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 tò 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 1 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: 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, sphincters, 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 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 tenderness of abdomen; results of manual examination; bounda ries of liver and spleen; auscultation; tumors; hernial protrusions; hemorrhoids. Condition of Urinary Organs.-Mieturition easy, frequent 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 employment of reagents, nature of pellicle or of deposits—if any; miscroscopical examination. Causes of Illness.-Assigned cause; probable cause; duration of. Diagnosis. General Rules of Treatment.-Regimen; diet; prescription. 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 examination 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 management all the important features of the case can be recorded, and they are at all times seen at a glance. Date. Disease, Name and address. No. of ward and bed. Age; single, married, or widowed. Date, and character of last labor. Date of marriage. 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 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 scissors 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 |