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 general 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, 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 depressions, 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

functions of sight and hearing; the ability or inability to sleep, to take exercise, and to make use of the mental faculties. 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, mensuration, 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 inspection, measurement, palpation, percussion, and auscultation. The 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 mode in 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 ascertaining the causes of the disease, whether it be hereditary or acquired, whether the present is the first attack or otherwise, and the ability of the sufferer to undergo the necessary treat

ment.

There are, of course, many circumstances which often prevent our making an examination in 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 person who is quite insensible, and we may be unable to obtain any history at all. The educated practitioner, however, will be at no loss how best to proceed on such an emergency.1

The student may advantageously refer to the "Mode of Interrogating a Patient," recommended by Dr. Spillan, in the introductory chapter of his Translation of Andral's "Clinique Medicale.”

Examination of Female Patients.-In examining into the history of a female patient, we must proceed as just recommended, 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 manner in which the catamenial function is performed; and the presence or absence of any leucorrhoeal or other discharge. SECTION 4. THE CLINICAL EXAMINATION OF CHILDREN.

The importance of attending to the diseases of children cannot 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-"Il perit près du quart des enfans pendant la première année." In many of the large manufacturing towns of England, the Registrar-General's Reports 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 childhood. As Dr. West justly says-"You try to gather information 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." 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 present 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

Education Physique des Enfans.

2 West on the Diseases of Infancy and Childhood.

mine the expression of the countenance, the character of the inspirations and expirations, &c. By this time the little sufferer 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 presence or absence of abdominal pain or tenderness on pressure, may now be ascertained, and by a little management auscultation 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 resonance 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 condition 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 practitioners, generally, do not pay greater attention to recording systematic notes of their more important cases. Lord Bacon has well observed, in speaking of the deficiencies of physicians"The first is the discontinuance of the ancient and serious diligence of Hippocrates, which used to set down a narrative of the special cases of his patients, and how they proceeded, and how they were judged by recovery or death." Such narratives, 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:

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General Observations.-Name; age; married or single; if 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.

of trunk and limbs ; deformities; height; weight; countenance; eruptions on skin, their form and nature; nervous excitability; disposition to sleep; habitual state of bowels.

Intellectual and Moral Peculiarities.—Education; memory; judgment; reasoning powers; behavior; disposition; religious feelings, &c.

Previous History.-Place of birth; condition in life, and health of parents; health of brothers and sisters; family diseases; present residence, and how long resident there; occupation; mode of living, appetite, and habits, whether temperate or otherwise; habitual use of medicines, and their nature, as narcotics, purgatives, &c.,; peculiar habits; venereal indulgences.

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 discharges; 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; shivering; skin harsh and dry, or moist; disposition to be anxious and depressed, or hopeful.

Condition of Nervous System.-Pain of head, or giddiness; 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