MEDICAL BOOKS ^.59ihSt.,N.Y. Cftbtmbia Umbertfttp (Baltag? af JttygmrtattH an& &iirg*atui l&tUvtni? ffitbrarg AN INDEX OF SYMPTOMS AN INDEX OF SYMPTOMS PRESS OPINIONS Medical Review. — ' Wholly admirable and unique.' Lancet. — ' It is undoubtedly a most useful compilation, and wonderfully complete. . . . The author is to be congratulated upon the happy thought which prompted him.' British Medical Journal. — ' We have nothing but praise for the very complete way in which the author has carried out his task, and can strongly recommend the book.' Glasgow Medical Journal. — ' The Lists are remarkably free from errors, and they are wonderfully complete.' Practitioner. — ' It represents a large amount of work, and will doubtless prove of use alike to students and practitioners. . . . We congratulate the author on the correctness of the lists.' Polyclinic. — ' The author deserves the hearty thanks of the profession.' Medical Press. — ' A useful book for the consulting-room table. It fills a genuine gap in medical literature.' Medical Record (New York). — ' This little volume, a pioneer of its kind, will prove of value, not only to advanced students, but to practitioners as well.' New York Medical Journal. — ' The book is unique, useful, and of convenient size and form. A valuable aid in perplexing cases.' Medical Times. — ' The book should be found in every prac- titioner's library. It will be found of great utility in diagnostic work.' Dublin Journal op Medical Science. — ' Even the best read and most experienced practitioner will often find it suggestive.' Chicago Medical Recorder. — ' An eminently practical book. We do not hesitate to recommend it highly.' Birmingham Medical Review. — ' Accurate and up-to-date.' 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CO P-l Passiv Thrill Palpati signs -5 c8 p— 1 AN INDEX OF SYMPTOMS WITH DIAGNOSTIC METHODS BY RALPH WINNINGTON LEFTWICH, M.D LATE ASSISTANT-PHTSICIAN TO THE EAST LONDON CHILDREN'S HOSPITAI AUTHOR OF ' TABULAR DIAGNOSIS,' ' A POCKET-BOOK OF TREATMENT ' 1 STPHONAGE IN THE LARGE INTESTINE,' ETC. Nihil humani a me alienum puto FIFTH EDITION NEW YORK m WOOD & COMPANY MDCCCCXV PRINTED BY SPOTTISWOODE AND CO. LTD., COLCHESTER LONDON AND ETON, ENGLAND i PREFACE TO THE FIFTH EDITION The present edition contains a large number of new symptoms and many new tests, while the interlineary notes have been much amplified. Further, an attempt has been made to devise a scientific classification of symptoms. The increase in matter has involved an increase in bulk, so that it is no longer a pocket book, but a book for the desk. The author is gratified to find his work so much in use by all classes, from the clinical clerk to the clinical lecturer. It is not always that pioneer work meets with prompt recognition. R. W. L. H6 Ebury St., Eaton Sq. London, S.W, Pfi EFACE TO THE FIRST EDITION (Abridged) The physician, in endeavouring to make a diagnosis, seizes first upon a few prominent features, which will enable him to say that the disease is one, of, perhaps, a dozen. He then looks carefully for further symptoms, and these, by a process of exclusion, gradually point to but one ailment. Should he find himself at fault, and conclude that no disease with which he is f amiliar is consistent with the particular grouping of symptoms in the case before him, he naturally refers to his books. Here he meets with a fresh difficulty ; for, in his text-books of medicine, in his Dictionary of Medicine, and even in his Handbook of Diagnosis, he finds, with rare exceptions, that diseases, not symptoms, form the headings ; the order being therefore the exact reverse of that which takes place in his own brain. He has consequently to wade through page after page and book after book before he succeeds, or is satisfied that he has failed, in the object of his search. But in the present work the symptom forms the heading, and the diseases in which that symptom occurs are placed under it. A mere glance, therefore, will often furnish the missing clue. It must not be supposed that each symptom is met with constantly in all the diseases placed after it. The author's presumption is that the physician in a difficulty is asking the question, ' To what disease or condition may this symptom point ? ' An attempt has been made to indicate in some measure the relative frequency of occurrence, and by other information to assist in differential diagnosis. The word ' symptom,' it is scarcely necessary to say, is taken in its broadest sense, and includes every factor in the diagnosis. R. W. L. London. CONTENTS (The numbers refer to the sections) Art of Diagnosis 1 Vision . 544-565 Classification of Nose 566-586 Patients 2 Smell . 587-590 Fallacies 3-11 Mouth . . 591-625 Classification of Teeth . 626-635 Symptoms 11a Palate 636-640 INTERRO GA TION Tongue . 641-671 Sex 12-13 J Taste 672-675 Age . 14-23 j Throat . 676-691 Occupation 24-27 < Swallow 692-693 History . 28-41 \ Larynx . 694-7US Propagation 42-50 Neck 709-736 Duration . 51-54 Chest . 737-768 Sleep 55-66 Breast . 769-776 Appetite . 67-70 Paracentesis . 777-805 Thirst -72 Back 806-817 Menstruation . 73-84 Abdomen . . 818-840 Pain 85-153 Limbs 841-912 Tenderness . 154-187 Joints . 913-920 Algesia . 188-197 Genitals 921-935 Sensation 198-231 Urination . 936-948 Weakness 232-235 Urine . . 949-1076 Rigors . 236-239 Bowels 1077-1084 INSPECTION Stools . . 1085-1108 Pulse 240-270 Vomiting . 1109-1138 Arterial Tension 271-275 Sputa . 1139-1191 Sphygmograph 276-282 Cough 1192-1197 Pulsation 283-289 Breath . 1198-1202 Temperature 290-306 Breathing 1203-1225 Nutrition 307-312 Voice . 1226-1234 Skin 313-356 Speech 1235-1255 Head 357-383 Writing . 1256-1260 Face 384-409 Intellect 1261-1271 Expression 410-416 Emotions . 1272-1280 Ears 417-430 Decubitus 1281-1289 Hearing . 431-450 Gait . 1290-1302 Eyes 451-534 Ataxia 1303-1304 XI Xll CONTENTS Paralysis Reflexes . Parergi^e Spasm Electrical Re- action Blood Bacteria PALPATION Lungs Heart Abdomen Uterus 1305-1356 1357-1395 1396-1405 1406-1433 1434-1447 1448-1494 1495-1585 1586-1591 1592-1607 1608-1642 1643-1656 PERCUSSION Lungs . . 1657-1688 Heart . . 1689-1694 Abdomen, etc. . 1695-1714 AUSCULTATION Lungs Heart . Vessels, etc. 1715-1744 1745-1771 1772-1802 MISCELLANEO US Time and Season . Tropical Diseases Radiography Tuberculin and other Tests Symptoms — Com- plex Synonyms Index 1803-1809 1810 1811-1814 1815-1828 1829 . 1830 . p. 491 ILLUSTRATIONS FIGURE 1. A Classification of Symptoms . 2. Points of a Sphygmogram . 3. Typical Sphygmograms 4. Types of Temperature 5. The Venous Pulse . 6. A New Regional Chart 7. The Viscera from Behind 8. Urinary Crystals 9. Urinary Casts .... 10. Segmental Areas of the Cord 11. Localisation of Reflexes 12. The Viscera from the Front 13. Cardiac Dullness . 14. Heart Murmurs . ... Frontispiece PAGE 103 105 108 224 229 241 300 305 375 376 420 447 461 AN INDEX OF SYMPTOMS INTRODUCTION Diagnosis is the most difficult part of the art of Medicine, and he who would excel in it must be well equipped both intellectually and physically. His ear must appreciate the finest distinctions of sound in intensity, pitch, and tempo ; his eye must note every variation in outline, movement, and colour ; his sense of touch must distinguish every little differ- ence of surface and form, and even his sense of smell must be well developed. Further, in addition to the natural employment of his senses, he must be skilled in the use of the various instru- ments and devices which have been introduced for the extension of their scope. On the intellectual side, his powers of judg- ment and comparison must be considerable ; for it is not only by a knowledge of all the symptoms of a given disease that a correct diagnosis is made ; it is necessary also to apportion due weight and value to each symptom. But there is still another faculty, the possession of which is indispensable to the physician who would deal successfully with a new problem or a new combination. This, the mind's eye, will enable him to form a clear mental picture of the various parts and organs of the body, not as he sees them in the dissecting-room or the post-mortem theatre, but as they are in life with all their functions, their movements, and their interdependence. Opera- tions give some idea of these ; but the lesson is marred by the paralysing effect of the anaesthetic. What a difference must Life make to our idea of the thorax and its contents — 2 DIAGNOSIS the expansion and shrinking of the lungs, the rising and falling of the diaphragm and of the ribs, the mighty contractions of the heart ! How marvellous, too, must appear the har- monious co-ordination of the many muscles used in a complex voluntary act — some slightly, some moderately, and some fully contracted ! What a contrast there must be between the flabby colon of the post-mortem room and the same organ shortened, thickened, and stiffened by the tonic contraction of its muscular bands. It is this power of visualising that makes the brilliant clinician. To complete the equipment of the ideal diagnostician, some- ' thing resembling legal acumen should be added, by the aid of which the statements of the patient and those of his friends may be so sifted that only the truth remains. A good rule is to ask no leading questions, for in this way the fallacy of ' suggestion ' may be avoided ; but with stupid people it is not always possible to avoid framing a question so as to get ' yes ' or ' no ' for an answer — at least not without much loss of time. 2. Classification of Patients.— Patients in this connection may be classified into four divisions : the pessimistic, the opti- mistic, the complaisant, and the mendacious. The Pessi- mistic Patient is usually either hysterical or ' liverish.' The former will speak with a cheerful countenance of agony endured ; the latter, like Rachel, refuses to be comforted. The Optimist is perhaps still more misleading, for he commonly fails to mention more than half his complaints and passes lightly over the others ; the statements of such patients should be checked by the results of a private interview with the nearest relation. The Com- plaisant Patient is one who, instead of the correct answer, gives that which he imagines is in the mind of the questioner. Is it a libel to say that he usually hails from the Emerald Isle ? The Mendacious Patient is found chiefly in hospital practice. Unlike the malingerer and the fraudulent claimant for compensation, he is not wilfully untruthful ; but by dint of exaggeration, misrepresentation, and omission, he often ends in being very misleading. Especially to be mistrusted in his statements of the views and diagnosis of the previous medical attendant. This should always be listened to with discreet silence. These, then, are some of the Fallacies of Diagnosis; but there are others : — 2 FALLACIES OF DIAGNOSIS 3 3. The Fallacy of Suggestion. — If it be true that suggestion can remove pain, it is no less true that it is capable of creating not only pain, but other nervous symptoms. To ask a neurotic patient day after day if a given pain or spasm have extended to another part, is just the way to make it do so. 4. The Fallacy of Antecedent Disease. — This is most likely to arise in a case of coma, or when the patient is otherwise un- able to speak. An old facial paralysis or squint in the subject of alcoholic coma would be very liable to lead to a diagnosis of apoplexy. 5. The Fallacy of Concurrent Disease. — An instance of this may be found when a chronic disease is mistaken for an acute one, owing to its association with simple tonsillitis or other unimportant condition involving a rise of temperature. I have known a clear case of gout diagnosed as gonorrhceal rheumatism because a urethral discharge was present. It is not to be expected that gonorrhoea would confer immunity from gout. 6. The Fallacy of Obsession. — It is very curious to notice that when a practitioner's mind is full of a certain disease — whether by a recent personal experience, a striking instance of a rare disease in his own practice, or even a noticeable discussion upon a given disease in the medical papers — a run of such cases is likely to follow even when there is no question of infection. Coincidence might account for a second case, but not a third or a fourth. The fact is, the diagnosis is faulty, and the fault is due to obsession. Appendicitis is very much in our thoughts just now, and I believe many abdominal affections are erroneously diagnosed as such by reason of this obsession. Again, when influenza was so rife, any acute disease beginning with pain in the head and limbs and shivering was liable to be attributed to it, much to the after discomfiture of the physician when the nature of the case became clear. This is the fallacy that besets the specialist, who is much too prone to find only his own speciality in the case before him. The point is of all the more importance because, owing to the unwieldiness of Modern Medicine, the time is rapidly coming when almost every doctor will be a specialist, and wide knowledge of Medicine will be rarely met with. The consultant will then be a sort of glorified general practitioner, who will collate and pronounce upon the findings of the specialists. B 2 3-6 4 FALLACIES OF DIAGNOSIS 7. The Fallacy of Perspective. — This is of two kinds. That of the old general practitioner lies in the assumption that his patient is the subject of some common disorder ; that of the advanced student and the junior consultant, that the patient is the subject of a rare disease. Hospitals are centres for rare diseases, and the one class sees too few, the other too many of them. 8. The Fallacy of Variations within the Normal. — A whole book might be written on this subject. Pathognomonic symp- toms are exceedingly rare, and it may be affirmed as a general proposition, that any variation which is absolutely unsupported by other evidence pointing to disease must be considered either normal or accidental. The usual formula with the laity is that such and such a peculiarity is constitutional. Many indi- viduals go through life with a slow pulse, a furred or fissured tongue, or contracted pupils, and are none the worse for these variations, while others show hyaline casts or present some solitary physical sign oi no significance. 9. The Fallacy of the Personal Equation. — This is of two kinds : that of the physician and that of the patient. The latter has been already dealt with in the paragraph on the classification of patients. The temperament of the doctor is apt to affect his diagnosis. While the cheery optimist refuses to believe until perhaps too late that his patient is the subject of a grave disease, the dismal doctor harrows unnecessarily the friends' feeling by his gloomy fears. Not only so, but even the same doctor, bright and fresh in the morning, may feel none of the forebodings which hampered his judgment when tired out and hungry overnight. 10. The Fallacy of Transferred Pain. — This is a common source of error. Where it depends upon well-known physio- logical laws, as in the case of pain in the knee in hip- joint disease, the difficulty is small ; but in other cases, such as the pain in the shoulder which occurs in disease of the colon, and still more when the pain and even the tenderness are referred to the opposite side, the difficulty, in the absence of objective symptoms, may be insurmountable. (Sse 153, 325.) 11. The Fallacy of Malingering. — The Malingerer belongs chiefly to the uneducated classes, and the master-key to his detection lies in the fact that he is unable to think of two things at the name time. For instance, the writer, who has a large 7-11 FALLACIES OF DIAGNOSIS 5 experience of these cases, found out that a man he was examining was a red-hot politician, and mistrusting the cries with which he rent the air when a certain part of his back was lightly touched, proceeded to vilify the man's political party. Then, taking advantage of his excitement, and exclaiming, ' Don't excite yourself,' he emphasised the remark with a sounding slap on the same spot. The man took no notice ! In practice it will often be found advantageous, while ostensibly examining one organ, to watch furtively another. A large number of notes bearing on the subject will be found scattered through this work. 11a. Classification of Symptoms.— Hitherto, the only suc- cessful classification has been the division into Subjective and Objective Symptoms. This is admirable as far as it goes, but it does not go far enough. It is true that there is the sub- class, Physical Signs ; though why signs elicited by the ther- mometer and sphygmometer, which have at least an equal right to the title, are excluded from the group is not clear. Classifica- tion according to the organ affected is also illogical, for the symptom cannot be classed until a diagnosis has been made ; dyspnoea for instance would be termed a lung symptom ; but after examination it might easily prove to be a blood symptom or a heart symptom. Moreover, one organ cannot be affected very long without involving others. Until its elements have been duly classified, Semeiology can have no claim to be regarded as one of the Sciences ; for classifica- tion is the foundation of all. The system here set forth provides a niche for every symptom known or unknown. It should lead to greater precision of thought and by exposing the gaps in our knowledge it should direct and stimulate further investigation. ll-lia PtVRT I INTERROGATION The order of the symptoms is approximately that adopted ki case-taking. The regions proceed from the head downwards. Notes beginning with a capital letter refer to the section ; those with a small letter to the preceding disease. Contractions : u, usually ; x, exceptionally ; *, tho most likely diseases. I, First stage ; n, Second stage ; in, Third or Final stage. PREDOMINANT SEX Irrespective of structural differences. 12. Male The diseases which pre- ponderate in the male are largely those due to laborious occupation, to exposure to weather, or to alcoholism or syphilis. Actinomycosis -^ Addison's Disease -j- Amyotrophic Lat. Sclerosis Aneurysm, Abdominal ^ ,, in general Angioneurotic (Edeina Angina Pectoris Aortitis Appendicitis |- Ascending Paralysis, Acute -£ Bilharzia Bulbar Paralysis Cancer of Kidney ,, of Rectum ,, of Stomach \ Cerebral Abscess Chloroma Ap Cirrhosis of Kidney -| ,, of Liver |- ,, of Stomach Claudication Intermittente Colour-blindness Cystic Kidney \ Cystinuria Diabetes \ except the hereditary form Diabetes Insipidus \ Duodenal Ulcer \ Dupuytren's Contrac- tion - 2 j& Endocarditus, Ulcerative \ Enteric Fever 12 SEX Male — continued Epilepsy Exophthalmic Goitre senile form Exostosis Fatty Degeneration of Heart y Gastritis, Chronic Gilles de la Tourette's Disease Gout Gumma y Hematoma Auris Hemoglobinuria, Inter- mittent Haemophilia -y 1 - Haemorrhage into Cord Hypertrophy of Heart Hypochondriasis Idiopathic Dilatation of the Colon — infants y Intussusception Laryngeal Affections Leukaemia y Locomotor Ataxy y Lymphadenoma y Meningitis, Cerebro- spinal ,, Simplex \ „ Spinal Myocarditis Myositis Ossificans Pachymeningitis Pancreatitis Paralysis agitans Paraplegia, Ataxic Peliosis rheumatica Pneumonia Progressive Muscular Atro- phy, f Pseudo-hypertrophic Para- lysis Pylorus, Congenital Hyper- trophy of -£ Rheumatism, Acute ^ Sciatica Schlatter's Disease Serratus Magnus Palsy \ Spasmodic Spinal Paralysis Stokes-Adams' Disease. Syringomyelia y Thomsen's Disease Tooth's Paralysis Valvular Disease Weil's Disease 13. Female The diseases to which female are specially subject are those that arise from indoor life and insufficient exercise. Acroparaesthesia - T ° Adiposis Dolorosa Anaemia Arthritis, Intermittent Atrophy, Acute Yellow especially during pregnancy Atrophy of Heart | Catalepsy Chlorosis Chorea T Cceliac Disease Constipation Dementia, Ac. Primary Disseminated Sclerosis Enteroptosis -y^- Erythema nodosum Facial Hemiatrophy Floating Kidney | Gall Bladder, Cancer of Y Gallstones | Gastralgia 12-13 SEX Female — continued Gastric Ulcer Goitre „ Exophthalmic ^ Hysteria Idiopathic Dilatation Colon — Adults \ Korsakoff's Syndrome Lupus Erythematosus Manus Valga Membranous Colitis Mitral Stenosis \ Mollities Ossium -^ My x oedema -| Neuralgia Piedra of Pharyngomycosis Proctitis, Ha3morrhagic Pscudangina Pulsating Aorta Pyelitis, Infantile j- Raynaud's Disease Rheumatoid Arthritis Rhinitis, Chr. Atroph. Scleroderma Stricture of Rectum Trance Trypanosomiasis European clothes ±£ Tuberculous Peritonitis % 13 10 AGE AGE Diseases prone to occur at certain ages. 14. In the absence of direct information, it may be necessary to form an estimate of the patient's age ; but, since illness is sure to add to this in appearance, it is not always an easy matter. The best guide, perhaps, is the texture of the skin, which becomes more and more inelastic and, later, more and more leathery, as age advances. Wrinkles are a guide to some extent ; but they develop prematurely in those much given to laughter or gesticula- tion. In women the advent of the menopause is often indicated by the growth of hair on the chin and upper lip ; and, in both sexes, middle age may be betrayed by a certain stiffness at the hip joints in walking. Grey hairs usually begin to appear about the fortieth year, but they are not very marked for ten or twelve years after that ; premature greyness, however, is common enough, and is then usually hereditary. The tortuous temporal artery and the arcus senilis are not necessarily confined to old age ; indeed, thanks to the very general use of artificial teeth, the classical signs of old age are rarely seen except amongst the very poor. 15. The Examination of Children presents many difficulties. The first thing to do is to endeavour to get the child's confidence. For this purpose the practitioner must give him time to get used to his presence by getting all the information possible from the nurse or mother. He may then ask the child to shake hands, and can surreptitiously feel the pulse at the same time, or perhaps get the mother to hold the child's hand while he does so. If the suspicious patient will not put out his tongue, he will probably open his mouth wheri asked and this will do nearly as well, and the opportunity may then be taken to pass the finger rapidly over the gums. The chest should next be listened to, and if a single stethoscope is employed, the child should previously have been allowed to examine it under the specious name of trumpet. Percussion is apt to make a child cry ; it should -therefore follow, not precede, auscultation, and as a rule, one finger only is necessary to form the plessor. The throat may be examined by using the handle of a teaspoon as a tongue- depressor ; the examination nearly always sets the child crying, but this is of less importance now, as the ordeal is nearly over, 14-15 AGE 11 and the cry affords an opportunity to determine the vocal fremitus and resonance. The symptoms of disease present certain modifications when affecting children. Thus, the pain of lobar pneumonia is often referred to the epigastrium, and the disease itself may affect the apex instead of the base. The rigor of onset is often replaced by convulsions. Vomiting is exceptionally common in children, perhaps from the more vertical position of the stomach, and this and diarrhoea are remarkable for the rapid wasting by which they are followed. The whoop of pertussis is often absent in young infants, and in all children it usually disappears temporarily during an attack of measles. Other peculiarities will be found noted in the interlineations of the text. In the following lists, where the disease occurs in more than one age section, the numbers of the others are given. In incurable diseases, only the age of onset is usually inserted. 16. Infancy (under 2 years) Amaurotic Family Idiocy Amyloid Degeneration (17) Bronchitis (17, 22) Broncho-pneumonia (17) Convulsions (17) Cretinism (17) Diarrhoea Diphtheria, Laryngeal (17) Erythema Infectiosum (17) Glands, Enlarged (17, 18) Glandular Fever (17) Hereditary Muscular Atro- phy Hooping Cough (17) Hydrocephalus (17) ,, Spurious Idiopathic Dilatation of the Colon Impetigo contagiosa (17) Infantile Hemiplegia Scurvy (17) begins at 6 to 10 m. Intertrigo Intussusception (17) 72 / o under one year Laryngismus stridulus (17) Laryngitis, Spasmodic (17) Lichen Manus Valga Measles (17, 18) Meningitis, Tuberculous (17) Meningitis, Post Basic u under 9 months Paralysis, Infantile (17) Ponos (17) Post-pharyngeal Abscess (17) Purpura, Henoch's Pyelitis Rickets (17) Rotheln (17, 18, 19) Scarlatina (17, 18) Seborrhoea (18) Spasmus nutans 15-16 12 AGE In fan c y — continu ed Syphilis, Hereditary it appears at 2 to G weeks Syphilitic Disease of Lungs (17) ,, Epiphysitis ,, Pemphigus (17) Tetany (17) VariceUa (17) Werdnig-Hofmann Atrophy (17) 17. Childhood Addison's Disease (x) (18,20) Adenoids Amyloid Degeneration (16) Banti's Disease Bronchitis (16, 22) Broncho-pneumonia (16) Cataract, Soft Cerebro- spinal Meningitis Chloroma (18) Chondroma (18) Chorea (18) Cirrhosis, Hypertrophic Bili- ary (x) Coeliac Disease begins about 2 Convulsions (16) Coxa vara about 3 and again at 14 Cretinism Diphtheria (16, 18) Encephaloid Cancer Endocarditis (18, 19, 20) Enteric Fever (18) Epilepsy (18) Erythema Infectiosum (16) Exophthalmic Goitre (x) Facial Hemiatrophy Floating Kidney (x) Friedreich's Disease (18) Gilles de la Tourette's Disease Glands, Enlarged (16, 18) Glandular Fever (16) ' Growth Fever ' Haemophilia Hooping Cough (16) Hydrocephalus Impetigo contagiosa Infantile Scurvy (16) Intussusception (16) Laryngismus stridulus (16) Laryngitis, Spasmodic (16) Little's Disease under 5 Lumbrici Measles (16, 18) Meningitis, Tuberculous (16) Mumps (16, 18) Myeloma (18) Myoclonus Multiplex Noma (Edema laryngis (18) Paralysis, Infantile (16) tj under 5 Paramyotonia Congenita Paroxysmal Tachycardia (x) Peritonitis, Tuberculous Ponos (16) f Post-pharyngeal Abscess (u under 4) Pseudo-hypertrophic Para- lysis Purpura, Henoch's Rheumatic Nodules Rheumatism (18, 19, 20) rare under 3 Rhinitis, Atrophic (18) 16-17 AGE 13 Childhood — continued Rickets (16) Ringworm Roseola Rotheln (16, 18, 19) Sarcoma, Renal Scarlatina (16, 18) Schlatter's Disease (18) Scurvy, Infantile (16) Spinal Paralysis, Epidemic Status Lymphaticus Syphilis, Hereditary (16) Syphilitic Lungs (16) ,, Pemphigus (16) Tetany (16) Thomsen's Disease 4 to 6 Threadworms (16) Tubercle of Bones, etc. Tuberculous Tumours of Brain Varicella (16) Werdnig-Hofmann Atrophy (16) 18. Adolescence Acne Addison's Disease (20) Amenda (19) Apoplexy, Spinal Appendicitis (19) Catalepsy Cerebellar Ataxy Cerebral Embolism (19. 20) Chloroma (17) Chlorosis Chondroma Chorea (17) Coxa vara (17) Dementia, Ac. Primary Diabetes Insipidus Diphtheria (16, 17) Endocarditis (19, 20) Enteric Fever (17) Epilepsy (17) Exophthalmic Goitre (x), (20, 21, 22) Exostosis Friedreich's Disease (17) Glands, Enlarged (16, 17) Goitre (21) Hysteria (21) Measles (16, 17) Meningitis, Simple Migraine Mitral Stenosis MoUities Ossium (20) Mumps (16, 17) Myeloma (17) Myocarditis Myomata (19, 20) Myxcedema (20) Nervous Atrophy CEdema laryngis (17) Periodic Paralysis (19) Pharyngomycosis (19) Phthisis (19) Progressive Muscular Atro- phy (x) (19, 20) Rhachitis adolescentium Rheumatism, Acute (17, 19, 20) Rhinitis, Atrophic (17) Rotheln (16, 17, 19) Sacro-iliac Disease Scarlatina (16, 17) Schlatter's Disease (17) Seborrhcea (16, 20) Spasmodic Spinal Paralysis Syringomyelia (19, 20) onset 17-18 14 AGE Adolescence — continued Trance Tuberculosis, Acute (19, 20) Ulcer of Stomach (19, 20) Vincent's Angina (19) 19. Young Adults Actinomycosis Anaemia (18) Appendicitis (18, 20) Cerebral Abscess (20) Cerebral Embolism (18, 20) Dementia Precox (20) Disseminated Sclerosis (20) Duodenal Ulcer Endocarditis ( 17, 18, 20) Gastralgia Hemorrhage into Cord (20) Myomata (20) Paralysis, Ac. Ascending (20) Peliosis rheumatica Periodic Paralysis (18) Pharyngomycosis (18) Phthisis (18) Poliomyelitis, Ac. Ant. (x) Primary Spastic Paraplegia (20) Proctitis, Hemorrhagic Progressive Muscular Atro- phy (18, 20) Rheumatism, Acute (18, 20) Rheumatoid Arthritis (20, 21) Rotheln (16, 17, 18) Seborrhcea Capitis Serratus Magnus Palsy (20) Symmetrical Adeno-lipoma- tosis (20) Syringomyelia (18, 20) Tuberculosis, Acute (18) Ulcer of Bladder „ of Stomach (18, 20) Vincent's Angina (18) Yellow Atrophy, Acute (x) (20) 20. Middle Age Addison's Disease (18) Aneurysm (22) Angina Pectoris (22) Apoplexy Cancer of Stomach, Liver, Larynx, Rectum, Uterus, or Breast Cerebral Abscess (19) Embolism (18, 19) (u under 50) Cirrhosis of Liver or Kidney Claudication Intermittente, (22) Cystic Kidney Diabetes Dissecting Aneurysm Dupuytren's Contraction Endocarditis (17, 18, 19) Epithelioma (22) Exophthalmic Goitre (18, 21, 22) Fatty Degeneration of Heart (22) Gallstones Gout (21, 22) Hemorrhage into Cord (19) Hypochondriasis Idiopathic Dilatation of Colon (x) Kidney, Movable Korsakoff's Syndrome Leukemia 18-20 AGE 15 Middle Age — continued Locomotor Ataxy Melancholia, Mollities Ossium (18) Myelitis Myomata (18, 19) Myx oedema (18) Nephritis, Chronic Neuralgia, Trigeminal Osteitis Deformans Osteo-arthritis. 22 Paralysis, Ac. Ascending (19) ,, agitans (22) ,, Bulbar „ General Paraplegia, Ataxic Pernicious Anaemia Primary Spastic Paraplegia (19) Progressive Muscular Atro- phy (u 25-45) Rheumatism, Acute (18, 19) Sciatica (22) Sclerosis, Disseminated (19) Serratus Magnus Palsy (19) Spinal Meningeal Haemor- rhage Stricture of Rectum Symmetrical Adeno -lipoma- tosis (19) Syringomyelia (18, 19) Thrombosis (22) Tumours, Intracranial except tuberculous Ulcer of Stomach (18, 19) ,, of Colon ,, of Duodenum Weil's Disease Yellow Atrophy, Acute (19) 21. Menopause Cancer Caruncle, Urethral Diabetes Exophthalmic Goitre Goitre Gout Hysteria Insanity Pruritus Vulvaj Pseudangina Rheumatoid Arthritis Uterus, Prolapse of 22. Old Age Aneurysm (20) Angina Pectoris (20) Aortitis Apoplexy u over 50 Arterio-sclerosis Brachial Neuritis Bronchitis (16, 17) Cancer Capillary Bronchitis Cataract Cerebral Thrombosis Chorea, Senile Claudication Intermittente (20) Diarrhoea Dissecting Aneurysm Ecthyma Epithelioma (20) Exophthalmic Goitre in men Fatty Degeneration of Heart (20) Gangrene Gout (20, 21) 20-22 1G AGE Old Age — continued Melancholia Osteoarthritis Pachymeningitis over 50 Paralysis agitans (20) Pemphigus Phthiriasis Prostatic Disease Pruri bus Sciatica (20) Thrombosis (20) Ulcer, Rodent 23. Congenital Affections The following diseases are, at least sometimes, congenital. Achondroplasia Amblyopia Amyotonia Congenita Angeiomata Aphasia Atelectasis Buhl's Disease Cataract Cholsemia, Congenital Chorea (x) Corneal opacities Deaf-Mutism Dermatitis Exfoliativa Development, Ai rested Dislocations of Hip, etc. Facial Hemiatrophy Haemophilia Heart Affections Hernia Hydrocephalus Hydronephrosis Ichthyosis Icterus neonatorum Idiocy Idiopathic Dilatation of the Colon Infantile Hemiplegia 4- ,, Hemoglobinuria Malformations Manus Valga Multiple Osteomata Naevi Paralysis of Sixth Nerve Paramyotonia Congenita Paraplegia, Spastic Pemphigus Progressive Muscular Atro- phy Pseudo-hypertrophic Para- lysis Ptosis Pylorus, Hypertrophy of Sclerema Spastic Cerebral Paraplegia Syphilis Syringomyelia Tetanus neonatorum Thomsen's Disease Word- Blindness, Cong. 22-23 OCCUPATION 17 OCCUPATION It may be necessary to know the past as well as tho present occupation. 24. Active Bichromate Workers : Aneurysm Ulcers, Erosion of Nasal Dislocations Septum Fractures Accumulator Heart, Hypertrophy of Makers Hernia Painters Rheumatic Fever Dyers Rupture of Valve Cusp Enamellers Lead- Sprains Potters \ poisoning, Gout Tetanus Glass Polishers 25. Sedentary Plumbers Anaemia White- Lead Arterio- sclerosis Makers Chlorosis Bark Strippers : Keratosis Constipation Buttle Makers : Cataract Dyspepsia Compositors : Nystagmus Fatty Heart Cooks : Eczema, Erythema Gallstones India-rubber Workers : Gastritis Amaurosis, Temporary Gout Hysteria and Mania, Peri- Haemorrhoids pheral Neuritis, Derma- Hysteria titis Hypochondriasis Pitch, Workers in : Warts Neuroses (becoming epithelioma- Obesity tous) Ulceration of Phthisis Cornea Ulcer of Stomach Dusty Trades : Cirrhosis of Lungs, Chronic Laryn- 26. Trade Diseases gitis Brass Founders : Pseudo- Brickmakers : Ankylosto- Ague miasis Boiler Makers : Deafness Miners : Phthisis, Anky- Bakers lostomiasis, Nystagmus, Grocers ■ Dermatitis ' Beat-knee ' or ' -elbow,' Bricklayers Epithelioma , (Scrotal) 24-26 18 OCCUPATION ) Anthrax Trade Diseases — continued Domestic Servants : Anae- mia, Gastric Ulcer, Ery- thema nodosum, Varicose Veins Butchers : Weil's Disease Skin Dressers Wool Sorters Sweeps : Epithelioma of Scrotum Gold-beaters ) Side- Olass Polishers j rosis Furriers : Arsenic-poison- ing, Mercurialism Felt-hat Makers : Mercurial- ism Gardeners : Tetanus Corn Trades : Actinomy- cosis, Aspergillosis, Ger- lier's Disease Bird Fanciers ; Psittacosis, Aspergillosis Stokers : Apoplexy Divers : Caisson Disease Match Makers : Phos- phorus-poisoning Electric-light Workers : Con- junctivitis X-Ray Workers : Derma- titis, Impotence Sailors : Exostosis of Ear Standing Occupations : Vari- cose Veins, Flat Foot 27. Occupation Neuroses Writer's Cramp : Clerks Laryngeal Spasm : Cornet Players Elocutionists Flautists Clonic and Tonic Spasms Ballet Dancers Compositors Hammermen Pianists Telegraphists Violinists Typists Tailors Sempstresses Shoemakers Cigarette Rollers Milkers 26-27 HISTORY 19 28. HISTORY Etiology is perhaps the least reliable of all our aids to diagnosis, for it bristles with fallacies and notably with the post hoc, ergo propter hoc variety. A good deal of care therefore is necessary to obtain accurate results, especially with uneducated people. A ' cold,' given as the cause of death, may be ascertained by questions as to duration, wasting, cough, or haemoptysis to have been in reality phthisis. ' A complication of diseases ' will generally be found to include dropsy ; and a few appropriate questions will usually elicit such information as will determine whether this was renal, cardiac, hepatic, pulmonary, or heemic. A state- ment of the causes of the deaths in the family is, however, not sufficient. Inquiry must be made as to whether any living member of the family is suffering from hereditary disease, and cross -heredity must be borne in mind. The subject is of special importance in examination for life insurance. According to Galton's Law, each parent contributes one-quarter of the inherited faculties and each grandparent one-sixteenth. 29. Hereditary Diseases Some of these may, like Tuberculosis, prove to be infectious with a prolonged latent stage. Acne Adiposis Dolorosa Angeioneurotic (Edenia Apoplexy Arterio-sclerosis Asthma, Hay (x) „ Spasmodic -l^ Cancer Calculus Colour- Blindness, Cong. Cystinuria Dementia Precox Diabetes 20% „ Insipidus (x) c 2 Disseminated Sclerosis Dupuytren's Contraction Eczema Emphysema Epilepsy -i- Facial Hemiatrophy (x) Fragilitas Ossium Friedreich's Disease Gout Haemophilia Heart Disease Hereditary Cerebellar Ataxy Hernia right side if paternal Huntington's Chorea Hysteria Hydrocephalus Hpyochondriasis 28-29 20 HISTORY Hereditary Diseases — con- tinued Ichthyosis Insanity f Landouzy-Dejerine Para- lysis Laryngismus stridulus Leprosy (?) Malformations Migraine Milroy's Disease Myositis Ossificans Nsevus Nephritis (x) Neurasthenia Neuroses Nystagmus (x) Obesity (Edema, Circumscribed Otosclerosis Paramyoclonus Multiplex Periodic Paralysis Phthisis Primary Spastic Paraplegia Progressive Muscular Atro- phy (x) Pseudo-hypertrophic Para- lysis Psoriasis (x) Retinitis Pigmentosa Rheumatic Fever Rheumatism Rheumatoid Arthritis, or Joint Trouble Senility, Early Spondylose Rhizomelique Syphilis Telangiectasis Tetany Thomsen's Disease Tooth's Paralysis Tuberculosis Tumours In many cases, what is really inherited is a dimin- ished power of resistance to a given disease and not the disease itself. 30. Cross Heredity Epilepsy — \ Insanity and vice Epilepsy — j versa Migraine ) Ac. Rheumatism — Valvular Disease 31. Familial Diseases Amaurotic Family Idiocy Congenital Chohemia Cretinism Diabetes (x) Disseminated Sclerosis (x) Fibroids, Uterine Friedreich's Disease Hereditary Cerebellar At- axia „ Muscular Atro- phy Ichthyosis Landouzy-Dejerine Para- lysis Lateral Sclerosis family type Myoclonus Epilepticus Pentosuria Periodic Paralysis Pseudo-hypertrophic Para- lysis boys of same family Retinitis Pigmentosa Spastic Paraplegia 29-31 HISTORY 21 Familial Diseases — contd. Splenic Anaemia, Gaucher type Telangiectasis Thomsen's Disease Word- Blindness, Cong. Xeroderma Pigmentosum 32. Previous Attack Favours a Diagnosis of Ague Angina Pectoris Appendicitis Apoplexy Asthma, Hay ,, Spasmodic Bronchitis Delirium Tremens Epilepsy Erysipelas Gallstones Gout Hemoglobinuria, Intermit- Lead-poisoning [tent Migraine Neuralgia Osteomyelitis Quinsy Renal Colic Rheumatic Fever Rheumatism Tonsillitis 33. Previous Attack Precludes There are many exceptions, however, since immunity following an attack of infectious disease is not necessarily life-long. Enteric Fever Hooping Cough Measles Mumps Rotheln Scarlatina Syphilis cong. or acquired Typhus Varicella Variola Yellow Fever * Diphtheria confers little if any immunity. Herpes Zoster seems to have some causal connection with Varicella. 34. HISTORY OF FORMER ILLNESS Gonorrhoea Gleet Iritis Ophthalmia Orchitis Pyaemia Rheumatism Stricture and in women, peritonitis and salpingitis. Gout Arterio- sclerosis Cerebral Haemorrhage Cirrhosis of Kidney Eczema Neuritis Phlebitis Lead-poisoning Cerebral Haemorrhage Cirrhosis of Kidney Fibroid Heart Gout Multiple Neuritis 31-34 22 HISTORY History of Former Illness — continued Rheumatic Fever Chorea Embolism Endocarditis Exophthalmic Goitre 10 per cent. Paramyotonia Congenita Valvular Disease Scarlatina Angina Ludovici Nephritis Otorrhcea Rheumatism Tonsillitis Valvular Disease Syphilis Aneurysm Cord, Sclerosis of Diabetes Eruptions General Paralysis Gummata liver, brain, scalp, etc. Heart, Fibroid Iritis Locomotor Ataxy Meningitis Pachymeningitis, Cervical Periostitis Phthisis Thrombosis of Brain Tumour of Brain 35. History of a Bite By a dog — rarely a cat or a fox. Hydrophobia Lyssaphobia Pyaemia Tetanus 36. History of Blow or Fall Abscess Arthritis Cancer Caries of Spine Concussion of Brain Dislocations Displaced Cartilage Epilepsy esp. Jacksonian Fibrositis Fractures Haemorrhages Meningitis Movable Kidney „ Liver Myositis Ossificans Neurasthenia, Traumatic Pachymeningitis Pleurisy Prolapsus Uteri Ruptured Muscle „ Viscus Shock Spondylitis, Traumatic Sprains Synovitis Tetanus Tuberculous Arthritis with a free interval Uterine Displacement Vein, Ruptured One-fifth of all cases of hysteria are of traumatic origin (Berbez). 37. History of a Strain Aneurysm Apoplexy Fibrositis Haemorrhage Heart Disease 34-37 HISTORY 23 History of Strain — continued Hernia Prolapsus Ani ,, Uteri 38. History of Dietetic Error Beri-Beri unpolished rice Botulism infected sausage, etc. Diarrhoea rich or tainted food Dyspepsia, Acute pork, crustaceans, etc. Ergotism fungous rye Hydatids raw, unwashed vegetables Lathyrism meal made from Lathyrus Pellagra maize, etc. Ptomainism decayed food (B. Coli, etc.) Trichinosis infected raw ham Urticaria shell fish, pork, rabbit, etc. Numerous diseases are due to infected milk or water. 39. History of Alcoholism Aneurysm Apoplexy Arterio- sclerosis Atheroma *Cirrhosis of Liver ♦Delirium Tremens Dementia, Chronic Dilatation of Stomach Emphysema, Atrophic Gastritis, Chronic Glycosuria *Gout Heart, Dilated „ Fatty „ Fibroid Kidney, Cirrhosis of „ Enlarged Korsakoff's Syndrome *Neuritis, Multiple Pachymeningitis Pharyngitis, Chronic Pneumonia Tuberculosis History of Rigor (see 236) History of Exposure to Con- tagion or Infection See Propagation (44, 45) History of Residence Abroad See Exotic Diseases, 1810 37-39 24 ONSET ONSET 40. Sudden Onset Acute diseases in general. All forms of lisemoirhago and embolism. Ague Angina Pectoris Ascending Paralysis, Acute Asthma Apoplexy, Cerebral some minutes Apoplexy, Pulmonary ,, Spinal Appendicitis Caisson Disease Catalepsy Cholera Colic, Hepatic ,, Renal Dengue Embolism, Cerebral instantaneous Embolism, Renal Epileptic Fit Erysipelas Facial Paralysis unless due to a tumour Glandular Fever Gout Hematocele, Pelvic Hemorrhage, Spinal Inter- meningeal Hydrarthrosis, Intermittent Infantile Paralysis Influenza Jaundice, Obstructive Korsakoff's Syndrome Laryngismus stridulus Mania Meniere's Disease Meningitis, Cerobro-spinal „ Internal Spinal „ Post-Basic (u) Myelitis Neuralgia Pancreatitis, Acute Paralysis, Acute Bulbar ,, Acute Spinal ,, Periodic Periarteritis Nodosa Peritonitis, Acute Pleurisy, Acute Pneumonia, Lobar Pyaemia Pyelitis, Acute Rheumatic Fever Syncope Thrombosis, Cerebral some hours Trance Tuberculosis, Acute Valve Cusp, Rupture of 41. Gradual Onset Chronic Diseases in general and all degenerative diseases. Acromegaly Amyloid Amyotrophic Lat. Sclerosis Aneurysm Ascites Ataxic Paraplegia Bulbar Paralysis Cancer Chorea Cirrhosis of any Organ Dilatation of Stomach Enteric Fever 40-41 ONSET 25 Gradual Onset — continued General Paralysis Hooping- Cough Landouzy-Dejerine Para- lysis Locomotor Ataxy Mastoiditis Myelitis, Chronic Occupation Neurosis Paralysis Agitans Pernicious Ansemia Phthisis Progressive Muscular Atro- phy Sclerosis, Disseminated Tooth's Paralysis Transverse Softening of Cord Tuberculous Meningitis Tumours, Cerebral days or weeks Tumours of Cord 41 26 PROPAGATION 42. PROPAGATION Sporadic cases of most of these diseases occur occasionally. 43. By Epidemic Anterior Poliomyelitis, Acute Asiatic Cholera Beri-Beri Cerebro-spinal Meningitis Chorea Magna Cough, Paroxysmal Dengue Diphtheria Dysentery Enteric Fever Ergotism Erysipelas (x) Erythema Nodosum (x) Hooping Cough Influenza Malta Fever Measles Mumps Paroxysmal Hsernoglobin- uria Plague Pneumonia, Acute (x) Psittacosis Relapsing Fever Roseola Rotheln Scarlatina Typhus Varicella Variola Yaws 44. By Infection Actinomycosis Dengue Diphtheria Enteric Fever Erysipelas Erythema Infectiosum Glandular Fever Hooping Cough Influenza Measles Mumps Plague Roseola Rotheln Scarlatina Tuberculosis Typhus Varicella Variola Yaws Yellow Fever Also, according to some authorities, Acute Rheu- matism and Acute Pneu- monia. 45. By Contagion Conjunctivitis Diabetes (x) conjugal form *Diphtheria Erysipelas Farcy Favus 42-45 PROPAGATION— SCHOOL QUARANTINE 27 By Contagion — continued Glanders ♦Gonorrhoea Hospital Gangrene Hydrophobia from rabies Impetigo contagiosa Leprosy slightly Malignant Pustule Molluscum contagiosum Porrigo children Purulent Ophthalmia Ringworm *Scabies ♦Soft Sore ♦Syphilis Trachoma Yaws 46. Infection by Clothing Diphtheria Influenza Hooping Cough Measles Puerperal Fever Rotheln ♦Scarlatina Typhus Varicella ♦Variola 47. Infection by ' Carriers ■ Cholera Diphtheria Dysentery Enteric Fever 3 per cent of cases Meningitis, Cerebro- spinal Paratyphoid Fever Yellow Fever 48. SCHOOL QUARANTINE 49 After Exposure to Infection (' Contacts ') Chicken-pox, 18 days Diphtheria, 12 days Enteric, 21 days Hooping Cough, 21 days Measles, 16 days Mumps, 24 days Ringworm, 10-14 days Rotheln, 16 days Scarlatina, 14 days Small-pox, 18 days Typhus, 21 days In the case of Pertussis, Mumps, Rotheln, or Varicella, one day's quarantine will suffice for a pupil after transient exposure, provided he has already had the disease. 50. After an Infectious Disease (The body and clothes hav- ing been disinfected.) Diphtheria 4 weeks after convalesence, provided there be no albuminuria and no dis- charge from nose, ears, eyes, throat, etc. (the bacillus is often found long after this). For adults, 3 weeks should suffice Enteric Fever 4 weeks from commence- ment of defervescence Follicular Tonsillitis 5 days 45-50 28 SCHOOL QUARANTINE After an Infectious Disease — continued Hooping Cough 6 weeks at least from begin- ning of whoop, provided whoop and spasmodic cough have ceased Influenza, Uncomplicated 7 to 10 days from com- mencement Measles 3 weeks from the disappear- ance of the rash, if peeling and cough have ceased Mumps 4 weeks from the commence- ment, if all swelling have subsided Ringworm one month after apparent cure Rot n elm 2 to 3 weeks Scarlatina 6 weeks from the disappear- ance of the rash if there be no sore-throat, or discharge from nose or ear. Desquamation is considered of less import- ance now than formerly Small-pox and Chicken- pox 1 week after every scab has fallen off Typhus 5 weeks 50 DURATION 29 51. DURATION 52. Acute Diseases iEstivo-Malarial Fever each ' fit ' 20 hours Ague cold stage 10 to 60 min. hot stage 2 to 6 hours sweating stage 2 to 3 hours Angeioneurotic (Edema 2 to 3 days ; recurring every 3 weeks or so Angina Pectoris from minutes to hours Antitoxin Rash incubation 1 week Apoplexy from minutes to days Asthma, Spasmodic from one hour to several days Bell's Mania from 3 days to 3 weeks Buhl's Disease about 2 weeks Catalepsy minutes to hours or days Cerebro-spinal Meningitis variable Chancre, Hard incubation 3 to 5 weeks Chancre, Soft incubation a few hours to a week Cholera incubation 3 to 5 days Dengue invasion 3 days : rash 1 to 2 days ; remission 2 to 4 days Diphtheria incubation | to 6 days ; invasion 3 to 4 days ; membrane 1 to 7 days ; paralysis begins 8 to 12 days after recovery Enteric Fever incubation 3 weeks ; in- vasion 11 days; rash 10 days Erysipelas incubation 15 to 60 hours Erythema Scarlatiniforme little or no incubation stage ; eruption 4 to 5 days or more Erythema Infectiosum incubation 6 to 14 days Follicular Tonsillitis incubation 4 days Gallstone Colic u a few hours Glandular Fever incubation 7 days ; disease 14 days Glanders incubation 3 to 8 days ; invasion 3 to 4 weeks ; developed stage 2 to 20 days Gonorrhoea incubation 3 to 5 days Herpes Zoster u 10 to 20 days Hooping Cough incubation 10 days ; in- vasion 7 days Hydrarthrosis, Intermittent 4 to 5 days ; interval 1 month or more 51-52 30 DURATION Acute Diseases — continued Hydrophobia incubation u 6 to 7 weeks, but may be much longer ; disease 1 to 4 days Influenza incubation 2 to 3 days ; disease 4 to 5 days Malta Fever incubation 8 to 14 days Measles incubation 10 to 12 days ; invasion 3 to 4 days ; rash 4 to 6 days Meningitis, Acute Simple 2 to 8 days Meningitis, Post Basic 3 weeks to 4 months Meningitis, Tuberculous 2 to 4 weeks Mumps incubation 8 to 21 days ; swelling 8 to 10 days Myelitis, Acute a few hours Nephritis, Acute 3 to 10 weeks Paralysis, Acute Ascending a few days when fatal Paratyphoid Fever from 12 days Periodic Paralysis attack a few hours to 1 or 2 days (53) Petit Mai a few seconds Plague incubation 3 to 5 or 7 days Pneumonia, Acute incubation 48 to 70 hours ; disease 5 to 7 days Pneumonia Serpens 2 to 3 weeks Poliomyelitis, Acute incubation 8 days ; fever 1 to 4 days ; paralysis on 2nd to 8th day Psittacosis 30 days altogether ; incuba- tion 7 to 12 days ; high fever 3 to 4 days Relapsing Fever pyrexial stage 5 to 7 days ; sweating 8 to 9 hours ; interval 6 to 8 days or more ; second attack 3 to 4 days Remittent Fever 5 to 14 days Roseola 4 to 7 days — face first Rotheln incubation 14 to 16 days, but variable ; invasion about 12 to 24 hours — longer in adults ; rash 3 days. ' In Fourth Disease ' the incubation is shorter in the scarla- tiniform type. Scarlatina incubation 8 to 9 days ; invasion | to 2 days ; rash 3 to 5 days Spasmus Nutans 3 weeks to 3 months Spinal Meningeal Haemor- rhage fatal cases a few hours Tetanus incubation 4 days to 4 weeks 52 DURATION 31 Acute Diseases — continued Trypanosomiasis Temp, above normal a few days, below normal a few days Tuberculosis, Acute a few days to a few weeks Typhus incubation 7 days ; invasion 4 to 5 days ; rash 8 to 9 days ; defervescence 3 days Varicella incubation 12 days ; in- vasion a few hours ; rash 5 to 10 days Variola incubation 12 days ; in- vasion 2 days ; rash 8 to 10 days Vincent's Angina about one week Yellow Atrophy, Acute 2 to 3 weeks Weil's disease 10 to 15 days Quarantine (see 49) 53. Chronic Diseases Acromegaly 10 to 20 years Addison's Disease 2 to 3 years Amyloid many years Banti's Disease many years Brown-Sequard Paralysis 2 to 5 years Cancer, Encephaloid about 1 year Cancer, Scirrhus about 2 years Chloroma 3 to 12 months Chorea 1 to 4 months Chorea, Huntington's 10 to 30 years Distomiasis haemoptysis 10 to 15 years Exophthalmic Goitre many months or years Friedreich's Disease many years General Paralysis a few months to 2 years Guinea Worm incubation 12 months Hereditary Muscular Atro- phy 3 to 4 years Idiopathic Muscular Atro- phy many years Kidney, Contracted from 4 to 10 years Landouzy-Dejerine Para- lysis for many years Leukaemia from ^ to 7 years Locomotor Ataxy from 1 to many years Lymphadenoma about 2 years Meningitis, Post Basic 1 to 4 months 52-53 32 DURATION Chronic Diseases — continued Miculi.cz' Disease 2 months to 10 years Milroy's Disease life-long ; but with inter- current acute crises Morvan's Disease for years Myelitis, Chronic ^ to 10 years Nephritis, Chronic 1 to 4 years Periodic Paralysis healthy interval 1 day to 1 year Pharyngomycosis months or years Primary Spastic Paraplegia for many years Sclerosis, Disseminated 5 to 10 years Syringomyelia 5 to 20 years Traumatic Neurasthenia latent 1 or more weeks Traumatic Spondylitis latent a few weeks Trypanosomiasis from 4 to 8 months Yaws 2 to 4 months or more 54. Recurrence, Periodical or Occasional Ague Angioneurotic (Edema Angina, Abdominal „ (Esophageal ,, Pectoris Appendicitis Asthma, Spasmodic Bronchitis Catalepsy Cyclical Vomiting of Children intervals irregular Eczema Epilepsy Hay Fever Henoch's Purpura Hydrarthrosis, Intermittent Intermittent, Pernicious Menstrual Disorders Migraine Mittelschmerz inter-menstrual Neuralgia Paroxysmal Hsemoglobin- uria Periodic Paralysis Pseudangina Psoriasis Relapsing Fever Rheumatism (See 32 and 301) 53-54 SLEEP 33 55. SLEEP The statements that patients make as to the duration of sleep are usually unreliable ; even the fact that they have heard the clock strike does not preclude sleep so light that this sound sufficed to wake them momentarily. The standard duration of sleep necessary for adults is 8 to 9 hours ; for old people, 5 to 6 hours, and for children, 12 hours. 56. Day Restlessness Alcoholism, Chronic Dysentery Dyspnoea (1223) Enteric (3rd week) Glossitis Hydrophobia, I. Hyperemia of Brain Laryngitis Meningitis, Simple, I. Myocarditis, Acute Tapeworm Throat Affections 57. Sleeplessness or Insomnia Anaemia, Severe Aortic Regurgitation Arterio- sclerosis with morning somnolence Cold Extremities Collapse of Lungs Constipation Delirium Tremens Dilatation of Heart Dysentery Dyspepsia Dyspnoea (1223) Flatulence Gastritis, Chronic Gout Hypereemia of Brain Kidnev Cirrhosis of Liver, Cirrhosis of Mania Melancholia Meningitis, I. Neurasthenia Paralysis, General Pneumonia, Acute Rickets Stomach, Atony of Teething Trichinosis Valvular Disease Other causes are mental strain or emotions ; pain, late meals, late use of tea or coffee, and unconscious hunger. 58. Night Terrors The child wakes up in the night, shrieking and be- wildered. Adenoids Colitis Dentition Epilepsy Frights Hysteria Indigestion Lithaemia Mucous Colitis Rheumatism 55-58 34 SLEEP Night Terrors — continued Syphilis, Hereditary Tonsils, Enlarged Worms Some cases are accounted for by a real, but, to the patient, an ' uncanny ' noise. 59. Nightmare and Starting Adenoids Aortic Regurgitation Delirium Tremens Dyspepsia Emboli, Small Cerebral Encephalitis, i. Hyperemia of Brain Hypertrophy of Heart Meningitis Mental Exhaustion Neurasthenia Teething Tonsils, Enlarged Worms Nightmare is often caused by insufficient bed-clothes or by the head slipping off the pillow. 60. Narcolepsy A sudden paroxysm of sleep in the midst of some occupation. Hysteria Jaundice Nephritis, Chronic Petit Mai Stomach, Overloaded 61. Drowsiness or Stupor Abscess of Brain, I. Acute Yellow Atrophy Alcoholism Acute, II. „ Chronic Anaemia (x) Asphyxia Atony of Stomach after meals Bromism Cerebellar Disease Chlorosis Cold, Intense Concussion of Brain Cyanosis Diabetic Coma Dilatation of Heart daytime Dyspnoea (1223) severe cases Encephalitis Embolism (clot) (fat) Epilepsy, n. Gangrene of Lung Hsematoma of Dura Mater Hsemoglobinuria, Infantile Hsemophilia, in. Hydrocephalus Intermittent Fever end of paroxysm Intermittent, Pernicious Jaundice (392) Lithsemia after meals Liver Disorders Meningitis, Cerebrospinal, II. ,, Simple, it. „ Tuberculous, n. Narcotic-poisoning Neurasthenia Plague 58-61 SLEEP 35 Drowsiness or Stupor continued Remittent Fever Septicaemia, in. Softening of Brain Spina bifida, in. Trypanosomiasis Typhic State (62) Typhus Uraemia 62. Typhic State or ' Typhoid State ' The expression ' Typhoid State ' is misleading as it refers to Typhus, not Typhoid Fever. *Acute Yellow Atrophy Anthrax Appendicitis, in. Dysentery (term.) Endocarditis, Septic *Enteric, Severe Erysipelas, Severe *Extravasation of Urine Hepatic Abscess Hydatids, Suppurating Jaundice, Severe Pernicious Malaria Phosphorus-poisoning Plague ^Pneumonia, Septic Ptomainism Portal Thrombosis, Suppura- ting Scarlatina, Malignant *Septiccemia Typhus, Malignant Variola, Malignant (See 1829) 63. Coma Vigil The patient rouses when spoken to, but immedi- ately relapses again into coma. Commencing Coma (64) Delirium Tremens Enteric Fever, in. Septicaemia Typhic State 64. Coma A deep stertorous sleep from which it is impossible to rouse the patient. Addison's Disease, in. * Alcoholism, Acute temperature subnormal Amyloid, in. *Apoplexy ^Asphyxia Atrophy, Acute Yellow „ of Kidney, Acute Cholangitis, Chronic Fibrous ^Compression of Brain Coal-gas-poisoning Diabetes, in. Disseminated Sclerosis, in. Embolism of Brain Encephalitis, ni. Erysipelas, Severe Exposure to Cold Fat Embolism *Fracture of Skull General Paralysis, in. Glanders, ni. Gout, in. (x) Haematoma of Dura Mater Hyperpyrexia Jaundice (x) Meningisme 61-64 d 2 36 SLEEP Coma. — continued Meningitis, in. simple, tuberculous, or cerebro -spinal Myxcedema, in. Narcotic-poisoning Pernicious Anaemia, in. „ Intermittent Remittent Fever (severe) Scarlatina maligna Softening of Brain, Exten- sive *Sunstroke Thrombosis of Brain Tumours of Brain, in. *Ursemia Variola maligna 65. Unconsciousness without Coma Addison's Disease Anaemia of Brain Anaesthesia, Incomplete *Aortic Stenosis Atrophy of Heart Bell's Mania Catalepsy incomplete Collapse incomplete Concussion of Brain rarely complete Epilepsy, n. except Jacksonian form Ergotism, Spasmodic Faints * Fatty Degeneration of Heart Gouty Heart Hypnotism Hysteria the eyelids often quiver Hy stero - epilepsy *Internal Haemorrhage Malformation of Heart *Malingering Shock Sunstroke Syphilitic Heart Syncope Trance (See Coma, 64 ; Faintness, 230) 66. Momentary Unconscious- ness Cerebral Embolism minute plug Cerebral Haemorrhage minute clot General Paralysis Laryngeal Vertigo Petit Mai Stokes-Adams' Disease 64-66 APPETITE 37 67. APPETITE 68. Increased (Bulimia) Bulimia Neurotica Chlorosis *Convalescence from Fevers ♦Diabetes Dilatation of Stomach (x) Epilepsy- Ergotism Exophthalmic Goitre Gastralgia Gastritis, Chronic (x) Hooping Cough Hyperchlorhydria Hysteria Insanity Iodism Neurasthenia (x) Pregnancy Tumour, Cerebral Softening, Cerebral Ulcer of Stomach (x) Worms 69. Diminished (Anorexia) Abscess of Liver Ague (prsem.) ♦Alcoholism, Chronic Anaemia *Anorexia nervosa Arsenic -poisoning Atony of Stomach Atrophy of Stomach *Cancer of Stomach or Liver Cirrhosis of Stomach Cceliac Disease Constipation Coryza Cystitis Delirium Tremens Duodenal Catarrh Dysentery, in. Empyema *Faecal Accumulation Gastritis, Acute Hepatitis, Acute ♦Influenza Melancholia Peritonitis, Chronic *Pyrexial Affections (295) Suppuration 70. Morbid (Pica) The patient eats nails, needles, or even dis- gusting substances. Anaemia Chlorosis ♦Hysteria Idiocy ♦Insanity Pregnancy 67-70 38 THIRST 71. THIRST This is usually the expression of deficiency of water, or of excess of salts, in the blood, and occurs, therefore, where there is loss of fluid by sweating, vomiting, diarrhoea, polyuria, haemorrhage or high temperatures on the one hand, and much salted food on the other. 72. Increased Abdominal Injuries Ague Arsenic -poisoning Cancer of Stomach Cholera *Diabetes ,, Insipidus „ ' Phosphatic ' Diarrhoea Dilatation of Stomach Gastritis, Acute and Chronic Glossitis Gout *Ha3inorrhage *Hyperidrosis Hysteria Intestinal Obstruction Kidney, Cirrhosis of *Pyrexial Diseases (295) Sunstroke Tetanus Xerostoma 71-72 MENSTRUATION 39 73. MENSTRUATION The menses usually appear about the age of fourteen, but they have been known to begin as early as eight. The average age for their cessation is forty-six, though they are usually irregular in their appearance for the last two years or more, and arp normally absent during pregnancy and lactation. 74. Amenorrhea (Menses Ab- sent) The menses may fail to appear owing to con- genital defects or to injuries received in child- hood (Primary Amen- orrhea) ; or, they may fail to re-appear (Secon- dary Amenorrhea). Absence of Uterus, Ovaries, or Vagina Acromegaly, n. Addison's Disease Alcoholism, Chronic ♦Anaemia Anorexia Nervosa Atrophy of Uterus Cachexia, Cancerous „ Syphilitic Cervical Catarrh ♦Chlorosis Colitis Cretinism ♦Diabetes Ectopic Gestation Endometritis Enteric Fever Exophthalmic Goitre Fibroids Hysteria Imperforate Hymen Os Lead-poisoning Leukaemia Lymphadenoma Malarial Cachexia Melancholia Mercurialism Metritis Morphinism Myxcedema Nephritis, Chronic Obesity Oophoritis Ovarian Cysts, Double Parametritis Pelvic Adhesions ♦Phthisis Renal Insufficiency Rheumatism, Acute Scarlatina Superinvolution Tuberculous Kidney Ulcer of Stomach The menses may also fail to appear owing to change of air or of occupation, to frights, and to intel- lectual strain or worry. 73-74 40 MENSTRUATION 75. Dysmenorrhea (Painful menstruation) *Anaemia Anteflexion Cancer Cervix, Long Conical Chlorosis (x) Congestion, Uterine dull pain Deflection of Canal Ectopic Gestation shreds or decidua vera *Endometritis Fibroids, Uterine Gout Hypertrophy of Uterus Neuralgia Neurosis Obstruction from clots, shreds, mem- branes, etc. Oophoritis Ovary, Small Cystic Peritonitis, Pelvic Polypus *Retroflexion Retroversion Rheumatism Salpingitis Stenosis of Canal 76. Menorrhagia (Excessive periodic flow) and 77. Metrorrhagia (Intermedi- ate Haemorrhage) *Abortion Abraded Os Adenoma Internum Alcoholism Anteflexion *Cancer of Uterus esp. near menopause i Chlorosis (x) Cirrhosis of Liver Congestion of Uterus Ectopic Gestation *Endometritis Emmenagogues Exophthalmic Goitre *Fibroids Fungous Degeneration Granular Os Hematocele Haemophilia Heart Disease Hypertrophy of Uterus Inversion *Lead-poisoning Leukaemia Malaria Menopause Metritis (x) *Miscarriage Myxcedema Nephritis Oophoritis Ovaries, Displaced Ovarian Growths Pelvic Cellulitis ,, Peritonitis Phosphorus-poisoning Plethora *Polypus Prolapsus Uteri Purpura Pyometra Retained Decidua Retroflexion Retroversion Salpingitis Sarcoma Scurvy Subinvolution Syphilis j 75-77 MENSTRUATION 41 Menorrhagia and Metror- rhagia — continued Uterus, Tuberculosis of Vaginitis, Senile Granular Variola, Malignant Yellow Atrophy, Acute 78. Dyspareunia(PainfulCoitus) Anal Fissure Bartholinitis Caruncle Cystitis Gonorrhoea Haemorrhoids Hymen, Partly Persistent Hymeneal Orifice, Inflamed Kraurosis Vulva? Labial (Edema Metritis Neuritis, Pudic Oophoritis, Adhesive Ovary, Prolapsed Perinatal Laceration Urethritis Vaginismus Vulvitis 76/77-78 42 DISCHARGES 79. VAGINAL DISCHARGES 80. White Discharge (Leucor- rhoea) * Anaemia Anteflexion (x) Bartholinitis duct external to hymen *Cervical Catarrh * Endometritis, Chronic Erosions, Cervical Fibroid Tumours Gleet '^Gonorrhoea Granular Cervix Hypertrophied Cervix Metritis, Chronic Pelvic Peritonitis Polypus Prolapsus Uteri Salpingitis Sarcoma of Uterus Tubal Colic intermittent Vaginitis, Catarrhal „ Granular Worms (children) 81. Sanguineo-purulent Dis- charge *Cancer of Uterus *Endometritis, Hemorrhagic *Endometritis, Purulent *Endometritis, Septic Endometritis, Senile Metritis, Acute Pelvic Abscess discharging Polypus 82. Offensive Discharge Abscess, Pelvic Cancer of Uterus *Death of Foetus Endometritis, Chronic „ Senile ,, Septic Fibroids, Sloughing Polypus, Cervical Puerperal state moderately so *Retained Decidua 83. Shreds and Membranes *Abortion Diphtheria Ectopic Gestation *Membranous Dysmenor- rhea *Miscarriage *Puerperal Decidua 84. Emission of Gas Garrulitas Vulvae noisy Recto-Vaginal Fistula 79-84 SENSIBILITY— PAIN 43 85. SENSIBILITY The sensory paths are divided into — Protopathic Cutaneous Sensibility — including pricking, fara- disation, freezing, and burning. Epicritic Cutaneous Sensibility, which includes light touches, and fine differences in temperature. Deep Sensibility comprising recognition of pressure pain, sensation from muscles and joints, and the vibration sense. The fibres run chiefly with the muscular nerves. When a peripheral nerve is divided, a small and well-defined area, in which both epicritic and protopathic sensibility are absent, is surrounded by a large ill-defined area in which only epicritic sensibility is abolished. But, when the nerve-root is divided, the areas of epicritic and protopathic sensibility coincide. In cord lesions, there are no partial changes ; it is a case of all or none ; whether with sensibility, temperature - sense, or position-sense. 86. PAIN Pain due to, or increased by, the breaking down of resistance in the higher centres is commoner on the left side. Thus, the pain from old uterine cancer is six times commoner on the left than on the right side. Pressure on the trunk of a nerve produces pain or tingling at the nerve termination. It is often difficult to estimate the degree of pain felt, for the patient's statement cannot always be relied upon. Some information may be obtained by a scrutiny of the expression, and some from the time spent in sleep. If a patient professes to be in constant acute pain, and nevertheless sleeps four or five hours at a stretch, credence must be witheld. Further, were anything like intense pain present, evidence of it would be found in the hard pulse, the quickened breathing, the dilated pupils, and the clammy skin. On the other hand some patients make too light of the pain felt. The pain in hysterical and neurasthenic patients is less marked when the attention is diverted. It is difficult to determine the seat of pain in an infant, but the nature of the cry (1233), the expression, and Jadelot's Traits (408), will usually provide a clue. 86-86 44 PAIN 87. General Pain ' Pain all over ' Anaemia Anterior Poliomyelitis,Acute onset *Dengue Diabetes Fevers, Onset of ' Growing Pains ' u rheumatic Gout Infantile Scurvy *Influenza Lead-poisoning Lithamiia Locomotor Ataxy Meningitis, Spinal Multiple Neuritis Nephritis, Chronic Osteomalacia Periarteritis Nodosa *Rhcumatism Rickets Scurvy Syphilis Trichinosis 88. REGIONAL PAIN Headaches. — The symptom is too common to be of much value ; but it may be noted that cerebral headaches are worse at night and often paroxysmal. High tension headaches and those con- nected with gastric disturbance are of a throbbing character and are often relieved by the recumbent posture. Of headaches due to eyestrain, those arising from Astigmatism are usually worse in the morning, while those due to other causes are worse in the evening. 89. Frontal Headache Adenoids *Anaernia Enteric Fever ceasing when delirium appears Eyestrain Fevers prodromal stages *Frontal Sinus Obstruction Gastritis Glaucoma Hsematoma of Dura Mater Iritis Lithaemia Malaria Neurasthenia Periostitis Syphilitic Nodes Thrombosis of Sup. Sinus Trigeminal Neuralgia Uraemia Long. 90. Occipital Headache *Adenoids *Asthenopia Buhl's Disease ^'Cerebellar Tumours ' headache of effort ' Cerebro-spinal Meningitis Cervico-occipital Neuralgia Cirrhosis of Kidney *Constipation Diabetes 87-90 PAIN 45 Occipital Headache — con- tinued Epilepsy Eyestrain Gout Locomotor Ataxy Naso-pharyngeal Disease Legal' s Disease Nephritis, Chronic *Ncurasthenia Pharyngitis Rheumatism Sphenoidal Disease *Syphilis Syringomyelia Tongue Lesions, Basal Uterine Diseases (See Nucha, 100) 91. Unilateral Headache Adenoids Antral Abscess Bone, Diseased Cancer of Tongue Carious Teeth Dysmenorrhea a Eyestrain, Unilateral Gouty State *Hysteria clavus Mastoid Abscess *Migraine Nephritis, Chronic Otitis Media Polypus, Nasal *Trigeminal Neuralgia paroxysmal Tumour, Cerebral *Wax in Meatus 92. Pain at Vertex Anaemia Chlorosis Constipation Epilepsy *Hysteria *Neurasthenia ' helmet headache ' Uterine Diseases 93. Unclassified Headaches Abscess of Brain Addison's Disease Ague Alcoholism *Amenorrhcea *Ana3mia Apoplexy (praam.) Arsenic-poisoning Asthma Atony of Stomach Aura Epileptica Catalepsy Chlorosis Cinchonism Cirrhosis of Kidney worse in morning Compression of Brain Congestion of Liver *Constipation *Coryza Dengue Diabetes Dilatation of Stomach Disseminated Sclerosis Duodenal Catarrh *Dysmenorrhoea Dyspepsia -Dyspnoea (x) (1223) 90-93 46 PAIN UNCLASSIFIED HEADACHES — continued Embolism, Cerebral Encephalitis Epilepsy Erysipelas Exophthalmic Goitre General Paralysis Glandular Fever Glaucoma Gouty state Hsematorna of Dura Mater circumscribed ^Haemorrhage *Hay Fever Hereditary Cerebellar At- axy Hydrocephalus Hyperoemia of Brain Hypertrophy of Brain „ of Heart ^Hysteria *Incubation of Fevers ^Influenza Iritis Jaundice Lactation, Prolonged Lead-poisoning Leontiasis Ossea Leucorrhcea Litheemia Measles Meningitis „ Cerebro-spinal Menopause Mental Overstrain Morphinism Nephritis *Neuralgia *Neurasthenia Oophoritis Oxaluria Pachymeningitis Plague Pneumonia, Acute Polycythsemia, Splenome- galic Polypus, Nasal * Pyrexia (295) Relapsing Fever Remittent Fever *Rheumatism Softening of Brain Spur of Septum Sunstroke Syphilis Tapeworm *Tension, High Arterial Thrombosis, Cerebral Tumour of Brain except when in c. callosum Turbinated Bone, Enlarged Typhus Uraemia Valvular Disease Variola, I. Weil's Disease Headache is often caused by impure air, fatigue, flatulence, and depression after excitement. It is also said to be caused by imperfect coagulability of the blood. 94. Eyeballs Conjunctivitis *Coryza *Eyestrain Glaucoma Injuries Iritis 93-94 PAIN 47 Eyeballs — continued Keratitis Migraine *Neuralgia of Fifth Nerve Ophthalmoplegia interna Panophthalmia Sphenoidal Sinusitis (See Photophobia, 561) 95. Earache * Abscess, Alveolar ,, Mastoid Anaemia Aneurysm of Innominate Caries of Temporal Bone Chloroma Eczema of Meatus * Foreign Body in Meatus Furuncle in Meatus Gland, Inflamed Mastoid Herpes Auris Injuries Larynx, Ulcer of Mastoiditis Mumps Neuralgia, Trigeminal *Otitis Media or Interna, Acute Perichondritis, Acute Pharynx, Ulcerated Polypus *Pulpitis, Dental lower molar Rheumatism, Temporo- maxillary Sphenoidal Sinusitis *Teething Tongue, Cancer of ,. Ulcer of Toxaemia 96. Nose *Antral Disease *Foreign Body * Frontal Empyema Glanders Syphilis 97. Upper Jaw * Abscess, Alveolar „ of Pulp Antrum, Disease of *Cancer Caries Exostosis, Dental *Neuralgia, Sup. Max. Periodontitis Periostitis Pulpitis S ah vary Calculus 98. Lower Jaw * Abscess, Alveolar * Abscess of Pulp Actinomycosis Caries Exostosis, Dental Fracture Mumps *Neuralgia, Inf. Max. Periodontitis Pulpitis S ah vary Calculus 99. Neck *Abscess Caries, Cervical Glandular Fever Innominate Aneurysm Lymphadenoma Polymyositis *Rheumatism Serratus Palsy *Strain Syringomyelia 94-99 PAIN 100. Nape of Neck (Nucha) Cerebellar Disease Cerebrospinal Meningitis ♦Cervico-occipital Neuralgia Muscles, Sprained *Neurasthenia Pharyngitis Refraction Error ♦Rheumatism Spinal Meningeal Haemor- rhage Tetanus 101. Throat Cancer Concretions in Tonsil Crico-arytenoid Arthritis ♦Diphtheria ♦Foreign Body Laryngitis ♦Nasopharyngeal Catarrh Pharyngitis Poisoning by — Aconite Cantharides Conium Corrosives Irritants Post-pharyngeal Abscess * Quinsy ♦Scarlatina ♦Tonsillitis Tuberculous Pharyngitis „ Tonsillitis ♦Uvula, Swollen (See Dysphagia, 693) 102. PAIN IN BACK 103. Spinal Pain Apoplexy, Spinal circumscribed Aneurysm, Abdominal „ of Descending Aorta Cancer of Liver „ of Spine Caries of Vertebras Cerebro -spinal Meningitis Compression of Cord Disseminated Sclerosis esp. the paraplegic form External Spinal Pachymen- ingitis Hyperaemia of Cord ♦Hysteria Meningitis, Internal Spinal Mollities Ossium Myelitis ♦Neuralgia ♦Neurasthenia Osteomyelitis Osteitis Deformans Rheumatoid Arthritis esp. cervical Salpingitis esp. 11th and 12th dorsal Spinal Meningeal Haemor- rhage Spondylose Rluzomelique Sprains increased by rotation Syringomyelia Traumatic Spondylitis Tuberculous Spinal Menin- gitis 100-103 PAIN 49 Spinal Pain — continued Tumour of Cord *Ulcer of Stomach lumbo- dorsal (See Interscapular Pain, 107) 104. Coccygeal Pain Pain at extremity of spine *Coccygodynia Fissure of Anus Fistula *Haemorrhoids Injuries Periproctitis *Rheumatism Sacro-coccygeal Tubercu- losis *Uterine Diseases 105. Sacral Pain Pain at lower part of spine. Ataxic Paraplegia Cancer of Rectum, Uterus, or Testis *Cervical Catarrh *Dysmenorrhcea *Endometritis Fibroids *Flexions of Uterus Haemorrhoids Hip Disease Inversion of Uterus Metritis *Neuralgia Orchitis Ovarian Disease Pelvic Peritonitis *Prolapsus Uteri Retroversion Sacro-iliac Disease Salpingitis Sarcoma of Uterus *Scybala Spinal Apoplexy Subinvolution Tumours of Uterus Venery, Excessive 106. Lumbar Pain Abscess, Lumbar ,, Perinaeal „ Rectal Aneurysm, Abdominal Appendicitis *Calculus, Renal unilateral *Calculus, Vesical Cancer of Spine „ of Stomach Caries of Spine Cauda Equina, Tumour of Chorea Chyluria Curvature, Lateral *Cystitis Dengue ' Diabetes, Phosphatic ' Dysmenorrhcea Embolism, Renal Enteroptosis *Faecal Accumulation *Fatigue Flatulence * Gravel Hernia Hydatids Hydronephrosis Infantile Paralysis onset *Influenza Kidney, Floating „ Tuberculous 103-106 50 PAIN Lumbar Pain — continued Kidney, Cancer of Lithoemia Locomotor Ataxy crisis ♦Lumbago Meningitis, Internal Spinal „ Tuberculous Spinal Miscarriage Nephralgia Nephritis, Acute „ Suppurating Neuralgia, Lumbo-abdomi- nal Neurasthenia Oophoritis Pachymeningitis, External Spinal Parasite of Kidney ♦Parturition Perinephritis Pleurisy (onset) Polycythemia, Splenome- galic Prostatitis Pyelitis Pyonephrosis Remittent Fever Retroflexion Thrombosis, Renal Tumour, Abdominal Typhoid Spine Variola, I. *** A common cause of lumbar pain is the wearing of high-heeled boots. 107. Interscapular Pain Aneurysm of Descending Aorta Atony of Stomach Cancer of Stomach cardiac end Caries of Dorsal Spine Cerebellar Tumour Cirrhosis of Stomach ♦Flatulence *Gastric Irritation ,, Ulcer Gastritis Mediastinal Abscess ,, Tumour ♦Rheumatism Tumour of Cord 108. PAIN IN CHEST 109. Mamma ♦Abscess, Mammary „ Retromammary ,, Tuberculous *Cancer ♦Cracked Nipple Cyst, Multiple Ectopic Gestation Hysteria Lobular Induration Mastitis, Chronic Menstruation (x) ♦Neuralgia Obstructed Lacteal Duct Ovarian Disease ♦Pregnancy 110. Sternum Aneurysm, Thoracic Angina Pectoris retro-sternal (Beaume's Sign) Aortitis Bronchial Calculus 106-110 PAIN Til Stern um — continued Bronchial Glands, Enlarged Bronchitis, Acute, I. Caries of Sternum or Spine Foreign Body in Lungs *Gastric Irritation Influenza Locomotor Ataxy Mediastinal Abscess ,, Tumour (Esophagismus Spinal Apoplexy Syphilis 111. Praecordium This is often hyperesthesia rather than pain. Anaemia Aneurysm „ of Heart *Angina Pectoris Aortic Cusp, Rupture of ,, Regurgitation Arsenic poisoning Beri-beri ♦Endocarditis Epilepsy Fibroid Disease of Heart ♦Flatulence Functional Heart Disorder Gastritis ♦Gastralgia Gout ♦Heartburn (220) Heartstrain *Hysteria Myocarditis, Acute Pericarditis ♦Pseudangina Syphilitic Heart Thrombosis of Pulmonary Artery Valvular Disease especially aortic 112. Pain in Side Caries of Spine Cholecystitis *Faecal Accumulation ♦Flatulence Fracture of Spine pressure of callus on nerve Herpes Zoster u on right side Hysteria ♦Intercostal Rheumatism ♦Intercostal Neuralgia U 6th to 9th rib. If bilateral, ' girdle pain ' Pleura, Cancer of ♦Pleurisy, Acute, i. ♦Pneumonia, Acute Pneumothorax onset Ribs, Carious „ Fractured Spondylose Rhizomelique Woillez's Disease 113. Right Hypochondrium or Pain over the Liver Abscess, Hepatic ,, Perinephric ,, Subphrenic Cancer of Colon of Duodenum of Liver of Pancreas of Pylorus of Stomach e 2 110-113 52 PAIN Right Hypochondrium — continued *Cholecystitis Cirrhosis of Liver Colic, Right Renal Constricted Liver Cyanotic Liver Distoma Hepaticum Empyema of Gall-bladder ^Gallstones Hepatitis, Acute Herpes Zoster Hydatids, Inflamed Movable Kidney Dietl's crisis Neuralgia, Intercostal Periarteritis Nodosa Perihepatitis Peritonitis Pleurisy Pneumonia Sprain ' bowler's side,' etc. Syphilitic Liver Ulcer, Duodenal Yellow Atrophy, Acute 114. Left Hypochrondrium Pain under the lower left ribs, in front. Abscess, Perinephric „ Subphrenic Ansemia Aneurysm, Abdominal Cancer of Colon splenic flexure Cancer of Stomach *Colitis *Fsecal Accumulation Gastric Catarrh Gastroptosis Herpes Zoster Malaria Movable Kidney (x) Neuralgia, Intercostal Peritonitis Pleurisy Renal Colic *Spleen, Enlarged Splenic Infarct Ulcer of Stomach 115. Unclassified Chest Pain Abscess, Mediastinal Adiposis Dolorosa Aneurysm „ Dissecting Atony of Stomach Bronchitis Cancer of Lung Diaphragm, Neuralgia of *Dyspepsia Emphysema Herpes Zoster even before vesicles appear MoUities Ossium Myalgia Neurofibromata Phthisis, Acute Pneumothorax onset Pulmonary Embolism sudden *Rheumatism *Sprained Pectorals Syphilitic Periostitis Tumour of Mediastinum 113-115 PAIN 53 116. PAIN IN ABDOMEN Pain in the middle line points to the large intestine if in the hypogastric region, the small intestine if in the umbilical, and the stomach if in the epigastric. A gastric ulcer is at the cardiac end if the pain is subxiphoid (Mackenzie). 117. Epigastrium or Pit of Stomach Abdominal Angina Abscess, Subphrenic Acute Yellow Atrophy Addison's Disease Aneurysm, Abdominal Appendicitis Larvata not relieved by vomiting Arsenic - poisoning * Atony of Stomach Cancer of Pancreas „ of Pylorus „ of Stomach Caries of Spine Cholecystitis, Acute Cholera, Asiatic Cirrhosis of Stomach Dilated Right Ventricle *Dilatation of Stomach *Distended Trans. Colon Enteroptosis Gallstones ' Gout of Stomach ' *Gastric Irritation Gastralgia Gastro-Intestinal Adhesions Gastro-cholecystic A d h e - sions Gastritis, Acute Erythema- tous * Gastritis, Chronic Hepatoptosis Hernia, Small Epigastric *Hyperchlorhydria 3 to 4 hours after a meal and continued till the next meal ('Hunger Pain') Intercostal Neuralgia Irritant-poisoning Liver, Abscess of ,, Cancer of ,. Cyanotic Locomotor Ataxy gastric crisis Pancreas, Cancer of Pancreatic Calculus Pancreatitis, Acute Pericarditis (x) Perihepatitis Pleurisy, Diaphragmatic (x) Pneumonia in children *Strain of Recti Muscles from coughing or vomiting Thrombosis, Pulmonary (x) Ulcer of Duodenum 2 hours after food *Ulcer of Stomach circumscribed pain, u 15 minutes after food Yellow Fever 118. Umbilicus Abscess, Peritoneal Cancer of Colon „ Secondary Cyst, Sebaceous 116-118 54 PAIN Umbilicus — contin/n d *Gallstones Gastric Ulcer u above and to right of navel *Hcrnia Omental Cancer Oophoritis to one side of navel Spine, Caries of Recti, Divarication of 119. Hypogastrium and Pelvis Amenorrhcea Bladder, Cancer of ,, Distended ,, Tubercle of ,, Ulcer of Calculus Cancer of Uterus Chyluria * Cystitis *Dysmenorrhcea ♦Endometritis, Chronic „ Gonorrhceal ,, Hemorrhagic „ Septic Fibroid, Uterine Hypertrophy of Uterus Inversion of Uterus Metritis, Acute Mittelschmerz intermenstrual, usually due to Salpingitis Mollities Ossium Neuralgia of Bladder „ of Uterus * Oophoritis Pancreatitis Pelvic Abscess ,, Hematocele Pelvic Peritonitis Perforation of Bowel sharp and sudden Pericystitis Phleboliths, Pelvic *Prolapsus Uteri Pyelitis Retroversion Salpingitis Subinvolution Tubal Colic ,, Fcetation Tumour of Cord 120. Iliac or Ovarian ♦Appendicitis right Caecum Mobile Cancer of Uterus Cervix, Eroded Colitis Diverticulitis left iliac *Dysmenorrhoea Enteric Fever right iliac Floating Rib pressing on crest of ileum *Hernia ♦Loaded Caecum right iliac *Loaded Sigmoid left iliac Neuralgia, Twelfth Dorsal ♦Neurasthenia Oophoritis Prolapsus Uteri Renal Calculus Retroflexion 118-120 PAIN 55 Iliac or Ovarian — continued Salpingitis Sigmoiditis Ureteral Calculus Varicocele 121. Groin, Pain in Often reflex Abscess, Spinal Calculus Cancer of Rectum Corn, Inflamed Haemorrhoids *Hernia, Inguinal „ Obturator „ Umbilical Meckel's Diverticulitis *Ovary, Prolapsed Polypus, Rectal Rider's Sprain Saphenous Varix Talipes Valgus Tibia, Old Fracture of ,, Osteoma of Testicular Cysts *Varicocele 122. Colic Including gastric crises. Abortion Appendicular Colic Cancer of Bowel Colitis Diarrhoea Dysentery Food-poisoning Foreign Body in Bowel Gallstones Henoch's Purpura Hernia, Strangulated Hydronephrosis Influenza Intestinal Concretion Intussusception Lead-poisoning Locomotor Ataxy Neuralgia, Intestinal Ovarian Cyst twisted pedicle Pancreatic Calculus Peritonseal Adhesions Pyloric Stenosis Renal Calculus Rheumatism, Intestinal Scybala Uterine Fibroid Ureteral Calculus 123. Unclassified Abdominal Pain Abscess, Subphrenic Achylia Gastrica Aneurysm, Abdominal Aortic Regurgitation Cancer Caries, Spinal Cholera *Colic Colitis *Diarrhcea *Dyspepsia Ectopic Gestation Embolism of Sup. Mesenteric Enteritis Enteroptosis Enterospasm *Faecal Accumulation Foreign Body *Gallstones *Gastralgia Glands, Inflamed Glandular Fever • 120-123 56 PAIN Unclassified Abdominal Pain — continued Henoch's Purpura gastric crisis *Hernia „ Diaphragmatic Herpes Zoster Hydronephrosis (when large) Hysteria Ileus *Influenza (gastric form) Intestinal Concretion „ Obstruction Intussusception Irritant-poisoning Kidney, Tuberculous *Lead CoHc Leukaemia Locomotor Ataxy gastric crisis Lymphadenoma Meningitis, Spinal Mesenteric Cysts Myalgia Neuralgia, Lumbo - abdo - minal ^Neurasthenia Ovarian Cyst Pancreatic Disease Perforation Periarteritis Nodosa Pericarditis (x) Peritonitis Pernicious Anaemia Pleurisy, Diaphragmatic „ Incipient (x) Pneumonia in children Pneumothorax (x) Polycythemia, Splenome- galic Ptomainism Rheumatic Fever Rheumatism Spinal Tumour Tabes mesenterica Thrombosis, Mesenteric Ulcer of Intestine Hypochondria (see Chest, 113, 114) 124. Perinaeum * Abscess, Ischio-rectal ,, Perinaeal ,, Prostatic Bartholinitis Bladder, Tuberculosis of Cancer of Bladder, Prostate or Rectum Calculus, Vesical or Pros- tatic Condylomata Cystitis Cystocele Epithelioma, Vaginal Extravasation of Urine *Fissure of Anus *Fistula *Hsemorrhoids Locomotor Ataxy rectal crisis Mania Prostate, Adenomatous ,, Tuberculous *Prostatitis Rectum, Ulcer of Seminal Vesiculitis Testicle, Perinaeal Uterine Disease Vaginitis, Acute (see Painful Defalcation, 1082) 123-124 PAIN 57 125. Rectum Abscess, Ischio -rectal „ Prostatic Cancer of Bladder, Prostate Rectum, or Uterus Colitis, Membranous Condylomata Cystitis Dysentery burning Fissure of Anus Fistula Faeces, Impacted Foreign Body Haemorrhoids Locomotor Ataxy rectal crisis Neuralgia, Rectal Perimetritis Salpingitis Ulcer, Rectal Vesiculitis, Seminal 126. Penis Bladder, Cancer of peduncular Bladder, Tuberculous glans Bladder, Ulcer of „ Villous growth of Calculus, Ureteral „ Urethral ,, Vesical in glans Cystitis Fissure of Anus (x) *Gravel Neuralgia Prostate, Abscess of „ Adenomatous „ Cancer of „ Tuberculous Renal Colic (x) Stone in Ureter *Stricture Urethral Granulations Venery, Excessive *** Also too acid urine. (See Painful Micturition. 941) 127. Testicle Abdominal Aneurysm ,, Tumour Calculus, Renal „ Vesical Cancer Caries, Lumbar Colon, Tumour of Cysts Embryoma *Epididymitis Gumma Hernia Hsematocele Hydrocele (x) ,, Encysted *Injury ^Neuralgia Nodules in Epididymis *Orchitis Sarcoma Torsion of Cord Tuberculous Testis *Varicocele Venery, Excessive 125-127 58 PAIN PAIN 128. Shoulder Aneurysm of Innominate Angina Pectoris u left shoulder Aortic Disease right shoulder *Atony of Stomach Cancer of Liver angle of right scapula ♦Cervico-brachial Neuralgia ♦Colitis Dental Caries (x) Diaphragmatic Pleurisy Duodenal Catarrh ,, Ulcer *Fibrositis Hepatic Abscess „ Colic right shoulder Hepatic Congestion Hepatitis, Acute Mediastinal Tumour *Neuritis Pleurisy, Acute (x) Pneumonia (x) Progressive Muscular Atro- phy, I. ♦Rheumatism Serratus Palsy ♦Synovitis (see Joints, 139) Tumour of Suprarenal Cap- sule tip of shoulder-blade 129. Arm Adiposis Dolorosa Amyotrophic Lat. Sclerosis Aneurysm, Subclavian ♦Angina Pectoris uleft Atonic Dyspepsia IN LIMBS Brachial Neuralgia ♦Brachial Neuritis Caries, Cervical Cervical Rib ♦Cervico-brachial Neuralgia ♦Fibrositis Morvans Disease Neurasthenia, Traumatic course of musculo-spiral nerve Neuroma ♦Occupation Neurosis (27) Pachymeningitis, Cervical Paralysis agitans Progressive Muscular Atro- phy ♦Rheumatism Syringomyelia Tumour, Spinal Valvular Disease (x) (See Limbs, 138) 130. Hand Acroparsesthesi a Chondroma ♦Gout Neuritis Neuroma ♦Occupation Neurosis (27) Raynaud's Disease Rheumatism ♦Rheumatoid Arthritis Teno-synovitis ♦Trauma Tubercle 131. Thigh Abdominal Tumour Aneurysm, Abdominal radiating Aneurysm, Femoral or Pop- liteal 128-131 PAIN 59 Thigh — continued Cancer of Rectum Caries, Lumbo-Sacral Colon, Growth on Dysmenorrhea *Fibrositis Hip Disease Hysteria *Impactecl Faeces Infantile Scurvy Locomotor Ataxy Lumbar Abscess Meningitis, Spinal Meralgia Paraesthetica Metritis *Neuralgia, Ant. Crural „ Obturator Neurasthenia *Neuritis Neuroma Ovarian Cyst Pelvic Cellulitis ,, Tumours Perimetritis Periostitis, Femoral Pregnancy Psoas Abscess Renal Calculus Sacral Glands, Enlarged Sarcoma of Femur ,, of Innominate *Sciatica Uterine Displacement Vesical Calculus 132. Howship-Romberg Sign Numbness or pain on the inner side of the thigh. Obturator Hernia ,, Neuralgia 133. Leg Claudication Intermittente Friedreich's Disease Infantile Paralysis onset Lead-poisoning Leukaemia *Neuralgia, Ant. Crural inner side Neuralgia. Ext. Cutaneous Osteomyelitis Periostitis *Phlebitis Phlegmasia Alba Dolens Primary Spastic Paraplegia *Rheumatism Sciatica Spinal Meningitis Tuberculous Bone 134. Foot *Callosities * Corns, etc. Erythromelalgia *Flat Foot *Gout Locomotor Ataxy Metatarsalgia Movable Kidney Nail, Ingrowing Neurasthenia Ovarian Diseases sole Periostitis Plantar Neuralgia Prostatic Disease sole Raynaud's Disease Renal Calculus *Rheumatism Trauma Tuberculous Bone 131-134 60 PAIN 135. Heel Sprain Arthritis, Gonorrhoeal Syphilis Calcanodynia Trichinosis *Gout Tuberculous Meningitis, I. Lithaemia Weil's Disease Neurasthenia calves Muscular pain is also com- 136. Heel-jar mon after unaccustomed exertion, and when owing The patient, standing on tip- to some disablement, mus- toe, experiences a spinal cular movements have pain on bringing the heels ceased to be automatic. suddenly to the ground. (See General Pain 87) Spinal Caries *** A similar pain, but felt 138. Limbs, Pain in (Unclassi- in one loin, is produced fied) One or both. by renal calculus, and in one hip, by hip disease. Abdominal Tumours 137. Muscles (Myalgia) Adhesions, Peritonaeal ♦Alcoholism Ague (praem.) Anaemia Appendicitis Biliary Congestion Beri-beri Cerebro-spinal Meningitis Caisson Disease Cholera Cancer of Rectum Coryza simulating sciatica Duodenal Catarrh Cancer of Bone Enteric Fever Cauda Equina, Tumour of *Fibrositis Compression of Cord ♦Illness, Acute Dengue onset and convalescence Diabetes ♦Influenza sometimes ' lightning ' ♦Invasion Stage of Exan- Erythromelalgia themata and Visceral of the swellings Inflammations Exostosis Locomotor Ataxy Fevers Milroy's Disease invasion stage crisis General Paralysis, I. ♦Muscular Rheumatism Glanders ♦Occupation Neurosis (27) Haemophilia Psittacosis Hysteria Relapsing Fever Impacted Embolism Rheumatic Fever, I. *Iniluenza *Scurvy Kidney, Floating Septicaemia 135-138 PAIN 61 Limbs, Pain in — continued Kink, Ileal Lead-poisoning (x) Lipomatosis Neurotica in the fatty patches Locomotor Ataxy ' lightning ' or rheumatoid Mollities Ossium *Multiple Neuritis Muscle, Rupture of e.g. plantar is Myalgia (137) Myelitis Myelosarcoma Myositis Neurasthenia *Occupation Neurosis Oophoritis Osteitis Paralysis Agitans Periarteritis Nodosa Periostitis Phthisis, Advanced Plague Progressive Muscular Atrophy Remittent Fever *Rheumatism *Rickets Softening, Chronic Spinal Apoplexy ,, Meningitis Strains Syphilis Tetanus Thrombosis Tonsillitis, Follicular Trichinosis Tuberculous Bone *Urticaria Uterus, Cancer of (x) Wasting^Diseases (311) 139. Joints Arthritis, Gonorrhceal ,, Pneumococcal „ Post-febrile ,, Rheumatoid Caisson Disease Cartilage, Displaced Chorea (x) Compression of Cord Coxa Vara sometimes begins in knee *Fibrositis Glanders *Gout ' Growth Fever ' epiphyses Gums, Septic *Hip Disease knee first Hydrarthrosis, Intermittent ' Hysterical Joint ' Infantile Paralysis onset *Injuries Lead-poisoning Locomotor Ataxy Loose Cartilage Malta Fever Myelitis, Acute Myelosarcoma Neuralgia Obturator Hernia knee Peliosis Rheumatica Phthisis, Advanced Pyaemia Recklinghausen's Disease *Rheumatism, Acute *Rheumatism, Chronic Rickets 138-139 62 PAIN Join ts — continued Scurvy *Synovitis Syphilis Syringomyelia Tuberculous Joint 140. CHARACTER OF PAIN The personal equation must be allowed for. sensitive to the sesthosiometer than are women. Men are more 141. Sharp Acute Inflammation of Ser- ous or Synovial Mem- branes in general Angina Pectoris Appendicitis Dissecting Aneurysm Ectopic Gestation Fractures Gout Neuritis Pleurisy, Acute Pneumothorax onset Spinal Meningeal Haemor- rhage 142. Dull Chronic Inflammation of Serous Membranes Inflammation of Mucous Membranes and of Visceral Parenchyma 143. Paroxysmal Aneurysm Angina, Abdominal ,, (Esophageal *Angina Pectoris Appendicitis * Appendicular Colic temperature normal Calculus of Pancreas Cancer of Pancreas Cancer of (Esophagus Cerebral Tumours *Clot in Ureter Colitis *Colic (122) relieved by pressure Diabetes (x) Disseminated Sclerosis *Distended Bladder Dysentery Dysmenorrhcea Erythromelalgia *Floating Kidney Dietl's crisis *Gallstone Colic Heart, Syphilitic Henoch's Purpura abdominal crisis Hepatic Aneurysm Hernia Hydatids of Kidney daughter cysts in ureter or gall -duct Intussusception *Lead Colic Locomotor Ataxy gastric, nephralgic, or other crisis Lumbrici Mercurialism Neuralgia Ovarian Cyst twisted pedicle 139-143 PAIX 63 Paroxysmal — continued Parturition Pulpitis, Dental Pyloric Ulcer ♦Renal Calculus Scybala or Concretions Spinal Meningitis Sporadic Cholera *Tic-douloureux Tubal Colic Tuberculous Synovitis Ureteral Calculus ♦Urethral „ Vesical „ Uterine Cancer „ Fibroids Polypus 144. Radiating Abdominal Aneurysm back, false ribs, groin, and testes Acute Aortitis arm Aneurysm of Asc. Aorta back, shoulders, and arms Aneurysm of Innominate right shoulder Angina, Abdominal Angina Pectoris left arm and shoulder and up neck to forehead Aortic Regurgitation arm and back Atony of Stomach shoulder Caries of Spine sternum, epigastrium, or abdomen Cerebellar Tumours nucha and between scapulae Cervical Rib shoulder, elbow, fingers Compression of Cord Gastritis, Acute Erythema- tous shoulder and left arm Hepatic Colic around umbilicus Hip Disease knee Liver Affections shoulder Xeuralgia nerve-terminations Oophoritis back and limbs Otitis Media. Acute occiput, vertex, and temple Pachymeningitis, External Spinal Pancreatic Calculus Pelvic Abscess thighs Pulmonary Abscess to larynx (on percussion of chest) Rectum, Cancer of limbs Renal Calculus thigh and testicle ; some- times referred to opposite kidney Spinal Tumour nerve- endings Spinal Meningeal Haemor- rhage nerve-endings Spinal Meningitis, Internal 143-144 04 PAIN Radiating — continued Spleen Affections left shoulder Uterine Fibroids genitals and legs Vesical Calculus meatus urinarius and testicle 145. Shifting Pain *Flatulence Gout Hysteria Locomotor Ataxy Neuralgia Rheumatism Spinal Tumour Tapeworm Trichinosis 146. Gnawing or Boring Pain * Abdominal Aneurysm in back Cancer of Stomach *Caries of Spine descending Thoracic Aneu- rysm Gout Lithsemia Mediastinal Growth Periostitis Spinal Meningitis 147. Increased by Food Arsenic -poisoning Cancer of Stomach „ of Duodenum „ of (Esophagus Gastritis Renal Calculus largo stono on left side Ulcer of Duodenum 2 hours after food Ulcer of Stomach £ hour after food 148. Relieved by Food ' Hunger Pain ' Appendicitis Cholecystitis, Chronic Gastralgia Hyperchlorhydria Ulcer, Duodenal 149. Relieved by Pressure If firm, flat, and gradual. Colic, Abdominal (122) Lumbago Pleurodynia Pleurisy Muscle, Ruptured Rib, Fractured 150. Increased by Movement Adhesions where one organ is fixed. Abscess, Local ,, Pelvic Acute Inflammatory Dis- eases Appendicitis Larvata brought on by exercise Arthritis *Caries of Spine Cartilage, Displaced Coxa vara Faecal Accumulation on running fast 144-150 PAIN Increased by Movement — continued Fibrositis Fractures Glandular Fever Gout Hernia, Obturator by hip movement *Lumbago Myositis Neuritis Oophoritis Ovarian Pedicle, Twisted Pachymeningitis, External Spinal Pelvic Cellulitis Perinephritis Peritonitis Pleurisy, Acute Pleurodynia Pneumonia, Acute *Renal Calculus esp. on stamping Rheumatism, Acute ,, Muscular Rheumatoid Arthritis *Ruptured Muscle contraction of opponent Salpingitis Sciatica Spinal Column, Sprain of on rotation Spinal Meningitis Spondylitis, Traumatic *Sprains ^Synovitis Tuberculous Joint Tumour, Cranial ,, Intracranial Tumour, Spinal Vesical Calculus Weil's Disease 151. Increased by Breathing or Coughing Caries of Sternum Cholecystitis Diaphragmatic Hernia „ Pleurisy Fractured Ribs *Intercostal Rheumatism Perforation of Stomach Perihepatitis Perinephritis Peritonitis *Pleurisy Pneumothorax Subphrenic Abscess Trichinosis 152. Increased at Night Most pain is so, but especially that from — Arthritis, Gonorrhoeal Carcinoma Erythromelalgia Locomotor Ataxy Neuritis Otitis Media Osteitis Periostitis Renal Calculus Rheumatism Syphilis Tuberculous Joint Ulcer of Stomach when adherent 150-152 66 PAIN 153. Referred Pain A pain which, though re f erred to the skin, origin- ates in a neighbouring viscus. It bears no rela- tion to nerve distribution. (See 325.) Angina Pectoris arm Dysmenorrhea thigh Heart Disease arm Liver Affections shoulder Ovarian Disease mamma Renal Colic testicle 153 TENDERNESS 67 154. TENDERNESS This is often untruthfully affirmed, especially when a claim for compensation is made. The patient should not be asked if pressure give pain ; but in the midst of conversation, the part should be pressed, at first very gently and afterwards with the force gradually increased, and if genuine, the pulse rate will go up (Mannkopf's sign). The countenance, too, should be watched all the time, and it will probably speak more truthfully than the tongue. Cutaneous hyperesthesia may be distinguished from tenderness by the pain being still complained of when the skin is lightly pinched without any pressure on subjacent parts. The pain of all inflammatory affections is accompanied by more or less tenderness. 155. Scalp Cerebral Tumour over site *Clavus Hystericus Erysipelas Gumma Herpes Hydrocephalus Lupus Erythematosus Mastoid Abscess Meningitis Migraine Neuralgia, Cervico-occipital *Neurasthenia Otitis Media Recklinghausen's D sease Rheumatism Rickets Sclerodermia *Seborrhsea, Acute Syphilis, Congenital Syphilitic Periostitis Thrombosis of Lateral Sinus behind ear Trauma Trigeminal Neuralgia 156. Spine The spinous processes should be percussed. Abscess, Lumbar „ Mediastinal „ Perinephric ,, Post Pharyngeal „ Subphrenic Aneurysm, Abdominal ,, of Desc. Aorta Arthritis, Rheumatoid Cancer of Spine Caries of Spine „ Sicca Compression of Cord *Gastritis 4th to 7th dorsal Glands, Enlarged Bronchial 4th and 5th dorsal Heart Disease upper dorsal Hepatic Colic 6tb to 9th dorsal *Hysteria 2 154-156 68 TENDERNESS Spike — continued Liver Diseases lower dorsal Mediastinal Tumour Meningitis, Cerebro-spinal „ Spinal Myelitis, Chronic not increased by movement ♦Neurasthenia Neurasthenia, Traumatic esp. 1st, 6th, 7th, 12th dor- sal, 1st sacral and coccyx Rickets Spinal Apoplexy „ Periostitis Spondylitis, Traumatic on stooping or rotation Sppndylose Rhizomelique Tumours of Spine Typhoid Spine Ulcer of Duodenum right of 12th dorsal Ulcer of Stomach to left of 12th dorsal and on percussion of 4th, 5th, 6th, 7th, dorsal spines,when on lesser curvature; of 10th, 11th, 12 th dorsal, when on greater curvature ; and of 8th, 9th, 10thdorsal,when the ulcer is on the side of the organ 157. Lumbar Tenderness Appendicitis right side *Lumbar Abscess Nephritis, Acute „ Suppurative Perinephric Abscess ♦Perinephritis Renal Calculus ,, Cancer ,, Infarct 158. Chest Abscess, Hepatic Aneurysmal Prominence *Angina Pectoris Bronchitis, Acute, I. Caries of Sternum Diaphragmatic Neuralgia zonal Empyema necessitatis Heart Strain Herpes Zoster Hysteria ♦Intercostal Neuralgia „ Rheumatism Mediastinal Disease Myocarditis Pericarditis Periostitis, Costal ,, Sternal Phthisis on percussion Pleurisy, Acute interspaces Pleurisy, Diaphragmatic 159. Mamma or Breast Abscess Hysteria Mastitis Menstruation Oophoritis Pregnancy Also in cancer, cysts, and tumours when inflamed. 156-159 TENDERNESS 69 160. Right Hypochondrium Including Liver Tenderness. Abscess of Liver Actinomycosis Acute Yellow Atrophy Asthma Cancer of Liver Cirrhosis of Liver, Hyper- trophic ♦Cyanotic Liver Empyema of Gall-bladder Fatty Degeneration of Liver ♦Gallstones Hepatitis, Acute Hydatids, Inflamed Influenza Jaundice, Obstructive (392) Malaria Myocarditis Perihepatitis Relapsing Fever Sarcoma of Liver Syphilitic Liver Weil's Disease 161. Left Hypochondrium Including tender spleen. Anaemia, Splenic (x) Enteric Fever ♦Impacted Faeces splenic flexure Influenza Leukaemia, Spleno-medul- lary Malaria Perisplenitis Relapsing Fever Spleen, Abscess of „ Cancer of „ Infarct of 162. ABDOMINAL TENDERNESS Firm and steady pressure relieves reflex abdominal tenderness, but aggravates tenderness due to inflammation. 163. Epigastrium Acute Yellow Atrophy Addison's Disease Appendicitis Larvata Arsenic-poisoning Cancer of Stomach moderate Cirrhosis of Stomach slight Dilated Right Ventricle Gallstones Gastritis, Acute Erythema- tous ♦Gastritis, Chronic Hypochondriasis Hysteria Irritant-poisoning Liver Tenderness (160) Pancreas, Inflammation of Pericarditis, Acute ♦Peritonitis Pleurisy, Diaphragmatic ♦Ulcer of Stomach acute ; small circumscribed area. Similar area in back 4s* Epigastric tenderness often follows severe coughing or vomiting. 160-163 70 TENDERNESS 164. Iliac Abscess of Abdominal Wall Alcoholism Appendicitis right side Caecum Mobile Calculus, Renal „ Ureteral Cancer of Caecum „ of Uterus Cervix, Eroded ♦Dysmenorrhcea Enteric Fever right side — gurgling Faecal Accumulation Hysteria Neuralgia of 12 Dorsal N. ♦Oophoritis Pelvic Cellulitis ,, Peritonitis Pneumoperitoneum Prolapsus Uteri Psoas Abscess Retroflexion Sacro-iliac Disease Salpingitis Sigmoiditis Tubal Gestation rupture Tubercle of Caecum Uterine Congestion 165. Erichsen's Sign Compression inwards of the two iliac bones causes pain in Sacro-iliac Disease but not in hip disease 166. Hypogastrium Bladder, Ulcer of Calculus, Vesical ♦Cystitis Dysmenorrhcea ♦Metritis, Acute Pelvic Peritonitis Pericystitis ♦Perimetritis 167. Perinaeum, Tender ♦Abscess, Ischio -rectal „ Prostatic „ Urethral Haemorrhoids, Inflamed Proctitis Prostate, Cancer of ♦Prostatitis 168. Unclassified Abdominal Tenderness Cancer of Intestine Colitis Diaphragmatic Pleurisy Dysentery Dysmenorrhcea Fibrositis of Abdominal Muscles only when contracted ♦Gallstones 1 in. to right of and above umbilicus Irritant-poisoning ♦Peritonitis, Acute ♦Sequela of Colic Strangulated Hernia unless gangrenous Ulceration of Intestine 164-168 TENDERNESS 71 169. Limbs, Tenderness of Bone, Cancer of Epiphysitis, Syphilitic ♦Erythema Nodosum Erythromelalgia Gout ' Growth Fever ' Hip Disease pain in knee on tapping trochanter ♦Infantile Scurvy lower end of thighs Leukaemia Myostitis ♦Neuritis ♦Neuritis, Multiple Osteitis Periostitis ♦Phlebitis a long hard vein Phlegmasia Alba Dolens usually left leg Polymyositis ♦Rickets, I. Schlatter's Disease tibial tuberosity Scurvy Spinal Meningitis, Int. Tetanus Trichinosis 170. Feet, Tender Callosities Chilblains Corns Gout Metatarsalgia Talipes Valgus Toenail, Ingrowing 171. Joints, Tender ♦Gout Hysterical Joint Loose Cartilage Malta Fever 50 per cent. Myelosarcoma Pyaemia ♦Rheumatism, Acute ♦Rheumatoid Arthritis Spondylose, Rhizomelique shoulders, hip, and spine ♦Sprain ♦Synovitis Tuberculous Arthritis 172. TENDER SPOTS 173. Clavus Hystericus Near parietal prominence. Hysteria 174. Signorelli's Sign Between the jaw and the mastoid process and below the ear. Meningitis Said to be earlier Kernig's Sign. than 175. Francke's Sign Deep tenderness over apex of lung behind. Early Phthisis 81% of cases 176. Ninth Right tilage Cholecystitis Enteric Fever early Costal Car- 169-176 72 TENDER SPOTS Ninth Right Costal Carti- lage — continued Gall-bladder, Calculus in ,, Cancer of ,, Empyema of 177. Babe's Sign Tenderness over splenic artery, accompanied by muscular rigidity. Aneurysm of Abdominal Aorta 178. Mendel's Sign A tender area, the size of a florin, elicited by light percussion in the epigas- trium. Duodenal Ulcer Gastric Ulcer 179. Mussy's Point A tender spot where the left sternal line extended downwards intersects a horizontal line on the level of the tenth ribs. (S 10, in chart.) Diaphragmatic Pleurisy 180. McBurney's Point Midway between umbilicus and anterior superior spine of right ilium. Munro's Point, instead of being midway, is at the outer edge of the rectus. It is said to be more exactly over the ileocecal valve. *Appendicitis Lead-poisoning (x) Ureteral Calculus 181. Bastedo's Test Pain at McBurney's Point produced by inflation of the colon. Appendicitis The test is not always safe in acute cases. 182. Blumberg's Sign Pressure over the descending colon produces pain in the right iliac fossa. Appendicitis 183. Bittorf's Sign On squeezing the testicle or pressing on the ovary during an attack of colic the pain radiates to the kidney in Renal Calculus 184. Douleur Signal (Leven) Abdominal pain ceases when the stomach is forced upwards by deep pressure in the hypogastric region. Dilatation of Stomach Thus differentiating it from Appendicitis. 185. Kink Sign Tenderness on a line drawn between the umbilicus and the middle of Pou- part's ligament. Ileal Kink 185. Boas' Point to left of 12th vertebra Gastric Ulcer dorsal 176-186 TENDERNESS 73 187. POINTS DOULOUREUX Often absent in first attacks. Trigeminal Neuralgia 1st division. — Supra-orbital notch, above parietal eminence, and junction of nasal bone with nasal cartilage 2nd division. — Infra-orbital foramen, malar bone, gum of upper jaw 3rd division. — Temple, in front of ear, mental fora- men and side of tongue Cervico- occipital Neuralgia midway between the mas- toid process and the 1st cervical vertebra Cervico-brachial Neuralgia axilla, upper part of deltoid, bend of elbow and behind inner condyle Intercostal Neuralgia spinous process, side of chest or abdomen, and a point just short of the mesial line Twelfth Dorsal Neuralgia Edge of quadratus lum- borum, ant. sup. spine, and near symphysis pubis. Lumbo - abdominal Neu- ralgia spinous process, midcrest of ilium, hypogastrium, groin, and scrotum Sciatica posterior iliac spine, sciatic notch, and behind knee, head of fibula, and ex- ternal malleolus 187 74 ALGESIC 188. ALGESIC Analgesia duo to a cord lesion is both deop and superficial ; but in that produced by a peripheral nerve lesion, the superficial analgesia may be combined with deep hyperalgesia. 189. Analgesia (Insensibility to pain) It is usually tested with pin-pricks. Arsenic -poisoning Brown-Sequard's Paralysis Catalepsy, Severe Diphtheritic Paralysis General Paralysis of Insane, ii. Hsematomyelia Hemiplegia *Hysteria often hemianalgesia *Hystero -epilepsy Insanity sometimes cubital *Locomotor Ataxy A zone on the trunk from the 2nd rib to the umbili- cus — early ; also an area on some part of the face — ' masque tabetique ' or Hutchinson's Mask. Morvan's Disease Myelitis Neuritis, Multiple Pseudo-tabes Syphilis Syringomyelia Transverse Softening of Cord Lesions of medulla and optic thalamus. 190. Analgesia, Deep This is tested by pinching muscles or tendons or by pressure upon sub- cutaneous bone such as the shin. Locomotor Ataxy Pseudo-tabes Syringomyelia 191. Hyperalgesia The pain of a pin- prick is out of all proportion to the injury. Inflamma- tory tenderness may be distinguished by the presence of local heat. Multiple Neuritis Optic Thalamus, Lesion of *** It is present in the repair stage of divided nerve, before the return of epicritic sensibility. 192. Muscular Hyperalgesia Intense pain is experienced when a muscle is grasped. Neuritis 193. Remak's Sign A pin- prick gives a double sensation, the second being the more painful. Locomotor Ataxy 194. Haphalgesia Intense pain is produced by even a light touch. Hysteria 188-194 ALGESIC 75 195. Illusional Pain (Akinesia Algera) Hysteria Neurasthenia 196. Anaesthesia Dolorosa Pain in a part that is both anaesthetic and analgesic. Compression of Cord 197. Simultaneous Polyalgesia A single pin -prick feels as if several had been made. Spinal Cord Affections 195-197 76 SENSATION 198. SENSATION 199. Sensation Tests. — To test with precision the degree of sensation present, Weber's aesthesiometer is employed. The standard is the distance at which two points are felt separ- ately and a rough substitute is a pair of compasses. Normally, the distance for various regions is as follows : Tip of Tongue, 1 mm. ; Underlip, 4 mm. ; Back of Hand, 25 mm. ; Back of Neck, 50 mm. ; Mid-dorsal Region, Mid-forearm and Mid- thigh, all 62 mm. The palms and parts covered with hair are not available. In ordinary practice, however, the skin is lightly brushed with a little jeweller's wool. One side should be compared with the other and results checked by asking the patient to put his finger on the spot just touched. 200. Janet's Test is useful to distinguish organic from functional anaesthesia. The patient is told to say ' yes ' or ' no ' according to whether he feels or not. Then, the eyes being closed, the skin is lightly touched at various points. If functional, the answer will be ' no ' when an anaesthetic area is touched ; if organic, no answer will be given, for he will not be conscious that he has been touched at all. As the result of pressure and of vascular disease, the sense of pain is lost first, then the temperature sense, and lastly the sense of touch. In lesions affecting the centre of the cord, such as syringomyelia, the order is pain, heat, and cold, concurrently with diminution of tactile sensibility. (See 85.) 201. Hyperaesthesia This can usually be dis- tinguished . from tender- ness by the skin or muscle being unduly sensitive after it has been raised from the subjacent tissues, and it may be elicited by the lightest brush with the finger. Acute Bronchitis sternal Alcoholism Appendicitis right iliac region Arsenic -poisoning Brown-Sequard's Paralysis paralysed side Caries, Spinal above ana-sthctic area *Clavus Hystericus Compression of Cord, i. Cord, Degeneration of Encephalitis Herpes Zoster Hyperaemia of Brain *Hysteria esp. mammary and ovarian 198-201 SENSATION 77 Hyperesthesia — continued Injuries of Nerves especially gunshot wounds Locomotor Ataxy- Mania, Acute Meningitis, Cerebro-spinal „ Int. Spinal ,, Simple „ Tuberculous Spinal Myelitis, Acute *Neuralgia esp. trigeminal — sometimes unilateral *Neurasthenia *Neuritis, I. *Ovarian Disease Pachymeningitis, External Spinal, i. Peritonitis Pernicious Anaemia Pregnancy Rickets Spinal Concussion Spinal Meningeal Haemor- rhage Tumours of Brain 202. Anaesthesia The upper limit of anaes- thesia in the trunk serves as a guide to the localisa- tion of the lesion in the spinal segment. The an- aesthetic area, especially in hysteria, sometimes coincides with the tract covered by a given gar- ment; thus, glove-, shoe-, and stocking-anaesthesia are recognised. Aneurysm of Desc. Aorta 3rd and 4th interspaces Anterior Crural Paralysis thigh and inner sido of leg and foot Apoplexy paralysed side, unless pons or medulla be the seat Apoplexy, Spinal lower extremities Brown-Sequard's Paralysis Caisson Disease Catalepsy (if severe) Cerebral Hyperaemia „ Tumours esp. of pons . Cerebro-spinal Meningitis, in. Chorea Compression of Cord, n. when gradual Concussion of Spine Dementia Praecox, i. Diphtheritic Paralysis Disseminated Sclerosis Embolism Fracture of Sup. Maxilla Friedreich's Disease legs General Paralysis of Insane Haematomyelia Haemorrhage into Spinal Arachnoid Herpes Zoster between vesicles Hypertrophy of Brain *Hysteria esp. plantar and palatine Klumpke's Paralysis inner side of arm Lead-poisoning Lepra anaesthetica 201-202 78 SENSATION A:n jESthesia — continued Locomotor Ataxy chest, glans penis, and soles. Also tendo Achillis (Abadie's Sign) and the popliteal space (Bech- terew's Sign) Meningitis, Simple „ Spinal, in. Morvan's Disease Myelitis, Acute, n. „ Chronic Neuritis most marked at periphery Neuroma Pressure on Nerve -trunk Raynaud's Disease Sciatica Softening, Chronic (x) Spinal Pachymeningitis, Ext, ii. Syringomyelia arms and chest Tetany Thrombosis Transverse Softening of Cord lower extremities Tumours of Cord Typhic State (62) Unilateral Lesion of Cord if dorsal region, one leg (See Numbness, 215) 03. Dissociated Anaesthesia Retention of tactile sensi- bility combined with loss of heat sense and of pain sense. Brown-Sequard's Paralysis Hsematornyelia Hysteria Multiple Neuritis Syringomyelia Thrombosis of posterior inferior cere- bellar artery 204. Hemianaesthesia (Sensa- tion absent on one side) Due, when organic, to a lesion involving the pos- terior third of the in- ternal capsule ; but it is often functional. Apoplexy (x) Brown-Sequard's Paralysis Cerebellar Disease s. of opposite side Disseminated Sclerosis *Hemichorea Hereditary-cerebellar Ataxy ♦Hysteria left side \ ♦Occupation Neurosis (27) ♦Paralysis of 5th Nerve Thrombosis or Rupture of Posterior Cerebral Artery Tumour of Brain Unilateral Atrophy of Brain 205. Allocheiria (Bamberger's Sign) A touch on one side is felt on the opposite side (rare). It is due to a unilateral destructive lesion of the cord. Allied to this is the pain, or even tenderness, some- times felt on the side opposite to the lesion ; e.g. in the left hypo- chondrium in hepatic colic . 202-205 SENSATION 79 Allocheiria — continued Callus, Pressure of Disseminated Sclerosis Endarteritis, Syphilitic ♦Hysteria Locomotor Ataxy Myelitis, Partial Subluxation, Spinal Thrombosis, Spinal Trauma 206. Retarded Sensation The pain or sensation is felt many seconds after the stimulus (rare). Locomotor Ataxy Multiple Neuritis 207. Astereognosis The patient, blindfolded, is unable to recognise solid bodies by touch Cerebral Haemorrhage „ Tumour or other coarse lesion 208. Muscular Sense Kinesthesia can be tested by making the patient distinguish between two dark bottles of the same shape and size — one empty, the other full. In the case of the legs, the bottles can be ban- daged one to each foot. A normal person recognises an increase of one-third the weight (Weber's Law). The lesion is in the deeper layers of the cortex. The sense is impaired or lost in — Brown Sequard's Paralysis Cerebral Haemorrhage ,, Thrombosis „ Tumour Hysteria Locomotor Ataxy Neuritis Syringomyelia Transverse Myelitis For Joint Sense, which is sometimes included under muscular anaesthesia, see 209. 209. Posture Sense (including Joint Sense) Passive movements of a limb having been made with the patient's eyes shut, he is asked to imi- tate the movements and posture with the sound limb. The sense is un- impaired in cerebellar lesions, but may be aSected in — Cortical Lesions Hysteria Locomotor Ataxy Neurasthenia (x) 210. Atopognosis The blindfolded patient, when pointing to the spot just touched, makes an error of several inches — and always too high. Cortical Lesion 205-210 80 SENSATION 211. Thermesthesia (Tempe- 214. Vibration Sense (Pallses- rature Sense) This may be determined with the aid of two spoons, one hot, the other cold, applying them to various areas and making the pa- tient distinguish between them. The tip of the tongue is not nearly so sensitive to heat as is the check or forearm. (See 85) 212. Lost or Diminished Brown Sequard's Paralysis opposite side Bulbar Paralysis *General Paralysis Hcematomyelia Lepra Ansesthetica *Locomotor Ataxy Syringomyelia Transverse Softening of Cord 213. Increased Cerebro-spinal Meningitis Degeneration of Cerebral Ganglia Neuritis Heat applied to an inflamed part increases the pain when pus is present, but diminishes it when absent. thesia) A largo C l tuning fork should be placed vibrating on the nails, the heads of the metacarpal or meta- tarsal bones, or on the shin. When there is loss of other forms of sensation, the vibration sense is also usually lost, but its loss may precede cutaneous anaesthesia. Lost Brown-Sequard's Paralysis opposite side Compression Myelitis Diabetes Disseminated Sclerosis Growth, Spinal Hemiansesthesia, Hysterical opposite side Locomotor Ataxy Peripheral Neuritis Spinal Syphilis Transverse Division of Cord The cord lesion must be in a part from which the bone tested derives its nerve supply. PARESTHESIA, ETC. 215. Numbness Aconite -poisoning Acroparaesthesi a fingers, toes, lips, and tongue Aneurysm Appendicitis right leg — early Apoplexy (prsem.) ,, Spinal Arteritis Aura epileptica Beri-beri Bromism Cervical Rib hand Circulation, Defective 211-215 SENSATION 81 Numbness — continued Disseminated Sclerosis often unilateral- Emboli Erb's Spinal Paralysis Hyperemia, Spinal Hysteria *Hysterical (Edema Leprosy *Locomotor Ataxy Meralgia Paresthetica outer side of thigh Myelitis, Acute Myxcedema Neuralgia (prsem.) Neurasthenia Neuritis Neuroma (x) ^Pressure upon a Nerve - trunk Recklinghausen's Disease Sciatica Sigmoid, Loaded Spinal Tumour Softening, Chronic Syringomyelia Tetany Thrombosis (See Anaesthesia 202) 216. Biernacki's Sign The well-known ' funny- bone ' sensation is absent. Dementia General Paralysis Idiocy Locomotor Ataxy 217. Magnan's Sign A subjective feeling as of sand or worms under the skin. Cocaine Habit 218. Itching, Formication, or Tingling These are, for convenience' sake, all put under one heading. Anaemia of Brain Aneurysm Apoplexy (praam.) Arsenic-poisoning Arteritis Arthritism Aura epileptica Cervical Rib hand Cheiropompholyx Chilblain Chloasma Copaibism Dermatitis „ Herpetiformis ^Desquamation *Diabetes Mellitus pubes Disseminated Sclerosis Drug Rashes Dysidrosis *Eczema Embolism Encephalitis Erb's Spinal Paralysis Ergotism Erythema Fsecal Accumulation Gout Haemorrhoids Hydroa Hyperemia of Brain Hypertrophy of Heart Hypochondriasis Hysteria Irregular Circulation Irritating Clothing 215-218 82 SENSATION Itching, Formication, or Tingling — continued Jaundice Lichen Leucorrhoea Locomotor Ataxy Lymphadenoma Meningeal Haemorrhage, Spinal ♦Menopause pruritus vulvae Meralgia Paraesthetica thigh Mycosis Fungoides Myelitis Nephritis Neurasthenia, Traumatic Neuritis, I. *Pediculi, etc. Pemphigus (x) Pityriasis rubra Pressure on a Nerve Prickly Heat ♦Prurigo usually due to lice *Pruritus, Bathing „ Senilis Psoriasis, I. Pyodermatitis Vegetans ♦Scabies Sciatica Scleroderma Seborrhcea Spinal Apoplexy „ Hyper aemia „ Meningitis Syphilitic Spinal Paralysis Syringomyelia T3tany Thrombosis Tumours of Brain Tumours of Spinal Cord ♦Urticaria Uterine Disease Variola *Worms mucous orifices Also stings of insects, jelly fish or plants. 219. Palpitation The patient is conscious of his heart beats. Amenorrhcea *Anaemia Aneurysm, Thoracic Angina Pectoris Arterio- sclerosis Ascites Chlorosis Cirrhosis of Kidney Dyspepsia, Flatulent Epilepsy Exophthalmic Goitre Fatty Heart Fibroid Heart ♦Hysteria Locomotor Ataxy Malformations of Heart Mediastinal Growth Menopause ♦Neurasthenia Ovarian Cyst, Large Paroxysmal Tachycardia Pericarditis Pericardium, Adherent Pernicious Anaemia Pregnancy Pseudo-Angina Spermatorrhoea Tumours, Abdominal Tympanites 218-219 SENSATION 83 Palpitation — continued Valvular Diseases Ventricle, Dilated Right Palpitation may also bo caused by cocaine, digita- lis, thyroidin or morphia, as well as by excessive use of tea, coffee, tobacco, alcohol or absinthe. 220. Heartburn (Cardialgia) Due to lactic or butyric acid. Cancer of Stomach ♦Dilatation of Stomach Gastralgia Gastritis ♦Indigestion esp. of fatty food ♦Pregnancy Ulcer of Stomach ,, of Duodenum 221. ' Precordial Anxiety ' or Sinking Feeling Aneurysm ♦Angina Pectoris Aortitis Arsenic-poisoning Asthenia in general Atony of Stomach Beer-Heart Cholera ♦Dilatation of Heart Displacement of Heart Fatty Heart Fibroid Heart ♦Flatulence Lithsemia Melancholia Myocarditis, Acute ♦Neurasthenia Pericarditis Syphilitic Heart Valvular Disease 222. Girdle Sensation A feeling like that produced by a tight girdle. It marks the upper limit of a cord lesion. Ataxic Paraplegia (x) ♦Crushing Lesion of Cord Disseminated Sclerosis Erb's Spinal Paralysis Locomotor Ataxy (x) ♦Myelitis, Transverse Paraplegia, Spastic Spinal Meningitis, Syph. Traumatic Spondylitis Tumours of Cord A sprained diaphragm from vomiting, etc., produces a similar sensation, as also does double intercostal rheumatism. 223. Sensation of Local Heat Erythromelalgia feet Exophthalmic Goitre *Influenza Irritant-poisoning epigastrium and throat Locomotor Ataxy ♦Menopause Neurasthenia vertex Paralysis Agitans epigastrium and back Rectum, Cancer of (See Heartburn, 220) 2 219-223 84 SENSATION Cold, Sensation of (Sec Chills, 239) 224. Sweating, Sensation of The skin being dry. Haematonryelia Syringomyelia 225. Throbbing, Sensation of This may be due to actual increase of pulsation, to extra - sensitiveness to normal pulsation or to clonic muscular spasm (myokymia). *Abscess *Ana3mia *Aneurysm *Aortic Regurgitation ' Beat Knee ' Exophthalmic Goitre Headache, Congestive Heart, Hypertrophy of Hysteria Inflammation, Local Migraine Neurasthenia *Palpitating Aorta Palpitation (See Abnormal Pulsation, 284) 226. Sensation of Fulness Atony of Stomach *Dilatation of Stomach Emphysema Fatty Degeneration of Heart Gastric Irritation *Gastritis, Chronc Goitre, Exophthalmic Hepatic Enlargements Hypertrophy of Heart *Hystcria in throat — Globus Hystericus Malaria *Menopause in throat — Globus Hystericus Peritonitis, Chronic Remittent Fever *Tympanites 227. Sensation of Weight Angina Pectoris Asthma Apoplexy (prsem.) Aura epileptica Cirrhosis of Liver, Hyper- trophic Dilatation of Heart Displacement of Heart Dyspepsia Endocarditis, Acute Exophthalmic Goitre *Fsecal Accumulation Flatulence Gastric Irritation Gastritis, Chronic Hajmatemesis (prsern.) epigastrium Haemoptysis (proem.) sternum Lithaemia epigastrium Neurasthenia limbs Neuritis, Multiple, I. limbs Paralysis, Flaccid Stomach, Atony of ,, Dilatation of Syphilitic Liver Trichinosis 224-227 SENSATION 85 228. Sensation of Bearing Down *Abortion (threatened) Cervicitis Cervix, Hypertrophied Distension of Bladder Dysnienorrhoea Endometritis, Hypertrophic *Enteroptosis *Faecal Accumulation Haemorrhoids *Labour Metritis Ovarian Cyst *Prolapsus Uteri Periproctitis Prostatitis Rectum, Cancer of „ Ulcer of Retained Menses or Decidua Retroversion Subinvolution Tumours, Pelvic esp. if impacted Uterine Fibroid or Polypus Uterus, Congestion of ,, Inversion of (See Tenesmus, 1081) 229. Sensation of Oppression *Aneurysm, Thoracic *Angina Pectoris Aortitis *Asthma, Spasmodic ' Beer Heart ' *Dyspepsia Emphysema Exophthalmic Goitre Hysteria *Mediastinal Tumour *Pericardial Effusion (See Weight, 227) 230. Faintness (with or with- out giddiness) Less important if the patient has always been subject to faints. * Addison's Disease *An3emia Aneurysm *Angina Pectoris Aortic Cusp, Rupture of ,, Disease Ascites Blows esp. over solar plexus Bradycardia *Dilatation of Heart *Diphtheria, m. Dissecting Aneurysm Emotion Exhaustion Fatty Degeneration of Heart ^Flatulence Haemorrhage *Heated Air Intercostal Neuralgia Leukaemia Meniere's Disease Pain, Acute Perforation of Bowel Pleural Effusion (esp. left) Pneumothorax Poisoning by Depressants *Pregnancy * Quickening ♦Shock Stokes-Adams' Syndrome *Strangulated Hernia Syphilitic Heart Tapeworm Thrombosis of Pulm. Artery „ of Superior Mes- enteric Artery 228-230 86 VERTIGO 231. VERTIGO OR GIDDINESS Vertigo may bo divided, though with some over-lapping, into : Nervous, Gastric, Toxic, Ocular, Aural, and Circulatory. If the vertigo is improved by closing the eyes, ocular trouble or neurasthenia is probable ; if made worse, locomotor ataxy and the diseases mentioned under ' Romberg's Symptom ' must be thought of ; while if unaffected, it may be gastric, toxic or circulatory. In the case of this last, pallor or perhaps flushing will accompany it. In doubtful cases, vertigo may be brought out by making the patient turn suddenly at the end of a short walk. ♦Alcoholism Aneurysm Antral Abscess Aortic Regurgitation Aortitis Apoplexy (prsem.) ♦Arterio-sclerosis Aura epileptica Bulbar Paralysis (prscm.) Catalepsy Cervico - occipital Neur- algia Cinchonism Cirrhosis of Kidney * Constipation Corrosive-poisoning ♦Dilatation of Stomach ' vertigo a stomacho lseso ' Disseminated' S clerosis Encephalitis Epilepsy ♦Eyestrain esp. of oblique muscles Facial Paralysis onset Gastritis, Chronic Gerlier's Disease Hsematoma of Dura Mater Hemianopsia Hereditary Cerebellar Ataxy Hydrocephalus, Chr. Hypersemia of Brain Hypertrophy of Heart Jaundice Labyrinthine Growths Labyrinthitis Laryngeal Vertigo Lithsemia Mastoid Abscess ♦Meniere's Disease Middle Ear Catarrh Migraine Miner's Nystagmus ♦Neurasthenia Pellagra Petit Mai Plague Polycythemia, Splenome- galic Ptomainism Stapes, Ankylosis of Stokes- Adams' Disease Tumour of Brain lesions of pons, c. quad- rigemina, cerebellum, or middle cerebellar peduncle 231 VERTIGO 87 Vertigo or Giddiness- tinued. Typhus invasion stage Wax in Meatus -con- Weil's Disease Also tight collars, abuse of tea or tobacco, and numbed feet. (See Gait, 1295; Mai-Co- ordination, 1303) 231 88 WEAKNESS 232. WEAKNESS Almost all diseases. The three following sections differ only in degree. 233. Lassitude and Debility ♦Addison's Disease ♦Anaemia Atony of Stomach Carcinoma *Chloroma *Chlorosis Convalescence from Acute Disease ♦Diabetes *Dilatation of Heart Dysentery *Exophthalmic Goitre Faecal Accumulation Incubation Stage of Exan- themata ♦Influenza, III. Jaundice ♦Leukaemia Lipomatosis neurotica Lithaemia Myxcedema Nephritis ♦Neurasthenia Pancreatic Disease Phthisis Pyelitis, Chronic Pyrexia Scurvy Trypanosomiasis 234. Prostration Acute Yellow Atrophy Buhl's Disease Cancrum Oris ♦Cholera Concussion of Brain or Spine Diarrhoea (severe) Dysentery, in. ♦Embolism of Pulmonary Artery ♦Endocarditis Eat Embolism Gangrene of Lung Glanders Hepatic Colic ♦Haemorrhage Hyperpyrexia Inversion of Uterus Plague Pellagra Ptomainism Relapsing Fever Tobacco -poisoning Trichinosis Tuberculosis, Acute ♦Typhic State (62) 235. Collapse Alcoholism, Acute Aniline-poisoning Embolism of Pulmonary Artery ♦Haemorrhage, Profuse ♦Hernia, Gangrenous Hydrophobia, hi. Perforation of Diaphragm ♦Perforation of Intestine ♦Perforation of Stomach Pneumo -pericardium 232-235 WEAKNESS 89 Collapse — continued Poisoning by Aconite and Heart Depressants gene- rally *Rupture of Bladder „ of Ectopic Amnion Rupture of Heart ,, of Liver „ of Ovarian Cyst „ of Spleen *Hupture of Uterus v 235 90 RIGORS AND CHILLS 236. RIGORS AND CHILLS The beginning of almost all pyrcxial diseases of sudden onset is marked by a rigor or chill, as also is the supervention of suppuration or sepsis in the course of an acute disease. 237. Rigors or Shivering Fits Usually initial. Abscess, Cerebral Hepatic Pelvic Prostatic Rectal Renal **• Subphrenic/- Appendicitis /■> *Calculus, Passage of *-■ Catheterisation Cholecystitis, Suppurating k Colic (x) ^ *Diphtheria Empyema Endocarditis, Septic Enteric Fever perforation Erysipelas Erythema Scarlatiniforme Hemoglobinuria, Parox. onset Hydatids, Suppurating Influenza Malaria Meningitis, Simple „ Cerebro-spinal ,, Internal Spinal Milroy's Disease acute crisis Myelitis, Acute Nephritis, Acute r~ Pelvic Peritonitis Periarteritis nodosa Peritonitis, Acute Phthisis, Acute *Pneumonia, Acute Poliomyelitis, Acute Portal Phlebitis suppuration Pyaemia Pyelitis, Acute Relapsing Fever Renal Embolism Rheumatism, Acute Scarlatina (x) *Septicsemia Suppurative Spinal Pachy- meningitis „ Synovitis Thrombosis Tuberculosis, Acute Typhus *Variola Weil's Disease onset Woillez's Disease onset Yellow Fever In an infant, convulsions often take the place of a rigor. 238. Recurring Rigors Actinomycosis Cholecystitis Cystitis (x) Endocarditis, Ulcerative *Gallstones 236-238 RIGORS AND CHILLS 91 Rectjrrikg Rigors — con- tinued Glanders Influenza (x) Leukaemia, Acute Lymphosarcoma, Acute Malaria Osteomyelitis, Acute Pancreatitis, Acute Perinephritis Phthisis, Acute Pleurisy (x) Pyelitis, Calculous Pyelonephritis Pyaemia „ Portal *Renal Calculus Septicaemia Syphilis, Secondary (x) Tuberculosis, Acute 239. Chills and Subjective Cold Pelt chiefly in the back. Chills are often a mild form of rigor. Coryza (x) Dysentery Erysipelas Glanders, I. Haematomyelia Herpes Laryngis Hysteria *Influenza Locomotor Ataxy Malaria Migraine, i. Mumps Myxcedema *Neurasthenia Neuritis, i. Paralysis agitans Periarteritis nodosa Phthisis, Acute Pleurisy, Acute Pyonephrosis Remittent Fever Rheumatism, Acute Salpingitis Sclerosis, Lateral Spasmodic Spinal Paralysis Spinal Meningitis Syringomyelia *Tonsillitis, Follicular 238-239 92 PULSE PART II INSPECTION AND OBSERVATION Contractions : u, usually ; x, exceptionally ; *, the most likely diseases ; i, First stage ; n, Second stage ; in, Third or Final stage. 240. THE PULSE Normal Rate 1st year 130-115 2nd year 115-100 3rd year 100-90 7th year 90-85 14th year 85-70 Adult age 80-70 Old age 70 -CO Decrepitude . . . . 75—65 The pulse is best felt with the patient's forearm pronated and it should not be counted until the patient has become accustomed to the presence of the physician. If the artery appears small, the pulse of the other hand should be felt, as there may be some abnormal distribution. The force or pressure is roughly determined by placing three fingers on the radial artery and estimating what pressure of the proximal finger is necessary to prevent the pulse being felt by the other two. It is high when the artery is full between the beats and can be rolled under the finger like a tendon. For exact results, the sphygmometer is necessary (see Tension). The artery between the pulsations, owing to the pressure of the finger, is transversely oval, so that each pulsation, by altering the shape to circular, produces under the finger a feeling of distension. In the erect position the pulse averages nine beats per minute more than in the recumbent, and every increase of 1° F. in the temperature sends up the pulse about eight beats. 241. Quick (Pulsus frequens, or if very rapid, ' Tachy- cardia ') The pulse is quickened under the influence of exertion or excitement and in all febrile diseases, except in yellow fever and where there is pressure on the brain. When the pulse is quickened it is the diastole, not the systole, that is shortened. (See Pyrexia, 295) Ac. Ascending Paralysis Addison's Disease Anaemia Aneurysm of Aorta 240-241 PULSE 93 Qu rcK — continued Angina Pectoris Appendicitis Belladonna -poisoning Chlorosis Chorea Collapse ,, of Lungs Coma Vigil Concussion of Brain or Cord Displaced Heart Epilepsy, n. Excitement Exertion Exophthalmic Goitre except during sleep Foreign Body in Heart Gout, Undeveloped Haemorrhage Hernia, Strangulated Irritation of Sympathetic not above 120 Leukaemia Lesion of Medulla Locomotor Ataxy Mediastinal Growth Mitral Stenosis Neurasthenia Periarteritis nodosi Pericarditis, Acute Pernicious Anaemia Phthisis, Incipient Pneumogastric Paralysis but not over 160 Pneumogastric Neuritis influenzal, diphtheritic, etc. Pneumonia, Acute 90 to 120, less than is usual with such a tem- perature. (See 267) Pneumothorax Pregnancy Rheumatoid Arthritis Shock Sunstroke, Syncopal Tachycardia, Paroxysmal Tobacco Heart Typhic State (62) Typhus Pulsus celer is not necessarily frequent. (See 250.) 242. Slow {Palsies rants) — Bradycardia Bradycardia is ' muscular ' when the Bundle of His is affected and ' nervous ' when due to direct or reflex irritation of the vagus. Some of the pul- sations may not reach the radial artery and the rate must be checked by auscultation. Aortic Stenosis, i. Arterio -sclerosis Asthma, Spasmodic Atonic Dyspepsia Chlorosis Cerebral Abscess ,, Aneurysm ,, Haemorrhage Cirrhosis of Lung Colic (x) *Coma Compression of Cord upper part Convalescence from Pneu- monia and Fevers Coronary Sclerosis Diabetes 241-242 94 PULSE Slow — continued Diphtheria sequela Enteric Fever relatively Epilepsy- Ergotism *Fatty Degeneration of Heart Fibroid Heart Gallstones Gastric Cancer „ Ulcer General Paralysis Hydrocephalus Influenza (x) *Irritation of Pneumogastric by tumours, etc. This cause can be counter- acted by atropine Jaundice (392) Lead Colic Lesion of Medulla Liver, Ruptured Melancholia *Meningitis, n. ♦Meningitis, Tuberculous, II. Mumps (x) Myxcedema Paralysis of Sympathetic Pregnancy Relapsing Fever Senility *Stokes-Adams' Disease from 14 ; pulse absent during the epileptiform attack Syphilitic Heart Affection Tumours of Brain Tumour of Heart invading Bundle of His Yellow Fever *** Exclude Pulsus alternans and the action of con- vallaria, digitalis, lead, opium, salicylates, stro- phanthus and conium. A slow pulse is normal in some individuals. (See 8.) 243. Erben's Phenomenon The pulse slows down when the patient leans forward. Neurasthenia 244. Pulse Tardy {Pulsus tardus) Slow rise and descent of the pulse wave — tension high. Aneurysm Angina Pectoris Aortic Stenosis Arterio-sclerosis Contracted Kidney Senility 245. Hard (Pulsus durus) Aortic Stenosis Apoplexy *Atheroma or, if combined with hypertrophy of heart, ' bounding ' Athleticism ♦Cirrhosis of Kidney Diphtheritic Laryngitis Enteritis Gout Hypertrophy of Heart Lead Colic Pericarditis, Acute Peritonitis, Acute Pleurisy, Acute 242-245 PULSE 95 246. Soft and Compressible or Weak (Pulsus mollis) *Ansemia Aneurysm of Heart Aortitis Asphyxia Asthma, Spasmodic Atony of Stomach Broncho-pneumonia Cancer of Stomach Cholera Colic Collapse Coma Vigil Concussion of Brain Delirium Tremens *Dilatation of Heart Diphtheria Dysentery Gallstones severe attack Glanders Gout, Undeveloped Haemorrhage Hyperpyrexia Mitral Regurgitation Pericarditis^ n. Perinephritis Poisoning by Depressants Pulmonary Apoplexy Pyaemia Pyrexia (295) Rheumatism, Acute *Shock Strangulated Hernia Sunstroke *Syncope Trance Typhic State (62) Typhus 247. Full or Large (Pulsus magnus) Aortic Regurgitation aortitic form Concussion of Brain, III. Erysipelas, I. Hypertrophy of Heart „ with Dilata- tion Pericarditis Rheumatism, Acute Spinal Meningitis 248. Small (Pulsus parvus) Ague cold stage Angina Pectoris Aortic Stenosis Asthma (paroxysm) Atrophy of Heart Broncho-pneumonia Cholera Collapse „ of Lungs Dilatation of Heart Dysentery Emphysema Endocarditis Enteric Fever third week Ergotism Fibroid Heart Gallstones Gangrene of Lungs Gout, Undeveloped Hyperpyrexia (298) Intestinal Obstruction Mitral Stenosis Myocarditis, Acute Noma Pericardium, Adherent 246-248 96 PULSE Small — continued Peritonitis, Acute Pleurisy, I. Pneumonia, Acute late Pneumothorax Scarlatina Strangulated Hernia Typhic State Typhus *** Also abnormal distribution. 249. Sustained (Pulsus plenus) Pulse full between the beats. Aortic Stenosis if associated with left hyper- trophy Contracted Kidney Hypertrophy of Heart Mitral Stenosis 250. Jerky (Pulsus celer) Tension low. * Aortic Regurgitation ' water-hammer ' or ' Corri- gan's Pulse ' — more evi- dent when the arm is raised Atheroma Collapse Debility Enteritis Fatty Degeneration of Heart Fibroid Heart *Ha3morrhage Pericarditis (x) Pernicious Anaemia Wasting Diseases (311) 251. Irritable Accelerated from slight causes. Dysentery Enteric Fever, 1st week Hysteria Masturbation *Neurasthenia Spermatorrhoea Also from nervousness or abuse of tea or tobacco. 252. Thrilling or Tremulous Anaemia Aneurysm Aortic Regurgitation with strong ventricle Neurasthenia Septicsemia 253. Pulsus Alternans Pulse beats unequal in strength. Weakness of Myocardium 254. Pulsus Bigeminus Two beats and a pause. There is also a Pulsus Trigeminus (three beats and a pause), and a Pulsus Quadrigeminus. The extra beat is some- times due to an extra systole. Epileptiform Attacks Heart Failure Mitral Stenosis esp. after digitalis Neurasthenia It also occurs after great mental or bodily strain. 248-254 PULSE 97 255. Pulsus Bisferiens The summit wave and tidal wave are felt separately. *Aortic Regurgitation (x) „ Stenosis Hypertrophy and Dilatation of Left Ventricle 256. Pulsus Paradoxus Smaller and less frequent during deep inspiration. Acute Laryngitis Adenoids Asthma Emphysema with dilated heart Enteric Fever (x) *Mediastinal Growths *Mediastinitis Pericardial Adhesions esp. if mediastinal Pericardial Effusion (x) Tracheal Stenosis In children any obstruction in the air passages will cause it, and it is some- times physiological. 257. Riegel's Pulse This differs from pulsus paradoxus in that the change takes place with expiration instead of inspi- ration. It has the same significance. 258. Arrhythmia The condition when ex- treme is termed delirium cordis. Pulse irregular, or inter- mittent, or both. The auricular systole, as shown in pulsating veins, often takes place when there is no ventricular systole. In general, gross irregu- larity is more serious than intermittency. Adherent Pericardium Aerophagia nervosa Arterio-sclerosis of Left Coronary usually every third beat dropped Aneurysm of Heart Aortic Aneurysm Apoplexy, Severe Arsenical-poisoning Auricular Fibrillation (259) *Cardiac Breakdown Collapse (235) Concussion of Brain, hi., „ of Spine Digitalis cumulative action of Dilatation of Heart Displacement of Heart Dyspepsia, Flatulent Emphysema *Endocarditis, Malignant Exophthalmic Goitre Fatty Degeneration of Heart Fibroid Heart Gangrene of Lung Gout, Undeveloped Hypochondriasis Influenza Jaundice (392) Lithaemia Lesion of Medulla Mitral Regurgitation Myocarditis, Acute Neurasthenia 255-258 98 PULSE Arrhythmia — continued Neurosis of Heart (Edema Laryngis Pericarditis Stokes-Adams' Disease auricular beat regular ; ventricular alternate Syphilitic Heart Tuberculous Meningitis, in. Also from senility, over work, nervousness, dis- tended stomach, or abuse of tea or tobacco. When the arrhythmia recurs regularly, it is termed AUorhythmia. 259. Auricular Fibrillation This accounts for 50 per cent, of all cases of cardiac irregularity (Price). It may be suspected when, late in the course of mitral stenosis or car- diac sclerosis, the pulse becomes irregular and the general condition graver, while the presystolic thrill and murmur dis- appear. The diagnosis must be confirmed by the Polygraph. Impending Heart Failure Fibrillation also takes place when adrenalin is injec- ted after an anaesthetic. 260. Dicrotic Pulse Exaggeration of the dicrotic wave. It is sometimes mistaken for a pulse of twice the rate. Alcoholism *Enteric Fever Erysipelas Hyperpyrexia Pericarditis Peritonitis, Septic Pleurisy, Acute, in. Also on exposure to great heat. (See Low Tension, 273) 261. Anacrotic Pulse The tidal wave is stronger than the summit wave. Aortic Stenosis 262. Weaker on one Side Abnormal distribution of the arteries is not un- common. Aneurysm of Ascending Aorta right side Aneurysm of Descending Arch left side Aneurysm of Innominate Artery right side Aneurysm of Subclavian, Axillary, or Brachial Artery same side Arteritis Cervical Rib, Unilateral stronger when the arm is raised Embolism of Brachial or Radial Artery- old or recent Hydrothorax Mediastinal Tumour Pleural Effusion, Large Pneumothorax Tumour of Neck, Chest or Axilla 258-262 PULSE 99 263. Weak in Posterior Tibial Artery Abnormal Distribution Aneurysm, Abdominal „ Iliac Claudication Intermittente Obliteration of Aorta 264. Later in Left Radiai Aneurysm between Innomi- nate and Left Carotid 265. Late in both Pulses Aortic Regurgitation 266. Artery Hard and Tortuous ' The artery feels like the stem of a tortuous clay pipe.' Alcoholism Aneurysm Gout Lead -poisoning Nephritis, Chronic Progeria Senility Syphilis Tortuosity and hardening of the radials do not necessarily indicate the same condition in the aorta. 267. Pulse-Respiration Ratio Normally 4 to 1. Narcotic-poisoning 6* to 1 Pneumonia, Acute 5 to 2 268. Pulse-Temperature Ratio Lowered — 'Relative Bradycardia * The puis 3 rate ordinarily rises 8 or 9 beats for every degree of temper- ature. Abscess, Cerebral Enteric Fever Influenza Meningitis, Acute, n. ,, Tuberculous, n. Relapsing Fever Yellow Fever 269. Venous Pulse, Centripetal Aneurysmal Varix Dilated Arterioles (See Venous Pulsation, 283, 725) 270. Schapiro's Test Normally, the pulse rate is lessened by 7 to 15 beats per minute when a patient lies down. When no diminution takes place there is — Cardiac Weakness H 2 263-270 100 ARTERIAL TENSION 271. ARTERIAL TENSION The normal systolic pressure, estimated in mm. of mercury is about 90 under fourteen years of age ; 100 to 115 up to twenty years of age, while from twenty-one to sixty-five it is usually 120 to 135. In very old age with rigid arteries it may go up to 200. The pressure in women is 10 to 15 mm. lower. It is low in children and in adults who have been kept in bed. Digital estimation is not very reliable, but the sphygmometer is not without its fallacies, and results must be received with caution when the artery is thickened, the skin oedematous, a superjacent muscle spastic, or the subject very fat. Gaertner's Finger Tonometer is free from some of these objections. The tension is determined by the sphygmometer, usually Riva-Rocci's or Hill and Barnard's. In using the Riva-Rocci instrument, the armlet is fixed securely to the upper arm and the pressure gradually raised until the pulse can no longer be felt at the wrist, when the reading is taken. As a check, the reading at the re-appearance of the pulse, when, by means of the valve, the pressure is gradually relaxed, should also be noticed. Diastolic Pressure is that which corresponds with the interval between the heart beats. It depends largely upon the degree of contraction or relaxation of the arterioles, and is best ascer- tained by the auditory method. In this, the stethoscope is placed below the armlet, and when the sounds disappear under a falling pressure, the number of mm. Hg is read off. Normally it is about 100. Arterial Tension is altered physiologically as follows : — Increased by : (a) Muscular or mental work or excitement. (b) Increase in rate and power of heart beat. (c) Increase in the quantity of blood (e.g. after a meal). (d) Increase in the contraction of the arterioles (e.g. by cold). Diminished by : Recumbent position, by warmth, and by diminution in (b), (c) and (d). 271 ARTERIAL TENSION 101 272. High Tension Powerful ventricular con- traction with contracted arterioles. Aneurysm of Aorta if of ascending portion, unilateral. Angina, Abdominal „ Pectoris Apoplexy, Impending Arterio-sclerosis Bronchitis, Chronic Cerebral Tumour, i. Cheyne-Stokes' Breathing Cirrhosis of Kidney sometimes over 300 mm. Constipation Cyanosis (396) Dilatation of Aorta Emphysema Glycosuria, Gouty Gout (tj) Hemicrania Hypertrophy of Heart Hysterical Seizure Lead-poisoning Locomotor Ataxy during crisis Malaria (cold stage) Melancholia Meningitis, I. Migraine Mitral Stenosis Pleurisy, Acute, I. Pregnancy Pseudo-Angina Rigor Toxaemia, Chronic Viscosity of Blood (1473) And all kidney affections except the amyloid, the suppurative, and the tuberculous. Further, too nitrogenous or too liquid a diet. 273. Low Tension Heart weak and arterioles dilated ; dicrotism well marked. Addison's Disease Anaemia Aortic Stenosis Asthma Chlorosis Cholera Debility Diabetes Diarrhoea Dilatation of Heart Dysentery Exhaustion Fatty Degeneration of Heart Fevers Fibroid Heart Haemorrhage Jaundice (392) Mitral Regurgitation Neurasthenia Obesity Phthisis, i. Pleurisy, Acute, u. Pyrexia (295) Shock Syncope Thrombosis Trypanosomiasis Vomiting Generally speaking, it occurs in all asthenic conditions, but it is also produced by dry diet, hot air, hot baths, or hot drinks, and by the action of chloral, cannabis indica, nitrite of amyl, nitroglycerin, nitrous ether, and mistle- toe. 272-273 102 ARTERIAL TENSION 274. Grunbaum's Test Suprarenal extract fails to raise arterial tension. Addison's Disease 275. Hertzel's Sign When the circulation in both legs and one arm is completely arrested by- pneumatic pressure, the bloo 1 pressure in the remaining arm rises about 5 mm. Hg. of 60 mm. place in — Arterio-sclerosis But Hg a rise takes (One would think that some risk of producing apo- plexy might be incurred by this procedure.) 274-275 SPHYGMOORAPH 103 276. THE SPHYGMOGRAPH Summit Wave Tidal Wave. \ '■■% Dicrotic Wave . ^^> e X 4^ Wave Di acjrammatic SphygmogTayn Fig. 2. — The Points of a Sphycmogkam As compared with the pulse felt by the finger, the rise of pressure corresponds with the ' line of ascent ' ; the duration of pressure, with that portion of the line ofjiescent extending from the ' summit wave ' to the dicrotic notch ; and the fall of pressure, from the dicrotic wave downwards. 277. LINE OF ASCENT Vertical Vigorous heart-contractions or relaxed arterioles. Aortic Regurgitation Oblique Weak ventricular con- tractions. Aortic Stenosis Aneurysm proximal side Mitral Regurgitation High Easy capillary circulation. Aortic Regurgitation Pyrexia Low Obstructed peripheral cir- culation, and contraction of muscular coat. Aneurysm Mitral Regurgitation Forked or Anacrotic High Peripheral Resistance as in Chronic Nephritis 276-277 104 SPHYGMOGRAPH Sharp 278. SUMMIT OF PERCUSSION WAVE Blunt Vigorous heart-contractions, easy capillary circulation, and relaxed muscular coat — tension low. Aortic Regurgitation Weak heart - contractions and contracted muscular coat — tension high. Aneurysm proximal side Aortic Stenosis Arterio-sclerosis 279. TIDAL WAVE Marked (high tension) Vigorous heart-contractions and obstructed peripheral circulation. Aortic Stenosis Arterio-sclerosis Faint Weak heart - contractions, or, if strong, associated with over-full arteries ; easy capillary circulation and relaxed muscular coat. Aneurysm proximal side Aortic Regurgitation Mitral Regurgitation 280. DICROTIC WAVE Marked (low tension) Vigorous heart-contractions, easy capillary circula- tion, and relaxed muscu- lar coat. of or Descending Abdominal Aneurysm Thoracic Aorta Pyrexia (See Dicrotic Pulse, 260) Faint (high tension) Weak heart ; or strong heart with over-full arte- ries, obstructed peripheral circulation, and contrac- tion of muscular coat. Aneurysm proximal side Aortic Regurgitation late Arterio-sclerosis Mitral Regurgitation 281. Line of Descent Irregular Mitral Regurgitation „ Stenosis 282. Base Line Undulating Dysprcea due to affections of the medulla Tuberculous Meningitis (See Cheyne- Stokes' Breath- ing, 1214) 278-282 SPHYGMOGRAPH 105 Normal Pulse. Aortic Regurgitation. Mitral Stenosis Aortic Stenosis Mitral Regurgitation. Fig. 3. — Typical Sphygmograms The tracings will vary according to the degree of compensation. 283. VENOUS PULSE This must be studied with Mackenzie's Polygraph. One of the most important points is the determination of the auricular systole. It immediately precedes the carotid wave, and the radial pulse is -^ second later than this. See 259, 269, 725. 283 106 PULSATION ABNORMAL PULSATION 284. Chest To detect supra-sternal pul- sation, it may be neces- sary to press a ringer firmly down behind the sternum. Aneurysm pulsation ' heaving ' or ex- pansile An aneurysm of the ascend- ing aorta first touches the chest wall in the second right space near the sternum (rarely to left) ; of transverse arch, behind manubrium ; of descending arch, below first left rib ; of innomi- nate artery, behind right sterno-clavicular articu- lation. There is no pulsation when the sac is solid. Aneurysm 'Mimic' A transient, fusiform dilata- tion ; u seat, abdominal aorta or subclavian artery. Appendix, Hypertrophied Left 2nd and (x) 3rd left space — presystolic Bursting of an Artery into an Abscess Cavity Cancer of Pleura Cardiac Aneurysm (x) precordial Dilated Aorta suprasternal notch Dilated Conus Arteriosus 2nd left space Dilated Right Auricle 3rd, 4th, and 5th right spaces Displaced Heart or Dextro- cardia 2nd to 5th right spaces Empyema Necessitatis Empyema Pulsating all one side Heart, Uncovered from retraction of lung Hypertrophy and Dilatation of Right Ventricle 3rd, 4th, 5th, and 6th spaces near left sternal edge Mediastinal Abscess above or at side of sternum Mitral Stenosis 3rd left space Pleural Effusion very rarely Pulmonary Artery, Pulsat- ing 2nd and 3rd left spaces near sternum Pulsating Liver (286) ,, Sarcoma Right Subclavian, Abnor- mal suprasternal notch Tumour, Mediastinal Pulsation in the supra- sternal notch is found normally in thin elderly persons and in many neurotic subjects. (See Pulsating Veins, 259, 269, 725, and Tracheal Tug, 713) 284 PULSATION 107 285. Abdominal Pulsation Aneurysm Cancer Embolism of Common Iliac ♦Palpitating Aorta lessened when patient leans forward Tumours (x) 286. Pulsating Liver Aortic Regurgitation Mitral Stenosis ♦Tricuspid Regurgitation Pulsation may also be trans- mitted to the liver by an aneurysm or a hyper- trophied heart ; but in these cases it is not expansile. 287. Epigastric Pulsation This is usually synchronous with the heart's systole. If delayed slightly it is probably neurotic, though it may be due to an aneurysm. Anaemia Aneurysm of Aorta ♦Aortic Regurgitation Dilatation of Right Ventricle diastolic Dilatation of Stomach Displacement of Heart to Right ♦Distension of Stomach Emphysema Haemorrhage Hepatic Abscess Hypertrophy of Right Ven- tricle Mitral Regurgitation Stenosis Neurasthenia ♦Palpitating Aorta or Coeliac Axis Pancreas, Enlarged Pericardial Effusion Pleural Effusion, Left Pulmonary Stenosis Pulsating Liver (28G) Short Sternum Tricuspid Regurgitation Tumour resting on Aorta 288. Capillary Pulsation Visible in the nails ; or alter- natively on a patch of erythema produced by drawing a line across the forehead or sternum with the thumb nail. Anaemia (x) Aortic Regurgitation Chlorosis Haemorrhage, Severe Heart-muscle Failure Pernicious Ansemia 289. Pulsation Synchronous with Respiration Hernia Cerebri „ Pulnionalis Meningo-myelocele (See Carotid Throbbing, 721) 285-289 108 TEMPERATURE 290. TEMPERATURE M. E.M. E.M. E. M. EM. E.M. E.M. E M. E.M. EM. E Fig. 4. — Types of Temperatures a, continued ; b, remittent ; C, severe or septic remittent. 291. To take the temperature, the register or column of mercury must be first shaken down to 97°. The thermometer bulb should then be placed under the patient's tongue, and the lips, but not the teeth, closed. After, say twice the time for which the instrument is guaranteed, it must be withdrawn very gradually and the degree noted. Twice a day, 8 a.m. and 8 p.m., is sufficient as a rule. In infectious cases a special thermometer should be used, and when no longer required it must be sterilised by thorough washing, followed by immersion for one hour in perchloride of mercury, 1 in 500 solution. In children the fold of the groin with the thigh flexed, or the rectum, is sometimes preferable to the mouth ; but it must be remembered that muscular exercise will raise the rectal temperature to 101° or 102° even in health. It is noteworthy that some individuals and some families will develop a high temperature from very slight causes. In others, the reverse is the case. To convert the Centigrade into the Fahrenheit scale it is useful to remember that 35° C. equals 95° F., and that, for higher 290-291 TEMPERATURE 109 temperatures, all that is necessary is to add 1*8° F. to each degree C., thus : 36° C. = 96-8° F. 37° C. = 98-6° F. 38° C. = 100-4° F. 292. Subnormal It is often betrayed by cold breath. Low temperature means low vitality. Abscess, Cerebellar Addison's Disease Alcoholic Coma Anaesthesia, Prolonged Arterio-sclerosis Asthma, Spasmodic Cancer Carbolic-acid-poisoning Cerebellar Tumour Cerebral Haemorrhage ,, Tumour Cirrhosis of Kidneys ,, of Lungs Caloral-poisoning * Cholera, Asiatic to 94° or less Cholera, Sporadic to 96° Chorea (x) Collapse (235) „ of Lungs Convalescence after fever Cretinism Cyanosis Diabetes Diarrhoea, Profuse Enteric Fever mornings only — 3rd week also a sudden fall on per- foration occurring ^Haemorrhage 39° C. = 40° C. = 41° C. = 102-2° F. 104-0° F. 105-8° F. Heart Disease, Chronic Intestinal Obstruction Malformation of Heart Melancholia Myxcedema (94°-98°) Neurasthenia Opium- poisoning Oxalic-acid-poisoning Peritonitis, Tuberculous Phthisis morning (x) Pituitary Tumours Pneumonia, Acute after crisis (x) Relapsing Fever defervescence *Sclerema neonatorum sometimes to 70° Septic-poisoning morning Shock Starvation Trance Trypanosomiasis at intervals Tuberculous Meningitis (x) Uraemic Attack (x) Valvular Diseases *** Also antipyretic drugs, cold sponging, and poisoning by depressants. Ex- treme external cold will lower the body tempera- ture. In Shackleton's expedition, when the external temperature was -30° to -40° F., the body registered 93° F. 291-292 110 TEMPERATURE 293. Local Lowering Aura epileptica one extremity Cerebral Haemorrhage, n. paralysed side Chronic Atrophic Spinal Paralysis Compression of Cord *Cyanosis Hysterical (Edema Locomotor Ataxy Paralysed Limb Scleroderma Spinal Apoplexy limbs Spinal Paralysis of Adults, Acute Syringomyelia Transverse Softening of Cord (See Cold Extremities, 870) 294. Local Rise Local inflammation in general. *Abscess Boil Carbuncle Convulsions, Unilateral affected side Corpus striatum, Lesion of paralysed side Gout Pneumonia Pulmonary Tuberculosis 0*4 in axilla of affected side Osteitis Deformans great rise on affected side Suppuration Synovitis Traumatic Neurasthenia vertex Vaso-motor Paralysis *** The temperature of the urine in inflammatory bladder affections is said to be higher than that in the rectum. 295. Raised, Markedly T. over 102°. All inflammatory diseases and the acute exanthe- mata. Abscess, Acute Ague cold stage, 100°-101° ; hot stage, 105° Appendicitis Aortitis, Acute Bell's Mania, n. Bronchitis, Acute Broncho-pneumonia Bruhl's Disease Cancrum Oris Cerebro -spinal Meningitis Cystitis Dengue Dentition Diphtheria Dysentery Empyema Encephalitis Endocarditis, Acute Enteritis, Acute Erysipelas Extravasation of Urine Eebricula Gastritis, Erythematous, Acute Glanders Glandular Fever 293-295 TEMPERATURE 111 Raised, Markedly — con- tinued Glaucoma, Acute Glossitis Gout Hepatic Abscess Hepatitis, Acute Herpes Pharyngis Hooping-Cough invasion Hydrocephalus, Spurious Hysteria (x) Hystero-epilepsy seizure Infantile Paralysis onset 102°-103° Influenza Labyrinthitis, Acute Mania Measles Mediastinal Abscess Meningitis, Cerebro- spinal „ Simple ,, Spinal Milroy's Disease crisis Mumps Myelitis, Acute Myocarditis, Acute Nephritis, Acute Oophoritis Ophthalmia Orchitis Otitis Media, Acute Pancreatitis, Acute Peliosis Rheumatica Pelvic Abscess „ Cellulitis „ Peritonitis Periarteritis nodosa Pericarditis Perihepatitis Perinephritis Periproctitis Peritonitis, Acute very rarely normal Phlebitis, Acute Phlegmasia Dolens Phosphorus-poisoning, Acute Phthisis Plague, ii. Pleurisy, Acute Pneumonia, Acute Polymyositis Post-pharyngeal Abscess Psittacosis Puerperal Septicaemia Pyelitis, Acute Quinsy Relapsing Fever Remittent Fever Renal Embolism Rheumatism, Acute „ Gonorrhceal Roseola Rotheln Scarlatina Spinal Concussion, n. Splenitis Syphilitic Lung Tabes mesenterica Tetanus Tetany in severe paroxysms Tonsillitis Trichinosis Tuberculosis, Acute Typhic State (62) Typhus Urticaria Febrilis Vaccinia Varicella 295 112 TEMPERATURE Raised, Markedly — con- tinued Variola, I., in. Weil's Disease Woillez's Disease Yellow Atrophy, Acute Fever 296. Raised, Slightly or Incon- stantly Between 99° and 102° F. Addison's Disease Apoplexy, u. Appendicitis Bacilluria Bronchiectasis Cancer of Liver Cirrhosis of Liver, Hyper- trophic of Lung Convulsions, Following Coryza Diarrhoea, Irritative Dietl's Crisis Erythema Scarlatiniforme Exophthalmic Goitre Gonorrhoea Haeniophilic Arthritis Haemorrhage also premonitory Hay Asthma Hepatic Colic Herpes Zoster Hydrophobia Hyperaemia of Lungs, Acute Hysteria (x) Infantile Hemiplegia Laryngitis, Acute „ Spasmodic Leukaemia Lymphadenoma esp. in the young Meningitis, Tuberculous Metritis Mollities Ossium Myelosarcoma Paralysis, Acute Ascending onset Peritonitis, Chronic Pernicious Anaemia Phthisis, i. Pyrexia Renal Calculus Sarcoma (x) Syphilitic Eruptions Variola, n. The temperature may be raised by exercise, excite- ment, the use of bella- donna, and in children by food containing an excess of carbohydrates. The t passage of a catheter may produce a ' reflex fever.' 297. Hyperpyrexia (temp. 106° and upwards) Occurs occasionally in the following diseases and commonly in the final stage of all brain affec- tions, the temperature sometimes rising still more after death. Burns Cerebral Haemorrhage esp. into upper part of pons or into one optic thalamus Cerebral Tumour or Abscess Dysentery Enteric Fever Erysipelas Fractured Skull 295-297 TEMPERATURE 113 Hyperpyrexia — continued Fractured Spine Hysteria (x) sometimes incredibly high without any constitutional disturbance Influenza ♦Injury to Cord cervical portion Intermittent, Severe Malaria Meningitis, Post Basal transient pyrexial crises Meningitis, Tuberculous, in. Myelitis, Traumatic Pachymeningitis, Purulent Spinal ♦Pneumonia, Acute Pyrexia, Neurotic Relapsing Fever Remittent Fever ♦Rheumatism, Acute Scarlatina Septicaemia ♦Sunstroke Tetanus Tumour of Pons Uraemia Yellow Atrophy, Acute Fever 298. Remittent Type, or Morn- ing Fall When the remission, while never reaching the normal point, is of about 1° or \\° the expression ' con- tinued fever ' is employed, but the term is used with little precision. Appendicitis Broncho-pneumonia Cirrhosis of Lung Empyema Endocarditis, Ulcerative ♦Enteric Fever Hepatic Colic Kala Azar Leukaemia Malta Fever Mollities Ossium Paratyphoid Phthisis, m. Pleurisy, Tuberculous Pyaemia Relapsing Fever Remittent Fever Rheumatism, Acute Septic Pneumonia Septicaemia Trichinosis Trypanosomiasis, n. Tuberculosis 299. Septic Remittent or Hectic Fever A high evening temperature and a low or even sub- normal morning tempera- ture. The term inter- mittent should not be employed for this type. Abscess, Mediastinal „ Tuberculous esp. in bones Actinomycosis, Pulmonary Cholangitis, Suppurative Dysentery, Chronic Empyema Endocarditis, Septic Enteric Fever 3rd week Hepatic Abscess Hydatids, Suppurating i 297-299 114 TEMPERATURE Septic Remittent or Hectic Fever — continued Malta Fever, in. Otitis Media, Suppurative Peritonitis, Chronic (x) ♦Phthisis, in. Portal Pyaemia ♦Puerperal Fever Pyaemia Pyelitis, Chronic Pyonephrosis Septicaemia Sphenoidal Sinusitis Tabes mesenterica Thrombosis, Sinus Tuberculosis, Acute Miliary Tuberculous Ulceration of Intestines ♦Typhic State (62) This type of temperature means, in general, septic infection. 300. Inverse Remittent (High Morning Temperature) Dentition Enteric Fever (x) ♦Lobular Pneumonia Tuberculosis 301. Intermittent Type Apyrexial intervals not limited to the morning. When, in Ague, alternate days are free from fever, the type is termed ' ter- tian ' ; when two clear days intervene, ' quartan.' When occurring in con- nection with liver or kidney affections, it is termed Hepatic or Renal Intermittent Fever. Abscess, Hepatic Abscess, Pyaemic Calculus, Hepatic „ Renal Cancer of Liver (x) Colitis, Mucous Leukaemia Liver, Syphilitic (x) Lymphadenoma 5 to 15 days' interval Lymphosarcomatosis ♦Malaria in general Pernicious Intermittent Pyelitis Pylephlebitis, Suppurative Relapsing Fever Trypanosomiasis 302. Spiked Chart Periodic rises lasting 24 hours each. Post Basal Meningitis 303. Termination by Crisis Sudden fall of temperature. Erysipelas Measles Paratyphoid (x) ♦Pneumonia, Acute Relapsing Fever Typhus 304. Termination by Lysis Gradual fall of temperature. Aspergillosis ♦Enteric Fever ♦Lobular Pneumonia Pleurisy Psittacosis Rheumatism, Acute Weil's Disease And most febrile diseases. 299-304 tf,mim:rati t re iir, 305. Sudden Invasion Endocarditis, Ulcerative Erysipelas Gastroenteritis Influenza Malaria Mastoiditis ( Osteomyelitis Otitis Media •Pneumonia, Acute Pyaemia Scarlatina Suppuration Tonsillitis (See Sudden Onset, 40) 306. Differential and Special Enteric Fever 1st week gradual rise to about 104° -with daily remission of 2°. 2nd week stationary, daily remission 1° to 1*5°. 3rd week stationary, daily remission 3 C to 5°. 4th week gradual return to normal temperature with remissions of 1° to 1*5°. Lymph adenoma Remittent with a fortnight's afebrile interval. Meningitis, Simple usually over 102°, irregular Meningitis, Tuberculous about 100°, rarely over 102° until approach <>f death P. hie Cellulitis under 102° Pelvic Peritonitis over 102° Pneumonia, Acute 103° to 105° ; morning re- missions absent or slight Relapsing Fever The rise to 104° on the first day lasts a week ; then comes an apyrexial inter- val followed by three days of fever. Other relapses may ensue. Scarlatina High the first four days, then a partial subsidence. Not normal till end of second week. Typhus 1st week 104° to 106°, then one day's remission. 2nd week, still higher. Varicella Usually slight, but recurring with each crop of vesicles. Variola A fall on appearance of rash and a second rise when pustulation begins. i 2 305-306 116 NUTRITION 307. STATE OF NUTRITION The patient may be described roughly as well or ill nourished, but for exact results he should be weighed and measured, and the result compared with Hutchinson's Table. It is almost impossible to carry this table in one's head. I have therefore devised the following formula, which gives almost identical results : The weight of a person 5 ft. high should be 115 lb. For every additional inch of stature add 5 lb. Thus for 6 ft. it would be 115+60 (5x 12)= 175 ; a margin of 20 per cent, either way is consistent with health. The full weight must not be expected in the immature. In the case of infants the weight for the first month may be taken as 7 lb. At six months this should be doubled, and at thirteen months trebled. At the end of the second year the weight should be 30 lb. ; of third, 34 lb. ; of fourth, 38 lb., and of fifth year, 42 lb. At six years of age a boy should weigh 50 lb. and a girl 40 lb., and both should add 5 lb. for every year of age up till ten. Between ten and sixteen the girl grows faster than the boy ; but after sixteen the boy soon passes her. During the first year of life an infant should grow 8 inches. At three years of age it should be half its adult height. The average annual growth from five to sixteen years of age is two inches. The body weight is least before breakfast. In the writer's opinion, too much importance is attached by Insurance Offices to the Weight for Age Table. The majority of those who attain a great age are of spare build, and some of the strongest men are of the wiry type. There is too the fallacy of length of limb. Many a man fails to come up to the standard because he happens to have long legs ; while others are pronounced to be too heavy for their height because they are endowed with immense limbs. The real test of standard nutrition is the formation and nutrition of the trunk, and the proper basis of a table should be the chest measurement as compared with the measurement from the tip of the coccyx to the vertebra prominens. This ratio should be about 8 to 5. (See 1204.) 307 NUTRITION 117 308. Development of Fat ♦Alcoholism ♦Cessation of Active Habits or Occupation Chlorosis Cretinism Dementia Encephalitis (x) Hypopituitarism buttocks, abdomen, and genitals Lipodystrophia lower linibs and buttocks Lipomatosis neurotica ♦Menopause Mitral Disease Myxoedema Pseudo-hypertrophic Para- lysis Rickets Sclerosis, Disseminated Tumour, Cerebellar „ of Pineal Gland 309. Local Muscular Wasting or Atrophy The cause may He in muscle, nerve or nucleus. Amyotrophic Lateral Scle- rosis hand, etc. Anterior Crural Paralysis quadriceps Arsenical Neuritis Arthritis, Gonorrhceal ,, Tuberculous Beri-beri Bulbar Paralysis tongue, lips, and (later) limbs Callus, Pressure of Cervical Rib hand and arm Circumflex Paralysis deltoid Compression of Cord Congenital Asymmetry one-sided Disuse Duchenne's Infantile Paralysis begins in face Elbow Joint Disease upper arm Erb's Paralysis begins in shoulder girdle Facial Paralysis nuclear or intranuclear Growths when pressing on a nerve Hereditary Muscular Atro- phy shoulders, arms, thighs, and feet Hip Disease Idiopathic Muscular Atro- phy including face ♦Infantile Paralysis Injury to Motor Nerve Knee-Joint Disease esp. in thighs Landouzy - Dejerine Para- lysis begins in face and extends to shoulder and arm Lead Palsy Long Thoracic Neuritis serratus magnus 308-309 118 NUTRITION Local Muscular Wasting or Atrophy — continued Median Neuritis pronators Mercurialism Morvan's disease Motor Neuritis, n. of muscle supplied Musculo-spiral Neuritis supinators Myelitis, Acute esp. when in lumbar enlarge- ment Osteo-arthritis Paralysis agitans hand ■"Peripheral Paralysis in general very rapid Phthisis about shoulder muscles Poliomyelitis, Anterior Polymyositis muscles firm Progressive Muscular Atro- phy ' main-en-griffe.' Ball of thumb first. Legs first in infantile form. Pseudo-hypertrophic Para- lysis of latissimus dorsi and sternal end of pectoralis major Rheumatism, Old Rheumatoid Arthritis Sciatica, Old Spinal Apoplexy ,, Paralysis of Adults, Acute Spinal Paralysis, Chronic Atrophic ,, Tumour Syringomyelia hand first Tooth's Paralysis ' bottle thighs ' Tuberculous Joint of muscles near it Ulnar Neuritis hypothenar 310. Muscular Prominence without increased strength Pseudo -Hypertrophic Para- lysis Thomsen's Disease 311. General Wasting and Cachexia Children get thin normally when they reach the rest- less age of four. * Addison's Disease Alcoholism, Chronic Anaemia Ankylostomiasis Anorexia Nervosa ,, Simplex Aspergillosis Bacteriuria Bilharzia Bronchiectasis Bronchorrhcea *Carcinoma Cholangitis, Chronic Fibrous Cholera Cirrhosis of Liver „ of Lung „ of Stomach Coeliac Disease 309-311 NUTRITION 119 General Wasting and Cachexia — continued Colon, Idiopathic Dilatation Constipation, Habitual ♦Diabetes „ ' Phosphatic ' Diarrhoea esp. in infants Dilatation of Stomach Duodenal Catarrh Dysentery ♦Dyspepsia, Carbohydrate Empyema Enteritis Exanthemata, The ♦Exophthalmic Goitre Gastritis, Chronic Growth, Rapid Haemorrhages Hydatids Infantile Scurvy Intrathoracic Tumours if obstructing thoracic duct Jaundice ♦Lactation, Prolonged Lead-poisoning Leukaemia Lipodystrophia upper half ♦Locomotor Ataxy Lymphadenoma Malaria Marasmus Infantum Measles even from 3rd day of incu- bation (Meunier's Sign) j Melancholia Meningitis Menopause chiefly in fat women who were thin as girls Mitral Disease in children Mollities Ossium Morphinism Multiple Myeloma Myelitis, n. (Esophageal Stenosis Ovarian Cyst Overfeeding infants Pancreatic Disease Pellagra Pelvic Abscess Peritonitis, Tuberculous Pernicious Anaemia ♦Phthisis Progeria Pyloric Obstruction Relapsing Fever Scurvy Spondylose Rhizomelique Suppuration, Chronic Suprarenal Tumour Sprue Syphilis, Hereditary „ Tertiary Tabes Mesenterica Thyroidism Trypanosomiasis Tuberculosis, Acute Worms 311 120 NUTRITION 312. STATURE High Acromegaly Gigantism Low Achondroplasia ' dachshund type ' Anosteoplasia Ateleiosis Cretinism Dwarfism, Cerebral esp. idiocy Fragilitas Ossium Infantilism Leontiasis Osssa Mongolian Idiocy Osteitis Deformans Osteo-malacia Pancreatic Insufficience Phocomelus, Congenital ' seal-like ' Progeria Rickets Spinal Curvature Splenomegaly 312 SKIN 121 313. THE SKIN The presence of oedema is ascertained by making a depression with the end of one finger, and immediately afterwards brushing the pulps of the other fingers across it. If the depression is still palpable, there is oedema. Dermatographia, which includes tache cerebrale, is elicited by drawing a line with the back of the nail across the skin ; after a few seconds a red streak should appear and remain visible for about half a minute ; in the case of urticaria, a wheal may follow. A chronic unhealthy flush, such as patients commonly complain of as being no guide to their condition, may usually be distinguished from a healthy colour by the presence of twigs of dilated arterioles and venules. Self-induced skin affections always occur within reach of the right hand. Ringworm. To show the mycelium in the scales, wash with ether, drop some liquor potassae on them, and after a quarter of an hour put the cover-glass on. To stain the spores in the hair, first wash with ether, then steep for twenty minutes in a saturated solution of gentian violet in aniline water, and for two minutes in Gram's iodine solution. Dry with blotting paper and add a drop of aniline oil which has been coloured mahogany with iodine. The small-spored variety stains more rapidly than the large. (See also 356.) 314. Dry Skin (Anidrosis) Ague (hot stage) Anasarca Ascites Atrophy, Senile Cretinism Compression of Cord, Slow *Diabetes *Dysidrosis Enteric Fever Gout during attack Ichthyosis Influenza Kidney, Cirrhosis of Melancholia Myxcedema Perinephritis Peritonitis, Chronic Prurigo Psoriasis Rheumatoid Arthritis except hands Sclerodermia Scurvy Sympathetic, Paralysis of affected side of face Syringomyelia affected limb 313-314 122 SKIN Dry Skin (Anidrosis) — con- tinued Trypanosomiasis Tumour of Brain Xeroderma *** A dry skin is the normal condition in many persons. 315. Clammy Skin Alcoholic Coma * Angina Pectoris Arsenic-poisoning Arterio-sclerosis Colic *Collapse (235) Delirium Tremens Hepatic Colic Intestinal Obstruction Lead-poisoning Meniere's Disease Rheumatoid Arthritis hands *Shock Sunstroke *Syncope Thrombosis, Cerebral 316. General Sweating *Ague, in. Apoplexy Bronchiectasis night Broncho -pneumonia Debility *Defervescence *Diaphoretics Dilated Stomach Dropsy, Cardiac Emotions Epilepsy Exophthalmic Goitre Fatty Degeneration of Heart Gallstones Glanders Gout, ii. Hectic Hydatid of Lung night *Influenza Phthisis night Pneumonia Polymyositis Pulmonary Osteoarthro- pathy *Pyaemia intermittent Pyonephrosis Relapsing Fever Remittent Fever Renal Colic *Rheumatism, Acute continuous — acid Septicaemia Spinal Appolexy Trichinosis Tuberculosis 317. Partial Sweating Bromidrosis feet and axillae Facial Hemihypertrophy affected side Hemiplegia (x) unilateral Intrathoracic Aneurysm or Tumour side of face Masturbation palms 314-317 SKIN 123 Partial Sweating — con- tinued Migraine unilateral Multiple Neuritis affected parts Rickets head Suppurative Parotitis unilateral Sympathetic, Paralysis of sound side Syringomyelia hemihyperidrosis (x) Irritating smells, such as that of mustard, induce facial sweating and help in the diagnosis of para- lysis of the sympathetic nerve. 318. Chyloserous Sweat Chyluria (rare) 319. Bloody Sweat (Haemi- drosis) General Paralysis of Insane Hysteria Menstruation, Vicarious Rupture of Capillaries into Sweat Ducts Self-inflicted Punctures 320. Coloured Sweat (Chromi- drosis) It is usually local and occurs mostly in neurotic young women. Blue B. pyocyaneus or indigo in sweat ; copper internally. Green iron internally Red bacteria Yellow jaundice 321. Abnormal Constituents of Sweat Albumen Acute Rheumatism Bile Pigment Jaundice Cystin Cystinuria Dextrose Diabetes Lactic Acid Lactation Puerperal Fever Rickets (x) Tuberculosis (x) Urates and Oxalates Gout 322. Odorous Sweat Addison's Disease negro -like Bacteriuria B. coli — fishy Cholera urinous Favus mousy Glanders sour Hepatic Abscess liverish Jaundice musky 317-322 124 SKIN Odorous Sweat — continued Measles like freshly- plucked feathers Osmidrosis cheesy Peritonitis musky Rheumatism, Acute sour Scarlatina like new bread Scurvy offensive Typhus like rotten straw Uraemia ammoniacal or urinous Variola greasy Sulphur taken internally makes the sweat smell like H 2 S. Foul sweat is sometimes due to a growth of B. foetidus. Itching (see 218) Pallid Skin (see Face, 385) 323. Yellow Skin Anaemia of dark persons Bruises, in. Chlorosis *Haemorrhage * Jaundice (392) Paroxysmal Haemoglobin- uria *Pernicious Anaemia lemon Xanthelasma esp. eyelids Yellow Fever *** Yellow palms are said to be common in enteric fever, but they also occur in functional livei affections. Picric acid and nitric acid stain the skin yellow. 324. Pigmented or Bronzed Patches Abdominal Tumours (x) Acanthosis Nigricans wart-like * Addison's Disease Arsenic-poisoning ' blue bottom ' Cancerous Cachexia Chloasma Chromidrosis soluble in ether Cirrhosis of Liver Cocainism of pricks Diabetes, Bronzed Exophthalmic Goitre earliest in eyelids *Freckles Haenioch r omatosis Haemoglobinuria, Infantile Kidney, Contracted (x) Lepra Anaesthetica Leprosy, Nodular Lymphadenoma Malarial Cachexia Melano-leucodermia Melanotic Sarcoma Morphea Naevus Ochronosis Pediculosis or bluish (' taches bleuativs') Pellagra, n. diffused and rough 322-324 SKIN 12/1 Pigmented or Bronze Patches — continued Pernicious Anamiia Polycythemia, Splenome- Pregnancy [galic (' masque des femmes enceintes ') Recklinghausen's Disease Rheumatoid Arthritis Scurvy Still's Disease Syphilide, Pigmentary Tinea Versicolor Tuberculosis, Abdominal Urticaria Pigmentosa Uterine Irritation Vagabond's Disease Xeroderma Pigmentosum * + * Also from intermittent pressure (garters, collar- stud, etc.), from the use of vesicants or oil of cade, and from exposure to the electric arc light or to heat. Grey Skin (See Face, 389) 325. Dermatographia Rubra Elicited by drawing the back of the thumb nail along the skin of the abdomen General Paralysis Int. Spinal Meningitis Tuberculous Meningitis Typhic State (62) Urticaria wheals in line And most cerebral disorders (< Tache Cerebrale'). *#* If a lasting red patch is produced by friction over a painful area, the pain is probably ' referred ' from a neighbouring viscus. 326. Dermatographia Alba (Sergent's White Line) The line is produced as in tache cerebrale. It ap- pears in from half to one minute and lasts 2 to 5 minutes. It disappears when adrenalin is injected and therefore indicates suprarenal inadequacy. Addison's Disease Fevers, Specific esp. scarlatina Influenza Locomotor Ataxy Poisoning by Corrosive Sub- limate Septicaemia 327. Atrophic Striae Stripes, at first red, after- wards white, and resem- bling the linese gravi- darum. Not necessarily over the seat of the lesion. Appendicitis Enteric Fever esp. a transverse fine above pateUaJ Pneumonia 328. White Patches Albinism, Partial Facial Hemiatrophy Keloid Leprosy Leucodermia pigmented border *Morphea not hard Neuritis Raynaud's Disease ; local syncope ' 324-328 126 SKIN White Patches — continued *Scars Sclerodermia hard (See Digiti Mortui, 871) Cyanosis (see Face, 396) 329. Thickened Skin Abscess, Impending Arsenic -poisoning soles and palms Cancer, Acute Mammary ' peau d' orange ' ♦Cellulitis Erysipelas Ichthyosis Keratosis *Keloid Leprosy Lichen ruber Paralysis agitans, n. Phlebitis Rhinoscleroma Scars Sclerema Sclerodactyla fingers and face Sclerodermia (Edema (see 335) 330. Red Skin *Abscess Cellulitis Chilblain Cirrhosis of Kidney or reddish brown ♦Erysipelas ♦Erythema ,, nodosum Erythromelalgia *Gout Lymphangiectasis Neuritis (x) Osteitis, Acute Pellagra, I. Rubefacients Scalds and Burns ♦Scarlatina Synovitis, Acute (See Erythema, 344 ; Face 387) 331. Sudamina and Miliaria Small or large vesicles due to blocking of the sweat glands. Cheiropompholyx ♦Enteric Fever Hyperidrosis ♦Malignant Fevers Meningitis, Cerebro-spinal ♦Phthisis Pneumonia, Acute Relapsing Fever Rheumatism, Acute Trichinosis 332. Petechiae, Ecchymosis, or Hematoma The effused blood in a petechia resembles a small circumscribed bruise, in ecchymosis a large diffused one. A hsematoma is a blood tumour due usually to a ruptured vein. Ague Amyloid Anoemia Antitoxin, Diphtheric ♦Blows Some persons, esp. females, bruise from very slight injuries. 328-332 SKIN 127 Petechia, Ecchymosis, or Hematoma — continued Buhl's Disease Cancer of Liver Cerebro -spinal Meningitis Chloroma Cholera Cirrhosis of Liver Dilatation of Heart Diphtheria Dysentery- Drugs, Occasional Effects of Antipyrin Arsenic Belladonna Butyl Chloral Chloral Copaiba Ergot Iodides Iodoform Mercury Phosphorus Potassium Chlorate Quinine Salicylic Acid Sulphonal Veronal Endocarditis, Ulcerative Enteric (x) Erythema multiforme Fleabites *Haemophilia Henoch's Purpura Infantile Scurvy Jaundice Kaposi's Disease ' black-currant rash ' Leukaemia . Locomotor Ataxy Lymphosarcoma Malaria, Severe Malignant Fevers esp. variola and typhus Measles Myelosarcoma Myelitis Myositis Haemorrhagica Nephritis Neuritis, Alcoholic Paroxysmal Haemoglobin- uria Peliosis Rheumatica Pernicious Anaemia Phthiriasis Phthisis (x) Plague Pseudo-Leukaemia Infan- tum Psittacosis Ptomainism *Purpura Haemorrhagica Pyaemia Remittent Fever Rheumatism, Acute (x) *Rupture of Muscle if of T. Achillis, ' H shape ' *Rupture of Vein Scarlatina (x) *,? curvy Septicaemia Snake Poison Splenic Anaemia Tuberculosis, General Typhic State (62) Valvular Disease Variola (x) Weil's Disease Yellow Atrophy, Acute „ Fever 332 128 SKIN 333. Trelat's Naevi Small multiple noovi. These in the subject of a breast tumour are said to point to : — Carcinoma 334. Rumpel-Lerde's Test An elastic ligature at the forearm produces pete- chise at the bend of the elbow. Diphtheria Measles Scarlatina rash stage — in half a minute Grocco's test for slight cases of Purpura and Peliosis rheumatica is similar, the result being slight punctiform haemorrhages. 335. (Edema and Anasarca A puffiness of the skin which on long pressure with the finger-point leaves a pit lasting about a minute. Anasarca is generalised oedema. *Abscess Amyloid, in. Amyotonia Congenita Ansemia Angioneurotic (Edema Anthrax (x) g Aortic Aneurysm „ Disease (x) very advanced cases Atrophy of Heart *Beri-beri Bronchitis, Chronic (x) Buhl's Disease ♦Cellulitis Cirrhosis of Liver termination Cirrhosis of Lung Diabetes, in. Dilatation of Heart Displaced Heart Emphysema, in. Empyema affected side ♦Erysipelas Erythromelalgia Essential Dropsy of Children Extravasation of Urine Fatty Degeneration of Heart Fibroid Disease of Heart Glanders *Gout Hypertrophy of Heart, n. Hysterical (Edema not pitting Locomotor Ataxy transient Malformation of Heart ♦Mitral Regurgitation Muscular Atony, Cong. Myositis Myxoedema not pitting Nephritis, Acute and Chronic Tubular Neuritis (x) Pericradium, Adherent Perinephric Abscess lumbar region Pleural Effusion same side (x) Pneumo-peritoneeum epigastrium Polymyositis Polyneuritis Scurvy (feet) Suppurative Synovitis 333-335 SKIN 120 (Edema and Anasarca — continued Syphilitic Disease of Heart Trichinosis Tricuspid Regurgitation *Urticaria ♦Varicose Veins Xeroderma pigmentosum Excess of salt in the dietary will produce oedema. (See Limbs, 863 ; Face, 403) 336. Circumscribed (Edema Abscess, Superficial Aneurysm of Asc. Aorta if intra-pericardial, nipple ; if extra-pericardial, fourth right cartilage Aneurysm of Transverse Aorta above left clavicle Angioneurotic (Edema Appendicitis (x) Caries of Sternum Empyema *Encysted Pleurisy ♦Furuncle in Meatus Hepatic Abscess Hydatids of Lung Mastoid Abscess Mediastinal Tumour or Abscess Necrosis Neurasthenia, Traumatic scalp Neuritis Osteomyelitis ♦Parotitis Pericarditis, Purulent Perinephric Abscess Poisoned Wounds Rickets (x) ♦Stings Thrombosis of Sinus scalp Tubercle of Ribs Tumour of Chest Wall (See Limbs, 863) 337. Blue (Edema Asthma, Spasmodic Hysteria non- pitting ; (' Charcot's (Edema ') Mitral Disease Syringomyelia (See Cyanosis, 306) 338. Emphysema, Interstitial Due to air or gas in the subcutaneous tissue. The skin crackles on pressure. Broncho-pneumonia Caisson Disease Foreign Body in Lungs Fractured Pelvis „ Ribs Glanders Perforation of (Esophagus, Stomach, or Bowel (x) Phthisis Pneumothorax (x) Rupture of Air Cells from shouting, coughing, lifting, etc. Ulceration of Larynx Wound of Lung, Mouth, Larynx, or Intestine *#* Some cases are due to infection with B. aero- genes capsulatus and a few to B. coli. 335-338 130 SKIN 339. Inelastic Skin This is often due to loss of tone in the minute skin muscles, as is seen in the skin of persons who, formerly stout, have become thin. * Atrophy, Senile Cholera Coma Diarrhoea, Profuse *Enteric Fever Meningitis Paralysis Agitans Starvation Syphilis, Hereditary *Typhic State (62) Typhus 340. Goose Flesh A roughened skin due to spastic contraction of the skin muscles. Rigors and Chills (236) 341. Glossy Skin ^Anasarca *Gout Injury to Nerves Leprosy — non-tuberculated Neuritis ^Stretched Skin from any cause Syringomyelia ' peau lisse ' 342. Scaling or Desquamation Sequel of dermatitis of some kind. Antipyrin Rash Belladonna Rash Copaiba Rash Dengue Dermatitis exfoliativa neo- natorum Desquamatio Periodica Eczema Enteric Fever (x) Erysipelas Erythema (x) Erythema Scarlatiniforme appears 2nd to 4th day Favus yellow Gout Herpes Ichthyosis Lupus Measles branny Morphia Rash *Pityriasis *Pityriasis rubra flakes *Pityriasis versicolor *Psoriasis Quinine Rash Rotheln slight Scarlatina from 7th day to about 7th week. Flakes are less common than formerly Scurvy legs Seborrhcea fatty scales Syphilis Tinea tonsurans Xeroderma ! ** Working men desquamate on the palms when out of employment. Carbolic acid and other disinfec- tant lotions or baths may produce it. 339-342 SKIN 131 343. Scars follow : — ♦Abscess Acne rosacea Anthrax *Boils Bubo * Burns if deep ♦Carbuncles Chancre Ecthyma Gangrene Glands, Tuberculous Gummata, Suppurating Herpes Zoster ♦Lupus erythematosus Lupus exedens *Lupus syphiliticus large Lupus vulgaris bluish and papery Serpiginous Syphilide bean-shaped Tubercles (350) ♦Ulcers Varicella (x) ♦Variola Wet-cupping ♦Wounds Linear scars follow over- stretching of the skin from, oedema, pregnancy, abdominal tumours, obe- sity, etc. (linese albicantes, see 822). 344. Erythema (Diffused Red- ness) Cerebro- spinal Meningitis Dengue Dermatitis exfoliativa neo- natorum K Drugs, Action of : Antipyrin Antitoxin Arnica Arsenic Belladonna Boric Acid Bromides Chloral Copaiba Croton Oil Cubebs Iodides (x) Xeo-salvarsan Quinine Rhubarb Salicylates Sulphonal Veronal ♦Erysipelas Erythema infectiosum circular patches beginning on face Erythema multiforme Erythema scarlatiniforme common after operations — throat normal or slightly reddened. ♦Erythema simplex Extravasation of L'rine ' Fourth Disease ' Gout Hydroa, I. Influenza sometimes scarlatiniform Intertrigo Kidney, Cirrhosis of Leprosy Malingering ' erythema artefactum ' Myositis Pellagra, I. 2 343-344 132 SKIN Erythema — continued Phlebitis Polymyositis Primula obconica contact with Ptomainism Raynaud's Disease Roseola, Syphilitic Rotheln *Rubefacients ♦Scarlatina neck first — punctate Sleeping Sickness annular Typhus (x) prodromal Urticaria around wheals Variola (x) prodromal stage Also from irritant baths or lotions and from soap enemata. 345. Macules or Flat Coloured Spots Angiokeratoma Dermatitis herpetiformis Erythrasma *Freckles Lupus Mycosis fungoides patches Nsevus Peliosis Rheumatica Purpura Roseola (x) Spilus Syphilis Typhus mulberry — chiefly on abdo- men 346. Papules A papule is a solid, circum- scribed, usually transient elevation less than a split pea in size. It may be the first stage of a vesicle pustule, or crust. *Acne Anthrax, I. Antitoxin Injection ' Caterpillar Rash ' Copaiba Rash Dermatitis herpetiformis Eczema, I. *Enteric Fever lenticular — several crops, chiefly about hypo- chondria Erythema multiforme Influenza Lichen planus flat-topped, purplish Lichen ruber flat and sometimes umbili- cated Lichen scrofulosorum confluent *Measles face first ; spots isolated at first, afterwards grouped Miliaria Papulosa Paratyphoid Phthiriasis Pityriasis rubra Prurigo Psittacosis Roseola Rotheln Scabies Sporotrichosis 344-346 SKIN 133 Papules — continued Syphilis esp. around forehead (' Corona Veneris ') Varicella, I. several crops Variola first 3 days of eruption — face and wrists first Verruca plana Xerodermia 347. Vesicles (' Watery Heads ') Anthrax Antimony externally Arnica externally Arsenic-poisoning, Chronic Bites Bromism Cheiropompholyx Dermatitis herpetiformis „ repens *Eczema Erythema multiforme Foot-and-Mouth Disease hands and feet Glanders Grocer's Itch Herpes iris rings Herpes simplex *Herpes zoster track of a nerve, u rt. intercostal Impetigo contagiosa Lichen urticatus Lymphangioma circum- scriptum Miliaria Poliomyelitis, Acute (x) *Scabies esp. between fingers Sudamina Sulphur Inunction Syphilis (x) * Varicella, i. 12th to 36th hour of disease, not umbilicated, collapse on pricking, several crops, fluid rarely turbid. Size variable, more numerous on trunk than on face and limbs. Variola 3rd to 6th day, umbilicated, do not collapse on prick- ing, single crop, become turbid before drying up. Size uniform, most marked on face and ex- tremities. More on back than on chest and abdo- men. 348. Bullae Anasarca Bromism Cheiropompholyx Dermatitis herpetiformis Epidermolysis bullosa Erysipelas Erythema bullosum iris Gangrene, i. Glanders Hydroa gestationis Impetigo contagiosa (x) Iodism (x) Leprosy Meningitis, Cerebro-spinal Mor van's Disease 346-348 134 SKIN Bullae — continued *Pemphigus Raynaud's Disease black and symmetrical Rupia, I. Scurvy containing blood Syphilis, Hereditary Syringomyelia affected limb Urticaria bullosa Bullse may also be due to burns, friction or vesi- cants, or to Primula obco- nica or Rhus toxicoden- dron, and they occur in workers in tar, varnish, and aniline dyes. 349. Pustules or Mattery Heads Anthrax *Ecthyma Eczema pustulare Drug Eruptions bromides, iodides, copaiba, etc. Glanders *Impetigo contagiosa Porrigo Pyodermatitis vegetans Scabies Sporotrichosis Sycosis Varicella (x) Variola 350. Superficial Nodules * Tubercles ' or A tubercle is a large papule which does not undergo resolution and is apt to cicatrise. *Acne *Bromism Carcinoma, Secondary Elephantiasis Epithelioma Gummata Iodism (x) Keloid Lupus *Molluscum Neuro -Fibromata Neuroma Phyma Recklinghausen's Disease generalised neuro - fibro- mata Rodent Ulcer, i. Scrofula Sporotrichosis Sycosis Syphilis Vitiligo *Warts Yaws 351. Gangrene Aneurysm Arsenic-poisoning *Atheroma Cauda Equina Affections Claudication Intermittente, in. *Diabetes Embolism s. symmetrical Emphysema, Cutaneous Endarteritis *Ergotism dry Ery thromelalgi a Iodides 348-351 SKIN 135 Gangkene — continued Impetigo Contagiosa Leprosy surrounding skin pale Locomotor Ataxy Leprosy Meningo-myelitis Lupus vulgaris Morvan's Disease ringed with ' apple jelly Myelitis nodules ' Neuritis, Peripheral Mycosis Fungoides Orthoform, Eifect of with tomato-like growths Paralysis Phlebitis Pemphigus vulgaris not raw underneath moist Psoriasis Rupioides Pyaemia base ulcerated Quinism *Raynaud's Disease Ringworm (x) ♦Senility Rupia Syringomyelia laminated cones Trauma ♦Scabies Thrombosis Sycosis Tumours, Pressure of ♦Variola Gangrene may be caused by Yaws, Secondary tight bandages and car- raspberry crusts bolic-acid dressings. Crusts often hide an ulcer (364). 352. Crusts or Scabs Due to ' caked ' discharge. 353. Wheals A crust may be the last Like nettle-stings stage of an eruption which Angeioneurotic (Edema began as a papule. Cerebro-spinal Meningitis Acne sebacea Dengue fatty Dermatitis herpetiformis ♦Ecthyma Gallstone Colic (x) ♦Eczema Gastro-enteritis Eczema rubrum Hydatids like guttapercha tissue Kidney, Cirrhosis of O J. Peliosis Rheumatica Erythema multiforme Polymyositis Favus Tapeworm yellow ' scutula ' or cups — ♦Urticaria scaly Also Nettle-sting and the Herpes following drugs : Impetigo Antimony 351-353 136 SKIN Wheals — continued Antipyrin Antitoxin Bromides Copaiba Iodides Morphine Quinine Santonin Sulphonal 354. Ulcers A circumscribed skinless area. Anthrax Atheroma Cancer Diabetes Eczema, in. Elephantiasis (x) Epithelioma Erythema Induratum Frostbite ringers, toes, and nose Gangrene Glanders Gout superficial, over gouty joints Innervation, Deficient see Perforating Ulcer (866) Lupus vulgaris with ' apple jelly nodules ' Rodent Ulcer Sarcoma Scurvy * bullock's liver crusts ' Senile Decay Syphilis, Tertiary circular, with abrupt edges and dark red areola Trauma Tuberculosis on neck or near a joint, oval or confluent, bleed easily, edges undermined, pink areola Varicose Veins *** (Edematous granulations usually imply diseased bone. 355. Condylomata Moist flattened swellings , occurring near junction o f skin with mucous mem- brane. Syphilis 356. Skin Organisms A rapid method of diag- nosing ringworm consists in dabbing a patch with some cotton wool soaked in chloroform. On evap oration, the hairs will look as if dusted with hoar frost (see 313). Acarus Scabiei (Itch) Achorion Schonleinii (Favus) Bacillus Acnes (Acne, Area, Seborrhoea) Cimex Lectularius Kala Azar (Host) Culex Fatigans (Carrier of Filariasis) 353-356 SKIN 137 Skin Organisms — continued Flask-shaped Bacilli (Seborrhcea, Area) Larvae of Flies (Myiasis) Microbacillus of Sabouraud (same as B. Acnes) Microsporon Audouini (Ringworm — 90 per cent, of London cases) Microsporon Furfur (Pityriasis versicolor) Microsporon Mentagraphytes (Sycosis) Microsporon Minutissimum (Erythrasma) Morococcus of Unna (Eczema) Pediculus Capitis Pediculus Corporis (Phthiriasis ; said also to be the carrier of Typhus) Pediculus Pubis Pulex Penetrans Trichophyton Megalosporon Ectothrix (Ringworm, esp. Kerion) Trichophyton Megalosporon Endothrix (Ringworm) (For Itching see 218) 356 138 THE HEAD 357. THE HEAD The three measurements used for determining the size of the head are, (a) from one meatus to the other ; (b) over the top of the head from the root of the nose to the occipital protuberance ; and (c) horizontally round the skull on the level of the supra- orbital ridges and the occipital protuberance. 358. Shape and Size Altered Achondroplasia large and broad, ' bull-dog ' type with large vault Acromegaly enlarged bones (esp. inf. maxilla) and soft parts Cretinism large, flat-topped Hydrocephalus large and spherical Hypertrophy of Brain even enlargement Idiocy, Macrocephalic large and irregular Idiocy, Microcephalic small and triangular, with apex at crown Infantile Hemiplegia flattened on one side Leontiasis Ossea large and globular, with pronounced orbits Mongolian Imbecility short and spherical Myxcedema large, with ' full-moon face ' Osteitis deformans uniformly large and grow- ing, with triangular face Rickets quadrilateral profile ; high, square, and prominent forehead Syphilis, Hereditary depressed sutures sur- rounded by bosses termed Parrot's Nodes ('hour- glass ' or ' hot-cross bun ' head). 359. Swellings on Head Abscess Cephalhaematoma neona- torum Cirsoid Aneurysm worm-like *Cysts, Sebaceous Hsematoma Hernia Cerebri Meningocele Mycosis Fungoides (x) Naevi Nodes Trauma Head Fixed (see Stiff Neck, 710) 360. Voluminous or Rolling Head Inability to support the weight of the head ; normal under 2 months. 357-360 THE HEAD 139 VOLUMINOUS OR ROLLING Head — continued Congenital Myotonia (x) Hydrocephalus Idiocy Multiple Neuritis (x) Myasthenia Gravis *Rickets (See Hypotonia, 1349) 361. Retracted Abscess, Postpharyngeal „ Subtentorial * Basilar Meningitis tuberculous or simple Catalepsy Cerebro -spinal Meningitis Cyanosis, Acute Encephalitis, Acute Faucial Inflammation Haemorrhage, Cerebellar Hydrophobia Hystero-epilepsy Meningitis, Suppurative ' Meningisme ' (Dupre) Otitis Media, Acute in infants Paramyoclonus multiplex Pneumonia, ' Cerebral ' Post-basic Meningitis Spinal Meningitis, Int. Strychnine-poisoning Teething (x) Tetanus Thrombosis, Sup. Longitu- dinal Torticollis, Spasmodic Tumours, Subtentorial, n. Typhic State (x) (62) (See Opisthotonos, 1426) 362. Oscillating Aortic Aneurysm Epilepsy Friedreich's Disease Hereditary Cerebellar Ataxy Meniere's Disease Otitis Media Paralysis Agitans ♦Rickets 363. Nodding (' Spasmus Nu- tans *) Epilepsy Habit Spasm Hysteria Miner's Nystagmus (See 1413) 364. De Musset's Sign A rhythmic nodding of the head, synchronous with the heart beat. * Aortic Regurgitation Arterio-sclerosis Exophthalmic Goitre (x) Left Hypertrophy with arterio-sclerosis *** The name is that of the poet — a sufferer. 365. Gould's Sign The patient sees best with the head bowed. Retinitis Pigmentosa 366. (Edematous *Abscess Anasarca Erysipelas Furuncle in Meatus behind ear 360-366 140 THE HEAD (Edematous- Glanders forehead :ontinued Mastoid Periostitis Mediastinal Tumour Otitis interna, Suppurative behind ear Thrombosis of Lat. Sinus behind ear Thrombosis of Superior Longitudinal Sinus forehead (See Anasarca, 335) 367. Enlarged Veins Hydrocephalus Mediastinal Tumour Thrombosis of a Sinus Tuberculous Meningitis Tumours of Neck 368. FONTANELLES The small soft areas on a baby's head. They should all close before the end of the second year. 369. Bulging Fontanelles Hydrocephalus Hypersemia of Brain Meningitis Tumour of Brain Ventricles, Effusion into 370. Depressed Fontanelles Anaemia of Brain Cholera Diarrhoea Marasmus Spurious Hydrocephalus Wasting Diseases (311) 371. Late in Closing Cretinism Hydrocephalus Mongolian Imbecility Rickets 372. Large Fontanelles Cretinism Hydrocephalus *Rickets Syphilis, Hereditary 373. Broad Sutures or Seams Cretinism Hydrocephalus Rickets 374. Overlapping Sutures Infantile Wasting Diseases (see Depressed Fontanelles, 370) 375. Craniotabes Areas of thinned bone in occipital and parietal regions. Hydrocephalus Rickets Syphilis, Congenital 366-375 THE HAIR J41 376. THE HAIR 377. Weak Hair. — The breaking strain of hair may be easily estimated by using a Salter's letter balance. Each end of the hair is held between finger and thumb and its middle is stretched over the letter holder, which is then slowly pulled down by the hair until the latter breaks. The number of ounces at which it breaks is noted. The author made a large number of experiments in this way, and found that 6| ounces was the general average for hair, that white hair was stronger than that which had not changed its colour, and that water and almost all toilet preparations weakened the hair to some extent, while oils strengthened it. The curling tongs had very little effect, but stretching produced a marked weakening, due to the hair not regaining its original length. As an aid to diagnosis, if falling hair prove of normal strength the cause must be in the scalp or in the failure of bodily strength, e.g. anaemia, fevers, etc. 378. Baldness or Thin Hair Alopecia universalis *An3emia Arsenic-poisoning *Convalescence from Fevers Cretinism Eczema, Chronic Enteric Fever Erysipelas Exophthalmic Goitre Facial Hemiatrophy on wasted side Gout Hydrocephalus Lymphadenoma (x) Mongolian Imbecility mousy Myxcedema Phthisis Progeria Psoriasis *Seborrhcea Senility Syphilis Thallium Acetate, Action of It is sometimes associated with neuralgia or dental trouble, and is often hereditary. 379. Bald Patches *Alopecia Areata Alopecia of Brocq depressed Eczema (x) Facial Hemiatrophy Favus Folliculitis Decalvans Gummata Ichthyosis Impetigo sequel Lupus erythematosus Keratosis 376-379 142 THE HAIR Bald Patches — continued Morphea Psoriasis Rickets back of head *Ringworm *Scars Sclerodermia Seborrhoea Syphilis, Secondary Variola (See Scars, 343) 380. Hypertrichosis Idiocy Menopause Moles Nephroma Suprarenal Tumour often sudden Tuberculosis of Children down or lanugo 381. * Point of Exclamation Hairs' (I) *Alopecia Areata Ringworm, in Seborrhoea (x) Absent in Brocq's Alopecia. 382. Matted Hair This is generally due to neg- lect of combing and oiling during a severe illness. Eczema *Pediculosis Plica Polonica 383. Beaded Hair Hodara's Disease Leptothrix Piedra Trichorrhexis Nodosa Trichosis, Giovanini's 379-383 THE FACE 143 384. THE FACE Pallor is chiefly of importance when the patient is known to have had a good colour previously. It is normal in night-workers and those who have insufficient sunlight. 385. Pallid (including Anaemia) Anaemia is distinguished by the pallor of the con- junctiva under the lids. Amenorrhcea Amyloid *Anaemia Ankylostomiasis *Aortic Regurgitation „ Stenosis Aplastic Anaemia Arsenic-poisoning Arterio-sclerosis or cyanosed Atony of Stomach Atrophy of Heart Banti's Disease Bilharzia Cancer of Pancreas Chloroma Chlorosis in blondes Cholera Dilatation of Heart Dysentery Endocarditis Exophthalmic Goitre Haematocele ♦Haemorrhage Hyperlactation Inversion of Uterus Leukaemia Lymphadenoma Malaria Menorrhagia Mercurialism Mitral Stenosis, I. patchy Multiple Myomata Myocarditis, Acute Myxcedema waxy Nephritis, Chronic Ovarian Disease Periarteritis Nodosa Pernicious Anaemia Phthisis, I. Plague Relapsing Fever Rheumatoid Arthritis Status Lymphaticus Tabes mesenterica Thrombosis of Pulmonary Artery Trichinosis Tuberculosis Uterine Fibroid 386. Transient Pallor Alcoholic Coma Angina Pectoris Asthma, Spasmodic or cyanosed Colic *Collapse Compression of Brain, in. ♦Concussion of Brain Epilepsy, I. Faints Gastric Irritation Meniere's Disease 384-386 144 THE FACE Transient Pallor — con- tinued Petit Mai *Shock ' Spinal Concussion ' *Syncope Trance Tuberculous Meningitis *** Also poisoning by depres- sants. 387. Flushed Face Ague hot stage Alcoholism, I. Apoplexy Cancrum Oris one cheek Concussion of Brain, in. Enteric Fever, in. hectic Fevers, i. Hysterical Convulsions Paralysis of Sympathetic unilateral Phthisis, in. hectic Pleurisy, Acute Pneumonia, Acute esp. on affected side Remittent Fever Rheumatism, Acute Uterine Tumours A flushed face is not incon- sistent with anaemia. 388. Transient Flushes Amenorrhea a Chlorosis Constipation Dysmenorrhea Enteric Fever Epileptic Aura Exophthalmic Goitre Indigestion Lactation *Menopause Neuralgia, Trigeminal Neurasthenia Nitrite of Amyl Nitroglycerin Pregnancy *Tuberculous Meningitis 389. Grey or Slaty Antifebrin Argyria Hse machrom atosis Pellagra Sulph-hsemoglobinuria 390. Earthy or Sallow Anaemia of Dark Persons Atony of Stomach Bromism Cancerous Cachexia Chlorosis greenish grey in dark per- sons Cirrhosis of Liver Colitis *Constipation Duodenal Catarrh Enteritis, Chronic Exophthalmic Goitre Facial Hemiatrophy parchment-like yellowish patches *Faecal Accumulation Fatty Degeneration of Heart Gastritis, Chronic Hepatic Abscess Lead-poisoning 386-390 THE FACE 145 Earthy or Sallow — continued Mediastinitis Pleurisy in Children Rheumatoid Arthritis *Syphilis, Hereditary ' cafe au lait ' 391. Lemon Yellow Aplastic Anaemia Congenital Cholaemia *Pernicious Anaemia 392. JAUNDICE ICTERUS R In old- standing cases, and especially in cancer of the liver, the skin becomes greenish, owing to the conversion of bilirubin into bilverdin. 393. Nervous Jaundice Anxiety Concussion of Brain (x) Fourth Ventricle, Lesion of Fright, etc. Menstruation (x) 394. Obstructive Jaundice (a) Intrinsic Obstruction within the duct. Cancer of Duct *Catarrh of Bile-ducts ,, of Duodenum Cholangitis Chronic Fibrous Cholangitis Congenital Deficiency of Duct Distomata Foreign Bodies from Intes- tines Gallstones absent or late when in cystic duct Hydatids rupturing into duct Icterus neonatorum 'Inspissated Bile' (?) Roundworm in bile-duct Stricture of Duct spasmodic or organic Tumefaction of Duct-wall (6) Extrinsic Pressure upon the duct or its branches. Abscess, Hepatic Dysenteric, or Pyaeinic Adhesions, Peritonaeal Aneurysm abdominal aorta, coeliac axis, hepatic artery, or superior mesenteric artery Cancer of Liver, Bile Duct, Duodenum, Pancreas, Right Kidney, or Omen- tum Cirrhosis of Liver slight Cyanotic Liver from mitral disease, etc. Cystic Tumour of Duct Duodenal Scar from old Ulcer Duodenitis Faecal Accumulation (x) Glands, Enlarged Portal from cancer, leukaemia, lymphadenoma, lympho- sarcoma, tuberculosis or syphilis 390-394 146 THE FACE Obstructive Jaundice — con- tinued Hepatitis, Acute (x) Hydatids Icterus neonatorum Kink of Bile Duct from tumours, Riedel's lobe, etc. Movable Kidney (rt.) intermittent Pancreatitis Perihepatitis from contraction Peritonitis (x) from contraction Pneumonia, Acute slight Pregnancy (x) Pylephlebitis, Suppurative Splenomegaly, Gross Syphilitic Liver Tumour of Duodenum, Rt. Kidney, Rt. Suprarenal Capsule, Liver, Pancreas, Ovary, Omentum, Sto- mach, Colon, or Uterus 395. Toxemic Jaundice Acute Yellow Atrophy Buhl's Disease Congenital Cholaemia Endemic Jaundice Endocarditis, Ulcerative (x) Hsemoglobinuria Infantum Haemorrhage Influenza (x) Malaria, in. Pernicious Anaemia Intermittent Poisoning by Antimony, Arseniuretted Hydrogen, Chlorate of Potash, Cop- per, Liquid Chloroform, Mercury, Phosphorus, or Snake-venom Pyaemia Relapsing Fever Remittent Fever Typhus Weil's Disease temporary Yellow Fever 396. Lividity or Cyanosis Usually due to insufficient air reaching the blood or vice versa. Ague cold stage Alcoholism Aneurysm, Intrathoracic (x) „ of Heart Arterio-sclerosis, in. Ascites, Extreme Asphyxia * Asthma, Spasmodic Bronchial Glands, Enid. * Bronchitis, Acute ,, Plastic Broncho-pneumonia Bulbar Paralysis Cancrum Oris one cheek Cholera, HI. Collapse of Lung Cyanosis, Enterogenous Dilatation of Heart Diphtheria, Laryngeal Displaced Heart Dyspnoea, Acute Emphysema, in. Epilepsy, ii. 394-396 THE FACE 147 Lividity — continued Fibroid Phthisis *Foreign Body in Air-pas- sages Glossitis, Acute Hemoglobinuria, Infantile Hernia, Diaphragmatic Hooping- Cough end of paroxysm Hydrothorax, Sudden Hypertrophy of Right Ven- tricle Hypostatic Congestion of Lungs Iodism (x) oedema laryngis Intercostal Rheumatism Laryngitis, Acute Laryngismus Stridulus Locomotor Ataxy laryngeal crisis Lung, Embolism of ,, Sarcoma of *Malformation of Heart esp. pulm. stenosis ; less marked in patent septum Mediastinal Tumours Mediastinitis *Mitral Disease Myocarditis, Acute (Edema of Lung Laryngis Paralysis, Bilateral Abduc- tor „ of Diaphragm „ of Respiratory Muscles Pericardial Effusion Pericarditis Pericardium, Adherent Pernicious Intermittent Peritonitis, Acute (x) Pleurisy ,, Diaphragmatic Pneumonia, Acute Pneumothorax Poisoning by Anilines, Anti- febrin, Antipyrin, Hydro- cyanic Acid, Nitro-Ben- zine, Opium, Phenacetin, Strychnine and Intestinal Toxines Pulmonary Apoplexy Retropharyngeal Abscess Spasm, Adductor Splenomegalic Polycythe- mia Sunstroke Tetanus Thrombosis of Pulmonary Artery Trypanosomiasis in patches *Tuberculosis, Acute greater than in bronchitis Tumour, Laryngeal Tympanites Vena Cava, Obstructed (See Dyspnoea, 1223) 397. Venous Stigmata Patchy redness showing groups of enlarged venules. *Alcoholism Cirrhosis of Liver Erythromelalgia Facial Hemihypertrophy Paroxysmal Cough Vomiting, Chronic l2 396-397 148 THE FACE 398. Ulceration, Facial Lupus vulgaris ' apple jelly nodules ' Rodent Ulcer rolled up edges Syphilis, Secondary or Ter- tiary (See Ulcers, 354) 399. Sides Unequal Congenital Asymmetry „ Torticollis Facial Hemiatrophy both tissues and muscles wasted Facial Hemihypertrophy Facial Paralysis, Old esp. if dating from child- hood Infantile Paralysis, Old Paralysis of Cervical Sym- pathetic 400. Flapping Cheek *Apoplexy Coma (64) Diphtheritic Paralysis ♦Facial Paralysis toothlessness may be misleading. *** Unilateral 401. Pinched Face Ague (cold stage) Atrophy Cholera Colic *Collapse (235) Death, Impending ' Facies Hippocratica ' Diarrhoea Dysentery ♦Enteric Fever Exophthalmic Goitre Gangrene of Lung Haemorrhage Idiopathic Muscular Atro- phy Lipodystrophia, Progressive Perforation of Stomach or Bowel *Phthisis Remittent Fever Rheumatoid Arthritis Sclerodermia Spinal Caries Strangulated Hernia Tabes mesenterica ♦Tuberculosis ♦Wasting Diseases (311) 402. Thickened Features Nonpitting Acromegaly Cretinism Leprosy Myxcedema Sclerema 403. Swollen Face Local or general ♦Abscess Actinomycosis lower jaw Anasarca (335) Aneurysm, Thoracic Angioneurotic (Edema Anthrax Boils Cancrum Oris one cheek 398-403 THE FACE 140 Swollen Face — continued Chloroma temples Dacryocystitis Dropsy etc., of Antrum Dengue *Dental Abscess Dyspituitarism ' pudding face ' Emphysema, in. Enlarged Bronchial Glands (x) * Erysipelas Exophthalmic Goitre Hooping Cough Hydrocephalus (x) Leprosy Mediastinal Tumour *Mitral Regurgitation Mumps Myxoedema *Nephritis, Tubular (Edema (335) „ Circumscribed Acute Parotid Tumour, Gaseous Parotitis, Gouty Pneumothorax Scurvy Thrombosis of Cavernous Sinus Thrombosis of Superior Lon- gitudinal Sinus forehead Trichinosis Trypanosomiasis *Urticaria Variola ^Confluent A puffy face is also common in wasted infants, and it may be caused by cough- ing or vomiting. 404. Prae-auricular Gland En- larged The area of irritation in- cludes cheek, eyelid, ear, and temple. Chancre of Eyelid Conjunctivitis, Parinaud's Dental Caries, Upper Epithelioma Melanotic Sarcoma Septic Infection Tuberculosis of Ear Varicella 405. Twitchings of Face Blepharospasm *Chorea Convulsions Dentition esp. wisdom teeth Epilepsy Exophthalmic Goitre of levatores palpebrarum ' Abaclie's Sign ' General Paralysis lips Gilles de la Tourette's Disease *Habit Spasm Hysteria Meningitis Mimic Tic *Muscular Asthenopia Paramyotonia congenita lower part — excited by cold Polypus Strychnine Tetanus Tic-douloureux Tooth, Carious (See Clonic Spasms, 1406) 403-405 150 THE FACE 406. Frontalis Symptom Involuntary persistence of a voluntarily induced wrinkling of the forehead Paralysis Agitans 407. Facies An experienced clinician may sometimes make a diagnosis at a glance. Abdominal Disease pinched face, sunken eyes, anxious expression Acromegaly lower jaw and all bony facial prominences en- larged. Long thick upper lip Adenoids vacant expression, open mouth and collapsed nos- trils Chloroma frog -like Chronic Bright' s Disease puffy, putty colour, ex- pressionless Cretinism face broad ; ears large ; nose flat and large ; lips and eyelids thick ; mouth open Enteric Fever drawn inelastic skin, pallor, resigned expression Exophthalmic Goitre eyes prominent and staring ; face drawn and thin ; tremors Facies Leonina (Leprosy) Due to thickened ridges of skin Hydrocephalus prominent forehead and small features — ' Marshall Hall Facies ' Leontiasis Ossea bony prominence over orbit. Lion-like expression Locomotor Ataxy forehead wrinkled ; eye- lids di'ooping ; pupils con- tracted and fixed Miculicz' Disease marked broadening of the cheeks with external ptosis Mitral Disease, Uncompen- sated puffy face, purple com- plexion, anxietas Mongolian Idiocy ears large ; palpebral fis- sures sloped downwards and inwards ; tongue thick and protruded ; complexion florid Myasthenia Gravis eyes drooping ; lower jaw dropped. Sometimes a ' nasal smile ' Myxcedema swollen expressionless fea- tures, thick lips and ears, scanty hair Paralysis Agitans face stiff — as if starched, eyelids retracted, eyeballs restless Syphilis, Congenital bumpy overhanging fore- head, pug nose, cafe-au- lait skin, radiating lines at angles of mouth 406-407 THE FACE 151 Facies — continued Typhic or Typhoid state flushed cheeks, bright eyes, tremulous lips *** Facies Hippocratica occurs in the dying and is marked by pinched and curved nose, sunken eyes and temples, open mouth, etc. 408. Jadelot's Traits Labial Line A line extending outwards from angle of mouth. Respiratory Diseases * * * Nasal Line A line starting from the nose and forming a semi- circle round the mouth. Digestive Diseases Dr. Ainslie Hollis has called attention to varia- tions in the angle of the naso-labial fold. 409. Omega Melancholicum Vertical folds resemble the Greek letter a> between the eyebrows (Schuelc's Sign) Melancholia 407-409 152 THE EXPRESSION 410. THE EXPRESSION In organic aphasia the expression sometimes represents the opposite, or a different, emotion ; so that a distressed look may be indicative of pleasure. The observation has doubtless been made by others ; but, if so, I have found no record of it. Since this was written, it has been termed 'paramimia.' (See 1249.) 411. Vacant Expression Adenoids Anaemia, Advanced Bulbar Paralysis Collapse Cretinism Dementia Diphtheritic Paralysis Disseminated Sclerosis Enteric Fever *Facial Paralysis Hydrocephalus Hysteria Idiocy Idiopathic Muscular Atro- phy Landouzy-Dejerine's Para- lysis Myasthenia Gravis Myxcedema sad Neuritis Optic Thalamus, Lesion of *Paralysis Agitans ' Parkinson's mask ' Paralysis, General Plague Tetanus, I. Typhus A Worms 412. Leonine Expression Leontiasis Ossea bony masses Leprosy Masses of thickened skin 413. Anxious Expression (' Anxietas ') Aneurysm *Angina Pectoris Appendicitis Colic (122) Diaphragmatic Pleurisy Dysentery *Dyspnoea, Acute (1223) Emphysema, Interstitial Empyema Fatty Degeneration of Heart Fractured Ribs or Sternum *Gallstone Colic Gangrene of Lung Glossitis, Acute Hepatic Abscess Hydrophobia Injuries, Severe *Intestinal Obstruction, Acute Laryngitis, Acute ,, Diphtheritic Lead Colic Myocarditis, Acute 410-413 THE EXPRESSION 153 Anxious — continued *(Edema Laryngis Pericarditis with lips retracted Perihepatitis Peritonitis, Acute Pleurisy, Acute Pneumonia, Acute Pneumothorax Septicaemia ♦Spasmodic Asthma ♦Strangulated Hernia Uraemia 414. Threatening Expression Delirium Tremens or suspicious Encephalitis Hydrophobia *Mania 415. Unmeaning Grimaces ♦Chorea ♦Gilles de la Tourette's Disease Hereditary Cerebellar Ataxy Hydrocephalus ] lysteria Insanity Malingering Spasm of Facial Nerve Strychninism Tetanus Tic Convulsif (See Twitchings, 1407) 416. Risus Sardonicus A drawing outwards of the angles of the mouth. Abdominal Cancer Catalepsy Hysteria Inflammation of Diaphragm Landouzy-Dejerine Para- lysis ' transverse smile ' ♦Peritonitis Scars, Contraction of Sclerodermia, Facial Spasm of Facial Nerves Strychnine - poisoning ♦Tetanus Ulceration of Intestine 413-416 154 THE EARS 417. THE EARS To examine the tympanic membrane, a Gruber's speculum, a strong light, and a laryngeal mirror of, preferably, 4-in. focus, should be used, or, failing this, Brunton's Auriscope. The external car being drawn upwards and backwards (in a child simply backwards), the speculum is gently inserted for about half an inch or so as to stop short at the bony portion of the canal. The light should be thrown slightly upwards. Wax must be softened by hydrogen peroxide and removed by syringing ; hairs should be either smeared flat with lanoline or removed with the scissors. 418. Malformations Absent Auricles or represented by tubercles Accessory Auricles Atresia Meatus Fistulous Auricles Frostbite Also injuries such as are received by prize-fighters. 419. Tophi nodules on ears Gout in system 420. Hsematoma (Blood tumour) It is much commoner on the left ear. *Dementia Epilepsy General Paralysis Idiocy especially in males Mania Melancholia Trauma 421. Waxy Ears Addison's Disease *Anaemia Chlorosis Frostbite, n. Leukaemia Myxcedema (See Pallor, 385) 422. Livid Ear Cold Cyanosis (396) Dyspnoea (1223) Malformation of Heart Nsevus 423. Swollen Ear Abscess Blows Erysipelas Furunculosis Gummata Herpes Inflamed Tophi Mastoiditis the auricle projecting down wards and outwards 417-423 THE EARS 155 Swollen" Eae — continued Naevus *