diathesis in whom pulmonary disease has not actually declared itself.

The effects of extreme cold are first shown in causing depression of the organic functions, as is seen in the dwarfish size of men and animals in cold regions, the shrinking of external parts, the diminished cutaneous circulation, the contraction of the skin around the hair-bulbs and sebaceous follicles -producing the peculiar appearance known as cutis anserina, and in the diminished power of the sexual organs. Long and unprotected exposure to extreme cold gives rise to torpor of the nervous system, confusion of the intellect, a staggering gait resembling that from drunkenness, and to an overpowering desire for sleep, which, if indulged, almost inevitably proves fatal. Cold proves more injurious, and is less easily borne, when applied by a wind or current of air, as well as when accompanied by moisture, than when the atmosphere is dry and at rest. Diseases of the pulmonary organs are the most common affections of cold climates.

In temperate latitudes there is a less exclusive tendency to disease of any special organ than in climates nearer the poles or the equator; although, owing to the sudden vicissitudes of temperature, the frequency of cold winds, and of moisture, there appears to be a morbid tendency to inflammatory, rheumatic, and catarrhal affections.

CHAPTER V.

ON THE SYMPTOMS AND SIGNS OF DISEASE.

WITHOUT a correct knowledge of symptomatology or semeiology—the science which treats of the symptoms and signs of disease-we can know but little of the art of medicine; since a thorough acquaintance with the structural and functional disorders to which the human body is liable, essentially comprises a recognition of existing symptoms and signs, a proper appreciation of their value, source, antecedents, causes, relations, and connections with each other, and the results which may be expected to flow from them singly or in combination. The importance of carefully studying the symptoms, therefore, can hardly be over-estimated, for from them we form our diagnosis and prognosis, and learn in what direction to conduct the treatment. It follows necessarily that he will prove the best physician who is the most sagacious in observing them, and in deciphering their import and true value.

What, then, it may be asked, is a symptom? I cannot do better than reply in the words of Dr. Watson, who says"Everything or circumstance happening in the body of a sick person, and capable of being perceived by himself or by others, which can be made to assist our judgment concerning the seat or the nature of his disease, its probable course and termination, or its proper treatment: every such thing or circumstance is a symptom." It thus appears that symptoms are obvious to all persons alike, to the educated as to the uneducated, in this respect differing from the signs of disease, which are generally speaking-intelligible to the medical eye alone. Signs indeed are, for the most part, deduced from symptoms, either from one symptom or from a combination. Thus cough is a symptom of many laryngeal and thoracic affections; but combined with a hooping noise during inspiration it becomes a sign. Symptoms have been aptly compared to words taken separately or put together at random; arranged in due order, put together in sentences, they convey a meaning, they become signs.

Various divisions of symptoms have been made, which are neither very philosophical nor of much practical utility. It is necessary to mention, however, that authors speak of symptoms as local, general, or constitutional; as idiopathic, when proceeding directly from a primary disease; symptomatic or secondary, when due to secondary disorders, or those produced by the primary affection; premonitory or precursory, or symptoms which indicate an approaching disease; of symptoms which are diagnostic, since they enable us to distinguish disorders which might otherwise be confounded; or of those which are prognostic, because they denote the probable issue of a case; or therapeutic, since they indicate the treatment. Moreover, those diagnostic symptoms which are peculiar to one disease are called pathognomonic, or pathognostic. When authors speak of physical signs, they allude to those phenomena which take place in the body in accordance with physical laws; when of vital symptoms, to such as depend on the vital properties of a part or parts of the body, as irritability, tonicity, sensibility, &c.

It may almost appear unnecessary to mention that in the study of semeiology every circumstance which is at all characteristic is important; and that the form and violence of the symptoms, the particular order in which they appear, and the manner in which these signals of disease are conjoined, merit especial attention.

1 1 Op. cit. vol. i, p. 111.

We would now proceed to the proper subject-matter of this chapter, according to the following arrangement:-1. The symptoms and signs afforded by the countenance, and the general appearance and condition of the body; 2, those symptoms and signs belonging to the organs and function of digestion; 3, those belonging to the function of respiration; 4, those belonging to the function of circulation; 5, those connected with the urinary and sexual organs; and 6, those derived from the nervous system.

SECTION 1. SYMPTOMS AND SIGNS AFFORDED BY THE COUNTENANCE, AND THE GENERAL APPEARANCE AND CONDITION OF THE BODY.

The manifestations of disease which have to be considered in this section are those derived from the expression of the countenance, from the eye and the function of vision, from the sense of hearing, and from the posture, and the general condition of the body.

The Expression of the Countenance. The facial expression is of importance in the recognition, diagnosis, and prognosis of most maladies, but especially perhaps in those of young children.

When the general expression of the countenance is serene, tranquil, or expressive of hope, it may generally be regarded as of favorable import in disease, especially if such expression supervene gradually on the disappearance of restlessness and acute symptoms generally; it must be remembered, however, that it may be though it is so rarely-an unfavorable sign, as when it occurs suddenly during the progress of severe organic disease on the unexpected cessation of pain, when it frequently indicates gangrene of the affected organ, or paralysis. In chronic disorders, unattended with pain or suffering, and in the low stages of fever, the countenance is often indifferent, the look is partly fixed, and the eyes bright. In the low stage of fever, however, the movements of the lips are tremulous, and the lips themselves are covered with sordes and with a brown or black coating, like that on the teeth and tongue. Immobility of the features may generally be looked upon as a sign of debility, or of loss of consciousness, or of general tonic spasms-as catalepsy.

Anxiety and pain produce a characteristic change in the features. At the commencement of acute diseases generally, in spasmodic affections, asthma, angina pectoris, &c., in inflammations of important viscera, in disorders of the genera

tive organs, and in hypochondriasis, the countenance assumes an anxious air; a peculiar mixed expression of anxiety and resignation is also common in organic diseases of the heart, and of the great vessels. The expression of terror or of great fear, is observed chiefly in delirium tremens, in hydrophobia, in certain forms of insanity, during or after hemorrhages, and after accidents. So the expression of rage occurs for the most part in inflammation of the brain, in hydrophobia, and in insanity. A bashful, downcast countenance, with inability to look one manfully in the face, is generally a sign of nervous exhaustion from masturbation, and often of impotency. That peculiar cast of countenance termed the Hippocratic is thus described by Hippocrates: "The forehead wrinkled and dry; the eye sunken; the nose pointed, and bordered with a violet or black circle; the temples sunken, hollow, and retired; the ears sticking up; the lips hanging down; the cheeks sunken; the chin wrinkled and hard; the color of the skin leaden or violet; the hairs of the nose and eyelashes sprinkled with a yellowish-white dust." Such is the alteration in the human physiognomy which usually precedes death, or which may be produced by intense anxiety, grief, or sudden fright, or by long-continued want of sleep: in all cases it renders the prognosis very unfavorable.

But of all the appearances presented by the countenance, that caused by facial paralysis is the most striking and peculiar, since from one-half of the face all power of expression is gone; the features are blank, still, and unmeaning; the paralyzed cheek hangs loose and flaccid; and the face is drawn on one side, the healthy side being that so drawn, owing to the action of the sound muscles not being counterbalanced by the play of those on the affected side. "The patient," says Dr. Watson,1 ,1 "cannot laugh, or weep, or frown, or express any feeling or emotion, with one side of his face, while the features of the other may be in full play. One-half of the aspect is that of a sleeping or of a dead person, or stares at you solemnly; the other half is alive and merry. The incongruity would be ludicrously droll, were it not so pitiable also, and distressing. To the vulgar, who do not comprehend the possible extent of the misfortune, the whimsical appearance of such a patient is always a matter of mirth and laughter." Happily, however, there is not in the greater number of cases any cause for real alarm; protracted cold, or some external injury or wound to the facial nerve-the portio dura of the seventh pair or pressure upon this nerve by an enlarged

'Op. cit. vol. i, p. 548.

parotid gland, being often the exciting cause of the complaint. In slight cases of hemiplegia the face is often unaffected, the paralysis being confined to the upper and lower extremities of one side; sometimes, on the contrary, however, the face is the part first affected, the motor portion of the fifth nerve being more or less involved in, or influenced by, the paralyzing lesion. In such cases, the motions of the jaw on the affected side are impaired, and mastication is impeded; but unless the portio dura is also involved there is little or no distortion of the features, and no loss of expression. The disease of the motor portion of the fifth pair may be seated in or near the origin of the nerve in the brain, or, more rarely and more favorably, in the course of the nerve; when there is loss of sensibility also, the sensitive branches of the fifth pair are likewise implicated.

The appearance of the lips and mouth alone, often gives valuable aid in diagnosis. Thus, retraction of the corners of the mouth, so as to produce the sardonic grin-risus sardonicus-is very remarkable in inflamation of the diaphragm, and in certain painful affections of the stomach and bowels. So in the last stage of phthisis, or of hectic from exhausting diseases, or of cancer, the thin, retracted appearance of the lips, as if they were stretched over the gums, is peculiar. Swelling of the lips often occurs in children suffering from intestinal worms, and in incipient phthisis; in strumous subjects the upper lip is generally enlarged. After hemorrhage, in anæmia, and in diseases of the uterine organs, the lips are pallid, and at the same time inclined to crack, and become sore; so on the contrary, they present a purple hue, when, from any cause, the blood is imperfectly arterialized, and when there is congestion of the thoracic viscera.

The hue or color of the countenance should be noticed. A pallid or anæmic tint attends all diseases caused by, or giving rise to, poverty or thinness of the blood, with a deficiency of the red corpuscles; a generally diffused redness of the face attends inflammatory fevers in their early stages; a dark, murky tint shows a morbid condition of the circulating fluids; a continued sallowness is common in diseases of the liver, with insufficient secretion of bile, as well as in diseases of the spleen; jaundice is caused either by some impediment to the flow of bile into the duodenum and the consequent absorption of the retained bile, or by defective secretion on the part of the liver, so that the principles of the bile are not separated from the blood; a blue, leaden tint is seen in cases of malignant cholera; while the face becomes livid, in obstructive diseases of the heart or great vessels, in general acute bron