are llr^l 
the ordinary bi)vrel-coiitt>nts, nnd then tniicui*, which may be bliKMJ- 
Htri^ SiK^ii the mucn.« bcci>mt« jelly-like in ap]H>aran<% and 
wore thick and tonatHoutt, and, tlnnlly, after seventi dayn it l»ugini« 
to I'litii nnicii-purulftil. nnd the stO')l!' arr- le** frc(|uei)t. Somolimcs 
email liiillct-like liarti \W'vav »i fecial nmttcr nrc ithot out of tli« 
rectum nftcr severe ^truiuing. Keouvory usually begins at from 
seven to ten dayi*. The entire trnnhle ^mm* to be in the large 
bowel, and jiiirticulurly iu the sigmoid flexure nnd rceluin. Sueb 
arc tho symptoms of ordinary mild dysentery of hot climates or of 
summer weiither in tlie tcinperstc unic. 

The severity of the dinaise is much gntiter in hot weather, and 
the prognosis is not good in severe vases eomiug on during an 

On the oilier hand, if the patient has an irregular diarrhira, after, 
or during, a residence in tmpienl parts, which may or may not have 
a sudden onset, with moderate fever and ciinsiderable loss of flesh, 
and has moderate bellyache, which soon becomes much less, and if 
the iitoolg as just deseribed above become more and monn fluid, ant) 



'- dburhoca iiitcrmite, the phymciaii should thiuk of tlio tnsp being 
probably one of so-called tropical dysentery, or amabic d\i»n\ier^,i\ 
condition of infection by tli« so-<Milled iunn>bie coli. The courw of 
tile di^^ise is slow, Wtin); from itix to twelve weoks, and the dcnUl- 
rule im hi^h. Convaleeceiiee Is always very sloiv, aud ltver-«b(KH?« 
due to an he[ntic infection by the amoebse coli is very {rvijiicot. 
Sometimes ahsc^cm of the lung develops. 

A positi\'e diagnosis of this %-ariety of dysentery is made by the 
discovery of the aimebte in the stools. These rakro-organisms pos- 
sess active amoeboid movements and are found in greater number 
when the diarrhtm is severe. Tliey are t^) be sought for iu the 
small gelatintms masses H-iiich are found in the feees. Snmelimee 
tJie entire stool seems loaded with amcehie, at other times only a 
mi>6t careful search will discover them. They are more refmeti%*e 
than the i-ells found in iJie feces, and contain numerous vacuoles, so 
numerous in some cases that the oells look \ery granular. These 
niiLHt not be mistaheu for tlie oomjmun'i gniunlar bodies found in 
the feoe!<. When tliey are aetiv<? a divinion into an eudosarc and 
au eetosaix: can be dtseovered. Often red blood-eells will be found 
in tlio amo-bu. 

Soiuctimut n diphlheritit^ or fnlw; membniwiiiit dywnt^ry \* devel- 
oped in penions hnvin^; ehrouie hcurt di^casOi and it liiw lieeti wen 
tts II Mquel of acute rroupoiu pncunmnia. Tliin w, c«ille<] tnxmdary 
diphlliffitlc ihinaitrrti, ami dinlli ptncrally rct>uit« from eshauittion, 
only n vtuspieiou of the intestinal ctniilition having existvil during 
life. Such a stiitv is Kimotimcs u oomplicution of Bright' )• disease, 
prxiliithly owing to the irritation of the intestinal mueuui' mombnitie 
pniiliiced by the un>u d(.'Com[H>sing ioto i:arlionale of anmioiiium, 
In nctUf primnry ilt/nenieiy of a lUfththrritic character tlie patient 
may rapidly {lass into a typhoid state, aud the ease lie diagnoeed as 
one of typhoid fever with profuse diarrban. The discharges are 
the only means of seimrating the two rauditions (enteric fever and 
diphtheritic dysentery), as they often are tilled with blood and 
mucus in dysentery, a coudition rarely seen in typhoid fever. 

Dysentery may be confused witli the diarrhtea sometimes ppo- 
duoed by a malignaut aud ulcerating growtli in tlie sigmoid Hexure 
or rectum, hut a physiiial exiimiiialion will usually reveal tJie tumor, 
and ttie cachexia will aid in (loiuting to it as the muse. 

Syphilitic ulceration of tlift<e jiarts may <^iu4e a somewliat tumilnr 
train of symptoms. Agniii| it i^ by no means rare to meet with 


the poaange of iu^vpnil niiirj)-jitirii1cut movi'inciits eiic]) day in [M>r- 
ftona who have piilmnnnrA- gnti^rciit; or piitinonat7 tiilKTciiln*ii», 
partly due la th« K\r:illiiwiii^ of fetid Npntuni i^r tiibomiliir tiloi-m- 
tion of the Imwi'ls. DinrHumi is nUo n ftvmptoin of i«-pti(!itniiii. 
DUtantIr alhwl to iIut* fmin "f tliurrlnvii i* tlmt eeoii iti {wrsoniM 
who havp (lii>HeoU'() ii |mtr»l boilv ("diNW-cliiig-room dtnrrh'M"! 
so called). I 

While it (low not fnll to tlio lot of llii* Iwnjk t«»Iiwuj«»lJii>i«jin|>- 
toms of th<> afTct;tioii.'< of the rTOtiim which arc to he rclifv('<l hy 
aiirgery, it is proiwr to sponk briefly of thoiaiii(M.«of hhwl in thr xfoolm 
in otKor stiilcM than rlyiwiiHrry. In iri<jiiiriiijf ii« to the hlooci in the 
stools, we ;<1iiiulil usk whuthiT it is iiiixed with tlic foeo* or is wn-n 
ill »trcjit{«, niul whether it pames in jvtM or not. If in jets, it will 
he fomid in the p<kn a^vny from the fccul niutt^T. W't dhonld osld 
an U) thu nmoiiiit of bluod and its oolur. If n)i.\i>d with the fecM* 
it prohiibly rc^iiltrt from u slow oozing from n hemorrhoid, or, if Ihv 
fcecK «!■<■ fDniiod. fmni some laikiitfj vo!5bcI in an nicer high up in 
the mgtnoid llexiire. If in strL^aks, it probuhly corner from ttiewall 
of an uleer which has hecn scraped by tlie fecul mass. If it is 
pHs»ed ill jcle, it probably comes from some vjiseular but small nrle- 
riat tnft of vesaela low down near the anus; and, finally, if it is 
dark and tarry-looking;, it U probably due to a leaking in the up|>er 
colon or ileum, whereo-s if light red in color it is from veaseU in tlw 
rectum. Most commonly it is from hemorrhoids, or from an ulcer- 
ated raucou.4 memlimne wavering a syphilitie dejMiflit, or elj*e .1 malig- 
nant growth. (Hee further on in this chapter.) 

Finally, it U int^-rejitiiig to note lliat ]iaroxysmal attacks of sercH 
miieou.t or bloody iliarrh(.i!a Hunu'times ciiine on in ea-ic of exopli- 
tlmlmio goitre. Diarrhrm of a more or less severe type may come 
on iit ivMcs of hysteria, <ifb'n nKsoeinitHl with tremendous cruclation.i 
of gas and nimbliiig in the stomach and bowels, 

Fittly diarrhttii may en-me if feeble penwms already sufTering from 
irritiihle Ijowels take an excew of eod-liver oil, but in olhcp dues it 
powwsses gTi'ut dia^nof^tie importauee. If iii«>ociat(^^ witli dialx^tra, 
it gives us reusoti to believe tliat there is «onte <lii^en«e of the pun* 
creas producing both the glycosuria and the lack of digetriion of tlie 
fats. Sometimes in jaundice, however, fut is found in tJic fttoola 
owing to the lack of bile to emulsify it in the intestiDC, 

The Feces. In this coonection we aatiintlly puss on to a divcus- 
sion of tlie diagnostic indications of th« fvoes. In the lint place, 


it nitist bo rcmemberi'tl that the quantity of tlio feces dcpetKia ujx>a 
x\iv <jii»ntitr of tlie food, and again that the quuntity varies with 
tin* character of the food, f«p if the food lie such as to l>e bulky, 
yet Gontaioa little nutritive nialerial, there will l>e a large residue to 
be pos^ out in the feces; uhereas if the food be almost entirely 
composed of materials which can he aiwimilaled very little residue 
■3 left, and the fecea are eonseijuently ftmatler in bulk. Thus the 
cow eals a large hulk of food and jms-ws lar^e atnnunU of fecal 
matter, whereas the dog eiittt inciit and iiasries very maaW amounts 
of fecal matter. 

Again, it ih not to lie forgi^ten that many foodx actually increase 
iatesdnal {■eri.'ttaUi^ and iko [troducNt lai^e and Ioobc movements, aa 
oatmeal and wlunt^n-griti* or applet, while other food«, itiidi a« 
(■liee^-, do tbi- opjxi^iu-. If the stools nrv large and ropioiu and the 
fotxt whii'h the jHttient hai* taken is in ntilily not of a kind Imving 
M !argi> rci^idue in the Itowel, the indication ii> llinl there k non- 
abtorptiun of nutritive nmterinU, with conwfitient wonting of tJic 

The ooni»i!»tency of the fcee» in health varitse from a formed 
"trtool" to a mnshy condition; but in disuiae we have u liquid 
watery stool if the trouble lie aemus diarrhcea, and a pasty and 
fllimy atoiil if it be due to a catarrhal state of the boweU. TIio 
IMssage of liard Hcybalous masses mixed with liquid indicates tJiat 
the feces have become dried and hard in the peculations of the 
colon, an<l are only jiassed out wIm-ii ihey mui^e «> much irritation 
80 to pnidiicc diarrhreo. If the feoes are in narrow hands or flat- 
tened ribbon-shapes, there is probably a stricture of the rectum, 
offering an obstruction to their passage. A mushy or semi-watery 
stool is often seen in typhoid fever. 

The od<»rof the stools depends very lately upon the food which 
is taken and upon the degree of fenuentarion pntwrtit in tiie boiveli). 
In nursing-ehildren tlie stools often have a faintly Hotir odor, and 
in the diarrh<ta of nurslings with iield fermenlation tlwre '\n an 
odor of the fatty ftoi<l!i. If the priMre^s !:• iiiarke<l, iJiio odor bectimeii 
actually foul, and in cholera infantum the xtiHiln have a uiuMty, 
mousy odor. If malignant growth of tlw Iwwel in prr-aent, the 
odor is fetid, as it \n nW> in gangrene of the intestine. Sitl{)hiir 
when taken internally cuuh> » very nfTennive kIooI, owing to tliu 
snl[itinn>tt<.-<l liydrog«n guH whioli \* dcvelop««l in tlie bowel. 

Th« color of tlto MtooU ill of great diagiioHtie imjiorlJincL' in several 


cnntlidons. In liealtli tint fpc-cs i-lioulil l)c lirown or bn>wiiiKU-)iUcti, 
the c-olor being partly' due tu the food, but chiL-fly to the bile (hydru- 
bilirubtn). Certain fruits render tlio st^wls dark in color, iind drnf!», 
such as iron and bismuth, do likewise, and Ineniotoxylon oftvn mukt^ 
tht-m look red. 

In tlie stools of per^oDs living on a pure inilk-<liet we luiinlly find 
little color comimratively. Again, in cases of jaundice, pho«pboru#- 
poisonin^, and acute j-ellow atmpliy of the liver, the stools are wry 
liglit in color, owing to their lark of biliary coloring. They are 
also apt to l>e very light in chronic lead-poisoning. | 

Bilious stooU are either gtilden-yellow, greenish, or ret1dif>h iu 
hue, and if tlie flow of bile ia ])rofaac, they are aj>t to be watery. 
Greenish stools looking aa if they contained chopped spinach are, 
however, a |>eoiiliarity of the dinrrhnea of fermentatjim, parlietilarly 
in infaniH, th<> color lieiii^ due to a ivtlor-forniing iniero-organisin. , 

If the itionb are well mixed witli mncn:^, the eatarr^ial prtice^sl 
probably exhin in ihi- iloiiui; but if they eonitiat of hard masses oCl 
fctva coate«I witli mucus, the disease is probably a colitis. ^ 

Bloody Mollis are most commonly due to hemorrhoids which are 
eroded. The blood may be bright if the hentorrhoid be a snail 
arterial bunch, or more dark and i^^rumous if «\ow uoniii: l»ii> gone 
oa for i^imc time prior to the movement. As a rule, the brightvr 
the bloixl ill the stool the nearer its source is to the nuu*, and tlK 
darker the blood the higher is its source in the bowel. Thus, if the 
stual« are tarry -loo king, the blood is almost certainly from the ifiiiall 
intestine, and prol>ably arises from a duodenal or other ulcer or from 
carcinoma of the stomach or bowel; while if it is only iK>n)cwhat 
changed in appearance, it may be due to an ulcer or tilccnitcil mor- 
bid growth in the colon. Sometimes, however, wliore the IwmoM 
rhage from the ilenm is very jirofnsc, as in typhoid fever, the blood 
oomen from ihc niiu.ii only slightly changed in appcaiuuoe. If 
blood is RU9]>ecIcd to be present, we can confirm its presi-noc by 
finding the <n>rpuwTlci) by the niioroi«cQ|)e or by testing the feces for 
liHimin. (Si!e chapter on Vomiting.) 

8tuul» tuntainini; pu» may receive this lualerial from the surfaces 
of uloers but usually the sounx; of tJie purideut matter, if it is 
prewjit in large amount. U an »b>«(*** which hapi ruptured into the 
bowel, as. for example, in pcri-rcelal alwciws. 

Finally, wc may lind gBll-«tunc« in the Mool», which, if they are 
|HU0cd soon after their escape iuto the bowel, are fwind to b« faceted. 




Stools wliich are being rearched for poll-stoues r<liou1d be wa^heil 
through n sieve in such a wuy as to catch the stone and let the fecal 
matter through. The intrahepatic gall-stone is not foceted and 
enitnbles easily. 

Very rarely a portion of the bowel iJoil^hii away, an<i yet recov- 
erj- taken place. This is seen Aoniettnies in intii^uitccjitinn, 

Aside from the eharaeter of the stooU themselves, we often .tcnrcli 
for the eaiiae of an ailment in Uie pa^^ages, either for fnrei^rn bodies, 
such a^ pebblett or pin», or for inttxtinnt panmUt (worms). Some- 
times wornus may exist for long periocb of tJme in the bowel with- 
out cau.'^ing any symptomi*, nnd, again, in childreii in |)»rticn1ar, 
they cause great systemi<' dij>turlianoc by pro<lticiiig disi^rder of the 
digestion or reflex irritation. 

Womia. Under tin; name of ta|K^worm or oc«tod«s we find in 
the inle>tiiK', and oftt-n in the sUmls, a |mnisite occiining in scg- 
mentH whirh arc flat and ribhon-Iike, and itsually from a <|i)arter 
to one-hnlf iin'h in Icnjitli, Tlic worm it.self may be sttvemi yurds 
long, Itj> liHul ii> ^mall. and it maintains in hold on the bowel by 
ita head. The segments are usually broken off one by one luid 
escape in the stiMls, and the stools nl»o contain (he ova or c^^ 
of ibe parasite, which are devclope<l in each segment, which abo 
poanises mule and female organs. 

According to the slia{)e of the head and the sixe of the worm and 
the Huuroe of infection, wo divide tapeworms into tliree elaascs: 
ticnia solium, the taenia mediocaucllata, and the buthrioceplialus 

If the patient posses a worm of from one to three yanls in lengtli, 
the hitid of which is al>out the size of a pin-tiead and glistening gray 
in apiK-aranee, the rest of the worm being yellowish-white, and if 
upon tiie hcnd can be seen four pigmcuted suckers surrounded by a 
crown of hooks, ihat worm is a uenia solium, and is probably 
derived by the )>atient from raw or uncooked i>ork. The eggs of 
the taenia solium nnuit be sought for by a microscope. They are 
rotm<l and covered hy a hard shell, whieh hreaks iijHin pressure into 
small fragments. In the shells may be found a few booklets. 
Thes<t eggs an- |ias.>i«d out in the feces by the host, and are then 
swallowed hy the pig, in who»e muscles the hooklcta migrate and 
form cyst«t. In Uie.-M- cystit the booklets develop, and when a man 
Wt« the nutat mw they enter his inteiitine, attach themselves, and 
from tliem a tH|><>wonn i» develojieil. 


If the worm i* fnmi fmir to five ytxA» IcHi;; iiikI tin- K-jiinctiw 
afurr It^viiig till- uiiiis liiivc molili^ [towurs, anil if tin- licii<i is Uiq^T 
tlinn that of tir'iiiii wiliiiiii niid ili-vokl of liouklvU ntwiit tliv kucIccta 

F». IH. 


Aiearla Iiunbrlcolflea, dloocled ana wtiU 
tbFDHii hurl:, illxt-UM.) ■. Ottilliil iirUIuc. 
fc Inlnlliiu. c. OTliJueUb dL LomcllwUnal 
btnd. e OtulM. 

Oiyuiti r«niil«uUrl«. uicnUM. (Payxl) 
a. YaaiMt (anule. A. Male, ft Hainra I 
mil u( c«s>. 



OD Its haul, it is prolxtldy ihf twain mf<li(K<iiiR-l]iit» ■>!' sii^iimta. 
TIm egg Is eli|;lit[y luri^LT tlmii llmt of titc i^uliiiiii. Tius worm 
luu&lly ooinw^ from cuting raw lx.i.-f. The botliriwL-i)]i»lii« Intuit is 
the hir^est of all lupt-wwrmn, oftfii roitnhin^ ecveii iti dglit janJi* in 
lon^lli. It Itiis a loti); liivul will) two lung, uiirrow Hiickvr». Tttc 
eggs HIV oval, very lar^c, niid tliu »1icll is light brown ill mIot, niid 
very Misily broken. Tins pamsitc iit not couimou in Amurivu, but 

hV.. 113. 

fM. IM. 

II Fetalis, k Mal«. 

is a very frequent caiiw of profound aniemia in the 
|>orsons wlioiu it infeiitt. Its joints arc only rarely 
throwD off, Ml its pre.^cnoe is often overWiked, antl 
this reiicjpis tin; *i'ari'li for the ""ggs very in)|)onant 
in i^ven? anii-Diin wllli tii> tuiiriliuMf ciiiiwo. Tlii.i 
worm ia iisiiiiMy tlerivuil from li<ili. A wurm which 
is comjKirntivoly rai^ i:t (lie Uiaut riinumerinii, which 
han a head with nixty liook)i. It infects dog», cnin, 
and Aonii>tim<>s children. 

A niuntl worm, looking like an onlinary mrlh- 
worm, appears Aimctimcit in the xtools, and in inllvd 
aMmri.-i himhriootdc'. It iit wiiiicfirncii voinil'-d, iind, 
mn'Iy,iTan^cH trouble by omwliiig int>> and bl<>ckin)j; 
t)i« common hiltnry dnd. 

Fine thn-itd-likc wurmt inhaliiling the Kduni are 
the oxyuri^ vcrniiotiliiris. , Ai.kyi.«.«n. 

A verj' impuriJiDt diiijfitrMttc tlnd in the fows is u iirj ihM*ioin.) 
wnmi lookinj; very niiich like the tlircad-worni, but "' •'""'*■ ^ "''^ 
suimewhnt larger, which inhitbita the diuidcntnn. It is coIIm) tlio 
nnkyhialonuiin dutKtonnle. The im[»ortanoi- of liiidin^ il lies in tlio 
fiict ihiit it produ'vs the nioM [irufonnd and acutv anieniia by suck- 
ing blood from the iutcf^titial wnll. 'Hie wonatt arc nsnally only 
found nft4'r ;i vcrinifn^e h taken, bnt the cgpi arc always present in 


the feces as on^mmetrioal, thiokly ooverad B^mented globules. 
If the stools coataining the ^gs be set sade in a warm place, the 
embiyos can be seen to develop. Bloody etooU may be doe to the 
preeenoe of this paraute. 

The so-called whip-worm, or tricbocephalas dispar, is a fioe 
thread-worm without any medical interest. 






TIm DMliods of (aking th* i«inp«niiuTe— Tht tlgitiflctiico of r«Ter— Tlic fubrile 
moveaienU of varioiu dUciURi 

Pf.vrr it> tliat *\atv uf the hurruin body io wliit^-h its temperature 
[m miM-cl ubovv tliu iiormul limit, ur ys.!*" F. Hy[)erpyrcxia i« a 
Utiu iipplii'U to » firbrile movement in whk'b the temperature riBes 
ns high us 106° F., and eases are on record of a temperatupc of 
115° or even more. 

The melhixl of taking the tcmjM'rature eoiMUta in plneing n ^olf- 
R^istt^rinii clinical ihermonieter in lb(- moiilli undi-r the sld« of the 
tongue, the lips iK'ing then cl»sc>(l tigbtly altoiit itit Mf.m; or of 
iu)«rting it in the axilla, the hand and arm Itfing tiicn pitiwd acroM 
the jtatient's chent, or Apigastritim, mi a^ ti> i^uw the axillury cixi*iU4 
tu he in rIoM> oontact uitli the bulb >if tlio thormomi^or. Itefore 
tl>e thennonieu-r is pljioe«l iit th«> iixilla thiH '•jxioc nhoiild be <itre- 
fiiUy wipMl dry, since if jierspiratJon in prvveiit \t» eviii«)mtiini will 
8o diill tlie tlieniioti)<?t^-r tliiit n fiiW recjinl will be innde by the 
\niex. SiiuiotimfM tlu* ti'iiijx'intiin- nf the |uitii-iit i» ukeii by inm*rt- 
ing tlie thermometer intu the rediim, and, if thia in dono, the bulb 
Htmiild Imj paiWrtl xvell iiisi<lc the external riphinctcr. Kiircly iho 
t«>iii)HT»tur<> ii tiikeii in tin- vagina. 

Tlio prcHiiiitioiM to l>e tnken in «ll oawh in whkli n thermoinvtwr 
w ii-ted, in luldtlion Ut th<Mir named, ix to have a tliermomi'ti'r uhioh 
is HTOuniU-, and to be T>iiru that ihert^ i<s no neiiio or ehronic iuHain- 
tnntory pnxx-w prv«*-nt whieli will prodiieu loc«] heat, and ho give 
an orruiteuiiH impnrvion n» to the ai-tiiiil teinpcminrv of the entire 
bwly. This i» |Kirti<-iilHrly apt to l>u tliu caw in diMsura of the 




moiitlt in uliiMrei), tlui« :Moinatitii< may miao tlio local l<.-[U{K-ni(iirc 
frum one to two(K'f;rccH. Hut li(|iiid8, if tiikca into tlic moiitli ymi 
pri'vions to or itiirtu^ tin; time at which Ih* ihtfrnntiui-tcr is insvnetl, 
will so rni^r the tonipi-nitiirt; of tliL- local tiiuiuos uh to make iJie theiv 
miinictcr R^fjit^tiT »cvonil di-^rcos above nurnml, and a similar effect 
may be proiiwcLtl by oold li(|uid6 or ic« htld in the month. This 
fiubjii-t Ims recontly Ik-od studied by Ijaxarus-Burlovr, who asserts 
that tlio effivrt)^ of hot ohjet'ls taken into thu month laj^ much longer 
than do tliufH> prudtictti by cold, and that a mouth-temperature 
should never he taki-n uithin one hour of the time tJiat auy t«t 
food i^ ingested. lie even eliowH that hohling the month open f 
some time renders a true eslimute of the hody-heat iropowihle, ain 
advises that the temjjeratiire sliall never be taken in the mouth if 
it id possible to take it elsewhere. 

The siguifieance of fever is great. It always shows the ftreaenw 
of an ailment sufficiently severe to make it wise for the phytueiaii 
to order the patient to bed till the fever abates or until he can surely 
determine its cause. The signiticance of a raised bodily teni]H>m- 
lure- from a physiological point of view is that tlie nervous opntrcs 
governing Iieat-produetion and heat-dissi])ation are cli»turl)e<l hy 
some rutbsUinre rinulatinj; in the blood nr by reHox irritation, 
pcrlmps by both. Tin- danger of high fevur in that it may caii: 
cougulnliuti of llic priitopliLtin of the heart or vital centn* in the 
l«i»e of the bruin, but tin- danger of ortliiinry febrile tenipfrnturw 
hM been grtaitty exaggi^mti-d. Itideid, in some coses moileintv 
fever probably aids the body in thmwing off or, rather, eoiujuering 
the disease, wliich ha* uttackiHl it, in three wayi*, tiamely, by pro- 
ducing a tcmpf^THtnrc Iviv favorable to the growtli of oertjiin diseR§e- 
germs than is the bodily t(4ii|>cniture in health; by inercasiug 
cellular activity it may increa«e phagocytojiix and the develtipment 
of antitoxic muteriaU; and, finally, by virtue of the luerejiscd tem- 
perature the efTeets of poisons may be rendered nil. This ts tlie 
case, for example, in regard to digitalis, which will rarely produce 
its ordinary effects on the heart when well-marked fever is prebcut. 
Auotlier point of Imporbmce in this connection Is this, namely, that 
the duration of fever has more to do with its importance as a flyui)>- 
torn than has its degree, for a tempemture of 105° for a few hour» 
may be borne witli imnuuiity, whereas one of 103° for many ilayit 
cannot fail to produce evil effects. 

Febrile movements are generally associated with a diy, hot 


btil NomHtmes nriUi a oold, viei skin. 'Die Utter condition itt of «vil 
sigiiificaiicie as a riilp, and imiitt be overcome if pois*il)]e. 

Fever in ctiildron cIih?^ imi poiuu>!<i« nearly an much .'^!|;iiifleAii<'e us, 
it does in adiitu, for children often develo[) }ii)r1i teni{H^nitiirc-.-< froin 
flight caiiiu'» and liave ti]>oec)y rewverii^. The IiiiIuium; of their 
lieat-ineclianUni is ea.<iily tip.-^et. Thi.' iildiT ilit' [Mtii-iil tlit- ^ix-jitvr 
the xif^niJicaiinc of fever, and a rii>e of two or tlin.*e di?{!ni:-Jt in a 
man of sixty years is mure alarming; than one of four or live d'.-}!rc>«>M 
ill a child of five nr six years. 

When fever is not due to some disliiict [mthotot^icul ohaii^ in 
some |)art nf thi' body, j^enerally of iiti inflammatory kind, it may 
arise from mild irritation of a tnticom* inemhrane no thnt u outarrhal 
oondition is set tip. Such fevers an weii in <nt8CM of mild gustni- 
intestinal catarrh in I'hildri-n after t.lic iii<;(>Htioit of lutil fo>id or 
ex|K>snn.? w cold, and »|i[mn-Htly arii-c at tinuw as the n-snlt of the 
reflex irritation |)ri>dn<H-d by diflienit IwthiuK- (Sw chapter on iJie 
Tonj^ie.) In inony in«tiiii(.H-K, however, the fever of dentition d<^ 
pciids upon a more or hsw closely rchiU'd, but ovcrliKikwl, gartrie 
calarrh. Hi>inclimi;s after n iircthml votiiid or catheurr hax been 
poa^ into tlie iirvthra of u mm, in tJic coiirac of u few miiiutex of 
hours he dcvclojw ii severe dull, followed by a fever whieh may 
Iw quite hip^h, hot dws not last long. 

Frver in IXFECTioPs DigEA8E8.' Nearly all iufwtiouK <lisca«M 
nn' iif«hered in by the development of fever of greiitcr or lc« degree, 
iind thii^ if particularly true of the exauthemnta. In ft/phoid /avr the 
febrile movement la very characteristic in some cases, although in 
nuiny instantx-H it does uol follow the dcHcriptiou laid down in tl'XI- 
iHKikii. After several days of general wretchedness tlio jMtient dt»- 
veloiM a flight fever of from IOC tu the morning to 101^ at night, 
and thiM tem|>emturc prugressively rises so that the next morning it 
may bo 101° and that night 102°, the next morning 102'', that night 
108°, and so on until the morning temperature may be 103° and 
th<' evening temperature 1(M* or rarely UK"*", The fever usually 
reaches its acme by the end of the first week or ten days, and then 
for another week remains almost unobanged, there being a morning 
fall and evening rise of an almoet equal extent. Toward tiie end 
of the third week, or sometimes earlier or later, uccxirding to th« 
HVerity of the attack, the morning remissions become more marked, 

■ lnUUa<oiiiwcilonthc«ail*ai*boiililftUni«>Oinil|»nof ikceh*H('Mitb«ikUidiTOlal 
UUi*coaMd«nUonar Uw<nii.(lT«lDlD;tluii><IMH«>. 


and then the evening: ri*c8 foil to rwicli thtir formiT height. Often 
these market] utoruing K.'Rii.-4iT>ioiis niv tlif first intlication of the ten- 
dency to recovery. Very high eveiiiiift tempcmtnres are iiidicati%'e 
of a severe nttack, hut an? nut «i> iii<)icntive of uerious UlnesH as are 
high leinperaturwin the morninj;. After the third weeic, in a mod- 
erately severe mw.-, tiio teiii|K'ratiiR' falls };rudually lill by tJie 
twejity-eif;htli day it iii>imlly rt-jiuhm the normal, lo very rare 
eas«i (lie tiinjteniturc (•pioiily rcnchwt its lU-ine at the vcrj* twigiR- 
iiing of the diiKW*; and then [uiex-s through the eourse already 
described. Sueh ««»«« arc gcnprally prolonged, but may in some 
ihiitiitiri^'^ i-nd hv the fuwi-ti-enth day. 

iSiidden fiilln of temperature during the course of typhoid fever 
are nearly alwnys of grave import. The most ooinmon cnu^ of 
wioh a i^iiddeti fall ii< an intestinal hemoi-riiage, and tlie fall may 
occur i<i)mctime8 before the hlood appears in the lilools. In olJicr 
case* such a fall Ls an evidence of intestinal perforation. The other 
eaUM-» of a sudden fall are severe nose-bleed, nr hemorrhage of any 
form; a», for example, tiiat ooeurring in connection with abortjoa 
in a fc-nialc patient. Sometimes, too, without any of th&se cnuwKS 
temperature falls verj' rapidly, and tJie patient goes into coll* 
Sueh t;afieit are very grave and the pri^no.'<ii> ii< iinfnvorahle. 

Pia. IS*. 



RiowUi)! ncnidaoonot ot (hvei In • «aw or tjrpbnld n*«r. 

A recrudoecence or return of the fever, in which it rises c|aite 
rapidly to a point as high or higher than at any time during the 
uttaelv, occurs in some persons who, during the stage of oonvale^ 
ccnce from typhoid fever, take solid food too soon, or are excited 
by the visitof a friend. Such rises are but temjwrary. {Pig. 185.) 









More rarely, hk a reritilt of getting out of txxl, »r bad feeding, or 
other <nii»e^, a triit; n-lniwc takw plane, and ihe disca-* mas a secood 
c»iir!>e, wliioli i» iiKimlly, btit iii»t iklwity^, of a shorter and milder 
character limn the lir»t attnek. (Fig. ISt;,) Sonietiiucst a niilJ, 
irritiittve fover, ;M;rlmp« line to anwiuiu, permute for !*ome weeks, 
but the pliyftiemu should not rt^'St eoiilent with a I>eli<^f tlint aojemia 
U the raiisi' until he luw cxelndeil nil |>ow(ibility of tlierc being 
pulmoDury, plcurul, or bone discuse, wt thc»c conditions wry mpi- 
mouly eiiHue lu sequeU of typhoid. In other inKtnitCM, aftdr ttit 
morning tcni]K'nitiire h»« restebed iiormul, the evenin)^ tein]M.>mtu 
remuius pyretie for a number of duya, and it luay giersist for 

If the fever of typhoid ever rises as high as 107" or 108*, tlie 
pi-ognoeis at oiico becomes very grave. 

Very rarely enteric fever, so called, rnna its entire course without 
any fever. Fisk, of Denver, has seen snch csLses, and the author 
had five of them at St. .Vgnea's Hospital in one term of scrviec. 

Striimpell asserts as a rare occurrence that the fever may become 
intermittent, being normal in the morning and as high as KH" at 
night during abiiost the entire illness. 

The a^MX^iation of such a tenipemture-ciirve as ju»I d«9oribed with 
the other eliarBet«riiitie piignx of typhoid fever, as, for example, ttie 
development of the ro.'W-nwh on the chwt and alHlomen, on ur 
about the wrventh day (ehapter on the Skin), the oehre-«)lonNl, 
loose dtooU, the peculiar stupid, drowsy appcamncc uf the tmoc, 
and in some ^tises the peculiar typhoid otlor about the jmtieitt, all 
make the diaf^ii^wis eertain. 

The dilTerentiid cliagnosis of acute Uihfrmtlmi* from typlioi<l fever 
may befpiile diilicult iti certain cases. When the symptoms of the 
two eouditious iwv eomjMiriil tins is not diHiuult to Ijclieve, for we 
often lui\x' in both diseii'ses heiuluehe, epistaxis, u very similar t«in- 
peratiirc-cliart, and a feeble pulse, while there niiiy be in both i\>u- 
ditions an eruption on the skin, which rather icmU to coiifuM: the^^ 
pbysietan than to aid him. A^uin, the delirium in each case ■S'^H 
very similar, and the facial expression of the patient in botJi dis- 
eases is u{uvtlietic. Even the n-spiratory sounds in botli disesses in 
their early stages may l>o uppurcntlyonly those of a moderate bmn- 
ohitis; and, tinally, abdominal swulling, tympanites, and met«ortsin 
may op«ir in botli maladies. Under these eireumstauees the heretl- 
itarv and recent history of the patient may bo of much value. 

3 , 



lOiowiiig a tt'iiitiMicy to tubereiilwis oil llio wits Iiniui, or oxiKwure lo 
ly[J]ui(l itifvdion on tlie otJiiT. Atnii»r if il Ix' tyi)ht>i<J ivvtt, the 
"•liiocn U nojirly nlvntv* found to bu iMiIni-^otl on in'Rriiwsiori. Tin'n, 
too, tltc kiiioiu in the luiipt of a lypliuid-fewr ]»itiuiit un- );iMK>rall,v 
at ttii.' buM'M, wliilo in (ubcn.'iito»tit th«y nrc oftcnvr nt tliv apicctt. 
Ttiu stooli! iiiuy be lootto iu both <li8niiH», but in tuberculosis tJiej 
art- not npt tu be oclirxMHtlurcJ; ami, a};»iii, in tubi!milo«A the \o9A 
of flesli i» often oscceiliugly rapid, and prufttw 6wi>ats and liigb fever 
are nut rarely »ecn. Tbc diseovoi^' of the bttotllus of Eborth in 
the feces and the presence of tlie dia/.o-ri'actiou in the iirine wrmW, 
of course, indieate typhoid fover, (See chapter on Urine.) Fiiiitlly, 
careful und repeated examinations of the cheet will usually, in tli« 
course of the dlaease, dcmonstmtu the presence of tubenutlosis of the 
lungs or boweU, if this Ire the cau-sc of the illness. It seems liardly 
necesaniy to state that if any expectoradoo eslats tbe sputum is to 
be carefully examined for t«bercle bacilli in all doiilitful case*. 

Irregular forms of malarial fever, particularly tJio-te forms due 
to infeetiou by tlie leiitivii-autumnal jMra-nite (f«e chapter on tJie 
Blood), may closely reDembltr typhoid fever. In many instauces 
t«uch case!4 are dia^^no^ a«« typhoid fever, and probably Honie casea 
of true typhoid fever arc thought to be malarial fever. The follow- 
ing tliffrrential table, drawn up by Thayer, is of interest in this 
oonaectiou. There is no such tUseose as typho-mnlariul fever. 


JtenUMI Awr. 
OtuM t*D«nllr iQWtmltMat. 
Irrtsulu moladoiu 

Onwt gmliial mQit pn^nKlra 

RcgnUr. Ihoufb nrj illiht nnniliv nods- 
itaat witb oi^niim oxnocrbtaoiitoC UminM- 

Tbi unvMinini lion not tmdtt 40» (1M°I 
taton Uw (litf4 or boitb Omj. 

BaHlMlw ttom Um tcdunlug. t^nnumil. 
M*w«, riwilal. 9cl*fa ablM^ 

Tit* untp*Mtaf« iak9 trilM •! «p (1H>) 
ifllblti Iwralj-ftiiit bnun. 

8««dwilM mra In ilu bqtloiitnK : of a iwu- 1 
Mtte «lwuMMr, iMlMUns, nriaW* ID II* 
rsMtonaodluUiHltr- Sclcmiiikl<i*tla from 

nwatatlwLlrciprtslanoflMbMkUieiItT- Tltn* (TmiMini ai« «Bll-aiMt«il and pfi^ 
MM of tb* uiDRUo. uniM Vfio tha Uclh an trtmlie. 
DM tviT maikBd. 


Bnaib bu ■ tociiltw nrauM-iUt* o4«*. 

nwil*Ui1llBnureom*OBt&UwM>l]r <ltr«i tMllloDi affaan only <* lien Uw illiiaia li 
It I* tccunvoi. ftnl obaosai wllb Ite (■xa<«(i«- ' wall laeminind ; It I* iiltoit iKnltUol aud 
UouorwiDieralaNaiidMbctiirBI'l'an". "kI mUWe onlT til ilitClM. 

. maj «1to <**t w (mm ijriairtoiM r«lat(d 10 

^m ouht (Iff *»■. 


Jtmtllenl /H»r. 

tf UicK b? putiDonuy oonctalloa, Uut coogb 

■dil Mlior lympluni* oatna on )Udd«nIr : lb* 

■nu •nvMd ohui|< from one to ihe oUiFt 

Mworttmcuid nwr dlwppow uid impjicai 

MMlD with nrrliig InMiMlly ; dnpnoa U virjr 
pionouooad i drrolalorr dlMurbuMi «« 
Burked. tumi t^ntope. 

knd mnitttjr 

■ muMd Miljr In tbe 

OmUMIo carport*). 

Peonllu iMTlih oolor of tkla ; woMllmH ■ 
•llSlit JsODdloa. 

Herpv cDmtnnii. 

AiumilK more or le 

No ohuxilvrMli: ciantlwni: urtloulB not 

At tlmo* (hoi» nait tw Inuiddil Irmpftnltea 
or llwMtvcal pirillni: llicy bib bia%UgbUj 
proaoUiKWil nnil parui^mniil i •llnrrliiM Ik 
(liBblorabMut. niiil liu iiol llii «h>r«ot«aiir 
Uut In Irt'liolil tent, 

Xo dliUcoi counft 

Vrina higii-roiond : mar (bow > tnecofblle; 
Kbrllcb'i illaio riHioiloii nnly pt««al. ' action pFavnt duHnR Uie helRht of (be ptoeaaL 

Blood (how no leuraorhnln : MilDOptille* lllood iho\>ii ii'i kuoocxIcaU ; ooalnopfallM 

notDolMbtr dlmlnUliod:iicmnidaainot rauiu dimlnlilicd or ahifiii .wmmcannagtlMMi* 

afftlanwntlori at trplin1<1 tnottll il-Mm>r. Uur- ail on of (fpb old baoUU ; m4lMlilTandtaftBd 

bam. and WMat) : nuiliLrUI puiullot and pl^ lOcmenl abNOI. 
mmlcd Icuvocylcn pfcwiii. 

Tiiftaid Am*. 
rulBonary vmftMvn U padiMl and t<t- 
fimiit: al«v* bJIMalMIc lllu banaaoddor- 
nl lurfteoiof Itaa Iimj^i : lh« djipno* It !•■ 
pronounced and Utir iiitpp«nncd«peiiitlBR 
inai» dpon Uw abdominal cnnditioiM (tyn- 
panllOk etc.). 

Thei* art luuallj raUuUaa, t«MUaUon, 

Ko Jauudlce. 

Bcrpa i»tt. 

AiiiBtala nbccnl. eiarUns In 

I'lianuti^rlillr nneola. 

TVlupalIl[«^ (urtlltig, dlanbua •PfMtr 
■lou'lj- and majr bMomo mil laarkcd. 

Hm a ftiFir ebuMMtinie MOBft 

L'nua Mch-coloTCa : W» attMiti Mmww 

I'erar dlaappcan undor quinine. 

It >ii andamlo diMBM oeaunlns tallica tarlr 
In tuni dliulott; nrolT efddeiDla; 

Fvrer ualulloenoad br qutoIncL 

Uniallf aiildamlo: [iieraJltns tommonlj In 

Till) febrile mnvemi^nt and other Hvm|itoD>8 gf enteric fever are 
often imitated verr closely br those of ufceralief endoeardUia of a 
typhoid type. lu a<ldition to an irregular fever, there may be diar- 
rhoea, parotitis, stupor, and progressive feebleness in both discai*e. 
An esamiiiation of the heart may reveal the presence of eudocar- 
ditis; or the existence of some foeits of infection, such its a wound, 
a Peptic process, or the fact tliat the [Kitieul is in the puerperium 
will, in combination with the .sudden development of endocarditis, 
render a dia^fnosis po>uiihle. 

An irregular fevt:r with miLsciilar pains and a great deal of dis- 
oomfort in tlie belly, the .stmiilatin); typhoid fever, may occar 
in casofl of lriefiino»i». 

A febrile movement oloiwly resiiembling tiiat of ty])hoid fev^r, a 
resemblance n-iitdi is increased by tlic ossuciatiua with it uf hvnd- 



f, in.wmniii, and anorexia, may be Malta freer, a disease wliich 
can* lie excluded in the va^t iitajoriU' of caseii if tbere is no hi-ttory 
of exjKHiiure to tJie exeiting naii»e in tlie ioland of Malta. Some- 
tiiiips it nii^lit be confuNwi with ivlapsinf^ fever, exeept for tlie longer 
febrile iiiovoiiieiit in tliis disiiwe. Tims after three or four weeks 
of ilbiesii eorivaWwiK* ^ii-m" to be efttablisbed, and the temjieratiire 
fii]|»i, but in ti f<.'W days uU the Mymplotii.-* return with even greater 
vchcjiiuiiw tlinn bt^fyrc. Siic-h rulniwos may oct'ur agniu and again. 
Violetil [Hiiii ill tlie joint* un moving Uic body i-i often pn-sent. 

Tin* temiK'mttin;-clmrt of typhus fevfr is m different from tlial of 
typbctid fever tliiit it gives w a vuUinble differential jiuint at llic 
veri' beginning of tbc di«'!i»e, for, after several ilays of Inngnor, 
lii^ilnnbe, and puin in the limbhi, the fever suddenly epring!< on the 
]iutieiit, no tliat on the Hrot night it may reach 105'' F. Often it 
nyti'.hex 106° in u day or two, and while present is eontttant, the 
morning full being very sligbt iiuleod. Tbe development of the 
apotit in a copious eruption on the third to tbe Heveuth day, wbieli 
spots may develop into |)etechiic before fading, or remain untfbuiigi.s1 
in appcaniuce, thv great exbaustioa, the severity of the illne^^, nn<l 
tlie sudden rise of temperature, followed by a i-on^tant fever, point 
to typhur^ fever. Finally, the conclusion of tbe febrile movement 
ii) favorable caaea by the end of the xeoond week by crisU or by a 
more rapid fall of temperature than we are accustomed to see ia 
typhoid, all help to make tlie differential diagnosis, which is, how- 
ever, in many cases very difficult or impossible at first. 

The temperature of rtlaimnff /invr nearly always rises suddenly 
at tbe bc^uning of the attack to from 10:!*^ to 105°, and remains 
high with slight morning remispiioiui from three to seven days, when 
it suddenly falls as by crisis to the normal or below it, after being 
on tbe preceding afternoon or evening unusually high. Si>metimc& 
it falls as low as U'2^ or 'XV F. 'I'be patient now remains free from 
fever for fn>m several days to two weeks, when with a snd<Ien leap 
tbe fever and other symptom* of tbe first attaek recur. A tempera- 
ture of 10.*>° ii> IOii° in relapsing fever rarely indinate* a grtve 04it- 
look an it doeif in typhoid, The only mmlilion wbtoh rewmbica 
this tem{icratu re- range of reliipMng fever i.'* int^'miilt^iit malarial 
fever; but tlie rarity of rela(»»!ng fever in America, the fre>|neney 
of malaria) fever in ecrtnin |kipIs, tlie presence nf the spiriltuin of 
Oliernieier in tlie blood in relapfiiig fever, and tbe mnlnrijd gi-rm 
iu tJie blood of intermilti'iit fever, all nutke tbe diiignogi* [lowtible. 


Ill gpnifrl /eoci- the tcm|)entiire sikIJcqIv rises nu the first day U» 
104° t« 105" F., and still higher the uext day, aiid theu reiuaius 
cimstant as long as the eru|itIon is on the skin io fall development. 
Just 8o Boon as the eniplion begins to fade ihe temjierature also 
falls, not by crisis, Imt by a lysis; not so slowly as in typhoid fever, 
hut far more slowly than in pneumonia. This arrest of the fever 
usually takes plaoe in niinple cases by the end of seven days; an<l 
if it pemsts longer, is probably due to some oomplications, siu'li as 
otitis, or tile " collar of brawn," du« to enlat^ed eervieal glands. 
(Fig. 187.) The characteristic strawberry puiiclaled rash and 

no. U7. 

ityiili 1 

B [ 4' 1 ' a 1 1 |« n 







■ t 

■ f.«( WE w (M ilm *c 

■I E 

■I I 

■ (" ij 




i ! I 













/ J 




1 I 

' / 

/\A A 





k .(jj 







Bcartet hue ajiiienriiig on the An*t or second day, the ultimate dermal 
desquamation, tlio violcnoc of the onset of ihe symptoms, the sore 
thr<iat, and the jKtculiar nppcjintnt^e of the skin, all complete the 
clinical pictnro, [wrticulnrly if the symptoms he in a child. (8ee 
chapter on Skin.) 

In rariKwsiw the fever ia Hnirlntina is remnrkahly mild or almoa 
absent, and thi^w oisej*, a* n rule, liavc n fuvuralili' prognosis. If^ 
the tt>m]M>nitiirr Im- very hi^h and iH*rsi;iti!nt, ou the otiier hand, tlie 
case is tuunlly to Ut regnnlwl vu most gmvo. 

In v>ea»U* the fever at first ri«-s fiharply to tO:J* or tl>en-abi>iit, 
then falls to n little above normal, i'f slight for :wvenl days, and 
tJicu markedly inervaiK's with the development of th« erupliou im 
tile fourth iJny, often ranninn as high ni» lOt" or 105°, at whieh 
point, with little variation, it remains fur the two days during 
which tlic nwh is well devclopi'd. (Fig. 188.) With the fading of 
the rash the tcmpcrstnro also fulls by erisis. If fever porstftn to 
any exU'ut, it is always duo tu fiome compUciting muse utlier tlmn 



tltft Dri^niil (litiMMc; such a comjiliintion, fur vxftmitlv, a» a brxui- 
*;liiiil iir fttutro-diiodcual catarrh. 

The (ever of r&theln, if any occiiri>, is very seldom mori" tlinn 
102°, hikI Im? no t_v[>ieal [>r<'1tiiiiiinrv riiti' im litis mtnsivs, so tbat 
IIk> U>mi)eraUire-cbart of (hi; (iJM^itsu may aid iiuitcnally in u diffei^ 
(See (rliaiiUT on tin- Skin.) 

eiiiial dingnui^a. 

rio, Wk 

Aa«1n«i«lllallbt«t «ltbUu)ut«tqu«iii ikiluKl tiituk rlMwIicnthomb It wvlldorclopo) 
InaMMorucHlw. AlMibotraaacndlncor ibcfnorhyrndi. 

The febrile movement of amaU/x>x [», witi) the exception of tluit 
nf typhoid, the most cliarartcriTitiv of idl tht; oru|)t)ve diwnMM. 
With a sudden onset of fever, |Min in thi> back, severe lii>sdach«, 
ami aialai»c, the patient takes u> lilx U-d if jwssible, ami liii> tvni- 
)>erature if taken will bpfmiud !<[)!KNli1y toriwoven to 105" or moro 
in M>me oasps, and tliun fiill^ lim-k lo almost normal for two or tbrw; 
days, during whii-h time the •>rujition appnir^. In thi^ way, tJiere- 
fore, the teniperatnre^hart of variola diffcnt diametrieally from lluit 
of the eruptive fevers «ii far iliwnsv^'d, fur in tlieae cuu the fevar 
rifles with the apjHiininei; of iho t'niption, whereaa to UiIh inHtnnco 
tlw tem|)r-rature falls with the appeaninw of the eniptioi). Thix 
lower Iem[MTiitor(! )M-r«iits for(*vcral days, from half to one dfrnrTmo 
nbovi* normal, till the ninth day of the diseaw or ilw "ixtli of tlio 
eniptiop, when witli the i-hanpe of the pocks from vi-sielvji to pns- 
lidei the temjH-nitiirvi riti-* again in wliat is called tln' fever of *up- 
pnmtion, which laiiLt with greater or leiM |ierH)jilenc« for nt lea»t u 


week, when it ends hy lysifi or a grailiial fall. Excessively hi;;!! 
fe%'er of 108° in a sigu of appi-oaclun;; death or at least of wry 
grave import, 

Tho febrilp movement of vartctlla, or Hiickcnpox, is uennlly of 
very short duration and of little severity; but it mar reach propor- 
tione entirely out of conmnanee with the general Hystcnii<; disturb- 
ance, which is usually very slight in previously healthy ehildreii. 
Thus it may rise in eliildreti who are prone (o active febrile move- 
ments t4j as high a point as 105° for a very brief jtcriod, and yet 
may not seem to render the child ill. 

Tho temperature- range seen in cases of erysipttns is (juite tx'pical. 
At the begiuiiiug of the attaek the rise is ipiite prompt and sharp 
to 106" or lOG" or even above this, and, instead of remaining coo- 
Btantly high through the course of thf iiiilnniniatory process in the 
skin, goes tlimugh niurk(;d iulermUsinnx or remiiisionii, which fre- 
quently ouotir and art* followed by risc» in teni|terature ai4 high as 
that which ocourriHi with the first onset. Tlii' fever ends in some 
coses by crisis, and in utlicm \>y tysia, the latt«r motle of finding 
usually taking place in those case^ which have had a very mver? 
attack prolonged in characti^r, or which have been tn an asthenic 
Klatti prior to the disease. The diagnosis of eryitipelas is easily 
made by the hniwny, swollen, and red skin, with the [)cculiar line 
of demarcation at the cilgeof the swelling. (Sue chapter on Skin.) 

A fever which rises sharply from normal to 103° or 104*, lioing 
pre<«ded by a ohill and followed in a very few hours by a sweat, 
the whole term of acute illness, if we exclude general physical dis- 
comfort, lifting but eight to twelve hours, is in tlie majority of 
casus that of itda-mittent malarial fevef. The peciiliuritiee of Inter- 
mittent malarial fever, aside from those just named, are that the 
febrile movement begins to decline before the stage of sweating 
begins, and in some cai*es it begins to rise before the sensation of 
chilliness of tile first stage leaves the patient. (Pig. 189.) 

The fall of temperature is usually less abrupt than the rise, and 
is sometimes delayed by slight temjiorary rises or arrcets in it* 
downward course. 'I'lie febrile movement ia rejieated at int«rvaU, 
ranging from one to seven days or even at longer intervals tlian 
this. If the attack!^ uconr daily, they are called cjuotidian, and tiii« 
in dne to infection by two set:* of tt^rttati (Kira.iitwt which segment on 
alternate days, or it may be lUic to inttiTtion with throe set* of qnar- 
tari pnnisitcj*. If tlie atttu-k» mxrur every other (hiy, ihcy arc culled 



tertian (Pijf. IJK>); if on \\w tliii-J dav, f|uartau; if on the fmirth, 
tjuinMn. If two iittiu.'l(# conn.' uii thi- ^me day, it in itillod dnublo 

rxi. M. 



v. ■ 





%VH - 



1 1 

B mil- f- 

iin, i— 


— H 


,H Infl f 

- ,1 . 


■ ' • t ■ r 

Sbowtns ilulr i«rai]tnD diic u> iloiililu loittan tnlbcUon. Ona ttl cd lanalHa MgDCDM)! 
M 1 r.H. Md Uic tecund •« fti s tM. Tuoxyva Moptcd by ■lUinlnc on Rxmb ihtir. 

Another jiotnt nf impnrtnnoo in connection with mtilarlnl attn<-k8 
w ttiat they often iwiir earliir ("ach day liy an hour or more. i{jin.'ly, 
tboy are delayed. 

fn. m. 







Sbovlni |«ioitiiniiio[ liitllnn tvtti, ihrm < 


< I' lb* (iivsiili 

fnlorniittcRt mabirial fever \» to \hi M-]uirat«l from oUter tot*!^ 
niittin^ fevers, by ii imnilK'r >if fiK^tx. First, the [>res<-uc^ of tlic 
inaiariuJ organiaiii in the IiIoikI iit lliu time of the attack, or eviilont'Vw 
of its presence at i>lhi?r timi'ji. (St-e rlmpter on Blofxl.) Swoiid, 
by the bi^ifiry of ("Xjiowun' to ninhiriiil inlliienoes. Third, hy tho 
(narked effect tor good un malaria] fever prodiiuetl by the iulinlni»- 
tratioii of <|uinine. Oiru niiwt always be taken that the inlermittinn 


446 Tirr: AfAXfrKSTATiox of hisease by sntPTOMS. I 

fev«r (>f Uit* viiri»ii.4 funiir* of ttf^p^lt are not diagno^ol a^ malarial 
iiitt-rmitteiil fwcr. The iiiosi cuiiinion error of lliU character i« 
ttie making of niliiLgna-«i«uf irrogiilaniinlnriut intermittent, liecauAe^ 
chillfi, ftfvvr, nml swwil nppimr «vcrv I'vcning, wIimi, in reality, tlie 
re«l cau»c is iiii iintliwwvoroil ]iulmi)niiry or abdominal tnlwrcnlosb. 
Agnin, aciiti- iiletTiitivc fniiu<-»r(]iti» iiml ])uriileiil plileWlis nmy 
cnuw Minilur ityoiptoms, tut miiy nUo hepatic- nh^oci^s imfmotinu of 
gnll'Stoni's, with »iippnrative chulnn^itis, cniuin); the Hiv-mlledj 
Charcot's fevor (sec bi-Iow). The iibeenee of !i hirtwry of niaianal^ 
exposure, the pos^hle preHi.>noe of a couf;)i, unil the iliwovery of a 
tubcr«iilar lu^ion In the cho^t or ahilumeii by cjirefnl phy:»ienl cxam-J 
iniition will aid in lU-culin); Uiat the fever is tiibercnhir find iwH 
miilarial in origin. (Sec chapters on Thomx and on Abdomen.) 

In uletralli'e fridocardifU the tcmpcmtu re-curve may <'sa<lly 
resemble intermittent malarial fever; but in many iii^tiuu-vs lh« 
presence of an external wound, acnle sepeis io some p«rt of tlie 
body, or the presence of the puerperium will reveal the eonrce uf 
an infection. (Fig. 191.) In the typhoid type of ulcerative omlo-- 
oardJtis the profound asthenia and general prostration will sepantt*! 
the diseofleB even if the tem]>et-ature-chart be UDe({iial. In tlm 
form tlie febrile movement Itt rarclv tvnicallv intermittent. The 
criioial of the difFerential dIagitoi*i.<i lie^ in an examination of 
the heart, in whtnh a murmur may he heard iu some but not in all 
case^, unle«fl there bii-s alrmdy been some gmve valvular mischief. 
The 0Brdift<: feebleues.* and asthenia, on the one baud, and the remit 
of the blood-examination, on the other, aid the diat^ioHitt. The dura- 
tion of the I'jLv i« not of much value in making a diagiio)ii.s for 
eases of ulcerative endo«^imlitiH have linttcd from two days to more 
than a year. Karely it hste more than six weeks. Denth usually 
Docnrs ill ulcerative endoc^inliti-i, unless there has be«*ii prcvioiwly 
pn-sent chruuic endocarditis, in which caec recoven,- may rarely 

The discover}' of some sjmC showing a phlebUia may point to chi« 
cause for luturmtttont fovcr. 

The fever of ailarrhal or mippurative cliolantfttU oft«n closely 
r(«emblcs intermittent fever, but tlie presence of hepatic symptoms, 
of marked jaundice, of a history of gall-stone colic, and of exceed- 
ingly severe rigors, enables iis to separate theni. 

When fever of an intermittent tyjw has been observed, and inter- 
mittent malarial fever, tuberculosb, and cholangitis cannot be dii^ 










covered iisfi oaiisc, ^earrJi shoiikl lie iiuide for tcmlcmcas an<l KW^lltiiK 
of the liver, clue lo Iiepatic abaceis. I'rofuse ewents also will be 
fount) in fruch cases, ua in most instances of septic fever. Tb« diaft- 
nosie of hepatic abMsess will \ie ntrengtlieneJ if there is a histoiy of 
the pnticot having sufFered from <lyt>enter/, as hepatic absoew a 
frequently caused by amoebic dyKenlery. 

The preHonce of fever preceded by chills, the temperature rising 
to 104^ or even lOS^, followed by excessive sweats, in a person wln) 
is profoiiiidly cachectic, may he due to pen\iciout an(emia or to arptic 
poinoning, as already pointed out; hut it should be recollected diat 
sucli a torn peratu re-char I is often seen in cases of gastric cancer. 
Similar symptoms as to fever in association with enlargement of 
the lymphatic glands, particularly those of tJie neck, indicate 
Hodgkin'n disease (see chu))ter on Blood), or even more commnnty 
tuberculous adenitis which, Iiou'cvcr, is more commonly met with in 
the young and involves the glands near the jdm*, while in Hoalgkin'x 
disease tlie glands near the clavicle an- affei-ml. f'ltrlher, in 1 Iin))^- 
kin's di.icnse tlie ^welling is t^iiially biliiteml and to he found else- 
where than in tlie neck. Agiiin, in tii1>i!rculitr di.->ease these glaiidit 
often suppurate. The pre^enre of tlie ttibcrck' l>nritltis in an ex- 
cised piece of the HWolling will decide the diiigiioaie. All intermit- 
tent fiivcr may also he mccu in •tnpptirative pyelitis, in ASMwiution 
witli pyuria. This pyelitis may or may not be tnlxrrcuhir. 

Remittent fever risiiip and falling even,' few days fur two or thn-« 
wivks, niri'Iy risinj; above lOS' to 104*, and even fidlinp to tlic 
normal line, associated with enlargement of the splceo and liver, 
yellowing of tlic !fk!n, or jaundice, bilious vomiting, and u history 
of exjiosure to malarial [toisoning, indJcJitca raniflrnt vuiltirlal /errr, 
a form more chronic and very much more grave Ihan tlie intermit- 
tent form just described, because it respoutbt loss n^adily to treat- 
ment, and, second, because it is accompanied by more marked 
changes in the viscera. It depends upon infection n-ith wbat ia 
known as the test ivo-antnm rial form of tlie malarial jiamsitc, which 
has an iiTegnlar or variable jjcriod of growth. The conditions pro- 
duced by this parasite are collectively groujied imder the names 
remittent, continued, bilious remitlent, and typho- malarial fever. 
In some cases the temperature and other symptoms will so closely 
resemble those of typhoid fever that nothing short of an examina- 
tion of tlie hloiid can d»!ci<le the diagnosis. If small ovoid, moving 
parasites are found in llie lir*t wii-k, or oreseentic parasites after 


tlint timt^', tliii; will dwnde thiit tlio case U malariitl. (See cliapt^r 
on the BlocxI.) 

A febrile pruui-t« fiumcn-lmt closely resembling reiiiitutnl uiulnrial 
fcvor, yet so nire, fomiwnitivclv. n» never to be Honfiwfl with 
it, it; Weift ideftur. In tii'iM cuitditioii tlii> fever nius n remitting 
coiinw, is aiwociiitcd with jiiumliee nnil iiwellinf; of the liver and 
spleoD, and the stools may be clay -colored. Thore i* oiw intiwrtnnt 
point of difTerenco between malnriul n-nittteiit fever »nd Weil'n 
di§ease, namely, that in the hitter gaHtro-iiiti«tiiial syniptoniit are 
nearly always wanting or are mild, wheri'iw in the former thty aro 
apt to l>e very severe. Usually the feverof Weil'«di«MUte cMxes by 
tlie end of two weeks or earlier. It is probably an infectious jaunflicv. 

In tiettgut, a disca^ seen most commonly in epidemics in evrtain 
parts of the southern Uniteil States, the patient, after sulTering 
from violent aching pains in the ba«ly and limbs, swelling of the 
joints, and th« develupnieiit of a variable rash on the ehott, devclogts 
an aetivo fever, which tasttf with the pain till the fifth day. when 
both the pnin and fever deereaso or eitase, and then often return 
with equal force. These faets. combined with tiic faet tliat it is an 
epidi-mie disease, separate it fntni malarial fever. 

The fever of jfelloic f'n-tr is rarely over IO;t° or lOt®, and la mie 
of the milder Hvmptoma of the disease; but it posseases this peculi- 
arity, namely, lliat after tJie lapAO of from twelve hours to sevcml 
davH tliere is a niarkul reml^ion of the fever and all the other 
aymptom.s and from tlii>4 timi^ on tlie patient may )^et well, or after 
a few iiiiur^ thi.4 i-ralni stiapx Ih followed by the true violent Aym|)- 
tonus of the di^-a-te, sucih a.-* blnek vomit, tarry atooid, jauiidioe, aud 
hetnorrlia^'^ from tlic nitieou.-i nieinbranci. (ieiierally tlie full 
connc of di^uSM to oinvali^^ieeiiee or dealli \* run in about one week. 

Tlierv i:< only *.>nv other dL-^iLse wliieh e&n l>c readily onnftiwd 
with yellow fever, namely, bilious n'inillfut fever, and a trotue of 
the latter di^ttw iHiuirring <ltiriti); an epidemic of yellow fever can 
Iwrdly fail tu be iiieorreelly diagnosed. In the abwncc of an epi- 
demic, however, the probal>ilitie.i nf the i-as*; being bilioii-. n-niiuent 
(ever are very great, and the ])r(■ltello(^ of ImIIous vomiting rather 
than ihal of blood, the elianieleriHlIr (ein|>enititn^Thiirt, and, above 
nil, the pre^m-v of a history of niainrial exjKiHiin; and of the sigiis 
of malarial infection in the hlooti, with the jMirtial control of the 
Hym|)t4)0iit by ipiiniiie in o<rrtain ntngi^t of n*mitt«tit fever, point to 
the roalarinl diiMiM: mther thou to yellow fever. 


Jiisl as ill yellow fever, so iii iiprttte<l fever or e^rtfiro-apinat nun4 
hiffilit of nil vpidiMuie form, the fever ib>elf is oiie of the Icaiil!^ 
important svniptoRis, for, a.siile from Hie fart that it is a|)t to be irtt^- 
ular and interrnittiiig, it is rarely very hi^li, as e(>in|>arc(I witb the 
violeiii eorehrn-niiiiial Hymptums, the rigidity of the back of tliv 
neok, iJie hi'iulaclK-, rK>ttviilMOiiM, and vomiting.