small intestines was connected with the abdominal parietes close to the umbilicus, forming a ring, through which part of the ileum had passed and become strangulated. A part of the bowel may likewise become strictured, either from simple thickening of its coats, or from malignant disease; or the uterus may become retroflexed, or retroverted, and by pressing upon the rectum materially diminish its calibre; and, lastly, the muscular fibres of the intestine may become paralyzed from over and long-continued distension, just as sometimes happens in the case of the urinary bladder.

The principal symptoms of obstruction are constant vomiting, which is at first simple-consisting of the contents of the stomach, and mucus, but which in a few days becomes stercoracious or fæcal; pain varying in degree, often very severe; great mental depression; and the pathognomonic symptomconstipation. The physical signs are such as indicate a state of emptiness below the seat of obstruction, and of distension above it. When the small intestines are greatly distended their convolutions are often traceable, and they may be felt by the hand to roll about with loud borborygmi; at the same time the abdominal enlargement and the distended small intestines obscure the resonant sound given out by the colon when empty. When the obstruction is seated only a little above the cæcum, this part may form a large dilated tumor in the right iliac region. When in the colon or rectum, assistance may often be derived from introducing the finger; or, if the obstruction be higher than the finger can reach, by using an elastic rectum tube, or by injecting warm water, and observing how much can be thrown up. The lower the obstruction is situated the less urgent will be the vomiting; if, for instance, it is in the duodenum, the vomiting will be incessant from the beginning; if in the colon, it may be absent for some time. It might be thought that the ilio-cæcal valve would prevent the return of the contents of the colon into the ileum; the preliminary dilatation, however, renders this valve quite patulous. When urine is freely secreted, the obstruction cannot be very high up.

5. AUSCULTATION.

Auscultation of the Abdomen in Health and Disease. -The audible movements which occur within the abdomen in health are two: 1. The movements of alimentary or secreted matters, as gas, within the digestive tube, either by the spontaneous action of the canal itself, or as the result of

manipulation; and, 2, the movement of the blood in the vessels.

On applying the stethoscope over the stomach, an almost constant succession of gurgling sounds is heard when it contains liquid and gaseous matters, owing to the commingling of these. The sounds emitted from the intestines-borborygmi-arise from the passage of the gas they contain through insufficient spaces from one part of the tube to another; they occur abundantly during the contractions which ensue on the operation of a purgative, and they may be at once induced by a draught of cold water.

The pulsations of the aorta are occasionally heard during health in spare subjects; they disappear opposite the division of the vessel into the iliac arteries.

In disease these sounds are merely modified as regards their clearness and extent. When the surfaces of the peritoneum are roughened by inflammation a friction-murmur may often be detected; this sound is often audible in cases where friction-vibration cannot be felt.'

Auscultation of the Abdomen during Pregnancy furnishes us with two very important signs-one derived from the uterus, the other from its contents. To detect them the patient should lie on her back with her shoulders raised, and the legs drawn up, in order to relax the abdominal integuments. The uterine murmur, known as the placental murmur or uterine soufflet, has its origin probably in the blood vessels of the uterus, and not, as was thought, in the placenta. My own reason for discarding the latter opinion is, that I have frequently heard a similar murmur in large fibrous tumors of the uterus, and have been helped thereby to diagnose such tumors from those caused by cystic disease of the ovary. M. Cazeaux has suggested that an altered condition of the blood may help to produce it. The character of the sound is that of a rushing, blowing murmur, synchronous with the maternal pulse, unaccompanied by any impulse, and requiring careful examination for its detection. It is generally first heard towards the end of the fourth calendar month, though it has been detected as early as the tenth week; it is frequently audible over the whole of the uterus, but is usually most developed over one or both inguinal regions. Its presence affords no evidence as to the life or death of the foetus.

The pulsations of the foetal heart afford a double sound somewhat resembling the ticking of a watch, varying in fre

See Dr. Ballard's valuable volume on the Diagnosis of Diseases of the Abdomen.

quency from 120 to 160 in a minute, and having no relation with the pulse of the mother. The pulsations are best detected between the umbilicus and the anterior superior spinous process of the ilium, on either side, but most frequently to the left; they are rarely audible before the end of the fifth month of pregnancy, and they become more distinct as gestation advances. When discovered they prove a certain sign of the presence of a live fœtus.

Occasionally the movements of the foetus can be detected both by palpation and ascultation, about the time that the foetal heart is heard; and, according to Dr. Kennedy, “the funic souffle," weaker than the uterine murmur and synchronous with the foetal heart, may sometimes be detected by the ear. In the course of a large number of examinations, however, I have never discovered the latter sound.

CHAPTER VIII.

GENERAL OBSERVATIONS ON THE DIAGNOSIS OF THORACIC DISEASES.

IN exploring the diseases of the lungs and heart by the physical methods of diagnosis, it must be remembered that the signs derived from these sourees are not to be solely trusted to, but that every circumstance bearing upon the case under examination is important, and must consequently be taken into consideration if we would wish our judgment to be unbiassed and our opinion correct. The maxim of the old logiciansthat it requires all the conditions to establish the affirmative, but that the negative of any one proves the negative-is in the main true as regards the diagnosis of many diseases. Thus, in suspected valvular disease of the heart, if the sounds be healthy, unattended by any murmur, we may be sure, however strong the other symptoms may be, that the suspicion is not well founded; but the converse does not hold good, that a bellows-murmur being present, there is consequent valvular affection. In order to aid the student in studying the chief pulmonary and cardiac affections I have devoted the present chapter to the consideration of their general diagnosis, and I trust it will not be thought unworthy of the close attention of the reader.

BRONCHITIS.

Inflammation of the bronchial tubes may be acute or chronic. Acute Bronchitis is a dangerous disorder, more especially on account of the frequency with which the inflammatory action spreads to the vesicular texture of the lungs.

The symptoms consist of fever, a sense of tightness or constriction about the chest, hurried respiration with wheezing, severe cough, and expectoration-at first of a viscid glairy -which subsequently becomes purulent. The pulse is frequent and often weak; the tongue foul; and there is headache, lassitude, and great anxiety.

mucus-v

On practising auscultation in the early stage of the inflammation, two dry sounds will generally be heard, viz., rhonchus and sibilus, both of which indicate that the air-tubes are partially narrowed that the mucous membrane lining them is indeed dry and tumid. Rhonchus in itself need give us no anxiety, as it belongs entirely to the larger divisions of the bronchial tubes; sibilus, on the contrary, bespeaks more danger, since it denotes that the smaller air-tubes and vesicles are affected. After a time, the inflamed mucous membrane begins to pour out fluid-a viscid, transparent, tenacious mucus is exhaled; this constitutes the second stage of the inflammation. Two very different sounds to those just noticed are then to be detected, viz., large crepitation and small crepitation-often called the moist sounds. As the air passes through the bronchial tubes it gets mixed, as it were, with the mucous secretion, so that numerous air-bubbles keep forming and bursting. When this occurs in the larger branches, it gives rise to large crepitation; when in the smaller, to small crepitation. We have, therefore, rhonchus and large crepitation, as respectively, the dry and moist sounds of the larger air-passages; sibilus and small crepitation, as those of the smaller branches. On practising percussion, no appreciable alteration in the resonance of the chest will be discoverable. If relief be not af forded by the copious expectoration, or by remedies, the disease assumes a more dangerous character, the strength becomes much reduced, signs of great pulmonary congestion ensue, and symptoms of partial asphyxia follow, soon ending in death. In favorable cases, however, the affection begins to decline between the fourth and eighth day, and shortly either entirely subsides, or passes into the chronic form.

Chronic Bronchitis is very common in advanced life. The slighter forms are indicated only by habitual cough, some shortness of breath, and copious expectoration. The majority

of cases of winter cough in old people are examples of bronchial inflammation of a low lingering kind. It may arise idiopathically, or it may follow an acute attack.

PLEURISY.

Pleuritis, or pleurisy, are terms applied to inflammation of the pleura-the serous membrane investing the lungs and lining the cavity of the thorax. The inflammation is of the adhesive kind, and is accompanied by the pouring out of serum, of coagulable lymph, of pus, or of blood.

The disease is ushered in with rigors followed by fever, and an acute lancinating pain in the side, called a stitch, which pain is aggravated by the expansion of the lung in inspiration, by coughing, by lying on the affected side, and by pressure: there is also a short harsh cough, the skin is hot and dry, the cheeks flushed, the pulse hard and quick, and the urine is scanty and high colored. If we listen to the painful part of the chest at the commencement of the attack, we shall hear the dry, inflamed membranes the pulmonary and costal pleura-rubbing against each other, and producing a frictionsound; if the hand be placed on the corresponding part of the thorax, this rubbing may also be felt. But the sound soon ceases; for either the inflammation terminates in resolution and complete recovery, or the roughened surfaces become adherent, or they are separated by the effusion of serum, and a kind of dropsy results, known as hydrothorax. If the pleurisy has been severe, the effusion becomes excessive (it may vary from an ounce to several pints), and the fluid accumulating in the sac of the pleura compresses the yielding lung, suspends its functions, displaces the heart, and somewhat distends the thoracie parietes. When the serous fluid is mixed with pus, the disease is termed empyema. If we listen to the chest now, we shall find the respiratory murmur diminished, in proportion to the quantity of fluid thrown out: where this is excessive and the lung is compressed backwards-flattened almost against the spinal column-no vesicular breathing at all will be audible, but instead we shall hear the air passing into the larger bronchial tubes, while the voice will be also abnormally distinct, the condensed lung and the layer of fluid acting as conductors of sound; we then say that bronchial respiration and bronchial voice or bronchophony exist. The bronchophony may be accompanied by a tremulous noise, resembling the bleating of a goat; it is then termed ægophony. If the lung be completely compressed, so that no air can enter even the bronchial tubes, then no sounds of any kind will be heard ; but