A MANUAL
CLINICAL MEDICINE,
A MANUAL
OF
CLINICAL MEDICmE.
PHYSICAL DIAGNOSIS.
BY
T. II. TA^'XER, M.D.,
LICENTIATE OF THE ROYAL COLLEGE OF PDYSICIANS ; PHYSICIAN TO
THE HOSPITAL FOR WOMEN, ETC., ETC.
TO WHICH IS ADDED
THE CODE OF ETHICS
AMERICAN MEDICAL ASSOCIATION.
PHILADELPHIA:
BLANCHARD & LEA.
1855.
SOEHMAN ft SON, PRINTERS,
19 Si. James Street.
Hist 7:)jv
TlS7yn
TO
ROBERT BENTLEY TODD, M.D., F.R.S.,
PHYSICIAN TO KI>-g'S COLLEGE HOSPITAL, ETC.,
THIS MANUAL IS DEDICATED,
FRIEND AND FORMER PUPIL,
THE AUTHOR.
1*
PUBLISHERS' ADVERTISEIMENT.
In presenting to the profession of the United
States this admirable little manual, the publishers
have thought that its value as a work for daily
reference would be enhanced by the addition of
the excellent " Code of Ethics of the American
Medical Association," which, adopted as it has
been by most of the State Medical Societies, may
be regarded as the standard guide of the American
profession.
Philadelphia, August, 1855.
PREFACE.
The following pages have been written with the
intention of removing some of the difficulties which
the student always — and the practitioner frequently
— must encounter, while studying disease in its Pro-
tean forms at the bedside. Remembering my own
impressions of bewilderment on beginning to "walk
the hospital," I have honestly endeavored to sim-
plify the task for others ; and should this treatise be
the means of doing so, I shall feel greatly rewarded
for my exertions.
Charlotte Street, Bedford Square,
February, 1855.
CONTENTS.
CH'APTER I.
ON THE CLINICAL STUDY OF DISEASE.
PAGE
Section 1. On the Faculty of Observation, . . "25
Section 2. The General Conduct of the Practi-
tioner OF Medicine, 27
Section 3. The Clinical Examination of a Patient,
Examination of the Exterior, 29
Interrogation of the Patient, . . . . . 29
Examination of the Cranium, . . . . .29
Thoracic Viscera, .... 30
Abdomen, 30
Present General Condition of the Patient, ... 30
Examination of Female Patients, . . . . .31
Section 4. The Clinical Examination of Children.
Section 5. Mode of taking Notes of a Case,
General Observations, ....... 32
Anatomical or Physiological Peculiarities, . . .32
Itellectual and Moral Peculiarities, .... 33
Previous History, ........ 33
General Healtli, 33
Present Illness, 33
Condition, . 33
Condition of Nervous System, . . . . .33
Organs of Respiration and Circulation, 34
Xll CONTENTS.
PAGE
Condition of Digestive Organs, . . . .34
Urinary Organs, ..... 34
Causes of Illness, 34
Diagnosis, , 34
Prognosis, ......... 34
General Rules of Treatment, 34
Section 6. Mode of taking Notes of Diseases of
Females.
Section 7. Mode of making a Post-mortem Examina-
tion,
Examination of the Skull, 35
Spinal Cord, .... 36
Thoracic and Abdominal Cavities, . 30
Urinary and Generative Organs, . 37
Section 8. Mode of taking Notes of a Post-mortem
Examination,
General Observations, ....... 37
Examination of Head, Face, Mouth, and Fauces, . . 37
Thorax, ....... 38
Abdomen, 38
Male Organs of Generation, . . .39
Female Organs of Generation, . . 39
Spinal Cord, 39
Section 9. The Clinical Examination of the Insane,
Investigation of the Physiognomy, ... . . 40
Actions, 40
The Conversation of the Insane, . . . . .41
The Memory, Written Letters, &c., of the Insane, . 41
Certificates of Insanity, 42
Medical Case Book, 43
Section 10. Examination of Persons for Life As-
surance,
Different Knowledge required in Life Office to the Con-
sulting-room, ... 44
Points especially to attend to in Examination of Appli-
cant, 44
Aphorisms on the Value of certain Lives, . . .45
Section 11. On Medico-legal Investigations,
Use of Notes, 46
Confessions and Death-bed Declarations, . . . 47
Reports for Judicial Purposes, 47
Medical Evidence at Inquests, 49
CONTEXTS.
CHAPTER II.
ON THE INSTRUMENTS EMPLOYED IN THE DIAGNOSIS
OP DISEASE.
TASK
Section 1. On the Microscope,
The Student's Microscope, ! 50
The Simple INIicroscope, ....... 50
The Compound Microscope, 50
The Magnifying Powers of the best Object-glasses, . . 51
Standards of Measurement, 53
Section 2. On the Test-tray,
The Apparatus required in 3Iedical Chemistry, . . 53
Dr. Lionel Beale's Cabinet of Apparatus and Reagents, . 54
Section 3. On the Spirometer,
Hutchinson's Spirometer, ....... 54
Mode of Testing the Vital Capacity, .... 54
Coxeter"s Portable Spirometer, ...... 55
Pereira's Spirometer, . 55
Section 4. On the Common Tape-measurp:, Stethome-
ter, Pleximeter, Stethoscope, Etc.,
The Common Tape-measure, ...... 56
Mode of ascertaining the Circumference and Mobility
of the Chest, 56
The Stethometer, 56
Dr. Sibson's Chest-measurer, ...... 56
The Movements in Respiration, ..... 57
Plessors, Pleximeters, &c., 57
Dr. Sibson's Spring Pleximeter, ..... 57
The Stethoscope, ........ 57
General Observations, ....... 58
Section 5. On the Dynamometer.
Section 6. On the instruments required for making
Local Applications to the Larynx, Etc.
Section 7. On the Ophthalmoscope.
Section 8. On the Speculum Uteri, Uterine Sound,
Etc.,
The Speculum — Varieties of, . . . . . .60
The Uterine Sound, 61
Sponge Tents, . . . . . . .61
Dr. Protheroe Smith's Uterine Dilator, .... 62
2
CONTENTS.
CHAPTER III.
ON DISEASE.
Section 1. The Nature of Disease,
Definition of Disease, ..... . .
Disease of Function, . ......
Structure, .......
Acute and Chronic Diseases, .....
Zymotic Diseases,
Sporadic Diseases, .......
Continued, Remittent, and Intermittent Diseases, .
Hereditary, Congenital, Specific, and Malignant Diseases,
Asthenic, Idiopathic, Symptomatic, and Intercurrent
Diseases, ........
Section 2. The Causes of Disease,
Predisposing Causes,
Exciting Causes,
Non-cognizable Causes, ......
Section 3. The Classification of Diseases,
The Division of Diseases by Sauvage,
Cullen,
Section 4. The Diagnosis of Disease,
Mode of making a Diagnosis,
Probability the Guide of Life, ....
Section 5. The Prognosis of Disease,
Importance of the Prognosis, ....
Positive Statements — their Efiect,
Section 6. The Terminations of Disease,
Termination in Health,
The Crisis of a Disease, .
Metastasis, ....
The Termination in Death,
Sudden Death and its Causes,
Death by Anoemia, .
Asthenia,
Asphyxia or Apncea.
Coma, .
63
63
63
64
64
65
65
65
66
66
67
67
68
68
69
69
70
71
71
72
73
73
74
75
75
75
76
CONTEXTS.
CHAPTER IV.
ON THE VARIOUS CIRCUMSTANCES WHICH MODIFY
DISEASE.
PAGE
General Remarks,
1. Sex, 77
2. Age, 78
3. Hereditary Tendency, 79
4. Temperament and Idiosyncrasy, . . . . .80
The Sanguine and Irritable Temperament, 80
The Lymphatic or Phlegmatic, . . .80
The Nervous, / 80
The Bilious, 80
5. Diathesis, SO
6. Habit, 81
7. Climate and Temperature, 81
A great Range of Temperature compatible with Life, 82
Capability of bearing a great Degree of Heat, . 82
Sudden Transitions in Temperature, . . . .82
Effects of Heat on the Human Body, ... 83
Effects of Extreme Cold on the Human Body, . . 83
Cold in Motion and Moisture, .... 84
Temperate Latitudes, ...... 84
CHAPTER V.
ON THE SYMPTOMS AND SIGNS OF DISEASE.
Introductory Remarks on the Importance of Semeiology, . 84
Various Divisions of Symptoms, ..... 85
Section 1. Symptoms and Signs afforded by the Coun-
tenance AND Condition of the Body,
The Expression of the Countenance, . . .86
The Countenance in Facial Paralysis, .... 87
The Appearance of the Lips and Mouth, . . . .88
The Hue or Color of the Countenance, .... 88
A Dark Circle under the Eyes, 89
Signs presented by the Eye, ...... 89
The Arcus Senilis, 90
The Function of Vision, 91
The Sense of Hearing, ....... 92
The Posture of the Body, 92
XVI CONTENTS,
PAOB
The Nutrition of the Body, 94
The Temperature of the Surface of the Body, . . 94
The Moisture of the Surface of the Body, . . . .95
Section 2. Symptoms belonging to the Organs and
Function of Digestion,
The Teeth and Gum?, 95
The Saliva, 96
The Tongue, 96
The Taste, 98
Deglutition, 99
The Appetite and Desire for Drink, .... 99
Jaundice, 100
Nausea and Vomiting, ....... 101
Deftecation, ......... 101
Section 3. Symptoms belonging to the Function
OF Respiration,
The Respirations, ........ 103
Dyspnoea, 103
Orthopnoea, 105
The Odor of the Breath, 105
The Temperature of the Expired Air, .... 106
Cough, 106
Hiccough, . . 107
Expectoration, 107
Stertor, 108
Yawning and Sighing, .108
Sneezing, 108
Section 4. Symptoms belonging to the function of
Circulation,
Palpitations of the Heart and Large Vessels, . . . 108
The Pulse, 109
Condition of the Capillaries, . , . . . .114
Venous Symptoms, 115
State of the Blood, 115
Section 5. Symptoms connected with the Urinary
AND Sexual Organs,
The Excretion of Urine, . . . . . .118
Dysuria, . .118
Strangury, . . . . . . . . .118
Ischuria, 118
Incontinence of Urine, . . . . . . .119
Sexual Organs in the Male, 120
The Uterine System, . . . . . . . 120
CONTENTS.
Section 6. Symptoms dbrfved from the Nervous
System^
Pain,
Diminished Sensibility,
Paralysis, .
General Paralysis,
Hemiplegia,
Paraplegia, .
Spasm,
Tonic Spasm,
Clonic Spasm, .
Delirium,
Coma,
121
122
123
123
123
123
124
124
124
124
125
CHAPTER VI.
ON THE DIAGNOSIS OF NATURAL FROM FEIGNED
DISEASE.
Introductory Observations, . 127
The Four Modes in which Disease may be simulated, . 127
A Table of Feigned Diseases, 128
Concluding Remarks, .138
CHAPTER VII.
ON THE PHYSICAL DIAGNOSIS OF DISEASE.
Introductory Remarks, . . . . . .138
The Nature of Physical Signs, 139
Section 1. The Physical Signs of Cerebral Disease,
Cerebral Auscultation, ....... 140
The various Auscultic Phenomena, . . . .140
Section 2. The Physical Diagnosis of Diseases of
THE Lungs and Heart,
Introductory Remarks on the Structure of the Lungs, . 142
Position of the Patient, 143
Regions of the Thorax, 144
Description of the Methods of Physical Diagnosis, . . 147
1. Inspection,
Form of Chest, 147
Size, 149
Movements, 149
2*
CO XT K NTS.
2. Palpation',
Vocal Vibration, or Fremitus,
Pulmonary Friction Fremitus,
Fluctuation,
The Heart's Impulse,
Fremissement Cataire,
Cardiac Friction Fremitus,
.^. Meksuratiox,
Circular Width of Chest, .
Variation of the two Sides, .
Diseases causing Enlargement,
Diseases causing Narrowing,
4. Succussiox,
Mode of Practising Succussion,
Uses of, .
7.
IS
Spirometry,
Vital Capacity as affected by Height, .
Weight as affecting Vital Capacity,
Age as affecting Vital Capacity, .
Percussion",
Mode of Practising, ....
Diminution of Clearness, .
Increase of Clearness, ....
Tympanitic Sound,
Amphoric Resonance and Metallic Tinkling,
Tubular Sound, .....
The Bruit de Pot Fele,
Auscultation,
Mode of Practising, ....
f Pulmonary or Vesicular Respiration,
Bronchial Respiration,
The Laryngeal Murmur,
Sounds caused by Morbid Secretion, ,
Dry Sounds,
]\Ioist Sounds, ....
^Friction-sounds, ....
p Bronchophony,
J Pectoriloquy,
iEgophony,
Morbid Phenomena of the Cough, .
Sounds of the Heart, .
Pericardial Friction-murmur
Endocardial Murmurs,
Diseases of the Cardiac Valves,
Inorganic Murmurs, .
CONTEXT!
Section 3. The Physical Diagnosis of Diseases of
THE Abdomen,
Regions of the Abdomen, 173
Modes of Physical Examination, . . . . .173
Inspection, ........ 174
Mensuration, 174
Palpation, 174
Percussion, 177
Auscultation, 179
Auscultation of the Abdomen during Pregnancy, . 180
CHAPTER Yin.
GENERAL OBSERVATIONS ON THE DIAGNOSIS OP
THORACIC DISEASES.
Bronchitis, 182
Pleurisy, 183
Pneumonia, . . . . . . . .184
Asthma, 186
Emphysema, ......... 187
Pneumothorax, 187
Phthisis, 188
Pericarditis, 190
Endocarditis, 191
Valvular Diseases of the Heart, 192
Atrophy of the Heart, 194
Hypertrophy of the Heart, . . . . . . .195
Cyanosis, ......... 196
Aneurism of the Aorta, 196
CHAPTER IX.
ON THE DIAGNOSIS OF DISEASES OP THE SKIN.
Willan's Classification, 198
Order 1. The Exanthemata,
Erythema, 199
Erysipelas, 199
Roseola, 200
Rubeola, 200
Scarlatina, 201
Urticaria, 204
XX CONTEXTS.
PAGE
Order 2. Vesicul.*:,
Miliaria, 204
Varicella, 205
Eczema, 205
Herpes, 205
Scabies, 206
Order 3. Bullj?,
Pempliigus, 206
Rupia, 206
Button Scurvy, 207
Order 4. Pustul.e,
Variola, 207
Vaccinia, 207
Ecthyma, 209
Impetigo, 210
Acne, 211
Mentagra, 211
Porrigo, 211
Plica Polonica, 212
Equinia or Glanders 212
Order 5. Papula,
Lichen, 212
Prurigo, 213
Order 6. Squama,
Lepra, 213
Psoriasis, . . . . . . . . .213
Pityriasis, ........ 214
Pityriasis Versicolor, 214
Ichthyosis, 214
Order 7. Tubercul^,
Elephantiasis GraBCorum, 214
Molluscum, 215
Frambcesia, 215
Order 8. Macule,
Lentigo, 216
Ephelides, 216
NfEvi, 216
Albinismus, 216
Vitiligo, 216
Order 9,
Lupus, 216
CONTEXTS.
PAGE
Order 10,
Pellagra, 217
Order 11,
Malum Allepporum, 217
Order 12,
Syphilida, 217
Order 13,
Purpura, 218
Order 14,
Elephantiasis Arabicum, 218
Order 15,
Cbeloidea, "219
CHAPTER X.
PARASITIC WORMS POUND IN THE HUMAN BODY.
Table of the Worms, 219
1. Internal Parasites,
Acephalocysts or Hydatids, 221
Echinococcus Hominis, .221
Filaria Oculi, Filaria Medinensis, and Filaria Bronchialis, 221
Cysticercus Cellulosee, . 222
Distomata, ........ 222
Polystoma Pinguicola, 222
Strongylus Gigas, 222
Dactylius Aculeatus, 223
Diplosoma Crenata, 223
Spiroptera Hominis, 223
Trichina Spiralis, 223
Tricocephalus Dispar, 224
Ascaris Lumbricoides, ...... 224
Ascaris Vermicularis, ....... 224
Ta-nia Solium, 224
Bothriocephalus Latus, 224
2. External Parasites,
Pulex Penetrans, ....... 225
Acarus Scabiei, ........ 225
Acarus FoUiculomm, 225
Pediculi, 226
CONTENTS.
CHAPTER XL
ON THE CHEMICAL AND MICROSCOPICAL EXAMINATION
OF THE BLOOD, EXPECTORATION, VOMITED MATTERS,
AND URINE.
FAGB
The Excretions generally, 226
Section 1. The Blood,
General Composition of, 227
Chemical Composition of, ..... 228
Microscopic Examination of, ..... 229
Mode of Examining Stains of, . . . . . 229
To detect Uric Acid in Serum of, . . . . . 229
Section 2. The Expectoration,
General Characters of, 230
Microscopic Examination of, . . . . .230
Section 3. Vomited Matters,
SarcinEB Ventriculi, 231
Section 4. The Urine,
Table of Solid Contents, 232
Mode of making a Clinical Examination o.^, . . 233
Increased Flow of Urine, 233
Deficiency of Urine, ....... 233
Reaction of Test-papers, 233
Urine depositing Uric Acid, 234
Urine containing an excess of Urea, . . . .234
Urate of Soda, Lime, &c., 234
Ammoniacal Salts, . 234
Urine containing Purpurine, ..... 235
. 235
. 235
. 236
. 236
. 2.36
. 236
238
. 239
Cystine, ....
Oxalate of Lime,
Gravel, ....
Mode of testing for Albumen,
Pus,
Sugar,
Kiestein, ....
Casts of Tubes, Epithelium, &c
Bile in the Urine, 239
Iodide of Potassium in the Urine, .... 239
CONTENTS.
CODE OF ETHICS OF THE AMERICAN MEDICAL
ASSOCIATION.
OF THE DUTIES OF PHYSICIANS TO THEIU PATIENTS,
AND OF THE OBLIGATIONS OF PATIENTS TO THEIR
PHYSICIANS.
PASE
Art. 1. Duties of Physicians to their Patients, . . 240
Art. 2. Obligations of Patients to their Physicians, . 242
OF THE DUTIES OF PHYSICIANS TO EACH OTHER, AND
TO THE PROFESSION AT LARGE.
Art. 1. Duties for the support of Professional Character, 244
Art. 2. Professional Services to each other, . . . 245
Art. 3. Of the Duties of Physicians as respects vicarious
offices, ........ 245
Art. 4. Of the Duties of Physicians in regard to Consul-
tations, 246
Art. 5. Duties of Physicians in cases of Interference, 248
Art. 6. Of Differences between Physicians, . . . 250
Art. 7. Of pecuniary Acknowledgments, . . . 250
OF THE DUTIES OF THE PROFESSION TO THE PUBLIC,
AND OF THE OBLIGATIONS OF THE PUBLIC TO THE
PROFESSION.
Art. 1. Duties of the Profession to the Public, . . 251
Art. 2. Obligations of the Public to Physicians, . 252
A MANUAL
CLINICAL MEDICINE
CHAPTER I.
ON THE CLINICAL STUDY OF DISEASE.
SECTION 1. ON THE FACULTY OF OBSERVATION.
All who have studied the writings of the greatest of
philosophers — Lord Bacon — must know that there are two
especial sources to which he refers men for real increase of
knowledge, namely, to observation and experiment, which he
insists are but questionings of Nature in respect of specific
matters. To cultivate the faculty of observation must then be
the first duty of those who would excel in any scientific pur-
suit,' and to none is this study more necessary than to the stu-
dent of medicine. To such an one it may be said, that the habit
of correct observation is that mode of learning his profession
which above all others he should most diligently cultivate ;
remembering that observation does not consist in the mere
habitual sight of objects — in a kind of vague looking-on, so
to speak — but in the power of comparing the known with the
unknown, of contrasting the similar and dissimilar, in justly
appreciating the connection between cause and effect, and in
estimating at their correct value established facts. The great
Newton has assured us that he knew of no difference between
himself and other men but in his habits of observation and
*"L'art d'observer est le seul moyen d'acqu6rir des coniiaissances
utiles." — La Croix.
3
26 CLINICAL STUDY OF DISEASE.
attention, and almost the same encouraging remark was made
by Locke.
The constitution of the human mind is such that the acqui-
sition of knowledge can only be very gradual. Just as there
is no royal road to learning, so there is no rapid method of
gaining experience ; and he who wishes to excel must not
only work assiduously, but must be careful that he toils in the
right direction. Although at first the difficulties in the way
of observing correctly may appear insurmountable, yet as the
habit is daily encouraged will the path become clear, until at
last what was at first a labor becomes a matter of almost
routine practice.
The most important part of the medical man's education is
undoubtedly to be gained at the bedside. In the wards of
our various hospitals every diversity of ailment, every variety
of injury may be carefully observed and investigated, first —
as disease appears naturally, when, as we may say. Nature is
performing her experiments for our wisdom ; and secondly —
as modified by a careful use of those remedial agents which
have been so bountifully bestowed upon us. In order, how-
ever, that the observation of disease may be profitable, it
must be complete. It will be useless unless the malady be
watched during its whole course, the symptoms as they arise
noted, and the effects of medicines carefully observed until
the termination in recovery or death. Especially is the ter-
mination of a case instructive, and not the less so when the
result is death, since we may then mark the way in which the
patient succumbed, and learn to guard against such an event
in similar examples for the future. Just as a man who wishes
to become acquainted with the nature and characteristics of
a foreign country may read a whole library on the subject,
inspect charts and panoramic views faithfully drawn, or study
a series of paintings delineating separately all that is most
worthy of observation, and yet certainly fail to obtain any
correct idea of the distant land ; so may a student learn the
entire practice of physic by heart from books, and yet be
unable to distinguish small-pox from measles when called upon
to put his theoretical knowledge into actual practice. Valua-
ble, therefore, and indeed indispensable, as is the assistance
to be derived from a careful study of the writings of the
masters of our profession, yet these ^vTitings must be regarded
principally, if not solely, as guide-books, that is to say, as
intended to smooth the difficulties which the observer will
have to encounter, but by no means calculated to do away
with the labor of self observation ; for it is not too much to
COXDUCT OF THE MEDICAL P R ACTITIO XER. 27
say that without practical experience all other acquirements
are of no avail to the practitioner of medicine. Truly excel-
lent, then, is the advice given by Dr. Latham to the student,
'' begin by learning to stand by the sick-bed, and make it
your delight." He who will be content to do this in a right
spirit, may be assured of becoming an eminently useful mem-
ber of the noblest profession that can engage the attention or
encourage the development of the highest qualities of the
mind of man : let him but work diligently, perseveringly, and
conscientiously, and he may be certain of ultimately acquiring
— if not the purse of Fortunatus — at least a competence ; but,
above all, will he experience that happiness which princes
may envy, but which they cannot bestow, the gratification of
knowing that — in however humble a degree — he is the
honored instrument of " God, who healeth our diseases."
SECTION 2. THE GENERAL CONDTJCT OF THE MEDICAL
PRACTITIONER.
Although much might be advantageously written upon this
subject, yet a very few words must suffice. The mere fact
that the practice of medicine arose from an instinctive impulse
to relieve the pains and sufferings of others is sufficient to
show that the medical man, of all men, should be free from
that vice which is the besetting sin of mankind — selfishness.
He must indeed, be thoroughly content to live, not for him-
self, but for others ; not to look to his own interests, not to be
guided in his actions by motives of policy, but to let the rule
of his life be to do as much good to others as possible. He
should think as little of pecuniary rewards as is compatible
with his own interests and that of his brother practitioners,
remembering the maxim adopted by La Bruyere from Con-
fucius — that he who esteems gold more than virtue, will be
likely to lose both gold and virtue. The physician, to be suc-
cessful, must not only possess a sound practical knowledge of
his profession, but he must also be careful that his moral
character be free from blemish ; that his general conduct be
not only above vulgarity, but such as to excite the respect of
his friends and neighbors ; that he be conscientious, attentive,
careful of the secrets of those who consult him, unmindful of
the worldly condition of his patients, sympathizing, calm, and
circumspect in his behavior generally. As it is his object to
prolong life, so he must leave no means unpursued in order
to attain such object, remembering that the mere prescribing
of medicines is often the least part of his duty. It would
28 CLINICAL STUDY OF DISEASE.
indeed be well if medical men generally thought more of the
moral remedies at their disposal ; and if more attention were
bestowed upon soothing the fleeting moments of the afflicted,
by inspiring them with hope, confidence, and ease of mind.
A man who practises his profession conscientiously will never
be unmindful of the duties which he owes to his colleagues —
to those treading the same path as himself. He will carefully
avoid all such short-sighted proceedings as may tend to elevate
himself by depressing others : he will strictly eschew those
disgraceful methods of obtaining notoriety, newspaper puffing
or prescribing ; and he will hesitate at giving, as a rule,
gratuitous advice, where such is not needed by the circum-
stances of the patient, and where such a course of proceeding
must injure those who are content to receive a small remune-
ration for their toilsome labors, and whose daily bread pro-
bably depends upon their obtaining such a return for their
exertions.
The encouragement bestowed upon medical men is for the
most part very deficient, their worth and usefulness being
unacknowledged, their fatigues and anxieties unheeded, and
their unselfishness and disregard of wealth abused. While
striving to diminish the sufferings of their afflicted fellow-
creatures, can it happen otherwise than that their feelings
should be hurt by observing the attention paid to men prac-
tising the most palpable absurdities and deceptions, by
witnessing the success of homoeopaths, table-turners, mes-
merists, and such like ? Has it not, however, always been so ?
Does not Bacon himself tell us, that " the weakness and cre-
dulity of men is such, as they will often prefer a mountebank
or witch before a learned physician,"' and is the present age
less credulous than that of the great philosopher? I fear
not ! But it is the prerogative of superior minds to rise with
the occasion. Let us, therefore, individually and collectively,
as students and practitioners, strive to improve our art : let us
each endeavor to attain that mental sagacity which will enable
us to perceive the important features of cases coming under
our care and the salient points of diagnosis ; that Avisdom
which can foresee the course and progress of disease ; that
judgment which will enable us to select the proper remedies ;
and that calm determination which will render us capable of
insisting that the necessary measures are thoroughly carried
out.
' The Advancement of Learning.
CLINICAL EXAMINATION OF A PATIENT. 29
SECTION 8. THE CLINICAL EXAMINATION OF A PATIENT.
Upon the application of a sick person to a medical man,
the first object of the latter must be to ascertain the exact
nature of the disease before him. As it often happens that
the sufferer is embarrassed by the novelty of his situation and
by general debility resulting from his malady, we must
endeavor by calmness, delicacy, patience, and kindness on our
part to put him at his ease, which will be readily done by one
who has accustomed himself to intercourse with invalids. A
few remarks on general subjects, inquiries as to his place of
residence, and the length of time he has suffered from bad
health, will enable the practitioner to learn much from —
An Examination of the Exterior, the physiognomy first
engaging attention, since from it may be learnt the patient's
apparent age, strength, state of mind, complexion — whether
pale, florid, or dusky, and his general constitution. The gene-
ral bulk of the body should then be cursorily examined,
noticing whether it be large and full, or thin and wasted ; the
condition of particular regions, whether swelled or attenuated ;
the presence or absence of any cutaneous eruptions ; and,
lastly, evidence is to be obtained as to the powers of voluntary
motion, as the use of the arms, of the legs in locomotion, &c.
Interrogation of the Patient. — We are now prepared to
interrogate the patient himself, and this we do by inquiring
whether he has any pain, where it is seated, and the lengthy of
time he has been ailing. "This leads him to enter into a
description of his sufferings, and of the means he has adopted
for their relief; and although in many instances he may not
make his statement the short simple narrative we might
desire, yet, as a general rule, it will always be better to let
him tell his own tale in his own fashion. Then, according as
complaint is made of suffering in any particular organ, we
proceed to investigate the condition of this and of all parts
connected with it. Thus, suppose pain be complained of in
the head, we proceed to make —
An Examination of the Cranium, as to its general form,
symmetry of the two sides, special prominences and depres-
sions, and heat of the integuments. Inquiries are then to be
made as to the nature and duration of the pain, as to whether
it is deep-seated or superficial, affected by pressure, by noise ;
whether it is periodic, or connected with neuralgic or rheu-
matic paius in other parts of the body. We must ascertain,
also, the presence or absence of vertigo ; the condition of the
3*
30 CLINICAL STUDY OF MEDICINE.
functions of sight and hearing; the ability or inability to
sleep, to take exercise, and to make use of the mental facul-
ties. Or, perhaps, the seat of disease may appear to be in
the thorax. "We then make —
An Examination of the Thoracic Viscera, resorting to
inspection, palpation — or the application of the hand, mensu-
ration, percussion, and auscultation, in the manner to be
hereafter noticed. We then endeavor to ascertain the presence
or absence of cough and its nature ; the characters of the
expectoration 5 the amount of facility or of difficulty of
breathing, both when the body is quiet and when undergoing
exertion ; the nature of the heart's action, whether there be
palpitation or no ; and the presence or absence of such
general symptoms as emaciation, purging, night-sweats, &c.
An Examination of the Abdomen, when any of the
abdominal viscera appear affected, must be made by inspec-
tion, measurement, palpation, percussion, and auscultation.
The boundaries of the liver, spleen, and stomach must be
ascertained ; the nature, duration, and seat of pain, if any ;
the presence or absence of tumors, and hernial protrusions ;
the condition and number of the alvine evacuations ; the
mode in which digestion is performed, and the state of the
appetite ; and the characters of the renal secretion.
Present General Condition of the Patient.— It then
remains for us to endeavor to ascertain accurately the present
condition of the patient, the state of his skin as to its tempe-
rature, &c., the condition of the tongue, and the nature of the
pulse. His real age, profession, whether married or single,
constitution, habits and mode of living, usual state of health,
&c., are then to be inquired into, and we conclude by ascer-
taining the causes of the disease, whether it be hereditary or
acquired, whether the present is the first attack or otherwise,
and the ability of the sufferer to undergo the necessary treat-
ment.
There are, of course, many circumstances which often
prevent our making an examination in the exact manner just
described. Thus, in many instances, we have to depend for
much of our information on the testimony of relatives or
friends, or we may even be called to a person who is quite
insensible, and we may be unable to obtain any history at all.
The educated practitioner, however, will be at no loss how
best to proceed on such an emergency.'
* The student may advantageously refer to the " Mode of Interrogatina- a
Patient," recommended by Dr. Spillan, in the introductory cliapter of his
Translation of AndraPs '-Clinique M6dicale. '
CLINICAL EXAMINATION OF CHILDREN. 31
Examination of Female Patients.— In examining into
the history of a female patient, we must proceed as just recom-
mended, at the same time paying attention to the condition of
the sexual system, ascertaining especially whether the patient
is single, married, or widowed ; the number of her pregnancies
and of her children, and the date of her last labor 5 the man-
ner in which the catamenial function is performed ; and the
presence or absence of any leucorrhoeal or other discharge.
SECTION 4. THE CLINICAL EXAMINATION OF CHILDREN.
The importance of attending to the diseases of children can-
not be too much insisted upon, especially seeing that so serious
are their maladies, and so great is the mismanagement to
which young children are often subjected, that it has been
calculated one child in every five dies within a year of its
birth, and one in three before the end of the fifth year ; while
of the deaths occurring within the first year, nearly one-third
are said to take place before the end of the first month. Some
authorities even estimate the mortality as higher than this.
Thus, Dr. Friedlander asserts — '' II perit pres du quart des
enfans pendant la premiere annee."' In many of the large
manufacturing towns of England, the Registrar-General's Re-
ports give a proportion of nearly one-fourth for the males and
one-fifth for the females, under one year of age, out of the
whole number of registered deaths.
In no case perhaps does the practitioner so much stand in
need of a certain tact as investigating the disorders of child-
hood. As Dr. West justly says — " You try to gather informa-
tion from the expression of his countenance, h\it the child is
fretful, and vdW not bear to be looked at ; you endeavor to feel
his pulse, he struggles in alarm : you try to auscultate his
chest, and he breaks out into a violent fit of crying.''^ But,
by patience and good temper, by a quiet demeanor and a
gentle voice, all may be made to go well, and a diagnosis may
be formed almost as easily as in the case of adults. The first
point is to be careful not to alarm the patient, but on entering
the room to gain quietly the previous history of the case from
the mother or nurse, the circumstances under which the pre-
sent illness has come on, its early symptoms, the child's sex
and age, the nature of its food, and whether it has been weaned,
the state of the bowels, and the nature of the evacuations ;
while, at the same time, without appearing to do so, you exa-
• Education Physique des Enfans.
a West on the Diseases of Infancy and Childliood.
32 CLINICAL STUDY OF MEDICINE,
mine the expression of the countenance, the character of the
inspirations and expirations, &c. By this time the little suf-
ferer will have become accustomed to your presence, and you
may advance to the bedside to examine it more closely. The
temperature of the body and condition of the skin, the nature
of the pulse, the state of the scalp and fontanelles, the pre-
sence or absence of abdominal pain or tenderness on pressure,
may now be ascertained, and by a little management auscul-
tation may be practised. It is worthy of remembrance that
immediate auscultation is generally to be preferred in these
cases, if possible, as the pressure of the stethoscope frightens,
if it does not hurt the child. In practising percussion, care
must be taken not to strike too smartly, the variations in reso-
nance being more readily appreciated by a gentle stroke : it
is almost unnecessary to say that mediate percussion must be
employed, that is to say, the blow must fall on the finger, not
on the chest walls. Lastly, the state of the tongue, the condi-
tion of the gums, and the number of the teeth, if any, remains
to be ascertained, it being generally better to defer this to the
last, since, as Dr. West observes, it is usually the most grievous
part of your visit to the child.
SECTION 6. MODE OF TAKING NOTES OF A CASE.
It has long been a matter of regret that medical practition-
ers, generally, do not pay greater attention to recording sys-
tematic notes of their more important cases. Lord Bacon has
well observed, in speaking of the deficiencies of physicians —
" The first is the discontinuance of the ancient and serious
diligence of Hippocrates, which used to set down a narrative
of the special cases of his patinets, and how they proceeded,
and how they were judged by recovery or death."* Such nar-
ratives, carefully arranged, not only prove of inestimable value
to the practitioner himself, but they forward the progress of
the healing art, and especially tend to increase our knowledge
of diagnosis and therapeutics.
In taking these notes, it is especially necessary to do so
methodically. The following plan will probably be found as
simple and useful as any: —
General Observations. — Name ; age ; married or single ;
if a female, number of children and date of last birth ; date of
coming under treatment.
Anatomical or Physical Peculiarities. — Development
» Advancement of Learning, Book ii. Narrationes medicinales.
MODE OF TAKING NOTES OF A CASE. 33
of trunk and limbs ; deformities ; height ; weight ; countenance ;
eruptions on skin, their form and nature ; nervous excita-
bility : disposition to sleep ; habitual state of bowels.
Intellectual and Moral Peculiarities. — Education;
memory ; judgment : reasoning powers ; behavior ; disposi-
tion ; religious feelings, &:c.
Previous History. — Place of birth ; condition in life, and
health of parents ; health of brothers and sisters ; family dis-
eases ; present residence, and how long resident there ; occu-
pation ; mode of living, appetite, and hal)its, whether temperate
or otherwise ; habitual use of medicines, and their nature, as
narcotics, purgatives, &c. ; peculiar habits ; venereal indul-
gences.
Previous General Health. — Habitual health and strength;
former illnesses, their nature and duration ; liability to colds,
coughs, fevers, fits, rheumatism, gout, hemorrhages from nose
or mouth, hernia. If a female, age at vdiich catamenia first
appeared ; nature and duration of the flow ; whether regular
or otherwise ; date of last period ; leucorrhoeal or other dis-
charges ; number of children or abortions; character of labors ;
suckled her children or not.
Present Illness. — Date and mode of commencement,
whether sudden or gradual ; symptoms complained of, with
date of accession and progress of each up to the present time ;
medical treatment to which patient has been subjected ; result
of such treatment.
Present Condition. — Aspect and complexion ; state of
nutrition ; state of strength ; fever ; sensation of cold ; shiver-
ing; skin harsh and dry, or moist; disposition to be anxious
and depressed, or hopeful.
Condition of Nervous System. — Pain of head, or giddi-
ness ; pain on pressure ; pain over any part of spinal column ;
impairment of sensibility or motion, in face, tongue, sphinc-
ters, extremities; power of mastication and deglutition;
intellect; memory; senses; capacity for mental exertion;
sleep, tranquil or disturbed.
Condition of Organs of Respiration and Circulation.
— Number and character of respirations and pulse ; cough ;
expectoration ; voice ; pain of chest ; decubitus ; size and
form of chest ; relative size of the two sides ; examination of
the expansive movements of the chest ; examination of the
lungs by the spirometer, by palpation or the application of the
hand, by percussion and auscultation. Phenomena of the cir-
34 CLINICAL STUDY OF MEDICINE.
culation — palpitation ; percussion and auscultation of the
heart ; point at which the apex is felt ; impulse ; auscultation
of the carotids, and other arteries ; state of the veins ; effect
of change of posture on the pulse.
Condition of Digestive Organs.— Appearance of mouth,
tongue, fauces, tonsils, and pharynx; thirst 5 appetite; nausea
or vomiting; character of vomited matters ; bowels, frequency
of defecation, and character of evacuations ; pain or tender-
ness of abdomen ; results of manual examination; boundaries
of liver and spleen ; auscultation ; tumors ; hernial protru-
sions ; hemorrhoids.
Condition of Urinary Organs.— Micturition easy, fre-
quent or otherwise ; character of urinary secretion, quantity
in twenty-four hours, color, odor, trransparency, reaction with
litmus and turmeric papers, specific gravity, results of the em-
ployment of reagents, nature of pellicle or of deposits — if any;
microscopical examination.
Causes of Illness. — Assigned cause ; probable cause ;
duration of.
Diagnosis.
Prognosis.
General Rules of Treatment.— Regimen ; diet ; prescrip-
tion.
At each subsequent visit the progress of the case must be
commented on, the effect of the remedies employed noticed,
and at the conclusion the interesting points should be summed
up in a few brief remarks.
Should the case terminate fatally, a post-mortem examina-
tion must be made in the manner to be presently described.
SECTION 6. MODE OF TAKING NOTES OF DISEASES OF
FEMALES.
The following is the plan adopted by myself at the Hospital
for Women. It is necessarily short, but by a little manage-
ment all the important features of the case can be recorded,
and they are at all times seen at a glance.
Date. No. of ward and bed.
Disease.
Name and address.
Age ; single, married, or widowed. Date of marriage.
No. of pregnancies. No. of children.
Date, and character of last labor.
r O S T - M O R T E M E X A M I N A T I O X. 35
Condition of life and general habits.
Catamenia — nature and duration of flow ; age at first appear-
ance : date of last.
Leucorrhoeal or other discharges.
History ; health of relations, &c.
Date of present illness.
Causes.
Symptoms.
Condition of nerv'ous system.
Condition of organs of respiration and circulation.
Organs of digestion.
Urinary organs, and secretion.
Examination per abdomen.
Examination per vaginam ; by the touch ; by the speculum ;
by the uterine sound.
Examination per rectum.
Progress, treatment, and termination.
SECTION 7. MODE OF MAZING A POST-MORTEM
EXAMINATION.
At a period varying from twelve to thirty-six, or even — in
cold weather — to forty-eight hours after death, the post-mortem
examination may be made.
Having carefully examined the external appearance of the
body,
The Skull is to be thus opened : — separate the hair, and
make an incision through the scalp from one ear across the
vertex to the other ; reflect the anterior flap over the face, the
posterior over the neck. Then with a saw make a cut through
the outer table of the bones of the skull, completely round the
cranium, passing the saw anteriorly about an inch above the
superciliary arches, posteriorly just below the tubercle of the
occipital bone, and on each side on a level with the cartilage
of the ear. Introduce the elevator or chisel, and by means of
a few smart strokes with the hammer, the inner table will be
readily fractured, and the calvarium may be then torn away.
The dura mater, the most external of the membranes of the
brain, being thus exposed, it must be cut through with a scis-
sors on either side — and in the direction of — the superior
longitudinal sinus ; divide the falx cerebri ; and elevating the
head by means of a block or tripod, proceed to remove the
brain, by gently raising it with the fingers placed under the
anterior lobes and olfactory bulbs. The internal carotid
artery, and second and third nerves, which first present them-
36 CLINICAL STUDY OF MEDICINE.
selves, are then to be divided ; the pituitary body to be dis-
lodged from the hollow in the centre of the sphenoid bone ;
and an incision is to be made through the fourth nerve, and
the tentorium cerebelli close to its attachment to the temporal
bone. We then successively perceive, and must divide, the
two roots of the fifth nerve, the sixth, the seventh with its
facial and auditory portions, the three divisions of the eighth —
the glosso-pharyngeal, pneumo-gastric, and spinal accessory, —
and the ninth nerve. Lastly, we cut across the vertebral
arteries as they wind round the upper portion of the spinal
cord, and then, as low as possible, divide the cord itself, with
the roots of the spinal nerves attached on each side. The
brain may now be readily taken from the skull, and carefully
examined, by slicing it in thin layers in the horizontal direc-
tion, from above downwards. The vascularity of the gray and
white portions, the quantity of fluid in the ventricles, and the
condition of the cerebral arteries must be noticed. To judge
of its consistence, a fine stream of water should be poured
from a height on the different parts, as they are successively
exposed.
The Spinal Cord is to be exposed by sawing through the
arches of the vertebras on each side, close to the articular pro-
cesses, after the skin and muscles have been divided doAvn to
the bones. In some parts — as in the hollow of the lumbar
region — difficulty will be experienced in using the saw; a
chisel and hammer will then be found useful. When the
spinal canal is opened, the strong tube of the dura mater pro-
longed from that lining the skull will be exposed ; this is to
be slit up, and the cord, examined in situ, at the same time
observing the quantity of fluid in the spinal canal, and the
condition of the spinal veins. Subsequently divide the anterior
and posterior roots of the thirty-one spinal nerves, and remove
the cord for a closer inspection.
The Thoracic and Abdominal Cavities.— For the pur-
pose of examining the morbid appearances presented by the
thoracic and abdominal viscera, we open the cavities contain-
ing them at the same time, by making a straight incision
from the thyroid cartilage of the larynx down to the symphysis
pubis. Dividing the integuments, muscles, and peritoneum,
we open the abdomen, the contents of which may be more
readily exposed by making, in addition, a transverse subcuta-
neous incision on each side, through the fascia, muscles, and
peritoneum ; then dissecting back the skin and muscles cover-
ing the front of the thorax, we expose the cartilages connect-
in f; the ribs with the sternum. The cartilages are then to be
NOTES OF POST-MORTEM EXAMINATION. 37
cut through at their junction with the ribs, except those of
the first ribs ; and the sternum may now be raised like the lid
of a box, a good substitute for a hinge being made by cutting
the articulation of the first joint of the sternum on the
inside.
In inspecting the trachea and bronchi, they should be
opened along their anterior surface. To show the valves of
the heart, the right ventricle must be opened by a V-shaped
flap, made by an incision immediately to the right of the
septum, meeting at the apex another, carried along the right
edge of the heart. Before laying open the pulmonary artery,
the finger should be introduced, so as to guide the incision
between the valves. The left ventricle should be opened by
an incision in the direction of the aorta, beginning at the
apex, a little to the left of the septum, having previously dis-
sected the pulmonary artery off from the aorta, and taking
care to use the same precaution against injuring the valves as
in opening the pulmonary artery.
The Urinary and Generative Organs may be readily
removed from the body for examination through the pelvis,
and if the integuments in the perineum be left uninjured, and
the several outlets stitched up, any portion presenting diseased
appearances may be taken away without disfiguring the body,
and without any of the contents of the abdomen protruding.
With regard to the remaining viscera, no special directions
seem necessary as to the mode of preparing them for inspec-
tion.
SECTION 8. MODE OF TAKING NOTES OF A POST-MORTEM
EXAMINATION.
As it is of course requisite that the details of the morbid
appearance should be strictly accurate, the notes should be
taken at the time of making the autopsy. The following
arrangement may be adopted : —
General Observations. — Name ; age ; day and hour of
death ; day and hour of examination ; temperature to which
the body has been exposed ; degree in which external sexual
characters are marked, mammae, mons veneris, &c. ; state of
nutrition; eruptions; peculiarities of formation, or deformi-
ties ; oedema of face, limbs, or trunk ; marks of violence, con-
tusions, wounds ; degree of rigor mortis ; and the presence or
absence of any marks of putrefaction.
Examination of Head, Face, Mouth, and Fauces. —
Bones of the head ; fractures and their seat ; adhesions of
4
38 CLINICAL STUDY OF MEDICINE.
calvarium to dura mater ; characters of dura mater, arachnoid,
and pia mater ; Pacchionian glands ; quantity and character
of the sub-arachnoid fluid. Weight of brain ; weight of
cerebrum, pons Varolii, medulla oblongata, and cerebellum.
Convolutions of the brain, their appearance and consistence.
"White and gray substance of hemispheres ; consistence —
■whether natural, increased, diminished, — soft, creamy, dif-
fluent; color of cut surface; number and size of red points.
Extravasation of blood ; situation ; quantity. Unnatural
cavities in cerebral substance ; situation ; contents ; linings ;
state of surrounding brain substance. Tubercular, calcare-
ous, or malignant deposits. Lateral ventricles ; contents —
color and quantity of fluid ; condition of choroid plexus.
Third ventricle ; contents. Optic thalarai and corpora striata.
Pons Varolii. Medulla oblongata. Cerebellum ; form ; firm-
ness ; color ; appearances on section. Face ; lips ; cavity of
mouth, contents — food or foreign substances ; teeth, whether
recently fractured ; tongue — size, form, papilla?, if stained or
corroded. Fauces ; tonsils ; pharynx, contents of, nature of;
oesophagus, dilated or constricted ; epiglottis ; rima glottidis.
Examination of Thorax. — Trachea; bronchial tubes.
Pleuree ; nature and quantity pf fluids eff'used into pleural
sacs ; adhesions. Lungs ; external characters ; degree of
collapse ; puckering at any part ; cicatrices ; emphysema ;
deposits of tubercle, of cancer ; hydrostatic test, whether the
lungs sink or float, result with various portions ; substance of
lungs, consistence, exudation of serum on section ; crepita-
tion ; abscess ; gangrene ; pulmonary apoplexy ; tubercles,
their seat and condition ; cavities, their seat, size, form, con-
tents, and if communicating with bronchial tubes ; cysts ;
deposits of cancer. Pericardium ; adhesions ; effusions ; white
spots, their size, shape, and situation. Heart ; weight ; size ;
quantity of blood contained in various cavities, and its condi-
tion, frothy, liquid, or coagulated ; thickness of walls ; size of
cavities, right auricle and ventricle, left auricle and ventricle ;
condition of musculi pectinati, columna? carneae, chorda3
tendineae ; condition of foramen ovale ; auriculo-ventricular
openings — tricuspid valve, bicuspid or mitral valve ; aperture
of pulmonary artery, semilunar valves, and corpora Arantii ;
aortic orifice, valves, and corpora Arantii. Coronary arteries,
their condition. Microscopical examination of muscular
fibres of heart.
Examination of Abdomen. — Peritoneum ; condition ;
contents ; parts through which hernia? have passed. Liver ;
external characters, form, measurement, weight, color, coudi-
CLINICAL EXAMINATION OF THE INSANE. 39
tlon of capsule ; substance, cut surface, color, degree of fat,
deposits of tubercle, of cancer ; cysts ; gangrene ; micro-
scopical examination. Gall-bladder ; size ; shape ; contents
calculi ; ductus communis choledochus. Spleen ; position
size ; weight ; capsule ; substance. Pancreas ; position
weight ; substance ; color ; duct. Kidneys ; external cha-
racters ; capsule ; surface after removal, if lobulated, grauu
lated ; cut surface ; cortical substance ; pyramidal portion
pel\-is of kidney; ureters ; microscopical examination. Uri-
nary bladder ; contents ; walls. Stomach ; position ; size
form ; contents ; condition of mucous membrane ; rugae
cardiac orifice : pyloric orifice ; walls of; cicatrices ; ulcers
perforations ; wounds. Abnormal condition of intestines
generally ; cicatrices ; ulcers ; wounds : perforations. Duo-
denum ; Brunners glands ; ductus communis. Jejunum and
ileum : valvulifi conniventes ; villi ; Peyer's patches ; glaudulae
solitariaj. Caecum ; appendix vermiformis ; ileo-C£ecal valve ;
ileo-colic valve. Colon ; glandular solitarioe. Rectum ;
hemorrhoids ; prolapsus.
Examination of Male Org-ans of Generation. — In-
guinal canal ; vasa deferentia ; spermatic cord ; tunica vagi-
nalis : testes ; penis ; prostate gland.
Examination of Female Organs of Generation. —
Labia ; nymph® : clitoris ; urethra ; hymen ; vagina ; uterus
— lips, size of cavity, thickness of walls ; Fallopian tubes ;
ovaries ; pelvic tumors.
Examination of Spinal Cord ; vertebral canal ; theca ver-
tebralis ; size and consistence of cord, cervical and lumbar
enlargements, gray and white substance ; roots of nerves ;
Cauda equina.
SECTION 9. THE CLINICAL EXAMINATION OF THE
INSANE.
The clinical examination of a man supposed to be insane
differs very materially from that adopted in the diagnosis of
corporeal diseases. To inquire of a lunatic of what he com-
plains — or where he suffers pain — or how long he has been
ill? — is in the majority of cases useless; since he will only
reply that he has no pain, that he is quite well, and that he
wishes to know by what authority you venture to question him.
Neither does the appearance of the tongue, the nature of the
pulse, nor the character of the secretions afford us any valu-
able indications ; but we are obliged to rely upon the informa-
40 CLINICAL STUDY OF MEDICINE.
tion gained from a close examination of the physiognomy,
actions, conversation, powers of memory, &c. The state of
the general health is, however, by no means to be neglected,
since, as is well known, the body affects but too closely the
state of the mental faculties : — want of vitality and of nervous
tone, deficient healthy action of the skin and internal organs,
and torpidity of the prima3 viae, are, moreover, exceedingly
common in the insane.
The difficulties experienced in the diagnosis of insanity
will, of course, depend upon the degree in which the mental
faculties are lost. The complete maniac lives in a waking-
dream ; he raves without the power to control himself, without
the power oL appreciating the necessity for doing so; he is
completely the victim, not in the least the master, of the
strongest impressions uppermost in his fancy. The partially
insane person, on the other hand, will restrain himself, though
probably with a great effort, on occasions when he thinks such
restraint advisable, as before strangers, &c. The majority of
insane people — especially chronic cases — are able by a greater
or less degree of exertion to restrain their insane impulses on
occasions, and they do so. Consequently, we must draw our
conclusions not merely from the evidence derived from the
nature of the countenance, or of the actions, or of the conver-
sation, but from our entire — and, if necessary, frequent and
unsuspected — examination of the patient.'
Investigation of the Physiognomy. — To appreciate cor-
rectly the inferences to be drawn from this examination, the
eye must be practised by long-continued observation not only
of the insane, but of the varieties of expression which indicate
the growth, normal state, and decline of mental vigor. We
should be familiar with the cheerful open countenance of the
man in the enjoyment of mental and bodily health and ease,
with the vacant stare of the thoughtless, the melancholy visage
of the disappointed, the dreamy look of the absent man, and
with the wildness of expression of the maniac ; we shall then
be able justly to estimate the evidence written upon the fore-
head, the expressive language spoken by the eyes — the mirror
of the mind, and the inward restlessness betokened by the
constant play of the muscles around the mouth. The more
closely these appearances have been observed, the more
readily will the peculiar manifestations of insanity be recog-
nized.
Investigation of the Actions.— From examining the
' See Remarks oii Insaniry, by Dr. Henry Monro.
CLINICAL EXAMINATION OF THE INSANE. 41
face, we shall proceed naturally to observe the attitudes, ges-
tures, movements, and general conduct. The facility, sup-
pleness, and co-ordination of the movements must be noticed.
The attitude of the old man with his head inclined to his chest,
his back bent, and his knees giving way under him, is not
more characteristic of a state of senility and exhaustion, than
is the position of an unfortunate human being seated on the
floor, with his chin resting on his knees, motionless for hours,
and entirely unmindful of all that is passing around, indicative
of incurable dementia. The gestures alone often indicate the
passion which predominates. In insanity from disappointed
love, airs of languor are often affected ; in that from religion,
great humility and attention ; in that from sexual excesses, a
downcast appearance, an evident desire to avoid notice, and
an inability to look one in the face. The various gestures and
actions of the insane, however, from the happy easy move-
ments of the man who believes himself a monarch, or the
excited violent ravings of one suffering from acute mania, to
the sad torpid listlessness of the incurably demented, require
to be drawn in stronger colors than I have the art of employ-
ing, in order to produce truthful portraits.
The Conversation of the Insane.— In endeavoring to
gain information from this source, we must first seek to obtain,
by kindness and a sympathizing manner, the confidence of the
patient ; for since it will frequently be necessary to ascertain
his thoughts on the most varied subjects, so — unless we do
so — and succeed in interesting him, he will often become sus-
picious of our motives, sullen, and uncommunicative. Lord
Erskine, in his defence of Hadfield, referred to the case of a
lunatic from whom he could draw no indication of insanity in
the course of an examination in a court of laAv, until Dr. Sims
entered, when the man addressed him as the Lord and Saviour
of mankind. In many cases of madness, the reasoning facul-
ties not being wholly lost, we are not surprised at finding that
the patient can discourse correctly on many topics, until some
accidental observation leads him to break out into the most
imbecile extravagance, or makes him confide to us plans of
revenge, or proposals for performing the most impracticable
achievements.
The Memory of the Insane. — Evidence may generally
be obtained more easily upon this point than upon most others.
A few quiet questions addressed to the patient as to his name,
age, and address, the members of his family, the nature of his
occupation, the day of the week, the name of the reigning
4*
42 CLINICAL STUDY OF MEDICINE.
monarch, &c., will often suffice ; or where there is evidently
mental weakness, we may ask him to shut his left eye, give
his left hand, put out his tongue, show his right leg, and so
on. An examination of the letters written by such an one
will often also give us information upon this head, while they
at the same time teach us his intimate thoughts. These let-
ters are often rambling and incoherent, and a very frequent
characteristic of them is that they are full of wants. The fol-
lowing copy of a paper given to Dr. ConoUy, by one who said
that he had " received a commission from God Almighty," is
a good example of this : — '' In the name of the most High,
Eternal, Almighty God of Heaven, Earth, and Space — I com-
mand you to procure me the following articles immediately : —
a Holy Bible, with engravings, &c., a Concordance, a Martyr-
ology, with plates. Some other religious books. A late
Geographical Grammar, a Modern Gazetteer, Newspapers,
Magazines, Almanacs, &c., of any kind or date. Musical
instruments and Music ; Large Plans, Maps, Guides, Directo-
ries, and Histories of Edinburgh, Glasgow, London, Dublin,
Paris, Rome, Naples, &c. ; Histories of Rob Roy ; Riley's
Itinerary, and his other works. Histories and Memoirs of
George the Third, Queen Charlotte, Princess of Wales, Prin-
cess Charlotte of Wales, the Regent and Court, Prince Cobourg,
Marquis of Hastings, Lords Sidmouth, Castlereagh, Bonaparte,
the Beast, &c. Wines, fruit, lozenges, tobacco, snufF, oysters,
money, everything fitting to Almighty God. Answer this in
three days or you go to hell. P. S. — A portable desk and
stationery, and a dressing case."
In connection with this subject it remains to say that the
practitioner should, as a rule, be introduced to the patient in
his proper character, and that he should bear in mind that the
object of his examination is not only to determine whether
the individual is of unsound mind, but if so, the treatment that
must be adopted, especially with reference to the necessity for
restraint, and the degree to which it may be called for. Should
the circumstances require him to give
A Certificate of Insanity, he must remember the strin-
gent rules with respect to it, enforced by the Act of Parliament,
which came into operation on the 4th of August, 1845. Ac-
cording to Section 45, no person (not a pauper) can be re-
ceived into or detained in any licensed house or asylum, with-
out an order from some responsible person, and two medical
certificates, which must be signed by two physicians, surgeons,
or apothecaries, not in partnership, and having no interest
CLINICAL EXAMINATION OF THE INSANE. 43
directly or indirectly in the house or hospital in which the
patient is to be confined. They must each separately examine
the alleged lunatic, not more than seven days prior to his
reception into the asylum ; and they must severally sign and
date the certificate on the day of examination, and state the
facts on which they form their opinion. The following is the
form of certificate in the case of a private patient : —
I being a (') hereby certify that
I have this day, separately from any other medical practitioner,
\asited and personally examined the
person named in the accompanying statement and order, and
that the said is a (^) and a proper
person to be confined, and that I have formed this opinion
from the following fact (^) viz. : —
Signed, Name.
Place of Abode.
Dated this day of one thousand eight hundred
and
Medical Case-book. — In the same Act of Parliament a
section has been introduced requiring that a medical case-
book shall be kept in every asylum throughout the kingdom,
in which the history, treatment, &c., of all patients shall be
from time to time recorded. The following is the plan
adopted by Dr. Stevens, at St. Luke's Hospital for Lunatics : —
Name ? Age ?
Married, single, or widowed?
Number of children ? Age of youngest ?
Occupation?
Residence ? Where born ?
Religion ? Disposition ?
Duration of existing attacks ?
Whether first attack ? Age on first attack ?
Previous place of confinement?
Date of previous admission ? And discharge ?
^ „ f Moral ?
C^^;^^- I Physical?
Hereditary ?
Diseases of children ?
Habits? Degree of education?
Complexion ? Hair ? Eyes ?
Natural affection perverted or not? How ?
Temperament ?
• Physician, surgeon, or apothecary, duly authorized to practice as such.
^ Lunatic, or insane person, or an idiot, or a person of unsound mind.
' Or facts.
44 CLINICAL STUDY OF MEDICINE.
Evidences of J
insanity ? 1
Form of insanity ?
Dangerous to self or others ?
Certificates ?
Previous treatment ?
State of bodily health ?
Any injuries from violence?
Admitted on day of into gallery ?
Progress, treatment, and result ?
SECTION 10. EXAMINATION OF PERSONS FOR LIFE
ASSURANCE.
The knowledge required by a medical man in ''the life
ofi&ce'' is somewhat different from that necessary in the private
consulting-room. In the latter the patient is full of complaints,
anxious to acknowledge all the pains and symptoms of disease
which he may be suffering from, and ready to communicate
the cause and history of his malady ; in the former he gene-
rally acknowledges no uneasiness, and does his best to appear
constitutionally strong and free from disease. In the consult-
ing-room no information is withheld, and it is only necessary
for the practitioner to weigh the value of the evidence laid be-
fore him, reject that which is worthless, and act upon that
which is to be relied on; in the assurance office the tendency
is to withhold and keep back everj^hing which the assurer
may deem calculated to make his life appear bad. The duty
of the medical officer, consequently, resolves itself into looking
out for and detecting any hidden diseases, malformations, or
conditions which may threaten to shorten or endanger life ;
as well as to observe upon the effects of any previous disorders
which may have tended to vitiate the constitution.
In most life offices the medical officer is required to fill up
a printed form of questions, which in many instances is un-
necessarily long and complicated. Indeed, it would be much
better for every office to select their physicians and surgeons
with care, and then be guided implicitly by their advice, with-
out also rendering it necessary for the practitioner to submit
to the directors the evidence upon which he founds his conclu-
sions. The points to which the medical man should chiefly
direct his attention are these :
1. The age, apparent age, occupation — and exposures
attending it, and general appearance.
EXAMINATION FOR LIFE ASSURANCE, 45
2. The family history, especially as regards scrofula, phthisis,
insanity, gout, apoplexy, epilepsy, and renal diseases, occur-
ring either in father, mother, brothers, or sisters.
3. Illnesses gone through since childhood, especially as
regards small-pox and vaccination, gout, rheumatism, spitting
of blood, asthma, pulmonary complaints, and fits of any kind.
4. The general habits and mode of living, inquiring as to
the employment of exercise, early hours, and the use of intoxi-
cating drinks, opium-eating, &c.
5. The character of the pulse and respirations.
6. The height, weight, and vital capacity — as ascertained
by the spirometer.
When an examination has been made in the above order,
the practitioner must proceed or not to make further investi-
gations as he may deem necessary, and in the manner his
judgment will suggest. In deciding upon a life, the recollec-
tion of the following aphorisms may lead to a correct decision.
If in doubt about the propriety of accepting a certain life,
consider whether it would be advisable for the office to have
one hundred such cases on its books.
Paucity of evidence in the family history must lead to in-
creased care in the personal examination of the applicant.
Decline the life of a person who is not sober. Even if he
has been given to drinking, and has reformed two or three
years, yet his life should be declined, since permanent refor-
mation is so very rare.
Tavern-keepers and such like, must be most carefully ex-
amined.
"When there is consumption in the parents, decline the case.
The parents being well, but two or three of the brothers or
sisters having died from phthisis, the life may be accepted, pro-
vided the applicant be strong and healthy, of proper weight
and vital capacity, and of good habits. Should there be any
flaw in the weight or vital capacity, decline.
If a man has had haemoptysis, decline.
If a woman has had haemoptysis, especially in early life, we
may accept after a careful examination.
If a man or woman be above the normal weight, and the
weight be rapidly increasing, decline ; since such a person is
quickly making fat, and may convert tissues whose integrity
is necessary to life into the same material ; especially in such
is there a tendency to apoplexy, fatty degeneration of the arte-
ries of the brain being often a cause of this disease.
Look with suspicion upon an applicant who has fatty de-
generation of the margin of the cornea (arcus senilis), since a
46 CLINICAL STUDY OF MEDICINE.
similar change may be taking place in the muscular fibres of
the heart, or in the cerebral vessels.
Where there is any hereditary tendency to insanity, be very
careful in the examination ; if the life be accepted, it should
only be at an increased premium.
It is almost unnecessary to add, in conclusion, that an epi-
leptic, or one who has had a fit of apoplexy — however slight, or
one afi'ected with paralysis — however partial, can never be
accepted.
SECTION 11. ON MEDICO-LEGAL INVESTIGATIONS.
In addition to the duties which every medical man owes to
the public individually in his capacity of a practitioner, there
are no less important obligations due from him to society at
large. He is therefore often called upon not only to save life
when it has been threatened by violence, the use of poisons,
&c., but also to give e^'idence, in courts of law, touching such
cases, in order that crimes against the person may be dis-
couraged by the detection and punishment of those who prac-
tise them.
Use of Notes.- — In the examination of such cases, it is
advisable that notes be made at the time of all the particulars,
whether they appear important or not, noting the time at
which the person was first seen, the hour, day of the week,
and day of the month being invariably mentioned, the period
of the occurrence of death, as well as the circumstances under
which the practitioner was summoned. The words, yesterday,
next day, and similar vague expressions, should never be em-
ployed in such records, as they cause great inconvenience if
referred to at a trial, and render a reference to almanacs
necessary. It is also indispensably necessary that the notes
should be taken on the spot at the time the observations are
made, or as soon afterwards as possible, otherwise, they are
not admissible as evidence. There is another rule which it
is essential to remember. The notes may have been made on
the spot in the manner required by law ; but when a witness
is about to refer to them in a court of justice, he will often be
asked whether he is using them for the purpose of refreshing
his memory, or whether he is about to speak only from what
is written on the paper, without having any precise recollec-
tion on the subject. If for the latter purpose, the evidence is
inadmissible, for it has been held by our judges that notes can
only be used in evidence for the purpose of refreshing the
memory on a fact indistinctly remembered ; they are, in other
MEDICO-LKGAL INVESTIGATIONS. 47
words, allowed to assist recollection, not to convey informa-
tion.
Confessions and Death-bed Declarations.— It not un-
frequeutly happens that the medical man is called upon by the
sufferer to receive a confession. He must be careful, in doing
so, to hold out no promise or threat of any kind. He should
receive it without comment, write it down at the time, read it
over to the person making it, obtain his signature to it, and
countersign it himself The same rules apply to all death-
bed declarations, which, it must be remembered, will only be
subsequently admissible as legal evidence, when the parties
making them were satisfied that recovery was impossible.
Reports for Judicial Purposes. — In drawing up a report
of the symptoms, post-mortem appearances, and results of a
chemical analysis, the facts should be in the first instance
plainly stated in language free from technical terms, and
easily intelligible to non-professional persons, any display of
erudition being misplaced. In recording facts also, a reporter
should not encumber his statements with opinions and infer-
ences, but should reserve his conclusions until the end of the
report. The language in which these conclusions are couched
must be precise and clear, and should form a concise summary
of the whole report, upon which the judgment of a magistrate
or the decision of a coroner's jury may be ultimately based.
They should be strictly kept to the matters under inquiry, and
ought commonly to refer to the following questions : — What
was the cause of death ? What are the medical circumstances
leading to a supposition that death was not due to natural
disease ? What are the circumstances leading to a supposi-
tion that death was caused by violence, by poisons? &c. It
must be remembered, also, that the conclusions are to be
founded only upon medical facts, and upon what the reporter
has himself seen ; a conclusion based upon mere probabilities
is of no value as evidence.
In performing a post-mortem examination, a note must be
made of the time afler death at which it is made. The ex-
ternal appearances of the body are to be then observed, noting
whether the surface be livid or pallid, the state of the coun-
tenance, and the presence or absence of marks of violence on
the person ; also, whether the rigor mortis has gone off, as
well as the presence or absence of warmth in the extremities,
or in the abdomen. The state of all the internal organs must
then be remarked, especially the condition of the abdominal
* See Dr. Guy's Forensic Medicine.
4d CLINICAL STUDY OF MEDICINE.
viscera. If the stomach and intestines be found inflamed, the
seat of inflammation should be exactly specified ; also all marks
of softening, ulceration, eff"usion of blood, corrosion, or perfo-
ration. The stomach must be removed and placed in a sepa-
rate vessel, with its contents, a ligature being previously ap-
plied to the cardiac and pyloric orifices. The state of the
thoracic viscera, of the brain, and of the spinal marrow, as
well as of the genital organs, should be examined.
Occasionally the inspection is required to be made some
time after interment. So long as the coffin remains entire,
the expectation of discovering certain kinds of mineral poi-
son in particular organs may be entertained ; although decom-
position may have advanced so as to destroy all pathological
evidence. The inspection in such cases is commonly confined
to the abdominal viscera, especially to the stomach, liver, and
spleen, which should be taken from the body, and immediately
sealed up in clean glass or porcelain vessels, and so kept for
analysis.
In drawing up a report on the results of a chemical analysis,
the following rules should be borne in mind: 1st. When,
how, and from whom, the liquid or solid reserved for analysis
was received ; its state, whether secured in any way or exposed ;
whether labelled or not 5 and the kind of vessel containing it.
2d. Where and when the analysis was made ; whether with
or without the assistance of a second person ; and where the
substance was kept during the intermediate period. 8d. The
physical characters of the substance ; the processes and tests
employed for determining whether it contained poison, not
detailing all the steps, but giving a general outline of the
analysis ; together with the strength of the poison, the
quantity present, and whether it could be produced or exist
naturally within the body. And 4th. What quantity of the
poison discovered would suffice to destroy life ; and to what
extent the dose might be modified by age or disease.
There are but few reports in which answers to these ques-
tions will not be required ; and unless the whole of them be
borne in mind at the time an analysis is undertaken, those
which are then omitted can never be subsequently answered
with satisfaction. The results of analysis, in the shape of
sublimates or precipitates should be preserved as evidence, in
small glass tubes hermetically sealed and labelled, so that
they may be produced at the inquest or trial.
In many medico-legal inquiries, we shall derive invaluable
assistance from the use of the microscope, as in diagnosing
blood-stains from discoloratious pr()duced by red fluids, human
THE SIMPLE MICROSCOPE. 49
hair from that of animals, as well as in discovering sperma-
tozoa in cases of rape. Should we resort to the employment
of this instrument, drawings must be made — by the aid of
the camera lucida — of the appearances found.
Medical Evidence at Inquests.—In giving evidence
before the coroner, the medical man should be as careful as
if in one of the superior law courts ; it being necessary to
remember that all he says is taken down by the coroner, and
that if the case be sent for trial, such depositions will be in
the hands of both judge and counsel. Should there conse-
quently be any discrepancy in the practitioner's evidence, he
will subject himself to severe censure.
CHAPTER II.
ON THE INSTRUMENTS EMPLOYED IN THE
DIAGNOSIS OF DISEASE.
SECTION 1. THE MICROSCOPE.
It is certainly not asserting too much to say that the micro-
scope^ is an instrument of paramount importance to the
medical practitioner of the present day. From having been
formerly used as a toy, it has now been rendered one of the
most important aids to scientific research, not more in natural
history than in physiology and pathology : and I know not
the way in which any other instrument can be substituted for
it in the diagnosis of many diseases, especially perhaps those
depending on the fatty degeneration of tissues, abnormal states
of the blood, and diseased conditions of the renal secretion.
The chief obstacle to the more frequent use of the micro-
scope is to be found in its expense ; it not being generally
known that with a cheap instrument, such as may now be
obtained for six or eight pounds from many makers (Pillischer,
Highley, Smith and Beck, and Salmon), under the name of
the studenfs microscope, almost all may be accomplished that
the practitioner need desire. Dr. Lionel Beale, in his " Tre-
tise on the Microscope," well describes these instruments, and
speaks highly of their utility. From my own observation, I
can especially recommend Pillischer's student's microscope,
which can be obtained complete for about £12.
Microscopes are of two kinds, the simple and the compound.
* Mtvpof, small, and cKoircoi, to view.
5
50 INSTRUMENTS EMPLOYED IX DIAGNOSIS.
The Simple Microscopes are of two sorts, namely, those
held in the hand, and those mounted on a stand ; the latter
have a stage for holding the object to be viewed, a mirror for
reflecting the light through transparent objects, and a con-
denser for throwing light on such as are opaque. The micro-
scopes held in the hand consist, for the most part, of double
convex or plano-convex lenses, mounted in tortoiseshell
frames, and varying in focal length from the quarter of an
inch to two inches ; or they may be formed of a sphere of
glass, round the equator of which a groove has been cut,
which has been subsequently filled up with opaque matter,
and then set in German silver, forming the Coddington lens ;
or they may consist of a double convex lens, with one convex
surface greater than the other, which form, placed in a silver
frame, is known as the Stanhope lens. Either of these
glasses will be found useful pocket companions, and when
mounted on a small stand, such as is used by the watchmakers
and engravers, may be emplo)'ed for dissecting the coarser
tissues. There are many other different forms of simple
microscopes, which of course are made to suit the fancy of
each optician. They are all useful, and many of them are
constructed very ingeniously so as to form a box, or to fold
up into the size of an octavo volume, by which contrivances
greater portability is secured.
The Compound Microscope. — This instrument differs
from a simple microscope, inasmuch as the image of an
object formed by the object-glass is further magnified by one
or more lenses forming an eye-piece ; or, in other words, the
rays of light from an object being brought into a new focus,
there form an image, which image being treated as an
original object by the eye-piece, is magnified in the same way
as the simple microscope magnified the object itself* A
compound microscope consists of two essential parts : the
stand — including a tube for carrying the optical apparatus
and the stage ; and the optical apparatus itself — consisting of
the object-glasses or magnifying powers, the eye-pieces, and
the mirror. In choosing a microscope, one of the great
requisites in the stand is steadiness — although a large instru-
ment is by no means necessary ; the tube should allow
of being moved by a coarse and fine motion, to permit of
accurate focal adjustment ; and the stage should be freely
movable in two directions, at right angles to each other,
either by screws, or by the rack and pinion. The object-glasses
* See Quekett on the Microscope, 2d edition, p. 67.
THE COMPOUND MICROSCOPE.
51
usually supplied with the best and most expensive instruments
are either six or seven in number, and vary in their magnify-
ing power from 20 to 2500 diameters ; they are called two
inch, one inch, half inch, one-quarter, one-eighth, one-twelfth,
and one-sixteenth ; '' but it must be understood that these names
are not derived from the distance the bottom-glass of each
combination is ft-om the object, but from a fact found in
practice, that a thin single lens, to magnify the same number
of diameters as any of the preceding achromatic combina-
tions, would be required to be of the same focal distance as
that given to the others by name. In other words, if a
single lens were made the object-glass of a compound micro-
scope, and if it were necessary to employ a power equal to
that of the one-fourth achromatic combination, with the same
compound body, it would be found that a thin single lens of
one-quarter of an inch focus would be required to give that
power." (Quekett, op. cit.) The eye-pieces furnished with the
compound microscopes are made on the Huyghenian principle,
and are three in number ; they are generally marked from the
lowest to the highest. A, B, C.
In estimating the magnifying power of a glass, we do so by
the measure termed linear. Thus, if a cube be magnified ten
times, we say that it is magnified ten times in diameter ; but
since it is magnified ten times in breadth as well as in length,
some persons, to excite the astonishment of the vulgar, give
the superficial magnifying power, and by squaring the linear
would assert that the cube was magnified one hundred times
(10x10 = 100). Such a mode of expression is not counte.
nanced by men of science.
The best microscopes at the present time are those made by
Ross, Smith and Beck, and Powell and Lealand, at a cost,
varying according to the number of object-glasses and appa-
ratus, from twenty-five to fifty or sixty pounds. The magnify-
ing powers obtained with the different eye-pieces and object-
glasses of these makers are shown in the following tables :
MR. ROSS.
Eye-
pieces.
OBJECT-GLASSES.
2-in.
1-in.
i-iu.
i-in.
i-in.
iV-i"-
A
B
C
20
30
40
60
80
100
100
130
180
220
350
500
420
670
900
600
870
1400
52
INSTRUMENTS EMPLOYED IN DIAGNOSIS.
MESSRS. SMITH AND BECK.
LINEAR MAGNIFYING POWER, NEARLY.
Focal
Length.
Angle of
Aperture
about
With Eye-piece.
1
2
3
Draw tube closed, . .
20
45
80
} 13 deg.
Iji-inch
Add for each inch of tube.
drawn out, ....
4
6
8
)
f-inch
Tube closed, ....
60
105
180
^'"
Add for each inch of tube,
7
12
20
jl^-incb
Tube closed, ....
120
210
350
|55 »
Add for each inch of tube.
12
20
35
4-inch
Tube closed, ....
205
360
620
^70 "
Add for each inch of tube.
25
35
60
^-inch
Tube closed, ....
240
430
720
1- "
Add for each inch of tube.
30
45
80
|-inch
Tube closed, ....
450
760
1300
^90 "
Add for each inch of tube.
40
60
115
-jijj-inch
Tube closed, ....
500
920
1500
I 120 "
Add for each inch of tube,
50
70
130
MESSRS. POWELL AND LEALAND.
Eye-pieces.
OBJECT-GLASSES.
2-in.
1-in.
i-in.
i-in.
i-in.
^V-in.
1st. Eye-piece,
2d. Eye-piece,
3d. Eye-piece,
20
40
70
40
80
140
75
150
250
170
340
600
330
660
1200
700
1400
2500
Although I have here given the magnifying powers of all
the different object-glasses, it by no means follows that the
practitioner need purchase a complete set, since all that he
will require to do — in the great majority of instances — can be
accomplished with two powers, the inch and the quarter.
The necessary accessory instruments are but few in number,
consisting of a diaphragm for cutting off the most oblique
rays of light, and those reflected from the mirror which are
not required for the illumination of the transparent object; a
bull's-eye condenser, for concentrating the light on opaque
objects ; a pair of forceps ; glass slides, three inches by one in
size ; thin glass covers ; a few watch-glasses, pipettes, needles
for unravelling various tissues, &c. Should expense be no
THE TEST-TRAY.
53
object, an achromatic condenser will be found useftil, for ex-
amining those delicate structures which require achromatic
light ; a polarizing apparatus, for viewing various crystals and
other substances by polarized light ; a camera lucida, for
making dramngs of the appearances observed ; and a microme-
ter, for measuring the size of minute objects.
In the perusal of foreign works on histological science, the
student will be often confused by the standards of measure-
ment employed on various parts of the Continent differing
from each other, and from that used in this country — com-
monly the inch. The following table, from Hannover's " Trea-
tise on the Microscope," will show at a glance the value of
the different measurements :
Milli-
metres.
Paris
Lines.
Vienna
Lines.
Rhenish
Lines.
English
Inch.
1
2-255829
2-195149
2-179538
25-39954
•443296
1
•973101
-966181
11-2595-2
•455550
1-027643
1
-992888
11-57076
-458813
1-035003
1-0071625
1
11-65364
•0393708
-0888138
•0864248
•0858101
1
For the microscopical examination of the blood, sputa, vomited
matters, uHne, &c., see Chapter XI.
SECTION 2. THE TEST-TEAY.
In the practice of medical chemistry, a small quantity of
apparatus, of an inexpensive nature, is all that is necessary,
which may be conveniently arranged in a common wooden
tray, about fourteen inches long, ten broad, and five deep ; it
should be covered in at the top by a piece of deal, in which
holes must be cut to receive the test-tubes, spirit-lamp, and
bottles containing the reagents.
The following articles are those which will be mostly re-
quired : A spirit-lamp ; a cylindrical precipitating glass ; a
urinometer, for taking the specific gravity ; blue litmus paper,
for testing acidity ; slightly reddened litmus and turmeric
paper, for testing alkalinity, the former being the most deli-
cate ; watch-glasses and evaporating dishes ; half a dozen
test-tubes ; a thermometer, with an exposed bulb ; a small
retort-stand ; a blow-pipe ; platinum foil ; a glass funnel and
filtering paper ; glass rods ; one or two pipettes ; and bottles
5*
54 INSTRUMENTS EMPLOYED IN DIAGNOSIS.
for the fojlowing reagents : nitric acid, sulphuric acid, acetic
acid, hydrochloric acid, liquor potassse, liquor ammoniaj, a
saturated solution of nitrate of barytes, solution of nitrate of
silver (one drachm of the crystallized nitrate to the ounce of
distilled water), solution of oxalate of ammonia, alcohol, and
rectified ether. Should the practitioner prefer a more porta-
ble case, he can purchase Highley's Cabinet of Apparatus and
Reagents, as selected by Dr. Lionel Beale, in which he will
find, — urinometer in case, test-papers, graduated 2 oz. mea-
sure, pipette, stirring-rod,- microscopic slides and thin glass,
watch-glasses, test-tubes, tube-holder, brass forceps, platinum
foil, spirit-lamp with wire ring, and seven capped dropping
bottles for the following reagents : nitric acid, acetic acid,
ammonia, potash, nitrate barytes, nitrate silver, and oxalate of
ammonia. With these agents he will be enabled to make a
clinical examination of the urine, blood, sputum, &c., as far as
it is necessary to do so in the practice of medicine for the pur-
poses of diagnosis. For the mode of making a chemical ana-
lysis of the blood and secretions, see Chapter XI.
SECTION 3. THE SPIKOMETER.
Under the designation of the pulmometre, the spirometer
has been known for the last half century, but it was of no
practical utility until the vital capacity of the lungs was ascer-
tained by the laborious researches of Dr. Hutchinson.'
Hutchinson's Spirometer. — This instrument — somewhat
resembling a small gasometer — consists of a cylindrical vessel
of japanned zinc, about two feet and a half high and two feet
in circumference, capable of holding many pints of water.
Into it is inverted a cylinder or receiver — somewhat smaller —
which is counterpoised by weights ; in its cover is inserted a
movable plug. Communicating with the smaller cylinder is a
tube, having an elastic tube and mouth-piece attached. A
graduated scale is fixed to one side of the instrument, extend-
ing some distance above the top of the large cylinder. On
respiring through the mouth-piece, the air passes into the
lesser cylinder, and causes it to rise by displacing the water ;
an indicator attached to it marks on the graduated scale the
number of cubic inches of air expired. We are thus enabled
readily to measure the volume of air expired from the lungs.
When the vital capacity is to be tested by this apparatus,
the patient should loosen his vest, stand perfectly erect, take
as deep an inspiration as possible, and then place the mouth-
* See Medico-Cliirurgical Transactions, vol xxix. p. 138.
i)K. pkrkira's si'iKo meter. 55
piece of the spirometer between his lips. The observer having
opened the tap, the patient empties his lungs, making the
deepest possible expiration, at the termination of which the
operator turns off the tap, thus confining the air in the
receiver. The receiver is then to be lightly depressed until
the surfaces of the spirit in a bent tube on the outside of the
instrument are on a level with each other, when the vital
capacity may be read off from the scale.
Coxeter's Portable Spirometer is of much more simple
construction than the preceding, and- is so compact that it can
be easily carried in the pocket. It consists simply of two
flexible, inelastic, air-tight bags, one being much larger than
the other and communicating with it by means of a piece of
tubing provided with a stopcock. It may be best compared
to the human stomach and duodenum, supposing that at the
cardiac orifice a mouth-piece, tube, and stopcock are attached;
another stopcock at the pyloric orifice, by which the opening
into the duodenal continuation can be opened or closed ; and
a third stopcock at the termination of the duodenal portion,
by opening which this part can be emptied of its contents :
we must also imagine the duodenum to be graduated, and to
be capable of containing exactly fifty cubic inches of air.
Suppose now that the two bags have been compressed in our
hands, the air expressed from them, and that they are kept
empty by closing the stopcocks; if we take a deep inspiration,
apply the mouth-piece, open the stopcock and expire, the
expired air will be forced into the large bag, where we retain
it by closing the tap ; by opening the communication with the
duodenal portion, and letting it fill with the expired air from
the large bag, we obtain precisely fifty cubic inches ; then, by
closing the communication, and opening the escape valve, we
have the duodenal part again empty, and ready to measure
another fifty cubic inches, or thirty, or forty, as the case may
be ; and so we proceed until the whole volume of the expired
air in the large bag has been ascertained.
Dr. Pereira's Spirometer. — This instrument is much the -
same in principle as Dr. Hutchinson's. It consists of a large
glass cylinder, suspended by means of a cord, in a reserv^oir
of water, the cord passing over a pulley, and having a weight
attached, so that by careful adjustment the cylinder may
balance in any position. A pipe, forming the continuation of
the tube through which the patient has to breathe, rises in
the bell-glass above the level of the water ; and by forcing
the air through this tube, the vessel will ascend, and indicate,
by a graduated scale affixed, the quantity of air passed
into it.
56 INSTRUMENTS EMPLOYED IN DIAGNOSIS.
SECTION 4. THE TAPE-MEASURE, STETHOMETER,
PLEXIMETER, STETHOSCOPE, ETC.
The Common Tape-Measure. — A common measure
thirty-six inches in length, fixed in a small German-silver box,
and made to act by a spring, will be found useful in the
diagnosis of diseases of the lungs. To ascertain the circum-
ference of the chest we pass the tape round it, over the region
of the nipples ; should the patient have his shirt and flannel
jacket on, we must make an allowance of a quarter of an
inch for each of these articles. To learn the mobility of the
chest, we pass the measure as just directed, request the
patient to fill his lungs as much as possible by taking a deep
inspiration, and note the number of inches on the measure,
this being of course the greatest circumference ; we then,
without moving the tape, make him expire to his utmost, and
noting the number of inches, we shall have the minimum
circumference 5 the difference between the maximum and
minimum will give us the mobility of the chest. In healthy
persons, of ordinary weight and middle age, the average
mobility is three inches, very rarely extending to four.
The Stethometer. — An instrument, called a stethometer,
for measuring the expansive movements of the thorax during
inspiration, and for ascertaining the difference in the mobility
of opposite sides of the chest, has been invented by Dr. Richard
Quain. It is a small machine about the size of a watch, with
a graduated dial, and an indicator ; a silk cord passes out of
the side of the case and is connected by an axle with the
indicator, which is capable of moving round the dial plate.
The cord being extended from one fixed point on the chest to
another, the extent of the respiratory movement becomes
manifested by the tension made on the cord being communi-
cated to the indicator, which thus shows the degree of expan-
sion during inspiration, and of contraction during expiration.
It is obvious that not only will the mobility of the chest be
' thus shown, but comparisons can also be readily drawn of
the action of different parts of the chest, giving this instru-
ment, therefore, advantages over the common tape-measure.
Dr. Sibson's Chest-measurer. — This instrument — some-
what resembling Dr. Quain's — is useful for ascertaining the
diameter of the chest, and for accurately measuring the
movements of respiration to the hundredth part of an inch.
In form it resembles a watch, with a small bar or rack pro-
truding from its lower part. This rack, when raised by the
THE STETHOSCOPE. 57
moving walls of the chest, moves, by means of a pinion, the
index on the dial 5 one entire revolution of the index showing
one inch of motion in the chest, and each division indicating
the hundredth of an inch.
The chest-measurer can be readily applied to any part of
the body, and, by successive applications of it over the chest
and abdomen, all the movements of respiration can be ob-
served with great facility. It indicates the rhythm of respira-
tion, showing whether the expiration be equal to, or longer or
shorter than the inspiration ; the character as well as the
extent of motion may be read off from the dial. By it, also,
we can perceive the exact amount of chest-movement, both
during tranquil breathing and the deepest possible inspiration
and expiration. It thus tells indirectly (though less accurate-
ly) the extreme breathing capacity of the chest, which is
rendered directly and exactly by Dr. Hutchinson's spirometer:
its inferiority in this respect is, however, in some measure
counterbalanced, by its possessing the additional faculty of
localizing the diminished movement, if it be local, and so
pointing to the diseased part ; or of showing it to be diffused
over the whole breathing apparatus, if the disease be more
general.
Plessors, Pleximeters, &C. — In practising percussion,
the fingers, as a general rule, are superior to any artificial
instruments. Occasionally, however, a small hammer tipped
with gutta percha, or a thimble headed with the same material,
may be useful as a plessor [Trhnc-a-u, I strike), and may enable
us to produce a clearer stroke ; these may be employed either
for striking on the index or middle finger as a pleximeter
5TX>)<rcra, and /utTpov, a measure), or the pleximeter may con-
sist of a small thin disk of ivory — as used by M. Piorry, or of
wood, or of India-rubber, each being provided with lips which
are used as handles. In some regions it is not always possible
to percuss with the fingers with an equal degree of force on
the two opposite sides, as in the axillae. In such instances,
Dr. Sibson's ingenious spring pleximeter may often be used
with advantage, since by it successive strokes are produced
exactly of equal force, which ought consequently to elicit,
under similar circumstances, exactly the same sound. An-
other advantage possessed by this instrument is the ease and
precision with which it can be applied over the clothes, in
which respect it will be found useful in percussing children
and females, as well as men during the cursory examination
usually made at the life-assurance office.
The Stethoscope. — The stethoscope ((TTJfSof, the chest,
58 INSTRUMENTS EMPLOYED IN DIAGNOSIS.
and 0-x.oviv, to examine) is a cylinder of soft wood (generally
cedar) from four to eight or nine inches in length, pierced
through by a longitudinal canal about a quarter of an inch in
diameter, and having one extremity large and flat as an ear-
piece, while the other is much smaller and funnel-shaped for
application to the thoracic walls. The object of such an
instrument is to collect and convey to the ear of the observer,
the vibrating impulse of the air, or of the solid walls of the
thorax, occasioned by the perpetual movement within.
General Observations. — From the numerous diseases
which derange the acts of respiration, and from the great
variety of these disturbed movements, it is clear that we
cannot form a diagnosis from the mere observation of the
exaggeration, restraint, or arrest of any special movement.
We are not, therefore, directed to any final diagnosis by the
indications derived from the spirometer, the chest-measurer,
the educated eye-sight, or the touch ; by these we are merely
led to make correctly the first step 5 from them we only learn
that there is derangement, and in some cases its seat. By
the aid of percussion we advance still further ; while by the
practice of auscultation — aided by a knowledge of all the
symptoms — we are enabled, in the great majority of cases, to
give an accurate opinion as to the situation and exact nature
of the disease, whether it be fixed in some part of the organs
of circulation or of the organs of respiration. What I would
insist upon, therefore, is this — that neither of the instruments
described in the preceding paragraphs must be trusted to
alone ; neither the spirometer nor the stethoscope may be
leant upon as a crutch, but merely employed as a staff to
explore the way •, auscultation and percussion are no substi-
tutes for other methods of diagnosis, they are merely most
valuable auxiliaries.
SECTION 5. THE DYNAMOMETER.
The dynamometer is an instrument, invented probably by
Mr. Graham, but improved by M. Regnier, for measuring the
comparative muscular strength of man and animals ; and
although not used perhaps in the practice of medicine, at
least to any extent, still it deserves mention. It consists of
an elliptical steel spring, of about twelve inches in circum-
ference, connected with an index and needle, so that when by
pressure the two sides are made to approach each other, the
needle moves upon a portion of a circle furnished with a scale
of kilogrammes, and one of myriagrammes. For example,
THE SATURATED SPONGE. 59
to measure the strength of the hands, the two branches of the
spring are firmly grasped, and brought as near together as the
experimenter's strength will enable him to accomplish. The
needle traversing the scale of kilogrammes indicates the
strength of the hands. Some interesting results relating to
the average strength of men at different ages, and of various
weights and sizes, have been deduced by M. Quetelet, of
Brussels, from numerous trials with this instrument. Accord-
ing to these experiments, a man twenty-five or thirty years of
age is said to exert a force equal, on an average, to fifty
kilogrammes, or 100 pounds.
SECTION 6. INSTRUMENTS REQUIRED FOR MAKING LOCAL
APPLICATIONS IN DISEASES OF THE PHARYNX AND
LARYNX.
Sir Charles Bell, MM. Trousseau and Belloc, and more
recently Dr. Horace Green, of Xew York, were the first to
resort to the practice of topical medication of the larynx.
The instruments required are, a tongue-depressor with a bent
handle, by means of which the tongue can be firmly pressed
down so as to expose the whole of the fauces and the upper
edge of the epiglottis ; and a whalebone probang, about ten
inches long, bent in a curve, and having securely fastened to
its extremity a nodule of fine sponge, about the size of an
ordinary bullet. The solutions of nitrate of silver generally
employed are of three strengths, consisting either of 9j, or
9ij, or 3J, to ,^j of distilled water. The method of introduc-
ing the saturated sponge is described somewhat thus by
Dr. Hughes Bennett, in his treatise on Pulmonary Tuber-
culosis. The patient being seated on a chair and exposed to
a good light, the practitioner stands on the right side, and
depresses the tongue with the spatula held in the left hand.
Holding the probang in the right hand, the sponge of which
has been saturated with the solution, it should be passed
carefully over the upper surface of the spatula, exactly in the
median plane, until it is above or immediately behind the
epiglottis. The patient must be now told to inspire, and as
he does so, the tongue should be dragged slightly forwards
with the depressor, and the probang thrust downwards and
forwards by a movement which causes the right arm to be
elevated, and the hand to be brought almost in contact with
the patient's face. The operation of course requires dexterity,
since the rim a glottidis is narrow, and unless the sponge
comes fairly down upon it, the aperture is readily missed.
60 INSTRUMENTS EMPLOYED IN DIAGNOSIS.
The passage of the sponge into the proper channel may be
determined by the sensation of overcoming a constriction,
which is experienced when the instrument is momentarily
embraced by the rima, as well as by the spasm and harsh
expiration which it occasions. The application will generally
require to be made about every other day, for a few weeks.
SECTION 7. THE OPHTHALMOSCOPE.
Attention has lately been directed in this country, by Mr.
Spencer "Wells and Dr. Wharton Jones, to an instrument in-
vented by Dr. Helmholtz, of Konigsberg, for exploring the
interior of the eyeball, in order to diagnose especially the mor-
bid states of the vitreous body, the choroid, and retina. There
are several modifications of the ophthalmoscope, but the most
simple seems to be that of Coccius, which consists of a small
plane mirror with a hole in its centre, so held that the light
which falls on it from a lamp, concentrated by a double con-
vex lens, is reflected into the eye to be examined : the observer
looks through the hole in the centre. When the observed or
observers eye is short-sighted, a concave glass is placed before
the observed eye. By means of this instrument, or one similar
to it in principle, morbid changes in the retina could be dis-
tinctly recognized in the majority of the cases of blindness
examined.
SECTION 8. THE SPECULUM UTERI, THE UTERINE
SOUND, ETC.
In the diagnosis of disease of the uterine organs we derive
assistance mainly from four sources : 1, from the history and
symptoms ; 2, from a tactile examination — the touch ; ,3, from
a visual examination with the speculum ; and, 4, from the use
of the uterine sound. I shall only speak here of the instru-
ments required in such examinations.
The Speculum. — This instrument is by no means of mo-
dern invention, assistance having been derived from its em-
ployment for many years ; and although numerous arguments
have been adduced in the present day against its use, from its
abuse, yet still it is found — as before — impossible to diagnose
many examples of uterine disease without its aid. Several
varieties of speculum have been invented, and doubtless the
ingenuity of mechanists will furnish more. The one that I
am constantly in the habit of using is that known as Fergus-
son's, which consists of a cylinder of glass, silvered externally,
and then covered with a thin layer of caoutchouc. It is ne-
THE UTERINE SOUND, ETC. 61
cessary to have four or five of these instruments of different
sizes : they should also be furnished with movable plugs, pro-
jecting about an inch and a half from the uterine extremity,
to facilitate their introduction. My colleague, Dr. Protheroe
Smith, has invented a very useful speculum by which a visual
and digital examination can be made at the same time. It is
formed of two cylinders, the outer one being of metal, and the
inner of glass ; in the former is an oval opening, to allow of
the passage of the finger. When the instrument is introduced,
the glass tube is withdrawn if a digital examination be neces-
sary, and the finger being then passed into the vagina poste-
riorly, enters the fenestrum, and so reaches the os uteri. A
third kind of speculum, which is often useful, is that made by
Mr. Weiss, and which consists of two parts — a dilator and a
cylinder. The dilator possesses three blades, which are ex-
panded by turning the handle ; when sufficiently dilated, the
cylinder is introduced between the blades.
Either of these instruments can be readily introduced, and
all the advantages to be derived from their use obtained, by
placing the patient upon a couch, on her left side, with the
knees drawn up — in fact, in the same position as for labor.
The practitioner should be careful that no exposure of the
person takes place, and must avoid anything approaching to
force in passing the speculum up to the os uteri.
The uterine Sound. — In the diagnosis of displacements
of the uterus, or of tumors of this organ, this instrument — the
invention of Professor Simpson — will be found invaluable.
To give an idea of the uterine sound, it may be compared to
a metallic bougie, curved so as to correspond with the natural
direction of the uterine cavity, and fixed in a wooden handle,
to facilitate manipulation. Its stem is divided into inches,
and two-and-a-half inches from the point is a slight elevation,
indicating the depth of the uterine cavity in its normal state.
It may be introduced through the speculum, or merely along
the finger passed up to the os uteri. I need hardly say that
its use demands caution and gentleness ; and although it may
be feared that in unskilful hands it has produced abortion and
other serious consequences, yet I believe that, when used by
those capable of using instruments generally, it has never been
productive of the slightest mischief, but, on the contrary, has
proved a very valuable aid to the correct interpretation of
disease.
Sponge-Tents. — The dilatation of the os uteri is some-
times rendered necessary by a suspicion of the existence of
intra-uterine polypi. A series of sponge-tents should be era-
6
62 ON DISEASE.
ployed for this purpose, a small one being first introduced be-
tween the lips of the cervix uteri, succeeded by a larger one
and a larger, until the amount of dilatation we desire has been
obtained. Where rapid dilatation is required, Dr. Protheroe
Smith sometimes uses an instrument very similar to a litho-
trite for producing this condition. Great caution, however, is
necessary in the employment of such an instrument.
CHAPTER III.
ON DISEASE.
SECTION 1. THE NATURE OF DISEASE.
Disease is known only by comparing it with the standard
of health, from which it is a departure. The standard of
health varies in different individuals, but, speaking generally,
it may be said that health consists in a natural and proper
condition and proportion in the functions and structures of
the several parts of which the body is composed. Physiology
teaches us that these functions and structures have to each
other as well as to external agents certain relations, which —
being most conducive to their well-being and permanency —
constitute the condition of health. But from the same science
we also learn indirectly, that function and structure may be
in states not conducive to their permanency and well-being —
states which disturb the due balance between the several pro-
perties or parts of the animal frame 5 and these states are
those of disease. Thus we learn from daily experience that
in health the digestion of food is easy and comfortable. But
when uneasiness, pain, flatulence, eructation, sickness, and
the like, follow the taking of food, we know that the function
of digestion is changed from the healthy standard — that it is
diseased; and if this diseased function continue long, in spite
of remedies which usually correct it, and if on examining the
abdomen we find at or near the epigastrium a hard tumor,
which anatomy teaches us is not there in health, we know that
there is also diseased stntciure. We find then that there is
disease of function, known by its deviation from a physiologi-
cal standard ; and a disease of structure, which we recognize
by an anatomical standard. These varieties of disease are
commonly combined, structural disease without disordered
function being rare ; while functional disease is often ac-
companied — or at all events followed — by change of structure.'
* Dr. C. J. B, Williams's Principles of Medicine. Second edition, p. 2.
STRUCTURAL DISEASE.
63
Ftmctioiial Diseases. — The leading features of this class
of disease may be briefly spoken of in connection with the
two most important systems of the body — the vascular and the
nervous.
In the vascular system there may be an excess of blood,
either generally or locally. Excess of blood generally, causes
plethora, with often increased natural secretions, increased
functional "vigor, irregular actions, excessive — and perhaps
morbid — growths. Locally increased supply of blood merely
gives rise to excitement, or to congestion, with oppression of
the congested organ. A defective supply of blood may also be
general or local ; when general, producing anaemia ; when
local, causing defective secretions, loss of energy, and a
tendency to disordered actions. The supply of blood may
likewise \)Q perverted, and thus produce disordered function.
In the nervous system we equally notice excessive, deficient,
or irregular distribution of nervous force, giving rise to tempo-
rary loss of health. Nervous disturbance may exist alone, or
may be combined with vascular irregularity, producing various
affections of nutrition, secretion, absorption, evacuation, mus-
cular motion, or of the sensorial offices, or of the intelligence
and will. But, as before observed, functional derangement
seldom continues long without producing, —
Structural Diseases, which may be comprehended under
the three heads of increased, diminished, and perverted nutri-
tion. Dr. Williams (op. cit. p. 345) has arranged the ele-
ments of lesions of structure in a table, essentially similar to
the following.
f Increased — Hypertrophy.
Diminished — Atrophy.
'Inflammation.
Perverted.
Induration.
Softening.
Transformation and Degeneration.
Euplastic. l^S^ membranes.
Deposits i Cacoplastic.
"o g C Contraction.
V. ~, Dilatation.
«■= I Obstruction. (, Growths.
'S^ I Compression.
? Jj Displacement.
(5;5 i Rupture, &,c.
1^ Aplastic.
Non-malignant,
Malignant.
("Cirrhosis.
! Fibro-carlilage.
] Gray tubercle.
( Atheroma, &c.
( Yellow tubercle.
/ Calcareous matter, &c.
i Cysts.
I Tumors.
( Hydatids,
iCai
En(
Me
&c.
Carcinoma.
icephaloma.
Melanosis, &c.
64 ON DISEASE.
Acute and Chronic Diseases. — The terms acute and
chronic have been arbitrarily employed to indicate the extreme
states, in respect to nature and duration, of certain diseases.
It must be remembered, however, that acute diseases often
become chronic, and vice versct ; that a disorder may be acute
in its nature and chronic in its duration ; and that there may
be disturbed action in every intermediate degree between
these two extremes.
Zymotic Diseases. — Zymotic (from ff/uoa, to ferment) is
an epithet proposed to characterize the entire class of epidemic,
endemic, infectious, and contagious diseases.
Epidemics [tTri, upon, and S>iuic, the people) are such dis-
eases as occasionally infest a community, more or less gene-
rally, at the same time, and w^iich are apt to recur at uncer-
tain intervals. They may be not inaptly compared to the
blights or tribes of animalcules which appear and disappear
without any evident cause, and which at certain seasons pro-
duce such havoc in the vegetable kingdom ; it is not impro-
bable that they are due to some atmospheric influence, though
the nature of this influence is unknown. Cholera, influenza,
and fever are the epidemics from which we suffer the most
severely : the ravages from cholera having been most alarm-
ing as it has gradually traversed Asia, Europe, and America,
in the year 1831-1832, 1848-1849, and 1853-1854.
A disease is said to be endemic (ev, in or among, and J«^of)
when it is peculiar to, or especially prevalent in, any particu-
lar locality. Thus ague is endemic in low marshy districts,
goitre in certain parts of Derbyshire, Switzerland, &c. But a
disease may also be epidemic and endemic, as is the case
with cholera, which appears to be endemic in India, and epi-
demic only in Europe.
Contagions diseases are tliose which are communicable
from one person to another. The terms contagion and infec-
tion are generally employed synonymously, though some have
applied the word infection to the communication of disease
from the sick to the healthy by a morbid miasm or exhalation
diffused in the air, reserving contagion to express the trans-
mission by immediate or mediate contact. Since, however, it
is obvious that these are merely modes of the same agency in
the great majority of cases, it seems better to view contagion
as merely one mode of infection. There are three modes in
which infection maybe produced: 1, through wounds or an
abraded surface, as in hydrophobia, vaccination, &c. ; 2,
through contact, as w^e see in gonorrhea, syphihs, and certain
cutaneous affections depending upon the existence of parasitic
HEKKDITARY DISEASES. 65
plants or animals; and, 3, through exhalations from the skin,
breath, perspiration, or other secretions, which becoming dif-
fused through the air to a certain extent, infect those who
come within reach of the poison, as is seen in measles, small-
pox, pertussis, fevers, and similar infectious disorders.
Sporadic Diseases. — Diseases which attack only one
person at a time, and which supervene indifferently in every
season or locality, from accidental circumstances, and inde-
pendently of epidemic or contagious influence, are termed
sporadic. Thus dropsy, cancer, gout, diseases of the heart,
and the great majority of the affections to which flesh is heir,
are sporadic. Occasionally, when an epidemic proceeds slowly
from one person to another, the attacks are said to occur spo-
radically.
Continued, Remittent, and Intennittent Diseases. —
Fevers are called contimted, when they pursue their course
without any well-marked remissions. In remiitent fevers cer-
tain intervals occur daily in the course of the disease, in which
intervals there is no cessation of the fever, but simply an
abatement or diminution. The remissions usually occur to-
wards the morning, and continue for six, ten, twelve, or four-
teen hours : they are followed generally, by increased feverish
excitement or exacerbation towards night, continuing for some
hours. In intermittent fevers there is an interval of almost
perfect health. The three common species of intermittent
fever or ague, are the quotidian, tertian, and quartan. When
the paroxysm occurs at the same hour every day, it is called
quotidian ague ; when every other day, tertian, though secun-
dan would be more appropriate ; and when it is absent for
two whole days and then recurs, quartan. In the first species
the interval is twenty-four hours, in the second forty-eight, in
the third seventy-two. The time between the commencement
of one paroxysm and the beginning of the next is termed the
interval 5 that between the termination of one paroxysm and
the commencement of the next, the intermission.
Hereditary, Congenital, Acquired, Specific, and Ma-
lignant Diseases. — Hereditary diseases are such as are
transmitted from an ancestor or parent to a descendant or
offspring ; they may exist at birth, or may become developed
at any subsequent period of life: gout and scrofula furnish
examples. Congenital affections are those born with the indi-
vidual, as congenital cataract, hernia, &c. Hereditary and
congenital affections differ from those which are acquired, that
is to say, derived from causes operating after birth. The term
6*
66 ON DISEASE.
sjyecijic is sometimes applied to diseases which are marked by
some disordered vital action not belonging to disease in gene-
ral, but peculiar to the individual case ; thus syphilis and hy-
drophobia are specific diseases. Malignant diseases are those
which are of a highly dangerous and intractable character,
and the symptoms of which are generally very formidable from
the commencement. Certain forms of typhus and typhoid
fever, which rapidly depress the vital energies, are said to as-
sume a malignant type ; so again, cholera is often called ma-
lignant. By some this term is used to denote cancerous
affections.
Asthenic, Idiopathic, Symptomatic, and Intercurrent
Diseases. — Most of these terms explain themselves, but it
may be as well to mention that diseases attended by manifest
depression of the vital powers are said to be asthoiic, in con-
tradistinction to those marked by activity of the vital forces —
sthenic disorders. Diseases, also, which are not dependent
upon or symptomatic of others, are called idiopatliic or pri-
mary ; while intercurrent disorders are those which arise in
individuals from incidental causes during the prevalence of
zymotic diseases.
SECTION 2. THE CAUSES OF DISEASE :— ETIOLOGY.
Whatever is capable of deranging either of the functions or
any part of the structure of the human body, must be ranked
amongst the causes of disease. It is not surprising therefore,
considering the numberless variety of circumstances to which
man is exposed, that these causes are very numerous, that in
any particular case they often elude our observation, and that
many attempts have been made to classify them without any
marked success. Thus they have been divided into external
or extrinsic, and internal or intrinsic, according as they ope-
rate on the body from without or from within ; into predis-
posing and exciting; into general and local 5 proximate and
remote ; into caiisce ahdiice and caiisce evidentes; into me-
chanical or chemical, and physiological 5 and so on. The
true simple view of all causes is, that they are circumstances
of the most variable nature inducing disease 5 and the most
simple division of them probably is into predisposing and
exciting. They may be arranged in two tables, partly accord-
ing to the plan adopted by Dr. C. J. B. Williams, in his excel-
lent work on the Principles of Medicine, from which I have
already quoted.
CLASSIFICATION OF DISEASE.
6t
Predisposing
Causes
Disease
f Debilitating influences.
Excitement
Previous disease.
Present disease.
^8 1 Hereditary constitution.
°^ ' Temperament.
Age.
Sex,
Occupation.
Climate.
1. Cognizable Agents
2. Exciting
Causes of
Disease.
2. Non cognizable Agents
1. Mechanical.
2. Chemical.
3. Ingesta.
4. Bodily exertion.
5. Mental emotion.
6. Excessive evacuation.
7. Suppressed or defective
evacuation.
8. Defective cleanliness, ven-
tilation, and drainage.
9. Temperature and changes.
(^ 10. Parasitic plants and ani-
mals.
1. Endemic i
Epidemic > Poisons.
Contagious S
!i
The scope of the present Manual will not permit of my
treating of each of these causes in exteiiso, neither is it neces-
sary to do so. I must, however, say a few words on the non-
cognizable causes or those due to miasmata secreted by the
human body, or generated largely from unknown sources,
which especially deserve the attention of the medical philoso-
pher, since they are most appalling in their effects, and but
very little is known of their nature. These morbid poisons
are all subjected to certain general laws, the most important
of which are —
1. That they all have, not capricious, but certain definite
and specific actions, and that they each affect especially cer-
tain organs, as in scarlatina — where the eruption differs from
all other eruptions, runs a course peculiar to itself, and where
the force of the poison is expended on the skin and mucous
membranes ; in hooping-cough — where the virus affects the or-
gans supplied by the eighth pair of nerves or thepneumogastrics.
2. That, after mingling with the blood, they continue in
latent combination with this fluid for a certain period of time
before their specific actions are set up. Thus in small-pox
there is a latent period — between infection and the appearance
of the phenomena of the disease — of from twelve to fifteen
days ; in measles from twelve to fifteen days ; in scarlatina
from four to six 5 and in ague an unknown period, twelve
months even having elapsed between the time of exposure to
the malaria and the appearance of the fever.
68 ON DISEASE.
3. That the phenomena resulting from the poison, when
roused into action, vary to a certain extent, according to the
strength of the poison, and the predisposition, temperament,
and constitution of the patient.
4. That they possess the power of generating to an im-
mense extent a poison of the same nature as that by which
the disease was first produced. Thus a quantity of small-pox
virus almost inappreciable in size may produce thousands of
pustules, each containing fifty times as much pestilent matter
as that originally introduced.
And 5. That many of these poisons possess the extraor-
dinary power of exhausting all future susceptibility in the
constitution of the affected party to any similar action of the
same agent, as is well known to be the case in scarlatina,
small-pox, hooping-cough, &c.
In considering the importance of the various causes of
disease individually, the student must bear in mind that
disease may be induced by one only, or by several acting
together or in succession ; and that they are modified by
several circumstances, but especially by the vis medicatrix
naiurce, which, in healthy persons, is sufficient to resist the
force of many circumstances that would otherwise give rise to
disordered action.
SECTION 3. THE CLASSIFICATION OF DISEASE:—
NOSOLOGY.
In order to simplify the study of morbid processes, it has
been found necessary to briefly designate the important
peculiarities, phenomena, and situations of diseases, and to
classify them according to some definite plan, dividing and
subdividing them into classes, orders, genera, and species.
The word Nosology is used to express this classification.
Several nosological systems have been proposed. Thus
Sauvage divided disease into ten classes, — viiia, fehres, phleg-
masice, spasmi, anhelationes, debilitates, dolores, vesanice.,f.uxus,
cackexice, taking as the foundation of each class the most
prominent symptoms. CuUen, proceeding on the same plan,
endeavored to simplify this arrangement by reducing the
classes to four, — pyrexice, neuroses, cacJiexice, and locales.
The great error in these classifications is, that symptoms are
regarded as the essential parts of disease, whereas they are
merely indications, are very variable, and by no means
uniformly correspond with the amount of disordered function
or diseased structure present. Thus delirium forms a promi-
DIAGNOSIS OF DISEASE. 69
nent symptom in many diseases of the most opposite nature ;
but what an amount of error would be involved were these
disorders all classed together on account of this symptom.
The true foundation of a natural classification of diseases is —
as observed by Dr. Williams — in a correct pathology, or
knowledge of the intimate nature of diseases ; the subdivisions
being conveniently determined by the chief seat of the disease,
or by some of its more prominent characters. There are,
doubtless, many difficulties in the way of making such a
classification, and when made it will be imperfect ; still it will
be the best, and will approach the nearest to that which is
unattainable — a perfect methodical nosology.
SECTION 4. THE DIAGNOSIS OF DISEASE.
The con-ect diagnosis of disease — the distinction of diseases
from one another — is the most important part of the physi-
cian's duty. To discriminate well the malady, and to discern
its effect upon the patient, requires the highest skill — a skill
which can only be obtained by observation and practice.
In attempting to make out the nature of a disease, every
branch of medical knowledge must be brought to bear upon
the inquiry ; information must be sought from every source
likely to afford aid. Having carefully learnt the general his-
tory of the patient, we must examine all the symptoms,
investigate the condition of suspected tissues or organs, inquire
into the assigned cause, and take into consideration all con-
trolling influences, such as age, sex, temperament, habits,
modes of living, constitutional peculiarities, &c. Accidental
circumstances often aid us considerably, especially when the
patient is unwilling to impart all the information he is capable
of giving. At the same time the feelings, prejudices, and
mental peculiarities of the sufferer must be consulted, and the
practitioner should endeavor to come to a correct conclusion
with as little that is disagreeable to him as possible.
Bishop Butler has well said that "probability is the guide
of life," since man may have sufficient evidence in a thousand
cases to warrant his actions, though that evidence is very far
removed from certitude. This is especially the case in the
diagnosis of disease, numerous maladies being discriminated,
treated, and cured as often under the guidance of sober con-
jecture as of undisputed certainty. Such conjecture, however,
is very different from arrogant guesswork, which fails much
more frequently than it succeeds, and knows not why it suc-
ceeds or fails. " The conjecture which should guide the
70 ON DISEASE.
physician is rigorous, and calculating, and honest. It acts
strictly by rule, and leaves nothing to chance. It does not
absolutely see the thing it is in quest of, for then it would no
longer be conjecture. But, because it does not see it, it pon-
ders all its accidents and appurtenances, and noting well
whither they point, it takes aim in the same direction, and so
oftener hits the mark than misses it. And succeeding thus,
it knows why it succeeds, and it can succeed again and again
upon the same terms. Next to knowing the truth itself, is to
know the direction in which it lies. And this is the peculiar
praise of a sound conjecture."'
The mode of diagnosing particular diseases will be treated
of in a subsequent part of this work.
SECTION 5. THE PROGNOSIS OF DISEASE.
In forming an opinion as to the future course, changes, and
termination of any disease, we must be chiefly guided by our
knowledge of the general progress of the class of disorders
to which it belongs, by the effect which the disease has had
upon the patient, by the degree to which it has hitherto been
controlled by remedies, and by the extent to which they are
likely to be further beneficial. It is usually of the greatest
consequence that the character of a disease should be plainly
perceived. In cases where there is a reasonable chance of
recovery the stimulus of hope is of great service, and in itself
favors the return to health. On the other hand, where a fatal
termination is indicated, a sick man, made aware of his dan-
ger, is enabled to arrange his worldly affairs, to make his will,
and to prepare for the awful change that awaits him. Fore-
seeing the event of a disease, it becomes a question whether
the practitioner should divulge his opinion. There is always
some risk of losing instead of gaining credit, by strong state-
ments, and confident predictions of the death or recovery of
a patient.* Hippocrates, in one of his aphorisms, says, "in
acute diseases it is not quite safe to prognosticate either death
or recovery." By giving an unfavorable prognosis, you may
lose your patient altogether ; for the friends, naturally arguing
that you are not infallible, that you may be mistaken, and
that because you know of no means of safety, it is no reason
why another practitioner should not be more successful,
dismiss you to seek other advice. This is not merely a
selfish question ; for it is the practitioner's duty to save his
* Lectures on Diseases of the Heart, by P. M. Latham, M. D. vol. ii. p. 5.
» Watson's Practice of Physic, third edition, vol. i. p. 114.
TERMINATIONS OF DISEASE. 71
patient from those unprincipled rapacious quacks who will
undertake to cure any case, however hopeless it may be, pro-
vided that there is sufficient plunder to be obtained. More-
over, it often happens that a person is dangerously ill of a
disease from which, however, recovery is by no means impossi-
ble. To take away hope in such an instance is often to cut
the thread of life. In these cases, my own plan is to commu-
nicate the condition of the patient to his most judicious
friend solely. But when my opinion is asked by a sufferer
from phthisis, cancer, &c., and where there is no hope what-
ever of the patient's life being long spared, I then think it a
positive duty to communicate my opinion to him, stating the
case fairly as to a reasonable being, explaining fully my own
opinions, and giving reasons for them. In many instances of
cancer of the uterus, for example, where I have been called
upon to state my views, I have done so fairly and unreservedly ;
and I certainly have never had cause to regret doing so, having
retained the patients under my care, in, at least, the majority
of the cases, and having, I believe, seen them soothed and
better prepared for the fatal event by the information, than if
they had been deceived. Indeed, for my own part, I should
regard that man as dishonest who would hold out hopes of
curing a patient, when he clearly saw that such was impos-
sible.
The instances in which the conscientious practitioner may
feel the greatest difficulty are cases of heart disease, since, so
strong is the belief that sudden death is the termination of
these affections, that great, injurious, and permanent mental
anxiety will result from telling the patient of his condition.
I should then communicate with some dear relative, explain
the case fully, and at the same time endeavor to convince that
in the majority of examples of cardiac disease death does not
occur suddenly, but as Dr. Stokes insists, gives notice of its
approach by long-continued symptoms of dropsy, pulmonary,
and hepatic disease.
SECTION 6. THE TERMINATIONS OF DISEASE.
All diseases ultimately terminate in health or in death.
Before ending in either, they may assume different forms and
characters to those which they originally presented, or they
may give rise to other diseases, or they may change their
situation by what is termed metastasis.
Termination in Health. — This takes place in very diver-
sified modes, according to the nature of the malady ; iu all
72 ON DISEASE.
cases it is due to the subsidence of the morbid actions, and
to the vital energy. In some instances — nervous affections,
for example — convalescence takes place suddenly. Most
frequently, however, the change is gradual, especially in acute
diseases ; a diminution in the frequency of the pulse, a
cleaning of the tongue, and a restoration of the secretions to
their normal condition, being the earliest symptoms. Often,
convalescence goes on happily ; but frequently, also, it is
delayed by unpleasant symptoms, such as night-sweats, loss of
appetite, mental despondency, restlessness, &c. Sometimes
the cure is interrupted by a return of the disease — by a
relapse, in which the patient's position is rendered more unfa-
vorable by the debility and unrepaired mischief remaining
from the first attack.
Great importance was formerly attached, during the pro-
gress of a malady, to what were termed crises, or turning
points — whether favorable or unfavorable — in the disease.
Critical days, critical symptoms, critical discharges, &c., were
then anxiously looked for. Hippocrates, who first drew atten-
tion to critical changes, believed that disease was more prone
to alter at certain periods than at others, and he accordingly
designated the seventh, fourteenth, twentieth, twenty-seventh,
thirty-fourth, and fortieth days as critical days. Crises are
said to manifest themselves chiefly by a diminution of fever,
by sweats, hemorrhages, increased flow of the secretions,
eruptions of the skin, boils, carbuncles, buboes, salivation,
and gangrene. The existence of critical days and critical
symptoms has been denied by most modern authorities, as, at
least, not applying to diseases as they now exist ; copious and
apparently critical discharges not only fi-equently appearing
without any influence upon the progress of the symptoms, but
many disorders ending favorably, without any excretion which
could be at all regarded as critical. It cannot but be allowed,
however, that there is, at all events, a foundation of truth in
these ancient doctrines ; and the practitioner will do well to
remember that where relief follows from the appearance of
critical symptoms, they at least show the direction in which
nature is acting, and point the way in which the physician
must work, in order to aid and not thwart the vis medicatrix
natur(E. The careful investigations of Dr. Traube, of Berlin,'
which have led him to revive the doctrine of crises and critical
days in fever, are deserving the attention of the reader who
wishes to learn all that can be said on this interesting
subject.
» Ueber Krisen und Krilische Tage. Von Dr. L. Traube, Berlin, 1852.
TERMIXATIOXS OF DISEASE. 1o
Not unfrequently an acute disease becomes chronic; that
is to say, the symptoms subside without disappearing, and
continue for a lengthened period.
Another mode in which disease may leave a particular
organ is by metastasis — from /uiBta-m/ui, I transfer. This
change is perhaps most frequently seen in gout or rheumatism,
either of which, suddenly disappearing from the affected
joint, may attack the head, or heart, or stomach. Dr. Copland
mentions two instances which fell under his own observation,
and which serve to elucidate this subject.* A medical friend
suffered from gout in the lower extremities, for which he took
a large dose of colchicum, before the morbid secretions had
been evacuated. He almost instantly had a violent attack of
the disease in the stomach, with simultaneous disappearance
of it from the original seat. The free use of stimuli caused
it to relinquish the stomach, and to reappear in the extremi-
ties. In this case, the transfer from one place to the other was
instantaneous, the medium being evidently the nervous
system. The second patient had, upon suppression of gout
from the lower extremities, an attack of simple apoplexy, for
which he was bled and purged. When Dr. Copland saw him
he was comatose, but the head was still cool. Mustard sina-
pisms to the feet, and ammonia with camphor, were ordered ;
the gout suddenly reappeared in the feet, the patient at the
same instant awakening as from a profound sleep, and with-
out evincing subsequently the least cerebral disturbance, either
organic or functional. Another form of metastasis is often
seen in cutaneous affections, when the eruption suddenly
ceases — often from improper medical interference — and dan-
gerous disease is developed in internal organs. The same
may also happen from the suppression of morbid secretions,
of discharges from ulcers, &c., which have become necessary
to the sustenance of health.
The Termination in Death. — Death is the condition to
which all organized bodies must ultimately be reduced. It
may take place naturally and gradually from old age — from
exhaustion of the vital forces, the active powers gradually de-
serting each organ, the functions of absorption and secretion
being arrested, the general circulation becoming slowly sus-
pended, and the heart ceasing to contract. Unfortunately,
death from mere old age is very rare. Haller estimated the
average probability of human life, and deduced the conclusion
that only one individual in 15,000 reaches the hundredth year.
* Medical Dictionary, vol. i. p. 600.
7
74 ON DISEASE.
Seeing, then, that death from disease or accident is the rule,
it behoves us, as guardians of the public health, to do our
utmost to remove the causes of disease, and to treat that which
is unavoidable with the greatest skill and caution. Death
from disease may take place in two ways — either suddenly,
the transition from life to death being made in a moment,
without warning, — or slowly and gradually, as the termination
of some lingering disorder.
The most frequent causes of sudden death are, apoplexy ;
rupture of an aneurism or large bloodvessel into one of the
three great cavities of the body 5 disease of the valves of the
heart — the liability to sudden death being greater in disease of
the mitral valve than in aortic valvular disease ; rupture of
the heart, from fatty degeneration ; laceration of the chordae
tendineae ; asphyxia, from obstruction of the glottis, or the
bursting of purulent cysts into the air-passages; syncope,
from severe shock or alarm; and injury of the spinal cord.
As regards the last-mentioned cause of sudden death, it must
be remembered that as the phrenic nerve arises from the
third, fourth, and tifth cervical nerves, so any severe injury to
the cord above the origin of the third nerve will produce
instant death, by suddenly paralyzing the diaphragm and in-
tercostal muscles ; while if the injury occurs below the sixth
vertebra the patient may live for some hours, if not days,
although the action of the greater number of the intercostal
muscles must be wholly or partially arrested.
One or two examples of sudden death have occurred lately,
in which the cause seemed to be latent pneumonia of one
lung. Slight indisposition appears to have been complained
of for a day or two, when suddenly, without any apparent
reason, death has taken place. Dr. Quain and Mr. Ashton
have related cases to this effect.
A large number of instances of sudden death occur annu-
ally in this country from the different causes just enumerated.
Very curiously, it appears that women have less chance of
dying suddenly than men — in the proportion of ten to eighteen
— but that more women than men die from paralysis. This
is proved by the following table, taken by Dr. Granville from
the reports of the Registrar-General, of the number of sudden
deaths, and of deaths from apoplexy and paralysis, in all
England and Wales, males and females, for the years as fol-
lows :'
* Granville on Sudden Death.
TERMINATIONS OF DISEASE.
75
Years.
SUDDEN.
APOPLEXY.
PARALYSIS.
Male. [Female. Total.
Male.
Female.' Total.'
Male. Female. :Tolal.
1847
1848
1849
1850
Total,
2154 i 1554 > 3708
1811 1 1386 i 3197
2012 ; 1543 ; 3555
2025 i 1535 3560
4007
3898
3896
; 4078
3874 I 7881
3704 : 7602
3901 : 7797
4016 8094
3376
3213
3428
3473
3695
3458
3900
3844
7069
6671
7328
7317
8002 i 6018 14020
15879
15495 131374
13490
14895
28385
Death as it occurs in disease is usually complicated ; but in
all cases, whether it take place suddenly or gradually, or
whatever may be the malady, it approaches through one of
the three vital organs — the brain, the heart, or the lungs. Life
being inseparately connected with the circulation of arterial
blood, death takes place directly the action of the heart is
completely arrested ; and since the action of the heart is de-
pendent upon the more or less perfect condition of all the
vital organs, which stand in a peculiar reciprocal relation to
each other, a cessation of the functions of either of the three
speedily arrests the remaining two. Thus innervation of the
muscles of respiration depends upon the medulla oblongata,
the energy of the medulla oblongata upon the decarbonization
of the blood, and the decarbonization of the blood upon the
circulation and respiration. The force of the heart, if not
directly, is indirectly connected with the medulla oblongata,
because the circulation of venous blood destroys the irrita-
bility of the muscles. And so it results that failure in any one
of the three links in the chain is fatal. Hence Bichat spoke
correctly of death beginning at the head, at the heart, and at
the lungs.
We may have then — 1st, Death by AncEmia, that form which
is caused by a want of the due supply of blood to the heart.
The deaths from flooding after labor, from the bursting of
aneurisms, &c., are good examples of this form ; on examin-
ing the heart afterwards, the cavities are found empty, or
nearly so, and contracted. 2d, Death hy Asthenia, in which
there is no deficiency of the proper stimulus to the heart's
action — the blood, but a total failure of the contractile power
of this organ. The effects of certain poisons — as hydrocyanic
acid, of strong mental emotion, of lightning, &c., furnish good
illustrations of this form. The state of suspended animation
common to both these modes of dying, is termed syncope.
3d, Death hy Asphyxia — or, as Dr. Watson terms it, by apnoea,
or, as we say commonly, by suffocation — is that which occurs
76 CIRCUMSTANCES WHICH MODIFY DISEASE.
when the entrance of air into the lungs is in any way stopped,
as in drowning, strangulation, spasmodic closure of the rima
glottidis, &c. I in this mode death begins in the lungs. The
blood being unaerated, continues venous, passes through the
pulmonary veins into the left side of the heart, and thence
through the arteries to all parts of the body. Venous blood,
however, being unable to sustain the functions of the organs
to which it is sent, its effect on the brain is at once seen by
the convulsions and insensibility which ensue ; the blood in
the pulmonary capillaries becomes retarded, and gradually
stagnates, leaving the lungs and right chambers of the heart
full and distended. 4th, Death by Coma, in which extinction
of organic life takes place in the same way as in the preced-
ing case, the difference between the two forms of dying being
this — that in death by apnoea, the chemical functions of the
lungs cease first, and then the circulation of venous blood
through the arteries suspends the sensibility ; whereas in death
by coma, the sensibility ceases first, and in consequence of
this the movements of the thorax are arrested, as well as the
chemical functions of the lungs. Thus the circulation of
venous blood through the arteries is in the one case the cause,
in the other the effect, of the cessation of animal life.^
CHAPTER IV.
ON THE VARIOUS CIRCUMSTANCES WHICH
MODIFY DISEASE.
Having shown in the previous chapter that disease consists
of disordered action in one or more parts of the machinery of
the body, it becomes necessary now to prove that these dis-
ordered actions vary much, in their nature, severity, and
duration, in different individuals ; being modified by age, sex,
constitution, temperament, and many other circumstances
which I now propose to speak of. To discriminate well the
malady and the exact condition of the patient, and to regard
both in the attempt to cure disease, must be the constant
endeavor of the skilled practitioner. The same disease in
one individual often assumes a different character in another,
and requires consequently a different method of cure. Just
as we never find two individuals perfectly alike in features,
stature, strength, constitution, &c., so we learn that disease
' Dr. Watson, op cii. Lecture V.
SEX. 77
becomes varied and modified, although its broad principles
maj remain unaltered. Physiologists have long since shown
us, that a poison of such potency as to destroy the life of an
animal in two minutes when introduced into the system, will
produce its fatal efi*ect in half a minute if the animal's
strength be reduced by bleeding. We are all familiar with
the fact that in typhus fever, for example, the patient will
bear a very large quantity of alcohol without being affected
by it, just as in tetanus and hydrophobia scarcely any amount
of opium will tranquillize the nervous system. So, again,
there are some few persons with constitutions so insensible to
the action of mercury, that no quantity will affect their gums
or increase the secretion of the salivary glands ; while others,
on the contrary, are so susceptible, that it is scarcely possible
to administer a grain of this metal without giving rise to its
specific effects. If, then, disease or constitution so qualifies
the action of these powerful agents, is it not reasonable to
suppose that many conditions of the system may in like
manner modify disease ? And this is really the case. How
often, for instance, do we see many people differently circum-
stanced exposed to the same morbid agency with a varied
result. Thus, of half a dozen persons exposed to the same
noxious influence — say that of wet and cold — one shall have
rheumatism, one an attack of influenza, a third catarrh, a
fourth ophthalmia, and so on. Again, a man may be exposed
to the influence of some infectious disease — as small-pox — and
not being predisposed to suffer from infection may escape
unharmed. Yet in a few days, nay, in a few hours, with his
system depressed from fatigue, the same morbid element
being encountered, he no longer escapes its influence, and the
variolous poison takes root — so to speak — and produces its
well-known fruit. Nature, thus apparently capricious, works
according to certain general laws ; and although our present
knowledge may not enable us on all occasions to solve these
laws, yet that they admit of solution there can be no doubt.
The following are the circumstances which chiefly modify
the nature, severity, and duration of disease :
1. Sex. — Both sexes are equally liable to many diseases.
Females, however, on account of the greater excitability of
their nervous system, and owing to their possessing an organ
— the uterus — whose lesions affect the whole system, are
especially predisposed to nervous complaints ; and such
causes as give rise to inflammation in males, will in them
often produce merely functional disorder. Thus gout and
rheumatism often lurk unsuspected in the female system,
78 CIRCUMSTANCES WHICH MODIFY DISEASE.
causing dyspepsia, palpitations, uterine and neuralgic affec-
tions, without manifesting themselves more openly. It has
been said that during the prevalence of epidemics women
suffer less than men ; which is probably to be accounted for
by their more regular habits, and their being less exposed to
the exciting causes of these diseases. The uterus is the
active centre of sympathies, from puberty to the period of
the change of life. The regular flow of the catamenia
becomes essential to health, and the interruption or cessation
of the discharge, except under certain circumstances, often
proves the cause of great constitutional disturbance. About the
age of puberty women are apt to suffer from anaemia, chorea,
and hysteria. The condition of pregnancy is favorable to
health ; while at the cessation of menstruation chronic inflam-
mations and lesions of the uterus, diseases of the breast, dis-
orders of the colon and rectum, and cancerous affections, are
likely to occur.
2. Age. — Each of the various epochs of life is liable to
certain peculiar diseases. Diinng the earliest period — from
birth to first dentition — not only is the body very frail, but
there is great irritability and sensitiveness, a predisposition to
spasms and convulsions, to hydrocephalus, inflammation of
the brain or its membranes, and to rickets, «S:c. Mankind
spring not up full-formed, and ready armed for battling with
adversity, like the fabled army from the teeth of dragons
sown by Cadmus ; but rather as the seed which is scattered
from the hand of God over all the earth.' As then the
young plant requires care and attention proportioned to its
frailness, so the tender infant demands the most constant
watchfulness and judicious management. The process of
dentition alone keeps up a constant irritation which impairs
the functions of the brain, alimentary canal, and skin ; and
many children die during teething. So slender indeed is the
thread of life, and so serious are the various infantile diseases,
that one child in every five dies within a year after birth, and
one in three before the end of the fifth year.
After the Jirst dentition to the sixth or seventh year, the
powers of life become more energetic ; there is great excite-
ment of the vascular and nervous systems, easy exhaustion
but also easy restoration. The predisposition is to inflamma-
tory affections, to attacks of fever, and to the exanthematous
disorders. In the inflammatory diseases of children there is
a strong tendency to the formation of coagulable lymph,
' Oil the Use of the Body in relation to the Mind. By G. Moore, M. D.
HEREDITARY TENDENCY. 79
and to the exudation of false membranes upon the mucous
surfaces.
After the second dentition until the age of puberty, is one of
the healthiest periods of life, the vital functions reacting
readily upon the depressing causes of disease, and being
eminently conservative in resisting noxious influences. The
predisposition to the eruptive or exanthematous fevers con-
tinues, and there is also a frequent liability to epistaxis. The
age of puberty is often attended with temporary constitutional
derangement, especially in the female, in whom disorder of
the uterine functions is common.
From the age of puberty till the time when growth ceases,
is a dangerous period, there being a strong predisposition to
hemorrhages, tubercular disease, scrofula, and disorders of
the digestive organs.
After maturity there is again a period of comparative ex-
emption from morbid tendencies, the functions being well
balanced, and the actions of each organ well regulated. In
females there is a tendency to disease of the reproductive
system about the time of the cessation of the catamenia —
from the forty-sixth to the fiftieth year ; and in both sexes, as
age advances after the fiftieth year, there is decrease of strength,
disturbance of certain functions, a tendency to degeneration
of tissues, and loss of power in different organs. Hence
there is a predisposition to various organic diseases ; the brain,
heart, and the genital and urinary organs being especially
prone to suffer. As senility advances sensibility decreases,
the memory fails, the muscular strength becomes diminished,
and gout, apoplexy, paralysis, softening of the brain, &c.,
often supervene to hasten the period of second childhood to
its close.
3. Hereditary Tendency. — As the child often resembles
the parents in form and feature, so frequently does he inherit
their constitutional peculiarities, and the morbid tendencies
growing out of them. It is not, generally speaking, diseases
that are inherited, but only those peculiarities of structure or
constitution which predispose to them. Thus children are not
born with phthisis, gout, rheumatism, calculus, &c., but only
with those conditions of system which favor the development
of these aftections when other causes co-operate. It some-
times happens, however, that the hereditary tendency is so
strong, that the disease becomes developed notwithstanding
the greatest efforts to prevent it, as is often seen in affections
of the lungs and brain. Where there is a predisposition to
disease, the time at which it appears depends generally on the
80 CIRCUMSTANCES WHICH MODIFY DISEASE.
nature of the disorder. Thus the disposition to convulsions,
hydrocephalus, idiotcy, and scrofula is most apparent during
the early periods of life ; to epilepsy and phthisis about the
age of puberty; to gout, rheumatism, and various nervous
disorders, during the years of maturity; and to cancer, asthma,
and paralysis at advanced stages of life. The inheritance
may proceed from one parent only, or from both. In the
former case the disposition is often slight, and with care the
offspring frequently escapes from any manifestation of the
affection ; in the latter, the chances of safety are greatly
diminished. Hence the danger of intermarriages between
relations, who may be supposed to have the same defects of
constitution.
4. Temperament and Idiosyncrasy. — There are few in-
dividuals possessing an organization so well constituted but
that they show some inequality of function, or some peculiar
susceptibility, or constitutional state favoring a particular
class of morbid actions. These peculiarities when affecting
classes of persons are called temperaments y when individuals,
idiosyncrasies. Thus the sanguine and irritable temperament^
in which excitement is easily produced, the circulation active,
and the passions strong, disposes to plethora, congestions,
inflammations, hemorrhages, and fevers of an inflammatory
character; the lymphatic or phlegmatic temperament, which is
characterized by a languid circulation, softness of the muscles,
and torpidity of the bodily and mental functions, — to chronic
diseases, debility, tubercular, scrofulous, and dropsical affec-
tions ; while the nervous temperament, in which the cerebro-
spinal system is peculiarly excitable, the circulation feeble,
and the moral susceptibilities acute, predisposes to convulsive
diseases, disorders of the nervous system, insanity, and me-
lancholia: and the bilious temperament — characterized by de-
cision of character, energy, and a capability for great physical
and mental exertion, — to dyspepsia, hypochondriasis, and dis-
ordered action of the liver.
Sometimes, indeed generally, the temperaments are mixed,
two or more existing in combination — as the sanguineo-hilious,
■when there is a tendency to inflammatory hepatic affections,
to inflammations of the intestinal canal, &c.
5. Diathesis. — A strong predisposition^-either hereditary
or acquired — to certain diseases is not uncommon. The
principal diatheses are the gouty, rheumatic, cancerous, tuber-
cular, and strumous. To refer to an illustration which I have
before employed, let us suppose five or six people to be ex-
posed to wet and cold. Of these one or two may escape
HABIT. 81
without any harm, one or two may merely suffer from simple
catarrh, but an individual of a rheumatic diathesis will most
probably suffer from an attack of rheumatism, while pulmonary
consumption may be induced in the person afflicted with the
tubercular diathesis.
Patients in whom certain deposits habitually occur in the
urine with corresponding constitutional disorder, are often
said to be of, or to suffer from, a lithic acid, or phosphatic, or
oxalic acid diathesis.
6. Habit. — The habits of life, mode of living, and nature
of occupation are amongst the most powerful predisposing
causes of — or safeguards against — disease. Habitual intem-
perance, fast or luxurious living, indolence, and excesses of
all kinds, as they sap the strength and impair the health, so
they increase the danger of accidents and of serious affections ;
while the same effect results from the opposite extreme — from
great privations, from too sedentary a life, from anxiety and
distress of mind, and from over-fatiguing mental or corporeal
employments. The habitual use of animal food in excess,
especially when a counterbalancing amount of exercise is not
taken, predisposes to inflammatory affections, to disorders of
the primae vias, to gout, apoplexy, &c. A vegetable diet, on
the contrary, leads to impoverishment of the blood, and its
attendant diseases. Alcoholic drinks too freely employed,
frequently excite plethora, paralysis, delirium tremens, and
dropsy ; while pulmonary disease, epilepsy, and insanity often
result from inordinate sexual intercourse. All these vitiated
habits, moreover, by depressing the powers of life, predispose
the system to receive any epidemic or infectious poison that
may be prevalent, and to which it may be accidentally exposed ;
while, by lowering the conservative powers of nature, the
constitution is less able to bear up against the resulting
diseases when developed.
In some instances the influence of habit is salutary, as we
see in persons who become acclimated in malarious or other-
wise unhealthy districts, and in those whose sensibility to cold
and wet is blunted by habitual exposure. In the same way
many systems become reconciled to the habitual use of certain
classes of poisons — probably those only which are derived
from the vegetable kingdom — as tobacco, opium, and alcohol,
which even become sources of enjoyment, and apparently, to
a certain extent, of health.
7. Climate and Temperature. — The influence of climate
and temperature over disease, either in promoting, modifying,
82 CIRCUMSTANCES WHICH MODIFY DISEASE.
or alleviating it, is now generally admitted by all practitioners
of medicine.
The range of atmospheric temperature compatible with life
is very extensive. Gibbon — after stating that the Roman sol-
diers, from their excellent discipline, maintained health and
vigor in all climates — adds, that " man is the only animal which
can live and multiply in every country, from the equator to the
poles." It seems probable, however, that for this boasted pri-
vilege man is more indebted to the ingenuity of his mind than
to the pliability of his body, being enabled' by the former to
raise up numerous barriers to protect his constitution from the
deleterious effects of extreme heat or cold. This fact is at
least certain, that a mode of living essential to health in the
northern regions, will prove rapidly destructive at the equator,
and vice versa ; though it is worthy of notice that greater care
is necessary to preserve life under very great cold than under
intense heat.
The power which man possesses, under certain circum-
stances, and for a short time, of enduring a much greater de-
gree of heat than the atmosplaere ever attains in any part of
the world, is very remarkable. Boerhaave's idea— deduced
from experiments on animals — that the blood would coagulate
in the veins at a temperature slightly above 100° Fahr., has
long since been disproved. MM. Duhamel and Tillet, making
some experiments on heat in 1760, found that a girl could
enter an oven and remain in it some ten minutes with the
thermometer at 288° Fahr., being 76° above the boiling-point
of water. Drs. Pordyce and Blagden, occasionally naked and
occasionally with their clothes on, entered and remained for
some time in rooms heated to 240° and 260° Fahr., with but
little inconvenience, although the same air which they respired
sufficed to cook eggs and beefsteaks.
It would appear, from the remarks of s^everal observers, that
either extreme of heat or cold is better borne than any sudden
change in temperature, though such changes are by no means
so destructive to health as is commonly imagined. Thus Dr.
"Walsh states, that sailing along the coast of Brazil, after en-
joying a temperature of 72°, the wind rose, and the thermome-
ter fell to 61°, when "the sense of cold from the sudden tran-
sition of temperature was quite painful. After bearing it for
some time shivering on deck, it became intolerable, and we all
went below, put on warm clothing, and dreadnoughts — and
again appeared with thick woollen jackets and trousers, as if
we had been entering Baffin's Bay, and not a harbor under
one of the tropics." A curious insta,nce of inconvenience
CLIMATE AND TEMPERATURE. 83
from a rise in temperature is related by Captain Parry, who
says that when in the Arctic regions the thermometer suddenly
rose from 13° below zero to 23° — or 9° below the freezing-
point, — when every one complained of the temperature being
much too high to be agreeable.
The first effect of extreme Jieat is on the organic functions
of the body, which become greatly stimulated, while the ani-
mal functions are depressed. The action of the heart becomes
accelerated, the pulse increases in frequency, the biliary secre-
tion is augmented — but deteriorated, and the skin perspires
freely. On the other hand, there is nervous depression, with
languor, lassitude, and an incapacity for mental or bodily
exertion.
The ill effects upon Europeans of residence in tropical cli-
mates — where the thermometer often ranges from 80° to 100°,
or even 110° Fahr., or higher,' — are soon seen in the liver,
causing an increase in the biliary secretion ; this gland being
maintained in a state of undue excitement, both from the
stimulating influence of the heat, and the additional duty
which it has to perform in the elimination of carbon. Hence
— as occurs in every organ stimulated to undue action — one
of two things occurs. Either — the cause being constant and
long maintained — serious injury accrues to the organ itself,
generally to the extent of structural alteration ; or — the cause
being only temporary — torpor or exhaustion of the gland
takes place, and in the performance of its functions it falls
short of the healthy standard ; in either case producing great
constitutional disturbance. Another primary effect of a hot
climate is seen on the cutaneous surface, in promoting per-
spiration, and also in giving rise to a morbid condition —
attended with pricking, tingling, and itching sensations — in
which the skin is generally covered with an eruption of vivid
red pimples. This disease, known as the prickly heat — lichen
tropicus — makes a tropical life for a time miserable, since it
causes irritation at the most unseasonable hours, for weeks
together.^
The covp de sohil, or sun-stroke, not uncommonly affects
individuals exposed to the direct beams of a hot sun, causing
insensibility, and frequently death. Examples of it are fre-
quently seen among the troops during long marches in India.
The individuals most benefited by a residence in the tropics
are those of a strumous habit, as well as those of a tubercular
' The mean temperature of the London atmosphere is 501° Fahr.
3 Johnson and Martin, on Tropical Climates.
84 SYMPTOMS AND SIGNS OF DISEASE.
diathesis in whom pulmonary disease has not actually declared
itself.
The effects of extreme cold are first shown in causing de-
pression of the organic functions, as is seen in the dwarfish
size of men and animals in cold regions, the shrinking of ex-
ternal parts, the diminished cutaneous circulation, the contrac-
tion of the skin around the hair-bulbs and sebaceous follicles
— producing the peculiar appeai*ance known as cutis aiiserina,
and in the diminished power of the sexual organs. Long and
unprotected exposure to extreme cold gives rise to torpor of
the nervous system, confusion of the intellect, a staggering
gait resembling that from drunkenness, and to an overpower-
ing desire for sleep, which, if indulged, almost inevitably
proves fatal. Cold proves more injurious, and is less easily
borne, when applied by a wind or current of air, as well as
when accompanied by moisture, than when the atmosphere is
dry and at rest. Diseases of the pulmonary organs are the
most common affections of cold climates.
In temperate latitudes there is a less exclusive tendency to
disease of any special organ than in climates nearer the poles
or the equator ; although, owing to the sudden vicissitudes of
temperature, the frequency of cold winds, and of moisture,
there appears to be a morbid tendency to inflammatory,
rheumatic, and catarrhal affections.
CHAPTER V.
ON THE SYMPTOMS AND SIGNS OF DISEASE.
Without a correct knowledge of symptomatology or
semeiology — the science which treats of the symptoms and
signs of disease — we can know but little of the art of medi-
cine ; since a thorough acquaintance with the structural and
functional disorders to which the human body is liable, essen-
tially comprises a recognition of existing symptoms and
signs, a proper appreciation of their value, source, antecedents,
causes, relations, and connections with each other, and the
results which may be expected to flow from them singly or in
combination. The importance of carefully studying the
symptoms, therefore, can hardly be over-estimated, for from
them we form our diagnosis and prognosis, and learn in what
direction to conduct the treatment. It follows necessarily that
he will prove the best physician who is the most sagacious in ob-
serving them, and in deciphering their import and true value.
SYMPTOMS AND SIGNS OF DISEASE. 85
"What, then, it may be asked, is a symptom ? I cannot do
better than reply in the words of Dr. Watson, who says —
^' Everything or circumstance happening in the body of a
sick person, and capable of being perceived by himself or
by others, which can be made to assist our judgment con-
cerning the seat or the nature of his disease, its probable
course and termination, or its proper treatment : every such
thing or circumstance is a symptom.'"* It thus appears that
symptoms are obvious to all persons alike, to the educated as
to the uneducated, in this respect differing from the signs of
disease, which are — generally speaking — intelligible to the
medical eye alone. Signs indeed are, for the most part,
deduced from symptoms, either from one symptom or from a
combination. Thus cough is a symptom of many laryngeal
and thoracic afifections ; but combined with a hooping noise
during inspiration it becomes a sign. Symptoms have been
aptly compared to words taken separately or put together at
random ; arranged in due order, put together in sentences,
they convey a meaning, they become signs.
Various divisions of symptoms have been made, which are
neither very philosophical nor of much practical utility. It
is necessary to mention, however, that authors speak of
symptoms as local, general, or constitutional ; as idiopathic,
when proceeding directly from a primary disease ; symptomatic
or secondary, when due to secondary disorders, or those pro-
duced by the primary affection; premonitory or precursory, or
symptoms which indicate an approaching disease ; of symp-
toms which are diagnostic, since they enable us to distinguish
disorders which might otherwise be confounded ; or of those
which are p)rognostic, because they denote the probable issue
of a case ; or therapeutic, since they indicate the treatment.
Moreover, those diagnostic symptoms which are peculiar to
one disease are called pathognomonic, ov patliognostic. When
authors speak of physical signs, they allude to those pheno-
mena which take place in the body in accordance with physi-
cal laws ; when of vital symptoms, to such as depend on "the
vital properties of a part or parts of the body, as irritability,
tonicity, sensibility, &c.
It may almost appear unnecessary to mention that in the
study of semeiology every circumstance which is at all
characteristic is important ; and that the form and violence
of the symptoms, the particular order in which they appear,
and the manner in which these signals of disease are con-
joined, merit especial attention.
' Op.cit. vol. i. p. 111.
8
86 SYMPTOMS AND SIGNS OF DISEASE.
We will now proceed to the proper subject-matter of this
chapter, according to the following arrangement: — 1. The
symptoms and signs afforded by the countenance, and the
general appearance and condition of the body ; 2, those
symptoms and signs belonging to the organs and function of
digestion ; 3, those belonging to the function of respiration ;
4, those belonging to the function of circulation ; 5, those
connected with the urinary and sexual organs ; and 6, those
derived from the nervous system.
SECTION 1. SYMPTOMS AND SIGNS AFFORDED BY THE
COUNTENANCE, AND THE GENERAL APPEARANCE AND
CONDITION OF THE BODY.
The manifestations of disease which have to be considered
in this section are those derived from the expression of the
countenance, from the eye and the function of vision, from
the sense of hearing, and from the posture, and the general
condition of the body.
The Expression of the Countenance.— The facial expres-
sion is of importance in the recognition, diagnosis, and prog-
nosis of most maladies, but especially perhaps in those of
young children.
When the general expression of the countenance is serene,
tranquil, or expressive of hope, it may generally be regarded
as of favorable import in disease, especially if such expression
supervene gradually on the disappearance of restlessness and
acute symptoms generally : it must be remembered, however,
that it may be — though it is so rarely — an unfavorable sign,
as when it occurs suddenly during the progress of severe
organic disease on the unexpected cessation of pain, when it
frequently indicates gangrene of the affected organ, or
paralysis. In chronic disorders, unattended with pain or
suffering, and in the low stages of fever, the countenance is
often indifferent, the look is partly fixed, and the eyes bright.
In the low stage of fever, however, the movements of the lips
are tremulous, and the lips themselves are covered with sordes
and with a brown or black coating, like that on the teeth and
tongue. Immobility of the features may generally be looked
upon as a sign of debility, or of loss of consciousness, or of
general tonic spasm — as catalepsy.
Anxiety and pain produce a characteristic change in the
features. At the commencement of acute diseases generally,
in spasmodic affections, asthma, angina pectoris, &c., in in-
flammations of important viscera, in disorders of the genera-
EXPRESSION OF THE COUNTENANCE. 8t
tire organs, and in hypochondriasis, the countenance assumes
an anxious air ; a peculiar mixed expression of anxiety and
resignation is also common in organic diseases of the heart,
and of the great vessels. The expression of terror or of great
fear, is observed chiefly in delirium tremens, in hydrophobia,
in certain forms of insanity, during or after hemorrhages, and
after accidents. So the expression of rage occurs for the
most part in inflammation of the brain, in hydrophobia, and
in insanity. A bashful, downcast countenance, with inability
to look one manfully in the face, is generally a sign of nervous
exhaustion from masturbation, and often of impotency. That
peculiar cast of countenance termed the Hippocratic is thus
described by Hippocrates: ''The forehead wrinkled and dry ;
the eye sunken •, the nose pointed, and bordered with a violet
or black circle ; the temples sunken, hollow, and retired ; the
ears sticking up ; the lips hanging down : the cheeks sunken ;
the chin wrinkled and hard ; the color of the skin leaden or
violet ; the hairs of the nose and eyelashes sprinkled with a
yellowish-white dust." Such is the alteration in the human
physiognomy which usually precedes death, or which may be
produced by intense anxiety, grief, or sudden fright, or by
long-continued want of sleep : in all cases it renders the prog-
nosis very unfavorable.
But of all the appearances presented by the countenance,
that caused hj facial paralysis is the most striking and pecu-
liar, since from one-half of the face all power of expression is
gone ; the features are blank, still, and unmeaning ; the para-
lyzed cheek hangs loose and flaccid ; and the face is drawn on
one side, the healthy side being that so drawn, owing to the
action of the sound muscles not being counterbalanced by the
play of those on the affected side. "The patient," says Dr.
Watson,' " cannot laugh, or weep, or frown, or express any
feeling or emotion, with one side of his face, while the features
of the other may be in full play. One-half of the aspect is
that of a sleeping or of a dead person, or stares at you
solemnly; the other half is alive and merry. The incongruity
would be ludicrously droll, were it not so pitiable also, and
distressing. To the vulgar, who do not comprehend the pos-
sible extent of the misfortune, the whimsical appearance of
such a patient is always a matter of mirth and laughter."
Happily, however, there is not in the greater number of cases
any cause for real alarm ; protracted cold, or some external
injury or wound to the facial nerve — the portio dura of the
seventh pair — or pressure upon this nerve by an enlarged
* Op. cit. vol. i. p. 548.
88 SYMPTOMS AND SIGNS OF DISEASE.
parotid gland, being often the exciting cause of the complaint.
In slight cases of hemiplegia the face is often unaffected, the
paralysis being confined to the upper and lower extremities of
one side ; sometimes, on the contrary, however, the face is the
part first affected, the motor portion of the fifth nerve being
more or less involved in, or influenced by, the paralyzing lesion.
In such cases, the motions of the jaw on the affected side are
impaired, and mastication is impeded 5 but unless the portio
dura is also involved there is little or no distortion of the fea-
tures, and no loss of expression. The disease of the motor
portion of the fifth pair may be seated in or near the origin of
the nerve in the brain, or, more rarely and more favorably, in
the course of the nerve ; when there is loss of sensibility also,
the sensitive branches of the fifth pair are likewise implicated.
The appearance of the lips and mouth alone, often gives
valuable aid in diagnosis. Thus, retraction of the corners of
the mouth, so as to produce the sardonic grin — risus sardoni-
cus — is very remarkable in inflammation of the diaphragm,
and in certain painful affections of the stomach and bowels.
So in the last stage of phthisis, or of hectic from exhausting
diseases, or of cancer, the thin, retracted appearance of the
lips, as if they were stretched over the gums, is peculiar.
Swelling of the lips often occurs in children suffering from in-
testinal worms, and in incipient phthisis ; in strumous sub-
jects the upper lip is generally enlarged. After hemorrhage,
in anaemia, and in diseases of the uterine organs, the lips are
pallid, and at the same time inclined to crack, and become
sore ; so, on the contrary, they present a purple hue, when,
from any cause, the blood is imperfectly arterialized, and when
there is congestion of the thoracic viscera.
The hue or color of the countenance should be noticed. A
pallid or anaemic tint attends all diseases caused by, or giving
rise to, poverty or thinness of the blood, with a deficiency of
the red corpuscles ; a generally diffused redness of the face
attends inflammatory fevers in their early stages ; a dark,
murky tint shows a morbid condition of the circulating fluids ;
a continued sallowness is common in diseases of the liver,
with insufficient secretion of bile, as well as in diseases of the
spleen 5 jaundice is caused either by some impediment to the
flow of bile into the duodenum and the consequent absorption
of the retained bile, or by defective secretion on the part of
the liver so that the principles of the bile are not separated
from the blood ; a blue, leaden tint is seen in cases of mahg-
nant cholera ; while the face becomes livid, in obstructive dis-
eases of the heart or great vessels, in general acute bron-
SIGNS PRESENTED BY THE EYE. 89
chitis, in the last stage of pneumonia, and in congestion of the
lungs.
A dark circle under and around the eyes is often observed in
females suffering from ovarian or uterine disorder, menorrhagia,
prolonged leucorrhoea, or who practise masturbation. It is not
uncommonly present also in connection with severe organic dis-
eases, especially perhaps when they are of a malignant character.
Puffiness or oedema of the eyelids is frequently seen in the
early stages of dropsy, dependent upon cardiac or renal
disease ; closing of the eyelids takes place from intolerance of
light, vertigo, or swelling; a falling of the upper lid — ptosis —
caused by paralysis of the third nerve, may be due to merely
local causes, as rheumatism, injury, &c., — or it may be the
consequence of cerebral disease, as apoplexy, concussion of
the brain, and so on, — or it maybe the precursor of an attack
of hemiplegia ; and lastly, a frequent tremulous movement of
the lids is observed in chorea, epilepsy, hysteria, and in cata-
lepsy towards the end of the paroxysm.
Signs presented by the Eye. — The eye may be increased
in size from hyperemia of its tissues, such as takes place in
impending suffocation, or in congestion of the brain, heart, or
lungs; it also becomes more prominent, and therefore ap-
parently increased in size, in convulsions, apoplexy, epilepsy,
and delirium tremens. Ecchymosis — or swelling of the con-
junctiva — is common in catarrh and many simple affections;
but enlargement of the whole organ takes place only in hy-
drophthalmia, or dropsy of the vitreous humor, and especially
in medullary cancer, in which the eye becomes extruded from
the cavity of the orbit as the disease advances.
The position of the eye, as regards prominence or sinking,
demands attention. Thus protrusion may occur from enlarge-
ment of the eye — as just noticed, from tumors developed
behind it, from infiamraation and turgidity of the surrounding
tissues, from enlargements of the lachrymal gland, from
aneurism, exostosis, or disease of the periosteum. Sinking of
the eye is, on the contrary, a sign of atrophy of the parts
behind the eyeball, and is seen in phthisis, in malignant and
all wasting diseases, after long fasting, or hemorrhages, or
violent evacuations, and fevers. As a rule, both eyes are
equally sunk : if only one be so, some local affection of the
brain, or paralysis of the optic nerve, is the probable cause.
The color of the eye should not be disregarded. Redness
of the conjunctiva is a symptom either of congestion and
inflammation of this tunic, or of congestion or inflamma-
tion of the brain or its membranes. In conjunctivitis,
8*
90 SYMPTOMS AND SIGNS OF DISEASE.
the enlarged vessels are seen generally of a bright scarlet
color, irregularly arranged over the whole of the membrane ;
when the vessels present a dirty brown appearance, a vitiated
state of the blood exists, and the prognosis is unfavorable.
The redness produced by inflammation of the sclerotic is very
characteristic, the turgid vessels being arranged regularly in
a radiated or zonular form, the radii running towards the
edge of the cornea ; the vessels are smaller, also, than in in-
flammation of the conjunctiva, and are seen to lie beneath the
membrane. Sclerotitis is generally due to injury, or to severe
catarrh, occurring in subjects predisposed to — or suffering
from— rheumatism. In iritis there is discoloration of the iris,
— if naturally blue, it becomes greenish ; if dark-colored, of a
red hue,— ^with contraction, irregularity, and immobility of the
pupil ; there is also dimness of vision, sometimes amounting
to blindness ; pain, which is especially severe around the orbit
at night ; and unless care be taken, adhesions are very likely
to form between the pupillary edge of the iris and the capsule
of the lens. A red or dirty gray turbidity at the bottom of
the eye indicates disease of the retina, and often disease of a
malignant character ; change of color from a clear white to a
thick yellow tint in the crystalline lens is a sign of cataract ;
while a greenish discoloration of the pupil is the pathogno-
monic sign of glaucoma.
The circumference of the cornea often undergoes a remarka-
ble change in individuals about the age of forty-five or fifty —
it is very rare before middle age — when, instead of presenting
that translucent appearance so characteristic of its perfect
state, it loses its lustre, and becomes opaque. This change,
so well known as the arcus senilis, comes on gradually, with-
out pain, and without giving rise to any loss of function ; it
also occurs simultaneously in both eyes, except in cases where
local disease or injury may have materially impaired the
nutrition of only one organ. We are indebted to Mr. Canton
for the discovery that this senile arc is due to fatty degenera-
tion of the edge of the cornea, and for the still more important
observation that it may be regarded as indicating a similar
state of decay in important internal viscera, as the heart, the
liver, the kidne}', the muscles, the coats of the small blood-
vessels of the brain, lungs, &o. <' I have in no instance," says
Mr. Canton,* ^' found the senile arc, when well developed, un-
accompanied by fatty degeneration of the heart. The extent
of degeneracy has appeared to me to bear a relation to the
degree to which the cornea was invaded by the deposit."
♦Lnncet, llih January, 1851.
SIGNS PRE SENT ED BY THE EYE. 91
This statement must be received, I believe, with some reserva-
tion, but that it approximates rather closely to the truth, most
practitioners allow; and I would say, therefore, that I should
fear the conversion of other tissues into fat, and their conse-
quent death — so to speak, and that life's forces altogether
were more spent than other appearances might indicate, in
any individual whose corneae presented well-marked senile
arcs. If in addition to the arcus senilis the pulse was feeble
and slow — below 50, and if the affected individual suffered,
also from repeated attacks of syncope, I should be inclined to
diagnose fatty degeneration of the muscular fibx'es of the heart.
The size of the pupil possesses some diagnostic importance.
A contracted pupil is observed in congestion of the brain, in
inflammation of this organ or of its membranes, in some un-
favorable cases of apoplexy and epilepsy, in hydrocephalus, in
inflammation of the retina, and in poisoning by opium. A
dilated pupil — when not due to an obstruction to the entrance
of the rays of light, as by cataract or other causes — is in-
dicative of some disease of the brain, attended with effusion
and pressure, as apoplexy, the advanced stage of hydroce-
phalus, &c. ; or of some sympathetic cerebral disturbance from
gastric or intestinal irritation ; or of amaurosis ; or of the
action of belladonna, or a poison of the same class. When,
during the progress of any cerebral affection, dilatation follows
rapidly upon contraction of the pupil, the occurrence of
eftusion or some organic change is to be feared, especially if
only one pupil be so affected.
The lustre of the eye is generally diminished at the com-
mencement of acute diseases, in all infectious and pestilential
maladies, after exhaustion from any cause, and in all affec-
tions where the nervous system is greatly debilitated. It is
increased in the early stage of cerebral inflammation, in
delirium, and in many forms of insanity, especially acute
mania. A glazed appearance of the eyes is common before
death.
The function of vision is early affected in some disorders.
Photophobia — increased sensibility to light — is observed in
diseases where the sensibility generally is exalted, as hysteria;
in irritation or inflammation of the brain; in inflammation of
the different textures of the eye; and in scrofula. In com-
mencing disease of the brain, or of the optic nerve (leading
to amaurosis), one of the earliest symptoms is generally in-
distinctness of vision — amblyopia ; or objects appear double
— diplopia ; or only one-half of a figure can be distinguished
at a time — hemiopia. In the same cases, scintillations, or
92 SYMPTOMS AND SIGNS OF DISEASE.
sparks or flashes of fire — photopsia — are seen ; or the patient
complains of dark spots, or black figures, or flies — muscae
volitantes — floating in the air.
Lastly, squinting, when congenital or acquired by habit, is
of no importance as regards diagnosis or prognosis ; but when
it occurs in cerebral inflammation, apoplexy, or indeed in the
course of any disease of the brain, it must be regarded as of
very unfavorable import. In paralysis of the third nerve —
which, it may be observed, is often a precursor of hemiplegia
— there is generally, in addition to a falling of the upper
eyelid, squinting of the eyeball outwards.
The Sense of Hearing. — Preternatural acuteness of the
sense of hearing sometimes precedes delirium and affections
of a spasmodic character, especially epilepsy and tetanus ;
when it occurs during the progress of severe diseases, the
prognosis is rendered suspicious, to say the least. The oppo-
site fault — obtuseness of hearing — is moi'e common, and
generally of less significance ; when it occurs in continued
fever, in the exanthemata. Sec, as it often does, it is not a
symptom of much moment. With the deafness depending
upon some physical imperfection in the organ of hearing, the
physician has but little concern ; it is only in instances in
which it has a deeper origin that his attention is excited. In
organic cerebral diseases especially, the occurrence of deaf-
ness must be regarded as an unfavorable sign ; such is also
the case in concussion of the brain, and in epilepsy.
A depravation of the sense of hearing, consisting of peculiar
ringing noises in the ears — tinnitus aurium — often results
simply from excitement of the imagination, and from too
strong throbbing of the arteries about the temple 5 congestion
of the cerebral vessels and morbid states of the brain of every
kind will also produce it. When more or less constant, and
of course supposing it to be independent of disease of the ear
or closure of the Eustachian tube, it has been regarded as a
sign of degeneration of the vessels of the head, and it may
then prove the precursor of apoplexy, or paralysis, or — more
fortunately — merely of epistaxis. Phenomena of a similar
kind are often complained of by aged persons of both sexes
who omit taking exercise in the open air ; and by women
sufiering from nervous exhaustion, anaemia, or disease of the
uterine organs. These annoying sounds are variously com-
pared to the rushing of the wind, the hissing or singing of a
tea-kettle, the beat of a drum, &c.
The Posture and General Condition of the Body. —
Inability to stand results from weakness in a great number of
GENERAL COXDITIOX OF THE BODY. 93
acute and chronic diseases. It may, however, be the conse-
quence of disease of the joints or bones of the lower extremi-
ties, or of paralysis, or of vertigo, as at the commencement of
many acute fevers. Inability to lie down — the necessity of
assuming the sitting attitude — is an important indication in
many disorders of the thoracic viscera. It is often hardly
possible to relinquish the sitting position in simple dyspnoea,
asthma, severe bronchitis, advanced phthisis, pleurisy with
copious effusion, pneumonia, and in many instances of
organic disease of the heart. In less urgent examples of
these affections the sufferer obtains ease in a semi-supine
posture, the shoulders and head being elevated by pillows. In
extreme cases of asthma, the patient is often obliged to lean
forwards, and place his elbows or arms on the window-ledge,
in order to procure a fixed point for a stronger contraction of
the muscles of respiration.
A constantly retained position on the back is common in
low fevers, and in the last stage of acute maladies, when the
vital powers are thoroughly exhausted ; there is often at the
same time unconsciousness, or coma, or low muttering
delirium, indicating extreme exhaustion of organic nervous
power. When this position is long retained, great attention
to cleanliness, and a water-bed or cushion, will be required to
prevent ulceration and gangrene of the skin over those parts
of the back most pressed upon.
The supine position, with the knees drawn up, so as to
relax the abdominal integuments, indicates peritonitis, or,
less frequently, inflammation of some of the viscera within
the abdomen. Lying on the abdomen, and tossing from the
prone to the supine posture, is observed in severe colic, during
the passage of gall-stones, &c.
A quiet position in lying down, with perfect consciousness
and strength, is a favorable sign in disease, showing that the
morbid processes are terminating. In acute rheumatism,
however, the patients lie quiet, owing to the pain caused by
any movement. A restless mode of lying down yields an
unfavorable prognosis in thoracic inflammations, in rheu-
matism, and in most organic diseases. Lying on the right
side is often preferred in health, and especially in pneumonia
of the right lung, or in pleurisy with effusion of the same
side, afler the acute and more painful symptoms have sub-
sided. Patients wish to lie on the left side in many organic
diseases of the heart, sometimes in aneurism of the thoracic
aorta, and in pneumonia or pleurisy of this side with effusion,
af\.er the pain has ceased. In the early stages of pleurisy of
94 SYMPTOMS AND SIGNS OF DISEASE.
either side the affected person mostly lies on his back, with
an inclination perhaps towards the affected side.
The nutrition of the body should always attract attention.
When there is emaciation, and it is rapidly increasing in
degree, we may feel certain of the existence of severe consti-
tutional disorder. In organic diseases of the lungs, heart, or
digestive organs, emaciation is always present: so also in
those affections attended with morbid discharges, as well as
in low, continued, remittent, and hectic fevers. A redundant
flow of milk — galactia — in women who are suckling, will give
rise to wasting. When some of the secretions are so increased
as to be exhausting, they are spoken of as colliquative, as
colliquative sweats, colliquative diuresis, &c. Arrest of the
progress of emaciation, and a more or less marked restoration
of the flesh, is always a very favorable symptom, especially if
at the same time there be an increase in strength. A sudden
tendency to become corpulent, without any change in the
habits and mode of living, must be viewed with some sus-
picion, such tendency being often a forerunner of apoplexy.
Care must be taken not to confound increased size, occasioned
by the deposition of fat, with serous infiltration and em-
physema.
Serous infiltration of the face and of the upper extremities
is a result of disease of the heart or lungs, rather than of the
abdominal viscera, although one of the earliest circumstances
which attracts attention in Bright's disease is frequently
oedema of the face. (Edema of the lower extremities indi-
cates some difficulty in the return of blood to the centre of
the circulating system, and is therefore most frequently met
with in diseases of the liver, heart, or spleen, or in renal
affections, or in cases where ascites or abdominal tumors
disturb the circulation. In acute diseases with great debilit}',
and in anaemia, partial oedema of the lower extremities and of
the feet often occurs, without rendering the prognosis unfavor-
able, since it rapidly disappears upon the employment of
appropriate treatment.
Coldness of the surface oftlie body often attends sinking of
the general strength, and when extreme and attended with
cold sweats, generally teaches that the fatal stage of disease
is approaching ; this is well seen in the state of collapse in
cholera. Chilliness, shivering, horripilation, or rigors, with a
remarkable feeling of coldness along the spine, usher in most
of the febrile and inflammatory affections, just as increase of
heat follows on the reaction of the vascular system. Shiver-
ing, when it occurs in intermittent fevers, is not a dangerous
THE TEETH AND GUMS. 95
symptom : when it takes place during the course of inflam-
mations, suppuration is to be dreaded. Rigors also, at the
height of such acute diseases as are associated with great
depression, stupor, or cold sweats, are bad ; they are much
less unfavorable when followed by heat.
A harsh, dry, burning heat of the bochj is always unfavor-
able, but especially so in inflammatory affections of important
viscera : if at the same time a sense of internal heat is ex-
perienced, with coldness of the feet and lower extremities,
restlessness, and anxiety, there is a great fear of a rapidly ap-
proaching fatal termination.
A perspirable condition of the skin is, in the majority of
cases, a favorable symptom, and more so when it arises natu-
rally than when due to medicine. On the supervention of the
sweating stage in ague, remarkable relief is experienced, as
occurs generally in most fevers, inflammations, and especially
in rheumatic fever.
SECTION 2. SYMPTOMS BELONGING TO THE ORGANS AND
FUNCTIONS OF DIGESTION.
The symptoms and signs furnished by the digestive func-
tions and organs comprise those evinced by the teeth and
gums, by the saliva, by the tongue, by the taste, by degluti-
tion, by the appetite, by jaundice, by nausea and vomiting,
and by defecation.
The Teeth and Gums. — In persons of good constitution
the teeth are often found sound and perfect until an advanced
period of life: their early decay indicates either prolonged
disturbance of the function of digestion, or loss of constitu-
tional strength, or constitutional vice, or the abuse of power-
ful medicines, as acids and mercurials. They become loose
in scurvy, purpura, and in mercurial salivation ; while impro-
per diet — especially the abuse of spirituous liquors, of acids,
and perhaps of sugar, renders them carious at an early age.
In low fevers they become covered with mucus and sordes of
a dark brown color, the extent of the sordes increasing with
the depression of the vital powers. The accumulation of
tartar round the teeth is said to show a disposition to calcu-
lous and gouty affections. Chattering of the teeth occurs in
the early stages of catarrh, fever, and acute inflammations
generally : it is most marked in the cold stages of agues.
Grinding of the teeth during sleep is common in irritable
persons, and in children during dentition, or when suffering
from intestinal worms, or from cerebral disease.
96 SYMPTOMS AND SIGN'S OF DISEASE.
The gums are pale in anasmia, in most exhausting diseases,
and after copious bloodletting. They are soft and disposed
to bleed in scurvy, and in cancrum oris. They become red,
spongy, and swollen in purpura, diabetes, salivation, and in
dyspepsia of long continuance. In lead poisoning they pre-
sent a blue margin ; a valuable symptom pointed out by the
late Dr. Burton as pathognomonic of the contamination of the
system by this metal.
The Saliva. — Increased secretion of saliva — salivation or
ptyalismus — may occur from the use of certain medicines, as
mercury, iodine, and antimony ; from disease of the stomach,
liver, or pancreas ; and from any cause which can irritate the
parotid, submaxillary, or sublingual glands, or the mucous
membrane of the mouth, as dentition, aphthae, small-pox, pus-
tules, glossitis, tonsillitis, &c. In epilepsy, hydrophobia, and
occasionally in apoplexy, the saliva is also increased in quan-
tity, and frothy ; while at the commencement of most acute
disorders there is diminution, with thickening of it.
The Tongue. — The general indications afforded by the
tongue are most important, since it not only sympathizes with
the different parts of the alimentary canal and the organs con-
nected with it, but more or less with the whole system.
The mode of protruding this organ deserves attention.
When in acute febrile diseases its movements are not under
the patient's control ; when, upon being requested to put out
the tongue, there is inability to do so ; or when the organ
trembles much in the attempt, there is either great prostra-
tion, or some exhausting nervous disorder, or dangerous cere-
bral disease. Under the same circumstances, a difficult, hesi-
tating mode of speaking, resembling stammering, is very un-
favorable. Slight paralysis of the muscles of the tongue, giv-
ing rise to indistinctness of speech, is not unfrequently the
forerunner of general palsy. In chorea, the manner of sud-
denly protruding and as rapidly withdrawing the tongue is
very peculiar. In cases of facial paralysis, and especially in
hemiplegia, when the ninth nerve is influenced by the paralyz-
ing lesion, the tongue will be protruded towards one side, and
generally towards the affected half of the body ; this is owing
to the muscles which protrude this organ being paralyzed on
that side, and in full force on the opposite, so that the strong
muscles prevail and push the tongue to the weakened part.
The hulk of the tongue may be increased or diminished.
It may become enlarged from inflammation, or as a result of
small-pox, scarlatina, syphilis, or the action of mercury or
THE TONGUE. 97
poisons. Chronic hypertrophy sometimes takes place without
any appreciable cause. When the enlargement of this organ
is not sufficient to be very obvious, it may be frequently recog-
nized by the appearance of indentations on the sides, caused
by the pressure of the teeth : at the commencement of saliva-
tion such an appearance is common. Actual diminution in
the size of the tongue is rare ; when it occurs it is probably
due to a deficiency in the quantity of the blood, or to feeble-
ness of the heart's action.
The condition of the tongue as to dryness and moisture is
often significant. Dryness may exist in different degrees. It
depends on a deficiency of saliva, or of mucus, and indicates
a general tendency to diminished secretion : it is most common
in continued fevers, in the exanthemata, in inflammation of
the abdominal viscera and the serous membranes, and in
many other diseases of an acute and febrile nature. "When
the tongue, after having been furred and loaded, becomes diy,
rough, hard, and dark-colored, a state of great and most dan-
gerous prostration is indicated, with contamination of the
blood, and suppression of the secretions. Humidity or mois-
ture of the tongue is generally a favorable symptom, especially
when it supervenes upon a dry or furred condition. In acute
disorders the humidity first appears at the sides, and gradu-
ally extends : this change is usually accompanied with a dimi-
nution in the severity of the general symptoms.
The color of the tongue is often changed from the natural
healthy hue. A pale color is frequently associated with a
similar appearance of the gums and lips, and is seen in
anaemia, after loss of blood, in affections of the spleen, and
during the progress of chronic disorders. A very red tongue
occurs for the most part in inflammations of the palate, tonsils,
and pharynx, and in the course of the exanthemata ; while in
gastric and bilious fevers, and in severe dyspepsia, the redness
is often limited to the tip and edges of the organ. When the
blood is insufficiently aerated the tongue assumes a livid or
purple color.
An aphthous state of the tongue is not uncommon in in-
fancy, when it constitutes a special disease — the thrush — as well
as in adults in the last stage of phthisis, and in several other
severe visceral diseases when tending towards a fatal termina-
tion. Some forms of aphthae are said to depend upon the
copious development of microscopical parasitic plants — the
Leptothrix huccalis and the Oidium albicans.
The temperature of the tongue is not often much affected.
It is probably diminished in all diseases hastening to a fatal
9
98 SYMPTOMS AND SIGNS OF DISEASE.
termination: in the collapse of epidemic cholera the coldness
of the tongue is always well marked.
But of all the conditions of this member, the most valuable,
as regards diagnosis, is that known as a furred tongue. In
this state the tongue is covered with a morbid coating, varying
in length, thickness, and color, and somewhat resembling the
pile on the surface of cotton velvets. A furred condition of
this organ is common in inflammations, in irritation of the
mucous membranes, in diseases of the brain and its mem-
branes, in all the varieties of fevers, and in short, in almost all
acute and dangerous maladies. The presence of a fur, how-
ever, is not always a sign of disease, since some persons
habitually have a coated tongue, especially on rising in the
morning, without any symptom whatever of disordered health.
When the fur is white, thick, moist, and uniform, it usually
indicates an active state of fever, without inflammation of in-
ternal organs, and without any malignant tendency. When of
a yellow hue, there is generally disordered action of the liver,
with retention of bile in the blood. When brown or black, a
low state of the vital powers is indicated, with contamination
of the blood. In many instances the white fur of the tongue
is modified by the tops of the red and swollen papillae project-
ing through it, an appearance which is well seen in scarlet
fever •, as the fur clears away, these papillae become more dis-
tinct, and give the tongue a strawberry appearance.
We may often learn much from the manner in which a
furred tongue begins to clean. Thus it is a sign of a rapid
and lasting convalescence when the fur slowly retires from the
tip and edges, thinning gradually as it recedes. When it
separates in flakes and patches, beginning at the middle or
near the root of the organ, and leaving a smooth, red, glossy
surface, the convalescence is apt to be more tedious and in-
terrupted. Sometimes the fur recurs again and again before
ultimately disappearing, especially in cases where the advance
towards health is uncertain and unsteady. And lastly, when
the crust is rapidly removed, and the exposed surface left of a
raw appearance, or glossy, or fissured, or dark-colored, the
prognosis is unfavorable.
The Taste. — The sense of taste is rarely rendered more
acute than natural, though it is so occasionally in nervous
affections, as hysteria, hypochondriasis, &c. It is often im-
paired in fevers, gastritis, gastro-enteritis, dyspepsia, catarrhs,
and influenza : its early restoration in such cases is a favorable
symptom. When lost from apoplexy, or some other cerebral
disease, and when not restored during convalescence, a re-
APPETITE AND DESIRE FOR DRINK. 99
lapse is to be dreaded. A vitiated taste is common in disor-
ders of the digestive organs, in affections of the lungs, in dis-
eases of the uterus, and in all nervons complaints : it may be
insipid, as in catarrhs ; or bitter, as in diseases of the liver ;
or saltish, as in phthisis ; or putrid, as in gangrene of the
lungs ; or metallic, as is occasioned by the action of metals on
the system, such as mercury, &c.
Deglutition. — This may be difficult — dysphagia; or im-
possible — aphagia. Both conditions may arise from enlarge-
ment of the tonsils, disease of the tissues, of the pharynx, or
of the oesophagus, or from disease of the brain, medulla ob-
longata or their membranes, and from structural changes in
the nerves distributed to the tongue, pharynx, or upper part of
the oesophagus. When the result of functional nervous dis-
order, as in hysteria, it is generally accompanied with spasms
in other parts, or with flatulent distension of the stomach, and
a sensation as of a ball rising in the throat — globus hystericus ;
in such cases it is of little moment. The prognosis is more
unfavorable when dysphagia occurs towards the termination of
acute diseases, than when it does so at their commencement;
when dependent upon paralysis or upon organic disease, it is
also a very unfavorable symptom. Aphagia, unless caused
by inflammation, is generally fatal.
The Appetite and Desire for Drink.— The appetite may
be diminished, or increased, or depraved. The temporary loss
of desire for food is one of the earliest results of disease, es-
pecially perhaps of fever, while its return is commonly one of
the first evidences of convalescence. The perfect loss of ap-
petite — anorexia — may depend upon the general disturbance
caused by all acute diseases ; or upon there being but little
necessity for food, as in aged persons, and in those of weak
constitution and sedentary habits; or upon malignant or
chronic disease of the stomach or some other part of the ali-
mentary canal ; or upon functional derangement of the nervous
system. Increased appetite — bulimia — more rare than the
preceding, is occasioned either by an increased want of nu-
trition from excessive consumption of the living tissues or of
the blood; or it may arise from irritation of the stomach, or
from the irritation of worms in the intestines, or from disease
of the nervous system. The existence of hunger during the
progress of fever is generally considered a bad sign, as indi-
cating great derangement of the nervous system. A voracious
appetite with vomiting — the bulimia emetica of Cullen — is
common in certain forms of inflammatory irritation of the
pylorus or of the mucous membrane of the stomach, and in
100 SYMPTOMS AXD SIGNS OF DISEASE.
hooping-cough. A vitiated or depraved appetite — pseudorexia
or dyspepsia pica — sometimes occurs in children, often in the
insane, and in pregnant, hysterical, and chlorotic women. It
is generally symptomatic of altered sensibility of the nerves ;
or of a disordered condition of the gastric secretions dependent
upon imperfect function ; or of an irritated state of some organ
related to the stomach, as the brain, uterus, ovaries, and large
intestines.
The desire for drink is frequently morbidly excessive — poly-
dipsia — and is often present when the appetite for food is
completely lost. Thirst may arise from excitement or from
depression ; it accompanies most cases of inflammation and
irritation, almost all diseases of the intestines, hemorrhages,
and those disorders where the excretions are excessive — as
diabetes, phthisis with profuse perspiration, simple and ma-
lignant cholera, &c. There is often the most pressing thirst
for ice or cold water in fevers as well as in all malignant forms
of disease attended with great prostration ; for demulcent
drinks in pulmonary affections ; for vinegar or acidulous fluids
in disorders of the uterine organs ; and for alcoholic drinks in
diseases of debility, and during the convalescence from fevers.
In the majority of chronic maladies there is an absence of
thirst.
Jaundice. — Icterus or jaundice, though often spoken of as
a separate disease, is in fact only a symptom of disordered
action of the liver. It may be produced in two ways : 1st, by
some impediment to the flow of bile into the duodenum, and
the consequent absorption of the retained bile ; and, 2d, by
defective secretion on the part of the liver, so that the princi-
ples of the bile are not separated from the blood.
The most common impediment to the flow of bile into the
duodenum is the impaction of a gall-sione in the ductus com-
munis choledochus. These concretions consist of inspissated
bile, and chiefly perhaps of cholesterine — a peculiar sub-
stance, which exists in a state of solution in healthy bile, but
which, under certain circumstances, becomes released from
its solvent, and assumes its natural crystalline form. In all
cases the nucleus of the concretion consists of a small piece
of solid biliary matter, or of inspissated bile cemented by
mucus. When the obstructing stone or stones have passed
into the duodenum they are voided with the faeces, and the
cause of the jaundice being removed, the skin and conjunc-
tivae gradually assume their natural color, the fasces become
dark instead of clay-colored, and the urine — from having
been of a safiron hue — returns to its natural pale yellow tint.
NAUSEA AND VOMITING. 101
The other causes of jaundice from obstructed gall-ducts are,
cancer of the liver or pancreas, closure of the ducts from adhe-
sive inflammation of the liver, from spasm of the ducts, and
from constipation — the loaded intestine pressing upon the
duct, and so impeding the flow of bile.
The secretion of bile may be suppressed or rendered defec-
tive by congestion and inflammation of the liver ; by mental
shocks, or grief, or dissipation ; by certain poisons in the
blood ; and by many disorders of the stomach.
Nausea and Vomiting. — Nausea commonly precedes
vomiting, and may be due to improper food, or to a disordered
state of the digestive organs — especially the stomach, or to
disease of the brain, or to some derangement of the nervous
system. Disease of the gastric or intestinal mucous mem-
brane, cancer of the stomach, obstruction of the intestines,
peritonitis, nephritis, metritis, and most of the exanthema-
tous fevers, are common causes of vomiting; when long con-
tinued, or when the vomited matters are fajcal, the prognosis
is very unfavorable. Nausea and vomiting accompanying
diseases of the brain or epilepsy, must be regarded as
dangerous symptoms ; on the contrary, when observed in
pregnancy, hysteria, or hypochondriasis, no alarm need be
excited, since they are merely symptomatic of irritation
transmitted by the ganglionic nervous system to the stomach.
When, in cases of encephalitis, nausea and vomiting are the
earliest symptoms, observation has shown we may conclude
that the inflammation has commenced in the cerebral pulp
rather than in the membranes of the brain : when, on the
contrary, the attack comes on with a sudden fit of convulsion,
the inflammation has commenced in the arachnoid or pia
mater. If considerable relief follow the vomiting, if the
loathing and nausea, oppression of the chest and stomach,
and headache disappear, the prognosis becomes much more
favorable. If, on the contrary, the phenomena which pre-
ceded the vomiting increase after it, and especially if eructa-
tions, hiccough, and spasms ensue, we must be prepared to
find that the disease has taken a dangerous turn. The sooner
the vomiting occurs after eating, the higher up in the alimen-
tary canal is the disease seated. Thus when it takes place
within one hour of taking food, the disease will be found in
the stomach ; when after the lapse of two or three hours, in
the pylorus or duodenum ; and after a longer interval, in the
large intestines. For the examination of the vomited matters,
see Chapter XL, Section 3.
Defsecation. — The examination of the intestinal evacua-
9*
102 SYMPTOMS AND SIGNS OF DISEASE.
tions should but seldom be omitted in any case, and never in
obstinate and severe diseases. A patient will often assert
that the bowels are open daily, when the evacuation is very
scanty, and quite insufficient to prevent a large fsecal accumu-
lation. Besides ascertaining the existence or non-existence of
constipation, the practitioner should ascertain the color of the
stools, their consistence, and nature.
The frequency of the evacuations will vary with the age
and mode of living : children at the breast evacuate the
bowels several times in the day ; adults once ] and old
people, and those of sedentary habits, more rarely. Diarrhoea
at the commencement of an acute inflammation of some
organ not belonging to the chylopoietic system, is generally^
an unfavorable symptom, as well as when relaxation of the
bowels sets in with collapse. If, however, the diarrhoea is
followed by alleviation of the general symptoms, and if the
strength increases, the prognosis is good. Tenesmus, or a
constant desire to go to stool, with pain and inability to pass
an evacuation, is a common symptom of dysentery, or of
some irritation of the rectum — such as arises from worms,
hemorrhoids, calculus of the bladder, retroflexion of the
uterus, &c.
Constipation may arise from a general morbid state of the
intestinal canal, such as is often produced by the habitual use
of purgatives, or from the commencement of inflammation of
some part of the intestines •, from disease of the liver ; from a
want of contractile power in the coats of the rectum ; from
some mechanical obstruction preventing the progressive
motion of the contents of the tube ; or, lastly, from organic
or inflammatory disease of the brain or spinal cord, or their
membranes.
SECTION 3. SYMPTOMS BELONGING TO THE FUNCTION
OF KESPIRATION.
These symptoms are of great importance, not only in refer-
ence to diseases of the organs of respiration, but also in
respect to many other maladies to which the human frame is
liable ; especially perhaps in regard to the diagnosis of
diseases of the heart and large vessels, diseases of the brain,
abdominal viscera, and certain febrile and constitutional dis-
orders. I shall first make a few remarks upon the function of
respiration, and then speak of the symptoms to be derived
from dyspnoea, orthopnoea, the odor of the breath, the tempe-
rature of the expired air, cough, hiccough, expectoration,
stertor, yawning and sighing, and, lastly, sneezing.
DYSPXCEA. 103
The various and highly important physical signs of pulmo-
nary disease made evident by auscultation, percussion, mensu-
ration, palpation, &c., will be discussed in another part of this
work, when treating of the diagnosis of the special diseases
of the lungs.
The Respirations. — In judging of the signs derived from
the character of the respirations, it must be remembered that
this function is remarkably influenced or modified not only by
disease, but also by age, sex, temperament, the sleeping and
waking states, mental emotions, the position of the body, and
the temperature and pressure of the air. Every respiration
consists of an inspiration and an expiration, each occupying
nearly equal spaces of time, the duration of inspiration
slightly predonderatiug over that of expiration. In the
healthy adult the act of respiration is performed almost
automatically, about eighteen times in a minute, or once for
every four beats of the heart; in women and children the
respirations are quicker and louder, averaging in the latter
about twenty-five in a minute. The number of respirations
is also less during the sleeping than the waking state ; in the
recumbent position, than in the sitting ; and in the sitting,
than in the erect posture. When, however, a part of the
lungs is rendered unfitted for performing its office, or when
too great a quantity of blood is sent to the lungs for decar-
bonization, the frequency of the respirations becomes in-
creased, this frequency varying until — in very unfavorable
cases — it even reaches sixty in the minute. When, from any
cause, a pause of three minutes takes place in the play of the
lungs, death is said to result.
Dyspnoea. — This term literally signifies difficult breathing,
a condition which arises when, from any cause — either de-
rangement of function or change of structure — the proportion
between the quantity of atmospheric air that reaches the
lungs, and the quantity of blood that is sent to them from the
right side of the heart to be arterialized, is altered. When
the dyspnoea is permanent, the prognosis will be very unfavor-
able : the greater its degree also the more there is to fear,
although it is not always directly proportioned to the organic
change.
The conditions leading to this alteration are numerous and
diversified. Thus the blood itself may be in such an un-
healthy condition that its circulation becomes impeded, as in
malignant cholera ; or it may become congested in the pul-
monary capillaries, and so retard the circulation, and, at the
same time, hinder the entrance of air into the pulmonary cells ;
104 SYMPTOMS AND SIGNS OF DISEASE.
or it may be sent too quickly to the lungs, as in fever and in-
flammation. So also the fault may be in the air, which may
be too much rarefied, or may have poisonous gases mingled
with it, and be thus rendered unfit for aerating the blood.
Different diseases of the lungs, giving rise to consolidation, or
compression, or destruction of the pulmonary tissue, or load-
ing the bronchial tubes and air-cells with liquid, will shut out
the air. Pneumonia, bronchitis, pulmonary hemorrhage,
phthisis, pleuritic effusion, the presence of air in the pleura,
pericarditis with effusion, and aneurismal or other tumors
within or pressing upon the thorax, will operate in excluding
the air from portions of the lungs ; and consequently the re-
spirations will be augmented, in order that the sound pul-
monary tissue may counterbalance, by increased work, the
loss of function in the diseased part. Constriction of the air-
passages by spasm — as in asthma, or by the presence of
tumors ; obstruction of the trachea by false membranes — as
in croup ; or great swelling of the tonsils ; or inflammation of
the glottis, will all impede the entrance of air to the lungs,
and give rise to dyspnoea. The pulmonary branches of the
par vagum constitute the principal and constant excitor, as
the nerves that supply the muscles of respiration — the phrenic,
intercostal, spinal accessory, long thoracic, and the branches
of the spinal nerves supplying the abdominal muscles — are
the motor links of the nervous chain by which the automatic
respiratory movements are governed. Hence disease in these
nerves, or in the parts of the nervous system from which they
arise, produces disorder in the function they govern, of the
most serious kind. The ultimate branches of the par vagum
being distributed over the stomach, accounts for the connec-
tion which so frequently exists between dyspnoea, dyspepsia,
and functional derangement of the heart. And, lastly, disease
of the muscles of respiration themselves, gives rise to dys-
pnoea ; the healthy muscles being stimulated to excessive
action, in order to compensate for the loss of power in those
afifected.
Healthy inspiration is performed with ease and freedom, and
is effected by a nearly equal elevation of the ribs, a turning of
their bodies outwards — by which the horizontal and antero-
posterior diameters of the thoracic cavity are enlarged, and a
depression of the diaphragm ; in women the respiration is
more costal and less diaphragmatic than in men. Ordinary
expiration is the natural return of the thoracic cavity to its
size during rest, owing to the weight and elasticity of its walls ;
the diaphragm becomes relaxed, and ascends into the chest ;
' ODOR OF THE BREATH. 105
the abdominal muscles, which had been protruded, return to
their natural position ; and the costal cartilages, which had
been rendered tense by the act of inspiration, bring their
elastic properties into play, and, aided by the resiliency of the
lung, combine to produce a general diminution of the thoracic
cavity. In certain forms of dyspnoea, however, the respiratory
exertion is more perceptible in one part than in another, and
authors therefore speak of abdominal, thoracic, and cervical
respiration. In ahdominal respiration the abdomen rises and
falls considerably, the diaphragm being chiefly exerted, while
the ribs remain motionless. It occurs when the thoracic
movements are rendered painful by pleurisy, or fracture of the
ribs ; and also in apoplexy, and in cases of extreme prostra-
tion when an insufficient supply of blood is sent to the brain.
The thoracic respiration, with suppression of the abdominal
movements, indicates obstruction to the free action of the
diaphragm, such as may arise from enlargement of the liver
or spleen, from an over-distended stomach, ascites, ovarian
dropsy, a very enlarged uterus, [&c. ; it also occurs in peri-
tonitis, when each movement of the abdominal parietes in-
creases the general distress and the local pain. And, lastly,
the cervical respiration — when each inspiration is efiFected with
considerable exertion of the superior ribs, the sterno-mastoids,
and other muscles of the neck — indicates that higher grade of
dffficult breathing so often seen in advanced stages of pul-
monary or cardiac affections, and in obstructive disease of the
larynx.
Orthopncea. — Orthopnoea is said to exist when the de-
rangement of the respiratory function is so great that the suf-
ferer cannot lie down, but can only respire in the erect
posture ; in which position greater freedom is allowed for the
expansion of the chest, and all pressure upon the diaphragm
by the abdominal viscera .is removed. This variety of dys-
pnoea is often witnessed in asthma, in certain stages of hydro-
thorax, in general dropsy, and in diseases of the abdominal
viscera. In asthma, the paroxysms of difficult breathing are
frequently so severe, that a person unacquainted with the
nature of the disease would suppose the sufferer to be at the
point of death 5 yet the attacks are seldom attended with im-
mediate danger, and often rapidly pass away.
The Odor of the Breath is subject to great variation,
being sweet and agreeable in perfect health ; foul and un-
pleasant in disorder of the digestive organs, in scurvy, malig-
nant sore throat, &c. ; and generally peculiarly faint at the
time of the flow of the catamenia. During the progress of the
lOG SYMPTOMS AND SIGNS OF DISEASE.
exanthematous, typhoid, and pestilential fevers, it is disagree-
able and infectious; but in no disease is it so bad — so over-
poweringly offensive — as in gangrene of the lung, which may
be almost diagnosed from the putrid odor of the breath alone.
The Temperature of the Expired Air.— In fevers, in
sthenic inflammations of the bronchial tubes, lungs, or pleura,
and in most inflammatory disorders during their early stages,
the temperature of the expired air will be found raised more
or less above the natural standard ; while, on the contrary, it
is lowered in all malignant and depressing affections, as in
the last stages of fever, in suffocative catarrh, and the collapse
of cholei'a.
Cough. — A common symptom in diseases of the chest is
cough, which may be defined as an abrupt, loud and violent
expiration, accompanied by a contraction of the glottis, tra-
chea,- and larger bronchial tubes; having for its object the
expulsion of a foreign body, the presence of which is irritating
the air-passages. It may therefore often be regarded as con-
servative — as an effort of nature to expel something from the
air-passages or lungs which should not be there. This is not
always the case, however ; since if, in any way, any portion of
the vagus nerve above the part where the pulmonary branches
are given off be irritated, cough will result.
There is a great diversity in the character of the cough,
which has received names corresponding with its peculiarities.
Thus, we have the dry cough, so often resulting from exposure
to cold, the inhalation of acrid or acid fumes and gases, the acci-
dental passage of foreign substances into the trachea, the irrita-
tion of the glottis by an enlarged uvula, and so on. Many hys-
terical, weak, nervous women, also, suffer frequently from a dry
barking cough — more painful to the bystanders than the indi-
vidual who utters it — without any appreciable cause. A dry
hoarse cough is often one of the earliest symptoms of severe
affections of the larynx, trachea, or lungs ; of organic disease
of the heart, or of the large thoracic blood-vessels ; and some-
times of an irritated condition of the mucous surface of the
stomach and oesophagus, of inflammation of the liver, and of
obstruction of the gall-duct; in the latter case, however, the
cough is generally spasmodic, recurring from time to time in
severe paroxysms. The moist or humid cough may follow the
preceding, or may occur primarily from any of the causes of
common catarrh. In old people it is a frequent sign of chro-
nic bronchitis ; and many delicate persons suffer yearly from
winter cough, with excessive secretion of mucus, and relaxation
of the vessels of the air-passages.
EXPECTORATION. 107
According as each paroxysm consists of one cough, or of a
series of them, so a different condition is denoted. The oc-
currence of a single sharp cough is common in pleurisy, in
the first stage of pneumonia, and in the early or crude stage
of tubercular deposit. On the contrary, the cough recurs in
paroxysms of some duration, in croup, hooping-cough, asthma,
bronchitis, emphysema of the lungs, phthisis with tubercular
cavities, diseases of the heart, and in cerebral irritation. In
many of these cases, moreover, the fits of coughing come on
in unequal paroxysms ; severe exacerbations being especially
frequent towards the morning, and less common as the evening
approaches.
Hiccoug'h. — Singultus, or hiccough, may be defined as an
uneasy sensation at the praecordia, with a spasmodic, rapid,
but momentary contraction of the diaphragm and other respi-
ratory muscles, occurring at short intervals and causing a
loud, frequent, and slightly painful inspiration. It is fre-
quently produced in infants, young children, and aged people,
by any slight irritation of the stomach or duodenum ; mental
emotions, as laughter or crying, as also uterine irritation, often
give rise to it in hysterical or pregnant women ; inflammation
of the liver, or diaphragm, or pancreas, or cardiac orifice of
the stomach will cause it; tumors pressing upon the eighth
pair of nerves may originate it ; and, lastly, it is common to-
wards the fatal termination of many acute diseases, fevers,
and hemorrhages, when it forms an important — because very
unfavorable — symptom.
Expectoration. — Expectoration is the act of discharging,
by coughing, hawking, or otherwise, the secretions or fluids of
the fauces and air-passages. The sputa are evacuated or ex-
pectorated with ease or difficulty, according to the nature and
stage of the disease, the age and strength of the patient, and
the viscidity or fluidity of the expectoration. An easy expec-
toration is usually regarded as favorable in all diseases of the
respiratory organs. In children, the sputa are generally swal-
lowed.
A difficult expectoration of viscid sputa, at the commence-
ment of any pulmonary affection, is of no unfavorable import;
but it becomes so, in an advanced stage of disease, whether
the cause be want of secretion, or too little power to discharge
it when formed. In gangrene of the lung, in the chronic
bronchitis of aged people, and in phthisis as death approaches,
the morbid secretion accumulates, is expectorated with greater
difficulty, and the weakness increasing, the functions of the
lungs become impeded, and ultimately arrested.
108 SYMPTOMS AND SIGNS OF DISEASE.
jPor the chemical examination of the sputa, and the signs to
be derived from their r/eneral appearance, d'c, see Chapter ^L,
Section 2.
Stertor. — Stertor, or stertorous breathing, is merely tbat
form of respiration in which each inspiration is attended with
deep snoring. It occurs during the insensibility following an
attack of apoplexy ; in compression of the brain from fracture
of the skull, and in many other cerebral diseases ; and in cases
of coma, a condition in which the functions of organic life —
and especially the circulation — continue in full force, while
the functions of animal life — with the exception of the mixed
function of respiration — are suspended.
Yawning and Sighing".— These are nearly related phe-
nomena, consisting of prolonged and deep inspirations, with
short and strong expirations ; and indicating fatigue from
nervous exhaustion and weariness, or the depression arising
from ungratified mental desires. Yawning is generally a sign
of mental vacuity and fatigue ; sighing, of mental depression
and sorrow. Yawning is often a troublesome and, generally,
an unfavorable symptom after an attack of hemiplegia ; it
comes on when the first effects of the shock are subsiding, and
is troublesome in proportion to the severity of the shock.
Sneezing. — Sneezing — sternutatio — is produced by a deep
inspiration, followed by a violent, loud, convulsive expiration,
whereby the air is driven rapidly through the nasal fossae, car-
rying with it the mucus and foreign bodies adhering to the
Schneiderian membrane. Anything which stimulates the
nasal mucous membrane will cause sneezing. It is commonly
occasioned by common catarrh, or by disease of the respira-
tory organs ; it is sometimes a sympathetic phenomenon in
hysteria, and in irritation of the intestinal canal from worms,
&c. Accompanied by vertigo and tinnitus aurium, it some-
times precedes or ushers in a fit of apoplexy, or an attack of
paralysis.
SECTION 4. SYMPTOMS BELONGING TO THE FUNCTION
OF CIRCULATION.
The morbid affections of the function of the circulation are
observed chiefly in palpitations of the heart and large vessels,
in the pulse, in the condition of the capillaries, in certain
symptoms derived from the venous system, and in the state of
the blood.
Palpitations of the Heart and Large Vessels.— In a
state of health we are not generally sensible of the beating of
THE PULSE. 109
our hearts ; but when the pulsations become much increased
in force or frequency, the distressing sensation known as pal-
pitation is experienced. Increased action of the heart results
from many conditions, both from slight effects — as violent
exertion and mental excitement, as well as from severe causes
especially such as give rise in any way to obstruction of the
circulation. In enlargement of the heart with thickening of
its parietes, there is palpitation, and the pulsations of the
carotids and other large arteries are violent, and painfully felt.
So, in atrophy of the heart with thinning of its walls, this
organ beats more feebly than in hypertrophy, but the pulsa-
tions spread over a greater extent of surface ; the beating of
the large vessels is not felt. There is also more or less palpi-
tation when the circulation becomes deranged from disease of
the lungs; as in pneumonia during the stage of hepatization,
in severe bronchitis, in hydrothorax, pleurisy, pneumothorax,
asthma, laryngitis, &c.
Palpitation is a common symptom in hysteria and other
nervous disorders ; and a more common symptom still, is a
feeling of '' fluttering " at the heart, and in the region of the
stomach, with throbbing of the temporal arteries. A sensa-
tion of pulsation in the epigastric region is often connected
with imperfect digestion in irritable constitutions, and gives
rise to great distress. A similar pulsation is experienced in
aneurism of the aorta, or when any tumor lies over this vessel.
But the most extraordinary degree of palpitation and of morbid
pulsation in the large arteries is observed in instances of ex-
haustion from the loss of blood. In a case of flooding after
parturition, which occurred in my own practice, the patient
complained much of her suflerings in this respect, and stated
that she could feel every artery in her body beat, until her
condition was relieved by the free employment of stimuli.
The Pulse. — In examining the pulse, there are a few brief
practical rules which it behoves the physician to bear in mind.
Thus—
1. The pulse should be felt by applying three or four fingers
to the radial artery, as it lies in front of the wrist. After as-
certaining the frequency and equality of the pulse, the fingers
should alternately press upon the artery, and relax the pressure,
so as to appreciate the degree of resistance. The pressure
should be sufficient to allow of the beats of the artery being
distinctly felt, yet not so forcible as to obliterate the pulse,
however weak it may be. The artery at the wrist affords, in
the majority of cases, the most eligible part for ascertaining
the state of the pulse ; still it occasionally becomes necessary
110 SYMPTOMS AND SIGNS OF DISEASE.
to examine the artery near the seat of disease, as, for example,
the temporal artery in cerebral affections.
2. In feeling the pulse of timid, nervous, or excitable per-
sons, great caution and calmness is necessary, in order not to
excite the heart to increased frequency of action. The patient
should be engaged in conversation, so as to divert his attention,
and the practitioner should wait until the first agitation oc-
casioned by his visit has subsided. The indications afforded
by the pulse cannot be relied upon immediately after bodily
exercise, or mental emotion of any kind.
3. The patient should be in the sitting or horizontal position,
unless it be desirable to ascertain especially the effect of
standing. Both wrists should be examined, since the vessel
on one side is sometimes larger than that on the other ; more-
over, the artery sometimes deviates from its natural course, so
that the patient may appear pulseless. Care must be taken
that no pressure is exerted upon the artery in any part of its
course by ligatures, tight sleeves, tumors, &c.
4. The pulse should, in acute cases, be felt more than once
at each visit ; its diversities will be thus positively ascertained,
and the conclusions formed by the practitioner from the first
examination confirmed or corrected.
The pulse is produced by the blood sent into the aorta by
each systole or contraction of the left ventricle of the heart ;
consequently, its nature will depend on the condition of the
arteries, of the blood, and of the heart. In each pulsation the
artery is slightly expanded, and perhaps laterally displaced ;
it then returns to its original size and position, after which
there is an interval of rest. The frequency of the pulsations, and
the regularity or irregularity of their succession must depend
upon the heart. The pulse at the wrist corresponds to the systole
of the ventricles, making allowance for the slight interval that
must elapse before the wave of blood reaches so distant a part.
In the healthy adult male, the pulse may be described as
regular, equal, compressible, moderately full, and swelling
slowly under the finger ; in the healthy female, and in children
of both sexes, it is rather smaller and quicker in the beat. In
individuals of a sanguine temperament, the pulse may be de-
scribed generally as full, hard, and quick ; in those of a ner-
vous temperament, it is softer and slower. In old age, the
pulse assumes a hardness which it would not otherwise possess,
owing to the increased firmness of the arteries.
The pulse has its maximum frequency in early infancy, and
its minimum in robust old age. According to Quetelet,* it
* Sur I'Homme, vol. ii. p. 86.
THE PULSE.
Ill
may be estimated to range in infancy from a maximum of
165 to a minimum of 104, the mean being 135. This agrees
with the conclusions of most authorities iu this country, who
regard it as being — at this period of life — on the average 140.
The average frequency of the pulse in 27 males and 34
females, each sex being of the mean age of 71 years, was
found by MM. Leuret and Mitivie to be, in round numbers,
76.* Dr. Pennock's observations on 170 males and 203 fe-
males, of the mean age of about 67 years, give as the average
75 beats iu a minute.^ A progressive decline from infancy to
old age, with a slight increase during the period of decrepitude,
may be stated as the true law of the pulse. This is well shown
in the following table, by Dr. Guy,^ which presents the num-
ber of the pulse at each quinquennial period throughout the
whole of life. The averages, for the first eight periods, are
founded each on fifty observations, of which half were made
on males and half on females. The average for the period
from seventy-six to eighty is deduced from the same number
of facts similarly divided ; while, for most of the other periods,
the averages are derived from forty observations — twenty on
males and twenty on females.
Age.
Max.
Min.
Mean.
Range.
2 to 5
128
80
105
48
5 — 10
124
72
93
52
10 — 15
120
68
88
52
15 — 20
108
56
77
52
20 — 25
124
56
78
68
25 — 30
100
53
74
47
30 — 35
94
58
73
36
35 — 40
100
56
73
44
40 — 45
104
50
75
54
45 — 50
100
49
71
51
50 — 55
88
55
74
33
55 — 60
108
48
74
60
60 — 65
100
54
72
46
65 — 70
96
52
75
44
70 — 75
104
54
74
50
75 — 80
94
50
72
44
80, and upwards,
98
63
79
35
» De la Fr6quence des Pouls. chez les Ali6n6s.
• Note on the Frequency of the Pulse and Respiration of the Aged.
"[American Journal of Medical Science," July, 1847.
• Cyclopaedia of Anatomy and Physiology : Article, Pids€.
112 SYMPTOMS AND SIGXS OF DISEASE.
The result of all these observations, and a careful examina-
tion of the foregoing table, shows that the pulse may be
stated, in round numbers, as being —
At birth, 140.
During infancy, 120 to 130.
In clnldhood, 100.
Youth, 90.
Adult male, 70 — 75,
Adult female, 75 — 80.
Old age, 70.
Decrepitude, 75 — 80.
The pulse is modified by several circumstances besides
disease. Thus posture has a very considerable influence on
its rhythm or frequency, even in healthy persons ; this in-
fluence being still more marked in disease, more in males
than in females, and in adult age than in youth. The pulse
is more frequent standing than sitting, and sitting than lying ;
on the contrary, it is stronger lying than standing, so that its
minimum of frequency and its maximum of strength are
attained together. According to Dr. Guy' the mean numbers of
the pulse, in the healthy adult male, are as follows : Standing,
79 ; sitting, 70 ; lying, 67 ; while, in the healthy adult female,
the numbers run : Standing, 89 ; sitting, 82 ; lying, 80.
Dr. Graves lays down as an established law that, in a debili-
tated person, when a sudden change of position — as from the
erect to the horizontal — makes little or no difference in the
frequency of the pulse, we may conclude that the heart or at
least its left ventricle, is increased in size and strength.^
Sex influences the frequency of the pulse to some degree.
The female pulse difi'ers but slightly from that of the male
during the earlier years of life ; but after about eight years of
age, the mean pulse of the female exceeds that of the male
by from six to fourteen beats, the average excess being about
nine beats in aminue. The pulse is usually also more frequent
and more developed during pregnancy, especially in excitable
women.
Muscular exertion temporarily increases the frequency of
the pulse more than any other cause. This is especially the case
in the early part of the day, the pulse, moreover, being always
more frequent and more excitable in the morning than in the
evening; the diminished frequency of the pulse towards the
after part of the day probably depends on the exhaustion of
*Op. cit. p. 189.
^ Lectures on Clinical Medicine. Second edition, vol. i. p. 50.
THE PULSE. 113
the strength. The pulse falls during sleep, considerably in
children and in irritable nervous persons, but slightly in
healthy adults. The general effect of food is to excite the
pulse ; warm drinks, alcoholic liquors, and tobacco especially
do so. So also heat, inflammatory action, fever, extreme
debility, sleeplessness, the first stage of plethora, loss of blood,
and the exciting passions and emotions increase the fre-
quency of the pulse, from seventy or eighty beats in a minute,
up to 100, 120, or even to 200; while cold, continued rest,
sleep, slight fatigue, want of food, digitalis, increased atmo-
spheric pressure, and the depressing passions of the mind,
diminish its frequency to sixty, fifty-five, or even forty beats
per minute.
Quickness of pulse differs from frequency, the latter having
reference to the succession of the pulsations, the former to
each beat separately. A frequent pulse is one in which the
number of pulsations is greater than usual in a given time ; a
quick pulse, one in which each beat occupies a less period of
time than naturally, although the whole number of beats may
not be materially increased. A quick pulse is generally a
sign of nervous disorder, indicating irritation with debility j
a frequent pulse is indicative of arterial excitement — fre-
quently of inflammation, or of great depression, as just
shown.
The jerking pulse is characterized by a quick, rather forcible
beat, followed by a sudden, abrupt cessation, as if the direc-
tion of the current had suddenly changed ; it was pointed out
by Dr. Hope as indicative of deficiency of the aortic valves,
and consequent regurgitation into the ventricle. Somewhat
allied to this is the thHlling pulse of aneurism, cardiac disease,
or anaemia.
Regularity of the pulse is generally a favorable sign in
disease, although cases are recorded in which the pulse being
uniformly irregular, or even distinctly intermittent in health,
has become regular during the progress of disease, and
resumed its irregularity on recovery. The intermittent pulse
— that in which a pulsation is occasionally omitted — is often
due to some obstruction to the circulation in the heart or
lungs, to aortic aneurism, or to some cerebral disturbance,
particularly inflammation and softening of the brain, apoplexy,
&c.; slighter causes, however, occasionally produce it, espe-
cially perhaps dyspepsia with flatulence, when occurring in
the debilitated or aged. The irregular pulse is a higher
degree of the intermitting, the pulsations being unequal, and
continuing an indefinite time ; disturbances of the circula-
10*
114 SYMPTOMS AND SIGNS OF DISEASE.
tion, of the respiration, or of the functions of the brain, orive
rise to it ; it is not unfrequently met with during the puerperal
state, especially at the accession of puerperal fever.
The volume of the pulse may be greater than usual, when
it is said to be full, as in general plethora, and in the early
stages of acute diseases ; or less than nsual, when it is known
as small or contraded — being sometimes so small that it is
said to be thread-like — as in anajmia, after severe hemorrhage,
and in all cases of great prostration. When the pulse resists
compression it is termed hard, firm, or resisient; when very
hard and at the same time small, iciry; softness of the pulse
is almost synonymous with compressibility, and generally indi-
cates defective tone and loss of vital power.
In fever, a dicrotous pulse — that is to say, a pulse which
beats twice as fast as in health — which is at the same time
hard, is a very unfavorable symptom, especially if it continue
more than twenty-four hours; if, however, it is succeeded by
epistaxis, and then disappears, it is more favorable. When,
in fever, a hard dicrotous pulse lasts for many days, without
any tendency to hemorrhage, the case — in nine out of ten —
ends fatally. In haemoptysis, long-continued epistaxis, and
internal inflammations, a very hard dicrotous pulse sometimes
occurs, which resists all treatment, and portends a fatal issue ;
no matter how much the other symptoms may improve, so
long as the pulse retains this character, the patient is in immi-
nent danger.'
Lastly, if the pulse at both wrists be not isochronous or
equal — if the beats do not occur at the same time — we must
suspect disease of one or the other radial arteries, or that
pressure is made upon some part of the arterial tract between
the heart and wrist by a tumor, aneurism, &c.
Condition of the Capillaries. — The state of the capil-
lary circulation on various parts of the surface, often furnishes
indications of some importance as respects vascular action
and vital power, especially in the exanthematous fevers and
in cachectic diseases. By pressing the finger upon the skin
and noticing' the rapidity with which the blood returns into the
whitened spot, we ascertain the rapidity of the circulation
through the capillaries ; when the blood returns quickly into
these minute vessels, the circulation is active and healthy ;
when it returns immediately, and the skin is of a vivid color,
there is congestion ; while if the redness at any one part
remains unaffected by pressure, we may be sure that there is
extravasation of blood. As old age advances the capillaries
* Graves, op. cit. p. 50.
STATE OF THE BLOOD. 115
become impaired in vital tone, and the skin consequently is
rendered colder and paler than in adult life. The same occurs
frequently from exhausting diseases, denoting a failure in the
general strength of the system which demands our greatest
attention.
Venous SjnnptoniS. — The veins furnish signs of disease
by their dilatation and over-distension, as occurs in the reins
of the temples, face, and neck, in congestion of the brain ; by
the slowness or rapidity of their distension when pressure is
applied in their course to the heart, showing the excess or de-
ficiency of blood in the system ; and by their occasional pulsa-
tions. The occurrence of a venous pulse results either from a
continuation of the heart's impulse through the capillaries,
when the circulation is much excited ; or from an artery lying
under or near a vein ; or it may be due — when felt in the
jugulars — to a retrograde current, produced by inordinate
contraction of the right ventricle and regurgitation of blood,
owing to hypertrophy of the right ventricle with dilatation of
the right auriculo-ventricular orifice and imperfect closure of
the tricuspid valve.
State of the Blood. — In man, as well as in the most per-
fect animals, the blood during life never rests, but is constantly
in active motion, running in a double circle, from the first
respiration until death. Having become impure in the course
of its circulation, it is purified in the lungs ; the pure blood is
then sent all over the body, when a part of it becomes solid, a
part is removed by the secreting organs, and the rest becom-
ing venous is again returned to the lungs and heart.
The supply of blood being adapted to the capacity of the
vascular system, any deviation from the normal quantity will
affect the whole body. Excessive fulness of blood will give
rise, in proportion to the fulness, to a full, broad, and tense
pulse ; to congestion of the sinuses and other vessels of the
cerebro-spinal system ; to congestion of the lungs, liver, and
other important viscera, as well as to spontaneous hemor-
rhages. Whe7i the blood is deficient in quantity, the pulse will
be found soft, weak, and very compressible, the impulse of
each wave of fluid through the artery being quick and sudden :
the vital powers will be found depressed to a low state, the
organic nervous energy weakened, and the different functions
will be feebly, if not imperfectly performed.
The morbid effects of the loss of blood may be divided into
the immediate and the remote. The immediate effects are
syncope or fainting, from its slightest to its fatal form ; con-
vulsions, most apt to occur in children, and in cases of alow
116 SYMPTOMS AND SIGNS OF DISEASE.
and excessive draining of blood ; delirium, as is frequently seen
in flooding after parturition ; coma, the comatose condition
being often as perfect as after a fit of apoplexy ; and lastly,
sudden dissolution may take place from copious bloodletting.
The remote effects are exhaustion with excessive reaction ;
exhaustion with defective reaction; exhaustion with sinking of
all the vital powers ; mania ; and coma, from which it is im-
possible to recover the patient.
Dr. Marshall Hall has suggested that, in cases in which it
is doubtful whether the pain or other local affection be the
effect of inflammation or of irritation, the doubt should be
solved by placing the patient upright, and bleeding to incipient
syncope ; in inflammation much blood flows, in irritation very
little. As this has been considered a very important means
of diagnosis, it is necessary for the reader to be acquainted
with it, though I doubt very much the propriety or even the
necessity of resorting to such a test. Happily, owing to our
increased knowledge of disease, the use of the microscope, and
the aid of chemistry, we are able, in the present day, to ascer-
tain all that it is desirable to know of the nature of the blood
from the examination of a very small quantity, such as a few
drachms, or even less.
If the quantity of blood in the system influences disease, it
will readily be imagined that the quality of this fluid must do so
to a very important extent ; and such is the case. There is,
however, no standard analysis of blood to which all other
analyses may be positively referred, since each moment the
composition of this fluid, as a whole, is changing. Thus the
water is always varying in amount ; the nitrogenized and un-
nitrogenized substances are always changing in quantity ;
even the salts, even the alkalescence of the blood is in a per-
petual state of variation, being hardly the same at any two
moments of the day. If this is the case in health, how much
more so will it be the case in disease. That the constituents
of the blood undergo various and important alterations in their
amount, in different constitutional affections, will be readily
seen by the table on p. 117, which presents roughly the most
striking variations.*
The facts which have been satisfactorily made out concern-
ing the morbid conditions of the human blood are not very
numerous, and much remains to be accomplished. Amongst
the chief diseases, however, in which a pathognomonic condition
of this fluid has been discovered, I may mention inflammatory
affections, characterized by the constant increase in the amount
• See Lecture on Animal Chemistry, by Dr. Bonce Jones, Lancet, 26th
January, 1860.
STATE OF THE BLOOD.
117
of the fibrin ; anaemia, by a decrease in the red corpuscles ;
certain renal afifections, by the diminution of the solids of the
serum, and frequently by an accumulation of urea ; gout, by
the existence of uric acid, as has been so ably demonstrated
by Dr. Garrod ; diabetes, by the presence of sugar; jaundice,
by the existence of the coloring principle of the bile 5 insanity
— more than two-thirds of the cases of madness being the
result of some alteration in the blood — (Romberg) ; and cho-
lera, in -which there is a diminution of the water — causing the
blood to become thicker, tar-like, and less coagulable, an in-
crease in the solid portions of the serum— especially the albu-
men, and a retention of urea.
Constituents
of
the Blood.
a
H
§
B
s
.a
1
1
<
il
^6
£5
Fibrin,
3
lOi to 1
10
•9
3-5
2-7
3-2
Globules, . . .
127
185 " 21
101
931
38-5
162-3
820
Solids of Serum,
80
114 " 57
90
86-0
89-0
1050
64-8
Water,
800
915 " 725
799
820-0
8690
7400
8500
1000
1000
1000-
1000-
1000- |iooo-
A few years since Dr. Garrod discovered a substance in the
blood which crystallizes in microscopic, octahedral crystals,
and which he regards as oxalate of lime.' And, more recently,
a very curious disease has been described by Virchow and Dr.
Hughes Bennett, named by the latter leucocythemia, from
x«/*!c, white, xwTcf, a cell, and */.«*, the blood; literally, white-
cell blood. On examining the blood microscopically, under a
magnifjring power of 250 diameters, in a case of leucocythemia,
the yellow and colorless corpuscles are at first seen rolling to-
gether, the excess in the number of the latter being at once
recognizable, and becoming more evident as the colored bodies
became aggregated together in rolls, leaving clear spaces be-
tween them filled with the colorless globules. A drop of blood
taken from a prick in the finger is sufficient for examination.
The chief symptoms presented by a person suffering from leu-
cocythemia are great pallor, with gradually increasing emacia-
tion and debility. It will probably be found, as we learn more
of this affection, to be associated with enlargement of some
or all of the following glands — the liver, spleen, thyroid,
thymus, supra-renal capsules, and lymphatics.
' Medic o-Chirurgical Transactions, 1849.
118 SYMPTOMS AND SIGNS OF DISEASE.
For an account of the chemical and microscopical examina-
tion of the blood, see Chapter XI. Section 1.
SECTION 6. SYMPTOMS CONNECTED WITH THE URINARY
AND SEXUAL ORGANS.
The symptoms furnished by the urinary organs divide them-
selves into two classes, i. e., into those to be gathered from a
chemical and microscopical examination of the urine, for the
purpose of discovering those morbid conditions of this secre-
tion "which may be produced by local disease of the renal
organs, by various constitutional conditions, and by disease of
the brain or spinal cord ; and those which depend on the
modes of voiding this secretion. The former will be fully
considered in Chapter XI., Section 4 ; the latter will now be
treated of.
The Excretion of the Urine may be difficult, or painful,
or changed, or arrested. With respect to the difficulty of void-
ing the firine, three grades have been distinguished : dysuria —
Jvc, with difficulty, and ovpoy, the urine — in which the urine is
voided with trouble or effort, pain, and a sensation of heat in
some part of the urethra 5 strangury — a-TpoLyyuv, to squeeze,
and oupov — in which the difficulty is extreme, the urine issuing
drop by drop, and being accompanied by heat, pain, and
tenesmus at the neck of the bladder ; and ischuria — tirx^t I
arrest, and ovfiov — in which no urine at all can be passed.
The first two species — dysuria and strangury — should
always attract attention, since they cause great suffering, and
lead to conditions by no means devoid of risk, more particu-
larly in aged persons. They may proceed — either from dis-
ease of the urinary organs or passages, as, stricture, or inflam-
mation of the urethra ; hypertrophy of the middle lobe of the
prostate ; spasm, catarrh, inflammation, or ulceration of the
bladder j and fungous or polypoid growths ; — from morbid
states of the urine, as, the admixture of pus, blood, mucus,
gravel, &c. ; or from this secretion being too irritating ; or
from the existence of one or more calculi in the bladder or
urinary passages : — or from disease of the adjoining viscera,
as in instances of dysentery, disease of the liver or spleen,
tumors of the abdomen, and uterine or ovarian affections.
Ischuria — in which no urine at all can be passed — is divided
into that of suppression, and that of retention. Suppression
of urine — sometimes called ischuria renalis, in which no urine
is secreted — is a most dangerous symptom, since the injurious,
effete, and poisonous materials which should be excreted by
INCONTINENCE OF URINE. 119
the functions of the kidneys, accumulate in and vitiate the
blood, and in a few days poison the sufferer. It maybe caused
by inflammation, suppuration, or other structural changes in
the kidneys themselves ; or by congestions occurring in the
course of the exanthematous or other fevers ; or by disease of
the blood, as is seen in malignant cholera and other pesti-
lences ; or by organic or other affections of the brain, spinal
cord, or their membranes. Retention of urine — ischuria vesi-
calis — may depend upon two sets of causes ; either upon some
obstruction to the flow of the secretion, as a calculus, tumor,
inflammation, &c., situated either at the outlet of the pelvis of
one or both kidneys, or in the course of the ureter, in which
case none of the urine will reach the bladder, but accumulate
behind the seat of obstruction ; or, the urine entering the
bladder, there may be inability to discharge it, from — first,
paralysis of the coats of this viscus consequent upon disease
of the brain or spinal cord, or upon congestion of the nervou3
centres and paralysis of the bladder — as occurs in the course
of low fevers, or from paralysis of the bladder from over-dis-
tension ; or, second, the bladder being healthy, there may be
some obstruction in the neck of this organ or in the passage
of the urethra, the obstructing cause consisting either of an
impacted calculus, or of a spasmodic or structural stricture.
It must also be borne in mind that nervous ansemic women,
and those who practise masturbation, often suffer temporarily
from hysterical retention of urine, sometimes necessitating
the use of the catheter for many days : recovery takes place as
the general health improves, and the bad habits are discon-
tinued.
Incontinence of Urine. — Inability to retain the urine —
incontinentia urinse, vel enuresis — presents different grades,
varying from very frequent and irresistible calls to micturate
to a constant dribbling. A frequent desire to pass water is
experiened in most inflammatory affections of the urinary
organs, especially those affecting the bladder ; in disease of
the neck of the bladder, as well as in cases in which foreign
bodies are present in this viscus — as calculi, clots of blood,
fungoid growths, &c.; and in many nervous affections,
hysterical women especially often suffering from it. The most
frequent cause of a constant dribbling of the urine is paralysis
of the neck of the bladder through general debility, as in
aged persons ; or paralysis of the lower half of the body —
paraplegia ; or over-distension of the bladder, producing com-
plete loss of contractile power in the coats of this organ, so
that the urine accumulating literally overflows. This latter
120 SYMPTOMS AND SIGNS OF DISEASE.
condition is readily recognized by the dull sound elicited on
practising percussion immediately over the pubes, by the pain
complained of in the same situation, and by the sense of ful-
ness communicated to the touch.
Symptoms from the Sexual Organs. — The symptoms
derived from the sexual organs in the male have not received
much attention. In health the penis and testes are well
developed, the scrotum firm and contracted, and the testes
drawn upwards by the contraction of the cremaster muscles.
Extraordinary size of the penis is a sign of sexual excess, and
in boys of onanism 5 irritation at the end of this organ, with
continued erections — priapism — is often symptomatic of the
presence of a calculus in the bladder. In low fevers, in dia-
betes, at the commencement of all acute disorders, and in all
cases of vital depression or of nervous exhaustion, the dartos is
no longer corrugated, and the scrotum therefore hangs loose and
flabby ; the cremasters do not contract, and the testicles, con-
sequently, hang low down ; and there is a want of the power
of erection, with loss or imperfection of the sexual desires.
It is perhaps remarkable that in chronic diseases of the lungs
and heart, and especially in pulmonary phthisis, the sexual
powers are seldom much impaired.
The influence exerted on the mind and body of women by
the wonderful nature of the uterine system, and the extraordi-
nary functions performed by it, is very remarkable. The reci-
procal relation existing between the uterine organs and the
nervous and sanguineous systems and the organs of nutrition,
is very much closer than that between the sexual system and
the same organs in man. The regularity or irregularity of
the menstrual flow, for example, affects the whole circle of
mental and corporeal actions ; the derangements of menstrua-
tion being in some instances causes, in others results, of
almost the entire class of female disorders. Amenorrhoea,
leucorrhoea, dysmenorrhoea, and menorrhagia are in general
merely symptoms of many opposite constitutional states ; and
to look upon or treat them as local diseases is, as a rule, to
commit a most pernicious error.
The amount of sympathetic irritation excited in the breasts,
in the stomach and bowels, and in the nervous system by
pregnancy, is always very considerable. M. Nauche states that
pregnancy in general increases acute diseases, especially those
involving the uterus ; chronic diseases are rendered slower in
their progress and sometimes cured, and a temporary benefit
is experienced in phthisis.^ Dr. Montgomery believes that
' Mai des Femmes, Part ii. p. 690.
PAIX. 121
pregnancy acts in a great degree as a protection against the
reception of disease, on the well-known common principle
that the continuance of any one very active operation in the
system renders it less liable to be invaded or acted upon by
another.'
SECTION 6. SIGNS DERIVED FROM THE NERVOUS
SYSTEM.
The signs derived from the nervous system, which it is
necessary here to consider, are not very numerous. They
consist chiefly of those derived from derangements of general
sensation, as pain, &c., from paralysis, from spasm, from
delirium, and from coma.
Pain. — General sensation may be deranged in two ways :
it may be either morbidly keen or morbidly obtuse. When
morbidly keen, it constitutes various kinds of uneasiness,
which may all be classed together under the head of pain.
Pain has various sources. Irritation or excessive excitement
of the nervous structures or functions -will produce it ; so will
inflammation, depression and debility, cold ; and in diseases
generally, the sensibility of the nerves being exalted, pain will
be caused by ordinary agents, which in health would excite
no sensation. A definition of pain is unnecessary, since all
have suffered from it at one time or another. It is a most
important sensation, since it often indicates the seat and
nature of disease. It differs exceedingly in degree, in its
duration and mode of recurrence, and in its character. Thus
in its different grades it is spoken of as slight^ moderate, severe,
violent, excruciating, intense, or agonizing. As regards its
recurrence, it may be/w^«Yii-e or persistent, icandering or Jixed,
intermittent, remittent, or continued. In character pain may
be dull, or obtuse, or Jieavg, or aching, as it usually is in con-
nection with congestions and chronic inflammations, or in
acute inflammations of parenchymatous organs ; or it may be
gnawing or lacerating, as is the pain of rheumatism and gout,
and of periostitis ; or it may be of a cutting, lancinating
character, as occurs in scirrhus, and in inflammation of the
nerves ; or it may be griping, or tioisting and spasmodic, as
accompanies dysentery, ileus, gastralgia, enteralgia, and
obstruction of the intestines. When pain is attended with a
beating, throbbing sensation, consequent upon the heart's
action, it is Q2.Wq<\ pulsating ; when with a feeling of tightness,
tensive; when with heat, burning. From this it is apparent
• Signs of Pregnancy, p. 25.
n
122 SYXIPTOMS AND SIGNS OF DISEASE.
that not only are different kinds of morbid action accompanied
by different varieties of pain, but that the same kind of morbid
action — inflammation, for example — produces different modi-
fications of suffering, according as it affects different parts.
Thus in inflammation of the serous and synovial membranes,
the pain is often very severe, and sharp or acute ; in the
mucous membranes and parenchyma of the viscera, it is dull
or heavy ; while in the skin it is apt to be burning, tingling,
&c. So again pain often takes place, not in the organ really
affected, but in some distant part. How commonly does
inflammation of the liver almost first show itself by the pain
it produces in the right shoulder ; stone in the bladder, by pain
at the end of the urethra ; chronic ovaritis, by pain down the
leg of the affected side ; inflammation of the hip-joint, by pain
in the knee ; and disease of the heart, by pain down the left
arm.
If pain be experienced only in a part when it is touched —
when pressure is made upon it, the part is said to be tender.
A part may, however, be both painful and tender. Increased
pain on pressure indicates vascular congestion, inflammation,
or some organic change the result of inflammation. Pain is
diminished by pressure in colic, in chronic rheumatism, and
in pure neuralgia, unless there be inflammation of the nerve
or its sheath.
In forming an opinion as to the nature and degree of pain
in any particular case, we must not allow ourselves to be mis-
led by the statements of the patient. Many people are so
prone to exaggerate the nature of their sufferings, and to use
strong expressions in order to impress the importance of their
symptoms upon the practitioner, that, to avoid being misled,
it is necessary to be guided more by the expression of the
countenance and the general appearance, rather than by what
is said. If a person, for instance, tells us in a calm tone of
voice, and with a composed countenance, that he is suffering
the most excruciating tortures, we shall be justified in esti-
mating the severity of the pains to be greatly less than the
terms "excruciating tortures*' would imply.
Diminished Sensibility. — This may vary from slight
numbness, or from local or partial loss of sensation, to total
loss of sensibility — anaesthesia. The sensibility is diminished
or lost in certain forms of cerebral disease — especially apoplexy,
epilepsy, catalepsy, and ramoUissement or softening of the
brain ; in certain varieties of low fever, as typhus and typhoid ;
and in that peculiar stupor — almost amounting to coma —
which often succeeds certain forms of delirium. Pressure
PARALYSIS. 123
upon tlie nerve of a limb will cause anaesthesia in the parts
below the seat of pressure. It is very rarely found that the
sensibility of a part is so completely lost as to be insensible to
severe kinds of injury; in general, there is only a numbness
of the skin. Paralysis of motion is often unattended by loss
of sensibility ; but when otherwise, it will generally be found
that anaesthesia more commonly precedes loss of motion of the
lower than of the upper extremities, and that in any instance
it rarely follows paralysis of motion.
Paralysis. — The functions of the brain and nerves may be
said to consist of sensation, thought, volition, and the power of
originating motion. The faculties of sensation, of thought,
and of the will belong to the brain, and probably to the cere-
brum alone 5 motive power resides in the spinal cord. Disease
of the brain or spinal cord involving the extremities of cer-
tain nerves there organized will necessarily be followed by
effects in the structures to which such nerves are distributed,
and of which indeed they form an integral and necessary part.
A common result of such disease is paralysis or palsy, by
which is meant a local or partial loss of sensibility, or of
motion, or of both, in one or more parts of the body. All
paralytic affections may be divided into two classes — the first
including those in which both motion and sensibility are
affected ; the second, those in which the one or the other only
is lost or diminished. The former is called perfect, the latter
imperfect paralysis. Imperfect paralysis is divided into
acinesia — paralysis of motion ; and ancesiJiesia — paralysis of
sensibility. Again, the paralysis may be general or partial, as
it affects the whole body or only a portion of it. General
paralysis, or complete loss of sensation and motion of the
whole system, cannot take place without death immediately
resulting. But this expression is usually applied to palsy
affecting the four extremities, whether any of the other parts
of the body are implicated or not. Partial paralysis is divided
into hemipleyia when it is limited to the lateral half, and
paraplegia when it is confined to the inferior half of the body.
The term local paralysis is used when only a small portion of
the body is aS'ected, as the face, a limb, a foot, &c.
Paralysis of the eye, or loss of sensibility of the retina to
the rays of light, is called amaurosis ; paralysis of the superior
branch of the third nerve supplying the levator palpebras
superioris muscle, causing the upper eyelid to fall over the
eye, is termed ptosis palpehrce ; insensiliility to the impression
of sounds (deafness), cophosis; insensibility to odors (loss of
smell), anosmia; loss of taste, ageustia.
124 SYMPTOMS AND SIGXS OF DISEASE.
There are also certain forms of paralysis arising from the
use of metallic poisons, as mercurial palst/, and saturnine or
lead palsy ; and lastly, there is a peculiar aflfection known as
paralysis agiians.^
Spasm. — Under the terra spasm, Sauvages arranged all
involuntary muscular contractions, and divided them into two
classes, ionic and clonic. This division is still generally
adopted.
Tonic spasm — called by Cullen spastic rigidity — is charac-
terized by a long-continued contraction of the affected muscles,
alternating with relaxation, the relaxation taking place slowly
and after some time, and being quickly followed again by
contraction. A very familiar example of tonic spasm is the
common cramp of the leg. So also is the principal symptom
of trismus, tetanus, and catalepsy. In clonic spasm, the con-
tractions of the affected muscles take place repeatedly, forcibly,
and in quick succession ; and the relaxation is, of course, as
sudden and frequent. Illustrations of clonic spasm are found
in convulsions, in the rapid convulsive movements of epilepsy,
of hysteria, chorea, &c. Occasionally we see the two forms of
spasmodic action occurring in the same individual at the same
time, some muscles being convulsed or affected with chronic
spasms, while others are affected with rigidity or tonic spasm.
The exciting causes of spasm are chiefly influences affecting
the nervous centres, the mind, the senses, the digestive viscera,
and the urinary or sexual organs. The immediate cause was
supposed to be irritation of the nerves supplying the affected
muscles, either at their origins, or in some part of their course,
or at their terminations; or else a sympathetic affection of
these nerves propagated from distant but related parts. "Within
the last few years, however, the doctrine of Sprengel has been
revived, who regarded spasm as the result of an alteration of
the polarization of the terminations of the nerves in relation to
the muscular fibres.
Delirium. — Delirium has been divided into the acute and
the chronic ; the former consisting of various morbid states of
the brain, attended by mental disturbance and fever — the
latter of mental alienation, unattended by fever or active bodily
disorder. Chronic delirium, therefore, comprises those states
of disordered mental manifestation known as insanity .^ Acute
delirium is more common in the severe affections of the young
than of the old, and in diseases occurring in individuals of a
' See the Author's Manual of the Practice of Medicine. Second edition,
page 148.
« See Copland's Medical Dictionary: Kx\\c\e Ddirmm.
COMA. 125
nervous temperament rather than in those of the sanguine. It
is said to be active or passive 5 the former — as a rule having
many exceptions — being characteristic of the existence of in
fiammatory action ; the latter — under the same circumstances
— resulting from exhausted nervous and vital power. The
active differs greatly in degree, being sometimes mild, some-
times violent or furious : in the mild form there is generally
mental aberration without any disposition to action; in the
furious grade, there is violence of manner, voice, and language
In passive delirium the mind appears to be wandering ; the
patient mutters sentences without meaning, but will answer
questions coherently and correctly if roused, or if the circula-
tion be quickened by a stimulant : the low muttering wander-
ing of typhus is a good example of this form of delirium.
In inflammation of the brain the raving is often very
violent. Cases of encephalitis, characterized by early and
fierce dehriura, are generally those in which the inflammatory
action has invaded the whole of the encephalon, cerebral sub-
stance, and the meninges simultaneously. When delirium
occurs during the progress of a case of pneumonia, it is a
very ugly symptom, since it generally denotes that the pulmo-
nary affection is largely interfering with the due arterializa-
tion of the blood. Delirium tremens is generally character-
ized by a busy, but not angry or violent delirium ; the patient
is constantly talking or muttering, his hands tremble, and his
manner is eager and excited. If you question him, he
answers rationally, though in an agitated manner, but he soon
relapses, and his mind wanders from the scene around him.
His thoughts usually appear to be distressing, and he is full
of anxiety, either as to his business or family, or the supposed
devices of some enemy determined to injure him. He looks
about him suspiciously, distrusts those near him, imagines
that vermin or various animals are running over his bed, or
that strangers are in his room to hurt him. These fancies are
often driven away by a sound refreshing sleep, which, however,
there is usually great difficulty in obtaining. In all cases,
the aphorism of Hippocrates is true, — ''When sleep puts an
end to delirium it is a good symptom."
Coma. — Coma is that condition of complete insensibility
in which the functions of animal life are suspended, with the
exception of the mixed function of respiration ; while the
functions of organic life, and especially of the circulation,
continue in action. There is neither thought, nor the power
of voluntary motion, nor sensation ; but the pulmonary
branches of the par vagum continue to excite, through the
11-
120 SYMPTOMS AND SIGNS OF DISEASE.
medulla oblongata, the involuntary movements of the thorax.
When this upper part of the cranio-spinal axis becomes
involved in the disease, and its reflex power ceases, the
breathing stops also, and the patient is presently dead.*
On being called to a case of deep coma there will often be
experienced great difficulty in deciding whether this condition
is due to apoplexy, or to a large dose of opium, or to a poison-
ous quantity of alcohol. All physicians engaged in hospital
practice have seen cases in which they have l)een placed in
this dilemma, — a most unhappy one, since the life of the
sufferer may depend upon the correctness of the diagnosis.
The points which will assist the practitioner in forming an
opinion are, — the history of the patient, his general appear-
ance, and such other circumstances as can be gleaned from
his friends, or those persons who picked him up in the street ;
the smell of his breath, — the odor of tobacco, of spirits, or of
wine, being often easily detected ; his condition in life ; and
the state of his mind for the previous few days. In cases of
poisoning by opium, however, the pupils are almost invariably
contracted, sometimes to the size of a pin's point 5 in deep
intoxication they are often dilated, but sometimes contracted ;
and so in apoplexy. When house physician to King's College
Hospital I saw more than one case of profound coma caused
by dead-drunkenness, which was quickly relieved by having
recourse to the stomach-pump, administering two or three
ounces of the liquor ammoniac acetatis, and afterwards
employing cold affusion. The diagnosis of intoxication is
often difficult, for though the odor of the breath is one of the
best means of throwing light on the case, yet it must be
remembered that a fit of apoplexy or epilepsy is very likely to
occur in a plethoric predisposed person after a glass or two of
spirits.
* Dr. Watson, op. cit. vol. i. p. 481.
XATUKAL A\D FEIGNED DISEASE. 12]
CHAPTER VI.
OX THE DIAGNOSIS OF NATURAL FROM
FEIGNED DISEASE.
Ix every age and in every country disease has been simu-
lated by all classes of society. Numerous examples to prove
the truth of this assertion might be quoted from the Scriptures
as well as from ancient and modern history, but such instances
■would prove more entertaining than useful. Suffice it to say
that the monarch, the statesman, the priest, the soldier, and
the criminal have alike feigned mental and bodily infirmities
for the advancement of their own ambitious or nefarious
designs. In the present day the majority of these impostors are
found amongst persons suspected of crime, vagrants, sailors,
soldiers — a soldier feigning illness is said to be malingering —
members of benefit societies, children, and such hysterical
and capricious women as, having no healthy occupation,
amuse themselves by simulating cardiac, pulmonary, spinal,
or uterine disease.
In the investigation of this class of cases great discrimina-
tion and ingenuity will be required, since the actors in these
deceits generally play their parts with considerable skill, and
often with a total disregard to trouble or even physical suffer-
ing. There are four modes in which disease may be said to
be simulated : — 1. Disease may be altogether feigned, the
person being in a state of health. 2. It may be exaggerated;
that is to say, there being a certain amount of disease, the
patient may pretend that it exists in a greater degree and
causes more disturbance and suffering than it truly does.
3. Disease may be artificially excited, sickness being actually
produced either by the patient, or with his concurrence.' And,
4. Disease may be artificially increased or aggravated during
its course.
The acompanying table exhibits the diseases which are
most frequently simulated, the mode in which they are feigned,
and the means to be adopted for their detection.
* Robertson, in his History of Charles the Fifth (Book xi.), telis us of
Pope Julius III., who l"eigned sickness to avoid holding a consistory, and,
in order to give greater color to his imposture, conhned himself to his
apartment, and changed his usual diet and manner of life. So effectually,
however, did he play his ridiculon? part, thai lip contracted a real disease,
of which he di^d in n few davn.
128
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loS PHYSICAL DIAGNOSIS OF DISEASE.
In considering the facts narrated in the foregoing table we
find much to excite our wonder and regret ; and without
indulging in any morbid or sentimental feelings, I think it
impossible not to come to the conclusion that many, especially
in civil life, who practise the deceptions detailed, at least do
so from folly and imbecility, as much as from vicious and
wicked motives. In treating such cases, therefore, it is not for
us at once to condemn or assume too harshly the characters
of judges. The constant practice of our profession makes us
acquainted with so much that is morally blamable, and teaches
us so forcibly the weakness of man and the proneness of the
best of us to err and trespass — for there is no '' happy valley"
where sin and sorrow are unknown, save in the fiction of
Rasselas — that we cannot but pity those who come under our
care Irom diseases self-inflicted or even simulated. Although,
consequently, the conscientious practitioner will not allow
himself to be imposed upon, yet he must not rest satisfied with
merely discovering the deceit 5 but remembering that the
quality of mercy is such, that it " blesseth him that gives and
him that takes,*' and bearing in mind how much we all stand
in need of a merciful interpretation of our daily conduct, he
will readily learn to make allowances for those who have
succumbed to temptation ; and by kindness, gentle reasoning,
and attempting, as far as in him lies, to smooth their path of
life, endeavor to lead them to a more healthy tone of thought,
and to teach them that however exalted or however humble
their occupation, still if they do their duty in it to the best of
their abilities, they must prove useful and valuable members
of society, and will be rewarded accordingly.
CHAPTER VII.
ON THE PHYSICAL DIAGNOSIS OF DISEASE.
The existence of disease involves the presence of physical
or anatomical change, sometimes confined to the part originally
affected, but often extending to the adjoining structures. ''The
anatomical changes thus arising," says Dr. Walshe, ''may or
may not be capable of accurate discrimination during life.
When they can be so discriminated, experience has shown
that their detection is not so much accomplished by means of
CEREBRAL DISEASES. 139
the vital functional derangements of the organs implicated,
as by the aid of various alterations in the physical properties
of those organs, — as, for example, their density, their faculty
of generating and of conducting sound, &c. So invariably
do these alterations bear a certain and fixed relation to the
phvsical nature of the anatomical conditions with which they
are associated, that the discovery of the former is conclusive
as to the existence of the latter. And not only the physical
nature, but the precise limits and the precise degree of these
conditions are disclosed by the alterations referred to, which,
for these reasons, constitute their j^hi/sical si/jns. Interpreted
by the observer, and not by the patient, — incapable, except in
the rarest instances, of being feigned, dissembled, or even
modified at will, — estimable in degree and extent with almost
mathematical precision, — susceptible of indefinite refine-
ment, — physical signs, like the whole class of objective pheno-
mena of disease, are Of immeasurably greater diagnostic,
greater general clinical value than its subjective symptoms.
Physical signs are, in fact, the true indices of the physical
nature, extent, and degree of textural changes, and may be
regarded as instruments of pursuing morbid anatomy on the
living body. But just as their significance is sure and pre-
cise, so is the difficulty of mastering their theory and practice
positive and great; and hence it is that physical diagnosis
has gradually acquired for itself the importance of a special
art.'"'
SECTION 1. THE PHYSICAL DIAGNOSIS OF CEREBRAL
DISEASES.
A few years since Dr. John Fisher and Dr. "Whitney, of the
United States, published some observations on Cerebral Aus-
cultation,^ which, though they do not appear to have attracted
as much attention as they merit, are yet deserving of our
notice, since the diseases of the brain are generally so obscure,
and their diagnosis — resting solely upon the plausibility of
physiological and pathological induction — is beset with so
many difficulties, notwithstanding the great advances which
have been made in the study of the nervous system, that any
attempt to increase the knowledge of this class of affections
is welcome, and deserving of careful consideration. That
' A Practical Treatise on Diseases of the Lun^s and Heart. Second
edition, p. 2.
• American Journal of Medical Science, vol. xxii.p. 277. and vol. sxxii.
p. 283.
140 PHYSICAL DIAGNOSIS OF DISK ASK.
practitioners should attempt by auscultation to ascertain the
various conditions of the parts within the thick-walled skull
under the influence of disease might naturally be expected,
especially when so much was daily being learnt — by the
same means — of pulmonary and cardiac affections. Neither
does it seem at all improbable at first sight that, e. g., in the
case of aneurisms of the cerebral arteries — the internal carotid,
the vertebral, or the basilar — the careful use of the stethoscope
might reveal the existence of a bellows-murmur, and so very
materially facilitate their diagnosis.
In practising cerebral auscultation, the person to be ex-
amined should be in a horizontal position, with his head sup-
ported by a pillow ; if it be a child, the examination can be
most satisfactorily made while it is asleep. In auscultating
the heads of healthy children, four different and perfectly
distinct bruits are heard passing through the brain, consisting
of the sounds produced by the acts of respiration and of
deglutition, and by the impulse of the heart and the voice.
The first which attracts attention is the ceplialic sound of
respiration, commencing and terminating with the respiratory
act, and produced " by the impinging of the air against the
wall of the nasal cavities during the act of respiration." The
second sound is that of the heart, the impulse which strikes
the ear seeming to be transmitted from a distance: it has been
called the cephalic sound of the heart. The sharp, piercing,
and vibratory sounds which accompany the act of crying or
speaking, and which can be heard over every part of the
skull, is termed the cephalic sound of the voice; while the
remaining one of the normal sounds of the head is a peculiar,
dull, massive, liquid sound, attending the act of deglutition,
and known as the cephalic sound of deglutition. As age
advances, and the density of the brain and cranium increases,
these sounds become modified and somewhat indistinct, while
in disease they become remarkably altered, as we shall
now see.
The auscultic phenomena which have been described by
Drs. Fisher and Whitney as characteristic of particular
pathological states of the encephalon are four, — i. e., 1, the
cephalic bellows-sound ; 2, the encephalic or cerebral oego-
phony; 3, the fremissement de cataire, or purring thrill; and,
4, the bruit de poussin, a cooing or musical sound.
The chief of these, the cephalic bellows-sound , can be most
distinctly heard in cei'tain of the cerebral affections of chil-
dren, by placing the stethoscope over the anterior fontanelle.
It has its seat and origin in the arteries, and proba])lyin those
CEREBRAL AUSCULTATION. 141
situated at the base of the brain. In raost cases it seems to
be due to compression of these vessels, but any cause which
narrows the artery, as inflammation, ossification, &c., or in-
deed any condition which produces an inequality or dispropor-
tion between the size of the vessel and the quantity of fluid to
pass through it, will give rise to it. The sound is loud, coarse,
abrupt, and rasp-like ; it is synchronous with the pulsations
and impulse of the heart and large arteries, and with the pul-
satory motions of the fontanelle ; compression of carotids
renders it feeble and indistinct : and nothing resembling it
can be heard in the arteries of any other part of the body.
The cephalic bellows-sound is not a phenomenon of health.
It cannot be detected in the heads of children or adults who
are free from disease, but it has been discovered in cases of
cerebral congestion, acute inflammation of the encephalon,
hydrocephalus, induration of the brain, and ossification of the
cerebral arteries. To discover this murmur is said to be in
many instances a matter of no small difficulty, and hence may
be explained the fact that many observers have failed to detect
it, even after repeated examinations.
The second sound — the encephalic or cerebral oegophony —
has been noticed only in those cases of cerebral disease which
are accompanied with eff"usion and extravasation of fluid over
the surface of the brain. "In every instance," says Dr. Whit-
ney, " in which I have noticed this hitherto undescribed
cephalic phenomenon, it has been connected, and existed
only, with a state of effusion and extravasation of fluid over
the surface ofthehrain. I have never been able to detect this
change in the character of the voice, in simple effusion into
the ventricles, nor in any acute or chronic lesion of the brain,
except accompanied with effusion and extravasation : conse-
quently I have been led to consider an extravasation of fluid
over the surface of the brain as a prerequisite to the develop-
ment of this phenomenon. Such a state of the brain, more-
over, accords with a similar state, which is known to accom-
pany a similar phenomenon of the lungs. It is owing,
therefore, to the natural resonance of the voice being rendered
more shrill and brazen by its transmission through a thin
layer of fluid in a state of vibration.''^
The third sound — thefremissement cataire, or purring ihriUj
has been heard only in one case of aneurism of the basilar
artery, and was supposed to be due to the disease of the arte-
rial tunics.
Lastly, the fowiJi sound — the bruit de poussin, or cooing or
' Op. cit. p.326.
142 PHYSICAL DIAGNOSIS OF PISEASR.
musical sound, may be considered simply as a modification of
the bellows murmur, seated in the arteries, and occurring in
cases of anaemia where the supply of blood to the brain is
imperfect or deficient.
The foregoing remarks contain all that is important in the
writings of Drs. Fisher and Whitney on cerebral auscultation,
as well as all that I can glean from other sources. The reader
will perceive that although much has not yet been accom-
plished, still something has been done, and it is certainly as
well that he should be acquainted with the attempts that have
been made. With regard to the results said to have been ob-
tained from the practice of percussion in cerebral disease I
hold the opinion of Zehetmayer, that percussion will undoubt-
edly inform us of the thickness of the skull, but up to the pre-
sent time, thick and hollow heads have been detected with toler-
able certainty without the necessity of percussing the cranium.*
SECTION 2. THE PHYSICAL DIAGNOSIS OF DISEASES OF
THE LUNGS AND HEART.
Introductory Remarks on the Structure of the
Lung's- The lungs — the organs of respiration — are con-
tained in the ca\aty of the thorax, one on either side of the
spiue. They are irregular conoid bodies, the bases of which
rest upon the diaphragm, while the apices project upwards,
extending slightly above the level of the clavicles. Between
the fourth and fifth ribs, near the left edge of the sternum, a
small oval-shaped space is left between the two lungs, where
part of the pericardium remains uncovered, the remainder of
the pericardium and heart being received into a depression in
the inner surface of the left lung. The right lung, somewhat
broader but shorter than the left, owing to the position of the
liver, is divided into three lobes ; the left into two.
The lungs are formed of — 1, bronchial tubes — composed of
cartilaginous rings, muscular fibres, and of mucous membrane
covered with vibrating ciliated epithelium — which commence
at the bifurcation of the trachea, divide and ramify through
the lungs, and terminate in — 2, the bronchial interceUular
passages, which, according to Mr. Rainey, are simply passages
running between, and communicating in all directions with —
8, the air-cells, or lung-vesicles. These air-cells are small,
generally four-sided cavities, communicating either directly
with the intercellular passages and bronchial tubes by large
circular apertures, or indirectly through the medium of other
* Grundziige der Percuss, und Aiiscult., p, 41.
FO.SITIUX OP THE PATIENT. 143
cells; the cells in the central parts of the lungs are smaller
but more vascular than in the peripheral portions. The pul-
monary membrane forming the cells and supporting the capil-
lary plexus of vessels is thin, transparent, composed of fibres
having no resemblance to muscular fibre either of the striped
or unstriped kind, unprovided with epithelium, and quite dis-
tinct from the membrane lining the bronchial tubes. 4. The
pkxuses of the capiUary vessels entering into the minute struc-
ture of the lungs are situated immediately beneath the pulmo-
nary membrane forming the air-cells, so that the most delicate
structure alone intervenes between the blood in the vessels
and the atmospheric air in the cells. Moreover, the capilla-
ries between the cells are aerated on both sides, being enclosed
in the fold of membrane forming the sides of contiguous
cells.' Lastly, each lung is invested by the pleura, a fine
serous membrane, which, being reflected from the pulmonary
surface over the internal parietes of the chest, forms a shut
sac. From the foregoing it may be concluded that the lungs
are merely expansions of a delicate memljrane, upon the op-
posite sides of which blood and air are situated ; the latter, by
its chemical action upon the former, converting the impure
venous blood of the pulmonary artery into the pure, arterial,
bright red blood of the pulmonary veins.
Position of the Patient. — In the investigation of pulmo-
nary or cardiac affections some care is necessary to place the
patient in such a position that the parietes of the chest may
be rendered firm and tense without affecting his ease or com-
fort, and without being inconvenient to the examiner. When
the fore part of the chest is to be examined, and the patient
is able to sit up, the best position of all will be sitting upon a
chair in the middle of the room, opposite to a good light, with
the arms hanging loosely down by the sides, the head thrown
back, and the upper part of the body uncovered. To examine
either lateral region, place the patient's hand of the side to be
examined upon the back of his head, and make him lean a
little to the opposite side. To percuss or auscultate the back,
let him lean well forwards, hold down his head, and fold his
arms across the breast.
The chest may also be very carefully explored while the
sufferer sits up, or even while lying down in bed, being turned
to either side as may be necessary, and as far as his strength
will admit. The surrounding bed-curtains and furniture have
* See Mr. Rainey's excellent paper on the Minute Structure of the Lungs,
in the "Mtdico-Chirurgical Transactions," vol. xxviii. p. 581,
144: PHYSICAL DIAOXOSIS OF DISEASE.
little or uo effect in deadening the sound educed by percussion,
although some practitioners have thought otherwise. It is of
importance, however, that the room in which the examination
is being made should be as quiet as possible, and the examiner
should also take care that no part of his own or the patient's
dress rubs against the stethoscope.
Regions of the Thorax. — Before proceeding to the con-
sideration of the various methods of physical diagnosis, it is
necessary to notice that the sin-face of the chest has been arti-
ficially mapped out into regions, for the purpose of localizing
the physical signs as accurately as possible. In dividing the
thorax into regions, different observers adopt different bounda-
ries. The plan proposed by Dr. Sibson is certainly the most
philosophical ; but the following arrangement has the merit of
simplicity, and is that most frequently followed :
Ecgions. Sub-Regio7is.
1. The two clavicular.
2. The two subclavian.
. ^ . \ 3 The two mamnmry.
Antenor.s i tu ^ ■ c
4. Ihe two uifra-mammary.
6. The sternal: j f ' The upper sternal.
(_ 0. i he lower sternal.
The two axillary.
b. Lateral. { 8. The two lateral.
The two lower lateral.
10. The two acromial.
C 7. 1
]8. 'I
(9. 1
Ti ^ ■ 11. The two scapular.
c. Posterior. < , -> rr., . • . i
I 12. Ihe two inter-scapular.
(l3. The two dorsal.
The first sub-region — fJie clamcular — one on each side, cor-
responds in outline with that portion of the clavicle behind
which the apices of the lungs lie, being nearly the inner half
of the bone. On percussion the sound should be very clear,
the resonance diminishing from the sternal to the acromial end
of the clavicle, until it becomes quite dull in the latter part.
The second sub-region — the subclavian — comprises that part
of the thorax between the clavicle and upper part of the fourth
rib, bounded outside by the deltoid, inside by the edge of the
sternum ; beneath it lies the upper lobe of the lung, and to-
wards the sternum the main bronchial tube. On the right side
also, close to the sternum, lie the superior vena cava, and a
portion of the arch of the aorta ; while on the left is the edge
of the pulmonary artery. The resonance afforded by percus-
sion should be very clear.
REGIONS OF THK THORAX. 145
A little lower down is the third or mammary sub-region, ex-
tendiug from the fourth to the seventh rib on each side, bounded
externally by a line drawn vertically about an inch and a half
external "to the nipple, and internally by the sternum. On the
right side the lung lies throughout immediately under the sur-
face, the sound educed by percussion being clear, except at
the lower part, where the right wing of the diaphragm and the
liver begin to mount : on the left side we find the heart, partly
uncovered by lung at the lower part of this region, and con-
sequently there is some degree of dulness.
The fourth, or infra-mammary svb-region, is bounded above
by the seventh rib, below by the edges of the cartilages of the
false ribs, externally by a continuation of the line of the mam-
mary region, and internally by the margin of the lower fourth
of the sternum. On the right side the liver — covered at its
upper part by the thin margin of the lower lobe of the lung —
occupies this region ; while on the left is found the stomach,
the anterior edge of the spleen, and generally towards its inner
part a small portion of the left lobe of the liver. The sound
elicited by percussion will be dull, unless the stomach be tym-
panitic, when it will be preternaturally resonant.
The ffth and sixth sub-regions, or the vpper and lower sternal,
comprise the sternum, and are the only single regions. In the
upper sternal portion, corresponding to that part of the sternum
above the lower border of the third rib, are found the left vena
inominata ; the ascending portion of the arch of the aorta ;
the aortic valves — near the lower border of the third left carti-
lage, and a little higher and just at the left edge of the sternum,
the pulmonary ; and the trachea with its bifurcation — on the
level of the second ribs : the inner edges of the lungs almost
unite over these parts down the centre of the region. The
sound on percussion should be moderately clear. The respi-
ratory murmur is heard mixed with true bronchial breathing,
and there will be resonance of voice. In the loicer sternal
portion, corresponding to the remainder of the sternum, is the
right ventricle ; and inferiorly a part of the liver, and often of
the stomach-, the tricuspid and mitral valves lie opposite the
upper edge of this region at mid-sternum.
The eighth sub-region, the axillary, consists of the axilla,
above the fourth rib, on each side. The ninth, or lateral, is
just below, between the fourth and seventh ribs ; while still
lower is the tentJi, or loicer lateral. In the first two the per-
cussion-sound is clear ; in the last it is dull on the right side,
owing to the position of the liver, and often tympanitic on the
left over the stomach.
13
146 PHYSICAL DIAGNOSIS OF DISEASE.
The posterior region includes the acromial sub-region, which
affords but little information on percussion, the sound being
dull; the scapular sub-region, corresponding to the middle
lobes of the lungs, but which gives a dull sound, owing to the
thickness of the bones and then* muscles ; the inter-scapular,
occupying the space between the inner edge of the scapula and
the spines of the dorsal vertebra from the second to the sixth,
and being resonant on percussion ; and lastly, the thirteenth, or
dorsal sub-region, answering to the base of the lung, and giving
at its upper part a clear sound ; but at its lower, on the right
side, a dull one, owing to the position of the liver; and a tym-
panitic one on the left, owing to the position of the stomach.
Another mode of dividing the chest into regions, with which
the reader should be acquainted, has been proposed by Dr.
Sibson, who defines the outlines of the regions by the anatomi-
cal boundaries of the subjacent organs. These regions con-
sist of:
C The right pulmonic.
The simple. < The left pulmonic.
I The cardiac.
r The pulmo-hepatic.
I The puhno-gastric.
The compound. -| The right puhno-cardiac.
I The left pulmo-cardiac.
\_The pulmo-vasal.
Of the simple regions, tJie right pulmonic is bounded above
by the apex of the right lung ; below by an imaginary line
drawn through the right convexity of the diaphragm or the
fifth intercostal space in front, and the articulation of the
eighth rib behind ; and internally, by a line drawn down the
centre of the sternum. The left pulmonic has the apex of
the left lung above ; an imaginary line resting upon the left
convexity of the diaphragm — which is an inch lower than on
the right side, below ; and internally the imaginary line drawn
down the centre of the sternum, except between the lower
margin of the fourth and the upper part of the seventh ribs,
where the lungs form a curve externally, leaving the pericar-
dium uncovered. The cardiac region corresponds to the
heart.
Of the compound regions, the pulmo-hepatic is over that
layer of lung which caps the upper portion of the liver on the
right side ; the pidmo- gastric, over that covering a part of the
liver, stomach, and spleen ; the pulmo-cardiac — right and left
— corresponds to the portions of the lungs overlapping the
FORM. 147
right and left sides of the heart ; while ihe pulmo-vasal cor-
responds to the layer of lung between the sternum and great
vessels, extending upwards along the sternum from the third
sterno-costal articulations.
Description of the Methods of Physical Diagnosis. —
The various means by which the physical signs of pulmonary
and cardiac affections are elicited, are termed methods of
physical diagnosis, and these methods consist of:
1. Inspection.
2. Palpation, or the application of the hand.
3. Mensuration.
4. Succussion.
5. Spirometry.
6. Percussion.
7. Auscultation.
The general mode of practising these methods, and the
signs to be deduced from the examination, have now to be
described and considered.
1. INSPECTION.
By inspection or ocular examination of the external surface
of the chest, we learn the general form of the framework, the
shape of the sternum and rib cartilages, the size of the
cavity, and the movements of its walls. The patient should
be placed in an easy, comfortable position ; sitting, if possible,
opposite a good light, and with the surface of the chest
exposed. Inspection should be practised anteriorly, posteri-
orly, and laterally, and the action of the two sides of the
chest should be closely compared ; since pulmonary diseases
are in the majority of cases limited to one side, and impede
proportionally the costal movements of one-half of the chest
only.
Form. — Regularly formed chests, presenting to the eye a
cone, having its narrow end uppermost, its two sides symme-
trical, and its transverse diameter exceeding the antero-poste-
rior, are much more rarely found than is commonly supposed,
certain marked deviations of form, which are quite compatible
with a perfect state of local and general health, being very
common. M. Woillez, who has paid much attention to this
matter, states indeed that the regularly formed chest exists in
scarcely more than twenty per cent, of adult males taken
indiscriminately; and he has divided the irregularities or
heteromorphisms — ^«T«pof, other, and («op<?'/, form — which render
148 PHYSICAL DIAGNOSIS OF DISEASE.
the chest non-symmetrical into two classes : the physiological
— or those compatible with health, and which are due to
natural conformation, or to peculiarity of occupation ; and
the patJioIof/ical — or those resulting from disease.' It need
hardly be mentioned that the practitioner must be on his
guard not to confound the natural alterations of shape, with
those dependent upon disease ; an error which he can scarcely
commit, provided attention be paid to all the circumstances of
the case. Undue prominence of one side of the chest, or
bulging of part of one side, is best seen in cases of abundant
pleuritic effusion, in pneumothorax, hydrothorax, effusion of
blood into the pleurae, effusion of fluid into the pericardium,
and general vesicular emphysema ; less distinctly in hyper-
trophy of the lung, and during the growth of intra-thoracic
tumors. In cases of pleurisy with abundant effusion, the
diseased side often measures an inch or even two inches more
than the other ; the ribs and cartilages assume the position
which they present during a deep inspiration ; the intercostal
spaces are pushed outwards, and in them fluctuation ma}^
occasionally be distinguished. In pericardial effusion, and in
hypertrophy of the heart, the bulging will be found in the
mammary and lower sternal regions ; while in aneurism of
the aorta it will be noticed in the upper and central parts of
the chest.
Retraction — a sinking of the framework of the chest on one
side, and depression — a sinking of only one spot or sub-region,
are the opposite states to undue prominence and bulging.
Retraction cannot be present without reduction in size of the
lung, which may be produced either by extrinsic pressure or
by changes in its own substance. Now, retraction is one of
the most common results of pleurisy, when the effused fluid
has been partially or entirely absorbed ; for the lung having
been compressed against the vertebral column, depi'ived of
its elasticity, and frequently bound down by the formation of
false membranes, is prevented from re-expanding and resum-
ing its original volume as the fluid is removed; so that in
order to obviate that void which would otherwise exist between
the ribs and the lung, the former sink in and approach the
latter. The retraction will also appear the greater from the
sound lung becoming hypertrophied, owing to its having to
perform double work. The lung is reduced in volume, so as
10 cause retraction and depression in tubercular disease, in
pneumonia during the stage of resolution, and in cases where
its functions are interfered with by the pressure of tumors, or
' Recherches Pratique 8ur I'lnspection et la Mensuration de la Poitrine.
PALPATIOy. 149
aneurisms, or enlarged glands. In healthy persons, the heart's
impulse is generally visible only at the apex, which beats in
the space between the left fifth and sixth ribs, about midway
between the nipple and left border of the sternum. In cases
of pericardial effusion, or of hypertrophy of the heart, the
cardiac region becomes arched forwards, the intercostal spaces
widen, and the left border of the sternum is pushed more or
less forwards ; the apex-beat of the heart is also raised in the
case of pericardial effusion, while in hypertrophy it is de-
pressed, sometimes being carried as low as the space between
the seventh and eighth ribs, or even slightly lower. If both
sides of the heart be equally hypertrophied, the apex point
will be displaced to the left ; if the left cavities alone, to the
left — even to as great an extent as three or four inches from
its natural spot ; while if the right cavities suffer mainly, the
impulse will be to the right — towards or even beneath the
sternum.
Size. — The variations in size between the two sides of the
thorax, occurring in consequence of disease, are more readily
appreciated by measurement than by inspection, and hence
will be treated of in the section on Mensuration. It may be
now mentioned, however, that in most persons the right side
of the chest is naturally rather larger than the left.
Movements. — The motions of the chest-walls may be in-
creased or diminished. In spasmodic asthma the movements
of both sides of the chest are much increased during the
attack, and such also is the case in many instances of croup,
laryngitis, and similar affections. There is a want of due ex-
pansion of the affected side in paralysis, and in great debility
of the respiratory muscles ; in pleurodynia, the early stage of
pleurisy, and rheumatism or neuralgia of the intercostal mus-
cles, when each movement causes acute pain ; in obstruction
to the functions of the lung from disease — as in advanced
phthisis, in pulmonary consolidation from pneumonia or other
causes, in pneumothorax, hydrothorax, and obstruction of the
main bronchial tube ; and, lastly, in disease of the heart, in
aneurismal tumors, and in enlargement of the liver, impeding
respiration on the right side.
2. PALPATION, OR THE APPLICATION OF THE HAND.
Palpation is employed in two ways : — 1. When the pheno-
mena of the disease are limited to a small extent, by pressure
with the tips of the fingers, as in the ordinary exercise of the
sense of touch ; and, 2, by placing the palms of the hands
13*
150 PHYSICAL DIAGNOSIS OK DISEASE.
upon both sides of the chest, gently and evenly, and with such
a moderate degree of pressure as to enable them to participate
in — but not to deaden — the vibrations, or to appreciate the
excess or defect of motion in the two sides, and thus to com-
pare the results.
Palpation — below the clavicles in the female, and below the
epigastrium in the male — is the best mode of learning the
number and force of the respirations.
Vocal Vibration, or Fremitus. — On applying the hand
to the chest of a healthy individual while he is speaking, a
slight thrilling sensation will be communicated to the fingers,
more marked in adults than in children, in males than females,
in short-chested than long-chested persons, and in the spare
and thin than in the stout : it is also most distinct over the
larynx and trachea, and generally better appreciated on the
right side than the left. The act of coughing produces a
similar but less marked vibration. The natural vocal fremitus
or thrill may be increased or diminished by disease. It is
augmented when the density of the pulmonary structure is in-
creased — unless the increase be very great — as in congestion
of the lung, in the early stages of pneumonia, in tubercular
infiltration, and in oedema of the lung: it is diminished or
anmdled when the lung becomes solid from any cause, in the
stage of pneumonic hepatization, and in instances of pleuritic
effusion.
Pulmonary Friction-fremitus. — The gliding motion of
the costal upon the pulmonary pleura gives rise to no vibra-
tion in health ; but, in many cases of pleurisy, when their
surfaces become roughened, a distinct cracking sensation or
rubbing movement — friction-fremitus — is conveyed to the
hands. Dr. Walshe states that he has met with this pheno-
menon to a higher degree at the absorption-period than at the
outset of pleurisy.
Fluctuation. — Palpation will sometimes detect the pre-
sence of fluids contained in the lungs or pleural, the sensation
communicated being that of ordinary fluctuation, with a cer-
tain amount of vibratile tremor.
The Heart's Impulse. — Synchronous with the systole of
the ventricles and the first sound of the heart an impulsive
movement is felt, depending on the shock of the apex against
the side ; the force of the impulse being, to a certain extent,
proportionate to the healthy condition of the muscular fibres
of the heart's walls. There is no sign of hypertrophy of the
heart so sure as that afFordsd by great increase of its impulse.
MENSURATION. lol
The inordinate action of the heart in anaemia and in valvular
diseases, as well as the extent and degree of aneurismal pul-
sations, will be ascertained by palpation.
Fremissement Cataire. — Of all the irregular vibrations
of the thoracic walls, the most important is the valvular thrill,
or purring-tremor, or J'remisse)nent cataire of Laennec, resem-
bling — it is said — the sensation afforded by stroking the back
of a purring cat. This phenomenon is always accompanied
by a bellows-murmur, and occurs in those conditions of the
heart — organic or inorganic — which yield this murmur with
the greatest intensity : thus.it is very distinct in mitral regur-
gitant disease, in constrictive aortic disease, and in chlorosis —
in the latter case proving a good index of the condition of the
blood, since it becomes less distinct as the quality of the vital
fluid improves.
Cardiac Friction-fremitus. — In inflammation of the
pericardium a friction-fremitus may sometimes, though rarely,
be felt. AVhen discovered, it will" always be found to be of
short duration and generally movable.
3. MENSURATION.
In applying mensuration a common tape measure is often
sufficient, though the double tapes, as suggested by Dr. Hare,
may be advantageously used, or — where great exactness is
necessary — Dr. Sibson's chest-measurer or Dr. Quain's steth-
ometer (see Chapter II., Section 4) may be found necessary.
The object of measuring the chest is to ascertain more exactly
than can be done by inspection and palpation the comparative
bulk and volume of the two sides, as well as the amount of
expansion and retraction of the chest-walls during inspiration
and expiration.
The circular width of the chest — taken opposite the ensi-
forme cartilage — varies considerably in healthy individuals:
it increases gradually with age, from sixteen to sixty, and is
greatest in persons whose occupations demand active exertions
of the whole frame ; probably thirty-three inches may be re-
garded as the fairest adult average. The two sides of the
chest are of unequal semi-circumference in the great majority
of healthy adults, the right side measuring about half an inch
more than the left ; in left-handed people, the two sides are
generally equal.
The diseases which cause enlargement of the affected side
of the chest are pleurisy with effusion, pneumothorax, hydro-
152 PHYSICAL DIAGNOSIS OF DISEASE.
thorax, emphysema, hypertrophy of the lung, and cancerous
tumors of the lung or pleura ; while the converse obtains in
pleurisy at the period of absorption with retraction, pleuro-
pneumonia, tubercular deposit in the second stage, chronic
consolidation of the lung, and infiltrated cancer of the lung.
From a large number of observations made by Dr. Sibson,
with his '^chest-measurer," he has established the following
propositions concerning the respiratory movements in health.
Thus, in the healthy robust male the forward movement of the
sternum and of the ribs — from the first to the seventh — ranges
from one-fiftieth to one-fourteenth qf an inch during an ordinary
inspiration ; and from half an inch or nearly two-thirds of an
inch to two inches — the amount varying with the extreme
breathing capacity — during a deep inspiration. Of the five
lower ribs the ordinary movement is less, and the forced move-
ment greater, than of the upper seven. The ordinary abdominal
movement is from a quarter to one-third of an inch ; the extreme
from about half an inch to an inch and a half. The ordinary
lateral expansion of the five lower ribs is greater, and the ex-
treme expansion is usually less, than the respective ordinary
and extreme expansion of the seven upper ribs. The expansion
of the second ribs is usually alike on both sides ; below these,
all the inspiratory movements, especially those over the
heart, are usually somewhat less on the left side than on the
right, both during ordinary and extreme inspiration. In the
healthy boy, owing to the greater flexibility of the costal car-
tilages, the motion of the sternum is less than that of the
ribs, but the extreme movement of the seven superior ribs
is greater in proportion to the breathing capacity than it is in
the adult ; the upper portion of the sternum advances more
than the lower end during a deep inspiration, but there is little
decided difference during tranquil respiration. In the old
man, owing to the consolidation of the cartilages, the motion
of the sternum during inspiration is usually greater than that
of the ribs, and the lower end of this bone usually advances
more than the upper. In females the expansion of the seven
superior ribs is exaggerated, and that of the diaphragm and
lower ribs restrained, owing — in a great measure — to the use
of tight stays. The restrained movement of the lower ribs
during a deep inspiration is much greater when the stays are
on than when they are off".
In those cases of disease in which there is great obstruction
to the entrance of air through the outer air-passages during
inspiration, as in cases of extreme narrowing of the larynx or
MENSURATION. 153
trachea, or obstruction of a large bronchus, the walls of the
chest actually fall backwards, to a greater or less extent, in
proportion to the obstruction, instead of advancing during
inspiration. The explanation of this phenomenon given by
Dr. Sibsou is, that the diaphragm acts with great power and
lengthens the lung, and as air can only rush into the length-
ened lung with great difficulty through the larynx, the lungs
collapse, just as a half- filled bladder collapses when it is
lengthened, and the presence of the atmosphere forces back-
wards the anterior walls of the chest.
In emphysema and bronchitis, in those cases where there
is an obstruction to the entrance of air into the air-cells
through the smaller air-tubes, the lower end of the sternum
and the adjoining cartilages fall backwards during inspiration,
while the upper part of the chest expands, and the diaphragm
descends with great power. In pleurisy with effusion, the
inspiratory expansion of the whole of the affected side of the
chest is diminished, or in some cases even reversed ; while
that of the opposite side is throughout exaggerated : the
inspiratory motion of the abdomen is also lessened or abolished
on the affected side, while on the opposite side it is increased.
When the whole of the lung is consolidated, from gray hepati-
zation or tubercular deposit, or condensed, from firm mem-
branous bands following pleurisy, then the expansion of the
whole of the affected side is diminished, arrested, or reversed,
while that of the healthy side is exaggerated. So also, when
the upper lobe of the lung is affected with phthisis, pneumonia,
or any local disease, or when the five superior ribs are injured,
or when the intercostal muscles moving them are inflamed or
affected with pleurodynia, or when the motion of these ribs
produces pain in the arm or shoulder-joint, then the inspira-
tory motion of the five superior affected ribs is diminished,
while that of the ribs of the opposite side is usually increased.
When the lower lobe of the lung is the seat of pneumonia or
any other disease, the motion of the ribs over that lobe is
usually, but not always, diminished ; and the motion of the
abdomen just below the ribs, on the affected side, is always
lessened.
When the heart is enlarged, and still more when the two
surfaces of the pericardium are adherent, there is diminished
motion of all the ribs on the left side, Avith the exception
usually of the second and third. If there be pericarditis, the
motion is still more interfered with, and the motion of the
abdomen just below the xiphoid cartilage is also much
affected, being in all cases lessened, and in extreme examples
154 PHYSICAL DIAGNOSIS OF DISEASK.
quite interrupted ; the motion of the abdominal walls on
either side is usually not affected.
In peritonitis, if the disease be general, the abdominal
motion is universally diminished ; if it be partial, the diminu-
tion of the respiratory motion is most marked over the imme-
diate seat of the inflammation.*
From the foregoing, it is apparent that the modifications of
the respiratory movements in disease are of great value in
aiding diagnosis, since although the nature of the disease is
not indicated by them, yet its seat is at once pointed out. In
the majority of cases, the indications afforded by the senses
of touch and vision will be sufficient ; but, in obscure exam-
ples of pulmonary disease, the observations will be rendered
more minute and accurate by the aid of the chest-measurer.
4. SUCCUSSION.
Succussion is performed by gently but abruptly pushing the
patient's trunk backwards and forwards, or, by the patient
himself making the same movement, Avhile the observer's ear
is applied to the walls of the thorax. It is employed to detect
the sound of thoracic fluctuation, produced by the violent
collision of air and liquid in a cavity of somewhat large
dimensions, and compared by Dr. AValshe to the splashing of
water in a partly-filled decanter held close to the ear ; the
precise tone, however, will vary with the density of the fluid,
and the proportion of fluid and air present. The sound
of thoracic fluctuation may also be accompanied with metallic
tinkling. It is elicited in cases of pneumo-hydrothorax, with
pulmonary fistula ; or, very rarely, in pneumo-hydrothorax,
when no fistulous communication exists between the lung and
pleura; and in phthisis, when the tubercular cavity is large
and partly filled with fluid.
5. SPIROMETRY.
The spirometer is an instrument for measuring the volume
of air expired from the lungs, the construction of which, as
well as the way in which it is to be used, is fully explained in
Chapter II., Section 3.
The extent of the movements performed by the thoracic
* Dr. Sibson: Oa the Movements of Respiration in Disease. Medico-
Chirurgical Trans., vol. xxxi. p. 376; and Prov. Med. and Surg. Journal,
5th Sept. 1849.
VITAL CAPACITY AS AFFECTED BY HEIGHT. 155
boundaries for the purposes of respiration, admits of three de-
grees of modification :
a. Extreme expansion (inspiration).
h. Extreme contraction (expiration).
c. Intermediate condition (ordinary breathing).
The first two movements displace a larger, and the third
movement a smaller volume of air. The spirometer measures
collectively these three volumes of air ; that is to say, the most
complete voluntary expiration immediately following the most
complete inspiration, which Dr. Hutchinson denominates the
" vital capacity,*' or the "vital volume."' The vital capacity
volume is the limit of all the requirements for air which man
can require ; the ordinary breathing is a quiet, gentle, and
more limited movement. The ordinary breathing movement
may be considered, then, to have "a spare margin which is
ever at command — a margin absolutely necessary to health.
When we cannot command this margin, i. e., extend the or-
dinary breathing movement into the extraordinary breathing
movement, the body is incommoded, and our well-being suffers
relative to the degree of change in the thoracic mobility." The
spirometer not only measures this margin together with the
ordinary breathing movement, but it also determines the per-
meability of the lungs to air. Dr. Hutchinson chose to found
his observations upon the vital capacity volume rather than
upon the ordinary breathing volume, because the former is
from twelve to twenty times greater than the latter, and an
error of a few cubic inches in the larger volume is of little con-
sequence ; while an error of a few cubic inches in the ordinary
breathing volume is of such importance as to disguise the cor-
rect measurement of the natural breathing volume, and is sure
to occur from the nervousness or stupidity of the person ex-
amined.
The vital capacity volume is affected by height, by attitude,
by weight, by age, and by disease.
The Vital Capacity as affected by Height.— From a
very large number of experiments. Dr. Hutchinson has deduced
the curious fact that the height of an individual is the chief
condition which regulates his vital capacity, and he lays down
the following rule : That in the erect position, for every inch
of stature from five feet to six feet, eight additional cubic
inches of air, at 60° Fahr., are given out in one volume, by the
deepest expiration, immediately following the deepest inspira-
tion. This table is intended to show the capacity in health
and in the three stages of phthisis.
* Medico-Chirufgical Transactions, vol. xxix. p. 138.
156
6
PHYSICAL
n I A G y s I s OF
DISEASE.
Height.
Capacity
IN Health.
Capacity in
Phthisis pulmonalis.
Ft.
in. Ft.
in.
Cub. in.
1st Stage.
Cub. in.
2d Stage.
Cub. in.
3d Stage.
Cub. in.
5
to 5
1 .
174
117
99
82
5
1 to 5
2 .
18-2
122
102
86
5
2 to 5
3 .
190
127
108
89
5
3 to 5
4 .
198
133
113
93
5
4 to 5
5 .
206
138
117
97
5
5 to 5
6 .
214
143
122
100
5
6 to 5
7 .
222
149
127
104
5
7 to 5
8 .
230
154
131
108
5
8 to 5
9 .
238
159
3 36
112
5
9 to 5
10 .
246
]65
140
116
5
10 to 5
11 .
254
170
145
119
5
11 to 6
.
262
176
149
123
This reads thus : — A man between 5 ft. 7 in. and 5 ft. 8 in.
in height, should be able to breathe, in health, 280 cubic
inches ; in the first stage of consumption this will be reduced
to 154; in the second to 131; and in the third to 108 cubic
inches.
"Weight as affecting the Vital Capacity.— In examining
diseases of the lungs, the indications aflfbrded by the weight of
the individual are invaluable. One of the first signs of disease,
generally, is loss of weight; a steady loss always precedes
consumption, and is the earliest symptom of tubercular 'disease.
Dr. Hutchinson has observed, that a slow and gradual loss is
more serious than a rapid and irregular diminution. A person
may lose weight, but he cannot do this gradually without some
severe exciting cause.
Weight in excess begins mechanically to diminish the
breathing movements when it has increased to 7 per cent,
beyond the mean weight ; and from this point the vital capacity
decreases 1 cubic inch per lb. for the next thirty-five lbs. The
ordinary weight increases with the height, probably about 6^
lbs. per inch of stature. It is unnecessary, however, to make
the correction for weight, unless it be much in excess. From
an examination of 2650 healthy men at the middle period of
life, Dr. Hutchinson has deduced the following table :
This table reads: — A man 5 ft. 8 in. should weigh 11 st.
1 lb., or 155 lbs. (14 lbs. = 1 stone) ; he may exceed this by
7 per cent., and so attain 11 st. 12 lbs., or IGG lbs., without
affecting his vital capacity ; beyond this weight his respiration
becomes diminished.
AGE AS AFFECTING THE VITAL CAPACITY. 157
Exact
Statore.
Ft. in.
5 2
5
5
5
5
5
5
5
5
5
6
3
4
5
6
7
8
9
10
11
Mean
Weight.
St. lbs. lbs.
8 8 or 120
" 126
7
13
2
5
Weight ixcreased
BY 7 PER CEAT.
133
139
142
145
8 " 14S
10 12
15.5 11 12
8 « 162
1 " 169
6 '^ 174
12 10 " 178
St. lbs. lbs.
9 2 or 128
9 9'^ 135
2 " 142
9 " 149
152
155
158
166
173
181
186
190
12 5
12 13
13 4
13 8
Age as affecting the Vital Capacity.— The vital capacity
is found to be at a maximum betweeu the ages of thirty and
thirty-five, though the effect of age is not very manifest until a
person has attained fifty-five years, when the capacity dimin-
ishes sufficiently to render it necessary to make a subtraction.
This we must do according to the annexed table :
Height.
Ft.
in. Ft.
in.
5
to 5
1
5
1 to 5
2
5
2 to 5
3
5
3 to 5
4
5
4 to 5
5
5
5 to 5
6
5
6 to 5
7
5
7 to 5
8
5
8 to 5
9
5
9 to 5
10
5
10 to 5
11
5
11 to 6
Age,
Age,
Age,
16per cent.
15 to 55.
55 to 65.
65 to 75.
below mean
. 174
163
161
146
. 182
173
168
153
. 190
181
175
160
. 198
188
182
166
. 206
196
190
173
. 214
203
197
180
. 222
211
204
187
, 230
219
212
193
. 238
226
219
200
. 246
234
226
207
. 254
242
234
213
. 262
249
241
220
Thus it appears that a man of 5 ft. 8 in., of the mean weight,
may be expected to breathe 230 cubic inches until the age of
fifty-five, 219 cubic inches from fifty-five to sixty-five, and 212
from sixty-five to seventy-five years of age.
In all the foregoing calculations, it is supposed that the
patients are dressed in ordinary attire. We therefore have to
make no allowance for boot-heels, weight of dress, &c. It may
be remarked, however, that M. Quetelet estimates the average
14
158 PHYSICAL DIAGNOSIS OF DISEASE.
weight of the clothes, at different ages, as one-eighteenth of the
total weight of the male body, and one-twenty-fourth of the
total weight of the female.
6. PERCUSSION.
For the invention of the method of percussion — so to speak
— we are indebted to Avenbrugger, who published at Vienna,
in 17Glj his " Inventum novum, ex pcrcussione thoracis
humani, ut signo, abstrusos interni pectoris morbos detegendi,"
a treatise which remained unread until Corvisart translated it
and brought it into general notice.
Percussion — the act of striking the parietes of the cavities
of the body in such a manner as to enable the examiner to
judge of the density of the subjacent parts — is one of the
most important means of physical diagnosis in diseases of
the chest. It is said to be immediaie or direct when nothing
intervenes between the percussing agent and the part per-
cussed 5 mediate when some solid substance — as the finger or
a plate of ivory — is placed upon the part to be explored, and
the blow made vipon such substance. In the present day
mediate percussion is generally employed ; the four fingers of
the left hand, pressed firmly against the chest, serving as a
pleximeter, while the ends of those of the right hand, brought
together into a line, form the j^^cssor or jJercussor. Immediate
percussion may be performed by striking the chest with the
palmar surface of the fingers. In practising percussion, it is
best to strike first on one side of the chest and then on the
corresponding spot of the other side, in order to compare the
results ; since our estimate of the presence or amount of
disease is determined more by the relative degree of dulness
or resonance on the opposite sides, than by any absolute
degree of dulness : in doubtful cases the observation should
be repeated many times, and in various postures. The strokes
also should be made quickly, smartly, and uniformly, and at
right angles to the part percussed ; and the hand should be
moved from the vn:ist alone, the forearm and arm being held
motionless, as the strokes will be better regulated, and fall
more uniformly on the parts struck.
In percussion, if the chest be struck over a portion of
healthy lung, a hollow or clear sound will be produced ; if
over a portion of lung which has lost its spongy character
and is void of air, or in any way solidified, either by pressure
from without — as in pleuritic effusion, or by deposit within —
as in pneumonia or pulmonary apoplexy, then only a dull,
TXCREASE OF CLEARXES3. 159
hea%7, or dead sound will be heard : so also when that part of
the parietes covering the heart — the lower sternal region and
that portion of the left mammary which is covered by the
cartilages of the fifth, sixth, and seventh ribs — is similarly
struck, the resulting sound will be dull ; and if the heart be
enlarged, or its investing membrane filled with fluid, or its chief
vessels enlarged by aneurism, the extent of dulness will be in-
creased in proportion to the extent of the disease. The lungs
yield their normal, full, clear sound, slightly more and more
distinctly from above downwards, owing to their increasing
capacity ; the sound being muffled, however, by the pectoral
muscles, the mammte, and the scapulee. On the right side,
from the sixth rib, a dead sound is produced from the presence
of the liver ; the same is elicited on the left, from the junction of
the fourth costal cartilage with the left border of the sternum,
to the point where the heart's impulse is felt, owing to the
position of the heart ; while below on this side, to the left, at
the sixth rib, the sound wdll be tympanitic, owing to the
stomach being subjacent.
The morbid states discovered by percussion are few in
number and simple in nature, but the indications they furnish
are valuable.
Diminution of Clearness. — "Whenever the density of the
materials underneath the part struck is increased, there will
be diminution of clearness — varying from a slight degree to
perfect dulness, in proportion to the increased density — with
shortening in the duration of the sound. Slight pleuritic
effusion, congestion and partial condensation of the lungs,
and spasmodic asthma duiing the paroxysm, are the chief
causes of a partially dull sound on percussion ; while in
pleurisy with great effusion, in hydrothorax, in pulmonary
apoplexy, in complete condensation of the lung from pneu-
monia, in phthisis, in cancer of the lung or pleura, in hyper-
trophy with dilatation of the heart, in pericarditis with effusion,
and over aneurismal tumors there will be an absence of any
resonant sound on percussion, or, in other words, perfect
dulness.
Increase of Clearness. — Increased clearness and duration
of sound, with excess of elasticity, is noted, where the relative
quantity of air within the chest is increased, but not carried
to such extremes as to interfere, by tension of the walls, with
their vibration, as — for example — in pneumothorax, and at
the upper part of the chest in hydro-pneumothorax, and in
atrophy, hypertrophy, and emphysema of the lung. Dr. Stokes
160 PHYSICAL DIAGNOSIS OF DISEASE.
has suggested that extreme anajraia, by lessening the relative
quantity of blood in the lung, may increase the clearness of
the percussion-sound. Increase of clearness and a duration
of sound, with diminished elasticity, is observed where there
is a surplus of air in the subjacent part, with considerable
induration of tissue between the surface and the part contain-
ing that surplus, — a combination of conditions sometimes met
with in phthisis, when a superficial cavity in the lung has a
thin, indurated, and adherent external wall.^
Tympanitic Sound. — This sound resembles the tone
obtained from a drum, and is produced on percussing the
stomach, or a portion of intestine filled Avith air, but never on
percussing the healthy chest. When therefore it occurs, we
may infer that a cavity filled with air exists beneath the spot
percussed ; and consequently in thoracic affections we obtain
the clearest tympanitic sound in pneumothorax. It may also,
however, be produced less perfectly in two conditions of the
lung, independently of pneumothorax, viz.: 1, in the emphy-
sematous portions of lung which often surround lung-tissue
solidified from hepatization, tubercles, &c. ; and, 2, according
to Skoda, when the lung is gradually recovering from the
compression of fluid previously effused into the pleural sac.
Amphoric Resonance and Metallic Tinkling.— Am-
phoric resonance — a modification of the tympanitic tone — is
similar to that occasioned by striking a wine-cask partially or
entirely empty. Cavities, larger than are required for the
production of the tympanitic sound, and in which air can
vibrate, are essential to the production of this tone. The only
diseases in which it is heard are pneumothorax, and in tuber-
cular cavities of large size, having walls equably and generally
condensed. When the cavities contain a small quantity of
fluid, metallic tinkling will be frequently audible, from drops
of the fluid falling fi-om the upper part of the cavity into the
liquid below.
Tubular Sound. — The tubular percussion-sound, elicited
from an elastic tube filled Avith air, is natural only when pro-
duced over the larynx or trachea. It is heard, however, when
any condition exists which brings the larger bronchial tubes
unnaturally near the surface, or when any solid, sound-con-
ducting substance is present between the bronchi and the
surface. Thus it will be elicited in dilatation of the bronchi,
in chronic consolidation of the lung, in some cases of pleu-
* See Dr. Walshe, op. cit. p. 71.
AUSCULTATION. IGl
ritic effusion, very rarely in pneumouia, in small tubercular
cavities, and in cases where a canceroiis mass exists around
the bronchial tubes.
The Bruit de Pot Fele. — The cracked-metal sound,
resembling, according to Laennec, the sound given by a
cracked pot when struck, or rather that elicited by the child's
trick of striking the knee with closed hands to convey the idea
that they contain money, is generated in the lungs when a
large cavity exists under the part struck, having thin elastic
walls, and a free communication with the bronchial tubes. It
seems to be produced by the sudden forcible ejection of air
and fluid along the tubes communicating with the excavation.
According to Dr. Stokes, it may sometimes be elicited in
cases of bronchitis where the secretion is thin and has gravi-
tated to the lower parts of the lungs.
7. AUSCULTATION.
The genius, enthusiasm, perseverance, and energy of the
author of the imperishable treatise, " De TAuscultation
Mediate, on Traite du Diagnostic des Maladies des Poumons
et du Coeur," have been so frequently discoursed upon, that it
may almost appear a work of supererogation again to dilate
upon that discovery by which Laennec forever holds mankind
his debtor. As the Highlander, however, will not pass the
cairn of his former benefactor or friend without adding a
pebble to the tumulus, in grateful remembrance of favors
received, so it is impossible for any author to enter upon the
consideration of the subject of auscultation without his
thoughts reverting to those days when, at the Parisian Hos-
pital Necker, Laennec commenced that series of observations
which enabled him, as he tells us, ''to deduce a set of new
signs of diseases of the chest, for the most part certain,
simple, and prominent, and calculated, perhaps, to render the
diagnosis of the diseases of the lungs, heart, and pleura as
decided and circumstantial as the indications furnished to the
surgeon by the introduction of the finger or sound in the
complaints wherein these are used.'' But although we are
now, one and all, only too happy to recognize the truth of
this prediction, yet it was not so when it was penned in the
years 1818 and 1819. How the facts brought forward were
disputed, the inferences denied, and the stethoscope laughed
at, are circumstances only too well known ; and there can be
but little doubt that had the work from which I have quoted
14*
1G2 PHYSICAL DIAGNOSIS OF DISEASE.
been written in a manner less excellent, or had the results
drawn from repeated observation been less conclusive,
Laennec would have shared the same fate as Avenbruorger,
and auscultation — like percussion — might have waited for a
Corvisart to introduce it to general notice.
It must not be imagined, however, that Laennec removed
all the impediments or solved all the difficulties that sur-
rounded the idol he set up. His death in 1826, in the forty-
fifth year of his age, prevented his doing much more than
clear the way, and indicate the right path for research.
Much remained to be done, and even now there is still much
to accomplish. Happily there are men in this country, in
Germany, and in France, whose chief desire appears to be
to remove the existing obstacles.
Auscultation — ausculto, to listen — signifies the investigation
of internal diseases by the sense of hearing. It may be
immediate, when the ear is placed in opposition with the sur-
face of the body, or mediate, when some conductor of sound,
as a stethoscope, is placed between the ear of the auscultator
and the person of the patient. Immediate auscultation may
be employed with the best success in some cases ; the patient's
chest should generally be covered with a soft towel or hand-
kerchief, smoothly spread, and tightly drawn over the surface,
and the examiner should take care that none of his hair inter-
venes between his ear and the chest of the examined, or
sounds may be produced which will be readily mistaken for
those proceeding from within. In the greater number of
instances, however, mediate auscultation is to be preferred, a
common hollow cedar-wood stethoscope being \ised as a con-
ductor between the parietes of the chest and the ear. In
employing this instrument it should be applied to the naked
skin firmly, and held steady, just above the trumpet-shaped
extremity, by the thumb, index, and second fingers ; all
friction between it and the clothes should be guarded against;
both sides of the chest should be thoroughly explored ; and
the posture of the observer should be free from constraint.
AUSCULTATION OF THE RESPIRATION.
On applying the ear to the healthy thorax, the air will be
heard entering and filling the lungs, and then leaving them,
in perpetual succession. The sound caused by the ingress
and egress of air, or, in other words, by inspiration and expi-
ration, has been termed the re><piratory mvrmnr ; it is caused
BRONCHIAL RKSPIRATIOX. 163
by the vibration of the tubes through Avhich the air rushes,
according to well-known acoustic principles, and it varies in
character according to the age of the subject, the sex — being
louder in females than males, — and the part of the chest
where it is heard, being spoken of as pulmonary or vesicular,
bronchial, and laryngeal.
Pulmonary or Vesicular Respiration is heard all over
the chest in health, except at those parts where it is super-
seded by bronchial or laryngeal breathing. The murmur is a
sound of a gentle, soft, breezy character, heard with the
movements of inspiration and expiration, but much more
intensely with the former than the latter: though in healthy
respiration the inspiratory and expiratory murmurs follow each
other so closely, that they may almost be said to be continu-
ous. The vesicular murmur is much louder during childhood
than in after life, just as the whole process of respiration is
then more active : hence a loud vesicular murmur is said to
be imerile. Now although puerile respiration is a sign of
health during the early periods of life, yet at other times it is
not so, being indicative either of temporary excitement or of
the presence of disease in some part of the lungs. Thus
when one lung is rendered powerless, from the compression
of fluid effused by an inflamed pleura, or when a portion only
of a lung becomes solidified, as in pneumonic hepatization,
the intensity of the respiratory murmur will be increased in
the healthy lung or in the unaftected parts of the diseased
lung, owing to the necessarily increased functional activity of
the same, the compensating powers of the healthy lung-tex-
ture being brought into play.
In place, however, of the respiratory murmur being
increased, it may become diminished or suppressed, as will
occur when, from any cause, air is prevented from freely
entering the lungs. Thus it will be diminished in obstructive
diseases of the larynx, trachea, or bronchi, in bronchitis, in
partial infiltration of the lung with tubercle, in pneumonia, in
pleurisy with limited effusion, and in some cases of pleurodynia
or even of old age, where there is feeble respiration from
diminished action. So also it may be perfectly suppressed in
complete obstruction of a bronchus, in pleurisy with abundant
effusion, in pulmonary apoplexy, in spasmodic asthma during
an intense paroxysm, and, very rarely, in infiltration of the
lung with tubercle or other morbid matters.
Bronchial Respiration is audible over the situation of the
large bronchial tubes, i. e., at the upper portion of the sternum,
between the scapulae on a level with their spines, and less
164 PHYSICAL DIAGNOSIS OF DISEASK.
clearly under the clavicles and in the axillae. It is generally
mixed with the vesicular murmur in health, than which it is
harsher, more tubular, and blowing.
This phenomenon is heard, however, in certain morbid con-
ditions, over parts naturally yielding the vesicular murmur,
which it supplants ; it then indicates condensation of the lung
from effusion into its air-cells and parenchyma, as occurs in
the second stage of pneumonia pulmonary oedema, pulmonary
apoplexy, malignant or tubercular deposits, intra-thoracic
tumors, &c. It is clear that the lung so condensed becomes a
better conductor of sound than a healthy lung, and hence con-
ducts the bronchial murmur to the ear of the auscultator ; the
murmur being loud in proportion to the extent and degree of
condensation, and the proximity of the condensed portion to
the larger bronchi.
Much discussion has lately taken place as to the view of
Professor Skoda, who explains the existence of abnormal
bronchial respiration by the laws of consonance ; but although
it may be useful for us to know the physical causes which pro-
duce auscultatory phenomena, yet in a work like the present I
deem it better to explain the diseased conditions on which they
depend.
The Laryngeal Murmur is heard normally over the larynx
and trachea, and is more intense, drier, hollower in quality
than the preceding ; in fact, it conveys the idea of air rushing
through a tube of large calibre. When heard in situations
where vesicular respiration alone exists in health, it is indica-
tive of a cavity communicating with the bronchi, and is then
called cavernous respiration ; while if it assumes an amphoHc
character it is diagnostic of pneumothorax with pulmonary
fistula.
Sounds caused by Morbid Secretion.— The sounds or
murmurs which have just been treated of are all to be heard
in the lungs during health, being merely modified by disease ;
those, however, which remain to be considered, viz., the secre-
tion-sounds and the rubbing or friction-sound, are entirely
adventitious phenomena. The sounds caused by morbid se-
cretion are as follows :
C Sibilus, in small tubes.
Dry Sounds < Rhonchus, in large tubes.
( Dry crackle, — crude tubercle.
C Small crepitation, — pneumonia.
-», . ^ 1 J Large crepitation, — bronchitis — cavernous
^ j gurgle.
[ Humid crackle, — softened tubercles.
SOUXDS CAUSED BY MORBID SECRETION. 165
Sihihts is a hissing or wheezing noise, and occurs when the
inflammation in catarrh or bronchitis has reached the small
bronchi and vesicles, and has diminished their natural calibre,
by rendering the membrane lining them tumid ; it is a sound
bespeaking some danger.
RJionchus is a snoring or droning hum, like the cooing of a
pigeon or the bass note of a violin. It belongs to the larger
division of the bronchial tubes, and denotes their partial nar-
rowing ; it is of much less importance than sibilus, and usually
implies no danger. It may exist alone, as in bronchitis, or
should the inflammation proceed, it will be conjoined with
sibilus.
Dri/ crackle, the craqnement of Laennec, resembles the
sound produced by blowing into a dried bladder or crump-
ling up in the hand very fine tissue-paper, and conveys the im-
pression of air distending lungs that have become more or less
dry, and whose cells have been unequally but much dilated.
It is only heard during inspiration in parts of the lung where
crude, unsoftened tubercle has been deposited in moderate
quantity.
Crepiiaiion is a moist sound, of two varieties, according to
the size of the tubes in which it is generated : there is no dif-
ference between the two kinds, except in degree, and they
generally merge insensibly into each other. In common bron-
chitis, for example, after a certain time, the inflamed membrane
ceases to be dry, and begins to pour out a stringy tenacious
fluid ; rhonchus and sibilus then cease to be heard, their place
being taken by crepitations — sounds resulting from the passage
of air through a liquid, and directly occasioned by the forma-
tion and bursting, in quick succession, of numerous little air-
bubbles. Large crepitation is readily detected, as the air-bub-
bles are large ; it takes place in the larger air-tubes, and is
indicative of the presence of serum, mucus, pus, or blood in
the large bronchial tubes. Small or Jine crepitation — a good
idea of this sound may be obtained from rubbing between the
finger and thumb a lock of one's own hair, close to the ear —
occurs in the very smallest ramifications of the bronchi and the
air-vesicles themselves ; it supersedes the vesicular breathing,
and indicates the presence of a small quantity of fluid in the
air-cells, a condition which may arise not only from inflamma-
tion of the lung, but from oedema, or from an effusion of blood
into the vesicles — as in pulmonary apoplexy. In the greater
number of cases, however, it is a pretty certain sign of the ex-
istence of pneumonia ; it may be heard from an early stage of
the inflammation until complete hepatization occurs, when it
1G6 PHYSICAL DIAGNOSIS OF DISEASE.
ceases, to reappear if the inflammation end in resolution in-
stead of going on to gray hepatization or suppuration, being
gradually succeeded — as the lung returns to its normal state —
by large crepitation, and ultimately by vesicular breathing.
Thus it appears that rhonchus and large crepitation are
respectively the dry and moist sounds of the larger air-tubes ;
sibilus and small crepitation, of the minutest divisions of the
air-tubes and ultimate vesicles of the lungs.
Humid crackle or the cavernous rhonchus, or gurgling, of
some authors, is characterized by a strongly marked mucous
gurgling or bubbling sound, most apparent after a full inspira-
tion, or a fit of coughing. When it occurs at the summit of
either lung it is in all probability indicative of tubercles be-
ginning to soften : when at the middle of one or both lungs, it
may result from the gurgling of fluid in a dilated bronchus ; or
from the passage of air through fluid in a tubercular cavity ;
or from abscess of the lungs ; or lastly, perhaps, from diffused
suppuration of the pulmonary texture, as occurs when pneu-
monia proceeds unchecked to its third stage.
Friction-sound. — This murmur is generally difficult of de-
tection by the ear alone, but if the hand be placed upon the af-
fected part a sensation of rubbing is generally perceived, which
is then communicated to the ear by auscultation ; it attends
both movements of respiration, but is loudest and most pro-
longed during inspiration. It occurs in pleurisy, when, the
polish of the healthy serous membranes being lost by the
exudation of lymph, the rubbing of the costal upon the pulmo-
nary pleura is distinguished. It of course ceases when the
exudation of serum is sufficient in quantity to separate the
costal from the pulmonary pleura, but returns as the fluid
poured out becomes absorbed, continuing until the lymph
itself is also absorbed, or until the opposed surfaces of the
pleura become adherent. It may also occur when deposits of
tubercles or carcinoma are so localized as to cause roughening
of the pleura, or even when interlobular emphysema gives rise
to the same conditions.
AUSCULTATION OF THE VOICE AND COUGH.
The voice, though chiefly produced in the larynx by the
vibrations of the air, of the chordae vocales, and of the trachea,
and passing outwards by the mouth and nostrils, has its sound
also partially propagated inwards to the lungs by the air in
the trachea and bronchial tubes, occasioning a vibratory sen-
^GO PHONY. 167
sation or fremitus in the smaller bronchi, or even a more dis-
tinct vocal resonance in thin persons having a large chest and
strong sharp voice.
Bronchophony. — In certain morbid states, the voice be-
comes indistinctly audible over portions of the lung where it
is not heard in health. This phenomenon, called bronchophony
or bronchial voice, is developed by the same causes that ren-
der the bronchial respiration morbidly audible, that is to say,
by condensation of the lung in the vicinity of large bronchial
tubes ; hence it is an important symptom in pneumonia and
phthisis. Bronchial respiration and bronchophony are fre-
quently heard together ; but since the sound of the voice is
much louder than the sound of respiration, bronchophony may
often be heard before the lung has become sufficiently solid to
render bronchial breathing audible.
Pectoriloquy. — When the stethoscope is placed on the
trachea, the voice articulates itself into the ear as if it came
from and through the instrument. This phenomenon, natural
over the trachea, is a sign of disease when heard elsewhere,
and is then called pectoriloquy ; it is, indeed, a loud broncho-
phony, and, except in extreme cases, it is often difficult to
determine whether the vocal resonance shall be designated
bronchophony or pectoriloquy. Pectoriloquy is generally
caused by condensation of the lung around a cavity having
free communication with the trachea through the larger
bronchi ; it may also arise from a very solid state of lung
alone, or from consolidation of the lung round a dilated bron-
chus. It is often very difficult, if not impossible, to distinguish
a dilated bronchus containing fluid from a tubercular cavity.
Aegophony is a modification of bronchophony, consisting
of a peculiar resonance of the voice, resembling the bleating
of a goat or the voice of Punch, following or accompanying
the words of the patient. Its usual position is at the lower
and posterior part of the chest, near the larger bronchi ; it is
so peculiar that once heard it cannot be mistaken, ^go-
phony was supposed by Laennec to be produced only by the
bronchial resonance of voice passing though a thin layer of
fluid between the pulmonary and costal pleurae, and conse-
quently was thought to be pathognomonic of pleurisy. It has,
however, also — though rarely — been heard in simple consoli-
dation of the lung, when no fluid could be detected in the
pleura, and although its occurrence under these circumstances
has not been satisfactorily explained, yet it is necessary to
remember it in practice. Still it appears probable that in the
majority of cases aegophony is due to the presence of pleuritic
168 PHYSICAL DIAGNOSIS OF DISEASE.
effusion ; and as it disappears when the effusion is great it
may be regarded as an index of the quantity of fluid present.
Morbid Phenomena of the Cough.— The remarks just
made as to the voice, will apply also to that unnatural vocal
sound — cough ; a few additional observations only being ne-
cessary as to a very peculiar sound called metallic tinJding,
which is sometimes heard during ordinary inspiration, but
which generally requires the act of coughing to elicit it. This
physical sign, likened by Laennec '' to the sound emitted by a
cup of metal, glass, or porcelain gently struck by a pin, or
into which a grain of sand is dropped," is made up of the
tinkling, properly so called, caused by the fall of a drop of
liquid from the upper part of a cavity into some liquid at the
lower part, and of the riiig or resonance, caused by the rever-
beration of the walls of the ca\dty, to which part of the
phenomenon many stethoscopists apply the term amphoric
resonance.
Metallic tinkling and amphoric resonance occur together
only under two circumstances: — 1. When a large cavity exists
in the lung, containing a small quantity of thin pus, and com-
municating freely with the bronchial tubes ; and 2, pneumo-
thorax, when there is a fistulous communication between the
lung and the cavity of the pleura. The latter is the most
fi'equent cause of metallic tinkling.
AUSCULTATION OF THE HEART.
The size of the heart is generally estimated to be about the
same size as the closed fist of the subject. The walls of the
left ventricle and auricle are thicker than those of the right.
The tricuspid valve — or that guarding the right auriculo-
ventricular opening — is situated behind the sternum, on a
level with the articulations of the fourth ribs with this bone.
The mitral valve — guarding the left auriculo-ventricular ori-
fice — lies behind the cartilage of the fourth rib, on the left of
the sternum. The three small semilunar valves of the pulmo-
nary artery lie just behind the junction of the cartilage of the
third left rib with the sternum. While the three semilunar
valves of the aorta are situated immediately below the pul-
monary valves, in the space between the cartilages of the
third and fourth lefl ribs.
In listening to the sounds produced by the action of the
heart, attention should be paid to the impulse, to the character
and rhythm of the sounds, and to the situation in which they
are most distinctly heard, as well as to the direction in which
they are propagated.
AUSCU J/I'ATIOX OF THE HEART. 16'J
To judge of the impulse, the spot where the apex of the
heart beats against the chest-walls should be felt for, and the
hand applied there. The stethoscope should then be placed
immediately over the same spot, when the Jirst or systolic sound
will be heard. This sound has its maximum intensity over
the heart's apex — below and rather to the outside of the
nipple. Then placing the instrument above, and a little to
the inside of the nipple, near the margin of the sternum, the
second or diastolic sound will be most distinctly heard —
sharper, shorter, and more superficial than the first. These
two sounds may be imitated by pronouncing in succession the
syllables luhh, dup}
The first or systolic sound of the heart, dull and prolonged,
coincident with the contraction or systole of the ventricles, the
impulse of the apex against the ribs, and with the pulse of the
large arteries, is probably chiefly caused by the contraction of
the muscles, the closing of the valves, the current or wave of
blood passing from one cavity into another, and perhaps by
the shock of the heart's apex against the side. The second
or diastolic sound, sharp and short, synchronous with the dila-
tation or diastole of the ventricles and with the recedence of
\he heart from the side, is agreed by all authorities to depend
upon the sudden tension and closing of the semilunar valves,
the recoil of the columns of blood in the aorta and pulmonary
artery upon the upper surfaces of these delicate folds of mem-
brane causing them to tighten with an audible check. At-
tempts have been made to assign the time occupied by each
sound and the interval of repose. Dr. J. C. B. Williams
divides the whole period from the commencement of one pul-
sation to the commencement of the next into five equal parts,
allotting two of these to the first sound, one to the second, and
two to the interval. This order of succession is called the
rhythm of the heart. Inspiration is for the most part synchro-
nous with the systole of the ventricles and diastole of the auri-
cles ; expiration, on the contrary, accompanies the diastole of
the ventricles and systole of the auricles.
The adventitious sounds heard on the surface of or within
the heart are termed murmurs; they are divided into peri-
cardial and endocardial, the latter being subdivided into
organic and inorganic.
Most of the alterations in the internal lining membrane of
the heart result from inflammation, which gives rise to a
deposit of lymph upon or beneath the serous membrane. The
* See Dr. Hughes Bennett's excellent "Introduction to Clinical Medi-
cine." Second edition, p. 40.
15
170 PHYSICAL DIAGNOSIS OF DISEASE.
valves thus lose their thinness and transparency, become
thick, puckered up, and adherent to each other or to the
opposite walls of the channel. Independently of inflamma-
tion, the valves may become covered with warty vegetations
or excrescences, or they may be converted into bone. When
affected in any of the foregoing ways they will act ineffectively,
and an organic bellows-murmur will result.
Pericardial Friction-murmur. — Pericardial murmurs
vary much in intensity, being sometimes so delicate that the
closest attention is requisite for their detection, sometimes so
loud that they can be heard over the whole cardiac region.
Though more singular and varied than the friction-murmurs
present in peritonitis or pleuritis, yet they have the same
superficial rubbing, or to-and-fro character ; they are generally
also double, the first murmur attending the systole of the heart,
the second the diastole. The rougher the lymph, and the less
the serum effused with it, the louder will be the friction-
murmur : it may disappear in a few hours on the effusion
becoming sufficient to separate the pericardial surfaces from
each other, reappearing as the serum becomes absorbed, and
remaining audible either until the membrane becomes smooth
and healthy, or until it becomes adherent. The friction-
murmur is pathognomonic of pericarditis. When — as often
occurs — endocarditis accompanies pericarditis, a bellows-
murmur, from fibrinous deposits in the texture or on the sur-
face of the valves, will coexist with the pericarditic friction-
murmur, and remain audible long after its cessation.
Endocardial Murmurs. — The natural sounds of the heart
are liable to be modified or changed by disease, causing either
sound or both to be accompanied or to be supplanted by a
noise which has been aptly compared to the blowing of a
pair of bellows ; hence it is termed by us a hellows-murmur,
and by the French a hmit de sovfflet. A bellows-murmur
may be harsh, or rough, or cooing, or whistling, or musical,
but these modifications are of little importance : of whatever
nature, it is caused either by the presence of obstructions
which impede the free flow of blood through the heart and its
great vessels — producing an organic murmur ; or by a sup-
posed peculiar condition of the blood — giving rise to an inor-
ganic murmur.
The lining membrane, valves, and orifices of the left side of
the heart are much more frequently diseased than those of
the right ; so much so, that it is almost a question whether
disease of the tricuspid or pulmonary valves can be accurately
diagnosed. Diseases of the left side chiefly affect the arterial
ENDOCARPIAL MURMURS. 171
pulse, o-iving rise to irregularity and inequality ; those of the
right side atfect the venous circulation, causing regurgitation
into the jugular veins — a condition known as the venous pulse.
Dropsy is more often connected with disease of the right than
of the lefl ca^-ities.
Disease of the semilunar valves of ilie aorta is not uncom-
mon. If the affected valves diminish the aortic orifice during
systole — or contraction — so as to prevent the blood from
freely flowing out of the ventricle, a systolic bellows-sound
will result, which will be best heard at tlie base of the heart,
along the course of the thoracic aorta, up towards the right
clavicle, and even in the carotids ; the sound diminishing as
the stethoscope is moved towards the apex of the heart. If
the valves close imperfectly, permitting reflux of blood from
the aorta, the morbid sound will be diastolic — will accompany
the dilatation of the ventricle. The pulse of aortic regurgi-
tant disease is peculiar, being generally sudden and sharp,
and without any prolonged swell of the artery ; Dr. Hope
calls it a jerking pulse. The short second sound of the heart
will also be muffled and indistinct. Sometimes we have both
these conditions of the aortic valves in the same case — a double
bruit or bellows-sound will then be produced.
The mitral valve, which guards the left auriculo-ventricular
orifice, may become thickened or ossified, the effect of which
is to prevent its closing the auricular orifice during systole, as
well as not to permit of its lying flat against the walls of the
ventricle, so as to allow the blood to pass freely out during
the diastole. In such cases the orifice is almost rendered a
permanent oval slit. A double bruit may perhaps be present;
the first, systolic, caused by the regurgitation of the blood
from the ventricle into the auricle ; the second, diastolic, and
due to the impediment to the passage of the blood from the
auricle to the ventricle ; it is but rarely heard, however. The
murmur or murmurs will be most distinct towards the apex of
the heart, on the left. The pulse will be irregular. Palpa-
tion also often discovers a purring thrill.
The semilunar valves of the pulmonary artery are very
rarely diseased ; so rarely, that any organic alteration in
them is a pathological curiosity. When, however, a bellows-
murmur can be traced from the middle of the left-edge
sternum up towards the left clavicle, and when this murmur
cannot be heard in the subclavian or carotid arteries, we may
perhaps assume that it originates at the orifice of the pulmo-
nary artery. The pulse will be unaltered.
The tricuspid valve, guarding the right auriculo-ventricular
172 PHYSICAL DIAGNOSIS OF DISEASE.
openinor, is also but seldom found otherwise than healthy.
When diseased, the arterial pulse will l)e unaffected, but there
will be turgescence, with pulsation of the jugular veins at
every ventricular systole. A bellows-murmur will be heard
over the central and lower part of the sternum, extending
downwards to the epigastrium, inaudible in the aorta and its
branches.
To determine the systolic or diastolic character of a murmur,
tlie pulse at the wrist must be carefully noted during ausculta-
tion ; if systolic, the bruit must of course be synchronous with
the pulse, and if most audible at the apex is indicative of mi-
tral disease; if diastolic, not synchronous with the pulse, and
most audible over the centre of the sternum and along the
course of the aorta, it is indicative of aortic disease.
" It too often happens," says Dr. Stokes, " when the exist-
ence of a valvular disease is determined, that great labor is
expended in ascertaining the exact seat and nature of the af-
fection. Long and careful examinations are made, to deter-
mine whether the disease exists at the right or left side of
the heart : whether it be a lesion of the mitral, tricuspid, or
the semilunar valves ; a contraction or dilatation ; an ossifica-
tion ; a permanent patency, or warty excrescence."* Now
these questions are unimportant compared to the following : —
I. Do the murmurs really proceed from an organic cause?
and 2, what is the vital and physical condition of the muscular
portions of the heart?
Inorganic Murnmrs — much less formidable than the or-
ganic — accompany impoverished conditions of the blood, espe-
cially those depending on a defect in the red globules 5 they
are heard in those conditions of the system known as anaemia,
chlorosis, &c., and result from starvation, loss of blood, sexual
excesses, and other circumstances producing great depression.
On auscultation over the base of the heart, a loud systolic bruit
or bellows-sound will frequently be detected, and may be traced
distinctly up the aorta, and in the subclavian and carotid arte-
ries. By placing the stethoscope over the jugular vein, espe-
cially over the right, a continuous humming, or cooing, or even
whistling sound — the bniit de diahle — will be heard ; a sound
which is probably caused, as Dr. Ogier Ward first pointed out,
l)y the descent of attenuated blood through the great cervical
vessels ; although some authorities regard the carotid artery as
its seat. The researches of Dr. Liman, of Berlin, show that
this bruit is sometimes heard during perfect health, especially
in the young.
» Diseases of the Heart, p. 131.
MODES OF PHYSICAL EXAMINATIOX. 173
SECTION 3. THE PHYSICAL DIAGNOSIS OF DISEASES OF
THE ABDOMEN.
The organs contained in the abdominal cavity can hardly be
considered of the same vital importance as the brain, lungs, or
heart : still the correct performance of the functions of the
abdominal viscera is most important to the welfare of the indi-
vidual, and the careful study of their diseases is incumbent on
every practitioner, since they cause much suffering, and ulti-
mately often destroy life.
Regions of the Abdomen, — For convenience in the de-
scription of its diseases, the abdomen, like the chest, is arbi-
trarily divided into regions. Thus we have, from above down-
wards :
The epigastric — and right and left hypochondria.
The umbilical — and right and left iliac.
The hypogastric — and right and left inguinal.
If a horizontal line be drawn round the body, touching the
extremity of the ensiform cartilage, this will form the superior
boundary of the abdomen ; draw another such line on a level
with the cartilages of the last false ribs, and a third on a level
with the crests of the ilia ; we shall thus have three horizontal
zones. These are to be subdivided each into three regions by
drawing two vertical lines— one on either side — from the
middle of Poupart's ligament perpendicularly upwards. The
three central regions thus formed are named — from above
downwards — the epigastric, the umbilical, and the hypogastric;
on either side of the tirst are the right and left hypochondria ;
of the second, the right and left iliac ; of the third or lower-
most zone, the right and left inguinal.
Modes of Physical Examination.— Five methods of
physical examination are resorted to in the diagnosis of diseases
of the abdomen, viz.: — 1. Inspection, by which much valuable
knowledge is obtained as to the shape, the positive and relative
size, and the situation and movements of the abdominal visce-
ra ; 2. Mensuration, by which we confirm the evidence obtained
by inspection ; 3. Palpation, by which the size, situation, con-
sistence, and tenderness of the different organs may be estima-
ted, and the presence of tumors when they exist ; 4. Percus-
sion, which often affords most important information, teaching
us the situation of the intestines, and whether the parts be-
neath are hollow and filled with air, or whether there is fluid
in the peritoneum, or whether there are any solid tumors ;
and 5. Auscultation, which is of especial value in the determi-
nation of pregnancy, of aneurisms of the abdominal aorta, and
of tumors generally.
15*
174 physical diagnosis of disease.
1. Inspection.
In examining the abdomen by the sense of sight, it is neces-
sary, in the majority of cases, that it be micovered and exposed
to a good light, which may be carefully done without any of-
fence to the patient's delicacy. The person to be examined
may be in the erect or recumbent posture, with the arms hang-
ing loosely by the side. When the abdominal walls and
viscera are healthy, the general form of the abdomen is gently
convex, both sides being symmetrical, and presenting here and
there slight rounded projections and depressions. Partial
abdominal enlargement will be manifested by unnatural ful-
ness or bulging of any part of the abdominal parietes, the situ-
ation depending upon the cause : in general enlargement, the
whole abdomen will bulge forwards, to a slight degree, when
the enlargement is due to a general increase in the thickness
of the parietes of the abdomen 5 more so when the abdominal
organs are increased in bulk ; and most of all when there is
an accumulation of gaseous, liquid, or solid matters within the
intestines, or within the cavity of the peritoneum. Fieculent
accumulations take place mostly in the large intestines, and in
the lower part of the ileum, causing distension of the colon
and caecum, manifested by irregular prominence in the right
iliac, both hypochondriac, and loft iliac regions. Disease of
the liver gives rise to enlargement of the right hypochondriac
and epigastric regions ; while enlargement of the spleen pro-
duces a projection of the lower left ribs at the side, and a tu-
mor in the left hypochondrium. Tubercular disease of the
mesenteric glands is generally accompanied by enlargement of
the whole abdomen, and by deviations from its natural form and
symmetry. In ascites, the smooth roundness of the abdominal
swelling is peculiar, so that when the fluid is abundant the
abdominal cavity is expanded into a large, smooth, and almost
polished globe ; while in pregnancy and in encysted ovarian
dropsy the tumors can be traced deeply into the pelvis.
2. mensuration.
In measuring the abdomen, a common tape measure will be
found the most useful. The measurements are usually made
at the margin of the lower ribs and the umbilicus, and when
the abdomen is partially distended at and around the most
prominent region.
3. PALPATION.
For accurate palpation, the hand should be applied directly
to the surface, using more or less pressure as we wish to
PALPATION. 175
determine the condition of the walls or of the deep-seated
viscera, and according to the existence or non-existence of
tenderness : occasionally the whole of the palmar surface of
the hand should be used, occasionally only the tips of the
fingers, which are very sensitive. In health the abdomen is
generally soft, and the walls are moderately elastic in each
region. Tumors are discovered by their resistance to pres-
sure, by their hard feel to the touch, and by the contrast
which the parts occupied by them present to the healthy
regions. Care must be taken not to mistake — as is often
done — the contraction of the central portions of the recti
muscles for ovarian and other tumors. This error may be
avoided by keeping the flat hand firmly and steadily applied,
while the patient's attention is attracted to other matters,
when the muscles will be found to relax, or so much to vary
their degree of tension as to show the cause of the hardness.
The right rectus is often more tense than the left, especially
if there be any tenderness of the liver.
The practice of palpation is eminently useful in the diag-
nosis of the following diseases :
Acute Inflammation of the Liver is signalized by pain,
more or less severe, in the region of the liver, increased on pres-
sure, deep inspiration or cough ; inability to lie on the left side ;
a yellow tinge of the conjunctiva, sometimes jaundice ; dys-
pnoea ; cough ; vomiting ; and hiccough. When the pain is
of a sharp, lancinating character, it is supposed to indicate
inflammation of the serous covering of the gland ; when dull
and tensive, the parenchyma is the part affected ; when the
convex surface of the organ is the seat of the inflammation,
the chest symptoms will predominate ; when the concave, the
stomach symptoms will be the most marked.
In Acute Inflammation of the Peritoneum the pain is
generally very severe, soon spreads over the whole abdomen,
and is aggravated by any movement which calls the abdominal
muscles into action, or by pressure — even the weight of the
bedclothes being insupportable : the patient consequently lies
quiet on his back, with his knees bent, and legs drawn up.
On careful examination, a sensation of friction will often be
communicated to the hand, which has been likened to a
gentle vibration under the fingers, or to a sensation of creak-
ing, or grating, or crepitus. The abdomen is tense, hot, and
frequently tympanitic 5 the bowels are constipated ; there is
often nausea and vomiting ; the skin is hot and dry ; the pulse
rapid and weak ; the respirations hurried ; the tongue furred 5
and the countenance is expressive of suffering and great
176 PHYSICAL DIAGNOSIS OF DISEASE.
anxiety. After a time the belly ceases to be tympanitic, but
remains somewhat enlarged from the effusion of serum.
"When a fatal termination is approaching, the abdomen often
becomes much distended, the pulse very quick and weak, the
countenance ghastly, and death occurs from exhaustion.
Ascites, or Dropsy of the Peritoneum, arises from many
causes, but most frequently from cirrhosis. The extent of
the abdominal enlargement will of course depend upon the
quantity of liquid present, but the distension will always be
uniform ; fluctuation will generally be distinct ; and there
will, in most cases, be resonance over the higher parts of the
belly on percussion, owing to the floating of the intestines,
thus prominently distinguishing ascites from ovarian dropsy.
I say, in most cases, for the distension may be so great that
the breadth of the mesentery may be insufficient to allow the
intestines to reach the surface of the fluid ; dulness will then,
of course, result. I have noticed, however, that where there
is any difficulty in the diagnosis of ascites and ovarian dropsy,
the mere fact of difficulty may be taken as presumptive evi-
dence in favor of the case being one of ascites. Ovarian
dropsy very rarely simulates ascites. In both diseases there
will be dyspnoea, which will be urgent in proportion to the
distension.
Ovarian Dropsy consists in the conversion of the ovary,
or of parts of it, into cysts ; generally perhaps by enlargement
of one or more of the Graafian vesicles. Under the same
name, simple serous cysts formed in the broad ligaments, and
dropsy of the Fallopian tubes arising from closure of their
extremities, have been included.
The first symptom of an ovarian tumor is enlargement of
the lower part of the abdomen — generally of one or the other
iliac regions. If palpation be practised, a tumor may be
felt ; but patients rarely apply for advice until the cyst has
obtained considerable size. Fluctuation will then be distin-
guished with ease or difficulty, according to the nature of the
tumor and its contents. In all cases there will be a dull
sound on percussion over the tumor.
An ovarian cyst may be single or multilocular ; that is to
say, it may consist of one sac only, or it may be made up of
a variable number of small cysts. All ovarian tumors run
their course much more rapidly than is generally supposed.
Cases of fibrous tumors of the uterus, which often exist for
years without any suffering, are repeatedly mistaken for
ovarian tumors. So also are concretions arising from the
accumulation of various indigestible matters in the bowels,
PERCUSSION. 177
especially when they occur in the ascending or descending
portion of the colon, and when they are large and slightly
movable. Adhesions often form between ovarian tumors and
the peritoneum ; I believe that they may be distinguished by
every physician possessing the Uicius enidilus.
Dilatation of the Stomacll is a curious disease, to which
attention has lately been directed. It is due generally to some
affection of the pyloric orifice, which, causing contraction,
prevents the food from readily passing into the duodenum.
Hence the stomach slowly and gradually dilates, until at last
it comes to occupy almost the whole of the abdominal cavity,
giving rise to appearances as if a tumor were present. These
appearances are the more deceitful when the stomach is full,
because fluctuation may then be present ; when this viscus is
empty, there will be a tympanitic sound on percussion.
Abscesses of the Liver sometimes attain a great size,
and, in extreme cases, may contain several pints of pus.
Fluctuation will then be perceptible, but only over the region
of the liver, where also a tumor will be felt. They may burst
into the peritoneum, and give rise to fatal peritonitis ; most
frequently, however, when the matter gets near the surface of
the gland, adhesive inflammation is set up in the portion of
peritoneum immediately above it, and lymph is poured out,
which glues the organ to adjacent parts — to the abdominal
parietes, the diaphragm, stomach, or some part of the intes-
tines ; the pus is then discharged externally, or into the lung
or pleura, or stomach, &c.
Abnormal Pulsations. — The pulsatory movements of the
abdomina aorta are generally lost to the touch, although they
may become evident both to the sense of touch and of sight
when the parietes are wasted, and the movements violent, as
in anaemia, or in disease of the coats of the vessel, or when a
tumor or a cancerous mass lies directly over the artery. The
pulsations are usually best seen at the epigastrium, and some-
times at the umbilicus ; on applying the hand, a jerking,
quick, strong, forward impulse is felt ; while auscultation
often discovers a bellows-murmur, especially if anaemia coex-
ists. I have found this pulsation not uncommon in cases of
uterine disease ; it has also been frequently noticed in hypo-
chondriacs, in those whose digestive organs are deranged, in
chlorotic females, &c.
4. PERCUSSIOX.
In the diagnosis of abdominal diseases, mediate percussion
is for the most part employed, the middle finger of the left
178 PHYSICAL DIAGNOSIf? OF DISEASE.
hand forming an excellent pleximeter. Over the region of
the liver the sound elicited is dull : over the stomach, when
empty, slightly hollow ; or when filled with gas, tympanitic:
over the colon, when distended with air, resonant; when
loaded with fasces, dull : while over the small intestines there
is generally resonance. Over all the intestines a sense of
elasticity is imparted to the percussing fingers. When the
liver is increased in size, or Avhen the spleen or the kidneys
are enlarged, or when any solid tumor occupies the peritoneal
cavity, there will be dulness on percussion in proportion to
the extent of the solid matter. AVhen, owing to perforation
of the intestines, there is air in the peritoneum, the sound on
percussion will be tympanitic, while the elasticity of the
abdomen will be increased ; when fluid or faecal matter has
been effused, there will be dulness. The great pain and con-
stitutional disturbance, however, will prevent any examination
but a cursory one.
Obstruction of the Bowels is a disorder, the diagnosis of
which will be much facilitated by the careful practice of
percussion, aided by palpation. This fearful accident — so to
speak — may arise from several conditions, which I shall briefly
consider on account of the great impoi'tance of the subject,
premising that it may occur at any part of the bowels from
the duodenum to the rectum, and that when there is obstruc-
tion with fajcal vomiting the disease is called ileus. Strangu-
lated heiiiia is perhaps the most frequent cause of obstruction;
consequently, in every case of obstinate constipation with
sickness, the practitioner should make a careful examination
of those parts of the abdomen, thigh, hip, and, in women, of
the vagina, at which the intestine may descend. Intestinal
concretions or calculi will also produce obstruction, and so
will polypi. In the museum of the Westminster Hospital
there is a preparation, showing a polypus entirely blocking
up the jejunum. Intussusception, which consists of a slipping
of a superior portion of the intestinal tube into an inferior,
will also give rise to it. A part of the bowel may become
strangulated by preternatural batids, the result perhaps of
previous peritonitis, or by elongations of the peritonemn.
Dr. Watson says he has twice seen the appendix vermiformis
prove the cause of fatal internal hernia. In one case, the free
end of the appendix became adherent to the mesocolon,
forming a loop, through which a portion of the gut passed and
became constricted. In the other instance the appendix was
literally tied round a piece of the intestine. In a case which
I saw at King's College Hospital, a diverticulum from the
AUSCULTATION. 179
small intestines was connected with the abdominal parietes
close to the umbilicus, forming a ring, thi-ough which part of
the ileum had passed and become strangulated. A part of
the bowel may likewise become sfricfured, either from simple
thickening of its coats, or from malignant disease ; or the
uterus may become retrofiexcd, or retroverted, and by pressing
upon the rectum materially diminish its calibre : and, lastly,
the mnscidar Jibres of the intestine may become paralyzed from
over and long-continued distension, just as sometimes happens
in the case of the urinary bladder.
The principal symptoms of obstruction are constant vomit-
ing, which is at first simple — consisting of the contents of the
stomach, and mucus, but which in a few days becomes sterco-
racious or faecal ; pain varying in degree, often very severe ;
great mental depression ; and the pathognomonic symptom —
constipation. The physical signs are such as indicate a state
of emptiness below the seat of obstruction, and of distension
above it. When the small intestines are greatly distended
their convolutions are often traceable, and they may be felt
by the hand to roll about with loud borborygmi ; at the same
time the abdominal enlargement and the distended small
intestines obscure the resonant sound given out by the colon
when empty. When the obstruction is seated only a little
above the caecum, this part may form a large dilated tumor in
the right iliac region. When in the colon or rectum, assist-
ance may often be derived from introducing the finger ; or, if
the obstruction be higher than the finger can reach, by using
an elastic rectum tube, or by injecting warm water, and
observing how much can be thrown up. The lower the
obstruction is situated the less urgent will be the vomiting ; if,
for instance, it is in the duodenum, the vomiting will be
incessant from the beginning ; if in the colon, it may be
absent for some time. It might be thought that the ilio-caecal
valve would prevent the return of the contents of the colon
into the ileum ; the preliminary dilatation, however, renders
this valve quite patulous. When urine is freely secreted, the
obstruction cannot be very high up.
5. AUSCULTATION.
Auscultation of the Abdomen in Health and Disease.
— The audible movements which occur within the abdomen
in health are two : 1. The movements of alimentary or
secreted matters, as gas, within the digestive tube, either by
the spontaneous action of the canal itself, or as the result of
180 PHYSICAL DIAGNOSIS OF I) I S E A S K.
manipulation ; and, 2, the movement of the blood in the
vessels.
On applying the stethoscope over the stomach, an almost
constant succession of gurgling sounds is heard when it con-
tains liquid and gaseous matters, owing to the commingling
of these. The sounds emitted from the intestines — bor-
borygmi — arise from the passage of the gas they contain
through insufficient spaces from one part of the tube to
another ; they occur abundantly during the contractions which
ensue on the operation of a purgative, and they may be at
once induced by a draught of cold water.
The pulsations of the aorta are occasionally heard during
health in spare subjects ; they disappear opposite the division
of the vessel into the iliac arteries.
In disease these sounds are merely modified as regards
their clearness and extent. When the surfaces of the perito-
neum are roughened by inflammation a friction-murmur may
often be detected ; this sound is often audible in cases where
friction-vibration cannot be felt.*
Auscultation of the Abdomen during' Pregnancy fur-
nishes us with two very important signs — one derived from
the uterus, the other from its contents. To detect them the
patient should lie on her back with her shoulders raised, and
the legs drawn up, in order to relax the abdominal integu-
ments. The uterine murmur, known as the placental murmur
or uterine soufflet, has its origin probably in the blood-vessels
of the uterus, and not, as was thought, in the placenta. My
own reason for discarding the latter opinion is, that I have
frequently heard a similar murmur in large fibrous tumors of
the uterus, and have been helped thereby to diagnose such
tumors from those caused by cystic disease of the ovary.
M. Cazeaux has suggested that an altered condition of the
blood may help to produce it. The character of the sound
is that of a rushing, blowing murmur, synchronous with the
maternal pulse, unaccompanied by any impulse, and requiring
careful examination for its detection. It is generally first
heard towards the end of the fourth calendar month, though
it has been detected as early as the tenth week ; it is frequently
audilile over the whole of the uterus, but is usually most
developed over one or both inguinal regions. Its presence
affords no evidence as to the life or death of the foetus.
The pulsations of the foetal heart afford a double sound
somewhat resembling the ticking of a watch, varying in fre-
* See Dr. Ballard's valuable volume on the Diagnosis of Diseases of the
Al)domen.
DIAGNOSIS OF T H O K A C I C DISEASES. 1 8 1
quencv from 120 to 160 in a minute, and haWng no relation
with the pulse of the mother. The pulsations are best detected
between the umbilicus and the anterior superior spinous pro-
cess of the ilium, on either side, but most frequently to the
left ; they are rarely audible before the end of the fifth month
of pregnancy, and they become more distinct as gestation ad-
vances. When discovered they prove a certain sign of the
presence of a live foetus.
Occasionally the movements of the foetus can be detected
both by palpation and auscultation, about the time that the
foetal heart is heard ; and, according to Dr. Kennedy, '^ the
funic souffle,^'' weaker than the uterine murmur and synchro-
nous with the foetal heart, may sometimes be detected by the
ear. In the course of a large number of examinations, how-
ever, I have never discovered the latter sound.
CHAPTER VIII.
GENERAL OBSERVATIONS ON THE DIAGNOSIS OF
THORACIC DISEASES.
In exploring the diseases of the lungs and heart by the
physical methods of diagnosis, it must be remembered that the
signs derived from these sources are not to be solely trusted to,
but that every circumstance bearing upon the case under ex-
amination is important, and must consequently be taken into
consideration if we would wish our judgment to be unbiassed
and our opinion correct. The maxim of the old logicians —
that it requires all the conditions to establish the affirmative,
but that the negative of any one proves the negative — is in the
main true as regards the diagnosis of many diseases. Thus,
in suspected valvular disease of the heart, if the sounds be
healthy, unattended by any murmur, we may be sure, however
strong the other symptoms may be, that the suspicion is not
well founded •, but the converse does not hold good, that a bel-
lows-murmur being present, there is consequently valvular af-
fection. In order to aid the student in studying the chief
pulmonary and cardiac affections I have devoted the present
chapter to the consideration of their general diagnosis, and I
trust it will not be thought unworthy of the close attention of
the reader.
16
182 DIAGNOSIS OF THORACIC DISEASES.
BRONCHITIS.
Inflammation of the bronchial tubes may be acute or chronic.
Acute Bronchitis is a dangerous disorder, more especially
on account of the frequency with which the inflammatory
action spreads to the vesicular texture of the lungs.
The symptoms consist of fever, a sense of tightness or con-
striction about the chest, hurried respiration with wheezing,
severe cough, and expectoration — at first of a viscid glairy mu-
cus — which subsequently becomes purulent. The pulse is
frequent and often weak ; the tongue foul ; and there is head-
ache, lassitude, and great anxiety.
On practising auscultation in the early stage of the inflam-
mation, two dry sounds will generally be heard, viz., rlioncitus
and sibilus, both of which indicate that the air-tubes are par-
tially narrowed — that the mucous membrane lining them is
indeed dry and tumid. Rhonchus in itself need give us no
anxiety, as it belongs entirely to the larger divisions of the
bronchial tubes •, sibilus, on the contrary, bespeaks more dan-
ger, since it denotes that the smaller air-tubes and vesicles are
affected. After a time, the inflamed mucous membrane begins
to pour out fluid — a viscid, transparent, tenacious mucus is
exhaled ; this constitutes the second stage of the inflammation.
Two very different sounds to those just noticed are then to be
detected, viz., large crepitation and small crepitation — often
called the moist sounds. As the air passes through the bron-
chial tubes it gets mixed, as it were, with the mucous secre-
tion, so that numerous air-bubbles keep forming and bursting.
When this occurs in the larger branches, it gives rise to large
crepitation ; Avhen in the smaller, to small crepitation. We
have, therefore, rhonchus and large crepitation as, respectively,
the dry and moist sounds of the larger air-passages ; sibilus
and small crepitation as those of the smaller branches. On
practising percussion, no appreciable alteration in the reso-
nance of the chest will be discoverable. If relief be not af-
forded by the copious expectoration, or by remedies, the dis-
ease assumes a more dangerous character, the strength be-
comes much reduced, signs of great pulmonary congestion
ensue, and symptoms of partial asphyxia follow, soon ending
in death. In favorable cases, however, the afiection begins
to decline between the fourth and eighth day, and shortly
either entirely subsides, or passes into the chronic form.
Chronic Bronchitis is very common in advanced life.
The slighter forms are indicated only by habitual cough, some
shortness of breath, and copious expectoration. The majority
PLEURISY. 183
of cases of winter cough in old people are examples of bron-
chial inflammation of a low lingering kind. It may arise idio-
pathically, or it may follow an acute attack.
PLEUEISY.
Pleuritis, or pleurisy, are terms applied to inflammation of
the pleura — the serous membrane investing the lungs and
lining the cavity of the thorax. The inflammation is of the
adhesive kind, and is accompanied by the pouring out of serum,
of coagulable lymph, of pus, or of blood.
The disease is ushered in with rigors followed by fever, and
an acute lancinating pain in the side, called a stitch, which
pain is aggravated by the expansion of the lung in inspiration,
by coughing, by lying on the affected side, and by pressure :
there is also a short harsh cough, the skin is hot and dry, the
cheeks flushed, the pulse hard and quick, and the urine is
scanty and high colored. If we listen to the painful part of
the chest at the commencement of the attack, we shall hear
the dry, inflamed membranes — the pulmonary and costal
pleurre — rubbing against each other, and producing a friction-
sound ; if the hand be placed on the corresponding part of
the thorax, this rubbing may also be felt. But the sound soon
ceases ; for either the inflammation terminates in resolution
and complete recovery, or the roughened surfaces become
adherent, or they are separated by the eff'usion of serum, and a
kind of dropsy results, known as hijdroihorax. If the pleurisy
has been severe, the eff'usion becomes excessive (it may vary
from an ounce to several pints), and the fluid accumulating in
the sac of the pleura compresses the yielding lung, suspends
its functions, displaces the heart, and somewhat distends the
thoracic parietes. When the serous fluid is mixed with pus,
the disease is termed empyema. If we listen to the chest now,
we shall find the respiratory murmur diminished, in proportion
to the quantity of fluid thrown out : where this is excessive
and the lung is compressed backwards — flattened almost
against the spinal column — no vesicular breathing at all will be
audible, but instead we shall hear the air passing into the
larger bronchial tubes, while the voice will be also abnormally
distinct, the condensed lung and the layer of fluid acting as
conductors of sound ; we then say that bronchial respiration
and bronchial voice, or bronchophony exist. The bronchopho-
ny may be accompanied by a tremulous noise, resembling the
bleating of a goat ; it is then termed cegophony. If the lung
be completely compressed, so that no air can enter even the
bronchial tubes, then no sounds of any kind will be heard ; but
184 DIAGNOSIS OF THORACIC DIHKASKS.
on the healthy side the respiration will be more distinct than
natural — will be piiei^ile. There will also be dulness on per-
cussion all over the affected side, if the pleura be full of fluid;
if it be only partially filled, we can judge of the quantity by
placing the patient in different attitudes ; for since the fluid
will gravitate to the most dependent part of the cavity, so it
will carry the dull sound with it. We shall also often be able
to judge of the amount of the effusion by the dyspnoea which
the patient suffers from, since this will, of course, be most
urgent when the lung is most compressed. At this stage also
the sufferer is unable any longer to lie on the sound side,
clearly because the movements of the healthy lung would be
impeded by the superincumbent weight of the dropsical pleura;
the pain, moreover, no longer prevents his resting on the
diseased side. If Ave measure tlie two sides of the chest, the
side containing the effusion will be found the largest ; we must
remember, however, that in many persons the right half of the
chest is naturally rather larger than the left.
After a time the symptoms begin to decrease, and absorption
of the effused fluid commences. Supposing the lung to be
bound down by adhesions, it will not expand in proportion to
the absorption of the fluid ; the affected side will then shrink
inwards, and instead of any longer remaining larger than the
sound side, will become smaller.
PNEUMONIA.
Pneumonia, or inflammation of the substance of the lungs,
consists of three degrees or stages, viz. : 1, that of engorgement ;
2, that of hepatization ; and .3, that of gray hepatization or
purulent infiltration. In each stage there is fever ; more or
less pain in some part of the chest — most severe at the com-
mencement of the attack ; accelerated and oppressed breath-
ing ; occasionally delirium ; cough ; and expectoration of
viscid, rust-colored sputa, which unite into a mass so tenacious,
that even inversion of the vessel containing the collection will
not detach it.
Til the first siage, or that of engorgement, the substance of
the lung becomes loaded with blood or bloody serum. It is of
a dark red color externally, and on cutting into it a quantity of
red, frothy serum escapes, while its appearance somewhat re-
sembles the spleen. If we listen to the chest when the lung
is in this condition we shall hear very fine crepitation, which
is known as small crepitation, or crepitant rhoncJius. If a lock
of one's own hair be rubbed between the finger and thumb
PNEUMONIA. 185
close to the ear, a sound will be produced resembling it. The
natural respiratory or vesicular murmur is still heard mingled
with this minute crepitation, especiallv at first; as the inflam-
mation advances, however, the healthy sound is quite displaced
by the morbid one. Percussion also, at first, affords the natu-
ral resonance, which gradually becomes obscured.
If the inflammation proceed, it passes into the second stage,
or that of hepatization, in which the spongy character of the
lung is lost, and it becomes hard and solid, resembling the cut
surface of the liver — whence it is said to be hepatized. If we
now practise auscultation, neither the minute crepitation nor
the vesicular murmur are any longer perceptible. Broncho-
phony, however, often exists, more particularly if the inflamma-
tion be seated near the upper part or in the vicinity of the root
of the lungs; it is accompanied also by bronchial respiration,
these sounds being conducted by the solidified lung. The
sound on percussion is dull over the whole of the affected part.
Advancing still further, we now have the third stage of pneu-
monia, or that of gray hepatization, or purulent infiliration,
which consists of diffused suppuration of the pulmonary tissue.
Circumscribed abscess of the lung is very uncommon, but dif-
fused suppuration is a frequent consequence of inflammation.
There are no physical signs by which this stage can be diag-
nosed, until part of the lung breaks down and the pus is ex-
pectorated 5 humid crackle or large gurgling crepitation will
then be heard.
If the inflammation subside before the stage of purulent
infiltration, as it fortunately often does, then the hepatized
condition may remain permanent, or may gradually cease ; in
the latter case we shall find the air slowly re-entering the lung,
as will be indicated by a return of the minute crepitation,
mingled with — and subsequently superseded by — the healthy
vesicular murmur.
Occasionally, in depressed constitutions, acute inflammation
of the lung terminates in gangrene. The characteristic symp-
tom of such an occurrence is, an intolerably foetid state of the
breath, resembling the odor which proceeds from external
gangrenous parts. Unless the mortified portion be small,
death will, in all probability, result.
Pneumonia may affect one lung or both, or, technically
speaking, may be double or single. The right lung suffers
from inflammation twice as often as the left ; about once in
eight cases both are affected. The lower lobes are more
obnoxious to inflammation than the upper. The average
duration of the disease is about ten days.
16*
186 DIAGNOSIS OF THORACIC DISEASES.
Pneumonia without bronchitis is probably never seen. It
may occur with or without pleurisy ; when the pneumonia
forms the chief disease, the double affection is termed pleuro-
pneumonia; when the pleurisy predominates, it is sometimes
called pnemno-pleuritis.
ASTHMA.
Asthma may be defined as consisting of paroxysmal attacks
of dyspnoea, accompanied with a wheezing sound of respira-
tion, the attacks ending, generally, in a few hours, with mucous
expectoration more or less abundant. The paroxysms appear
to be due to obstruction of the smaller bronchi from tonic
contraction of the circular muscular fibres.
A fit of asthma is either preceded by various digestive, or
nervous, or other disturbances ; or it occurs suddenly, without
any warning. The patient awakes an hour or two after mid-
night with a sensation of suffocation, or constriction about
the chest ; the efforts at inspiration are convulsively violent ;
the expiration is prolonged, and comparatively easy ; both
acts, but especially the first, are attended with wheezing,
and occasionally rhonchus and sibilus are heard in place of
the natural respiratory murmur. Various postures are assumed
to facilitate the attempt at filling the lungs ; the patient stands
erect, or leans his head forwards on his hands, or rushes to
the open window — at which he will remain almost for hours
gasping for air. The pulse is small and feeble ; the eyes
staring : the countenance anxious ; the skin cold and clammy,
His whole appearance is most distressing, and he looks
beseechingly at the practitioner for relief from his misery.
Then, after a certain lapse of time, comes a remission ; cough
ensues, and with the cough expectoration of mucus ; and soon
the paroxysm ceases, to allow the sufferer to fall into the long-
desired sleep.
When the attack ceases with expectoration, the case is said
to be one of humid or humoral asthma ; when without, it is
called dry asthma. Both forms are often connected with
emphysema of the lungs, and with disease of the heart.
When the attacks are merely nervous, the patient enjoys good
health during the intervals ; when there is chronic bronchitis,
or emphysema, or heart disease, the symptoms of these con-
ditions remain more or less prominent.
Repetition of asthmatic fits often leads to dilatation of the
right cavities of the heart, and to insutficiency of the tricuspid
valve ; this occurs most frequently when there is emphysema.
PNEUMOTHORAX. 187
EMPHYSEMA.
The diseases of the lungs thus denominated are of two
kinds. One consists essentially of enlargement of the air-
cells, atrophy of their walls, and obliteration of their vessels ;
this is called vesicular or pulmonary empliysema. When, on
the other hand, there is infiltration of air into the interlobular
areolar tissue, or into the sub-pleural areolar tissue, the disease
is known as interlobular emphysema. Both forms give rise to
habitual shortness of breath, with occasional severe paroxysms
of dyspnoea or orthopnoea, resembling asthma; they are at all
times very distressing complaints, and quite unfit the sufferer
for any active occupation. Emphysema is a common cause
of asthma.
The physical signs consist of unnatural clearness and
resonance on percussion, while only a very indistinct vesicular
murmur is heard on auscultation. The diseased side of the
thorax is also more prominent and rounder than the healthy
one. Thus, as regards percussion and auscultation, emphy-
sema aflFords results the reverse of most other affections : the
disease consisting, as it were, of a superabundance of air,
which is not in motion, and hence does not pass away, there
is more resonance on percussion, but less respiratory sound
on auscultation.
PNEUMOTHORAX.
The jagged ends of a fractured rib will often wound the
pulmonary pleura, and thus allow the air to escape from the
lung into the pleural sac. The same condition may arise
from an external wound, or from ulceration during the exten-
sion of a tubercular cavity. When the pleura contains air
alone, we say there is pneumothorax; when, as generally
happens, there is liquid with the air, we call the disease hydro-
pneumothorax, ot pneumothorax with effusion.
The physical signs of pneumothorax are great resonance
on percussion, with indistinctness of the respiratory murmur
on auscultation ; while the patient's voice and cough give rise
to a ringing metallic noise, like that produced by blowing
obliquely into an empty flask, and hence called amphoric
resonance. When there is also liquid with the air, we obtain
in addition, on practising succussion, a sound known as
metallic tinkling, which results from a drop of fluid falling
from the upper part of the cavity into the liquid below, and
causing a little splash.
188 DIAGNOSIS OF THORACIC DISEASRS.
PHTHISIS.
Tubercular phthisis, or pulmonary consumption, is a consti-
tutional disease manifesting itself chiefly by certain changes
in the lungs.
Tubercle, or tuberculous matter, is the specific product of
a peculiar constitutional disease. It is deposited in distinct
isolable masses, or is infiltrated into the tissues of many
different organs ; most frequently, however, it is found in the
lungs, constituting pulmonary tuberculosis, or tubercular
disease of the lungs, or phthisis or consumption, these terms
being synonymous. The morbid condition of system which
gives rise to this production, wherever it may be deposited, is
now usually known as tuberculosis, or tubercular disease : the
tendency to it is often hereditary. According to Rokitansky,
pulmonary tubercles are found in two varieties, or in forms
intermediate between them, viz., as the gray or miliary, and
the yellow tubercles. By some it is supposed that these
varieties merely represent two stages of the same disease.
Rokitansky maintains, however, that they are always different
substances, and that although they often coexist in the same
lung, yet that they never become transformed the one into the
other. Be this as it may, it is certain that the minute struc-
tures of both are essentially similar. Of course, there has
been a vast amount of speculation as to the mode of forma-
tion aad nature of tubercle. The best explanation, and that
to which many authorities — as Lebert, Ancell, and Dr. John
Hughes Bennett — subscribe, is that it consists of an exuda-
tion of the liquor sanguinis, presenting marked differences
from the simple or inflammatory exudation on the one hand,
and the cancerous exudation on the other. From its chemical
analysis, it would appear to consist of animal matter — princi-
pally albumen — and certain earthy salts, chiefly the insoluble
phosphate and carbonate of lime, and the soluble salts of
soda.
In phthisis the tubercular deposit takes place in the areolar
tissue between the air-cells, in the air-cells themselves, and in
the smaller bronchial tubes communicating with them ; wher-
ever a speck of this matter is deposited from the blood, it
continues to increase by constant addition. In its hard state
it is called crude tubercle. After a time, inflammation arises
in the pulmonary substance around the deposit, suppuration
occurs, the tubercular matter softens and breaks down, and at
length is gradually expelled through the bronchi, trachea, and
mouth, leaving cavities or excavations behind, of various
PHTHISIS. 189
sizes. Sometimes these cavities close and heal ; more fre-
quently tubercular matter continues to be deposited on their
sides and in other parts of the lungs, until these organs be-
come diseased to an extent incompatible with life.
The general symptoms of phthisis are cough, debility, muco-
purulent expectoration, acceleration of the pulse, dyspnoea,
haemoptysis, loss of flesh, hoarseness, a peculiar transparent
appearance of the edge of the gums where they are reflected
over the teeth, sweating, and diarrhoea. The disease ordina-
rily sets in with a short dry cough, which may continue some
time without being aggravated, or without the supervention of
any other symptom. Frequently there is haemoptysis, which,
recurring at variable intervals, gives the first intimation of the
disease. The patient complains also of languor ; slight exer-
tion — ascending a hill or going up stairs — causes fatigue, hur*
ries the breathing, and often gives rise to palpitation. When
this state has lasted for some time, during which the cough
and expectoration have been increasing, hectic fever appears.
The debility becomes more marked ; the countenance is fre-
quently flushed ; chilliness is complained of in the evening,
while on awaking in the morning the body is found bathed in
a profuse sweat ; and there is loss of appetite, with thirst, kc.
The patient now rapidly loses flesh : diarrhoea often sets in
and increases the feebleness ; the lower extremities become
oedematous ; and death soon ends the scene.
Some authors have divided phthisis into three stages. Dur-
ing the first — that in which tubercles become developed in
the lungs — neither the local nor the general symptoms warrant
us in announcing the presence of any other affection than
severe catarrh ; if the tubercles be deposited, however, in con-
siderable quantity, the sound on percussion will be dull, the
act of expiration will be prolonged — from impairment of the
elasticity of the lungs, and bronchial respiration and broncho-
phony will be heard ; the vesicular murmur will be feeble or
even absent. In the second stage, the tubercles increase both
in number and size, so as to compress and obstruct the sub-
stance of the lung, and occasion dyspnoea : large crepitation
will be distinct, and in the sound lung puerile breathing. In
the third stage, the tubercles become softened; they make
an opening for themselves through some of the surrounding
or involved bronchi, and being thus evacuated, they give rise
to the formation of cavities. Auscultation now elicits a pecu-
liar sound, called gurgling or humid crackle, caused by the
bubbling of air with the pus or mucus contained in the cavity.
Gurgling, it must be remembered, may also arise from that
190 DIAGNOSIS OF THORACIC DISEASES.
rare disease, circumscribed abscess of the lungs, as well as
from the mixture of air with liquid in a dilated bronchus
affected with chronic inflammation. When the cavity con-
tains no liquid, we hear cavernous respiration ; if it be large,
amphoric resonance and pectoriloquy will also be distinguish-
able. Notwithstanding the existence of one large or of nume-
rous cavities, percussion almost invariably affords a dull sound,
owing to the layer of lung forming the wall of the cavity being
dense and solid.
Phthisis may be inherited or it may be acquired ; it is not
contagious. Of 1000 cases collected by Dr. Cotton, at the
Consumption Hospital, 367 were hereditarily predisposed ; 582
were males, and 418 females. The left lung suffers more fre-
quently than the right; in Dr. Cotton's cases the left lung was
"affected in 455, the right in 384, and both in 161. The apices
and posterior parts of the upper lobes of the lungs are ordi-
narily the situations in Avhich the deposit first takes place.
No period of life is exempt from this scourge. Insufficient
and bad food, impure air, confinement, deficiency of light, and
immoderate indulgence of the sensual passions may be re-
garded as frequent causes. Its ordinary duration is about six
or nine months : it rarely proves fatal in three months.
PEEICARDITIS.
Inflammation of the external serous covering of the heart —
pericarditis — frequently arises from cold, from mechanical in-
juries, from a contaminated state of the blood produced by
renal disease, and from acute rheumatism.
The symptoms of this affection are, high fever; pain referred
to the region of the heart, often darting through to the left
scapula, upwards to the left clavicle and shoulder, and down
the arm ; violent palpitation, the motions of the heart being
tumultuous, and perceptible at a distance from the patient ;
irregularity of the pulse ; hurried respiration ; incapacity of
lying on the left side ; strong pulsation of the carotids ; anxiety
of countenance ; and frequently noises in the ears, giddiness,
and epistaxis. As the disease advances, there is extreme de-
bility, cough, suffocative paroxysms, occasionally a tendency
to syncope, and oedema of the face and extremities. These
symptoms often vary much in different cases ; thus, as Dr.
Hope has remarked, if the effusion which results from the in-
flammation consists almost entirely of coagulable lymph, or
if the serum thrown out has been rapidly absorbed and adhe-
sions early effected, the circulation will be less interfered with,
and less suffering will result, than in those more formidable
ENDOCARDITIS. 191
lEstances where there is a copious fluid efiiision painfully dis-
tending the inflamed membrane, pressing upon the heart, and
embarrassing its movements.
On practising auscultation, we shall find — in the earliest
stages — increased intensity of the natural sounds ; if endocar-
ditis coexists, as it so frequently does, a loud systolic bellows-
mu7'77iur yviW also be heard. Very early, too, a distinct friction,
or alternate rubbing, or a io-and-fro murnmr — as Dr. Watson
terms it — will be audible. The bellows-murmur indicates fibri-
nous deposits in the texture as well as on the surface of the
valves, from inflammation of the internal membrane of the
heart — the endocardium — and it generally continues for life.
The to-and-fro or friction murmur is indicative of inflamma-
tion of the pericardium, and it generally ceases in a few days
when this membrane becomes adherent to the heart, as it
almost always does if the patient survive. When copious
effusion takes place, we shall have dulness on percussion over
a larger surface than in health 5 if the fluid does not become
absorbed, we say that hydro-pericardium exists, which usually
proves fatal.
From the foregoing it appears that we may classify the
physical signs of pericarditis as follows :
1 . Sensations of friction communicated to the hand.
2. Friction-sounds: the "attrition-murmurs" of Hope.
3. Extension of dulness over the heart, resulting from liquid
effusion.
4. Friction signs, attended with — or preceded by — valvular
murmurs.
5. Signs of eccentric pressure analogous to those of em-
pyema.
6. Signs of excitement of the heart.
7. Signs of weakness or paralysis of the heart.
ENDOCARDITIS.
Inflammation of the lining membrane of the cavities of the
heart — endocarditis — occurs much more frequently in the left
cavities than in the right, and affects the valvular apparatus
more strikingly than the general tract of the membrane. The
chief symptoms are, a sense of oppression and uneasiness at
the praecordial region ; fever ; small, feeble, and intermittent
pulse; great anxiety, cold sweats 5 oppressive dyspnoea ; jac-
titation ; and syncope. When the inflammation is only of
limited extent, or when it assumes a chronic form, the symp-
toms are much milder and moi'e obscure.
192 DIAGNOSIS OF THORACIC UISEASRS.
If we apply the hand to the chest in simple endocarditis,
the action of the heart will appear to be very violent ; some-
times a vibratory thrill will appear to be felt. Percussion
often discovers an augmented extent of dulness in the prajcor-
dial region ; this dulness may be distinguished from that caused
by pericardial effusion, by the beat of the heart appearing
superficial instead of remote and distinct. If we listen to the
heart's action we shall detect a bellows-murmur, the most con-
stant and characteristic of the phenomena of endocarditis.
The murmurs of purely acute endocarditis are thus arranged
in order of frequency by Dr. Walshe : — Aortic obstructive ;
mitral regurgitant ; aortic regurgitant 5 aortic obstructive and
mitral regurgitant together; aortic obstructive and regurgi-
tant together. Pulmonary systolic and diastolic murmurs are
infinitely rare. Dr. Walshe has never observed acute obstruc-
tive mitral murmur, nor acute regurgitant tricuspid murmur.*
Valvular diseases of the Heart.— In exploring the
diseases of the valves of the heart, whether resulting from
endocarditis, or from the formation upon them of warty
excrescences, or from the tearing of their tissues, or from their
conversion into bone, assistance may be derived from remem-
bering — in addition to the physical signs pointed out in the
preceding chapter — the following principal physiological or
functional symptoms which they often present to greater or
less extent :
1. Difficulty of breathing, varying from the slightest dys-
pnoea to the most severe orthopnoea ; much increased on
ascending a height or making any exertion.
2. Palpitation and irregular action of the heart, with
certain sounds and murmurs discoverable by auscultation, &c.
3. Irregular pulse. In mitral disease the pulse is generally
soft and irregular; in aortic, hard, jerking, but regular.
4. Congestion of the lungs ; bronchitis ; pneumonia ; pul-
monary hemorrhage, with or without pulmonary apoplexy ;
these symptoms are most urgent in mitral disease.
5. Hemorrhages from the nose, bronchial tubes, or mucous
membrane of the stomach.
6. (Edema of the lower and sometimes of the upper ex-
tremities, and face ; hydrothorax ; and ascites. Dropsy is
more common in disease of the right cavities of the heart
than in affections of the left.
7. Cephalagia, tinnitus aurium, vertigo, syncope, cerebral
congestion, and cerebral hemorrhage, most urgent in aortic
disease.
•Op. cit.,p. 611.
ENDOCARDITIS. 193
8. Broken rest, with startings during sleep, and frightful
dreams.
9. Enlargement of the liver and spleen, with disorder of
the digestive organs generally.
10. A peculiar appearance of the countenance, wherein the
face is puffed, the cheeks flushed and of a purple hue, the lips
congested, and the eyes bright.
As regaixls affections of the heart generally^ the diagnosis
will be assisted by attention to the following points, many of
which are well laid doAvn by Dr. Spillan.*
The causes which have occasioned an affection of the heart
may throw some light on its nature ; as when either of the
parents have labored under some particular heart disease we
shall have reason to fear that the offspring will be affected
■vvnth the same disease. With respect to age and sex, the
affections of the heart during the early periods of life are
generally attributable to inflammation and to congenital
lesions, whilst in the aged they are due to fatty degeneration
of the muscular fibres, to ossifications, or to pulmonary
disease. In early life, and perhaps in women, the mitral
valve and corresponding auriculo-ventricular orifice are most
frequently diseased ; in advanced life, and in men, the aortic.
Young girls, about the age of puberty, and anaemic women
generally, are especially liable to palpitation and other tem-
porary symptoms of cardiac disease without any organic
lesion.
With regard to form of body, it has been noticed that robust
persons, if they lead a sedentary life and live freely, are liable
to certain symptoms of heart disease, which, though at first
easily removed by bloodletting, purging, exercise, &c., yet, if
allowed to continue, ultimately lead to hypertrophy. A person
who has a large abdomen, or an abdominal tumor, or who
overloads his stomach, and so causes the viscera to be pressed
upwards, thus diminishing the size of the thorax, may experi-
ence many of the symptoms of disease of the heart, without
any organic change really existing.
Occupation has some influence in giving rise to cardiac
affections 5 persons who make great muscular exertions, or
who carry heavy loads, being especially predisposed.
The manner in ichich cardiac affections first set in may
often throw some light on the diagnosis. Thus, if the attack,
be sudden, an acute affection may be the source of the evil.
If there be at first rupture or distension of muscles, followed
'See Dr. Spillau's translation of Schill's '-Pathological Semeioloj^',"
p. 93.
17
194 DIAGNOSIS OF THORACIC DISEASES.
by acute pains in the region of the heart, we may suspect that
the fleshy fibres are affected. If a rheumatic inflammation
precedes or accompanies the attack, the pericardium, or, less
probably, the endocardium, or even both, will be the seat of
the disease. If pleurodynia with hgemoptysis has preceded
the cardiac attack, the right side of the heart is affected in
consequence of the pulmonary circulation being disturbed.
Again, if the onset of the disease has been marked with
slight symptoms, which have slowly and gradually increased,
there is reason for apprehending the existence of some
organic lesion, which will become more certain if the symp-
toms go on uninterruptedly, if they steadily increase in
severity, and if they give rise to those general constitutional
disturbances previously noticed.
Lastly, as regards the seat of the disease, it should be borne
in mind, as I have already so strongly insisted on, that the
left side of the heart is much more obnoxious to morbid
changes than the right ; and that when both sides are impli-
cated, the alteration will be more decided in the left than in
the right chambers. In nineteen cases out of twenty of val-
vular disease, the valves of the left ventricle — the mitral or
aortic — will prove to be those afi'ected ; disease of the tri-
cuspid valves guarding the right auriculo-ventricular orifice is
rare, and of the semilunar valves of the pulmonary artery
exceedingly uncommon.
ATROPHY OF THE HEART.
There are two forms of atrophy of the heart : one in which
the organ simply wastes, and dwindles in all its parts ; the
other, in which the texture of the muscle suffers a sort of
conversion into fat — becomes affected with fatty degene-
ration.
Fatty degeneration of the heart is a most interesting dis-
ease, for a full knowledge of which the student must refer to
the writings of Drs. Quain and Ormerod, and Messrs. Paget
and Barlow. It occurs under two circumstances ; either alone,
or in conjunction with fatty diseases of the other organs, as
the kidneys, liver,' cornea, &c. Its diagnosis is beset with
difficulties, and when existing alone it is frequently not sus-
pected until after death, and after a microscopic examination
of some of the muscular fibres of the heart. The most pro-
minent symptoms are feeble action of the heart, remarkably
slow pulse — sometimes as low as fifty or forty-five, general
debility, and a feeling of nervous exhaustion, loss of tone, &c.
HYPERTROPHY OF THE HEART. 195
It is uot an uncommon cause of sudden death. " On opening
a heart thus affected/' says Dr. Ormerod, " the interior of the
ventricles appears to be mottled over with buff-colored spots of
a singular zigzag form. The same may be noticed beneath
the pericardium also ; and in extreme cases the same appear-
ance is found, on section, to pervade the whole of the thick-
ness of the walls of the ventricle and of the carueae columnae."
On microscopically examining these spots, their nature is
revealed; they are not deposits, but degenerated muscular
fibres. Instead of seeing transverse striae and nuclei, the
evidences of a healthy state — little can be distinguished but
a congeries of oil-globules. The muscular fibres are also
found 'to be short and brittle ; and Dr. Quain has pointed out
that the coronary arteries are often obstructed. Mr. Paget
well remarks that ^' the principal characters which all these
cases seem to present is, that they who labor under this disease
are fit enough for all the ordinary events of calm and quiet
life, but are wholly unable to resist the storm of a sickness,
an accident, or an operation."
HYPERTKOPHY OF THE HEAET.
The heart is stated roughly to be about the same size as the
closed fist ; its mean weight is between eight and nine ounces.
The muscular walls of one or more of the cavities of the
heart may become thickened without any diminution in the
size of the chamber ; this is called simple Jiypeiirophy. Or,
as most frequently happens, the walls may be thickened and
the chamber become larger than natural ; this is eccentric
Jiypertrophy. On the other hand, the increase in thickness
may be accompanied with diminution in the size of the cavity ;
this is known as concentric hypertrophy.
The cause of the hypertrophy is usually some obstruction
either to the flow of blood through the heart, or to the free
play of this organ ; the symptoms are palpitation, dyspnoea,
difiiculty of walking quickly, uneasiness and pain in the
cardiac region, headache, and frequent attacks of vertigo. If
we listen to the heart's movements we shall merely find the
systolic sound less distinct than in health ; but we shall also
feel that the extent of the pulsation beyond the praecordial
region, and especially the degree of impulse against the walls
of the chest, are both much increased.
Simple Hypertrophy of the Left Ventricle with no
Obstruction to the Flow of Blood.— This condition is rare.
On ausculting the heart the systolic sound is less loud and
196 DIAGNOSIS OF THORACIC DISEASES.
clear than natural, but no bellows-murmur is heard. On
placing the hand over the pra?cordial region the impulse of
the heart will be found increased.
Hypertrophy of Left Ventricle with Valvular Dis-
ease. — A systolic bellows-murmur will generally be heard,
and the heart's impulse will be much increased. The hyper-
trophy in this case is often an endeavor towards health, the
increased power compensating for the obstruction to the flow
of blood caused by the valvular disease.
CYANOSIS.
Cyanosis, morbus caeruleus, or blue disease, are terras
applied to a condition characterized by blue or purplish dis-
coloration of the skin, arising generally from some malforma-
tion of the heart, permitting direct communication between
the right and left cavities.
The chief malformations are, permanence of the foramen
ovale ; abnormal apertures in some part of the septum of the
auricles or of the ventricles ; origin of the aorta and pulmo-
nary artery from both ventricles simultaneously ; extreme
contraction of the pulmonary artery; or, lastly, continued
patescence of the ductus arteriosus.
In addition to the discoloration of the shin, the patients
who survive their birth suffer from coldness of the body, pal-
pitation, fits of dyspnoea, or syncope on the least excitement,
and dropsical effusions.
ANEUEISM OF THE AORTA.
Three forms of aneurism are usually described : tme
aneurism, in which all the coats of the artery dilate and unite
in forming the walls of the pouch ; false aneurism, in which
the inner and middle arterial tunics being ruptured, the walls
are formed by the cellular coat and contiguous parts ; and
mixed or consecutive false aneurism, in which the three coats
having at first dilated, the inner and middle ones subsequently
rupture as the distension increases.
Aneurism of the Thoracic Aorta is chiefly met with in
the ascending portion, or in the arch. Its general sijmptoms
are very obscure, partly in consequence of their similarity to
those arising from disease of the heart. When the aneurismal
tumor is large and pulsating, and rises out of the chest, pro-
ducing protrusion or absorption of the sternum and ribs,
then the diagnosis is altogether as easy as it was before
ANEURISM OF THE HEART. 197
diflficult. When the sac presses upon the trachea, there will
be dyspncea ; when on the recurrent laryngeal nerves, aphonia,
and occasionally a mimicry of laryngitis ; when on the oeso-
phagus, dysphagia and symptoms of stricture ; and when on
the thoracic duct, inanition, and engorgement of the absorbent
vessels and glands.
Aortic aneurism is sometimes accompanied by a bellows-
sound, sometimes not. In false aneurism there is generally a
murmur both with the entrance and exit of blood into the
sac ; or there may be one loud, prolonged, rasping bruit, from
the passage of the blood over the roughened inner surface of
the vessel. In true aneurism or mere dilatation of a part of
the wall of the artery, murmurs are seldom audible. A small
but free opening from the canal of the artery into the aneu-
rismal sac, and a roughened state of the arterial tunics, from
degeneration or from atheromatous deposit, are, however, two
conditions which will give rise to a bruit. In both forms,
when a murmur exists, a peculiar thrilling or purring tremor
will be felt on applying the hand over the sternum.
Aneurism of the Abdominal Aorta often gives rise to
acute pain in the lumbar region, occasionally shooting into
either hypochondrium, and downwards into the thighs and
scrotum ; constipation aggravates the pain. By careful
examination, a tumor may generally be felt, which communi-
cates a constant and powerful pulsation to the hand. On
applying the stethoscope, a short, loud, abrupt bellows-sound
will be heard.
Aneurism of the Heart occurs in two forms ; either there
is simple dilatation of the wall of a ventricle, forming the
improperly called passive aneurism of Corvisart ; or a pouched
fulness arises abruptly from the ventricle, constituting a tumor
on the heart's surface. The sac often contains laminated
coagula of blood, especially when its mouth is constricted.
The symptoms are uncertain and obscure. Death may
result from rupture into the pericardium, or, if the pericar-
dium be adherent to the heart — as it mostly is in these cases
— into the pleura.
Aneurisms of the coronary arteries sometimes occur. I
know of no signs on which the physician can rely for their
detection.
17*
108 DIAONOSIS OF DISEASES OF THE SKIN.
CHAPTER IX.
ON THE DIAGNOSIS OF DISEASES OF THE SKIN.
It is a very generally entertained opinion that the diagnosis
of cutaneous diseases is extremely difficult, that the treatment
of these affections requires special study, and that the subject
of cutaneous pathology should be viewed as a distinct branch
of medicine. I belie v^e that such ideas are very erroneous
and mischievous ; the various phenomena presented by each
class of these disorders being generally very characteristic,
always appreciable by the eye, and their treatment being by
no means difficult, but often remarkably simple. Since,
moreover, the majority of cutaneous affections are merely
symptomatic of other diseases affecting diflPerent organs, I
hold that no man can pretend to be a sound practitioner of
medicine who is not fully acquainted with them in all their
bearings.
In treating of the diagnosis of the various skin diseases I
shall adopt the classification of Willan, as modified by Biett ;
which is, however, like the Linnaean classification of the vege-
table kingdom, entirely artificial. I am of course conscious
that in a work like the present only a faint outline of this
important and interesting subject can be presented ; and I
therefore take the opportunity of referring those who Avish to
study the subject of cutaneous pathology thoroughly to the
excellent translation of Cazenave's " Manual on Diseases of
the Skin," by Dr. Burgess, to which I am myself indebted
for much very valuable information.
Willan's Classification, modified by Biett.
Order. I. Exanthemata. — Erythema ; erysipelas ; roseola ;
rubeola 5 scarlatina ; urticaria.
Order II. Vesiculce. — Miliaria ; varicella ; eczema ; herpes ;
scabies.
Order III. Bullae. — Pemphigus ; rupia ; button scurvy.
Order IV. Pustulce. — Variola ; vaccinia ; ecthyma ; impe-
tigo ; acne ; mentagra ; porrigo ; plica polonica 5 equinia or
glanders.
Order V. Papula;. — Lichen ; prurigo.
Order VI. Squamce. — Lepra ; psoriasis ; pityriasis ;
chthyosis.
ERYSIPELAS. 199
Order VII. Tiibercula. — Elephantiasis GrEecorum ; mol-
luscum I framboesia.
Order VIII. Maculce. — Colorationes : — Fuscedo cutis ;
ephelides ; nsevi. Decolorationes : — Albinismus ; vitiligo.
Order IX. Lupus.
Order X. Pellagra.
Order XI. Malum Alepporum.
Order XII. Sypliilidas.
Order XIII. Purpura.
Order XIV. Elephantiasis Arabicum.
Order XV. Cheloidea.
ORDER 1. THE EXANTHEMATA.
The exanthemata consist of variously formed superficial
reddish patches, varying in intensity and size, disappearing
under pressure, and terminating in resolution or desquamation.
They are frequently complicated with gastro-intestinal irrita-
tion or inflammation, and with cerebral, or pulmonary diseases.
This order includes erythema, erysipelas, roseola, rubeola,
scarlatina, and urticaria.
Erythema — is a non-contagious affection, characterized by
slight superficial red patches, irregularly circumscribed, of
variable form and extent, and most frequently seen on the
face, chest, and extremities. Its duration varies from a week
to a fortnight ; it is seldom preceded or accompanied by
febrile symptoms ; it causes but slight heat, and no pain ;
and the prognosis is always favorable. The principal species
of this disorder is known as erythema nodosum, in which the
eruption is confined to the fore part of the leg, taking the
form of one or more large oval patches, running parallel to
the tibia, and rising into painful protuberances, much resem-
bling nodes. It occurs commonly in young women when
badly nourished or overworked.
Erysipelas, — called in Scotland the rose, in this country St.
Anthonys fire, is an inflammatory affection of the skin, and
very commonly of the areolar tissue, characterized by the af-
fected part becoming of a deep red color, hot, painful, and
swollen. No portion of the surface is exempt from attacks of
it, but the integuments of the face and head are most com-
monly the seats of idiopathic erysipelas — that which arises
from internal causes ; while traumatic erysipelas — that which
follows wounds — may occur on any part.
Idiopathic erysipelas resembles the other exanthemata, in-
asmuch as it is preceded by fever and general constitutional
200 DIAGNOSIS OF DISEASES OF THE SKIN.
disturbance. It often sets in with distinct rigors, and sore
throat is an early and frequent accompaniment of it; disturb-
ance of the cerebral functions, nausea, vomiting, and diarrhoea
may also be present. Then, on the second or third morning
from the rigor, redness and swelling appear on some part of
the skin, frequently on one side of the nose, spreading to the
rest of the face, and often extending over the scalp, neck, and
shoulders. The lips swell, the cheeks enlarge, the eyes become
closed by their puffy lids, and all traces of the natural features
are completely lost. After three or four days the redness
fades, the swelling subsides, and the cuticle desquamates. In
most cases the inflammation is merely superficial ; occasionally
it affects the subcutaneous areolar tissue — phlegmonous ery-
sipelas — and is then apt to be followed by suppuration and
sloughing.
Erysipelas may prove fatal, by the extension of the inflam-
mation to the brain or its membranes, giving rise to effusion
and coma. The same result may occur from the mucous
membrane of the glottis becoming affected, so that the chink
gets closed, and the patient dies unexpectedly from suffocation.
In other cases, death is owing to failure of the vital powers.
Erysipelas may arise from infection or from contagion. When
it prevails epidemically, as it sometimes does, intemperance,
insufficient food, foul air, and trifling injuries favor its occur-
rence.
Roseola. — Roseola is a mild, non-contagious inflammation
of the skin, characterized by transient patches of redness, of
small size and irregular form, distributed over more or less of
the surface of the body ; its duration varies from twenty-four
hours to six or seven days. The eruption, at first brightly red,
gradually subsides into a deep roseate hue, and slowly disap-
pears. It is accompanied by slight fever. There is one form
of this affection which frequently affects adults, especially
females, in the summer ; it is called roseola cestiva.
Rubeola.— Rubeola (Willan), Morbilli (Sydenham), the
Measles (Cullen), are terms employed synonymously to desig-
nate a disease, the distinguishing characters of which are a
continued contagious fever, accompanied by an eruption, and
frequently attended with inflammation of the mucous mem-
brane of the respiratory organs.
The symptoms are lassitude, shivering, pyrexia, and catarrh ;
the conjunctivae, Schneiderian membrane, and mucous mem-
brane of the fauces, larynx, trachea, and bronchi are much
affected. Swelling of the eyelids ; eyes suffused and watery,
and intolerant of light; sneezing; dry cough, with hoarseness
SCARLATINA. 201
and severe dyspnoea ; drowsiness ; great heat of skin ; fre-
quent and hard pulse. The period of incubation — or, in other
words, the time which elapses between the period of infection
and the appearance of eruption — is from ten to fifteen days.
Dr. Watson has known several instances in which it was
exactly a fortnight. The eruption comes out on the fourth day
of the disease, seldom earlier, often later ; it consists of small
circular dots, lik^ flea-bites, which gradually coalesce into
small blotches of a raspberry color ; they present often a horse-
shoe shape, and are slightly raised above the surface of the
skin. The rash appears first on the forehead and face, and
gradually extends downwards ; it begins to fade on the seventh
day in the same order, and is succeeded by slight desquamation
of the cuticle, and great itching.
It is worthy of notice that the fever does not abate on the
appearance of the eruption, as in small-pox, nor does the se-
verity of the attack at all depend upon the quantity of the rash.
The contagion of measles is strong. It is mostly seen in
children ; and, as a rule, occurs only once.
The prognosis must depend upon the mildness or severity of
the chest symptoms ; the complications most to be feared are
croup, bronchitis, and pneumonia. The diarrhoea, which often
sets in as the rash declines, is for the most part beneficial.
Scarlatina. — Scarlatina or scarlet fever is a contagious fe-
brile disease, characterized by scarlet efflorescence of the skin
and of the mucous membrane of the fauces and tonsils, com-
mencing about the second day of the fever, and declining about
the fifth ; it is often accompanied by inflammation of the throat,
and sometimes of the submaxillary glands. The time which
elapses between infection and the period of the eruption varies
from four to six days. Like measles, it is essentially a disease
of childhood, but is more to be dreaded.
There are three varieties of this disorder. Scarlatina siiji-
plex, in which the skin only is affected ; scarlatina anginosa,
in which both skin and throat are implicated ; and scarlatina
maligna, in which all the force of the disease seems to be ex-
pended upon the throat.
Scarlatina simplex commences with slight fever, lassitude,
and headache. The eruption appears on the second day about
the neck, face, chest, and flexures of the joints, in the form of
numberless vivid red points, which run together, form large
irregular patches having the tint of a boiled lobster, and often
almost cover the whole body in about twenty-four hours. The
efflorescence commonly terminates by desquamation of the
cuticle, which begins about the end of the fifth day on those
202 DIAGNOSIS OF DISEASES OF THE SKIN.
parts where the rash first appeared. On the face and trunk
the desquamation is in the form of scurf, while on the hands
and feet large flakes of cuticle are detached, so that sometimes
a glove or slipper of scarf skin comes away at once.
At the same time that the efflorescence has been spreading
on the surface of the body, the mucous membrane of the mouth,
fauces, and nostrils has also been affected. The tongue espe-
cially puts on an appearance characteristic of scarlatina. It
is at first covered with a thick white fur, through which the red,
elongated papilla3 project; but as this fur clears away, it be-
comes clean and preternaturally red, and of a strawberry ap-
pearance. The affection of the mucous membrane of the
mouth, &c., terminates by resolution ; with the disappearance
of the rash the febrile symptoms subside, and the disease ceases
at the end of eight or nine days, leaving the patient very weak.
Scarlatina anginosa is ushered in Avith more violent symp-
toms than the preceding. There is headache, with some
delirium, more pungent heat of the skin, and marked prostra-
tion. About the second day there is stiffness of the neck,
uneasiness in the throat, hoarseness, and pain on swallowing.
The fauces, palate, uvula, and tonsils are red and sw()llen, and
the inflamed surfaces are covered with an exudation of
coagulable lymph. As this inflammation goes on, all the
febrile symptoms increase, and the skin becomes very dry and
hot. The efflorescence does not observe the same regularity
as in the simple form 5 it does not appear so early, is delayed
to the third or fourth day, comes out in scattered patches on
the chest and arms, and shows a tendency to vanish the day
after its appearance, and to reappear partially at uncertain
times. With the fading of the eruption, about the fifth or
sixth day, the fever and inflammation of the throat begin to
abate, although the throat often remains sore for a week or
ten days after the disappearance of the rash. Occasionally
this variety of scarlet fever assumes a more aggravated form,
being accompanied with an acrid discharge from the nostrils
and ears, deafness, and inflammation of the parotid and cer-
vical glands — sometimes going on to suppuration.
During the progress of the disease particular attention
should be paid to the internal organs, since there is a great
predisposition to inflammation of the serous and mucous
membranes.
Scarlatina maligna^ described by Cullen under the title of
Cynanche maligna, difiers but little in its symptoms, at first,
from scarlatina anginosa. The fever, however, soon assumes
a malignant or typhoid character, great cerebral disturbance
SCARLATINA. 203
beinjT superadded to the affection of the fauces and skin.
There is great irritability, restlessness, and delirium ; the
delirium being sometimes violent, but usually of the low mut-
tering kind. The tongue is dry and brown, tender and
chapped : the lips, teeth, and gums are covered with sordes ;
and the breath is extremely fetid. The throat is not much
swollen, but appears of a dusky red hue, while the velum,
uvula, and tonsils are covered with dark incrustations, con-
sisting of exudations of lymph ; in some cases there is gan-
grenous inflammation of these parts followed by sloughing.
The cervical glands are often involved in the inflammation.
The rash is exceedingly irregular as to the time of its appear-
ance and duration, often coming out late, disappearing after a
few hours, and being renewed several times during the pro-
gress of the disorder. It is at first of a pale hue, but soon
becomes changed to a dark livid red : petechias also often
appear upon the skin.
In manv instances this malignant form of scarlet fever
terminates fatally on the third or fourth day. It is always a
disease of such extreme danger that only patients with vigor-
ous constitutions survive it ; great hopes may be entertained,
however, if the seventh day be passed.
Sequelce. — Children who have suffered from scarlatina are
very liable to have their health permanently affected, and to
become afflicted with some of the many forms of scrofula,
especially strumous ulcers, ophthalmia, scrofulous enlarge-
ments of the cervical glands, diseases of the scalp, &c. But
the most frequent and most serious sequel is anasarca — serous
infiltration of the subcutaneous areolar tissue — often accom-
panied by dropsy of the larger serous cavities : it occurs about
the twenty-second day from the commencement of the fever.
Now it is curious that this scarlatinal dropsy is more frequent
after a mild than after a severe attack, owing probably to the
want of caution which is often observed in such cases during
the period of desquamation. The patient gets exposed to
cold, and immediately the escape of the fever-poison through
the pores of the skin is checked, and, as a consequence, is
directed to the kidneys in larger quantities than they can
bear, giving rise to acute clesquamative nephritis.^ This renal
affection has its origin from many causes (intemperance, cold,
the cholera-poison) besides the one we are considering, but
however produced, its symptoms are the same. It commences
usually with rigors or chilliness, followed by feverish reaction,
headache, restlessness, pain and tenderness in the loins, and
' See Dr. George Johnson on Diseases of the Kidney.
204 DIAGNOSIS OF DISEASES OF THE SKIN.
often vomiting. The dropsy is an early symptom ; the face
first becomes puffy, followed by general swelling of the areolar
tissue throughout the body, and by effusion of fluid into one
or more of the serous cavities. At the same time there is a
frequent desire to pass urine, which is scanty, of a dark
smoky color, and on being tested by heat and nitric acid, is
found to be highly albuminous. Examined microscopically,
it is seen to contain masses of coagulated fibrin, blood-cor-
puscles, epithelial casts and cells, and occasionally crystals of
lithic acid. The earliest sign of improvement is a disappear-
ance of the dropsy and an increase in the quantity of urine
secreted.
ITrticaria. — Urticaria or nettle-rash is a non-contagious
exanthematous eruption, characterized by long prominent
patches or wheals, either red or white, of irregular shape, of
uncertain duration, and accompanied by intense heat, a
burning and tingling in the affected spots, and great itching.
There are two varieties : one in which it is acute, running
a short, rapid course ; another in which it is chronic, very
obstinate, and either persistent or intermittent: both forms
attack individuals of all ages and constitutions. The chronic
intermittent variety is the urticaria evanida of Willan; it
sometimes lasts for months, or even years.
Urticaria is caused by certain derangements of the digestive
organs, arising from the use of particular articles of diet,
such as shell-fish of different kinds, cucumbers, mushrooms,
bitter almonds ; certain medicines, as turpentine, balsam of
copaiba, &c.
ORDER 2. VESICULE.
A vesicle is a slight elevation of the epidermis, containing
a serous fluid — generally transparent, but occasionally opaque
or sero-purulent. The fluid may be absorbed, or it may be
effused upon the surface, causing excoriation and small thin
incrustations. Vesicular eruptions are occasionally preceded
by fever, but often appear imperceptibly ; they give rise to a
peculiar appearance, as if drops of water had been scattered
over the surface of the skin. In this order we find miliaria,
varicella, eczema, herpes, and scabies.
Miliaria. — Miliaria (sudamina, millet-seed rash, &c.) is
characterized by an eruption of small vesicles, which spread
over a large surface of the skin ; it is often present in fever —
especially in the latter stages — and in diseases affecting the
serous membranes.
HERPES. 205
Many authors doubt the existence of miliaria as a distinct
fever, attributing the eruption to the action of the skin under
irritation, or any treatment producing copious sweating. This
view would seem to be negatived, however, by the fact that
the appearance of the vesicles is often attended by peculiar
symptoms, such as constriction of the thorax, dyspnoea, great
depression, and a tendency to fainting, which continue while
the eruption lasts — for ten or twelve days.
Varicella. — Varicella, or variola spuria, or chicken-pox, is
a trifling contagious complaint, almost peculiar to infants and
young children, and occurring but once during life. It con-
sists of an eruption of transparent vesicles, surrounded by a
slight redness, commencing on the shoulders and breast, af-
fecting the scalp, but often sparing the face, and remaining
visible for five or eight days ; the preceding and accompanying
pyrexia is slight.
' Eczema. — Eczema, crusta lactea, humid tetter, or scall, is
a non-contagious disease, consisting of an eruption of small
vesicles on various parts of the skin, closely crowded together,
and often running into each other, so as to form, on being rup-
tured, superficial moist excoriations. There are several spe-
cies of this disease. When the eruption consists of minute
vesicles on different parts of the skin, without any inflamma-
tion, it is called eczema simplex; when the skin is inflamed, and
there is heat and swelling, eczema ruhi-um. Eczema impetigi-
nodes is a severe degree of eczema rubrum. AVhen arising, as
it sometimes does, from great heat, especially from the heat of
the sun, it is called eczema sol are ; when as a result of the use
of mercury, eczema merciiriale. In infants at the breast, and
in children during dentition, it often affects the scalp — eczema
capitis.
Herpes. — Herpes, or tetter, is a transient, non-contagious
affection, consisting of clusters of vesicles upon inflamed patches
of irregular size and form. The eruption runs a definite
course, rarely continuing for more than two or three weeks ;
it is not usually severe, nor is it accompanied by any constitu-
tional symptoms. Care must be taken not to mistake its na-
ture, since herpes prcepidialis has been actively treated as
syphilis, and herpes circinahis — when occurring on the scalp —
as tinea tonsurans or ringworm. A singular species of this
disease is known as herpes zoster, or zona, or the shingles, in
which the inflamed patches with their clustered vesicles are
arranged in the form of a band, encircling half the circumfe-
rence of the body : in nineteen cases out of twenty the zone
will be found to occupy the right side of the body.
18
20G DIAGNOSIS OF DISKASES OF THE SKIN.
Scabies. — Scabies, or psora, or the itch, is a contagious
disease — contagious in that sense which implies contact — con-
sisting of a vesicular eruption, presenting a number of watery
heads, more or less distinct from each other, and attended with
violent itching. It may attack every part of the body, with the
exception of the head and face ; it most frequently occurs in
the flexures of the joints, especially on the fingers. The cause
of the disease is au insect called the Acarus scabiei, which is
to be found about a line from, but not in, each vesicle.
ORDER 3. BULL^.
As a general rule, bullae differ from vesiculge merely in being
larger, and hence it is almost unnecessary to separate them
into two orders : they are small superficial tumors, caused by
effusions of serum beneath the epidermis. Pemphigus and
rupia are the two eruptions which come under this denomina-
tion, according to Willan; but Dr. Burgess has judiciously
added button scurvy.
Pemphigus. — This affection is characterized by the ap-
pearance ot large bullae, two or three inches in diameter, upon
one or more regions of the body. The eruption is generally
preceded for twenty-four or forty-eight hours by slight general
indisposition, fever, and itching of the skin; small red circular
patches then form, gradually increase in extent, and become
covered with bullje, which either fade away on attaining their
full size, or burst, and are replaced by thin brownish colored
incrustations. The duration of this disease is usually from one
to three weeks, although it occasionally becomes chronic and
prolonged for months.
Pompholyx — is merely a variety of pemphigus, unattended
with fever, and running its course in eight or ten days ; it is
very rare. A kind of artificial pompholyx may be produced
by the application of cantharides. I have already referred to
the case of a young woman in King's College Hospital who
deceived her physician for a short time by rubbing powdered
cantharides into various parts of her person, and thus raising
numerous small blisters.
Rupia. — Rupia may be considered as a modification of
pemphigus occurring in persons of debilitated constitutions,
and in those whose systems have been contaminated with the
poison of syphilis. It is characterized by the eruption of small
flattened bullae, containing at first serous fluid, which soon be-
comes purulent or sanguinolent, and concretes or dries into
dark, black, rough crusts. When the crusts fall off, they leave
VARIOLA, OR SMALL-POX. 207
circular ulcers, of various sizes, indisposed to heal. The
lower extremities are most frequently affected. Its duration
varies from two or three weeks to several months.
Button Scurvy. — Ecphyma globulus, or button scurvy, as
it is popularly misnamed, is a singular cutaneous disease pre-
valent in the middle and southern counties of Ireland. " This
disease," says Dr. Burgess, ''is characterized by an eruption of
one or more scattered excrescences on different parts of the
body, each of which in form resembles a convex button —
hence its name — and varies in size from four or five-tenths of
an inch to an inch and a quarter in diameter. It is highly
contagious (through the medium of the fluid secreted by the
excrescence), and is described by some writers, erroneously, as
confined to the cuticle. It is not a syphilitic disease ; although
sometimes bearing a resemblance to the syphilitic condylomata
described by Fricke."'' It is ordinarily unattended by consti-
tutional symptoms, and is merely a local affection, as is clearly
proved by the ease with which the application of the nitrate of
silver generally cures it.
ORDER 4. PUSTTJL.E.
The pustular affections of the skin aje characterized by the
formation, between the cuticle and cutis vera, of small tumors
containing purulent fluid, called pustules. The pustules are
sometimes scattered irregularly, sometimes united in clusters ;
they are succeeded by scabs, and frequently by permanent
cicatrices. The diseases of this class are — variola, vaccinia,
ecthyma, impetigo, acne, raentagra, porrigo, and equinia or
glanders ; to which I have added a disease but little known in
this country — plica polonica.
Variola, or Small-pox. — This affection may be defined as
a fever commencing with lassitude, headache, rigors, heat of
skin, vomiting, and pain in the back ; succeeded on the third
day by an eruption of pimples, which in the course of a week
inflame and suppurate. In many instances it is accompanied
by a similar afl'ection of the mucous membrane of the nose and
mouth ; in some, by swelling and inflammation of the subja-
cent cellular tissue ; and occasionally by affection of the ner-
vous system. When the vomiting and pain of the back are
violent, they are generally the precursors of a severe form of
the disease.
The period of incubation, or the time which elapses from
» Burgess's translation of Cazenave's "Manual on Skin Diseases." Se-
cond edition, p. 160.
208 DIAGNOSIS OF DISEASES OF THE S K I X.
the hour of infection to the establishment of the fever, is
twelve days, during which the patient's health is apparently
perfect. It is curious that, when the disease is received into
the system by inoculation, only seven days elapse between the
reception of the virus and the appearance of the fever.
The peculiar eruption of pimples or papulie always begins
to show itself on the third day of the fever, first appearing on
the face, the neck and wrists, the trunk, and, lastly, on the
lower extremities. The papulee then gradually ripen into
pustules, the suppuration being complete by the eighth day, at
which time the pustules break, and crusts or scabs form. In
four or five days more these scabs are falling off.
The following table shows the period of incubation, time of
the eruption appearing, and date of its disappearance in
measles, scarlatina, and small-pox.
Disease P®"^'^ ^^
Disease, inclination.
Measles. '10 to 15 days.
Scarlatina. 4 to 6 days.
Small-pox. 1 12 days. .
Eruption appears.
On 4th day of fever.
On 2d day of fever.
On 3d day of fever.
Eruption fades.
On 7th day of fever.
On 5th day of fever.
Scabs form on 8th day,
I and fall off about 12th.
Now the severity of small-pox almost always bears a direct
relation to the quantity of the eruption. When the pustules
are few, they remain distinct and separate from each other ;
when very numerous, they run together, coalesce, and lose
their regularly circumscribed circular form. We thus have a
division of this disease into two varieties, — variola discreta
and variola confiuens. The former is seldom attended with
danger ; the latter is never free from it. The eruption on the
face may be of the confluent form, while it is scanty
elsewhere; still the disease is of the confluent kind. Some-
times the pustules are so numerous that they touch each
other, but nevertheless do not coalesce ; the disease has then
been said to be of the cohering or semiconjiuent form.
In variola discreta, the eruption, in the words of Willan, is
papular. On the third day a small vesicle, with a central
depression, appears on each papula, containing some thin
transparent lymph ; around this an inflamed areola forms
About the fifth day of the eruption, or the eighth of the dis-
ease, the vesicles lose their central depression, become turgid,
and hemispheroidal. Suppuration has occurred, and the vesi-
cles have become pustules, containing yellowish matter. A
peculiar disagreeable odor now begins to emanate from the
patient, which once smelt cannot be forgotten ; from it alone
VACCIXIA, OR COW-POX. 209
the disease may be diagnosed. About the eighth day a dark
spot appears on the top of each pustule, the cuticle bursts,
the matter oozes out, and the pustule dries into a scab. la
about four or six days more the crusts fall off, leaving a
purplish-red stain, which slowly fades ; or where the pustule
has gone so deep as to destroy a portion of the true skin, that
permanent disfigurement, the so-called pitting or pock-mark
results.
Variola conjiuens is usually ushered in by more violent
fever than is the discrete variety. The eruption comes out
earlier ; the eyelids swell, so that by the fifth day the patient is
often unable to see ; the parotid glands become affected ; there
is salivation also, and the limbs swell. The vesicles on the
face run together into one bleb, containing a thin brownish
ichor ; face is pale and doughy. The vesicles on the trunk
and extremities, though often not confluent, have no areola,
and are pale. On the breaking of the pustules, large black
or brown scabs are formed, exhaling great fetor : pulse rapid ;
great debility ; and restlessness. The mucous membranes
become involved ; those of the nose, mouth, larynx, and
trachea are the seat of an eruption ; tongue and palate
covered with vesicles ; throat is very sore ; there is difficulty
of swallowing ; hoarseness ; dyspnoea ; cough ; the glottis
often becomes narrowed, and suffocation may ensue. Delirium
frequently occurs. When to the foregoing symptoms malig-
nancy and putrescency are added, the disease becomes malig-
nant small-pox.
But the greatest difference between variola^ discreta and
variola confluens is in the secondary fever; which, slightly
marked in the former, is intense and perilous in the latter. It
sets in usually about the eleventh day of the disease, or the
eighth of the eruption, and occasionally at once proves fatal,
the system appearing to be overwhelmed by the virulence of
the poison. During its course various troublesome complica-
tions may arise, such as erysipelas, swelling of the glands in
the groin and axilla, phlebitis, pneumonia, &c.
Vaccinia, or Cow-pox- — Since the discovery of vaccina-
tion by Jenner, towards the close of the eighteenth century,
the fatality of small-pox has been very much diminished.
When vaccination has been successfully performed on a
healthy child, an elevation may be felt over the puncture on
the second day, accompanied by slight redness ; on the fifth,
a distinct vesicle is formed, having an elevated edge and
depressed centre ; on the eighth, it is of a pearly color, and is
distended with a clear lymph. The vesicle is composed of a
18*
210 DIAGNOSIS OF DISEASES OF THE SKIN.
number of cells, by the walls and floor of which the lymph is
secreted. An inflamed ring or areola now begins to form
round the base of the vesicle, and to increase during the two
succeeding days ; about the eleventh day it fades, and the
vesicle, which has now burst and acquired a brown color, has
by the end of the second week become converted into a hard,
round scab. This falls off" about the twenty-first day, leaving
a circular, depressed, striated cicatrix, which is permanent in
after life. The constitutional disturbance which accompanies
vaccination is usually very slight. Some interesting experi-
ments lately made by Dr. Gustav Wertheim, of Vienna, tend
to show that the frequency of the pulse is permanently
increased by the process of vaccination. Thus, a man aged
thirty-eight, and a woman aged thirty-three, neither of whom
had suffered from small-pox, were vaccinated for the first time ;
the pulse, in both cases, increased in frequency up to the sixth
day after vaccination, when it began to decline; never de-
clining — not at least for the four months during which the
observations were continued — as low as it was before the
introduction of the vaccine virus. For example, before vacci-
nation, the man's pulse was on an average 66 ; afterwards the
average was 78.
In practising vaccination, it is better to use recent lymph,
which should be taken from vesicles between the fifth and
ninth days, the eighth being probably the best. If preferred,
the virus may be taken direct from the cow. Dairy-women
are often infected from milking cows with the eruption of
vaccinia on their teats. When small-pox occurs after vaccina-
tion, as it sometimes will, the disease is much milder and
shorter, and is unaccompanied by secondary fever ; it is then
called modified small-pox.
Ecthyma. — Ecthyma is an acute inflammation of the skin,
characterized by large, round, prominent pustules, occurring
upon any part of the body, though very rarely on the face or
scalp. The pustules are usually distinct, seated upon a hard
inflamed base, and terminate in red stains or in thick dark-
colored scabs, which leave superficial ulcers, followed by cica-
trices. This disease is often caused by stimulating applications
to the skin, such as lime, salt, sugar, &c. Grocers and brick-
layers are liable to it, especially when overworked, or when
their systems are depressed by bad or insufiicient food.
Impetigo. — Impetigo, or running-tetter, is a severe non-
contagious inflammation of the skin, characterized by an
eruption of small hemispheroidal or flattened pustules, most
frequently grouped in clusters, and forming thick, rough, yel-
PORRTGO. 211
lowish scabs or incrustations. From beneath the incrustations
a discharge takes place ; the crusts become thicker and larger,
and fall off, leaving a raw surface. The mode of distribution
of the pustules has caused a division of the disease into two
varieties — impetigo Jigiirata and impetigo sparsa. The first
occurs generally on the face, especially on the cheeks ; it is
attended with constitutional disturbance ; and as the pustules
burst and form scabs, the heat and itching become intolerable.
In children the impetiginous eruption sometimes covers the
face like a mask, and is called crusta lactea. The second form
merely differs from the first, inasmuch as the pustules are more
scattered, being sometimes distributed over an entire limb, or
even over the whole body.
Acne. — Acne, or gutta rosacea, or coppernose, is a chronic
pustular affection, characterized by small pustules with a deep
red base, leaving behind small, hard, red tumors, the seat of
which appears to be the sebaceous follicles of the skin. It
appears most frequently between the ages of eighteen and forty,
is often very chronic, and affects especially the temples, nose,
cheeks, and forehead.
Mentagra. — Mentagra, or sycosis, or tinea sycosa, is cha-
racterized by inflammation of the hair-follicles, causing suc-
cessive eruptions of small acuminated pustules, occurring most
frequently upon the chin and other parts occupied by the beard ;
it rarely occurs upon the scalp, and rarely affects women. The
disease is either due to, or — less probably — is attended by, the
development of a microscopic parasitic plant — the Microsporon
mentagropliyies.
PorrigO. — This is a very frequent variety of cutaneous
disease, affecting especially the hairy scalp, but occasionally
appearing on the forehead, temples, chin, and eyebrows. There
are three species of porrigo, all of which are probably due to
the development of parasitic plants.
Porrigo Favosa, or tinea favosa, most commonly affects the
scalp in the form of small, cup-shaped, dry, yellow crusts, each
containing a hair in its centre, and somewhat resembling a
piece of honeycomb — hence its name ; it is contagious. The
parasitic plant causing or accompanying it is the Achorion
Schonleinii.
Porrigo Smdulata, or tinea tonsurans, or vulgarly ringworm,
is a chronic contagious disease, known by the decolorization
and brittleness of the hairs, the scaly eruption, and the round-
ness of the diseased patches. The parasitic plant is the Tri-
chophyton tonsurans.
Porrigo Decalvans, or tinea decalvans, is readily diagnosed
212 DIAGNOSIS OF DISEASES OF THE SKIN.
by the perfectly smooth bald patches which result from the hair
falling otF on one or more circular spots, these spots varying in
size from a sixpenny piece to five or six inches in circumfe-
rence. The parasitic vegetable is Microsporon Audouini.
Plica Polonica. — Plica polonica, or trichosis plica, is a
disease of the hair little known in this country. It is charac-
terized by tenderness and inflammation of the scalp ; the hairs
become swollen and imperfectly formed ; and the hair-follicles
secrete a large quantity of viscid, reddish-colored fluid, which
glues the hairs together, uniting them into a mass. It is
caused or accompanied by two parasitic plants — the Tt'icJio-
phyion tonsurans and Trichophi/ion spondoides.
Equinia, or Glanders. — Farcinoma, farcy, or glanders, is
attended by symptoms somewhat similar to those of glanders
in the horse, viz., by fever, great debility, pains in the Hmbs,
profuse offensive discharge from the nostrils, and the formation
of a number of pustules and tumors in different parts of the
body, which have a great tendency to suppurate and become
gangrenous. The pustular eruption does not appear until
about the twelfth day ; it is accompanied by profuse fetid
sweats, and sometimes by the formation of black bullae. The
disease generally proves fatal before the twentieth day. It
occurs for the most part in grooms, stable-men, &c. There is
abundant proof of the transmission of the glanders from the
horse to man.
ORDER 5. PAPULA.
A papula or pimple is a small, solid, acuminated elevation
of the cuticle, resembling an enlarged papilla of the skin, gene-
rally terminating in resolution or in slight desquamation, and
sometimes in ulceration of its summit. Papular eruptions are
usually preceded by itching ; are rarely accompanied by fever ;
slowly developed ; not contagious ; developed on any part of
the body 5 and varying in their duration from a week to several
months. Lichen and prurigo are the diseases of this class.
Lichen. — This is a papular affection readily recognized by
the minute, hard, red elevations of the skin which it presents,
together with the annoying pruritus. There are three forms.
Lichen simplex, in which the eruption consists of small ag-
glomerated papulae, rarely larger than a millet-seed.
Lichen strophulus^ or red-gum, tooth-rash, &c., which gene-
rally attacks infants at the breast, and is characterized by an
eruption c^" minute, hard, sometimes slightly red pimples,
attended with itching, and appearing upon part or the whole
surface of the body.
PSORIASIS. 213
And Lichen agrius^ in which the papulae are more inflamed,
and developed on an erythematous surface, which appears hot
and painfully distended. The itching is very intense, and the
duration of this form is often very prolonged.
Prurigo. — Prurigo — itching — is a cutaneous disease cha-
racterized by an eruption of small papulte or pimples, of the
natural color of the skin. It is a chronic affection, lasting for
months or years, and causing great discomfort, not to say
misery. Patients afflicted with it scratch and tear themselves
constantly till the blood flows ; their sufferings are aggravated
by warmth. Willan describes three varieties, — prurigo mitiSj
prurigo formicans, and prurigo senilis. The first is the
mildest form ; in the second the itching is combined with a
sensation like the creeping of ants or the stinging of insects ;
while the third occurs in old persons, and is the most obstinate,
often continuing for the rest of the patient's life. In the di-
agnosis of prurigo care must be taken not to confound it with
the itching which arises from the presence of pediculi.
ORDER 6. SQTJAMJE.
The term squamae is applied to the scales of degenerated,
thickened, dry epidermis, which cover minute papular eleva-
tions of the skin ; they are readily detached, and are repro-
duced by successive desquamations for a long time. The
scales or scurf are the result of a morbid secretion of the
epidermis ; their formation gives rise to but slight constitu-
tional disturbance, and to mere local heat and itching : none
of the squamous diseases are contagious, but they are very
chronic in their duration. Lepra, psoriasis, pityriasis, and
ichthyosis are the diseases included in this order.
Lepra. — Lepra, or lepra vulgaris, is perhaps the most
obstinate and troublesome of all cutaneous diseases. It is a
non-contagious chronic eruption, consisting of red, scaly,
circular patches, of various dimensions, scattered over different
parts of the body, but more frequently found in the neighbor-
hood of the joints, especially near the knee and elbow. By
degrees, the patches increase in size and number, and extend
along the extremities to the trunk.
When the patches are small, white, and of long standing,
the disease is termed lepra alpJioides ; when copper-colored,
and the result of syphilis, syphilitic lepra.
Psoriasis. — Psoriasis, psora leprosa, or dry tetter, is a
chronic non-contagious inflammation of the derma, character-
ized by the development of patches of various extent and
214 DIAGNOSIS OF DISEASES OF THE SKIN.
form, slightly raised above the level of the skin, covered by
thin, whitish scales of altered epiderma, and accompanied by
rhagades or fissures of the skin. The eruption may be local,
or it may be diffused over the whole body. The local varieties
consist of psoriasis palpebrarum, psoriasis labialis, psoriasis
pra^putialis, psoriasis scrotalis, psoriasis palmaris, and psori-
asis unguinum. The general varieties are psoriasis vulgaris,
psoriasis gyrata, and psoriasis inveterata.
Psoriasis is closely allied to lepra in its appearance, and
general pathology : in the former disease, the patches are
irregular, and not depressed in the centre ; in the latter they
are circular, and depressed in the centre, with elevated
margins.
Pitjrriasis.— Pityriasis is a chronic inflammation of the
skin, attended with redness and itching, and characterized by
the production of minute white scales or scurf in great
quantity. It may attack any region, but the scalp and parts
covered with hair are the most common seats of it. The des-
quamation takes place copiously and incessantly. It is often
very rebellious to treatment.
Pityriasis versicolor^ or chloasma, or liver spot, makes its
appearance generally on the front of the chest or abdomen,
in the form of small spots of a dull reddish color, which
gradually increase in size, and assume a yellow tint. It may
last from a few days to many months or years. It is contagi-
ous. According to Eichstedt, this disease is caused by a
cryptogamic plant — Microsporon furfur.
Ichthyosis. — Ichthyosis, the fish-skin disease, is character-
ized by the development, upon one or more parts of the inte-
guments, of thick, hard, dry, imbricated scales of a dirty gray
color, resting upon an uninflamed surface, and unattended by
heat, pain, or itching. It is said to be a congenital disease,
and to last during life.
ORDEE 7. TTTBERCULA.
The diseases belonging to this order — Elephantiasis Grae-
corum, molluscum, and framboesia — are characterized by
small hard tumors or tubercles, more or less prominent,
circumscribed in form, and persistent ; they may become
ulcerated at the summit, or they may terminate in suppura-
tion. Tubercular diseases are slowly developed, are very
chronic, are almost peculiar to tropical regions, and their
symptoms are so characteristic that their diagnosis is easy.
Elephantiasis GrSBCOrum. — This terrible and dangerous
MACULAE. 215
disease, non-contagious, hereditary, and generally incurable,
is characterized by the appearance of patches of a purplish
color, succeeded by elevated tumors, having the same tint,
irregular in shape and size, soft, smooth, and insensible to the
touch, and which generally — after a certain time — become the
seat of unhealthy ulceration. It is not met with in temperate
climates, but there is found to be a disposition to it as we
approach the polar regions on the one hand, and the tropics
on the other. Males suffer from it more than females. It is
designated by the Jews tsaraath.
Molluscuin. — This affection — so called from the similarity
of the tubercles characterizing it to the eminences growing on
the bark of the maple tree — consists in the presence of small
tumors, varying in size from a pea to a pio'eou's egg, some-
times of a brown color, and sometimes growing from a broad
base, and sometimes from a narrow peduncle. There are two
forms — one contagious, the other not. Contagious molluscum
is a very rare, severe, and chronic affection : Bateman saw two
cases onlv. Non-contagious molluscum is less severe, and
does not produce as much irritation as the opposite kind ;
after a time the tumors neither grow nor alter, but remain
stationary for life.
Frambcesia. — Frambcesia, or pian, or yaws — in Guinea,
is rarely met with in Europe, but is common in Africa,
America, and the "West Indies. Without any precursory
symptoms, parts of the skin — especially about the face, scalp,
axillae, or genital organs — become covered with small dusky-
red spots, which gradually become converted into larger
tubercles, isolated at their summits, but collected together at
their bases, and often resembling raspberries or mulberries in
their color and form. The tubercles are generally hard, covered
with dry scales, and are sometimes inflamed ; if the inflam-
mation spreads, ulceration sets in, and a yellow sanious dis-
charge results, which forms scabs around the tumors. The
disease continues for years, or even for life.
OKDER 8. MACTJL.E.
This order of cutaneous diseases is characterized by certain
changes of color in parts of the skin — giving rise to spots of
various appearance and size — or in the whole of the cutaneous
envelope. The maculae are seated in the rete mucosum, and
depend on some alteration of its coloring matter ; they are
generally incurable, and unattended by any derangement of
health ; and they may be divided into two classes, those
216 DIAGNOSIS OF DISEASES OF THE SKIN.
attended by cliange of color, and those marked by absence of
color.
Changes of Color. — The skin sometimes becomes of a
bronze or slate color, as may occur — either — after a long-con-
tinued use of nitrate of silver, or naturally, without any appre-
ciable cause. The change is generally permanent.
Lentigo, or Freckles, or Sunburn, is generally congenital ;
the spots mostly cover the parts of the body exposed to light.
Freckles are more common in the fair than the dark-com-
plexioned ; are sometimes excited by the sun, and are most
common in warm countries.
Ephelides are yellow irregular spots, which sometimes
appear temporarily on the chest, abdomen, and groins, from
errors in diet, &c.
Ncevi, or Mother-marks, or Moles, are either small congeni-
tal dis colorations of the skin, or they consist of vascular spots
of variable size, formed by a congeries of bloodvessels.
Loss of Color. — The absence of the coloring matter of the
skin may be congenital or accidental.
In Albinismus the skin is of a dull white, milky color ; the
body is covered with a woolly white down, and the eyebrows,
eyelashes, and hairs generally are smooth, silky, and white.
The iris is of a rose color, and the pupils present a deep red
appearance, owing to the absence of pigment in the choroid
uvea. The albino is generally weak-minded, and of a delicate
constitution ; he is found amongst all the races of mankind.
When the skin is the seat of a partial discoloration, con-
genital or accidental, the affection is known as vitiligo. The
discoloration may appear on any part of the body in the form
of smooth, milky-white colored patches ; when it occurs on the
scalp it causes baldness. It may occur at all ages, and it
generally lasts for years.
ORDER 9.
Lupus. — The only disease in this order is lupus, a most
formidable affection. Dr. Burgess, in his translation of Ca-
zenave, says that it commences with purple and red spots, or
more frequently with livid indolent tubercles, the chief charac-
ter of which is their tendency to end in destructive ulceration
of the surrounding parts. There are two varieties of this dis-
ease, lupus non exedens, and lupus exedens or uoli me tangere.
In the_;^'r.s^ there is no ulceration, yet the tubercles leave deep
cicatrized pits behind them 5 when it spreads rapidly and su-
perficially, it leaves the skin crossed by white scar-like ridges
SYPHILIDA. 217
and bands. The second is very destructive ; it attacks the nose
more frequently than any other region of the body, though
why it does so is unknown. The extent of parts which it de-
stroys varies ; sometimes the whole nose being eaten away,
sometimes only the point.
OEDEE 10.
Pellagra. — This is a peculiar disease very common in
Lombardy, in which the skin becomes wrinkled, and assumes
— in those parts exposed to the air — a scaly appearance. The
strength diminishes, the digestive organs are deranged, the
spirits are generally depressed, the intellectual faculties and
sensations become obscure, and cramps and convulsions often
supervene. In addition, chronic pulmonary affections often
supervene and contribute to the fatal result. It is often he-
reditary, non-contagious, incurable, may occur at any age, and
is supposed to be caused by confinement and isolation, by bad
food, and by the habitual use of Indian corn.
ORDEE 11.
Malum Alepponmi. — This is a peculiar disease, consist-
ing in the eruption of one or more tubercles, followed by a
permanent cicatrix ; it occurs generally in the face ; is not
very formidable, its greatest inconvenience being the unsightly
scar ; and it occasionally prevails endemically in towns on the
banks of the Tigris and Euphrates, and especially at Aleppo.
ORDEE 12.
Syphilida. — Syphilis is a very grave, contagious disease,
of modern origin, dating probably from the close of the fif-
teenth century, consisting of an ulcer, termed '^ the primary
symptoms,'' produced in that part of the skin or mucous mem-
brane to which the poison has been directly applied ; the ulcer
is frequently followed or accompanied by bubo — specific en-
largement or suppuration of the lymphatic glands — usually
those of the groin. Gonorrhoea and syphilis are essentially
distinct affections ; the former never gives rise to " secondary
symptoms," the latter frequently does, and always — according
to Ricord — when the primary sore has consisted of an indu-
rated chancre ; the matter of gonorrhoea will never produce a
specific venereal ulcer. These secondary symptoms consist of
inflammation of the skin, of the palate, of the throat, of the
eye, of the bones, of the periosteum, of the joints, and the
formation of warty growths ; they manifest themselves usuallv
19
218 DIAGNOSIS OF DISEASES OF THE SKIN.
from six weeks to six months after the cure of the primary
sore, although three or four years may elapse between the two
affections. Secondary syphilitic cutaneous eruptions are gen-
erally of a copper color, scaly, have a tendency to run into
chronic ulceration, occur most frequently in the face, forehead,
back, and shoulders, and according to most authorities are
non-contagious ; secondary symptoms may, however, be trans-
mitted from the parent to the offspring. '' Tertiary symptoms"
are not uncommon, consisting generally of inflammatory affec-
tions of the mucous membrane of the fauces, and of disease
of the bones. The duration of syphilis varies according to
the severity and treatment of the primary symptoms, and the
nature of the secondary affections : it may last from a few
days to many years.
ORDER 13.
Purpura. — Purpura consists of a morbid condition of the
capillaries, owing to which blood is eff'used into the different
tissues of the body, the eff"usion giving rise to the formation of
sanguineous patches of various size. When the patches are
small — mere spots — they are termed petecliice ; when large,
ecchymoses.
The spots vary in color, being either red, purple, livid, or
reddish-brown ; they bear a great resemblance to bruises ;
pressure does not efface them. Five varieties are usually enu-
merated, namely, purpura simplex, purpura urticans, purpura
haemorrhagica, purpura senilis, and purpura cachectica. This
disease must not be confounded with scurvy, which it some-
what resembles. It diff'ers, however, inasmuch as it often ap-
pears suddenly, is not attended by a livid, spongy state of the
gums, and is not owing to any want of vegetable food.
ORDER 14.
Elephantiasis Arabicum. — This affection is characterized
by great swelling and induration of the skin and of the sub-
jacent areolar and adipose tissues, producing marked defor-
mity. It frequently attacks one of the lower extremities,
causing great swelling, so that the limb becomes double its
natural size, hardness, severe pain, and an appearance re-
sembling — it is fancifully said — the leg of an elephant. It is
uncommon in Europe, occurring principally in the West In-
dies ; it generally continues for life ; causes alarming consti-
tutional disturbance ; is neither contagious nor hereditary ;
and attacks males and females, rich and poor indiscriminately.
PARASITIC WORMS IN THE HUMAN BODY. 219
ORDER 15.
Cheloidea. — Cheloidea, or keloide, or cancroide, was first
described by Alibert under the above names, owing to the dis-
ease presenting a flattish raised patch of integument resem-
bling the shell of a tortoise. It forms small, flat, painful tu-
mors, one or two inches in diameter, raised a few lines above
the level of the skin, having irregular forms, slight depres-
sions in their centres, and being covered with wrinkled epi-
dermis. Sometimes there is only one tumor, sometimes seve-
ral ; the disease is developed slowly, rarely ends in ulceration,
often disappears spontaneously merely leaving a cicatrix, is
usually found on the chest between the mammte, and is very
uncommon.
CHAPTER X.
PARASITIC WORMS FOUND IN THE HUMAN BODY.
In considering the parasitic worms of the human body it is
necessary to divide them into two classes — according as they
occupy internal or external tissues — and then to subdivide
them according to the textures they severally inhabit. Thus
we have,
1. Internal Parasitic Worms.
Brain, Acephalocystis multifida.
Eye, Filaria oculi.
Cysticercus celluloste.
Liver, Acephalocystis endogena, or pill-box hydatid.
Echinococcus hominis.
Gall bladder, .... Distoma hepaticum. or liver-fluke.
Spleen and Omentum, Echinococcus hominis.
Kidney, Strongylus gigas.
Ovary Polystoma pinguicola.
Urinary Bladder, . . Diplosoma crenata.
Small Intestines, . . Ascaris lumbricoides, or round-worm.
Taenia solium, or common tape-worm.
Bothriocephalus latus, or broad tape-worm.
Large Intestines, . . Tricocephalus dispar, or long thread-worm.
Ascaris vermicularis, or common thread-worm.
Areolar Tissue, . . . Filaria Medinensis, or Guinea-worm.
Muscular Tissue, . . Trichina spiralis.
Cysticercus cellulosse.
Bronchial Glands,. . Filaria bronchialis.
220 PARASITIC WORMS IN THE HUMAN BODY.
2. External Parasitic Worms.
Skin, . . ~. . , • Pulex penetrans, or chigoe.
Acarus scabiei.
Ilair-follicles, . . . Acarus foUiculorum.
Surface of the Body, . I'ediculus corporis.
Hair of the Head, . Pediculus capitis.
Hair of ihe Pubes, . Pedicuhis pubis.
Eyelashes, .... Pediculus ciliorum.
1. INTERNAL PARASITIC WORMS.
Acephalocysts or Hydatids. — These peculiar parasites
are met with in different parts of the body, but especially in
the liver, brain, spleen, and omentum.
Hydatic tumors occur in the liver more frequently than in
any other organ. They consist of a sac, lined by a thin blad-
der or cyst, and filled with a limpid colorless fluid, floating in
which numerous small cysts, similar to the cyst lining the
sac, and varying in size from a pea to a pigeon's egg, are
usually found. To these cysts or bladders Laennec gave
the name acephalocyst — a bladder without a head. The
acephalocyst lining the sac is composed of finely laminated,
friable coats, about the firmness of coagulated albumen.
Sometimes it contains no floating hydatids, or very few ; in
other cases it is literally crammed with them; and these again,
it is said, may contain another generation. To distinguish
these difi'erent kinds, as well as to mark the mode of their in-
crease, naturalists have divided these productions into two
species : 1st, the acephalocystis endogena of Kuhn, likewise
called socialis, vel prolijera by Cruveilhier, the pill-box hydatid
of Hunter, which is the kind most commonly developed in the
human subject, and in which the fissiparous process of genera-
tion takes place usually from the internal surface of the parent
cyst, the progeny being sometimes successively included ; and,
2d, the acephalocystis exogena of Kuhn, eremita, vel sterilis of
Cruveilhier, which developes its progeny generally from the
external surface, and is found in the ox and other domestic
animals. The true nature of these acephalocysts has long
been a subject of investigation. M. Livois seems, however,
to have settled the question by his discovery that they are the
dwelling-place of those minute animalcules to which Rudolphi
gave the name echinococcus, from the cylinder of hooks sur-
rounding the head. M. Livois states that echinococci exist
in all acephalocysts, and this observation has been in a great
measure confirmed by Dr. Budd and other observers. When
an acephalocyst is opened, its inner surface is seen to be stud-
ded with numerous white opaque particles, which are found
by the microscope to be distinct echinococci.
FILARIA OCULI, ETC. 221
The ecliinococcus hominis is a transparent, colorless, oval-
shaped animalcule, displaying an apparatus of suctorial pro-
minences and hooklets at the cephalic extremity, and measur-
ing about the one two-hundredth of an inch in length, and
rather less in breadth. In structure the animal is a mere
integument, one half — the head and neck — being susceptible
of retraction into the other half. The head is a flat disc at
the extremity of the neck, having imbedded in its substance
an apparatus of small hooks, thirty-four in number, disposed
in a circle. Immediately behind the head are four rounded
suctorial processes, beyond which follows the body, while at
the extremity of this is a short peduncle by which the animal
attaches itself to the wall of the acephalocyst. When the
animal is A-iewed with its head retracted within its body, the
circle of hooks is seen through the transparent integument
appearing like a ring in the centre of the body.*
When a hydatid tumor forms in the liver, its growth is
generally slow. It gives rise to little inconvenience beyond a
sensation of weight, so that its presence is often not suspected
until found after death. WTien the tumor is of a large size, it
may then be easily felt ; sometimes it compresses the portal
vein or vena cava, causing ascites and oedema of the legs. It
may burst into the peritoneum — causing fatal peritonitis, or
into the lung, or into the intestines, or through the abdominal
wall ; in the two latter cases, the contents will often be entirely
discharged, and the sac ultimately closing up, ^vill leave the
patient well. When the tumor opens into the lung, the suf-
ferer becomes so worn out with the constant expectoration of
hydatids and puriform matter, and the constitutional distur-
bance is so severe, that he generally sinks under it.
Sometimes a hydatid tumor gets well without opening,
namely, by the secretion of a thick putty-like matter within its
sac, owing either to the destruction, or at all events causing,
the destruction of the hydatids.
The Filaria Oculi, Filaria Medinensis, and Filaria
Bronchialis. — These various filariae are small, hollow, cylin-
drical worms, possessing a distinct alimentary canal, a mouth
and anus separate, and organs of generation placed on sepa-
rate individuals. The filaria oculi was detected by Xordman
in the liquor Morgagni of the capsule of the crystalline lens of
a man who had been operated upon for cataract ; it was curled
up in the form of a ring, and measured three-fourths of a line
* Erasmus Wilson on the Echinococcus Hominis : Med. Chir. Trans.,
vol. xxviii.
19*
222 PARASITIC WORMS IN THE HUMAN BODY.
in length. A larger species is found in the eye of the horse.
It gives rise to no symptoms.
The filaria medinensis, or Guinea-worm, has its residence
in the subcutaneous areolar tissue, and generally in that
of the feet, though it may occur in any superficial situa-
tion. It is a long, slender, uniformly shaped worm, resem-
bling a fiddle-string, varying in length from six inches to eight
or even twelve feet, and being about one line in thickness.
It appears to be endemic in the tropical regions of Asia and
Africa. The symptoms of its presence are great uneasiness
and itching, and ultimately suppuration.
The filaria bronchialis is a slender worm about an inch in
length. It was detected by Treutler in an enlarged bronchial
gland of a patient who died from phthisis.
The Cysticercus Cellulosae. — This parasite is for the
most part found in subjects of the leucophlegmatic tempera-
ment, but it is not common. It has been met with in the
muscles — especially the glutei and extensors of the thigh, in
the muscular tissue of the heart, and in the brain and eye.
It is generally surrounded by an adventitious capsule formed
of the neighboring tissue condensed by inflammation ; it
consists of a head, neck, and dilated cyst-like body, and va-
ries in length from a quarter to three-quarters of an inch. It
is very commonly found in the hog, giving rise to that state of
the muscles known as " measly pork."
The Distomata. — The distoma hepaticum, or fluke, or
liver-fluke, is found in the gall-bladder and ducts of the liver
of a variety of quadrupeds, and especially in the sheep in
connection with the disease called "the rot." When it occurs
in man it is generally developed in the same situation. In
form it is flattened, ovate, and elongated ; its under surface
presents three pores, the anterior being the mouth, the middle
being for the purpose of generation, and the posterior for ad-
hesion or locomotion ; and it is of a light brown color. The
flukes give rise to no characteristic symptoms.
A second species of distoma was described by Rudolphi as
the distoma lanceolatum ; it is only the young, however, of the
distoma hepaticum.*
The Folystoma Pingnicola was discovered by Treutler
in the cavity of a mass of tubercle in the left ovarium of a
young woman who died in labor. It is about three-quarters of
an inch in length, truncated towards the head, and pointed
towards the other extremity. «
The Strong^lus Gigas — sometimes occupies the human
» Article Entotoa, by Professor Owen : Cyclopaedia of Anatomy and
Physiology.
ENTOZOA IS THE INTESTINAL CANAL. 223
kidney. It is the largest of tlie parasitic worms, varying in
length from five inches to a yard, and being sometimes half an
inch in diameter. The male is smaller than the female.
This worm causes great suffering ; there are no symptoms
of its presence that can be relied upon. It has been passed
by the urethra, and the patient recovered.
The Dactylius Aculeatus — was first described by Mr.
Curling, who discovered several of them in the urine of a
little girl recovering from fever. The worm is of a light color,
cylindrical, and about four-fifths of an inch long. The male
is smaller than the female.
The Diplosoma Crenata — varies in length fi-om four to
six or eight inches, is solid throughout, without any trace of
internal organization, and of a yellow-white color. A patient
of Mr. Lawrence's voided numbers of these parasites for a
length of time from the urinary bladder ; they were pro-
bably contained in a cyst which was ruptured by passing a
catheter.'
The Spiroptera Hominis. — This worm was first disco-
vered in the urine of Mr. Lawrence's patient just alluded to.
Rudolphi examined some specimens which were forwarded to
him, and found them to be of different sexes — the female ten
lines in length, the male about eight — of a white color, slender,
and very elastic.
The Trichina Spiralis. — This microscopic entozoon ex-
ceeds in minuteness of form and in numbers every other
parasite of the human body ; its seat is the muscular tissue.
The worm exists coiled up in minute elliptical cysts, which
are readily examined by the microscope with a half-inch ob-
ject-glass. "When extracted from its habitation this parasite
is found to measure about one-thirtieth of an inch in length,
and about one seven-hundredth of an inch in diameter. It is
cylindrical and filiform, and possesses an alimentary canal ;
when found in the muscles it is generally in those that are
superficial, where it exists in immense numbers. No cause
has been suggested for their presence, neither do they give
rise to any symptoms which could lead to the supposition of
their existence during life.
Entozoa found in the Intestinal Canal.— There are five
entozoa — svto?, within, and (^aiiv, an animal — occasionally found
inhabiting the intestinal canal, of which three possess an ali-
mentary tube, and are therefore called hollow worms, or Coelel-
muitha — x«Ac?, hollow, and U/uiv;, a worm — and two which
» Medico-Chirurgical Transactions, vol. ii.
224 PARASITIC WORMS IN THE HUMAN BODY.
have no abdominal cavity, and are hence termed solid worms,
or Sterehniniha — a-Ttpfot, solid, and ekfjuvi. Such of the para-
sites as I have already described are also arranged by some
authors under one or other of these heads, but the distinction
with them is of secondary importance.
In the first class we have,
1. The Tricocephalus DispaVj or long thread-worm, usually
found in the coecum and large intestines, measuring about
two inches in length, and having a very slender body. It is
often found in considerable numbers, even in the intestines of
healthy persons ; during life they give rise to no symptoms.
2. The Ascaris Lumbricoides, or large round-worm, is found
in the small intestines, especially of ill-fed children. It some-
what resembles in size the common earth-worm, varies in
length from six to nine inches, and is of a light yellow color.
The symptoms which it gives rise to are thirst, disturbed
sleep with grinding of the teeth, pallid countenance, foetid
breath, swelled belly, emaciated extremities, depraved appe-
tite, slimy stools, itching of the nose, tenesmus, and itching of
the anus.
3. TJie Ascaris Vermicularis, or small thread-worm, is found
in the rectum, and is the smallest of the intestinal worms,
averaging usually about a quarter of an inch in length. It
gives rise to intolerable itching and irritation about the anus,
tenesmus, depraved appetite, picking of the nose, depraved
breath, and disturbed sleep.
In the second class we find,
1. The Tceiiia Solium, or common tape-worm of this coun-
try, which exists in the small intestines, varying in length
from five to ten feet, and in breadth from one line — at its
narrowest part — to four or five at its central or broadest por-
tion. The head of this parasite is small and flattened, having
in its centre a projecting papilla armed with a double circle
of hooks, around which are four suckers or mouths, by which
nourishment is imbibed ; the generative apparatus consists of
a ramified canal or ovarium containing the ova, and occupying
the centre of each joint. The symptoms of its presence are
not very striking, its existence being generally unsuspected
until single joints are passed in the stools ; in many cases,
however, there is a continual craving for food, debility, pain in
the stomach, emaciation, and itching about the nose and anus.
2. The Bothriocephalus Laius, or broad tape-worm, is almost
peculiar to the inhabitants of Switzerland, Russia, and Poland.
It differs from the common t^pe-worm in having its segments
of a greater breadth than length. The extreme fertility of
THE ACARUS FO LLICULORUM. 225
the hoilirioceplialus latus may be understood by considering
that each foot of the well-developed worm contains 150 seg-
ments or joints, each joint possessing its own ovary and male
organs. Hence each joint is fertile, and as each ovary would
produce 8000 ova, it may be calculated that ten feet of such a
worm would produce 12,000,000 of ova. They are very
rarely met with in this country, but they are so occasionally.
Professor Owen, examining the collection of a worm doctor
in Long Acre, found three specimens ; two had come from
persons who had been in Switzerland, but of the third nothing
was known.
2. EXTEBNAL PAEASITIC WORMS.
The Pulex Penetrans, or Chigoe. — This small insect is
found in America and the Antilles ; it penetrates the epider-
mis, and there lodges its eggs to about the number of sixty,
which, when hatched, create great irritation, and often serious
mischief. The native inhabitants extract them very skilfully
with a needle, taking care not to rupture the cyst in which they
are enclosed.
The Acarus Scabiei. — This little parasite, belonging to
the class Arachiida (spiders) of articulated animals, is now
generally admitted to be the cause of that loathsome, conta-
gious disease of the skin — scabies. It is generally found about
a line from, but not in, each vesicle.
M. Bourguignon's researches on the nature and habits of the
acarus scabiei show that the male is but one-third of the size
of the female •, that he is the most nimble of the two, being
very lively when the body is warm ; and that he is the least
frequently met with. He has suckers on two of his hind feet,
and genital organs on the surface of the abdomen. The female
burrows into the epidermis, and lays four eggs at intervals of
about four days between each deposit, shifting her position in
the meantime until sixteen eggs are inserted beneath the skin.
In ten days the shells are broken, and the insects make their
appearance as six-legged larvoe, increase rapidly in size for a
few days, then shed the shell — like the Crustacea — and acquire
eight legs, when they are perfectly developed, and capable of
tormenting man and reproducing their species. The males
and young females do not burrow into the epidermis as the
pregnant females do, but run about on the surface, puncturing
the skin merely for blood-globules and serum, on which they
live.
The Acams FoUiculonim. — The acarus folliculorum, or
22G EXAMINATION OF THE BLOOD, ETC.
the steatozoon folliculorum,' was discovered by Dr. Simon, of
Berlin, in the sebaceous substance with which the hair-follicles
— especially those on the face — are commonly filled. It is very
minute in size, measuring little more than a quarter of a line
in length, and being undistinguishable by the naked eye ; it is
divrsible into a head, thorax, and abdomen, and resembles in
form and shape the common caterpillar. This animalcule is
found in numbers varying from one to twenty in the sebaceous
follicles or oil-tubes of the skin in the majority of mankind,
and always when any disposition exists to the unnatural accu-
mulation of sebaceous matter: the skin at the same time is
apparently healthy. They may be obtained by compressing
the skin until the sebaceous matter is squeezed out : a micro-
scope magnifying 250 diameters will detect them. Mr. Eras-
mus Wilson regards these steatozoons as performing a benefi-
cent purpose in the economy of the skin, that purpose being
the disintegration of the over-distended cells, and the stimula-
tion of the tubes to perform their office more efficiently.
Pediculi. — The human body is infested with four different
species of the pediculus, or louse — of which the pedicuhis capi-
tis, or louse of the head, is the most common 5 next, the pedi-
cutis j9w6i>, or crab-louse, which attaches itself to the hair
about the pubes and anus ; the pediculus corporis, or body
louse, often found in the clothes ; and,\sist\j,i\\c pediculus cili-
orum, or louse of the eyelash, which is very rare.
CHAPTER XI.
ON THE CHEMICAL AND MICROSCOPICAL EXAMI-
NATION OF THE BLOOD, EXPECTORATION, VO-
MITED MATTERS, AND URINE.
It was my original intention to devote this chapter to a full
consideration of all the secretions and excretions of the human
body ; but want of space compels me to limit myself to the
examination of the blood, sputa, vomited matters, and urine.
I may, however, observe that the chief excretions consist of the
watery vapor and carbonic acid exhaled by the lungs ; the
sweat, excreted by the skin, consisting chiefly of watery vapor,
lactic acid, a small quantity of carbonic acid, a little oily matter,
and a small proportion of the same animal and saline matters as
are contained in the blood ; the excretions from the bowels,
* Wilson, on " Diseases of Ihe Skin," p. 466.
THE BLOOD. 227
including the bile ; and, lastly, the most complex of all the
excretions — the urine. The retention of any of these excre-
tions in the body is most injurious, and often fatal, since the
peculiar matters characterizing them are not formed from the
blood, but actually separated from it, at the parts where they
appear ; allow, therefore, these excrementitious matters to ac-
cumulate in the circulating fluid, and general constitutional
disturbance must result. This is well seen when the principles
of the bile remain unseparated from the blood, owing to de-
fective secretion on the part of the liver, and jaundice results;
or, to take another example, when, owing to severe renal
disease, the urea, instead of being removed by the kidneys
from the circulating fluid, accumulates in it, and actually poi-
sons the suflerer.
SECTION 1. THE BLOOD.
The general appearance of the blood is familiar to every
one : it is slightly alkaline ; has a faint odor ; a saline, disa-
greeable taste ; and a higher specific gravity than any other
animal fluid — averaging 1050 or 1055.
When circulating in the vessels, blood is composed of a nearly
colorless, transparent liquid — the liquor sanguinis — in which
numberless minute disc-shaped bodies or corpuscles are sus-
pended or floating. The liquor sanguinis consists of water,
fibrin, serum holding albumen in solution, certain extractive
and fatty matters, and fixed saline matters. The blood-cor-
puscles — usually forming about 130 parts in every 1000 of
healthy blood — are of two kinds : the red corpuscles, by far the
most numerous, to which the red color of the blood is due,
about the ^^noir^^ of an inch in diameter, consist of mem-
branous vesicles filled with red fluid, which fluid is composed
of coloring matter containing iron — termed haematin, and of a
protein compound, somewhat analogous to albumen, called
globulin ; and the wTiite corpuscles, somewhat larger than the
red ones, about the ^^Viyth of an inch in diameter, irregular
in form, slightly granular on the surface, and apparently
identical with the peculiar corpuscles found in the lymph and
chyle.
On removing blood from the vessels, and allowing it to
repose for a short time, it coagulates — that is to say, the
liquor sanguinis separates into two portions : the colored clot
or crassamentum — consisting of the fibrin and blood-corpus-
cles, — and the fluid portion, consisting of the serum holding
the albuminous and saline matters in solution. The forma-
tion of the clot is owing to the solidification of the fibrin,
which, while becoming solid, entangles the red and white
228
EXAMINATIOX OF THE BLOOD, ETC.
blood-corpuscles in its meshes. In certain states of the system,
when the fibrin coagulates more slowly, or when the corpuscles
sink more rapidly than in healthy blood, the upper surface of
the clot will be colorless, presenting an appearance known as
"the bufify coat," which was formerly thought to be indicative
of inflammation. Occasionally this buffy coat, when the
blood is rich in fibrin, is depressed in its centre, and the blood
is then said to be "cupped and buffed."
Chemical Comi)osition of Human Blood. — To make a
complete quantitative analysis of the blood, including the
separation from each other and estimation of all the ingre-
dients, is a complicated and difficult task, and requires the
person undertaking it to be a good chemist. Such an analysis
is, however, quite unnecessary for clinical purposes, although
it is as well that the result of such an examination should be
roughly remembered. I shall therefore quote the following
table by Dumas :
130 Clot,
Analysis of Healthy Venous Blood.
Fibrin,
Globules, {^^^"^^"'
:,i
3
2
125
790
70
Globulin,
' Water,
Albumen,
Oxygen,
Nitrogen,
Carbonic Acid,
Extractive matter, * "*
Phosphorized fat,
Cholesterin,
870 Serum,<( Serolin,
Oleic and margaric acids,
Chlorides of sodium and potassium, . .
Muriate of ammonia,
Carbonates of soda, lime, and magnesia,
Phosphates of soda, lime, and magnesia,
Sulphate of potash,
Lactate of soda,
Salts of the fatty acids,
1000 [^Yellow coloring-matter, _
Arterial blood merely differs from venous in containing less
solid matter, less albumen, less salts, and in being of a bright
scarlet color, which latter is probably due to the influence of
the oxygen of the air. In anaemia and chlorosis the water is
sometimes increased to 900 parts in 1000, and the globules
diminished even to as low as 21 in 1000. In fever the glo-
bules have been known to amount to 185 in 1000; while in
10
1000
URIC ACID IX THE BLOOD. 229
many iuflammatory diseases the quantity of fibrin appears to
be increased. In diabetes, sugar may usually be detected in
the blood ; while in jaundice the presence of bile may be
demonstrated.
Microscopic Examinatioa of the Blood.— If a drop of
blood be placed under the microscope, and examined with a
quarter of an inch object-glass, the red globules will be seen
as a multitude of pale, red, round, bi-concave discs, having a
tendency to turn upon their edges, and to arrange themselves
in rolls like rouleaux of coins ; a very few white corpuscles,
irregular in form, granular on the surface, and rather larger
than the red globules, will also be readily distinguished.
Long maceration in serum or in water will frequently cause
the red globules to diminish to half their size in bulk, and to
present a perfectly spherical slightly colored body. Strong
acetic acid dissolves them rapidly. Acetic acid renders the
external cell-wall of the colorless corpuscles very transparent,
and also brings the nucleus into view, consisting of one or
two round granules. In leucocythemia — as described by
Dr. Hughes Bennett — the colorless corpuscles become much
increased in quantity, so that, instead of two or three being
seen in the field of the microscope at the same time, some
thirty, forty, or more become visible.
To Examine Stains of Blood. — To discover whether a
certain stain consists of blood, it must be moistened with
some fluid having a specific gravity of 1040 or 1050 — white
of egg will answer very well — scraped ofi" the material holding
it, and examined microscopically with a quarter of an inch
object-glass ; blood-corpuscles will be rendered distinctly
visible if the stain consists of blood.
Dr. Garrod's Plan of ascertaining* the Presence of an
Abnormal Quantity of Uric Acid in the Serum of the
Blood. — From the researches of Dr. Garrod, I entertain but
little doubt that the presence of an abnormal quantity of uric
acid in the blood — such a quantity as is capable of being
demonstrated — is a pathognomonic sign of gout ; and that,
consequently, where the diagnosis rests between gout and
rheumatism, the presence or absence of this acid from the cir-
culating fluid will decide the question.
Take from one to two fluid drachms of the serum of the
blood, and put it into a flattened glass-dish or capsule ; to
this add the strong acetic acid of the London Pharmacopoeia,
in the proportion of about six minims to each fluid-drachm of
the serum. A few bubbles of gas are generally evolved at
first ; but when the fluids are well mixed, two or three fine
. 20
230 EXAMINATION OF THE EXPECTORATION.
threads, or one or two ultimate fibres from a piece of unwashed
huckaback, are to be introduced. The glass is then to be put
aside in a moderately warm place — as on the mantelpiece in
a room of ordinary temperature — until the serum is quite set
and almost dry, the time required varying from eighteen to
forty-eight hours. If the cotton fibres be then removed and
examined microscopically with an inch object-glass, they will
be found covered with crystals of uric acid, if this agent be
present in abnormal quantity in the serum. The crystals
form on the thread, somewhat like the crystals of sugar-candy
on string.
When it is undesirable to remove even a few drachms of
blood, we may examine the fluid effused by the application of
a blister, since the uric-acid thread experiment may be as
readily employed for the discovery of uric acid in blister-
serum as in blood-serum. It is only necessary to observe the
precautions alluded to in examining the blood-serum, and also
to be careful not to apply the blister to an inflamed part,
since the existence of inflammation appears to have the
power of preventing the appearance of uric acid in the effused
serum.'
SECTION 2. THE EXPECTORATION.
The character of the expectoration often furnishes us with
instructive signs. The basis of all kinds of expectoration is
the natural secretion of the mucous membrane of the air-
tubes, which is a transparent, colorless, glutinous liquid, con-
sisting chiefly of water, mucus, and saline matter. In simple
catarrh the natural secretion is merely increased in quantity ;
in bronchitis the sputa are often glairy — like white of egg —
and streaked with blood ; in haemoptysis the expectoration may
consist entirely of blood ; in phthisis, purulent fluid and por-
tions of softened tubercle are expectorated, occasionally with
cretaceous or calcareous masses of phosphate and carbonate
of lime ; while in pneumonia, at the outset, there is merely
expectoration of bronchial mucus, but in two or three days
the sputa assume a very characteristic appearance, being
transparent, tawny or rust-colored, and united into a jelly-like
mass of great viscidity.
To examine the sputa microscopically, they should be thrown
into water, when the lighter portions will float on the surface,
while the more dense sink. These latter can be broken up,
and small particles placed on a glass slide for examination.
The matters usually found consist of epithelium, portions of
food — as muscular fibre, oil-globules, starch-granules, &c. —
'Medico-Chirurgical Transactions, vol. xxxvii. p. 51.
VOMITED MATTERS. 231
and occasionally of vegetable fungi, whicli are often present
about the fauces. In phthisis, a number of small, round,
oval, or triangular-shaped bodies — tubercle corpuscles — are
frequently found, containing granules in their interior, and
mingled with granular matter. Occasionally fine molecular
fibres, which have been separated from the areolar and elastic
tissue of the air-cells of the lung, are also seen, showing that
•ulceration or sloughing of the pulmonary texture is going on.
Schroeder van der Kolk states that these fragments may be
found before the physical signs of ulceration of the lung are
well marked ; but Dr. Hughes Bennett — a great authority on
this subject— disputes the assertion, though he allows that in
doubtful cases, especially where — from chronic pleurisy or
pneumonia — there is dulness on percussion, whilst the other
physical signs are more or less obscure, the presence of these
fragments will confirm a previous suspicion of existing phthi-
sis.* In pneumonia, fibrinous casts of the minute bronchi
may often be observed, sometimes infiltrated with pus-corpus-
cles. And, lastly, the dirty green or black inspissated sputum,
so commonly expectorated in the morning by residents in cities,
consists of mucus and epithelial cells containing carbon,
probably derived from the smoky atmosphere.
SECTION 3. VOMITED MATTERS.
But little attention has been paid to the microscopic exami-
nation of these matters, and but little therefore is known of
them. The chief substances found are epithelium, starch-
granules, torulse and other varieties of vegetable fungi — re-
sembling the yeast plant, vibriones, and sarcinje.
The Sarcince Ventriculi — first described by Goodsir — consist
of square bundles, divided by vertical and horizontal lines
into four parts, and each ha\-ing a resemblance to a woolpack
— whence its name ; they are seen either singly or aggregated
into masses. These vegetable parasites are found in the vo-
mit when it is very acid, and when it resembles yeast in ap-
pearance.
Dr. Todd has found the sarcinae in ulceration and enlarge-
ment of the stomach with contraction of the pylorus, and he
suggests that these vegetable organisms result from the long
detention of food in the stomach. There is but little doubt
that this explanation is correct ; but it is also probable that
the intensely acid fluid in which the sarcinas are found may
itself irritate and close the pylorus spasmodically ; in such
cases consequently, if we check the formation of these growths
we shall cure the disease.
» Op. cit., p. 92.
232
EXAMINATION OF THE URINE.
Sarcinse have also been found in the urine, faeces, and in
the fluid of the ventricles of the brain.
SECTION 4. THE URINE.
Healthy human urine is a limpid, pale, amber-colored fluid,
free from any deposit, of acid reaction, unaffected by heat,
nitric acid, liquor potassse, &c., and having an average spe-
cific gravity of 1018. Dr. Prout estimates the normal quanti-
ty of urine secreted in the twenty-four hours to be from thirty
ounces in the summer, to forty in the winter. A distinction is
usually drawn between the urina jyoius, or that passed shortly
after taking fluids 5 the urina cht/Ii, or that evacuated soon
after the digestion of a full meal ; and the urina sanguinis, or
that which is voided on first awaking in the morning, and
which may generally be taken as a fair specimen of the renal
secretion. The solid matters in the urine may be said to con-
sist of urea, uric acid, hippuric acid, vesical mucus and epithe-
lium, ammoniacal salts, fixed alkaline salts, earthy salts, and
animal extractive.
Solid Contents. — To estimate the solid contents as well as
the weight of an ounce of urine, of any specific gravity be-
tween 1010 and 1040, the late Dr. Golding Bird constructed
the following very useful table :
Weight
Weight
Specific
of one
Solids in
Specific
of one
Solids in
Gravity.
fluid
ounce.
one ounce.
Grayity
fluid
ounce.
one ounce.
Grains.
Grains.
1010
441-8
10-283
1025
448-4
26-119
lOll
442-3
11-336
1026
448-8
27-188
1012
442-7
1-2-377
1027
449-3
28-265
1013
443-1
13 421
1028
449-7
29-338
1014
443-6
14-470
1029
450-1
30-413
1015
444-
15-517
1030
450-6
31-496
1016
444-5
16570
1031
451-
32-575
1017
4449
17-622
1032
451-5
33-663
1018
445-3
18-671
1033
451-9
35-746
1019
445-8
19-735
1034
452-3
36-831
1020
446-2
20-792
1035
45-2-8
37-925
1021
446-6
21-852
1036
453-2
38-014
1022
447-1
22-918
1037
453-6
39-104
1023
147-5
23 981
1038
454-1
40-206
1024
448-
25051
1039
454-5
41-300
REACTION OF THE URINE TO TEST-PAPERS. 233
Clinical Examination of Urine. — On making a clinical
examination of the urine, we should first ascertain the quan-
tity passed in the twenty-four hours ; its acidity or alkalinity,
by the use of litmus and turmeric papers ; its specific gravity,
by means of the urinometer ; and its behavior on the applica-
tion of heat, nitric acid, and liquor potass^. To examine it
microscopiaily, a portion should be placed in a conical glass,
and allowed to stand for some hours ; a few drops of the de-
posit at the bottom of the glass are then to be placed by
means of a pipette on a glass slide, and covered with thin glass.
Crystals of uric acid, deposits of urate of soda, and deposits
of phosphates, will be readily distinguished with a good half-
inch achromatic object-glass ; oxalate of lime, carbonate of
lime, cystine, blood-corpuscles, casts of tubes, pus, mucus,
epithelium, and certain fungi, as torulae, &c., will require a
quarter-inch object-glass ; while spermatozoa and vibriones
can only be distinctly examined with the one-eighth of an inch
glass.
An Increased Flow of Urine, or diuresis, may be tem-
porary, and merely dependent on the large quantities of
fluid taken ; or it may be permanent for a time and associated
with disease, as it very constantly is in diabetes, and in those
states of the system connected with a peculiar state of nervous
irritability — as hysteria, &c.
A Deficiency of Urine may also be the temporary result
of abstinence from fluids, unusual cutaneous activity, &c. ; or
it may be permanently associated with certain constitutional
and local afl"ections, as with inflammatory states of the system
generally.
Reaction of the Urine to Litmus and Turmeric Test-
papers. — In many diseases — as gout, rheumatic fever, &c. —
we find the urine unusually acid, which may be owing to an
excess of acid, or it may be caused by the presence of oxalic
acid. On the other hand, this secretion may be alkalme,
though it is very doubtful if the urine is ever so secreted. It
generally happens thus : — a patient is unable completely to
empty his bladder, and therefore, after each attempt to do so,
a small quantity of urine is left which soon becomes alkaline ;
this suffices to contaminate the acid urine as it drops guttatim
from the ureters. Of course, as a rule, the vital endowments
of the bladder are sufficient to preserve its contents from under-
going that change which so readily takes place out of the body,
viz., decomposition. But this preservative power depends upon
the integrity of the spinal nerves and branches from the or-
ganic system supplying this viscus; if, therefore, any injury
20*
284 EXAMINATION OF THE URINE.
be inflicted upon these nerves, directly or indirectly, the result
will be diminution of vital power, and the urine will undergo
certain changes, as it would out of the body. One of these
changes is the union of urea with the elements of water, and
the formation of carbonate of ammonia. Ammoniacal urine
inflames the mucous membrane of the bladder, and gives rise
to the secretion of mucus of a viscid character ; the mucus be-
comes puriform when the alkaline urine has kept up the in-
flammation for a certain time.
TTrine depositing* Uric Acid — is very acid ; of a reddish-
brown color; generally of a specific gravity above 1020 ; and
on cooling deposits crystals of uric acid, resembling a yellow
crystalline sand. This deposit does not dissolve on the appli-
cation of heat 5 but if — as often happens — the urine contains
an excess of urates, this excess will be dissolved, and hence the
crystals of uric acid will become more distinct. Nitric acid
dissolves the deposit, while hydrochloric and acetic acids have
no action ; heated with liquor potassa?, the uric-acid crystals
dissolve, from the formation of urate of potass, which is readily
soluble in alkaline fluid. Examined microscopically, large
rhomboidal crystals are seen 5 occasionally lozenge-shaped and
square crystals are present.
Urine containing an Excess of Urea— may be known
by its high specific gravity — 1020 to 1030 — and by crystals of
nitrate of urea forming on adding nitric acid to a portion of
the urine in a test-tube. If the urea be only slightly in excess,
the urine should be concentrated, by evaporation to about one-
third its l)ulk, before adding the acid.
Urine containing an Excess of Urate (or Lithate) of
Lime, Soda, &C., will be distinguished by its high color, in-
creased density, and turbid appearance when cold — somewhat
resembling pea-soup. On applying heat with a spirit-lamp, it
immediately becomes bright and clear. Examined by the
microscope, an abundant amorphous precipitate is seen.
These deposits were formerly regarded as consisting of
lithate of ammonia. It has, however, been lately shown that
they have a variable constitution, being made up of urates of
lime, potash, soda, with only very small quantities of ammonia.
Even this last is probably derived from the decomposition of
urea.
Urine containing anExcess of Ammoniacal and Fixed
Alkaline Salts — is generally of a pale color, and rather low
specific gravity. On the application of heat, a deposit is pro-
duced resembling albumen, from which it is distinguished,
however, by its being dissolved on the addition of a few drops
OXALATE OP LIMK. 235
of nitric acid. Sometimes, when the quantity of albumen
present is small, the cloudiness produced by heat will be dis-
solved by a drop or two of nitric acid, but will reappear on
continuing to add more of this agent 5 but the phosphatic
cloud remains permanently dissolved. Liquor potassae and
liquor ammonias also produce deposits of phosphates. Ex-
amined with the microscope, crystals presenting the form of
triangular prisms, sometimes truncated, at others having ter-
minal facets, are readily distinguished ; occasionally they pre-
sent a star-like or foliaceous appearance.
Urine containing' Purpurine. — Purpurine never occurs as
a deposit unless the urates are in excess, when it gives them a
beautiful tint, varying from a pale flesh color to a deep carmine.
The presence of an excess of purpurine appears to depend on
some imperfection in the excretion of carbon by the organs
destined to eliminate this element from the blood, as the liver
and lungs.
Cystine. — This substance never occurs in healthy urine,
and rarely in diseased ; it has been found especially in the re-
nal secretion of scrofulous patients. It forms a fawn-colored
deposit, somewhat resembling the urates, but which is un-
changed by heat, and slowly dissolves on the addition of nitric
or hydrochloric acid ; it is readily soluble in liquor ammonise.
A greasy-looking pellicle, consisting of crystals of cystine and
ammonio-phosphate of magnesia, soon forms on cystic urine.
When a few drops of ammoniacal solution of cystine are
allowed to evaporate spontaneously on a piece of glass, crystals
in the form of six-sided laminae will be seen by the micro-
scope ; they are probably short hexagonal prisms.
Oxalate of Lime. — Oxalate of lime is often present in the
urine, and is a constituent of one of the most annoying forms
of calculi. The urine is generally of a fine dark amber hue,
of a specific gravity varying from 1015 to 1025, natural in
quantity, and free from any precipitate — unless there be also
an excess of urates. Examined by the microscope, crystals,
in the form of transparent octahedra with sharply-defined
edges and angles will be detected ; if the light be bright, these
crystals generally resemble cubes marked with a cross. Very
rarely, the crystals are shaped like dumb-bells, or like two
kidneys with their concavities opposed. Dr. Golding Bird
was of opinion, however, that these crystals consisted of oxa-
lurate of lime, a salt differing from oxalate of lime in ultimate
constitution only in the presence of the elements of urea and
absence of the constituents of water.'
» Urinary Deposits, fourth edition, p. 219.
236 EXAMINATION OF THE URIXE.
Gravel in the Urine. — When a patient discharges gritty
powder, or sand, or small calculi, with the urine, he is com-
monly said to have " a fit of the gravel." The most common
forms of gravel are the urates of lime, potash, and soda, with
a small quantity of ammonia, often called lithate or urate of
ammonia. Next in frequency we find lithic or uric acid, or
red sand ; then a deposit, consisting mainly of the triple
phosphate of ammonia and magnesia, mixed with amorphous
phosphate of lime ; next, a deposit of oxalate of lime ; and,
lastly, one of cystic oxide. Urinary calculi are composed of
either urate of lime and potash, &c. ; or of uric acid ; cystic
oxide; carbonate of lime ; oxalate of lime ; triple phosphate
of ammonia and magnesia ; phosphate of lime ; or of silica.
Mode of Testing for Albumen in the Urine. — Two tests
must be employed — heat and nitric acid. On applying heat —
the most delicate of the two tests — to albuminous urine in a
clean test-tube, the albumen coagulates and produces a cloud
varying in density. This only happens, however, when the
urine is acid ; alkaline urine may be loaded with albumen, yet
heat will produce no deposit. In such a case the urine must
be rendered acid by the addition of a drop or two of acetic or
nitric acid, and heat then applied. So, also, urine containing
an excess of earthy phosphates, as mentioned in the preceding
paragraph, will become cloudy on the application of heat : for
this reason therefore we employ nitric acid, which dissolves
the phosphates, but renders the albuminous deposit perma-
nent. Nitric acid alone will coagulate albuminous urine, but
it must not be trusted to, since it also often produces a whitish
amorphous precipitate of uric acid, Avhen the urine contains a
large quantity of urates ; this precipitate, which might be mis-
taken for albumen, is distinguished by its not being produced
by heat.
When, therefore, we obtain a deposit by both heat and
acetic or nitric acid, we may be sure that it consists of
albumen.
Mode of Testing Purulent Urine. — On adding liquor
potassae to urine containing pus, it is rendered viscid, so that
the mixture can hardly be poured from one test-tube to
another. By the microscope numerous globular corpuscles,
about the jo'iJ^T^b o^ an inch in diameter, with smooth margins
and granular surfaces, are seen floating in the liquor puris ;
each corpuscle generally contains one or more round or oval
nuclei. On adding strong acetic acid, the cell- wall is dis-
solved and the nuclei liberated.
Urine containing Sugar. — Diabetic sugar differs from
URINE COXTAIXIXG SUGAR. 237
cane-sugar ; it has the same chemical composition as that
contained in most kinds of fruit, commonly known as grape-
sugar, or glucose.
Diabetes can hardly be called a disease of the kidneys,
since in it the sugar is likew-ise found in the blood and in the
faeces. From the researches of Bernard we learn that the
blood from the hepatic vein always contains sugar 5 that it is
the result of the digestion of food, for if an animal be starved
it disappears ; it is found also independently of the nature of
the aliment taken. Section of both pneumogastric nerves, as
well as any violent shock to the nervous system, destroys the
power of the liver to form sugar. Irritation of the root of the
pueumogastrics in the fourth ventricle of the brain increases
the formation of sugar, and causes it so to abound in the blood
that it is secreted with the urine — in short, artificial diabetes is
produced. When the respiratory function is violently stimu-
lated, sugar appears in the urine ; or when ether or chloroform
is given, a temporary diabetes is often produced.
Diabetic urine has a sweetish taste and odor, is generally
of a pale color, is secreted in very large quantity — sometimes
forty, fifty, or more ounces — and is of a high specific gravity,
varying from 1025 to 1050 ; the worse the disorder, the higher
will be the specific gravity. It was at one time thought that
torulie were developed only in saccharine urine ; Dr. Bence
Jones and others have proved the incorrectness of this view,
and taught us that though often formed in acid diabetic urine,
yet that they are not peculiar to it, being especially frequent
in acid albuminous urine, or even in healthy acid urine after
exposure to the air. Dr. HassalP has also shown that the
so-called torute are identical with the Penicilium glaucum,
the fungus which imparts the mildewed appearance so com-
mon to decaying vegetable and animal substances. Dr. Has-
sall has succeeded in proving, however, that a distinct species
of microscopic fungus, identical with the yeast plant, is de-
veloped in saccharine urine, and in this urine only, when it is
acid, is fireely exposed to the air, and is kept at a moderate
temperature. The presence of this sugar-fungus indicates the
vinous fermentation, its development being accompanied by
the disengagement of carbonic acid and the formation of
alcohol. The Penicilium glaucum and the yeast-fungus not
unfrequently exist together in diabetic urine 5 but the latter —
it must be remembered — is alone peculiar to it, and may be
found when the quantity of sugar is too small for detection by
the potash and copper tests.
* Medico-Chirurgical Transactions, vol. xixvi.
238 EXAMINATION OF THE URINE.
Several tests have been proposed for the detection of sugar
in urine.
Moore's Test. — Add to the suspected urine, in a test-tube,
about half its volume of liquor potassae, and boil the mixture
gently for a few minutes. If sugar be present, the liquid will
assume a dark brown tint. If, on the contrary, the urine be
healthy, it will only be very slightly darkened.
Care must be taken — as Dr. Owen Rees has pointed out —
that the liquor potassjB does not contain lead, as it often will if it
has been kept in a white glass bottle. When it does so, the
sulphur in the urine produces a dark color with the lead, which
might lead to an incorrect diagnosis. The test-solution should
be kept in a green glass bottle, free from lead.
Fermentation Test — Mix a few drops of fresh yeast, or a
little of the dried German yeast, with the suspected urine, and
then fill a test-tube with the mixture. Put some of the urine
also into a saucer, and then invert the tube and stand it upright
in this vessel, taking care that the tube is full and free from
bubbles of air; set aside in a warm place, having a tempera-
ture of 70° F., for twenty-four hours. If sugar be present, it
begins very shortly to undergo the vinous fermentation, by
which it becomes converted into carbonic acid and alcohol ;
which change will be recognized by the bubbles of carbonic
acid causing gentle effervescence, and afterwards collecting in
the upper part of the tube. If the' urine is free from sugar,
no gas will be formed.
Troj7imer^s Test. — A little of the suspected urine is to be
placed in a test-tube, and a drop or two of a solution of sul-
phate of copper added, so as to give the mixture a slight blue
tint. A solution of potash is now added, in quantity equal to
about half the volume of urine employed ; this will throw
down a pale hlue precipitate of hydrated oxide of copper,
which, if there be any sugar, will immediately redissolve,
forming a purplish-blue solution. We must then cautiously
warm the whole over a spirit-lamp, without boiling it ; when,
if sugar be present, a yellowish-brown precipitate of sub-oxide
of copper will be deposited. If there is no sugar, a black
precipitate of the common oxide of copper will be thrown
down. This test is very delicate, and will detect very small
quantities of sugar.
Kiestein. — This is a peculiar principle said to exist in the
urine of pregnant women, and to become visible — when the
secretion is allowed to repose in a cylindrical glass — in the
form of a cotton-like cloud, which, after four or five days, be-
comes resolved into a number of minute opaque bodies, which
IODIDE OF POTASSIUM IN THE URINE. 239
rise to the surface and form a fat-like scum, remaining perma-
nent for three or four days. In these cases the urine has a
peculiar cheesy odor, and remains faintly acid until the scum
or pellicle breaks up. Dr. Kane says that, in eighty-five cases
of pregnancy, he obtained a well-marked pellicle in sixty-
eight, a modified but recognizable one in eleven, while six
gave no pellicle.' I may mention that I have failed to obtain
it when the urine contained an excess of lithates. It has
been found before the second period of suspended menstrua-
tion. Its presence is undoubtedly connected with the lacteal
secretion, for when the lacteal elements are secreted without
a free discharge at the mammae, it may be found. Dr. Kane
remarked that it continued in the urine for a short time after
labor, until the mother began to suckle fi-eely. Often women,
eight exhibited it at the period of weaning. I entertain a
high opinion of the importance of kiestein, as diagnostic of
pregnancy, having repeatedly tested its value ; still I should
hardly rely upon it alone.
Casts of Tubes, Epithelium, Blood-globules, &c.— On
examining the urine microscopically in acute and chronic
desquamative nephritis, in fatty degeneration of the kidney,
&c., numerous fibrinous casts of the uriniferous tubes are
seen, occasionally containing large quantities of oil-globules.
So, numerous blood-corpuscles and epithelial scales are found
in the same diseases, which latter, in fatty degeneration of the
kidney, are often loaded with oil-globules. In most of these
cases the urine will also be albuminous.
Bile in the Urine. — The coloring matter of the bile, when
it exists in the urine, is readily detected, by the dark yellow
color it gives to the secretion, by the yellow color it communi-
cates to a piece of white linen dipped in it, or by the dark
green and afterwards purple color which the urine assumes
when a sufficient quantity of sulphuric acid is added to it in a
test-tube, or on a white plate.
Iodide of Potassium in the Urine — may be detected by
adding, first, starch to the cold secretion, and then a few drops
of nitric acid (or solution of chlorine) ; the blue iodide of
starch will be formed, if an iodide be present.
» American Journal of Medical Science, July, 1842.
240 CODE OF ETHICS OF
CODE OF ETHICS
OF THE
AMERICAN MEDICAL ASSOCIATION
ADOPTED MAY, 1847.
OF THE DUTIES OF PHYSICIANS TO THEIR PATIENTS
AND OF THE OBLIGATIONS OF PATIENTS TO THEIE
PHYSICIANS.
Art. I. — Duties of physicians to their patients.
§ 1. A physician should not only be ever ready to obey the
calls of the sick, but his mind ought also to be imbued with the
greatness of his mission, and the responsibility he habitually in-
curs in its discharge. Those obligations are the more deep and
enduring, because there is no tribunal other than his own con-
science to adjudge penalties for carelessness or neglect. Physi-
cians should, therefore, minister to the sick with due impressions
of the importance of their office; reflecting that the ease, the
health, and the lives of those committed to their charge, depend
on their skill, attention and fidelity. They should study, also, in
their deportment, so to unite tenderness with firmness and conde-
scensio7i with authority, as to inspire the minds of their patients
with gratitude, respect, and confidence.
§ 2. Every case committed to the charge of a physician
should be treated with attention, steadiness, and humanity. Rea-
sonable indulgence should be granted to the mental imbecility and
caprices of the sick. Secrecy and delicacy, when required by
peculiar circumstances, should be strictly observed ; and the fa-
miliar and confidential intercourse to which physicians are ad-
mitted in their professional visits, should be used with discretion,
and with the most scrupulous regard to fidelity and honor. The
THE AMERICAN MEDICAL ASSOCIATION. 241
obligation of secrecy extends beyond the period of professional
services; — none of the privacies of personal and domestic life, no
infirmity of disposition or flaw of character observed during pro-
fessional attendance, should ever be divulged by the physician,
except when he is imperatively required to do so. The force and
necessity of this obligation are indeed so great, that professional
men have, under certain circumstances, been protected in their
observance of secrecy by courts of justice.
§ 3. Frequent visits to the sick are, in general, requisite, since
they enable the physician to arrive at a more perfect knowledge
of the disease — to meet promptly every change which may occur,
and also tend to preserve the confidence of the patient. But un-
necessary visits are to be avoided, as they give useless anxiety to
the patient, tend to diminish the authority of the physician, and
render him liable to be suspected of interested motives.
§ 4. A physician should not be forward to make gloomy
prognostications, because they savor of empiricism, by magnifying
the importance of his services in the treatment or cure of the
disease. But he should not fail, on proper occasions, to give to the
friends of the patient timely notice of danger when it really occurs ;
and even to the patient himself, if absolutely necessary. This
office, however, is so peculiarly alarming when executed by him,
that it ought to be declined whenever it can be assigned to any
other person of sufficient judgment and delicacy. For, the physi-
cian should be the minister of hope and comfort to the sick ; that,
by such cordials to the drooping spirit, he may smooth the bed of
death, revive expiring life, and counteract the depressing influ-
ence of those maladies which often disturb the tranquillity of the
most resigned in their last moments. The life of a sick person
can be shortened not only by the acts, but also by the words or the
manner of a physician. It is, therefore, a sacred duty to guard
himself carefully in this respect, and to avoid all things which
have a tendency to discourage the patient and to depress his
spirits.
§ 5. A physician ought not to abandon a patient because the
case is deemed incurable ; for his attendance may continue to be
highly useful to the patient, and comforting to the relatives around
him, even in the last period of a fatal malady, by alleviating pain
and other symptoms, and by soothing mental anguish. To decline
attendance, under such circumstances, would be sacrificing to
fanciful delicacy and mistaken liberality, that moral duty, which
is independent of, and far superior to, all pecuniary consideration.
§ 6. Consultations should be promoted in difficult or protracted
cases, as they give rise to confidence, energy, and more enlarged
views in practice.
§ 7. The opportunity which a physician not unfrequently
enjoys of promoting and strengthening the good resolutions of his
21
242 CODE OF KTHICS OF
patients, suffering under the consequences of vicious conduct,
ought never to be neglected. His counsels, or even remonstrances^
will give satisfaction, not offence, if they be profJered with polite-
ness, and evince a genuine love of virtue, accompanied by a sin-
cere interest in the welfare of the person to whom they are ad-
dressed.
Art. II.— Obligations of patients to their physicians.
§ 1. The members of the medical profession, upon whom is
enjoined the performance of so many important and arduous
duties towards the community, and who are required to make so
many sacrifices of comfort, ease, and health, for the welfare of
those who avail themselves of their services, certainly have a
right to expect and require, that their patients should entertain a
just sense of the duties which they owe to their medical attendants.
§ 2. The first duty of a patient is, to select as his medical
adviser one who has received a regular professional education.
In no trade or occupation, do mankind rely on the skill of an un-
taught artist ; and in medicine, confessedly the most difficult and
intricate of the sciences, the world ought not to suppose that
knowledge is intuitive.
§ 3. Patients should prefer a physician whose habits of life
are regular, and who is not devoted to company, pleasure, or to
any pursuit incompatible with his professional obligations. A
patient should, also, confide the care of himself and family, as
much as possible, to one physician ; for a medical man who has
become acquainted with the peculiarities of constitution, habits,
and predispositions of those he attends, is more likely to be suc-
cessful in his treatment than one who does not possess that
knowledge.
A patient who has thus selected his physician, should always
apply for advice in what may appear to him trivial cases, for the
most fatal results often supervene on the slightest accidents. It
is of still more importance that he should apply for assistance in
the forming stage of violent diseases ; it is to a neglect of this
precept that medicine owes much of the uncertainty and imper-
fection with which it has been reproached.
§ 4. Patients should faithfully and unreservedly communicate
to their physician the supposed cause of their disease. This is
the more important, as many diseases of a mental origin simulate
those depending on external causes, and are only to be cured by
ministering to the mind diseased. A patient should never be
afraid of thus making his physician his friend and adviser ; he
should always bear in mind that a medical man is under the
strongest obligations of secrecy. Even the female sex should
THE AMERICAN MEDICAL ASSOCIATIOX. 243
never allow feelings of shame or delicacy to prevent their dis-
closing the seat, symptoms, and causes of complaints peculiar to
them. However commendable a modest reserve may be in the
common occurrences of life, its strict observance in medicine is
often attended with the most serious consequences, and a patient
may sink under a painful and loathsome disease, which might
have been readily prevented had timely intimation been given to
the physician.
§ 5. A patient should never weary his physician with a
tedious detail of events or matters not appertaining to his disease.
Even as relates to his actual symptoms, he will convey much
more real information by giving clear answers to interrogatories,
than by the most minute account of his own framing. Neitlier
should he obtrude on his physician the details of his business
nor the history of his family concerns.
§ 6. The obedience of a patient to tlie prescriptions of his
physician should be prompt and implicit. He should never
permit his own crude opinions as to their fitness, to influence his
attention to them. A failure in one particular may render an
otherwise judicious treatment dangerous, and even fatal. This
remark is equally applicable to diet, drink, and exercise. As
patients become convalescent, they are very apt to suppose that
the rules prescribed for them may be disregarded, and the con-
sequence, but too often, is a relapse. Patients should never allow
tliemselves to be persuaded to take any medicine, whatever, that
may be recommended to them by the self-constituted doctors and
doctresses, who are so frequently met with, and who pretend to
possess infallible remedies for the cure of every disease. How-
ever simple some of their prescriptions may appear to be, it
often happens that they are productive of much mischief, and in
all cases they are injurious, by contravening the plan of treat-
ment adopted by the physician.
§ 7. A patient should, if possible, avoid even the friendly
visits of a physician who is not attending him — and when he does
receive them, he should never converse on the subject of his dis-
ease, as an observation may be made, without any intention of
interference, which may destroy his confidence in the course he
is pursuing, and induce him to neglect the directions prescribed
to him. A patient should never send for a consulting physician
without the express consent of his own medical attendant. It is
of great importance that physicians should act in concert; for,
although their modes of treatment may be attended with equal
success when employed singly, yet conjointly they are very likely
to be productive of disastrous results.
§ 8. When a patient wishes to dismiss his physician, justice
and common courtesy require that he should declare his reasons
for so doing.
244 CODE OF ETHICS OF
§ 9. Patients should always, when practicable, send for their
physician in the morning, before his usual hour of going out ; for,
by being early aware of the visits he has to pay during the day,
the physician is able to apportion his time in such a manner as
to prevent an interference of engagements. Patients should also
avoid calling on their medical adviser unnecessarily during the
hours devoted to meals or sleep. They should always be in
readiness to receive the visits of their physician, as the detention
of a few minutes is often of serious inconvenience to him.
§ 10. A patient should, after his recovery, entertain a just and
enduring sense of the value of the services rendered him by his
physician ; for these are of such a character, that no mere pecu-
niary acknowledgment can repay or cancel them.
OF THE DUTIES OF PHYSICIANS TO EACH OTHER, AND
TO THE PROFESSION AT LARGE.
Art. I. — Duties for the support of professional
character.
§ 1. Every individual, on entering the profession, as he
becomes thereby entitled to all its privileges and immunities,
incurs an obligation to exert his best abilities to maintain its
dignity and honor, to exalt its standing, and to extend the bounds
of its usefulness. He should, therefore, observe strictly, such
laws as are instituted for the government of its members ; —
should avoid all contumelious and sarcastic remarks relative to the
faculty, as a body; and while, by unwearied diligence, he resorts
to every honorable means of enriching the science, he should
entertain a due respect for his seniors, who have, by their labors,
brought it to the elevated condition in which he finds it.
§ 2. There is no profession, from the members of which
greater purity of character, and a higher standard of moral
excellence are required, than the medical 5 and to attain such
eminence, is a duty every physician owes alike to his profession
and to his patients. It is due to the latter, as without it he can-
not command their respect and confidence, and to both, because
no scientific attainments can compensate for the want of correct
moral principles. It is also incumbent upon the faculty to be
temperate in all things, for the practice of physic requires the
unremitting exercise of a clear and vigorous understanding ; and,
on emergencies, for which no professional man should be unpre-
pared, a steady hand, an acute eye, and an unclouded head may
be essential to the well-being, and even to the life, of a fellow-
creature,
§ 3. It is derogatory to the dignity of the profession to resort to
public advertisements, or private cards, or handbills, inviting the
THE AMERICAN MEDICAL ASSOCIATION. 245
attention of individuals affected with particular diseases — pub-
licly offering advice and medicine to the poor gratis, or promising
radical cures ; or to publish cases and operations in the daily
prints, or suffer such publications to be made ; to invite laymen
to be present at operations, to boast of cures and remedies, to ad-
duce certificates of skill and success, or to perform any other
similar acts. These are the ordinary practices of empirics, and
are highly reprehensible in a regular physician.
§ 4. Equally derogatory to professional character is it, for a
physician to hold a patent for any surgical instrument or medi-
cine ; or to dispense a secret nostrum, whether it be the composi-
tion or exclusive property of himself or of others. For, if such
nostrum be of real efficacy, any concealment regarding it is in-
consistent with beneficence and professional liberality ; and, if
mystery alone give it value and importance, such craft implies
either disgraceful ignorance or fraudulent avarice. It is also re-
prehensible for physicians to give certificates attesting the efl[i-
cacy of patent or secret medicines, or in any way to promote the
use of them.
Art. II.— Professional services of physicians to each
other.
§ 1. All practitioners of medicine, their wives, and their chil-
dren while under the paternal care, are entitled to the gratuitous
services of any one or more of the faculty residing near them,
whose assistance may be desired. A physician afflicted with
disease is usually an incompetent judge of his own case ; and the
natural anxiety and solicitude which he experiences at the sick-
ness of a wife, a child, or any one who, by the ties of consan-
guinity, is rendered pecuharly dear to him, tend to obscure his
judgment, and produce timidity and irresolution in his practice.
Under such circumstances, medical men are peculiarly dependent
upon each other, and kind offices and professional aid should
always be cheerfully and gratuitously afforded. Visits ought not,
however, to be obtruded officiously ; as such unasked civility
may give rise to embarrassment, or interfere with that choice on
which confidence depends. But, if a distant member of the
faculty, whose circumstances are affluent, request attendance, and
an honorarium be offered, it should not be declined ; for no pecu-
niary obligation ought to be imposed, which the party receiving
it would wish not to incur.
Art. III.— Of the duties of Physicians as respects
vicarious offices.
§ 1. The affairs of life, the pursuit of health, and the various
accidents and contingencies to which a medical man is peculiarly
21*
246 CODE OF ETHICS OF
exposed, sometimes require him temporarily to withdraw from
his duties to his patients, and to request some of his professional
brethren to officiate for him. Compliance with this request is an
act of courtesy, which- should always be performed with the
utmost consideration for the interest and character of the family
physician, and when exercised for a short period, all the pecu-
niary obligations for such service should be awarded to him. But
if a member of the profession neglect his business in quest of
pleasure and amusement, he cannot be considered as entitled to
the advantages of the frequent and long-continued exercise of this
fraternal courtesy, without awarding to the physician who offi-
ciates the fees arising from the discharge of his professional
duties.
In obstetrical and important surgical cases, which give rise to
unusual fatigue, anxiety, and responsibility, it is just that the fees
accruing therefrom should be awarded to the physician who
officiates.
Art. IV.— Of the duties of physicians in regard to
consultations.
§ 1, A regular medical education furnishes the only presump-
tive evidence of professional abilities and acquirements, and
ought to be the only acknowledged right of an individual to the
exercise and honors of his profession. Nevertheless, as in con-
sultations the good of the patient is the sole object in view, and
this is often dependent on personal confidence, no intelligent re-
gular practitioner, who has a license to practice from some medi-
cal board of known and acknowledged respectability, recognized
by this association, and who is in good moral and professional
standing in the place in which he resides, should be fastidiously
excluded from fellowship, or his aid refused in consultation, when
it is" requested by the patient. But no one can be considered as
a regular practitioner or a fit associate in consultation, whose
practice is based on an exclusive dogma, to the rejection of the
accumulated experience of the profession, and of the aids ac-
tually furnished by anatomy, physiology, pathology, and organic
chemistry.
§ 2. In consultations, no rivalship or jealousy should be in-
dulged ; candor, probity, and all due respect should be exercised
towards the physician having charge of the case,
§ 3. In consultations, the attending physician should be the
first to propose the necessary questions to the sick ; after which
the consulting physician should have the opportunity to make
such farther inquiries of the patient as may be necessary to
satisfy him of the true character of the case. Both physicians
should then retire to a private place for deliberation ; and the one
THE AMERICAN MEDICAL ASSOCIATION. 24t
first in attendance should communicate the directions agreed upon
to the patient or his friends, as well as any opinions which it
may be thought proper to express. But no statement or discus-
sion of it should take place before the patient or his friends, ex-
cept in the presence of all the faculty attending, and by their
common consent; and no opinions or prognostications should be
delivered, wliich are not the result of previous deliberation and
concurrence.
§ 4. In consultations, the physician in attendance should deliver
his opinion first ; and when there are several consulting, they
should deliver their opinions in the order in which they have been
called in. No decision, however, should restrain the attending
physician from making such variations in the mode of treatment,
as any subsequent unexpected change in the character of the case
may demand. But such variation, and the reasons for it, ought to
be carefully detailed at the next meeting in consultation. The
same privilege belongs also to the consulting physician if he is
sent for in an emergency, when the regular attendant is out of the
way, and similar explanations must be made by him at the next
consultation.
§ 5. The utmost punctuality should be observed in the visits of
physicians when they are to hold consultations together, and this
is generally practicable, for society has been considerate enough
to allow the plea of a professional engagement to take precedence
of all others, and to be an ample reason for the relinquishment of
any present occupation. But, as professional engagements may
sometimes interfere, and delay one of the parties, the physician
who first arrives should wait for his associate a reasonable period,
after which the consultation should be considered as postponed to
a new appointment. If it be the attending physician who is pre-
sent, he will of course see the patient and prescribe; but if it be
tlie consulting one, he should retire, except in case of emergency,
or when he has been called from a considerable distance, in
which latter case he may examine the patient, and give his
opinion in writings and under seal, to be delivered to his associate.
§ 6. In consultations, theoretical discussions should be avoided,
as occasioning perplexity and loss of time. For there may be
much diversity of opinion concerning speculative points, with
perfect agreement in those modes of practice which are founded,
not on hypothesis, but on experience and observation.
§ 7. All discussions in consultation should be held as secret and
confidential. Neither by words nor manner should any of the
parties to a consultation assert or insinuate, that any part of the
treatment pursued did not receive his assent. The responsibility
must be equally divided between the medical attendants — they
must equally share the credit of success as well as the blame of
failure,
248 CODE OF ETHICS OF
§ 8. Should an irreconcilable diversity of opinion occur when
several physicians are called upon to consult together, the opinion
of the majority should be considered as decisive ; but if the
numbers be equal on each side, then the decision should rest with
the attending physician. It may, moreover, sometimes happen,
that two physicians cannot agree in their views of the nature of
a case, and the treatment to be pursued. This is a circumstance
much to be deplored, and should always by avoided, if possible,
by mutual concessions, as far as they can be justified by a con-
scientious regard for the dictates of judgment. But, in the event
of its occurrence, a third physician should, if practicable, be
called to act as umpire ; and if circumstances prevent the
adoption of this course, it must be left to the patient to select the
physician in whom he is most wiUing to confide. But, as every
physician relies upon the rectitude of his judgment, he should,
when left in the minority, politely and consistently retire from
any farther deliberation in the consultation, or participation in the
management of the case,
§ 9. As circumstances sometimes occur to render a special con-
sultation desirable, when the continued attendance of two physi-
cians might be objectionable to the patient, the member of the
faculty whose assistance is required in such cases, should sedu-
lously guard against all future unsolicited attendance. As such
consultations require an extraordinary portion of both time and
attention, at least a double honorarium may be reasonably
expected.
§ 10. A physician who is called upon to consult, should observe
the most honorable and scrupulous regard for the character and
standing of the practitioner in attendance ; the practice of the
latter, if necessary, should be justified as far as it can be, con-
sistently with a conscientious regard for truth, and no hint or in-
sinuation should be thrown out which could impair the confi-
dence reposed in him, or affect his reputation. The consulting
physician should also carefully refrain from any of those extra-
ordinary attentions or assiduities, which are too often practised
by the dishonest for the base purpose of gaining applause, or in-
gratiating themselves into the favor of families and individuals.
Art. V. — Duties of Physicians in cases of interference.
§ 1. Medicine is a liberal profession, and those admitted into
its ranks should found their expectations of practice upon the ex-
tent of their qualifications, not on intrigue or artifice.
§ 2. A physician, in his intercourse with a patient under the
care of another practitioner, should observe the strictest caution
and reserve. No meddling inquiries should be made — no disin-
genuous hints given relative to the nature and treatment of his
THE AMERICAN MEDICAL ASSOCIATION. 249
disorder ; nor any course of conduct pursued that may directly or
indirectly tend to diminish the trust reposed in the physician
employed.
§ 3. The same circumspection and reserve should be observed
when, from motives of business or friendship, a physician is
prompted to visit an individual who is under the direction of
another practitioner. Indeed, such visits should be avoided, ex-
cept under peculiar circumstances ; and when they are made, no
particular inquiries should be instituted relative to the nature of
the disease, or the remedies employed, but the topics of the con-
versation should be as foreign to the case as circumstances will
admit.
§ 4. A physician ought not to take charge of or prescribe for
a patient who has been recently under the care of another mem-
ber of the faculty in the same illness, except in cases of sudden
emergency, or in consultation with the physician previously in
attendance, or when the latter has relinquished the case, or been
regularly notified that his services are no longer desired. Under
such circumstances no unjust and illiberal insinuations should be
thrown out in relation to the conduct or practice previously pur-
sued, which should be justified as far as candor and regard for
truth and probity will permit ; for it often happens that patients
become dissatisfied when they do not experience immediate relief,
and, as many diseases are naturally protracted, the want of suc-
cess, in the first stage of treatment, affords no evidence of a lack
of professional knowledge and skill.
§ 5. When a physician is called to an urgent case, because the
family attendant is not at hand, he ought, unless his assistance in
consuhation be desired, to resign the care of the patient to the
latter immediately on his arrival.
§ 6. It often happens, in cases of sudden illness, or of recent
accidents and injuries, owing to the alarm and anxiety of friends,
that a number of physicians are simultaneously sent for. Under
these circumstances, courtesy should assign the patient to the first
who arrives, who should select from those present, any additional
assistance that he may deem necessary. In all such cases, how-
ever, the practitioner who officiates should request the family
physician, if there be one, to be called, and, unless his farther
attendance be requested, should resign the case to the latter on
his arrival.
§ 7, When a physician is called to the patient of another prac-
titioner, in consequence of the sickness or absence of the latter,
he ought, on the return or recovery of the regular attendant, and
with the consent of the patient, to surrender the case.
§ 8. A physician, when visiting a sick person in the country,
may be desired to see a neighboring patient who is under the
regular direction of another physician, in consequence of some
250 CODE OF ETHICS OF
sudden change or aggravation of symptoms. The conduct to be
pursued on such an occasion is to give advice adapted to present
circumstances; to interfere no farther than is absolutely necessary
vi^ith the general plan of treatment; to assume no future direction,
unless it be expressly desired; and, in this last case, to request
an immediate consultation with the practitioner previously em-
ployed.
§ 9. A wealthy physician should not give advice gratis to the
affluent; because his doing so is an injury to his professional bre-
thren. The office of a physician can never be supported as an
exclusively beneficent one ; and it is defrauding, in some degree,
the common funds for its support, when fees are dispensed which
might justly be claimed.
§ 10. When a physician who has been engaged to attend a
case of midwifery is absent, and another is sent for, if delivery
is accomplished during the attendance of the latter, he is entitled
to the fee, but should resign the patient to the practitioner first
engaged.
Art. VI.— Of differences between physicians.
§ 1. Diversity of opinion and opposition of interest, may, in
the medical as in other professions, sometimes occasion contro-
versy and even contention. Whenever such cases unfortunately
occur, and cannot be immediately terminated, they should be re-
ferred to the arbitration of a sufficient number of physicians, or
a court-medical.
§ 2. As peculiar reserve must be maintained by physicians to-
wards the public, in regard to professional matters, and as there
exist numerous points in medical ethics and etiquette through
which the feelings of medical men may be painfully assailed in
their intercourse with each other, and which cannot be under-
stood or appreciated by general society, neither the subject-matter
of such ditferences nor the adjudication of the arbitrators should
be made public, as publicity in a case of this nature may be per-
sonally injurious to the individuals concerned, and can hardly
fail to bring discredit on the faculty.
Art. VII.— Of pecuniary acknowledgments.
Some general rules should be adopted by the faculty, in every
town or district, relative to pecuniary acknowledgments from their
patients ; and it should be deemed a point of honor to adhere to
these rules with as much uniformity as varying circumstances
will admit.
THE AMERITAX MEDICAL ASSOCIATION. 251
OF THE DUTIES OF THE PROFESSION TO THE PUBLIC,
AND OF THE OBLIGATIONS OF THE PUBLIC TO THE
PROFESSION.
Art. I.— Duties of the profession to the public.
§ 1. As good citizens, it is the duty of physicians to be ever
vigilant for the welfare of the community, and to bear their part
in sustaining its institutions and burdens ; they should also be
ever ready to give counsel to the public in relation to matters es-
pecially appertaining to their profession, as on subjects of medical
police, public hygiene, and legal medicine. It is their province
to enlighten the public in regard to quarantine regulations — the
location, arrangement, and dietaries of hospitals, asylums, schools,
prisons, and similar instimtions — in relation to the medical police
of towns, as drainage, ventilation, &c. — and in regard to mea-
sures for the prevention of epidemic and contagious diseases;
and when pestilence prevails, it is their duty to face the danger,
and to continue their labors for the alleviation of the suffering
even at the jeopardy of their own lives.
§ 2, Medical men should also be always ready, when called
on by the legally constituted authorities, to enlighten coroners'
inquests, and courts of justice, on subjects strictly medical — such
as involve questions relating to sanity, legitimacy, murder by
poisons or other violent means, and in regard to the various other
subjects embraced in the science of Medical Jurisprudence. But
in these cases, and especially where they are required to make a
post-morteni examination, it is just, in consequence of the time,
labor, and skill required, and the responsibility and risk they
incur, that the public should award them a proper honorarium.
§ 3. There is no profession, by the members of which eleemo-
synary services are more liberally dispensed than the medical,
but justice requires that some limits should be placed to the per-
formance of such good offices. Poverty, professional brotherhood,
and certain of the public duties referred to in the first section of
this article, should always be recognized as presenting valid
claims for gratuitous services ; but neither institutions endowed
by the public or by rich individuals, societies for mutual benefit,
for the insurance of lives or for analogous purposes, nor any pro-
fession or occupation, can be admitted to possess such privilege.
Nor can it be justly expected of physicians to furnish certificates
of inability to serve on juries, to perform militia duty, or to testify
to the state of health of persons wishing to insure their lives, ob-
tain pensions, or the like, without a pecuniary acknowledgment.
But to individuals in indigent circumstances, such professionai.
services should always be cheerfully and freely accorded.
252 CODE OF ETHICS, ETC.
§ 4. It is the duty of physicians, who are frequent witnesses
of the enormities committed by quackery, and the injury to
health and even destruction of life caused by the use of quack
medicines, to enlighten the public on these subjects, to expose
the injuries sustained by the unwary from the devices and pre-
tensions of artful empirics and impostors. Physicians ought to
use all the influence which they may possess, as professors in
Colleges of Pharmacy, and by exercising their option in regard
to the shops to which their prescriptions shall be sent, to dis-
courage druggists and apothecaries from vending quack or secret
medicines, or from being in any way engaged in their manufac-
ture and sale.
Art. II.— Obligations of the public to physicians.
§ 1, The benefits accruing to the public, directly and indi-
rectly, from the active and unwearied beneficence of the profes-
sion, are so numerous and important, that physicians are justly
entitled to the utmost consideration and respect from the com-
munity. The public ought likewise to entertain a just apprecia-
tion of medical qualifications; to make a proper discrimination
between true science and the assumptions of ignorance and
empiricism — to afford every encouragement and facility for the
acquisition of medical education — and no longer to allow the
statute-books to exhibit the anomaly of exacting knowledge from
physicians, under a liability to heavy penalties, and of making
them obnoxious to punishment for resorting to the only means of
obtaining it.
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