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 Observation of symptoms, 
 
 1 1924 003 508 862 
 
Cornell University 
 Library 
 
 The original of this book is in 
 the Cornell University Library. 
 
 There are no known copyright restrictions in 
 the United States on the use of the text. 
 
 http://www.archive.org/details/cu31924003508862 
 
OBSERVATION OF 
 SYMPTOMS 
 
 BY 
 
 ALFRED T. HAWES, M.D. 
 
 ARRANGED FOR THE USE OF NURSES 
 
 THIRD PRINTING 
 
 WHITCOMB & BARROWS 
 
 BOSTON, 1921 
 
Copyright 1908 
 By ALFRED T..HAWES, M.D. 
 
 Thomas Todd Co., Printers 
 14 Beacon Street, Boston, Massachusetts 
 
INTRODUCTION 
 
 An important part of the work of a trained nurse con- 
 sists in giving an accurate report of the condition of the 
 patient and in the ability to notice any change or the 
 beginning of any complication. The observation of symp- 
 toms, therefore, becomes an important matter. A good 
 nurse must be a good observer of the sick, and this power 
 comes only through training. 
 
 The study of symptoms is the study of the patient. 
 Every phenomenon, no matter how slight, may be an 
 expression of the condition of the patient. The nurse 
 should be familiar with all the manifestations of abnormal 
 function in order that she may report the condition of the 
 patient and may note anything unusual ; but the combina- 
 tion of symptoms and their interpretation, which constitutes 
 diagnosis, does not come within her province. 
 
 First of all, it is necessary to have a thorough under- 
 standing of the human organism in health to know the 
 normal standard of healthy function. Then by close 
 observation it may be known in what respect the patient 
 differs from this normal standard of health. 
 
 This book endeavors to give the nurse a list of the 
 symptoms which may be recognized by general observation 
 during her care of the patient. Intelligent observation 
 means the use of sight, hearing, touch, and even smell, 
 and their degree of acuteness measures the ability of the 
 observer. 
 
 A list of the diseases in which each symptom is likely 
 to be found is given to enable the nurse to fix that symp- 
 tom in memory. In a general way the more common 
 diseases are placed first on the lists. The lists should be 
 read across the page. All symptoms which require the 
 use of instruments or apparatus for their recognition 
 have been excluded ; and with the exception of the use 
 of the clinical thermometer, every symptom mentioned may 
 be recognized by the intelligent use of the senses. 
 
 3 
 
OBSERVATION OF SYMPTOMS 
 
 The functions of the different organs of the body, 
 whose proper action is necessary to life, are controlled 
 by nerve centers in the brain. 
 
 The cerebrum is that portion of the brain through 
 which the intellect acts. Impressions which are con- 
 veyed to the cerebrum give rise to the mental activities 
 called thought, emotion, and will. 
 
 The cerebellum presides over the movements of the 
 voluntary muscles — the coordination of muscles. All 
 the complex' movements of the muscles necessary for 
 standing or walking are under the control of this 
 portion of the brain. 
 
 The medulla oblongata contains nerve centers which 
 control the vital actions of the body, such as the action 
 of the heart, respiration, etc. From the medulla oblon- 
 gata and from the under surface of the cerebrum arise 
 the cranial nerves which govern the organs of special 
 sense. Any injury of the medulla oblongata results in 
 death. 
 
 The spinal cord, by means of the spinal nerves, 
 conveys impressions from the surface of the body to 
 the brain and conveys back motor impulses to the 
 muscles. The spinal cord also contains nerve centers 
 which control the functions of certain organs of ""the 
 body. 
 
 TEMPERATURE 
 
 The functional activity of all the organs and tissues 
 is attended by the giving off of heat, and heat is a 
 necessary condition for the proper performance of the 
 bodily functions. The degree of heat of the body is 
 
 5 
 
O OBSERVATION OF SYMPTOMS 
 
 influenced only slightly by external conditions of tem- 
 perature, it being the same in both a warm and a cold 
 atmosphere. 
 
 Every tissue of the body produces heat according 
 to its degree of activity. The combustion of the food 
 taken in, every contraction of a muscle, the action of 
 the secreting glands, all give off heat. 
 
 Some regulation of the production and, dissipation 
 of heat is necessary, because the tissues of the body 
 would soon do themselves harm on account of their 
 over-production of heat during their activity. The body 
 has this pOwer of regulation, and although it is con- 
 stantly losing heat by radiation and evaporation, it has 
 the power of renewing its heat, of maintaining it at 
 a certain degree, and of preventing its over-production. 
 
 This regulation is performed by the brain. In the 
 medulla oblongata is a nerve center, the heat center, 
 whose function it is to direct the rapidity of combus- 
 tion or the development of heat in the body. 
 
 Controlling this heat center are two others: (i) the 
 accelerator heat center, whose function is to increase 
 - the production of heat ; and (2) the inhibitory heat 
 center, whose function is to prevent too rapid produc- 
 tion of heat. 
 
 Thus the heat center, with its controlling accelerator 
 and inhibitory centers, maintains the body at a constant 
 temperature. 
 
 In conditions of disease this normal mechanism is 
 disturbed ; there is no longer the normal action of the 
 heat-producing and heat-regulating centers, an over- 
 production of heat occurs, and the condition is known 
 as fever. 
 
 Continuous high temperature (pyrexia) : 
 
 (a) Toxcemia -. — the circulation in the blood of the 
 
TEMPERATURE 7 
 
 toxincs of certain diseases which poison the nerve centers 
 
 and interfere with their action : 
 
 Cellulitis Typhoid fever 
 
 Influenza Rheumatism 
 
 Contagious diseases Tetanus 
 
 Acute inflammation of any organ of the body 
 
 (b) Disturbance of the heat-regulating mechanism 
 by organic or functional disease of the brain or nervous 
 system : 
 
 Injury to spinal cord Apoplexy 
 
 Sunstroke Insanity 
 
 Hydrocephalus Hysteria 
 
 Infantile paralysis Tetany 
 
 Very high temperature (hyper-pyrexia) 105" or 
 over : 
 
 Injury to spinal cord Tumor of brain 
 
 Sunstroke Scarlet fever 
 
 Meningitis Hysteria 
 
 Acute rheumatism Tetanus 
 
 Remittent temperature. The difference between 
 morning and evening temperature is considerable (2° 
 or 3°), but the temperature does not reach the normal 
 point : 
 
 Phthisis Septicaemia 
 
 Pyaemia Empyema 
 
 Septic endocarditis 
 
 Intermittent temperature. The temperature rises 
 to a high point and falls in a few hours to normal : 
 Malaria Hysteria 
 
 Surface temperature. The surface temperature is 
 taken by a thermometer, the base of which has been 
 flattened, or has been made in the form of a coil, so 
 
8 OBSERVATION OF SYMPTOMS 
 
 as to present as large a surface as possible for contact 
 with the skin : 
 
 (a) Elevated. 
 
 Cellulitis in any part of the body 
 
 Over areas affected by vaso-motor paralysis 
 
 (b) Lowered. 
 Over areas of gangrene 
 
 Thrombosis of an artery (over parts supplied by this 
 
 artery) 
 Paralysis of an extremity 
 Heart weakness (observed in hands, feet, and nose) 
 
 Subnormal temperature. In certain conditions 
 the temperature falls below the normal point. This 
 condition is caused by diminished production of heat 
 on account of injury or disease, and is a more serious 
 symptom than a rise of temperature : 
 Surgical shock Profuse hemorrhage 
 
 Heart diseases (later stages) Acute alcoholism 
 Cancer Spasmodic asthma 
 
 Cholera Starvation 
 
 Chloral poisoning 
 
 PULSE • 
 
 The pulse is the sudden distention of an artery 
 caused by the forcing of a quantity of blood into the 
 artery at each beat of the heart. This distention takes 
 place both in a transverse direction and in a longi- 
 tudinal direction. The arteries are constantly full of 
 blood, and they must expand to accommodate them- 
 selves to the quantity of blood forced in by the heart 
 beat. The pressure originating at each heart beat 
 excites a pulse wave which passes from the heart 
 toward the capillaries. It is this pulse wave which 
 is felt by the examining finger. Each pulse wave rep- 
 
PULSE 9 
 
 resents a heart beat, but not the blood thrown out 
 of the heart at that beat. The stroke given by the 
 heart moves forward the whole column of blood in 
 the arteries. 
 
 What makes the heart ' beat ? There are situated 
 in the muscle of the heart certain nerve centers or 
 ganglia, and whenever they are stimulated they make 
 the heart muscle contract. The blood which enters 
 the heart acts as a stimulant, and each time a quantity 
 of blood enters the chambers of the heart the ganglia 
 are stimulated and the heart contracts, thus forcing out 
 the blood. 
 
 If this were the only way that the heart was made 
 to act, the heart muscle would become more and more 
 irritable, and would soon wear itself out. It needs 
 some controlling action. 
 
 There come down fibers from the pneumogastric 
 nerves (tenth cranial nerves), and these act on the 
 heart as inhibitory nerves ; that is, they prevent the 
 heart from contracting too fast. 
 
 So the heart has these two sources of nervous 
 supply : (i) the ganglia in the walls of the heart, which 
 cause the heart muscle to contract, and (2) the in- 
 hibitory nerves, which prevent the heart from con- 
 tracting too fast and wearing itself out. 
 
 Rapid pulse (tachycardia) is caused by (1) irritation 
 or over-sensitiveness of the ganglia in the heart muscle 
 or (2) interference with the action of the inhibitory 
 nerves (the pneumogastrics). In many cases both 
 these conditions act as the cause. 
 
 Rapid pulse occurs in acute febrile conditions (ex- 
 cept those producing brain pressure, which cause slow 
 pulse) : 
 Heart diseases (some forms) Surgical shock 
 
IO OBSERVATION OF SYMPTOMS 
 
 Profuse hemorrhage Concussion of brain 
 
 Exophthalmic goiter Sunstroke 
 
 Excitement Anaemia 
 
 Violent exercise Poisoning by certain drugs 
 
 Reflex irritation from uterine or ovarian disease 
 
 Pressure of a tumor on the pneumogastric nerve 
 
 Addison's disease 
 
 Slow pulse (bradycardia) is caused by (i) inter- 
 ference with the action of the ganglia in the heart 
 muscle or (2) irritation or over-sensitiveness of the 
 pneumogastric nerves. 
 
 Slow pulse occurs in : 
 Old age Meningitis 
 
 Puerperium Fatty degeneration of 
 
 Sclerosis of heart muscle heart 
 
 Convalescence from acute Arterio-sclerosis 
 fevers Chronic gastritis 
 
 Conditions causing jaundice Emphysema 
 Uraemia Apoplexy 
 
 Tumor of brain Abscess of brain 
 
 General paresis Melancholia 
 
 Spasmodic asthma 
 Poisoning by digitalis, alcohol, tobacco, coffee 
 
 Irregular pulse is caused by a disturbance of the 
 normal governing mechanism of the heart. A differ- 
 ence in the regularity of the heart beats, as well as 
 in the rate, may be caused by changes in the heart 
 ganglia or interference with the pneumogastric nerves. 
 
 Intermittent pulse consists of the omission of one 
 or more impulses against the examining finger. The 
 absent impulse may be due to weak contraction of the 
 heart at that time, the contraction not being sufficiently 
 strong to send a perceptible wave into the radial artery. 
 
PULSE I I 
 
 The causes of irregular or intermittent pulse are 
 
 (a) Changes in the heart : 
 Degenerative changes in the cardiac ganglia 
 Changes in the muscular walls of the heart caused by 
 Dilatation of heart Fatty degeneration of 
 Sclerosis of heart muscle heart 
 
 (b) Pressure on the heart from outside : 
 Pleuritic effusion Pericardial effusion 
 Tumor of pleura 
 
 (c) Cerebral causes : 
 
 Concussion of brain Profuse hemorrhage 
 
 Emotions 
 
 (d) Toxic causes : 
 
 Excessive use of tobacco, coffee, or tea 
 
 (e) Reflex causes : 
 
 Dyspepsia Diseases of the lungs, 
 
 liver, or kidneys 
 
 Palpitation is a name given to a rapid, violent 
 pulsation of the heart, of which the patient is conscious. 
 The causes are 
 
 (a) Changes in the heart: 
 
 Myocarditis Valvular diseases of the 
 
 heart 
 
 (b) Irritation in the stomach : 
 Chronic gastritis Flatulency 
 
 (c) Toxic causes : 
 
 Excessive use of tobacco, coffee, or tea 
 
 (d) Nervous causes : 
 Excitement Hysteria 
 Puberty Climacteric 
 Menstruation 
 
 Blood Pressure. — The walls of the arteries are 
 made up of three coats: (i) an outer coat composed of 
 
12 OBSERVATION OF SYMPTOMS 
 
 elastic tissue ; (2) a middle coat composed of elastic and 
 muscular tissue ; and (3) an inner coat composed of a 
 thin membrane lined with endothelial cells. 
 
 The fibers of the middle or muscular coat encircle 
 the artery, and when they contract the caliber of the 
 artery becomes smaller. These muscular fibers are 
 supplied by nerves coming from the sympathetic nerv- 
 ous system. These nerves are called vaso-motor nerves. 
 
 The vaso-motor nerves are under the control of, and 
 are governed by, a nerve center situated in the medulla 
 oblongata, the vaso-motor center. If this nerve center 
 is irritated, all the vaso-motor nerves which govern the 
 muscular coat of the arteries are stimulated and the 
 caliber of the arteries becomes smaller. This increases 
 the pressure on the blood inside the artery and makes 
 the artery feel hard to the examining finger. 
 
 The opposite takes place if the vaso-motor center 
 is paralyzed. The muscular coat of the arteries relaxes 
 and the artery feels soft to the examining finger. 
 
 So a rise in blood pressure (high tension) or a fall 
 in blood pressure (low tension) is spoken of when 
 examining the pulse. The vaso-motor center is always 
 at work, exerting at different times a constricting or 
 a dilating action upon the arteries. 
 
 Hard pulse (high tension) is caused by irritation 
 of the vaso-motor center, which produces contraction of 
 the walls of the arteries. In this condition the blood 
 which is passing through the artery is held in a tighter 
 grasp : 
 
 General peritonitis Acute nephritis 
 
 Chronic interstitial nephritis Apoplexy 
 Fracture of base of skull Tumor of brain 
 Chronic lead poisoning Angina pectoris 
 
 Toxic doses of digitalis 
 
PULSE 1 3 
 
 Hardness of the pulse may also be caused by the 
 thickened condition of the walls of the arteries : 
 Arterio-sclerosis 
 
 Soft pulse (low tension) is caused by paralysis of 
 the vaso-motor center, allowing the walls of the artery 
 to relax : 
 
 Surgical shock Profuse hemorrhage 
 
 Typhoid fever All conditions of exhaustion 
 
 Dilatation of the heart Phthisis 
 
 Ansemia 
 Poisoning by certain drugs (chloral, amyl nitrite) 
 
 Dicrotic pulse is a pulse in which two distinct 
 beats are felt for each pulsation of the heart. The 
 first beat is stronger, and is the true pulse beat. The 
 second beat is caused by the closure of the aortic 
 valves, and on account of the low tension of the arteries 
 a recoil wave travels along the blood stream. This kind 
 of pulse occurs only,in conditions of low arterial tension. 
 
 It is often difficult to distinguish the true beat from 
 the false one, and in these cases the heart beat should 
 be counted by placing the hand on the chest over the 
 apex of the heart. 
 
 Dicrotic pulse occurs in : 
 Conditions causing soft pulse (see soft pulse). 
 
 Large pulse refers to the large quantity of blood 
 in the artery as felt under the examining "'finger. 
 A pulse may be hard and still not be large ; for ex- 
 ample, in general peritonitis the pulse is hard and 
 small (wiry) : 
 
 Hypertrophy of heart Conditions of plethora 
 
 Over-action of the heart in acute fevers 
 
 Small pulse refers to the small quantity of blood 
 
14 OBSERVATION OF SYMPTOMS 
 
 in the artery. A small pulse may be hard or it may 
 be soft : 
 
 General peritonitis Aortic regurgitation 
 
 Mitral stenosis Aneurism of aorta 
 
 Corrigan's pulse (Water-hammer pulse). The im- 
 pulse against the examining finger quickly fades away. 
 This is caused by the defect in the aortic semi-lunar 
 valves by which the column of blood is not held in the 
 aorta but allowed to fail back into the left ventricle : 
 Aortic regurgitation 
 
 RESPIRATION 
 
 Respiration is the function by which oxygen is 
 taken into the lungs, and from there absorbed into 
 the blood, and carbon dioxide is exhaled from the 
 lungs. It consists of two movements : (i) inspiration, 
 and (2) expiration. 
 
 Inspiration is the active process by which the thorax 
 is expanded and air is taken into the lungs. 
 
 Inspiration enlarges the chest in all diameters. The 
 vertical diameter is increased by the contraction and 
 descent of the diaphragm. The antero-posterior and 
 the transverse diameters are increased by the elevation 
 and rotation outward of the ribs, which also elevates the 
 sternum. 
 
 If there is any impediment to inspiration, then 
 certain auxiliary muscles are brought into play which 
 forcibly increase the capacity of the chest to the utmost 
 limit. 
 
 In a full inspiration the diaphragm flattens and its 
 dome is drawn downward. This causes pressure on 
 the intestines, and the anterior abdominal wall is seen 
 to bulge slightly. 
 
RESPIRATION 1 5 
 
 Expiration is a passive act. The chest walls de- 
 .scend by their own weight, and there is the recoil of 
 the elastic tissue in the lungs. 
 
 The diameters of the chest are all diminished. The 
 vertical diameter is diminished by the ascent of the 
 diaphragm. The antero-posterior diameter is dimin- 
 ished by the depression of the ribs and sternum. 
 
 Any impediment to expiration brings into play 
 certain auxiliary muscles which still further diminish 
 the capacity of the thorax. 
 
 The movements of respiration, although they are 
 capable of being modified by effort of the will, are 
 largely automatic in character. This is proved by the 
 fact that respiration goes on during sleep and. uncon- 
 sciousness. 
 
 The movements of respiration are under the control 
 of a nerve center which is situated in the medulla 
 oblongata, the respiratory nerve center. This center is 
 kept alive by the condition of the blood. If the quan- 
 tity of oxygen in the blood is too small, the nerve center 
 sends out impulses and increases the rate of respiration. 
 
 Rapid respiration : 
 
 (a) Febrile conditions. The increased rate is caused 
 by the irritation of the respiratory nerve center by the 
 toxines of disease, and also by the stimulation of the 
 nerve center by warmer blood. 
 
 (B) Conditions causing dyspnoea (see dyspnoea). 
 
 (c) Reflex irritation, as a result of pain in other 
 organs. 
 
 (d) Deficient quality of the blood: 
 Anaemia Leucemia 
 
 (e) Certain nervous disorders : 
 Hysteria 
 
1 6 OBSERVATION OF SYMPTOMS 
 
 Slow respiration : 
 
 Uraemia Acute alcoholism 
 
 Apoplexy Fracture of base of skull 
 
 Tumor of brain Abscess of brain 
 
 Poisoning by opium, chloral, chloroform, aconite, antimony 
 
 Irregular respiration. The breathing may be irreg- 
 ular in time intervals or in depth of respiration. 
 
 Conditions causing dyspnoea (see dyspnoea). 
 Surgical shock Apoplexy 
 
 Meningitis Tumor of brain 
 
 Chorea (involving the respiratory muscles) 
 
 Cheyne-Stokes respiration. The respiratory move- 
 ments gradually decrease both in depth and rapidity 
 until they cease altogether. For several seconds there 
 are no respiratory movements ; then there is a feeble 
 respiration, followed by a somewhat stronger one, and 
 respiration gradually returns to normal, after which it 
 again declines in a similar manner. 
 
 The cause of this form- of respiration is not fully 
 understood, but it is probably due to exhaustion of the 
 respiratory center. 
 
 It is noticed in : 
 Apoplexy Meningitis 
 
 Sunstroke Uraemia 
 
 Arterio-sclerosis Tumor of brain 
 
 Fatty degeneration of the heart 
 
 Sighing is an occasional slow, deep inspiration fol- 
 lowed by a more rapid expiration. This is nature's 
 method of filling the lungs with air and giving more 
 oxygen to the blood : 
 
 Profuse hemorrhage Surgical shock 
 
 Over-distended stomach Dilatation of heart 
 
 Meningitis Sunstroke 
 
RESPIRATION \J 
 
 Tumor of brain . Addison's disease 
 
 Syncope 
 
 Prominent thoracic respiration (normal in women) : 
 Paralysis of the diaphragm General peritonitis 
 Pressure on the diaphragm by 
 Ascites Tympanites 
 
 Abdominal tumor Pregnancy 
 
 Prominent abdominal respiration (normal in men) : 
 Pleurisy with effusion Empyema 
 
 Fractured rib Paralysis of muscles of 
 
 Pleurisy respiration 
 
 Unequal expansion of the chest : 
 Pleurisy with effusion Empyema 
 
 Pneumonia Tumor of lung or pleura 
 
 Bulging of one side of chest : 
 Pleurisy with effusion Empyema 
 
 Tumor of lung or pleura 
 
 Retraction of one side of chest : 
 Pleuritic adhesions Phthisis 
 
 Curvature of spinal column Foreign body in bronchus 
 
 Stertorous respiration is caused by paralysis of 
 the muscles of the tongue, which allows the base of 
 the tongue to fall back into the pharynx : 
 Acute alcoholism Apoplexy 
 
 Uraemia Diabetic coma 
 
 Poisoning by narcotic Paralysis of the soft 
 
 drugs palate 
 
 Forced respiration. In this form the patient uses 
 the auxiliary muscles of respiration both on inspiration 
 and expiration. The air as it passes in and out of the 
 lungs makes a harsh whistling sound. 
 
1 8 OBSERVATION OF SYMPTOMS 
 
 The causes are 
 
 (a) Obstruction in the larynx : 
 Diphtheritic membrane Foreign body in larynx 
 CEdema of the glottis Cancer of larynx 
 
 (b) Spasm of the muscles of the larynx so that the 
 glottis does not open freely : 
 
 Spasmodic croup Laryngismus stridulus 
 
 Strychnia poisoning _ Tetanus 
 
 (c) Spasm of the bronchial tubes : 
 Asthma (see asthma) 
 
 Asthma is a spasmodic contraction of the muscular 
 fibers of the bronchial tubes, thus narrowing the caliber 
 of the tubes. This causes the air to pass in and out of 
 the air vesicles with great difficulty. 
 
 This spasmodic contraction of the bronchial tubes 
 is caused by irritation of fibers of the pneumogastric 
 nerves (tenth cranial nerves). The pneumogastric nerves, 
 by their own fibers and by anastomosis with fibers from 
 other nerves, are distributed to the pharynx, the heart, 
 the lungs, the stomach, the intestines, and various 
 glandular organs. Reflex irritation in other organs 
 may also produce an attack of asthma. 
 
 The causes are : 
 Excitement Nervousness 
 
 Nasal polypi Naso-pharyngitis 
 
 Inhalation of dust, pollen of flowers, or irritating vapors 
 Heart diseases Acute indigestion 
 
 Kidney diseases Uterine disturbances 
 
 Dyspnoea is difficult or painful respiration. 
 
 The causes are 
 
 (a) Mechanical hindrance of the entrance of air into 
 the pulmonary air cells : 
 Inflammation in the larynx Inflammation in the trachea 
 
RESPIRATION 1 9 
 
 Foreign body in larynx Diphtheria 
 
 CEdema of the glottis Bronchitis 
 
 Pneumonia Phthisis 
 
 CEdema of the lungs 
 Conditions causing asthma (see asthma) 
 Spasm of the respiratory muscles in epilepsy, tetanus, 
 or strychnia poisoning 
 
 (b) Pressure on the lungs from outside, which pre- 
 vents their expansion : 
 
 Pleurisy with effusion Empyema 
 
 Pericardial effusion Tumor of pleura 
 
 Ascites Pregnancy 
 Tympanites 
 
 (c) Pain caused by the act of respiration : 
 Pleurisy Fractured rib 
 Intercostal neuralgia Pneumonia 
 
 General peritonitis Diaphragmatic pleurisy 
 
 Rheumatism of the respiratory muscles 
 
 (d) Disturbance of the circulation of blood in the 
 lungs. There are two kinds of blood supply to the 
 lungs: (1) the pulmonary artery supply, which supplies 
 the blood to be purified in the lungs ; and (2) the 
 bronchial artery supply, which supplies blood for 
 the nourishment of the lung tissue. Interference with 
 either of these blood supplies will cause dyspncea : 
 Dilatation of the heart Pulmonary embolism 
 
 (e) Deficient quality of the blood: 
 Anaemia Chlorosis 
 Leucaemia 
 
 CEdema of the glottis : 
 Cellulitis of the neck Fracture of hyoid bone 
 
 Irritant poisons (carbolic acid) Chronic nephritis 
 Foreign bodies in larynx Scalds of larynx 
 Wounds of base of tongue Cancer of larynx 
 Anthrax Erysipelas 
 
20 OBSERVATION OF SYMPTOMS 
 
 Dyspnoea on exertion : 
 
 Heart diseases General debility 
 
 Anaemia Phthisis 
 
 Obesity Chronic bronchitis 
 
 Emphysema 
 
 Paroxysmal dyspncea : 
 Conditions causing asthma (see asthma) 
 Spasmodic croup Angina pectoris 
 
 Pressure of a tumor on pneumogastric nerve 
 
 COUGH 
 
 The removal of foreign substances from the respira- 
 tory passages is effected by the act of coughing. After 
 a deep inspiration the glottis closes. Then the con- 
 traction of the auxiliary muscles of expiration increases 
 the pressure in the chest, and suddenly the glottis 
 opens and there results an audible outrush of air which 
 brings with it the substances which form expectoration. 
 
 Coughing is excited by irritation of branches of the 
 pneumogastric nerves (tenth cranial nerves). (For dis- 
 tribution of pneumogastric nerves, see asthma.) Irri- 
 tation of any of the organs supplied by these nerves or 
 reflex irritation in other organs may be the means of 
 exciting cough. The causes are 
 
 (a) Irritation in the lung tissue : 
 Bronchitis Pneumonia 
 Phthisis Abscess of lung 
 Foreign body in bronchus Whooping cough 
 Inhalation of irritating vapors 
 
 (b) Irritation in structures adjacent to the hcngs : 
 Pleurisy Pericarditis 
 Empyema Fractured rib 
 Thoracic aneurism Enlarged bronchial glands 
 Mediastinal tumor Cancer of oesophagus 
 
RESPIRATION 
 
 21 
 
 (c) Reflex irritation in other organs : 
 Nasal polypi Adenoids 
 
 Enlarged tonsils Relaxed uvula 
 
 Impacted ear-wax Heart diseases 
 
 Chronic gastritis Cirrhosis of the liver 
 
 Gall-stones Uterine disorders 
 
 Dry cough : 
 
 Bronchitis (first stage) Pneumonia (first stage) 
 
 Phthisis (first stage) Foreign body in bronchus 
 
 Inhalation of irritating vapors 
 Any irritation of structures adjacent to the lungs 
 
 (See causes of cough, section b) 
 Any reflex irritation in other organs 
 
 (See causes of cough, section c) 
 
 Loose cough : 
 
 Bronchitis (later stages) 
 Phthisis (later stages) 
 
 Pneumonia (later stages) 
 Whooping cough 
 
 Hoarse cough : 
 Diphtheria 
 Laryngitis 
 
 Spasmodic croup 
 Whooping cough 
 
 Brassy cough : 
 
 Thoracic aneurism 
 
 Paroxysmal cough : 
 
 Whooping cough 
 Mediastinal tumor 
 
 Bronchitis 
 Thoracic aneurism 
 
 Painful cough : 
 
 Pleurisy 
 Fractured rib 
 Intercostal neuralgia 
 Injury to abdominal wall 
 
 Pneumonia 
 General peritonitis 
 Pericarditis 
 
22 OBSERVATION OF SYMPTOMS 
 
 Inability to cough : 
 
 Paralysis of respiratory General debility 
 
 muscles 
 Diaphragmatic pleurisy 
 Pressure on diaphragm by ascites, tympanites, or 
 
 abdominal tumor 
 
 Mucous rattle, both on inspiration and expiration : 
 Extreme exhaustion Approach of death 
 
 Hawking is an effort to clear the upper respiratory 
 passages : 
 
 Nasal catarrh Pharyngitis 
 
 Laryngitis 
 
 SPUTUM 
 
 Sputum consists of the substances expelled from the 
 air passages by the act of coughing. It is composed 
 of the secretions of the mucous membrane of the 
 larynx, the trachea, and bronchi, and from the cavities 
 of the lung tissue. Certain substances from the 
 mouth, the nose, and the throat, such as blood, mucus, 
 remnants of food, etc., also appear in the sputum. 
 
 Scanty sputum : 
 Bronchitis (first stages) Pneumonia (first stages) 
 
 Phthisis (first stages) Conditions causing asthma 
 
 Profuse sputum : 
 
 Bronchitis (later stages) Pneumonia (later stages) 
 
 Phthisis (later stages) Whooping cough 
 
 Purulent sputum consists of a mixture of mucus 
 and pus. In some cases pus from the pleural cavity 
 may rupture through the pleura and appear as sputum : 
 Abscess of the lung Ruptured empyema 
 
 Sputum from phthisical Bronchiectasis 
 
 cavity 
 
DIGESTIVE SYSTEM 23 
 
 Serous sputum is of very fluid consistence and is 
 usually frothy on account of the mixture of air bubbles : 
 CEdema of the lungs 
 
 Bloody sputum. A slight mixture of blood is 
 seen in the sputum as bloody streaks (rusty sputum) : 
 Pneumonia Blood from the pharynx 
 
 Blood from the nose Fractured rib (if lung 
 
 Scurvy is lacerated) 
 
 Hemophilia 
 
 Hemoptysis is the expectoration of pure blood : 
 Phthisis Heart diseases 
 
 Ruptured aneurism Excessive bodily exertion 
 
 Odor of sputum is usually not noticeable. When 
 the sputum is scanty it may be mixed with the secre- 
 tions of the mouth, and is often offensive. A foul odor 
 is noticed in : 
 
 Abscess of the lung Gangrene of the lung 
 
 Sputum from phthisical Bronchiectasis 
 
 cavity 
 
 Foreign substances in sputum: 
 Remnants of food 
 
 Coal dust causing a grayish black color 
 Iron dust causing a reddish black color 
 Portions of lung tissue in abscess of the lung 
 Sloughing tissue from ulceration in larynx or trachea 
 Casts of trachea or bronchi in diphtheria 
 
 DIGESTIVE SYSTEM 
 
 Lips. The mucous membrane of the lips is nor- 
 mally smooth, red, and moist. 
 
 (a) Pale color: 
 Anaemia Chlorosis 
 
24 
 
 OBSERVATION OF SYMPTOMS 
 
 Conditions causing 
 cyanosis 
 
 Chronic alcoholism 
 
 Acute febrile conditions 
 Meningitis 
 
 Rickets 
 Pregnancy 
 
 (b) Bine color: 
 Exposure to cold 
 
 Tremor of lips : 
 Old age 
 Emotion 
 
 Herpes labialis : 
 Pneumonia 
 Trifacial neuralgia 
 Malaria 
 
 Caries of the teeth : 
 Lack of care 
 Diabetes 
 Phosphorous poisoning 
 
 Notched teeth : 
 
 Hereditary syphilis 
 
 Loosened teeth : 
 
 Stomatitis Alveolar abscess 
 
 Salivation from mercury Scurvy 
 
 Chronic phosphorous poisoning 
 
 Sordes on the teeth : 
 
 Typhoid fever 
 
 Grinding the teeth (in children) : 
 Intestinal parasites Intestinal indigestion 
 
 Meningitis Tumor of brain 
 
 Hydrocephalus Epilepsy 
 
 Chorea 
 
 Gums. 
 (a) Pale: 
 Anaemia 
 
 Chlorosis 
 
DIGESTIVE SYSTEM 2$ 
 
 (b) Red and spongy : 
 
 Stomatitis Salivation by mercury 
 
 General debility Scurvy 
 
 (c) Gray line at border of gums : 
 
 Chronic lead poisoning Chronic copper poisoning 
 
 Tongue. The color of the tongue, its movements, 
 and any enlargements are of importance. 
 
 (a) Pale color : 
 
 Anaemia Chlorosis 
 
 (b) Blue color: 
 Conditions causing cyanosis 
 
 (c) Red color: 
 
 Scarlet fever Febrile conditions 
 
 Coated tongue. The coating on the tongue con- 
 sists of epithelial cells, micro-organisms, and remnants 
 of food : 
 
 Chronic gastritis Constipation 
 
 Typhoid fever Conditions causing 
 
 Septicaemia jaundice 
 
 Excessive smoking 
 
 Enlarged tongue : 
 Glossitis Cancer of tongue 
 
 Acromegaly 
 
 Circumscribed enlargement : 
 
 Cancer of tongue Syphilitic nodules 
 
 Tremor of tongue : 
 Chronic alcoholism Typhoid fever 
 
 Paralysis agitans Nervousness 
 
 Scars on tongue : 
 Healed ulcers Injuries 
 
 Bite during epileptic convulsion 
 
26 OBSERVATION OF SYMPTOMS 
 
 Paralysis of tongue : 
 
 Apoplexy General paresis 
 
 Locomotor ataxia Tumor of brain 
 
 (advanced stages) 
 
 Puffing of one cheek on expiration : 
 
 Apoplexy Paralysis of facial nerve 
 
 Absence of teeth on (seventh cranial) 
 one side 
 
 Inability to open the mouth: 
 
 Fissures of lips Tonsilitis 
 
 Stomatitis Mumps 
 
 Tetanus 
 
 When the respiratory passages are in normal con- 
 dition there is no odor to the air which is expired from 
 the lungs. In diseased conditions of the respiratory 
 passages, or in certain constitutional diseases, there is 
 a marked odor present. 
 
 Odor of the breath. The causes are 
 
 (a) Conditions in the nose : 
 Nasal catarrh Ozsena 
 
 Ulcers of nose (tubercular, syphilitic) 
 
 (6) Conditions in the mouth: 
 Decayed teeth Retention of food 
 
 Stomatitis remnants 
 
 Cancrum oris Alveolar abscess 
 
 (c) Conditions in the throat : 
 Tonsilitis Pharyngitis 
 Diphtheria Ulcer of larynx (tuber- 
 Cancer of pharynx cular, syphilitic) 
 
 (d) Conditions in the lungs : 
 
 Phthisis (later stages) Chronic purulent bronchitis 
 
 Abscess of lung Emphysema 
 
DIGESTIVE SYSTEM Z"J 
 
 (e) Conditions in the stomach : 
 Chronic gastritis Constipation 
 
 (f) Constitutional conditions : 
 Diabetes produces a fruity odor of the breath 
 Uraemia produces a urinous odor of the breath 
 Febrile conditions produce a characteristic odor of the 
 
 breath 
 
 Saliva is the product of all the salivary glands. 
 The secretion is constant, and moistens the mouth for 
 speech and for deglutition. 
 
 The secretion of saliva is regulated by a nerve 
 center in the medulla oblongata. Stimuli, which are 
 excited by the presence of food in the mouth, reach 
 this nerve center, and motor impulses are sent out 
 which increase the secretion of the salivary glands. 
 Certain conditions of disease also influence the flow 
 of saliva. 
 
 Increased saliva : 
 
 Nausea Dentition 
 
 Stomatitis Glossitis 
 
 Facial paralysis Pregnancy 
 
 Salivation by mercury Hysteria 
 Hydrophobia 
 Certain drugs (potassium iodide, pilocarpine) 
 
 Diminished saliva : 
 
 Febrile conditions Fright or excitement 
 
 Mouth breathing Chronic gastritis 
 
 Diabetes Certain drugs (atropine, 
 Cholera opium) 
 
 Impacted salivary Prolonged enteritis 
 calculus 
 
 Dribbling of saliva : 
 Facial paralysis Idiocy 
 
28 OBSERVATION OF SYMPTOMS 
 
 Difficult or painful mastication : 
 Inflammatory conditions of lips, gums, or tongue 
 Defective teeth Paralysis of muscles 
 
 of mastication 
 
 Loss of appetite (anorexia) : 
 Febrile conditions Excessive fatigue 
 
 Depressing emotions Use of narcotic drugs 
 
 Chronic gastritis Ulcer of stomach 
 
 Cancer of stomach Constipation 
 
 Increased appetite (boulimia) : 
 Habit of overeating Intestinal parasites 
 
 Diabetes Convalescence from fevers 
 
 Hysteria Insanity 
 
 Depraved appetite (pica). The patient craves ab- 
 normal articles of food, such as chalk, slate pencils, etc. : 
 Chlorosis Pregnancy 
 
 Idiocy Insanity 
 
 Hysteria 
 
 Increased thirst : 
 Febrile conditions Diabetes 
 
 Chronic gastritis Cholera 
 
 Profuse hemorrhage 
 
 Dysphagia is difficulty or pain in the act of 
 swallowing. 
 
 It is caused by 
 
 (a) Conditions in the mouth: 
 Stomatitis Glossitis 
 Cancer of tongue 
 
 (b) Conditions in the pharynx : 
 Tonsilitis Diphtheria 
 Scarlet fever Measles 
 
 Mumps Cancer of pharynx 
 
DIGESTIVE SYSTEM 29 
 
 Retro-pharyngeal abscess Paralysis of soft palate 
 Ulcer of pharynx (tubercular, syphilitic) 
 
 (c) Conditions in the larynx : 
 Laryngitis Cancer of larynx 
 Ulcer of larynx (tubercular, syphilitic) 
 
 (d) Conditions in oesophagus : 
 Inflammation Stricture 
 Ulcer Cancer 
 
 (e) Pressure on oesophagus from outside : 
 Enlarged thyroid gland Thoracic aneurism 
 Enlarged bronchial Mediastinal tumor 
 
 glands 
 Pericardial effusion 
 
 (/) Spasm of the pharyngeal muscles (when the 
 patient attempts to swallow) : 
 Hydrophobia Tetanus 
 
 Strychnia poisoning Hysteria 
 
 NAUSEA AND VOMITING 
 
 The act of vomiting is under the control of a nerve 
 center in the medulla oblongata, the vomiting center. ■ 
 When this nerve center is irritated it sends out im- 
 pulses which produce the muscular act of vomiting. 
 Vomiting is preteded by a feeling of nausea, during 
 which there is a copious flow of saliva into the mouth. 
 
 The muscular act of vomiting consists of a sudden, 
 deep inspiration. Then the glottis closes and there is 
 a strong contraction of the diaphragm and of the ab- 
 dominal muscles. At the same time that the dia- 
 phragm and abdominal muscles contract, the cardiac 
 opening of the stomach relaxes and the contents of 
 the stomach are forced out. The contraction of the 
 diaphragm and of the abdominal muscles plays the 
 principal part in the act of vomiting, and the contraction 
 of the walls of the stomach plays a very small part. 
 
30 OBSERVATION OF SYMPTOMS 
 
 Irritation of the vomiting center may be caused by 
 
 (a) Impulses sent out from the digestive organs : 
 Indigestible food Irritant poisons 
 Chronic gastritis Ulcer of stomach 
 Cancer of stomach Cirrhosis of liver 
 Gall-stone colic Enteritis 
 
 General peritonitis Appendicitis 
 
 Cholera infantum Strangulated hernia 
 
 Intestinal obstruction 
 
 (b) Irritation of the brain and surrounding mem- 
 branes. Vomiting from this cause occurs independently 
 of taking food or drink, and on account of its particularly 
 violent character is called projectile vomiting : 
 Meningitis Tumor of brain 
 Apoplexy Fracture of skull 
 Abscess of brain Thrombus, of brain 
 Concussion of brain 
 
 (c) Certain poisons circulating in the blood which 
 irritate the vomiting nerve center: 
 
 Uraemia Septicaemia 
 
 (d) Reflex irritation : 
 
 Pregnancy Gall-stone colic 
 
 Renal colic Severe injuries 
 
 Floating kidney Menstrual disorders 
 
 Extreme pain in any part of the body 
 
 (e) Deficient blood supply to the brain : 
 Syncope Surgical shock 
 Profuse hemorrhage 
 
 (f) Mental emotion : 
 Disgust Fear 
 Excitement 
 
 (g) Disturbance of the sense of equilibrium : 
 Vertigo Seasickness 
 Meniere's disease Migraine 
 
DIGESTIVE SYSTEM 3 I 
 
 (ti) Contraction of the abdominal muscles in violent 
 coughing : 
 Whooping cough Phthisis 
 
 Vomited matter. The appearance of material 
 ejected from the stomach will oftentimes give valuable 
 information. 
 
 Mucus vomitus : 
 Chronic gastritis 
 Mucus from the upper respiratory passages 
 
 Watery vomitus : 
 Chronic alcoholism Hyperchlorhydria 
 
 Hysteria 
 
 Bilious vomitus : 
 Long-continued vomiting General peritonitis 
 Intestinal obstruction 
 
 Bloody vomitus : 
 Ulcer of stomach Cancer of stomach 
 
 Irritant poisons Cirrhosis of liver 
 
 Chronic nephritis Vicarious menstruation 
 
 Scurvy 'Hemophilia 
 
 Blood which has been swallowed from : 
 Epistaxis Ulcer of larynx 
 
 Ulcer of oesophagus Pulmonary hemorrhage 
 
 Rupture of aneurism into the oesophagus 
 
 Fecal vomitus : 
 General peritonitis Intestinal obstruction 
 
 Purulent vomitus. Rupture of an abscess of an 
 adjacent organ into the stomach, such as : 
 Hepatic abscess Pancreatic abscess 
 
32 OBSERVATION OF SYMPTOMS 
 
 Intestinal parasites : 
 Tape-worm Round-worm 
 
 Thread-worm Trichinae 
 
 CONSTIPATION 
 
 The peristaltic action of the intestines by which the 
 contents are pushed toward the rectum is produced by 
 motor nerve centers situated in the walls of the in- 
 testines. These motor nerve centers are under the 
 control of the sympathetic nervous system. 
 
 Normal peristalsis depends on the healthy condition 
 of the intestinal mucous membrane, on the healthy 
 action of the nervous mechanism, and on adequate 
 stimulation of both by the contents of the intestines. 
 Constipation, therefore, is caused by (i) a lack of 
 normal secretion of the intestinal mucous membrane, 
 (2), by a lack of normal muscular peristalsis, and (3) 
 by an insufficient amount of waste material to stimulate 
 the intestines. 
 
 These causes are : 
 Improper diet Deficient quantity of fluids 
 
 Neglect of habit Sedentary occupation 
 
 Deficiency of bile Febrile conditions 
 
 Weak abdominal muscles 
 Lessening of the quantity of fluids in the body (profuse 
 
 sweating, diabetes) 
 Conditions preventing normal nervous excitability (anae- 
 mia, neurasthenia, malnutrition) 
 Overuse of purgative medicines 
 
 Intestinal obstruction is caused by 
 Impacted feces Strangulated hernia 
 
 Intussusception Volvulus 
 
 Cancer of intestine Stricture of intestine 
 
 Adhesions between intestine and adjacent organs 
 
DIGESTIVE SYSTEM 3*, 
 
 Pressure on the intestine by a tumor of an adjacent 
 
 organ 
 Gall-stones Enteroliths 
 
 Foreign bodies which have been swallowed 
 Excessive doses of bismuth or magnesia 
 
 Tympanites (meteorism) is the accumulation of gas 
 in the intestinal canal : 
 Intestinal fermentation Typhoid fever 
 
 General peritonitis Tubercular peritonitis 
 
 Intestinal obstruction Paralysis of intestine 
 
 Hysteria 
 
 DIARRHOEA 
 
 The frequent discharge of liquid feces constitutes 
 diarrhoea. In this condition the food is propelled rap- 
 idly through the intestine, allowing no time for the 
 absorption of the fluid portions. It is caused by 
 
 (a) The presence of irritating substances iti tlie 
 intestine, which excite the action of the nerve centers 
 and cause rapid peristalsis : 
 
 Indigestible food Irritant poisons 
 
 Hardened feces Purgative drugs 
 
 (b) An inflamed condition of the mucous membrane 
 of the intestine, which causes over-sensitiveness of the 
 nerve centers and consequently excessive peristalsis : 
 Enteritis Cholera 
 
 Cholera infantum Appendicitis 
 
 Proctitis 
 
 (c) An abnormal condition of the nervous mechan- 
 ism, so that it responds abnormally to stimulation, 
 although the intestinal mucous membrane may be 
 normal : 
 
 Locomotor ataxia Floating kidney 
 
 Hysteria Nervousness 
 
34 OBSERVATION OF SYMPTOMS 
 
 Tenesmus is a persistent desire, accompanied by 
 painful and ineffectual efforts to defecate : 
 
 Proctitis Fissure of anus 
 
 Hemorrhoids Hardened feces 
 
 Prolapse of rectum Ulcer of rectum 
 
 Cancer of rectum Lacerated perineum 
 Prolapse of uterus 
 
 FECES 
 
 Incontinence of feces. The sphincter ani is a 
 muscle which is normally in a state of tonic contraction. 
 This tonic contraction is under the control of a nerve 
 center which is situated in the lumbar portion of the 
 spinal cord. This nerve center is inhibited by the 
 action of the will, and relaxation of the sphincter ani 
 takes place. In certain conditions of disease the con- 
 trol of the sphincter ani may be lost. 
 
 Incontinence may occur 
 
 (a) On account of impaired intelligence ': 
 Idiocy- Typhoid fever 
 Conditions of coma Surgical shock 
 
 (b) On account of severe enteritis : 
 Cholera Cholera morbus 
 Cholera infantum 
 
 (c) On account of injury or disease of the spinal 
 cord : 
 
 Fracture of spine Myelitis 
 
 (d) On account of excessive stimulation of the nerves 
 governing peristalsis : 
 
 Strychnia poisoning Tetanus 
 
 (e) On account of injury or disease of the rectum ; 
 Laceration of sphincter ani Cancer of rectum 
 Ulcer of rectum (tubercular, syphilitic) 
 
 Small caliber stools : 
 
 Stricture of rectum Prolapse of rectum 
 
DIGESTIVE SYSTEM 35 
 
 Flattened stools : 
 
 Hemorrhoids Cancer of rectum 
 
 Enlarged prostate gland Retroversion of uterus 
 
 Scybala (rounded masses of hardened feces) : 
 Chronic constipation 
 
 Mucous spools : 
 Entero-colitis Proctitis 
 
 Removal of impacted feces 
 
 Clay-colored stools are caused by a deficiency of 
 bile in the intestines : 
 Conditions causing jaundice (see jaundice) 
 
 Greenish stools : 
 
 Fermentation of food Administration of calomel 
 
 Bloody stools. If the blood comes from the upper 
 part of the digestive canal, it is partially digested and 
 is black and tarry in color, unless the quantity is very 
 large, and then it is red. If the blood comes from the 
 large intestine or rectum it is bright red in color. 
 
 Bright red stools: 
 
 Hemorrhoids Fissure of anus 
 
 Proctitis Ulcer of rectum 
 
 Hardened feces Abdominal injuries 
 
 Rectal polypi Typhoid fever 
 
 Rupture of aneurism into the intestine 
 
 Black, tarry stools : 
 Blood from the nose or throat 
 Blood from the lungs 
 Blood from the stomach 
 Ulcer of duodenum Cirrhosis of liver 
 
 Cancer of liver Purpura hemorrhagica 
 
 Hemophilia Leucemia 
 
36 OBSERVATION OF SYMPTOMS 
 
 Masses of slough in the stools : 
 
 Gangrenous enteritis Cancer of intestine 
 
 Sloughing polypi Corrosive poisons 
 
 Ulceration of intestine (tubercular, syphilitic) 
 
 Casts of the intestine : 
 Membranous enteritis Proctitis 
 
 • 
 
 Pus in the stools. 
 
 (a) In small qua?itity : 
 Enteritis Proctitis 
 Ulcer of rectum (tubercular, syphilitic) 
 
 (b) In large quantity : 
 
 Rupture of an abscess into the intestine, such as pelvic 
 abscess, peri-proctitic abscess, peri-nephritic abscess 
 
 Foreign bodies in the stools : 
 
 Undigested food Excess of milk diet 
 
 Gall-stones Enteroliths 
 
 Foreign bodies which have been swallowed (cherry 
 stones, grape seeds, grape skins, etc.) 
 
 Intestinal parasites : 
 Tape-worm Round-worm 
 
 Thread-worm 
 
 URINE 
 
 The excretion of urine goes on constantly. The 
 minute streams are constantly passing along the tu- 
 bules of the kidneys, and the urine is collected in the 
 pelves of the kidneys and passes through the ureters 
 to the bladder. The passage of urine through the 
 ureters is caused partly by the force of gravity and 
 partly by the peristaltic action of the muscular walls 
 of the ureters. 
 
 The bladder is a muscular bag, which when empty 
 
URINE 37 
 
 is collapsed and the walls are thrown into folds. The 
 collection of urine distends the bladder. 
 
 At the neck of the bladder, where the urethra 
 joins, is a circular muscle, the sphincter vesica muscle. 
 This muscle is kept in a state of tonic contraction by 
 the action of a nerve center in the lumbar portion of 
 the spinal cord, and it prevents the urine from passing 
 into the urethra. 
 
 Another nerve center in the lumbar portion of the 
 spinal cord takes part in the mechanism of urination. 
 This nerve center governs the contraction of the 
 muscular walls of the bladder. 
 
 When urination takes place the nerve center gov- 
 erning the sphincter vesicae muscle is inhibited, and 
 the sphincter relaxes and allows the urine to pass 
 into the urethra. At the same time, the nerve center 
 which governs the contraction of the bladder walls 
 sends out impulses, and the bladder walls contract and 
 force out the urine. 
 
 Increased quantity : 
 Diabetes Chronic interstitial 
 
 Hypertrophy of heart nephritis 
 
 Nervousness Arterio-sclerosis 
 
 Administration of diuretics 
 
 Diminished quantity: 
 Febrile conditions Acute nephritis 
 
 Chronic parenchymatous Dilatation of heart 
 
 nephritis 
 Loss of water from the tissues (excessive sweating, 
 
 severe enteritis) 
 
 Painful or difficult urination (dysuria) : 
 Cystitis Vesical calculus 
 
 Stricture of urethra Enlarged prostate gland 
 
38 OBSERVATION OF SYMPTOMS 
 
 Urethritis Prolapse of uterus 
 
 Cancer of uterus Acute metritis 
 
 Atony of bladder walls 
 Certain drugs (cantharides, turpentine) 
 
 Frequent urination : 
 
 Cystitis Diabetes 
 
 Urethritis Chronic interstitial 
 Vesical calculus nephritis 
 
 Enlarged prostate gland Renal calculus 
 
 Administration of diuretics Nervousness 
 
 Incontinence of urine is caused by conditions which 
 allow relaxation of the sphincter vesicae muscle : 
 Conditions of coma Typhoid fever 
 
 Idiocy Insanity 
 
 In certain injuries or diseases of the spinal cord 
 there is paralysis of the nerve center which governs 
 the sphincter vesicae muscle, but there is also paralysis 
 of the nerve center which causes contraction of the 
 bladder walls. In these conditions the bladder becomes 
 filled with urine and overflows with constant dribbling : 
 Fracture of spine Tumor of spine 
 
 Locomotor ataxia Myelitis 
 
 Incontinence during muscular exertion (coughing, 
 sneezing, etc.) : 
 Atony of sphincter vesicae Lacerated perineum 
 
 muscle Fibroids of uterus 
 
 Cystocele 
 
 Enuresis (involuntary micturition) in children is 
 caused by over-sensitiveness of the nervous mechanism 
 governing urination. Local irritation or general nerv- 
 ous condition may be the cause of this over-sensitiveness : 
 Cystitis Phimosis 
 
 Contracted meatus Vesical calculus 
 
URINE 
 
 39 
 
 Concentrated urine Intestinal parasites 
 
 General nervous condition 
 
 Retention of urine. In this condition the urine is 
 excreted and distends the bladder, but cannot be ejected 
 from the bladder : 
 
 Stricture of urethra Enlarged prostate gland 
 Injuries or diseases of the Typhoid fever 
 
 spinal cord (see incon- Tumor of neck of bladder 
 
 tinence of urine) ' Conditions of coma 
 
 Impacted calculus in Hysteria 
 
 urethra Atony of bladder walls 
 
 Suppression of urine (anuria). In this condition 
 no urine is excreted by the kidneys : 
 Acute nephritis Typhoid fever 
 
 Following the administration of ether 
 Poisoning by carbolic acid, cantharides, turpentine, or 
 phosphorus 
 
 Obstructive suppression : 
 
 Pressure on both ureters by an abdominal tumor or 
 
 aneurism of the abdominal aorta 
 Cancer of the bladder involving the entrance of the 
 
 ureters 
 Impacted calculi in both ureters 
 
 Pale urine : 
 
 All conditions in which the quantity is increased (see 
 increased urine) 
 
 Cloudy urine : 
 
 Cystitis Mixture with mucus, 
 
 Chyluria blood, or pus 
 
 Increase of indican or urobilin 
 Normal in specimens which have stood for several hours 
 
4<3 OBSERVATION OF SYMPTOMS 
 
 Mucus in urine : 
 
 Urethritis Cystitis 
 
 Mixture of urine with vaginal discharge 
 
 Blood in urine (hematuria) may come from the 
 urethra, the bladder, the ureters, or the kidneys : 
 Urethritis Enlarged prostate gland 
 
 Cystitis Cancer of bladder 
 
 Tuberculosis of bladder Vesical calculus 
 
 Irritation of ureter by Acute nephritis 
 
 calculus Scurvy 
 
 Injury of urethra, bladder, Leucemia 
 
 or kidney Mixture with menstrual 
 
 Tuberculosis of kidney blood 
 
 Malaria Hemophilia 
 
 Poisoning by carbolic a£id, cantharides, etc. 
 
 Pus in urine may come from the urethra, the blad- 
 der, the ureters, or the kidneys : 
 
 Urethritis Abscess of prostate gland 
 
 Cystitis Pyelitis 
 
 Infection of lining membrane of ureters 
 Tuberculosis of kidney Peri-nephritic abscess 
 
 Calculi in urine : 
 Vesical calculi Renal calculi 
 
 Shreds of tissue in urine : 
 Urethritis Cancer of bladder 
 
 Tuberculosis of bladder Echinococcus cyst 
 
 SKIN 
 
 The skin acts as a protective to the sensitive nerve 
 endings. It is richly supplied with blood vessels. 
 
 The color of the skin, its degree of moisture, and 
 any eruption give information of great value. 
 
SKIN 4 1 
 
 Redness of the skin : 
 Febrile conditions Sunburn 
 
 Hypertrophy of heart 
 Poisoning by alcohol, belladonna, hyoscyamus, etc. 
 
 Temporary redness : 
 
 Emotion (blushing) Severe muscular exertion 
 
 Excitement Administration of amyl 
 
 nitrite 
 
 Redness of the cheeks : 
 
 Febrile conditions Phthisis 
 
 Excitement 
 
 Redness of one cheek : 
 
 Pneumonia Migraine 
 
 Pallor of the skin is noticed, especially on the 
 mucous membrane of the lips and conjunctiva. It is 
 caused by 
 
 (a) Weakening of the heart's action : 
 Heart diseases Surgical shock 
 Syncope 
 
 (b) Contraction of the arterioles by the action of 
 the vaso-motor nerves : 
 
 Fright Nausea 
 
 During a chill Nervousness 
 
 (c) Ancemia. The deficient quality of the blood 
 which constitutes anaemia may be caused by : 
 Insufficient food Poor hygiene 
 
 Chronic gastritis Tuberculosis 
 
 Malaria Syphilis 
 
 Cancer (a yellowish color) 
 
 Chronic nephritis (a waxy color) 
 
 Intestinal parasites Diseases of the spleen 
 
 Prolonged lactation Chronic enteritis 
 
42 OBSERVATION OF SYMPTOMS 
 
 Long-continued suppuration 
 Chronic poisoning by arsenic, lead, or mercury 
 Recurrent hemorrhages from the lungs, from the stom- 
 ach, from the uterus, or from hemorrhoids 
 
 Cyanosis. The blue color of the skin depends 
 upon a diminished amount of oxygen in the blood and 
 an increased amount of carbon dioxide. It is best 
 observed on the lips, the ends of the fingers, and the 
 lobes of the ears. It is caused by conditions causing 
 dyspnoea (see dyspncea). 
 
 Jaundice is a yellowish discoloration of the skin. 
 
 It is best observed on the mucous membrane of the 
 conjunctiva. 
 
 (a) Causes inside the liver : 
 Cirrhosis of liver Cancer of liver 
 Abscess of liver Yellow atrophy of liver 
 Administration of Pyaemia 
 
 chloroform 
 Acute febrile conditions 
 Certain poisons (phosphorus, arsenic) 
 
 (b) Causes outside the liver: 
 Gastro-duodenal catarrh Impacted gall-stone 
 Impacted intestinal parasites 
 
 Stricture of common bile duct 
 
 Pressure on common bile duct by ascites, tumor of 
 stomach or omentum 
 
 (c ) Constitutional diseases : 
 
 Yellow fever Typhus fever 
 
 Bronze color of skin : 
 
 Addison's disease 
 
 Gray color of skin : 
 Long-continued administration of silver nitrate 
 
skin 43 
 
 Local discoloration of skin : 
 Bruises Cellulitis 
 
 Erysipelas 
 
 Red spots under the skin which disappear on 
 pressure, showing that they are not true hemorrhages : 
 Typhoid fever Certain skin diseases 
 
 Hemorrhage under the skin : 
 Bruises Purpura hemorrhagica 
 
 Pyaemia Flea bites 
 
 Smallpox Scurvy 
 
 Phosphorous poisoning Yellow atrophy of liver 
 
 Eruption on the skin. 
 
 (a) Exanthemata : 
 
 Measles Chickenpox 
 
 German measles Scarlet fever 
 
 Smallpox Vaccinia 
 
 (b) Non-contagious diseases : 
 
 Skin diseases Typhoid fever 
 
 Meningitis Septicaemia 
 
 Purpura hemorrhagica Scurvy 
 Hemophilia 
 
 Drug rashes. Certain drugs given in medicinal 
 doses, by their action on the nervous supply of the 
 skin, may produce an eruption : 
 Iodides Bromides 
 
 Opium Belladonna 
 
 Salicylates Chloral 
 
 Quinine Coal-tar products 
 
 Sulphur Copper 
 
 Lead Mercury 
 
 Cubebs Santonin 
 
 Arsenic Tartar emetic 
 
 Cannabis indica Copaiba 
 
44 OBSERVATION OF SYMPTOMS 
 
 PERSPIRATION 
 
 Perspiration is secreted by the sudoriparous or 
 sweat-producing glands, which consist of coiled tubes 
 situated in the true skin and in the subcutaneous 
 tissue, and opening on the epidermis. 
 
 The elimination of perspiration is continuous. It 
 takes place so gradually that as fast as it is formed it 
 passes off by evaporation as insensible perspiration. 
 When a person is exposed to great heat or exercises 
 violently the evaporation is not sufficiently rapid, and 
 it appears as sensible perspiration. 
 
 The secretion of perspiration is regulated by the 
 nervous system. Two sets of nerves are concerned : 
 (i) the vaso-motor nerves, which regulate the blood 
 supply to the sweat glands ; and (2) the secretory nerves, 
 which stimulate the activities of the glands themselves. 
 Usually the two conditions exist together, namely, in- 
 creased blood flow and increased glandular action ; 
 that is, when the skin is red the secretion of sweat 
 increases. 
 
 In some conditions, such as surgical shock, there is 
 profuse clammy perspiration with diminished blood flow 
 (pale skin). 
 
 Increased perspiration : 
 
 Nausea Malaria (third stage) 
 
 Surgical shock Acute rheumatism 
 
 Pyaemia Conditions causing 
 
 Rickets dyspnoea 
 
 Severe pain General debility 
 
 Diaphoretic drugs Crisis of pneumonia 
 
 Diminished perspiration : 
 Febrile conditions Diabetes 
 
 Severe enteritis Chronic skin diseases 
 
skin 45 
 
 Night sweats : 
 
 Phthisis General debility 
 
 Convalescence from fevers 
 
 CEdema. The cause of oedema is a disturbance of 
 the relation between the amount of fluid which tran- 
 sudes from the capillaries and the amount which is 
 absorbed and carried away by the lymphatics. If the 
 lymphatics are obstructed, or if for any reason the 
 capillaries allow more fluid to transude from them than 
 can be removed, this excess of fluid will accumulate in 
 the connective tissue spaces and lymph radicles. 
 
 The causes are 
 
 (a) Obstruction of the return of venous blood to the 
 heart : 
 
 Heart diseases Kidney diseases 
 
 Liver diseases Thrombosis of a vein 
 
 Pressure of a tumor on a vein 
 
 (b) Alteration in the walls of the blood vessels due 
 to weakness: 
 
 Tuberculosis (last stages) Pernicious anaemia 
 Last stages of wasting diseases 
 
 (c) Inflarnmation of the tissues (local cedeind) : 
 Cellulitis 
 
 Ascites is a collection of fluid in the peritoneal 
 cavity : 
 
 Heart diseases Cancer of omentum 
 
 Cirrhosis of the Kidney diseases 
 
 liver Cancer of the liver 
 
 Tubercular peritonitis Phthisis (last stages) 
 
 Pruritus (itching) is caused by irritation of the 
 terminal nerve endings in the skin. 
 
 (a) General itching : 
 Skin diseases Conditions causing 
 
 jaundice 
 
46 OBSERVATION OF SYMPTOMS 
 
 Desquamation after Gout 
 
 eruptive fevers 
 Administration of opium 
 
 (b) Of external genitals : 
 
 Diabetes Leucorrhoea 
 
 Hysteria 
 
 (c) Of anal region : 
 
 Hemorrhoids Intestinal parasites 
 
 Fissure anus 
 
 GENERAL OBSERVATION OF THE 
 PATIENT 
 
 Position in bed. The patient naturally takes the 
 position which is most comfortable and causes the 
 least movement of an inflamed region. 
 
 (a) On the back: 
 
 Acute rheumatism Typhoid fever 
 
 (b) On the back with knees drawn up : 
 General peritonitis Appendicitis 
 Pelvic peritonitis 
 
 (c) On the affected side : 
 
 Pleurisy Pneumonia 
 
 Fractured rib Intercostal neuralgia 
 
 (d) On the side with knees drawn up : 
 Intestinal colic Gall-stone colic 
 Renal colic 
 
 (e) Retraction of the head : 
 Meningitis Uraemia 
 Strychnia poisoning Tetanus 
 Hysteria 
 
 (/) Sitting up in bed: 
 Conditions causing dyspnoea 
 
 Increased body weight : 
 
 Excess of nourishment Convalescence from fevers 
 
GENERAL OBSERVATION OF THE PATIENT. 
 
 47 
 
 Chronic alcoholism 
 Myxcedema 
 
 Dementia 
 Cretinism 
 
 Diminished body weight : 
 
 Typhoid fever Tuberculosis 
 
 Chronic enteritis Marasmus 
 
 Cancer Diabetes 
 
 All conditions interfering with digestion (stricture of 
 oesophagus, chronic gastritis, ulcer of stomach, etc.). 
 
 Expression of the face 
 the disease from which the 
 
 (a) Color of the face : 
 (See color of the skin) 
 
 (b) Vacant expression : 
 Typhoid fever 
 Extreme weakness 
 
 (c) Anxious expression : 
 General peritonitis 
 Pleurisy 
 
 Septicaemia 
 Conditions causing 
 dyspnoea 
 
 is often characteristic of 
 patient is suffering. 
 
 Surgical shock 
 Idiocy 
 
 Pneumonia 
 Angina pectoris 
 Following profuse 
 
 hemorrhage 
 Some forms of insanity 
 
 Risus sardonicus is caused by a spasm of the 
 facial muscles which draws back the angles of the mouth 
 and gives to the face the expression of smiling. 
 
 It is noticed in : 
 Tetanus Strychnia poisoning 
 
 Mouth breathing: 
 
 Adenoids 
 Habit 
 Nasal polypi 
 
 Enlarged tonsils 
 Influenza 
 Deviated septum 
 
 Enlarged upper portion of head : 
 Hydrocephalus Rickets 
 
48 ■ OBSERVATION OF SYMPTOMS 
 
 Cretinism 
 
 Idiocy 
 
 Acromegaly 
 
 Myxcedema 
 
 Fontanelles in infants. 
 
 
 (a) Bulging: 
 
 
 Hydrocephalus 
 
 Meningitis 
 
 Acute febrile conditions 
 
 
 (b) Sunken : 
 
 
 Cholera infantum 
 
 Malnutrition 
 
 Tuberculosis 
 
 
 Inability to move the head : 
 Conditions causing torticollis (see torticollis) 
 
 Swelling of the face : 
 Abscess of cheek Alveolar abscess 
 
 Mumps Sarcoma 
 
 Anthrax 
 
 Twitching of facial muscles : 
 Chorea Hysteria 
 
 Toxic doses of strychnia Tetanus 
 
 Premonitory of uraemia 
 
 Uni-lateral facial paralysis : 
 Apoplexy Tumor of brain 
 
 Fracture of skull Neuritis of facial nerve 
 
 Bi-lateral facial paralysis : 
 
 Pressure at base of brain Multiple neuritis 
 
 Torticollis (stiff-neck). In this deformity the head 
 is held in a distorted position by the spasm of certain 
 of the neck muscles : 
 
 Congenital condition Injuries at birth 
 
 Rheumatism of Cellulitis of neck 
 
 cervical muscles Carbuncles 
 
 Boils . Following eruptive fevers 
 
GENERAL OBSERVATION OF THE PATIENT 49 
 
 Pott's disease (cervical) 
 
 Inflammatory conditions in the throat (tonsilitis, retro- 
 pharyngeal abscess, etc.) 
 Hysteria 
 
 Pressure of sarcoma on sterno-cleido-mastoid muscle 
 Compensatory to lateral curvature of dorsal spine 
 
 Enlarged lymphatic glands in neck : 
 Enlarged septic tonsils Pediculi of scalp 
 
 Tuberculosis • Diphtheria 
 
 Scarlet fever Measles 
 
 Erysipelas Syphilis 
 
 Leucemia Glanders 
 
 Abnormal pulsation of carotid arteries : 
 
 Hypertrophy of heart Excitement 
 
 Aneurism of carotid artery Exophthalmic goiter 
 
 Small, depressed scars on the skin : 
 Lacerated wounds - Subcutaneous tumors 
 
 removed 
 Broken-down glands (in cervical or axillary regions) 
 
 Pits or depressions : 
 Aene Boils 
 
 Carbuncles Chickenpox 
 
 Smallpox 
 
 Smooth, irregular scars : 
 Burns Cellulitis 
 
 Destruction of the skin by chemical agents 
 Healed ulcers 
 
 Thick abdominal wall : 
 Obesity (Edema of abdominal wall 
 
 Lax abdominal wall : 
 Old age Wasting diseases 
 
SO OBSERVATION OF- SYMPTOMS 
 
 Following pregnancy 
 
 Following the removal of ascites or abdominal tumor 
 
 Rigid abdominal walls : 
 General peritonitis Intestinal colic 
 
 Pneumonia Pleurisy 
 
 Rigid right rectus muscle : 
 Appendicitis 
 
 Distention of abdomen : 
 Obesity Tympanites 
 
 Ascites 
 
 Localized distention of abdomen : 
 Distended bladder Pregnant uterus 
 
 Abdominal tumor Impacted feces 
 
 Enlarged liver Phantom tumor 
 
 Retraction of abdomen : 
 Old age Wasting diseases 
 
 Cholera infantum Lead colic 
 
 Linea scars on abdomen (from over-stretching of 
 the skin) : 
 
 Pregnancy Ascites 
 
 Large abdominal tumors 
 
 Dilated superficial veins of abdomen : 
 Cirrhosis of liver Cancer of liver 
 
 Heart weakness Pressure of tumor on 
 
 vena cava 
 
 Umbilicus retracted : , 
 
 Obesity 
 
 Umbilicus projecting: 
 
 Pregnane} Ventral hernia 
 
 Ascites Cirrhosis of liver 
 
 Cancer of liver 
 
GENERAL OBSERVATION OF THE PATIENT 
 
 51 
 
 Swelling in the groin : 
 Tubercular adenitis 
 Syphilitic adenitis 
 Undescended testicle 
 Femoral hernia 
 Aneurism of femoral artery 
 
 Vaginal discharge : 
 Leucorrhcea 
 Cancer 
 
 Gonorrhceal adenitis 
 Leucemia 
 Inguinal hernia 
 Psoas abscess 
 
 Gonorrhoea 
 
 Hemorrhage from vagina : 
 
 Menstruation 
 Beginning labor 
 Endometritis 
 Retained secundines 
 Uterine fibroids 
 
 Swelling on the back : 
 Spina bifida 
 Lipoma 
 Peri-nephritic abscess 
 
 Stiffness of the back : 
 Long confinement in bed 
 Sprain of muscles 
 Pott's disease 
 
 Miscarriage 
 
 Injury 
 
 Subinvolution of uterus 
 
 Uterine polypi 
 
 Pott's disease 
 Carbuncle 
 Cancer of kidney 
 
 Lumbago 
 
 Arthritis deformans 
 Paralysis agitans . 
 
 Posterior curvature of spine (kyphosis) , 
 Pott's disease Rickets 
 
 Injury to spinal column 
 
 Lateral curvature of spine (scoliosis) : 
 Pott's disease Rickets 
 
 Habitual one-sided position of the body 
 Obliquity of the pelvis from shortening of one leg 
 Atrophy of the muscles on one side 
 Over-use of the muscles on one side 
 
52 OBSERVATION OF SYMPTOMS 
 
 Spasm of the muscles on one side from disease of the 
 
 central nervous system 
 Healed empyema of one side, contracting the chest wall 
 Injury of the sacro-iliac articulations 
 
 Anterior curvature of spine (lordosis) : 
 Pott's disease Rickets 
 
 Congenital dislocation of hip 
 
 Bow-legs (genu varum) : 
 Over-use in early life Rickets 
 
 Cretinism 
 
 Knock-knees (genu valgum) : 
 Rickets Traumatism 
 
 Arthritis Infantile paralysis 
 
 Flatfoot 
 
 Anchylosis of joint : 
 
 Fracture into the joint Tuberculosis of joint 
 
 Dislocation of joint Septic infection of joint 
 
 Chronic rheumatism 
 
 Arthritis, following typhoid fever, gonorrhoea, syphilis, 
 gout, scarlet fever, measles, or smallpox 
 
 Shortening of one leg : 
 
 Fracture of neck of femur Fracture of shaft of femur 
 
 Congenital dislocation Unreduced dislocation 
 
 of hip of hip 
 
 Former hip-joint disease Infantile paralysis 
 
 Swelling of one leg: 
 
 Psoas abscess Phlebitis 
 
 Embolism 
 
 Swelling of ball of great toe : 
 
 Gout Cellulitis 
 
 Rheumatism Pressure of tight shoe 
 
GENERAL OBSERVATION OF THE PATIENT 53 
 
 Varicose veins are permanent dilatation of veins : 
 Long-continued standing Constipation 
 Pregnancy Abdominal tumors 
 
 Ulcers are areas of loss of continuity upon the 
 surface of the body which show no tendency to heal. 
 
 They are caused by : 
 Injury Varicose veins 
 
 Syphilis Tuberculosis 
 
 Cancer Embolism 
 
 Coldness of feet and hands : 
 
 During a chill Conditions causing 
 
 Chronic gastritis cyanosis 
 
 Rheumatism Anaemia 
 
 Tuberculosis Heart weakness 
 
 Profuse hemorrhage Surgical shock 
 
 Sweating of feet and hands : 
 Nervousness Bromidrosis 
 
 Odor of feet : 
 Lack of cleanliness Bromidrosis 
 
 Gangrene is the death of the soft tissues in greater 
 or smaller masses. 
 The causes are 
 
 (a) Obstruction of the blood vessels : 
 Ligation Arterio-sclerosis 
 Over-tight plaster of Paris bandage 
 Embolism following typhoid fever or scarlet fever 
 
 (b) Mechanical crushing of the blood vessels : 
 Injuries 
 
 (c) Obstruction of the blood supply by the exudation 
 resulting from inflammation : 
 
 Frostbite Burns 
 
 Scalds 
 
54 OBSERVATION OF SYMPTOMS 
 
 (ti) Continued pressure on tlie tissues : 
 Bed-sores Splint sores 
 
 (e) Dist>irbance of the trophic nerve supply : 
 Injury to spinal cord Raynaud's disease 
 
 (/) Constitutional diseases : 
 Diabetes 
 
 PAIN 
 
 Stimuli transmitted along sensory nerves from 
 any part of the body to the brain produce sensations. 
 These sensations are acted upon by the brain, and the 
 proper movement takes place. 
 
 If the stimuli along the sensory nerves become 
 stronger the sensations in the brain become unpleas- 
 ant, and if stronger still the sensations become painful. 
 Pain, therefore, is caused by over-stimulation of sensory 
 nerves. 
 
 Kinds of pain. 
 
 (a) Sharp pain : 
 Acute inflammation 
 
 (b) Dull ache : 
 
 Chronic inflammation Bruises 
 
 Necrosis of bone Lumbago 
 
 (c) Darting pain : 
 
 Acute rheumatism Neuralgia 
 
 Locomotor ataxia Hysteria 
 
 Trichiniasis 
 
 (d) Boring pain . 
 
 Necrosis of vertebra Thoracic aneurism 
 
 Cancer of stomach 
 
 (e) Burning pain : 
 Irritative skin diseases 
 
 (/) Cramps (involuntary muscular contractions) : 
 Acute gastritis Intestinal colic 
 
pain 5 5 
 
 Gall-stone colic Renal colic 
 
 Writer's cramp Muscular cramps 
 
 (g) Pain increased by motion : 
 Acute inflammation Rheumatism 
 
 Sprains Injury or disease of 
 
 joints 
 
 (h) Pain relieved by pressure : 
 Intestinal colic Hysteria 
 
 Headache. The pain in the head is usually accom- 
 panied by mental irritability and loss of intellectual 
 power. 
 
 The causes are 
 
 (a) Irritation in the digestive canal : 
 Acute gastritis Chronic gastritis 
 Constipation Enteritis 
 Conditions causing jaundice 
 
 (b) Certain poisons circulating in the blood: 
 Impure air Uraemia 
 
 Toxins of fevers Lithasmia 
 
 Syphilis Gout 
 
 (c) Congestion of the cerebral blood vessels : 
 Hypertrophy of heart 
 
 Administration of amyl nitrite, quinine, etc. 
 
 (d) Deficient quatitity of blood sent to the brain : 
 Dilatation of heart Surgical shock 
 Arterio-sclerosis Syncope 
 
 (c) Deficient quality of blood sent to tlie brain : 
 Anaemia Chlorosis 
 
 (f) Inflammation of or pressure on the brain: 
 Meningitis ■ Fracture of skull 
 
 Tumor of brain Abscess of brain 
 
 is) Poisoning by certain drugs : 
 Alcohol Opium 
 
 Tobacco Lead 
 
 Mercury 
 
56 OBSERVATION OF SYMPTOMS 
 
 (li) Diseases of the nervous system : 
 Epilepsy Migraine 
 
 Hysteria 
 
 (i) Irritation in other parts of the body {reflex 
 headache) : 
 
 Eye strain Adenoids 
 
 Diseases of the nose Impacted ear-wax 
 
 Uterine disorders 
 
 (J) General physical condition : 
 Excessive fatigue Nervous strain 
 
 (k) Irritation on the outside of the cranium : 
 Injury of the scalp Rheumatism of the scalp 
 
 Periostitis of the cranial Mastoiditis 
 
 bones 
 Necrosis of the cranial bones 
 
 Location of headache. 
 
 (a) Uni-lateral headache : 
 
 Migraine Trifacial neuralgia 
 
 Ear diseases Mastoiditis 
 
 Toothache Necrosis of bone 
 
 (b) Frontal headache : 
 
 Nasal catarrh Adenoids 
 
 Gastritis Constipation 
 
 Eye strain Anaemia 
 
 (c) Occipital headache : 
 
 Uraemia Meningitis 
 
 Diseases of spinal cord Diseases of cervical 
 Hysteria vertebrse 
 
 (d) Vertex headache: 
 
 Menstrual disorders Rheumatism of scalp 
 
 Pelvic inflammation Hysteria 
 
 Neuralgia is pain which follows the distribution of 
 a nerve. It may be due to inflammation of the nerve 
 
pain 5 7 
 
 sheath (neuritis), to irritation at any point along the 
 course of the nerve, or to certain poisons circulating 
 in the blood. 
 
 The causes are 
 
 (a) Inflammation of the nerve sheath : 
 Injury Exposure to cold 
 
 (b) Mechanical pressure on the nerve : 
 Tumor Aneurism 
 Periostitis 
 
 (c) Constitutional diseases : 
 Syphilis Rheumatism 
 Malaria Gout 
 Diabetes 
 
 (d) Toxic drugs : 
 
 Alcohol Lead 
 
 Mercury Arsenic 
 
 (e) Deficient quality of the blood: 
 Anaemia Phthisis 
 
 Pain in the face : 
 
 Injury Toothache 
 
 Alveolar abscess Salivary calculus 
 
 Neuralgia (see neuralgia) 
 
 Pain in the throat (sore throat) : 
 
 Tonsilitis Pharyngitis 
 
 Foreign body in throat Diphtheria 
 
 Scarlet fever Measles 
 
 Irritant poison Retro-pharyngeal 
 
 Tubercular ulcer abscess 
 
 Cancer Syphilitic ulcer 
 
 Pain in the neck (see torticollis) : 
 
 Pain in side of chest : 
 Pleurisy Pneumonia 
 
 Intercostal neuralgia Fractured rib 
 
58 OBSERVATION OF SYMPTOMS 
 
 Pain in praecordium : 
 
 Bronchitis Pericarditis 
 
 Endocarditis Angina pectoris 
 
 Thoracic aneurism Mediastinal tumor 
 
 Foreign body in bronchus Enlarged bronchial glands 
 Necrosis of sternum 
 
 Pain in mammary gland : 
 Mastitis Cracked nipple 
 
 Pregnancy Hysteria 
 
 Cancer Uterine disorders 
 
 Pain in abdomen. The abdomen is divided by 
 certain imaginary lines into nine regions. One line 
 encircles the body on a level with the costal cartilages 
 of the tenth ribs. Another line encircles the body on 
 a level with the anterior-superior spines of the ilia. 
 
 Two vertical lines intersect these horizontal lines. 
 They are drawn on either side through the ilio-pectineal 
 eminences and end on the first mentioned horizontal 
 line which connects the costal cartilages of the tenth 
 ribs. 
 
 The three highest regions are bounded above by 
 the diaphragm. The three lowest regions are bounded 
 below by the brim of the true pelvis. 
 
 These nine regions are as follows : 
 
 i. Right hypochondriac region contains the right 
 lobe of the liver, the gall-bladder, the upper part of 
 the right kidney, and the right supra-renal capsule. 
 
 Pain in right hypochondrium : 
 
 Gall-stones Cirrhosis of liver 
 
 Cancer of liver Abscess of liver 
 
 Colitis Floating right kidney 
 
 Pyelitis Sub-phrenic abscess 
 
pain 59 
 
 2. Epigastric region contains part of the stomach 
 and left lobe of the liver, the cceliac axis, the solar 
 plexus, the pancreas, and parts of the aorta, inferior 
 vena cava, venae azygos, and thoracic duct. 
 
 Pain in epigastrium : 
 Gastritis Flatulency 
 
 Ulcer of stomach Cancer of stomach 
 
 Irritant poisons Colitis 
 
 Inflammation of left Ursemia 
 
 lobe of liver Cancer of pancreas 
 
 Diaphragmatic pleurisy 
 Necrosis of dorsal vertebras 
 
 3. Left hypochondriac region contains the greater 
 part of the stomach, the spleen, the splenic flexure of 
 the colon, the greater omentum, the upper part of the 
 left kidney, and the left supra-renal capsule. 
 
 Pain in left hypochondrium : 
 Gastritis Ulcer of stomach 
 
 Colitis Impacted feces in colon 
 
 Cancer of stomach Floating left kidney 
 
 Enlarged spleen from typhoid fever, malaria, or leucemia 
 Pyelitis Sub-phrenic abscess 
 
 4. Right lumbar region contains part of the right 
 kidney, the small intestine, and the ascending colon. 
 
 Pain in right lumbar region : 
 
 Colitis Floating right kidney 
 
 Pyelitis Sub-phrenic abscess 
 
 5. Umbilical region contains the transverse colon, 
 the greater omentum, the small intestines, and the 
 mesentery. 
 
60 OBSERVATION OF SYMPTOMS 
 
 Pain in umbilical region : 
 Ventral hernia Cancer of omentum 
 
 6. Left lumbar region contains part of the left 
 kidney, the small intestines, and the descending colon. 
 
 Pain in left lumbar region : 
 Colitis Floating left kidney 
 
 Pyelitis Sub-phrenic abscess 
 
 7. Right iliac region contains the caecum, the ver- 
 miform appendix, the right ureter, and the right sper- 
 matic vessels. 
 
 Pain in right iliac region : 
 
 Appendicitis Enteritis 
 
 Typhoid fever Renal colic 
 
 Right inguinal hernia Varicocele 
 
 8. Pubic region contains the bladder, part of the 
 small intestines, and the uterus during pregnancy. 
 
 Pain in pubic region : 
 
 Cystitis Tuberculosis of bladder 
 
 Cancer of bladder Vesical calculus 
 
 Menstruation Diseases of uterus and 
 
 ovaries 
 
 9. Left iliac region contains part of the sigmoid 
 flexure, the left ureter, and the left spermatic vessels. 
 
 Pain in left iliac region : 
 Impacted feces in Enteritis 
 
 sigmoid flexure Renal colic 
 
 Proctitis Varicocele 
 
 Left inguinal hernia 
 
 General abdominal pain : 
 General peritonitis Intestinal colic 
 
PAIN 
 
 61 
 
 Onset of appendicitis 
 
 Tubercular peritonitis 
 
 Enteritis 
 
 Hysteria 
 
 Crisis of locomotor ataxia 
 
 Strain of recti muscles from violent vomiting or coughing 
 
 Intestinal obstruction 
 Irritant poisons 
 Rheumatism of abdominal 
 muscles 
 
 Pain in perineum : 
 Hemorrhoids 
 Enlarged prostate gland 
 Proctitis 
 Fissure ani 
 Uterine diseases 
 
 Pain in back : 
 Onset of acute disease 
 La grippe 
 Gastritis 
 Labor pains 
 Psoas abscess 
 Meningitis 
 Rickets 
 
 Peri-nephritic abscess 
 Hysteria 
 
 Pain in arm : 
 Over-exertion 
 Neuritis 
 
 Progressive muscular 
 atrophy 
 
 Pain in hand : 
 Rheumatism 
 Teno-synovitis 
 Occupation neurosis 
 
 Pain in thigh : 
 
 Rheumatism 
 
 Cystitis 
 
 Ischio-rectal abscess 
 Fistula in ano 
 Vesical calculus 
 
 Prolonged standing position 
 Lumbago 
 Uterine diseases 
 Lacerated perineum 
 Necrosis of vertebrae 
 Tumor of spinal cord 
 Pyelitis' 
 Curvature of spine 
 
 Rheumatism 
 Occupation neurosis 
 Trichiniasis 
 
 Ar|hritis deformans 
 Gout 
 
 La grippe 
 
62 
 
 OBSERVATION OF SYMPTOMS 
 
 Hip-joint disease (on the inside of the thigh) 
 
 Sciatica Locomotor ataxia 
 
 Chronic lead poisoning Phlebitis 
 
 Sarcoma of femur Hysteria 
 
 Pressure on the anterior crural nerve caused by : 
 
 Pregnancy Pelvic tumor 
 
 Impacted feces Psoas abscess 
 Cancer of rectum 
 
 Pain in leg : 
 Rheumatism 
 Varicose veins 
 Phlebitis 
 Gout 
 Rickets 
 Chronic lead poisoning 
 
 Pain in foot : 
 
 Rheumatism 
 Sprain 
 Bunion 
 Gout 
 
 Pain in joints : 
 
 Rheumatism 
 
 Rickets 
 
 Gonorrhceal arthritis 
 
 Pyaemia 
 
 Syphilis 
 
 Hysteria 
 
 La grippe 
 Ulcer 
 
 Periostitis of tibia 
 Alcoholic neuritis 
 Locomotor ataxia 
 
 Flatfoot 
 
 Chilblains 
 
 Cellulitis 
 
 Sprain 
 
 Floating cartilage (in 
 
 knee joint) 
 Tubercular arthritis 
 Arthritis deformans 
 Gout 
 
 Referred pain. Irritation of a nerve at any point 
 along its course is referred to the end of the nerve. 
 
 Pressure of a cicatrix causes pain referred to am- 
 putated fingers or toes. 
 
 A blow on the ulnar nerve at the elbow causes pain 
 in the little finger and one-half the ring finger. 
 
NERVOUS SYSTEM 63 
 
 Pressure on the posterior tibial nerve causes numb- 
 ness of the foot (foot asleep). 
 
 Necrosis of vertebrae causes pain in the side and 
 front of the chest. 
 
 Pneumonia sometimes causes pain which is referred 
 to the abdomen. 
 
 Hip-joint disease causes pain on the inside of the 
 thigh and knee. 
 
 Pressure on the anterior crural nerve by a pelvic 
 tumor causes pain down the front of the thigh. 
 
 Pressure on nerves from an unreduced dislocation 
 of the shoulder causes pain in the arm. 
 
 Enclosure of the anterior tibial nerve in the callus 
 after a fracture of the tibia causes pain along the dorsal 
 surface of the foot. 
 
 NERVOUS SYSTEM 
 
 The mental condition of the patient changes accord- 
 ing to the disease. 
 
 Mental excitement : 
 
 Acute fevers Acute alcoholism 
 
 Mania Administration of ether 
 
 Mental depression : 
 Chronic gastritis La grippe 
 
 Conditions causing Melancholia 
 
 jaundice 
 
 Change of disposition : 
 Pregnancy Epilepsy 
 
 Tumor of brain Typhoid fever 
 
 Insanity 
 
 Mental instability : 
 
 Hysteria Insanity 
 
 Anaemia Menopause 
 
64 OBSERVATION OF SYMPTOMS 
 
 Dullness of mind : 
 Typhoid fever Tumor of brain 
 
 Abscess of brain Embolus of brain 
 
 Onset of coma 
 
 Loss of memory : 
 
 Old age Bromism 
 
 Epilepsy Insanity 
 
 Delusions, illusions, and hallucinations : 
 Injury of head Insanity 
 
 Certain drugs (opium, belladonna, cannabis indica) 
 Administration of ether or chloroform 
 Conditions causing delirium (see delirium) 
 
 Delirium is a condition of mental agitation. It is 
 caused by 
 
 (a) Irritation of the nerve centers in the brain by 
 the toxins of disease : 
 
 Typhoid fever Pneumonia 
 
 Septicaemia Urasmia 
 
 (b) Action of certaiti drugs on the brain: 
 Opium Belladonna 
 Cocaine Cannabis indica 
 
 (c) Irritation of the brain by injury or disease : 
 Fracture of skull . Apoplexy 
 
 Tumor of brain Abscess of brain 
 
 Meningitis 
 
 (d) Deficient blood supply to the brain : 
 Heart diseases (late stages) 
 
 (e) Exhaustion of the nerve centers in the brain : 
 Surgical shock Post-operative delirium 
 Following epileptic convulsion 
 
 Sleep is a periodic condition of the nervous system 
 in which the activities of the higher nerve centers 
 partially or completely cease. 
 
NERVOUS SYSTEM 65 
 
 Insomnia. 
 The causes are 
 
 (a) Irritative conditions : 
 
 Severe pain Inflammatory processes 
 
 Indigestion Pruritus 
 
 Intestinal parasites Asthma 
 
 (b) Psychic conditions : 
 Worry Grief 
 Responsibility Habit of wakefulness 
 
 (c) Toxic conditions : 
 
 Acute fevers Nephritis 
 
 Chronic alcoholism Use of cocaine 
 
 Excessive use of coffee or tea 
 
 (d) Degenerative conditions : 
 
 Senility Diseases of the brain 
 
 Somnolence. 
 
 The causes are : 
 Over-eating Chronic gastritis 
 
 Uraemia Use of narcotic drugs 
 
 Diseases of the brain and meninges 
 
 Coma is a condition of unconsciousness from which 
 the patient cannot be aroused. 
 It is caused by 
 
 (a) Inflammation of or pressure on the brain : 
 Meningitis Apoplexy 
 Fracture of skull Tumor of brain 
 Abscess of brain Embolus of brain 
 
 (b) Certain poisons circulating in the blood : 
 Uraemia Typhoid fever 
 Pyaemia Poisoning by coal gas 
 Poisoning by certain drugs such as : 
 
 Q\lcohol Opium 
 
 Chloral Ether 
 
 Chloroform 
 
66 OBSERVATION OF SYMPTOMS 
 
 (c) Constitutional diseases : 
 Diabetes Epilepsy 
 
 Sunstroke Hysteria 
 
 Coma vigil is a condition in which the patient 
 lies with his eyes open, but is not conscious of his 
 surroundings : 
 Typhoid fever 
 
 Syncope (fainting) is caused by deficient blood 
 supply to the brain : 
 
 Heart diseases Profuse hemorrhage 
 
 Nervous emotion Severe pain 
 
 Anaemia Pregnancy 
 
 Vertigo is a subjective sensation of movement or 
 rotation of surrounding objects : 
 Chronic gastritis Constipation 
 
 Ear diseases Impacted ear-wax 
 
 Eye strain Heart diseases 
 
 Arterio-sclerosis Thoracic aneurism 
 
 Chronic nephritis Locomotor ataxia 
 
 Tumor of brain Abscess of brain 
 
 Hysteria Anaemia 
 
 Petit mal 
 Premonitory of apoplexy or uraemia 
 
 COORDINATION OF MUSCLES 
 
 The action of every muscle in the body is governed 
 by a nerve, and only by the coordination of groups of 
 muscles are the complicated movements of the body 
 carried out. The coordination of muscles is governed 
 by nerve centers situated in the cerebellum. 
 
 Standing is a position in which a line drawn through 
 the center of gravity falls between the feet. This posi- 
 
COORDINATION OF MUSCLES 6j 
 
 tion is maintained by the action of the muscles at the 
 back of the neck, which firmly fix the head, and by 
 making the vertebral column rigid. The rigid vertebral 
 column is maintained by the action of the muscles of 
 the back. 
 
 Walking is a complicated act involving nearly all of 
 the voluntary muscles of the body. These muscles act 
 either for the purpose of progression or for balancing 
 the head and trunk. 
 
 Incoordination of muscles : 
 
 Acute alcoholism Tumor of cerebellum 
 
 Locomotor ataxia Meniere's disease 
 
 Numbness, noted especially iii the fingers and 
 toes.: 
 
 Premonitory of apoplexy Locomotor ataxia 
 
 Tumor of brain Myelitis 
 
 Poisoning by aconite Local application of 
 
 carbolic acid 
 Pressure on or injury of nerves supplying fingers and 
 toes 
 
 Paralysis is a condition in which the muscle cannot 
 be made to contract by the action of the will. 
 
 (a) Hemi-plegia is paralysis of one-half of the body : 
 Apoplexy Fracture of skull 
 Tumor of brain Abscess of brain 
 Embolus of brain 
 
 (b) Para-plegia is paralysis of the lower part of the 
 body : 
 
 Degeneration of Fracture of spinal column 
 
 spinal cord Hemorrhage into spinal 
 
 Tumor of spinal cord cord 
 
 Paralysis of one nerve or group of nerves : 
 Pressure on nerve by tumor or aneurism 
 
68 OBSERVATION OF SYMPTOMS 
 
 Neuritis caused by : 
 
 Injury Exposure to cold 
 
 Rheumatism Syphilis 
 
 Alcohol Lead 
 
 Mercury Arsenic 
 
 Dragging one foot : 
 Hemi-plegia from apoplexy, tumor of brain, etc. 
 Peripheral neuritis 
 
 Limping : 
 Partial paralysis of one leg Rheumatism 
 Sciatica Gout 
 
 Bunion or corn 
 Injury or disease of ankle, knee, or hip-joint 
 
 Atrophy of muscles from non-use : 
 Non-use of an arm or leg from fracture or other injury 
 Atrophy of stump following amputations 
 Atrophy following anchylosis of a joint 
 
 Atrophy of degeneration : 
 
 All diseases causing pressure on or degeneration of 
 the spinal cord. Degeneration of the spinal cord causes 
 changes in the trophic nerve supply to the muscles. 
 
 Hypertrophy of muscles : 
 
 Over-use (when the other arm or leg is paralyzed) 
 Acromegaly 
 
 Flaccid muscles: 
 
 Conditions causing Conditions causing 
 
 paralysis atrophy 
 
 Rigid muscles: 
 
 Meningitis Spastic paralysis 
 
 Hysteria Tetanus 
 
 Strychnia poisoning 
 
COORDINATION OF MUSCLES 69 
 
 Contracture of muscles : 
 Paralysis of the opposing muscles 
 Changes in the muscular tissue 
 Abnormal nervous impulses (neuropathic contracture) 
 
 Tremor of muscles is noticed especially when the 
 hand is held out and is unsupported : 
 Old age Nervousness 
 
 Chronic alcoholism Paralysis agitans 
 
 Multiple neuritis 
 Excessive use of opium, tobacco, or coffee 
 
 Twitching of muscles : 
 Chorea Nervousness 
 
 Typhoid fever (sub- Toxic doses of strychnia 
 
 sultus tendinum) 
 Premonitory of ursemic convulsion 
 
 Chill. A chill is caused by contraction of the arte- 
 rioles under the influence of the vaso-motor nerves. 
 This causes the feeling of coldness : 
 Onset of acute disease Nervousness 
 
 Malaria Pysemia 
 
 Chilly feelings felt up and down the back : 
 La grippe Tonsilitis ' 
 
 Beginning typhoid fever Rheumatism 
 
 Tuberculosis 
 
 Convulsions. A convulsion is a violent involuntary 
 contraction of all the muscles of the body. Convulsions 
 are usually followed by coma. 
 
 They are caused by 
 
 (a) Inflammation of or pressure on the brain: 
 Meningitis Fracture of skull 
 
 Tumor of brain Abscess of brain 
 
 Embolus of brain 
 
JO OBSERVATION OF SYMPTOMS 
 
 (b) Certain toxins of disease which irritate the nerve 
 centers in the brain: 
 
 Uraemia Tetanus 
 
 Hydrophobia 
 
 (c) Certain drugs which irritate the nerve centers 
 in the brain : 
 
 Strychnia poisoning 
 
 (d) Constitutional conditions : 
 Epilepsy Hysteria 
 
 Consciousness preserved in convulsions caused by : 
 Tetanus Strychnia poisoning 
 
 Hydrophobia Hysteria - 
 
 Convulsions in infants. Since the nervous system 
 
 of infants is more sensitive than in adults, convulsions 
 are much more common : 
 
 Indigestible food Intestinal parasites 
 
 Onset of acute disease Phimosis 
 
 (pneumonia, scarlet Rickets 
 
 fever, measles, etc.) Epilepsy 
 
 Ear diseases General debility 
 
 Injuries at birth Infantile paralysis 
 
 Night terrors in infants : 
 Adenoids Enlarged tonsils 
 
 Indigestible food Fright 
 
 Intestinal parasites Dentition 
 
 Jacksonian epilepsy is characterized by epilepti- 
 form convulsions, which are limited to the muscles of 
 an extremity or to the facial muscles of one side. 
 
 The cause is injury or disease of that portion of the 
 brain which governs these muscles. 
 
 Tonic spasm of muscles. When a stimulus is 
 applied to a muscle through a motor nerve, the muscle 
 
COORDINATION OF MUSCLES J I 
 
 contracts. If the stimuli follow one another rapidly, 
 the muscle does not have time to relax in the inter- 
 vals ; the contractions become fused together, and the 
 muscle remains in a state of continuous or tonic 
 Contraction : 
 
 Meningitis Epilepsy (first stage) 
 
 Tetanus Strychnia poisoning 
 
 Hiccough (singultus) is an intermittent, sudden 
 contraction of the diaphragm. It is caused by irrita- 
 tion of the phrenic nerve and certain fibers of the 
 pneumogastric nerve. This irritation may come from 
 organs in the abdominal cavity or it may originate in 
 the brain itself. 
 
 The causes are 
 
 (a)' Irritation in the stomach : 
 Indigestible food Swallowing hot liquids 
 
 Flatulency 
 
 (b) Inflammatory conditions : 
 
 General peritonitis Intestinal obstruction 
 
 Appendicitis Strangulated hernia 
 
 (c) Irritation in the brain : 
 
 Tumor of brain. Abscess of brain 
 
 (d) Constitutional conditions : 
 Chronic nephritis Diabetes 
 Gout 
 
 (e) Nervous conditions : 
 Surgical shock Hysteria 
 
 Kernig's sign. The patient lies upon the back, 
 and the thigh is placed at a right angle to the body. 
 An attempt is then made to extend the leg and bring 
 it in line with the thigh. If the patient is suffering 
 from meningitis it will be impossible to straighten the 
 extremity on account of contracture of the muscles 
 . which flex the leg. It is noticed in : 
 Meningitis 
 
72 OBSERVATION OF SYMPTOMS 
 
 Babinski reflex. This consists of the deliberate 
 extension of the toes, and especially of the great toe, 
 followed by dorsi-flexion of the ankle joint, when the 
 sole of the foot is gently stroked. 
 
 Normally when the sole of the foot is stroked, the 
 toes flex. 
 
 It is noticed in conditions causing spinal paralysis. 
 
 EYE 
 
 Swelling under the eyes: 
 CEdema of nephritis Chronic poisoning by 
 
 arsenic 
 
 Ecchymosis under the eye : 
 Bruise Fracture of skull into 
 
 the orbit 
 
 Drooping of the upper eyelid (ptosis) : 
 Paralysis of the motor oculi nerve (third cranial nerve) 
 
 Redness of the conjunctiva : 
 
 Foreign body in eye Cold wind 
 
 Influenza Alcoholism 
 
 Gonorrhoeal infection Septic infection 
 
 Administration of iodides Measles 
 
 Whooping cough Trifacial neuralgia 
 Asthma 
 
 Moisture of eye increased : < 
 All conditions causing redness of conjunctiva 
 
 Moisture of eye diminished : 
 
 Typhoid fever Surgical shock 
 
 Prominence of eye-ball: 
 Exophthalmic goiter Tumor of orbit 
 
 Hemorrhage into the orbit 
 
EYE 73 
 
 Sinking in of the eye-ball : 
 
 Typhoid fever Choleta infantum 
 
 Marasmus 
 
 Tuberculosis 
 
 Pain in the eye-ball: 
 
 
 Glaucoma 
 
 Migraine 
 
 Trifacial neuralgia . 
 
 Coryza 
 
 Sensitiveness to light : 
 
 
 Inflammatory diseases 
 
 Meningitis 
 
 of the eye 
 
 Influenza 
 
 Measles 
 
 Hysteria 
 
 Whooping cough 
 
 
 Internal strabismus : 
 
 Diseases at the base of the brain 
 
 Action of certain poisons 
 
 Paralysis of certain ocular muscles caused by ; 
 
 Syphilis Rheumatism 
 
 Diphtheria 
 
 External strabismus : 
 Epileptic convulsion Hysteria 
 
 Nystagmus is a condition in which there are con- 
 tinuous oscillatory movements of the eye-ball which 
 cannot be controlled by the patient : 
 Abnormal conditions of the ocular muscles 
 Meningitis Locomotor ataxia 
 
 Hydrocephalus 
 
 Pupil. The iris is a circular curtain which regulates 
 the amount of light entering the eye. The opening 
 in this curtain is the pupil. 
 
 The iris contains two sets of muscular fibers : 
 (i) circular fibers, which contract the pupil, and (2) 
 radiating fibers, which dilate the pupil. 
 
74 OBSERVATION OF SYMPTOMS 
 
 Dilated pupil : 
 
 When a small amount of light falls on the retina 
 When the eye is adjusted for far objects 
 During violent muscular exertion 
 In conditions causing dyspnoea 
 Under the influence of emotions 
 
 It is also noticed in : 
 Surgical shock Nausea 
 
 Syncope Mania 
 
 Exophthalmic goiter General debility 
 
 Anaemia Nervousness 
 
 Over-dose of ether or chloroform 
 Administration of certain drugs (atropine, cocaine) 
 
 Contracted pupil : 
 In normal sleep 
 
 When an intense light falls on the retina 
 When the retina or optic nerve is inflamed 
 When accommodation takes place for far objects 
 When the eye-ball is turned inward 
 
 It is also noticed in : 
 Uraemia Meningitis 
 
 Certain diseases of the Locomotor ataxia 
 
 brain 
 Administration of certain drugs (opium, physostigma) 
 
 Argyll-Robertson pupil reacts to accommodation 
 but not to light : 
 
 Locomotor ataxia Paretic dementia 
 
 Atrophy of brain Syphilis of brain 
 
 Hydrocephalus 
 
 Unequal pupils show that there is irritation in one 
 hemisphere of the brain or paralysis of the third cranial 
 nerve on one side : 
 Apoplexy Fracture of skull 
 
EAR 75 
 
 Tumor of brain Abscess of brain 
 
 Embolus of brain 
 
 Paralysis of the motor oculi nerve (third cranial nerve), 
 which supplies the circular fibers of the iris 
 
 Double vision : 
 Action of certain drugs (atropine, alcohol, gelsemium) 
 Defective action of the ocular muscles caused by : 
 Tumor of brain Hemorrhage of brain 
 
 Spots or flashes before the eyes : 
 Chronic gastritis Constipation 
 
 Anaemia Migraine 
 
 Premonitory of uraemia Hypertrophy of heart 
 
 Hysteria 
 
 Amaurosis is blindness which comes on more or 
 less suddenly : 
 
 Uraemia Following profuse 
 Migraine hemorrhage 
 
 Optic neuritis Embolus in blood ves- 
 Diabetes sel of retina 
 
 Excessive doses of Excessive use of tobacco 
 
 quinine Hysteria 
 
 Atrophy of optic nerve from poisoning by wood alcohol 
 
 Cataract is a cloudiness of the crystalline lens or 
 its capsule. 
 
 It is caused by : 
 Old age (senile cataract) Injury (traumatic cataract) 
 
 Diabetes (diabetic cataract) 
 
 EAR 
 
 Pain in the ear : 
 Inflammation of auditory Foreign body in ear 
 canal Toothache 
 
76 OBSERVATION OF SYMPTOMS 
 
 Mastoiditis Trifacial neuralgia 
 
 Alveolar abscess Cancer of maxilla 
 
 Discharge from the ear : 
 
 Abscess of external meatus Irritation of a foreign body 
 Diseases of the middle ear 
 
 Bleeding from the ear : 
 Injury to meatus Rupture of tympanic 
 
 Fracture of base of skull membrane 
 
 Hemophilia 
 
 Tinnitus aurium is a subjective sensation of ring- 
 ing or buzzing noises in the ear : 
 Ear diseases Impacted ear-wax 
 
 Anaemia 
 Over-dose of certain drugs (quinine, salicylates) 
 
 Deafness : 
 
 Diseases of the ear Typhoid fever 
 
 Adenoids Impacted ear-wax 
 
 Tumor of brain Abscess of brain 
 
 Meningitis Ruptured tympanic 
 Mumps membrane 
 
 Hysteria Following scarlet fever 
 
 Subjective sounds : 
 Delirium Certain diseases of the 
 
 Hyperasmia of brain brain 
 
 Insanity 
 
 NOSE 
 
 Red color of nose : 
 
 Acne rosacea Chronic gastritis 
 
 Chronic .alcoholism Menstrual disorders 
 
 Erysipelas 
 
NOSE 
 
 77 
 
 Blue color of nose 
 Conditions causing 
 cyanosis 
 
 Pain in the nose : 
 Ulcer in nose 
 Foreign body 
 
 Sneezing : 
 Influenza 
 Whooping cough 
 Inhalation of dust or irritating vapor 
 
 Dilating alae nasae : 
 Excitement Pneumonia 
 
 Conditions causing dyspnoea 
 
 Regurgitation of food through the nose 
 
 Exposure to cold 
 
 Coryza 
 Nasal catarrh 
 
 Measles 
 
 Administration of iodides 
 
 Cleft palate 
 
 Nasal voice : 
 Habit 
 
 Enlarged tonsils 
 Post-diphtheritic paralysis 
 Influenza 
 Retro-pharyngeal abscess 
 
 Post-diphtheritic paralysis 
 
 Adenoids 
 Nasal polypi 
 Deviated septum 
 Diphtheria 
 
 Discharge from the nose : 
 Influenza Nasal catarrh 
 
 Diphtheria Measles 
 
 Nosebleed (epistaxis). 
 
 (a) Local causes : 
 Injury 
 Nasal polypi 
 Nasal catarrh 
 
 lb) Constitutional causes : 
 Typhoid fever Puberty 
 
 Ulcer in nose 
 Foreign body 
 
78 OBSERVATION OF SYMPTOMS 
 
 Anaemia Chronic nephritis 
 
 Hypertrophy of heart Purpura hemorrhagica 
 
 Scurvy Hemophilia 
 Vicarious menstruation 
 
 Loss of sense of smell : 
 Influenza Necrosis of nasal bones 
 
 Nasal polypi 
 Administration of certain drugs (opium, atropine) 
 
 Subjective odors : 
 Atrophic rhinitis Hysteria 
 
 Insanity 
 
 VOICE 
 
 Indistinct speech : 
 Alcoholism Absence of teeth 
 
 Facial paralysis Bromism 
 
 Certain diseases of the brain 
 
 Aphonia is the loss of speech from causes arising in 
 the larynx : 
 
 Excessive use of voice Acute laryngitis 
 
 Ulcer of larynx (tuber- Diphtheria 
 
 cular or syphilitic) Hysteria 
 
 Pericardial effusion 
 Pressure of tumor on the vocal cords 
 
 Aphasia is the loss of speech from causes arising in 
 the brain. There is inability to use the right words 
 in their proper order. 
 
 The cause is : 
 Disease of that portion of the brain which governs the 
 function of speech 
 
INDEX 
 
 Abdomen, distention of, 50 
 
 linea scars on, 50 
 
 pain in, 58 
 
 retraction of, 50 
 Abdominal walls, lax, 49 
 
 rigid, 50 
 
 thick, 49 
 Alte nasae, dilating, 77 
 Amaurosis, 75 
 Anorexia, 28 
 Anuria, 39 
 Aphasia, 78 
 Aphonia, 78 
 Appetite, depraved, 28 
 
 increased, 28 
 
 loss of, 28 ( 
 
 Arm, pain in, 61 
 Ascites, 45 
 Asthma, 18 
 
 Babinski reflex, 72 
 Back, pain in, 61 
 
 stiffness of, 5 1 
 
 swelling of, 51 
 Blood pressure, 1 1 
 Body weight, diminished, 47 
 
 increased, 4b 
 Boulimia, 28 
 Bow-legs, 52 
 Bradycardia, 10 
 
 Cataract, 75 
 
 Cheek, puffing of, 26 
 
 Cheeks, redness of, 41 
 
 Chest, bulging of one side, 17 
 pain in side of, 57 
 retraction of one side, 17 
 unequal expansion of, 17 
 
 Chill, 69 
 
 Chilly feelings, 69 
 
 Coma, 65 
 
 Coma vigil, 66 
 
 Conjunctiva, redness of, 72 
 
 Constipation,32 
 
 Convulsions, 69 
 in infants, 70 
 
 Coordination of muscles, 66 
 
 Cough, 20 
 brassy, 21 
 
 Cough, dry, 21 
 
 hoarse, 21 
 
 inability to, 22 
 
 loose, 21 
 
 painful, 21 
 
 paroxysmal, 21 
 Cyanosis, 42 
 
 Deafness, 76 
 Delirium, 64 
 Delusions, 64 
 Diarrhoea, 33 
 Digestive system, 23 
 Disposition, change of, 63 
 Drug rashes, 43 
 Dysphagia, 28 
 Dyspnoea, 18 
 
 on exertion, 20 
 
 paroxysmal, 20 
 Dysuria, 37 
 
 Ear, 75 
 
 discharge from, 76 
 
 pain in, 75 
 Enuresis, 38 
 Epigastrium, pain in, 59 
 Epistaxis, 77 
 Eye, 72 
 
 ecchymosis under, 72 
 
 moisture diminished, 72 
 
 moisture increased, 72 
 Eyes, swelling under, 72 
 Eye-ball, pain in, 73 
 
 prominence of, 72 
 
 sinking in of, 73 
 Eyelid, drooping of, 72 
 
 Face, expression of, 47 
 
 pain in, 57 
 
 swelling of, 48 
 
 twitching of, 48 
 Facial paralysis, bilateral, 48 
 
 uni-lateral, 48 
 Fainting, 66 
 Feces, 34 
 
 incontinence of, 34 
 Feet, odor of, 53 
 Feet and hands, coldness of, 53. 
 
 sweating of, 53 
 
 79 
 
8o 
 
 OBSERVATION OF SYMPTOMS 
 
 Flashes before the eyes, 75 
 Fontanelles in infants, 48 
 Foot, dragging of, 68 
 pain in, 62 
 
 Gangrene, 53 
 
 General observation, 46 
 
 Genu valgum, 52 
 
 Genu varum, 52 
 
 Great toe, swelling of, 52 
 
 Groin, swelling in, 51 
 
 Gums, 24 
 
 Hallucinations, 64 
 
 Hand, pain in, 61 
 
 Hawking, 22 
 
 Head, enlarged upper portion, 47 
 
 inability to move, 48 
 Headache, 55 
 
 location of, 56 
 Hematuria, 40 
 Hemoptysis, 23 
 Herpes labialis, 24 
 Hiccough, 71 
 
 Illusions, 64 
 
 Incoordination of muscles, 67 
 
 Insomnia, 65 
 
 Intestinal obstruction, 32 
 
 parasites, 36 
 Intestine, casts of, 36 
 Itching, 45 
 
 Jacksonian epilepsy, 70 
 Jaundice, 42 
 Joint, anchylosis of, 52 
 Joints, pain in, 62 
 
 Kemig's sign, 7 1 
 Kyphosis, 51 
 
 Left hypochondrium, pain in, 59 
 Left iliac region, pain in, 60 
 Left lumbar region, pain in, 60 
 Leg, pain in, 62 
 
 shortening of, 52 
 
 swelling of, 52 
 Limping, 68 
 Lips, 23 
 
 tremor of, 24 
 Lordosis, 52 
 
 Mammary gland, pain in, 58 
 Mastication, difficulty of, 28 
 Memory, loss of, 64 
 Mental depression, 63 
 excitement, 63 
 
 Mental instability, 63 
 Meteorism, 33 
 Mind, dullness of, 64 
 Mouth breathing, 47 
 
 inability to open, 26 
 Mucous rattle, 22 
 Muscles, atrophy of, 68 
 
 contracture of, 69 
 
 flaccid, 68 
 
 hypertrophy of, 68 
 
 rigid, 68 
 
 tonic spasm of, 70 
 
 tremor of, 69 
 
 twitching of, 69 
 
 Nasal voice, 77 
 
 Nausea, 29 
 
 Neck, enlarged glands in, 49 
 
 pain in, 57 
 
 stiff, 48 
 Nervous system, 63 
 Neuralgia, 56 
 Night sweats, 45 
 
 terrors in infants, 70 
 Nose, 76 
 
 bleed, 77 
 
 blue color of, 77 
 
 discharge from, 77 
 
 pain in, 77 
 
 red color of, 76 
 
 regurgitation of food through, 
 
 77 
 Numbness, 67 
 Nystagmus, 73 
 
 Odor of breath, 2b 
 (Edema, 45 
 of glottis, 19 
 
 Pain, 54 
 
 general abdominal 60 
 
 kinds of, 54 
 
 referred, 62 
 Palpitation, 1 1 
 Paralysis, 67 
 
 of one nerve, 67 
 Perineum, pain in, 61 
 Perspiration, 44 
 
 diminished, 44 
 
 increased, 44 
 Pica, 28 
 
 Position in bed, 46 
 Pruritus, 45 
 Ptosis, 72 
 
 Pubic region, pain in, 60 
 Pulsation of carotids, 49 
 Pulse, 8 
 
INDEX 
 
 8l 
 
 Pulse, Cdrrigan's, 14 
 
 dicrotic, 13 
 
 hard, 12 
 
 high tension, 12 
 
 intermittent, 10 
 
 irregular, 10 
 
 large, 13 
 
 low tension, 13 
 
 rapid, 9 
 
 slow, 10 
 
 small, 13 
 
 soft, 13 
 
 water-hammer, 14 
 Pupil, 73 
 
 Argyll-Robertson, 74 
 
 contracted, 74 
 
 dilated, 74 
 Pupils unequal, 74 
 
 Rectus muscle, rigid, 50 
 Region, epigastric, 59 
 
 left hypochondriac, 59 
 
 left iliac. 60 
 
 left lumbar, 60 
 
 pubic, 60 
 
 right hypochondriac, 58 
 
 right iliac, 60 
 
 right lumbar, 59 
 
 umbilical, 59 
 Respiration, 14 
 
 abdominal, 17 
 
 Cheyne-Stokes, 16 
 
 forced, 17 
 
 irregular, 16 
 
 rapid, 15 
 
 slow, 16 
 
 stertorous, 17 
 
 thoracic, 17 
 Right hypochondrium, pain in, 58 
 Right iliac region, pain in, 60 
 Right lumbar region, pain in, 59 
 Risus sardonicus, 47 
 
 Saliva, 27 
 
 diminished, 27 
 
 increased, 27 
 Scoliosis, 51 
 Scybala, 35 
 
 Sensitiveness to light, 73 
 Sense of smell, loss of, 7S 
 Sighing, 16 
 Singultus, 71 
 Skin, 40 
 
 bronze color of, 42 
 
 depressions in, 49 
 
 eruption on, 43 
 
 gray color of, 42 
 
 Skin, hemorrhage under, 43 
 
 local discoloration, 43 
 
 pallor of, 41 
 
 redness of, 41 
 
 red spots under, 43 
 
 scars on, 49 
 Sleep, 64 
 Sneezing, 77 
 Somnolence, 65 
 Sore throat, 57 
 Speech, indistinct, 78 
 Spine, anterior curvature of, 52 
 
 lateral curvature of, 51 
 
 posterior curvature of, 51 
 Spots before the eyes, 75 
 Sputum, 22 
 
 bloody, 23 
 
 substances in, 23 
 
 odor of, 23 
 
 profuse, 22 
 
 purulent, 22 
 
 scanty, 22 
 Standing, 66 
 Stools, black, 35 
 
 bright red, 35 
 
 clay-colored, 35 
 
 flattened, 35 
 
 foreign- bodies in, 36 
 
 greenish, 35 
 
 mucous, 35 
 
 pus in, 36 
 
 slough in, 36 
 
 small caliber, 34 
 Strabismus, external, 73 
 
 internal, 73 
 Subjective odors, 78 
 
 sounds, 76 
 
 Tachycardia, 9 
 Teeth, caries of, 24 
 
 grinding of, 24 
 
 loosened, 24 
 
 notched, 24 
 
 sordes on, 24 
 Temperature, 5 
 
 continuous high, 6 
 
 intermittent, 7 
 
 remittent, 7 
 
 subnormal, 8 
 
 surface, 7 
 
 very high, 7 
 Tenesmus, 34 
 Thigh, pain in, 61 
 Thirst, increased, 28 
 Throat, pain in, 57 
 Tinnitus aurium, 76 
 Tongue, 25 
 
82 
 
 OBSERVATION OF SYMPTOMS 
 
 Tongue, coated, 25 
 
 enlarged, 25 
 
 paralysis of, 26 
 
 scars on, 25 
 
 tremor of, 25 
 Torticollis, 48 
 Tympanites, 33 
 
 Ulcers, 53 
 
 Umbilical region, pain in, 60 
 
 Umbilicus, projecting, 50 
 
 retracted, 50 
 Urination, difficult, 37 
 
 frequent, 38 
 
 involuntary, 38 
 Urine, 36 
 
 blood in, 40 
 
 calculi in, 40 
 
 cloi'dy, 39 
 
 diminished, 37 
 
 incontinence of, 38 
 
 increased, 37 
 
 mucus in, 40 
 
 Urine, pale, 39 
 pus in, 40 
 retention of, 39 
 shreds of tissue in, 40 
 suppression of, 39 
 
 Vagina, discharge from, 51 
 
 hemorrhage from, 51 
 Varicose veins, 53 
 Vertigo, 66 
 Vision, double, 75 
 Voice, 78 
 
 Vomited matter, 31 
 Vomiting, 29 
 Vomitus, bilious, 31 
 
 bloody, 31 
 
 fecal, 31 
 
 mucous, 31 
 
 purulent, 31 
 
 watery, 31 
 
 Walking, 67 
 
"If 
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