No. 3457.

NOVEMBER 30, 1889.

Clinical LecturesDelivered to the Students of the

MANCHESTER ROYAL INFIRMARY

during the Summer Session, 1889,

BY THOMAS HARRIS, M.D. LOND., M.R.C.P.,SENIOR ASSISTANT PHYSICIAN TO THE INFIRMARY, PHYSICIAN TO THE

MANCHESTER HOSPITAL FOR CONSUMPTION AND DISEASES OFTHE THROAT, AND SENIOR DEMONSTRATOR OF

PATHOLOGY IN THE OWENS COLLEGE.

LECTURE II.

THE DIAGNOSIS OF THE EARLY STAGE OF PULMONARYPHTHISIS.

GENTLEMEN,-The diagnosis of phthisis in its earlystage is often most difficult, and you will find that you notunfrequently meet with cases which will cause you con-siderable anxiety, on account of the difficulty of coming toa conclusion as to whether you have to deal with phthisisor with a less serious ailment. It is scarcely necessary forme to point out to you the importance of being able toarrive at a correct diagnosis in such cases. A mistake indiagnosis may have many serious consequences. In thefirst place, if we err in saying that a patient has phthisis,when there is no such serious lesion present in the lung, WEshall not only cause the patient and his or her friend;unnecessary anxiety, but we shall probably be the caus(of a serious interruption to the patient’s education or to hiiprofessional or business career. If, on the other hand, wffail to diagnose a case of phthisis, when we have seen it iran early stage, we lose most valuable time. If cases ojphthisis were recognised more frequently at an early date.and proper treatment could be adopted, there would be pro-bably even more cases of arrest or of complete recoverythan at present ensues. Doubtful cases of phthisis are so- common that the question of the points which are of mostvalue in the diagnosis of the early stage of the disease isone of the first importance. The difficulties attending thediagnosis of phthisis in its early stage are often very great.In some cases, however careful and skilled the medical manis, a positive diagnosis cannot be made, and we are com-,pelled to act upon probabilities. There are many cases whereit is absolutely impossible to state definitely and with cer-tainty whether a person is or is not suffering from the com-mencement of pulmonary consumption. There are manycauses of this difficulty, but the most common one is pro-duced by the great variability in the physical signs which- cases of early phthisis present. Cases of acute phthisis, andof chronic phthisis beginning abruptly, present difficulties of.a different nature from those presented by phthisis of gradualand insidious onset. In the former cases we usually haveno difficulty in recognising the fact that we have to dealwith a serious disease. Our difficulty is in recognising itsexact nature-for instance, whether it is a case of acutepneumonia, enteric fever, or acute phthisis ; whereas inthe case of chronic phthisis which has commenced graduallyand not abruptly, we more commonly have a difficulty incoming to a conclusion as to whether we really have to dealwith a serious ailment. This latter class of cases are mostcommonly mistaken for the less serious affections, bronchitis-or for simple anasmia.The first point of value in the diagnosis of the early stage

of phthisis to which I wish to direct your attention is thehistory of the case. You will often find that the history ofthe illness, of the previous health, and the family history,are of immense value to you. It is common for patientssuffering from the early stage of subacute or chronic phthisisto tell us that they have had a cough for the past few weeksor months. This cough has been probably only especiallytroublesome at night or the first thing in the morning. Thecough has been accompanied by the expectoration of a smallamount of phlegm, which on one or more occasions has beennoticed to be streaked or tinged with blood, or they mayhave had a more profuse haemoptysis; that recently theyhave lost a considerable amount of flesh and have felt lessable than formerly to perform their usual duties. Suchhistory differs from that usually met with in a case of IN ’!7

bronchitis, which is the disease most commonly mistakenfor phthisis. Bronchitis is more frequently met with inpersons of advanced age than is the case with phthisis, andwhen chronic bronchitis is seen in young adults we mostcommonly find that it has been of very long duration, andthat they have been subject to repeated attacks since child-hood. So that the first points of importance bearing on ourpresent subject are the age of the patient and the durationof the symptoms. A history of cough for a long time pastwith the absence of definite physical signs of phthisis speaksvery much against phthisis.Then the history of haemoptysis is very important. A

profuse haemoptysis in the case of young adults is, in themajority of cases, the result of pulmonary phthisis. Asregardssmaller attacks of haemoptysis, such as the appearance ofstreaks of blood in the expectoration or a diffuse tinging ofthe sputum, the case is somewhat different. You not un-commonly find patients with chronic bronchitis, especiallywhen the cough has been very troublesome, tell you thatthey have on a few occasions expectorated a small quantityof blood. Nevertheless, streaks of blood in the phlegm, orblood diffused through the sputum, are of far more frequentoccurrence in the case of phthisis. Where we have ahistory of cough which has only been present for a fewmonths, and where the expectoration has contained bloodon several occasions, the significance of the presence of thehaemorrhage can scarcely be overrated, and should makeyou especially careful in the examination of the chest.

- ’ Although a history of haemoptysis is of great importance,, it is frequently necessary to make very careful inquiries asto its frequency, its amount, and the duration of the attacks.

3These inquiries are necessary because, among the numerouscauses of the expectoration of blood other than pulmonaryphthisis, we occasionally meet with one which is especiallyliable to mislead and to give rise to trouble in diagnosis. Ii refer to the cases which have been described as "spurious

r hmoptysis." Patients so affected are in the habit ofperiodically expectorating small quantities of blood, and,although the amount at one time is rarely large, they

expectorate small quantities for long periods and at notinfrequent intervals. It is not always possible to saywhence the blood arises in these cases, but in many youwill find that the teeth are much decayed and the gumssoft and spongy, readily giving rise to haemorrhage onpressure, and it is probable that in such instances the gumsare the source of the expectorated blood. So that it is verynecessary to examine the mouth in cases where you are indoubt as to the true nature of the haemoptysis. By afortunate coincidence, we have two patients attendingthe out-patient department at the present time who aresuffering from this form of haemoptysis, and who I am ableto show you. The first case is that of a young female adultwho came to the infirmary complaining of " spitting blood."The most noteworthy point in her history is that, althoughthere has never been any profuse haemoptysis, she has beenexpectorating a small quantity of blood a few days in nearlyevery week for the last twelve months. There could be nodoubt about the accuracy of her statement that she didexpectorate blood, because we saw her do so whilst in oneof the dressing-rooms. Examination of the chest revealedno signs of phthisis, but, although the gums were notspongy, blood was found to be oozing from the gum at theside of one of the upper bicuspid teeth. As you see,she is a very nervous girl, a condition not uncommonin patients with this form of haemoptysis. It is not at allprobable, however, that the case is one of malingering. Theother case is that of a man thirty-one years of age, who is,as you observe, a very delicate-looking person, and not at

all unlike a man suffering from phthisis. He states thathe has not much cough, but that he has been repeatedlyexpectorating small quantities of blood during the pasteighteen months. The physical examination of the chestreveals no signs of phthisis-in fact, as is evident to you ata distance, the upper part of the chest expands exceptionallywell. The teeth, however, are very much decayed and thegums spongy, and there can be little doubt that the gumsare the source of the haemorrhage.Although I bring forward these two cases to illustrate a

haemorrhage not the result of phthisis, I hope that you willnot be too ready to explain a haemoptysis by saying it comesfrom the gums or from the throat. Persons are commonlytold that the source of haemorrhage is the throat, evenwhen such a statement is not made in order to calm their

1100

fears, whilst in reality it arises from early mischief in thelungs. You will do well to regard all cases, where there isa history of even slight haemoptysis, as serious until you cansatisfactorily explain to yourselves the source whence theblood arises. A history of a profuse liemoptysis or of therepeated presence of small quantities of blood in the expec-toration is to be regarded as of great value in the diagnosisof the early stage of phthisis.

0

Another point in the history of cases of phthisis is the lossof flesh. The history of emaciation is very important, andvery frequently, now that automatic weighing machines areso widespread, persons are able to tell you how much theyare below their usual weight. The loss of weight in themajority of cases of phthisis is a most marked feature. Itis true that persons affected with bronchitis often lose fleshconsiderably, but it is rarely such a marked feature of thecase as in phthisis. It is also true that some persons affectedwith phthisis retain for a long time their usual weight, butsuch cases are exceptional and do not materially lessen thevalue of a history of marked loss of flesh.There is one point in the history of phthisical cases which

has not received the attention of observers which it prob-ably deserves. This is the history of previous illness.Phthisis probably becomes arrested far more frequently thanis usually believed to be the case, and careful inquiry intothe history of the state of health of a patient suffering fromphthisis will often elicit the fact that the present attack isnot the only one from which they have suffered. Mostcommonly we find that phthisical patients will give a his-tory of previous attacks of " bronchitis" or of " inflamma-tion of lungs," and in many cases these illnesses have inreality been not bronchitis or simple inflammation of thelungs, but phthisis which has been temporarily arrested.In other cases we get a history of some illness whichhas been very obscure at the time and has been incor-rectly diagnosed; but a careful inquiry into the sym-ptoms renders it probable that the previous illness wasphthisis, which became arrested. Lately several of suchcases have come under my own observation, and I am ableto show you one patient where the illness from which theman had previously suffered was at the time stated to betyphoid fever. The man is a delicate-looking person, thirty-one years of age. He states that his present illness beganonly six weeks ago. During this time he has been ex-pectorating a considerable amount of phlegm, has had avery troublesome cough, and has lost flesh. The physicalexamination of the chest reveals definite signs of phthisisin an early stage. He stated that, with the exception ofhaving had " typhoid fever" four years ago, he had enjoyedgood health, and had had no other illness. Careful inquiryinto the symptoms of the illness said to have been typhoidleft no doubt in my own mind that what he had previouslysuffered from was not typhoid fever but probably phthisis,which subsequently became arrested. There had been nosymptoms of typhoid, but he had been laid up in bed forseveral weeks with a cough, which had been present fromquite the commencement of the illness, and he had repeatedsmall attacks of haemoptysis. The cough persisted afterthe acute period of the illness for several months, and hethen became free from it and remained in good healthuntil the onset of his present illness six weeks ago. Itis not common for attacks of phthisis which have becomearrested to be mistaken for typhoid fever. Very fre-

quently the illness has been an obscure one, and notcorrectly diagnosed. But the most frequent history toget is that the person has had what was believed to bebronchitis or simple inflammation of the lungs. So that

you will often find that the careful sifting of the previoushistory is of great value as a help in diagnosing the earlystage of tubercular phthisis.

n

The family history is also sometimes of importance inenabling us to come to a conclusion in a doubtful case ojphthisis. Where there is a marked history of tubercle in th(family, slight physical signs and symptoms of phthisis havffar greater significance than they would have if presenteeby a person with a good family history. A case at presentunder observation at the Manchester Consumption Hospitaillustrates the value of the family history. It is that of s

girl who came to the out-patient department about foumonths ago. At that time she was moderately welnourished. She presented signs of consolidation of thlleft apex, but her illness was an acute one. It ha(begun abruptly only two weeks previously, up to which timishe had always enjoyed very good health. The phy

sical signs were consistent with the case, being one ofsimple acute pneumonia; but the history of tuberculosisin the family was so marked that the diagnosis of phthisiswas rendered more probable. Her mother and father hadboth died of phthisis ; her brother was at that time attendingthe hospital, and was in the third stage of the disease; shehad lost one sister of consumption, and her other sister was,in a delicate state of health. The subsequent history of thecase has proved that it was one not of simple pneumonia,but of phthisis. You will understand, therefore, that thehistory of the illness, the history of the previous health, andthe family history are each of importance in the diagnosis.of cases of phthisis. Often you will find great help bygiving careful attention to the points in the history of thecase, because, as we shall see, the physical signs in the earlystage of phthisis are often very indefinite.The physical signs at the commencement of phthisis vary

considerably in different cases. The signs presented by theacute cases and by the chronic ones which have begunacutely differ from those met with in the chronic cases

which have shown no acute onset, but which have beguninsidiously. We will, however, consider the physical signs.commonly present in the early stage of phthisis, irrespectiveof the differences met with in various types of the malady.The importance of inspection as a method of physical

diagnosis of diseases of the chest can hardly be overrated.By simply looking at a patient we often obtain most.important information, and have our attention directed to.facts which would otherwise escape recognition. It is a,

well-known fact that students and medical men make moremistakesthrough carelessness than from ignorance. Mistakesin the diagnosis of chest ailments are very commonlyattributable to a neglect to employ inspection carefully-It is no unfrequent occurrence to see a student, who isgiven a chest case to examine, at once proceed, after he hasmade a few preliminary inquiries into the previous historyof the illness, with percussion and auscultation, withoutever first carefully looking at the patient generally, or at,his chest in particular. If we all made it a rule to spend afew moments in simply looking at our patients, withoutproceeding with a more detailed examination, we shouldmake fewer mistakes, and find the time so employed wellspent. These remarks on the value of carefully employinginspection apply to all chest cases, and you will find thatin the diagnosis of the early stage of phthisis a carefulinspection will often give you valuable aid. I show youhere a patient who illustrates the value of inspection insuch cases, and specially the importance of getting a goodand full view of the chest. With female patients this isoften a difficulty; but it is impossible to make a careful andsatisfactory examination of a female’s chest if such a persononly unfastens the dress and underbodice. This patient is.a delicate-looking girl who has some symptoms of phthisis,but in whom the physical signs are very indefinite. Youwill notice, however, at the lower part of the neck and at theouter part of the right infra-clavicular region two large scars.These scars are in such a position that they might easily beoverlooked if the chest had not been freely exposed to view.The presence of the scars, however, is of great importancefrom a diagnostic point of view. They indicate that this.patient has some time ago had scrofulous disease of thelymphatic glands, and we know that such persons often ata later period of life suffer from pulmonary phthisis. Thepresence, consequently, of these scars makes us attach moreimportance to the symptoms from which she is suffering,and to the slight and indefinite physical signs of phthisis,

, than we should do in a healthy-looking person who pre-. sented no such indications of previous tuberculosis. Persons

with phthisis are usually spare, ansemic, and the shape ofthe chest in many cases differs from that seen in healthy

l individuals. These signs are also often present in the earlyE stage of the disease. The chest is often long and narrow,; with a small antero-posterior measurement. On careful

inspection we can frequently observe that the upper part ofl the chest on one or both sides shows imperfect movement,b the expansile movement being most frequently deficient.1 On percussion you can in the early stage of many casesdetect no difference between the two sides. But in ther majority of cases, and especially in cases where the onset1 has been a gradual one, we find that the patients do not3 come under our observation until the percussion note is1 altered. In many cases we can only detect impairede resonance over one apex, over the supra-clavicular, clavi-- cular, or infra-clavicular regions, or behind over the extreme

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upper part of the interscapular region or supra-spinous fossa.There are not sufficient data for ns to say which of theseregions most frequently presents the abnormal signs in the.early stage of phthisis. My own experience leads me todirect your attention to the examination, with special.care, of the posterior parts of the apex of the lung, to the- examination of the extreme upper part of the interscapular.and the supra-spinous regions. I believe that the examina-tion of the posterior parts of the lungs more commonlyogives us definite results than the examination of the anteriorportions. In other cases there is no impaired resonanceover the diseased apex; but the volume of sound obtained- on percussion may be actually greater than over the healthyapex. In many of these cases we find that, although thevolume of sound is greater over the diseased apex, the pitchis raised and the quality altered, the latter often being’hard or wooden. In other cases the percussion note is ofa different type, being an approach to the tympaniticquality, and which has been described under the name of2us’u’lbitt;m"panitic." These cases, where the actual volumeof sound is not diminished or is actually increased, are notunfrequently misleading. An inexperienced observer mayreadily mistake the healthy for the affected side. I showyou here a case of undoubted early phthisis, where the per-cussion note over the upper part of the interscapular regionof the right side is not dull, but of the sub-tympanitic quality.Another point which you can frequently detect even in an

FIG. 1.

e’arrly case of phthisis is the increased resistance to thi

finger which is acting as the pleximeter. There is one sigrof consolidation of the apex of a lung which has not receivecin this country the attention which it probably deserves.The effect of consolidation is to diminish the volume of theapex, and that diminished volume can often be demonstratedby percussion of the apex. If we percuss out the upperlimit of the lungs in a healthy individual, it is found thatthe upper limit is the same on both sides, the upper limit asobtained by percussion not being higher on the right than theleft side. In cases of early phthisis, however, the upperlimit of the affected apex is lower than that of the healthylung. The difference in these cases may be marked in frontand behind, or in only one or other of those regions. Inmapping out the upper limit of the lung, you will lind it mostconvenient to stand behind the patient, even when per-cussing the upper limit of the anterior aspect of the apex.I show you here a patient affected with early phthisis wherethis difference in the height of the apex on the two sidesis evident. (Figs. 1 and 2.) Figs. 1 and 2, taken from aphotograph, show the difference in the upper limit ofpulmonary resonance in front and behind in a case ofconsolidation of the right apex. In reference to thispoint of the diminution in the volume of the apex, youmust be warned that you may be unable to recognise Iany difference between the two sides in consequence

1of the presence of emphysema round the consolidated Iportion of lung. It is a sign, however, which in some cases ,s

is of value in the diagnosis of early phthisis. I believe iwill be found especially of value in those cases where we finimpaired resonance over one apex, and where we are unablto say whether such impaired resonance really indicates an,consolidation of the lung beneath, or whether it is only ;difference which may be present in some persons who havno lung mischief. If we find that there is not only impaire(resonance, but that the upper limit of the apex on that sidlis lower than on the other side, we then have evidence thathe impaired resonance is probably due to actual change iithe lung beneath.Vocal fremitus gives us very little help in the diagnosis

of early tubercular disease of the lungs. We might expectthat the consolidation would cause an increase of the voca]fremitus ; but the early changes in phthisis occurring mostcommonly in the apex, and being also of limited extent, weare as a rule not able to recognise any difference between thevocal fremitus of the two sides.The auscultatory signs in the early stage of phthisis vary

considerably. In some cases the most careful examina-tion of the whole chest may fail to reveal any abnormalsounds. As a rule, however, we can by careful comparisonof corresponding parts of the chest recognise either somealteration of the respiratory murmur, or the presence ofsome variety of adventitious sounds, such as crepitations,rhonchi, or friction sounds. As regards the alterations ofthe vesicular murmur which are met with in early phthisis,

FrG. 2.

, we may find that simply weaker, without any alteration iuits quality, over the anterior or the posterior aspect of oneapex, as compared with the corresponding part of the otherside. This weak vesicular murmur is certainly very com-monly heard over an apex in early phthisis. It may be theonly feature to be recognised, existing alone without anyalteration in the quality of the inspiratory portion, andwithout any prolongation of the expiratory division.In other cases the respiratory murmur is divided, and

the expiratory portion is more or less prolonged. Greatcare is requisite in recognising this divided respiration andthe prolongation of expiration. It is very easy to mistakethe transmitted pharyngeal sound for prolonged expiration,and another frequent source of error arises from theartificial separation of the inspiratory from the expiratory,and the rendering of the expiratory portion more distinctthan is usual by the manner of respiration. It is certainthat we not unfrequently get divided respiration with theexpiratory portion more distinct and prolonged, where thepatient is told to take a deep breath, without there beingany consolidation of the lung near the part of the chestauscultated. It is the fact of one or both these signs beingaudible at some point oa one side, whilst the phenomenonis not audible at the corresponding point of the other side,which gives the sign its value. So that a most carefulcomparison of the two sides must be made. I think, how-ever, that the value of the prolongation of expiration as’a sign of early phthisis has been much exaggerated, and,

1102

as Dr. Walshe states, when unaccompanied by any alterationin quality, it must be received with great caution as a signof that condition.

In some cases the inspiratory portion of the vesicularmurmur is not smooth and uniform, but is irregular,wavy, or jerky. Here, again, it is necessary to warn youto be careful in your observation, because inspirationmay become uneven and irregular in consequence of themanner in which the patient respires, apart from anychanges in the lung ; and also consolidation of the lung isnot the only cause of true jerking inspiration. In othercases the inspiratory portion of the vesicular murmur isharsh, whilst the expiratory division is not altered. In stillother cases the expiration is harsh and prolonged, and sepa-rated from inspiration by a short interval. In some casesthe breath sound is more than harsh ; it is quite bronchialin type. Bronchial breathing, however, is not commonlyaudible in the early stage of chronic phthisis, but it

may be heard at a very early period in that variety ofphthisis which in our pathological classification we termedthe confluent or lobar variety of caseous pneumonia. Inthe early stage of chronic phthisis the breathing is morecommonly harsh than truly bronchial.

(To be continued.)

Introductory AddressON

THE ART OF OBSERVING.Delivered at the opening of the Session of the Belfast

Royal Hospital,BY JAMES ALEXANDER LINDSAY, M.A., M.D.,

PHYSICIAN TO THE BELFAST ROYAL HOSPITAL, CONSULTINGPHYSICIAN TO THE ULSTER HOSPITAL, &C.

LADIES AND GENTLEMEN,-My first words to you thismorning must be those of welcome. Some of you are

returning to the scene of former labours, others appearamongst ua to-day for the first time ; some of you are onlyon the threshold of the medical curriculum, others are

approaching its goal ; on behalf of the staff of this hospitalI bid you all heartily welcome, and on their behalf also Iexpress the earnest hope that the days spent by you withinthe walls of this institution may serve to lay for each ofyou the foundations of an honourable and prosperous career.

Standing here to-day, my thoughts naturally revert to themorning when I sat for the first time as a student uponthese benches and listened to an address from my esteemedfriend and colleague, Dr. Ross. I remember very vividlythe feelings of that day-feelings of doubt and apprehensionregarding the future, and of helplessness and ignorance inview of the great world of disease just beginning to openbefore me. If feelings in any way analogous to these shouldaffect you this morning, let me express my full sympathywith them- the sympathy which comes of practical expe-rience. I speak to you to-day as one who is still near

enough to his student days to recall all their hopes andfears, their difficulties and misgivings, and who will thinkhis best efforts well spent if he can in any way lighten yourlabours and facilitate your progress.

I do not propose to stay this morning to offer you anyexhortations to diligence and industry. I have had too

many proofs both in my present and my late position inthis institution of your zeal and capacity for work, to thinkthat such exhortation is needful. Your zeal, I feel sure,needs guidance rather than stimulation. Some of you Imay have found deficient in knowledge, in powers of obser-vation, or in accuracy of reasoning. Idle or indifferent Ihave never found you, and I believe I never shall find you.Therefore I shall not stay to remind you, except in thebriefest manner, that you are now entering upon the mostcritical period of your existence. You have only one life tolive; only one period of preparation for that life; only onespring-time for the sowing of the seed, which your wholeafter life will be spent in reaping. This is true of all men ;it is doubly true of you. You have chosen a career among

the most responsible and difficult in the human lot. Nowis your time for ensuring that that career will be one ofbenefit to others and honour to yourself, not a career ofuseless regrets, of ineffectual efforts to overtake the los#hours, and of ultimate failure. Now’.J.re open to you theopportunities and facilities for becoming masters of your-art. They are offered once, and once only. Men of excep-tional talent and uncommon energy may in after life recover-the ground lost in youth, but in the great majority of cases.the loss is final and irreparable. The converse is no less.true. Good work done by you now cannot fail of its reward.This reward may not to all of you take the form of wealth-or repute, but reward there will be in some shape. At the-lowest, you will have the consciousness that you know your-busines-3 in life, that your opinion and judgment are reallyworth something, that you are good workmen, not bunglers.intermeddling with what others could do better. Fix your-mind, then, to-day steadfastly upon this ideal of personalefficiency, of individual competency, and cherish the hope.’that if this be assured the future must bring you some share’of happiness and satisfaction. Use the opportunities thatare now open to you; dwell in the present, but endeavourthat the present be such that you may never have to lookback upon it with self-reproach. Take as your motto thewords of the great German poet, Goethe,

" Ernst ist das Leben, mochte ich es fuhlen,"or the still higher note of our own Milton,

" Nor love thy life, nor hate; but what thou liv’stLive well; how long or short, permit to Heaven."

I propose to spend our time together to-day mainly haconsidering the faculty of observation, its mode of exercise,.how it may be developed, and the errors and fallacies to-which its exercise is liable. How to observe, what to>observe, what errors to shun while observing, these are ourtopics, and I need not dwell upon their supreme importance.The entire science and art of medicine rest primarily uponthe recognition of the indications of disease. All our treat-ment, all our forecast of the probable course and durationof disease, rest upon our power first to observe, and thento reason from, the signs by which we recognise its existence.Diagnosis is the foundation both of prognosis and thera-peutics, and you need not wonder at the large place-almostthe exclusive place-which diagnosis holds in clinical instruc-tion. To diagnose correctly you must first observe correctly.The rest is then usually easy. When the medical student

first enters the wards of a large general hospital he isconfused, bewildered, perhaps discouraged, by the varietyand complexity of the morbid phenomena which meet hiseye. He seems to walk through a mighty maze, and for a.time it appears without a plan. He is at a loss how tobegin his examination ; he knows not what questions are-pertinent to put; he is uncertain which of the various.instruments of precision he should first call to his aid.Obviously, what he needs is some method by which to-proceed. Two rules seem to me at this stage to possesshigh value: (1) employ your own senses -sight, touch,hearing, &c. -- in a certain definite and fixed order, and’(2) observe a similar fixed order and routine in examiningthe various organs of the patient’s body. Let the cuta-neons, respiratory, circulatory, digestive, urinary, repro-ductive, and nervous systems pass successively underrevie’.v. When you have acquired a considerable practicalacquaintance with disease, you may afford to dispense with.this routine, and may often reach your goal by a shorterroad, but while your knowledge is limited and your ex-perience small you cannot safely ignore any of these stages.Let us look at these two rules a little more closely.

In observing the phenomena of disease we employ mainlythree of our senses-sight, touch, and hearing. Taste andsmell, although occasionally useful, are only exceptionally-required. Your business, then, in the main is to learn allyou can by the use of the eye, the hand, and the ear. Look,feel, listen-this is what you have to do, and you had best,take the stages in this order. This is the natural order, the’order of passing from the simpler to the more complex, andits observance helps wonderfully to keep our ideas clear andsystematic. No mistake is more common among studentsthan reversing this order or hovering between two of thesemethods. Thus a student approaches a case which he hasreason to suspect is one of cardiac disease. In nine casesout of ten he at once applies his stethoscope, hears a.murmur, makes up his mind as to its nature, and forth-with gives his opinion. Now, how much surer his diagnosis.