ease.

By the ear, we take cognizance of a diseased action of the heart and lungs, as, also, of many changed conditions of the structure of those organs. By the touch, we learn the character of the pulse, the consistency of the tissues, and the position and relation of various organs. The sense of smell alone will often decide the character of a disease, as in the case of cancerous and febrile affections. Even the taste has sometimes been employed upon the excretions, to detect the existing malady.

This division, though simple, is of but little practical utility; and, hence, different classifications have been suggested.

In reference to pulmonary diseases, Dr. John A. Swett of New York, adopts the following division of symptoms.

"The constitutional symptoms,-which are the changes produced by these diseases, in the general system and in remote organs:

“The rational symptoms,—which are the changes produced, by a perversion of the healthy functions, or of the physiological action of the lungs :

'And, finally, the physical signs,—which are produced by physical changes in the structure and condition of these organs."

According to this division, the furred tongue, the excited pulse, and the hot skin produced by pneumonitis, for instance, are constitutional symptoms. The cough, the expectoration, and the dyspnoea are rational symptoms; while the dulness on percussion, the shrill bronchial sound in respiration, and the like evidences of the disease are physical signs. This distinction, we may, if we choose, apply to the indications of other diseases, as well as those of the lungs.

Sometimes, symptoms have been divided into general and physical. When this division is employed, the phrase general symptoms is intended to embrace what Dr. Swett would include under the two heads of constitutional and rational.

A better division is into general symptoms and special. The former class embraces phenomena which respect the constitution generally, or parts remote from the immediate seat of the disease. The latter includes the indications which arise more directly from the part affected, or what Dr. Swett would place in the two classes of rational symptoms and physical.

Sometimes, and with much propriety, a technical distinction is made between symptoms and signs. According to this distinction, symptoms are the existing phenomena, as they appear to all, without revealing any condition of things as their cause. These same phenomena become signs, when they are understood to indicate some particular state of the system. Thus a certain crackling sound, proceeding from the thorax, gives, to the uninstructed man, no important information whatever. He knows not of what disease it is indicative, or whether, even, it may not accompany a state of health. It is, to him, a mere symptom. To the intelligent physician, however, it is something more. It speaks the existence of incipient pneumonitis, and is, therefore, called a sign of that disease.

Several symptoms, existing together, may render certain the existence of a particular disease, though any one of them, by itself considered, gives but a doubtful indication. Such a collection of symptoms is called a diagnostic sign. By comparing present symptoms with those which have preceded, at different times, we judge of the prospect for the future, and, thereby, make the succession a prognostic sign. A pathognomonic sign is one which attends but a single condition of things, and, therefore, makes that condition absolutely certain.

In general, however, without an accurate regard to such distinctions as the above, we apply the terms, physical symptoms and physical signs, rather indiscriminately, to those indications of disease which are embraced in auscultation, percussion, and their kindred means of diagnosis.

CHAPTER II.

TOPOGRAPHICAL TERMS.

To assist in describing the physical examination of a patient. it is convenient to have certain topographical terms, marking different superficial portions of the thorax.

For this purpose, we may divide the anterior portion into three parts, on each side of the sternum. The superior, extending

from the summit of the lungs to the top of the third rib, is the right and the left superior third. This region, on each side, which may be called the supra-mammary, is important; and, for further convenience, may be sub-divided into the post-clavicular space, or that partially behind and partially above the clavicle;the clavicular, corresponding to the clavicle; and the sub-clavicular, beneath the clavicle. The middle third, on each side, which may be called the mammary region, may be made to extend from the top of the third rib to the top of the sixth. The inferior third, on each side, will, of course, extend from the top of the sixth rib to the inferior margin of the thorax. This may be called the infra-mammary region. Sometimes, too, we give, to certain localities of the anterior portion of the thorax, other names according to anatomical relations, as the præcordial region, the sternal region, &c.

The posterior portion of the thorax may be divided into thirds, the superior extending from the top of the shoulders to a line drawn horizontally over the spine of the scapula. This may be called the superior dorsal region. The second third may be called the middle dorsal region. It extends, from the lower margin of the superior third, to another horizontal line drawn so as to touch the inferior angles of the scapula. This may be called the inferior dorsal region. Each of these three regions may be sub-divided, by the spine of the back, into the right and the left parts of the regions severally. Here, likewise, we sometimes derive, from anatomical parts, other terms to designate particular localities; and we speak of the scapular regions, the intra-scapular, the dorsal, &c.

The spaces in the axillæ and above the fourth rib on each side may be called the axillary regions. The lateral spaces beneath these, extending downward to the seventh ribs, may be called the lateral regions. And, sometimes, the narrow spaces at the very tops of the shoulders, extending from the acromion processes to the neck are called the humeral regions.

In like manner, for examining the abdomen (including the pelvis), we have a topography sufficiently accurate, in the following delineation. Suppose a line, drawn horizontally around the body, so as to touch the extremity of the ensiform cartilage. This

will define, near enough for practical purposes, the superior boundary of the abdomen. Suppose a second line, drawn parallel to the first and touching the lowest portion of the last false ribs. Between these two lines, we have a zone or belt across the abdomen. Suppose, now, a third line, drawn parallel to the former two and touching the crest of each ilium. Between this and the second, we have a second zone; and, below this, we have a third zone. Suppose, now, we raise a line, vertically, on each side of the abdomen, from the anterior spinous process of the ilium, so as to cut the horizontal lines at right angles. This will divide each zone into three regions. The middle region of the superior zone may be called the epigastric; and those on each side the right and the left hypochondriac. The middle region of the middle zone may be called the umbilical; and those on each side the right and the left iliac. The middle region of the lowest zone may be called the hypogastric; and those on each side the inguinal. Sometimes, terms designating particular parts of the superficies of this cavity are suggested by other anatomical considerations, or by the position of certain viscera within. Hence, we speak of the pubic region, the hepatic, the gastric, &c.

CHAPTER III.

THE POSITION OF THE PATIENT.

For interpreting the constitutional and rational symptoms generally no specific rules need be given; but, to be taught correctly by physical signs, various directions must be carefully observed. Such of these as relate to the position of the patient I will now briefly point out.

For succussion, the upright posture is mostly, though not always, required. For palpation, both the upright and the recumbent posture are necessary in different cases, and, sometimes, in the same case. Abdominal and pelvic examinations mainly demand the recumbent posture, and generally a dorsal decubitus,— sometimes, however, one partly lateral. Inspection and mensuration usually require, each, the upright posture; though, from the re

cumbent, with dorsal decubitus, some information may be gained.

For percussion, the proper position of the patient varies according to the relation and circumstances of the part to be examined. In abdominal examinations, the recumbent posture is generally needed, and almost always dorsal decubitus. In thoracic examinations, however, the case is different. Ordinarily, the upright posture, but sometimes the recumbent, and sometimes both in connexion are required. When the upright posture is to be assumed, if the patient is well able to leave his bed, I choose to have him seated in a convenient chair. Let the muscles of his chest be put somewhat upon the stretch, and the skin be rather closely drawn, so as to render the parietes as tense and elastic as convenient.

When the percussion is anterior, the shoulders should be thrown slightly backwards, so as to give a little tension to the pectoral muscles; and the arms should hang easily by the sides, or the hands be laid forward upon the thighs. In posterior percussion, on the contrary, the patient should lean forward, and firmly clasp his arms in front. The dorsal and cervical vertebræ thus forming a curve, the scapula will be drawn away from the spine, and the muscles of the back will be rendered suitably tense. To percuss either axilla, let the arms be raised, and the palms of the hands rest lightly on the top of the head.

If, however, the feebleness of the patient forbids his being seated in a chair, he may sit upright in his bed; or, if too feeble for that, he may be percussed with accuracy, while recumbent. For anterior percussion, let him lie evenly upon his back, with his head and shoulders but slightly raised, and with no such elevation or depression of any portion of the body as shall vary the symmetry of his form. For posterior percussion, he may be turned upon his face and abdomen. For axillary percussion, he may lie partially on the opposite side.

For auscultation, essentially the same rules are to be observed, in regard to the position of the patient, as have been given for observance in percussion. Less attention, however, needs be paid to the tension of the muscles and the skin; as, in the suitable application of the ear to hear, this object will be sufficiently accomplished. When the strength of the patient does not allow