COLUMBIA LIBRARIES OFFSITE 
 
 HEALTH SCIENCES STANDARD 
 
 HX64146812 
 RC61 .W24 The student's guide 
 
 RECAP 
 
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G. L. PEABODY 
 
THE STUDE^S'T'S GUIDE 
 
 TO 
 
 CLINICAL MEDICINE 
 
 AND 
 
 CASE-TAKING 
 
 BY 
 
 FKAXCIS WARXER, M.D. Lond., F.RC.P. 
 
 ASSISTANT PHYSICIAN, LECTURER ON BOTANY, AND LATE MEDICAL REGISTRAR TO THE 
 LONDON HOSriTAL; LATE PHYSICIAN TO THE EAST LONDON HOSriTAL iOR CHILDREN 
 EXAMINER TO THE UNIVERSITY OF ABERDEEN 
 
 SECOND EDITION 
 
 PHILADELPHIA 
 
 P. BLAKISTON, SON & CO. 
 
 1012, WALXUT STREET 
 
 1885 
 
INTKODUCTIOX TO SECOND EDITION 
 
 FuRTHEE experience gained since the publication of the former 
 edition, has shown that students commencing clinical work 
 need to be taught to think, and reason for themselves, as well as 
 to observe. It is hoped that the plan of this work tends to 
 give such training if properly used. 
 
 The size of this work has not been increased, but new 
 material has been added, and corrections have been made in 
 accordance with the advances of clinical medicine, especially in 
 the chapter on diseases of the nerve-system. A special scheme 
 for taking notes of children has been added, and the index has 
 been made more complete. 
 
 F. W. 
 24, Harley Street, W. 
 
 December, 1884. 
 
miKODUCTIOX TO FIRST EDITION. 
 
 DuEiNG the three years that I held the office of Medical 
 Registrar to the London Hospital, I saw that the student, on 
 commencing his duties as clinical clerk, required some guide 
 as to the method of arranging the history of his case, and the 
 facts observed. A card of "instructions for case-taking" 
 was provided, almost similar to that given at page xi. It was 
 further evident that with each case the student needed, when 
 taking his cases, to be told what special points to note iu 
 the history, and what special points to look to under each 
 of the heads of the "instructions." Further, zeal was much 
 stimulated in the thoughtful student by telling him why these 
 special points should be enquired for, and their presence or 
 absence noted. 
 
 Such points, with regard to the more commonly recurring 
 diseases, have been put together, and presented in the 
 following pages. 
 
 The object has been to provide, in a small space, a guide for 
 the student to use at the bedside, when wanting to know 
 what to look for, and what to note. Pathology and treatment 
 are not touched upon, and for this reason, independent of 
 the general incompleteness of this little work, the student 
 is recommended to read, in some text-book, all about his 
 case in hand. Much attention has been given to the special 
 conditions met with in disturbance and disease of the nervous 
 system. 
 
vi INTRODUCTION. 
 
 To encourage enquiry as to the origin of disease, the 
 principal causes in each case are indicated under the heading 
 "causation," which will usually be found on the left-hand 
 page, sometimes on the right-hand ; thus the student may find 
 his enquiries directed on reasonable grounds. As to the scheme 
 of the work, as far as possible the facts indicated as specially 
 to be observed are arranged under the ordinary heads of a case 
 on the left-hand page, and on the corresponding right-hand 
 page are given explanations, characters of the special disease, 
 or points of interest in its natm'al history, etc. This plan 
 could not in all cases be adhered to, and general convenience 
 and the necessities of printing had then to take precedence of 
 the original scheme. 
 
 Names printed in the text in thick type are heads of chapters 
 contained in the work, which may be found on reference to the 
 index. Thus, in taking a case of fever, look for "Signs of 
 Fever," and if Vomiting or Jaundice be present look up these 
 heads by means of the index. 
 
 F. W. 
 
 24, Harley Street, W. 
 1881. 
 
CONTENTS. 
 
 TAVrV. 
 
 Instructions for Case-taking .... xi — xiii 
 
 Additional Instructions for Children's Cases xiv, xv 
 
 Table Showing Healthy Development of an 
 
 Infant xvi 
 
 General Diseases — Class I. 
 
 Common bad Hygienic Conditions — Signs of Fever — 
 Table of the Specific Fevers : Enteric Fever ; Typhus ; 
 Scarlet Fever ; Measles ; Variola ; Varicella — Erysipelas 
 — Diphtheria — Pyaemia — Puerperal Fever — Ague — 
 Hooping-cough — Syphilis, inherited ; Syphilis, acquired 1 — 17 
 
 General Diseases — Class IL 
 
 Signs of Defective Development — Anaemia ; Pernicious 
 Anaemia — Cancer — Rickets— Emaciation — (Edema or 
 Anasarca — Amyloid Degeneration — Scrofulosis : General 
 Miliary Tuberculosis — Table of Differences and Resem- 
 blances between Enteric Fever and Tuberculosis — 
 Diabetes Mellitus — Addison's Disease — Purpura — De- 
 velopmental Defects — Senile Degeneration . , .19 — 33 
 
 Arthritic Diseases. 
 Arthritis — Rheumatoid Arthritis — Table of Joints for 
 Description — Rheumatism ; Gqaiorrhceal Rheumatism — 
 Gout 34-39 
 
Vni CONTEXTS. 
 
 Diseases of the Nervous System. 
 
 PAGE 
 
 General Conditions of the Xervous System — Intel- 
 ligence — Speech — Sleep — Head-pain — Headache — 
 Vomiting — Coma — Vertigo — Delirium — Typhoid State 
 — Paralysis — -Tendon Reflexes — Skin Reflexes — Table of 
 Diagnosis of Functional from Organic Paralysis — Elec- 
 tric Tests — Convulsion — Spasm — Laryngismus — Tremor 
 - Athetosis — Motor Power — Sensation — Muscular Anses* 
 thesia — Special Senses — Cranial Nerves — Bell's Paralysis 
 of the Face — Brain Disease — Ophthalmoscopic Appear- 
 ances — Pupils — Signs of Spinal Cord Disease — Minor Para- 
 lyses : Progressive Muscular Atroph}' ; Pseudo-hyper- 
 trophic Paralysis ; Paralysis of Extensors of Forearm ; 
 Cross Paralysis ; Bulbar Paralysis ; Paralysis of Face — 
 Neuralgia : Sciatica ; Intercostal Neuralgia — Hemiplegia 
 - — Chorea — Table of Diagnosis of Chorea from Sclerosis — 
 Hysteria ; Epilepsy ; Table of Diagnosis of Epilepsy 
 from Hysteria — Cerebral Tumour — Cerebral Meningitis — 
 Chronic Hydrocephalus — Table of Diagnosis of Hydro- 
 cephalus from Rickets— Alcoholism- —Acute Alcoholism — 
 Delirium Tremens — Insanity— General Paralysis of the 
 lasane— Paralysis Agitans — Sclerosis of the Cord — Te- 
 tailus — Locomotor Ataxy— Infantile Paralysis — Graves' 
 Disease — Plumbism — Diphtheritic Paralysis — Herpes 
 Zoster 40—101 
 
 Diseases of the Vascular System. 
 
 Physical Examination of the Heart : Pulse ; Passive 
 Congestion — Important Anastomoses — Table of Signs of 
 Valvular Lesions, Mitral Regurgitation and Obstruc- 
 tion ; Aortic Regurgitation and Obstruction ; Hj'per- 
 trophy and Dilatation of the Heart — Cardiac Displace- 
 ments — Valvular Disease — Heart Disease — Table of 
 Diagnosis of Functional from Organic Palpitation — Angina 
 Pectoris — Pericarditis — Congenital Defects of the Heart 
 — Tricuspid Regurgitation — Thoracic Aneurism — Disease 
 of Vessels .,,,,,,. 102—123 
 
CONTENTS. 
 
 Diseases of the Respieatory System. 
 
 PAGE 
 
 Clinical Regions of tlie Chest — Physical Examination 
 of the Chest — Auscultation — Cough — Sputum — Hemo- 
 ptysis ; Table of Diagnosis of Heemoptysis from Hiema- 
 temesis — -Dyspnoea — Pulmonary (Edema — Contraction of 
 Lung — Solidification of Lung — Table of Diagnosis of 
 Pneumonia from Pleuritic Effusion — Pleurisy; Em- 
 pyema ; Hydrothorax — Phthisis — Pneumonia — Em- 
 physema — Bronchitis — Asthma — Laryngeal Diseases. 124 — 149 
 
 Diseases of the Digestive System. 
 
 Signs of Digestive Functions : Appetite — Intestinal 
 Worms — Examination of the Mouth and Throat : 
 Tongue ; Palate ; Tonsils ; Pharynx ; Teeth ; Gums — 
 Diarrhcea — Vomiting — Acute Abdominal Pain — Dys- 
 phagia — Htematemesis — Meltena — Obstruction of the 
 Bowels — Gastric Ulcer — Typhlitis — Abdominal Cancer : 
 Cancer of Stomach ; Cancer of Intestines — Ulceration of 
 Bowels : Dysentery ; Tubercular Ulceration — Abdominal 
 Tumours : Ovarian ; Kidney ; Spleen ; Abdominal 
 Aneurism; Tumours arising from the Pelvis — Faecal 
 Accumulations — Phantom Tumour — Intussusception — 
 Examination of Abdomen — Fluid in Peritoneum — Dia- 
 gnosis of Ovarian Tumour from Ascites — Peritonitis . 150 — 173 
 
 Diseases of the Liver. 
 
 Jaundice ; Table of Causation ; Jaundice from Ob- 
 struction or Independent of Obstruction — Large Livers : 
 Lardaceous, Fatty, Hydatid — Cancer of the Liver — 
 Small Livers — Acute Yellow Atrophy — Cirrhosis of the 
 Liver — Syphilitic Disease of the Liver — Gall-Stones ; 
 Biliary Colic— Hydatid of Liver .... 174—18^ 
 
CONTEXTS. 
 
 Diseases or the Up.inary System. 
 
 PAGE 
 
 Bii^t's Disease — Uraemia — AlbtuaiiLiiria — Hsma- 
 tmia — ^Paroxysmal Haematuria — Acute Briglit's Disease 
 — GiamilaT Contracted Eidneys — Fatty Kidneys — Amy- 
 loid and Laige White Eidneys — Briglit's Disease, Acute 
 or Chroiiic — ^Disrases of the Bladder — Renal Calculus ; 
 Benal Colic — ^Description of Urine ; Examination of the 
 Deposit, ChemieaUj and Microscopically — Normal Con- 
 stitn^Lts of the Urine ; Abnormal Constituents j Albu- 
 men, Sngar, Bile, Leucine, Tyrosine — ^Urinarj'^ Calculi 
 —Mnrexide Test for Uric Acid . . . . 184—203 
 
 SlGXS OF PBEGlfAJfCY — COESrCIDENT SiGXS AXD 
 
 Symptoms ....... 204, 205 
 
 I>-DEX . 206—211 
 
INSTRUCTIO]S"S FOR CASE-TAKING. 
 
 I. Enter name, age, occupation, address, date of admission 
 to hospital, and date at which the notes were taken, 
 
 II. State what the patient complains of, as far as possible 
 using his own words. With children say what the friends 
 complain of, 
 
 III. Family History. — Number and condition of health of 
 those living. Ages and diseases of those dead. Specially 
 enquire as to points in the inheritance bearing on the case 
 and its causation. 
 
 Personal History. — Habits, occupations, residences, 
 previous illnesses and diseases. Indications of scrofula, 
 gout, rickets, syphilis, etc. Give dates. 
 
 History of Present Illness. — Date and manner of com- 
 mencement ; date when last at work. Order of the 
 occurrence of symptoms, with date. Indicate the day of 
 illness on the temperature chart. In taking this history 
 look up the causation and course of the disease as given 
 in the text. Probable causes. 
 
 IV. Present Condition. — General condition. Intelligence; 
 mental state ; sleep ; complaints of pain, etc. Nutrition ; 
 emaciation ; anaemia ; oedema ; complexion ; any specially 
 obvious abnormal condition or source of distress, etc. 
 Position of patient in bed ; orthopnoea ; dorsal decubitus ; 
 etc. Pulse = ; Temperature = ; Respirations = ; 
 Weight = . 
 
Xll INSTRrCTIOXS FOE CASE-TAKING. 
 
 Lymphatic Glands in neck, axilla, groins ; size, hardness, 
 mobility ; tendency to suppuration. 
 
 Locomotor System. — State of bones, muscles, joints, scars, 
 nodes. Skin, dry or moist ; bed-sores. 
 
 Y. l^ervous System. — General Condition. Intelligence ; 
 sleep ; speech. Vertigo ; head-pain. Delirium ; paralysis ; 
 convulsion ; tremor ; coma, etc. 
 
 Motor Foiver. — Ability to stand or work ; movements 
 of extremities ; gait in walking ; co-ordination of limbs. 
 Eeflezes, 
 
 Sensibility. — Tactile sensibility of skin ; sensibility to 
 beat and cold, also to pricking. Anaesthesia ; hyper- 
 ffistbesia ; dyssesthesia. Special senses. 
 
 Cranial Nerves. — Movements of eyes, tongue, palate, 
 face. State of pupils. Ophthalmoscopic examination. 
 
 YI. Vascular System. — Pulse, frequency and other characters ; 
 condition of the vessels, especially the arteries. Cyanosis. 
 Heart ; palpate, auscultate, percuss. ^STote precordial 
 dulness if normal. Palpitation, pain or signs of heart 
 disease. 
 
 YII. Respiratory System, — Dyspnoea, frequency and charac- 
 ters of the respiratory movements. Cough ; expectoration ; 
 hsemoptysis. 
 
 Physical Exariiination. — -Inspection; palpation; percus- 
 sion ; auscultation. Signs of bulging or contraction of 
 chest or solidification of lungs, etc. Larynx. 
 
 YIII. Digestive System. — Tongue; teeth; throat. Appetite ; 
 thirst. Vomiting ; haematemesis ; melaena. State of 
 bowels ; tenesmus ; griping ; piles. Fulness or pain after 
 food .; flatulence ; pyrosis ; colic or other disturbance. 
 Abdominal pain or tenderness, 
 
INSTP.rCTIOXS FOR CASE-TAKING. Xlll 
 
 ii ye /'.— Size and general characters as determined by 
 percussion and palpation : whether tender or not, 
 Jaundice. 
 
 Spleen. — Size as determined by percussion and pal- 
 pation. 
 
 Abdomen. — Physical examination. Whether tender, dis- 
 tended, retracted. Ascites. Tumour. 
 
 IX. Urinary System. — TJrine, quantity, colour, reaction, Sp. 
 gr. Albumen, bile, sugar. Deposit, its general, chemical, 
 and microscopical characters. Frequency of micturition ; 
 if accompanied by pain ; heematuria. 
 
 X. Generative System. — Menstraation : frec|uency ; duration ; 
 quantity increased or otherwise ; whether painful ; other 
 discharges. Conditions of uterus and pelvic organs. 
 
 XI. Treatment. — Prescriptions and diet, etc., should be 
 entered in the notes, and all alterations noted, with 
 the dates. 
 
 XII. Diagnosis. — Should enumerate the principal disease, 
 secondary lesions, complications and specially important 
 conditions, symptoms or points in the treatment. 
 
ADDITIONAL INSTRUCTIONS FOR 
 
 CHILDREN'S CASES. 
 
 II. State complaints made concerning the child, or obvious 
 conditions of disease. 
 
 III. Family History. — Number and condition of health of 
 those living. Ages and diseases of those dead. Specially 
 enquire as to the inheritance bearing on the case. 
 History of mother's health during the intra-uterine life of 
 the child. Note any miscarriages, Avith dates. 
 
 Personal History. — Whether healthy at birth ; how 
 brought up ; if suckled ; if farinaceous food has been used. 
 Previous illnesses, and diseases. 
 
 IV. Present Condition. — General condition: plumpness; skin 
 elastic, clear or muddy looking, with aged appearance. 
 
 Condition of Development. — Anaemic ; hsemorrhagic flea 
 bites ; sweating. Bones, feel them all while the child is 
 stripped. Signs of syphilis, rickets, etc. Note Avarmth 
 of the limbs ; whether the child sheds tears in crying. 
 T. = ; P. = ; R. = ; "W. = . Signs of 
 
 defective development. 
 
 V. Nervous System. — General condition. Note the amount 
 of movement of limbs, hands, and feet, or whether this is 
 absent. Intelligence, as indicated by movements of face 
 and eyes directed towards objects noticed. Sleep ; making 
 noises ; consciousness ; exhaustion ; coma. Paralysis ; 
 examine each limb. Spasm ; tremor ; contraction. 
 
ADDITIONAL INSTRUCTIONS FOR CHILDREN S CASEUS. XV 
 
 Motor Power. — Reflex action on tickling hands, putting 
 finger in mouth, etc. Playfulness ; ability to laugh. 
 Power over large joints, small joints, movements of 
 fingers, etc. 
 
 Cranial Nerves. — Movements of eyes and face. 
 
 Head. — Its shape and circumference. Fontanelle is 
 patent, prominent, or depressed. State of other sutures. 
 Ophthalmoscope. 
 
 VI. Vascular System. — Pulse : frequency and character. 
 Cyanosis. Heart : palpate, percuss, auscultate. 
 
 VII. Respiratory System. — Dyspnoea; frequency of respiratory 
 movements ; laryngeal stridor, spasm, or obstruction. 
 Warmth or coldness of breath. Cough. 
 
 Physical PIxamination. — Inspection ; signs of collapse 
 at bases and clavicular regions. [To examine back, let 
 child be held leaning over nurse's shoulder.] Palpation ; 
 rhonchi may sometimes be felt. Percussion. Aus- 
 cultation. In children, and especially infants, the feeling 
 of resistance of lung, or its elasticity beneath the finger 
 struck, gives valuable information as to its consolidation or 
 clearness. 
 
 VIII. Digestive System, — Tongue, lips, throat ; state of den- 
 tition. Appetite and liking for food ; how it is fed. 
 Vomiting. State of bowels. Abdomen : whether full or 
 empty ; palpate ; note size of liver and spleen. State of 
 umbilicus. Pain after food ; flatulence ; abdominal ten- 
 derness ; griping of bowels. Test milk used for cream and 
 acidity. 
 
 ' In examining an infant, it is necessary to determine if 
 it be well developed. See Developmental Defects. 
 
 The child should be weighed, and the circumference of 
 the head, at its longest, should be measured. 
 
XVI ADDITIONAL IX.STIiUCTlON.S FOR CHILDREN" S CASES. 
 
 Tlw fulloicing Table is for a licalthy well-developed infant of 
 good-class : — 
 
 Infant at birth -weighs six to ten pounds ; head circum- 
 ference, 11 "15 — 12'5 inches. 
 
 S« I Points indicating Stage and Progress of 
 M s i Development. 
 
 I. 
 
 II. 
 
 III. 
 
 lbs. j ins. j 
 
 7tolOj 14 "5 I Power to suck; regular succession of feeding and 
 
 sleeping ; hand reflex. 
 11 "0 15*25 ' Hair in eyelashes and eyebrows ; may be occasional 
 
 strabismus. 
 13-5 16-5 Capability of shedding tears ; no strabismus. 
 
 IV. 15*0 I 17"0 Constant movement while awake. 
 
 V. j 15*5 I 17"0 Turning head to a light or sound. 
 
 t ! 
 
 VI. I 16*0 1 17 "25 Pi.ecognizing objects, as mother, nurse. 
 
 VII. ! 17*5 j 17"5 Holding object in hand, and carrying it to mouth. 
 
 VIII. ! 18 "5 ; 17 '75 Various sounds made ; commencing dentition. 
 
 IX. 19"5 \ IS'O Some power to hold up head Avhen lying do-^^Ti. 
 
 X. i 19'6 18'25 Holding an object without dropping it. 
 
 XI. I 19'7 i 18"4 ' Power to transfer object from one hand to the other. 
 
 j I 
 
 XII. 20"0 18*5 i Commencing to crawl or stand with assistance. 
 
THE 
 
 STUDENT'S GUIDE TO CLINICAL MEDICINE. 
 
 GENEKAL DISEASES— CLASS I. 
 
 Specific diseases caused by semie poison received by tJie 
 patient from without, andj in many cases communicable from 
 one patient to another. 
 
 COMMON BAD HYGIENIC CONDITIONS. 
 
 Drawing drinking-water from a cistern over w.c. 
 
 Overflow pipe from a cistern opening into a sewer or soil-pipe 
 instead of into open air. 
 
 Drain from a kitchen sink opening direct into a sewer or cess- 
 pit instead of into open air over a drain. 
 
 Want of proper traps cutting off house-sewer from street-sewer, 
 and each soil-pipe from house-drain. 
 
 Want of ventilation of house-drains and soil-pipes, with 
 arrangements for access of air into them, and exit of sewer- 
 gas from them, may cause foul smells. 
 
2 CLINICAL MEDICINE AND CASE-TAKING. 
 
 FEVER, SIGNS OF. 
 
 General condition. — Temperature raised ; respirations and pulse 
 frequent ; skin diy and hot, or sweating ; rigors ; fever: 
 pains ; acMng in back and limbs ; prostration of muscular 
 power ; face presents depressed look. P, = ; T. = ; 
 R. = . 
 
 Mode of onset. — Sudden, with rigors, headache, pains in back 
 and limbs ; gradual, with anorexia and thirst, loss of 
 strength. 
 
 Digestion. — Anorexia ; thirst ; bowels confined or relaxed ; 
 describe the motions passed. Tongue furred, dry, or 
 moist ; papillse may be enlarged. State of gums ; teeth. 
 Throat ; tonsils. Vomiting, Spleen may be enlarged. 
 lAver, see Jaundice. 
 
 Vascular system. — Pulse frequent, soft, may be dicrotous and 
 intermittent. Heart's action quick ; note strength of 
 impulse and first sound. Tendency to capillary con- 
 gestion. 
 
 Respiratory system. — Respirations frequent ; tendency to con- 
 gestion of the lungs. Pulmonary (Edema; Bronchitis; 
 Pneumonia; Pleurisy. 
 
 Nervous system. — Mental condition, see general condition of 
 Nervous System. Sleep ; Headache ; Delirium ; Typhoid 
 State. 
 
 Urine. — Scanty. Sp. gi". high. Commonly a deposit of 
 Lithates. It may be jaundiced or albuminous. Urea may 
 be in excess. 
 
 Look for rash and the characters of the Specific Fevers ; local 
 and general complications. 
 
GENEKAL DISEASES — GLASS I, 
 
 FEVER, SIGNS OF. 
 
 General condition. — An exanthematous fever does not often 
 recur in the same individual. The date and mode of onset 
 are important, so also whether sudden or gradual, with 
 or without rigors. 
 
 Digestion. — Sordes and accumulations of mucus may occur 
 on lips and teeth. Note any inability to take food or to 
 swallow. Jaundice is common in relapsing fever, and 
 may be present with Pyaemia, Typhus, etc. 
 
 Vascular system, see Pericarditis. — Danger may arise from 
 failure of heart's action, and weakness of the circulation. 
 Note complexion of the lips and face, fulness and tension 
 of pulse. 
 
 Pkespiratory system. — Note fulness or shallowness of respirations. 
 Examine lungs fi'equently, even if there be no symptoms 
 of their disturbance. Note cough or Expectoration. 
 
 Nervous system. — Mental condition disturbed ; delirium not 
 necessarily of bad prognosis. Hyperpyrexia and ady- 
 namia dangerous. 
 
 Urine. — Albuminuria may be temporary, or it may lead to 
 chronic Bright' s disease. 
 
 Look for causation ; cold, contagion in case of specific fevers, 
 bad hygienic conditions. 
 
 Causation. — Contagion ; concurrent or previous illness in same 
 house ; smells from sewers ; water supply ; date of 
 exposure to contagion ; infection by clothes. 
 
CLINICAL MEDICINE AND CASE-TAKING, 
 
 SPECIFIC ERUPTIVE FEVERS. 
 
 DAYS OF FEVER AND RASH. 
 
 ENTERIC FEVER.— Onset 
 gradual ; temperature slowly 
 rising, falling at end of 3rd or 
 in the 4tli week with exacer- 
 bations at night. Small oval 
 hypersemic spots on abdomen 
 in successive cro^^s in 2nd and 
 early in 3rd weeks. 
 
 SIGNS AND SYMPTOMS. 
 
 Abdominal pain and ten- 
 derness; gurgling over cae- 
 cum. Bowels usually relaxed. 
 Spleen large. Temperatm'e 
 may be excessive. Occasion- 
 ally sudamina. Bronchitis 
 common. Bowels may be 
 constipated. 
 
 TYPHUS FEVER. — Onset 
 severe, with rigors and pains in 
 back and limbs. Temperature 
 rises rapidly 4 to 5 days, 
 falling about 14th day. Mul- 
 berry-coloured maculae, at 
 first slightly raised, then dull 
 mottling, appear in 1st week, 
 disappear end of 2nd week. 
 
 SCARLET FEVER.— Onset 
 rather sudden, with chilliness. 
 Temperature rising rapidly. 
 Rash 2nd day on neck, chest, 
 and trunk, extending to the 
 limbs ; minute red points, 
 quickly becoming a diffused 
 erythema. Rash passes off 
 about 7th day, leaving 
 desquamation of skin. Tem- 
 perature falls about same 
 time. 
 
 Headache and nervous 
 symptoms prominent ; de- 
 lirium usual. Much tendency 
 to heart failure and hypo- 
 static congestions. Bron- 
 chitis. Bowels not usually 
 relaxed. 
 
 Tongue thickly coated, 
 with enlarged red papillae 
 protruding ; tip quickly be- 
 coming red. Fauces inflamed ; 
 tonsillitis. Desquamation 
 specially seen on hands and 
 feet. Occasionally there is 
 no rash. Delirium. 
 
GENEEAL DISEASES — CLASS I. 
 
 SPECIFIC ERUPTIVE FEVERS. 
 
 COMPLICATIONS. 
 
 ENTERIC FEVER.— Signs of 
 heart failure. Delirium. 
 Typhoid State. Hypostatic 
 congestion of lungs. Albu- 
 minuria. Hsemorrliage from 
 bowels ; perforation of intes- 
 tine. Profuse sweating, see 
 Tuberculosis. Phlebitis. Se- 
 quential abscesses. Tendency 
 to relapses of fever and 
 other symptoms. 
 
 TYPHUS FEVER.— Active Deli- 
 rium passing into the Typhoid 
 State. Hypostatic pneu- 
 monia. Albuminuria. "Weak 
 action of ventricles, and 
 very soft pulse. 
 
 CAUSATION. 
 
 Impure water. Sewer 
 gas. Probably not con- 
 tagious, but by the evacua- 
 tions. Note occupation ; 
 residence, and its hygienic 
 condition ; sources of milk 
 supply. 
 
 Contagious from the sick 
 to the healthy. Its spread 
 is favoured by over-crowding, 
 bad hygienic conditions, and 
 starvation. 
 
 SCARLET FEVER.— Albumi- 
 nuria and ansemia with ana- 
 sarca from Acute Bright' s 
 Disease. Inflammation of the 
 throat may be excessive, with 
 ulceration. Arthritis. Scarla- 
 tinal rheumatism. Inflam- 
 mation of the middle ear. 
 Glandular abscess in neck. 
 Hyperpyrexia. Pleurisy or 
 empyema rather than pneu- 
 monia. Convulsions. Scarlet 
 Fever. — Rheumatic symp- 
 toms often commence at 
 the beginning of the 2nd 
 week with swelling in sheaths 
 of tendons, and some redness, 
 tenderness, and moisture of 
 skin. Subsequently stiff" neck 
 not uncommon. 
 
 Highly infectious, especi- 
 ally through the dust of 
 the skin. The type varies 
 greatly in diff'erent epi- 
 demics ; in some, greater 
 tendency to complications 
 or death. 
 
CLINICAL MEDICINE AND CASE-TAKING. 
 
 SPECIFIC FEVERS. 
 
 DAYS OF FEVER AND RASH. 
 
 MEASLES. — Rash appears 
 about 4th day ; begins on 
 face, spreading to the trunk 
 aud limbs. Fine red points, 
 becoming flat and forming 
 crescentic patches. Tempera- 
 ture begins to fall two or 
 three days after rash appears. 
 
 SIGNS AND SYMPTOMS. 
 
 Specially common in chil- 
 dren. Onset with chills or 
 rigors. Sleepiness. Catarrh ; 
 conjunctivee watery ; coryza. 
 If rash is full, desquamation 
 mav follow. 
 
 VARIOLA.— Rash appears 3rd 
 day, fii'st on forehead as red 
 papules, soon becoming vesi- 
 cles, feeling hard as shot ; 
 5th day they become umbili- 
 cated and purulent ; 8 th day 
 pustules mature, then scab. 
 Temperature rises rapidly ; 
 falls as rash appears ; secon- 
 dary fever vith the suppura- 
 tion. 
 
 Incubation after inocula- 
 tion, 7 days ; after infection, 
 12 days. Onset with great 
 pains in limbs and back. 
 Rigors. Vomiting'. The 
 pustules may become con- 
 fluent or remain distinct. 
 
 VARICELLA.— With onset, 
 small red spots appear on 
 trunk, face, scalp, becoming 
 resides, but these are not 
 cellular or umbilicated ; they 
 crust. Temperature not high. 
 
 Very little constitutional 
 disturbance. 
 
GENEEAL DISEASES — CLASS I. 
 
 SPECIFIC FEVERS. 
 
 COMPLICATIONS. 
 
 MEASLES.— Mostly in respi- 
 ratory system. Bronchitis. 
 Acute broncho - pneumonia, 
 which, may become chronic. 
 Laryngitis may be severe ; it 
 precedes the rash. There may 
 be vomiting and diarrhoea. 
 Delirium. Rarely cutaneous 
 haemorrhages. Occasionally 
 Albuminuria. 
 
 CAUSATION. 
 
 Very infectious, especially 
 during the eruptive stage. 
 
 VARIOLA. — Mucous surfaces 
 frequently affected, especially 
 conjunctivae, throat, nose. 
 Bronchitis ; Pneumonia ; 
 Pleurisy ; diarrhoea ; Albu- 
 minuria ; abscesses. Cuta- 
 neous haemorrhages and 
 bleeding from the mucous 
 surfaces, Typhoid State. 
 
 Very infectious. Inocul- 
 able by pus of vesicles, also 
 by scabs. 
 
 VARICELLA.— Ifone are usual. 
 
 Infectious. 
 
CLOnCAI. MEDIdSTE AlO) CASE-TAKING. 
 
 ERYSIPELAS. 
 
 Tj., -:i:: :: ::^ /;-'_rr mncli swollen, red, 
 
 i:o"iis , "rViiti^ei ZL.^ i_.i:^:r.5 of the i nfl aTned part 
 rimed or diffiiaed. 3^::^ :-.-r-- Tesieles or buBsB. 
 ::; ralaiged tymphalic glands. I^ote signs and 
 mi of Fever. 
 
 CemfiiMa&m&. — CeUnliiis ; alisoess; gangvene. Ddirinn.; the 
 Ijrplioid State; ADbaniKiiria; FBeuuniiB; FletoiBy; 
 FUeUtis; FeiietiriitiB; tedeaiia of lazynx; infamina- 
 tioM of £aiiD^u Diaxdioea. ; relapses of the disease. 
 
 DIPEIHEEIA, 
 
 Q<- :; :Lr : 2.7:t:.: . i';.!:?;" to swallow, strengtli of 
 
 voiee, Djspaicea, 3 '-it.::. : : body. P. = ; T. = ; 
 
 R.= . "Rya. ^ 2£:-j.iii and Throat for redness and 
 
 sweDing of Uit :i: r- soft palate, nvnla, pharynx; 
 paibGlies of meii- : i :. : : - ^r^idation, wMtisli or greyish, 
 oflbeaa mnlltiple : i:.t"_i. i^i-t id ay be peeled off, leaving 
 smrfeffle of imac:'i.? iiTi_::i"-:-r raw, but not ex<^vated. 
 Zxi-iir.-^ Ir; = : It -"_•:-, r:;::-^. .-'.ir. is Hinder the Jaw. Note 
 
 igeal Bisease. 
 
 - T ,. . 
 
 iMrymt^ooA sym^^wis. — CommeiMaiig with a short eongh, and 
 -■_i:lt li:^:"i'— ' ::" ^'r. h^^i:sL2 : "':reathii!g noisy, stridnlous, 
 — :1 1, iir'illi-v-: ;:. l::.^- : : : ^-.i : weak voice; straggling 
 : : ::riT'_ l... - i::;:;;^!- : :'...t~: c-oHapsing ; pnlse weak; 
 i^It ':'_:.:-':. : rrTiri-^Lnes cold ; sweating. Note if trache- 
 iTiii"'.' .: ■: :_i_ 11 ::_-::. or not. 
 
 — Faenumia; Flemisy; Mbaadnnxia; adynamia 
 il^raae on oomjnnctiva and ^in ; Faralysis. 
 
GENERAL DISEASES — CLASS I. 
 
 ERYSIPELAS. 
 
 An acute febrile disease characterized by local diflFiised inflamma- 
 tion of skin and cellular tissue with bullse and vesiculation. 
 Idiopathic erysipelas usually attacks the face, commenc- 
 ing about the eye. 
 
 Causation. — Epidemic and endemic causes. Exposure to cold, 
 and bad hygienic conditions ; contagion. It may follow 
 injury or operation. Those once attacked by the disease 
 are liable to recurrence. 
 
 DIPHTHERIA. 
 
 A febrile contagious disease, characterized by the formation of 
 membranous exudations on the fauces and respiratory 
 mucous membrane, frequently obstructing the larynx, 
 often attacking the mucous membrane of the nose and 
 causing an acrid discharge. It is asthenic in its course, 
 and attended by gi'eat debility, frequently proving fatal 
 through Laryngeal Obstruction or by pneumonia. The 
 period of incubation is various. It may commence with 
 lassitude, febrile disturbance, sore -throat ; or those pre- 
 liminary symptoms may be absent, laryngeal stridor being 
 the first symptom noticed. Sometimes swelling of the 
 glands under the jaw first attracts attention. There may 
 be membrane in the larynx, and none on the fauces. 
 There is less pain on attempting to swallow than with 
 quinsy. Fever not prominent ; rarely runs high. When 
 paralysis follows, it is usually after convalescence. 
 
 Causation. — Communicable from the diseased to the healthy 
 by secretion of mouth, vomits, expired air. Bad water ; 
 sewer gas, and bad hygienic conditions. Most common in 
 children. It may be epidemic or endemic. 
 
10 CLINICAL MEDICINE AND CASE-TAKING. 
 
 PYEMIA. 
 
 Examine the body all over for any wound, local inflammation, 
 or suppuration. A very slight wound may produce the 
 disease, e.g., a thorn under the nail, etc. See Signs of 
 Fever and General Condition of the Nervous System, 
 prostration. Coma, Typhoid State. 
 
 Causation. — Suppui'ation connected with diseased bone ; whit- 
 low ; Phlebitis ; softening clots ; ulceration from tertiary 
 syphilis ; Periostitis. Occasionally it is secondary to 
 internal suppuration or ulceration, e.g., enteric fever, 
 gastric ulcer, abscess of kidney, etc. 
 
 ComjMcations. — Occasionally a cutaneous erythema. Jaundice, 
 without signs of obsti-uction ; Albuminuria ; haemorrhages 
 in skin or from mucous membranes. Low forms of 
 inflammation ; Pericarditis ; Pneumonia ; Pleurisy ; em- 
 pyema ; Peritonitis. 
 
 PUERPERAL FEVER. 
 
 GeTieral condition. — General signs of Fever. Patient usually 
 
 assumes the dorsal decubitus. There is much tendency to 
 
 adynamia and the Typhoid State, with sweating and 
 
 Delirium. 
 Ahdoriicii. — Usually distended and tympanitic ; bowels often 
 
 costive. There may be local tenderness over the uterus 
 
 or in either iliac fossa. 
 Genito-iirinary system. — Xote pain or difiiculty on micturition 
 
 or defsecation. Lochial discharge, its amount, if off'ensive ; 
 
 any clots or pieces of placenta or membranes passed. 
 
 Albuminuria. Breasts, if milk is secreted ; condition of the 
 
 glands, tenderness. 
 Causation. — Epidemic at periods. Endemic in a house or 
 
 hospital ; due to inoculation by nurse or attendant, e.g., from. 
 
 a case of erysipelas, or another puerperal case. Infection 
 
 with an acute specific fever, e.g., scarlet fever. Local septic 
 
 poisoning from metiitis, decomposing clobs, or portions of 
 
 placenta. Bad hygienic conditions. 
 
GENERAL DISEASES — CLASS I. 11 
 
 PYJEMIA. 
 
 Usually commences by an insidious onset, or with chilliness or 
 rigors, and fever with sweating and great prostration. It 
 is characterized by the formation of multiple abscesses, and 
 arthritis with a tendency to suppuration in or around the 
 joints. The tendency is to death by exhaustion, the 
 patient passing into the typhoid state, or by its com- 
 plications. It may be mistaken for Eheumatism or 
 Enteric Fever, or ma}^ be confounded with broncho- 
 pneumonia, which often accompanies it. Any source of 
 suppuration may lead to the disease, whether the pus be 
 discharged, as from an open abscess, or retained in deep 
 parts, as from periostitis and acute necrosis. 
 
 PUERPERAL FEVER. 
 
 An acute febrile disease, probably of septic origin, following 
 shortly after confinement, and incommunicable to those not 
 in the puerperal state. The onset occurs about 2nd or 
 3rd day after confinement, with chilliness or rigors, and 
 the signs- of Fever. Usually this is attended with scanty 
 and offensive uterine discharges. The secretion of milk is 
 often suspended, but what is formed does not hurt the 
 infant. 
 
 Complications. — Pleurisy. Empyema. Pneumonia. Pericarditis. 
 Albuminuria. Pelvic cellulitis or parametritis. Peritonitis. 
 Mammary abscess. Phlebitis, or phlegmasia dolens. 
 Arthritis. 
 
 Varieties of Fever. — It may be specially characterized by 
 Peritonitis ; by pelvic cellulitis ; metritis, with much 
 abdominal pain and tenderness. Simple fever, with 
 alteration of secretions, but no other local manifestations ; 
 the fever tending to exhaustion, adynamia, and the 
 Typhoid State. 
 
12 CLINICAL MEDICINE AND CASE-TAKING. 
 
 AGUE. 
 
 Enquire as to the periodicity of the paroxysms. Describe ar 
 attack, giving, if possible, the duration of the stages. 
 Note conditions of health in the inter-paroxysmal period. 
 Paroxysms may occur daily — quotidian ; with one-day 
 interval — tertian ; mth two-days interval — quartan. Note 
 general appearance and condition ; whether Anaemia or 
 cachexia. Examine optic discs : sometimes hsemorrhages 
 are seen in the retina. Urine. T. = ; R. = ; P. = . 
 Also note condition of Spleen and liver. General condition 
 of the Nervous System. 
 
 ComjMcoMons mul Sequelce. — Enlargement of spleen and 
 
 occasionally liver ; digestive organs disturbed. Dysentery ; 
 
 jaundice ; Anaemia ; melansemia (pigment granules in 
 
 blood) ; retinal hemorrhages ; cachexia ; Neuralgia ; 
 brow-ague. 
 
 Causation. — Endemic, in low and ill-drained districts. 
 Symptoms may follow in a few hours after imbibing 
 the poison, or may be delayed. 
 
 HOOPING-COUGH. 
 
 Geiiera.l condition. — State of nutrition ; look for signs of Rickets. 
 P. = ; T. = ; R, = ; W. = , Enquire for signs of 
 catarrh preceding the development of hooping ; simple 
 cough, with expectoration, running at nose, etc. 
 
 Respiration. — Physical examination of lungs ; the chest, its 
 shape and movements, signs of collapse. Cough ; 
 paroxysms, describe them, their frequency, duration, and 
 mode of subsidence ; note the amount of asphyxia and 
 venous congestion. 
 
 Complicatimis. — Pulmonary collapse ; specially in cases of 
 Eickets, which usually do badly. Bronchitis and broncho- 
 pneumonia ; Convulsions ; Diarrhoea. Epistaxis ; blood 
 often ejected from mouth. 
 
GENERAL DISEASES — CLASS I. 13 
 
 AGUE. 
 
 Characterized by feverish paroxysms, recurring at regular 
 intervals, the patient being well between the paroxysms. 
 
 Paroxysm. — 1. Cold stage: Lassitude, headache, malaise, chilli- 
 ness, shivering, passing on to rigors, the teeth chattering 
 and limbs trembling ; muscular pains ; epigastric discom- 
 fort ; goose-skin ; face dusky, pinched, shrunken. Pulse 
 small ; respirations quick ; temperature rising rapidly. 
 
 2. Hot sta.ge : Rigors and chilliness disappear, succeeded by a 
 comfortable warmth ; face less shrunken. Patient then 
 feels hot ; flushes ; there may be mental excitement. Skin 
 dry and frequently hot ; pulse full and strong ; respirations 
 more rapid. Headache. Temperature rises higher. Urine 
 abundant. 
 
 3. Sweating stage : Feeling of heat diminishes ; temperature 
 falls. Skin becomes moist and sweating profuse. Pulse 
 and respiration fall in frequency. Headache passes off. 
 Patient feels easy and sleeps, awaking feeling well. Urine 
 scanty, depositing lithates. 
 
 Temperature may rise without a developed paroxysm. 
 
 HOOPING-COUGH. 
 
 Characterized by paroxysms commencing with a series of 
 expiratory coughs, followed by deep, full inspiration with 
 loud laryngeal spasm. Frequently vomiting and expecto- 
 ration with paroxysms. Child may be comparatively well 
 in intervals. Asphyxia in paroxysms very great ; this may 
 lead to ecchymosis under conjunctiva. Sublingual ulcer often 
 results from stretching the fraenum over the lower incisors 
 during paroxysms. Ejection of blood not a bad symptom. 
 Look for any spasmodic signs, such as Tetanus or chronic 
 spasmodic conditions of muscles of one extremity ; this is 
 almost entirely confined to Rachitic children. Enquire as 
 to a source of contaffion. 
 
14 CLI>:iCAL MEDICINE AND CASE-TAKING. 
 
 SYPHILIS— Inherited. 
 
 General condition. — Unhealthy aspect ; dull earthy complexion ; 
 old and shrivelled appearance. Rash on skin ; erythe- 
 matous patches with abrupt margins ; coppery tint. 
 Squamous skin lesions about mouth, chin, limbs, soles of 
 feet. Sometimes a scab or a pustular rash with bullse ; 
 there may be much desquamation. The skin about nates 
 and mouth mostly aifected. Nails may be unhealthy and 
 chippy. 
 
 Mucous membranes. — Mucous tubercles or condylomata at anus 
 and at angles of the mouth ; diffuse stomatitis ; inflamma- 
 tion of gums and tooth-sacs. Thrush. Discharge from 
 nose, often excoriating the lip ; snuffles. Laryngitis ; voice 
 or cry hoarse. 
 
 Viscera may be affected : spleen large ; liver. 
 
 Bmies. — Periostitis may be very extensive, causing much 
 deformity of limbs and thickening of the skull. Skull 
 thick ; forehead prominent ; craniotabes. Swelling of ends 
 of long bones just above epiphyses. 
 
 Nervous system. — Deafness (nerve disease) and amaurosis more 
 common than with the acquired disease ; palsy of a single 
 nerve less common ; occasionally epilepsy or imbecility. 
 
GENERAL DISEASES — CLASS I. .15 
 
 SYPHILIS— Inherited. 
 
 This may lead to deposit of gummata. 
 
 Eyes. — May be early the seat of iritis, later of keratitis, which 
 occurs towards adult life and is usually symmetrical. 
 There may also be choroiditis. 
 
 Nose. — Mucous membrane swollen ; this leaves nose sunken and 
 flattened. Occasionally, in severe cases, the skin disease 
 is obvious at birth, but usually child appears perfectly 
 healthy till about six weeks old ; the thrush and the rash, 
 etc., then appear. 
 
 Marks left in adult. — Bridge of nose sunken in ; linear scars 
 near angles of mouth and about anus. Interstitial 
 keratitis ; iritis ; choroiditis. Prominent forehead* 
 
 Nerve deafness. — Often only slight and temporary ; in some 
 absolute and permanent. 
 
 Teeth. — All the incisors may be dwarfed and malformed. 
 The upper central incisors are most reliable, dwarfed, 
 usually narrow and short, with atrophy of the middle lobe, 
 leaving a single broad vertical groove. 
 
16 CLINICAL MEDICINE AND CASE-TAKING. 
 
 SYPHILIS — Constitutional and Acquired. 
 
 Stages : — Incubation ; efflorescence ; decline ; relapse ; sequelae. 
 General condition. — Tendency to emaciation ; debility ; vague 
 pains. Anaemia. Look for scar of primary sore. 
 
 Digestion. — Mucous tubercles of lips ; sores, leaving scars, at 
 angles of mouth. Tongue, Soft Palate, pharynx ; ulceration 
 on tonsils. Superficial and symmetrical ulcers in first 
 stage ; deep, destroying parts, when tertiary ; destruction 
 of these parts. Ulceration and condylomata of anus. 
 Liver, perihepatitis ; gummata. 
 
 Besjiiration. — Laryngeal Disease with ulceration and tendency 
 to contraction. Lung disease of chronic character. 
 
 JVervotis system. — Disease of Brain or Spinal Cord. Gummata, 
 forming tumour in brain. Palsy of Cranial Nerves, 
 especially nerve iii. and nerve vi. ; disease of auditory 
 nerve. Iritis ; choroiditis ; retinitis. Meningitis ; pre- 
 disposition to Ataxy. 
 
 Locomotor system. — Nodes and thickening of bones ; Periostitis. 
 Skin : syphilides, psoriasis, serpiginous tubercular patches, 
 ulcers with ragged edges, etc. 
 
 Lymphatic glands. — Generally enlarged in neck and groins, 
 without tendency to suppuration. 
 
 Special phenomena. — Gummatous masses in viscera and skin, 
 etc. Condylomata and mucous patches on mucous 
 membranes, or ulceration with tendency to contracting 
 scars. Disease of testes. 
 
GENERAL DISEASES — CLASS I. 17 
 
 SYPHILIS* — Constitutional and Acquired. 
 
 These phenomena may be considered as occurring in the second 
 and third stages. 
 
 SecoTid stage. — Follows six weeks to two months after inocula- 
 tion. Rash on skin, scattered coppery eruption ; or it 
 may be scaly, papular, pustular, rather on flexor than 
 dorsal aspect. On mucous membranes symmetrical ulcers, 
 tonsils especially, with abrupt edges ; condylomata may 
 form anywhere. Iritis usually symmetrical. Occasionally 
 slight periostitis. 
 
 Third stage. — Tendency to unsymmetrical ulceration of skin 
 and mucous membranes, with great tendency to relapse. 
 Scars tend to contraction and pigmentation. Tendency 
 to sloughing. 
 
 Bone disease. — Periostitis, nodes, chronic thickening, 
 destruction of nasal and palatal bones. 
 
 Gummata may form in any viscus. In liver they may 
 be felt during life ; in brain may cause signs of tumouk ; 
 in skin may lead to extensive sloughing. 
 
 Arteries often diseased. This may lead to aortic 
 Aneurism, minute arterial aneurisms in brain, and 
 haemorrhage, Thrombosis, and gangrene. 
 
 * Mr. Hutchinson's Article— Reynolds' "System of Medicine." 
 
GENEEAL DISEASES— CLASS II. 
 
 Diseases often inherited, frequently arising from some internal 
 changes in the patienf s tissues or organs, hut often due to causes 
 acting from ivithout. 
 
 SIGNS OF DEFECTIVE DEVELOPMENT. 
 
 Search for accompanying congenital defects of development. 
 Defect of heart ; cleft palate ; deformity of hands or 
 feet ; supernumerary fingers and toes ; epicanthic folds in 
 excess ; unusual shapes of the ears, and asymmetry between 
 the two ears ; coarse or ichthyotic skin ; hair on forehead. 
 Abnormal conditions of head ; size and shape ; fontanelle 
 and sutures, whether open. They are sometimes pre- 
 maturely ossified, and the forehead prow-shaped. Eye : 
 Coloboma ; congenital defect of sight. Undescended 
 testicle ; hydrocele ; hernia. Skin : Coarse, ichthyotic ; 
 deficient in elasticity ; increased areolar tissue ; extremi- 
 ties blue ; chilblains. 
 
 Description. — But little spontaneous movement ; dirty habits ; 
 fits ; paralysis ; inability to hold head up, to talk or 
 walk. In low-class cases repetitive movements are com- 
 mon, e.g., continuous movement of one arm, purposeless 
 and rhythmical ; absence of intelligence ; not attracted by 
 light or sound. 
 
 Lungs. — Liability to bronchitis. 
 
 Nervous system. — Defective in intelligence ; convulsions ; 
 defective motor power ; insuf&cient power of co-ordina- 
 tion. 
 
 Causation. — Syphilis ; drunkenness in parents ; relationship 
 between the parents. Most common in first member of a 
 family. 
 
20 CLINICAL MEDICINE AND CASE-TAKINQ. 
 
 ANEMIA. 
 
 Pallor of skiu and mucous memlDranes, lips, aud conjunctivae. 
 When the fingers are held up to the light the redness of 
 the borders is seen diminished. (Edema of feet ; possibly 
 puffiness of face. ^ 
 
 Circulation. — Examine arteries and veins in the neck ; condition 
 of heart. See condition of the blood and its microscopical 
 characters. Look for Diseases of Vessels. Breathlessness. 
 
 Nervous system. — Headache; Neuralgia, especially spinal; 
 intercostal nem-algia ; drowsiness ; mental weakness and 
 irritability ; muscular weakness ; pains in back. Examine 
 optic discs. 
 
 Me7istrv^Mo7i. — Disordered ; usually lessened, or absent. 
 
 Look for Pernicious Anaemia, leucocythsemia, enlarged glands, 
 cancer, hsemori'hages from mucous membranes or under 
 skin ; heart disease ; chronic lung disease ; Bright' s 
 Disease. Examine urine. Examine liver and spleen. 
 T. = : P. = : R. = : W. = . 
 
 PERNICIOUS (Progressive) ANEMIA. 
 
 Look for general signs of anaemia, and the ordinary causes. See 
 amount of redness of the fingers held before a strong light. 
 Examine optic discs ; there may be retinal haemorrhages. 
 Note condition of the joints and general power of the 
 patient ; also state of digestion. 
 
 CANCER. 
 
 Geiural conditio7i. — Anaemia; cachexia; Emaciation; loss of 
 muscular strength. Temperature not raised. 
 
 Disturbed functimi of ^jar^s affected. — Pressure signs from 
 growth of mass, e.g. — (1) Glands in transverse fissure of 
 liver obstructing the vena portse and causing Ascites, or 
 the duct, causing jaundice ; (2) Mediastinal tumour ; (-3) 
 Pressure on veins, e.g., vena cava or iliac veins ; (4) Intra- 
 cranial tumoui' ; (5) Annular stricture of intestine. 
 
GENERAL DISEASES — CLASS II. 21 
 
 ANiEMIA. 
 
 Circulation. — Over jugular vein, especially on the right side, a 
 thrill may be felt with the fingers, particularly in children ; 
 but this does not necessarily indicate anaemia. A con- 
 tinuous humming sound heard, Bruit de Diable, over 
 jugular like wiind among trees, varying with the pressure 
 of the stethoscope. Systolic blowing over the carotid or 
 subclavian artery on very slight pressure. Over the 
 pulmonary (2nd left) costal cartilage a systolic bellows, 
 the second sound being often sharp and accentuated. 
 Heart's action quick ; easily excited to palpitation. Pulse 
 soft and frequent. 
 
 Causation. — Haemorrhage ; menorrhagia. Sequent to acute 
 disease. Defective hygienic surroundings. Hot rooms. 
 Want of good food regularly taken. Dyspepsia ; chronic 
 gastric disease; Alcoholism; Plumbism; mental exhaus- 
 tion ; fright ; Malaria ; heart disease ; Cancer ; often due 
 to over-long lactation ; general delicacy ; disturbed nights 
 as well as lactation ; re-establishment of menstruation 
 during lactation. Coincident disease ; Bright's disease 
 sequent to pregnancy ; rapid development of phthisis, which 
 was quiescent during pregnancy. 
 
 PERNICIOUS (Progressive) ANiEMIA. 
 
 Profound increasing aneemia, accompanied by increasing 
 debility and prostration, tending to death in many cases. 
 
 Haemorrhages ; spongy gums ; epistaxis ; breathlessness ; palpi- 
 tation on exertion. Fat of the body not absorbed ; the 
 subconj unctival fat yellowish . Excretion of urea diminished . 
 There may be irregular pyrexia. 
 
 CANCER. 
 
 Causation. — Hereditary ; declining period of life ; sequent to 
 blows. Organs commonly affected — uterus, mammse, liver, 
 stomach, peritoneum, other abdominal sites, lungs. 
 
 Secondary deposits. — In liver, from the rectum, sigmoid flexui'e, 
 stomach, etc. In lymphatic glands next to the organ 
 affected. 
 
 Complications. — Serous effusion ; adjacent inflammations ; 
 thrombus of veins. 
 
22 CLINICAL MEDICINE AND CASE-TAKING. 
 
 RICKETS. 
 
 Eaquire as to conditions of feeding ; ability to stand or walk ; age 
 at "wMch walking commenced ; previous health, especially 
 as to symptoms and complications of rickets. Examine 
 bones, head, abdomen. Anaemia. 
 
 Bo>ie$. — Ribs beaded ; enlargement of ends of ribs at their 
 junction with the cartilages. Sternum thrust forward by 
 the falling in of the ribs at side of chest ; hypochondriac 
 regions depressed. Spine may be bent backwards, but is 
 capable of being sti'aightened on suspending the body, 
 lifting the child by the arms. Shaft of long bones often 
 bent, especially in tibiae if child has walked ; epiphysis 
 enlarged, particularly in radius. Skull may remain patent 
 long after the first year ; the head is large, wide, and flat 
 on the vertex. See diagnosis from Chronic Hydrocephalus. 
 Head may be small and not ill-shapen. Craniotabes, or 
 soft spots viith deficiency of bone, can be felt sometimes 
 in the occipital bone. 
 
 EMACIATION. 
 
 History as to probable causation. Emaciation, whether gradual 
 or sudden, or coincident -with other signs of disease. Dis- 
 tribution of the emaciation, especially in children. The 
 emaciation often afiiects the body and extremities more 
 than the head and neck. Examine all the organs and 
 urine. Kote weight of patient, and record it once a week. 
 Specially enquire as to histoiy of phthisis. Look for 
 Anaemia, and the signs of any disease supposed to have pro- 
 duced the emaciation. When a muscle is stinick, e.g., biceps, 
 note its irritability, longitudinal contractions, and ti'ans- 
 verse knotting. 
 
 Kidritioii indicated by the relation of age, height, weight, etc. 
 W. = . Spare, thin, emaciated, stout, fat, good muscular 
 development, strong, weak. 
 
 Growth rapid, moderate, slow. 
 
GENERAL DISEASES — CLASS II. 23 
 
 RICKETS. 
 
 Thickening and deformity of bones. The child may be fat or 
 ill-nourished. Much tendency to sweating, especially 
 about the head ; throws off the clothes at night ; head much 
 rubbed on the pillow, so that hair is worn from occiput. 
 Dentition late ; the teeth often devoid of enamel — soon 
 decaying. General tenderness, so that child cries 
 on being moved. Late in walking. Late signs : Head 
 large, flat, square ; figure too small in the legs. 
 
 Complications. — Tendency to catarrh of intestines ; diarrhoea; 
 abdomen large and prominent ; Spleen and liver large. 
 Bronchitis ; collapse of base of lungs. If Hooping-Cough 
 supervenes, it runs an unfavourable course with bronchitis ; 
 Convulsions and Laryngismus. 
 
 Causation. — Ill-feeding during infancy, especially with farina- 
 ceous food ; intestinal catarrh ; bad hygienic conditions : 
 premature birth. 
 
 Digestion. — Teeth late in appearing, and often deficient in 
 enamel ; abdomen large, prominent, tympanitic, partly 
 owing to weak condition of its muscles. 
 
 Nervous system. — Liability to convulsion; laryngismus; tetany, 
 or chronic contraction of muscles of extremities. 
 
 EMACIATION. 
 
 Causation. — Chronic lung disease ; Phthisis ; caseous bronchial 
 glands. Cancer. Chronic stomach disease ; Diarrhoea ; 
 Vomiting. Starvation and ill-feeding, especially in 
 infants. Defective hygienic conditions. Senile Degenera- 
 tion. Sequent to acute disease. Fever. Diabetes. General 
 Tuberculosis. Disturbance of the general condition of the 
 Nervous System. 
 
 In infants often called Marasmus. Look for signs of Congenital 
 Syphilis ; collapse of lungs ; Rickets. See state of skin ; 
 fulness or retraction of abdomen. State of bowels ; con- 
 stipation or chronic diarrhoea. State at birth, if suckled ; 
 how fed, and nature of foods. Thrush. 
 
24 CLINICAL MEDICINE AND CASE-TAKING. 
 
 (EDEMA OE ANASARCA. 
 
 Anaemia. Signs of disease of heart or vessels. Look fox 
 Cardiac Dilatation or degeneration. 
 
 Lungs. — Especially empliysema or phtliisis. 
 
 Urine.— See signs of Bright's Disease. 
 
 If anasarca be thought to be due to passive congestion, look 
 for the signs of passive congestion, and note if the oedema 
 lessen or increase •with such other signs ; e.g., note if oedema 
 lessen with the disappearance of pulmonary oedema, etc. 
 If anasarca be due to Bright's disease, note if it lessen 
 with lessening Albuminuria, and increase of the quantity 
 and sp. gr. of the urine. 
 
 AMYLOID DEGENERATION. 
 
 Pasty, anaemic appearance. Anasarca. 
 
 Liver. — Large, firm-edged, uniformly enlarged, smooth. 
 Usually no jaundice or ascites. 
 
 S^ileen. — Large, firm, smooth. 
 
 Kidneys. — Urine very albuminous. Anasarca. 
 
 Intestines. — Diarrhoea. 
 
 CoALsaMon. — Syphilis. Chronic suppuration. Phthisis, with 
 suppuration of bronchi. Chronic disease of bone, see 
 Scrofula. 
 
GENEKAL DISEASEg-^CLASS II. 25 
 
 (EDEMA OR ANASARCA. 
 
 Causation — 
 Obstruction at heart. — Passive (Cardiac) Congestion. Cardiac 
 valvular disease ; failure of the ventiicles ; fatty heart ; 
 dilated right ventricle. Adherent pericardium. 
 
 Obstruction at lungs. — Emphysema. Chronic bronchitis. 
 Conditions obstructing circulation in one lung, e.g., 
 chronic pleurisy, empyema, collapse of one lung. 
 
 Local pressure on veins. — Pressure on vena cava or iliac veins 
 in abdomen from enlarged glands, Cancer, Aneurism, 
 pregnancy. Abdominal Tumour, pelvic effusion ; pres- 
 sure from ascites. Pressure on subclavian vein from 
 thoracic aneurism or mediastinal tumour. 
 
 Changes in blood or vessels. — Bright's Disease. Anaemia ; 
 extreme debility from chronic disease, e.g., cancer, 
 Phthisis, diarrhoea in children, Phlebitis, phlegmasia 
 dolens, varicose veins. 
 
 SCROFULA. 
 
 General condition. — W. = ; T. = ; R. = ; P, = . Intelligence 
 dull ; phlegmatic temperament. Coarse, flabby, ungainly 
 children, outlines of body ill-marked. Features plain, 
 complexion pasty. Liable to ophthalmia ; tinea tarsi ; 
 otorrhcBa, eczema, lichen, lupus, chilblains, blue hands. 
 Forehead and back hairy. 
 
 Respiratory system. — Liability to bronchitis and chronic pneu- 
 monia passing on to Phthisis. 
 
 Digestive system. — Abdomen full ; liability to diarrhoea. Teeth, 
 no distinctive condition, liable to decay, may be devoid 
 of enamel. Upper lip thick. Gums unhealthy. Tonsils 
 large. 
 
 Locomotor system. — Bones thick ; joint disease frequent. Skin 
 easily inflamed. Glands enlarged and suppurate, specially 
 in neck. 
 
26 CLINICAL MEDICINE AND CASE-TAKING. 
 
 GENERAL MILIARY TUBERCULOSIS. 
 
 General condition. — Look for signs of strumous disease in bones, 
 joints, spine ; enlarged glands ; Emaciation ; state of skin. 
 P. = ; T, = ; R. = . Look for Signs of Fever. 
 
 Respiratory system. — Signs of Consolidation of Lung or 
 Phthisis ; enlarged bronchial glands ; cough. 
 
 Digestive system. — Vomiting; state of bowels, see Ulcer ation 
 of Bowels ; ability to take food. 
 
 Nervous system. — Signs of Meningitis ; signs of Brain Disease. 
 Ophthalmoscopic examination may show optic neuritis 
 or tubercles in choroid. Tubercle in choroid indicates 
 tuberculosis, not meningitis ; optic neuritis with tubercle 
 indicates probable tubercular meningitis. 
 
 The onset may be insidious, with a previous period of emaciation 
 and lassitude, and after a few days or weeks may be 
 followed by the somewhat sudden onset of a special 
 complication, as Pneumonia ; Meningitis. The general 
 symptoms are mostly prostration, Emaciation, sweating, 
 cough, moderate fever — this may be absent. Some of the 
 complications are usually present, and frequently there 
 are the signs of old strumous disease. The disease tends 
 to death by exhaustion or by complications. The presence 
 of miliary tubercles in the lungs does not necessarily cause 
 any abnormal physical signs. 
 
GENERAL DISEASES — CLASS II. 
 
 27 
 
 ENTERIC FEVER resembles GENERAL MILIARY 
 
 Diarrhoea from typhoid 
 
 ulceration of Payer's patches. 
 
 I. Evening exacerbations of 
 
 fever, mostly in 3rd or 4th 
 
 Aveeks. 
 
 III. Profuse sweating, with 
 great debility and prostra- 
 tion. 
 
 IV. Bronchitis and pneumonia 
 common complications. 
 
 V. Emaciation from fever. 
 
 VI. Mental dulness from fever. 
 
 TUBERCULOSIS. 
 
 Diarrhoea from tubercu- 
 lar disease of intestines. 
 
 Remittent hectic fever 
 common, with caseous lung 
 or glands, etc. 
 
 Profuse sweating a part 
 of the natural course of the 
 disease. 
 
 Chronic pneumonia may 
 set up general tuberculosis. 
 
 Emaciation from tubercu- 
 losis. 
 
 Commencing Meningitis. 
 
 DIAGNOSTIC DIFFERENCES. 
 
 I. Characteristic rash on the 
 abdomen, etc. 
 
 II. Diarrhoea and abdominal 
 symptoms prominent. 
 
 III. Spleen often large. 
 
 IV. Lung symptoms late in 
 appearing. 
 
 V. Delirium and exhaustion, 
 proportioned to height and 
 duration of fever. 
 
 VI. Occurs in those previously 
 healthy. 
 
 VII. Profuse sweating less 
 common. 
 
 VIII. High fever. 
 
 IX. History of individual and 
 family healthy. 
 
 X. Any age. 
 
 No exanthem. Skin may 
 be erythematous ; or suda- 
 mina. 
 
 Bowels usually consti- 
 pated. 
 
 Spleen usually normal 
 size. 
 
 Lung symptoms appear 
 early. 
 
 Definite signs of menin- 
 gitis. 
 
 Usually previous lung 
 disease. 
 
 Sweating usual. 
 
 Fever not high. 
 Individual or family scrof- 
 ulous. 
 
 Usually young. 
 
28 CLINICAL MEDICINE AND CASE-TAKING, 
 
 DIABETES MELLITITS. 
 
 General conditimi. — Emaciation; weakness. Skin harsh and 
 dry. Mental aberration ; low spirits. See Nervous 
 System. 
 
 Digestion. — Appetite gi'eatly increased ; intense thirst. 
 Tongue frequently devoid of epithelium, raw and cracked. 
 Bowels costive ; sometimes diarrhoea. 
 
 TJrine. — Quantity usually greatly increased ; greenish colour ; 
 high sp. gr. ; sugar abundant. Micturition frequent. 
 
 Causation. — Most common in males and middle-aged adults ; 
 frequent in phthisical families. Exposure to cold. 
 Alcoholism ; excessive use of sugar ; violent emotional 
 disturbance ; organic Brain Disease ; over mental Avork or 
 anxiety. It may be associated with Gout. 
 
 ADDISON'S DISEASE. 
 
 General condition. — Debility, faintness, pigmentation. Antemia. 
 Frequently tubercular tendency. Shallow, feeble breath- 
 ing ; breathlessness, sighing, gasping, especially on 
 any effort. T. = ; usually subnormal. If not compli- 
 cated, no emaciation. Feeble heart action, faintness, pulse 
 thready. Death by asthenia, sudden or preceded by 
 incoherence, delirium, convulsions. 
 
 Digestion. — Nausea, retching, Vomiting, epigastric pain. 
 Examine buccal mucous membrane and that of lips. 
 Hiccough ; anorexia. 
 
 Nervous system. — Its general condition. Pains and sleeplessness. 
 Loss of nerve -muscular power ; extreme depression. 
 
GENERAL DISEASES — CLASS II. 29 
 
 DIABETES MELLITUS. 
 
 Characterized by excessive tliii'st, excessive hunger, emaciation. 
 Urine saccharine, dense, and greatly increased in quantity, 
 as a constant occurrence. Saccharine urine may be tem- 
 porary, as after a convulsion or administration of chloro- 
 form. Diabetes is the more permanent condition of 
 glycosuria, with constitutional symptoms and a tendency 
 to certain complications ; it usually has a fatal tendency. 
 Onset of symptoms may be insidious or sudden, with 
 nervous disturbance. Sugar may be detected in sweat, 
 tears, saliva. 
 
 Urine. — The quantity of sugar usually greatest after food. 
 Glucose may temporarily disappear ; so also, not uncom- 
 monly, shortly before death. 
 
 CoonpUcaticms. — Broncho-pneumonia ; Phthisis ; Pleurisy, 
 
 Serous inflammation of low type. Head-pain; sudden 
 
 Coma ; cataract ; Albuminuria, Skin disease, boils, 
 carbuncle, psoriasis, diarrhoea. 
 
 ADDISON'S DISEASE. 
 
 Characterized by pigmentation of the skin ; attacks of syncope 
 and extreme debility ; Anaemia, often without emaciation. 
 Vomiting, nausea, or epigastric pain. Discoloration is 
 a bronzing colour, specially marked in face, hands, neck, 
 groins, axillae, penis, scrotum ; areolae very dark ; buccal 
 mucous membrane stained ; conjunctiva always free. 
 Tendency to advance to death by asthenia. Sometimes 
 termination is sudden. 
 
30 CLIXICAL MEDICINE AND CASE-TAKING. 
 
 PURPURA. 
 
 Skin. — Description : Hseniorrliages into skin may occur in semTy, 
 
 typhus, measles, variola, or from injury. Ecchymoses 
 
 occur on forehead and under conjunctiva from asphyxia as 
 
 * in epilepsy, if stage of tonic spasm is prolonged, and after 
 
 severe paroxysms of hooping-cough. 
 
 It comes out in successive crops in aggi'egations of spots. Note 
 their size, situation ; whether separate or confluent. They 
 do not fade on pressure, do not enlarge ; but others may 
 occui' near those first produced, and become confluent with 
 them ; they soon absorb, undergoing changes like a bruise. 
 Some fade, while others appear. They occur mostly in 
 dependent parts, and are apt to occur in the legs in cardiac 
 or other obstruction. 
 
 The spots may be small, "petechia," or elongated patches, 
 "vibices," or in irregular patches, "ecchymoses." 
 The colour is violet, purple, or blackish. At first the 
 margins are abnipt, but these soon fade. Rarely the cuticle 
 is raised, forming "blebs." Development of spots 
 favoured by standing. 
 
 Causation. — Hepatic disease ; rheumatism ; syphilis ; heart 
 disease ; any debilitating conditions ; too restricted a 
 
 diet. 
 
 Not uncommon in old age, and accompanying insanity. 
 
 Look for htemon'hages of gastro-intestinal canal. Albuminuria 
 and signs of heart disease : albumen may be temporary. 
 See Heart and state of Vessels. General condition of 
 lassitude, with pain in limbs and joints. 
 
GENERAL DISEASES — CLASS II. 31 
 
 DEVELOPMENTAL DEFECTS. 
 
 Head,. — Ill-shapen ; narrow, prow-shaped forehead ; hyper-ossi- 
 fication in various parts. It may be too large or too small. 
 lU-shapen in the anterior or posterior segments. Forehead 
 overhanging. 
 
 Face. — Hare-lip ; epicanthic folds in excess. 
 
 Mouth. — Cleft palate and uvula. 
 
 Eyes. — Coloboma of iris or choroid, i.e., a deficiency or cleft ; 
 mall-shaped eyeball. 
 
 Ea.rs. — Asymmetry ; one or both may be more or less rudi- 
 mentary ; helix partly unrolled, with rudiment of third 
 lobe ; frequently are deformed with ichthyosis. 
 
 Skin. — Ichthyosis ; hair in excess on forehead, arms, back in 
 children; eyelashes too long ; fine or coarse. 
 
 Fingers. — "Webbed; supernumerary fingers or two thumbs, etc. ; 
 inspect feet and toes. 
 
 Heart. — See Congenital Defects. 
 
 Special abnormalities. — Patency of abdominal rings , non- 
 descent of testicle ; long prepuce ; imperforate anus ; 
 nsevus. 
 
32 CLINICAL MEDICINE AND CASE-TAKING. 
 
 SENILE DEGENERATION. 
 
 General condition. — Nutrition ; atrophy, or fatty growth. 
 Goitre occasionally. W. = . Skin, hair, colour ; abun- 
 dance. Involution of generative sj^stem. 
 
 Locomotor system. — Power to move about; state of joints; 
 power to walk. 
 
 Nervous system. — Look for tremors and Paralysis Agitans. 
 Sleep ; pains ; mental power ; memory ; neuralgia. 
 
 Eyes. — Arcus senilis ; cataract ; presbyopia ; hearing and special 
 senses. 
 
 Vascular system. — State of Vessels; heart-force. Look for 
 varicose veins ; purpura. 
 
 Respiratory system. — Emphysema ; dyspnoea on exertion 
 (cardiac). 
 
 Digestive system. — Teeth, gums, jaw ; feeble digestion ; flatu- 
 lence, constipation. 
 
 Urinary. — Albumen. 
 
GENERAL DISEASES — CLASS II. 33 
 
 SENILE DEGENERATION. 
 
 Sjjecial degenerative and 2Mthological tendencies. — The degene- 
 ration may be simply atrophy, the skin becoming wrinkled, 
 or there may be fatty growth generally under skin. Skin 
 loses elasticity, becomes wrinkled and pigmented ; it loses 
 transparency and brilliancy. Hair grows on chin in old 
 women ; cancer. 
 
 Nervous system. — Brain may be perfectly sound with an 
 atrophied body. 
 
 Prognosis as to life. — Soundness of the organs. The degree of 
 senility not being greater than the age of patient indicates. 
 Longevity is often inherited. Adaptation of patient's life 
 to state of his body. 
 
34 CLINICAL MEDICINE AND CASE-TAKING. 
 
 ARTHRITIC DISEASES. 
 ARTHRITIS. 
 
 Note pain, tenderness, swelling, lieat, redness, effusion in joints, 
 periarthritis. Deposits or enlargement of ends of bones or 
 out-growth therefrom. Position of joints ; mobility or 
 anchylosis. P. = ; T. = ; R. = . 
 
 Look for signs of Rheumatism and its complications ^Gonor- 
 rhcEal Rheumatism ; Gout and its history ; Rheumatoid 
 Arthritis, especially when the arthritis has a chronic course 
 with much stiffness and but little fever. 
 
 Tabulate the joints affected, indicating the condition of each 
 — "effusion," "swollen and painful," "tender and 
 red," etc. 
 
 RHEUMATOID ARTHRITIS. 
 
 Joints. — Arthritis may be acute or subacute. There may be 
 effusion, or only stiffness and pulpy feeling on manipula- 
 tion. The hand, when made into fist and squeezed, is 
 tender if finger joints are affected. Enumerate joints 
 affected ; it may attack temporo-maxillary articulation, or 
 stiffen cervical spine. Every joint in the body may be 
 anchylosed. Dislocation of affected joints may occur. 
 
 Causation. — Debilitating causes, haemorrhages, mental depres- 
 sion, starvation , dampness, and possibly heredity. It may 
 occui" at any age. 
 
ARTHRITIC DISEASES. 
 
 35 
 
 
 
 ARTHRITIS. 
 
 
 
 JOINTS. 
 
 
 EIGHT. 
 
 I 
 
 Shoulder. — 
 
 
 Shoulder. — 
 
 Elhow. — 
 
 
 Elbow.— 
 
 Wrist.— 
 
 
 Wrist.— 
 
 LEFT. 
 
 Hand. — Note separately the Hand. — 
 metaearpo-phalangeal joints 
 and internodes. 
 
 Hip. — Hi}). — 
 
 Ankle. — Ankle.-^ 
 
 Foot. — Specially note meta- Foot. — 
 carpo-phalangeal joint of 
 great toe. 
 
 Temporo- maxillary and vertebral joints. 
 
 RHEUMATOID ARTHRITIS. 
 
 Small joints commonly first affected, but large joints may be 
 equally attacked. The attacks last longer, are less severe ; 
 less pyrexia and constitutional disturbance than with Gout 
 and acute Rheumatism; more thickening left, with 
 deformity of joints. No deposits of urate of soda ; no 
 sweating. More commonly commences in fingers than 
 toes, and not with a sudden short attack of single joints. 
 
 Complications and accompaniments. — Any organic disease. 
 Anaemia ; Neuralgia. 
 
36 CLINICAL MEDICINE AND CASE-TAKING. 
 
 RHEUMATISM. 
 
 Histoiy of rheumatism ; heart disease ; chorea in family and in 
 collateral relations. Previous attacks in patient. 
 
 Present condition. — General signs of Fever. P. = ; T. = ; 
 R. = . Skin moist, sweating, sudamina. Note any 
 erythema. 
 
 Joints. — Whether tender or painful on movement ; swollen with 
 effusion, with or without cutaneous redness. Enumerate 
 the joints affected, specially noting whether large or small 
 joints are mostly affected. 
 
 Vascular system. — Development of cardiac bruits from valvular 
 disease ; pericarditis, with or without effusion. Always 
 map out area of cardiac dulness. Pulse, regularity, etc. 
 
 Eesjnra.tor]/ system. — Pleurisy, single or double ; extensive 
 effusion common. Pneumonia, usually at base ; it may 
 occur without special acute symptoms. 
 
 Nervous system. — Rheumatism may alternate with chorea, one 
 follo\^ing the other, near or at distant intervals. Occasion- 
 ally delirium. Sleep. 
 
 Urine. — Usually a deposit of pink lithates during fever. Rarely 
 a trace of albumen. 
 
 IthcumaMsm in children. — Symptoms often less severe than in 
 adults ; less pain, but little fever ; skin often dry ; great 
 tendency to heart disease, even when able to walk about ; 
 often thought to be "growing pains ;" duration of fever a 
 very few days, or it may be absent. 
 
 Noddies wwdiQY skin not uncommon, even without arthritis or 
 pain ; most common on prominences of bones or tendons, 
 about elbow, knee, ankle, spine. They are usually 
 accompanied by progressive heart disease. 
 
 Minor sym,2ytoms.' — Liability to swollen joints on over-exertion ; 
 stiff neck ; effusion in sheaths of tendons. 
 
 Purpura. — Great liability of serous inflammations without 
 arthritis. Erythema. 
 
ARTHRITIC DISEASES. , 37 
 
 RHEUMATISM. 
 
 A febrile disease, characterized by pyrexia and arthritis with 
 effusion, the inflammation changing from joint to joint and 
 attended with great pain. Skin moist, often sweating ; 
 this may be excessive and produce miliaria. Great tendency 
 to serous inflammations attended with great effusion, 
 usually quickly absorbed and not leading to suppuration. 
 Tendency of all these conditions to relapse after convales- 
 cence. Subacute attacks often succeed the acute. 
 
 In children pain and fever often slight, but still tendency to 
 heart damage very great. 
 
 Nodules. — Small masses of fibrous growth from size of a pin's 
 head to an almond, often felt better than seen ; painless, 
 usually movable. 
 
 Complications. — Inflammatory conditions ; endocarditis ; Peri- 
 carditis; Pleurisy; Pneumonia; Bronchitis. Relapses of 
 fever and arthritis. Erythema. Hyperpyrexia ; Delirium ; 
 Chorea. Albuminuria occasionally. 
 
 Tonsillitis is frequent at the onset with fever, or it may precede 
 it by a week or two. At same time there may be stiff" neck. 
 
 Causation. — Exposure to cold and wet. Inherited tendency. 
 Tendency to recurrence, especially in early years. 
 
 Exciting causes. — Exposure, over fatigue. Xote recent ante- 
 cedents ; scarlet fever, tonsillitis, pharyngitis. 
 
38 CLINICAL MEDICINE AND CASE-TAKING. 
 
 GONORRHCEAL RHEUMATISM:. 
 
 Joints. — Wrist and knee affected by preference. Pain and 
 effusion ; much stiffness, often causing a considerable 
 amount of anchylosis, No tendencj^ to suppm-ation, but 
 infilti'ation and thickening around joint. 
 
 Generative system. — Muco-purulent or gleety discharge from 
 urethra. 
 
 GOUT. 
 
 Joints. — Enumerate joints affected. Note periarthritic inflam- 
 mation and infiltration, deposit of concretion, or thickening 
 of bones. Examine bursse for tophi. Take the history of 
 previous joint affections. See Arthritis. 
 
 Vascular system. — When gout has lasted many years the 
 vascular system often degenerates ; Heart becomes dilated 
 and hypertrophied, especially with Granular Kidneys. 
 Pulse, force and tension. 
 
 Digestive system. — General signs. These functions are often 
 disturbed. Teeth much gi'ound. Liver disease common. 
 Enquire for piles. 
 
 Urine. — Often albuminous with signs of chronic Bright's 
 disease. Amount of TJric Acid deficient. 
 
AETHRITIC DISEASES. 39 
 
 GONORRHEAL RHEUMATISM. 
 
 Seldom seen in females. The disease runs its course through 
 weeks or months. After slightly affecting many joints it 
 becomes confined to one or two. No great pyrexia ; but 
 little tendency to inflammation of internal organs. 
 
 GOUT. 
 
 An acute attack usually commences in early morning in one 
 great toe. Severe pain, followed by swelling around the 
 joint ; local oedema ; skin red and glazed, exquisitely tender. 
 Attacks tend to recur at shorter intervals. Tophi or 
 concretions of urate of soda may form around joints, in 
 bursse, or in the external ears. 
 
 Causation. — Most common in males at middle life. Hereditary 
 tendency marked. Habits of intemperance ; exposure to 
 weather. Plumbism. Any depressing circumstances or 
 injury may excite an attack. 
 
 Complications aind accompaniments. — Chronic Bright's Disease. 
 Heart changes and Disease of Vessels. Skin affections ; 
 psoriasis, eczema. Diabetes. Liver disease. Thrombus in 
 veins. Tophi may discharge, forming sinuses. 
 
40 CLINICAL MEDICINE AND CASE-TAKING. 
 
 DISEASES OF THE NEEYOUS SYSTE:M 
 
 NERVOUS SYSTEM. 
 
 General conditions. — Intelligence ; Speech ; Sleep ; Head- 
 pain ; Vertigo ; Coma ; Vomiting ; Paralysis ; Convul- 
 sion ; Spasm ; Tremor ; Rhythmical Muscular Move- 
 ments ; Delirium. 
 
 INTELLIGENCE. — Giving good clear answers to questions. 
 Memory : Memory for past events, or those of recent 
 occuiTence ; power to perform easy calculations. The 
 face may temporarily or permanently lose the expression of 
 intelligence. 
 
 SPEECH. — Stammering. Slow, jerky. Using inarticulate 
 sounds only. Mute. Aphasia. 
 
 SLEEP. — Easily falling asleep ; sleeping soundly and waking 
 up refreshed in the morning. Wakeful ; disturbed by 
 dreams ; remembering dreams. Insomnia, i.e. , loss of sleep. 
 Raving at night. Somnambulism. Tooth gi'inding. 
 
 HEAD-PAIN. — 1 . Its situation, whether general or local. 
 
 2. Its characters — heavy, dull, aching, throbbing, shoot- 
 
 ing, darting, sense of fulness. Whether constant, inter- 
 mittent, recurrent, or periodical. Its intensity and 
 variability. 
 
 3. Effects of movement and change of position, of light and 
 
 sounds, etc. 
 
 4. Its mode of onset. If previous attacks, note periodicity. 
 
 5. If accompanied by soreness or tenderness at particular 
 
 spots, see Neuralgia. 
 
 6. Look to state of Special Senses, especially Sight ; Inquire 
 
 for dysesthesia of sight. 
 
 7. If accompanied by Vomiting, note its relation to pain. 
 
 8. Look for signs of Brain Disease, Convulsions, Paralysis, 
 
 Hysteria, Condition of Sensation. Examine Optic 
 Discs. Look for Neuralgia. 
 
 9. Examine urine for sugar and albumen. 
 10. Character of pulse ; temperature. 
 
 History of neurosis in individual or family. History of 
 phthisis or strumous affections. 
 
DISEASES OF THE XERVOUS SYSTEM. 41 
 
 NERVOUS SYSTEM. 
 
 Oeneral conditions. — Note all departures from the physiological 
 condition. The muscular power should be such as to 
 enable ordinary work to be performed. 
 
 INTELLIGENCE may be naturally dull or mental power may 
 be lost from disease, e.g., senile decay, dementia, general 
 paralysis, epilepsy. Mental delusions may arise in sane 
 people. Intelligence is proportioned to age, education, 
 and surroundings. Ask as to school- work in children. 
 
 SPEECH. — Aphasia = loss of faculty to speak words, though 
 he can recognize them when written or spoken. 
 
 Amnesia — loss of faculty for the memory of words, but 
 can repeat them if suggested to him. 
 
 SLEEP. — Restless tendency to turn the body may prevent 
 sleep even if drowsiness is present ; frequent in Alcoholism, 
 Insomnia may be caused by heart disease or over mental 
 exertion. Muscular tmtching and cramps not uncommon 
 from fatigue. Pain may prevent sleep. 
 
 HEAD-PAIN. — The first thing to decide is whether the case 
 be one of organic or functional disease ; in the latter case, 
 the attacks, when recur^-ent, are commonly spoken of as 
 headaches. 
 
 HEADACHE may be pericranial, frontal, occipital, or diffused, 
 or bilateral. Headaches may recur periodically ; in women 
 frequently at the menstrual period. After an attack there 
 is a certain amount of immunity. Attacks may be excited 
 by over-work, sleeplessness, want of food, errors of diet, 
 constipation, etc. With the attacks disorders of sight are 
 common : sparks, coloured stars, zig-zags Avith coloured 
 bright margins; hemiopia (seeing only half of any object 
 looked at). Other senses may be disordered. Vomiting 
 frequently terminates the attack. Accompanying the 
 attacks, or alternating with them, may be much mental 
 depression, mental weakness, and perverted ideas of things. 
 Such recurrent headaches are common during pregnancy. 
 Such attacks, accompanied by vomiting and coloured 
 vision, are often spoken of as " bilious attacks." 
 
 History. — Look for signs of Meningitis and Brain Disease. 
 
42 CLINICAL MEDICINE AND CASE-TAKING, 
 
 VERTIGO. 
 
 I. Feeling of giddiness experienced by the patient, objects 
 
 appearing stationary. 
 
 II. External objects appear to move, e.g. , up and down, 
 horizontally, approaching and receding. 
 
 Vertigo may be increased or relieved by movement and 
 
 position. 
 Test hearing and sight. Examine for diplopia. Look for signs 
 
 of Brain Disease. Anaemia. Examine Vascular System. 
 
 Urine. 
 
 COMA. 
 
 History ; onset ; previous signs of Brain Disease ; Convulsions ; 
 
 Vomiting. 
 Causation. — 1. Injury to head. 
 
 2. Examine urine generally, and for sugar and albumen ; also 
 
 for alcohol and poisons. 
 
 3. Cerebral Heemorrhage. See signs of Bright' s Disease. 
 
 Vascular Degeneration. 
 
 4. Coma sequent to Convulsion. 
 
 5. Coma may occur during fevers. 
 
 6. Meningitis and coarse brain disease. 
 
 7. Heart failure. Examine pulse and heart's sounds. 
 
 8. Delirium frequently ends in coma. 
 
 9. Alcoholism and poisons. 
 
 Circulation. — Xote pulse, small and soft in syncope, often hard 
 
 in ursemia. First sound in heart failure. 
 LooJc for signs of Brain Disease. State of Intelligence and 
 
 Sensation. Test poAver to perform certain acts, e.g., 
 
 protrude tongue, swallow food, move fingers, etc. 
 
 Condition of sphincters. Note condition of sleep. 
 
 Delirium. Subsultus tendinum. Position of body, e.g., 
 
 dorsal decubitus. Character of respiration, whether 
 
 stertorous. 
 Examine for signs of Brain Disease and Paralysis. Examine 
 
 urine ; lungs ; heart, its strength and sounds ; pulse ; 
 
 condition of arteries. Smell breath for alcohol. (Edema. 
 
 Temperature. Action of sphincters. Eyes : strabismus ; 
 
 Pupils. Ophthalmoscope. Reflexes. 
 
DISEASES^ OF THE NEEYOUS SYSTEM. 43 
 
 VERTIGO. 
 
 May occur during sleep or on waking. It is common at 
 climacteric period with degeneration of vessels, 
 Emphysema, Bright' s Disease. Vertigo may be due to 
 diplopia dependent upon weakness of an ocular muscle 
 or to some error of refraction as hypermetropia. 
 Meniere's disease of ear ; Alcoholism ; excessive smoking ; 
 mental or physical exhaustion ; dyspepsia ; anaemia; 
 heart disease ; exposure to the sun. It may accompany 
 simple recurrent Headaches . 
 
 COMA. 
 
 History. Coma may result from old-standing brain disease. 
 
 There may be history of chronic disease capable of 
 
 producing coma. 
 
 Causation. — 1. Injury may produce compression of the brain. 
 
 Collapse ; shock ; syncope. 
 
 2. See Uraemia. In Diabetes glycosuria may disappear 
 
 before coma sets in. 
 a. Extensive cerebral hsemorrhage may cause deep coma. 
 Haemorrhage into pons causes universal powerlessness 
 and contracted pupils, resembling opium poisoning. 
 
 4. Any severe exhaustion may cause coma. 
 
 5. Exposure to great heat, as summer sun. 
 
 6. Almost any brain disease may end in coma. 
 
 7. Arterial Disease may lead to cerebral haemorrhage ; 
 
 heart disease to Embolism. 
 
 8. This is a great danger in fevers. 
 
 Look for — Coma may be partial or complete, constant or 
 remittent. Signs of motor power may be partially 
 or wholly lost. It may be a sign of the Typhoid state, 
 with delirium ; then the pulse is usually very soft. 
 "Wandering at night in febrile diseases may pass on into 
 Delirium and coma. The lungs are usually congested, with 
 pulmonary oedema or hypostatic pneumonia. 
 
 ExamiTie for Alcoholism; smell breath and test urine. The 
 vomits or washings of the stomach may be smelt and 
 tested for poisons — opium, alcohol, hydrocyanic acid. 
 Urine may be obtained by the catheter. Stomach-pump 
 may be used in poisoning cases. Avoid mistaking brain 
 disease for poisoning. 
 
44 CLINICAL MEDICINE AND CASE-TAKING. 
 
 VOMITING. 
 
 Describe vomits ; containing undigested food, frothy like 
 yeast ; look for sarcinse ; watery ; smell ; containing blood 
 or bile. 
 
 See State of Tongue and bowels ; Abdominal Pain ; signs of 
 dyspepsia. 
 
 Look for reflex causes, e.^., pregnancy, Ovarian Tumour, disease 
 of liver, Gall-stones ; Renal Calculus. Examine urine. 
 
 Causatiaa. — Stomach disease or derangement. ffisophageal 
 obstruction. Obstruction of Bowels. Poisons. Alcoholism. 
 Uraemia. Hepatic disease. Pelvic disease. Pregnancy. 
 Ovarian disease. Addison's Disease. Brain Disease or 
 disturbance. Migraine. 
 
 DELIRIUM. 
 
 Its characters ; if attended with illusions and purposeless 
 muscular movements, e.g., subsultus tendinum, picking of 
 bed-clothes, etc. Test consciousness by speaking to 
 patient and requiring an ansAver to a question, or that he 
 shall protrude his tongue, etc. 
 
 Causation. — Plumbism, Alcoholism, and such causes as may 
 produce Coma. Belladonna. Camphor. 
 
 TYPHOID STATE. 
 
 Asthenia or adynamia. Temperature not high. Tongue 
 tends to dryness, with crusting and formation of sordes on 
 teeth and gums ; lips cracked and dry ; deglutition difficult. 
 Pulse very soft, compressible, dicrotous, irregular. Heart's 
 action weak ; first sound hardly heard. Tendency 
 to pulmonar}^ congestion, cedema, and hypostatic 
 pneumonia. 
 
 Drowsiness ; Delirium ; Coma ; subsultus tendinum ; picking 
 bed-clothes. Paralysis of sphincters or retention of urine. 
 Dorsal decubitus complete. 
 
DISEASES OF THE NERYOUS SYSTEM. 45 
 
 VOMITING. 
 
 If of cerebral origin it is — 1. Purposeless, not specially after 
 taking food, and not relieving symptoms. 
 
 2. Tongue clean ; no special signs of Digestive Disturbance. 
 
 3. General absence of premonitory symptoms or nausea before 
 
 vomiting ; contents of stomach ejected easily without 
 retching or much effort. 
 
 4. Yomiting frequently aiTested by the horizontal position, 
 
 recurring on becoming erect. 
 
 5. Concomitant signs of disturbance of the Nervous System 
 
 or signs of Brain Disease. 
 If vomiting appear to be of cerebral origin use Ophthalmoscope. 
 Take temperature ; look for other signs of Brain Disease. 
 Intermittent pulse is an early sigu of Meningitis in 
 children. 
 
 DELIRIUM. 
 
 May be active ; violent ; low muttering. It usually commences 
 at night with talking and wandering of the mind. AVhen 
 moderate in degree temporary consciousness may be 
 restored by speaking loudly and clearly, Is usual in the 
 course of fevers. It may be due to simple exhaustion ; as 
 from hsemorrhage after labour, etc. 
 
 TYPHOID STATE. 
 
 A prostrated condition, nervous symptoms, heart failure. An 
 unfavourable termination of Delirium, Coma, delirium 
 tremens, and acute febrile diseases. Note at each observa- 
 tion strength of heart sounds, force of pulse, and the mani- 
 festation of any further nervous symptoms. Dorsal decu- 
 bitus is usually complete, i. e. , the patient lies flat in the 
 trough of the bed ; muscular power is prostrated. If pro- 
 longed, bed-sore may form. Albuminuria and hypostatic 
 pneumonia frequently coincident. 
 
46 CLINICAL MEDICINE AND CASE-TAKING. 
 
 PARALYSIS. 
 
 See Hemiplegia ; Palsy of Cranial Nerves ; Minor Paralyses. 
 Test Motor Power. 
 
 See signs of Brain Disease ; signs of Disease of Spinal Cord. 
 
 View the part paralysed, and examine as to Motor Power. 
 Note the parts paralysed and the muscles affected, stating 
 whether the fine and general movements of the limb are 
 wholly lost. Kote state of nutrition of the part, contrac- 
 tions, rigidity, etc. Test reflex action by tickling, 
 pricking, etc. See Sensation. Electric Tests. Examine 
 Optic Discs. Look for signs of Syphilis. Vascular 
 Degeneration. 
 
 ELECTRIC TESTS. 
 
 If one muscle contract to a lesser force of the cuiTent than 
 another, it is said to be more irritable, To ascertain the 
 irritability of a muscle reduce the strength of the current to 
 the lowest point at which it will produce action. A full 
 power of current simply shows the strength of the muscle. 
 If in hemiplegia there be a well-marked difference in the 
 reaction of the two sides the paralysis is not feigned. 
 Diminished contractility may be due to disease of brain, 
 cord, motor nerve, morbid condition of the muscle. 
 
 The faradaic current may be applied over the muscle to be 
 tested, or the galvanic current to the nerve supplying it. 
 
 Loss of electric contractility is a sui'e sign of disease. 
 Faradization is sometimes useful to prove the presence of 
 muscle in a fat limb in which it is suspected that tissue 
 is wasted. 
 
 Functional aphonia may be from hysteria or exhaustion. Some- 
 times the fauces, palate, and pharynx are anaesthetic. 
 Laryngoscope shows healthy, motionless, white true cords, 
 and a larynx otherwise healthy. 
 
 Histoi'y — Often sets in suddenly. Liable to relapses. 
 
 Look for Hysteria, Phthisis. Signs of mediastinal pressure. 
 
DISEASES OF THE NERVOUS SYSTEM. 
 
 47 
 
 PARALYSIS. 
 
 Paralysis may depend upon disease of nerves or nerve-centres, 
 or may be only Functional Paralysis. "When a muscle is 
 paralysed, it usually atroj)hies in a short time, and on 
 regaining strength regains its nutrition. In pseudo- 
 hypertrophic Paralysis, the flexor muscles of the lower 
 extremities become weak, but greatly enlarged. 
 In paraplegia, see Spinal Cord Disease. 
 
 Paralysed muscles often become rigid, e.g., hemiplegia, 
 Infantile Paralysis. General muscular weakness, not 
 dependent on simple debility and not secondary to disease 
 of viscera, is seen in General Paralysis and Diphtheritic 
 Paralysis. See Minor Paralyses. 
 
 FUNCTIONAL. ORGANIC. 
 
 Age and sex. — Most frequent at Most common in degene- 
 
 onset of puberty and climac- ration ; sexes more equally 
 teric period ; almost confined 
 to females. 
 Hysteria. — Present more or less. 
 No signs of organic disease. 
 
 ^ trophy of palsied iKtrt. — Palsied 
 part well nourished. No 
 bed-sore. 
 
 Sensation. — May be lost, hy- 
 persesthetic, or perverted. 
 
 Reflex action. — Not obliterated. 
 
 Electric tests. — Reaction readi- 
 ly obtained. 
 
 Palsy of Cranial Nerves. — Not 
 seen. 
 
 Aphonia. — Common ; may be 
 the only palsy. 
 
 Part paralysed. — Frequent 
 change. Often partial of one 
 limb or part. Sphincters not 
 paralysed. Urine often re- 
 tained. 
 
 affected. 
 
 No signs of Hysteria of 
 Epilepsy. Disease of heart, 
 kidneys, etc. 
 
 Atrophy follows paralysis. 
 Sacral bed-sore frequent. 
 
 If lost temporarily, usually 
 returns before motor power. 
 In very many cases lost. 
 Lost in disease of cord. 
 
 Common ; specially of face 
 and tongue. 
 
 Rare from organic nerve 
 disease. See Aphasia in 
 right hemiplegia. 
 
 No changes without fresh 
 lesion. May be perma- 
 nently rigid, with coldness 
 and tendency to slight 
 ojdema. 
 
48 
 
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50 CLINICAL MEDICINE AND CASE-TAKINa. 
 
 CONVULSION. 
 
 Par oxy 3771. — Note the order, progress, and kind of spasm ; 
 whether mostly Tonic or Clonic Spasm, Commencement, 
 whether general or local ; commencing on one side, e.g., one 
 hand or finger. Note suddenness of onset, whether 
 attended with asphyxia and marked cyanosis ; its 
 duration. Face pale or flushed ; fulness of veins ; 
 whether distortion of face ; head retracted. Eyes : their 
 position ; strabismus ; state of Pupils. Condition of 
 consciousness. 
 
 Premonitory symptoms. — Aura Epileptica; muscular twitches; 
 dilatation of pupils. 
 
 Causation. — Brain Disease ; Rickets ; Syphilis ; Bright's 
 Disease ; Epilepsy; Hysteria. Acute diseases — (1) Cerebral ; 
 
 (2) Febrile ; (3) Exanthemata ; (4) Pulmonary. Reflex 
 exciting causes, e.g., indigestion, w^orms, teething, ear 
 disease. Examine heart, urine, temperature. 
 
 Sequelce. — Paralysis ; amaurosis ; strabismus ; defect of speech ; 
 mental disturbance ; mania ; drowsiness ; sleep ; Coma. 
 
 SPASM. 
 
 1. Tonic Spasm = continuous muscular contraction during a 
 
 longer or shorter interval. 
 
 2. Clonic Spasm = alternate contraction and relaxation of 
 
 muscles. 
 
 racial Spasm is usually one-sided only. The successive clonic 
 spasms are of equal extent and severity, so that successive 
 grimaces resemble one another. In many cases it is 
 chronic in duration and unaccompanied by other spasms. 
 In these particulars it differs from Chorea. 
 
 Writers' Cramp. — On attempting to wTite, the muscles 
 ordinarily used in the act are thrown into a state of tonic 
 spasm ; this subsides on discontinuing the act of WTiting. 
 Other dissimilar acts may be performed without spasm. 
 
DISEASES OF THE NERVOUS SYSTEM. 51 
 
 CONVULSION. 
 
 Paroxysm. — Usually commences wdth tonic spasm and pallor 
 or cyanosis, followed by clonic spasms. One side or one 
 limb may be primarily or chiefly affected ; then, occasionally, 
 the eyes and head turn to that side, and there may be a 
 few one-sided jerks of the head. Pupils usually dilated. 
 
 Premonitory sym,ptoms. — In children, frequently, fist is clenched, 
 with thumb turned in. Laryngismus may precede 
 convulsion. 
 
 Causation. — In children convulsions are very easily produced 
 by slight causes. Ill-feeding, teething, worms, and 
 Rickets very common predisposing causes. Pyrexia may 
 be due to an acute disease or to continued tonic spasm. 
 Urine may be albuminous from Blight's Disease, or may 
 contain albumen or sugar consequent upon the convulsion. 
 
 Sequelce. — Convulsions may be symptomatic of brain disease, 
 which may subsequently advance. 
 
 SPASM. 
 
 Tonic Spasm is frequently attended by pain, and may be 
 preceded by hypersesthesia. It is seen in the first stage 
 of an Epileptic convulsion ; trismus, or lock-jaw ; tetanus ; 
 spasmodic talipes ; spasmodic torticollis. 
 
 Clonic Spasm may be increased by effort or mental excite- 
 ment, and may subside during sleep and under chloroform, 
 e.g., epilepsy. It causes movement or displacement of 
 the limb or part affected. It is seen in chorea and 
 muscular tic. 
 
 Causation. — Look for signs of Hysteria. Reflex exciting 
 causes, e.g., pregnancy, intestinal worms, teething. 
 Dyscrasise, Ursemia, fevers, spinal irritation, and menin- 
 gitis. Hydrophobia. Hysteria. Brain Disease. 
 
52 CLINICAL MEDICINE AND CASE-TAKING. 
 
 LARYNGISMUS. 
 
 Look to Nervous System. Convulsion. General convulsions 
 often follow. It may occur in hysterical women, but is 
 most common in infants. Paroxysms may be brought on 
 by excitement or fatigue. Look for Rickets, teething, 
 constipation. There may be tonic contretction of muscles 
 of limbs. 
 
 TREMOR. 
 
 L Tremor absent when at rest, but of various intensity when 
 executing a more or less co-ordinated movement, e.g., 
 raising a glass of water, picking up a pin. 
 
 IL Tremor continuous and permanent. Purposive movements 
 exaggerate it, but it does not disappear on repose. 
 
 K'ote the sets of muscles affected ; whether head is moved ; 
 whether muscles supplied by Cranial Motor Nerves are 
 affected. Test Patellar Tendon Reflex, Take sample of 
 patient's writing. 
 
 RHYTHMICAL MUSCULAR MOVEMENTS. 
 
 Athetosis = gliding movements, frequently repeated in the 
 same order. Generally accompanies epilepsy, and usually: 
 hemiplegic in situation. 
 
DISEASES OF THE NERVOUS SYSTEM. 53 
 
 LARYNGISMUS. 
 
 Characterized by paroxysmal convulsion of the laryngeal 
 muscles and noisy inspiration ; no specific catarrh or 
 special lung trouble, as in Hooping-cough. Muscles of 
 chest and abdomen may be involved. Most common in 
 young boys, and on waking from sleep. It may become 
 almost continuous crowing, the veins being distended and 
 face distressed. Child rarely dies in an attack. 
 
 TREMOR. 
 
 In Paralysis Agitans, tremor continues when at rest. 
 
 In Sclerosis, ti'emor is increased by movement, ceasing during 
 repose ; so also in mercurial tremor. 
 
 In paralysis agitans, the face, head, and cranial nerves usually 
 escape. 
 
 Sleep arrests ti'emor temporarily. Tremor may be general, 
 affecting the head, or not ; it may be localized to 
 a limb. Tremor is a simple vibratory repetition of 
 purposeless movements, not displacing a limb greatly. 
 Fine movements are those through small arcs. 
 
 Muscular tremor is a characteristic symptom in paralysis 
 agitans. Disseminated sclerosis ; Alcoholism ; mercurial 
 tremor ; General Paralysis of the Insane. 
 
 RHYTHMICAL MUSCULAR MOVEMENTS. 
 
 Athetosis may be a congenital or an acquired disease ; it may 
 be hemiplegic or both-sided. 
 
54 CLINICAL MEDICINE AND CASE-TAKING. 
 
 MOTOR POWER. 
 
 Ability to stand, -walk, walk up stairs, work, etc. State some 
 act the patient can or cannot perform ; how far he can Avalk. 
 Power over large joints, small joints, finer movements of 
 fingers, e.g., writing. 
 
 Movements of upper mid lower extremities. — Test power of 
 simple movement, and power to overcome resistance. 
 Test movements of larger joints and muscles ; and power 
 over individual digits. 
 
 Movements of head and trunk. — Patient lying on his back, let 
 him erect trunk -without use of hands. Examine spine. 
 
 Respiratory movements. — Note respiratory rhythm ; movements, 
 whether principally thoracic or diaphragmatic. 
 
 Co-ordinaMon of the limbs. — Gait in walking ; walking well 
 and firmly with head erect ; also walking straight with 
 eyes shut ; walking stiff, one joint being kept immobile 
 from pain ; hip movements much restrained in Sciatica. 
 Circumducting one leg, s\vinging it round, not moving it 
 forward as the other, seen in Hemiplegia. Staggering, 
 moving trunk over place where the legs are. Lifting legs 
 inordinately high, then bringing them suddenly down. 
 Walk with eyes shut. Test for Muscular Anaesthesia. 
 
DISEASES OF THE NERVOUS SYSTEM. 55 
 
 MOTOR POWER 
 
 May be lessened from general weakness or be lost in one or 
 two extremities only, or in a certain group of muscles. 
 See Paralysis. 
 
 Movements of upper and lower extremities. — Palsy of upper 
 extremity, if of cerebral origin, is usually accompanied by 
 weakening of lower extremity. Let patient move limbs 
 to order ; lift weights ; pick up a pin, etc. 
 
 Movements of head and trunk. — Motor power over spine may be 
 lost from caries of spine. Pseudo-hypertrophic Paralysis. 
 View spine ; feel for curvatures. 
 
 Respiratory tnoxiements. — Cheyne's respiration. = a series of 
 respirations hurried and deep up to a certain point, then 
 subsiding to a dead pause. 
 
 Go-ordination of the limbs. — If defective, examine joints. 
 Sciatica. Spasms. Tremors. Paraplegia. Chorea. In 
 Paralysis Agitans there is a tendency to propulsion or 
 retropulsion. In General Paralysis, stumbling and 
 staggering, or tottering. In Ataxy, muscular power in 
 the legs is not lost ; the patient may walk, feeling the 
 ground with a stick. In Hemiplegia the patient in 
 walking swings round the leg, and then keeping it stiff 
 balances the trunk upon it. 
 
56 CLINICAL MEDICINE AND CASE-TAKING. 
 
 SENSATION. 
 
 Objective sensibility (ascertained by examination). — Tactile 
 sensibility of skin. Examine separately the flexor and 
 extensor surfaces, face, trunk. Test tbe least distance at 
 Avbich two points can be distinguished in various regions. 
 Sensibility to heat and cold. Apply to various parts two 
 test tubes, one containing hot water, the other cold. Or 
 apply a hot and cold sponge alternately. 
 
 Subjective sensibility (sensations experienced by patient). — 
 Localized pain in the area of a certain cutaneous nerve, 
 constant or periodical, suggests enquiry as to Neuralgia. 
 Sensibility may be lessened, anaesthesia ; exalted, hyper- 
 esthesia. Sensation may be perverted, the patient ex- 
 periencing altogether abnormal sensations, dyssesthesia, 
 e.g., numbness, "pins and needles," a sense of burning, 
 heat and cold. If subjective sensations are complained 
 of, examine for an objective cause, e.g., local tenderness, 
 local inflammation or disease, periostitis. Reflex causes, 
 gasti'ic, uterine, etc. See Head-pain, Vertigo, Hysteria, 
 Neuralgia, Muscular Anaesthesia. 
 
 MUSCULAR ANESTHESIA. 
 
 Let patient carry his hand to his mouth, and repeat the act 
 with his eyes shut ; let him state the position of his limbs 
 A^-ith his eyes shut ; let him distinguish between diff'erent 
 weights. In all such attempts he fails. Test reflex 
 action, and electric excitability (usually diminished). 
 Note what muscles are aff'ected ; state of muscular 
 nutrition ; presence or absence of pain. Test cutaneous 
 sensibility. 
 
DISEASES OF THE NERVOUS SYSTEM. 0/ 
 
 SENSATION. 
 
 Anaesthesia, loss or diminution of sensibility ; hypersesthesia, 
 exaltation of sensibility. Both these conditions frequently 
 met with in Hysteria. 
 
 Hemianaesthesia is usually functional ; it may paralyse the 
 special senses of side affected ; it is frequent in hysteria. 
 Analgesia is the loss of sensibility to pricking, pinching, 
 etc. It may be temporarily removed or transferred to the 
 other side of the body. 
 
 Subjective sensibility may be ansesthetic, hypersesthetic, or 
 dyssesthetic, i.e., sensibility may be lessened, exalted, or 
 perverted. The brain centres of the organs of special sense 
 may be altered in any of these ways ; so also the sense of 
 touch. As sensations of physical life we may speak of 
 "organic sensations," or those due to the changes occurring 
 in the organs of digestion, circulation, respiration, etc. ; 
 the "appetites," a group of uneasy feelings produced 
 by the recurring wants or necessities of the physical 
 system, as sleep, exercise, repose, thirst, hunger, etc. 
 Special dysaesthesise are the epileptic aura, the lightning 
 pains of ataxy, the sensation of girthing frequent in spinal 
 cord disease. 
 
 MUSCULAR ANESTHESIA.* 
 
 ' ' A loss of the feeling of muscular action, attended by 
 irregularity, sluggishness, and diminished force of volun- 
 tary movement ; but unattended by any necessary loss of 
 cutaneous sensibility or by distinct paralysis." 
 
 A condition frequently seen in Hysteria. Usually there is no 
 pain in the limbs, but pain is common in Locomotor Ataxy. 
 It may be local. It often precedes paraplegia. Usually 
 impaired or lost in General Paralysis. Some muscular 
 anaesthesia may accompany attacks of migraine. See 
 Headache. 
 
 * Dr. Reynolds' " System of Medicine." 
 
58 CLINICAL MEDICINE AND CASE-TAKING. 
 
 SPECIAL SENSES. 
 
 Sight. — Test acuteness of vision witli test-type. Examine for 
 perception of colour. To completely examine the sense of 
 sight, further test poAver of accommodation, refraction, 
 action of ocular muscles separately and in the combined 
 movements of the eyes. Examine the field of vision. 
 See Pupils. Ophthalmoscopic Appearances. 
 
 Hearing. — Test hearing with a watch held at the greatest 
 distance at which it can be heard from each ear. If 
 watch cannot be heard thus, test auditory power of the 
 nerve for sounds conducted through the skull, i.e., place 
 watch on forehead or between teeth. Look for otorrhoea ; 
 examine throat ; use ear speculum. 
 
 Taste. — For acids, bitters, sapid substances ; determine each 
 separately at anterior and posterior portions on either side. 
 
 Smell. — For pungent substances, e.g., ammonia; aromatic 
 substances, e.g., oil of cinnamon. 
 
 CRANIAL NERVES. 
 
 Observe movements of eyes, tongue, face, lips, palate, muscles 
 
 of mastication and deglutition. Pupils. 
 Test Special Senses ; sensibilit}'" of head and face. 
 Nerve I.— Olfactory, See Smell. 
 
 Nerve II. — Optic, see Sight, Pupils, Ophthalmoscopic appear- 
 ances. 
 Nerve III. — (Palsy). — Ptosis or drooping of the upper eyelid ; 
 
 permanent external strabismus ; dilated pupil ; loss of 
 
 accommodation for near objects. 
 Nystagmus = purposeless vibratory movements of the eyes ; 
 
 usually the movements are in the horizontal plane. 
 Nerve IV. — Superior oblique muscle. Palsy produces no 
 
 appreciable deviation of the axis of the eye, but diplopia 
 
 results and the diagnosis generally depends upon the 
 
 relative position of the two images. 
 Nerve V. — Motor to temporals, masseters, and pterygoid 
 
 muscles. Examine condition of its separate branches. 
 
 See Neuralgia, Trigeminal. Examine power of Taste. 
 
 Look for tooth grinding. 
 
. DISEASES OF THE NERVOUS SYSTEM. 59 
 
 SPECIAL SENSES. 
 
 Sight — Defects may occm- from errors of accommodation, myopia, 
 hypermetropia, or astigmatism, from changes in the optic 
 nerve or other parts. Illusions may represent an aura 
 preceding an epileptic fit ; common in delirium and insanity, 
 not uncommon with recurrent Headache. 
 
 Hearing. — Deafness may result from obstruction of the Eusta- 
 chian tube from pharyngeal catarrh, or tonsil disease ; wax 
 in ear ; disease of tympanum. The nerve may be paralysed 
 from disease, e.g., Syphilis; rarely from cerebral tumour. 
 Tinnitus common with and without ear disease. 
 
 Taste. — Taste may be lost on one side only. It is impaired in 
 some cases of palsy of Nerve YII. 
 
 Smell. — Test either nostril separately. 
 
 CRANIAL NERVES 
 
 Are some sensory, others nerves of special sense, while others 
 are purely motor. The condition of the parts that they 
 supply, as found on examination, often throws much light 
 on the condition of the brain. Paralysis of an ocular muscle 
 or the tongue would indicate intra-cranial disease. 
 
 Nerve III. — Paralysis often partial, e.g., ptosis only. Accom- 
 modative power alone may be lost, e.g., in Diphtheritic 
 Paralysis. This nerve is frequently paralysed from 
 Syphilis. 
 
 Nystagmus. — A chronic condition, usually congenital, and 
 dependent upon deeply-seated brain lesion. 
 
 Nerve V. — Sensory branches give sensibility to the lateral and 
 anterior parts of the head and the eyeball, and common 
 sensibility with taste to the anterior two-thirds of the 
 tongue. It is the afferent nerve in reflex winking on 
 touching the eyeball ; if palsied, the eyeball becomes 
 insensitive and the cornea ulcerates and sloughs. See 
 Neuralgia, Trigeminal. 
 
€0 CLINICAL MEDICINE AND CASE-TAKING. 
 
 CRANIAL NERVES. 
 
 Nerve VI. — External rectus of the eye. 
 
 Nerve VII. — Examine movements of face in natural expression, 
 in forced voluntary movements, e.g., to giin and show 
 teeth, to frown, to elevate the forehead, to whistle. See 
 respiratory movements of alee nasi. Facial movements, are 
 they symmetrical ; compare the two sides of the face. See 
 position of the angles of the mouth, and slope and 
 curve of the upper and lower lips. The depth of the naso- 
 labial groove. Orbicularis oris, its power of holding air in 
 the mouth with the cheeks blown out. Orhiciilo.ris oculi^ 
 its action in closing the eyelids, in producing similar folds 
 of the eyelids on the two sides ; a similar width of palpe- 
 bral fissure on the two sides ; a firm application of the 
 lower eyelid to the globe, with the punctum applied to the 
 conjunctiva. Note action of Occipito-frontcdis and Cwru- 
 gatoT. Test reflex actions of the eyes. Note pronunciation. 
 Examine with care the movement of the soft palate and 
 tongue. Test Hearing, Sight, Smell, Taste. Look for 
 dryness of mouth from want of saliva. 
 
 Nerve VIII. — Pneumogastric ; Glosso-pharyngeal ; Spinal 
 Accessory^ Pneumogastric. Not pui-ely a cerebral nerve ; 
 partly spinal, and receiving branches from the sympathetic. 
 
 Motor braiiches. — To larynx, pharynx, oesophagus. Pharyngeal, 
 concerned in reflex act of deglutition. 
 
 Sujjerio^' laryngeal. — Mostly sensory, but motor to arytenoid 
 and crico-thyroid. Its stimulation inhibits inspiration, 
 e.g., when opening of larynx is irritated. 
 
DISEASES OF THE NERVOUS SYSTEM. 61 
 
 CRANIAL NERVES. 
 
 Nerve VI. — It is opposed by Nerve III. 
 
 Nerve VII. — Motor to muscles of face, these muscles being 
 used in expression, respiration, eating ; certain reflex 
 actions, e.g., eyelids, mouth. 
 
 Intra-cranial branches. — Ch'eat petrosal through Michel's gang- 
 lion to levator palati and azygos uvulae. Small 2)etrosal 
 through otic ganglion to tensor palati and tensor tympani 
 and parotid gland. Tympanic branches to stapedius and 
 laxator tympani. Chorda tyr)i2Kini to submaxillary gland 
 and lingualis. 
 
 Bell's Paralysis of the Face differs from the facial paralysis 
 produced by brain disease in being more complete and 
 general in distribution ; in the latter the muscles about 
 the angles of the mouth are mostly affected as seen in 
 grinning. Bell's paralysis affects all the muscles on the 
 side of the face ; the eyelids, however, retain a little 
 power. The creases of the face are obliterated, as seen 
 on the forehead and in the naso-labial groove ; the eye 
 remains more or less permanently open, and the tears 
 overflow. The patient cannot distend the mouth with air, 
 and food accumulates in the cheeks. 
 
 Causation. — Cold, disease of ear, syphilitic disease of temporal 
 bone, pressure of glands on facial nerve. 
 
 Nerve VIII.— 
 
 Pneumogastric nerve. — Is concerned in certain reflex actions, e.g., 
 deglutition, reflex movements of glottis. 
 
 Pharyngeal branches. — Palsied in Diphtheritic Palsy, in Bulbar 
 Paralysis, and much dulled in the Typhoid State. Con- 
 cerned in reflex throat cough. 
 
 Sicjjerior laryngeal. — Afferent nerve in reflex movements, 
 closing larynx in deglutition or when irritated. 
 
62 CLINICAL MEDICINE AND CASE-TAKING. 
 
 CRANIAL NERVES 
 
 2{erve VIII. — Continued. 
 
 Recurrent laryngeal. — Chiefly motor ; supplies all the muscles 
 of the larynx except the crico-thyroid. 
 
 Cardiac hranclies. — Inhibitory ; pulse may be irregular from 
 brain disease, and small from mental depression. 
 
 Pulmonary branches. — Afferent fibres convey the feeling of the 
 necessity to breathe. Motor fibres supply the bronchi. 
 
 Gastric branches. — Regulate the peristaltic movements, and the 
 secretion of gastric juice. 
 
 Abdomviud branches. — Supply liver and are connected with the 
 renal plexus. 
 
 Glosso-pharyngeal nerve. — Gives common and gustatory sensi- 
 bility to the tongue, supplying circumvallate papillse at 
 back of tongue. 
 
 Spinal accessory nerve. — A motor nerve closely associated with 
 the pneumogastric and giving it motor fibres, some of 
 which go to larynx. 
 
 Nerve IX. — Principally motor to the tongue and depressors of 
 the larynx and lower jaw. 
 
DISEASES OF THE NERVOUS SYSTEM. 63 
 
 CRANIAL NERVES. 
 
 Nerve VIII. — Continued. 
 
 Recurrent laryngeal. — Left winds round arch of aorta, right 
 round innominate artery. When paralysed glottis is 
 passively narrowed on inspiration, and passively dilated 
 on expiration. It may be paralysed by thoracic Aneurism 
 or mediastinal tumour, and thus lead to palsy of cor- 
 responding vocal cord. 
 
 Tulmonary hranclies. — Concerned in spasmodic Asthma, 
 Hooping-cough, Laryngismus Stridulus. When para- 
 lysed leads to congestion of the lungs, e.g., in Typhoid 
 State. 
 
 Gastric branches. — Afferent in cerebral Vomiting. Dyspepsia 
 may result from brain disturbance. 
 
 Ahdominal branches. — Mental shock may excite Diabetes. 
 Anxiety causes flow of pale urine of low sp, gr. 
 
 Glosso-pharyngeal nerve. — It is concerned in reflex deglutition 
 
 Spinal accessory 7ierve. — Motor to sterno-mastoid and trapezius ; 
 fibres pass to the larynx and control the voice, not respira- 
 tory movements. 
 
 Nerve IX. — Concerned in articulation, mastication, and the 
 commencing act of deglutition. Each function may be 
 separately lost. 
 
64 CLINICAL MEDICINE AND CASE-TAKING. 
 
 BRAIN DISEASE, SIGNS OF. 
 
 Head-pain ; Vertigo ; Cerebral Vomiting ; Convulsion ; 
 Paralysis ; Hemiplegia ; palsy of Cranial Nerves ; sti-abis- 
 mus ; palsy of Special Senses. Mental or intellectual 
 disturbance : Coma ; Aphasia. Changes in Optic Nerve. 
 Pnlse, interniittence of. Pupils. See general condition of 
 the Nervous System ; Sensation ; Hysteria. 
 
 ExoAnirmtion. — Look for history of neuroses ; previous signs of 
 Brain Disease. Indications of acute diseases, e.g., take 
 temperature and look for other signs of Fever. Examine 
 vascular system and urine. 
 
 OPHTHALMOSCOPIC APPEARANCES. 
 
 Test sight and examine Pupils previous to using ati'opine. 
 Some of the principal conditions of the fundus that may 
 be observed are — Optic Neuritis ; Optic Atrophy, (1) 
 primary, (2) secondary to neuritis or consecutive atrophy ; 
 over-fulness of veins ; emptiness of arteries ; Haemor- 
 rhages ; Choroiditis ; Tubercle of Choroid ; retinitis 
 albumin urica. 
 
 OPTIC NEURITIS. — Disc blui'red, outline indistinct ; vessels on 
 disc in parts covered with effusion ; veins large. Yision 
 may be perfect. ^Neuritis is very indicative of coarse 
 intra-cranial disease, e.g., Tumour. This condition may 
 subside, leaving but little change noticeable, or it may 
 leave consecutive atrophy. See signs of Brain Disease. 
 
 OPTIC ATROPHY.— May he sec|uent to neuritis. It differs in 
 appearance from primary atrophy in having more 
 disturbance of the choroidal pigment around the disc, a 
 less sharply-defined margin, and sometimes thickening of 
 the sheaths of the vessels remains ; it looks dull. Primary 
 optic atrophy gives a more clearly-defined margin ; it is 
 clean cut, and its general appearance brighter. Vessels 
 atrophied or obliterated. 
 
DISEASES or THE NERVOUS SYSTEM. bD 
 
 BRAIN DISEASE, SIGNS OF. 
 
 The condition of the brain may be judged of by observation 
 of the optic discs and retina, as expansions of nerve matter 
 in connection with the circulation of the brain. Also by 
 the condition of parts supplied by nerves having their 
 centres in the brain. Special signs are found in conditions 
 of the muscles, paralysis, spasm, convulsion, want of 
 co-ordination, etc. See Motor Power. 
 
 Exami nation. — Onset of acute febrile disease may cause 
 cerebral symptoms. Cerebral symptoms with pyrexia 
 contra-indicate a purely functional disturbance. 
 
 OPHTHALMOSCOPIC APPEARANCES. 
 
 HiEMORRHAGES in the fundus are usually situated in the 
 retinffi. They are common in Pernicious Anaemia ; in 
 Retinitis Albuminurica — here they are accompanied by 
 white shining spots. They may be seen in ague and 
 leucocythasmia. Haemorrhages, even if considerable, may 
 be quickly absorbed, and may recur. 
 
 CHOROIDITIS.— Dull yello^vish patches over fundus ; there 
 may be subsequent atrophy, the shining sclerotic showing 
 through. Around the patches the choroidal pigment is 
 much disturbed, forming black rings or patches. It may 
 be disseminated or marginal. It is often syptilitie. 
 
 TUBERCLE OF CHOROID.— Small circular spots, more or less 
 circumscribed, reddish or greyish-white in colour. They 
 may be elevated above the level of the choroid with 
 retinal vessels passing over them ; adjacent choroid may 
 be normal. Their growth in size may be watched. See 
 General Tuberculosis. 
 
 TUBERCLE IN CHOROID is rather a sign of general 
 tuberculosis than a sign of meningitis ; but coincident 
 optic neuritis indicates probable tubercular meningitis. 
 Tubercle in choroid in a case of continued fever suggests 
 tuberculosis as its cause. 
 
 F 
 
66 CLINICAL MEDICINE AND CASE-TAKING. 
 
 PUPILS* 
 
 Let a full light fall upon the face. Keep one eye covered and 
 test the other ; letting light suddenly fall upon it, observe 
 its reaction. Partially screening one eye, let light fall 
 suddenly upon the other, and observe the reflex effect 
 upon the first eye. This reaction involves the optic nerve 
 on side exposed to light, corpora quadrigeniina, and Nerve 
 III. on the side shaded. Note contraction of pupil on 
 near accommodation. 
 
 Observe. — 1. Its shape, regularity, and outline ; adhesions may 
 cause irregularity ; shape when dilated. 
 
 2. Size ; may be measured by reference to the holes of 
 catheter gauge. 
 
 3. Activity to light and on near accommodation. 
 
 4. Any differences between the two pupils. 
 
 5. Colour of iris, distinctness of muscular bundles. 
 
 Mydriasis = great dilatation of pupil. 1. Artificial, by atropine. 
 2. Paralytic, from palsy of Nerve III. 3. Spasmodic. 
 
 Myosis =■ contraction of pupil. 
 
 * See Mr. Hutchinson's article on " States of the Pupil." " Brain," 
 Vol. i. ii. 
 
DISEASES OF THE NERVOUS SYSTEM. 67 
 
 PUPILS. 
 
 Large in Anaemia and debility ; dilated during rigor and 
 Convulsion. May be exceedingly mobile in debility. 
 Sluggish pupils indicate defect of vaso-inotor nerve, and 
 then the pupil is rather small. A pupil sluggish to the 
 direct action of light may respond immediately when the 
 other eye is acted on by light, thus — (1) Irido-motor appa- 
 ratus is sound ; (2) Peripheral structures of the second eye 
 are sound ; (3) There is a defect in the percipient structures 
 of the first eye. Pupils may remain active with optic 
 atrophy. The movements upon accommodation (Xerve 
 III.) may be good though reaction to light (vaso-motor) 
 be lost, e.g., in Ataxy. Precise symmetry in size of the 
 eyes is not common. 
 
 Iridoplegia — palsy of pupil to light, but not to drugs. 
 
 Cyclojylegia = absolute loss of accommodation. 
 
 Ophthahyiojjlegia interna = both the radiating and circular 
 fibres of iris and the ciliary muscle are paralysed. Pupil 
 is motionless and accommodation lost. 
 
 Iritis may be a sign of previous Syphilis. 
 
68 CLINICAL MEDICINE AND CASE-TAKING. 
 
 SPINAL CORD DISEASE, SIGNS OF. 
 
 Paraplegia, partial or complete ; Spasms ; Tremors. Dysaesthesia, 
 principally confined to the lower extremities ; Paralysis 
 of Sphincters ; sacral bed-sore ; atrophy of optic nerve. 
 
 Motor poiver. — See power of co-ordination of the limbs ; their 
 state of nutrition. Enquire as to the state of sphincters. 
 Test reflex action of extremities and patellar tendon reflex.* 
 If there be paralysis, state what groups of muscles are 
 involved, and which escaped ; gait in walking. 
 
 Sensation. — Objective sensibility ; examine the muscular 
 sense. See Muscular Anaesthesia. Subjective sensibility ; 
 dyssesthesia of lower extremities. 
 
 Look for Ophthalmoscopic appearances; condition of spine. 
 See Pupils. 
 
 Causatimi. — Exposure to cold ; over-exertion ; functional para- 
 j)legia in hysteria ; heredity ; reflex paraplegia, from 
 urethral stricture, sequent to confinement ; spinal menin- 
 gitis ; spinal hsemorrhage ; injury to back ; Syphilis ; 
 Alcoholism. 
 
 * Dr. Gowers: "Med.-Chir. Trans." 1879. 
 
DISEASES OF THE NEEVOUS SYSTEM. 69 
 
 SPINAL CORD DISEASE, SIGNS OF, 
 
 Muscles supplied by spinal nerves are alone paralysed. See 
 if signs of Brain Disease and Palsy of Cranial Nerves are 
 absent. Paraplegia may be purely functional. 
 
 Motor power. — If there is paralysis of a special gi'oup of 
 muscles, see Minor Paralyses. Specially note the power 
 of Co-ordination of the Limbs. 
 
 Sensation. — Sensation of girthing round abdomen, frequent in 
 
 spinal cord disease. 
 *' Lightning pains," darting, burning, or pricking; common 
 
 prodromata of Ataxy, often mistaken for rheumatism. 
 
 Look for sacral bed-sore, very apt to form in myelitis, probably 
 as the direct effect of the nervous lesion. Ko bed-sore in 
 Hysteria. Test reflexes. 
 
 Causation. — Reflex paraplegia seldom complete, less widely- 
 spread, and less defined than paraplegia from myelitis. 
 See Paralysis, Functional or Organic. 
 
70 CLINICAL MEDICINE AND CASE-TAKING. 
 
 MINOR PARALYSES. 
 
 Paralysis of isolated muscles, or groups of muscles. Spinal 
 (Infantile) Paralysis. Onset sudden ; most common in 
 infancy ; frequent in liealthy children ; occurs but once ; 
 large muscles principally aflected, e.g., deltoid rather than. 
 muscles of fingers. 
 
 PROGRESSIVE MUSCULAR ATROPHY.— A chronic disease 
 causing atrophy of certain muscles, with corresponding 
 loss of power, attacking shoulder and ball of thumb by 
 preference, gradually involving more muscles ; no pain. 
 
 PSEUD 0-HYPERTROPHIC PARALYSIS.— Enlargement of 
 muscles paralysed ; usually attacks calves, thighs, buttocks, 
 erector spinal muscles ; mostly seen in children — male 
 children ; several children in same family may be affected. 
 
 PARALYSIS OF EXTENSORS OF FOREARM.— Usually due 
 to plumbism. 
 
 CROSS PARALYSIS.— Palsy of face on one side, and hemiplegia 
 of the opposite side. 
 
 LABIO-GLOSSO-LARYNGEAL PARALYSIS (Bulbar para- 
 lysis). — Paralysis of muscles of tongue, palate, pharynx, 
 orbicularis oris ; death by asphyxia. 
 
 PARALYSIS OF THE FACE.— See Bell's Paralysis. Paralysis 
 of muscles of deglutition frequently due to Diphtheria. 
 
 NETTRALGIA. 
 
 Symptoms. — Onset, whether sudden or gradual, whether pre-; 
 ceded by general or local disturbance ; the paroxysms, 
 whether severe, their frequency, the character of the pain. 
 The effect of heat and cold upon the pain. Look for tender 
 points in the course of the nerve affected, and its branches. 
 Examine cutaneous sensibility at the seat of pain. 
 
 Causation. — Age, sex, heredity, injury to neiTe, frequent move- 
 ment of the limb, or pressure upon a nerve. Malaria, 
 Syphilis, Gout, Rheumatism, Alcoholism, Anaemia, Hysteria, 
 cold, mental anxiety, carious teeth. Reflex causes, e.gf., from 
 pregnancy, pain in eyeball from caries of a tooth. 
 
 Conditions cTiaroAAerised hy neuralgia. — Locomotor Ataxy, lower 
 extremities ; Herpes Zoster, a long area of skin supplied b; 
 nerve affected ; Herpes Labialis. 
 
DISEASES OF THE NERVOUS SYSTEM. 71 
 
 MINOR PARALYSES. 
 
 Paralysis of isolated muscles, or groups of muscles. See 
 Infantile Paralysis. 
 
 PROGRESSIVE MUSCULAR ATROPHY.— Enquire for injury 
 to nerves ; lead poisoning ; the nature of the employment, 
 as to its using one particular set of muscles. Electric 
 tests. Irritability of muscles when struck. Cutaneous 
 sensibility, 
 
 PSEUDO-HYPERTROPHIC PARALYSIS.— Test reflex action, 
 
 and electric tests. See motor power. 
 
 PARALYSIS OF EXTENSORS OF FOREARM.— Supinator 
 longus and extensor carpi rad. longior usually escape. 
 
 CROSS PARALYSIS.— May be due to disease of pons. 
 
 LABIO-GLOSSO-LARYNGEAL PARALYSIS.— Often accom- 
 panies hemiplegia and chronic brain disease. 
 
 PARALYSIS OF FACE.— May be due to lesion of brain, or 
 Bell's Paralysis. 
 
 NEURALGIA. 
 
 Symptoms. — Pain localized, almost invariably unilateral ; in 
 recent cases paroxysmal or distinctly intermittent. 
 Gradual formation of tender points, where nerve-branches 
 become superficial, passing through bone or fascia, the 
 points of Valleix. * Absence of local causes of pain, sucli 
 as inflammation, periostitis, new growth. Absence of fever 
 or local heat. 
 
 Causation. — Most common in females at puberty ; when 
 developing at forty years or older, is very intractable. 
 Malarial neuralgia, usually in supra-orbital nerve. Injury 
 to a nerve may cause neuralgia of branches communicating 
 with it. 
 
 Conditions characterized by neuralgia. — The subjects of hysteria 
 and epilepsy are very liable to neuralgia. 
 
 * See Anstie on " Neuralgia." 
 
72 CLINICAL MEDICINE AND CASE-TAKING. 
 
 NEURALGIA. 
 
 TRIGEMINAL.— Tender points. 1. Supra-orbital. 2. Palpebral, 
 iu upper eyelid. 3. Nasal, at junction of nasal bone and 
 cartilage. 4. Ocular, a point in the eyeball. 5. Trochlear, 
 at inner angle of orbit 
 
 Superior maxillary division. — 1. Intra-orbital. 2. Malar. 3. A 
 point in the line of the upper jaw. 
 
 Iiiferior division. — 1 . Temporal, a little in front of the ear. 
 
 2. Inferior dental (mental), towards front of lower jaw. 
 
 3. Lincrual, at side of tongue. 
 
 SCIATICA. — Is a neuralgia of the sensory fibres of the sciatic 
 plexus. Note gait in walking ; the muscular power of 
 the limb ; the state of its nutrition. Look for tender 
 points — along the com'se of the nerve and its branches, e^g., 
 superficial cutaneous branches in gluteal region ; down 
 back of thigh, calcanean and malleolar branches ; also 
 behind trochanter. 
 
 INTERCOSTAL NEURALGIA.— There is pain and tenderness 
 in the course and distribution of the nerve or nerves 
 afiected. It is most common in the left infra-mammary 
 nerve. Pain is constant, at times shooting. Painful points. 
 1. Vertebral. 2. Lateral, along outer margin of trapezius. 
 3. Sternal. 
 
DISEASES OF THE NERVOUS SYSTEM. 
 
 NEURALGIA. 
 
 TRIGEMINAL. — Causation : Any cause of neuralgia, especially 
 malaria ; dental or maxillary disease ; cerebral tumour. 
 It mostly occurs in conditions of low nervous depression. 
 Some severe cases are associated with, hereditary insanity. 
 With disease of trigeminal nerve there may be profound 
 disturbance in the eyeball, as in cases of herpes in this 
 region. Ulceration of Cornea, iritis, suppuration, and 
 disorganization. 
 
 SCIATICA. — CaiisaMon : Rare under twenty years. Cold ; 
 peripheral irritation, e.g., tight boots. May arise from 
 pressure on the sacral plexus, e.g., pelWc tumours, ovarian, 
 hard fseces. Examine hip-joint. 
 
 Pain is more constant and less paroxysmal than in other 
 neuralgia ; motor as well as sensory fibres often affected, 
 diminishing muscular strength ; the limb may emaciate 
 and become somewhat ansesthetic. In walking, the foot 
 on side affected is planted carefully, so as to avoid any jar 
 which would increase the pain. 
 
74 CLINICAL MEDICINE AND CASE-TAKING. 
 
 HEMIPLEGIA. 
 
 State side affected. Give history of the onset, whether 
 sudden, gradual, with convulsion or loss of consciousness ; 
 whether preceded by abnormal sensations ; whether first 
 attack. 
 
 p, (7, —General condition of Nervous System. Look for palsy of 
 Cranial Nerves. Examine limbs affected as to Motor 
 Power, coarse movements, e.g., power to raise limb from 
 the bed, to move large joints, pronate and supinate ; to lift 
 weights. As to finer movements, e.g., use of fingers, to pick 
 up a pin, button shirt, point with index and little fingers, 
 etc., to write. Note power of tongue and face. Palsied 
 limbs, their temperature, atrophy, or rigidity, condition of 
 Sensation. Look for signs of Brain Disease. Special 
 Senses. Condition of cranial nerves. Sight, examine for 
 limitation of the field of vision. Facial Palsy from cerebral 
 disease. Examine Optic Discs. Look for bed-sore. 
 
 Causation. — Examine heart, and look for signs of Vascular 
 Degeneration. Look for signs of Bright's Disease. Look 
 for signs of Syphilis. Hysteria. 
 
 Superficial reflexes diminished on side of palsy. Rigidity in 
 part paralysed later on. If involuntary movements of 
 parts palsied. 
 
DISEASES OF THE NERVOUS SYSTEM. - 75 
 
 HEMIPLEGIA* 
 
 Right hemiplegia commonly associated with Aphasia. Hemi- 
 plegia from Embolism most commonly right-sided. Onset 
 sudden in embolism, and in cases of extensive haemorrhage. 
 Sometimes premonitory warnings are experienced in the 
 head or limbs. 
 
 P.C. — Nerve YIL, when affected, is usually partially paralysed, 
 muscles about mouth being most weakened. There may 
 be the following phenomena : — 
 
 1. Head turned to side of lesion. 
 
 2. Conjugate deviation of the eyes, both being turned to the 
 
 side of lesion. 
 
 3. Muscles of chest and belly weakened on side opposite to 
 
 lesion. 
 
 4. Paralysis of muscles passing from the trunk to the limbs 
 
 paralysed. 
 
 5. The face paralysed on the side of hemiplegia. 
 
 6. The tongue protruded to side of hemiplegia. 
 
 7. Arm and leg paralysed on the side opposite to the lesion. 
 Nos. 1 and 2 are very temporary. Those parts suffer most 
 
 and longest which have the most voluntary uses. Sensi- 
 bility is usually restored before motor power. 
 
 Causation. — Valvular Disease of the Heart may lead to em- 
 bolism, Atheroma to cerebral hsemorrhage or thrombus. 
 Bright's disease, being associated often with disease of 
 vessels and hypertrophy of heart, frequently leads to 
 cerebral haemorrhage. Syphilitic disease of arteries. 
 
 * Dr. Hughlings- Jackson : Reynolds' " System of Medicine." 
 
CLINICAL MEDICINE AND CASE-TAKING. 
 
 CHOREA. 
 
 If there have been previous attacks, say whether one-sided, 
 and state side affected. The manner of commencement. 
 Previous history as to the general condition of the Nervous 
 System. History of school-life, Headaches. 
 
 F. H. 0/ Neuroses, headaches, hysteria, chorea, fits in infancy 
 epilepsy. Rheumatism. 
 
 p. (7. — Xote state of nutrition ; general condition of the ner- 
 vous system. Look for signs of Brain Disease. Specially 
 note condition of Intelligence, Speech, Sleep. 
 
 Motor Power. — Whether muscles supplied by cranial and spinal 
 nerves are alike affected. Examine face, tongue, soft 
 palate, movements of eyes, movements of head, respiratory 
 movements, movements of trunk and head. 
 
 Examine the extremities in detail, e.g., right upper extremity. 
 Is the shoulder much moved ? in which direction principally '? 
 by the action of what muscles ? The elbow, is it more or 
 less moved than the shoulder ; what are the principal 
 movements — flexor, extensor, pronator, or supinator ? The 
 hand ; movements of wrist, fingers, thumb. Fingers may 
 tAvitch with extensor-flexor or adductor-abductor move- 
 ments ; some digits may move more than others. Postures 
 of hands when held out, also of trunk and spine. 
 
 Complicatioois.— Onset of Rheumatism, Pericarditis, Endocar- 
 ditis. Mental symptoms. Look for Rheumatic Nodules. 
 
 EoMmine heart, its sounds, regularity. Look for signs of 
 Anaemia. Examine urine for urea and uro-hfematin. 
 
 Causation. — The most distinctly demonstrated lines of causation 
 are in connection with Rheumatism, Heart Disease, and 
 
 sudden mental impressions. Reflex causes, e.g., intestinal 
 worms, pregnancy. Enquire for arthritis with enlargement, 
 attended with feverishness or not ; over-work, or complaint 
 of school lessons. 
 
DISEASES OF THE NERVOUS SYSTEM. 77 
 
 CHOREA. 
 
 S2)ecial character of the tnuscular movements. — Are the move- 
 ments due to mere clonic jerks of certain muscles, repeated 
 in a meaningless manner (muscular tic), or are they of the 
 character of gesticulations, wriggling, testing movements, 
 flinging the limbs about ? Do the movements greatly 
 displace the limbs, or after the movements do the limbs 
 always fall back into their previous position ? Are the 
 movements independent of voluntary efforts ? are they 
 increased by voluntary efforts ? are they equal on the two 
 sides ? Accompanying muscular weakness. Urine often 
 of high sp. gr. and loaded with urea. 
 
 SCLEROSIS.* CHOEEA. 
 
 Rhythmical oscillations. In The main direction of 
 
 lifting the arm, the main motion is disturbed from the 
 direction of the movement outset by contradicting move- 
 persists in spite of the obsta- ments which cause the goal to 
 cles caused by the jerks of the be missed. Movements sud- 
 tremors, and it reaches its den, and unexpected when the 
 goal. limbs are at rest, and apart 
 
 from the action of the will. 
 Complications. — In pregnant women miscarriage is frequent 
 
 and attended with danger. 
 Examine. — Mitral bruits, very common. Urine often scanty 
 and very dense, being loaded with urea ; uro-hoematin 
 often in large amount. 
 Causation. — The connection with rheumatism is shown by its 
 occurrence before, after, or with the chorea. The frequency 
 of cardiac bruits has suggested that the disease is due to 
 embolism. If pregnancy excites chorea, there has usually 
 been chorea in childhood. Chorea most common in 
 females, and in childhood near puberty. Exciting causes — 
 fright, falls, etc. , over- work at school, imitation. Enquire 
 for symptoms before occurrence of acute movements ; 
 whether fidgety, frequently dropping things, clumsy, 
 
 nervous. 
 
 * Charcot ; New Syd. See. Trans. 
 
78 CLINICAL MEDICINE AND CASE-TAKING. 
 
 HYSTERIA. 
 
 Describe briefly patient's complaints. State if able to perform 
 ordinary work ; if not, say why. Enquire if any "attacks, 
 fits, or Convulsions occur ; " if they do, note time and cir- 
 cumstance. Note general condition of Nervous System; 
 signs of Brain Disease. 
 
 Motor Power. — General character of movements, whether 
 
 active or sluggish. Test reflex excitability. 
 Setisation. — Should be examined carefully. Globus (sensation 
 
 of a ball rising in the throat and choking). Headaches. 
 
 Neuralgia, specially Infra-mammary Neuralgia, and of 
 
 Nerve V. Look for Muscular Anaesthesia. Note mental 
 
 condition and Intelligence. 
 Causation. — Almost exclusively in female sex ; common in early 
 
 life ; may be very persistent. 
 
 EPILEPSY. 
 
 A condition of disease characterized by convulsive paroxysms 
 with loss of consciousness. Look to the general condition 
 of the Nervous System, and signs of Brain Disease. See 
 Convulsions. Note history of onset, frequency of 
 paroxysms, their periodicity and characters, condition in 
 intervals of the paroxysms. 
 
 Paroxysms. — Note state of consciousness, whether persistent, 
 partially or wholly lost. Note carefully the degree, kind, 
 and range of Spasm, whether Tonic or Clonic. The 
 amount of fixation of respiratory muscles and signs of 
 cyanosis. Whether head is drawn to one side, face 
 distorted, or signs of opisthotonos. Position of eyes and 
 state of pupils. Look for spasms in muscles supplied by 
 cranial nerves, and one-sided, local, or repeated movements. 
 Condition of sphincters. Temperature, pulse, heart. 
 Next passed urine. 
 
 Starting points. — (1) Hand, usually index finger, thumb, or 
 both ; (2) face, usually near mouth, or tongue, or both ; 
 (•3) foot, usually great toe. Note range of spasm. 
 
DISEASES OF THE NERVOUS SYSTEM. ,79 
 
 HYSTERIA. 
 
 The will is defective ; all voluntary movements are usually 
 sluggish and wanting in energy, but movements excited by 
 emotion may be in excess. The condition is most common 
 in young females, and is frequently associated with 
 disordered menstruation. A special character is the liability 
 to attacks of convulsive nature. Disturbance of Sensation 
 is very common, sometimes assuming the form of hemi- 
 ansesthesia, one half the body having lost sensibility, or 
 hypersesthesia. Functional Paralysis is common in this 
 condition ; it may be paraplegic, hemiplegic, or of a single 
 extremity — functional aphonia. Spasm of Muscle, more or 
 less continued, is not uncommon, thus causing contraction 
 of a joint, talipes, or a phantom tumour in the rectus 
 abdominis. Among signs of disturbance of organic nerves 
 are Vomiting- and Angina Pectoris. 
 
 Causation. — Inherited tendency to neuroses. Disordered men- 
 struation. Depressing mental circumstances. 
 
 EPILEPSY.* 
 
 Symptoms of the Attack. — Stage I. Sudden loss of consciousness ; 
 tonic rigidity of muscles ; arrested respiration, often with 
 a cry due to forcing air through closed glottis. Pallor or 
 duskiness. Pupils dilated. Stage II. — Unconsciousness 
 continues ; clonic convulsion ; laboured breathing and 
 foaming ; profuse sweating. Stage III. — Partial return 
 of consciousness and voluntary power. 
 
 Glasses of Paroxysms. — I. Loss of consciousness without 
 evident spasm. 
 II. — Loss of consciousness with local spasm. 
 
 III. — Loss of consciousness with general tonic and clonic 
 convulsion. 
 
 IV. — "Without complete loss of consciousness, convulsion 
 being general or partial (abortive epilepsy). 
 Le petit mal — classes I. and II. 
 
 * Dr. Reynolds' " System of Medicine." 
 
80 CLI^'ICAL MEDICINE AND CA.SE-TAKIXG. 
 
 "ETlLEPSY—contimced. 
 
 FremonitoTy symptoms. — Mental condition, excitability, dul- 
 ness, vertigo, dyssestliesia. Aura epileptica stiictly 
 implies a sensation of wind blowing upon a limb. An 
 aui'a may commence in a limb, or the epigastrium, or in 
 tbe pharynx, in each case passing upwards towards the 
 brain. An aura may commence in an organ of special 
 sense, e.g., the vision of a shape or colom", a "nasty taste," 
 a sound, a smell, a mental sensation. The aura is 
 immediately followed by loss of consciousness. 
 
 Sequelce. — Pennanent impairment of intelligence and mental 
 capacity. Vertigo. 
 
 Corii2)lications. — Post - epileptic mania may succeed the 
 paroxysm ; in this state acts of violence or homicide may 
 be unconsciously performed. In a condition after the 
 paroxysms termed " reduction " the patient may perform 
 unconscious acts, e.g.. place things in sti'ange places. - 
 
 Causation. — Age, sex, psychical causes, and heredity. The 
 commonest antecedents are reflex causes, teething, in- 
 testinal worms ; physical causes, e.g., blows on head, 
 exposure to great heat. 
 
 Commonest in female sex and from thirteen to sixteen years 
 of age ; may be secondary to other organic changes ; 
 heart disease is common. 
 
DISEASES OF THE NERVOUS SYSTEM. 
 
 81 
 
 CONVULSIONS. 
 
 EPILEPTIC or 
 
 Onset. — Sudden, often with an 
 aura. Loss of consciousness 
 usually complete. 
 
 Prodroma. — Aura epileptica. 
 
 Asphyxia — Often very complete. 
 
 i^ace.— Features distorted. 
 
 Coma. — Usually profound, with 
 stertorous breathing. Con- 
 junetiva insensible. 
 
 Subsequent state. — Coma ; stu- 
 por ; drowsiness. Subjunc- 
 tival haemorrhages. 
 
 P'lfi'exia. — May arise if much 
 tonic spasm is present. 
 
 Sleep. — Common during sleep 
 and when falling asleep. 
 
 Tongue. — Often bitten. 
 
 General condition. — Signs of 
 epilepsy. 
 
 Urine. — Occasionally contains 
 albumen or sugar. 
 
 HYSTERICAL. 
 
 Less sudden, with emo- 
 tional disturbance. Loss of 
 consciousness, more pro- 
 tracted, or very apparent. 
 
 Globus hystericus. 
 
 Flushed, not asphyxiated. 
 
 Not distorted. 
 
 Insensibility complete. Re- 
 flex movements of eye usually 
 continue on touching it. 
 
 Exhaustion. 
 
 Temperature normal. 
 
 Usual during day-time 
 when others are about. 
 
 Not bitten. 
 
 Signs of emotional dis- 
 turbance. 
 
 Copious, limpid, light- 
 coloured, sp. gr. low. 
 
 G 
 
82 CLINICAL MEDICINE AND CASE-TAKING. 
 
 CEREBRAL TUMOUR. 
 
 Special syinptoiiis. — Vomiting, Head-pain, Paralysis of Cranial 
 Nerves, palsy of Special Senses, Optic Nerve changes, 
 Convulsions, Hemiplegia, or other form of Paralysis. 
 
 Temperature sometimes very higli, witliout any inflammation. 
 
 Look for Syphilis, Scrofula, Phthisis, Cancer, or new growth 
 in other parts. See Motor Power, and gait in walking. 
 Examine urine for sugar and albumen. 
 
 Causation. — Syphilis. Scrofulous diathesis leading to tuber- 
 cular mass. Tubercular tendency. Cancer. 
 
 Tumour may be caseous mass, gumma, glioma, cancer, growth 
 of pituitary body, cyst, hydatid, aneurism, blood-cyst in 
 
 membranes, exostosis. 
 
 CEREBRAL MENINGITIS. 
 
 Xote sj'mptoms, with date and manner of commencement. 
 
 Special synvptoms. — See general condition of Nervous System, 
 signs of Brain Disease, vomiting, paralysis of Cranial 
 Nerves, intermittent pulse. Look for signs of General 
 Tuberculosis, Phthisis, strumous disease. Ophthalmoscopic 
 examination may show tubercles in the choroid. Note eyes, 
 their movements, strabismus, state of Pupils, photophobia ; 
 general state of nutrition. Take temperature. Examine 
 lungs as to phthisis and recent pneumonia or pleurisy. 
 Examine urine, and note whether it be retained. 
 
 Look for Head-pain, Vomiting, ear disease, Syphilis. Take 
 temperature. 
 
DISEASES OF THE NERVOITS SYSTEM. 83 
 
 CEREBRAL TUMOUR. 
 
 Head-pain may be localized, and permanent, or intermittent 
 with exacerbations. Vertigo is common. Hearing is not 
 commonly palsied. Urine may be saccbarine. 
 
 Convulsions, partial, clonic, or tonic, not uncommon ; tbey may 
 resemble epilepsy, but usually differ from such attacks as 
 follows : — 1. Irregular in development, with less loss of 
 consciousness and no asphyxia or subsequent coma. 2, 
 Not specially a disease of female sex or early period of life. 
 3. Less tendency to mental disturbance. 4. No special 
 inheritance of neurosis. 5. Characteristic symptoms of 
 tumour develop. 
 
 The course of the disease is generally slow. Hemiplegia, if 
 present, usually develops slowly ; if on the right side 
 may be accompanied by aphasia. Preceding death the 
 temperature often rises high. 
 
 Causation. — Cerebral tumour may cause ventricular efiiision, 
 resembling Hydrocephalus. 
 
 CEREBRAL MENINGITIS. 
 
 Onset often insidious ; poorliness and loss of appetite, with 
 head-pain and vomiting. Temperature is a very uncertain 
 sign ; vomiting, though important when present, is 
 frequently absent throughout. Intermittence of the pulse 
 and paralysis of a cranial nerve are very important signs. 
 Tubercles may occur in the choroid, independently of 
 meningitis. 
 
 Causation. — Miliary Tuberculosis. Disease of ear. Syphilis, 
 Injury to head. Cerebral Tumour. 
 
84 CLINICAL MEDICINE AND CASE-TAKING. 
 
 CHEONIC HYDROCEPHALTJS. 
 
 History of family ; of tie pregnancies and labours of the 
 mother. State of the head at birth, or date at which 
 symptoms were first observed. Enquire for Convulsions. 
 iSTote general Motor Power. Sensation. Nutrition ; power 
 to hold head up. Eyesight. Hearing. Intelligence, 
 whether child notices sounds and colours, and plays with 
 toys, or is backward for age. 
 
 Head. — Is it held well up, well shaped ; its circumference, 
 measurement from ear to ear, over the vertex, and from 
 the nose to the occiput. State of sutui'es and fontanelles, 
 whether patent or ossified. Take tracings of skull with 
 cyrtometer. 
 
 Eyes, whether of normal direction ; condition of optic nerve. 
 Dentition. Look for signs of Eickets. 
 
 Look f 01' signs of Defective Development. 
 
DISEASES OF THE NERVOUS SYSTEM. 
 
 85 
 
 CHRONIC HYDROCEPHALUS. 
 
 Must not be mistaken for the large head of rickets. Con- 
 genital hydrocephalus usually causes difficult labour. 
 Head may be normal at birth, subsequently enlarging. 
 Sometimes accompanied by spina bifida. Tendency to 
 enlargement of the head is progressive. 
 
 HYDROCEPHALUS. 
 
 EICKETS. 
 
 No signs of Rickets, but Signs 
 
 signs of Brain Disease. Rickets. 
 
 and symptoms of 
 
 Head has a tendency to glo- 
 bular shape ; eyes depressed ; 
 often strabismus ; optic nerves 
 atrophied. Cranial bones thin. 
 Cannot hold head up. Para- 
 lysis common, or a contracted 
 limb. 
 
 Head large, tending to 
 broadness and squareness ; 
 there may be irregular thick- 
 ening of bones. No paralysis, 
 head held up, child playful. 
 
 Tendency to increase of 
 relative size of head to body, 
 indicated by measurements. 
 Progressive enlargement ; pa- 
 tency of fontanelle continuing. 
 Usually imbecile. Optic atro- 
 phy. 
 
 As signs of Rickets pass 
 away the relative size of the 
 head less noticeable. May 
 have good power. 
 
86 CLINICAL MEDICINE AND CASE-TAKING. 
 
 ALCOHOLISM. 
 
 See Nervous System. See Motor Power. Tendency to tremor ; 
 tongue tremulous, coated, glazed. Muscular weakness 
 and want of muscular co-ordination. See co-ordination of 
 the limbs. Muscular inquietude ; muscular fidgetiness. 
 Look to Muscular Sense (usually diminished). Paralysis, 
 Paraplegia. See signs of disease of Spinal Cord and 
 General Paralysis. Flushing and congestion of the face 
 and eyes. Vomiting, especially in the morning. Conditions 
 of Sleep. Neui-algic pains. Anaemia. 
 
 Mental disturbance. — Deterioration of mental power, restlessness, 
 loss of memory, hallucinations, delusions. Mental altera- 
 tion, e.g., inaptitude for business, avoidance of friends. 
 
 Sensation. — Cutaneous sensibility, dyssesthesia, muscse voli- 
 tantes, buzzing in ears, vertigo. Note state of nutrition. 
 
 <''omplications. — Look for signs of disease of liver, kidneys, 
 vascular system, emphysema. Acne rosacea of nose. 
 Bronchitis. Pneumonia. Delirium and symptoms of 
 delirium tremens. 
 
 ACUTE ALCOHOLISM. 
 
 Excessive dose may produce Coma ; breathing stertorous ; 
 breath smelling of alcohol. Appearance of face. Examine 
 urine for albumen and alcohol. Look for signs of general 
 condition of Nervous System. Vomiting. Paralysis. 
 See causes and examination of cases of coma. Examine 
 heart and condition of blood-vessels. 
 
 Look for — Injury to head. Uraemia. Simple exhaustion. 
 Meningitis. There may be Albuminuria from acute renal 
 congestion. Complications of chronic alcoholism. 
 
DISEASES OF THE NERVOUS SYSTEM. 87 
 
 ALCOHOLISM. 
 
 Principally produces nervous symptoms ; affects next the diges- 
 tive system. Nutrition may become much, impaired. In 
 chronic cases, kidneys and liver often become cirrhotic. 
 Vascular system degenerates. Emphysema. 
 
 Chronic Cases. — In advanced stages, the lower extremities may 
 become unsteady, hands and fingers tremulous, so also the 
 tongue. At first the tremors may be restrained by 
 voluntary eS'ort. Acne rosacea. 
 
 Diagnosis from — 
 
 Commencing General Paralysis of Insane, mind depressed. 
 
 Paralysis Agitans. 
 
 Plnmbism, with tremor and delirium. 
 
 Locomotor Ataxy. 
 
 Paraplegia, from Disease of Cord. 
 
 Senile Degeneration. 
 
 Sclerosis. 
 
 Hysteria. 
 
 Nervous malaise, from simple dyspepsia. 
 Complications. — Cirrhosis of Liver and Ascites. Chronic 
 
 Bright's Disease. Atheroma or Degeneration of Arteries 
 
 and small vessels. Chronic gastritis. Fatty degeneration 
 
 of heart and liver. 
 
 ACUTE ALCOHOLISM. 
 
 Acute symptoms may be due to Delirium Tremens, or to an 
 excessive dose causing toxic efiects, e.g., coma, etc. When 
 drunk — Coma, face livid, breath smelling of alcohol, ten- 
 dency to vomit. Vomits or washings of stomach contain 
 spirit. In very deep coma there may be strabismus. There 
 may be great excitement in place of coma. Cerebral 
 haemorrhage may occur during intoxication. Alcohol in 
 urine. 
 
-CLINICAL MEDICINE AND CASE-TAKING. 
 
 DELIRIUM TREMENS. 
 
 Delirium, delusions, illusions of Sight and hearing. Vomiting, 
 inability to take food. Intense restlessness. Look for the 
 degenerative changes of chronic alcoholism. Specially 
 examine lungs, urine, heart, and pulse. ISTote muscular 
 condition, general strength, and power of movement. 
 Tremor, subsultus tendinum. Sleep ; degree of con- 
 sciousness. 
 
 Complicatwiis. — Typhoid State. Subsultus. Coma. Heart 
 failure and pulmonary congestion. Syncope. Albuminuria. 
 Pneumonia. Rapid development of phthisis. 
 
 INSANITY. 
 
 1. Mania. 2. Monomania. 3. Melancholia. 4. Puerperal 
 mania. 5. Moral insanity. 6, Dementia. 7. Idiocy, 
 including imbecility. 8. General Paralysis or Paresis. 
 
 Causation. — Heredity of primary importance ; enquire back to 
 the third generation in the families of each parent. See 
 also as to collateral relations. 
 
 Alcoholism. Habits and mode of life. Mental anxiety. 
 Injuries to head. 
 
 Signs of Insanity. — Talking to self, fantastic dress, refusing 
 food, squandering property, kleptomania, self-injury, 
 violence, delusions, melancholy, incapacity for business, 
 avoiding friends, delirium. See signs of Brain Disease. 
 
 Illusions of the senses. Sight ; they may be coloured, moving 
 forms. Hearing, smell, taste, touch. The perception 
 of the sense is mistaken, and the impression made 
 is false. 
 
 Complications. — Phthisis, fragile bones, heart disease, Epilepsy. 
 Attacks of partial coma. 
 
 Examination of Patients. — Test Motor Power, Pupils, Muscular 
 Sense, Nervous System, Sensation, heart and lungs. 
 
DISEASES OF THE NERVOUS SYSTEM. 89 
 
 DELIRIUM TREMENS. 
 
 Usually the efiFect of long-continued drinking, witli dyspepsia 
 and deprivation of food. Commences with disturbance 
 of general condition of the Nervous System ; diminished 
 motor power. Insomnia, night-wandering, and horrors, 
 with delusions, passing on to delirium with violence and 
 suicidal tendency. Delirium may be busy, low muttering, 
 or talkative. 
 
 Complications. — Sudden syncope during violent struggling in 
 the delirium may lead to sudden death. 
 
 GENERAL PARALYSIS OF THE INSANE. 
 
 Characterised by progressive diminution of mental power, 
 followed by paralysis, involving the whole of the muscular 
 system. Pupils show want of symmetry of size, and want 
 of mobility. Mental condition characterized by an exag- 
 gerated feeling of power, extravagant exalted ideas, loss of 
 memory, attacks of excitement and violence. Hallucina- 
 tion ; delusion. 
 
 Motor Power. — Failure first seen in tongue ; inaccurate articu- 
 lation, fibrillar trembling of the tongue. Pupils unequal. 
 Automatic and reflex actions lessened ; electric contracti- 
 lity of muscles retained. Teeth-grinding. Late in disease, 
 SDhincters lose their control, and there is tendency to 
 choking. Bones may be very brittle. 
 
 SeTisation. — Cutaneous sensibility usually diminished, and later 
 lost. Muscular Sense lost. Attacks of excitement and 
 violence ; epileptiform convulsions. Face becomes ex- 
 pressionless. 
 
 Diagnosis from Alcoholism. — Ideas of exaltation ; pupils un- 
 equal : effect of removing alcohol ; paralysis of sphincters. 
 
 Caicsation. — Inheritance, intemperance ; most common in men. 
 
90 CLINICAL MEDICINE AND CASE-TAKING. 
 
 PARALYSIS AGITANS. 
 
 State principal sites of tremor ; hemiplegic type, paraplegic, or 
 confined to one extremity. Examine Motor Power ; whether 
 movements of liead, face, tongue ; if speech be affected. 
 Expression of face- Power to walk ; gait in walking. Note 
 any tendency to involuntary forward or backward move- 
 ment, or dragging of limbs, etc. Ability to perform 
 certain acts, walk, bold out limbs, pick up a pin, or write ; 
 keep specimen of writing. Let bim bold a glass of water, 
 and carry it to bis moutb. Note efi'ect of emotion on 
 tremors. Describe tbe Tremor. 
 
 SCLEROSIS OF CORD. 
 
 Examine condition of tbe Motor Power and reflex excitability. 
 Tremors ; see wbetber tbey cease during repose and are 
 increased by voluntary acts. Let patient raise a glass of 
 water to bis moutb, and describe tbe result. Let bim stand 
 and walk ; tben close bis eyes and again perform tbe same 
 acts. Note wbetber tremors are fine or coarse. Note tbe 
 extent of parts affected by tremor ; wbetber bead, trunk, 
 and all tbe extremities are aflected. Examine for Brain 
 Disease. Ankle clonus. 
 
DISEASES OF THE NEEVOUS SYSTEM. 91 
 
 PAEALYSIS AGITANS. 
 
 Characterized by muscular tremor, constant even in repose ; 
 muscular power diminislied. Head not tremulous, but 
 may be shaken by movements of the body. Tremor con- 
 sists of jerks, more regular and rapid than in Disseminated 
 Sclerosis. 'No real difficulty of speech, but the utterance 
 is slow and with jerk-like effects. Respiratory movements 
 not affected. In advanced cases muscular rigidity may 
 lead to deformity ; this is specially seen in the hand. 
 There may be a subjective sensation of heat. No Nys- 
 tagmus. Face stiff, expression still. 
 
 SCLEEOSIS OF CORD. 
 
 Characterized by muscular tremor, increased in direct pro- 
 portion to the extent of any movement executed. It is 
 only manifested by voluntary movements of some extent, 
 and ceases when the muscles are in complete repose. The 
 oscillatians are larger than in Paralysis Agit'ans, and more 
 resemble the gesticulations of Chorea. Yoluntary acts 
 may be performed despite the tremors. Closing the eyes 
 does not affect the tremors, as in ataxy. Movements are 
 not seen, independent of voluntary efforts, as in chorea. 
 The head is usually affected with tremor ; Nystagmus is 
 common. Patellar tendon reflex is exaggerated in sclerosis, 
 obliterated in Ataxy. 
 
92 CLINICAL MEDICINE AND CASE-TAKING. 
 
 TETANUS. 
 
 General condition. — T. = ; sweating. Occurs in the robust 
 rather than in the weak. 
 
 Special condition of muscular system. — Tonic spasm. Trismus 
 (lock-jaw). Opisthotonos, i.e., body drawn backwards, 
 or emprosthotonos, body drawn forward. Eyes may be 
 retracted from spasm of recti muscles. Face set hard with 
 sardonic grin. Tetanic convulsions frequently repeated. 
 
 Modes of onset. — Commencing about six days or sooner after 
 injury, may be two to four weeks after injury. Injury 
 may have been overlooked, and the wound healed. The 
 earlier the commencement, the more rapid the case and the 
 more certainly fatal the result. There is a gradual progress 
 of the symptoms. Tonic contraction commences with 
 trismus, extending to throat, back of neck, abdomen. 
 
 Causation. — Injury, blows, burn ; forcing bodies under skin or 
 under nail. Excited by exposure to cold ; war ; opera- 
 tion. Injury to nerve. Males rather than females. 
 Idiopathic cases due to exposure to wet and cold : this not 
 common. May occur spontaneously in infants within 
 eight days of birth. 
 
 Diagnosis. — From hysterical opisthotonos. Strychnia poisoning. 
 Hydrophobia. 
 
DISEASES OF THE NERVOTJS SYSTEM. 
 
 93 
 
 TETANUS. 
 
 STEYCHNIA POISONING.* 
 
 1. Period of onset ; not con- 
 nected witli food. 
 
 1. Onset soon after food. 
 
 2. Stiffness first perceived 
 in jaws ; it tlien progressively 
 extends downwards, attacking 
 the body and limbs, the hands 
 not being commonly affected 
 till the last. Progressive in- 
 vasion, with somewhat gradual 
 increase. 
 
 2. Sudden and violent onset 
 of symptoms : commences with 
 shivering, gasping for breath, 
 trembling ; the body and limbs 
 are then simultaneously af- 
 fected, hands clenched, feet 
 curved; at a later date the 
 jaw becomes fixed during a 
 paroxysm. 
 
 3. Duration of the case 
 rarely less than twenty-four 
 hours. Seldom fatal in idio- 
 pathic cases. 
 
 3. Rarely survive two hours 
 after a fatal dose. 
 
 4. Discovery of nux vomica, 
 strychnia, brucin, or other 
 poison in food, vomits, or 
 washincrg of stomach. 
 
 4. Absence of wound, ulcer, 
 or traumatism to account for 
 tetanus ; exposure to cold, or 
 special nervous susceptibility. 
 
 5. Muscular rigidity almost 
 without intermission. 
 
 5. Intervals or remissions of 
 rigidity of muscles. 
 
 See Taylor on the Poisons. 
 
94 CLINICAL MEDICINE AND CASE-TAKING. 
 
 LOCOMOTOR ATAXY. 
 
 Examine condition of the Motor Power ; especially the gait in 
 walking, and co-ordination of the limbs. Let him walk 
 ■with his eyes open, then shut ; let him walk with slight 
 assistance or using a stick. Also test power to keep knee 
 flexed or extended. Test upper extremities, e.g., precision 
 with which he can touch an object, his eye or nose, or 
 execute definite movements. Reflexes, and patellar tendon 
 reflex. 
 
 Electric Tests. 
 
 Setisation. — Tactile sensibility ; sense of heat and cold. Sub- 
 jective sensibility ; consciousness of ground in walking ; 
 perverted sensations in lower extremities. Sight, reaction 
 of Pupils, Ophthalmoscopic Appearances. 
 
 Examine the joints and skin. Look for signs of Disease of 
 Cord. Temporary defects of third nerve common. Bowels 
 and action of bladder sluggish. This disease is often 
 associated with Syphilis. Occasionally gastric crises or 
 attacks of vomiting. 
 
DISEASES OF THE NERVOUS SYSTEM. 95 
 
 LOCOMOTOR ATAXY. 
 
 Characterized by difficulty in walking, especially with the 
 eyes shut ; there being no motor paralysis and no loss of 
 nutrition of the lower extremities — patient still having 
 voluntary power to keep the limb flexed or extended with 
 good force. Commonest in males, and at ages thirty-five 
 to fifty years. In walking there is exaggeration of the 
 movements ; the feet are lifted too high and the heel 
 brought suddenly down. The lower extremities are the 
 most afi'ected, but there may be want of co-ordination of 
 the upper extremities also. Electric irritability not im- 
 paired. Patellar tendon reflex obliterated more or less 
 completely. In early stages "lightning-pains" in legs 
 and back are usual ; they may last for years and cause 
 much distress. 
 
 Pupils usually small, inactive to light (vaso-motor palsy) ; 
 contraction for near accommodation intact, i.e., ciliary 
 muscle sound — ^it is supplied by Nerve III. ; ptosis some- 
 times. The optic nerves sometimes become white from 
 atrophy. Large joints may be the seat of efiusion and 
 chronic absorption of the cartilages. It is distinguished 
 from disseminated sclerosis by the marked increase of 
 symptoms produced by closing the eyes ; this does not so 
 modify the rhythmic jerks of sclerosis. 
 
 Perforating ulcer of foot ; deafness from atrophy of nerve — some- 
 times found. 
 
 Urine may be retained. 
 
96 CLINICAL MEDICINE AND CASE-TAKING. 
 
 INFANTILE PARALYSIS. 
 
 History. — General condition of healtli. Look specially for 
 Eickets. Test general strength of motor power. State 
 whieli extremity is affected ; note its state of nutrition. 
 Examine tlie separate muscles. Test reflex action and 
 sensation. Electric Tests. Observe temperature of the 
 paralysed limb, and the condition of the skin. 
 
 Upper extremity. — Can he move the fingers separately ? point 
 with index and little fingers, etc. ? Movement of wrist ; 
 power of pronation and supination ; hold out the limb from 
 the shoulder ; put his hand to back of his head. Measure 
 length and circumference, and compare with opposite side. 
 
 Lower extremity. — Can child walk, stand, move toes, flex ankle 
 and knee, or hold out the limb 1 When sitting down can 
 he get up ? 
 
 Catisation. — Age six months to six years. Equally in both 
 sexes. Sequel to exposure to cold or an exanthematous 
 fever. Possibly due to dentition. 
 
 Rigid contraction frequently causes talipes in leg ; such de- 
 formities much less common in upper extremity. Oc- 
 casionally the bones do not grow in length, and a shortened 
 limb results in after life. 
 
DISEASES OF THE NERVOUS SYSTEM. 97 
 
 INFANTILE PARALYSIS 
 
 Occurs during ages from six months to seven years, attacking 
 a certain muscle or gi'oup of muscles. It is unattended by 
 pain or signs of brain disease. It often occurs in children 
 apparently perfectly healthy. The attack of paralysis is 
 never repeated. 
 
 Invasion. — There maybe premonitory symptoms two or three 
 days, or more ; then the limb may be found paralysed. 
 Such premonitory symptoms may be wholly absent. 
 Onset not usually attended with much distiu'bance of 
 the general condition of the nervous system. Paralysis 
 may be noted without any premonitory symptoms. 
 
 Course of disease. — Usually the general health remains good. 
 Most of the muscles first paralysed usually regain power 
 in two or three weeks, leaving some muscles, or a single 
 muscle, e.g., deltoid, permanently weakened. In regaining 
 power the order of recovery is the reverse of that seen in 
 paralysis from brain disease ; the finer movements are first 
 regained, e.g., movements of fingers and toes before the 
 wrist and ankles. The muscles permanently paralysed 
 atrophy. The growth of the limb may be checked, espe- 
 cially in the lower extremity. Permanent paralysis may be 
 in one leg only. The palsied limb becomes cold and bluish. 
 
 Sensation not affected. Reflex excitability impaired or 
 abolished, and electric excitability lost. 
 
98 CLINICAL MEDICINE AND CASE-TAKING. 
 
 GRAVES' DISEASE (Exophthalmic Goitre). 
 
 Exophthalmos. — Frequently eyelids cannot close over eyeballs, 
 the eyes remaining open even during sleep. The degree 
 of prominence of either eye is usually equal, but may be 
 more marked on one side. Eyelids tremble on endeavouring 
 to cover eyeball. Eyes appear staring, bright, and 
 glistening. Test sight and optical refraction, and move- 
 ments of eyes. Ophthalmoscopic appearances. Examine 
 pupils. 
 
 Goitre. — This sign may be absent. Enlargement usually 
 moderate, "with a thrill felt and heemic murmur on 
 auscultation. It is very rarely cystic. Thyroid enlarge- 
 ment usually first seen on the right side. 
 
 Vascular system. — Throbbing in arteries of neck, and in thyroid. 
 Hfemic bruits over goitre and vessels in neck. Tiolent 
 and frequent action of heart even without exertion. Left 
 ventricle may be dilated. Valvular lesion not very 
 common. 
 
 Com2JilicaMons. — Dilatation of heart. Asphyxiating attacks. 
 Diarrhoea. Vomiting. Bronchitis. Paraplegia. Head- 
 ache. 
 
 PLUMBISM. 
 
 General condition. — Anaemia ; emaciation ; gout. 
 
 Digestive system. — Attacks of colic and constipation, may be 
 with vomiting, nausea, loss of appetite. Blue line on 
 margin of gums, especially opposite the teeth. Abdomen 
 retracted. Breath foetid. 
 
 Nervous system. — Paralysis usually of extensors of forearm, 
 attended with atrophy and loss of electrical reaction. 
 Usually paralysis is preceded by attacks of colic Look 
 to the general condition of the Nervous System. Motor 
 Power. Sensation. See Optic Discs. 
 
DISEASES OF THE NERVOUS SYSTEM. 99 
 
 GRAVES' DISEASE (Exophthalmic Goitre). 
 
 Mainly cliaracteiized by prominence of the eyeballs. Pulsating 
 goitre. Palpitation. Usually there is Anaemia and 
 disordered menstruation. Emaciation. Mental irritability 
 and want of sleep. See Motor Power. There is a tendencj- 
 to intercurrent attacks of diarrhoea ; appetite capricious. 
 Occasionally enlargement of liver, spleen, and mammae. 
 Frequently there is increase of the symptoms at the 
 menstrual periods. 
 
 Pupils. — No alteration from the normal ; natural size and 
 activity ; accommodation normal. 
 
 Ccmsation. — Usually develops in females above age of puberty ; 
 rare in men. May date from a mental shock or period of 
 over-work. It is connected with anaemia and disordered 
 menstruation. 
 
 PLUMBISM. 
 
 Characterized by colic, anaemia, blue lines on gums. Paralysis 
 of extensors of forearm, and brain disturbance. 
 
 Nervous system. — There may be profound disturbance of the 
 brain , Optic neuritis. Delirium. Epileptiform convulsions. 
 General Tremors. Palsy of the extensors of the forearm, 
 principally marked on the right side ; the supinator longus 
 and extensor longior carpi radialis escape palsy. 
 
 Sensation may be at fault ; numbness in limbs, neuralgia, 
 headache. 
 
 Complications. — Crout ; Bright's Disease ; optic nerve changes ; 
 paralysis. 
 
100 CLINICAL MEDICINE AND CASE-TAKING. 
 
 DIPHTHERITIC PARALYSIS. 
 
 History. — Previous attack of sore-tliroat. Possible source of 
 infection ; evidence as to the diplitlieria. 
 
 General condition. — W. =. ; nutrition; T. = . 
 
 Month. — Condition of mucous membrane as indicating previous 
 inflammation. Movement of palate ; fauces ; tongue ; 
 pharynx. 
 
 Nervous system. — Speech, whether nasal or twangy, under- 
 standable or voiceless. Pain, giddiness. 
 
 Motor poiver. — Ability to stand and walk ; gait. Eyes, their 
 movements ; vision, accommodation, pupils. 
 
 Sensation. — Dyssesthesia, with numbness and formication, may 
 precede palsy in limbs. 
 
 Urine may be albuminous. 
 
 HERPES ZOSTER. 
 
 History of illness ; date of onset of symptoms, and of the 
 appearance of rash. Enquire as to recent use of arsenic. 
 Look to general condition, debility. Anaemia, etc. 
 
 Look for signs of Neuralgia, condition of skin at seat of pain, 
 sensibility, subjective pain, etc, tenderness, tender points 
 along the course of the nerve supplying area afl'ected. 
 Note any nutritional effects on parts affected, ulceration, 
 scars (with Nerve V. see Iritis) ; note subsequent state of 
 Sensation. 
 
DISEASES OF THE NERVOUS SYSTEM. 101 
 
 DIPHTHERITIC PARALYSIS. 
 
 Histm^y. — Palsy follows the sore-throat in two to six weeks. 
 Primary illness rarely attended with laryngitis. Complains 
 usually as to motor power, sight, speech, deglutition. 
 
 P. C. — Area of muscular weakness may be limited to fauces and 
 accommodation of eyes. The limbs, if much weakened, 
 emaciate proportionally. Respiratory muscles may be 
 involved. Palsy is usually symmetrical ; lower extremities 
 often palsied more than upper. Eye -muscles, and tongue 
 and face may be palsied. 
 
 Prognosis. — Cases usually recover. Danger from heart failure, 
 choking, paralysis of respirator}'' muscles. 
 
 HERPES ZOSTER. 
 
 Commonly occurs in young subjects ; it has been noted as 
 common in persons taking arsenic. The disease does not 
 return. Pain precedes the eruption ; it may be severe and 
 last for days. The rash is vesicular, vesicles appearing 
 along the area of a cutaneous nerve ; the vesicles contain 
 a clear watery fluid, and may have inflamed bases. The 
 patches seldom cross the median line, Vesicles dry up 
 and scab ; in debilitated subjects ulceration may follow. 
 
102 CLINICAL MEDICIXE AND CA.SE-TAKINU. 
 
 DISEASES OF THE VASCULAR SYSTEM. 
 HEART— PHYSICAL EXAMINATION. 
 
 riis]3ectlon. — See front of cliest. Look for and define apex- 
 beat ; it should be seen in iiftli space an inch below, and 
 internal to, left nipple. Look for other sites of pulsation. 
 Pulsation of left auricle may be seen in third space. 
 
 Palimtion. — Feel the general force of the cardiac impulse, 
 indicating strong or weak action, Hypertrophy or Dila- 
 tation. Determine area of impulse and site of apex-beat. 
 Search for a thrill, especially towards apex ; feel first 
 with tips of fingers, afterwards mth ends of metacarpal 
 bones. Look for friction fremitus. See pericarditis. See 
 Displacement of Heart. 
 
 Auscultation. — Listen for 1st and 2nd sounds ; each should be 
 clear "lub-dub. " 
 
 1st Sound. — Systolic, coinciding Avith the impulse. 
 Loudest towards apex ; to be traced upwards to the base, 
 towards epigastrium and to axilla. Note character of 
 sounds, sharp, clear, feeble, dull, prolonged, or short, or 
 much resembling 2nd sound (tic-tac). Accompanying 
 bruits are termed systolic. 
 
 2nd Sound. — Diastolic, coinciding Avith subsidence of 
 cardiac impulse. Loudest, at level of second costal car- 
 tilage ; aortic valves to the right side (aortic cartilage), 
 pulmonary valves to the left (pulmonary cartilage). 
 Trace the sound to the apex. The whole 2nd sound may 
 be accentuated, or either the aortic or pulmonary only. 
 It may be reduplicated. Accompanying bruits are 
 termed diastolic. 
 
 Cardiac Mimnurs, — The fact of a cardiac mm'mur being 
 decided, determine its periodicity — systolic, diastolic, or 
 presystolic ; the site of maximum intensity ; and relative 
 conductivity in various directions, towards base or apex, 
 to axilla or along sternum, or along the vessels at the base. 
 Observe if audible by spine or at angle of left scapula. 
 Character of murmurs — plain bellows sound, musical, 
 rasping. 
 
DISEASES OF THE VASCULAR SYSTEM. 103 
 
 HEART— PHYSICAL EXAMINATION. 
 
 liispcction. — May detect a diffused wave of impulse, e.g., 
 Pericarditis. Hypertropliied left auricle may be seen 
 pulsating in mitral stenosis or contraction of left lung. 
 Abnormal site of pulsation from Aneurism, usually in right 
 third space. See bulging of precordium. 
 
 Palpation. — Pulsation may be detected in epigastrium in dila- 
 tation. Thrill systolic over aortic cartilage (second right) 
 in aortic stenosis or aneurism ; at apex in mitral regurgita- 
 tion. A diastolic thrill in base at aortic regui'gitation ; at 
 apex just before the systole in mitral stenosis. Strong 
 heaving impulse with hypertrophy. 
 
 Auscultation. — Determine if heart's sounds are healthy and in 
 due rhythm ; if accompanied b}^, or replaced by, abnormal 
 sounds (bruits or murmurs) which are generally due to 
 pathological conditions of the valves. jSTote they may be 
 due to Anaemia or Aneurism. 
 
 1st Sound. — Indicates the muscular condition of the heart, 
 and how it is working ; strong in Hypertrophy, weak in 
 degeneration of the walls. It may be reduplicated ; may be 
 masked by Emphysema. Ansemic bruit at base common. 
 
 2nd Sound. — Due to closure of semilunar valves, aortic 
 and pulmonary ; each should be examined separately. 
 Pulmonary 2nd sound not often accompanied by a bruit 
 unless from ansemia ; it is accentuated in recent pulmonary 
 congestion, as from recent mitral regm'gitation. Aortic 
 2nd sound accentuated in obstructed arterial (systemic) 
 circulation, as in Bright' s Disease. 
 
 Cardiac Murmurs. — If the normal heart's sounds are heard, 
 and the other physical signs and the pulse are healthy, 
 we may conclude that the heart is healthy. If a bruit be 
 heard, look for all the Signs of Heart Disease and the 
 presence or history of some cause likely to produce val- 
 vular defects. If there be no other proof of heart disease 
 than the bruit, look for signs of Anaemia and ansemic 
 bruits. The character of murmurs often changes. 
 
104 CLINICAL MEDICINE AND CASE-TAKING. 
 
 HEART— PHYSICAL EXAMINATION. 
 
 Percussion. — Detennine and mark out the area of relative 
 and absolute precordial dulness. In health it extends 
 from about the third left cartilage to the apex-beat, being 
 limited below by the line of the liver, and not crossing 
 the median line. Area of dulness may be diminished by 
 atrophy of the heart, as in old age, or heart may be 
 overlapped by Emphysema of the lungs. The area may be 
 increased by pericardial effusion as a triangle, larger than 
 the normal area, with its apex towards the top of the 
 sternum. 
 
 PULSE. 
 
 Usually felt in radial artery ; it may be examined in any 
 superficial artery. 
 
 1. Frequency. — Frequent or infrequent refers to the number of 
 
 'pulsations per minute. P. = 
 
 2. Quick or slotv. — Refers' to the time occupied by each beat, 
 
 not including the interval between it and its successor. 
 
 3. Bhythm. — Regular or irregular implies the order of succession. 
 
 Intermittent, the occasional dropping of a beat. 
 
 4. Large or small. — Refers to the degree of dilatation of the 
 
 artery. 
 
 5. Jerking or collapsing. — Full, rising quickly and falling 
 
 suddenly. 
 
 6. Tension. — Soft or hard. Felt by the fingers and measured 
 
 by the force required to extinguish the pulse by pressure. 
 
 7. Dicrotous. — The wave is double-headed and the pulse soft. 
 
 8. Locomotor. — When the artery is seen to _'travel like a snake 
 
 under the skin. 
 
 State of arteries. — Examine radial, brachial, femoral, dorsalis 
 pedis, temporal, etc. The artery as a piece of tissue may 
 be hard or soft, irregular on the surface, dilated, etc. 
 
DISEASES OF THE VASCULAR SYSTEM. 105 
 
 HEART— PHYSICAL EXAMINATION. 
 
 Percussion. — H}^erti'opliy of right ventricle increases the 
 width of the area of duhiess, so that it may reach to the 
 right of the median line. Hypertrophy of the left 
 ventricle extends the dulness ontwards and downwards. 
 Abnormal areas of dulness adjoining the heart may be 
 due to Consolidation of Lung, mediastinal tumour, or 
 Aneurism. 
 
 PULSE. 
 
 May indicate the condition of the cavities of the heart and 
 valves, and the state of the nervous system. 
 
 1. Frequency. — High in fever and in mental excitement ; in 
 
 disease of the valves and walls of the heart ; in Graves' 
 Disease. 
 
 2. QuicTcness. — Chiefly affected by conditions of the nervous 
 
 system. 
 
 3. Hhythm. — Irregularity may depend upon valvular lesions, 
 
 especially mitral disease, or on the state of the muscular 
 walls of the heart; bra\n disease, e.g., Meningitis; reflex 
 causes, e.g., dyspepsia. 
 
 4. Large or small. — Depends upon strength of the left ventricle 
 
 and condition of valves. It may be small in mitral disease 
 or depressed innervation. 
 
 5. Jerking. — In aortic regurgitation with hypertrophy of left 
 
 ventricle. This character may be less marked if mitral 
 disease coexist. 
 
 6. Tension. — High in Chronic Bright's Disease, and in the 
 
 cold stage of ague. Low in Typhoid State and conditions 
 of adynamia. 
 
 7. Dicrotous. — In fevers, especially in the typhoid state. 
 
 8. Locomotor. — Indicates a hard, thickened, or Atheromatous 
 
 Artery, or an h}'pertrophied left ventricle. 
 State of Arteries. — Rigid, tortuous, and rough upon the surface 
 in atheroma. See Vessels, Disease of. 
 
106 CLINICAL MEDICINE AND CASE-TAKING. 
 
 PASSIVE (Cardiac) CONGESTION. 
 
 Starting from an obstructed circulation on tlie left side of the 
 lieart, e.g., mitral obstruction. 
 
 Fulmonary veins overfull (open into left auricle) ; receive blood 
 from pulmonary capillaries and some of the bronchial 
 capillaries. 
 
 Bronchial capillaries overfull ; hence tendency to 
 Bronchitis. 
 
 Pulmonary capillaries overfull; hence Pulmonary (Edema, 
 i.e., effusion into air vesicles. 
 
 PulmoTiary artery (leading from right ventricle) conveys blood to 
 the overfull pulmonary capillaries ; hence tension rises in 
 the pulmonary artery, and pulmonary 2nd sound ma^ be 
 accentuated. 
 
 Right ventricle (drives blood into the pulmonary artery, which 
 is overfull). It becomes over-distended and dilated ; this 
 may lead to Tricuspid Regurgitation. 
 
 Eight auricle (drives blood into the right ventricle, which is 
 overfull). It receives blood from superior and inferior 
 venae cavse and bronchial veins. 
 
 Superior vena cava receives blood from bronchial veins; these 
 carry blood from bronchial capillaries (which also partly 
 empty into pulmonary veins) ; hence Bronchitis, The 
 bronchial veins also receive blood from the pleura ; hence 
 Hydrothorax. 
 
 Jugular veins, and the veins of the head and upper 
 extremities, send their blood to the superior cava ; hence 
 Cyanosis of the Face, jugulars standing out in the neck, 
 Congestion of the Brain, (Edema of the upper extremities. 
 If there be tricuspid incompetence, jugulars may be seen 
 and felt pulsating. 
 
 [Continued next page. 
 
DISEASES OF THE YASCULAK, SYSTEM. 107 
 
 PASSIVE (Cardiac) CONGESTION. 
 
 Inferior vena cava receives blood from tlie hejKiiic vein ; hence 
 congestion of intra-lobiilar veins and hepatic capillaries in 
 the lobules causes Enlargement of the Liver and Jaundice, 
 also obstruction to the outflow from the vena port», and 
 congestions of the vessels emptying into the j^ortal system, 
 viz., gastiic, splenic, intestinal, hemorrhoidal ; hence 
 Spleen large. Ascites, Hsematemesis, or Melaena. 
 
 Renal veins (branches of the inferior cava) receive the 
 veins which collect blood from the capillary plexus sur- 
 rounding the uriniferous tubes ; this plexus becomes 
 primarily cor<5ested, and as it receives blood from the 
 aft'erent vessels of the Malpighian tufts, these capillaries 
 become secondarily congested, leading to Scanty Secretion 
 of Urine and Albuminuria. 
 
 Iliac and femoral veins return blood from the lower 
 extremities, and their over-fulness leads to capillary con- 
 gestion and (Edema of the Feet, the pressure being the 
 greatest in the most dependent set of capillaries. 
 
 IMPORTANT ANASTOMOSES. 
 
 In portal obstruction, anastomosis of inferior haemorrhoidal veins 
 of the internal iliac with branches of the inferior mesenteric 
 of the portal system. In portal obstruction, blood flows 
 from intestines through the rectum to the internal iliac 
 veins. Piles result. 
 
 In obstruction of inferior {a\idiOViiinal) vejia cava, e.g., by pressure 
 of a growth or tumom*, anastomosis of epigastric veins of the 
 iliacs with mammary branches of superior cava. Enlarged 
 veins on abdominal walls common in ascites. 
 
 Radial a'od ulnar arteries. — When radial pulse is obliterated we 
 may have a retui'n current by deep palmar arch. 
 
108 
 
 CLINICAL MEDICINE AND CASE-TAKING. 
 
 MITRAL EEGTJRGITATION. 
 
 MITRAL OBSTRUCTION 
 
 Inspection. — Apex - beat dis- 
 placed outwards and down- 
 wards ; impulse diffused. 
 Eight ventricle probably 
 dilated. 
 
 Pulsation of hypertro- 
 pbied left auricle sometimes 
 seen in third left interspace. 
 Right ventricle probably 
 dilated. 
 
 Palpation. — Right ventricle 
 usually hypertrophied or 
 dilated. Apex-beat displaced 
 outwards and downwards. 
 
 Pulse frequent, small, ir- 
 regular. Systolic thrill at 
 apex. Heart's action may be 
 irregular. 
 
 Right ventricle hypertro- 
 phied. Thrill at apex jusb 
 preceding impulse. 
 
 Pulse small. 
 
 Auscultation. — Systolic bruit at 
 apex conducted well into 
 axilla, also heard at angle 
 of left scapula. Pulmonary 
 2nd sound accentuated. 
 
 Presystolic bruit at apex. 
 Pulmonary 2nd sound accent- 
 uated from increased tension 
 in pulmonary artery. Aortic 
 2nd sound feeble at apex. 
 Bruit almost localized to 
 apex-beat. 
 
 Percussion. — Dilatation or hy- 
 pertrophy of right ventricle. 
 
 Left auricle and right side 
 of heart hypertrophied. 
 Left ventricle not hypertro- 
 phied. 
 
DISEASES OF THE VASCULAR SYSTEM, 
 
 109 
 
 AORTIC REGURGITATION. AORTIC OBSTRUCTION, 
 
 Jnspection. — Left ventricle Hy- 
 pertrophied ; apex-beat dis- 
 placed outwards and down- 
 wards ; much precordial 
 impulse seen. Pulse seen 
 locomotor. 
 
 Left ventricle hypertro- 
 phied, but less dilated than 
 with, regurgitation. 
 
 JPalpation. — Thrill diastolic, 
 distinct afc base ; great hy- 
 pertrophy of left ventricle, 
 precordium thrust forward at 
 systole, etc. 
 
 Pulse full and Collapsing. 
 
 Thrill systolic over aortic 
 valves. Signs of hypertro- 
 phy ; impulse strong, heav- 
 ing. 
 
 Pulse small or not abnor- 
 mal. 
 
 Auscultation. — Diastolic bruit 
 at aortic cartilage and con- 
 ducted down left side of 
 sternum. 
 
 ■Co-existing Mitral disease 
 common. 
 
 Systolic bruit over aorfcic 
 cartilage conducted to right 
 sterno-clavicular joint. 
 
 Exclude Anaemic Bruit. 
 
 Percussion. — Area of dulness 
 increased downwards and 
 outwards, from hypertrophj'- 
 of left ventricle. 
 
110 CLINICAL MEDICINE AND CASE-TAKING, 
 
 HYPERTROPHY OF HEART. 
 
 Insijection. — Heart's impulse may loe seen over an extended 
 precordial area, shaking and thrusting forward the chest- 
 walls. Apex-beat displaced, usualh^ outwards and down- 
 wards. In children the cardiac area may be bulged 
 forward. 
 
 Palpation. — Shock of heart against chest- wall very distinct, 
 raising the hand or stethoscope. Impulse felt in several 
 interspaces. Epigastric pulsation if right ventricle is 
 hypertrophied. Pulse full and strong in proportion to the 
 hyperti'ophy. 
 
 Aiiscidtatioii. — Fu'st sound prolonged, dull, strong. Aortic 
 2nd sound intensified. ' A-ofe diagnosis from pericardial 
 effusion by intensity of 1st sound coinciding ^Yith increased 
 area of dulness. 
 
 Percussion. — Area of dulness. Left ventricle enlarged down- 
 wards and outwards, and may extend a little upwards. 
 Right ventricle enlarged laterally, and may extend to 
 right of sternum. 
 
 HYPERTROPHY AND DILATATION. 
 
 Causation — 
 
 Obstructions in tlw jjidmonary circulation {right heart 
 affected). — Emphysema. Chi'onic bronchitis. Chronic 
 pleurisy. Adhesions of lung preventing expansion. 
 
 Obstructions in tlic aortic circulation {ijrinutrily aifecting 
 left side). — Arterial disease. Chronic Bright's Disease, 
 ^^-ith thickening of small arteries. General plethora. 
 Repeated pregnancies. 
 
 Causes originating in or about the heart. — Primary 
 dilatation, -e.g., after fevers, in Anaemia, Vahoilar disease 
 and stenosis of the outlets. Adherent pericardium. Ex- 
 cessive exercise. Displacements of the Heart. Mal- 
 formations. Emotional disturbance long continued. Fatty 
 or other form of degeneration. 
 
DISEASES OF THE VASCULAR SYSTEM. Ill 
 
 DILATATION OF HEART. 
 
 Inspection. — Impulse diffused, not bulging or shaking walls 
 of chest. If right ventricle is dilated, epigastiic pulsation 
 may be seen, and Tricuspid Eegurgitation may lead to 
 pulsation in jugular veins. Cyanosis and dropsy common. 
 
 Palpaticm. — Impulse diffused ; it may be heaving if ventricles 
 are hypertrophied, or feeble if walls are degenerate. 
 Impulse may be masked by emphysematous lung over- 
 lapping the heart. Pulse weak, especially if walls of 
 ventricle are degenerate. 
 
 Auscultation. — If walls of heart are degenerate, 1st sound 
 feeble, short, and much resembling 2nd sound. 
 
 HYPERTROPHY AND DILATATION. 
 
 Dilatation of either ventricle may exist without much compen- 
 sative hypertrophy ; perhaps this is most common on the 
 right side. A dilated and hypertrophied heart may be 
 capable of carrying on the circulation so perfectly as to 
 compensate for a valvular lesion, but when degeneration 
 of the heart-walls follows, then signs of Cardiac Congestion 
 are apt to supervene. Very great hyperti'ophy of the left 
 ventricle without any bruit or valvular lesion is common 
 with Granular Contracted Kidneys. The cardiac impulse 
 and area of dulness are often masked by emphysema of the 
 lungs ; but still, with hyperti'ophy the pulse is strong. 
 Examine heart, lungs, urine. 
 
112 CLINICAL MEDICINE AND CASE-TAKING. 
 
 CARDIAC DISPLACEMENTS. 
 
 Pleuritic Effusion, pushing the heart to the opposite side ; 
 .subsequent contiaction of lung may draw it to the side 
 affected. Cirrhosis of lung, or other form of contraction, 
 drawing heart to side affected. Cancer of lung, if diffused, 
 dragging it to side affected by conti'acting. Mediastinal 
 tumour, cancer. Aneurism, glandular, pushing heart aside. 
 Abdominal Tumour, hepatic, ovarian, etc., pressing up 
 diaphragm may displace heart. 
 
 VALVULAR DISEASE. 
 
 Causation.- — Rheumatism, atheroma, rupture of valves, scarlet 
 fever. Syphilis, Alcoholism, muscular over-strain, con- 
 genital heart defect. 
 
 HEART DISEASE. 
 
 General symptoms. — Seldom attended with pain, unless Angina. 
 
 General condition. — Anaemia, mal -nutrition, (Edema, haemor- 
 rhages, faintness, languor. 
 
 Digestion. — Dyspepsia, Jaundice, Ascites, Liver large. 
 
 Vascular system. — Palpitation. Irregularity of heart's action. 
 Haemorrhages. Cyanosis. See Passive (Cardiac) Conges- 
 tion. Dropsy. Embolism. Irregular pidse, feeble, etc. 
 Over-fulness of veins. 
 
 Nervous system. — Distui'bance of general condition of Nervous 
 System. Insomnia. Vertigo, Headache, Chorea, Convul- 
 sions, Paralysis, Angina Pectoris. 
 
 Respiratory system. — Orthopncea. Dyspncea, especially on 
 exertion. Respirations frequent. Bronchitis, Emphysema, 
 Cough. 
 
 Urine. — Scanty, with deposit of lithates. Sp. gr. high. May 
 contain albumen or blood. 
 
DISEASES OF THE VASCULAR SYSTEM. Hi 
 
 CARDIAC BISPLACEMENTS. 
 
 May be diagnosed by palpation and percussion principally. 
 The heart may be raised by pericardial eflusion. Apex- 
 beat may be displaced by cardiac Hypertrophy or Dila- 
 tation. Displacement may cause cardiac dyspnoea, etc., 
 e.g., in cases of sudden pleuritic effusion. 
 
 VALVULAR DISEASE. 
 
 Causation. — Rheumatism usually attacks the mitral valve, and 
 may spread to the aortic. Atheroma spreads from the 
 aorta to the valves. 
 
 HEART DISEASE. 
 
 Enquire for signs and symptoms of heart disease, then make 
 a careful physical examination. Listen for the normal 
 sounds, and bruits accompanying or replacing them. 
 Look for signs of Hypertrophy or Dilatation. If a bruit 
 is heard, look for signs of anaemia. Note state of pulse 
 and respiratory system. Examine arteries. Valvular 
 lesions are often combined, e.g., aortic regurgitation and 
 mitral regurgitation coexisting, etc. Many symptoms 
 result from passive congestion, e.g., oedema, cyanosis, 
 pulmonary oedema, bronchitis, hydrothorax, haemoptysis, 
 large spleen, enlargement of liver, jaundice, ascites, 
 Albuminuria, congestion of brain. These symptoms then 
 vary with the heart's condition. 
 
114 
 
 CLINICAL MEDICINE AND CASE-TAKING. 
 
 PALPITATION. 
 
 FTTNCTIONAL. 
 
 Disturbance of the general 
 condition of the Nervous 
 System. 
 
 Excessive smoking, or use of 
 tea and coffee. 
 
 Often relieved by exercise. 
 
 Frequent in recumbent pos- 
 ture. 
 
 Mostly in hysterical women. 
 
 Attacks intermittent, as 
 causes producing them vary, 
 e.g., dyspepsia, menstruation. 
 
 Between attacks heart and 
 pulse natural. 
 
 Often accompanied by neur- 
 algic pains. 
 
 ORGANIC. 
 
 Physical signs of disease 
 of walls of heart or its 
 valves. 
 
 Accompanying general 
 Signs of Heart Disease. 
 
 Excited by exertion, re- 
 lieved b}'' rest. 
 
 Mostly while at work. 
 
 Mostly in men who labour. 
 
 Coincide with the amount 
 of exercise, but may be ex- 
 cited by emotion. 
 
 In intervals signs of heart 
 disease may be best detected. 
 
 Xot often accompanied by 
 distinct pain, but there may 
 be attacks of Angina Pec- 
 toris. 
 
 In attack, pulse small and 
 irretfular. 
 
 Disease of walls of heart, 
 vessels ; Aneurism. 
 
 In attacks face may be 
 flushed, throbbing in ears, 
 tinnitas aurium. 
 
 Gout ; masturbation ; want of 
 sleep ; Graves' Disease. 
 
 Cmisation. — Heart disease ; Dilated Heart ; Hysteria; hyper- 
 trophied heart with degeneration. Reflex uterine ; 
 dyspepsia. 
 
 Exawtine heart, its sounds, impulse, regularity. Look for 
 Vascular Degeneration. 
 
DISEASES OF THE VASCULAE, SYSTEM. 115 
 
 ANGINA PECTORIS. 
 
 Note exciting causes of paroxysms, the times and circumstances 
 under which they occur. 
 
 In the paroxysm, note position and attitude of patient, facial 
 expression, ability to speak or othermse, state of skin ; 
 Pulse, its frequency and characters ; action of heart during 
 attack. Note state of respiration. Examine urine passed 
 after attack. Examine heart and vessels in the intervals 
 of the paroxysms. 
 
 It is characterized by sudden paroxysms of intense suffering, 
 with the sense of impending death, or a sense of want of 
 air, burning pain in chest, or sense of constriction, pain 
 radiating from the chest down the left arm. In paroxysms 
 there may be profuse sweating, face pale, occasionally 
 flushed, palpitation, subsequent exhaustion. 
 
 Pulse may be small and weak, or strong and not frequent. 
 
 Causation. — Organic disease of heart, walls, or valves. Disease 
 of vessels. See Signs of Heart Disease, especially hyper- 
 trophy and dilatation. Atheroma of arteries. Syphilis, 
 Aneurism, over-exertion. Alcoholism, Gout, Hysteria. 
 
 Reflex exciting causes, e.g., dyspepsia, uterine derange- 
 ment, mental excitement. 
 
116 CLINICAL MEDICINE AND CASE-TAKING. 
 
 PERICARDITIS. 
 
 Precordial pain and tenderness. Dyspnoea, especially in upright 
 posture. Tendency to syncope. Palpitation. Pain on 
 swallowing. Fever. 
 
 liispection. — A diffused wavy impulse ma}^ be seen. In young 
 subjects the precordial region may bulge. 
 
 Palpation. — Precordial fremitus may be felt, especially if 
 patient sit or stand up. Apex-beat may be elevated and 
 slightly displaced outwards. Tenderness on upward 
 pressm'e fi'om epigastrium. Pulse feeble, irregular, inter- 
 mittent. 
 
 Auscultation. — Friction sound not suspended on holding the 
 breath ; it may be altered by pressure — " to-and-fro, " or 
 only systolic ; a brush or hard grating sound. Describe 
 the heart's sounds heard as well as these adventitious 
 sounds. 
 
 Percussion. — Tenderness. Enlarged area of cardiac dulness ex- 
 tending as a triangle, apex upwards, to second rib, and 
 even passing to right of sternum. Area of dulness may 
 pass outside apex-beat. 
 
 Ga.usation. — Rheumatism. Bright's Disease. Scarlet Fever. 
 Erysipelas and other fevers. Pyaemia. Cold. Neighbour- 
 ing abscess or cancer, etc. 
 
DISEASES OF THE VASCULAE SYSTEM. 117 
 
 PEEICAEDITIS. 
 
 May coexist with other inflammatory conditions, e.g., Pneu- 
 monia, Pleurisy. If valvular disease coexist there may 
 be orthopnoea. The cesophagus is in close relation to the 
 pericardium. 
 
 Inspection. — Extended wave of impulse may be due to 
 Aneurism or Retracted Lung exposing the left auricle. 
 
 Palpation. — Fremitus may be absent in recumbent posture, 
 if effusion be excessive or purulent. Diffused impulse 
 may be mistaken for cardiac dilatation ; it is weaker than 
 in cardiac Hypertrophy. 
 
 Auscultation. — Friction may be inaudible with excessive serous 
 effusion or with pus ; it ceases when adhesion occurs. 
 Friction of a roughened pleura moved by heart may 
 be mistaken for pericarditis. Endocardial murmurs ma}' 
 accompany those exocardial. 
 
 Percussion. — Extended area of dulness may suggest hyper- 
 trophy, but in pericardial effusion the sounds are indistinct. 
 Extended dulness, apparently cardiac, may be due to 
 solidification of the left lung. 
 
 Diagnosis. — From endocardial murmurs by the friction being 
 felt, and being heard as localized and not specially 
 conducted in certain directions. Fremitus may be altered 
 by pressure of the stethoscope on the chest, especially 
 in young subjects. The friction is heard as superficial 
 and more grating than an endocardial murmiu'. 
 
118 CLINICAL MEDICINE AND CASE-TAKING. 
 
 CONGENITAL DEFECTS OE THE HEART. 
 
 Among the signs of malformation or congenital defects 
 of tlie heart and vessels there may be cyanosis, clubbed 
 lingers and toes, low temperature, a general want of 
 development, or some special deformity of the mouth, 
 ears, fingers, etc. Enquu'e as to the history of the 
 mother's pregnancy. 
 
 Make physical examination of the heart ; there may be 
 hypertrophy of one or both ventricles in various forms of 
 malformation. Tricuspid Constriction may result from 
 fcetal endocarditis. 
 
 See Developmental Defects. 
 
 TRICUSPID REGURGITATION. 
 
 Systolic murmur at the lower part of the sternum to its right 
 side or near the ensiform cartilage, not conducted to the 
 aorta. Examine for other valvular lesions and Emphy- 
 sema. As a primary disease it is rare, and usually 
 congenital. Examine jugulars for venous pulse, and see if 
 they refill from below when emptied. 
 
DISEASES or THE VASCULAR SYSTEM. 119 
 
 CONGENITAL DEFECTS OF THE HEART. 
 
 Some conditions are incompatible with life. The conditions 
 most commonly met with are communications between the 
 ventricles through the septum ; these may be accompanied 
 by a systolic bruit heard near the base of the heart, not 
 conducted into the arteries. Cyanosis is not a necessary 
 accompaniment ; the bruit may not be constant. Patent 
 foramen ovale but rarely produces a murmur ; it is often 
 accompanied by a contracted pulmonary orifice, which 
 produces a systolic murmur at the base. 
 
 TRICUSPID REGURGITATION. 
 
 Usually secondary to mitral disease or emphysema ; the 
 right ventricle is then hypertrophied. At systole 
 regurgitation takes place into the vena cava, causing 
 venous pulse in the neck, the pulsation being perceptible 
 to sight and touch. It may be temporary from over- 
 distension of right ventricle during an attack of 
 Bronchitis. 
 
120 CLINICAL MEDICINE AND CASE-TAKING. 
 
 THORACIC ANEURISM. 
 
 Physical signs. — Pulsation, wlien the aneurism points against 
 the chest-wall, most usually about third right rib. The 
 chest-walls may be bulged, the ribs absorbed, and the 
 tumour become prominent. Impulse may be felt with a 
 thrill at same point. The heart may be displaced, but 
 is not usually hypertrophied. The sternum or chest-walls 
 may be heaved up without any prominent tumour. A 
 systolic or double bruit may be heard at seat of impulse, 
 but not necessarily so. Heart-sounds may be heard 
 as distinctly over the aneurism as over the heart itself. 
 The aortic valves may be incompetent. Dulness over 
 chest in an abnormal situation mthout signs of lung 
 consolidation. 
 
 Pressure signs. — Pressure on one lung or bronchus causes 
 dyspncea on exertion, and loss of respiratory murmur over 
 the lung compressed. Haemoptysis, or ulceration of 
 bronchus or ti-achea. Dysphagia from pressure on the 
 oesophagus. Constant pain in back. Pressure on sub- 
 clavian artery causing unequal pulses in radials. Pressure 
 on veins causing oedema and enlargement of superficial 
 veins. Irritation of sympathetic nerve in chest causing 
 dilatation of the corresponding Pupil, or its contraction if 
 nerve is paralysed. Paralysis of one recurrent laryngeal 
 nerve causing paralysis of the corresponding vocal cord, 
 cough, laryngeal stridor, and metallic-toned voice. {Note — • 
 the left nerve turns round the arch of aorta, the right 
 round the innominate artery. ) Pressure on trachea causes 
 spasmodic cough, often with tracheal respiration, heard 
 over sternum and vertebrae. 
 
DISEASES OF THE VASCULAR SYSTEM. 121 
 
 THORACIC ANEURISM. 
 
 Prominent symptoms. — Pulsation on the surface of the chest, 
 vdih dulness at a point remote from cardiac impulse ; 
 dyspnoea on exertion ; stridulous laryngeal breathing from 
 paralysis of one vocal cord ; pressure signs in thorax ; 
 Angina Pectoris ; Hsemoptysis. 
 
 CoAisatio^n. — Atheroma of aorta. Syphilitic arteritis. Strains 
 and injuries. Most common in men and in middle and 
 later life. See Vessels, Disease of. 
 
 Diagnosis from chronic laryngitis ; cough loud and paroxys- 
 mal with a ringing sound, laryngoscope showing palsy 
 of one cord with no other disease. The pulmonary 
 artery or left auricle may be uncovered by retraction 
 of the left lung, and abnormal pulsation on the surface 
 may result, with an enlarged area of dulness. A cancerous 
 tumour may be pulsatile. Earely, an empyema may 
 pulsate. 
 
 Course of disease. — The tendency of an aneurism is to increase 
 in si2e. If blood is pumped into the sac at a pressure of 
 one ounce to the square inch, that amount of pressure is 
 exerted on each square inch of the aneurism. Pressure may 
 cause absorption of vertebrae, ribs, sternum. The sac may 
 burst into the pleura, lungs, pericardium, oesophagus, 
 or externally, etc. 
 
 Signs of rujjture. — Sudden or rapidly increasing dyspnoea. 
 Paleness. 
 
122 CLINICAL MEDICINE AND CASE-TAKING. 
 
 VESSELS, DISEASE OF. 
 
 Look for Anaemia, Heart Disease, (Edema, Bright's Disease, 
 
 cutaneous hsemorrliages, loss of elasticity of skin, SypMlis, 
 Gout, Alcoholism, Epistaxis. 
 
 Arteries. — Examine all the superficial arteries, e.g., radials, 
 brachials, temporals, femorals, dorsales pedis, etc. Feel the 
 condition of the vessels, whether soft or hard, rough upon 
 the surface, rigid, calcareous, locomotor, tortuous, snake- 
 like. Embolism may occlude any artery in the limbs : in 
 spleen, causes its enlargement A\ith tenderness ; in kidney, 
 temporary albuminmia or htematuria ; in brain, hemi- 
 plegia. Retinal artery may be blocked. 
 
 Veins. — Most often diseased in lower exti-emities ; may be 
 enlarged, showing situation of valves. Varicose veins may 
 become hard from occurrence of thrombosis, the clot 
 organizing and becoming hard and cord-like ; then ulcer 
 of the skin may result. 
 
 Phlebitis may occur during fevers, e.g., enteric, scarlet 
 fever, erysipelas, the vein becoming tender, swollen, hard, 
 cord-like. There may be cedema and subsequent abscess. 
 Look for gout, pressure on the vein, cancer, phthisis, or 
 other cause of great debility. Aneemia. 
 
 Capillaries. — Often seen dilated over malar bones in persons 
 exposed to the weather ; in Cirrhosis of the Liver, chronic 
 
 Bright's disease, heart disease, alcoholism. 
 
DISEASES OF THE VASCULAR SYSTEM. 123 
 
 VESSELS, DISEASE OF. 
 
 Often coexists with general degeneration of the tissues of the 
 body, and especially of the kidneys. 
 
 Arteries. — Disease may be senile degeneration or due to local 
 injury or strain, atheroma, gout, rheumatism, syphilis, 
 alcoholism. There may result Aneurism, aortic incom- 
 petency, thrombus, embolism, gangrene, cerebral haemor- 
 rhage. Arteritis ; if diseased, specially liable to give way 
 when heart is hypertrophied, as with Granular Kidney. 
 It is apt to lead to vertigo, hemiplegia. Embolism may 
 start from a diseased valve or point of atheromatous artery. 
 Onset of symptoms often sudden ; it may obstruct any 
 systemic artery ; it often occurs in brain. 
 
 Veins. — Staining of the legs in course of veins may result 
 from constantly sitting before the fire. Varicose veins 
 may result from long standing or constipation. Phlegmasia 
 dolens after confinement. Loss of fat from the legs removes 
 their natural support. 
 
 Phlebitis, or inflammation of a vein. The clot may 
 break down and lead to pyaemia. It may be detached 
 and carried to the right side of the heart, and plug 
 the pulmonary artery or a branch, causing dyspncea, 
 haemoptysis from collateral hypersemia, syncope from 
 arrest of circulation in the right heart, and sudden death. 
 It may occur deep in a limb. 
 
 Capillaries. — Chronic capillary congestion in a limb often seen 
 when the nervous centres are diseased, e.g., paralysis, 
 idiocy, etc. ; hands blue and cold ; chilblains. 
 
124 CLINICAL MEDICINE AND CASE-TAKING. 
 
 DISEASES OF THE EESPIRATOEY SYSTEM. 
 CLINICAL REGIONS OF THE CHEST.* 
 
 Supra-clavicular. — From outer end of clavicle to ti*achea. 
 
 Clavicular. — Behind inner half of cla^"icle. 
 
 Infro.- clavicular. — From clavicle to lower border of third rib, 
 and outwards to a vertical line from the acromial angle 
 which divides the anterior from the lateral regions. 
 
 Mammary. — Extends to lower border of sixth rib. The nipple 
 is usually" over the fourth rib. 
 
 Infra-nianvinafi'y. — Extends to lower margin of the ribs. 
 
 Lateral regions : Axillo/nj. — From apex of axilla to line con- 
 tinuous with lower border of mammary region, and bounded 
 posteriorly by scapula. 
 
 Infra-axillary. — Extends down to the margin of the ribs. 
 
 Upper and loioer scapular regions. — Above and below spine 
 
 of scapula. 
 Inter -scapular region. — Between inner edge of scapula and 
 
 spines of dorsal vertebra. 
 Infra-scapmlar region. — From angle of scapula to margin of 
 
 ribs. 
 
 Upper sternal. — Extends to lower border of third rib. 
 
 Lower sternal. — From third rib downwards. 
 
 * After Dr. Walshe : " Diseases of the Lungs." 
 
DISEASES OF THE RESPIRATORY SYSTEM. 125 
 
 CLINICAL REGIONS OF THE CHEST. 
 
 Supra-clavicular. — Contains apex of lung ; this is usually 
 highest on the right side ; also portions of subclavian and 
 carotid arteries, and large veins. 
 
 Clavicular.- — Lungs, large arteries. 
 
 Infra-clavicular. — Upper lobe of either lung. Right side, close 
 to sternal border lie the superior cava and part of the 
 arch of aorta. Left side, edge of pulmonary artery, the 
 base of the heart being below. 
 
 Mammary. — Right side, middle lobe of lung. Left side, pre- 
 cordial area, sloping outwards and downwards to a point 
 about an inch below and internal to nipple. 
 
 Infra-mammary. — Right side, liver dulness, the lung encroach- 
 ing to a variable extent on full inspiration. Left side, 
 stomach, and inner portion of left lobe of the liver. Spleen 
 rising to sixth rib in lateral region. 
 
 Lateral regions : Axillary. — Contains upper lobes of the lungs. 
 
 Infra-axillary. — Lower margins of the lungs sloping down- 
 wards and backwards. Right side, liver ; left side, spleen 
 and stomach. 
 
 Upper and lower scapular regions. — Contains lungs. 
 
 Inter-scapular region. — Lungs, main bronchi, and glands, 
 
 descending aorta, oesophagus. 
 Infra-scapular region. — Lungs down to eleventh rib ; liver lies 
 
 below this on right side. Left side may be partially 
 
 occupied below by intestine. Aorta descends along the 
 
 left inner boundary. 
 Upper sternal. — Contains large vessels ; transverse portion of 
 
 the arch of aorta. Aortic valves at level of third right 
 
 cartilage, pulmonary valves to the left. Bifurcation of 
 
 trachea at level of second rib. 
 Lower ster'nal. — Main portion of right ventricle and a small 
 
 portion of the left resting upon the diaphragm and liver ; 
 
 at upper part a small portion of the left lung. 
 
126 CLINICAL MEDICINE AND CASE-TAKING. 
 
 PHYSICAL EXAMINATION OF THE CHEST. 
 
 Inspecticrti. — Observe general configuration ; form, especially local 
 or on one side, e.g., bulging or retraction ; observe spine, if 
 straigbt. Cbest movements — thoracic, abdominal. In 
 health, expansive movements are forward and upward. The 
 sternum moves forwards and upwards on inspiration. 
 Specially observe expansive movements in the infra-clavi- 
 cular regions. In calm breathing, abdominal movements 
 are scarcely observable. Observe position of heart's apex- 
 beat, and the condition of the intercostal spaces. 
 
 PATHOLOGICAL CONDITIONS. 
 
 Exjxinsion, or bulging, may affect one or both sides ; it may be 
 general over one side or only affect a particular area. 
 Observe intercostal spaces, whether bulged or sunken. 
 Look for position of heart's apex-beat. In all cases 
 carefully compare the corresponding regions on the two 
 sides. 
 
 Betraction, or depression, may be general over one or both sides 
 of the chest. It may be localized in one side, as in jQatten- 
 ing or retraction in the infra- cla\4cular region or in the 
 axillary regions. Examine spine ; it may be bent to side 
 contracted, with dropping of that shoulder. Contraction in 
 infra-mammary regions common in infants from Rickets 
 and collapse of lung. 
 
 Chest movements. — Deficient expansion may be bilateral and 
 general, one-sided or local. There may be a permanent 
 condition of expansion, e.g., Pleuritic Effusion, or j)erma- 
 nent Contraction, In women, respiratory movements are 
 principally thoracic. Movements of diaphragm may be 
 restricted by various conditions of the abdomen, e.g., 
 Ascites, ovarian tumour, Abdominal Tumour, 
 
 Rhythm of the respiratory act. — In health, if the total 
 dui'ation of one movement be taken at 10, inspiratory 
 movement = 5, expiratory 4, pause 1. 
 
DISEASES OF THE RESPIRATORY SYSTEM. 127 
 
 PHYSICAL EXAMINATION OF THE CHEST. 
 
 Inspection. — The general fomi should be symmetrical on the 
 two sides, and slightly convex in the infra-clavicular 
 regions. Shoulders should be on the same level, and the 
 spine straight. Specially observe movements, and Signs 
 of Retraction in the infra-clavicular regions. The two 
 sides of chest should be symmetrical, but, in men, muscular 
 development may cause greater fulness on the right side. 
 There may be expansion, or bulging, or retraction, or 
 altered chest movements. Chest may be deformed from 
 Bickets. 
 
 PATHOLOGICAL CONDITIONS. 
 
 Expansion, or bulging. — General enlargement of both sides may 
 be due to Emphysema. If one-sided from Pleuritic Effusion 
 or pneumothorax, the heart is then generally displaced. 
 Local bulging may be due to Aneurism, mediastinal 
 tumour, encysted empyema ; in right infra-axillary region 
 from enlargement or tumour of liver. In children, Cardiac 
 Hypertrophy may cause local bulging. 
 
 Retraction, or depression, implies contraction of the lung corre- 
 sponding, as from consolidation or pleurisy. It may be 
 general in atrophous emphysema. In infra-clavicular 
 regions it is an important indication of Phthisis. Collapse 
 of lung may occur from Laryngeal Disease, and accompanies 
 " pigeon-breast " in rickets. 
 
 Chest mowmewfe.— Movement may be restricted by the pain of 
 a pleuritic stitch or by pleurodynia ; by ossification of the 
 ribs, or by conditions of the lung and pleura. Deficient 
 movement in the infra-clavicular spaces accompanies con- 
 traction of the apex. In Emphysema vertical movement 
 of the sternum is usually unaccompanied by any forward 
 expansive movement. 
 
 Rhythm of the respiratory act. — Duration of expiratory 
 movement maybe greater than the inspiratory, e.g., in 
 obstruction to entry of air, in emphysema. Inspiration 
 may be short and abrupt. 
 
128 CLINICAL MEDICINE AND CASE-TAKING. 
 
 PHYSICAL EXAMINATION OF THE CHEST. 
 
 Palpation. — Observe movements of tlie cliest, both general and 
 local. Compare the two sides. Determine the intensity 
 of tactile vocal fremitus (T.V.F.) in various situations. A 
 friction fremitus from pleurisy or pericarditis, or from a 
 rlionclius in young subjects, may be detected. 
 
 Percussion. — Percuss each region of the chest, and determine the 
 boundaries of the heart and liver, height of apices of lungs 
 in neck. If the percussion note varies from the normal, 
 determine the area of this abnormality, and compare with 
 the same region on the other side. 
 Hyper -resonant or tympiccnitic. 
 
 Cracked-pot sound. — Jerky and with metallic character. 
 
 Amphoric. — Like the sound of filliping the cheeks tensely 
 distended. 
 
 AUSCULTATION.* 
 
 Kote separately inspiration and expiration, their character, re- 
 lative dui-ation, and whether accompanied by adventitious 
 sounds. Auscultate each region of the chest. 
 
 Normal respiration. — Vesicular murmur ; breezy. 
 
 Puerile respiration. — Exaggerated in both sounds, increased in 
 intensity, especially the expirator3^ 
 
 ABNORMAL SOUNDS FROM ALTERED CONDUCTIVITY OF LUNG- 
 TISSUE. 
 
 Harsh respiration. — Loss of natural softness and breeziness. 
 Expiration increased in duration and in intensity. 
 
 BroncMal respiration. — A higher degree of harsh respiration. 
 
 Both inspiration and expiration are altered. 
 Tubular respiration. — Air heard drawn in and puffed back with 
 
 a metallic character. 
 Cavernoics respiration. — Hollow metallic sound. 
 
 * These definitions are mostly quoted from Dr. Walshe, op. cit. 
 
DISEASES OF THE EESPIEATORY SYSTEM. 129 
 
 PHYSICAL EXAMINATION OF THE CHEST. 
 
 Palpation. — Of great value in detecting local contractions and 
 
 impairment of niovement. T.V.F. (tactile vocal fremitus) 
 
 increased (usually) over Solidified Lung and diminished 
 over a Pleuritic Effusion. 
 
 Percitssion. — In healtli, the sound is resonant, and resistance 
 vibratile over lung. Sound approaches dulness, and resist- 
 ance increases with various degi'ees of consolidation of the 
 lung, or pleuritic effusion. Dulness may be noted on 
 superficial or deep percussion only. 
 
 Hyjjcr -resonant or Tympanitic. — Over Emphysema or 
 Pneumothorax. 
 
 Craclced-pot. — Over a vomica ; sometimes in young 
 children without disease. 
 
 Amphoric. — Yomica. Pneumothorax. 
 
 AUSCULTATION. 
 
 Helps to determine the physical condition of the lungs, and the 
 position of their margins. In health, duration of inspi- 
 ratory sound to the expiratory is as 3 : 1 (inspiratory move- 
 ment of chest to expiratory as 5 : 6). Note separately the 
 respiratory murmur and any adventitious sounds. 
 
 Puerile respiration. — Normal in children. In adults, frequently 
 due to a portion of lung doing extra work (supplemental 
 respiration) on account of neighbouring lung-tissue con- 
 solidated or compressed. 
 
 ABNORMAL SOUNDS FROM ALTERED CONDUCTIVITY OF LUNG- 
 TISSUE. 
 
 Harsh respiration. — In moderate degrees of consolidation and 
 
 in Emphysema. 
 Bronchial respiration. — Indicates slight condensation of lung 
 
 substance. 
 Tubular respiration. — Perfectly developed over hepatized lung 
 
 in pneumonia. 
 Cavernous respiration. — Indicates probable cavity from phthisis; 
 
 dilated bronchus. 
 
 K 
 
130 CLINICAL MEDICINE AND CASE-TAKING. 
 
 AUSCULTATION. 
 
 ADVENTITIOUS SOUNDS. 
 
 FJionchi. — "Whistling, cooiug, bubbling, crackling sounds. 
 
 Sonorous rhonchus. — Inspiratory and expiratory usually; 
 sometimes beard without contact "with the chest. It is a 
 snoring sound. 
 
 Sibilant rhmicJius. — Dry sounding ; high pitched, some- 
 times hissing; in character ; ^yhistling. 
 
 CrejJitations are crackling rales occurring in successive pufi's, all 
 resembling one another. They may occur with inspiration 
 or expiration. 
 
 Fine crepitation resembles the sound produced by rubbing 
 hair near the ear ; it occurs on inspu'ation in the first stage 
 of Pneumonia. 
 
 Pleural friction sound. — Heard only with respiratory move- 
 ments, except that occasionally a lung, roughened at its 
 margin, is moved by the heart. It may be heard on inspi- 
 ration and expiration ; jerky in character ; grating ; like a 
 simple brush ; or a creak like that of new leather. 
 
 COUGH. 
 
 Xote character and frequency ; paroxysmal, e.g., Hooping 
 Cougli ; whether occurring in prolonged attacks ; accom- 
 panied by Sputa. 
 
 Causation. — Bronchitis; lung disease; Phthisis; broncho- 
 pneumonia ; Pleurisy ; Heart Disease ; pressure on air 
 tubes in chest, e.g., Aneurism, mediastinal tumour, en- 
 larged bronchial glands. See hooping cough. Reflex causes ; 
 examine Mouth, fauces, pharynx, Larynx, 
 
DISEASES OF THE EESPIEATORY SYSTEM. 131 
 
 AUSCULTATION. 
 
 ADVENTITIOUS SOUNDS. 
 
 Rhonchi may be greatly altered by a cough ; they may 
 disappear and return, being much less constant than 
 the frictions, which they sometimes resemble. They are 
 characteristic of Bronchitis, and are frequently so loud 
 as to mask all respiratory sounds. The fremitus pro- 
 duced by a rhonchus may commonly be felt in children 
 on palpation. 
 
 Crepitations may be mistaken for pleuritic friction. Small 
 bubbling crepitations are heard at bases in Pulmonary 
 (Edema. Scattered crepitations are commonly heard at 
 the apices in Phthisis. Crepitati<)ns are sometimes absent 
 till patient has coughed and cleared the bronchus leading 
 to the seat of crepitus. 
 
 Pleural friction sound. — It is more lasting than a rhonchus, 
 and cannot be coughed away. It indicates a roughened 
 pleura, but may not be heard in Pleurisy on account 
 of Pleuritic Effasion, or the hepatization of lung beneath 
 pleura preventing its movement. 
 
 COUGH. 
 
 Xot a necessary accompaniment of lung disease, and often 
 not dependent upon lung disease. Prolonged attacks of 
 coughing sometimes cause so much asphyxia that tem- 
 porary loss of consciousness arises from passive congestion 
 of the brain. 
 
132 CLINICAL MEDICINE AND CASE-TAKING. 
 
 SPUTUM. 
 
 Its amount, consistence, whether aerated, colour, mixture of 
 substances, blood, colourless, mixed with blood, streaked 
 with blood, yellowish, white ; frothy, mucilaginous- 
 looking, watery, viscid, grumous ; mucus, purulent, 
 nummulated, in viscid masses. 
 
 H-a:MOPTYSIS. 
 
 Causatimi — 
 
 Valvular disease of left side of heart (pulmonary). 
 
 Valvular disease of right side of heart (bronchial). 
 
 Embolism of pulmonary artery from peripheral veins 
 (infarction). 
 
 Embolism of bronchial artery from left side of heart. 
 
 Blow on chest. 
 
 Bronchitis. Plastic bronchitis. Foreign body in trachea. 
 
 Blood entering the larynx and coughed up. 
 
 Aneurism bursting into bronchus. 
 
 Spasmodic Asthma (bronchial). 
 * Emphysema. Asphyxia (bronchial). 
 
 Scurvy. Htemorrhagic diathesis. 
 
 Renal disease (vessels diseased). Uraemia (blood changes). 
 
 Degeneration of tissues and vessels (alcoholic). 
 
 Phthisis. Cancer of lung. 
 
 Pneumonia. Abscess of lung. 
 
 Vicarious menstruation attended with amenorrhcea. 
 After an attack of haemoptysis there may be signs of blood 
 
 having run down to base of lungs (crejjitations and 
 
 dulness). It may occur accidentally without organic 
 
 disease. Hsemorrhage from the throat may be mistaken 
 
 for haemoptysis. 
 
DISEASES OF THE EESPIRATOEY SYSTEM. 133 
 
 SPUTUM. 
 
 Often frotliy water, colourless in early PhtMsis ; later purn- 
 lent, copious, and (when vomicEe have formed) nummulated. 
 Viscid, sticky, golden coloured in Pneumonia, and prune- 
 juice colour if mixed with blood. "White, aerated, frothy 
 in simple bronchitis. Stinking with gangrene of lung, and 
 in some cases of dilated bronchial tubes. 
 
 Diagnosis of HEMOPTYSIS from HEMATEMESIS. 
 
 Blood ejected. — Bright, frothy. Dark, clotted, mixed with 
 
 may be mixed with mucus. food. Acid. 
 Alkaline. 
 Manner of ejection. — Coughed Vomited mixed with food. 
 
 up, expelled without effort ; Acid. Patient often faints 
 faintness subsequent to ejec- before ejection. 
 tion. No food expelled. 
 Previonitory symptoms. — Cough, Signs of Ulcer or Cancer 
 
 signs of Phthisis, previous of Stomach, pain with food, 
 specks of blood with expec- epigastric tenderness, mala- 
 toration. ria. Cirrhosis of Liver, 
 
 Subsequent symptoms. — Subse- Subsequent blood by stool, 
 
 quent expectoration of mucus usually black, tar-like 
 and blood. matter. 
 
 Haemoptysis is mostly due to disease of the lungs or heart. 
 It may also be due to blood changes, e.g., ursemia. Care- 
 fully examine heart, lungs, urine. P. = ; T. = ; 
 E. = ; W. = . Enquire as to history of lung disease 
 in patient or his family, also for early deaths in family. 
 General condition of nutrition, etc. Haemoptysis may 
 apparently be sometimes purely accidental in a lung 
 previously healthy, and blood remaining in the lung may 
 set up phthisical changes. 
 
134 CLINICAL MEDICINE AND CASE-TAKING. 
 
 DYSPNCEA. 
 
 General condition. — Position of the . patient, orthopncea, cya- 
 nosis, fulness of the veins, (Edema, Anaemia. P. = ; 
 T. = ; E,. = . Xote any stridulous breathing or sign 
 of Laryngitis. Respiratory movements, whether thoracic 
 or abdominal ; if accompanied by collapse of the base of 
 the chest or recession of the epigastrium on inspiration. 
 Ability to speak ; voice. Character of the dyspnoea, con- 
 stant or paroxysmal ; causing much distress ; attended 
 Avitli pain, cough, and expectoration. Increased by exer- 
 tion or occurring on exertion only (probably cardiac). 
 Examine the lungs, heart, urine. Note condition of the 
 cu'culation. Pulse, Vessels. Respiratory muscles, if in a 
 sta-te of over-action, especially the sterno-mastoids. Action 
 of alae nasi. Fixation of the arms to enable chest muscles 
 to act at gi'eater advantage. General condition of the 
 Nervous System. 
 
 PULMONARY (EDEMA. 
 
 At base of lungs abundant small bubbling rales. T.Y.F. may 
 be increased or diminished. On percussion resonance 
 diminished and resistance increased. Dyspnoea, 
 
 Xote position of patient ; signs of Typhoid state. Examine 
 urine, Xote general condition of patient, specially of 
 Nervous System. 
 
DISEASES OF THE HESPIEATOEY SYSTEM. 135 
 
 DYSPN(EA. 
 
 Causation — 
 
 Structural clmnges. — Emphysema; PhtMsis; Pneumo- 
 nia; Bronchitis. (Edema of lungs. Pleuritic Effusion, 
 pneumo-thorax, acute pleurisy. Upward pressiu'e of 
 diaphragm from ascites. 
 
 Conditions of pulnionary circulation. — Congestion. Heart 
 disease. Emholism of pulmonary artery. Clot in heart. 
 Heart failure as when fatty or dilated. Anemism or 
 mediastinal tumour pressing on trachea or bronchus. 
 
 Laryngeal obstruction. — Laryngitis ; paralysis of cord ; 
 growth upon cord ; oedema of larynx. 
 
 General condition. — ^Ansemia. Fever. Uraemia. 
 
 Nerve co^/iditions. — Asthma. Hysteria. Paralysis of 
 nervous centres. Graves' Disease. Spasm of respiratory 
 muscles, e.g., from tetanus. 
 
 (EDEMA OF LUNGS. 
 
 In the course of pneumonia it may occur in lung tissue 
 adjacent to that inflamed, or in the opposite limg. May 
 attend hronchitis or any lung disease. With pleuritic 
 effusion may attack the other lung. Uraemia ; Fevers ; 
 Passive (cardiac) Congestion from valvular disease, or 
 degeneration of heart's walls. Frequent in conditions 
 of prostration with dorsal decubitus. 
 
136 CLINICAL MEDICINE AND CASE-TAKING. 
 
 CONTRACTION OF LUNG. 
 
 Tns'jjection. — Over portion of lung contracted, thorax contracted ; 
 expansion (inspiratory) diminislied. Contraction of one side 
 of chest suggests previous Pleurisy; of an apex, Phthisis. 
 Contraction of left lung may uncover left auricle. Look 
 specially at infra -clavicular regions in adults, and at bases 
 in infants. 
 
 Palpation. — Note diminislied expansion, general, one-sided, or 
 local. Position of heart ; it may be drawn over by a 
 contracting lung. Pulsation of left auricle may be felt if 
 left lung is contracted. T.Y.F. may be increased. 
 
 Percussion. — Sound may be of impaired resonance from thicken- 
 ing of pleura with lung consolidation. The resistance 
 felt may be increased. Frequently dulness exists from 
 coincident consolidation. 
 
 Area of pulmonary resonance above clavicle diminished over 
 a contracted apex. 
 
 Auscultation. — Respiratory sounds usually weak and may be 
 abnormal from altered conditions of the lung. 
 
 Look for signs of Consolidation. Phthisis. 
 
DISEASES OF THE EESPIKATOEY SYSTEM. 137 
 
 SOLIDIFICATION OF LUNG. 
 
 Inspection. — Yery commonly coincident signs of contraction, 
 especially if the consolidation is at the apex, 
 
 Palpation. — T.V.F.* increased. Diminished expansive move- 
 ment may also be detected. Note area affected, and 
 whether over one or both luners. 
 
 FercTission. — Dulness or various degrees of impaired resonance 
 may be observed over area of solidification ; line of dulness 
 not level, and changing with position of patient as in 
 pleuritic efiusion. Note efiect of light and deep percus- 
 sion. 
 
 Auscultatiov.. — V.R.f increased. Respiration harsh, bronchial, 
 or tubular ; may be cavernous if there be excavation. 
 Puerile in neighbourhood of consolidation. 
 
 Look for signs of Contraction of Lung ; Phthisis ; Pneumonia. 
 
 * T.V.F. = Tactile vocal fremitus, 
 t V.E.= Vocal resonance. 
 
138 
 
 CLINICAL MEDICINE AND CASE-TAKING. 
 
 Diagnosis of PNEUMONIA from PLETJRITIC EFFUSION. 
 
 Inspection. — Expansion di- 
 minished. Ko contraction 
 of chest unless lung shrinks 
 from chronic changes. 
 
 Palpation. — T.V.F. increased 
 (sometimes diminished), 
 occasionally a pleuritic 
 fremitus felt. 
 
 Mcnsuratiwu — Karely any 
 bulging. 
 
 Av^sciUiation. — First stage, 
 fine inspiratory crepitant 
 rales, often also pleuritic 
 rub. Second stage, tubular 
 respiration. Rhonchus or 
 scattered rales. V.R. in- 
 creased. Resolution: Redux 
 loose crepitus, inspiratory 
 and expiratory. Friction 
 sound may return. 
 
 Percussion. — Dulness at base, 
 usually follo'R'ing the line of 
 lower lobe downwards and 
 forwards. Increased resist- 
 ance felt. No change with 
 alteration of position. 
 
 Determination of the posi- 
 tion of heart and liver. Is o 
 displacement. 
 
 Bulging of side of chest 
 affected, also of the intercostal 
 spaces. As fluid is absorbed, 
 contraction and bending of 
 spine to side affected. 
 
 T.V.F. absent below line of 
 dulness ; may be increased 
 above. Fremitus in first stage. 
 
 Bulging usual. Tracing by 
 cyrtometer. 
 
 First stage, pleuritic fric- 
 tion, inspiratory, expiratory, 
 or both. Second stage, efiu- 
 sion. Respiratory murmur 
 absent in axilla, frequently 
 blo-^ing respiration near spine ; 
 puerile at apex. V.R. absent 
 or ffigophonic. Resolution : 
 Return of respiratory sounds 
 at base. Redux friction. 
 
 Line of dulness at base level 
 coming round to the front. 
 Dulness shifting with position 
 of patient. May be tympan- 
 itic above fluid. 
 
 Heart displaced, especially 
 with efiusion on left side ; 
 liver may be depressed. 
 
 Hypodermic syringe may be 
 used to draw off the fluid. 
 
DISEASES OF THE EESPIEATOEY SYSTEM. 139 
 
 PLEUEISY. 
 
 Friction heard during inspiration, or expiration, or during 
 both, periods ; it is lost after effusion has occurred, and 
 may return after absorption of fluid or reduction of a » 
 pneumonia. 
 
 Friction fremitus often felt. 
 
 Friction of pleural surface usually attended with pain, causing 
 patient to hold his breath ; he lies on side affected. 
 
 If the pleurisy be secondary to lung disease, e.g., phthisis, 
 symptoms will be those of the lung disease. Pyrexia in 
 pleurisy, lower than the inflammatory fever of pneumonia. 
 
 See signs of Pleuritic Effusion, P. = ; T. = ; R.= . 
 
 Causation, see same in Pneumonia. 
 
 Pleuritic effusion is always albuminous ; occasionally it coagu- 
 lates from presence of fibrin. 
 
 EMPYEMA. 
 
 Often not distinguishable from serous effusions before tapping. 
 It is most common in young subjects, debilitated or very 
 strumous. Also when effusion is very chronic. Tempera- 
 ture not necessarily high. More displacement of chest 
 walls and viscera than with serous effusion. 
 
 Temperature often elevated, but not necessarily so. It may 
 point under the skin in front of chest, laterally, or behind. 
 May occur in Septicsemia, Pyaemia, Erysipelas, Scarlet 
 Fever, Puerperal Fever. It may discharge by bronchus. 
 
 HYDROTHORAX. 
 
 Passive dropsical effusion without pleurisy. May occur from 
 Passive (cardiac) Congestion, Bright's Disease, etc. It is 
 usually double and unaccompanied by fever. 
 
140 CLINICAL MEDICINE AND CASE-TAKING. 
 
 PHTHISIS. 
 
 Physical signs. — Signs of Consolidation and Contraction of 
 
 Apex of lung. Carefully ins])ect movement in infra- 
 clavicular fossa on each side, examining for signs of 
 contraction of tlie apex. Palpate, noting if T.V.F. is 
 increased. In some cases the left auricle is uncovered 
 from contraction of the left lung. Percussion gives a dull 
 or wooden note ; note the sound of light or deep per- 
 cussion. The resistance increased over consolidated lung. 
 It may be amphoric over a vomica, but still the resistance 
 is augmented. Auscultation shows V.R. increased, respira- 
 tion harsh or bronchial, with adventitious sounds, scattered 
 rales, crepitation. 
 
 Digestion. — Dyspepsia often troublesome. Diarrhoea may be 
 due to tubercular Ulceration of Intestines. 
 
 Circulation. — Note force and strength of heart's action ; it often 
 partakes in the general wasting. 
 
 Nervous system. — General condition. Sleep. 
 
 Urine. — Albuminuria may be present. Diabetes is a frequent 
 cause of phthisis. 
 
DISEASES OF THE EESPIEATOET SYSTEM. 141 
 
 PHTHISIS. 
 
 Cough, vritli expectoration and Haemoptysis, debility and 
 weakness, emaciation. Sweatings especially at night. 
 Flushings ; fever ; dyspnoea on exertion. Angemia, and in 
 women amenorrhoea. Muscular irritability often marked. 
 In pregnant women phthisis is often temporarily arrested, 
 becoming active after parturition. In advanced cases 
 there may be cedema of the legs. 
 
 Causation. — Inheritance ; history of consumption or Scrofulous 
 disease in family ; give ages of any members of the family 
 who died. Hygienic conditions, locality of residence with 
 regard to climate and dampness, dusty trades. Exposure 
 to cold. Sequent to acute lung diseases, or haemoptysis. 
 A common termination in diabetes mellitus. 
 
 Possibly it is communicated from the diseased to persons 
 predisposed. 
 
 Complications. — Laryngitis, bronchitis, pneumonia, heemop 
 tysis. Pleurisy, empyema, pneumo-thorax. 
 
 Failure of heart's action ; thrombosis ; bed-sores. Diarrhoea or 
 Melsena from tubercular ulceration of intestines ; fistula ; 
 Peritonitis ; Liver large, fatty or amyloid ; Albuminuria ; 
 General Miliary Tuberculosis ; CEdema of legs. 
 
 Signs of a cavity (vomica). Percussion, giving a metallic 
 cracked-pot sound on auscultation ; respiration blowing, 
 tubular, cavernous, with moist rales at apex. Pectoriloquy. 
 
142 CLINICAL MEDICINE AND CASE-TAKING, 
 
 PNEUMONIA. 
 
 Physical signs. — Signs of Consolidation over hepatized lung. 
 Earliest sign, fine inspiratory crepitation resembling the 
 rustling of hair ; there may be also a pleuritic friction. 
 In hepatization, dulness along outline of the lobe solidified ; 
 if at base, sloping downwards and forwards. T.V.F. 
 usually increased. Respiration tubular and often accom- 
 panied by rhonchus and rales. Voice broncho-phonic. 
 On resolution respiration becomes less tubular ; crepitation, 
 loose inspiratory and expiratory ( = redux crepitation). A 
 return of the friction rub may be heard. 
 
 V^ Digestiwi. — Tongue furred ; thirst ; anorexia. There may be 
 I vomiting, diarrhoea, Jaundice. 
 
 Circulation. — Note force of impulse and first sound of heart. 
 Characters of pulse. 
 
 Nervous system. — General condition of Nervous System; sleep, 
 restlessness. Delirium. 
 
 Urine. — Scanty, with excess of lithates ; chlorides deficient. 
 May be albuminous. 
 
 Complications. — Pulmonary oedema ; collateral congestion. 
 Bronchitis ; high fever ; failure of heart, pulse becoming 
 weak and soft. Jaundice ; Delirium ; Albuminuria ; 
 Typhoid State, 
 
DISEASES OF THE RESPIRATORY SYSTEM. liS 
 
 PNEUMONIA. 
 
 In acute cases onset sudden with rigor, fever, quick breathing. 
 Pleuritic pain and dyspnoea usually subside -^ith the 
 pyrexia, and coincidently with the signs of hepatization. 
 Cough ; expectoration viscid, golden colour, occasionally 
 streaked with blood ; it may be accompanied by aerated, 
 frothy bronchial sputum. N"ote date of disease ; P. = ; 
 T. = ; R. = . Pleuritic pain may return during resolu- 
 tion. Symptoms usually subside by crisis ; dyspncea, fever, 
 disti-ess passing off suddenly, leaving lung hepatized and 
 patient prostrated. 
 
 Classes ofPneuvionia. — Acute sthenic as above described : usually 
 at base. Asthenic "odth adynamic symptoms : less sudden 
 onset and no marked crisis ; less distinctly marked signs of 
 solidification ; much tendency to bronchitis and pulmonary 
 cedema, patient tending to the Typhoid State. , It may end 
 in Gangrene of Lung-. 
 
 Pneumonia of the apex. Frequently accompanied by grave 
 nervous disturbance, and long convalescence or subse 
 quent phthisis. 
 
 Causati&iu — Exposure to cold. A complication of fevers. 
 Secondary to chronic disease, e.g., of lungs or kidneys; 
 rheumatism ; injur}'- ; adjacent inflammation or disease, 
 e.g., pneumonia, cancer, tubercle. 
 
 \ 
 
144 CLINICAL MEDICINE AND CASE-TAKING. 
 
 EMPHYSEMA. 
 
 Physical sigris. — Chest may be large or small ; expansion is 
 markedly diminished, and such movement as there may be 
 is usually vertical without forward expansion. Heart's 
 impulse more or less encroached upon, and marked by 
 lung covering it, but it may be felt as somewhat diffused. 
 General hyper-resonance on percussion. Absolute dulness 
 over heart may be wanting with an extended area of 
 relative dulness. On auscultation, expiratory sound much 
 prolonged ; feeble and toneless, harsh, often accompanied 
 by rhonchi and sibili. Liver may be depressed. 
 
 Circulation, — Pulse feeble ; right ventricle dilated ; heart may 
 be hypertrophied. Passive Venous Congestion. 
 
 Urine. — May be scanty and albuminous. Chronic Granular 
 Kidney not uncommonly accompanies emphysema. 
 
 Causation. — Vicarious dilatation, e.g., adjacent to pulmonary 
 collapse or consolidation, or cells obstructed by bronchitis, 
 Paroxysmal cough ; laborious work ; Hooping Cough ; 
 heart disease ; Alcohol ; Gout leading to ill-nourished 
 condition of lungs. Senile changes. 
 
DISEASES OF THE RESPIRATORY SYSTEM. 145 
 
 EMPHYSEMA. 
 
 Lungs lose their elasticity, much aerating smface is lost, and 
 many pulmonary capillaries destroyed, thus obstructing the 
 flow from the right ventricle. Passive venous congestion 
 results. The difficulty of expanding lungs with diminished 
 elasticity throws respu'atory muscles into strong action, 
 and the sterno-mastoids are often hypertrophied. 
 
 The patient may emaciate or grow fat ; in neither case is nutri- 
 tion good. Usually chronic winter cough and liability to 
 acute bronchitis. 
 
 Complications and accompaniments. — Heart : right Ventricle 
 Dilated and hypertrophied ; veins large ; cyanosis ; Tri- 
 cuspid Eegnrgitation. (Edema of feet. Bronchitis due 
 to passive congestion of bronchial veins, which empty their 
 blood into the right heart. Dyspnoea on exertion. 
 
 Albuminuria may be from coexisting Bright's disease, and is 
 then usually constant ; if albumen be due to renal conges- 
 tion it may pass off with other signs of congestion, the 
 albumen lessening and the quantity of urine increasing. 
 
 Cutaneous capillaries of cheeks often enlarge. 
 
146 CLINICAL MEDICINE AND CASE-TAKING. 
 
 BRONCHITIS. 
 
 Physical signs. — If bronchitis is secondary to, or complicates 
 other disease of lungs, the signs will be partly those of that 
 
 other diseased condition. 
 
 Aiiscultaiion. — Often gives negative results, especially iu 
 chronic winter bronchitis. E-honchi ; sibili ; rales. 
 
 Palpation. — Rhonchi are sometimes felt by the hand 
 especially in the elastic chests of infants. Palpate heart. 
 
 Percussion. — Xo change from the normal, or temporary 
 tonelessness in parts. 
 
 Inspectimi. — Observe chest movements ; collapse of chest 
 at apices, or in hj'pochondriac regions. Dyspnoea. 
 
 Urine may be albuminous, a similar cause producing 
 Bright's disease and bronchitis. See Albuminuria. 
 
 Inquire for—?. = ; T. = ; R. = ; W. = . Signs of 
 Consolidation of Lungs ; signs of contraction. Cough ; 
 Expectoration ; Haemoptysis. 
 
 ASTHMA. 
 
 Respiration. — Percussion unaltered during paroxysms ; shrill 
 whistling sibili. Examine lungs during paroxysms and 
 during intervals. The paroxysms, note their frequency 
 and duration, exciting and predisposing causes. Cough ; 
 expectoration. 
 
 Causation. — Hereditary tendency to neurosis. Reflex causes, 
 uterine, constipation. Tubercular diathesis ; Emphysema ; 
 Heart Disease; Uraemia. May occur in Bright's disease 
 without other signs of anaemia. 
 
DISEASES OF THE RESPIRATORY SYSTEM. 147 
 
 BRONCHITIS. 
 
 This condition may be acute or cki'onic ; primary or secondary 
 to other disease, e.g., Emphysema, Phthisis, Pneumonia, 
 etc. 
 
 It is characterized by cough, "with expectoration usually frothy 
 and watery, sometimes viscid or purulent ; dyspncea. 
 Fever usually slight, but high in children. Post-sternal 
 pain and tenderness, increased on coughing ; skin over 
 sternum sometimes sore. 
 
 Causation. — Exposure to cold ; fevers ; bronchitis secondary to 
 chronic lung conditions ; phthisis ; emphysema secondary 
 to acute conditions ; pneumonia ; pleurisy. 
 
 Secondary to heart disease ; Eickets ; mechanical irritants. 
 
 Course of disease if towards fatal termination. — Inability to 
 expectorate. Rapid respiration. Pulse becoming weak, 
 compressible, irregular ; heart distended on the right side ; 
 veins prominent ; cyanosis. (Edema of legs increasing. 
 Rales all over lungs. Sleeplessness. Tendency to Coma 
 and the Typhoid State. 
 
 Urine scanty and albuminous. Temperature falling. In 
 children collapse of chest at bases with infalling of epi- 
 gastrium. 
 
 ASTHMA. 
 
 An affection characterized by paroxysms of dyspnoea. 
 
 Paroxysms. — Orthopnoea ; respiratory muscles, ordinary and 
 extraordinary, at work. Chest fully dilated and respi- 
 ratory movement almost nil. Sense of want of air. Yoice 
 weak or lost. Onset of paroxysm sudden, subsidence rapid ; 
 they frequently occur at night. They may be preceded by 
 drowsiness and a sense of fatigue. 
 
14S CLINICAL MEDICINE AND CASE-TAKING. 
 
 LARYNX, DISEASE OF. 
 
 Acute conditions. — Diphtheria, croup, catarrh, oedema, lar}m- 
 gismus stridulus. 
 
 V 
 
 Chronic conditions. — Laryngitis : syphilitic, strumous, or phthi- 
 ■ sical. Hysteria. Palsy of vocal cords, or one cord. 
 
 General condition. — P. = ; T. = ; R. = ; W. = . State 
 of nutrition ; signs of struma or Syphilis ; Rickets ; 
 Phthisis. 
 
 Digestion. — Examine mouth and fauces, using laryngeal re- 
 flector. 
 
 Circulation. — Examine heart as to strength and dilatation of 
 right side ; venous fulness ; strength and regularity of 
 pulse. Seek for signs of Aneurism. 
 
 Respiration. — Signs of laryngeal disease ; laryngoscopic appear- 
 ances ; movements of cords. Bronchitis, oedema of lungs, 
 pneumonia, etc. Chest movements. Look for Phthisis. 
 
 Xervous system. — Signs of Convulsions, thumb turned in fist ; 
 chronic spasm of muscles ; hysteria. Palsy of one cord, 
 usually from pressure on recurrent nerve. See Aneurism. 
 
 Urine often albuminous in diphtheria ; there may be coincident 
 acute Bright's disease. 
 
DISEASES OF THE PwESPIKATOEY SYSTEM. 149 
 
 LARYNX, DISEASE OF. 
 
 Signs of Laryngeal disease. — Voice husky or lost ; stridulous 
 inspiration, aphonia, cough, dyspncea, cyanosis. Dila- 
 tation of right side of heart, and other signs of obstruction 
 to the entrance of air, e.g., infallingof supra-sternal notch, 
 supra-clavicular spaces, and epigastrium, and in young 
 children collapse of the hypochondriac regions. Tracheo- 
 tomy may be required when this obstruction is extreme ; 
 in such a case observe the condition of the heart, pulse, and 
 circulation before and after operation. 
 
 Laryngismus Stridulus. — Mostly in children ; spasmodic crow 
 ing sound on inspiration, child being well in intervals. 
 Frequent during dentition, in Rickets, and associated with 
 general Convulsions. 
 
 (Edema may occur during Bright's Disease, Erysipelas, etc., 
 acute catarrh from cold, or with onset of Measles. In 
 Hysterical Aphonia cords are seen healthy but motionless : 
 pharynx often very anaesthetic. 
 
 Functional Aphonia. 
 
150 CLINICAL MEDICINE AND CASE-TAKING. 
 
 DISEASES OE THE DIGESTIVE SYSTEM. 
 SIGNS OF DIGESTIVE FUNCTIONS. 
 
 Ajwetite. — Good, bad, indifferent, altogether lost. Frequency 
 of recurrence, capricious and fanciful; variable, excessive, 
 voracious. Nausea. Vomiting". 
 
 Fulness or pain after food. Enquire how soon after food ; its 
 character and duration ; whether pain is relieved by- 
 vomiting. "Whether pain without food. Flatulence and 
 eructations. 
 
 Eructations. Heartburn. "Water-brash. Pyrosis, 
 
 State of Bovjels. — Regular, constipated, relaxed, with or with- 
 out pain. Diarrhoea ; frequency of action. If disturbed 
 see and describe the motions — solid, liquid, light, clay- 
 coloured, dark, black ; hard scybala, flattened or tape-like, 
 well formed, with blood, pus, etc. 
 
 INTESTINAL WORMS. 
 
 T(xnia mediocanellata — beef tapeworm. — The head is at the 
 narrow portion of the worm ; it has four sucking discs, 
 but is unarmed. 
 
 Taenia solium. — Less common in England. Pork tapeworm ; 
 four suckers and an armed head. T. Bothriocephalus 
 latus. They live in small and large intestines. Thread 
 worms — Oxyuridis — live chiefly in rectum ; common in 
 children. 
 
 Lumhricus, round worm. Ascaris lumbricoidis lives in upper 
 intestine, and may be vomited. 
 
DISEASES OF THE DIGESTIVE SYSTEM. 151 
 
 SIGNS OF DIGESTIVE FUNCTIONS. 
 
 Appetite increases with thirst in Diabetes. Anorexia (loss of 
 appetite) and thirst in Fever. In children often variable, 
 especially in nervous cases ; they often drink much in 
 health, when urine is scanty with high sp. gr. Appetite 
 is often lost in functional disturbance of the nervous 
 system, e.g., over- work, loss of sleep. In Hysteria and 
 insanity the appetite may be greatly perverted ; so also 
 during pregnancy. 
 
 State of Bowels. — Constipation may result from Plumbism, 
 senile atrophy of bowels, inactive habits of life, ill- 
 arranged diet. 
 
 Relaxation or looseness from Dysentery, Tllceration of Bcwels, 
 
 or other organic condition. In infants from ill-feeding or 
 summer heat. 
 
152 CLINICAL MEDICINE AND CASE-TAKING. 
 
 EXAMINATION OF THE MOUTH AND THROAT. 
 
 On obtaining a good view of all parts of the mouth, see — 
 tongue ; hard and soft palate, with uvula ; pillars of the 
 fauces, anterior and posterior ; tonsils ; pharynx ; the 
 buccal cavity ; cheeks and lips, mucous membrane ; gums ; 
 teeth. 
 
 Tongue. — Mucous membrane and condition of muscle. In- 
 dented at edges by the teeth ; flabby ; clean or coated with 
 far ; white, yellow, dirty, dry, or moist. Enlarged papillae 
 at tip projecting through far. How protruded ; straight 
 or deviating to one side, kept well out and steady, or 
 a jerked, tremulous, distinct muscular tremor. 
 
 Palate and Uvula. — High arched roof, cleft. Ulceration, 
 destruction of soft palate, adhesions. Movements of soft 
 palate and fauces. 
 
 # 
 
 Tonsils. — Enlarged, one or both. Smooth, pale or congested ; 
 "with large follicles. Ulcers superficial or deep, if sym- 
 metrical. Exudation on surface. 
 
 Pharynx. — Mucous membrane and movements. Look for ulcers 
 or old sears and adhesions. Thrush in children ; exuda- 
 tion in diphtheria. 
 
 Teeth.. — Look for tender teeth ; those subjects of caries ; see if 
 wisdom teeth be cut. Note condition as to dentition 
 
 in infants. 
 
 Gums. — Whether of normal substance or shrunken ; condition 
 of mucous membrane. 
 
DISEASES OF THE DIGESTIVE SYSTEM. 153 
 
 EXAMINATION OF THE MOUTH AND THROAT. 
 
 It is necessary to obtain a good light in the pharynx ; hence it 
 is often convenient to use a lamp and the frontal reflector 
 of laryngoscope. There may be signs of local or general 
 disturbance. 
 
 Tongue. — Flabby and coated in dyspepsia ; often red with 
 Gastric Ulcers and Cerebral Vomiting. Protruded to one 
 side in Hemiplegia. Tremulous in Alcoholism, excessive 
 smoking, General Paralysis of the Insane. Jerked and 
 twitching in Chorea. Ulceration from local irritation. 
 Ulcer of frsenum in hooping cough. Syphilis. Epi- 
 thelioma. 
 
 Palate and Uvula. — Palate high, arched, flat, cleft. Ulcer- 
 ation, scars, adhesion from scrofulous disease or Syphilis. 
 Uvula commonly elongated. Movements of palate and 
 uvula affected in palsy of Nerve YII. 
 
 Tonsils. — Chronic enlargement in rickets, often with deafness. 
 Ulcers symmetrical in secondary syphilis. See Quinsy, 
 Diphtheria, Syphilis. 
 
 Pharynx. — Scars from syphilis or strumous ulceration. Paralysis 
 from diphtheria. Epithelioma. Post-pharyngeal abscess 
 from spinal caries. 
 
 Teeth. — Upper central incisors (of second dentition) may be 
 dwarfed, with atrophy of the middle lobe in Inherited 
 Syphilis. Much ground in gouty people and children who 
 suffer from Headaches. 
 
 Gums. — Blue line in Plnmbism. Spongy in mercurialism. 
 Swollen and bleeding in scurvy. Covered with sordes 
 in fever. 
 
15i CLINICAL MEDICINE AND CASE-TAKING. 
 
 DIARRHCEA. 
 
 K'ote mode of onset and duration ; if attended with pain, 
 griping ; Melaena ; tenesmus (frequent desire to evacuate 
 the bowels, but without effect). Whether acute with 
 paroxysmal griping, melaena, collapse, as in cholera. 
 
 Motions passed. — Relaxed, liquid, pea-soup-like ; containing bile 
 or not ; scybala, shreds of mucous membrane, undigested 
 food, worms. 
 
 VOMITING. 
 
 Note the frequency of vomiting ; whether it occurs only after 
 food ; whether giving relief to symptoms ; if affected by 
 position. State of tongue and bowels. Examine abdomen 
 for tenderness ; signs of disease of stomach. See general 
 condition of Nervous System. Signs of Brain Disease. 
 Examine urine. 
 
 Matters vomited. — Food unchanged; bile-stained fluid; clear 
 acid fluid ; yeast-like matter containing sarcinae seen 
 on microscopical examination ; blood (hsematemesis) ; 
 dark coffee-grounds-like matter, altered blood ; lumbrici. 
 Faecal matters may be thrown up in obstruction of bowels 
 low down. 
 
DISEASES OF THE DIGESTIVE SYSTEM. 155 
 
 DIARRHCEA. 
 
 May be indicative of local disease or general disturbance. 
 
 Causation. — Disease of tbe bowels; Tubercular TJlceration ; 
 Amyloid Disease ; stricture of bowel, rectum ; scybala ; 
 enteric fever ; Dysentery ; cbolera ; erysipelas, etc. ; 
 Bright' s Disease; ill-feeding; Alcoliolisni ; exposure to 
 heat and cold ; poisoning ; Rickets ; nervous disturbance ; 
 Graves' Disease. Previous constipation. 
 
 VOMITING. 
 
 May indicate local or general disturbance or brain disease. See 
 Cerebral Vomiting. 
 
 Causation. — 
 
 Stortiach. — Gastritis ; dilatation of stomach. ; catarrh 
 secondary to Cirrhosis of the Liver ; irritating food ; 
 Alcoholism; poisons; Cancer; Gastric Ulcer ; constriction 
 of pylorus or duodenum. 
 
 Eeflex causes. — Pregnancy; ovarian disease; uterine 
 disturbance ; dysmenorrhcea ; dentition ; intestinal worms ; 
 Gall-stones ; Eenal Calculus ; Addison's Disease ; liver 
 disease, cancer, abscess, etc.; disturbance of special senses, 
 glaucoma, ear disease. Attendant on paroxysms of hoop- 
 ing cough. 
 
 Brain disease. — Headache; Hysteria. See Cerebral 
 Vomiting. 
 
 Blood conditions.— Ferer ; malaria ; Bright' s Disease ; 
 Obstruction of Bowels; Peritonitis. 
 
156 CLINICAL MEDICINE AND CASE-TAKING. 
 
 ACUTE ABDOMINAL PAIN. 
 
 Enquire as to digestive functions ; previous attacks of Biliary 
 
 Colic, Eenal Colic, gastric ulcer. 
 Examine mouth and tongue for indications of Gastric Ulcer, 
 
 poisoning ; and gums for Line lead line. 
 Palpate and examine abdomen ; note if tender and tympanitic ; 
 
 position of the patient, whether still and prostrate or 
 
 moving about. In females look for signs of pregnancy, 
 
 uterine action, or haemorrhage. 
 Examine heart, pulse, skin, pupils, urine. T. = . Note 
 
 if much collapsed ; whether able to speak ; whether 
 
 vomitincr. 
 
 DYSPHAGIA. 
 
 General Condition. — Anaemia. Signs of Cancer. General con- 
 dition of Nervous System. Syphilis. Senile degeneration. 
 
 Digestion. — Examine mouth and throat for ulceration, scars, 
 etc. Auscultate spine while patient drinks, looking for 
 gurgling at one point. Pass oesophageal bougie. 
 
 Vascular system. — Signs of disease of vessels or aneurism. 
 
 H^MATEMESIS. 
 
 Enquire as to the general signs of the Digestive Functions, 
 previous vomiting, pain, tenderness, etc. See causes of 
 Vomiting. Examine the matters vomited and the motions 
 as to htemon-hage, etc. Examine the abdomen generally. 
 Look for disease of stomach and liver. Examine lungs 
 and heart to detennine absence of causes of hemoptysis. 
 See diagnosis of Haemoptysis from Haematemesis. Urine. 
 Anaemia. Amenorrhcea. 
 
DISEASES OF THE DIGESTIVE SYSTEM. 157 
 
 ACUTE ABDOMINAL PAIN. 
 
 Causation. — Rupture of hollow viscera, stemach, intestine, 
 bladder. Renal or Biliary Calculus. Irritant poison. 
 Over-feeding. Colic, simple or from gout. Plumbism, 
 often relieved by pressure. Rupture of abdominal 
 Aneurism, abscess, Hydatid. Peritonitis. Perihepatitis. 
 Ulceration of bowels with peritonitis or perforation. 
 Tubercular Ulceration. Acute disease, e.g., cholera. 
 In females during pregnancy, concealed accidental 
 haemorrhage. 
 
 Pain and tenderness suggest enteritis or peritonitis, rather 
 than colic, the latter being often relieved by pressure. 
 
 DYSPHAGIA. 
 
 Causation. — Tonsillitis ; syphilitic ulcerations ; disease of larynx ; 
 cancer of oesophagus or of cardiac end of the stomach ; 
 thoracic tumour ; abscess, post-pharyngeal or mediastinal ; 
 Aneurism ; traumatic injury or action of caustics ; ulcer of 
 stomach at cardiac end ; Diphtheritic Paralysis ; Bulbar 
 Paralysis. 
 
 lu General Paralysis of the Insane there is much tendency to 
 choking. Hysterical dysphagia. 
 
 HiEMATEMESIS. 
 
 Causation. — Gastric Ulcer. Corrosive poisons. Cancer of 
 Stomach. Continued vomiting (reflex). Acute gastric 
 catarrh. lardaceous Disease. Pyloric ulcer. Bright' s 
 Disease ; uraemia. Passive Congestion of stomach. Scurvy. 
 Cirrhosis of Liver. Vicarious menstruation. Blood 
 swallowed and vomited. Patient often faints from 
 haemorrhage, previous to the discharge of the blood from 
 the mouth. 
 
158 CLINICAL MEDICIXE AND CASE-TAKING. 
 
 MELiENA. 
 
 General condition. — State of nutrition. Anaemia or cacliexia. 
 
 Digestion. — Examine motions ; presence of abdominal pain or 
 signs of gastric disease, pain on defaecation, etc. 
 
 Enquire for signs of Cancer ; history of malaria ; previous 
 
 diarrhcea ; signs of stricture of bowels. 
 Examine abdomen ; if necessary examine rectum ; urine ; lungs, 
 
 as to signs of tubercular disease. 
 
 OBSTRUCTION OF THE BOWELS. 
 
 General condition. — Position of patient ; pain ; abdominal 
 tenderness ; signs of collapse. T. = . Note wlien 
 bowels last acted. 
 
 Digestion. — Habitual condition of bowels, regular, costive, or 
 relaxed. Previous signs of disease, e.g., Melaena, Vomiting. 
 State of tongue. See and describe the motions passed. 
 
 Examine abdomen, especially the abdominal rings, and 
 femoral rings for hernia. Note fulness, tenderness, local 
 swelling or tumour ; an elongated tumour from Intussuscep- 
 tion. Signs of Peritonitis. Track out colon, if distended, 
 by palpation and percussion. Note if any signs of con- 
 traction at any point. 
 
 Examine rectum with the finger, or give enema noting 
 what quantity of fluid can be retained ; pass the long 
 tube. Sometimes the whole hand is introduced into the 
 rectum. 
 
 Examine per vagiaajn. — Signs of pregnancy. See general 
 sicrns of Cancer. 
 
DISEASES OF THE DIGESTIVE SYSTEM. 159 
 
 MELJENA. 
 
 May be caused by all tbe causes of Hsematemesis, the blood 
 passing from the stomacli to tbe intestines. Cirrhosis of 
 Liver, or other obsti'uction to portal circulation. TJlceration 
 of Bowels, tubercular. Gastric Ulcer. Cancer of bowels. 
 Enteric Fever. Dysentery. Intussusception. Pelvic 
 hsematocele or abscess. Piles may cause bleeding from the 
 anus. Villous growth in rectum. Bright's Disease. 
 
 OBSTRUCTION OF THE BOWELS. 
 
 Causation. — I. Compression. — Cancer or inflammatory mass 
 involving intestine ; Abdominal Tumour ; pregnant uterus ; 
 ovarian tumour ; pelvic tumour ; uterine, ovarian, cellu- 
 litis ; retroverted uterus. 
 
 II. Changes in wall of gut. — Cicatrization of intestinal 
 ulcers, dysenteric, tubercular ; congenital deformity of 
 rectum, etc. ; Cancer ; epithelioma and syphilitic disease 
 of rectum. 
 
 III. Strangulation. — Generally in small intestine, 
 hernia ; constriction from mesentery of portion of intes- 
 tine drawn into a hernial sac ; or from bowels, due to 
 peritonitis. 
 
 IV. Plugging. — Undigested substances, fruit stones and 
 seeds, hardened fgeces, masses of worms. 
 
 Intussusception ; volvulus. 
 
 Symptoms vary according to the position of the obstruction, its 
 degree, its cause, the complications. If in small intestines 
 there may be no marked and characteristic symptoms. 
 
 The motions may be pipedike or not formed. Formed motions 
 may be produced by faeces passing the stricture and being 
 moulded in rectum. Constipation ; flatulence. If in 
 rectum, pain and straining on defsecation. 
 
160 CLINICAL MEDICINE AND CASE-TAKING. 
 
 GASTRIC ULCER. 
 
 Digestimi. — Pain immediately after food, relieved only by 
 vomiting. Water-brasli vomiting. HEematemesis. Melaena. 
 Inability to take solid food. Localized tenderness at 
 epigastrium ; no tumour felt. Bowels usually confined ; 
 examine the motions. Tongue usually red. 
 
 JVote. — General condition ; position of patient ; state of nutri- 
 tion ; signs of Ansemia. General condition of abdomen. 
 Signs of Hysteria. General condition of the Nervous 
 System. W. = . Urine. 
 
 TYPHLITIS. 
 
 Local examination of right iliac fossa. Vaginal or rectal 
 examination to determine absence of pelvic cellulitis. 
 
 Causatimi. — Hardened fseces ; undigested food ; dysentery. 
 Local concretion in appendix. Cherry stone, or fish 
 bone, etc. 
 
DISEASES OF THE DIGESTIVE SYSTEM. 161 
 
 GASTEIC TJLCER. 
 
 Pain may be less if the ulcer is on the lesser curvature of 
 stomach. In long-lasting cases, some thickening of walls 
 of stomach may be felt, or stricture of the pylorus may 
 result. Usually there is emaciation, antemia, or cachectic 
 appearance. Menstruation absent or disturbed. Recovery 
 may occur for a while with tendency to relapse of the 
 symptoms, or perforation and Peritonitis, vomiting, 
 haemorrhage, exhaustion. 
 
 Causation. — Most common in females ; specially accompanies 
 disordered menstruation ; may result from action of 
 caustics. 
 
 Complications. — Fistulous communication -udth external surface 
 or with other parts of intestines. 
 
 Pyaemia. 
 
 TYPHLITIS. 
 
 Abdominal pain ; local signs of inflammation in the right iliac 
 fossa, pain, tenderness, swelling. Local peritonitis with 
 infiltration of the cellular tissue ; it may suppurate. 
 Constitutional disturbance with fever may be considerable 
 if the bowel is involved ; less acute if only around the 
 bowel. Perforation of bowel may follow. Usually pain 
 and difficulty in moving right leg. 
 
 M 
 
162 CLINICAL MEDICINE AND CASE-TAKING. 
 
 ABDOMINAL CANCER. 
 
 General condition. — Note state of nutrition, W. = 
 Emaciation. Pain in back, exhaustion, and cachexia, 
 Avith the general signs of Cancer. 
 
 Digestion. — Signs of digestive functions. Vomiting, haemor- 
 rhage, acid secretions, stomach pain. 
 
 Examine abdomen. — Clear out bowels A^ith purgatives or 
 enemata ; empty bladder. Palpate and percuss to detect 
 any abdominal tumour. Note any signs of Obstructed 
 Bowels ; Peritonitis ; Ascites. Examine rectum and per 
 vaginam if necessary. 
 
 Cancer of Stomach, — A mass may be felt in epigastrium, or an 
 increased resistance, often most distinct along greater 
 curve of stomach. A rounded and movable mass may be 
 felt over the pylorus. 
 
 Cancer of Intestines. — A mass may be felt on palpation ; 
 it may be movable. Clear out bowels. Inspect and 
 describe the motions, whether full-sized or flattened and 
 small. Melaena. If there is obstruction, or arterial haemor- 
 rhage, examine rectum with finger. Look for piles. 
 
DISEASES OF THE DIGESTIVE SYSTEM. 163 
 
 ABDOMINAL CANCER. 
 
 May affect stomacli, intestines, peritoneum, mesenteric glands, 
 liver, kidneys, spleen, uterus. Secondary deposits in tlie 
 liver are common. See Abdominal Tumour. 
 
 Cancer of Stomach. — General signs of cancer. Pain in region 
 of stomacli, a very varying symptom. Vomiting acid 
 frothy matter, often with sarcinee ; there may be arterial 
 Haematemesis or coffee-ground-like matter. Excessive acid 
 secretion. Usually it is primary. Secondary deposits may 
 occur in the liver ; it may creep on to pylorus and involve 
 gall-duct. Jaundice. A mass may thicken the pylorus 
 causing a tumour that can be felt there, and stricture 
 with vomiting late after food. Scirrhus of stomach may 
 run its course through many years. With a mass that can 
 be felt, patient may still gain weight. 
 
 Cancer of Intestines. — Usually primary ; most common in the 
 sigmoid flexure, csecum, and rectum. Abdominal pain. 
 Tendency to annular contraction, causing Obstruction, 
 May be mistaken for feecal accumulations. 
 
 Note. — Ulceration of rectum may be from epithelioma oi 
 Syphilis. 
 
164 CLINICAL MEDICINE AND CASE-TAKING. 
 
 ULCERATION OF BOWELS. 
 
 Typhoid. Cancer. Epithelioma at anus. Syphilis. Ulceration 
 from gall-stones, scybala, intussusception, etc. 
 
 Dysentery. — Note state of nutrition ; Anaemia. P. = ; 
 T. = ; R. = ; W. = . 
 
 Digestion. — Appetite. Abdominal pain or tenderness. Evacua- 
 tions: colour, consistence, smell, bile, mucus, or sloughs. 
 
 Liver. — Size, absence of tenderness, jaundice, etc. 
 
 Complications and Sequelce. — Chronic dysentery. Haemorrhage 
 
 from bowel. Abscess of liver. 
 
 Tubercular Ulceration. — Getieral condition. — Emaciation ; 
 excessive sweating. 
 
 Digestion. — Appetite. Abdominal condition ; fulness, tender- 
 ness, pain, general or localized. Bowels relaxed ; may be 
 acting with pain and Melaena. Enquii'e for fistula in ano. 
 
 Eespiration. — Examine lungs, and look for signs of Phthisis. 
 
DISEASES OF THE DIGESTIVE SYSTEM. 165 
 
 ULCERATION OF BOWELS. 
 
 Dysentery. — A disease more common in the tropics than here. 
 Caused by malaria, scorbutus, bad water, salt food, etc. 
 It may occur in an acute or chronic form. It is febrile, 
 characterized by tenesmus with the passage of mucus 
 without fsecal matter or bile , sloughs may be passed with 
 blood. These symptoms depend upon inflammation of 
 the colon with exudation ; it may extend to the small 
 intestine. 
 
 Tubercular Ulceration. — Common in cases of jjhthisis and 
 other sti'umous affections. Abdominal pain, diarrhoea, 
 and melsena may result. The tubercular ulcers in the 
 bowels are transverse ; they may heal up, leading to scars, 
 which may cause stricture of the bowels. Ulcers occur 
 mostly in the lower part of the ileum and caecum. 
 
 Complications. — Peritonitis. Ascites. Perforation of bowels 
 Acute Miliary Tuberculosis. 
 
166 CLINICAL MEDICINE AND CASE-TAKING. 
 
 ABDOMINAL TITMOUIIS. 
 
 General condition. — State of nutrition. "W. = . Signs of 
 Cancer or Scrofulosis. Abdominal pain, tenderness, vomit- 
 ing, condition of bowels, signs of Obstruction, Digestive 
 functions. Look for Ascites, Peritonitis, Abdominal 
 Cancer, oedema. Urine. 
 
 Examination of oJbdomen. — Palpate and percuss abdomen ; tliiis 
 endeavour to detect any tumour present. Define its 
 position Tritb regard to tlie anatomical regions ; determine 
 its boundaries and connections ; particularly note if 
 distinct fi'om liver and pehdc organs. Map out liver and 
 spleen, showing them of normal size. Xote physical 
 conditions of tumour, its size, if smooth, rounded, lobu- 
 lated, hard, impressible, doughy, fluctuating. If mov- 
 able or moving "Rdth respiratory movements. Measure 
 the abdomen, girth at base of chest and at the umbilicus, 
 vertical measurements from umbilicus to pelvis, and 
 umbilicus to xiphoid cartilage. In the normal the um- 
 bilicus is about an inch nearer to the pubes than to the 
 sternum. Xote pain or tenderness. Empty bowels and 
 bladder. 
 
 History. — ^Commencing on one side ; enlarging from below 
 upwards ; enlarging of the abdomen uniformly ; with pain 
 and fever or not. Did symptoms commence at a menstrual 
 period ? 
 
 Percuss, palpate liver, define and mark on skin the vertical and 
 other dimensions. 
 
DISEASES OF THE DIGESTIVE SYSTEM. 167" 
 
 ABDOMINAL TUMOURS, 
 
 Ovarian.— 'Globular, movable, fluctuating ; usually situated 
 more to one flank than th.e other. Springing from the 
 pelvis and may be felt there. Usually dulness in centre of 
 abdomen with resonance in the flanks. If very large may 
 be mistaken for ascites. See diagnosis of Ovarian Tumour 
 from Ascites. It may be accompanied by ascites. Dulness 
 over an ovarian tumour shows that no intestines are 
 in front of it ; so also with a pregnant uterus. 
 
 Kidney. — Colon usually passes in front of tumour however large 
 it becomes ; this may be indicated by partial and varying 
 resonance over it. There may be mixed resonance and 
 dulness, varying on different occasions. Tumour may be 
 felt in the flank, usually between false ribs and ilium ; a 
 tumour in this region may be renal, peri-nephritic, fsecal in 
 colon. Abscess ; cancer ; hydro-nephrosis ; blood-tumour. 
 The outline is rounded or lobulated (cystic tumour), not 
 easily defined. Absence of fluctuation. 
 
 liver. — See Large Livers. A hepatic tumour descends on in- 
 spiration. Gall-bladder ; Hydatid;. Cancer. 
 
 Abdominal Pulsation common in hysterical women and 
 dyspeptic subjects. Throbbing of abdominal aorta also 
 common in emaciatioiL. 
 
168 CLINICAL MEDICINE AND CASE-TAKING. 
 
 FLUID IN peritoneum:. 
 
 Physical signs. — Enlargement of abdomen. In dorsal position, 
 dulness on percussion over tlie fltiid, which gravitates into 
 the flants leaving central region clear ; on the dependent 
 side of abdomen, a distended colon may give a tympanitic 
 note, but on palpation in this flank the weight of the fluid 
 is felt, line of dulness shifting with position. Thrill 
 transmitted on filliping abdomen ; fluctuation. When 
 placed on hands and knees, fluid will gra^atate to the 
 umbilicus. Clear out bowels j §mpty bladder ; examine 
 per vaginam. 
 
 Symptoms. — Dyspnoea and thoracic breathing. Pressure on 
 renal veins may cause scanty urine and Albuminuria, 
 Pressure on iliac veins causing oedema of legs. Superficial 
 abdominal veius enlarged. 
 
 Causation, — Cirrhosis of Liver, Cardiac disease. Disease of 
 peritoneum, tubercle, cancer, Peritonitis. Exposure to 
 cold. Ovarian or other abdominal tumour, 
 
 CVjiditions simulating Ascites. — Ovarian cyst. Hydatid cystic 
 kidney. Pregnant uterus. Distended urinaiy bladder, 
 Eluid in intestines. See Abdominal Tumours, 
 
DISEASES OF THE DIGESTIVE SYSTEM. 169 
 
 ABDOMIKAI TUMOUES, 
 
 spleen. — Feel for the notcli toi;v'ards anterior margin. Usually 
 firm, flat superficial under abdominal walls without intes- 
 tine in front. Stretching from left hypochondrium. Sur- 
 face may be lobulated ; it may be tender and movable. 
 
 Pancreas. — Has been stated to be frequently the seat of cancer. 
 Examine fseces for fat ; shake up with ether. 
 
 Causation. — Hypertrophy ; chronic congestion from cardiac or 
 liver disease ; Ague ; Amyloid Disease ; cancer. Examine 
 blood for leucocythaemia. In children Rickets. Syphilis. 
 Large sometimes in fevers, specially enteric. Frequent 
 seat of Embolism. 
 
 Abdominal Aneurism.— A tumour pulsating and laterally 
 expansile, with a thrill and systolic bruit often also heard 
 over spine. Pain. No necessary dyspeptic symptoms. 
 Pressure signs less common than in thorax ; it may press 
 on vena cava, or cause erosion of Vertebrae, producing great 
 pain. It does not fall forward Avhen patient is in knee-elbow 
 position. A tumour lying on the aorta may receive a com- 
 municated impulse. The pulsating aorta without disease 
 may often be felt in nervous or dyspeptic patients, especially 
 in females if emaciated. See Aneurism, 
 
170 
 
 CLINICAL MEDICIKE AND CASE-TAKING. 
 
 Diagnosis of 
 OVARIAN TUM0T7R from 
 
 ASCITES. 
 
 Palpation. — Definite margins 
 may be felt. Usually situate 
 more in one side of abdomen 
 than in the other. It may be 
 traceable into the pelvis and 
 felt there. 
 
 Percussion. — Dulness in cen- 
 tral regiqn, intestines giving 
 a resonant note in the lumbar 
 regions. But little shifting 
 of dulness on alteration of 
 position of patient. 
 
 Menmiration. — Distance of um- 
 bilicus from sternum, equal 
 to or less than that from the 
 pelvis. Greatest girth below 
 the umbilicus- 
 
 Piispection. — Gen eralroundness 
 of abdomen ; tumour may be 
 seen somewhat rounded and 
 prominent. 
 
 Fluctuation may be de- 
 tected ; thrill transmitted in 
 any direction on filliping the 
 surface. 
 
 Dulness in flanks ; cen- 
 tral region tympanitic as 
 patient lies on her back, and 
 
 shifting with alteration of 
 position. 
 
 Distance between umbilicus 
 and sternum maintains nor- 
 mal ratio. Greatest girth at 
 umbilicus or above it. 
 
 Abdomen flattened, but 
 prominent and broad. 
 
DISEASES OF THE DIGESTIVE SYSTEM. 171 
 
 ABDOMINAL TUMOURS. 
 
 Tumours ai-ising from the j^^^'vis. — Examine per vaginam. 
 Ovarian. Perimetritis. Pregnant uterus. 
 
 Inflamiiiatory swellings. — Renal or perinephritic abscess. 
 Pelvic cellulitis. Parametritis ; towards groins and iliac 
 fossse. 
 
 Fmcal accumulations. — Usually in colon, in either iliac fossa. 
 There may be coincident diarrhoea. 
 
 Tubercular mesenteric glands. — Masses may be felt. Belly large 
 
 /and tender, emaciation, diarrhoea. Signs of Scrofulosis. 
 
 Usually coincident signs of Tubercular Peritonitis. 
 
 Tympanites. Ascites. Abdominal Cancer may cause 
 enlarged glands. 
 
 Phantom Tumour. — Arises from local contraction of rectus 
 muscle, one or both. It may be dull on percussion, and 
 visibly prominent ; usually it occurs in the lower portion 
 of the abdomen. It subsides under chloroform. Not 
 uncommon in Hysteria. 
 
 Intussusception. — Cylindrical tumour produced by intus- 
 suscepted bow^el, movable from day to day. Tenesmus ; 
 passage of blood and mucus. Signs of Obstruction of 
 Bowels. 
 
172 CLINICAL MEDICINE AND CASE-TAKING. 
 
 PERITONITIS. 
 
 General condition of po-tient.— Volition, complaints of pain, 
 state of skin, tongue, pulse. Look for emaciation or other 
 signs of chronic disease. T. = ; R. = ; P. = ; W. = . 
 See Ascites ; Abdominal Tumour ; Abdominal Cancer ; 
 Acute Abdominal Pain ; Hysteria. Examine abdomen. 
 
 Causation. — Traumatic. Rupture of bladder or other \ascera. 
 Ulceration from a gall-stone, etc., action of poisons, 
 pressure on gut from hernia, etc. Exposure to eokl. 
 -pyaemia. Puerperal fever. Bright's Disease. Enteric 
 fever. Enteritis. Cancer. Tubercular Ulceration of 
 Bowels. Pelvic inflammations. Perityphlitis. Abdominal 
 Tumour. 
 
 Diagnosis. — From gastritis, enteritis, metritis, cystitis, and 
 distension of bladder ; colic ; abdominal hysteria. 
 
DISEASES OF THE DIGESTIVE SYSTEM. 173 
 
 PERITONITIS. 
 
 Acute and chronic. Acute cases cliaracterized by abdominal 
 pain and tenderness, with fever, nausea, vomiting, con- 
 stipation, abdominal distension, cold sweats. Patient 
 usually lies on his back with the legs drawn up on the 
 abdomen; collapse, pulse small and wiry, skin moist, 
 extremities cold. Abdomen distended and tympanitic. 
 There may be effusion of fluid. Bowels constipated. 
 Respiration shallow and thoracic. Tubercular peritonitis 
 usually occurs in young scrofulous subjects. • Masses of 
 glands may be felt in abdomen. 
 
174 CLINICAL MEDICINE AND CASE-TAKING. 
 
 DISEASES OF THE LIVER. 
 JAUNDICE.* 
 
 A. — Mechanical Obstruction of Bile Duct. 
 
 I. Obstruction by foreign bodies within tlie duct. 
 
 II. Obstruction by stricture or obliteration of the duct. 
 
 III. Obstruction by Abdominal Tumours closing the orifice of 
 the duct, or gi'owing into its interior. 
 
 B. — Jaundice Indepeiident of Mechanical Ohstrioction of the 
 Bile Duct. 
 
 I. Poisons in the blood interfering with chemical changes 
 
 in bile. 
 
 II. Mineral poisons. 
 
 III. Liver diseases. 
 
 IV. Nervous causes. 
 
 Y. Intestinal accumulation. 
 
 Jaundice. — Shade and depth of colour. It affects also urine, 
 sebaceous matter and sweat, milk. Taste bitter. Heart's 
 action slow. Cerebral depression common in cases depend- 
 ent upon obstruction, and when there is no obstruction 
 tendency to stupor, coma, typhoid state. Skin liable to 
 urticaria, lichen, boils, vitiligoidea ; itchiness of skin may 
 precede the jaundice. Digestion disturbed, constipation, 
 flatulence, emaciation. In chronic hepatic affections 
 haemorrhages are common. 
 
 * See Dr. Murchison's table: "Diseases of the Liver." 
 
DISEASES OF THE LIVER, 175 
 
 JAUNDICE. 
 
 A. — Mechanical Obstruction of Bile Duct, 
 
 I. Gall-stones, inspissated bile, foreign bodies from intestines. 
 
 II. ia) Catarrb of duodenum, extending from gastric catarrh. 
 (&) Congenital defect, (c) Cicatrix after gall-stones, 
 
 III. Also pressure of glands of transverse fissm-e of liver, 
 amyloid or cancerous. Cancer of Liver. 
 
 B. — Jaundice Independent of Mechanical Obstrudion of the 
 Bile Duct, 
 
 I. Relapsing fever, enteric, typhus, pyemia, 
 
 II. Phosphorus. Metallic poisons. 
 
 III. Acute yellow atrophy. Congestion of liver in heart 
 disease, 
 
 lY. Sudden fright. 
 
 V. Chronic constipation. 
 
 Jaundice. — Colour pale sulphur, lemon, deep olive. As it 
 passes off skin is the last to clear. Urine may contain 
 jaundiced easts. There may be a bitter taste from bile 
 acids. 
 
 Diagnosis from — 1, Yellow eye due to subconjunctival fat, 
 
 2. Addison's Disease. Here discoloration of skin is 
 patchy and urine is normal, 
 
 3. Urine blood-coloured ; may resemble jaundice, but is 
 also albuminous. 
 
 4. Infants soon after birth may be red and subsequently 
 yellow, suggesting icterus neonatorum. 
 
 5. Cachexia from Anaemia or malignant disease. 
 
176 CLINICAL MEDICINE AND CASE-TAKING. 
 
 LARGE LIVERS * 
 
 1. Lardaceous. Uniform enlargement. See Amyloid Degea- 
 eration. 
 
 2. Fatty. Uniform enlargement. 
 
 3. Hydatid tumour. Bulging or projecting from liver. 
 
 4. Tight lacing may cause do%vnward bulging of liver. 
 
 5. Congestion, passive, e.(/., from heart disease. Enlargement 
 uniform. 
 
 6. Catarrh of bile ducts. Enlargement uniform. 
 
 7. Obstruction of common duct, e.g., sequent to Gall-stones. 
 
 8. Pysemic abscess. If numerous, enlargement uniform. 
 
 9. Tropical abscess, causing a bulging tumour. 
 
 10. Cancer, if secondary, is usually diffused, e.g., secondary to 
 ■ cancer of sigmoid flexure or stomach. 
 
 Note size of liver, "whether enlargement be uniform or irregular ; 
 whether it be tender ; if accompanied by Jaundice. T.= . 
 Percuss ; palpate and map out the liver. 
 
 Normal Liver Dulness. — Commencing posteriorly about the 
 tenth or eleventh dorsal vertebra, it ascends slightly 
 towards the axilla and the nipple, then again descends 
 gi'adually towards the median line in front. In median 
 line in front usuall}^ corresponds with the base of the 
 ensiform cartilage, and to the left of this blends with the 
 cardiac dulness at level of fifth space. In right mammary 
 line 4 — 5 inches. 
 
 Cancer of Liver. — General condition, see Cancer, signs of. Note 
 if jaundiced. Liver large ; its measurements, outline, 
 condition of surface and margin ; if smooth, rough, 
 nodular with masses. Xote pain or tenderness. Spleen 
 rarely enlarged. Look for other signs of Abdominal 
 Cancer. Ascites. 
 
 ♦ See Dr. Murchison, 
 
DISEASES OF THE LITER. 177 
 
 LARGE LIVERS. 
 
 1. Firm, smooth, easily felt and defined. 
 
 2. Less definable ; there may be general fatty growth in 
 
 the body. 
 
 3. A prominent and fluctuating tumour may be felt. 
 
 4. Tissue of liver may be healthy, and symptoms may 
 
 be absent. 
 
 5. Active congestion in fevers ; frequent in tropical climates. 
 
 6. Accompanied by signs of dyspepsia and jaundice. 
 
 7. External pressure on duct may obstruct it. 
 
 8. There may be large abscesses, and irregular enlargement. 
 
 9. Usually secondary to Dysentery. 
 
 10. Primary cancer usually forms a mass that can be felt. 
 
 Look for — Anaemia. Causes capable of producing Passive 
 Congestion. History of Alcoholism or residence in tropical 
 climates. Malaria. 
 
 Cancer of Liver. — In primary cases usually cancerous masses, 
 or large nodules, that can be felt. It may be secondary 
 to other abdominal cancer ; then usually diffused in liver, 
 enlarging it uniformly. Such deposits occurring may 
 cause vomiting. 
 
 Diagnosis from — Nodular contractions of rectus muscles ; 
 Amyloid or Cirrhosis of Liver ; multiple hydatid. 
 
 N 
 
178 CLINICAL MEDICINE AND CASE-TAKING. 
 
 SMALL LIVERS. 
 
 1. Simple atrophy. 2. Acute yellow atrophy. 3. Chronic 
 ati'ophy. 
 
 1. Simple atl'ophy occurs in senile degeneration and 
 
 inanition. 
 
 2. Acute Yellow Atrophy. — General condition much disturbed. 
 
 History. — Habits, especially as to intemperance. Syphilis. 
 Pregnancies. 
 
 Jjigcstion. — Anorexia ; vomiting ; tongue fuiTed. 
 
 Liver. — Xote size and subsequent diminution. Jaundice, with 
 bile in feces. 
 
 j\'ervoas system. — Headache ; loss of muscular power ; 
 muscular twitchings. General distmbance of Nervous 
 System tending to Coma. 
 
 Urine. — Urea, uric acid, and salts diminished. Presence of 
 leucine and tyrosine, products of metamorphosis inter- 
 mediate between albumen and the less complex nitrogenous 
 (Compound, urea. 
 
 Cm'sation. — Alcoholism. Syphilis. Malaria. Typhus. Strong 
 emotional distui'bance. Frequent pregnancy. 
 
DISEASES OF THE LIVEK. 179 
 
 SMALL LIVERS. 
 
 1. No disease and no change of structiu'e of the tissue. 
 
 2. Acute Yellow Atrophy. — Liver rapidly decreasing in size ; 
 
 jaundice without obstruction ; symptoms of blood- 
 poisoning. 
 
 Fremonitory symj)toms. — Digestion disturbed ; general vague 
 pains. Jaundice slight, bile still appearing in fteces. 
 
 Fully established disease. — Sets in with sudden onset of 
 symptoms due to the blood-poisoning, depending upon the 
 defective formation of urea and uric acid ; this affects the 
 general condition of the patient. Loss of strength. 
 Jaundice increases ; headache, restlessness, delirium, 
 convulsions, vomiting, coma. Typhoid State. Tongue 
 dry and brown. Hgemorrhages in skin and mucous 
 membranes may occur. Liver dulness constantly and 
 rapidly diminishes. Spleen may enlarge. 
 
180 CLINICAL MEDICINE AND CASE-TAKING. 
 
 CIRRHOSIS OF LIVER. 
 
 GeneraJ condition. — Anaemia; emaciation; sallownes3 ; epistaxis; 
 Ascites. 
 
 Digestion. — Dyspepsia ; flatulence ; vomiting ; piles. 
 
 Spleen. — Often large. 
 
 Liver. — Usually small, but it may be enlarged in early stage ; 
 edge and surface rough, h.ob-nailed, hard. Jaundice may 
 be present ; then it is slight. Subsequently liver con- 
 tracts. If there be peri-hepatitis, liver is tender. 
 
 SYPHILITIC DISEASE OF LIVER. 
 
 Gummata may be felt on palpation. Liver may be tender 
 from peri-hepatitis ; lobulated from irregular contraction, 
 producing a notched margin. See signs of Syphilis. 
 
DISEASES OF THE LIVER. 181 
 
 CIRRHOSIS OF LIVER. 
 
 A chronic disease, mostly caused by chronic Alcoholism. 
 Dyspeptic symptoms, subsequently Ascites or Haema- 
 temesis. Often associated Avith Emphysema and Granular 
 Kidneys. 
 
 Spleen large from obstruction to the return of its venous 
 blood. 
 
 SYPHILITIC DISEASE OF LIVER. 
 
 May result from inherited or acquired disease. There may be 
 gummata, a general change throughout the liver, or 
 peri-hepatitis. 
 
182 CLINICAL MEDICINE AND CASE-TAKING. 
 
 GALL-STONES. 
 
 Occasionally they may be felt on palpation, or heard on 
 auscultation. There may be pain on jolting or any 
 sudden movement. They are common with cancer of 
 gall-bladder. A stone may cause obstruction of the 
 common duct and Jaundice. There may be recurrent 
 attacks of biliary colic. Ulceration of gall-bladder may 
 result, and extend to neighbouring organs, causing per- 
 . foration of any of the hollow viscera. 
 
 BILIARY COLIC. 
 
 Attacks of severe Abdominal Pain, due to passage of a gall- 
 stone from the gall-bladder to the duodenum. The 
 attacks usually set in suddenly after exertion, and ma}' 
 subside suddenly, and be followed by jaundice. Attacks 
 are apt to recur if there be many stones present. 
 
DISEASES OF THE LIVER, 183 
 
 HYDATID OF LIVER. 
 
 A chronic tumour causing an irregular outline to the liver ; 
 usually painless, unless it be inflamed. It may be of 
 any size ; is usually rounded, firm, slightly fluctuating. 
 If there be no adhesion it is depressed on deep inspira- 
 tion ; not accompanied by jaundice unless there be some 
 complication. Usually single, but there may be many in 
 the liver. 
 
 Diagnosis from — Cancer ; gummata or syphilitic liver witli 
 irregular contractions ; abscess of the liver ; distended 
 gall-bladder ; cystic tumour of kidney ; ascites. See 
 Abdominal Tumours. The spleen is not enlarged, as in 
 some other conditions. 
 
 Course of disease. — The hydatid may suppurate and burst into 
 the abdomen, lungs, pleura, etc. ; it may form adhesions ; 
 it may shrink up. 
 
 Fluid in cyst. — Often removed by aspiration. It is not 
 albuminous if there has been no inflammation. Sp. 
 gr., about 1005 ; chlorides abundant. Microscopically, 
 small cysts, with secondary cysts inside, may be seen ; 
 "heads," separate booklets. Highly refractive particles. 
 Cholesterin may be found in fluid. 
 
184 CLINICAL MEDICINE AND CASE-TAKING. 
 
 DISEASES OF THE URINARY SYSTEM. 
 
 BRIGHT'S DISEASE. 
 
 General debility. Anaemia. Dyspepsia. (Edema or anasarca. 
 Necessity to urinate frequently. Skin dry ; often unable 
 to perspire. TTraemia. 
 
 Digestion. — Dyspepsia ; Vomiting ; diarrhoea ; Haematemesis ; 
 melsena. 
 
 Vascular system. — Hypertrophy of Heart ; bigh. tension of 
 pulse ; arteries tliickened and bard ; capillaries dilated on 
 cbeeks. Liability to baemorrbages, epistaxis, bsemoptysis, 
 etc. Excited action of the heart in ursemia. 
 
 Nervous system. — Disturbance of the general condition of 
 Nervous System; Vomiting, Headache, Vertigo, etc. 
 Retinitis albuminuiica. See Uraemia, Convulsions. 
 
 Uriiu. — Albuminuria almost always present in Brigbt's disease. 
 Quantity altered, usually diminished. Sp. gi\ low ; the 
 total of urea excreted diminished. Casts : fatty, hyaline, 
 larger, small, epithelial, granular. Apparent absence of 
 casts not an absolute proof of absence of Brigbt's disease, 
 but evidence in that direction. 
 
DISEASES OF THE UEINAEY SYSTEM. 185 
 
 BRIGHT' S DISEASE. 
 
 The name signifies disease of tlie kidneys accompanied by 
 Albuminuria, and dependent upon structural changes. 
 The disease is usually unattended with pain, or any 
 subjective symptoms characteristic of the disease. Pallor 
 of the face is often a marked sign, and in elderly people 
 is often suggestive of albuminuria. Attention must 
 always be given in taking the history, and in observing, 
 to determine if the disease be Acute or Chronic. 
 
 Vascular system. — May be profoundly altered and disturbed, as 
 indicated on the other page, the blood changes being 
 shown by anaemia, tendency to haemorrhages, secondary 
 inflammations, etc. 
 
 Causation. — Exanthemata, specially scarlet fever ; febrile 
 conditions, e.g., pneumonia, rheumatic fever, ague, ery- 
 sipelas ; Alcoholism ; exposure to cold ; wet and cold 
 work ; repeated pregnancies ; dyspepsia ; Gout. 
 
 It is of great importance to determine whether the disease is 
 acute or chronic. 
 
 ComplicatioTis. — Inflammatory conditions ; Pericarditis ; Pleu- 
 risy ; Pneumonia. Cerebral haemorrhage ; haemorrhages 
 from mucous membranes. Epistaxis. Uraemia. 
 
186 CLINICAL MEDICINE AND CASE-TAKING. 
 
 UREMIA. 
 
 General condition. — Anasarca. Ansemia. Skin liarsli and dry. 
 Look for signs of Contracted Kidneys. 
 
 Nervous system. — Head Pain; drowsiness; Delirium; Coma; 
 temporary blindness ; retinitis albuminurica ; neuro- 
 retinitis ; Typhoid State ; muscular twitchings ; Convul- 
 sions. 
 
 Vascular system. — Liability to hgemorrhages from mucous 
 membranes, e.g., epistaxis, Haemoptysis; Hypertrophy of 
 Heart, pulse hard. Pulse often strong till death is at 
 hand. 
 
 Digestive system. — Dyspepsia; Diarrhoea; Vomiting. 
 
 Respiratory system. — Breath smelling ammoniacal ; paroxysmal 
 dyspncea, resembling asthma. 
 
 Urine. — Quantity ; albuminous ; sp. gr. low ; deficient in urea 
 and salts ; Heematuria. Casts in deposit. 
 
 Gausatio7i. — Bright's disease, acute or chronic. Suppression of 
 urine from obstruction of ureters. Obstruction to renal 
 veins or arteries. Destruction of one or both kidneys by 
 abscess, calculi, etc. Cystic kidneys ; surgical kidneys, 
 sequent to stricture and pyelitis. 
 
DISEASES OF THE UEINARY SYSTEM. 187 
 
 UIliEMIA. 
 
 Many of these signs may be met with without urfemia. 
 Inflammatory complications, e.g., Pericarditis, Pleurisy. 
 Dropsical complications, Hydrothorax, hydropericar- 
 dium, Ascites. Ursemia is a condition of blood-poisoning; 
 the breath becomes ammoniacal, and the excretion of urea 
 is much diminished. Diarrhoea or vomiting may lead 
 to a favourable termination. The skin seldom acts 
 spontaneously, but its action is favourable. Symptoms 
 may set in gradually or suddenly, with convulsions. 
 Progress may be towards recovery, especially in acute 
 Bright' s disease ; it frequently ends in death. Relapses 
 and the recurrence of symptoms are common. Pulse full, 
 strong, hard ; heart's impulse strong. 
 
 Urine. — Scanty or suppressed from Bright's disease. Passive 
 Congestion of kidneys, or pressure upon renal vessels, etc. 
 
 Causation. — Ureters may be obstructed by calculi or pressed 
 upon by pelvic tumour, e.g., ovarian. Venous congestion 
 may result from heart disease, Emphysema, etc. Renal 
 arteries may be obstructed by embolism or pressure on 
 arteries by an Abdominal Tumour. 
 
188 CLINICAL MEDICINE AND CASE-TAKING. 
 
 ALBUMINURIA. 
 
 Causation. — Bright' s Disease. Passive Congestion of the 
 
 kidneys. Simple or latent albuminuria.* Albuminuria 
 from fevers. Calculous disease, due to presence of pus or 
 blood in urine. In females from leucorrhoeal discharge, 
 etc. , or menstruation. 
 
 Passive {mechanical) congestion. — Heart Disease or Emphysema, 
 etc., may produce over-fulness of vena cava, and con- 
 gestion of the kidneys. Pressure on the renal veins may 
 also prevent return of blood from kidneys, and be due 
 to pressure of a pregnant uterus or Abdominal Tumour. 
 Ascites pressing on renal veins. 
 
 Urine. — Sp. gr. ; quantity. Albumen, its quantity and 
 variability under circumstances. Deposit, casts, crystals, 
 blood discs, epithelium. Reaction. 
 
 LooTc for — Signs of Bright's Disease. Heart disease and 
 Diseased Vessels. Emphysema and other lung disease 
 Causes of passive congestion. 
 
 * Dr. Geo. Johnson : "Brit. Med. Journ." Dec. 13, 1879. 
 
.DISEASES OF THE URINARY SYSTEM. 189 
 
 ALBUMINURIA. 
 
 Passive congestion of the kidney s. — Then the amount of albu- 
 men tends to vary with the other signs of passive conges- 
 tion, e.g., ascites, jaundice, oedema of legs, etc. No history 
 of Bright's disease previous to the cause of congestion. 
 Albumen less abundant and casts but scanty if Bright's 
 disease is absent. Urine of high sp. gr., scanty in quantity, 
 a few granular casts. 
 
 Simple Albuminuria, i.e., not dependent upon Bright's disease. 
 — Urine albuminous without any marked sti'uctural lesion. 
 May be due to exposure to cold ; excess of nitrogenous 
 food. Often accompanied by oxalates. During fevers 
 and febrile conditions, e.g., typhus, enteric, cholera, 
 diphtheria, pneumonia, rheumatic fever. But few casts, 
 if any. 
 
190 CLINICAL MEDICINE AND CASE-TAKING. 
 
 HJEMATITRIA. 
 
 Causatio7i. — Disease in renal tissue, pelvis of kidney, ureter, 
 bladder, urethra. Bright's Disease, acute or chronic. 
 Passive congestion of kidneys. See Passive (Cardiac) Con- 
 gestion. Active congestion of kidneys from alcohol, tur- 
 pentine, cantharides. Traumatic injury. Stone. See Renal 
 Calculus. Bladder, Disease of: cystitis, stone, cancer, 
 villous growth, etc. In females during menstrual period. 
 Paroxysmal Hsematuria. 
 
 Uriiie. — Albuminous, alkaline, smoky, blood-coloured, porter- 
 like. Containing heematin, but no corpuscles. See if in 
 subsequent course albumen occurs without blood. Note 
 the colour in relation to the amount of albumen and sp. gr. 
 
 Dejjosit. — Lithates with high sp. gi\ from renal con- 
 gestion. Blood casts ; renal casts ; epithelial and hyaline 
 casts in Bright's disease ; granular and hyaline in renal 
 congestion. Crystals. 
 
 JBlood may be mixed with the urine ; in clots ; in clots moulded 
 in ureter. 
 
 Note quantity of urine, and any difficulty in micturition. 
 
DISEASES OF THE URINARY SYSTEM. 191 
 
 HiEMATTJRIA. 
 
 If blood comes from the renal structure usually there are blood- 
 casts and smoky urine ; if from the urinary passages no 
 casts ; if from the bladder or urethra pm-e blood and clots 
 may be passed, usually after micturition. Periodical 
 attacks of discharge of porter-like urine, with granules and 
 hyaline casts, and the deposit of brownish granular matter 
 in place of corpuscles. See paroxysmal hematuria. Hsema- 
 tmia may appear in early inflammation, and in acute exa- 
 cerbations. Occasionally late in cirrhosis. Rare in lardaceous 
 disease. 
 
 Paroxysmal Hsematuria. — At irregular intervals sudden attacks 
 of rigors, the next urine passed being loaded with blood. 
 Health may long continue good. The paroxysms are un- 
 attended with pain ; there may be a feeling of chilliness 
 across the loins, weakness, nausea, vomiting, joint-pain. 
 The patient becomes languid, Aveak, anaemic. See 
 Anaemia. Examine heart and vascular system. Optic 
 discs. See Haematuria, with description of urine ; Eenal 
 Calculus. / 
 
 Causation. — It is independent of any known structural change 
 in the kidneys. Supposed to be connected with ague, 
 rheumatism, exposure to cold ; certainly such exposure 
 may excite the paroxysms. It almost always occurs in 
 males, usually adults. There is sometimes oxaluria. 
 
192 CLINICAL MEDICINE AND CASE-TAKING. 
 
 BRIGHT'S DISEASE, ACUTE. 
 
 - Sigiis a'od symptoms. — Anasarca. Suppression of urine, more 
 or less complete. Skin harsh. Tendency to somnolence, 
 head-pain, vomiting, coma. Uraemia. Usually after ex- 
 posure to cold or scarlet fever. It may resolve or terminate 
 in a large white kidney. 
 Uri'ive. — Smoky ; very albuminous ; blood discs and large 
 
 I epithelial casts abundant. In quantity, scanty. Blood 
 
 "casts. 
 
 GRANULAR CONTRACTED KIDNEYS. 
 
 Signs and symptoms. — If any oedema it is slight and transient. 
 Heart hypertrophied ; pulse of high tension. Liability 
 to epistaxis and hgemorrhages from mucous membranes. 
 Albuminuric retinitis. Tendency to uraemia. Commonest 
 in advanced life. Often there is coincident cirrhosis of the 
 liver. 
 
 Urine. — Clear, with little deposit ; quantity large ; albumen, a 
 trace. Small granular and hyaline casts. Sp. gr. low. 
 
 FATTY KIDNEYS. 
 
 Signs and symptoms, — Usually anasarca. Face pale and puffy. 
 
 Has a fatal tendency. May result from acute Bright's 
 
 disease. Not uncommon in phthisis. 
 Urine. — Fairly copious ; albumen much. Fatty casts ; fatty 
 
 cells. Sp. gi\ rather low. 
 
 AMYLOID KIDNEYS. 
 
 Sig7is and symptoms. — Anasarca moderate. Pasty anaemic look. 
 
 Emaciation and signs of amyloid disease of other organs : 
 
 spleen, liver, intestines. 
 Urine. — Urine copious. Sp. gr. various. Much albumen ; a 
 
 few hyaline casts. 
 
 LARGE WHITE KIDNEYS. 
 
 Signs and symptoms. — Anasarca. Ansemia. Results from acute 
 Bright's disease. Liability to intercurrent acute attacks, 
 with increase of the symptoms. 
 
 Z7ri7i€.— Scanty ; pale. Casts, hyaline or granular. During 
 exacerbations blood in urine. Albumen. 
 
DISEASES OF THE URINAET SYSTEM. 193 
 
 BRIGHT'S DISEASE, ACUTE. 
 
 Kidney enlarged and congested, the wliole structure of tlie 
 organ being involved. Cortex much swollen ; pyramids 
 very dark and congested ; glomeruli large and congested. 
 Epithelium swollen and cloudy. Veins of the surface 
 dilated. 
 
 GRANULAR CONTRACTED KIDNEYS. 
 
 Kidney small ; capsule adherent ; surface gTanular and reddish. 
 Frequent cysts in cortex. Much wasting of cortex. 
 Arteries thickened. 
 
 FATTY KIDNEYS. 
 
 Kidney large, yellow, pale, soft, easily broken down. 
 
 AMYLOID KIDNEYS. 
 
 Kidney large and pale ; surface smooth ; cortex thick ; 
 glomeruli and vessels stain with iodine. 
 
 LARGE WHITE KIDNEYS. 
 
 Kidney large, smooth, white. Cortex much swollen from over- 
 development of epithelium in convoluted tubes ; but 
 little change in Malpighian tufts. 
 
194 
 
 CLINICAL MEDICINE AND CASE-TAKING. 
 
 BRIGHT'S DISEASE. 
 
 ACUTE, 
 
 CHRONIC. 
 
 Causation. — Cold. Scarletfever. 
 
 Anasarca. — Present. 
 
 Heart and 2^ulse. — No hyper- 
 trophy. There may be pal- 
 pitation in uraemia. 
 
 OpJithaJmoscojrlc aiojjearances. — 
 Usually no changes. 
 
 Urine. — Smoky colour. Casts, 
 with large granular epithe- 
 lium and blood. 
 
 Alcoholism. Gout. Senile 
 degeneration. 
 
 Present with fatty, amy- 
 loid, and large white kidney ; 
 usually absent with granular 
 kidney. 
 
 Hyj)ertrophy ; pulse hard. 
 
 May be haemorrhages or 
 retinitis albuminurica. 
 
 Hyaline casts, large and 
 small ; granular casts ; fatty 
 casts. 
 
 Duration of albuminuria. — Many months. 
 
 Short period. 
 
DISEASES OF THE URINARY SYSTEM. ' 195 
 
 BLADDER, DISEASES OF. 
 
 Disease of the bladder and genito-minary excretory apparatus 
 may be indicated by — 
 
 1 . Urine, — Thick, with deposit of mucus, pus, phosphates, 
 blood, etc. ; reaction alkaline ; smell offensive. Such urine 
 is passed with cystitis. 
 
 2. Micturition clijfficvU. — This may be from stricture of 
 the urethra, a bladder paralysed with retention, or over- 
 flow, or complete incontinence. This may arise fi'om 
 disease of the Spinal Cord or Brain Disease, Meningitis, 
 or Hysteria. 
 
 3. Hypogastric pain and tenderness with fever. 
 
 Cystitis may be acute or chronic. It may result from paralysis 
 or atony of the bladder, calculus, cancer, villous growth. 
 Much mucus renders the urine alkaline by causing the 
 breaking up of the urea into ammonia salts ; phosphates 
 are then precipitated. Cystitis is a common and grave 
 complication of Disease of the Cord ; in such cases it is 
 usually painless. 
 
196" CLINICAL MEDICINE AND CASE-TAKING. 
 
 RENAL CALCULUS. 
 
 A clironic condition ; liability to acute attacks. 
 
 Chronic course. — Aching continuous pain in one lumbar region, 
 shooting downwards. Occasional passage of blood-stained 
 urine, pus, gravel, epithelial debris. Hsematuria, especially- 
 after jolting exercise. There may be tenderness in the 
 loin. Occasional attacks of renal colic. Bladder : there 
 may be signs of stone in the bladder, or Cystitis. 
 
 Enquire for history of attacks of renal colic, Gout, Uraemia, 
 signs of disease of bladder. 
 
 Complications. — Stone in the bladder. Nephritic or peri- 
 nephritic abscess. Suppression of urine from impaction of 
 calculus in ureter on each side. 
 
 Urine. — Quantity. 
 
DISEASES OF THE URINARY SYSTEM 197 
 
 RENAL CALCULUS. 
 
 Urine. — Varying on different occasions. It may be mixed 
 with blood, usually not forming clots. Albuminuria 
 usually proportioned to the amount of blood unless the 
 kidneys are degenerated ; then albuminuria may occur in 
 degree over and above the albumen due to the blood. 
 There may be crystals of oxalates or uric acid, etc. 
 Usually no casts. 
 
 Renal Colic. — Attacks may come on without any previous 
 symptoms of calculus. In the attack paroxysmal j)ain 
 in one lumbar region, severe, causing collapse, vomiting, 
 and sometimes suppression of urine. The attack may 
 cease suddenly ; then the next urine passed may be 
 bloody, and may bring away the calculus per urethram. 
 Such paroxysms especially occur after exertion ; they may 
 last days or weeks. There is often retraction of the tes- 
 ticle on the side of pain (irritation of the genito-crm'al 
 nerve) ; the pain shoots down the inner side of the thigh, 
 and is accompanied by frequent desire to micturate. 
 
198 CLINICAL MEDICINE AND CASE-TAKING. 
 
 TJIIINE, DESCRIPTION OF. 
 
 Quantity. — In healthy adult forty to sixty ounces per diem. 
 
 Colour. — Light or dark sherry ; colourless ; smoky ; blood- 
 coloured. 
 
 Reaction. — Acid (normal) ; neutral ; alkaline. 
 
 S2). grr.— Normal, 1015—1025. 
 
 Urea. — Normal, 400 — 600 grains per diem; 1'5 per cent. tt> 
 4*0 per cent. 
 
 Albumen. — Abnormal. See Albuminuria. 
 
 Sugar. — Abnormal. See Diabetes. 
 
 Deposit. — Bulk in proportion to urine ; colour ; light or heavy. 
 
 CHEMICAL EXAMINATION OF THE DEPOSIT. 
 
 Phosphates. — Soluble in nitric acid ; insoluble in liq. potassse. 
 Urine usually alkaline. 
 
 Litliates. — Soluble in liq. potassse, or on warming deposits. 
 Urine when warm as passed is clear. 
 
 Uric acid. — Soluble in liq. potassae, and precipitated from that 
 solution by hydrochloric acid. See Murexide Test. 
 
 AIucus. — Coagulated by boiling with liq. potassee. 
 
 MICROSCOPICAL EXAMINATION OF THE DEPOSIT. 
 
 1. Casts. — Large, small, hyaline, granular, epithelial, contain- 
 
 ing large swollen epithelium ; blood casts. 
 
 2. Crystals. — {a) Triple phosphate : Triangular prisms, often 
 
 large ; when very short they may be mistaken for octa- 
 hedral oxalates. (&)Uric acid : Usually coloured ; crystals 
 regular, lozenge-shaped or square, elongated or acicular. 
 (c) Oxalates : Octahedra with bright centres. Dumb-bells. 
 {d) Cystine : Hexagonal plates. 
 
 3. E2nthelium. — Glandular ; squamous from vagina or bladder, 
 
 4. Fus,— 
 
DISEASES OF THE URINAEY SYSTEM. 99 
 
 imiNE, DESCRIPTION OF. 
 
 Qiiantity. — Increased in Diabetes, 
 
 Colour. — May indicate Jaundice; Hsematuria; greenish n 
 
 diabetes. 
 Reaction. — In alkaline urine usually a deposit of phosphates. 
 Sx>. gr. — Dense in Diabetes, or if much urea, etc. Low in 
 
 Granular Contracted Kidneys. 
 Urea. — Usually a large percentage if sp. gr. is high vrithout 
 
 sugar. 
 Albumen. — May be a transient ingredient, therefore look for it 
 
 repeatedly. 
 Suga.r. — Occasionally present in Brain Disease. 
 Deposit. — Give general, chemical, and microscopical characters. 
 
 CLINICAL INDICATIONS OF THE DEPOSIT. 
 
 Pliosipliates. — Common in hot weather, when urine ferments 
 
 readilj''. Abundant when there is much mucus or pus. 
 Lithates. — Copious deposit in febrile conditions and in Passive 
 
 Congestion of kidneys ; also usually in healthy scanty 
 
 urine. 
 Uric acid. — Like grains of cayenne pepper. May indicate gouty 
 
 tendency or calciilus-formation. Deranged liver. 
 Mucus. — Copious in cystitis. 
 
 1. Casts. — Coming from uriniferous tubes indicate their condi- 
 
 tion. Numerous in acute Bright' s Disease ; abundant and 
 varied in inflammation ; few in lardaceous disease ; few in 
 cirrhosis ; common in other cases of albuminuria. 
 
 2. Crystals. — {a) Triple phosphates are common in alkaline 
 
 urine in cystitis, and in urine that has decomposed. (&) 
 Uric acid : Deposited in the gouty diathesis, (c) Oxalates : 
 Dyspepsia may produce oxaluria, so anemia, {cl) Cystine 
 may form calculi. 
 
 3. Epithelium. — Common in Bright's disease. 
 
 4. Pus from a pelvic abscess may be discharged into the 
 
 bladder or urinary tract. Copious in renal abscess, and 
 in cystitis. 
 
200 CLINICAL MEDICINE AND CASE-TAKING. 
 
 NORMAL CONSTITUENTS OF URINE. 
 
 Chlorides. — A few drops of nitric acid, then an excess of 
 solution of nitrate of silver ; white precipitate of chloride 
 of silver thrown down. (N.B. — Mtric acid prevents 
 phosphate being precipitated. ) Wash precipitate and prove 
 its solubility in ammonia. 
 
 Phosphoric Acid. — (a) Solution of nitrate of silver gives a ■ 
 white precipitate of phosphate of silver, soluble in nitric 
 acid, but insoluble in ammonia. (6) To urine tested as 
 below for sulphuric acid, and thus deprived of sulphates, 
 add excess of ammonia ; phosphate of baryta is thrown 
 down. 
 
 Sulphuric Acid. — Add a few drops of niti-ic acid, then chloride 
 of darium, which gives a white precipitate of the sulphate. 
 
 Urea.— If the sp. gr. of the urine be from 1023—1030 it 
 usually crystallizes with an equal bulk of nitric acid, the 
 solution being cooled. Beautiful crystals of nitrate of 
 urea are formed. See quantitative examination. 
 
 Uric Acid. — Precipitated from urine by hydrochloric a.cid, and 
 waiting twenty-four houi^s. Soluble in liq. potassse. See 
 Murexide Test. 
 
 (a) Quantity.* — 1. Diminished in early inflammatory conditions. 
 
 2. Normal in middle inflammatory stage, and in early 
 . stage of cirrhosis. 
 
 3. Increased in lardaceous kidney, and here may precede 
 albuminuria. In cirrhosis, late stage. Sometimes in ad- 
 vanced inflammation and dming absorption of dropsies. 
 
 4. Suppressed in acute and adA^anced inflammation, and 
 in advanced cirrhosis. 
 
 (&) Sp. Gr. and Solids. — Depend upon water, m'ea, other 
 
 solids. 
 
 * After Dr. Grainger Stewart. 
 
DISEASES OF THE URINARY SYSTEM. 201 
 
 ABNORMAL CONSTITUENTS OF URINE. 
 
 Albumen. — 1, Heat urine, and when boiled add nitric acid ; a 
 precipitate indicates albumen. 
 
 2. Float in test-tube on nitric acid ; a non- crystalline 
 cloud at the junction of the two fluids indicates albumen. 
 
 Sugar: Moore s test. — Mix urine with half its volume of liq. 
 potassse and boil ; a brownish colour shows sugar. 
 
 Trammer's test. — Add to urine one or two drops of 
 solution of sulphate of copper, then about half as much 
 liq. potassse as urine. If sugar be present, the precipitate 
 at first produced dissolves, producing a blue solution. 
 Now boil this solution ; sugar causes decomposition, and 
 the brown oxide of copper is precipitated. 
 
 Fehling's test. — Cupric sulphate, 40 grammes; potass, 
 tartrat., 160 grammes; liq. sodee (sp. gr. 1"12), 750 
 grammes ; distilled water to 1,154*5 c.c. Boil some of 
 this solution ; then add urine, a few drops at first, and 
 if it be saccharine the red suboxide of copper precipitates 
 at once. 
 
 Bile : Pettenkofers test. — Dissolve a gi'ain or two of white 
 sugar in a drachm of urine ; then add, drop by drop, 
 strong sulphuric acid. A characteristic violet-red colour 
 will be produced if bile be present. 
 
 Leucine. — A morbid product, crystallizes as small spheres 
 which are composed of acicular crystals which radiate 
 from a common centre. 
 
 Tyrosine. — Crystallizes in long white needles. 
 
202 CLINICAL MEDICINE AND CASE-TAKING. 
 
 URINARY CALCULI. 
 
 Heat a specimen on platinum foil over spirit jfiame ; afterwards 
 witli blowpipe. 
 
 I. It hurns away, leaving only a minute trace of ash, probably 
 
 either Uric Acid, Urate of Ammonia, or Cystine. Proceed 
 to test calculus with (a) liq. potassse ; soluble. See Uric 
 Acid. (&) Soluble in hot water or with liq. potassfe, 
 ■ evolving ammonia = urate of ammonia. (c) Insoluble 
 in hot water, but readily soluble in ammonia, the solution 
 on evaporation giving hexagonal plates — Cystine. 
 
 II. It proves incoinhustihle before the blow-pipe, {a) Soluble in 
 dilute hydrochloric acid = Phosphate of Lime. Ammonia 
 added to such solution gives an amorphous precipitate. 
 (&) Fusible before blow-pipe and soluble in hydrochloric 
 acid = Triple Phosphate. The precipitate produced by 
 ammonia from the solution is crystalline. (c) Before 
 ignition soluble without effervescence in hydrochloric 
 acid, this acid solution giving a white precipitate with 
 ammonia. After ignition soluble with effervescence in 
 hydrochloric acid, this solution giving no precipitate with 
 ammonia = Oxalate of Lime. 
 
DISEASES OF Tl^E FRINARY SYSTEM. 203 
 
 UEINARY CALCULI. 
 
 Uric acid and pliospliatic calculi common. 
 
 Murcxide test of Uric Acid. — Dissolve the substance to be 
 tested in nitric acid, and gently warm ; when cold touch 
 residue with liq. potassee ; a beautiful purple solution 
 indicates uric acid 
 
204 CLINICAL MEDICINE AND CASE-TAKING. 
 
 SIGNS OF PREGNANCY. 
 
 General condition. — Chloasma. 
 
 Nei'vous system. — Head-ache. Altered mental condition, some- 
 times great sleepiness, at other times insomnia. Neuralgic 
 pains of all kinds. 
 
 Vascular. — Heart beats become more frequent. Pulse of high 
 tension. 
 
 Ee^piratory, — Dyspnoea on exertion. Cough, reflex. 
 
 Digestive. — Heartburn, salivation. Nausea may occur at once, 
 but commonly not till second month. Sense of sinking in 
 epigastrium ; cravings for food. 
 
 Digestive disturbance. — Appetite increased ; may be strangely 
 altered or perverted. Vomiting ; morning sickness. 
 Bowels disturbed ;. piles from pressure ; often consti- 
 pation. 
 
 Urine. — Kyestein floats as a pellicle on urine after it has stood 
 twenty-four to thirty-six hours, subsequently falling as a 
 milky deposit. Not a sure sign. Albuminuria. 
 
 Diagnosis from — Ascites ; amenorrhoea from other causes. 
 Ovarian dropsy. Phantom tumour ; abdominal tumour. 
 
 Duration of pregnancy. — Calculate the full time complete at 
 forty weeks, dating from a fortnight after commencement 
 of last menstruation. 
 
SIGNS OF PREGNANCY. 205 
 
 PEEGNANCY.— COINCIDENT SIGNS AND 
 SYMPTOMS. 
 
 Sincial signs of pregnancy. — 1. Suppression of tlie menses, 
 under the climacteric age, and without anaemia or known 
 uterine disease. Balottement. 
 
 2. Changes in the breasts which early become somewhat 
 enlarged, their sensitiveness increased, with a feeling of 
 fulness, weight, and shooting pains. Veins in skin en- 
 larged, the glands feeling hard and knotty, and being 
 tender, and sometimes subcutaneous fat augmented. 
 Areola darkened, with a secondary areola outside ; moist 
 with enlarged sebaceous follicles, milk in breast in last 
 month. Nipples turgid and prominent. 
 
 3. Changes in abdomen. — No visible tumour till third 
 month. At first umbilicus is sunken from growth of fat ; 
 later it is protruded by internal pressure. Uterine tumour 
 elastic ; very slightly fluctuating ; at fifth month reaches 
 half up to umbilicus. 
 
 4. Auscultation of uterus. — Foetal heart. Placental 
 souffle. 
 
 Complications. — Obstruction of bowels ; haemorrhage from uterus. 
 
 Pressure signs, — On bladder. Piles. 
 
I X D E X 
 
 Abdomen, examination of, 166 
 Abdominal cancer, 162 
 
 pain, acute, 156 
 
 pulsation, 167 
 
 tumonr, 166 
 Acute Blight's disease, 192 
 Acute yellow atrophy of liver, 
 
 179 
 Addison's disease. 28 
 Adynamia, see Typhoid state, 
 
 44 
 Ague, 12 
 Albumen, 201 
 Albuminuria, 188 
 
 latent, 189 
 Alcoholism, 86 
 
 acute, 88 
 Amnesia, 41 
 
 Amphoric respiration, 128 
 Amyloid degeneration, 24 
 
 kidneys, 192 
 Anaemia, 20 
 
 pernicious, 20 
 Ansesthesia, 57 
 
 muscular, 56 
 Analgesia, 57 
 Anasarca, 24 
 Aneurism, 120 
 
 abdominal, 169 
 Angina pectoris, 115 
 Ankle clonus, 48 
 Aortic obstruction. 109 
 
 Aortic regurgitation, 109 
 
 Aphasia, 41 
 
 Aphonia, 149 
 
 Appetite, 150 
 
 Arteries, 122 
 
 Arthritis, 34 
 
 Ascites, 165 
 
 Ascites or ovarian dropsy, 170 
 
 Asthma, 146 
 
 Ataxy> 94 
 
 Atheroma, 123 
 
 Athetosis, 52 
 
 AiU'a, 57 
 
 Auscultation, 128 
 
 Bell's paralysis, 61 
 
 Bile in urine, 201 
 
 Biliary colic, 182 
 
 Bilious attacks, 41 
 
 Bladder, disease of, 195 
 
 Blood in expectoration, 132, 133 
 
 motions, 158 
 
 urine, 190 
 
 vomit, 133, 156 
 Bone disease, 17, 22 
 Bowels, state of, 150 
 
 obstruction of, 158 
 
 ulceration of, 164 
 Brain disease, 64 
 Bright's disease, 184 
 
 acute, 192 
 
INDEX. 
 
 207 
 
 Blight's disease, acute or chronic, 
 
 194 
 Bronchitis, 146 
 Bronzing of skin, 29 
 Bruit de Diable, 21 
 Bulbar paralysis, 70 
 Bulging of chest, 127 
 
 Calculi, biliary, 182 
 
 renal, 196 
 
 urinary, 202 
 Cancer, 20 
 
 abdominal; 162 
 
 of intestines, 163 
 
 of liyer, 177 
 
 of stomach, 163 
 Cardiac congestion, 106 
 
 dilatation, 111 
 
 displacements, 112 
 
 hyperti'ophy, 110 
 Casts, urinary, 198 
 Cerebral meningitis, 82 
 
 tumour, 82 
 
 vomiting, 45 
 Chest, movements of, 126 
 
 regions of, 124 
 Children's case-taking, xiv 
 Chlorides in urine, 200 
 Chorda tympani, 61 
 Chorea, 76 
 Choroiditis, 65 
 Chronic Bright's disease, 192 
 Circumduction, 54 
 Cin-hosis of liver, 180 
 Clonic spasm, 50 
 Colic, biliary, 182 
 
 renal, 197 
 Coma, 42 
 Condylomata, 14 
 Congenital defects of heart, 118 
 Congenital syphilis, 14 
 Congestion, passive, 106 
 Consolidation of lung, 137 
 Contraction of lung, 136 
 Convulsion, 50 
 Co-ordination of limbs, 54 
 
 Cough, 130 
 
 Cracked pot sound, 128 
 Cramp, 50 
 Cranial nerves, 58 
 Craniotabes, 14 
 Crepitations, 130 
 Cross paralysis, 70 
 Ciystals in urine, 199 
 Cycloplegia, 67 
 Cystine, 202 
 Cystitis, 195 
 
 Delirium, 44 
 
 tremens, 87 
 Developmental defects, 31 
 Diabetes, 28 
 Diarrhoea, 154 
 Digestive functions, 150 
 Dilatation of heart, 110 
 Diphtheria, 8 
 Diphtheritic paralysis, 100 
 Diplopia, 58 
 
 Displacements of heart, 112 
 Dorsal decubitus, 42 
 Drunkenness, 86 
 Duchenne's disease, 70 
 Dyssesthesia, 57 
 Dysentery, 165 
 Dysphagia, 156 
 Dyspnoea, 134 
 
 Electric tests, 46 
 Emaciation, 22 
 Embolism, 122 
 Emphysema, 144 
 Empyema, 139 
 Enteric fever, 4 
 
 diagnosis from tuberculosis, 
 27 
 Epilepsy, 78 
 Epistaxis, 12 
 Erysipelas, 8 
 
 Examination of abdomen, 166 
 Exophthalmos, 98 
 Expectoration, 132 
 Extensors, paralysis of, 70 
 
208 
 
 INDEX. 
 
 Face, paralysis of, 61, 75 
 Facial nerve, 60 
 Facial palsy, cerebral, 75 
 Facial spasm, 50 
 Fatty kidneys, 192 
 Feliling's test, 201 
 Fever, signs of, 2 
 
 enteric, 4 
 
 scarlet, 4 
 
 typh-us, 4 
 Fevers, specific, 4 
 Fine movements, 46 
 Functional paralysis, 47 
 
 Gait, 54 
 
 Gall-stones, 182 
 
 Gasti'ic crises, 94 
 
 Gastiic ulcer, 160 
 
 General paralysis of insane, 89 
 
 Girthing sensation, 57 
 
 Glosso-labio-laryngeal palsy, 70 
 
 Glosso-pliaryngeal nerve, 62 
 
 Goitre, exoplitlialmie, 98 
 
 Gonorrhceal rheumatism, 38 
 
 Gout, 38 
 
 Granular contracted kidneys, 
 
 192 
 Graves' disease, 98 
 Gummata, 17 
 Gums, 152 
 
 Haematemesis, 156 
 Hsematuria, 190 
 
 paroxysmal, 191 
 Hfemoptysis, 132 
 Haemoptysis or Hcematemesis, 
 
 133 
 Haemorrhage in retina, 65 
 Headache, 41 
 Head-pain, 40 
 Hearing, 58 
 Heart, congenital defects of, 118 
 
 dilated and hypertrophied, 
 110 
 
 disease, 112 
 
 displacements of, 112 
 
 Heart, hypertrophy, 110 
 
 physical examination of, 
 i02 
 Hemiansesthesia, 57 
 Hemiopia, 41 
 Hemiplegia, 74 
 Herpes zoster, 100 
 Hooping-cough, 12 
 Hydatids, 183 
 Hydrocephalus, 84 
 Hydrothorax, 139 
 HyperEesthesia, 57 
 Hyperpyi'exia, 5 
 Hysteria, 78 
 Hygienic conditions, 1 
 
 Idiots, 19 
 
 Illusions, 88 
 Infantile paralysis, 96 
 Insanity, 88 
 Insomnia, 40 
 
 Insti'uctions for case-taking, xi 
 additional for children, xiv 
 Intelligence, 40 
 Intercostal neuralgia, 72 
 Intermittent hsematuria, 191 
 Intussusception, 171 
 Iridoplegia, 67 
 Iritis, 16 
 
 Jaundice, causation, 174 
 Joints, 34 
 
 Knee-jerk, 46 
 
 Kidney, tumour of, 167 
 
 Kidneys, amyloid, 192 
 
 fatty, 192 
 
 granular conti'acted, 192 
 
 large white, 192 
 
 Labio-glosso-larjmgeal palsy,. 70 
 Laryngeal obstruction, 8, 148 
 
 symptoms, 8, 148 
 Laryngitis, 149 
 Laryngismus, 52, 149 
 LarjTix, disease of, 149 
 
INDEX. 
 
 209 
 
 Lead poisoning, 98 
 Leucine, 201 
 Lightning pains, 69, 95 
 Liver, acute yellow atrophy, 
 178 
 
 cancer of, 176 
 
 cirrhosis of, 180 
 
 large, 176 
 
 small, 178 
 
 syphilitic diesase of, 180 
 Locomotor ataxy, 94 
 
 pulse, 104 
 Lung contraction, 136 
 
 solidification, 137 
 
 Malformation of heart, 118 
 Mania, post epileptic, 80 
 Marasmus, 23 
 Measles, 6 
 Melsena, 158 
 Meningitis, 82 
 Mercurial tremor, 53 
 Michel's ganglion, 61 
 Migraine, 41 
 Miliaria, 37 
 Minor paralyses, 70 
 Mitral obstruction, 108 
 
 regurgitation, 108 
 Motor power, 54 
 Mouth and throat, 152 
 Movements of extremities, 54 
 
 fine, 46 
 
 of head and trunk, 54 
 Mucous patches, 14 
 Muscular anaesthesia, 56 
 
 movements, hysterical, 78 
 Murexide test, 203 
 
 Nerve, recurrent laryngeal, 62 
 superior laryngeal, 61 
 
 Nervous system, 40 
 
 Neuralgia, 70 
 
 conditions characterized by, 
 
 70 
 trigeminal, 72 
 
 N dules, rheumatic, 37 
 
 Normal respii-ation, 128 
 Nutrition, 22 
 Nystagmus, 58 
 
 Obstruction of bowels, 158 
 (Edema, 24 
 
 pulmonary, 134 
 Ophthalmoplegia interna, 67 
 Ophthalmoscopic appearances, 64 
 Optic discs, 64 
 
 atrophy, 64 
 
 neuritis, 99 
 
 otorrhoea, 58 
 Ovarian dropsy or ascites, 170 
 Ovarian tumour, 167, 170 
 Oxalates, 198 
 
 Pain, abdominal, 156 
 Palate, 152 
 
 Palpitation, functional or or- 
 ganic, 114 
 Palsy of cranial nerves, 58 
 Paralysis, 46 
 
 agitans, 90 
 
 diphtheritic, 100 
 
 functional and organic, 47 
 
 infantile, 96 
 
 labio-glosso-laryngeal, 70 
 
 of extensors of forearm 
 98 
 
 of face, 61, 75 
 
 of face. Bell's, 61 
 Paraplegia, 68 
 Paroxysmal hgematuria, 191 
 Passive cardiac congestio n, 106 
 Patellar tendon reflex, 48 
 Pernicious aneemia, 20 
 Pericarditis, 116 
 Periostitis, 16 
 Peritoneum, flidd in, 168 
 Peritonitis, 172 
 Phantom tumour, 171 
 Pharynx, 152 
 Phlebitis, 123 
 Phosphates, 198 
 Phosphoric acid, 200 
 
^m 
 
 mm