§|lte§v........ ITCfti/iimij; f' "il:^V:i|:-::-.,ii SPPiffllBjI.V.i. r h '! f':i NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland ,^RF0 WHAT TO OBSERVE IN MEDICAL CASES. WB 14-3 WHAT TO OBSERVE MTHE BED-SIDE AND AETER DEATH IN MEDICAL CASES. PUBLISHED UNDER THE AUTHORITY OF THE LONDON MEDICAL SOCIETY OF OBSERVATION. SECOND AMERICAN, FROM THE SECOND AND ENLARGED LONDON EDITION PHILADELPHIA: 1_____ BLANCHARD AND LEA^^ltaSTg^;^ 1855. . (/ .«-% Nq*o*,, d. < U)fc& Piinted by T. E. & P. G. Collins. PREFACE TO THE SECOND EDITION. The favourable manner in which the First Edition has been received, and the sale of a large impression in little more than one year, has encouraged the Society to believe that the anticipations of the usefulness of this little volume have not been unfounded. In preparing the Second Edition the whole of the work has been carefully revised by the Committee who drew it up, assisted by some other members of the Society.1 A section on Treatment, with some modifications in the arrangement, has been introduced, and greater precision of expression has been aimed at; but the original cha- racter of the work, and, as far as was consistent with the additions, the same numbering of the paragraphs, have been preserved. The suggestions of the Reviewers of the first edition have also been adopted, whenever it was practicable to do so. 1 The members of the Committee who drew up the First Edition were — Drs. Walshe, Jenner, Parkes, Snow Beck, Hare, and Ballard: who have been assisted in preparing the Second Edition by Drs. Reynolds and Lionel Beale, and Mr. Morris. London, October, 1854. PREFACE TO THE FIRST EDITION. The circumstances under which this little book is pub- lished may be very shortly stated. Soon after the Medical Society of Observation had been formed,1 it was felt by the members, that the labour of analyzing and comparing clinical observations would be greatly lightened, and the precision of the observations themselves increased, if the records of these were in every instance arranged on an uniform plan. The Society in consequence adopted, with some modifications, a form of arrangement of symptoms and after-death appearances, which had been framed by Dr. Walshe. The publication of this form seeming desirable, it was referred to a Committee, who expanded and altered various parts of it, and finally threw it into its present shape. The supervision of the whole was intrusted to Dr. Ballard, who has bestowed upon his task great labour and attention. The Society believes that this scheme or method of arranging the clinical and anatomical phenomena of disease, will prove useful both to those who desire to learn 1 The members who took part in founding the Society were — Drs Walshe, Jenner, Parkes, Snow Beck, Hare, and Sieveking. PREFACE. systematically with what amount of detail, and in what order, those phenomena should be looked for, and also to those who wish to record with accuracy the results of their experience. It will probably be admitted, too, that errors in diagnosis are more frequently traceable to for getfulness in searching for all possible evidences of disease, than to misinterpretation of those actually discovered : the physician proceeding to the investigation of an obscure case may, then, in a book of the present kind, occasionally find a useful remembrancer. The Society is fully aware that many portions of their scheme are far from perfect; but it is hoped that the diffi- culties of the task, which have been considerable, may be received as sufficient excuse. London, November, 1852. CONTENT S. PART I. Page CLINICAL EXAMINATION OF A PATIENT............... 25 §1. The.Personal Description and Peculiarities of the Patient in Health................................................... 25 Physical description and peculiarities....................................... 25 Race, l1— Sex, 2— Age, 3 — Anatomical peculiarities, 4 — Physiological peculiarities, 5. Intellectual and moral peculiarities.......................................... 28 Intellectual peculiarities, 6 — Moral peculiarities, 7. \ II. The Previous History of the Patient..................... 30 A. Hygeia............................................................................ 30 Parentage, 8 — Infantile management, 9 — Place of birth or former residence, 10-— Present residence, 11 — Trade or oc- cupation, 12 — Food, 13 — Drink, 14 — Clothing and firing, 15—Cleanliness, 16 — Exercise, 17 — Sleep, 18—Study, 19 — Medicines, 20 — Habitual use of narcotic drugs, 21 — Peculiar habits, 22 — Venereal indulgences, 23. B. Previous General Health................................................ 32 Infantile health, 24 — Adult health, 25. C. Previous Sexual Condition.............................................. 33 Catamenia—antecedents of first discharge—first discharge —subsequent discharges—health in intervals—suspensions —final cessation, 26 — Sexual intercourse, marriage, 27 — Masturbation, 28 — Pregnancies, 29 — Labours, 30--Mis- carriages, 31 — Children, 32 — Lactation, 3C D. Family History of Patient......................;....................... 35 Parents, 34 — Uncles or aunts, 35 — Brothers or sisters, 36 ■— Children, 37 — Nephews or nieces, 38 — Family diseases and peculiarities, 39. ' The numbers thus placed refer to the numbered paragraphs of the work. Where the heading of-ft paragraph is placed between commas, it indicates that the paragraph referred to contains points for observation of special importance in medico-legal inquiries. CONTENTS. Page \ III. The Course of Existing Disease prior to the Patient coming under observation........................................ 37 Circumstances attending seizure, 40. A. Prodromata.................................................................... 37 Atmospheric states and changes, 41 — Exposure, to heat or cold, 42 — Exposure to atmospheric impurities, 43 — In- gesta—food—drinks—medicines, etc., 44 — Sources of me- chanical injury, 45 — Alterations in health, 46 — Excesses, 47 — Exposure to epidemic or endemic influences, 48 — Al- terations in pecuniary circumstances, etc., 49. B. Invasion.......................................................................... 39 Symptoms not necessarily peculiar to any particular disease — symptoms connected with particular organs, 50 — Mode of progress of disease, 51. C, Progress of Case up to Time of Observation................... 39 Order of symptoms, etc.—how long off work, etc., 52. \ IV. Condition of the Patient at the Time of Observation, 40 A. Generalities................................................................... 40 State of nutrition, 53 — Strength, 54 —Walk, 55 — Weight, 56 — Posture, 57 — Expression of countenance—face—fea- tures— eyes — lips—jaws, 58 — General sensations, 59 — Rigors, 60—Spirits, 61 — Temper, 62. B. Integument and its Appendages........................................ 42 Generally........................................................................ 42 Surface, 63 — Colour — generally — locally, 64 — Tempera- ture, 65 — Cuticle, 66 — Sebaceous follicles—oiliness, 67 — Perspiration, 68 — Vascularity, 69 — Contusion and pres- sure marks, 70 — Old scars and marks of previous disease, 71 — Hair—on head—on other parts, 72 — Nails, 73— Sub- cutaneous cellular tissue, 74—"Serum of vesications," 75 — Sensibility, 76. Special eruptions.............................................................. 44 Locality of eruption, 77 — Forms of eruption — flat or mi- nutely rough—elevated—depressed or with ulceration, 78 — Cicatrices, 79 — Alterations of sebaceous follicles, 80 — Al- terations of hair, 81 — Alterations of nails, 82. C. Organs of Locomotion...................................................... 47 Joints, 83 — Bones, 84—Periosteum, 85 — Tendinous and fibrous structures, 86 — Muscles, 87. D. Organs of Digestion........................................................ 48 Mouth............................................................................ 48 "Lips—labial glands," 88 — Gums, 89—Teeth — mastica- tion, 90—"Cheek, palate, cavity of mouth—buccal mem- brane"—buccal glands—Steno's ducts, etc., 91 — Tongue— papillas—furs—sensations, etc., 92 — Protrusion of tongue, 93 — Odour of breath, 94 — Taste in mouth, 95. x CONTENTS. Page Salivary Glands.............................................................. 50 Parotid, 96—-Sublingual, 97—Submaxillary, 98—Saliva, 99. Throat, etc....................................................................... 51 Uvula, 100 —Soft palate, 101 —Fauces, 102 — Tonsils, 103 — "Pharynx," 104 — Oesophagus, 105 — Deglutition, 106 — Regurgitation — regurgitated matters, 107. Physical examination of the Abdomen generally......................... 52 Inspection, 108—Measurement, 109 — Palpation, 110 — Percussion, 111 — Auscultation, 112. Physical Examination of the Liver, Gall-bladder, and Ducts........ 57 Inspection, 113 — Palpation, 114 — Percussion, 115 — Aus- cultation, 116. Physical examination of the Spleen......................................... 58 Inspection, 117—Palpation, 118 — Percussion, 119 — Aus- cultation, 120. Physical examination of the Stomach...................................... 59 Inspection, 121 — Palpation, 122—Percussion, 123 — Aus- cultation, 124. Physical examination of the Colon, Rectum, and Anus................ 60 Inspection—examination by speculum, 125 — Palpation — examination per anum—examination by bougie, 126 — Per- cussion, 127 — Auscultation, 128. Physical examination of Abdominal Tumours............................ 61 Inspection, 129 — Palpation, 130 — Percussion, 131 — Aus- cultation, 132. General Symptoms referable to the Abdomen.............................. 64 Abnormal sensations—pain, etc., 133 — Tenderness, 134 — Appetite — weight of food eaten — nature of food, 135 — Thirst — quantity drunk — nature of drink, 136—Nausea, 137—Vomiting, 138 —"Vomited matters," 139 —Eructa- tion or regurgitation — eructated or regurgitated matters, 140 — Hiccup, 141 — Defalcation, 142—" Stools — their constituents, etc.," 143—Anus, 144. Results of Paracentesis Abdominis......................................... 68 Operation, 145 — Matters removed, 146-—Physical exami- nation of abdomen after tapping, 147. E. Organs of Respiration..................................................... 69 Nares, etc........................................................................ 69 Nares—discharge from them—haemorrhage—movements of alto, 148 — Sensibility, 149—Sneezing, 150—Frontal sinus- es, 151. Upper Air Passages and Vocal Apparatus-............................... 70 Examination of throat externally — size of larynx and tra- chea, etc.—manual examination—percussion—auscultation, 152 —Epiglottis, 153 —Glottis, 154 —Sensibility, 155— Voice, 156 — Other symptoms, 157. B xi CONTENTS. Page Physical examination of the Lungs, Pleural, etc........................ 71 Inspection, 158 — measurement — chest-measurer — spiro- meter, 159 — Palpation, 160 — Percussion, 161 — Auscul- tation, 162. General Thoracic Symptoms................................................. 74 Pain in chest — other sensations, 163 — Tenderness, 164 — Cough, 165 — Expectoration, 166 — Sputa, 167 — Expecto- ration of blood, 168 — Respiration — dyspnoea, etc., 169 — Expired air, its characters, 170. Results of Paracentesis Thoracis............................................ 77 Operation, 171 — Matters removed, 172. Diaphragm...................................................................... 77 Level of diaphragm—pain—hiccup—movements, 173. F. Organs of Circulation.—Blood......................................... 77 Physical examination of the Heart and Pericardium................... 77 Inspection, 174 — Measurement, 175—Palpation, 176 — Percussion, 177 — Auscultation—sounds—murmurs, 178. General Cardiac Symptoms.................................................. 80 Pain—other sensations—tenderness, 179 — Palpitation, 180. Arteries........................................................................... 80 Inspection, 181—Palpation, 182 — Auscultation, 183 — Radial pulse, 184. Swellings connected with Arteries............................................ 81 Inspection, 185—Palpation, 186—Measurement of tumour, 187 — Percussion, 188 — Auscultation, 189 — Rupture of swelling, 190 — Abnormal sensations, 191. Veins............................................................................. 82 Inspection, 192 — Palpation, 193 — Auscultation, 194 — Condition of skin over veins, 195. Sivellings connected with Veins.............................................. 83 Physical examination, 196—Abnormal sensations, 197. Blood............................................ ................................ 83 Phlebotomy or arteriotomy—circumstances of—condition of patient, etc., 198 — Characters of blood drawn—process of coagulation—clot—serum, 199 — Microscopical examination of blood—from finger of patient—drawn from a vein, 200— Chemical examination of blood, 201. G. Lymphatic System............................................................ 84 Lymphatic vessels, 202 — Lymphatic glands, 203. H. Urinary Organs.—Urine.................................................. 85 Physical examination of the Kidneys, Supra-renal Capsule, and Ureters........................................................................ 85 Inspection, 204 — Palpation, 205 — Measurement, 206 — Percussion, 207 — Auscultation, 208. xii CONTENTS. Physical examination of Bladder and Prostate Gland................. 86 Physical examination of hypogastric region—inspection__ palpation —percussion—auscultation, 209 — Examination through rectum, 210— Examination through vagina, 211 — Catheterism, 212. Physical examination of Urethra........................................... 86 Inspection — discharge — stains on linen, 213 — Palpation, 214 —Catheterism, 215. General Symptoms referable to the Urinary Organs.................... 87 Pain — other sensations, 216 — Tenderness, 217—Mictu- rition, 218 — Haematuria, 219. Urine............................................................................ 88 Quantity, 220 — Characters of urine, 221 — Microscopical examination of deposit,222—"Chemical examination,"223. I. Organs of Generation...................................................... 90 1. Female........................................................................ 90 Pudendum....................................................................... 90 Labia, nymphae, and clitoris, 224 — Abnormal sensations, 225 —Urethral orifice, 226 —"Hymen," 227—Protrusion from vulva externally, 228. Examination by the touch, through the Vagina.......................... 91 Vagina—orifice—direction, etc., 229—Urethra, 230—Blad- der, 231 — Uterus—neck—lips—orifice—body—cavity, 232 — Tumour felt through wall of vagina—ovaries and Fallo- pian tubes, 233. Examination through the Vagina and Abdominal Wall conjoined... 93 Continuity of tumour—size, etc., 234. Examination by the touch, through the Rectum.......................... 94 Introduction of finger — of bougie, 235 — Uterus — ovaries and Fallopian tubes, 236 — Bladder, 237—Tumour, 238. Examination through the Rectum and Abdominal Wall conjoined... 94 Particulars, 239. Examination through the Rectum and Vagina conjoined............... 94 Thickness between fingers, etc., 240. Examination by the Uterine Sound......................................... 95 Introduction of sound—uterine cavity—thickness of wall, etc., 241 — Movableness of uterus, 242. Examination by the Speculum............................................... 95 Introduction of speculum, 243—Vagina—surface—openings, etc., 241—Orifice of uterus, 245—Lips and neck of uterus, 246. General symptoms referable to the Female Generative Organs........ 96 Catamenia — periods, etc. — physical characters of fluid — suppression, 247 — Haemorrhage, 248 — Liquid discharge from vagina—circumstances—characters, 249 — Discharge of gas from vagina, 250—Solid or organized matters dis- charged from vagina, 251 — Pain in vagina, 252 — Pain in pelvis, 253 — Itching, 254 — Sexual intercourse, 255. xiii CONTENTS. Page Mammal......................................................................... 98 Physical characters of mammae—nipple—areola—substance of gland, etc., 256 — Pain in breast, 257. 2. Male........................................................................... 98 Scrotum, 258 — Testicles, 259 — Penis, 260 — Spermator- rhoea, 261. K. Encephalon and its Coverings and Appendages................ 99 Examination of Cranium, etc............................................... 99 Cranium—form—measurement—facial angle—bones—fon- tanelles—sutures, 262 — Integuments—temperature, etc.— hair, 263 — Tumours, 264 — Auscultation, 265. Alterations of Sensibility.................................................... 100 Pain in head, 266 — Altered sensibility of skin—increased — diminished — perverted, 267 — Muscular sense, 268 — Other alterations of sensibility, 269. Alterations of Motility....................................................... 102 Attitude—erect—in decumbency — in sitting — in progres- sion, 270—General muscular agitation—tremblings—mus- cular twitchings — unsteadiness of limbs, 271 — Automatic movements, 272 — Slow movements of extension or of flexion, 273 — Power of directing movements, 274 — Rigid- ity, 275—Spasmodic contractions, 276—Convulsion—ante- cedents — phenomena — sequences, 277 — Other spasmodic phenomena—strabismus, etc., 278 — Cataleptic immobility, 279 — Paralysis — limbs — thorax and abdomen — face — tongue—articulation—muscles of deglutition—stomach — rectum — anus — bladder — larynx, 280— Muscular irrita- bility of paralysed parts, 281. Intellectual and Moral Faculties........................................... 107 Consciousness, 282—Sleep,283—Dreaming—incubus—som- niloquism—somnambulism, 284—Behaviour, 285—Temper, 286 — Spirits, 287 — Attention — exaggerated — defective, perverted, etc., 288—Apprehension, 289—Memory—exag- gerated—defective—perverted, 290 — Speech, 291—Con- versation, 292 — Confessions and complaints of patient re- specting his mental condition, 293—Disordered judgment— reasoning, 294 — Fixed delusion or predominance of one idea, etc., 295—Hallucinations, 296—Illusions, 297—Deli- rium, 298 — Alterations in moral feelings and affections, 299 — Sexual passion, 300. »i. Spinal Cord, its Coverings and Appendages..................... 114 Physical examination of the Spinal Column............................. 114 Curves—antero-posterior—lateral, 301—Spinous processes, 302 — Vertebral grooves, 303 —Tumour, 304—Fistulous openings, etc., 305 — Other appearances, 306 — Examina- tion of spine anteriorly, 307 — Percussion, 308. General Symptoms referable to the Spinal Cord, etc.................... 115 Manual examination of spinal column—by finger—by per- cussion, etc., 309 — Local spontaneous pain, 310 — Altera- tions of sensibility, 311—Alterations of motility, 312. xiv CONTENTS. M. Organs of the Senses.................................................... 116 Organs of Touch.............................................................. 116 Particulars, 313. Organs of Smell............................................................... 117 Physical examination, 314 — Sense of smell, 315. Organs of Taste................................................................ 11 Physical examination, 316 — Sense of taste, 317. Organs of Hearing............................................................ 117 Physical examination—external ear—mastoid process — meatus externus — Eustachian tube — membrana tympani, 318—Pain referred to the ear, 319—Sense of hearing, 320. Organ of Vision and its Appendages...................................... 119 Eyebrows—eyelids—eyelashes—tarsal cartilages, etc., 321 —eyeball generally—conjunctiva—sclerotica—cornea—iris —pupils, etc., 322—Tears, 323—Pain—sensibility to light, 324 —Sense of sight, 325. N. Nerves........................................................................... 122 Pain—other sensations—tenderness, etc., 326. 0. Vascular Glands............................................................ 122 Thyroid gland—thymus gland—supra-renal capsule, 327. § V. Treatment............................................................. 123 A. Regimen......................................................................... 123 Residence — apartment, 328 — Clothing, 329 — Avoidance of exposure, 330—Cleanliness, 331—Rest, 332—Exercise, 333 — Posture, 334—Moral and mental treatment, 335 — Occupation, 336 — Sleep, 337 — Relinquishment of habits, 338 — Marriage, etc., 339. B. Diet.............................................................................. 124 Solid food—animal—vegetable—meals, 340 — Liquid food —water—animal broths—milk—vegetable infusions, etc.— meals, 841 — Condiments, 342 — Alcoholic drinks, 343 — Meals, 344 — Artificial introduction of food, 345. C. Operations..................................................................... 125 Bloodletting, 346—Leeching, 347—Cupping, 348—Trans- fusion, 349— Acupuncture, 350—Incision, tapping, etc., 351 — Ablation, 352 — Seton, 353. D. External Appliances....................................................... 126 Pressure—bandage—truss, etc., 354—Friction, 355—Elec- tricity—electro-puncture, 356—Actual cautery, 357—Hot button, 358 — Ice, etc., 359 — Hot dry applications, 360 — General baths — hot-air —vapour — water, 361 — Local baths, 362—Dry cupping, 363—Medicinal substances, 364. B 2 XV CONTENTS. Page E. Internal Appliances........................................................ 128 Mechanical appliances—catheter — bougie, etc., 365 — Lo- tions, etc., 366—Injections, 367 — Inhalations, 368 — Topi- cal applications to mucous surface by the hand, 369 — Medicines swallowed, 370. Progress of Case—administration and effects of remedies—cessation of symptoms—period of recovery—phenomena of death.... 129 PART II. EXAMINATION OF A BODY AFTER DEATH............... 131 § I. Points to be Ascertained and Noted Prior to com- mencing an Examination........................................... 131 Name, 371 —Date of death, 372 — "Date of examination," 373 — Weather — temperature, 374—"Medium in which body has lain," 375—"Substance on which body has lain," 376—Posture of body, 377—" Position of body in relation to the room, etc.," 378 — "Odour in the room," 379 — "Clothing on and near the body—stains of various kinds," 380—"Degree of manipulation to which body has been exposed," 381 —"Cord, etc. round neck," 382— "Articles about the body," 383 — Faeces and urine found under the body, 384.— "Examination of body," 385. \ II. Points to be Noted during an Examination.............. 134 A. Generalities................................................................... 134 Sex, 386—Apparent age, 387—"Posture of body," 388 — " Expression of countenance," 389—Measurements of body, 390—Weight of body, 391—" Striking individual peculiari- ties," 392—Temperature of body, 393—Cadaveric rigidity, 394—Nutrition of body, 395—" Putrefaction of body," 396. B. Integument and its Appendages........................................ 135 " Colour of surface," 397—" Cuticle," 398—"White lines," 399 — " Contusions," 400 — " Eruptions, etc.," 401 — " Burns," 402—" Mark round neck," 403—" Wounds, cica- trices, etc.," 404—"Hair," 405 —"Nails," 406—CEdema, 407 — Emphysema, 408 — Subcutaneous fat, 409. C. Organs of Locomotion............................................ ......... 138 "Muscles," 410 — Tendons and aponeurosis, 411—-"Bones —fractures—peculiarities connected with age and sex, etc.," 412 — Thoracic cartilages, 413 — Intervertebral substance, 414 — Joints, 415. D. Organs of Digestion........................................................ 140 Mouth............................................................................. 140 "Lips," 416 —"Jaws," 417 —"Cavity of mouth," 418— " Gums," 419 —" Teeth," 420 —Cheeks, 421 —" Tongue," 422 — Hard palate, 423. xvi CONTENTS. Page Salivary Glands and Ducts.................................................. 142 Glands (Parotid, Sublingual, and Submaxillary, 424—Ducts, 425. Throat, etc....................................................................... 142 Fauces, 426 — Uvula and velum pendulum palati, 427 — " Tonsils," 428—" Pharynx" —pharyngeal muscles, 429— " CEsophagus," 430. Abdomen generally............................................................ 144 " External characters," 431 — " Umbilical cord," 432. Peritoneum...................................................................... 144 Contents, 433—Condition of membrane, 434—Herniae, 435 — Tumours, 436 — Sub-peritoneal tissue, 437 — Mesenteric and other lymphatic glands, 438. Stomach.......................................................................... 145 External characters, 439—"Contents," 440 — "Mucous membrane," 441—Muscular coat, 442—" Substance of wall of stomach," 443 — Cardiac opening, 444 — Pylorus, 445. Intestines generally............................................................ 148 External characters, 446—" Contents," 447—Mucous mem- brane : secretions, etc., on surface of, 448 — Muscular coat, 449 — "Substance of wall of intestine," 450. Special portions of Intestines................................................ 150 Duodenum—Brunner's glands, 451—"Jejunum and ileum— valvulaB conniventes — villi — Peyer's patches — solitary glands — crypts of Lieberkuhn," 452 — Caecum — appendix vermiformis—ileo-csecal valve, 453—Colon—solitary glands, 454 — Rectum, 455. Liver.............................................................................. 151 External characters, weight, measurements, form, etc., 456 — Capsule, 457—.Substance, 458 — Veins, 459—Hepatic ducts, 460. Gall-bladder..................................................................... 154 External characters, 461—Cavity, 462—Walls, 463—Ductus communis choledochus—cystic duct, 464. Spleen............................................................................ 154 External characters, 465 — Substance, 466. Pancreas......................................................................... 155 External characters, 467 — Substance, 468 — Duct, 469. E. Organs of Respiration..................................................... 156 External characters of thorax, 470. Pleurce........................................................................... 156 Contents, 471 — Condition of membrane, 472 — Sub-pleural tissue, 473 — Subjacent bony and muscular parietes of thorax, 474. Nares............................................................................ 156 Malformations—closure, etc., 475 — Bones, 476 — Mucous membrane, 477. xv ii CONTENTS. Page Larynx, Trachea, and Bronchial Tubes................................... 156 Generalities, 478—Larynx (epiglottis, rima glottidis, car- tilages, etc.), 479 —"Trachea," 480 —"Bronchi," 481. Lungs............................................................................ 158 Examination in situ, 482—"External characters," 483 — Substance—bronchial tubes, 484 — Extravasation of blood, 485 — Adventitious products, 486 — Cavities, 487 — " Hy- drostatic test," 488. Diaphragm...................................................................... 161 Position—substance, 489. F. Organs of Circulation..................................................... 161 Pericardium..................................................................... 161 External characters, 490 — Contents, 491 — Internal sur- face, 492. Heart............................................................................. 162 Examination in situ—position—shape—measurements, etc., 493 — Examination after removal, 494 — Right auricle, 495 —Right auriculo-ventricular opening, 496—Right ventricle, 497 — Tricuspid flaps, 498 — Sinus arteriosus, 499—Pul- monary opening, 500—Pulmonary valves, 501—Left auricle, 502—Left auriculo-ventricular opening, 503—Left ventricle —septum ventriculorum, 504 — Mitral flaps, 505 — Aortic opening, 506—Aortic valves, 507—Coronary arteries, 508— Substance generally—weight—wounds—growths, etc., 509. Arteries........................................................................... 165 Examination before opening vessel, 510—Examination after opening vessel, 511 — "Ductus arteriosus," 512 — Micro- scopical characters, 513. Dilatation of Arteries, and Aneurisms.................................... 166 External characters, 514 — Characters after opening dila- tation, 515. Veins............................................................................. 168 Examination before opening vessel, 516—Examination after opening vessel, 517. Blood............................................................................ 169 Physical characters — microscopical characters — chemical characters, 518. G. Lymphatic System............................................................ 169 Lymphatic Glands............................................................. 169 Characters observed before section, 519 — Characters ob- served after section, 520 — Special lymphatic glands—cer- vical—axillary, etc., 521. Lymphatic Vessels............................................................. 170 Size, consistence, etc.—lymph, 522. Lacteal Vessels.................................................................. 170 Particulars, 523. xviii CONTENTS. Page H. Urinary Organs.............................................................. 170 Kidneys and Ureters.......................................................... 170 Absence, etc., 524 — External characters—position—size— etc., 525 — Capsule, 526 — Surface of kidney after removal of capsule, 527 — Substance of kidney, 528 — Cut surface, 529 — Cortical substance, 530 — Pyramidal position, 531 — Mammillae, 532 — Abnormal growths and deposits, 533 — Pelvis of kidney, 534 — Ureters, 535. Urinary Bladder............................................................... 173 External characters—size—position, etc., 536—Contents— urine, etc., 537 — Walls, 538 — Mucous membrane, 539. Urethra.......................................................................... 174 Direction — calibre, etc. 540 — Mucous membrane, 541 — Contents, 542. I. Organs of Generation...................................................... 174 1. Female...................................................................... 174 "Labia, nymphae, and clitoris," 543—Urethral orifice, 544 — " Hymen," 545. Examination of Generative Organs by the Introduction of the Finger......................................................................... 175 Vagina, 546—Uterus, 547—Ovaries and Fallopian tubes, 548. Examination in situ............................................................ 176 Uterus, 549—Fallopian tubes, 550 — Ovaries, 551 — Pelvic tumour, 552. Examination after removal................................................... 176 Uterus—lips—external characters—weight—measurements —form, etc.—characters observed on section—uterine wall —uterine cavity, ovum, 553 — Fallopian tubes—calibre — contents, etc., 554 — Ovaries—external characters—condi- tion of sheath—characters of section, 555 — Vagina, 556. " Mammai...................................................................•...... 179 External characters—nipple—areola, etc., 557 — Section of gland, 558. 2. Male........................................................................... 179 Inguinal canal, 559 — Testicles, 560 —Vasa deferentia, 561 __Spermatic cord, 562—Tunica vaginalis, 563 — Vesicuke seminales, 564—Prostate gland, 565 — Penis, 566. K. ENCEniALON AND ITS COVERINGS AND APPENDAGES................ 180 " External examination of integument and cranium," 567 — "Scalp," 568—"Cranium," 569 — Dura mater, 570 — Arteries at base of brain, 571 — Arachnoid membrane, 572 —Sub-arachnoid serosity, 578—Pia mater, 574—Sinuses of dura mater, 575. Brain...................................._•...................................... 184 Generalities—weight, etc., 576. xix CONTENTS. Page Cerebrum................................................................. ...... 184 Points to be observed before removal of arachnoid and pia mater, 577—Parts at base of brain, 578—Removal of arach- noid, 579—"Convolutions externally," 580 — Section of Convolutions, 581—White substance of hemispheres, 582— Extravasation of blood, 583—Cavities in cerebral substance, 584 — Cicatrices in cerebral substance, 585 — Wounds of cerebral substance, 586 — Adventitious products, 587 — Minute vessels of brain, 588 — " Lateral ventricles, velum interpositum, etc." 589 — Septum lucidum—fifth ventricle, 590—Fornix, 591 —Third ventricle, 592 — Optic thalami and corpora striata, 593—Condition of parts on upper sur- face of pons Varolii—pineal body, etc., 594. Pons Varolii..................................................................... 189 External characters, 595 — Appearances on section, 596. Medulla Oblongata............................................................. 189 External characters, 597 — Fourth ventricle, 598—Section of medulla oblongata, 599. Cerebellum....................................................................... 190 External characters, 600 — Section of cerebellum, 601 — Peduncles of cerebellum, 602. L. Spinal Cord and its Coverings and Appendages................ 190 Integuments over spine, 603—Vertebrse, 604—Intervertebral substance, 605 — Vertebral canal, 606 — Theca vertebralis, 607—Spinal arachnoid membrane, 608 — Cerebro-spinal fluid, 609—Ligamentum denticulatum, 610—Pia mater, 611. Spinal Cord..................................................................... 191 External characters, 612 — Section of cord, 613 — Roots of nerves, 614—Cauda equina, 615. M. Organs of the Senses..................................................... 192 Organs of Touch............................................................... 192 Integument—nerves, 616. Organs of Smell............................................................... 192 Nares—olfactory nerves, 617. Organs of Taste................................................................. 192 Tongue and fauces—nerves, 618. Organ of Vision and Us Appendages....................................... 193 "Eyelids," 619 —"Eyeball"—optic nerve, 620. Org&n of Hearing audits Appendages.................................... 193 External ear, 621 — External meatus—tympanic membrane, 622 — Internal ear—Eustachian tube, 623 — Osseous struc- tures, 624 — Auditory nerve, 625. N. Nerves............................................................................ 194 Nerve............................................................................. 194 External characters, 626—Neurilemma, 627—Nerve tissue, 628. XX CONTENTS. Ganglion........................................................................ 195 External characters, 629 — Sheath of ganglion, 630 — Sec- tion of ganglion—microscopical characters, 631. 0. Vascular Glands............................................................. 195 Thymus gland, 632—Thyroid gland, 633—Supra-renal cap- sules, 634. APPENDIX. Mucous Membrane.............................................................. 197 "Secretions and exudations on surface—mucus lymph__ blood," 635 — Condition of membrane—colour— transpa- rency—haemorrhagic spots—surface—epithelium, etc., 636 — Sub-mucous tissue, 637. Serous Membrane............................................................. 198 Contents—gas—liquid matters—solid matters—blood, 638 —Condition of membrane—adhesions—false membranes__ colour, etc., 639 — Sub-serous tissue, 640. Redness........................................................................... 200 Situation—extent—hue—form, etc., 641. Serosity........................................................................... 201 Amount—odour—etc.—chemical characters, etc., 642. Purulent-looking Fluid........................................................ 201 Quantity—colour, etc.—deposit, etc., 643. Lymph and other Exudations................................................ 201 Amount—colour—form—distribution — adhesion, etc., 644 — Substance of lymph or exudation, 645. Adhesions....................................................................... 202 Situation—colour, etc, 646. Abscess.......................................................................... 202 Diffused, 647—Circumscribed, 648—Opening, 649—Walls, 650—Contents, 651—Cicatrix, 652—Condition of parts sur- rounding abscess, 653. Fistula.......................................................................... 203 Orifices, 654—Fistulous passage or canal—termination—in- ternal orifices, 655 — Lining membrane, 656 — Discharge, 657 — Surrounding tissues, 658. Mortification—Gangrene—Sphacelus....................................... 204 External characters, 659—Line of Demarcation, 660—Dis- section, 661 — Motility and sensibility, 662 — Marks of in- jury, etc., 663 — Surrounding parts, 664. Ulcers............................................................................ 205 Number, etc.—edges—floor—granulations, 665. xxi CONTENTS. Page Perforations..................................................................... 206 Number—form—edges—direction, etc., 666. Wounds......................................................................... 206 "Facts ascertainable before dissection — number—seat — form—direction—edges, etc.," 667 — "Facts ascertainable by dissection—depth—parts divided—adhesions, etc.," 668 —" Examination of a weapon, if any discovered," 669. Cicatrices........................................................................ 208 On the surface of structures, 670 — In the substance of organs, 671. Tumours......................................................................... 209 Number—size, etc., 672—Superficial characters—surface— smoothness — colour, etc., 673 — Characters on section or fracture( 674. Cysts..............................,.............................................. 210 Number—situation—size, etc., 675 — Walls of cyst, 676 — Contents of cyst — hair—teeth — bones, 677 — Secondary cysts, 678. Cancer or Cancerous-looking Matter....................................... 211 External characters, 679 — Characters on section — loculi, etc., 680—Characters on fracture, 681—Effects of pressure, 682—Chemical characters, 683—Microscopical characters, 684. Tubercle or Tubercular-like Bodies......................................... 212 Situation—size—colour—consistence, etc., 685. Microscopical characters...................................................... 213 Granules—effect of re-agents, 686—Globules—effect of re- agents, 687—Fibres—effect of re-agents, 688—Cells—cell- wall—contents—nucleus — nucleolus—effect of re-agents, 689 — Crystalline or amorphous saline bodies, 690. Chemical examination of Urine............................................. 214 Re-action—sp. gr.—colour, etc., 691—Organic constituents —urea—creatine—fatty matter—uric acid—hippuric acid, etc., 692—Inorganic constituents—chloride of sodium—in- organic acids — inorganic bases, 693. Chemical examination of Urinary Deposits............................. 217 Lithates—starch—lithic acid—cystine—pus — phosphates, etc., 694. Chemical and Microscopical examination of Morbid Fluids............ 218 Reaction—sp. gr.—deposit, etc., 695—Examination of de- posit, 696 — Examination of fluid, 697. Chemical examination of Solid Textures................................... 220 Sp. gr., etc., 698 — Organic constituents, 699—Inorganic constituents, 700. xxii WHAT TO OBSEKVE IN MEDICAL CASES. PART I. CLINICAL EXAMINATION OF A PATIENT. § I.—The Personal Description and Pe- culiarities OF THE PATIENT IN HEALTH. [Individual peculiarities form part of the healthy standard by which the morbid character of observed phenomena is tested.1] Physical description and peculiarities. 1. Name :—Race :—country of birth. 2. Sex:—degree in which sexual characters are marked (general conformation, external sexual or- gans, mammae, voice, beard, etc.) 3. Age—real and apparent. 4. Anatomical peculiarities— Height; — width from acromion to acromion. Form of trunk: natural curves of spine, antero 1 From particulars of this kind the " temperament" of an individual is determined. c 25 Physical. peculiarities. Name—race. Sex. Age. Anatomical pe- culiarities— height— width—form of trunk. § I.] THE PERSONAL DESCRIPTION AND [PART I. measurements: of head. of neck. of trunk. limbs. weight. muscular de- velopment. cellulo-fatty development. skin. hair. complexion. countenance. eyes. lips. form of hands, etc. posterior and lateral dorsal; apparent relative size and length of thorax and abdomen; patient high shouldered or not? Measurements: of head; circular (over super- ciliary ridges and occipital protuberance), across vertex (from ear to ear), along middle line (from root of nose to occipital protube- rance):—of neck; circumference opposite cri- coid cartilage ;—of trunk ; circumference op- posite ensiform cartilage, midway between nipples and clavicles, at margin of false ribs, at level of umbilicus. Limbs : well or ill formed ? proportional and symmetrical or not ? Weight. Muscular development (in trunk and limbs): its degree; proportional or not in tipper and lower extremities ? symmetrical or not on the two sides of body ? Cellulo-fatty development: its amount; uniform or affecting a particular locality ? Skin : its colour; apparent coarseness or fine- ness ; visibility of subcutaneous veins. — De- velopment of hair, on the head and elsewhere; its colour; arrangement and mode of growth. — Complexion. Countenance of patient: its physiognomical ex- pression. — Prominence of eyes; colour and vascularity of conjunctivae; colour of irides, alike or not in the two eyes ? various in differ- ent parts of the same iris; size of pupil. — Thickness of lips, etc. Form of hands, fingers and feet; conformation of nails; condition of skin on hands, etc.; connection of the above with habits and occu- pation of the individual. 26 PART I.] PECULIARITIES OF THE PATIENT. [§!• 5. Physiologicalpeadiarities— Skin : its ordinary condition as to moisture and greasiness; readiness to sweat under exertion; proneness to sweat in certain localities, under what circumstances ?—characters of sweat as to abundance, odour, acidity, etc. ; colour of stain given to linen ? Muscular strength (measured by dynamometer); comparative strength of the two sides; power of enduring continued muscular exertion, whether of upper or lower extremities most remarkable ?—Patient right or left handed ? Digestive system : Saliva; abundance, reaction. — Natural amount of appetite; quantity of food habitually taken; which is the principal meal? time usually accorded to meals;—is any kind of food naturally and habitually avoided, and why ? is any followed constantly by symptoms of disease ? — Natural degree of thirst; quantity of drink habitually taken.— Habitual condition of the bowels, frequency and character of the stools. Respiratory system: natural frequency of respira- tion ;—readiness with which accelerated by ex- ercise, etc.; — respiratory capacity of chest as measured by spirometer; — natural pitch of speaking voice. Circulating system, etc. : sensibility to changes of temperature or of hygrometric state of atmo- sphere ;—readiness of reaction after chilling the surface; habitual warmth or coldness of feet and hands; — habitual character of the pulse as to frequency, fulness, force, and regularity;—ten- dency to blushing. Urinary system : habits of voluntary retention of urine or of frequent micturition; — readiness Physiological peculiarities. skin. sweat. muscular strength. digestive system. appetite. thirst. state of bowels. respiratory system. circulating system. urinary system. § I.] INTELLECTUAL AND MORAL PECULIARITIES. [PART I. with which diuresis is produced by mental affec- tions ;—amount of urine customarily passed iu twenty-four hours; quantity of urea, uric acid, sulphates, phosphates, etc.;—reaction, effect of meals upon it. Generative system : sexual peculiarities; natural force of instinct.—Catamenia (26). Nervous system: nervous excitability; habitual effect of mental influenoes on the pulse and respiration;—habitual wakefulness or readiness to sleep; quickness or hebetude of senses. generative system. nervous system. Intellectual and Moral pecu- liarities. Intellectual peculiarities. Moral pecu- liarities. Intellectual and Moral peculiarities.1 6. Intellectual peculiarities :—amount of educa- tion; readiness to learn; character of favourite studies or reading;—habit of reading popular medi- cal works.—Habits of business; power and habit of concentrating attention.—^Readiness of conception.— Memory, generally or in respect of special subjects. —Reasoning powers and judgment;—habitual cha- racter of association of ideas, philosophical, etiologi- cal, utilitarian, poetical, trivial, etc. — Power of imagination.—Power of language and expression. 1. Moral peculiarities: — general behaviour. — Disposition cheerful or melancholy; communicative, reserved, or sulky; social or retiring?—Inquisitive or careless; closely observant or not of the state of the bodily functions and of variations in health ?— Amount of ambition, its direction; vanity; self- love ; love of applause; excess or deficiency of the 1 This subdivision has especial, but not sole, reference to cases of insanity; every man having his own standard of psychical health, by which presumed aberrations are to be judged. 28 PART I.] INTELLECTUAL AND MORAL PECULIARITIES. [§ I. above principles. — Natural boldness or timidity; fortitude.—General benevolence or malignity of dis- position ; readiness with which the passions are ex- cited.—Force of domestic affections ; of sexual love. — Force of sense of duty or of the moral sense; religious feeling; candour; integrity; veracity, or tendency to deceit and cunning.—Natural sympathy; tendencv to imitation.—Prudence.—Tastes, etc. c2 29 § H. A.] HYGEIA. [PART I. § II. A. Parentage. Infantile ma- nagement. Place of birth or of former residence. Present resi- dence— duration. dimensions, etc. drainage, etc. malaria. number of occupants. Occupation — character. posture dur- ing. § II. — The Previous History of the Patient. (Note from whom the particulars have been derived.) A.—HYGEIA. 8. Parentage: — what child (first, second, third, etc) ? — Age of parents at birth of patient. — Any known peculiarity, physical, intellectual, or moral, in either parent at time of conception, or of birth. 9. Infantile management: — nursed by mother; by some other person ; for what period ? —brought up by hand, entirely or partially. 10. Place of birth or of former residence: — length of time resident in each; — ever abroad, or in intertropical climates ? 11. Present residence: — for what period? if in London, or some other large town, how long resi- dent there? — dimensions of residence; — its venti- lation, lighting, warming, etc. — its position, on high or low ground ? its aspect. — Drainage; neighbour- hood of fens, standing or running water, sewers, cesspools, trees or buildings. — Exposure to noxious gases and vapours, animal, vegetable, or inorganic (from manufactories, etc.) — Number of occupants in house or apartment, by day and by night 12. Trade or occupation: — age at which com- menced. —^ Change of occupation at any time, and the reason of it. — Precise character of work; hy- gienic condition of work-room (11); habitual ex- posure to cold and wet. — Posture during work; pressure made on any part of body. — Number of 30 PART I.] HYGEIA. [§ II- A. hours employed, by day and by night. — Weekly wages : number of persons dependent on individual; whether without work of late or at any other time ? 13. Food: — quantity obtainable or habitually taken.—Quality ; frequency of animal food, of salt- ed food; vegetables taken in sufficient quantity or scantily. — Meals; their number, regularity ; hours of meals; time given to each. — Mastication of food. 14. Drink: — quantity habitually taken.—Qua- lity ; water or alcoholic beverages. — Supply of water for drinking, etc. from springs (of what kind ?); from public companies (the source whence they ob- tain their supply). — Time of the day when alco- holic drinks are taken ; taken in place of food; be- fore, with, or after meals. — Habit of tippling (liquor commonly used); habit and frequency of intoxication. — Habitual use of strong tea or coffee, cool or very hot ? 15. Clothing and firing : — sufficient or not, by day and by night? use of flannel clothing; cloth- ing of feet. — Habitual use of tight stays or neck- cloths.—Sufficiency of bedding and bedclothes. 16. Cleanliness : — of person ; habitual change of clothing; ablutions; habitual use of baths, and of what kind ? of sea-bathing; — of bedding and bedclothes; their saturation with urine, discharges, etc.; purification of them; of habitation; flooring, walls; frequency of whitewashing; if a public in- stitution, the use of water or dry rubbing in | leansing the wards ? etc. 17. Exercise : — number of hours devoted to it; place; time of day; special character of exercise. 18. Sleep:—number of hours habitually taken; period of twenty-four hours in which taken; rest habitually broken or undisturbed ? 31 hours. wages. Food- quantity. quality. meals. mastication. Drink— quantity. quality. intoxicating drinks. strong tea or coffee. Clothing and firing. tight liga- tures. bedding. Cleanliness— of person. bedding. habitation. Exercise. Sleep. § II. B.] PREVIOUS GENERAL HEALTH. [PART I. Study. Medicines. Narcotic drugs — opium. tobacco. Peculiar habits Venereal in- dulgences. § II. B. Infantile health — vaccination. re-vaccina- tion. variolous in- oculation. diseases. dentition. Adult health- diseases. 19. Study :—number of hours habitually devoted to it; its special nature and object. 20. Medicines or other therapeutical agents ha- bitually used (purgatives, issues, blisters, bloodlet- ting, chloroform, etc.); ostensible reason for their use. 21. Habitual use of narcotic drugs, etc.—Opium, quantity used (stating whether the information is derived from the patient or from other sources); how long habituated to it? — Tobacco; mode of using it (by smoking, snuffing, or chewing); quan- tity used daily or weekly; habitually used before or after meals. 22. Peculiar habits. 23. Venereal indulgences; habitual frequency.— Masturbation (28). B. PREVIOUS GENERAL HEALTH. 24. Infantile health.—Vaccination; age at which performed; its success. — Re-vaccination; age at which performed ; its success; — character of cica- trices. —Variolous inoculation; age at which per- formed; severity or mildness of disease; number of pustules; — character of cicatrices. — Principal diseases from which patient has suffered (scalp diseases; sore eyes, ears, lips, nose; glandular swellings; tumid abdomen; worms; fits or convul- sions; laryngismus stridulus; measles; scarlatina; small-pox; hooping-cough ; rheumatism); — dates of occurrence, duration, severity, and sequelae of each. — Dentition; period of commencement of first and second; — their connection in point of time with diseases of patient. 25. Adidt health.—Diseases from which patient has suffered (general loss of strength, colour, spirits, etc.; local or general pains; fevers; inflammations; 32 PART I.] PREVIOUS SEXUAL CONDITION. [§ n. c. haemorrhages, from mouth, gums, nose, lungs, stomach, bowels, urinary or genital organs, skin, frequency and amount of them ; colds; coughs; gas- tro-iutestinal derangements; piles, etc.; rheuma- tism, acute or chronic, with or without probable cardiac complication as judged of by the employment of cupping, leeching, or blistering, over the region of the heart during treatment of one or more attacks; delirium tremens; special diseases arising from trade, e. g., lead-colic; hysterical or other fits; menstrual derangements; venereal diseases, their sequelae; ulcers, scars observable; hernia; acci- dental injuries, to great cavities, etc.); — precise period at which each occurred; its duration, severity, sequelae, repetition.—Treatment adopted, especially venesection and salivation. — Previous attacks of disease similar to the present. C.—PREVIOUS SEXUAL CONDITION. 26. Catamenia.—Antecedents of first discharge: social condition and habits, etc. ;—bodily or mental phenomena observed (marked alteration in conduct, local pains, swelling of the breasts, leucorrhcea, vaginal pruritus, particular states of any bodily functions, etc.) — First discharge: precise age of patient; month, day of month ; by night or by day; —character of discharge, its colour, odour, consist- ence; accompanied by coagula or not?—attended by pain or other suffering, hysteric paroxysm, etc.; followed by development of mammae or limbs.— Subsequent discharges: regular or irregular from first; if irregular, when and from what cause?— exact periods of recurrence, especially of second discharge; — how commenced and attended, by sacral, femoral, mammary or hypogastric pains, treatment. previous at- tacks similar to the pre- sent. \ II. C. Catamenia—■ antecedents of first dis- charge. first dis- charge. date. character. accompani- ments. subsequent dis- charges— regu- larity. accompani- ments. § II. C.] PREVIOUS SEXUAL CONDITION. [PART I. duration. quantity. quality. circum- stances affecting. health in intervals. suspensions. cause of. final cessa- tion. age. accompani- ments. Marriage. Masturbation. Pregnancies — accompani- ments. menstrua- tion during. cephalalgia, swelling of breasts, constipation, di- arrhoea, hysteric paroxysm, etc. ? — duration of discharge in days, variable or constant; — its quantity, variable or constant ? proportional each day;, its quality, colour, odour, coagula;—circum- stances which have influenced discharge, whether, residence in town or country, moral emotions, over- work or exercise, riding, dancing, immersion of feet or hands in cold water, baths, venesection, medi- cines, enemata, etc.;—effect of catamenial discharges upon any particular function, upon temper, upon general bodily or mental activity. — Health at intervals: leucorrhoea preceeding or following dis- charge, its duration, quantity, quality, (249).— Suspensions of catamenia: times of their occur- rence; period of discharge at which they occurred; their presumed cause;—influence exerted by them, on the function subsequently, on the general health. —Final cessation : age of patient; change of social condition, etc. preceeding or accompanying it; cessation sudden or gradual ?—attended or not with general or local disturbance of any kind, by flushings, perspirations, indigestion, etc. ? 27. Sexual intercourse, marriage :—age at mar- riage, or first sexual intercourse; habitual frequency of intercourse. — Husband or wife living or not? — Subsequent marriages; their dates; age of patient when each was contracted. 28. Masturbation :—habit, when contracted ? 29. Pregnancies.—their number; duration; ge- neral character; — alteration in bodily functions or mental phenomena attending them; change of tem- per, spirits, etc.; constipation, diarrhoea, piles, etc. —Occurrence of menstruation during pregnancy, during every pregnancy or not ? number of months 34 PART I.] FAMILY HISTORY OP PATIENT. [§ LT. D. during which it has recurred; duration of discharge, in days. 30. Labours: — their number; dates of each; their character, natural, difficult, instrumental, com- plicated (with eclampsia, etc.); important sequelae, puerperal fever, phlegmasia dolens, mania, haemor- rhage, etc. 31. Miscarriages: — their number; dates of oc- currence ; month of pregnancy at which they oc- curred (noting on whose authority, or on what evidence each illness is stated to be a miscarriage); their presumed causes; their sequelae. 32. Children: — their number; period of time within which produced; their sex. 33. Lactation : — number of children nursed at a time; duration of each period of lactation; supply of milk.—Menstruation during lactation; its charac- ter, periodicity, duration; quantity, quality, etc. (26). D. — FAMILY HISTORY OF PATIENT. 34. Parents: — living or dead? age at which either died; —their general state of health ; diseases from which they were known to have suffered, ma- nia, syphilis, gout, etc.; their habits, temperate or intemperate? — fatal diseases, phthisis, etc. (proof derived from some distinct symptoms). 35. Undcs or aunts (noting whether paternal or maternal) : — diseases to which they have been sub- ject; — if dead, age at death and fatal diseases. 36. Brothers and sisters: — number of each living; number of each dead (note whether these were born before or subsequently to patient, and whether during the same or some other marriage); 35 Labours. Miscarriages. Children. Lactation— menstrua- tion dur- ing. \ II. D. Parents. Uncles or aunts. Brothers and sisters. § II. D.] FAMILY HISTORY OF PATIENT. [PART I. Children. Nephews or nieces. Family diseases, etc. — diseases from which they have suffered; ages at death; fatal diseases. 37. Children: — number of each sex; their health; any difference in the health of elder, younger, or of the two sexes; — children dead; ages at death; fatal diseases. 38. Nephews or nieces: — their health; —if any have died, ages at death, and fatal diseases. 39. Family diseases and peculiarities: — tem- perament; malformations; tendency to bleed on trifling injuries, etc. (sex presenting these peculiari- ties).— Fecundity of females. — Presumed family diseases; age at which any hereditary disease has appeared in any members of the family, epilepsy, insanity, phthisis, gout, etc. — General duration of life in family. 36 PART I.] PRODROMATA. [§ HI. A. § III. — The Course of Existing Disease prior to the patient coming under Observation. 40. Circumstances attending seizure:—precise period of first invasion, day of the week or month, hour of the day or night; symptom or symptoms from which commencement of illness is dated.— Where patient was at the time, in bed, in the street, etc. ? — How employed at the time ? — Occurrence of seizure during a meal, after a meal; quantity and nature of meal; length of time intervening. A. — PRODROMATA. (Note intensity of supposed cause or causes of ill- ness, the precise date of their application, their duration or repetition, and the exact period, in days or hours, between their application and the appearance of the first symptom of disease.) 41. Atmospheric states and changes: — tempera- ture; barometric pressure; dew-point; weather; direction and force of wind; electrical state; quan- tity of ozone, how determined ? etc. 42. Exjyosures:— to heat, in what way? insola- tion ? — exposure to cold, in what way ? — exposure to wet, in what way? — circumstances attending either of the above, and precautions subsequently taken; — use of cold baths or cold drinks when heated ; alterations in clothing. 43. Exposure to atmospheric impurities:—con- finement to close rooms and impure air; — respira- d 37 Circumstances of seizure. I III. A. Atmospheric states and Exposure to heat or cold. Atmospheric impurities. § ni. A.] PRODROMATA. [PART I. Ingesta — food. drinks. medicines. poisons. Mechanical injuries. Alterations in health. Excesses. Epidemic or endemic in- fluences. Altered cir- cumstances in life. tion of deleterious gases (chlorine, carbonic acid, sulphuretted hydrogen); of metallic vapours (fumes of lead, copper, etc.); of vapour of phosporus; of air containing metallic particles (e. g., during dry grinding, etc.); — exposure to marsh or other mias- mata;— are any precautionary means employed? 44. Ingesta. — Food: excess of, deficiency of; irregularity of meals; — use of unwholesome food ; prolonged use of salted provisions; — deficiency or excess of animal food; deficiency or excess of vege- table food, cooked or uncooked; —use of food cooked or preserved in poisonous vessels; introduction of poisons (e. g., white lead) from want of.cleanliness; use of certain special articles of diet (e.- g., mussek or other shell-fish, ergoted rye,'mushrooms, etc.) — Drinks: excess or deficiency of;—unwholesome or poisonous water (from leaden pipes or cisterns, com- munication with sewers, etc.); — intoxicating drinks, quantity taken; nature of liquid. — Medicines: abuse of. — Poisonous substances. 45. Sources of mechanical injury : — muscular efforts; violent exertion, etc.—Blows, falls, etc. 46. Alterations in health :—note general condition of health at time of attack;—excessive or defective evacuations, as to quantity and repetition ; character of evacuation;—suppression of any customary dis- charge, etc. 47. Excesses:—over-fatigue; loss of sleep; over- work, bodily or mental;—venereal excesses;—mental anxiety; violent emotion, grief, joy, fright, etc. 48. Exposure to epidemic or endemic influences : — duration and constancy of patient's residence in locality of disease; exposure to infection; inocula- tion. 49. Considerable alterations in pecuniary circum- stances or station in life. 3.8 PART I.] INVASION.—PROGRESS OF CASE. [§ III. B. C. B.—INVASION. (Note the exact date of commencement and cessation of each leading symptom.) 50. Symptoms not necessarily peculiar to any particular disease: —rigors, their severity, accom- panied or not by chattering of teeth or sense of chilliness? their recurrence; — sense of heat, of chilliness; sweating;—general pains or soreness; aching of limbs, loins, etc.; lassitude;—prostration of strength;—headache; somnolence;—abdominal pain; anorexia; thirst; nausea; vomiting; diar- rhoea, etc. — Symptoms connected with particular organs : skin, locomotive organs, organs of diges- tion, of respiration, etc. (following the order ob- served in § iv.) 51. Mode of progress of disease: sudden in in- vasion and subsequently stationary; ingravescent; remittent; intermittent; diminishing. C. — PROGRESS OF CASE UP TO TIME OF OBSER- VATION. (Note the symptoms in the order of their occurrence, with the precise date of the commencement and duration of each.) 52. How long off work in consequence of illness ? —Has patient kept his bed, and how long ?—If in hospital, etc., how was the place reached by patient ? was he able to walk there, and what was the dis- tance walked ?—Treatment employed. \ III. B. Symptoms— general. local. Mode of pro- gress of dis- ease. \ III. C. Order of symp« toms, etc. 39 IV. A.] GENERALITIES. [PART I. § IV.—Condition of the Patient at the Time of Observation. A.— GENERALITIES. 53. State of nutrition.—Amount of subcutaneous fat; corpulence, its degree ;—emaciation, its degree, peculiarities of tenseness or looseness of integument over deeper structures, degree to which eye is sunk in orbit; — condition of muscles, lessened or not ? firm, flabby. 54. Strength: — undiminished; diminished, de- gree of diminution of strength (weaker than usual, very weak, unable to stand, unable to rise in bed). 55. Walk:— uncertain; fearful; staggering, etc. 56. Height — Weight. 57. Posture :—indifferent;—recumbent, on back, on right or left side, diagonal,1 twisted, with legs extended or drawn up ? with shoulders elevated;— sitting, supported or propped up? with head bent forwards; with arms thrown forwards; with arms pressing abdomen. — Patient composed; restless; trunk and limbs tranquil, but head restless; jactita- tion.— Posture of head in erect or recumbent po- sition or in progression (head supported and steadied by the hands, chin resting on breast, etc.) — (See also 270.) 58. Expression of countenance:—natural (calm, cheerful); suffering (anxious, haggard, risus sardo- nicus); heavy (indifferent, inattentive, melancholic, idiotic); excited (wild, fierce, threatening, surprised, 1 "Diagonal"—i. e., midway between back and side. 40 PART I.] GENERALITIES. [§ IV. A. agitated, terrified); imploring. — Face : pale, very pallid; flushed generally, locally, colour of flush (dark, pink, etc.); locally flushed, but elsewhere pallid ; alternating flush and pallor. — Features: pinched, drawn, distorted (in what way ?); lips re- tracted ; eyelids surrounded by an areola, its colour, size. — Eyes: natural; open, half closed, closed, drooping ;—heavy; glistening ; suffused ; glazed;— staring fixedly, at observer, at some supposed object, at vacancy. — Lips : open, closed, compressed; — their colour natural, pale, livid, etc.—Jaws: open; clenched. 59. Sensations of patient.—General feeling of ill- ness, in what way ? feeling of getting worse, in what way ? feeling of improvement, in what way ?—Sensa- tion of heat, of flushing; of chilliness, cold, creep- ing, shivering (267) ; circumstances under which either occur.—Sensitiveness to atmospheric changes of temperature, etc.—Sense of sinking through bed; apprehension of falling, etc.—Pains (269). 60. Rigors:—their severity; accompanied or not by chattering of teeth or by sense of chilliness? duration; period of occurrence; frequency; perio- dicity. 61. Spirits: — despairing, depressed, anxious, hopeful, elevated, variable; — disposition to laugh, to cry, to sigh, etc. 62. Temper :—natural; subdued, resigned; irri- table, violent (under what circumstances?); vari- face. features. eyes. lips. jaws. General sensa- tions. Rigors. Spirits. Temper. d2 41 § IV. B.] INTEGUMENT AND ITS APPENDAGES. [PART I. \ IV. B. Generally. Surface. Colour— generally. locally. Temperature-- to hand. to thermo- meter. to patient. Cuticle. Sebaceous fol- licles— oiliness. Perspiration— general. local. characters. B.—INTEGUMENT AND ITS APPENDAGES. Generally. 63. Surface :—soft, harsh; smooth, tense, shin- ing; wrinkled;—cutis anserina. 64. Colour—over body generally: natural to the individual; pale, waxy-looking; straw-coloured; greenish; yellow (its shade) ; dusky, livid.—Local alteration of colour: on cheeks ; over depending parts; over other parts;—apparent cause of colour, vascularity or pigment ? 65. Temperature—as felt by the hand: cool, cold, icy; — hot, very hot, pungent, mordant. — As ob- served by thermometer: in axilla; on front of chest; on being grasped by hand of patient; over-paralysed as compared with non-paralysed parts. — As expe- rienced by patient: comfortable ; — cold, creeping, shivering;—warm, hot, burning. 66. Cuticle: — desquamating (at wbat points ?); rough; scaly; thickened. 67. Sebaceous follicles:—of moderate size, large; — surrounding skin greasy or thickened; —orifices closed ; black points; orifices widely open; — scaly appearance around orifices. — General oiliness of surface. 68. Perspiration: — its amount, generally; skin very dry, dry, moist, sweating, sweating profusely (state how this is judged of).—Local perspiration, its situation and amount. — In the case .both of general and local perspiration, ascertain period of twenty-four hours when it occurs or is most abun- dant, and the circumstances which give rise to it; 42 PART I.] INTEGUMENT AND ITS APPENDAGES. [§ IV. B. its odour; colour (affecting colour of linen); reac- tion. 69. Vascularity of skin: — apparent enlargement of small arteries and capillaries, on cheeks, on nose, on other parts; — colour given to parts by such en- largement, rosy, dark, like a faded leaf. — Super- ficial veins (192). 70. Contusion and pressure marks: — their lo- cality ; colour, uniform, varying from centre towards circumference; — flat or elevated ? — borders well defined or otherwise ? — condition of cuticle over the marks, perfect, raised by effusion, detached par- tially or entirely; —condition of cutis vera, lacerated, ulcerated, gangrenous. 71. Old scars and marks of previous disease: — their locality (examine arms for vaccination or small-pox marks); their form, colour, general cha- racters. 72. Hair — on the head: its quantity; colour; — falling-off; thinning uniformly or falling-off in patches ? with desquamating cuticle or not ? (note condition of sebaceous glands). — On other parts of body : downiness between scapulae, on sternum. 73. Nails: — thick, thin, irregular, convex, in- curvated ; — their colour, livid, blue; presenting white patches or rings. — Excoriations and sores around nails, from picking, etc. 74. Subcutaneous areolar tissue: — puffy, cede- matous, pitting on pressure; special locality of oede- ma, its limits, its variations with posture, time of day, etc.; — if acupuncture be performed, chemical examination of dropsical fluid (695) (examine spe- cially for urea). — Thickened with exudation of any kind; indurated to the feel. — Emphysematous; crepitation under pressure of hand. Vascularity. Contusion and pressure marks. Old scars, etc. Hair — on head. on other parts. Nails. Subcutaneous areolar tis- sue — oedema. thickening. emphysema. 43 § IV. B.] SPECIAL ERUPTIONS. [PART I. Serum of vesi- cations. Sensibility. Special Eruptions. Locality. Forms of erup- tion — 1. Flat or minutely rough— arrange- ment— form. size. colour. surface. borders. sensation. 75. Serum of vesications: — its microscopical characters; its chemical characters (695) (examine specially for urea); "examine for arsenic," etc., in cases of "suspected poisoning." 1 76. Sensibility: — alterations of (267). Special Eruptions. 77. Locality of eruption ; its extent; symmetri- cal distribution. 7 8. Form s of eruption — Flat or minutely rough : — arranged in spots, in patches, in blushes,2 in lines; diffused.— Form; round, oval, serpentine, irregular.— Size. — Colour : white, pale-red, rosy, dark- red, livid, yellow, blue, grey-black, etc. : — effect of pressure on colour; unaltered, fading^ disappearing, and for what length of time ? — apparent cause of colour, vascularity, pigment changes, effusion of blood. — Condition of sur- face: smooth; minutely rough; apparent cause of roughness, changes in true skin, changes in cuticle; effect of pressure on roughness; — surface dry, moist (apparent cause of moisture). — Condition of borders : defined ; undefined, fading into colour of surrounding skin. — Sen- sation; spontaneous (itching, pricking, tingling, 1 Those points for observation which are, here or else- where in the work, included within commas, have special reference to medico-legal inquiries. ' The terms " spots, patches, and blushes" are arbi- trary divisions introduced for the sake of convenience; the "spots" are always small; the "patches" larger; and the "blushes" are not less in size than the palm of the hand. ' " Fading on pressure" — i. e., becoming less marked, but not altogether disappearing. 44 PART I.] SPECIAL ERUPTIONS. [§ IV. B. formication, etc.) ; — developed by pricking, etc. — Temperature. — Phenomena of disap- pearance as regards colour, roughness, sensa- tion, temperature;—consecutive condition of true skin and cuticle. Elevated:—apparent cause of elevation, thicken- ing of skin alone or accompanied by thickening of subcutaneous tissues? effusion of fluid be- tween cutis and cuticle, scales or crusts. — Designation of elevation, according to noso- logical terms (papula,1 tubercle, vesicle, bulla, pustule, thickening in patches or diffused, scales, crusts).—Number of elevations. — Dis- tribution of elevations, isolated, concrete, ir- regular;— special character of grouping, in rings or parts of rings, in belts, in variously sized islands.2—Individual elevations, their size, degree of elevation; — their surface, smooth, rough, furrowed (condition of cuticle over it); — their form, flat, acuminated, round- ed, umbilicated, raised in centre or at circum- ference;— their base, flat, raised, hardened; its width ; —their border, gradually fading, de- fined; condition of skin around border as to colour, thickening, and sensation; — colour (of solid elevation); condition of dryness or mois- 1 Papula and tubercle — solid elevations, separated arbi- trarily by difference of size. Vesicle and bulla — cuticular elevations, containing a clear, transparent, or slightly grayish fluid — arbi- trarily separated by difference of size. Pustule — cuticular elevation, containing a turbid and usually thick fluid. a The term " island" is used to express the condition sometimes seen, when papulae or vesicles are arranged in groups, separated from each other by intervals of sound skin. 45 2. Elevated- cause of ele- vation. § IV. B.] SPECIAL ERUPTIONS. [PART I. sensation. temperature. other condi- tions pre- sent. hair and skin about eruption. duration. phenomena of disap- pearance. 3. Depressed or with ul- ceration. Cicatrices. ture (of solid elevation); — character of fluid within vesicles, bullae and pustules; its colour, transparency, reaction, chemical examination, microscopical examination (686, 695 et sej.); — degree of attachment of scales and crusts; kind of attachment (at centre only or over whole surface); condition of skin under scales and crusts; —minute anatomy of elevation, of crusts and scales.— Sensation: spontaneous; — as tested by pricking, etc. — Temperature. — Simultaneous presence of other conditions ; e. g., non-elevated eruptions, ulcers, etc.— Condition of hair at and between affected points.— Condition of skin between affected points, its colour, dryness or moisture, sensa- tion, temperature. — Duration of eruption.— Phenomena of disappearance: of solid cuta- neous elevations; change of colour, subsidence of elevation; — subsequent condition of skin as to hardness, colour, sensation, depression or ir- regularity of surface. — Of liquid elevations: absorption of fluid and gradual desiccation; bursting of elevation,, incrustation and desic- cation ; colour, thickness, form and degree of moisture and adherence of crusts; — condition of surface after their detachment; period of detachment after desiccation; microscopical characters of crusts (686 et seq.~). — Of cuticu- lar alterations, detachment or breaking up of scales, etc. Depressed or with ulceration :—its form ; colour; condition of surface, of borders. (See ulcers, 665.) 79. Cica trices :—their form, size, colour;—con- dition of surface, as to elevation, depression, furrow- 46 PART I.] ORGANS OF LOCOMOTION. [§ IV. 0. ing, bridling, etc.;—sensibility;—condition of hair sweat-glands, and sebaceous follicles. 80. Alterations of sebaceous follicles :—their size, form ; condition of their orifices;—condition of skin around, dry, greasy, scaly, thickened.— Contents of follicles: their consistence; colour; odour; reac- tion ; microscopical characters (686 et seq.~) 81. Alterations of hair:—as affects roots; swell- ing, humidity;—exudation into; microscopic charac- ters of exudation.—Detachment of hair; mode of detachment.—Colour of hair; transparency; mois- ture or dryness ?—configuration of shaft; coarseness, thickness, consistence, fragility; microscopical cha- racters.—Hair follicles : condition of orifice. 82. Alterations of nails :—detachment of nails;— alterations in their shape; convexity, thickenings, furrows;—alterations in colour; livid, blue, present- ing white points, belts, or depressions, etc. C.--ORGANS OF LOCOMOTION. 83. Joints: — spontaneous pain, its character, severity; mode in which produced; — most severe when warm or cool ? at what period of twenty-four hours most urgent ? by what posture most relieved ? how affected by manipulation and passive motion of joint ? — Tenderness on pressure, generally over joint, or in some one spot? effect of impulse upon extremity of limb.— Temperature.— Colour of skin over joint; cede ma. — Position of limb. — Size of joint; its shape; is fluctuation perceptible ? in the instance of the knee joint, can patella be made to strike against end of femur ?—Power of movement by patient, by observer; amount permitted; creak- ing or crepitation perceptible ? 84. Bones: — spontaneous pain, its characters, 47 Alterations of sebaceous follicles. contents. Alterations of hair. of roots. detachment. of shaft. Alterations of nails. detachment. shape. colour § IV. C. Joints— pain. tenderness. temperature. colour. position. size, etc. movement. Bones— pain. § IV. D.] ORGANS OF DIGESTION. [PART I. severity;—effect of weather and temperature upon it; at what period of twenty-four hours most urgent? Tenderness.—Shape altered generally or locally (deformities arising from this cause); swellings, their position, size, shape, solidity, presenting quasi-fluc- tuation; painful; tender on pressure ; condition of skin over them.—Brittleness (spontaneous fracture). 85. Periosteum :—thickened; tender. 86. Tendinous and fibrous structures, aponeu- roses, fasciae, etc.— pain; tenderness; thickening; contraction; crepitation. 87. Muscles generally :—firm ; flabby; atrophied. —Locally : swollen; atrophied (name muscles or bundles of muscles which are thus affected).—Spon- taneous pain; particulars as joints (83);—pain on movement;—tenderness on pressure over muscles. Potcer of contraction ; paralysis of special muscles (280); — effect of electricity in exciting contraction (281); — irregular muscular movements; contrac- tion ; quiverings; jerkings; cramps; their seat, severity, time of occurrence, customary mode of relief (271 et seq.)—Muscular sensibility (268). D. -ORGANS OF DIGESTION. Mouth. 88. Lips; — size; thickness; — malformations; —colour; pale, red, livid, etc.; — " stains on and about, their colour, reaction of stain."—Condition of surface; dry; moist; smooth; fissured, oozing of blood from fissures.— Tension; flaccidity; oede- ma; abscess (647 et seq.~); tumour (672); slough- ing (659 et seq.~); ulcers (665); cicatrices (670).— Sordes; exudations (644); foam about lips; sali- vary dribbling; mucous or purulent-looking matter 48 PART *] MOUTH. [§ IV. D. about lips; "other matters about them." — Labial glands; their condition. 89. Gums;—size; consistence; hard, soft, fluc- tuating; colour, generally; blue line along edge; red line along edge, its brightness and width; rela- tion to tartar on teeth.—Sponginess and readiness to bleed ; spontaneous bleeding. — Abnormal secre- tions and exudations (644); abscesses; fungosities; tumours (672); sloughing (659 et seq.); ulcers (665). 90. Teeth ;—their number; which absent ? irregu- larity; state of axes; absence of opposing teeth to those of upper or lower jaw;—looseness of teeth ;— colour; smoothness and polish; transparency, etc. —Effects of percussion on teeth.—Tartar on teeth : situation ; thickness. — Sordes, their characters.— Mastication ; hasty or deliberate ? performed only on one side of mouth. 91. Cheek, palate, cavity of mouth; — cheek; hard, soft; tender (ascertained by external or in- ternal examination?)—Buccal membrane; colour; "stains, their colour;" thickness; oedema; dryness or moisture; vesicles ; exudations (644).—Abscesses (647 et seq.) : fungosities; tumours (672); slough- ing (659 et seq.); ulcers (665); cicatrices (670).— Buccal glands ; their characters. — Steno's ducts ; state of their orifices. — Temperature of cavity of mouth (bulb of thermometer being placed between gums and cheek); sense of heat or cold in mouth. —Hard palate ; malformations.—Inability to open mouth ; from what cause ? 92. Tongue (noting its characters as early as possible in the examination of the patient): — its size; form ; thickness; — general colour, pale, red, livid, etc.; — colour, locally, at tip, edges, etc.—■ Surface of tongue; dry; moist; smooth; glazed; E 49 labial glands. Gums— size, colour, etc. sponginess. secretions, etc Teeth- number, etc. percussion. tartar. sordes. mastication. Cheek, palatd etc.— cheek. buccal mem- brane. abscesses, etc. buccal glands. Steno's ducts. temperature of mouth. hard palate. inability to open mouth. Tongue— size. etc. surface. § IV. D.] SALIVARY GLANDS. [B*RT I. consistence, etc. papillae. furs, etc. sensations of tongue. Protrusion of tongue. Odour of breath. Taste in mouth. Salivary glands. Parotid— swelling, etc. pain, etc. Sublingual— size, etc. Submaxillary- swelling,etc. Saliva— amount characters. fissured; lobulated; exhibiting marks of bites; vesicles. — Consistence ; hard ; soft; fluctuating; tense; flaccid; cedematous; presenting sodden ap- pearance; indented by teeth.—Abscesses (647 et seq.); tumours (672); fungosities ; sloughing (659 et seq.); ulcers (665). — Papillae ; their size and form, (stating which papillae and where situated).—■ Furs on tongue : their position, colour, thickness; degree of adhesion to surface; — mucous coating on tongue; watery aspect of tongue ,—exudations, etc.; bleeding. — Sensations of heat in tongue, of cold- ness ; pain, throbbing, etc.;—degree of tactile sensi- bility, at tip, sides, and base of tongue (tested by Weber's method). 93. Protrusion of tongue :—darting, dilatory;— complete, incomplete, impossible; tremulous ;—de- viation of tongue, its degree, to which side ? (280); tongue not withdrawn after protrusion. 94. Odour of breath:—sweet, acid, sickly, malt- like, alliaceous, faecal, putrid, etc. 95. Taste in mouth:—salt, acid, sweet, bitter, faecal, putrid, metallic, etc.; clammy sensation. Salivary Glands. 96. Parotid glands:—swelling externally behind ramus and angle of jaw; in course of Steno's duct; oedema; fluctuation.—Pain on attempting to open mouth;—extent to which mouth can be opened ; — tenderness over gland and duct. 97. Sublingual glands : — their size ; condition of surface;—tumours (672); ulcers (665);—state of orifices of ducts, etc. 98. Submaxillary glands :—swelling; pain; ten- derness;—orifice of ducts, calculi within them, etc. 99. Saliva :—deficient;—excessive in quantity; measure of saliva discharged in twenty-four n*ours ; 50 PART I.] THROAT, ETC. [§ IV. D. accompanied or not by nausea or drivelling ?—colour; viscidity; odour; — bloody;—sweet to taste;—its reaction; if acid, due to volatile or fixed acid ? Throat, etc, 100. Uvula :—length; form ; thickness; direction of its axis ;—surface, smooth, glazed; colour;—cede- matous; flaccid;—abscess (647 et seq.) ; sloughing (659 et seq.); ulcers (665); vesicles; exudations (644), etc. 101. Soft palate:—(particulars as Uvula). 102. Fauces:—size of opening; state of pillars (particulars as Uvula).—Pain; its direction; — other sensations, constriction, dryness, etc.;—tactile sensibility, increased, diminished.—Noisy respira- tion ; snoring. ]03. Tonsils: — swelling and tenderness exter- nally.—Position of tonsils; distance between them; —size; form ; consistence; fluctuating;—tender to touch ; — colour; — surface; dry, moist, smooth, glazed, uneven; openings on surface; — oedema; abscess (647 et seq.); sloughing (659 et seq.); ulcers (665); secretions and exudations on surface (644). 104. Pharynx :—size of cavity;—apparent thick- ness of membrane.—Surface of mucous membrane; smooth, glazed, granulated; dry, moist; — vessels apparently full;—its colour; "stains."—Secretions; exudations (644); blood on surface.—(Edema; bog- giness; fluctuation ; abscesses; tumours; sloughing; ulcers and other destructions of substance (665); cicatrices (670). — Condition of follicles. — Projec- tions from posterior nares into cavity.—Abnormal sensatioiis in pharynx; burning, dryness, constric- tion, etc.—Tenderness. 51 Throat, etc. Uvula. Soft palate. Fauces— size of open- ing. pain, etc. noisy respi- ration. Tonsils— b welling, etc. Pharynx— size of cavi- ty, etc. mucous sur- face. secretions, etc. oedema, etc. follicles. projections from nares. sensations. tenderness. § IV. D.] EXAMINATION OF ABDOMEN. [PART Oesophagus— swelling, etc. examination with bougie. dilatation. pain, etc. Deglutition— painful. other cha- racters. Regurgitation. regurgitated matters. Physical exami- nation of Abdo- men generally. Lnspection— fat, etc, in wall. form of organs visible. 105. (Esophagus :—swelling in neck externally. —Examination with bougie ; obstruction to passage, its seat, can it be overcome by moderate pressure ?—■ Signs of dilatation and sacculation ? — Is anything visible during retching ?—Pain in course of gullet, during swallowing or at other times ;—sense of con- striction, burning, globus, etc. 106. Deglutition :—pain during the act; its seat, extent, duration, character. — Deglutition difficult; period of act at which difficulty is perceived; — at- tempt to swallow productive of sense of suffocation, of spasm of muscles of throat or pharynx;—is diffi- culty greatest with solids or liquids ?—what matters are swallowed most easily ?—is a large gulp of liquid swallowed more easily than a small one ? — has the patient any contrivance for rendering the act easier ? —does the act produce cough ?—do swallowed mat- ters return by nostrils ?—is the act affected by tem- perature of matters ?—is the site of obstruction dis- tinct to patient, and how ?—is deglutition favoured by a recumbent posture ? (see also 280.) — Fre- quently or constantly repeated efforts at deglutition. 107. Regurgitation :—period after swallowing at which it occurs; attended with effort, anxiety, or nausea ? accompanied by any stethoscopic sound ?— Physical characters of regurgitated matters; their reaction Physical examination of the Abdomen generally. 108 Inspection :—Development of subcutaneous fat; oedema of wall, its seat; hernial protrusions; —swellings over recti muscles; — form of organs visible on exterior, stomach, colon, intestinal convo- 52 PART I.] EXAMINATION OF ABDOMEN. [§ IV. D. lutions, etc.— General enlargement of abdomen, its form;—local fulness or enlargement, its seat, form; alteration in form and seat of enlargement or fulness with changes in posture of patient, with varying states of stomach and bowels; — eveision of carti- lages of false ribs, of tip of ensiform cartilage;— size of costal angles.1 — Depression or retraction of abdomen; general, partial. — Umbilicus ; position, vertical and transverse; — aspect; convex, concave, flat with or without stretching; — ulceration; dis- charge from umbilicus;—presence and condition of a portion of umbilical cord.— Venous enlargements: on one or both sides? extent; size; tortuosity; — course of blood in enlarged veins. — Movements: vermicular, resembling movements of foetus, etc.; their seat. — Pulsation : its seat, extent, violence; —circumstances under which it occurs. — Fluctua- tion on percussion.—Abdominal respiratory move- ments, including those of lower ribs, amount gene- rally or locally. — State of surface of abdomen : smooth, shining; fissures; — lineae albicantes; — brown colour around navel and in course of linea alba;—local redness; — surface dry or moist; — cuticle desquamating; eruptions (B. p. 44).—Ab- normal openings on surface, their seat; — discharge from them; its appearance, odour, etc.; effect of pressure (where ?) or of respiration upon it. Slough- ing (659 et seq.); ulcers (665). 109. Measurement:—circular and semicircular; at level of umbilicus, of greatest abdominal promi- nence ; — variations of each with ordinary and deep inspiration. — Measurement between umbilicus and " Costal angles"—i.e., the angle included between the middle line of the abdomen and the margin of the carti- lages of the false ribs. e2 53 Measurement § IV. D.] EXAMINATION OF ABDOMEN. [PART I. lower extremity of sternum; between umbilicus and pubic symphysis. — Application of chest-mea- surer to determine respiratory movements of abdo- men, anteriorly and laterally; of lower ribs, etc. 110. Palpation :—Indications afforded confirma- tory of the results of inspection (108). — Tempera- ture of surface.—Resistance to pressure unusually great; generally, or locally? its exact limits, if local; confined to one side, or observed upon both symmetrically ? confined to recti muscles, on one side or on both ? disappearing under steady pres- sure ; — knotted feel of wall. — Sense of resistance less than natural, generally or locally? parietes flaccid.—Sense of thickening of the soft parietes of the abdomen;—its apparent cause, deposition of fat, oedema, thickening of deeper tissues; — sense of unusual thinness of wall. — Elasticity of wall; increased, diminished.— Tumour (130). — Movable- ness of abdominal parietes diminished ; — sense of adhesion of soft wall to deep parts.—Sense of move- ment beneath the hand ; — its character; gradual elevation or depression, vermicular movement, fluttering, resembling that of living body in abdo- men, etc.; — its seat; readiness of perception; apparent depth from surface; activity; frequency, etc.— Vibration : arising from passage of intestinal gas ;—friction-vibration; its locality (over a tumour or not?); perceptible with or without exerting pressure ? during acts of respiration ; its character. —Sense of crepitation or grating under pressure; —gurgling;—their exact locality; apparent depth from surface; connection with palpable tumour.— Fluctuation (or bogginess); posture in which dis- covered ; 'seat; deep or superficial ? following im- mediately the impulse given to surface or not? apparent size of waves;—effect of intervening pres- 54 PART 1-3 EXAMINATION OF ABDOMEN. [§ IV. D. sure upon it; effect of change of posture upon its seat and readiness of perception; — peripheric fluc- tuation. — Repercussion (stating posture in which perceived). — Pulsation: seat; transmitted from heart? connected or not with tumour (186) ? super- ficial or deep ? — in course of aorta or other known vessel, within abdomen, or in its wall? extent of vessel over which perceived; — its abruptness; expansile force; direction, merely elevating hand or presenting lateral expansion also ? — time of day or circumstances under which it occurs; its perma- nence ;—accompanied or not by increased pulsation of femoral arteries ? — Thrill: connected or not with tumour (186) ? continuous or intermittent ? synchronous with arterial systole or diastole ? seat; —extent over which felt. — Effect of sudden deep pressure in various parts; is tumour perceptible ? 111. Percussion : — after determining boundaries of liver (115), spleen (119), and stomach (123).— Abdominal resonance: unusually extensive up- wards; diminished in extent (in either case note exact limits); — replacing dulness of liver; — un- usually uniform in pitch over all parts of surface; — pitch and special characters of resonance; tubular, tympanitic, with metallic tinkling or humoric sound (noting exact seat of these and their degree of per- manence). — Dulness (noting posture in which ob- served)": exact seat, extent, and limits; — present- in^ or not a line of level? limited by a curved or irregular line? — replaced or not by resonance on deep pressure? — effect of change of posture on re- sults of percussion;—i3 the dulness the same on deep or superficial percussion?—Sense of resistance or elasticity perceived by percussing fingers; — hy- datic fremitus; readiness of perception. 112. Auscultation:—not including signs noted 55 repercussion. pulsation. thrill. effect of sud- den deep pressure. Percussion— resonance. dulness. resistance. Auscultation — § IV. D.] EXAMINATION OF ABDOMEN. [PART I. borborygmi. friction- sound. crepitation. gurgling. fluctuation- sound. tfenia-sound, etc. foetal move- ments. aortic impul- sive sound. murmur. fcetal heart. under spleen (120), and stomach (124). — Borbo- rygmi: locality; loudness (heard at a distance from patient?); special character; —circumstances under which they occur; permanence; — intestinal sounds inaudible under all circumstances over abdomen (note extent and whether over tumour or not).— Friction-sound (particulars as friction-vibration, 110); its special similitude.— Crepitation or grat- ing : how developed ? its position, connection with tumour or not, deep or superficial ? — Gurgling: its seat, audible on pressure or independently of it, with inspiratory acts; special characters, accompa- nied by metallic tinkling. — Fluctuation-sound: spontaneous; its seat, connection with tumour; ob- served on succussion. — Taenia-sound; — hydatic sound, superficial or deep-seated ? — Sound of fcetal movements. — Sounds of aorta : impulsive sound increased. — Murmur: arterial; its seat, connec- tion with tumour, extent, intensity, special charac- ters ; accompanying systole or diastole of vessel or both ? accompanied by shock or not ? influenced by pressure on either side of stethoscope ? effect of pos- ture on its development; — venous murmur; its seat, extent, intensity, special similitude; — continuous murmur (audible at a distance from patient ?) — uterine murmur; effect of posture upon it; its seat, loudness, special character. — Foetal heart sounds : where best heard and to what extent? their fre- quency ; readiness of perception; effect of posture on perception of them. — Sounds audible at a dis- tance from patient. 56 PART 1.3 EXAMINATION OF LIVER, ETC. [§ IV. D. Physical examination of the Liver, Gall-bladder, and Ducts. 113. Inspection i — Fulness or bulging (specially affecting right hypochondrium, epigastrium, or upper part of abdomen); —state of depression below carti- lages of false ribs; — visible downward extent of liver; —state of intercostal spaces on right side; — special prominences (pointing) apparent, their seat and form; variation in fulness, etc., with varying states of stomach or after vomiting. — Colour of skin over liver or special prominences; oedema over liver. 114. Palpation: — Temperature over hepatic region. —Resistance to pressure below false ribs on right side, as compared with left; downward extent of resistance; — contraction of right or left rectus muscle on pressure; of other muscles of the soft wall. — Edge of liver (if palpable, after evacuation of bowels): its position and direction; effects of standing or recumbent posture or of deep inspira- tion on its position; — its characters, indurated, thin, thick, irregular, etc.; — interlobular notch ; its depth, direction. — Surface of liver : smooth, nodu- lated ; — character of elevations on surface, round, pitted, etc.; —form of organ tuberous; — sense of adhesion to parietes; friction palpable over it (110); — consistence of liver; hard, soft; presenting bog- giness or fluctuation (connected with tumour or not ?) — Gall-bladder: is its form palpable ? tu- mour in its situation, its physical characters (130) presenting fluctuation (generally or in centre only?) condition of surrounding tissues as to hardness, etc. crepitation. Physical exami- nation of Liver, Gall-bladder, and Ducts. Inspection— fulness, etc. colour of skin. oedema. Palpation— resistance. edge of liver. surface of liver. consistence of liver. gall-bladder. 57 § IV. D.3 EXAMINATION OF THE SPLEEN. [PART I. Percussion— dulness. resonance. Auscultation. Physical exami- nation of Spleen. Inspection. Palpation. Percussion. Auscultation. 115. Percussion:—Extent of dulness (super- ficial and deep); vertical (in anterior median line, in line of nipple, of axilla, and posteriorly); trans- verse;— effect of inspiration, posture, or varying states of stomach or colon on extent of dulness; — lower outline of dulness; amount of stomach or in- testinal note near margins of liver. Resonance over. liver, generally (the dulness being quite lost); — locally; its special character. — Hydatic fremitus. 116. Auscultation : — Breath sound, audible or not over liver? its special characters;—voice and cough sounds audible, their special characters; — gurgling; how developed, by respiration, cough, or pressure?—friction-sound (112). Physical examination of the Spleen. 117. Inspection: — Fulness or bulging (in left hypochondrium, epigastrium, left side of abdomen, etc.); well defined? — effect of change of posture upon it;—condition of intercostal spaces over region of spleen. 118. Palpation : — Spleen felt below margin of left false ribs; extent of tumour;—direction of long axis ; form; outline and characters of anterior and posterior margins;—movableness of tumour; effect of posture on its position;—condition of its surface, smooth, nodulated;—consistence; fluctuation. 119. Percussion: — Extent of dulness upwards, downwards, transversely (variation in its extent during and between paroxysms of ague); form of organ as traced out by percussion; — hydatic fre- mitus. 120. Auscultation :—Splenic murmur; its exact seat, characters, etc. (194). 58 PART ij EXAMINATION OF THE STOMACH. [§ IV. D. Physical examination of the Stomach. 121. Inspection:—Prominence (in epigastrium, over cartilages of left false ribs, and hypochondrium ; elsewhere in soft wall); variation of fulness with varying conditions of stomach (after meals or vomit- ing) ; with change of posture; — form of stomach traceable through parietes. 122. Palpation:—Temperature over region of stomach.—Sense of resistance or yielding at epigas- trium, or below margin of false ribs ;—tumour (130); effect of posture, meals, etc., upon it.—Sense of grating (as from foreign substances within it); fluc- tuation ; effect of posture, meals, and vomiting upon it. 123. Percussion : — Stomach-resonance; its ex- tent, position, special character (lower limit of stomach determined by percussion after a large draught of water).—Dulness; its seat, extent, per^ manence. — Effect of posture, meals, or vomiting upon the signs derived from percussion. 124. Auscultation : — Gurgling under pressure over seat of stomach ; its locality, permanence; — fluctuation sound on succussion, its permanence; — sounds of liquid and food entering stomach, where heard ?—spontaneous sounds (churning, etc.); their permanence; special characters.—Special characters of heart's sounds as heard over stomach. Physicalexam i- nation of Stomach. Inspection. Palpation. Percussion. Auscultation. 59 § iv. d.3 EXAMINATION OF COLON, ETC. [PART I. Physical exami- nation of Colon, Rec- tum, and Anus. Inspection— prominence. prolapsus. examination by specu- lum. Palpation— tumour. crepitation. gurgling. examination per anum. examination by bougie. Percussion— Physical examination of the Colon, Rectum, and Anus. 125. Inspection:—Colon: Prominence (specially affecting right or left iliac regions, flanks or else- where in course of colon); its amount, constancy; — outline and course of colon traceable through parietes;—effect of defaecation upon prominence.— Anus: its form; fissures; fistulas; vegetations ; tumours; piles; ulcers; excoriation. — Prolapsus of rectum: its extent, circumstances under which it occurs;—characters of prolapsed portion; colour, vascularity, etc.—Examination by speculum : state of mucous surface ; its colour, vascularity;—haemor- rhage from it; secretions upon it; apertures ; slough- ing (659 et seq.); ulcers (665); cicatrices (670), etc.; exact position of these. 126. Palpation : — Tumour; in course of colon, in iliac fossae, etc.; its characters (130); effect of purgatives or enemata upon it. — Crepitation or grating; its seat, connection with tumour, apparent depth. — Gurgling on pressure; its seat.—Exami- nation per anum : Imperforation of anus; coarc- tation; resistance to introduction of finger; — capacity of rectum; temperature of rectum ;—faecal accumulation within it; foreign bodies; tumour;— stricture; its seat, form; length of strictured por- tion; yielding of walls on pressure (see also 235). — Examination by bougie; length to which bougie may be passed. 127. Percussion:—in course of colon or in iliac regions, over tumour (131); special characters of sounds; — effect of defaecation upon its results. — Length of colon over which the dulness produced 60 PART 1.3 ABDOMINAL TUMOURS. [§ IV. D. by a large and forcible injection extends (noting quantity of water which may be injected).—Per- cussion over sacrum. 128. Auscultation: — Audible gurgling; under pressure or independently of it? — spontaneous sounds, their seat and characters (112). — Extent of colon into which the liquid of a large and forcible injection may be heard to enter. Physical examination of Abdominal Tumours. 129. Inspection: — (see Physical examination of abdomen generally, 108; of liver, 113; spleen, 117; and stomach, 121.) — Colour of skin over tu- mour;— oedema, pointing, etc. 130. Palpation: — Apparent number of tu- mours; united or separate? — mode in which most readily perceived; — exact position of tumour; traceable under margins of false ribs on either side, or towards anterior or lateral parts of trunk; felt descending into pelvis, from centre or from one side of abdomen;—dimensions of tumour; extent of abdomen which it occupies; — its relation to the surface, deep or superficial ? its apparent continuity with known solid organs (liver, spleen, uterus, etc.) — Form: similar to that of known organs (liver, kidney, etc.); of limbs or other parts of a child; of certain foreign bodies;—condition of its margin, well or ill defined ? can fingers be passed beneath it, and at what part? — margin regular or irregular, notched, hard or soft, thick or thin, etc. ?—Sur- face: smooth; irregular; lobulated; size, form, and uniformity of irregularities or lobulations.— Consistence: hard, soft, elastic, impressible;—pre- senting yielding line across surface; — bogginess; fluctuation, deep or superficial, limited or not to ex- p 61 - after injec- tion. Auscultation— with injec- tion. Physical exami- nation of A b- dominal Tu- mours. Inspection— Falpation— number. position. size, etc. form. surface. consistence. §IV. D.] ABDOMINAL TUMOURS. [PART I. circumstan- ces affect- ing it. movableness weight. spontaneous movement. pulsation. thrill. Percussion— , resonance. dulness. circumstan- ces affect- ing percus- sion sound. tent of tumour ? effect of posture upon its seat and readiness of perception. — Effect of pressure, of varying states of stomach and colon, of purgatives or enemata, and of catheterism on tumour.—Movable- ness of tumour; effect of posture of patient upon its position and distinctness;—readiness and extent to which it may be displaced by the hands (upwards, downwards, laterally); slipping from under hand; rolling under hand; — soft parietes movable over it; soft parietes apparently adherent to it, tumour and soft wall moving together; skin attached to tu- mour ; — radiating portions perceived at its margin ; — movableness of apparent tuberosities of surface apart from general mass of tumour; — movement of tumour on deep inspiration; — when more than one tumour is present, note independent mobility of them. — Apparent weight of tumour. — Sense of spontaneous movement in tumour; its character.— Crepitation, gurgling, etc. on pressure.—Repercus- sion.—Pulsation: its exact seat; extent; is it con- fined to a line across surface of tumour ? (see also Swellings connected with arteries, p. 81); — abrupt- ness or expansile force; — direction, merely elevating hand, or in lateral direction also ? — permanence; circumstances affecting it; effect of posture (on hands and knees, etc.) upon it; effect of displacing tumour upon it. — Thrill: accompanying pulsa- tion ; with arterial systole or diastole or both ? con- tinuous. 131. Percussion : — Resonance; its special cha- racter, uniformity of pitch, etc. — Dulness; its ex- tent and outline; uniform or not over all parts of tumour ? continuity of dulness with that of known organs (liver, spleen, uterus, etc.). — Results of su- perficial and deep percussion (specially at margin of tumour); effect of posture on percussion sounds; 62 PART I.] ABDOMINAL TUMOURS. [§ IV D. effect of meals, vomiting, enemata, purgation, cathe- terism, etc.; extent of dulness of tumour modified or not by deep inspiration? — Dulness of tumour crossed by a resonant line (exact seat and direction of line) ; — dulness intermixed with resonance. — Hydatic fremitus.—Sense of resistance or elas- ticity perceived; uniform or not over surface of tu- mour? 132. Auscultation: (see Physical examination of the abdomen generally, 112; of liver, 116; spleen, 120; stomach, 124; and colon, 128.) — Impulsive sound; — diastolic shock. — Arterial murmur : its exact seat and extent; extent of ves- sel upwards and downwards from tumour over which heard; — part of tumour at which heard, in frontv only or laterally also ? — following a line on surface of tumour; — characters; loud, soft, harsh, etc.; — systolic, diastolic, or both ? accompanied or not by shock or pulsation ? — effect of strong pressure upon it; of pressure on either side of stethoscope; of change of posture, from recumbent to erect, or vice versa; of posture on hands and knees, etc.; — effect of displacing tumour upon it (see also, Swellings connected with arteries, p. 81); —effect of any other circumstances upon its loudness or other characters. — Venous murmur : its exact seat; extent; charac- ters;— circumstances modifyiug it.— Continuous murmur: its loudness (heard at a distance from pa- tient ?) ; effect of arterial systole or inspirations upon its intensity. — Uterine sound: its seat; extent; character; intensity; influenced or not by posture of patient ?—Hydatic sound. Auscultation- 63 § IV. D.] GENERAL SYMPTOMS. [PART I. General symp- toms. Abnormal sen- sations— pain. other sensa- tions. Tenderness. General symptoms referable to the Abdomen. 133. Abnormal sensations: — Pain: precise seat, extent; — severity, seat of greatest intensity; — di- rection ; towards the spine, chest, shoulders, pelvis, etc.; — special character; like a weight, twisting, lancinating, burning, etc.—Time of its occurrence; constant, paroxysmal, periodical; — when stomach is full or empty ? if after a meal, after which meal and how soon after it ? ■■— effect of solid food and of hot, tepid, or cold liquids, or of alcoholic or stimu- lant liquids, in inducing or relieving it. — Duration. — Effect of posture upon it (note posture of patient during its presence) ; — effect of pressure with flat hand or points of fingers in increasing or relieving it;'—effect of inspiration or coughing upon it; — effect of agitation of bed or apartment upon it; — its connection with mental agitation.—Does it precede or follow acts of defaecation? — has it any connec- tion in point of time with other symptoms (borbo- rygmi, vomiting, eructations, etc.)? — is it relieved by expulsion of gaseous, liquid, or solid matters from stomaeh or rectum ? — has the patient any contrivance for relieving it ? — Other abnormal sen- sations : of sinking, heat, weight, fulness, dragging, constriction (particulars as Pain). — Sensation of food passing over a circumscribed sore spot in stomach. — Sensation of movement in abdomen; seat, character, and special similitude; — circum- stances under which it occurs. 134. Tenderness: — seat and extent;—connec- tion with tumour;—special direction of pressure necessary to elicit it;—amount of pressure by which it is elicited, pinching the skin gently, dragging fin- ger over its surface, etc.; moderate pressure; strong 64 PART ij GENERAL SYMPTOMS. [§ TV. D. and deep pressure; — is it observed when attention of patient is withdrawn? — does patient cry out be- fore being touched? — is pressure of bed-clothes borne ? — Does tenderness extend beyond limits of the abdomen, if so, in what direction, and how far ? 135. Appetite: — wanting (partially or wholly), for all or for certain meals ? with or without loath- ing ? — voracious; —untimely (at night, shortly after a meal, etc.); — depraved (with voracity ?) — When is most appetite felt ? — Special desire or pre- ference for certain kinds of food; for tasteless, acid, alkaline, sweet, or bitter articles; for sugar, salt, vegetables, fruit, meat, etc.; — special dislike of cer- tain kinds of food. — Weight of food eaten in twenty-four hours;—nature of food, relative amount of solid and liquid matters contained in it; — pro- portion of nitrogenous and non-nitrogenous matter in food. 136. Thi?'st:—wanting; — dislike or horror of liquids; horror of sight or sound of liquids; — pe- riod when thirst is chiefly felt; after meals, after special meals or articles of food ; — excessive thirst; relieved by taking large draughts of water or other thin liquid (best cold or warm ?), by repeatedly moistening mouth and throat. — Special desire or preference for certain kinds of liquid, tasteless, acid, alkaline, sweet, bitter, or salt; for broths, etc.; — special dislike of the above. — Quantity drunk in twenty-four hours by measure; nature of drink. 137. Naxisea: — time of its occurrence; accom- panied or not by retching or vomiting ? — duration; — occurring after food or drink generally, or after particular kinds of food. 138. Vomiting : — time of its occurrence; fre- quency or periodicity; occurring after food or drink, generally; after special kinds of food or drink; f2 65 Appetite— weight of food eaten. nature of food. Thirst- quantity drunk. nature of drink. Nausea. Vomiting. § IV. d.3 GENERAL SYMPTOMS. [PART I. its immedi- ate cause. accompani- ments. relief it affords. Vomited mat- ters— appearance, etc. contents. microscopi- cal exami- nation. after certain meals only; time after any meal at which it occurs; occurring after minute quantities of food or drink ; when stomach is empty.—Occur- ring in one posture more than in another; on changing the posture; — during act of defaecation. — Its immediate cause; — spontaneous; — induced by coughing; the tickling of an elongated uvula; bodily effort; mental emotion or passion ; the influ- ence of pain; the influence of bad odours (arising from the patient himself or near him); the taste and smell of eructated gases or liquids, of discharges from the nares, etc.—-Is it accompanied or preceded by nausea, or by any other abnormal sensation ? — is it accompanied by coughing? — Characters; fa- cility; painful or not? accompanied by straining efforts. — Does it relieve any uneasy sensations tem- porarily or permanently? — Has the patient any contrivance for obviating its occurrence ? 139. Vomited matters:1 — quantity; taste as per- ceived by patient; odour; colour, uniform or va- rious? "changed by exposure to light;" aeration; yeasty appearance.— Contents:—food; its state of division ; special articles of food distinguishable; indigestible substances; degree of chymification of vomited food;—"foreign substances recognisable by the eye; organic (e. g. portions of seeds, leaves, elytrae), their characters, etc.; mineral (crystals, ete.);" —faeces; their consistence, colour, and other characters; — blood; its quantity, consistence, aera- tion ; pure or mixed with other matters ? — sooty matters; coffee-ground matters;—oily matters; wa- tery fluid; mucus; pus; bile; worms; hydatids; calculi, etc.—Microscopical examination of vomited 1 These particulars apply also to matters removed by stomach-pump. 66 PART 1-3 GENERAL SYMPTOMS. [§ IV- D. matters: of matters picked out; of liquid (686 et seq.);—special inquiry to be made for blood, pus, exudation-corpuscles, cancer-cells, torulae, sarcinae. — Chemical examination} of vomited matters; their reaction, before and after evaporation; of matters picked out; of liquid; — special examination for bile, sugar, ammonia, "urine; the vegetable or mineral poisons." 2 140. Eructation or regurgitation: — time of occurrence ; relation to quantity or quality of food; time which elapses after food; — accompanied or not by nausea ? — Eructated or regurgitated mat- ters : gas, liquid, food; — their quantity, taste, odour; — if liquid, its apparent temperature and physicaf characters. (Further particulars as Vomited matters, 139.) 141. Hiccup: — its time of occurrence; fre- quency; periodicity; noisy or not? continuing or not during sleep ? 142. Defalcation: — its frequency; time elapsed since last stool; periods of defalcation ; — position chosen during the act; — amount of effort required; force of evacuation. — Is obedience to the desire ever in vain? is any obstruction felt, and where? — Pain preceding, during, or after the act; its seat, charac- ters, duration; — tenesmus. — Stools passed beneath patient; from carelessness, wilfulness, local defect of sensibility, inability to retain motion, general stupor, etc. (280) ? 143. Stools: — quantity; at each evacuation in 'the twenty-four hours (measured or weighed); — odour;—consistence, solid, liquid, pultaceous, 'In this and every other "chemical examination," note accurately the process adopted. 3 " Poisons to be sought for, also, in articles of dress, etc., on which vomited matters may have fallen." 07 chemical ex- amination. Eructation— nature of eructated matters. Hiccup. Defoecation- pain. involuntary. Stools- physical character. § IV. D-3 RESULTS OF PARACENTESIS ABDOMINIS. [PART I. constituents. microscopi- cal exami- nation. chemical ex- amination. Anus. Results of Para- centesis Ab- dominis. Operation. Matters re- moved— yeasty-looking; if solid, note any peculiarity in width or form, and whether it is of constant occur- rence; degree of solidity or hardness;—colour; aeration.— Constituents of stools:—fixcal matters; unchanged food; special articles of food distin- guishable ; food in a state of incomplete digestion; —foreign substances recognisable by the eye; — blood; passed alone; mixed with faeces, uniformly, or in patches or striae?—following the act of defae- cation ; — physical characters of the blood; — mu- cus ; pus; fibrinous matter; oily matter; epithelial shreds; casts of intestine; portions of intestine (their physical characters); calculi (their physical characters); worms; hydatids; urine, etc. — Micro- scopical examination of stools: of matters picked out; of liquid (particulars as Vomited matters, 139). — Chemical examination of stools : their reaction ; — of matters picked out; of liquid; — special exa- mination for albumen, fat, phosphate of magnesia and ammonia, mineral substances taken as medicine or " as poisons." 144. Anus: — pain ; sense of itching; constric- tion; dragging; sense of heat; — discharges from anus. Results of Paracentesis Abdominis. 145. Operation :—its mode of performance, seat of puncture and peculiarities of operation (e. g., size of trocar, length of time occupied, posture of patient); readiness of flow of fluid; completeness of evacua- tion; necessity for a second puncture; — faintness resulting from operation? 146. Matters removed: — their quantity (mea- sured) ; colour; degree of transparency; consistence; odour; specific gravity;—relative character of fluid 68 PART ij ORGANS OF RESPIRATION. [§ IV. E. at different periods of its flow;—flocculi in fluid, their quantity and apparent characters. — Changes occurring in fluid after standing, coagulation, etc.— Microscopical examination -of fluid; of matters picked out (686 et seq.). — Chemical examination of fluid; special examination for fibrin, for albumen (its kind). 147. Physical examination of abdomen after tapping. E.--ORGANS OF RESPIRATION. Nares, etc. 148. Nares: — form; condition of alae; size of anterior aperture of nares; eruption about alae (77 et seq.); ulcers (665); excoriations from picking, etc.;—condition of cartilaginous septum;—condition of bones.—Mucous membrane (as visible); its colour; raw appearance of it; covered with secretion, liquid or adherent.—Tumours on mucous membrane (672); polypi; ulcers (665), etc. — Foreign bodies.—Dis- charge from nares : — quantity; colour and other physical characters; foetor;—containing blood, par- ticles of bone, etc.—Haemorrhage from nares :—its amount; circumstances inducing it.—Movements of alee in respiration : — their amount; —equal or un- equal on the two sides ? 149. Sensibility, etc. :—pain, its characters; ten- 'derness; itching;—sense of fulness, affected or not by weather ?—Alteration in tactile sensibility (tested by introduction of substances into nostrils, snuff, etc.);—alteration in special sense of smell (315). 150. Sneezing: — its frequency; circumstances inducing it. 69 microscopical examination. chemical examination. Physical exa- mination of abdomen af- ter tapping. I IV. E. Nares. Nares— external cha- racters. mucous mem- brane. tumours. foreign bodies. discharge. haemorrhage. movements of alee. Sensibility— pain, etc. tactile sensi- bility. Sneezing. § iv. e.3 AIR PASSAGES. [PART I. Frontal sinu- ses. Upper Air Pas- sages, etc. Examination of throat exter- nally— size of larynx and trachea, etc. manual ex- amination. percussion. auscultation. Epiglottis. Glottis. Sensibility. Voice. 151. Frontal sinuses : — their apparent develop- ment. — Painful sensations referred to their site; weight, stuffing; soreness, etc. Upper Air Passages and Vocal Apparatus. 152. Examination of throat externally. — Size of larynx and trachea : their form ; — ulcers; — fistulae or openings communicating with air-passages; passage of air through them during acts of respira- tion ; — swellings externally about these organs; their characters, oedematous, fluctuating, etc. — Manual examination : laryngeal fremitus; heat of surface; crepitation. — Percussion applied over larynx and trachea, its results. — Auscultation: altered respiration audible at a distance; its charac- ters, rough, stridulous; — expiration prolonged, la- borious;—constancy or paroxysmal character of the above phenomena ; — auscultation by aid of stetho- scope ; respiration rough, whistling, accompanied by tracheal or laryngeal rhonchus. 153. Epiglottis (examined with or without specu- lum) :— wanting; — prominent; thickened; flat; curled; — its colour; — irregular on surface or on edge; ulcerated; covered with secretion; presenting enlarged glands.—Examination with the finger. 154. Glottis: — result of examination with spe- culum. 155. Sensibility:—pain or other abnormal sensa- tion ;—pain on swallowing, speaking, singing, etc.; —tenderness on pressure. 156. Voice :—wheezing; hoarse; rough ; croupy; cracked ; — feeble, almost inaudible, whispering;—■ totally lost; constancy of the aphonia or circum- stances under which it occurs. 70 PART ij LUNGS, PLEURA, ETC. [§ IV. E. 157. Other symptoms, e. g., cough, expectoration, haemorrhage, etc. (particulars, see General thoracic symptoms, p. 74). Physical examination of the lungs, Pleurae, etc. (In all cases the corresponding parts on the two sides should be compared.) 158. Inspection.—Form of the thorax: general shape; — elevation or flattening of the supra-clavi- cular and infra-clavicular spaces; condition of supra- sternal hollow; form of clavicles and direction of their curves. — Height of the shoulders; shoulders thrown forwards; comparative distance of nipples from the clavicle, and from the median line of the trunk. — Form of the sternum; arching, bulging, concavity. — Form of the spine; curvatures, lateral or angular (301).—Position of scapulae, their promi- nence, nearness to spine, rotation, etc.—Form of lateral regions of chest; general prominence or retraction. — Condition of intercostal spaces; their width; bulging or depression. — Local bulging or retraction, its seat, amount, etc. — Costal angles, their size.— Size of thorax (general idea of it, making allowance for fatness or emaciation).— Thoracic movements: relative duration of inspira- tory and expiratory acts, as measured by seconds;— amount and relation of costal and abdominal expan- sion in inspiration; amount of costal elevation in inspiration as compared with expansion ; — thoracic retraction in inspiration, its seat, extent; — rhythm of respiratory movements, equable or not? — move- ments at any particular spot, compared with those at a corresponding point on opposite side;—condition 71 Physical exami- nation of Lungs, etc. § IV. E.] LUNGS, PLEURAE, ETC. [PART I. fluctuation. pulsation. Measurement- general. partial. by chest- measurer. spirometer. Palpation. Percussion— dulness. clearness. characters affecting percussion sounds. resistance. Auscultation- inspiration. of intercostal spaces during inspiration and expira- tion.—Fluctuation.—Pulsation (174). 159. Measurement (by tape or by callipers):—in rest and in motion; in deep, and medium inspira- tion and expiration.— General measurements; circu- lar, opposite ensiform cartilage, midway between nipples and clavicles; — transverse, from point of one acromion to that of the other, in axillae, at base of chest;-—antero-posterior, under the clavicles, at base of chest; — vertical, from clavicle to most depending point of ribs. — Partial measurements; from nipple to middle line of sternum ;—from sterno- clavicular articulation to nipple;—from nipple to antero-superior spine of ilium; —from most depend- ent point of twelfth rib to same process.—Measure- ment by chest-measurer, in tranquil and forced breathing.—Results of use of spirometer. 160. Palpation :—Indications afforded confirma- tory of the results of inspection ;—exact position of nipples, opposite which rib or space ?—movement of walls, etc.;—fremitus, vocal, tussive, rhonchal, fric- tion, pulsatile ;—pulsation;—fluctuation, peripheric, rhonchal. 161. Percussion: — Sound normal; — too dull; special character of dulness, if any, wooden, cracked- metal ;—sound too clear; special character of clear- ness, tympanitic, amphoric, tubular;—seat and extent of dull or clear sounds;—pitch; fulness or emptiness of sounds. — Influence of deep inspiration or expiration upon sounds or upon their limits; influence of alteration of position upon them.— Resistance of parts percussed. 162. Auscultation (specifying the different re- gions) : during easy and deep respiration, and during and after coughing—Inspiratory sound: its loudness, natural, exaggerated, weak, suppressed;—: • 72 PART 1-3 LUNGS, PLEURA, ETC [§ TV. i. its quality, natural, harsh, bronchial,1 blowing (dif- fuse or tubular), hollow,2 metallic;3—its length; — its rhythm, even, jerking, cog-wheeled. — Expiratory sound: its loudness, actual and as compared with inspiratory;—its length,—its quality (see Inspira- tory sound, supra) ;—rhythm, divided from inspira- tory, jerking.—Rhonchi or rales, their quality, dry or moist?4 if dry, whether sonorous, sibilant, creak- ing, crepitation, or crackling (fine or coarse ?), clicking;—if moist, size of bubbles (large, small?), equal or unequal?—rhonchi metallic or not? loud- ness; how evolved (slowly, rapidly, in puffs, etc.)? —at what time audible, with inspiratory act throughout, or at its commencement or close, with expiratory act, and at what part of it, with tranquil or forced respiration, or with coughing ?—constantly or only occasionally audible ? — effect of coughing and expectoration. — Friction-sound: its quality, grazing, rubbing, creaking;—its loudness; — when audible, during whole act or at beginning or close of respiration ? with expiration entirely or at begin- ning or close? with easy or forced respiration?— Effect of position upon it; effect of heart's impulse upon it. — Metallic tinkling: at what time heard, with respiration, cough, or voice ? — constantly or occasionally audible?— Voice: amount of vocal resonance, natural, diminished, increased;—with 1 " Bronchial:"—quality and intensity equal to natural bronchial respiration, as heard under first bone of ster- num. a "Hollow" includes what is sometimes called cavern- ous. * " Hollow" and "metallic" include amphoric. • " Dry or moist;" note the impression given to the ear, without reference to the supposed mode of produc- tion. g 73 § IV. E-3 THORACIC SYMPTOMS. [PART I. cough. heart sounds. succussion. General symp- toms. Pain- other sensa- tions. Tenderness. Cough. or without vibration;—its qualities or special char- acters, hollow, twanging, nasal, aegophonic, metal- lic ; distinctness or indistinctness of articulation;— constancy or otherwise of increased resonance or of special quality; — effect of coughing and expectora- tion upon vocal resonance.— Cough : its resonance. —Heart sounds and murmurs (178) : transmission of them; degree and direction of their transmission. —Succussion : its results; thoracic fluctuation. General Thoracic Symptoms. 163. Pain in the chest: — exact locality (if there be more kinds of pain than one, each should be distinctly particularized); — severity; — charac- ter, dull, aching, sharp, stabbing, catching, burning, etc.; — direction, towards the spine, shoulders, down the arms, etc.; — mode in which it is deve- loped, by breathing (ordinary or forced), by sigh- ing, by coughing, by movement of the trunk, arms, or other parts of the body, etc.; — effect of posture upon the pain; — pain occurring after food;—re- lief or otherwise afforded by eructation, etc.; — Other abnormal sensations : weight; oppression; dragging, etc.; — circumstances under which they occur. 164. Tenderness:—its seat; perceived on pres- sure beneath margin of false ribs, between ribs, over certain muscles; — perceived on gentle pinch- ing of skin, on rubbing the muscles over the surface of the ribs and cartilages, etc. 165. Cough : — severity; frequency ; periods of its occurrence;—mode of its excitement (by breath- ing cold air, etc.);—character, short, hacking, pro- longed, uncontrollable, paroxysmal, noisy, barking, wheezing, hoarse, ringing, etc.; — character of the 74 PART I.] THORACIC SYMPTOMS. [§ IV. E. back-draught, hooping, crowing,' etc.;—whether cough dry or accompanied by expectoration? — at- tended by pain or other uneasy sensation in chest (163) or elsewhere; — followed by vomiting, sweat- ing, exhaustion, etc.; — effect of posture on cough. — Hawking. 166. Expectoration: — easy or difficult? accom- panied or not by pain ? — effect of posture on readi- ness of expectoration; — relief afforded by it to dyspnoea or other uneasy sensations. ,167. Sputa:—their quantity (measured), in each twelve hours of the twenty-four; — their form, round, flat, discoid, ragged, indefinite; — size of the masses; — their transparency or opacity; colour, white, grey, yellow, green, pink, red, rusty, brown, blackish; — viscidity or adhesion to vessel; — odour; — taste and apparent temperature to the pa- tient.— Special characters; thin, serous, frothy; — containing particles like boiled rice, or little matters of other kinds (e. g., tartar of teeth, etc.); contain- ing pseudo-membranous matters; like current jelly or prune juice; mixed with fibrinous casts; mixed with blood-streaks; intimately mixed with blood; containing calcareous matter, hydatids, etc.—Micro- scopical examination of sputa (686 et seq.): pre- sence of epithelium (flat, cylinder, ciliated), granu- lar cells, nucleated cells, fibrinous coagula (their form and length), blood disks, fat, molecular matter, crystals, pseudo-membrane, fibres (their characters), vessels, hooklets of echinococci, fungi, foreign sub- stances derived from food (starch, muscular fibres, vegetable cells and fibres, etc.). — Chemical exami- nation of sputa (695). 168. Expectoration of blood:—quantity of blood expelled; — mode in which brought up; in mouthfuls, in a gush,'by an action like vomiting, by 75 hawking. Expectoration. Sputa— quantity. physical characters. special cha- racters. microscopi- cal exami- nation. chemical ex amination. Expectoration of blood. quantity. mode of ex- pulsion. § IV. E.] THORACIC SYMPTOMS. [PART I. characters. immediate cause. sensations preceding. repetition. sequel??. Respiration— dyspnoea. respiration noisy. number of respirations. Expired air— chemical examination. hawking, etc.; —- its colour; clotted or not ? its de- gree of aeration;—pure or mixed with sputa, in streaks or uniformly, in masses surrounded by sputa ? — Immediate cause of the haemoptysis; coughing, exertion of the voice, muscular exertion of other kinds. — Sensations preceding it; heat of "chest, salt or other taste in mouth, etc. — Repeti- tion of haemoptysis; at what intervals ? — character of each discharge (as above). — Haemoptysis fol- lowed by bloody expectoration and of what variety ? by black stools, etc. 169. Respiration : — Sense of dyspnoea : its severity, sense of suffocation; constant or not ? cir- cumstances under which it occurs; — effect of pos- ture upon it; variation with the times of day or night; effect of meals upon it, of exertion, of mental emotion.—Inability to hold the breath for a reasonable time; frequent arrests in the act of speaking to take breath. — Dyspnoea paroxysmal; time of occurrence of paroxysms; their duration; — appearance and posture of patient during them. —Acts of inspiration or expiration painful;—noisy; rattling; prolonged; wheezing; cooing;—inspira- tion crowing—Number of respirations in a minute; their apparent fulness; — movement of alae nasi during the acts, on both sides, or on one more than the other;—visible action of supplementary muscles of respiration. — Sensation experienced by patient of the air entering unequally on the two sides of the chest. 170. Expired air:—its temperature; its odour. — Chemical examination of it; the absolute and relative quantities of oxygen, nitrogen, carbonic acid, and watery vapour; presence of ammonia? 76 PART ij ORGANS OF CIRCULATION. [§ IV. F. Results of Paracentesis Thoracis. 171. Operation:—(particulars as Paracentesis abdominis, 145). 172. Matters removed:—(particulars as Paracen- tesis abdominis, 146). Diaphragm. 173. Level of diaphragm (determined by inspec- tion, fremitus, percussion, and Harrison's process). — Pain in course of diaphragm (particulars as 163). — Hiccup (141). — Movements of diaphragm, as estimated by movements of abdomen and lowest ribs. F.--ORGANS OF CIRCULATION.—BLOOD. Physical examination of the Heart and Peri- cardium. 174. Inspection: — Shape of cardiac region: bulging or depression of second, third, fourth, and fifth left costal cartilages and ribs; — shape of ad- joining part of sternum:—Condition of intercostal spaces as to widening, bulging, retraction; influence of respiratory acts.— Visible pulsation : its site and extent; visible point of apex beat;—undulatory pulsation; double pulsation, locality and time of;— force of pulsation as estimated by the eye; retrac- tion of any intercostal space or of epigastrium during systole or diastole; — effect of position and inspira- tion upon visible pulsation. 175. Measurement:—distance of left nipple from g2 77 Results of Para- centesis Thora- cis. Operation. Matters re- moved. Diaphragm. Level— pain, etc. hiccup. movements. § IV. F. Physical exa- mination of Heart, etc. Inspection— shape of car- diac region. intercostal spaces. pulsation. Measurement. § IV. F-3 HEART AND PERICARDIUM. [PART I. Palpation— seat of apex beat. characters of impulse. back-stroke. rhythm. thrill, etc. Percussion— superficial. deep-seated. Auscultation- sounds. middle line; of upper edge of third left costal carti- lage from upper edge of sixth, one inch outside sternum (the above compared with analogous mea- surements on right side). (See also 176 and 177.) 176. Palpation : — Exact position of apex of heart, during impulse (noting the rib or interspace, and the exact relative position, by measurement, of the spot to the nipple, to the sternum, or to the ensiform cartilage) ; effect of inspiration or expira- tion on seat of impulse; effect of change of posture on seat of impulse.—Characters of impulse; extent; strength; duration;—impulse given by apex only or by greater or less extent of heart's surface ? its frequency; strength of impulse compared with arterial pulsation.—Back-stroke. — Rhythm of im- pulse; irregularity of impulse, of what kind?.— Thrill; its exact position; extent; amount; ac- companying systole or diastole ? its presumed origin. —Vocal fremitus over and around praecordial re- gion. 177. Percussion:—of praecordial space; its gene- ral characters as to clearness, dulness, etc.—Super- ficial dulness (determined by light percussion, dur- ing tranquil breathing); highest point of dulness ; inner and outer limits; lowest point; shape of dul- ness;— measurements of dulness, vertical, oblique, and horizontal diameter.—Deep-seated dulness (de- termined by strong percussion on full expiration; particulars as Superficial dulness). — Effects of change of posture on results of percussion. 178. Auscultation. — Sounds1 (first and second) normal and abnormal; — their characters in respect of intensity, pitch, quality, duration, rhythm, redu- 1 The term "sound," refers only to the natural sounds of the heart, either normal or abnormal -— i. e., modified as to duration, pitch, or timbre. 78 PART ij HEART AND PERICARDIUM. [§ IV. F. plication, and apparent distance, at each of the fol- lowing points: viz., at third interspace, and along third rib for the distance of three inches from left edge of sternum (for all the sounds); — at point where apex beats (for mitral sounds); — at left of sternum, and over ensiform cartilage, if apex be not in this position (for tricuspid sounds); — at third left costal cartilage, and adjoining part of sternum (for both aortic and pulmonary sounds);—at second right and second left costal cartilages (for sounds of aortic and pulmonary orifices respectively). Transmission of sounds to right and left acromial angles. — Murmurs.1—locality, as of sounds (see supra). — Time of occurrence; presystolic (occur- ring before first sound and impulse); systolic (coin- cident with first sound and impulse); postsystolic (continuing after first sound and impulse, but before second sound) ; diastolic (coincident with or follow- ing second sound); — continuous; —loudness, abso- lute (estimated per se); relative (as compared with murmurs in other localities); —affected or produced only by pressure or posture;—apparently deep or superficial ? — Pitch. — Special quality (blowing, cooing, whispering, hissing; rough, rasping, filing; grazing, rubbing, creaking, grating; musical): — Duration. — Rhythm. — Relation to respiratory movements : — transmission (noting exact direction and extent) to sternal notch, acromial angles, infe- 1 The term " murmur" is applied to an adventitious and superadded phenomenon, which may occur with one or more "sounds," or at their expense. Although a line between sounds and murmurs cannot always be perfectly drawn, this is no reason for abandoning a distinction of great importance, and one that is, in most cases, easily made. 79 § IV. F.] ARTERIES. [PART I. General Car- diac symptoms. Pain. other sensa- tions. tenderness. Palpation. A rteries. Inspection. Palpation. Auscultation. Radial pulse— number. size, force. resistance. rhythm. special cha- racters. rior angles, of scapulae, and vertebral grooves.— Presumed origin of sound (endocardiac, pericardiac, or exocardiac).1 General Cardiac Symptoms. 179. Pain: — locality; severity; characters; di- rection ; constancy; — accompanied or not by dysp- noea ? — how induced ? — effect of posture upon it. — Other abnormal sensations : sinking; faintness; pressure; weight; drawing, dragging.— Tenderness: its locality, in interspaces or on ribs? by what amount of pressure caused ? 180. Palpation: — severity; frequency; con- stancy ; — circumstances giving rise to it, exertion, going up stairs or up hill, mental emotion, etc. Arteries. 181. Inspection: — Pulsation visible or not? characters of movements, locomotive ? 182. Palpation: — Pulsation; its frequency; strength; lateral impulse;—time as compared with that of heart's impulse. 183. Auscultation: — Sounds and murmurs, with and without pressure. 184. Radial pulse: — number;—size and force; large, small, thready, equal, unequal, strong, feeble; — resistance; soft, compressible, hard, incompres- sible;— rhythm; regular, irregular, intermittent; — time as compared with that of heart's impulse; — artery tortuous, rigid. — Special characters of 1 "Exocardiac" — i.e., a sound produced during the heart's action, but having a cause external to the heart and pericardium. 80 PART 1-3 ARTERIES. [§ IV. F. pulse; jerking, bounding, undulatory, continuous (one pulse appearing to run into the following), vibrating, quick, tardy, vermicular, tremulous, redu- plicate.— Effects of posture on pulse (its number and other characters). — Phenomena of pulse in one arm as compared with the other. Swellings connected with Arteries. 185. Inspection:—position of swelling; size, shape; pulsation. 180. Palpation: — size of tumour; readiness of definition; form; surface; movableness; consistence; uniform or not ? fluctuation; capable of being emp- tied or not by pressure of the hand (noting phe- nomena of return of blood ?) — Pulsation : charac- ters of pulsation, heaving, expansile, hammering, abrupt, etc.; force; time as compared with heart's impulse; — perceived only in front of tumour, or laterally also? — effect of displacement of tumour upon pulsation ; effect of exercise or emotion upon it;—pulsation felt in a line along surface of tu- mour. — Effect of posture on the tumour and on its pulsation; — effect of pressure on proximal side of tumour.— Thrill: perceived in front or laterally? with impulse or diastole of tumour, or both ? con- tinuous ; during return of blood after compression. — Diastolic shock. 187. Measurement of tumour: — diameters; ele- vation, etc. 1S8. Percussion:—sound and resistance; size and shape of part dull on percussion ; — effect pro- duced by pressure on proximal side of tumour. 189. Auscultation : — sounds and murmurs; sin- gle, double, continuous;—their loudness; pitch; quality and special characters; presenting suction 81 Swellings con- nected with Arteries. Inspection. Palpation- size, etc. pulsation. thrill. diastolic shock. Measurement. Percussion. Auscultation. § IV. F.3 VEINS. [PART I. Rupture of swelling. Abnormal sen- sations. Veins. Inspection— size, etc. visible pul- sation. Palpation. Auscultation. Skin over veins. character. — Sounds and murmurs constant or not ? effect of posture on them ; effect of movement; effect of pressure on vessel; if near or in the thorax, effect of respiration on them; — period of sounds and murmurs as compared with impulse of swelling, heart's impulse, and heart's sounds. 190. Rupture of swelling : — phenomena attend- ing it; — alteration in the signs derived from in- spection, palpation, measurement, percussion, and auscultation. (Vide supra.) 191. Abnormal sensations: — pain, seat, charac- ters, intensity, direction, etc. (326); aching, its seat, etc.; tenderness; throbbing; tension. Veins. 192. Inspection (on thorax, abdomen, neck, upper and lower extremities, etc.) : — size; course; tortuosity; apparent connection with deep veins; — direction of flow of blood in enlarged veins.—Visi- ble pulsation (noting in which vein or veins); de- gree and characters; cardiac or respiratory ? its time as compared with heart's impulse; — influence of posture, exercise, emotion, respiration, coughing, pressure, etc. upon it. 193. Palpation:—hardness of veins (noting seat and extent of this and other phenomena), thickening, cording, etc.; pulsation; thrill. 194. Auscultation: — murmurs; their charac- ters ; rhythm; influence of position, pressure, respi- ration, heart's action, etc. upon them. 195. Condition of skin over veins :—redness, etc. 82 PART 1-3 VEINS. — BLOOD. [§ rv. r. Swellings connected with Veins. 196. Physical examination : — Position; shape; size; hardness; — thrill; — results of percussion and auscultation. 197. Abnormal sensations, etc. :—pain, its cha- racters; tenderness, etc. Blood. 198. Phlebotomy or arteriotomy:—Period of day when blood is drawn; its relation to meals.— Stale of pulse before bleeding. — Posture of patient during operation; position of limb or part. — Name of vessel; any peculiarity connected with it? size of incision. — Flow of the blood (noting and com- paring particulars at different periods of the bleed- ing and at its close): facility of the flow; force; volume; rhythm; height;—colour of blood as it streams, natural, black, violet, bluish, whitish, red- dish, scarlet, variegated; — its fluidity; — its tem- perature (taken near the orifice, that of the atmo- sphere being observed at the same time); — its odour (with or without addition of sulphuric acid). (See also 201). — Quantity of blood drawn: time occupied in obtaining it. — Condition of patient: during and immediately after bleeding; especially as regards changes in pulse, state of skin, intellect (syncope, delirium), etc. 199. Cliaracters of blood drawn: — description of vessel into which the blood has been received.— Process of coagulation: blood completely or par- tially coagulated; time of commencement and com- pletion of process; appearances attending it; — 83 Swellings con- nected with Veins. Physical exa- mination. Abnormal sen- sations. Blood. Phlebotomy or. arteriotomy. period of day pulse. posture. vessel. flow. quantity drawn. effects. Characters of blood. coagulation. § !V. 0-3 LYMPHATIC SYSTEM. [PART I. clot. Microscopical examination- from finger. from vein. Chemical examination. halitus. § IV. G. Vessels. accidental occurrences which may affect it, tempera- ture, exposure to air, etc. — The clot: position in respect of vessel, in respect of serum; size; form, round, ovoid, flat, cupped, etc.; — colour, mottled, etc.; aeration; cohesion, etc.; — buffy coat or sizi- ness, its colour, thickness; proportion to entire clot; surface (smooth, granulated); cohesion; degree of cupping.— The serum: colour; transparency (if milky, note effect of ether upon it); viscidity; spe- cific gravity; chemical reaction. 200. Microscopical examination of blood: — of drop of blood taken from finger of patient; period of day when taken; time of last meal. — Elements observed; — movements of red corpuscles, time of running together into rouleaux, length of rouleaux, duration of aggregation; — relative numbers of white and red corpuscles; — effect of agents on microscopic elements. — Of blood drawn from a vein and coagulated; examination of clot, buff, and serum. 201. Chemical examination of blood: — pro- portion of each of normal elements; — examination of serum for presence of sugar, urea, uric acid, ammnoia, etc. — Examination of halitus for am- monia, sulphuretted hydrogen, etc. G.—LYMPHATIC SYSTEM. 202. Lymphatic vessels (noting locality and extent of all observed phenomena): — hardness; enlargement; — tenderness; pain. — Redness or other discoloration over them, occurring in patches, along line of superficial lymphatic vessels (noting exact course, and whether linear or blotch-like in 84 PART ij URINARY ORGANS. [§ IV. H. form; — oedema or abscess of adjacent cellular tissue. 203. Lymphatic glands (noting situation of glands affected) : size; form ; readiness of circum- scription; surface; induration, general or partial, its degree; softening; fluctuation; — pain, tender- ness, etc.—Cicatrices over seat of glands. H.--URINARY ORGANS.—URINE. Physical examination of the Kidneys, Supra- renal Capsule, and Ureters. 204. Inspection (in postero-lumbar, lateral lum- bar, and antero-lumbar regions).—Fulness; oedema of integuments; redness; fistulae, etc. 205. Palpation: — temperature of surface in renal regions. — Tumour; its size; state of surface, even or nodulated ? size of nodulations (their uni- formity); firmness of tumour; fluctuation, readi- ness of its perception ;—presence of yielding portion in front of tumour?—(further particulars as Ab- dominal tumours, 130).— Movableness of kidney discoverable anteriorly. — Swelling in course of ureter; effect of pressure upon it; its movableness. 206. Measurement:—vertical from antero-supe- rior spine of ilium to lowest rib; semicircular; antero-posterior (with callipers). 207. Percussion (after defining previously, if possible, the limits of liver and spleen) :—extent of dulness anteriorly; how connected with that of liver and spleen ? extent of dulness posteriorly; trans- verse dulness (measured).— Intestinal note ante- riorly to tumour; course of line of intestinal note, transverse, vertical, irregular; (further particulars as Abdominal tumours, 131). H 85 Glands. I IV. H. Physical exami- nation of Kidneys, etc. Inspection. Palpation. Measurement. Percussion. § IV. H.3 EXAMINATION OF URETHRA. [PART I. Auscultation. Physical exami- nation of Bladder, etc. Hypogastric region— inspection. palpation. percussion. auscultation. By rectum- prostate. By vagina. Catheterism. Physical exami- nation of Urethra. Inspection— orifice. discharge. stains on linen. 208. Auscultation (with pressure or percussion) : —sound of collision of calculi; (further particulars as Abdominal tumours, 132). Physical examination of Bladder and Prostate Gland. 209. Physical examination of hypogastric re- gion: — fulness; tension. — Palpable tumour; its form, size, consistence, fluctuation;—effect of cathe- terism upon it. — Form of distension as established by percussion.—Auscultation combined with use of sound; audible collision of sound against a calculus, against a tumour; (further particulars as Abdominal tumours, p. 61). 210. Examination through rectum:—size of pro- state gland; enlargement to right or left side ?—con- dition of bladder beyond prostate; fluctuation com- municated by percussion on hypogastrium, its de- gree and extent. 211. Examination through vagina (231). 212. Catheterism: — direction of prostatic part of urethra; dalculus felt in bladder, etc.; — effect of catheterism on physical signs. Physical examination of Urethra. 213. Inspection: — malformations (e. g., epi-or hypo-spadias) ; vegetations at orifice ; — vascular tumours ; number, seat, tenderness, etc.—Discharge from urethra: abundance, circumstances influenc- ing it; — physical characters, colour, consistence, odour; coagulability;—duration of discharge; — results of inoculation with discharge (in evidence of chancre within urethra). — Stains upon linen : 86 PART ij URINARY ORGANS. [§ IV. H. abundance ; size ; precise form; precise tint; stiff- ness or pliability; — results of steeping in distilled water and microscopical and chemical examination. 214. Palpation (in course of urethra) : — swell- ing ; hardness; knottiness, etc. 215. Catheterism : — length and direction of urethra (determination of this and of thickness of urethra and tissues about it assisted by finger in vagina or rectum).—Strictures: number; situation; closeness of stricture; hardness of walls;—effects of stricture upon micturition and ejaculation of semen. General symptoms referable to the Urinary Organs. 216. Pain :—in renal regions; in direction and course of ureters; in region of bladder; in direction of spermatic cord, with or without retraction of the testicle ? in course of urethra; at extremity of penis.—Its severity; constancy, if paroxysmal, state period, frequency, and duration of attacks; — circumstances under which it occurs; after walk- ing, riding, jolting, etc.; effect of different kinds of food or drink upon it; — its precise seat and ex- tent ? if in renal region, on one or both sides ?—its direction; — accompanying phenomena; faintness, sickness, sweating, etc.;—special character of pain. — Other abnormal sensations: fulness; tension; itching at extremity of urethra, etc. 217. Tenderness (in renal and hypogastric re- gions and in course of urethra): — superficial or deep-seated ? its amount; limited to spot touched, or radiating elsewhere ? 218. Micturition:-.—desire to pass urine or not? its frequency, its urgency. — Frequency of micturi- tion; facility of micturition, effect of posture upon 87 Palpation. Catheterism- strictures. General symp- toms. Pain— seat. severity. circumstan- ces affect- ing it. accompanying phenomena. other sensa- tions. Tenderness. Micturition— desire. frequency. § rv. h.] URINE. [PART I. stream. pain. stillicidium. Haematuvia— quantity. circumstan- ces affect- ing. characters of blood. phenomena preceding. Urine. Quantity. Characters— appearance. odour. specific grav- ity. reaction. coagulation. pellicle. deposit. it;—stream of urine, interrupted, in drops, forked, spiral. — Painful micturition; pain preceding, ac- companying, or following the act; characters of pain ; constancy ; duration ; seat. — Stillicidium urinae; constant or occasional ? urine passed into bed at night, from what cause ? 219. Haematuria :—quantity of blood passed; frequency of occurrence ; — circumstances giving rise to it, walking, jolting, etc.; — blood passed at commencement or close of micturition, or mixed generally with urine ? — blood fluid or coagulated ? form of coagula, lumpy, vermicular; colour of blood or of urine containing it. — Phenomena preceding the discharge. Urine. 220. Quantity of urine (in fluid-ounces), in course of day and night; — gelation of this to the quantity of liquid drunk. 221. Characters of urine (in important cases, separate examinations should be made at different periods of the twenty-four hours, before and after meals, etc.) : — transparency; milkiness; — colour; pale, yellow, greenish, tinged with blood, smoky, etc.; odour: urinous, whey-like, sweet, sweet-briar- like, strongly acid, ammoniacal, fishy, musty, etc.; —specific gravity (noting how determined and tem- perature), before deposit; after deposit; after ebul- lition;— its reaction; acid, neutral, alkaline, (from volatile or fixed alkali ?).—Spontaneous coagulation; size, colour, and consistence of coagulum.—Pellicle, iridescence; — cloud; — deposit; its position, pro- portion to entire specimen of urine, density, colour — special physical character of, bulky, flocculent; dense and opaque; granular or crystalline and small PART 1-3 URINE. [§ IV. H. in quantity. — Foreign substances in urine; milk, fasces, ink, worms, entozoa, etc. — Changes in urine on standing for several hours, days, or weeks. 222. Microscopical examination of deposit.1— Bulky flocculent deposits. — Casts of the urini- ferous tubes, their diameter, transparent, granular or clear, " wax-like " ; substances entangled in the fibrinous casts. — Epithelial cells, containing oil- globules or not ? sharp and well-defined, or granular and disintegrated ? blood corpuscles; pus globules; crystals; are they present in considerable number or sparingly ? — Mucus.—Torulae.—Sarcinas.—Vibri- ones. — Spermatozoa. — Free epithelial cells, scaly, columnar, globular; their size; nucleus present or not ? — Extraneous matters; portions of hair; bed- flock ; feathers, etc. Bulky, dense, and opaque.— Pus. — Triangular prisms, or other form of triple phosphate (phosphate of ammonia and magnesia). —Amorphous deposit (phosphate of lime or lithate of soda and ammonia), etc. Extraneous matters, flour, starch, portions of potatoe, etc. Granular or crystalline and small in quantity. — Rhom- boidal, lozenge-shaped, or other forms of lithic acid. —Dumb-bell, or octohedral crystals (oxalate of lime). — Triangular prisms or other forms of triple phosphate.—Cystine.—Carbonate of lime. — Blood- globules. — Extraneous matters, claws of Echino- cocci, sand, etc. 223. Chemical examination of urine: — (691, etc.) "Examination for arsenic, etc., in cases of suspected poisoning." 1 The upper, middle, and lower portions of the deposit to be separately examined. foreign sub- stances. Microscopica examination of deposit. Chemical examination. h2 89 § iv. i.] ORGANS OF GENERATION. [PART I IV. I. Pudendum. Labia, etc.— swelling. ulcers, etc. tumours. discharge, etc. Sensations. Urethral orifice— appearance. growths. displacement. Hymen— presence. characters. Protrusion from vulva. inspection. palpation. percussion. I.—ORGANS OF GENERATION. 1. Female. Pudendum. 224. Labia, Nymphce, and Clitoris: — enlarge- ment; swelling hard, soft, fluctuating, cedematous; colour; degree of vascular injection; — excoriation, its seat, extent, etc.; ulcers (665); cicatrices (670);—vegetations; condylomata, elevated or flat? —tumours, their exact seat, size, form, colour of surface, consistence, fluctuation, movableness, dis- appearing or not on lying down ? — Discharge; amount, odour, and other characters; other matters about external genitals, blood, etc. 225. Abnormal sensations: — pain, itching, ten- derness, etc. 226. Urethral orifice:—its prominence; thick- ening of tissues around it; its colour; sensibility. — Growths within and about it, warts, vascular tumours, etc. (their number, exact seat, size, and other characters.—Displacement of urethral orifice. 227. Hymen :—absent or present ? imperforate; its precise state, "surrounding the en tire, vaginal orifice or only a part of it ? its strength." 228. Protrusion from vulva externally: — num- ber of protrusions; size; form; colour; — pre- senting the os uteri upon it, etc. — Palpation of protrusion;—soft, elastic, fluctuating; character of contents, intestines, omentum, etc.; — form, size, and situation of uterus. — Percussion of protrusion, resonant, dull. — Effect of posture, coughing, or catheterism on protrusion; sound or sensation to hand on reduction. 90 PART lj EXAMINATION BY VAGINA. [§ iv. I- Examination by the touch, through the Vagina. 229. Vagina: — orifice, its size; contracted by muscles; surrounded by swollen mucuous mem- brane ; — direction of vagina in relation to pelvis; length; breadth; narrowing of any part, its seat, degree, and apparent cause; complete closure of canal, its seat; —mode of termination. — Mucous membrane: smooth, velvety, rough, corrugated, swollen, or thickened; presenting puckering, fraena, vegetations, etc. (their seat, etc.) — Pulsation of arteries perceptible or not ? generally or limited (to what part) ? — Tension, hardness, or resistance to pressure at any part of the wall ? — Openings, into rectum, bladder, or other cavity; their exact seat, character of edges, connection with tumours, etc.;— nature of matters discharged from the openings, hair, portions of fcetal substance, bones, etc.— Tumours attached to wall of vagina; their position, size, form, etc.; sessile or pedunculated ? their sensibility (distinguishing between sensibility of tumour and that of mucous membrane). — Con- tents of vagina; clot; polypus, tumour, its size, shape, consistence, sensibility, etc., traced to os uteri (232) ; foreign substances in vagina (pessaries, etc.) 230. Urethra: — thickening in its course, its extent, hardness, etc. (judgment assisted by simul- taneous use of catheter). 231. Bladder : — distended ; protruding anterior vaginal wall; fluctuation felt on impulse over supra- pubic region; — effects of pressure in supra-pubic region on tumour; effect of catheterism, of efforts 91 Examination by Vagina. Vagina—^ orifice. direction. size. closure. termination. mucous mem- brane. pulsation of arteries. resistance. openings, etc. tumours. contents. clot. polypus. foreign sub- stances. Urethra. Bladder- distension. § IV. I.] EXAMINATION BY VAGINA. [PART at micturition. — Solid tumour about situation of bladder; its form, irregularity, extent, mobility, etc. 232. Uterus. — Neck: its position in pelvis, elevated, depressed (amount of each), displaced towards either side, forwards or backwards; — axis altered; direction and amount of alteration. — Size of neck, natural, smaller than usual, enlarged; amount and direction of enlargement; shortened, lost; elongated;—consistence, soft, cushiony, hard; covered with transverse folds of mucous membrane; irregularities or elevations on surface; — tender- ness;—pulsation of arteries on its surface;—de- struction, its character and extent (624); tumours, their extension in direction of body of uterus or towards other organs; — adhesion of neck of uterus, at what part ? — Lips of uterus: natural; of ring- like form; hard ; soft; irregular; enlarged (stating which lip); flat; everted; thin ; smooth; lobulated (in two, three, or more lobules ?); excavated, etc. — Orifice of uterus: incapable of being reached, from what cause ? direction of, forwards, backwards, to either side; surrounded by cicatrix; its shape, natural, oval, rounded, irregular; elevated on one side; closed; — open, degree of (admitting one or more fingers); —obstructed, nature of obstruction (if ascertainable);—tumour projecting through orifice; its extent (229), narrowing of tumour oppo- site orifice, attachment of tumour to any part, or readiness with which finger can be passed round its neck. — Body of uterus: position, in centre of pel- vis, directed forwards, backwards, or to either side (partially or completely); ante-flexed, retro-flexed, amount of angle formed with the neck; apparent size (amount of enlargement above the cervix); en- larged equally in all directions, or in what direc- tion?— form of enlargement; lobulation or other 92 / PART ij EXAMINATION BY VAGINA. [§ IV. I. irregularities of surface; — consistence, hard, soft, fluctuating; — fixity of uterus;—apparent weight of uterus. — Repercussion (ballottement). Preg- nancy ; character of presenting part, foetus, coagula, placenta, tumour, etc. — Results of introduction of finger through the orifice; escape of gas, of fluid matters (their characters); —solid substance felt within it; polypus, its point of attachment (by a neck, or extended surface), size, form, consistence, degree of sensibility; characters of any substance brought away by the finger. 233. Tumour felt through wall of vagina (this includes the examination of the Ovaries and Fallo- pian tubes) : — exact position in regard to vagina, pelvic viscera, and pelvis; anteriorly (superiorly or inferiorly ?), posteriorly (superiorly or inferiorly ?), laterally; — size ; extent of pelvic cavity occupied by it;—form, cylindrical, rounded, irregular, etc.; — surface ; smooth, irregular, nodulated (equally or unequally ?); — consistence; hard, soft, elastic, im- pressible, fluctuating; giving the idea of limbs or other parts of a foetus; —its connection with known organs, as uterus, bladder, or rectum; — effect of straining or labour-pains on its position or tension; — mobility or fixedness of tumour. — Tenderness. Examination through the Vagina and Abdominal Wall conjoined. 234. Continuity and connection or otherwise of tumours felt through vagina, with others felt above brim of pelvis; — transmission of impulse or fluctu- ation from one to the other; elevation of the one accompanied or not by elevation of the other? — descent or not of pelvic tumour on pressing down- 93 repercussion. cavity. polypus. Tumour— seat form. consistence. connections. mobility. tenderness. Examination by Vagina and Abdominal Wall. Continuity of tumour— § IV. 1-3 EXAMINATION THROUGH RECTUM. [PART I. Bize of tu- mour. Examination by Rectum. Introduction of finger. of bougie. Uterus. Ovaries and Fallopian tubes. Bladder. Tumour. Examination by Rectum and Abdominal Walls. Examination by Rectum and Vagina. wards abdominal tumour ? — Size of mass felt. —■ Effect of elevation of abdominal tumour upon the position or mobility of pelvic organs or tumour. Examination by the touch, through the Rectum. 235. Introduction of finger:—facility with which permitted; passage of finger along canal opposed, by accumulated faecal matter, by foreign bodies, by compression from tumour externally, by stricture; closeness of stricture; extent to which finger can pass. —Introduction of bougie. (See also 126.) 236. Uterus:—position; size, form, etc., of such parts as can be reached; mobility; — its fundus, form, relation in position to pelvic tumours, etc.— Ovaries and Fallopian tubes (if capable of being recognised) :-^position; mobility; size; form; con- dition of surface; consistence; pulsation of arteries; tenderness, etc. 237. Bladder: — its relation in position to fun- dus of uterus and pelvic tumours. 238. Tumour: — its position relatively to rectum and pelvis; its characters (particulars as 233). Examination through the Rectum and Abdominal Wall conjoined. 239. (Particulars as 234). Examination through the Rectum and Vagina con- joined. 240. Thickness of substance between the fingers; tumour, its size and characters (233, 238); fluctua- tion, etc. 94 PART 1.3 EXAMINATION BY SPECULUM. [§ IV. I. Examination by the Uterine Sound (when necessary.) 241. Introduction of sound:—facility of intro- duction and extent to which effected; pain on intro- duction ; escape of blood; sickness, faintness, etc., induced ? — Uterine cavity : its length; direction, presenting angular flexion, direction in relation to tumours of the pelvis or abdomen. — Can the ex- tremity of the sound be felt through the abdominal parietes, vagina, or rectum ? — Thickness of inter- vening substance. 242. Movableness of uterus by means of the sound : —is it capable of being moved from or inde- pendently of pelvic or abdominal tumour? — can ab- dominal tumour be moved while uterus is fixed by the sound? — does movement of abdominal tumour occasion a corresponding movement of handle of sound ? Examination by the Speculum. 243. Introduction of speculum (stating kind of instrument used): — facility of introduction; pain on introduction; its exact seat. 244. Vagina: — its colour, uniform or not? mottled; surface, smooth, velvety, rough, corru- gated;—excoriations; ulcers (665); cicatrices (670); vegetations; tumours (672).—Abnormal openings; their situation; form, etc.;—character of matters passing through them. — Secretion on surface of mucous membrane; abundance, characters (249). 245. Orifice of uterus:—natural; open; occu- pied by glairy or gelatinous mucus, tumours, etc.; 95 Examination by Uterine Sound. Introduction— uterine cavity. thickness of wall. Movableness of uterus. Examination by Speculum. Introduction. Vagina— surface. openings. secretions. Orifice of uterus. § IV. I.] GENERAL SYMPTOMS. [PART I. size; form, rounded, irregular, etc.; — discharge emerging from orifice or covering its lips, its charac- ters;— characters of mucous membrane. 246. Lips: — their size; form, flat, uneven, everted, lobulated (size and characters of lobula- tions) ; colour, bright, livid, dusky red, etc.; — raw appearance around orifice of uterus (extending or not into cervical canal ?); its form, size, exact situa- tion, elevation or depression from level of surface generally? mammillation of its surface, etc.;—ex- coriations; ulcerations (665), etc. General symptoms referable to the Female Genera- rative organs. 247. Catamenia:— periods of their recurrence; duration of discharge (in days or hours); discharge continuous or intermittent ? —quantity of discharge, natural to the individual, scanty, increased, very abundant. — Phenomena of flow; occurring sud- denly at catamenial period; on excitement; at irre- gular periods; — accompanied or not by pain, from first appearance or from what date ? occurring be- • fore, during, or after the flow? trifling or severe? its exact seat, character, duration. — Physical cha- racters of fluid: colour; consistence; odour; accom- panied or not by clots ? — Catamenia entirely sup- pressed: for what period ? 248. Haemorrhage: — frequency; periods of oc- currence;—circumstances inducing it, fatigue, long- standing, heated apartments, etc.;—its abundance; — relief afforded by it to uneasy or painful sensa- tions ; phenomena of decrease, gradual, sudden, etc. 249. Liquid discharge from vagina :—amount; constant or intermittent ? periods of its occurrence; gradual or in a gush ? — Characters of discharge: 96 PART ij GENERAL SYMPTOMS. [§ IV. I. transparent; opaque; its colour, white, yellow, pink, greenish; streaked with blood;—its consistence, watery, thin, glairy or viscid, stringy; — its special characters, puriform, curdy, like white of egg or jelly, bloody; mixed with urine or faeces;—con- taining organic detritus, tuberculous or calcareous matter, cancerous matter, etc.;—stains produced by it upon linen ; their colour, etc.—Microscopical cha- racters of discharge (686 et seq.); specially, sper- matozoa, urinary or other crystals.— Chemical cha- racters of discharge (695 et seq.) 250. Discharge of gas from vagina :—frequency of discharge; circumstances under which it occurs, spontaneously or during vaginal examination ? accom- panied or not by sound ? apparent quantity of gas discharged; its odour. 251. Solid or organized masses discharged from vagina : — circumstances of expulsion ; — their nature, an ovum (its degree of development), a coagulum, fibrous or calcareous matter, a mole, hy- datids, etc. (their anatomical characters), etc. 252. Pain in vagina:—constant, occasional; cir- cumstances under which it occurs; its characters, lancinating, shooting, throbbing, burning, etc.; in- creased by evacuation of bowels; sense of swelling or distension ; — difficulty or pain in walking ; ten- derness on sitting down. 253. Pain in pelvis: — its exact seat; circum- stances under which it occurs; its special characters, continuous, paroxysmal, shooting, expulsive, bear- ing-down, etc.; its extent, direction. 254. Itching:—seat, external or internal; severity; circumstances under which it occurs. 255. Sexual intercourse :—imperfect from phy- sical obstacle ; painful, seat of pain ; — followed by microscopical characters. chemical cha- racters. Discharge of gas. Solid dis- charges. Pain in va- gina^— circumstan- ces. characters. Pain in pelvis- circumstan- ces. characters. direction. Itching. Sexual inter- course. I 97 § iv. i-3 MAMMAE. [PART Mammae. Physical exa- mination— form. surface. nipple. areola. substance. tumour. ulcer. Pain. Scrotum. Testicles. discharge of blood, by weight about anus, by hys- terical fits, etc.; disgust of. Mammae. 256. Physical examination of mammae :—their form; size, equal or unequal ? affected or not by catamenial period ? surface, its smoothness, colour; — silvery lines or other visible marks of previous enlargement; condition of veins.—Nipple: colour; degree of fulness and turgidity; flattened or drawn in, amount of puckering inwards; dryness or mois- ture of surface; discharge from it; excoriations; ulcers (665), etc. — Areola: size; colour; mois- ture;— follicles, their size, position, and colour;— firmness or softness of skin.—Substance of gland: knotty; its mobility; tenderness;—fulness or hard- ness of lymphatic vessels, of axillary or supra-cla- vicular glands.—Tumour: precise seat; form; sur- face; solidity; elasticity; adherent to skin or to deep parts; tender; painful after examination. — Ulceration : its situation, size, and precise characters (665). 257. Pain in breast: — its characters, aching, throbbing, like a weight, lancinating, etc.; limited to breast or radiating elsewhere ? influence of cata- menial periods upon it. 2. Male.1 258. Scrotum :—anasarca; eruptions (77 et seq.); hernia, etc. 259. Testicles: — absent from scrotum; very 1 Such points alone are here noted, as have especial reference to medical cases. 98 PART 1-3 ENCEPHALON. [§ IV. K. small; enlarged (one or both ?), character of en- largement; mobility.—Pain; constant or occasional? its character;—tenderness. 260. Penis:—unusually small; enlarged, cause and character of enlargement; enlargement of cor- pora cavernosa; hardness of corpus spongiosum;— condition of urethra (213 et seq.); tenderness, its seat. 261. Spermatorrhoea:—its frequency; amount; erotic or not ? nocturnal or diurnal ? induced by de- faecation ; influenced by temperature, by state of bowels, by anxiety of mind, by sexual excitement; —sequelae of discharge, headache (occipital or other- wise), constipation, failure of sight, confusion of thought, insomnia or drowsiness, lumbar pain, etc. K.--ENCEPHALON AND ITS COVERINGS AND AP- PENDAGES. Examination of Cranium, etc. 262. Cranium: — general form, conical, lozenge- shaped, etc.; — form of frontal, parietal and occipi- tal regions; —prominence;—flattening; — symme- try of the two sides; — special depressions or emi- nences, from injury, etc. — Its size; height, length, breadth. — Measurement: circular (over superciliary ridges and occipital protuberance), noting separately the anterior and posterior segments as divided by the ears; compared with circumference of neck op- posite cricoid cartilage; — across vertex (from ear to ear), along middle line (from root of nose to occipital protuberance). — Facial angle.— Cranial bones: their apparent thickness; fixed or loose.— Fontanelles: closed, open, size; prominent or de- pressed? tense; fluctuating; pulsating; relation of 99 Penis. Spermatorr- hoea. \ IV. K. Cranium, etc. Cranium— form. symmetry. measure- ment. facial angle. bones. fontanelles. § IV. k.3 SENSIBILITY. [PART I. sutures. Integuments— temperature, etc. ecchymosis. wounds, etc. hair. Tumours— Beat. mobility. consistence. characters. integument over. pain. Auscultation. Sensibility. Pain in head- how indi- cated. antecedents. pulsation to heart's systole and to respiratory acts. — Sutures : closed, open; to what extent ? 263. Integuments, etc. — Temperature, compared in different parts; colour; fulness of vessels; pulsa- tion. — Ecchymosis, with or without swelling ? — Wounds (626); abrasions; ulcers (665); eruptions (77 et seq). — Hair; its arrangement, erect, flat or depressed ? disordered; — rubbed off certain parts. 264. Tumours: — number; precise seat, over su- tures, fontanelles, bone; size; pedunculated or ses- sile? mobility; fixity to skull; consistence; elas- ticity; fluctuation; — if perforating skull, note state of edges of opening, smooth or rough, surrounded or not by an elevated rim?1 — tumour diminished in size or reducible by steady pressure; pressure pro- ductive of cerebral symptoms; —»- tumour erectile, pulsating (effect of pressure upon carotid artery on these phenomena). — Murmurs audible over tu- mour, arterial, venous.—Precise condition of in- tegument over tumour, its colour; oedema. — Pain; tenderness, etc. 265. Auscultation in course of sinuses, especially over torcular Herophili; venous hum. Alterations of Sensibility. 266. Pain in the head:.— complained of ver- bally, indicated by patient putting hand to head or otherwise ? — antecedents of pain, a fall, a blow, a strain of any kind, dietetic irregularities, unusual intellectual work, moral excitement, sexual excesses, 1 This " elevated rim" may exist without perforation, as in sub-pericranittl cephalhematoma and in collections of blood in the adult, producing a deceptive sensation of perforation. 100 PART 1-3 SENSIBILITY. [§ IV. K. etc-; — precise seat of pain ; symmetry (hemicra- nial?);—character of pain, sense of weight, throb- bing pain, expansile, bursting, lancinating; deep- Beated or superficial ? its intensity; sense of intense heat; characters changeable or not? — accompanied or not by undue carotid pulsation ? by sense of sick- ness or vomiting ?—Affected by pressure, by light or sound; by movement of muscles of face or scalp; by movement of eyes (in what direction?); by movement of head or body; by respiration, by deep inspiration or deep expiration; by posture; by muscular effort, coughing, etc.; by pressure on carotid arteries, one or both; by stimulants.—Time when pain most felt, in morning, evening, on wak- ing, after eating, etc. — Duration of pain, its con- stancy ; periodicity. — Connected or not with neu- ralgic or rheumatic pains elsewhere ? 267. Altered sensibility of skin: — (note precise locality of altered sensibility, whether it is symme- trical or not; course pursued by it, upwards, down- wards, or irregularly). — Sensibility increased: de- gree of increase, stating how judged of; to pinching, to gentle friction, to touch; endeavour to distin- guish between acuteness of touch, or hyperaesthesia, and augmented sensibility to pain, or hyperalgesia). — Sensibility diminished: degree of diminution (stating how judged of); results of application of Weber's test, with points of compasses placed parallel with axis of part or transversely ? objects appearing separated from skin by some intervening substance; inability to distinguish form and character of surface of objects by the touch; unconsciousness of contact of bodies; (endeavour to distinguish between dimi- nution or loss of touch or anaesthesia, and diminished or abolished sensibility to pain, or analgesia); total abolition of all sensibility.— Sensibility perverted: 12 101 seat. characters. accompani- ments. circumstan- ces affect- ing. time. duration. other pains. Sensibility of skin— increased. diminished. perverted. § ^ K-3 MOTILITY. [PART I. sense of heat or of cold (compare with indication of thermometer);—numbness; formication; prickling; tingling; itching, referred to surface, subcutaneous parts, or deeper in limb; spontaneous or induced ? if the latter, method of production ? transference to other localities; — aura. Muscular 268. Unconsciousness of position of limbs :—in- sense. ability to perform or continue muscular acts without concentrating attention upon them (so-called mus- cular sense). Other sensa- 269. Other alterations of sensibility : — pain in back, limbs, etc.; precise locality of pain, its cha- racter ; circumstances influencing it; pain affecting course of special nerves (326); affecting muscles (87), bones (84), or joints (83); globus, sensation Vertigo— as 0f a string around thorax or abdomen.— Vertigo: — its severity; apparent motion of body or of sur- causes. rounding objects? vertical, horizontal, swimming, etc. ?—circumstances which induce or exasperate it, e. g., position of entire body, of the head, impres- sions on the organs of the senses; — its duration; accompanied or not by nausea ?—(See also 59.) Alterations of Motility 270. Attitude: — in erect posture ; unsteadiness on centre of gravity, with eyes shut or open suc- cessively.—Attitude in decumbency (57): tendency to turn on one side, to turn round and round. — Attitude in sitting posture (57). —Attitude during progression ; walk staggering or faltering; — drag- ging of either leg; — patient compelled to adopt a running pace; — tendency to fall, from what cause (vertigo, not feeling the ground, weakness of either or both limbs) ? — tendency to go irresistibly for- wards, backwards, sideways, diagonally, to turn 102 duration. Motility. Attitude— in erect pos- ture. decumbency. sitting. in progres- sion. PART I.] MOTILITY. [§ IV. K. round and round. — Attitude of head in each pos- ture (57) ; boring head into pillow. 271. General agitation, of voluntary muscles: intermittent or continual ? under what circumstan- ces? automatic or delirious?—Tremblings: their site; occurring in all or in certain postures ? per- sistence during sleep. — Muscular twitchings: in face, extremities, etc.; subsultus tendinum; car- phology.— Unsteadiness of limbs when raised up. 272. Automatic movements:1—limbs or parts of body affected; unilateral or bilateral ? affecting special muscles of tongue, pharynx, eyeball, etc.; — degree or violence of movements; character of movements; their constancy or variation; — in- fluence of sleep upon them, of irritation, of mental excitement, of sensory impressions (tactile or special), of directing attention to them; relation to voluntary movement; subjection to the will. 273. Sloiv movements of extension or of flexion of limbs without apparent object. 274. Power of directing movements of upper or lower limbs, normal, lost or impaired; how indi- cated? (268.) 275. Rigidity: with extension or with flexion of limbs ? angle of flexion at which it is perceived; rigidity affecting other parts; its degree; — persis- tent ; alternating with relaxation; occurring only after flexion and extension; recognition of by patient; painful or not ? relation to volitional movement; — effect of flexing or extending wrist upon rigidity of fingers. 276. Spasmodic contractions: — clonic; tetanic (trismus, emprosthotonos, opisthotonos, pleurostho- 1 Under ''automatic movements" are here included the kinds of movement recognised as " choreal." 103 carriage of head. Muscular agi- tation— tremblings. twitchings. unsteadiness. Automatic movements- seat. circumstan- ces affect- ing. Slow extension and flexion. Power of direc- tion. Rigidity. Spasmodic contractions. § iv. kJ MOTILITY. [PART I. Convulsion— antecedents. tonos); their duration and intervals; — spontaneous or excited by movements, by nervous impressions (as a start), by being touched; by percussion of muscles, extent of muscular contraction from point percussed ? periodical. 277. Convulsion:—constant or occasional? in- tervals of recurrence ; periodicity—induced by sight or sound of liquids, etc.—Antecedents of seizure: changes in mental or emotional state (282 et seq.); countenance (58); dazzling before eyes; sudden failure of sight; fixing of eyes; dilatation of pupils; tinnitus; globus; feeling of tightness in throat and sense of suffocation ; rigors; clonic spasm; aura ; peculiar cry; fall, etc.;—time which elapses between these phenomena and seizure. — Phenomena of seizure : site of convulsions; on one or both sides ? alteration in features; amount of convulsion; dura- tion of attack ; — tendency chiefly to rapid jerking movements, to rigid flexions, to rigid extensions (solely, in association or in sequence?); — accom- panied by foaming at the mouth, by biting the tongue, by vomiting, by ejection of faeces, urine, or semen, by a tendency to bite, by a dread of liquids and shining bodies;—direction of axes of eyes during seizure; — state of consciousness, perfect, impaired, abolished;—state of skin, as to colour, temperature, and perspiration;—state of pupils (322), pulse (184), and respiration (169);—heart's sounds (178), and impulse (176);—discharge of flatus.—Evidence of occurrence of convulsions during sleep; — influence of the will upon them.—Sequences of attack : sleep, its duration, comatose state, perspirations, discharge t of urine, frequency of micturition, quantity and special characters of urine (220), etc.;—recollection of attack by the patient. 278. Other spasmodic phenomena: — strabismus 104 PART 1-3 MOTILITY. [§ IV. K. (322) ; rolling of eyes; cramps (87); grinding of teeth ; jerking or kicking movements of limbs, time when chiefly observed, painful or not? priapism, etc. —Mode of exciting any of these phenomena;—time of their occurrence; —condition of sensation in limb generally at the time of their excitement, impaired, or totally absent (267);—concomitant deviation of spine. 279. Cataleptic immobility :—parts affected; its degree; frequency and duration of seizures. 280. Paralysis:— Affecting the limbs: how judged of? — its exact site; affecting flexors or extensors solely or principally? affecting special muscles;—accom- panied or not by twitchings of the paralysed muscles ?—progressing upwards or downwards ? —perfect or imperfect in degree ? constant or variable ? relation to volition, emotion, or other accidents; compared upon the two sides and in upper and lower extremities.—Bulk of limbs estimated by measuring their circumference; nutrition of paralysed limbs and muscles esti- mated by the feel;—temperature of paralysed compared with non-paralysed limb;—pulse, comparative size, force and rhythm. Affecting the thorax and abdomen: rhythm of respiration; — expansion during inspiration, measured on both sides;—any increase of num- ber of respirations and of expansion of chest by irritating soles of feet ? — tendency of fluid to accumulate in bronchi, etc. Affecting the face : any peculiarity of expression ? comparison of the two sides, condition of wrin- kles on the two sides; effect of laughing or smiling on the two halves.—Comparison of po- sition of pinnae of ears; of halves of occipito- 105 how excited. accompani- ments. Cataleptic im- mobility. Paralysis— limbs. thorax and abdomen. face. § IV. K.] MOTILITY. [PART I. frontalis, symmetry of wrinkling on the two sides during frowning or elevation of eyebrows; — comparison of height of eyebrows; degree to which eyelids are apart, ptosis, lagophthal- mia; course of tears;—size of aperture of nares, flapping of nares on either side;—condi- tion of cheeks and lips, comparison of commis- sures of mouth, note manner of whistling, of blowing out cheeks, etc.; accumulation of food behind teeth. Affecting the tongue (93) : deviation of tongue, in protrusion or retraction ? its direction, amount, constancy; variation with degree of protrusion (noting condition of teeth); power of directing tongue to either side; — alteration in form of tongue; wasting of either side;—induration or rigidity of either side; twitching of either side. —Articulation: thick, confused (noting class of consonants most difficult of pronunciation), mumbling, unintelligible, jerking, stammering. Affecting the muscles of deglutition: state of deglutition; stage of act at which difficulty is experienced (106);—abnormality in position of larynx, etc., visible externally, in respect to median line. Affecting the stomach : facility of vomiting (138). Affecting the rectum: faeces retained, accumu- lating. Affecting the anus: stools involuntary; — paraly- sis accompanied by local loss of sensation; faeces felt on arriving outside anus, etc. (142). Affecting the bladder: retention of urine; stillici- dium urinae (218). Affecting larynx: aphonia (156); difficulty in inspiration or expiration ? 106 PART I.J INTELLECT AND MORAL FACULTIES. [§ IV. K. 281. Muscular irritability compared in paralysed and non-paralysed parts: as tested by percussion; as tested by galvanic current (stating force of pile and kind of instrument used), with current direct, reversed, continuous, or interrupted. Intellectual and Moral Faculties.* 282. Consciousness: — impaired; indifference; dreaminess; hebetude; stolidity; doziness, readi- ness with which patient is roused; patient, after being roused, relapsing immediately, or after an in- terval of longer or shorter duration ? stupor; som- nolence ; coma; coma-vigil. — Consciousness abo- lished ; abolition gradual or of sudden occurrence ? duration of loss of cousciousness; posture_and occu- pation of patient when it occurred; phenomena at- tending it. 283. Sleep : —deficient (peculiarities of the defi- ciency— e.g., patient a long time going to sleep, waking after a short sleep, and then not sleeping any more, etc.); — totally absent, how accounted for by patient ? patient feeling the want of sleep or not? exhausted by it or not? —interrupted by sud- den wakings with affright;—unduly protracted.— Soundness of sleep; amount of refreshment expe- rienced.— Sleepiness at improper times, especially ' This subdivision has especial, though not sole, refer- ence to cases of insanity. In the present state of our knowledge of the several mental conditions included under this term, it has been considered advisable, and more likely to conduce to pure observation, to group the manifestations of disordered intellect and of the disorders of the moral faculty together, rather than to attempt their separation. 107 Muscular irri- tability— how tested. Intellect and Moral Faculties. Consciousness. impaired. degree of. abolished. circumstances of abolition. Sleep— deficient. absent. interrupted. protracted. soundness. sleepiness. § IV. K.J INTELLECT AND MORAL FACULTIES. [PART I. somniloquism. somnambulism. on sitting down or after meals. — Snoring during sleep. — Posture in which patient goes to sleep. 284. Dreaming: — different in any way from what is customary to the individual; subject of the dreams, something habitual to the individual when * out of health; their character, terrific, fatiguing, distressing, etc.; clearly recollected or not? — In- cubus : position in which it occurs; at what period after falling asleep ? — Somniloquism. — Somnam- bulism : phenomena presented during this state and on being suddenly awakened, perversions of the special senses, etc.;. — condition of the pulse, respi- ration, and temperature of the body. — Frequency of occurrence of incubus, somniloquism or somnam- bulism ; — conditions of their occurrence in regard of food, occupation, mental emotion, physical health, etc. 285. Behaviour: — generally or in some particu- lar respect different from that of all sane persons, or from that which is habitual to the individual when in health. (If the eccentric behaviour be paroxysmal, note at what time the paroxysms occur, and the circumstances which induce them). — Un- usual reserve; obstinate silence; sulkiness; apathy; inactivity; neglect of business; refusal to eat or drink; melancholy; refusal to pass evacuations; dirtiness; refusal or indisposition to go to bed or to get up. — Unusual and unnecessary bustling, with or without motive; hastiness of conduct; conduct furious or uproarious, disposition manifested to strike, bite or injure persons and things (noting readiness or difficulty of controlling patient); un- usual gesticulations; fanciful or eccentric dressing and decoration of the person, house, or room; con- stant repetition of the s*ame act or acts without appa- rent object; individual walking about restlessly at 108 PART I.J INTELLECT AND MORAL FACULTIES. [§ IV. K. night; absenting himself from home, and wander- ing. — Behaviour haughty or inconsistent with indi- vidual's rank or station in life. — Oversight or ne- glect of ordinary moral obligations; disposition exhibited to solitude or to company, to extrava- gance, gaming, debauchery, drunkenness, indecency, cunning, falsehood, avarice; collecting or secreting odd and useless articles, or articles of trifling value; attempts at stealing, murder, suicide, arson, or other crimes; unusual selfishness, etc. — Eccentricity of behaviour, constant or varying in its character ? attempts to control, hide, or display eccentricity. 286. Temper:—unaltered; unusually good; cap- tious; peevish; morose; surly; irascible; violent (285). 287. Spirits :—even and calm ; peculiar hopeful- ness ; ennui; indifference; melancholy ; unnatural gaiety and excitement; spirits variable; involuntary laughter or crying, circumstances inducing them; alternation of laughter and crying. 288. Attention:—exaggerated; engrossed by some one object of perception, external or internal, by the internal functions of the body, by certain mental ideas. — Defective; degree of impairment of atten- tion, impossible to be fixed at all, capable of being directed for a time only (noting degree of difficulty in arresting attention); patient gazing steadily at questioner as if attending, but giving no sign by speech or otherwise of understanding him. — Per- verted; want of fixedness of attention to one ob- ject, but flying off to others (distraction); attention engrossed by trivial matters. — Apparent endeavour made by patient to regulate the attention, if en- grossed to distribute it to other objects, if defective to exercise it more fully, if distracted to concen- trate it. k 109 Temper. Spirits. Attention— exaggerated. defective. perverted. influence of will. § IV. R.J INTELLECT AND MORAL FACULTIES. [PART I. Apprehension. quick. dull. absent Memory— exaggerated. defective. special de- fects. perverted. Speech— peculiarities. 289. Apprehension: — unusually quick for the age of the individual; great readiness to learn.— Individual dull; stupid; unable to comprehend when addressed; unaffected in any way by passing occurrences; feeling no wants. — Total incapacity; connection of this with physical imperfection or de- formity (cretinism). 290. Memory (retentiveness and readiness of me- mory are, where possible, to be distinguished): — memory exalted Or unusually good for age of indi- vidual;— specially exalted for certain subjects, as music, languages, rhymes, etc.;—the above subjects, after being long forgotten, recollected. — Defective; degree of impairment of memory estimated by ques- tions respecting the course of events while patient has been under observation, respecting the day of the week, the period of the last meal, etc., by ques- tions in multiplication table;—forgetfulness of recent events, rather than of others long passed;—special impairment of memory, of the names of persons and things (note amount of assistance necessary for their recollection), of dates, of periods of time, of the sounds of printed characters (hence, the inability to read);—does memory appear to improve under emo- tion or excitement, pleasurable or the reverse ?—Per- verted; hallucinations of memory (persons, events, etc., being presumedly recollected which were never, at any time, under the notice of the individual). 291. Speech (as an intellectual act.—For Articu- lation, see 280) :—slowness;—limited to monosyl- lables;— speechlessnes, from want of volition, from trouble in speaking, from loss of memory of words; speech replaced or aided by signs;—ability to write words and answers to questions which patient is unable to pronounce.—Confusion of words (e. g., yes for no, shoulder for head, etc.); when patient has 110 PART I.] INTELLECT AND MORAL FACULTIES. [§ IV. K. used a wrong word, is he conscious of its being wrong ? if so, how is consciousness of it exhibited, by anger, by laughing at himself, etc. ? — More or less constant repetition of syllables, of words, of sentences, of ideas, of the words of a question, of the words of the patient's own answer. — Pecxdiar cries, screams, moaning, etc. 292. Conversation: — individual exhibiting re- serve, indisposition to enter into conversation; replies to questions, short, hasty, rude; obstinate tacitur- nity.—Individual entering readily into conversation; garrulous; freely opening his thoughts, exhibiting an absence of prudent reserve upon personal or family matters, etc. — Conversation coherent; its subject and character; constant disposition to intro- duce some one subject or class of subjects on all oc- casions ;—constant repetition of the same words and phrases; — indecency of conversation; swearing; — eccentric, silly, or absurd reasoning or association of ideas; absurd theorizing and speculation (where pos- sible, trace the chain of ideas; see also Disordered judgment, 294). — Conversation hurried; rapid change of subjects (if possible, trace the general character of their association). — Conversation inco- herent and unintelligible. — Soliloquism, its subject and characters; accompanied or not by gesticulations ? 293. Confessions and complaints of patient re- specting his mental condition: — expression of belief that the intellect is disordered or is becoming so; — complaints of loss of voluntary control over course of ideas;—of criminal thoughts (blasphemous, sui- cidal, homicidal, etc.); — consciousness of delirium and of extravagance of language, gesticulation, etc.; — of insane impulse, means which patient is com- pelled to adopt to resist its operation; — expression of misery or happiness. Ill cries. Conversation- reserve. garrulity. coherent. hurried. incoherent. soliloquism. Confessions of mental state. § IV. k.3 INTELLECT AND MORAL FACULTIES. [PART I. Disordered judgment- reasoning. Fixed delusion or idea. 294. Disordered judgment: — disbelief in self- evident truths; in personal identity; in the evidence of consciousness, perception, or memory; in the natural succession of events (e. g., that night will succeed the day, etc.) — Defective power of deduc- tive reasoning; conclusions slow, uncertain ; degree of defect tested by the power to follow out simple processes of reasoning (e. g., a syllogism). — Per- verted judgment; grossly and absurdly incorrect conclusions drawn from correct data, or vice versa, (endeavour to trace the cause of this in the perver- sion of. the faculties necessary to the reasoning pro- cess, in a ruling idea, in wandering of the ideas, perverted association of ideas, hallucinations of the senses or memory, etc.) 295. Fixed delusion or predominance of one idea, or of a certain series of ideas : — in relation to the past, the present, or the future; in relation to reali- ties or to mental phantasms.—Delusion in reference to patient's own body, the entire or some part of it (inquire into condition of part referred to), e. g., that he is mercurialized, or suffering from syphilis, etc.;—in reference to his personality;—in reference to rank ;—in reference to wealth or poverty; — de- gree of pertinacity of delusion. — Belief that he is being persecuted; that his life or property is being sought after; that he is about to be incarcerated.— Morbid dread of something definite or indefinite about to happen, e. g., of death, of being poisoned, etc.—Religious delusion, its character.—Eroto- mania. — Effect of fixed delusion or predominant idea upon behaviour (285), temper (286), spirits (287), and conversation (292) of patient; — their connection with illusions or hallucinations of senses (296), as cause or effect; connection with suggested ideas. 112 PART I.J INTELLECT AND MORAL FACULTIES. [§ IV. K. 296. Hallucinations :x—of sight (325), of hear- ing (320), of taste (317), of smell (315); their characters; degree of belief expressed by patient in the reality of these; — their influence on the spirits (287), behaviour (285), conversation (292), and reasoning (294) of the patient. 297. Illusions:2 — same particulars as halluci- nations (296). 298. Delirium:—constant or occasional? by night or by day ?—fixed delirium, its subject, (if on any bodily function, note condition of organs per- forming that function);—variable as to subject; its general character, muttering, surly, loquacious, noisy, violent (patient attempting to get out of bed, to jump out of window, etc.), furious, wild, cheer- ful, jocular, fearful.—Recollection of delirium. 299. Alterations in moral feelings and affections : — evidenced by unusual and extraordinary conduct towards relatives and friends; — sudden or violent partialities or dislikes (either eccentric, or contrary to patient's habits) manifested towards certain sounds, colours, inanimate objects, animals, etc.; — tumultuous feelings and emotions, joy, anger, sor- row, etc., alternating, with or without reasonable cause; — pleasure derived from toys or trifles. — Longings for improper or disgusting objects; for improper or unattainable articles of food.—Nos- talgia.—Misanthropy ; misogyny.—Suspicion (285, 292). 300. Sexual passion : — defective ; aversion to sexual intercourse;—exaggerated ; satyriasis ; nym- 1 "Hallucinations" — i. e., true mental phantasms or creations, bearing no relation to objects of perception present. 1 ''Illusions"—i. e., real objects perceived with charac- ters different from those which they actually possess. k2 113 Hallucinations. Illusions. Delirium— circumstan- ces. subjects. character. Alterations in moral feel- ings, etc. Sexual pas- sion— defective. exaggerat- ed. § IV. L.J SPINAL CORD. [PART I. phomania (signs to be sought in behaviour and countenance of individual in presence of the other sex, blushing, changes of colour, brilliancy of eyes, sighing, heaving or irregular respiration, etc.) J priapism; masturbation, etc. L.--SPINAL CORD, ITS COVERINGS AND APPEN- DAGES. Physical examination of the Spinal Column. 301. Curves, etc. (examine patient in erect pos- ture, when possible) :—Antero-posterior curves (cer- vical, dorsal, lumbar); their condition; degree of posterior prominence of sacrum; altered position or inclination of os coccygis. — Lateral curves : condi- tion of natural dorsal lateral curve; — abnormal lateral curvatures (estimate the amount by letting fall a cord perpendicularly from centre of nucha); elevation of procidentia of either shoulder; patient appearing to lean to either side or forwards; tilting outwards of either scapula; alteration in direction of ribs. 302. Spinous processes.—Any particular spinous process or processes thickened; unduly prominent or depressed, either when patient stands erect, bends forward or to either side? — direction of adjoining spinous processes in regard to each other. 303. Vertebral grooves:—compared in regard of fulness on the two sides; local prominence pro-* duced in either by bending forwards. 304. Tumour: — its site; form; transparent or opaque ? solid; containing fluid, amount of fluctua- tion perceptible; attended or not by obvious fissure of the spine ? — Condition of integument over tu- 114 PART I.J GENERAL SYMPTOMS. [§ IV. L. mour; alteration in colour, thickness, etc. (B. p. 42). 305. Fistulous openings, sinuses, etc.: — charac- ters of discharge from them (657); microscopical (686 et seq.), chemical (695 et seq.). 306. Other appearances: — wounds (667); con- tusions; ecchymoses or other marks of injury (70). — Bed-sores. 307. Examination of spine anteriorly, through abdominal soft parietes : — undue prominence ante- riorly or laterally; tumour appreciable in connec- tion with spinal column or dependent on bodies of vertebrae themselves (129 et seq.). — Displacement of aorta; unnatural amount of aortic pulsation (182). 308. Percussion. — Any undue extension of per- cussion-dulness to side of spine ? General symptoms referable to the Spinal Cord, etc. 309. Manual examination of spinal column.— Effects of gently passing the pulp of the finger or some light body along spinous processes or vertebral grooves; sensation natural, mere tickling, shudder- ing, creeping sensation of cold, sickness, faintness, globus, hypochondrial pain, acute pain in spinal re- gion ; — precise point at which any of the above results are produced; does this vary by moving the skin ? — Effect of percussion of medium strength, or of kneading, over spinous processes from above downwards; — effect of strong percussion;—effect of passing a heated iron (skin being protected by brown paper or similar substance), or of a sponge squeezed out of hot water along spine; if pain is produced, note its position, character, and direction. 115 Fistulae. Other appear- ances. Spine ante- riorly— tumour. Percussion. General symp- toms. Manual exa- mination of spinal column by finger. by percussion. § IV. M.J ORGANS OF THE SENSES. [PART I. Local pain— character. extent constancy. accompani- ments. circumstances affecting. Sensibility. Motility. I IV. M. Organs of Touch. 310. Local spontaneous pain: — precise charac- ter, lancinating, pulsatile, vibratile, creeping, aching, etc.; — seat; course upwards or downwards? limited to spinal region ; extending to right or left of trunk, or to upper or lower extremities ? its precise direc- tion and point of termination; — pain constant or occasional? paroxysmal, slowly or suddenly deve- loped?— accompanied by special sensations, sick- ness, faintness; palpitation of heart with paroxysms. — Pain influenced or not in amount and character by flexion, anterior, posterior, or lateral, of trunk, or by still slighter movements; by walking; by turn- ing in bed; by kicking either heel forcibly against the ground; by jumping on heels; by supporting body on crutches; by rotation of trunk in sitting posture; by jerking movements given to the body by observer; by various kinds of percussion; by passing hot iron or hot sponge over spine; by nervous excitement, etc. 311. Alterations of sensibility (K. par. 266 et seq.) : — effect of prone, supine, or erect postures upon these. 312. Alterations of motility (K. par. 270 etseq.) : — effect of prone, supine, or erect postures upon these. M.—ORGANS OF THE SENSES. Organs of Touch. 313. For particulars see Integument, p. 42, and Alterations of sensibility, p. 101. 116 PART I.J SMELL. — TASTE. — HEARING. [§ IV. M. Organs of Smell. 314. Physical examination, etc. (148). 315. Sense of smell: — perception of odours, im- paired, absolutely wanting; — exaggerated; per- verted, illusions or hallucinations of smell.—Pecu- liar influence of special odours. Organs of Taste. 316. Physical examination, etc. (Tongue, 92; Palate, 91; Fauces, 102. 317. Sense of taste: — impaired; absolutely wanting;—unusually acute; — sense of taste com- pared at base and tip, or on two halves of tongue; any special point deficient in power of taste (state how many of the above have been determined); — particular sensibility to special tastes, e. g., sweet, bitter, etc. — Taste perverted; illusions of taste, e. g., acid substances tasting alkaline, sweet substances tasting bitter, etc.; hallucinations of taste, e. g., bit- ter, acid, disagreeable tastes, etc., in the mouth. Organs of Hearing. 318. Physical examination.—External ear: its form; size; swellings, their exact seat, character, and contents; colour; temperature; eruptions (77 et seq.), ulcers (665). — Mastoid process: unduly prominent or depressed on either side; subcutaneous emphysema produced or not by blowing nose; — results of auscultation over mastoid process; entry of air into cells marked by distinct murmur or attended by rhonchus. — Meatus externus: tender to touch ; — lining membrane swollen, turgid, dis- 117 Organs of Smell. Physical exa- mination— Sense of smell. impaired. exaggerated. perverted. Organs of Taste. Physical exa- mination. Sense of taste. impaired. too acute. perverted. illusions. hallucinations. Organs of Hearing. Physical exa- mination— external ear. mastoid pro- cess. meatus exter- nus. § IV. M.J HEARING. [PART I. foreign bodies. discharge. Eustachian tube. membrana tympani. Pain— other sensa- tions. Sense of hear- ing- exaggerated. defective. perverted. illusions. hallucinations coloured generally or over particular points; — fun- gosities, vegetations, ulcerations (665), incrustations, eruptions, etc.— Cerumen too abundant; deficient; altered in quality; microscopical examination (686 et seq.); presence of entozoon folliculorum ? — Fo- reign bodies in meatus. — Discharge from meatus; its abundance; its appearance, serous, purulent, bloody; its odour; accompanied by particles of bone, by foreign bodies; containing bubbles of air. —Eustachian tube: results of catheterism of Eusta- chian tube; test its perviousness by auscultation over mastoid process. — Membrana tympani: state of its surface; colour, rosy, dull white, etc. — per- forated or entire ? sibilation produced by forcible ex- piration, the mouth and nose being closed (audible by patient or on use of stethoscope) ? movement of the flame of a taper held opposite the meatus during the same process? 319. Pain referred to ther ear: — its character; apparent depth ; severity; constant or periodical ? circumstances inducing it. — Sense of pulsation in ear; other abnormal sensations, as tickling. 320. Sense of hearing: (examine each ear sepa- rately):—exaggerated; intolerance of sound gene- rally, slightest sounds appearing more or less in- tense ; intolerance of particular kinds of sound. — Defective; amount of impairment of hearing (dis- tance at which the ticking of a watch is heard); im- paired for notes of particular pitch, high or low; are sounds heard better when sonorous body touches teeth, mastoid process, or external ear? — Per- verted; illusions of hearing, e. g., murmuring or other continuous noise mistaken for voices and con- versations, etc.; — hallucinations of hearing, various sounds in the ears; tinnitus aurium, in one or both ears ? its precise character, constant or transient 1 118 PART I.J VISION. [§ IV. M. affected or not by closure of ear, by posture, efforts, exercise, eating ? accompanied or not by sounds in the vessels discoverable by auscultation ? voices and conversations imagined to be heard, etc. — Sensi- bility to discords and pleasure from concords lost. Organs of Vision and its Appendages. 321. Eyebrows: — their comparative elevation, etc. (280.) — Eyelids: their thickness; colour; vascularity; state of integument, eruptions (77 et seq.), oedema; solid indurations. — Degree of clo- sure, as compared on the two sides; facility with which eyelids are closed; contraction of orbicularis, permanent or spasmodic ? degree of resistance to the eye being opened by observer; nictitatury move- ments. — Lids motionless when conjunctiva is touched or a body is suddenly brought near the eyes. — Abnormal sensations accompanying move- ments of lids, pain, stiffness, dryness, etc.—Eye- lashes: absent, scanty, abundant; their length, direction, etc. — Tarsal cartilages: thickened; turned inwards or outwards;—their edges, red, injected, covered with secretion (its character.) — Meibomian glands and ducts: their appearance, enlarged, obstructed, etc. — Puncta lachrymalia: freedom of orifices. — Carunculai lachrymales: their size; colour; uneasy sensations referred to them. 322. Eyeball generally:—its size ; its degree of prominence (compared on the two sides); its form. — Its movements; eyeball motionless, incapable of movement in one or more directions; movements irregular, rotatory; tendency to turn upwards or in any particular direction.—Direction of axes of eyes (luscitas, strabismus), convergent or divergent? 119 Organ of Vision, etc. Eyebrows, etc. eyelids. eyelashes. tarsal carti- lages. Meibomian glands. puncta lachrymalia. carunculae lachrymales. Eyeball- prominence. movements. § IV. M.J VISION. [PART I. natural direction of axis of affected eye restored or not by closing unaffected one?—Conjunctiva (gene- rally or locally) : its transparency, colour, thickness; moisture, abundance of secretion; particles of mucus accumulated upon it; its degree of vascular injec- tion; mammillations or granulations; vegetations, ulcers (665); foreign bodies. — Sensibility of con- junctiva.—Sclerotica : vascular injection, generally or in the form of a zone around the cornea ? its de- gree ; general colour of sclerotica, dull white, waxy, yellow, yellowish-green, bluish, like tarnished ivory. — Cornea: its form, degree of convexity; smooth- ness of surface;—transparent; opaque (partially or entirely?); opaque ring at its periphery; arcus senilis; — cicatrices; ulcers (665); wounds, with protrusion of iris or not ?—Foreign bodies sticking in cornea, etc. — Iris : its colour; presenting two rings, their comparative size; form; convex for- wards or backwards ? borders, thin, thickened (ir- regularly or equally ?), free or adherent ? angular, puckered;—fissures in iris ; deposits or tumefactions upon it; — oscillation or tremulousness of iris.— Pupils: dilated, equally or unequally ? contracted, equally or unequally? one dilated and the other contracted; alternate contraction and dilatation of pupil.—Pupil affected or not by light? contraction, slight, marked, slow or immediate? dilatation; slight contraction followed by dilatation; contraction followed by oscillation;—effects of admitting the light or shutting it out from the other eye.—Aque- ous humour: its quantity; colour ; transparency or opacity ?—foreign bodies in it; entozoa.—Lens : its position; transparency or opacity, its degree, ex- tent, and colour.— Vitreous humour: its colour and appearance. 323. Tears: their abundance;—flow excited by 120 PART I.J VISION. [§ rv. m. trifling circumstances; — stillicidium ; epiphora; — acridity of secretion; chemical reaction of tears. 324. Pain: — seat, deep or superficial ? charac- ters ; increased by movements of the eye, by light; following the course of any particular nerve; — at- tended by any temporary peculiarity of vision, by vomiting or nausea. 325. Sense of sight: — length of distinct vision of distant objects; focal distance, vision of near and distant objects compared; myopia, presbyopia; amount of light necessary for perfect vision. — Hemeralopia; nyctalopia; total blindness, "how tested ?" — Extreme sensibility to light; photopho- bia ; opsiphobia (or fear of using vision); — readi- ness with which spectra are formed, their distinct- ness, persistence, and apparent size in relation to locality.—Vision defective; amount of vision re- maining, power of distinguishing light from dark- ness, the general form of objects, etc.;—defect con- stant or occasional? — portions or points of an ob- ject not being seen, or replaced by black spots; — visibility of luminous ring on pressing eyeball. — Sensibility of eye to particular colours lost, the complementary colours being perceived,—Vision perverted; illusions of vision, objects appearing of different form, colour, etc., or mistaken in their cha- racters; objects appearing double (tested in each eye separately), the objects lying one above the other or side by side ? dazzling, (effect of erect or recumbent posture upon it);—hallucinations, flashes of light in darkness, sparks, muscae volitantes, visions (their characters and character of outline); effect of closure of eyes;—sympathetic effects of a strong light, sneezing, sickness, tickling in internal ear, etc. Pain- seat. characters. Sense of sight- focal distance. blindness. sensibility to light. defective vision. sensibility to colours. perverted vision. illusions. hallucinations. sympathetic effects L 121 § IV. N.—O.J NERVES.—VASCULAR GLANDS. [PART I. 2 IV. N. Pain— seat. characters. accompani- ments. duration. other sensa- tions. enlargement of nerve. tenderness. I IV. 0. Thyroid gland. thymus gland. supra-renal capsule. N.—NERVES. Cerebrospinal and sympathetic. 326. Pain: — its seat; nerves affected by it; its characters, obtuse, acute, burning, shooting; direc- tion and course of pain; — colour, temperature, etc., of skin over painful parts; appearances in neigh- bouring organs; enlarged veins; throbbing of arte- ries ; increased secretion from neighbouring mucous membranes; disturbed function of neighbouring organs — e. g., intolerance of light, etc.; —pain ag- gravated by a slight touch; relieved by firm pres- sure ; — continuous, remittent, intermittent; dura- tion of paroxysms; time at which they occur. — Other sensations, numbness, creeping, pricking, itch- ing, etc. — (See also Pain and other abnormal sen- sations referable to head (266), thoracic organs (163), abdominal organs (133), joints (83). — En- largement in course of a nerve. — Tenderness in course of a nerve, exact points where such tender- ness is discovered. 0.— VASCULAR GLANDS. 327. Thyroid gland: — enlargement, its size, form, on one or both sides? consistence; tender- ness; effect of pressure, exertion, or mental emotion upon it. — Thymus gland: — fulness at lower part of neck;—dulness on percussion over region of gland, its extent; alterations in auscultatory signs (152, 162); — respiration, its characters, etc. (169). —Supra-renal capsule:—(see Abdominal tumours, p. 61.) 122 PART I.J REGIMEN. [§V.A. § V. — Treatment. A.—REGIMEN. 328. Residence: — changed? to what place? — Travelling.—Apartment: ventilated;—temperature of air of apartment, how maintained? — Moisture of air, its degree; how maintained ? 329. Clothing:—its amount; — special articles of clothing worn or discontinued; — special cover- ings to certain parts, of what kind and material ? — Removal or loosening of tight articles of dress. — Removal of ligatures about parts of body. 330. Avoidance of exposure to cold and damp air; to evening or early morning air; to sun's rays; to draughts of air; to light.— Precautions observed when exposure is unavoidable. 331. Cleanliness :—of entire body, how ensured? Of hands (e.g., of workers in metals) before meals. —Removal of articles of clothing or bedding soiled or saturated with discharges or excretions.—Method adopted in cleansing diseased surfaces. 332. Rest: — Confined to bed or not ? — Rest of certain parts; how ensured ? 333. Exercise:—of what kind? to what extent? at what time taken? where specially avoided? — Gymnastic exercises; — of what character ? 334. Posture:—constantly maintained?—changed from time to time, and under what circumstances ?— patient rising or not from bed to pass evacuations ? —special arrangements for avoidance of pressure on parts of body. 335. Moral and mental treatment. — Seclusion. — Withdrawal of mental stimuli. — Restraint; its 123 Residence Clothing. Avoidance of exposure. Cleanliness. Rest. Exercise. Posture. Moral and mental treatment. § V.B.J DIET. [PART I. Occupation. Sleep. Relinquish- ment of habits. Marriage, etc. Solid food- animal. vegetable. meals. Liquid food- water. animal broths. milk. vegetable in- fusions, etc. special character. — Threats and intimidation. — Amusement; of what kind? Study prohibited or not? reading and conversation on certain subjects prohibited. 336. Occupation : — its kind ; — cessation from business; entire, partial or occasional ? 337. Sleep: amount; at what hours? — is any posture during sleep prohibited ?—very sound sleep permitted or prohibited ? 338. Habits, relinquishment of:—tippling; smok- ing; opium-eating; abuse of tea or coffee, etc.; — masturbation, etc. 339. Marriage:—sexual abstinence; continence. B. — DIET. 340. Solid food.—Animal food:—special arti- cles allowed or forbidden; mode of preparation; weight in twenty-four hours; quantity at each meal. — Vegetable food : — special articles allowed or for- bidden, bread, farinaceous substances, cruciferous or leguminous vegetables, raw vegetables, fruits (of what kind ?), gluten, gum, sugar, etc.; mode of preparation and form in which used; quantity (weight) in twenty-four hours — quantity at each meal. — Meals at which any of the above varieties of solid food are allowed or prohibited. 341. Liquid food:—Water; amount in twenty- four hours; its source; quantity taken at a time; frequency of drinking; temperature.—Ice: — swal- lowed in substance, or allowed to melt in mouth; ices containing cream, etc.—Animal broths :—how and from what substances prepared ? containing ve- getable matters or not? quantity in twenty-four hours; frequency of use; quantity taken at a time; temperature.—Milk : pure or diluted; temperature, etc.— Vegetable infusions and decoctions: tea, coffee, 124 PART I.J OPERATIONS. [§ V. 0. cocoa, etc.; infusions of fruits (acidulous or not), e. g., lemonade, tamarind-water, etc.; containing fa- rinaceous matters, e. g., barley-water, gruel, arrow- root, etc.; containing mucilaginous matters, gum- water, linseed-tea, etc.; quantity in twenty-four hours; frequency of use; quantity taken at a time; temperature. — Meals at which any of the above varieties of liquid food are allowed or prohibited. 342. Condiments: allowed or prohibited ? salt; vinegar; oil; sugar; aromatic substances, etc. 343. Alcoholic drinks: — special articles allowed or prohibited; beer, wine (of what kind ?), ardent spirit (of what kind?); the above pure, or diluted, or mixed with articles of food; quantity in twenty- four hours; quantity at a time; hours or meals at which taken. 344. Meals:—hours at which taken; are certain meals prohibited? — quality and quantity of solid and liquid articles of food taken at each meal (340, 341); time devoted to meals; mastication. 345. Introduction of food by artificial means:— injection into the stomach or rectum;—by the skin; milk baths, introduction of oleaginous substances by friction. C. — OPERATIONS. [Remedial measures involving wounds of the inte- gument or mucous membrane.J 346. Bloodletting: — from what artery or vein ? when performed ? posture of patient;—size of orifice, small or large ? flow of blood slow or rapid ? quan- tity of blood drawn; — form of vessel into which received (198). 347. Leeching: — when employed ? number of l2 125 meals. Condiments. Alcoholic drinks. Meals. Artificial intro- duction of food. Bloodletting. Leeching. § V. D.J EXTERNAL APPLIANCES. [PART I. Cupping. Transfusion. Acupuncture. Incisions, tap- ping, etc. Ablation. Seton, etc Pressure— bandage. truss, etc. Friction. leeches applied; precise spot of application; quan- tity of blood taken; how estimated ? — After treat- ment ; quantity of blood flowing from bites; how estimated ?—Haemorrhage, how arrested; spontane- ously, or by remedial appliances ? 348. Cupping with use of scarificator:—when employed ? where applied ? quantity of blood taken. 349. Transfusion: — particulars of person from whom blood is taken; quantity transfused. 350. Acupuncture:—how performed ? where ap- plied ? number of needles used, or punctures made; length of needles introduced; duration of operation; — quantity and character of fluid exuding from puncture. 351. Incisions, tapping, etc.: — number of in- cisions ; — where made ? — precise spot of — their length, depth, direction ;—where fiuids are evacuated by incisions, in addition to the above particulars, note readiness of flow, duration of flow, posture of patient during operation, amount, seat, and mode of applying pressure to aid the flow.—Special mode of performing operation; — instrument used. — Fluid evacuated;—its quantity, quality (601, 602, 636). Subsequent injection of cavity (367). 352. Ablation: — when performed? how per- formed ? parts removed. 353. Seton: — where made? — Issue:—where made ? D.—EXTERNAL APPLIANCES. 354. Pressure: — where applied? — by what means ?—Bandages:—of what material ? — degree of tightness.— Truss:—kind of? 355. Friction:—general or partial—by the hand, flesh brush, hair glove, etc. ?—gentle or forcible ?— 126 PART I.J EXTERNAL APPLIANCES. [§ V. D. duration of friction; — effect produced.—Handling — kneading, moulding, shampooing;—passive ex- tension and flexion of joints. 356. Electricity:—how applied? — sparks taken —electric bath — electric aura — electric friction— shocks; number, intensity.— Voltaic current (noting size and number of plates used) : direction and ex- tent (stating where terminal wires are placed). — Electro-puncture. — (In any of the above methods note time and duration of application of the remedy, and apparatus employed;—where voltaic electricity is employed, is it the battery or induced current ? material of poles applied to surface ?) 357. Actual cautery : — where applied?—how applied, by red hot iron or moxa ? — application of wire heated by galvanism. 358. Hot metallic button: — where applied? — duration of application;—effect produced. 359. Ice or freezing mixtures:—where applied ? in what way ? duration of application. 360. Hot dry applications:—hot flannels;—tins or bottles of hot water, etc.; — where applied? — duration of application. 361. General baths. — Hot air bath : — how ar- ranged ?—its temperature;—head included or not ? — Vapour bath : —■ how arranged ? — medicated or not ? — head included or not ? — Fumigation with vapours of volatile substances, e. g., sulphuret of mercury.— Water bath:—its temperature; — medi- cated or not? e. g., sulphuret of potassium, nitro- muriatic acid, etc. — Affusion of water. — Shower bath : — quantity of water used; — amount of fall; —any part protected ?—Sponging with water, medi- cated or not ?—Wet sheet.—Affusion of cold water or cold bath after warm water or vapour bath.—(In handling. Electricity— electro-punc- ture. Actual cau- tery. Hot button Ice, etc. Hot dry appli- cations. General baths. hot air. vapour. water. affusion. shower. sponging. wet sheet. 127 § V. E.J INTERNAL APPLIANCES. [PART I. Local baths. Dry cupping. Medicinal sub- stances. §V. E. Mechanical ap- pliances— catheter. bougie. uterine sound. pessaries. plugs, etc. stomach pump, etc. each of above instances note time of employment and duration of application.) 362. Local baths:—part to which applied.—Local vapour bath.—Vapour douche.—Water bath (hip bath, foot bath, eye bath, etc.); — its temperature. —Affusion; irrigation. — Douche. — Fomentations, medicated or not ? — Poultices, of what material ? medicated or not ?—Lotions, how medicated ?—(In each of above instances note time of employment and duration of application.) 363. Dry cupping:—where applied ?—when ap- plied?— duration of application of glasses;—fre- quency. 364. Medicinal substances: — applied to skin denuded or not of epidermis? — Form in which ap- plied ;—with or without friction ? — Parts to which applied;—frequency and duration of application.— Obvious effects;—rubefaction, vesication, etc. E.—INTERNAL APPLIANCES. [Remedies applied to mucous canals, serous mem- branes, or abnormal cavities, or injected into veins.J 365. Mechanical appliances : — Catheterism ; size, form, and nature of instrument; ease of intro- duction ; quantity of fluid drawn off.—Passage of a bougie; — into which canal ? how far passed ? size of instrument; ease of introduction; how long re- tained in canal ? —bougie armed or not ? — Use of uterine sound, with what object? — introduction of finger into mucous canals, with what object ?—Pes- saries. — Plugs. — Tents, etc. — Use of stomacl pump; — introduction of a tube into stomach oi rectum;—of what length? 128 PART I.J INTERNAL APPLIANCES. [§ V. E. 366. Lotions, etc.:—to mouth or to mucous sur- faces exposed by prolapsus;—composition of them. — Gargles.—Fumigations, etc. 367. Injections: — into a vein; — into mucous canal or cavity, stating which ?—into serous cavity; —into cavity of cysts and abscesses.—State in each instance the quantity and composition of injected fluid; mode of performing operation; rapidity of injection; length of time injection was retained. 368. Inhalations: — of watery vapour, simple or medicated ? — of vapour of volatile medicinal sub- stances or of gases; by what apparatus ? — of medi- cinal powders, by what means? — time of inhala- tion; quantity inhaled; frequency? 369. Topical applications to mucous surfaces made by the hand: — suppositories; — cauterisa- tion ; — solutions of salts (e. g., nitrate of silver).— State special mode in which application ensured (e. g., by use of speculum, by Green's throat pro- bang, etc.); — composition of matters applied; — frequency and time of application. 370. Medicines swallowed:— form of adminis- tration ; — dose; — degree of dilution; — tempera- ture. — Period of day when taken; — frequency of repetition; — interval between taking food and medicine. Lotions, etc. Injections. Inhalations. Topical appli- cations to mu- cous surface by the hand. Medicines swallowed. [In observing the progress of the case up to recovery or death, the phenomena should be noted in the same order as in § IV., and any new influence brought to bear upon the patient in the same order as in § III. It should likewise be noted whether the treatment ordered has been carefully carried out, and at what hours the several remedies have been applied or given. The period, also, at which the notable 129 REMARKS. [PART I. effects of remedies (e. g., vomiting after emetics, sleep or cessation of pain after narcotics, dilatation of the pupil or dryness of the fauces after belladonna, etc.) have occurred, the date of the cessa- tion of the different symptoms of disease, and the period of conva- lescence or recovery, and of discharge (if the patient be in a hos- pital), should be closely observed and carefully described. If the case prove fatal, the phenomena of approaching death should be accurately noted, and also whether the fatal termination be accompanied by symptoms referable to asphyxia, coma, syncope, etc., the condition of the mental faculties, and whether convulsions be present or absent.J 130 PART II. EXAMINATION OF A BODY AFTER DEATH. § I. — Points to be ascertained and noted PRIOR TO COMMENCING AN EXAMINATION. 371. Name. 372. Date of death, presumed or ascertained. 373. Date of examination : — "in a medico-legal case, precise time (local time) when called to see the body."» 374. Weather, from the date of death to that of examination. — Temperature to which body has been exposed. 375. " Medium in which body has lain from date of death to that of examination;—in earth, clay, sand, gravel, mud; — in water, salt, fresh, Btagnant, running, turbid (from earthy, vegetable or animal matters ?); — in gas, carbonic acid, sul- phuretted hydrogen, etc. (noting circumstances under which it has been exposed to the above.)" 376. " Substance on which body has lain." 377. Posture of body between death and exami- nation ; on back, on face, etc.; — length of time it has lain in that posture. 1 As in Part I., the several points for observation in- cluded within commas have especial reference to medico- legal inquiries. 131 81- Name. Date of death. Date of exami- nation, Weather. Medium in which laid. Substance on which laid. Posture. §!•] POINTS TO BE ASCERTAINED. [PART II. Position in re- lation to other objects. Odour. Clothing— vomited mat- ters. blood-stains. other stains. wounds of dress. burns of dress position of bed-clothes. Manipulation. 378. " Position of body in relation to the room, stairs, etc.; to articles of furniture; — relation of parts of body to the above. — If found hanging, note posture of body, and how much touches ground." 379. " Odour in the room, at different parts of it; near body or at a distance from it ? — Odour about body itself before stripping, after clothes have been removed (of poisons, of putrefaction, etc.)." 380. " Clothing on body or lying near it (noting special articles.). — Nature and amount of cover- ings; their arrangement; evenly or in creases? — Vomited matters upon them, on what part ? exa- mine for poisons (139). — Blood-stains on clothes, on which articles ? chemical and microscopical exa- mination of stains; — part of clothing thus marked, so as to indicate posture of individual at time blood flowed over clothing;—blood appearing to have been sprinkled, as by jets from an artery, over the articles of dress; smeared, generally; soaked through; stain chiefly outside or inside the gar- ment?— does stain correspond with a wound in the dress or body ? — marks of a bloody hand on cloth- ing, at what parts? of one or both hands ?— Stains of other kinds: of semen; of discharges; micro- scopical examination of stains (show absence of starch); — of acids. — Wounds of dress ; their situa- tion; size; cut or torn? corresponding or not with wounds in body? — bloody or not? side to which blood chiefly applied. — Dress blackened or burnt, extent and situation of injury.—Position of bed- clothes, if body is in bed." 381. " Degree of manipulation to which body has been exposed; — removal from the place at which death occurred, or where it was first found: 132 PART n.J POINTS TO BE ASCERTAINED. [§ I. the manner in which this was effected, lifted by hands or feet, or both, etc." 382. " Cord round neck: — its precise charac- ters ; — mode in which placed round, and its exact situation ; — situation of knot; — knot single or double? firmness of each knot.— Umbilical cord; if round neck or body, note in what manner it is dis- posed, its condition, amount of stretching, etc." 383. "Articles about body:—-furniture and walls;—spots of blood on them, their exact situa- tion, size, form, and direction; shining or dull ? — Weapons (669). — Dishes, plates, or articles of food. — Bottles, corked or not? — Vomited matters, their exact situation, characters (139). — (Preserve and examine chemically and microscopically any of the above which may throw light on the case.)" 384. Fauces and urine, found under body. 385. " When body is exhumed, note condition of coffin as to soundness. — Examine soil, if necessary, for presence of metallic poisons Copper." e. g., arsenic or Cord round neck— umbilical cord. Articles about body. Faeces, etc., under body. Condition of coffin, etc. M 133 § H. A.J GENERALITIES. [PART II. I II. A. Sex. Age. Posture. Countenance. Measurements. height. width. length of trunk, etc. circumfer- ence of limbs, etc. Weight. Individual pe- culiarities— § II. — Points to be noted during Examination. a.--generalities. 386. Sex:—degree in which external sexual cha- racters are marked; general conformation, external sexual organs, mammae, beard, pubic hair, etc. 387. Apparent age: — evidences of age (412); — if infant, proportional size of head and trunk. 388. " Posture of body;—at time of examination, or when first seen by observer; on the back, on the face, etc.;—composed as in natural rest; constrained; limbs flexed or extended ? position of head, etc.; hands clenched, in what manner? thumb turned into palm of hand, and fingers closed upon it, etc.; —toes contracted.—Limbs secured by ligatures." 389. "Expression of countenance :—calm; suf- fering; features distorted; lips retracted so as to show the teeth; — eyes prominent and staring; — fulness of features as during life; countenance bloated." 390. Measurements of body:—Height, from ver- tex to plantar surface of feet.— Width from acromion to acromion; of hips, from extreme right to extreme left borders of iliac crests.—Length of trunk, from top of sternum to symphysis pubis; length of limbs. — Relative circumference of limbs; circumference of thorax (159); circumference and other measure- ments of head (4). 391. Weight of body. 392. " Striking individual peculiarities:—spinal curvature; depression of lower end of sternum; 134 PART II.J INTEGUMENT AND ITS APPENDAGES. [§ II- B. deformities of limbs, etc.; want of symmetry on the two sides of body (note in what particulars).—Marks upon the surface, their characters (e. g., tattooed marks, etc.) ;—complexion.—Form of lips.—Form of hands, fingers (especially their extremities), and feet;—state of the nails, worn down or not ?—thick- ening of skin on hands, corns, etc., their exact situ- ation, size, colour, etc.;—stains on hands and arms, etc. (as indicating trade or occupation of person)." 393. Temperature of the body (as perceived by the hand and by thermometer) ;—on exposed parts; on covered parts; in axillae; in mouth, etc. 394. Cadaveric rigidity:—its degree at particular joints; relative degree on the right and left sides; —date of appearance and disappearance. 395. Nutrition of body :—body apparently well nourished; muscular; fat. — Emaciation : its de- gree ; degree of sinking in of eyeballs and cheeks; looseness of integument, etc. 396. Putrefaction of body:—colour of surface (397); coherence of parts of body, of bones and soft parts; state of cuticle (398).—"Saponification ; name parts converted into adipocire, and degree of conversion;—examination of adipocire for poisons." —Incrustation with saline matter. B.—INTEGUMENT AND ITS APPENDAGES. 397. Colour of surf ace:—generally; over supe- rior parts; over depending parts; over superficial veins; over abdomen; over parts exposed to pres- sure ;—tint uniform or mottled ?—effect of pressure upon it; — " stains of acids, etc." — Special colour of hands and nails; of fingers at roots of nails; — " hands discoloured by gunpowder, one or both ?"— colour of face. 135 deformities. marks on surface. form of lips. form of hands, etc. Temperature. Rigidity. Nutrition— emaciation. Putrefaction— saponifica- tion. incrustation. I II. B. Colour of sur- face— of hands. of face. § II. B.J INTEGUMENT AND ITS APPENDAGES. [PART II. vernix case- osa. White lines. 398. " Cuticle:—adherent;—ruffled or shrivelled; capable of being readily detached; detached and lying on skin; absent; (note the exact spot and ex- tent over which the above are perceived.) — Cuticle dry or moist ?—In new-born infant, presence or ab- sence of vernix caseosa." 399. "White lines: — on abdomen and outside thighs (lineae albicantes); on breasts.—Brown line from umbilicus to pubes." 400. "Contusions:1—their locality; on one or both sides ? measurements; — colour; condition of cuticle over them. — Form of ecchymosis; resem- bling or not marks of fingers ? their exact relative position (with a view to determine which hand was used in causing them);—resembling mark of a cord, or presenting form of some weapon ?—Blood found effused on dissection, its amount; liquid or coagu- lated? extent of effusion; is any large vein ruptured? Firmness or tenacity of skin at ecchymosed spot;— does discolouration extend through its thickness, or only partially through it ?" 401. "Eruptions:—their locality, characters (77 et seq.); — sudamina, their number, situation, size, contents, reaction. — Bullae or vesications. — Flea-bites. — Purpuric spots; condition of cutis on section through them. — Indurated yellow patches, as after blisters." 402. "Burns: — locality; size; depth; — con- dition of edges; condition of cuticle around; — ve- sication ; surrounded by redness or not ? width of redness, terminating abruptly or shading off gra- 1 In bodies which have been submerged, marks of bruises should be looked for, not only immediately on removal from the water, but again when the body has become dry. 136 PART II.J INTEGUMENT AND ITS APPENDAGES. [§ II. B. dually ? depth of redness;—white line surrounding the burn ; — contents of vesication, air, serum; colour of true skin beneath; — charring of tissues; fissures in charred part (particulars as wounds, 667, et seq.) ; vessels seen running across fissures or not ? —slough (659 et seq.)—Condition of clothing about parts burned or charred (380)." 403. "Mark round neck: — single or double? Mark round extending round neck entirely or partially ? — exact nec situation, in relation to larynx; — direction, hori- zontal, oblique; if oblique, where is lowest part situated ?—-accompanied or not by a groove ?—width of mark; colour; ecchymosis;—cuticle abraded or ruffled, shining or not ? — depth of ecchymosis; — condition of parts beneath the mark;—cellular tissue, condensed, of silvery whiteness, containing blood or noi ? — condition of muscles, trachaea, larynx, etc., as to laceration, fracture, or effusion of blood;—any injury of vertebrae, ligaments, or spinal » cord ?—Examine for marks of fingers or nails about face and throat (400)." 404. " Wounds (667 et seq.).— Cicatrices (670.) Wounds, etc. — Punctures: their exact seat, corresponding to spinal cord, fontanelles, cribriform plate of ethmoid bone, etc. — Abrasions or scratches; their locality; size, etc.; direction of scratches; marks of nails, their situation (specially examine hands or fingers.)" 405. "Hair: — colour; quantity; length; con- Hair. dition." 406. " Nails : — their form; degree of develop- Nails. ment; size; — morbid conditions; colour; lacera- tion ; length ;—condition of ends (e. g., split, bitten, etc.); —foreign substance under nails, their precise characters (preserve and compare these with matters near which body was discovered, etc.)." m2 137 § n- c] ORGANS OF LOCOMOTION. [PART n. CEdema. Emphysema. Subcutaneous fat. \ II. C. Muscles— development. colour, etc. section. extravasated blood, etc. microscopical examination. growths. Tendons, etc. Bones— size, form, etc. exostoses. consistence. caries, etc. length. periosteum. endosteum. medulla. fractures. 407. CEdema:—of trunk; of limbs; of face.— Characters of fluid obtained by puncture (642). 408. Emphysema:—locality; degree; nature of gas. 409. Subcutaneous fat:—amount, on limbs; on abdominal and thoracic walls; colour. C. — ORGANS OF LOCOMOTION. 410. Muscles:—degree of development; dimi- nished in bulk, increased in bulk (if not general, name muscles affected); — colour; degree of firm- ness ; — section, dry, moist, sticky; " odour on sec- tion." — Blood extravasated among fibres (fluid or coagulated ?); — abscess or infiltration of pus. — Rupture of fibres. — Gangrene (659). — Wounds (667).—^Foreign bodies.—Parasites.—General sapo- nification. — Microscopical examination; fatty de- generation or other changes.—Growths in muscles, their characters. 411. Tendons and aponeurosis: — colour; con- sistence ; thickness; degree of moisture or dryness; transparency; rupture; ossification; calcification. 412. Bones: — "size;" alterations from normal shape;—increased diameter or thickness; diminished diameter or thinness; — condition of apertures on surface; — exostoses, their situation, size, and other characters; — density of substance; flexibility; fra- gility; caries; necrosis; abscess"; haemorrhage; can- cerous (679 et seq.) or tubercular-looking matter (685). — " Length of long bones; height of entire body as calculated therefrom."—Periosteum: co- lour; thickness; degree of attachment, etc. — En- dosteum and medulla : changes in them. — " Frac- tures : their exact seat;—ununited; edges showing marks of cutting instruments or not ? — Amount of 138 PART n.J ORGANS OF LOCOMOTION. [§ II. 0. union process; — united. — Condition of soft parts over fracture.—Fracture on one or both sides ?—In bones surrounding large cavities, note condition of contained parts, extravasation of blood, wounds, lacerations, etc. — Effusion of blood about fracture, its amount. — Peculiarities connected with age : state of ossification; condition of epiphyses; — condition of fontanelles, sutures, diploe;—shape of maxillae and condition of dental alveoli; — neck of femur, angle formed with shaft. — Peculiarities connected with sex: clavicles; pelvis;—general smoothness or roughness of bones ? — In cases of suspected poisoning, examine if necessary for ar- senic." 413. Thoracic cartilages: consistence; colour; degree of ossification. 414. Intervertebral substance:—consistence; co- lour ; degree of union to bone; foreign matter in it. 415. Joints:—form ; measurements; flexibility. — Condition of integument over them; its colour, vascularity, and tension; — fistulae; laceration.— Fluid within joint; its characters. — Condition of the several parts of the joint; synovial membrane, cartilages, ligaments. — Anchylosis; nature of con- necting medium.—Foreign bodies in joint; their number, form, size, and nature;—loose or attached ? — Condition of articular ends of bones; deepening or shallowness of articular cavity; apparent cause of these conditions; eburnation.—Condition of soft parts around joints; thickening, etc.—Dislocations: recent or of long duration ? peculiarities from age. from sex. Thoracic carti- lages. Intervertebral substance. Joints— form,size, etc. skin over. fluid within tissues of joints. anchylosis. foreign bodies. ends of bones. surrounding soft parts. dislocations. 139 § H. D.J ORGANS OF DIGESTION. [PART n. § II. D. Mouth. Lips- matters about lips. relative posi- tion of lips and teeth. external cha- racters. labial glands. Jaws. Cavity of mouth. contents. Gums— external cha- racters. D. — ORGANS OF DIGESTION. Mouth. 416. Lips:—absent? apparent cause of absence; — malformations. — Open; closed, by rigidity of muscles, by " aid of ligatures," etc.—Foreign mat- ters about lips or coherent to them (e. g. portions of food, of dress or of soil); — fluid about lips; in- creased or not by pressing thorax or abdomen, or by moving the body ? its characters, frothy, etc.; colour, red (from blood or other matter? determined by mi- croscope), dirty green, yellow, etc.—dried foam, etc. —Relative position of lips and teeth ; lips indented, clasped, or lacerated by teeth.—Size of lips; thick- ness;— colour, pale, livid, white, brown, black, yellow; reaction of surface, if stained; — surface, moist or dry ?—cuticle peeling, detached ;—vesicles; exudations (sordes); sloughs (659); ulcers (665); tumours (672 et seq.); wounds (667), etc.—Labial glands: their size and characters. 417. Jaws: — open, to what degree ? capable or not of being closed? — closed, completely or not? capable or not of being opened ? " means adopted to keep them closed;"—muscles rigid or not? 418. Cavity of mouth: — contracted, from what- cause ?—communicating with nose or with the exte- rior (in what way?)— Contents; food, foreign mat- ters, etc. "degree of impaction." 419. Gums:—size;—colour; generally, at edges (if purple, breadth of purple line and its definition ; if red, breadth of line and intensity);—surface, dry, or moist;—consistence; hard, soft, spongy;—degree of adhesion to teeth.—Exudations (sordes), etc., on surface (635); — "foreign substances adherent to 140 PART n.J ORGANS OF DIGESTION. [§ II. D. them;" — sloughs (659) ; ulcers, (665), on surface or confined to line of junction of gums and teeth ;— solutions of continuity from recent extraction of teeth. — Section of gums; characters of tissue and of fluid exuding. 420. Teeth: — number? names of those present (noting whether of the first or permanent set); — number absent? names of absent teeth; cause of absence, non-development or extraction ?—Loose or firmly fixed? carious; "recently fractured;" — amount of fangs left uncovered by gums;—condi- tion of alveoli (abscess, fracture, etc.) — Exudation (sordes), etc. on teeth; amount of tartar;—" foreign matters adherent to teeth or clenched between them." ;'- 421. Checks: — outer surface, its condition; — inner surface; adherent to maxillae; bulging;—con- dition of mucous membrane (636); secretions or exudations upon it (635). — Substance of cheek; thickness; consistence; oedema; tumours (672); wounds (667), corresponding or not in position with fractured teeth? cicatrices (670); — section; cha- racters of tissue and of fluid exuding. 422. Tongue: — absent? apparent cause of ab- sence; malformation; — adherent or not to cavity of mouth or sides of fauces? — Size; — form.— Position; retracted, protruding from mouth. — Sur- face ; fissured, furrowed, lobulated, presenting marks of bites (recent or not?), sodden-looking, denuded of epithelium, clean, furred; — edge, indented by teeth; — colour, pale, white, livid, brown, black, red, yellow (" if stained, reaction of stained part"); —papillae, their condition ; — vesicles, exudations, etc>—condition of under surface; minute vesicles or abscesses. — Submucous tissue at root of epi- glottis, its condition (637). — Substance of tongue; 141 section. Teeth. Cheek- external cha- racters. substance. Tongue— size, form, etc. surface. substance. § II- D.] THROAT, ETC. [PART II. Hard palate— Salivary Glands and Ducts. Glands— external cha- racters. section. Ducts. Throat, etc. Fauces- Uvula and ve- lum pendulum, Tonsils— external cha- racters. consistence; oedema; sloughs (659); ulcers (665); cicatrices (670); tumours (672 et seq.); wounds (667); — section; characters of tissue and of fluid exuding. 423. Hard palate:—malformations; fissures, etc. Salivary Glands and Ducts. 424. Glands (Parotid, Sublingual, and Sub- maxillary):— swelling externally, over glands, in course of Steno's duct; oedema;—size; consistence. — Section: texture of cut surface; colour; — fluids expressible; abscess (647 et seq.); cysts; tu- mours (672 et seq.); etc. 425. Ducts: — size; dilatation, general or par- tial? its physical cause; obliteration; thickness of coats; size of orifices; — fistulae; — calculi, their number, size, and physical characters; — retained saliva, its characters. Tliroat, etc. 426. Fauces: — size of opening; if contracted, from what cause ? — condition of pillars; — exuda- tion, etc. (635); condition of mucous membrane (636). 427. Uvula and velum pendulum palati:—mal- formations ; fissure, etc.; — size of uvula, especially its length; condition of free extremity, excised or not? — colour, etc. (636); — exudations upon sur- face (635); microscopic fungi present or absent? condition of subjacent mucous membrane (636); — condition of submucous tissue (637). 428. Tonsils: — size, absolute and comparative; form; position; interval between, them; — surface, smooth, uneven, rough, pitted; — condition of open- 142 PART II.J THROAT, ETC. [§ II. D. ings; follicles empty or blocked up with secretion? — secretions, their odour; lymph or other exuda- tion (644); calculi; tunrours (672 et seq.);—colour of surface (636); "if stained, reaction of stained surface;" — sloughs (659 et seq.), their size, degree of detachment; condition of subjacent surface (636); —ulcers (665), etc — Section; characters of cut surface, colour, consistence, etc.; character of fluid expressible. 429. Pharynx: — size of cavity; if contracted, whether from contraction of membranes, thickening of sub-mucous tissue, or pressure of tumours, etc., external to it?—Contents of cavity; "foreign bodies; their nature and degree of impaction (if portions of linen, etc., preserve them for compari- son)."— Diverticula; seat; size; form; relation to surrounding parts; tissues composing them; con- tents (food, etc.) — Mucous membrane; its condi- tion (636); exudations and secretions on surface (635), presence or absence of microscopic fungi; — ulcers (665); sloughs (659 et seq.); fissures; wounds (667 et seq.) — Sub-mucous tissue; its con- dition (637). — Pharyngeal muscles; colour, firm- ness, etc. 430. Oesophagus: — malformations; — displace- ment; its direction; cause, tumours or collections external to it, etc.; — dilatation; general, with hy- pertrophy or attenuation of muscular coat ? partial, its seat and size; — contraction or stricture; seat; extent; depending upon a morbid state of the sub- stance of the oesophagus, or upon a tumour, etc., external to it? calibre of oesophagus at strictured part, above it, below it; condition of edge of stric- ture; ulceration present or absent? mucous mem- brane around puckered or not? condition of sub- mucous tissue; induration of substance of cesopha- 143 section. Pharynx— size, etc. contents. diverticula. mucous mem- brane. sub-mucous tissue. pharyngeal muscles. QSsophagus— displacement. dilatation. stricture. § n. d.J ABDOMEN. — PERITONEUM. [PART II. diverticula. contents. mucous mem- brane. sub-mucous tissue. muscular coat openings. wounds. Abdomen gene- rally. External cha- racters. Umbilical cord. Peritoneum. Contents. Condition of membrane- of folds. gus, at or around strictured part ? cause of indura- tion.—Diverticula : position; form; size ; relation to surrounding parts; tissues composing them ; con- tents.— Contents of oesophagus; food; "foreign bodies, mud, etc., their character, degree of impac- tion," etc.—Mucous membrane (636); — secretions and exudations (635); ulcers (665); sloughs (659 et seq.), etc.—Sub-mucous tissue (637).—Muscular coat; colour; firmness, etc.; — circular or longitu- dinal fibres abnormally developed, generally or par- tially ? — if stricture be present, condition of mus- cular coat above and below it. — Openings through oesophagus; parts with which they communicate; apparent cause of opening (congenital, bursting of abscess and aneurism, softening of cancerous matter, etc.) — Wounds. Abdomen generally. 431. External characters: — (108 et seq.) 432. " Umbilical cord:—adherent or detached? length of attached portion; presence or absence of a ligature ? nature of ligature; extremity, cleanly cut or torn ? colour; dry or moist ? corrugated or not ? — if detached, condition of surface of umbili- cus, healed or not ?" Peritoneum. 433. Contents: — Articles of food, etc.; their amount, position on membrane, special nature; — condition of membrane in neighbourhood. 434. Condition of membrane (639) : — Specify the exact seat and extent of any morbid changes; correspondence with morbid appearance of parts and organs which membrane covers; condition of dupli- 144 PART II.J 6T0MACH. [§II. D. catures of peritoneum, omenta, mesentery, mesoco- lon, ligaments of liver, spleen, uterus, etc. (particu- lars as peritoneum generally). 435. Hemioz:—parts through which they have occurred; — organs or parts of organs included in herniae; their condition (439, 446). 436. Tumours (631 et seq.). 437. Sub-peritoneal tissue (640). 438. Mesenteric and other lymphatic glands (519 et seq.) Stomach. 439. External characters: — Position: in rela- tion to general cavity of the abdomen, to adjoining parts and organs; in herniae; in cavity of thorax.— Size: measurements (before and after opening stomach); extreme length from fundus to pylorus : extreme transverse measurement; transverse mea- surement iu the middle of the organ; length of smaller curvature; length of greater curvature.— Form: presenting annular contraction or saccula- tion (443) ? effect upon these of inflating the sto- mach.—Adhesions (646).—Condition of peritoneal coat (639): relation of morbid states of peritoneal coat, as regards position, to abnormal appearances of mucous membrane (441, 443). 440. Contents: — quantity of contained matters, (measured or otherwise estimated ?) — odour; colour generally; reaction; microscopical characters (sar- cinae ventriculi). — " Food: its special nature, if capable of being identified; bread, etc (tested for by iodine) ; fat (tested for by heat); degree of diges- tion." — Blood: pure or mixed with food: fluid or coagulated ? colour : apparent source, if discoverable. — " Foreign matters recognisable by the eye (en- N 145 Herniae. Tumours. Sub-peritoneal tissue. Mesenteric glands, etc. Stomach. External cha- racters— position. size. form. adhesions. peritoneal coat. Contents— food. blood. foreign mat- ters. § n. d.J STOMACH. [PART II. faecal matters. poisons. gas. Mucous mem- brane— secretions, etc, on surface. rugae. condition of membrane. sub-mucous tissue. Muscular coat. deavour to identify them); — vegetable matters, their special characters and apparent source; — mineral substances, salts, powders, metallic parti- cles ; — spirits, their odour; — water, its quantity, special character, and contents (e.g., algae); mud; hair, etc." — Fozcal matters: quantity; charac- ters ; — bile ; calculi; pus; worms.—" Where poi- sons are suspected to be present, determine presence and quantity by chemical examination; test for volatile substances with the least possible delay." — Gas: quantity; odour, and other characters. 441. Mucous membrane.—Secretions, etc. on sur- face (635) : " Foreign particles entangled in mucus, their physical and chemical characters: condition of membrane subjacent." — Limitation of lymph, etc. to surface of rugae.—Rugoz: present or absent? their situation. — Condition of membrane (636) : colour generally; colour of rugae; of parts between rugae; — relative depth of hue of anterior and poste- rior surfaces, of cardiac and pyloric extremities.— Redness general or limited to surface or edges of rugae ? — Mammillation; its seat and extent. Ab- sence of any part of membrane ? are sub-mucous or muscular coats wanting at same spot ? — if a portion is absent or removable by washing, is its seat at the most depending part of organ, or at the rugae? aspect of adjacent bloodvessels. — Length of strips obtainable from pyloric extremity; from cardiac extremity; from curvatures, greater and smaller; from anterior and posterior surfaces. — Thickness at pyloric extremity; at cardiac extremity; at lesser curvature; at greater curvature; on surface of rugae; between rugae. — Sub-mucous tissue: its condition (637). 442. Muscular coat: — thickness; alterations in 146 PART II. J STOMACH. [§ n. D. thickness, general or partial? — degree of visibility of muscular fibres. 443. Substance of wall of stomach: — trans- parency when held between observer and the light; thickness (measured in various parts). — Wounds (667). — Perforation (666) : exact situation, on which surface ? near which curvature, etc.—" Alter- ations in organs adjacent to perforated spot; sof- tening ; corrosion; blackening, etc." — Rupture; its seat, extent, direction, etc. — If adhesion be ob- served between stomach and adjacent parts, note if it corresponds in position with ulcers, cicatrices, or perforations discovered after opening the organ. — If circular constriction be observed, note if it cor- responds in position with softening or induration of mucous or sub-mucous coats, ulcers, perforations, or cicatrices.—Weight of stomach.—"In case of sus- pected poisoning, examine tissue chemically for mineral poisons." 444. Cardiac opening : — constricted or not ? cause of constriction;—condition of epithelium. 445. Pylorus: — abnormally open; constricted; constriction overcome or not by slight force ?—open- ing smooth or fissured round edges?—Mucous mem- brane; its condition (636); puckered or not? — Ulcer (665).—Sub-mucous coat; its condition (637). — Muscular coat; thickness as measured; degree of visibility of muscular fibres; of different layers of fibres; — presence between the fibres of adven- titious products; colloid, encephaloid, scirrhous or common exudation matter; their microscopical cha- racters. Substance of wall— thickness. wounds. perforation. rupture. adhesion. constriction. weight. examination for poisons. Cardiac open- ing. Pylorus— openness. constriction. mucous mem- brane. Bub-mucous coat. muscular coat 147 § n. D.J INTESTINES GENERALLY. [PART II. Intestines generally. [The following particulars are to be noted through- out the canal, but it is to be specified in which division each is observed, whether in the duode- num, jejunum, ileum, caecum, colon (ascending, transverse, or descending), sigmoid flexure, or rectum. J 446. External characters.—Position : in relation to general cavity of abdomen; to adjoining parts and organs; — in herniae, external or internal; de- gree of constriction undergone by bowel; appear- ance of constricted part, of part involved in hernia; condition of parts above and below hernia (con- tracted, dilated, etc.);—cause and nature of con- striction ; an intestinal diverticulum, adhesions, holes in the mesentery, bands and cords formed by omentum, etc.; — twisting of portions of intestine; form and precise characters of affected portion. — invagination. Invagination: number of invaginations; situation; size; direction, upwards or downwards ? ease with which reduced;—condition of serous membrane (639), of mucous membrane (636), (distinguishing the separate layers of the invagination); colour, thickness, consistence; lymph, pus, adhesions, etc.; —condition of mesentery included within sheath.— calibre. Calibre: in general terms. — Special dilatation or dilatation. contraction ; extent of affected portion ; — circum- constriction. ference of normal, dilated, contracted, or constricted portions; of intestine above and below contracted or dilated portion ; — is contraction partially or en- tirely removed by stretching ?— apparent cause of constriction; abnormities exterual to canal, in walla 148 Intestines generally. External cha- racters— position. hernias. PART II. J INTESTINES GENERALLY. [§ H. D. of canal itself; condition of coats at, below, and above constricted or dilated portion (448 et seq.); degree of visibility of muscular fibres.—Diverticula: number; situation, at distal or attached side of in- testine? shape; size; structure; — presence or ab- sence of fibrous cord ? its length;—contents.—Ad' hesions (646, 450).—Peritoneal coat; its condition; — relation of abnormal appearances, in respect of position, to morbid states of mucous membrane. 447. Contents.—Gas: quantity; odour and other characters. — Mucus : quantity; colour; transpa- rency ; consistence; reaction; adhesion to mucous membrane. — Blood: mixed with faeces or not ? quantity; fluid or coagulated? colour;-?— apparent source, if discoverable.—Pus : quantity; apparent Bource.—Faecal matter: quantity ; aeration; colour; consistence ; indurated scybala. — " Meconium." — Foreign substances: indigestible alimentary matters (e. g., cherry or plum stones); concretions, their size, form, constituents; portions of non-alimentary substances, their form and physical characters; biliary calculi; — " poisonous matters; distinguish- able by physical characters; ascertained by chemical analyses."—Entozoa: number and character. 448. Mucous membrane.—Secretions, etc., on sur- face (635); limited or not to border of valvulae conniventes? to Peyer's patches? to prominent folds of large intestine ? — if a patch of lymph is linear, does its long axis correspond with that of intestine, or is it disposed circularly ? — Condition of mem- brane (636). — Sub-mucous tissue: its condition (637). 449. Muscular coat: — thickness; alterations in thickness (general or partial), especially in parts al- tered in calibre (446);—development of longitudinal fibres; of circular fibres. n2 149 diverticula. adhesions. peritoneal coat Contents— gas. mucus. blood. pus. faecal matter. meconium. foreign sub- stances. poisons. entozoa. Mucous mem- brane. secretions on surface. condition of membrane. sub-mucous tissue. Muscular coat. § II. D.J SPECIAL PORTIONS OF INTESTINES. [PART II. Substance of wall— thickness. wounds. perforation. rupture. adhesion. examination for poisons. Special portions of Intestines. Duodenum— Brunner's glands. ductus com- Jejunum and ileum— valvulae con- niventes. villi. Peyer's patches. 450. Substance of ivall of intestine : — transpa- rency, when held between observer and the light; thickness (measured in various parts), especially in parts altered in calibre (446).—Wounds (667 et seq.).—Perforations (666) : exact situation, near at- tached or distal side of tube ? — Rupture; its seat, extent, direction, etc.—If adhesion be observed be- tween intestine and any other part, note if it corre- sponds in position with ulcers, cicatrices, perforations, or abnormal growths or deposits.—" In cases of sus- pected poisoning, examine tissue chemically for mineral poisons." Special portions of Intestines. 451. Duodenum.—Brunner's glands : degree of development;—if there be ulceration, note the rela- tion of smallest ulcers to orifices of glands.—Ductus communis : condition of orifice ; — permeability of common and biliary ducts. 452. Jejunum and ileum.— Valvulae conniventes: "present or absent?" size; peculiarities;—extent of intestine occupied by them. — Villi: degree of development; colour. — Peyer's patches : number; situation; — matters adhering, mucus, phosphates, etc. (635); degree of visibility; level at, above, or below that of adjacent membrane? — rugae; pits; sacculi;—deposit; its colour, consistence; in sepa- rate points, in one layer; situation, on mucous mem- brane, in sacculi, in sub-mucous tissue, in muscular tissue, in sub-peritoneal tissue, in several or all of the above;—colour of patch (636), condition of ves- sels, etc.;—transparency, of patch, of tissues around; — consistence; length of strips obtainable from mucous membrane; adhesion between coats of in- testine in situation of patch;—ulcers (665); sloughs 150 PART II.J LIVER. [§ II. D. • • (659 et seq.); cicatrices (670) ; puckering — condi- tion of peritoneum corresponding to patch. — Soli- tary glands : number; situation; degree of promi- nence ; — deposit; colour; ulcers, etc. — Crypts of Licberkuhn: degree of visibility; colour. 453. Caecum: — situation; extent uncovered by peritoneum;—gelatinous softening.—Appendix ver- miformis: situation; length ; calibre; adhesions; contents; perforation; ulcers, etc.—lleo-caecalvalve: hypertrophy, etc.—'Are morbid states of caecum or ileum arrested at the valve ? 454. Colon: — position and course.—Solitary glands: degree of visibility; prominence; colour; induration;—ulceration (665); size of ulcers; situ- ation, at apex or base of glands ? — sloughing (659 et seq.); size of slough; situation in reference to glands. — Ulcers unconnected with solitary glands (665) ; if oval, direction of long axis; — situation with reference to prominent folds in colon. — Rela- tive number of ulcers in caecum and other parts of colon. 455. Rectum: — haemorrhoids; their anatomical characters; — prolapsus; its extent; structure, and condition of prolapsed portion of bowel. Liver. 456. External characters.—Absent?—number; —malformations;—position in respect of cavity of abdomen generally, and with relation to other or- gans; extent uncovered by cartilages of ribs.—Ad- hesions (646) ; their length and the relation between their diaphragmatic and hepatic attachments; — if surface of liver be irregular, are adhesions attached to depressed or elevated portions?—Weight (mth gall-bladder attached, but emptied). — Measure- 151 solitary glands. crypts of Lieberkiihn. Caecum— appendix vermiformis. ileo-caecal valve. Colon— solitary glands. ulcers. Rectum. Liver. External cha- racters. position. adhesions. weight. measure- ments. § H. D.J LIVER. [PART II. form. surface. Capsule— surface. thickness. detachment hepatic sur- face after re- moval. Substance- lobules. granulations. ments: transverse: antero-posterior (from rounded to thin edge); of greatest thickness. — Form: generally; — acute margin; thick, thin, rounded, irregular; reduced to a fibro-cellular band, depth to which this band extends inwards.—Surface (noting particulars with respect to superior surface, inferior surface, acute margin, on and between the lobules, etc.): colour generally, or in various parts of sur- face, in elevated or depressed portions; — depres- sions ; size, form, colour, etc.; — corresponding or not to ribs* ? — pits produced by pressure; — eleva- tions; size, form, colour, consistence, etc.;—lobula- tion ; its physical cause ;—puckerings;—opacities, linear or racemose ? their direction ; — roughness, its physical cause;—granulations, their situation, size (uniform or not ?), colour, compound or single ? — cysts (675); tubercle (685), etc 457. Capsule (noting various parts of surface) : — lymph on surface; pus on surface; — polish; transparency; vascularity;—thickness;—fragility; elevation of capsule; by air, serosity, pus, blood;— facility with which detached from hepatic substance; amount of hepatic substance removed with capsule ; condition of hepatic surface after removal of cap- sule; smoothness; colour; — condition of substance subjacent to morbid alterations of oapsules or adhe- sions. 458. Substance: — cut surface : degree of mois- ture or dryness; flaccidity; fragility; aspect of fractured surface; — colour; relative position of yellow and red substances; their relative propor- tion ; — transparency; — consistence; specific gra- vity ; — emphysema;—fluids expressible;—haemor rhage into substance. — Lobules : degree of separa- tion; mode of separation; — situation of red and yellow substance in separate lobules. — Granula- 152 PART II.J LIVER. [§ II- D. tions: number; size; colour; structure.— Cica- trices (671); relation to branches of portal vein, of hepatic duct; to abnormities seen on surface—e. g., puckerings, opacities, etc.—Pus in detached points; number, size, form and arrangement of the points; condition of tissue around them;—abscesses (647 et seq.); connection with, or openings into surround- ing parts; ducts opening into them; tissue sur- rounding them ; evidence of contraction; — fistulae (654 et seq.). — Calcareous matter: number of de- posits ; situation; size; form; relation to the seve- ral elements of liver — e. g., lobules, ducts, and veins. — Gangrene (659 et seq.). — Growths: li- poma ; cancer (679 et seq.).— Tubercles or tubercu- lar matter (685). — Cysts (675 et seq.) : hydatids. — Wounds (667 et seq.). — Rupture : number of fissures; extent; situation; depth; direction; condi- tion of edges, etc. — Microscopical examination, of lobules, etc 459. Veins: — Portal vein (see Veins, 516 et seq.); — malformations;—ductus venosus, open or closed ? if open, its calibre, contents, thickness of coats, condition of interior;—umbilical vein, open or clo.-ed ? if open, its calibre, contents, thickness of coats, etc. — Divisions of portal vein : their condi- tion ;— relation of branches to linear opacities, puckered spots, abscesses, cicatrices, gangrene, etc. — Hepatic vein (for particulars, see Veins, 516 et seq.) 460. Hepatic ducts: — contents; — calibre; — contracted, obliterated, dilated; seat and extent of the above changes; — thickness of walls; — mucous membrane (635 et seq.).— Divisions of ducts; rela- tion to puckered spots, cicatrices, abscesses, etc. 153 cicatrices. pus. abscesses. fistulae. calcareous matter. gangrene. growths. tubercles. cysts. wounds. rupture. microscopical examination. Veins— portal. ductus venosus. umbilical. hepatic. Hepatic ducts. § II. D.J GALL-BLADDER. — SPLEEN. [PART II. Gall-bladder. External cha- racters. Cavity— contents. Walls mucous mem- brane. Ductus com- munis cho- ledochus— calibre. contents. mucous mem- brane. cystic duct. Spleen. External cha- racters— weight. measurements form. capsule. Gall-bladder. 461. External characters:-—absent? — size; shape; colour of surface; adhesions (646). 462. Cavity: — obliterated ? — Contents: air;— bile; its amount, colour, consistence, odour, taste, specific gravity, reaction, chemical and microscopical characters; — calculi; attached or not to bladder? in what way? — number, size, situation, form, sur- face, colour, section, chemical and microscopical cha- racters ; — serous fluid; mucus; pus, etc 463. Walls: — thickness; transparency; oedema; emphysema; adipose deposit; calcification; abscess; tubercle; cancer; — wounds; rupture. — Mucous membrane (635 et seq.). 464. Ductus communis choledochus: — calibre; —abnormal contraction or dilatation; their seat and extent; — impervious; from what cause? pressure externally from enlarged glands, pancreas, etc. ad- hesion of walls, contraction, obstruction by calcu- lus, etc ?—condition of duct above and below point of contraction or obstruction; — orifice (451).— Contents of duct; — condition of walls (as 463); condition of mucous membrane (635 et seq.)— Cystic duct (as Ductus communis). Spleen. 465. External characters: — absent ? — num- ber;— splenculi, their size, shape, and mode of attachment to spleen (if any) ; — malformations; — position, in respect to cavity of abdomen generally, and in respect to other organs. —Adhesions (646). Weight. — Measurements: length, breadth, and thickness. — Form: surface. — Capsule: — lymph 154 PART II.J PANCREAS. [§H. D- or false membranes on surface (644); smoothness; polish; roughness, its physical cause; corrugation; colour; transparency.—Thickening, general or par- tial ? extent; form; .depth; consistence; — facility of detachment. 466. Substance:—cut surface; degree of mois- ture or dryness; colour; — consistence; fragility; aspect of fractured surface;—number of white spots visible; their size, etc —Wounds (667); rupture; abscesses (647 et seq.); tubercle (685); cancer (679 et seq.); calcareous matter; gangrene (659 et seq.); cysts (675 et seq.). — Microscopical exami- nation of pulpy matter; of white spots, crystals pre- sent or not ? if present, their exact characters, within cells or free ? Pancreas. 467. External characters:—absent? — malfor- mations;— position; relation to other organs of ab- domen. — Adhesions (646). — Weight. — Measure- ments. — Form: — surface. 468. Substance: — cut surface; degree of mois- ture or dryness; colour; consistence; degree of separation of lobules; colour of lobules; condition of interlobular tissue; —wounds; abscesses (647 et seq.); cretaceous masses; tubercular-like matter (685); cancer (679 et seq.); cysts (675 et seq.). 469. Duct:—calibre; — dilatation, general or partial ? — contraction or obliteration; its seat; physical cause; — contents; calculi, pus, blood, etc. —Walls (as 463); —fistulae (654 et seq.); with what communicating ? Substance microscopical examination. Pancreas. External cha- racters— weight. measurements. form. Substance. Duct. 155 § II. E.J ORGANS OF RESPIRATION. [PART II. \ II. E. External cha- racters of thorax. Pleural. Contents. Condition of membrane. Sub-pleural tissue. Subjacent pa- rietes. Nares. Malformations and foreign bodies. Bones. Mucous mem- brane. Larynx, Tra- chea and Bron- chial Tubes. Generalities— position, etc. mucous mem- brane. wounds. contents. Larynx— epiglottis. E. — ORGANS OF RESPIRATION. 470. External characters of thorax. — (158 et> seq.) Pleura. 471. Contents: — (638).—Blood; when sup- posed due to a wound, examine condition of inter- costal arteries. * 472. Condition of membrane:—(639). 473. Sub-pleural tissue: — (640). 474. Subjacent bony and muscular parietes of thorax: — (410, 412.) Nares. 475. Malformations.— Closure.— "Foreign bo- dies : their situation, nature, degree of impaction." 476. Bones: — their condition (412). 477. Mucous membrane: — (635 et seq.). Larynx, Trachea, and Bronchial Tubes. 478. Generalities. — Position; — malformations; — shape; size. — Mucous membrane : its condition (635 et seq). — Wounds (667 et seq.). — Contents: "water (its amount); foreign bodies;" mucus; lymph (644); puriform matter (643), blood, etc.— their amount; degree to which they occupy the several cavities; their degree of adhesion to sub- jacent mucous membrane. 479. Larynx.—Epiglottis: shape; surface (up- per and under), inequalities of them ; colour; thick- 156 PART II. J LUNGS. [§ H. K. ness, thickening due to condition of mucous mem- brane or of sub-mucous tissue? oedema; ulcers (665); sloughs (659 et seq.).—Superior aperture of larynx: size.—Aryteno-epiglottidean folds : colour; thickness; transparency; oedema; adherent secre- tions; ulcers; sloughs; polypi;—sub-mucous tissue; its condition (637); fluid contained in its meshes.— Ventricles of larynx and sacculi laryngis : condition of mucous membrane (636); oedema, etc—Rima glottidis: size and shape; plug of mucus or other body present ? — Chordos vocales: extent to which they are in apposition; their thickness, colour; — oedema; ulcers (665), sloughs (659 el seq.), are these on edges of chordae vocales or not? — Muscles of larynx : colour; size; consistence; fluids infil- trating them.— Cartilages of larynx : condition of perichondrium (especially of parts beneath ulcers of mucous membrane); denudation of cartilages; ossifi- cation; caries; necrosis.--- State of parts adjacent , to external surface, of larynx. 480. Trachea.—Diameter; form, compressed or narrowed by tumour,etc.,'externally.—Mucous mem- brane (635 et seq.); diverticula;, tubercle, etc. — Contents (478): " mucous froth, size of vesicles." — Cartilages of trachea; degree of resistance or brittleness; degree to which denuded of mucous membrane ; ulceration; ossification. 481. 'Bronchi as trachea, (480). superior aper. ture of larynx. aryteno- epiglottidean folds. ventricles. rima glottidis. chordae vo- cales. muscles. cartilages. adjacent parts. Trachea— diameter. mucous mem- brane. contents. cartilages. Bronchi. 0 157 § H. E.J LUNGS. [PART II. Examination in situ— position. adhesions. wounds, etc. External cha- racters— weight, etc. form. colour. compressi- bility, etc. crepitation. effect of infla- tion. emphysema. seed-like bodies. Lungs. [Facts to be noted in respect of each lung sepa- rately.] 482. Examination in situ:—position; degree of collapse; amount to which pericardium is un- covered ; — adhesions (646);—wounds (667); rup- ture ; fistulae (654 et seq.). 483. External characters.—Weight "of both, after tying vessels, with trachea and bronchi at- tached;" of each separately, before and after escape of fluid; number of cubic inches of water dis- placed?— Form when laid on the table;—number of lobes, any peculiarity in their shape ? adhesion of lobes;—puckering at apex or at any other part; — " visibility of air-cells;" — shape of margin of lung, anteriorly, at base.—Colour externally (noted as soon as possible after opening the thorax); shape and position of discoloured portions, and relation between them and any solid portions of lung; — amount and position of pulmonary black matter. — Appearance of lungs as if macerated. — Degree of compressibility; resiliency; flaccidity; sensation of solidity imparted to fingers; crepitation; are the solid or the crepitant portions the more prominent ? — relation between the solid portions and disease of pleura. — Effect of inflation on colour and other characters of previously solid portion.—Emphysema; interlobular; vesicular; size, shape, prominence, etc., of air cells;—thickness of tissue between the fingers after expression of air and fluid.—Seed-like bodies; their situation, colour, consistence, etc — 158 PART II.] LUNGS. [§ II- E- Tuberculous-looking masses (685) relation to pleura, etc.—Cancerous-looking masses (679 et seq.). 484: Substance of lung:—consistence; flaccidity; fragility, under pressure of fingers, tearing, etc.; carnified appearance; smoothness; granular ap- pearance and colour of cut or torn surface (before and after pressure). — Fluid exuding on section of different parts, especially of most dependent part, apex, etc.; its amount, colour, degree of aeration, etc.—Crepitation; its degree.—Any partially cre- pitant or non-crepitant portions? their size, shape, outline;—relation to each other, to pulmonary sub- stance, to interlobular septa;—condition and con- tents of bronchial tubes and pulmonary vessels lead- ing to and through them, compared with those in other parts of same lung; — condition of lung sub- stance immediately adjacent.—Abscess (647 et seq.) — Gangrene (659 et seq.) — Vessels of lung, their condition. — Foreign bodies in lung; condition of tissue immediately surrounding. — Bronchial tubes. — Contents (478) ; in larger or smaller divisions of tubes; " water (its amount);" degree to which they are filled; lymph on surface, occupying or not whole circumference of tubes? rendering them impervious to air (note state of pulmonary tissue to which im- pervious bronchial tubes lead, 484)?—Contraction or dilatation; number and extent of contracted or dilated parts; — measurements of tube above, at, and below contracted and dilated parts;—their form; — contents of dilated part, and of tubes leading to or from it;—their walls, thicker or thinner than natural, etc. ? condition of mucous membrane of the parts (635 et seq.);—condition of pulmonary tissue around them, absolute and comparative; state •of pleura over dilated portions; — relation between dilated portions and thoracic parietes; thickness of 159 i tubercle. cancer. Substance— consistence. surface of section. fluid exuding. crepitation. abscess. gangrene. vessels. foreign bodies. bronchial tubes— contents. contraction. dilatation. § II- E.J LUNGS. [PART II. walls. cartilages. mucous mem- brane. Extravasation of blood. Adventitious products - cretaceous bodies. tubercles. Cavities— seat. size, etc. contents. relation to vessels and bronchire. intervening lung substance.— Walls of tubes ; thicker or thinner than natural?—perforation of them, com- municating with other parts? size and shape of open- iug (direct, oblique, valvular), amount of interven- ing lung substance.— Cartilages; ulceration; ossi- fication.—Mucous membrane (635 et seq.). 485. Extravasation of blood: — extent of lung implicated;—masses of haemorrhagic effusion; their number, size, and shape; completely circumscribed or gradually blending with surrounding lung sub- stance? confined to certain lobules; consistence of masses, hard or pulpy ? their colour, dark purple, brightish red, etc.; appearance of section, granular or smooth ? appearance of cut surface after being scraped by scalpel; — degree to which parenchyma of lung is broken down; is effusion surrounded by a cyst ? 486. Adventitious products.— Cretaceous bodies: at what part of lung situated, near surface or not ? their colour, size, shape, consistence, fragility; softer at centre or externally? — condition of sur- rounding parts, pulmonary or pleural ? — Tubercles or tuberculous-looking matter : — seat; amount and distribution, isolated, scattered, clustered, etc.; size, colour, and form; transparent or opaque : opaque at centre and transparent at edges, or the reverse ? con- sistence, etc. (685). — Condition of interstitial and surrounding tissue, natural, indurated, congested, emphysematous; its colour, etc — Cancer or can- cerous-looking matter (679 et seq.). 487. Cavities:—seat; relation to surface;—size; shape; distinct or communicating? — contents; pu- riform matter, softened tubercle, cretaceous masses, blood; — crossed or not by septa or bands ? nature of these, do they contain vessels and are the vessels pervious? — communicating or not with bronchial 160 PART n.J ORGANS OF CIRCULATION. [§ n. f. tubes ? mode of termination of bronchial tubes, re- lation of orifice of tube to contents of cavity. — Walls of cavity; — condition, smooth, irregular, coated with lymph, sloughy; — condition of tissues surrounding cavity;—relation of cavity to adhesions, thickenings, etc., of pleura. — Cysts: relation to bronchial tubes, pulmonary substance and vessels of lung;—size; thickness of parietes, contents, etc. (675.) 488. " Hydrostatic test:—results of placing lungs, bronchi, and trachea together in water (noting its temperature and source); do they sink or float ? if they sink, do they fall slowly or rapidly ?—Results with each lung separately. — Results with portions of each lung; if any of them float, do they rise above surface of water, or float below it or at its level ? do they float after compression ? do bubbles of air rise on compressing portions under water ?" Diaphragm. 489. Position:—on both sides; height to which it rises into chest; — apertures (666); herniae; wounds (667), etc. — Substance: serous surface (638 etseq.); muscular and tendinous tissues (410, 411). F. — ORGANS OF CIRCULATION. Pericardium. 490. External characters: — shape; measure- ments from above downwards, and transversely; extent uncovered by lungs.—Vascularity of surface; effusion of serosity, pus or fibrinous exudation on surface; cancerous-looking matter (679 et seq.); tu- 02 161 walls. cysts. Hydrostatic test. Diaphragm. Position- substance. 2 II. F. Pericardium. External cha- racters. § II. P.J HEART. [PART II. Contents. Internal sur- face— adhesions. white spots. Heart. Examination in situ— position. shape. measure- ments. consistence. Examination after removal. blood in venae cavae. shape. size of ven- tricles. Right auricle- blood con- tained. size of cavity. lining mem- brane. bercle (685). — Amount of fat on sac. — Wounds (667). 491. Contents (638). 492. Internal surface (639 et seq.)—Adhesions : extent and other characters (646).— White spots on serous membrane; their locality, shape, size, thick- ness ; — flocculent or smooth ? — facility of detach- ment. Heart. 493. Examination in situ : — exact position ; point of thoracic parietes to which apex and right and left borders correspond; — relation of heart to liver;—direction of axis of heart.—Shape; extent of left ventricle seen; degree of distension of right auricle.—Measurements; from extreme base to apex; from auriculo-ventricular groove to apex; transverse measurement at auriculo-ventricular groove. — General estimate of rigidity or flabbiness of tissue. 494. Examination after removal:1—Amount of blood discharged from superior and inferior venae cavae;—kind of blood, liquid, mixed with gas, coagu- lated, large pale clots, etc. (518). — Shape of heart when removed, rounded, elongated ? apex formed by right or by left ventricle ? apparent relative size of right and left ventricle; if either ventricle be contracted, note its capability of dilatation. 495. Right auricle: — quantity of blood con- tained in cavity; — its condition, liquid, frothy, coagulated; its colour, etc. (518);—general estimate of the size of cavity after removal of blood.—Lin- ing membrane: smoothness, polish, transparency, 1 The venae cavae being supposed to be cut through close to the auricle, the aorta and pulmonary arteries just above the free edges of the valves. 162 PART II.J HEART. [§•11. F. colour, thickness;—deposition upon it, in granules, layers, etc.; deposit below membrane, its characters; —ecchymoses;—ulcers and sloughs of lining mem- brane ; — readiness of detachment from muscular fibres.—Condition of foramen ovale; of orifices of venae cavae; of mouths of coronary veins. — Mus- cular walls; thickness, colour, consistence; con- dition of musculi pectinati; — extent to which en- croached upon by external deposition of fat; — fatty streaks; mottling and yellow spots among fibres;—ecchymoses; haemorrhage; pus; fibrous tissue. 496. Right auriculo-ventricular opening:—its shape as viewed from above; — apparent diameter when stretched to a round shape; — rough estimate of its size, by introducing fingers; size as measured by a graduated cone ; — projections, calcifications, etc., on auricular surface of ring; extent to which opening is diminished by them;—circumference of ring (as measured after cutting through it and stretching it out without using much force).1 497. Right ventricle: — amount and characters of blood contained in cavity (518); attachment of coagula to lining membrane and interlacement among columnae carneae; — general estimate of size of cavity;—its general shape;—length of interior from centre of auriculo-ventricular ring to apex; — extent to which septum bulges into cavity.—Lining membrane (495).—Muscular walls: thickness at base, middle, and apex; colour; consistence; mot- tling or streaking as seen before and after removal of endocardium ; — size of columnae carneae ; con- 1 The best mode of measuring the several openings is by means of a wet piece of string, which will follow the inequalities of the opening. 163 foramen ovale. muscular walls. Right auriculo ventricular opening— form. projections. circumfer- ence. Right ventri- cle— blood con- tained. size of cavity. lining mem- brane. muscular walls. columnae car- neae. § II. p.] HEART. [PART II. chordae ten- dineae. Tricuspid flaps— thickness. granulations, etc. length, etc. Sinus arterio- sus. Pulmonary opening— shape, etc. efficiency of valves. circumfer- ence. Pulmonary valves— smoothness, etc. irregularity, etc. competency. malformation. Left auricle. Left auriculo- ventricular opening— size, etc. circumference. dition of chordae tendineae, their length, flexibility, thickened or not at point of attachment to valves ? — softening; rupture, its extent, situation, etc.; — ecchymosis; haemorrhage; pus; fibrous tissue, etc. 498. Tricuspid flaps:—natural, thickened, thin- ned, contracted; — presenting granulations or vege- tations ; — shortened; rolled back; length of flaps. — Can the auriculo-ventricular opening be closed ? if not, is this due to shortness of chordae tendineae, or to what other cause ? 499. Sinus arteriosus :—its size, shape;—deposi- tion upon its lining membrane. 500. Pulmonary opening : — its shape as seen from below; — smoothness of ring, of ventricular surface of flaps;—exudation upon or shrinking and apparent incompetency of flaps; does water pass through when poured into pulmonary artery ? and if so, does it pass freely or in drops ? apparent size of abnormal opening; — circumference of opening, (as measured at the attached border of valves, after opening the artery and stretching out the ring with- out force). 501. Pulmonary valves (viewed from pulmonary artery) : — their smoothness; colour; — thickening, or irregularity, their cause; contraction; reticula- tion ;—competency.—If there be any malformation, etc., of flaps, note their number, size, thickness, power of closing, opening, condition of corpora Arantii, etc. 502. Left auricle:—particulars as right auricle (495), pulmonary veins being of course noted in- stead of venae cavae and coronary veins. 503. Left auriculo-ventricular opening:—appear- ance when looked at from above; size and shape of opening; rough estimate of size by introducing fingers; size as measured by graduated cone;—cir- 164 PART II.J ARTERIES. [§ II. P. cumference of opening (measured after ventricle has been opened). ,. 504. Left ventricle: — particulars as right ven- tricle (497).—Septum ventriculorum : thickness at base, middle, and apex; — deficient, entirely or par- tially ?—if presenting an aperture, its size, thickness, and character of edges, etc. 505. Mitral flaps :—their size;—apparent com- petence or the contrary, cause of incompetency; — colour; smoothness; polish; — thickening; retrac- tion ; adhesion; deposits upon or into them, etc. 506. Aortic opening:—particulars as Pulmonary opening (500). 507. Aortic valves: — particulars as Pulmonary valves (501). 508. Coronary arteries: their size ; —atheroma or calcification of them;—obstruction from coagula, etc. 509. Substance generally: — Weight (the heart being supposed to be taken out as directed in the note, p. 162, and all blood and coagula to have been removed).— Wounds (667 et seq.).— Growths; their locality, size, etc. (672 et seq.); effect on shape of heart and condition of cavities. — Malformations; their special description.—Microscopical examina- tion of contained blood, and of the several cardiac structures. Arteries. 510. Examination before opening vessel: — mal- formations;—size; course;—condition of external coat aud of tissues around it; vascularity; exuda- tion (pus, etc.). 511. Examination after opening vessel:—con- tained blood, its quantity, colour, etc. (518), coagu- lated or not? — degree of adhesion of coagula to 165 Left ventricle. septum ven- triculorum. Mitral flaps— size, etc. thickening, etc. Aortic open- ing. Aortic valves. Coronary arte- ries. Substance- weight wounds. growths. malforma- tions. microscop- ical exami- nation. Arteries. Examination before open- ing vessel. Examination after open- ing vessel- contents. § II. *.] ANEURISMS. [PART n. walls. lining mem- brane. middle coat. external coat. Ductus arteri- osus. Microscopical characters. Dilatations of Arteries and Aneurisms. External cha- racters— size. shape, etc. lining membrane; colour, consistence, presumed age and arrangement of coagula. — Size of vessel after detachment of clots; transverse measurement, when opened and laid flat;—general thickening;—rigidity or flaccidity of walls.—Lining membrane: its colour; tint uniform, in patches, in streaks (on an- terior or posterior wall ?) ;—transparency; smooth- ness; polish;—readiness of detachment from middle coat; — thickness;—fissures; ulcers.—Inequalities on lining membrane; in points, patches, or ridges; their size, shape, degree of elevation; their appa- rent cause, as atheroma, calcification, fibrinous exu- dation, gelatiniform exudation; — exact relation of the above to the internal coat, upon it, below it but incorporated with it, below it but easily separated from it, below with partial destruction of it.—Middle coat: its thickness; colour; connection with lining membrane; — deposit between middle and internal coats; deposit in middle coat, its colour, consistence, and apparent nature (supra); blood between middle and inner or outer coats.—External coat: its thick- ness ; colour, etc. 512. "Ductus arteriosus: — condition, open or closed ? — diameter, at commencement, middle, and termination; — condition of interior; thickness of wall," etc. 513. Microscopical characters of normal and ab- normal arteries; of their several structures; of con- tained blood. Dilatations of Arteries and Aneurisms. 514. External characters:—size (as expressed in general terms and by measurement); shape, globular, pyriform, etc. — Relation to the vessel, whether a general dilatation or a lateral detrusion ? if a lateral 166 PART II.J ANEURISMS. [§ II. F- detrusion, note exact point of vessel from which it arises, and whether anteriorly, posteriorly, or late- rally ?— Sensation of thickness, thinness, density, fulness, emptiness, etc., given to hand. — Relation of surrounding parts to enlargement; are they ad- herent or not to enlargement? — Openings as seen externally; their position, size, depth; — free or blocked up by coagula ? degree of freedom with which a probe enters;—effusion of blood from open- ing, its quantity, position, etc. 515. Characters after opening dilatation : —con- tents; blood, liquid or coagulated;—layers of fibrin; their number, thickness; colour and density (absolute and relative) of outer and inner strata. — Size and shape of cavity in which liquid blood was free to move. — Opening from artery into cavity; size; shape; straight or oblique ? — characters of lips of opening; shape, thickness, hardness; apparent effect on entrance or exit of blood; apparent capability of being thrown into vibrations by its entrance or exit. — Inner surface of cavity; how constituted? by lining membrane of vessel, by adventitious mem- brane, by coagula or fibrin ? rough ; smooth ; calci- fied, etc.—Walls of dilatation, how constituted ? by all or by one or more of the coats ?—state of coats forming boundary; separated, amalgamated, thick- ened, thinned, atheromatous, calcified, etc.—Condi- tion of lining membrane in vicinity of opening into artery ; smooth, rough, atheromatous ;—does lining membrane appear to cease at orifice of aneurism or to be continued into it ?—Size of artery above and below aneurism ; — effect of aneurism on branches of artery.—Microscopical characters of arterial and aneurismal coats; vibriones present or not ? Characters af- ter opening- 167 § II- *•] VEINS. [PART II. Veins. Examination before open- ing- size, etc. feel. exudations. Examination after open- ing- contents. calibre. lining mem- brane. valves. communication with artery. phleboliths. Veins. 516. Examination before opening vessel: — size and general appearance; bulging, thickening; colour; vascularity;—feel to hand, hard, corded, thin, full, empty; — exudation upon and into outer coat, fibrin, pus, etc. 517. Examination after opening vessel: —Con- tents of vessel; blood, liquid or coagulated ? its colour; — fibrinous matter; its colour, consistence, adhesion to lining membrane; — pus or puriform- looking fluid, its microscopical characters (686 et seq.). — Calibre of vessel; if small, due to contrac- tion of vessel or to deposit on lining membrane? — Lining membrane : colour, uniform or in patches ? depth and uniformity of tint;—smooth; rough; ap- parent cause of roughness; size of elevations; their colour, consistence, degree of adherence;—polished; dull; tarnished. — Consistence of membrane; its thickness or thinness; its degree of adherence; softening; laceration; Assuring; rupture.-^Valves: condition as to thickness, colour, shape, and compe^ tency. — Abnormal communication between an ar- tery and vein: communication by a direct or oblique opening? immediate or by a sinus? size of open- ing ; — condition of arterial and venous wall of orifice;—size, of vein and artery at affected point.—- Phleboliths: their number; size; free or attached, and in wbal manner? relation to lining membrane; microscopical and chemical characters. 168 PART U.J BLOOD. — LYMPHATIC SYSTEM. [§ II. Q. Blood. 518. Physical characters:—colour; consistence; — fluid or coagulated? — characters of coagulum; form, size, consistence (uniform or not?), colour (uniform or not ?); relative amount and consistence of pale and dark portion*; position of pale and dark portions in relation to one another and to posture of body; — Microscopical characters (200), crystals; Chemical characters (201).— "Examination for poisons." — Blood mixed with gas; amount and nature of gas; vessels in which found. G. — LYMPHATIC SYSTEM. Lymphatic Glands. 519. Characters observed before section: — size; colour; consistence; flaccidity, etc.;—condition of capsule; — condition of tissue in which they are im- bedded. 520. Characters observed after section : — colour of surface; amount and situation of black matter; — general aspect of cut or of fractured surface; consistence, soft, hard, calcified; — containing tuber- culous-like matter (685); containing cancerous-look- ing matter (679 et seq.);—character of fluid exud- ing from cut surface on pressure, to naked eye and under microscope. 521. Special lympJiatic glands. — Cervical glands: part and side of neck on which diseased glands are situated. — Axillary glands. —- Inguinal glands: above or below Poupart's ligament? — Ap- pearance of skin covering these several groups of p 169 Blood. Physical cha- racters— microscopical characters. chemical cha- racters. § II. G. Lymphatic Glands. Characters be- fore section. colour, etc. capsule. Characters after section. colour, etc. consistence. tubercle. cancer. fluid exuding. Special glands. cervical. Axillary. inguinal. § II- H.J URINARY ORGANS. [PART II. bronchial. mesenteric. lumbar, etc. Lymphatic Vessels. Size-— consistence, etc. lymph. Skin, etc. over. Lacteal Vessels. I II. H. Kidneys and Ureters. Absence, etc. External cha- racters. position. size, etc. weight glands; — openings from the glands on surface of skin; discharge from openings or not ? characters of discharge (642, 643). — Bronchial glands.— Mesenteric glands: number visible; relation of en- larged glands to particular portions of intestines or to diseased conditions of them.—Lumbar, iliac, and sacral glands. Lymphatic vessels. 522. Size of vessels; — thickness, consistence, and colour of coats; — amount of lymph contained within them ; its degree of fluidity; transparency or turbidity ; its colour; microscopical characters;— colour of skin in course of lymphatics; abscesses in connection with them. Lacteal vessels. 523. For particulars, see Lymphatics (522). Contents of vessels; degree of fluidity, etc. H. ■URINARY ORGANS. Kidneys and Ureters. 524. Absence of both kidneys, or of either? — Number of kidneys ? — Kidneys united ? (The following facts are to be noted in respect of each kidney separately.) 525. External characters : — degree of develop- ment; position; form; — size, extreme length, ex- treme breadth, extreme thickness; — weight after 170 PART II.J URINARY ORGANS. [§ II- H. removal of capsule; — amount of fat at hilus; — wounds (667 et seq.); rupture. 526. Capsule: — transparency; vascularity; con- sistence; thickness;—facility with which removed from cortical substance; readily separable or not into layers? portions of cortical substance removed or not with the capsule ? number, size, and shape of portions of cortical substance removed. 527. Surface of kidney, after removal of capsule (noting differences, if any, on anterior and posterior surfaces) : — smooth; lobulated, size of lobules; — puckered ; situation, shape, size, and colour of puck- ered spots;—presenting depressed spots; situation, shape, size, and colour of depressed spots; adhesion of capsule to these spots;—granulated; situation, size, and colour of granulations; colour of inter- granular substance.—Colour of surface of kidney; greyness of surface; its depth, situation, shape, ex- tent; pallor, its tint; marbling; redness, dependent on staining or vascularity ? venous polygons; stellate injection; punctiform redness (size of punctae).— Cysts (675 et seq.). 528. Substance of kidney: — consistence, flac- cidity, fragility;—fracture, granular or not? — wounds (668); rupture. 529. Cut surface:—amount of blood or serosity exuding from cut surface; presence of fat on surface of exudiug fluid ?—general hue of cut surface; rela- tive hue of cortical and pyramidal portions; line of demarcation between these portions abrupt or imper- fectly marked ?—amount of blood in vein at base of pyramids; hue of tissues immediately adjacent to that vein. 530. Cortical substance:—specific gravity; — breadth at base of pyramids;—general colour; red striae, their amount, breadth, continuous or made up 171 fat, etc. Capsule. Surface. cysts. Substance. Cut surface— fluid exuding. colour, etc. Cortical sub- stance— specific gravity. breadth. § II- H.J URINARY ORGANS. [PART II. colour. Malpighian corpuscles. granulations. microscopical characters. Pyramidal por- tion— striae. colour. microscopical characters. Mammillse. Abnormal growths, etc. cysts. fibrinous masses. tubercle. cancer. abscesses. Pelvis of kid- ney— contents. walls. mucous mem- brane. of separate points? red punctae; ecchymoses;—Mal- pighian corpuscles; their degree of visibility; colour, pale, red; — granulations, their colour, consistence. —Condition of cortical substance subjacent to any puckered spots seen upon the surface.—Microscopi- cal characters.—Matrix, amount of; quantity and character of epithelium in tubes, oil-globules, crys- talline bodies;—minute arteries thickened or not ? — diameter of central canal compared with total diameter of vessel;—character of coats, transpa- rency, granular or not ? presence of oil globules, etc. 531. Pyramidal portion:—degree in which nor- mal striae are marked; arrangement of striae in the pyramidal portion, and where this passes into corti- cal portion;—general colour;—white opaque streaks; yellow deposit, granular or linear, general or limited to base ?—Microscopical characters. 532. Mammillae:—their consistence; colour; fluid expressible from them ; gangrene. 533. Abnormal growths and deposits: — Cysts (675 et seq.) ; their relation to Malpighian bodies. Fibrinous masses; their size, shape, consistence; colour of tissue adjacent, red, grey.—Tubercle (685). —Cancer (679 et seq.).—Chalky matter.—Abscesses (647 et seq.).—Microscopic characters of any of the above. 534. Pelvis of kidney.—Absent ?—Calyces; their length and size;—mode in which ureter opens into pelvis, and whether in a valvular manner or not? loculated, bases of loculi radiated or not ^—Contents of pelvis; fluid, its quality, capable or not of boing expressed through the ureter ?—solid (calculi), their exact situation, size, surface, structure, etc.—Wails of pelvis; thickness, consistence, transparency, colour.—Mucous membrane (635 etseq); deposit or not of minute crystals.—Wounds (667).—Fistu- 172 PART H.J URINARY BLADDER. [§ n. H. lous openings (654 et seq.).—If any solid body lie openings. in the pelvis, note the condition of wall and of mu- cous membrane with reference to its exact seat. 535. Ureters :—absence ? (if absent, note exist- Ureters__ ence or not of a condensed band of fibrous tissue in its situation);—number;—calibre, if altered at one calibre. spot, note condition of tissue adjacent to that spot and calibre of ureter above and below;—contents of ureter; if a calculus, its position, size, surface, etc., condition of mucous membrane in contact with it;— mucous mem- mode in which ureter opens into pelvis of kidney °rane. and bladder; — consistence. — Mucous membrane (635 et seq.). Urinary Bladder. 536. External characters: — Absent?—Malfor- mations.—Adhesions (646).—Size; amount of con- traction or dilatation ; degree of dilatability;—posi- tion of bladder; shape;—diverticula, their seat, size, shape, tissues forming them, contents; — wounds (667). 537. Contents :—urine, its quantity and physical characters (221);—blood, its amount and charac- ters ; pus, etc.;—calculi, their number, size, position, shape, surface, section, and chemical and microscopi- cal characters;—other bodies. 538. Walls:—their thickness; condition and thickness of the several coats.—Growths (672).— Sinuses.—Perforations (666); rupture, seat, extent, direction; wounds (667); tubercle (685); cancer (677 et seq.)—Condition of adjacent tissues and organs. 539. Mucous membrane (635 et seq.). p2 173 Urinary Blad- der. External cha- racters— size. position. shape. diverticula, etc Contents. Walls. Mucous mem- brane. § II. I.J ORGANS OP GENERATION. [PART 11. Urethra. Direction— calibre. obstructions. wounds, etc. Mucous mem- brane. Contents. 2 II. I. 1. Female. Labia, nymphae. clitoris— marks of vio- lence, etc. Urethral orifice. Hymen. Urethra. 540. Absence ? — malformations;—direction; — calibre; contractions and dilatations, their seat, num- ber, mutual relations; condition of several tissues of urethra at the seat of abnormal calibre and of tis- sues about it;—obstructions of canal, their character and cause;;—abscesses opening into or in relation with canal;—wounds; rupture. 541. Mucous membrane (635 et seq.):—abnormal appearances uniform or not ?—condition of follicles and sinuses;—excrescences, their situation, form, size, colour, vascularity, consistence.—Absence or changes in verumontanum, hypertropy, atrophy. 542. Contents of urethra :-~-solid and fluid; cal- culi, impacted ? i.—organs of generation. 1. Female. 543. Labia, nymphoz, and clitoris:—absence ?— malformations;—size; colour; oedema;—condition of epithelium; abrasion, its extent; — ulceration (665);—-secretion covering these parts, its appear- ance and characters;-—abscess (647 et seq.); erup- tion; vegetations; condylomata, their number, form, and size; tumours (672 et seq.); gangrene (659 est seq.); — " marks of violence; blood about external genitals; appearances of recent connection." 544. Urethral orifice:—growths within and about it; their size, number, exact seat, elevation, etc 545. Hymen:—absent or present ? its precise 174 PART II.J ORGANS OF GENERATION. [§ H. I- Btate, " entire or lacerated ? surrounding the entire vaginal orifice or only a part of it ? imperforate;— its strength;" dilatable or not ? Examination of the Generative Organs by the In- troduction of the Finger. r 546. Vagina: — Prolapsus; protrusion of either wall, apparent cause; protrusion of mucous mem- brane, its colour, and other characters.—-Malforma- tions and congenital deficiencies; divided vagina;— elongated; shortened; narrowed; dilated; closed; seat and extent of the above changes; apparent cause of contraction;—direction;—condition of ori- fice.— Contents of vagina; "foreign substances, their exact situation, size, and other characters; poisonous substances." — Mucous membrane (635 et seq.); corrugated; lying in loose folds; — "do secretions on surface contain seminal animalcules ?" — Fissures, or ruptures, their seat, extent, direction, with what part or organ they communicate ? wounds (667 et seq.); perforations (666);—cancer (679 et seq.). — Submucous tissue (637); condition of layer of erectile tissue at lower part of vagina. 547. Uterus: —position of in pelvis, ante-verted, retro-verted, turned to either side, degree of each; ante-flexed, retro-flexed, etc.; angle formed between body and neck; — size; enlarged uniformly or in what part? — hard, doughy, elastic, etc 548. Ovaries and Fallopian tubes:—size; small, enlarged (equally or unequally ?); surface, smooth, or lobulated; position in respect of other pelvic viscera; general physical characters, etc. Examination by introduction of finger. Vagina— prolapsus. malformations. length. width. contents. mucous mem- brane. fissures, etc. sub-mucous tissue. Uterus— position. size, etc. Ovaries, etc. 175 § II. I.J ORGANS OF GENERATION. [PART II. Examination in situ. Pelvic tumour. Examination after removal. Uterus— orifice. size, shape, etc. Examination in situ. 549. Uterus: — absence ?—malformations.— G e- neral appearance and rough estimate of size;—posi- tion of fundus and of cervix (aiding the determina- tion of this and other points by the introduction of a finger into vagina); — organ straight or bent upon itself, in what way ? occupying its proper position in the pelvis, or lying diagonally, or turned forwards or backwards (noting its exact position) ? high or low in pelvis ? lying against perineum, rectum, or blad- der, or descended towards vaginal outlet, and to what extent ? — adhesions (646). — General form and character of enlargement, amount of pelvis occupied; relation to pelvic parietes and neighbour- ing organs. 550. Fallopian tubes: — their absolute position and direction; — position and direction relatively to the uterus, ovaries, pelvic tumours, etc.;—general characters of size, colour, etc.; — adhesions (646). 551. Ovaries: — their position;—general esti- mate of their size; general character of the enlarge- ment, hard, soft, uniform or irregular? — adhesions (646). 552. Pelvic tumour (672 et seq.) : — its relation to walls of pelvis, uterus, Fallopian tubes, broad liga- ments, ovaries, bladder, rectum, etc. Examination after removal. 553. Uterus:—orifice;—size; shape, natural, oval, rounded, irregular, etc.; — open; obstructed, nature of obstructing substance; — discharge lying within it, its characters; — tumour occupying it, its characters (672). — Lips: size, equal or unequal? 176 PART II.J ORGANS OF GENERATION. [§ II. I. — form, flat, uneven, everted, lobulated (size and characters of lobulation) ; — colour, uniform or not ? — abrasion, its exact situation and extent, depth;— ulcerations (665), their exact situation;—granular- looking patches, their exact situation, size, form, colour, elevated or depressed? epithelium on surface present or absent ? tumours (672 et seq.).—External characters (distinguishing, where necessary, neck and body): — weight;—extreme length, breadth, and thickness; measurements at various points; — form of organ;—characters of surface; colour; peri- toneal covering smooth, shining, rough, transparent or opaque? covered with lymph (644); — tumours, their position, size, etc. (672 et seq.);—fissures or ruptures, their seat, extent, depth, direction;— ulcerations (665); wounds (667 et seq.); cicatrices (670);—consistence of organ or of parts of it; hard, soft, flabby, boggy, irregular, fluctuating, etc. — Characters observed on section : — Uterine wall: thickness at cervix, body, and various parts of these; consistence; colour of section;—amount of blood in tissue; condition of blood-vessels as to size, ful- ness with blood, etc.; — fluids exuding from cut surface on pressure; — abscess (647 et seq.); — tumours (672 et seq.); their position, nearness to outer or inner surface, their size, characters on sec- tion ; — condition of subperitoneal blood-vessels and cellular tissue ; — microscopical characters of tissue, fatty degeneration, etc — Uterine cavity (distin- guishing that of cervix and body); closure of cavity, its cause; — dimensions of cavity; — contents of cavity ; — secretions or exudations covering its sur- face (0-W); condition of rugae and glands of cavity ; — mucous membrane (635); — condition of sub- mucous tissue (637); — tumours projecting into cavity (672 et seq.), their number, position, size, 177 shape. colour. abrasion. ulcerations, etc. external cha- racters gene- rally. weight. measurements. form. surface. tumours. fissures, etc. consistence. Characters on section. wall. cavity. contents. secretions, etc. rugae and glands. mucous mem- brane. submucous tissue. tumours. § II. I.] ORGANS OF GENERATION. [PART II. os internum. Fallopian tubes. calibre. colour. contents. mucous membrane, etc. Ovaries— external characters. size, colour. surface. cysts. consistence. sheath. characters of section. aspect. colour. stroma. cicatrices. cysts. tumours, etc Vagina. abrasions. ulcerations, etc. characters externally and on section; character of surface; continuous or not with disease in the wall ? —size and condition of internal orifice of uterus;— cancerous growths (679 et seq.).— Ovum: its size, degree of development, etc. 554. Fallopian tubes: — absence? — malforma- tions ;—length; direction, apparent cause of altera- tions in length and direction; — calibre, dilated, contracted; canal obliterated; — colour; contents, microscopical examination of; thickness of walls; —condition of mucous membrane (636); secretions, etc. on surface (635) ;—condition of fimbriated ex- tremity;—cysts (675 et seq.); tumours (672 etseq.); tubercle (685); cancer (679 et seq.). 555. Ovaries.^External characters :—absence ? size; colour, generally and partially;—effused lymph on surface; condition of surface, smooth, rough, irregular, lobulated; marked by cicatrices (670); fissured, etc.; — cysts beneath surface, or projecting from it (675 et seq.);—consistence of ovaries, soft, boggy, fluctuating, firm, hard, irregular, etc.— Con- dition of sheath : its colour, thickness, consistence, etc. — Characters of section : general appearance, uniform or varied, and in what manner? colour; — state of stroma, its consistence, etc.;—corpora lutea, true or false, their situation, size, and general cha- racters ; — fluid exuding on pressure; — section of cicatrices;—cysts, their position, number, size, con- tents (675 et seq.); — tumours (672 etseq.), their situation, number, size, general characters; — ab- scesses (647 et seq.);—collections' of blood; tubercle (685); cancer (679 et seq.), etc—Condition of tis- sues in neighbourhood of diseased ovaries. 556. Vagina : — mucous membrane (636) ; — granular patches; minute characters of abrasions; extent; situation, etc.;—ulcerations (665); extent 178 PART II.J MAMMJE. [§ H. I- and depth of excavation; character of surface and edges; amount to which sub-mucous tissue is in- volved, etc. —vegetations, tumours (672), etc. Mammae. 557. External characters : — number; size; po- sition of supernumerary glands; — silvery lines on integument, or other visible marks of previous en- largement.—Nipple; its colour; size; flattened or drawn in? excoriations; ulcers (665), etc.—Areola; its size, colour, etc. — Substance of gland to feel, soft, knotty, etc., hard. 558. Section of gland: — colour of cut surface; fluids exuding on section or on pressure; —consist- ence of gland;—abscesses (647 et seq.); cysts (675 et seq.); tumours (642 et seq.); tubercle (685); cancer (679 et seq.). 2. Male. 559. Inguinal canal: — its contents; — hernia; its size; parts forming it, their condition. 560. Testicles:—absent ? malformations of them ; —their exact position, in scrotum or abdomen ? de- gree of descent; — size; consistence to the feel; — condition of fibrous coat;—character of section, colour, consistence; — abscess (647); cysts (675 et seq.); tumours (672 et seq.); tubercle (685); cancer (679 et seq.). 561. Vasa deferentia : — thickness; contents; condition of mucous membrane (635). 562. Spermatic cord:—condition; cancer (679 et seq.), etc 563. Tunica vaginalis: — malformations; adhe- 179 Mammoz. External cha- racters— silvery lines. nipple. areola. substance. Section— colour. fluids exud- ing. consistence, etc. 2. Male. Inguinal canal. hernia. Testicles— descent. size. consistence. section. Vasa deferen- tia. Spermatic cord. Tunica vagina- lis. § II- K.J ENCEPHALON. [PART II. Vesiculse semi- nales. Prostate gland— size. surface. section. Penis— urethra. II. K. External exa- mination. Scalp— thickness. section. adhesion. collections of fluid, etc. sions;—contents of sac (638);—condition of serous membrane (639), etc. 564. Vesiculse semhiales :—absence ?—malform- ations ;—calibre; dilated; contracted; obliterated ; thickness of parietes ;—contents; their colour, con-. sistence, etc.; — condition of mucous membrane (636); secretion covering its surface (635) ; — tu- bercle (685); abscess (647); cancer (679), etc. — condition of adjacent tissues. 565. Prostate gland:—size; consistence; partial enlargement of middle or lateral lobes? impediment offered by it to passage of urine ; — surface of en- larged gland;—colour of section; fluid exuding on section or pressure, its ahundance, colour, etc.; — abscess (647); — tumours (672); tubercle (685); cancer (679 et seq.). -<— Contents of ducts; calculi, their size and chemical characters. 566. Penis :—size; malformations; ulcers (665); tumours (672 et seq.).—Urethra (540 et seq.) K.--ENCEPHALON AND ITS COVERINGS AND APPENDAGES 567. External examination of integument and cranium (397 et seq., 262). — "In newly-born in- fants note presence or absence of customary tumour on scalp." 568. Scalp:—thickness of integument and apo- neurosis; —amount of blood effused on section ; — colour of section ; — degree of adhesion to surface of cranium;—"extravasation of blood; its relation to contusion-marks externally;" collections of fluid, its characters ;—cysts (675 et seq.); tumours (672 et seq.), etc; connection of any of the above with apertures in the cranium. —" Wounds (667 et seq.)." 180 part n.J ENCEPHALON. [§ H. K. 569. Cranium. — Exposed surface: its colour; — smoothness or roughness; seats of roughness or irregularity; degree of roughness, its extent, cause; —condition of calvaria opposite diseased appearances on scalp. — " Fractures; their position relatively to marks of injury observed on scalp; with or with- out depression ?"— Removal of calvaria : — adhe- sions to dura mater; their situation, and where most numerous and strongest? — force required to detach calvaria; can it be detached at all, or is it necessary to remove any part of dura mater with it ? —Inner surface of calvaria : its form, symmetrical or not? — elevations or depressions; their seat, ex- tent, degree, and symmetry;—smoothness of vitreous table; roughness ; its degree, position, corresponding to diseased appearance externally, or to adhesions of dura mater? — vascular grooves, their depth; bloody points on surface; colour of surface; cha- racters of surface in lines of sutures; deposit of new bone on surface; extent, thickness, density; adhesion to dura mater or calvaria.— Ossification of calvaria, its degree; state of fontanelles. — Thick- ness of cranial bones; abnormal thinning or thicken- ing ; their exact seat, measurement, extent, etc.; symmetry of thickness; which table is most con- cerned in the thickening? — width of diploe; ful- ness of diploic veins; colour of diploe; fluids con- tained within diploic structure, pus, etc.;—condition of frontal sinuses, of their mucous membrane (594 et seq.) — Openings in calvaria; their position, size; — parts passing through them; condition of edges of opening, and their relation to parts passing through. — Condition of base of cranium (noted after removal of brain and membranes): depres- sions and elevations; their degree, symmetry, etc. (particulars as Inner surface of calvaria, supra); Q 181 § II- K.J ENCEPHALON. [PART II. Dura mater— colour. bloody points. haemorrhage. pus. thickness. vascularity. tumours. falx cerebri and tentori- um. Arteries at base of brain. Arachnoid membrane. contents. coagulum. — condition of foramina and of bone in their im- mediate vicinity; — condition of petrous portions of temporal bones, apertures leading to internal ear, fluids contained within them, etc. 570. Dura mater:—characters of surface ; cojour generally or partially, white, yellow, red, etc.;— bloody points on surface, their abundance and prin- cipal situation; — haemorrhage on surface (between it and calvaria), its situation; condition of blood, fluid or coagulated ? amount; extent over surface; condition of parts about blood, of bone (fissures, necrosis, etc.); condition of vessels in vicinity of effused blood; — pus between dura mater and cal- varia ; its situation, amount, extent, boundaries, etc (647);—thickness of dura mater, separating readily into layers; transparency or opacity?—vascularity, order of vessels filled with blood, and their situation ; — sloughs (659 et seq.); — tumours (672 et seq.); their relation to depressions on inner surface of cal- varia or other diseased appearance; — wounds (667 et seq.). — Falx cerebri, and tentorium: depth; presence or absence of reticulation? (other par- ticulars as dura mater generally).—Inner surface of dura mater. (See Arachnoid Membrane, 572). 571. Arteries at base of brain (510 et seq.). 572. Arachnoid membrane :—contents of cavity; serosity (642); — fluid blood; its situation, quan- tity, colour; — coagulated blood; situation, form, size, colour and consistence of coagulum; state of its surface; is coagulum adherent or not to arach- noid ? presence or absence of a serous membrane on surface of coagulum ? presence or absence of epi- thelium on the serous membrane ? vascularity of coagulum, vessels capable of injection from those of membranes or not ? characters of section, condition of the interior as compared with the exterior of the 182 PART II.J ENCEPHALON. [§ II. K. coagulum, as to consistence, colour, and microsco- pical characters; — hydatids in cavity of arachnoid. — Adhesions between the two layers of arachnoid (646).—Surface of arachnoid, noting separately that of convexity and base of brain, that covering each portion of encephalon, and that covering dura mater (639) ; granulations (tubercles) on membrane (685) ; their capability of removal, etc.; left on pia mater on stripping off the arachnoid. — Transparency of arachnoid, generally, between the convolutions, in vicinity of longitudinal fissures; — special seats and extent of opacity. — Colour of membrane generally or in parts; — its vascularity noted with that of pia mater; — its consistence noted with that of pia mater; its thickness. 573. Sub-arachnoid serosity: — its quantity; — position, occupying intergyral spaces ? raising arach- noid from surface of convolutions (to what extent?); limited to certain spots ?—its colour, etc. (642). 574. Pia mater (noting exact locality of all ab- normal appearances, and distinguishing the mem- ' brane covering each portion of the encephalon) : amount of contained serosity, its colour, transpa- rency, etc. (642); — lymph; its situation, extent, colour, consistence, opacity, etc. (644); — granula- tions (tubercles); their number, position, form, size, etc. (685);—cancerous matter (679 et seq.); — vas- cularity of membrane as seen through arachnoid, degree of fulness of larger vessels between and upon convolutions, of smaller vessels; air in vessels, its abundance; degree of fulness of vessels situated in folds which dip between convolutions; degree of fulness of vessels which dip into grey matter (ob- served when detaching pia mater from surface of convolutions); relative degree of fulness of vessels of membrane covering anterior and posterior lobes; 183 adhesions. surface. transparency. colour, etc. Sub-arachnoid serosity. Pia mater— serosity. lymph. granulations, etc. vascularity. § H. K.J BRAIN--CEREBRUM. [PART II. blood. transparency. thickness. consistence. adhesions. Sinuses. Brain. Generalities— weight, etc. a. Cerebrum. Points observ- ed before removing membrane. Parts at base. — fluid blood, its situation, quantity, etc.; — coagu- lated blood, situation, form, size, colour, and consist- ence of coagulum; coagulum laminated or not ? ad- herent or not to parts adjacent? condition of large vessels near clot; — transparency of pia mater; — thickness;—consistence ;—size of portions of arach- noid and pia mater removable by the forceps from the convolutions without tearing;—adhesions of pia mater, number and size of portions of convolutions detached with pia mater when that membrane is re- moved by forceps. 575. Sinuses of dura mater:—their fulness, etc. (See Veins 516 et seq.). Brain. 576. Generalities:—weight generally, and that of cerebrum, pons Varolii, medulla oblongata, and cerebellum separately; — specific gravity of various parts.—Rapidity with which substance softens on exposure or by handling. a. Cerebrum. 577. Points to be observed before removal of arachnoid and pia mater (as much as possible being noted while brain is in situ:) — degree of develop- ment ; size;—form ; symmetry of two sides;—space between surface of brain and calvaria. 578. Parts at base of brain.— Crura cerebri; locus niger; optic tract; optic commissure; corpora albicantia; tuber cinereum; infundibulum; pi- tuitary body, etc.—In respect of each of the above, note their size, symmetry, colour on surface, consist- ence, appearance on surface, appearance on section, 184 PART n.J CEREBRUM. [§ H. K. etc. as (582); extravasation of blood (583), etc. — Attached portions of cerebral nerves, their condition (626 et seq.); condition of membranes about them. 579. Removal of arachnoid and pia mater: — tenacity with which pia mater adheres to surface of cerebrum; apparently increased or not? its cause (softness of convolutions, absence of normal amount of serosity, increased number and consistence of vessels passing from pia mater into convolutions). 580. Convolutions externally: —number; " fully developed or not ?" breadth;—breadth of intergyral spaces; — flattening, local or general; — local bulg- ing; local depression; — smoothness of convolu- tions ; polish; granular appearance; worm-eaten appearance. — Colour of convoluted surface; yellow patches; crimson spots; — situation and extent of discoloured parts; number of convolutions involved. — Consistence of convolutions; amount removed in detaching membranes; gravitative flattening of sur- face of brain locally; consistence to the touch; effect of a stream of water (no breach of continuity previously existing); — relative consistence of con- volutions of anterior and posterior lobe, or of any parts discoloured or otherwise changed.—Ulcers (665); relation between meninges and the edges and floor of the ulcer; condition of brain substance around and beneath ulcer, its consistence, colour, vascularity, etc., extent to which it is altered. — Sloughs (659 et seq.); relation to meninges; tenac- ity with which slough adheres to adjacent brain sub- Btance; condition of brain substance around. — Deposits; tumours (672); wounds (667); pucker- ings, etc 581. Section of convolutions: — breadth of grey matter of convolutions; hue; consistence; specific gravity; vascularity.—Condition of grey matter sub- q2 185 cerebral nerves. Removal of arachnoid Convolutions externally— size. flattening, etc. colour. consistence. ulcers. sloughs, etc Section of con- volutions— grey matter. §n.K.J CEREBRUM. [PART II. microscopical characters. White sub- stance— consistence. colour. blood in ves- sels. corpus cal- losum. microscopical characters. Extravasation of blood— situation, etc. coagulum. Cavities— measurements, etc. contents. jacent to abnormal portions observed on surface. — Microscopical characters, of tissue, of minute vessels. 582. White substance of hemispheres :—moisture of cut surface;—consistence of the substance, dimi- nished, soft, pulpy, creamy; diffluent; consistence increased, — extent of substance altered in consist- ence;—adhesion of cerebral substance to the knife; — sense of resistance local or general offered to the knife; its apparent cause (calcification of vessels, etc.) ;—specific gravity;—colour of cut surface, dead white, cream-coloured, green, rose, orange; —fluids expressible.—Blood in vessels; number and size of red points; number and length of red lines (these facts to be noted in reference to the anterior and posterior lobes, and to corresponding parts of the two hemispheres).— Corpus callosum (particulars as above). — Microscopical characters, of tissue, of minute vessels (especially of parts altered in colour or consistence). 583. Extravasation of blood: — its exact situa- tion ;—if the layer of blood be thin, note whether it lies in the plane of the cerebral fibres or across them (i. e., whether or not it has necessarily ruptured the cerebral fibres); — fluid blood, its amount, colour, and consistence; — coagulated blood; — coagulum ; its measurements; colour, at centre, at circumfer- ence, uniform or laminated ? shade of red, shade of orange; degree of attachment to walls of cavity in which it lies; its mode of attachment, by vessels, by fibrin, etc. — Walls of cavity in which blood lies (584). — Microscopical characters of coagulum, of tissue of wall of cavity. 584. Cavities in cerebral substance :—their num- ber; measurements; capacity; shape. — Contents; blood (583);—purulent-looking fluid (643), its quan- tity, colour (especially reddish, orange, yellow, or 186 PART II. J CEREBRUM. [§ H. K- greenish); its consistence, at centre, at circum- ference;—serosity (042);—fluid like milk of lime, its quantity, consistence;—microscopical characters. — Bands crossing cavity; cellular or consisting of vessels ?—their consistence;—adhesions between op- posite walls of cavity; readily separable or incapable of separation ?—Inner surface of cavity; consistence; —smooth ; polished; lined or not by a serous mem- brane ? ragged; characters of flocculi, their colour, consistence, structure (consisting of cerebral sub- stance, of vessels); — colour of inner surface, espe- cially shades of yellow, green, orange, or red.—Con- dition of cerebral substance around cavity; consist- ence diminished, soft, pulpy, creamy, diffluent; con- sistence increased ; — colour, especially shades of yellow, green, orange, or red; —vascularity;—stud- ded with points of extravasated blood;'—puckering towards any part of cavity;—linear cicatrix extend- ing from any part of cavity (585). ? 585. Cicatrices in cerebral substance (671): — radiated; linear;—their situation, size, colour, trans- parency, consistence, etc.;—condition of cerebral substance around (582), consistence, puckering, etc. 586. Wounds of cerebral substance (667). 587. Adventitious products; calcareous masses, their size, consistence, microscopical characters, etc.; tumours (672 et seq.); tubercle (685); cancer (679 et seq.). Condition of cerebral substance around each of the above (581, 582). 588. Minute vessels of brain :—coats thickened, calcareous, etc.;—their microscopical characters.— Note their condition, especially in and around soft- ened and indurated parts, and around extravasation of blood. 589. Lateral ventricles (noting any difference in the two ventricles): — contents; fluid, its quantity, 187 bands. adhesions. inner surface. surrounding substance. Cicatrices. Wounds. Adventitious products. Minute vessels. Lateral ven- tricles— contents. § II- K.J CEREBRUM. [PART II. choroid plexus. velum inter- positum. . foramen of Munro. lining mem- brane. Septum luci- dum— fifth ventricle. Fornix. Third ventri- cle— contents. commissures. " odour," colour, transparency, etc. (642) ;—solid ; lymph (644), coagulated blood (583), hydatids, etc. — Choroid plexus: pale, oedematous; loaded with blood; — cysts, their situation, size, structure, etc. (675 et seq.); — calcareous bodies, their situation, size, consistence, microscopical characters, etc.— Velum interpositum : its transparency, consistence; vessels empty or filled with blood ? — Foramen of Munro: degree of patency.—Lining membrane of ventricles: its integrity; dryness or moisture ? de- gree of polish; — roughness, from minute pits over surface, from granulations, from vesicles; — abnor- mally vascular; number, size, and situation of ves- sels;—consistence, tough, offering resistance to knife; thickness; transparency;—apertures visible, leading to extravasations of blood (583) or collections of puriform matter (648); cicatrices (670), their situ- ation, size, colour, form, transparency, consistence, puckering of membrane around, etc. (Note exact situation of any morbid appearance, especially in relation to corpora striata or thalami optici.) 590. Septum lucidum:—present or not ?—aper- tures, their situation, size, form; state of lining membrane at edge of aperture; — consistence ; fa- cility with which torn;—colour;—oedema;—extra- vasation of blood into substance (583). — Condition of fifth ventricle; size; contents; condition of its lining membrane. 591. Fornix (distinguishing the condition of an- terior and of posterior pillars, of intermediate por- tion, and of part included between posterior pillars) : consistence; colour; oedema;—vascularity; extra- vasation of blood (583). 592. Third ventricle:—contents; capacity;—ex- travasation of blood (583). — Commissures, their consistence, vascularity, etc; soft commissure ab- 188 PART II.J CEREBRUM. [§ n. K. sent ? double ? — Lining membrane, its integrity (especially to be noted where soft commissure ap- pears absent);—consistence, etc., of surface of optic thalami in ventricle. 593. Optic thalami and corpora striata :—size; symmetry; condition of surface (as seen in ventri- cles, 589, 592). — Section (particulars as 582); if softened, extent of softened substance; extravasation of blood (542), etc. 594. Condition of parts on upper surface of pons Varolii. — Pineal body and its peduncles ; corpora quadrigemina ; processus e cerebello ad testes ; valve of Vieussens; corpora geniculata; noting in re- spect of each, external appearances, symmetry, colour, consistence, and characters of section; ex- travasations of blood, etc.; presence, microscopical and chemical characters of corpora amylacea. b. Pons Varolii. 595. External characters: — colour of surface; consistence, etc;—condition about superficial origin of nerves. 596. Appearance on section, specifying exact situation of morbid changes (particulars as 582);— extravasation of blood (583), etc c. Medulla Oblongata. 597. External characters : — size ; shape; sym- metry; colour;—degree of adhesion of membranes; — consistence of surface (noting exact locality and extent of abnormal appearances).—Condition about superficial origin of nerves. 598. Fourth ventricle:—its contents;—extrava- 180 lining mem- brane. Optic thalami and corpora striata— section. Upper surface of pons Va- rolii— pineal body, etc. b.Pons Varolii. External cha- racters. Section. c. Medulla Ob langata. External cha- racters. Fourth ventri- cle. § II- L.J SPINAL CORD. [PART II. Section. d. Cerebellum. External cha- racters. Section. Peduncles. ILL. Integuments over spine— tumours. Vertebrae. sation of blood (583);— condition of floor of ven- tricle; its colour, vascularity, consistence, etc. 599. Section of medulla oblongata (noting the several portions of it which are the seat of any morbid change, and its extent); colour; vascularity; consistence;—extravasation of blood, etc. d. Cerebellum. 600. External characters :—size; form; symme- try ; — general firmness or consistence; — adhesion of membranes;—consistence of surface; colour of surface (noting exact locality of morbid change in this or any other respect);—local fulness; local de- pression. 601. Section of cerebellum (noting the exact locality and extent of any morbid change) :—colour; vascularity; consistence; — extravasation of blood (583); cavities (584); cicatrices (585); .wounds (667 et seq.); condition of minute vessels (588); tumours (672 et seq.); tubercle (685); cancer (679 et seq.), etc 602. Peduncles of cerebellum : — their colour, consistence, etc. L.—SPINAL CORD, ITS COVERINGS AND APPENDAGES. 603. Integuments over spine (397 et seq.). — Tumours; their exact seat; form; size; shape; consistence;—effect of pressure on them. 604. Vertebras (to be examined both behind and anteriorly, in the neck, in the chest, and in the abdomen). — Condition of bodies, arches, spinous 190 PART II.J SPINAL CORD. [§ II- L. processes, etc. (412). — Angular projections or cur- vatures of spine; condition of vertebrae, etc., giving rise to them. — Fissures (spina bifida); their seat; extent;—size of prominence; — tissues forming the tumour observed externally; — quality of con- tained fluid. 605. Intervertebral substance (414). 606. Vertebral canal. — Peculiarities of form or size; proportional width to mass of cord; — fluid contained within it; its amount and characters; — fat contained in it; its amount, exact seat.—Spinal veins: their size, fulness, etc. (516 et seq.). 607. Theca vertebralis: — filled out or not ? bulged in any particular part ? (other particulars as 570). 608. Spinal arachnoid membrane (particulars as 572). 609. Cerebrospinal fluid:—amount; where ac- cumulated ? movable or not along cord ? — colour, etc. (642). 610. Ligamentum denticulatum : — colour, con- sistence, etc. 611. Pia mater: — thickness; firmness; vascu- larity ; attachment to cord (further particulars as 574). Spinal Cord. 612. External characters:—weight; size, gene- rally or locally (noting exact seat and extent of en- larged or diminished parts) ; — cervical and lumbar enlargements, obvious or not? in what degree?—its consistence generally ;—fissures, anterior, posterior, and lateral; their condition ; colour and consistence of surface about them, and of the several columns of the cord. 191 Intervertebral substance. Vertebral canal— spinal veins. Theca verte- bralis. Spinal arach- noid. Cerebro-spinal fluid. Ligamentum denticulatum. Pia mater. Spinal Cord. External cha- racters— weight. size. fissures, etc. § II- M.J ORGANS OF THE SENSES. [PART II. Section. Roots of nerves. Cauda equina. g II. M. Organs of Touch. Integument— Organs of Smell. Nares— nerves. Organs of Taste. Tongue and fauces— nerves. 613. Section of cord:—(distinguishing the exact seat and extent of any morbid changes, and whether involving the gray or white matter only, or both)— (particulars as 582).—Distinctness of gray substance; its tint, etc. 614. Roots of nerves:—especially with regard to size of foramina, or pressure upon any of them. — (Other particulars as 626 et seq.). 615. Cauda equina. M.—ORGANS OF THE SENSES. Organs of Touch. 616. Integument :—its condition (397 et seq.). Nerves; their condition (626 et seq.). Organs of Smell. 617. Nares: — their condition (475 et seq.)- Olfactory nerves (578, 626 et seq.). Organs of Taste. 618. Tongue and Fauces:—their condition (422, 426).—Nerves supplying tongue and fauces (glosso- pharyngeal, gustatory, and other branches of the fifth); their condition (626 et seq.). 192 PART II.J ORGANS OF THE SENSES. [§ II. M. Organ of Vision and its Appendages. 619. Eyelids: — " open or closed ? adherent ?" oedema, etc. 620. Eyeball: — prominent; depressed; — eye dull; bright; glistening; — cornea full of flaccid ? arcus senilis present or not ? its width, microscopic characters, etc.;—lymph on iris (644); — size of pupil, medium, contracted, dilated; — "presence or absence of membrana pupillaris?" — Contents of eyeball; condition of several humours. — Lens and its capsule, condition, microscopical characters. — Retina; its condition. — Optic nerve; its size, con- sistence, etc (578, 626.) Organ of Hearing and its Appendages. 621. External ear: — its condition. 622. External meatus:—its diameter; contents; microscopical characters;—condition of lining mem- brane, polypi, etc. — Tympanic membrane: its thickness, colour, form, opacity; — perforation, its size, situation, etc 623. Internal ear (distinguishing the several parts which are the seat of morbid alteration) : — mucous membrane of tympanum and mastoid cells (635 et seq.); contents of tympanum and mastoid cells;— condition of Eustachian tube; its permea- bility ; condition of mucous membrane (685 et seq.). 624. Osseous structures (412). — Connection of morbid alterations with disease of brain or its mem- branes (K. p. 182). 625. Auditory nerve :—its condition (578, 626). Organ of Vision and its Ap- pendages. Eyelids. Eyeball. Organ of Hear- ing and its Appendages. External ear. External mea- tus. tympanic membrane. Internal ear. Osseous struc- tures. Auditory nerve. R 193 § U. N.J NERVE*. [PART II. II. N. Nerve. External cha- racters. Neurilemma. Nerve tissue. N.—NERVES. [Cerebrospinal and Sympathetic—noting the nerve and its branch or the ganglion which is the seat of abnormal appearances. J Nerve. 626. External characters: — size, actually and comparatively with that of opposite side of body; form; flattening; colour; consistence; tumours upon it (672 et seq.); — condition of tissue around altered part of nerve; tumours in the neighbour- hood of and pressing upon nerve, alterations in course of nerve from this or other causes.—Wounds (667); apparent union after wound; appearance of united part; — character of ends of divided nerve, noting size, etc. of each portion. 627. Neurilemma :—colour; vascularity; thick- ness; consistence; opacity; fluids infiltrating;—con- dition of funicular sheaths. 628. Nerve tissue:—colour; consistence; flujds expressible; -— tumours (672 et seq.); their connec- tion with nerve fibres. — Anatomical characters and arrangement of nerve fibres and neurilemma at ex- tremities of divided nerve, or at point of union of a previously divided nerve.—Microscopical characters of nerve substance and neurilemma of any abnormal portion. 194 PART H.J VASCULAR GLAND8. [§ n. O Ganglion. 629. External characters: — size; general con- sistence ; colour; — condition of tissues about it. 630. Sheath of ganglion :—colour; vascularity; opacity; thickness; consistence; fluids infiltrating it. 631. Section of ganglion:—colour; vascularity; consistence; dryness or moisture; fluids expressible. — Microscopical characters; — condition of nerve tubes passing through ganglion. 0. ■VASCULAR GLANDS. 632. Thymus gland: —present or absent ? — its position; height to which it extends; relation to surrounding parts; — size; weight; form; colour externally; general consistence; — condition of tis- sues about it. — Cellular investment; its colour; vascularity; thickness; consistence, etc. — Section of gland; colour of cut surface; its general aspect; vascularity; consistence; fluids exuding or expres- sible ; suppuration ; microscopical characters. 633. Thyroid gland:—size; if enlarged, special seat of enlargement, direction in which it has ex- tended;—form; weight; colour externally; general consistence ; -— condition of surrounding parts, dis- placement, etc— Cellular investment; its colour, vascularity, thickness, consistence, etc.—Section of gland; colour of cut surface; vascularity; matter exuding on pressure; — extravasation of blood, sur- rounded or not by a cyst? condition of blood;— cysts, their, size, number, contents (fluid, solid, or gelatinous matters, blood, etc.); microscopical cha- 195 Gdnglion. External cha- racters. Sheath. Section. \ II. 0. Thymus gland: presence. size, etc. cellular sheath. section. Thyroid gland: size, etc. cellular sheath. section. § ii. o.J VASCULAR GLANDS. [PART racters of any of the above;—other abnormal growths or deposits, fibrous, calcareous, etc. Supra-renal 634. Supra-renal capsules:—their size; weight; sfzTete8- Position; form; colour externally.—Cellular invest- cellular ' ment; its colour, vascularity, thickness, consistence, sheath- etc.— Section of body; condition of cortical sub- section • stance, its diameter, colour, vascularity, consistence; fluids exuding or expressible; — central substance, its size, colour, consistence, etc.;—extravasation of blood; suppuration; abnormal growths and deposits, cancer, tubercle, etc 196 APPENDIX. Mucous Membrane.' 635. Secretions and exudations on surface.— Mucus: quantity generally or at particular spots; colour; consistence; degree of adhesion to mem- brane ; " foreign matters mixed with it, their charac- ters."— Lymph (644). — Blood: fluid or coagu- lated? form of coagulum; quantity; distribution; colour; odour; mixed or not with secretions? etc.— is source of blood discoverable (lens used or not) ? 636. Condition of membrane.— Colour ; noting whether colour observed is general, partial, or in patches or streaks; defined or gradually shading off? mottled; — white, pallid, livid, red (641), yellow, green, grey, black, slate-coloured;—uniform sooty discolouration, its situation;—black, charred aspect; — 6taining, uniformly or dotted with yellow spots. — dyeing, from what apparent cause?—Transpa- rency.—Hasmorrhagic spots: their situation; colour; definition; depth to which they extend; effect of a stream of water upon them.—Surface : dry or moist (noting length of time exposed to air)? — smooth? glistening; dull; rough; mammillated; situation and degree of mammillation; puckered, situation, size, shape, and colour of puckered spots; -— condi- tion of papillae; condition of follicles;—eruption; r2 197 APPENDIX.J SEROUS MEMBRANE. [APPENDIX. vesicles; pustular elevations, their contents and characters.—Epithelium : detached, entirely or par- tially ? no trace of it remaining. — Consistence: length of strips obtainable from different parts (regulated by consistence of membrane or degree of adhesion between mucous and submucous coats ?) ; seat of altered consistence (the most dependent part, etc.); membrane removable by washing, by a stream of water, etc.; — colour, thickness, transparency, and appearance of the vessels at any softened part; — are edges of softened portion well defined? — Thickness: at different parts; relative thickness of normal, softened, and indurated parts.— Ulcers (665).—Sloughs (659 et seq.): situation; extent; colour; depth; consistence, etc.;—colour, etc. of surrounding tissue. — Perforations (666); fistulae (654 et seq.).—Wounds (667 et seq.).—Cicatrices (670).— Tumours; polypi, formed of local hyper- trophy of mucous membrane, of fatty growth, of fibrous tissue, of vascular tissue, etc. (672 et seq.). —Diverticula: number; situation; size; shape;— condition of mucous membrane forming them; — their contents. 637. Submucous tissue :—colour; — ecchymosis; its situation and extent, colour of blood, elevation or not of mucous membrane over its seat? — thick- ness ; consistence; — degree of laxity or. firmness ; — infiltration with serum, pus, etc.; emphysema.— Tumours beneath mucous membrane; tubercular- looking matter (685); cancerous-looking matter (679 et seq.), etc. Serous Membrane. 638. Contents.— Gas: quantity (how estimated ?); position, occupying cavity generally or limited to a 198 APPENDIX.J SEROUS MEMBRANE. [APPENDIX. particular locality ? — apparent source; — odour; chemical characters; — colour of surrounding tex- tures.—Liquid matters: quantity; apparent source; — position, occupying cavity generally, or limited to a particular part ? how circumscribed ? — odour; colour; transparent or opaque? consistence, thick, gelatinous, thin, etc.; serous (642); purulent-look- ing (643); — special characters; mixed with bile, faecal matter, etc. — coagulable or not on removal from body, spontaneously or by use of agents? — containing solid particles; amount and character of deposit after standing;—microscopical characters.— Solid matters: characters; their apparent source; — cysts (675); — foreign bodies, loose or circum- scribed;—gall-stones; phleboliths; worms, etc.— Blood: amount; position; colour; mixed or not with other matters ? coagulated or not, before or after removal from body ? — apparent source. 639. Condition of membrane.—Adhesions (646) : general or partial ? parts between which adhesion is observed.—False membranes : lymph or other exu- dations (644).— Colour: ash, grey, red (641), edges of redness defined or shading off into colour of sur- rounding part, etc.;—vascularity; — size of vessels. —Ecchymoses. — Surface: moist; sticky; dry; — Bmooth; rough, physical characters of inequalities producing roughness;—polished or not ? glistening, bright, pearly; dull; — puckered; situation and ex- tent of puckering; condition of subjacent tissue.— Substance: transparent or opaque ?—thickness; if increased, extent of thickness; appearance of thick- ened part on section;—consistence; — opaque white patches; their size and shape; are there correspond- ing patches on opposed serous surface ?—semi-cartila- ginous patches;—ossific deposit; its thickness, size; consistence; friability; denuded of serous mem- 199 liquid matters. solid matters. blood. Condition of membrane— adhesions. false mem. branes, etc. colour. ecchymoses. surface. substance. APPENDIX.J REDNESS. [APPENDIX. olcers, sloughs, etc. malformations. Sub-serous tissue— colour. consistence. thickness. infiltration, etc. tumours, etc. Redness. Situation— extent. hue. form. fulness of veins effect of gra- vitation. brane at any part, or covered by it at all parts . — tubercles or tuberculous-looking matter (680); — cancerous-looking matter (679 et seq.). — Ulcers (665); sloughs (659 et seq.); ruptures, situation, extent; perforations (666); fistulae (654 el seq.); wounds (667) ; cysts (675) ; cicatrices, 610.—Mal- formations ; their character; — absence of mem- brane; over what extent? apparent cause of ab- sence; condition of edges of membrane where absence commences. 640. Sub-serous tissue: — colour; — consistence^ degree of laxity or firmness; thickness;—infiltration with serum, pus, etc.; — containing blood, extent, character, colour, etc., of effusion; apparent source of blood ; extent to Which it elevates membrane; — emphysema. — Tumours beneath serous membrane; (672 et seq.); — tubercular-looking matter (685); cancerous-looking matter (679 et seq.); cysts (675 et seq.), ossific matter, etc Redness. 641. Situation of redness, especially with refer- ence to the position of the subject.—Extent of red- ness ; — edge defined or gradually shading off into colour of surrounding parts ?—Hue: bright red scar- let, dusky red, violet, brownish red, verging to grey; — if there be two tints, note their relative situation and amount.—Form : uniform, from staining, from juxtaposition of capillaries; punctiform, punctae formed by minute extravasations of blood, by pecu- liar arrangement of injected vessels; capillary; rami- form (large or small ?) — Degree of fulness of veins leading from the red part to be traced back towards the heart. — Effect of gravitation on the redness; 200 APPENDIX.J SEROSITY, ETC. [APPENDIX. effect of washing. — Note condition of blood gene- rally as to fluidity. Serosity. 642. Amount; odour; colour; transparency; specific gravity;—chemical characters (695 et seq.), reaction, presence and quantity of albumen, pre- sence of urea, etc.; its microscopical characters (686 et seq.). Purulent-looking Fluid. 643. Quantity; odour; colour; consistence; effects of liquor potassae on its' consistence; specific gra- vity; reaction.—Presence of curdy or flaky-looking matter; of clots of blood; of sloughy-looking par- ticles. — After standing, deposition of a sediment; amount of sediment; its colour, consistence;—super- natant fluid; its colour, transparency, reaction. — Microscopical characters (686 et seq.). — Chemical characters (695 et seq.). Lymph and other Exudations. 644. Extent and thickness; — colour generally; colour of free surface, of attached surface.—Form: an even layer; villous-looking, length of villi; gra- nular, size of granules. — Distribution : uniformly over the surface; limited to particular spots (e. g., on the peritoneum, to the angles formed by adjacent convolutions of intestines); in patches.—Adhesion to membrane on which it is seated; firmness of ad- hesion ; — condition of membrane after removal of lymph; its colour, polish, cousistence, etc. 645. Substance of lymph or exudation: — its 201 effect of wash- Serosiiy. colour, etc. chemical cha- racters. microscopical characters. Purulent-look- ing Fluid. colour, etc. deposit. microscopical characters. Lymph and other Exuda- tions. colour. form. distribution. adhesion. membrane beneath. substance. APPENDIX.] ADHESIONS.—ABSCESS. ^APPENDIX. microscopical characters. Adhesions. situation, etc. colour, etc. new products in adhesion. Abscess. • Diffused. Circumscribed. form. surface. palpation. condition; elasticity; -^- amount of serosity expres- sible from it; alterations in physical characters pro- duced by expression of the serosity.—Microscopical characters (686 et seq.). Adhesions. 646. Parts between which they are observed. — Number; situation; form ; extent; length; breadth; thickness; colour; transparency; consistence; elas- ticity ; vascularity; arrangement of the vessels; — infiltration with serum.—New products in their sub- stance, tubercle, cretaceous matter, etc—Correspond- ence of adhesions with morbid changes in adherent parts or organs. Abscess. 647. Diffused;'—the exact parts and extent occu- pied by it; the condition of the parts in contact with the pus, as to colour, consistence, etc.; cha- racters of pus (643). 648. Circumscribed:1 — by cyst, condensed cel- lular tissue, integuments, fascia, etc.;—form, ovoid, pyramidal, flat, etc ; — prominence, its degree; — colour of surface; red (bright, or dull), bluish, purple; uniform or more intense at certain points ? circumscribed or diffused ? — if under integuments, shining appearance of surface, cracking or separa- tion of cuticle;—any appearance of pus being seen through the thinned walls ? — Palpation; sensation conveyed to fingers; soft, semi-elastic, boggy, elastic, 1 In living subject, note also heat of surface, pain, ten- derness, etc. 202 APPENDIX.] FISTULA. [APPENDIX. tense; — fluctuation, its degree and extent;—do parietes feci thin or the reverse ? do they feel thin- ner at one part than another? 649. Opening: — natural or artificial;—exact position and direction, with regard to abscess itself (at upper part, centre, most depending part, etc.) aud to the surrounding parts; — length; breadth ; — valvular or not ? — Edges of opening : smooth; uneven; inverted; overhanging the cavity; fixed and adherent or loose ? indurated or the reverse ?— thickness; colour. 650. Walls: —- thickness; consistence; of what tissues composed? — Internal appearance of walls; their colour; — smooth ; irregular; flocculent; gra- nular ;—granulations: size, prominence; firm or flabby ? colour; vascularity; covered with pellicle of lymph, pus, etc. 651. Contents:—(643). 652. Cicatrix: — partially or entirely formed? (670 et seq.). 653. Condition of parts surrounding the abscess : colour; consistence; swelling; puckering, etc. Fistulae. 654. Orifices (on surface of skin, etc.):—one or more ?—size; shape ;—condition of edges as regards smoothness, hardness, colour, etc.;—whether raised into a papilla or depressed ? 655. Fistulous passage or canal:—direction, straight, tortuous, oblique, etc (ascertained by probe or dissection? if by a probe, its size, etc);—exact relation to surrounding parts;—=■ length; diameter at different parts of its course;—sinuses in its walls, — Termination: in cuUde-^sac; in a cavity; an abscess; opening into some ether part or viseu#. ^= 203 Opening— edges. Walls- granulations. Contents. Cicatrix. Surrounding parts. Fistula*. Orifices. Fistulous pas sage— direction. length, etc. termination. APPENDIX.J MORTIFICATION, ETC. [APPENDIX. internal ori- fices. Lining mem- brane. Discharge. Surrounding tissues. Mortification, etc. External cha- racters— colour. swelling, etc. dryness or moisture. state of cuticle. fluid under cuticle. crepitation. Internal orifices : one or more ? — their character, size (654);—if in rectum, the distance of orifice of fistula from anus; precise position of opening (deter- mined by finger introduced into rectum or by dis- section ?) 656. Lining membrane : —its character; colour; vascularity, smoothness, hardness, etc. 657. Discharge:—colour, consistence, odour; puriform (643); aqueous (642), etc.; mixed or not with other substances, as faeces, bile, blood, etc. ?— occurring spontaneously or only on pressure ? does pressure cause discharge when applied to any neigh- bouring part ? 658. Surrounding tissues: — colour, swelling; firmness;—infiltration with pus, serum, urine, etc; — abscess, slough, or gangrene. — If fistula opens on surface of body, is skin near the orifice firmly adherent to subjacent tissue or partially separated from it? Mortification—Gangrene—Sphacelus. 659. External characters : — colour of the part affected; yellowish, ash-coloured, livid, purple, green- ish, brown or black ? intensity of colour; mottled or uniform; — extent of surface, etc., affected;—colour well-defined, diffused, shading off into natural colour of surrounding textures.—Tumefied or not? flaccid, soft, or hard? shrunk or not?—Hygrometric condi- tion ; moister or drier than natural ? feeling greasy. — Skin tense or loose ? — Cuticle detached or not ? shrivelled^ or not? — Fluid effused under cuticle (642); generally, or in bullae ? bullae numerous or solitary ? their size and prominence;—fluid movable or not, by pressure, from one part of the gangrenous surface to another ? — Crepitation on pressure. — 204 APPENDIX.J ULCERS. [APPENDIX. Odour, faint, foetid, garlick-like.—Temperature.'— Pulsation of arteries in part affected.1 660. Line of demarcation from healthy texture; breadth of line; colour, intensity of redness; small vesicles or not on line of demarcation ? width and depth of fissure or chink, if any; etc. 661. Dissection:—depth to which discoloration, etc., extend; affecting skin, cellular tissue, muscles, tendons, bone;—in viscera, is the morbid state limited to surface, single lobules, lobes, etc., or dif- fused ? . . ; 662. Motility and sensibility:'—Power of moving the part retained by patient. — Pain, tenderness, numbness, pricking or stinging sensations; sensa- tion of heat or cold. 663. Marks of injury or of prior applications to the part; redness from pressure;—other sores pre- sent or not ? — infiltration of parts with urine, etc. 664. Surrounding parts : — oedema, etc.; condi- tion of arteries (510 et seq.) and veins (516 et seq.) leading to and from the part. Ulcers. 665. Number; situation; form; superficial extent; depth.—Edges; level with surrounding tissue, be- velled, raised, everted, inverted, undermined, de- tached, ragged ; smooth; — their thickness; — their consistence;—colour, red, slate-coloured, etc.— Floor, its colour; vascularity; — consistence; — covered with a scab; characters of the scab, its de- gree of adhesion to floor and to edges of ulcer, its consistence, thickness, colour, and microscopical cha- racters;— covered by fluid; degree of adhesion of 1 To be noted in living subject. S 205 odour. temperature. arterial pul- sation Line of demar- cation. Dissection. Motility and sensibility. Marks of in- jury. Surrounding parts. Ulcers. form, etc. edges. floor. APPENDIX.] PERFORATIONS.—WOUNDS. [APPENDIX. granulations. Perforations. situation. form, etc. edges. direction. adjacent parts. Wounds. Before dissec- tion— seat, etc, form. fluid, its colour, tenacity, and microscopical ele- ments;— tissue constituting floor of ulcer; — floor smooth, polished, ragged; — covered with granula- tions, their size, colour, consistence, bleeding or not on manipulation ?—open mouths of vessels apparent on floor, artery or vein. Perforations. 666. Number; — situation, anteriorly, posteriorly or at most dependent part of organ ?—shape, circu- lar, oval, slit-like; effect of moderate stretching on shape; — size (in situ and when moderately stretched); — closed or not by contact with adjoin- ing structures, partially or entirely?—edges smooth, ragged, irregular, flocculent; perpendicular, as if punched out, bevelled; consistence, hard, soft, pulpy; colour, pale, greyish, red, etc.; dotted or streaked with sooty points or lines; — mucous coat or subjacent tissues (e. g. peritoneum) most exten- sively destroyed ? — direction taken by perforation, direct, oblique, etc;—alterations (softening, etc.) in parts adjacent or subjacent to perforation, their ex- tent ; — apparent cause of openings on membrane ; their connection with abscesses, aneurism, softened cancerous matter, etc. Wounds. 667. "Facts ascertainable before dissection:1 — Number;—seat (noting not only the tissue or organ, but also the particular part of the structure injured) ; 1 These are points which, in medico-legal inquiries, are to be noted during life, as well as in the examination of a dead body. 206 APPENDIX.J WOUNDS. [APPENDIX. —extent; length; breadth;—shape, e.g., irregular, triangular, rounded, oval, valvular (in which direc- tion ?) ;—measurements before manipulation; depth as estimated by the eye;—direction with reference to the structure or organ in which it is seated, trans- verse, longitudinal, oblique. — Edges of wound; foreign matters adhering to them ; hair, weeds, iron rust, blood, scabs; — blackened by powder; — posi- tion of edges, in apposition, gaping;—tissue consti- tuting them (if apparent) ; — form; cleanly cut, lacerated, jagged; contused; swollen; everted; in- verted; moist or dry ? gangrenous;—colour; pallid, vivid red, purple, black.—Examine angles of wound, to determine direction in which a wound was made, from right to left, from above downwards, or from below upwards.— Contents of wound: foreign matters derived from without, e. g., bullets, portions of clothing, earthy particles, etc.;—blood; its consistence, degree of adhesion; purulent-look- ing fluid, etc. — Condition of parts adjacent to wound; their form, swollen, puckered;—consistence, boggy, indurated;—colour, mottled, purple, yellow, green, etc." 668. " Facts ascertainable by dissection :—Depth of the wound; are skin or deep parts most injured ? which extremity of wound (if incised) is the deeper ? —its direction below surface of wound.—Parts di- vided : relation to each other of the various struc- tures divided, e. g., muscles, cellular tissue, fasciae, etc—Relative position of the divided parts of struc- tures, e. g., divided extremities of muscles and ves- sels more widely separated than the cut surfaces of other structures.—Adhesions, e.g., divided parts united so firmly as to be indistinguishable or insepa- rable the one from the other;—other degrees of ad- hesion. — Foreign matters, e. g., purulent fluid or 207 measurements. direction. angles. contents. parts adjacent. On dissection- depth, etc. parts divided. adhesions. foreign mat- ters. APPENDIX.J CICATRICES. [APPENDIX adja- blood between the various structures; their amount and extent.— Tissues adjacent to wound; their colour, consistence, etc.—containing serosity, lymph, puriform matter.—Extravasation of blood; its ex- tent;— consistence of the blood; — blood collected in a mass; infiltrated into tissues; particular tissues into which it is infiltrated, and their consistence." 669. "If a weapon be discovered, compare it with wound, its sharpness with character of edges of wound (626); —were all wounds found on body apparently inflicted with the same instrument ? — Weapon found in hand of individual; in which ? how held, and with what firmness? — is any blood on hand grasping it or not? — found at a distance, how far and on which side of body ? — Foreign bo- dies found adhering to weapons; blood (determined chemically and microscopically); hair, does it agree in character with hair in neighbourhood of wound, or with hair of wounded person ?—is weapon injured (examine its edge) ? — Mode in which blood is dif- fused over a weapon (in a thin layer generally, on edge only, in drops); are blood-stains nearest to point or handle ?" Cicatrices. 670. On the surface of structures: — their num- ber;— form, linear, oval, irregular, radiated;—defi- nition ; — measurements ; — depressed, depth of de- pression ; smooth ; puckered; — movable or not over subjacent tissue?—colour, compared with adja- cent tissue ; vascularity; — epithelium present or not?—is any hair growing upon it?—Surrounding tissue: smooth; of glistening appearance; puck- ered ;—its consistence, colour, vascularity, etc. 671. In the substance of organs :—their number • 208 APPENDIX.] TUMOURS. [APPENDIX. — definition; — measurements;—continuous or not with the surface of the organ ?—colour, vascularity. — Parenchyma, between the cicatrix and surface, and around the cicatrix; its condition.—Depression on the surface corresponding to cicatrix; its charac- ters. — Cavities in its substance, their size, walls, contents; — cretaceous matter imbedded in cicatrix, its abundance, situation, consistence, adhesion. — Relations of cicatrix to the trunks of tubes and vessels permeating the organ. Tumours. 672. Number; size; position; — relation to sur- rounding organs; — connection with surrounding organs, sessile, pedunculated, adherent (605). — Weight. 673. Superficial characters : — surface uniform ; polished; rough, physical cause of roughness; gra- nulated, size of granules; nodulated, size of nodules; furrowed, extent and depth of furrows; — colour generally; colour of particular parts, e. g., of fur- rows, nodules, etc ; transparency; — blood-vessels on surface, their size and fulness. — Elasticity, flac- cidity, fragility.—Apertures leading to the interior; their size, number, situation; condition of their edges; substances expressible from them. 674. Characters on section or fracture:—odour; consistence; flaccidity, fragility, elasticity;—specific gravity of portions of tumour.—Fractured surface; smooth; granular; fibrous.— Cut surface; smooth; granular; fibrous, arrangement of fibres; loculated, number, size, situation, and contents of loculi. — Substances expressible; substances removable by scraping ; — their consistence, colour, transparency, and microscopical character. — Colour of section : s2 209 definition, etc. colour. parenchyma about it. surface corre- sponding. cavities, etc. relations to vessels, etc. Tumours. Number, size, etc. Superficial characters- smoothness, etc. granulation, etc. colour elasticity, etc. apertures. Characters on section— consistence. fractured sur- face. cut surface. substances expressible. colour. APPENDIX.J CYSTS. [APPENDIX. microscopical characters. Number, size, etc. transparency. — Blood-vessels; their size; arrange- ment; relative proportion of arteries, veins, and ca- pillaries ; their origin; mode of termination. — Mi- croscopical characters. — (If different parts of a tumour vary in consistence, colour, or transparency, the above facts should be noted with reference to each part of the mass.) Cysts. 675. Number; situation; size; form;—relative position in regard of each other; connection with each other and with adjacent parts; — relation of cysts to the blood-vessels and ducts of the organ in which they are seated. 676. Walls of cyst:—structure; thickness; con- sistence ; transparency; colour; vascularity; lami- nated ? covered with lymph; —epithelium apparent or not on inner surface ? sebaceous or hair follicles present or not?—microscopical characters. 677. Contents of cyst:—fluid, its quality; coag- ulated or not? spontaneously or by agents? — solid matter, its size;—odour; consistence; transparency; colour; vascularity; fracture;—mode of attachment to the walls; — sparkling crystalline plates; chole- sterine; — microscopical characters; chemical cha- racters. — Hair in cyst: its quantity; length; con- sistence; colour; condition of extremities,, pointed, bulbous, truncated, etc.; — free; aggregated in masses, their number, size, form, cut surface; — attached to wall of cyst; portion of hair attached; part to which hair is attached; its mode of attach- ment ; character of the wall at the point of attach- ment.— Teeth in cyst: their number; characters;— free; — attached to walls of cyst, mode of attach- ment;— attached to bone, mode of attachment; if 210 APPENDIX.] CANCER. [APPENDIX. several, their arrangement in respect to eaGh other; characters of the bone; presence of alveoli.—Bones in cyst: their number; size; form; — mode of at- tachment to cyst, to each other;—microscopical cha- racters.—Fat in cyst: amount, consistence, colour, transparency. 678. Secondary cysts: — their number; size; form; — connection to containing cyst; relation of contained cysts to each other; — walls and contents (particulars as above). Cancer or Cancerous-looking Matter. 679. External characters:—size; shape; form; — precise situation in relation to affected tissues; — mode of connection with tissues; infiltration at edges of tumour with cancer or ordinary exudation matter (determined by microscope, 686 et seq.); — capable of being enucleated;—surrounded by a cyst (true or pseudo-cyst?); does it send processes in- wards into cancerous mass ?—Surface; even, knotty, tuberous, granulated, etc.; —colour; odour;—con- sistence, resembling that of any tissue or known object ? elasticity ; — are consistence and elasticity equal in all parts ? 680. Characters on section : — General resem- blance to any known object;—colour; consistence; —colour and consistence uniform or not?—lobulated aspect of masses or not?—Arrangement, locular or not ? characters of loculi, their size, shape, general uniformity (or the contrary), degree of distinctness; — general comparison of locular and intra-locular substances; — fineness or coarseness of locular tex- ture ; — intra-locular separable or not from locular substance ? with what ease ? — Vascularity; its de- gree, colour, closeness, uniformity;—connection with 211 bones. Secondary cysts. Cancer, etc. External cha- racters— shape. connection with tissues. cyst. surface. consistence. colour, etc. Characters on section— loculi. vascularity. APPENDIX.J TUBERCLE. [APPENDIX. other matters. Characters on fracture. Effects of pres- sure. Chemical cha- racters. Microscopical characters. Tubercle, etc. Situation, size, etc.— colour. consistence, etc. vascularity. microscopical characters. surrounding tissues. capability of removal. surrounding vessels apparent or not ? — results of injection; veins, arteries. — Matters observed on section different from cancer; melanic matter, pus, tubercle, fat, pseudo-tissues, etc. 681. Characters on fracture : — is fracture per- mitted ? its degree of sharpness. 682. Effects of pressure: —on form and consist- ence of matter;—fluids expressible; by what degree of force ? quantity; characters to naked eye, to mi- croscope (645 et seq.). 683. Chemical characters: — effects of boiling. 684. Microscopical characters (686 et seq.): — nuclei; proportion to perfect cells, their form; pro- portion of size of nucleus to cell (estimated by the eye or by the micrometer);—evidence of changes in cells, diffluence, fatty change, thickening, de- siccation. Tubercle or Tubercular-like Bodies. 685. Situation; number; relative position;—size; form, spherical, pyriform; — colour, yellow, grey, white (if of more than one colour, note relative po- sition of the two); transparency or opacity.— Con- sistence ; generally, of centre, of circumference; pre- senting cavity in centre ? fluids expressible; — cha- racter of cut surface.—Vascularity; relation of ves- sels to the tubercular-like matter, to adjacent tissues. —Microscopical characters (686 et seq.).—Condition of tissue surrounding tubercle as to colour, thickness, consistence, etc. — Situated on a membrane; is it capable of removal without injury to membrane ? appearance of surface after its removal; — insepara- bly united with membrane. 212 APPENDIX.J MICROSCOPICAL CHARACTERS. [APPENDIX. Microscopical Characters. 686. Granules :' — number; — aggregation, size and other characters of aggregation. — Effect of re- agents, water, acetic acid, hydrochloric acid, ether, and liquor potassae;—granules unaffected by them; dissolved without effervescence; dissolved with es- cape of gas; rendered more distinct; rendered in- distinct. 687. Globules:2 — number, size, colour; aggre- gation, size and other characters of aggregation.— Effect of re-agents. 688. Fibres:—their definition; size; arrange- ment, parallel or interlacing? form, straight, wavy, curled; colour;—presence of nuclei; their number, size, form, definition.—Effect of re-agents, water, acetic acid, hydochloric acid, ether; —■ fibres unaf- fected; dissolved; rendered more distinct; rendered indistinct; caused to swell up;—effect of the same re-agents on the nuclei; nuclei unaffected; rendered more distinctj rendered less distinct; nuclei not pre- viously seen brought into view. 689. Cells: — their definition; size; form; elas- ticity; consistence; colour.-—Cell-wall; transparent; granular; hyaline; plicated.— Contents of cell; granules, their number, size, colour, and molecular movement.—Nucleus-: number of nuclei; shape; size; definition; — if several, their situation with reference to each other and to the cell-wall. — Nu- cleolus ; number of nucleoli; size; form; character 1 Granules appear opaque dots under high magnifying powers. 1 Globules—spherical bodies, with dark well-defined outline, and transparent centre. 213 Microscopical Characters. Granules— number, size, etc. effect of re- agents. Globules; Fibres— definition. size, etc. nuclei. effect of re- agents. Cells- definition. size, etc. consistence. cell-walls. contents. nucleus. nucleolus. APPENDIX.J CHEMICAL EXAMINATION OF URINE. [APPENDIX. effect of re- agents. Crystalline or amorphous saline bodies. Chemical Exa- mination of Urine. Reaction— specific gravity. colour. Organic con- stituents— urea. of outline; colour.—Effect of re-agents, water, acetic acid, ether, liquor potassae, solution of iodine, on cell-wall, granular contents and nucleus separately; —unaffected ; enlarged; contracted ; rendered more transparent; rendered less transparent; dissolved ; rendered more distinct; rendered less distinct. 690. Crystalline or amorphous saline bodies: — their precise characters; effects of re-agents upon them. Chemical Examination of Urine.* 691. Reaction (221).—Specific gravity (221).— Solid matter: — per centage of solid matter; what precautions used in drying, and the manner in which the evaporation was conducted?— Colour (221) :— depth of; amount of; how determined ? — Change produced by the action of air.—Play of colours pro- duced upon the addition of a few drops of nitric acid to the urine spread out upon a white plate.—Colour- ing matter of the bile: whether associated or not with biliary acids, as proved by the production of a deep violet tint upon the addition of one drop of syrup to a small quantity of the urine in a test tube, and the subsequent addition by drops of two-thirds of its bulk of strong sulphuric acid, and the appli- cation of a moderate heat, if necessary (Pettenko- fer's test). 692. Organic constituents destroyed by a red heat:—Urea—Upon the addition of an equal quan- 1 In this and future sections, it has been thought useful by the Society in some measure to depart from the spirit of " What to Observe," by reminding the clinical observer of a few of the most practical methods of detecting some of the most important substances. 214 APPENDIX.J EXAMINATION OF URINE. [APPENDIX. tity of nitric acid to the urine, a crystalline precipi- tate of nitrate of urea (relative excess of urea); — absolute quantity of urea excreted in a given time (24 hours); how estimated, as urea, as nitrate, by Liebig's or any other method? — Relative propor- tion of urea to other constituents of the urine, i. e., the per centage of urea in the solid matter, and es- pecially the relation which the quantity of the urea bears to that of the sulphates. — Creatine, creati- nine.—Formation of crystalline tufts when the con- centrated alcoholic solution is mixed with a syrupy solution of chloride of zinc and allowed to stand for some time. This compound must be afterwards subjected to careful examination. — Fatty matter: — quantity; how determined? quantity excreted at different periods of the day. — Condition in which present in the urine, in free globules, in globules enclosed in cells or casts, or in a state of very minute division (molecular state) (221).— Uric or lithic acid.—Upon the addition of a small quantity of acetic or nitric acid to the urine, after standing for twenty-four hours, a crystalline precipitate (uric acid crystals). Absolute and relative amount of; how estimated ?—Note whether purified or weighed with colouring matter. — Hippuric acid: — a precipitate upon the addition of hydrochloric acid to the mother liquor obtained by concentrating the urine and re- moving salts, which by subsequent purification and crystallization from a watery or alcoholic solution yields crystals of hippuric acid. Quantity present; how determined? — When this acid has been de- tected, the urine should always be carefully tested for the presence of sugar. — Lactic acid— lactates. — Oxalic acid:—Quantity, how determined ? period at which the examination was made.—Albumen:— An amorphous precipitate upon the addition of nitric 215 APPENDIX.J EXAMINATION OF URINE. [APPENDIX. sugar. Inorganic con- stituents— chloride of sodium. Inorganic acids —carbonic. Bulphuric. phosphoric. Inorganic bases—soda. potash. magnesia. acid, or upon the application of heat (albumen). If the urine have an alkaline reaction, it should be acidified by the addition of a few drops of acetio acid, before heat is applied.—Quantity of albumen ; how estimated ? — Quantity passed at different periods of the day, before and after meals, etc.— Sugar: — a dark sherry-red colour produced upon boiling the urine with half its bulk of potash (Moore's test), the solution becoming clear upon the addition of excess of nitric acid with the evolution of the odour of melassic acid; — or a pale reddish brown precipitate (suboxide of copper) if the urine be heated to the boiling point with potash and a drop or two of a solution of sulphate of copper (Trommer's test). 693. Inorganic constituents of the urine.— Chlo- ride of sodium:—a precipitate of chloride of silver, soluble in ammonia, and insoluble in nitric acid, produced upon the addition of nitrate of silver: quantity present. — Combined inorganic acids: — Carbonic acid: effervescence produced upon treat- ing the saline residue of the urine with a strong acid: amount of. — Sulphuric acid: a precipitate of sulphate of baryta, insoluble in strong acids and alkalies produced Upon the addition of chloride of barium : quantity of.—Phosphoric acid: a precipi- tate of phosphate of baryta, produced by adding excess of ammonia to the solution filtered from the precipitate of sulphate of baryta (phosphate of baryta is soluble in acids, but insoluble in alkalies)— quantity of.— Combined inorganic bases: — Soda : — quantity, how determined ? — Potash: a precipi- tate of potassio-chloride of platinum, produced by the addition of bichloride of platinum to an aqueous solution of the salts.—Magnesia: a crystalline pre- cipitate of ammoniaco-magnesian phosphate, pro- 216 APPENDIX.J URINARY DEPOSITS. [APPENDIX. duced upon the addition of ammonia and phosphate of soda to an aqueous solution of the salts.—Lime: an amorphous precipitate of oxalate of lime, inso- luble in alkalies and in acetic acid, but soluble in the mineral acids; produced upon the addition of oxalate of ammonia to an aqueous solution of the salts previously acidulated with acetic acid.—Am- monia: production of vapour upon treating the fresh urine with solution of potash.—Ammoniacal vapours may be recognised by their odour and by the production of dense white fumes of muriate of ammonia when a glass rod which has been dipped in hydrochloric acid is brought towards them. Cliemical Examination of Urinary Deposits. [Always note whether the deposit was present in the urine when passed, or if it occurred subse- quently, and at what period of time. In the latter case any alteration in the reaction of the urine should be carefully noticed; and it is im- portant to observe if the appearance of the de- posit is accompanied with the development of fungi.J 694. Deposit dissolved upon the application of a gentle heat, and also upon the addition of an alkali (lithates). — Deposit dissolved, forming an almost clear solution upon the application of heat; — ren- dered of a deep blue colour upon the addition of a solution of free iodine (starch of extraneous origin.) — Deposit not dissolved upon the application of heat; but readily soluble in solution of potash (lithic acid);—soluble in ammonia; the solution, upon evaporation, yielding six-sided crystals (cys- tine). — Deposit yielding a clear, glairy, and very T 217 lime. Chemical Exa- mination of Urinary De ■ Lithates. Starch. Lithic acid. Cystine. APPENDIX.] MORBID FLUIDS. [APPENDIX. Pus. Phosphate of lime. hosphate of lime and mag- nesia. Carbonate of lime. Oxalate of lime. Sand. Chemical and Microscopical Examination of Morbid Fluids. Reaction, etc. viscid, tenacious mass, upon the addition of solution of potash (pus). — Deposit insoluble in alkalies, soluble in weak acids, as acetic acid; — forming an amorphous deposit upon the addition of excess of ammonia to the acid solution (phosphate of lime); forming a crystalline deposit (phosphate of ammonia and magnesia).—Deposit soluble in weak acids with effervescence (carbonate of lime).1 — Deposit in- soluble in alkalies, and unaffected by acetic acid, but soluble in the strong mineral acids (oxalate of lime).—Deposit insoluble in the strongest acids and alkalies (sand, of extraneous origin).—( With refer- ence to the nature of the deposit, see also " Micros- copical characters," p. 89.). Chemical and Microscopical Examination of Morbid Fluids.2 695. Reaction; specific gravity; odour; viscidity; clear or turbid ?—Presence or absence of deposit.3 1 Effervescence may take place in consequence of the action of the acid upon carbonate of ammonia in solution in the urine, and care must be taken to distinguish this from effervescence produced by the action of the acid upon the deposit. B In this and the following section, only a few of the most important constituents are alluded to. The reader is, therefore, referred to works devoted to this subject. 3 In order to obtain the deposit suspended in a fluid for microscopical examination, the latter should be allowed to stand for some time in a conical glass vessel. When the deposit has subsided, a small quantity may be re- moved with a pipette, placed upon a glass slide or in a glass cell, covered with thin glass, and examined in the usual manner. The deposit should always be examined soon after the fluid in which it was suspended has been 218 APPENDIX.J MORBID FLUIDS. [APPENDIX. 696. Examination of the deposit from a fluid Examination by the microscope, and with the aid of chemical deposit. tests : — granules; globules; fibres; cells (686 et seq.).—Claws of echinococci; crystals of colouring matter of the blood or haematin. — Deposit soluble in alcohol or ether (fatty acids, cholesterine).—De- posit soluble in mineral acids (phosphate of lime, oxalate of lime, arnmoniaco-magnesian phosphate, with effervescence, carbonate of lime). — Deposit soluble in alkalies (lithic acid, lithates, epithelium, pus, etc.). — Deposit insoluble in alkalies (oxalate of lime, carbonates and phosphates of lime and magnesia, silica, etc.). 697. Examination of the fluid after subsidence Examination of the deposit:—Reaction; specific gravity; clear- ° U1 ' ness or turbidity; colour. — Proportion of solid matter; — amount of organic matter destroyed by a red heat; amount of inorganic salts fixed at a red heat. — Fluid coagulating spontaneously (fibrin); fluid giving a precipitate upon the application of heat, after adding a few drops of acetic acid, or upon the addition of nitric acid (albumen).—Pre- cipitate produced by alcohol soluble in water at a temperature of 95° (par-albumen); — not pre- cipitated by acetic acid and ferrocyanide of potas- sium; no distinct precipitate by boiling aqueous solution, after adding a few drops of acetic acid (met-albumen).—Fluid upon evaporation becoming covered with a membranous scum, precipitated by acetic acid and by the addition of chloride of cal- cium and subsequent boiling ; and by rennet (casein); —fluid upon spontaneous evaporation between slips removed from the body, and also at a later period, and any change in its microscopical characters should be care- fully noted. 219 APPENDIX.J SOLID TEXTURES. [APPENDIX Chemical Exa- mination of Solid Textures. Specific gra- vity, etc. Organic con- stituents. of glass, after the addition of a drop of water, alcohol, or ether, yielding red or almost colourless crystals (haematih);—fluid of a glutinous consist- ence, and yielding a precipitate upon the addition of acetic acid, insoluble in excess (pyin, mucine from mucus), a precipitate upon neutralizing the acid or alkaline solution (globulin) ; — fluid origin- ally turbid, but becoming clear upon being shaken with ether, either with or without the previous addition of a few drops of potash or soda. — (Fatty matter in a minute state of division, or in globules, each being covered with a delicate investing mem- brane.)— Bile pigment and biliary matter, urea, sugar, lithic acid, hippuric acid, lactic acid, creatin, creatinine, extractive matters; sulphuric acid, phos- phoric acid, chloride of sodium, lime, magnesia, ammonia. Chemical Examination of Solid Textures. 698. Specific gravity, how determined?—water, solid matter, amount of?—precautions used in de- siccation ;—organic constituents, carbonized by a red heat;—inorganic constituents, remaining after expo- sure to a red heat; proportion of. 699. Organic constituents: — exhaling ammo- niacal fumes when boiled with potash (nitrogenized matter); — burning with a yellow, smoky flame (fatty matter); — forming a white coagulum upon the addition of nitric acid, or upon the application of heat (albumen); upon being boiled with water for some time, yielding a solution which solidifies upon cooling, and giving a precipitate with a solution of tannin (gelatine);—dissolved in boiling water (ex- tractive matters, alkaline salts, etc.);—dissolved by alcohol (extractive matters, urea, creatine, etc.);— 220 APPENDIX.J SOLID TEXTURES. [APPENDIX. dissolved by potash, and giving a black precipitate when boiled in an alkaline solution of oxide of lead, in consequence of the formation of sulphuret of lead (albuminous matter). — General characters: — dis- solved by boiling water only, urates, alkaline salts, gelatine chondrin, etc.;—dissolved by boiling water and alcohol, urea, creatin, hippuric acid, lactic acid, extractives, etc.; — dissolved by alcohol only, alco- holic extract, cholesterine, seroline, fatty acids, fatty matters, etc.;—dissolved by ether, fatty matter, etc.; —dissolved by potash, albuminous textures, uric acid, urates, etc.;—dissolved by acetic acid, globu- lin (with effervescence, carbonate), phosphates of lime, and of ammonia and magnesia; rendered trans- parent and slimy by acetic acid (white fibrous tis- sue); not dissolved by acetic acid, yellow fibrous tis- sue, pyin ;—insoluble in alkalies and in acetic acid, yellow elastic tissue, oxalate of lime, etc.;—insolu- ble in strong mineral acids and alkalies, carbona- ceous matter, silica. 700. Inorganic constituents (693). THE END. T2 221 Inorganic con- stituents. - THE LONDON MEDICAL SOCIETY OF OBSERVATION. MEMBERS. 33resfuent. DATE OP ADMISSION. W. H. Walshe, M.D. Professor of the Principles and Prac- tice of Medicine in University College................... 1850 Secretary. T. Snow Beck, M.D., F.R.S., Physician to the Samaritan Free Hospital............................................... 1850 ©tufitarj JWemoets. W. Jenner, M.D., Professor of Pathological Anatomy in University College.......................:.................. 1850 E. A. Parkes, M.D., Professor of Clinicial Medicine in University College.......................................... 1850 C. J. Hare, M.D., Assistant Physician to University Col- lege Hospital................................................. 1850 S. W. J. Merriman, M.D., Physician to the Royal In- firmary for Children........................................ 1850 R. H. Semple, M.D., Physician to the Islington Parochial Infirmary..................................................... 1850 A. P. Stewart, M.D., Assistant, Physician to Middlesex Hospital....................................................... 1850 F. Sibson, M.D., F.R.S., Physician to St. Mary's Hospital, 1850 W. H. O. Sankey, M.D., Resident Medical Officer to the London Fever Hospital.................................... 1851 223 LONDON MEDICAL SOCIETY OF OBSERVATION. ( DATE OJ ADMISSION. E. Ballard, M.D., Physician to the Farringdon General Dispensary................................................... 1851 S. Morris, Esq., Peckham House Asylum................... 1851 H. Weber, M.D., Physician to the German Hospital...... 1851 Lionel Beale, M.B., Professor of Physiology in King's College........................................................ 1852 Henry Briggs, M.B............................................ 1852 William Squire, Esq., late Resident Medical Officer to the Marylebone Infirmary.................................. 1852 J. Russel Reynolds, M.D.................................... 1853 Septimus Gibbon, A.B. and M.B., Assistant Physician to the London Hospital........................................ 1853 T. Armitage, M.D., Physician to the Marylebone Dis- pensary........................................................ 1853 C. B. Radcliffe, M.D., Assistant Physician to Westmin- ster Hospital................................................. 1853 W. M. Graily Hewitt, M.B................................. 1853 S. J. Goodfellow, M.D., Assistant Physician to Middle- sex Hospital........................,......................... 1853 William Ogle, M.D............................................ 1854 Wilson Fox, Esq................................................ 1854 D. Conway Evans, Esq........................................ 1854 Thomas Hillier, Esq., Resident Medical Officer, Univer- sity College Hospital........................................ 1854 J. S. B. Sanderson, M.D,, Medical Registrar at St. Mary's Hospital...................................................... 1854 ffiorresjxwofnfl Members. W. Beneke, M.D., late Resident Physician to the German Hospital....................................................... 1850 W. T. Gairdner, M.D., Pathologist to the Royal Infir- mary, Edinburgh...................................,t....... 1850 R. Neale, M.B., Fazeley....................................... 1850 T. E. Leudet, M.D., late Vice-President of the Medical Society of Observation, Paris.............................. 1851 W. H. Ransom, M.D., Nottingham............................ 1853 224 LONDON MEDICAL SOCIETY OF OBSERVATION. LAWS The objects of the Society are to promote the advancement of accurate Pathology and Therapeu- tics, by clinical and allied investigations, the value of which shall be estimated by the numerical method; and to exhibit the special advantages which may accrue to the science of medicine, by the co- operation of several persons working on a uniform plan towards the elucidation of given medical ques- tions. II. The Society shall consist of a president, secretary, ordinary and corresponding members. The number of ordinary members shall be limited to thirty. Candidates for admission into the Society shall be proposed by two members, and ballotted for at the first subsequent meeting. One black ball in five to exclude the candidate. ill. The Society shall pursue its objects by the follow- ing means:— (1.) By the collection of records of cases observed by the members, the particulars in every instance (whether observed at the bedside or after death) to be noted in writing at the moment of observation,— fulness of detail to be constantly held in view as deeply important, but accuracy alone to be considered absolutely necessary. 225 Objects. Constitution. Means. LONDON MEDICAL SOCIETY OF OBSERVATION. Rules of pub- lication. (2.) By the accumulation of observations of spe- cial phenomena of disease, and the relations subsist- ing between them, with the view of ascertaining their regulating laws,—it being understood that the sub- ject and the plan of observation shall, in each in-t stance, be sanctioned by the Society. It shall be competent for the Society to request the particular attention of members to certain special classes of disease. Any member proposing a subject for investigation, shall submit it, and the plan of observation, to the Society; and should they be adopted, the proposer shall furnish each member with a copy of the plan drawn out in a tabular form. In order to facilitate their arrangement and analysis, the Society can accept from its members the records of such cases only, as shall have been legibly written out on the right-hand side of Bath post paper, and the particulars of which have been arranged in the order, or according to the form, adopted by the Society. Each ordinary member shall be expected to read the records of two cases, and to give ten answers to questions for the special phenomena of disease during the period of each year; and in the event of any member failing to read one case, and to give five answers to questions, he shall cease to be a member of the Society,—unless some satisfactory reason for his failure be assigned. The records of cases, etc, shall be kept in the custody of the Secretary, to be put to any use the * Society may determine. rv. The Society shall, as often as may be deemed fit, publish the results of its labours, under the title of 226 LONDON MEDICAL SOCIETY OF OBSERVATION. " Transactions of the London Medical Society of Observation." The Transactions to consist of:— (1.) Analyses of the records of cases (and, when deemed desirable, the cases themselves), from the collection in the possession of the Society. (2.) Analyses of the observations of special phe- nomena of disease. (3.) Analytical papers by ordinary or correspond- ing members, founded on observations and inquiries, conducted in accordance with the principles recog- nised by the Society. The Society shall be responsible for the analyses, the individual observers for the accuracy of the facts. The analyses of the collections of records of cases, and of special observations, shall be made by one or more members, to be appointed for that purpose by the Society. The names of the contributors of the records of cases, etc., and of their analysers, shall be severally prefixed to any paper published in the Transactions. The Society shall appoint a Committee to report upon the papers prepared for publication; but it shall rest with the Society to order their insertion in the Transactions. v. The Society shall meet on the first and third Wednesday of each month, at eight P. M., and ad- journ at ten o'clock, unless the President shall con- sider it desirable to prolong the meeting. The place of meeting to be at'the houses of the ordinary members, in rotation. Each member may introduce one visitor to the ordinary meetings of the Society. Meetings 227 LONDON MEDICAL SOCIETY OF OBSERVATION. VI. Ordinary busi- The ordinary business of the Society shall consist ness. ».__ (1.) The reading aloud of the observations upon special phenomena of disease. (2.) The reading aloud of the records of a case or cases. (3.) It shall be competent for each member (or visitor) to address to the author of these cases, etc., queries, having for their object the elucidation of facts obscurely or insufficiently described,—it being understood that all questions are put with the direct sanction of the President. Discussions on general subjects shall be avoided, and may be repressed by the President. VII. Alteration of AH resolutions affecting the laws of the Society, shall be proposed at one meeting, and considered at the first subsequent meeting of the Society. No alteration of, nor addition to, the laws shall be made, except at a special meeting convened for the purpose. 228 CATALOGUE OF MEDICAL, SURGICAL, AND SCIENTIFIC WORKS, PUBLISHED BY BLANCHARD & LEA, PHILADELPHIA. AMERICAN JOURNAL OF THE MEDICAL SCIENCES. —Edited by Isaac Hats, M.D. Published Quarterly, each number containing about 300 large octavo pages. Price, $5 per annum. When paid for in advance, it is sent free by post, and the " Medical News and Library," a monthly of 32 large 8vo. pages, is furnished gratis. Price of the " Medical News," separate, $1 per annum, in advance. ABEL (F.A.), F.C.S., and C. L. BLOXAM. — Handbook of Chemistry, Theoretical, Practical, and Technical, with a Recommendatory Preface by Dr. Hofmann. In one large octavo volume of 662 pages, with illustrations. (Now Ready.) ASHWELL (SAMUEL), M. D.—A Practical Treatise on the Diseases Peculiar to Women. Illustrated by Cases derived from Hospital and Private Practice. With additions by Paul Beck Goddard, M J). Second American edition. In one octavo volume of 520 pages. ARNOTT (NEILL), M.D.—Eijements of Physics; or, Natural Philosophy, General and Me- dical. Written for universal use, in plain or non-technical language. A new edition, by Isaac Hays, M.D. Complete in one octavo volume, of 484 pages, with about two hundred illustrations. BENNETT (J. HUGHES), M.D.—The Pathology and Treatment of Pulmonary Tubercu- xosis, and on the Local Medication of Pharyngeal and Laryngeal Diseases, frequently mis- taken for, or associated with, Phthisis. In one handsome octavo volume, with beautiful wood-cuts. (Now Ready.) BENNETT (HENRY), MJ).—A Practical Treatise on Inflammation of the Uterus, its Cervix and Appendages, and on its Connection with Uterine Disease. Fourth American, from the third and revised London edition. In one neat octavo volume, of 430 pages, with wood-cuts. (Now Ready.) BEALE (LIONEL JOHN), M.R.C.S.—The Laws of Health in Relation to Mind and Body. A Series of Letters from an old Practitioner to a Patient. In one handsome volume, royal 12mo., extra cloth. BILLING (ARCHIBALD), M.D.—The Principles of Medicine. Second American, from the Fifth and Improved London edition. In one handsome octavo volume, extra cloth, 250 pages. BLAKISTON (PEYTON), M.D.—Practical Observations on Certain Diseases of the Chest, and on tho Principles of Auscultation. In one volume, 8vo., 384 pages. (1) 2 BLANCHARD & LEA'S MEDICAL PUBLICATIONS. BURROWS (GEORGE), M.D. —On Disorders of the Cerebral Circulation, and on the Con- nection between the Affections of the Brain and Diseases of the Heart. In one 8vo. vol., with colored plates, pp. 216. x BUDD (GEORGE), M.D.—On Diseases of the Liver. Second American, from the second and enlarged London edition. In one very handsome octavo volume, with four beautifully- colored plates, and numerous wood-cuts. 4t>8 pages. New edition. (Just Issued.) f BUCKLER (T. H.). M.D. — On the Etiology, Pathology, and Treatment of Fibbo-Bronchitis and Rheumatic Pneumonia. In one handsome octavo volume, extra cloth. (Now Ready.) BUSHNAN (J. S.), M.D.— Principles of Animal and Vegetable Physiology. A Popular Treatise on the Functions and Phenomena of Organic Life. In one handsome royal 12mo. volume, extra cloth, with numerous illustrations. (Now Ready.) BLOOD AND URINE (MANUALS ON). —By John William Griffith, G. Owen Reese, and Alfred Markwick. One thick volume, royal 12mo., extra cloth, with plates. 460 pages. BRODIE (SIR BENJAMIN C), M. D., Clinical Lectures on Surgery. One vol., 8mo., cloth. 350 pages. BRODIE (SIR BENJAMIN C), M. D. — Select Surgical Works, 1 vol. 8vo. leather, con- taining Clinical Lectures on Surgery, Diseases of the Joints, and Diseases of the Urinary Organs. BIRD (GOLDING), M. D. — Urinary Deposits : their Diagnosis, Pathology, and Thera- peutical Indications. A new and enlarged American, from the last improved London edition. With over sixty illustrations. In one royal 12mo. volume, extra cloth. (Now Ready.) BIRD (GOLDING), M. D.—Elements of Natural Philosophy; being an Experimental Intro- duction to the Physical Sciences. Illustrated with nearly four hundred wood-cuts. From the third London edition. In one neat volume, royal 12mo. 402 pages. BARTLETT (ELISHA) M. D.—The History, Diagnosis, and Treatment of the Fevers of the United States. Third edition, revised and improved. In one octavo volume, of six hun- dred pages, beautifully printed, and strongly bound. BOWMAN (JOHN E.), M.D. — Practical Handbook of Medical Chemistry. In one neat volume, royal 12mo., with numerous illustrations. 288 pages. BOWMAN (JOHN E.), M. D. — Introduction to Practical Chemistry, including Analysis. With numerous illustrations. In one neat volume, royal 12mo. 350 pages. BARLOW (GEORGE II.), M.D. — A Manual of the Principles and Practice op Medicine. In one octavo volume. (Prtparing.) COLOMBAT DE L'ISERE.—A Treatise on the Diseases of Females, and on the Special Hygiene of their Sex. Translated, with many Notes and Additions, by C D. Meigs, M. D. Second edition, revised and improved. In one large volume, octavo, with numerous wood- cuts. 720 pages. COPLAND (JAMES), M. D.—Of the Causes, Nature, and Treatment of Palsy and Apoplexy, and of the Forms, Seats, Complications, and Morbid Relations of Paralytic and Apoplectic Diseases. In one volume, royal 12mo., extra cloth. 32G pages. BLANCHARD & LEA'S MEDICAL PUBLICATIONS. 3 CLYMER (MEREDITH), M. D., Ac.—Fevers; their Diagnosis, Pathology, and Treatment. Preparod,and Edited, with large Additions, from the Essays on Fever in Tweedie's Library of Practical Medicine. In one octavo volume, of 600 pages. CARSON (JOSEPH), M. D. — Synopsis of the Course of Lectures on Materia Medica and Pharmacy, delivered in the University of Pennsylvania. In one very neat octavo volume, of 208 pages. CARPENTER (WILLIAM B.), M.D. — Principles of Human Physiology; with their chief applications to Psychology, Pathology, Therapeutics, Hygiene, and Forensic Medicine. Fifth American, from the fourth and enlarged London edition. With three hundred and fourteen illustrations. Edited, with additions, by Francis Gurney Smith, M. D., Professor of the Institutes of Medicine in the Pennsylvania Medical College, &c- In one very large and beautiful octsvo volume, of about 1100 large pages, handsomely printed, and strongly bound in leather, with raised bands. New edition. (Lately Issutd.) CARPENTER (WILLIAM B.), M.D. — Principles of Comparative Physiology. New Ame- rican, from the fourth and revised London edition. In one large and handsome octavo volume, with over three hundred beautiful illustrations. (Now Ready.) CARPENTER (WILLIAM B.), M. D.—The Microscope and its Revelations. In one hand- some volume, beautifully illustrated with plates and wood-cuts. (Preparing.) CARPENTER (WILLTAM B.), M. D. — Elements (or Manual) of Physiology, including Physiological Anatomy. Second American, from a new and revised London edition. With one hundred and ninety illustrations. In one very handsome octavo volume. CARPENTER (WILLIAM B.), M.D.— A Prize Essay on the Use of Alcoholic Liquors in Health and Disease. New edition, with a Preface by D. F. Condie, M. D., and explanations of scientific words. In one neat 12mo. volume. (Now Ready.) CHRISTISON (ROBERT), M.D. — A Dispensatory; or, Commentary on the Pharmacopoeias of Great Britain and the United States; comprising the Natural History, Description, Chemistry, Pharmacy. Actions, Uses, and Doses of the Articles of the Materia Medica. Second edition, revised and improved, with a Supplement containing the most important New Remedies. With copious Additions, and two hundred and thirteen large wood- engravings. By R. Eglesfeld Griffith, M. D. In one very large and handsome octavo volume, of over 1000 pages. CIIELTUS (J. M.), M. D.—A System of Si'rgery. Translated from the German, and accom- panied with additional Notes and References, by John F. South. Complete in three very large octavo volumes, of nearly 2200 pages, strongly bound, with raised bands and double titles. CONDIE (D. F.), M. D— A Practical Treatise on tiie Diseases of Children. Fourth edition, revised and augmented. In one large volume, 8vo., of nearly 750 pages. (Just Issued.) COOPER (BRANSBY B.), M. D.—lectures on the Principles and Practice of Surgery. In one very large octavo volume, of 750 pages. (Lately Issued.) COOPER (PTR ASTLEY P.) — A Treatise on Dislocations and Fractures of the Joints. Edited by Bransby B. Cooper. F.R.S., &c. -With additional Observations by Prof. J. C. Warren. A new American edition. In one handsome octavo volume, with numerous illustrations on wood. COOPER (SIR ASTLEY P).—On the Anatomy and Treatment of Abdominal Hernia. One large volume, imperial 8vo., with over 130 lithographic figures. 4 BLANCHARD & LEA'S MEDICAL PUBLICATIONS. COOPER (SIR ASTLEY P.)—On the Structure and Diseases of the Testis, and on the Thymus Gland. One vol. imperial 8vo., with 177 figures, on 29 plates. COOPER (SIR ASTLEY P.)—On the Anatomy and Diseases of the Breast, with twenty-five Miscellaneous and Surgical Papers. One large volume, imperial 8vo. with 252 figures, on 36 plates. CHURCHILL (FLEETWOOD), M. D. —On the Theory and Practice of Midwifery. A new American, from the last and improved English edition. Edited, with Notes and Additions, by D. Francis Condie, M. D., author of a " Practical Treatise on the Diseases of Children," &c. With 139 illustrations. In one very handsome octavo volume, 510 pages. (Lately Issued.) CHURCHILL (FLEETWOOD), M.D.—On the Diseases of Infants and Children. In one large and handsome volume of over 600 pages. CHURCHILL (FLEETWOOD), M.D— Essays on the Puerperal Fever, and other Diseases Peculiar to Women. Selected from the writings of British Authors previous to the close of the Eighteenth Century. In one neat octavo volume, of about 450 pages. CHURCHILL (FLEETWOOD), M.D.—On the Diseases of Women; including those of Preg- nancy and child-bed. A new American edition, revised by the Author. With Notes and Additions, by D. Francis Condie, M. D., author of " A Practical Treatise on the Diseases of Children." In one large and handsome octavo volume, with wood-cuts, 684 pages. (Just Issued.) DEWEES (W. P.), M. D.—A Comprehensive System of Midwifery. Hlustrated by occasional Cases and many Engravings. Twelfth edition, with the Author's last Improvements and Corrections. In one octavo volume, of 600 pages. (Just Issued.) DEWEES (W. P.), M. D.—A Treatise on the Physical and Medical Treatment of Children. Tenth edition. In one volume, octavo^ 548 pages. (Just Issued.) DEWEES (W. P.), M. D.—A Treatise on the'Diseases of Females. Tenth edition. In one volume, octavo, 532 pages, with plates. (Just Issued.) DRUITT (ROBERT), M. R. C S.—The Principles and Practice of Modern Surgery. A new American, from the improved London edition. Edited by F. W. Sargent, M. D., author of " Minor Surgery," &c. Illustrated with one hundred and ninety-three wood-engravings. In one very handsomely-printed octavo volume, of 576 large pages. DUNGLISON, FORBES, TWEEDTE, AND CONOLLY.—The Cyclop2edia of Practical Medi- cine : comprising Treatises on the Nature and Treatment of Diseases, Materia Medica and Therapeutics, Diseases of Women and Children, Medical Jurisprudence, &c. &c. In four large super-royal octavo volumes, of 3254 double-columned pages, strongly and hand- somely bound. *** This work contains no less than four hundred and eighteen distinct treatises, contri- buted by sixty-eight distinguished physicians. DUNGLISON (ROBLEY), M. D.—Medical Lexicon; a Dictionary of Medical Science con- taining a concise Explanation of the various Subjects and Terms of Physiology, Pathology Hygiene, Therapeutics, Pharmacology, Obstetrics, Medical Jurisprudence, &c. With the French and other Synonymes ; Notices of Climate and of celebrated Mineral Waters; For- mulae for various Officinal. Empirical, and Dietetic Preparations, &c. Eleventh edition revised. In one very thick octavo volume, of over 900 large double-columned pages! strongly hound in leather, with raised bands. (Just Issued.) BLANCHARD & LEA'S MEDICAL PUBLICATIONS. 5 DUNGLISON (ROBLEY), M J).—The Practice of Medictne. A Treatise on Special Pathology and Therapeutics. Third edition. In two large octavo volumes, of 1500 pages. Upon every topic embraced in the work, the latest information will be found carefully posted up.—Medical Examiner. DUNGLISON (ROBLEY), M. D. — General Therapeutics and Materia Medica ; adapted for a Medical Text-book. Fifth edition, much improved. With one hundred and eighty-seven illustrations. In two large and handsomely-printed octavo volumes, of about 1100 pages. (Just Issued.) DUNGLISON (ROBLEY), M.D.—New Remedies, with Formula for their Administration. Sixth edition,;with extensive Additions. In one very large octavo volume, of over 750 pp. DUNGLISON (ROBLEY), M. D. — Human Physiology. Seventh edition. Thoroughly revised and extensively modified and enlarged, with nearly five hundred illustrations. In two large and handsomely-printed octavo volumes, containing nearly 1450 pages. DUNGLISON (ROBLEY), M. D.—Human Health; or, the Influence of Atmosphere and Lo- cality, Change of Air and Climate, Seasons, Food, Clothing, Bathing, Exercise, Sleep, &c. &c, on Healthy Man; constituting Elements of Hygiene. Second edition, with many Modifi- cations and Additions. In one octavo volume, of 464 pages. DURLACHER (LEWIS). — A Treatise on Corns, Bunions, the Diseases of Nails, and the General Management of the Feet. In one 12mo. volume, cloth. 134 pages. DE JONGH (L. J.), M. D.—The Three Kinds of Cod-Liver Oil, comparatively considered, with their Chemical and Therapeutic Properties. Translated, with an Appendix and Cases, by Edward Carey, M. D. To which is added an article on the subject from " Dunglison on New Remedies." In one small 12mo. volume, extra cloth. DAY (GEORGE E.), M. D. —A Practical Treatise on the Domestic Management and More Important Diseases of Advanced Life. With an Appendix on a new and successful mode of treating Lumbago and other forms of Chronic Rheumatism. One volume octavo, 226 pages. ELLIS (BENJAMIN), M. D. — The Medical Formulary: being a Collection of Prescriptions, derived from the writings and practice of many of the most eminent physicians of America and Europe. Together with the usual Dietetic Preparations and Antidotes for Poisons. To which is added an Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform. The whole accompanied with a few brief Pharmaceutic and Medical Observations. Tenth edition, revised and much extended, by Robert P. Thomas, M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one neat octavo volume, of 296 pages. (Now Ready. Revised and enlarged to 1854.) ERICH9EN (JOHN).—The Science and Art of Surgery; being a Treatise on Surgical Inju- ries. Diseases, and Operations. With Notes and Additions by the American Editor. Illus- trated with over three hundred engravings on wood. In one large and handsome octavo volume, of nearly 900 closely-printed pages. (Now Ready.) This is a new work, brought up to May, 1S54. FERGUSSON (WILLIAM), F.R.S.—A System of Practical Surgery. Fourth American, from the third and enlarged London edition. In one large and beautifully-printed octavo volume, of about 700 pages, with three hundred and ninety-three handsome illustrations. (Just Issued.) FRTCK (CHARLES), M. D.—Rfnal Affections ; their Diagnosis and Pathology. With illus- trations. One volume, royal 12mo., extra cloth. FOWNF.S (GEORGE), PH. D. — Elementary Chemistry; Theoretical and Practical. With numerous illustrations. A new American, from the last and revised London edition. Edited, with Additions, by Robert Bridges. M.D. In one large royal 12mo. volume, of over 550 pages, with 181 wood-cuts: sheep, or extra cloth. (Notv Ready.) 6 BLANCHARD & LEA'S MEDICAL PUBLICATIONS. GRAHAM (THOMAS), F.R.S.—The Elements of Chemistry. Including the Application of the Science to the Arts. With numerous illustrations. With Notes and Additions, by Robert Bridges, M. D., &c. &c. Second American, from the second and enlarged London edition. PART I. (Lately Issued) large 8vo., 430 pages, 185 illustrations. PART II. (Preparing) to match. GROSS (SAMUEL D.), M.D. —A Practical Treatise on the Diseases and injuries of the Urinary Organs. In one large and beautifully-printed octavo volume, of over 700 pages. With numerous illustrations. GROSS (SAMUEL D.), M. D. —A Practical Treatise on Foreign Bodies in the Air-Passaoes. In one handsome octavo volume, with illustrations. (Nearly Ready.) GROSS (SAMUEL D.), M. D. — A System of Surgery ; Diagnostic, Pathological, Therapeutic, and Operative. With very numerous engravings on wood. (Preparing.) GLUGE (GOTTLIEB), M. D.—An Atlas of Pathological Histology. Translated, with Notes and Additions, by Joseph Leidy, M. D., Professor of Anatomy in the University of Penn- sylvania. In one volume, very large imperial quarto, with 320 figures, plain and colored, on twelve copperplates. GRIFFITH (ROBERT E.), M. D. —A Universal Formulary, containing the Methods of Pre- paring and Administering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceutists. Second edition, thoroughly revised, with numerous Additions, by Robert P. Thomas, M. D., Professor of Materia Medica in the Philadelphia College of Phar- macy. In one large and handsome octavo volume, of over 600 pages, double columns. (Just Ready.) GRIFFITH (ROBERT E.), M. D. — Medical Botany; or, a Description of all the more important Plants used in Medicine, and of their Properties, Uses, and Modes of Adminis- tration. In one large octavo volume, of 704 pages, handsomely printed, with nearly 350 illustrations on wood. GREGORY (WILLIAM), F. R. S.E. — Letters to a Candid Inquirer on Animal Magnetism. Description and Analysis of the Phenomena. Details of Facts and Cases. In one neat volume, royal 12mo., extra cloth. GARDNER (D. PEREIRA), M. D.—Medical Chemistry, for the use of Students and the Pro- fession: being a Manual of the Science, with its Applications to Toxicology, Physiology, Therapeutics, Hygiene, &c. In one handsome royal 12mo. volume, with illustrations. HASSE (C E.), M. D.—An Anatomical Description of the Diseases of Respiration and Cir- culation. Translated and edited by Swaine. In one volume, octavo. HARRISON (JOHN), M. D.—An Essay towards a Correct Theory of the Nervous System. In one octavo volume, 292 pages, ^y HUGHES (H. M.), M.D.—A Clinical Introduction to the Practice of Auscultation, and other Modes of Physical Diagnosis, in Diseases of the Lungs and Heart. Second American from the second and improved London edition. In one royal 12mo. volume. (Just Ready.) HORNER (WILLIAM E.), M. D.—Special Anatomy and Histology. Eighth edition. Exten- sively revised and modified. In two large octavo volumes, of more than 1000 pages, hand- somely printed, with over 300 illustrations. HOBLYN (RICHARD D.), A. M.—A Dictionary of the Terms used in Medicine and the Col- lateral Sciences. Second and improved American edition. Revised, with numerous Ad- ditions, from the second London edition, by Isaac Hays, M. D., Ac. In one large royal 12mo. volume, of over 400 pages, double columns. (Nearly Ready.) BLANCHARD & LEA'S MEDICAL PUBLICATIONS. 7 HOPE (J.), M. D. — A Treatise on the Disfasfs of the Heart and Great Vessels. Edited by Pennock. In one volume, octavo, with plates, 572 pages. HERSCHEL (SIR JOHN F. W.), F.R.S.—Outlines of Astronomy. New American, from the third London edition. In one neat volume, crown octavo, with six plates and numerous wood-cuts. (Just Issued.) HUMBOLDT (ALEXANDER). — Aspects of Nature in Different Lands and Different Cli- mates. Second American edition, one vol. royal 12mo., extra cloth. JONES (T. WHARTON), F.R.S.—The Principles and Practice op Ophthalmic Medicine and Suroery. Edited by Isaac Hays, M. D., &c. In one very neat volume, large royal 12mo., of 529 pages, with four plates, plain or colored, and ninety-eight wood-cuts. JONES (C HANDFIELD), F.R.S., AND EDWARD H. SIEVEKING, M. D. — A Manual of Pathological Anatomy. With numerous engravings on wood. In one handsome volume. (In Press.) KIRKES (WTLLIAM SENIIOUSE), M.D., AND JAMES PAGET, F.R.S.—A Manual of Phy- siology. Second American, from the second and improved London edition. With 165 illustrations. In one large and handsome royal 12mo. volume. 550 pages. (Just Issued.) KNAPP (FO, Ph.D. — Technology; or, Chemistry applied to the Arts and to Manufactures. Edited, with numerous Notes and Additions, by Dr. Edmund Ronalds and Dr. Thomas Richardson. First American edition, with Notes and Additions, by Professor Walter R. Johnson. In two handsome octavo volumes, printed and illustrated in the highest style of art, with about 500 wood-engravings. LEHMANN.—Physiological Chemistry. Translated by George E. Day, M. D. (Preparing.) LEE (ROBERT), M. D.—Clinical Midwifery; comprising the Histories of Five Hundred and Forty-five Cases of Difficult, Preternatural, and Complicated Labor, with Commentaries. From the second London edition. In one royal 12mo. volume, extra cloth, of 238 pages. LA ROCHE (R.), M.D.—Pneumonia; its Supposed Connection, Pathological and Etiological, with Autumnal Fevers, including an Inquiry into the Existence and Morbid Agency of Malaria. In one handsome octavo volume, extra cloth, of 500 pages. (Now Ready.) LONGET (F. A.)—Treatise on Physiology. With numerous Illustrations. Translated from the French by F. G. Smith, M. D., Professor of Institutes of Medicine in the Pennsylvania Medical College. (Preparing.) LAWRENCE (W.), F.R.S.—A Treatise on Diseases of the Eye. A new edition, edited, with numerous Additions, and 243 Illustrations, by Isaac Hays, M. D., Surgeon to Wills' Hos- i pital, &c. In one very large and handsome octavo volume, of 950 pages, strongly bound i in leather, with raised bands. (Now Ready.) This work is thoroughly revised, and brought up to 1854. LAWRENCE (W.), F.R .S. — A Treatise on Ruptures. From the fifth London edition. In one octavo volume, sheep, 480 pages. LISTON (ROBERT), F. R. S. —Lectures on the Operations of Surgery, and on Diseases and Accidents requiring Operations. Edited, with numerous Additions and Alterations, by T. D. Matter, M.D. In one large and handsome octavo volume, of 566 pages, with 210 wood-outs. 8 BLANCHARD & LEA'S MEDICAL PUBLICATIONS. LALLEMAND (M.)^The Causes, Symptoms, and Treatment of Spermatorrhea. Translated and edited by Henry J. McDougal. In one volume, octavo, of 320 pages. Second Ame- rican edition. (Now Ready.) LARDNER (DIONYSIUS), D.C.L.—Handbooks of Natural Philosophy and Astronomy. Revised, with numerous Additions, by the American editor. First Course, containing Mechanics, Hydrostatics, Hydraulics, Pneumatics, Sound, and Optics. In one large royal 12mo. volume, of 750 pages, with 424 wood-cuts. Second Course, containing Heat, Elec- tricity, Magnetism, and Galvanism, one volume, large royal 12mo., of 450 pages, with 250 illustrations. Third Course (now ready), containing Meteorology and Astronomy, in one large volume, royal 12mo., of nearly 800 pages, with 37 plates and 200 wood-cuts. The whole complete in three volumes, of about 2000 large pages, with over 1000 figures on steel and wood. MEIGS (CHARLES D.), M. D.—Woman : her Diseases and thetr Remedies. A Series of Lec- tures to his Class. Third and improved edition. In one large and beautifully-printed octavo volume. (Just Ready. Revised and enlarged to 1854.) MEIGS (CHARLES D.), M. D. — Obstetrics : the Science and the Art. Second edition, revised and improved. With 131 illustrations. In one beautifully-printed octavo volume, of 752 large pages. (Lately Published.) MEIGS (CHARLES D.), M. D. — A Treatise on Acute and Chronic Diseases of the Neck of the Uterus. With numerous plates, drawn and colored from nature, in the highest style of art. In one handsome octavo volume, extra cloth. (Now Ready.) MEIGS (CHARLES D.), M.D— Observations on Certain of the Diseases of Young Children. In one handsome octavo volume, of 214 pages. MEIGS (CHARLES D.), M. D.—On the Nature, Signs, and Treatment of Puerperal Fever. In one handsome octavo volume. (In Press.) MILLER (JAMES), F.R.S.E.—Principles of Surgery. Third American, from the second and revised Edinburgh edition. Revised, with Additions, by F. W. Sargent, M. D., author of "Minor Surgery," Ac. In One large and very beautiful volume, of 752 pages, with 240 exquisite illustrations on wood. MILLER (JAMES), F.R.S.E.—The Practice of Surgery. Third American, from the second Edinburgh edition. Edited, with Additions, by F. AY. Sargent, M. D., one of the Surgeons to Wills' Hospital, &c. Illustrated by 319 engravings on wood. In one large octavo volume, of over 700 pages. MALGAIGNE (J. F.). — Operative Surgery, based on Normal and Pathological Anatomy. Translated from the French, by Frederick Brittan, A. B., M. D. With numerous illustra- tions on wood. In one handsome octavo volume, of nearly 600 pages. MOHR (FRANCIS), Ph. D., AND REDWOOD (THEOPHILUS).—Practical Pharmacy. Com- prising the Arrangements, Apparatus, and Manipulations of the Pharmaceutical Shop and Laboratory. Edited, with extensive Additions, by Prof. William Procter, of the Phi- ladelphia College of Pharmacy. In one handsomely-printed octavo volume, of 570 pages, with over 500 engravings on wood. MACLISE (JOSEPH).—Surgical Anatomy. Forming one volume, very large imperial quarto. With sixty-eight large and splendid Plates, drawn in the best style, and beautifully colored. Containing 190 Figures, many of them the size of life. Together with copious and explanatory letter-press. Strongly and handsomely bound in extra cloth, being one of the cheapest and best executed Surgical works as yet issued in this country. Copies can be sent by mail, in five parts, done up in stout covers. BLANCHARD & LEA'S MEDICAL PUBLICATIONS. 9 MAYNE (JOHN), M. D. — A Dispensatory and Therapeutical Remembrancer. Comprising the entire lists of Materia Medica, with every Practical Formula contained in the three British Pharmacopoeias. AY'ith relative Tables subjoined, illustrating, by upwards of six hundred and sixty examples, the Extemporaneous Forms and Combinations suitable for the different Medicines. Edited, with the addition of the Formulae of the United States Pharmacopoeia, by R. Eglesfeld Griffith, M. D. In one 12mo. volume, extra cloth, of over 300 large pages. MULLER (PROFESSOR J.), M. D. — Principles of Physics and Meteorology. Edited, with Additions, by R. Eglesfeld Griffith, M. D. In one large and handsome octavo volume, extra cloth, with 550 wood-cuts, and two colored plates. NEILL (JOHN), M. D., AND FRANCIS GURNEY SMITH, M.D.—An Analytical Compendium of the Various Branches of Medical Science; for the Use and examination of Students. Second edition, revised and improved. In one very large and handsomely-printed royal 12mo. volume, of over 1000 pages, with 350 illustrations on wood. Strongly bound in leather, with raised hands. NELIGAN (J. MOORE), M. D.—A Practical Treatise on Diseases of the Son. In one neat royal 12mo. volume, of 334 pages. OWEN (PROF. R.). — On the Different Forms op the Skeleton. One royal 12mo. volume, with numerous illustrations. (Now Ready.) PHILLIPS (BENJAMIN), F.R.S. — Scrofula ; its Nature, its Prevalence, its Causes, and tho Principles of its Treatment. In one volume, octavo, with a plate. PANCOAST (J.), M. D. — Operative Surgery; or, A Description and Demonstration of the various Processes of the Art; including all the New Operations, and exhibiting the state of Surgical Science in its present advanced condition. Complete in one royal 4to. volume, of 380 pages of letter-press description, and eighty large 4to. plates, comprising 486 illus- trations. Second edition, improved. Blanchard & Lea having become the publishers of this important book, have much plea- sure in offering it to the profession. PARKER (LANGSTON).—The Modern Treatment of Syphilitic Diseases, both Primary and Secondary; comprising the Treatment of Constitutional and Confirmed Syphilis, by a safe and successful method. With numerous Cases, Formula?, and Clinical Observations. From the third and entirely rewritten London edition. In one neat octavo volume. (Now Ready.) PEREIRA (JONATHAN), M.D.—The Elements of Materia Medica and Therapeutics. Third American edition, enlarged and improved by the author; including Notices of most of the Medical Substances in use in the civilized world, and forming an Encyclopaedia of Materia Medica. Edited, with Additions, by Joseph Carson, M. D., Professor of Materia Medica and Pharmacy in the University of Pennsylvania. In two very large octavo volumes of 2100 pages, on small type, with over 450 illustrations. (Now Complete.) Volume I.—Lately issued, containing the Inorganic Materia Medica, over 800 pages, with 145 illustrations. Volume II. —Now ready, embraces the Organic Materia Medica, and forms a very large octavo volume of 1250 pages, with two plates, and 300 handsome wood-cuts. PEASELEE (E. R.), M. D.—Human Histology, in its Applications to Physiology and General Pathology, designed as a Text-book for Medical Students. With numerous illustrations. In one handsome royal 12mo. volume. (Preparing.) PIRRIE (WILLIAM), F.R.S.E.—The Principles and Practice of Surgery. Edited by John Neill, M. D., Demonstrator of Anatomy in the University of Pennsylvania, Surgeon to the Pennsylvania Hospital, &c. In one very handsome octavo volume, of 780 pages, with 316 illustrations. (Just Issued.) RAMSBOTHAM (FRANCIS H.), M. D.—The Principles and Practice of Obstetric Medicine and Surgkry, in reference to the Process of Parturition. Sixth American, from the last London edition. Illustrated with lis Figures, on fifty-five Plates. In one large and handsomely-printed volume, imperial octavo, with 520 pages. 10 BLANCHARD & LEA'S MEDICAL PUBLICATIONS. RICORD (P.), M.D.—Illustrations op Syphilitic Disease. Translated from the French, by Thomas F. Betton, M. D. With the addition of a History of Syphilis, and a complete Bibli- ography and Formulary of Remedies, collated and arranged by Paul B. Goddard, M. D. With fifty large quarto plates, comprising 117 beautifully-colored illustrations. In one large and handsome quarto volume. RICORD (P.), M. D. —A Treatise on the Venereal Disease. By John Hunter, F. R. S. With copious Additions, by Ph. Ricord, M. D. Edited, with Notes, by Freeman J. Bumstead, M. D. In one handsome octavo volume, with plates. (Now Ready.) RICORD (P.), M.D. —Letters on Syphilis, addressed to the Chief Editor of the Union Medi- cale. With an Introduction, by Amedee Latour. Translated by W. P. Lattimore, M. D. In one neat octavo volume. RICORD (P.), M.D.—A Practical Treatise on Venereal Diseases. With a Therapeutical Summary and Special Formulary,. Translated by Sidney Doane, M. D. Fourth edition. One volume, octavo, 340 pages. RIGBY (EDWARD), M.D. —A System of Midwifery. AVith Notes and Additional Illustra- tions. Second American Edition. One volume, octavo, 422 pages. ROYLE (J. FORBES), M. D.—Materia Medica and Therapeutics; including the Preparations of the Pharmacopoeias of London, Edinburgh, Dublin, and of the United States. With many new medicines. Edited by Joseph Carson, M. D., Professor of Materia Medica and Pharmacy in the University of Pennsylvania. With ninety-eight illustrations. In one large octavo volume, of about 700 pages. SKEY (FREDERICK C), F.R.S. Operative Surgery. In one very handsome octavo volume of over 650 pages, with about 100 wood-cuts. SHARPEY (WILLIAM), M.D., JONES QUAES', M.D., AND RICHARD QUAIN, F.R.S., Ac- Human Anatomy. Revised, with Notes and Additions, by Joseph Leidy, M. D. Complete in two large octavo volumes, of about 1300 pages. Beautifully illustrated with over 500 engravings on wood. SMITH (HENRY H.), M. D., AND WILLIAM E. HORNER, M. D. — An Anatomical Atlas illustrative of the Structure of the Human Body. In one volume, large imperial octavo, with about 650 beautiful figures. SARGENT (F. W.), M. D.—On Bandaging and other Points of Minor Surgery. In one hand- some royal 12mo. volume of nearly 400 pages, with 128 wood-cuts. STANLEY (EDWARD). —A Treatise on Diseases of the Bones. In one volume, octavo, extra cloth, 286 pages. STILLE (ALFRED), M.D.—Principles of Therapeutics. In one handsome volume. (Pre- paring.) SIMON (JOHN), F.R.S.—General Pathology, as conducive to the Establishment of Rational Principles for the Prevention and Cure of Disease. A Course of Lectures delivered at St. Thomas's Hospital during the summer Session of 1850. In one neat octavo volume. (Lately Issued.) SMITH (TYLER AY.), M.D.—On Parturition, and the Principles and Practice of Obstetrics. In one large duodecimo volume, of 400 pages. BIBS0N (FRANCIS), M.D. —Medical Anatomy. Illustrating the Form, Structure, and Po- sition of the Internal Organs in Health and Disease. In large imperial quarto, with splendid colored plates. To match " Maclise's Surgical Anatomy." (Preparing.) BLANCHARD & LEA'S MEDICAL PUBLICATIONS. 11 SOLLY (SAMUEL), F.R.S. —The Human Brain; its Structure, Physiology, and Diseases. With a Description of the Typical Forms of the Brain in the Animal Kingdom. From the Second and much enlarged London edition. In one octavo volume, with 120 wood-cuts. SCIKEDLER (FRIEDRICH), Ph. D.—The Book of Nature; an Elementary Introduction to the Sciences of Physics, Astronomy, Chemistry, Mineralogy, Geology, Botany, Zoology, and Physiology. First American edition, with a Glossary and other Additions and Improve- ments; from the second English edition. Translated from the sixth German edition, by Henry Medlock, F.C.S., &c. In one thick volume, small octavo, of about 700 pages, with 679 illustrations on wood. Suitable for the higher schools and private students. (Now Ready.) TAYLOR (ALFRED S.), M. D., F. R. S.—Medical Jurisprudence. Third American, from the fourth and improved English edition. With Notes and References to American Decisions, by Edward Hartshorne, M.D. In one large octavo volume, of about 700 pages. (Just Issued.) TAYLOR (ALFRED S.), M. D— On Poisons, in Relation to Medical Jurisprudence and Medi- cine. Edited, with Notes and Additions, by R. E. Griffith, M.D. In one large octavo volume, of 688 pages. THOMSON (A. T.), M.D.—Domestic Management of the Sick-Room, necessary in aid of Me- dical Treatment for the Cure of Diseases. Edited by R. E. Griffith, M. D. In one large royal 12mo. volume, with wood-cuts; 360 pages. TOMES (JOHN), F.R.S.—A Manual of Dental Practice. Illustrated by numerous engravings on wood. In one handsome volume. (Preparing.) TODD (R. B.), M.D., AND WILLIAM BOWMAN, F.R.S. —Physiological Anatomy and Physi- ology of Man. AVith numerous handsome wood-cuts. Parts I., II., and III., in one octavo volume, 552 pages. Part IV. will complete the work. WATSON (THOMAS), M. D., &c — Lectures on the Principles and Practice of Physic. Third American, from the last London edition. Revised, with Additions, by D. Francis Condie, M.D., author of a "Treatise on the Diseases of Children," &c. In one octavo volume, of nearly 1100 large pages, strongly bound, with raised bands. WALSHE (W. H.), M. D.—Diseases of the Heart, Lungs, and Appendages; their Symptoms and Treatment. In one handsome volume, large royal 12mo., 512 pages. What to Observe at the Bedside and after Death, in Medical Cases. Published under the authority of the London Society for Medical Observation. In one very handsome volume, royal 12mo., extra cloth. (Just Issued.) AVILDE (W, R.).—Aural Surgery, and the Nature and Treatment of Diseases of the Ear. In one handsome octavo volume, with illustrations. (Now Ready.) WinTEHEAD (JAMES), F.R.C.S., &c —The Causes and Treatment of Abortion and Ste- rility; being the Result of an Extended Practical Inquiry into the Physiological and Morbid Conditions of the Uterus. Second American Edition. In one volume, octavo, 368 pages. (Now Ready.) WEST (CHARLES), M.D.—Lectures on the Diseases of Infancy and Childhood. Second American, from the second and enlarged London edition. In one volume, octavo, of nearly 600 pages. (Now Ready.) 12 BLANCHARD & LEA'S MEDICAL PUBLICATIONS. WEST (CHARLES), M. D.—An Inquiry into the Pathological Importance of Ulceration of the Os Uteri. Being the Croonian Lectures for the year 1854. In one neat octavo volume, extra cloth. (In Press.) WILSON (ERASMUS), M.D., F.R.S. —A System of Human Anatomy, General and Special. Fourth American, from the last English edition. Edited by Paul B. Goddard, A. M., M. D. With 250 illustrations. Beautifully printed, in one large octavo volume, of nearly 600 pages. WILSON (ERASMUS), M.D., F.R.S. —The Dissector; or, Practical and Surgical Anatomy. I Modified and Rearranged, by Paul Beck Goddard, M.D. A new edition, with Revisions and Additions. In one large and handsome volume, royal 12mo., with 115 illustrations. WILSON (ERASMUS), M. D., F. R. S.—On Diseases of the Skln. Third American, from the third London edition. In one neat octavo volume, of about 500 pages, extra cloth. (Just Issued.) Also, to be had done up with fifteen beautiful steel plates, of which eight are exquisitely colored; representing the Normal and Pathological Anatomy of the Skin, together with accurately-colored delineations of more than sixty varieties of disease, most of them the size of nature. The Plates are also for sale separate, done up in boards. WILSON (ERASMUS), M.D., F.R.S. —On Constitutional and Hereditary Syphilis, and on Syphilitic Eruptions. In one small octavo volume, beautifully printed, with four exqui- site colored plates, presenting more than thirty varieties of Syphilitic Eruptions. WILSON (ERASMUS), M. D., F.R. S.—Healthy Skin; a Treatise on the Management of the Skin and Hair in Relation to Health. Second American, from the fourth and improved London edition. In one handsome royal 12mo. volume, extra cloth, with numerous illus- trations. Copies may also be had in paper covers, for mailing, price 75 cents. (Now Ready.) WILLIAMS (C. J. B.), M.D., F.R.S.—Principles of Medicine; comprising General Pathology and Therapeutics, and a brief general view of Etiology, Nosology, Semeiology, Diagnosis, Prognosis, and Hygienics. Edited, with Additions, by Meredith Clymer, M.D. Fourth American, from the last and enlarged London edition. In one octavo volume, of 476 pages. (Now Ready.) WILLIAMS (C. J. B.), M. D., F.R.S.—A Practical Treatise on Diseases of the Respiratory Organs ; including Diseases of the Larynx, Trachea, Lungs, and Pleurae. With numerous Additions and Notes, by M. Clymer, M.D. With wood-cuts. In one octavo volume, pp. 508. YOUATT (WILLIAM), V.S. —The Horse. A new edition, with numerous illustrations; together with a General History of the Horse; a Dissertation on the American Trotting Horse; how Trained and Jockeyed; an Account of his Remarkable Performances; and an Essay on the Ass and the Mule. By J. S. Skinner, formerly Assistant Postmaster-General, and Editor of the Turf Register. One large octavo volume. YOUATT (WILLIAM), V. S.—The Dcg. Edited by E. J. Lewis, M. D. With numerous and beautiful illustrations. In one very handsome volume, crown 8vo., crimson cloth, gilt. Blanchard k Lea have now ready a detailed Catalogue of their publications, in Medical and other Sciences, with Specimens of the Wood-engravings, Notices of the Press, &c. &c, forming a pamphlet of sixty-four large octavo pages. It has been prepared without regard to expense and may be considered as one of the handsomest specimens of printing as ^et executed in this country. Copies will be sent free, by post, on receipt of two three-cent postage stamps Detailed Catalogues of their publications, Miscellaneous, Educational, Medical &c fur- nished gratis, on application. ' "' £■■** 4 mm* ■ ' '-a-^fmi