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RečtRt Medual Puhliiations.
Maim, A Manual of Prescription Writiag. Bv

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8TUDENT8' AID8 8ERIE8.

AIDS TO DIAGNOSIS

PAET L— SEMEIOLOGT

J. MILNER FOTHERGILL

IfEMBSB OF THB BOTAL COLLEOB OF FHTSICIANS OF LOITDON

BTC, XTO., BTO.

NEW TORK

G. P. PUTNAM^S SONS
27 Airo 29 Wbst 23d Street

1881

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PREFACE.

The študent is often lost in surprise, not nncommonly
blended with suspicion or scepticism, as to what it
is which directs an experienced practitioner as to
the qaestions which he puts to his patients; which
causes him to use his instruments of precision little ;
and sometimes induces him to dispense with tbem
altogether.

It is Semeiologj.

What is meant by and involved in the term
*Semeiology* it will be essajed to explain in the
following pages. As sueh a work is largelj original,
allowances are craved for defects and shortcom^ngs«

Octoier 2ni, 1880.

5ti9i4\

AIDS TO DIAGNOSIS.

SEMEIOLOGT.

Sf/uecov— ft sign or a 8yinptom. Semeiologj ii used here to
Bignify the signs and 8yinptoms which are noted by the eje,
before a phjsical examination of the patient is made. But it is
found that the information afforded by feeling the pulse and
taking the temperature must be discussed under this heading*
and even the examination of the urine, etc. Students are taught
physical signs at the present tirne v.ery carefully ; so carefully,
indeed, that while they can measure the amount of disease pre-
sent in the lungs with much accuracy, they know very little
about the individual in whom that disease exists. Ali that the
old practitioner has leamt to take in by the eyes, they are largely
left to leam at the bedside for themselves, and by them-
selves, when they get into practice, and at the expense of their
patients. Some teachers point out many things, signs of value,
to their students, while others make close observation of their
patients when stripped ; but are comparatiyely indifferent about
them while they have their clothes on. But caref ul observation
will often teli a great deal, from the phy8iquc, the gait, and
the indications fumished by the contour of the bead, and by
the outlines of the face. Such observation, it will be found,
tells much about the general condition which underUes the
malady, or ailment specially complained of. Such observation
will ' furnish most useful hints as to the line of treatment to be

6 *

adopted ; which af ter aH is the end to which accurate diagnosis
is the means. A copper-coloured spot on the forehead will often
cleai up the nature of a very puzzling form of hemiplegia in a
young person, just as will a tubercle on the iris ; a scar at the
comei of the mouth will reveal the secret of a čase of malnutri-
tioD in a child which has hitherto resisted ali remedial measures,
but which becomes suddenly tractable, when mercury is added
to the chalybeate ; a little puffiness under the lower eyelid may
indicate the chronic Brighfs disease underlying the bronchitis
which is the prominent trouble for which the doctor is consulted ;
the hue of the skin will often furnish the clue to the malarial
neuralgia, which is very troublesome ; just as a tortuous visibly-
pulsating temporal artery will teli in ali but articulate language
of the goaty heart and its associated conditions. These are a
few instances of what the eye can do in the way of diagnosis ; it
gives the direction to phy8ical examination, and guides the line
of treatment when otherwi8e a trackless waste appears to lie
before the puzzled youthful therapeutist. It is ali very well to
treat symptoms ; but in the numerous maladies which are but
the special manifestation of the general condition, the treatment
of the general condition is that of the special manifestation, as is
so well seen in gouty and syphilitic affections. A copper-
tinted blush on a baby's bottom may throw a flood of light upon
the otherwise obscure lung mischief in its f ather, and f urther-
more suggest the appropriate specific treatment.

At present the remarks apply to a patient as seen with his or
her clothes on ; at a later period something will be said about
patients when first seen in bed. When a patient walks into the
Consulting room, whether private or at the hospital, or into the
general practitioner's surgery, the first thing to be done is to
look at him. Look him or her caref ully over ; and my young
friend the reader, if you wi]l only do this sufficiently carefully,
you will soon be surprised to find how much you can see. The
more the eye leams to see, the more it can see, and will see.
Because you cannot see ali at first, you m ust not be čast down.
A\juggler wiir keep six balls in the air at pnce : you see him do
it» but that will not enable you at once to do the same. As he

learnt to do it with mnch patience, long and determined per-
severance, so must you, if you wish to do it. There is nothing
worth knowing that is got without trouble. So it is with the
education of the eye. Bobert Houdin, the famous ITrench con-
juror, set himself to see how much he could note of the contenta
of different tradesmen's dressed window8 in walking past them.
' In a little tirne he could note an ahnost incredible number of
objects in an apparentlj brief passing glance. We ali remember
the interesting child's 8tory of ' Ejes and no Ejes.' The educa«
tion of the eye is most important to a medical man : it cannot
be f orgotten or mislaid, like an instrument ; it is of Incalculable
yalue when the patient is unconscious, or deaf ; or a f oreigner
whose langtiage the doctor does not know, and who does not
speak the doctor*s language. The careful education of the eye
is invaluable in ali these cases. Further, it spares much wa8te of
labour of ten, and puts the practitioner on the right scent in many
obscure cases. Especially is the information so fumished valu«
'able as to certain diathetic (inherited) and cachectic (acquired)
conditions, which underlie the malady of which the patient
mainly complains. The reader will see, as the matter is un-
folded, that the semeia we note teli chiefly of gout, struma,
8yphilis, and ansemia, ali underlying conditions of the greatest
moment in treatment; the hue of the skin in jaundice and
Addison's disease being ind^d the chief indication of the malady.
The physiognomy of Grayes's or Basedow's disease forms the
diagnosis ahnost. The blurred outlines of some faces teli of
mitral disease, just as 8urely as the pallor of other faces tells of
the large white kidney. Ali this, when learnt, is of the greatest
service eyery day in practice. Froude say8 truly enough : ' The
knowledge which a man can use is the only real knowledge ;
the only knowledge which possesses growth and yitality and
converts itself into practical power. The rest hangs like dnst
about the brain, or dries like rain-drops off the stones.' Some
varieties of information may be 8afely left in the library, and
it is quite enough for the bu8y practitioner to know where
to find it when he wants it ; but there is other information
which is required several times evezy day, and of such nature is

i— w«l ^

Hiis vhlch I un liow e»KyiDg to fnmhh to tla rtndent — wftl
liow mnoh auccea« it would not be judiejoua to Hay. The aubject
b^ nut bean »jstemsticaJlj bandled before.

Tbe late Frofessor Lajcock, ot Edinburgh, w&9 tha fiiet peraoti
tn insigton 'ph;aiugnomiaa1iJiagDOBiB,'iiiidon dintbeiea Bod tbeii
indicaCions ; Jonathan Hutchinaon haa told os niucb about the
teetb; the late Manhnll Hull wrQte an exQe11ent Bcticle oD
' SjtnptomatDlog; ' in the 'CyclopffidiB of Fraclical Medicine;'
3. WUka haa written on ' Tomperameots j" Prof eesor Aastio Flint
has an e^ceUeot Beotioo an the aubjeet in his ' Clinical Medicine ;'
Dr. Southej, oC St. Bartholnmew's Hnsrital, has written a aeries
of articies in tbe Laaecl, Vol. I., 1878, on 'Diatbeses;' and
Dr. FinIajBon, of G]aflgnw, bas written on the aubject in his
'Clinieal Manual for the Study of Medical Cases i' and I mjaelf
faave written on the aubjeat in ' The Maintenance af Health,'
and in "The PractiUoner'a Handbouk dE Treatment, or the
Principle« o( TberapeaUcs.' Bo far as I know. the liat given
comprisas tbe bulic of ^rhat hoa been writteD on tbe Bubjeot.
Li>vater'a wark vhb rslited to p!iynia'jntimy, and ao aie tbe
aiimeioiie pbrenolugical worIta, and not to phjeical indications.
Profesaor Laycock'a worl( stands out in bold relief, and is by far
tlie mDBt important oontributiun on the subject. Hib ' Medical
ObservntioD and Reaearch' ougbt to be in every študent'«
handg, and before long will be h> ; fc!r its practical value is mneh
^;reater than tbe študent at firat sigbt will be led to anppoia.
Perhapi wbat is saiil hcra will atimulate htm to penise Dr.
I>aycock'B u-ritinga for himaelf, eapccinlly the loctucea in the
Gret half of 1802 in the Medkal Times and Oaselle.

Making oll allonrances, tbon, for tha itnmatnritj of tbe sab-
jcct, and Femembering that it is hut in its early infancy, tba
plunge muat be e»ayed.

GENEBAL APPEAaAHCE,— The flrat objoct to noto 1b tha
general appearance of the patient ; wbicb tella tbe sax certainly,
the age approx[mnte1y. If obese, Ulere Is nn questian of vastin^
diseaee ; if Horid, there is no amenuB; if palliii, tbere is do
vaaimlar fulnesa; if emaclated, then phthieis, dyapepaia, diar-
clUBa, caocer, or female tconbtes are probably preseut. Tbura

xnay be dropsy present, as seen in the swollen feet or bloated
f eatures ; or if it be abdominal, the unfastened gown or gaping
waistcoat teli us quickly in which direction to pursue our in-
quiries. The general appearance will teli us whether the patient
is f airly well generallj, whether broken down by disease, or how
far enf eebled — will, indeed, teli us rudely how ' ill ' the patient
is, and direct our examination. *

THE ATTITUDE.— The attitude is often suggestive. The
patient may be bowed by sheer debility, or by abdominal pain,
or spinal disease ; or bent to one side, in order to give some part
resti as in pleurisy, when the patient bends to the affected side,
80 as to lessen the friction of the two inflamed serous surfaces.
Then the totit ensenible is often most instructive. There is the
pale, thin, cast-down and unhappy-looking young woman with
dyspepsia, and trouble of various kinds in her reproductive
organs ; there is the panting patient with raised shoulders, who
has chronic bronchitis and emphysema simply written legibly
npon the figure ; there are the liniments of struma as distinct as
a written page, especially in children ; the snuffles of a syphilitic
baby are pathognomonic ! It is well f or the študent to 8tudy
types, or well*marked varieties of disease, which spares much
time, in out-patient practice especially ; as, once the type well-
recognised, it is easy to find out the peculiarities of the individual
patient. The eye leams a certain type of person with persisting
lithiasis, and this will often guide one 8afely through a perfect
maže of symptoms and statements of subjective sensations
otherwise unintelligible. This is very common among elderly
patients ; and is as marked as that of the ansemis young woman.
There is a certain attitude and carriage which tells one, in no
doubtful accents, that there is pulmonary phthisis, and leads one
to examine the patienfs chest without more ado. Then the
bearing is very different A consumptive is often abnormally
acute, and will note a piece of paper on the floor under the table,
and dive for it before one is well aware that he is in the room ;
whereas patients with chronic bronchitis and emphysema, or
with fatty degeneration of the heart, appear bewildered and
stupid. Then in chorea the movemeuts moke the diagnosls;

Bometfmes, however,.the arm is quiet, and looks as if paraljsed,
and 80 the practitioner is set off on a wrong scent. In paraIyB]8
agitans the moveinents of the forearm are indicative of the
changes in the nervous sjstem. Then there is tremorj which ia
well seen in ansemic women who take tea to excess. It is also
well marked in chronic alcoholism, when the tremor of the dif-
ferent muscles, and the ninsteadiness of the carriage, of ten teli
what the patient endeavours hard to conceaL

FHYSIOGNOMT.— Then the phjsiognomj is not without
value. There is the bowed-down look of cerebral anaemia ; the
depression of melancholia ; the excitement of mania ; the elation
of general paraljsis ; and the wom look of mental wony or
anxiety are ali visible enough. There are the general evidences
of nutrition and a well-fed nervous sjstem, usuallj with a fuU
pulse ; and the muscular listlessness of malnutrition, and a soft^
compressible pulse.

FAHALTSIS. — This maj be partial — ^the hand and aim being
fixed — the remains of a whilom hemiplegia. This condition,
however, may be simulated by some accident or affection of tiie
bones ; or the patient may have slept with the arm over the
back of a chair, as men when drunk are apt to do, and the prea«
sure on the brachial nerve be the cause of the paralysis.

Then there are the differences in gait, attitude, and walk pro* .
duced by different forms of nervous disease and osseous changes.
There is, first, the walk of ordinary hemiplegia ; where the patient
circumducts the affected leg, trailing the shoe>toe on the ground,
sometimes the outside, sometimes the inside, so that the toe of
the shoe becomes irregularly wom. Often, the shoulder of the
opposite side is thrown outwards at each step, so as to tilt up the
pelvis on the affected side, and thus make it easier to circumduct
the leg. Here the knee action is lost. Often the arm of the
affected side hangs down rigid, with the fingers closed. In para*
plegia the feet are not lifted up, but shuffled along the ground ;
in advanced cases there is never a distinct interval betwixt the
feet, and each attempt at a step does not reačh the length of the
shoe. In hysterical paralysiB the feet are dragged along, usuallj
one more markedly tiian the other ; while the patient is apt to

drop * in a lump.* The fact, too, that the patient is a joung
woinan is verj significant. In true paraplegia the patient does
not drop so long as the power to walk alone remains. In pseudo-*
hjpertrophic paraly8is there is a * duck-like walk ' or waddle, not
unlike the walk pf double talipes varua. * " Is that the long word
you call it when a fellah walks so V said the young man, making
his fists revolve round an imaginarj axis, as you may have seen
yonth of a tender age and limited pugilistic experience do when
they show how they .would punish an adversary, themselves pro-
tected by this rotatory guard' (Oliver Wendell Holmes). Then aH
are f amiliar with the manner in which the f eet are lifted up abnor«
mally high, and then brought down with a flop, in the disease
known as locomotor ataxy. In disease of the cerebellum the
gait is that of a drunken person, staggering, unsteady, or reeling.
In paralysis agitans the patient comes Hrotting' forward much
fts an elderly actor comes on the stage ; while the body is bent
f orward, with the shaking hands held out in front. This is simu-
lated to a great extent in lead and mercurial poisoning. In pro-
gressive muscular atrophy the rolling gait of the sailor before he
has acquired his * land-legs ' is exaggerated ; whi]e the muscles of
the bali of the thumb are wasted, and if the patient attempt to
unbutton his waistcoat, he does not try to use his thumb and
index-finger, but thrusts the upper edge ofE the buttons with the
dorsal aspect of his fingers. v

Then there are sources of error ; a patient may have a cork
leg, or there may exist osseous changes. In hip-joint disease, ' in
the early stage the limb is usually straight, carried slightly for*
ward, or perhaps somewhat abducted, owing to the irritation and
contraction of the capsular muscles on the anterior and outer
aspects o( the joint. As the disease advances the limb becomes
adducted, so that the knee is carried against the lower part of
the sound thigh * (Erichsen). Or the walk may be modified by
a broken bone badly set. A limp is of ten caused by a sprain, or
a tight boot ; then ther% are the disturbances of the gait pro-
duced by coms ; and the hobble of gout. Or the gait may be
altered by intoxication, acute or chronic.

Then there is the 8winging round of the affected leg, instead

of the nonnal straight-f orward step, when there Is disease of the
hip-joint) usuallj called * rheumatic ' ; and the same in rigidity
of the knee. Or, in children, there is the pecidiar gait, with the
pelvis tilted up, which tells of morhus coxariu8,

DIATHESES.— The diathesis, the inherited constitution of thtt
patient, is of the utmost importance. It will teli of liability to
certain forms of disease according to the diathesis. A certain
dlathesis maj have engrafted upon it a cachexia — an acquired
condition, as a person of strumous diathesis may have a syphilitio
cachexia ; in which čase you will have a maladj which you will
find veij intractable, and which will tax ali your therapentio
capacitj. In describing these diatheses I shall abbreviate Prof essor
Laycock's descriptions in ' Medical Observation and Besearch.'

The gouty or sanguine arthritic diathesis presents the follow«
ing features : a well-developed osseous system, firm musdes,
carriage erect, a generally robust appearance ; nutrition active ;
digestion U8ually good : respiration deep ; large heart, with
florid skin, usually ; large head and lower jaw, with solidlj
enamelled teeth, often wom down; while the hair is usuallj
strong and thick, not falling easily. The pnlse is usually firm
and steady, and the blood pressure in the arteries is high.
Disease of the vascular system, the gouty heart, with its almost
innumerable associations, is common with this diathesis ; and
high blood pressure in the arteries leads to atheroma, as a per«
manent condition, with apoplexy, aneury8m, and angina pectoris
as passing conditions ; and an hypertrophical left ventricle, with
or without valvular disease, ending in decay and fatty degenera*
tion of the heart walls.

The strumous diathesis gives an imperfectly developed osseous
Bystem ' of a retrogressive type, either towards the infantile or a
lower ethnic form, both as to cranium and other bones/ The
bones of the thorax are small; the shafts of long bones are
slender, while their epiphyses are large in large bones (*double-
jointed ' is the north country expression), while the hand is un-
8ightly. The forehead is often lofty and prominent ; there is a
certain fulness of the lips, and alse naši, with long silken eye-
lashes, and in very bad struma ophthalmia tarsi ; the teeth are

carions, the lower jaw often light and thin. Halr fine and thin,
often of a light hue ; the eyebrows arched or veij straight, often
veij thick and well-marked, especiallj in brunettes. The skin
is often moist with acid perspirations. Then there is defective
nutrition of the tissues. Diseases of the bones, morhus coxariu$,
rickets, spinal cnrvature, opcur in childhood $ or enlarged mes-
-enteric glands, or a lardaceous liver ; af ter puberty pulmonary
consumption and snppuration of the glands of the neck appear.
Wonien of this tyge often have children qiiickly, and then die off
prematurely. Tubercle in ali its f orms, f rom meningitis in child>
hood to phthisis in adult lif e, is found with the strumous diathesis.
It is alwa7s difficult to maintain the nutrition in this division of
patients ; and whenever there is disease of the osseous sjstem,
or of the lungs, it will demand careful and prolonged treatment,
8yphilis nsuallj is severe in strumous subjects.

The nervous diathesis fumishes a class of small beings rarely
richlj endowed with fat. Small, active, restless unweai7ing
beings, with a small osseous framework; but with more muscular
power than one would credit from their size. Thej are very
energetic, and usually willingly carrj other's burdens as well
as their own. The forehead is high, and there is a well-vaulted
skull, with small well-fonned f eatures and an active looking eye.
They are the commonest subjects of overwork, and their nervous
Bystem often falters- from the escessive demand upon it. They
are liable to visceral derangements, especially dy8pep8ia and con-
stipation.^ They are difficult to treat ; being either intensely sus-
ceptible to neurotio agents, or requiring them in huge doses.
From this class spring persons who possess * idiosyncrasies/ and
very cautious the young practitioner must be about them. They
usually prefer tea to alcohol, and are affectionate beings ; but
iii^hen advanced in years, especially if they become gouty, they
are irritable and often very trying. Their f amily history usually
reveals various neuroses amongst the different members.

The bilious diathesis manifests itself in a dark skin .with black
liair, often with a yellow tinge on the conjunctiva. Persons of
this class may be large or small, active or indolent ; according as
the bilious element is blended with the gouty, nervous, or ^ym*

phatic diathesis. When associated with the strnmous diathesis,
the product is a being in which, if once tubercle set in, it goes
rapidly downwards; its course here resembling that of tuber-
culosis in the dark races. Bilious individuals do not usuaUt/ put
on fat, and hydro-carbons are not well assimilated. From the
•chemical composition of the bile acids we can trace their origin
from the albuminoids of our food ; and the presence of bile acids
in exces8 in the blood of the bilious, affecting their intestinal
canal, is as commop as is lithiasis in the gouty. In each čase the
product is of albuminoid descent ; and abstinence in the matter
of nitrogenising foods and alkaline purgatives are indicated in
each čase. It is in these persons that we most commonly find
localised spots of pain, which can be covered by the thumb,
at or about the lower inner angle of the scapulee ; which knowing
old doctors teli us mean 'liver and kidney/ They are quite
right ; but why a waste-laden blood should give rise to these
Bpots of pain is, as yet, an unsolved problem.

The lymphatic diathesis is the antithesis of the nervous,
large unenergetic listless beings, of the ' f at cow ' type usually.
They are always * below par,' and require to be whipped up with
large quantities of rich food and wine in order to possess an
approach to a sense of energy. They usually have a large osseous
framework, but their muscles are soft and their intellects inac-
tive. They are not usually florid, and are commonly pallid.
They are never well in low-lying districts. They require active
treatment of a stimulo-tonic character in their illnesses : and de-
pressants are badly borne by them. Women of this diathesis
are liable to menorrhagia, and almost always have leucorrhcBa ;
and in parturition are liable to flood profusely.

CACH£XIiE. — ^With each form of diathesis may be superim-
posed a cachesia. The gouty individual may be anaemic, or the
Bubjeci of lead-posoning, to which persons of this diathesis are
very susceptible. The strumous person may have gout ; the
nervous individual may be the subject of malarial cachexia ; or
the lymphatic individual may have acquired 8yphilis. In ali
8ucb cases it is necessary to keep in mind the diathesis as well
as the cachexia, and to allow for both in the treatment adopted.

The leading cachexiffl are syphilis, gout, malarial poisonirig,
ansemise of varied origin, either from waiit of food, from mal-
assimilation, from poisons formed withm the body, or absorbed
from without ; as lead in painters, plumbers, and compositors ;
niercury in gilders and looking-glass makers; arsenic from
wall-papers and other coloured objects; copper from kitchen
utensils, or tin from the tinned provisions in vogue now. In aH
ansemise associated with a poison, the specific f or the poison musb
be added to chalybeates for the treatment to be successful.

HTJE OF THE 8KIN. — This is important. It may be deepened
in plethora, in the goutj heart with atheromatous arteries, in
which cases the face is usuallj red ; when the hue is purplish,
then there is venous congestion. This is seen in mitral disease,
in dilatation of the left ventricle, in cases of embarrassment
of the pubnonic circulation ; indeed, in ali cases where the right
Tentricle is oveitaxed* As cjanosis in babies, it indicates con-
genital malformation or imperfect development of the heart.
Purplish congestion of the face with hurried respiration in pul-
monary phthisis indicates much invasion of the lungs, and is of
the worst prognostio omen. An increase in the natural vascu-
laritj of the face, with a certain ' blurring of the oiitlines ' of the>
face, a f ulness of the lips and alae naši, is found with organic
changes in the heart in young subjects, generallj indicating
mitral disease. It is also seen with some women about the
menopause, when they are not so well as usual, and there is a
certain amount of vaso-motor paresis .with low arterial tension.
By a caref ul observation of the f eatures in the last čase a 8hrewd
practitioner sees that his patient is not so well, and putshis opening
question accordingly. (It is of great moment, youthful reader,
to mind this little matter. Never, if you can avoid it, put yoi2r
greeting, • "VVell, you are a little better to-day !* when the patient
is worse ; or, 'I am afraid you are not so well to-day V when
the patient is feeling better.) ' Circumscribed redness of one or
both of the cheeks, with abruptly defined borders, is diagnostic
of acute pneumonia. If it be observed in a čase of chronic pul-
monary disease it denotes the so-called hectic f ever, and is a sign
of phthisis.' (riint.) Then there is a peculiar blueness of the

noše, lips, and cheek-bones, which is seen in some persons who
resort to chloral. It is a hue quite srn generis, and nnlike any
other ; the same hue may be seen on the hands.

Pallor is even stili more common. There is simple pallor dne
to ansemia ; whether caused by mal-assimilation or def ective food,
or by a drain, as diarrhoea, menorrhagia, with or without len«
corrhoea, repeated epistaxiSy or loss of blood from any cause.
The hue is more cachectic-looking, approaching the cancerous
character, in some cases of gastric ulcer — a waxiness, indeed. The
cancer hue is slightly yellowish, yet distinct enough commonly.
Then Brighfs disease has its own pallor in large white kidney,
often with unnatural smoothness of the skin in some cases, as in
middle-aged ladies, or comparatively young men. In older
persons the skin is wrinkled more than is naturaL In both
cases it is abnormally dry» and perspiration is not readily excited.
Then there is ansemia with the skin looking like parchment, as
if the subcutaneous fat was absorbed, and the dry skin tightly
drawn upon the solid understructures, bringing out the temporal
arteryy usually tortuous, in strong relief. This condition I have
obserred in spare young men with syphilis, and spare old per-
sons with visceral cirrhosis ; in the latter the hue is sometimes
that of discoloured parchment. Then in chlorosis the pallor has
a greenish tint. This is seen in girls, who often at the same
time are obese. Then there is the pallor of malarial mischief«
whether neuralgic or dysenterio.

At times pallor is accompanied by oedema. This b seen in
acute nephritis, in some cases of renal dropsy of a chronic cha-
racter ; or it may occur where there exists some obstruction to
the circulation in the upper vena cava. Then there is pallor
with or without much wasting, with a greasy unctuous skin, in
certain cases of phthisis ; these patients never do well, and
rarely live long, do what one will. At other times the skin is
pale, with a greasy feel, and degenerative changes in it, in aortio
valvulitis in its later stages.

COLOUB. — ^Then there are conditions where the colour of the
skin is changed. For instance, there is jaundice, where the face
is stained yellow with bile« In Addison'8 disease there is bronz«

Ing of the ^in. The colour of the skin in these two conditioii8
18 an essential part of the diagnosis. It is well, however, to be
careful. A cplleague of mine at the West London Hospital
once made a curious mistake. He mistook a gipsy for a čase of
Addison's disease. However, he was quite sharp enough to find
it out himself, and tells the story with glee. In cases where
nitrate of silver has been taken for some time, as it used to be
for epilepsy, the skin becomes stained where it is exposed to
light, as in the face, and then a^blue colour is produced. The
* blue man ' is c6mparatively rarelj seen now.

EXPBESSIONS. — There are, too, what maj be rather termed
expressions of the face. There is the choleraic face, ashen in hue,
with sunken eye and Uvid skin. The Hippocratic face is pale^ of
leaden hue, with simken eyes, eyelids separated, cornea losing
its transparency, the noše pinched, the temple hollow, and the
lower jaw falling. This is the face of death, and when well
marked no recovery is possible. In the typhoid condition the
face is expressionle8s and dull, the lips and tefeth covered with
Bordes, while the patient lies flat on the back in the middle of
the bed. In py(£mia the expression is lost, or is that of dull
indifference.

In peritonitis the upper lip is raised so as to expose the front
teeth in a manner which is quite unique. Like the twitch of
abdominal pain which flits over the face, producing a twitching
of the lips and contraction of the eyebrows with a frown ; it must
be once noted, when it can never be forgotten. The twitch is
peculiar to disease below the diaphragm, and is best studied,
in the face of the parturient woman when the pains come 0%
especially in the second stage of labour.

Then there is the face of grave organic disease, where pallor is
blended with an expression of suffering, such as is seen in verte-
bral cancer ; abdominal aneurysm, where there is also spinal
caries ; in caries of the vertebrsB ; in repeated angina ; and
with a look of depression in persistent headache, especially if of
organic origin.

The face of hectic, the wasting, the general pallor, with the
bright red spot over the cheek-bones, the quiyering of the nos-

trils, ali suggest, in the language of the author of * 6uy Living-
stone/ * that consumption has already hoisted her bloody flag of
no surrender.* At times, however, when the family hlstory is-
good, this condition is survived ; the tuberculous mass softens
and is expectorated, and the patient recovers with a cayity.
Stili, it is a very grave condition.

THE HAIB. — ^The hair is snggestive. When strong and
coarse it iisually indicates a strong constitution. If early grey,
this coarse hair indicates a gouty taint. Such coarse hair rarely
falls early, and is often found thick and white in very advanced
life. Thin fine hair is found in certain strumous cases, especiallj
when very fair — the hair of youthful precocious fairies, who
rarely stay long with us, but are carried off by tubercle in some
of its f orms.

Fine hair falls soon ; often a fringe, like a monk's tonsure, is
found round a pate as smooth as a bladder of lard; seen in
persons with lithiasis or chronic Brighfs disease, but not neces-
sarily in the subjects of this disease only. Greying of the hair on
the temples indicates approaching age. In some cases isolated
very white hairs are found sčattered through hair of raven black-
ness ; in my observations in the dead-house of Vienna in such
cases there was always some pathological change in the kidneys ;
thougb these were not so advanced as to be a factor in the pro*
duction of death in most instances.

When the hair is glossy and bright it indicates good nutrition.
The hair loses its lustre, becomes dry and brittle in advancing
phthisis ; and recovers its natural look and appearance as a
retum to health is made. When a consumptive patient has not
been seen for some tUne, the condition of the hair is often a sure
and certain index of the general state and condition. A good
full head of hair, like good teeth, U8ually indicates a good con-
stitution; ike eaceptions are found in certain strumous in-
dividuals.

THE FOBEHEAD.— The forehead is important. When well
vaulted it forms a part of the nervous diathesis. When broad
and rather low, it usually goes with a stalwart f rame and a bulky
bodj. The lofty brow is usually accompanled by a thin flank

ftnd a ' weasel-belly * — indeed, with small digestlve viscera, and a
liabilitj to indigestion ; the broad low brow goes U8ually with *
8quare abdomen, large digestive organs, and good assimilation-«
witb gout looming in the distance, or even actuallj present. It
may be protuberant from exces8ive ossification of the centres of
the frontal bones, and this is apt to be found with defective
development of the rest of the bones, and wide fontanelles, as
seen in hjdrocephalic infants. It is also seen in the rachitic
forehead. 'The head of the child in rickets is generallj un-
U8ually large, the vertex flattened, and the forehead prominent,
broad, and 8quare, with considerable expansion at the centres of
the parietal bones.' Sometimes the sutures remain open ; at
other times they are closed prematurely, and then the growth of
the cranium is arrested, and the child remains a child in intel«
lect, or is a cretin or an idiot. Imbecilityy however, is not
always accompanied by a small cranium. In strumous children
with a 8yphilitic taint, the forehead may become protuberant
and project in front of the face. Here the arrested development
of the facial bones intensifies the deformity. In some cases the
forehead carries with it a moral significance. There is the
broad ebumated forehead, the forohead Jeremiah recognised
when he said, ' Thou hadst a whore's forehead, thou refusedest
to be ashamed.' The woman with this forehead will deny
pregnancy with the most unblushing efrrontery ; and is utterly
nntruthful when anything oonnected with morals is involved
Then the forehead may manifest one single copper-coloured spot,
pathognomonic of 8yphilis. Ulceration of the forehead is alway8
8yphilitic, except when the result of a wound. The scars are
equally significant and suggestive.

ETEBBOW. — The form and charaoter of the eyebrow is often
suggestive. When the eyebrow8 are exceedin5ly arched, or
unusually straight, and stili more, when they are also very thick
and bushy, they indicate struma. When such persons become
the subjects of phthisis, they usually ha ve it in a severe form, and
soon succumb. Severe and repeated attacks of facial neuralgia
may lead to increased growtb of the eyebrow, especially the

oiiter extrexnity, while thcre may be a patch of dark colourcd
skin around it.

EY£LASHES.— These are also modified by struma : m the
finer fonns the eyelashes are very long and silken, giving a
pleasing expres3ion to the face ; but when the condition of
opthalmia tarsi is reached, then the expression is Yery unpleasing,
Bometimes even repulsive.

ETELIDS. — The ejelids may be oedematons, especia]ly the
lower eyelid. This oedema ninder the lower eyelid, seen dia-
tiiictly on gotting up, and largely disappearing during the day, is
associat^d with chronic Brighfs disease. It is comnionly seen
in ladies of middle age with pallor, the ansemic form ; but in
advanced life it is not unfrequently seen even along with a high
complexion. It is common to look inside the lower eyelid to
measure the amount of anaemia in a čase. Then the upper eye-
lid may be paralysed, as in ptosis, when the superior branch of
the third nerve is involved. A dark pigmentation of the eyelids
is not unusual in pregnancy, where pigment changes are com-
mon. Sometimes there are patches of deep pigmentation on the
brow as well. These pigment changes indicate pregnancy in
some women at a very early period. They are apt to recur in
the same individual. A dark areola is often seen at the
menstrual periods, especially when a woman is in bad health,
and has severe catamenial losses.

EYE. — The eye tells a great deal, and should be carefullj
studied. The eye is oblique in many idiots and imbeciles ; who
are apt to manifest the Mongoiian type of features. In ez«
ophthalmic goitre, the eye is very prominent ; in slight cases the
prominence is only such as to make the face more interesting,
but when more pronounced it gives a disagreeable ezpression to*
the features. Then the conjunctivse may be stained yellow
in jaundice or biliousness ; or be pearly white in certain cases of
•hronic Brighfs disease. It is apt to be vascular where there is
f ree indulgence in alcohol. In the * Bright eye ' there is a
minute quantity of fluid behind the conjunctiva which looks like
a tear ; but it can be moved, which a tear cannot.

A Bquint is often significant of hydrocephalus in infants ; m

moinentaTy sqtiiiit at first, but becoming more persistent as the
čase moves on to its enoL In like manner a 8quint is developed
in brain disease in adultr« At other times the ejeball is oscU-
lated slightlj, but rapidly, from side to side. This is called
nystagmus; It has no significance.

Then tbe comea may be affected, and is chronically inflamed
by S3rphilis about puberty, and until about seventeen. Under
proper treatment it may clear np ; but if neglected permanent
opacity may result. At the union of the comea and the sclerotic
a ring is sometimes seen ; this is the arctis senUis, It indicates
advancing age, as its name implies; but it is necessary4x) have
clear ideas on the subject, eise error may arise. There are two
forms of arcus : one veij suggestive and of evil omen ; the othcr
withoat any significance. The latter being the more pronounced
of the two, careless observers have often been misled. To take
the innocent form first may be welL It is very distinct, with
8harply-defined outlines and a clear comea. It is calcareous in
its nature, and is very common in hale old people ; especially
persons with light-blue eyes. It corresponds to the bony plates
found in birds at the point of attachment of the comea to the
sclerotic. It has no significance ; but the other form tells of
tis8ue-decay. This arcus has badly defined edges ; while the
comea is hazj and cloudy from fat-granules being scattered
throughout it.^ It is more pronounced under the eyelids, where
the arcus is often to be seen very di8tinctly, when scarcely
recognisable in that portion which is exposed to light. It is
often well, then, to lift the upper eyelid when in doubt ; as when
the que8tion arises as to whether or not there be fatty degeneration
in the fibres of the heart. Arcus is a bow : annulus a ring. It
Is arcus senilis, not annulus senilis. Then as to the pupils.
Sometimes the iris is the seat of inflammation ; and the forma-
tion of a tubercle at the inner or free edge of the iris is common
in syphilis. Then the pupils may be of unequal size. Gontrac-
tion bf one pupil is often found in aneurysm of the aorta.
When the pupils are both contracted, and severely contracted,
then the suspicion of opium poisoning is aroused, or indulgence
in cougb-lozenges containing opium ; or may be hsemorrhage into

the pons varolil. In apoplexy the pupil of the paraljsed side !s
usuallj dilated ; but this is not invariablj the čase. It is well to
note inequalities in the pupil ; but the subject of the causes of
the inequalities is too wide a one to be entered upon here. In
convulsive seizures the pupil may be widely dilated, contracting
again when the attapk is over. Dilatation of the pupil occors
just before death in opium-poisoning. As a guide to the con«
tinuance or discontinuance of belladonna given intemallj, the
condition of the pupil is utterlj valueless ; and the administration
of atropia, as in the night-sweat8 of phthisis, should not be
stopped, because the pupils are dilated thereby. The mobility
of the pupil under light is significant ; and the circumstances
under which there is mobilitj to light, but not to distance
accommodation, are interesting, but cannot be reviewed here.

The steadiness of gaze, or the unsteadiness, often tells of the
character and habita of the individuaL The secret drinker
rarely has a 8teady eye. The averted look often is significant
when ft question involving morals is mooted. In in8anity the
eye tells of the gloom of melancholia, the excitement of mania,
or the elation of general paralysis ; while there is the glare of
suspicion or of persecution ; or the vacant gaze of dementia. It
is alway8 desirable to watch the patienfs eye. In ali relations
of life a struggle for mastery is unoonsciously going on ; and the
eye will generally teli when the patient is going to be obedient ;
and also when the doctor has got the wor8t of it, and the patient
does not intend to f ollow the proffered advice. And a doctor
has always practically failed when he feels he has not convinced
the patient sufficiently to make him or her obedient 1

KOSE. — The noše often has its tale to teli. The nostrils plaj
and quiver in thoracio disease, or condjtions of nervousness.
When the bridge is sunken, inherited syphilis is suggested. The
' snuffles ' of syphilitic infants is well known ; and the chronic
inflammation of the bones of the noše set up thereby may result
in their arrested growth, and thus be instructive ever after-
wards. Then the als naši may be f ull, as in struma. The tip
is red and tuberous in chronic alcoholism — a condition simulated
by disease in sooie cases. The red tip in womeii uaually indi-

cates indigestion or eonstipation, or both, with or w]thout pelvic
cojuplications ; or the noše maj be abnormallj pale. In either
čase there are usuallj cold feet.

LIFS. — Sometimes a dyed moustache will reveal the design
of the individual to conceal his age ; a matter which may not
be, at times, without significance. Then in strumous children
the lips are f uller than usuaL In slighter cases, this, with f ul-
ness of the alse naši and the long silken ejelash, gives a yery
pleasant, often piqiiant, face ; but in severe struma the thick
coarse lip and noše brutalise the expression of the face. Then
a certain fulness of the lips, and cspecially of the under lip,
commonly goes with well-marked sexiial proclivities. The full
under-lip of the House of £urgundy niay stili be traced in the
House of Austria — the full lip and the light morals of the
Hapsburgs. The lips are apt to become fuller and coarser in an
individual after prolonged 8exual indulgence in excess. Then
scars at the angles of the moutb are always pathognomonic of
8yphilis. The sordes on the lips and teeth will be considered
when the typhoid condition is described.

6UHS. — ^The blue lead line along the teeth puts the observer
on the right track in lead-poisoning. A spongy state of the
gums is found in purpura and scurvy ; or in mercurial poisoning.

TEETH. — Much useful information may be gleaned from
careful observation of the teeth. They may indicate exces8ive
tobacco-smoking, or chewing, from their colour ; and in that
čase are usually natural teeth. And this is a point not to make
any mistake about — before observing the character of the teeth,
be certain that they are the patient'8 natural teeth, and not
artificial teeth. Artificial teeth are generally better shaped,
more perfect and ipguls^ than natural teeth. £adly-decayed
teeth generally indicate unsoundness of the constitution, or
delicacy ; persons with bad teeth rarely have robust health.
Their bad teeth lead to indigestion, because the food is not
properly masticated. Often when the front teeth look well, the
molars are decayed or gone. Strumous persons usually have
decayed teeth, with a blueish hue around the caries. Where the
teeth are diseased as a consequence of mercury, thej are rather

' dlrtj ' In hne, than blua around the earlotu portioiu. Then
' goatj ' teetli &re tbick and heaTiIy emuuelled, and nSDiiHf
woni dowii, At timeB the two upper incisors are very large and
masBirs. At other timea, in peinona of the gouty diathesiv tha
teeth fall ont fronl periostitis without any caries. The larger
masBiTe weU-fornied Bound teeth of the gouty dialheBls ofleu
f umish moet nseful ioformaitiaD about tho patient.

The modificatioDS of the teeth produced b; congenital
STphilU bltve been made the subject of careful abservation b^
Jonathan Hutchinson. He nrites : 'It !b ver; common to find
aH the iousor teeth dwaifed and malformed. Sometimea the
canlnea are afFected also. Those teeth are naiTOW, and rounded,
and peg'Iibe ; their edge« at« JBgged and iiot<:hed. Oiring to
theic Biaallnesa, their sides do not touch, and interapaces aie left.
II i«, howaver, the upper oentral incison vhich are the most
reliable for puiposea of djagnosis. When the otber teeth are
affected these veiy rarelj eac^ie, and ver; oEten they are mal-
formed wbeh ali the others are of f»irly good shape. Tho
oharacteristic nulformation of the upper central incisors ooiuista
in a dnarfing of the tooth, which ia uauall; both narrow and
ehort, and in the atrophj of ita middle labe. This Rtrophy
leaveB a aingle broad notch (vertical) in the edgs of the tooth ;
and sometimes from thia notoh a ahalIow furrow pBSaes apward«
on both auterior and poaterior aurf ace nearly to tbe gum.

WiIb notchlng U nanallj ajmmetrical. It may varj voij
much m degree in different casea ; aometimea tbe teeth diverga

and at others tliey slont towarcls each other. Thd appended
woodcut illustrates a good exainple of the deformitj. In any
čase in which the malformation wa8 as marked as in the sketch,
I should feel no hesitation in pronouucing the possessor of the
teeth to be the subject 6f inherited syphilis, even in the absence
of any other testimony, I have never yet seen such teeth,
excepting in patients of this class. In the majority of cases,
however, the condition of the teeth is snfficient only to excite
suspicion, and not to decide the question.> In a few rare cases
oniy one of the upper central incisors is malf ormed, the other

Fig. 2.— AFTEB HUTCHINBOir.

being of natnral shape and size. A good instance of this state
of things is shown in this woodcut. In a considerable number
of cases of hereditary syphilis the teeth show no deviation from
the normal standard, and in such the diagnosis must be guided
by other conditions. In addition to the peculiar malformations
above described and illustrated, there are uthers which, although
less characteristic, are yet very valuable to a trained observer.
They do not, however, admit of description without great risk of
misleading the reader. Before leaving the subject of dental
malformation, I may again ask attention to the fact, that it is
only in the permanent set that any peculiarities are observed.
The first set are liable to decay, but are not malformed/

The študent must not confound *craggy* teeth, with their
horizontal furrows, with Hutchinson's teeth with vertical
furrows. Also many children have notched teeth, with the
absence of the fourth denticle, who have no syphilitic taint.
Where the jaw is small, and a child delicate, and its tissues im-
perfectly nourished, the teeth are apt to be notched, and present

three denticles only. Sjphilis is an * imitator/ and mimics con-
ditions produced by other morbid states ; and, except in the very
pronounced teeth given above, mimics the malformed teeth
otherwise produced. When three denticles are found in other-
wise well formed, large, good teeth, in my mind they suggest
Buspicion of a syphi]itic taint. To say more might mislead.

CHIN. — The chin tells little except as to the diathesiB and
constitution. A massive square chin usually goes with a good
physique ; and is part of the well developed osseous 8y8tem of the
gouty. A small, light, slender chin and jaw goes with the
nervous or the strumous diathesis. A massive chin indicates
uHiially a strong, good constitution ; while a small chin indicates
dclicacy. A prominent chin goes with the full under lip and
the light morals.

VASCTJLABITT.— The vascularity of the face has been
alluded to before ; so far as it indicates phethora by redness,
or anaemia by pallor. But further 8tudy of the vascular
condition 6t the skin will yield Information of value. The
presence of a high compIexion may teli of exposure to the
weather rather than plethora; the vascular fulness protecting
the skin from the cold to which it is exposed. Then pallor of
the face may indicate the merely opposite state of in-door
occupation. A mili hand, a clerk, or a compositor could 8carcely
be expected to manifest much facial colour. At times little
dendritic twigs are seen where the tiny artery pierces the skin
and shows upon the surface. Professor Laycock speaks of
' blood;vessels largely developed over the malar bones, and vari-
cosed ' in the phy8iognomy of the sanguine gouty cachexia ; and
the condition of the facial arterial twigs is very suggestive as to
the state of the arterial system generally. More especially is
this the čase where there is pallor of the face with deeply in-
jectod arterial twigs. They may also be seen, but are scarcely
so conspicuous, in florid persons. These dendritic arterial twig8
are part of the atheromatous changes which accompany 'the
gouty heart.' A hard radial pulse, an h3rpertrophic left ventricle,
an accentuated aortic second sound, are the associated conditions ;
the urine is copious, and the patient commonly gets up at night

to make water — a Tery * fetching * question when }udicioTi8ly put
in the right plače ; and «ortic dilatation, apoplexy, aneury8m,
and angina pectoris are commonly found therewith. As the
heart fails there is arterial ansmia, with pallor ; venous fulness,
with liyidity about the lips ; and a countenance, a tout ensemhle,
wbich speaks volumes. Then there is the expressive, if inarticu-
late temporal artery. This may be tortuous in young persons,
especially in industrious, studious young men ; and may even be
seen to pulsate, when a strong light f alls upon the face, without
any significance. But usually the condition of the temporal
artery reveals that of the general arterial condition. It is
tortuous ; it expands laterally, as well as elongated, as the pulse-
wave of each ventricular 8ystole reaches it. In aortic regurgita-
tion the diagnosis may at times be made by observation of the
temporal artery. The impression of * balls of blood shot under
the finger,' as applied to the sensatiou Imparted on feeling the
radial pulse, is conveyed to the eye ; it is possible almost to see
the ventricle rapidly impel its contents into the arteries ; and
then the sudden collapse as the backward flow, on the aortic
recoil, is no longer arrested by healthy aortic valves. Such
abrupt collapse indicates considerable shrivelling of the free
edges of the aortic valves; with the patency aggravated by
dilatation of the aortic conus. Where the iQCompetency is
blended with a rigid condition of the aortic valves, constituting
obstruction, then this ' water-hammer ' pulse and 8uddenly
collapsing temporal artery are not found.

The atheromatous change in the arterial wall may be of two
kinds. In the one čase it is thick and soft, suggesting the idea
of being 8wollen ; here the pulse is comparatively soft, and fatty
degenerative changes are associated therewith. At other times
it is small and hard ; and then it is suggestive of viscerai
cirrhoses. The radial artery and the temporal are both influenced
in the same direction by like degenerative changes ; whether
the arterial 8ystem generally is the subject of fatty or calcareous
degeneration. In some young men a parchment-looking skin
is tightly stretched over the tissues beneath, and the temporal
artery is veij conspicuous, being both tortuous and thickened.

The first time this condition came vividly nnder my notice wa8
in a South-We8tem railway carriage ; I was much puzzled to ao-
count for such advanced arterial change in so young a man.
Beside him sat his wife with an infant in her lap. A puff of
wind from the carriage window lifted, for a moment, a veil over
the baby's f oreh^ad, when a well-marked syphilide near its scalp
— ^the corona veneris — presented itself ; the mystery was solved.
Syphilis and alcoholism expedite atheromatoiis changes in the
arteries. Shortly after this, I was called in in consultation to
see a young man with an irregular form of paralysis. There,
again, the tightly-stretched skin and conspicuous tortuous tem-
poral artery were present together ; on examining the skin
carefully, disseminated coppery stains of jpsorioMS guttata were
found ; the nature of the malady was thus distinctly revealed.

HEBVOUS SUPPLY.— The face may be distorted by paraly8i8.
The features are drawn towards the sound side, the šaliva
dribbles from the palsied side ; the cheek is flaccid and is blown
out by strong expiration. The patient cannot frown with the
affected side, nor shut the eye, though that on the sound side is
firmly closed ; he cannot whistle, nor pronounce the labial con-
sonants distinctly, unless the palsied side of the lower lip be
held up by the finger ; while on protruding the tongue, it curves
round to the p^sied side. The sensation of the paralysed side
is generally unimpaired. Inability to close an eye, or ptosis,
usually indicates intra-cranial disease ; while facial paraly8is, gene-
rally, may be local and periph^aL

Of course, mere observation of facial paralysis will not deter-
mine whether it is peripheral or central. Then at times there is
the tic convulsive, where there is intermitting spasm of the
facial muscles. In some cases it is confined to the eye muscles,
where it simulates a very strong * wink '; at other times it impli-
cates other muscles, and gives an odd comic look to the face.
The facial expres8ion of idiots and imbeciles is given by Dr.
Langdon Down at length. The following is an abbreviation :
Their eyes are oblique, and the face simulates the Mongolian
type. There are semi-lunar folds of skin at the intemal canthus
c^ the eje (the third eyelid of the bird). The lips are thick.

especiallj the lowep one ; they are often marked by transverse
fissures ; also, they are often deficient in muscular power, so
tbat the šaliva dribbles. The angle o£ the jaw is obtuse, while
the ears are placed usually far back. The mouth is arched, the
tongue large, rugous, and fissured, while its papillsB are enlarged.

THE £ABS. — The ear is often instructive. It may contain
otolites, pathognomonic of gout. Or as Professor Laycock in-
sisted, the lobe may be red, full, and glistening, as if the stretcbed
flkin was about to crack. This is common in gouty persons in
iniddie age. As nutrition fails, the lobe may become wrinkled.
It goes with the skin of the face to a great extent. A wrinkled
ear lobe with a fac^ seameTl with' wrinkles usually goes with
extensive but very chronic visceral cirrhosis. Here the skin is
very dry and imperspirable. Then the' ear may be deformed by
cethoematoma, most comnionly seen in the general paralysis of
the insane. A discharge from the ear should always claim care-
ful attention ; chronic otorrhoea not rarely ends in meningeal
inilammation and death. Wagging of the ears has no signifi-
cance.

THE NECK.— Observation of the neck is of moment. Wry-
neck riay be temporary, and dne to rheumatism or cold : or
permanent, as the result of inflamed glands af ter scarlatina or
measles : or from disease of the spinal vertebrae : or from the
cicatrix of a burn. Then there may be enlargement of the thy-
roid gland. This may be due to a varicose condition of its
vessels ; but more commonly its enlargement goes with exoph-
thalmos, and is part of Graves's disease. The enlargement may
be bilateral or unilateral. It is not uncommon in various parts
of England, but is not associated with cretinism in this
country. Then the neck may present enlarged glands, or the
scars of by-past ulceration of a scrofulous character. The
muscles of the neck are part of the accessory muscles of the
respiration, and are thrown into action when the respiration is
embarrassed. In severe dyspnoea they act violently, drawmg up
the bony framework of the thorax while the diaphragm is
descending. Th6 arteries of the neck are commonly seen to pui-
sate violently and difitinctly in aortic regurgitation ; or on one

side only in anenrism involving the carotid artery. At other
times the jugular veins pulsate, indicating regurgitation of
venous blood on the sjstole of the riglit ventricle, with or with-
out tricuspid incompetencj.

THE SESFIBATION.— The character of the respiration is
often instmctive. It may be hurried and 8hallow ; or it may be
deep and laboured. The first may arise from nervousness, or be
associated with pulnionary phthisis. The latter is rather fonnd
with chronic bronchitis and emphjsema ; when the latter is
pronounced there is djspncea, where the respiration is both
rapid and laboured. The character of the respiration, the pallid
or Uvid countenance, and the di8quieted look, will often establish
the diagnosis of chronic bronchitis and emphysema, without a
r^le being heard ; physical examination here only corroborates
the diagnosis. In pneumonia the breathing is hurried. The
rapidity of the respiration is the measure of the amount of
disease, and by comparison of it with the pulse rate the amount
of lung-inflammation, or consolidation, or congestion, the extent
of eniphysema, or of the diminution of the lumen of the bronchial
tubes, may be rudely measured ; often, however, with much accu-
racy. This matter will be f urther considered in relation with
the pulse. When both are excited and rapid, a febrile condition
or a nervous condition are indicated ; sometimes both. There is
a certain modification of the shoulders in chronic asthmatics.
They are elevated and drawn forwards, by the pectoral muscles
being accessory muscles of respiration ; and when they have been
much used as such they draw the shoulders forward. They may
also be so changed by emphysema, or chronic phthisis.

The thoracic change visible to the eye through the patient's
clothes is confined to the barrel-formed chest of extensive
emphysema, and the flat chest of those predisposed to phthisis.
What is seen on stripping the patient will be found in Dr.
Thorowgood'8 division of the subject.

THE ABDOMEN. — This is fuller than natural in pregnancy,
ovarian disease, large uterine fibroids ; in hydatids of the liver,
ascites in amyloid disease of it, especially in boy8, cancer in older
persons, in liver-enlargement from alcoholism; and at timea

from tjmpanitis. Or the abdominal f ulness may be merelj a
pad of f at. In young children the belly is 8Wollen jn disease of
the mesenteric glands. Enlargement of these glands may remain
as * pot belly.' When there is much abdominal fat without corres-
ponding bulk el8ewhere, the condition is more distinctly patho-
logical than where there is general 6be8ity. The condition is
pathological in so far that the largč increase of abdominal fat is
usually due to free living; and the younger the subject the worse
the prospect.

THE HAND.— The hand, too, should he observed. 4?he arm
is straight and rigid, and the fingers bent in the late rigidity
which follows some attacks of hemiplegia. At other times the
fingers are spasmodically dosed in some women who are the
Bubjects of neurosal affections of an hysterical, or 'hysteroid
character, the spasm being intermittent. Then there is the
condition of athctosis, where the extensor and flexor muscles
rhythmically counteract each other in wave-like movements.

Or the hand may be dropped in lead-poisoning, or be the
subject of * writers' cramp.' In hydrocephalus in children the
hand is closed upon the thumb, often tightly ; and this charac-
teristic hand should always put the young practitioner on his
guard. Then again in chorea the movements of the hands con-
stitute the diagnosis. At times there is rather paralysis than
movement, and the mother will teli you that the child * has lost
the use of its arm ;' nevertheless the malady is chorea. Chorea
may be uni-lateral or bi-lateral, or confined to the hands, or im-
plicating the f eet and at times the muscles of the trunk^

Then the hand may teli of constitutional conditions. In gout
the joints are swollen and thickened, and there are deposits of
tirate of soda in the fingers ; and occa8ionally, but rarely, in the
thumb. Or a finger may be drawn down by gouty inflammation
in the tendon and its sheath, a condition whrch Sir James Paget
8ays is pathognomonic of gout. The patient will teli you it is
caused by his walking-stick, or geological hammer, or other
local cause ; but usually the same thing will be found in the
other hand, only not so far advanced. It may of course be the
result of local disease ; in whicb čase the other hand is not

affectcd. This * drawn-down * fingcr is not found nsuallj with
the characteristic enlarged knuckles of gout. Then ali are
f amiliar with the distorted hand of rheumatic gout. Patients
usually call any deformity of their hands * rheumatic' in its
nature. Then again there is the hand of the strumous diathesis.
Here the characteristics are large epiphjses with slender shafts
to the bones. The knuckles are large and prominent ; the joints
thick and coarse, while the middle portion of the phalangeal
bones is slender. Such was the fist of the great lexicographer,
Dr. Jo&nson, who also had a stronglj marked strumous face ;
wherever an engraving of him hangs the študent should study
the hand, especially in connection with the features. In girls
this modification is often seen. It detracts from the 8ymmeti7
of the hand, and gives trouble in connection with the getting off
and on of rings. . This enlargement of the epiphyses is well seen
in children with rickets, at the union of the costal cartilages and
the ribs. The little prominences 'hang like festoons, and the
name * the rachitic garland ' has been given to this condition.
Then the hands often indicate the general wasting. The inter-
ossei muscles waste in phthisis, and the atrophy of them gives to
the hand a listless look and feeble grip. At other times the full
blue veins in the hand indicate debility with venous fulness.
Then there are the ' clubbed ' fingers of congenital heart mis-
chief seen in perfect development^ when the hand may be deep
red or even blue, with livid nails ; of chronic phthsis ; or of
chronic mitral disease. The attempt has been made to distin-
guish the two ; in pfithisis it is asserted that there is wa8ting of
the subcutaneous fat with incurvation of the nail on each side.

* In some old persons we have observed a remarkable tendenejr
to lividity of the finger-nails. It appears to us to be from defec-
tive power8 of the capillary circulation that cold is so difficultlj
borne by infants and very old persons ' (Marshall Hali).

The hand, too, will often teli of the nature of the patienfs
occupation, whether the hand does in-door or out-door work, and
lo give useful Information. 'Where there are black, sodden

* hang -nails ' on the fingers of girls, they teli of illicit practises,
and so are very instructive. £specially is this the čase where

th^re is a cold, wet palm. The damp palm Is very snggestive $
and a rudimentary growth of hair on the upper lip. Dr. Robert
Greenhalgh tells me, bas often guided him to a suspicion of
what direct inquiry proved to be a fact (manu-stupration).
Then in idiots there is a * woolly hand,' from the skin being
loose and looking as if too big for the hand. In imperfect jaun-
dice, or where it is doubtful, it is well to stretch the skin on
the back of the hand, when the yellow shade becomes apparent
— if it be there at alL

NAILS. — Then the nails are changed in chronic gout, and are
striated ; showing that they consist of agglutinated hairs. Dis-
ease often affects the nails ; in my own čase, an attack of gout
will leave its mark on nearly every nail, and the date of it can
be guessed from the position of the mark. It takes about seven
inonths for the nail to grow the tell-tale mark out. According
to Mr. Jonathan Hutchinson, the white patches on the nails
known as *fiowers' or ^lies' are * often seen in the nails of
children and delicate persons, who are in the habit of picking
the nail at its joot and thus injuring its soft structures.' He is
in accord with B. W. Bichardson in thinking psoriasis of the
nails associated with the dartrous diathesis (Asclepiad).

THE F££T.— These teli of gout and dropsy as constitutional
States. The protuberances of gout may be mistaken for
bunions, and vice versd, Dropsy is shown by the unlaced boots,
or the slit shoes, or the projection of the stocking over the top of
the shoe or boot in slighter cases. Such dropsy is usually
cardiac, and points to mitral disease, or dilatation, or * failing
hypertrophy ;' but there may be renal complications. The
altered movements produced by nervous or osseous diseases are
given in a previous section.

THE CLOTHES.— The arrangement, or the want of it, of the
dothes often gives a quantity of useful Information. When
there is failing brain-power the clothes are not attended to pro-
perly. The drunkard becomes first dirty, with unbrushed
dothes, and then ragged. The same neglect is seen in braiii
Oisease, where the coat coUar is not tumed down, or the waist-
coat is buttoned awry, or the trousers are partially unbuttoned,

whi]e the shoe is often ' down at heel ;' the taui ememhh often
being most instructive.

In a drinkiiig bout, or fit of drunkenness lasting some da^s,
the drunkard will often attire himself grotesqT3ely ; as also do
certain lunatics. Peculiarities in dress are significant of msanity
or oddity. The trousers are stained with sugar in diabetes, or
are wet in incontinence of urine.

THE VOICE.— This is affected by a cold, op by laryngeal dia-
ease, as syphilis and phthisis ; and by hysteria in girls. The
articulation of words is affected by cerebral mischief in the
neighbourhood of Broca's convolution. The tone is enf eebled in
disease, or the patient can only speak in a whisper in some cases
where there is laryngeal disease; or only very slowly and
deliberately after cerebral exhaustion, as in the typhoid con-
valescence. Or there may be inability to pronouAce the labial
consonants from causes affecting the lips. In the general
paraly8i9 of the insane th% utterance is thick, or the words are
'clipped/ as in intoxication.

COUOH. — This is often instructive. There is the cough of
bronchitis, acute or chronic, and the bubbling of r^lesu There is
the cough of phthisis ; in the first stage, where there is consoli-
dation, it is often a * hemming ' or * phthisacking ' cough ; later
on it is apt to occur in severe paroxysms, leaving the patient
exhausted and bedewed with sweat. Then there is the short,
dry cough of pulmonary congestion due to mitral disease. The
neurosal cough is either a small, frequent cough, like the
'phthisacking' cough, or a loud, ringing, barking cough. The
latter cough is also heard com9ionly in aneurysms, involving the
recurrent laryngeal nerve ; sometimes it is * brazen,' as if a brasa
musical instrument was being coughed into.

THE ]iANN£B.^Obseryation of the patienfs manner will
often f umish usef ul Information. There is a certain brusque-
ness in country people who are much out in the open air, whicn
contrasts with the sedate quietne8s usually found in those wno
live by indoor work, book work, or behind the counter. Th«
chronic invalid has usually a look of langnor and self -conscious-
ness; while a lady with the vapoun geta herself up with oazo-

ful, indced minute, attention to everj detail of dress and manner
w]uch can make her more interesting. Where there is something
to^nceal there is a certain restraint of demeanour to be noted,
as seen in some girls who are pregnant without any preliminary
legal procednres; while others adopt an attitude of defiant
indignation.

Such, then, is the Information afforded to the eye as it slowly
passes over the patient ; quietly, steadily, and observantly. And
very valuable Information is thls so fumished. But this cannot
ali be leamt In a day ; and the perusal of this little brochure
shoTild set the študent a-noting every patient carefully. In a
little time the eye will leam a great deal, and direct the inquiries
in a practically useful manner. When the eye is not so trained
the practitioner is apt to pursue fruitless and futile lines of
inquiry, and wastes time, and only bothers the patient ; where it
is carefully trained the inquiry takes the right direction at once
and forthwith.

THE TWITCH OF ABBOKINAL PAIN.— This Is weU<marked
in many cases. There iš a contraction of the. forehead, like a
frown, with a twitch of the lips which Is most expressive. It
comes and goes In spasmodic affections, as colic. It is well seen
at the commencement of ' a pain ' in labour ; and the študent
who carefully scrutinises this twitch In the face of a parturient
woman will never forget it, or mistake it after. It is patho-
gnomic. It may be more continuous in persisting pain. Thus
Flint describes 'the facies of acute peritonitis' thus: 'The
tipper lip raised so as to expose the front teeth, gives an aspect
which characterises, In a certain proportlon of oases, acute peri-
tonitis. It is often wanting, but, when present, It Is strongly
dlagnostic' Dr. Marshall Hali describes this twitch with fuller
detalL He WTites : ' In inflammation of the abdomen with
severe pain, there is a continued state of contraction of the
muscles of the face, inducing an unnatural acuteness of the
features ; the forehead Is wrinkled and the brows are knit ; the
nostrils are acute, drawn upwards, and moved by the alternate
and Irregular acts of the respiration ; the wrlnkles which pass
iiom the nostrils obliqueIy downward8 are deeply marked ; the

upper lip is drawii upwarcl8, and the under one perliaps down-
wards, exposing the teeth ; the chin is often marked vfhh
dimples. This state of the features is aggravated on any incnHie
of pain, from change of position, muscular effort, or eztemal
pressure. Indeed, in cases of abdominal affection, it is better to
press on the abdomen, or to beg the patient to raise the head and
shoulders, and watch the effect on the expression of the counte-
nance whilst the patienfs mind is occupied with some other
subject, than to ask the direct question whether pressure produces
pain, as is usually done : for patients naturally suppose that eveij
painful part must also be tender, and are therefore apt to answer
in the affirmative, although incorrectly. In cases attended with
spasmodic abdominal pain, the contraction pf the muscles of the
countenance are more violent but less permanent ; during the
paroxysms, the distortions of the countenance take plače in a
degree scarcely observed; in the intervals the countenance
recovers a calm, imusual, if not incompatible, with inflammation«
The transition of spasmodic into inilammatory pain, may often
be traced with great distinctness, by carefully observing these
changes and modifications in the expression/ Dr. Hali wa8 a
Tery successful practitioner, as well as a scientific študent of
medicine. Such expression of the countenance is instructive in
renal or tireteral colic, as well as ordinary colic or uterine spasms.
Its absence puts the observer on his guard against hy8terical
peritonitis.

LOOK OF PAIH.—Dr. Hali says further : *The appearance of
ihe countenance affords a valuable source of distinction betw6en
chronic dyspepsia and insidious organic disease. In the latter
there is a characteristic early and progressive loss of flesh, with
paleness, perhaps slight flushing, but without sallownes8; the
bony and muscular parts become exposed, the integuments are
drawn into deep ivrinkles, and there is often coldness and
perhaps lividity. Such a state of the countenance, with an
expression of pain, uneasiness and anxiety, often leads to the
detection of 8low and insidious pleuritis or peritonitis, as well as
of other diseases which would long remain hidden, from being
nnattendod with acute pain.' This ' look of pain ' is quite

characteristic, and shonld alway8 pat tlie practitioner on hh
g^ard against occult mischief. It is seen in osseous pain,
ani^tliysm, visceral disease, and is nsuallj accompanied by pallor
or sallowness. Deep-seated pain in the spine, when accompanied
b/this peculiar but almost indescribable pain, shonld suggest
the suspicion of aneurysm, or inter-vertebral cancer. There is
aiso a ' bowed down ' expression of suffering on the face in ex-
treme cases of chronic headache : especially in markedly bilious
persons. These facial expressions are often noticeable when
inspecting the tongue.

THE TONGUE. — Much may be leamed from accurate observa-
tion of the tongue ; how much, a f ew old practitioners almost alone
can teli. In the treatment of phthisis, inspection, minute and
scrutinising, of the tongue is far more important than the wielding
of the stethoscope, however 8kilfully. The one tells much of the
amount and nature of the disease, the latter gives information,
often priceless, as to the precise line of treatment to be adopted ;
for the tongue is the index of the state of the intestinal canal,
and if the pnmce vkB are disordered, they must be put right
before any other therapeutic measure can be 8afely adopted.

Teli the patient to put out his tongue fully, so that the cir-
cumvallate papillse can be clearly seen ; it is no use to study the
tip. If the patient is an infant, Sir William Jenner's plan of
placing a drop of fluid, especially if viscid as syrup, upon the chin,
is well worth following. A tickling sensation is produced, and
the little patient tries to remove the cause of irritation with its
tongue. The condition of the tongue can thus be studied without
much disturbance to the child. The manner of protrusion is in*
structive. ■ In the typhoid condition of fevers, and in some cere-
bral affections, the reguest to put out the tongue has to be
repeated, and loudly, before the patient does as is requested :
and similar reiteration is requisite to induce its withdrawal. 'It
is a curious f act that patients will f requently protrude the tongue
when they cannot be made to do aught else, owing to the state
of their mental faculties ' (Flint). Then tremulousness of the
tongue indicates alcoholism : and less frequently lead or mercu-
rial poisoning. Tremulousness of the tongue may denote mus«

enTar weakne88. When seen in the earlj stages of typba8, oi
typhoid fever, it indicates a grave condition of bad prognostio
omen. In advanced stages the tongue is protruded 8lowly and
with difficulty, indicating impaired power over the muscles. In
hemiplegia the tongue when protruded tums its apez to the
paraljsed side, from diminution of power in the genio-hjoglossus
mnscle of the affected side. In bulbar, otherwi8e glosso-hbbial
paraljsis, the capacitj to protmde the tongue is impaired or lost
In f acial paraljsis, without hemiplegia, this loss of power to pro-
trude the tongue tells that the mischief is central, and within
the skuU ; and not peripheral, or Bell'8 palsj.

Dryness of the tongue is f ound in pyrexia, whether the fever
be specific or 8ymptomatic. It is also dry in diabetes, and other
conditions of polyuria, and in some of the functional disorders
of digestion. It becomes dry and hard, as well as brown, from
the accumulation of dead epithelium cells upon it in the typhoid
condition and in uraemia. When the mouth is kept open it
becomes dried, as is seen in some forms of dyspn(£a. Then it is
edentated ; and marked by the teeth in conditions of debility,
from menorrhagia, chronic diarrhoea, or acute prostration, how-
ever induced. Then as to the state of the tongue known as
<coated' or 'furred.' This is constant with some individuals
who are well and strong ; and a f urred tongue, especially in the
morning, is common with heavy smokers. £ut usually a furred
tongue denotes disturbance of the digestive organs, or the
oncome of acute disease, especially the specific fevers. When
found with shivering fits, this condition of the tongue tells of
coming trouble. When the coating has a distinctly yellow or
brownish hue, there is usually a bad taste in the mouth in the
morning when awakening ; the taste and the colour are both
due to tauro-cholic acid. This is denied by some authorities,
who say there is no connection betwixt the state of the tongue
and the condition of the liver ; but the great bulk of medical
experience is dead against them. The f ur on the tongue consists
mainly of dead epithelium cells, mucus, partides of food, and
dust inhaled by the breath. As the rude index of the condition
of the gastro-iutestinal canal, the state of ibe tongue fornisbes

raloable information. Where the coat isthick, it Is evfdent that
absorption of food from the intestines must be very imperfect,
through the layer of dead epithelial cells ; and our efforts are
directed to remove this obstructive layer. Cofisequently we
inspect the tongue in acute disease, and in convalescence in order
to ascertain, with such an approach to accuracj as the tongue
oan teli us, whether the state of the intestinal canal is such as
vili pennit of the assimilation of the injesta. When the tongue
cleans, then we know assimilation is going on 8atisfactorily.'
"^Vhen the tongue remains coated, we aid the natural efforts to
remove the fur bj a mercurial laxative. Bepeated free purga-
tion without a mercurial often leaves the tongue as thicklj
coated as before ; and a f ew grains of calomel produces a clean
tongue in a few hours. At pther times a dose of calomel may get
the credit of cleaning the tongue, when it is due to a natural pro-
cess. I remember well the čase of a boy who had been threatened
vith enteritis. He was progressing nicely, but the tongue did
not clean ; I spoke of giving him a powder, but counter-ordered
it. ' Next day he had two free semi-fluid motions, and the
tongue was quite clean. Had the powder, which would have
consisted of three grains of calomel, been given, it would un-
questionably have got the credit of producing the change. This
ivas years ago, in the early days of general practice, but the lesson
has never been forgotten. It is always well to see the tongue
clean ; and in private practice more attention is, and has to be,
paid to the state of the tongue than is given to it in hospital
practice usually. In acute disease the mucous membrane
commonly is unequal to shedding its dead epithelium, and when
the shedding occurs it is a good omen of returning vigour. In
protracted illness the fur may be shed and reproduced again
several times. After acute disease, and especially fevers, the
fur may disappear bit by bit, commencing at the tip, and creep-
ing along the edges : leaving a thick coat up the mesial line and
npon the base, which in time also disappears. Such clearing up
of the tongue is of the best prognostic omen, and tells of unin-
terrupted convalescence. In scarlet fever the tongue often
assumes a * strawberry ' appearance ; sometimes the red papiUa

stand ottt on a red snrface like a ripe red 8trawberry, at other
tinies the red papillae stand out upon a coat of fur, like the seeds
on an unripe white strawberry. A furred tongue is manifested
in many cases of dyspepsia, especially when many * by-product8 '
o| digestion are formed in the digestive act. Both in indigestion
and artificial digestion there are by-products formed as well as
peptones, and these * by-products * are offensive and objection-
able. In some cases of acid heartbum the chief offending agent
is butyric acid. In almost every cas6 of indigestion with a
furred tongue constipation is present, and must be considered in
the therapeutic plan. Here nothing but a continuous course of
laxatives, and occasionally acute purgation at intervals, will be
of any serviee ; and the treatment must be continued, no matter
how long, until the system rights itself. In some cases the
patience of doctor and patient becomes severely tried, but per-
severance brings with it at last its reward. Ali mechanical
means of cleaning the tongue, as seraping it, or rubbing it with
lemon-juice or vinegar, are well enough for the local sense of
cleanliness and comfort, especially in pyretic states ; but they
are utter rubbish and nonsense as to cure, which depends upon
other measures altogether.

Then the tongue may be furred along one side only, or may
be raw and irritated, or even ulcerated, by a decayed tooth with
a jagged edge. At other times the epitheliimi of the tongue is
stained, as by drinking elder wine, sucking a piece of liquorice,
or chewing tobacco ; or it may be discoloured by some prepara-
tion of iron. These modifications of its appearance are the more
distracting and puzzling when the tongue is coated with fur
pretty thickly,

The *raw' or 'bare' tongue. This condition of the tongue
has not, in my experience, received from medical writ€r8 a
tithe of the attention it deserves to have paid to it. Here the
superficial structures of the tongue are denuded, more or less
C )mpletely, of the natural epithelium. In convalescence from
anute conditions, where the tongue has been coated, sometimes
the tongue is abnormally red and imperfectly covered with
epithelium, and here a coat is apt to form again (FUnt).

Both in acnte or chronic conditions, the absence of the normal
epithelial covering, whether slight or considerable, should re-
ceive the keenest attention of the practitioner. As long as
the tongue is * raw * or * bare,' the line of treatment to be followed
is that of bland food, with sedati ves to the gastro-intestinal
tract, as bismuth, with alkalies, or opium, or both. So long as
this condition remains, tonics are nseless, and are not digested.
At the risk of being charged with dogmatism, I venture to
insist upon this. Perhaps it is in phthisis, of ali diseases, where
this rawness of the tongue excites one's apprehensions ; at least,
it is of ali semeia the one I personallj dislike most. It is not
asually complete over the whole tongue, but lies as a large patch
in the middle of the tongue, the irregular edge U8ually extending
f urther on one side of the mesial line than on the other. We
have eveiy reason for supposing that this condition of tongue is
significant of the state of the unseen portion of the gastro-
intestinal canal ; and the absence of epithelium interferes with
assimilation. This it is which excites one's apprehension in ali
wasting diseases. 'After a meal the epithelium cells of the
villus are found crowded with fat. Since the striation of the
hyaline border of the cells is not due to pores, as was once
thought, the particles must have entered into the cells very much
as foreign particles enter the body of an amoeba. The epithelium
may, in fact, be said to eat the fat ' (Michael Poster)*. If, then, the
epithelial layer be defective from absence of epithelium, or from
the epithelial cells being imperfectly developed, and therefore
f unctionally defective, fat cannot be properly absorbed ; and
that absorption of fat is of ali things what we especially desire
in wasting disease. Not only is the epithelial layer important
in the absorption of nutritive material from the food in the
intestines, but it is essential to secretion. ' The food, in passing
along the alimentary canal, is subjected to the action of certain
juices which are the products of the secretory activity of the
epithelium cells of the alimentary mucous membrane itself, or of
the glands which belong to it. These juices {viz., šaliva, gastric
juice, bile, pancreatic juice, succus entericus, and the secretion
of the large intestine), poured upon and mingling*with the food,

prodnce in it such changes, tbat from being largelj insoluble it
becomes largely eoluble in an alkaline fluid such as blood, or
otherwise modify it in such a way that the larger portion of
what is eaten passes into the blood, either directly by means of
the capillaries of the alimentary canal, or indirectly by means of
the lacteal system, while the smaller part is discharged as ex-
crement * (Foster). Nbw, if * the epithelium cells of the alimen-
tary canal play this important part in the digestive act, it is
quite obvious and abundantly clear that deficiency.in number
or perfection of these epithelium cells must exercise a deep and
profound influence upon digestion, absorption, and nutrition.
That aH the practitioner's energies should be bent towards the
restoration of the epithelial layer to normal perfection, or the
best approach thereto, is intelligible enough ; and the attention
paid to the primcB vicB by our predecessors was amply justified
by its importance. It is, too, comparatively easy to get rid of
' the layer of dead epithelium cells of the coated tongue ; but it
often taxes ali our resources to restore the epithelial coat to its
integrity where the tongue is * raw * or * bare.' Yes, and sadly,
too often, our best efforts are futile and unproductive of good
result ! When the * bare * tongue is the index of a deficient
epithelial layer in the alimentary canal — and no other index do
we possess — the first duty of the practitioner is to do his utmost
to restore it to the normal condition. How this is to be achieved
will be considered in another brochure (*Aids to Bational
Therapeutics'). When, then, under appropriate treatment the
tongue assumes its normal appearance, and the epithelium once
more grows freely upon it, then we know the digestive powera
are returning, and that we may venture on tonics, and more
food of a less restricted character. A 8hrewd practitioner,
young or old, will always study the condition of the epithelial
layer of the tongue carefully, sagaciously, with a full knowledge
of what is revealed by the condition of that part only of the
&limentary canal which is open to our vision. So long as the
condition of * raw ' or * bare * tongue continues, so long must our
therapeutic measures be directed to the restoration of the
epithelial layer.of the alimentary canal to its integrity— or the

nearest attsdnable approach thereto. Then the tongne may
present a * beefsteak ' appearance when it is denuded of epithe-
lium, as it is apt to do When the brown f ur of the typhoid, or
uraemic condition has been shed. The 8ystem is equal to shed-
ding the dead epithelium, but it is not quite equal to the
production of a new layer of perfect epithelium.

The epithelial lajer of the tongue is often suggestive of other
conditions than those of the alimeutary canal. There is a pecu-
liar silverj sheen of the epithelial covering of the tongue in many
cases of menorrhagia ; especially when the tongue looks swollen
and shows the indentation of the teeth. I ha ve nothing to 8ay
as to the * how ' of this association; but it is certainly 8ufficiently
common to give this condition of the tongue a distinct diagnostic
value.

In relapsing fever there is often a small triangle on the tip
of the tongue, much cleaner, or ' rawer/ than the rest of it!
Each side of this equilateral triangle is about balf an inch in
length. I have seen it both here and in Germany.

Then the surface of the tongue may be altered. The mucous
membrane may be ulcerated, as in stomatitis. Glossitis it is not
iny province to describe. Or it may be fissured. Deep rugous
fissures are very suggestive of 83rphilis. So is a large bare patch
'with or without fissures, without acute disturbance of the health ;
while patches of syphilitic psoriasis where the affected epithe-
lial scales are shed and a bare patch is left, are not at ali uncom-
mon. The tongue may be the seat of a chancre, which must be
discriminated from cancer : this is done by the history, the age,
and the conditions of the glands of the neck. When inspecting
the tongue, other evidences of 8yphiliR may be fumished by the
State of the pharynx, or soft palate. Then the tongue may be
indented by the teeth. ' Indentations on the margins may be
produced by the pressure of the teeth. These occur if the organ
be 8wollen ; otherwise they 8imply show that it has remained in
contact with the teeth for a cousiderable tirne. In health, during
wakeful hours, it is frequently moved, not remaining, except
inomentarily, in the same plače. . The indentations due to dimin-
isbed movements denote mental hebetude. The tungue occa-

sionallj presents fissures or cracks m the course of fevers, and
these sometimes continue into convalescence. Gicatrices are
observed in persons subject to epilepsy, as the result of wounds
inflicted by the teeth during the paroxysms. These may be
useful in determining that paroxysms which a patient has expe*
rienced were epileptic in character. Coldness of the tongue
beloiigs to the moribund condition, without reference to the
disease, and it is a striking symptom in the algide stages of epi-
demic cholera ' (Flint).

A tongue fissured not deeply, but with many little fissnres
o ver its surface, I have very commonly noted in persons who
drink their tea very hot ; but it is not invariably, though com«
monly, so associated.

When looking at the tongue, the eye may note several other
conditions. It may detect that the teeth are artificial, or that
while the front teeth look well and are sound, the molar teeth
are extensively decayed: the latter fact is instructive where
dyBpepsia is complained of. Then there are some more special
matters to be alluded to, in relation with the mouth.

THE BOOF OF THE HOTTIH.— This may be highly arched,
as in idiots or iihbeciles. Or it may be largely wantiug, as the
result of congenital defect, or of acquked syphilis.

THE TONSILS.— These may be enlarged, or they may be
ulcerated. In acute disease there may be quinsy, or the fihn of
diphtheria or of scarlatina. Ulceration usually denotes syphili8,
especially when there is another ulcer in the sof t palate.

THE TTVULA. — This may be lohg, so as to tickle the epiglottis,
and give rise to a persisting intractable cough. Or it may be
removed by 8yphilitic ulceration.

THE FAUCES. — Here, again, we are apt to find 8yphilitio
ulceration.

THE FHAItY17X.->This may be raw and irritated, as in
ordinary sore throat or * hospital ' sore throat. Or the condition
may be more permanent, as clergyman'8 sore throat. Or the
pharynx may be the seat of troublesome chronic follicular ulcera-
tion. It is very apt to be affected by 8yphilis, not only in the
early stage of secondaries with the associated rash ; but a grey

elonghj ulceration is often found in the pharyiix in more con-
firmed syphilis, or a punched-out looking hole. Ulceration of
the soft palate along with it is not uncommon in sjphilis.

So much, then, for what is seen when the oval orifice is opened,
and its contents exposed to view. Of local disease, as cancer, it
is not the plače here to attempt a description. Aphthse are
often seen in infants, .denoting great debility.

FAEASITES. — It is not common to find parasites on the skin,
but sometimes they are present and indicate poverty, careless-
ness; squalor, or an impaired constitution. In the latter čase
we find phtheiriasis very intractable, and tbis intractable
character points to great constitutional debility, f rom which the
patient is not likely to rally or recover i£ old, or the suBject of
serious organic diseaso.

SMELL. — ^The senae of smeli possessed by some men is very
acute, and is sufficiently developed in most men to give it a cer*
tain diagUostic value. In the exanthemata a certain animal
odour often amounting to a positive stench is emitted. Certain
lunatics, and markedly general paralytics, possess a very disagree-
able odour — so strong, often, as to have a diagnostic value. Iq
pyaemia the breath carries with it a charactenstic smeli, described
as that of hay or of earth. In f oetid bronchitis, in gangrene of
the lung, and in ozsena, the breath is very olfensive. In stoma*
titis, the breath is unpleasant. Then in favus there is a mouse«
like smelL There is an offensive breath with many persons
wben the bowels are neglected, and in indigestion. Many
persons, especially men in middle age, have a disagreeable breath.
A friend with a very acute noše informs me that he has observed
this offensive breath to correspond to perioda of overwork or
worry ; being most proiiounced then.

Sueb, then, are the indications revealed to the senses by the
appearance, and sometimes by the odour of a patient. These
indications are of cardinal viJue in giving direction to the ques«

tions and to the phjsical exaTnination. Of how much value
they are, only experienced practitioners can teli.

THE PULSB.— The next proceeding is to feel the patient*8
pulse. Take čare alway8 to feel both the radial arteries ; and
not one, as is usual. Fut the patient in a good light, and feel the
arteries steadily for a minute ; v/hile the eye is making its obser*
vations, the finger is fumisbing valuabje Information. The
character of the pulse is the first thing to be observed. Whether
it is full and incompressible, or feeble and obliterated by the
pressure of the finger. When the arteries are Tuli of blood the
artery is not to be obliterated by moderate pressure during the
diastole, that is, in the interval betwixt the beats. A full pulse
then means high blood-pressure in the arteries, ie., the arteries
are full. When, on the other hand, the pulse is feeble, then
there is a comparatively empty artery, and the blood is mainlj
in the veins. A full pulse is a slow pulse ; broadly. speaking. A
slack pulse is usually a fast pulse. The rapidity of the heart*
stroke is regulated by the condition of the arterioles. The
arterioles are almost entirely muscular as regards their walls,
and their calibre is regulated by the vaso-motor nerves. When
the arterioles are dilated, the blood runs freely out of the arteries,
and therefore the artery is slack and compressible, and the heart
beats rapidly. Such is the condition of the vascKlar system in
fevers. In sthenio inflammations, ».e., in inflammatory conditions
in robust persons, the pulse is full, rapid, and bounding. Especially
is this the čase in acute thoracic inflammations, as pleuri8y and
pneumonia. In the latter disease, however, if both lungs become
extensively implicated, the pulse will become small, weak, and
often irregular, because the blood cannot pass freely through the
lungs. When the pulse fails in pneumonia, and at the same
time the heart is found beating violently, it indicates commene«
ing failure in the right ventricle. A bounding, full pulse is the
characteristic of acute inflammation of the thoracic viscera, and
of the meninges of the brain. But in abdominal inflammation
the artery is contracted, feels like a pulsating wire, and is incom«
pressible. Why there should be this marked difference is not
very clear ; but it exist8. In peritonitis, in inflamrnation affect«

ing the tirnica vaginalis, there is this contracted, incompressible
artery. It is of the utmost importance to be able to correctlj
estimate the pulse. Dr. Thorowgood has described the pulse in
the different forms of heart-disease, therefore it is not necessary
for me to go over the same ground. It is enough to say that
carefnl examination of the pulse will of ten teli the form of heart-
disease under which the patient suffers. The 'splashing,'
' collapsing ' pulse of aortic regurgitation is quite characteri&tic.
Irregularity of the hearfs action is found in conditions of car-
diac dilatation and in mitral disease, and especially when the
two are combined. Intermittency in the pulse is of three kinds.
1. A simple halt or pause in the regular beat ; often a mere
nervous trick, and nothing more, especially in young persons.
Ilf is, however, often found with evidences of degenerative
changes in persons advanced in years. Its significance depends
upon its surroundings. 2. A halt, preceded by a f ew rapid feeble
strokes, aggravated by effort. Here there is a dilated heart,
with or without mitral disease. It is very significant ; and it is
Yery important to distinguish this form from the preceding one.
Much misery has been caused unneces8arily by attributing to
the first form the significance which attaches to the second form.
3. This is where the contraction of the left ventricle is so feeble
that the impulse of the blood wave driven into the aorta fails to
reach the radial artery. The intermission may be isolated or in
clusters ; but if the ear be placed over the heart, its action will
be found to be comparatively regular, and rhythmic. Some-
times not half the ventricular contractions reach the radial
artery. In cases of pulmonary embarrassment, the pulse may be
irregular and intermittent as a consequenc6 of partial failure in
the right heart. The amount of blood passing through the
pulmonary circulation is insufficient to fumish a fair blood wave
into the aorta on the contraction of the left ventricle. The left
ventricle can only pass onward what blood comes to it, and no
more. This form of intermittency is best seen when a patient ia
sinking from some disease of the respiratory organs. While tho
pulse flutters and intermits, and the flame of lif e is flickering out|
the heart, and especially the right ventricle, will be heard labour-

ing away at its ineffectual task. Disparitj b8twixt the volmne
of the pulse and the energy of the cardiac contractions indicates
enlargement of the right ventricle; except in cases of aortio
stenosis.

It has been said before that both radial pulses should invari-
ably be felt. Sometimes there is an abnormal distribution of
the radial artery, and it courses over the dorsal surface of the
hand to the phalanges of the index finger ; if it were made a
regular practice to feel both pulses this could not, as it some-
times does, lead to confusion.

Then comes the question of rapidity of the pulse. Your
phjsiological teacher will have told you about the relations of
the vagus nerve to the heart. I am not here going to describe
that nerve in its entirety ; it is enough for the present purpose
to 8ay that it contains various nerve-fibrils, some of which
accelerate the heart's action, while others 8low it. These are
called respectively the * accelerator/ and the ' inhibitory * fibres
of the vagus. When the blood-supply to the roots of the vagus
nerve in the medulla oblongata is insufficient, the * accelerator '
fibres are thrown into action, and the heart beats rapidly, so as
to pump more blood f rom the veins into the arteries. When, on
the other hand, the roots are flooded with blood from well-filled
arteries, then the * inhibitory ' fibres are thrown into action, and
the heart's action held back. By this 8lowing of the heart's
action, the blood has tirne to escape out of the arteries through
the contracted arterioles, before the next ventricleful of blood
is thrown into the arteries. If it were not for this last arrange-
ment, rupture of arteries, especially tho cerebral arteries, would
be much more common. There are other interesting mattera
connected with the fibres of the vagus, which may be added in
future editions ; it is here essential to my purpose to 8how how
the ' f ast ' and the * slow ' pulse are brought about. It is very
important that this broad division be clearly comprehended in
daily practice ; as it not only helps to clear up the diagnosis, but
gives direction to the therapeutic measures. The slow, incom-
pressible, usually strong pulse indicates a totally different con-
dition from the fast, small, compressible pulse. The latter ma/

Indicate debility or eshaustion, or may be 8tr!ctly nervons.
When a patient is first seen, the pulse is apt to be very much
ftccelerated, especially if the patient be nervous or excited. It
is well then to feel the p^lse at the end of the examination as
well as at the commencement ; the information fumished by the
second examination of the pulse will often correct any erroneous
impre&fiion produced by the first feeling of the pulse. In many
diseases the pulse mounts as death approaches ; and when in
severe disease the pulse becomes irregular as well as fast, the
condition is fraught with imminent danger. It may become
snerely a ' webbling thread/ indeed ; or at other times it is a
' fluttering ' rather than a rhythmic beat. In conditions of great
debility, especially when brought on by haemorrhage, the pulse
may become weak and irregular or intermittent, without much
real danger. The examination of the pulse ought, then, to indi-
cate careful investigation as to the associated general condition,
and will often put the practitioner on his guard in insidious
States. A persistingly rapid pulse over 100 per minute is
regarded by many practitioners as a certain prodromic indica-
tion of commencing phthisis. It certainly is a semeion of evil
omen, especially when found with actual lung mischief.

One thing there is about the rapidity of the pulse which ought
to be brought more conspicuously before the študent than is
done at present, and that is, the jn^oportion betwixt the rate oj
ihe puhe and tJte respircUion* Normally the proportion is as 4
to 1. If we regard normal respiration as 18 per minute, we get
a pulse rate of 72 per minute. This is the proportion in health«
In febiile and inflammatory diseases both mount, and we may
have the respirations 30 per minute and tho pulse at 120. Hera
the disturbances are such as to affect the re pliation and the cir-
culation alike. But when the proportion is disturbed it is most
signiiicant. If the pulse be rapid while the respiration is calm,
it is well to examine the heart, to see if there be any dilatation
ftbout it. Dilatation and debility in the heart will send up the
pulse, without the respiration being necessarily affected. On the
other hand, where there is thoracic embarrassment, the ratio of
the .espirations mounts up out of normal proportion to the pulse

■t

rate. This disturbance of the proportion will not teli wliat b
the nature of the disturbing agent, of course ; but it teUa in dia«
tinčt language that some abnormal factor is at work. The cansa
may be emphjsema, with or without some bronchitis ; or a largo
portion of one or both lungs may be Consolidated either in
pneumonia or piilmonary phthisis ; or there may be progressing
congestion in acute disease. The študent in the hospitsd waid
is £Jways taught carefully to examine the patienfs posteiior
thoracic regtbns when congestion is suspected ; but this is not
always convenient in ordinary practice. A private patient has
his or her own opinion and feeling, which must be consulted,
and cannot saf ely be ignored, by the practitioner : and an ex-
amination of the back is disagreeable, troublesome, and often
repugnant to the feelings, and should not be done without good
and valid reason theref ore. To examine the back daily to see if
there be hypo8tatic congestion is unnecessary in many cases, and
distresses or annoys the patient ; it should therefore only be done
when there is good reason f or it. If the practitioner were accus-
tomed to take the rate of the respiration as systematically as
that of the pulse, which certainly ought to be the čase, a disturb-
ance in the proportion would at once strike him, and put him on
his guard. When the respirations commence to mount without
a corresponding rise in the pulse-rate, then the lungs should he
carefully examined to ascertain the canse of the disproportion.
So long as the normal proportion is maintained, the mind may
be pretty easy as to lung-congestion. The correct tiniing of the
respiration and the circulation is a most importaSit matter, in
thoracic disease especially, which will have more attention paid
to it in the future than has been accorded to it in the past.

Then there are nervous conditions when both pulse and re-
spiration mount up ; even the tepiperature may go up too. Austin
Flint talks of * being fooled by temperature ; * and when the
subject of temperature is discussed, the nervous element will bo
considered more fully.

In pyrexia both pulse and respiration are accelerated, as woU
as the temperature raised ; and a fall in any of the three is of
good omen, aa improvement in the other two follows. The usa

of the watch is now not nearly so great as it ongbt to be. Other
and more recent instrumenta of precision have taken precedence
of the watch ; but the day of the use of the watch will come
again : only it will in the f uture be used with more precision tban
it has hitherto been.

Then the pulse may be abnormally sIow, either as mere idio«
syncracy, or in cerebral mischief, or in fatty degeneration of the
heart.

Then, again, the character of the wall of the artei7 is worth
noting. Atheroma is a growth of connective tissue in the
arterial wall ; either found in patches, and e8pecially on points
of flexion, as the knee and axilla, or at the outer curve of the
aortic arch ; or a more general distribution, where the arteries
feel more like tendons than normal blood-vessels. This condi«
tion is U8uaUy, if not always, due to sustained high arterial
tension. In tirne the artery feels to the touch elongated as well
as broadened at each beat. This atheromatous change proceedt
in two directions. (1) Towards fatty degeneration, and (2) cal-
careous change. The first is most common in the atheromatous
patch, where the neoplasm softens and is washed away piece-
meal in the blood-current, leaving an ulcer which is apt to
become an aneurysm. The latter change is more general, and in
very marked cases the arteries feel as rigid as pipe stems. The
atheromatous artery is a very important matter, f rom its associa-
tions with an hypertrophical left ventricle, contracted kidney8,
and a waste-laden condition of the blood. Even when the left
ventricle begins to fail, the atheromatous artery gives the im-
pression of a good pulse — it exaggerates the pulse-wave so as
often to be very deceptive. The condition present may be
one of temporary asthenia, and yet an atheromatous radial
artery may oreate the impression that lowering measures are
indicated.

It has been said before that it should be the rule to feel both
radial arteries 8imultaneously. By so doing, many an aneurysm
of the aortic arch would be detected which escapes observation.

After pyrexia, inflammatory or other, a fall in the pulse-rate
marks the defervescenceof the malady. In feeling the pulse, it is

well to let the ring and little finger tips trail over the palm ; wbeii
thid is wet and cold it indicates exhau8tion, not unfrequently
associated with disturbance in the reproductive organs. In
hectic fever the hand is often buming. In wasting disease the
hand f eels listless and limp. In hospital practice thd soft pahn
and fingers teli, in a man, of indolence, and indicate very com-
monly a gaol-bird. The hand will often teli much as to the
mental attitude, the amount of will, or the want of it in the
patient ; and when presented in order that the pulse may be
felt, it is well to feel the hand first, as a preliminary to feeling
the pulse.

THE BESFIBATZON.— The importance of comparing the rato
of the respiration and the pulse has just been insisted upon
above. Then the character of the respiration is important.
Ihtrc is the rapid shallow breathing of nervousness, of phthisis,
and of emphjsema, When the lung-space is infringed upon by
a morbid growth within the thorax, by congestion of blood in
mitral disease, by consolidation, pneumonic or other, the breath*
ing is rapid. Then, too, it may be laboured, as seen by the
accessory muscles of respiration being brought into play ; this
last is well seen in cases of emphy&ema, with chronic bronchitis
and enlargement of the right heart. The blue hue of venous
congestion on the lips, taken along with exalted respiration, will
often make a physical examination a mere matter of form, cor*
roborating the diagnosis. In the present prominence of physical
examination, the other means of ascertaining the condition of
the thorax are apt to be put aside too much. When the breatb"*
ing is accelerated without rise in pulse-rate, or temperature,
then disseminated mischief in the lung is suggested, as interstitial
pneumonia, or miliary tubercle. Dyspnoea is paroxycmal in asthma
of whatever form. There is true genuine asthma, due to spasm
of the bronchial muscular fibres, coming on at intervals, tho
palnent being quite well betwixt the attacks. Then there is
dyspn(Ba produced by exertion, 8howing that the lung space is
infringed upon either by solid growth or vascular fulness, as in
mitral disease ; this is usually found along with dilatation of
the right ventricle. Or it may be due to general emphysema of

the lung, or pleuritic effasion, op empjema. Wheii the Kning
membrane of the bronchise is swollen, and the lumen of the
tubes thus diminished, dyspnoea on effort results. While the
patient is quiet, the breathing is unperturbed in many cases of
extensive mischief ; but the disturbance caused by slight effort
tells that the thoracic space is.infringed upon. This being ascer-
tained, it next becomes necessary to find the exact nature of the
disturbing cause. Then in children there is the embarrassing
respiration of croup, and the same in laryngeal disease in adults.
There is the peculiar, loud, noisy inspiration of hooping-cough ;
and the crowing sound of laryngismus stridula. When the
respiration has often been interfered with, the shoulders are
apt to be thrown forward ; this is well seen in persi^ns who
•uffer from, and have long suffered from, attacks of genuine
asthma.

THE COUGH.— A patient often coughs, and the form of
cough is often significant. There is a little *hemming' cough,
often the precursor of phthisis : very frequently a nervous trick,
which, however, alarms the mother of the patient, who is usually
a girl. Then there is the loud brazen cough, also a neurosis,
which is closely simulated by the cough of aneurysm, especially
when the recurrent laryngeal nerve is pressed upon. Then there
is the dry cough of pleurisy and of pulmonary congestion,
common with mitral* disease. There is the reflex cough, the
*cradle-cough* of pregnancy. There are also a *liver cough,*
from interference with the diaphragm ; and an ' ear cough,' from
irritation in the ear acting through the chorda tympanum. Then
there is the paroxysm of coughing common in phthisis, which
inay be relieved by the expectoration of softened tubercle ; or it
inay be set up by a mass not yet softened, where it is exhausting
as well as futile. Then there is the ordinary cough, f ollowed by
expectoration, in bronchitis ; and very commonly, especially in
winter, the cough on getting out of bed in a moming, when the
mucous which has accumulated in the air-tubes during th&
night is expectorated. There is also a cough in getting into
bed at night, from the general cutaneous surface being chilled
by oontact with the cold bedclothes. Here the cooled Uuod

reaching tbe lungs sets up a cough, or a series of conghs. la
chUdren, especially of the struiuous diathesis, there is often a
dry, frequent cough which goes on in sleep.

THE £XP£CTOBATION.— It is of much moment to closelj
observe the character of the sputum expectorated in cases of
thoracic disease. In pneumonia the expectoration is rusty in
hue, and is so viscid that a quantity adheres to the bottom of
the vessel when inverted. Later on the sputum is of grey hue.
In bastard pneumonia the expectoration resembles prune-juice.
In carcinoma of the lung the sputum resembles currant jelly.
In bronchitis, at an early stage, the expectoration is marked by
streaks or spots of blood ; when the phlegm becomes looser, that
is, the Kcretion more abundant, then the sputum is white and
frothy ; afterwards it becomes rather like starch. At times pus
cells are present, and the secretion is muco-purulent. At other
times the sputum is flattened and round, resembling a piece of
money; here it is called *nummular/ and is often found in
phthisis. In oedema of the lungs, and in bronchorrliGea, the
secretion contains serum, and is a thin watery fluid. It maj
co-exist with mitral obstruction. Fibrinous casts of the bronchi,
or bronchia, are expectorated sometimes, as well as croupous
casts of the larynx and trachea. At other times calcareous
concretions are expectorated. These are generally supposed to
be the earthy salts of what were once tul)erculous masses ; cer-
tainly they are most commonly found in phthisical subjects.
They should not be confounded with the masses which some-
times form in the f ollicles of the tonsils ; these latter are masses
of pus>cells which are unctuous to the touch and emit an offen-
sive odour. In smoky towns and in dusty weather the sputum
becomes dark>coloured from the presence of minute particles of
carbon ; and after a thick fog the sputum may be inky-black.
As to the presence of hydatid hooks, cancer cells, pieces of lung-
tissue, or epithelial cells, as seen under the microscope, their
description is not within the scope of this work.

RSHOPTYSIS. — ^This is much more alarming than any other
form of expectoration, as it is generally supposed to indicate
pulmonary phthisis. This opinion is shared by the profession at

large, and by the public; nor is it wise or prudent to nnder-
estimate the gravity of hsmoptjsis. It should always cause
careful examination of the čase. It is in woinen a form of
vicarious menstruation verjr coinmonly. Then it may be due
to pulmonary congestion, the result of effort. As associated
with actual mischief in the lung, it is very necessary for the
študent to ha ve clear views about it. 'Before pu1monary
cavities have formed the hsemorrhage is from the bronchial
lining membrane * ( Austin Flint). In the early stages of lung-
oonsolidation h8emoptysis is rarely fatal. It may occur in small
or large amounts, and is often a useful form of local bleeding,
giving relief to ali the symptoms. As such it may recur in the
same patient. When cavities are formed, then the prognosis is
prof oundly altered. When a tubercnlar mass softens, the blood-
vessels usually wither up to a dry cord (Rokitanski) ; at times
this is not the čase, and the coat of a blood-vessel is cut through
by ulceration, and serious hsmorrhage follows. Or a cavity ia
formed, and a blood-vessel bordering on the cavity bulges in an
aneurysmal manner into the cavity. The aneury8mal pouch is
ruptured in the act of coughing, and dangerous heemorrhage
followsk These two latter forms of h8emopty8is plače the
patienfs life in imminent peril, and do not frequently recnr.
The iirst form is much more common, is usually less in quantity,
and often recurs, and is of less seriousness. But the študent,
when at the examination table, should have his mind fixed little
on this less grave form, but 8teadily fixed on the graver forms.
He should never under-estimate the gravity of h8emoptysis,
especially before an examiner. H8emoptysis may result from an
aneurysm bursting into the bronchi or trachea, as was the čase
with the late famous surgeon, Bobert Liston. After a severe
bleeding, a clot got into the orifice and plugged it ; and fatal
hsemorrhage did not occur till some time later.

When present at the time, it is not difficult to distinguish
betwixt h8emoptysis and haematemesis, but when the explana-
tion of the appearance of the blood has to be gathered from
Btatements, difiiculties arise. In haematemesis the colour of the
blood is U8ually dark or black, while the blood in h8emopty8i8 is

nsuallj bright and frotbj. The one is got np by vomiting, the
other by coughing ; h8emoptysis is usually preceded by evidences
of thoracic mischief . It is well to make sure that the blood does
not come from some lesion in the mouth, or throat, or palate.

At other times blood appears at the anal orifice. When from
the rectum, it is usually bright in colour, and passed without
pain, whether hsemorrhoids be present or not. When from
f urther up the bowels it is dark in colour, and is usually found
along with typhoid f ever, or tubercular ulceration of the bowelB.
It may be associated with dysentery when it is accompanied by
patches of mucous membrane. When proceeding from the
nrethra, it may co-exist with renal mischief, when it is thoroughly
inixed with the urine ; or an enlarged prostate when it followa
af ter the urine ; or stone^^or cancer of the bladder, when it usuallj
precedes the flow of urine.

The stream of urine is forked or twisted in stricture; it
dribbles in enlarged prostate, and is intermittent and liable to
Budden stoppage in stone in the bladder.

THE TTillNE; — ^There are a large number of cases in whioh
it is of primary importance to carefully examine the urine.
The first question to be asked is i^s amount, or bulk. The bulk
of urine, co^eris paribus, is the measure of the blood pressure in
the arteries : when the arteries are f uU the bulk of urine is large^
as in the middle stages of gouty kidneys, where there is hyper-
trophy of the left ventricle and a tense pulse. When the circu-
latiou fails and the veins are full, then the bulk of urine falls, as
seen in the scanty urine of heart failure. It is yery important
for the študent to make himself familiar with the relations of
the bulk of urine to the condition of the irascular system. Some
years ago, Sir William Jenner pointed out in the most lucid and
instructive manner the diagnostic significance of a modification
of the bulk of the luine. In the middle stages of chronio
Brighfs disease the patient passes a large bulk of urine of low
specific gravity ; but when the čase has progressed to the point
of the heart commencing to fail, the bulk of urine falls beIow
the norm and resembles that of advanced heaft failure. As the
power of the heart wanefly the bulk of urine falls below that of

Borm^i faealth ; its, character, too, changes : from being pale,
watery, and of low specific gravity, it becomes deeper in colour,
and of a higher specific gravitj as it decreases in bulk ; from a
pale watery urine it becomes denselj saturated with lithates,
usually pink or red in colour. The question of these alterations
in the urine alongside the well-recognised changes in the vas-
cular sjstem in the course of chronic Brighfs disease, other-
wi8e termed 'the goutj heart,' are well worth serious and
careful attention from the študent, They illustrate well the
light phy8iology can throw on the facts of clinical medicine.
The študent should -ask his teachers, physiological and clinical,
for further elucidation of the subject, which is one that will tum
up in practice constantly from day to day ; and nothing but
careful consideration of the subject will enable the študent, when
he has become a practitioner, to read aright the informatiou
afforded by the bulk of urine.

Norm al changes in the bulk of the urine go on in healthy
individuals, according to the amount of perspiration, and the
amount of fluids swallowed ; the one drains away the fluids of
the body, and leaves the urine small in bulk and of high specifio
gravity : the other fills the blood-vessels and so increases the
bulk of urine. When a large bulk of fluids has been drank,
especially if the skin be not active, then the urine is copious,
wat6ry, and almost free from solids. But in certain cases of
kidney disease these changes are exaggerated, or brought about
without obvious cause ; and the patient will teli one, often with-
out asking, of the great variation in the bulk and character of
the urine passed. If the patient get up at night to void urine,
the Buspicion of kidney disease in an early form ia very strong
indeed. In hysteria, where the arteries are corded and the heart
beats yiolently, the attack passes off with the discharge of an
immense mass of limpid urine. Then there is a diabetes insipidtia
where the flow of urine is large and watery, which is to be dis-
tinguished &om diabetes mellUus, where sugar is present in the
urine.

A small bulk of urine is found in pyretic conditions, thougb
the patient may be drinking large quantities of fluids, and yet

not be perspiring. In beart failure, when the circu|0>tion it
affected — ^when the arteries are slack and the veins are f ull — thi
bulk of urine falls. The decrease of the bulk of urine tells witl:
strict veracity of the failure of the circulation. When the bulli
of urine increases, whether from a turn in the čase, or from the
therapeutic plan adopted, the aspect of the čase brightens. Th€
friends of dropsical patients watch with intense anxiet7 the
variations in the bulk, colour, and character of the urine : so the
študent should be auJhU with this matter of the bulk of urine
f or every reason.

The colour of the urine may only be spoken of broadly, and tbc
same may be said of urinary deposits. Fale urine is usually ol
low specific grayity, and contains comparatively few urine solidi
—it may, however, contain either sugar or albumen. Higb
coloured urine is usually of high specific gravity. The bulk and
the specific gravity of non-saccharine urine are nsually in in-
verse proportion to each other. Then as to urinary deposita
white lithates are usually associated with imperfect assimilation,
and defective action in the liver. Bed or pink deposits usually
indicate defective oxidation, and are more distinctly gouty in
character. Tawny or fawn-coloured lithates lie half •way betwixt
the red and white lithates. Uric acid crystal8 resembling
cayenne grains are f ound in the gouty, and especially where there
is also a strumous diathesis. In decidedly strumous young per-
sons uric acid crystals are commonly f ound ija. the urine. Some-
times they are passed in considerable quantities, constituting ' an
attack of graveL' At other times the urine contains deposits of
phosphates ; about these, however, there is such divergence ol
opinion as yet, that nothing can be said about them here. Pus
xnay be found in the urine as the result of cystitis, or from sup-
puration in the kidney itself . The bladder is very intolenont of
purulent urine. A urine of high specific gravity is best and
longest tolerated, Le. of normskl urine solids. Urine containing
tugar soon teases the bladder.

There are mucous deposits in the urine from spermatorrhoea
true or false, in man ; from vaginal discharjes in the f emale.
Benal casts, and epithelial scales, each often revealing much«

are tu be fonnd nnder the microscope. When nrine fs of high
specific gravity, not being saccharine, it usuallj contains large
cjuantities of urea. The addition of a little nitric acid brings
out crystals of nitrate of urea. Baruria, or azoturia, as this con-
dition bas been termed, is not a common maladj. In the high
specific gravity of the urine in fevers, and especially typhoid or
enteric f ever, the proportion of urea is of ten verj high. A great
deal of stress wa8 laid upon this large amount of urea some years
ago, as it was held to represent the waste /of the nitrogenised
tissues of the body by the fever. The fallacy of assuming this
without calculating for the nitrogenised matters swallowed per
diem by*the fever patient, is now generally recognised.

So much then, broadly, for ordinary urine. It next devolves
npon me to discuss the subject of albuminuria and g]ycosuria ;
and as my views on these two subjects are not those ordinarily
taught, it will be yery necessary for me to be careful : first, as
to giving the študent the correct, or what I honestly believe to
be the correct views on the matter ; and, second, not to get him
into trouble with his examiner8. Advanced views are not always
held by examiners, and a študent may get into trouble from the
possession of knowledge — as well as from the want of it. Just
as the študent was instrw:ted to take the gravest view of
h8emoptysi8 before an examiner, so he should speak of albumi-
nuria and glycosnria with almost bated breath. H8emoptysis
not rarely is followed by instant death ; albuminuria and gly-
cosuria were first observed in persons seriously ill, consequently
they are spoken of as most serious symptoms. So they often are
in practice ; but they should be invariably of grave significance
at an examination table. If the študent is willing to speak dis-
dainfully of the significance of these two conditions of urine in
an examination, he must be prepared for one of two altematives.
Either to demonstrate that he 'thoroughIy knows what he is
talking about, and has studied the subject very carefully ; orthe
more probable alternative, viz., to be referred to his studies for
a little while lon^er — ^to the wounding of his self pride, to the
detriment of his progenitor's purse, and the chagrin and sorrow
of his f emale relatives. So let him understand distinctlj that

he rnnst never tinderrate the significance of either indication. It
is scarcely my province here to teli the študent how to find
sugar or albumen in the urine. But it is much easier to find these
substancesthan to make out their significance when they are found.

The two common tests for albumen are to boil the suspectecP
urine in a test-tube, or to add some nitric acid, allowing it to
trickle slowly down the side of the test-tube into the urine. If
albumen be pr^sent it is coagulated. (Any lengthy description
of the cautions to ^ observed, and the fallacies to whicl:i the
methods are liable, is unnecessary here, as the correct testing of
the urine is one of the things which the študent certainly is
taught very thoroughly. ) Albumen may be present in the urine
as chylous urine, a rare malady ; after a meal Iargely albuminous^
as eggs ; or f rom slight disturbanceš, as dyspepsia or febrile con-
ditions. Setting aside these unimportant exceptions, albumi«
nuria must always be looked upon as a grave symptom of dis*
ea^e ; and when discovered, it becomes an anxious question to
the practitioner : What significance has it ?

* The pathological states in which albumen appears constantl/
or occasionally in the urine may be arranged in the following
groups :

1. Acute and chronic Brighfs disease of the kidney8.

2. Pregnancy and the puerperal state.

8. Febrile and inflammatory diseases. (Zymotic diseases^
Buch as scarlet fever, measles, small-pox, typhoid, cholera, yellow
fever, ague, diphtheria, etc. ; inflammatory diseases, such as
pneumonia, peritonitis, traumatic fever, acute articular rheuma«
tism, etc)

4. Impediments to the circulation of the blood (emphysein%
heart disease, abdominal tumours, cirrhosis, etc.)

5. A hydr8emic or dissolved state of the blood and atony of
the tissues (puipura, 8curvy, pyeemia, hospital gangrene) ; also^
hsematinuria.

6. Satumine intoxication.

7. Neurotic albuminuria (nervous disturbance). When alba«
men is found in urine, the important point to decide is, whether
it indicates the esistence of organic disease of the kidnejs or not.

The qtie8tioii, in any individual čase, must be considered chiefly
iu connection with the three following points jointly, namely :

i. The temporary or persistent duration of the albuminiiria.

ii. The quantity of the albumen, and the recurrence and char-
aoter of a deposit of renal derivatives.

iii. The presence or absence of any disease ontside the kidneya^
which will account f or the albuminuria ' ( William Koberts on
• Urinary and Renal Diseases ').

As to point 1, he refers to the researches of FarkeSj as to *tem*
poraij albuminuria.'

As to point 2, he states : * The greater the quantity of albu«
men, the more likely is the existence of renal disease ; and a
laige quantity of albumen (one half and upwards) is rarely found
except in undoubted acute or chronic Brighfs disease.' Tha
bulk of urine must be allowed for. * Indeed, of ali urines, there
are none more surely indicative of Brighfs disease than a pale,
dilute, abundant urine, which is, at the same time, more or lesa
albuminous. On the otber hand, as a rule, with very few excep-
tions, when the urine is only slightly albuminous, and at the
same tirne dense and high-coloured, Brighfs disease is not
present, and the albuminuria is owing either to pyrexia, or some
impediment in the circulation of the blood.'

On point 3, he says : * When the urine is found permanently
albuminous, and there exists neither pyrexia nor thoracic disease^
or other recognisable condition which can account for the albu-
men, the inference is almost irresistible that there exists »
primaiy organic disease of the kidneys.'

Now I ha ve put before the študent what is said by one of our
Tery best authorities on the subject, a man of much acumen and
of very extensive research. The študent should certainly start
out with the fixed impression that albuminuria is the evidence of
renal mischief, primary or secondary. Until his last examina-
tion is passed, he may not safely swerve from this faith. But
when he becomes a practitioner, he will have to determine for
faimself, as best he can, what the albumen signifies in each indi«
vidual čase. If he make his diagnosis solely from the reaction
o£ urine in» test tube, he may make a profound mistake; causing

much avoidable ini8ery to the patient and his friends in the first
plače, and ultimatelj bringing much discredit upon himself . So
let him be cautious 1

There has as yet come no Daniel to read f or us the significance
of albiuninuria, taken alone. We are as much in the dark as
were the companions of Belshazzar as to the writing on his
palače wall, on this matter of albuminuria, pur et simple.

Let me 8ay that making the que8tion of the presence or
absence of kidney mischief tum on the evidence fumished b7
the test tube, has been abandoned by many thoughtful practi«
tioners. The testimonj of the test-tube is but one factor in
forming the diagnosis. The presence of albuminuria may be
without significance in some cases ; its absence may give no
comfort in other cases. For attend to what William Roberta
says of the urine ; * it may contain only the minutest traces of
albumen, even in confirmed and fatally-tending cases ;' and
further : * But it must be admitted that chronic degenerations of
the kidneys, not distinguishable from some forms of Brighfs
disease, do exist under certain circumstances, without albumin-
uria.' And Professor Grainger Stewart writes, in speaking of
cirrhosis of the kidney, which he says ' is the most hopeless of ali
forms of Brighfs disease in relation to treatment,' the following
significant remarks : * Albumen is rarely present in any con-
siderable quantity, and its presence — fitful in appearance^ and
varying in its amount — is also difficult of explanation.'

Austin Flint says : * The presence of albumen in the urine is
by no means always evidence of renal disease ;' on the other
hand, I can affirm that chronic old-standing kidney disease of
the gravest character may exist without giving rise to albumin-
uria, even though repeated examination has been made of the
most careful character. (* The Heart and its Diseases, with their
Treatment ; including the Gouty Heart,' 2nd ed., p. 456.)

There is one form of albuuiinuria that is fairly accuratel/
significant, and that is the form associated with cardiac failure
and dropsy. When the venous engorgement has proceeded to »
certain length, then albumen makes its appearance in the urine ;
first M a mere trace, then a little more ; disappearing as treat-

ment^relieves the renotis congestion ; after a while 8howing itself
again, and persisting. About the fatal significance of this form
of albuminuria there exists no room for doubt.

In albuminuria without other evidences of disturbance of
health, tbe študent will do well to keep any opinion he may
entertain to himself, and refer the patient to some known
authority on tbe subject. Many a reputation bas been 8orely
shaken by too confident reliance on the prognosis formed from
the evidence f umished by^ a test tube.

OLTCOSURIA. — The appearance of sugar in the urine is
iisually regarded as the herald of disaster ; and sadly too fre-
quently it is such. As to its detectionj it is simple. Put some
Febling's solution into a test-tube — about an inch is enough — or
dissolve one of Fayy's cupric capsules ; boil it, then add a drop
of ' the suspected urine ; boil again — ^the orange-red oxide of
copper falls to the bottom of the test-tube. Or put a piece of
German yeast, the size of a pea, into a test-tube, then fill the
tube with the urine, plače a saucer on the tube, tum the whole
iipside down swiftly ; leaving the tube erect, bottom upward8, on
the saucer. Soon carbonic acid forms, and in a few hours the
tube is free from fluid. This last is the easiest, and at the same
time most absolutely certain, of ali tests for sugar. Having
found the sugar, it is necessary to take the specific gravity ; and
fdl urines over 1025 are to be suspected, and ought t^ be ex-
amined. Then ascertain the total bulk of urine voided per diem.
If the specific gravity be great, and yet the bulk of urine be
smaU, the daily loss of sugar may be less than in those casea
where the specific gravity is comparatively low, but the bulk of
urine voided is large.

As my personal views on the significance of glycosuria would
be held by some to be heretical — heretical in the fact that I
have seen a number of cases where a considerable quantity of
sugar exists in the urine continuously without any disturbance
of the general health, I will again quote William Koberts :
' Gases of sa<X!harine urine may be primarily divided into two
broad classes or divisions.

' One class consists of instances in which a small quantity ol

sngar appears in the urine for very short perioda, withont rele«
vant sjmptoms — the circumstance being a temporarj and inci-
dental consequence of some physiological or pathological
antecedent which has little or no affinity to diabetes, as dini-
cally understood. Belonging to this class are examples of saccha-
rine urine after the administration of chloroform, after eating
an excessive quantity of saccharine and amylaceou8 food, in
recovery from cholera, and after paroxysms of whooping-cough,
asthma, or epi]epsy. These may be designated as cases of
incidental glpcosuria.

* In the other class of cases the glycosnria is more intense ; it
constitutes a permanent symptom, and persists for considerable
periods of tirne, and is associated with a serious departure from
health. To this dass alone is the term diabetes at ali appli-
cable.

* This second class again is divisible into two groups. In the
first the glycosnria is persistent and intense, and the flow of
urine is greatly increased ; this state of urine is associated with
thirst, debility, emaciation, and a train of grave fatally-tending
8ymptoms, which constitute a familiar, easily-recognised clinical
unity. This is the classical diabetes of authors, and to this the
name of diabetes was limited, before our more refined and ready
analysis disclosed the presence of sugar in urine in a number of
other and different states.

' The second group embraces those less serious type8 in which
sugar is present in the mine, sometimes abundantly, sometimes
8cantily ; sometimes persistently, sometimes intermittently ;
always with a weakly condition of health, but without thirst or
conspicuous emaciation, often indeed with corpulence ; without
any or only slight increase in the quantity of urine, and without
that fixed tendency to death which stamps the first group —
occurring also generally in advanced years, or at least beyond
the tirne of early manhood/

The študent will see from this that diabetes was a well-recog-
nised form of disease before the discovery of sugar in the urine
was made. Now the presence of sugar in the urine is apt to
be made the evidence of diabetes par exc€Uence. The student» '

then, must not conclude from fche presen6e of sugar in the urine
tiiat therefore the disease diabetes is necessarily present.
Epilepsj may be a mere disorder, or it may be the result of most
serious organic change. So with diabetes. A prominent
sjmptom 18 not a disease, as is too often carelesslj »ssmned.
Gljcosuria may only exist after meals, when grape sngar is
made faster than the liver can dehydrate it into glycogen.
These cases must be discriminated from those others where sugar
is continuously present. Then sugar in the urine may altemate
with gout, a matter yet little understood generally. It may
occur in corpulent persons without producing any subjective
sensations ; here it is a sort of * waste-pipe business/ running ofif
the superfluous sugar which the system does not require.. It
may be induced by a shock or mental upset ; here it usually
comes on severely as well as quickly, and is usually very amen-
able to treatment. On the other hand, when there is emaciation
along with it, it is impossible to overrate its grim significance.
This is what Boberts calls the ' classical diabetes ;* and this is
the form an examiner always means when he talks of or asks
about diabetes. Further, in elderly persons who begin to grow
thin, the f aintest trace of sugar in the urine, should awaken the
gravest suspicions, and cause the greatest attention to be paid
to the čase. Here not only is the * break-up/ of which the sac-
charine condition of the urine is but one of the evidences, of the
most intractable character ; but it is usually swif t in its operation.

I desire the študent to distinctly understand that there is no
wish to here underrate the gravity of diabetes — true * classical
diabetes ' — in making the statement that glycosuria is often a
matter of little real significance. Its gravity depends essentially
on its associations.

Buckle writes pithily : * To be willing to perf orm our duty is
the moral part ; to know how to perform it is the intellectual
part.' The reader, then, should neither lose his head and act
precipitately on the discoveiry of sugar in any particular urine,
whether his own or anybody else's ; nor should he conclude that
diabetes — * classical diabetes * — is merely a matter of sugar in the
urine.

TITBE CASTS.— These can only just be mentioned here. They
are of various kinds. The študent must investigate this subject
by the light of special treatises ; any brief statement would be
wor8e than useless to him.

HJBMAOLOBiniN.— On testing urine with nitric acid for
albumen, a distinct pink or crimson zone is often produced. I
the test-tube be then placed in the flame of a špirit lamp, the
whole body of the urine becomes of the same hue. If another
specimen be boiled with hydrochloric acid, the urine will assume
a claret-and-water hue. The substance here present is hsemaglo-
bulin, otherwise uro-hsematin. It is the colouriug matter of the
blood, a most highly elaborated compound ; but nothing as yet
is systematically taught about it.

Sometimes the chrysophanmc acid of rhubarb causes the urine
to look * bloody.* To the eye the deception is often complete.

TEMTERATUSE.— This is a semeion of the most cardinal un-
portance in a large class of maladies. By the use of the dinical
thermometer, the temperature is revealed to the eye. It may be
below the norm (99° ; or 98*6° Fahr., to be extremely and minutely
particular) in cases of collapse, in deep alccAiolism, or in embarrass-
ment of the respiration. In disease of the respiratoij organs, a
f ali in the temperature is often a most grave matter ; indeed, there
are times when a high temperature is a matter of much comfort,
and a f ali even to the norm is of evil omen. When the tempera-
ture falls below 95** the condition is becoming very serious.

Infinitely more commonly the body-temperature is above the
norm. It is only of recent /etars that the body-temperature in
disease has been systematically and generally studied. The
dinical th^mometer is one of the most valuable additions to our
means of ezamining our patients. As ordinarily used by most
practitioners, it merely tells the rise and fall of a pyrexia, as an
exanthem or pleurisy ; indicating the febrile rise or the oom-
mencement of defervescence — ^very useful in its way, no doubt ;
but a great deal more may be ascertained by it if a little physio-
logical knowledge and intelligent attention be given to its use.
It is not, however, every practitioner who wields a dinical ther-
mometer 8kilfullyy any more than a gtethosoope. It is easy to

pat either to the patienfs body — ^trae ; bat after aH the instru-
ment is valueless or valuable according to the brain that super-
intends the operation. The most delicate or requi8ite instru-
ment cannot illumine a defective or imperfectlj educated mind.
' After ali, it is not the instrument that knows 1' Some men act
as if they thought that if they only could secure a perfect instru-
ment, it would do away with the necessity f or knowledge, and
abolish the need of thought. It would do aH f or them. This is
80 obyioasIy absurd, that it woidd seem a superfluity to allude to
it ; if it were not so prevalent it would be quite unnecessary to
ref er to it I

In order to wield the dinical thermometer intelligently, and
to comprehend the information afforded by it, the študent must
fully lealise the fact that a high body-temperatare maj be.pro-
ducedby

1. Imperfect heat loss.

2. Increased heat productioik

3. Both combined.

For succesbful treatment it is of the highest importance to
determine how the pyrexia is brought about. When the skin is
dry, and stili more when it is buming as well, then there is
defective heat loss par ezceUence, whether there be any increase
of heat production therewith or not. In rising fever there is no
perspiration. Heat is radiated away f rom the body by the vas-
cularity of the cutaneous area, and stili more by the cooling
effect of the evaporation of the water of the perspiration. Sus-
tained effort leads to 8weating. In effort, more body-heat is
prodaoed than in quiet ; and this increase in heat production is
f ollowed by an increase in the perspiration with resultant in-
creased heat loss. Thus the temperature equilibrium is main-
tained. In rising fever ali perspiration is arrested, and the
exhalation of heat from the buming skin is insufficient to keep
down the temperature. Consequently high temperatures with a
dry skin are not so serious as equal temperatures with a wet or
moist skin.

When the skin is wet, showing great heat loss, a high tempeva-
ture indicates greatly increased heat production. Here, in spite

5—2 •

of an abnormalIy great heat loss, the body-temperature keep«
high. Post partum conditions often present this wet-skinned
pyrexia, requiring active meaBures for its reduction. (This im-
portant matter will be oonsidered in another of this series, * Aids
to Bational Therapeutics.' In the meantime, the študent who
wishes to know more on this matter can consult the chapter on
*Body Heat and Fever/ in the * Practitioner'8 Handbook of
Treatment.') In taking the temperature, the condition of the
skin should be carefully noted : when wet, the rise over the
normal temperature is of much greater gravity than where there
is a dry skin. It is necessary to insist upon this !

In many cases there is a certain amount of inoreased heat
production, as in local inflammation, with a certain diminution
in the heat loss from inactivity in the 8weat glands.

Then there is the rapidity of the rise to be oonsidered. A
rapid rise is more common with children than adults. The
younger the organism, the more unstable andmobileare its heat-
regulating processes. A rise of two or three degrees Fahrenheit
in a child is of little moment ; but in a person over sixty it should
be looked to carefully. A rapid rise to 103° or 104° or more in
a child usu£dly means acute indlgestion. ^e more rapid the
rise, the less serious its indication. Fevers rise slowly, and take
day8 to reach a point attained in dyspepsia in as many hours.

Then there are sunstroke, or ' heat-apoplexy,* when the tem-
perature bas more than a diagnostic value; and *heat-diarrhoea'
requiring its own management. Hyperpyrexia, that is, a tem-
perature above 105**, is applied to conditions where an abnor-
mally high temperature 8uddenly mounts. It is alwayB »
serious affair.

When the temperature mounts to 107° the patienfs life is in
great danger; at lOS** interrible danger; at 110° the prospects of
life are ali but blotted out. A f ew cases of survival after a tem-
perature of 110° are on record.

Then the temperature is often higher at night than in the
moming, as in some surgical fevers, and in phthisis. So long
as the moming temperature keeps near the norm, a rise of a few
degrees in the evening does not much alarm one. But when the

moming temperature motuits and approacnes the evening tem-
perature, the prognosis waxes gloomier. On the other hand,
when the morning temperature drops, and there is a distinct gap
betwixt it and the evening temperature, then the outlook is
brightening. Often a rise or fall in the temperature heralds a
coming change, of which it may be the first outward sign. On
the other hand, the študent must know that at times rapid rises
of temperature are nervous in origin,are, in fact, *trueneuroses.*
In one čase which came under my notice, in a very nervous girl,
for months the temperature, when taken, was over 103**. This
rise was accompanied by increased rapidity in the respiration and
the pulse. Yet she was sinking of inanition, and never ap-
proached the typhoid condition which is the consequence of a
sustained high temperature, nor gave any indication of persisting
fever. Once the temperature, when taken, was 104°, yet she was
not at aH 'feverish ;' it was just excitement, and too evanescent to
produce any distinct consequences. Further, listen to what
Austin Flint says : * The physician is liable to be misled by
placing too much reliance on the laws of temperature. They
are not infrequently interfered with by complications and acci-
dental events. As an illustration, a young girl had passed
through typhoid fever, convalescence being declared, in connec-
tion with other symptom8, by the laws of thermometry belonging
to the decline of fever or defervescence in this disease. Suddenly
hysterical symptoms were manifested, and the temperature rose
to 105°. The physician, a man of leaming and large experience,
was naturally alarmed. In a few hours, however, the tempera-
ture declined, and recovery took plače without further impedi-
ment. The expressive comment made by the physician was,
" This is not the first time I have been fooled by temperature 1"
With regard to the Information furnished by the thermometer,
as well as other diagnostic symptoms, it is to be borne in mind
that there are exceptions to rules which are generally applicable.'
It is in the female sex that these neurosal disturbances are
usually manifested. At the catamenial week of the menstrual
cycle, temperature perturbations are common, and a pyrexia, for
which there is no apparent cause, may at these times cause on-
necessary alarm. Experte čredo/

A STistained high temperature ever causes anzietj, as the
result is the typhoid condition with ali the dangers which follow
in its train. A siistained pyrexia melts down the body-tissue8
and endangers life from the accumulation of the products of
nitrogenised waste in the bloodi

Finally, a word as to the utility of instroments of precision.
The more precise our instruments, the more extensive and aoca-
rate should be our general knowledge ; so as to wield them skil-
fully, to read readily the information they fumish ; and to be
on our guard against disturbing f actors, so as not to fall into
error over them or through them. The more delicate the instru-
ment the greater need for knowledge as regards its variations,
and the exciting causes of its perturbations. We are now
almost encumbered by our various instruments of precision in
every direction ; but these may be made misleading if used
without the knowledge requisite for their correct use and appli-
cation. It is the more essential to insist upon this, as many
young men take to medicine as a socially respectable method of
getting a living, and, impressed with its evident attractions,
believe that it is their special vocation in life ; too frequently
this is a mistake, just as a maiden may misinterpret the. first
impulses of a merely sexual preference for the indicatidhs of a
life-long individual attachment.

ON VISITINO A PATIEKT AT HOME.— There are some
* further points to be noticed when the patient is visited at home.
The first thing to be noted about the patient is whether in bed
or up ; conventionally dressed or otherwise. When up and ordi-
narily attired, the čase is not usually immediately serious, unless
some fit or vascular disturbance be present, or some surgical
emergency. When the patient is in an armchair in dishabille
the čase is more serious. It may, indeed, be very'serious, as
when a patient with heart disease cannot lie in bed. Take a
8teady suryey of the patient, in a good light if possible, and
note the expre8sion, whether intelligent, with the eye bright, or
listless and indifferent. Observe the rapidity of the respiration,
its character, the play of the nostrils ; this will give valuable
information, if only in the direction of putting the questiooi

Asked to the point. Then note the hands, wlietlier sodden or
firm, or wa8ted and transparent. Or the patient may be up,
convalescing and recovering the normal state ; or be an invalid
confined to the room, or to the house. Throw away nothing by
an ill-directed or inappropriate remark, originating in imperfect
observation.

At other times the patient is in bed; but even then the atti-
tude is far from being uninstructive. If there is orthopncea,
and the patient cannot lie down, but is propped up in bed, or is
half-recumbent with a lot of f^illow8 behind him, it tells of
disease of the heart, or of the respiratory organs. If the patient
be rolling about in bed or tossing, there is usuallj encephalic
trouble, unless it be in colic or after acute heemorrhage ; in the
last čase the face is blanched. When the head is roUed about,
headache of a severe character is rarely absent. Or the patient
maj be on the back, with the legs raissd to lif t the weight of the
bedclothes off the abdomen, which suggests the suspicion of peri-
tonitis. When pressure is exercised upon the abdominal parietes
colic is probably present. In a child, in colic, the legs are
generally kicked against the belly.

Then again, note if the patient is confined to one position, or
can move readily. If he can only lie on one side, there is gener-
ally a local reason for it, as enlarged liver, causing the patient to
lie on the right side ; or a left side pleuritic effusion, causing
him to lie upon the left side. Here the side next the bed is little
moved by the act of respiration, while the upper side is chiefiy
in action ; the patient therefore avoiding throwing the affected
side into action, and so escaping suffering. When the patient
lies on the back without power to move, then the typhoid con-
dition is commonly present, or there may be rheimiatic fever.
In the latter, the expression of pain and helplessness is usually
well seen upon the countenance, while the hands and wrists are
yery suggestive in their swollen stiffness. The typhoid condition
is graphically described by Tweedie : * It is announced by the
decline of the previous more acute symptoms; by the pulse
becoming more rapid and soft, the tongue dry and brown,
tremulous, and protruded with difficulty ; by the incnistation of

the teeth with sordes ; by the increasing intellectual disorder,
indicated by the condition of the muscular ejstem, evinced by
muscular tremor and subsultus tendinum, and in some instances
by irregularity or intermission of the pulse ; by the patient lying
šunk on his back, or slidiiig to the foot of the bed, the muscles
being unable to support the body even in the horizontal posture/
There are many points included in this able sketch ; but perhaps
the slipping down to the foot of the bed is the semeion of wor8t
omen, as indicating extreme muscular prostration. If, on the
next visit, the patient is more on the pillow, it is a good sign ;
and as soon as it is possible to lie on either side the čase is
becoming brighter in prospect, as this allows of one kidney being
relieved from hypo8tatic congestion. The appearance of the
patient also is yery instructive. There is the lack of intelligence
in the f ace, the absence of expression indicating the stupor in
which the intellectual faculties are wrapped. The sordes on the
lips and teeth are significant ; while the brown, dry, of ten fissured
tongue, tells in inarticulate language of a condition where life
is most gravely imperilled. The twitching of the tendons is of
bad omen, telling of muscular spasms, which differ from convul-
sions but in degree. Then there is that dreaded phenomenon,
' picking the bed clothes/ Here vision and the intellect both
manifest how seriously affected they are. The description of the
death of F&lstaff is very faithful. *After I saw him fumble
with the sheets, and play with flowers, and smile upon his
fingers' ends, I knew there was but one way ; for his noše wa3
as sharp as a pen, and 'a babbled of green fields. " How now,
Sir John ?" quoth I : " What, man ! be of good cheer." So *a
cried out — " God, God, Gk)d !" three or four times. Now I, to
comfort him, bid him, 'a should not think of God ; I hoi)ed, there
was no need to trouble with any such thoughts yet : So 'a bade
me lay more clothes on his feet : I put my hand into the bed, and
felt them, and they were as cold as any stone ; then I felt his
knees, and they were as cold as any stone, and so upward| and
upward, and ali was as cold as any stone.'

Then there is the 8tatuesque position with the facies Hippo-
craticai Here the noše is pinched, the jaw dropped, and the

mouth open ; the ejes sunken, while the comea is dull and -has
lost its transparency ; the eyes are open ; the temples are hollow ;
the ears shrunken, while the skin is pale and leaden looking, or
livid. This indicates a djing oondition, and that the sands of
life are near run out.

Then, again, there is the pecnliar totU enaernble of carbonic acid
poisoning, the terminal phase of many cases of mitral disease, or
other heart failure. The desire for sleep is intense ; but as soon
as unconsciousness arrests the voluntarj efiforts to maintain the
respiration, the patient is awakened by acute dyspnoea; the start
is sudden, and \a preceded by a horrid dream ; the respiration is
roused up for a tirne, and in dread of that terrible dream and
start, the patient makes a vigorous effort to keep awake. But
the drowsine8s creeps on again, and stealthily WTaps the patient
in unconsciousness, which is soon again rudely broken. This
goes on till the respiratory centre is utterly exhausted ; and then
the patient sleeps at last to wake no more. The same is seen in
chronic bronchitis ; but in death from acute bronchitis the failure
of the respiration is too swiftly complete for the terrible struggle
just described. Then there is the Cheyne-Stokes phenomenon.
Here the respirations rise and fall, growing 8hallower and slower
8teadily ; then rising again in depth and f requency to f uU-drawn
inspirations, after which they again f alL In one well-marked čase
fifteen inspirations made the complete cycle. It always indicates
serious disease, as a fatty heart, apoplexy, or brain disease.

Or the patient may be lying in simple unconsciousness. This
may be due to cerebral disease, to rupture of an encephalic vessel,
or to ursemia. In the last, the respiration is hissing, while in
apoplexy it is stertorous. Or it may be due to alcohol, or to sun-
stroke; and less frequently to cerebral exhaustion, or acute
vaso-motor spasm of the cerebral arteries. Then there is coma
somnolentaj where the patient sleeps, but can be roused ; and the
more significant condition, mostly found in children, known as
coma vigUj where there is unconsciousness with the eyes partially
open.

Or the patient may be in bed ; motionless, because paralysed.

Then there are acute conditions where the face is flushed, and

general exciteinent is preeent: as in acute indigestion, acute
inflammation, and in the exanthemata. It is well for the študent
to observe if there be any rash on the skin when called to
patients taken acutely iU in bed, especiallj if children or ado-
lescenta, so as to note a coming exanthem. In measles the
cresentic rash is of ten first manif ested near the frontal hair ; while
the blush of scarlatina verj f requently 8hows itself first nnder
the clavicles. In small-pox there is often a pustule forming at
the side of the noše over the wing of the alar bones, feeling to
the touch like a No. 5 shot under the skin. But to f ollow out
the diagnosis of the exanthemata is no part of the scheme of this
book. Ne siUor uUra crepidem !

There are some points about the diagnosis of disease in children
which are worth consideration. And I will extract some re-
marks from the excellent work of my colleague, Dr. Eustace
Smith, on *The Wasting Diseases of Children.' A careful
perusal of the face \a of the utmost importance : by it we may
not only diagnose pain, but even its seat. Pain in the head is
indicated by contraction of the brows ; in the chest by a sharp-
ness of the nostrils ; in the belly by a drawing of the upper lip.
Enlargement of the belly is U8ually attributed to mesenterio
disease, yet this is yery rare in children under three years of
age. Percussion will teli if it is due to flatus — a yery common
cause. This is due to bad feeding, which should be remedied.
Mesenteric disease \a not uniform ; and when the swelling of the
belly is uniform and no tumour can be felt, this is not, whateyer
may be, the cause of the enlargement of the abdomen. If the
liver is enlarged its edge can U8ually be felt. The colour of the
face is suggestive. Liyidity indicates a weak circulation or an
hnpeded respiration ; a waxy tint indicates syphilis ; while an
earthy tinge is seen in many cases of bowel complaint. Cool-
ness and pallor of the face, with liyidity of the eyelids, the lower
parts of the whites of the eyes being exposed, with depression of the
f ontanelles, mean eshaustion and the necessity for restoratives.
' Snuffles ' teli of 8yphili8, and so do chaps and fissures at the
mouth and anus. If the breathing is rapid, the chest should be ex-
amin« ' and unequal movement of the two .sides of the chest is

significant of a leslon in the less active side. If the acces8ory
muscles of respiration are active, there is probably some abdo-
minal mischief; if the action of the abdominal muscle be
increased. there is probablj some mischief in the thorax.

*The cry of the infant varies yery much in character. In
cerebral affections it is sharp, short, and sudden. In lesions of
the abdomen, exciting pain, it is prolonged. In inflammatorj
diseases of the lungs and in severe rickets the child is usnally
quiet, and unwilling to crj on account of the action interfering
with the respiratorj functions. In inflammatoi7 diseases of the
larynx it is hoarse and may be whispering. In inherited
syphiliB it is high-pitched and hoarse.' The crj of a sjphilitic
child once well-noted is unmistakable ever aftenvards. Then
it is well to leam to distinguish the howl and screech of temper
from the cry of sudden pain, or other cause of distress.

Beflex excitability is de8troyed by cachexia. If in a healthy
child the finger-nail b6 drawn along the upper two-thirds of the
inner aspect of the thigh, the testicle on that side is drawn
close to the abdominal ring by the action of the cremastor
muscle. In a cachectio child this does not follow. Any sudden
weakening of a healthy child is accompanied by reflex move-
ments, as convulsions. 'When>the debility is produced more
slowly the same result does not f ollow, and the excitability of
the nervous 8ystem, instead of being exalted, is more or less
completely destroyed.' Where there is great emaciation with a
f urfuraceous skin, it 8hows neglect and often resort to narcotics,
especially in manufacturing districts, where the mothers work
from home.

TBB SNOb

LANE MEDICAL LIBRARY

Tq anoid ^e, this book should be retumed on
or before the date last siamped be!ow.

1 .

• n,

L71 PotherrsliJ , J. M.

1'76 Al(is t= HlEgnoaio.,

lesi »"O

DATE DUB

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Full text of "Aids to diagnosis. v.3, 1882"

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