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Jungheinrich Forklift EFG 213 320 Electric & Hydraulic Schematic

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For the purposes of the medical practitioner all professional studies unite to the end of furnishing preparation for the diagnosis and treatment of diseases. At the bedside the cardinal questions are, How does the present condition of our patient differ from health? and, What ought we to do to bring about his recovery?

Diagnosis involves three main directions of inquiry: 1, as to the general bodily state of the patient; 2, morbid changes in particular organs, tissues, or functions; 3, as to what name properly designates the disorder, according to accepted nomenclature.

Pathology can never be out of view in connection with either the theoretical or the practical study of diagnosis. But it is most closely regarded when the last of these questions is before us, since the names of diseases generally have a more or less distinct reference to their pathological nature. Yet clinical observation always suggests the early use of provisional terms for recognized groupings of morbid phenomena; and sometimes these clinical designations remain for a long time in use because of the imperfection of pathology.

We ascertain, in practice, the nature of a given case, first, by considering its symptoms. These are those obvious evidences of deviation from health which the patient himself is aware of, or which the physician readily discerns or elicits by simple inquiry or examination.

Secondly, taking the clue furnished by symptoms, a closer inspection is made, with the intent of finding what is the actual state of important organs, as the heart, lungs, liver, spleen, kidneys, and alimentary canal.

Lastly, when these means fail to remove all obscurity, or when special scientific investigation is practicable, instruments of precision are employed, as the thermometer, sphygmograph, ophthalmoscope, æsthesiometer, or aspirator; or by the microscope and chemical

analyses still more minute examination is made into the particulars of the morbid processes present and their results.

We may subdivide diagnosis, then, into: 1, symptomatology; 2, organoscopy or physical diagnosis; 3, instrumental diagnosis.

Symptomatology.

Semeiology (from [Greek: sêmeion], a sign) is a term much in use, with essentially the same meaning as symptomatology, but less conveniently distinctive, since it does not so well indicate the contrast between obvious signs, or symptoms, and those more recondite, obtained by the methods of physical diagnosis.

Signs of disease cannot be recognized as such except by one who is familiar with the appearances, actions, and manifestations which belong to health. Nor can they be understood, so as to infer what they mean, without knowledge of normal physiology on the one hand, and, on the other, of the natural history of diseases.

Physiology constitutes the etymological grammar, symptomatology the vocabulary, and diagnosis the syntax of practical medicine. Just as grammatical knowledge will not enable any one to read or speak a language without acquaintance with its words, so clinical observation is necessary to the physician over and above all the knowledge he may have of physiology and pathology. He must learn to know diseases by sight, or at least by personal contact and observation.

Every one has, of course, a general familiarity with the state and actions of his own and other bodies in health, yet a more exact knowledge of the movements of respiration, circulation, secretion, etc., as well as the form, size, and relative location of all the organs of the body, is needed. Physiology and medical anatomy furnish such information. The more thorough this knowledge is appropriated, the

better fitted the student is for practical diagnosis. For its application, however, cultivation of all the perceptive powers is very important.

Some men have a genius for quick and clear discernment of symptoms and for their interpretation, as well as for that of physical signs. But all can much improve their senses, and their sagacity in using them, by experience. For this, if for no other reason, scientific training, in field or laboratory studies, affords the best introduction to the work of the medical student and physician. The traits most needed for success in diagnosis are exactness and comprehensiveness. First, to be sure precisely what each sign is that comes under observation; next, to overlook no existing symptoms or physical signs; and, last, so to combine them into a mental map, diagram, or picture, as to make a coherent and rational whole. This nosogram may then be compared with the descriptions of standard authorities, to find its place (if it has one) in technical classification.

First, however, ascertain the thing, the morbid state or combination of states; afterward the name, or morbid species, when practicable.

It is always to be remembered that complication of diseases, or at least the existence of some irregular manifestations along with those which are characteristic, is more common than the occurrence of purely typical cases. The portraits of most diseases in the books are averages, like the composite class-photographs of Douglas Galton.

Not nearly every case will correspond with such an average in all respects. Moreover, so great is the possible variety of alterations among the different organs of the body that the chances of two instances of disease being precisely alike in every particular are hardly greater than those in favor of every move being the same in two games of chess with the same opening.

In an essay like the present it is not easy to decide upon the best manner of treating the subject before us. Too much or too little may be said. With advanced readers the whole history of symptoms and physical signs might be left to the special discussions occurring in articles upon different diseases. But it may be taken for granted that those who consult the present work will do so either at a comparatively early stage of their studies or when time has made

desirable a renewal of what may have been once known and then forgotten. Since, then, it is impossible to anticipate what may be the exact needs of either class, a somewhat elementary statement of main facts appears justifiable here.

Following the natural method, we may suppose a call to visit a patient. Arriving in his presence, the first question (mostly left out of view and rarely expressed) may be, Is it a case of real or only imaginary indisposition? Army medical officers, more than most others, can appreciate the possibility of this inquiry sometimes disposing of the whole case.

Supposing it to be real, is it an illness or an accident or other injury?

Is it severe or of trifling account? Acute or chronic? We observe the position of the patient, lying quietly in bed, sitting up, or walking restlessly about the room. Then the countenance is observed—pale or flushed, tranquil or excited in expression. We feel the forehead, touch the cheek and hand. Is the skin hot or cold, dry or moist? The pulse is felt; the breathing also is counted.

Of the patient himself or of another (in serious acute cases better of his care-taker, in another apartment) we ask questions whose answers give us the general history of the case. When not before known these should include his antecedent personal history, even extending to that of the family, as far as can be learned. What tendencies have they, or has he or she, shown by previous attacks and their results?

So we come to the present attack: When did it begin, and how?

What have been its prominent symptoms since? Questions are then to be put concerning the heat of the body, appetite, complaint of pain, sleep, movement of the bowels, discharge of urine: in the female, menstruation; if married, pregnancy or parturition, how often and when occurring last. Thus the practitioner is enabled to get a clue to the diagnosis, to be followed out through his own observation and closer examination. If the patient be a child and the

attack be acute and febrile, an early question must be as to its having passed or not through the different diseases of childhood— viz. the exanthemata, mumps, and whooping cough, and also what exposure to any of these it may have been recently subjected to.

Going farther into particulars, let us review some of the possible developments obtained in the above questioning of symptoms.

When lying in bed the decubitus may be significant, as, upon the back with the knees drawn up in peritonitis; with the hands pressing the abdomen in colic; tossing to and fro in the delirium of fever or of early cerebral inflammation; on one side constantly in acute inflammation of the liver or in pleurisy. Or the patient may be obliged to be propped in a sitting posture (orthopnoea) from heartdisease, asthma, or ascites, or leaning forward upon the back of a chair or a pillow with aneurism of the aorta. More remarkable still may be the subsultus tendinum of low fever, the opisthotonos of tetanus, the respiratory spasms of hydrophobia, or the clonic movements of epileptic, hysterical, or occasional convulsions.

In the face we see pallor in syncope and in anæmia in any of its varieties and with varied associations; a general redness in some cases of apoplexy and in remittent fever; flushing of the forehead and eyes especially in yellow fever; dusky redness in typhus, and a more purple hue in typhoid fever; yellowness in jaundice, in some cases of remittent and in most of yellow fever; sallowness in cancer; a bright central glow upon each cheek in early pneumonia or the hectic of phthisis; a blue or ashen appearance in the collapse of cholera, and blackish-blue in cyanosis or carbonic acid poisoning; bronzed in Addison's disease; puffy about the eyelids in Bright's disease; the surface swollen, yet resistant to the touch, in myxoedema. The eyes (one or both) glare prominently in exophthalmic goitre; squint in advanced cerebro-meningitis; roll to and fro often in the prostration of cholera infantum and in convulsions; are clear and bright in phthisis; yellowish in hepatic

disorder; dull and clouded in low fevers; without expression in imbecility and general paralysis.

Contraction of the pupil is observed in inflammation of the retina or of the brain, narcotism from opium (until near death) or eserine, or apoplectic effusion near the pons varolii. Dilatation of the pupil is seen in most cases of hydrocephalus and of apoplexy; in nerveblindness (amaurosis), glaucoma, cataract, and narcotism from atropia, duboisia, or hydrocyanic acid. Inactivity of the pupil (Argyll Robertson) under changes of light and darkness is common in locomotor ataxia. Different states of the two pupils under the same light show disorder, either ophthalmic or cerebral in site, or may indicate pressure on the cervical sympathetic ganglia, as from aortic aneurism.

In elderly persons we ought always to look for the arcus senilis, which is a sign of a tendency to fatty degeneration. It is a ring, or part of a ring, with ill-defined edges, best seen by lifting or depressing an eyelid, at the junction of the cornea and sclerotic coat of the eye. In some quite healthy old persons there may be seen at the same junction a clearly-defined circular line of calcareous nature.

This must be distinguished from the true fatty arcus senilis.

Of the face we may also notice the pinched nose, hollow eyes, and falling jaw of the facies Hippocratica, presaging death; the square forehead of the rickety child (not common in this country); ulcers on the forehead, scars at the mouth-corners, or copper-colored eruptions in syphilis; the full, flabby lips of scrofula. In peritonitis or gastritis the mouth is apt to be drawn up with a peculiar expression of suffering and nausea. Very striking is the characteristic one-sided appearance in facial palsy, from lesion of the seventh nerve. There may be a smile, a frown, or other expression on the sound side of the face, while the paralyzed side is quite immovable. As the seventh nerve (portio dura) supplies the orbicularis muscles, its paralysis (so often temporary) may cause inability to close the eye upon the affected side. Ptosis, or inability to open the eye, involving the

levator palpebræ, which is innervated by the third nerve (motor oculi) is more significant of cerebral lesion.

Even the ears may have language, as when their lobes are full and glistening red in the gouty diathesis, or wrinkled in prolonged cachexiæ, or when they are running with discharges in the struma (scrofula) of childhood. The hair becomes dry and lustreless in phthisis, and falls out during convalescence from many acute diseases.

If we look at the gums in a case of lead-poisoning, we may expect to find a blue line along their edges. Scurvy is betokened by a swollen, spongy, and easily-bleeding state of the gums. Many scorbutic cases, however, lack this so-called pathognomonic feature.

It may be remarked, by the way, that absolutely pathognomonic signs of particular diseases, never absent and exclusively seen in them, are very few. Albuminuria, for example, is not always present in Bright's disease, and is also met with in a number of other affections. Sugar in the urine may follow inhalation of chloroform or an attack of cholera, as well as diabetes mellitus. Rice-water discharges may be absent in the collapse of cholera, and patients may die with yellow fever without black vomit. Still, these symptoms have great diagnostic value, and, taken with others associated with them, may often enable us to attain to a diagnosis of much importance.

Perfect teeth in an adult in this country are rather the exception than the rule. In the notched incisors of inherited syphilis, however, there is something quite distinctive. The notches in Hutchinson's teeth are vertical, not horizontal.

Old as medicine is the examination of the tongue in disease. It may be protruded with difficulty, as in low fevers, in apoplexy, and in cerebral paralysis (bulbar sclerosis, glosso-labio-pharyngeal paralysis) or thrust to one (the paralyzed) side in hemiplegia. It is pallid in anæmia; yellow in bilious disorder; red in glossitis (then

swollen also), in scarlet fever, and in gastritis; furred in indigestion, gastro-hepatic catarrh, and the early stage of various febrile attacks; dry, brown, cracked, or fissured in typhus or typhoid fevers and in the typhoid state of malarial remittent fever; bare of epithelium in advancing phthisis and in imperfect convalescence from severe acute diseases. Coldness of the tongue is one of the worst signs in the collapse of cholera.

As we examine the throat internally we look for signs of faucial inflammation in redness and swelling, with or without enlargement of the tonsils, or relaxation and elongation of the uvula, or ulceration, or the gray or brown membranous deposit of diphtheria.

In the mouth of a child we may find the little white vesicular patches called aphthæ, the curd-like exudations of thrush, or possibly the much worse grayish ulcerations of cancrum oris, or the rarer ashen sloughs of gangrene of the mouth.

Outside of the throat we must remember the significance of glandular swellings or scars of suppurated glands in children; nor overlook, if present, stiffness of the muscles, or torticollis, or goitrous enlargement of the thyroid gland. Observation should be made also of the site of the carotid artery on each side, and of the jugular veins, since aortic regurgitation may be indicated by violent action of those arteries or tricuspid regurgitation by pulsation of the veins in the neck.

Long before vaso-motor physiology had any place in science the pulse was known to afford valuable indications in disease. Either of the accessible arteries will answer instead of the radial; its convenience merely makes the wrist the common place of comparison. By careful examination of the pulse something may be learned of several of the factors concerned in its production. These factors are—1, the muscular force of the walls of the heart; 2, the state of the cardiac valves; 3, the muscularity of the arteries; 4, the elasticity of the arterial coats; 5, the state of the capillary circulation;

6, the qualities of the blood; 7, the condition of the nervous system as to excitability or apathy.

A feeble heart must induce a feeble pulse. Moderate debility may be attended by slowness of the pulse, but usually a weak circulation is marked by frequent, small beats, like the vibrations of a short pendulum. A strong heart-beat (other things being equal) is relatively slow, with a proportionate pause after the second sound.

Valvular lesions produce various effects upon the pulse. Most notable are the irregularity connected often with mitral insufficiency and the jerking pulse (Corrigan) of aortic regurgitation.

Believing, as the present writer does, in the existence of a true arterial systole following and supplementing the ventricular contraction,38 it must be urged that a vigorous muscularity in the arteries promotes strength in the pulse—not by resistance, but by auxiliary propulsion of the blood. Another condition altogether is tonic, spasmodic contraction of the arteries. This is not often met with pure and simple, but a measure of it is seen in the corded or wiry pulse of acute enteritis or peritonitis.

38

This view, although advocated by Sir Charles Bell, Legros and Onimus, Hermann of

Zurich, and others, is opposed to the most prevailing vaso-motor physiology. Several complications and some contradictions in pathological discussion at the present time would be cleared up by the abandonment of the now commonly-held stopcock theory of arterial function, which has really nothing whatever to support it except the misinterpretation of some experiments upon arteries made many years since.

Deficient elasticity of the arteries is not easily separated in observation from muscular relaxation. When arteries undergo degeneration (atheromatous, fatty, or calcareous), their middle coat suffers the deterioration of both elastic and muscular tissues, these being substituted by materials either more or less yielding, and always less resilient, than the natural fabric of the vessels.

The influence of the condition of the capillary circulation upon that of the arterial system and the heart is manifest in inflammations. By reflex excitation the arteries are made to contract actively and impel the blood more forcibly than in the normal state toward the centre of impeded nutrition (stasis). This has been abundantly proved by the comparison of the amount of blood flowing through the arteries of a sound limb and those of its fellow, when the latter is the seat of a violent acute inflammation.

Blood-states also affect the pulse by the differences in direct stimulation to which the heart and arteries are subjected according to the qualities and composition of the blood. It is probable that the fever-pulse of typhus, typhoid, the exanthemata, septicæmia, and pyæmia has its origin in morbid conditions of the blood, acting in a twofold manner—directly upon the heart and arteries themselves, and mediately through the vaso-motor ganglia.

Lastly, the nervous system stands in an important relation to the action of the heart and arteries, and thus to the pulse. In a nervous, excitable person, changes in the rate of the pulse may take place, with slight significance, which in a different constitution might be of serious import.

To understand the language of the pulse care must be taken in several respects: 1. Both wrists should be felt. Sometimes there is an abnormal variation in the course of the main radial trunk which may pass over the thumb. Again, an aneurism may cause a great difference between the two radial pulses, or, possibly, an embolus may occlude one of the radial vessels, annulling its pulsation.

2. Other arteries also, especially the carotids, should be examined— in all obscure cases at least. Visibly beating, distended, and tortuous temporal arteries are occasionally met with. They are not pathognomonic of any one malady, although often referred to the

gouty diathesis. They may attend irregular malarial attacks, or may be connected simply with a hyperæmic state of the brain.

3. The heart's impulse should always be compared with the arterial pulsation. The former may be strong and regular, while the latter is small, feeble, or intermittent. Something must then be wrong, either in the aortic valves or in the arterial system.

5. On account of possible nervous agitation, the pulse should usually be examined more than once, during each visit to the patient.

6. Sex, age, position of the body, and time of day must all be taken account of. In men the average rate of the pulse is between 65 and 75 per minute; in women, between 70 and 80. The pulse-rate of early infancy varies from 100 to 120, and is very easily hurried. That of old persons is commonly between 60 and 70, until, at a very advanced age, with debility, its frequency may be increased, especially upon exertion. Lying down, we find the slowest pulse; sitting, somewhat more rapid; and most so in the standing position.

In health the time of day makes no constant difference apart from the effects of food and exercise. In disorders attended by fever there are important changes to be regularly observed. Excepting the variable paroxysms of remittent and intermittent, which are a law unto themselves, in febrile affections the pulse may be expected to be slowest in the morning and most excited in the early part of the night. A diminution of this difference is a favorable sign. Sleep generally slows the pulse decidedly. The ordinary statement is, that the pulse is always slower during sleep, but I have several times found that in states of exhaustion without fever it may be considerably more rapid while the patient is asleep. Nothing is more sure to increase the strength and rapidity of the pulse than high temperature.

7. Very important is the relation between the pulse and respiration.

Normally, four pulsations occur to each respiratory act. In pulmonary affections, while the circulation is often disturbed pari passu with the

breathing, it may be quite otherwise. Great acceleration of the rate of breathing, with little increase in the rapidity of the pulse, should lead us to suspect disease involving the respiratory organs.

Conversely, a much hurried or otherwise perturbed pulse, with little or no change in the breathing, points toward the heart as either functionally or organically the seat of disorder.

Let us further consider, briefly, the kinds of pulse to be met with and interpreted in practice.

A natural pulse is always, per se, a good sign. Yet in the history of a disease usually so well marked as yellow fever some fatal cases have been recorded (walking cases) in which the pulse, almost to the last, was natural.

Strength of the pulse, to a certain degree, belongs to it normally. But this is often exaggerated, and we may have the strong, hard, full, perhaps bounding, pulse of an inflammatory affection (of the brain, for example, or of the joints in acute rheumatism) in a person of vigor. A bounding pulse often accompanies mere palpitation of the heart, whose source may be the sympathetic influence of indigestion or nervousness. A similar pulse is apt to be constantly present in hypertrophy of the heart. In this case it is made more forcible as well as more rapid by active exertion; while palpitation, without organic trouble, is usually diminished by moderately active exercise.

A full pulse is not always strong, nor is a small pulse necessarily weak. Mention has been made already of the tense, corded pulse met with in acute peritonitis, and sometimes in enteritis. Gastric inflammation, with nausea, may exhibit a depressed pulse, weak and but little accelerated. Under still other circumstances we may find a full pulse which is soft, easily compressible, even gaseous. Most frequently a feeble pulse is rapid, and a very rapid pulse is weak.

Slowness, in marked degree, attends apoplexy, opium narcotism, and fracture of the skull compressing the brain. Functional disturbance of the heart may occasionally exceed in effect these

causes of retardation. I have met, under such circumstances, with a pulse of 20 in the minute; one of 18 has been recorded. A few apparently healthy persons have habitually a pulse with but 40 or 50 beats in the minute.

Quickness in each beat may occur, while a long interval makes the rate per minute slow. The jerking pulse of aortic regurgitation is the most remarkable example of this. Galabin asserts that without imperfection of the valves of the aorta a decidedly abrupt pulse may attend great lowering of arterial tension. Something of the same kind may be noticed in the temporarily excited pulse of very nervous subjects under agitation.

Dicrotism, or reduplication of the pulse-beat, is not uncommon in typhus and typhoid fever. Here relaxation of the heart as well as of the blood-vessels appears to allow a momentary interruption in the succession of the arterial upon the cardiac systole.39 39

An exceptional phenomenon, noticed by a few observers, is the recurrent pulse; i.e.

a pulsation felt below the finger, whose pressure interrupts the flow of blood through an artery. It may be explained by supposing unusual fulness of the vessels (local, if not general) with, at the same time, relaxation of their walls; bearing in mind, also, the manner of anastomosis of the radial and ulnar branches which favors recurrence.

Intermittence and irregularity of the pulse are not exactly the same thing. Occasional intermittence may be merely a nervous symptom or a muscular twitch of the heart, like the twitches now and then occurring without significance in voluntary muscles. Persistent intermittence, with feebleness of the pulsations (these being generally somewhat rapid), is among the signs of dilatation of the heart.

It is possible for intermittence of the radial pulse to accompany regularity in the heart-beat. This usually results from narrowing (stenosis) of the aortic valvular outlet from the left ventricle. Only a

certain number of impulses fairly reach the more distant arteries.

This symptom may result also from fatty degeneration of the heart.

Absence of pulse in one radial vessel, while it is present in the other, shows the presence of an obstacle to the circulation on one side, which may be an aneurism, or an embolus plugging the artery.

Irregularity of the pulse, a total derangement of its rhythm, while not often important in young children, is a serious symptom at other times of life. In one disease most common in childhood, acute hydrocephalus, the pulse in the first stage is apt to be hard and rapid, in the middle stage slow and tolerably full, in the third rapid, feeble, and often irregular. Mitral disease frequently presents considerable irregularity of the pulse; and so does dilatation, even without mitral lesion. Brain trouble, especially late in life, whether structural or functional, may produce the same symptom. B. W. Richardson has pointed this out as one of the effects of the excessive use of tobacco, even in young persons.

The pulse of continued, relapsing, and remittent fevers is, during the febrile exacerbation, rapid (100 to 120); in the earlier part of the attack full, but only moderately hard, or even soft and yielding. As the attack passes its height and critical defervescence occurs, the pulse grows slower, unless great prostration has supervened; in which case it increases in rapidity, while it fails more and more in fulness and resistance.

The pulse of the moribund state is nearly always small, very rapid (130-150), and thready, without force or fulness. It may become imperceptible before death. A pulse of 140 beats in the minute is always alarming; if much beyond that rate the case is desperate. A pulse of more than 150 beats in the minute is very difficult to count accurately.

Exophthalmic goitre is attended characteristically by a full, somewhat rapid, and bounding pulse, the cardiac impulse being also

proportionately violent and extended. Exercise much increases this hyper-pulsation.

Pulsation of the jugular veins is ordinarily explained by tricuspid regurgitation, a portion of the blood being sent back to the vena cava with an impulse reaching to the jugulars. In some instances, however, as the writer has repeatedly observed, jugular pulsation takes place without any abnormality in the action or condition of the heart, from a local inflammation (as tonsillitis) causing a marked exaggeration of the muscular contractility resident in the larger veins.

Retardation of the flow of blood through the veins is manifest during the collapse of epidemic cholera. On pressing the blood back in a vein upon the hand, for example, and then lifting the finger, instead of the movement being, as in health, too swift to be seen, it is so slow as to be easily followed.

Capillary movement may be estimated in a similar manner. If it be very sluggish, pressure upon the cheek, forehead, or hand will cause a pallor which remains for some seconds, instead of disappearing at once when the pressure is withdrawn. This is, it may be noticed, entirely different from the pitting upon pressure, without much if any change of color, in local oedema or general anasarcous effusion. The tache méningitique of Trousseau is a pink or rose-red line left for a time after drawing the finger across the forehead or abdomen in cases of acute hydrocephalus (tubercular meningitis).

Respiration must be watched carefully in all cases of disease.

Normally, in the adult, while at rest, from 16 to 18 respiratory movements occur in each minute. The number is somewhat greater in women, and is considerably increased in children, at birth being about 40 in the minute. Men breathe most by the diaphragm; in women there is a greater lifting of the ribs. In either sex a disorder attended by pain in breathing may modify this proportion. If pleurisy, for example, be present, the ribs will be but slightly lifted, abdominal

breathing taking predominance. When peritonitis makes every movement of the abdomen painful, costal respiration is maintained almost alone. Likewise, a unilateral pleurisy or pneumonia will check the respiration on the affected side, with an increased movement on the sound side. This difference is less manifest to the eye than to the ear in auscultation. In all febrile affections respiration is hurried proportionately with the pulse, unless some complicating local disorder disturbs the relation.

Dyspnoea may be produced by many different causes, whose possibility must be remembered in its interpretation as a means of diagnosis. In asthma violent efforts are made to compel the entrance of air into the lungs by the intercostal muscles and diaphragm, aided by all the accessory muscles of respiration, including the sterno-cleido-mastoid and others of the neck.

Expansion of the nostrils may occur in sympathy with these efforts.

Yet the amount of resistance may be shown by a partial sinking-in of the lower ribs, as well as by the patient's distress. These last signs are sometimes very marked in the collapse of one or both lungs now and then occurring in whooping cough.

Croup induces a similar struggle for breath, although the obstruction is differently located. Early in the croupal attack a hoarse sound may accompany each inspiration and expiration. Later, when the danger to life from apnoea becomes more imminent, a hissing or whistling sound succeeds. This last-mentioned kind of sound results temporarily, also, from the spasmodic obstruction to breathing in laryngismus stridulus.

Besides the affections of the lungs which impede respiration (as pneumonia, hydrothorax, etc.), we may have dyspnoea induced by extra-pulmonary causes, such as dilatation of the heart, aneurism of the aorta, mediastinal cancer, pleuritic effusion; also by abdominal dropsy, extreme elephantiasis, etc. Mention need hardly be made here of respiratory obstruction from defective or injurious qualities of the air, threatening or producing asphyxia.

Sighing respiration takes place in heart disease not infrequently. A peculiar modification of the breathing movements has been associated especially with fatty degeneration of the heart. From the distinguished authors who first described it this is called the CheyneStokes respiration. Intervals of suspension of breathing occur, after which short, shallow inspirations begin, and gradually increase for a time in depth; then they grow shorter and shallower again, until apnoea is reached. Such a cycle may occupy from half a minute to a minute and a half, with from fifteen to thirty increasing and decreasing respirations in all. It has been shown by several observers that this type of respiration is not peculiar to fatty degeneration of the heart. It has been met with in cases of cardiac dilatation, aortic atheroma, cerebral hemorrhage, tubercular meningitis, and uræmia.

Sometimes a kind of dyspnoea common in advanced disease of the heart, especially in mitral lesion with dilatation, has been confounded with this. Here the breathing is constantly labored (orthopnoea); but the patient from time to time dozes off into an imperfect sleep, in which the breathing almost entirely ceases. Then he is awakened with a start of distress, perhaps out of a painful dream. This succession of dozing apnoea and waking dyspnoea belongs to a late stage of heart disease, and usually ends in death.

Stertorous respiration is familiar in apoplectic coma, as well as in that of brain compression from injury or from opium or alcoholic narcotism. In uræmic coma true stertor is less apt to be observed; sometimes the respiration in this condition has a hissing sound.

Along with the movements of respiration we may notice that the breath is hot and has a heavy odor in the early stages of all febrile disorders. Disagreeable breath is common, however, in persons not ill, from bad teeth or from indigestion. It is worst of all, putrid, in gangrene of the lung. Certain cases of chronic or subacute bronchitis (as well as of ozæna) also have very offensive breath. Coldness of

the breath is a very bad sign; it is observed sometimes before death in the collapse of cholera.

Hiccough (singultus) is a spasmodic affection of the diaphragm. It is innocent, though annoying, in most cases, resulting from indigestion or from nervous disorder; in children, occasionally, from long crying.

When it takes place in cases of general prostration it betokens threatening depression or exhaustion of vital energy.

The voice is mostly altered by serious disease. It may be feeble and whispering, from debility; hoarse, from laryngeal inflammation and tumefaction; thick, from cerebral oppression; lost (aphonia), in some cases of chronic laryngitis and in paralysis of the vocal muscles. The manner of articulating words is often changed in disorders of the nervous system. A marked example of this is the monotonous scanning speech of cerebro-spinal sclerosis.

Cough is an extremely variable symptom, always to be understood in connection with the attendant circumstances. Usually, however, the character of the cough itself is more or less distinctive. A dry, hard cough may be merely sympathetic or nervous, or it may belong to the first stage of acute bronchitis. A hacking cough, with little expectoration, is not infrequently observed for a time in incipient phthisis. Pneumonia has, if any, a short and rather sharp cough.

Progressing bronchitis is recognized by the deepening and greater or less loosening of the cough. In advanced phthisis there are distressing spells of deep, laborious coughing, especially in the night or in the morning after sleep. Croup is known (whether sporadic or in the form of laryngeal diphtheria) by the barking cough of the early stage and its whistling character toward the fatal end. Nearly the same sort of hissing or whistling sound in breathing has been mentioned already as occurring in laryngismus stridulus. Paroxysms of coughing, with or without whooping, are pathognomonic of pertussis.

Expectoration often affords important signs. Briefly, it may suffice to say here that it is mucous, whitish, or colorless in early bronchitis; more or less yellowish and muco-purulent in severe and protracted bronchitis; rusty, from admingling of the coloring matter of blood, in pneumonia, early and middle stages; bloody and muco-purulent in early and of heavy roundish (nummular) masses in late pulmonary phthisis; putrid, rotten, in gangrene of the lung.

Continuing our survey of obvious symptoms, we must now take account of the conditions of the general surface of the body.

Temperature is of great consequence. Most precisely determinable by the thermometer, the touch, when educated, will give very useful indications of its changes. It is difficult, and not commonly desirable, to separate variations of moisture from those of temperature.

Reserving for another place the special consideration of medical thermometry, it may be here said that the skin is hot and dry in the typical condition of fever, whatever its special associations. Heat and moisture of the skin are more often met with together in the fever of acute articular rheumatism than in any other affection. As a rule, perspiration lessens febrile heat. Copious (colliquative) sweating is habitual in many wasting diseases, notable in pulmonary phthisis. It is then a sign of great general relaxation of the system.

Coldness of the surface attends prostration, either from temporary collapse or from positive exhaustion. The skin is perceptibly cold in the algid stage of cholera. It may be so in very severe cases of sporadic cholera morbus. In the chill of intermittent, while the patient has the subjective sensation of coldness, his temperature is seldom reduced, and is often higher than natural, although lower than during the febrile exacerbation.

The color of the skin is pallid in anæmia, phthisis, dropsy, etc., and in syncope; ashen or livid in cholera collapse and in the cold stage of pernicious malarial fever; yellow in jaundice, remittent, and yellow fever; sallow in chlorosis, cancer, and chronic dyspepsia; purple, almost black (especially the lips and ends of the fingers), in

asphyxia; dark, as if stained with ink, after long use of nitrate of silver; bronzed in Addison's disease; bright red in scarlet fever, etc.

The eruptions of this and other exanthemata, and of the different cutaneous diseases, will be best considered in the special articles treating them of in this work.

Odor is perceptible and peculiar (though not easily described) in some bad cases of typhus fever and of small-pox; less often in aggravated chlorosis. Lunatics and paralytics (especially when assembled together in institutions) often give off a noticeable smell.

Most distinct, however, is the cadaverous odor, sometimes perceptible for hours before death. Corroborative of this, in summer, is the flocking of flies around the bed of a dying patient. In a hospital ward this selection amongst a number of patients may be quite observable.

Emphysema, from the presence of air in the connective tissue under the skin, is rarely met with except as the consequence of an injury or of local gangrene.

Oedema is local watery effusion, which may have various causes and significance. Anasarca must have a general causation, either connected with the state of the blood or with disorder of the heart, kidneys, or liver, or of more than one of those organs at once. Pitting on pressure is the sign of watery effusion. Soft crackling under the touch distinguishes emphysema. A firm enlargement of the surface of the face and upper part of the body occurs in myxoedema.

Swellings of all kind must be carefully observed, and their nature inquired into—whether they be inflammatory or other chronic enlargements of joints, tumors, fibrous, fatty, or cancerous, aneurisms, hernial protrusions, or of any other character. In protracted disease of the liver (cirrhosis) it is not uncommon to find the superficial abdominal veins dilated and tortuous.