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 CONTENTS
PART I - CLINICAL CASES
1. HISTORY TAKING AND SYMPTOMATOLOGY

1. Weight loss 2 24. Heart burns 5

2. Weight gain 2 25. Vomiting 6
3. Anorexia 2 26. Hematemesis 6
4. Fever 2 27. Constipation 6
5. Chest pain 2 28. Flatulence 6
6. Dyspnea 3 29. Diarrhea 6
7. Cough 3 30. Bleeding per rectum 6
8. Hemoptysis 3 31. Jaundice 6
9. Palpitations 3 32. Epistaxis 6
10. Syncope 3 33. Bleeding Gums 6
11. Polyuria 3 34. Hoarse Voice 7
12. Pyuria 4 35. Itching 7
13. Frequency of Micturition and Nocturia 4 36. Hirsutism 7
14. Hesitancy and Precipitancy of Urine 4 37. Gynecomastia 8
15. Retention of urine 4 38. Backache 8
16. Hematuria 4 39. Hiccough 8
17. Anuria 4 40. Headache 8
18. Pain in the Loin 5 41. Tinnitus 9
19. Abdominal Pain 5 42. Tingling and Numbness 9
20. Dysphagia 5 43. Cramps 9
21. Water brash 5 44. Intermittent Claudication 9
22. Indigestion 5 45. Vertigo 9
23. Eructation 5

2. GENER AL EXAMINATION
1. Built 10 11. Skin and its Appendages 27
2. Body Proportions 14 12. Vertebral Column 31
3. Nutrition 14 13. Thickened nerves 32
4. Decubitus 15 14. Joints 32
5. Clubbing 15 15. Temperature 36
6. Cyanosis 16 16. Pulse 39
7. Jaundice 19 17. Jugular Venous Pulse (JVP) 43
8. Pallor 22 18. Blood pressure 46
9. Lymphadenopathy 23 19. Hypertension 48
10. Edema 25 20. Hypotension 53
 3.ABDOMEN

1. Proforma 55 10. Alcoholic Liver Disease 87

2. Examination 56 11. Malaria 90
3. Hepatomegaly 65 12. Kala Azar 95
4. Splenomegaly 67 13. Typhoid 98
5. Ascites 70 14. Leukemia 102
6. Abdominal Lump 72 15. Malignant lymphoma 106
7. Acute Viral Hepatitis 77 16. Human Immunodeficiency Virus (HIV)
8. Cirrhosis of Liver 82 Disease Acquired Immune Deficiency
Syndrome (AIDS) 109
9. Portal Hyp ertension 84

4. RESPIRATORY SYSTEM
1. Proforma 122 10. Chronic Obstructive Pulmonary Disease
2. Examination 124 (COPD) (Emphysema and Chronic
Bronchitis) 168
3. Pleural Effusion 135
11. Pneumonia 172
4. Collapse / Atelectasis of Lung 143
12. Bronchiectasis 175
5. Pulmonary Fibrosis /
Interstitial Lung Diseases 145 13. Lung Abscess 178

6. Pneumothorax 149 14. Solitary Pulmonary Nodule (SPN) 180

7. Pulmonary cavity 154 15. Obstructive Sleep Apnoea 182

8. 16. Hepatopulmonary Syndrome 185

Bronchogenic Carcinoma 155
9. Pulmonary Tuberculosis 158 17. Allergic Bronchopulmonary Asperigillosis
(ABPA) 187

5. CARDIOVASCULAR SYSTEM
1. Proforma 188 12. Cyanotic Congenital Heart Disease 243
2. Examination 189 13. Patent Ductus Arteriosis (PDA) 250
3. Rheumatic fever 203 14. Ventricular Septa! Defect (VSD) 252
4. Infective Endocarditis 205 15. Atrial Septa! Defect (ASD) 253
5. Ischemic Heart Disease 208 16. Coarctation of Aorta 255
6. Cardiac Failure 220 17. Aneurysm of Aorta 257
7. Mitra! Stenosis (MS) 225 18. Pericardia! Effusion 259
8. Mitral Regurgitation (MR) 232 19. Cardiomyopathy 260
9. Mitra! Valve Prolapse (MVP) 236 20. Fitness for surgery
10. Aortic Regurgitation (AR) 237 (Pre-operative Evaluation) 263

11. Aortic Stenosis (AS) 241

 6. CENTRAL NERVOUS SYSTEM
I. Proforma 264 8. Myasthenia Gravis 340
2. Examination 266 9. Cerebellum 341
3. Cranial Nerves 298 10. Tuberculosis of Nervous System 344
4. Bulbar Palsy 321 11. Cerebrovascular Diseases 349
5. Hemiplegia 322 12. Parkinsonism 357
6. Paraplegia 326 13. Coma 365
7. Quadriplegia 336 14. Syphilis of Nervous System 370

PART II-TABLE-WORK
7. MEDICAL EMERGENCIES
1. Cardiac Arrest 374 28. Acute Retention of Urine 395
2. Cardiac Failure 377 29. Acute Renal Failure (ARP) 395
3. Ischemic Heart Disease 377 30. Diabetic Ketoacidosis 396
4. Stokes Adams Syndrome 377 31. Hypoglycemia 397
5. Hypertensive Crisis 377 32. Respiratory Acidosis 398
6. Hypertensive Encephalopathy 378 33. Metabolic Acidosis 399
7. Shock 379 34. Respiratory Alkalosis 399
8. Anaphylactic Shock 380 35. Metabolic Alkalosis 399
9. Pulmonary Embolism and 36. Dehydration 400
Deep Vein Thrombosis 380 37. Hypernatremia 400
10. Hemoptysis 382 38. Hyponatremia 400
11. Bronchial Asthma 383 39. Hyperkalemia 401
12. Respiratory Failure 385 40. Hypokalemia 401
13. Tension Pneumothorax 386 41. Acute Hypercalcemia 401
14. Hematemesis 387 42. Amebic Dysentery 401
15. Acute Gastroenteritis / Food poisoning 388 43. Bacillary Dysentery 402
16. Acute Pancreatitis 389 44. Cholera 402
17. Hepatic Coma 389 45. Typhoid 403
18. Coma 390 46. Dengue 403
19. Meningitis 390 47. Leptospirosis 404
20. Cerebrovascular Diseases 391 48. Diphtheria 405
21. Subarachnoid Hemorrhage 391 49. Tetanus 405
22. Epilepsy 391 50. Rabies 406
23. Sickle Cell Crisis 393 51. Cerebral Malaria 406
24. Acute Hemolytic Crisis 393 52. Acute Poisonings 406
25. Aplastic Anemia 394 53. Organophosphorous Compound
26. Hemophilia 394 Poisoning 407
27. Renal Colic 394 54. Acute Alcoholic Intoxication 408
55. Barbiturate Poisoning 408 59. Snake Bite 410
56. Acute Salicylate Poisoning 409 60. Scorpion Bite 411
57. Carbon Monoxide Poisoning 409 61. Hyperpyrexia 413
58. Carbon Dioxide Narcosis 410 62. Drowning 413

8. ELECTROCARDIOGRAPHY
1. Introduction 415 6. Rhythm Disturbances 422
2. Normal ECG 415 7. Conduction Defects Atrioventricular
3. Waves and Complexes 416 Block (AV Block) 429
4. Myocardial Infarction 421 8. Effect of Drugs and Electrolytes 430
5. Ventricular Enlargement 421

9. RADIOLOGY
1. X-ray chest 432 5. Barium studies 443
2. X-ray Chest - Heart 437 6. X-ray of Bones 447
3. Plain X-ray Abdomen 438 7. X-ray Skull 452
4. Urogenital System 440

10. INSTRUMENTS
1. Endotracheal Tube 455 20. Urosac Bag 465
2. Tracheostomy Tube 456 21. Stomach Tube 466
3. Laryngoscope 457 22. Ryle's Tube (RT) or Nasogastric Tube 466
4. Oxygen Mask and Oxygen Cannula 23. Sengstaken Blakemore Tube (S.B. Tube) 467
(Nasal Prongs) 458 24. Infant Feeding Tube 468
5. Nebulizer Chamber 458 25. Record Syringe and Needle 469
6. Metered Dose Inhaler 458 26. B.D. Syringe and Needle 469
7. Spacehaler 459 27. Tuberculin Syringe 470
8. Rotahaler 459 28. Insulin Syringe 470
9. Nelson's Inhaler 459 29. Lumbar Puncture Needle 471
10. Ambu Bag (Self-inflating Ventillation Bag) 460 30. Cisternal Puncture Needle 471
11. Airway 460 31. Vim-Silverman's Needle 471
12. Mouth Gag 461 32. Menghini's Needle and Syringe 471
13. Tongue Depressor 462 33. Bone Marrow Aspiration Needle 471
14. Trocar and Cannula 462 34. Pleural Biopsy Needle 472
15. Asepto Syringe and Bulb 462 35. Trucut Needle 472
16. Simple Rubber Catheter 462 36. Southey's Tube and Needle 472
17. Foley's Self-retaining Catheter 463 37. Tourniquet 472
18. Malecot's Catheter 465 38. Venesection Needle 473
19. Condom Catheter 465 39. Scalp Vein Needle 473
 40. Pleural or Ascitic Aspiration Needle 473 44. Clinical Thermometer 475
41. Intravenous Cannulas 45. Flatus Tube 476
(Venflow or Angiocath) 473 46. Proctoscope 476
42. Three Way 474 47. Stethoscope 477
43. I.V. Set 474 48. Central Venous Catheter 477

11. PROCEDURES
1. Transvenous Pacing 479 11. Ascitic Tapping 490
2. Cardioversion 479 12. Gastric Analysis 491
3. Lumbar Puncture 480 13. Glucose Tolerance Test (G.T.T.) 492
4. Cisternal Puncture 484 14. Intravenous Therapy 493
5. Liver Biopsy 484 15. Subcutaneous Infusions 495
6. Kidney Biopsy 486 16. Tracheostomy 495
7. Bone- marrow Aspiration 487 17. Oxygen Therapy 496
8. Pleural Fluid Aspiration 488 18. Enema 497
9. Aspiration ofPneumothorax Cavity 489 19. Parenteral Hyperalimentation 499
10. Pericardia! Aspiration 490

12. HEMATOLOGY
1. Blood Collection 501 11. Electronic Cell Counters 514
2. Preparation ofBlood 502 12. Red Cell Indices 514
3. Hemoglobin Estimation 505 13. Red Cell Morphology 515
4. Packed Cell Volume (PCV ) 507 14. Anemias 517
5. Erythrocyte Sedimentation Rate (E.S.R.) 507 15. Differential Leucocyte Count 522
6. Reticulocyte Count 509 16. Leukemias 525
7. Osmotic Fragility ofRBCs 510 17. Parasites in Blood 525
8. Total Red Cell Count 510 18. Multiple Myeloma 526
9. Total White Cell Count 511 19. Coagulation studies 526
10. Platelet Count 513 20. Normal Hematological Values 613

13. CLINICAL PATHOLOGY

1. Urine Examination 533 3. Feces Examination 539
2. Sputum 539 4. Helminthic Infections 541

14. PATHOLOGY SP ECIMENS

1. Central Nervous System 546 5. Large Intestines 553
2. Cardiovascular System 547 6. Liver 553
3. Lung 549 7. Kidney 555
4. Small Intestine 552

L_
 15. DRUGS
1. Cardiovascular Drugs 557 5. Antibacterial Agents 585
a) Inotropic Drugs 557 a) Sulfonamides 585
b) Anti-arrhythmic Drugs 558 b) Quinolones 586
c) Anti-angina! Agents 560 c) Beta-lactams 586
d) Anti-hypertensive Agents 561 d) Macrolides 588
e) Anti-thrombotic Agents 566 e) Aminoglycosides 589
e) Heparins/Aprotinin 566 f) Tetracyclines 589
f) Diuretics 567 g) Chloramphenicol 590
2. Autonomic Nervous System 568 6. Anti-tuberculous Drugs 590
a) Catecholamines 568 7. Anti-leprosy Drugs 591
b) Cholinergic and Anti-cholinergic Agents 569
8. Anti-amoebic Drugs 592
3. Drugs in Respiratory Diseases 570
9. Drugs for Kala- azar 593
a) Anti-asthma Agents 570
b) Agents for Cough and Expectoration 572 10. Anti-malarial Drugs 593
c) Anti-allergic Drugs 572 11. Anti-helminthic Agents 594
d) Serotoninergic Agents 573 12. Anti-fungal Agents 597
4. Drugs in Central Nervous System 13. Anti-viral Agents 598
Diseases 573
a) Opioids 573 14. Anti-retroviral Agents for HIV Infection 599
b) Analgesics and Anti-inflammatory Drugs 574 15. Alcohol 601
c) Drugs in Migraine 576 16. Anti-malignancy Agents 601
d) Drugs in Gout and Arthritis 576
17. Hemopoietic Drugs 603
e) Anti-epileptic Drugs 577
f) Muscles Relaxants 579 18. Chelating Agents 604
g) Anti-psychotic Drugs 579 19. Drugs in Endocrine Disorders 605
h) Sedatives / Hypnotics 580 20. Drugs for Diabetes 607
i) Anti-depressants 582
21. Lipid Lowering Agents 608
j) Anti-parkinsonism Drugs 583
k) Drugs in Stroke 584 22. Gastro-intestinal Drugs 609
I) Drugs in Degenerative Brain Disorders 584 23. Electrolytes 611
25. Plasma Expanders 612

List of Contributors for the 20th Edition

Dr. Hardik Shah Dr. Sunita Iyer Dr. Nikesh Jain Dr. Rajiv Shah
H
istory taking is an art, which a doctor learns with their time ofoccurrence, duration and results
over the years by repeated practice and ex­ should be noted. Childhood illnesses (eruptive
perience. History is the record of medical fevers, per tussis, influenza), tuberculosis,
events that have already taken place in the patient. diabetes, hyp ertesnion, asthma, heart disease,
Since every disease has a pattern of behavior, a good jaundice, joint swelling, etc. must be inquired into.
history combined with a sound knowledge of medicine Past injuries, accidents, operations or hospital
would help the doctor to judge the likely cause(s) that stay and blood transfusion history must also be
may be responsible for the patient's problems. In over noted in details.
80% cases the most likely diagnosis can be reached 5. Personal history: Patient's appetite, food habits,
by a proper history. On clinical examination, the type of diet, bowel and micturition habits, sleep
clinical state of the patient is determined at that given and addictions like alcohol, smoking, tobacco
time. However, nothing is usually known of the past chewing, charas, ganja, marijuana etc., must
problems. Hence, without an appropriate history, an be inquired into. Loss of appetite and weight
incorrect interpretation of the physical findings may may suggest an active disease process. Similarly
be made. E.g. a person has brisk reflexes and extensor improper sleep due to other symptoms would
plantar: a recent history of transient ischemic attack suggest that those symptoms require urgent
would suggest recent stroke, whereas an old history attention. Alcohol, tobacco, smoking and other
of stroke a few years ago would suggest residual effect intoxicants can adversely affect many systems
of a past stroke. in the body and the role of these substances in
A good history must record the following information the patient's problems can be easily judged by
in a systematic order. the history. E.g. alcohol may be responsible for
1. Biodataofthe patient: This should include name, liver cell failure and cirrhosis as well as acute
age, sex, address, occupation, religion and marital gastritis. Heavy smoking may be responsible
status of the person. for precipitating coronary artery disease or
hypertension in the young.
2. Complaintsofthepresentillness: The complaints
with which the patient has come should be 6. Family history: Any illness in the family must
recorded in chronological order and the duration be recorded. The state of health of parents, peers
should be noted. and children should be noted. If any member is
deceased, the cause of death should be noted.
3. Origin, duration and progress: Details of each
Some genetically transmitted diseases are:
symptom must be recorded separately. The mode
of onset, whether sudden or gradual, the duration a. X-linked recessive diseases (e.g. Duchenne
of each symptom and its progress and finally the muscular dystrophy, hemophilia, G6PD
present status of the symptom must be noted. deficiency, ichthyosis). Women are carriers
Associated symptoms must also be inquired into and do not suffer from the disease, whereas
and recorded. males suffer from the disease. Hence, in such
illnesses, the family history would suggest
4. History of past illness: Similar illness in the past
similar illnesses in the patient's brothers,
 PRACTICAL MEDICINE

sister's sons, mother's brother and mother's

sister's sons. 2 > Weigc.___ht_ G_ai__
n __
_ _
b. Autosomal dominant disorders ( e.g. 1. Increased water retention: Cardiac failure,
familial hyperlipidemias, polycystic kidney, cirrhosis of liver, nephrotic syndrome,
Huntington's disease, neurofibromatosis, hyp oproteinemia, edema states, etc.
congenital spherocytosis, myotonia 2. Increased tissue mass:
dystrophica). There will be a family history a) Obesity
of similar illness in either of the parents and/
b) Endocrine diseases: Cushing's disease,
or grandparents.
hyp othyroidism, acromegaly, etc.
c. Autosomal recessive disorders (e.g. beta
c) Hypothalamic diseases: Craniopharyngi-oma,
thalassemia, sickle cell anemia, spinal
Frohlich's syndrome, hamartoma, etc,
muscular dystrophy, phenylketonuria, cystic
fibrosis, congenital adrenal hyperplasia). d) Drugs: e.g. steroids
There is usually no history of similar illness

3 > Anorexia
in the parents since they may be heterozygous
and hence only carriers. However, history
of consanguineous marriage in the parents 1. Viral hepatitis including anicteric hepatitis
(marriage between cousins or brother and
2. Tuberculosis
sister or uncle and niece) may be present and
may be responsible for the homozygous state 3. Carcinoma of stomach and other malignancies
in the patient and thus the manifestation of 4. Endocrine diseases: Addison's disease,
the disease. panhypopituitarism
7. Menstrual and obstetric history: In females, 5. Chronic wasting diseases: Uremia, cirrhosis of
the date of onset of menstruation, date of last liver, chronic alcoholism, chronic smoking etc.
menstruation and the amount of blood flow, 6. Drugs: Digitalis, quinine, metronidazole, etc.
regularity and pain during menstruation should
be noted. In a woman who has conceived, details
of past abortions, premature births and normal 4 Fever
or abnormal deliveries should be noted.
(Refer Pg. 36: Temperature)
Some of the common symptoms which the patients
present with and their causes are given below:
5 > Chest Pain
1
- -
Weight
- Loss 1. Cardiac: Ischemic heart disease, pericarditis,
1. Caloric malnutrition: Fasting, inappropriate diet infective endocarditis, cardiomyopathy, valvular
heart disease, dissecting aneurysm of aorta, etc.
2. Infections (chronic): Infective endocarditis,
tuberculosis, amebic liver abscess, fungal 2. Respiratory: Pleurisy, pneumothorax, pulmonary
infections, H.I.V. infection, etc. embolism, pulmonary hypertension, malignancy
3. Acute infections: Viral hepatitis, typhoid, 3. Musculoskeletal: Rib fracture, vertebral collapse,
septicemia costochondritis, myositis of pectoral muscle, etc.
4. Malignancy 4. Functional
5. Malabsorption syndrome 5. Miscellaneous: Herpes zoster of intercostal
6. Endocrine diseases: Diabetes m ellitus, nerves, esophagitis, pancreatitis, peptic ulcer,
thyrotoxicosis, panhyp opituitarism, Addison's cholecystitis, splenic flexure syndrome, etc.
disease, etc.
7. Anorexia nervosa
2
( 1 > History Taking and Symptomatology

6>D s nea B>Hemop�ysi�

� s_ _
_ _
1. P hysiological: Mountaineers, exercise, (Refer Pg. 382)
hyperpyrexia, anemia

9 > Palpitations
2. Respiratory: Airway obstruction, bronchial
asthma, chronic obstructive lung disease,
pulmonary infections, pulmonary edema, 1. Physiological: Exercise, emotional or sexual
pulmonary embolism, bronchogenic carcinoma, excitement, etc.
pleural effusion, pneumothorax, etc.
2. Excessive tea, coffee, tobacco, alcohol
3. Cardiac: Acute myocardial infarction, valvular consumption
heart disease, left ventricular failure, congenital
3. Anxiety state
cyanotic heart disease, etc.
4. High output state: Anemia, beriberi,
4. Metabolic: Diabetes, uremia, hypokalemia
thyrotoxicosis, A-V fistula, Paget's disease, etc.
5. Neurological: Respiratory center depression as
5. Cardiac arrhythmia: Extrasystoles, paroxysmal
in syringobulbia, motor neuron disease, Guillain
tachycardia, atrial fibrillation, heart block, etc.
Barre syndrome, bulbar polio, myasthenia gravis
6. Drugs: Sympathomimetic agents, nitrates,
6. Psychogenic
overdose of digoxin or insulin
(For ATS Dyspnea Scale: Refer pg. 125)
7. M i s ce l l a n e o u s : P h e o c h r o m o c y to m a ,
(For NYHA Classification: Refer pg. 211) hypoglycemia, etc.

7>Coug�
-
h �-
- - -
� 1 O > si_n_co__.p_e___
1. Respiratory: 1. Vasovagal syncope
a. Laryngeal and pharyngeal infections and 2. Postural hypotension
neoplasms
3. Cardiac arrhythmia: Stokes Adam's syndrome
b. Tracheobronchial: Tracheobronchitis, bronchial
4. Stenotic lesions of the heart: Aortic stenosis,
asthma, bronchiectasis, bronchogenic
hypertrophic subaortic stenosis, pulmonary and
carcinoma, pressure over the trachea and
mitral stenosis, Fallot's tetrad, ball valve thrombus
bronchus from outside, aspiration, etc.
in left atrium.
c. Lung: Pneumonia, tuberculosis, lung abscess,
5. Cerebrovascular insufficiency: Vertebrobasilar
tropical eosinophilia, pulmonary edema and
insufficiency, carotid sinus syncope, etc.
infarction, interstitial fibrosis, etc.
6. Miscellaneous: Massive myocardial infarction,
d. Pleural: Pleural effusion, pneumothorax, etc.
pericardial tamponade, left atrial myxoma,
2. Cardiac: Left ventricular failure, mitral stenosis, micturition syncope, cough syncope, internal
aneurysm of aorta, etc. bleeding, etc.
3. Mediastinum: Enlarged lymph nodes, mediastinal

11 > Poli�u.:...:
tumors, etc.
4. Psychogenic ri-=- a____ _
_
5. Reflex: Wax or foreign body in the ear, subphrenic 1. Transient: Excessive water drinking, diuretic
or liver abscess, etc. therapy, cold weather, stress
2. Persistent:
a. Diabetes mellitus

3
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 PRACTICAL MEDICINE

b. Diabetes insipidus (pituitary and nephrogenic)

15 > Retention of Urine
c. Renal: Chronic renal failure, recovery from
acute tubular necrosis, analgesic abuse I. Neurological: Spinal cord diseases (transverse
nephropathy, etc. and compression myelitis), cauda equina lesions,
multiple sclerosis
d. Compulsive water drinking
2. Genitourinary:

12 > P}f_u_ri_a ______

a. Penis: Phimosis
b. Urethra: Posteriorurethral valves, foreign body,
1. Renal: stones, stricture, rupture, spasm of sphincter,
etc.
a. Infective: Pyelonephritis, pyonephrosis,
perianal abscess, renal tuberculosis c. Prostatic enlargement

b. Non-infective: Hypersensitivity nephritis, d. Bladder: Atony, tumour, stone, or compression

analgesic nephropathy, hypo kalemia, by fibroids or retroverted uterus.
nephrocalcinosis, lead poisoning, radiation e. Following parturition.
nephritis 3. Drugs: Sympathomimetic agents, salbutamol,
2. Lower urinary tract: terbutaline, anticholinergic drugs, etc.
a. Cystitis: Infective, radiation, cytotoxic drugs 4. Functional
b. Urethritis
3. Adnexa: Perinephric abscess, gynecological
infections
16 > Hematuria
1. Renal: Glomerulonephritis, renal infarction,

13 > Frequency of
stones, tumors, tuberculosis, interstitial
nephritis, papillary necrosis, polycystic
Micturition and kidneys, etc.
Nocturia 2. Ureteric: Trauma, tuberculosis, stones, neoplasms
3. Bladder: Trauma, tuberculosis, stones, neoplasms,
1. Bladder: Cystitis, small contracted bladder,
cystitis, following cyclo-phosphamide therapy
tumors, vesicular calculus, cystocele
4. Urethral: Trauma, stones, foreign body, urethritis
2. Bladder neck: Incomplete evacuation due
to enlarged prostate or stricture of urethra, 5. Prostatic: Prostitis, neoplasms
incompetent internal urethral sphincter, ectopic 6. Systemic diseases: Diabetes, amyloidosis,
ureter collagen disease, DIC, etc.
3. Urethra: Urethritis, neoplasms, balanitis, stricture

17 > Anuria
of urethra, pinhole meatus, phimosis
4. Miscellaneous: Polyuria, psychogenic, pregnancy,
pressure from surrounding structures 1. Renal: Glomerulonephritis, pyelonephritis,
polycystic kidney, chronic renal failure,

14 > Hesitancy and

nephrotoxic drugs, SLE etc.
2. Pre-renal: Diarrhea and vomiting, burns, blood
Precipitanci of Urine loss, hypotension, septicemia, intravascular
hemolysis, etc.
1. Cerebral: Cerebrovascular accidents, cerebral
3. Obstructive: Calculi in kidney or urinary tract,
tumors, head injuries, etc.
blockage of ureters by malignancy or crystals,
2. Urinary tract disease: Enlarged prostate, bladder retroperitonealfibrosis, accidental ligation during
neck obstruction surgery, etc.
4
( 1 ) History Taking and Symptomatology

18 > Pain in the Loin 21 > Water Brash

1. Renal: Stone, malignan c y, infections 1. Normal individuals following heavy meals
(pyelonephritis, perinephric abscess, etc.), 2. Incompetent lower esophageal sphincter
polycystic kidney, Dietl's crisis, etc.
3. Peptic ulcer disease
2. Extrarenal: Acute pancreatitis, cholecystitis,
4. Biliary tract disease
appendicitis, porphyria, ruptured duodenal ulcer
or spleen, ectopic gestation, etc.
22 > lndi estion
19 > Abdominal Pain 1. Upper gastrointestinal tract: Alcohol, following
heavy meals, aerophagia, hiatus hernia,
1. Acid peptic disease
gastroesophageal reflux, peptic ulcer disease,
2. Peritonitis gastritis, drugs, etc.
3. Mechanical obstruction of hollow viscus 2. Lower gastrointestinal tract: Parasites, Food
4. Colic: Intestinal, renal, biliary, etc. intolerance, irritable bowel syndrome, increased
5. Vascular disturbances producing ischemia and intraluminal gas, etc.
abdominal angina: Thromboembolism, sickle cell 3. Hepatobiliary: Cholecystitis, stones, pancreatitis,
crisis, rupture of aneurysm, etc. splenic flexure syndrome, etc.
6. Abdominal wall: Fatty hernia through linea alba, 4. Systemic diseases: Uremia, cardiac failure,
trauma or infection of the muscle etc. tuberculosis, malignancy
7. Referred pain: Pneumonia, pleurisy, ischemic 5. Functional
heart disease, panniculitis, torsion of the testes

23 > Eructation
or ovary.
8. Metabolic: Diabetes, uremia, porphyria, lead
poisoning, Henoch Schonlein purpura 1. Faulty dietary habits: Aerated water, chewing
9. Neurogenic: Herpes zoster, tabes dorsalis, etc. gum, mouth breathing, etc.
10. Functional 2. Addiction: Smoking, alcohol, betel nut, pan, etc.
3. Gastrointestinal: Gas tritis, peptic ulcer,

20 > Dysphag ia
hiatus hernia, cholecystitis, stones, irritable bowel
syndrome
1. Esophageal: Inflammation, webs, strictures, 4. Psychogenic: Anxiety, depression, etc.
tumors, achalasia cardia, spasm, hiatus hernia,

24 > Heart Burns

Chagas' disease, scleroderma, radiation, etc.
2. Upper gut: Pharyngeal and laryngeal lesions
3. External compression: Cervical spondylitis, 1. Organiclesions: Refluxesophagitis, hiatus hernia,
retropharyngeal abscess, goitre, enlarged left peptic ulcer, etc.
atrium, aneurysm, etc. 2. Functional: Faulty dietary habits, addictions, etc.
4. Neurological: Bulbar palsy, polyneuropathy, 3. Psychogenic: Neurosis, repressed emotions etc.
motor neuron disease, myopathies, myasthenia,
dermatomyositis.

5
 PRACTICAL MEDICINE

25 >Vomitin 28 > Flatulence

1. Abdominal: 1. Gastric: Aerophagy, neurosis, gastric or
a. Gastritis and Peptic ulcer biliary disease (hiatus hernia, pyloric stenosis,
b. Colic biliary dyspepsia), following vagotomy etc.

c. Acute abdominal emergencies: Appendicitis, 2. Food intake: Cabbage, cauliflower, peas,

cholecystitis, peritonitis, pancreatitis, beans, etc.
intestinal obstruction, etc. 3. Intestinal: Steatorrhea, intestinal obstruction,
2. Cardiac: Myocardial infarction, cardiac failure, malignancy, etc.
etc. 4. Systemic diseases: Cardiac failure, cir�hosis, etc.
3. Central: Raised intracranial tension, Meniere's

29 > Diarrhea
disease, motion sickness, radiation, etc.
4. Metabolic: Diabetes, alcohol, pregnancy,
hypercalcemia, Addison's disease 1. Osmotic: Laxative abuse, maldigestion of food
5. Toxic: Febrile illnesses (viral hepatitis), cholera, 2. Infections: Typhoid, cholera, amebiasis,
drugs (salicylates), corrosive poisons giardiasis, helminthiasis, H.I.V. infection, etc.
6. Functional 3 Endocrine diseases: Thyrotoxicosis, diabetes,
Addison's disease, etc.

26 > Hematemesis
4. Drugs: Thyroxine, prostigmin, ampicillin,
_ phenolphthalein, etc.
5. Anxiety: Irritable bowel syndrome, etc.
(Refer Pg. 387)
6. Miscellaneous: Malignant carcinoid syndrome.

27 > Consti
30 > Bleeding Per Rectum
1. Acute:
1. Anal: Fissure, fistula, foreign body, etc.
a. In t e s t i n a l o b s t r u c t i o n : Vo l v u! u s ,
intussusception, hernia, etc. 2. Rectal: Piles, proctitis, foreign body, neoplasms
3. Colonic: Bacillary and amebic dysenter y,
b. Acute abdomen: Appendicitis, salpingitis,
ulcerative colitis, carcinoma, polyps, diverticula,
perforation, colic, etc.
ischemia, irritant drugs, etc.
c. General: Septicemia
4. Hematological: Blood dyscrasias, anti-coagulant
2. Chronic: therapy, uremia, etc.
a. Faulty habits: Laxative abuse, prolonged travel,

> Jaundice
insufficient dietary roughage, etc.
b. Painful anal conditions: Piles, fissures, etc. 31
c. Organic obstruction: Carcinoma, diverticulum, (Refer Pg. 19)
strictures, etc.

32 > Epistaxi_s_
d. Adynamic bowel: Scleroderma, myopathies,
myotonia, etc.
e. Metabolic: Hypothyroidism, hypokalemia, 1. Hematological:
hypercalcemia, porphyria, lead poisoning a. Thrombocytopenia: ITP, leukemia, aplastic
f. Drugs: Atropine group, opium group, tricyclic anemia, etc.
antidepressants, coffee, etc.

6
( 1 ) History Taking and Symptomatology

b. Qualitative platelet defects: Glanzmann's

thrombasthenia, von Willebrand's disease, etc. 34 Hoarse Voice
c. Coagulation disorders: Hemophilia, 1. Local: Singer's nodules, laryngitis, foreign body,
afibrinogenemia, etc. tumours of larynx.
d. Miscellaneous: Hypersplenism, vitamin B 12 2. Recurrent laryngeal nerve palsy
deficiency, etc. 3. Systemic diseases: Myxedema, angioneurotic
2. Nasal diseases: Trauma, tumors, rhinitis, edema, etc.
diphtheria, sinusitis, etc. 4. Toxic: Tobacco, alcohol
3. Systemic diseases:

35 Itching_
a. Infective fevers: Typhoid, malaria, measles,
viral infections, etc.
b. Hypertension 1. Skin disease: Scabies, candidiasis, psonas1s,
c. High altitude urticaria, pediculosis, allergic dermatitis, dry skin
d. Collagen disease: Pseudoxanthoma elasticum, 2. Systemic diseases:
Ehlers' Danlos syndrome, etc. a. Drug reaction
b. Senile purpura

33 > Bleeding'---
Gums
-
- -------
c. Infections: Enterobius vermicularis, hook­
worm, tinea infections, hydatid cyst, etc.
1. Hematological: d. Endocr ine diseases: Diabetes mellitus,
a. Thromboc ytopenia: Leukemias, aplastic hyp othyroidism, hepatic diseases, obstructive
anemia, ITP, etc. jaundice, primary biliary cirrhosis, etc.
b. Qualitative platelet defect: Glanzmann's e. Renal diseases: Chronic renal failure, etc.
thrombasthenia, von Willebrand's disease, f. Blood diseases: Polycythemia vera, malignancy,
giant platelet syndrome, etc. Hodgkin's disease, myeloma, etc.
c. Coagulation disorders: Hemophilia, Christmas 3. Pregnancy
disease, vitamin K deficiency, afibrinogenemia,

36 > Hirsutism
anticoagulants, etc.
d. Miscellaneous: Hypersplenism, vitamin
B 12 deficiency, disseminated intravascular I. With virilization: Arrhenoblastoma, malignant
coagulation, etc.
adrenal tumors, congenital adrenal hyp erplasia,
2. Gum diseases: Gingivitis, periodontitis, herpes, testicular tumors, etc.
Vincent's infection
3. Systemic disease:
a. Scurvy
b. Drugs: Phenytoin therapy
c. Diabetes mellitus, Cushing's syndrome
d. Pregnancy
e. Henoch-Schonlein purpura
f. Connective tissue disease: Ehlers' Danlos
syndrome, etc.

7
 PRACTICAL MEDICINE

2. Without virilization: 3. Infection: Osteomyelitis, tuberculous spine (Pott's

a. Familial spine)
b. Idiopathic 4. Neoplastic: Primary tumors, secondaries,
c. Polycystic ovarian syndrome multiple myeloma, etc.
d. Acromegaly, Cushing's syndrome, HAIR-AN 5. Metabolic: Osteoporosis, osteomalacia,
syndrome, congential adrenal hyp erplasia hyp erparathyroidism, renal stones, etc.
e. Drugs: Androgens, phenytoin sodium, 6. Congenital: Spina bifida
minoxidil 7. Arthritis: Rheumatoid arthritis, osteoarthritis,
ankylosing spondylitis, etc.

37 > _&�necomastia_
8. Referred pain: Pancreatitis, retroperitoneal
tumors, cholecystitis, diverticulitis, retroverted
1. Physiological: During infancy and at puberty uterus, uterine prolapse, etc.
2. Refeeding: Recovery from wasting diseases 9. Spinal deformities: Kyphosis, scoliosis and
3. Testicular: Agenesis, orchitis, tumour, Klinefelter's lordosis
syndrome, etc.
4. Endocrine: Acromegaly, adrenal tumors, ectopic
hormone production, etc.
39 > Hiccoug<.:_h_____
5. Drugs: Digitalis, spironolactone, phenothiazine, 1. Metabolic: Uremia, diabetes
metoclopramide, cimetidine, etc. 2. Toxemia: Septicemia, high fever
6. Miscellaneous: Cirrhosis of liver, rheumatoid 3. Abdominal: Liver abscess, peritonitis, subphrenic
arthritis, leprosy, etc. abscess, etc.
4. Thoracic: Aortic aneurysm, mediastinal glands,
substernal goitre, etc.
5. Neurological: Encephalitis, meningitis, brain
tumour, etc.
6. Psychogenic: Hysterical, neurosis
7. Epidemic hiccoughs

40 > Headache
1. Intracranial:
a. Meningeal: Meningitis
b. Vascular: Intracranial aneurysm, malignant
hyp ertension, subarachnoid hemorrhage
c. Skeletal: Metastasis, Paget's disease, etc.
d. Space occupying lesion: Subdural hematoma,
tumors, granulomas, abscess

38 > Backache 2.
e. Post lumbar puncture
Extracranial
1. Physiological: Faulty posture, asthenic a. Vascular: Migraine, cluster headache, temporal
individuals, pregnancy arteritis, etc.
2. Trauma: Prolapsed intervertebral disc, b. Skeletal: Paget's disease, torticollis, etc.
lumbosacral strain

8
( 1 ) History Taking and Symptomatology

c. Referred pain: Sinusitis, eyestrain, glaucoma, 3. Neurological: Amyotrophic lateral sclerosis,

aural, etc. muscular dystrophy, myotonia, peripheral
3. Miscellaneous: Psychogenic, posttraumatic, neuritis
alcohol, nitrates, monosodium glutamate 4. Metabolic: Uremia, McArdle's disease
ingestion etc. 5. Occupational: Miners, writers, typists, tailors,
telephone operators, etc.

41 > Tinnitus 6. Miscellaneous: Pregnancy, dehydration, chronic

wasting diseases, overexertion.
1. Auditory:

44 > Intermittent
a. External ear: Wax, polyp, foreign body, etc.
b. Middle ear inflammation
c. Internal ear: Meniere's disease, labyrinthitis,
Claudication
acoustic neuroma 1. Arterial: Atheroma, embolism, Buerger's disease
2. Systemic: Migraine, barotrauma, anemia, aortic 2. Systemic: Diabetes mellitus, syp hilis, anemia,
regurgitation, salicylates, quinine, etc. McArdle's disease, overexertion

42 > Tingling and Numbness 45 > Vertigo

1. Peripheral neuropathy 1. Cerebellar: Cerebellitis, injury, infarction, etc.
2. Ent rapment neuropathy: Carpal tunnel 2. Brain Stem: Vertebrobasilar insufficiency
syndrome, thoracic inlet tumor 3. Vestibular: Neuronitis, acoustic neuroma,
3. Skeletal: Cervical spondylitis, lumbar canal cerebello pontine angle tumour, etc.
stenosis, disc lesion, tumour, etc. 4. Auditory: Acute labyrinthitis, Meniere's disease,
4. Transient toxic effects of alcohol, streptomycin, salicylates,
spread of disease from middle ear, Eustachian

43 > Cram�s
tube blockage
- --- ------ 5. Miscellaneous: Migraine, aura of epilepsy,
1. Idiopathic anemia, hypotension, head injury, etc.
2. Elect rolyte distur bances: Hyponatremia,
hyp ocalcemia, hypomagnesemia

For details refer to P.J. Mehta's "Common Medical Symptoms" 6th Edition, 2013

9
T
he general examination of the patient must 4. Metabolic: Marfan's syndrome, homocystinuria
be done systematically, noting the following: 5. Miscellaneous: Cerebral gigantism, etc.

Differential Diagnosis
1. Built 11. Skin, hair and nails
1. Constitutional: Usually in constitutional tall
2. Body proportions 12. Vertebral column
stature the parents are also tall. In all children
3. Nutrition 13. Thickened nerves whose parents or grand parents are also tall, a
4. Decubitus 14. Joints suspicion of a pathological disorder must be
5. Clubbing 15. Temperature raised. The child is otherwise normal. In boys
usually no treatment is required. In girls long
6. Cyanosis 16. Pulse
term estrogen could be used to suppress further
7. Jaundice 17. Jugular venous growth. However, because of its side-effects,
8. Pallor pulse & pressure usually it is avoided unless the predicted adult
9. Lymphadenopathy 18. Blood pressure height is more than 183 ems.
10. Edema 19. Respiration 2. Gigantism (Acromegaly!Hyperpituitarism): In
gigantism the patient is very tall but with normal
body proportions. However, the features are
1 > Built coarse with increased heel pad thickness. There
may be evidence of raised intracranial tension
Built is the skeletal structure in relation to age and and bitemporal hemianopia. Pituitary tumors
sex of the individual as compared to a normal person. need surgery.
Tall Stature 3. CerebralGigantism(Soto'ssyndrome): Children
with cerebral gigantism have a large elongated
A child is considered to be tall when the height is head, prominent forehead, large ears and jaws,
greater than 2 standard deviations above the mean elongated chin, antimongoloid slant to the eyes
for the age. Gigantism is the term applied when the and coarse facial features. They have subnormal
patient's height is greatly in excess of the normal for intelligence and impaired coordination. The cause
his age before fusion of epiphysis. There is no fixed is not known.
height to constitute a giant, but in adults, it is applied 4. Sexual Precocity and virilizing disorders: In
for individuals with a height of more than 6� ft. these children, acceleration of linear growth
Causes occurs simultaneously with signs of premature
sexual development or inappropriate virilization.
1. Simple or primary gigantism: Racial, familial or This disorder may be due to congenital adrenal
constitutional hyperplasia, adrenal tumor, gonadal tumor or
2. Endocrine: Hyp erpituitarism, hyp ogonadism premature secretion of gonadotropic hormones.
3. Genetic: Klinefelter's syndrome The bone age is usually advanced so that the adult
stature may be diminished.
{ 2 ) General Examination

Table 2.1 : Differential Diagnosis of Gigantism when Upper Segment = Lower Segment
Constitutional Hyperpituitarism Cerebral gigantism

1. Family history +
2. Obesity + +
3. Mental retardation +
4. Otherfeatures OfGigantism Macrocrania, large hands andfeet

5. Post-glucose growth hormone (G.H.) N Increased N

Table 2.2 : Differences between Marfan's Syndrome and Homocystinuria

Marfan's Syndrome Homocystinuria

1. Inheritance Autosomal dominant Autosomal recessive

2. Ectopia lentis Upward dislocation Downward dislocation

3. High arched palate Present Absent

4. Loose jointedness Present Absent

5. Arachnodactyly Strikingly seen Not striking

6. Mental retardation Absent Present

7. Vascular disease Aortic Thrombotic

8. Urine Benedict's test Normal Positive

9. Cyanide Nitroprusside test Absent Cystine and homocystine present

10. Liver biopsy Normal Low activity ofCystathionine synthetase

5. Marjan 's syndrome: These patients are tall Short Stature (Dwarfism)
with long limbs, narrow hands, long slender
Dwarfism is the term applied when the patient's
fingers (arachnodactyly), hyperextensible joints,
height is 2standard deviations less than that for
dislocation of the lens, high arched palate,
his/her age and sex. Mid-parental height usually de­
kyphoscoliosis, arm span greater than the height
termines the final height.
and the lower segmetnt more than the upper
segment. Causes
6. Homocystinuria: This condition resembles
1. Hereditary/Genetic
Marfan's syndrome. The differences are mentioned
in the table. 2. Chromosomal: Turner's syndrome (45XO),
Down's syndrome, Noonan's syndrome, etc.
7. Klinefelter's syndrome:
3. Constitutional growth delay
a. Lower segment more than the upper segment
4. Delayed puberty
b. Gynecomastia
5. Nutritional: Malnutrition, malabsorption, rickets
c. Small, firm testes, azoospermia
6. Endocrine: Growth hormone deficiency,
d. Chromatin (Barr) body usually present
hypopituitarism, hypothyroidism, excessive
(47XXY). Some may be chromatin negative.
androgens, Cushings syndrome, congenital
e. Mental retardation may be associated. adrenal hyperplasia
f. Associated with mongolism and leukemia. 7. Skeletal: Achondroplasia, spinal deformities,
g. Chronic pulmonary disease, varicose veins skeletal dysplasias
and diabetes are more common 8. Systemicdiseases: Renal tubular acidosis, uremia,

11
 PRACTICAL MEDICINE

congenital cyanotic heart disease, cirrhosis of low hairline, square and shield-like chest, cubitus
liver, etc. valgus and mental retardation. Although short,
they grow at the rate of less than 4 cm each year
Differential Diagnosis with normal bone age and dental age but absent
1. Hereditary: In hereditary short stature there is pubertal growth spurt, so that during adolescence,
no endocrine abnormality. The bone age and the the skeletal age is delayed due to the absence of
dental age are normal. Although they are short, sex hormones (streak ovaries).
they grow at a constant rate of 4-5 ems a year and Giving them oxandrolone 0.15 mg/kg/day with
they have normal body proportions for age. This growth hormone from early adolescence till
may be either genetic (if there is a family history of puberty can increase the height. After the age of
short stature) or primordial (if there is no family 15 years cyclical estrogen replacement therapy
history of short stature). The latter may be due to in physiological doses is given for life. Growth
intrauterine growth failure or postnatal growth hormone replacement is recommended before
retardation. These children require no endocrine epiphyseal fusion.
treatment. 4. Hypopituitarism (including Growth Hormone
2. Constitutional growth delayand delayed puberty: deficiency): These children have the skeletal age
This disorder is common among adolescent boys. and the dental age delayed by more than 2 years.
There is no true endocrine deficiency. They grow The growth rate is less than 4 cm/year. The ratio
at a constant rate of about 4 cm a year but their of the upper segment and the lower segment is
bone age and dental age is delayed by about 2 normal. They have genetic defects (prop- I, pit­
years. Often there is a history of delay in growth I gene deficiency). MRI shows hypoplastic or
and pubertal development in the father and other aplastic pitutaries. Growth hormone replacement
male relatives. is necessary.
If puberty does not occur spontaneously by 15 years 5. Hypothyroidism: These children have mental,
of age, it can be induced by testosterone enanthate dental and skeletal retardation since birth. There
250 mg IM once a month for 3 months. would be coarse dry skin and constipation. Their
3. Turner's syndrome (SHOX gene deficiency): body proportion is infantile i.e. upper segment
These children are girls who have agenesis of is more than lower segment. Lifelong thyroxine
their ovaries. The chromosomal pattern is 45XO. replacement is required.
They have a characteristically short webbed neck, 6. Achondroplasia: Achondroplastic dwarfs have
short limbs resulting in short stature. Hence,
Table 2.3 : Differential Diagnosis of Short Stature (Dwarfism)
Constitutional Hereditary Hypopituitarism Hypothyroidism Turner's syndrome

1. Family history + +
2. Birth wt. and height N ,I. N N ,I.
3. Pattern of growth Slow from birth Slow from birth Slow few months Slow from birth Slow from birth
4. Features Immature but Mature Immature Infantile Characteristic
later normal features
5. Bone age Slight delay N Progressive Marked N
retardation retardation
6. Dentition N N Delayed Delayed N
7. Mental status N N N Retarded Retarded/N
8. Puberty Later but normal N Delayed Marked delay Absent
eventually

12
( 2 ) General Examination

Table 2.4 :Vitamins

Vitamin (Daily Sources Deficiency State Therapeutic dose
Requirement)

1. Vitamin A Carrot, Spinach, sweet Night Blindness, Bitot's spots 500 IU/kg/day I.M.
(5000 IU, 80001U potatoes, milk, liver and Xerophthalmia, Keratomalacia, Toxic effects: Painful bone
in pregnancy) fish liver oils Imperfect enamel formation. Exostosis, premature epiphyseal
Follicular hyperkeratosis of fusion. Pruritus, intracranial
skin hypertension, anorexia,
irritability, dry itchy skin, sparse
hair

2. VitaminD Milk butter, yeast, fish, Tetany and rickets in children 5001U/day
(4001U) liver oil, egg yolk, Synthesis Osteomalacia in adults Toxic effect: Anorexia,
in skin when it is irradiated vomiting, diarrhea, lassitude,
thirst, sweating and headache

3. VitaminE Whole rice, wheat germ oil, In man- No symptoms Uses:

(2 00/400/ lettuce, maize, molasses, In animals - habitual abortion, 1. Premature infants
6 001U/day) peas and meat testicular degeneration, etc . 2 . Retrolental fibroplasia
3. G.PD deficiency - to prevent
hemolysis

4. VitaminK Green vegetables, cabbage, Hemorrhagic diathesis 10mg lM

(40mg/day) spinach, tomatoes, egg yolk. Uses:
It is also synthesised in the In newborn, to prevent
intestines. Haemorhagic Disease of New
born

5. Vitamin81 Whole grain, cereals, yeast, Anorexia and nausea, Dry & 100mg orally or IM
(Thiamine) beans, liver, meat, egg yolk wet beriberi, Wernicke's
(1-2mg/day) encephalopathy. Korsakoff's
psychosis

6. Riboflavin Germinating seeds, milk Angular stomatitis, cheilosis 10mg orally

(2 mg/day) eggs, liver or magenta tongue, corneal
vascularisation, scrotal
dermatitis

7. Nicotinic acid Rice, liver, brain, eggs, Erythema, Pigmentation, 500 mg orally.
(15-2 0mg) meat and yeast hyperkeratosis of skin, Toxic effects: itching,
seborrhea around the nose, flushing, amblyopia, liver
raw red tongue, diarrhea, dysfunction and hyperuricemia
dementia and paraplegia.

8. Pantothenic acid Whole grain, milk, eggs, Burning feet syndrome 4-10mg orally
(3-10mg) liver, kidney, meat

9. Pyridoxine/ Yeast, cereals, lettuce, Nasolabial seborrhea, 50-1000mg orally

Vitamin86 spinach, milk, eggs, meat cheilosis, glossitis, peripheral Uses:
and liver neuropathy, convulsions, 1. With INH, cycloserine, oral
(1-2 mg/day)
hypochromic microcytic contraceptives, hydrallazine
anemia, lymphocytopenic and and D-penicillamine
eosinophilia 2. Alcoholism
3. Hyperemesis gravidarum,
Motion sickness, radiation
sickness
4. Sideroblastic anemia
5. Agranulocytosis
6. Infantile convulsions
7 . Homocystinuria, hyperoxaluria
and Hartnup's disease

13
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Table 2.4 : Vitamins (Contd...)

Vitamin (Daily Source5 Deficiency State Therapeutic do5e
Requirement)

10. Inositol Green citrus fruits, grains, yeast. Not known in man. In animals
(not known) - alopecia, dermatitis and fatty
liver

11. Biotin Liver, eggs, meat. Not known in man

12. Choline Egg yolk, liver, meat Fatty liver and cirrhosis 3-6mgorally
Hemorrhagic renal lesions
13. Folic acid Yeast, fresh green vegetables, Pernicious anemia, Glossitis lSmg orally
(0.05-0.2 mg) cereals, liver, kidney, meat

14. Cyanocobala- Liver, Synthesized in colon Pernicious anemia, Glossitis, 100 mcg orally or IM
min but not useful to the host as Subacute combined degene­
Vitamin 8 12 it is excreted and not ration of spinal cord.
(1 mcg) absorbed

15. Vitamin( Green vegetables, citrus Scurvy 50-100 mg/day

(Ascorbic acid) fruits, strawberries, potatoes Toxic Effects: Uses : Scurvy.
1. Oxalate and urate stones Wound healing, common cold,
2. Iron overload in iron storage Threatened abortion, Alkalosis.
disease Methemoglobinemia
Alkaptonuria, prickly heat
With iron therapy
Hemorrhagic disease of newborn

3 > Nutrition
the lower segment is always less than the upper
segment. Their mental and dental ages are normal
and so are the endocrine functions. A normal person is well nourished as regards proteins,
7. Systemic diseases: Most chronic systemic diseases fats, carbohydrates, vitamins and minerals. Certain
can cause growth failure during childhood. These clinical signs help to diagnose deficiency of one or
illnesses can be recognized by their own specific more of these nutrients.
clinical features and growth failure is a secondary 1. Proteins: Hypoproteinemia causes rough skin
problem. and later edema of feet and brittle hair.
2. Fats: Fat malnutrition leads to cachexia with

ortions
hollowing of cheeks, loss of the shape of hips (due
to loss of fats), flat abdomen and absent fat over
Normally, in adults, the height of the person is equal the subcutaneous tissues of the elbows.
to the length of arm span. The upper segment (from 3. Carbohydrates: Carbohydrate malnutrition
vertex to the pubic symphysis) is equal to the lower is difficult to detect clinically because there is
segment (from pubic symphysis to the heel). gluconeogenesis from fats or proteins.
In infants, the upper segment is greater than the lower 4. Vitamins: These can be fat soluble (Vitamins A,
segment and the height is greater than the arm span. D, E, K) or water soluble (rest) and are discussed
This infantile type of body proportion persists in in the tables.
achondroplasia, cretinism and juvenile myxedema. 5. Minerals: Deficiency of two minerals can be
The reverse of infantile body proportion i.e. arm span diagnosed clinically. Iron deficiency causes
greater than height and lower segment greater than koilonychia and pallor whereas calcium deficiency
upper segment occurs in eunuchoidism, Marfan's causes tetany.
syndrome, homocystinuria, Klinefelter's syndrome
and Frohlich's syndrome.

14
< 2 > General Examination

4 > Decubi�_u_s ____

b. Cyanotic congenital heart diseases,
Eisenmenger's physiology
Decubitus or the posture a patient adopts when lying c. Atrial myxoma
in bed often gives a valuable diagnostic clue. 3. Alimentary
1. Hemiplegia: The patient lies in bed with one side a. Ulcerative colitis
immobile, the affected arm flexed and the affected
leg externally rotated and extended. b. Crohn's disease
c. Cholangiolitic cirrhosis
2. Meningitis and tetanus: The patient has neck
stiffness and opisthotonos. d. Biliary cirrhosis
3. Colic: In renal, biliary or intestinal colic, the e. Hepato-pulmonary syndrome
patient is markedly restless and tossing and 4. Endocrine
turning in bed in agony. a. Myxedema
4. Acute inflammatory abdominal disease: The b. T hyroid acropachy (thyroid nails of
patient lies on his back quietly with legs drawn hyperthyroidism e.g. in Grave's disease)
up.
c. Acromegaly
5. Cardiorespiratory embarrassment: The patient
5. Miscellaneous
is more comfortable in sitting-up position. This
position is also assumed in abdominal distention a. Hereditary
and ascites when intra-abdominal pressure is b. Idiopathic
raised. c. Unilateral: Pancoast tumor, subclavian and
6. Pneumonia and pleurisy: The patient is most innominate artery aneurysm
comfortable lying on the affected side because d. Uni digital: Traumatic or tophi deposit in gout
the movement on the affected side is restricted.
e. Only in the upper limbs in heroin addicts due

5 > Clubbing
to chronic obstructive phlebitis

Grades
Definition I. Softening of nail bed
II. Obliteration of the angle of the nail bed
Clubbing is bulbous enlargement of soft parts of the
terminal phalanges with both transverse and longitu­ Ill. Swelling of the subcutaneous tissues over the base
dinal curving of the nails. The swelling of the terminal of the nail causing the overlying skin to become
phalanges occurs due to interstitial edema and dilation tense, shiny and wet and increasing the curvature
of the arterioles and capillaries. of the nail, resulting in parrot beak or drumstick
appearance (Figs. 2.1 & 2.2).
Causes IV. Swelling of the fingers in all dimensions associated
1. Pulmonary with hypertrophic pulmonary osteoarthropathy
causing pain and swelling of the hand, wrist etc.
a. Bronchogenic carcinoma, mesothelioma
and radiographic evidence of subperiosteal new
b. Lung abscess bone formation (commonly seen in bronchogenic
c. Bronchiectasis carcinoma, paraneoplastic syndromes).
d. Tuberculosis with secondary infection
Schamroth's Sign (Fig. 2.3)
e. Diffuse fibrosing alveolitis
Normally when two fingers are held together with
f. Empyema nails facing each other, a diamond-shaped space is
2. Cardiac seen at the level of proximal nail fold. This is lost in
a. Infective endocarditis case of clubbing

15
 PRACTICAL MEDICINE

enters the systemic circulation, it causes dilation

ofarteriovenous anastomosis and hyp ertrophy of
((( the terminal phalanx resulting in clubbing.

\
3. Platelet-derived growth factor causing
vasodilatation.
(a) Pseudoclubbing

___JI(��--=�:
In hyp erparathyroidism or leprosy excessive bone
resorption may result in disappearance of the ter­
minal phalanges with telescoping of soft tissues and
a 'drumstick' appearance of the fingers resembling
clubbing. However, the curvature of the nail is not
(b) present.
: Fig 2.1 (a)& 2 1 (b) (a) Normal nail bed, Profile angle=
180°, (b). Severe clubbing- hypertrophy of soft tissues,
\
I_
__ Pr�file an_gle � � �0 _
°
---� 6 > �ianosis
DEFINITION: Cyanosis is a bluish discoloration ofthe
nails due to increased amount of reduced hemoglobin
(more than 5 mg%) in capillary blood.

Types
I. Central
II. Peripheral
III. Cyanosis due to abnormal pigments
No space
IV. Mixed
Space
Table 2.5 : Differences between Central
and Peripheral Cyanosis
Central Peripheral

1. Mechanism Diminished Diminished

arterial oxygen flow of blood to
saturation the local part
2. Sites On skin & mucous On skin only
membranes
e.g. tongue, lips,
Normal Schamroth's sign
cheeks etc.
Fig 2 3: Left: Normal; Right Schamroth's sign
I • n --- � --- ----- - --�
-
3. Temperature Warm Cold
of the limb
Mechanism
4. Clubbing and Usually Not associated
1. The exact mechanism is not known. It is believed polycythemia associated
that the stimulus for clubbing is hypoxia. Hypoxia
5. Local heat Cyanosis remains Cyanosis
leads to opening of deep arteriovenous fistulas, abolished
which increase the blood supply of the fingers
6. Breathing pure Cyanosis Cyanosis persists
and toes causing it to hypertrophy. oxygen decreases
2. Another hyp othesis is that when reduced ferritin
in venous blood escapes oxidation in the lungs and

16
 ....
N
'Y

"';:
c;".l

CYANOSIS

;:!
Warm extremities tongue Cold extremities, Only in upper limbs / Cold extremities 5·
and blue tongue ;:,
also cyanosed pink tongue lower limbs ::.
C;:

I�"" I Peripheral
Mixed
(See separate flow chart)

Low BP Normal BP Sudden dyspnea Progressive

frothy dyspnea

Cold Exposure Diarrhea Precordial pain, Local arterial Plethoric face I Acut!LVF I Mitral

I
Thrombophtebitis vomiting perspiration constriction
hemorrhage Stenosis

Hypovolemic Myocardial Raynaud's Polycythemia Differential

Shock Infarction Disease
Cardiogenic
Shock
Upper Limbs Lower Limbs

I
PDA with Transposition of PDA with reversal of
great arteries with reversal of shunt shunt
Preductal Coarctation
of Arteries

'""'
'-l
�
00

CENTRAL CYANOSIS

Giddiness Effect of oxygen

No Cardio-Respiratory
signs
No improvement Improvement
Blood electrophoresis

I ClubbingPoly­ LoudP 2 Sudden Gradual High attitude

ythemia Sing]e Dyspnea Dyspnea

I
Abnormal Normal
globulin

I
globulin

�-�r
Hb-M Spectroscopy of Dry cough Hemoptysis Clubbing Following
disease Pleuritic Instrumentation
Fallot's Eisenmenger
chest pain
Tetrad Complex
Pul. Atresia Primary or
Secondary Pulmonary Pneumothorax Pulmonary Collapse
Right to Foreign Body
Band at Band at 618 Hypertension Embolism Stricture
Left Shunt
630mU mU

Methemoglobin Sulphemoglobin

No cough Hemoptysis Exacerbation

and remission
R
Interstitial Bronchogenic I CO,PD I r
)>

Fibrosis Carcinoma m
0
R
zm
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was looked upon by practical men as a visionary subject of
investigation, which had a tendency to make those who engaged
in it atheists, and the enemies of Socrates took advantage of the
prejudices then prevailing against it to represent him as a
meteorologist. See Aristophanes (Nub. 225.) Aristophanes, who
would appear to have been always too ready to pander to the
popular prejudices of the day, also represents the physicians as
being “meteorological impostors,”—μετεωροφένακας. (Ibid. 330.)
The enlightened mind of Aristotle, however, regarded
meteorology in a very different light, and accordingly he wrote a
work on the subject replete with all the astronomical and
geological knowledge of his time. In it he professes to treat of the
heavenly bodies and atmospherical phenomena, including winds,
earthquakes and the like; also of minerals, fossils, etc. See the
introduction to his Meteorologica.
[388] Upon reference to the editions of Coray, Clifton, and
Littré, it will be seen that the text here is in a doubtful state. I shall
not weary the reader by stating my reasons for adhering to the
meaning which I have adopted.
[389] In place of the common reading, παιδίον, Coray adopts
θεῖον which certainly, at first sight, appears to be an improvement.
But I admit, with Littré, that the authority of Galen (tom. v., p. 447,
ed. Basil), is quite decisive in favour of παιδίον. It is also to be
taken into account in this place that the author of the treatise on
Dentition brings prominently into view the connection between
infancy and convulsions, which adds probability to the supposition
that in those days convulsions may have been called “the disease
of infancy.”
[390] The Hepialus is a species of intermittent fever, very
common in warm climates. It would appear to be a variety of the
quotidian. See Paulus Ægineta, Vol. I., 252, Syd. Soc. edition.
[391] Frequent mention of this disease of the skin occurs in
the works of the ancient writers on medicine. See Paulus
Ægineta, Vol. II., 40. We have there stated that it would appear to
have been some species of Eczema, with which we are now
unacquainted. Coray has a very lengthy note on it, but arrives at
no satisfactory conclusions on the subject. He brings into review
three cutaneous diseases, namely, the bouton d’Alep.. (described,
Mémoir. de la Société Royale de Médic., année 1777, 1778, t. i.,
p. 313;) the pelagre, (described, Toaldo, Essai Méteorolog., pp.
19, 20; Comment. de Rebus in Scient. Nat. et Médec. Gestis.,
tom. xxxi., p. 553; and Journ. de Médec. tom. lxxx., p. 272;) and
the lepre des Asturies or mal de la rosa, (described by Thieri,
Journ. de Médec., tom. ii., p. 337.)
 [392] Coups de soleil, or strokes of the sun, are often
mentioned incidentally in the works of the ancient authors, but no
one has treated of them in any very systematic manner, as far as
I recollect. On the effects of exposure to cold and heat, see,
however, Paulus Ægineta, Vol. I., 49–51, Syd. Soc. edition.
[393] Ῥηγματα καὶ σπάσματα. There has been much
difference of opinion as to the exact import of these two terms. It
would appear to me that they were intended to apply to a rupture
or straining of the fibres, occasioned by external violence. M.
Littré has a very interesting note on this subject, tom. v., p. 579.
On these strainings see further Coacæ Prænotiones, 376, 418.
M. Littré, l. c., relates a case of empyema brought on by lifting a
heavy piece of wood. On these terms see further the Annotations
on Demosthenes, Olynth. ii., 8, ed. Dobson; and Foës, Œc.
Hippocr.
[394] Clifton translates this clause of the sentence thus: “Even
if there be but a small distance between them,” and, I think,
correctly, although Coray is not quite satisfied with this
interpretation. The stadium was nearly the eighth part of a Roman
mile, that is to say, it consisted of 94½ French toises, or 625
English feet.
[395] In another place, I have given a summary of the
information supplied by the ancient authors on this subject,
(Paulus Æginata, Vol. I., 66.) Upon the whole, none of them
gives so much valuable matter on it as our author. Coray has
some elaborate annotations on this passage.
[396] It can scarcely admit of a doubt that our author here
alludes to scurvy. (See Coray at this place, and Lind on Scurvy,
iii., 1.) He also describes the disease distinctly in the second book
of Prorrhetics, that is to say, if Hippocrates be actually the author
of that book. See also Epidem. ii., 1; de Affection., de inter. affect.;
Cælius Aurelianus, Tard. Pass. iii., 4; Celsus, iv., 9; Aëtius, x., 11;
Pliny, H. N., xxv., 3; Aretæus, Morb. Diuturn, i., 14; and Paulus
Ægineta, iii., 49; Marcellus, de Medic. ii.
[397] The leucophlegmasia is treated of in different parts of the
Hippocratic treatises, as Aphor. vii., 29; de Morb. ii. By it he
evidently meant a species of dropsy, as Galen remarks in his
commentary on the Aphorisms (l. c.). It occurs in Aretæus’s
chapter on dropsy. Morb. Diuturn. ii., 1; Octavius Horatianus, v.
Celsus makes it to be synonymous with anasarca, iii., 21. Our
author would seem to notice these varieties of dropsy as being
affections to which pregnant women are subject.
[398] On hydrops uteri see the authorities quoted in the
Commentary on Paulus Æginata, B. III., 48, Syd. Soc. edition. It
may appear singular that hydatids of the womb should be
particularly prevalent in the case of women that drink
unwholesome water from marshes, and yet our author’s
observation is confirmed by a modern authority as quoted by
Coray: “Il a été également prouvé par les observations des
Modernes, que les fausses grossesses produites par les
hydatides; sont très-communes dans les pays marécageux, ou la
plupart des habitans ont une constitution lâche, propre à
l’affection scorbutique, qui y est presque endémique, qu’elles
terminent plus ou moins tard par l’excrétion de ces hydatides.”—
(Notes sur le Traité des Airs, &c., p. 106.) Sydenham, moreover,
describes the symptoms of false pregnancy in much the same
terms as our author. (Tract de Hydrop.)
[399] On the Thermal waters of the ancients, see Paulus
Æginata, Vol. I., 72. I have treated fully of the ancient alum and
nitre under στυπτηρία and λίτρον, in the Third Volume. Coray, in
his notes on this passage, does not throw much light on this
subject. The opinion here delivered by our author, that these
metallic substances are produced by the operation of heat, is
adopted and followed out by Aristotle towards the end of the third
book on Meteorologia.
[400] Corny appears to me to be unnecessarily puzzled to
account for our author’s statement, that saltish waters, although
held to be purgative, are, in fact, astringent of the bowels. But,
although their primary effect certainly be cathartic, is it not
undeniable that their secondary effect is to induce or aggravate
constipation of the bowels? Certain it is, moreover, that all the
ancient authorities held salts to be possessed of desiccant and
astringent powers. See Paulus Ægineta, Vol. III., under ἂλες.
[401] Aristotle discusses the subject in his Problems, ii., 9, 36,
37; ii., 15; i., 53; v., 34, and arrives at nearly the same conclusions
as Hippocrates. See also Theophrastus de Sudoribus.
[402] I cannot hesitate in adopting the emendation suggested
by Coray (ἀποσήθεσθαι) in place of the common reading
(ἀποσήπεσθαι), which evidently has no proper meaning in this
place. I am surprised that M. Littré should have hesitated in
admitting it into the text.
 [403] Athenæus, in like manner, praises rain water. Deipnos ii.,
5.
[404] It appears singular that Athenæus, who is undoubtedly a
most learned and judicious authority on all matters relating to
Dietetics, speaks as favorably of water from ice as he does of rain
water. Both he praises for their lightness, (l. c.) Celsus gives the
character of the different kinds of water with his characteristic
terseness and accuracy: “Aqua levissima pluvialis est; deinde
fontana; tum ex flumine; tum ex puteo: post hæc ex nive, aut
glacie; gravior his ex lacu; gravissima ex palude,” (ii., 19.) Galen
treats of the medicinal and dietetical properties of water in several
of his works, and uniformly agrees with Hippocrates in the
judgment he pronounces on them. See in particular, De Ptisana;
De Sanit. tuend. ii.; Comment. ii. in Libr. de Ratione victus in
Morb. acut.
[405] Athenæus, on the other hand, argues from the fact that
ice is lighter than water, that water formed from ice must be light.
Pliny gives a lucid statement of the opinions of those who held
that water from ice is light and wholesome, and those who, like
Hippocrates, held it to be just the reverse. He says in the words of
Hippocrates, literally translated, “nec vero pauci inter ipsos e
contrario ex gelu ac nivibus insaluberrimos potius prædicant,
quoniam exactum sit inde, quod tenuissimum fuerit.” (H.N. xxxi.,
21.) See also Seneca, Quæst. Natural. iv. It would appear that
iced liqueurs were greatly relished at the tables of gourmands in
those days. I need scarcely remark that there has been great
difference of opinion in modern times regarding the qualities of
water from melted snow and ice. It was at one time generally
believed that it is the cause of the goîtres to which the inhabitants
of the valleys bordering on the Alps are subject. This opinion,
however, is by no means generally held at the present time.
[406] This is a most interesting chapter, as containing the most
ancient observations which we possess on the important subject
of urinary calculi. The ancients never improved the theory, nor
added much to the facts which are here stated by our author. We
have given the summary of their opinions in the Commentary on
Paulus Ægineta, B. III., 45. I would beg leave to remark that,
notwithstanding the number of curious facts which modern
chemistry has evolved regarding the composition of urinary
calculi, the etiology of the disease is nearly as obscure now as it
was in the days of Hippocrates.
 [407] Coray remarks that Prosper Martian, in his commentary
on this passage, confirms the truth of the observation here made,
that persons affected with calculus have the bowels constipated.
[408] Theophilus, in his treatise De Urinis, would seem to
contradict this observation of Hippocrates, when he states that
the urine of calculous persons is thick and milky (8.) But,
according to Prosper Martian, when the calculus is in the state of
formation, its characters are as described by the latter, whereas,
when the calculus is already formed, the urine is limpid, as
described by Hippocrates.
[409] It is worthy of remark that Celsus states just the reverse
with regard to the practice of women laboring under the stone; he
says: “Feminæ vero oras naturalium suorum manibus admotis
scabere crebro coguntur.” (ii., 7.) Are we to suppose that he
followed a different reading? Considering how well he shows
himself acquainted with the works of Hippocrates, it cannot be
thought that he had overlooked this passage.
[410] Our author, it will be remarked, ascribes the comparative
immunity from calculus which females enjoy to their freer use of
liquids. Celsus, in laying down directions for the regimen of a
calculous person, as preparatory for the operation, among other
things, directs, “ut aquam bibat,” (vii., 26–2.) Coray collects the
opinions of several modern authorities in favor of drinking water
as a preventive of calculus. Thus Tissot states that the Chinese,
who drink so much water with their tea, enjoy almost an immunity
from the disease. (De la Santé des Gens de Lettres, p. 196,)
Campfer, in like manner, affirms that calculus has become less
common in Europe since the introduction of tea, which he justly
attributes to the amount of water drunk with it, rather than to any
virtues of the plant itself. (Comment de Reb. in scient. nat. et
medic. gestis, vol. xvi., p. 594.) Metzger attributes the diminution
of the number of calculous cases in Königsberg to the use of
draughts of tepid water. (Journal de Médec., vol. lxvii., 348.) The
Turks, according to Thevenot, owing to their free use of water, are
almost exempt from the disease. (Voyage au Lévant, c. xxvii., p.
70.)
[411] Coray makes the following remarks on the natural
characters of the seasons in Greece. The natural temperature of
the winter in Greece was cold and humid; thus a dry and northerly
winter was reckoned an unnatural season. Spring was reckoned
unnatural when the heat and rain were excessive. See further
Theophrast. de Caus. Plant. ii., 1.
[412] See Aphorism iii., 11.
[413] The celebrated Haller charges Hippocrates with
inaccurate observation in stating that dysenteries are epidemic in
spring, which, he contends, is contrary to modern experience.
(Bibl. Med. Pract., vol. i., p. 61.) Hippocrates, however, is
defended by Gruner (Cens. libr. Hippocrat. ii., 5, p. 51), and by
Coray. (Notes, etc., p. 159.) The latter justly argues, that although
dysentery may not prevail at that season in Germany, that is no
reason for holding why it may not be so in Greece. He also refers
to the works of Birnstiel and Stoll for descriptions of epidemical
dysentery, occurring in the season of spring.
[414] See Aphorism iii., 12; also Aristot. Probl. i., 9; Celsus, ii.,
1.
[415] Coray, in this place, refers to an epidemic of the same
description related by Caillar, which prevailed in the winter of
1751, and was treated by emetics more successfully than by
bleeding.
[416] By sphacelus of the brain Clifton understands “paralytic
diseases,” which is not far removed from the conclusion which we
have arrived at respecting it in the Commentary on Paulus
Ægineta, Vol. I., p. 365. See Coray’s lengthened note on this
passage.
[417] Aphorism, iii., 13.
[418] Aphorism, iii., 14.
[419] I have stated in my analysis of the short treatise “On
Purgative Medicines,” that the author of it forbids the
administration of these medicines, that is to say, of drastic
purgatives, during excessive heat or cold.
[420] One may see, upon consulting the editions of Clifton,
Coray, and Littré, that there are great varieties of readings in
regard to the word which I have translated “affectionate.” It will be
remarked that I have followed Coray and Littré in reading
εύοργητότερα. Clifton adopts ἀεργότερα, and translates it
“unactive.”
[421] This expression of our author is ambiguous. Coray
explains it thus: “il entend le lever d’été, qu’il place à 45 degrés de
l’Est au Nord, dans l’horizon de la Grece, et particulièrement celui
de l’île de Cos; et le lever d’hiver qu’il place à 45 degrés de l’Est
au Sud.”
[422] The sense undoubtedly requires this addition, and
therefore I have not scrupled to follow the reading of Cornarius,
καὶ τοῡ θερμοῡ.
[423] The term here used meant particularly the fructus horæi,
or summer fruits; namely, cucumbers, gourds, and the like. (See
Paulus Ægineta, B. I., § 80.) Surely Coray forgot himself, when
he wrote thus regarding the distinction between the summer and
autumnal fruits of his country: “les Grecs entendoient
particulièrement par ὡρᾱια les fruits de la fin de l’été, c’est-à-dire,
de cette partie de l’année qu’ils appelloient ὀπώραν, etc.”
[424] It is but too apparent that there is a lacuna in the text
here. A chapter devoted to an examination of the peculiarities of
the Egyptians and Libyans is evidently lost. As M. Littré has
remarked, Galen appears to refer to the contents of the lost
chapter. (Opera, tom. xvi., p. 392; ed. Kühn.)
[425] That is to say, the Sea of Azoff. See Herodotus, iv., 86,
who calls it Μαιῆτις. This was generally held to be the division
between Europe and Asia, as stated by our author. As Coray
remarks, its borders on the north-west are occupied by the
inhabitants of Little Tartary: it has the Crimea on the south-west;
the Tartars of Cuban and the Circassians on the south-east.
[426] That the inhabitants of a country bear a resemblance to
the country itself, is no doubt a profound and most philosophical
remark, although it must be admitted that the comparisons which
our author makes are somewhat quaintly expressed, and hence a
German physician wished the passage expunged, as being
unworthy of Hippocrates. (Comment de Reb. in Scient. Natur. et
Med. gestis, vol. xx., p. 131.) There can be no question, however,
that it embodies a grand general truth, although the particular
application of it may not always be apparent.
[427] On the Macrocephali, see Pliny, H. N. vi., 4; Stephanus,
de Urbibus; Suidas and Harpocration in Μακροκέφαλοι;
Pomponius Mela, i., 19; Strabo, xii.; Scholiast Apollon. Rhod., i.;
Dionysius Periegetes.
The exact situation of the savage nation of the Macrocephali
cannot be precisely determined, but it was evidently not far from
the Palus Mæotis, and most probably in the vicinity of the
Caucasus. Little is known of them, except what our author says
respecting the practice which they had of disfiguring their heads
by squeezing them, in early infancy, into an elongated shape. It is
well known that the same absurd usage prevailed among the
early inhabitants of Mexico. I need scarcely say that much
important information respecting them has been obtained of late
years. M. Littré, in the fourth vol. of his edition of Hippocrates,
supplies some very important information in illustration of this
subject, from a recent publication of Dr. H. Rathke. Certain tumuli
having been excavated at Kertch, in the Crimea, there were found
in them, besides different utensils and statues, several skeletons,
and it was most remarkable that the form of the head was greatly
elongated, in the manner described by Hippocrates with regard to
the Macrocephali. The author’s words are: “On y remarquait, en
effet, un hauteur extraordinaire par rapport au diamètre de la
base, et par là ils frappaient même les personnes qui n’avaient
aucune connaissance de la structure du corps humain.”
[428] The same theory respecting the secretion of the semen
is given in the treatises “De Genitura” and “De Morbo Sacro.” It is
espoused by Galen, in his little work. “Quod animal sit quod utero
continetur.” Coray remarks that Hippocrates’s theory on the origin
of the fœtus does not differ much from that of Buffon.
[429] I need scarcely remark that both the river and city of this
name are very celebrated in ancient mythology and history. See in
particular Apollonius Rhodius, with his learned Scholiast, Arg. II.;
Strabo, xi.; Pliny, H. N., vi., 4; Procopius, Pers., ii., 29; Mela, i., 85;
Arrian, periplus. The river takes its rise in the Caucasus, and
terminates in the Black Sea. It is called Rion by the inhabitants,
and the river and a city situated upon it are called Fache by the
Turks. See Coray at this place, and Mannert., Geograph., iv., 394.
[430] Coray quotes from Lamberti, a modern traveller, a
description of the Colchide and its inhabitants, which agrees
wonderfully with the account of both given by our author. The
following is part of his description: “Il sito della Colchide porta
seco un’ aria tanto humida che forse in altro luogo non si è veduta
la simile. E la ragione si è perchè venendo dall’ occidente
bagnata, dall’ Eusino, et dall’ oriente cinta dal Caucaso, dal quale
sorgano gran quantità di fiumi rende da per tutto l’aria
humidissima affatto. A questo s’ aggiungono la frequenza de’
boschi, fra quali non viene agitata l’aria da’ venti, et li spessi venti
marini apportatoi di pioggie et de’ vapori del mare. Questa
humidità si grande genera poi gran quantità de’ vapori, che
sollevati in alto si dissolvono in frequentissime pioggie.”—
Relatione della Colchide, c. 27. He goes on to state that a great
part of the inhabitants are fishers.
[431] It is singular that Procopius, on the other hand, states
that the Phasis is a very rapid river, and Chardin confirms his
statement. (Voyage en Perse, vol. i., p. 105.) Lamberti reconciles
these discrepant accounts by explaining that the river is rapid in
its course near where it rises among the mountains, but quite
smooth and stagnant when it arrives at the plain.—Relat. dell
Colchid., 29.
[432] The best practical proof of the justness of our author’s
reflections in this place is the result of the battle of Salamis; and
the noblest intellectual monument which ever the wit of man has
raised to the triumph of freedom is the Persæ of Æschylus, in
celebration of that event. A single line, descriptive of the Greeks,
is sufficient to account for their superiority to the Asiatics:

Οὔ τινος δοῦλοι κέκληνται φωτὸς, οὐδ' ὑπήκοοι.—1., 240.

None seem to have felt the force of this great truth so much as
the Persian despots themselves, or to have estimated the effects
of civil liberty higher than they did. The younger Cyrus, before the
battle of Cynaxa, addresses his Grecian soldiers in the following
memorable words: Ὦ ἄνδρες Ἕλληνες, οὐκ ἀνθρώπων ἀπορῶν
βαρβάρων συμμάχους ἡμᾶς ἄγω, ἀλλὰ νομίζων ἀμείνονας καὶ
κρείττους πολλπῶν βαρβάρων ὑμᾶς εἶναι διὰ τοῦτο προσέλαβον
ὅπως οὖν ἔσεσθε ἄνδρες ἄξιοι τῆς ἐλευθερίας, ἧς κέκτησθε, καὶ
ὑπὲρ ἧς ὑμᾶς ἐγὼ εὐδαιμονίζω· εὖ γὰρ ἴστε, ὅτι τὴν ἐλευθερίαν
ἑλοίμην ἂν ἀντὶ ὧν ἔχω πάντων καὶ ἄλλων πολλαπλασίων.—
Anab., i., 7. Such being the established opinions of the intelligent
portion of mankind in the days of Hippocrates, the sentiment here
expressed would then be regarded as a self-evident truth. Plato,
indeed, modifies this opinion in so far when he holds despotism to
be the consequence and not the cause of servility.—De Repub.,
viii.
[433] The name Sauromatæ or Sarmatæ was applied by the
ancient geographers to certain inhabitants of that vast and, to
them, nearly unexplored country, extending from the Sinus
Codanus or Baltic Sea, to the Euxine or Black Sea. It
comprehends, then, a large portion of Russia, Poland, and
perhaps Prussia. (See Pomponius Mela, iii., 4; Ptolemy,
Geograph.; and Maltebrun, Geograph., vol. i., p. 126.) That the
Sarmatians and Scythians were the same race of men, although
some of the authorities make a distinction between them, can
scarcely admit of a doubt. Our author, it will be remarked, seems
to restrict the name to a peculiar race of Scythians, who lived
near the Palus Mæotis (or Sea of Asaph). From the account
which he gives of them it is impossible to doubt that he alludes to
the Amazonians, so celebrated in ancient legends. The opinion
which I entertain of them is pretty fully stated in the Argument to
this treatise. That our author should not have doubted the real
existence of the Amazonians need excite no wonder, considering
the very positive and very circumstantial account of them given by
his contemporary Herodotus (iv., 110–18).
[434] It may at first sight appear singular that our author
should have mixed up his account of the Scythians with allusions
to the Egyptians; but he probably had in view Herodotus (ii., 103–
6), who connects the Egyptians with the Scythians, and more
especially with the tribe of them called Colchians. He states in
particular that the Colchians and Egyptians resembled one
another in the fashion of their linen, their whole course of life, and
in their language.
[435] Herodotus (iv., 28, 29) and Strabo (Geogr., vii.), assign
the same reason for the Scythian cattle not having horns.
[436] This description evidently applies to the wandering tribes
which roam over the steppes of Tartary. The passage is of
classical celebrity, for I cannot but fancy that certainly Virgil
(Georg., iii., 349–83), and perhaps Horace (Od. iii., 24), had it in
view when they drew their pictures of the nomadic life of the
Scythians. The extraordinary cold of that region, notwithstanding
its southern latitude, has not been exaggerated by ancient
authors; but to account for it, as the modern traveller, Clark,
remarks, is still a problem which no one has solved. Strabo
mentions that carts were driven across the Palus Mæotis (Geogr.,
vii., 3). The chariots covered in from the inclemency of the
weather with a roof of felt, are described also by Strabo (Geogr., l.
c.); and, according to Dr. Coray, similar contrivances are still to be
found among the Kalmucs and other savage nations. (Notes sur
le Traité des Airs, etc., h. 1.) A preparation from milk resembling
the hippace is still used by the inhabitants of that region. On the
people who lived upon this composition from milk, see in
particular Strabo, vii., 3.
 [437] The following lines of Virgil, referred to above, may be
almost said to be a translation of this passage:

“Semper hiems, semper spirantes frigora Cauri.

Tum sol pallentes haud unquam discutit umbras;
* * * * *
Talis Hyperboreo septem subjecta trioni
Gens effrena virûm Rhiphæo tunditur Euro.”

It was in this region of mist and cold that the celebrated race
of the Cimmerians resided. See Herodot., i., 6, etc.; Homer,
Odyss. x., 14. The montes Rhiphæi would appear to have been
the Ural mountains which separate Russia from Siberia.
[438] It is well known now that excessive cold has a tendency
to retard the growth of animals. This opinion is confirmed in
several instances by Pallas (Voy. en Russie, i., 197; iii., 431.)
Strabo mentions, as the consequences of the cold which prevails
in the country of the Getæ, that there are no asses in it, the cattle
want horns, and the horses are small. (Geogr., vii., 3.)
[439] Buffon, on the other hand, maintains that the Nomadic
race are men of active habits. (Hist., Nat., tom. iii., p. 384.) Pallas,
however, confirms the judgment of Hippocrates. (Voyag. en
Russie, tom. i., p. 499.) See also Coray, ad. h. l.
[440] It is to be borne in mind that Hippocrates, and after him
most of the ancient authorities, held that the fœtus is formed from
the male semen. This doctrine prevailed generally down to the
days of Harvey. Some of the ancient physiologists, however,
maintained that “omne animal est ab ovo.” See Plutarch, de
Placit. Philos.
[441] Ὑγρότης, when applied to the body, may signify both
humidity and relaxation, in like manner as the adjective (ὑγρὸς)
signifies humid and relaxed. We shall see an example of the latter
signification in the Prognostics.
[442] This practice came to be one of the regular operations of
surgery, being performed with the view of correcting the tendency
of a joint to dislocation. It is minutely described by Hippocrates
(De Artic., xi.), Paulus Ægineta, (VI., 42), Albucasis (Chirurg., i.,
27), Haly Abbas (Pract., ix., 78). See the Sydenham Society’s
edition of Paulus Ægineta, 1. c.
 [443] The meaning of this passage is ambiguous. I have
followed Coray, who gives some very interesting annotations on it.
He translates these words, “Ils sont naturellement d’une
complexion lâche et trapus; premièrement, parceque dans leur
enfance ils ne sont point emmaillotés, non plus que les
Ægyptiens.” Clifton has given nearly the same meaning of the
passage: “Their fluidness and breadth proceed first from their
neglect of bandages, as in Egypt.” Littré, on the other hand,
appears to give a different interpretation of the passage: “D’abord
parceque on ne les emmaillotte pas, comme en Egypte.”
[444] A fat condition of the body was also supposed adverse
to conception in the case of cattle. Virgil alludes to this opinion,
and the means used to counteract the effects of an excessively
fat state of the body in the following verses, which have been
always admired as an example how delicately a great genius can
touch upon an indelicate subject:

“Ispa autem macie tenuant armenta volentes,

Atque, ubi concubitus primos jam nota voluptas
Sollicitat, frondesque negant, et fontibus arcent.
Sæpe etiam cursu quatiunt et sole fatigunt;
Hoc faciunt nimio ne luxu obtusior usus
Sit genitali arvo, et sulcos oblimet inertes;
Sed rapiat sitiens venerem, interiusque recondat.”
Georg., iii., 136.

[445] On the nature of this affection see the Argument. There

is a variety in the reading, most of the MSS. having ἀνανδριείς,
but the one usually marked 2146, which is followed in the Aldine
edition, reading ἀνδριεῖς. See a long discussion in Coray’s edition
on this point. There seems to be no good reason for at all
interfering with the text as it now stands.
[446] Our author in this place, as in the treatise on the Sacred
Disease, holds the philosophical opinion in opposition to the
superstitious, that all diseases have natural causes, and that no
one more than another is to be ascribed to the extraordinary
interference of supernatural beings. Plato, his contemporary,
would appear to have endeavored to steer a sort of middle course
between the scientific and the popular belief. Thus he ascribes
epilepsy, like all other diseases, to a natural cause, namely, in this
instance, to a redundancy of black bile; but he qualifies this
opinion by calling the passages of the brain (the ventricles?) most
divine, and adds that the disease had been most appropriately
denominated sacred. (Timæus, § 66.)
[447] The origin and signification of this term are by no means
well defined. See Galen (Exeges, etc.), Foës (Œcon. Hippocr.),
and Coray (ad h. l.). It has been applied first, to certain varieties
of morbus coxarius; secondly, to chronic buboes, superinduced by
disease of the hip-joint; thirdly, to paralysis of the muscles about
the genital organs; fourthly, aneurismal varix. (See Aretæus,
Morb. Acut., ii., 8; and the note in Boerhaave’s edition.) I must
own that I find some difficulty in deciding to which of these
significations I should give the preference; I rather incline,
however, to the first, from what our author says towards the end
of this section, namely, that all men who ride much “are afflicted
with rheums in the joints, sciatica and gout, and are inept at
venery.”
[448] This opinion of our author was no doubt founded on the
erroneous notion regarding the distribution of the veins which
prevailed in his time, and which we find advocated in the tract “on
the Nature of Man,” and elsewhere. (See Aristot., H. N., iii., 3.)
Coray strives hard, in his annotations on this passage, to make
out that the fact may be as stated by his ancient countryman,
although the hypothesis by which he explained it be false. It is
singular, however, that, after the lapse of more than two thousand
years, Phrenology should have come to the assistance of
Hippocrates in this case. I need scarcely remark that Gall and his
followers hold that the cerebellum is the seat of the animal
appetites, so that, if this be really the fact, a close sympathy
between the back of the head and the genital organs may be very
legitimately inferred. At all events, this coincidence between
ancient observation and modern hypothesis must be admitted to
be very remarkable.
[449] Aristotle, on the other hand, holds that the effects of
equitation are aphrodisiac. (Probl. iv., 12.) Coray attempts to
reconcile the discordant opinions of the physician and
philosopher, by supposing that moderate exercises may excite
the venereal appetite, whereas excessive extinguish them. Van
Swieten agrees with Hippocrates that inordinate exercise in riding
may induce impotence. (Comment. in Boerh. Aphor., § 1063.)
[450] It is a singular idea of our author that the wearing of
breeches by confining the development of the genital organs
impairs the sexual desires. It is curious, as remarked by Coray,
that the same opinion is advocated by Hunter in his treatise on
the Venereal Disease. Coray also quotes the following passage
from Lalement: “Sæpe audivimus pistores et cæteros quorum
partes pudendæ subligaculis non obteguntur sed liberius pendent
crassos et bene nutritos habere testiculos.”—Comment. in
Hippocrat. de Aer., etc.
[451] I trust I shall be excused in quoting entire Dr. Coray’s
note on this section: “Trente mille Macédoniens (dit Pauw) ont
conquis la Perse; quarante mille Mogols ont conquis les Indes;
cinquante mille Tartares ont conquis la Chine, où l’on comptait
alors plus de quarante millions d’habitans, qui abandonnèrent
leurs souverains. On a vu de nos jours l’armée du grand Visir
déserter presque complètement dans les environs de Varna; et
jamais les Turcs n’eurent plus de bon sens qu’en cette occasion
là; car leurs tyrans ne méritent pas qu’on verse une seule goutte
de sang pour les maintenir sur le trône de ces contrées qu’ils ont
dévastées en voleurs et en brigands. (Recherch. philosoph. sur
les Grecs.)—Par ce dernier exemple on voit encore combien les
causes politiques ou morales, et les causes naturelles, peuvent
se modifier réciproquement. Les Russes, quoique soumis à un
gouvernement despotique, ont cependant été la terreur des
Turcs, à cause, sans doute de la différence du climat, de la
discipline militaire, et des progrès dans la civilisation. Ces
circonstances ont concouru à mitiger le despotisme Russe, et à le
rendre si différent du despotisme brutal des Turcs. Il en est de
même des autres peuples Septentrionaux de l’Europe. Quoique
gouvernés par des loix qui ne sont point leur ouvrage, ils sont très
belliqueux, et par la nature de leur climat, et par les lumières que
les sciences et les arts ont répandues parmi eux.”
[452] Aristotle, in drawing the traits of the European and
Asiatic character, would appear to have borrowed freely from our
author. He says the inhabitants of cold countries and of Europe
are full of spirit, but deficient in intellect and skill; they therefore
remain in a state of freedom, but without regular government, and
they are incapable of governing their neighbors. The inhabitants
of Asia are described by him as being intellectual and skilled in
the arts, but deficient in courage, and therefore they are in
constant subjection and slavery. The Greeks, he maintains, held
an intermediate place between these two, have both courage and
intellect, and therefore enjoy freedom and good government.
(Polit., iii., 7.)
 [453] We have lately had a notable example of the warlike and
independent spirit of mountaineers in the determined resistance
which the Circassians have made to the colossal power of
Russia. Great Britain, too, I may be permitted to remark,
experienced disasters in contending with the mountaineers of
Affganistan, such as she had never met with in the rich plains of
India. And, by the way, the conqueror of Greece and of Persia
was very nearly cut off by the same people. See Arrian, Exped.
Alexandr., iv., 22, etc.
[454] Ἄναρθροι. The meaning of this term seems to be,
persons whose joints are indistinct owing to fatness.
[455] Coray supposes, and apparently with justice, that our
author in this passage tacitly refers to the inhabitants of Attica. It
is worthy of remark that Thucydides ascribes the early civilization
of the Athenians to the infertility of the soil. (Ἀττίκην λεπτόγεων, i.,
2.) See Arnold’s Note, h., 1.; also the quotation from Aristotle at §
23; and Plato’s Timæus, tom. iii., p. 247; ed. Bekker. According to
Coray (but perhaps he was partially disposed towards his
adopted country), the characters of Provence and Marseilles are
analogous to those of Attica and Athens, and the effects on the
inhabitants similar. That Marseilles was at one time a flourishing
seat of learning is undoubted; see Tacitus (Agricola) and Strabo
(Geogr., iii.); but in literary celebrity it cannot surely aspire to be
put on a level with the region which produced an Æschylus, a
Thucydides, a Plato, and a Demosthenes! And it may be doubted
whether even the Marseillais Hymn equals in masculine energy
the war songs of Tyrtæus!
[456] Its title is, Specimen Historico-Medicum Inaugurale de
Hippocratis Doctrina a Prognostice Oriunda. Lugduni Batavorum,
1832.
[457] Cap. v.
[458] Comment. in Prognos. ap. Dietz.
[459] The opinion here advanced is expressed with great
precision by a French writer who has been making some figure in
the political world of late. “Great men,” says Louis Blanc, “only
govern society by means of a force which they themselves
borrow. They enlighten the world only by a burning focus of all the
scattered rays emanating from itself.”—Organization of Labor, p.
98, English edition.
 [460] Ascarus, a Theban statuary for one. See Pausanias, v.,
24, 1.
[461] See the Commentary of Simplicius. As I quote from
memory I cannot refer to the page.
[462] Galen, in his Commentary on this clause of the
sentence, acutely remarks that patients are justly disposed to
form a high opinion of a physician who points out to them
symptoms of their complaint which they themselves had omitted
to mention to him. And Stephanus further remarks that the patient
naturally estimates highly the acumen of the physician who
detects any errors in regimen which he has been guilty of, such
as drinking water, or eating fruit when forbidden; (Ed. Dietz, p.
54;) or when he has some disease about him, such as bubo or
inflammation, which he wishes to conceal. (Ibid., p. 63.)
[463] It has puzzled all the commentators, ancient and
modern, to explain satisfactorily why Hippocrates, in this place,
seems to adopt the popular creed, and acknowledge that a
certain class of diseases are of divine origin; whilst in his treatises
“On Airs,” etc., and “On the Sacred Disease” he combats this
doctrine as being utterly unfounded. Galen attempts to get over
the difficulty by supposing that, in this place, by divine our author
means diseases connected with the state of the atmosphere; this,
however, would merely imply that, on the present occasion, he
expressed himself in accordance with the popular belief. And, by
the way, I would beg leave to remark that the plague which is
described by Homer in the exordium to the Iliad, and is referred to
the wrath of a god, that is to say, of Apollo, was at the same time
held by Eustathius and other commentators to be connected with
the state of the atmosphere; that is to say, agreeably to the vulgar
belief, epidemical diseases were looked upon as divine. See also
Stephanus, the commentator, t. i., p. 77; ed. Dietz. M. Littré has
given, from a MS. in the Royal (National?) Library at Paris, a
gloss never before published, which contains an interesting
extract from one of the early Hippocratic commentators,
Xenophon of Cos, bearing upon this passage. It is to this effect,
that Bacchius, Callimachus, Philinus, and Heraclides Terentinus,
supposed that by divine, in this place, was meant pestilential,
because the pestilence was held to be from god; but that
Xenophon, the acquaintance of Praxagoras, reckoned the nature
of the critical days divine; for, as to persons in a storm, the
appearance of the gods Dioscuri brings safety, so do the critical
days bring life to men in disease. (Opera, tom. i., p. 76.) See
some remarks on this scholium by Grote, Hist. of Greece, vol. i.,
p. 488. On the θεῖον of Hippocrates see further Berends, Lect. in
Aphor., p. 349.
[464] It will be remarked that, in his sketch of Prognosis
(πρόνοια), in this place our author uses the term with
considerable latitude; in fact, it comprehends the past, the
present, and the future condition of the patient. Hippocrates, in a
word, appears to have desired that the physician should be in his
line what his contemporary, Thucydides, describes Themistocles
to have been as a statesman: “Quod de instantibus (ut ait
Thucydides), verissime judicabat, et de futuris callidissime
conjiciebat.”—Cornelius Nepos, in vita Themistocles. See also
Thucydides, i., 138. Probably both these writers had in his mind
the character of the prophet as drawn by Homer: Ὃς ᾔδη τά τ'
ἕοντα τά τ' ἐσσόμενα πρό τ' ἔοντα.. (Iliad i.)
[465] The groundwork of the matters contained in this section
is to be found in the Coacæ Prænotiones, 212; but it is greatly
expanded and improved by our author. I need scarcely remark
that the description of the features of a dying man is of classical
celebrity. It is given in elegant prose by Celsus, ii., 6; and by
Lucretius it is thus put into a poetical form:

“Item ad supremum denique tempus

Compressæ nares, nasi primoris acumen
Tenue, cavati oculi, cava tempora, frigida pellis
Duraque, inhorrebat rictum, frons tenta minebat.”
De Rerum Natura, vi., 1190.

Shakespeare’s description of the death of Falstaff, by the way,

contains images which have always appeared to me to be
borrowed (at second-hand, no doubt) from this and other
passages of the present work: “For after I saw him fumble with
the sheets, and play with flowers, and smile upon his fingers’-
ends, I knew there was but one way: for his nose was as sharp as
a pin, and he babbled of green fields.—So he bade me lay more
clothes on his feet: I put my hand into the bed and felt them, and
they were as cold as any stone,” etc.—Henry V., ii., 3. Although
perhaps it may be thought rather hypercritical, I cannot omit the
present opportunity of making the remark, that it appears to me
rather out of character to make the wandering mind of a London
debauchee dwell upon images “of green fields.” One would have
thought that “the ruling passion strong in death” would have rather
suggested stews and pot-houses to the imagination of such a
person.
[466] It will be remarked that our author modifies his judgment
on the result of the ensemble of dangerous symptoms which he
has just described, provided they be connected with want of food
and of rest, or with looseness of the bowels. See Galen’s
Commentary on this passage. Celsus renders this clause of the
sentence as follows: “Si ita hæc sunt, ut neque vigilia
præcesserit, neque ventris resolutio, neque inedia.”—ii., 6. I may
briefly mention that both Galen and Stephanus seem to have
understood this passage as I have translated it. Littré it will be
seen has rendered it somewhat differently.
[467] The prognostics, drawn from the position in which the
patient is found reclining, are mostly taken from the Coacæ
Prænotiones, 497. As usual, however, Hippocrates has improved
very much the materials which he avails himself of.
I would here point out a mistake which most of the modern
translators have committed respecting the meaning of an
expression contained in this paragraph. It is καὶ τὸ ξύμπαν σῶμα
ὑγρον κείμενον, which Clifton, Moffat, and even Littré understand
as descriptive of the body’s being in a moist state with sweat.
Littré’s translation is, “Le corps entier en moiteur.” The translators
forget that the word ὑγρὸν is used by the best classical authors to
signify “relaxed” or “soft.” Thus Pindar, in his celebrated
description of the eagle perched upon the sceptre of Jupiter, and
lulled asleep by the power of music (every English scholar will
remember Gray’s version of it in his Ode on the Progress of
Poesy), has the expression ὑγρὸν νῶτον, which Heyne interprets
by flexile and lubricum. (Ad Pyth., 1.) See also the Scholiast, in h.
1. Galen apprehends the meaning of the term as I have stated it:
thus he defines it as applying to the position intermediate
between complete extension and complete flexion, that is to say,
half-bent or relaxed. Foës also renders the expression correctly
by “corpus molliter positum.” (Œconom. Hippocrat.) See also
Stephanus (p. 96, ed. Dietz), who decidedly states that the epithet
(ὑγρὸς), in this place, means slightly bent or relaxed. Heurnius
explains ὑγρὸν as signifying “molliter decumbens,” p. 189. Celsus
renders the words in question by “cruribus paulum reductis,” ii., 3.
[468] This is taken pretty closely from the Coacæ
Prænotiones, 235.
 [469] This sentence is thus translated by Celsus: “Ubi ulcus,
quod aut ante, aut in ipso morbo natum est, aridum, et aut
pallidum, aut lividum factum est.” (ii., 6.) It is imitated from the
Coacæ Prænotiones, 496.
[470] This graphic description of the movement of the hands in
delirium is nearly original, being but slightly touched upon in the
Coacæ Prænotiones, 76. The terms are copied by most of the
ancient authors subsequent to Hippocrates, in their descriptions
of phrenitis and febrile delirium. See in particular Paulus
Ægineta, Book III., 6. Stephanus, in his Commentary, has several
very philosophical remarks on this passage, namely, upon the
rationale of the ocular deception which leads to these
extraordinary movements of the hands. (Ed. Dietz, t. i., pp. 103,
104.)
[471] This is imitated pretty closely from the Coacæ
Prænotiones, 260. Dr. Ermerins remarks that there is a greater
number of symptoms in the Prænotiones than in the Prognostics.
He therefore suggests the question whether there may not be a
lacuna in the text. The description of the respiration preceding
dissolution in the Prænotiones is certainly most graphic, and it
appears wonderful that it should be omitted by Hippocrates in the
Prognostics.
[472] The paragraph on sweats is founded on the Coacæ
Prænotiones, 572, 573; but the Prognostics is much fuller than
the other. The cold sweats described in this paragraph were
called syncoptic by the ancients, and were supposed to be
connected with atony of the pores of the skin. See Galen, h. 1.,
and De Causis Sympt. iii., 9. Stephanus, with rather too much
logical parade, gives a good many acute and interesting remarks
on this passage. He says that cold sweats are connected with a
complete prostration of the innate heat (calidum innatum). (p.
114.)
[473] The characters of the hypochondriac region are copied
in part from the Coacæ Prænotiones, 279, 280, 282; but they are
much improved in the Prognostics. It will be remarked that in the
Epidemics great attention is paid to the state of the hypochondria.
Stephanus remarks that pulsation or palpitation in the
hypochondria is caused by violent throbbing of the aorta as it
passes through this region, which is occasioned by the
effervescence and inflammation of the important parts which are
situated in it, and with which the brain is apt to sympathize. (p.