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SPECIFIC DIAGNOSIS: 
 
 STUDY OF DISEASE 
 
 WITH SPECIAL REFERENCE TO THE 
 
 ADMINISTRATION OF REMEDIES. 
 
 BY 
 
 JOHN M. SCUDDER, M. D.. 
 
 PROFESSOR OF PATHOLOGY AND THE PRACTICE OF MEDICINE IN THE ECLECTIC 
 MEDICAL INSTITUTE ; AUTHOR OF THE PRACTICE OF MEDICINE ; THE 
 PRACTICE OF MEDICINE IN DISEASES OF CHILDREN ) THE 
 PRINCIPLES OF MEDICINE J DISEASES OF WOMEN J ON 
 THE USE OF INHALATIONS ) SPECIFIC MEDICA- 
 TION AND SPECIFIC MEDICINES, ETC., ETC. 
 
 CINCINNATI: 
 
 WILSTACH, BALDWIN & CO., PRINTERS. 
 1874. 
 
Entered according to Act of Congress, in the year 1874, 
 
 BY JOHN M. SCUDDER, 
 
 In the office of the Librarian of Congress. 
 
PREFACE. 
 
 In presenting this volume to the profession, as a com- 
 panion to "Specific Medication and Specific Medicines," 
 my object has been to make a study of the prominent ex- 
 pressions of disease, with reference to the administration of 
 remedies. However learned we may be in pathology, and 
 associate branches of medical study, unless we can make our 
 knowledge point to means for the relief of suffering, the 
 arrest of disease, and restoration to health, it will be of but 
 little use. 
 
 We believe that the expressions of disease are uniform, and 
 always have the same meaning, and that the action of reme- 
 dies is something definite aud uniform — "that like causes 
 always produce like effects." If we properly study our cases, 
 so as to determine a definite condition of disease, and know 
 the direct action of remedies in such conditions, we will 
 have a certain and rational practice of medicine. 
 
IV PREFACE. 
 
 I concede that the study is difficult, but it is difficult 
 principally because it is new, and sufficient observations have 
 not been made. Physicians have so long practiced by rote, 
 and taken it for granted that there was no "certainty in medi- 
 cine," that we have not the material we would wish for spe- 
 cific diagnosis. But attention is being directed to it, and the 
 time is coming in which the field will be full of observers. 
 
 No apology is made for the shortcomings of this little book, 
 though I hope that in the main, experiment will prove the 
 correctness of its statements. It would be singular if there 
 were not some errors, and some things to be corrected by 
 further experiment and study. It does not profess to be a 
 complete treatise, or to give all the information that might 
 be thought desirable. But it is a study of disease, which 
 may be continued by other books and at the bed-side of the 
 sick. 
 
 If it serves the purpose of stimulating investigation and 
 thought, pointing the road to a better system of medicine, I 
 will be fully compensated for the labor. 
 
 Cincinnati, Nov. 15, 1874. 
 
ON THE 
 
 STUDY OF DIAGNOSIS. 
 
 XT/E wish to make a new study of Diagnosis— one 
 that will show us the relation between symptoms 
 of disease and the curative action of drugs. Evi- 
 dently this is what we need to give us a rational prac- 
 tice of medicine — very certainly it must be the founda- 
 tion of specific medication. 
 
 It is yet the opinion, that " diagnosis " has reference 
 to the classification of disease according to the received 
 nosology ; that it means naming the affection " bilious 
 fever," "typhoid fever/' " pneumonia," " nephritis," etc. 
 And so it does with the genus doctor, at large, and their 
 souls travail in diagnosis until a suitable name is deliv- 
 ered. And then they consult their memories and books 
 for recipes to throw at this name, which to them seems 
 almost an entity. 
 
 It looks absurd when thus plainly stated, yet it is 
 true to a far greater extent than the majority suppose. 
 If we examine the literature of the profession, we find 
 that writers on the "Practice of Medicine" labor to 
 
 (9) 
 
10 STUDY OF DIAGNOSIS. 
 
 make diagnosis in this way, and so arrange the symp- 
 toms of disease that their readers may be enabled to 
 follow in their lead. The student would certainly think, 
 from this teaching, that getting a name for a disease, 
 was the first and principal object in medical practice. 
 Not only does this seem the principal, but the only end 
 of medical study, and men pride themselves on their 
 skill in naming diseases — calling it diagnosis. 
 
 What can be more natural than that medicines should 
 be prescribed at names, when so much trouble is taken 
 to affix them ? And so we find that treatises on thera- 
 peutics are efforts to associate drugs with names of dis- 
 ease, with a — " this has been used with advantage" — 
 "this has been employed in," etc., etc. The trouble is 
 that almost every remedy in the materia medica has 
 been prescribed at the more common diseases — pneu- 
 monia, for instance — and the student has difficulty, not 
 from the paucity of his means, but from their abun- 
 dance. 
 
 Some go a little further than this. They want a 
 name for their disease, it is true, but they also make 
 their diagnosis extend far enough to guide their thera 
 peutics. Thus they determine a condition of the stom- 
 ach that indicates an emetic, constipated bowels a ca- 
 thartic, dry skin a diaphoretic, scanty urine a diuretic, 
 periodicity Quinine, sleeplessness or pain an opiate, 
 heat and dry skin baths, etc. Add to this counter-irri- 
 tation for the relief of local disease, and we have the 
 ordinary round of treatment. 
 
 This kind of diagnosis is well enough — is very much 
 better than that which simply names the disease — but 
 it also is very crude at times. For we find at times that 
 there are very much better means to relieve the stom- 
 
 ■Mid 
 
STUDY OF DIAGNOSIS. 11 
 
 ach than an emetic; and that in some, where seemingly- 
 indicated, it would do more harm than good. That 
 constipation is not an indication for cathartics, and that 
 this class of remedies are so used as to do a vast amount 
 of harm. That impaired secretion from the skin does 
 not mean diaphoretics ; for when most indicated they 
 will frequently not cause secretion ; and that other 
 means, not directed to the skin, will cause it. That 
 scanty urine does not mean diuretics, for they will fre- 
 quently fail to influence the kidneys when they seem to 
 be indicated most, and will sometimes still further ar- 
 rest secretion. Periodicity does not always mean Qui- 
 nine, for Quinine fails nine times where it succeeds 
 once, sometimes intensifying disease, at others produ- 
 cing a disease peculiar to itself — quinism — worse by far 
 than the disease for which it is given. And sleepless- 
 ness does not mean Opium, for it fails frequently, and, 
 as generally used, does far more harm than good. 
 
 It is still worse when the physician thinks he sees 
 the need^ of cathartics, diuretics, diaphoretics, tonics, 
 Quinine, nervines, etc., and gives them all at once, or in 
 a miscellaneous hodge-podge. The common result is to 
 intensify the disease, derange the stomach, and impair 
 the vegetative nervous system. The remedies are fre- 
 quently given so that the action of one opposes that of 
 another, as for instance a cathartic with a diaphoretic, 
 or at such times that they can not possibly do what they 
 are intended for. 
 
 How, then, shall we study diagnosis ? Is there any 
 better method than that usually pursued ? 
 
 I believe there is a right way to study diagnosis — one 
 that will prove satisfactory to patient and physician — 
 will name the disease for the one, and determine a ra- 
 
12 STUDY OF DIAGNOSIS. 
 
 tional therapeutics for the other. Such a way I endeav- 
 ored to point out in my Principles of Medicine, to which 
 my readers are referred for my opinions in extenso. 
 
 Man has but one body, and though it may be divided 
 into parts, each has the same life, is supplied from the 
 same blood, governed by the same nerves, and has the 
 same nutrition and waste. Only in so far as drugs act 
 on special parts or organs, need we study disease of 
 these independent of the organism at large. 
 
 Man has but one life, and it is the same for all parts. 
 The normal manifestations of this life we call health ; 
 the abnormal manifestations of it disease. If we can 
 always think of disease as a method of life, in a living 
 body, we will have gotten rid of an old error, and have 
 made the first step toward a correct diagnosis, and a 
 rational therapeutics. 
 
 Disease, then, is not an entity — something to be for- 
 cibly expelled from a living body — but is actually a 
 method of life. It can not be purged from the bowels, 
 vomited from the stomach, strained from skin and kid- 
 neys, or exorcised by counter-irritation. Such means 
 may do good, as when they remove an offending sub- 
 stance, or when they establish a function that is defi- 
 cient, but they should have a rational use. 
 
 The life of disease is not as good as the life of health, 
 neither in the whole nor in any individual part. It is 
 always exhaustive, impairing the life now, and the life 
 to come by renewal of tissue. It makes no difference 
 what may be the seeming condition of the body or a 
 part in disease, the real condition is, an impairment of 
 life. We study disease, therefore, as a method of living ; 
 and we treat the diseased body as a living body, which 
 
STUDY OF DIAGNOSIS. 13 
 
 has been placed in such position that its life has been 
 enfeebled or deranged. 
 
 We next want to understand clearly the structure and 
 uses of the various parts of this one body. We want to 
 know clearly the conditions necessary to healthy life, 
 and how their change works that we call disease. If 
 we can understand clearly the relation of a condition 
 or function to healthy life, we are in a position to learn 
 how the change in condition or function produces dis- 
 ease, and a correct therapeutics is at once suggested. 
 
 Examining the human body, we find certain condi- 
 tions and functions underlie others, and seem to be first 
 elements in the sum of life. Of these I may name tem- 
 perature, circulation, innervation, nutrition and waste, 
 and the blood. We always study these first, and we 
 want to know the exact character of the wrong, in one 
 or all, and how that wrong may be corrected. 
 
 Going one step farther, we want to know the relation 
 of these conditions and functions to one another. There 
 is a general relation in health ; possibly they are of equal 
 importance in the problem of life. But in disease one or 
 other may stand first, and serve as a basis for wrong of 
 life in many directions. Thus a disease involving every 
 function of life, may arise in a wrong of the temper- 
 ature and circulation of the blood. There is a want of 
 appetite that tonics will not reach ; a wrong of secre- 
 tion that can not be righted with cathartics, diaphoretics 
 and diuretics ; a wrong of innervation that can not be 
 reached with narcotics and nervines. Direct remedies 
 that restore normal temperature and circulation, control 
 the entire process of disease ; like a card-house, the re- 
 moval of a first card is sufficient for the overthrow of 
 the entire structure. 
 
14 STUDY OF DIAGNOSIS. 
 
 It is not so easy, always, to determine which wrong 
 is thus first, yet with care it may be determined — and 
 this is an essential in good diagnosis. A disease pre- 
 senting similar symptoms — the same symptoms to an 
 ordinary observer — may rest equally upon a first lesion 
 of the circulation, innervation, nutrition and waste, 
 blood-making, or the conditions of the blood. We want 
 to know which stands first, and then rectifying the first 
 wrong the treatment is easy and successful. 
 
 Disease has certain expressions, which we call symp- 
 toms, as health has certain expressions. We find that 
 the manifestations of life in health are very uniform, and 
 consistent, and one can hardly mistake their meaning. 
 So in disease, the expression of morbid life is uniform, 
 and constant, and does not vary in different individuals, 
 as many have supposed. If we determine in any given 
 case the expression of diseased life, we will find it the 
 same in all cases. 
 
 It has been claimed, and tacitly admitted that symp- 
 toms of disease were so changeable and inconstant, that 
 they could not be depended upon with any certainty. 
 This was certainly true to those who made their di- 
 agnosis according to the recived nosology, and then pre- 
 scribed at the name. For as very diverse pathological 
 conditions would be grouped under each name, the 
 symptoms would of course vary, and the treatment 
 would show the element of uncertainty in so marked a 
 maner that idiosyncrasy would be constantly called in to 
 explain the trouble. 
 
 We propose studying the expressions or symptoms of 
 disease with reference to the administration of reme- 
 dies. It is a matter of interest to know the exact char- 
 acter of a lesion, but it is much more important to know 
 
STUDY OF DIAGNOSIS. 15 
 
 the exact relationship of drug action to disease expres- 
 sion, and how the one will oppose the other, and restore 
 health. If I can point out an expression of disease 
 which will be almost invariably met by one drug, and 
 health restored, I have made one step in a rational 
 practice of medicine. 
 
 I have no hesitation in affirming that if we have once 
 determined such relationship, we have determined it 
 in all diseases alike, in all persons, and for all time to 
 come. If, with this symptom or group of symptoms, 
 my Aconite, £fux or Podophyllin cures to-day, it will 
 cure to-morrow, next year, and so long as medicine is 
 practiced. If it cures Tom, it will be equally applicable 
 in the same condition to his father, mother, wife, or 
 mother-in-law. 
 
 " Do you. mean to say," asks the reader, " that the 
 present system of nosology is useless? " Yes, so far as 
 curing the sick is concerned, that is just what I mean 
 to say. Not only useless, but worthless — a curse to 
 physician and patient — preventing the one from learn- 
 ing the healing art, and the other from getting well. 
 But you may ask, "how would you make out the certifi- 
 cate for the Undertaker V That's just what we wish to 
 avoid, we don't care about furnishing subjects, and 
 would very much rather people should die of old age, 
 and then we would write it in English — " old age." 
 
 The first lesson in pathology we want to learn is, that 
 disease is wrong life. The first lesson in diagnosis is, 
 that this wrong finds a distinct and uniform expression 
 in the outward manifestations of life, cognizable by our 
 senses. The first lesson in therapeutics is, that all 
 remedies are uniform in their action ; the conditions be- 
 ing the same, the action is always the same. We learn 
 
16 STUDY OF DIAGNOSIS. 
 
 to know the healthy man — know him by exercising all 
 our senses upon him. We want to know how he feels, 
 how he looks, how he smells, how he tastes, and what 
 kinds of sound he makes. Then we want to learn tho 
 diseased man in the same way, and compare him with 
 our healthy standard — certain expressions of life mean- 
 ing health, and certain other expressions meaning dis- 
 ease. Then we study the action of drugs upon the 
 sick, and when we find them exerting an influence op- 
 posed to disease and in favor of health, we want to 
 know the relation between the drug and the disease — 
 between disease expression and drug action. 
 
 I do not say that we should not study drug action in 
 health — indeed I think it a very important study. You 
 may, on your own person, study a wholly unknown 
 drug, and determine its proximate medicinal action. 
 How ? Easy enough. You will feel where it acts ; that 
 points out the local action of the drug, and as a matter 
 of common sense, you would use it in disease of that 
 part, and not of a part on which it had no action. You 
 will feel how it acts — stimulant, depressing, altering the 
 innervation, circulation, nutrition and function. If now 
 you want to use it in disease, use it to do the very things 
 it did in health, and not as our Homoeopathic brethren 
 would say, to do the very opposite things. 
 
 This might not seem altogether pertinent if we were 
 studying old diagnosis, but new diagnosis means medi- 
 cine, and must point out the cure for the particular case 
 in hand. 
 
STUDY OF DIAGNOSIS. 17 
 
 THE STUDY OF LIFE. 
 
 The diagnosis that wc are studying has a physiologi- 
 cal basis, and we want to learn something of the hind 
 of physiological knowledge necessary. Is it that which 
 may be learned from Carpenter, Draper, Huxley, etc. ? 
 Most decidedly it is not. The knowledge from books is 
 most important, excellent in its place, but worth nothing 
 here unless supplemented by a new study. 
 
 We must study the living man, and learn to recognize 
 every manifestation of this life by our senses. 
 
 Nothing less will serve the purpose in rational med- 
 icine. We want to bring our own senses to bear upon 
 him, and hnow how he feels, tastes, smells, and how he 
 looks and what sounds he makes. This study of the 
 living man, the most important study in medicine, is al- 
 most wholly neglected. Men live a lifetime, and know 
 nothing of the manifestations of life. Students become 
 conversant with books, attend their lectures, pass their 
 examinations, and yet have no practical knowledge of 
 human life. And physicans will practice medicine a life- 
 time, and yet fail to know what healthy life is. 
 
 How would you make a good surgeon ? There is but 
 one way. He must exercise his senses on the human 
 body, and learn to know it for himself. He studies upon 
 the cadaver, and learns the relation of parts; and he 
 also studies che living man, and learns to recognize 
 these relations by the sense of touch. Your accom- 
 plished surgeon recognizes a displacement or fracture, 
 as soon as his eyes rest on the part. Let him pass his 
 fingers over a limb in the dark, and he will tell you if 
 anything is wrong, and just what the wrong is. He is 
 a good surgeon, just exactly as he is an expert in this. 
 2 
 
18 STUDY OF DIAGNOSIS. 
 
 Not a year passes but what we have one or more 
 suits for malpractice against physicians of our school, 
 arising out of bad bone-surgery. (They have quite aa 
 many in other schools.) Why these cases ? Simply be- 
 cause they have not taken the trouble to learn on the 
 cadaver and living body for themselves, just how it is 
 made, and the relation of one part to another. Any 
 man, whether he is a surgeon or not, can so train his 
 senses, and know the anatomy of man, that mistakes 
 would be impossible, and cases of malpractice would 
 be the result of accident, or the fault of patients. 
 
 I say to the student, study anatomy and physiology 
 on the living man. Observe him closely with your eyes, 
 until you learn his varied expressions. See him walk, 
 sit, lie, work, eat, breathe, talk, etc. Feel of him, and 
 see how he is made, and what he feels like in different 
 parts. Learn every prominence of bone in the body, 
 and its relation to articulations, blood-vessels, nerves, 
 organs, etc. Hear every sound he makes, and learn to 
 recognize its character. And, lastly, learn to recognize 
 all of the many smells of which he is the base. Learn 
 him from the crown of his head to the sole of his foot, 
 and analyze him with your own senses, and you will 
 have the foundation for a good physician. 
 
 I place very great stress on this method of studying 
 physiology, and recommend it to the old practitioner as 
 well as the medical student. No knowledge in the 
 memory can take its place. It must be the basis of a 
 rational practice of medicine, for unless we know what 
 health is, we can not know disease, and unless we know 
 disease we will have a random and very uncertain 
 therapeutics. 
 
 I have already called attention to the necessity of 
 
STUDY OF DIAGNOSIS. 19 
 
 training all our senses so that we may be able to observe 
 well. These faculties are like many others, they may 
 be so trained under the influence of the will, that 
 after a time they work automatically, and with a rapid- 
 ity that is astonishing. This is the work of time — but 
 time placed where it will do the most good. All that 
 one need do, to have good, active senses, is to use what 
 he has rightly. 
 
 There is no mistake about these things, and I will 
 guarantee any physican a success that will astonish him, 
 if he will put them in practice, Need I say that the 
 reward is great. Outside of professional reputation, 
 and the ordinary rewards of successful business, there 
 are sufficient returns. A man's conscious life is in and 
 through his senses, and as these are educated and en- 
 larged, his life becomes larger, and his pleasures in- 
 creased. Nature is a most bountiful mother, and her 
 laws bring certain compensation ; and of these there is 
 none truer than that " a man grows as he is rightly 
 used." 
 
 Applied Anatomy. — The ordinary study of anatomy 
 is a good thing, and is the basis for a sound medical 
 education. Yet T am sorry to say that the study of 
 anatomy with the majority of physicians is very *• ordi- 
 naiy." It is a good thing to be able to name the 
 various bones, processes, muscles, and organs of the 
 body, but it is very much better to know them, as a 
 man knows his best friend. I may know a man's name, 
 and yet know really nothing about him, physically, 
 mentally, or morally. So it is in the common study of 
 anatomy, the memorizing of names takes the place of 
 that study which will enable one to really know the 
 structure of the human body. 
 
20 STUDY OF DIAGNOSIS. 
 
 A good anatomist will strongly insist on dissection as 
 an important means of learning. He well understands 
 and endeavors to impress the fact that it is only by 
 personal examination that one may know the various 
 tissues and organs, and their relation to one another. 
 
 The surgeon supplements this by the additional state- 
 ment that the most important preparation for the use 
 of the knife in surgery, is the use of the knife in dis- 
 section. K"ot only to acquire anatomical knowledge, 
 but to know the resistance of different tissues to the 
 scalpel, and to train the sense of touch. 
 
 An accomplished pl^sician should be a good anato- 
 mist — the skilled diagnostician is a good anatomist. 
 No one need say he has no opportunity, for every one 
 can make opportunity. A dead man is a good thing in 
 this study, but any animal or part of an animal will 
 serve the purpose of the man who really wishes to 
 know, and there is not so very much difference between 
 man and the remainder of the mammalia. The nearest 
 butcher shop will furnish material in abundance — from 
 eyes, to tongue, larynx, trachea, bronchial tubes and 
 lungs ; the digestive canal and its associate organs ; 
 kidneys, etc. : whilst a quarter of lamb or veal gives 
 pretty good muscular dissection. 
 
 The worthless curs prowling about the village or 
 town, give excellent facilities for dissection or vivisec- 
 tion. Chloroform the brute, and he is ready for work, 
 and you may educate your touch on living tissue, as 
 well as learn anatomy. 
 
 In the olden time the study of anatomy was com- 
 menced with the bones — not with pictures or plates of 
 bones* This study in which bones are tangible reali- 
 ties, and convey to the sense of touch and the eye their 
 
STUDY OF DIAGNOSIS. 21 
 
 peculiarities is the right study. Every physician 
 should be able to recognize any bone by the sense of 
 touch, and at once give it its proper position. Just as 
 he should be able to recognize the normal from the ab- 
 normal in shape, size and position. The skeleton prop- 
 erly articulated is a valuable adjunct, and if it was 
 thoroughly studied by the hands in a dark room, we 
 would have but few cases of mal-practice in bone- 
 surgery. 
 
 But this study of anatomy from the skeleton, and by 
 dissection, assisted by reading and lectures, is but pre- 
 liminary to a more important study. We want to study 
 anatomy upon the living man. We want to know the 
 situation and the relation of various parts, so that we 
 may be able to put our finger upon them at once, and 
 detect the slightest variation. We want the impress 
 of this living man upon our senses, so that they may 
 know him intimately. What does he look like? What 
 does he smell like ? What does he taste like (in so far 
 as taste is applicable) ? What sounds does he make ? 
 And how does he feel? 
 
 We want to know his every expression, standing, 
 sitting, lying, on his back, sides, etc. His expression 
 in activity, and at rest. We study his muscles in life, 
 their arrangement on the bones, and their influence in 
 giving the body motion. We study the situation of 
 blood-vessels in the same manner, and learn to trace 
 their course by the prominences of bone, relation to 
 muscles, etc., and going deeper, we study osteology 
 again, as the bones are clothed in tissue. 
 
 No man need excuse himself for want of opportu- 
 nity, so long as he possesses a body of his own, and 
 there are so many other bodies that might be engaged 
 for the purpose. 
 
22 STUDY OF DIAGNOSIS. 
 
 There are two objects in this study, both important. 
 The one is to knoiv the mechanism of life, and the 
 other is to educate the senses. The importance of the 
 first will not be disputed, and before we have concluded 
 this study, I think the other will be conceded. 
 
 Applied Physiology. — The knowledge of physiology 
 from the books is a good thing, but it is not sufficient 
 for our purpose. We not only wish to learn that Car- 
 penter, Huxley, and others, have witnessed certain phe- 
 nomena, and learned to know them as constant expres- 
 sions of life, but we wish to know them of ourselves, 
 and through our senses. 
 
 Dr. Huxley introduces the study of physiology by 
 saj T ing — " The body of a living man performs a great 
 diversity of actions, some of which are quite obvious; 
 others require more or less careful observation ; and yet 
 others can be detected only by the employment of the 
 most delicate appliances of science. 
 
 " Thus, some part of the body of a living man is 
 plainly always in motion; even in sleep, when the 
 limbs, head and eyelids may be still, the incessant rise 
 and fall of the chest continue to remind us that we are 
 viewing slumber and not death. 
 
 " More careful observation, however, is needed to de- 
 tect the motion of the heart; or the pulsation of the 
 arteries ; or the changes in the size of the pupil of the 
 eye with varying light; or to ascertain that the air 
 which is breathed out of the body is hotter and damper 
 than the air which is taken in by breathing. 
 
 "And lastly, when we try to ascertain what happens 
 in the eye when that organ is adjusted to different dis- 
 tances; or what in a nerve when it is excited ; or of 
 
STUDY OF DIAGNOSIS. 23 
 
 what materials flesh and blood are made ; or in virtue 
 of what mechanism it is that a sudden pain makes one 
 start — we have to call into operation all the methods of 
 inductive and deductive logic; all the resources of 
 physics and chemistry ; and all the delicacies of the art 
 of experiment." 
 
 Huxley is an admirable teacher, probably the best 
 living, and we will do well to get an idea of these 
 methods. The first lesson we learn from these brief, 
 but expressive paragraphs is, that we are to observe this 
 man, who " is plainly always in motion," and that we 
 are not to be satisfied with the observations of another. 
 Then follows the natural sequence in these observa- 
 tions. At first the gross expressions of the body, and 
 the difference between the man awake, asleep, dead. 
 Next a k *more careful observation," determining the 
 motion of the heart, etc. And lastly, the skilled obser- 
 vation, from a trained mind, aided by the various in- 
 strumentalities and appliances of science. 
 
 Books are useful in this study, though not the object 
 of study ; it is the man we want to know, not the book 
 nor its author. The book may serve as a guide-board 
 pointing the way, and at the same time give us a 
 standard of comparison. It tells us what to exercise 
 our senses upon — what to observe — and it informs us 
 what others have observed, and what is the common 
 standard of healthy activities. 
 
 There is nothing in the life of the man but should 
 be a subject of close scrutiny. We want to know him 
 in the entirety of his action, as we wish to know^ him 
 in every detail. And we want to know him so inti- 
 mately and thoroughly, that this physiological man 
 shall be always present with us as a standard of com- 
 parison. 
 
24 STUDY OF DIAGNOSIS. 
 
 The reader will at once see the necessity of this study 
 as a basis for diagnosis. The physiological man is the 
 man of health, the pathological man is one who has left 
 this common standard of being. The physiological 
 man is the standard of measurement, the common mean 
 that we measure from. To have a measurement at all, 
 it is necessary to have a fixed point to start from ; this 
 healthy man is the fixed point. 
 
 Measurement has reference to certainty, and certainty 
 is what we most desire in medicine. A measured mile 
 is a definite distance, an imaginary mile, having its 
 origin and termination in the cranium of Paddy 
 Ochhone, is a very different thing, though very like the 
 ordinary measurements in medicine. 
 
 The first thing that the physician wants, then, is a 
 sound physiological standard, which he carries with 
 him as he makes his rounds. It is lain by the side of 
 the patient in bed, sits by him on the chair, stands by 
 him, walks by him, puts out its tongue, extends its 
 hand to give the pulse, has lungs, bowels, kidneys, re- 
 productive apparatus, etc., always at your service, and 
 open for comparison. 
 
 Disease is wrong life, and a wrong presupposes a 
 right. To determine the existence of a wrong, we must 
 know what the right is ; to determine the character of 
 the wrong, we must compare it in all its parts with the 
 standard right. This is diagnosis, as the reader can at 
 once see. 
 
 TIow now shall we get this physiological standard. 
 Clearly by observation with our own eyes, and the use 
 of our own senses. Each man must make it for him- 
 self, and give it distinctness by the education of his 
 own senses. Theoretical knowledge will not do. 
 
STUDY OF DIAGNOSIS. 25 
 
 If we take Huxley's first example, " awake, asleep, 
 dead," we find an excellent study. Can you tell the 
 difference between the appearance of sleep, sleep and 
 death ? Hardly by the first glance, and possibly only 
 by a very close examination, and some experimenta- 
 tion, (the last especially evidences a state of uncer- 
 tainly). But if we carefully observe the phenomena 
 of sleep, in the infant, the child, the adult, we will soon 
 have a healthy standard, and the expressions of sleep 
 are so distinctive, that no one could deceive us by 
 shamming sleep. 
 
 So, too, if we carefully observe and study death, we 
 will never mistake it. There are distinct expressions 
 of body in death that can never be counterfeited. It is 
 not only the absence of motion, of respiration, of pulse, 
 or heart-beat, of heat, but there is an absence of the 
 expression of life in its totality, and an expression of 
 lifelessness that is characteristic. The relaxation of 
 death is distinctive, as is the rigor-mortis, as is the de- 
 composition of tissue. 
 
 It is a good thing to have a standard of death for 
 comparison as well as of life. Not that we usually 
 have any doubt of death, but that we require it as a 
 measure of life. It is well to have two points to mea- 
 sure from — the standard of life and the standard of 
 death. There is an approximate death, as well as a 
 total death ; a dying by degree, or part, as well as a 
 dying at once and in entirety. 
 
 Taking a man in entirety, we find a distinct expres- 
 sion when he walks, stands, sits, or lies. Every part 
 of the man talks to us, his hands, his arms, his legs, his 
 feet, even his "calves may wink," as described by 
 Dickens in one of his Christmas stories. 
 3 
 
26 STUDY OF DIAGNOSIS. 
 
 We not only learn from this much of the physical life 
 of the outer man, but learn of the life within. The 
 expression is the shadowing forth of the underlying 
 nervous system, and this again of the real or spiritual 
 man behind this. As physical, mental and moral 
 health has a distinct expression in the outer man, which 
 we purpose using as a standard of admeasure ; so all 
 diseases, physical, mental and moral, have a distinct 
 expression in the outer man. You will no more find 
 disease under a healthy exterior, than you will find a 
 devil in the garb of an angel. 
 
 We have a standard temperature, which we may 
 learn to recognize by the hand, though it is best to 
 measure it with a thermometer. We have a standard 
 electrical condition as an important factor of life, which 
 we will learn to recognize in the general expression 
 and movement, the special expression of the face and 
 eyes,, and by the touch. And we have a standard 
 formative force, which we will recognize in the expres- 
 sion of tissues, and the sensations they give to touch. 
 
 We have a standard color for the general surface, 
 and for special parts that the eye will learn to recog- 
 nize, and use for comparison. We make this study 
 thorough ; it is the skin at large, and then those por- 
 tions where the circulation is less free, where it is very 
 superficial and free, the nails, hair, veins, etc. We have 
 a standard color for mucous membranes, for lips, gums, 
 tongue, teeth> etc. 
 
 We have a standard in touch — of smoothness, resist- 
 ance, elasticity, size and association ; and we have it of 
 every part of the body. Of course we have not learned 
 it of Huxley or Carpenter, but by the use of our own 
 hands on the human body. 
 
STUDY OF DIAGNOSIS. 27 
 
 We have a standard respiration, in frequency, full- 
 ness, depth and freedom, which is distinct and clear, 
 and which we know of ourselves by observation. 
 
 We have a standard circulation, which we know at 
 the radial artery, by the even, distinct, regular blood 
 wave that passes under our finger, as well as by the ex- 
 pression and color of the surface, and the expression of 
 parts associated with the heart in action. 
 
 We have a standard condition of the digestive organs, 
 which we learn from books and by observation. It 
 don't take long to learn, even by the general expres- 
 sion, and the special expression of the muscles of the 
 mouth, whether a man has a good appetite, good diges- 
 tion and good blood-making. Even constipation will 
 be shadowed forth in the outer man so that one may re- 
 cognize it. 
 
 Blood-making and nutrition must have distinct ex- 
 pression, and a standard for measurement will be readily 
 formed, for all functional activity is dependent upon 
 nutrition. 
 
 The standard of healthy excretion by skin, kidneys, 
 and bowels is readily formed by observation. Not ob- 
 servation on the sick, and under the influence of drugs, 
 as many suppose, but upon the well. 
 
 Thus we see it is possible to so learn our physiology, 
 that it may serve as the basis of a rational practice of 
 medicine. And I think every reader will see that this 
 education is essential to good diagnosis, and that its at- 
 tainment is the first object in medicine. This is not a 
 question of schools ; it is a question of sheer empiri- 
 cism, (call it quackery if you will), or rational medi- 
 cine ; it is a question of whether the physician is to be 
 a coadjutor and aid to death, or whether his influence 
 will be upon the side of life and health. 
 
28 STUDY OF DIAGNOSIS. 
 
 METHODS OF DIAGNOSIS. 
 
 Where do we find the expressions of disease ? When 
 you think of this question a moment, it does not seem 
 so easily answered ; indeed it furnishes good material 
 for thought. Probably we had better preface it with 
 another. How do we find the expressions of disease ? 
 Man has knowledge of things external to him, by means 
 of the general sense of touch, and the special senses — 
 sight, hearing, smell, taste. We may ask, then, when 
 brought in contact with the sick, what do we feel, see, 
 hear, smell, taste, that differs from the normal condi- 
 tion — health. What the patient feels, sees, hears, smells 
 and tastes is not so important, for his senses are im- 
 paired by disease, they have never been educated, 
 and his mind is not in a good condition to receive im- 
 pressions. 
 
 I imagine the reader saying to himself — well — really 
 — I don't know afiout that. I don't feel my patients 
 much, and am not sure that I learn much by feeling. I 
 see them — but — I don't know that I can tell the char- 
 acter of disease by sight. I hear — yes — I hear all the 
 patient has to tell me about his bowels, number of ope- 
 rations, whether he passes wind up or down, or both, 
 makes water, where he has aches and pains, etc. I 
 don't smell much, unless I examine the bed-pan or 
 chamber utensil, and I don't want to taste in the sick 
 100m. That is — he makes his diagnosis, from the 
 patient's feelings, and not by the use of his own senses 
 — a very imperfect way of making a diagnosis. 
 
 We have called attention to the uncertainty of diag- 
 nosis from " what the patient says," yet it is the com- 
 
STUDY OF DIAGNOSIS. 29 
 
 nion means of diagnosis with all schools of medicine. 
 If the patient was wholly truthful there would be suf- 
 ficient uncertainty, for they have little knowledge of 
 disease, little skill in observation, and from disease they 
 are incapacitated for reasoning. The patient can not, in 
 the very nature of the case, know very much of his dis- 
 ease, and does not know that little well. 
 
 If now we supplement this by the well known ten- 
 dency to exaggeration by the sick and friends, we find 
 still more uncertainty. You ask when you visit a 
 patient whether he slept. The wife answers — " not a 
 wink," and yet you know from the patient's expression 
 that he has rested during the night, though his sleep 
 may have been broken. Or the nurse answers, " Oh, 
 yes, he had a good night's rest," though the only 
 ground she has for supposing so is because she slept 
 herself, but the patient's expression shows you he has 
 passed a restless night. You ask if the patient has 
 taken food — " no, he hasn't been able to take a bite," 
 though you find on persistent inquiry, that he has had 
 broth, or milk in sufficient quantity. You ask if he has 
 passed urine — " Oh, yes, sufficient," yet you see by the 
 pinched, anxious countenance, and position of abdomen 
 and pelvis, that he is suffering from retention or sup- 
 pression of urine. You ask if the patient suffers much 
 — " Oh, yes," is the reply, " I have had severe pain," 
 or "I have suffered intensely," yet you see by the 
 countenance that the statement is false cr overdrawn. 
 
 I do not believe that my patients aro worse in this 
 respect than others, yet I have occasion to say to 
 myself every day, when listening to the patient's or 
 nurse's story — " Madam, or sir, you are lying." Indeed, 
 I have always made it a rule to believe nothing that 
 
30 STUDY OF DIAGNOSIS. 
 
 was told me in a sick room, unless it was corroborated 
 by my examination of the patient. 
 
 I have tried the experiment several times, of seeing 
 how far the patient and attendants would go in their 
 exaggeration. Take one that is imaginative, and by 
 leading questions and promptings you can get the 
 symptoms of every ailment to which man is subject ; 
 and the story will have more consistence and semblance 
 of truth, the more the patient knows of disease. The 
 nurse is frequently as bad as the patient in this respect, 
 and quite as easily led to exaggeration. I had an illus- 
 tration of this a few weeks since in the person of a 
 monthly nurse. The mother and child were doing well, 
 yet you would think from the nurse's description that 
 they were just on the point of having every ailment 
 that the puerperal state would afford. The mother was 
 not easily influenced, or the nurse would really have 
 made her sick. 
 
 Why has a good physician better success in diseases 
 of children than in other cases ? There is no doubt of 
 the fact, and I have heard it remarked many times — 
 '' I would much rather treat children than adults — 
 medicines act better." You can't question the child, and 
 you •^arn but little that is important from the mother — 
 hovi do you get your information ? True, the mother 
 and Triends will say — " it is so hard to doctor children, 
 you can't find out what is the matter with them." But 
 a good practitioner knows better than this, and though 
 possibly he has never thought about the subject, he 
 knows he can treat children better than grown persons. 
 
 "Why ? For the very good reason that he uses his 
 senses, and prescribes from what he knows, instead of 
 tv ring the say-so of patient or nurse as a basis for the 
 
STUDY OF DIAGNOSIS. 31 
 
 prescription. If I should suggest to you, that in the 
 practice of obstetrics you should place dependence 
 upon the statement of nurse and patient, instead of 
 making an "examination" — you would think it most 
 absurd. Yet, in reality, it is not more absurd, than de- 
 pending upon the story of nurse and patient in ordi- 
 nary diseases. 
 
 If these are facts, and I think the experience of every 
 reader must satisfy him that they are, we want to 
 change our method and get a better basis for diagnosis 
 and prescription in diseases of the adult. Let us sup- 
 pose every patient a child — which they are in fact, so 
 far as medicine is concerned — and give them the same 
 careful examination that we would to the child, and 
 thus reach conclusions from what we know, rather than 
 from what patients or nurses say. 
 
 We do not wish to lose the advantage of any infor- 
 mation we may get from patient or nurses, but we pro- 
 pose to make no suggestions in the manner or charac- 
 ter of questions, that will bring false answers. There 
 are some things the patient will know, and a little care 
 will frame the questions so as to get at the real facts. 
 There are some things the friends or nurse will know, 
 and direct questions will usually bring straight replies. 
 But there are many things that neither can know any- 
 thing about, at least with any certainty, and these 
 should always be avoided. 
 
 All answers should pass in review of our own senses, 
 and what we know of health and disease. These are 
 the judges, and if the evidence is good it will have their 
 approval ; if it does not have their approval we throw 
 it to one side. We do not purpose receiving anything 
 that is opposed to what we know of disease, and we do 
 
32 STUDY OF DIAGNOSIS. 
 
 not purpose believing anything that is opposed to the 
 evidences of our senses. 
 
 THE EDUCATION OP THE SENSES. 
 
 We have already seen that the education necessary 
 to make a good physician, is not from books, or of the 
 memory — both good in their place, but insufficient. 
 The education that gives the best results, and makes 
 the successful practitioner, is of the senses, and of the 
 brain to receive impressions, and make deductions. 
 
 We have called attention to the proper study of an- 
 atomy, by which one may know the structure of the 
 human body of himself; and the right study of phy- 
 siology, by which one may know the various activities 
 of this mechanism. To make these attainments re- 
 quires study — not midnight oil burned in reading 
 books, but the continuous exercise of our senses upon 
 the human body, living and dead. 
 
 The same course of study is necessary to know dis- 
 ease. The description from Aitkin, Wood or Scudder, 
 is not the knowledge we want ; it is not what another 
 man knows that is of advantage to us, any more than 
 it is another man's dinner that sustains our life. We 
 want to know disease for ourselves, and we learn it by 
 the exercise of our senses upon diseased bodies. 
 
 If the senses, then, are the instruments by which we 
 obtain knowledge, it will at once be patent to the reader 
 that their development and goodness will be the mea- 
 sure of our ability and our attainments. Hence the 
 man of educated and acute senses will be for superior 
 to and have every advantage over the man who has not 
 been thus trained and developed; 
 
STUDY OF DIAGNOSIS. 33 
 
 Most persons seem to think that the human senses 
 are natural, not acquired — that they are born to us, and 
 not the result of education. This is a very great mis- 
 take, and a grave error to the physician. Man is born 
 with an organism that, so to speak, has germinal capaci- 
 ties for use, and its future development is by normal 
 use. The child at birth has perfect hands and arms, 
 every bone, muscle, bloodvessel and nerve being there ; 
 but they are as yet wholly useless. Its feet and legs 
 have all the parts of the adult, but it can not walk, or 
 even wag its toes under the influence of the will. Its 
 eyes are perfect, yet the images formed upon the retina 
 are wholly without meaning, and might quite as well 
 be a blank. 
 
 The child slowly learns to use its hands, and months 
 pass before it can hold an object, and a still further time 
 before it can move the object in obedience to the will. 
 We see it d&y by day learning to see, slowly taught by 
 its surroundings. And the adaptation of the nether 
 limbs to walking is the persistent work of the first 
 twelve or sixteen months. Compare the child of these 
 attainments of one year with the child of two years, 
 and you see a wonderful difference. The education has 
 been continually going on during this period, and with 
 continued use in right directions comes increased devel- 
 opment. At the third year there is further improve- 
 ment, and thus, as we go on to the fifth, the tenth, the 
 twentieth year, we observe a continued education of 
 the senses, and a better development of them. 
 
 I want to call attention to the fact that we find every 
 grade of development in different individuals, from the 
 ■first year up to maturity, and that this development 
 does not always depend upon the original capacity. A 
 
34 STUDY OF DIAGNOSIS. 
 
 difference in use or in education, so to speak, gives dif- 
 ferent capacities. It is not in the initial or starting 
 point, but in the method of progress, that gives the 
 fully developed sense. If the child has been rightly 
 directed, and the senses have been rightly used, they 
 will have proportionate capacity. 
 
 Many who would admit that the human senses*are 
 acquired, think of them as being acquired very much 
 as the man increases in stature and weight, and some- 
 thing essentially belonging to this period of growth. 
 They conclude that the senses grow with the body, and 
 attain maturity when it has reached the full size and 
 stature of a man ; and now a man, having his full 
 capacity, will find neither increase nor diminution so 
 long as he may live. They measure a man in all his 
 parts in this way ; his every function is now developed 
 for life. A greater mistake could not.be made. 
 
 The law of development is always in operation in the 
 human body, as it is throughout the animal and vege- 
 table world. As any organ or part is rightly used, it grows 
 in capacity. Not only in infancy, in childhood, up to 
 adult years, but each and every year of a man's life to 
 old age. It is more marked, of course, when the repro- 
 ductive powers are active, but it is always a law of life. 
 The man between thirty and forty years, will lind that 
 lie still has the germs of a large capacity, which needs 
 but the right use for development. He may grow legs, 
 arms, body, chest, lungs, brain, the sense of touch, of 
 taste, of smell, of hearing, of sight, if he will ; all that 
 is necessary is, that he should rightly use that he has. 
 
 Shakspeare makes his typical Dogberry say, 
 
 "To be a well-favored man is the gift of fortune; 
 But to write and read comes by nature:' 
 
STUDY OF DIAGNOSIS. 35 
 
 But however it may be with reading and writing, very 
 surely acute sight, smell, taste, hearing, touch, do not 
 come by nature. We all recollect the tedious process 
 of education — how we slowly attained our A, B, C's, 
 and what a work we had done when we could spell b-a 
 ba, k-e-r ker, baker — and so on through, whether it has 
 been little or much. This is the type of education, and 
 this is the way it is obtained — little by little, and by 
 continuous application. 
 
 But there is another view of the question, quite as 
 important to many persons. The law is not only ope- 
 rative in the one direction — to increase functional 
 capacity — but quite as much so in the other direction — 
 to lessen or take away that we have. The part or organ 
 disused loses its functional capacity, becomes atrophied, 
 and finally loses the power of reproduction — is wholly 
 gone. The Indian Faakar, who vows to hold his arms 
 above his head, finds after years are passed, that they 
 are no longer obedient to the will, are lost. This is the 
 oase with any part of the body — with the organs of 
 special sense, and with the brain and its functional ac- 
 tivities. It is the application in the human body of 
 Christ's parable of the talents : 
 
 " For the kingdom of heaven is as a man traveling 
 into a far country, who called his own servants, and de- 
 livered unto them his goods. And unto one he gave 
 five talents, to another two, and to another one; to 
 every man according to his several ability ; and straight- 
 way took his journe} 7 . Then he that had received the 
 five talents went and traded with the same, and made 
 other five talents. And likewise he that had received 
 two, he also gained other two. But he that had re- 
 ceived one, went and digged in the earth and hid his 
 lord's money." 
 
36 STUDY OF DIAGNOSIS. 
 
 The reader will recollect the application of the para- 
 ble — the one who had used his talents found them in- 
 creased ; the one who buried his, had taken away from 
 him that which he had. The divine Teacher enunci- 
 ated a law as wide as the universe, and as applicable to 
 physical and mental growth, as to moral development. 
 It is just as applicable to the training of the senses of 
 the physician, as it is to the growth of the moral nature 
 of man. The lesson is clear : if we want anything, we 
 must work for it ; if we will not work, we lose that we 
 have. 
 
 Man has conscious life in his brain and through his 
 senses. Take away his senses, and he has lost all com- 
 munication with the world without. Through his 
 senses he has pleasurable life, and it is deep and broad 
 in proportion to their development. One would think 
 that this would be sufficient incentive to their full de- 
 velopment. But, unfortunately, men dislike work, not 
 realizing that even this will prove a jDleasure. 
 
 It is the continued and orderly exercise of parts that 
 gives them increased capacity. Not by fits and starts, 
 but continuously, day by day, week by week, month by 
 month, year by year. The organs of special sense have 
 in them a mechanism for skilled use, as well as for the 
 gross purposes of life, and it is this skilled use we pur- 
 pose to call forth in diagnosis. 
 
 Man has five senses — of touch, of sight, of hearing, 
 of smell, of taste — all of which are useful in this study, 
 find all require training. The physician of unskilled 
 touch, sight, hearing, smell, taste, can never be suc- 
 cessful. It is hardly necessary to give examples of 
 this, as every reader's experience will show it a truism, 
 but a few may stimulate thought. 
 
STUDY OF DIAGNOSIS 37 
 
 In the obstetric art the skilled touch is the important 
 element of success to the accoucheur. Without it he is 
 groping in the dark, and is obliged to sit passively by 
 the bedside and wait. He can not know, and of course 
 can not give intelligent assistance when assistance may 
 be required. In the same way the unskilled touch 
 could never use a knife in surgery, could not pass a 
 catheter, could not recognize the variations of the pulse, 
 could not determine the condition of the skin, could not 
 do a great many things that might be done if the touch 
 were educated. 
 
 The untaught eye can not distinguish the variations 
 of form, size, color, and other physical properties of 
 bodies, which tell of condition, and functional activity. 
 To the extent that it is uneducated the man is blind, 
 and of necessity is groping in the dark. 
 
 The untaught ear has no use for the beautiful mechan- 
 ism that adapts the organ to receive the varied impres- 
 sions of sound. It can hear thunder, and it can hear 
 noise, but to the " concord of sweet sounds " it is deaf. 
 In medicine the ear requires education by use in order 
 to detect some of the minute sounds, as the " respira- 
 tory murmur," and a still further education to detect 
 the minute shades of difference in sound, which tell of 
 disease. 
 
 The same may be said of the educated senses of smell 
 and taste. The uneducated nose may recognize the 
 genus stink, but has no power of analysis ; as it may 
 recognize fragrance, and have no pleasure from it. To 
 the uneducated taste all substances are savory, or un- 
 pleasant, and with this gross classification the sense is 
 satisfied. To the educated taste there is every grada- 
 tion of the one and the other, and a power of discrimi- 
 
38 STUDY OF DIAGNOSIS. 
 
 nation that is sometimes really wonderful in its acute- 
 ness. 
 
 How may we Cultivate the Senses? — This is the 
 really important question, though the answer has been 
 partly given in the above study. We cultivate the 
 senses by continuously using them, and their education 
 is the work of months and years. We can always find 
 objects to exercise them upon, the training school is all 
 about us, and we have only to make intelligent use of 
 the facilities at our command. It is well, however, to 
 have an intelligent plan, and follow it up assiduously, 
 recollecting that " time, patience and perseverance will 
 accomplish all things." 
 
 The senses are intimately associated with the brain, 
 and their education implies a mental training as well. 
 Whilst we develop the organ of sense by use, we develop 
 the brain upon which the impression is made, and the 
 higher brain which takes cognizance of, and analyzes 
 the sensations. The development is thus a double one, 
 and both are essentials in correct diagnosis. A plan 
 presupposes thought, the act of the rational mind, as 
 well as orderly activity.* 
 
 ^Sensations and Judgment. — (That the reader may have 
 before him a brief synopsis of the physiology of sensation, I give 
 the following description from Huxley's Physiology:) 
 
 "In explaining the functions of the sensory organs, I have 
 hitherto confined myself to describing the means by which the 
 physical agent of a sensation is enabled to irritate a given sen- 
 sory nerve ; and to giving some account of the simple sensations 
 which are thus evolved. 
 
 " Simple sensations of this kind are such as might be produced by 
 the irritation of a single nerve-fibre, or of several nerve-fibres 
 by the same agent. Such are the sensations of contact, of 
 
STUDY OF DIAGNOSIS. 39 
 
 The Touch. — The tactile sense has its highest de 
 velopment in the hands, and it is in this locality, espe- 
 cially, that we purpose cultivating it. Delicacy of touch 
 is associated with a normal condition of the skin, and 
 necessitates care of the hands. It does not mean a life 
 of idleness, but it means proper protection from cold, 
 cleanliness, and an avoidance of such work as thickens 
 the epidermis, or gives it unnatural hardness. " Clean 
 hands and a pure heart " is a gospel expression that 
 we can w^ell apply to medicine, both essentials. Show 
 me the physician with rough, unpleasant, grimy hands, 
 and I will show you the man who is unsuccessful in his 
 calling, and is being gradually imbruted in his nature. 
 The hand is the characteristic feature of man, and is 
 the outer expression of the reason within, and the 
 spirit that is above the beast. A French writer once 
 remarked, " Show me the man's hand, and I will tell 
 you what manner of man he is." 
 
 A plan of use ? It suggests itself at once — we will 
 exercise our touch upon every object we come in con- 
 tact with. Here are objects large and small, long and 
 short, rough and smooth, of varied form, with special 
 Inequalities of surface, of varied consistence, and we 
 
 warmth, of sweetness, of an odor, of a musical note, of whiteness, 
 or redness. 
 
 " But very few of our sensations are thus simple. Most of 
 even those which we are in the habit of regarding as simple, are 
 really compounds of different sensations, or of sensations with 
 ideas, or with judgments. For example, in the preceding cases, 
 it is very difficult to separate the sensation of contact from the 
 judgment that something is touching us; of sweetness, from the 
 idea of something in the mouth ; of sound or light, from the 
 judgment that something outside us is shining, or sounding." 
 
40 STUDY OF DIAGNOSIS. 
 
 purpose feeling them until we can recognize them as 
 well in the dark as in the light. 
 
 We take the bones of the skeleton, and learn to re- 
 cognize them by the touch as well as by the sight. Our 
 Profs. Freeman or Howe will tell you the bones as well 
 by touch as by sight. We take the dead body, and 
 train the touch to recognize every part, by its form and 
 resistance. We take the living body, and learn to re- 
 cognize the impressions given by the skin, fasciae, mus- 
 cles, bones, and by the cavities of the body. 
 
 Attention has already been called to the necessity of 
 the skilled touch in the obstetric art. You know a ver- 
 tex presentation by the impression made upon the fin- 
 gers brought in contact with the head. You determine 
 fontanelles and sutures in the same way, and thus know 
 the position. The nates give a different impression, 
 and the finger recognizes the genitalia of male and 
 female, as additional evidence. It recognizes a shoulder 
 or elbow, a hand, a knee, or foot. How? Not intui- 
 tively ; we have no natural knowledge of this kind, it is 
 cultivated. Shall we wait until in obstetric practice we 
 learn and acquire a skilled touch ? That would be very 
 bad policy, especially for our patients. The sense of 
 touch is first trained by general use, and then we find 
 opportunity upon the child already born, to acquire the 
 knowledge of how a cranium, suture, fontanelle, nates, 
 genitalia, shoulder, elbow, hand, knee, foot, feels — it is 
 easy enough to find the opportunity, if one is inclined 
 to learn, and it is easy to get this necessary skill in 
 obstetric diagnosis if one is inclined to improve his 
 opportunities. 
 
 Sight. — The sense of sight is one of the most impor- 
 tant in diagnosis, and it, like others, requires education, 
 
STUDY OF DIAGNOSIS. 41 
 
 both as to the eye which receives and the brain upon 
 which impressions are made. The eye receives im- 
 pressions of color, and by education learns to detect 
 the form, size, distance, and many of the physical prop- 
 erties of objects. 
 
 Color being one of the .prominent characteristics of 
 health and disease, the ability to accurately distinguish 
 colors must be a great aid to the physician. The un- 
 educated eye receives the impress of color very much 
 as it does light and shade, attaching about the same 
 meaning to it, but when trained by use, it readily de- 
 tects slight variations. 
 
 It is quite easy to form a cabinet of colors, from 
 natural objects which may be studied in detail, and 
 this is suggested to the reader in preference to giving 
 the color sheets here as first intended. The vegetable 
 and insect worlds furnish them in great abundance, and 
 specimens can be readily preserved. Quite soon the 
 eye has learned to distinguish color from light and 
 shade, and in a few weeks will become quite skilled, 
 and yield much pleasure by the habit of observation 
 thus acquired. There is nothing trivial in nature, and 
 nothing so poor or worthless that it should not be 
 known ; this is especially true to the physician because 
 he must be a student of nature, to be able to deal with 
 nature's greatest work, the human life. 
 
 The practical education of the eye to color is com- 
 pleted upon the human body. We find distinct varie- 
 ties of color in health — of skin, of mucous membranes, 
 of parts where the circulation is superficial, showing 
 arterial blood, of veins, of the eye, the nails and the 
 hair. We want to learn to know the healthy man by 
 his color, and we may know him by this. 
 4 
 
42 STUDY OF DIAGNOSIS. 
 
 There is also abundant opportunity to educate the 
 eye to the variations of color in disease, so that they will 
 be readily recognized, and their true meaning known. 
 We may procure types of these morbid colors, so that 
 we will be enabled to refresh the memory with them. 
 Some of these will be given farther along in this work, 
 but the reader is advised to select samples of other 
 colors for himself. 
 
 The training the eye to the determining of size is not 
 so important, yet will be found quite useful. One phy- 
 sician will recognize a swelling, which evidences local 
 disease, which another has failed to notice. So one 
 will recognize a fullness of skin, of cellular tissue, of 
 mucous membrane, of tongue, which another fails to 
 see. 
 
 Training the eye to recognize form is very important, 
 both to the physician and surgeon. The trained eye 
 of the surgeon at once detects a deformity, and deter- 
 mines its cause, whether from fracture, dislocation, or 
 structural disease. The trained eye of the physician 
 should be able to recognize at once the general form of 
 health, in the posture and expression of the patient, 
 and the evidences of disease in the changes of form, in 
 position, in sitting, lying, in the position of the limbs, 
 and in the expression of the features. The trained eye 
 recognizes changes in the form of the tongue, which 
 express conditions of disease, and call for special reme- 
 dies. 
 
 Hearing.— Physicians do not seem to have realized 
 the importance of the ear in diagnosis. It is true that 
 we have a system of physical diagnosis for diseases of 
 the chest, which the student is advised to learn ; but, 
 
STUDY OF DIAGNOSIS. 43 
 
 unfortunately, the advice is not supplemented by the 
 lesson we are trying to teach — that these organs must 
 be educated'. The student applies his untrained ear, 
 and hears nothing, or is unable to distinguish variations 
 in sound, and becoming disgusted, gives physical diag- 
 nosis over to the expert or the specialist. Even if he 
 persists in trying to learn, he finds that he can not hear 
 the sounds described in the books, (simply because there 
 are no such sounds produced),, and is thus discouraged. 
 
 All nature is vocal with sound, and the sounds are 
 the expressions of life. The old Hebrew poet recog- 
 nized this fact, and gives expression to it — even " the 
 morning stars sang together." All nature is vocal with 
 sound, but to the uneducated ear it might quite as well 
 be still, for it expresses naught to him. Train the ear, 
 and educate the brain, and we have a " concourse of 
 sweet sounds," taking the entire range of life, express- 
 ing all its feelings, its hopes, its fears, its griefs, its 
 cares, its pleasures, its pains. It recognizes the love 
 song of the bird, the tone of wedded bliss, the gush of 
 parental affection, the cry for assistance, the shriller cry 
 of assault, the song of victory, the wail of defeat, and 
 the moan of death. 
 
 There is a fascination in the study of sound when 
 once commenced, that will carry the observer on, and 
 he will find a continued reward from it. If we take up 
 the single study of the expression of animals in their 
 cry, we find it of wonderful interest. We learn to re- 
 cognize the speech of bird and beast, though we may 
 not have slept with the fairies, as did the little boy of 
 old. The cry of pain in the animal kingdom is so ex- 
 pressive, that it will be recognized at once, and pretty 
 soon we will find ourselves locating and giving charac- 
 
44 STUDY OF DIAGNOSIS. 
 
 ter to the disease by this expression. One of the most 
 striking examples of this I have ever witnessed, was in 
 the case of a pet goat that was poisoned by eating 
 paint. The cry was as expressive as that of a child, 
 and one involuntarily located the wrong in the intes- 
 tinal canal — it was lead colic. 
 
 " Ears ye have but ye hear not/' is applicable to the 
 physician in ordinary. He is diligent in questioning 
 the sick, and seems to think there is wisdom in the 
 thoughts of the poor sick brain. The expressions of 
 the voice, which tell the condition of the brain, and of 
 the life of the man, to a considerable extent, is never 
 heard, the doctor is deaf. 
 
 In auscultation, the first lesson is in learning to hear. 
 It requires close and continued study to hear the respi- 
 ratory murmur distinctly, and this study must be con- 
 tinued if we expect to recognize the variations of this 
 and the sounds produced in the bronchial tubes. Skill 
 in physical diagnosis does not come by nature ; it is the 
 result of study, and the education of the ear and brain. 
 No man can expect to succeed in it unless he is willing 
 to give months to it, first to educate the ear to the hear- 
 ing and analysis of sound, and next to the hearing and 
 analysis of the sounds heard in the chest. 
 
 Smell.— Of still less importance is the sense of smell, 
 and yet it has its place in diagnosis. A good nose is a 
 good thing, and the sense of olfaction should not only 
 be a safeguard to the individual, warning him of noxious 
 influences, but should be a source of pleasure as well. 
 To some extent this sense is instinctive, especially as it 
 warns against irritant substances, and leads to their 
 avoidance. But it is one that may be educated to a 
 
STUDY OF DIAGNOSIS. 45 
 
 very high degree. We have examples of this in some 
 varieties of merchandising. The wine merchant grades 
 his wine by its boquet, as well as the taste. The tea 
 dealer will classify his wares, and price them, by their 
 odor, as will the fancy grocer with a majority of the 
 edibles he deals in. 
 
 We want a good nose for the purposes of diagnosis, 
 and we especially want a good nose that it may look 
 after the hygienic surroundings of our patients. There 
 is an abundance of bad smells about the sick room, 
 some peculiar to the condition of disease, and some the 
 result of want of cleanliness and ventilation. We want 
 to know them, and to do so we require an educated 
 nose. 
 
 What is an educated nose? It is one so trained by 
 use that it transmits sensations to the brain, which has 
 also been trained b}^ use to receive and analyze them. In 
 other words, it is the association of brain and nose in 
 the work. This sense is educated in the same manner 
 as the others. We find odorous objects, and use this 
 sense in their cognition. Pursuing the study we learn 
 to discriminate between odors, and to recognize them 
 immediately, and the character or condition of bodies 
 they express. 
 
 It will require but little training to enable this sense 
 to detect the unpleasant surroundings of a patient. The 
 first impression of the air of the sick room tells of a 
 want of ventilation, of a deficient supply of oxygen, a 
 superabundance of carbonic acid gas, and a surplus of 
 foul gases. The nose not only recognizes these wrongs, 
 but will insist upon their abatement. It says, open the 
 windows and doors, let in the sunlight, build an open 
 fire, and wash up. There is no mistaking the language, 
 
46 STUDY OF DIAGNOSIS. 
 
 and the physician feels that he must carry out its 
 orders. 
 
 It recognizes a want of bathing upon the part of the 
 patient, dirty clothing, dirty bed-clothes, a foul chamber 
 utensil under the bed, dirty dressings, dirty or bad 
 food, dirty medicines, and says in unmistakable lan- 
 guage, get these things away. u Cleanliness is next to 
 godliness,'' and of far more importance in the recovery 
 of the sick. 
 
 It will also point out conditions of disease, and talk to 
 you of special medicines. It says, typhoid, sepsis, loss 
 of life and breaking down of tissue plainly ; and sug- 
 gests for your consideration an individual of the group 
 antiseptic — chlorate of potash, sulphite of soda, sul- 
 phurous acid, carbolic acid, baptisia, permanganate of 
 potash, etc. 
 
 Taste. — Whilst the sense of taste is a good thing, 
 and should be well cared for, we do not propose to 
 make much use of it in medicine. It is well, however, 
 to use it upon the food prepared for the sick, because 
 we find a great many w^rongs here. Peopie have not 
 lost the old impression that the sick need no food, and 
 that it makes but little difference what kind is given, or 
 how it is prepared. If the physician does not look 
 after this, he will find many times that his patient is 
 being starved because food is unpalatable, or so badly 
 prepared that it is indigestible, or so changed in char- 
 acter, that it really does the patient a wrong. 
 
 If the physician has a right appreciation of the ne- 
 cessity of good food, and the nurse or friends know 
 that he will make it his business to look after it, and 
 see that it is well prepared, they will probably use 
 
STUDY OF DIAGNOSIS. 47 
 
 more care, and will ask for information when it is re- 
 quired. 
 
 There are some things that the physician will do well 
 not to cultivate a taste for or in. He should not be a 
 connoisseur in liquors. It is far better that the patient 
 run the risk of getting bad whisky, brand}', or wine, 
 than that his medical attendant should have acquired 
 the ability to determine for him. If there is any one 
 road shorter than another to want of success, loss of 
 character, poverty and wretchedness, it is the habit of 
 tippling. The road seems especially broad, smooth and 
 direct to the doctor, and he may well apply the old 
 Latin quotation from Virgil : u Facilis descensus Averni" ; 
 and the second line — " but to escape is indeed a work 
 of difficulty." 
 
 We have thus briefly examined the means by which 
 one is prepared for the practice of medicine. The 
 reader will have noticed that we place great stress on 
 self-education, as the basis of skilled diagnosis and 
 therapeutics. All knowledge is available in medicine, 
 and we do not wish to depreciate the ordinary medical 
 course of study, and would advise that the study of 
 medicine and the collateral sciences should be carried as 
 far as possible — and it is possible, even with the busiest 
 man, to make very considerable attainments outside, as 
 well as inside the range of studies usually pursued. 
 Still, unless the physical organism be trained to use, 
 our other education will prove a dead letter. It is the 
 means that brings man in relationship to, and gives him 
 cognizance of his surroundings and the world at large. 
 He not only has knowledge of things through his 
 senses, but his practical knowledge is in proportion to 
 their education and acuteness. 
 
48 STUDY OF DIAGNOSIS. 
 
 In the study of disease it will be best to change the 
 order in "which we have noticed them here. The phy- 
 sician sees his patient first, and then the examination 
 commences with the sight, touch, hearing, smell, taste. 
 This may be regarded as the natural order, and we will 
 observe it in the further study of the subject. 
 
 THE USB OP THE SENSES IN THE DIAG- 
 NOSIS OP DISEASE. 
 
 It is well to notice that we have a two-fold object in 
 studying. We wish to determine the locality and 
 nature of disease — its pathology ; but we also wish to 
 determine those agencies which will oppose disease and 
 restore health — its therapeutics. These are both im- 
 portant studies, and we do not wish to neglect either, 
 yet the reader will see that the last is the practical one, 
 If we can determine what will cure, we have accom- 
 plished the important object of medicine. 
 
 The means of cure have held a secondary place m 
 medicine, and indeed it seemed sometimes that it held 
 no place. Physicians would be very learned as to 
 pathology, and able to divide and subdivide the lesions 
 of function and structure until they would be " an im- 
 mense multitude," yet you could count their remedies 
 upon your fingers, and these were of the olden time, 
 devitalising, and most absurd. You would find an im- 
 mense volume on pathology and diagnosis, teeming 
 with wisdom, and a therapeutics meager and feeble in 
 everything but its power to do harm. 
 
STUDY OF DIAGNOSIS. 49 
 
 In this study we wish to make therapeutics occupy 
 the first place, and the diagnosis will mean remedies, 
 whenever this is possible. We do not care so much to 
 affix a name, by which the wrong may be known, as to 
 prefix a remedy by the means of which the disease will 
 not be known. Or to put it in plainer form 7 the object 
 of examination is to determine what will cure. 
 
 It is my opinion that we can so study disease, that 
 its symptoms or expressions will talk to us of individual 
 remedies, and in language so plain that it can not bo 
 misunderstood. As this is the first object of study, we 
 will keep it constantly in view. 
 
 DIAGNOSIS BY THE BYE. 
 
 The educated eye requires no prompting to do its 
 work in the examination of the sick — its training is to 
 this end. It takes in the appearance of the patient and 
 his surroundings in all their detail. An effort of the 
 will is required to make the mind attentive, and to co- 
 ordinate the impressions, and reach conclusions from 
 them. 
 
 It would seem unnecessary to say that many conditions 
 of disease find outward expression through the muscu- 
 lar system and its investing connective tissue and skin, 
 and that the physician should recognize them as soon 
 as his eyes have made their examination, and yet the 
 study of medicine is pursued as if this were not so. 
 The doctor is very eager to see the patient's tongue and 
 feel his pulse, and ask all manner of questions pertinent 
 and absurd, but he is blind to these natural expressions, 
 or if he learns, it is slowly and because the facts are 
 5 
 
50 STUDY OF DIAGNOSE. 
 
 forced upon his consciousness. The reason is obvious — 
 his attention has never been directed to it, and he has 
 failed to study the subject as it was presented to him 
 in practice. 
 
 This study requires an exercise of the mind, and that 
 the reader may commence thinking to advantage, we 
 will take some very familiar examples in the animal 
 kingdom. Let us see, for a moment, how animals ex- 
 press emotion (the action of the mind in so far as it is 
 developed). If you notice your dog or cat for a few 
 days, you will see the clear expression of the entire 
 range of the emotions, anger, fear, love, hate, joy, grief, 
 consideration, conclusions reached, etc., and so plainly 
 that you can make no mistake. Examine your horse, 
 and you will find the same clear and striking language 
 of expression. It is really wonderful, this voiceless 
 language of animal life, and well repays study. 
 
 Supposing now we study the expression with refer- 
 ence to rest. You notice the dog taking his siesta, and 
 carefully scan his posture and feature, and the idea of 
 rest is so strongly impressed that you are sure you 
 could not be mistaken. Whistle sharply, and notice the 
 change to a position and expression of activity and ex- 
 pectant attention. Give his ear a sharp pinch, and you 
 will sec the evidences of pain as clearly as you would 
 in the expression of man. 
 
 Think of the sickness you have seen among animals. 
 The cat or dog with a " sick stomach " — before they 
 have made an effort at vomiting you have jumped for 
 the door to let them out. In ordinary ailments the 
 drooping head, ears and tail, the expressionless eyes 
 and face, and indeed the entire want of muscular ex- 
 pression, tells the story of impairment of life. Take 
 
STUDY OF DIAGNOSIS. 51 
 
 an irritative disease, of the intestines for instance, and 
 the marked contraction of muscular tissue; the rough- 
 ened coat, the strong drawn lines of the face, the re- 
 tracted lips, tell you the kind of wrong. 
 
 Would you know if your horse was sick by his ex- 
 pression f I think you would, and if the subject had a 
 little study you would know the kind of sickness as 
 well. If you found him in the morning with drooping 
 ears and tail, expressionless eyes and nose, you would 
 hardly take him out for a day's ride. You recognize 
 the expression of exhaustion from over-work, and feel 
 so much for your companion that the stable is visited 
 before retiring, and you probably know from his pos- 
 ture and expression in the stall whether he is resting, 
 or in a condition that precludes rest. 
 
 If in driving you notice the ears drooping or turned 
 backward continuously, you know there is something 
 wrong. That the one means a wrong of exhaustion, 
 and the other a wrong of irritation. If you notice his 
 tail fall helplessly between his legs, you feel sure he is 
 in no condition for work, is suffering from exhaustion. 
 Suppose you observe an unnatural twist in his tail to 
 one side, and you are quite as sure he is sick, the dis- 
 ease one of irritation, probably colic. 
 
 Carry this observation a little further, and watch the 
 process of labor in animals, and you will be still more 
 surprised at the wonderful mechanism of voiceless ex- 
 pression. You will be able to read the history as plainly 
 as if expressed in language. The process of dilatation, 
 the expulsive second stage, the tedious and difficult 
 labor, the irregular and inefficient uterine contractions, 
 the rigid soft parts, etc. Let us watch the case of a 
 cow with puerperal fever, (yes, she has puerperal fever, 
 
52 STUDY 01 DIAGNOSIS, 
 
 and other puerperal diseases as has the human mother), 
 and you will Bee every phase of Buffering, ami Bee it so 
 distinctly that you can not forget it if you would. 
 
 Yon notice a horse put out one of his feet in stand- 
 ing, ami at oiuv you think of disease. By the expres- 
 sion of the leg and its position, your accomplished 
 horseman will loeate the wrong tor you : telling you 
 Whether it is in the shoulder, leg, knee, in the lower 
 articulations, or in the hoot'. How does he tell? Be- 
 eanse the leg has a language, and he has learned it. 
 
 I have eited these examples as subjects of thought. 
 This study requires thought, and the doctor is so little 
 in the habit of right thinking with reference to human 
 disease and diagnosis, and so certain that everything 
 must be known, that it is better to get a basis for 
 thought outside. If the reader recognises the truth of 
 these statements, and can confirm them by observation, 
 he will say at once — ' v if disease is thus clearly ex- 
 pressed in the lower animals, there must be similar ex- 
 pressions in man, and the subject is well worth my 
 attention." Disease has a voiceless language, and it is 
 this we wish to study, but in order to do so successfully, 
 the reader must get a basis for thought, commence to 
 think of it, and find his illustrations in every-day life. 
 
 It is well to have clearly before us at the commence- 
 ment, the objects of the examination, and the faets that 
 may be determined ; they may be classified as follows: 
 l>t. The right life that we designate as health ; 2d. The 
 wrong of life that we call disease — the amount of vital 
 impairment; 3d. The condition of rest : 4th. The con- 
 dition of unrest : 5th. Disease of excitation ; 6th, Dis- 
 ease of depression ; 7th. Pain ; 8th, The evidence of 
 local disease, both as to structures involved, and kind. 
 
STUDY OF DIAGNOSIS. 53 
 
 Decumbence. — In acute disease, the impairment of 
 life is usually such that the patient assumes and keeps 
 a horizontal position, as this requirestheexpenditureof 
 much less power than any other. We use the term de- 
 cumbence in preference to the old medical one, decubi- 
 tus, and it is defined by Worcester as " The act, or the 
 posture of lying down, prostration." In health the de- 
 cumbent position is associated with the idea of rest, 
 and when assumed at unusual times, with the idea of 
 debility. Thus the first idea obtained from seeing the 
 patient in bed is, that there is impairment of life. It 
 would be a blessing to the sick if the physician could 
 get this fact so thoroughly impressed, that he would re- 
 fuse to depress the life still more by the administration 
 of drugs. 
 
 Evidently this fact is one of much importance, and 
 whilst the general expression may not be absolute evi- 
 dence, it is among the best we have. If in acute dis- 
 ease the patient keeps his bed all the time, there is con- 
 siderable impairment of life. If in ordinary chronic 
 disease we find the patient frequently assuming the de- 
 cumbent position, and maintaining it for a considerable 
 time, we have to consider it an evidence of enfeeble- 
 ment, and we husband our patient's strength, and em- 
 ploy the class of remedies known as restorative, with 
 appropriate food. 
 
 Studying the patient's expression in bed, we find that 
 it gives us additional information. If he lies on his 
 sides, changes his position readily, holds his shoulders 
 and extremities in position, we conclude that the im- 
 pairment is not great as yet. But if we see him in- 
 clined to lie upon the back, or if upon the side that the 
 shoulder falls forward or down, the arm falls and is 
 
5± STUDY OF DIAGNOSIS. 
 
 expressionless, the upper leg and hip show the inclina- 
 tion to fall, and even the soft tissues of the face droop, 
 we are certain there is great impairment of life, and the 
 treatment must be conservative and restorative. In the 
 worst case, where the patient lies continuously upon his 
 back, and is inclined to slip toward the foot of the bed, 
 physicians usually recognize the approach of death. 
 
 There can be no mistake about the importance of the 
 inquiry, or the character and certainty of these expres- 
 sions. If we know that the life is feeble, we will care- 
 fully husband it, and guard against unnecessary expen- 
 diture. If we know the life is feeble, we will be sure 
 to avoid unpleasant and harsh medicines, especially the 
 class antiphlogistic. If we know the life is feeble, we 
 will appreciate the im])ortance of keeping the digestive 
 organs in good condition, and giving the necessary 
 food. If we know the life is feeble, and we have any- 
 thing in our Materia Medica that will aid and strengthen 
 it, we will realize the importance of its use. 
 
 To determine the condition of rest or unrest is of 
 great importance. When a man or a part is sick, rest 
 is necessary to recovery, and very much of the treat- 
 ment used looks to procuring rest. The position of de- 
 cumbence is assumed to get rest, yet we find that many 
 times it is not sufficient. It is well to know that we 
 have to think of this with reference to sleep as when 
 awake, for though sleep usually means rest in health, it 
 may not give rest in disease. 
 
 It is well to get an idea of perfect rest in health, as a 
 standard of comparison. Observe the child sleeping, 
 and the perfect equipoise of the entire muscular system, 
 and the natural position of the extremities show the 
 condition of rest. Even when the child falls asleep in 
 
STUDY OF DIAGNOSIS. . 55 
 
 a constrained and unnatural position, the body so 
 adapts itself to it, that we have the idea of rest. A 
 group of harvest workmen, taking their noonday rest 
 on the grass under the shade of a tree, will give every 
 shade of this restful expression, and is well worth our 
 study. We learn something here that can not be told 
 in words, but which serves as an excellent standard of 
 comparison at the sick bed. Notice the position of a 
 healthy person in sleep, especially how the body accom- 
 modates itself to bed and pillows, so that one position 
 will sometimes be maintained the whole night, with 
 rest to every part. 
 
 Now when we come to examine the sick, the condi- 
 tion of unrest is clearly expressed. The body does not 
 accommodate itself to the bed, and the effort to main- 
 tain the position shows itself in the constraint of dif- 
 ferent parts. We see it in the evident contraction of 
 the cervical muscles to hold the head in position ; in 
 the unnatural flexure of the extremities to maintain the 
 body and themselves in position. AVe have every 
 gradation of these expressions, from that which comes 
 some time after the position of the body has been 
 moved, when the patient is tired, to that which is so 
 continuously marked, that we know the patient has not 
 one moment's rest. 
 
 The position of the body also tells us something with 
 reference to the fifth and sixth propositions — whether 
 the disease is one of excitation or depression, especially 
 as regards the circulation. This also is an important 
 element in diagnosis, and refers us to appropriate reme- 
 dies. 
 
 The condition of excitation is marked by constraint 
 and undue contraction. We notice it in the expression 
 
56 study oe Diagnosis. 
 
 of the entire person, and of special parts. In the first 
 it has reference to the entire body, in the second it is 
 more the expression of local disease. The ideas that 
 we get is of want of ease, and of constant effort on the 
 part of the muscular S3 T stem to obtain it. An unusual 
 and constrained position of one or more of the extremi- 
 ties is quite a common expression. It may be but 
 flexure of one leg, throwing it out or from the body, or 
 a contraction and elevation of one shoulder, or a prone 
 fore-arm and hand with marked muscular contraction, 
 or an unpleasant constrained position of the head, with 
 prominence of the cervical muscles, or we may have it 
 in facial expression. Once the mind is directed to it, 
 these features are quickly learned, and having the 
 knowledge of health, we quickly determine the extent 
 of the lesion. 
 
 The evidences of enfeebled function — depression, are 
 just the opposite. Whilst in the previous case, we have 
 an unusual excitement of the nerves, and of the vascu- 
 lar S3 T stems, in this we have deficient innervation, and 
 impaired circulation. In this there is want of expres- 
 sion, the body lies, so to speak, as if no effort was made 
 to hold it in position ; parts fall of their own weight. 
 This want of expression is noticed especially in the 
 subcutaneous muscles, and in the skin, giving an un- 
 pleasant uniformity of surface, and a sodden expression 
 to the soft tissues. 
 
 Pain, or suffering, is expressed in every portion of 
 the body, and one may learn to recognize it as soon as 
 the eyes strike the body, and yet it would be difficult 
 to describe the expression. When pain is associated 
 with, or the result of undue excitation, the expression 
 will be that just named under this head. But if asso- 
 
STUDY OF DIAGNOSIS. 57 
 
 ciated with, or the result of an enfeebled condition, 
 either of the entire body, the part suffering, or the 
 brain, the general expression may be quite the reverse, 
 and will more resemble the exhaustion that follows ex- 
 cessive grief — one of anguish. 
 
 As has been clearly shown by Darwin ,* expression is 
 most marked in those muscles in most common use, or 
 those associated with mental activity. Thus we would 
 
 *Ihave now described, to the best of my ability, the chief ex- 
 pressive actions in man, and in some few of the lower animals. 
 I have also attempted to explain the origin or development of 
 these actions through the three principles given in the first chap- 
 ter. The first of these principles is, that movements which are 
 serviceable in gratifying some desire, or in relieving some sensa- 
 tion, if often repeated, become so habitual that they are per- 
 formed, whether or not of any service, whenever the same desire 
 or sensation is felt, even in a very weak degree. 
 
 Our second principle is that of antithesis. The habit of volun- 
 tarily performing opposite movements under opposite impulses 
 has become firmly established in us by the practice of our whole 
 lives. Hence, if certain actions have been regularly performed, 
 in accordance with our first principle, under a certain frame of 
 mind, there will be a strong and involuntary tendency to the 
 performance of directly opposite actions, whether or not these 
 are of any use, under the excitement of an opposite frame of 
 mind. 
 
 Our third principle is the direct action of the excited nervous 
 system on the bod}-, independently of the will, and independently, 
 in large part, of habit. Experience shows that nerve-force is 
 generated and set free whenever the cerebro-spinal system is ex- 
 cited. The direction which this nerve-force follows is necessarily 
 determined by the lines of connection between the nerve-cells, 
 with each other and with various parts of the body. But the 
 direction is likewise much influenced by habit; inasmuch as 
 nerve-force passes readily along accustomed channels. 
 
58 STUDY OF DIAGNOSIS. 
 
 expect to find the most marked expression in the face, 
 and next probably in the hands and the extremities. 
 If the reader will think for a moment, he will probably 
 recall distinct expressions in these forms. He will 
 especially recollect the common expressions of pain in 
 the muscles of the orbits and frontal region from con- 
 traction of the corru gator supercilii, some of the fibres 
 of the occipito frontalis, the orbieulars, and sometimes 
 the zygomatic. His attention will only need be called 
 to the forced contraction of the flexors of the hand 
 during labor, the involuntary expression of pain, and 
 to similar contraction in the feet. Indeed here is a 
 most excellent sfoKiy. and one may learn the natural 
 history of pain by closely observing a few labors. 
 
 There is nothing like having a familiar example for 
 study, and we may look still further at the phenomena 
 of childbirth. I need hardly say that these expressions 
 have the same meaning as in ordinary disease, though 
 here we find them greatly intensified. Possibly we will 
 get as good an idea of rest during the absence of pain 
 in a natural labor, as we can get anj T where. And in a 
 difficult labor we will get as distinct an idea of the state 
 of unrest. We observe the pain, finding expression in 
 marked muscular contraction of the muscles of the 
 upper and lower extremities and the forced flexion of 
 the muscles of the hands and feet. We also see the ex- 
 pression of pain in the countenance, but in natural 
 labors it is evanescent and not very marked. In diffi- 
 cult labors, especially where the pains are inefficient, we 
 find the constant contraction of the " muscles of pain/' 
 and it is one of the evidences of this condition. 
 
 The evidence of local disease will be found in the po- 
 sition of the body with reference to removing pressure 
 
STUDY OF DIAGNOSIS. 59 
 
 from the part, or giving it support. This is sometimes 
 so distinct that the attention is at once directed to the 
 affected part. Ii the position of the body is such as to 
 take off muscular pressure, we conclude that the disease 
 is one of excitation. If, on the contrary, the position is 
 such as to give additional support, we would think of 
 it as being one of impaired innervation and circulation, 
 possibly congestion. A man gives a diseased leg rest 
 in the same manner as a horse. Flexion takes off ten- 
 sion, and if the disease is one of irritation, the limb is 
 flexed. Disease of bladder or rectum will be indicated 
 by flexure and crossing of one thigh over the other. 
 Disease of the abdominal viscera, by flexion of the 
 thighs upon the trunk and probably flexion of the trunk. 
 Disease of one kidney will be announced by flexion of 
 the body on the affected side. Disease of stomach by 
 marked flexion of the trunk, and relaxation of the ab- 
 dominal muscles and diaphragm, and thoracic respira- 
 tion. Disease of one lung will be indicated by the 
 flexion of the body on the affected side, and the droop- 
 ing of that shoulder. Disease of the upper lobe of the 
 lungs will be indicated by the falling of the shoulders 
 forward, the additional curvature in the upper dorsal 
 and cervical spine, and by abdominal respiration. 
 
 A very natural expression of disease is the involun- 
 tary movement of the hand to it. In typhoid fever, 
 when the patient is seemingly wholly unconscious, we 
 find the hand over the bladder in retention of urine, as 
 it seeks the umbilicus when disease of Peyer's patches 
 is marked. The child suffering from disease of the 
 ear involuntarily carries the hand to the affected part. 
 In acute disease of the kidneys the hands are carried to 
 the loins. In some gastrointestinal disease the hands 
 
60 STUDY OF DIAGNOSIS. 
 
 sometimes go to the mouth, and it seems as if the child 
 wanted to get something out of its throat. It is always 
 well in low forms of disease to carefully watch these 
 expressions, as they give us early intimations of local 
 trouble. And in diseases of children, when we have to 
 depend almost wholly upon our own observation, it is 
 also well to carefully observe every expression. 
 
 Facial Expression. — The fact has already been no- 
 ticed that mental states find easiest expression in the 
 usual channels of innervation, and through those mus- 
 cles in common use. This is not only true of mental 
 activity, but is also true of disease. There is no disease 
 without a wrong of the nervous system, and I think I 
 may add with truth, that there is no wrong of life that 
 is not represented upon the surface through the nervous 
 system. We may not be able to read it, because our 
 senses have not been trained to observation, and we 
 have not sufficient experience, but the fact that disease 
 is thus expressed should stimulate to study. 
 
 The face will show clearly the right life that we call 
 health ; and the wrong life we call disease. If one will 
 closely study the expression of the face in health, and 
 compare it with the expression seen in sickness, this 
 fact will be clearly seen. It not only tells us of im- 
 paired life, but also of the kind of impairment, and of 
 the remedies that will remove the wrong, and restore 
 health. It will be w r ell to make this study with refer- 
 ence to — 1st. The condition of the brain ; 2d. With 
 reference to the condition of the sympathetic nervous 
 system, and associated spinal cord; 3d. With reference 
 to the condition of the circulation and the blood ; 4th. 
 With reference to local disease; 5th. With reference to 
 pain ; 6th. Resistance of disease. 
 
STUDY OF DIAGNOSIS. 61 
 
 The Condition of the Brain is very clearly ex- 
 pressed in the face, and we have learned quite a good 
 deal of its language. We may subdivide this study 
 into — a. With reference to the circulation, determiuation 
 of blood, congestion, inflammation, effusion ; b. The nu- 
 trition of the brain ; c. Its functional activity. 
 
 Determination of Blood is marked by flushed faca, 
 bright eyes, contracted pupils, and general but moderate 
 contraction of the facial muscles. The expression is 
 one of excitation, and the patient is restless and uneasy. 
 
 The direct remedy is Gelseminum. The indirect 
 means are those which relieve vascular excitement, and 
 the old-fashioned derivatives— counter-irritation, etc.* 
 
 Congestion is marked by dull eyes, dilated pupils, 
 immobile pupils, expressionless face, patient dull, in- 
 clined to sleep, and eventually coma. 
 
 *A bright and sparkling eye is as characteristic of a pleased or 
 amused state of mind, as is the retraction of the corners of the 
 mouth and upper lip with the wrinkles thus produced. Even the 
 eyes of microcephalous idiots, who are so degraded that they 
 never learn to speak, brighten slightly when they are pleased. 
 Under extreme laughter the eyes are too much suffused with tears 
 to sparkle; but the moisture squeezed out of the glands during 
 moderate laughter or smiling may aid in giving them lustre; 
 though this must be of altogether subordinate importance, as they 
 become dull from grief, though they are then often moist. Their 
 brightness seems to be chiefly due to their tenseness, owing to the 
 contraction of the orbicular muscles and to the pressure of the 
 raised cheeks. But, according to Dr. Piderit, who has discussed 
 this point more fully than any other writer, the tenseness may be 
 largely attributed to the eyeballs becoming filled with blood and 
 other fluids, from the acceleration of the circulation, consequent 
 on the excitement of pleasure. He remarks on the contrast in 
 the appearance of the eyes of a hectic patient with a rapid cir- 
 
62 STUDY OF DIAGNOSIS. 
 
 The direct remedy is Belladonna. In some cases, 
 and when associated with local disease with impairment 
 of the involuntary muscles, Ergot The indirect means 
 are counter-irritation, dry or wet cupping, stimulant 
 cathartics. 
 
 An intermediate hypercemia, observed in apoplectic 
 conditions is marked by fullness of eyes, which are 
 protruded, fullness of face, prominent veins, and from 
 contraction of the platysma a drawing down of the face 
 and angles of the mouth. 
 
 For this condition the direct remedies would be 
 Ergot, Lobelia in stimulant doses, Apocynum. The in- 
 direct remedies, dry or wet cupping, stimulant hydra- 
 gogue cathartics. 
 
 Inflammation is marked by still greater contraction 
 of the muscles, especially those of the orbits and the 
 frontal region, the deeper flushing of the face, the 
 sharper expression of the eyes, which are dry and 
 pinched, the contracted pupils, and as the life is im- 
 paired, by the appearance of constriction of all the tis- 
 sues around the base of the brain. 
 
 The direct remedies in the first stage of an inflamma- 
 tion of the brain are : The proper sedatives, Aconite or 
 Veratrum, and Gel semi num. These may be followed 
 and aided by such as increase the action from skin, kid- 
 neys and bowels. The indirect remedies are such as 
 may call the excitation to other parts. 
 
 culntion, and of a man suffering from cholera with almost all the 
 fluids of his body drained from him. Any cause which lowers 
 the circulation deadens the eye. I remember seeing a man 
 utterly prostrated by prolonged and severe exertion during a 
 very hot day, and a bystander compared his eyes to those of a 
 boiled codfish. — Darwin. 
 
STUDY OF DIAGNOSIS. 63 
 
 Effusion is marked by the dullness, and finally by 
 coma. The eyes lose their sharp, bright expression and 
 become dull ; the muscles of the lower part of the face 
 relax, as do the muscles that move the inferior maxillary 
 and the mastoid. If the irritation still continues, the 
 contraction of the orbiculars and frontal muscles per- 
 sists, and the evident constriction or pinched appearance 
 around the base of the brain becomes more prominent. 
 If the irritation passes away with the effusion, these 
 muscles gradually lose their power, and the upper part 
 of the face assumes a dull, sodden appearance. 
 
 The direct remedies are small doses of Aconite and 
 Belladonna, alternated with Apocynum. The indirect 
 means will consist in cupping the spine, and the use of 
 a stimulant hydragogue cathartic. 
 
 The Nutrition of the brain is not so easily deter- 
 mined, yet I think we may reach correct conclusions in 
 the majority of cases. The enfeebled nutrition will be 
 marked by a want of expression, especially in the mouth, 
 showing a want of decision. The eyes may have a 
 normal appearance at first sight, yet as we watch them 
 uncertainty is shown in their movements. In some 
 cases, the expression when the patient's attention is not 
 attracted, is very like that which follows exhaustion 
 from excessive emotion. 
 
 Softening of the Brain, so called, will be marked 
 by a smooth, placid countenance, the want of expres- 
 sion in the forehead being especially marked. In some 
 of these cases the tissues have their ordinary fullness, 
 and sometimes the soft tissues of the face are unusually 
 full, yet they look soft and flabby, and hang in un- 
 natural folds. 
 
 Atrophic Irritation of the Brain is marked by 
 
64 STUDY OF DIAGNOSIS. 
 
 the pinched and uneasy expression of the upper facial 
 muscles, the muscles of the orbits and the frontal region. 
 The patient holds his head in a constrained position, 
 frequently inclined to one shoulder, and the face turned 
 to one side, giving the eyes an unpleasant expression of 
 obliquit}^. The elevation of one eyebrow and the fall- 
 ing of the other, with an apparent divergence in the 
 axis of the eyes, will locate the lesion in or near the 
 cerebellum. 
 
 The evidences of structural disease vary with the situ- 
 ation and character of the lesion. They may be 
 divided into irritative and atonic, the one showing 
 marked contraction of some muscle or muscles of ex- 
 pression, the other a want of contraction, and conse- 
 quent fullness and drooping. Sometimes in the severest 
 structural disease there is no external expression. 
 
 The Functional Activity is very clearly shown in 
 facial expression, and we will observe the entire range 
 from normal function to furious delirium on the one 
 hand, and to entire loss of function and conscious life 
 on the other. 
 
 Activity is not only shown in muscular contraction, 
 but in alternate contraction — the play of the emotions — 
 of the muscles. This change of expression is one of 
 the most familiar examples of mental activity. In de- 
 lirium we observe that the play of the muscles is exag- 
 gerated, as indeed is the expression of all the emotions. 
 This is especially noticeable in the expression and 
 movement of the eyes, and their external muscles. 
 
 Want of Activity is expressed by want of contrac- 
 tion of the facial muscles; dull, immobile eyes, and full 
 lids. 
 
 The condition of the sympathetic nervous system is 
 
STUDY OF DIAGNOSIS. 65 
 
 pretty clearly shown by the eyes, the orbital muscles, 
 and the tissues about the base of the brain. The disease 
 of irritation is shown by the contraction of the tissues 
 which form the bed of the eye, the retraction of the 
 eye, especially upward, the thinned and constricted 
 eyelids, and the tissues about the temples. In some 
 cases the pinched or contracted alae nasi is a marked 
 feature. The disease of atony is shown by the full, ex- 
 pressionless eyes, fullness of the lids, pallid and waving 
 alae nasi, and fullness and want of expression about 
 the mouth. 
 
 A temporary want of sympathetic innervation that is 
 rectified by Podophyllin, is shown in the fullness of all 
 the tissues of the face, especially the ujyper portion, and 
 by fullness of the veins. 
 
 For the disease of irritation, 1 prefer Aconite, Ehus, 
 B^onia, Muriatic Acid, Nitric Acid, the selection being 
 made by the other symptoms present. Temporary re- 
 lief is obtained by the local application of Chloroform 
 before and behind the ears, and over the first cervical 
 ganglion. The Chloroform is so applied as to prevent 
 evaporation, and a change in the pulse will usually be 
 noticed in a few minutes from its first application, and 
 the relief is marked, and very frequently it lasts for 
 some time. 
 
 The disease of atony is met by Nux, Phosphorus, 
 Quinine, stimulant doses of Lobelia, minute doses of 
 Podophyllin, Digitalis, more rarely Veratrum, the bitter 
 tonics and food. 
 
 Whilst the expression of the face will give us pretty 
 
 accurate information with regard to the circulation, we 
 
 may obtain this information more directly elsewhere. 
 
 If the cellular tissue is full, we think of Veratrum. If 
 
 6 
 
66 STUDY OF DIAGNOSIS. 
 
 it is shrunken, Aconite. If the expression of the eyes 
 and associate muscles is dull, with fullness, we think of 
 capillary congestion, and Belladonna. If the cellular 
 tissue is full, the face expressionless, and the veins 
 prominent, Podophyllin. If the eyelids are especially 
 full, Apocynum. If the eyes have a pinched expres- 
 sion, dry in acute disease, secretion of tears in absence 
 of fever, dry, shriveled epidermis, flushed left cheek, 
 Elms Toxicodendron. Eight eyebrow drawn down, and 
 expression of eye changed, flushed right cheek, Bryonia. 
 These are the most prominent examples, and in each 
 case there is a wrong of the circulation, which may be 
 the predominant wrong. At any rate, the remedies 
 thus indicated will prove curative. 
 
 With reference to the condition of the blood, we may 
 find more direct expressions than in the face, yet these 
 are not unimportant. The sodden tissue evidences 
 poor blood and poor nutrition, as the firm elastic tissues 
 show good blood and good nutrition. The typhoid con- 
 dition of the blood will be clearly shown in the con- 
 tracted and opaque skin in the one case, and the sodden 
 inelastic tissues in the other. Pyaemia will show itself 
 first, in the marked contraction of tissue about the base 
 of the brain, sinking in of the bed of the eyes, and espe- 
 cially by retraction in the upper part of the orbit. 
 
 Some local diseases are clearly indicated by facial ex- 
 pression. Disease of the respiratory apparatus will be 
 shown by the expression of the nose and accessory 
 muscles. The lesions of irritation by contraction, the 
 lesions of atony by relaxation. Any one who has 
 watched the progress of an acute inflammation of lungs, 
 of pleura, of bronchia, with irritative cough, must have 
 seen the pinched expression of the nose, and the con- 
 
STUDY OF DIAGNOSIS. 67 
 
 traction of the alse. So marked is this, that sometimes 
 it seems to precede the trouble, and will be marked, be- 
 fore the disease of the respiratory apparatus has full 
 development. The relaxed and waving aloe nasi gives 
 an unpleasant impression of disease, and as before 
 named, has reference to the lesion of innervation, as 
 well as to impairment of the respiratory function. 
 
 The expressions of the mouth are associated with dis- 
 ease of the abdominal and pelvic viscera. Let us take 
 the familiar examples of intestinal worms as an illus- 
 tration. The full upper lip, with pallor, the white lines 
 arcund the mouth, and picking the nose, is the most 
 pronounced evidence of ascaris lumbricoides This 
 worm inhabits the small intestine, and the conditions 
 present are atony of mucous membranes, with impaired 
 function, and increased secretion of mucus, and at once 
 we think of the associated symptoms and the intestinal 
 wrong. 
 
 The remedies will be those which will give normal 
 stimulation to the structures involved, Podophyllin, 
 Santonine, some of the ordinary cathartics, the sto- 
 machic bitters, and sometimes the alkaline salts, or 
 acids, as may be indicated by other symptoms. 
 
 If fullness in this case means atony and impaired 
 function, and increased mucous secretion, it must mean 
 it always, and we will always think of such remedies 
 as will influence the small intestine and associate viscera, 
 giving normal stimulation and circulation, and restoring 
 functional activity. There is a peculiar expressionless 
 mouth, or an expression of u loss of spirits/' with a little 
 depression of the angles of the mouth, that invariably 
 means Kux Vomica. 
 
 Nausea is shown by depression of the angles of the 
 
68 STUDY OF DIAGNOSIS. 
 
 mouth, and slight incurving of the lower lip. If the 
 tissues are full, we know that there is atony ; if pinched 
 and shrunken, that there is irritation and determination 
 of blood. 
 
 It is a singular fact, and one not heretofore noticed, 
 so far as my reading extends, that simulation of these 
 expressions will provoke sensations in the parts referred 
 to. The instance just given affords a marked example. 
 Let a person draw down the angles of the mouth and 
 incurve the lip, and he will be quite certain to feel 
 nausea after a time. In two persons who tried it the 
 sense of nausea was very marked ; in one producing 
 vomiting, in the other an arrest of digestion and head- 
 ache. Try to simulate the frontal expression of pain, 
 and it will be singular if you do not wake up unpleasant 
 sensations somewhere, perhaps real pain. 
 
 Contraction of the orbicularis oris is usually found in 
 some diseases of the reproductive organs, especially of 
 the female. In chronic disease, there is distinct retrac- 
 tion from the other muscles of the face, and the entire 
 tissues seem thinned. In some of these cases the zygo- 
 matic muscles are also prominent. 
 
 Pain and Suffering are distinctly expressed in the 
 features, yet not always in the same way. Firm con- 
 traction of muscles is the most common expression. 
 Thus every reader will recollect the contracted brow as 
 evidencing pain, especially pain with irritation of the 
 nerve centres. We involuntarily associate contraction 
 of the structures about the eyes, and the wrinkled skin, 
 with pain, or with suffering. But we have the evidence 
 of pain in this region without muscular contraction ; 
 indeed there is the reverse, drooping of the tissues, the 
 expression is sad, of the exhaustion that follows exces- 
 
STUDY OF DIAGNOSIS 69 
 
 sive grief, and we are assured that there is enfeebled 
 circulation in the brain, and the pain is the expression 
 of atony. 
 
 It is very important to make these distinctions in 
 order to select remedies. Pain is the result of two very 
 opposite conditions — an excited circulation and an en- 
 feebled circulation. In the one case we use Gelsemi- 
 num, the sedatives, salines, Ehus, Macrotys, Bryonia, 
 as may be indicated. In the other we use Quinine, 
 stimulant doses of Opium, JSTux, stimulants, tonics, 
 beef tea or other histogenetic food. 
 
 Pain in the abdomen, pelvis, or lower extremities, 
 finds expression in the mouth. Acute pain almost 
 always finds expression in contraction of the mouth ; 
 when very severe the lips are firmly drawn in, the 
 angles of the mouth retracted, and somewhat depressed. 
 In some other cases, the angles of the mouth are drawn 
 in, and there is that action of the muscles of the upper 
 lip that gives it and the cheeks a full expression. 
 
 I hardly need call attention to the fact, that some 
 patients resist disease by an influence of the will, and 
 that sometimes this effort is very important. Others 
 yield to it from the first, and thus favor its progress. 
 Every one has made these observations, and will recog- 
 nize the importance of knowing whether a patient re- 
 sists or yields, as it may determine whether he will re- 
 cover or die. 
 
 Darwin remarks that — " The firm closure of the 
 mouth tends to give an expression of determination or 
 decision to the countenance. No determined man 
 probably ever had an habitually gaping mouth. Hence, 
 also, a small and weak lower jaw, which seems to indi- 
 cate that the mouth is not habitually and firmly closed, 
 
70 STUDY OF DIAGNOSIS. 
 
 is commonly thought to be characteristic of feebleness 
 of character. A prolonged effort of body or mind im- 
 plies previous determination ; and if it can be shown 
 that the mouth is generally closed with firmness before 
 and during a great and continued exertion of the mus- 
 cular system, then, through the principle of association, 
 the mouth would almost certainly be closed as soon as 
 any determined resolution was taken." 
 
 I do not think any one can make a mistake here, and 
 certainly it is important to know whether the patient is 
 inclined to resist disease, and is determined to get well, 
 or whether he is yielding, despondent, hopeless. The 
 firm mouth means that the patient will get well if he 
 can. The relaxed, drooping mouth, falling jaw, trem- 
 bling muscles, show us the need of giving the patient 
 courage, and strengthening the will power. It also 
 shows the necessity of increased care to conserve vital- 
 ity, and of the employment of restorative remedies. 
 
 Expression in Motion. — We not only find disease 
 expressed in position, and in persistent muscular con- 
 traction, as heretofore named, but it is also shown in 
 motion. We see a man standing or sitting, and ob- 
 serve that his soft tissues seem to sit on him like a 
 badly fitting suit of clothes, and we think at once of 
 impaired nutrition and degeneration of tissue. But it 
 may be only a want of innervation, from habitual 
 torpor of the nervous system. Set him in motion, and 
 we will soon see whether this is so or not, for there are 
 none so sluggish in this respect, but what they may be 
 aroused. 
 
 We notice the movements of the person that we may 
 confirm the diagnosis of expression, especially as re- 
 
STUDY OF DIAGNOSIS. 71 
 
 gards the important point of undue irritation and cir- 
 culation, or impaired innervation and circulation. 
 The quick, restless movement is characteristic of the 
 first. The desire to lie still, and the slow movements, 
 of the second. Possibly there is no evidence of disease 
 more definite than this, and it should be allowed its full 
 weight in diagnosis. 
 
 In some cases the rapid movement is but a means of 
 removing excessive excitement of the brain and spinal 
 cord, as in great grief or joy, or in case of severe, but 
 temporary pain. In such cases it may be looked upon 
 as a means of relief, for if the excessive emotions, or 
 pain were pent up, the person might suffer severely 
 from it. 
 
 But in other cases, whilst i,t tells of nervous irrita- 
 bility, the bodily movements give no relief, but even in- 
 tensify the wrong, besides causing exhaustion. In 
 these cases we endeavor to get bodily rest from the 
 first, as a means of allaying the nervous excitation. 
 Every one will have noticed the influence of the phy- 
 sician, nurse, or iriend, who with kindness but firm- 
 ness, insists on keeping still. The hand placed upon 
 the body of the sufferer to give support, seems to 
 strengthen the will power, and frequently with an effort 
 on the part of the patient comes rest and relief. 
 
 There is a case of restlessness from an enfeebled and 
 atonic condition of the nerve centres that requires 
 notice. The unsteady movement, or the evidence of 
 exhaustion following it, with the anxious, depressed 
 countenance, tells the story. In the other case we will 
 find almost continued tension of the muscular system. 
 
 Whilst in the case of irritation and determination of 
 blood, we would employ the sedatives, with Gelseminum. 
 
72 STUDY OF DIAGNOSIS. 
 
 or remedies exerting a like influence, in that of atony, 
 we would use Quinine, Nux, Phosphorus, stimulants, 
 tonics, and histogenetic food — beef-tea. 
 
 Increased movement is not associated with structural, 
 or even with severe local functional disease, so that un- 
 less it points to a wrong of the cerebro-spinal centers 
 we do not regard it as an unpleasant symptom. In or- 
 dinary colic the patient is restless, and seems to get re- 
 lief from motion, but in the severer forms of colic, 
 called " bilious," and in acute enteritis, he remains 
 very still. 
 
 In local disease the patient favors the affected part in 
 movement. Frequently the first evidence we have of 
 morbus coxarius, is the care shown in moving the leg 
 and placing the feet in walking, and the elevation of 
 the hip to remove pressure from the joint. Turning 
 the toes inwards, both in movement and rest, has the 
 same signification. One can readily distinguish a wrong 
 of the pelvic viscera by the movement of the hips and 
 extremities, showing the constant effort to prevent 
 stress or pressure of the parts. This will be noticed in 
 some uterine disease (irritative) as well as in displace- 
 ments. In chronic disease of the kidneys, a forward 
 curvature of the spine is frequently marked, and the 
 patient is observed to put the hands upon the hips in 
 rising from the chair, and sometimes in walking. If 
 but one kidney is involved, or the liver, or spleen, we 
 observe the slight flexure to one side, and the effort to 
 save the part from the movement of muscles. Evi- 
 dently the drawing forward of the shoulders — " winged 
 scapula," is a symptom of similar import so far as the 
 lungs or thoracic region is concerned. So certain is 
 this, that with the marked falling forward of the 
 
STUDY OF DIAGNOSIS. 73 
 
 shoulders, and separation of the scapulae, one may be 
 sure there is some disease in the thorax. The head 
 drooped forward has a similar import, though this is 
 sometimes an indication of a wrong of the sympathetic 
 nervous system. 
 
 In irritative disease of the cerebrum, or of the organs 
 of special sense the head is flexed, but in disease of the 
 medulla oblongata, cerebellum, pons and crura, the 
 head is drawn backwards. Forced extension, or head 
 drawn backward, will be recollected as a prominent 
 symptom in cerebro-spinal meningitis. 
 
 In all these cases flexion and favoring the part in 
 muscular movement are evidences of irritative disease, 
 and indicate the treatment. First, remedies that influ- 
 ence the affected part ; and second, remedies that re- 
 move excited innervation and circulation or functional 
 activity. 
 
 In another class of cases, we will find flexion from or 
 opposite the affected part, and the position of the body, 
 and muscular motion is such as to give support and 
 moderate pressure. The evidence in this case is of im- 
 paired circulation, congestion, effusion, and enlarge- 
 ment. It is safe to say that in the majority of these 
 cases the remedies w^ill be such as will give additional 
 stimulus. 
 
 If one will closely observe the movements of the ab- 
 dominal muscles, they may determine conditions of dis- 
 ease in pelvis or abdomen. The careful, slight move- 
 ment evidences disease of the pelvic viscera if especially 
 marked below — the chylopoietic viscera, if especially 
 marked above. The full abdominal walls, with slug- 
 gish movement, evidences atonic disease and congestion. 
 
 If we examine with reference to the thorax, we will 
 7 
 
74 STUDY OF DIAGNOSIS. 
 
 find that free movement of the abdominal muscles and 
 diaphragm, and but slight movement of the upper 
 thorax, is evidence of disease of the upper lobes of the 
 lungs. On the contrary, thoracic respiration, with but 
 slight and careful movement of the abdominal muscles, 
 evidences disease of stomach or liver. 
 
 We have already examined the expression of the face 
 sufficiently, and the movements of the muscles do not 
 give much additional evidence. Twitching of the 
 muscles is an unpleasant expression, and indicates un- 
 due spinal irritation, or irritation of the basilar brain, 
 the cause being frequently extrinsic. If of the mouth, 
 our attention is directed to the abdominal organs ; if of 
 the upper lip and face, to the stomach ; if of the nose, to 
 the lungs ; and if of the eyes and forehead to the brain 
 and spinal cord. 
 
 The quick, involuntary movement of the eyes, refers 
 us at once to the excito-motor nervous system, and at 
 once we make an examination to determine the source 
 of the lesion, its cause, and adopt means to prevent 
 its further progress, and convulsions. The forced con- 
 traction of one of the muscles of the eyeballs, turning 
 them upwards, downwards, to one side, or causing stra- 
 bismus, evidences disease of the brain, which may or 
 may not be associated with wrong of the spinal cord. 
 The character of the disease may be determined by the 
 expression of the eyes and associate muscles, or by 
 other symptoms. 
 
 In diseases of children we will notice that sudden 
 contraction of muscles and movement of parts is a pre- 
 cursor of convulsions. The quick movement of the 
 hand, with contraction of the fingers, the quick move- 
 ment of the lower extremities, with forced flexion, or 
 
STUDY OF DIAGNOSIS. 75 
 
 the quick movement of the head upon the pillow, or 
 the sharp, jerking movement of the shoulder, should 
 never be neglected. 
 
 This is but a mere outline of the subject, yet if it 
 stimulates to observation, pointing out the way, it will 
 serve its purpose. It is something one must learn from 
 observation, and not simply store up in the memory. 
 Indeed, unless the senses can be trained with the 
 memory of facts, but little benefit will follow. 
 
 COLOE OF THE SURFACE. 
 
 As has already been named, the education of the eyes 
 to distinguish colors, is of much importance in diag- 
 nosis ; and the reasons will be obvious to the reader. 
 There is no property of living bodies so sensitive as 
 color. It is usually thought of as evanescent, change- 
 able, fleeting, and the expressions of poetry in this re- 
 gard, but represents the results of close observation. 
 
 The florist is guided by it to a very considerable ex- 
 tent. When he visits his green-houses in the morning, 
 his eye closely scans the plants with reference to their 
 health. Change of color, even so slight that it would 
 not be noticed by an ordinary observer, is to him evi- 
 dence of disease. He recognizes in change of color, 
 the escape of gases from his flues, want of ventilation, 
 a wrong in the temperature, the want of, or a wrong 
 plant food, the presence of parasites, etc. He not only 
 makes his " diagnosis " from change of color, but gives 
 the prognosis as well. 
 
 The farmer, without any special training, or knowing 
 why, recognizes the wrong color in his plants, and 
 
76 STUDY OF DIAGNOSIS. 
 
 speaks of their sickly appearance. If he has been a 
 close observer, there is a something about their expres- 
 sion, and usually in their color, that tells him of the 
 character of the wrong — from drouth, from wet, from 
 too much heat, from cold, from atmospheric changes, 
 from want of plant food, from excess of certain foods, 
 or from a wrong kind. He recognizes the coming of 
 blight, rust, mildew, and the various parasitic diseases, 
 by these changes, before the diseases are fully de- 
 veloped. 
 
 These are familiar examples, and should prompt to 
 diligent study on our part. For, if in the vegetable 
 world, disease may be recognized in changes of color, 
 should it not be a means of diagnosis in animals and 
 man? And if so definite in determining the kind of 
 disease in vegetable life, will it not be equally definite 
 in determining disease in man? It will be noticed 
 further that color has reference to the life ; to the life of 
 the blood, to the nutrition of tissue, to the oxygenation 
 and decarbonization of the blood, and to the waste and 
 excretion. 
 
 Even here the popular expression should have stimu- 
 lated professional inquiry — he has a healthy color — 
 what is the color of health ? he has a sickly appearance, 
 what is a sickly color? If the popular mind recognizes 
 health in color, and disease in color, is it not well that 
 we should make a careful study of it ? 
 
 Color in man has two sources — a, from the blood ; 6, 
 from pigment — and it is well to distinguish these. In 
 the first case the changes of color are referred to wrongs 
 of the blood ; in the second they are referred to changes 
 in the quantity or character of the pigmentary matter 
 of the body. A simple division would be into — i, color 
 
STUDY OF DIAGNOSIS. 77 
 
 which has red for a basis ; 6, color which lacks red, is 
 a shade of yellow, brown, black. 
 
 In making examinations with reference to the blood, 
 we select parts where the circulation is free and the 
 epidermis or epithelium is thin — where the skin is thin, 
 and the mucous membranes delicate. We examine the 
 nails, the lips, the cheeks, the hands, sometimes the 
 feet, the tongue, and mucous membranes of the mouth. 
 
 What is the color of health as shown from the blood? 
 It is rosy, a light shade of carmine and lake, and is 
 clear, transparent, and offers no darkness, or admixture 
 with blue, purple, or brown. As the finger is pressed 
 upon the surface, or pressed over it, toward the heart, 
 the rosy color is removed, leaving the structures clear 
 and transparent, and the color comes back quickly when 
 the pressure ceases. It is difficult to describe color 
 in words, but if the reader will now make his examina- 
 tions of health he may readily learn to distinguish the 
 color of health. 
 
 The shade of rose color in mucous membranes differs 
 somewhat from the skin, because it is modified to some 
 extent by the pigment in the rete-mucosum. It is well 
 to get a clear idea of it by examinations of the lips, the 
 tongue, the mucous membranes of the mouth, and 
 fauces. The color of mucous membranes is quite 
 changeable to a slight degree, even in health, having 
 shades of blue, violet, white, probably from the secre- 
 tions of the mouth, and the food and drink; and we 
 never regard these slight variations as diagnostic. 
 
 The pigment color of health varies in different races, 
 and in different individuals. But if we say it is some- 
 what transparent and clean, we may express its char- 
 acter for all races. If we take a negro for example, we 
 
78 STUDY OF DIAGNOSIS. 
 
 will find the jetty black has a transparency and clean- 
 ness — glossy and smooth, which will be readily recog- 
 nized. Let this man become sick, and the color grows 
 dingy and opaque. If we take the olive or brown 
 skin, the same cleanness and clearness of color is 
 marked, and it seems so transparent that you may 
 almost look into the skin. If you take the Caucassian, 
 the brunette will show the same clearness in the skin 
 pigment, and in the healthy blonde it seems as if you 
 cauld look quite through the skin, it is so transparent. 
 We may even notice these peculiarities in the color of 
 the hair, as it shows health and disease like other parts, 
 but modified more by local conditions. 
 
 In studying color, especially that given by the pres- 
 ence of blood, it is well to note that it may be changed 
 in quantity (so to speak), and in kind. Change in 
 quantity has reference to an increased circulation, and 
 an increased amount of blood in the capillaries; change 
 in kind, to the condition of the blood. 
 
 Simple excess may be noticed from any cause increas- 
 ing the circulation to the surface, or to a part. We ob- 
 serve this excess of color in slight acute diseases, where 
 the activity of the heart is increased, and there is gen- 
 eral vascular excitement. It is not an unpleasant 
 symptom, and points clearly to the arterial sedatives, 
 Aconite and Yeratrum, as the special remedies. 
 
 If a part of the surface shows this excess, we at once 
 think of its relation to internal organs and functions. 
 If of the upper portion of the face and eyes, we refer 
 the wrong to the brain. If of the cheeks, one or both, 
 we refer it to the respiratory organs or apparatus of 
 circulation. If of the mouth and lower part of the face, 
 we refer it to the abdominal viscera. 
 
STUDY OF DIAGNOSIS. 79 
 
 As the excess refers to vascular excitement, and 
 means general sedatives, so these local excesses mean 
 local vascular excitement and local sedatives if we have 
 them. Thus for the brain it would mean Gelseminum ; 
 for the thoracic organs, Veratrum ; for the abdominal 
 viscera, Aconite, Ipecac, etc. 
 
 It is well to note the condition of the capillaries in 
 this examination, and we may determine somewhat of 
 their condition by the effects of pressure. If the capil- 
 laries are in normal condition, pressure should efface 
 the redness, but it is but momentary. If the finger is 
 drawn across the reddened surface we notice the white 
 line made by displacing the blood, but it rapidly passes 
 away, and the blood flows quickly in and fills the ves- 
 sels. If now we examine the redness in scarlet fever 
 in the same way, we will find that the fingers carried 
 over the part with pressure, effaces the redness, and 
 leaves a distinct white line, more or less persistent, as 
 the fever is severe. 
 
 This shows enfeeblement of the capillary circulation, 
 especially from the arterial side, and is an indication for 
 Belladonna. In the larger number of cases, Aconite is 
 the arterial sedative. The next best remedy to Bella- 
 donna is the Carbonate or Hydrochlorate of Ammonia. 
 
 If the capillary wrong is from venous obstruction, 
 the color will be deeper, and the wrong will be asso- 
 ciated with fullness of cellular tissue in many cases, 
 and the white line made by pressure is not so clear. 
 In this case, Podophyllin, Lobelia, Bryonia, are reme- 
 dies. 
 
 We not only find an excess, as above named, but in 
 other cases a defect in color, showing poor blood, leuco- 
 sythaemia, or an impaired circulation to the surface. The 
 
80 STUDY OF DIAGNOSIS. 
 
 pallor of anaemia is shown in all parts of the body, and 
 is associated with evidence of impaired nutrition. In 
 the rare pathological condition, leucocythsemia, there is 
 sometimes marked pallor, but usually it is disguised by 
 increase or change in the pigment of the skin. In de- 
 ficient circulation to the surface, we have want of color, 
 but no evidence of want of blood in totality, or impaired 
 nutrition. 
 
 Deepening of color — dark red — is usually associated 
 with zymosis, and has reference to sepsis of the blood. 
 It is associated with asthenia, and when observed it 
 tells of impaired function. But it especially shows the 
 need of acids, and in this respect refers to a direct 
 remedy. It makes no difference where we find it most 
 marked, its meaning is quite the same, of course modi- 
 fied to some extent by local disease. 
 
 If the reader Avill think for a moment of the cases he 
 has seen presenting deep redness of the surface, he 
 will recognize the truth of these statements. In typhus 
 fever, the gravity of the disease is shown by the flushed 
 skin — dark-red. If in smallpox, we find the skin 
 assuming this dark-red color, we are confident the dis- 
 ease will be severe, showing depravation of the blood, 
 and marked asthenia. If we observe it in measles, we 
 anticipate trouble from tardy appearance of the erup- 
 tion, depravation of the blood, respiratory trouble, and 
 impairment of function. If seen in pneumonia, it talks 
 to us of approaching " typhoid symptoms," of a low 
 grade of inflammation, and great prostration. So clear 
 is the evidence, and so rare the exceptions, that it be- 
 comes one of the most reliable evidences of disease we 
 possess. 
 
 The meaning is modified to a certain extent by the 
 
STUDY OF DIAGNOSIS. 81 
 
 results of pressure — whether the color is solid and un- 
 yielding as the finger is pressed over the surface— or 
 whether it is effaced by such pressure as heretofore 
 named in simple excess. In the first case it has refer- 
 ence wholly to the lesion of the blood, in the other in 
 part to the lesion of circulation — at least the evidence 
 is less grave. 
 
 If the dark redness is an evidence of zymosis — sepsis 
 — it speaks directly of antiseptics as a necessary part of 
 the treatment. It says clearly — this patient must be 
 kept clean, his clothing and the bed-clothing must be 
 frequently changed, and kept clean and sweet, all the 
 surroundings must be clean, he must have good air, fre- 
 quently changed by good ventilation. It means further, 
 that proper means shall be employed for disinfection 
 when this becomes necessary. 
 
 If the dark-redness is associated with asthenia and 
 impairment of life, and gives us timely warning of such 
 impairment, it will caution us against the use of all de- 
 pressant remedies, or anything that will impair any of 
 the important functions of the body. And it suggests 
 the necessity of keeping the stomach in condition to 
 receive food, and the proper selection and preparation 
 of food during the progress of the disease. 
 
 But it directly refers to acids as remedies, and this is 
 of much importance. Acids here are the antiseptics 
 and antizymotics. We give Muriatic Acid, Acetic 
 Acid in the form of good cider, and Lactic Acid in the 
 form of whey, and we find the condition of the patient 
 markedly improved. Muriatic Acid is especially the 
 antiseptic, though the others have an influence in this 
 direction. 
 
 The dull purple (bluish) of venous blood has reference 
 
82 STUDY OF DIAGNOSIS. 
 
 to imperfect venous circulation, and imperfect decarbon- 
 ization of the blood. It may be caused by disease of 
 heart or lungs; if not we recognize a lesion of sympa- 
 thetic and associate spinal nervous systems. It evi- 
 dences an unpleasant condition of life, and one that 
 should be removed if possible. In some cases the dull- 
 ness of color becomes so marked, that we designate it 
 as leaden. 
 
 If we find local structural disease to account for it, 
 this will receive our attention. If it is sudden, and 
 associated with precordial oppression and constriction 
 of the chest, Lobelia is the remedy. If less marked and 
 chronic, we will think of Cactus, Digitalis and Pulsa- 
 tilla. In acute cases, Chloroform counter-irritation 
 around the lower margin of the thorax, gives speedy 
 and marked relief. 
 
 In the lesion of cholera we will find the blueness of 
 hands and feet dependent upon enfeebled capillary cir- 
 culation, the blood being loaded with carbonic acid 
 gas. If the condition of the blood can be so changed, 
 as to enable it to circulate, this passes off. This blue- 
 ness with pallor is one of the most marked indications 
 for common salt as a medicine. 
 
 Want of color, with a shade of solid blue where the 
 blood shows freely as under the nails, the lips, tho 
 cheeks, and thin skinned portions of the body, may be 
 assumed to indicate the want of Iron. 
 
 A violet tint with increase of redness uniformly, or 
 only where the circulation is superficial, is a prominent 
 indication for Nitric Acid. 
 
 Deep color, with purplish, brown, or black tinge, is a 
 prominent indication for Baptisia. 
 
 Color not deep, but muddy or dirty, of parts freely 8 
 
STUDY OF DIAGNOSIS. 83 
 
 supplied with blood, is an indication for Sulphurous 
 Acid. If there is this dirty shade with pallor, we would 
 use Sulphite of Soda. 
 
 When we come to study the local changes of color 
 referred to the blood, we divide them into two classes, 
 the one in which the change is to be referred to a lesion 
 of some other part — sympathetic ; the other in which 
 it is dependent upon local disease. The reader will 
 notice that the significance of color must depend very 
 much upon this, for whilst the one may have no refer- 
 ence to the condition of the blood at large, or to any 
 structural lesion, the other is wholly referred to the 
 lesion of the structures, and to changes in the blood. 
 
 We always want familiar examples to show that a 
 method of study is likely to prove advantageous — that 
 is a basis of fact, and we will adduce the three familiar 
 cases of — change in the color of areola of the nipple, 
 the dark line under the eyes in certain conditions of 
 women, and the white line around the mouth in some 
 intestinal diseases of children. 
 
 Every practitioner will have noticed the darkened 
 areola of the nipple as an evidence of pregnancy, but 
 may not have had his attention called to it as an evi- 
 dence of disease of the reproductive function. In 
 wrongs of this function simulating spermatorrhoea, we 
 will find this change of color marked, as we will in 
 scanty menstruation with congestion, and in hyper- 
 trophy of the cervix uteri. Of course we do not look 
 for this, except in the diagnosis of pregnancy, but in 
 this case it is one of the most valuable symptoms. 
 
 If you should notice the deep color under or around 
 the eyes in women, you would say at once there was a 
 wrong of the reproductive organs or function, and you 
 
84 STUDY OF DIAGNOSIS. 
 
 would rarely make a mistake. If the tissues seemed 
 dry, the eyelids sunken and contracted, it would be 
 safe to say that the disease was one of irritation, and 
 would probably be relieved by Pulsatilla and Macrotys, 
 (especially if functional.) And if the eyelids were 
 full, swollen, relaxed, that the disease was of congestion 
 or atony, and would be benefited by Hamamelis, Apo 
 cynum, Staphysagria, Phosphorus, Iron, etc. 
 
 Many cases present themselves where we do not wish 
 to suggest an examination of the reproductive organs 
 at first, or there may be some reason why it should not 
 be made at present, hence the importance of other 
 means of knowing the character of the wrong, and the 
 class of remedies we may select from. 
 
 If one should notice the white line around the mouth, 
 with full pallid upper lip, full or contracted mouth, he 
 would at once refer the symptom to a wrong of the 
 gastro-intestinal apparatus. The reference is undoubt- 
 edly right, if we except the rare case in which the 
 symptom is dependent upon lesion of the brain. There 
 is a wrong of the stomach and bowels. What is the 
 character of that wrong ? If the structures are full, it 
 is pretty surely one of atony — a want of innervation 
 and a sluggish circulation. If the structures are con- 
 stricted and pinched, the wrong is very certainly one 
 of irritation, excited innervation and circulation. 
 
 Is it worth our while to read the evidences of disease 
 in the patient's face? I think it is, especially when the 
 remedies are at once suggested. The white line around 
 the mouth — gastro-intestinal disease. With fullness of 
 tissue — Podophyllin, Hydrastia, Santonine. With con- 
 striction and thinning of structures — Aconite, Ipecac. 
 
 But suppose we notice a peculiar bluish or leaden 
 
STUDY OF DIAGNOSIS. 85 
 
 tint to this white line around the mouth, and see a 
 slight dragging down of the corners, we would recog- 
 nize the gastro-intestinal lesion— remedy. Bismuth, or 
 sometimes minute doses of Arsenic. 
 
 Increased color of cheeks has been noticed as a symp- 
 tom of thoracic disease for thousands of years. What 
 relation has this flushing of cheek to the condition of 
 the lungs ? Can you explain the nervous and vascular 
 connections ? Evidently we can not tell why, and I 
 doubt if the evidence would be any more valuable if we 
 could tell why. This is one of many examples that the 
 interrogatory — why? is not always a profitable study 
 in medicine. 
 
 We know the fact, that a habitual recurring flush 
 of one or both cheeks has reference to an irritable or 
 diseased lung. The persistent high color, even thougb 
 it be a distinctly circumscribed spot, has a different 
 meaning. If we notice this circumscribed flushing of 
 the cheeks, our attention is at once attracted to the re- 
 spiratory apparatus. Associated with frequency of 
 pulse and increased temperature, it telle us of com- 
 mencing tubercular deposit. In this case the one cheek 
 is usually flushed. 
 
 It may be remarked further, that this symptom is 
 always associated with a wrong of the sympathetic 
 nervous system, especially in its relation to circulation 
 and nutrition, and in phthisis we only find the bright, 
 flushed cheek with irritation. Sometimes there is quite 
 as marked pallor, and the evidence would be a want of 
 innervation. 
 
 The bright-red flush of left cheek in acute disease is 
 usually referred to thoracic disease, but does not always 
 indicate it. It evidences a lesion of sympathetic and 
 
86 STUDY OF DIAGNOSIS. 
 
 spinal innervation, but is especially valuable as calling 
 our attention to .Rhus Toxicodendron as the probable 
 remedy. 
 
 The deeper flush of right cheek is more frequently 
 seen in disease of serous membranes and fibrous tissues, 
 but is especially valuable because it points out Bryonia 
 as the probable specific remedy. 
 
 Whilst the bright color of the cheeks, where it has 
 reference to disease of the respiratory organs, tells us 
 of irritation and activity of circulation, deep color in- 
 dicates impairment of the circulation and of the life. 
 The livid, purplish color in some cases of angina pec- 
 toris, may be taken as the type. We have it in much 
 less degree in thoracic aneurism, in apoplexy of lungs, 
 and in some very severe cases of asthma with conges- 
 tion. The dark redness is always evidence of a difficult 
 and imperfect circulation. 
 
 There is a, pinkish color of parts freely supplied with 
 blood, that is regarded by some as an unpleasant symp- 
 tom. As this color becomes more pronounced, we ob- 
 serve it in the veins as well. In women we may usually 
 refer it to a menstrual wrong, which will be corrected 
 by the use of small doses of Pulsatilla. Actea Alba, 
 Helonias. For the chronic lesion we think of Phos- 
 phorus, the Hypophosphites, the bitter stomachics, and 
 food. 
 
 Among the things that old women know is — that 
 prominent blue veins crossing the nose in children is a 
 si^n of feeble vitality, and it is quite as true as if a phy- 
 sician knew it. There is something wrong in the life 
 when you observe these cutaneous veins showing the 
 distinct and constant blue line, whether it is across the 
 nose, at the wrists, upon the back of the hand, over the 
 
STUDY OF DIAGNOSIS. 87 
 
 breast or abdomen, or elsewhere. Whilst it may not 
 point out any special medicine, it does prompt us to ad- 
 vise that the child have abundant out-door exercise, 
 good blood-making food, and that it shall not commence 
 study early, or be much confined until there is a much 
 stronger and robust life. 
 
 Unusual blueness of veins is a very good indication 
 for Iron. If associated with pallor of surface, we may 
 s< loot Iron by Hydrogen, or Yalett's mass, but if there 
 is deep color of tongue, Tincture of Muriate of Iron. 
 
 The color of the conjunctiva and sclerotic will some 
 times give us information in regard to the circulation 
 of the brain. If we find an injected conjunctiva (not 
 the result of local disease), we conclude that the cere- 
 bral circulation is similarly affected. If the color is 
 bright, and the surface looks smooth and moist, we have 
 evidence of determination of blood. If the color is 
 deep and the surface looks dull and dingy, or dry and 
 pinched, it represents hyperemia, with obstruction to 
 the return of blood — the apoplectic condition. The 
 dull, colorless eye is the best indication for Belladonna, 
 though we use it when the eye is injected, with tortuous 
 vessels. 
 
 In superficial disease, the color of the part is a means 
 of determining its condition, If we take the ordinary 
 symptoms of inflammation, increased color — redness — is 
 one of the first named as constant. Given increased 
 color, with heat, pain and swelling, and we say there is 
 inflammation ; but which of these will best tell us the 
 real condition of the part? I should answer, color. 
 
 If the color is bright, healthy red, we know at once 
 that the inflammation is simple, and is not very likely 
 to work a very great wrong to the part, or to the body 
 
88 STUDY OF DIAGNOSIS. 
 
 at large. It tells us of irritation, determination of 
 blood, and of activity of circulation ; the second part 
 of the wrong of circulation — stasis — is in but small pro- 
 portion. It says, give general arterial sedatives, use 
 local sedatives, get rid of increased heat, and establish 
 secretion. The evidence is quite the same, whether we 
 are looking directly at the inflamed part, or at some 
 distant surface, that is influenced by sympathy. 
 
 If the color is deep-red and dull, we are confident 
 there is marked impairment of life and arrest of circu- 
 lation. The fact that there is too much blood in the 
 part is evident, that the capillaries are enfeebled, and 
 the circulation in them is sluggish or arrested, that 
 change has commenced in the stagnant blood, and that 
 the life of the part will be destroyed, unless these 
 wrongs are corrected. It saj^s distinctly, strengthen 
 the general circulation, whilst you lessen its frequency, 
 and conserve and sustain the life of the blood by rest 
 and food. If a local application is to be made, it is now 
 stimulant — we want to strengthen the life of the part. 
 If we select an internal remedy that is to influence the 
 part from the blood, this remedy must be stimulant or 
 tonic in its character. 
 
 If the part assumes a blue or purplish color we recog- 
 nize venous stasis, and an obstruction to the circulation 
 from the part. With our attention called to the nature 
 of the wrong, we will find its cause and remove it if 
 possible. My attention was first called to this evidence 
 of venous obstruction in a case of fracture of the fore- 
 arm, with laceration of the hand, in which a roller was 
 applied before the splints, yet not very tight. Inflam- 
 mation sprang up in the hand, and the third day came 
 this bluish discoloration, with a great deal of local 
 
STUDY OF DIAGNOSIS. 89 
 
 trouble. The roller was removed, and the difficulty 
 slowly passed away. I have seen the same wrong arise 
 from the position of an extremity being such as to im- 
 pede the circulation of blood. 
 
 In some cases the wrong being general, venous im- 
 pairment is cardiac. We do not know why, bat we 
 rarely find an impairment of the right heart, when the 
 left is sufficient for the systemic circulation. Lobelia in 
 stimulant doses exerts a very favorable influence in these 
 cases. If there is fullness of cellular tissue, Apocynum 
 may be associated with it, or given alone. If the 
 wrong is from venous impairment, and is chronic, 
 Hamamelis is probably the remedy. 
 
 The erysipelatous redness is so distinctive, that being 
 once seen it can hardly be forgotten. The vivid color- 
 ation, evident dryness, shining appearance, give the be- 
 holder a sense of burning. It makes no difference so 
 far as the significance of this coloration is concerned, 
 whether we have the local inflammation of the skin or 
 not, it refers us to a lesion of the blood, zymotic in 
 character. If the surgeon find this tint of vivid red- 
 ness on the edges of a wound, or the flaps of an ampu- 
 tation, he would be at once on the alert to get rid of 
 the lesion of the blood. If the physician observed this 
 erysipelatous flush on the cheek in inflammation of the 
 lungs, or any where on the surface during the progress 
 of an inflammation or fever, he might feel sure he would 
 have a more than usually serious case to manage. 
 
 We may distinguish four shades of this erysipelatous 
 redness quite well marked in many cases, pointing out 
 the remedies for the disease of the blood, and the local 
 inflammation. In the first the redness is quite vivid, 
 and the edges of the local disease show a simple erythe- 
 8 
 
90 STUDY OF DIAGNOSIS. 
 
 matous flush, and the part does not look dry and con- 
 stricted. Sometimes there is arterial throbbing of the 
 part, and the pulse is full. In this case Veratrum is the 
 general and topical remedy. In the second case the 
 redness is very vivid, and the parts dry and constricted, 
 with sometimes the appearance of a slight pustular 
 eruption. The pulse is small, sharp, vibratile ; the 
 remedy is Eh us Toxicodendron. In the third case the 
 redness has a deeper shade, sometimes vivid, sometimes 
 dull. The remedy, both general and local, is Tincture 
 of Muriate of Iron. The fourth case shows more or 
 less of a blanched appearance, as the disease advances : 
 sometimes in the centre, sometimes at the borders, 
 sometimes of the deep structures — you seem to be look- 
 ing through the superficial redness. In these cases the 
 general remedy is Sulphite of Soda, the local remedy 
 Sulphurous Acid, Permanganate of Potash, or Carbolic 
 Acid. 
 
 The variations of pigment color in different individ- 
 uals is so great in health, that it might seem almost im- 
 possible to get definite information from its variations 
 in disease, yet I think we will find it quite as certain 
 as other evidences of disease. Of course we must have 
 a correct idea of normal pigment coloration, and some 
 guide to the natural tint of the individual. Transpa- 
 rency and cleanness are the characteristics of health, 
 whatever may be the shade. The lesions might be 
 divided into those of excess, defect and perversion, 
 though the last is the most important. 
 
 Excess of pigment, when it retains the clearness and 
 transparency of health, is usually evidence of active 
 life, and good nutrition and excretion. Of course out- 
 door exposure is always taken into consideration, as 
 
STUDY OF DIAGNOSIS. 91 
 
 causing an increase of pigment. Local excesses of 
 pigment have a variable meaning, though if still clear 
 and transparent we think of functional activity. If we 
 take the areola of the nipple, the clean, transparent, 
 deep color evidences healthy gestation, as does the 
 deepened color over the gland. The increase of abdom- 
 inal pigment has the same meaning, as has the increased 
 pigment color of the vulva. Even the increased pig- 
 ment of face observed during gestation is an index of 
 healthy function. Not so the unequal and unpleasant 
 brownish coloration known as morph. 
 
 The deep pigment coloration of the neck in brain 
 workers is a sign of healthy nutrition of the nerve 
 centres, whilst the want of pigment would indicate 
 anaemia, and the dirty pigment would show a wrong of 
 nutrition. 
 
 The coloration of the skin and hair have the same 
 associations. The clear, transparent color is the evi- 
 dence of health, especially of the skin. The deepened 
 color is evidence of an active life, especially of the vege- 
 tative functions ; whilst a loss of color is at once re- 
 ferred to impaired nutrition. Even the color of the 
 hair is subject to slight changes, and one may learn to 
 distinguish by this the condition of the nutritive func- 
 tions. It is an unpleasant sign to find the hair becom- 
 ing dull and sickly in color. 
 
 There is an increase of pigment distinctly brown, 
 and in patches on various parts of the body, which is 
 known as " liver spots." They generally make their 
 appearance on parts covered by the clothing, and may 
 be quite large and extensive. We refer them to a 
 wrong of the bile pigment, and frequently find it asso- 
 ciated with a wrong of digestion, and impairment of 
 
92 STUDY OP DIAGNOSIS. 
 
 the function of the brain. The remedy is Podophyllin, 
 associated with its natural bitter principle, Bebeerina, 
 (Hydrastia). 
 
 The brownish-yellow coloration is evidence of a 
 wrong of the organs of digestion. We may find it 
 only about the mouth or the face, or we may find it 
 pretty general where the lesion is chronic. It refers 
 us to Nux Vomica as the remedy. 
 
 Give us the same color, but dull and opaque, or with 
 a leaden tinge of adjacent skin, and we again refer it 
 to a lesion of the organs of digestion. The remedy is 
 Chelidonium ; Podophyllin, if the tissues show more 
 than usual fullness. 
 
 The bright yellow of jaundice is a symptom of wrong 
 of the liver. What the condition of the liver may be 
 other symptoms must decide. But in so far as the 
 color is concerned, we expect to wash it out through the 
 kidneys. 
 
 There is a peculiar sallowness with a tinge of green 
 that indicates great impairment of blood-making and 
 nutrition. The remedy is Copper; we usually give 
 Eademacher's Tincture. 
 
 No one could mistake the opaque, tallow-like color 
 of hypochondria, and associate states. It tells us of 
 impairment of the digestive and blood-making organs, 
 of nutrition, and of waste and excretion. There is a 
 slow renewal of life, and the tissues are old and feeble. 
 Very clearly in this case we want a more active " re- 
 newal of life/' and we stimulate the processes of retro- 
 grade metamorphosis and excretion on the one hand, 
 to remove the old structures, and see that the function 
 of digestion is well performed, that we may have in- 
 creased nutrition. 
 
STUDY OF DIAGNOSIS. 93 
 
 One could hardly mistake the evidence of the dingy, 
 dull, grimy, dirty color of skin. It refers us to a wrong 
 of the blood — " bad blood," and we conclude that the 
 blood is as dirty as the skin. Of course it would not 
 do to mistake the dingy, dirty skin of the " great un- 
 washed," but this is not very likely. Soap and water 
 will show the difference. In this case remedies to in- 
 crease secretion, and sometimes to promote retrograde 
 metamorphosis, hold the first place, though we do not 
 forget the importance of improved nutrition. 
 
 There is a deepened tint of skin, dull and opaque, 
 that is a very good indication for Arsenic or Phos- 
 phorus. The tissue seems to have lost life, and is in- 
 elastic. Dullness of color and opacity, may be regarded 
 as the special features ; and opacity where the color is 
 lighter than usual may indicate the remedy. 
 
 If we have a distinct want of pigment, the want of 
 color not dependent upon anaemia, or an enfeebled cir- 
 culation of blood, we think of Sulphur as a possible re- 
 storative. Given in small doses, we sometimes find it 
 exerting a marked influence upon the nutritive pro- 
 cesses. 
 
 EXAMINATION OF THE TONGUE. 
 
 " Let me see your tongue," says the doctor at every 
 visit, though what he expects to learn from " seeing 
 the tongue " he would be puzzled to tell you, unless it 
 was that the patient was " bilious." Of course habitu- 
 ally seeing the tongue in disease will, unconsciously, 
 many times, grow some knowledge of its diagnostic 
 value, and if the physician is a close observer, it will 
 give him valuable aid in determining the character of 
 
94 STUDY OF DIAGNOSIS. 
 
 disease. But many men are so little in the habit of 
 using their eyes, and thinking for themselves, that they 
 learn but very little. 
 
 If we think for a moment, we will see that the tongue 
 may tell us of — a, the condition of the digestive appa- 
 ratus ; b, the condition of the blood; c, the condition of 
 the nervous system • ind d, of the functions of nutri- 
 tion and excretion. As these are important inquiries, 
 indeed just the things we want to know, we will make 
 the tongue talk as plainly as possible* 
 
 We find the expression of disease in — a, its form ; &, 
 its condition of dryness or moisture ; c, its coatings ; d, 
 its color; and e, its motion. It is well to think of the 
 subject in this methodical way, even though we are not 
 able to follow it wholly in this study. 
 
 The common idea of physicians is, that the tongue 
 expresses the condition of the stomach and intestinal 
 tract, and it should be examined with reference to this ; 
 few think that it may give further information. Being 
 a part of the digestive tract, supplied by the same 
 nerves, and invested by the same mucous membrane, 
 we would naturally expect it to show something of the 
 condition of parts below. 
 
 If we say that its condition may be taken as the type 
 of the condition of parts below, we will not be far out 
 of the way. True, there are many exceptions, but the 
 rule is a very good one, and will hardly lead to serious 
 error. The mind at once recognizes the changes of 
 form, movement, condition, color, and secretion, as ex- 
 pressions of local disease. It will not be far wrong, if 
 it recognizes them as expressions of disease of the entire 
 digestive apparatus. 
 
 Change of form is quite expressive, and rarely leads 
 
STUDY OF DIAGNOSIS. 95 
 
 us into error. The elongated and pointed tongue ex- 
 presses the condition of irritation and determination of 
 blood to stomach and intestinal canal very distinctly, 
 and it is safe practice to give it full weight, and be very 
 careful in the administration of remedies. As it is 
 associated with excitation of the nerve centres, this is 
 to be taken into consideration, when we value the evi- 
 dence with reference to the stomach and bowels. If we 
 observe this change of form early in the disease, we not 
 only anticipate unpleasant gastric irritation through 
 the sickness, and use care in avoiding irritants, but we 
 employ means to remove it. Among these may be 
 named minute doses of Aconite, Ipecac, Hydrocyanic 
 Acid, Peach-bark infusion, small doses of Ehubarb, and 
 Bismuth. 
 
 The full tongue, broad and thick, is the evidence of 
 atony of the digestive tract, especially of the mucous 
 membranes. In this case the stomach and intestinal 
 canal tolerates the common medicines given, and the 
 use of cathartics is less harmful, and may be more bene- 
 ficial than in others. 
 
 The pinched, shrunken tongue expresses a want of 
 functional activity in the digestive apparatus. It is the 
 tongue of advanced acute disease, and is usually asso- 
 ciated with dryness. " Want of functional activity " 
 hardly expresses the condition, for the life of the diges- 
 tive apparatus has suffered to such an extent, that there 
 can be but little function. Whilst it is one of the indi- 
 cations of want of food, it causes us to be very careful 
 in its selection and administration, giving small quan- 
 tities at a time, and at such periods as the unpleasant 
 symptoms are least marked. 
 
 The fissured tongue in chronic disease points us to 
 
96 STUDY OF DIAGNOSIS. 
 
 lesion of the kidneys inflammatory in character. In 
 some cases the fissures are transverse only, but in severe 
 cases they are somewhat irregular, and by pressing the 
 tongue down it is seen to separate in irregular patches 
 of prominent villi. The symptom is so definite, that 
 one may be assured of inflammation when this tongue 
 presents. 
 
 The fissured tongue in the advanced stage of febrile 
 diseases refers us to lesion of the kidneys, or irritation 
 of the nerve centres. In many cases we find a wrong 
 in the secretion of urine, and close examination shows 
 a condition of kidneys bordering on inflammation. It 
 deserves careful consideration, and especially means to 
 place the skin in better condition, and to allay irrita- 
 tion of the cerebro-spinal centres. 
 
 The conditions of dryness and moisture are important 
 evidences of the condition of the intestinal tract. If 
 the tongue is dry, we are sure the stomach and intes- 
 tinal canal can do but little digestive work, and we give 
 it as much rest as possible. In such cases food is always 
 given in fluid form, and usually above the temperature 
 of 100°. It is also carefully selected and prepared, 
 that the labor of digestion may be as small as possible. 
 If the tongue is dry we are confident there is want of 
 secretion from the intestinal canal and associate glands, 
 and indeed that there is a condition present which will 
 prevent the action of direct remedies to favor secretion. 
 It is most absurd to employ cathartics in such cases, 
 unless the object is simply to remove irritant accumula- 
 tions. Moisture, on the contrary, expresses a condition 
 favorable to functional activity. True, there may be 
 impairment of function, as when the tongue is full, 
 showing atony, or heavily coated, showing increased 
 
STUDY OF DIAGNOSIS. 97 
 
 mucous secretion, or dirty, showing depravation of the 
 blood and secretions. 
 
 If in acute disease with dryness of the tongue, we 
 observe it becoming moist, we are confident of improve- 
 ment, of the establishment of secretion, and indeed of 
 all the vegetative processes. Having this meaning, it 
 is nearly alwaj^s regarded as a favorable symptom. 
 
 The coatings of the tongue are observed with care, 
 as they are thought to be especially symptomatic of the 
 condition of the digestive tract and the " liver."* 
 
 * Appearance of the Tongue as a Symptom of Disorder 
 of the Stomach — The aspect of the tongue was held by the 
 older writers in medicine to be one of the most important criteria 
 of the state of the digestive organs; and its morbid appearances 
 were therefore carefully observed and minutely described by 
 them as indications for both diagnosis and treatment 
 
 In more recent periods, however, the value of the evidence 
 furnished by this organ has been, if not entirely denied, at least 
 so greatly depreciated, that it seems desirable to ascertain what 
 are the limits of our knowledge with regard to the association of 
 changes on its surface with those occurring in lower portions of 
 the alimentary canal. 
 
 The question appears to be capable of being resolved into three 
 principal divisions : 
 
 1. What are the nature and causes of the alterations in the 
 tongue which have been regarded as diagnostic of affections of 
 the stomach ? 
 
 2. In what other diseases, occurring independently of stomach 
 affections, are these changes observed ? 
 
 3. What is the nature of the alterations of the digestive organs 
 with which these conditions of the tongue have been found to be 
 associated ? 
 
 The appearances of the tongue which have been most com- 
 monly believed to be associated with the diseases of the rest of 
 the intestinal canal, are (a) an increase of its epithelial covering 
 9 
 
98 STUDY OF DIAGNOSIS. 
 
 Whilst there is much of error in the common ideas of 
 "furred tongue," something valuable maybe learned. 
 
 The vivid whiteness of the tongue, evidently a change 
 in the epithelium, evidences simple functional wrong, 
 and is associated with the febrile state. If observed at 
 other times, it may be taken as an indication that the 
 stomach and digestive tube want rest. 
 
 The thin, transparent mucoid coating of the tongue, 
 evidently upon and from the secretions of the mouth, 
 evidence enfeebled digestive function, frequently from 
 intemperate eating or drinking. 
 
 or "fur," which may present various degrees of thickness, and 
 different shades of color; (b) enlargement of its papil; (clae ) 
 various shades and degrees of redness of the mucous membrane ; 
 and (d) certain alterations in its size and shape. 
 
 (1) The fur or coating (saburra,) has been shown by micro- 
 scopic examination to consist of epithelium scales, which are 
 often fattily degenerated, and sometimes massed together, of free 
 fat drops, and of confervoid growths ; of these the largest pro- 
 portion is formed of the epithelial cells which are derived from 
 the covering of the organ together with the saliva and buccal 
 mucus, which in drying form a thick glutinous material, con- 
 glomerating the other elements into a mass. 
 
 The fur may be of greater or less thickness, dry or moist, uni- 
 form, or accumulated more particularly at the posterior portions* 
 it is sometimes deeply fissured by sulci, which may extend into 
 the mucous membrane beneath. At other times it may separate 
 in flakes from the surface, which then may look raw, and of a 
 deeper red than natural, but which may, when the process of 
 separation is gradual, present no deviation from the normal 
 appearance. 
 
 Mixed with the fur may be sometimes found pigment, blood 
 corpuscles, mucous or pus corpuscles, or the remains of vegetable 
 and animal portions of food. 
 
STUDY OF DIAGNOSIS. 99 
 
 The fur which has consistence is evidently upon the 
 tongue, and can be scraped off — evidences impairment 
 of function, and the wrong is generally in proportion 
 to its thickness. If uniformly distributed it may be 
 regarded as having reference to the entire intestinal 
 tract ; if restricted principally to the base, we think of 
 greater wrong of the stomach. The heavily loaded 
 tongue would call our attention to accumulations in the 
 bowels, and would prompt to means (mild) to secure 
 their evacuation. The heavily loaded tongue at the base 
 calls attention to accumulations in the stomach, and 
 
 The color may be white or milky, or may present various 
 shades of yellow or brown. 
 
 The nature and cause of some of the changes in color are very 
 imperfectly understood. Some of them arise from articles if 
 food, medicinal substances, tobacco, etc.; a large proportion, how- 
 ever, are caused by slight hemorrhages from the gums ; while 
 some others, and especially those occurring in fevers, remain un- 
 explained. Excepting, however, those cases where there is direct 
 pigmentary discoloration from jaundice, when other tissues par- 
 ticipate in the change, there is no foundation for the common 
 belief that a yellow fur on the tongue has any necessary connec- 
 tion with hepatic disorder. 
 
 As regards the chief causes to which the production of this fur 
 is attributable, may be mentioned: 
 
 (a) Idiopathic conditions in which the tongue of some persons 
 may, consistently with apparently perfect general health, form 
 and throw off a much larger amount of epithelial covering than 
 is ordinarily the case; inquiry should, therefore, be directed to 
 this point before any general conclusions are formed respecting 
 the indications to be drawn from its presence. 
 
 Qb) States in which a coating is formed on the tongue by the 
 Bimple drying of inspissated mucus and saliva, owing to the 
 mouth being kept open, as is oft^n the case during sleep. 
 
 (c) Conditions of irritation in the mouth itself, giving rise to 
 
100 STUDY OF DIAGI^OSIS. 
 
 suggests the use of an emetic to free this viscus, and 
 stimulate normal innervation and circulation. 
 
 Yellowness of coating is thought to arise from wrong 
 in the hepatic function, and to point to the use of" liver 
 remedies." Whilst it may have this reference in some 
 cases, it is well to avoid the usual cholagogues. It may 
 be said to call for Nux Vomica, small doses of Podo- 
 phyllin and Hydrastine. A dull, leaden, yellow fur is 
 an indication for Chelidonium. A dull, cheesy look- 
 
 an .ncreased production of epithelium on the cheeks, gums and 
 tongue, and which, from their similarity to the state of other 
 mucous membranes, where increased secretion, attended with 
 shedding of the epithe.ial covering, is the result of irritation or 
 subacute inflammatory action, are usually termed catarrhal. 
 The belief that this is the true pathology of this state,, is also 
 favored by the coincidence, in many such cases, either of a gen- 
 eral redness of the surface, beneath the thickened epithelium, or 
 of hyperemia and enlargement of the papillae, especially of the 
 papillae fungiformes of the lateral and anterior portions. In 
 some instances, also, the inflammatory state is further evidenced 
 by the production of aphthae, giving rise to slight and superficial 
 ulcerations, with a reddened base, and often surrounded by a 
 reddened margin. 
 
 Many of these conditions of the tongue may, however, be due 
 to local causes, such as carious teeth, or other sources of irritation 
 to the fifth nerve, or to accumulation of food around the bases 
 of the teeth, or to medicinal agents affecting the salivary glands 
 and mouth, as Iodide of Potassium and Mercury, or to the habit 
 of smoking (though this does not ordinarily produce a thickened 
 epithelial fur, nor hyperemia of the papillae fungiformes, its 
 effects being, generally limited to an enlargement of the papillae 
 filiformes, which gives to the surface a finely roughened aspect). 
 As smoking, however, is not an unfrequent cause of stomach 
 affections, our observations on this head are always attended 
 with certain grounds of fallacy. — Fox on Diseases of Stomach. 
 
STUDY OF DIAGNOSIS. 101 
 
 ing fur, with slight green tinge, is an indication for 
 Copper. 
 
 The bright redness of tip and edges, especially of 
 papillae is an evidence of irritation with determination 
 of blood. It always suggests care in the use of reme- 
 dies, rest to the stomach, and the special agents named 
 to remove irritation. A good condition of stomach is 
 of first importance in the treatment of disease, and 
 when these symptoms present, these means will hold a 
 prominent place. 
 
 The tongue gives us the best evidence of the condi- 
 tion of the blood, and of the remedies which rectify its 
 wrongs. All exudations or secretions from the blood 
 must give information of the character of this fluid, 
 and there is no better place to observe them than in the 
 mouth. The circulation of blood is also very free and 
 superficial in the tongue, and we are thus enabled to 
 observe its changes of color better than in other situa- 
 tions. The reader will recollect the distinction between 
 the tongue itself and the fur or coating, when color is 
 spoken of, as the one is from the circulating blood, and 
 the other from the exudation. 
 
 The broad, pallid tongue — marked want of color in 
 the tongue itself — evidences the want of the alkaline 
 elements of the body. The evidence is clear and dis- 
 tinct, and the want one of much importance. It may 
 be the basis of the entirety of the disease, which will 
 fade away as soon as the proper alkali is given, or it 
 may be but a portion of the wrong, and the alkaline 
 salt prepares the way and facilitates the action of other 
 remedies. 
 
 If there is no special indication for some other, we 
 prescribe Soda because it? is the salt of the blood. 
 
102 STUDY OF DIAGNOSIS. 
 
 Usually we direct the bicarbonate added to water to 
 make a pleasant drink, and given freely as the patient 
 wishes it. If there is predominant wrong of the mus- 
 cular system, we may select a salt of Potash. If of tho 
 cellular tissue, a salt of Lime. 
 
 The deep red tongue, (usually contracted and dry), 
 evidences the want of an acid, as well as that condition 
 of the blood known as " typhoid." Here, as in the 
 preceding case, the want of an acid (undue alkalinity 
 of blood), may be the principal element of disease, and 
 all the symptoms are ameliorated, and the patient con- 
 valesces when it is given. In other cases it is but a por- 
 tion of the disease, and the acid facilitates the action 
 of other remedies. It is a very common symptom in 
 typhoid and typhus fevers, and the use of an acid in 
 these cases has been found a very successful treatment 
 by Chambers, Anstie and others in the London Hospi- 
 tals. Our Prof. King, some twenty-five years since, 
 suggested the use of good sharp cider in these cases, 
 and it has been employed with much success. He did 
 not say there was deep redness of mucous membranes, 
 but he might have said so, for he did name the dry and 
 contracted tongue with dark sordes, and they are asso- 
 ciated together. 
 
 In this case we select with reference to the condition 
 of the stomach, and the blood poisoning, and some- 
 times we may defer to the taste of the patient. Muri- 
 atic Acid usually receives the preference, as it is well 
 borne by the stomach, is a natural acid, and is a power- 
 ful antiseptic. It is added to water to make a pleasant 
 acid drink, and given ad libitum. In some cases sharp 
 cider is better borne by the stomach, is grateful to tho 
 taste, and the small amount of alcohol in it is beneficial. 
 
STUDY OF DIAGNOSIS. 103 
 
 In others lactic acid, in the form of whey, answers an 
 excellent purpose, as it furnishes a calorifacient food as 
 well. 
 
 The deep red, or deep violet colored mucous mem- 
 branes, with fullness, evidences sepsis, and is an indica- 
 tion for the special remedy, Baptisia. The acid should 
 also be given in some cases. 
 
 The full color, with violet shade, superficial and trans- 
 parent, is the indication for Nitric Acid, and it will be 
 found one of the most valuable remedies of the Materia 
 Medica. 
 
 The tongue large, thick in centre, with incurved 
 edges, and of a dull blue, or leaden color, is one of the 
 strongest indications for Arsenic, and it will rarely fail 
 to arrest the progress of disease in such cases. 
 
 The same dull, leaden color, with no change in size 
 or shape of the tongue, is one of the best indications 
 for the use of Phosphorus, or the Hypophosphites. 
 
 The slick, raw-beef tongue, the papillae wholly effaced, 
 evidences sepsis of the blood, and is one of the most 
 marked of the " typhoid " symptoms. The color of 
 the tongue is usually deep, and we will emploj r an Acid 
 or Baptisia. 
 
 The exudation or fur upon the tongue is a pretty 
 good index of the condition of the blood. Of course 
 we must weigh the influence of local disease of the 
 mouth and teeth, and the sympathetic relations with 
 the stomach and bowels, as heretofore named. (See 
 note.) 
 
 The dirty fur is an indication of sepsis of the blood, 
 as well as of depravation of the secretions. It is fre- 
 quently associated with moisture, and the redness is 
 rarely increased. We use the common word " dirty/' 
 
104 STUDY OF DIAGNOSIS. 
 
 because it expresses our meaning clearly — the impres- 
 sion upon the senses is that of dirt, and its meaning is 
 dirt. It may be a dirty- white, a dirty -gray, a dirty- 
 yellow, or a dirty -brown, but the dirty, grimy appear- 
 ance always assumes prominence in the mind. 
 
 If we have a dirty tongue, pallid, we usually think 
 of Sulphite of Soda. If the redness is natural, we may 
 use Sulphurous Acid or Sulphite of Magnesia. If dirty, 
 with increased redness, Muriatic Acid. 
 
 All shades of brown and black have reference to the 
 condition known as typhoid. We have every shade of 
 color from the slight tinge of brown to the deep brown 
 or almost black. It is not only the coating of the 
 tongue that shows this color, but accumulations of 
 sordes about the teeth, and sometimes crusts upon the 
 lips. As is the deepness of color, so is the wrong known 
 as " sepsis," and so is the need of the class of reme- 
 dies known as " antiseptic." As is the deepness of 
 color, so is the impairment of life, and the need of care 
 and rest to conserve it, and of food and restoratives to 
 support it. 
 
 These dark coatings are so usually associated with 
 deep redness, that we usually think of acid remedies, 
 first of which is Muriatic Acid. But some of the cases 
 will need Baptisia, others Chlorate of Potash, and some 
 will be benefited by Carbolic Acid. Cleanliness is of 
 especial importance in these cases, as all decomposing 
 animal matter in the air or surroundings, increases the 
 wrong of the blood. 
 
 The reader may not have thought that the tongue 
 could tell him much with regard to the condition of 
 the nervous system, and yet a little study will show 
 that it does give very important evidence. It has 
 
STUDY OF DIAGNOSIS. 105 
 
 special reference to the condition of the sympathetic 
 nervous system, and this may be regarded as the most 
 important, but we also learn much of cerebro-spinal in- 
 nervation. 
 
 We associate dryness of tongue with excitation of the 
 nerve centres, especially the ganglionic. So positive is 
 the evidence that it is not possible to mistake it. Dry- 
 ness of tongue is associated with vascular excitement, 
 and with arrest of secretion from this cause. If in 
 acute disease with dryness of tongue, we find it becom- 
 ing moist, we know that the nerve centres are being re- 
 lieved, and that the circulation is improved, and secre- 
 tion is commencing. If in a case of disease marked by 
 enfeebled innervation from the sympathetic, and moist, 
 relaxed tongue, the tongue commences to dry and be- 
 comes firmer, we know that this nervous system has 
 been stimulated, and many times it is a first evidence 
 of amendment. 
 
 Whilst dryness always evidences undue excitement 
 of the nerve centres, and calls for sedatives, or that 
 class of agents which remove this, too much moisture and 
 relaxation is evidence of the opposite condition. The 
 reader will recollect the typical salivation from Mercury, 
 and its influence in this regard, and will weigh the de- 
 pressant influence of the mineral upon the sympathetic 
 nervous system, by these conditions. If after mercu- 
 rial salivation, the nerve centres are stimulated by 
 Quinine, or Quinine and Opium with Ipecac, the tongue 
 will become firmer and may become dry, and if not too 
 great, this has been regarded as a good symptom. 
 Moisture of tongue is one of the prominent conditions 
 assuring us of the kindly action of Quinine, and even 
 of Opium when indicated. If marked, and accompanied 
 
106 STUDY OF DIAGNOSIS. 
 
 by full, relaxed tissues, the patient always requires 
 nerve stimulants. 
 
 Contraction is always an evidence of an excited nervous 
 system. Sometimes, indeed, we may measure the 
 wrong of innervation by this symptom, as in typhoid 
 and typhus fevers, and in the later stages of acute dis- 
 ease. The reader who has seen the great nervous 
 wrongs of these affections, will recollect the pinched, 
 contracted tongue as one of the prominent symptoms. 
 
 Fullness of tongue has the opposite meaning. If 
 marked, we are quite sure that innervation is impaired 
 from atony, or want of normal stimulus of the nerve 
 centres, especially of the sympathetic. It suggests 
 nerve stimulants as a part of the treatment, Podophyl- 
 lin and Lobelia for the solar and cardiac plexus, Nux 
 Vomica, Strychnia, Belladonna, Ergot, for the associate 
 sympathetic and spinal nervous systems, and Quinine 
 for the associate wrong of the three, or simply for the 
 brain alone. 
 
 Whilst the elongated and pointed tongue has especial 
 reference to the stomach and intestinal canal, it is one 
 of the expressions of disease of the base of the brain. 
 It is well to note this fact, for we may have the wrong 
 of the brain as the primary lesion, the nausea and vom- 
 iting being but the result, and if treatment was wholly 
 directed to the stomach, we would make a great mis- 
 take. Gelseminum assumes a prominent place here, 
 associated either with Veratrum or Aconite. Rest is 
 obtained by the topical action of Chloroform about the 
 ear. 
 
 The small tongue, full in the centre, which is covered 
 with a thick, tenacious mucoid coat, is an indication of 
 marked disturbance of the brain, unless we have evi 
 
STUDY OF DIAGNOSIS. 107 
 
 dence of acute disease of ears, the globes of the eyes, 
 or the sphenoidal or ethmoidal cells. It may indicate 
 a very grave lesion, or in the latter case will pass away 
 with the local disease. In those cases where the coat- 
 ing is removed, the surface is left slick, and very dark 
 colored. 
 
 The tongue covered with a grayish or yellowish fur, 
 showing small patches of red distributed uniformly 
 over the surface, is the tongue of scarlet fever. The 
 same appearance will be seen in other cases, where the 
 capillary circulation of the skin is enfeebled. 
 
 The eroded appearance of the papillae at the tip of 
 the tongue, looking like small, rose-colored bubbles, 
 evidences a peculiar wrong of the nerve centres and of 
 the blood, for which Ehus Toxicodendron is the 
 remedy. 
 
 The movements of the tongue are sometimes of im- 
 portance in determining the condition of the brain. If 
 the patient has complete command over it, we conclude 
 that the functions of the brain are still well performed. 
 But if it is protruded with difficulty, is tremulous, or is 
 inclined constantly to one side, we are confident we 
 have a proportionate cerebral lesion. Whilst we might 
 get the evidence elsewhere, it is quite as well to give 
 weight to these symptoms, and when observed, to adopt 
 means early for the relief of the brain. 
 
 From what has been said, the reader will draw the 
 conclusion that impairment of nutrition and secretion 
 will be indicated by marked dryness and contraction 
 on the one hand; or increased moisture and relaxation 
 on the other. In the first case there is undue excita- 
 tion, and if we select remedies to increase secretion or 
 excretion, they will be of a sedative character. In the 
 
108 STUDY OF DIAGNOSIS. 
 
 other case there is a want of innervation, and the reme- 
 dies will be those which will give stimulus and tone. 
 
 There is a sodden, unpleasant looking tongue, which 
 is quite as good evidence of cacoplastic material in the 
 blood as any we can find. We recognize at once the 
 evidence of enfeeblement of the digestive functions, 
 and if there is local irritation we expect that the exu- 
 date will be of this character, readily breaking down 
 and destroying the tissues. 
 
 EXAMINATION OF THE DISCHARGES. 
 
 The examination of the discharges in common dis- 
 eases is usually quite superficial, and whilst it has some 
 diagnostic value is usually of little importance. The 
 physician from force of habit asks after the discharge 
 of urine and feces. Has the patient passed urine? 
 freely? was it high colored, or what was its color? 
 Has the patient's bowels been moved? how often? 
 These are the common questions, and the answers are 
 very uncertain and indefinite. Possibly the physician 
 wishes to examine " the vessel," but in these days he 
 is usually satisfied with these casual inquiries, and pre- 
 fers to get his information from pleasanter sources. In 
 the olden time examination of " the vessel " was of 
 greater importance, for the principal part of the phy- 
 sician's business was to fill it — medicine meant dis- 
 charges. 
 
 It may be well to give this subject a brief study, 
 though we do not attach such great importance to it. 
 We may divide the study into five parts — a, with refer- 
 ence to the discharge from nose and mouth; 6, with 
 
STUDY OF DIAGNOSIS. 109 
 
 reference to the discharges from the skin ; c, with refer- 
 ence to the discharges from the urinary apparatus ; d y 
 with reference to the discharges from the bowels ; and 
 e, with reference to the discharges from the reproduc- 
 tive organs. 
 
 From the Nose. — The discharges from the nose are 
 of local significance, and indicate changes of function 
 and structure in these cavities. In measles and typhus, 
 catarrhal symptoms are among the most prominent, 
 and in the first are almost pathognomonic ; but these 
 and epidemic influenza are the only instances where the 
 disease is referred to the blood. 
 
 The thin, glairy secretion is evidence of irritation 
 and determination of blood. The white of egg looking 
 mucus of active inflammation. The yellowish, glairy 
 discharge of commencing suppuration — muco-pus, and 
 the opaque, yellowish, non-tenacious secretion, of the 
 subsidence of inflammatory action. 
 
 Dryness of the anterior nares is usually referred to 
 scanty or arrested lachrymal secretion ; too much mois- 
 ture of the anterior nares, thin, watery, to increased 
 lachrymal secretion. 
 
 In chronic disease of the nasal cavities, the condition 
 of the parts is pretty clearly shown by the character 
 of the discharges which have the entire range of mucus, 
 muco-pus and pus. In determining the diagnostic 
 value of these discharges, we will be guided by the same 
 rules as in other situations. We wish to know the phy- 
 sical properties of normal mucus, and of normal pus, 
 and we will then have a standard of comparison ; this 
 we will study in discharges from the respiratory tract 
 below. 
 
110 STUDY OF DIAGNOSIS. 
 
 From the Mouth. — The discbarges from the mouth 
 proper are of saliva with some mucus secretion. But 
 through the mouth we have all the discharges from the 
 respiratory tract below, of mucus, pus, blood, exudative 
 material, etc. We also have occasionally discharges 
 from the digestive tract, the stomach, upper small intes- 
 tine, and secretion from the liver. 
 
 The saliva normally is a thin, transparent, slightly 
 viscid fluid, with a marked alkaline reaction to litmus 
 paper. If it loses these properties in degree, or is iL- 
 creased, we will conclude that the first act of digestion 
 is improperly performed. Physicians have not been 
 properly impressed with the importance of buccal diges- 
 tion, and frequently direct their remedies to the stomach 
 when it is not at fault. 
 
 We have already seen that dryness of the mouth evi- 
 denced arrest of secretion, and necessarily impairment 
 of the digestive process. If the salivary secretion is 
 found to be scanty, we anticipate a wrong of digestion, 
 especially of starchy foods, and a wrong of nutrition. 
 It is usually associated with excitation of the nerve 
 centres, and local disease presents unusual irritation. 
 We have the same results where the saliva is constantly 
 thrown off in chewing and smoking. 
 
 The remedies suggested in chronic disease by scanty 
 secretion of saliva are, Iris Versicolor, Phytolacca, 
 Panax, and some others of this class, with the Iodides 
 and Bromides, especially of Ammonium. 
 
 Increased secretion of saliva is found as a symptom in 
 some forms of chronic disease, and occasionally in 
 acute disease. If marked, it interferes with digestion, 
 and is a cause of depravation of the blood. This may 
 seem singular to the reader, and yet I think any one 
 
STUDY OF DIAGNOSIS. Ill 
 
 who has closely observed cases presenting this symptom 
 will bear me out. The tendency is always to low 
 grades of albuminoid deposits — eacoplastic, or aplastic. 
 
 In acute disease the remedies will be the Alkaline 
 Sulphites or Sulphurous Acid, or sometimes Chlorate 
 of Potash, or Chloride of Sodium. Quinine and Nux 
 Vomica are thought of for the wrong of innervation, 
 and Hydrastis and Podophyllin for the wrongs of the 
 intestinal canal. The same remedies will be applicable 
 in chronic disease, and in addition we may think of 
 Phosphorus, Sulphur, and sometimes Arsenic. 
 
 It is hardly worth w^hile to speak of changes in the 
 character of saliva as regards its viscosity, as it is always 
 associated with excess in quantity, and the indications 
 for remedies will be as above. I would call attention, 
 however, to the need of antiseptics in these cases, for 
 very surely we will have sepsis as a prominent feature in 
 the progress of acute disease. If the proper antiseptic 
 is selected, as elsewhere described, whether Sulphite of 
 Soda, Sulphurous Acid, Chlorate of Potash, Baptisia, or 
 Muriatic Acid, this symptom will pass away. 
 
 The reaction of the secretions of the mouth to test 
 paper will be found to vary, and this will sometimes in- 
 dicate the class of remedies to be selected. The alka- 
 linity may be markedly increased, and acids will be as- 
 sociated with remedies to influence the digestive pro- 
 cess. In such a case, with dyspepsia, Muriatic or Lactic 
 Acid, largely diluted, with the addition of a small por- 
 tion of Nux, will cure when the ordinary means have 
 failed. In infantile dyspepsia, w^e sometimes find the 
 saliva neutral, or in rare cases the entire secretions of 
 the mouth are slightly acid. We find the same condi- 
 tions in the adult, though not so often nor so marked. 
 
112 STUDY OF DIAGNOSIS. 
 
 In such cases we would give Phosphate of Soda, and 
 surely expect the patient to amend rapidly. 
 
 From the Stomach. — Ejections from the stomach as 
 the result of disease may sometimes give valuable in- 
 formation, though usually we depend more upon what 
 the patient tells us than upon what we see. But as a 
 matter of interest we may examine the discharges. 
 
 Eructations in dyspepsia are very acid or feebly acid. 
 The first is very common and is usually met by an 
 alkali or Bismuth, though experience shows that this is 
 not good treatment, or at least but a part of good treat- 
 ment. It is associated with hyperesthesia, demanding 
 Aconite, Hydrocyanic Acid, Ehubarb, Ipecac, and like 
 remedies ; with externally the wet pack, either of water 
 or water with an acid. The second evidences a condi- 
 tion of atony, and suggests Muriatic and Lactic Acids, 
 with Hydrastis and similar bitters, Podophyllin, etc. 
 
 Eructations containing a yellowish, or yellowish- 
 brown coloring material, and of a bitter taste, shows 
 irritation of the upper small intestine, and sometimes 
 an irritation of the entire chylof>oietic apparatus. The 
 remedies will be such as prove sedative to these parts. 
 
 Blood in the discharges has a variable significance. 
 If in small quantities, during violent vomiting, we may 
 conclude that some mmr.te vessels have given away; if 
 dark colored and clotted, we conclude there is passive 
 hemorrhage — usually from congestion, except in the 
 rare case of ulceration, with erosion of some of the 
 vessels, when the discharge may either be of bright or 
 clotted blood. 
 
 Vomiting of considerable quantities of mucus is occa- 
 sionally noticed in persistent atonic dyspepsia, and its 
 
STUDY OF DIAGNOSIS. 113 
 
 therapeutic value will be obvious. Vomiting of pus is 
 at once referred to ulceration, the result of chronic in- 
 flammation. 
 
 The " black vomit " of yellow fever, and some rare 
 cases of congestive, intermittent and remittent fevers, 
 shows the breaking down of the blood, as well as the 
 congestion of the digestive mucous surfaces. 
 
 From the Eespiratory Tract. — The discharges from 
 the respiratory tract are of mucus, pus, blood, and the 
 material of exudation. As heretofore remarked, we 
 wish to have a clear idea of the origin and value of 
 these discharges, and senses trained to recognize them 
 when seen. In health the respiratory mucous mem- 
 brane is continuously lubricated with mucus, but it is 
 not in quantity to be discharged by mouth ; even the 
 increase of quantity is evidence of disease. 
 
 If mucus is thin, glairy, and very tenacious, we know 
 that it comes from a mucous membrane in a condition 
 of great vascular excitement — inflammation. The more 
 marked these proporties, the more active the excite- 
 ment. We see it in minor degree in catarrhal bron- 
 chitis, but most marked in sthenic bronchitis when 
 secretion is first established. The typical remedy is 
 Yeratrum. 
 
 The opaque mucus, not so tenacious, is associated 
 with a subsidence of the inflammation and resolution. 
 The quantity may be such as to enfeeble the part or the 
 patient, but other than this it is regarded as a favor- 
 able symptom. The reader must not suppose from this 
 that abundant opaque mucous discharges are essential to 
 recovery, for they are not, and the patient convalesces 
 better if the discharge is never in excess, and but little 
 10 
 
114 STUDY OF DIAGNOSIS. 
 
 changed in character. The typical remedy is Ipecac. 
 Change of color evidences local structural disease, and 
 disease of the blood, whatever the color may be. 
 Shades of yellow and green show suppuration — the dis- 
 charge is more or less purulent. Shades of brown, if 
 not from blood in this discharge, show a low grade of 
 inflammation and impairment of the blood. In some 
 of these cases the discharges look like "prune juice/' 
 or still worse, like the washings of spoiled beef. 
 
 Globular sputa is characteristic of pneumonia, as the 
 glairy, tenacious mucus is of bronchitis. So marked is 
 this character of the expectoration in inflammation of 
 the parenchyma of the lungs, that it is evidenced, not 
 only in the single portions of mucus expectorated, but 
 when the patient spits in a vessel, they all run together 
 to form a globular mass. 
 
 The cheesy expectoration, lacking consistence, seem- 
 ing to be somewhat granular, is usually regarded as 
 tuberculous. Whilst there are exceptions, it is prob- 
 able that it may usually be regarded as evidencing 
 aplastic or cacoplastic deposits, and a condition favoring 
 tuberculosis, if it is not broken down tubercle. 
 
 Masses of dessicated mucus are sometimes expec- 
 torated, that are well calculated to deceive. They are 
 in larger and smaller granules, and fully meet the 
 popular idea of tubercular deposit. Yet when we take 
 a portion and soften it with water on a glass, it gives 
 the glairy, tenacious mucus, and not the friable, tuber- 
 cular matter. These little bodies are evidently from 
 accumulations in mucous follicles, principally in the 
 larynx, which are forced out in the act of coughing. 
 
 Pus from mucous membranes, will in appearance take 
 the entire range of this product. It is usually admixed 
 
STUDY OF DIAGNOSIS, 115 
 
 with mucus, and thus has greater consistence. It is 
 laudable, or bad, thin, thick, bland, ichorous, yellow, 
 green, brown, etc. It evidences local destruction, 
 though it may be but superficial, the relationship be- 
 tween mucus and pus being very intimate. The grada- 
 tions of pus have the same significance here as elsewhere. 
 
 Blood may be discharged from the throat and pha- 
 rynx, from the stomach, from the larynx, and from the 
 lungs. From the throat and pharynx it is of usual 
 color, is not frothy, and is ejected by an act of the will. 
 Blood from the stomach is of darker color, is sometimes 
 admixed with food and the secretions of the stomach, 
 or is in part clotted. Blood from the larynx is but little 
 frothy, is of usual color, and is in part discharged by 
 an act of will. Blood from the lungs is usually bright, 
 frothy, and wells up into the mouth without the con- 
 sciousness of the patient. 
 
 We always want to know whether hemorrhage is 
 active or passive, as the treatment will depend upon 
 this. Very fresh and bright blood would evidence 
 active hemorrhage, whilst deeper colored blood would 
 evidence passive hemorrhage. Yet we will find better 
 evidence in the color and expression of the face and in 
 the pulse. Active hemorrhage calls for Veratrum and 
 Ipecac, whilst passive hemorrhage refers us to Erigeron, 
 Gallic Acid and Ergot. 
 
 Mucus streaked with bright blood evidences inflam- 
 mation, and is seen in sthenic bronchitis. If the blood 
 is less bright it evidences a lower degree of inflamma- 
 tion, or rather impairment of the life of the part, and 
 if it assumes the " prune juice " character, it evidences 
 an unpleasant condition. The blood in the sputa of 
 pneumonia is rusty, and maybe found perfectly admixed 
 
116 STUDY OF DIAGNOSIS. 
 
 with the mass of mucus, or forming a central nucleus. 
 If here it becomes brown, or has the "prune juice" 
 character, it evidences a low grade of inflammatory 
 action and impairment of the life. 
 
 We occasionally see exudative material. First, as 
 fibrinous exudations from the mucous surfaces, in croup 
 and in croupous bronchitis; second, as broken down 
 tubercular material from the parenchyma of the lungs. 
 The last is sometimes very characteristic, but at others 
 it is so masked by the bronchial secretions and by the 
 breaking down of the structures, that we can hardly 
 recognize it. Gall it cheesy, friable, and the fluid dif- 
 fering in character from laudable pus in consistence, 
 color, etc., and the reader will get a fair idea of it. 
 
 EXAMINATION OP THE TJKIJSTE. 
 
 The physician in common practice has but little 
 knowledge of the urine — possibly he maj^ not know 
 the physical properties of normal urine. As we have 
 stated so often, this is the first thing that needs be 
 learned. If we can recognize normal urine when we 
 see it, it will be possible to tell its common variations 
 by sight. Yet here we find a serious obstacle in the 
 way — the very great variations of normal urine both in 
 color and in quantity. Yet there is a normal color, and 
 these differences are more in its concentration than in 
 any real change. The quantity may vary very greatly 
 without any marked change in the excretion — water 
 forming its bulk.* 
 
 ^Composition of Kenal Excretion. — The renal excretion has 
 naturally an acid reaction, and consists chiefly of urea, with some 
 uric acid, sundry other animal products of less importance, in- 
 
STUDY OF DIAGNOSIS. 117 
 
 The majority of physicians attach but little value to 
 the ordinary examination of urine by the sight, which 
 is popularly known as " Uroscopy." Yet whilst we are 
 convinced that there is a broad basis of charlatanry, 
 there is evidently something real that serves as a basis 
 for selecting remedies. Evidently it is worth study, 
 and I think I can point out a method by which the 
 reader can learn all there is to be known. 
 
 It is claimed that all disease is represented in change 
 of the urinary secretions, and that these changes can 
 be recognized. Let us admit it, and then to study 
 diagnosis by the urine we will take cases of disease 
 
 eluding certain coloring-matters, and saline and gaseous sub- 
 stances, all held in solution by a large quantity of water. 
 
 The quantity and composition of the urine vary greatly ac- 
 cording to the time of day ; the temperature and moisture of the 
 air; the fasting or replete condition of the alimentary canal; 
 and the nature of the food. 
 
 Urea and uric acid are both composed of the elements carbon, 
 hydrogen, oxygen, and nitrogen ; but the urea is by far the more 
 soluble in water, and greatly exceeds the uric acid in quantity. 
 
 An average healthy man excretes by the kidneys about fifty 
 ounces, or twenty-four thousand grains of water a day. In this 
 are dissolved five hundred grains of urea, but not more than ten 
 to twelve grains of uric acid. 
 
 The amount of other animal matters, and of saline substances^ 
 varies from one-third as much to nearly the same amount as the 
 urea. The saline matters consist chiefly of common salt, phos- 
 phates and sulphates of potash, soda, lime and magnesia. The 
 gases are the same as those in the blood — namely, carbonic acid, 
 oxygen, and nitrogen. But the quantity is, proportionally, less 
 than one-third as great; and the carbonic acid is in very large, 
 while the oxygen is in very small, amount. 
 
 The average specific gravity does not differ very widely from 
 that of blood-serum, being 1.020. — Huxley. 
 
118 STUDY OF DIAGNOSIS. 
 
 where tbe diagnosis is well made, and compare the urine 
 with the normal standard of health. Certainly we will 
 now be able to see these differences if they exist. Here 
 is the patient suffering with pneumonia, bronchitis, or 
 tuberculosis. Is there a urine that represents pneu- 
 monia^ bronchitis, or tuberculosis? Here are patients 
 suffering from well recognized nervous lesions, neural- 
 gia, paralysis, epilepsy, etc. Is there a urine that rep- 
 resents neuralgia, paralysis, epilepsj', etc. ? Here are 
 certain well defined lesions of digestion, blood-making, 
 nutrition, and retrograde metamorphosis. Are there 
 urines that represent these lesions of digestion, blood- 
 making, nutrition, and retrograde metamorphosis? 
 
 But supposing we do not find that these diseases are 
 represented in the urines, and we can not diagnose the 
 situation of local disease from it, possibly we can diag- 
 nose a general condition of disease. At least we will 
 very certainly learn what is to be learned, and we will 
 learn something that is valuable. 
 
 The ordinary examination is conducted with refer- 
 ence to — a, quantity; b, specific gravity; c, color; </, 
 deposits ; and e, change in its constituents. In eveiy 
 day practice the examination is of necessity superficial, 
 and it is only when symptoms point to lesions of the 
 urinary apparatus, or the disease is so obscure that we 
 resort to every known means, that a critical examina- 
 tion of urine is made. 
 
 To determine anything definitely with regard to this 
 secretion, the urine must be passed in a separate vessel, 
 (which should be clean), and the urine of twenty-four 
 hours saved for inspection. All tests of color should 
 be made in clear white glass containers by means of 
 transmitted light, and all deposits should be examined 
 in a similar manner. 
 
STUDY OP DIAGNOSIS. 119 
 
 Quantity. — The normal quantity of urine in the 
 healthy man is about fifty ounces in the twenty- four 
 hours, and this is of a specific gravity of 1.020, contain- 
 ing 1080 grains of solid matter. The urine may mea- 
 sure but thirty ounces, yet the specific gravity being 
 high, 1.030, the secretion will be sufficient for blood 
 depuration. Again, the urine may be passed in normal 
 quantity, or as much as sixty or seventy ounces daily, 
 and yet being of low specific gravity, 1.010, the patient 
 will suffer from uraemia There is thus such indefinite- 
 ncss, that even though we know the quantity of urine 
 in twenty-four hours, we can not tell whether depura- 
 tion is sufficient or not. 
 
 It may be remarked further that we do not expect 
 as large secretion from the kidneys in disease, when the 
 body is inactive, as in health when it is active. Scanty 
 urine is characteristic of all forms of disease, and even 
 an accurate measurement of quantity and specific 
 gravity will not tell ns so well whether it is sufficient, 
 as other symptoms that might seem to the casual ob- 
 server to be more indefinite. 
 
 Specific Gravity. — The specific gravity is deter- 
 mined by a urinometer, and having the quantity passed 
 in twenty-four hours, we will, with this instrument, be 
 able to determine the amount of solids in this period. 
 But it does not determine what solids. If the urine is 
 of low specific gravity, and in small quantity, the blood 
 may be so freed from urea, that the function may be 
 regarded as normal, for there may be but little of the 
 " 500 grains of other animal matter and saline sub- 
 stances " passing out, and the urea for excretion may 
 not be more than two or three hundred grains. Con 
 
120 STUDY OF DIAGNOSIS. 
 
 versety, if the urine is of high specific gravity, and 
 passed in considerable quantities, the patient may still 
 suffer from uraemic poisoning, for the adventitious solids, 
 sugar, albumen, saline matters, etc., take the place of 
 urea. 
 
 It is well to get an idea of the uncertainty of this 
 examination, otherwise we might be led into error. We 
 reach no conclusions from these examinations that are 
 not proven by other symptoms ; and usually we make 
 these examinations to confirm conclusions reached by 
 more definite expressions of disease. If the patient is 
 suffering from the nervous excitation or coma of re- 
 tained urinary excretion, the examination determining 
 scanty urine becomes of value. If the patient shows 
 evidence of waste, and we find too free excretion, we 
 conclude that this drain upon the blood should be 
 stopped. 
 
 In any wrong of innervation, we think of the urinary 
 excretion as a possible source of disease, and if Ave do 
 not find the cause elsewhere, we give the urine a critical 
 examination. In any disease of debility, especially 
 when chronic, if we can not find the cause elsewhere, 
 we turn at once to the kidneys as a possible seat of the 
 trouble, and make the necessary examination. 
 
 Color * — The color of the urine has been regarded 
 as the best diagnostic evidence in the common exami- 
 
 ^Urohaematin, the substance which gives to healthy urine its 
 peculiar tint, is of more importance to the Clinical Physician 
 than the majority of urinary ingredients: for the quantity passed 
 in the twenty-four hours is not only an index to the tear and 
 wear of the tissues, but the best measure we at present possess 
 of the rapidity with which man burns life's lamp. The amount 
 
STUDY OF DIAGNOSIS. 121 
 
 nation of this fluid. Of necessity, if any definite in- 
 formation is to be bad, the urine must be passed apart 
 from the faeces, and as before named, it should be exam- 
 ined in white glass by transmitted light. 
 
 The physician in ordinary, recognizes the normal 
 color varying from a pale straw to a yellowish brown 
 tint, and he classes the urine of disease as dark and 
 light or pale. Scanty and high colored urine is asso- 
 ciated with acute febrile and inflammatory diseases, 
 and pale urine with diseases of relaxation. Possibly 
 this is quite as definite as the ordinary professional 
 thought, and we may well ask ourselves if there is any 
 reason for this indefiniteness. Most assuredly there is ; 
 and we find it in the wide range of coloration in health, 
 and also in diseases in which color has but little 
 meaning.f 
 
 of all the ingredients of the urine we have hitherto considered, 
 are much more under the influence of the diet than that of uro- 
 haematin, the quantity of which may be said to be a tolerably 
 exact measure of the destruction of blood corpuscles. — Harley. 
 
 "(The color of the urine varies greatly in disease. It may be 
 perfectly white, yellow, brown, red, black, green, or blue, and 
 each of these tints, in the absence of ingesta capable of acci- 
 dentally producing them, invariably indicates the existence of 
 grave disease. 
 
 Normally colored urine does not, however, exclude the possi- 
 bility of disease, for the color of the freshly passed urine is no 
 absolute criterion either of the quantity or the kind of coloring 
 matter it contains. The abnormal like the normal pigments are 
 often combined with some of the other urinary ingredients in the 
 form of colorless compounds, and it is not until the compound is 
 decomposed, and the pigment set free, that we can take cogni- 
 zance either of its quantity or its quality. For example, here are 
 three urines: 1st. A pale, almost colorless urine from a healthy 
 
 11 
 
122 STUDY OF DIAGNOSIS. 
 
 Let us take the opinion of Dr. George Hurley, (and 
 I give it in extenso in the foot note,) a most excellent 
 observer, that the coloring matter of the urine — uro- 
 
 infant, aged 18 months. It lias a specific gravity of 1 018. 2d. 
 An equally pale, almost colorless urine from a girl, aged 19, suf- 
 fering from chlorosis. It has also a specific gravity of 1.018. 3d. 
 A dark straw-colored, but perfectly transparent urine from a 
 healthy man, aged 33. It has likewise a specific gravity of 1.018. 
 In fact, these three urines have been purposely selected on 
 account of their having the same specific gravity. To each of 
 these add a quarter of their bulk of strong nitric acid, and bring 
 them to the boiling-point. Watch the change. The infant's 
 pale urine is scarcely altered ; the man's dark urine is only 
 slightly deepened in tint; whereas the almost colorless urine of 
 the chlorotic girl has assumed an intensely red hue. "What is the 
 cause of this difference? The infant is in the bloom of health — 
 there is no waste of blood-corpuscles in it — all the blood discs it 
 possesses are employed in the development of its frame. The 
 man has arrived at maturity; he is still in the prime of life, and 
 in the enjoyment of perfect health ; his blood-corpuscles are not 
 wasted, but merely consumed in the tear and wear of every-day 
 life. The young woman, on the other hand, is suffering from 
 chlorosis; she has a pale lip, and a blanched cheek; her corpus- 
 cles are being too rapidly consumed ; her life's blood is oozing 
 away by the kidneys, and there it appears as an excess of urohae- 
 matin in her urine. 
 
 Take again these two urines so different in appearance. They 
 are from young men about the same age (24 years,). The one 
 urine is perfectly colorless, like water ; the other is of a deep red 
 color— case of hematuria from disease of the kidney. On adding 
 strong hydrochloric acid to the colorless urine it rapidly assumes 
 a port wine tint, whereas the same amount of acid added to the 
 red urine, instead of heightening, actually destroys the color it 
 already possesses. And why ? Simply because the pale urine 
 contains an excess of combined urohaematin, which is liberated 
 by the acid ; whereas, the red urine contains merely a number 
 of free blood-corpuscles, which become coagulated, and, as tlu 
 
STUDY OF DIAGNOSIS. 123 
 
 hseniatin — represents the wear and tear of the tissues, 
 and especially of the red corpuscles. We might expect 
 this to show us definitely the extent of this wear and 
 
 coloring matter in them is insignificant in quantity when com- 
 pared with the amount of urohaematin in the other, no sooner are 
 their cell-walls destroyed and the contained haemato-globulin 
 set free and coagulated, than the red color disappears. Now 
 which of these two classes of urine denotes the most danger? 
 Most assuredly not that containing the free blood-cells. A very 
 small quantity of blood will sometimes color a great deal of 
 urine; whereas an immense destruction of blood-corpuscles may 
 take place in the body, and their debris be so eliminated as to be 
 invisible to the eye until the application of an acid sets it free. 
 In fact, experience has shown me that the normally colored urine 
 of disease is a most treacherous guide to go by. It often lulls 
 the inexperienced into the belief that there is nothing materially 
 wrong, when a grave lesion is making rapid strides toward a 
 fatal termination. Not very long ago I was told by an intelli- 
 gent practitioner that a young lady, regarding whose health we 
 were consulting, was laboring undei hysteria " The secretions," 
 as he termed them, being " all right," my opinion had been 
 asked more with the view of satisfying the friends who were get- 
 ting fidgety than anything else. The case appeared to be what 
 he said, until he added, " She is well fed, and yet she loses flesh, 
 and I don't know why." This remark at once brought us back 
 to the urine, which he assured me was perfectly natural in color, 
 and contained neither sugar nor albumen. I analyzed some, and 
 the case proved the very counterpart of the lad's just spoken of. 
 Although the girl's urine was natural in color^ her life's blood 
 was imperceptibly oozing away with it. This is no solitary ex- 
 ample: I might cite many cases of so-called hysteria, which were 
 in reality cases of serious, though obscure disease; but that is 
 surely unnecessary. Who amongst us has not seen patients die, 
 and their disease put down as, only hysteria ? The time is, nev- 
 ertheless, not far distant when we shall learn that hysteria is 
 something more than "mere functional derangement." Hysteria 
 may be a convenient term, but, after all, it is only a cloak of 
 
124 STUDY OF DIAGNOSIS. 
 
 tear. But it does not; for as the cases given show, the 
 color is not in proportion to the amount of urohaematin, 
 but in proportion to that uncombined, and to its degree 
 of oxidation. 
 
 ample dimensions which hides the rags of ignorance. It is a 
 name instead of an explanation, a sham instead of a reality. 
 And what is still worse, it tends to keep us in ignorance by sti- 
 fling legitimate inquiry; for no sooner do the majority of practi- 
 tioners find a name for the disease than they cease to fathom its 
 cause. In some cases of cerebral and spinal disease the excess 
 of urohaematin in the urine is so great that after it has been set 
 free by an acid and taken up with ether, the ether, after stand- 
 ing, solidifies into a red currant jelly-like mass, and may actually, 
 in some cases, be cut with a knife. 
 
 The best way of showing this is to boil four ounces of urine ; 
 then add nitric acid to set the coloring matter free. When cool, 
 put the urine into a six-ounce bottle along with an ounce of 
 ether. Cork the bottle, thoroughly shake it, and afterwards place 
 it aside for twenty-four hours. At the end of that time the ether 
 will sometimes be found to be like a red tremulous jelly. Such a 
 case is, of course, a very bad one; but these are not nearly so 
 uncommon as one would imagine. In some of the worst cases of 
 urohaematuria the urine is neutral or even alkaline, and the fons 
 et origo mali is to be looked for in the brain or spinal cord. In- 
 deed, we may often be led to a correct diagnosis of obscure cere- 
 bral and spinal disease, by finding urohaematuria associated with 
 a saccharine or a phosphatic condition of the urine. 
 
 In a case of chronic cerebral disease, which I saw with Mr. T. 
 Carr Jackson, the quantity of urohaematin regularly varied pari 
 passu with the severity of the paroxysms, nitric acid turning the 
 urine red, purple, or even bluish (blue matter being after a time 
 deposited on the bottom and sides of the test-tube), according to 
 the severity and duration of the attack. It ought never to be 
 forgotten that alkaline remedies, as well as certain vegetable 
 foods, may increase the urohaematin. Even the external use of 
 carbolic acid sometimes turns it black. 
 
 When urohaematin exists in a free state, the urine is red '- 
 
STUDY OF DIAGNOSIS. 125 
 
 Notwithstanding this we always associate the high 
 colors or the wrong colors with severe disease. As Dr. 
 Harley remarks, " it may be perfectly white, yellow, 
 brown, red, black, green or blue, and euch of these 
 
 color before any acid is added. These cases differ from hsematu- 
 • ria, in the urine being clear and transparent, and devoid of 
 blood-corpuscles, and from intermittent hematuria in the absence 
 of congestive casts. If it contains a deposit, the deposit may or 
 may not be high-colored; but in any case the supernatant liquid 
 is clear as well as red. Another fact, which is of great clinical 
 importance is, that the urohsematin is not always in the same 
 state of oxidation ; and, like indigo, its color depends on the 
 amount of oxygen it contains. It may be yellow, red, or brown. 
 In consequence of this, different acids act upon the urine differ- 
 ently. In one case nitric, sulphuric, or hydrochloric acid may 
 produce the same results ; in another hydrochloric acid turns the 
 urine red, while nitric acid makes it blue, green, or yellow. In 
 a third sulphuric acid may develop the color better than the 
 others. 
 
 To illustrate these remarks : Take the case of a gentleman 33 
 years of age, whose urine to the eye appeared perfectly normal 
 in color. On adding strong nitric acid, however, to this urine it 
 immediately became of a blood-red hue, whereas hydrochloric 
 acid had no effect upon it until some minutes had elapsed, when 
 it gradually caused it to assume the same tint as that produced 
 by the nitric acid. When sulphuric acid is slowly added so as to 
 fall to the bottom of the test-tube, a reddish-brown line appears 
 at the point of contact, and this gradually deepens until, in the 
 course of six hours or so, it assumes a more intense color than 
 that produced by either of the other acids. 
 
 This is an important case in another point of view, namely, as 
 proving the value of urinary analysis in cases of obscure disease. 
 The only symptoms that this patient labors under are those of an 
 irregular kind of dyspepsia, with an occasional pain in the epi- 
 gastrium. He is in easy circumstances, takes plenty of nourishing 
 food, wants for nothing, yet he gradually gets weaker and 
 weaker, and has lost 17 lbs. in the course of the last year. Even 
 
126 STUDY OF DIAGNOSIS. 
 
 tints, in the absence of ingesta capable of accidentally 
 producing them, invariably indicates the existence of 
 grave disease." But though we concede the general 
 indication, is there any one who can tell the diagnostic 
 
 the locality in which the patient lives is a remarkably healthy 
 one (he was sent to me from Anglesey by Dr. D. Williams, of 
 the Menai Bridge), and if it had not been for the condition of 
 the urine, his symptoms would have remained a mystery. This, 
 too, was one of those cases in which the amount of urohaematin 
 was so great that it caused the ethereal solution to solidify into a 
 
 jelly. 
 
 An excessive excretion of urohaematin is not limited to cases 
 such as we have been describing. It occurs to some extent in 
 several diseases, especially those in which there is an excessive 
 tissue metamorphosis, and consequent too rapid blood consump- 
 tion. Hence we occasionally meet with it in low fevers, in diph- 
 theria, in pneumonia, and some other inflammatory affections, 
 in lesions of the nervous system, during an attack of gout, after 
 the fit of ague, and during convalescence from nearly all grave 
 diseases. It is, however, in chlorosis (either in the male or 
 female), and the many unnamable obscure affections of that 
 class, where it becomes a dangerous symptom. In fact, it always 
 indicates the existence of a past or present mischief meriting the 
 closest attention of the physician, and where we can not remove 
 the cause we must at least attempt to check the effects of the 
 symptom, namely, to restore to the blood as much as possible of 
 the material which is being drained from it. Every one knows 
 the effects of iron upon the system, but iron alone is not always 
 sufficient for our purpose. Something more is wanted, and that 
 is best supplied by the preparations called the syrups of phos- 
 phate of iron. Many syrups have been sold under this title. 
 There are the, American syrups; the compound syrup of the 
 phosphate of iron, or "chemical food," as it is sometimes named ; 
 the syrup of the superphosphate of iron and lime (excellent for 
 children) ; and a few others. One and all of them are good in 
 particular cases, but they must always be associated with a 
 
STUDY OF DIAGNOSIS. 127 
 
 value of each or either of these colors, and make it point 
 us to the remedy? This, as the reader will see, is the 
 practical question, and I confess that I can not do it. 
 In exhaustive disease, in which we may suspect the 
 
 judicious selection of regimen in order that the full benefit may 
 be derived from them. 
 
 The preparations of zinc, in grain or grain and a half doses, 
 are also occasionally useful astringent tonics when the drain is 
 very great. 
 
 In some cases of disease the excretion of urohaematin by the 
 kidneys appears to be diminished, but this is only when the sys- 
 tem has been so drained that there is little more to come away. 
 In the last stage of chlorosis a great diminution in the amount 
 of the urohamiatin in the urine takes place; so also in chronic 
 cases of hematuria, notwithstanding that the urine perhaps 
 looks red. Likewise in cases of chylous urine, in the albuminu- 
 ria of pregnancy, and in chronic Bright's disease. In ail these 
 cases the blood has already been well drained of its constituents 
 before a marked diminution in the amount of the eliminated 
 urohaematin takes place. 
 
 Blue and Green Urine, — A great sensation was created some years 
 ago among Clinical Physicians and Pathologists when the first 
 cases of blue and green urine were reported ; all doubted, and 
 many disbelieved in their existence. The least uncharitable 
 thought that the patient had hoaxed the doctor. Knowledge has, 
 however, advanced since then. Not one, but many observers 
 have met with the same conditions; and now the doubters and 
 disbelievers in the existence of either blue or green urine are 
 only to be found among the ignorant. 
 
 To Dr. Hassall we owe the first good report on the existence of 
 blue urine. It was entitled — "On the Frequent Occurrence of 
 Indigo in Human Urine, and on its Chemical, Physiological and 
 Pathological Relations." 
 
 I must here guard you against falling into the common error 
 of supposing that the urine is blue or green at the moment of 
 being voided, for, as far as I am aware, such a condition has 
 
128 STUDY OF DIAGNOSIS. 
 
 removal of the blood corpuscles by way of the kidneys, 
 the addition of Nitric, Muriatic or Sulphuric Acid to 
 the urine may give us the evidence of this masked 
 hemorrhage through these organs. The directions 
 given in the foot note may be followed. 
 
 never yet been observed. In the cases, hitherto reported it has 
 only been after exposure to the air, or after the application of 
 chemical agents, that the urine has been observed to become of 
 the colors alluded to. In HassaH's best-marked case, for exam- 
 ple, the urine was of a light brown color when voided, somewhat 
 alkaline, and had a specific gravity of 1.017. In the course of 
 three or four days it became thick and turbid, deep brown, 
 greenish, bluish-green, yellowish-green, and finally nearly black: 
 the scum on the surface remaining of a permanent, deep indigo- 
 blue color. All these changes followed upon simple exposure to 
 the air; but, as just said, chemical agents may produce one or 
 more of these changes. Thus, for example, in jMunk's case of 
 green urine, when passed the urine was of a dark red color, but 
 on the addition of ammonia it became green. Like everything 
 else when properly understood, these changes have nothing mys- 
 terious about them. The body has not created anything new in 
 making blue or green urine. Indeed, as in disease no new func- 
 tions are ever created, but only a change occurs in the rhythm 
 and force of those already existing, so in disease no new sub- 
 stances are ever created, but only a change tarkcs place in the 
 quantity or in the quality of those normally existing. It is now 
 twelve years since I adopted these views, and the longer and 
 deeper I peer into the wondrous workings of the human frame, 
 the more am I satisfied with them, and the easier do I find the 
 comprehension of disease. Physiology and Pathology are but 
 one study; and although a man may be a Physiologist without 
 being a Physician, no man can be a Physician without being a 
 Physiologist. The same laws that regulate health regulate dis 
 ease. The very effects we are now studying are a striking illus- 
 tration of the justice of these observations. 
 
STUDY OF DIAGNOSIS. 129 
 
 Deposits * — A deposit from the urine is " always a 
 sign of something wrong," but, unfortunately, it does 
 not always determine for us the character of the wrong, 
 or the remedy. To obtain a deposit, the urine is passed 
 in a separate vessel, which being covered, is allowed to 
 
 *A. deposit in the urine is always a sign of something being 
 wrong, and although, as we have seen, it may occur from very 
 trivial causes, whenever it takes place without appreciable cause, 
 in the otherwise apparently healthy, it is a sign not to be disre- 
 garded, as, under such circumstances, it is not unfrequently either 
 the forerunner or associate of gravel or stone. Uric acid in 
 some form or other is the commonest ingredient of all calculi, 
 and there is no period of life exempt from them. 
 
 Urates are a very common deposit in the course of acute dis- 
 ease, and they even seldom fail to recur at some period or other 
 in the course of chronic affections. It is, however, only in dis- 
 eases of an acute febrile or inflammatory type that their sudden 
 appearance can be regarded as indicative of a crisis. Their sud- 
 den appearance is due to an important change having occurred 
 in the condition of the patient, and in general, though not 
 always, it is a change for the better. Such, for example, is ob- 
 served to occur in cases of gout and rheumatism where the climax 
 has been reached. So also in pneumonia and pleurisy when re- 
 solution and absorption commence. 
 
 Should a patient, not laboring under any febrile or inflamma- 
 tory affection, be every now and then troubled with a pink de- 
 posit in the urine without any assignable cause, it will be found, 
 in almost nine cases out of ten, that he is suffering from some 
 chronic affection of the heart, liver, or spleen, with which is asso- 
 ciated a tendency to gravel. In all such cases, therefore, steps 
 should immediately be taken to counteract this disposition by the 
 administration of alkaline tonics. Should there, however, be any 
 counter-indication to the direct alkaline treatment, those acid 
 salts are to be employed which, during their passage through the 
 body, are converted into alkaline carbonates — such, for example, 
 as citrates, tartrates, lactates, and acetates. Every now and then 
 
130 STUDY OF DIAGNOSIS. 
 
 stand from one to twelve hours. It is not well to ex- 
 amine deposits from old urine, urine admixed with 
 faeces, or urine in a chamber utensil that is continuously 
 foul for want of proper washing. Urine undergoes de- 
 composition, and this will give rise to some deposits ; 
 faecal matter will obscure the subject, and a utensil that 
 is allowed to contain decomposing matter will set r.p 
 processes of change in urine recently passed. 
 
 With regard to the value of deposits I can not do 
 better than quote from Golding Bird, as his methods 
 are the clearest I have seen : 
 
 " On the Clinical Examination of the Urine. — 
 The following observations may be of service to the 
 practitioner, as a guide to his proceedings in the super- 
 ficial examination of the urine, the most important part 
 of which can be readily performed in a few moments 
 in the sick room. Premising that the urine presented 
 for inspection is either an average specimen of that 
 passed in the preceding twenty-four hours, or at least 
 that resulting from the first act of emission after a 
 night's rest, unless the urine secreted at other times of 
 the day be specially required. 
 
 " Urine without any visible deposit, or decanted from the 
 sediment. — A piece of litmus paper should be immersed 
 in the urine, which, if acid, will change the blue color 
 of the paper to red. Should no change occur, a piece 
 of reddened litmus paper must be dipped in, and if the 
 secretion be alkaline, its blue color will be restored ; 
 but if its tint remains unaltered, the urine is neutral. 
 
 an exceptional case may arise, where a mineral acid tonic is de- 
 manded; under such circumstances the above rule ma}' be de- 
 parted from, and the case treated according to its special require- 
 ments — Harley. 
 
STUDY OF DIAGNOSIS. 131 
 
 "Some of the urine should then be heated in a pol- 
 ished metallic spoon over a candle, or, what is prefer- 
 able, in a test-tube over a spirit lamp, and if a white 
 deposit occurs, albumen or an excess of the earthy 
 phosphates is present ; the former, if a drop of nitric 
 acid does not redissolve the deposit, the latter, if it 
 does. 
 
 * If the urine be very highly colored, and not ren- 
 dered opaque by boiling, the coloring matters of bile, 
 or purpurine, are present. To determine which, pour 
 a thin layer of urine on the back of a white plate, and 
 allow a few drops of nitric acid to fall in the centre : an 
 immediate and rapidly ending pla} r of colors, from 
 bluish-green to red, will be observed if bile, but no such 
 change will be observed if purpurine alone exists. 
 Should the highly colored urine alter in color or trans- 
 parency by heat, the presence of blood must be sus- 
 pected. 
 
 " If the addition of nitric acid to deep red urine, un- 
 affected by heat, produces a brown deposit, an excess 
 of uric acid exists. If a specimen of urine be pale, 
 immerse the gravimeter, and if the specific gravity be 
 below 1.012, there is considerable excess of water, but 
 if above 1.025, the presence of sugar, or a superabun- 
 dance of urea is indicated. To determine the existence 
 of either of these conditions, place a few drops of the 
 urine in a watch-glass, add an equal quantity of nitric 
 acid, and allow the glass to float on some cold water ; 
 crystals of nitrate of urea will appear in two or three 
 minutes, if the latter exists m excess. Should this 
 change not occur, the urine must be examined specially 
 for sugar, which, it must be remembered, may exist in 
 small quantities, without raising the specific gravity of 
 
132 STUDY OF DIAGNOSIS. 
 
 the fluid. For this purpose boil a small portion witl 
 an equal bulk of liquor potassae in a test-tube, and the 
 development of a brown color will at once afford evi- 
 dence of the almost certain existence of sugar. An 
 excess of coloring matter, rich in carbon, should always 
 be sought after, on account of its pathological import- 
 ance. This is readily done by boiling some urine in a 
 tube, and, whilst hot, adding a few drops of hj'dro- 
 chloric acid. If an average proportion of the pigment 
 exist, a faint red or lilac color will be produced ; but if 
 an excess is present, it will be indicated by the dark 
 red, or even purple tint assumed by the mixture. 
 
 " Should the urine be alkaline, add a drop of nitric 
 acid ; if a white deposit occurs, albumen is present ; if 
 brisk eifervescence follows the addition of the acid, the 
 urea has been converted into carbonate of ammonia. 
 
 " Examination of the Sediment Deposited. — If the de- 
 posit is flocculent, easily diffused on agitation, and 
 scanty, not disappearing on the addition of nitric acid, 
 it is chiefly made up of healthy mucus, epithelial de- 
 bris, or occasionally, in women, of secretions from the 
 vagina, leucorrhoeal discharge, etc. 
 
 " If the deposit is ropj^ and apparently viscid, add a 
 drop of nitric acid ; if it wholly or partly dissolves, it 
 is composed of phosphates, if but slightly affected, of 
 mucus. If the deposit falls like a creamy layer to the 
 bottom of the vessel, the supernatant urine being co- 
 agulable by heat, it consists of pus. 
 
 " Urine sometimes appears opaque, from the presence 
 of a light flocculent matter diffused through it, neither 
 presenting the tenacity of mucus, nor the dense opacity 
 of pus. Although scarcely sufficient in quantity to in- 
 terfere with the perfect fluidity of the urine, if a little 
 
STUDY OF DIAGNOSIS. 133 
 
 be placed in a test-tube and agitated with an equal bulk 
 of liquor potassae, the mixture will often become a stiff, 
 transparent jelly. This peculiar appearance is demon- 
 strative of the presence of the exudation, or large or- 
 ganic globules formed under the influence of irritation, 
 providing the urine does not coagulate by heat, for 
 should it do so, the existence of minute quantities of 
 pus maybe suspected. 
 
 "If the deposit is white, it may consist of urate of 
 ammonia, phosphates, or cystine ; tbe first disappears on 
 heating the urine, the second on the addition of a drop 
 of diluted nitric acid, whilst the third dissolves in am- 
 monia, and the urine generally evolves an aromatic 
 odor like the sweetbrier, less frequently being fetid. 
 
 " If the deposit be colored, it may consist of red par- 
 ticles of blood, uric acid, or urate of ammonia, stained 
 with purpurine. If the first, the urine becomes opaque 
 by heat; if the second, the deposit is in visible crystals ; 
 if the third, the deposit is amorphous, and dissolves on 
 heating the fluid. 
 
 " Oxalate, and more rarely oxalurate (?) of lime are 
 often present diffused through urine, without forming a 
 visible deposit : if this be suspected, u drop of the urine 
 examined microscopically will detect the characteristic 
 crystals. 
 
 " If the urine be opaque like milk, allowing by re- 
 pose a cream-like layer to form on the surface, an emul- 
 sion of fat with albumen is probably present. Agitate 
 some of the urine with half its bulk of ether in a test- 
 tube, and after resting a few minutes, a yellow ethereal 
 solution of fat will float on the surface of the urine — a 
 tremulous coagulum of albumen generally forming be- 
 neath it. 
 
134 STUDY OF DIAGNOSIS. 
 
 " Much of the little time required for the investiga- 
 tion thus sketched out, may be saved by remembering 
 the following facts : 
 
 ** If the deposit be white, and the urine acid, it in the 
 great majority of cases consists of urate of ammonia ; 
 but should it not disappear by heat, it is phosphatic. 
 
 " If a deposit be of any color inclining to yellow, 
 drab, pink, or red, it is almost sure to be urate of am- 
 monia, unless visibly crystalline, in which case it con- 
 sists of uric acid. 
 
 " The following tables briefly point out the readiest 
 mode for the examination of crystalline deposits, both 
 by chemical tests and by microscopic examination. 
 The latter mode is of course preferable to all others, 
 both for the accuracy and extent of the information it 
 affords, as well as for economy of time : 
 
 TABLE FOE DISCOVERING THE NATURE OF URINARY DEPOSITS BY CHEMICAL RE- 
 AGENTS. 
 
 , f Deposit white, 2 
 
 '\ •' colored, 5 
 
 „ / M dissolves by heat, Urate of ammonia. 
 
 '\ " insoluble by heat, 3 
 
 o J w soluble in liquor ammonise,... Cystine. 
 
 ( " insoluble in, " ... 4 
 
 a f " soluble in acetic acid, Earthy phosphates. 
 
 '\ 4< insoluble in " Oxalate and oxalurate of lime. 
 
 B f ** visibly crystalline, Uric acid. 
 
 ' \ " amorphous, 6 
 
 pale, readily soluble by heat, Urates. 
 deeply colored, slowly soluble 
 
 oy heat Urates, stained by purpurine. 
 
 ••{ 
 
 TABLE FOR THE MICROSCOPIC EXAMINATION OF URINARY DEPOSITS. 
 
 , (Deposit amorphous, 2 
 
 * ( * 4 visibly crystalline, 3 
 
 f " vanishes on the addition of 
 
 2. ■< liquor potasses Urate of ammonia. 
 
 (^ •* permanent after the addition 
 
 of liquor potassse. Phosphate of lime. 
 
 o Crystals in well denned octahedra, Oxalate of lime. 
 
 44 not octahedral, 4 
 
STUDY OF DIAGNOSIS. 135 
 
 f Crystals in six-sided tables, soluble in 
 
 i. < ammonia, Cystine. 
 
 (^ " not tabular, nor soluble in 
 
 ammonia, 5 
 
 - ( *' soluble in acetic acid, 6 
 
 * \ " insoluble in acetic acid, 8 
 
 « f " in prisms or simple pennse,... Neutral triple phosphate. 
 °* ( M radiated or foliaceous « 7 
 
 soluble in acetic acid with ef- 
 fervescence, Carbonate of lime. 
 
 soluble in acetic acid without 
 
 effervescence Bibasic-triple phosphate. 
 
 in dumb-bells or radiated, Oxalurate (?) of lime. 
 
 spherical or colored, 
 
 in lozenges or compound 
 
 crystals, Uric acid. 
 
 in spherical crystals Urate of soda or ammonia. 
 
 
 EXAMINATION OF THE F.ECES. 
 
 The Bowels. — Excretion by the bowels does not 
 hold that importance now that it did in olden times. 
 We learn by experiment that of the four to six ounces 
 of fseces, giving one to one and a half ounces of solid 
 residue, but about 100 grains are of excrementitious 
 matter* 
 
 The liver, which was formerly thought to play so im- 
 portant a part in removing waste of tissue, and excre- 
 mentitious matter, yields but a few grains of this (four 
 to eleven grains). It has also been conclusively deter- 
 mined that there are no agents that act upon the liver, 
 increasing its secretion {cholagogues) ; that mercury in 
 any of its forms does not influence it in the least, ex- 
 cept when it produces its constitutional effect, and when 
 given to catharsis, it lessens the secretion. All cathar- 
 tics in cathartic doses diminish the secretion. Even 
 our Podophyllin, which has been regarded as a Samson 
 
 *See Principles of Medicine, p. 126. 
 
136 STUDY OF DIAGNOSIS. 
 
 in its influence upon the liver, diminishes the secretion 
 in cathartic doses, and in minute doses lessens the bile 
 solids while it slightly increases the quantity excreted. 
 
 If we can learn that the liver performs an important 
 function in digestion and in blood-making, furnishing 
 its secretion for these purposes, and that it is admirably 
 adapted to these purposes, and rarely the subject of 
 disease, and that we have no medicines that influence 
 it directly, to increase secretion, we will have made an 
 important advance in pathology, and will have much 
 improved our therapeutics. We may classify it with 
 the pancreas, and may expect to influence it only by 
 those remedies that control the circulation, act through 
 the sympathetic nervous system, and influence the pro- 
 cesses of blood-making. 
 
 Our inquiry in regard to the faeces will have refer- 
 ence, lirst, to the increase or diminution of the secre- 
 tion ; second, to the condition of the intestinal canal, 
 as an apparatus for digestion ; and third, to any abnor- 
 mal constituent, or marked change in the character of 
 the excretion. 
 
 Increase of the feces, in proportion to its extent and 
 duration, causes debility; for histogenetic material, 
 either as food or tissue, is proportionably removed. 
 
 Fluid faeces, whilst very frequently in excess as above, 
 deserve attention more particularly as evidencing such 
 lesion of the intestinal canal, as interferes with diges- 
 tion and blood-making ; and also with that due degree 
 of distension of the blood vessels, which is necessary 
 to proper circulation. 
 
 Deficiency of faeces may depend upon the quality of 
 the food, or upon its quantity ; the largest proportion 
 of faecal material being furnished by the debris of 
 
STUDY OF DIAGNOSIS. 137 
 
 food; or it may depend upon an arrest of secretion, in 
 which case we will have the same constitutional evi- 
 dence that we would have in similar arrest from the 
 skin and kidneys ; or it may be dependent upon atony 
 of the intestinal canal, which allows the material to ac- 
 cumulate, without the natural effort at removal. 
 
 Simple constipation gives rise to derangements of 
 digestion, and the retention of effete material in the 
 bowels occasions a feeling of malaise and dullness, with 
 headache and fever, in so far as they are retained in 
 the blood, or re- absorbed. 
 
 The color of the discharges is sometimes of import- 
 ance in determining the character of disease. The 
 natural color, like the natural fetor, evidencing a con- 
 dition of the intestinal canal in which its functions may 
 be properly performed. 
 
 The dark-brown or almost black color of the faeces, 
 observed in typhoid disease, arises from the excretion 
 of the coloring material of the blood ; the red globules 
 being broken down rapidly. 
 
 The use of iron in any of its forms, and occasionally 
 of sulphur or its salts, will darken the color of the faeces. 
 The dark-green color of the faeces that followed the ad- 
 ministration of mercury, and was thought to be bile, 
 was due to the formation of sulphuret of mercury. 
 
 Greenish discharges are generally dependent upon an 
 increase of acid in the intestinal canal, with irritation 
 and consequent indigestion. It may, in part, be de- 
 pendent upon the coloring matter of bile, which is 
 thrown off by the faeces, in consequence of such irrita- 
 tion. 
 
 Clay-colored discharges refer to a general want of 
 secretion ; not only of the solitary glands of the intes- 
 12 
 
138 STUDY OF DIAGNOSIS. 
 
 tine, but of the associate viscera. It is an atonic con- 
 dition, with impaired innervation and circulation. 
 
 The natural odor of faeces seems to be dependent upon 
 a special secretion in the neighborhood of the caecum. 
 It may be regarded as an evidence of normal activity 
 throughout the entire intestinal track. 
 
 Diminution of the odor is an indication of want of 
 functional activity, as an increase will indicate in- 
 creased activity. 
 
 Fetor refers to decomposition of the intestinal secre- 
 tions. It varies greatly from local causes, and can not 
 be relied upon as indicating any special condition of 
 the general system. 
 
 The cadaverous fetor may, however, be taken as evi- 
 dencing a septic condition, not only of the intestinal 
 secretions, but also of the fluids and solids. 
 
 It is difficult to determine change in the elements of 
 faeces, and it will hardly form a part of ordinary ex- 
 aminations. The principal of these I append, Lehman's 
 Chemical Physiology being the authority. 
 
 u The excrements in consumption are sometimes 
 found to contain more fat than usual. Sugar is occa- 
 sionally found in the faeces of diabetic patients. The 
 stools are found to be black, chocolate-colored, or tar- 
 like, when blood is contained in them, and this arises 
 from the upper intestinal canal ; so also the semi-liquid, 
 green excrements which are observed occasionally in 
 typhus and other diseases, depend upon blood, which is 
 easily recognized by the microscope. Soluble albumen 
 is found in the stools in dysentery, typhus, and occa- 
 sionally in Bright's disease, and in cholera. The great- 
 est quantity of epithelial cells are found in the dejec- 
 tions of cholera. Cytoid corpuscles are very numerous 
 
STUDY OF DIAGNOSIS. 139 
 
 in the excrements in catarrhal diarrhoeas, in dysentery, 
 and occasionally in typhus and cholera. Hyaline mucus 
 is observed in the excrements in catarrh of the large 
 intestine; it arises from the follicles of the colon, and 
 contains round or oval, pale or granular cells and cell 
 nuclei. Fibrinous exudations occur in the faeces in folli- 
 cular ulceration and in dysentery." 
 
 DIAGNOSIS BY THE TOUCH. 
 
 In our study of the senses, we found that the tactile 
 sense could be wonderfully developed. Marked exam- 
 ples of this may be found in the mechanic arts, not 
 only of extreme delicacy, but of complex and difficult 
 work accomplished through this sense alone. The 
 education of this sense in the blind is another marked 
 example, and it is well that a phj-sician should make 
 himself acquainted with the education of the blind, to 
 see the range of this sense which in the majority has 
 such imperfect development. 
 
 What information can we gain by the sense of touch ? 
 Not much, one would say at first thought; yet we find 
 it an important means of diagnosis if we study it care- 
 fully, and train the sense of touch. The obstetrician 
 relies wholly upon it, not only determining the presen- 
 tation and position of the child, but the condition of 
 every part engaged in the process. His touch tells him 
 the condition of the depending portion of the uterus as 
 an outlet,. and also the condition of the organ as re- 
 gards the power of expulsion. It determines the con- 
 dition of the vagina as a parturient canal, and becomes 
 so sensitive that it recognizes intuitively changes of 
 
140 STUDY OF DIAGNOSIS. 
 
 condition that will render the labor painful, protracted, 
 or difficult. In diseases of women, many physicians 
 rely upon the sense of touch far more than sight, and 
 very rarely use the speculum. The finger tells the 
 condition of the uterus, not only as regards position, 
 but pathological changes as well. It determines dis- 
 eases of vagina, bladder, rectum, indeed of all these 
 parts, and does it so well that it becomes our most re- 
 liable guide to treatment. 
 
 I will guarantee that there is not one medical reader 
 but what could to-day, blindfolded, determine better 
 by simply placing his hand on the patient what kind 
 of a bath should be employed, or whether any at all, 
 than he can with his eyes open and without the touch. 
 Try the touch in cases of intestinal disease, shutting 
 your eyes to shut out ordinary impressions, and 3^011 
 will be astonished at the result. Pass the hand over 
 the abdomen and at once you know whether a diarrhoea 
 is irritative or atonic, and a correct treatment is sug- 
 gested. You may determine the character of a dys- 
 pepsia in the same way, and the general outline of 
 treatment. You can locate the disease and determine 
 its kind. Even in uterine disease the abdominal touch 
 becomes important. Try a case of pneumonia — let the 
 hand rest on the chest, slowly passing it over, and 3^011 
 will be surprised to know how much may be learned — 
 a Winter's practice, and it becomes a means of physical 
 diagnosis. 
 
 A most excellent way of making this study is to take 
 a note-book and enter every question that may suggest 
 itself with reference to the various sensations given to 
 touch. Then question our experience — when and where 
 have I met each of these ? what has been the nature, 
 
STUDY OF DIAGNOSIS. 141 
 
 progress, duration, and termination of the disease. 
 Now with what we know we will carry on a series of 
 experiments in every case of disease, making use of 
 what we have for the benefit of the patient, and learn- 
 ing what we can for the advantage of others in the 
 future. 
 
 Let mc put a few questions which will serve as an 
 example. If I put my finger on the tongue, and find 
 it dry, contracted, or rough, would you give Podo- 
 phyllin ? an emetic? Quinia? Opium ? or a stimulant? 
 If I put my hand on the abdomen and find the walls 
 tense and contracted, the patient having diarrhoea, 
 what will be the remedy ? If relaxed and tumid what ? 
 If in uterine disease the abdominal wall is tense and 
 contracted, what is the nature of the disease ? If all 
 the tissues are soft, full, doughy, what ? If the hand 
 placed upon the forehead gets the sense of relaxation 
 and moisture, what would be the character of a head- 
 ache ? If the forehead was tense and dry, what ? I 
 offer these as examples of questions that one may ask 
 himself, and as the reader will see they can be greatly 
 varied, and asked of every part of the body, as well as 
 of the body as a whole. Ask then with reference to the 
 conditions of disease, but especially with reference to 
 remedies, as the diagnosis that suggests treatment is 
 that which we want especially. 
 
 In a case of labor, if the examination shows constric- 
 tion with want of secretion — pinched expresses the con- 
 dition of the parts, both of the lower segment of the 
 uterus, vagina, and perineal tissues — we know we will 
 have a protracted and difficult labor. If the hand is 
 placed upon the abdomen over the uterine globe and 
 we get the same sensation of unnatural contraction — 
 
142 STUDY OF DIAGNOSIS. 
 
 pinched — there is possibly rigidity of os, or perineum ; 
 what is the remedy ? You answer Lobelia, because it is 
 the common remedy for rigid os and perineum. But you 
 give it without any advantage, and it sometimes causes 
 a very unpleasant irritation of the stomach and nervous 
 system, and makes things worse rather than better. 
 Let us ask your hand in place of your head. If this 
 was a headache, and you had a similar sensation when 
 your hand was placed on the patient's forehead, what 
 would you give ? You answer promptly, Gelseminum ; 
 good, then give Gelseminum and not Lobelia. If upon 
 examining muscular tissues you had the same unplea- 
 sant sensation of contraction and irritability with pains 
 what would you give ? Aconite or Veratrum with 
 Macrotys — good, give Aconite and Macrotys in this 
 case. If in chronic disease of the pelvic viscera we ob- 
 tained the same sensation as the hand rested upon the 
 lower abdomen, what would we give ? Gelseminum, 
 Aconite, Macrotys. 
 
 If in this examination during tedious labor, we found 
 the tissues thick and doughy, with rigid os and rigid 
 everything else, what would we give? With this con- 
 dition shown by an internal examination, the hand 
 placed upon the abdomen would receive the same sensa- 
 tion of unnatural fullness and want of action. Here 
 we would give Lobelia. The touch tells the story 
 clearly and explicitly, and names the remedy, which we 
 find upon trial acts " specifically." Supposing now it 
 should be pneumonia or bronchitis, and the hand placed 
 upon the chest gets the same sensation of unnatural 
 fullness, would the remedy be Lobelia? Or if the 
 finger placed upon the tongue obtains the sensation of 
 doughy fullness, or the eye obtains it, would the remedy 
 
STUDY OF DIAGNOSIS. 143 
 
 be Lobelia? Most assuredly, unless something else 
 acting in the same way is more prominently indicated 
 by other symptoms. 
 
 In speaking of the touch as a means of diagnosis, 
 we must not omit to notice the lesions of nutrition and 
 excretion — supply and waste. How do you determine 
 impaired nutrition ? Surely not by the fullness or lean- 
 ness of the face ? if you do you are frequently mistaken. 
 You want to know if the loss of size and weight is 
 from want of fat or muscle, and your hand at once 
 seeks the covering of the false ribs for the one, and 
 grasps a group of muscles — say of the arm, for the 
 other. It would be absurd to feed a patient with beef 
 tea or other histogenetic material if we wanted fat, 
 though we might give calorifacient food to save 
 tissue. 
 
 We not only get the evidence of impaired nutrition 
 by the touch, and the food designated, but it tells us of 
 medicines that will prove curative. If the sensation is 
 of want of tone — tissues loose and flaccid — we think of 
 Bitter Tonics, Quinine, the Hypophosphites, and Iron. 
 If the sensation is of structures pinched and stringy, 
 we look fbr lesions of the nerve centres, and think of 
 Macrotys, Muriatic and Lactic Acids, Phosphoric Acid, 
 fatty inunction, etc. 
 
 The sensation of fullness without elasticity, would 
 suggest old tissues, and the necessity of active waste, 
 and would suggest Acetate of Potash, Iodide of Potas- 
 sium, and stimulant cathartics and diaphoretics. If 
 digestion remained good, these might be sufficient, for 
 the tissues would be renewed as fast as broken down. 
 But if their use gave soft and flaccid tissue, we should 
 supplement them by such a restorative as the triple 
 
144 STUDY OF DIAGNOSIS. 
 
 phosphate of Quinia, Strychnine and Iron — "Com- 
 pound Tonic Mixture. " 
 
 We would never give Iodide of Potassium in second- 
 ary syphilis, where the tissues give the pinched and 
 stringy sensation to the touch. Such a case would ask 
 for Veratrum, Cod Oil, Iodide of Ammonium, and some 
 would say Arsenic. Let one of those cases of secondary 
 syphilis, characterized by full, inelastic, lifeless tissues 
 fall into the hands of the routinist who prescribes Pro- 
 toiodide of Mercury in all cases, and he loses appetite, 
 digestion and blood-making, and grows worse rapidly. 
 
 This is but an imperfect and partial sketch of one of 
 our means of diagnosis, and one that has been regarded 
 as least useful. Yet it points out the method of rational 
 diagnosis, and the one we purpose studying in consid- 
 erable detail. As the reader thinks of the subject, and 
 recalls and arranges his experience, he will be surprised 
 how much he knows practically, and still more sur- 
 prised as he puts it in practice intelligently, how it aids 
 him in the selection of remedies. 
 
 THE PULSE. 
 
 Among the most important of the functions of life is 
 a normal circulation of blood, indeed it seems to serve 
 as a basis for the performance of ail other functions. 
 Healthy life is dependent upon a regular and uniform 
 circulation of blood, and disease must follow any con- 
 siderable or continued variation in this function.* 
 
 *If the finger be placed upon an artery, such as that at the 
 wrist, what is termed the pulse will be felt ; that is to say, the 
 clastic artery dilates somewhat, at regular intervals, which an- 
 
STUDY OF DIAGNOSIS. 145 
 
 Whilst the heart is the centre and principal source 
 of power of the circulation, every vessel does its part 
 in aid of the movement of the blood. We have, there- 
 fore, to determine by the pulse the condition of the 
 heart, the condition of the arteries, the condition of 
 the capillaries, and to some extent the condition of the 
 veins. As these movements are stimulated and co-or- 
 dinated by the sympathetic nervous system, it should 
 also tell us of wrongs of innervation. As the move- 
 ment of the blood depends, to a certain extent, upon its 
 organization and condition, it may also determine for 
 us something of the wrongs of this fluid. 
 
 We will probably study the pulse to better advantage 
 if we analyze it, and think of its elements separately. 
 Put your finger on the radial artery and carefully ob- 
 serve the movement. It first divides itself into : (a) a 
 
 swer to the beatings of the heart. The pulse which is felt by the 
 finger, however, does not correspond precisely with the beat of 
 the heart, but takes place a little after it, and the interval is 
 longer the greater the distance of the artery from the heart. 
 The beat of the artery on the inner side of the ankle, for exam- 
 ple, is a little later than the beat of the artery in the temple. 
 
 The reason of this is that the sense of touch by finger is only 
 delicate enough to distinguish the dilatation of the artery by the 
 wave of blood, which is driven along it by the elastic reaction 
 of the aorta, and is not competent to perceive the first shock 
 caused by the systole. But, if, instead of the fingers, sufficiently 
 delicate levers were made to rest upon any two arteries, it would 
 be found that the pulse really begins at the same time in both, 
 the shock of the systole making itself felt all over the vascular 
 system at once; and that it is only the actual dilatation of the 
 arterial walls, which, traveling in the form of ,a wave from the 
 larger to the smaller arteries, takes longer to reach and distend 
 the more distant branch. — Huxley. 
 13 
 
146 STUDY OF DIAGNOSIS. 
 
 dilatation of the artery, and (6) a succeeding contrac- 
 tion. The wave of blood forced forward by contraction 
 of the ventricles, gives us the arterial dilatation, whilst 
 the contraction of the artery may represent the subse- 
 quent filling of the ventricles from the auricles. 
 
 To this extent the pulse evidences the time of con- 
 traction, or the rapidity of heart-beat. Even to this 
 extent the information is important, for a healthy life 
 can only be maintained when the movement of the 
 blood is well timed. If the heart beats too rapidly, we 
 must have a wrong in the life, as if it beats too slowly 
 we will have a wrong in the life. 
 
 With regard to frequency of pulse we are in the habit 
 of saying — as is the frequency so is the impairment of 
 all the vegetative functions — of the appetite, digestion, 
 blood-making, nutrition, excretion from skin, kidneys 
 and bowels — wrongs of the blood, the activity of zymotic 
 poisons, etc. There may be exceptions to this general 
 rule, but it is so constant that we find it important to 
 act upon it in every case of disease. Given, frequency 
 of pulse, the questions at once suggested are — what is 
 its cause ? what is the remedy ? 
 
 Whilst frequency of pulse suggests to us the use of 
 that class of remedies called sedative (special or arte- 
 rial sedatives), they will not always answer our pur- 
 pose. If the wrong is purely one of the circulatory 
 apparatus, functional in its character, and depending 
 upon a wrong of sympathetic innervation, these reme- 
 dies will probably be sufficient. But if the frequency 
 of pulse represents and is dependent upon some other 
 lesion, as of the blood, or local disease, then other and 
 different remedies may prove the sedatives. 
 
 Frequency of pulse is associated with frequent rcspi- 
 
STUDY OF DIAGNOSIS. 147 
 
 ration. The proportion is usually five beats of the 
 pulse to one respiration. Thus an adult man in the 
 sitting position will make thirteen to fifteen respirations 
 each minute, and the proportionate pulse will be sixty- 
 five to seventy-five beats per minute. With a pulse of 
 one hundred and ten beats per minute, we will have 
 twenty-two respirations per minute. The relation of 
 frequent respiration to various wrongs of function will 
 be known to the reader, and evidently a slower respi- 
 ration is something to be desired in all cases of disease, 
 and something that must be obtained in some cases if 
 the patient recovers health. 
 
 Without reference to the undue general excitation 
 that comes from frequent respiration, and the exhaus- 
 tion that must follow this severe muscular work, I 
 would call attention to the marked wrong it must work 
 in diseases of the respiratory apparatus. Rest is an 
 essential to recovery in all diseases of excitation, and 
 in most diseases of structure. With a rapid pulse, we 
 can not have rest of the respiratory apparatus, for the 
 movement of the chest is related to the movement of 
 the blood. Make the pulse go slow, and the movement 
 of the chest is likely to be slow in proportion. 
 
 The relation between the frequency of pulse and the 
 temperature will be borne in mind. For each increase 
 of ten beats per minute of pulse, there is an increase 
 of one degree in the temperature. Thus with a normal 
 circulation of seventy beats per minute, and a normal 
 temperature of 98°, we will find an increase of pulse to 
 ninety will give a temperature of 100° ; with an in- 
 crease of pulse to one hundred and twenty we wil.l have 
 a temperature of 103°, and so on. This rule does not 
 hold good in all cases, possibly not in the majority, for 
 
148 STUDY OF DIAGNOSIS. 
 
 the high range of temperature, from 103° to 108°, does 
 not carry the pulse up proportionately. 
 
 When we come to consider the influence of changes 
 of temperature we find them similar to those that 
 follow change in the time of pulsation. In the ratio 
 of increased temperature we find arrest of excretion, of 
 nutrition, of digestion, of blood-piaking, and of inner- 
 vation, and that zymotic poisons propagate themselves 
 more rapidly. With the temperature maintained above 
 103°, death is a matter of time, indeed molecular death 
 is going on from the time the temperature strikes this 
 point. 
 
 It was mentioned that local processes of disease are 
 severe in proportion to the frequency of the pulse. 
 This will be noticed especially in inflammation — as is 
 the frequency of the pulse so is the intensity of the in- 
 flammation, the impairment of the life of the part, and 
 the danger of a termination in death. The local hyper- 
 emia is increased by the rapid pulse, and the final 
 arrest of circulation is also promoted by it. If, there- 
 fore, we wish to stop the process of inflammation, we 
 select those remedies which will lessen the frequency 
 of the pulse. 
 
 If in any case we have a structural lesion, whatever 
 may be its nature — either an impairment of nutrition, 
 or from deposit — we will find, frequently, that its pro- 
 gress will be in proportion to the rapidity of the pulse. 
 In these cases remedies that influence the circulation, 
 giving it normal frequency and freedom, will be very 
 important. 
 
 It was also named that zymosis or sepsis was rapid 
 in proportion to the frequency of the pulse. This may 
 be noticed in those diseases known as typhoid, in ery- 
 
STUDY OF DIAGNOSIS. 149 
 
 Bipelas, the eruptive fevers, diphtheria, as well as in 
 typhoid and typhus fever. As is the frequency of the 
 pulse, so is the evidence of sepsis, as marked by dirty, 
 brown, or black coatings on the tongue, sordes on the 
 teeth, pungent heat, offensive discharges, etc. The 
 danger to life is frequently in proportion to the fre- 
 quency of the pulse, and means that will give a better 
 circulation as regards time, freedom, and uniformity 
 in all parts of the body, lessen those unpleasant- 
 symptoms. 
 
 . But frequency is only one of the wrongs of the cir- 
 culation, and but a part of the information we should 
 obtain from the pulse, Frequency has reference to the 
 rapidity of the blood-waves — the number that passes 
 under our finger in one minute. In addition to this wo 
 have to notice that there are peculiarities in the blood- 
 wave, and in the current after this wave has passed. 
 The pulse has volume — referring to the size of the 
 artery. It has varying impulses in the wave of the 
 blood, and also in the interval between the waves. 
 
 Volume, or increased size of the artery may have 
 reference to the amount of blood, to its increased circu- 
 lation, or to some obstruction to its free movement. 
 We will have a large pulse in the plethoric, we may ex- 
 pect a small one in the anaemic, and these conditions 
 will be determined by other evidences. If the artery 
 is large> and the person is not plethoric, we ask the 
 question — is it dependent upon a more rapid movement 
 of the mass of the blood, especially to the surface, or is 
 it dependent upon an obstruction to its movement 
 through the capillaries ? Freedom in the pulse-wave in- 
 dicates the one, and a want of freedom — oppression — 
 indicates the other condition. 
 
150 STUDY OF DIAGNOSIS. 
 
 The sharp impulse of the wave of blood, as it strikes 
 the finger, may be referred to lesions of the nerve cen- 
 tres, especially of the sympathetic. The wrong is of 
 irritation, and calls for remedies that relieve it. If 
 the impulse is sharp, the wave short, and the inter-cur- 
 rent vibratile, the irritation is extreme. 
 
 The dull, elastic stroke of the wave refers us to an 
 impairment of innervation from the sympathetic and 
 spinal cord. The more marked this is, the greater the 
 necessity for those remedies which stimulate and give 
 strength to these nerve centres. 
 
 The length of blood-wave has reference to that con- 
 dition known as " sthenia," an excitation founded on 
 strong life. This is especially the case where the wave 
 is large in volume, and well supported by the column 
 of blood behind. 
 
 The oppressed pulse is marked by a want of power in 
 the stroke, and more especially by a feeling as if the 
 current in advance of the wave broke its force. Evi- 
 dently the blood-wave does not measure the amount of 
 blood passing through the artery. It refers us to ob- 
 struction in the capillary vessels, or possibly an impair- 
 ment of the large vessels as well, or a wrong in the 
 blood unfitting it for circulation. 
 
 If the finger is carefully trained it will notice a vari- 
 ation in the surface of the wave, as well as in its length. 
 Many times it is distinctly felt as two waves — a first 
 sudden and short, and a second full, even and prolonged 
 The first may be called the shock-wave, and the second 
 the sj^stolic-wave which represents the movement ol 
 blood from the heart. 
 
 The shock-wave sharp and pronounced may always be 
 referred to undue excitation of the nerves distributed 
 
STUDY OF DIAGNOSIS. 151 
 
 upon the vessels, and an undue contraction or tension 
 of their walls. 
 
 The full, strong, systolic-wave may be referred to ex- 
 citation of the heart and strength in its movement. 
 
 The short, systolic-wave evidences a want of cardiac 
 power, and especially of impaired innervation from the 
 spinal cord and sympathetic. 
 
 The inter-wave current sometimes gives valuable in- 
 formation, and it is well for the reader to observe it 
 carefully in health and learn its normal condition. 
 We find in disease that it has more or less volume, has 
 more or less strength, and has more or less of the vibra- 
 tile quality. 
 
 When we speak of a full pulse 3 we have reference to 
 the inter-wave current as well as to the wave, and the 
 condition of sthenia will be determined by this. It is 
 strong life in a state of excitation. 
 
 If now we add hardness, we have added an especial 
 lesion of innervation, of excitation steadily maintained. 
 
 If we speak of a small pulse hard, we refer it to im- 
 pairment of life from activity, still maintained. 
 
 If we have a small pulse soft and easily compressed, 
 we refer it to deficient innervation. 
 
 If we have a small pulse vibratile, we say it is the ex- 
 pression of impaired life, with great excitation of the 
 nerve centres. 
 
 If we have an empty pulse, the inter-wave current 
 hardly perceptible, it is the evidence of impaired life, 
 with enfeebled innervation from the sympathetic. 
 
 There are other changes of the pulse which might be 
 noticed, bat they are difficult to describe and learn. I 
 do not think that we can tell every lesion by it, as 
 Chinese doctors believe, but to the educated touch it 
 
152 STUDY OF DIAGNOSIS. 
 
 gives most valuable information with regard to the most 
 important functions of life. I doubt not many physi- 
 cians can locate lesions with very great certainty from 
 it alone ; that they can distinguish lesions of the brain, 
 lungs, digestive apparatus, urinary apparatus, etc., and 
 determine, to some extent, their character. 
 
 But in the practice of medicine, there is something 
 of more importance than locating a disease, or even de- 
 termining the character of the lesion. The important 
 object is to associate the evidences of disease with reme- 
 dies for their cure, and to make the expressions of dis- 
 ease point to the medicine. 
 
 Feeling the pulse gives us a knowledge of the lesions 
 of the circulation — most important information in the 
 majority of diseases. Every lesion of the circulation 
 is distinctly announced to the cultivated touch, as is 
 some lesions of the blood and of the nervous system. 
 In so far as we study the pulse, I desire that it shall 
 mean special remedies — not names of disease. 
 
 Frequency calls attention to a wrong of the circulation 
 and prompts the asking of ther question — why? It 
 does not necessarily mean Veratrum, Aconite, Gelsemi- 
 num, etc., though it is suggestive of them. Why ? Is the 
 wrong in the vessels an obstruction to the free circula- 
 tion of blood, requiring an increased movement of the 
 heart to compensate it ? Is the wrong an enfeeblement 
 of the heart, requiring increased frequency of impulse 
 to compensate for want of power? Is the increased 
 frequency dependent upon irritation of the cardiac 
 plexus ? Is the frequency dependent upon a wrong of 
 the blood? Upon a cerebro-spinal wrong? 
 
 The full pulse with strength means medicine — Vera- 
 trum. Whether full and hard, full and bounding, the 
 
STUDY OF DIAGNOSIS. 153 
 
 special sedative named is at once suggested. It may 
 not be all that the patient wants, but it is one, and in 
 many cases will stand first. 
 
 The full pulse doughy (lacks the marked vibration) 
 means Lobelia ; or if marked and associated with full- 
 ness of mucous membranes and purplish discoloration, 
 Baptisia; or if accompanied with muscular pain, Apo- 
 cynum. 
 
 The full pulse open, is kindly influenced by Podophyl- 
 lin, and especially by Quinine in full doses. 
 
 The large pulse empty calls for the alkaline sulphites, 
 Sulphurous Acid, stimulant baths or fatty inunction, 
 Quinine, and histogenetic food. The sensation we get 
 in this case is of an artery of large calibre, but with too 
 little volume of blood — the sensation after the impulse 
 being of emptiness. 
 
 The full pulse vibratile calls for Gelseminum, usually 
 associated with Yeratrum. 
 
 The full pulse oppressed, calls for Belladonna, alter- 
 nated with Yeratrum ; if sepsis, Baptisia. 
 * The small pulse usually means Aconite. 
 
 The small pulse vlbratile Aconite and Gelseminum. 
 
 The small pulse oppressed Belladonna and Aconite. 
 
 The small, soft, easily compressed pulse, Aconite, 
 stimulants. Small doses of Quinine with Opium and 
 food. 
 
 The small pulse, frequent, easity compressed, the wave 
 of blood giving a sense of squareness as it passes under 
 the finger, Opium. 
 
 Want of power in the impulse suggests Digitalis, 
 Capsicum. 
 
 The sharp stroke of the pulse with tremulous wave be- 
 tween strokes, means Rhus. 
 
154 STUDY OF DIAGNOSIS 
 
 The sharp stroke of pulse, with even, small, vibratilo 
 current between strokes — Bryonia. 
 
 The dull stroke with tremulous or vibralile wave — 
 Phytolacca. 
 
 The open, tremulous pulse — Arsenicum. 
 
 The small or open pulse in which the wave of blood 
 drops suddenly as it passes the finger — Pulsatilla or 
 Cactus. 
 
 Irregularity of pulse, soft or open, with a distinct 
 wrong in the stroke — Cactus. 
 
 The steady, vibratile pulse, without marked wave — 
 Macrotys. 
 
 We have often reason to believe that Quinine is indi- 
 cated bj^ the periodicity of the disease, and yet our ex- 
 perience with the remedy raises doubts of whether it 
 will be well received and exert a kindly and curative 
 action. If the pulse is hard and vibratile, wiry, we will 
 not give it; if it is soft and open we may expect its 
 kindly action. The physician who would administer 
 Opium or its salts with a hard, wiry pulse, would be 
 doing his patient a great wrong. Here, also, we want 
 a soft, open pulse for the kindly action of the medicine. 
 No one in his senses would give Podophyllin when 
 there was a small, wiry pulse, or when it had a sharp 
 stroke — the patient might get through safely, and it 
 might kill him. 
 
 This is only a partial consideration of the subject, 
 and the results of my own experience. It should agree 
 with what others know of the pulse as a means of 
 diagnosis, and 1 hope will be thoroughly proven. 
 Even if proven to be without foundation in fact, the 
 investigation will give practical knowledge, and will 
 increase our knowledge of the relationship between 
 the evidences of disease and remedies. 
 
STUDY OF DIAGNOSIS. 155 
 
 If the reader will notice carefully, he will see a 
 marked resemblance between the touch of the pulse, 
 and the general sense of touch when the hand is applied 
 to the skin. The sensation from the slight oedema of 
 cellular tissue, that indicates Apocynum, and the pulse 
 that says Apocynum is wonderfully similar. The sen- 
 sation from the skin that says Lobelia and the pulse 
 that says Lobelia is the same. The pulse of Veratrum 
 is associated with the skin of Veratrum. And so we 
 will find it all the way through, if we see the indica- 
 tions for remedies rightly they never conflict. 
 
 THE TEMPEBATUKE. 
 
 Among the evidences of disease, none are more defi- 
 nite and important than changes in the temperature. 
 Heat is not only force in the animal bod}^, but it is also 
 a condition of life ; a man has activity through it, and 
 he has life by it. The theory of Samuel Thomson — 
 " Heat is life, cold is death," was very simple, and had 
 much of truth in it — it was just one-third of the truth. 
 Cold is death, but so is too high a temperature, and an 
 unequal distribution of heat. 
 
 The human body maintains its healthy functions at a 
 temperature varying from 98° to 98.5°. This is a con- 
 dition absolute for health. If the temperature varies 
 from this above or below, disease must result. We may 
 state the proposition in a different form — no disease 
 can exist without changing the temperature of the 
 body, either raising it, depressing it, or rendering it 
 unequal. Thus, change of temperature becomes an 
 absolute evidence of disease, though it may not point 
 out the character or the location of the lesion. 
 
156 STUDY OF DIAGNOSIS. 
 
 In the olden time changes in the temperature were 
 determined by the hand applied to the surface of the 
 body. With some physicians the touch would be so 
 educated that it would recognize these changes with 
 considerable accuracy. Whilst it would not note the 
 changes within one or two degrees when the tempera- 
 ture was above, it would recognize certain alterations 
 of the skin, and modifications of heat or electricity, 
 that the body thermometer does not take cognizance 
 of. This information is of great importance, and whilst 
 we highly value the body thermometer, we purpose to 
 cultivate the touch as far as possible. 
 
 The Body Thermometer. — The thermometer is pre- 
 sented to us as a new means of diagnosis, but as far 
 back as 1754, one hundred and twenty years ago, An- 
 tonius De Haen, the first clinical teacher of medicine 
 at Yienna, insisted upon its use to determine the tem- 
 perature of the body, rather than to judge by the hand. 
 But though De Haen showed that it was the only cor- 
 rect index of heat, and seemingly indispensable in 
 diagnosis, if it was desirable to determine the temper- 
 ature, he was not able to convince the profession that 
 this was desirable, and its use lapsed with his death. 
 
 The use of the thermometer has been revived within 
 the last fifteen years, and is now exciting much attention, 
 and is employed by many as a most valued means of 
 diagnosis and prognosis. It is valued now, because we 
 appreciate the fact that the vital processes can only be 
 performed in perfection at the normal temperature of 
 98°, and that just in proportion as it varies from this, 
 either above or below, they are changed or arrested. 
 Indeed, it would seem, that heat, at this degree, was thu 
 
STUDY OF DIAGNOSIS. - 157 
 
 most essential condition of life, and that if there is a 
 variation from it, those means which will restore the 
 thermal equilibrium are the most direct and important. 
 
 The difficulty in the way of using the thermometer 
 to determine the temperature of the body, seemed to 
 be in a want of sensitiveness, and precision in marking 
 fractions of a degree. This has been overcome by em- 
 ploying a large quantity of mercury in the bulb, and a 
 short stem graduated from 80° to 115°. By thus in- 
 creasing the quantity of mercury, the degree, as marked 
 upon the scale, was so lengthened that it could readily 
 be divided into fourths, and even eighths or tenths. 
 And the sensitiveness to heat was in direct proportion 
 to the increased length of a degree as marked upon the 
 scale. 
 
 A registering thermometer is one in which a small por- 
 tion of mercury is detached from the main column in 
 the stem of the instrument. This detached portion is 
 elevated by the expansion of the mercury below, which 
 ascends in the stem below it, and thus marks the degree 
 of heat. But it is not influenced by the descent of the 
 main column, but remains in its place, thus acting as a 
 register. In using this thermometer, the detached por- 
 tion of mercury is lowered in the stem below the 
 register by giving it three or four gentle taps with the 
 hand from below. 
 
 As the instruments require great accuracy in manu- 
 facture, they exceed in price the ordinary thermometer. 
 Tet very good instruments may be purchased for 
 $2.50 to §5.00; the self-registering, in morocco cases, 
 I would recommend as preferable. 
 
 It may be remarked, that we employ thermometers 
 graduated to Fahrenheit's scale, but some of the 
 
158 STUDY OF DIAGNOSIS. 
 
 cheaper German instruments have the scale of Reaumur 
 or Centigrade. 
 
 Applying the Thermometer. — The majority of 
 writers direct that the thermometer be applied in the 
 axillae, as it is there completely enclosed and sur 
 rounded by the soft parts. When it is convenient, as 
 in some acute diseases, the person being in bed, I think 
 the axillae the best, yet there are many cases when we 
 should like to test the temperature, that it would be 
 very inconvenient for the person to unfasten the clothes 
 to reach this part. Women, especially, will object to 
 this method of examination. 
 
 To suit these cases, I apply the bulb of the ther- 
 mometer under the tongue, having the patient close 
 the mouth. This is much more convenient, and so far 
 as my experience extends, just as reliable. 
 
 The thermometer should be retained in its place from 
 three to five minutes, as it requires this length of time 
 for the full influence of the body's heat. It is well 
 also, in some cases, to watch the register to see how 
 rapidly the mercury rises, as there is much difference 
 in this in different cases, and it also becomes an element 
 in diagnosis. 
 
 Ranges of Temperature in Health. — The standard 
 temperature of the healthy body is 98.5°, and is sub- 
 ject to a slight variation during the day of about 0.820°. 
 The maximum temperature is in the early morning; it 
 fluctuates and gradually decreases during the day, and 
 is lowest at midnight. 
 
 " The observations of Drs. Edwards and Davy have 
 shown that the amount of animal heat may be consid- 
 erably altered by a number of collateral circumstances. 
 
STUDY OF DIAGNOSIS. 159 
 
 But the great distinction between these alterations of 
 temperature in health, and those which are the result 
 of disease is, that these variations are generally tempo- 
 rary, and within narrow limits — amounting to mere 
 fractions of a degree — rarely more than 1.8° Fahr. to 
 3.6° Fahr. whereas those which are due to disease are 
 persistent so long as the disease exists. 
 
 " The following are the collateral circumstances 
 which mainly influence animal heat in our daily life, 
 and which require to be remembered in order that erro- 
 neous conclusions may not be drawn: 1. Active exercise 
 [not carried to the extent of exhausting fatigue] raises 
 the temperature proportionally to the degree of mus- 
 cular exertion made. 2. Exposure to cold without exer- 
 cise lowers the temperature. 3. Sustained mental ex- 
 ertion reduces temperature about half a degree* 4. The 
 amount of heat is also reduced by a full meal and the 
 use of alcohol ; but it rises again as digestion advances. 
 5. There are diurnal fluctuations capable of being thus 
 determined. 6. The temperature of the body rises 
 with the temperature of the air ; and sudden transitions 
 from a cold to a hot climate induce a feverish state 
 marked by increase of temperature on bodily exertion. 
 7. The average temperature within the tropics is nearly 
 1° Fahr. higher than in temperate regions. 8. The 
 temperature is more readily and rapidly affected — more 
 sensitive, so to speak — than either the pulse or the res- 
 piration ; and this is especially the case in disease." — 
 Ait ken. 
 
 Eanges of Temperature in Disease. — We have to 
 study both an increase and a decrease in the temperature 
 of the body, the first being of most common occurrence 
 
160 STUDY OF DIAGNOSIS. 
 
 and having the greatest range. Thus whilst a decrease 
 of but one degree, if maintained for a considerable 
 time, will result in death, an increase of two to four 
 degrees may be maintained for a month with safety to 
 life. 
 
 The increase of temperature is usually proportionate- 
 to the frequency of the pulse, one degree corresponding to 
 an increase of ten beats per minute. Thus : 
 
 With a temperature of 98° pulse of 60 
 
 99°. 
 100°. 
 101°. 
 102°., 
 103°., 
 104°. 
 105°. 
 106°. 
 
 70 
 80 
 90 
 100 
 110 
 120 
 130 
 140 
 
 This table is for adult males of good development, 
 and will not apply to those of feeble constitution, of 
 sedentary habits, or of a nervous temperament. In 
 such, with a normal temperature of 98°, the pulse would 
 be 70 or 80, and the increased frequency to each degree 
 would be but six or eight, until the 103° was passed. 
 
 In chronic disease we also find an increase of tem- 
 perature, and the thermometer becomes almost as cer- 
 tain a means of diagnosis and prognosis as in febrile 
 and inflammatory affections. Thus, for instance, in 
 phthisis pulmonalis, we find a permanent increase of 
 temperature to 99° and 100°, in the 'first stages, in- 
 creasing to 101° and 102°, as the disease progresses. 
 This increase is so uniform that it will furnish the best 
 evidence of the nature of the disease in its earliest stage. 
 The frequency of the pulse corresponds to the increase 
 
STUDY OF DIAGNOSE. 161 
 
 of temperature. Breaking down of the tubercles is 
 announced by a marked increase of temperature, cor- 
 responding to the destruction of lung tissue, and the 
 danger to life. 
 
 In acute fevers and inflammations, we find the tem- 
 perature increasing in the ratio of the severity of the 
 disease. It does not, however, remain uniformly the 
 same throughout the twenty-four hours, but presents a 
 marked morning decline and evening elevation. This 
 is very distinct, even in continued fevers, which we are 
 accustomed to think of as being uniform in all their 
 phenomena. This fluctuation is rarely less than one 
 degree, and is frequently two degrees cr more. 
 
 The value of the thermometer, as a means of diag- 
 nosis, is thus estimated by Dr. Aitken : 
 
 " In the course of many diseases, whose diagnosis 
 has be^n accurately determined, if the temperature de- 
 parts from its normal or typical range, the thermometer 
 will furnish the best and the earliest indication of any 
 untoward event, such as the additional development of 
 disease, or other visceral complications, in its course. 
 
 " When once the typical range of temperature (nor- 
 mal, as it were, of the particular disease) is determined, 
 a basis is laid for appreciating irregularities or compli- 
 cations in its course in particular cases. For example, 
 a patient exhibits symptoms of fever of the typhoid 
 type, but during the progress of the first week his tem- 
 perature becomes normal, for however short a space of 
 time — the occurrence of this event proves that the fever 
 is not what it was suj)posed to be. Again, a patient 
 may suffer from all the general symptoms of incipient 
 pneumonia ; but there still is a doubt as to whether in- 
 farction of the lung has taken place. The sputa being 
 14 
 
162 STUDY OF DIAGNOSIS. 
 
 suppressed, or not procurable, does not assist the diag- 
 nosis. If, however, the temperature is found to be 
 normal, it is certain that no croupous exudation has 
 taken place in the lung, and that there is no pneumonia. 
 Again, if a tuberculous patient has a sudden attack of 
 haemoptysis, and if the temperature of his body is 
 normal during and subsequent to the. attack, no reactive 
 pneumonia, nor any exacerbation of the tuberculous 
 exudation need be expected. This is a new field open 
 for investigation in cases of phthisis. 
 
 " Again : In all cases of convalescence, so long as the 
 defervescence proceeds regularly, as measured by the 
 temperature, no relapses need be feared ; on the other 
 hand, delayed defervescence in pneumonia, the persist- 
 ence of a high evening temperature in typhus or 
 typhoid fever, or the exanthemata, and the incomplete 
 attainment of normal temperature in convalescence, 
 are signs of great significance. They indicate incom- 
 plete recovery, supervention of other diseases, unfavor- 
 able changes in the products of disease, or the continu- 
 ance of other sources of disturbance requiring to be 
 carefully examined into. The onset of even a slight 
 elevation of temperature during convalescence is a 
 warning to exercise careful watching over the patient, 
 and especially for the maintenance of a due control 
 over his diet and actions." 
 
 The Influence of Treatment on the Tempera- 
 ture. — By reference to table on page 160, it will be 
 noticed that there is a constant relation between the 
 frequency of the pulse and the temperature : that with 
 a range of temperature of 103° to 105°, we find a pulse 
 ranging from 110-115 to 130-140. It is evident, there- 
 
STUDY OF DIAGNOSIS. 163 
 
 fore, that if we have any means that will control the 
 circulation — lessening the frequency of the pulse — it 
 will also lower the temperature. 
 
 The question then arises, if a treatment will thus 
 control the pulse and temperature, may it not change a 
 severe and dangerous case into a mild one without 
 danger? We answer this question in the affirmative, 
 not as a theory, but from observations on many cases 
 of disease. 
 
 I think I am justified in stating, as an axiom, that 
 just in the ratio that the circulation is thus controlled, 
 and the temperature reduced, the fever is rendered 
 mild. 
 
 I wish it distinctly understood, however, that I refer 
 only to those influences which can be continued for 
 some days, and not to those which endure but a few 
 hours. The use of large doses of Veratrum will bring 
 down the pulse from 120 to 60 or 70 beats per minute, 
 in six to ten hours, and with a corresponding reduction 
 in temperature ; but it is not possible to continue this 
 influence, as in a few hours the stomach becomes irri- 
 table and rejects it, or the depression of the sympathetic 
 nervous system is such as to peril life. 
 
 But if the remedy is given in doses of half to one 
 drop, sedation is slowly produced, the stomach receives 
 it kindly, and instead of depression of the vegetative 
 functions, the remedy acts as a stimulant to them. 
 
 But is it possible to arrest a fever before it has run its 
 course? I am satisfied that this question may also be 
 answered in the affirmative. Not that every case can 
 be shortened, for in some the local lesion of Peyer's 
 glands proves an insurmountable obstacle ; but many 
 can be arrested from the seventh to the ninth day, more 
 
164 STUDY OF DIAGNOSIS. 
 
 by the fourteenth, and in nearly all the disease can be 
 restricted to twenty one days. 
 
 A fever terminates naturally — by a decrease in the 
 frequency of the pulse, a diminution of the tempera- 
 ture, and the re-establishment of secretion, by which 
 the cause of the disease is removed. If, then, by the 
 use of sedatives, we lessen the frequency of the pulse, 
 and obtain an equal and uniform circulation, with a 
 corresponding decline in temperature, we find it easy 
 to establish secretion from the skin, kidneys and 
 bowels, by the usual means. And in a majority of 
 cases these processes may be sustained by the use of 
 nutritious food, and the use of small doses of the Bitter 
 Tonics. 
 
 But the question arises, does the temperature bear 
 the same relation in chronic disease, and will treatment 
 influencing the temperature have a like curative influ- 
 ence? I answer the question in the affirmative, and 
 adduce as an example phthisis pulmonalis, one of the 
 most intractable diseases we have to contend with. 
 
 In this, so long as the increased temperature is main- 
 tained, the disease progresses ; and very frequently its 
 rapidity is in exact ratio to this. Diminish the temper- 
 ature, and the disease progresses more slowly. Reduce 
 it to 98.5°, and maintain it at this, and the patient re- 
 covers. 
 
 The wrong of temperature is but the expression of 
 disease. If the disease is favorably influenced by rem- 
 edies the temperature falls or rises towards the normal 
 standard. I'hus in a given case of disease we may see 
 the pathological wrong, whether of the blood, the 
 nervous system, or of waste and excretion, and at the 
 same time the indications for the remedy which will 
 
STUDY OF DIAGNOSIS. 165 
 
 right the lesion, and we know that its use will reduce 
 the temperature. Thus in a case of zymotic fever the 
 evidences of sepsis are marked, and with sepsis there 
 must be an exalted temperature. If now we select the 
 right antiseptic, say Sulphite of Soda. Chlorate of 
 Potash or Baptisia, the temperature will fall with its 
 use. If in any given case we have a special indication 
 for Nitric Acid, for Podophyllin, Quinine, etc., they 
 will influence the temperature toward the normal 
 standard. 
 
 But in many cases the wrong of temperature may be 
 regarded rather as a cause than as a result. If the 
 temperature is above the normal standard the functions 
 of life are impaired in the ratio of the excess. Thus as 
 we have already seen — increase of temperature is asso- 
 ciated with acceleration of the pulse — increase of tem- 
 perature is associated with frequent respiration. With 
 an increase of temperature there is an arrest of diges- 
 tion, blood-making, nutrition, waste, retrograde meta- 
 morphosis, and secretion from skin, kidneys and bowels. 
 We also find that structural lesions are influenced in 
 the same manner. Inflammation is active in propor- 
 tion to increased temperature, as is also the tendency 
 to suppuration and death of the part. The influence 
 of zymotic causes of disease is also increased in tho 
 ratio of increase of temperature, and the condition 
 known as typhoid is marked in proportion to it. In 
 surgical disease we find the processes of repair arrested 
 when the thermometer marks 103° ; above this the pus 
 loses its laudable character, becomes thin, ichorous, 
 etc., and presently the structures soften and break 
 down. 
 
 The fact that increase of temperature is a condition 
 
1<)6 STUDY OF DIAGNOSIS. 
 
 in many chronic diseases has already been noticed. In 
 phthisis pulmonalis the first advent of disease is an- 
 nounced by a temperature of 100°. In morbus coxa- 
 rius, white swelling, etc., increase of temperature is 
 one of the most pronounced and distinctive symptoms. 
 In all these cases we may say that the rapidity of dis- 
 ease is in the ratio of increased temperature, and so 
 long as the temperature is thus high no amendment 
 need be expected. If the temperature can be reduced 
 and maintained at or near the normal standard, the de- 
 structive processes are less active, and a cure rendered 
 possible. 
 
 If we decide that a wrong of the temperature is a 
 cause rather than a result, even though but in part, we 
 wish to know the means by which it may be rectified. 
 The first proposition — " as is the pulse so is the tem- 
 perature " — gives us the use of the very important 
 class of remedies — the special sedatives. If these rem- 
 edies exert a direct influence in giving a slower and 
 better circulation, they will also lessen the temperature. 
 Certain remedies especially influence the temperature 
 through the nervous system, as Ehus, Gelseminum, 
 Bryonia, Belladonna, Nux, Nitric Acid. Others influ- 
 ence it through the constitution of the blood, as alka- 
 lies, acids, food, etc. 
 
 Then again we look to the skin as the regulator of 
 heat in the body. It is possible that a wrong in the 
 condition of this apparatus is the cause, in whole or 
 part, of this lesion. What is the condition of the skin ? 
 Is it dry, constricted, full, relaxed ? What remedies, 
 in the form of baths, or otherwise, will right these 
 wrongs ? 
 
 If we take the simple lesion of excess of temperature 
 
STUDY OF DIAGNOSIS 167 
 
 and frequency of pulse, as seen in febricula, we will 
 find a cure in the cold wet-sheet pack, as we would in 
 the early stages of a sthenic inflammation. Or in place 
 of this the ordinary vapor bath or spirit-vapor bath 
 might be employed. In many cases with a diy and 
 constricted skin the sponge baths are found to place 
 this organism in better condition, and lessen the tem- 
 perature. 
 
 If a bath is medicated, we select it as we would the 
 internal remedy. If an alkali is indicated internally 
 by pallid mucous membranes, it will be found best for a 
 bath. If an acid is indicated internally by deep colora- 
 tion of mucous membranes, we will employ an acid 
 bath. If the skin is relaxed and enfeebled, we think 
 of stimulant, tonic, or astringent baths. We employ 
 fatty inunction in two conditions — when the skin is dry 
 and constricted, and when it is relaxed and enfeebled — 
 in both the inunction answers a good purpose. In 
 some cases w r e combine with it a stimulant, or one of 
 the essential oils ; in others we make it a vehicle for the 
 topical application of Quinine. 
 
 If the increase of temperature is associated with 
 waste of tissue, we find it important to provide a better 
 fuel for burning, and thus allay the excitation caused 
 by destruction of tissue. Thus in chronic disease we 
 think of Cod Oil, and foods that contain calorif'acient 
 material in excess, and that are at the same time easily 
 digested. In acute disease we furnish similar kinds of 
 food, whilst at the same time we modify the process of 
 combustion as much as possible. 
 
 In depression of temperature we find every function 
 of life impaired, but in this case the lesion is always of 
 depression, whilst in the preceding it was most fre- 
 
168 STUDY OF DIAGNOSIS. 
 
 quently of excitation. It requires but a slight fall of 
 temperature to impair and finally arrest functional ac- 
 tivity. With a depression of a single degree a man ia 
 sick, and if this is maintained death will result in from 
 two or three days to a week. 
 
 In some cases of chronic disease we find a slight de- 
 pression of temperature, as a part of the lesion. At 
 once we ask the question, what is the cause ? Is it de- 
 pendent upon want of food, or of proper food? A 
 wrong of digestion ? An impairment of the respiratory 
 function, and of the burning ? Or a wrong of the skin, 
 so that it permits a rapid escape of heat? On the 
 answer obtained to these questions, will depend the 
 treatment. 
 
 If it is a want of food, or of calorifacient food, a right 
 treatment will look to the selection of appropriate 
 kinds. If we find a lesion of digestion, either buccal, 
 stomachic, or intestinal, means to rectify these lesions 
 will be demanded. If it arises from deficient respira- 
 tion, Ave will direct such exercise as will call into activ- 
 ity the respiratory function, and facilitate comb.ustion. 
 It is possible there may be a defect in certain materials 
 that favor combustion. Thus in some cases I have 
 found the want to be of Phosphorus, and its administra- 
 tion at once restored the calorific function. In others 
 it may be of Sulphur, or of Soda, or in some cases it 
 would be met by Cod-Oil. Wrongs of the skin, per- 
 mitting the escape of heat, are readily recognized by 
 the touch, as evidences of relaxation, of exudation of 
 water from the blood, or hyper-activity of the sudori- 
 ferous glands. The remedies will consist of stimulant 
 and tonic baths, or sometimes the use of fatty inunction 
 with stimulants or with Quinine. 
 
STUDY OF DIAGNOSIS. 169 
 
 An irregular or unequal distribution of heat is a 
 source of trouble as well as its increase or diminution. 
 If we have too much heat in one place and too little in 
 another, we will find associate wrongs of circulation and 
 innervation, and there will be impairment of digestion, 
 blood-making, nutrition, waste, retrograde metamor- 
 phosis, and excretion. Wrongs of the blood are like- 
 wise increased, and there is the tendency to deposits of 
 imperfectly formed albuminoid material. Local dis- 
 eases are also more severe, and the tendencj 7 to struc- 
 tural changes more marked. 
 
 In chronic disease we will frequently find that no im- 
 provement takes place until the wrong of temperature 
 is rectified. Getting well may hinge on getting the 
 feet warm. With cold feet, remedies which seem 
 adapted to the case, continually fail ; warm the feet, 
 even by sprinkling Capsicum in the stockings, and the 
 patient improves at once. In some of these cases topi- 
 cal means will be all-sufficient, but in others we will 
 have to employ such as give strength to the circulation 
 and improve innervation. 
 
 In acute disease unequal temperature is one of the 
 most unpleasant symptoms met with, and it is always 
 looked for in the advanced stages of severe disease. 
 The experienced physician examines the patient's toes, 
 his knees, his ears, the tips of his fingers, with as much 
 interest, as he examines the pulse. If he finds coldness 
 of these parts, he is at once awake to the necessity of 
 every means for the conservation of life, whether it 
 has reference to means to prevent undue expenditure, 
 or such as will increase the forces of the body. Cold- 
 ness of parts distant from the heart at once suggests 
 the idea of alcoholic stimulants as food, to be supple- 
 15 
 
170 STUDY OF DIAGNOSIS 
 
 merited, as soon as may be by such foods as seem best 
 adapted to the case. 
 
 Changes of kind in temperature will not be recog- 
 nized by the thermometer, and hardly by the physician 
 who prides himself on being " scientific." " Kinds of 
 heat indeed ! there is but one heat, and it is nonsense to 
 try to make a distinction in kind " (?) This is all very 
 well, but the practiced physician knows that there are 
 kinds, at least in so far as his sensations are concerned, 
 and that these " kinds " tell him of definite lesions, 
 and point to remedies. We do not know just why we 
 have varying sensations of kind, but we do even in 
 warming apparatus. The sensation of heat is not the 
 same from a coal stove, an open fire, hot water pipes, 
 or a Dutch earthen-ware oven. And the sensation of 
 heat by the hand is not the same in simple febricula, 
 remittent fever, typhoid, typhus, yellow fever, scarlet 
 fever, etc. The kind is unmistakable, and becomes 
 more and more so as the wrong of the blood and of the 
 nervous system increases. 
 
 If one applies the hand upon a surface from which a 
 sinapism has been recently removed, a peculiar sense 
 of " pungency " is experienced. Quite as distinct a 
 sensation comes in severe scarlet fever, in malignant 
 rubeola, and in diseases characterized by the symptoms 
 known as typhoid. We get a similar pungent heat 
 when there is great excitation of the sympathetic and 
 spinal nervous systems. We may say then, that this 
 character — pungent heat — which is so readily recog- 
 nized by most persons, refers us to lesions of the blood — 
 sepsis, and to lesions of the nerve centres — excitation. 
 We at once think of antiseptics as appropriate reme- 
 dies, and select the particular one by symptoms already 
 
STUDY OF DIAGNOSIS. 171 
 
 named. In so far as the nervous lesion is concerned, 
 we will be guided in the selection of remedies by the 
 facial expression and by the pulse. 
 
 It is possible many times, to determine the character 
 of a local lesion by the sensation given the hand. Thus 
 one very readily recognizes the peculiar pungent heat 
 of erysipelas, and sometimes the touch will determine 
 the advent of this lesion in surgical disease before the 
 eye would recognize the change of color, or the intu- 
 mescence of tissue. The hand placed upon the abdo- 
 men will feel the advent of puerperal inflammation 
 before it will be recognized by ordinary symptoms. 
 There is very much to be learned in this regard, and it 
 is well to give it thought and experiment. 
 
 DIAGNOSIS BY THE EAK. 
 
 The ear may not be as important in diagnosis as the 
 eye or touch, yet we purpose employing it to its fullest 
 capacity. To the routine physician who asks questions 
 and depends for his knowledge of disease upon what 
 the patient tells him, it is the organ of greatest impor- 
 tance. But we have already seen that we do best when 
 we study disease with our senses, and depend but little 
 upon what the patient says. 
 
 If the reader will refer back to our study of facial 
 expression, he will notice the statement that wrongs of 
 life find expression through the usual channels of ex- 
 pression ; where the nerve currents have been most in 
 the habit of flowing in health, they incline to flow in 
 disease. Mankind use the facial muscles to express 
 their feelings or sensations, and hence disease is ex- 
 
172 STUDY OF DIAGNOSIS. 
 
 pressed in the face. For the same reason we should 
 expect to find wrongs of life expressed m the voice, in 
 all animals using the voice, and especially in man who 
 finds it a principal instrument of expression.* 
 
 *The character of the human voice, under the influence of 
 various emotions, has been discussed by Mr. Herbert Spencer in 
 his interesting essay on Music. He clearly shows that the voice 
 alters much under different conditions, in loudness and in quality, 
 that is, in resonance and timbre, in pitch and intervals. No one 
 can listen to an eloquent orator or preacher, or to a man calling 
 angrily to another, or to one expressing astonishment, without 
 being struck with the truth of Mr. Spencer's remarks. It is 
 curious how early in life the modulation of the voice becomes ex- 
 pressive. With one of my children, under the age of two years, 
 I clearly perceived that his humph of assent was rendered by a 
 slight modulation strongly emphatic; and that by a peculiar 
 whine his negative expressed obstinate determination. Mr. 
 Spencer further shows that emotional speech, in all the above 
 respects is intimately related to vocal music, and consequently to 
 instrumental music; and he attempts to explain the character- 
 istic qualities of both on physiological grounds, — namely, on 
 " the general law that a feeling is a stimulus to muscular action.'' 
 It may be admitted that the voice is affected through this law; 
 but the explanation appears to me too general and vague to 
 throw much light on the various differences, with the exception 
 of that of loudness, between ordinary speech and emotional 
 speech, or singing. 
 
 That the pitch of the voice bears some relation to certain 
 states of feeling is tolerably clear. A person gently complaining 
 of ill-treatment, or slightly suffering, almost always speaks in a 
 high-pitched voice. Dogs, when a little impatient, often make a 
 high piping note through their noses, which at once strikes us 
 as plaintive, but how difficult it is to know whether the sound is 
 essentially plaintive, or only appears so in this particular case, 
 from our having learnt by experience what it means! Kcngger 
 states that the monkeys ( Cebus azara;), which he kept in Para- 
 
STUDY OF DIAGNOSIS. 173 
 
 As we come into the sick room we give attention to 
 the voice of the sick person, quite as much as we do to 
 what he is saying. We find that it expresses strength 
 and weakness, is free or difficult from local disease, and 
 shadows forth the condition of the brain in its tone, 
 which varies from the listlessness of atony to the quer- 
 ulousness of excited feebleness, and the excitation of 
 over activity. 
 
 In studying the voice as the expression of disease, 
 we recognize its three-fold bearing as it refers us to a 
 general impairment of life, a lesion of the brain, and 
 to lesions of the respiratory apparatus. If we did not 
 keep these sources of wrong in view we might make 
 serious mistakes. If, for instance, we have feebleness 
 of voice, it may be due to general impairment of life, 
 to impairment of the functions of the brain, to deficient 
 innervation from the spinal cord, or to a lesion of the 
 respiratory apparatus. 
 
 Whilst strength of voice is usually regarded as evi- 
 dence of good vital power, and a good respiratory ap- 
 paratus, it will not do to place too much dependence 
 
 guay, expressed astonishment by a half-piping, half-snarling 
 noise; anger or impatience, by repeating the sound hu hum a 
 deeper, grunting voice; and fright or pain, by shrill screams* 
 On the other hand, with mankind, deep groans and high piercing 
 screams equally express an agony of pain. Laughter may be 
 either high or low; so that, with adult men, as Haller long ago 
 remarked, the sound partakes of the character of the vowels (as 
 pronounced in German) and A ; whilst with children and 
 women, it has more of the character of E and /; and these 
 latter vowel-sounds naturally have, as Helmholz has shown^ a 
 higher pitch than the former; yet both tones of laughter equally 
 express enjoyment or amusement. — Darwin. 
 
174 STUDY OF DIAGNOSIS. 
 
 upon it in these regards. It certainly evidences good 
 innervation from the brain and spinal cord. But if 
 these nerve centres are sound, active, and well supplied 
 with blood, we may have a strong voice, even though 
 the body at large is nearly exhausted. Usually it is a 
 favorable symptom. 
 
 Feebleness, on the contrary, evidences a lesion of atony, 
 either of the body at large, of the brain or mind, of the 
 spinal cord, or of the respiratory apparatus. Whilst 
 the probabilities are in favor of its being a nervous 
 lesion, we will not take it for granted, but make such 
 examinations as will localize the lesion. Feebleness 
 simply, without querulousness, suggests the use of 
 Phosphorus, the Hypophosphites, Cod Oil, Alcohol as 
 food, Iron, Arsenic, Quinine. If it is associated with a 
 marked effort from the will, and a sighing respiration, 
 we refer it to deficient innervation from the spinal cord, 
 and think of Strychnia, Ergot, or Santonine as reme- 
 dies. In lesion of the respiratory apparatus there will 
 be change in the voice other than feebleness. 
 
 It is difficult to give a name to the peculiar expres- 
 sion of voice associated with nervous irritation and vas- 
 cular excitement, yet the reader will learn to recog- 
 nize it readily, and may frequently be able to deter- 
 mine these characters of disease by simply hearing the 
 patient speak. There is a sharpness, and want of 
 smoothness, representing pretty accurately in degree 
 the amount of disease. 
 
 The halting voice, evidencing a labored action of the 
 brain, tells the story of congestion, and suggests the 
 use of Belladonna, or if markedly halting, of Lobelia. 
 
 The oppressed voice, hollow and unsteady, evidences 
 a general impairment of life, and calls for stimulants, 
 tonics and food. 
 
STUDY OF DIAGNOSIS. 175 
 
 The oppressed voice from the upper part of the lungs 
 suggests deficient innervation to heart and respiratory 
 apparatus, and causes us to think of stimulant doses of 
 Lobelia. 
 
 Sharpness of voice suggests nervous excitation, and 
 will sometimes point to the remedy, as in the peculiar 
 sharp accentuation of the Rhus voice, resembling the 
 cry cncephatlque of the child. 
 
 The cry of the child will frequently inform the phy- 
 sician of the location and character of the disease. Of 
 course we recognize the fact that there may be but 
 little change in the ciy, or that there may be changes 
 without corresponding disease, but we have other 
 means of diagnosis to supplement this, and prevent 
 error. Physicians who have given this subject atten- 
 tion will recall the peculiar cry of abdominal distress, 
 the change which marks disease of the respiratory ap- 
 paratus, the oppressed cry of congestion, the shrill, 
 metallic cry of inflammation of the brain, etc. It does 
 not take much observation to distinguish the cry of 
 disease from the cry of hunger, or anger. 
 
 In the preceding paragraph a peculiar cry, encepha- 
 Uque, was noticed, which is so distinctive that it will 
 never be mistaken. Its suddenness and shrillness is 
 characteristic. In its slighter forms it arises from cere- 
 bral irritation and determination of blood, and calls for 
 Gelseminum as the rernedj\ When marked and shrill, 
 I should always think of Ehus Toxicodendron as the 
 remedy. 
 
 A sudden cry, followed by sobbing respiration, is a 
 prominent indication for Bromide of Ammonium. 
 
 The voice is the function of the larynx, and its 
 changes will point us to disease of this organ. The 
 
176 STUDY OF DIAGNOSIS. 
 
 croupous cry and voice is quite as distinctive as the 
 croupous cough. If it evidences moisture, we have 
 mucous croup; if it is dry and metallic, pseudo-mem- 
 branous croup; if variable in tone and character, spas- 
 modic croup. 
 
 In chronic disease of the larynx, roughness of the 
 voice is one of the first symptoms. As the disease pro- 
 gresses, we have various changes in the voice and dif- 
 ficult use of it, as characteristic symptoms. 
 
 In chronic bronchitis we also find change, but not 
 similar in kind. It may give the voice shrillness, as 
 in irritative bronchitis, or dullness, hollowness, or rever- 
 beration, as in asthenic bronchitis. 
 
 Cough. — Whilst cough calls our attention to a prob- 
 able disease of the respiratory apparatus it does not in- 
 dicate with any certainty the character of the disease. 
 But even to this extent it is important, for it is possible 
 to overlook local disease, from the prominence of gen- 
 eral symptoms. 
 
 Whilst cough is usually the expression of diseaso of 
 the respiratory apparatus, it may have its origin in 
 other diseases. Thus we find cough from gastric, 
 biliary and intestinal lesions, and from disease of 
 the nerve centres, and our examination is made with 
 reference to these probable causes in obscure cases. 
 
 Cough is the expression of irritation, and comes from 
 the sense of an irritant material in the respiratory pas- 
 sages, which it is intended to remove. But many times 
 there is nothing to be removed — it is a misconception 
 of the respiratory nerves, which suffer from irritation, 
 and we wish to determine whether or not the effort is 
 to be favored. In the larger number of cases expccto- 
 
STUDY OF DIAGNOSIS. 177 
 
 ration is undesirable, and if we remove the irritation 
 of the nerves the cough ceases. 
 
 A little attention upon the part of the physician will 
 determine this point, as it is quite easy to distinguish 
 the cough necessitated b} T increased secretion, and at- 
 tended by expectoration, from the inefficient, rasping 
 cough of irritation. In either case, but especially in 
 the last, an effort of the will is of marked benefit in 
 checking cough. 
 
 The character of the cough expresses to some extent 
 the condition of the respiratory passages. If dry, 
 ringing, metallic, we think of irritation, determination 
 of blood, and arrest of secretion, and the remedies at 
 once suggested are those which allay irritation, check 
 determination of blood, and favor normal secretion. 
 If moist, rattling, gurgling, dull, stimulants to the res- 
 piratory passages, as well as remedies to relieve irrita- 
 tion are suggested. 
 
 A cough is more or less forcible, and more or less 
 easily under the control of the patient. If forcible, 
 not under control, or explosive, we at once suspect a 
 wrong of the nerve centres, usually of the basilar brain, 
 and select remedies accordingly. Of course we may 
 have si'ich uncontrollable cough from local irritation, 
 especially of the throat, but this will be readily recog- 
 nized by the expression, as well as from the patient's 
 sensations. 
 
 A cough has more or less evidence of strength, both 
 of the respiratory apparatus, and of the body at large. 
 The strong, well sustained cough may be a source of 
 annoyance, but evidences good vitality and a naturally 
 good condition of the respiratory organs. A feeble 
 cough, on the contrary, is the evidence of debility, and 
 
178 STUDY OF DIAGNOSIS. 
 
 at once suggests the necessity of care in the conserva- 
 tion of life, and the employment of means which will 
 give strength, especially the selection of proper foods. 
 A cough may be feeble from deficient spinal innerva- 
 tion, and spinal stimulants would prove the best reme- 
 dies. 
 
 Coughs are spoken of as short, hacking, deep, bron- 
 chial, etc., and these characteristics may suggest the 
 locality of disease. A short cough may arise from dis- 
 ease of the upper lobes of the lungs, or it may be due 
 to disease of the parenchyma of the lung, as in the 
 first stage of a pneumonia. The hacking cough evi- 
 dences irritation of the respiratory nerves pointing 
 in the throat. The deep or bronchial cough is at once 
 referred to lesions of the bronchial tubes, though it is 
 not as good evidence as we would wish. 
 
 A cough niay have its origin in irritation of any part 
 of the respiratory apparatus, from the pharynx, larynx, 
 trachea, bronchial tubes, parenchyma of lungs, to the 
 pleura. As named above, its character may suggest the 
 seat of disease, but as a rule, it is not definite. A sin- 
 gular thing about coughs is, that the irritation points 
 so that many times the patients can localize the sensa- 
 tion of irritation for us. Cough very frequently points 
 in the pharynx, and the irritation of the throat seems 
 to be its direct cause ; such a cough is based to a con- 
 siderable extent upon irritation of the respiratory 
 nerves, and remedies directed to relieve this will be the 
 best cough medicines. In other cases cough points 
 about the supra-sternal notch, and if very severe and 
 persistent suggests the use of remedies which influence 
 the sympathetic nervous system, as Veratrum, Bryonia, 
 Cactus, Pulsatilla. 
 
STUDY OF DIAGNOSIS. 179 
 
 Coughs may be spasmodic and paroxysmal, even in 
 severe cases, showing distinct, epileptiform symptoms. 
 Whooping cough is the typical spasmodic cough, but 
 we have in the cough of measles, and some diseases of 
 the respiratory apparatus, the same characteristics. It 
 suggests Drosera, Belladonna, and Bromide of Ammo- 
 nium. 
 
 PHYSICAL DIAGNOSIS. 
 
 Diseases of the respiratory organs and the heart are 
 diagnosed in part by an exploration of the chest with 
 the ear. Whilst an examination of the chest with the 
 e}^e and the touch will determine something of the 
 character of disease, and direct our attention to reme- 
 dies, our reliance will be placed principally upon what 
 we hear. 
 
 In the case of the respiratory organs, a very import- 
 ant part is to determine the capacity of the lung for 
 air, or the amount of air contained in the chest, and 
 this is accomplished by percussion. The walls of the 
 chest are thin and elastic, whilst the lung which fills it 
 contains normally four or five times as much air as 
 there is of solid substance. Any elastic body contain- 
 ing air will give resonance when struck, and the reso- 
 nance will be in proportion to the amount of air. 
 Lessen the amount of air, replacing it with a solid or 
 fluid, and dullness of sound is the result. 
 
 The object of percussion then, in diseases of the re- 
 spiratory organs, is to determine the condition of the 
 parencl^ina of the lungs with reference to capacity for 
 air. By examination of the healthy thorax we obtain 
 a standard of normal resonance for different parts of 
 
180 STUDY OF DIAGNOSIS. 
 
 the chest, and this we use as a basis for comparison. 
 In many cases, but one side of the thorax being in- 
 volved in disease, a comparison is instituted between 
 the sound and the diseased side. In such cases, of 
 course the information is more accurate, as we have the 
 normal standard of resonance before us. 
 
 Percussion is either direct or mediate, as we strike 
 directly upon the wall of the chest, or interpose some- 
 thing between. Direct percussion may sometimes be 
 employed with advantage, using one or two fingers to 
 give the blow. The only objection to this method is 
 the unpleasantness to the patient, and the difficulty of 
 making percussion of the intercostal spaces. In medi- 
 ate percussion an ivory or rubber plate (pleximeter) is 
 sometimes employed, using the finger for the stroke, or 
 a small mallet of similar materials. The best method, 
 however, is to apply one or two fingers accurately to 
 the wall of the chest, and use the middle finger, sup- 
 ported b} T the ring finger and thumb to give the stroke. 
 It is necessary to use care in this, the fingers of the one 
 hand being accurately applied to the chesty and the 
 stroke being at right angles, and the muscles of the 
 hand held firmly so as to give a quick rebound. 
 
 As the object to be determined is the capacity of the 
 lung for air, we make percussion both during full in- 
 spiration and after expiration. In examining the mar- 
 gin of the lungs over the false ribs and the sternum, it 
 is necessary to have the patient take a full inspiration 
 to carry the lung down to the insertion of the diaphragm 
 in the one case, and to the mesial line in the other. In 
 making percussion over muscles it is well to put the 
 body in such position that the muscles will be rendered 
 tense. In examinations about the shoulder, it is raised 
 
 i 
 
STUDY OF DIAGNOSIS. 181 
 
 to allow our examinations to be carried up in the 
 axillary space, or thrown forward or backward, to 
 enable us to reach the upper part of the chest. 
 
 In making comparison between the two sides, we are 
 careful that there is the same degree of inflation, and it 
 is better to have the patient take a full breath, and hold 
 it as long as he can conveniently, or cease respiration 
 for a moment, after the air is thrown out. 
 
 Normal resonance tells us that the parenchyma of 
 the lung is free from .effusion, it may be the seat of irri- 
 tation, but the capacity for air is not interfered with. 
 
 Increased resonance in slight degree is heard when 
 the function of one lung being impaired, the other does 
 an increased work. In greater degree it is the evidence 
 of emphysema. When very marked, and over a lim- 
 ited portion, it is the evidence of a cavity. 
 
 Dullness on percussion evidences that the air is re- 
 placed by a solid or fluid ; as is the degree of dullness, 
 so is this change in the physical condition of the lung. 
 We have dullness in acute pneumonia commencing 
 about the third day, sometimes earlier, and increasing 
 as deposit takes place in the air cells and intercellular 
 passages, and in the connective tissue — as is the dull- 
 ness, so is the intensity of the disease. Resonance returns 
 when the circulation is restored, and effused materials 
 are absorbed. Dullness is also an evidence Of chronic 
 inflammation of the lungs, being usually much more 
 extensive than in phthisis pulmonalis, for which it 
 might be mistaken. Dullness on percussion, is heard 
 in phthisis, when the tubercle is deposited in consider- 
 able quantit} r and near the surface. In the earlier 
 stages the dullness is so slight that it is not an import- 
 ant evidence of disease. 
 
182 STUDY OF DIAGNOSIS. 
 
 We have dullness on percussion where there is fluid 
 in the pleural cavities, whether it is simply of water, or 
 the products of inflammation. In this case the dullness 
 is of the most dependent part, and unless it is an ex- 
 treme case, changing the position of patient, will change 
 the situation of the dullness. 
 
 Wc have dullness on percussion in hydropericardium, 
 and to a limited extent in hypertrophy of the heart. 
 The situation of the dullness, and the change in the 
 sounds from the heart, will determine the condition of 
 disease. 
 
 Occasionally we have dullness on percussion from the 
 formation of a thoracic aneurism, and still more rarely 
 from growths in the cavity of the chest. Other symp- 
 toms will determine the character of the wrong. 
 
 The reader will notice that in acute disease dullness 
 on percussion has reference mostly to effusion into, and 
 solidification of the parenchyma of the lung. The ex- 
 tent of the dullness determines the amount of tissue 
 involved, and its intensity determines, to some extent, 
 the severity of the lesion. In so far as it suggests 
 treatment, it would say — lessen irritation and determi- 
 nation of blood to the lungs — give the respiratory appa- 
 ratus rest — by appropriate food, and in so far as medi- 
 cines act to sustain the life of the part, and of the body at 
 large — and by the establishment of secretion, promote 
 the absorption of the effused material. 
 
 Percussion is sometimes employed in other parts than 
 the thorax to give evidence of disease. Thus we find 
 that some wrongs of the stomach, of the liver, spleen, 
 bowels, and reproductive apparatus, give rise to 
 changes in the sound? heard on percussion. 
 
 Disease of the stomach with generation of gas, will 
 
STUDY OF DIAGNOSIS. 183 
 
 be evidenced by marked resonance on percussion over 
 the stomach. In some cases of chronic disease, this 
 condition is persistent, and the continually distended 
 stomach is pressed upwards until it occupies consider- 
 able space, and resonance might lead us to suppose that 
 a cavity had formed in the inferior lobe of the lung, 
 had we not symptoms of gastric lesion, and the reso- 
 nance extending across the epigastrium. 
 
 On the right side an enlarged liver pressed upwards 
 encroaches upon the cavity of the chest, and gives 
 marked dullness on percussion over the right false ribs. 
 The evidences of wrong digestion, and the fullness at 
 the margin of the ribs will correct the diagnosis. 
 
 In distension of the bowels by gas, we get the evi- 
 dence of resonance on percussion. If of the small in- 
 testine it occupies the anterior part of the abdomen; if 
 of the large intestine it is lateral, or in the situation of 
 the transverse colon. 
 
 In ascites the small intestine distended with gas floats 
 at the top, and though we get the dullness of water 
 below, and succussion on palpation, there is resonance 
 at the highest part, if the convolutions are free to 
 move. 
 
 In ovarian dropsy, on the contrary, the sac displaces 
 the small intestine as it grows, and either crowds it 
 upward or backward. Intestinal resonance on the 
 surface, in dropsy, is therefore one of the differential 
 points in distinguishing between ovarian disease and 
 ascites. 
 
 We employ palpation to determine the presence of 
 fluid, whether in the cavities, or formed by the break- 
 ing down of tissue. In some cases the evidence of 
 fluctuation is very distinct, the wave of fluid passing 
 
181 STUDY OF DIAGNOSIS. 
 
 distinctly from the hand on the one side, to the hand 
 on the other. In other cases, we only obtain a sense 
 of mobility and the elasticity of fluid. 
 
 When parts give rise to sound in the performance of 
 their functions, the character of this becomes evidence 
 of disease. This is the case with the respiratory appa- 
 ratus, the heart, and to a less extent with some other 
 parts. 
 
 Listening to sounds thus produced is called ausculta- 
 tion, and as practiced may be either direct or mediate. 
 In direct auscultation, the ear is applied to the part, 
 and the sounds heard. In mediate auscultation, an 
 instrument called a stethoscope is employed as a con- 
 ductor of sound. 
 
 I prefer direct auscultation, as we desire to hear the 
 exact sounds produced, neither intensified nor modified. 
 It is quite as easy to apply the ear as a stethoscope, 
 and except in some rare cases of cutaneous disease 
 there is nothing objectionable in such examination. 
 It is claimed that female modesty might be shocked by 
 this direct examination, both of the chest, and especially 
 of the lower abdomen to detect the beatings of the 
 foetal heart. But I confess that in my professional life 
 I have met with but little of this mock modesty. 
 
 The special value of the stethoscope is the impression 
 it makes upon the public. In the olden time the ph}- 
 sician carried a gold or ivory headed cane, or rather 
 a staff, to give him an appearance of dignity, and the 
 professional pose, as shown by Hogarth, with the head 
 of the cane pressed against the nose or forehead, in 
 profound thought, is a fair representation of the dig- 
 nity " that pays." As the physician's cane has gone 
 out of fashion, the stethoscope, and instruments of 
 
STUDY OP DIAGNOSIS. 185 
 
 similar kind earne in to sustain the dignity of the pro- 
 fession. 
 
 Stethoscopes are made in varied forms, from the sim- 
 ple short wooden cylinder (with a hole through it) to 
 the double ear-tube instrument of Camman. Some are 
 bo illy adapted to their use, that scarcely anything can 
 be heard, except the unpleasant roaring from ill adap- 
 tation to the ear. The best stethoscope is a simple 
 cylinder of solid wood, with the one end adapted to the 
 walls of the chest, and the other to the physician's ear. 
 It may be long or short, or have any shape the taste 
 of the maker may give it, if it possess the characters 
 named, it will answer its purpose well. 
 
 In the practice of auscultation, whether direct or 
 with a stethoscope, the physician is careful to avoid 
 adventitious sounds, and to place his body in a conve- 
 nient position for listening. The rubbing of clothing, 
 either upon itself, or against a stethoscope, will fre- 
 quently mask the sounds we wish to hear. A con- 
 strained position of body frequently interferes with 
 listening. 
 
 In auscultation of the chest in health two respiratory 
 sounds are heard — the respiratory murmur, and the 
 bronchial sound. The first is heard during inspiration 
 and expiration over the entire surface of lung ; the 
 second is heard by applying the ear over the spinal 
 column from the middle cervical region to the sixth 
 dorsal vertebra — the spinal column being a good con- 
 ductor of sound. If the normal respiratory murmur 
 is heard we know this portion of the parenchyma of 
 lung is healthy ; if it is changed in character, or re- 
 placed by adventitious sounds from the air cells and 
 email passages, we know that there is disease. 
 16 
 
l86 STUDY OF DIAGNOSIS. 
 
 Id studying auscultation, it is well to study in the 
 language most familiar to us. If we are original 
 Eomans we may pursue the study in Latin ; if French, 
 we may use French technical terms; but if English is 
 our mother tongue, we had better e m pi oy English, and 
 use words with especial reference to their meaning. I 
 think it is possible to so classify and name the morbid 
 sounds that the reader can learn them without trouble. 
 
 We may say first, that a wrong sound made in the 
 respiratory apparatus is evidence of disease of this 
 apparatus. We want then to determine the value of 
 the sound, and the distinct lesion that produces it. 
 
 To this end, the first question is as regards the 
 medium for the conduction of sound. Solids conduct 
 sound best, fluids next best. Air stands next as a con- 
 ductor, and mixed bodies last. The lung, with its 
 spongy tissue filled with air is a bad conductor of 
 sound. If it is solidified, it becomes a good conductor, 
 and sounds will be heard, which otherwise would not 
 reach the ear. Fluids compressing the lung are also 
 good conductors of sound. To determine this point, 
 then, percussion is made — if there is resonance the 
 sound is referred wholly to a wrong of the part where 
 it is produced ; if there is dullness on percussion, it is 
 referred in considerable part to the consolidation of 
 lung, or to the effusion, which gives a better conductor 
 of sound. 
 
 Morbid sounds may be divided first into blowing and 
 crepitant, having reference to the parts in which they 
 are produced. Blowing sounds are produced in bron- 
 chial tubes, and crepitant sounds in the intercellular 
 passages and air cells, 
 
 Blowing sounds are blowing. The idea the listener 
 
STUDY OF DIAGNOSIS. 187 
 
 gets is of air blown through a tube possessing some 
 elasticity. In the blowing sounds heard in diseases of 
 the respiratory apparatus, the listener gets an idea of 
 obstruction ; the air does not pass as freely as in health. 
 In one case the sense is of constriction — evidently the 
 calibre of the tube has been diminished— the sound has 
 the higher tone or shrillness that would be thus pro- 
 duced. In another case the obstruction is evidently 
 within the tube, either from fullness of mucous mem- 
 brane, or from increased secretion, and the sounds are 
 lower in tone — duller — or show the evidence of mucus in 
 more or less of gurgling. In a third class of cases, the 
 obstruction is evidently from want of elasticity and 
 tone in the tube, which yields before the passage of air, 
 both in inspiration and expiration — the wavering tone 
 of the sound determines this condition. 
 
 In so far then as we have analyzed the simple char- 
 acter blowing, we have suggested to us a rational prac- 
 tice of medicine. Contraction of bronchial tubes is in 
 the majorit}^ of cases from irritation — employ those 
 remedies which take away the irritation. Fullness of 
 mucous membrane suggests the use of means to relieve 
 determination of blood, and to promote absorption 
 Increased secretion suggests the employment of means 
 to take away irritation and determination of blood, and 
 check secretion. Whilst the wavering sound indicating 
 atony, calls for stimulants, tonics and restoratives. 
 
 Blowing sounds are dry and moist, and these common 
 words express clearly the idea formed upon hearing the 
 sounds. They are dry and moist, as they refer to a 
 condition of dryness or moisture of the mucous lining 
 of the bronchial tubes. 
 
 Dry blowing sounds evidence a condition of bronchial 
 
188 STUDY OF DIAGNOSIS. 
 
 tubes in which there is an impediment to the free 
 passage of air, and more or less arrest of the normal 
 mucous secretion. Dryness itself is an impediment to 
 the passage of air, but in addition there is contraction 
 of the bronchial tubes. We are in the habit of saying — 
 as is the blowing, so is the contraction of the tubes — 
 as is the sound of dryness, so is the arrest of secretion. 
 
 Contraction of bronchial tubes results from irritation, 
 and it suggests that such means be employed as will 
 relieve irritation. Dryness results from irritation, de- 
 termination of blood, and the developed inflammatory 
 process. Given a dry blowing sound, we at once think 
 of general and local sedatives which lessen determina- 
 tion of blood, remedies which "allay irritation, remedies 
 which so rectify general lesions of circulation and tem- 
 perature as to permit secretion, and remedies which 
 restore secretion, if such be necessary. Thinking in 
 straight lines, our ear gives us information of the con- 
 dition of the air passages, Ave at once think of the 
 pathological states, and having the factors of disease 
 before us, we at once think of those remedies which 
 restore normal functional activities. 
 
 Moist blowing sounds tell us of obstruction to the 
 free passage of air, and to the pressure of fluid in the 
 air passages. As is the blowing so is the impediment 
 to the passage of air ; as is the moisture, rattling, bub- 
 bling, gurgling, so is the amount of fluid in these pas- 
 sages. 
 
 The ear readily determines from the character of the 
 sound, whether the blowing is still due to contraction 
 of the tubes, for in this case the sound is steadier and 
 more resonant, than if caused by obstruction from accu- 
 mulated fluids, or from atony. The well-sustained, 
 
STUDY OF DIAGNOSIS. 189 
 
 sonorous sound always means contraction — contraction 
 results from irritation — use remedies to lessen or take 
 the irritation away. 
 
 The impediment from secretion of mucus, muco-pus, 
 or purulent fluid is clearly expressed in the sounds 
 heard, and it is well to take the evidence of the ear, 
 rather than any technical classification of sound. The 
 presence of just sufficient secretion to lubricate the 
 passages, of occasional accumulations which need re- 
 moval by expectoration, of continued accumulation, 
 giving rise to rattling sounds like the bursting of large 
 bubbles, or the gargling which comes from large quan- 
 tities of fluid, are distinct and unmistakable. The 
 treatment is clear — take away the causes of determina- 
 tion of blood, whether due to irritation of the respira- 
 tory nerves, or some general lesion. Give these tissues 
 such support as we can, by the use of remedies that 
 give local or general stimulus and tone. And to a cer- 
 tain extent favor the removal of these accumulations 
 by expectoration — usually by giving strength to the 
 respiratory apparatus. 
 
 The evidence of atony of the respiratory passages 
 is found in the yielding or tremulous character of the 
 sound. Whilst the evidence of contraction was found 
 in the well sustained sound, this is found in the feebly 
 sustained sound. The treatment is clear — to sustain 
 and increase the strength of the patient, and to stimu- 
 late and strengthen this enfeebled organism. In some 
 cases alcoholic stimulants give prompt relief, and their 
 effect is maintained by Quinine, restoratives, and food. 
 The local remedy is Lobelia in stimulant doses, and we 
 always think of this, especially in infancy and child- 
 hood. 
 
190 STUDY OF DIAGNOSIS. 
 
 When cavities arc formed in the lung, communicating 
 with a bronchial tube, the ear detects a peculiar blow- 
 ing sound, as of air blown into a bottle. This may be 
 dull and more or less gurgling, showing that the pro- 
 cess of removal is not yet completed, and the walls of 
 the cavity are of the spongy, partly broken down lung. 
 Or it may be clear, well sustained, and more or less re- 
 sonant, showing the removal of deposit, and cicatriza- 
 tion. 
 
 Small blowing sounds, varying in character, shrill, 
 whistling, piping, irregular, tortuous, dry, moist, rat- 
 tling, all combined, in varying proportions, are the best 
 evidences of phthisis pulmonalis. If the reader will 
 think for a moment of the structures involved, the 
 situation of the tubercular deposits, how they must 
 press upon the smaller bronchial tubes, changing their 
 position, making them tortuous, changing their calibre, 
 he will see at once that these are just such sounds as 
 might be expected. 
 
 In addition to these small, queer, blowing sounds, the 
 ear detects that known as dry crackling. During a full 
 inspiration three or four distinct crackling sounds are 
 heard, which seem to the ear veiy much like the sounds 
 produced by separating two surfaces attached by a glu- 
 tinous fluid. And undoubtedly this is the condition, 
 for if the tubercle is so deposited as by pressure against 
 a bronchial tube to efface its cavity, the separation of 
 the glutinous walls of mucous membrane would give 
 just such sound. 
 
 Crepitant sounds take the place of the respiratory 
 murmur, and are formed in the air-cells, the intercel- 
 lular passages, and the minute bronchial tubes. When ? 
 therefore, small crepitation is heard, we refer it at once 
 
STUDY OF DIAGNOSIS. 191 
 
 to disease of the parenchyma of the lung. If we in- 
 quire into the condition of the lung — the changes of 
 structure that will produce such sound — we find it in 
 irritation, determination of blood, and slight effusion 
 into these minute air passages. If the effusion goes on, 
 the lung is rendered impermeable to air, and the crepi- 
 tant sound ceases. 
 
 Crepitance is therefore the evidence of inflammation 
 of the lung in its first stage, and is associated with re- 
 sonance on percussion, for the disease has not pro- 
 gressed to hepatization. Where effusion has taken 
 place to the extent of giving dullness on percussion, 
 the crepitant sounds are replaced by blowing sounds 
 from the bronchial tubes, the lung being now a better 
 conductor of sound. Larger crepitance refers us to 
 the minute bronchial tubes, and is the evidence of 
 capillary bronchitis. The smaller crepitance is not 
 only heard in the first stage of an inflammation of the 
 lungs, but returns with the absorption of the effused 
 material, and resolution, and is therefore the evidence 
 of the subsidence of the disease. 
 
 As crepitance is the evidence of the active stage of 
 an inflammation, in which irritation and determination 
 of blood are the prominent factors, the treatment is 
 plain. In so far as we can take away the irritation, 
 and stop the determination of blood, our treatment 
 will be rational. The frequent pulse, the high temper- 
 ature, and the rapid respiration, are important elements 
 in the furtherance of the local disease, and means 
 which will rectify these wrongs, are of first importance. 
 As the succeeding stage is one of local depression of 
 life, no means should be emplo}-ed that will depress 
 either the life in general, or of the affected part. 
 
v 192 STUDY OF DIAGNOSE, 
 
 Where solidification of a lung has tciken place, it 
 becomes a better conductor of sound, and if now the 
 ear is applied and the patient is engaged in conversa- 
 tion, the voice seems to come out through the chest. 
 We do not get articulate speech, but simply the modu- 
 lations of the voice. This is called bronchophony 
 (speaking through the bronchial tubes), but its only 
 value is to determine solidification of the lung, and per- 
 cussion is the better evidence. 
 
 If there is fluid in the chest, and the ear is applied 
 over it, the patient conversing, the voice seems to come 
 out through the chest, but has a tremulous tone. This 
 has been called segophony, and is one of the evidences 
 of fluid in the pleural cavities. 
 
 If the ear is applied over a cavity, which is free and 
 communicates with a bronchial tube, and the patient is 
 engaged in conversation, the articulate voice comes to 
 our ear through the chest. This is called pectoriloquy, 
 and is additional evidence of the formation of a cavity 
 in the lungs. 
 
 In some cases of structural disease of the pleura, the 
 result of inflammation, certain friction sounds are 
 heard, but they are not very common, distinct, or defi- 
 nite. Once in a while they are said to assume the dis- 
 tinctness of the u creaking of new leather," but in the 
 two cases I have seen, the sounds were evidently 
 from wrong of the parenchyma of the lung, and not 
 from the change of the pleura. 
 
 We employ auscultation in the examination of the 
 heart with as much advantage as in diseases of the 
 respiratory apparatus. As the sounds produced by the 
 heart are much louder, and more distinct or arbitrary, 
 many persons will succeed better in auscultation of the 
 heart, than of the lungs. 
 
STUDY OF DIAGNOSIS. 193 
 
 The normal sounds of the heart are smooth, uniform 
 m tone, regular in time, and give the ear an agreeable 
 sensation. Ko description in words would give the 
 reader a sufficient knowledge of them; they must be 
 heard to be thoroughly known. It is hardly worth 
 while to call the reader's attention again to the impor- 
 tance of knowing the phenomena of life for himself, 
 and especially with regard to things that may so easily 
 be known by the senses. 
 
 If, in examination of the heart, we find that the 
 sounds are normal, we are quite sure that there is not 
 structural disease of this organ. If there are general 
 symptoms of heart disease, the wrong is functional. 
 If, on the contrary, the sounds of the heart are changed, 
 or replaced by adventitious sounds, we are just as sure 
 that there is structural disease of the organ. The two 
 exceptions to these rules are : — 1st, in case of anaemia 
 or spansemia, we hear blowing sounds, which are re- 
 ferred to the wrong of the blood, and not to the heart ; 
 and 2d, in fatty degeneration, no change in the sounds 
 of the heart announce the structural lesion. 
 
 The morbid sounds of the heart may be divided into 
 blowing and sawing, and the ideas conveyed by these 
 words represent exactly the character of the sound. 
 Whilst blowing sounds may be referred sometimes to 
 lesions of the walls of the heart, and a wrong in mus- 
 cular contraction, the sawing sounds are referred to 
 the openings of the heart, and to the valves, and 
 usually to lesions that obstruct the free flow of blood. 
 
 The blowing sounds have been named bellows mur- 
 murs, and have every range between the simple, 
 smooth, blowing sound, similar to that heard from the 
 bronchial tubes, to the roughened, irregular, rattling 
 17 
 
194 STUDY OF DIAGNOSIS. 
 
 sound, similar to that produced by a pair of bellows in 
 motion. If the sound is dependent upon poor blood, it 
 may many times be heard over the larger arteries as 
 well as the heart, and in this case will call for the 
 proper restoratives and food to make good blood. If 
 dependent upon enfeebled nutrition, or degeneration 
 of the walls of the heart, we employ means to give the 
 heart rest, see that it is not subject to excitement, and 
 employ means to improve nutrition. The rough, 
 irregular sound that is attributed to valvular insuffi- 
 ciency and regurgitation, would demand the same 
 treatment. 
 
 The saw sound has been divided into three varieties, 
 the saw, rasp and file sounds, but the distinction has 
 but little reference to conditions of disease, or to the 
 use of remedies. Possibly the finer sounds may refer 
 us to a more acute condition of disease, in which plastic 
 material is yet being deposited. In some cases of val- 
 vular insufficiency we hear a marked saw sound, but it 
 has an irregularity and dullness that we do not meet 
 with in the other cases. 
 
 The more common lesions that give rise to contrac- 
 tion of the openings of the heart, and such disease of 
 the valves as prevent their free movement, are inflam- 
 matory, and give fibrinous exudation as the result. 
 The most of these are rheumatic in character, involving 
 the tendinous portions of the muscle, and the endo- 
 cardium. There are rare cases in which the sounds are 
 due to fibrinous vegetations from the valves, or to 
 ossific deposit in their structure. 
 
 The treatment suggested by these sounds has refer- 
 ence, first to rest, and secondly, to means which will 
 promote absorption, and give us a better renewal of 
 
STUDY OF DIAGNOSIS. 195 
 
 life. Eest is absolutely essential to recovery from 
 chronic inflammation and the absorption of its pro- 
 ducts. We want physical rest, and mental rest, and 
 such relief from irritation of the cardiac nerves as may 
 be obtained from the use of Cactus, Pulsatilla, and the 
 special sedatives. Eemoval of deposits is facilitated by 
 the establishment of free secretion, and a better heart 
 is made by means to obtain good blood, and good 
 nutrition. 
 
 To determine pregnancy after the fifth month the 
 ear is applied over the lower abdomen to hear the beat- 
 ings of the foetal heart. If it is heard the diagnosis is 
 clear, but if not, we are not yet certain that pregnancy 
 does not exist, for in many cases, from feebleness of the 
 movement of the foetal heart, excess of liquor amnii, 
 thick abdominal walls, or the position of the child, it 
 can not be heard until late in pregnancy, or not at all. 
 
 DIAGNOSIS BY THE SENSE OF SMELL. 
 
 The sense of smell has less development in the 
 majority of men than any other of the senses — as some 
 writer has recently remarked — " it is yet in the savage 
 state." It may not be of much use in diagnosis, and yet 
 the little it may tell us we want to know. It requires 
 education, as do the others, and we must learn to dis- 
 tinguish pleasant odors from stin7ts, and thus be able to 
 analyze stinks, and determine their influence upon the 
 human body. It is possible that some persons will 
 never be able to recognize the genus " stink," much 
 less be able to assort them for our present purpose. 
 
 It is well for the physician to commence educating 
 
196 STUDY OF DIAGNOSIS. 
 
 his nose at home, and to start with a realization of the 
 fact that all unpleasant smells are noxious to the human 
 body. It requires very little exercise of reason to 
 reach this conclusion, for if the thing was not unplea- 
 sant or noxious to the economy, the nose would not 
 give the warning of unpleasantness. What is the evi- 
 dence of disease to the person suffering? Unpleasantness ; 
 the very expression used, " persons suffering," tells the 
 story of disease. Is disease ever pleasant ? No. Are 
 causes of disease ever pleasant ? No. Do causes of 
 disease ever pleasantly impress the senses? You 
 might answer yes, but I say no again. 
 
 Commencing at home I put my nose inside your 
 office door, and — heaven preserve me — what a com- 
 pound of stinks, from Asafoetida to Jalap, from Castor 
 Oil to Turpentine. Lesson No. 1, true remedies have 
 no bad odor, clean up j^our stinks and put them in the 
 nearest privy-vault, and have a thorough disinfection. 
 Eeason why — it will be money in your purse— people 
 that paj^ good bills don't like stinks, as a rule. Let me 
 nose your saddle-bags and pocket-case ? Faugh ! what 
 a terrible sickly smell! — reminds me of the old country 
 doctor, who was always announced by a mixed smell 
 of Asafoetida and Jalap. It won't do in this age ; burn 
 them up, and order a new stock. Now clean up your- 
 self, and get your nose in good working order, that j^ou 
 may learn diagnosis with it. Do you know how to eat 
 onions and go-a-sparking too ? Have the maiden taste 
 them. Eeverse the simile — if you cany bad smells 
 about you, j*ou will not be able to detect them in the 
 sick room — and it is a most important work, believe me. 
 
 When I visit a sick room, my nose commences the 
 inquiry, (it is a most excellent interrogation point). 
 
STUDY OF DIAGNOSIS. 197 
 
 What provisions have you made for fresh air, sunlight, 
 and cleanliness ? It says straightway, the air is bad, 
 there must be ventilation, and opens a window, builds 
 an open fire, and does what is necessary. It noses a 
 stink from under the bed, and suggests half cleaned 
 chamber utensils, excreta, dirty clothes, dirtied floors, 
 etc. It says with emphasis there must be a thorough 
 cleaning up. The excretions muot be removed as soon 
 as voided, the utensils thoroughly cleansed and disin- 
 fected, every loose thing removed, the floor cleansed, 
 the bed drawn from the wall, and so arranged that the 
 air can pass freely under it. It says you have been 
 trying to feed this patient upon stale, badly prepared 
 food, and it detects it remaining in the room hour after 
 hour, poisoning the atmosphere, and taking away what 
 little desire the patient may have for nourishment. It 
 says, the food for the sick must be nicely prepared, 
 fresh and savory, at such times as he can best take it, 
 and then promptly removed from sight or sense. It 
 says — you are dirty — dirty in person, dirty in clothing, 
 dirty in bed. You must be thoroughly cleaned up, 
 washed with soap and water, have frequent changes of 
 clothing and bed linen — " cleanliness is next to godli- 
 ness." 
 
 You can't hide dirty sheets from this nose, or a bed 
 soiled by involuntary discharges, or a bed sore, a badly 
 dressed w^ound, however you may try to cover them 
 up. It recognizes the row of nasty medicine bottles, 
 and says, "take them out" — your spoiled poultices 
 and fomentations, and says, " fresh water." It tells 
 you of damp walls, of lack of sunshine, of choked 
 drains, of ground saturated with garbage, of foul 
 closets, of cellars uncleaned, of decomposing vegetables, 
 
198 STUDY OF DIAGNOSIS. 
 
 and of the hundred and one noxious agencies which 
 breed disease and steal away a man's life. 
 
 But it not only tells you of dirt, and specifies clean- 
 liness as the remedy, but it tells of specific agents to 
 destroy causes of disease. I will warrant that you 
 have already associated an unpleasant odor of decay 
 with lime. Lime to freshen the air of cellar, lime to 
 slush a bad drain or cess-pool, lime to make way for 
 sunlight, and to get rid of the de<xd air of a house. 
 You will recognize a sweetish, mawkish, unpleasant 
 odor, similar to that exhaled from smallpox, and it 
 saj^s Sulphurous Acid, as plainly as it can be expressed. 
 You burn Sulphur in the room, or in the whole house, 
 and jom are surprised how it changes the air, and how 
 much the patient is benefited by it. In other like cases 
 you sprinkle the floors with Sulphurous Acid, wash the 
 chamber utensils with it, and the dressings in surgical 
 disease. It is not simply to get rid of a bad smell that 
 we do this, but it is to remove a cause of disease. 
 
 There are other cases in which a peculiar putres- 
 cence reminds you that Chlorine, Carbolic Acid, or 
 Iodine are required. You employ Labaraque's disin- 
 fecting solution, or Chloride of Lime, and you see a 
 decided improvement. Or you use a solution of Car- 
 bolic Acid, especially as a wash to things which are 
 soiled, to wash dressings, or as an application to 
 wounds, and there is a change for the better. There 
 is a bad odor that simulates the offensive sputa of 
 chronic bronchitis, and some cases of phthisis, which 
 would at once suggest Iodine, and we use it as a disin- 
 fectant, a dressing, a local application, or as an'inha- 
 lation. So too there is an unpleasant odor, peculiar to 
 phlegmonous erysipelas, that says Permanganate of 
 
STUDY OF DIAGNOSIS. 199 
 
 Potash so plainly that no one can mistake the remedy. 
 I do not wish to place too much stress upon the evi- 
 dence of this sense, for as stated in the beginning it is 
 but rudimentary, yet some things it does tell us with 
 certainty. A sweetish or mawkish odor from the 
 breath wants Sulphurous Acid, or Sulphite of Soda. 
 An odor resembling an offensive lochial discharge, is 
 the best evidence of the want of Chlorate of Potash. 
 The hot breath, with unpleasant pungence, as of Am- 
 monia, calls for Muriatic Acid. The fetor resembling 
 that from cynanche maligna, calls for Baptisia. 
 
 But whether we can distinguish one bad smell from 
 another or not, we know one thing, that they demand 
 cleanliness, good ventilation, and a restorative treat- 
 ment. Going one step further, they evidence the con- 
 dition of sepsis or zymosis, and demand that we select 
 the proper antiseptic. If we can select it from the 
 odor, good ; if not, and in any case, we have other ex- 
 pressions of disease that will point out the particular 
 remedy required. 
 
 If we apply the sense of smell to the excreta we find 
 it of some value, though possibly not of very much. 
 The cutaneous excretion gives a distinctive odor, and 
 in disease we sometimes find marked changes in this. 
 It is not difficult to recognize the pleasant odor from 
 the healthy skin, kept clean, as it is not to recognize 
 the odor of the parson kept dirty. In treating children 
 the evidence of our nose is frequently opposed to the 
 evidence of our eyes. The child seems clean, but the 
 unpleasant odors tell you to look beneath the surface, 
 and it is dirty. We find all manner of odors from the 
 person, running the range of" from grave to gay," and 
 the}^ tell the story of disease and vitiated secretion. 
 
200 STUDY OF DIAGNOSIS. 
 
 Some of these are so characteristic that they can not 
 be mistaken, as for instance, the peculiar urinous smell 
 in tinea capitis. 
 
 The urine has a distinctive odor, that may be called 
 healthy. It may lose odor, or it may have a wide range 
 of morbid smells, each of which should have a distinct 
 meaning in the diagnosis of disease. If a Septimius 
 Pease was to study uriscopy, he would probably trust 
 his nose in preference to his eyes. 
 
 The seminal odor is so distinctive that it can hardly 
 be mistaken, and as it is very persistent, and may per- 
 vade the entire person, it will sometimes give impor- 
 tant information. So too is the odor from the sexual 
 organs of both male and female, in certain cases of 
 disease. 
 
 The fetor of the fasces is peculiarly unpleasant, yet 
 the odors are distinctive, and would suggest health in 
 one case, and disease in another. I have no penchant 
 for the olden -time examination of faeces, yet even here 
 I would about as soon trust my nose as my eyes. Pos- 
 sibly the characteristic stinks, already named, will be 
 found here, and the same class of remedies indicated. 
 
 INFORMATION FROM PATIENT AND NURSE. 
 
 We neglect no source of information with reference 
 to the origin, condition, or progress of disease, and 
 whilst careful not to be guided by information from 
 nurse, friends and patient, we wish to give it its true 
 value. Attention has already been called to the many 
 sources of error. To a want of knowledge and care 
 in observation on the part of nurse and friends, as well 
 
STUDY OF DIAGNOSIS. 201 
 
 as their prejudices and tendency to distortion. To the 
 want of knowledge upon the part of the patient, want 
 of language for description, and the impairment of his 
 powers of sensation and reason from disease. 
 
 The elements of uncertainty are thus very great, and 
 we have to pursue our inquiries with much care. 
 Questions should never be suggestive, but should be so 
 put as to let nurse or patient tell what they know, or 
 to require but the simple and direct answer, yes or no. 
 Careful attention to these points, and a continued guard 
 upon the tongue, will soon form a habit of examination, 
 that will lessen the danger of erroneous information. 
 
 We prefer to get information from attendants with 
 regard to the general condition of the sick, and the 
 performance of the essential functions of life. From 
 the patient we desire to know his sensations, as these 
 are changed by disease. 
 
 A first examination may take the following course : 
 How long sick? What are the seeming causes of the 
 sickness? How did it commence? What has been 
 noticed with reference to the progress of disease up to 
 the present time? How does the patient rest in the 
 daytime? at night? What food and drink does he take ? 
 How often does he have a motion of the bowels? How 
 does he pass urine? These questions may seem sug- 
 gestive, and once in a while they may take a simpler 
 form as — does he sleep? does he eat? does he drink? 
 
 It is most absurd for the attendant to attempt a de- 
 scription of the sensations of the sick, and yet they 
 almost always volunteer to do it. Many times they 
 will be continuously making suggestions to the patient, 
 and lead him into erroneous statements. They will 
 probably have formed some theory of the disease, and 
 
202 STUDY OF DIAGNOSIS. 
 
 will bend everything to the support of their theory. 
 Physicians are very frequently guilty of this, and 
 should try to get rid of the bad habit which they con- 
 demn in nurses. 
 
 The question — how do you feel ? elicits a loose, wan- 
 dering description of the patient's sensations, and is 
 only important, in that it suggests special questions and 
 examinations. The question — where do you feel bad? 
 is pertinent, and will elicit valuable information of 
 local disease. It does not do to take it for granted 
 that the patient's anatomical or physiological knowl- 
 edge is perfect, and that his reference to heart, lungs, 
 stomach, liver, etc., means heart, lungs, stomach, liver. 
 The direction at once follows — put your hand on the 
 place. It is a little singular to find after a patient has 
 located a disease in his own mind, the hand meanders 
 about with uncertainty, trying to find its location. If 
 the unpleasantness is marked, and means local disease, 
 the patient has no difficulty in placing his hand upon 
 the exact spot. 
 
 If there is anything uncertain in the patient's man- 
 ner or method, and especially if uneducated, we wish 
 him to describe his sensations, with the hand upon the 
 affected part In many cases we will find that the de- 
 scription commences to wander as soon as the hand is 
 removed. There is a reason for this ; with the hand 
 upon the part, the mind is directed to it and concen- 
 trated, extraneous ideas are rejected, and the descrip- 
 tion is of actual sensations. 
 
 We want to know the character of the pain, its dura- 
 tion, exacerbations and remissions, periods of recur- 
 rence, and its influence on function. In this examina- 
 tion the physician should show by his questions and 
 manner that he wants concise and specific answers. 
 
STUDY OF DIAONOSTS. 203 
 
 The subject of pain is a study of itself, and much 
 less is known of it than we would wish. In some 
 cases it indicates the special remedy which will cure, 
 in others it simply points to a pathological condition, 
 and remedies must be selected by other symptoms. 
 
 Thus if we have a pain in the head, heavy, tense, 
 and sleepy, we give Belladonna; if it is sharp and 
 restless, Gelseminum ; if sharp, limited in location, de- 
 spondent, Pulsatilla. If of the frontal region and 
 orbits, with burning, .Rhus ; if of the right side passing 
 from before backwards, Bryonia ; if of the back of the 
 head, dull and heavy, Iron. 
 
 The pain in right hypochondrium, pointing to the 
 umbilicus, indeed, all pains pointing at the umbilicus, 
 Nux Vomica. Pains deep in the ischiatic notches, 
 Podophyllin. Pains that are tensive and paroxysmal, 
 Macro tys. 
 
 The pain of Macrotys is a singular one. It feels as 
 if dependent upon tension, and is decidedly remittent — 
 a continued succession of tensive pains. We usually 
 prescribe Macrotys for muscular pain, no matter what 
 its character, and hit it in a large majority of cases. 
 For this remittent tensive pain — waves of pain — no 
 matter where it is, we may prescribe the Macrot}'S with 
 certainty, (the pain is not throbbing.) A recent case 
 of facial neuralgia was very striking. The gentleman 
 had suffered for some weeks, and had taken various 
 remedies without relief; and I had made three failures 
 myself. Close questioning brought out the character 
 of the pain, and Macrotys gave prompt relief. 
 
 I admit that it is very much easier to prescribe from 
 the location of the pain, than from its character, for 
 whilst a patient maj 7 be able to locate it correctly, it is 
 not possible for him to describe its character. 
 
204 STUDY OF DIAGNOSIS. 
 
 If we take the pain of Lobelia, we will find its prin- 
 cipal characteristic anguish, of which angina pectoris 
 and neuralgia of the heart offer the most common ex- 
 amples. It is that indescribable sensation as if the life 
 was being forcibly riven from the part — anguish ex- 
 presses it. Lobelia is specific to it. Give twenty to 
 forty drops of a good tincture of the seed to a person 
 suffering from angina, and there is instant relief, which 
 becomes complete in a short time. I have seen one 
 case of uterine neuralgia presenting this character, and 
 from which the patient had suffered beyond conception 
 — a single dose arrested the paroxysm ; and its repeti- 
 tion when the symptoms were felt, gave a radical cure. 
 I have seen two cases of abdominal pain presenting this 
 character to some extent, and both were relieved by 
 Lobelia. A singular case of hypochondria, in which 
 the feeling as if a movement of the body would endan- 
 ger life, but without pain, was cured with Lobelia, 
 
 The peculiarity of this pain or sensation is so dis- 
 tinct, that patients may describe it. For many years 
 (indeed it was one of the first things I learned in prac- 
 tice) I have given Lobelia in certain cases of labor 
 where the pains assumed this character. Every one 
 will have recognized the two classes of pain, one of 
 which is well borne, which is really relieved by the 
 action of the will, and the other which finds no such 
 antagonism. In the latter class I find the indication 
 for Lobelia, and it has proven one of the most efficient 
 agents I have ever used in obstetric practice. Of the 
 two agents Ergot and Lobelia, I would take the last a 
 hundred to one. 
 
 Let me briefly call attention to the abdominal pain 
 of Nux Vomica. 
 
STUDY OF DIAGNOSIS. 205 
 
 I say it is any pain having a tendency to point at the 
 umbilicus; it is pretty accurately located. It may be a 
 simple colic, a bilious colic, a derangement of the func- 
 tion of the liver, a wrong of the spleen, a dj^smenor- 
 rhoea, a disease of the colon, irritation of the bladder — 
 if the pain shows the constant tendency to the umbili- 
 cus — I should give Nux. I should fail sometimes, but 
 the failures would be small in proportion to the suc- 
 cesses. The definiteness of the symptom, and its easy 
 recognition, are what please me. 
 
 The pain indicating Ehus Toxicodendron is very dis- 
 tinctive. Frontal pain, especially involving the orbits, 
 and inclined to be more severe on the left side. Such 
 pain would lead me to prescribe Rhus, if there were no 
 other indications. Add the peculiar appearance of the 
 papillae at the end of the tongue, and I would have a 
 positive assurance of success. To any pain add burning 
 and we would think of Ehus as a possible remedy. 
 Given, the pains of rheumatism with burning, and Ehus 
 is the anti-rheumatic, or is alternated with Macrotys. 
 A case of puerperal fever this Summer in which burning 
 sensations and pains were pronounced, was cured with 
 Aconite and Ehus; and arrested so promptly that there 
 could be no mistake in the action of the remedy. 
 
 The pain calling for Bryonia, whilst it may be sharp 
 or dull, always has with it a sense of oppression, as if 
 the part were enfeebled, and could not perform its 
 function. Homoeopaths speak of burning as character- 
 istic of this pain, but I have not been able to see it. 
 Take a case of pleurisy, or pleuro-pneumonia, or pneu- 
 monia, with this sense of oppression and feebleness, as 
 if the part could not and should not do its work, and 
 Bryonia, with the proper sedatives, will prove curative. 
 
206 STUDY OF DIAGNOSIS. 
 
 In the same way a rheumatism giving the same symp- 
 toms of inability, with increased pain following the 
 use, will be cured with Biyonia. 
 
 The pain calling for Belladonna is dull, heavy, full, 
 with a sense of functional impairment. It makes but 
 little difference where you find it, or in what disease ; 
 whether a simple headache, an ague, u bilious fever,' ' 
 or inflammation of the lungs, Belladonna will prove 
 curative. 
 
 The pain calling for Stramonium is constrictive, and 
 when involving muscular structures, is attended with 
 persistent contraction, and of the outlets of the body 
 is expulsive. A case of dysentery, with most violent 
 expulsive movement of the pelvic muscles, was speedily 
 relieved with Stramonium; as was a case of broncho- 
 pneumonia, showing as a symptom a most marked and 
 unnatural constriction of the chest. 
 
 The pain calling for Gelseminum has as a marked 
 feature exalted sensibility and arterial throbbing. In 
 some cases, especially in the head, the patient dreads 
 movement, and the pulsation of the arteries is distinct 
 and painful. With such pain in any part of the body, 
 we would prescribe Gelseminum with every assurance 
 of success. 
 
 The pain calling for Chelidonium is dull, heavy, ten- 
 sive, with occasional twinges, as if the part was being 
 torn. Situated in the hypochondria or epigastrium, 
 Chelidonium is the " liver " medicine. 
 
 The pain calling for Iodide of Ammonium seems to 
 involve a definite amount of tissue, as in inflammation, 
 and yet points at some particular place which might 
 be covered with the tip of the finger. 
 
 In thus calling attention to the symptomatology of 
 
STUDY OF DIAGNOSIS. 207 
 
 pain in therapeutics, I do not wish to be understood as 
 claiming that it is infallible. Our own senses are suf- 
 ficiently imperfect, even when trained by long obser- 
 vation. The senses of the patient are untrained and 
 impaired by disease, and his descriptive powers may 
 be very feeble. 
 
 NOSOLOGY. 
 
 A distinct department which has for its object the 
 classification of diseases, is named nosology, and though 
 we do not propose to make such classification, the sub- 
 ject demands a brief study. In so far as the ordinary 
 classification facilitates study, and the knowledge of 
 disease, it will prove beneficial, but whenever it is 
 made the basis of therapeutics, it must work an injury. 
 
 Nosology is said to have three objects of considera- 
 tion : 1st. The distinction and definition of particular 
 diseases. 2d. The nomenclature of the diseases, or the 
 assignment of the names by which they are to be des- 
 ignated, so that each disease may be distinguished and 
 known by an appropriate name. 3d. The arrangement 
 or classification of diseases in some methodical and con- 
 venient order by which they may be distributed into 
 classes., orders, genera, or species." 
 
 We employ this method in natural history, and 
 divide animals and vegetables into " classes, orders, 
 genera, or species ;" why should we not employ it in 
 the study of disease ? If one will think for a moment 
 the reason will be obvious. The individual, animal, or 
 vegetable, is a distinct, tangible entity; disease is a 
 method of life. When we use this classification, we 
 
208 STUDY OF DIAGNOSIS. 
 
 think of the object as things, not conditions or states. 
 Thus this method of classifying disease carries to tho 
 mind the idea of disease as an entity, a thing that has 
 precise form and condition. This idea has been the 
 foundation of an erroneous practice, and the obstacle 
 to a successful study of medicine. 
 
 The reader will understand me to say that so far as 
 therapeutics, or the giving of remedies for disease is 
 concerned, the common nosology is a continued source 
 of error, though in so far as it may facilitate the study 
 of pathology it may answer a good purpose. Used to 
 direct the means of cure, it is wholly insufficient, and 
 many times erroneous. Under single names are 
 grouped the most diverse characters of disease, varying 
 in different persons and at different times. 
 
 If disease is an entity, the doctor thinks of his medi- 
 cine as a policeman who takes that entity by the 
 collar and walks it out of the body. Whj^ not? 
 "Worms" is a disease, then ascaris lumbricoides, a 
 variety of this disease — send in Mucuna Pruriens to 
 tickle the disease to death and make it u vamose the 
 ranche." Or, we might arrange it as follows : Class — 
 eccritica ; genus — mails ; species — pediculis capitis ; treat- 
 ment — crack them. 
 
 It does look a little funny when we take this view of 
 it, and 3-et j r ou may say that this is an exceptional 
 case ; let us see. Disease erysipelas, grows by continuity 
 of structure ; treatment — fence it in and keep it from 
 spreading. And so the doctor takes Nitrate of Silver, 
 Tincture of Iodine, or Tincture of Muriate of Iron, 
 and makes his dark line on the outside of the disease, 
 saying, here is an obstruction, I want you to stay on 
 your own side. If the eiysipelas had been a v.cious 
 
STUDY OF DIAGNOSIS. 209 
 
 animal, he could not have built his fence with a more 
 determined purpose. 
 
 If the reader will think for a moment, he will be 
 surprised how strong a hold this idea of disease as an 
 entity has upon the profession, and how it is made to 
 serve as a basis for the most unpleasant medication. 
 The physician forgets the life of the patient in his effort 
 to rid him of his disease — a disease that he has caught, 
 or one that has caught him. He forgets the impair- 
 ment of life, the functional wrongs ; that disease is a 
 condition of life — is life, and that it can not be vomited 
 through the mouth, purged from the bowels, sweated 
 from the skin, passed with the urine, drawn by a lancet 
 from the bloodvessels, killed with mercury or tartar 
 emetic, or so afflicted by the class antiphlogistic that in 
 sheer desperation, it will take itself out of the body. 
 
 Distinction and Definition. — Our authority says 
 that the first object of nosology is "the distinction and 
 definition of particular diseases, or of their genera and 
 species." Here is the common error, of disease as an 
 entity, for which he wishes a distinction and definition. 
 He does not desire a definition of pathological life or 
 groups of unvarying pathological wrongs, but such dis- 
 tinction as will enable him to affix a name. 
 
 Neither are we to understand that this " distinction 
 and definition " is to have reference to means of cure, 
 or indeed that they will serve as any ^uide to reme- 
 dies. Aitken remarks : " In modern times the great 
 advantages that have arisen from establishing defini- 
 tions in natural history upon fixed and determinate 
 principle, not only of its various objects individually, 
 but also of the groups under which it was found pos- 
 18 
 
210 STUDY OF DIAGNOSIS. 
 
 sible to arrange them, suggested to medical men tho 
 idea that much advantage might also result to tho 
 science of medicine from defining diseases, and such 
 groups of diseases as might be found expedient to re- 
 cognize, under general terms or common names, based 
 upon some fixed and determinate principles. " The 
 reader will notice in this quotation the tendency to the 
 error named, and the student finds it impossible to 
 read medicine without getting the idea, that diseases 
 thus classified must be something definite, like the 
 animals and vegetables whose classification is appro- 
 priated. 
 
 Nomenclature. — The second object of nosology is 
 to name the diseases thus defined, and the medical 
 world has travailed in labor with names, for many 
 years. It is very much as recorded in Genesis : " And 
 out of the ground the Lord God formed every beast of 
 the field, and every fowl of the air, and brought them 
 unto Adam, to see what he would call them ; and what- 
 soever Adam called every living creature, that was the 
 name thereof" 
 
 A name should carry to the hearer an accurate idea 
 of the person or thing in its various attributes, and if 
 names of diseases did this we could not object. In so 
 far as names do indicate the wrong of life, names are 
 useful as guides to correct practice. In so far as 
 names direct the mind in pathological inquiry, they 
 will prove of advantage in medical study. But when- 
 ever they are recognized as entities, at which remedies 
 are to be hurled, and which must be forced out of the 
 human body, then they will prove a source of error. 
 
 Plancquet claimed that " the name of each diseaso 
 
STUDY OF DIAGNOSIS. 211 
 
 or species should be so significant that a person slightly 
 acquainted with the language and the subject, should, 
 on hearing it, immediately understand what is the 
 nature of the disease it designates. " To such a nomen- 
 clature we should not object, and if it should go one 
 step further, that on hearing it we should immediately 
 understand what remedy would rectify the wrong, or 
 cure it, then it would be perfect. 
 
 If we take the nomenclature of the Eoyal College 
 of Physicians, of London, we find 1,146 distinct dis- 
 eases, and if we would add the named sub-classes or 
 varieties it would bring the number up to near 2,000. 
 A man has one right life, and his varied physiological 
 processes can be studied under one or two score heads, 
 but his wrong life requires a classification under 1,146 
 heads, or distinct varieties. 
 
 If we examine the therapeutics which go with this 
 classification, we find that it numbers but about one 
 hundred remedies in use, and but about twenty in gen- 
 eral use, and of these five to ten are in common use for 
 everything. This shows a wonderful discrepancy 
 between the nosology of disease and its therapeutics. 
 
 Classification of Diseases. — Probably more is 
 gained in the classification of disease than in its nomen- 
 clature. The object of classification is to notice the 
 resemblances rather than the differences, to determine 
 the pathological wrongs common to a series of diseases, 
 rather than to determine the special symptomatic dif- 
 ferences. With regard to classification, Dr. Aitken 
 remarks : 
 
 " It is obvious that any single character, or combina- 
 tion of characters, in respect of which diseases agree 
 
212 STUDY OF DIAGNOSIS. 
 
 with or differ from each other, may be made the basis 
 of methodical arrangement, under a larger or smaller 
 number of divisions, or of higher or lower genera 
 (language of logicians), or of classes, orders, and genera 
 (language of naturalists). By ingenious devices of the 
 mind the physician or the statist may classify and 
 arrange his knowledge so as to bring it all more readily 
 within his reach for any special purpose — so as to make 
 it, in fact, more at his disposal — to facilitate and pave 
 the way for further investigation. Such are the legiti- 
 mate objects and the results of all methodical arrange- 
 ments. Classification, therefore, being only a method 
 of generalization, there are, of course, several classifi- 
 cations of disease which may be used with advantage 
 for special purposes. The physician, the pathologist, 
 the jurist, the hospital statist, the army or navy medi- 
 cal officer, may each legitimately classify diseases from 
 his own point of view, and for his own purposes, in the 
 way that he thinks the best adapted to facilitate his 
 inquiries, and to yield him general results. The 
 medical practitioner may found his main divisions of 
 diseases on their treatment, as medical or surgical ; the 
 pathologist, on the nature of the morbid action or pro- 
 duct; the anatomist or the physiologist, on the tissues 
 and organs involved ; the medical jurist on the sud- 
 denness, slowness, violent or unnatural mode of the 
 death ; the hospital statist, on the kind of diseases 
 which are treated in its wards ; and all of these points 
 of view may give useful and interesting results, (Farr). 
 " There is thus no question on which more diversi- 
 fied opinions are legitimately entertained than on that 
 of classification. Although it is the aim of all syste- 
 matic writers and observers to arrange the objects of 
 
STUDY OF BIAGNOSrS. 213 
 
 study in the most natural order possible, and although 
 diseases are named as if they were individual entities, 
 yet they present so great varieties that they will not 
 admit of that definite and, in many respects, natural 
 species of classification which can be made with objects 
 of natural history. Manifest reasons of convenience 
 and facility for work can therefore be assigned as the 
 great incentive to classification; and numerous reasons 
 exist for classifying diseases in various ways: (1.) Men 
 differ in their estimation of the characters on which 
 different arrangements may be founded. (2.) The 
 facts and phenomena of diseases on which classifica- 
 tions may be made are not all regarded from the same 
 point of view. Most systems are avowedly artificial, 
 being arranged with the view to elucidate or support 
 a theory, or otherwise to effect a definite end. For ex- 
 ample, by classifying diseases and recording the causes 
 of death, the most valuable information is obtained 
 relative to the health of the people, or of the unwhole- 
 someness and pestilential agencies which surround 
 them. 'We can take this or that disease,' says Dr. 
 Farr, « and measure not only its destructiveness, but 
 its favorite times of visitation ; we can identify its 
 haunts and classify its victims.' We are able to trace 
 diseases also as they perceptibly get weaker and weaker, 
 or otherwise change their type, as some have done from 
 time to time. We know from the valuable returns of 
 the Registrar-General, prepared periodically by Dr. 
 Farr, that certain diseases are decreasing, or growing 
 less and less destructive ; that certain other diseases 
 have ceased in some measure ; while other severe dis- 
 eases have exhibited a tendency to increase. The ad- 
 vantages, therefore, of adopting some system of class i- 
 
214 STUDY OP DIAGNOSIS. 
 
 fying diseases, which can be put to such useful prac- 
 tical purposes, must be obvious to every one." 
 
 If one can free the mind from the idea that nosology 
 has a direct relation to therapeutics, these subjects may 
 be studied to advantage. We want to learn the natura! 
 history of diseased life as we have learned the natura! 
 history of healthy life. If a classification and nomen- 
 clature will aid in this, even if only as guide boards 
 and mile posts, we may employ them. 
 
 To a certain extent, the common nomenclature of 
 disease is a necessity. It is quite as necessary to be 
 able to name a disease for the satisfaction of friends, 
 as it is to give successful treatment. The name may 
 not probably have anything to do with the manage- 
 ment of the case, or the selection of remedies, indeed 
 should have nothing to do with it, yet we are forced to 
 give a name. The first question asked of the physician 
 in the sick room is, " What do you call it ? " and we 
 must be able to " call it " correctly according to the 
 commonly received nosology. 
 
 If we can simplify our classification, so as to make it 
 a good guide for study, we will do well ; if we can 
 make it suggestive of causes of disease which may be 
 avoided, of right attention to hygiene, and an outline 
 of treatment, we will have accomplished all that can 
 be reasonably anticipated. Let us see how far we can 
 make such classification. 
 
 The first division will have reference to causes of dis- 
 ease, as well as to pathological conditions. It will be 
 into epidemic , contagious, endemic and sporadic diseases. 
 The reader will notice that this is a natural classifica- 
 tion, referring to causes of disease and their avoidance, 
 and to a less extent to the conditions of disease and 
 means of cure. 
 
STUDY OF DIAGNOSIS. 215 
 
 The second division will have reference to the general 
 or local nature of the morbid states, and as will be 
 noticed occupies the same ground as the preceding, 
 this having reference to the conditions of disease and 
 not to its cause. All disease may be classified under 
 these two heads, though many times it will only have 
 reference to the primary lesion, for as the wrong goes 
 on, a disease which was primarily general becomes 
 localized, and one which was primarily local will cause 
 general disease. 
 
 A third division has reference to the structure of 
 parts or to their functional expression, and diseases are 
 divided into structural and functional. Again, it will be 
 seen that this classification of disease occupies the 
 ground of both the first and second, for all disease 
 must be structural or functional. Here, as before, we 
 find it especially applicable to the primary disease, for 
 one may have commenced as a functional wrong, and 
 grown into a structural disease, as a structural disease 
 may have first existed, but this being cured, other func- 
 tional lesions persist. 
 
 A fourth division might be called physiological, and 
 would have reference to the functions of the body. 
 If, for instance, we make the usual classification in 
 teaching the principles of medicine : 
 
 C Formative, 
 Force.-! Heat, 
 
 ( Electricity. 
 
 C Formative, tissue making. 
 
 Cells.-! Secreting, does the work of secretion. 
 
 ( Necrological, pus cells. 
 
 C Digestion, 
 Nutrition. J Blood making, 
 ( Tissue making. 
 
216 
 
 STUDY OF DIAGNOSIS. 
 
 Secretion.. 
 
 f Recrementitious, 
 \ Excrementitious. 
 
 C Arterial, 
 Circulation.-! Venous, 
 
 ( Capillary. 
 
 Innervation 
 
 Brain, 
 
 nal cord, 
 mpathetic. 
 
 f Bra 
 i Spi 
 
 I Syr. 
 
 Taking this classification, and assuming that there is 
 a normal standard of health which may be known, and 
 that disease is a departure from this standard, all 
 lesions may be classified as being in excess, defect, or 
 perversion. This classification is used by Dr. C. J. B. 
 Williams in his Principles of Medicine, as in the follow- 
 ing tables : 
 
 PRIMARY ELEMENTS OF DISEASE. 
 
 STRUCTURAL CONSTITUENT. ITS FUNCTION. 
 
 STRUCTURAL DISEASE 
 
 Contractile fiber. 
 
 ( Irritability. 
 ( Tonicity. 
 
 f Tubular (the con- 
 ductor of nerve 
 
 I force.) 
 Nervous «{ Vesicular (the 
 structure I generator and 
 
 I combiner of nerve 
 
 t force.) 
 
 Secreting structure. Secretion. 
 Red corpuscles. 
 White corpuscles. 
 Fibrin. 
 Albumen. 
 Oil, and combus- 
 
 tive matters. 
 Inorganic ingredients, 
 (saline and mineral ) 
 Water. 
 
 Sensation. 
 
 Voluntary motion. 
 
 Involuntary motion, 
 (excited motor ac- 
 tion.) 
 V Sympathetic action. 
 
 Element- 
 ary com 
 ponents 
 of blood. 
 
 Elementary fS^S-- 
 
 ' Excessive — Hyper- 
 trophy. 
 
 Deficient— A tro 
 phy. 
 
 I Perverted— Degen- 
 eration. 
 
 
 [By foreign matter. 
 
 ^^-•iC 
 
STUDY OF DIAGNOSIS. 
 
 217 
 
 PROXIMATE ELEMENTS OF DISEASE. 
 
 f Deficient in quan- f General, 
 tity— Anaemia. (Partial. 
 
 f General— Plethora. 
 
 Excessive in 
 « quantity — Hyper- 
 emia. 
 
 Partial — Local hy- 
 peremia. 
 
 
 £3 
 
 j2 (Perv'ted in qual- 
 H ity — Cachsemia. 
 
 f Deficient — Atrophy. 'i 
 
 Nutrition of I Excessive — Hypertrophy, 
 textures. < ( Degenerations of tissues, 
 
 I Perverted. < Morbid deposits. 
 
 [ (^Morbid growths. 
 
 Increased — Sthen ic. 
 Dimin'd — Asthenic. 
 
 Increased — Determi- 
 nation of blood. 
 Dimin'ed — Congest'n. 
 Partly inc. jlnflam- 
 Partly dim. jmation. 
 
 If now we add to this the ordinary nomenclature of 
 disease, employed in this country, the reader will have 
 before him a brief resume of nosology. It will be seen 
 that these various classifications point the way to certain 
 necessary studies, having reference to causes of disease, 
 their general expression, their influence on the func- 
 tions of life, and lastly the technical language by which 
 they are designated and known. 
 
 It will be recollected that diseases are first divisible 
 into general and local, and the first may be arranged 
 according to the classification of Wunderlich as follows : 
 
 f Tabes. 
 
 Chlorosis. 
 
 Scorbutis. 
 
 Dropsy. 
 General Disease — Dyscrasia.^j Diabetes. 
 
 I Rheumatism. 
 
 Pyaemia. 
 I Tuberculosis. 
 [_ Carcinoma. 
 
 Lesions induced by{^P ecilic A S ents ' 
 
 .Vegetable Substances. 
 
 19 
 
218 
 
 STUDY OF DIAGNOSIS. 
 
 Periodic. 
 
 Fevers. -{ Continued. 
 
 Eruptive. 
 
 /Intermittent. 
 Rpmittent. 
 
 Yellow. 
 
 Febricula. 
 
 Synocha. 
 
 Synoehus. 
 
 Typhoid. 
 
 Typhus. 
 C Variola. 
 -J Scarlatina. 
 
 Contagious.} — — 
 
 {Spotted. 
 Stf&St* Meningitis - 
 Erysipelas. 
 
 Local diseases are usually arranged in groups accord- 
 ing to the function of parts. This seems to be the 
 most natural arrangement, as the expression of disease 
 is frequently a wrong of function. 
 
 (Of the Brain. ) Q . n . fn „ Ql 
 Of the Nervous System. ] Spinal Cord. ~i 
 f Sympathetic.) 
 
 f Eye — sight. 
 
 (Ear — hearing. 
 Nose — smelling. 
 Mouth — taste. 
 Skin — touch. 
 
 i 3 
 
 Of the Respiratory 
 
 
 r Nose. 
 
 
 
 Pharynx. 
 
 r- e* 
 
 
 Larynx. 
 
 5 & 
 
 Apparatus, -j 
 
 Trachea. 
 
 
 
 Bronchia. 
 
 •1 ™ 
 
 
 Lungs. 
 
 
 
 Pleura. 
 
 
 
 Heart. 
 
 
 
 Pericardium. 
 
 
 
 Arteries. 
 
 3 C 
 
 Apparatus. - 
 
 Capillaries. 
 
 
 
 Veins. 
 
 5'S 
 
 C3 3 
 
 
 Lymphatic Vessels. 
 
 fLP 
 
 
 Lymphatic Glands. 
 
 
STUDY OF DIAGNOSIS. 
 
 219 
 
 'Mouth. 
 
 Salivary Glands. 
 Tonsils. 
 Pharynx. 
 (Esophagus. 
 
 ^ SmXlntestine. 
 
 Large Intestine. 
 
 Liver. 
 
 Spleen. 
 
 Pancreas. 
 
 Peritoneum, 
 f Supra-renal Capsules. 
 | Kidneys. 
 Of the Urinary Apparatus. -\ Ureters. 
 
 | Bladder. 
 (Urethra. 
 
 § 5" 
 
 o c 
 
 hrj03 
 
 
 Of the Reproductive Organs. 
 
 Of the Skin. 4 
 
 Of the Organs of Locomotion. 
 
 'Scrotum. 
 Testes. 
 
 Vesiculae Seminales. 
 Prostate. 
 Penis. 
 Ovaries. 
 Uterus. 
 Vagina. 
 Vulva. 
 Urethra. 
 " Cutis Vera. 
 Rete Mucosum. 
 Epidermis. 
 Sudoriferous Glands. 
 Sebaceous Follicles. 
 Hair. 
 Nails. 
 
 Bones. 
 
 Articulations. 
 Cartilages. 
 Muscular Tissue. 
 Fibrous Tissue, 
 Connective Tissue. 
 
 5 * 
 
 5 ^ 
 
 The reader will notice that whilst this classification 
 is exceedingly simple, it directs attention to the part 
 diseased, the function impaired, and in so far as reme- 
 dies act on particular parts, it suggests appropriate 
 
220 STUDY OF DIAGNOSIS. 
 
 remedies. In ordinary professional consultation it 
 proves sufficient, as it does in writing, and it is quite 
 sufficient to satisfy the popular demand for names. 
 
 GENEKAL CLASSIFICATION 
 
 We will make a study of disease according to the 
 four general divisions heretofore named. 1st, with ref- 
 erence to the cause — epidemic, contagious, endemic, spo- 
 radic; 2d, as it is general or local ; 3d, as it is structural 
 or functional ; and 4th, as it shows a departure from 
 the 'physiological standard. In doing this the special 
 features will be so pointed out, that the reader will be 
 enabled to recognize the divisions, and classify his 
 cases according to them. 
 
 It is possible that the description will be at times 
 longer than is really necessary for the purposes of 
 diagnosis, as we wish as far as possible to study the 
 natural history of disease, but it will be made as con- 
 cise as possible. 
 
 EPIDEMICS. 
 
 A thorough study of epidemic influences has not yet 
 been made, and we know much less of the subject than 
 we should, yet what Ave do know has an important 
 bearing upon practical medicine. 
 
 Many physicians have recognized the fact, that the 
 conditions of life do change from time to time, and that 
 as the result of this there are variations in the wrongs 
 of life — diseases — and in their expression. That in 
 some years and seasons, these changes were so great as 
 <o give that character to disease which is usually known 
 
STUDY OF DIAGNOSIS. 221 
 
 as epidemic. The fact has been recognized, that this 
 epidemic condition might influence but one disease, or 
 a class of diseases, as those called contagious, those 
 called zymotic, or it might influence all diseases or 
 pathological states. 
 
 The general epidemic influence is known by some 
 special character of disease, which is wide-spread, and 
 is noticed in many localities. In some cases it will be 
 seen as a condition of asthenia, in others of undue ex- 
 citation. In some it partakes of the z}miotie character, 
 and this influence upon the blood is noticed in a 
 majority of cases of acute disease. Physicians will re- 
 collect it under the name of typhoid, giving a peculiar 
 character to fevers and inflammations, and even 
 noticed in minor affections. 
 
 This epidemic influence is frequently marked by 
 special symptoms calling for special remedies. Thus 
 the diseases of the Winter of 72-73 were characterized 
 hy a peculiar frontal pain, frequently localizing itself 
 in the left orbit; a peculiar appearance of tongue, with 
 prominence and redness of the papillae of the tip ; the 
 tendency To erythematous redness and inflammation of 
 skin and mucous membranes. Epidemic remedy — 
 Rhus Toxicodendron. The present year, 1873-74, we 
 notice the common basilar pain,. and the impairment 
 of the venous circulation — fullness of veins, a pecu- 
 liarity of pain, especially of right side, and affection of 
 serous membranes. Epidemic remedies — Podophyllin, 
 Bryonia. In 1870-71, we noticed especially the deep 
 coloration of mucous membranes, the tendency in 
 severe disease to brown tongue and sordes. Epidemic 
 remedy — Muriatic Acid. 
 
 To diagnose this epidemic influence, one must be a 
 
222 STUDY OF DIAGNOSIS. 
 
 reader of the periodical literature of the day, so as to 
 see the expressions of disease in different localities. 
 It is true that observations are made without reference 
 to this, and the reporters do not believe in it, but the 
 evidence is all the more valuable. No one can take a 
 half dozen of our medical periodicals, and compare 
 them for a series of years, without being struck with a 
 certain similarity in the diseases of a year, or a series 
 of years, which can be accounted for in no other way. 
 It would be possible from our periodical literature to 
 tabulate the character of these epidemic influences for 
 a considerable period of time, and this no doubt will 
 be done in the future. 
 
 The reader will have no doubt observed, that the dis- 
 eases of some seasons, no matter *how diverse in special 
 characteristics, would have something in common, 
 which something w r ould be especially manifest in the 
 treatment. That in some seasons Quinine would cure 
 everything, in others the sedatives would cure every- 
 thing, in others a remarkable benefit from Podophyllin, 
 so that when you had once determined a good treat- 
 ment, you would persist in it for all affections, with 
 very little modification. 
 
 And this brings prominently before us the fact, for 
 fact it is, that there is an endemic or epidemic consti- 
 tution of disease, that should be well studied, and 
 always regarded in treatment. Success or failure will 
 very frequently depend upon this knowledge, and it is 
 something that must be relearned every year. 
 
 It was a prominent doctrine of Eademacher and his 
 followers, and he had remedies for three such constitu- 
 tions. These were Iron, Copper, and the Nitrate of 
 Soda. There was some truth in this, how much I don't 
 
STUDY OF DIAGNOSIS. 223 
 
 know, for I have not had the opportunity to experi- 
 ment, and, indeed, have not had time to give his works 
 the examination they should have, as I read German 
 slowly, and they have never been translated. 
 
 I believe, however, I have passed through one year, 
 in which Iron was the remedy for almost everything, 
 and I think probably some of our old practitioners 
 may recollect it, if they by chance had used Iron. 
 The season commenced in December with a large num- 
 ber of cases of erysipelas, for which Iron was a specific, 
 and for some fourteen months I prescribed Iron daily 
 for almost everything, with the most flattering results, 
 I have experimented with Copper and Nitrate of Soda 
 to but a limited extent. 
 
 Kademacher applied the principle to chronic disease. 
 Grauvogl says : 
 
 "One experience gained by this school is worthy of 
 special consideration — ' that, in old chronic diseases, the 
 previous epidemic constitution always decides, first of 
 all, upon the present indication of a remedy, hence, in 
 every case which comes up for treatment, the time of 
 its first appearance should be learned, as far as possible, 
 for, by this, frequently, if the then epidemic curative 
 remedy is known, the primary seat and the primary 
 kind of the diseased process are known also, and this 
 very remedy will still effect a care, if a cure is yet 
 possible, or, if the disease is not already succeeded by 
 another disease of the first affected organ or blood, or 
 if disease of another organ has not ensued. But, even 
 in this latter case, that knowledge gives the point of 
 departure for the whole chronic affection.' 
 
 " That is in gross, what we see happen on a smaller 
 scale, after strong or oft-repeated doses of long-acting 
 
224 STUDY OF DIAGNOSIS. 
 
 remedies. First appear symptoms at the point of 
 application, then of its reception in the blood, finally, 
 the affections of the specifically affected organs and 
 systems in succession, and often, at great intervals, as 
 we have observed veiy distinctly with quicksilver, for 
 instance. The only difference consists in this, that 
 epidemic injurious influences, often after very many 
 years, to the surprise of many, bring to view their con- 
 tinued operation as a token of the presence of their re- 
 sults under. various forms of disease, while the continued 
 operation of drugs is of proportionally shorter dura- 
 tion." 
 
 If this theory of epidemics is borne out by future 
 observation, it must have an important bearing upon 
 therapeutics. If we determine a common element in 
 the diseases of a season, we will have something common 
 in the remedies. If we have an underlying influence 
 of this kind, giving character to disease throughout a 
 considerable extent of country, it is an influence that 
 should be known, and have due weight in our estimate 
 of pathological processes. If we can go still furth er, 
 and find certain epidemic remedies opposed to this in- 
 fluence, whatever it may be, it will greatly aid our 
 treatment. 
 
 I am not only satisfied that we have these epidemic 
 constitutions of disease, but that we have epidemic 
 remedies as well. And going further than this, I 
 believe with Eademacher, that this epidemic influence 
 persists in chronic disease, and that the knowledge of 
 the epidemic influence at the time the disease com- 
 menced, may give us in the epidemic remedy of that 
 year, the means of cure. 
 
 We need not re-discuss the change of type theory, 
 
STUDY OF DIAGNOSIS. 225 
 
 and 3^et I have no doubt but that disease does change 
 its type; that for a number of years it has the char- 
 acter of asthenia, and for another period it Will be 
 sthenic. The knowledge of this will be available in 
 the selection of remedies. 
 
 Again we find years in which the peculiar wrongs 
 known as typhoid are prominent. All acute diseases 
 seem to partake of this character, and if of consider- 
 able duration, t3^phoid symptoms will be developed. 
 We have "typhoid pneumonia," "typhoid dysentery," 
 intermittents and remittents run into typhoid, as well 
 as other diseases. This epidemic influence is readily 
 recognized, and suggests treatment. 
 
 Zymotic diseases are not unfrequently epidemic, or 
 have underlying them the epidemic character. It is 
 true they frequent 1 ^ produce a specific contagion, which 
 serves as a cause of their propagation, and this we wish 
 to keep distinct from the character we are now studying.. 
 The epidemic influence is that which renders the com- 
 munity veiy susceptible to the contagious poison, or 
 gives it specific characters, or renders it more destruc- 
 tive to life. 
 
 Readers will readily recall epidemics of this character. 
 Seasons in which smallpox, scarlet fever, measles, 
 whooping cough, were remarkabl} T prevalent, easily 
 transmitted, difficult to protect against, possessed dis- 
 tinctive features, and required special treatment. And 
 they will likewise recall the fact, that in these years 
 other diseases would show similar peculiarities, and 
 would require similar remedies. This will have been 
 noticed in local complications, as well as in the general 
 features. That in some years there was a remarkable 
 tendency to disease of the respiratory apparatus, or of 
 
22G STUDY OF DIAGNOSIS. 
 
 the bowels, or of the kidneys, or of the nerve centres, 
 and that these local affections were to be met with as 
 complications of all diseases. 
 
 I have alread}^ noticed the fact that such epidemic 
 influences may be discovered in chronic diseases; that 
 many times the disease will partake to a greater or less 
 extent, of the epidemic constitution of the year in 
 which it was contracted, and will require the epidemic 
 remedies of that year in its treatment. Indeed, in 
 some cases, we find that determining this, and knowing 
 the constitution of disease at the time it commenced, 
 and the remedies that were curative then, we have de 
 termined the remedies which will prove curative, 
 
 It is not only important to thus be constantly on the 
 alert to determine the presence of epidemic influences, 
 and carefully note the expressions of disease at such 
 times, but it is well to keep memoranda for future use. 
 It is true that all disease has distinct and definite ex- 
 pression, and that for this we may find distinct and 
 definite remedies ; quite as much for this epidemic con- 
 stitution of disease as any other. 
 
 We are acquainted with quite a number of epidemic 
 remedies, and find the list continuously enlarging. So 
 marked is the influence, and so distinct the features, 
 that we sometimes find a single remedy sufficient for 
 the entirety of disease. It is possible that we may 
 make the best study of remedies in such seasons, for I 
 have noticed that if a remedy has thus proved markedly 
 curative at such times, the epidemic symptoms indicat- 
 ing it being pronounced, the remedy would prove cura- 
 tive in sporadic, endemic, or contagious diseases, wher- 
 ever the special symptoms were present. 
 
 The remedies worthy of special notice in this cor 
 
STUDY OF DIAGNOSIS. 227 
 
 nection are Quinine, Muriatic Acid, Soda, the Antisep- 
 tics, Sulphurous Acid and Sulphite of Soda, Chlorate 
 of Potash, Baptisia, Aconite, Vera tr una, Belladonna, 
 Gelseminum, Ehus Toxicodendron, Iron, Nitric Acid, 
 Podophyllum, Lobelia, Bryonia, Nux Vomica. 
 
 All of these, and such others as may have attracted 
 the attention of the reader as being especially useful 
 in certain years, may be advantageously studied in this 
 connection. 
 
 CONTAGIOUS DISEASES. 
 
 In this classification ^ye fi n d that certain diseases are 
 produced by a specific cause, generated during the pro- 
 gress of the disease, and propagated from person to 
 person. In them we find that the contagious element 
 is continuously reproduced in kind, and the expressions 
 of disease are alike. As before noticed, it may and 
 does vary from epidemic influences, and as we will 
 hereafter see, from endemic influences, but in general 
 features there will be a remarkable likeness, &nd in 
 therapeutics there will be something in common. 
 
 The diseases grouped under this head are the erup- 
 tive fevers — variola, rubeola, scarlatina, varicella; the 
 contagious cough — pertussis — whooping cough; some 
 zymotic diseases — erysipelas, puerperal fever, diphthe- 
 ria, spotted fever, cerebro-spinal meningitis ; some 
 fevers and inflammations, cholera, typhoid, typhus and 
 yellow fevers, inflammations with typhoid symptoms. 
 
 The general diagnostic feature is that the disease can 
 be traced from person to person, and when the fact of 
 exposure is known, we are justified in giving it the 
 
228 STUDY OF DIAGNOSIS. 
 
 care, and using the precautions against the spread of 
 contagion that may be necessary. 
 
 These diseases have certain distinct expressions by 
 which they may be known, and when we have a first 
 case, the contagious element will receive due considera- 
 tion, especially in guarding against its communication 
 to others, in some cases by the use of appropriate pro- 
 phylactic means. We also regard the fact, that the 
 contagion generated during the progress of the disease 
 may unpleasantly influence the j>atient, indeed his life 
 may be destroyed by its presence with and around him. 
 
 Variola. — The diagnosis of smallpox will be made 
 by — a, the intense, aching pain in all parts of the body, 
 deep seated, during the first day of febrile reaction ; b, 
 the appearance of the eruption, as distinct red spots, 
 Which give to the touch the sensation of hardness like 
 a shot under the skin ; c, the regular development of 
 the pustules in a period of nine days; and d, the flat- 
 tened and umbilicated form of the pustules. 
 
 It suggests protection by vaccination, by avoidance 
 of the cause, by the use of proper antiseptics. In the 
 treatment of the disease, that the contagion be removed, 
 as far as possible, by the excretory organs, and at 
 length by the completed stages of the eruption. When 
 the contagious virus is in large quantity, as shown by 
 the nsual evidences of decomposing animal matter, it 
 suggests the use of antiseptics, agents that destroy the 
 material of contagion, great cleanliness, and a sustain- 
 ing treatment. 
 
 Eubeola. — The diagnosis of measles will be made 
 by — a, the catarrhal sj-mptoms, full, suffused and in- 
 jected eyes, w T hich announce the attack; b, the pecu- 
 
STUDY OF DIAGNOSIS. 229 
 
 liar and constant cough ; and c, the irregular form of 
 the eruption. 
 
 It suggests Lobelia and Asclepias to favor the deter- 
 mination of the eruption upon the skin, and relief of 
 irritation of mucous membranes, and Drosera as the 
 special remedy for the cough. 
 
 Scarlatina. — The diagnosis of scarlet fever will be 
 made by — a, the early appearance of a sore throat, 
 which persists and is a marked feature of the disease ; 
 6, the high range of temperature, and dryness of sur- 
 face ; c, the vivid scarlet redness of the eruption ; and 
 J, the evident impairment of the cutaneous capillaries, 
 as marked by the persistent white line left as the finger 
 is drawn over the surface. 
 
 It suggests Belladonna in minute doses as a prophy- 
 lactic, Belladonna and Carbonate of .Ammonia as stim- 
 ulants to the capillary circulation of the skin. And 
 the use of fatty inunction alone, or with stimulants — 
 Creosote and Common Salt. 
 
 Varicella. — The diagnosis of chicken pox will be, 
 made by — a, the irregular appearance of the points of 
 eruption ; 6, their speedy development ; and c, their 
 vesicular form. 
 
 Pertussis — The diagnosis of whooping cough will 
 be made by — a, the occurrence of cough without febrile 
 symptoms ; 6, its parox}^smal and spasmodic character ; 
 and c, the whoop, the sibilant or whistling sound as the 
 air is forcibly drawn through the contracted larynx 
 during or at the close of the paroxysm. 
 
 It suggests specific remedies, Drosera, Belladonna. 
 
230 STUDY OF DIAGNOSIS. 
 
 Nitric Acid, and Trifolium Pratense, as may be indi- 
 cated in each case by special symptoms. 
 
 Zymotic Disease. — Whilst all contagions may bo 
 classed as zymotic, all zymotic diseases are not conta- 
 gious. Those named — erysipelas, diphtheria, spotted 
 fever, and cerebro-spinal meningitis — maybe epidemic, 
 endemic, or contagious, and we study them in each of 
 these classes. When they prove contagious, it may be 
 from either of two conditions — the intensity of the dis- 
 eased action, or the loss of life and breaking down 
 of the tissues. 
 
 If we take the first disease, erysipelas, we will find 
 that it sometimes develops remarkable virulence in this 
 direction ; so much so that it will attack almost every 
 surgical case in a hospital, and will be contracted by 
 nurses and others. This of course will be noticed espe- 
 cially in certain years (epidemic influence) and in cer- 
 tain localities (endemic influence), but we can not 
 neglect to notice the contagious element. 
 
 In the one case we notice the intensity of disease, both 
 as to its local and general symptoms. The part is in- 
 tensely hot, burning, painful, and is dry and tense, and 
 its color, whether bright or dark, is vivid. The pulse is 
 frequent, tense, and unyielding, the temperature has a 
 high range, and the nervous system shows great exci- 
 tation. Whenever such symptoms show themselves, 
 we may fear contagion, and will employ means to pre- 
 vent the infection of others. 
 
 In the second case we have the evidences of sepsis 
 and deliquescence of tissue. Locally the part is full, 
 and wants elasticity, the epidermis yields, and presently 
 the connective tissue The discharge becomes offen- 
 
STUDY OF DIAGNOSIS. 231 
 
 sive, the pulse oppressed and feeble, and the tissues at 
 large softened. 
 
 Whilst in the first case remedies would have reference 
 to the intensity of diseased action, and consist princi- 
 pally of the five specifics — Iron, Veratrum, Ehus, Apis, 
 Belladonna; in the second it will consist in the 
 use of the proper antiseptics, with restoratives and 
 food. 
 
 In the second, puerperal fever, we notice the same two 
 elements of contagion, quite as marked as in erysipelas. 
 But there is added a third, an infectious material 
 thrown off from the reproductive organs. So marked 
 and virulent is this, that it is readily communicated by 
 the physician from patient to patient, even through an 
 interval of days or weeks. It is not only thus infec- 
 tious, but is intensely poisonous to the patient, and its 
 re-absorption intensifies disease, and frequently leads 
 to a fatal result. 
 
 Having regard to tho means named in erysipelas, the 
 physician gives especial attention to prevent the spread 
 of contagion. In some cases this may be avoided by 
 strict attention to cleanliness, change of clothing, and 
 the use of antiseptics, as washing with a solution of 
 Chlorate of Potash, Sulphite of Soda, Labaraque's 
 Solution, or dilute Sulphurous Acid. To prevent re- 
 absorption, we use great cleanliness, and the antiseptics 
 just named. 
 
 In diphtheria the contagious property seems to be 
 developed more by the intensity of disease, than by 
 devitalization of tissue and putrescence, and it is 
 always well to use extra precautions when the febrile 
 action and local inflammation are intense. But here as 
 i n puerperal fever a specific infection is generated at 
 
232 STUDY OF DIAGNOSIS. 
 
 the point of local disease, and is readity communicable 
 to others. This is so marked that the diphtheritic de- 
 posit is readily inoculable, not only in the throat, but 
 on almost every abraded surface. 
 
 The knowledge of these facts will not only cause us 
 to guard against the general conditions of contagion, 
 as in the other cases, but especially against the trans- 
 mission of the local infection by coming in immediate 
 contact with the patient and inhaling the breath, the 
 use of towels, handkerchiefs, before they have been 
 thoroughly purified b}^ boiling, and especially the use 
 of probangs, swabs, or surgical instruments that have 
 been employed on a diphtheritic patient. 
 
 In cerebrospinal meningitis and spotted fever we have 
 the double element of contagion first named. The 
 generation of the infectious material by intensity of 
 disease, and b3 r loss of life in tissues, and putrescency. 
 The same means will be employed as in the case of 
 erysipelas, both to prevent the spread of contagion, 
 and to protect the patient against the poison generated 
 in his own body. 
 
 Cholera. — Asiatic cholera might be studied in the 
 class of epidemic diseases, as in the seasons of its prev- 
 alence there is a marked epidemic influence, that shows 
 itself in other diseases as well as this. But though we 
 recognize this, the evidence that it is propagated b 4 y a 
 specific contagion is too well proven to allow us to 
 neglect it. Cholera advances on lines of travel, and 
 renews its strength as it goes, going with people, being 
 propagated by and in people. Gaining strength and 
 virulence b}^ special combination of circumstances in 
 its native country India, it takes passage by steamship 
 
STUDY OF DIAGNOSIS. 233 
 
 to Europe, from Europe to America, where it is dis 
 tributed by railroad, steamboat and stage 
 
 It is probable that the infectious poison is found prin- 
 cipally in the excretions, and mainly in the dejections 
 from the bowels, and the disease is especially propagated 
 from them. If so, it points the physician to the neces- 
 sity of especial care in the removal of the dejections, 
 and that they be so disposed of as not to endanger 
 others, either by their exhalations, or by contaminating 
 the water supply. 
 
 We diagnose an attack of cholera by— a, the great 
 exhaustion that attends the first discharges ; 6, by the 
 evidences of imperfect circulation and aeration of the 
 blood, as seen in the bluish discoloration of the ex- 
 tremities ; c, by the want of color in the faeces, " rice 
 water"; d, by the marked enfeeblement of the circu- 
 lation, and lowered temperature ; and e, by the exces- 
 sive thirst, nausea and vomiting, and muscular cramps. 
 
 Typhoid Feveb, and acute diseases assuming typhoid 
 symptoms, usually possess the contagious element in 
 slight degree. Yet in some cases we observe a remark- 
 able development of this character which demands the 
 attention of the physician. Typhoid is generally 
 thought to mean asthenia, but it is better to think of it 
 as having reference to sepsis of the blood. With the 
 condition' of sepsis, comes the property of contagion, 
 and under some circumstances this becomes marked. 1 
 think diseases called typhoid will be found to develop 
 the character of contagion both from intensity of dis- 
 ease, and from impairment of the life of tissue and 
 putrescence. The most marked cases I have known 
 were when there was great nervous excitation, tense 
 20 
 
234 STUDY OF DIAGNOSIS. 
 
 tissues, high temperature, and the sensation of pungent 
 heat when the hand was applied to the surface. The 
 other cases are distinguished by a peculiar sweetish 
 cadaveric odor of breath, dark fetid faeces, and fetor of 
 urine. 
 
 Typhus Fever is markedly contagious, and may be 
 wholly propagated by a specific contagion generated 
 during the progress of the disease, and thrown off in 
 the excretions both from bowels, kidneys, skin and 
 lungs. It has been noticed that here intensity of dis- 
 ease, marked by great febrile excitement, was more 
 likely to develop the contagious element, than the con- 
 dition commonly known as putrescence. 
 
 Yellow Fever is undoubtedly contagious in degree, 
 sometimes very markedly, and at others so as to exert 
 but little influence. Both conditions of contagion have 
 been noticed : that from great intensity, of disease, 
 with the symptoms heretofore named, and from putres- 
 cency appearing in the last stage with the black vomit. 
 
 ENDEMIC DISEASES. 
 
 If disease showing distinct peculiarities is confined 
 to a locality, it is said to be endemic, especially if it 
 prevails to any considerable extent. In such cases the 
 cause is evidently local, and it is evident that many 
 times it may be discovered, removed, or avoided. 
 
 These diseases have a definite and distinctive expres- 
 sion, which should and may suggest the means of cure. 
 In some the endemic influence is so wholly the cause, 
 and the endemic expression so clearly indicates the 
 
STUDY OF DIAGNOSIS. 235 
 
 lesion, that remedies will be remarkable for their cura- 
 tive influence. At other times the endemic influence, 
 and disease produced, will be but a part of the wrong, 
 &nd whilst the endemic remedies are important, they 
 are not so certain as before, and have to be aided by 
 other means. 
 
 The diagnosis of endemic disease is usually very 
 clear : a, There is something distinct and special in the 
 expression of disease ; 6, there are a number of cases, 
 showing these special features ; c, the diseases are re- 
 stricted to definite localities. 
 
 First among the diseases included in this classifica- 
 tion are all those showing periodicity, including inter- 
 mittent, remittent, and yellow fevers. Following these, 
 wc find that an endemic influence may give rise to the 
 series of continued fevers, to all inflammations, and to 
 many functional and structural diseases. And it is to 
 be noticed that as -a rule the endemic influence intensi- 
 fies the natural disease in addition to giving it special 
 features. 
 
 Periodicity. — Whatever may be the cause of period- 
 icity in disease, the fact is sufficient^ 7 tangible, easily 
 recognized by the periodic expression, which indicates 
 a special pathological condition, and calls for a special 
 group of remedies, anti-periodics — Quinine. As before 
 remarked, the periodic element may serve as a basis of 
 nearly every named disease, which will be cured by the 
 one remedy, Quinine. Or it may only be a complica- 
 tion, or part of the disease, and Quinine will only be 
 one of the remedies called for. But periodicity does 
 not always mean Quinine, and it is sometimes difficult 
 to determine whether it does or not. All diseases are 
 
236 STUDY OF DIAGNOSIS. 
 
 periodic to a certain extent, having* periods of increase 
 and diminution, as may be noticed even in the fevers 
 called continued. Indeed all the functions of life, both 
 in health and disease, have something of periodicity in 
 their performance. 
 
 The diagnosis of periodicity will be made by — a, The 
 marked remission or intermission of the evidence of 
 disease, and return to the healthy standard of life ; fc, 
 the equally marked exacerbation of disease, especially 
 with reference to the wrongs of innervation, tempera- 
 ture and circulation ; c, the disposition to continue such 
 functional aberrations without change of structuve; and 
 d y the fact that such disease is endemic in the localitj r . 
 
 Intermittent Fever. — We diagnose an ague by — a, 
 the marked cold stage ; Z>, followed by a hot s.tage ; c, 
 a sweating stage — all occupying a comparatively short 
 time, usually less than twenty-four hours ; and <?, a 
 more or less complete intermission of the disease, and 
 return of normal functional activity. 
 
 If the intermission is complete, with normal temper- 
 ature, normal circulation, innervation and secretion. 
 Quinine will be the remedy. If functional wrongs 
 should persist during the intermission, appropriate 
 means should be employed for their removal, and the 
 Quinine given if the disease persists. 
 
 Eemittent Fever* — We diagnose remittent fever by 
 — a, A forming stage which may be brief or of one or 
 two weeks duration, and which is frequently attended 
 by gastric disturbance, and frontal pain ; 6, a chill, not 
 nearly so intense as in ague, but well marked ; and r, a 
 hot stage which is distinctly broken up into remissions 
 
STUDY OF DIAGNOSIS. 237 
 
 and exacerbations, and continues to the sweating stage, 
 which is the termination of the disease. 
 
 The distinct remissions and exacerbations— periodi- 
 city — means Quinine, and in some cases this remedy 
 will be sufficient to arrest the entire series of morbid 
 processes. This condition will be known by — a. The 
 soft and open pulse; 6, the moist and cleaning tongue ; 
 r, the soft and moist skin; and d, return of normal in- 
 nervation — at the remissions. If these conditions do 
 not present, we determine the character of the wrongs 
 and employ the means necessary to remove them. 
 
 Yellow Fever. — Though there is undoubtedly an 
 epidemic influence in some seasons, and the disease is 
 more or less contagious, we find that the endemic con- 
 ditions are of great importance. Yellow fever can not 
 prevail in unfavorable situations, (it is said never to 
 prevail at altitudes of more than four hundred feet 
 above the ocean), and just in proportion as the local 
 influences favor it, the disease will be severe and fatal. 
 Bad drainage and want of cleanliness are especially 
 noted as likely to favor the propagation of yellow 
 fever. 
 
 The diagnosis of yellow fever is made by — a, The 
 marked chill, attended by lumbar and frontal pain, 
 nausea and vomiting ; 6, the rapid accession of the hot 
 stage which is very intense, lasting from twenty-four 
 to seventy -two hours ; c, the abatement of febrile ac- 
 tion, but with marked prostration, and gradually in- 
 creasing yellowness of skin ; and d, the return of nau- 
 sea and vomiting — the black vomit 
 
 Typhoid — Next to periodicity the most frequent and 
 marked endemic influence is that which gives the 
 
238 STUDY OF DIAGNOSIS. 
 
 typhoid character to fever. It may produce typhoid 
 fever with disease of Peyer's glands, may cause typhoid 
 symptoms in remittent fever, and all the inflammations. 
 A very common manifestation of the influence is in 
 typhoid dj r senteiy, and typhoid pneumonia. The local 
 cause is evidently decomposition of vegetable and 
 animal matter, the products being thrown off into the 
 the air and inhaled, absorbed by food, or infecting the 
 water supply. As it is possible to remove such causes, 
 the physician should always direct attention to them 
 in these cases, that they may be removed. 
 
 Using the word typhoid as an adjective to designate 
 a condition of disease, it has reference to the condition 
 of sepsis and putrefaction. The enfeebloment or asthe- 
 nia is but an incident, and is sometimes not noticed 
 until a late stage, though the typhoid symptoms are 
 marked. 
 
 The diagnosis is best made by examining the exuda- 
 tions or secretions. It is especially marked in the 
 mouth ; on the tongue by dirty coating, or a fur that 
 assumes a brownish tinge and gradually becomes deeper 
 until it is almost black ; dirty or dark sordes upon the 
 teeth ; unpleasant, dark, and offensive feces ; urine 
 that is frothy, and gives an unpleasant cadaveric odor. 
 We also notice it in the sense of pungent heat when 
 the hand is applied to the surface, and in the low de- 
 delirium. In surgical diseases, the discharge from 
 wounds or injuries, or operations, will show it, in a 
 wrong of the pus, which becomes thin, ichorous, fetid, 
 and in a tendency to softening of tissues and sloughimr. 
 
 It suggests the class of antiseptics, especially Sulphite 
 of Soda, Sulphurous Acid, Muriatic Acid, Chlorate of 
 Potash, and JBaptisia, which are selected according to 
 special indications hereafter named. 
 
STUDY OF DIAGNOSIS. 239 
 
 TVe also find special expressions of disease, when 
 endemic, that indicate special remedies, and these prove 
 curative. As in the case of epidemic influence, we find 
 that these symptoms are common to many or nearly all 
 the diseases of the season or year, and the remedy in- 
 dicated assumes a very j^rominent place in treatment. 
 Thus all the remedies named as being indicated in 
 epidemics, are found indicated when the causo is 
 endemic. 
 
 Thus we sometimes find an erysipelas, puerperal 
 fever, or dysentery, that is clearly endemic, and the 
 special indications for remedies will be distinct, We 
 want Iron, Yeratrum. Ehus, Podophyllin, etc., and the 
 indications are so direct and positive that a cure is cer- 
 tain and speedy. 
 
 SPORADIC DISEASE. 
 
 In this last class we find no special expression of 
 disease, or in other words, we find the regular succes- 
 sion of symptoms as given by authorities. The causes 
 are in the acts or indiscretions of the individual, in ex- 
 posure to heat, cold, wet; want of proper clothing or 
 protection ; intemperance in eating and drinking ; over- 
 exertion, physical or mental — and the reverse, a want 
 of exercise. Or the cause may be found in the general 
 conditions of life ; sudden changes of temperature ; 
 more or less moisture in the atmosphere ; and a greater 
 or less electrical condition. 
 
 These causes are temporary, and avoidable, and it is 
 well to study them in relation to disease. Whilst a man 
 may not escape an epidemic, contagious, or endemic 
 
240 STUDY OF DIAGNOSIS. 
 
 cause, right living will usually prevent the class of dis- 
 eases called sporadic. 
 
 It is also well to notice that these diseases are usually 
 simple in their structure, and very amenable to reme- 
 dies. If we take the physiological study of disease, 
 and determine which is theirs* wrong of function, and 
 right it, we will have but little trouble in treatment. A 
 sporadic fever yields readily to the special sedatives — 
 agents that rectify the wrongs of the circulation ; or at 
 farthest will need but the help of those which increase 
 secretion. An inflammation readily yields to the gen- 
 eral sedatives, and those which remove the irritation of 
 the part. The important points to determine in these 
 cases are — the character of the general disease, and 
 the remedies which will right it ; the situation and 
 character of the local disease, and the remedies that 
 will influence the part, and influence it in a right direc- 
 tion. 
 
 GENERAL AND LOCAL DISEASE. 
 
 This would seem to be a very simple and profitable 
 classification, both in determining the character and 
 gravity of disease, and in selecting remedies. Yet 
 when we come to the bedside we find it very difficult 
 to make the diagnosis. Disease may be so uniformly 
 distributed, that it is impossible to say that one part 
 suffers more than another, or it may be so localized 
 and restricted to a part, that its general influence is 
 hardly noticed. Yet in most cases we will find the two 
 associated together. It is difficult to find a person so 
 uniformly constructed that there is not some weaker 
 part, and in disease which otherwise would be general. 
 
STUDY OF DIAGNOSIS. 241 
 
 this weaker part suffers. If it were not so, the happy 
 man would be like Dr. Holmes' " one horse shay," and 
 like it would fall to pieces at once, somewhere between 
 three score and ten and five-score years. And there 
 is no part so disconnected with the organism as a 
 whole, that can suffer disease without influencing the 
 body at large. 
 
 Though the body, so varied in function, is one, yet 
 it is of advantage to think of disease as being general 
 and local (in principal part), and associate with these 
 ideas thoughts of general and local remedies. To get 
 a fair conception of the elements of general disease it 
 is well to think of those functions which are common 
 to the entire man, or which are equally necessarj^ in 
 their resujts to the entire man. And to get a fair con- 
 ception of local disease, we stucfy the function of each 
 part, in so far as it can be dissevered from the life in 
 its totality. 
 
 We might make a group of the elements of general 
 disease, according to our physiological classification, 
 somewhat'as follows : 
 
 ( Formative — for organization. 
 Force ^|^ c t | ricity | Conditions of life and motion. 
 
 f flncreased, 
 
 I In its circulation.^ Diminished, 
 
 (Wrong in kind. 
 The Blood.<Inits organization A with reference to nutrition, todegener* 
 i ° i tions, deposits and growths. 
 
 f Retained excreta. 
 Influenced by <j Malaria. . 
 I J ] Zymctic poisons 
 
 ^Specific poisons. 
 ( For the supply of Oxygen. 
 The Respiratory Function. «j For the removal of Carbonic Acid. 
 (As an aid to the circulation. 
 fFrom the sympathetic, co-ordinating the vegetative process. 
 | From the spinal cord, as influencing the automatic function?}. 
 Innervation. ^ f Reason. 
 
 [From the Bra.n.jfX'r- 
 t Sensation. 
 
 21 
 
242 STUDY OF DIAGNOSIS. 
 
 It is not necessary to consider each of these in this 
 place, but having them grouped before the eye, the 
 mind can analyze each one as a factor of disease, and 
 combine them in natural groups, as usually seen. The 
 mind not only recognizes them as general elements of 
 disease, but will soon learn to recognize the common 
 expressions of wrong, according to the classification of 
 excess, defect and perversion. And it will soon go further 
 than this, recognizing remedies which reach each in- 
 dividual element, and do that necessary to be done — 
 opposing the morbid action and influencing the func- 
 tion toward the normal standard. If there is an ex- 
 cess — above, the influence is to bring down to the stand- 
 ard of health. If there is a defect — below, the influ- 
 ence is to elevate or bring up to the normal standard. 
 And if there is a perversion — a departure from, the in- 
 fluence is to bring back to the normal standard. 
 
 We have already noticed that none of these elements 
 of general disease can exist without producing more 
 or less of local disease, and we may also say without 
 influencing the entire series named. With reference 
 to local disease we find it severe and destructive in 
 proportion to the severity of the general lesions. So 
 too we find that the influence of some of these elements 
 of disease sets up a series of lesions which are severe 
 in proportion to the severity of the original one. In 
 both cases general remedies are most important, and in 
 so far as they rectify wrongs, and restore normal struc- 
 ture and function, they are most important. 
 
 In some cases the general lesion determines the 
 character of the local one. This is especially the ense 
 when the general lesion is of the blood, giving caco- 
 p las tic or aplastic deposits. An inflammation may 
 
STUDY OP DIAGNOSIS. 243 
 
 Bpring up, simple in its character, from the common 
 causes, and if there had been no wrong of the blood, it 
 would have readily passed away by resolution. Yet, 
 there being cacoplastic material in the blood, this is 
 thrown out as an exudation, and breaking down, causes 
 most serious destruction of tissue. If in such cases as 
 this the character of the general lesion was recognized 
 early, and proper means employed to remove the im- 
 perfect material by way of the excretory organs, and 
 so improve digestion and blood making as to prevent 
 its renewal, the local lesion would be less severe and 
 destructive. In place of a " white swelling," or " mor- 
 bus coxarius," the inflammation would run its regular 
 course of six to nine days to resolution. 
 
 If we take the case of phthisis pulmonalis, we find 
 another good example. Say there was an original want 
 of formative force, and in consequence there is continu- 
 ously produced an imperfect material in the blood. 
 Its deposit in the lungs comes wheneverfrom any cause 
 excretion is arrested, preventing its normal removal, 
 and when an irritation of and determination of blood 
 to the lungs is set up — the material being carried to 
 the lungs and there excreted. In this case a rational 
 practice of medicine looks first to an increase of forma- 
 tive force, getting thereby a better blood, better tis- 
 sues, and a stronger life. When the disease has once 
 developed itself, the treatment will of course look to 
 the establishment of the processes of combustion and 
 excretion — removing the material from the blood in 
 this way — and the arrest of irritation of the lungs, 
 which is the cause of the deposit there. 
 
 If we take the single factor, heat, as the example, we 
 find the very same state of affairs. If, for instance, we 
 
244 STUDY OF DIAGNOSIS. 
 
 have the lesion of the blood known as " typhoid," we 
 find that its increase is in proportion to the wrong of 
 the temperature. If we have an inflammation of the 
 lungs, the local disease is destructive in proportion to 
 the increase of temperature. If Ave have a phthisis 
 pulmonalis, the deposit is rapid in proportion as the 
 temperature is high, and the destruction of lung tissue 
 is in the same ratio. We say, therefore, that diagnosis 
 by the body thermometer, must suggest a class of gen- 
 eral remedies, which will prove efficient in modifying 
 and arresting general and local disease. 
 
 There is no doubt but that lesions of excess and de. 
 feet of electricity, as a condition of life, and as a force, 
 have a similar influence upon disease. Plus electricity, 
 and we have increased disease by excitation; minus 
 electricity, and we have increased disease by want of 
 excitation. The diagnosis will be formed in most cases 
 by the degree of excitation as manifested by expres- 
 sion, and the proper remedies will suggest themselves 
 to relieve the body of its superabundance, or to employ 
 means which will add to, or prevent its waste. 
 
 When we study the circulation of the blood as a 
 factor in disease, we see how marked the influence of 
 one of these general wrongs. Given a lesion of fre- 
 quency in movement only, and we find that any morbid 
 process is increased in proportion. Secretion is 
 arrested, the appetite is lost, blood making and nutri- 
 tion are impaired, waste is interfered with, and every 
 cause of disease intensified. Wrongs in the circulation 
 other than frequencj', give the same results. Even an 
 unequal circulation of the blood may lead to such 
 serious impairments of function, as to be a cause of 
 death. Evidently the diagnosis of these genera! 
 
STUDY OF DIAGNOSIS. 245 
 
 wrongs, and the use of remedies to reach them, are of 
 prime importance. 
 
 When we study the influence of lesions of the circu- 
 lation upon local disease, we find them playing the 
 same important role. If you have a local disease, in- 
 flammatory or otherwise, it will be to a considerable 
 extent severe and destructive in proportion to the 
 lesion of the circulation. If we have an inflammation 
 of the lungs, it will be severe in proportion to the fre- 
 quency and wrong in the circulation. With a pulse of 
 100 beats per minute, and free, there is little danger ; 
 but with a pulse of 130, small and sharp, there is most 
 serious danger. If in such case, the lesion of the cir- 
 culation can be removed, the local disease will be modi- 
 fied in the same proportion. 
 
 Continuing on with this classification, attention 
 might be called to the next group — the blood influenced 
 by certain causes of disease. Take first retained ex- 
 creta, and we have a most excellent example of the 
 need of diagnosis by this classification. We are treat- 
 ing an injury, a wound for instance, and everything 
 progresses well, until from some cause one or more 
 secretions are arrested. At once we see a change in 
 the local disease, the part suffers, its temperature rises, 
 becomes painful, the process of repair stops, the exuda- 
 tion is changed in character, the pus is unpleasant, and 
 finally the repair accomplished is broken down, and it 
 may be the part sloughs. Surely it is well to be able 
 to recognize this wrong, and bring such means to bear 
 as will re-establish waste and excretion. 
 
 Or a person from some common cause may have a 
 simple fever. At first there are no unfavorable symp- 
 toms, and we reasonably expect a speedy con vales- 
 
246 STUDY OF DIAGNOSIS. 
 
 cence, but from some cause there is arrest of secretion, 
 which is retained in the blood. All the febrile symp- 
 toms are increased, and in addition we notice in the 
 brown tongue, sordes, etc., the evidence of sepsis of the 
 blood. Here it is well to recognize the importance of 
 this general element of disease, and by early recogni- 
 tion prevent the unpleasant consequences named. 
 
 Malaria has played a most important part in disease, 
 and the reader will at once recognize its importance. 
 Given a case of disease, most simple in form, seemingly 
 and with this element characterized by periodicity, the 
 disease may go on from bad to worse, until possibly, 
 death results. It does not make much difference 
 whether it is a fever, an inflammation, or some other 
 disease. If we take inflammation of the lungs, the re- 
 cognition or non-recognition of this element of disease 
 (periodicity), may be that upon which the life of the 
 patient depends. Without remedies directed to this 
 special element, the disease goes on to destruction of 
 the lung tissue. With Quinine property administered, 
 it runs a brief course, and terminates in resolution. 
 
 The influence of zymosis is well illustrated by ery- 
 sipelas. You notice the swollen, red. and glistening 
 spot on the skin, and as the patient complains of the 
 peculiar burning, you call it erysipelas. If your atten- 
 tion is not called to the element, zymosis, by the pecu- 
 liar tongue, pulse, condition of innervation, etc., and 
 you prescribe empirically at a local inflammation, you 
 may lose your patient. Recognizing the Z3 r motic char- 
 acter of the disease, and uniting it with proper reme- 
 dies for this, the patient gets along well. 
 
 Dysentery is another excellent example of this. In 
 the minor sporadic cases, Podophyllin to catharsis. 
 
STUDY OF DIAGNOSIS. 247 
 
 White Liquid Physic, or Castor Oil and Turpentine, 
 may serve the purpose, and the sufferer gets well after 
 a time. But do not trust zymotic dysentery to this 
 treatment. Here the wrong of the blood, working 
 typhoid symptoms, is the principal factor of the disease 
 and the element of danger. It is to be met by specific 
 epidemic remedies, or those which we class as anti- 
 zymotic or antiseptic. 
 
 The influence of specific poisons well illustrates the 
 truth of what has just been said, though the illustra- 
 tion is outside of ordinary practice. The hunter in the 
 Carolina mountains feels something prick his leg, and 
 getting through the brush he pulls up his pants, and 
 finds but a slight wound, and the smarting has already 
 ceased. It amounts to but little as a wound, but if he 
 has heard the rattle of a serpent, or has seen it in the 
 act of striking him, he is at once awake to danger. 
 He has made specific diagnosis, and by sucking the 
 wound, the use of Ammonia, or the free use of Whisky, 
 he provides against the specific poison. 
 
 We get a practical example of these lesions in the 
 case of syphilis. A man finds a small sore on his penis, 
 which as yet has given him no annoyance, and if he 
 had no experience with such things, he would expect it 
 to disappear as rapidly as it came. But as days go by, 
 it gets larger, and seems more prominent, and after a 
 time comes skin disease, sore throat, falling of the hair, 
 iritis, nodes, etc. Surely there is something more than 
 a simple abrasion here — from a strain. Supposing the 
 physician should only recognize it as a sore, ignoring 
 the specific poison of syphilis, what would be the suc- 
 cess of treatment? And yet he could do this with 
 quite as much credit, as to fail in recognizing the 
 
248 STUDY OF DIAGNOSIS. 
 
 specific wrongs in zymotic dysentery, in typhoid fever, 
 in bin all pox, in scarlet fever, or in measles. 
 
 If we study the function of respiration in its influ- 
 ence upon processes of disease, we reach the same re- 
 sults. With wrong respiration, every other wrong ja 
 intensified; with right respiration ameliorated. There 
 is such a thing as too much oxygen, and consequently 
 increased burning and excitement, just as ther*; is such 
 a thing as blood loaded with carbonic acid .gas, and so 
 burdened that the varied functions of the be ay can not 
 be properly performed. Surely it is worth our while 
 to endeavor to diagnose these conditions, and to em- 
 ploy remedies which directly reach the wrongs and re- 
 move them. 
 
 When we study the lesions of innervation, we are 
 impressed with their influence upon all parts of the 
 body, and the necessity of directing the mind to them 
 in all forms of disease for the purpose of diagnosis. 
 Whether our senses will detect a lesion, frequently de- 
 pends upon our method of thinking. If the mind 
 directs the necessary examination, the evidences of dis- 
 ease may be quite clear, when otherwise they would 
 scarcely be noticed, and would not make the necessary 
 impression. 
 
 If we study thoroughly the physiology of the sympa- 
 thetic, nervous system, and get correct ideas of its con- 
 trolling influence over all the functions of vegetative 
 life, we will always direct our observation to those ex- 
 pressions of disease which give information with re- 
 gard to this! Remedies influencing disease through the 
 sympathetic are among our most important therapeu- 
 tic agents, and fortunately the expressions of diseaso 
 are quite clear. If we commence with the lesions of 
 
STUDY OF DIAGNOSIS. 249 
 
 the circulation — frequency of pulse, change in its char- 
 acter — lesions of temperature, change in the condition 
 of the skin, some changes in muscular expression, 
 change in the respiratory function, we will find a group 
 of symptoms that are distinct and expressive, and so 
 closely associated with individual remedies, that the 
 remedy is at once suggested by the symptoms. 
 
 The influence of lesions of spinal innervation is well 
 shown in many cases of chronic disease, where" spinal 
 irritation " is a complication. A disease of the diges- 
 tive or urinary apparatus may seem quite clear and 
 simple — one that remedies will readily reach, and yet 
 when we prescribe them, there is continued failure. 
 We have failed to recognize a " spinal irritation," but 
 from this wrong of innervation, the local disease is 
 continuously kept up. If the special wrong is diag- 
 nosed, and proper means used for its relief, the reme- 
 dies which had before failed with the local disease, are 
 more speed \\y successful. 
 
 We £et another good example of this in some cases 
 of continued fever, and other low forms of disease. A 
 patient is doing well enough, other than he can not 
 sleep from difficulty of respiration. When awake the 
 respiratory function is carried on by the influence of 
 the will, but when this is in abe}^ance, the automatic 
 function of the spinal cord is not sufficient. Unless 
 this wrong is recognized, and means employed to rectify 
 the wrong of spinal innervation, the patient will prob- 
 abh~ die. We may get evidence of similar wrong, in 
 one case in retention of urine, in another case in incon- 
 tinence, in a third in convulsions or muscular wrongs, 
 and in all we are impressed with the importance of 
 remedies that influence the spinal cord, and influence 
 
250 STUDY OF DIAGNOSIS. 
 
 it in the direction of health. It would be most absurd 
 to omit from our diagnosis the evidence of a convulsive 
 tendency, and it would be quite as absurd to omit to 
 look after and recognize any evidence of spinal lesion. 
 
 When we study the functions of the brain, we find 
 them exerting similar influences over the body at large, 
 both in health and disease. It will not do to under- 
 value a right action of the mind, as an element in the 
 recovery of the sick, as it will not do to undervalue a 
 wrong action of the mind in perpetuating disease. 
 Given a mind at ease and restful, and a patient may 
 recover from disease or injury, which under other cir- 
 cumstances would most certainly be fatal. So true is 
 this that we are always on the watch for symptoms 
 shadowing forth the condition of the brain. The quer- 
 ulous voice, the hopeless voice and expression, the 
 unstable voice, the tone of excitation, the tone of pros- 
 tration, all convey valuable information, which must 
 not be neglected. 
 
 We find cases in which an emotional wrong may 
 originate or so intensify processes of disease as to en- 
 danger life. A very familiar example of this is found 
 in nostalgia, or " home-sickness." In the late war, it 
 was found that this so influenced disease in the hospi- 
 tals, at times, as to double the mortality; indeed, many 
 times a furlough to go home was the only reprieve from 
 death. In the recent Franco-German war, many cases 
 were noticed. Fernand Papillon writes : "During the 
 last war nostalgia carried off many sufferers among our 
 unhappy prisoners dispersed throughout Germany. It 
 at tucked the soldiers and mobiles during the seige of 
 Paris, especially toward the close of it, when privations 
 and successive defeats began to reduce the most robust 
 
STUDY OF DIAGNOSIS. 251 
 
 organizations." I have seen just such cases in private 
 practice, and the hope and promise of a return to home, 
 was the strongest remedy toward recovery. 
 
 " Hope is an anchor " for many wearied and suffering 
 souls, binding them to this world, lightening their suf- 
 fering, and giving increased strength for recovery. 
 The want of hope is one of the most serious things we 
 have to contend with in disease. To give hope to the 
 sick, is one of the many duties of the physician. 
 
 It is possible that some may give little credence to 
 the statements regarding the influence of the emotions 
 in disease. And yet every one practicing medicine for 
 some years will have seen the influence of love, fear, 
 anger, grief, etc., so clearly manifested, that there can 
 be no mistake in the matter. I have seen grief so pro- 
 found, that every function of life was seriously im- 
 paired, and unless the current of thought could be 
 changed, there was danger to reason or life. A free 
 outburst of tears might give relief to the overburdened 
 heart (brain.) 
 
 Every physician in active practice has realized the 
 influence of the will upon disease, and every one will 
 wish to know the condition of this function in serious 
 or protracted disease. The evidence of a strong will, 
 and intention to get well, is a real encouragement to 
 the phj-sician, as the want of will in this direction is a 
 great discouragement. If we recognize a want of voli- 
 tion in severe or protracted disease, we do all we can 
 to call, it out and strengthen it, and in so far as we do 
 this our patient is benefited. Even in the treatment 
 of a cough we find this is important. If the patient 
 can be impressed with the importance of controlling 
 the cough by the will, we will find it much easier to 
 check it. 
 
252 STUDY OF DIAGNOSIS. 
 
 Physicians are always awake to wrongs of sensation, 
 though frequently the only idea that follows is, the use 
 of means to obtund the sensibility of the brain. It is 
 true that unpleasant sensations or pain intensify pro- 
 cesses of disease, and wrong the entire body by depriv- 
 ing it of necessary rest, yet many times far less harm 
 comes from this than we would suppose. Indeed, in 
 the larger number of cases It is better that the patients 
 suffer pain, than that they be relieved by the ordinary 
 narcotics. If by the study of pain we can select a 
 remedy for disease, then it becomes a valuable evidence. 
 A remedy in this case looks not so much to the removal 
 of the pain, as to the arrest of the disease of which 
 pain is a symptom. 
 
 The study of local disease becomes important in that 
 it directs the mind to limited parts and functions, and 
 thus specializes the wrong. We group the most im- 
 portant functions of the body, as of digestion, circula- 
 tion, respiration, excretion, etc., and then study each 
 particular organ or part. If we take digestion, wo 
 stud}' the function in the mouth, the stomach, the large 
 and small intestine, and as influenced by liver, pancreas, 
 etc. If a certain group of organs or parts do a par- 
 ticular work, we will find diseases of it announced by 
 wrongs of that work. Thus the wrongs of function 
 point us to the locality of the lesion, and a closer ex- 
 amination determines the particular part or organ in- 
 volved. 
 
 Knowing the lesion of function we readily determine 
 its influence upon the life in its totality, and upon 
 other parts and functions. It is possible in some cases 
 to provide against these influences, by calling into ac- 
 tion other functions which may be supplementary or 
 
STUDY OF DIAGNOSIS. 253 
 
 vicarious. As for example, if the digestive organs are 
 in such condition that they can not appropriate calori- 
 facient food, we may for the time being use alcoholic 
 liquors, which require no act of digestion to furnish 
 heat, until food can be taken. Or in similar cases, re- 
 quiring histogenetic food or the stimulus of beef-essence, 
 we employ it per rectum. 
 
 We have similar examples in the relation between 
 the excretory organs — kidneys, skin and bowels. If 
 the function of one is impaired, or there are special 
 reasons why one organ should have rest, we call upon 
 one or both the others, to do additional work. In some 
 of these cases, the vicarious action will free the blood 
 from noxious materials, and thus give a chance for re- 
 covery. In others, the relief of the part from work, 
 gives an organ opportunity to recover its normal con- 
 dition by improved nutrition. 
 
 In the study of local disease we not only have in 
 mind the influence of changed function, but also that 
 which may arise from a change in the circulation, in- 
 nervation, and nutrition of a part. We can not have 
 an excess of blood in a part, without depriving some 
 other part of blood. We can not have a too rapid cir- 
 culation in a part, without influencing the circulation 
 at large. We can not have an arrest of circulation in 
 apart, without impairment of that blood, and a wrong 
 to the whole of this fluid. We can not have a wrong 
 of innervation of a part, without suffering of the nerve 
 centres and a reaction upon the body at large ; as we 
 can not have a wrong of nutrition, or waste, without 
 general suffering from it. 
 
 As the mind grasps these varied factors of disease, it 
 is better able to appreciate the present condition, and 
 
254 STUDY OF DIAGNOSIS. 
 
 provide against other phases of disease. We not only 
 want to know the condition of disease at the present 
 time, but we also wish to know, from this, what will be 
 the probable condition to-morrow, or some subsequent 
 time. If to-daj^ we can arrest the wrongs of life now 
 present, and turn the tide toward the standard of 
 health, well. If not, we wish to make provision, so far 
 as Ave can, against the wrongs of to-morrow or next 
 week. 
 
 Further along, Ave Avill give the diagnostic features 
 of the general lesions here named, as Avell as the more 
 important evidences of local disease. The object in 
 this chapter being specially to direct the mind to the 
 advantages of this classification, in determining the 
 real nature of disease, and as being suggestive of cer- 
 tain classes of remedies. As before stated, there are 
 many lines of thought in diagnosis, and we do not wish 
 to get them tangled. We wish to do our thinking 
 methodically, and in so far as Ave can, we take one at a 
 time. 
 
 PHYSIOLOGICAL DIAGNOSIS. 
 
 Some may think the heading of this chapter a mis- 
 nomer, as they can not harmonize the name physio- 
 logical, which means right life, with disease, which is 
 Avrong life. But if we explain that in diagnosis we 
 must haA r e a standard to measure from — that is, health. 
 — then the term, " physiological diagnosis," is most 
 appropriate. The most important element here is the 
 point to measure from ; without this, diagnosis Avould 
 be the merest guess work. 
 
 It might be asked, how we can harmonize this method 
 
STUDY OF DIAGNOSIS. 255 
 
 with the diagnosis by, and prescription for special 
 symptoms, as described in the first part of this work ? 
 If remedies are indicated by special expressions of dis- 
 ease — symptoms — which may be common to many and 
 different pathological conditions — why not employ this, 
 to the exclusion of all other methods ? If it is true to 
 any considerable extent, should it not be true in all 
 cases, and furnish the only sure basis for therapeutics ? 
 
 These are pertinent questions, and I doubt not many 
 readers have asked them time and again. If a certain 
 pain in the left orbit, a certain appearance of the 
 papilla of the tongue, and a certain sharp stroke of the 
 pulse, says to us that Ehus Toxicodendron is the 
 remedy, whether the disease be fever, inflammation of 
 the lungs, conjunctivitis, diarrhoea, or erysipelas, what 
 do we want of a physiological standard? True, in 
 such cases we do not want it as a basis for prescription, 
 and if we know enough of the relation between reme- 
 dies and disease, we should not make this a study, at 
 least not as :i basis for prescription. But, unfortunately, 
 we do not know enough of this. As far as we know 
 it, we base our therapeutics upon it ; when it fails, we 
 must supplement it with other methods. Practical 
 medicine is in its infancy, and until it attains the firm 
 step of adult years, we must second it with all the aids 
 that can give it support. 
 
 If the reader will refer back to page 216, he will find 
 a table which will serve as the ground-work for this 
 study. We purpose examining the various functions 
 of the body, setting up a physiological standard — health 
 — and measuring from it. We find that all lesions 
 can be grouped under the three heads of — excess, defect 
 and perversion — above, below, from. If once we are 
 
256 STUDY OF DIAGNOSIS. 
 
 able to recognize these departures, and have a knowl- 
 edge of the action of remedies upon function, we may 
 make a rational selection. If the condition of disease 
 is u above " the normal standard, we employ those 
 means which will bring it down. If the condition of 
 disease is "below" the normal standard, we employ 
 those means w r hich will bring it up. If the condition 
 of disease is a departure " from " the normal standard, 
 we employ those means which will bring it back. 
 
 The reader will notice that it makes no difference 
 what " school " of remedies is prescribed from, as it is 
 quite as well adapted to the one as another. Take tho 
 gross dose of regular medicine, and the physician using 
 it should know the locality of its action, and the quality 
 of its action. And even when the action is secondary 
 or indirect, this method of prescribing is still good, for 
 the mind associates the secondary influence upon a part 
 or function with what needs be done to restore health. 
 If the modern Eclectic prescribes the usual dose of 
 specific medicine, he has clearly in view its direct ac- 
 tion upon a part or function, and he associates the 
 action of the drug with that which needs be done to 
 oppose disease, and restore health. Our Homoeopathic 
 brother, with his minute doses or infinitesimals, fre- 
 quently prescribes on the same basis. He knows where 
 the disease is, and he prescribes a remedy which spe- 
 cially influences that part; he knows the character of 
 the disease, and he prescribes remedies which his expe- 
 rience has shown opposes the disease, and favors the 
 return of health. 
 
 Having thus shown the advantage of this study, as 
 being applicable to all systems of therapeutics, and 
 even adapting itself to each individual expression, I 
 
STUDY OF DIAGNOSIS. 257 
 
 desire to call attention to its value as a training for the 
 mind, and a study of the phenomena of life. " Think- 
 ing in straight lines " has been our motto, and most 
 certainly this is such method of thought. As we edu- 
 cate the mind, so it will do our work, and this I think 
 one of the best studies. This is a study of life in all 
 its phases. It is a study of normal life, for without 
 this it has no basis. And it is also a critical study of 
 wrong life in all its phases, for this is its end. 
 
 It may be well to call attention again to the too com- 
 monly received methods of examination and diagnosis 
 • — direct and by exclusion. In direct diagnosis the 
 sj'mptoms are marked and point directly to the locality 
 and character of the wrong. But in some cases there 
 are no such direct symptoms, and we proceed to make 
 an analysis of the life before us, questioning each par- 
 ticular part or function, until we have found the seat 
 and the quality of the lesion. This is diagnosis b}^ ex- 
 clusion. 
 
 Formative Force. — The force of organization is re- 
 ceived by inheritance, and the rule reads — as is this 
 force in the parents, so will be its manifestation in the 
 children. Thus it is sometimes an important element 
 in diagnosis, to know the parentage, and in so far as 
 we can, their physical history. From feeble parents 
 we usually expect feeble children. From parents who 
 have had an imperfect organization, and wrongs of 
 blood, degenerations, deposits and growths, we expect 
 children with like imperfect organization, and with the 
 same tendency to disease. If we know that parents 
 have died of phthisis pulmonalis, or other tubercular 
 disease, a cough or articular irritation has a deeper 
 22 
 
258 STUDY OF DIAGNOSIS. 
 
 signification, and we are wide awake to the necessity 
 of early- means for protection. 
 
 If parents or near relations have had cancer, we view 
 with suspicion any growth that may make its appear- 
 ance. If they have suffered with Bright's disease, 
 diabetes, epilepsy, insanity, or other similar disease, we 
 are advantaged by knowing the facts. 
 
 The force of organization is very rarely in excess, 
 probably never, as regards the whole man. Once in a 
 while we notice examples. of it as affecting parts. Thus 
 we may have hypertrophy of the adipose tissue ; hyper- 
 trophy of bone ; of the epithelium ; of cellular tissue, 
 taking the form of growths. All of these will be read- 
 ily recognized, though it is not so easy to find reme- 
 dies*which will arrest or modify the condition. Still 
 bearing in mind the distinction between the unknown 
 and the unknowable, we may expect to find remedies 
 for even such wrongs as these. 
 
 The wrong of defect is very common, and met with 
 in many cases of disease. We recognize it in defective 
 or feeble nutrition, parts being small, wanting normal 
 solidity, and lacking the usual capacity of our standard 
 man. The functional activity is usually the measure 
 of the force of organization ; for though the organism 
 in such case may for a limited time give a large amount 
 of work, it is rapidly exhausted, and requires much 
 more than the usual time for recovery. 
 
 We may learn that such defect is inherited ; that it is 
 the result of bad conditions of life ; that it results from 
 over-work, or is caused by disease. Whilst we can not 
 rectify the present wrong of inheritance, we can pro- 
 vide to a certain extent against this in the children of 
 the future. But in the other cases the treatment is 
 
STUDY OF DIAGNOSIS. 259 
 
 quite plain — we rectify the conditions of life and make 
 them healthful ; we prevent over-work, and remove 
 such diseases as influence nutrition. Following this we 
 observe the great law of development — " as a part or 
 function is rightly used, it gains size and capacity." 
 As we exert the force of organization, we call into 
 right action that which the person has, and as it is thus 
 normally used, it grows. 
 
 Heat. — The normal temperature of the human body 
 is 98° and a fraction, say 98.4°. To have healthy life 
 this must be maintained, with but very slight varia- 
 tion ; even the change of one degree producing disease. 
 The temperature is accurately determined by the body 
 thermometer, applied in the axillae, or under the tongue, 
 though it may be recognized less definitely by the 
 touch. 
 
 Excess of temperature is met with in fevers, inflam- 
 matory diseases, and most diseases accompanied with 
 change of structure. As a rule the excess of tempera- 
 ture is associated with corresponding frequency of pulse, 
 frequent respiration, arrest of excretion, digestion and 
 nutrition. In proportion to the excess of temperature 
 is the activity of causes of disease, of wrongs of the 
 blood, and the tendency to destruction in local disease. 
 Thus to a certain extent, the excess of temperature 
 which we can measure so accurately, becomes a means 
 of diagnosing all the wrongs of life. 
 
 As heretofore named, when studying the changes of 
 temperature as an element of disease, the saving fea- 
 ture is the diurnal variations in the range. Though 
 in protracted disease it may reach the height of 105° 
 to 107°, at some period of the day, it falls to 103° to 
 
260 STUDY OF DIAGNOSIS. 
 
 102°, at others, and in this fall of temperature the per- 
 son has a promise for the maintenance of life. Whon 
 the high temperature is maintained throughout the 
 twenty-four hours, the disease is necessarily of short 
 duration, either in a fall of temperature and return to 
 health, or in death. 
 
 Excess of temperature calls for remedies which 
 lessen the processes of combustion, and provide for the 
 better removal of heat. The relation between the cir- 
 culation and the temperature is very suggestive — as is 
 the circulation, so is the temperature — lessen the fre- 
 quency of the pulse, and you reduce the temperature. 
 Thus the special sedatives are suggested, as among the 
 most prominent remedies. Wrongs of sympathetic in- 
 nervation (excitement) are associated with excess of 
 temperature, and those special remedies, Rhus, Bryonia, 
 Gelseminum, Lobelia, etc., become remedies. Excita- 
 tion of the brain and spinal cord are associated with 
 excess of temperature, and when noticed, call for rem- 
 edies which relieve such excitation. Lesions of the 
 blood, especially those of a septic or zymotic character, 
 are associated with excess of temperature, and anti- 
 zymotic remedies are suggested in these cases. 
 
 The skin is the regulator of the temperature of the 
 body. In the continued evaporation from- the surface, 
 excess of heat is removed. With a high range of tem- 
 perature the function of the skin is impaired, and 
 transpiration more or less arrested. Among the ser- 
 viceable means to remove the excess of heat, are those 
 that put the skin in better condition, favoring transpi- 
 ration. Among these means, baths hold a prominent 
 place, and should not be neglected. 
 
 Excess of temperature is quite as important a factor 
 
STUDY OF DIAGNOSIS. 261 
 
 in chronic, as in acute disease, and its recognition is an 
 important element in diagnosis. Whatever may be the 
 wrong, a range of temperature of 100° and over, means 
 a continuation of the disease, and eventually a destruc- 
 tion of life. On the contrary, amendment is always 
 preceded or associated with a fall of temperature, and 
 if this is maintained at the standard of 98°, we may ex- 
 pect recovery. Thus in phthisis pulmonalis the range 
 of temperatnre is over 100°, even in the first stago, and 
 if maintained at this, recovery is impossible. If it can 
 be reduced, and held permanently at or near the nor- 
 mal standard, the patient may get well. 
 
 There seem to be three factors in thib high range of 
 temperature, which require study — the frequency of 
 circulation, a wrong in combustion, and a defect in the 
 means for regulating the temperature. In some cases 
 remedies directed to the wrong of circulation is most 
 efficient, as when we employ Yeratrum, Digitalis, Cac- 
 tus, Lycopus, etc. In others the wrong is of combus- 
 tion, either in a deficiency of some element of the 
 blood, or in an undue excitation of the nerves govern- 
 ing the respiratory function. For the first we think of 
 Cod Oil, the Hypophosphites, Sulphur, and appropriate 
 foods. For the second, Arsenic, Phosphorus, Ehus, 
 Bryonia, Belladonna, Lobelia, etc. In the third the 
 lesion of the skin is prominent, and calls for such 
 means as will restore normal functional activity. It 
 may be the use of baths — alkaline, acid, stimulant, 
 tonic, astringent, inunction, electricity by Faradization, 
 or the use of internal remedies that specially influence 
 this organ. 
 
 Deficiency in temperature is less frequently met with, 
 and not so easily diagnosed. If the thermometer in 
 
262 STUDY OF DIAGNOSIS. 
 
 axillae or under the tongue, shows 98°, but there is 
 coldness of the extremities and surface, showing in 
 some places not more than 90°, we have determined 
 our case. Or possibly we ma}^ find that the normal 
 condition of heat, 98°, can be maintained in a state of 
 rest, but there is little surplus for motion — we have 
 heat as a condition of life, but not as a force. In the 
 last class of cases, the want of power, with exhaustion 
 and lowered temperature after exertion, tells the 
 story. 
 
 Deficiency of heat may be dependent upon want of 
 calorifacient food, upon wrongs of digestion, upon the 
 want of some special material in the blood to facilitate 
 combustion, upon deficient innervation, upon a wrong 
 of the skin permitting heat to be wasted, and upon an 
 impairment of the respiratory function. In our ex- 
 amination of the sick, the mind at once determines a 
 comprehensive plan of examination, and our inquiries 
 proceed in this regular order — with regard to food, 
 with regard to digestion, with regard to the need of 
 special material for the blood, with regard to innerva- 
 tion, with regard to the condition of the skin, and with 
 regard to the respiratory function. Finding the princi- 
 pal wrong, the mind at once turns to the remedies that 
 influence the part and function, and selects from them 
 the special agent or agents that do that which is needed 
 to bring the part or function back to its normal condi- 
 tion. 
 
 Unequal distribution of heat is not quite as important 
 an element of disease as excess or defect, but in some 
 cases plaj^s a not unimportant part. If in long-con- 
 tinued and severe chronic disease, we have this unequal 
 temperature — the trunk being too hot, the extremities 
 
STUDY OF DIAGNOSIS. 263 
 
 cold — do means will prove curative until the tempera- 
 ture is equalized. Physicians may laugli about " equal- 
 izing the circulation," " equalizing the temperature, " 
 but these inequalities are very common elements of 
 disease, and recovery can not take place until they are 
 rectified. Hence sometimes means to restore heat to 
 the part which is too cold, are among the most impor- 
 tant to the cure. Take a protracted case of chronic 
 gastritis or dyspepsia, with continued cold feet, and 
 Capsicum in the stockings may be the remedy, or at 
 least it will put the patient in the way of being bene- 
 fited by others. 
 
 There are some peculiarities in the temperature that 
 the thermometer will not recognize. For instance, in 
 some cases of z}'motic disease, typhoid and t3 r phus 
 fever, protracted disease showing " typhoid " symp- 
 toms, the hand placed upon the skin gets a sensation 
 of pungent heat, very like that when it is placed upon a 
 surface reddened with mustard, or eantharides. The 
 sensation is very distinctive to most persons, and gives 
 the idea of sepsis, and unnatural irritation of the vege- 
 tative nerve centres. There is nothing more certain 
 than this evidence, whenever it is presented, and wo 
 are at once awake to the danger to life, and the neces- 
 sity of means to overcome the morbid process going on 
 in the blood, and to relieve the over-excited nervous 
 system. At once we examine our patient with refer- 
 ence to the indications for the special antiseptic — 
 Muriatic Acid — the Alkaline Sulphite, Sulphurous Acid, 
 Chlorate of Potash, or Baptisia, and with reference to 
 the remedies which influence the nerve centres— Aco- 
 nite, Veratrum, Rhus, Gelseminum r etc. 
 
264 STUDY OP DIAGNOSIS. 
 
 Electricity, like heat, is both a condition of life and a 
 force for carrying on the various activities of the body. 
 Like heat, it may be in excess or defective, or have an 
 unequal distribution. The diagnosis, however, is diffi- 
 cult, for we have no instrument to measure its varia- 
 tions, as we have in the body thermometer. 
 
 Excess is determined in part by the unnatural state 
 of excitation, there being no wrong of the nerve cen- 
 tres to account for it, and by a peculiar dry and con- 
 stricted condition of the skin. In some rare cases the 
 excess is so marked, that sparks may be elicited by 
 rubbing the head or the surface in a dark room. When 
 the evidence is closely examined we will find that the 
 conditions of life have been such as to produce this 
 condition. The patient has been a hard brain-worker, 
 has lived or worked much in a confined room, heated 
 bj^ a stove, causing dryness of the atmosphere, and at 
 the same time has worn clothing that was a bad con. 
 ductor. Taking, therefore, the symptoms of excitation, 
 the constriction of the skin, and the previous history, 
 the diagnosis is pretty accurate ; nnd if we add to this 
 the evidence of exclusion — no other lesion being found 
 that would account for the symptoms — we are certain 
 of the lesion. 
 
 The treatment will look to a change in the conditions 
 of life. Less work, good ventilation, a moist atmo- 
 sphere, and cotton under clothing. Then will come the 
 use of appropriate baths to rectify the wrong of the 
 skin. And finally, the use of non-stimulating foods, 
 and appropriate remedies to lessen nervous excitement. 
 
 Defect in electricity is indicated by opposite symptoms. 
 There is a want of energy, and of capacity for con- 
 tinued effort, that can not be accounted for by any 
 
STUDY OF DTAGNOSIS. 265 
 
 lesion of digestion, blood-making or nutrition, or by 
 local diseases. The skin is relaxed and atonic, the 
 temperature is inclined to be low, and all the processes 
 of life are performed with less than usual vigor. These 
 symptoms will sometimes be supplemented by a his- 
 tory of the conditions of life. A low situation of 
 house, dampness of living rooms or shops, trades that 
 give a superabundance of moisture in the air, the wear- 
 ing of cotton, the use of non -stimulating foods, exces- 
 sive drains upon the system in the shape of sweating, 
 urination, or seminal secretion, etc. 
 
 Having thus determined the condition of disease, we 
 at once think of changing the patient's surroundings. 
 He is to have a diy atmosphere, an elevated position if 
 possible, air directly influenced by sunshine, sometimes 
 sun baths, and that kind of exercise which will call 
 into action the respiratory function. This is supple- 
 mented by non-conducting clothing of woolen or silk, 
 by the use of stimulating inunction, or dry friction 
 with the hand, or flannel or silk. The selection of 
 proper food is sometimes quite important, animal foods 
 taking precedence. Some of the restoratives arc use- 
 ful, especially the preparations containing Phosphorus, 
 sometimes Iron, and occasionally the Bitter Tonics. 
 These may be supplemented by nerve stimulants, Qui- 
 nine, ISTux Vomica, and agents of like character. 
 
 Cellular Patholooy. — During the past twenty-five 
 years we have heard much of cellular pathology, and 
 it has been proposed to refer us back to these primar}" 
 forms for the history of all disease. According to 
 some enthusiasts in the study of cell life, we not only 
 need to study disease as manifested in cell life, but our 
 23 
 
266 STUDY OF DIAGNOSIS. 
 
 diagnosis should go back to reach these primary organ- 
 isms. Taking the truism, that all wrongs of life must 
 be based upon change of structure, and all manifesta- 
 tions of life flow from, or are the aggregate of cell life, 
 the theoiy becomes yery plausible. 
 
 But there is this difficulty: Cells are organisms so 
 minute that they are beyond the ken of our grosser 
 senses. True we can bring them into view with the 
 microscope, and to a limited extent we can determine 
 changes of shape, but even this is somewhat difficult. 
 The best microscopist will fail to detect differences in 
 cells, when the expressions of disease maj r have been 
 of the most marked character. 
 
 It is possible to determine degenerations, some de- 
 posits, and to a limited extent growths, but many times 
 the diagnosis would be post-mortem, rather than at 
 such period of life as would give any practical advan- 
 tage from it. Even in the case of growths, the micro- 
 scope fails to detect the difference between those which 
 are benign, and those that are malignant. True there 
 are distinctive cancer cells, but then there are malig- 
 nant growths without such cells, as there are benign 
 growths with those which so closely resemble them, 
 that the best observer may be mistaken. 
 
 The microscope will enable us to recognize some 
 changes in the blood-globules, the presence of white 
 globules, some changes in secretion and excretion, and 
 in the formation of pus, and in so far as it does this, 
 it is a valuable aid. Yet in the main, we find it better 
 to rely upon the more common and gross expressions 
 of disease, especially as these are suggestive of reme- 
 dies. 
 
 If by conceding that life is from cells, and that as are 
 
STUDY OF DIAGNOSIS. 267 
 
 these cells, so is its expression, we must be referred to 
 cells in the stud} 7 of disease, we may go one step further 
 back and say that all life is from molecules, and as are 
 the molecules so is the life, and refer you to the com- 
 pound molecules. Failing in this to get beyond the 
 human senses, we might go a step backward, and en- 
 deavor to fix the life of health and the life of disease 
 in the ultimate atom, when surely we will be lost. 
 Molecular pathology is quite as rational as cellular 
 pathology, quite as easy in diagnosis, and furnishing 
 just as good a basis for therapeutics. 
 
 Nutrition. — In studying the diagnosis of lesions of 
 nutrition, we observe the same order. Having clearly 
 before us the factors — food, digestion in mouth, stomach, 
 intestine, the process of blood-making, the circulation, 
 the condition of the tissues with reference to appropri- 
 ation, and even the adverse side, retrograde metamor- 
 phosis. Any one or more of these factors may be 
 wrong, and we desire to so localize it, that we can 
 select our remedy with certainty. It would be most 
 absurd, to give " Bitter Tonics and Iron," when the 
 wrong was a want of proper food ; quite as absurd to 
 employ a- stereotyped tonic when the patient failed to 
 properly masticate and insalivate his food, or when the 
 lesion was one of the intestinal canal, or a wrong of 
 the circulation. We must know the exact location and 
 character of the lesion, if we are to prescribe with cer- 
 tainty. 
 
 Many wrongs of nutrition are dependent upon a 
 want of proper food. In this country where food is 
 abundant, it is not usually the want of foods in gross. 
 as it is a want of proper selection and preparation. 
 
 BH 
 
268 STUDY OF DIAGNOSIS. 
 
 As the attention is directed to this matter, inquiry sooc 
 elicits the facts of wrong food, or bad cooking in which 
 good food is spoiled, and we are able to set our patient 
 right. 
 
 We not unfrequently find that food is wrong in kind, 
 though it may be good in quality, and well prepared. 
 If a man wants animal food, vegetables containing a 
 large proportion of starch Avill not answer well ; if he 
 wants calorifacient food, it does not do to feed him upon 
 beef-tea. Again we must have regard for the power 
 of appropriation by the individual, who may be able to 
 digest certain varieties of food, when he can not others. 
 
 Wrongs of buccal digestion are easily diagnosed in the 
 majority of cases by the history given. The patient 
 eats rapidly, " bolting his food," which is not properly 
 chewed or insalivated. Or he may be an habitual 
 tobacco chewer or smoker, and thus by continued abuse 
 of the salivary glands have so changed the character 
 of this secretion that it can not do its work. 
 
 The treatment of such cases is veiy plain. The 
 patient must be instructed as to the uses of the mouth, 
 and the necessity of amending his bad habits. Abun- 
 dant time is to be given to each meal, and the food 
 thorough ly masticated. If tobacco has been the cause 
 of trouble it is to be dispensed with in all forms Fre- 
 quently this, without medicine, is sufficient for the cure 
 of severe cases. 
 
 The wrongs of stomachic digestion are frequently an- 
 nounced by unpleasant sensations which the patient 
 refers to the stomach, and points you directly to the 
 *eat of the trouble. We have the evidences of indi- 
 gestion, and a wrong of blood-making and possibly of 
 nutrition, in addition to the localization of unpleasant 
 
STUDY OF DIAGNOSIS. 269 
 
 sensations. Of course the unpleasantness varies in 
 different cases, and has the entire range between sen- 
 sations of fullness, weight, heaviness, to the most ex- 
 quisite pain. 
 
 But having thus localized the lesion, we have only 
 made a commencement, for it is necessary to know its 
 character, and this may be determined in part by the 
 sensations of the patient, and examination of the 
 tongue and the epigastrium, and by the discharges from 
 the stomach. It is possible first to arrange these lesions 
 in two classes — irritative and atonic — and even to make 
 these classes embrace structural lesions. Probably 
 this is the simplest, as it is certainly the best classifica- 
 tion, because it points out the remedies required. Kenn- 
 edies influencing the stomach are readily divided into 
 sedative and excitant — the one removing irritation, and 
 the other giving stimulation. 
 
 The evidence of irritative lesions is found in uneasi- 
 ness or pain of a somewhat acute character, tenderness 
 on pressure over the epigastrium, and in many eases 
 by injection of the papillae of the tongue, especially of 
 the tip and edges, giving the characteristic redness. 
 We have every degree in the intensity of these symp- 
 toms, from the slight irritation with determination of 
 blood, to the well developed inflammation. 
 
 With these evidences of disease, the mind at once 
 turns to those remedies which allay irritation — Hydro- 
 cyanic Acid, Peach Bark, minute doses of Aconite, 
 Ipecac, Bhubarb, Bismuth, Oxide of Zinc, and some of 
 the simpler stomachic bitters, as the Hydrastis. If we 
 have the general indications for a group of medicines, 
 we will find it much easier to select the special one 
 which will be most efficient. The reader will notice 
 
270 STUDY OF DIAGNOSIS. 
 
 that these remedies are alike applicable in all cases 
 characterized by irritation and determination of blood, 
 even in cases of severe structural disease. 
 
 The evidences of atony are impaired circulation and 
 innervation, and want or perversion of function from 
 this, is found in sensations of weight and fullness in 
 the epigastric region, a sense of oppression referred 
 by the patient to the epigastric region. When we ex- 
 amine the patient we find that the expression of the 
 face is dull, the movements listless and show a want 
 of energy. If we examine the tongue we find it full, 
 and expressionless, in some cases pitting where it comes 
 in contact with the teeth. As a rule there is increased 
 secretion of mucus, and the bowels are constipated. 
 
 The symptoms above named point the physician to 
 that class of remedies which are topical excitants to the 
 stomach, and that stimulate a better circulation and 
 innervation. Nux Vomica and Strychnine may be 
 taken as the type of such stimulants, and are fre- 
 quently employed when the impairment is temporary. 
 The bitter tonics — stomachic tonics — are the remedies 
 usually selected when the impairment is of longer dura- 
 tion ; Hydrastis Canadensis, Gentian, Columbo, etc., 
 may be taken as examples of this class. With atony 
 there maybe irritability, and in such cases the remedies 
 might be Amygdalus Persica, or Matricaria Chamo- 
 milla. If the atony is very marked we may employ 
 topical stimulants, as White Mustard, the peppers, or 
 combine with the stomachic bitter small portions of 
 Podophj^llin. 
 
 Atony with increased mucous secretion will be marked 
 by the coated tongue, yellowish or gray, especially 
 toward the base, full and expressionless features, dull 
 eyes, and evidence of oppression. 
 
STUDY OF DIAGNOSIS. 271 
 
 In acute disease it may call for an emetic, may be 
 relieved by a cathartic carefully given, by the use of 
 saline diuretics, or by the use of the Alkaline Sul- 
 phites. 
 
 Excess of gastric juice will usually be known by its 
 eructation, the sense of acidity of stomach, elongated 
 papillae of the tongue tipped with white, and mal- 
 digestion. 
 
 For it we think of remedies that allay irritation, or 
 that remove diseases of which this is sympathetic, as 
 of Bismuth, powdered Charcoal, the Alkalies, or the 
 Acids, as may be indicated by other symptoms'. 
 
 Deficienc}^ of gastric juice is shown by mal-digestion 
 and eructations of undigested food for some hours after 
 eating. 
 
 It may require stimulants, tonics, acids, alkalies, 
 Podophyllin, etc. Kecognizing the deficiency, the 
 mind is directed to the cause, and when determined, 
 the treatment will be very direct and certain. 
 
 Excess of acid is determined by the eructations, and 
 the sense of acidity, but if of the blood as well it will 
 be shown in pallor of mucous membranes. 
 
 Whilst the alkalies would seem to be the direct rem- 
 edies in the treatment of these cases, the}' are really 
 curative only where there is evidence of this lesion of 
 the blood. In other cases the cause must be determined. 
 Many times it is a wrong of innervation, and when 
 this is removed, the acidity ceases. In some cases, in- 
 deed, acids have a more direct influence in effecting a 
 cure than the use of alkalies. 
 
 Deficiency of acid may be known by the unpleasant 
 fluid eructations, greasy if fatty matter is taken as 
 food. The general defect will be shown in the deep 
 
272 STUDY OF DIAGNOSIS. 
 
 redness of mucous membranes, and wherever blood 
 comes to the surface. 
 
 This is sometimes the cause of serious functional 
 wrong, and until the acid is restored digestion will not 
 be well performed. In these cases we usually think of 
 Muriatic Acid as the remedy, though in many Lactic 
 Acid will give the best results. 
 
 The symptoms pointing to Pepsin as a remedy are 
 not very direct. Indeed if we should say there was 
 an entire absence of symptoms it would be a better 
 guide to the physician. Given a case in which there 
 is indigestion or enfeebled digestion, and there are 
 neither evidences, of irritation nor atony, acidity nor 
 alkalinity, or wrongs of innervation, or disease of 
 which this maybe sympathetic, and we would say, give 
 Pepsin. 
 
 The wrongs of Intestinal digestion require care in diag- 
 nosis, as many of the symptoms are obsure and indirect. 
 The lesions ma3 r be classified as in case of the stomach, 
 into irritative and atonic, and the sensations of the 
 patient, if they are described, will usually lead to a 
 correct conclusion. The pinched expression of face, 
 the loss of adipose tissue, giving a shrunken appear- 
 ance of body, the contracted tongue, slick, seemingly 
 divested of papillae, tell the story of irritation. The 
 atony will be indicated by fullness of the abdomen, 
 with a sense of atony as the hand is passed over it; the 
 full, doughy tongue, inclined to be coated, and the gen- 
 eral oppression of the nervous system, give very clear 
 intimations of the character of the lesion. 
 
 The irritative condition calls for Aconite, Ipecac, 
 Matricaria, An^gdalus, Bismuth, the stomachic bitters? 
 Epilobium, etc., and they may usually be selected with 
 
STUDY OF DIAGNOSIS. 273 
 
 considerable certainty. The atony calls for Nux 
 Vomica. Chelidonium. Podophyllin, etc. In many of 
 these cases the combination of Podophyllin in minute 
 doses with one of the simpler bitters, answers an ex- 
 cellent purpose. 
 
 As a rule good blood-making follows good digestion, 
 and having secured the one we are not troubled to 
 look after the other, j^et sometimes we have the fault 
 here and must rectify it. Good blood-making is de- 
 pendent upon, the conditions already named. There 
 must be a normal temperature, a normal circulation, 
 normal activity in use, normal waste and normal ex- 
 cretion. -If there is a wrong of either factor we may 
 expect some degree of wrong in the making of blood, 
 and in nutrition. If at any time we suspect this 
 lesion we examine our patient thorough!}' with refer- 
 ence to these important functions, and finding the 
 wrong, whatever it tnay be, we right it. 
 
 There ma}' be a want of some particular material in 
 order to make good blood and good tissue. This has 
 been recognized by physicians, and is the basis of that 
 called restorative medication. We have already seen 
 that the physician must select the proper food for his 
 patients, and that more may depend upon giving his- 
 togenetic or calorifacient food, than upon medicine. 
 
 u Restorative medication" is an indefinite term, as 
 used, and may mean remedies that stimulate an appe- 
 tite, increase digestion, giving of proper food, as well 
 as the use of those agents which add a needed constitu- 
 ent to the blood. It would be better to restrict the 
 term to the use of agents that enter into the formation 
 :>f the blood and the tissues. We may sum these up as 
 Iron. Phosphorus, Soda, Lime, Potash, Sulphur, Silica, 
 
 ^m 
 
274 STUDY OF DIAGNOSIS. 
 
 Copper, and the bitter principle. These may not be 
 all, but if we can get a clear conception of their use, 
 the wrongs that follow their defect, and the symptoms 
 that point them out, we will do well. 
 
 As Iron is the coloring material of the blood, want 
 of color is generally regarded as indicating the use of 
 this remedy as a restorative. In some cases the evi- 
 dence is sufficiently clear, and when Iron is given the 
 effect is direct and positive. If taking the symptoms, 
 " want of color from blood, " we are careful in our ex- 
 amination to exclude those cases where other and pri- 
 mary lesions exist, th^ certainty would be almost abso- 
 lute. But there is another indication quite as certain 
 as " want of color," when tissues, especially the tongue, 
 show a solid but not deep blue. In these the action 
 of Iron is specific. Again we find certain lesions of 
 the blood, more noticeably those which give an erythe- 
 matous eruption (erysipelas), in which the redness is 
 dirty or dulled, in which Iron is specific. 
 
 When the diagnosis is carefully made, the action of 
 Iron will give great satisfaction. A recent case of 
 uterine disease of long standing with greatly impaired 
 nutrition, presented as a prominent feature frequent 
 erythematous eruptions of this dirty, though somewhat 
 vivid redness, and the cervix uteri and vaginal tissues 
 presented the same color. One grain of Iron by 
 Hydrogen three times a day, was sufficient to effect a 
 cure in a month. In another, where there was im- 
 paired nutrition of many years' standing, and no direct 
 symptoms but the solid blue tongue, the patient made 
 a quick and good recovery on Iron alone. 
 
 The best indication for Phosphorus in its varied 
 forms, will probably be found in the v>an t of expression, 
 
STUDY OF DIAGNOSIS. 275. 
 
 both ill the face and in movement, an enfeebled respi- 
 ration and unequal temperature. The sensations of 
 the patient may point to impaired nutrition of the 
 nerve centres, or simply to a general failure of life. 
 The indications for Phosphorus in the ordinary dose, 
 are invariably of atony — impairment of the circulation 
 and innervation. In a minute dose it may be used 
 where there are evidences of vascular and nervous ex- 
 citement with enfeebled tissue — as instanced in low 
 grades of inflammation of the lungs. 
 
 Soda "is a true restorative in some conditions of dis- 
 ease. If deficient in quantity every function of life is 
 impaired, and without its restoration recovery can not 
 take place. In some cases want of Soda is the basic 
 lesion, and its administration all that is necessary- for a 
 cure. In others this deficiency is but one of many 
 lesions, and the giving of Soda will be but one of the 
 means employed. 
 
 The indication for the use of Soda is clear and un- 
 mistakable — want of color in mucous membranes — 
 which are usually full. Usually we are guided by the 
 tongue, and the expression would be full and pallid — 
 Soda. 
 
 The indications for Lime are not so distinct, but yet 
 quite definite. We are in the habit of saying that 
 Lime is indicated in all idiopathic cases of suppurative 
 disease of cellular tissue. The very fact of inflamma- 
 tion with a low euplastic or cacoplastic deposit, not the 
 result of injury, evidences a peculiar wrong, and for 
 this Lime is the remedy. Furuncular disease in all its 
 forms, finds a remedy in Lime. In the majority of 
 cases, there will be pallor of mucous membranes, though 
 in some cases they will be purplish or blue. Lime is 
 
276 STUDY OF DIAGNOSIS. 
 
 employed in chronic disease of the lungs, with eaeo- 
 plastic deposit, determined by a low grade of inflamma- 
 tion. 
 
 The indications for Potash will be found in pallor of 
 mucous membranes, calling for an alkali, and impair- 
 ment of muscular power. In most cases a dull, leaden 
 hue oi mucous membrane with pallor, will point espe- 
 cially to the Salts of Potash. A marked example will 
 be found in syphilis, in which this coloration is the in- 
 dication for Iodide of Potassium. In some cases a Salt 
 of Potash may be needed, even though the deep color- 
 ation calls for an acid ; this is sometimes seen in scurvy. 
 Here the Soda is excess, Potash is defect, and the 
 patient is cured by the administration of Lemon juice 
 and vegetables containing Potash in large quantity. 
 
 The best indication for Sulphur as a restorative is a 
 change in or want of the pigment of the skin and hair. 
 In some cases the dull, dirty color may call for Sulphur, 
 in others the blanched surface. Rapid loss of color in 
 the hair will sometimes be an indication. Sulphur is 
 also indicated by a peculiar blue or leaden color of 
 urine and faeces. It would be designated by some ? 
 "want of color," and so there is a marked lack of the 
 natural coloring material of these excretions. If I 
 were picking a case to obtain the most marked curative 
 action of this drug, I would take the dirty or tawny 
 skin with bluish urine. 
 
 The indication for Silica is not very well known. 
 I have used it with most advantage when the epithe- 
 lium had a lifeless appearance, and there was continued 
 tendency to desquamation. In some cases these symp- 
 toms are followed by severe ulceration of the skin. 
 Hahnemann claimed that it was a valuable remedy in 
 
STUDY OF DIAGNOSIS. 277 
 
 rachitis of children, and named sweating of the head, 
 as one of its most prominent indications. 
 
 Copper is not usually regarded as a constituent of 
 the body, yet I think it is clearly proven that it is 
 present in small quantity. The indication for its use is 
 the unpleasant greenish pallor of skin met with in 
 some diseases of women, and a veiy similar coloration 
 of tongue. In some cases the patient has not lost 
 flesh, and nutrition seems to be quite as good as usual, 
 but there is a want of energj^ and power of endurance. 
 
 The Bitter Tonics are in such common use, that it 
 would seem hardly necessary to point out the indica- 
 tions for their use. But one would find it a little diffi- 
 cult to point out clearly the cases in which the bitters 
 are direct remedies. One might say "want of appe- 
 tite," and as by their topical action they are appetizers, 
 he would guess his case off right with the majority. 
 Or we may say "' impaired digestion/' and by their 
 topical action the)^ do improve digestion, and we would 
 be right in the majority. Or we might say " enfeebled 
 nutrition, " and as they do improve nutrition, we would 
 make a right diagnosis in a great many cases. The 
 blood requires a bitter principle, and its want is the 
 cause of most serious disease, yet I can not point the 
 reader to any better evidence of it tban impaired 
 appetite, digestion and nutrition. 
 
 Further along, we will see that a right circulation is 
 essential to carry the blood, thus well made, to the tis- 
 sues where it is to be used. Wrongs of the circulation 
 impair the quality of the blood, and the power of the 
 tissues to withdraw from it the materials for nutrition. 
 Thus in all cases of lesion of nutrition a right circula- 
 tion must be maintained. In this connection attention 
 
278 STUDY OF DIAGNOSIS. 
 
 may also be called to the necessity of having the 
 normal temperature of 98°, which, as we have already 
 seen, is a condition of healthy life, 
 
 A patient may have good food, good digestion, and 
 good blood-making, and yet there will be a failure in 
 nutrition. If the tissues are not in a condition to ap- 
 propriate the material and weave it into organic forms, 
 the patienjb would be better not to take it as food. We 
 have already referred briefly to the properties of form- 
 ative cells, and have seen that we have no means of 
 determining their condition, except by the physical 
 properties of the tissues en masse. If they have normal 
 hardness, elasticity, form, and activity, we have reason 
 to conclude that nutrition is good, in so far as the 
 power of appropriation is concerned. Conversely we 
 may say, if they want hardness, elasticity, form, and 
 activity, there is a want of power to organize new 
 tissue. Diagnosis is here made by the tactile and 
 visual senses, and will be valuable just in proportion 
 as these have been trained to use. 
 
 Concluding from these evidences that the tissues 
 lack the power of appropriation, what will be the 
 remedies ? In so far as internal remedies are con- 
 cerned, we have but few that influence the function of 
 the formative cells. To a limited extent, some of the 
 bitters may do this. Yet when we subtract their topi- 
 cal influence upon the digestive apparatus in increasing 
 the appetite and improving digestion, and the slight 
 stimulant influence upon the circulation and innerva- 
 tion, there is but a small fraction to be accounted for. 
 
 Want of hardness, elasticity and activity will show 
 a want of nutrition, whilst the change in form, want 
 of expression — dull and lifeless — may be taken as evi- 
 
STUDY OF DIAGNOSIS. 279 
 
 dences of a want of retrograde metamorphosis. We 
 have already made reference to the great law of animal 
 life — as an organism is used it gains the power, of re- 
 production and increased use; as it is disused it loses 
 this power. But it is well not to forget that over-use 
 will impair reproduction, the forces of life being thus 
 exhausted. In many cases, after providing for good 
 food, good digestion, and good blood-making, a good 
 circulation, normal temperature, and good innervation, 
 we stimulate the appropriation of material by the tis- 
 sues by well regulated exercise. Or if the patient is 
 over-worked, and thus exhausts his powers of repro 
 duction, by recommending rest. 
 
 In some cases the patient requires exercise under 
 the influence of the will, innervation in this way being 
 of as much importance as the activity of tissue. In 
 other cases it requires passive movement, with as little 
 expenditure of nervous power as is possible. In some 
 cases the stimulus of electricity becomes an important 
 means, and by its general use normal nutrition of tis- 
 sues may be obtained. 
 
 The character of deposits may usually be determined 
 by the symptoms indicating the condition of the gen- 
 eral health, and by the local appearance of the part 
 when near the surface. Bearing in mind that good 
 blood will give euplastic deposits, an inferior blood 
 cacoplastic deposits, and a very poor blood aplastic 
 deposits, we will be in a pretty good position to judge. 
 The means of determining this have already been 
 pointed out. 
 
 As regards the local symptoms we may say that the 
 inflammatory process, regular in its course, is the best 
 evidence of euplastic deposit. All irregularities, 
 
280 STUDY OF DIAGNOSIS. 
 
 whether of time, intensity, or of the common symptoms 
 — heat, pain, redness or swelling — point to a deposit of 
 lower character. So certain is this that the pl^sieian 
 will very rarely make a mistake if irregularities cause 
 him to employ greater vigilance. If for instance, in 
 local disease, there is too much or too little heat, too 
 much or too little pain, too much or too little swelling, 
 too much or too little redness, or if the color is changed, 
 we are sure the deposit, if there is one, will be low in 
 character. So if the disease runs its course too rapidly, 
 or progresses too slowly, we conclude that the deposit 
 will be of lower grade. So true is this, that we look 
 with suspicion on all alterations of the inflammatory 
 process, and use extreme care in the treatment of such 
 cases. 
 
 Degeneration is not easily recognized, and in a major- 
 ity of cases it progresses until the destruction is beyond 
 remedy. Of course I exclude granular degenerations 
 of the kidneys (known by albumen in the urine), and 
 degeneration of the liver (known by jaundice), which 
 present characteristic functional disturbance. The 
 gradually decreasing power of continued exertion is an 
 important point in the diagnosis. Persons having de- 
 generation will find themselves incapable of prolonged 
 exertion. There is a want of expression in every part, 
 and the soft tissues sit upon the bones like an ill-fitting 
 suit of clothes. A want of sharpness and strength in 
 the wave of blood as it passes under the finger is an 
 additional element. 
 
 In the treatment of degenerations we wish to re- 
 establish this " renewal of life." Whilst we want good 
 food, .good digestion and blood-making, adding any 
 agents of the class restorative that may be needed, and 
 
STUDY OF DIAGNOSIS. 281 
 
 an active condition of the formative cells, we also want 
 increased retrograde metamorphosis to remove the old 
 and degenerated tissue. In so far as the tissue is de- 
 generated it can never be replaced, but it is possible to 
 so improve the function of nutrition, that what yet re- 
 mains may serve the purpose of the organism. 
 
 The diagnosis of growths belongs to the province of 
 surgery, and requires but a brief notice here. They 
 are classified as benign and malignant, and to deter- 
 mine to which of these two classes a growth belongs is 
 the first object. As a general rule we may say a benign 
 is a growth from the tissues, whilst a malignant is a 
 growth in. A benign growth is distinctly separate 
 from the tissues, and though it may be deeply seated it 
 obtains room for its enlargement by separating them, 
 and occupying the place of the connective tissue. It 
 may interfere with the nutrition and use of tissue by 
 pressure and weight, and in rare cases when inflamma- 
 tory action is set up may form adhesions to them, other- 
 wise it maintains a distinct and separate existence. 
 On the contrary, a malignant growth takes possession 
 of the tissues of the body, and grows in them, trans- 
 ferring the structure into its own lowered forms. It is 
 no respecter of tissue, and occupies one quite as readily 
 as another, taking possession alike of skin, connective 
 cellular tissue, muscle and bones, using the fibrous 
 tissue as its skeleton, and the blood-vessels, lymphatics 
 and nerves, for its supply, waste and innervation. 
 
 The reader will notice that if in any case it be pos- 
 sible to determine the condition of a growth — from or 
 in — the diagnosis is readily made. A growth that does 
 not interfere with or take possession of tissue, is of 
 necessity benign, whilst a growth that does appropriate 
 24 
 
282 STUDY OF DIAGNOSIS. 
 
 the normal tissues is as surely malignant. In a major- 
 ity of cases careful inspection of the part will deter- 
 mine this. 
 
 A benign growth is generally of uniform consistence, 
 smooth, and of equal elasticity as the hand is passed 
 over it. The reader will readily see why this should 
 be the case, as it has a single point of origin and 
 supply, and consequently a uniform development. But 
 in the case of a malignant growth, its consistence and 
 elasticity will depend to a considerable extent upon the 
 tissues it appropriates, and hence it will be of unequal 
 hardness and elasticity — nodulated. 
 
 There is a marked difference in the sensations of the 
 part, The benign growth has no nerves, and any sen- 
 sation experienced will be from its pressure or drag- 
 ging upon adjacent parts. The malignant growth 
 appropriates the nerves of the part, and hence inter- 
 stitial pain of a peculiar character is usually found in 
 these cases. 
 
 A benign growth has no lymphatics, and does not 
 influence the blood other than by withdrawing the 
 materials for its supply. On the contrary, the malig- 
 nant growth appropriates the lymphatics as it does 
 other tissue, and furnishes through them a cancerous 
 lymph which eventual^ produces the constitutional 
 impairment so generally noticed. 
 
 SECRETION. 
 
 Among the important functions changed by disease 
 secretion holds a first place, and in the practice of 
 medicine remedies influencing the secretions have held 
 
STUDY OF DIAGNOSIS. 283 
 
 a first place. But very crude ideas of the function of 
 secretion have been held, and of course the medication 
 based upon these was equally crude and empirical. 
 Whilst phj'siologists have been pretty clear in their 
 teaching that (in the main) secretion was purely a vital 
 function performed through certain cells, called secre- 
 tory, physicians have acted as though they believed it, 
 a purely physical process, like the osmose that occurs 
 through an animal membrane. If secretion is a vital 
 process, life is an essential, and the conditions of life 
 necessary; if it is a physical process of straining, then 
 a dead tissue may secrete as well as a living one. 
 
 There is little use to talk of diagnosis here, unless 
 we have first a clear idea of the apparatus of, and the 
 conditions for secretion. If we can clearly appreciate 
 that in the case of all the secretions — recrementitious 
 and excrementitious — there must be a membrane con- 
 tinuously giving birth to secreting cells, and that these 
 grow to the normal stature of cells, withdraw from 
 the current of blood the special material of their secre- 
 tion, and then discharge themselves with it in the com- 
 mon duct, we will have a basis for correct diagnosis 
 and therapeutics. 
 
 Taking one step further, we find that function not 
 only depends upon life, but upon the normal conditions 
 of life. This is true of every part and every function 
 of the bod}'. Studying the life of cells, and secreting 
 cells bear a very close relationship to formative, we find 
 that a certain temperature, circulation and innervation 
 are necessary .* Probably the life of the secreting cell 
 
 *These conditions are as necessary to the entire organism as 
 to the individual cell, otherwise we would not be benefited by 
 
284 STUDY OF DIAGNOSIS. 
 
 is not so much affected by changes of these, as the life 
 of the formative cell, but in a certain range it is so de- 
 pendent ; whilst the range is greater the effect bej^ond 
 certain points is just the same. 
 
 The cause of lesions of secretion maj T be general or 
 local, and the diagnosis is made by an analysis of gen- 
 eral symptoms influencing secretion at large, and 
 symptoms pointing to local lesion of the secreting 
 organs. When secretion in general is affected, we have 
 good reason to think that the lesion is general ; when 
 but a single secretion is affected we have good reason 
 to believe that the lesion is of the organ furnishing the 
 secretion. 
 
 When all the secretions are involved, the cause, as a 
 rule, will be found in changes of temperature, circula- 
 tion, innervation, digestion, blood-making and waste. 
 
 knowing them. We haveconstant cognizance of the gross form, 
 while the minute structure is beyond our vision oply as Ve bring 
 the microscope to bear upon it. Let us now see how they are 
 applicable to the body as a whole. - 
 
 First.—- An original viability is seen to be an imperative condi- 
 tion. A want of this gives us hereditary diseases and early 
 death. A. want of it also gives us an enfeebled life and a want 
 of resisting power to the ordinary causes of disease; while a 
 strong viability gives great resisting power to disease, and long 
 life. This has already had a partial consideration. 
 
 Second.— A proper supply of nutrient material is also an abso- 
 lute condition, as man only lives by a constant renewal of his 
 bodv. The material for this renewal being furnished, and the 
 cells possessing a normal formative power, life continues in a 
 regular manner. 
 
 Third. — The circumstances favorible for normal development 
 in man are a normal circulation, innervation, temperature, and 
 excretion. — Principles of Medicine. 
 
STUDY OF DIAGNOSIS. 285 
 
 If now secretion is to be restored to its normal condi- 
 tion, we want normal temperature, normal circulation, 
 innervation and waste, especially the first three. In a 
 large majority of cases, secretion is re-established so 
 soon as the conditions of life permit, without the use 
 of special means to this end. Thus in acute disease, if 
 means are employed to rectify the wrongs of circula- 
 tion, the temperature and innervation, Ave find that the 
 tendency is to a re establishment of secretion as the 
 conditions of health are approached. 
 
 Local lesions of the secretory apparatus are best 
 classified as irritative and atonic, as it points out the 
 classes from which our remedies are to be drawn. 
 When a part is involved there will be in nearly all 
 cases such unpleasantness of it as will call the attention 
 of patient and physician to the wrong. It may be 
 pain, or something less pronounced than pain, but it 
 gives the special part a distinctive character sejmrate 
 from the general life. In health the body is a unit, 
 and all sensations are pleasurable, in local disease there 
 is a feeling of separateness between the part and the 
 life, and the severer the disease (as a rule) the more 
 distinct this feeling which regards the suffering part as 
 distinct from the life — a foreign body, which it would 
 be well to get rid of. 
 
 It is true these subjective sensations are not always 
 pronounced, and in some cases the suffering is so mani- 
 fested that it seems of some other and distant part. 
 Yet if the patient's attention is excited, he readilj^ de- 
 termines the wrong sensation, and our knowledge of 
 nervous distribution and sympathies will soon translate 
 the character and situation of pain. 
 
 The reader will already have been impressed with 
 
286 STUDY OF DIAGNOSIS. 
 
 the character of pain as determining the condition of 
 a part as regards excitation and atony. Excluding 
 neuralgia, acute sharp pain is the evidence of undue 
 excitation and an active condition, whilst dull pain and 
 sensations of weight and fullness, indicate atony, with 
 impaired circulation and innervation. It may be said 
 that this method of diagnosis is too gross and arbi- 
 trary, but I think in the majority of cases it will serve 
 as a good basis for the selection of remedies. 
 
 With this method, we should say the absence of local 
 symptoms points to general disease, and we carefully 
 examine our patient with reference to the conditions 
 of normal secretion. Finding the wrong in tempera- 
 ture, circulation, or innervation, we select from those 
 remedies that influence the particular function, and 
 take that one which in its action is opposed to the dis- 
 ease, and in its influence brings the functional wrong 
 toward the standard of health. Determining a local 
 wrong, we at once think of those remedies that espe- 
 cially influence the organ or part, and take that one 
 which in its action will do that which favors the healthy 
 life of the part. Nothing can be simpler than this in 
 theory, as nothing, I am sure, will furnish a better 
 basis for a successful practice of medicine. 
 
 Secretion is divided into two classes, recrementitious 
 and excrementitious, and it is well for the reader to 
 have a good knowledge of these distinct from each 
 other, learning the uses of each. We want to know 
 the simple facts, w T ith regard to the use of saliva, gas- 
 tric juice, bile, pancreatic fluid, and the small gland ul® 
 of the intestine in digestion, that we may weigh the 
 wrongs which may arise from changes in these secre- 
 tions. We want to know the value of mucus as a 
 
STUDY OF DIAGNOSIS. 287 
 
 lubricant and protector of mucous membranes, and of 
 the sebaceous secretions as a lubricant and protector 
 of the skin. And we want to know the value of excre- 
 tion from the lungs, the kidneys, skin, and bowels, as a 
 means of removing worn out and effete material from 
 the body. It is direct thought that we want, for when 
 the mind is directed to a single object it readily grasps 
 it, but when it is made to embrace a multitude of 
 objects, they become indefinite and indistinct. 
 
 If, for example, we are called to a case of increased 
 secretion of .saliva the diagnosis is easily made, for the 
 senses can not fail to be impressed by the increased 
 amount of fluid in the mouth. But the questions that 
 follow are not so easily answered — is it mercurial? 
 from local disease of the salivary glands? from disease 
 of parts contiguous ? from diseases of the digestive 
 apparatus below ? from disease of the brain ? or from a 
 lesion of the sympathetic system of nerves? It seems 
 difficult at first to make such diagnosis, and yet as the 
 mind considers one after the other of these, with such 
 light as additional symptoms may throw on it, the 
 problem is soon solved, and in its solution we are 
 directed to the particular class from which the remedy 
 is to be selected, and possibty the special remedy which 
 will cure. 
 
 The example given above is one of the most com- 
 plex, and we will find the others simpler. If we take 
 the secretion of gastric juice we might make a different 
 study. First, is the disease general, local, or sjnnpa- 
 thetic? If the examination is carefully conducted, the 
 absence of evidence of local disease, and of parts with 
 which the stomach is in special sympathy, and the evi- 
 dences of general lesions which might affect the 
 
288 STUDY OF DIAGNOSIS. 
 
 stomach, will determine the first classification. But if 
 the local symptoms were pronounced, and there was 
 wanting the evidences of general or sympathetic dis- 
 ease we would have determined the second classifica- 
 tion. Whilst if we had pronounced disease of parts 
 with which the stomach sympathizes, as of the uterus 
 or brain, but without marked symptoms of local or 
 general disease, we would have determined the third 
 classification. It may be that we will find two, or pos- 
 sibly three of those causes in some cases, but we reach 
 our conclusions by these methods of examination and 
 thought. 
 
 If we take the liver as the next example, we will 
 find it necessary to employ a different method. The 
 first questions we ask are with reference to local disease. 
 Has the patient unusual sensations in the right hypo- 
 chondrium, of pain, weight, distension, pressure up- 
 wards on lungs, toward the mesial line on the stomach ? 
 is there tenderness on pressure, sense of fullness when 
 the hand is passed over the part, or can the organ be 
 felt below the margin of the ribs ? Is there expression 
 of disease from adjacent parts, as from the bowels, 
 stomach, lungs? Is there a wrong in the uses for 
 which the bile is secreted? 
 
 It is always well to get rid of old-time errors, and in 
 these methods of diagnosis we wish to start with a 
 right physiology. What is the use of bile? Your 
 physiologist will tell jou^ possibly, that he does not 
 know, but he is sure that it is not, as was formerly 
 thought, an excretion, but that it is elaborated to serve 
 uses in digestion and blood-making. As you read on, 
 and think of what you are reading, you see the absur- 
 ditjr of the old practice of medicine, which was con- 
 
STUDY OF DIAGNOSIS. 289 
 
 tinuously looking after the liver and the secretion of 
 bile, and talked glibly of liver complaint, liver disease, 
 "your liver is affected," and about liver pills, chola- 
 gogues, " touching the liver," etc. It requires but 
 little stud}^ to get rid of this old rubbish, and reach 
 the conclusion that the liver does its work very kindly 
 and well, and is an organ that aids nutrition, and not 
 waste. If, therefore, we find a wrong of intestinal 
 digestion, in which the liver is very surely concerned, 
 we may look after the condition of this organ. 
 
 The secretion is peculiar in color, and sometimes 
 wrongs of the liver may be determined by this. Thus 
 faecal matter is to some extent colored with biliverdin, 
 and if the color is dark we say, excess of bile — if it is 
 light we say deficiency of bile. This method of diag- 
 nosis is a little crude, for there are many sources of 
 error. Thus Lehman showed that the peculiar green 
 stools following the administration of Calomel were 
 not due to any action of that drug upon the liver, but 
 to the presence of Sulphate of Mercury in the faeces. 
 An excess of acid may also produce green stools, as a de- 
 ficiency may render them lighter in color. 
 
 The cutaneous pigment will prove a better guide 
 than the color of the fasces. The yellowness of jaun- 
 dice will be called to mind as an instance, and many 
 will recollect brownish spots — liver maculae — that are 
 very clearly traceable to the liver and its associate 
 organs. But a change in the pigment less marked than 
 this has a very definite meaning. I allude to a tawny 
 coloration of the skin, giving it a dull, dirty appear- 
 ance. I believe this always points to a wrong of the 
 chylopoietic viscera, especially to innervation from the 
 25 
 
290 STUDY OF DIAGNOSIS. 
 
 solar plexus, and indicates the class of remedies that 
 have been regarded as " liver medicines." 
 
 But the really important point to determine in these 
 cases is, the condition of the organ with regard to ex- 
 cess or defect, in its circulation and innervation — is 
 there excitation or atony? The symptoms are usually 
 distinct so far as this is concerned, and the remedies 
 will be clearty pointed out. And yet there is nothing 
 in which mistakes are so frequently made. Take, for in- 
 stance, a case of jaundice, and the teaching of the books, 
 is to give hepatic stimulants — Podophyllin, Leptandrin, 
 Blue Pill, Calomel, etc., without reference to the condi- 
 tion of the liver. But in one-half the cases, there arc 
 evidences of excitation in pain, tenderness on pressure, 
 and accelerated circulation, increased temperature, dry 
 skin and scanty urine. Surely hepatic stimulants are 
 not remedies here, and they usually do much harm in- 
 stead of good. In such case the patient requires the 
 special sedatives, Gelseminum, Acetate of Potash, the 
 bath, and possibly the cold-pack or fomentations to tho 
 right hypochondrium. In the opposite class of cases, 
 with sensations of weight, fullness, oppression, unequal 
 temperature, etc., such remedies as will stimulate the 
 liver and associate organs will prove remedies. 
 
 Again we wish to know in this connection that tho 
 bile pigment when once deposited in the cutaneous 
 tissues is never removed by way of the liver, but is 
 always excreted in principal part by the kidneys. In 
 so far then as getting rid of the unpleasant coloration 
 of skin in jaundice is concerned, we might just as well 
 give a remedy to act upon the salivary glands as the 
 liver. There are scores of these olden-time errors in 
 
STUDY OF DIAGNOSIS. 291 
 
 practice that can only be gotten rid of by a careful 
 study of physiology. 
 
 The pancreas does a most important work in secretion, 
 one which the physiologist clearly understands, and yet 
 we hear nothing about " pancreatic complaint," " pan- 
 creatic disease," or " touching the pancreas." Indeed 
 there are no pancreatic remedies in our Materia Medica. 
 Why is this ? There is nothing like getting these sub- 
 jects fairly in view, that we may think of them. Leh- 
 man remarks — " The function of the pancreatic fluid in 
 digestion, may be two-fold, according to the above men- 
 tioned properties, namely : to change starch into sugar, 
 and to decompose the fats, so as to render them absorb- 
 able. That it actually performs the former in diges- 
 tion, has been placed beyond doubt by numerous ex- 
 periments. The pancreatic fluid possesses this property 
 in a much higher degree than the saliva; it is opera- 
 tive at even a low temperature ; neither bile, nor gas- 
 tric juice, nor free acids, interfere with the function of 
 the fluid." 
 
 What then would be symptoms of disease of the pan- 
 creatic secretion? Most surely they would be func- 
 tional, and we would find them in imperfect digestion 
 of calorifacient foods, a deficient supply of burning 
 material, and a more or less rapid consumption of the 
 fat stowed in the body. We would naturally expect to 
 find unchanged starch and fat globules in the fasces, 
 and examination shows that this is the case. Just so 
 soon as we begin to reason rightly, we reach definite 
 results. 
 
 But if we have no " pancreatic medicines," how will 
 we rectify these wrongs, after we have found them ? 
 This is also easy enough. There are in almost all cases 
 
292 STUDY OF DIAGNOSIS. 
 
 certain general lesions of the circulation, temperature, 
 innervation, excretion, etc., easily recognized, and 
 which must be relieved in all cases preparatory to a 
 successful local treatment. As local remedies we may 
 think of Veratrum, Cactus, Chelidonium, Oxide of 
 Zinc, Nux Vomica, Podophyllum, Iodine in minute 
 closes, Panax, etc. They all act " there or thereabouts," 
 and we can choose from the list those that act in the 
 right direction. 
 
 To the doctor in ordinary, the intestinal canal is a 
 place to put pills, powders and potions, for purgation. 
 Bowels were made to be moved, and it is the doctor's 
 business to move them, and sometimes, it seems, it is 
 almost his whole business. He never thinks that the 
 intestinal canal is a digestive .apparatus, and if he has 
 ever learned this in his physiology he has forgotten it. 
 And yet this function of the intestinal canal is really 
 the most important element in digestion. 
 
 In addition to the bile and pancreatic fluid, we have 
 an intestinal fluid secreted by the " bottle- shaped " 
 glands of the alimentary canal. With regard to this 
 Lehman remarks — u The intestinal fluid serves, as re- 
 gards its function, as a complement to the digestive 
 fluids, the gastric and pancreatic fluids, which become 
 inoperative toward the middle of the small intestine ; 
 it possesses not only, as the latter of these does, the 
 power of rapidly changing starch into grape sugar, 
 but also of dissolving and rendering absorbable flesh 
 and other protein bodies. In tied knuckles of intes- 
 tine, into which starch or paste has been introduced, 
 all the starch is transformed into sugar at the end of 
 three hours, and in a great measure absorbed. Pieces 
 of meat or coagulated albumen disappear from such 
 knuckles after six to fourteen hours." 
 
STUDY OF DIAGNOSIS. 293 
 
 This is good reading, my friend of many cathartics, 
 and it is well to give it a prayerful consideration. Here 
 is a fluid that will do the entire work of digestion, and 
 here is an apparatus that really does do a considerable 
 part of it. When you have occasion to use the old- 
 fashioned harsh remedies, think twice, and possibly 
 you may see that the wrong done to this important 
 function may outweigh, man}' times, the good that 
 comes from counter-irritation. 
 
 The remedies named above, for wrongs of the pan- 
 creatic secretion, may be employed here, with some 
 additional ones. What we want to know, as a basis for 
 a rational prescription is — do we want sedation or 
 stimulation — do we want it of the circulation, or the 
 innervation, though these are usually associated. It is 
 hardly worth while to point out now the special indi- 
 cations for Amygdalus, Bismuth, Nux, Chelidonium 
 Aconite, Ipecac, Nitric Acid, Podopl^llin, etc., for their 
 uses will have been learned elsewhere. 
 
 Mucus is secreted to lubricate and protect mucous 
 surfaces, and in normal amount it favors the perform- 
 ance of function. Wrongs of the secretion are usually 
 easily determined. If of the outlets of the body, the 
 condition may be seen and felt. Thus it is easy to re- 
 cognize increased secretion from the nose, throat, and 
 genito-urinary passages, from the abundant discharge. 
 Increased secretion from the bronchial mucous mem- 
 branes is known by its discharge, and also by the blow- 
 ing and rattling sounds heard during cough and on 
 auscultation. Increased secretion of mucus in the 
 stomach is usually shown by the heavily loaded tongue 
 at its base. Whilst increased secretion of mucus in the 
 intestinal canal will be shown by .the uniformly dirty 
 
294 STUDY OF DIAGNOSIS. 
 
 tongue, and by the tumid abdomen. Scanty secretion 
 gives rise to irritation, and this is one of the prominent 
 signs, and taken together with the absence of discharge 
 is very good evidence. 
 
 With a wrong of mucous secretion we ask the ques- 
 tions — what are the general wrongs, operative in this 
 case ? what is the condition of the mucous membrane, 
 as regards its circulation and innervation? It is a 
 rule in practice, to rectify any general lesions, prepara- 
 tory to the cure of local disease, and many times with 
 this the local disease will disappear. Thus in a given 
 case of acute disease, we have a frequent pulse, high 
 temperature, and excited innervation, with dry mucous 
 membranes; the use of the appropriate general reme- 
 dies will establish secretion. And on the contrary, if 
 secretion is too free, the use of appropriate general 
 remedies will lessen it. 
 
 When we think of local remedies we want to grouj), 
 a, those which act upon mucous membranes ; 6, those 
 that act upon the special organ, part, or function in- 
 volved. Having the classes of remedies before us, we 
 now select a stimulant, sedative, or one which by its 
 action tends to change the character of the secretion 
 or function. It is not difficult to select a local remedy 
 if we know exactly what needs be done, and we have 
 a clear knowledge of the value of remedies. 
 
 A change in the sebaceous secretion frequently gives 
 rise to cutaneous disease. If our attention is directed 
 to the function of this secretion, as a lubricant of the 
 skin, its lesions will readily be detected. The treat- 
 ment here will have reference to the condition of exci- 
 tation or atony of the circulation and innervation, and 
 to changes in the nutrition of the organ. Sedatives in 
 
STUDY OF DIAGNOSIS. 295 
 
 the one case, stimulants and tonics in another, and 
 remedies that alter morbid action in others, will be 
 selected to meet the different cases. 
 
 A wrong in the secretion of tears, or the meibomian 
 secretion, may occasion serious trouble with the eye. 
 Profuse lachrymal secretion is sometimes a source of 
 irritation, always a source of feebleness to the tissues. 
 Scant}- secretion on the contrary, by leaving the eye 
 dry, and without the protection given by this fluid, is 
 a cause of irritation. The secretion of the meibomian 
 glands serve an important purpose, and when in excess 
 or defect, the function of the eye is impaired, and un- 
 pleasant disease may be grown. 
 
 Just so soon as the mind is directed to the parts 
 which may be diseased, it is pretty certain by direct 
 symptoms or by exclusion, to determine the exact loca- 
 tion and kind of disease. Then knowing the action of 
 remedies, local and general, these may be selected with 
 reasonable certainty. 
 
 A wrong in the secretion of cerumen is a vciy fre- 
 quent cause of partial deafness, and many aural un- 
 pleasantnesses. It is surely well to know this, and by 
 a careful examination determine the character of the 
 disease — whether in excess, defect or perversion — and 
 also the condition of the secreting structures as it re- 
 gards increased excitation or atony. With such knowl- 
 edge as may be readily obtained by any one, the treat- 
 ment of these diseases becomes successful. 
 
 The principal object in the consideration of these 
 secretions is to call attention to the necessity of con- 
 stantly keeping our physiological knowledge well in 
 hand, and directing attention first to the use, that 
 we may be able to understand the disease. If at any 
 
296 STUDY OF DIAGNOSIS. 
 
 time we forget this, and tako the ordinary writers on 
 pathology and therapeutics as authority, we are quite 
 sure to go astray. 
 
 The excrement it ions secretions are four in number — the 
 lungs, the skin, the kidneys and the bowels — and these 
 remove the waste of the body. The due performance 
 of the function of excretion is essential to health, and 
 in disease we invariably find a lesion of one or more. 
 If the excretions are in excess, debility is the result, 
 and becomes a prominent symptom. If they are in 
 defect, materials which should be removed, are re- 
 tained within the body; the result being irritation or 
 oppression, according to the character of the material, 
 and the amount retained. 
 
 Excretion by the lungs is but little studied, and yet 
 this is one of the most important of the excretions, 
 being to the extent of 517 grains of carbonic acid per 
 hour. In a rough estimate the value of these excretions 
 may be written — lungs eight, kidneys two, skin and 
 bowels each one. True it is carbon which is thus ex- 
 creted by the lungs, (this being regarded in the olden- 
 time as the special province of the liver), but a simple 
 experiment in closing the mouth and nose of an animal 
 will show that it will kill in a very few moments. 
 
 Excretion by the lungs may be in excess, and this 
 will be seen by the vivid redness of the blood where it 
 reaches the surface, by the frequent full respirations, 
 an exalted circulation, an excited nervous system, a 
 high range of temperature, and rapid waste of tissues. 
 We find these evidences of excess both in acute and 
 chronic disease, and it must be evident to the reader, 
 that means to check it will be of value in both cases. 
 
 Such a remedy as Veratrum, and to a less extent 
 
STUDY OF DIAGNOSIS. 297 
 
 Lycopus, Cactus, Sticta, must prove of great value in 
 such cases, associated with such local and topical ap- 
 plications as relieve irritation and give rest. The 
 reader will see very clearly that in the early stage of 
 pneumonia with such symptoms, Veratrum and a mush- 
 jacket may prove speedil}' curative, and that in some 
 cases of phthisis, Veratrum becomes a prominent 
 remedy. 
 
 Defect in excretion from the lungs will be known by 
 the darker color of the blood where it conies to the 
 surface, the evident defect in the movements of the 
 chest, fullness of superficial veins, and the oppression 
 of all the functions from retention of carbonic acid gas. 
 
 At once our attention is directed to such remedies as 
 prove excitant to this function, as Xux, if there is de- 
 ficient spinal innervation, Phosphorus, Arsenic, Lobelia, 
 Bryonia, Drosera, Apocynum, etc. If by these means, 
 excretion of carbonic acid can be increased, the various 
 functions of life are relieved from oppression. 
 
 Even if this knowledge did not point us to special 
 remedies, it would be valuable as suggesting a proper 
 hygiene, The patient suffering from excess wants 
 quiet and rest, a moist atmosphere, and one not stimu- 
 lant. The patient suffering from defect requires such 
 exertion as will call into action the respiratory appa- 
 ratus, a dry atmosphere, and one which is stimulating. 
 Proper direction in these regards may be the one thing 
 necessary to recovery, and we can only give such ad- 
 vice when we thoroughly understand our case. 
 
 The attention of physicians has been specially 
 directed to the skin, kidneys and the bowels, as the 
 apparatus of excretion, the importance of this function 
 to health, and as a cause of disease. Indeed they have 
 
298 STUDY OF DIAGNOSIS. 
 
 received too much attention (such as it was) for three- 
 fourths of the Materia Medica has for its object an ac- 
 tion on these emunctories. If we should take away 
 from the regular physician his cathartics, diaphoretics 
 and diuretics, he would be poor (for harm) indeed. 
 Whilst I do not wish to depreciate these functions, 
 either in health or disease, I think a much more care- 
 ful study should be made of them, and that their thera- 
 peutics should be improved. 
 
 This fact should be especially learned — that in a 
 large majority of cases wrongs of excretion are depen- 
 dent upon changes in general conditions of life — the 
 circulation, temperature and innervation — and that 
 when these are corrected, the excretions resume their 
 normal condition. Even when the function is not re- 
 stored, very simple means are usually all that is required. 
 
 Excess in secretion from the skin is readily deter- 
 mined by its moisture to the touch, dampness of the 
 clothing, as well as by the patient's sensations. The 
 questions that follow are — is it from excitation, or is it 
 a result of debility? It rarely results from excitation 
 in disease, though once in a while from increased circu- 
 lation to the skin, as in some cases of rheumatism, and 
 in the so-called sweating fever, and some other anoma- 
 lous cases, this will be found to be the case. Here the 
 diagnosis is quite clear — the skin has an active circula- 
 tion, is deepened in color, and the temperature is in- 
 creased. The increased perspiration of debility is not 
 secretion, but an exudation of water, washing away a 
 small quantity of albuminoid materials. The condi- 
 tion is determined by the evident relaxation and loss 
 of tone to the touch, the pallor, and usually the want 
 of sensitiveness. 
 
STUDY OF DIAGNOSIS. 299 
 
 Evidently the treatment will be different in the two 
 cases. The one of excitation requires the special seda- 
 tives, Aconite, Veratrum. Gelseminum, or special reme- 
 dies influencing the sympathetic nervous system as the 
 Rhus, Ly cop us, etc. We want to relieve the undue ex- 
 citation of the skin, and this accomplished the sweating 
 ceases. In the other case an opposite treatment is re- 
 quired. Here we select such remedies as stimulate the 
 the skin — stimulant diaphoretics — Serpen taria, Senega, 
 Erigeron, Erecthites, Polygonum, etc. Or stimulants 
 to the circulation and innervation, as Belladonna, 
 Lobelia, Ipecac, Bryonia, etc. Local means will vary 
 just as much, in the one case being sedative, in the 
 other stimulant. 
 
 Defect in secretion may usually be known by exam- 
 ining the skin, which in one class of cases gives the 
 hand a sense of dryness and constriction, and in another 
 dryness with want of elasticity and life. The symp- 
 toms produced by retention of this excretion, are first 
 of oppression, terminating in chill, and second of exci- 
 tation, giving the phenomena of fever. As will be seen, 
 the general symptoms are somewhat indefinite, for both 
 the oppression and stimulation may be the result of 
 other causes. It is well to give due weight to this 
 lesion, though we ma} 7 not rest our entire practice 
 upon it. 
 
 If the defect in secretion is due to an increased cir- 
 culation and temperature, means to rectify these wrongs 
 will stand first. In a majority of cases of fever and in- 
 flammation, a right use of the special sedatives and 
 proper baths will place the skin in such condition that 
 it will resume its function ; or that it can be called into 
 action by very simple remedies. In other cases, where 
 
300 STUDY OF DIAGNOSIS. 
 
 the wrong of circulation, temperature and innervation 
 is bused upon other special lesions, the use of the special 
 remedy for this, is followed by a return of normal cir- 
 culation, temperature and secretion. A marked ex- 
 ample of this will have been seen in the administration 
 of Tincture of Muriate of Iron in some cases of erysip- 
 elas, as well as in the use of Ehus, when special!}^ 
 indicated. 
 
 If the defect is due to a want of excitation in the 
 cutaneous nerves and circulation, remedies are employed 
 which exert a stimulant influence upon the skin. Many 
 diaphoretics owe their power to influence this secretion 
 to their stimulant influence, and of course they can be 
 beneficial only when a correct diagnosis is made, and 
 they are rightly used. 
 
 Perversions of this secretion are not uncommon, but 
 owing to our imperfect means of diagnosis are rarely 
 recognized. " This fluid, (sweat), as it collects in drops 
 on the skin of one perspiring, is colorless, tastes salty, 
 has a peculiar odor, is poor in solid constituents, and, 
 when recent, always reddens litmus." Yet we find in 
 disease that it has color, sometimes to the extent of 
 coloring the clothing, varying in shade and intensity ; 
 has a variety of tastes, sweet, sour, acrid ; is rich in 
 albuminoid elements ; and is sometimes neutral to test 
 paper, and in other cases will change red litmus blue. 
 Evidently here is a field that will repay investigation. 
 Authorities upon skin diseases have recognized the fact, 
 that perversion of the secretion may be a cause of 
 some of these, and may perpetuate the most intract- 
 able. 
 
 In so far as we know now treatment will be directed 
 to the physical condition of this organ, as shown by 
 
STUDY OF DIAGNOSIS. 301 
 
 examination, and to lesions of the blood. The last are 
 sometimes very important, for so long as there is in 
 this fluid morbid material that is excreted by the skin, 
 so long will the skin suffer. 
 
 Before leaving this subject, I wish to call the reader's 
 attention to the character of normal cutaneous secre- 
 tion, and to the fact, that in so far as it is a secretion it 
 is effected by secreting cells. In its normal state the 
 skin has a uniform temperature slightly below that of 
 the blood, gives to the hand a pleasant sensation of 
 softness and elasticity, is not damp and moist, indeed 
 rarely shows moisture upon the surface except on in- 
 crease of temperature and exertion. As this is the 
 condition in which it does the best work, it is the con- 
 dition we wish to obtain in disease. Many act as if 
 they supposed secretion from the skin necessitated the 
 pouring out of an increased quantity of fluids upon the 
 surface, as from the old class of sudorifics. Yet in 
 practice we find that the soft and but slightly moist 
 skin is the best evidence of secretion. 
 
 We have already studied the urine as an index to 
 disease and a means of diagnosis, and it will only be 
 necessary here to notice a few of the more salient fea- 
 tures connected with this study. Whilst the physician 
 is aware that the seeretion of urine is indispensable to 
 life, in that it removes the largest portion of the nitro- 
 genized waste, he finds the common means of diag- 
 nosis so defective, that he takes it for granted that the 
 kidneys are doing their work right, because in a very 
 large percentage of cases, they do their work right. 
 As a matter of form he will ask — "how is your urine? " 
 and in the olden time he might examine a mixture of 
 urine and faeces in the chamber utensil. If the patient 
 
302 STUDY OF DIAGNOSIS. 
 
 complained of scanty urine, it might mean something, 
 if there was uneasiness in voiding it, there was prob- 
 ably something wrong, and if there was arrest, very 
 surely something must be done. But just what that 
 something should be, was not so definite, only that it 
 must be drawn from the class diuretics, and was usually 
 the favorite prescription. 
 
 In this study it would be well for us first, to see wliy 
 in any case the urine should receive a special examina- 
 tion, and then how this examination should be con- 
 ducted. We take it for granted that in ordinary prac- 
 tice examinations of urine will not be made. 
 
 In acute disease retention of the elements of tho 
 urine are so clearly shown by the nervous system, that 
 there can hardly be a failure to have our attention 
 directed to them. The first influence is that of excita- 
 tion — the patient becomes restless and irritable and suf- 
 fers more than the condition of disease will account for. 
 The second influence is of oppression — the patient be- 
 comes dull and lethargic, and finally sinks into coma. 
 Of course Ave may have cerebral excitation and coma, 
 without any wrong of the urinary secretion, but we 
 never fail in these cases to make diligent inquiry, and 
 satisfy ourselves as to the source of the nervous 
 lesions. 
 
 Now scanty urine has a definite meaning, as has un- 
 pleasant sensations in its passage, or a failure to pass 
 it, or going further, we may make a critical examina- 
 tion of it, as heretofore named. I do not wish to be 
 understood as saying that inquiries with regard to tho 
 urine need not be made unless there is nervous dis- 
 turbance, for there can be no harm in thorough exami- 
 nations in all directions — but I desire to impress it 
 
STUDY OF DIAGNOSIS. 303 
 
 upon the mind of the reader that these are the cases 
 where such examination is imperative. 
 
 But finding a failure upon the part of the kidneys to 
 do their work, we are not yet ready to say — give " diu- 
 retics*" We want to know the condition of the kid- 
 neys as regards their circulation and innervation. Such 
 arrest may result from irritation and determination of 
 blood, and any excitant may so increase this as to en- 
 tirely suppress the secretion and cause death. Or it 
 may result from capillary congestion, which the ordi- 
 naiy diuretics would increase, and thus death might 
 result from the use of remedies which in ordinary cases 
 would increase secretion. 
 
 The condition of the kidneys may be determined in 
 part from the patient's sensations, and in part from a 
 personal examination. In irritation with determina- 
 tion of blood (active condition) the patient will have a 
 sense of constriction in the loins with tensive or draw- 
 ing pain, sometimes seeming to be in the spine. Some- 
 times the sense of irritation extends to the bladder, the 
 urethra, the testes, and even to the rectum. In irrita- 
 tion the patient is restless, quick in his movements, the 
 eyes are bright, the tissues around them seemingly con- 
 tracted, the tongue small and pointed, and the pulse 
 small, wiry, or vibratile. In congestion the patient 
 complains of a sense of fullness and weight in the loins, 
 and sometimes the same sense of fullness and weight 
 in the pelvis. The patient is dull and apathetic, the 
 eye dull, the face expressionless, the tongue somewhat 
 full, and the pnlse lacks sharpness in the wave — op- 
 pressed. 
 
 Such diagnosis is of especial value, because it en- 
 ables the practitioner to select his remedies with cer- 
 
304 STUDY OF DIAGNOSIS. 
 
 tainty. If we have the condition of irritation, we give 
 Gelseminum, with or without the sedatives, as may be 
 indicated. If there is the condition of congestion wc 
 give Belladonna, Ergot, or Solan um, with or without 
 Aconite as the sedative. Diuretics are not given until 
 there is marked relief, and secretion has become more 
 free; indeed, sometimes they will not be required at all. 
 When we do give them, they are selected with refer- 
 ence to the condition of the kidneys — sedative diure- 
 tics for the condition of irritation, stimulant diuretics 
 for that of congestion. 
 
 Excess in this secretion is not of frequent occurrence, 
 and is usually recognized without trouble. The large 
 amount of urine in diabetes, insipidus and mellitus, at- 
 tracts the patient's attention, and is evidence to the 
 physician of the nature of the wrong. But there are 
 a few other cases in which the excess is not marked in 
 this way — the patient passing but the usual amount of 
 urine, or possibly it is less in volume than usual. It is 
 only when tested with the urinometer that it is found 
 continuously of high specific gravity, and that the 
 solids are increased from one-tenth to possibly one- 
 fourth more, and still it does not contain sugar or albu- 
 men. Such excess will be marked by loss of flesh and 
 strength, and by feelings of weight and dragging in 
 loins or pelvis. 
 
 The wrong may be wholly due to a lesion of the 
 kidneys, or principally to an excess in retrograde me- 
 tamorphosis. This of course must be determined to 
 give us a rational treatment. 
 
 Attention is rarely called to lesions of perversion by 
 the common examinations of the urine. Of course 
 there are exceptional cases, as the excess of urine in 
 
STUDY OF DIAGNOSIS. 305 
 
 diabetus nielli tus, and urinary irritation in some cases 
 of deposit, in which the direct symptoms are sufficient 
 to excite attention. In the majority, the diagnosis is 
 made by exclusion. There is an impairment of the 
 health; object — to locate and determine the character 
 of the lesion. And thus we give the patient a thor- 
 ough examination, with reference to the more import- 
 ant functions and organs. Is it of the circulation, 
 digestion, respiration, innervation, nutrition, secretion 
 of skin, bowels, kidneys f Thus excluding one after 
 the other, as we find them free from disease, we at last 
 reach the affected part. Even now we do not know 
 the character of the lesion, and proceed by the same 
 method to determine it Is there sugar in the urine, 
 albumen, blood, the phosphates, or some of the rarer 
 morbid materials? The general symj)toms may point 
 us to the special examination, or we may be obliged to 
 make test after test, until we determine what the real 
 trouble is. 
 
 But having learned the character of the perversion, 
 we are not yet ready for treatment. It will not do to 
 say, here is a remedy for all cases of diabetus mellitus, 
 albumien blood, deposit of the triple phosphates. 
 The examination must go a step further — to what extent 
 is it a lesion of the kidneys, or of some other part, the 
 blood, nervous system, or the associate secretions from 
 lungs, skin and bowels? and still a step further, we want 
 to know the physical condition of the kidneys, and the 
 special character of any other wrong. 
 
 The reader may say these methods are very com- 
 plex, and it will be difficult for one to follow them 
 out (?) I admit it, and whenever possible, should rather 
 prescribe from a single characteristic symptom, but 
 26 
 
306 STUDY OF DIAGNOSIS. 
 
 there are cases that require just such thorough analysis 
 to give succeesful treatment. 
 
 When we study excretion from the bowels, we want 
 first to correct our physiological ideas of the value of 
 the secretion. Plrysicians have made a hobby of the 
 bowels and have ridden millions of them to untimely 
 graves. We want to know if bowels were made to be 
 continuously phj^sicked? and whether good or harm is 
 most likely to result from the common use of purga- 
 tives ? If we consult Lehman again, (a most excellent 
 authority), we find that — "The contents of the intes- 
 tines, even after the use of tolerably simple articles of 
 diet, consist of a mixture of undigested, indigestible, 
 and already changed or decomposed substances, with 
 which are mingled constituents, partly undecomposed, 
 partly already metamorphosed, of the digestive fluids." 
 But of a real secretion eliminated by the glandulse of 
 the intestine the faeces contain but a small proportion — 
 probably less than the excretion from the skin. 
 
 Excess is usually associated with frequent fluid evac- 
 uations — diarrhoea — yet we must not take it for granted 
 that in all cases of diarrhoea there is excess. Excessive 
 discharges of fasces produce debility, first by the re- 
 moval of some portions of the food, and secondly by 
 withdrawing some of the albuminoid materials of the 
 blood. 
 
 Constipation is not to be regarded as positive evi- 
 dence of defect in secretion from the bowels, as it is 
 possible, and not uncommon, for constipation to exist 
 for days, and yet excretion goes on into the bowels as 
 before. But even constipation may be a cause of dis- 
 ease, either from irritation produced by the debris of 
 digestion, or by the decomposition of some of the 
 
STUDY OF DIAGNOSIS. 307 
 
 material, or by the generation of offensive gases, or the 
 absorption of some of the decomposed matters. Evi- 
 dences of irritation, or of oppression, when they can 
 be referred directly to inaction of the bowels, may be 
 regarded as an indication for the simpler cathartics. 
 The more harsh remedies of this class have usually 
 been used for their derivative effect, and the saline 
 hydragogue cathartics to deplete the blood-vessels of 
 fluid. 
 
 Small doses of some of the cathartics, as Podophyl- 
 lum, Apocynum, etc., do increase the secernent function 
 of the intestine, and at the same time improve its func- 
 tion of digestion. The dose is less than that required 
 for catharsis, and the indications are sensations of full- 
 ness, weight and atony. 
 
 Perversions of the secretions of the bowels and acces- 
 sory glands are recognized principally by changes in 
 color and in odor, but these are not as certain as would 
 be thought at first sight. The reasons are clear — there 
 is so much and varied coloring material taken with the 
 ingesta, and the odor naturally intense and foul is so 
 readily changed by decomposition of faecal material. 
 Still it is well to make the faeces yield all the informa- 
 tion possible. 
 
 A few examples may be given in illustration. The 
 vivid green discharges of childhood, acrid and irritat- 
 ing, give information of excess of acid, and suggest the 
 use of alkalies. The extreme yellow (chrome) of in- 
 fantile discharges, evidence an insufficient digestion of 
 the food, both of albuminoid material and fat, and sug- 
 gest more care in diet, and the use of remedies that give 
 tone to the digestive apparatus. The clay-colored evac- 
 uations of disease tell of want of secretion from all 
 
308 STUDY OF DIAGNOSIS 
 
 the intestinal glands (liver included), of impaired 
 power of digestion, and suggest the use of stimulants to- 
 the upper intestinal canal and associate viscera. The 
 yellow rye-mush feces of typhoid fever is characteristic, 
 and calls our attention to commencing disease of Peyer's 
 glands. The deep brown or black feces, with greenish 
 tinge, sometimes yeasty, is one of the most marked in- 
 dications of the typhoid condition, and calls attention 
 to the necessity of antiseptics. The color and physical 
 properties of mucus, pus and blood, are readily \*ecog- 
 nized, and either by their quantity, condition, or some 
 local symptoms, their source may be readily detected. 
 
 THE BLOOD. 
 
 The study of the blood is one of much interest to 
 the physician, for in changes of its structure and circu- 
 lation Ave find a principal element in many diseases. 
 The old Hebrew poet well remarked that — " the blood 
 is the life of the man," at least Ave find by experience 
 that Avrongs of the blood are manifested by impairment 
 of the life. We study both the lesions of the blood 
 and the lesions of its circulation, and it is well to keep 
 them separate in the mind. 
 
 Excess in the amount of blood is of very rare occur- 
 rence as a cause of disease, and yet occasionally Ave 
 meet with cases in which, from local disease, the high 
 stimulus of a large amount of rich blood is injurious. 
 We find such cases in local disease of the kidneys, the 
 lungs, the heart, the brain, in which these organs, en- 
 feebled by disease, can not bear the strain of such vig- 
 orous life. This has been named sthenic plethora. 
 
STUDY OF DIAGNOSIS. 309 
 
 There is another condition in which a large amount of 
 blood is continuously made, but owing to exhaustion of 
 the circulatory apparatus and nervous S3^stem by ex- 
 cesses, its circulation is sluggish. 
 
 Excess of blood is readily recognized by the fullness 
 of the blood vessels, especially of the capillary system 
 of the surface, which shows the deep tint of abundant 
 red globules, by the full firm tissues, and the vigorous 
 performance of function. Asthenic plethora will be 
 recognized by fullness of blood vessels, oppression in 
 the stroke of the pulse, and a turgid venous circulation, 
 giving the surface the peculiar color of venous blood. 
 The color is so characteristic, that when associated with 
 the full animalized tissues, and the full blood vessels, 
 there can be no mistake in the diagnosis. 
 
 When high stimulus is likely to be a source of danger, 
 we take measures to lessen the quantity of the blood. 
 The safest means is to diminish the supply of food to a 
 minimum, and select such vegetables and fruits as yield 
 small proportions of nitrogen ized material. In some 
 crises the saline purgatives and diuretics may be em- 
 ployed to a limited extent with advantage, which, with 
 well regulated exercise, will remove the source of 
 danger. Many a man has lost his life because his 
 digestive and blood-making organs were so much 
 better than the remainder of his body, that they have 
 furnished the material for a too active life. In asthenic 
 plethora the important remedy is right living. Cut off 
 the supply of stimulant drinks and food, establish good 
 excretion, and have the patient take such exercise as 
 will promote a more rapid combustion and waste of 
 effete material, and in a few months the patient will be 
 on safe ground. 
 
310 STUDY OF DIAGNOSIS. 
 
 Defect in the quantity of the blood — ancemia — is 
 readily recognized by the want of color of surface, and 
 the loss of that hardness and elasticity of tissue that 
 we call tone, and a loss of size and functional activity 
 of the soft structures of the body. " As the life of the 
 man is his blood," we have a loss of life in proportion 
 to the condition of anaemia. 
 
 But we may have gone so far in our diagnosis as to 
 determine absolutely that there is a want of blood, and 
 yet not be ready to make a prescription. It will not 
 do to say, give Iron, or give " Bitter Tonics and Iron." 
 We want to know why a sufficient amount of blood is 
 not made, or why, if made, it is not applied to its proper 
 use — nutrition. In one case it will be a want of proper 
 food, or of some special element of the blood, in another 
 a want of buccal, gastric or intestinal digestion, in 
 another a wrong in the blood-making organs, in an- 
 other a lesion of the circulation, in another a lesion of 
 innervation, in another a lesion of retrograde meta- 
 morphosis or excretion. Is it too much to ask that 
 each of these receive due consideration, and that our 
 prescription should be directed to the special fault? 
 It requires a little time to pass all this in review, but 
 the mind works very rapidly, and taught to work 
 right, it will do all of this automatically. 
 
 Of course the treatment of anaemia must vary in 
 different cases, as the cause of it varies so much. In 
 one case good food, well prepared, is all sufficient ; in 
 another some special element of blood needs to be 
 added — as Iron, Phosphorus, Soda, Potash, etc. ; in an- 
 other the digestive apparatus requires stimulation ; in 
 another special stimulants are required -to increase sym- 
 pathetic innervation ; in another special means to give 
 
STUDY OF DIAGNOSIS. 311 
 
 a right circulation and temperature ; in another stimu- 
 lants to the formative cells by remedies and exercise ; 
 and in others still the cure comes from stimulating the 
 processes of waste and excretion, thus getting rid of 
 old and feeble forms. 
 
 The consideration of spanhcemia, or poor blood, is 
 hardly necessary here, because it is included in the 
 general term anaemia. Whilst it is possible to have a 
 normal amount of blood, yet poor in some of its ele- 
 ments, this is a rather rare condition. It will be known 
 by the full, limp, inactive tissues, the full, blue veins, 
 the full pulse without power in its stroke, and the ten- 
 dency to dropsical effusions. It is really a worse con- 
 dition than a simple anaemia, and requires more care in 
 its treatment. As we employ means to increase the 
 formation of blood, and add those elements necessary 
 to its proper structure, we at the same time wish to get 
 rid of the old stock, and the safest way to do this is by 
 well regulated exercise and gentle stimulation of the 
 apparatus of excretion. 
 
 As remarked under the head of anaemia, special con- 
 sideration is always given to a want of some of the ele- 
 ments of blood, and to the means which will restore 
 them. This is the basis of the treatment called restora- 
 tive. If the blood requires Phosphorus, it will not do 
 to give it Iron, as when it requires Iron it will not do 
 to give it Sulphur or a bitter. The special symptoms 
 heretofore named, showing these defects, should be 
 closely studied. 
 
 But the blood may be bad, or changes may be going 
 on within it which will work its destruction. You may 
 say that " bad blood " is a popular myth, and does 
 well enough to base a nostrum advertisement upon, but 
 
312 STUDY OF DIAGNOSIS. 
 
 it will hardly do for specific medication (?) There you 
 are wrong, for " bad blood " is a real, tangible entity, 
 with definite expressions, and a definite therapeutics. 
 How will we recognize it? Assuredly in the ordinary 
 way, by an inspection of it where it sIioavs at the sur- 
 face, by any material (secretion) that is drawn -from it, 
 and by wrongs in the nutritive function which is based 
 upon it. When you think of these methods for a 
 moment you will see that they have a physiological 
 basis, are plain, and eminently practical. 
 
 In acute disease we are more interested in those 
 changes going on in the blood which we call septic, 
 than in any special material contained within it, and 
 these changes are more readily recognized by exuda- 
 tions than other means. Attention has already been 
 called to the secretions and deposits upon the tongue, 
 as evidencing the condition of the blood. We find that 
 all exudations that might be called dirty, and all changes 
 in color toward brown and black, might be regarded 
 as certain evidence of sepsis, and of the impairment of 
 the blood. We put the proposition in this form — "as 
 are the secretions of the mouth (notablj 7, the coating 
 of the tongue) dirty or of deep color, so is the intensity 
 of sepsis, and the death of the blood." In so far as the 
 term typhoid is applicable to sepsis, these symptoms are 
 among the most prominent in typhoid diseases. 
 
 Any exudation will serve to show the character of 
 the blood as well as the coating upon the tongue. The 
 discharges from the bowels and of urine, the sputa in 
 disease of the respiratory apparatus, the lochia in puer- 
 peral disease, the " washings-of-meat" discharges in 
 dysentery, the secretions of an ulcer, the sanies of an 
 injury or surgical operation, all tell the story explicitly. 
 
STUDY OF DIAGNOSIS. 313 
 
 It is not possible to get a good secretion or exudation 
 from septic blood, and the character of the one will 
 show the condition of the other 
 
 In some forms of chronic disease there is effete or 
 imperfectly elaborated albuminoid material in the blood 
 in considerable quantity. It serves to lower the char- 
 acter of this fluid, and to impair all vital activities, and 
 by influencing the nutrition of structures it gives rise 
 to local disease. This bad blood has been a basis for 
 the administration of the various compounds called alte- 
 rative, so extensively employed by the profession, and 
 also for nostrum venders, and no doubt the treatment 
 adopted, by increasing waste and nutrition, has cured 
 many cases. 
 
 The evidence of bad blood is best found in wrongs of 
 excretion and of nutrition. There can not be a wrong 
 of this character without an effort upon the part of the 
 skin, kidneys and bowels to remove the unpleasant 
 material, and we will usually find that all three of these 
 emunctories show a lesion caused by the effort, though 
 one ma} r suffer more than another. In the case of the 
 skin it manifests itself in cutaneous disease, taking the 
 forms of the exanthemata in the simpler cases, and the 
 graver forms of the pustulse, squamae and tuberculae, 
 when the lesion is more persistent and severe. This 
 fact has long been recognized, in so far as the treat- 
 ment of skin diseases has embraced means for remov- 
 ing effete and unpleasant materials from the blood. 
 
 We frequently hear it remarked, "I know my blood 
 is bad, because my flesh does not heal easily, and 
 wounds and scratches inflame and suppurate." True 
 there is something wrong here, and it maybe " bad 
 blood," according to our definition above. At least in 
 27 
 
314 STUDY OF DIAGNOSIS. 
 
 a large number of cases, a treatment that looks to the 
 increase of excretion, and better digestion and blood- 
 making, removes all the unpleasantness. In the re- 
 maining cases some special material of the blood is 
 wanting, frequently Lime, sometimes Soda, Potash, 
 Phosphorus, etc. 
 
 In some cases the urinary apparatus is the special 
 seat of suffering. The entire apparatus is irritable, and 
 the urine contains an abundance of ammoniacal com- 
 pounds, and gives characteristic deposits. The effort at 
 removal may be continued by these organs, until severe 
 disease is induced, as seen in some cases of chronic in- 
 flammation, and an occasional case of degeneration. 
 The bowels always suffer more or less, indeed 1 hardly 
 think it possible that this condition should continue 
 long, without a loss of regularity in defecation, and a 
 change in the character of the stools. 
 
 The lesions of nutrition may take the form of de- 
 generation, or of deposits. In the one case we have 
 the symptoms heretofore described, of enfeebled func- 
 tion, and a want of expression in the soft tissues. In 
 the other comes the evidence of local disease, enlarge- 
 ment preceding inflammatory action, which, runs a very 
 irregular course. The last is so important an evidence 
 that it is well to read it over. Whenever swelling 
 and change in the form and functions of a part precede 
 inflammatory action, there is a wrong of the blood, and 
 means must be employed to remove the unpleasant 
 material by excretion, and to provide for better blood- 
 making. 
 
 In place of thinking of certain remedies called " alte- 
 rative," which act in " an insensible and inexplicable 
 manner," it is best to think of the process of cure. 
 
STUDY OF DIAGNOSIS. 315 
 
 The bad material is to be removed, and good material is 
 to be introduced in its place. We wish to know 
 whether it is necessary to employ means to stimulate 
 retrograde metamorphosis, by exercise or medicines, 
 to increase the processes of combustion, to employ 
 remedies that modify and arrest the septic processes, 
 or to use such as increase excretion It is possible that 
 the habits and surroundings of the patient must be 
 changed before a cure is effected, or that he should 
 have better food, better digestion, or better blood- 
 making. In thus getting a better blood, there is less 
 tendency to depravation. 
 
 THE CIECULATION OF THE BLOOD. 
 
 Among the most common lesions in disease are 
 wrongs of the circulation of the blood. We may state 
 it as an axiom that the condition of health requires a 
 circulation normal in time and character, and just in 
 proportion as we have a change from this normal 
 standard we have severity of disease. The time of the 
 pulse varies greatly in different individuals in a state 
 of health, in the adult having a range of from 50 to 90 
 beats per minute, yet in its other characteristics it is 
 pretty uniform, and can hardly be mistaken. The 
 finger on the pulse is trained to determine lesions of 
 the circulation, and should rarely make any mistake. 
 
 The wrongs of the circulation may be general or 
 local, and classified under the three heads, excess, de- 
 fect and perversion. The first has reference to rapidity, 
 the second to an impairment or checking of the circu- 
 lation, and the third may embrace cases in which the 
 circulation is not uniform, or is irregular. 
 
316 STUDY OF DIAGNOSIS. 
 
 Increased frequency of pulse is one of the character- 
 istic symptoms of fever, and is usually associated with 
 a proportionate increase of temperature. As a rule we 
 estimate that ten pulsations represent 1° of tempera- 
 ture — that is for each degree of increased temperature 
 we may expect to find an increase often pulsations per 
 minute. There are many exceptions to this rule, the 
 increased frequency of pulse being sometimes more, 
 sometimes less, and indeed sometimes showing but 
 little relation. As a rule, increased frequency of pulse 
 represents gravity of disease, and we are accustomed 
 to think of it as an unpleasant symptom. As is the 
 frequency of the pulse, so is the arrest of secretion, the 
 increase of heat, the impairment of digestion and blood- 
 making, the arrest of nutrition, the development and 
 progress of sepsis, the progress of inflammatory dis- 
 ease, and the danger to life, local and general. Hence 
 the importance of means which influence the circula- 
 tion, reducing its frequency without impairing its free- 
 dom. 
 
 Frequency of Pulse may be the basis of fever or 
 inflammation, and when the pulse is brought down to 
 a normal standard all the other phenomena of disease 
 may disappear. Thus we often observe under the in- 
 fluence of the special sedatives, that as the frequency 
 of pulse is reduced, the temperature falls, the nervous 
 system is relieved, the skin softens and becomes moist, 
 the urine is increased, the bowels move of themselves, 
 and the appetite returns. Or, in case of inflammation, 
 the pain, ceases, there is less heat, redness and swelling, 
 and resolution rapidly progresses to complete restora- 
 tion. These results are so common, that we are sur- 
 prised in some seasons and in some cases to find that 
 the sedatives do not seem to produce sedation. 
 
STUDY OF DIAGNOSIS. 317 
 
 This brings up the important point in the study of 
 disease — that there is a first and predominant wrong 
 upon which the entire morbid process rests. In some 
 cases, as in the instances given, this is so markedly the 
 case that when Ave have removed this, the whole disease 
 rapidly fades away. But in others this simply paves 
 the way for the doing of something else, and this again 
 for the restoration of other functions, and thus a suc- 
 cession of means may be required in a single case. 
 
 It will not do to say here, I have frequency of pulse, 
 and my patient requires a sedative, taking any one of 
 this class at random. The ten or a dozen remedies 
 grouped under this head are not alike, and can not be 
 used one for the other. It is true that we may so sub- 
 stitute Yeratrum and Aconite in many cases, but even 
 these had better be given according to the special indi- 
 cations heretofore named — Yeratrum when the pulse is 
 full, Aconite when it is small. Then we have Digitalis 
 when the impulse is feeble, Lobelia when it is op- 
 pressed and the artery is turgid with blood, Gelsemi- 
 num when it is full and vibratiie, Belladonna when it is 
 full, soft, and without strength, etc. For these indica- 
 tions and others, the reader is referred to a former con- 
 sideration of the pulse as an element of diagnosis. 
 
 Slowness of Pulse is not a common symptom in 
 disease, but is occasionally met with in chronic disease. 
 It indicates a want of innervation, or excitability of 
 parts supplied from the sympathetic. The wrong may 
 be found in degeneration of tissue, or simply a want of 
 waste and nutrition, the tissues becoming old and in- 
 active. In some cases the pulse will be slow when the 
 patient has remained quiet for some time, but is in- 
 creased in frequency upon exertion. 
 
318 STUDY OF DIAGNOSIS. 
 
 These cases will be benefited by the use of small 
 doses of Lobelia, Digitalis, or Ergot, with the use of 
 means to stimulate increased waste and nutrition. 
 
 Changes if* the character of the pulse are of very fre- 
 quent occurrence, and many of them have already been 
 named in connection with special remedies. In most 
 severe diseases change in the character of the pulse 
 will be found associated with frequency, and will prob- 
 ably point out the sedative which will be found most 
 useful. As heretofore stated, our examination of the 
 pulse has reference to size, the movement of the mass 
 of the blood, the impulse of the wave, its length, gen- 
 eral character and termination, and the inter wave- 
 current. A reference to any sphygmographic illustra- 
 tions will show that there is very great variation in all 
 of these, and that they do represent definite pathologi- 
 cal conditions. 
 
 Irregular distribution of blood is frequently met with 
 in disease, and a popular expression in treatment is, 
 " equalize the circulation." Some have laughed at the 
 expression as being indefinite, unscientific, and partak- 
 ing of the character of u old women's " medicine. But 
 there is no plainer pathological fact than that the cir- 
 culation of blood is unequal in many instances — here 
 too much blood, there too little — a want of circulation 
 to the extremities and surface, too much blood in the 
 cavities of the body. That such inequality is the cause 
 of disease is very easily shown by many examples. 
 Every one will recollect the cold feet and chilled sur- 
 face that attends an ordinary bad cold, and will recall 
 the local and general wrong that comes from a similar 
 condition at the period of the menstrual flow, xcvy 
 greatly increased by the local stasis of blood in the 
 
STUDY OF DIAGNOSIS. 31S 
 
 uterus if the flow should be stopped. Many can recall 
 cases of chronic disease, associated with cold feet and 
 a tendency to chilliness of the surface from imperfect 
 circulation, and they will recollect that such cases were 
 very intractable. Some will recall cases of pneumonia 
 or of typhoid fever, in which an irregularity of the cir- 
 culation, and a tendency to accumulation of blood in 
 .the cavities, and a want of blood to extremities and 
 surface were prominent features, and they will recall 
 the gravity of such cases. 
 
 As the mind recalls these well-known facts, the im- 
 portance of equalizing the circulation will be seen. 
 If in the commencement of a cold, means are employed 
 to give an equally vigorous circulation to surface and 
 extremities, the mucous membranes cease to suffer If 
 in chronic disease we so improve the circulation that all 
 parts receive an equal quantity of blood, we have ac- 
 complished one of the essential things necessary to re- 
 covery. If in severe local disease, or the graver acute 
 affections called typhoid, we find an irregular distribu- 
 tion of blood and heat, getting well will probably de- 
 pend upon our ability to rectify this wrong. 
 
 The Local Lesions of the Circulation that interest 
 us most are embraced under the head of hyperemia, or 
 an excess of blood in a part. This has special reference 
 to the capillary circulation, though arteries and veins 
 are involved to a limited extent. The condition of 
 local hyperemia is easily understood and recognized. 
 In health the mass of capillaries are not full, indeed it 
 is impossible that they should be full at once. If there 
 is an increased amount of blood in a part, with its 
 motion unchanged, there will be increase of size— swell- 
 
320 STUDY OF DIAGNOSIS. 
 
 ing — redness, if the part is superficial, and increase of 
 temperature and sensitiveness. 
 
 Whilst it is possible to have the condition above 
 nanied.it is uncommon. As a rule there is a change in 
 the rapidity of the circulation as well. Thus we divide 
 hypersemia into two varieties, active and passive — in 
 the one there is excess of blood in a part with its move- 
 ment increased, and in the other excess of blood in a 
 part with its movement diminished. We call the first 
 determination of blood, and the second congestion. It 
 will not do to mistake these pathological conditions, as 
 the treatment of one is almost the opposite of that of 
 the other. 
 
 The cause of determination of blood is one — irrita- 
 tion — xibi ivrilatio ibi jiuxus ; and the condition of the 
 part is one of excitation. The symptoms are very 
 clear — there is swelling, heat, increased sensitiveness, 
 and redness. In minor degree the functional activity 
 of organs and parts is increased; but when in excess, 
 though the part is excited, the function is diminished. 
 
 If now we compare with this the condition of the 
 capillary circulation in congestion, we will see that 
 there is much difference. In this the capillaries are 
 filled with blood, but the movement of the blood is 
 sluggish, or entirely arrested in some vessels. The 
 active life of the part is impaired to the extent of the 
 impairment in the circulation, and all the expressions 
 show dullness and want of functional activity. 
 
 Whilst there wns but one cause for determination of 
 blood, in congestion we may have three. The principal 
 one of these is an impairment of the life of the part — 
 the structures being enfeebled the capillaries yield to 
 the visa (ergo of the blood. In some cases an irritation 
 
STUDY OF DIAGNOSIS. 321 
 
 of the part is a first cause, determining a greater amount 
 of blood to it than its weakened vessels can withstand. 
 In other cases an obstruction to the return current by 
 way of the veins, is a principal cause. 
 
 As before named, the symptoms are all of impaired 
 function and oppression, and when we compare this 
 with the excitation of the active state of determination 
 of blood, the distinction will be clear. We say that 
 the sensations are of fullness, weight, dullness, and if 
 there is pain it will partake of these characters. The . 
 objective symptoms when near the surface are of swell- 
 ing, and an increased redness that has not the bright- 
 ness of the active circulation ; the temperature may or 
 may not be increased. 
 
 If we take some examples of the two conditions, the 
 subject may be clearer. In determination to the brain, 
 there is a flushed face (bright), bright eyes, contracted 
 pupils, increased temperature, and excitation of func- 
 tion — the patient being excited, restless and sleepless. 
 In congestion the face is usually flushed (dusky, pur- 
 plish or livid), the eyes are dull, pupils dilated or im- 
 mobile, the mind is sluggish and the patient inclined 
 to coma. If we take the lungs, we find in determina- 
 tion a rapid, uneas}' respiration, characterized by quick 
 movements of the walls of the chest, and the patient 
 shows the excitation in the sharp, forcible cough, and 
 frequent change of position to get relief. The func- 
 tional activity of the lungs being increased, the color 
 of the blood when it reaches the surface is brighter than 
 usual, and the surface is therefore flushed. In conges- 
 tion, the movement of the chest is sluggish, labored and 
 oppressed, and the cough has a like dull and oppressed 
 character. The function of the lungs being diminished 
 
322 STUDY OF DIAGNOSIS. 
 
 the surface is inclined to be dull, dusky, or livid. If 
 we take a. diarrhoea as an example, the symptoms are 
 quite as clear. With determination of blood, there is 
 marked uneasiness, and the evacuations are unpleasant 
 or possibly painful, and attended with some tenesmus. 
 From congestion, the bowels are tumid, have a sensa- 
 tion of weight and fullness, and the discharges are free 
 and without uneasiness. 
 
 Whenever we find these two conditions, the symp- 
 toms will have the same character, and will be shown 
 by the sensations, and by the function of the part. In 
 determination there is the feeling of increased activity, 
 and in congestion the feeling of impaired activity; in 
 determination there is excited function, in congestion 
 impairment of function. 
 
 As the cause of determination is irritation of the part, 
 any agent which will remove this irritation becomes a 
 remedy. As the circulation in its entirety is controlled 
 by a system of nerves, a lesion of a part may some- 
 times be best relieved by an action upon the whole 
 through the sympathetic. Determination of blood to 
 any part may be relieved by the use of Veratrum, 
 Aconite and Gelseminum. Other than these general 
 remedies, we select those that influence the special part 
 affected, and that remove irritation. In determination 
 to the brain we use Gelscminum ; to the lungs Vera- 
 trum or Ipecac; to the kidneys Gelseminum ; to the 
 bladder Eryngium ; to the bowels Aconite and Ipecac ; 
 to the uterus Aconite and Macrotys. In so far as we 
 use local applications they are selected in the same 
 way: wet packs, poultices, fomentations, enemata, in- 
 halations, etc., are selected with reference to their seda- 
 tive character. 
 
STUDY OF DIAGNOSIS 323 
 
 In congestion the part requires stimulation, especially 
 stimulation through the sympathetic. It may also be 
 influenced to a greater or less extent by remedies 
 stimulating the circulation at large. Thus Belladonna, 
 Lobelia, and to some extent Aconite, are of value in all 
 cases of congestion. Other remedies are selected with 
 reference to their action upon the part, as stimulants 
 or excitants. In congestion of the brain we use Bella- 
 donna; in congestion of the lungs or of the heart, 
 Lobelia ; in congestion of the abdominal viscera, Nux 
 Vomica ; in congestion of the kidneys, Belladonna, etc. 
 In selecting local applications we observe the same 
 rule ; whatever their form, they should be excitant to 
 the part. In studying the action of remedies, we first 
 wish to know where they act, and second the kind of 
 action. If a part is diseased, we wish a remedy that 
 acts upon that part particularly, and which does that 
 which is necessary to restore it to health. In the case 
 of determination of blood — the active circulation — we 
 want a remedy that will remove irritation, and the un- 
 due excitation of its circulation ; in congestion we want 
 a remedy that will increase the life of a part, or that 
 will give the necessaiy stimulus to the capillary vessels. 
 
 According to Dr. Williams, inflammation is a local 
 hyperemia, with the movement of the blood partly in- 
 creased and partly diminished. We study this process 
 of disease, with reference to its cause, the lesion of the 
 circulation, the exudation, and the result or termina- 
 tion. The cause is one, irritation with such impairment 
 of vegetative life. From the irritation comes an in- 
 creased circulation to the part, the capillaries are filled 
 with blood, which in some moves slower and slower, 
 until the circulation through them is arrested ; and yet 
 
324 STUDY OF DIAGNOSIS. 
 
 in others the movement of the blood still continues 
 rapid. As the capillaries lose their strength and be- 
 come thus filled, the fluid portion of the blood is exuded 
 into the intercapillary spaces, or upon free surfaces. 
 This completes the pathological process, and we next 
 study its result upon the life of the part. If the origi- 
 nal lesion has not impaired the vegetative life too much, 
 or the lesion of the circulation has not been too great, 
 we find that after a time these minute vessels regain 
 their tone, and the circulation is re-established in them. 
 As the current of blood commences to flow through 
 them, the material exuded is drawn into the current 
 and carried away, thus leaving the part in its original 
 condition. This termination is called "resolution," 
 and is the result most to be desired in all cases. But 
 if the life of the part be so impaired by the cause, that 
 it can not renew itself; or if the impairment of the cir- 
 culation be so great as prevent its receiving tho 
 necessary amount of oxygen, and the removal of car- 
 bonic acid gas, then it must die and be removed. This 
 death and removal takes place in two ways — by sup- 
 puration, and by gangrene or mortification. In sup- 
 puration the process of death is modified by a lower 
 form of life — the production of pus-cells, from the 
 formative cells of the part, and thus the remainder of 
 the body is protected in part, and repair facilitated. 
 But if the impairment of life is greater than this, the 
 part dies, and is removed en masse, by the suppurative 
 process when the tissues still retain sufficient life. 
 
 The symptoms of inflammation, according to the old 
 authorities, are pain, heat, swelling and redness, and 
 for superficial parts these are characteristic and definite, 
 but for internal and concealed parts we are obliged to 
 
STUDY OF DIAGNOSIS. 325 
 
 rely uj^on the first, and the evidences of impaired func- 
 tion, and the influence upon the general health. 
 
 Pain is a very constant expression of inflammation, 
 though it is very common from other causes. It varies 
 from simple uneasiness from over-excitation, to the 
 sharpest and most severe suffering, and its intensity is 
 not to be taken as the measure of inflammatoiy action 
 in anj^ case. It becomes symptomatic of inflammation 
 only when there is evidence of a wrong circulation, and 
 increase of temperature, general or local. 
 
 Heat is a constant symptom, and much more reliable 
 than pain. It may be but local in superficial inflam- 
 mation, or when but a small and unimportant part is 
 affected, but is general when an important part or much 
 tissue is involved. In some cases the patient's sense of 
 heat may be taken as evidence, though this is very 
 liable to error. As a rule the temperature of an in- 
 flamed part will not rise higher than 102°, unless there 
 is a corresponding elevation in the temperature of the 
 body, and there is rarely more than one or two degrees 
 difference between the general and local temperature. 
 The sense of heat, when the hand is placed upon a 
 superficial inflammation, is due in part to arrest of 
 secretion from the skin, which is also the cause of any 
 difference there may be in temperature. 
 
 Swelling is also a constant symptom, though not so 
 marked when free surfaces are involved, or very "dense 
 tissues. It is not a reliable symptom, however, for it 
 may be due to changes in the nutrition of a part, to 
 growths, deposits -.and exudations. To be of any im- 
 portance in diagnosis it must be associated with evi- 
 dences of derangement of the circulation, and with in- 
 creased heat. 
 
326 STUDY OF DIAGNOSIS. 
 
 Redness is only an evidence in superficial inflamma 
 tion, and is due to the presence of a large number of 
 red globules. It is deeper than in determination of 
 blood, though it may be simulated by some rarer con- 
 ditions of the skin. 
 
 Among the prominent and most valuable symptoms 
 of inflammation are wrongs of function ; these are con- 
 stant and characteristic. In the early stage of excite- 
 ment the functional activity of some parts will be in- 
 creased ; but in a majority it simply shows excitement 
 and is really impaired. As the capillary stasis in- 
 creases, and exudation occurs, the function becomes 
 more and more impaired, until in some cases it is com- 
 pletely arrested. Thus in inflammation of the brain, 
 we have at first great mental excitement, then delirium, 
 then probably incoherent (muttering) delirium, and 
 finally from exudation — coma. In this case the symp- 
 toms of the first and second stages are almost opposite — 
 active delirium and coma. In inflammation of the 
 lungs we find at first increased activity and a rapid oxi- 
 dation of the blood ; but in the second stage there is 
 oppression, and an imperfect aeration of the blood. In 
 inflammation of the liver, there maybe at first stage an 
 increase of biliaiy secretion, w T hilst in the second there 
 is complete arrest. So in inflammation of the kidneys, 
 the first excitement produces increased secretion of 
 urine, whilst the second may arrest it entirely. 
 
 The different phases of the inflammatory process and 
 its results, require care in diagnosis. Recognizing the 
 presence of an inflammation, we want to know the 
 danger to the life of the part, and to the life as a whole. 
 In this respect it may be said, that those cases of but 
 moderate excitement are most favorable. When the 
 
STUDY OF DIAGNOSIS. 327 
 
 vascular and nervous excitement are extreme we may 
 anticipate an unfavorable result, as well as when we 
 have marked swelling and redness, with impaired sen- 
 sibility and arrest of function. Tbe sensation given to 
 the touch will be most reliable in external inflamma- 
 tions; the greater the departure from the normal stand- 
 ard, the greater the danger to the tissues. 
 
 Suppuration is announced by an increased fullness of 
 the tissues, a sense of increased tension, and a change 
 in the character of the pain, which becomes throbbing. 
 If but a moderate amount of tissue is involved in an 
 unimportant part, suppuration is followed by relief of 
 the general symptoms, but when considerable tissue is 
 broken down, or important organs are involved, it is 
 frequently ushered in with a chill, and attended by a 
 fever having somewhat the character of hectic. 
 
 Gangrene of external parts is announced by the 
 change iu color — purplish or black — by coldness, and a 
 want of sensibility. Internally it is announced by 
 great prostration, the subsidence of pain, loss of sensi- 
 bility, and a soft, feeble pulse. 
 
 The general symptoms are those of fever. The cause 
 of inflammation is depressing to the life of the indi- 
 vidual as well as to the life of the part, and when con- 
 siderable structures are involved the expressions are 
 very distinct. The first influence gives the listlessness, 
 languor and loss of function ; this culminates in a chill 
 or rigor ; and this is followed by the symptoms of 
 febrile reaction — frequent pulse, increased temperature, 
 arrest of secretion, and derangement of the nervous 
 system. 
 
 In the severer cases of inflammation these general 
 symptoms are as pronounced as in fever, and it is some- 
 
328 STUDY OF DIAGNOSIS. 
 
 times difficult to determine a local lesion, except by 
 close examination and attention to special symptoms. 
 If care is used, however, a special wrong of function 
 will attract attention to a part or organ, and symptoms 
 of inflammation will be detected. 
 
 The close relationship between fever and inflamma- 
 tion should not be forgotten, and indeed it is well in 
 practice to recognize them as requiring the same treat- 
 ment ; an inflammation is fever of a part. The reme- 
 dies for fever are remedies for inflammation, and in 
 many cases they are the best and most direct, we have. 
 If, in the majority of cases, the pulse is brought down 
 to a normal standard, the temperature reduced, inner- 
 vation normal, and the secretions restored, the inflam- 
 matory process will cease, and if the life of the part 
 has not been too much impaired, resolution will be 
 rapidly effected. 
 
 In studying the treatment of inflammation it is well 
 to bear in mind the different phases of the morbid pro- 
 cess. First, irritation and determination of blood ; 
 second, impairment of capillary circulation until its 
 final arrest, and lastly, the impairment of the life of 
 the tissues from this and the exudation. The irritation 
 may continue through the entire progress of the in- 
 flammation, and thus will continuously attract the blood 
 to the part, Avhilst from the commencement there are 
 marked evidences of impairment of tissue life. 
 
 Anything that will lessen or remove irritation will 
 prove a remedy in inflammation. Take away the irri- 
 tation, and you take away the cause of an excited cir- 
 culation of blood to and in a part. The general means 
 have been already referred to, but some of them are 
 local as well. The sedatives, Veratrum and Aconite. 
 
STUDY OF DIAGNOSIS. 329 
 
 influence the inflammatory process directly, wherever 
 it may be located. So do the indirect sedatives of the 
 olden time — the nauseant emetics, and the more power- 
 ful diaphoretics. 
 
 In the selection of local means, we must closely 
 value the inflammatory process, and determine the 
 kind of influence most desirable. It may be directly 
 sedative, removing irritation, and in some instances 
 maj r be depressant. In others, whilst an object is to 
 remove irritation, we also keep in view the greater ne- 
 cessity of stimulation to the capillary circulation. And 
 in many we keep in view, as a principal object, such 
 treatment as will increase the life of the tissues. 
 
 When we have determined by an examination that 
 the inflammation must terminate in suppuration, we 
 should not forget that resolution goes on at the same 
 time, and that it is our business to confine the suppu- 
 rative process to as small a proportion as possible, and 
 to obtain resolution as far as is practicable. The treat- 
 ment is just the same as in mortification ; we wish to 
 restrict the death to as small a portion as possible, and 
 we do it by strengthening the life of the tissues. 
 
 The means named are those which might be em- 
 braced under the head of physiological medicine, and 
 give us an excellent basis of treatment in man}^ cases. 
 In some we have special means, the action of which 
 can not be explained in this way. These remedies are 
 indicated by some special expression of disease, and as 
 we have already seen, they prove curative in very 
 diverse (seemingly) conditions of disease. I need but 
 instance the action of Tincture of Muriate of Iron in 
 erysipelas ; the action of Rhus, Bryonia and Macro tys 
 and some other agents in the arrest of special inflam- 
 28 
 
330 STUDY OF DIAGNOSIS. 
 
 mations, or the special action on individual parts or 
 associate functions, as Phytolacca in mammary inflam- 
 mation, or in. disease arising from nursing. 
 
 INNEKVATION, 
 
 We divide the nervous sj^stem into three parts, for 
 study— the brain, the spinal cord, and sympathetic* 
 The first is the organ of conscious life, the second of 
 automatic movement, and the third governs and asso- 
 ciates the functions of vegetative life. The functions 
 of the brain are reason, emotion, volition and sensation ; 
 of the spinal cord, the co-ordination of muscular action, 
 and the functions of respiration, defsecation and urina- 
 tion, and expulsion of the uterine contents ; and of the 
 sympathetic, digestion, circulation, nutrition, and secre- 
 tion and excretion. 
 
 Lesions of innervation may be due to a change in the 
 condition or structure of the nerve centres, or to some 
 iesion external to these. The more common lesions are 
 of the circulation, and we have them from the two 
 opposite conditions of an excited circulation — too much 
 blood in a part, or an enfeebled circulation — too little 
 blood in a part. Whenever we find these legions, this 
 is the first question we ask, and usually the symptoms 
 of hypersemia or anaemia will be distinctly marked. 
 A physiological treatment will be based upon this, to a 
 considerable extent. If we have hyperemia we use 
 remedies which lessen excitation, if it is anaemia we 
 emploj 7 such agents as stimulate and give a more vig- 
 orous circulation. In the first cases the treatment may 
 be temporarily depressant, in the second it is always 
 restorative and tonic. 
 
STUDY OF DIAGNOSIS. 331 
 
 Delirium in acute disease is readily recognized. 
 The inability to reason rightly, and the illogical and 
 
 unreasonable expressions tell the story clearly. We 
 say delirium is active, it is passive, it is coherent, it is in- 
 coherent — tailing the entire range of that active con- 
 tinued expression, in which it is almost impossible to 
 control the patient, to the dreamy delirium of typhoid 
 fever, in which the patient is calm and still, or the mut- 
 tering delirium that soon passes into coma. 
 
 But we are not so much interested in the expression 
 of delirium as we are in the symptoms indicating the 
 physical condition of the brain. We want to know 
 whether there is an active circulation, or an enfeebled 
 one : whether the patient can bear temporary depres- 
 sants, or requires stimulants and restoratives. The 
 practitioner will recognize the pertinence of this in- 
 quiry, as it points the way to the selection of direct 
 remedies. In the first case we use the sedatives and 
 ;iate means that relieve excitement, and the special 
 remedy. Gelseminum. In the second we u^e Quinine, 
 stimulants, restoratives, tonics and food. 
 
 It may be remarked here, that in addition to the 
 means selected in this way. any remedy which may be 
 indicated by special symptoms, is a remedy for delirium. 
 Thus we see a delirium rapidly disappear under the use 
 of an acid, an alkali, one of the antiseptics. Rhus, and 
 other agents heretofore spoken of. The two methods 
 may be sometimes combined ; though, if the symptoms 
 indicating a single remedy are pronounced it should be 
 first given. 
 
 In delirium tremens, we also find two conditions of the 
 brain as a basis for the wrong reason. A want of re- 
 cognition of this fact has given us some queer medical 
 
332 STUDY OP DIAGNOSIS. 
 
 literature. For a time we will find our medical peri- 
 odicals teeming with recommendations of stimulants, 
 tonics and food as the means of cure ; then for a time 
 they will recommend a sedative and depressant treat- 
 ment. It never seems to have impressed the profession 
 that delirium tremens might arise from two opposite 
 conditions of the brain — one in which the circulation 
 of the organ is depressed, and the other in which it is 
 too active — and yet this is very certainly the case. 
 
 If we find our patient with sunken eyes, blanched or 
 livid lips, cold extremities, and a small and feeble pulse, 
 we know that he requires stimulants, and especially 
 food. In the early stage of such a case we would ex- 
 pect to arrest its progress by the stimulant action of 
 Nux, Iodine and Hydrastis, and the use of beef-tea. 
 We can see how it is that Capsicum in large doses 
 should prove curative, and how small doses of Quinine, 
 Opium and Camphor exert a beneficial influence. 
 
 But if we find him with a florid face, full, bright eyes, 
 increased temperature, and a full, hard pulse, we recog- 
 nize a condition of undue excitement, and would hardly 
 use the treatment just named, though it has proven 
 successful in cases of delirium tremens. On the con- 
 trary, we propose to select remedies which will remove 
 the undue excitement of the circulation, and give rest 
 to the brain. Thus we give full doses of Veratrum and 
 Gelseminum, saline cathartics and diaphoretics, and 
 possibly follow with Bromide of Potash and Chloral. 
 
 If we study puerperal mania, or acute insanity, we 
 find two classes of cases, as in delirium tremens. In 
 one from exhaustive discharges, lactation, and starva- 
 tion (the regulation toast and tea), we have a condition 
 of anaemia. We find the face pallid, the eyes dull, the 
 
STUDY OF DIAGNOSIS. 333 
 
 tongue broad and pallid, the pulse small and feeble, and 
 the extremities cool. We at once recognize that this 
 patient wants proper stimulants, tonics, restoratives, 
 and food, and as we give them we find that there is a 
 stead}' improvement. If we had emploved the olden 
 stereotyped treatment of purgatives and depletives, we 
 would have had a funeral, or a case for the lunatic 
 asylum. 
 
 But in other cases we do find a flushed face, full, 
 bright eyes, contracted tongue, increased temperature, 
 a fnll, hard pulse, and partial arrest of secretion. The 
 case is just as clear as the first one, and we cure it by 
 the use of the proper sedative, Gelseminum, and means 
 which will restore secretion and excretion. In this 
 case temporary depressants may sometimes be employed 
 with good results. 
 
 In chronic mania, the diagnosis of the physical condi- 
 tions of brain and body will be made in the usual way. 
 All wrongs of function and structure are to be removed 
 as far as possible, and the patient placed in the best 
 possible health. Thus if there are special indications 
 for any single remedy, this should be given. In some 
 cases the action of such agents is very speedy and per- 
 manent. 
 
 With regard to the psychological treatment, but little 
 need be said. It must be based upon this law of 
 nature — "that in proportion as an organ or function is 
 used it gains strength ; and as it is disused it loses 
 strength." In so far as the morbid mind has material 
 to feed upon, and has exercise, the insanity will be in 
 creased ; and in so far as the normal functions of the 
 mind are disused, they become enfeebled. The object, 
 therefore, is, to call out the mind in orderly channels as 
 
334 STUDY OF DIAGNOSIS. 
 
 much as possible, and to give as little cause for the in- 
 sane manifestations as possible, that the one may gain 
 strength and the other lose it. 
 
 What has been said with reference to reason is appli- 
 cable to the emotions, in so far as the necessity of re- 
 cognizing the physical lesions are concerned. Emo- 
 tional wrongs have a physical basis, and if perfect 
 health can be restored, they will pass away. Indeed, 
 permanent cures can only be effected in this way. 
 
 The wrongs of the emotions may be in either of the 
 three ways — excess, defect and perversion — but the first 
 and last associated, are usually met with. The expres- 
 sion is so distinct that it can hardly be mistaken ; too 
 great a manifestation and rapid alternation of grief, 
 joy, hope, fear, exaltation, depression, etc., without 
 sufficient or corresponding cause, tells the story. Hys- 
 teria is the type of this class of diseases, though it in- 
 volves other than the emotions. 
 
 A defect in volition is often noticed as an element of 
 mental disease, and as an attendant upon some other 
 diseases. It is often remarked that the strong will is 
 an important means of recovery — " that when one wills 
 to get well, he will get well " — and every practitioner 
 will have noticed the difficulty of managing those cases 
 in which there was an indifference, or want of volition. 
 The expression of the face will frequently give this in- 
 formation before a word is spoken. The firm expres- 
 sion of the muscles of the mouth and closure of the 
 jaws is characteristic of strong will ; whilst the relaxed 
 muscles of the mouth, and the general want of expres- 
 sion, tells of enfeebled will. 
 
 Eecovery will frequently depend as much, or more, 
 upon strengthening the will, as upon the use of reme- 
 
STUDY OF DIAGNOSIS. 335 
 
 dies. If we can call it into action, by presenting addi- 
 tional motives for its exercise, or by a judicious stimu- 
 lation from attendants and friends, we find that it will 
 grow by exercise, and that which was difficult to the 
 patient at first soon becomes easy and natural. 
 
 The brain receives impressions from the world with- 
 out, and from the various parts of the body, through 
 the apparatus and nerves of special and general sense — 
 and this we call sensation. In the healthy body all 
 sensations from it are pleasurable, and the use of the 
 special senses is a source of pleasure. But in disease 
 sensation is unpleasant, and a source of discomfort, and 
 we designate it as pain. It is well to become thor- 
 oughly conscious of this, by passing the various sensa- 
 tions in review. To the sound eye, use is a pleasure, 
 and we only know the organ through the pleasurable 
 sense of vision ; the impulse of sound waves upon the 
 ear is pleasurable; so is the use of the sense of taste, 
 and of smell. When we direct the mind to the appa- 
 ratus of digestion, we find that it gives pleasurable sen- 
 sations, in so far as it gives sensation at all ; the func- 
 tion of respiration is pleasurable, and so is defalcation 
 and urination. 
 
 When this sense of pleasure is lost, we may know 
 that an organ or part is diseased, though the discomfort 
 may not tell us the quality or amount of disease. If 
 the use of the eye becomes a source of discomfort, our 
 attention is called to that organ as the seat of disease, 
 and we at once make a proper examination to deter- 
 mine its character. If the use of the ear is a source of 
 discomfort, we at once conclude that it is the seat of 
 disease, and we make the necessary examinations to 
 determine its exact character. If there is discomfort 
 
336 STUDY OF DIAGNOSIS. 
 
 in the sense of taste, we know there is a wrong in the 
 mouth where these nerves are distributed, or of the 
 digestive apparatus to which these- nerves stand sen- 
 tinel. If there is discomfort in the sense of smell, Ave 
 at once conclude there is disease of the nasal cavities. 
 So when there is discomfort from any apparatus or 
 function — the throat, larynx, lungs, stomach, bowels, 
 defecation, urination, etc., we know there is disease, 
 and having our attention directed to its seat, we pro- 
 ceed with the proper examinations to determine its 
 character. 
 
 Persons will sometimes have their first knowledge of 
 organs or functions through discomfort and pain. The 
 dyspeptic realizes that he has a stomach through pain ; 
 the minister realizes that he has a larynx, when it has 
 become irritable and painful by abuse ; the location of 
 lungs, liver, spleen, bowels, kidneys, bladder, uterus, 
 etc., is first realized by many through the suffering of 
 disease. 
 
 It is well to bear in mind that pain may have two 
 causes — it may be due in principal part or in whole from 
 disease of the part that suffers, or of the brain that re- 
 ceives the impression. To determine this is an impor- 
 tant part of the diagnosis of pain. A little care in 
 noting the expression of the face, the eyes, and the 
 other functions of the brain will determine this in most 
 cases, and this may be supplemented by a careful ex- 
 amination of the part. 
 
 The diagnosis between the pain of structural disease 
 and neuralgia is usually made with ease. The absence 
 of heat, redness and swelling, in any considerable de- 
 gree, is usually sufficient, but in obscure cases it is well 
 to cany the examination further to determine lesions 
 of the blood, of nutrition, waste and excretion. 
 
STUDY OF DIAGNOSIS. 337 
 
 General disease will give rise to the conditions of 
 pain, and to a considerable extent may be considered 
 its cause. Thus, the vascular excitement and increased 
 temperature of fever render the brain more sensitive 
 to impressions, and the nerves more active purvej r ors. 
 The symptomatic fever that attends inflammation has 
 the same influence in increasing pain. Thus, in those 
 cases where pain is very severe, the means that lessen 
 the frequency of the pulse, diminish the temperature, 
 and establish secretion, are the most effective to cure 
 pain. 
 
 When we study the condition of the brain as a cause 
 of pain, we find that it is not one, as generally sup- 
 posed, but two, possibly three. In one case we have 
 evidence of vascular excitement in the flushed face, 
 bright eyes, contracted pupils, and increased tempera- 
 ture. And we meet this condition with Gelseminum, 
 the sedatives, and possibly the saline diuretics and 
 cathartics. In the second case we find the evidence of 
 an enfeebled circulation in the pallid, expressionless 
 lips, the dull eyes, dilated or immobile pupils, and pos- 
 sibly the coolness of nose, ears and forehead — the gen- 
 eral expression is of want of stimulus. In these cases 
 we think of nerve stimulants, of Belladonna, Quinine, 
 Xux, Ammonia, etc. The feeling of dullness and in- 
 clination to sleep attending some forms of pain is met 
 especially by Belladonna and Ergot. The wrongs of 
 perversion are not so easily determined, but with care 
 we may find the indications for special remedies, some- 
 times in the expression of the face, sometimes in the 
 appearance of the tongue, and sometimes in the changes 
 of the pulse. 
 
 There is no doubt that many times the character of 
 29 
 
338 STUDY OF DIAGNOSIS. 
 
 the pain may point out the special remedy for the cure 
 of the disease, though it is not as certain as other 
 mean3 of diagnosis. If we could feel the pain, as we 
 feel the pulse, it would be different, but trusting to the 
 patient's uneducated senses, and his imperfect power of 
 analysis and expression, we find it uncertain. If per- 
 sons are trained to close observation, analysis and ex- 
 pression in this regard, as in some Homoeopathic fami- 
 lies, it may become very reliable. 
 
 Lesions of spinal innervation are diagnosed from 
 wrongs of function controlled by this nerve-center. 
 Thus impairment of muscular motion may be referred 
 to an enfeebled spinal cord, an exalted sensibility of 
 muscles, to increased spinal innervation, whilst all 
 forms of convulsion may be attributed to perverted 
 spinal innervation. Among the important functions 
 controlled from the spinal cord is that of respiration. 
 We will sometimes find deficient respiration, that phy- 
 sical examination will determine is not from structural 
 disease, and we reach the conclusion that it is want of 
 innervation. In acute disease we sometimes find this 
 so marked, that respiration can not be carried on except 
 through the influence of the will and the external re- 
 spiratory muscles. We notice that so soon as the 
 patient sleeps, respiration becomes more and more dif- 
 ficult, until at last he is suddenly aroused by a feeling 
 of asphyxia ; thus rest is prevented, and death may re- 
 sult. In all these cases we think of spinal stimulants 
 as remedies, Nux Vomica and Strychnine being the 
 t} r pe — and increasing spinal innervation, we find our 
 patient breathes better, and gets necessary rest. 
 
 The lesions of excess are rather rare, but still they 
 deserve close study. We will find it marked in some 
 
STUDY OF DIAGNOSIS. 339 
 
 cases by excessive muscular irritability, so that the 
 patient exhausts himself by over-exertion, or more fre- 
 quently by that uneasiness which might be called mus- 
 cular fret. In others the lesion is principally manifested 
 In the respiratory muscular apparatus, giving frequent 
 or irregular respiratory movements — respiratory fret — 
 or sometimes severe and intractable cough from very 
 slight internal irritation. In other cases we find the 
 evidence in defecation and urination, giving frequency 
 and some tenesmus, without corresponding internal 
 disease. 
 
 In these cases there is usually hyperaemia of the cord, 
 marked by a full, hard pulse, tense skin and muscular 
 structures, and rigidity or contraction in all the expres- 
 sions of the body. The remedies will be Veratrum, 
 Gelseminum, Sulphur in free doses, the saline cathartics 
 and diuretics, the cold wet-sheet pack, alkaline batL, 
 etc. 
 
 In some rare cases, there is a condition of anaemia, 
 and the patient requires Nux, Strychnine, Quinine, 
 Iron, Arsenic, stimulant baths, with restoratives and 
 animal foods. 
 
 The lesion of perversion gives us the entire series of 
 convulsive affections, so frequently met with in the 
 practice of medicine. In this case the spinal cord takes 
 complete control of the body, and sets it into disorderly 
 movement. How the wrong is produced, or what is 
 its exact character, is not known, but when once it has 
 obtained, the tendency is to its repetition. There is no 
 difficulty in its recognition ; the complete arrest of the 
 function of the brain, and the disorderly activity of the 
 muscles is so marked that it can not be mistaken. 
 
 Two causes of convulsions are recognized : the one 
 
340 STUDY OF DIAGNOSIS. 
 
 disease of the spinal cord itself — intrinsic, the other a 
 lesion of some other part — extrinsic. The exact condi- 
 tions of the spinal cord are not well known, but we 
 may recognize one of vascular excitement, and one of 
 atony and impaired circulation. In the first the surface 
 and face is flushed, the eyes bright and pupils con- 
 tracted, the pulse somewhat full and hard, and the tem- 
 perature usually increased. In the other the face is 
 pallid or livid, the eyes dull, the pupils dilated in the 
 intervals of spasm, the extremities cold, and the pulse 
 small and frequent. There is a third case in which 
 there is very evident congestion of the cord, and the 
 face will be full and dusky, the eyes protruding, and 
 the pulse full and oppressed. 
 
 These cases are usually so well marked that the diag- 
 nosis is not difficult, and a correct treatment is at once 
 suggested. In the first case we use Gelsemjnum or 
 Veratrum, or both. In the second case we use Lobelia, 
 Chloroform, Bromide of Ammonium, or the foetid gum 
 resins. In the third case, Belladonna, Ergot, and pos- 
 sibly Aconite; Bromide of Ammonium is sometimes an 
 excellent remedy here. 
 
 It is most absurd to think of treating all cases of 
 convulsions with one prescription. Specific Medication 
 never goes that far, it treats conditions of disease, and 
 not names. The instance of convulsions furnishes a 
 very good example of the necessity of accurate diag- 
 nosis. 
 
 It is well to note here that the spinal cord having 
 formed a habit of convulsive action, lias a tendency to 
 repeat this at varying intervals, even though no change 
 of structure, or disease of other parts can be found to 
 account for it. In addition to the treatment for the 
 
STUDY OF DIAGNOSIS. 341 
 
 convulsions, this habit, or tendency to recurrence is to 
 be broken up, and we find in many cases that the 
 longer the convulsive action can be postponed, the less 
 disposition there is to its recurrence. In the treatment 
 of some cases of epilepsy, this is a principal object, and 
 any means which will even temporarily ward off an 
 attack, becomes a part of the cure. 
 
 The extrinsic causes deserve consideration, though 
 many times they have ceased before we are called to 
 treat the cases. If in infancy we find the gums swollen 
 and purplish, a free incision over the coming tooth may 
 relieve the convulsion at once. If green fruit or other 
 irritant ingesta has proven a cause of convulsions 
 through irritation of the stomach, an emetic will give 
 the speediest relief. If it has come from irritation of 
 the solar plexus, attended by pain — colic — ISTux Yomica 
 will give relief. If from irritating materials in the 
 intestine, cathartic enemata ma} 7 be of great service. 
 If from partial suppression of urine, the hot pack over 
 the loins, with Geiseminum, will be the treatment. 
 
 Worms may be a cause of convulsions, and yet I do 
 not think it advisable to give worm medicines, until all 
 symptoms of nervous irritation and convulsions have 
 been removed. Otherwise the additional irritation from 
 the worm medicine may prove fatal. 
 
 In epilepsy the original cause may pass away in a 
 few hours, or it may persist for years. Thus in some 
 cases an epilepsy will arise from a temporary irritation 
 of the stomach, the intestinal canal, or the reproductive 
 apparatus, and no traces of the lesion will be found 
 when we are called to treat the patient. But in other 
 cases the lesions will persist, and their occasional or 
 periodical increase will determine the convulsion. Thus, 
 
342 STUDY OF DIAGNOSIS. 
 
 menstrual derangement may prove a continuous cause, 
 as will disease of kidneys, stomach, bowels, and some 
 other parts. In all cases the examination is careful \y 
 made to detect local lesions, and when found, means are 
 employed to remove them as part of the cure. 
 
 The study of paralysis might follow the consideration 
 of the lesions of the brain and spinal cord, as it may 
 embrace either or both. When the lesion is of one of 
 the hemispheres of the brain, the paralysis is of one- 
 half of the body, divided vertically, and is called hemi- 
 plegia. When it is of the spinal cord, it is of the lower 
 portion of the body, the division being horizontal, and 
 involves all parts below the seat of disease ; this is 
 called paraplegia. When of but limited extent, we call 
 it local paralysis, and we trace it to a lesion in the 
 course of the nerves, or to a limited disease of the cen- 
 tre from which the nerve has its origin. 
 
 We must not suppose that when we have diagnosed 
 a paralysis by the impairment or total loss of motion 
 or sensation, or both, that we are ready to make a pre- 
 scription, and that all that is necessary to be done is 
 to stimulate the nerve centres or the affected parts, by 
 Strychnia, or electricity. We want to know the char- 
 acter of the wrong, both of the nerve centres and of 
 the general health, and when we have determined this 
 we can prescribe intelligently. 
 
 In hemiplegia we will find two conditions of the 
 brain. In one case we will have a flushed face, bright 
 eyes, contracted pupils, increased temperature, im- 
 paired excretion, and a pulse characterized by fullness 
 and hardness. Surely no sane person would treat this 
 case with Nux or Strychnine? On the contrary, we 
 use the proper sedative, Gelseminum, means to establish 
 
STUDY OF DIAGNOSIS. 343 
 
 secretion, and possibly suppurative counter-irritation. 
 In a second case the face is swollen and dusky, the lips 
 livid or purple, the eye dull, pupils dilated or immobile, 
 and the pulse full and oppressed. This patient wants 
 Belladonna, Ergot, Bromide of Ammonium, and wet- 
 cups to the spine, with, possibly, stimulating cathartics. 
 In a third case the head is cool, the face lacks expres- 
 sion, and the pulse is nearly normal, but wants force. 
 Every symptom points to anaemia of the brain, and to 
 the want of restoratives. Here we give Nux or Strych- 
 nine as nerve stimulants, the bitter tonics, good food, 
 and use electricity for its stimulant influence. 
 
 The diagnosis will take the same course in acute 
 paraplegia, and the same means will be used in its treat- 
 ment. When it has been preceded by an injury, or b}" 
 inflammation, we wish to determine as nearly as pos- 
 sible the condition of the part, and whether or not the 
 lesion has destroyed the nerve structures. Even here 
 the treatment may be rational. We do that which 
 needs doing, whether it be to promote the removal of 
 effusion of organized lymph, or of water, or by an in- 
 crease of waste and nutrition gradually renew the dis- 
 eased structures until they are capable of doing their 
 work. 
 
 Wrongs of the sympathetic nervous system are so in- 
 timately associated with lesion of the vegetative func- 
 tions that we find difficulty in separating them. Pos- 
 sibly it is only where an important part or the whole 
 of this system is involved, that it requires special study. 
 We may classify these lesions as an excess, defect, or 
 perversion, though the excess is more an undue excita- 
 tion than an increase of power. 
 
 We will find this excess marked in an unnatural and 
 
344 STUDY OP DIAGNOSIS. 
 
 unaccountable frequency or hardness of pulse, and an 
 unpleasant irritability of the organs of digestion and 
 secretion. There can be no improvement until we can 
 have better innervation. In such cases Veratrum has 
 a most excellent action, and followed by Arsenic, will 
 frequently effect cures in very stubborn cases. 
 
 Defect is marked by a feeble circulation, the artery 
 giving the sensation of a want of tone or elasticity, 
 and all the vegetative functions are feebty and imper- 
 fectly performed. That it is not due to a wrong of the 
 organs themselves is readily determined by other symp- 
 toms. In these cases, Phosphorus, Sulphur, Iron, Cod 
 Liver Oil, Pulsatilla, Digitalis, Aconite, are especially 
 indicated, the particular remedy being selected by spe- 
 cial symptoms. 
 
 Perversion of sympathetic innervation is shown by 
 irregularity in the performance of the vegetative func- 
 tions, and by changes in the character of the pulse, 
 other than frequency, strength, or feebleness, The 
 remedies will be selected, as named in the first part of 
 the work. 
 
 The association of the sympathetic with the spinal 
 nervous system gives us that condition of disease known 
 as spinal irritation. It is of frequent occurrence in 
 chronic disease, and when marked is sufficient to pre- 
 vent a cure by the ordinary means, being a continued 
 source of wrong innervation. It is a little singular 
 that the source of this lesion of the spinal cord should 
 always be an organ supplied from the sympathetic, and 
 that irritation should be so readily propagated back- 
 ward along these nerves. Yet it is a fact that a dis- 
 ease of irritation can not exist long in an organ with- 
 out some disturbance of the great sympathetic, and the 
 
STUDY OF DIAGNOSIS. 345 
 
 spinal cord immediately behind the ganglion, that fur- 
 nish the nervous supply. 
 
 Spinal irritation is usually marked by tenderness on 
 pressure over the bodies of the vertebrae, and when 
 such tenderness is found, it is taken as evidence of this 
 lesion. But once in a while we will find the evidence 
 at some distance from the spine, but always in the 
 course or termination of the posterior spinal nerves. 
 
 It has been proposed by Prof. John King, to deter- 
 mine the locality of chronic visceral disease, by an ex- 
 amination of the spine, and this can be done where 
 there is spinal irritation. If the reader will refer to a 
 text-book on anatomy, he will see that the distribution 
 of sympathetic nerves, and connection with the spinal 
 cord is very simple. The sympathetic ganglia send off 
 large nerves, which before their distribution form a net- 
 work, called a plexus, and from this the nerves are dis- 
 tributed upon the nearest arteries. Thus if we know 
 the source of nerve supply to a plexus, and the distri- 
 bution of the arteries nearest to this, we will readilv 
 make the association between a particular part of the 
 spinal-cord, and a special organ or organs. It might 
 be remarked that the connection between the cord and 
 the ganglia which lie upon the bodies of the vertebrae 
 in front, is immediately backward and forward by fila- 
 ments of communication, and that a limited portion of 
 the gray substance of the cord is thus associated in 
 action with a ganglion. 
 
 The first cervical ganglion sends its branches upwards 
 on the carotids, to supply the brain andL the organs of 
 special sense ; and a nerve downward, which through the 
 cardiac plexus is distributed to the heart; thus to a 
 certain extent associating the brain and heart in action. 
 
346 STUDY OF DIAGNOSIS. 
 
 The other cervical ganglia, send nerves downward to 
 the cardiac plexus, which supplies the heart, and to 
 some extent the lungs. The upper dorsal ganglia 
 send off the great splanchnic, which passing through the 
 diaphragm form the solar plexus, and from this the 
 nerves are distributed upon the cceliac axis to the 
 stomach, liver and spleen, and upon the superior me- 
 senteric to the small intestine and pancreas. Branches 
 from this pass downwards upon the spermatic artery to 
 the testes in the male and the ovaries and uterus in the 
 female. The lower dorsal ganglia furnish the lesser 
 splanchnic nerves, which form above the renal arteries 
 the renal plexus, and furnish nervous suppty to the 
 kidneys, ureters and bladder. The dorsal ganglia fur- 
 nish nerves for the formation of the hypogastric plexus, 
 which gives nervous supply to the pelvic viscera. The 
 sacral ganglia furnish nerves for the sacral plexus, 
 which supplies some parts at the outlets of the pelvis, 
 and the lower extremities. 
 
 The above is but a brief synopsis of this subject, and 
 the reader will do well to give it a thorough study, and 
 trace out the distribution of these nerves on an anatom- 
 ical plate. It will be found that there is a free inter- 
 communication between different parts, some more 
 especially than others, and thus many sympathies ob- 
 served in health and disease can be accounted for. 
 
 In the olden time we were in the habit of recom- 
 mending the irritating plaster for all these cases, and 
 though unpleasant, it may be employed with advantage 
 in a great many. It is better, however, to determine 
 more exactly the condition of the cord, as quite surely 
 it is not always the same. Possibly our old division 
 will serve our purpose here, classifying them with refer 
 
STUDY OF DIAGNOSIS. 347 
 
 ence to the circulation — a, with vascular excitement; 
 h, with enfeebled circulation, or spinal anaemia. 
 
 The case of vascular excitement will be shown in the 
 bright eyes and contracted pupils, slight increase of 
 temperature, and a pulse that has hardness and undue 
 vibration as an element. It is especially the case for 
 suppurative counter-irritation over the site of tender- 
 ness, though I prefer, as being much pleasanter, the use 
 of the wet-pack, of water, vinegar, or water acidulated 
 with Sulphurous Acid. The internal remedies will em- 
 brace Veratrum, Gelseminum, Bromide of Potash, and 
 these may be aided by means to establish secretion. 
 
 The case of anaemia of the cord will be recognized 
 by the dull, sunken eye, feeble circulation to the sur- 
 face and extremities, and a pulse that wants strength. 
 In many of these cases the skin is relaxed, and there is 
 undue exudation. These cases may have the irritating 
 plaster used to rubefaction, stimulant frictions, rubbing 
 of the spine with salt water, the use of electricity 
 (Faradization) and means of a similar character. In- 
 ternally the remedies will embrace Nux, Ergot, stimu- 
 lant doses of Iodine, Pulsatilla, Bromide of Ammonium, 
 and if the pulse is small and vibratile, Ehus. 
 
 There are a few cases, marked by a full, sluggish, 
 and oppressed pulse, dull eye and dilated pupil, in 
 which Belladonna and Ergot will prove very efficient 
 internal remedies, and in which a Belladonna plaster is 
 the best local application. 
 
348 STUDY OF DIAGNOSIS. 
 
 NOSOLOGICAL CLASSIFICATION. 
 
 The stucty of this is beyond the scope of this little 
 volume, and the reader is referred to works on the 
 u Practice of Medicine," or special treatises on diag- 
 nosis, in which this classification is the basis. Our 
 study has been wholty with reference to the selection 
 of remedies, and the ordinary nomenclature interests 
 us only as it points us to groups of remedies. 
 
 The stud}' of nosology is of some importance in 
 enabling one to give appropriate names, in writing or 
 conversing of disease, and especially as satisfying the 
 friends of a patient, who are always desirous of having 
 a disease named. If the reader will take the classifica- 
 tion given, and apply the methods of examination 
 named through this work, he will find but little diffi- 
 culty. We will pass it in brief review, pointing out the 
 method of studj^, and giving the most pronounced 
 symptoms. 
 
 Chlorosis. — In the early menstrual period, usually 
 before the age of twenty ; is characterized by want of 
 blood, impaired nutrition, loss of flesh and strength, and 
 differs from anaemia only in a greenish coloration of 
 the otherwise blanched and bloodless skin. The name 
 has no meaning in selecting remedies, unless in some 
 cases, the peculiar shade of green would indicate Cop- 
 per, and in others Sulphate of Alumina and Iron. 
 
 Scorbutis — Is caused by a want of vegetable food, 
 and is especially marked by softened and spongy gums, 
 usually of a deeper color than natural ; and, finally, by 
 a tendency to deliquescence in all tissues of low organi- 
 
STUDY OF DIAGNOSIS. 349 
 
 zation, espcciall} 7 cicatrical tissue. The name indicates 
 a special pathological condition, and calls for vegetable 
 acids (Citric Acid or lemon juice), and for vegetables, 
 especially those containing a considerable amount of 
 Potash. 
 
 Dropsy — Has different causes, which require special 
 study. It is characterized by exudations of water into 
 the cellular tissues — oedema, anasarca ; or into the 
 serous cavities — ascites, hydrothorax, hydropericardium, 
 hydrocephalus, hydrocele, and hydrops articuli. The 
 diagnosis is made b} r the touch, which gives a different 
 sensation from growths, deposits, or accumulations of 
 pus, blood, or gases. It refers us to special remedies, 
 Apocynum, Aralia, and the hydragogue cathartics and 
 diuretics for the removal of the accumulated fluid. 
 
 Diabetes Mellitus. — Increased flow of urine, with 
 loss of flesh and strength, and impairment of every 
 function. Examination of the urine, as named under 
 that head, determines the presence of sugar. The name 
 does not point to remedies, which must be selected with 
 reference to the symptoms in each individual case. 
 
 Pyemia. — A condition of blood simulating suppura- 
 tion in solids, usually having its origin in injuries or 
 wounds of loose, non-vital tissues, though it may arise 
 from wounds of any part in which putrescency develops. 
 The condition may be known by the extreme restless- 
 ness, and fear of a fatal result, a small, tremulous pulse, 
 (sometimes the pulse has its usual inflammatory condi- 
 tion until a short time before death), a peculiar con- 
 striction of tissue about the base of the brain, pinched 
 nose, and a general expression of irritability. It points 
 
350 STUDY OF DIAGNOSIS, 
 
 us to antiseptics and good food, as the means of cure. 
 Opiates should not be used to relieve pain, if it is pos- 
 sible to get along without them. 
 
 Tuberculosis. — The impairment of the blood that 
 gives rise to aplastic and cacoplastic deposits, has 
 already been described. There is impairment of diges- 
 tion, blood-making and nutrition, with loss of flesh 
 and strength, local symptoms indicating the situation 
 of the deposit. The treatment is suggested by the 
 above description — increase retrograde metamorpho- 
 sis and excretion, and remove the low albuminoid mate- 
 rials, and improve nutrition. 
 
 Fever. — The different forms of fever have been de- 
 scribed in a preceding classification, and it is only 
 necessary here to call attention to the principal phe- 
 nomena, and the treatment. A fever is a disease of 
 four stages — forming, cold, hot and sweating. The 
 symptoms of the first are of prostration — there is an 
 impairment of life. In the second this impairment is 
 still greater, especially of innervation and circulation, 
 and the patient feels cold. In the third vascular and 
 nervous excitement are marked, the pulse is frequent, 
 the temperature increased, the secretions partially 
 arrested, and the vegetative functions impaired in pro- 
 portion to the severity of the disease. In the fourth 
 stage, the various functions are restored, and excretion 
 established — it is convalescence. Whether a fever lasts 
 a day or a month, it has these symptoms, with addi- 
 tional ones showing a wrong of the blood. 
 
 The treatment suggested is very plain. In the form- 
 ing and cold stages means to increase the life, and espe- 
 cially to stimulate the nervous and vascular systems. 
 
STUDY OF DIAGNOSIS. 351 
 
 In the hot stage, to reduce the frequency of the pulse, 
 the temperature and excitation of the nervous sj^stem, 
 and to increase excretion and the vegetative functions, 
 employ such means as will check destruction of the 
 blood, or that will neutralize any morbid element in it. 
 
 Local Disease. — Local disease is determined by the 
 unpleasant sensations in the part, experienced by the 
 patient; by change in its functional expression; and 
 by an examination with our senses, and the application 
 of any instrumentality that medicine affords. 
 
 The distinction between functional and structural 
 disease is determined by the careful examination of the 
 physician. In functional disease we expect to find 
 little or no change in the physical properties of the 
 part; in structural disease such changes will be de- 
 tected 
 
 The Brain, — Disease of the brain is shown by un- 
 pleasant and painful sensations experienced in the 
 organ, a change in the expression of the face and body, 
 and changes in its functional expression. The charac- 
 ter of the disease will be diagnosed by symptoms 
 already pointed out. 
 
 It suggests the use of brain remedies, in addition to a 
 right general treatment. As examples we may name 
 Gelseminum, Belladonna, Pulsatilla, Opium, Bromides 
 of Potash and Ammonium, Phosphorus, Cypripedium, 
 Camphor, Nux, Quinia, Ehus. 
 
 The Spinal Cord. — Disease of the spinal cord is 
 shown by unpleasant sensations experienced in the 
 spine by the patient, by wrongs of muscular movement, 
 respiration, etc. The same remedies are employed as 
 for the brain a 
 
352 STUDY OF DIAGNOSIS. 
 
 Of the Nose. — Unpleasant sensations in and change 
 in secretion of the nasal mucous membrane. Remedies 
 that influence mucous membranes. 
 
 Pharynx. — Sore throat, with unpleasant sensations 
 in deglutition and respiration. The throat can be in- 
 spected and changes of structure noted. 
 
 Larynx. — Unpleasant sensations in the part ; change 
 in the voice; difficulty of respiration ; cough; sputa; 
 and change in* the sounds on auscultation. Special 
 remedies, Aconite, Spongia, Antimony, Collinsonia. 
 
 Bronchia. — Unpleasant sensations in the thorax; 
 difficult respiration ; cough ; sputa; and change in the 
 sounds heard on auscultation — blowing. Treatment 
 will be general, and remedies that influence mucous 
 membranes. 
 
 Lungs. — Unpleasant sensations in the thorax ; diffi- 
 cult respiration ; cough; sputa; sounds heard in aus- 
 cultation — crepitant; percussion gives dullness when 
 consolidation has taken place from any cause. Reme- 
 dies, Aconite, Ipecac, Lobelia, Drosera, Agrimonia, 
 Phosphorus. 
 
 Heart. — Unpleasant sensations in the* prsecordia; 
 sense of oppression and impending danger ; change in 
 the pulse; and impairment of the circulation. Special 
 remedies, Veratrum, Aconite, Digitalis, Cactus, Pulsa- 
 tilla, Rhus, Bryonia. 
 
 Pleura. — Pains of a sharp, lancinating character; 
 difficulty in inspiration; cough; no change upon aus- 
 cultation except in rare cases ; dullness on percussion 
 from effusion. Remedies are all general, unless we ex- 
 cept Bryonia and Asclepias. 
 
STUDY OF DIAGNOSIS. 353 
 
 Mouth and Salivary Glands. — Unpleasant sensa- 
 tions, especially on taking food ; on exposure structural 
 lesions can be seen and felt. Special remedies, Mer- 
 cury, Iris, Podophyllin, Phytolacca, Collinsonia. 
 
 (Esophagus. — Difficult deglutition. Eemedies gen- 
 eral, except for nervous dysphagia, Pulsatilla. 
 
 Tonsils. — Uneasy sensations in the throat ; difficult 
 deglutition and respiration ; can be inspected and 
 changes in size and form noted. Eemedies, Aconite, 
 Nitrate of Potash. 
 
 Stomach. — Unpleasant sensations in the region of 
 the stomach, and impairment of function. Special 
 remedies, Hydrocyanic Acid, Bismuth, Muriatic Acid, 
 Lactic Acid, Pepsin, Hydrastis, Podophyllin, Leptan- 
 drin, Nux, the class of emetics. 
 
 Small Intestine. — Uneasiness in the abdomen ; im- 
 pairment of digestion ; diarrhoea. Special remedies, 
 Bismuth, Podophyllin, Nitric Acid, Hydrastis, Nux, 
 Agrimonia, Epilobium, Aconite, Ipecac, a part of the 
 class of cathartics. 
 
 Large Intestine. — Uneasiness in the abdomen; 
 tormina ; tenesmus ; and small, non-faecal evacuations. 
 Special remedies, Aconite, Ipecac, Aloes, Colocynth, 
 Hamamelis, Collinsonia. 
 
 Liver. — Unpleasant sensations in right hypochon- 
 drium, with occasional slight change in form and size ; 
 impairment of digestion ; and changes in the color of 
 the skin. Special remedies, Leptandra, Nux, Nitric 
 Acid, Sulphur. 
 30 
 
354 STUDY OF DIAGNOSIS. 
 
 Spleen. — Unpleasant sensations in left hypochon- 
 drium; change in form and position of the organ de- 
 termined by the touch ; and impairment of blood-mak- 
 ing and nutrition. No special remedy unless it be the 
 Uvedalia. 
 
 Peritoneum. — Sharp, lancinating pain in the abdo- 
 men, increased by pressure, motion or respiration, with 
 small, wiry pulse, if inflammatory. No special reme- 
 dies. 
 
 Supra-E-enal Capsules. — But one disease known— 
 Addison's — characterized by bronzed discoloration of 
 the skin, gradually increasing, and associated with im- 
 pairment of the vegetative functions. No remedies 
 known. 
 
 Kidneys. — Unpleasant sensations in the lumbar re- 
 gion near spine, in the urinary apparatus below, and in 
 micturition ; changes in the urine determined by ex- 
 amination ; and an influence upon the nervous system 
 by retained urea — excitation at first, coma following. 
 Special remedies, G-elseminum, Belladonna, and the 
 class of diuretics. 
 
 Bladder. — Unpleasant sensations behind the pubes; 
 perineal pressure ; difficult and painful micturition ; and 
 the presence of its secretion, mucus or pus, in the 
 urine. Special remedies, Eryngium, Apis, Phosphorus, 
 Hydrangea, Agrimonia, Staphysagria. 
 
 Prostate Gland. — Unpleasant sensations in the peri- 
 neum; difficult and painful micturition; and an ex- 
 amination externally and by rectum determines change 
 in size and sensibility. Special remedies, Staphysagria, 
 Hamamelis, Phosphorus, Pulsatilla. 
 
STUDY OF DIAGNOSIS. 355 
 
 Urethra. — Unpleasant sensations in passing water ; 
 discharges. Special remedies, Cannabis Indica, Copai- 
 ba, Cubebs, Macrotys, Sandal Wood. 
 
 Testes. — Unpleasant sensations in ; changes in size 
 and form. Special remedies. Phytolacca, the Bromides, 
 Pulsatilla, Staphysagria, Phosphorus, Iodine. 
 
 Ovaries. — Unpleasant sensations in the iliac regions ; 
 change of size and sensibility to the touch ; and wrongs 
 of the reproductive function. Special remedies, Ma- 
 crotys, Actea, Caulophyllum, Pulsatilla. 
 
 Uterus. — Unpleasant sensations in the pelvis ; change 
 of size and form ; change of position ; change in the 
 menstrual and reproductive functions by the discharges ; 
 change in the tissues determined by the touch and by 
 sight. Special remedies, Ergot, Macrotys, Caulophyl- 
 lum. 
 
 Vagina and Yulva. — Unpleasant sensations ; by the 
 discharges ; and by an examination by the touch and 
 speculum. Special remedies, those which influence the 
 reproductive function ; other remedies such as influence 
 mucous membranes, and the general health. 
 
 Arteries.— Changes in the sensation given to the 
 touch, and impairment of the circulation. Special 
 remedies, the same that influence the heart. 
 
 Veins. — Change in size, form, course, and in their 
 color. Special remedies, Hamamelis, Ergot, Iron. 
 
 Lymphatic Glands. — Changes in size, in tempera- 
 ture and in sensibility; with special impairment of the 
 
35G STUDY OF DIAGNOSIS. 
 
 blood, and of nutrition in some cases. Special reme- 
 dies, Phytolacca, Iris, Stillingia, Alnus, Scrophularia, 
 Iodine, Bromine, Phosphorus, Arsenic. 
 
 Skin. — Unpleasant sensations ; changes in structure 
 determined by examination. Special remedies, diapho- 
 retics, Arsenic, Phosphorus, Sulphur. 
 
 Eye. — Unpleasant sensations ; wrongs of function. 
 Special remedies, Belladonna, Calabar Bean, Gelsemi- 
 num, Opium, Bhus, Macrotys, Cannabis Indica, Arsenic. 
 
 Ear. — Unpleasant sensations ; wrongs of function. 
 No special remedies. 
 
 Bones. — Unpleasant sensations ; change of form, size, 
 sensibility, and impaired use. No special remedies. 
 
 Muscular Tissues. — Unpleasant sensations in move- 
 ment ; changes in size, form and sensibility. Special 
 remedies, Macrotys, Apocj-num, Bryonia, Sticta, Phyto- 
 lacca, Colchicum, Potassae. 
 
 Articulations. — Unpleasant sensations ; changes in 
 form, size and sensibility. No special remedies, except 
 possibly Bryonia and Macrotys. 
 
 Cellular Tissue. — Symptoms of inflammation, sup- 
 puration. Special remedy, Lime. 
 
 We have passed most of the organs and tissues in 
 review, in order to impress the fact that remedies do 
 act on special parts. Only a few remedies have been 
 named as examples, but the reader is advised to make 
 notes of remedies under the various heads as they come 
 to his notice by reading or experiment. It must prove 
 
STUDY OF DIAGNOSIS. 357 
 
 of value in therapeutics, to be able to at once associate 
 a group of remedies with special parts and functions, 
 as having them thus clearly before us we can better 
 choose the individual remedy applicable to the case in 
 hand. 
 
 Much more might have been written on this subject, 
 and I doubt not the reader will feel that a more minute 
 examination of local disease would have been profit- 
 able. Yet there are many authorities who give this 
 information, and as said before, it is beyond the scope 
 of our work to make this study. 
 
 Something must be left for each reader to think out 
 for himself, (and this is really the most profitable 
 study), and I have endeavored to point out the way, 
 and give subjects for such thought. The physician 
 who does his own thinking will always have the 
 largest measure of success, and the greatest pleasure in 
 and from his work. 
 
INDEX OF REMEDIES. 
 
 In appending an index of remedies, I desire to point out the 
 prominent indications for their use, whilst reference is made to 
 the pages where the agents are noticed. "With some of the agents 
 this index will be quite a complete study, and as the reader has 
 all the special indications before him, he will be better able to 
 group them together. So in the study of individual remedies, 
 I thought it would be better to so arrange the index that the 
 reader might do his reading with reference to the one agent; or 
 when using it as a work of reference, he would be pointed to the 
 special feature he desired to study. 
 
 Acids, Indicated by deep redness of tongue and other parts 
 
 freely supplied with blood, 80, 81, 102 
 
 Slick tongue 103 
 
 In stomachic digestion 271 
 
 Acid Acetic, Indicated by deep redness, zymosis 81, 102 
 
 Lactic, Indicated by deep redness 81 
 
 Tissues pinched and stringy 143 
 
 Eructations from stomach 112 
 
 Sepsis Ill 
 
 Gastric digestion. 272 
 
 In diseases of the stomach 353 
 
 Muriatic, Contraction of tissues 65 
 
 Deep redness of mucous membranes 81 
 
 " and condition of stomach 102 
 
 Slick tongue 103 
 
360 STUDY OF DIAGNOSIS. 
 
 Acid, Muriatic, Sepsis , Ill 
 
 Eructations from stomach 112 
 
 Hot breath, pungent 199 
 
 As an epidemic remedy 221, 227 
 
 Typhoid symptoms 238 
 
 Pungent heat 263 
 
 Gastric digestion 272 
 
 In diseases of the stomach 353 
 
 Nitric, Irritation of sympathetic 65 
 
 Yiolet color 82, 103 
 
 To influence the temperature 166 
 
 As an epidemic remedy 229 
 
 "Whooping' cough ,.. 230 
 
 To influence the pancreas 293 
 
 Sulphurous, Color muddy or dirty 83 
 
 Erysipelatous redness, blanched 90 
 
 Dirty tongue.... 104 
 
 Increased secretion of saliva Ill 
 
 Large pulse, empty 153 
 
 Mawkish odor from excreta 198 
 
 " u breath 199 
 
 As an epidemic remedy 227 
 
 Zymosis 231 
 
 Typhoid symptoms 238 
 
 Pungent heat 273 
 
 Aconite, Illustrating the certainty of medicine 15 
 
 Inflammation of brain 62 
 
 Effusion, with bright eyes 63 
 
 Constriction about temples 65 
 
 Shrunken face 66 
 
 Simple increase of color 78 
 
 Vascular excitement 79 
 
 Constriction and thinning of structures 84 
 
 Elongated and pointed tongue 95 
 
 Contraction of tongue , 106 
 
 Eructations from stomach 112 
 
 Contraction and irritability of muscular tissue 142 
 
 Small pulse 153 
 
INDEX. 361 
 
 Aconite, Epidemic remedy ... 227 
 
 To influence the nerve centers 263 
 
 Tongue, redness of tip and edges 269 
 
 Contracted slick tongue 272 
 
 To inflnence the pancreas 293 
 
 To influence secretion . 299 
 
 To influence the kidneys 304 
 
 Frequency of pulse , 317 
 
 Determination of blood 322 
 
 Congestion 323 
 
 In inflammation 328 
 
 To influence sympathetic innervation 344 
 
 In diseases of the larynx, lungs and heart 352 
 
 In diseases of the stomach and intestinal canal 353 
 
 Acetate of Potash, Sensation of fullness without elasticity... 143 
 To remove bile pigment 290 
 
 Alkaline Salts, Pallid tongue 101 
 
 Acidity of stomach 211 
 
 Potash, Muscular wrongs 102 
 
 Alcoholic Stimulants, Oppressed voice, hollow and unsteady, 174 
 Small, soft pulse 153 
 
 Asclepias, Rubeola, measles 229 
 
 Apis, Surface hot, burning, painful, dry 231 
 
 In disease of the bladder 354 
 
 Aralia, A remedy for dropsy 349 
 
 Ammonia, Enfeebled capillary circulation 79 
 
 Scarlatina 229 
 
 As an antidote 247 
 
 As a cerebral stimulant 337 
 
 Actea, Pinkish color 86 
 
 In the treatment of disease of the ovaries 355 
 
 Arsenic, White line around mouth, dragging down of corners, 85 
 
 Tongue large, thick in center, incurved edges 103 
 
 Dull and opaque skin 93 
 
 Increased secretion of saliva Ill 
 
 Pinched, contracted tissues 144 
 
 Open, tremulous pulse 154 
 
 Feebleness of voice 174 
 
 31 
 
362 STUDY OF DIAGNOSIS. 
 
 Arsenic, Influence upon the temperature 261 
 
 Defect in excretion from the lungs 297 
 
 Anaemia of the spinal cord 339 
 
 In the treatment of diseases of the skin 356 
 
 Alnus, In disease of the lymphatic glands 356 
 
 Apocynum, Fullness of eyes, fullness of face, drawing down 
 
 of corners of mouth 62 
 
 Dull eyes and relaxation of face 63 
 
 Full eyelids 66, 84 
 
 Full pulse, doughy, accompanied by muscular pain... 153 
 
 (Edema of cellular tissue 155 
 
 Defect in excretion from the lungs 297 
 
 To increase excretion from bowels 307 
 
 A remedy for dropsy 349 
 
 In diseases of muscular tissue 356 
 
 Asclepias, In disease of the pleura 352 
 
 Agrimonia, In diseases of the respiratory apparatus 352 
 
 In diseases of the gastro-intestinal canal 353 
 
 In diseases of the kidneys 354 
 
 Aloes, To influence the large intestine 353 
 
 Baptisia, Deep color, purplish, brown, black 82 
 
 " sepsis 103 
 
 Saliva, viscosity of Ill 
 
 Full pulse, oppressed 153 
 
 Pungent heat 165 
 
 Fetor of cynanche 199 
 
 An epidemic remedy 227 
 
 Typhoid symptoms 238 
 
 Pungent heat, sepsis. r 263 
 
 Belladonna, Dull eyes, dilated pupils 62 
 
 Dull, sodden expression of face 63 
 
 Expressionless eyes 66 
 
 Slow return of capillary circulation when pressure is 
 
 made upon the skin 79 
 
 Dull, colorless eye 87 
 
 Fullness of tongue 106 
 
 Full, oppressed pulse 153 
 
 To influence the temperature. 166, 261 
 
INDEX. 363 
 
 Feebleness of voice .174 
 
 Spasmodic cough 179 
 
 Pain in head, heavy, dull, sleepy 203 
 
 Pain dull, heavy, full, with sense of functional im- 
 pairment 206 
 
 An epidemic remedy 227 
 
 Scarlatina 229 
 
 In convulsions... 231 
 
 To influence the skin 299 
 
 To influence the kidneys 304 
 
 To influence the circulation 317 
 
 A remedy for congestion 323 
 
 Feeble cerebral circulation 337 
 
 In the treatment of paralysis 343 
 
 In disease of the brain 351 
 
 In disease of the kidneys 354 
 
 In disease of the eye 356 
 
 Bismuth, Dragging down of corners of mouth 85 
 
 Elongated and pointed tongue 95 
 
 Eructations, pyrosis 112 
 
 Irritation of stomach 269 
 
 Excess of gastric juice 271 
 
 Intestinal dyspepsia 272 
 
 To influence the pancreas 293 
 
 In diseases of the stomach and small intestine 353 
 
 Bitter Tonics, Kelaxation of tissue 143 
 
 Defect in electricity 265 
 
 Absurdity in prescription .... 267 
 
 Want of expression 270 
 
 Intestinal atony 273 
 
 Want of appetite 277 
 
 Bryonia, Constricted tissues 65 
 
 Eight eyebrow drawn down, flushed right cheek 6Q 
 
 Pain, excited circulation 69 
 
 . Deep flush of right cheek 86 
 
 Yenous obstruction 79 
 
 Sharp stroke of pulse, even vibratile current 154 
 
 To lessen the temperature 166 
 
3()i STUDY OF DIAGNOSIS. 
 
 Bryonia, Cough points at supra-sternal notch 178 
 
 Pain in right side of head, passing from before back- 
 ward 203 
 
 Pain, with sense of oppression 205 
 
 An epidemic remedy 221, 227 
 
 Excess of temperature 260 
 
 "Wrong in combustion 261 
 
 To influence excretion from the lungs , 297 
 
 To influence excretion from the skin M ... 299 
 
 In the treatment of inflammation m 329 
 
 In diseases of the respiratory apparatus 352 
 
 In diseases of the articulations 356 
 
 Beeberina, Brownish discoloration of skin 92 
 
 Bromides, Scanty secretion of saliva - 110 
 
 In diseases of the testes .«.< , 355 
 
 To influence the lymphatic glands 356 
 
 Bromide of Ammonium, Sudden cry, with sobbing respira- 
 tion 175 
 
 Spasmodic cough , 179 
 
 In disease oi the spinal cord 340 
 
 In the treatment of paralysis 343 
 
 In the treatment of spinal irritation. 347 
 
 In diseases of the brain , 351 
 
 Bromide of Potash, A remedy in delirium tremens 332 
 
 In spinal irritation 347 
 
 In disease of the brain 351 
 
 Carbolic Acid, Blanched appearance in inflammation 90 
 
 Dark coating of tongue 104 
 
 Fetor of putrescence 198 
 
 Camphor, In disease of the brain 351 
 
 In delirium tremens 332 
 
 Caulophyllum, In disease of the ovaries 355 
 
 Cactus, Precordial oppression 82 
 
 Irregularity of pulse, wrong of stroke 154 
 
 Cough pointing at supra-sternal notch 178 
 
 Morbid sounds from the heart 195 
 
 To influence the temperature 261 
 
 To "influence the pancreas .... 291 
 
INDEX. 365 
 
 Oactus, To influence the skin 297 
 
 In diseases of the heart 352 
 
 Canabis Indica, In diseases of the urethra 355 
 
 In diseases of the eye « 356 
 
 Calabar Bean, To influence the eyes 356 
 
 Capsicum, Want of power in pulse 153 
 
 Cold feet 169, 263 
 
 In the treatment of delirium tremens 332 
 
 Chloroform, to relieve irritation of the sympathetic nervous 
 
 system 65 
 
 Precordial oppression 82 
 
 Elongated, pointed tongue * 106 
 
 In the treatment of convulsions 340 
 
 Chloral, In the treatment of delirium tremens 332 
 
 Cathartics, Stimulant, Congestion of brain 62 
 
 Hydragogue, Effusion into brain 63 
 
 Full, broad tongue 95 
 
 Heavily loaded tongue 99 
 
 Creasote, In scarlet fever 229 
 
 Chloride of Sodium, Blueness with pallor 82 
 
 Increased secretion of saliva Ill 
 
 In scarlet fever , 229 
 
 Colocynth, To influence the large intestine 353 
 
 Chlorate of Potash, Appearance of tongue 104 
 
 Increased secretion of saliva Ill 
 
 Sepsis 165 
 
 Odor resembling lochial discharge 199 
 
 An epidemic remedy 227 
 
 In puerperal fever 231 
 
 Typhoid symptoms 238 
 
 Pungent heat 263 
 
 Chlorine, Odor of putrescence 198 
 
 Chlorinated Soda, In puerperal fever 231 
 
 Cod-liver Oil, Pinched, stringy tissues 144 
 
 Want of calorifacient food 169 
 
 Feebleness of voice 174 
 
 To influence the temperature 261 
 
 In defective sympathetic innervation 344 
 
366 STUDY OF DIAGNOSIS. 
 
 Chloride of Lime, As a disinfectant 198 
 
 Cider, Deep red tongue, dry t contracted, with dark sordes... 102 
 
 Collinsonia, In diseases of the larynx 352 
 
 Influences the large intestine and rectum 353 
 
 Chelidonium, Color dull and opaque 92 
 
 Dull, heavy, tensive pain, with occasional twinges, as 
 
 if the part was being torn 106 
 
 Dull, leaden, yellow fur 100 
 
 Intestinal dyspepsia 273 
 
 A pancreatic medicine 292 
 
 Chamomilla, Gastric indigestion 270 
 
 Intestinal indigestion , 272 
 
 Charcoal, Excess of gastric juice 271 
 
 Columbo, Atony of stomach 270 
 
 Copper, Sallowness with a tinge of green 92 
 
 Dull, cheesy-looking fur with tinge of green .101 
 
 An epidemic remedy , 222, 223 
 
 As a restorative 274 
 
 Greenish pallor of skin 277 
 
 In Chlorosis 348 
 
 Colchicum, In disease of muscular and fibrous tissue 356 
 
 Cupping, Congestion of brain 62 
 
 Effusion into brain 63 
 
 Cypripedium, In the treatment of diseases of the brain 351 
 
 Digitalis, Fullness of the tissues of the face ,... 65 
 
 Dull, leaden color 82 
 
 Pulse, want of power in impulse 153 
 
 To influence the temperature/ 261 
 
 Frequent pulse 317 
 
 Change in the character of the pulse 318 
 
 To influence the sympathetic nervous system 344 
 
 Drosera, Spasmodic cough 179 
 
 Whooping cough 229 
 
 Measles, 229 
 
 To influence excretion from the lungs. 297 
 
 In diseases of the respiratory apparatus 352 
 
 Emetics, Heavily loaded tongue at base...., 99, 271 
 
 Erecthites, In excessive secretion from skin 299 
 
INDEX. 367 
 
 Erigeron, Passive hemorrhage r 115 
 
 To influence secretion from the skin 299 
 
 Ergot, Fullness of eyes, face, prominent veins 62 
 
 Passive hemorrhage 115 
 
 Feeble voice, sighing respiration 174 
 
 A remedy for congestion 304 
 
 Slowness of pulse - 318 
 
 In the treatment of paralysis » 343 
 
 In disease of the spinal cord 347 
 
 To influence the uterus 355 
 
 Electricity, To influence the temperature 261 
 
 Epilobium, Intestinal irritation 272 
 
 In disease of the gastro-intestinal canal 353 
 
 Eryngium, Irritation of the bladder 322 
 
 In disease of the bladder 354 
 
 Gentian, Loss of appetite, 270 
 
 Gelseminum, Bright eyes, contracted pupils, flushed face 61 
 
 Inflammation of brain 62 
 
 Pain, with evidence of excitation 69 
 
 Restlessness, with determination of blood - 71 
 
 Vascular excitement.*., 70 
 
 Elongated and pointed tongue *. 106 
 
 Pinched, contracted tissues 142 
 
 Full pulse, vibratile ~ 153 
 
 To influence the temperature 166, 260 
 
 Sudden, shrill, sharp cry 175 
 
 Pain, sharp, restless 203 
 
 Exalted sensibility, arterial throbbing 206 
 
 An epidemic remedy 227 
 
 To influence the skin 299 
 
 In jaundice * 290 
 
 In irritation of the kidneys- 304 
 
 Frequent pulse 317 
 
 In the treatment of delirium 331 
 
 " mania , 333 
 
 '* convulsions .,o 340 
 
 paralysis 34? 
 
 " delirium tremens 332 
 
368 STUDY OF DIAGNOSIS. 
 
 Gelseminum, Determination of blood 322 
 
 In hyperemia of the spinal cord , 339 
 
 In suppression of urine 341 
 
 To influence the sympathetic 347 
 
 Gallic Acid, Passive hemorrhage 115 
 
 Helonias, Pinkish color of surface 86 
 
 Hydrastis, Yellow coating of tongue 100 
 
 Intestinal dyspepsia Ill 
 
 Eructations feebly acid 112 
 
 Indigestion 269 
 
 Tongue full and expressionless 270 
 
 In disease of the stomach 353 
 
 In delirium tremens 332 
 
 Hamamelis, Swollen, relaxed eyelids 84 
 
 Color purplish from venous stasis 89 
 
 In diseases of the large intestine 353 
 
 " urinary apparatus 354 
 
 " venous system 355 
 
 Hydrangea, In diseases of the bladder 344 
 
 Hypophosphites, Pinkish color of surface 86 
 
 Dull, leaden color of tongue 103 
 
 Tissues loose and flaccid 143 
 
 Feebleness of voice. 1 74 
 
 To influence the temperature 261 
 
 Hydrocyanic Acid, Elongated and pointed tongue, reddened 
 
 tip and edges 95 
 
 Acid eructations 112 
 
 Gastro-intestinal irritation 269 
 
 In diseases of the gatro-intestinal canal 353 
 
 Iodides, Scanty secretion of saliva 110 
 
 Iodide of Ammonium, Tissues pinched and contracted 144 
 
 Localized pain 206 
 
 Iodide of Potassium, Fullness without elasticity 143 
 
 Not when tissues are pinched or stringy 144 
 
 Iodine, As a disinfectant 198 
 
 To influence the pancreas. 292 
 
 In the treatment of delirium tremens 332 
 
 A stimulant to the sympathetic 347 
 
INDEX. 369 
 
 Iodine, To influence the lymphatic system 356 
 
 Iron, Muriate of, To influence the skin 300 
 
 In the treatment of inflammation 329 
 
 Solid blue color 82 
 
 Eyelids full, swollen 84 
 
 Blueness of veins . 87 
 
 Tissues loose and flaccid 143 
 
 Feebleness of voice 174 
 
 Pain in the back of head, dull, heavy 203 
 
 An epidemic remedy 222, 223 
 
 In zymotic disease 231 
 
 An endemic remedy 239 
 
 Defect in electricity 265 
 
 As a restorative 273 
 
 Want of color.. 274 
 
 Anaemia 310 
 
 Anaemia of the spinal cord 339 
 
 Deficient sympathetic innervation 344 
 
 In chlorosis 348 
 
 In wrongs of the venous circulation 355 
 
 Muriated Tincture, Blueness with deep color of tongue 87 
 
 " " Deep erysipelatous redness 90 
 
 Iris, Scanty secretion of SaMva 110 
 
 Enlarged thyroid gland 
 
 In disease of the lymphatic system 356 
 
 Ipecac, Excess of color 79 
 
 White line around mouth with thinning of tissue 84 
 
 Elongated and pointed tongue 95 
 
 Acid eructations 112 
 
 Opaque mucus 114 
 
 Active hemorrhage 115 
 
 To relieve irritation of stomach 269 
 
 Pinched face . ..... 272 
 
 To influence the pancreas 293 
 
 To influence the skin 299 
 
 Irritation of the bowels 322 
 
 In disease of the respiratory apparatus 352 
 
 In disease of the ^astro-intestinal canal 353 
 
370 STUDY OF DIAGNOSIS. 
 
 Lobelia, General bluish or purplish color from venous ob- 
 struction 89 
 
 Fullness of eyes and face 62 
 
 Want of sympathetic innervation 65 
 
 Capillary stasis from venous obstruction 79 
 
 Precordial oppression and constriction of the chest... 82 
 
 Fullness of tongue 106 
 
 Full and doughy tissues 142 
 
 Pulse full and doughy , 153, 155 
 
 Halting voice 174 
 
 Oppressed voice 175 
 
 Yielding or tremulous character of sounds from the 
 
 chest 189 
 
 Anguish, fear of impending danger 204 
 
 An epidemic remedy 1 227 
 
 In measles 2*29 
 
 To influence the temperature 260 
 
 Defective excretion from the lungs 297 
 
 To influence the skin 299 
 
 To influence the circulation 317 
 
 Slowness of pulse 318 
 
 Congestion 323 
 
 In disease of the respiratory apparatus 352 
 
 In the treatment of convulsions 340 
 
 Lime, As a restorative 273 
 
 In disease of cellular tissue 275, 356 
 
 In lesions of nutrition 314 
 
 Lycopus, To influence the temperature 261 
 
 " " " respiratory function 297 
 
 " " " skin ., 299 
 
 Macrotys, Pain from an excited circulation 69 
 
 Deep color under the eyes 84 
 
 Contraction and irritability with pain 142 
 
 Steady vibratile pulse without wave 154 
 
 With Khus 205 
 
 Continued succession of tensive pains 203 
 
 In determination of blood to the uterus 322 
 
 In the treatment of inflammation 32? 
 
INDEX. 371 
 
 Macrotys, In diseases of the reproductive apparatus 355 
 
 In diseases of muscular and fibrous tissues 356 
 
 Nux Vomica, Illustrating the action of medicine. 15 
 
 Full, expressionless eyes and face 65 
 
 Expressionless mouth 67 
 
 Pain with enfeebled circulation 69 
 
 Unsteady movement, anxious countenance 72 
 
 Brownish-yellow coloration , 92 
 
 Yellow coating of tongue... 100 
 
 Fullness of tongue, 106 
 
 Increased secretion of saliva.. Ill 
 
 Influences the temperature 166 
 
 Pain pointing at umbilicus 203, 205 
 
 An epidemic remedy 227 
 
 Defect of electricity 265 
 
 Atony of stomach.. 270 
 
 Atony of intestine 273 
 
 To influence the pancreas 292 
 
 To influence excretion from the lungs 297 
 
 In congestion 323 
 
 In the treatment of delirium tremens 332 
 
 To influence the brain 337 
 
 To influence the spinal cord 338 
 
 In anaemia of the spinal cord 339, 347 
 
 In the treatment of convulsions 341 
 
 In the treatment of paralysis 343 
 
 In diseases of the brain 351 
 
 In diseases of the gastro-intestinal canal 353 
 
 Nitric Acid, (See Acids,) Violet color 82, 103 
 
 Nitrate of Soda, An epidemic remedy 222, 223 
 
 Opium, Pain with evidence of atony 69 
 
 Moisture of tongue.... 105 
 
 Small pulse, open, square wave. 153 
 
 Pulse soft and open ■. 154 
 
 In delirium tremens 332 
 
 To influence the brain 351 
 
 Oxide of zinc, Gastric irritation 269 
 
 A pancreatic remedy... 292 
 
372 STUDY OF DIAGNOSIS. 
 
 Panax, Scanty secretion of saliva 110 
 
 To influence the pancreas , 292 
 
 Peach bark, Amygdalus, elongated and pointed tongue, red- 
 dened tip and edges 95 
 
 Irritation of stomach , 269, 270 
 
 Intestinal irritation 272 
 
 To improve digestion 293 
 
 Permanganate of Potash, Erysipelatous redness, blanched... 90 
 Cadaverous fetor , 198 
 
 Phosphorus, Full, pallid face, waving alae nasi 65 
 
 Unsteady movement 71 
 
 Eyelids full, swollen, expressionless 84 
 
 Pinkish color 86 
 
 Dull and opaque skin 93 
 
 Dull, leaden color of tongue . 1C3 
 
 Moist mouth Ill 
 
 Feebleness of voice 174 
 
 To influence the temperature 261 
 
 Deficient electricity 265 
 
 As a restorative 273 
 
 "Want of expression 274 
 
 To influence excretion from the lungs.... 297 
 
 Anaemia 310 
 
 Bad blood 314 
 
 To influence sympathetic innervation 344 
 
 In disease of the brain 351 
 
 In disease of the respiratory apparatus..... 352 
 
 In disease of the urinary and reproductive organs 354 
 
 In diseases of the skin. 356 
 
 Phosphate of Soda, Secretions of the mouth neutral or acid.. 112 
 
 Phosphoric Acid, Tissues pinched and stringy 143 
 
 Potash, As a restorative 273 
 
 Pallor of mucous membranes, impairment of muscular 
 
 power 276 
 
 In anaemia 1 310 
 
 Bad blood 314 
 
 In the treatment of scorbutis 349 
 
 In disease of muscular tissue 356 
 
INDEX. 373 
 
 Polygonum, To influence excretion by the skin 299 
 
 Phytolacca, Scanty saliva....... 110 
 
 Pulse, dull stroke with tremulous wave 154 
 
 Mammary inflammation 330 
 
 In diseases of the mouth and salivary glands 353 
 
 In disease of the testes 355 
 
 In disease of muscular tissue 356 
 
 Pepsine, Enfeebled digestion 272 
 
 In disease of the stomach..., 353 
 
 Podophyllin, Illustrating the action of medicine 15 
 
 Fullness of the tissues of the face 65 
 
 Cellular tissue full, veins prominent 6Q 
 
 Full upper lip, pallor 67 
 
 Yenous obstruction 79 
 
 Fullness of tissue 84 
 
 Change in pigment, liver spots 92 
 
 Yellow coat of tongue 100 
 
 Fullness of tongue 106 
 
 Moist mouth Ill 
 
 Full, open pulse 153 
 
 Contra-indicated when pulse is small and wiry 154 
 
 Pain in ischiatic notches 203 
 
 An epidemic remedy 221, 227 
 
 An endemic remedy 239 
 
 Dull, expressionless face 270 
 
 Deficiency of gastric juice 271 
 
 Intestinal atony 273 
 
 To influence the pancreas 292 
 
 To increase intestinal secretion 293 
 
 To increase excretion by the bowels 307 
 
 In diseases of the gastro-intestinal canal 353 
 
 Pulsatilla, Color dull purple 82 
 
 Eyes sunken, contracted 84 
 
 Sudden dropping of wave of blood as it passes the 
 
 linger 154 
 
 Cough points at supra-sternal notch 178 
 
 Mental rest 195 
 
 Pain, sharp, limited in location, despondent....... ...... 203 
 
374 STUDY OF DIAGNOSIS. 
 
 Pulsatilla, To influence the sympathetic nervous system 344 
 
 To influence the brain 351 
 
 To influence the heart 352 
 
 In dysphagia ....... 353 
 
 To influence the reproductive organs... 354, 355 
 
 Quinine, Full, expressionless face C5 
 
 Drooping tissues, expression sad ,.... 69 
 
 Unsteady movement, relaxation of muscles 72 
 
 Causes dryness of tongue 105 
 
 Moist mouth Ill 
 
 Tissues loose and flaccid 143 
 
 Soft pulse 153 
 
 Contra-indicated by hard and wiry pulse 154 
 
 Feebleness of voice...... , 174 
 
 Tremulous sounds from chest 189 
 
 An epidemic remedy 227 
 
 Periodicity 235, 236, 237 
 
 Malaria 246 
 
 A. nervous stimulant .\... 265 
 
 To influence the brain 331, 351 
 
 In delirium tremens 332 
 
 As a remedy for pain ; 337 
 
 To influence the spinal cord 339 
 
 Rhubarb, Elongated and pointed tongue, gastric irritation... 95 
 
 Acid eructations 112 
 
 Irritation of gastro-intestinal canal 269 
 
 Restoratives, Want of expression 54 
 
 To increase the blood 273 
 
 Rest, Expression of 54 
 
 Rhus, Constriction about temples and eyes 65 
 
 Pinched eyes 66 
 
 Pain with excitement of circulation 69 
 
 Bright flush of left cheek 85 
 
 Bright redness of surface 90 
 
 Eroded appearance of anterior papillae of the tongue, 107 
 
 To influence the temperature 166 
 
 Sharp cry, cry encephalique 175 
 
 Frontal pain, pain in left orbit 203 
 
INDEX. 375 
 
 Rhus, Burning pain 205 
 
 An epidemic remedy 221 
 
 Zymosis 231 
 
 An endemic remedy 239 
 
 Illustrating prescription from single symptoms 255 
 
 To influence the temperature 260, 261 
 
 Pungent heat .. ... 263 
 
 To influence the skin 300 
 
 In the treatment of inflammation 329 
 
 " delirium 331 
 
 " spinal irritation 347 
 
 To influence the "brain 351 
 
 In diseases of the heart 352 
 
 " eye 356 
 
 Santonine, White line around the mouth with fullness of 
 
 tissues o.... 84 
 
 Sighing respiration 174 
 
 Full upper lip, picking at the nose 67 
 
 Staphysagria, Full, swollen eyelids 84 
 
 In disease of the reproductive apparatus 354 
 
 Senega, To influence excretion by the skin 299 
 
 Strychnia, Sighing respiration 174 
 
 Fullness of tongue , 106 
 
 Atony of gastro-intcstinal canal 270 
 
 To influence the spinal cord 338, 339 
 
 Serpentaria, to influence excretion by the skin 299 
 
 Stramonium, Constrictive pain, muscular contraction 206 
 
 Sticta, To influence excretion by the lungs 297 
 
 In diseases of muscular and fibrous tissues 356 
 
 Sulphur, Want of pigment, change of color 93 
 
 Moist, dirty tongue Ill 
 
 As an antiseptic or disinfectant 198 
 
 To influence the temperature 261 
 
 Change of pigment..... 276 
 
 In hyperemia of the spinal cord 339 
 
 To influence sympathetic innervation. , 344 
 
 In disease of the liver 353 
 
 " skin 356 
 
376 STUDY OF DIAGNOSIS. 
 
 Solanum, Congestion of the kidneys 304 
 
 Sinapis Alba, Atony of stomach 270 
 
 Sulphite of Soda. Erysipelatous redness 90 
 
 Pallor of tongue, with dirty coat 83 
 
 Dirty tongue 104 
 
 Viscidity of saliva Ill 
 
 Large, empty pulse 153 
 
 To influence the temperature . 165 
 
 Mawkish or sweetish odor 199 
 
 An epidemic remedy 227 
 
 Zymosis 231 
 
 Typhoid symptoms , 238 
 
 Heavily coated tongue , 271 
 
 Sulphurous Acid, (see Acid Sulphurous.) 
 
 Sulphite of Magnesia, Dirty tongue, redness natural 104 
 
 Sedatives, Dryness of tongue 105 
 
 Silica, Dullness of epithelium, desquamation 276 
 
 Soda, An epidemic remedy 227 
 
 Asa restorative 275 
 
 Anaemia 310 
 
 Bad blood 314 
 
 Trifolium Pratense, Paroxysmal, spasmodic cough 230 
 
 Veratrum, Inflammation of brain « 62 
 
 In disease of atony 65 
 
 Color, simple excess of. 78 
 
 In disease of thoracic organs 79 
 
 Bright redness, arterial throbbing 90 
 
 Elongated and pointed tongue, evidencing vascular 
 
 excitement in the brain 106 
 
 Glairy, tenacious mucus 113 
 
 Active hemorrhage 115 
 
 Or Aconite 142 
 
 Tissues pinched and stringy , 144 
 
 Pull pulse, with strength 152 
 
 Influence of large dose 163 
 
 Cough 178 
 
 An epidemic remedy 22 7 
 
 Zymosis 231 
 

 INDEX. 377 
 
 Veratrum, An endemic remedy 239 
 
 To influence the temperature 261 
 
 A pancreatic medicine 292 
 
 To increase excretion from the lungs 296, 297 
 
 To influence excretion by the skin 299 
 
 Frequency of pulse 317 
 
 In determination of blood * 322 
 
 A remedy for inflammation 328 
 
 In the treatment of delirium tremens 332 
 
 Hyperemia of the spinal cord 339 
 
 In the treatment of convulsions 340 
 
 spinal irritation 347 
 
 In diseases of the respiratory apparatus 352 
 
 Wet Sheet Pack, In simple increase of temperature 167 
 
 32 
 
INDEX 
 
 Abdomen, pain in 69 
 
 Acids as remedies 81 
 
 Adventitious sounds .....193 
 
 ^Egophony 192 
 
 Anatomy applied 19 
 
 Animals, Study of 50 
 
 Anaemia 310 
 
 Applied anatomy 19 
 
 Apoplectic condition of brain 62 
 
 Appearance sickly 76 
 
 Arteries 355 
 
 Articulations 356 
 
 Areola 83 
 
 Atrophic irritation 63 
 
 Auscultation 184 
 
 Stethoscope 184 
 
 Healthy sounds in chest.185 
 
 Study in English 186 
 
 Physics of 186 
 
 Morbid sounds 186 
 
 Blowing sounds 187 
 
 Blowing and moist 188 
 
 Tremulous sound 189 
 
 Sounds from cavities 190 
 
 Small 190 
 
 Dry 190 
 
 Crepitant sounds 191 
 
 Broncophony 192 
 
 ^Egophony • 192 
 
 Pectoriloquy 192 
 
 Of the heart .193 
 
 Adventitious sounds 193 
 
 Of the foetal heart 195 
 
 Bath in temperature 167 
 
 Basis for all schools 256 
 
 Blood, condition of the 66 
 
 Color from the 77 
 
 Blueness of..... 82, 115, 308 
 
 Pulse waves 149 
 
 Wave, length of. 150 
 
 Circulation of the 244 
 
 Condition of the 244 
 
 Making 273 
 
 Excess of. 308 
 
 Defect 310 
 
 Bad 311 
 
 Evidences of.. 313 
 
 Sepsis of 312 
 
 Exudates from 312 
 
 Circulation of 315 
 
 Irregular distribution of318 
 
 Determination of 320 
 
 Evidences of determina- 
 tion of 321 
 
 Examination of 112 
 
 Black vomit 113 
 
 Blowing sounds 187 
 
 Bladder 354 
 
 Boquet 45 
 
 Books, advantage of 23 
 
 Bowels 135 
 
 Body thermometer 1 56 
 
 Bowels, liver, percussion of..l83 
 
 Excretion from the 306 
 
 Bones 356 
 
 Brain, condition of the 61 
 
INDEX. 
 
 379 
 
 Brain, Congestion 61 
 
 Determination of blood.. 61 
 
 Apoplectic condition 62 
 
 Inflammation 62 
 
 Effusion 63 
 
 Nutrition 63 
 
 Softening 63 
 
 Atrophic irritation 63 
 
 Functional activity 64 
 
 Innervation from.. 250, 330 
 Pain, condition of.. .337, 351 
 
 Brown color 91 
 
 Broad and full tongue 95 
 
 Broad and pallid tongue 101 
 
 Brown and black fur 104 
 
 Broncophony 192 
 
 Cadaverous faeces 138 
 
 Capsules, Supra-renal 354 
 
 Cardiac wrongs, Color from. 89 
 
 Cavities, Sounds from 190 
 
 Certainty 24 
 
 Cerebro-spinal meningitis... 232 
 
 Cells, Secreting 283 
 
 Cerumen 295 
 
 Cellular tissues 356 
 
 Children, Better diagnosis 
 
 with 30 
 
 Childbirth, Expression in 59 
 
 Change of form of tongue... 94 
 
 Cheesy sputa 114 
 
 Changes of kind of tempera- 
 ture 170 
 
 Chest, Healthy sounds from. .185 
 Chronic disease, Epidemic 
 
 influence in 223 
 
 Change of type in disease 224 
 
 Chicken-pox, Varicella 229 
 
 Cholera 232 
 
 Character of normal secre- 
 tion from skin... 301 
 
 Changes in the character of 
 
 the pulse 318 
 
 Chlorosis .>348 
 
 Clay-colored faeces 137 
 
 Clinical examination urine...l30 
 
 Cleanliness 197 
 
 Classification, general... 21 7, 220 
 
 Classification, nosological.... 348 
 Condition of the sympa- 
 
 thetics 65 
 
 Condition of the blood QG 
 
 Convulsions, symptoms of... 74 
 
 Color of the surface 75 
 
 From the blood 77 
 
 Of health 77 
 
 Of mucous membranes.. 77 
 
 Pigment of health 77 
 
 Transparency and clear- 
 ness 78 
 
 Excess of 78 
 
 Capillary circulation.... 79 
 
 Eftacement of. 79 
 
 Venous obstruction 79 
 
 Defectof 80 
 
 Deepening of 80 
 
 Dark red 80 
 
 Typhoid 80 
 
 Unyielding 81 
 
 An evidence of sepsis... 80 
 
 Deep redness 81 
 
 Acids as remedies 81 
 
 Dull purple 81 
 
 Blueness 82 
 
 Violet 82 
 
 Deep purplish brown... 82 
 
 Muddy... 82 
 
 Local 83 
 
 Of the areola of the 
 
 nipple 83 
 
 Under the eyes 83 
 
 Of conjunctiva". 87 
 
 Of bright red 87 
 
 Of deep red 88 
 
 Of purplish 88 
 
 From cardiac wrong 89 
 
 Erysipelatous redness... 89 
 
 Pigment 90 
 
 " Excess 90 
 
 " Transparent.... 90 
 " Local excess.... 91 
 
 " Deep 91 
 
 " Brown 91 
 
 u Greenish yellowyi 
 " Dull & opaque. 92 
 " Bright yellow.. 92 
 
380 
 
 STUDY OF DIAGNOSIS. 
 
 Color, pigment, greenish 92 
 
 " Tallow-like 92 
 
 " Dirty 93 
 
 " Want of 93 
 
 Of faeces 137 
 
 Coatings of tongue 97 
 
 Yellow 100 
 
 Dark 104 
 
 Contraction of tongue 106 
 
 Cough 176 
 
 Expresses irritation 176 
 
 Dry, ringing 177 
 
 Forcible ■. 177 
 
 Strength 177 
 
 Short, sharp, hacking... 178 
 
 Points 178 
 
 Spasmodic 179 
 
 Contagious diseases 227 
 
 Condition of the blood .245 
 
 Of the tissues 278 
 
 Of the kidneys 303 
 
 Constipation 137, 306 
 
 Congestion 61, 320 
 
 Evidence of. 321 
 
 Convulsions 339 
 
 Intrinsic 340 
 
 Extrinsic 341 
 
 Cord, spinal 351 
 
 Cry of pain 43 
 
 Encephalique .175 
 
 Cu'tivation of the senses 38 
 
 Dark red color 80 
 
 Dark coatings .104 
 
 Dark brown faeces 137 
 
 Dead, awake, asleep 25 
 
 Development of senses by 
 
 use.. 34 
 
 Decumbence 53 
 
 Depression or excitation 55 
 
 Determination, expression of 69 
 Defeneration, expression of.. 70 
 
 Defect of color 80 
 
 Deepening of color 80 
 
 Deep redness, associated with 
 
 asthenia 81 
 
 Deep purplish brown 82 
 
 Deep color 91 
 
 Dessicated mucus ,114 
 
 Deposits, urinary.. 129 
 
 Table of urinary 134 
 
 Deficient fieees 136 
 
 Deposits 279 
 
 Degeneration 280 
 
 Defect in secretion 299 
 
 In excretion from lungs,297 
 
 Of the blood 310 
 
 Determination of blood 320 
 
 Delirium 331 
 
 Delirium tremens 331 
 
 Diagnosis, study of 9 
 
 Anatomy necessary in ... 20 
 
 Methods of 28 
 
 Better with children 30 
 
 Use of the senses in 48 
 
 By the eye 49 
 
 By the touch 139 
 
 By the ear 171 
 
 Physical 179 
 
 Disease not an entity 12 
 
 Expressions of.....* 14 
 
 .Relation between reme- 
 dies and 15 
 
 Varieties of color in 42 
 
 Evidence of local 58 
 
 Local 66 
 
 Range of temperature inl59 
 Temperature in chronic 160 
 
 Cause of. 165 
 
 Voice expresses 173 
 
 Laryngeal, voice changed 
 
 by 176 
 
 Diseases, classification of. 21 1 
 
 Contagious... 227 
 
 Change of type in 224 
 
 Disuse, senses lost by 35 
 
 Dirty color 93 
 
 Dirty fur 103 
 
 Discharges, examination of.. 108 
 
 Disinfection 198 
 
 Distinction and definition of 
 
 disease 209 
 
 Digestion, intestinal 272 
 
 Distribution of blood irreg- 
 ular 7..318 
 
 Diabetes 349 
 
INDEX. 
 
 381 
 
 Doctrine of Kademacher 222 
 
 Dryness of tongue 105 
 
 D;y, ringing cough 177 
 
 Dropsy 349 
 
 Dull purple color 81 
 
 Dull and opaque color 92 
 
 Dull, elastic stroke of pulse.. 150 
 Dullness on percussion 181 
 
 Ear 356 
 
 Education of the senses 32 
 
 Educated nose 45, 196 
 
 Effusion 63 
 
 Effort for rest 71 
 
 Effacement of color... 79 
 
 Elongated & pointed tongue 
 
 95, 106 
 
 Elements of disease, first 13 
 
 Empty pulse 151 
 
 Emotion 334 
 
 Entity, disease not an 12 
 
 Encephaliquc cry 175 
 
 English, study of ausculta- 
 tion in 186 
 
 Equalizing the circulation. ..319 
 
 Errors from nosology 9 
 
 Eructations, examination of.112 
 
 Expression of the mouth 67 
 
 Provokes function 68 
 
 Of disease 14 
 
 In the Horse , 51 
 
 Law of. 57 
 
 In the face 58 
 
 In Childbirth 58 
 
 Facial 60 
 
 Of determination 69 
 
 In motion 70 
 
 Of degeneration 70 
 
 Of the voice 172 
 
 Expresses disease 173 
 
 Examination of tongue 93 
 
 Of the discharges. ....... .108 
 
 Discharges from nose.... 109 
 
 Discharges from mouth..H0 
 
 Saliva increased 110 
 
 Saliva, reaction of Ill 
 
 Of discharges from the 
 stomach , 112 
 
 Examination of blood 112 
 
 Eructations 112 
 
 Vomiting 112 
 
 Black Vomit 113 
 
 Of discharges from res- 
 piratory tract 113 
 
 Mucus, thin, glairy 113 
 
 Mucus opaque 113 
 
 Globular sputa 114 
 
 Cheesy sputa 114 
 
 Dessicated mucus .14 
 
 Pus 114 
 
 Blood 115 
 
 Mucus streaked with 
 
 blood 115 
 
 Exudative material 116 
 
 Of the .urine 116 
 
 Objects of. 118 
 
 Clinical of urine 130 
 
 Of thesediment 132 
 
 Of the feces...... 135 
 
 Care in 202 
 
 Of the urine 301 
 
 Excess of the urine 304 
 
 Of the excretions from 
 
 the bowels 306 
 
 Of blood 308 
 
 Of color pigment 90 
 
 Of color pigment local.. 91 
 
 In secretion from skin... 298 
 
 Exaggeration by the sick.... 29 
 
 liy the nurse 29 
 
 Excitation or depression 55 
 
 Extension, flexion 73 
 
 Excretions, odor of. 199 
 
 From lungs, defect in. ..297 
 
 From the bowels 306 
 
 From bowels, excess of.. 306 
 
 Perversion of the 307 
 
 Exudates from blood 312 
 
 Extrinsic convulsions 341 
 
 Evidence of local disease 58 
 
 Determination of blood.321 
 
 Of congesiion.. 321 
 
 Of baof blood... 313 
 
 Eye 3^6 
 
 Diagnosis by the 49 
 
 Color under the 83 
 
382 
 
 STUDY OF DIAGNOSIS. 
 
 Facial expression 60 
 
 Favoring the affected part... 72 
 
 Faeces, examination of 135 
 
 Increase of 136 
 
 Fluid 136 
 
 Deficient 136 
 
 Color of 137 
 
 Dark brown 137 
 
 Greenish 137 
 
 Clay-colored 137 
 
 Fetor of 138 
 
 Cadaverous.... 138 
 
 Odor of. 200 
 
 Feebleness of voice 174 
 
 Foetal heart, auscultation of. 195 
 First elements of disease... 13 
 
 Fivesenses 36 
 
 Fissured tongue 95 
 
 Flexion, extension 73 
 
 Fluid, dullness from 182 
 
 Forcible cough 147 
 
 Form, recognition of 42 
 
 Frequenc}^ of pulse 146 
 
 Increased 316 
 
 Functional activity of brain. 64 
 Function, expression pro- 
 vokes 68 
 
 Full and broad tongue 95 
 
 Fur, dirty tongue 103 
 
 Fullness of tongue 106 
 
 Full, systolic wave of pulse. 151 
 Full pulse 151 
 
 Gangrene 327 
 
 Glyiry, thin mucus 113 
 
 Globular sputa 114 
 
 Glands, intestinal...... 292 
 
 Greenish yellow color 92 
 
 Grayish or yellowish fur 107 
 
 Gravity, specific 119 
 
 Greenish faeces 137 
 
 Growths 281 
 
 Hardness of pulse 151 
 
 Hard, small pulse 151 
 
 Halting voice 174 
 
 Hacking, short, sharp cough. 178 
 Hearing 42 
 
 Health, color of pigment in. 77 
 
 Hemorrhage 127 
 
 Healthy standard of temper- 
 ature 155 
 
 Health, range of tempera- 
 ture in 158 
 
 Healthy sounds in chest 185 
 
 Heart, auscultation of the.... 193 
 Foetal, auscultation of... 195 
 
 Heat from inflammation 325 
 
 Hemiplegia 342 
 
 Heart 352 
 
 I Huxley, method of 22 
 
 Imagination 30 
 
 Irritation, atrophic 63 
 
 ; Irritation 322 
 
 \ Indications for quinine 154 
 
 I Inflammation and fever,tem- 
 
 peraturein 161 
 
 J Influence of sedatives 163 
 
 j Increased frequency of pulse316 
 
 | Inter-wave current-pulse.... 151 
 
 Inflammation 62, 323 
 
 Symptoms of .....324 
 
 liesolution of 324 
 
 Pain from 325 
 
 Heat from 325 
 
 Swelling from 325 
 
 Kedn ess from 326 
 
 Wrong of function from326 
 Danger to the life from. 326 
 
 Innervation * 330 
 
 From the brain 330 
 
 Insanity 333 
 
 Intrinsic convulsions 340 
 
 Innervation, sympathetic. ...343 
 
 Intestine, small 353 
 
 Large 353 
 
 Intestinal digestion 272 
 
 Glands 292 
 
 Irregular temperature 169 
 
 Distribution of blood. ...318 
 Irritation, spinal 344 
 
 Kidneys, condition of... 303, 354 
 
 Knowledge, source of 17 
 
 Senses the source of 32 
 
INDEX. 
 
 383 
 
 Law of expression 57 
 
 Larynx 352 
 
 Large intestine. ., 353 
 
 Lesions of nutrition 314 
 
 Life, one 12 
 
 Wrong 12 
 
 Stud}- of 13, 16, 17 
 
 Living man, study of. 18 
 
 Light 40 
 
 Lines, white around mouth... 84 
 
 Lip, pallid upper 84 
 
 Liver, percussion of.183, 289,353 
 Local disease, evidence of.... 58 
 
 Diseases 66 
 
 Color 83 
 
 Bright red color 87 
 
 Excesi of color 91 
 
 Disease 51 
 
 Lungs, the 352 
 
 Defect in excretion from297 
 Lymphatic glands 353 
 
 Man, study of the living... 18 
 
 Mania, puerperal 332 
 
 Method of Huxley 22 
 
 Measurement 24 
 
 Methods of diagnosis 28 
 
 Mediate or direct percussion 180 
 
 Medical stinks 196 
 
 Medication, restorative 273 
 
 Metamorphosis, retrograde.. 2 79 
 
 Mouth, expression of. 67 
 
 White lines around the. 84 
 Bluish tint around the... 85 
 
 Salivary glands 353 
 
 Movement, rapid 71 
 
 Unsteady 71 
 
 Moistening tongue 96 
 
 Movements of tongue 107 
 
 Morbid sounds 186 
 
 Moist, blowing sounds 188 
 
 Muscles 74 
 
 Mucous membranes, color of 77 
 
 Muddy color of blood 82 
 
 Mucus, thin, glairy, opaque..H3 
 
 Dessicated 114 
 
 Streaked with blood, 1 15,293 
 Muscular tissue 356 
 
 Names, prescribing at 10 
 
 Nausea 67 
 
 Names necessary 214 
 
 Nipple, areola color of the... 83 
 
 Nosology 207 
 
 Errors from 9, 208 
 
 Distinction & definition. 2o9 
 
 Useless 15 
 
 Nosological classification.. 348 
 
 Nose.... 352 
 
 Educated 196 
 
 Examination of dis- 
 charges from the 109 
 
 Nomenclature 210 
 
 Nutrition, lesions of 314 
 
 Objects of the examination... 118 
 
 Odor of the excretions 199 
 
 Of the urine 200 
 
 Seminal 200 
 
 Of fseces 200 
 
 (Esophagus 353 
 
 One body, one life 12 
 
 Opaque mucus 113 
 
 Ovaries... 355 
 
 Pain 56, 68, 203, 336 
 
 Cry of 43 
 
 From inflammation 325 
 
 The result of two condi- 
 tions 69 
 
 In the abdomen 69 
 
 Pallid upper lip 84 
 
 Pallid and broad tongue 101 
 
 Palpation 183 
 
 Patient, information from. ..200 
 
 Pancreas.. 291 
 
 Paralysis 342 
 
 Paraplegia 343 
 
 Percussion 179 
 
 Direct or mediate 180 
 
 Rules for 180 
 
 Object of... 180 
 
 Standard of comparison. 181 
 
 Normal resonance 181 
 
 Increased resonance 181 
 
 Dullness 181 
 
 Dullness from fluid 182 
 
384 
 
 STUDY OF DIAGNOSIS. 
 
 Percussion on other parts... 182 
 Over liver and bowels... 183 
 
 Pectoriloqy 192 
 
 Perversion of secretion 300 
 
 Of urine 304 
 
 Of the excretions from 
 
 the bowels 307 
 
 Peritoneum.. 354 
 
 Physical diagnosis 179 
 
 Physiology applied 22 
 
 The basis of practice 27 
 
 Physiological standard 24 
 
 Table 215 
 
 Physics of auscultation 186 
 
 Pharynx 352 
 
 Pigment color of health... 77, 90 
 Pinched & shrunken tongue. 95 
 
 Pleura , 352 
 
 Polypharmacy 11 
 
 Position to remove pressure. 59 
 Pointed, elongated tongue... 
 
 95, 106 
 
 Prescribing at names 10 
 
 Prostate gland ■. 354 
 
 Purple dull color 81 
 
 Purplish 82 
 
 Color, local 88 
 
 Pus 114 
 
 Puerperal mania 332 
 
 Pulse, the.., 144 
 
 Anal}-sis of 145 
 
 Frequenc}' of 146 
 
 Respiratory association 147 
 Relation of temperature 
 
 to 148 
 
 Blood waves .149 
 
 Volume 149 
 
 Sharp impulse 150 
 
 Dull, elastic stroke 150 
 
 Length of blood wave... 150 
 
 Oppressed 150 
 
 Surface of wave ....150 
 
 Shock wave 150 
 
 Full, systolic wave 150 
 
 Inter-wave current 151 
 
 Full 151 
 
 Hardness 151 
 
 Small, hard 151 
 
 Pulse, small, soft 15\ 
 
 Small, vibratile 151 
 
 Empty ....151 
 
 Remedies indicated by ...152 
 Indications for quinine..!54 
 
 Relation to touch 155 
 
 Relation to temperature. 160 
 Increased frequency of..316 
 
 Slowness of. 317 
 
 Changes in the charac- 
 ter of 318 
 
 Pyaemia 349 
 
 Quantity of urine 119 
 
 Quinine, indications for 154 
 
 Rapid movement 71 
 
 Range of temperature in 
 
 health 158 
 
 In disease 159 
 
 Recognition by touch 21 
 
 Of form 42 
 
 Rest and unrest 54 
 
 Eftbrt for 71 
 
 Resonance normal 181 
 
 Increased 181 
 
 Red, dark color 80 
 
 Bright color, local........ 87 
 
 Deep color, local 88 
 
 Redness, erysipelatous color, 89 
 
 Tip and edges of tongue, 101 
 
 Red, deep tongue, 102 
 
 Reactions of saliva. ...... .....Ill 
 
 Respiration, association of 
 
 pulse 147 
 
 Remedies indicated by pulse, 152 
 Relation to touch by pulse... 155 
 Registering thermometer.... 157 
 Relations of pulse and tem- 
 perature 148, 160 
 
 Restorative medication 273 
 
 Retrograde metamorphosis..279 
 Recrementitious secretion ... 286 
 Resolution of inflammation..324 
 
 Saliva, increased 110 
 
 Salivary glands 353 
 
 Scanty urine 302 
 
INDEX. 
 
 385 
 
 Scor'butis 348 
 
 Senses, education of 32 
 
 The source of knowledge, 32 
 
 Acquired 33 
 
 Developed by use 34 
 
 Lost by disuse , 35 
 
 Conscious life thro' the... 36 
 
 Five 36 
 
 Cultivation of the 38 
 
 Use of in diagnosis 48 
 
 Sediment of urine, examina- 
 tion of 132 
 
 Seminal odor 200 
 
 Secretion.. 282 
 
 Secreting cells 283 
 
 Secretions, recrementitious...286 
 
 Sebaceous ,294 
 
 Excrementitious 296 
 
 Defect in 299 
 
 Perversion of 300 
 
 From the skin, excess in, 298 
 
 Sepsis of blood 312 
 
 Sensibility 335 
 
 Shrunken, pinched tongue... 95 
 
 Sharp pulse 150 
 
 Shock wave 150 
 
 Sharpness of voice 175 
 
 Shrillness of voice 175 
 
 Short, sharp hacking cough, 177 
 Sick, exaggeration by the.... 29 
 
 Sickly appearance 76 
 
 Skin, regulating temperature 
 
 by ,166,356 
 
 Slick tongue 103 
 
 Slowness of pulse 317 
 
 Smell 44 
 
 Small tongue, full in centre, 106 
 
 Hard pulse 151 
 
 Soft pulse. 151 
 
 Smell, diagnosis by 195 
 
 Small intestines 353 
 
 Source of knowledge 17 
 
 Softening of the brain 63 
 
 Sobbing respiration 175 
 
 Sounds, healthy in chest 185 
 
 Morbid 186 
 
 Blowing 187 
 
 Blowing and moist 188 
 
 Sounds, tremulous 189 
 
 From cavities 190 
 
 Small, blowing 190 
 
 Crepitant 191 
 
 Adventitious. 193 
 
 Sputa, globular 114 
 
 Cheesy 114 
 
 Specific gravity 119 
 
 Spasmodic cough 179 
 
 Spanaemia 311 
 
 Spinal innervation 338, 344 
 
 Cord 351 
 
 Spleen 354 
 
 Study of diagnosis 9 
 
 Of life 13, 16, 17 
 
 Of the living man 18 
 
 Of animals , 50 
 
 Objects of 52 
 
 Standard, physiological 24 
 
 Stomach, examination of 
 
 discharges from 112 
 
 Stroke, dull, elastic of pulse.150 
 
 Strength of voice 173 
 
 Of cough 177 
 
 Standard of comparison 181 
 
 Stethoscope 184 
 
 Study of auscultation in 
 
 English 186 
 
 Stinks, medical 196 
 
 Stomach 353 
 
 Surgeon, education of 17 
 
 Surface, color of 75 
 
 Of pulse wave 150 
 
 Suppuration 327 
 
 Swelling from inflammation, 325 
 Sympathetic, condition of... 65 
 Symptoms of convulsions... 74 
 
 Systolic wave, pulse full 151 
 
 Symptoms of inflammation. .323 
 Sympathetic innervation.. ..343 
 
 Taste 46 
 
 Tallow-like color of pigment, 92 
 Table of urinary deposits. ...134 
 
 Physiological 215 
 
 Of Dr. Williams.. 216 
 
 Temperature. 155 
 
 Healthy standard of 155 
 
386 
 
 STUDY OF DIAGNOSIS. 
 
 Temperature, range of in 
 
 health 158 
 
 Kange of in disease...... 159 
 
 Relation to pulse 160 
 
 In chronic diseases 160 
 
 In fever and inflamma- 
 tion 161 
 
 Treatment for 162 
 
 Influence of sedatives on 163 
 Relation to functional 
 
 disease 164 
 
 A cause of disease 165 
 
 Regulation of the skin... 166 
 
 Baths in 167 
 
 Waste of tissue 167 
 
 Depression of 168 
 
 Irregular 169 
 
 Changes of kind.... 170 
 
 Tears 295 
 
 Testes 353 
 
 Thermometer, body .156 
 
 Registering 157 
 
 Use of ..158 
 
 Tissues, condition of 278 
 
 Muscular 356 
 
 Tongue, examination of the, 93 
 
 Indications from 94 
 
 Change of form 94 
 
 Elongated and pointed.. 95 
 
 Full and broad 95 
 
 Pinched, shrunken. .... 95 
 
 Fissured 95 
 
 Dryness, moisture 96 
 
 Coatings of 97 
 
 Coatings, whiteness of... 98 
 Coatings, transparent... 98 
 
 Heavily loaded 99 
 
 Coatings yellow 100 
 
 Redness of tip and edgeslOl 
 Represents the blood... 10 1 
 
 Broad and pallid 101 
 
 Deep red 102 
 
 Violet colored- 103 
 
 Thick and large 103 
 
 Leaden 103 
 
 Slick 103 
 
 Dirty fur 103 
 
 Brown and black fur... 104 
 
 Tongue, dark coatings 104 
 
 Dryness of .105 
 
 Contraction of 106 
 
 Fullness of 106 
 
 Elongated and pointed..] 06 
 
 Small, full in centre 106 
 
 Grayish or yellowish fur, 107 
 Movements of 107 
 
 Touch, the 21, 39 
 
 Diagnosis by the 139 
 
 In obstetrics 141 
 
 Relation of pulse to 155 
 
 Tonsils 353 
 
 Transparency and clearness 
 
 of color 78 
 
 Transparent color of pigment. 90 
 
 Track respiratory, examina- 
 tion of discharges from.. 113 
 
 Tremulous sounds on auscul- 
 tation 189 
 
 Typhoid color 80 
 
 Unrest 54 
 
 Unyielding color 81 
 
 Uncertainty of information 
 from patient and nurse .201 
 
 Upper lip pallid 84 
 
 Urine, examination of the... 
 
 116,301 
 
 Deposits from 129 
 
 Clinical examination of, 130 
 Without visible deposit, 130 
 Examination of the sed- 
 iment 132 
 
 Odor of 200 
 
 Scanty 302 
 
 Urinary deposits, table of... 134 
 Wrongs, symptoms of... 302 
 
 Urethra 355 
 
 Uroscopy 117 
 
 Useless nosology 15 
 
 Use of the senses in diagno- 
 sis 48 
 
 Uterus 355 
 
 Variations of color in disease, 42 
 
 Vagina and vulva 355 
 
 Venous obstruction 79 
 
INDEX. 
 
 387 
 
 Veins 355 
 
 Blueness of 86 
 
 Violet color 82 
 
 Colored tongue 103 
 
 Vibratile pulse 151 
 
 Vomiting.'. 112 
 
 Vomit, black 113 
 
 Volume of pulse 149 
 
 Volition, will 334 
 
 Voice, expression of the 172 
 
 Expresses disease 173 
 
 Strength of 173 
 
 Feebleness of 174 
 
 Of nervous irritation.... 174 
 
 Halting 174 
 
 Oppressed 174 
 
 Sharpness of 175 
 
 Encephalique 175 
 
 Shrillness of 175 
 
 Sobbing respiration 175 
 
 Want of color 93 
 
 Wave of blood 149 
 
 Blood, length of 150 
 
 Surface of 150 
 
 Shock 150 
 
 Full, systolic 151 
 
 Intercurrent 151 
 
 Waste of tissue , 167 
 
 White lines around mouth... 84 
 
 Whiteness of tongue 98 
 
 Will, volition 334 
 
 Williams Dr., table of 216 
 
 Wrong life 12 
 
 Cardiac, color from 89 
 
 Wrongs of function from in- 
 flammation 326 
 
 Yellow, greenish color of 
 
 pigment 92 
 
 Bright color of pigment 92 
 Coatings of tongue 100 
 
 Yellowish fur on tongue 107 
 
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