THE ^DIAGNOSTICS OF _ INTERNAL MEDICINE A CLINICAL TREATISE UPON THE RECOGNISED PRINCIPLES OF MEDICAL DIAGNOSIS, PREPARED FOR THE USE OF STUDENTS AND PRACTITIONERS OF MEDICINE BY V GLENTVVORTH REEVE BUTLER, A.M., M. D. Chief of the Second Medical Division, Methodist Episcopal Hospital ; Attending Physician to the Brooklyn Hospital ; Consulting Physician to the Bushwick Central Hospital ; formerly Associate Physician, Departments of Diseases of the Chest and Diseases of Children, St. Mary's Hospital, Brooklyn, N. Y. ; Fellow of the New York Academy of Medicine ; Member of the Medical Society of the County of Kings, etc. WITH FIVE COLOURED PLATES AND TWO HUNDRED AND FORTY- SIX ILLUSTRATIONS AND CHARTS IN THE TEXT NEW YORK D. APPLETON AND COMPANY 1902 COPYRIGHT, 1901, BY D. APPLETON AND COMPANY PREFACE THIS book has been written from the point of view of practical clinical work. The physician meets primarily symptoms and signs the evidences of disease; subsequently it is decided that the symptoms found indicate the presence of a specific ailment. This volume, therefore, naturally divides itself into two parts : first, a study of symptoms and their indications ; and, second, a study of diseases and their characteristics. Part I The Evidences of Disease comprises : (1) A brief con- sideration of the clinical anatomy and physiology of certain organs and systems ; practical points of everyday utility. (2) A description of the approved methods of examination. It has been well said by a capable reviewer that "the basis of the art of diagnosis is a thorough knowledge of clinical methods." (3) A careful considera- tion of the many signs and symptoms encountered in the practice of internal medicine. (4) A statement of the diagnostic significance of each sign and symptom i. e., the disease or diseases, the pres- ence of which is more or less strongly suggested by the finding of a given sign or symptom. While a prominent symptom seldom leads directly to the discovery of a disease, yet it is of importance to know the diagnostic value of individual symptoms. Part II Diagnosis, Direct and Differential contains : (1) Suc- cinct descriptions of recognised diseases and their symptoms, with (2) special reference to the diagnosis, direct and differential, of each disease. The qualifying terms applied to diagnosis are scientifically indefensible, but clinically useful. The two parts are, indeed, complementary. For example, if in Part I it is stated that the finding of a persistently rapid pulse may be explained by the presence of exophthalmic goitre ; or of a dry tongue and an inordinate thirst, by diabetes, one can turn to Part II and compare his case with the symptom-group of the disease in question. Conversely, when in Part II a high-tension pulse is mentioned as a symptom of angina pectoris, or Kernig's sign of meningitis, a reference to Part I will discover the method of esti- mating high tension or of eliciting Kernig's sign. iv PREFACE It is hoped that, owing to its choice of material and method of arrangement, the book contains between two covers practically all that is essential for the making of a diagnosis, and that no helpful clew in obscure cases has been overlooked. The value of modern laboratory methods has been fully appreciated; so also has the importance of symptoms, subjective and objective. Xo one can write upon the subject of this book without lying under obligations for the major portion of his material to the Mas- ters of Internal Medicine, but, as space forbids detailed references, this brief acknowledgment must stand as a very inadequate voucher for a heavy debt. Everything, indeed, has been subordinated to the main purpose of the book, which is to facilitate in a practical way the making of a thorough examination and a correct diagnosis. It is believed that the Synopsis of Examinations, which immediately precedes the body of the book, will be found useful. Special care has been taken to secure clearness of arrangement by the liberal use of italics and bold-face type to catch the eye ; and to promote ease of reference by varying the odd-page headings, as well as by the provision of an ample, but not too bulky, index. Plates III and IV are composed of selections reproduced (with the kind permission of the authors and publishers) from the excel- lent illustrations in Cabot's Examination of the Blood and Simon's Clinical Diagnosis, mainly from the former ; Plate V of similar selections from Thayer's fine drawings of the malarial parasite. A large proportion of the illustrations are either original or redrawn, without, it is believed, sacrificing utility for originality. Mr. Howard J. Shannon has put my rough sketches into workmanlike and, so far as compatible with the subject, artistic form. For his aid I am indebted to the liberality of the publishers, whose imprint is a guarantee of good work and good material. The bulk of the volume (pages 1 to 908) is from my own pen. Of the remainder, Dr. Frank TV. Shaw, my associate at the Metho- dist Episcopal Hospital, has prepared the sections on Parasites and the Intoxications ; Dr. Henry G. Webster, my associate at the Brooklyn Hospital, those on Diseases of the Kidney and Constitu- tional Diseases ; Dr. Henry P. De Forest, of Brooklyn, that on Dis- eases of the Blood and Ductless Glands ; and Dr. Smith Ely Jelliffe and Dr. A. B. Bonar, of Manhattan, that upon Diseases of the Ner- vous System assistance kindly given and gratefully received. Dr. J. P. TVarbasse has made valuable criticisms. G. E. B. 229 GATES AVENUE. BOROUGH OF BROOKLYN, CITY OF NEW YORK. CONTENTS PAGE SCHEDULE OF EXAMINATIONS xix PRELIMINARY CONSIDERATIONS 1 Diagnosis 1 Difficulties in 3 Obtaining evidence 5 Keeping case histories . . . . . 6 PAKT I THE EVIDENCES OF DISEASE SECTION I. Considerations which may suggest or qualify a Diagnosis . . 13 Family history 13 Age 15 Sex 16 Nationality 17 Occupation 18 Residence 19 Habits 20 Previous diseases 20 SECTION II. History of Present Illness 23 SECTION III. Diagnostic Indications from the General Appearance . . 24 Dress and behaviour 24 Height and weight 25 Amount and character of adipose and muscular tissue .... 26 Conformation of body 27 Diatheses and cachexias 28 SECTION IV. Posture in Bed Mode of Moving Gait Station ... 30 SECTION V. Pain 35 Tenderness 52 Paraesthesias 54 SECTION VI. Vertigo 58 SECTION VII. Temperament Psychical Condition Insomnia ... 60 SECTION VIII. Disturbances of Consciousness 66 Diagnostic significance of coma 66 Diagnosis of the varieties of coma 67 SECTION IX. General Convulsions 71 SECTION X. Cutaneous Surface 75 Colour of skin . . . . 75 Heat of skin 81 v vi CONTENTS PAGE Moisture of skin 82 Rash or eruption , 83 Cicatrices 86 Dropsy, oedema, anasarca 87 Condition of veins 91 Emphysema of skin 92 Condition of joints 93 SECTION XI. The Temperature of the Body 95 Fever 100 Terminology of 102 Diagnostic classification of 106 Chills Ill SECTION XII. General Diagnostic Evidence from the Digestive and Genito- urinary Systems 112 Appetite 112 Thirst 113 Vomiting and gross character of the vomitus 113 Indications from presence of vomiting 116 Indications from macroscopic character of vomitus .... 122 Defecation and gross character of the stools 125 Constipation 126 Diarrhoea . 128 Faecal incontinence 130 Painful defecation 130 Rectal tenesmus 132 Character and abnormal contents of stools 132 Urination 139 Symptoms belonging to the genitalia . . . . . . . . 144 Males 144 Females 146 SECTION XIII. Symptom Groups of Clinical Significance 149 Coma: Dyspnoea: Fever 149 Hyperpyrexia : Internal hemorrhage 150 Shock or collapse 151 Syncope: Weakness or debility 152 Irritant poisoning : Jaundice : Obstructed portal circulation : Suppura- tive or hectic fever: Pyaemia: Tympanites: Typhoid status . . 153 SECTION XIV. Head and Face 154 Size and contour 154 Fontanels and sutures 158 Cranial bones 160 The facies of disease 160 Colour of the face 163 Skin of the face 164 The hair 165 (Edema or swellings of the face 166 Abnormal movements of the head 166 Abnormal fixity of the head 167 Facial spasm 167 Facial spasm 169 CONTENTS vii PAGE SECTION XV. The Ear 175 SECTION XVI. The Eye 180 The eyelid 180 The conjunctiva, sclerotic, and cornea 183 The pupil 185 The eyeball . 190 Vision . . . . 202 SECTION XVII. The Nose 211 SECTION XVIII. The Mouth 218 Lips 218 Buccal cavity 219 Gums 222 Teeth . 223 Tongue 225 SECTION- XIX. The Palate, Tonsils, and Pharynx 233 SECTION XX. Dysphagia 237 SECTION XXI. Examination of Larynx 238 Laryngeal paralysis 240 SECTION XXII. Voice and Speech 243 Aphasia 246 SECTION XXIII. Cough 256 SECTION XXIV. Sputum and its Gross Characters 259 SECTION XXV. The Neck 263 SECTION XXVI. The Extremities 271 Nails 271 Hand and fingers 272 Arm 278 Foot and leg 279 SECTION XXVII. The Back 284 SECTION XXVIII. Theory and Practice of Palpation, Auscultation, and Per- cussion 286 SECTION XXIX. The Chest (Thorax) 296 SECTION XXX. Anatomical Landmarks and Topographical Areas of the Thorax 304 SECTION XXXI. Examination of the Circulatory System 308 Pathological physiology of valvular defects 312 Topographical anatomy of the heart and its valves 318 Physical examination of the heart and its neighbourhood .... 321 Inspection and palpation 321 Percussion of the heart 330 Auscultation of the heart 339 Endocardial sounds (murmurs) 347 Exocardial sounds 360 Physical examination of the blood vessels (including the pulse) . . 363 The pulse 367 The sphygmograph 378 SECTION XXXII. Examination of the Lungs and Pleurae .... 382 Topographical anatomy 382 Physiology of the lungs 384 Inspection and palpation with reference to the lungs .... 386 viii CONTENTS PAGE Percussion of the lungs 396 Teehnic 396 Results of percussion in normal lungs 398 Results of percussion in disease of lungs or pleurae, or of neighbouring organs 399 Auscultation of lungs 409 Teehnic 409 Varieties and characteristics of the normal breath sounds . . . 410 The breath sounds in disease 413 The voice sounds in health and disease 417 Adventitious sounds or accompaniments 418 SECTION XXXIII. The Abdomen. Methods and Results of its General Ex- amination 423 Topographical marks, areas, and anatomy of the abdomen . . . 423 Methods and general results of abdominal inspection .... 427 Methods and results of general abdominal palpation and percussion . 430 SECTION XXXIV. Examination of the Digestive System .... 444 The esophagus 445 The stomach 447 Anatomy and surface relations . . . 447 Physical examination 448 Interpretation of the results of the physical examination of the stomach 455 Intestines and peritoneum 456 Topographical anatomy of intestines . . 456 Examination of intestines 457 The liver and gall bladder 461 Topographical anatomy of liver 461 Physical examination of liver and gall bladder 463 Diagnostic results of physical examination of liver and gall blad- der 467 The pancreas 470 SECTION XXXV. Examination of the Spleen 471 Topographical anatomy 471 Physical examination 471 Results of examination 474 SECTION XXXVI. Examination of Kidneys, Ureters, and Bladder . . 475 Kidneys 475 Topographical anatomy 475 Physical examination 476 Diagnostic results of physical examination 479 Bladder and ureters 480 SECTION XXXVII. Examination of the Nervous System .... 481 Physiological and anatomical data 481 Degeneracy 507 Examination of the muscles with reference to their nutrition, tone, and motor power 509 Motor disturbances 514 Spasm 514 Paralvsis . . 520 CONTENTS i x PAGE Sensory disturbances 527 Methods of examination 528 Diagnostic significance of 531 The reflexes 536 Superficial 536 Deep 537 Electro-diagnosis (nerve and muscle) 542 Apparatus and technic 542 Diagnostic indications from 547 Va-Miinotor and trophic disturbances 549 Cranial nerve functions 550 Cerebral localization . 553 Summary of diagnostic points 555 SECTION XXXVIII. Examination of the Blood 559 Technic of clinical examination of the blood 559 Counting red cells 559 Counting white cells 564 Estimating the haemoglobin 567 Microscopical examination of the blood 571 Order of procedure in the clinical examination of the blood . . . 574 The results and diagnostic significance of the clinical examination of normal and abnormal blood 575 The red cells 576 The leucocytes 579 Blood plates and M filler's blood dust 587 Parasites in the blood 587 Piagmodium malarice 587 Spirochcetce of relapsing fever . . . 591 Filaria Itominis sanguinis 591 Serum test (Widal) for typhoid fever 592 Blood tests for diabetes 593 Iodine reaction in suppuration 594 Results of haemanalysis in special diseases 595 SECTION XXXIX. Microscopical Examination of the Sputum . . . 596 SECTION XL. Examination of the Stomach Contents 604 Physiology of digestion 604 The chemical examination of the stomach contents, and the determi- nation of the motor power of the stomach 604 Test meals 605 The chemical tests and their technic 606 Testing the motor power of the stomach . . . . . . 612 The microscopic examination of the stomach contents .... 613 Diagnostic value of an examination of the stomach contents . . . 614 SECTION XLI. Microscopical Examination of the Fences 618 SECTION XLII. Diagnostic Inferences from the Results of Urinalysis . . 621 Evidence from physical examination of urine (quantity, colour, odour, consistence, specific gravity, deposits, etc.) 621 Evidence from chemical examination of urine (reaction, chlorides, phosphates, oxalates, sulphates, indican, urea, uric acid, albumin, blood and its compounds, the diazo-reaction, etc.) .... 626 x CONTENTS PAGE Evidence from microscopical examination of urine (fat, pus, red cells, epithelial cells, tube casts, etc.) 639 Collective results of urinalysis in special diseases and conditions . . 645 SECTION XLIII. Diagnostic Puncture and the Evidence derived therefrom . 648 Technic of puncture 648 Examination of fluid . . . ... . . . . . 649 Characters of the fluid according to its source 650 SECTION XLIV. The Uses of the Rontgen Light in Medical Diagnosis . . 654 PAET II DIAGNOSIS, DIRECT AND DIFFERENTIAL SECTION I. INFECTIOUS DISEASES Typhoid fever 655 Typhus fever . . . . . . 668 Relapsing fever 670 Dengue 671 Cerebro-spinal meningitis 672 Influenza 675 Whooping cough 677 Epidemic parotitis (mumps) . 678 Smallpox (variola) . . . . . . . . . . . 679 Vaccinia (cowpox) 683 Varicella (chicken pox) 683 Dysentery 700 Cholera Asiatica 703 Bubonic plague 705 Malarial fever 705 Rheumatic fever 710 Lobar pneumonia 712 Tuberculosis 723 Syphilis 737 Gonorrhceal rheumatism 742 Anthrax 743 Glanders (farcy) 744 Scarlet fever (scarlatina) 684 Measles (rubeola) 688 Rubella (rotheln) 689 Diphtheria 690 Erysipelas 693 Toxaemia, septicaemia, pyaemia 694 Yellow fever .699 Actinomycosis 745 Leprosy 745 Tetanus 746 Hydrophobia 747 Beri-beri 748 Mountain fever and sickness 749 Ephemeral fever febricula 749 CONTENTS xi SECTION II. DISEASES OF THE DIGESTIVE SYSTEM PAGE Diseases of the mouth 750 Diseases of the tongue 752 Diseases of the salivary glands 753 Diseases of the pharynx 753 Diseases of the tonsils 755 Diseases of the esophagus 757 Diseases of the stomach 760 Diseases of the intestines 776 Diseases of the liver, gall bladder, and bile ducts . . . . . . 800 Diseases of the pancreas 816 Diseases of the peritoneum 820 SECTION III. DISEASES OF THE RESPIRATORY SYSTEM Diseases of the nose 828 Diseases of the larynx 830 Diseases of the bronchi 833 Diseases of the lungs 841 Diseases of the pleura (and mediastinum) 856 SECTION IV. DISEASES OF THE CIRCULATORY SYSTEM Diseases of the pericardium 870 Diseases of the heart 875 Diseases of the arteries 900 SECTION V. DISEASES OF THE BLOOD AND DUCTLESS GLANDS Anaemia 908 Leucaemia 911 Pseudo- leucaemia 913 Purpura 916 Haemophilia 918 Scurvy 918 Addison's disease 922 Diseases of the spleen 923 Diseases of the thyroid gland 925 Diseases of the thymus gland 929 SECTION VI. DISEASES OF THE KIDNEY Movable kidney 929 Renal congestion 930 Uraemia 930 Acute Bright's disease 932 Chronic Bright's disease 933 Amyloid kidney 935 Pyelitis 936 Hydronephrosis 937 Nephrolithiasis 938 Tumours of the kidney 939 Cysts of the kidney 940 Perinephritic abscess 941 xii CONTENTS SECTION VII. DISEASES OF THE NERVOUS SYSTEM The neuroses: Diseases of undetermined pathogeny. PAGE A. Sensori-motor neuroses 942 B. Motor neuroses 950 C. Trophoneuroses 956 Diseases of the peripheral nervous system. A. Diseases of the peripheral sensory neurones 958 B. Diseases of the peripheral motor neurones 963 Diseases of the spinal cord and bulb 972 Systemic cord diseases 985 Inflammation of the spinal meninges 990 Inflammation of the membranes of the brain 992 Diseases of the cerebral substance 994 Syphilis of the nervous system 1004 SECTION VIII. DISEASES OF THE MUSCLES Myositis . 1005 Myotonia 1007 Myoclonia 1007 SECTION IX. CONSTITUTIONAL DISEASES Chronic rheumatism 1007 Muscular rheumatism 1008 Diabetes insipidus 100$ Diabetes mellitus . . . . 1009 Gout 1010 Arthritis deformans 1012 Rickets 1014 Obesity 1015 SECTION X. THE INTOXICATIONS : SUNSTROKE Alcoholism . 1016- Morphinism 1018 Acute opium-poisoning . 1018- Lead-poisoning 1019- Arsenical-poisoning 1023 Food-poisoning 10*23 Sunstroke 1025 SECTION XI. DISEASES DUE TO ANIMAL PARASITES Distomiasis . . . . . . 1027 Nematodes 1027 Cestodes 1029 Parasitic arachnida 1032 Parasitic insects . ...... 1033 PLATES, CHARTS, AND ILLUSTRATIONS FACING PLATE PAGE I. THE SHAPE AND RELATIONS OF THE THORACIC AND ABDOMINAL VIS- CERA, ANTERIOR ASPECT (Semi-diagrammatic) . ... 1 II. THE SHAPE AND RELATIONS OF THE THORACIC AND ABDOMINAL VIS- CERA, POSTERIOR ASPECT (Semi-diagrammatic) .... 1 III. RED CORPUSCLES, NORMAL AND ABNORMAL 578 IV. THE VARIETIES OF LEUCOCYTES 582 V. THE PLASMODIUM MALARIA, SELECTED AND REPRODUCED FROM THAYER'S PLATES . 588 I. Abortive pneumonia . . . . 97 II. Types of fever. Continued, remittent ; quotidian and tertian types of intermittent . . . . 103 III. Types of fever. Intermittent, quartan type ; suppurative and hectic fevr . 103 IV. Diagnostic indications from a sudden invasion of fever. No. 1 . . 106 V. Diagnostic significance of a gradual rise of temperature . . . 107 VI. Diagnostic significance of a gradual termination of fever . . . 107 VII. Diagnostic indications from a sudden invasion of fever. No. 2. . 108 VIII. Diagnostic indications from a sudden fall of temperature . . . 109 IX. Blood chart and haMnanalysis card for recording examinations . . 560 X. Typhoid fever. Showing typical temperature curve and prominent symptoms {557 XI. Typhoid fever. Fatal hemorrhage 662 XII. Typhoid fever. Bathing chart. Recovery 663 XIII. Typhus fever 669 XIV. Relapsing fever . .670 XV. Smallpox 679 XVI. Varioloid 681 XVII. Varicella 683 XVIII. Scarlet fever 685 XIX. Measles 688 XX. Pyaemia, post-operative, with pulmonary gangrene .... 697 XXI. Lobar pneumonia. Pulse, respiration, and temperature . . . 712 XXII. Broncho-pneumonia 845 xiii x i v PLATES, CHARTS, AND ILLUSTRATIONS FIGURE PAGE 1. Example of a case-history card cardiac 7 2. Example of a case-history card gynaecological 8 3. Box for keeping history cards 9 4. Card for recording urinalysis 10 5. Showing the location of transferred pains 39 6. Showing the location of transferred pains 41 7. General indications from seat of pain in head and face .... 42 8. Causes of localized headache according to its site 43 9. Causes of localized headache according to its site 44 10. Showing the causes of pain in the trunk and extremities, according to its locality 45 11. The same 46 12. The same 47 13. The same 48 14. The same . . .49 15. The same . 50 16. The same 51 17. Diagram of vomiting centre in medulla 115 18. Congenital hydrocephalus 155 19. Rachitic head 155 20. Sporadic cretinism 156 21. Face of acromegaly 157 22. Face of myxoedema 157 23. Facial hemiatrophy 158 24. Leontiasis ossea 159 25. Leontiasis ossea 159 26. Varieties and causes of facial paralysis 170 27. Base of the brain 172 28. Base of the skull and exits of nerves 173 29. Communications between superior longitudinal and external sinuses and external veins 181 30. Communications between lateral and cavernous sinuses and external veins 182 31. Nervous mechanism of the iris 187 32. Showing ocular muscles and their innervation 196 33. Structures in right cavernous sinus 200 34. Showing optic tracts, visual fields, and causes of hemiopia . . . 204 35. Visual colour field, right eye 207 36. Rhinoscopic view of posterior nares 213 37. Syphilitic "screw-driver "teeth 224 38. Unilateral atrophy of tongue 226 39. Showing motor and sensory supply of tongue 227 40. View of normal larynx in mirror 239 41. Showing paralyses of the vocal cords 241 42. Showing localization of cerebral motor and sensory functions, outer sur- face, left hemisphere . . . , 249 43. Showing principal convolutions and fissures, outer surface, left hemisphere 249 44. Showing functions, convolutions, and fissures, inner aspect, right hem- isphere 250 45. Showing association tracts, left hemisphere 251 46. Gland groups of head and neck 266 PLATES, CHARTS, AND ILLUSTRATIONS XT FIGURE PAGE. 47. Diagram of right external and internal jugulars 268 48. Diagram showing systolic and presystolic jugular pulse .... 270 49. Normal hand (cast drawing) 273 50. Spade hand 275 51. Claw hand 273 52. Morvan's disease . 274 53. Hand of pulmonary osteo-arthropathy 275 54. Skiagraph of hand in Fig. 53 275 55. Hands of arthritis deformans 27ft 56. Hand showing Heberden's nodes 277 57. Skiagraph of hand in Fig. 56 277 58. Gland groups in groin 270 59. Sabre-shaped tibia 280 60. Pesequinus 282. 61. Pes varus 283 62. Pes calcaneus 283 63. Paralysis of serratus magnus 285 64. Diagram varying force of percussion 291 65. Diagram auscultatory percussion 292 66. Diagram lines of percussion 292 67. Section of emphysematous chest 299 68. Sections of healthy and rachitic chests 300 69. Section of unilaterally contracted chest 302 70. Section of scoliotic chest 302 71. Topographical areas of thorax, anterior aspect 306 72. Topographical areas of trunk, posterior aspect 307 73. Showing events of cardiac cycle and sounds of heart .... 309 74. Nervous mechanism of the heart 310 75. Diagram explanatory of arterial tension 311 76. Showing vasomotor nervous mechanism 312 77. Semi-diagrammatic section of heart 313 78. Diagram showing insufficiency and stenosis ' . 314 79. Showing indirect effects of valvular lesions 317 80. Showing relations of heart to chest walls 319 81. Normal boundaries of heart and great vessels 320 82. Position of apex beat and other pulsations 326 83. Site and rhythm of thrills and friction fremitus 329 84. Exposed and covered dulness of normal heart 332 85. Percussion lines for determining cardiac dulness 333 86. Sansom's plexi meter 334 87. Normal area of entire cardiac dulness 336 88. Dulness in hypertrophy of left ventricle 336 89. Dulness in hypertrophy and dilatation of right heart .... 336 90. Dulness in dilatation and hypertrophy of both ventricles .... 337 91. Dulness due to large pericardial effusion 337 92. Dulness due to moderate pericardial effusion 337 93. Heart valves and their areas of audibility 340 94. Two variations from normal cardiac rhythm 346 95. Chronological types of murmurs 349 96. Relative frequency of anaemic murmurs 351 xvi PLATES, CHARTS, AND ILLUSTRATIONS 97. Diagram mitral presystolic murmurs ....... 352 98. Diagram varieties of murmur of mitral stenosis ..... 353 99. Diagram mitral systolic murmur ........ 354 100. Diagram aortic systolic murmur . . . ...... 355 101. Diagram aortic diaotolic murmur ......... . . . 356 102. Diagram tricuspid presystolic murmur . . ..... 357 103. Diagram tricuspid systolic murmur ....... 357 104. Diagram pulmonary systolic murmur ....... 358 105. Diagram combined murmurs . . ....... 359 106. Diagram combined murmurs ......... 360 107. Sphygmograms diagrammatic and actual ...... ;j?4 108. Sphygmograms actual .......... 375 109. Dudgeon's sphygmograph ..... ..... 379 110. Showing lobes of right lung ......... 383 111. Showing lobes of both lungs posteriorly ....... 384 112. Diagram of the respiratory centre ........ 385 113. Showing auscultatory areas of apices ....... 397 114. Showing relative resonances of thorax ....... 398 115. Showing variations of lessened resonance ....... 401 116. Dulness of fluid in reflected pleura (left) ....... 402 117. Conditions causing hyper-resonance ........ 403 118. Percussion and auscultation above consolidations or effusions . . 404 119. Findings over open cavities or pneumothorax ...... 407 120. Gerhardt's and Wintrich's phenomena . . ...... 408 121. Coin percussion . . .......... 409 122. Normal bronchial and broncho- vesicular breathing, anteriorly . .411 123. Normal bronchial and broncho- vesicular breathing, posteriorly . .412 124. Varieties of breathing and vocal resonance in disease .... 413 125. Results of auscultation over pleural effusion ...... 414 126. Adventitious respiratory sounds ........ 419 127. Surface and bony landmarks of abdomen ...... 423 128. Showing nine topographical areas of abdomen ..... 425 129. Quadrants of abdomen. Locating lesions ...... 426 130. Contents of topographical areas of abdomen ...... 427 131. Central tympanicity and lateral dulness of fluid ..... 434 132. Dulness of both flanks in ascites, dorsal posture ..... 434 133. Change of line of flatness in ascites ........ 434 134. Dulness and tympanicity in abdominal tumours ..... 435 135. Cross section explanatory of Fig. 134 ....... 435 136. Cross section of tympanitic abdomen . ...... -137 137. Showing tumour areas of abdomen ........ 439 138. Possible findings in hepatic and appendical areas ..... 440 139. Possible findings in splenic and sigmoid areas ...... 441 140. Possible findings in gastric and pelvic areas ...... 442 141. Possible findings in umbilical area ........ 443 142. Shape and relations of the normal stomach ...... 447 143. Auscultatory percussion of stomach ........ 451 144. Auscultatory percussion of gastric tumour ...... 452 145. Showing gastroptosis and gastrectasia ....... 455 146. Topographical relations of colon and appendix ..... 457 PLATES, CHARTS, AND ILLUSTRATIONS xv ii FIGURE PACK 147. Auscultatory percussion of colon 458 148. V-shaped colon 459 149. Auscultatory percussion of tumour of colon 460 150. Determining size and position of normal liver 461 151. Surface relations of liver, right lung, and pleura 462 152. Results of percussion of normal liver 464 153. ) Determining by auscultatory percussion whether a tumour is or is not 154. ^ connected with the liver 466 155. Showing the relations of the pancreas 470 156. Topography of the spleen 472 157. Tympanicity of colon over tumour of kidney 473 158. Anterior surface relations of kidney 476 159. Posterior surface relations of kidney 477 160. Section through kidney and lumbar muscles 479 161. Diagram of the neurone 482 162. Diagram of motor pathways 484 163. Diagram of sensory pathways 485 164. Relation of spinal cord to dorsal surface of trunk 486 165. Relation of spinal segments and nerves to the spinous processes . . 487 166. Tracts of spinal cord and their names 488 167. Functions of tracts of spinal cord 489 168. Functions of fibres of anterior and posterior roots 490 169. Columns of cord and diseases affecting them 490 170. Location of spinal segments for sensibility and motion .... 491 171. Relation of skin areas to spinal segments (anteriorly) .... 498 172. Relation of skin areas to spinal segments (posteriorly) .... 499 173. Relation of skin areas of head and neck to spinal segments . . . 500 174. Sensory supply of skin of trunk and leg (anteriorly) .... 501 175. Sensory supply of skin of trunk (posteriorly) 502 1 76. Sensory nerves of skin of arm (anteriorly) 504 177. Sensory nerves of skin of arm (posteriorly) 504 178. Sensory nerves of skin of leg (posteriorly) 504 179. Sensory nerves of skin of foot 505 180. Showing arteries of base of brain 506 181. Arterial supply of cerebral hemispheres 506 182. Infantile spinal paralysis of left leg 509 183. Pseudo-muscular hypertrophy 510 184. Wrist-drop 512 185. Foot-drop 513 186. Athetoid movements 516 187. Hand of tetany 518 188. Contractures of hand 519 189. Relative positions of cranial nerve nuclei, posterior aspect . . . 522 190. Relative positions of cranial nerve nuclei, lateral aspect .... 523 191. Effects of lesions of motor path in brain and cord 525 192. Showing hemianaesthesia 531 193. Mono-anjesthesia, bilateral anaesthesia, hysterogenic zones . . . 532 194. Showing disseminated anaesthesia 533 195. Showing segmental localization of reflexes and automatic centres in spinal cord 537 2 PLATES, CHARTS, AND ILLUSTRATIONS FIGURE PAGE 196. Showing re-enforcement of percussing finger 538 197. Showing mechanism of deep reflexes, and two main types of paralysis . 540 198. Motor points of head and neck 542 199. Motor points of arm 543 200. Motor points of arm 544 201. Motor points of thigh, anteriorly 545 202. Motor points of thigh and leg, posteriorly 546 203. Motor points of leg, laterally 547 204. Sensory supply of skin of face and neck 551 205. Thoma-Zeiss pipettes 561 206. Blood counting slide, plan . 562 207. Blood counting slide, elevation 562 208. Group of sixteen squares under microscope 563 209. Von Fleischl's haemometer 568 210. Gowers' haemometer . . 569 211. Resting attitudes of culex and anopheles 588 212. Filaria alive in blood 591 213. Elastic tissue, from lung, in sputum 598 214. Bronchial cast from case of plastic bronchitis 599 215. Curschmann's spirals in sputum 599 216. Charcot-Leyden crystals 600 217. Echinococcus hooklets 600 218. Actinomyces in sputum 601 219. Microscopical view of vomited matter 613 220. Ovaofentozoa 619 221. Amceba dysenteriae 620 222. Emphysematous chest 851 223. Parts first attacked in muscular dystrophies and atrophies . . . 969 224. Mode of rising in pseudo-muscular hypertrophy 970- " I do not know ... I will investigate." PASTEUR. " First tell me what I am to look for." FARADAY. SYNOPSIS (OR SCHEDULE) OF EXAMINATIONS CONSTITUTING AN ORDER OF PROCEDURE, AND A SYMPTOM- GUIDE; WITH REFERENCES TO PART I OF THIS BOOK To insure completeness in the examination of patients and for purposes of record, it is desirable to have a definite and comprehen- sive order of procedure. The subjoined schedule, which may be modified according to personal requirements, is based partly on sci- entific necessities, partly on clinical convenience. Incidentally, the symptoms indicating disease of a particular viscus or system are grouped, in order to direct attention to the organ at fault. Further- more, for convenience, references are given to the pages upon which special symptoms, signs, or methods of examination are described in detail. The three main divisions of the schedule comprise : I. The History or Anamnesis. II. The General Examination ) Present Condition or III. The Special Examinations f Status Praesens. I. THE HISTORY OR ANAMNESIS Ascertain the name, age, sex, civil condition (single, married, widow, widower), nationality, occupation, and residence. Note the date of examination. Family History. Inquire concerning the diseases which have prevailed and the causes of deaths (if such have occurred) among father, mother, brothers, sisters, or children ; also as to the diseases, if any, which prevail among the living. Consider whether or not the stated ailments are of an hereditary character (pages 13 to 15). Previous Personal History. Bear in mind the diseases which predominate : (1) At the age period of the patient (pages 15, 16). (2) In the sex (pages 16, 17); and if the patient is a woman, inquire regarding the menstrual life, pregnancies, and miscarriages. (3) In the race or nationality (page 17). (4) What is the character of the occupation, and does it predis- pose toward special diseases (pages 18, 19) ? xx SYNOPSIS OF EXAMINATIONS (5) Consider the residence, bearing in mind the geographical dis- tribution of disease (pages 19, 20). (6) Inquire concerning the habits : of men, with reference to the daily amount and kind of alcoholic beverages taken, whether before or after meals ; tobacco, kind, amount, and manner of using ; sexual indulgence, frequency ; of both men and women, with reference to the amount and strength of tea and coffee taken. (7) Inquire with reference to previous injuries and diseases (pages 20, 21), ascertaining their date, duration, character, and whether or not recovery was considered to have been complete. Are the previous diseases of such a nature that a second attack is prob- able ; or is it unlikely ; or are sequelae to be expected ? Search especially for previous gonorrhoea, syphilis, nephritis, rheumatism, or malaria. History of Present Illness. Inquire regarding the possible cause of the illness ; the date and manner of its onset, never failing to fix in mind the nature of the earliest symptoms, and, if possible, the organ or system to which they belong e. g., stomach, circulatory apparatus the subsequent symptoms and their order of appearance to the present time ; the symptoms now present ; and the previous treatment, if it can be ascertained (pages 22 to 24). II. THE GENERAL EXAMINATION 1. Observe the dress and general behaviour (pages 24, 25). 2. Estimate (or measure) the height and weight, and note the amount and character of the adipose and muscular tissue (pages 25 to 27). 3. Study the shape and general configuration of the body (pages 27, 28). 4. Note the complexion, and colour of hair and eyes (pages 28, 165). 5. So far as possible, determine the diathesis (usually done at the end of the examination), and note the presence of any cachexia (pages 28 to 30). 6. Observe the posture and manner of moving (pages 30 to 32). 7. If practicable, test the station or power of standing, and ob- serve the gait or manner of walking (pages 32 to 34). 8. Pain. If pain is a subject of complaint, make due allowance for susceptibility (page 35) and manner of statement (pages 35, 36). Can any diagnostic inference be drawn from the character (pages 36, 37) or the seat (pages 38 to 52) of the pain ? 9. Tenderness. Is there tenderness (pain on pressure), and is its location significant (pages 52 to 54) ? HISTORY AND GENERAL EXAMINATION XX J 10. Parsesthesias. Are there abnormalities of sensation not amounting to pain (paraesthesias) ? If so, consider the site, variety, and possible significance (pages 54 to 58). 11. Vertigo. Inquire for the existence of vertigo, having in mind both its common and less frequent causes (pages 58 to 60). 12. Temperament. What is the temperament (mainly psychical) of the patient (pages 61, 62) ? 13. Psychical State. What is the present psychical state of the patient as shown by the facial expression (pages 62, 63) ; the emo- tional state (page 63) ; and the condition of intellection (pages 63 to 65) ; the abnormalities of the latter, embracing mental dulness, loss of memory, delusions, or delirium ? Inquire as to sleep (page 65). 14. Consciousness. Is the patient fully conscious ? If not, what is the degree of disturbance (page 66) ; what may it signify in gen- eral (pages 66, 67) ; and to what is it due in this particular case (pages 67 to 71) ? 15. Convulsions. If general convulsions have occurred or are present, to what may they be attributed (pages 71 to 74) ? 16. Cutaneous Surface. Observe and examine the cutaneous sur- face with reference to colour (pages 75 to 81), heat (pages 81, 82), moisture (pages 82, 83), rash or eruption (pages 83 to 86), scars (pages 86, 87), dropsy (pages 87 to 90), condition of the veins (page 91), and emphysema (page 92). 17. Pulse. Take the pulse (pages 367 to 369). Observe its fre- quency, 'rhythm, tension, and other qualities. Note the condition of the arteries. If variations from the normal are found, consider their significance (pages 369 to 378). 18. Respiration. Take the respiration. Observe its frequency, type, rhythm, and other characteristics (pages 386 to 394). 19. Temperature. Take the temperature of the body (pages 95 to 100). If fever is present, consider its height, type, manner of invasion, course, and termination (pages 102 to 105). What diag- nostic inferences may be drawn from these observations (pages 105 to 111)? Has the fever been preceded or accompanied by chills (page 111)? If the temperature is subnormal what may it indicate (page 111)? 20. Inquire concerning the appetite and thirst (pages 112, 113) ; vomiting (pages 113 to 121) and the gross characters of the vomitus (pages 122 to 125) ; defecation (pages 125 to 132) and the gross char- acters of the stools (pages 132 to 139) ; the character and frequency of urination (pages 139 to 144) ; and certain genital symptoms in men and women (pages 144 to 149). xx ii SYNOPSIS OF EXAMINATIONS III. SPECIAL EXAMINATIONS By means of a more or less discursive examination, as just out- lined, the observer obtains a conception of the general condition of the patient ; and also, in the majority of cases, an indication for a special examination of a particular part, organ, or system. The spe- cial examinations embrace the signs and symptoms which occur in connection with various parts of the body e. g., head and face, tongue ; or which belong to an organ e. g., spleen ; or a system e. g., respiratory. 1. Head and Face. Observe the size and contour of the head and face ; in infants, the condition of the f ontanels and sutures ; and the consistence and surface of the cranial bones (pages 154 to 160). Study the expression of the face and consider whether it is indicative of certain diseases (pages 160 to 163). Xote the colour of the face, and the state of the skin of the face (pages 163, 164). What is the colour of the hair, and is it abundant, or scanty (page 165) ? Is there general or circumscribed swelling of the face (page 166)? Are there abnormal movements of the head, or does it lack normal mobility (pages 166, 167) ? Are the facial muscles in a state of clonic or tonic spasm (pages 167 to 169), or are they paralyzed (pages 169 to 174) ? 2. Ear. Has the patient complained of pain in the ear (page 175)? What is the colour and shape (pages 175, 176) of the ear? Is there a discharge from the external meatus (page 176) ? Does the patient complain of tinnitus (pages 176, 177) ? Does the patient hear well ; is he deaf, and, if so, is the deafness due to nerve lesions or aural lesions (pages 177 to 179) ? Is the hearing hyperacute (page 180) ? 3. Eye. Are the eyelids swollen or ulcerated; in a state of spasm; too widely opened; or abnormally drooping (pages 180 to 183) ? What is the colour of the sclerotic, the state of dryness or moisture of the eye, and the condition of the cornea (pages 183 to 185) ? Are the pupils large or small, equal or unequal ; do they respond to light and to accommodation (pages 185 to 190)? Are the eyeballs painful ; do they protrude, or are they more sunken than normal ; what is their position (pages 190 to 192) ? Are the eyeballs normally mobile, or are there symptoms of ocular paralysis ; and if ocular paralysis is found, what is its cause (pages 192 to 202) ? Does the patient complain of any abnormality of sight (page 202) ? If alterations in the shape or size of the visual fields have been found, what may be their significance (pages 202 to 208) ? If an ophthal- SPECIAL EXAMINATIONS xx iii moscopic examination of the eye grounds has been made, do the findings indicate extra-ocular disease (pages 208 to 211) ? 4. Nose. The following symptoms demand an examination of the nose : Pain in or around the nose (page 213), frontal headache, or trigeminal neuralgia. Mouth-breathing and its typical facial ex- pression due to nasal stenosis (page 162). Snoring and restless sleep. Nasal voice. Nasal discharges (page 215), epistaxis (pages 215, 216), or bad odour of the expired air (pages 219, 220). Deafness. Cough or bronchial asthma. To Examine the Nose. Having noted the shape and colour of the nose, together with such other points as may be observed by ordinary inspection, examine the nasal chambers (using the probe) by anterior and posterior rhinoscopy (pages 211 to 213). Test the sense of smell (pages 216 to 218). 5. Mouth. Examine the lips, buccal cavity, gums, and teeth (pages 218 to 225). Note the condition of the tongue with reference to colour, size, spasm, tumour, paralysis, scars, fissure, ulcers, etc. (p ges 225 to 230). Does the tongue present an appearance which is of general diagnostic value (pages 230 to 232) ? Test the sense of taste (pages 232, 233). 6. Examine the palate, tonsils, and pharynx (pages 233 to 237). What is the shape of the palate ; is it paralyzed, anaesthetic, or otherwise abnormal ? Are the tonsils acutely swollen, chronically enlarged, ulcerated, or covered with exudate ? What is the colour of the pharynx; is there exudate or ulceration; is there bulging posteriorly ; is it paralyzed or anaesthetic ? 7. Does the patient complain of dysphagia, and, if so, to what may it be due (pages 237, 238) ? 8. Larynx. The following symptoms demand an examination of the larynx: Pain, burning, or soreness over and around the larynx. Alterations in the character of the voice sounds, viz., apho- nia or hoarseness (dysphonia). Inspiratory dyspnoea, especially if accompanied by stridulous (wheezing or squeaking) respiration. Cough, particularly of the laryngeal type (tight or croupy). Dyspha- gia, difficulty or pain in swallowing. To Examine the Larynx. (See pages 238 to 243). Do not omit an inspection of the lingual tonsil. 9. Cough. Has the patient a cough ? If so, observe its char- acter and consider its causes (pages 256 to 259). Examine the spu- tum (if any) with reference to its character (pages 259 to 261 and 596 to 603). Has he had haemoptysis (pages 261 to 263) ? 10. Speech. Xote alterations in the voice or the manner of speaking (pages 243 to 246). Is there aphasia (pages 246 to 255) ? xxiv SYNOPSIS OF EXAMINATIONS 11. Neck. Observe the shape of the neck ; is it rigid ? Are the sterno-mastoids or clavicles prominent ; is the thyroid gland enlarged or atrophied (pages 263, 264) ? Does the trachea descend with inspiration, or can tracheal tugging be felt (page 265) ? What is the condition of the cervical glands (pages 265 to 267) ; of the arteries of the neck (page 267) ; of the veins of the neck (pages 267 to 271) ? 12. Extremities. Examine the nails (pages 271, 272) ; the hand and fingers (pages 272 to 278) ; the arm (page 278) ; the foot and leg (pages 279 to 283). 13. Back. Examine the back for alterations of shape, promi- nence of the scapulae, stiffness, and swellings or bulgings (pages 284 to 286). 14. Chest. Examine perhaps measuring and outlining the chest with reference to bilateral or unilateral deformities, flexibility of ribs, and the presence of enlarged veins (pages 296 to 303). 15. Heart and Blood-vessels. The following symptoms demand an examination of the heart and blood-vessels : Dyspnoea (perhaps orthopncea), especially if made worse by physical exertion or accompanied by cyanosis. (Edema, especially of the feet and ankles. Palpitation, prcecordial pain, anxiety, or distress, particularly if in- creased by exertion. Sudden vertigo. Eestless sleep, dreaming, start- ing during sleep. Cough, especially if chronic; or an unusually persistent attack of bronchitis. Chronic digestive disturbances. Hemorrhoids. Great obesity. If such symptoms are present inquire further (with reference to causation) concerning: Prolonged and severe muscular exertion. Many years of constant mental excitement or anxiety. Excessive eating and drinking, especially of rich food and alcoholic beverages ; these, and the foregoing, partly with reference to arteriosclerosis. Excessive use of tobacco, tea, and coffee (in relation to cardiac neu- roses'). Previous attacks of chorea, gout, rheumatic fever, or other, usually acute, infectious diseases, especially scarlatina, diphtheria, typhoid fever, tonsilitis, syphilis. The family history : does it reveal rheumatism, gout, angina pectoris, apoplexy, or organic cardiac disease 9 To Examine the Heart. Inspect and palpate the thorax, noting, if present, distended veins, pulsating jugulars, epigastric pulsation, and pulsating liver. Xote, as of prime importance, the position, character, and extent of the apex-beat (pages 321 to 329). Percuss the heart (pages 330 to 339). Auscultate the heart with reference to the intensity and character of the sounds (pages 339 to 347), and the presence of adventitious sounds, either endocardial (pages 347 to SPECIAL EXAMINATIONS xxv 3GO) or exocardial (pages 360 to 363). Examine the pulse (pages 367 to 378). Use the sphygmograph (pages 378 to 382). To Examine the Blood-vessels. Inspect, palpate, and auscultate the accessible arteries and veins (pages 363 to 367). Xote any ab- normal capillary pulsation (page 271). 16. Lungs and Pleurae. The following symptoms demand an . examination of the lungs and pleura : Cough, with or without expecto- ration. Haemoptysis or spitting of blood. Pain in the side of the chest. Dyspnoea. Night sweats. Loss of flesh and strength. Additional evidence should be sought for, viz., a family history of consumption, asthma, bronchitis, or scrofulous (tuberculous') dis- eases ; and a personal history of enlarged cervical glands, or tuber- culous disease of bone, or association with a consumptive, or an occu- pation predisposing toward pulmonary disease. To Examine the Lungs. Inspect and palpate the chest with reference to its shape (pages 296 to 303). Measure it. Count the respiration (page 386) ; determine its type, degree of expansion and retraction, and its rhythm and other characters (pages 386 to 394). Is fremitus obtained (pages 394 to 396)? Is dyspnoea pres- ent ? If so, what is its character ? Percuss the lungs front, sides, and back (pages 396 to 409). Auscultate the lungs front, sides, and back, determining the character of the breath sounds (pages 409 to 416) and the presence and variety of adventitious sounds (pages 418 to 422). 17. Abdomen. If complaint is made of abdominal pain or dis- comfort, inspect the abdomen (pages 427 to 430). Palpate and per- cuss the abdomen (pages 430 to 444). Auscultate the abdomen (page 444). 18. Stomach. The following symptoms require an examination of the stomach: Fulness, sinking feelings, pain or discomfort in epi- gastrium, lower sternum, between the scapula. Increased or lessened appetite or increased thirst. Nausea or vomiting (of stomach contents, or blood). Pyrosis, eructations, or flatulence. Mental depression. Rapid emaciation. To Examine the Stomach. Incidentally inspect the lips, mouth, gums, teeth, and tongue. If the food is arrested in the throat, or before it enters the stomach, and is regurgitated, palpate, auscul- tate, and instrumentally examine the esophagus (pages 445, 446). Inspect and palpate the stomach (pages 448, 449). Percuss the stomach by ordinary and auscultatory percussion (pages 450 to 453). Innate the stomach (page 453). Obtain the contents of the stomach (pages 453 to 455) after a test meal, and examine by chemical and microscopical methods (pages 604 to 618). xxv i SYNOPSIS OF EXAMINATIONS 19. Intestines. Constipation, diarrhoea, and abdominal pain are the symptoms which require an examination of the intestines. To Examine the Intestines. Inspect the stools (pages 132 to 139). Inspect, palpate, percuss, and auscultate the abdomen in general (pages 427 to 444), and the intestines (including a digital examina- tion of the rectum) in particular (pages 457 to 461). 20. Liver and Gall Bladder. The following symptoms de- mand an examination of the liver and gall bladder: Pain, of the hepatic type, over the right hypochondrium. Jaundice, dark urine, clay-coloured stools. Irregular chills and fever. Cutaneous pruritus. Hmmatemesis. Digestive disturbances. If such symptoms are present, inquire further (with reference to causation) concerning: Previous attacks of jaundice ivith or without hepatic colic. Previous catarrh of the stomach, or acute indigestion (catarrh of bile ducts). Strong emotions (anger or fright). Chronic alcoholism (hepatic cirrhosis). Syphilis, tuberculosis, or long-con- tinued suppuration (amyloid disease). Possibility of phosphorus poisoning. To Examine the Liver and Gall Bladder. Rarely inspection and auscultation are of use ; ordinarily palpation and percussion (pages 463 to 470) are to be relied upon. 21. Spleen. The size, shape, and position of the spleen should be determined, mainly by palpation and percussion (pages 471 to 475), in the following conditions and diseases: Emphysema, left pleural effusion, and left pneumothorax. Ascites, tympanites, and large abdominal tumours. In all acute infectious diseases (e. g., typhoid fever, malarial fever). Leuccsmia. Cirrhosis or amyloid disease of the liver. 22. Kidneys. The following symptoms demand a physical examination of the kidneys, and a chemical and microscopical exami- nation of the urine : Pain in the posterior lumbar region, especially if of the renal type. (Edema or puffiness of the face, especially about the eyelids in the morning. General osdema (anasarca). Painful or frequent urination. Smoky or turbid urine ; notable increase or diminution in its amount. Headache, drowsiness, nausea, and vomiting. Dyspnoea or asthma, ivithout other discoverable cause. Dimness of vision. Convulsions or paralyses. Irregular chills and fever (pyelitis). If such symptoms are present, inquire further (with reference to causation) concerning : A family history of nephritis, apoplexy, or gout. A personal history of alcoholism, gout, lead-poisoning, renal colic, chilling of the surface of the body, acute infectious diseases (such as scarlet fever, malaria, tonsilitis, diphtheria), and long- SPECIAL EXAMINATIONS xxv ii continued suppuration, tuberculosis, tertiary syphilis, and malaria (amyloid disease}. To Examine the Kidneys. Inspect and palpate anteriorly; in- spect, palpate, and percuss posteriorly (pages 475 to 480). Examine also the heart and blood-vessels for cardiac hypertrophy and general arteriosclerosis. Examine the urine physically, chemically, and mi- croscopically (pages 621 to 648). If necessary, examine the bladder and ureters. 23. Nervous System. The following symptoms require an examination of the nervous system : Frequent or continuous headache. Frequent vomiting. General convulsions, or localized spasm. Paral- yses (ocular or skeletal). Vertigo. Speech disturbances. Difficulty in standing or walking if not due to weakness, injury, or disease of joints. Mental disturbances. Dysphagia (sometimes). If such symptoms are present, inquire further (with reference to etiology) concerning: A family history of psychoses (insanity), hys- teria, chorea, epilepsy, neurasthenia, paralysis, convulsions, or hered- itary syphilis. A personal history of alcoholism, syphilis, injury ; discharge from the ear ; any of the acute infectious diseases ; poison- ing from lead, mercury, arsenic, tobacco, or naphtha; and exposure to cold. To Examine the Nervous System. Xote the presence of the stig- mata of degeneration (pages 507 to 509). Examine the muscles with reference to their nutrition, tone, and motor power (pages 509 to 514). Are there motor disturbances ? If so, is there increased mo- tility (spasm, pages 514 to 519), or decreased motility (paralysis, pages 520 to 527) ? Are there disturbances of sensation (pages 527 to 535) ? What is the condition of the superficial reflexes (pages 536, 537) ; of the deep reflexes (pages 537 to 542) ? "What is the electrical reaction of the muscles and nerves (pages 542 to 549) ? Are there vasomotor and trophic disturbances (pages 549, 550) ? What is the condition of the cranial nerve functions (pages 550 to 553) ? What are the find- ings from an examination of the eye grounds (pages 208 to 211) ? 24. Blood. The following symptoms require an examination of the blood : Dyspnoea and palpitation upon exertion. Pallor of the skin and mucous membranes. Headache and vertigo. Debility. Dis- turbances of digestion and gastric pain. (Edema of the feet. If such symptoms are present, inquire further (with reference to causation) concerning: Hereditary or personal haemophilia. Loss of blood (injury, menorrhagia, bleeding piles, haemoptysis, hcematemesis, etc.). Malaria, rheumatic fever, lead-poisoning. Chronic gastric or intestinal catarrh; or a long-continued diarrhoea. Worry and men- tal excitement. Wasting diseases. xxv iii SYNOPSIS OF EXAMINATIONS To Examine the Blood. Count the red and white cells (pages 559 to 567). Estimate the haemoglobin (pages 567 to 571). Stain a dried specimen of the blood and make a differential count of the leucocytes (pages 571 to 586). Examine a fresh specimen of the blood (espe- cially for the malarial organism, pages 587 to 591). 25. Diagnostic Puncture. If desirable, obtain fluid by punc- ture (pages 648, 649) from cavities or cysts ; examine the fluid, and from its character endeavour to determine its source (pages 649 to 653). PLATE I. THE SHAPE AND RELATIONS OF THE THORACIC AND ABDOMINAL VISCERA, .ANTERIOR ASPECT (SEMI-DIAGRAMMATIC) PLA; I30QAJ8 JJAO THE SHAPE AND Rr AEi 5CERA, POSTERIOR A c AGRAM?. PLATE I. THE SHAPE AND RELATIONS OF THE THORACIC AND ABDOMINAL VISCERA, .ANTERIOR ASPECT (SEMI-DIAGRAMMATIC) PLATE II. THE SHAPE AND RELATIONS OF THE THORACIC AND ABDOMINAL VISCERA, POSTERIOR ASPECT (SEMI-DIAGRAMMATIC) PLATE upttADflir DAflT 10 r / VENA/ CAW JLDWER { PLEU GALL BL At . , Wjt.il : ^ ; C^ ^ ^ I ^--" NAL VISCERA. -tMI-DIAGRAMM, PLATE II. THE SHAPE AND RELATIONS OF THE THORACIC AND ABDOMINAL VISCERA, POSTERIOR ASPECT (SEMI-DIAGRAMMATIC) THE DIAGNOSTICS OF INTERNAL MEDICINE PRELIMINARY CONSIDERATIONS Diagnosis. This, in its narrowest sense, consists in bestowing a name upon a certain assemblage of pathological phenomena. It should include also a knowledge of the causal factors of the disease ; a determination of its character with reference to type and severity ; an estimate of the amount and kind of damage, both general and local, which has been sustained by the organism ; a forecast of the probable course and duration of the morbid process ; and a cogni- zance of the personal characteristics of the patient, whether psychic or physical, inherited or acquired. Its final object is to be able to treat disease intelligently, and the application of scientific meth- ods to the completest discrimination and recognition of disease con- stitutes the art of diagnosis. A diagnosis is made by means of symptoms, which constitute the evidence upon which is based a judgment as to the nature of the case. Symptoms, the phenomena caused by morbid processes, are divided into subjective, those which can be appreciated only by the patient, and objective^ comprising those which are detected by the personal examination made by the physician. The term physical signs is by common consent applied to the objective symptoms revealed by special methods of examination, used mainly in deter- mining the condition of the organs contained in the chest and abdomen. In addition to a knowledge of the symptoms, subjective or objec- tive, which may exist at the time of examination, it is necessary to ascertain the presence or absence of hereditary taints or tendencies, to know something about the habits and occupation of the patient, to learn of past illnesses or injuries, and to obtain a clear idea of the manner of onset and subsequent evolution of the present disease. Finally, it is well to study the temperament and personal character- istics, mainly psychical, of the individual patient so far as practicable. The family and personal history, the history of the present illness, and the results of the examination constitute the evidence upon 1 2 THE DIAGNOSTICS OF INTERNAL MEDICINE which the final judgment as to the nature of the case is to be based. A necessarily heterogeneous collection of facts must be classified with reference to their relative value and significance and compared with the previous knowledge and experience of the diagnostician, after which a judgment may be rendered as nearly as possible in accordance with the facts. This constitutes the second and final step in the making of a diagnosis. The process is thus seen to con- sist of two elements observation, in its broadest sense, and reason- ing, applied to the results of the observation. Certain terms of some practical value and convenience are used to qualify a diagnosis, as follows (the definitions are largely from Foster) : LIST OF DESCRIPTIVE TERMS EMPLOYED WITH REFERENCE TO DIAGNOSES, SYMPTOMS, AND SIGNS Diagnoses : 1. Anatomical. Based on a knowledge not only of symptoms or phenomena, but also of definite anatomical alterations on which the phenomena depend ; or a post-mortem diagnosis. 2. Clinical. Based upon the symptoms manifested during life. 3. By Exclusion. Eeached by a deductive process, all the affec- tions which present salient points of similarity with the one to be diagnosticated being reviewed in turn, and each suc- cessively discarded as one or more of its essential features are missed in a given case, until but one possibility remains, which is accepted as the true one. 4. Differential. The process of distinguishing between different diseases which resemble one another more or less closely. 5. Direct. The symptoms are of such a nature that they point to the presence of one special disease, and are not capable of misinterpretation. 6. Pathological. Of the nature of a lesion, without regard to its situation. 7. Physical. By means of physical (objective) signs, irrespec- tive of subjective symptoms, as by palpation, auscultation, etc. 8. Presumptive. Not regarded as certain. 9. Retrospective. Of some antecedent disease or injury, the nature of which can be deduced only from the history given and from the persistent effects. 10. Symptomatic. Consisting simply in the determination of the: most striking symptoms. 11. Topographical. Of the seat of a lesion. PRELIMINARY CONSIDERATIONS 3 Symptoms : 1. Constitutional. Those that may result from unbalancing of the organism as a whole, and are common to affections of many kinds. 2. Direct. Those that depend directly upon the disease. 3. General. Constitutional. (See above.) 4. Indirect. Which are the indirect consequences of the disease. 5. Local. Which result from localized disease, and are usually confined to the site of the diseased organ or tissue. 6. Negatively Pathognomonic. Which seldom or never occur in a certain disease, and consequently, if present, show that the case is not one of that disease. 7. Pathognomonic. Which undeniably indicate the existence of a certain disease. 8. Reflex. Which are caused by local disease, but manifest them- selves by means of the nervous system in an otherwise unre- lated organ or part of the body. 9. Sympathetic. Which appear with the essential ones, but for the presence of which no cause can be assigned except that of sympathy. Signs : 1. Physical. Already defined. 2. Rational. Signs and symptoms, subjective or objective, cor- responding to the alterations in structure and mechanical conditions discovered by physical examination. 3. Stethoscopic. Those discovered by auscultation. Difficulties in Diagnosis. For various reasons it may be difficult or impossible to make a diagnosis. The most important of these reasons are as follows : (1) The subjective symptoms may be puzzling or incongruous. (2) The objective symptoms and signs may be ill-defined, obscure, or, if present, as discovered later, may be impossible of detection by the most searching examination e. g., a beginning, small peri- nephritic abscess in an unusually obese patient, which can not be palpated until it reaches a certain size. (3) Certain symptoms essential to a diagnosis may not appear until the disease has advanced to a certain stage e. g., the splenic enlargement and rose rash of typhoid fever. (4) Several diseases, each of which in other cases may constitute the sole morbid process, may co-exist, one as the primary or main disease, the others attending as complications or sequelae. One or more of the secondary lesions may be recognised, and the underlying or primary disease or condition be overlooked e. g., pleurisy with 4 THE DIAGNOSTICS OF INTERNAL MEDICINE effusion occurring as a result of previously unrecognised pulmonary tuberculosis, and masking the primary lesion in the lungs. (5) The rarity of a disease may lead to its non-recognition be- cause of unfamiliarity with its history and symptomatology, and perhaps the consequent failure to elicit all the diagnostic data. (6) The lack of a full and accurate history is at times a serious hindrance in making a diagnosis. The patient may be deaf and dumb or speak an unfamiliar tongue, or he may be unconscious, delirious, mentally unsound, or so ignorant and stupid that no reli- able information can be obtained from him, and intelligent friends or relatives may not be available. On the other hand, in conse- quence of a variety of motives, essential facts may be concealed by the patient or the friends. (7) Drug symptoms, unless known and due allowance made for them, may so disguise, add to, or simulate certain diseases that the diagnosis may be shrouded in uncertainty. (8) The diagnostician must be a good observer, and at the same time be able to reason correctly. As Huxley well says : " Scientific reasoning differs from ordinary reasoning in just the same way as scientific observation and experiment differ from ordinary observa- tion and experiment that is to say, it strives to be accurate ; and it is just as hard to reason accurately as it is to observe accurately. In scientific reasoning general rules are collected from the observation of many particular cases ; and, when these general rules are estab- lished, conclusions are deduced from them, just as in everyday life. If a boy says that ' marbles are hard,' he has drawn a conclusion as to marbles in general from the marbles he happens to have seen and felt, and has reasoned in that mode which is technically termed induction. If he declines to try to break a marble with his teeth, it is because he consciously, or unconsciously, performs the converse operation of deduction from the general rule ' marbles are too hard to break with one's teeth.' . . . The man of science, in fact, simply uses with scrupulous exactness the methods which we all, habitually and at every moment, use carelessly." While medicine is to a certain extent a science, and requires sci- entific modes of reasoning, medical art is, in a large proportion of cases, obliged to reason from probabilities as premises, and its final results can not be expressed in the exact formulae of the mathema- tician. In obedience to some law which we do not yet know, 2 and 2 do not always make 4 in the reactions of the human body, otherwise patients would not be encountered who present serious symptoms after a medicinal dose of morphine, or blaze out with urticaria after eating strawberries. PRELIMINARY CONSIDERATIONS 5 To study and to compare ; to approach a case with a mind open to impressions, and without preconceived or fixed ideas as to its nature, based upon previous hearsay ; to review and balance the evidence from time to time in the course of the disease ; to ques- tion one's self " Is there any other disease or condition which may tetter explain these symptoms than that which I have already assigned ? "these and other habits of thought make the difference between the man who sees without learning and he who learns by seeing. Obtaining Evidence. The diagnostician acquires the facts upon which he is to form an opinion : (1) By Interrogation in- quiry of the patient or his friends ; (2) by Observation an. ex- amination, mainly objective, of the patient. Information obtained by interrogation is called the History or Anamnesis (remembrance) ; that derived from observation, the Present Condition or Status Prcesens. From a purely scientific and diagnostic point of view, the first questions addressed to the patient will be with reference to his an- cestry ; next, in regard to his personal history antecedent to the present disease ; then as to the existing disease, followed by a care- ful and systematic examination, first of the general condition, then of special organs, one by one, together with such chemical, micro- scopical, bacteriological, and other investigations as appear to be demanded. But for obvious reasons this order of pursuing the inves- tigation is for the most part impracticable, and consumes an un- necessary amount of time. In the vast majority of cases the facts are acquired by the physi- cian in the reverse order. The first question asked is, " In what way do you feel ill?" " Of what are you complaining?" Or, the patient will volunteer a statement as to his subjective sensations. The question or the statement will direct attention at once to the probable or possible seat or nature of the disease. Further in- quiries are put as to the duration and character of the morbid sensations. During these interrogations the physician attentively scrutinizes the general aspect of the patient in search of obvious objective symptoms. The pulse, respiration, and temperature are taken. The organ or part which appears to be most at fault is first examined, after which due attention is paid to other por- tions of the body. Finally, the family and social history may be ascertained. This is the logical order of investigation, as conditioned by actual circumstances. It is a matter of indifference as to the sequence in which the symptoms are learned, provided that the examination is 3 6 THE DIAGNOSTICS OP INTERNAL MEDICINE sufficiently intelligent and systematic to be sure of eliciting all the facts, and that the facts when obtained are so arranged in the mind of the physician that they form a clear and coherent picture, and are capable of being recorded in an orderly manner. It is to be remembered in this connection that in many cases it is just as neces- sary to note negative facts i. e., the absence of certain symptoms or signs as it is to ascertain the presence of others. Keeping Case Histories. This habit promotes accuracy of observation, completeness in examination, and affords trustworthy material. The physician who keeps adequate records acquires facil- ity in describing symptoms, signs, and morbid conditions. The drawbacks are the time consumed and the amount of work involved, but by late methods the time and labour required are reduced to a minimum. To accomplish this requires certain materials and acces- sories. The essential elements (DICKINSON) of the outfit are of two- kinds : (1) Cards made and handled according to the card cata- logue system, and (2) rubber stamps made to suit individual re- quirements. (1) Card Outfit. Eecords are made (Figs. 1 and 2) upon cards (6 by 6f inches), one or more being used for each case, standing on edge in a box or drawer and ranged under an alphabetical index, each letter printed on a buff Bristol card (guide or index cards) which stands higher than the history cards. The size of the history card is such that, by folding once (the line of the fold must be vertical), it will fit into the pocket-book or visiting list. The cards are kept in a box with a sliding top,. or with a lid which is the upper third of the box (Fig. 3). When Mr. A. or Mrs. S. enters the consulting room, the cards under A or S are picked up and shuffled through until the desired one is found. The necessary record or entry is made and the card returned to- its proper place. For patients ill at home, cards are picked out and placed in the pocket-book before starting on morning rounds. Cards of convalescents are dropped. If two or more cards are found to be necessary for a long case, they may be fastened together with a brass clip. Cards differing in colour are useful for special purposes, i. e., buff- coloured cards for consultation cases, salmon colour for surgical cases, and the like. Another method of special classification is to have two- or more alphabetical indexes, the cards which belong to a special class of cases being ranged under the corresponding separate index,, in the same box or drawer. Loose notes, letters, or sketches may be pasted to the case card or kept in envelopes of the same size as the cards and filed. PRELIMINARY CONSIDERATIONS 9 Temperature cards (Chart I), urinalysis cards (Fig. 4), and cards for blood examinations (Chart IX) have been devised by De Forest. (2) ftnbber Stamps. These are of two kinds outline stamps and stamp forms for recording special data. Outline Stamps. These, as the name indicates, are rubber stamps representing in more or less detail various regions or organs of the body, and employed when it is desired to represent by the graphic method any changes of structure, the exact location and character of physical signs, the outline of tumours, etc. An ink pad is required, FIG. 3. preferably red or blue. The case card is placed upon a level surface, the stamp inked, and adjusted on the desired place, and a quick, light blow given with the palm of the hand. On the outline thus printed may be sketched or written with pen or pencil whatever abnormalities it is desired to represent. Further changes which occur may be entered on the same outline, the date being appended, or a new print may be made. The use of the outline stamp has proved invaluable, because of the increased accuracy of observation to which it leads, even leaving out of consideration its value as a record. (See Figs. 1 and 2, red outlines.) FIG. 4. PRELIMINARY CONSIDERATIONS 11 Type Stamps. These are used in noting any set of answers which require frequent asking, or which may be involved in special investi- gations, like the following example : SHORT MED TALL FT IN : STOUT THIN WEIGHT LBS : BLON BRU INDETER: EYES BLU BR BLK : SLIGHTLY VERY NEUROTIC:. MENTALITY HIGH MED LOW: SLEEPS WELL POORLY: APPT GOOD POOR: VOMITG ERUCTS FULNESS DISCOMF PAIN IMMED HRS AFTcR BEFORE EATING: BOWELS HABITUAL OCCAS CONSTIP LOOSE REG FLATULENCE: URINATION NOT FREQ PAINFUL: URINE AMT INCREAS DIMIN : MENSES PAIN SLIGHT SEVERE NOT REG FREE SCANTY VAG DISCH LABOURS SEVERE NO FEVER : TOBACCO HABIT OCCAS MOD EXCESS: COFFEE TEA BOTH HABIT OCCAS MOD EXCESS: PULSE RATE NOT REG TENSION HIGH LOW : ARTERIES HARD SOFT : RESP RATE COSTAL ABDOM EXPANS GOOD POOR: TEMP A large amount of writing is saved by this device. The imprint is made in the same manner as with the outline stamps. The words required are underlined, special emphasis indicated by double under- lining, and doubtful points followed by a question mark. Any de- sired set of words can be made to suit individual requirements. The set should not cover a space greater than H* X 3*, or 2" X 4", as a larger size will not print evenly. The stamp may be a self-inker or a hand stamp. The hand stamp is less expensive and, with care in printing, answers perfectly. PART I THE EVIDENCES OF DISEASE SECTION I CONSIDERATIONS, NEITHER SYMPTOMS NOR SIGNS, WHICH MAY QUALIFY OR SUGGEST A DIAGNOSIS THE considerations which may qualify or suggest the diagnosis in a given case relate to the family history or hereditary tendencies, and the personal history up to the date of the present illness. The personal history includes age, sex, nationality, occupation, residence, habits, and previous diseases or injuries. Such considerations em- brace also the chronological occurrence, seasonal or diurnal, of cer- tain diseases, and the comparative infrequency of others. I. Family History. The family history of the patient is of much importance, because of the light which may be cast by it, not only upon the present illness, but also upon the constitution and tenden- cies of the patient. Unfortunately, it is not always possible to obtain a complete and accurate family history. It is usually necessary to cross-examine the patient with some particularity, inquiring into the symptoms and duration of illnesses attributed to ancestors, and bearing in mind the approximate meanings of various popular terms, such as "gastric fever," " dropsy," " blood-poisoning," " teething," " cold," " nervous prostration," which latter may cover insanity or hysteria. " Old age " is frequently assigned as a cause of death, which has, of course, little meaning. " Childbirth," when assigned as a lethal cause, not infrequently proves to be a rapid phthisis pulmonalis. Inquiries regarding certain diseases should be made very cau- tiously, because of the possibility of arousing feelings of shame or fear in the patient. It is better to ask if there is " lung trouble " in the family than to use the word " consumption." So, too, it is strongly advisable to ask after the symptoms without mentioning the names of suspected syphilis, tuberculosis, or cancer. There is a certain reproach to family or personal pride in the acknowledg- ment of the existence of some ailments, which may lead to the con- cealment of important information. 13 14 THE EVIDENCES OF DISEASE A full statement of the family history includes the nature of the illnesses (with the age of the living) and the causes of deaths (with the age at death) which may have occurred in the patient's parents, paternal and maternal grandparents, brothers and sisters. It is requisite at times to ascertain similar facts with reference to aunts, uncles, and cousins. It should be borne in mind that transmissible tendencies may pass over one generation. It is important during this inquiry to bear in mind that certain diseases are either frequently associated or are manifestations of a common cause. In some cases there is a curious alternation between two diseases, one replacing the other e. g., migraine and epilepsy. This may occur in the individual, or in alternating generations. Heredity may be direct, the offspring showing the lesions of the disease at birth, as in syphilis. In the majority of cases, a certain stamp or type of tissue and organization is transmitted which ren- ders the individual vulnerable to special micro-organisms, as in tuberculous subjects, or liable to perversions of the nervous system, or prone to degenerations and disturbances of metabolism. HEREDITARY DISEASES OR CONDITIONS Rheumatism. Cardiac diseases. Chorea. Nephritis. Renal calculus. Emphysema. Bronchitis. Psoriasis. Tuberculosis. Phthisis pulmonalis. Tuberculous glands. Tuberculous disease of bones. Tuberculous peritonitis. Tuberculous meningitis. Hydrocephalus. Haemophilia. Diabetes. Syphilis. Alcoholism. Acne. Eczema. Ichthyosis. Leprosy. Insanity. Hysteria. Hypochondria. Epilepsy. Migraine. Neuralgias. Many neuroses. Gout. Diseases of the liver. Chronic nephritis, especially cirrhotic. Renal calculus. Angina pectoris. Cardio-vascular disease. Apoplexy. Asthma. Lichen. Naevus. Malformations. Pseudo-hypertrophic paralysis. Progressive muscular atrophy. Huntington's chorea. Thomsen's disease. Friedreich's ataxia. AGE INFANCY AND CHILDHOOD 15 A list of diseases and conditions which are considered to be trans- missible in varying degrees is given on the preceding page. The bracketed groups are composed of those which have affiliations either of conjoint occurrence or common causes. II. Age. Anatomical structure varies with age, and physiological processes have peculiarities which are characteristic of different periods of life. Moreover, the effects of environment, occupation, habits, the beginning and end of sexual life, and the wearing out of the organism by constant friction, are necessarily manifested at vary- ing ages. Consequently there is a distinct preponderance in the frequency of certain diseases or classes of disease at special age pe- riods. The diseases of youth are often the direct progenitors of those of old age, and the life of the individual may be a constant struggle with diseased conditions which began in antenatal life. (1) Infancy and Childhood. At this age there is a special liability to digestive disorders, because of the relatively large amount of work required to meet the pressing needs of a rapidly developing organ- ism, and because of the peculiar susceptibility to infection of the gastro-intestinal tract in children. Inflammations of the respiratory apparatus are frequent, because oi the tendency of the cells of the mucous membranes to undergo rapid proliferation under slight and unaccustomed irritations. Xervous diseases and reflex disturbances are common for the reason that the cerebro-spinal and sympathetic apparatus is developing, and has not yet settled into habits of regu- lar innervation. This is also the age, above all others, at which the organism is susceptible to certain infectious diseases the exan- themata. The following diseases are those which are most common at this age period. Some are congenital. Diseases mentioned under a given head may begin later than the period under which they are classed. Post-pharyngeal abscess. Endocarditis. Amyloid disease. Disease of the lymph glands. Bronchitis. Haemophilia. Convulsions. Hydrocephalus. Primary renal sarcoma. Idiocy. Cretinism. Intertrigo. Soft cataract. Impetigo contagiosa. Chorea. Intussusception. Diarrhceal diseases. Lumbrici. Diphtheria. Laryngismus stridulus. Eczema. Diphtheria of the larynx. Epilepsy (beginning). Spasmodic laryngitis. 16 THE EVIDENCES OF DISEASE Malformations. Measles. Meningitis. Mumps. Naevi. Xoma. Infantile paralysis. Pseudo-hypertrophic paralysis. Pemphigus. Lobular pneumonia. Progressive muscular atrophy. (2) Puberty and Adolescence Acne. Addison's disease. Anaemia. Chlorosis. Catalepsy. Epilepsy. Fever. (3) Middle Age : Aneurism. Angina pectoris. Apoplexy. Cancer. Diabetes. Gout. Gallstones. Hypochondriasis. Leucocythemia. (4) Old Age: Aortic disease. Atheroma. Cerebral degenerations. Chronic bronchitis. Rachitis. Roseola. Rotheln. Scarlatina. Seborrhoea. Strophulus. Congenital syphilis. Tetany. Varicella. Variola. Hysteria and spinal irritation. Exophthalmic goitre. Myxoedema. Lobar pneumonia. Acute rheumatism. Acute tuberculosis. Gastric ulcer. Melancholia. Mollities ossium. Myxcedema. Paralysis agitans. General paresis. Bulbar paralysis. Sciatica. Stricture of rectum. Degenerations of the heart. Broncho-pneumonia. Prostatic diseases. Gangrene of extremities. III. Sex. Putting aside the diseases due to differences in struc- ture and function between male and female, there remain certain maladies which occur more frequently in one sex than in the other. These discrepancies are caused mainly by the manner of life. Men suffer especially from diseases induced by exposure, hard physical or mental work and worry, and by the acquirement of injurious habits. SEX NATIONALITY 17 Women lead an indoor life, and many are harassed by household and domestic anxieties. If not occupied by domestic cares, or if without definite aims and interests, a habit of morbid self-examina- tion is apt to be formed. Moreover, the nervous system in women is normally more unstable in its equilibrium. Because of all these factors, functional nervous diseases (neuroses) are much more com- mon in women than in men. The following list, which is by no means exhaustive, contains some of the more common diseases, classified according to sex fre- quency. The figures are only approximate. (1) Males : Aneurism in general. Abdominal aneurism, 8 to 1. Angina pectoris. Progressive muscular atrophy, 6 to 1. Locomotor ataxia. Carcinoma of the stomach or rec- tum, 2 to 1. Diabetes, 2 to 1. Epilepsy. Haemophilia, 11 to 1. (2) Females : Anaemia. Arthritis deformans. Catalepsy. Chloro-anaemia. Chorea, Erythema nodosum. Gallstones. Goitre (ordinary and exophthal- mic). In women the regularity, profuseness, and attendant pain of the menstruation, the number of pregnancies and miscarriages and their sequelae should be ascertained, for the reason that deviations from the normal in these respects may be of much importance as possible causes of subsequent disease. IV. Nationality. The susceptibility or its opposite, immunity, possessed by certain races has been commented upon by some ob- servers. Among these may be noted the liability of the Jewish race to diabetes, of the Scandinavian and African to phthisis pulnionalis, and the comparative immunity of the African to yellow fever. Fatty heart, 2 to 1. Gout. Chronic gastritis. Hypochondriasis. Intussusception. Leucaemia, 2 to 1. Pseudo-leucaemia, 3 to 1. General paresis. Pseudo-hypertrophic paralysis. Typhoid fever, 4 to 1. Valvular diseases of heart. Hysteria. Movable kidney. Myxcedema. Neuralgias. Neurasthenia. Osteomalacia, 30 to 1. Spinal irritation (neurasthenia). Ulcer of the stomach. 18 THE EVIDENCES OF DISEASE V. Occupation. With reference to the effects of occupation in causing disease, it will be found necessary to ascertain the details of the patient's employment, whether active or sedentary in character, and whether or not it requires the handling or breathing of toxic or irritating substances. Possible overuse of the eyes, playing wind instruments, and the care of domestic animals, are other details a knowledge of which may be useful. All previous occupations should be ascertained. It should be remembered that the state of health sometimes enforces the occupation. (1) Diseases Incident to Active Occupations: Aneurism. Pneumonia. Rheumatism. (2) Diseases Incident to Sedentary Occupations, including Mental Work : Anaemia. Gallstones. Xeuroses. Chlorosis. Hemorrhoids. Obesity. Constipation. Hysteria. Ulcer of the stomach. Digestive disorders. Hypochondriasis. (3) Diseases Incident to Special Occupations : Pulmonary phthisis. Accountants, book-keepers, clerks, compositors, printers, pressmen, marble and stone cutters. Fibroid phthisis, from dust. Grinders, file cutters, potters, glass polishers, wool and cotton spinners, millers. Anthrax. Skin handlers. Internal anthrax. Wool and rag sorters. Glanders and tetanus. Hostlers. Anaemia, gastric ulcer, eczema, erythema nodosum. Domestic servants (female). Varicose veins. Coachmen, shop girls, and others accustomed to long maintenance of the standing or part standing position. Writer's cramp (scrivener's palsy). Clerks and writers. Septic infection. Butchers and slaughterhouse employees. Conjunctivitis. Electric-light workers. Probably caused by actinic rays. Nystagmus. Miners. Emphysema. Players upon wind instruments. Insomnia, dyspepsia, disease of liver and kidneys, neurasthenia, irritable heart, apoplexy, and paralysis. Brain workers. Typhoid fever, pneumonia, cardio- vascular and renal disease, morphine and cocaine habits. Physicians. Lead poisoning. Lead miners and smelters, painters, gilders, makers of white and red lead, seamstresses (from silk thread loaded with acetate of lead), makers of artificial flowers. Mercurial poisoning. Cinnabar miners, makers of cheap looking glasses or mirrors, makers of felt hats (from the bath of acid nitrate or mercury used to promote felting). OCCUPATION RESIDENCE 19 Arsenical poisoning. Wall-paper workers (formerly), workers on artificial flowers and fancy glazed-paper boxes. Phosphorus poisoning. Matchmakers. Chromium and zinc poisoning. "Founders' ague " in brass foundries. Disease of hair follicles. Operatives in oil refineries and paraffin works. VI. Residence. A knowledge of the place of residence may be of considerable importance, if not with regard to diagnosis, at least with regard to the prophylaxis of future attacks. In the diagnosis of sus- pected cases of cholera, yellow fever, and the pernicious or severe malarial fevers, the fact of the patient having visited or lived in countries or localities where they are prevalent may furnish a clew otherwise lacking. Goitre, rachitis, calculus, cretinism, dysentery, and lung diseases have at times special affinities with certain localities. The following list comprises the more important geographical associations of disease, which may be of diagnostic value in connec- tion with a patient fresh from residence in the countries named : Africa. Dengue, Guinea- worm disease. Africa, South. Bilharzia haematobia. Africa, West Coast. Yellow fever, framboesia. America, South. Chigoe, ainhum (negro). Arabia. Bilharzia haematobia. Canada, New Brunsirick, Cape Breton. Leprosy. China. Beri-beri, bilharzia haematobia. Egypt. Bilharzia haematobia, plague. England, Certain Counties. Renal calculus. Europe, Large Cities. Rachitis. France, South of. Pellagra. India, East. Beri-beri, Delhi boil, dengue, bilharzia haematobia, Asiatic cholera, framboesia, Guinea-worm disease, ainhum (negro). West Indies. Chigoe, dengue, yellow fever, framboesia. Italy. Goitre, cretinism, pellagra. Japan. Beri-beri, bubonic plague, bilharzia haematobia. Malt/i. Malta fever. Morocco. Plague. Naples. Malta fever. Noricay. Le prosy . Spain. Pellagra, goitre (Pyrenees). Switzerland, Alps. Goitre, cretinism. Syria. Plague. Tropical Regions in General. Epidemic dysentery, pernicious intermittent and remittent fevers, acute hepatitis and hepatic abscess, leprosy, filaria san- guinis hominis. I' a it