ing these points and we do not exactly know whether a fever from an infection is favorable or unfavorable or of neutral importance to the animal economy. Thus our antipyretic efforts through hydrotherapy or chemical antipyretics may or may not be of value in a given case, but may be rational as favoring increased elimination through the skin, etc. Our knowledge regarding subnormal temperature is meagre.

The temperature is a very important aid to diagnosis. A fever temperature may mean very little, but it always means something, and should stimulate us to look for and, if possible, to find the cause. A single notation of temperature is not of much value in obscure disease, and it frequently becomes necessary to study the temperature curve extending over one, two, or more weeks. A daily remission to the normal usually excludes typhoid fever and speaks for malaria. Unresolved pneumonia and tuberculous pneumonia show a marked difference in the temperature curve. A sudden rise of temperature following an operation puts us on our guard for a complication. Mild abdominal symptoms and a low fever curve in children, in the absence of a painful appendix and of Widal's typhoid fever reaction, are suggestive of tuberculous peritonitis. Thus, in obscure cases, the patient, if not in a hospital or under the care of a trained nurse, must be taught to take and note his temperature several times a day. According to the writer's observations, adults and children with valvular heart lesions sometimes have a "normal" temperature of 100° F. In acute indigestion in children very high temperatures are observed, and some children show very high temperature from any slight cause. The term aseptic fever is sometimes employed by surgeons to designate a rise of temperature following an operation which can not be localized as to cause and which is unaccompanied by other symptoms of septic infection.

Clinically, high temperatures have been observed in tetanic muscular contractions, in infectious diseases, in insolation, and in lesions of the bulbocervical cord. In acute illness the temperature may be taken every four hours or at the time of a chill. In chronic illness once or twice a day is sufficient. The various types of fever-continued, remittent, intermittent, irregular, etc.will be mentioned in their clinical relations to disease.

Pain; Tenderness; Paræsthesia; Headache.-Pain may be acute or dull or paroxysmal or shifting-gnawing or crampy or tenesmic or pulsating. It may increase by motion and disappear on firm pressure.

Pain, as a symptom in children and adult neurotics, is not always a reliable factor on which to base a conclusion. The cause or origin of a given pain is to be made out by the associated signs and symptoms. It is generally true that if we elicit tenderness in an organ that organ is disordered. It is important to note the character and the seat of pain. It must not be forgotten that we meet with many instances of pain quite remote from the seat of the trouble which produces it, i.e., children frequently complain of pain in the abdomen in pneumonia or pleurisy.

Pain in joints and muscles is easily made out on motion and is as readily simulated. Pain in vomiting and defæcation and urination or coughing is usually characteristic owing to posture and expression. The hydrocephalic cry is characteristic. Intestinal, renal, biliary, and appendicular colic, gastrointestinal neuroses and crises, and pains from intestinal worms and pelvic adhesions are not always easily distinguished from one another. The agoni

REGIONAL EXAMINATION

15

zing pain of angina pectoris is characteristic. Pain in the region of the heart or kidney is usually muscular. When children have pain in the ear they hold their hand to the affected side and the head is held in a strained position on account of indurated and painful lymph nodes behind the ear.

Certain forms of disease have characteristic points of pain on pressure, which are mentioned elsewhere.

The diagnostic import of the seat of pain can not be scheduled, but its exact location is very important in diagnosis. Headache is a symptom of multiple origin and deserves special mention. A localized neuralgic headache or pain is frequently of malarial origin, but may also be due to local irritation. A dull general headache and coated tongue are generally due to indigestion. Headache may be of reflex character and take its origin in any disturbance of the bodily functions-circulatory, digestive, respiratory, eliminative, or excretory. It may accompany acute and chronic infection or take its origin in the nervous system-from fright, in injury, from hunger or fatigue, from eye strain, from disease of the sexual organs, from nasal irritation, from bad teeth, or from anæmia or hysteria. Persons who live in overheated and ill ventilated rooms are subject to headache.

In parasthesia there are subjective sensations such as formication, itching, bearing down, numbness, burning, cold and heat, girdle sensation, præcordial tightness and constriction, which will be discussed in their relation to special diseases.

The Preliminary Examination of the Urine and Blood.-After eliciting and grouping the symptoms in a given case of illness, we are ready to proceed with the special or regional examination in order to ascertain whether we have to deal with a structural or functional disturbance.

Before we begin our regional examination we should, if circumstances will allow, make a preliminary examination of the urine. This is of the utmost clinical importance. A qualitative examination of the urine for albumin, sugar, and bile can be made in five minutes, and the knowledge it imparts is like a guide post at a cross road-it points in the direction of a correct diagnosis.

A preliminary examination of the blood for Plasmodium malaria in febrile disease is also important and enables us to inaugurate specific treatment if necessary without much temporizing. Whenever a blood examination can not be made immediately in a suspected case of "malaria " we may with advantage send out a "diagnostic feeler "in the shape of a brisk cathartic combined with quinine (the therapeutic test).

REGIONAL EXAMINATION

It is assumed that the practitioner and advanced student are familiar with physical diagnosis methods and with the employment of ordinary specula and instruments for regional examinations, the use of which can not be learned from books, without which knowledge no one is competent to make a regional examination.

A REGIONAL EXAMINATION IS FACILITATED BY GROUPING THE REGIONS AND ORGANS IN CONFORMITY WITH MODERN SPECIALISM, AND BY BEARING IN MIND THAT WE MAY CONSTANTLY MEET WITH MALFORMATION, INJURIES,

ACUTE AND CHRONIC INFECTIONS AND THEIR SEQUELÆ, PARASITIC INVASION, AND AN UNLIMITED NUMBER OF REFLEX NEUROSES AND INTOXICATIONS FROM

WITHOUT OR FROM WITHIN (BY REASON OF FAULTY INTERNAL SECRETION).

SPECIAL EXAMINATIONS

Examinations with Röntgen Rays are an established feature in medicine and surgery. X ray pictures, like all shadowgraphs, are apt to be deceptive and misleading. Stereoscopic or double ray prints are apt to give a clearer insight into the actual relation of the parts than plain shadowgraphs. In making an x ray exposure, every precaution should be taken to avoid burns. In lengthy exposures the tube must be from ten to fourteen inches from the skin and the latter may be anointed with vaseline.

Transillumination of organs and regions by means of condensed light occasionally gives definite results.

The Tuberculin Test, which is of inestimable value in detecting bovine tuberculosis, may occasionally be employed; but in the present state of our knowledge the writer does not advocate its routine employment. See also article on Tuberculosis of Lungs.

Exploratory Puncture and Incision are not performed often enough, and many a doubtful case could be readily cleared up by such a procedure under antiseptic precautions.

Other Examinations, such as an examination of a patient in a comatose condition, are extremely unsatisfactory as a rule. One should be very guarded in expressing an opinion in such cases, and emergency treatment is indicated without an exact knowledge of the underlying condition. See Coma.

Finally, cases will be met with in which the practitioner is compelled to anææsthetize the patient in order to clear up certain conditions. Hysterical contractures and stiff joints are thus detected, and a painful examination is made possible by the complete relaxation which anaesthesia affords. When anasthesia is employed for diagnostic purposes, the patient has a right to expect that the evidence to be elicited should be conclusive one way or the other. For laboratory findings, see following chapter. When a positive diagnosis has been made the line of treatment to be adopted is self-evident, and it should be carried out on the principle of "non nocere." When the diagnosis is "in dubio," the treatment is naturally symptomatic.

CHAPTER I-Concluded

LABORATORY AIDS TO CLINICAL DIAGNOSIS

SYNOPSIS: List of Apparatus and Chemicals.-Examination of Urine, Fæces and Entozoa, Gastric Contents, Sputum, Discharges, Exudates, Transudates, Puncture Fluids, Cyst Contents, Breast Milk, Cultures (Bacteria), Blood, Tissues, Calculi.—Drinking Water. -Remarks on Cytodiagnosis (cell diagnosis), Cytolysis, Hæmolysis, Cryoscopy.-Estimation of Renal Function by means of Phloridzin.-Directions for Preparing Specimens.

INTRODUCTORY REMARKS

The Laboratory is to the physician what the clearing house is to the business man. Laboratory work is necessary for correct diagnosis. The microscope shows a series of specific microorganisms, and also changes in tissues and blood. Pathological changes in the eliminative organs may often be inferred from a clinical examination of various secretions.

While fine laboratory work is a specialty in itself, the general practitioner must avail himself of such laboratory facilities as are at his command. As a matter of expediency and convenience the gross analysis of urine, blood, spu tum, and stomach contents can readily be made, as heretofore, in the office. The value of laboratory reports depends upon the time, care, and knowledge employed in making them. In important cases the knowledge and technique of the observer must be beyond question, and the clinician must rank foremost in the final adjustment of therapeutic measures. In acute illness, however, the proper management of suspected disease should not be delayed until a laboratory report is obtained. Many death certificates have been written in diphtheria cases because the practitioner waited for a laboratory report before giving antitoxine.

A complete outfit of apparatus and chemicals can be obtained from large drug firms.

METHOD OF PROCEDURE IN EXAMINING URINE

Color.-Wide variation in normal urine. Usually amber colored, light or dark according to concentration. The presence of blood gives color from carmine to jet black, depending upon amount and upon changes which it may have undergone. Bile gives the urine color from greenish yellow to greenish brown. Chyle occasionally found in urine makes it milky. Poisoning from carbolic acid and its related drugs makes urine often smoky or black. Salol has been observed to make urine green. Rhubarb and senna may give a brown or deep red color. Methylene blue makes urine a greenish blue.

Odor. Similar to odor of bouillon; more often it is aromatic. When undergoing fermentation or decomposition, it has an odor peculiar to itselfthe so called "urinous odor," more often fœtid and frequently ammoniacal.

Turbidity. May be due to urates, phosphates, pus, epithelium, bacteria, casts, and chyle in suspension. Persistent turbidity is almost always due to pus, most frequently it is due to bacteria; when due to pus alone, the urine becomes clear on standing, a greater or less abundant sediment being deposited. Elongated needles of monohydrated magnesium phosphates are sometimes found in the urine of persons who have taken magnesia internally. Phosphates are precipitated by heat and dissolve on the addition of nitric acid.

Consistence. Usually fluid. Sometimes presence of pus and mucus render it thick and viscid. In chyluria the urine often coagulates.

Reaction. Normally acid, intensely so in fevers and in certain diseases. of the stomach where HCl secretion is diminished; in gout, lithæmia, acute articular rheumatism, chronic Bright's disease, diabetes, scurvy, leucæmia, etc.