V -i ' '•'•'",'v''.'\ ;^^it;v:; .:■•;.•■::: ■:■::::;: SURGEON GENERAL'S OFFICE % Section,___l.l.U/k. | xo.f.lfaQf+%. I > A MANUAL CLINICAL MEDICINE. A MANUAL CLINICAL MEDICINE, PHYSICAL DIAGNOSIS. T. H. TANNEKJtf.D. JjANNE^M. LICENTIATE OP THE ROYAL COLLEGE OF PHYSICIANS J PHYSICIAN TO THE HOSPITAL FOR WOMEN, ETC. ETC. TO WHICH IS ADDED ^ (/// O- <2J THE CODE OF ETHICS fc\ V/ r AMERICAN MEDICAL ASSOCIATION. PHILADELPHIA: BLANCHARD AND LEA; 1 S 5 f>. C SHERMAN & SON, PRINTERS, 19 St. James Street. ROBERT BENTLEY TODD, M.D., F.R.S., PHYSICIAN TO KING'S COLLEGE HOSPITAL, ETC., THIS MANUAL IS DEDICATED, BY HIS FRIEND AND FORMER PUPIL, THE AUTHOR. \ 1* % PUBLISHERS* ADVERTISEMENT. In presenting to the profession of the United States this admirable little volume, the publishers have thought that its value as a work for daily reference would be enhanced by the addition of the excellent " Code of Ethics of the American Medical Association," which, adopted as it has been by most of the State Medical Societies, may be regarded as the standard guide of the American profession. Philadelphia, October, 1856. l/ V Jf^. * PREFACE. The following pages have been written with the intention of removing some of the difficulties which the student always—and the practitioner frequently —must encounter, while studying disease in its Pro- tean forms at the bedside. Remembering my own impressions of bewilderment on beginning to "walk the hospital," I have honestly endeavored to sim- plify the task for others; and should this treatise be the means of doing so, I shall feel greatly rewarded for my exertions. Charlotte Steeet, Bedford Square, February, 1855. CONTENTS. CHAPTER I. ON THE CLINICAL STUDY OF DISEASE. PAGE Section 1. On the Faculty of Observation, . . 25 Section 2. The General Conduct of the Practi- tioner of Medicine, . . . .27 Section 3. The Clinical Examination of a Patient, Examination of the Exterior,......29 Interrogation of the Patient, ...... 29 Examination of the Cranium,......29 Thoracic Viscera, .... 30 Abdomen,...... 30 Present General Condition of the Patient, ... 30 Examination of Female Patients......31 Section 4. The Clinical Examination of Children. Section 5. Mode of taking Notes of a Case. General Observations, ....... 32 Anatomical or Physiological Peculiarities, . . . .32 Intellectual and Moral Peculiarities, .... 33 Previous History, . ......33 General Health,......33 Present Illness, ........ 33 Condition, ....... 33 Condition of Nervous System,......33 Organs of Respiration and Circulation, . 34 xji CONTENTS. rAGE Condition of Digestive Organs,.....34 Urinary Organs,.....^ Causes of Illness,........ Diagnosis,......... Prognosis,......... General Rules of Treatment,.....<*4 Section 6. Mode of taking Notes of Diseases of Females. Section 7. Mode of making a Post-mortem Examina- tion, Examination of the Skull,......35 Spinal Cord......36 Thoracic and Abdominal Cavities, . 36 Urinary and Generative Organs, . 37 Section 8. Mode of taking Notes of a PoSt-mortem Examination, General Observations, ....... 37 Examination of Head, Face, Mouth, and Fauces, . . 37 Thorax,.......38 Abdomen, ...... 38 Male Organs of Generation, . . .39 Female Organs of Generation, . . 39 Spinal Cord.......39 Section 9. The Clinical Examination of the Insane, Investigation of the Physiognomy,.....40 Actions, ..... 40 The Conversation of the Insane, . . . . .41 The Memory, Written Letters, &c, of the Insane, . 41 Certificates of Insanity, ....... 42 Medical Case Book, ....... 43 Section 10. Examination of Persons for Life As- surance, Different knowledge required in Life Office to the Con- sulting-room, ........ 44 Points especially to attend to in Examination of Applicant, 44 Aphorisms on the Value of certain Lives, . . .45 Section 11. On Medico-legal Investigations, Use of Notes,.......# ,46 Confessions and Death-bed Declarations, . . .47 Reports for Judicial Purposes, . . . 47 Medical Evidence at Inquests, . . .'.".' 49 CONTENTS. CHAPTER II. ON THE INSTRUMENTS EMPLOYED IN THE DIAGNOSIS OF DISEASE. PAGE Section 1. On the Microscope, The Student's Microscope, . . . . 50 The Simple Microscope, . . . . .50 The Compound Microscope, .... 50 The Magnifying Powers of the best Object-glasses, . 51 Standards of Measurement, .... 53 Section 2. On the Test-tray, The Apparatus required in Medical Chemistry, . . 53 Dr. Lionel Beale's Cabinet of Apparatus and Reagents, 54 Section 3. On the Spirometer, Hutchinson's Spirometer, . . • .54 Mode of Testing the Vital Capacity, ... 54 Coxeter's Portable Spirometer, . . . .55 Pereira's Spirometer, ..... 55 56 Section 4. On the Common Tape-measure, Stethome- ter, Pleximeter, Stethoscope, Etc., The Common Tape-measure, . Mode of ascertaining the Circumference and Mobility of the Chest, •••••' — The Stethometer, . • • • 5® Dr. Sibson's Chest-measurer, »6 The Movements in Respiration, . . • ' 2j Plessors, Pleximeters, &c, °7 Dr. Sibson's Spring Pleximeter, . . ' % The Stethoscope, ' ' ' ' ' sr General Observations, • . D& Section 5. On the Dynamometer. Section 6. On the instruments required for making Local Applications to the Larynx, Etc. Section 7. On the Ophthalmoscope. Section 8. On the Speculum Uteri, Uterine Sound, Etc., fin The Speculum—Varieties of,. . • ™ The Uterine Sound, 61 Sponge Tents, • • fi„ Dr Protheroe Smith's Uterine Dilator, . • • 2 xiv contents. CHAPTER III. ON DISEASE. PAGB Section 1. The Nature of Disease, Definition of Disease,..... 63 Disease of Function, . . . . .63 Structure, ..... 63 Acute and Chronic Diseases, . . . .64 Zymotic Diseases, . . . . 64 Sporadic Diseases, . . . . .65 Continued, Remittent, and Intermittent Diseases, . 65 Hereditary, Congenital, Specific, and Malignant Diseases, 65 Asthenic, Idiopathic, Symptomatic, and Intercurrent Diseases, Section 2. The Causes of Disease, Predisposing Causes, ..... 66 Exciting Causes, . . . . . .66 Non-cognizable Causes, . . . . 67 Section 3. The Classification of Diseases, The Division of Diseases by Sauvage, . . .68 Cullen, ... 68 Section 4. The Diagnosis of Disease, Mode of making a Diagnosis, Probability the Guide of Life, Section 5. The Prognosis of Disease, Importance of the Prognosis, Positive Statements—their Effect, Section 6. The Terminations of Disease, Termination in Health, . The Crisis of a Disease, Metastasis, The Termination in Death, . Sudden Death and its Causes, Death by Anaemia, Asthenia, Asphyxia or ApnoBa, . Coma, 69 69 70 71 71 72 73 73 74 75 75 75 76 CONTENTS. CHAPTER IV. ON THE VARIOUS CIRCUMSTANCES WHICH MODIFY DISEASE. General Remarks, page 1. Sex, ........ 77 2- Age......'•'.'.". 78 3. Hereditary Tendency, ...... 79 4. Temperament and Idiosyncrasy, . . . 80 The Sanguine and Irritable Temperament, . . 80 The Lymphatic or Phlegmatic, . . . .80 The Nervous, . . ..... 80 The Bilious, ........ go 5. Diathesis, ...... 80 6. Habit, . . . . . . _ . .81 7. Climate and Temperature,.....81 A great Range of Temperature compatible with Life, 82 Capability of bearing a great Degree of Heat, . 82 Sudden Transitions in Temperature, . . .82 Effects of Heat on the Human Body, ... S3 Effects of Extreme Cold on the Human Body, . . 83 Cold in Motion and Moisture, .... 84 Temperate Latitudes, ...... 84 CHAPTER V OF THE SYMPTOMS AND SIGNS OF DISEASE. Introductory Remarks on the Importance of Semeiology, Various Divisions of Symptoms, .... Section 1. Symptoms and Signs afforded by the Coun tenance and Condition of the Body, The Expression of the Countenance, The Countenance in Facial Paralysis, . The Appearance of the Lips and Mouth, The Hue or Color of the Countenance, A Dark Circle under the Eyes, Signs presented by the Eye, The Arcus Senilis, The Function of Vision, The Sense of Hearing, . The Posture of the Body, . 84 85 86 87 88 88 89 89 90 91 92 92 xvl CONTENTS. The Nutrition of the Body,......94 The Temperature of the Surface of the Body, . . 94 The Moisture of the Surface of the Body, . . .95 Section 2. Symptoms belonging to the Organs and Function of Digestion, The Teeth and Gums,.......95 The Saliva, ....... qq The Tongue,........95 The Taste, ...... 90 Deglutition,........ ,99 The Appetite and Desire for Drink, . . . ' . " 99 Jaundice, ...... inn Nausea and Vomiting, . . .. . t 101 Defaecation........' jq. Section 3. Symptoms belonging to the Function of Respiration, The Respirations, ..... 193 Dyspnoea,......... 103 Orthopncea......t jq,- The Odor of the Breath, .... . 105 The Temperature of the Expired Air, . . ' . ' 106 Cough, . . ........106 Hiccough,.........107 Expectoration, ...... 107 Stertor,........' jq8 Yawning and Sighing,......' jog Sneezing, ...... iqo Section 4. Symptoms belonging to the Function of Circulation, Palpitations of the Heart and Large Vessels, . . .108 The Pulse, . ' .q„ Condition of the Capillaries, . ..." 114 Venous Symptoms, . . '11s State of the Blood,. . .".'.* . ' JJ5 Section 5. Symptoms connected with the Urinary and Sexual Organs, The Excretion of Urine,..... llg Strangury, . • • • • . 118 Ischuria, . . • • . 118 Incontinence of Urine, ' .....118 Sexual Organs in the Male* . ' . ' ' ' Ji? I he Uterine System % " 1~u '........120 contents. xvn PAQB Section 6. Symptoms derived from the Nervous System, Pain,.........121 Diminished Sensibility,.......122 Paralysis,........123 General Paralysis,.......123 Hemiplegia,........123 Paraplegia, ........ 123 Spasm,.........I24 Tonic Spasm,........124 Clonic Spasm,.......124 Delirium, ....•••• 124 Coma,.........125 CHAPTER VI. ON THE DIAGNOSIS OF NATURAL FROM FEIGNED DISEASE. Introductory Observations,. . • • • • • j2? The Four Modes in which Disease may be Simulated, . 127 A Table of Feigned Diseases,......128 Concluding Remarks,....... CHAPTER VII. ON THE PHYSICAL DIAGNOSIS OF DISEASE. 1 "38 Introductory Remarks,.......„ The Nature of Physical Signs,..... Section 1. The Physical Signs of Cerebral Disease, Cerebral Auscultation,.......„ The various Auscultic Phenomena, ..•■•«■ Section 2. The Physical Diagnosis of Diseases of the Lungs and Heart, Introductory Remarks on the Structure of the Lungs, . l« Position of the Patient, . l44 Regions of the Thorax, . • • • \ '147 Description of the Methods of Physical Diagnosis, . 147 1. Inspection, !47 Form of Chest, . ' l4y Size, . 149 Movements, • • ' , " # CONTENTS. 2. Palpation, Vocal Vibration, or Fremitus, Pulmonary Friction Fremitus, Fluctuation, . The Heart's Impulse, Fremissement Cataire, Cardiac Friction Fremitus, Mensuration, Circular Width of Chest, . Variation of the two Sides, . Diseases causing Enlargement, Diseases causing Narrowing, Succussion, Mode of Practising Succussion, Uses of, .... . Spirometry, Vital Capacity as affected by Height, Weight as affecting Vital Capacity, Age as affecting Vital Capacity, . Percussion, Mode of Practising, Diminution of Clearness, . Increase of Clearness, . Tympanitic Sound, ..... Amphoric Resonance and Metallic Tinkling, Tubular Sound, The Bruit de Pot Fele\ Auscultation, Mode of Practising, ' Pulmonary or Vesicular Respiration, Bronchial Respiration, The Laryngeal Murmur, Sounds caused by Morbid Secretion, Dry Sounds, . . Moist Sounds, .... , Friction-Sounds, g C Bronchophony, .... SJ Pectoriloquy, .... M ^gophony, .... L Morbid Phenomena of the Cough, f Sounds of the Heart, . tg \ Pericardial Friction-Murmur, • -j Endocardial Murmurs, ^ Diseases of the Cardiac Valves, [ Inorganic Murmurs, . PAGE 150 150 . 150 150 . 151 151 contents. xix Section 3. The Physical Diagnosis of Diseases of"' the Abdomen, Regions of the Abdomen,......!73 Modes of Physical Examination. . . . ' . " 173 Inspection, ..... 174 Mensuration, ...... 174 Palpation, ....... . 174 Percussion, ...... 177 Auscultation, ...... .179 Auscultation of the Abdomen during Pregnancy, . 180 CHAPTER VIII. GENERAL OBSERVATIONS ON THE DIAGNOSIS OF THORACIC DISEASES. Bronchitis, . . . . . . . . .182 Pleurisy,..........183 Pneumonia, ......... 134 Asthma, .......... 186 Emphysema,......... 187 Pneumothorax, . . . . . . . . .187 Phthisis, ......... 188 Pericarditis, . . . . . . . . . 190 » Endocarditis, . . . . . . . .191 Valvular Disease of the Heart, . . . . . . 192 Atrophy of the Heart,.......194 Hypertrophy of the Heart,......195 Cyanosis,.........196 Aneurism of the Aorta, ....... 196 CHAPTER IX. ON THE DIAGNOSIS OF DISEASES OF THE SKIN. Willan's Classification,.......198 Order 1. The Exanthemata, Erythema, . . . . . . . ,199 Erysipelas, . . . . . . . .199 Roseola, ........200 Rubeola,.........200 Scarlatina,....... 201 Urticaria,......... 204 XX CONTEXTS. PAGE Order 2. Vesiculj?, Miliaria,.........20\ Varicella,.........205 Eczema,.........205 Herpes,.........205 Scabies,.........206 Order 3. Bullae, Pemphigus,.........206 Rupia,.........206 Button Scurvy,........207 Order 4. Pustule, Variola,.........207 Vaccinia, .... ...... 207 Ecthyma, .........209 Impetigo,.........210 Acne, . ......... 211 Mentagra,.........211 Porrigo,.........211 Plica Polonica,........212 Equinia, or Glanders, .......212 Order 5. Papulae, Lichen, ......... 212 Prurigo, .... . . ... 213 Order 6. Squamae, Lepra,..........213 Psoriasis, . . . . . . . . .213 Pityriasis,'.........214 Pityriasis Versicolor, ....... 214 Ichthyosis,.........214 Order 7. Tubercul^e, Elephantiasis Grsecorum, . . . . . .214 Molluscum,........• 215 Frambassia,......... 215 Order 8. Macule, Lentigo,.........216 Ephelides,........216 Nasvi,...... . . .216 Albinismus,...... . .216 Vitiligo, ;........216 Order 9, Lupus, . 216 CONTENTS. xxi 0 1 rv PAGE rder 10, Pellagra,........017 Order 11, Malum Alepporum,......217 Order 12, Syphilida,.....# m .217 Order 13, Purpura,........218 Order 14, Elephantiasis Arabicum,.....218 Order 15, Cheloidea, . . . . . . . .219 CHAPTER X. PARASITIC WORMS FOUND IN THE HUMAN BODY. Table of the Worms,.......219 1. Internal Parasites, Acephalocysts or Hydatids,.....221 Echinococcus Hominis, . . . . . .221 Filaria Oculi, Filaria Medinensis, and Filaria Bronchialis, 221 Cysticercus Cellulosae,......222 Distomata,........222 Polystoma Pinguicola, ...... 222 Strongylus Gigas, .......222 Dactylius Aculeatus, ....... 223 Diplosoma Crenata, ...... 223 Spiroptera Hominis, ....... 223 Trichina Spiralis, ....... 223 Tricocephalus Dispar, ...... 224 Ascaris Lumbricoides, ...... 224 Ascaris Vermicularis, ..... . 224 Taenia Solium,.......224 Bothriocephalus Latus, ...... 224 2. External Parasites, Pulex Penetrans, ....... 225 Acarus Scabiei, . . . . . . . . 225 Acarus Folliculorum,......225 Pediculi,.........226 CONTENTS. CHAPTER XL ON THE CHEMICAL AND MICROSCOPICAL EXAMINATION OF TnE BLOOD, EXPECTORATION, VOMITED MATTERS, AND URINE. The Excretions generally, Section 1. The Blood, General Composition of, . — . Chemical Composition of, Microscopic Examination of, Mode of Examining Stains of, To detect Uric Acid in Serum of, Section 2. The Expectoration, General Characters of, Microscopic Examination of, . Section 3. Vomited Matters, SarcinoD Ventriculi, PAGE 226 227 228 229 229 229 230 230 231 Section 4. The Urine, Table of Solid Contents, Mode of making a Clinical Examination of, Increased Flow of Urine, Deficiency of Urine, .... Reaction of Test-papers, Urine depositing Uric Acid, Urine containing an excess of Urea, Urate of Soda, L Ammoniacal Salts Urine containing Purpurine, . Cystine, ..... Oxalate of Lime, . Gravel, ..... Mode of testing for Albumen, Pus, . Sugar, Kiestein, ..... Casts of Tubes, Epithelium, &c, Bile in the Urine, Iodide of Potassium in the Urine, me, &c. 232 233 233 233 233 234 234 234 2,34 235 235 235 236 236 236 236 238 239 239 239 CO NT K NTS. XXlii CODE OF ETHICS OP THE AMERICAN MEDICAL ASSOCIATION. OF THE DUTIES OF PHYSICIANS TO THEIR PATIENTS, AND OF THE OBLIGATIONS OF PATIENTS TO THEIR PHYSICIANS. PAGE Art. 1. Duties of Physicians to their Patients, . 240 Art. 2. Obligations of Patients to their Physicians, . 242 OF THE DUTIES OF PHYSICIANS TO EACH OTHER, AND TO THE PROFESSION AT LARGE. Art. 1. Duties for the support of Professional Character, 244 Art. 2. Professional Services to each other, 245 Art. 3. Of the Duties of Physicians as respects vicarious offices, ..... 245 Art. 4. Of the Duties of Physicians in regard to Consul- tations, .... 246 Art. 5. Duties of Physicians in cases of Interference, 248 Art. 6. Of Differences between Physicians, 250 Art. 7. Of Pecuniary Acknowledgments, 250 OF THE DUTIES OF THE PROFESSION TO THE PUBLIC, AND OF THE OBLIGATIONS OF THE PUBLIC TO THE PROFESSION. Art. 1. Duties of the Profession to the Public, . 251 Art. 2. Obligations of the Public to Physicians, . 252 A MANUAL OF CLINICAL MEDICINE. CHAPTER I. ON THE CLINICAL STUDY OF DISEASE. SECTION 1. ON THE FACULTY OF OBSERVATION. All who have studied the writings of the greatest of philosophers—Lord Bacon—must know that there are two especial sources to which he refers men for real increase of knowledge, namely, to observation and experiment, which he insists are but questionings of Nature in respect of specific matters. To cultivate the faculty of observation must then be the first duty of those who would excel in any scientific pur- suit,1 and to none is this study more necessary than to the stu- dent of medicine. To such an one it may be said, that the habit of correct observation is that mode of learning his profession which above all others he should most diligently cultivate; remembering that observation does not consist in the mere habitual sight of objects—in a kind of vague looking-on, so to speak—but in the power of comparing the known with the unknown, of contrasting the similar and dissimilar, in justly appreciating the connection between cause and effect, and in estimating at their correct value established facts. The great Newton has assured us that he knew of no difference between himself and other men but in his habits of observation and 1 " L'art d'observer est le seul moyen d'acqu^rir des connaissances utiles."—La Croix. 3 26 CLINICAL STUDY OF DISEASE. attention, and almost the same encouraging remark was mad by Locke. The constitution of the human mind is such that the acqui- sition of knowledge can only be very gradual. Just as there is no royal road to learning, so there is no rapid method of gaining experience ; and he who wishes to excel must not only work assiduously, but must be careful that he toils in the right direction. Although at first the difficulties in the way of observing correctly may appear insurmountable, yet as the habit is daily encouraged will the path become clear, until at last what was at first a labor becomes a matter of almost routine practice. The most important part of a medical man's education is undoubtedly to be gained at the bedside. In the wards of our various hospitals every diversity of ailment, every variety of injury may be carefully observed and investigated, first— as disease appears naturally, when, as we may say, Nature is performing her experiments for our wisdom ; and secondly— as modified by a careful use of those remedial agents which have been so bountifully bestowed upon us. In order, how- ever, that the observation of disease may be profitable, it must be complete. It will be useless unless the malady be watched during its whole course, the symptoms as they arise noted, and the effects of medicines carefully observed until the termination in recovery or death. Especially is the ter- mination of a case instructive, and not the less so when the result is death, since we may then mark the way in which the patient succumbed, and learn to guard against such an event in similar examples for the future. Just as a man who wishes to become acquainted with the nature and characteristics of a foreign country may read a whole library on the subject, inspect charts and panoramic views faithfully drawn, or study a series of paintings delineating separately all that is most worthy of observation, and yet certainly fail to obtain any correct idea of the distant land ; so may a student learn the entire practice of physic by heart from books, and yet be unable to distinguish small-pox from measles when called upon to put his theoretical knowledge into actual practice. Valua- ble, therefore, and indeed indispensable, as is the assistance to be derived from a careful study of the writings of the masters of our profession, yet these writings must be regarded principally, if not solely, as guide-books, that is to say, as intended to smooth the difficulties which the observer will have to encounter, but by no means calculated to do away with the labor of self-observation ; for it is not too much to CONDUCT OF THE MEDICAL PRACTITIONER. 27 say that without practical experience all other acquirements are of no avail to the practitioner of medicine. Truly excel- lent, then, is the advice given by Dr. Latham to the student, "begin by learning to stand by the sick-bed, and make it your delight." He who will be content to do this in a right spirit, may be assured of becoming an eminently useful mem- ber of the noblest profession that can engage the attention or encourage the development of the highest qualities of the mind of man: let him but work diligently, perseveringly, and conscientiously, and he may be certain of ultimately acquiring —if not the purse of Fortunatus—at least a competency; but, above all, will he experience that happiness which princes may envy, but which they cannot bestow, the gratification of knowing that—in however humble a degree—he is the honored instrument of " God, who healeth our diseases." SECTION 2. THE GENERAL CONDUCT OF THE MEDICAL PRACTITIONER. Although much might be advantageously written upon thi3 subject, yet a very few words must suffice. The mere fact that the practice of medicine arose from an instinctive impulse to relieve the pains and sufferings of others is sufficient to show that the medical man, of all men, should be free from that vice which is the besetting sin of mankind—selfishness. He must, indeed, be thoroughly content to live, not for him- self, but for others ; not to look to his own interests, not to be guided in his actions by motives of policy, but to let the rule of his life be to do as much good to others as possible. He should think as little of pecuniary rewards as is compatible with his own interests and that of his brother practitioners, remembering the maxim adopted by La Bruyere from Con- fucius—that he who esteems gold more than virtue, will be likely to lose both gold and virtue. The physician, to be suc- cessful, must not only possess a sound practical knowledge of his profession, but he must also be careful that his moral character be free from blemish; that his general conduct be not only above vulgarity, but such as to excite the respect ot his friends and neighbors; that he be conscientious, attentive, careful of the secrets of those who consult him, unmindtul of the worldly condition of his patients, sympathizing, calm, and circumspect in his behavior generally. As it is his object to prolon.'life, so he must leave no means unpursued in order to attain such object, remembering that the mere prescribing of medicines is often the least part of his duty. It would 28 CLINICAL STUDY OF DISEASE. indeed be well if medical men generally thought more of the moral remedies at their disposal; and if more attention were bestowed upon soothing the fleeting moments of the afflicted, by inspiring them with hope, confidence, and ease of mind. A man who practises his profession conscientiously will never be unmindful of the duties which he owes to his colleagues— to those treading the same path as himself. He will carefully avoid all such short-sighted proceedings as may tend to elevate himself by depressing others; he will strictly eschew those disgraceful methods of obtaining notoriety, newspaper puffing or prescribing; and he will hesitate at giving, as a rule, gratuitous advice, where such is not needed by the circum- stances of the patient, and where such a course of proceeding must injure those who are content to receive a small remune- ration for their toilsome labors, and whose daily bread pro- bably depends upon their obtaining such a return for their exertions. The encouragement bestowed upon medical men is for the most part very deficient, their worth and usefulness being unacknowledged, their fatigues and anxieties unheeded, and their unselfishness and disregard of wealth abused. While striving to diminish the sufferings of their afflicted fellow- creatures, can it happen otherwise than that their feelings should be hurt by observing the attention paid to men prac- tising the most palpable absurdities and deceptions, by witnessing the success of homoeopaths, table-turners, mes- merists, and such like? Has it not, however, always been so? Does not Bacon himself tell us, that " the weakness and cre- dulity of men is such, as they will often prefer a mountebank or witch before a learned physician,"1 and is the present age less credulous than that of the great philosopher? I fear not 1 But it is the prerogative of superior minds to rise with the occasion. Let us, therefore, individually and collectively, as students and practitioners, strive to improve our art: let us each endeavor to attain that mental sagacity which will enable us to perceive the important features of cases coming under our care and the salient points of diagnosis ; that wisdom which can foresee the course and progress of disease; that judgment which will enable us to select the proper remedies; and that calm determination which will render us capable of insisting that the necessary measures are thoroughly carried out. ' The Advancement of Learning. CLINICAL EXAMINATION OF A PATIENT. 29 SECTION 3. THE CLINICAL EXAMINATION OF A PATIENT. Upon the application of a sick person to a medical man, the first object of the latter must be to ascertain the exact nature of the disease before him. As it often happens that the sufferer is embarrassed by the novelty of his situation and by general debility resulting from his malady, we must endeavor by calmness, delicacy, patience, and kindness on our part to put him at his ease, which will be readily done by one who has accustomed himself to intercourse with invalids. A few remarks on general subjects, inquiries as to his place of residence, and the length of time he has suffered from bad health, will enable the practitioner to learn much from— An Examination of the Exterior, the physiognomy first engaging attention, since from it may be learnt the patient's apparent age, strength, state of mind, complexion—whether pale, florid, or dusky, and his general constitution. The gene- ral bulk of the body should then be cursorily examined, noticing whether it be large and full, or thin and wasted ; the condition of particular regions, whether swelled or attenuated; the presence or absence of any cutaneous eruptions; and, lastly t evidence is to be obtained as to the powers of voluntary motion, as the use of the arms, of the legs in locomotion, &c. Interrogation of the Patient.—We are now prepared to interrogate the patient himself, and this we do by inquiring whether he has any pain, where it is seated, and the length of time he has been ailing. This leads him to enter into a description of his sufferings, and of the means he has adopted for their relief; and although in many instances he may not make his statement the short simple narrative we might desire, yet, as a general rule, it will always be better to let him tell his own tale in his own fashion. Then, according as complaint is made of suffering in any particular organ, we proceed to investigate the condition of this and of all parts connected with it. Thus, suppose pain be complained of in the head, we proceed to make— An Examination of the Cranium, as to its general form, symmetry of the two sides, special prominences and depres- sions, and heat of the integuments. Inquiries are then to be made as to the nature and duration of the pain, as to whether it is deep seated or superficial, affected by pressure, by noise ; whether it is periodic, or connected with neuralgic or rheu- matic pains in other parts of the body. We must ascertain, also, the presence or absence of vertigo; the condition of the 30 CLINICAL STUDY OF MEDICINE. functions of sight and hearing; the ability or inability to sleep, to take exercise, and to make use of the mental facul- ties. Or, perhaps, the seat of disease may appear to be in the thorax. We then make— An Examination of the Thoracic Viscera, resorting to inspection, palpation—or the application of the hand, mensu- ration, "percussion, and auscultation, in the manner to be hereafter noticed. We then endeavor to ascertain the presence or absence of cough and its nature; the characters of the expectoration; the amount of facility or of difficulty of breathing, both when the body is quiet and when undergoing exertion; the nature of the heart's action, whether there be palpitation or no; and the presence or absence of such general symptoms as emaciation, purging, night-sweats, &c. An Examination of the Abdomen, when any of the abdominal viscera appear affected, must be made by inspec- tion, measurement, palpation, percussion, and auscultation. Ihe boundaries of the liver, spleen, and stomach must be ascertained; the nature, duration, and seat of pain, if any • the presence or absence of .tumors, and hernial protrusions; the condition and number of the alvine evacuations; the modem which digestion is performed, and the state of the appetite; and the characters of the renal secretion. Present General Condition of the Patient.—It then remains for us to endeavor to ascertain accurately the present condition of the patient, the state of his skin as to its tempe- rature, &c, the condition of the tongue, and the nature of the pulse. His real age, profession, whether married or single, constitution, habits and mode of living, usual state of health &c, are then to be inquired into, and we conclude by ascer- taining the causes of the disease, whether it be hereditary or 3T^V1?the„rJe P^sent is the first attack or otherwise, men? "* t0 Underg° the necessar7 treat' Drevero,^^- C°UrSe' man?. cir™mstances which often described Tht^ M examinatl0n » the exact manner just described. Thus in many instances, we have to depend for much of our information on the testimony of relatives or friends or we may even be called to a perL who is auhl insensible, and we may be unable to obtain any Story at aU Sstt0prCoeeeedPraCtltlL°ner' h0wever>wi» be It no kL how uestto proceed on such an emergency.1 Translation of Andrall'^l^rRIediral^ imroduc,orv th»P'er of L CLINICAL EXAMINATION OF CHILDREN. 31 Examination of Female Patients.—In examining into the history of a female patient, we must proceed as just recom- mended, at the same time paying attention to the condition of the sexual system, ascertaining especially whether the patient is single, married, or widowed ; the number of her pregnancies and of her children, and the date of her last labor; the man- ner in which the cataraenial function is performed; and the presence or absence of any leucorrhceal or other discharge. SECTION 4. THE CLINICAL EXAMINATION OF CHILDREN. The importance of attending to the diseases of children can- not be too much insisted upon, especially seeing that so serious are their maladies, and so great is the mismanagement to which young children are often subjected, that it has been calculated one child in every five dies within a year of its birth, and one in three before the end of the fifth year; while of the deaths occurring within the first year, nearly one-third are said to take place before the end of the first month. Some authorities even estimate the mortality as higher than this. Thus, Dr. Friedlander asserts—" II perit pres du quart des enfans pendant la premiere annee."1 In many of the large manufacturing towns of England, the Registrar-General's Re- ports give a proportion of nearly one-fourth for the males and one-fifth for the females, under one year of age, out of the whole number of registered deaths. In no case perhaps does the practitioner so much stand in need of a certain tact as investigating the disorders of child- hood. As Dr. West justly says—" You try to gather informa- tion from the expression of his countenance, but the child is fretful, and will not bear to be looked at; you endeavor to feel his pulse, he struggles in alarm ; you try to auscultate his chest, and he breaks out into a violent fit of crying."2 But, by patience and good temper, by a quiet demeanor and a gentle voice, all may be made to go well, and a diagnosis may be formed almost as easily as in the case of adults. The first point is to be careful not to alarm the patient, but on entering the room to gain quietly the previous history of the case from the mother or nurse, the circumstances under which the pre- sent illness has come on, its early symptoms, the child's sex and age, the nature of its food, and whether it has been weaned, the state of the bowels, and the nature of the evacuations ; while, at the same time, without appearing to do so, you exa- 1 Education Physique des Enfans. > West on the Diseases of Infancy and Childhood. 32 CLINICAL STUDY OF MEDICINE. mine the expression of the countenance, the character of the inspirations and expirations, &c. By this time the little suf- ferer will have become accustomed to your presence, and you may advance to the bedside to examine it more closely. The temperature of the body and condition of the skin, the nature of the pulse, the state of the scalp and fontanelles, the pre- sence or absence of abdominal pain or tenderness on pressure, may now be ascertained, and by a little management auscul- tation may be practised. It is worthy of remembrance that immediate auscultation is generally to be preferred in these cases, if possible, as the pressure of the stethoscope frightens, if it does not hurt the child. In practising percussion, care must be taken not to strike too smartly, the variations in reso- nance being more readily appreciated by a gentle stroke; it is almost unnecessary to say that mediate percussion must be employed, that is to say, the blow must fall on the finger, not on the chest walls. Lastly, the state of the tongue, the condi- tion of the gums, and the number of the teeth, if any, remains to be ascertained, it being generally better to defer this to the last, since, as Dr. West observes, it is usually the most grievous part of your visit to the child. SECTION 5. MODE OF TAKING NOTES OF A CASE. It has long been a matter of regret that medical practition- ers, generally, do not pay greater attention to recording sys- tematic notes of their more important cases. Lord Bacon has well observed, in speaking of the deficiencies of physicians— "T'ie first is the discontinuance of the ancient and serious diligence of Hippocrates, which used to set flown a narrative of the special cases of his patients, and how they proceeded, and how they were judged by recovery or death.'" Such nar- ratives, carefully arranged, not only prove of inestimable value to the practitioner himself, but they forward the progress of the healing art, and especially tend to increase our knowledge of diagnosis and therapeutics. In taking these notes, it is especially necessary to do so methodically. The following plan will probably be found as simple and useful as any:— General Observations— Name ; age; married or single ; it a female, number of children and date of last birth ; date of coming under treatment. Anatomical or Physical Peculiarities—Development 1 Advancement of Learning:, Book ii. Narrationes medicinales. MODE OF TAKING NOTES OF A CASE. 33 of trunk and limbs ;"deformities; height; weight; countenance ; eruptions on skin, their form and nature; nervous excita- bility ; disposition to sleep ; habitual state of bowels. Intellectual and Moral Peculiarities.—Education ; memory; judgment; reasoning powers; behavior; disposi- tion ; religious feelings, &c. Previous History.—Place of birth ; condition in life, and health of parents ; health of brothers and sisters; family dis- eases ; present residence, and how long resident there ; occu- pation ; mode of living, appetite, and habits, whether temperate or otherwise ; habitual use of medicines, and their nature, as narcotics, purgatives, &c,; peculiar habits; venereal indul- gences. Previous General Health.—Habitual health and strength ; former illnesses, their nature and duration ; liability to colds, coughs, fevers, fits, rheumatism, gout, hemorrhages from nose or mouth, hernia. If a female, age at which catamenia first appeared; nature and duration of the flow; whether regular or otherwise ; date of last period; leucorrhoeal or other dis- charges ; number of children or abortions ; character of labors ; suckled her children or not. Present Illness.—Date and mode of commencement, whether sudden or gradual; symptoms complained of, with date of accession and progress of each up to the present time ; medical treatment to which patient has been subjected ; result of such treatment. Present Condition.—Aspect and complexion; state of nutrition ; state of strength ; fever ; sensation of cold; shiver- ing ; skin harsh and dry, or moist; disposition to be anxious and depressed, or hopeful. Condition of Nervous System.—Pain of head, or giddi- ness ; pain on pressure ; pain over any part of spinal column ; impairment of sensibility or motion, in face, tongue, sphinc- ters, extremities; power of mastication and deglutition; intellect; memory; senses; capacity for mental exertion; sleep, tranquil or disturbed. Condition of Organs of Respiration and Circulation. —Number and character of respirations and pulse ; cough ; expectoration ; voice ; pain of chest; decubitus ; size and form of chest; relative size of the two sides; examination of the expansive movements of the chest; examination of the lungs by the spirometer, by palpation or the application of the hand, by percussion and auscultation. Phenomena of the cir- 34 CLINICAL STUDY OF MEDICINE. culation—palpitation ; percussion and auscultation of the heart; point at which the apex is felt; impulse ; auscultation of the carotids, and other arteries ; state of the veins ; effect of charge of posture on the pulse. Condition of Digestive Organs.—Appearance of mouth, tongue, fauces, tonsils, and pharynx ; thirst; appetite; nausea or vomiting; character of vomited matters ; bowels, frequency of defecation, and character of evacuations; pain or tender- ness of abdomen ; results of manual examination ; bounda- ries of liver and spleen ; auscultation ; tumors ; hernial protru- sions ; hemorrhoids. Condition of Urinary Organs—Micturition easy, fre- quent or otherwise ; character of urinary secretion, quantity in twenty-four hours, color, odor, transparency, reaction with litmus and turmeric papers, specific gravity, results of the em- ployment of reagents, nature of pellicle or of deposits—if any; miscroscopical examination. Causes of Illness-—Assigned cause; probable cause; duration of. Diagnosis. Prognosis. General Rules of Treatment.—Regimen ; diet; prescrip- tion. At each subsequent visit the progress of the case must be commented on, the effect of the remedies employed noticed, and at the conclusion the interesting points should be summed up in a few brief remarks. Should the case terminate fatally, a post-mortem examina- tion must be made in the manner to be presently described. SECTION 6. MODE OF TAKING NOTES OF DISEASES OF FEMALES. The following is the plan adopted by myself at the Hospital for Women. It is necessarily short, but by a little manage- ment all the important features of the case can be recorded, and they are at all times-seen at a glance. Date. No. of ward and bed. Disease. Name and address. Age ; single, married, or widowed. Date of marriage. No. of pregnancies. No. of children. Date, and character of last labor. POST-MORTEM EXAMINATION. 35 Condition of life and general habits. Catamenia—nature and duration of flow; age at first appear- ance ; date of last. Leucorrhoeal or other discharges. History ; health of relations, &c. Date of present illness. Causes. Symptoms. Condition of nervous system. Condition of organs of respiration and circulation. Organs of digestion. Urinary organs, and secretion. Examination per abdomen. Examination per vaginam; by the touch; by the speculum ; by the uterine sound. Examination per rectum. Progress, treatment, and termination. SECTION 7. MODE OF MAKING A POST-MORTEM EXAMINATION. At a period varying from twelve to thirty six, or even—in cold weather—to forty-eight hours after death, the post-mortem examination may be made. Having carefully examined the external appearance of the body, The Skull is to be thus opened:—separate the hair, and make an incision through the scalp from one ear across the vertex to the other; reflect the anterior flap over the face, the posterior over the neck. Then with a saw make a cut through the outer table of the bones of the skull, completely round the cranium, passing the saw anteriorly about an inch above the superciliary arches, posteriorly just below the tubercle of the occipital bone, and on each side on a level with the cartilage of the ear. Introduce the elevator or chisel, and by means of a few smart strokes with the hammer, the inner table will be readily fractured, and the calvarium may be then torn away. The dura mater, the most external of the membranes of the brain, being thus exposed, it must be cut through with a scis- sors on either side—and in the direction of—the superior longitudinal sinus ; divide the falx cerebri; and elevating the head by means of a block or tripod, proceed to remove the brain, by gently raising it with the fingers placed under the anterior lobes and olfactory bulbs. The internal carotid artery, and second and third nerves, which first present them- 36 CLINICAL STUDY OF .MEDICINE. selves, are then to be divided; the pituitary body to be dis- lodged from the hollow in the centre of the sphenoid bone; and an incision is to be made through the fourth nerve, and the tentorium cerebelli close to its attachment to the temporal bone. We then successively perceive, and must divide, the two roots of the fifth nerve, the sixth, the seventh with its facial and auditory portions, the three divisions of the eighth— the glosso-pharyugeal, pneumogastric, and spinal accessory,— and the ninth nerve. Lastly, we cut across the vertebral arteries as they wind round the upper portion of the spinal cord, and then, as low as possible, divide the cord itself, with the roots of the spinal nerves attached on each side. The brain may now be readily taken from the skull, and carefully examined, by slicing it in thin layers in the horizontal direc- tion, from above downwards. The vascularity of the gray and white portions, the quantity of fluid in the ventricles, and the condition of the cerebral arteries must be noticed. To judge of its consistence, a fine stream of water should be poured from a height on the different parts, as they are successively exposed. The Spinal Cord is to be exposed by sawing through the arches of the vertebra? on each side, close to the articular pro- cesses, after the skin and muscles have been divided down to the bones. In some parts—as in the hollow of the lumbar region—difficulty will be experienced in using the saw; a chisel and hammer will then be found useful. When the spinal canal is opened, the strong tube of the dura mater pro- longed from that lining the skull will be exposed; this is to be slit up, and the cord, examined in situ, at the same time observing the quantity of fluid in the spinal canal, and the condition of the spinal veins. Subsequently divide the anterior and posterior roots of the thirty-one spinal nerves, and remove the cord for a closer inspection. The Thoracic and Abdominal Cavities.—For the pur- pose of examining the morbid appearances presented by the thoracic and abdominal viscera, we open the cavities contain- ing them at the same time, by making a straight incision from the thyroid cartilage of the larynx down to the symphysis pubis. Dividing the integuments, muscles, and peritoneum, we open the abdomen, the contents of which may be more readily exposed by making, in addition, a transverse subcuta- neous incision on each side, through the fascia, muscles, and peritoneum; then dissecting back the skin and muscles cover- ing the front of the thorax, we expose the cartilages connect- ing the ribs with the sternum. The cartilages are then to be NOTES OF POST-MO KTEM EXAMINATION. 37 cut through at their junction with the ribs, except those of the first ribs; and the sternum may now be raised like the lid of a box, a good substitute for a hinge being made by cutting the articulation of the first joint of the sternum on the inside. In inspecting the trachea and bronchi, they should be opened along their anterior surface. To show the valves of the heart, the right ventricle must be opened by a V-shaped flap, made by an incision immediately to the right of the septum, meeting at the apex another, carried along the right edge of the heart. Before laying open the pulmonary artery, the finger should be introduced, so as to guide the incision between the valves. ' The left ventricle should be opened by an incision in the direction of the aorta, beginning at the apex, a little to the left of the septum, having previously dis- sected tie pulmonary artery off from the aorta, and taking care to use the same precaution against injuring the valves as in opening the pulmonary artery. The Urinary and Generative Organs may be readily removed from the body for examination through the pelvis, and if the integuments in the perineum be left uninjured, and the several outlets stitched up, any portion presenting diseased appearances may be taken away without disfiguring the body, and without any of the contents of the abdomen protruding. With regard to the remaining viscera, no special directions seem necessary as to the mode of preparing them for inspec- tion. SECTION 8. MODE OF TAKING NOTES OF A POST-MORTEM EXAMINATION. As it is of course requisite that the details of the morbid appearance should be strictly accurate, the notes should be taken at the time of making, the autopsy. The following arrangement may be adopted:— General Observations.—Name; age ; day and hour of death; day and hour of examination; temperature to which the body has been exposed ; degree in which external sexual characters are marked, mammas, mons veneris, &c.; state of nutrition; eruptions; peculiarities of formation, or deformi- ties ; oedema of face, limbs, or trunk ; marks of violence, con- tusions, wounds; degree of rigor mortis; and the presence or absence of any marks of putrefaction. Examination of Head, Face, Mouth, and Fauces;— Bones of the head; fractures and their seat; adhesions of 4 3S CLINICAL STUDY OF MEDICINE. calvarium to dura mater; characters of dura mater, arachnoid, and pia mater; Pacchionian glands; quantity and character of the sub-arachnoid fluid. Weight of brain ; weight of cerebrum, pons Varolii, medulla oblongata, and cerebellum. Convolutions of the brain, their appearance and consistence. White and gray substance of hemispheres; consistence— whether natural, increased, diminished,—soft, creamy, dif- fluent; color of cut surface ; number and size of red points. Extravasation of blood; situation; quantity. Unnatural cavities in cerebral substance; situation ; contents; linings ; state of surrounding brain substance. Tubercular, calcare- ous, or malignant deposits. Lateral ventricles; contents— color and quantity of fluid; condition of choroid plexus. Third ventricle; contents. Optic thalami and corpora striata. Pons Varolii. .Medulla oblongata. Cerebellum; form; firm- ness ; color ; appearances on section. Face; lips ; »avity of mouth, contents—food or foreign substances; teeth, whether recently fractured ; tongue—size, form papillae, if stained or corroded. Fauces; tonsils ; pharynx, contents of, nature of; oesophagus, dilated or constricted ; epiglottis, rima glottidis. Examination of Thorax.—Trachea; bronchial tubes. Pleurae; nature and quantity of fluids effused into pleura. sacs; adhesions. Lungs; external characters; degree of collapse ; puckering at any part; cicatrices ; emphysema ; deposits of tubercle, of cancer; hydrostatic test, whether the lungs sink or float, result with various portions; substance of lungs, consistence, exudation of serum on section; crepita- tion ; abscess; gangrene; pulmonary apoplexy; tubercles, their seat and condition ; cavities, their seat, size, form, con- tents, and if communicating with bronchial tubes ; cysts • deposits of cancer. Pericardium ; adhesions; effusions ; white spots, their size, shape, and situation. Heart; weight • size • quantity of blood contained in various cavities, and its'condi- tion, frothy, liquid, or coagulated; thickness of walls ; size of cavities, right auricle and ventricle, left auricle and ventricle- condition of musculi pectinati, columns carnea?, chorda^ tendineaj; condition of foramen ovale; auriculo-ventricular openings—tricuspid valve, bicuspid or mitral valve ; aperture ot pulmonary artery, semilunar valves, and corpora Arantii • aortic orifice, valves, and corpora Arantii. Coronary arteries' their condition. Microscopical examination of muscular fibres of heart. Examination of Abdomen—Peritoneum; condition- contents ; parts through which herniae have passed. Liver •' external characters, form, measurement, weight, color, condi! CLINICAL EXAMINATION OF THE INSANE. 39 tion of capsule ; substance, cut surface, color, degree of fat, deposits of tubercle, of cancer; cysts; gangrene; micro- scopical examination. Gall-bladder ; size ; shape ; contents ; calculi; ductus communis choledochus. Spleen ; position ; size; weight; capsule; substance. Pancreas ; position; weight; substance; color; duct. Kidneys; external cha- racters ; capsule; surface after removal, if lobulated, granu- lated ; cut surface; cortical substance; pyramidal portion; pelvis of kidney; ureters; microscopical examination. Uri- nary bladder; contents ; walls. Stomach ; position ; size ; form; contents ; condition of mucous membrane ; rugse; cardiac orifice; pyloric orifice; walls of; cicatrices; ulcers; perforations; wounds. Abnormal condition of intestines generally ; cicatrices ; ulcers ; wounds ; perforations. Duo- denum ; Brunner's glands ; ductus communis. Jejunum and ileum ; valvulae conniventes ; villi; Peyer's patches ; glandulse solitariae. Caecum; appendix vermiformis ; ileo-caecal valve ; ileo-colic valve. Colon; glandulae solitariae. Rectum; hemorrhoids; prolapsus. Examination of Male Organs of Generation.—In- guinal canal; vasa deferentia ; spermatic cord ; tunica vagi- nalis ; testes ; penis ; prostate gland. Examination of Female Organs of Generation — Labia; nymphae ; clitoris ; urethra; hymen ; vagina ; uterus —lips, size of cavity, thickness of walls ; Fallopian tubes ; ovaries; pelvic tumors. Examination of Spinal Cord; vertebral canal; theca ver- tebralis; size and consistence of cord, cervical and lumbar enlargements, gray and white substance; roots of nerves; cauda equina. SECTION 9. THE CLINICAL EXAMINATION OF THE INSANE. The clinical examination of a man supposed to be insane differs very materially from that adopted in the diagnosis of corporeal diseases. To inquire of a lunatic of what he com- plains—or where he suffers pain—or how long he has been ill ?__;s in the majority of cases useless; since he will only reply that he has no pain, that he is quite well, and that he wishes to know by what authority you venture to question him. Neither does the appearance of the tongue, the nature of the pulse, nor the character of the secretions afford us any valu- able indications; but we are obliged to rely upon the informa- 40 CLINICAL STUDY OF MEDICINE. ge since, as state of the ai neaitn is, nowever, Dy no means to De negiectea, is well known, the body affects but too closely the nunc ui ihe mental faculties :—want of vitality and of nervous tone, deficient healthy action of the skin and internal organs, and torpidity of the primae via1, are, moreover, exceedingly common in the insane. The difficulties experienced in the diagnosis of insanity will, of course, depend upon the degree in which the mental faculties are lost. The complete maniac lives in a waking dream ; he raves without the power to control himself, without the power of appreciating the necessity for doing so ; he is completely the victim, not in the least the master, of the strongest impressions uppermost in his fancy. The partially insane person, on the other hand, will restrain himself, though probably with a great effort, on occasions when he thinks such restraint advisable, as before strangers, &c. The majority of insane people—especially chronic cases—are able by a greater or less degree of exertion to restrain their insane impulses on occasions, and they do so. Consequently, we must draw our conclusions not merely from the evidence derived from the nature of the countenance, or of the actions, or of the conver- sation, but from our entire—and, if necessary, frequent and unsuspected—examination of the patient.1 Investigation of the Physiognomy.-To appreciate cor- rectly the inferences to be drawn from this examination, the eye must be practised by long-continued observation not only of the insane, but of the varieties of expression which indicate the growth, normal state, and decline of mental vieor. We should be familiar with the cheerful open countenance of the man in the enjoyment of mental and bodily health and ease with the vacant stare of the thoughtless, the melancholy visa^ Sith S,Ji?frnted;the dre-my l00k °f the absent ■»», ^d with the wtldness of expression of the maniac; we shall then LnH ,VUStly t0 eStimate the evidence written'upon the fore head the expressive language spoken by the eyes-the mirror constanri' S^6 ""T1 restless«ess betokened by the -ddy will the peculiar manifestaS of in^'ty t re^g! Investigation of the Actions.-From examining the 1 Spp Remarks on Insanity, by Dr. Honry Monro. CLINICAL EXAMINATION OF THE INSANE. 41 face, we shall proceed naturally to observe the attitudes, ges- tures, movements, and general conduct. The facility, sup- pleness, and co-ordination of the movements must be noticed. The attitude of the old man with his head inclined to his chest, his back bent, and his knees giving way under him, is not more characteristic of a state of senility and exhaustion, than is the position of an unfortunate human being seated on the floor, with his chin resting on his knees, motionless for hours, and entirely unmindful of all that is passing around, indicative of incurable dementia. The gestures alone often indicate the passion which predominates. In insanity from disappointed love, airs of languor are often affected ; in that from religion, great humility and attention ; in that from sexual excesses, a downcast appearance, an evident desire to avoid notice, and an inability to look one in the face. The various gestures and actions of the insane, however, from the happy easy move- ments of the man who believes himself a monarch, or the excited violent ravings of one suffering from acute mania, to the sad torpid listlessness of the incurably demented, require to be drawn in stronger colors than I have the art of employ- ing, in order to produce truthful portraits. The Conversation of the Insane.—In endeavoring to gain information from this source, we must first seek to obtain, by kindness and a sympathizing manner, the confidence of the patient; for since it will frequently be necessary to ascertain his thoughts on the most varied subjects, so—unless we do so—and succeed in interesting him, he will often become sus- picious of our motives, sullen, and uncommunicative. Lord Erskine, in his defence of Hadfield, referred to the caseof a lunatic from whom he could draw no indication of insanity in the course of an examination in a court of law, until Dr. Sims entered, when the man addressed him as the Lord and Saviour of mankind. In many cases of madness, the reasoning facul- ties not being wholly lost, we are not surprised at finding that the patient can discourse correctly on many topics, until some accidental observation leads him to break out into the most imbecile extravagance, or makes him confide to us plans of revenge, or proposals for performing the most impracticable achievements. The Memory of the Insane.—Evidence may generally be obtained more easily upon this point than upon most others. A few quiet questions addressed to the patient as to his name, acre, and address, the members of his family, the nature of his occupation, the day of the week, the name of the reigning 42 CLINICAL STUDY OF MEDIC1NK. monarch,