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 COLUMBIA LIBRARIES OFFSITE 
 
 HEALTH SCIENCES STANDARD , 
 
 HX64119360 
 RC66 . D65 Outlines lor case ta 
 
 RECAP 
 
 MEDICAL CLINIC 
 
 THIRD EDITION 
 
 GEORGE DOCK 
 
OUTLINES 
 
 'FOR 
 
 CASE TAKING 
 
 AND 
 
 Routine Ward and Laboratory Work 
 
 AS USED IN the; 
 MEDICAL CLINIC 
 
 OF THE 
 
 WASHINGTON UNIVERSITY 
 
 BY 
 
 GEORGE DOCK, A.M., M.D., Sc.D. 
 
 Professor of Medicine, Washington University 
 
 St. Louis, Mo. 
 
 (Third Edition Revised) 
 
 George Wahr 
 Publisher 
 
 ANN ARBOR, MICH. 
 

 COPYRIGHT 1902 
 COPYRIGHT 1 9 13 
 
 COPYRIGHT 192 1 
 
 BY GEORGE WAHR 
 
 1? C CG 
 
 Dcr 
 
 THE ANN AReO"? PRESS 
 
PREFACE 
 
 These outlines, based originally on Strum- 
 pell's Leitfaden, have long been used in my 
 clinic in type-written copy as guides in case- 
 taking. Being intended merely as outlines, 
 methods are not included. Laboratory manip- 
 ulations necessary in the study of cases are 
 for the most part familiar to the student when 
 he begins clinical work. Hand-books are avail- 
 able in the clinical laboratory and should be 
 consulted freely. 
 
 1902. 
 
 Preface to Second Edition 
 
 The first edition of this little work has been 
 used with considerable satisfaction in practical 
 work in the medical wards. In preparing the 
 present edition I have profited by experience 
 in previous years and have also had the val- 
 uable assistance of Doctor J. S. Brotherhood 
 in adding material. I am especially indebted 
 to Doctor Ernest Sachs for additions and 
 improvements in the neurological section. 
 
 1913. 
 
 Preface to Third Edition 
 
 The revision of this guide to case-taking 
 has unavoidably increased its size, but it is 
 hoped the enlargement will not lessen useful- 
 
— 4 — 
 
 ness. As in previous editions, compactness is 
 sought by giving a general outline, Avith skele- 
 ton additions for cases found to belong to 
 special categories, as well as for special exam- 
 inations. 
 
 In order profitably to use the book the begin- 
 ner must have : 
 
 1. A general knowledge of internal diseases; 
 
 2. Facility in elementary laboratory technic ; 
 
 3. The foundation of p^hysical diagnosis. 
 
 The beginner should read the book in order 
 to know where to find needed information, and 
 follow it in the actual work of taking histories 
 until the act becomes unconscious. Telegraph 
 style should be used. 
 
 It is a pleasure to acknowledge the con- 
 tinued assistance, often unconscious, of many 
 colleagues, assistants, and undergraduates, and 
 especially the numerous suggestions of my 
 friend Dr. George Herrmann, Instructor in 
 Medicine, University of Michigan. 
 
 GEORGE DOCK, 
 
 June 21, 192 1. 
 
HISTORIES ARE NEVER TO BE TAKEN 
 FROM THE WARD 
 
 Front Page. Fill in : 
 
 General Hospital Number. 
 Medical Service Number (added by sec- 
 retary). 
 
 Patient's name in full — no initials (e. g., Smith, 
 John, Mary) ; sex ; age ; married ; single ; 
 . widowed ; divorced ; occupation ; nativ- 
 ity; residence. 
 
 Name and address of Patient's nearest relative 
 or friend in St. Louis, or nearest relative 
 at home. 
 
 Name and address of Family Physician. If 
 Patient is from the Hospital Dispensary, 
 give service number and date and get 
 history from record room. 
 
 Date of admission to the Hospital. 
 
 Note former admissions to this Hospital. (Date 
 of Admission and Discharge, Medical 
 Number and Diagnosis.) Read former 
 histories and abstract important data. 
 
Digiiized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/outlinesforcasetOOdock 
 
I. FOR MISCELLANEOUS CASES AND 
 ACUTE INFECTIONS. 
 
 (For special diseases see Scheme II, etc.) 
 
 1. Name. Put patient's name at top of each 
 
 history page. Number each page i, 2, 3, 
 etc. 'Date and initial each note. 
 
 2. Patient's complaints; briefly but fully, in 
 
 original words, but avoid loose expres- 
 sions such as "kidney trouble," "gastri- 
 . tis," etc. ; or, circumstances and con- 
 dition in which the patient enters clinic. 
 If delirious or too weak to talk, try to 
 get particulars from those who bring 
 him, or who call ; also from former phy- 
 sician, if possible. 
 
 3. Family History. Health or causes of 
 
 death and ages of father and mother ; 
 (of uncles and aunts, and grandparents, 
 if indicated) ; ascertain fullest possible 
 details, with special reference to nerv- 
 ous, metabolic, ductless gland, and blood 
 diseases. Clear up diagnoses given by 
 histories ; avoid all forced conclusions ; 
 use " " for unverified diagnosis. Broth- 
 ers and sisters : ages, conditions, causes 
 of death. Children : Number ; ages ; 
 health of each; if dead, causes of. 
 
 4. In Women. Menstruation. If married, 
 
 how long; pregnancies; abortions. 
 
— 8 — 
 
 5- Previous History. Condition from infancy, 
 in chronologic order. Inquire especially 
 as to complications and sequels of vari- 
 ous diseases in turn. Avoid leading 
 questions as far as possible; also sug- 
 gestions of symptoms. Investigate 
 especially possible relations with pres- 
 ent disease — i. e., scarlatina, measles, 
 Avhooping-cough, typhoid fever, malaria 
 (caution); rheumatism, influenza (cau- 
 tion), sepsis, erysipelas, diphtheria, sore 
 throat, gonorrhea, syphilis, nephritis, 
 endocarditis, pleurisy, pneumonia, cho- 
 rea, gout, lead poisonino-; exposure to 
 epidemics. If there is a history of any 
 disease, make full notes as to duration, 
 complications if any, i. e., scarlet fever, 
 ear trouble or nephritis; rheumatism, 
 severity, condition of joints, of heart. 
 Scrutinize all diagnoses, as in the study 
 of the present disease. 
 
 6. Occupations and habits; environment of 
 
 home and work place; kind and quality 
 of food; regularity of meals; mastica- 
 tion; alcoholics, substitutes and drugs 
 in detail; tea; coffee; tobacco. Avoid 
 "light," "moderate," "heavy" ; make 
 definite statements of amount used, and 
 effects. 
 
 7. Investigation of the sexual life, when indi- 
 
 cated. 
 
— 9 — 
 
 8. Present Disease. Date (not day of the 
 
 week) of onset; probable cause, in opin- 
 ion of patient, relatives or physician ; 
 trauma ; "cold" ; mental or physical over- 
 work ; mental shock ; exposure to infec- 
 tion ; hygienic conditions. 
 
 9. Mode of Onset. Sudden or gradual ; first 
 
 symptoms, as chill, fever, pain : location 
 and character ; stomach and bowels 
 (vomiting in acute infection) ; weakness. 
 
 10. Later Course. Try to have patient de- 
 scribe this in chronologic order and in 
 his own way, but seek accuracy and 
 fulness. Note especially the following: 
 Weakness, loss of weight; chills: fever; 
 thirst; sweats; headache; vertigo; sleep; 
 lacrimation ; photophobia ; pain in eyes : 
 rhinitis, epistaxis ; mouth, teeth and 
 gums ; sore throat ; hoarseness ; dyspnea ; 
 cough ; expectoration ; source of sputum ; 
 palpitation of heart ; appetite ; degluti- 
 tion; eructations; nausea; vomiting; 
 flatulence ; stools ; urination ; frequency 
 of, amount ; pain ; alterations of men- 
 struation ; extremities, sensations in ; 
 muscles, bones, joints; edema. Never 
 fail to ask: "Is that all?" 
 
 Modifications by treatment or otherwise 
 (avoid critical allusions to views or 
 treatment of former physician). 
 
10 
 
 11. Present Symptoms. Summarize these. 
 
 Read carefully before takin^j- S. P. 
 (status praesens) and ahvays bear in 
 mind in making later examinatioijs, and 
 especially on discharge. 
 
 12. Physical Examination. Present Condition 
 
 (S. P.). Temperature; pulse; respira- 
 tion ("T. P. R."). 
 
 13. Body in General. Habitus ; height ; frame, 
 
 small; medium, or large ; slender or 
 heavy ; symmetrical or not, with details 
 in latter case ; usual weight ; alterations 
 in weight ; panniculus ; musculature ; 
 lymph glands ; vertebrae ; ribs ; intercos- 
 tal spaces; long bones: joints; flatfoot. 
 Reflexes. 
 
 14. Position (decubitus); station; gait; tre- 
 
 mor. General appearance; expression. 
 Mental condition ; Orientation ; vSpeech ; 
 memory ; attention ; apathy ; coma ; 
 delirium; carphologia ; jactitation. 
 
 15. Skin. Color of face, bodv and extremities; 
 
 visible mucous membranes ; cyanosis ; 
 icterus ; skin warm or cold, dry or moist ; 
 elastic or inelastic; edema; eruptions; 
 ulcers ; striae ; scars ; subcutaneous 
 nodules. Hair of head and other parts. 
 Nails. 
 
 16. Head. Skull; eyes; ears, tophi and dis- 
 
 charge ; cheeks ; nose ; accessory nasal 
 
II 
 
 sinuses ; herpes ; mouth ; teeth ; tongue ; 
 soft palate, gums and buccal mucous 
 membrane in 'general ; tonsils ; adenoid 
 tissue ; lingual tonsil ; pharynx. Swab 
 for smear and culture. 
 
 17. Neck. Shape; size. Larynx.; thyroid; 
 
 lymph-glands: blood-vessels. Torticol- 
 lis. Tumors; cysts; fistulae; scars (ori- 
 gin). 
 
 18. Thorax. Shape : size ; type of respiration ; 
 
 diaphragm phenomenon ; lagging, retrac- 
 tion ; palpation, percussion and auscul- 
 tation of lungs. 
 
 19. Heart. Inspection ; position and character 
 
 of apex beat; thrill; percussion; auscul- 
 tation. Radial pulse ; palpation of wall ; 
 rate (increase on sitting up?); size; 
 rhythm; tension. Other vascular anom- 
 alies, such as pulse in other arteries ; 
 veins ; epigastrium ; liver ; capillaries. 
 Blood pressure. 
 
 20. Abdomen. Form ; size ; floating tenth rib ; 
 
 visible peristalsis; eruptions; palpation; 
 pain or tenderness ; succussion ; percus- 
 sion (change of position). Liver: Per- 
 cussion and palpation ; gall-bladder. 
 Spleen : Percussion ; palpation. Pylorus. 
 Pancreas. Appendix region. Pelvis 
 (examine by A^agina and rectum if indi- 
 cated). Perineum; (hemorrhoids). 
 Sites of hernia. 
 
12 
 
 21. Genito-urinary apparatus: Kidneys, palpa- 
 
 tion. Bladder, palpation and percussion. 
 Penis : Ulcers ; scars ; discharge. Scro- 
 tum : Varicocele ; hydrocele ; induration 
 in testes or cords. Prostate; seminal 
 vesicles. Vulva ; vagina ; uterus ; ova- 
 ries; tubes. 
 
 22. Urine. Amount; sp. gr. ; color; albumin; 
 
 glucose; sediment and "floaters." (See 
 VI.) 
 
 23. Blood. Macroscopic appearance and exam- 
 
 ination of fresh drop ; red corpuscles ; 
 leucocytes ; hemoglobin. (See V.) Was- 
 sermann test; blood culture. 
 
 24. Stools. Always examine. (See IV.) 
 
 25. Sputum. Type pneumococci. (See II.) 
 
 26. Other secretions and excretions. Spinal 
 
 fluid in suspected meningitis. Cultures 
 and animal inoculations of exudates and 
 secretions. 
 
 27. Special Examinations. Tuberculin tests; 
 
 x-ray filrns of teeth; fluoroscopic and 
 skiagrams of thorax. 
 
— 13 — 
 
 11. DISEASES OF THE RESPIRATORY 
 ORGANS. 
 
 3. Family History. Investig-ate. histories of 
 father, mother, brothers and sisters with 
 reference to all possible diseases of res- 
 piratory organs, and to tuberculosis in 
 various forms. Avoid writing doubtful 
 diagnoses ; if necessary, put statements 
 in " ". Note dates of illnesses and 
 deaths. Add histories of other relatives 
 if clear and noteworthy. 
 
 5. Previous Diseases, etc. Enlarged glands, 
 
 duration, location, severity; bone and 
 joint disease; diseases of the nose, 
 throat, larynx, lungs and pleura. 
 
 6. Occupations, etc. Exposure to dust or 
 
 irritating vapors, grinding, cold storage, 
 etc. ; exhausting or depressing occupa- 
 tions; living with or nursing persons 
 with cough or tuberculosis. In women, 
 .. puerperal state. 
 
 8. Aspiration of foreign bodies. 
 
 9. Onset. Anemia; anorexia; emaciation; 
 
 hoarseness; aphonia; cough; expectora- 
 tion ; hemoptysis ; weakness ; fever ; 
 chills ; diarrhea ; hemorrhoids ; bronchi- 
 tis; pleurisy; pneumonia; amenorrhea. 
 
 10. Later course: Dyspnea; night sweats; 
 fever ; chills. 
 
— 14 — 
 
 II. Present Symptoms. Pain in thorax; dura- 
 tion, location; character. Cough, time 
 o£ occurrence ; character, dry or with 
 expectoration ; with or without pain ; 
 type of respiration ; stridor. 
 
 Expectoration. Amount, appearance, con- 
 sistency, odor. 
 
 Blood spitting. How excited, amount, 
 appearance. 
 
 Dyspnea. When noticed, character, degxee. 
 
 Larynx. Pain in, how excited, as by talk- 
 ing, swallow^ing, singing; voice, altera- 
 tions of. 
 
 Alimentary apparatus: Compare scheme 
 for Diseases of Organs of Digestion. 
 
 Night-sv/eats. 
 
 13. Body in general: Myoidema; fingers (club- 
 bing) ; nails. 
 
 15. Skin. Flush on face; pallor ; traces of cya- 
 
 nosis on face or extremities ; herpes ; 
 dilated veins on thorax. 
 
 16. Head. Otoscope. Al^e nasi; movement of, 
 
 larynx. 
 
 17. Laryngoscopic examination ; pharynx ; root 
 
 of tongue ; epiglottis ; arytenoids; poste- 
 rior wall; ventricles; cords; trachea. 
 
 18. Thorax. Shape in general ; (kyphosis ; sco- 
 
 liosis) ; length; breadth; depth; circum- 
 ference (cyrtometer) ; interspaces ; epi- 
 gastric angle ; Louis' angle ; clavicles, 
 
— 15 — 
 
 supra- and infra-clavicular foss?e; ver- 
 tebrae ; symmetry ; expansion ; ratio of 
 in- and expiration ; inspiratory retrac- 
 tion ; diaphragm phenomenon. 
 
 Percussion. Always compare opposite 
 side. Note volume, pitch and quality of 
 sound and resistance all over, and espe- 
 cially in apices, front and back; height 
 of apices, front and back ; lower boun- 
 daries (Grocco), with mobility on respi- 
 ration, and change of position; Traube's 
 . space. 
 
 Auscultation. Vesicular breathing, weak, 
 exaggerated, puerile ; broncho-vesicular ; 
 blowing, soft or harsh ; amphoric ; ratio 
 of in- and expiration ; breathing after 
 coughing. 
 
 Adventitious sounds. Location ; character 
 (crackling rales, fine, medium or coarse; 
 dry or moist ; few or many ; in- or expi- 
 ration ; rhonchi, character, location ; 
 effect of coughing). Friction; location, 
 character, phase of respiration, effect of 
 pressure, position, cough, deep breath- 
 ing. 
 
 Auscultation of voice. Whispered voice ; 
 of cough. Auscultatory percussion ; 
 coin sound. 
 
 Palpation. Vocal fremitus ; friction ; pain 
 or tenderness ; muscular rio-iditv. 
 
— i6 — 
 
 ig. Heart. Pulmonary second sound ; epigas- 
 tric and cervical pulsations ; dicrotic 
 pulse. 
 
 20. Abdomen. Spleen. Liver. Cojnpare 
 
 scheme IV. 
 
 21. Urine. Tubercle bacilli; diazo reaction. 
 
 24. Stools. Pus; blood; tubercle bacilli. 
 
 25. Sputum. Quantity; color; consistency; 
 
 character (watery, mucous, muco-puru- 
 lent, purulent, blood3^ rusty, prune 
 juice, nummular, layers) ; odor; reaction. 
 
 Cells : pavement epithelial ; alveolar ; dust- ; 
 heart-failure-; leucocytes; mononuclear; 
 eosinophile. Colloid ; ''myelin." 
 
 Red blood cells: number; condition. 
 
 Elastic tissue, kind and quantity ; Charcot- 
 Leyden crystals ; hematoidin ; fat-crys- 
 tals; spirals; bronchial casts. 
 
 Tubercle bacilli, number; appearance; in 
 cells. 
 
 Other bacteria : influenza ; diplococci ; 
 streptococci ; staphylococci ; strepto- 
 thrix; (actinomyces) ; yeasts; molds; 
 sarcines. Spirochetes ; (stain, dark 
 field). Protozoa; larvae; ova. 
 
 26. Miscellaneous. Exploratory aspiration ; 
 
 chemical and microscopic examination 
 of fluids. 
 
 27. Bronchoscopy. Fluoroscopic and skia- 
 
 graphic examination of lungs and pleu- 
 rae. Spirometer. Vital capacity. 
 
17 
 
 III. DISEASES OF THE CIRCULATORY 
 APPARATUS. 
 
 3. Family History. History of valvular dis- 
 
 ease ; arterio-sclerosis ; syphilis ; apo- 
 plexy; sudden death; family tendency 
 to circulatory disease. 
 
 4. In Women. Effect of possible pregnancies 
 
 on the course of the disease should be 
 borne in mind in connection with 5. 
 
 5. Previous Diseases. "Rheumatism" ; chorea 
 
 (St. Vitus' dance) and all acute infec- 
 tious diseases; tonsillitis; scarlet fever; 
 diphtheria ; pneumonia ; typhoid ; influ- 
 enza : syphilis ; nephritis ; exophthalmic 
 goitre, 
 
 6. Severe manual labor; athletics; excite- 
 
 ment; over-eating; excessive use of alco- 
 holics (beer) ; tobacco ; coffee and tea. 
 
 7. Sexual anomalies and masturbation. 
 
 8. Present Disease. Full details, 
 
 . 9. Mode of onset. Note earliest appearance, 
 with details of dyspnea ; edema ; weak- 
 ness; palpitation of the heart; causes of 
 attacks ; pain in heart region, with 
 details of character, radiation (arm, 
 head, etc.); intermittent limping; sub- 
 jective feeling of heart, character; epis- 
 taxis ; cough, expectoration ; vertigo ; 
 
i8 
 
 tinnitus aurium ; cyanosis; pallor; flush- 
 ing ; fainting- ; sputum (bloody) ; change 
 in quantity of urine. Sleep. Stomach. 
 
 10. Later course in detail. 
 
 11. Present Symptoms. Subjective symptoms 
 
 in full. 
 
 13. General. Faulty development in congeni- 
 tal heart disease and that acquired in 
 early childhood. Clubbed fingers. 
 
 15. Skin. Combination of cyanosis and. icte- 
 
 rus ; pallor ; flushes ; oedema ; tropho- 
 neuroses. 
 
 16. Head. (Early grayness in atheroma). 
 
 Arcus senilis; conjunctival vessels. 
 
 17. Neck. Inspection and auscultation of arte- 
 
 ries of neck ; pulsation in cervical veins ; 
 systolic venous pulse; pulsation in jugu- 
 lar fossae (palpate) ; tracheal tug ; aus- 
 cultation of goitre. Laryngoscope for 
 hoarseness ; brazen cough ; aphonia 
 (vocal cord paralysis). 
 
 18. Thorax. Lungs. Emphysema ; pneumo- 
 
 thorax ; bronchitis ; hydrothorax ; con- 
 gestion ; infarct. Diastolic thoracic 
 rebound. 
 
 19. Heart. Inspection : Prominence in heart 
 
 region. Apex beat: Location; character; 
 diffuse pulsations; retraction. Epigas- 
 
— 19 — 
 
 trium; pulsations in other parts of tho- 
 rax (aneurysm; pulsating exudates.) 
 
 Palpation. Strongest and most distinct 
 location of apex beat ; force ; heaving 
 impulse ; shock ; rhythm. Thrill and 
 friction fremitus ; location ; time ; char- 
 acter,. Palpation of other pulsating areas 
 in the thorax. Palpation of back. 
 
 Percussion- Outline and make diagram. 
 Percussion of cardiac dulness in the 
 back; change of position. 
 
 Auscultation. Note character (weak, 
 strong, pure, impure, clear, murmurish, 
 accentuated, snapping) of sounds at 
 apex ; along left edge of sternum, on ster- 
 num, to right of sternum, in left axilla, 
 to right of ensiform, along carotids and 
 subclavians, in back ; rhythm ; extrasys- 
 tole.; gallop rhythm (analyze) ; emibryo- 
 cardia ; auricular fibrillation or flutter; 
 alternating beat. Adventitious sounds: 
 ■ Time, character ; w^here best heard ; 
 transmission. 
 
 Blood-vessels. Visible pulsations in arte- 
 ries and veins ; capillary pulse in nailbed, 
 soft palate and pharynx, on forehead ; 
 pulsating liver. 
 
 Radial artery. Wall ; course ; size of pulse ; 
 quick or slow ; hard or soft ; tension ; 
 rate ; rhythm. Pulse deficit. 
 
 Auscultation of arteries. Double tone ; 
 
— 20 — 
 
 murmurs (note effect of .pressure on 
 murmurs). 
 
 Enlarged veins on trunk ; sketch or photo- 
 graph. Venous tones and murmurs. 
 Sphygmomanometer; polygraph. 
 
 20. Abdomen. CEdema; ascites. Liver. Spleen. 
 
 22. Urine. Complete examination as in 
 
 Scheme VI. 
 
 23. Blood. Full examination. Scheme V. 
 
 25. Sputum complete. Scheme II. 
 
 27. X-ray examination of heart and sites of 
 aneurysm. Seven-foot skiagram of heart. 
 Electrocardiograms. Exercise tests. 
 Vital capacit}^ 
 
 IV. DISEASES OF THE ORGANS OF DI- 
 GESTION (OESOPHAGUS, STOMACH, 
 INTESTINE, LIVER AND PANCREAS). 
 
 6. Special attention to habits of eating and 
 drinking. Meal hours ; bolting food ; 
 eating alone or in company; reading at 
 meals. Condition of teeth ; caries, arti- 
 ficial teeth; care of mouth. Quality and 
 quantity of food ; proteid ; carbohy- 
 drates ; fats ; salt ; milk, how taken. 
 Water, when and how taken ; temper- 
 ature. Tea; coffee; cocoa. Alcoholics 
 
— 21 — 
 
 in detail. Tobacco. Work and exercise. 
 Mental anomalies. 
 
 7. Sexual history often important, especially 
 in neuroses of stomach. 
 
 II. Present Symptoms. Appetite, degree of; 
 perversions ; is appetite lost or recovered 
 by eating? lost after a few mouthfuls? 
 
 Thirst. (Is urine in proportion to water 
 ingested?) 
 
 Taste. Normal or abnormal ; disagreeable 
 taste in mouth ; stale, sour, rotten, sweet; 
 dryness of mouth ; burning in mouth. 
 
 Saliva, alterations of. 
 
 Swallowing. Pain ; seat ; character. 
 
 Obstruction. Apparent seat, change of; 
 constant or variable ; to what kinds of 
 food, liquid, soft or solid? Onset and 
 duration of. 
 
 Hemorrhage from pharynx or oesophagus ; 
 
 time ; character of blood. 
 
 Feeling of pressure in stomach region; 
 
 exact seat ; relation to taking of food or 
 kind of food ; duration. 
 
 Feeling of distention. Location ; time and 
 duration of; relation to food. 
 
 Pain. Seat ; character ; boring, colicky, 
 cutting, burning, etc.; time of occur- 
 rence, circumscribed or diffuse ; radia- 
 tion ; degree ; effects of pressure ; of heat, 
 
22. 
 
 food, sodium bicarb. (Gastric crises, 
 gall-stones, renal colic.) 
 
 Regurgitation and eructation. Time ; 
 degree ; consistence ; character ; odor ; 
 taste; amount of fluid regurgitated; 
 regurgitation of food; condition of, time 
 of. Rumination. Hiccup. 
 
 Nausea. Time; degree; apparent cause. 
 
 Vomiting. Time; frequency; relation to 
 meals ; amount and character of vomi- 
 tus ; color, taste and odor ; food eaten 
 many hours before; mucus; bile; blood, 
 appearance. Symptoms accompanying 
 ^^omiting : nausea, pain, weakness, faint- 
 ness, colic, cram.p. Fecal vomiting. 
 Sensations after vomiting. 
 
 Flatulence. Duration of ; degree ; constant 
 or variable ; relation to food ; noises in 
 abdomen. Is wind passed up or doAvn? 
 
 Subjective motions in abdomen : seat : rela- 
 tion to eating-. Pulsations: when felt; 
 degree. 
 
 Stools. Number ; character ; is latter con- 
 stant or variable? If constipation, w^hat 
 is and has been used to overcome it? 
 Appearance of stools. 
 
 Pain in defecation. Location, character. 
 
 Mucus, pus or blood in stools; describe in 
 patient's w-ords. 
 
 Hemorrhoids: fissure; fistula; tenesmus. 
 
— 23 — 
 
 Tumors, masses, "bunches" (or other 
 terms applied to/iiew-growths) in abdo- 
 men : when discovered ; constant or 
 variable ; size and change of size ; pain ; 
 position; mobility. 
 
 Pain in region of liver or gall-bladder; 
 occurrence, duration, character, degree. 
 
 Jaundice. Duration, degree ; associated 
 symptoms ; nervous symptoms. 
 
 13. General. Emaciation; cachexia; lymph 
 glands. 
 
 15. Skin. Color and other condition of skin 
 
 (naevi) ; examine w^hole body. 
 
 16. Head. Tongue. Teeth in detail. Pharynx. 
 
 17. Neck. Tumors in oesophagus; stricture; 
 
 spasms. Examination of oesophagus; 
 soft tube ; probe (caution : X-ray first 1 
 aneurysm!); swallowing murmurs. 
 
 18. Effusions or new-growths in thorax. Lor- 
 
 dosis ; scoliosis ; retraction. 
 
 20. Abdomen. Size and shape of abdomen, 
 both lying and standing. 
 
 Skin. Texture, color, triae ; veins ; visible 
 tumors; patterns of tumidity; pulsa- 
 tions ; peristaltic motion. 
 
 Palpation. Thoroug'h, with reference to 
 position, size, shape and consistence of 
 all organs. 
 
— 24 — 
 
 Percussion. (Not so valuable as palpation 
 and inspection, but can often add to pre- 
 vious information. Percussion of liver 
 important in suspected peritonitis.) 
 Percussion on changing position ; in 
 knee-hand position. Fluctuation on tap- 
 ping with fingers. 
 
 Auscultation. Gurgling; succussion. Fric- 
 tion sound over liver ; murmur in abdom- 
 inal veins. 
 
 Stomach. Inspection; palpation, percus- 
 sion and auscultatory percussion ; suc- 
 cussion (exact position of) ; distention by 
 air or by other method ; note curvatures. 
 Stomach tube or duodenal tube. Test 
 meals, shredded wheat biscuit, bread and 
 water, dinner. For scheme, see below. 
 
 Intestines. Distention; peristalsis; pat- 
 tern ; distention of colon by rectal tube 
 and bulb (x-ray preferable). Palpation 
 for tenderness, rigidity, and tumors ; note 
 all characteristics. Appendix. Appen^ 
 dix region; tenderness; other details. 
 
 Liver. Inspection, palpation (standing as 
 well as lying) ; percussion; position and 
 outline of borders; thickness of loAver 
 edge ; surface smooth or uneven ; scars ; 
 nodules; tumors; depressions; abnormal 
 lobes ; friction ; tenderness on pressure. 
 Aspiration of liver and sub-diaphragm- 
 atic space. 
 
— 25— • • 
 
 Gall-bladder. Position, size, shape, con- 
 sistence. 
 
 Spleen. Position, size, shape, consistence. 
 
 Pancreas. Size, shape and consistence. 
 
 Palpation and auscultation of peritoneal 
 friction and gurgling. 
 
 Examination of anus and rectum. Ulcers, 
 
 fissures, hemorrhoids, fistula, stenosis, 
 inflammation and new growth in the 
 rectum. Sites of herniae. Pelvis. 
 
 Palpation of tumors. Position in abdomen 
 and in relation to other organs ; size (in 
 exact figures or plain comparisons) ; 
 shape ; surface ; smooth, even, nodular ; 
 consistency ; hard, soft, fluctuating ; 
 mobility; spontaneous, with respiration, 
 by pressure ; resistence when held down 
 in inspiration ; pain in tumor. 
 
 22. Urine. Always m.ake complete examina- 
 
 tion of urine. Scheme VI. 
 
 23. Blood. Always make complete examina- 
 
 tion of blood. Scheme V. 
 
 24. Stools and defecation. Frequency; quan- 
 
 tity; color; odor; reaction; consistence; 
 if formed ; size and shape ; presence of 
 foam (in relation to time out of body) ; 
 mucus; blood; occult blood (method); 
 pus ; food remains ; sloughs ; parasites ; 
 ova. 
 
— 26 — 
 
 Microscopic examination. Food remains; 
 muscle fibres ; connective tissue ; vege- 
 table fibres and cells : starch ; leucocytes ; 
 red blood corpuscles ; epithelial cells ; 
 crystals, as bismuth, triple phosphates, 
 Charcot crystals (large numbers in some 
 cases of helminthiasis) ; vegetable crys- 
 • tals and sand; fat; fatty acids; soap; 
 bacteria ; yeasts ; protozoa ; eggs. Look 
 for tubercle bacilli in all cases with pus 
 in stools. 
 
 Bile coloring matter (bichloride test). 
 
 26, Other examinations as indicated, including 
 palpation in hot bath and under anaes- 
 thesia. 
 
 Scheme for Examination of Stomach Con- 
 tents. Fasting contents in all cases. 
 Examine and note as for test-meal. Note 
 food previously eaten. Test-meal, kind ; 
 time after eating. Method of removal 
 (stomach tube ; duodenal tube ; expres- 
 sion, aspiration). Quantity; color: odor; 
 food-particles ; mucus ; blood ; bile. 
 
 Lavage after removal, results of. 
 
 Microscopic examination. Food remains 
 in detail. Blood-corpuscles; leucocytes; 
 bacteria fdetails) : sarcines ; yeasts ; 
 molds; protozoa; epithelial cells; tissue 
 fragments ; "myelin." 
 
 Filtrate. Quantity ; Sp. G. ; reaction to lit- 
 mus ; to Congo ; Giinzberg's phloroglucin 
 
— 27 — 
 
 and vanillin ; dimethyl-amido-azo-ben- 
 zole. Lactic acid tests ; Uffelmann ; 
 (other methods)'. Acetone (in distil- 
 late). 
 
 Quantitative tests. Give method ; chart, if 
 fractional. Free HCl ; total acidity. 
 Hydrogen ions. 
 
 Digestion tests. Pepsin (rennin). Results 
 of digestion : Albumoses ; peptones. 
 
 Starch digestion. Erythrodextrin ; mal- 
 tose; dextrin. 
 
 Absorption tests. 
 
 Motor power tests (Fluoroscopy). 
 
 Special examination. Fluoroscopy and 
 skiagraphy of gastrointestinal tract 
 (teeth, oesophagus, stomach, small intes- 
 tine, appendix, colon (diverticulosis) ; 
 gall-bladder. Diagnostic pneumoperi- 
 toneum. Duodenal and gall-bladder 
 diagnostic aspiration. Esophagoscopic ; 
 proctoscopic ; sigmoidoscopic. 
 
 V. DISEASES OF METABOLISM, BLOOD 
 AND DUCTLESS GLANDS. 
 
 3, 4. Examine family and personal histories 
 with care. 
 
 5. Previous conditions. Investigate histories 
 if possible ; stomach diseases ; diarrhea ; 
 parasites and poisons ; rickets. 
 
— 28 — 
 
 6.. Note injurious mental habits or emotions, 
 shock, business reverses and strains. 
 
 9. Onset. Note especially particulars of 
 weakness ; changes of appetite ; hiinger ; 
 thirst; loss of weight; gain of weight; 
 vision ; anomalies of sleep ; impotence. 
 
 11. Present Symptoms. In case of headache, 
 
 note characteristics ; vertigo ; tinnitus 
 aurium ; epistaxis ; hemoptysis ; neural- 
 gias ; stomach and intestinal symptoms 
 in detail. 
 
 12. Always give T. P. R. and status praesens 
 
 in detail, according to general and spe- 
 cial schemes. 
 
 13. Ideal v^eight; habitus. Distribution of 
 
 subcutaneous fat; fat tumors. Extrem- 
 ities and "ends" (acra) ; nose; chin; 
 tongue, etc. Tremors, writing or tracing. 
 
 14. Position; appearance; mind. Note fully 
 
 all details. 
 
 15. Skin. Pigmentation; depigmentation of 
 
 skin ; mucous membranes ; edema ; myx- 
 edema ; scleroderma ; vasomotor anom- 
 alies; trophic changes; itching: urti- 
 caria (hives) ; sweating; flushing. Tophi. 
 
 16. Head. Eyes and eyelids; Graefe's, Stell- 
 
 wag's and Moebius's symptoms; pupils 
 and their reflexes. Ophthalmoscope. 
 Spacing of teeth ; changes in ''bite." 
 Hard palate. Salivary glands. 
 
— 29 — 
 
 ly. Neck. Pulsations ; thrill. Auscult thyroid 
 when enlarged. . 
 
 i8. Thorax. Percuss for thymus. 
 
 22. Urine. See Scheme VI. 
 
 23. Blood. Fresh drop : flow ; color, consist- 
 
 ence. Fresh drop, microscopic ; red cells, 
 size, shape, color, relative number, rolls, 
 Leucocytes, relative number, other char- 
 acteristics. Platelets. Fibrin. Para- 
 sites : describe fully. 
 
 Number of red cells. 
 
 Number of leucocytes. 
 
 Hemoglobin (method used) ; color index. 
 Specific gravity (method). 
 
 Differential count. Stain. Number of cells 
 counted. Small lymphocytes ; large lym- 
 phocytes; transitional; polynuclear; 
 eosinophile polynuclear; eosinophile 
 mononuclear ; myelocytes ; mast cells ; 
 degenerates ; other forms. 
 
 Red cells ; microcytes ; macrocytes ; micro- 
 blasts ; normoblasts ; megaloblasts ; poi- 
 kilocytes ; vacuolated ; punctate ; poly- 
 chromatophile ; Howell's bodies ; Cabot's 
 rings ; Schiiffner's granules ; undeter- 
 mined. 
 
 Platelet count. 
 
 Coagulation time ; bleeding time. Viscos- 
 ity. Fragility. 
 
— 30 — 
 
 Blood chemistry: Total N, non-protein 
 N; ammonia N; amino-acid N; uric 
 acid ; creatinin ; sugar ; calcium ; chlo- 
 rides. Total solids. CO.. combinins; 
 power ; O affinity of Hb ; H-ion con- 
 centration ; lecithin ; total fat ; choleste- 
 rol ; diastasic activity; plasma COo ; 
 alkalinity; Na feeding test. 
 
 27. Special examinations. Skiagram of skull 
 (sella); long bones; joints; vertebrae. 
 Excision of specimens, skin, subcutane- 
 ous, hanph nodes for histologic exam- 
 inations. Pharmacodynamic tests. Pro- 
 tein sensitization. Alveolar air, COo 
 tension of. Basal metabolism. Sugar 
 tolerance curve (give data). 
 
 VI. DISEASES OF THE URINARY AND 
 SEXUAL ORGANS. 
 
 3. Family history. Details as to diseases of 
 
 eenital and urinarv ors^ans in immediate 
 family. 
 
 4. In women. Complications in vagina, ute- 
 
 rus, bladder or kidneys in pregnancy or 
 puerperium. 
 
 5. Previous condition. Exposure to cold and 
 
 wet. 
 
 7. Sexual. In detail, with care in putting 
 questions. 
 
— 31 — 
 
 g. Onset. Earliest appearance of pallor ; dys- 
 pnoea ; oedema of face, feet, hands, body; 
 weakness ; headache ; vertigo ; eye symp- 
 toms ; epistaxis;loss of appetite; gastric 
 symptoms in detail ; pain in back ; altera- 
 tions of micturition ; pain in urinary 
 tract ; unusual appearances in urine ; dis- 
 charges from genitals, characters of. 
 
 i6. Head. Arteries, eyegrounds. 
 
 i8. Thorax. Bronchitis ; emphysema ; hydro- 
 thorax. 
 
 ig. Heart. Complete examination ; notice sec- 
 ond aortic sound; pulse, ^ tension: 
 (SphygmomanomxCter.) 
 
 20. Abdomen. Ascites. 
 
 21. Full examination o£ genito-urinary appa- 
 
 ratus. Prostate and seminal vesicles; 
 massage ; 2 or 3 glass test. Cystoscope ; 
 ureteral catheterization. 
 
 22. Scheme for Examination of Urine. 
 
 Quantity. When passed, as sample, giving 
 time of day; day or night; 24 hours. 
 (Bladder must be emptied at end of 
 every period. If per catheter, note.) 
 
 Specific gravity ; reaction ; color ; odor ; 
 clear or turbid ; floaters (make film, 
 stain, examine, describe). 
 
 Albumin tests. Boiling and dilute acetic 
 acid ; Heller's ; acetic acid and ferrocy- 
 
— 32 — 
 
 anide; other methods. For quantitative, 
 note bulk after boiling and acid, in vul- 
 gar fractions, or Esbach (Tsuchiya) ; 
 Kjeldahl. 
 
 Albumose; Bence-Jones proteid. Globu- 
 lin ; mucin. 
 
 Glucose tests, a, Fehling's (Benedict) ; b, 
 boiling with KOH solution ; c, phenyl- 
 hydracin ; d, fermentation ; e, polariscope. 
 For quantitative, Benedict, d, e. 
 
 Bile coloring matter. Foam; Gmelin ; Uro- 
 bilin ; urobilinogen. 
 
 Bile acids. Hemoglobin; indican ; acetone; 
 diacetic acid ; beta-oxybutyric acid ; hae- 
 matoporphyrin ; melanin; leucin ; tyro- 
 sin; alkapton ; H^S; cystin; phenol; 
 pyrocatechin ; hippuric acid. 
 
 Quantitative tests. Total acidity and alka- 
 linity; chlorides; sulphates, inorganic, 
 conjugated, neutral sulphur; phos- 
 phates ; total N ; non-protein N ; urea ; 
 uric acid ; ammonia ; creatinin : creatin ; 
 alloxur Tpurin) bases; oxalic acid; indi- 
 can ; oxybutyric acid ; acetone bodies ; 
 hydrogen-ion concentration. 
 
 Sediment. (Fresh specimens.) Amount; 
 color; appearance. Mucus. Centrifu- 
 gate ; amount and macroscopic appear- 
 ance. Epithelial cells, number and kind ; 
 leucocytes, number and kind; red-blood 
 cells, number and condition; crystals; 
 
— 33 — 
 
 casts, number and kinds (urates ; uric 
 acid ; calcium oxalate ; phosphates ; car- 
 bonates) ; cylindroids ; spermatozoa ; bac- 
 teria, number and kind (tubercle-, smeg- 
 ma-) ; protozoa ; animal parasites ; 
 embryos ; ova. 
 
 23. Blood. ' Complete blood chemistry. 
 
 27. Functional tests. Phenol-sulphone-phtha- 
 lein; lactose; sodium chloride; potas- 
 sium iodide ; concentration diuresis. 
 
 Special examinations. Pyelograms. Skia- 
 grams for calculi. 
 
 VII. DISEASES OF THE NERVOUS 
 SYSTEM. 
 
 {. Family history. Careful investigation of 
 family history for nervous and mental 
 diseases. Congenital abnormalities. 
 "Nervousness" (peculiarities of^ ; neu- 
 rasthenia ; epilepsy ; insanity ; drunken- 
 ness ; syphilis ; suicide (assigned cause) ; 
 deaf mutism ; precociousness ; brilliancy ; 
 talents ; eccentricities ; marriage of blood 
 relations. Health of latter. Effect of 
 narcotics and alcohol. History of rapid 
 success ; failures ; disappointments. 
 
 4. In women. Full history of menstruation ; 
 pregnancy ; abortion ; confinement ; puer- 
 peral disease; pelvic disease. 
 
— 34 — 
 
 5- Injury or disease at birth. (Birth palsy) ; 
 convulsions; syphilis; dentition; closure 
 of fontanelles ; growth; time of begin- 
 ning to walk ; symptoms at puberty and 
 early adult life; accidents; injuries: sen- 
 ility (symptoms) ; headache ; apoplexy ; 
 epilepsy; paralysis. 
 
 Temperament ; disposition ; change of dis- 
 position (often noticed by others than 
 patient or relatives) ; extravagance in 
 plans or expenditure. 
 
 6. Occupation and Habits. School history; 
 
 Overwork; exercise; rest. Use of pois- 
 ons and narcotics, especially alcohol, 
 morphine, heroin, chloral, cocaine, ether. 
 
 7. Sexual Life. Often essential to investigate 
 
 closely. Masturbation ; sexual excesses ; 
 perversions ; failure of sexual power. 
 
 8. Present disease; repressed desires; moral 
 
 or physical shock. Business cares, over- 
 exertion, fright. 
 
 9. 10. Under Course and Present Symptoms 
 
 describe symptoms in sequence. Note : 
 Pain, location and character; pain on 
 pressure ; hyperesthesia ; hyperalgesia ; 
 radiation of pain; e. g., in trigeminal 
 neuralgia; sinusitis; otitis media; reflex 
 symptoms, as cough in irritation of pos- 
 terior portion of Eustachian tube, pain 
 in back on aspiration of foreign body, 
 polyesthesia in spinal cord disease; 
 
— 35 — 
 
 hyperesthetic zones; anesthesia; pares- 
 thesia (numbness, formication) ; tics ; 
 tremors; tetany; spasmophilia; contrac- 
 tions, fibrillary; contractures; convul- 
 sions, tonic, clonic; epilepsy; hysteria; 
 catalepsy; aura; paralysis (details) ; loss 
 of memory; alterations of sleep; disturb- 
 ance of vision ; double vision ; tinnitus 
 aurium ; dysphagia ; disturbance of 
 speech ; vomiting- (details) ; gastric 
 crises. 
 
 Subjective Sensations. 
 
 a. Referable to face or extremities, ting- 
 ling, etc. 
 
 b. Vision (colors, rotation of person or 
 surrounding objects. Side from which 
 appear objects, persons, etc. Dizzi- 
 ness. 
 
 c. Hearing. 
 
 d. Taste. 
 
 e. Smell. 
 
 f. Dreamy states. 
 
 Upper Extremities. Loss of power or par- 
 tial paralysis. 
 Changes in sensation. 
 Tremors; changes in nails; unusual per- 
 spiring. 
 
 Abdomen. Bladder or rectal symptoms. 
 Paradoxical incontinence ; retention ; 
 true incontinence. 
 
-36- 
 
 Lower Extremities. Loss of power, change 
 in sensation. 
 
 Tremors, changes as above. 
 Gait, tendency to fall, and how. 
 
 13. Body in general. Abnormalities and defor- 
 
 mities ; stigmata. Trophic changes in 
 bones' and joints. 
 
 14. Under mental condition describe fully 
 
 whether mind is clear or clouded ; exalted 
 or depressed ; coma ; stupor ; delirium (d. 
 of grandeur) ; present disposition ; atten- 
 tion ; memory; lethargy; narcolepsy. 
 
 Speech. Anarthria ; aphasia. 
 
 Writing (voluntary, by dictation and copy- 
 ing)- 
 
 Gross Localization. Cerebral cortex. Par- 
 alysis, flaccid, spastic; describe localiza- 
 tion ; cutaneous sensibility ; muscle 
 sense: astereognosis; visceral sensa- 
 tions. Spasm, Jacksonian epilepsy. 
 
 Centrum semiovale. — Paralysis ; sensory 
 disturbance ; aphasia ; neighborhood 
 symptoms: distal symptoms; shock 
 symptoms. Diaschisis. 
 
 Corpus striatum. — Wilson's disease : paral- 
 ysis agitans ; Huntington's chorea. 
 
 Corpus callosum. — Apraxia. 
 
 Thalamus. — Thalamic syndrome ; hemian- 
 opsia. 
 
— 37 — 
 
 Internal capsule. — Hemiplegia ; hemianes- 
 thesia. 
 
 Crura. — Spastic paralysis ; crossed paraly- 
 sis ; Weber-Gubler syndrome ; hemianop- 
 sia : ataxia ; disturbance of hearing ; 
 oculo-motor paralysis; NothnageFs syn- 
 drome. 
 
 Corpora quadrig-emina. — Pupillary reac- 
 tion ; auditory disturbance ; mastication 
 affected; ataxia. 
 
 Pons and Medulla. — Crossed paralysis ; 
 motor or sensory ; spastic paralysis ; 
 abducens or hypoglossus paralysis ; 
 anarthria; deglutition disturbance; con- 
 jugate paralysis of eyes; dissociated sen- 
 sory disturbance ; tetraplegia. 
 
 Cerebellum. — Ataxia ; hypotonia ; asthenia ; 
 volitional tremor ; vertigo ; disturbance 
 of equilibrium; nystagmus. Rebound 
 phenomenon ; adiodochokinesis ; point- 
 ing test ; attitude ; gait ; ocular disturb- 
 ance ; atonia ; asthenia ; astasia. 
 
 Hypophysis. Signs of hypo- or hyperpi- 
 tuitarism. Bone changes of hands, feet 
 or face, teeth, palate ; bitemporal blind- 
 ness ; skin ; genitals ; hair on body ; adi- 
 posity; sugar tolerance, alterations of. 
 
 Skin. Scars as evidence of syphilis. Skin, 
 color of ; local alterations of color and 
 temperature ; visible mucous membranes, 
 color ; local cyanosis and congestion ; 
 
-38- 
 
 sweating; glossy skin; scaly skin; exan- 
 themata ; edema ; hemorrhage ; pigmen- 
 tation ; atrophy ; ulceration. Nails : 
 lunula ; surface ; thickness ; brittleness. 
 
 i6. Head. Shape of head in detail. Pain ; pain 
 on pressure or tapping. Auscultation. 
 Face. Symmetry of halves. Forehead, 
 wrinkles of, symmetry. Twitching. 
 
 Cranial Nerves. 
 
 Nose. Nostrils; nasolabial folds. 
 
 I. Smell (both sides). 
 
 Eyes. Lids, motion of ; tension of bulb ; 
 motion of eyes, up, down, left, right; 
 convergence ; nystagmus. Pupils : diam- 
 eters ; reflexes to light and accommoda- 
 tion. Ophthalmoscope. Color sense. 
 Tears. 
 
 II. Vision and color fields, scotoma; 
 hemianopsia. 
 
 Ill, IV, VI. Ocular movements ; diplo- 
 pia. 
 
 V. Sensory. Sensation of face and cor- 
 nea. 
 Motor. Mastication. 
 
 VII. Atrophy or paralysis ; herpes ; 
 sweat, anomalies of; conjunctivitis. 
 
 Ears. Hearing; aural speculum. 
 
 VIII. Cochlear. Bone and air conduc- 
 tion. Vestibular. Rotation tests. 
 Caloric tests. Barany test; 
 
— 39 — 
 
 Mouth, Straight or crooked; movements 
 of lips, as in AvhistHng-; laughing; blow- 
 ing ; chewing. Teeth. 
 IX. Taste. 
 
 Vault of Palate. Saliva. 
 X. 
 
 Soft Palate. Velum. Laryngoscope in 
 case of alterations of voice; laryngeal 
 muscles ; tumors ; ulcers. 
 
 Tongue. Position, protrusion ; atrophy ; 
 hypertrophy ; tremor ; fibrillary tremor. 
 XL Sternomastoid ; trapezius. 
 XIL Movement of tongue. 
 
 Movements of neck : to right ; left ; nod- 
 ding; turning; resistance of neck; stiff 
 neck. Vertebrae, cervical; tenderness; 
 deformity. Thyroid gland : Atrophy, 
 goitre. 
 
 Thorax. Dorsal and lumbar vertebrae ; 
 shape: rigidity; pain on pressure. 
 
 (a) Special examination of muscles and 
 nerves. 
 
 Shoulder. Nutrition. Scapulae, position. 
 Arms and hands, nutrition ; position 
 (drop wrist) ; thenar and hypothenar 
 eminences ; interosseous muscles. 
 
 Motor power of arms. Raising shoulders. 
 
 Arms. Rotating arms; Forearm: Flex; 
 extend ; pronate ; supinate. 
 
— 40 — 
 
 Hands and fingers. Flex and extend ; 
 spread lingers. Hypotonus ; hypertonus. 
 
 Thumbs. Movements. Grip : Both hands. 
 Ataxia ; finger-nose test ; finer coordina- 
 tion movements. 
 
 Thighs. Flex, abduct; adduct; rotate. 
 
 Legs. Nutrition ; position ; trochanters. 
 Leg : flex, extend. Power of walking. 
 
 Feet. Flex, extend. Toes, same. 
 
 Complicated movements. Ataxia; tremors, 
 kind ; equilibrium with eyes closed ; 
 walking with eyes open and closed; 
 Motion of legs while lying, with eyes 
 open and closed ; crossing legs ; walking 
 movements : heels on opposite knees ; 
 describe circles with leg. 
 
 Hands. Touch nose, chin and forehead. 
 Writing. 
 
 Electric examination of motor nerves and 
 
 muscles : see text-books on diagnosis. 
 . Palpation and percussion of nerve-trunks. 
 
 Sensation, objective tests. Gentle touch ; 
 moderate touch ; pinching ; pricking ; dif- 
 ference between point and head of pin ; 
 electric current. Temperature; deep 
 sensation ; point sensation. 
 
 Pressure. Cold and heat. Localization of 
 sensations. Stereognosis. Muscle sense 
 (weights) . 
 
 Passive motion. 
 
41 
 
 Reflexes. Skin and mucous membrane ; 
 sole ; palm ; cremaster ; abdomen ; eye- 
 lid ; sclerae ; palate ; tendon and perios- 
 teum; patellar; Achilles; foot-clonus; 
 Babinsky; Oppenheim; Gordon; Chad- 
 dock; adductors; biceps; triceps; jaw. 
 
 Kernig's sign; Brudzinski. 
 
 Abdomen. Shape (retraction in meningi- 
 tis) ; reflexes ; sensation. 
 Rectum. Paral3^sis. 
 
 Genito-urinary. Examine bladder ; incom- 
 tinence ; retention ; frequent micturition. 
 
 Spinal puncture. Pressure ; appearance. 
 Microscopic : Cells, number and kind ; 
 bacteria, other organisms. Wasser- 
 mann. 
 
 Chemical. Globulin; sugar; colloidal gold 
 curve. 
 
 Special Examination. Mental tests ; ven- 
 tricular puncture; skiagram; injection of 
 air in ventricles. 
 
 Cystoscopic (neurogenic bladder). 
 
— 42 — 
 
 SCHEME FOR THE EXAMINATION 
 OF SENSIBILITY. 
 
 (After Head and Holmes.) 
 
 A. Spontaneous Sensations, 
 
 Pain, numbness, tingling. 
 
 Position of the limb. Idea of the limb. 
 
 B. Loss of Sensation. 
 
 1. Touch. 
 
 (a) Light touch. 
 
 Cotton-A^'ool on hairless and hair-clad 
 
 parts. 
 Threshold with von Frey's hairs. 
 
 (b) Pressure touch. 
 
 Threshold with the pressure-aesthe- 
 
 siometer. 
 
 2. Localization. 
 
 Naming the part touched. 
 Henri's method, as miodified by Head and 
 Holmes. 
 
 3. Roughness. 
 
 Threshold Avith Graham-Brown's aesthe- 
 siometer; sand-paper tests; discrimina- 
 tion of relative roughness. 
 
 4. Tickling and scraping. 
 
 Tickling on soles and palms. 
 Cotton-wool rubbed over hair-clad parts. 
 Light scraping with the finger nails. 
 
— 43 — 
 
 5- Vibration. 
 
 Loss or diminution of sensibility. 
 
 Alteration in the character of the sensa- 
 tion evoked. 
 
 6. Compasses. 
 
 Points simultaneoiisly,applied. 
 Points successively applied. 
 
 7. Pain. 
 
 (a) Superficial pain. 
 Pin-prick. 
 
 • Threshold with the algesimeter. 
 Reaction to measured painful stimuli. 
 
 (b) Pressure pains. 
 
 Threshold with the algometer. 
 Reaction to painful pressure. 
 
 8. Temperature. 
 
 Threshold for heat and cold. 
 
 Effects of adaptation on the threshold. 
 
 Discrimination of different degrees of heat 
 and cold. 
 
 Affective reactions (a) to extreme degrees; 
 (b) to warmth. 
 
 9. Positions. 
 
 By imitating with the sound limb the posi- 
 tion of the aff'ected limb. 
 
 By pointing with the sound limb. 
 
 Measurement of defect by Horsley's 
 method. 
 
— 44 — 
 
 10. Passive Movement. 
 Appreciation of movement. 
 Recognition of direction of movement. 
 Measurement of the angle of the smallest 
 
 movement which can be appreciated. 
 Falling away of the unsupported limb 
 when the eyes are closed. 
 
 11. Active Movement. 
 
 Imitation of movement by sound limb. 
 Ability to touch known spot. 
 Measurement of the defect by Horsley's 
 method. 
 
 12. Weight. 
 
 (a) With the hand supported : 
 Recognition of differences in weight 
 
 applied successively to one hand. 
 Appreciation of increase or decrease 
 
 of weight. 
 Comparison of two weights placed 
 
 one in each hand. 
 
 (b) With hand unsupported : 
 Comparison of two weights placed one 
 
 in each hand. 
 Recognition of differences in weights 
 applied successively to one hand. 
 
 13. Size. 
 
 Difference-threshold. 
 
 Distinction of the head from the point of 
 pin. 
 
— 45 — 
 
 14. Shape. (Two-dimensional.) 
 
 15. Form. (Three-dimensional.) 
 Recognition of common objects by their 
 
 form. 
 
 16. Texture. 
 
 17. Dominoes. 
 
 Ability to count points by touch. 
 
 18. Consistence. 
 
 19. Testicular sensibility. 
 
 Light pressure. 
 Painful pressure. 
 
 20. Sensibility of the glans penis. 
 
-46- 
 
 ROUTINE WARD AND LABORATORY 
 WORK IN MEDICAL WARDS. 
 
 All Patients — on Admission. 
 
 1. Complete history as per outline, 
 
 2. Physical examination. 
 
 3. Red blood count ; white blood count. 
 Hemoglobin estimation. 
 
 4. Blood for Wassermann. 
 
 5. Urine analysis. 
 
 6. Stool examination. 
 
 7. Sputum examination (all sputum must 
 be examined). 
 
 8. Blood pressure ; on leg also if high pres- 
 sure. 
 
 9. Phenol-sulphone-phthalein. 
 
 The above must be completed on each case 
 before Medical Rounds at 9 a. m. the m.orning 
 following admission to the hospital. 
 
 Special Cases. 
 
 Typhoid Fever. 
 
 1. AVhite blood count every other day, or 
 oftener if indicated. 
 
 2. Red blood count once a week. 
 
 3. Hemoglobin once a week and at once on 
 suspicion of hemorrhage. 
 
 4. Urine analysis every day (diazo, acetone 
 bodies). 
 
— 47 — 
 
 5- Blood pressure every day, and at once on 
 suspicion of perforation or heniorrha2:"e. 
 
 6. Stools. First stools and all suspicious 
 stools must be sent to laboratory and exam- 
 ined. (Infectious — handle with care.) 
 
 7. Blood, stool and urine cultures and Widal 
 test by laboratory staff; note results. 
 
 8. Fluid intake and output charts. 
 
 9. Food calories daily. 
 
 Pneumonia. 
 
 1. White blood count every day. 
 
 2. Red blood count once a week. 
 
 3. Hemoglobin once a week. 
 
 4. Urine analysis every day (quantitative 
 chloride). 
 
 5. Blood pressure every day (systolic, dias- 
 tolic) (a. m. and p. m.). 
 
 6. Sputum and sputum cultures and typing 
 by laboratory staff; note results. 
 
 Malaria. 
 
 1. Blood examination every day (concen- 
 tration method). Fresh and stained specimens. 
 All blood smears (stained) must be carefully 
 labelled with patient's name, date, diagnosis, 
 and given to Ward Doctor. 
 
 2. White blood count daily during fever and 
 twice a week at same time of day. 
 
 3. Red blood count daily during fever and 
 twice a week. 
 
-48- 
 
 4- Hemoglobin twice a week. 
 
 5. Blood pressure daily during fever and 
 twice a week, 
 
 6. Urine analysis twice a week ; daily, it 
 abnormal. 
 
 Diabetes. 
 
 1. Red blood count once a week. 
 
 2. White blood count once a week. 
 
 3. Hemoglobin once a week. 
 
 4. Urine analysis every day. 
 
 (a) Keep a chart of quantitative sugar 
 output. Grams per liter. Per cent. 
 
 (b) Total output (grams) per 24 hours. 
 
 (c) Acetone ; diacetic acid ; beta-oxybuty- 
 ric acid. 
 
 (d) Total N determination (D :N ratio). 
 
 (e) Microscopic examination of urinary 
 sediment. 
 
 5. Keep chart of special dietary measures, 
 with daily special laboratory findings. 
 
 6. Alveolar air and blood CO^ by staff of 
 Chemical Laboratory. 
 
 Pulmonary Cases. 
 
 1. Red blood count once a week. 
 
 2. White blood count once a week. 
 
 3. Hemoglobin once a week. 
 
 4. Blood for complement fixation. 
 
 5. Urine examination twice a week; daily, if 
 abnormal. 
 
— 49 — 
 
 6. Sputum examination every day. Note 
 amount. 
 
 (Elastic tissue, Tbs., pneumococci, influenza 
 bacilli. Dark field for spirochetes.) 
 
 7. Examination of pleural fluid, whenever 
 obtained. 
 
 (a) Amount, character, specific gravity. 
 Albumin (quantitative). 
 
 (b) Cytological examination in citrate 
 specimen. Culture. Inoculation. 
 
 8. Tuberculin tests only when ordered. 
 Preserve slides, carefully labelled, with 
 
 patient's name and date, and give to Ward 
 Doctor. 
 
 Also set aside 50 cc. of fluid for special exam- 
 ination. Add small amount of toluol for pres- 
 ervation. 
 
 Gastro-Intestinal Cases. 
 
 1. Red blood count once a week, 
 
 2. White blood count once a week. 
 
 3. Hemoglobin once a week. 
 
 4. Differential count (500 cells) as re- 
 quested. 
 
 5. Stool — careful examination of each speci- 
 men sent to clinical laboratory. 
 
 6. Examination of contents of fasting stom- 
 ach. (First examination by Ward Doctor.) 
 
 7. Test meals. Analysis, as requested. Spe- 
 cial chart. 
 
 8. Duodenal and bile tests. 
 
— 50 — 
 
 Cardio-Nephritic Cases. 
 
 1. Cardio-renal charts; pulse deficit chart. 
 
 2. Red blood count once a week. 
 
 3. White blood count once a week. 
 
 4. Hemoglobin once a week. 
 
 5. Blood pressure every day. 
 
 6. P. S. P. and N. P. N. as ordered. 
 
 7. Daily urine examination (separate day 
 
 and night specimens). 
 
 (a) Careful microscopic examination 
 (cells, casts, crystals). 
 
 (b) Quantitative albumin estimation 
 every day (Esbach, Tsuchiya's rea- 
 gent). 
 
 (c) Special examination in chemical lab- 
 oratory. Note results daily. 
 
 8. Stool examination (whenever specimen is 
 sent to clinical laboratory). 
 
 9. Tracings to be taken by Ward Doctor. 
 
 10. Electrocardiograms and special vital 
 capacity tests by Heart Station. 
 
 Blood Cases. 
 
 Anemias ; leukemias ; Hodgkin's dis- 
 ease ; polycythemia. 
 
 1. Red blood count; white blood count; 
 hemoglobin estimation; color index. 
 
 2. Differential count (500 cells). 
 
 3. Fresh and stained blood smears (as 
 ordered by Ward Doctor). 
 
— 51 — 
 
 4- Vital stains ; fragility ; peroxidase : coag- 
 ulation time; bleeding time, platelets. 
 
 All blood smears (stained) must be carefully 
 labelled with patient's name, date, diagnosis, 
 and given to Ward Doctor. 
 
 5. Grouping. (Always to be controlled in 
 biologic laboratory.) 
 
 6. Gastric analysis. 
 
 7. Duodenal contents ; pigment. 
 
 8. Urine analysis twice a week. (Occur- 
 rence of urobilin or urobilinogen.) 
 
 9. Stool examination (parasites, blood). 
 
 Ductless Gland Cases. 
 
 1. Pharmacologic tests by expert; keep 
 notes. 
 
 2. Sugar tolerance in chemical laboratory. 
 Note. 
 
 3. Basal metabolism in chemical laboratory. 
 Note. 
 
 4. Photographs and x-rays. 
 
 Neurological Cases. 
 
 Complete medical routine. 
 Special neurologic examination. 
 Lumbar puncture only as ordered. 
 
 DIAGNOSIS AND CONTINUATION. 
 
 Tentative diagnosis should be written as 
 soon as made, beginning with the end of the 
 anamnesis. All positive diagnoses, including 
 
those of consultants, are to be written in the 
 space designated on the front history sheet. 
 Daily notes should include subjective symp- 
 toms, physical, laboratory and special exam- 
 ination, requests for consultations, all prognos- 
 tic statements to patients or others, and all 
 therapeutic measures, with statements as to 
 effects. Orders other than routine and diag- 
 nostic procedures should be entered in the front 
 sheet, under "Remarks," when ordered, and 
 results entered, briefly, when made, with date. 
 
 All laboratory findings are to be charted on 
 history same day as examination is made. 
 Report all unusual findings to Ward Doctor 
 at once. 
 
 All unknown objects must be shown, also all 
 positive specimens. 
 
— 53 — 
 
 ABBREVIATIONS PERMITTED. 
 
 General. 
 
 R. =z= right. 
 L. = left. 
 
 C. C. = chief complaint. 
 F. H. = family history. 
 M. = mother ; f. = father ; s. = sister ; b. = 
 • brother. Number for order of birth; i. e., 
 bi, b2, SI, etc. 
 1. = living; w. = well ; d. = dead. 
 Numbers only in Arabic figures. 
 P. . I. = present illness. 
 P. S. = present symptoms. 
 S. P. = status praesens. 
 
 Head. 
 
 m. m. =mucous membrane. 
 L. and Ace. ■= Ijght and accommodation. 
 (Reference to reaction of pupils.) 
 
 Thorax. 
 
 Lungs — 
 
 V. F. = vocal fremitus. 
 B. S. = breath sounds. 
 P. N. t= percussion note. 
 W. = whisper. 
 S. V. = spoken voice. 
 
 Heart — 
 
 P. M. I. = point of maximal impulse. 
 
 M. S. L. = mid-sternal line. 
 
 I. C. S. = intercostal space. 
 
 R. C. D.^= relative cardiac dulness. 
 
 A. C. D. = absolute cardiac dulness. 
 
— 54 — 
 
 Ao = aortic second sound. 
 P2 = pulmonic second sound. 
 EKG. = electrocardiogram. 
 
 Pulse — 
 
 f . and r. ^ force and rhythm. 
 y. AV. = vessel wall. 
 B. P. = blood pressure. 
 
 Abdomen. 
 
 R. M. = respiratory movement. 
 
 R. H. D. = relative hepatic dulness. 
 
 R. I. F. = right iliac fossa. 
 
 L. I. F. = left iliac fossa. 
 
 M. L. = mid line. 
 
 A. S. S. = anterior superior spine. 
 
 Extremities. 
 
 K. K. = knee kicks (jerks). 
 
 Dr. J. J. Singer's Symbols for Physical Signs 
 in Lungs. 
 
 B. S.++ = i^^ormal breath sounds. 
 B. S.-j- = decreased breath sounds. 
 
 B. S. + + + or more, increased breath 
 
 sounds. 
 W. S.+ ^ normal whisper. 
 W. S.++ ^increased whisper, etc. 
 W. S. — = absent whisper. 
 M. S. = muscle spasm ; -f- marks to indi- 
 
 cate degree. 
 
 ////// = impaired resonance. 
 = dulness. 
 = flatness. 
 
 %Go^Oo = rales. 
 

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