Manual of clinical diagnosis

Front matter

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Preface To The First Edition

The presentation of this manual to the public is due to the encouragement of our highly esteemed teacher and chef, Geheimrath Professor Gerhardt. We have endeavored to supply a want by giving in an epitomized form, the different methods of examination, as well as a convenient collection of those data and figures which should always be familiar to the physician and student. These data, on account of their number and variety, cannot be remembered with the necessary exactness, and, on the other hand, are so scattered throughout numberless text-books and monographs, that it would be troublesome and time-wasting to search for them. In selecting and arranging this material, we have been led by the experience gained in holding courses, and we have also endeavored to consider the practical needs of the student and physician by noting only what is reliable, and omitting every thing self-evident and of secondary importance.

THE AUTHORS.

Wurzburg and Berlin, April, 1886.

Preface To The Third Edition

In preparing the third edition of this manual, I have endeavored to do justice to all the wishes expressed by the different critics, as well as to consider any wants which have become apparent since the last edition. Consequently, a number of improvements and additions have been made, and among them it seemed necessary to add some new illustrations, especially to the chapters on blood and urine. The illustrations of the leucocytes are from preparations of Professor Ehrlich, and those of the urinary sediment are, in part, taken from the physicochemical atlas of Funke. The tables in the last chapter are intended to make the questions of diet and assimilation of practical use in the sick-room. In conclusion, I should like to thank all those gentlemen who have so kindly assisted us by their suggestions.

Berlin, October, 1886.

TRANSLATOR'S PREFACE.

The favor with which this book has been received in Germany, and its eminently practical and concise manner of dealing with the different important points in diagnosis, seem to justify its translation into English. It has been brought down to the latest acquisitions of science, thus representing the most advanced views. For the sake of clearness, the figures relating to weight, measure, length, etc., as well as the dose table at the end of the book, have been modified to conform to the system used in America and England. Translations from the original into French and Russian are now in press.

The translator takes great pleasure in thanking in this place his friend Dr. Robert T, Wilson, for kind services and valuable suggestions rendered in the proof-reading and correction.

W. B. C.

TRANSLATOR'S PREFACE TO THE SECOND ENGLISH EDITION.

The exhaustion of the first edition and the changes in the original call for a revision of this translation. The principal changes are certain additions in diseases of the heart and lungs, an entire revision of the everchanging section on bacteriology, the correction of certain errors kindly pointed out by critics, and the addition of a handsomely executed chromo-lithograph of the micro-organisms.

W. B. C.

November, 1890.

Measles 10

Scarlet-Fever ......... io

Small-Pox ii

Typhoid Fever ........ 12

Typhus Fever 13

Relapsing Fever ........ 13

Pneumonia Crouposa . . . . . . .15

Chap. III. — Organs of Respiration 16 Topography of the Chest . . . . . . .16

Percussion of the Thorax . . . . . . .21

The Normal Boundaries of the Lung . . . .21

Topography of the Different Lobes of the Lung . . 22

Auscultation ......... 27

The Breathing Sound ....... 27

Rales .28

Auscultation of the Voice . . ... 29

Chap. IV. — The Sputum 32 Morphological Constituents ...... 34

•Chap. V. — -Laryngoscopy and Rhinoscopy .. . - 37

The Muscles of the Larynx ...... 38

ix

CONTENTS.

Nerves of the Larynx .

Paralysis of the Vocal Cords Chap. VI. — Circulatory System Inspection and Palpation Percussion of the Heart .

Auscultation of the Heart The Heart Murmurs Auscultation of the Blood-Vessels Chap. VII.— The Pulse Chap. VIII. — Digestive and Abdominal Organ The Teeth .....

The Saliva .

(Esophagus .....

Stomach ......

Examination of the Stomach's Contents Liver ......

The Spleen . .

Abdomen .....

The Faeces

Chap. IX. — The Urine-Producing System The Genito-Urinary Organs The Urine .....

Normal Constituents of the Urine Inorganic Constituents of the Urine Pathological Constituents of the Urine Organic Sediments Chap. X. — Transudations and Exudations Chap. XL — Parasites .... i. animal parasites :

Cestodes — Tape-Worms Nematodes — Round-Worms Trematodes — Flat-Worms Arthropodes ....

Protozoa ..... ii. vegetable parasites :

Hyphomycetes ....

Yeast Fungi ....

Schizomycetes or Bacteria

PAGE

38 39 41 41

43 45 46

77 89

91 96

101 102 102

CONTENTS.

XI

Chap. XI. — The Nervous System Testing the Sensibility Testing the Motility

Motor Symptoms of Irritation Diagnosis by Means of Electricity Reflexes ......

The Most Important Clinical Points the Nervous System .

Brain and Spinal Cord .

Cranial Nerves ....

Spinal Nerves .

Chap. XIII. — Analysis of the Pathologicai

ments

Urinary Concrements ....

Concrements of the Intestine .

Salivary Calculi

Gall Stones

Chap. XIV. — Metabolism and Nutrition

Table of the Weights of the Human Body Dose Table .......

Appendix .......

the Anatomy

Concre

PAGE

113 121

124 124 127 129

132 132 134 134 134 136

143 144 163 175

Fie. 1

Fig. 2

r ,

Pneumonococcus

Bacillus Cholera

Fig. 3

Fig.*

V

BacStus Anthracis

SpirHhurv Obermeiri

Fig. 5

Fig. 6

StapTiflo coccus pyogenes aureus

Streptococcus Brysipelatos

Pig. 7

** if

PflTi"^

Bacillus Tuberculosis

Fig.

Fig. 9

Bacillus Leprae

Bacillus Eqvimae

Fig. 10

*****

Fig. 11

Bacillus Typhosus

LiLh . CJSrst Leipzig.

CLINICAL DIAGNOSIS.

Chapter I. The Blood

The whole quantity of blood in the body of an adult is equal to about -^ of the weight of the body — that is, on an average, 5 kilograms [10 lbs.]. 1

The specific gravity varies in health between 1045 and

The reaction of the blood is alkaline.

The amount of hcemoglobin' 1 in the blood is about 14.57 grams [4 drachms] in men, and 13.27 grams [31 drachms] in women, in 100 ccm. [3 ounces] of blood. On heating, the haemoglobin is resolved into brown haematin and albumen.

If some blood {e. g., that obtained from a blood stain on wood or linen), be heated to the boiling point with glacial acetic acid and a trace of common salt, and then slowly evaporated, there are formed brownish-yellow rhombic crystals of the muriate of hcematin, which is the same thing as hcemin or Teichmann's crystals. The preparation should then be moistened with a little glycerine, and examined with a high power under the microscope.

The red blood corpuscles measure in healthy individuals

1 That part enclosed in [ ] is by the translator. a The amount of haemoglobin is determined by the quantitative spectral analysis or by means of a hsemochromometer.

from 6.7 j.i to 9.3 /O The average size is 7.8 jn (Gram). Giant blood corpuscles (measuring from 10 to 15 yu) are found principally in the blood of the anaemic, and especially in those suffering from progressive pernicious anaemia. The dwarf Mood corpuscles measure from 2.2 to 6 //, and are like the normal ones, only slightly more biconcave. These are also found frequently in anaemia.

By Poikilocytes are meant those red corpuscles of irregular form (pear-, club-, or biscuit-shaped) which are seen in all anaemic conditions. Microcytes are small spherical bodies, generally very rich in haemoglobin, and

Fig. 1.

Nucleated red blood corpuscles. Poikilocytes.

Dwarf (W)

Mood corpuscles. >-—«______ c

A normal red blood corpuscle*

<-> r^n J y^) ^ Giant f^ ^7 M"~^-^ - blood corpuscles.

Microcytes.

are found in many cases of burning and poisoning. Still we must very often consider them as artificial products. It is uncertain whether red corpuscles with crenated edges (thorn-apple-shaped corpuscles) appear in normal blood or not. When seen, they are generally considered artificial products caused by evaporation. Notwithstanding this, they are observed to form more quickly and abundantly in many cachectic conditions than in normal blood.

1 /Li = the one-thousandth part of a millimetre, and is known as a

THE BLOOD. 3

Nucleated red blood corpuscles are seen in all severe cases of anaemia but they can only be recognized in stained preparations. 1 Very large nucleated blood corpuscles (megalocytes) are seen in progressive pernicious anaemia.

Blood-plaques (Bizzozero 2 ) = Hcematoblasts (Hayern 3 ) are colorless flat round discs about one half the diameter of a red blood corpuscle. They change their shapes very quickly when outside of the blood-vessel. The elementary granular masses are small, often angular, colorless granules with a diameter of 1-2/i. They consist in part of fat, and are probably for the most part disintegrated products of the blood-plaques.

Fig. 2. Fig. 3. Fig. 4. Fig. 5.

V

Lymphocytes. Large mononuclear Polynuclear

Small size. Large size. cell. cell.

The white blood corpuscles (Leucocytes) are divided according to Ehrlich into : (i) Lymphocytes, which are about the size of a red blood corpuscle or somewhat larger, with a large round nucleus, and a very small, often scarcely visible, protoplasm. We distinguish two forms, a smaller and a larger, which latter is only the former in a more progressive stage of development. The lymphocytes have their origin in the lymphatic glands. (2) Large mononuclear forms, with large round or oval nucleus and broad protoplasmic body. These are the earlier stages of development of the third. (3) The large polynuclear form, containing a nucleus very much divided and lobulated, and which may be deeply stained

1 Fortschritte der Medicin, 1884.

3 Bizzozero : Vi re how's Archiv., Bd. xc.

3 Hayem : Archive de Physiologie, iS 78-79.

with aniline colors. They form by far the greatest number of the leucocytes, and are found almost exclusively in pus. Ehrlich designates as eosinophile cells those leucocytes in whose protoplasm a quantity of coarse, fatty, shining granules are seen, which are colored an intense red on staining a preparation of dried blood with a one-per-cent. watery solution of eosin. These cells have their origin in the marrow of bones, and are present in normal blood in small quantities only. In myelogenetic leucaemia they are seen in large numbers. In lymphatic leucaemia it is principally the small lymphocytes which are increased in number

In order to examine the blood, it is generally sufficient to cleanse and dry the finger, and, with a needle or lancet, to make a quick and deep puncture in the tip. The drop of blood should then escape without squeezing the finger, and be dropped on a clean cover-glass, which is, in turn, dropped on the slide in such a way that the blood is spread out in a thin film. In order to see the blood-plaques, a drop of a one-per-cent. osmic-acid solution is applied to the finger, and the puncture is made through this drop. Instead of the osmic acid, which is simply a conservative fluid, a thin watery solution of methyl violet with 0.6 % of common salt may be used, which colors the blood-plaques and the nuclei of the nucleated red bloodcorpuscles. In finer examinations of the blood, it is better to color a dried preparation {vid. Chap. xi. for preparation) with the following solution :

IJ Hematoxylin, 2 grams [30 grains].

Alcohol, Glycerine,

Distilled water, aa 100 grams [3 ounces].

Glacial acetic acid, 10 grams \2.\ drachms]. Alum in excess.

This mixture should stand 3 weeks in the light, and a few granules of eosin should be added to it. The dry preparations remain from 6-12 hours in the staining fluid, and then are to be washed off with water and examined. The nuclei of the nucleated red bloodcorpuscles will be found to be stained intensely black. (Ehrlich.)

THE BLOOD. 5

The number of red blood corpuscles is, on an average, in men, in the normal condition, 5 million ; in women, 4j- million, to a cubic millimetre [a millimetre equals ^ of an inch].

The number of white blood corpuscles varies between 5,000-10,000, and is temporarily increased after a hearty meal. The number of blood-plaques is about 200,000 to the cubic millimetre.

The proportion between white and red blood corpuscles is, in healthy individuals, 1-500 to 1-1,000. A proportion which is more than 1 to 400 must be considered as a pathological increase in the number of white corpuscles.

Welker and Moleschott considered the proportion of white to red corpuscles to be 1:330 and 1.357. Dupe'rie found 5.500,000, red to 5,000 white, or 1:1100 ; Malassez, 1:1200 ; Hayem, Bouchut, Dubrisay found, on an average, 1:500—1,000 ; Halla, 1:422-811. Laache and Otto found, on an average, for men 4.97 and 4.99 million, and for women 4.43 and 4.58 million red blood corpuscles.

In order to count the corpuscles, a deep puncture is made into the finger-tip, and the escaping drop is sucked up into the me'langeur until it reaches the mark 1. The point of the instrument is then wiped off, and the diluting fluid 'is sucked up to the mark 101. This mixture of blood and diluting fluid 1 is well shaken and introduced into the counting chamber, and covered by the cover-glass, which should be lightly pressed on, and then the corpuscles are counted in each square, which is etched on the cover-glass. If a thousand corpuscles have been counted in one square, the amount of corpuscles in a cubic millimetre can be calculated, since the dilution of the blood (1:100) and the depth of the chamber are known. By using the chamber of Thoma-Zeiss (depth ^ mm., 1 square = ^-J-^ cubic millimetre), the average number of corpuscles in a small square

1 This fluid may be either a 3 % solution of common salt, or a 5 % solution of Glauber's salt, or Hayem's solution, which is corrosive sublimate, 0.5 grams [7 grains], Glauber's salt, 5.0 [1^ drachms], common salt, 2.0 [4 drachm], distilled water 200.0 grams [6 ounces].

is multiplied by 400,000 — that is, the whole number of corpuscles is to be divided by the number of squares which have been counted. It is more convenient to count the four small squares in one column and calculate the average result of a large number of counts. This number, which is the number of blood corpuscles in any four squares, is then multiplied by 100,000. In using the chamber of Malassez or Hayem, which has a depth of \ mm., the average number which is in a large rectangle (=20 small squares) is to be multiplied by 10,000. If the blood dilution is 1:200 instead of 1:100, i. e. (up to mark 0.5 of the melangeur), the result should be multiplied by 2.

Leucocytosis, that is, an increase of the leucocytes in proportion to the red corpuscle, is observed in numerous acute diseases (typhus abdominalis, erysipelas, etc.), also in cachectic conditions (cancer). This increase of leucocytes is often very great, and may even reach as high as 1 to 60 red corpuscles.

In Leuccemia, the amount of red corpuscles as well as of haemoglobin is generally considerably decreased, so that the number of leucocytes is very considerably increased, and almost equals that of the red corpuscles ; indeed it may equal or exceed it. In the first stages of the disease, when the increase of the white corpuscles is often less than in severe leucocytosis, the diagnosis of leucaemia can be certain only when, in its further course, a rapid increase of leucocytes makes it very evident ; or when the proportion of white to red exceeds 1:50. In myelogenetic leucaemia, there are numerous eosinophile leucocytes, and also nucleated red blood corpuscles to be seen. Ly?nphatic leucaemia is characterized by an increase of lymphocytes.

In pseudoleuc&mia there is a slight decrease in the number of red corpuscles, and in the amount of haemoglobin, and no increase of the leucocytes.

In the first few days after heavy loss of blood, the amount of red corpuscles as well as of the haemoglobin sinks markedly to over 50 % of the normal, whereas the number of leucocytes increases. In the period of convalescence, the amount of red corpuscles increases more quickly than that of the haemoglobin. In the secondary ancsmice, after typhus abdominalis, tuberculosis, malaria, lead poisoning, ankylostomiasis, nephritis, cancer, etc., the number of red corpuscles as well as the amount of haemoglobin is diminished, and the amount of white blood corpuscles increased (leucocytosis).

THE BLOOD. 7

In chlorosis the amount of haemoglobin is very greatly decreased, whereas the number of red corpuscles is often very little or not at all increased. These are therefore very pale. The amount of white corpuscles is normal.

In progressive pernicious anamia, the number of red corpuscles is enormously reduced, often to T V of the normal, whereas their size, and above all things, the amount of haemoglobin is increased.

An increase in the number of red corpuscles is observed in thickening of the blood in cholera, as well as in many heart affections.

After long-existing malaria, pigment-containing leucocytes are at times seen in the blood.

Micro-organisms are also observed in the blood— e. g., tubercle bacilli in miliary tuberculosis, bacilli lepra, bacilli anthracis, and the spirilla of relapsing fever. The latter can be seen with medium power, and are best recognized from the fact that when they come in contact with the red blood corpuscles, they impart to them a jerking motion ; or they can be recognized by coloring them as a dried preparation,' with a watery solution of gentian violet, as in the case of the bacilli anthracis. 1

Chapter II. Temperature

The temperature of the body is generally taken either in the axillary space or in the rectum [and under the tongue]. In the rectum it is about 0.5 — 1° higher than in the axilla.

The temperature of the healthy individual measures 1 in the axilla between 3 6.2 C.[97.i°F.] and 37. 5 C.[99.5°F.]. The highest temperature is late in the afternoon, and the lowest, very early in the morning. An elevation of temperature can temporarily occur in consequence of bodily exertion, taking food, hot-baths, etc. A continuous elevation of temperature occurs in fever. According to Wunderlich we have :

The temperature of collapse, 36 C. [96. 8° F.].

Moderate fever 39 C. [102.2 F.] morning ; 39. 5 [103. i° F.] evening.

Considerable fever 39.5 C. [103. i° F.] morning ; 40.5 C. [io4.9°F.] evening.

High fever over 39-5°C. [103. i° F.] morning; over 40. 5 C. [104.9 F.] evening.

1 In order to convert from one scale to the other, the following formula may be used :

Hyperpyrexia, or fever over 41. 5 C. [106. 7 ].

Also in fever there is usually a morning remission and an evening exacerbation. Exceptionally, especially in phthisis, we have the reverse — typus inversus. The difference between the highest and lowest temperature decides its type of the fever, thus :

Febris continua = a daily difference of not more than i° C. [i.8° F.].

Febris remittals = a daily difference of not more than 1.5° C. [2.7° F.].

Febris intermittens = in the course of the day the high temperature is varied by a period of no fever.

In the course of a fever we distinguish :

I. Stadium incrementi = a quick rise of temperature, generally accompanied by a chill or a slowly rising temperature.

II. Fastigium = ora stage of highest temperature. Its transition to the next stage is known as the amphibolic stage.

III. Stadium decrementi. The fever fall can follow either slowly, in course of several days, in which case we have lysis ; or quickly, the crisis. At the actual crisis the temperature falls rapidly (in one day) until it goes below normal. This fall is generally accompanied by a profuse perspiration. A high rise of temperature often precedes the crisis, which is called perturbatio critica.

In acute infectious diseases we distinguish the stage of incubation — that is, the time between the moment of contagion and the outbreak of the disease. Also in acute exanthematous diseases there is the prodromal stage, or stage of the first morbid appearances, /. e., before the outbreak of the eruption.

IO

CLINICAL DIAGNOSIS.

Morbilli— Measles.

Incubation, ten days. Prodromal stage, three days, characterized by affections of the mucous membranes.

Fig. 8.

Temperature chart in Morbilli,

It begins with chill and high fever ; and on the second or third day there is a slight fall of temperature. At the appearance of the eruption (on the face) the temperature rises again, and reaches its highest point when the erup- .6 tion is most widely dissemi- 9 <5_ 8 nated. This is the stadium

Prodromes. Eruption. Defervescence. floHtionis, and lasts three tO

four days. The critical fall of temperature occurs on the sixth or seventh day of the disease, after which desquamation begins.

Scarlatina — Scarlet-Fever.

Incubation, four to seven days. Prodromal stage, one to two days. It is characterized by angina. It begins with a chill and quick rise of temperature. At the end of the first or second day there is an outbreak of the c ° eruption (on the breast), and 41,* as it spreads the tempera- 40 ture rises. Defervescence begins on fourth to seventh day of the disease, and comes 3 ' to an end slowly, with the 37 paling of the eruption in 3 6, three to six days later. Desquamation then follows.

Fig. 9.

Temperature chart in

Scarlatina.

TEMPERA TURE.

II Variola— Small-pox

Incubation, nine days (nine to sixteen days), at the end of which time there is general disturbance of functions. The prodromal stage (two to five days) begins with a chill, with sudden rise of tern- c perature, and 41 often on the 4<3

second or

39 third day the

. 38

first signs of

the eruption 37 are observed. 3 6 With the beginning of the pustulation there is a quick fall of temperature. Then comes a second and in the beginning a slight febrile movement, which reaches its climax on about the ninth day (fever of suppuration), preserves a remittent type for some time, and after a varying length ends in lysis (period of desquamation). About the sixteenth day the stadium decrustationis begins.

Variolois — Varioloid.

Fig:, to. Temperature chart in Variola.

lllllllplllllll

iiiiiiiiiiitll!

I mmmmmmm

Iliigglilliigl

96.8

Prodromes. Eruption. Fever of suppuration. Desquamation.

Fig. tt. Temperature chart in Variolois.

iiDHIIil

HHHiiHH iiUmiHIIilllin JSMyiiHHiiliH

The incubation

et° and prodromal stag-

8 es are the same as

in variola vera, only

much lighter. The

second period of

[ °°' 4 fever (fever of sup-

98.6 puration) is want-

968 ing. The period of

CLINICAL DIAGNOSIS.

desquamation often begins as early as the ninth or tenth day, and is generally accompanied by slight rise of temperature.

Varicella— Chicken-pox.

The prodromes ase generally wanting. The eruption " j. S ? 5 " of the vesicles begins with slight fever. The vesicles dry up after three or four days.

Typhus Abdominalis— Typhoid Fever.

Incubation, seven to twenty-one days. The prodromal stage lasts several days to a week, and is accompanied by general disturbances. In the first week of the disease the temperature rises by degrees, accompanied by slight chills, and reaches, on the fourth or seventh day, its highest point.

This continues as a febris continua until the third week in the milder forms, and until the fifth week in the more severe forms. Then the morning temperature begins gradually to fall, while the evening temperature still remains high, until gradually lysis results, which in mild cases is in the fourth week. There is also

TEMPERA TURE.

tumefaction of the spleen in the second half of the first week of the disease. Roseola occurs on the sixth to ninth day of the disease.

Typhus Exanthematicus — Typhus Fever.

Incubation varies from a few days to three weeks. The prodromal stage is not marked. The disease begins with a chill and rapid rise of temperature, and then it remains febris continua until the thirteenth to the seven-

Fig. 13. Temperature chart in Typhus exanthematicus.

j ^j^ ^i|r||M5 KinlJa &^fc^

41.0 40.0 jmmmmmmmmk

■HBBBH

iSilQHilliMiiesiii iiigiiiiliiliHiiiii

Illll UJl J I fl

100.4 98.6 96.8

Eruption.

teenth day. There are often remissions at the end of the first week. There is then a critical fall of temperature, at times with transitory perturbatio critica. The eruption appears on the third to the sixth day after an inflammation of the mucous tracts.

Febris Recurrens— Relapsing- Fever.

Incubation five to seven days. The prodromal stage is not clearly marked. The fever begins with violent chill and a (high) sudden rise of temperature, which continues as in febris continua until the fifth or seventh day, and then critically falls. After a period of apyrexia, lasting about a week, there is again an attack of fever as at

first, but not lasting so long. Often, after a period of seven days, there is a third attack, lasting one to two days.

Fig. 14. Temperature chart in Febris recurrens.

Malaria — Febris Intermittens.

Incubation seven to twenty-one days. Prodromal stage is not marked. There is a chill, and the temperature rises to very great height, and then sinks after a few hours to or below the normal. There is also strong per-

Temperature chart in Febris intermittens

LIS

According occurs every lllblllili

"lUUHIIINHIJ

fl&E&sasisBSSssas::

S!!SS!i3!5iiS5S5S:!SiiSg5£3S;3f

HIIHIBIHr'

spiration. the fever

day, or every second and third day, it is called quotidian, tertian, and quartan intermittent fever.

Febris intermittens duplicata is that type in which two attacks occur in quick succession in the course of the same day. Febris intermittens anteponens and post-ponens is that type in which the new attack of fever does not generally occur at the same hour of the day as the preceding attack, but sooner or later

11IB1IHI11

100.4 98.6 96.8

Temperature chart in

Erysipelas.

Erysipelas.

Incubation one to eight days. It generally begins with a chill and high temperature. On the first or second day an inflammation of the c skin is observed. The tern-

perature continues high as ilssani^BwiRsi long as the morbid process 4 °'° fillip j iliilfs!! spreads, and quickly falls as 39 '° |ig|[ isfill soon as the erysipelas ceases 38, ° f|g| 11110111 spreading. With the spas- 37.0 §§§||||§|§ f||| modic spread of the erup- 36o 11511111

105.8

102.2

100.4

98.6

96.8 tion there is often found a remittent or intermittent fever.

Pneumonia Crouposa.

It begins with a chill and sudden rise of temperature. There is a continued fever during the spread of the peneumonic infiltration. On the fifth to the seventh day, and at times later, the crisis occurs, generally very

Fig. 17. Fig. i3.

Temperature charts in Pneumonia crouposa.

suddenly, with strong perspiration, and, at the same time, a decrease in the frequency of the pulse and respiration. There is often a pseudo-crisis (v. Fig. 18) one or two days before the real crisis, but here the pulse and respiration remain high.

Chapter III. Organs Of Respiration

Topography of the Chest.

The vertebral column has a normal curvature at the cervical, dorsal, lumbar, and sacral regions. A pathological curvature of the vertebral column convexly backward is called cyphosis. The same deformity, not curved but angular in character, is called gibbus. A curvature forward is called lordosis, and a lateral curvature scoliosis. A deforming curvature both laterally and backward is called cypho-scoliosis.

The sternum in the adult is about 16-20 cm. [6-S inches] long. The angular prominence between the manubrium and body is called the angulus Ludovici. A bending inward of the xiphoid process, and of the lower part of the body, is called funnel breast. This latter shape of the thorax is acquired, and is seen in some occupations, e. g., in cobblers who press their instruments against the breast (cobbler's breast). When the costal cartilages in rachitis are pressed in by lateral compression, and the sternum has a keel shape, it is called pectus carinatum or chicken breast.

The clavicle has a supra- and infra-clavicular groove in it. The external part of the latter is called Mohrenheim's groove.

The scapula covers the second to seventh or third to eighth rib, and is provided with a fossa supraspinata and

t5 a fossa infraspinata. Between the inner border of each scapula is the inter-scapular space.

In order to determine the height of the thorax in front, we must follow the ribs by beginning to count at the second ; and behind the landmarks are the spinous processes, beginning with the seventh cervical, the vertebra prom in ens.

The Harrison furrow has a horizontal direction at the level of the xiphoid process, and corresponding to the •normal attachment of the diaphragm. The region below this furrow to the angle of the ribs is called the hypochondrium.

In order to determine the breadth of the thorax, we make use of the following perpendicular lines :

(i) The median line.

(2) The parasternal line, drawn half-way between the border of the sternum and the nipple.

(3) The mammary line, drawn through the nipple, which, in healthy adults, lies between the fourth and fifth ribs, 10 cm [4 inches] distant from the border of the sternum.

(4) The anterior, middle, and posterior axillary line ; the former drawn through the anterior, the latter through the posterior, boundary of the axilla.

(5) The scapular line, drawn through the lower border of the scapula.

The costo-articular line is a line drawn from the sterno-costal articulation to the tip of the eleventh rib.

Size of the Thorax. The sterno-vertebral diameter of the thorax measures, in healthy men, 16.5 cm. [6J inches] above, and 19.2 cm. [7J inches] below, and in women it is somewhat smaller. The broad diameter of the chest is, in men, at the height of the nipple, 26 cm. [10 inches].

1 8 CLINICAL DIAGNOSLS.

The circumference of the chest at the height of the nipple measures, in healthy men, 82.0 cm. [32J inches], after deep expiration, and 90 cm. [36 inches] after deep inspiration — that is to say, the maximum excursion of the thorax in respiration is 8.0 cm [3 inches]. In those who are right-handed, the circumference of the right half of the chest is 0.5 to 2.0 cm [J- to 1 inch] larger than the left. In left-handed persons the left side is slightly larger.