Methods of Medical Examination

Methods of Medical Examination

I. General principles of medical examination. The growth and deepening of our knowledge, the increasing technical equipment of clinics based on the use of the latest achievements in physics, chemistry, and technology, and the associated complication of methods of examination and treatment, have led to the replacement of the universal clinic by the specialized clinic, and the general practitioner by the specialist physician. The basis of specialization is mainly the organopathological principle (clinics of skin, ear, nervous, eye diseases, etc.), although in addition to these, there are clinics built on the nature of therapeutic intervention (surgical clinic), on age criteria (children's clinic), etc. Each special clinic often uses its own special methods, which are given below. However, even with existing specialization, the clinic of internal diseases occupies a special place, remaining a general type clinic where the future physician acquires the basic skills of the clinical approach to the patient. 'It undoubtedly stands at the center of medical education, it gives a strict school without which it is impossible to do in any specialty' (Goldscheider). That is why the principles, tasks, and methods of patient examination in the clinic of internal diseases are discussed in greatest detail below; the examination of patients in specialized clinics are only necessary additions to this main section. 'Every true physician is at the same time a scientist, every pathological process is a new phenomenon of nature that has not existed before, and this process must be recognized and analyzed by the physician' (Kreyl). The examination of the patient is not merely the collection of subjective and objective data and their mechanical placement in one or another known semiotic scheme. 'It would be erroneous to think that the latter (examination of the patient) is a purely mechanical occupation, the collection of information in a known order,' we read in Zakharyin. It is therefore natural that even the best scheme or questionnaire for examining a patient does not in itself ensure the quality of the results obtained, since the decisive importance is the level of training, experience of the physician, and the ability to analyze and generalize data from clinical, laboratory, instrumental, and other examinations. However, it would be wrong to refuse any scheme whatsoever and the systematic examination of the patient. A certain system of questioning and objective examination of the patient not only disciplines the physician's thinking but also aims to ensure obtaining the minimum of necessary data for diagnosis and therapy regarding the most essential subjective and objective conditions of the patient. It is not by chance that the largest representatives of clinical medicine, along with the study of various general and private problems of pathology, invariably also dealt with the issues of patient examination. Zakharyin, Botkin, Ostroumov dwelled in detail in their lectures on the principles, methods, and schemes of patient examination, and when we speak of one or another clinical school, we thereby seek to give a general characterization of those principles of clinical research used by this school. The methods of medical examination are becoming more complex and perfected each year. New and new methods are continuously being introduced, making possible ever deeper examination and more accurate and earlier diagnosis. The enormous development of technology in recent decades has raised the technical equipment of medicine to a great height, both in the field of diagnosis, as we shall discuss below, and in the field of treatment (electrotherapy, surgical equipment) and the fight against infectious diseases (disinfection). The importance of these new methods of medical examination has especially grown in connection with the so-called functional-pathological direction (Kreyl, Bergmann), which has placed functional methods of research in the first place. Below is only a general scheme of patient examination, which finds various specific forms of application not only depending on the nature of the disease but also on the circumstances in which the examination is conducted and on the objectives of the examination. If in a hospital it is necessary for each patient to collect a detailed history and status, then in the conditions of a polyclinic or outpatient department the physician mainly focuses on the complaints and status of the patient, resorting to questioning about this or that details of the history (heredity, past diseases, socio-domestic conditions in the past, etc.) only in cases where this has diagnostic value. For those seeking treatment for any infectious diseases (influenza, angina), especially when there is an epidemic outbreak, there is hardly any need for detailed collection of history. On the other hand, when it comes to chronic patients or those who have been ill for a long time, who often and repeatedly seek treatment even for influenza, then here, of course, the detailed socio-professional history, heredity, and past diseases are of considerable interest and often help to identify the cause of frequent morbidity either in professional and domestic conditions or in hereditary-constitutional features of the patient. Both indicate the ways of rational intervention in these cases. It is necessary to resort to a special scheme also in cases when mass polyclinical examination or periodic examination of harmful industries is carried out, where it is necessary to take into account the nature of occupational hazards and the specific features of the clinical manifestations of their effects on humans. For the purpose of identifying early symptoms of occupational disease or poisoning, which has great preventive significance, it is sometimes necessary to involve a number of specialists (neuropathologist, ophthalmologist, etc.) in the examination, to conduct special laboratory studies, and to pay attention and record specific symptoms. Thus, for example, when examining workers exposed to lead, in addition to taking into account clinical symptoms (lead colic, lead line, attacks of abdominal pain, constipation, dizziness, etc.), it is also necessary to conduct blood studies, paying main attention at this time to the early symptoms of lead exposure (basophilic granular erythrocytes, polychromasia, increased number of reticulocytes, etc.), which acquire even greater significance when found in a significant part of those examined. When examining a group of workers exposed to prolonged cooling, variable temperature influences, etc., it is necessary to pay attention to the so-called rheumatic, joint, and neuromuscular diseases, etc. We have dwelled on these questions here because in the conditions of the USSR, where so much attention and resources are devoted to the fight against occupational hazards and diseases, examinations of this kind are provided for by legislation in a number of industries, and in others are often carried out on the initiative of medical and public organizations, and every clinician must know that using a general type of patient history in these cases is insufficient. Essentially, this is about the examination of practically healthy people, where this or that, often difficult to detect, deviations from normal in each individual case do not have great clinical significance, but, when regularly repeated in a professional group, they necessitate resorting to this or that preventive health measures in the production or domestic life of those examined or raise questions of medical and professional selection, etc. Naturally, the various types of therapeutic and preventive institutions—diet kitchens, night sanatoriums, rest homes, sanatoriums, etc.—again require their own special schemes for patient examination. However, the basic scheme of clinical examination, which ultimately, with this or that abbreviations, additions, and changes, finds application also in specialized clinics and in institutions of the above-mentioned character, is the scheme of examination of the general type clinic—the clinic of internal diseases, which plays a leading role in the system of clinical training of physicians. It is therefore expedient to dwell on this scheme in detail. 'The purpose of clinical examination,' says Ostroumov (Clinical Lectures, ed. 11, p. 10), 'is to study the conditions of existence of the human organism in the environment, the conditions of adaptation to it and the disorders.' The fulfillment of the task of research so broadly formulated by Ostroumov, if one also takes into account that in essence we are not talking about the human organism but about a person of a certain social affiliation, in relation to which the conditions of the environment, the conditions of adaptation, and the reactions cannot be interpreted as in relation to the animal organism in general, that in this case we are talking not only about the object of environmental influence, as is the case in the animal world, but about the subject, who by his practical activity changes the conditions of nature and social environment—then the entire complexity of research grows in all its significance and magnitude. In the scheme of clinical research proposed by Zakharyin, 12 questions are devoted to 'the most important conditions in which the patient lives, his way of life,' starting from the locality where the patient lives, the dwelling, the nature of the patient's activity (mental or physical), food, etc., and ending with questions of rest, daily stay in the open air, etc. Zakharyin's questioning about the condition of the patient contains 21 questions.'

The complexity of the task naturally determines a certain bulkiness of the scheme, and its simplification is impossible without the risk of oversimplifying the problem of clinical research itself. Ostromov also sets as the goal of clinical research 'to determine why a given subject fell ill under the conditions of his environment, why the disease manifested itself in this rather than another organ, why the disease took this rather than another course.' In essence, here we are talking not only about the diagnosis of the disease (morbi), but about the diagnosis of the illness (aegri). Zakharin believes that diagnosis includes the 'main disease' (morbus) and secondary disorders and all the peculiarities of the patient (aegrum). In clinical practice, in each individual case, we are dealing not with a disease, which determines the general specific features of the process, allowing us to classify and group patients from this point of view, but with the illness in this particular patient, the course of which has its individual characteristics, conditioned by the entire complex of psychological and somatic peculiarities of the patient, as well as the socio-domestic and working conditions. In each individual case, the examination of the patient aims to grasp that which is general, which allows for the diagnosis of the disease, and at the same time also how this general, in connection with individual peculiarities, is manifested in this particular patient. For example, if we touch upon the question of the interconnection of psychological and somatic processes, clinical practice has accumulated many facts that beautifully illustrate this connection. It is necessary to remember that the vegetative nervous system and the endocrine glands, which play an enormous role in regulating the functions of internal organs, are easily susceptible to psychogenic influences. The vasomotor phenomena observed even in a healthy person, accompanying certain psychological reactions—blushing 'from shame', paleness from fear, dyspeptic phenomena, palpitations, heart stopping, etc.—serve as the most elementary illustration of the above propositions. It is not difficult to imagine that the state of the neuropsychic sphere cannot but influence the course and form of the specific manifestation of the somatic pathological process in a person. There are known cases when a psychic affect is accompanied by a sudden illness of a somatic nature. Cases of the appearance of jaundice 'from fear' have been described, it is known that attacks of angina pectori also often accompany periods of great neuropsychic tension, and in the literature there are indications of the so-called 'stock exchange diabetes' and the like. All these facts, of course, cannot make us consider this or that state of the psyche as the etiology of jaundice, diabetes, angina pectori, etc., however, in some cases the psyche can play the role of a factor that reveals, contributes to the manifestation of the said sufferings, despite the fact that the pathways of realization of such psychic influences are still insufficiently studied. The course of the illness is undoubtedly influenced by how the patient himself evaluates his illness, whether he considers it dangerous or mild. There is no need to prove that the patient's conception of the disease will not always correspond to the objective state of affairs, but in all cases, other conditions being equal, it will exert this lesser or greater, this useful or harmful influence on the course of the disease. 'The physician must together with the patient look at the disease from the patient's point of view. Only then will he be able to understand the origin and development of certain pathological phenomena. For the course of this or that process in the human body depends on the influence of human consciousness,' says Krell (Vol. II, p. 5). Goldscheider called the psychic complex, which represents the picture of the disease in the patient's consciousness, the 'autoplastic' picture of the disease. If the role and significance of the psyche in somatic processes are so significant, then it is natural that the state of the psychic sphere of the patient must be taken into account in every patient, both for diagnosis and for therapeutic intervention, along with the data obtained by so-called objective research (percussion, auscultation, laboratory, instrumental research, etc.). Thus, even in cases where we are dealing with somatic diseases, it is absolutely necessary to take into account the psychic state for the correct conduct of research, since the latter, if it does not determine the specificity of the picture of the disease, can still influence the course of the illness. Both Zakharin and Ostromov emphasize the exceptional importance of studying the conditions of the environment and an individual approach in each individual case. 'Who has mastered the method and skill of individualization, he will also find in every new for him case—a case presenting unprecedented peculiarities, and such new cases are always quite numerous even for the most experienced physicians and incomparably more so for beginners. Such is the peculiarity of medical, like any other, 'practice,' i.e., activity in real conditions—conditions of reality' (Zakharin, Clinical Lectures, Vol. 1). When we speak of individualization, we of course have to take into account not only the psyche, but also the socio-domestic and professional conditions of the past and present, as well as heredity and constitutional peculiarities of the patient, which also do not remain without influence on the course of the illness, but in relation to some diseases are the main etiological factor. Thus, the examination of the patient represents an extremely complex process and by no means consists merely in identifying this or that symptoms and their systematization in a certain semiotic scheme. It is necessary to take into account not only the morphological and functional peculiarities of organs and systems and their mutual connection and interdependence from the point of view of the integrity of the organism, but also to keep in mind that in each individual case we are dealing not only with an organism, but with a personality with all its psycho-somatic peculiarities. Only in this case is the problem of 'disease' and 'patient,' the problem of 'disease' and 'illness,' the problem of 'morbi' and 'aegri' correctly solved. The examination of the patient is conventionally divided into two main sections: subjective and objective—history and status praesens. The history includes all that the patient can report not only about the illness, but also in general about his past and present, and which can acquire this or that significance in the process of research, and often also in the treatment of the patient. Reference information (sex, age, profession, address, etc.), complaints, history of the present illness, past illnesses, heredity, socio-domestic and professional conditions of the patient in the past and present, etc., i.e., all those data that can be obtained by the method of questioning the patient, constitute his history. It is quite natural that the history is not the complete and exhaustive autobiography of the patient recorded by the physician, since he is interested only in those moments from the past and present of the patient that can play the role of factors conditioning or contributing to the illness in this or that case. When we speak of the socio-domestic and professional part of the history, we limit ourselves only to identifying the unfavorable from a hygienic point of view conditions, for example, dampness in the dwelling, professional hazards, etc. The data of objective research is considered to be all that is obtained directly by the physician's sense organs or with the help of laboratory and instrumental research. However, this division is extremely conditional, since even in time these parts of research cannot be strictly separated, for example, when questioning the patient, collecting the history, one simultaneously observes the color of the skin and mucous membranes, the play of the vasomotors, how the patient breathes, etc., thus obtaining purely objective data. On the other hand, even in the stage of objective research, one often has to return to additional questioning of the patient about this or that details of the history. But the subjective and objective in the examination of the patient cannot be strictly separated in another sense. For example, the concept of dull and slightly dull tones, although it belongs to the so-called section of objective research, is extremely subjective, whereas the bloody vomiting, diarrhea and constipation, etc., in the patient's complaints, although they constitute part of the subjective research of the patient, are undoubtedly, strictly speaking, purely objective data, with the exception, of course, of those cases where there is reason to think that the patient is consciously or unconsciously lying. As for the diagnostic value of the data of subjective and objective research, for example, the patient's complaints of shortness of breath with slight physical exertion or of attacks of shortness of breath at night have much greater significance for assessing the functional state of the heart than, for example, the slightly dull and dull tones found on objective research. Thus, without diminishing the importance of the data of objective research, i.e., symptoms perceived directly by the physician's sense organs, one still cannot underestimate the subjective research of the patient, the history. A one-time objective research is insufficient at least because it at best gives us the statics of the illness, whereas the dynamics of the patient's condition we learn only from questioning, which has no less importance for diagnosis. Let us give a concrete example: a patient consults a physician about the appearance of jaundice.'

Objective examination reveals a somewhat enlarged, firm, and sensitive liver. However, whether we are dealing here with a primary disease of the liver, gallbladder, stomach, pancreas, etc., can be determined through detailed questioning, and if it is found that jaundice appeared immediately after an acute attack of pain in the right hypochondrium, then it is most likely to be assumed as cholecystitis or cholelithiasis; we will come to a different conclusion when the patient reports a gradual, slow development and increase of jaundice. Thus, even in the presence of sufficiently pronounced objective symptoms of the disease, it is necessary to collect additional anamnestic data for diagnosis. In the process of taking the history, we form an impression of the patient's general mental state, which forces us to evaluate his individual complaints or reported data in one way or another. It is not by chance that Kre'hl says that 'no omission takes such revenge as an insufficient conversation with the patient, as insufficient information about all the details of the disease.' However, it is most often necessary to guide the patient's story within certain frameworks in order to focus him on the moments that are of interest to the physician. But all this must be done in such a way as not to traumatize the patient and, by unsuccessfully interrupting his story, not to cause him to withdraw and, at best, limit himself to laconic answers to the questions asked. It is quite natural that no detailed instructions or schemes can be given in this regard. The physician must remember that the question of establishing contact with the patient, the question of the patient's confidence, plays an enormous role from the very first moment of contact with him. A calm, attentive attitude toward the patient as a person, and not as a sum of certain altered signs, a tactful questioning of the patient with consideration, as far as possible, of his 'sore' spots, create an atmosphere of the most normal relationships with the patient, which has a huge psychotherapeutic effect, which, under otherwise equal conditions, plays a significant role. When asking the patient questions, they should not be phrased in such a way as to suggest a positive or negative answer to the patient. If in this sense the patient's answers arouse suspicion, then it is necessary to resort to control questions that could verify the correctness of the answers. For example, the patient, when asked in a general form whether he suffers from shortness of breath when climbing a hill or stairs, gives a positive answer, but upon further questioning it is found that the patient lives on the 4th or 5th floor and climbs the stairs several times a day without shortness of breath or easily copes with professional work requiring significant physical exertion. All these points must be taken into account if one wants to obtain reliable anamnestic data. One of the essential elements of the subjective part of the examination of the patient are complaints. Reference information is usually recorded in the patient's history by middle medical personnel and includes the surname, name, patronymic, age, sex, nationality, home and business address of the patient, literacy, detailed profession, etc. The examination of the patient usually begins with a question about his main painful sensations, about what prompted him to seek medical help. There is no need to prove that what the patient considers the main thing, for example, pain in a particular organ, will really indicate the involvement of exactly this organ, or that the patient will always direct the physician's attention to the main thing. The most difficult in this respect is the question of pain, which in many, even serious diseases, can often be completely absent (typhoid fever, cancer), on the one hand, and on the other hand, pain is often localized far from the position of the affected internal organs. If we take, for example, an attack of acute pain in the abdominal area, then not to mention that they can be caused by diseases of the most diverse organs of the abdominal cavity (cholecystitis, appendicitis, renal colic, acute gastroenteritis, lead colic, perforation of an ulcer, etc.), there are frequent cases when lobar pneumonia is accompanied initially by such sharp pains in the abdominal area that until sufficiently clear data of percussion and auscultation from the lungs appear, appendicitis, etc., is sometimes diagnosed. Cases of attacks of angina pectoris have been described, which were accompanied by localization of pain in the right hypochondrium and simulated cholecystitis or perforation of an ulcer. On the other hand, in many cases the pains are so typical and characteristic that it is sufficient to learn about them from the patient to be able to with greater or lesser probability assume the presence of one or another disease. Such are the characteristic pains in the heart area during angina pectoris, accompanied by fear of death, which are often almost the only symptom in these cases, since the data from the objective examination of the heart rarely give anything substantial for diagnosis. The onset of pain in connection with the time of food intake has great importance for the diagnosis of ulcer disease, pain in dry pleurisy, pain in the joints in rheumatic diseases, pain and difficulty in swallowing in diseases of the esophagus, etc. When speaking of pain, it is necessary to determine under what circumstances the pains arise. For example, pains in the heart area will have different diagnostic value in the case when they appear without any visible cause for the patient at night, and in the case when these pains accompany only moments of neuropsychic or, say, physical exertion, pains and unpleasant sensations in the heart area after a heavy meal, etc. Despite all the caution with which it is necessary to approach the accounting of the patient's pain sensations, which can sometimes distract attention from the main disease, despite the need to take into account the cultural level of the patient and his ability to more or less correctly analyze his sensations, no complaint of the patient about any pains, subjective sensations, should be overlooked by the physician even when, as it were, at first glance, confirmation in the objective examination is not found. As for complaints of other types, they can be the most diverse - shortness of breath, palpitations, cough, disturbance of intestinal function (diarrhea, constipation, vomiting), etc.; complaints of this type represent a more reliable criterion, especially in a hospital setting, where they can be verified by objective observation. In these cases too, they require clarification by additional questioning, for example, shortness of breath at rest or with movement and physical exertion, during the day or at night, in attacks or constant, etc.; cough dry or with sputum, at night or during the day, character of sputum, etc. In many cases, even before the beginning of objective examination, the diagnosis seems to be sufficiently clarified, and in relation to some patients, where objective data are sometimes not found by clinical examination, complaints and in general the anamnesis represent the only basis for diagnosis and medical intervention. It is not by chance that Struempel, speaking of the importance of the anamnesis, writes: 'A precisely and thoroughly collected anamnesis has the same, if not greater, importance for clarifying the diagnosis as objective examination' (Clinical Examination of Patients, 1924, Preface). We must always be sure that the complaints have been collected with sufficient completeness. 'A young physician, if he has not mastered the method, has not yet been convinced of its necessity, asks questions haphazardly: in one case this way, in another that way, he is carried away by the first impression made by the patient's complaints (for example, shortness of breath, pain in the side, cough), and, assuming on this basis a certain disease, hopes to quickly resolve the matter by asking the patient a few relevant questions, but without exhausting the questioning of the condition of the entire organism. He will be convinced by bitter experience (if he is at all capable of self-improvement) that such a method does not lead to the goal, that it is not condemned in vain by experience, and that the only correct, although slower and more difficult path is to observe completeness and a certain once accepted order in the examination' (Zakhar'in, Clinical Lectures, vol. 1). Therefore, without limiting oneself to registering the complaints stated by the patient, a thorough questioning of the patient is conducted by systems of organs (respiratory organs, circulatory system, digestion, nervous system, etc.), about subjective sensations and about function. As a result of this questioning, sometimes the main disease has to be diagnosed far beyond the limits of those organs and systems with which, at first glance, one could connect the complaints independently stated by the patient. For example, the patient seeks help for shortness of breath and unpleasant sensations in the heart area, but upon additional questioning it is found that in addition he suffers from chronic constipation, heaviness in the epigastric area after eating, meteorism, etc. In objective examination in such cases, a somewhat distended abdomen, high position of the diaphragm, the heart elevated by the diaphragm are often found, and attention is shifted from the cardiovascular system, to which the main complaints of the patient directed it, to the digestive organs. Period of childhood and youth. Special attention in the anamnesis is paid to the period of childhood and youth.

Here it is necessary to clarify both the course of the general and physical development of the child, as well as the socio-domestic conditions of childhood and youth. It would of course be incorrect to assume that exhaustive data can be obtained from the patient in this part, however, we already get a general impression of this period of the patient's life when we learn about the parents' profession, whether the patient spent their childhood in the city or village, from the general description of housing and nutrition, etc. One of the essential questions, which is often a control in relation to the answers given to other questions in this section, is the question of the time of beginning paid labor. The lower the age of beginning paid labor, the more grounds there are to assume unfavorable socio-domestic conditions of childhood and youth. In this sense, it is especially necessary to highlight the period of puberty (from 14 to 18 years), the transitional age, when the body needs particularly favorable conditions and when harmful socio-domestic factors have enormous significance. During this same period of their life, a person often, under the influence of their surroundings, acquires harmful habits (alcoholism, smoking). Socio-domestic and professional anamnesis. The collection of socio-professional anamnesis of course does not aim to obtain an exhaustive biography of the patient, but only to clarify those moments which may have sanitary, medical significance, i.e., only factors of socio-domestic and professional character that exert harmful influence on health. When we speak of socio-domestic and professional anamnesis, we mean primarily data from the patient's past, connected with their work in the pre-revolutionary period, the period of imperialist and civil wars on the one hand, and on the other hand, those unfavorable conditions of life and labor which are a legacy of the past (alcoholism), difficult housing conditions, etc. - Turning directly to the question of the patient's professional anamnesis, it is necessary to remember that socio-domestic conditions, on the one hand, and profession, on the other, are in close mutual connection and interdependence. Social conditions determine the possibility of obtaining qualifications - and thereby the choice of profession, while the profession in turn determines the wage, and thereby other socio-domestic conditions (nutrition, etc.). Unfavorable socio-domestic conditions, by lowering the body's resistance to professional harmfulness, infections, contribute to professional and general morbidity; conversely, favorable socio-domestic conditions can mitigate the harmful influence of professional and other factors. Socio-professional anamnesis covers both the past and the present of the patient. They usually begin from the time of beginning paid labor and, in chronological order, successively inquire about individual periods of professional activity. In the social part, we are interested, by periods, in the amount of wages, length of the working day, work during the day or night, housing conditions, nutrition conditions. The so-called professional route of the patient as a whole has great social significance. In some cases, the patient remains in one profession for many years (sometimes their entire life), gradually rising in terms of qualification. In other cases, the working life of the patient represents an extremely motley picture of frequent changes of profession. Sometimes frequent changes of profession are of medical interest in that they are conditioned by the state of health, the search for easier work, sometimes the patient indicates that he changed profession on the advice of a doctor. In some cases, frequent changes of profession are connected with the psychological instability of the patient, which is also not without medical significance. Change of profession sometimes also occurs as a result of professional disease, etc. All these moments naturally may be of interest to the examining physician, and sometimes may be related to the patient's main disease. - As for the harmfulness to which the patient is exposed in different periods of professional activity, the sanitary conditions of work and the labor process itself and the material with which the worker comes into contact, which separately or taken together can determine the harmfulness of the profession, are of importance. Often, when examining the patient, sufferings are discovered that are not connected with the profession in which the patient is found, but with his activity, sometimes of varying duration, in some other harmful production. Vigdorchik, studying the professional anamnesis of several hundred workers of non-lead professions, found among them 6.9% of persons who had contact with lead in the past, on average for over 4 years. Naturally, within the framework of studying their present profession, one could not obtain an explanation for the clinical phenomena of saturnism. One can cite a number of similar examples emphasizing the enormous importance of socio-professional anamnesis. Naturally, one cannot demand from the patient a detailed sanitary characterization of all periods of his diverse professional activity. Therefore, they are limited to a number of basic questions, starting first with the name of the detailed profession (miner, metal turner, blacksmith, hammerman, painter, spinner, etc.), which in itself is already associated with certain harmfulnesses (heavy physical labor, overstrain of individual organs and organ systems, increased humidity, dustiness of the room with organic or inorganic dust, uneven pace of work, poisonous substances, etc.). Next follows clarification of all these moments by a number of questions related to clarifying the local features of the workshop, machine, working material and enterprise where the patient worked. The main harmfulness is often indicated by the patient himself, without waiting to be questioned, for example, emphasizing: 'during this period it was necessary to work in a basement, damp, dark room' or 'it was so hot in the room that it was often necessary to open the windows even in winter', 'ventilation worked poorly, eyes watered from smoke', 'it was often necessary to be burned by acid and alkali', etc. Into the patient's history is not inserted a detailed description of all these periods, but only their sanitary assessment. - When collecting socio-professional anamnesis from men, it is necessary to pay special attention to the question of military service. If the patient was in military service, then naturally it is necessary to inquire about the branch of service in which he served, whether he was at the front, participated in battles, etc. If the patient was exempt from military service, it is necessary to inquire about the reason for exemption. Sometimes the reason for exemption is some or other chronic disease which may have direct relation to the given disease. More detailed attention is paid to the socio-domestic and professional conditions of the present time, since if the socio-professional past of the patient often reveals the etiology of the disease, the socio-professional status of the patient plays a huge role also in relation to the therapy of the disease and the prevention of its complications. On the other hand, in this part the data are more reliable, and if necessary can be verified by objective researches (sanitary inspection of housing, production). To clarify housing conditions, they ask about the area occupied, as well as the sanitary aspect (light, dry, warm housing). In relation to nutrition, we are interested in its quantitative and qualitative aspects: the total caloric value and its correspondence to the patient's build and profession, the approximate ratio of proteins, fats and carbohydrates, the presence of vitamins and salts in the food. In addition, great attention must be paid to the regime of nutrition, timely and regular intake of hot food. All these moments may have diagnostic value, and depending on the nature of the disease, the physician's attention is sometimes directed in this direction. To this same section belong questions of personal hygiene and hygienic habits (how often he bathes, changes bed and underwear), whether he engages in physical culture, how he uses his day off, etc. Abuse of narcotics (nicotine, alcohol) is clarified by questions about the number of cigarettes smoked per day, from what age he started smoking, as well as inquiries about how often and in what quantity he uses alcohol, whether he gets drunk, is prone to binge drinking, and on the basis of the data obtained, moderate or immoderate consumption of alcohol or alcoholism is noted. If in relation to smoking one almost always gets a more or less accurate and truthful answer (smokes 25-30 cigarettes a day), then abuse of alcohol is often concealed by patients, and therefore in cases causing doubt, the correctness of the patient's statement should be verified by questioning, where possible, family members or those around him. In the part concerning professional conditions of the present time, the patient is asked about the sanitary condition of the working room (cubature, ventilation, heating, lighting, etc.), about harmfulnesses connected with the processed material (poisons, infected material, etc.) and with the labor process itself (position of the body, strain of certain organs, etc.). In many cases, only knowledge of professional conditions can ensure correct diagnosis and therapy, especially in those cases when the professional disease is not sharply expressed or when its symptoms are not strictly specific and are also encountered in other diseases. For illustration, we will give the following example: the patient complains of chronic fatigue.

Constipation can be caused by changes in the motor or secretory function of the stomach, various changes in the intestine, as well as causes lying outside the gastrointestinal tract (neurogenic), etc. However, if we know that the patient has contact with lead, it is necessary to exclude constipation as one of the symptoms of lead poisoning. A detailed investigation of the patient in this direction clarifies the diagnosis and indicates the paths of rational therapy, sometimes associated with the need to change profession for the prevention of further development of a pronounced professional disease. Knowledge of professional conditions is also necessary in cases where we are dealing with a non-professional disease, for determining the work prognosis, and in particular for solving questions of professional capacity to work, and it is quite natural that in these cases we are interested in both the question of whether the patient will cope with further work in his profession, and what effect this work will have on the course of his disease. All these questions, which have enormous significance in daily work at the patient's bedside, cannot be solved without sufficient knowledge of the patient's working conditions, without a carefully collected social-professional history, and sometimes without familiarizing oneself on the spot with the patient's working conditions. The social-professional history in Soviet clinic conditions has not only purely diagnostic value but also enables the physician to correctly use the most effective therapeutic-social measures of Soviet health care in relation to the patient (transfer to another job, individual modification of work regimen, dietary, sanatorium, resort treatment, etc.). In the process of collecting the history, the patient's subjective evaluation of his profession is also of interest. All other conditions being equal, the worker's subjective attitude toward his profession, the positive or negative emotion aroused by work, cannot but weaken or, conversely, strengthen the influence of professional harmful factors on the worker. Indications of the patient's attitude toward his profession are also obtained indirectly from answers to questions about whether he is a shock worker and how he performs production assignments. On the other hand, all these questions introduce us to the patient not only as an organism suffering from certain changes localized in certain organs, but also as a personality, introduce us to his social face, which is absolutely necessary in order to critically evaluate all information provided by the patient. Past illnesses. As for past illnesses, one separately inquires about childhood diseases, mainly acute infectious diseases (measles, scarlet fever, diphtheria, whooping cough, etc.) and about diseases in mature age. Here we are interested in both acute (typhoid, angina, pneumonia) and chronic infections (tuberculosis, syphilis). Knowledge of past illnesses makes it possible in some cases to exclude diseases that confer lasting immunity (scarlet fever, typhus), and, on the other hand, conversely, to suspect a disease that does not confer immunity but has a tendency to recur (lobar pneumonia). One should not limit oneself to a simple enumeration of past illnesses, but it is necessary to inquire about the duration and character of the course, about complications that occurred. One checks the source of the diagnoses reported by the patient, the names of past illnesses, whether the patient was in a hospital, whether he was treated by a physician at home, etc. All these questions clarify the information provided by the patient in one direction or another. For example, a patient often confuses lobar and grippe pneumonia. With additional questions about the duration of the illness, the height of the temperature, the character of the sputum, etc., one can to some extent clarify the patient's answer and assume with greater or lesser probability one or the other type of pneumonia. One has to proceed in the same way in cases where it is necessary to clarify the nature of the typhoid fever the patient had suffered. In this respect, the patient's indications of 'rheumatism' in the history require special verification. Naturally, in these cases it is important to determine whether we are speaking of acute rheumatism in the narrow sense or of gouty joint pains or neuromuscular pains, while all this usually appears in the patient's report as 'rheumatism'. With additional questions about age, onset of illness, duration, character of course (temperature, localization of changes, etc.), about the illness immediately preceding the one in question (angina, etc.), it is possible to exclude or assume one or the other type of past 'rheumatism'. Changes in the heart valve apparatus found during objective examination often confirm the historical data about past acute ('true') rheumatism. The question of complications accompanying various diseases is also of no less importance. For example, it is known that the first attack of acute rheumatism is often accompanied by angina, on the other hand, repeated anginas in those who have had acute rheumatism often lead to a recurrence of rheumatism. Indications of an attack of cholecystitis that followed an attack of typhoid fever sometimes facilitate the task, which is often difficult, of differential diagnosis of attacks of pain in the right hypochondrium. Great attention must be paid to infections complicated by kidney involvement, middle ear involvement, thrombophlebitis, etc., because the recurrence of various infections in the same individuals often leads to the same recurrent complications. The question of past chronic infections and in particular syphilis sometimes proves difficult to clarify. Often here the patient's false shame and attempts to conceal this disease play a role. Meanwhile, syphilis often leads to a series of changes in internal organs (heart and blood vessels, liver, etc.) which are sometimes difficult to distinguish from non-syphilitic diseases. In these cases, the question of syphilis has not only diagnostic but also important therapeutic significance, since one can resort to effective specific treatment. Therefore, it is necessary to question the patient about past illnesses in such a way that during the process of collecting the history the question of the presence of syphilis in the past is clarified. For this it is not sufficient to directly ask: 'have you had syphilis'. It is necessary to ask a series of control questions: was he treated with injections in the buttock area, intravenous infusions, does the patient have children, were there stillbirths, miscarriages or premature births in the patient's (the patient's wife's) history, etc. Sometimes one has to return to this question at subsequent visits to the patient, etc. It is also necessary to ask the patient where and when he was treated. The patient, when asked 'have you had tuberculosis', answers negatively. However, it later turns out that he is under constant observation at a tuberculosis dispensary, has been repeatedly sent by the latter for sanatorium-resort treatment, etc. In other cases, it is incidentally clarified that besides the disease for which the patient consulted, he has been on dietary food for a long time because of a stomach ulcer or kidney disease, the presence of which often needs to be taken into account when prescribing one or another treatment. The illustrations given naturally do not exhaust all the cases where the question of past illnesses acquires exceptional significance, but what has been said is sufficient to take into account all the importance of careful collection of the history in this respect. History of the present illness. The history of the present illness covers the period of time from the moment which the patient considers the beginning of the illness to the moment of the examination being performed. The patient cannot always note the beginning of the illness as precisely as is the case when the illness has an acute and violent onset (lobar pneumonia, etc.) or has the character of an attack (malaria, renal or hepatic colic, appendicitis, etc.). Especially when it comes to a chronic disease developing insidiously, gradually (cancer, arteriosclerosis, stomach ulcer, etc.), the patient finds it difficult to establish the exact time of onset of the illness. Sometimes the beginning of the present illness must be sought in past illnesses. If the patient consults for a decompensated heart defect, then essentially the beginning of his illness should sometimes be considered the preceding acute rheumatism, accompanied by myocardial and endocardial damage. When it comes to late manifestations of visceral syphilis, then here too the disease actually begins from the moment of infection during the intra- or extrauterine period of existence. In these cases it is difficult to distinguish between past and present illness. However, in many cases the time of onset of the illness has great diagnostic significance, especially when it comes to acute infectious diseases having a definite incubation period and a specific picture of course, temperature curve, etc.

It is necessary to question the patient in detail not only about the time of onset of the disease, but also about the circumstances immediately preceding it, about the first symptoms, about the nature of the development of the clinical picture, about fluctuations in temperature, about the diagnoses of the physicians to whom he applied, about their prescriptions, etc.—all these moments may have diagnostic significance. For example, if an acute disease with a rapid and sharp rise in temperature was preceded by a trip by railroad during an unfavorable time for typhus, and if the time between the onset of the disease and the trip does not exceed the incubation period, then it is natural to suspect typhus. If a patient who had previously had malaria, in damp weather or after overheating in the sun, after bathing, etc., complains of chills, high temperature, then it is necessary to exclude a relapse of malaria. If the patient complains of an acute onset of the disease, accompanied by a significant increase in temperature, pain in the side, intensifying with cough, and the expectoration of rusty sputum, then lobar pneumonia can already be presumed in advance. Sometimes the time of year when the disease began is of importance; for example, exacerbation of the tuberculous process, stomach ulcer, and other diseases with a cyclic course are more often observed in autumn or spring.—The history of the present disease is also of great importance when speaking of food poisoning. As is known, patients are very prone to associate the onset of the disease with the ingestion of food preceding it, and thus direct the physician's attention toward food intoxication. Without ignoring the patient's indications in these cases, it is nevertheless necessary to question him: did anyone else besides him eat (family members, and if we are talking about a cafeteria, comrades, etc.), and are there any sick among them, what exactly did the patient eat, in order to establish the correspondence between the clinical picture and the nature of the food ingested, etc.—Naturally, we have limited ourselves to only a series of examples, which by no means exhaust all possible variants of the history of the present disease, which are extremely diverse and require consideration of both the clinical picture and the individual characteristics of the patient in each particular case. Percussion and auscultation, which have not lost their significance at the present time, were almost the only methods of objective clinical examination in the 19th century. Modern clinical medicine, possessing a significant number of diverse methods of objective investigation, based on the use of the latest achievements of technology, physics, physical and biological chemistry, includes laboratories and diagnostic offices as an integral part. Starting from the comparatively simple instrumental investigation of arterial pressure with a sphygmomanometer and the most complex graphic methods of investigation with the help of special apparatus (electrocardiograph, radiokymograph, etc.), on the one hand, and ending with the most precise microchemical investigations—on the other,—all this is placed at the service of functional diagnosis. The new methods of investigation themselves are continuously being perfected and find ever wider application in clinical medicine. Thus, despite the fact that since the discovery of X-rays by Röntgen (1897) about 40 years have passed, during which the X-ray method has become an integral part of clinical investigation, in recent years new and new possibilities for the functional-diagnostic use of X-rays are being revealed. Radiokymography, which makes it possible to judge the contractile function of the heart as a whole and its individual parts, angiography, cholecystography, determination of the relief of the gastric and intestinal mucosa, etc., can serve as an illustration of the latest achievements of the X-ray method of investigation. Electrocardiography (see) has acquired special importance in the study of functional pathology of the heart, opening the possibility of precise differential diagnosis of various types of rhythm disturbances and the finest changes in the heart muscle, which escape detection by ordinary clinical methods. Investigation of gas exchange plays an enormous role in the functional diagnosis of metabolic disorders and endocrine disturbances. In the same sense, biochemical investigations have become very important. For example, determination of residual nitrogen in the blood makes possible early and more accurate recognition of uremia, the direct and indirect van den Berg reaction makes it possible to clarify the pathogenesis of various types of jaundice, and thereby the diagnosis. In modern clinical medicine, methods of functional investigation have acquired special importance for the early diagnosis of insufficiency of this or that organ or system with the help of so-called loads: dosed physical load in the investigation of the cardiovascular system [Martin's test, Stange's test] and others—, alimentary load (carbohydrate, uric acid, etc.) in the investigation of liver function and metabolic disorders, functional tests of the kidneys by Volhard and Fahr, etc.—We do not have the opportunity within the framework of the present article to enumerate the numerous methods of functional investigation currently used in clinical medicine and to dwell on the characterization of the significance of EACH OF THEM.

B. Kogan. II. Objective Research. Status praesens objectivus. Objective research of the patient is performed by the following methods. 1) Direct accessible perception and observation of what can be determined by sight, hearing, touch, smell, and by the aggregate of impressions from the patient and their surrounding environment. 2) Routinely used methods of medical research, for the performance of which relatively simple instruments are mostly needed; these include: systematic inspection, methodical palpation, percussion, succussion, auscultation, determination of various reflexes, etc., as well as measurement of temperature, height, weight, etc. 3) Direct determination of the properties of various secretions (without laboratory assistance). 4) Clinical methods of research, such as for example research of the functions of the gastrointestinal tract and kidneys, inflation of the stomach and intestines, trial punctures, sphygmography and sphygmomanometry; for the performance of such research methods corresponding clinical skills and mostly special instruments are needed. 5) Special methods of research, for the performance of which both special equipment and special preparation are required; these are various types of endoscopy and X-ray research, used in various fields of applied medicine. 6) Chemical-physical and microscopic laboratory research of various secretions, blood excretions, punctates; for the performance of some laboratory methods relatively simple equipment is needed, while for others more complex instruments and in any case corresponding preparation are necessary. Of the listed research methods, those mentioned in paragraphs 1, 2, 3 are mandatory under all conditions of medical work and in all branches of medicine. Many of the remaining methods are also an integral part of patient research, especially in clinics of internal diseases, and undoubtedly significantly clarify the diagnosis, thereby improving patient care. The examination is divided into 1) general, 2) systemic, and 3) special (follow-up research). 1. General examination aims to determine the general appearance and condition of the patient through direct observation, and it is necessary first of all to establish the more stable - static - somatic and psychological signs, such as: height, build, musculature, thickness and distribution of fat deposits, color and properties of the skin and visible mucous membranes, development of external genital organs and secondary sexual characteristics; condition of lymph nodes; structure of the skull, facial features, especially the eyes (width of the palpebral fissure, color of the iris, gaze, brightness); lips (shape, thickness); properties of facial skin (folds, wrinkles); hair on the head and face, their color; presence of teeth, etc. On the other hand, more variable, transient - dynamic - signs must be taken into account, such as changes in facial expression (mimicry), blood filling and color of the face (flush, pallor, tan); expression of the eyes; general behavior, manner of holding oneself, speaking, expressing oneself; manner of dressing; character of movement, gait, posture, etc. The aggregate of these static and dynamic signs of the subject being researched, to a large extent summed up subconsciously, presents to the researcher's mind a distinctive general appearance, behind which can be recognized: a certain constitutional type, a known somatic appearance, sex, sexual coloring; age and nationality are often guessed, and characteristic features imposed by living conditions, social status and profession, as well as temperament, intellect - in general, the individual appearance of the patient - are captured. Using direct observation and without resorting to any special research methods, the psychological and somatic condition of the patient must also be determined. The basis for this is the presence of various variable (dynamic), partly already indicated manifestations, especially mimetic changes, hyperemia, pallor of the face, expression and febrile brightness of the eyes, tears, immobile gaze, closed eyes, hysterical laughter, altered weak voice, groans, incoherent speech, disordered movements, convulsions, general immobility, loss of consciousness, etc. By various combinations of such signs, the patient's condition is determined as visible weakness, exhaustion; excited, febrile, typhoid, delirious, soporose, fainting state; stupor, coma. Determination by direct observation of such changes in general condition, often insufficiently taken into account, has much greater significance than establishing even serious changes in individual organs, seemingly by more reliable research methods. Thus, for prognosis, general adynamia in lobar pneumonia can tell the doctor much more than dullness and bronchial breathing in the affected lung. No less important are the indicative symptoms determined by general examination through direct perception, indicating various characteristic disorders of the patient's functions. These are: visible pulsation of large vessels or undulation of neck veins, profuse sweat, characteristic changes on the skin, visible dyspnea, altered type of breathing; hoarse voice, characteristic cough, rumbling in the abdomen, odor from the patient, incontinence of urine and feces, arrhythmia, nuchal rigidity, etc. Also of very great importance is the direct assessment by the attending physician and medical personnel of the properties of various patient secretions - sputum, vomitus, feces, urine, wound exudate, etc.; the quantity, color, consistency, form, odor, various unusual components, etc., are determined. If necessary, each portion can be examined in this way; this often makes it possible to quickly catch very important and characteristic changes that remain unnoticed when researching in the laboratory, where corresponding objects are sent only occasionally and often in insufficient quantity; moreover, the laboratory technician may not have in mind what is especially important for the attending physician to know, and the delivery of written conclusions (analyses) from the laboratory is often greatly delayed. Thus, through general direct examination of the patient, in the doctor's mind a picture of a certain disease emerges through individual indicative signs or their combination. These are: yellowish color of the skin and sclera, scratches on the skin, bright yellow spots on linen, urine the color of dark beer, discolored feces - in mechanical obstruction of bile. Bronze color of the skin, general adynamia, small soft pulse - Addison's disease. Amimia, monotonous speech, stiffness - in epidemic meningoencephalitis. Open mouth, salivation, rare, difficult, apparently very painful swallowing movements, pinched nasal voice - in phlegmonous angina. Hot skin, febrile, hyperemic face, herpes on the face, rapid, superficial, groaning breathing and a blushing cough with very difficult to expectorate, scanty, sticky, rusty or bloody sputum - in lobar pneumonia. General severe condition, earthy color of the face, odor of putrefaction in the exhaled air - in gangrene of the lungs; deep tense (Kussmaul's) breathing, odor of acetone - in diabetic coma. Hippocratic facies, general exhaustion, distended abdomen, hiccups, vomiting movements - in general acute purulent inflammation of the peritoneum. Odor of urine from clothing (involuntary urination), ataxic gait, narrow, unchanging pupils - in tabes dorsalis, etc. All these indicative signs, especially in the indicated combinations, are of course sufficiently perceptible, but still sometimes remain misunderstood and unnoted in the doctor's pursuit of more complex research methods. The environment and everything surrounding the patient, especially in sudden illness, should be the subject of the doctor's attention, since some characteristic phenomena may lead to substantially important conclusions. This includes for example the odor in the patient's room or from their clothing, stains on clothing, on linen and even on the floor, a vial or ampoule from under a strongly acting substance, remains of poor quality food somewhere on the windowsill and much else. - 2. Systematic examination aims to determine in the subject being researched possible deviations from norm in all systems and organs accessible to research, using the so-called physical methods, such as inspection, feeling (palpation), tapping (percussion, shaking (succussion), listening (auscultation), anthropometric measurements, weighing, measurement of temperature. In this case, to determine the nature of the existing pathological changes, various research methods are used sequentially as much as possible, and the results of one method are verified by means of another. Systematic examination must always be conducted in the same order, starting with a more precise determination of the somatic appearance, which has been carried out in general terms during the general examination. - Order of systematic examination. General build: height, development, length and circumference of individual parts of the body (head, neck, trunk, chest, pelvis, extremities), ratio between them (proportionality) and relation to the total body length; development of musculature, weight, relation of height to weight.

Skin: blood supply and color, tension (turgor), moisture, temperature; various pathological changes (rashes, ulcers, scars, etc.). Distribution and degree of hair growth on the body skin, their thickness. Nails. Subcutaneous tissue: thickness and distribution, tenderness to pressure, fatty nodes and other subcutaneous tumors; subcutaneous emphysema; general and local edema; their distribution, degree and consistency (soft and hard wax); mucous edema. Lymph nodes: submandibular, tonsillar, cervical, parotid, supra- and infraclavicular, axillary, cubital, inguinal and femoral; their size, density, tenderness, fusion with each other, with the skin and with surrounding tissues, fistulas. The combination of features of the skeletal framework, musculature, skin, subcutaneous tissue, lymphatic system gives a general idea of the constitutional type and somatic habitus (see). Head. Size, structure of the skull, bony prominences, sutures, thickenings; supraorbital arches, cheekbones, nasal bridge, lower jaw, facial angle. Tenderness of the head on percussion, tender points. Face as a whole: haggard, deeply sunken (facies hippocratica), feverish (facies hectica, risus sardonicus) - for details see above. Eyes: their shape, palpebral fissure, eyeball (enophthalmos, exophthalmos); hyperemia and changes in the conjunctiva, color of the sclera, color of the iris, transparency of the cornea, width of the pupils; eyelids, eyelashes; edema under the eyes; eyebrows. Ears: size and shape of the auricle, attached lobe, gouty nodes, tenderness on pressure on the mastoid processes; approximate hearing test. Nose (its shape). Lips (open mouth, dry lips, deposits on lips, herpes). Oral cavity: its mucous membrane (loosening, deposits, color, pigment spots). Tongue: its size, swelling of the mucous membrane (tooth imprints), moisture, deposits (their color, thickness, localization), crusts, cracks, bite marks, ulcers, scars, development of papillae. Gums: pallor, swelling, loosening, bleeding, gray border. Teeth: number of healthy teeth, carious, loose, artificial; Hutchinson's changes; pyorrhea. Hard and soft palate, its color, swelling, paralysis of the uvula, its defect. Pharynx and throat: size, changes in the tonsils (plugs, deposits); character of the pharyngeal mucosa; posterior wall. Neck: shape, circumference; cartilages, lymph glands; pulsation of arteries, swelling and undulation of veins. Thyroid gland: size, consistency, shape; pulsation in its area.

< Torso. When examining the torso, the localization of found changes should be determined not according to descriptive-anatomical principles, but primarily according to topographical features, based on reference points and lines, bony protrusions, etc., with designation of corresponding areas. - Chest. General examination technique. Before fully exposing the chest, the following can be directly determined: the predominant type of breathing, tempo, rhythm, depth and tension of breathing, visible type of dyspnea; signs of difficult breathing - suffocation (cyanosis, flaring of nostrils, participation of accessory neck muscles in respiratory movements, patient's position - orthopneic). For more precise examination of the patient, if possible, the patient stands, the chest is exposed, arms are lowered. When examining from behind, the patient's arms are crossed over the chest, shoulders are lowered, head is tilted slightly forward. With the patient at rest, the shape of the chest, epigastric angle, sternum, ribs, costal cartilages, intercostal spaces, supra- and infraclavicular fossae, spine, position of scapulae are determined by inspection; dilation of cutaneous and subcutaneous veins; while simultaneously palpating - swelling, local edema. Further, with slow and deep respiratory movements - the respiratory excursion of the chest and scapulae is determined by inspection, and in the recumbent position - Litten's diaphragmatic phenomenon. Palpation determines: tender points on the chest and tenderness along the course of intercostal nerves, tension of external tissues; during phonation - vibration of the chest, i.e., vocal fremitus, and resistance of the chest wall (due to the proximity of denser organs, consolidations in lung tissue and pleura). Percussion at rest determines the same relationships; during inspiration - clarification of sound 1) in the lower parts of the lungs due to displacement of the diaphragm and filling of the expanding lung sinuses; 2) at the apices due to their filling with air; 3) in different body positions - change in the boundaries of dull sound due to displacement of fluid in the pleural cavity (in pneumothorax) and in large cavities. - When determining the mobility of the diaphragm and re-expansion of the lower lung borders, as well as during auscultation, the subject should breathe deeply and prolonged, without forcing either inspiration or expiration, and making a slight pause after each expiration. Therefore, it is necessary to regulate the subject's breathing through appropriate explanation and to encourage each subsequent inspiration by touching the chest. Auscultation is first conducted roughly in the supra- and infraclavicular, supra-, inter-, and subscapular areas, then systematically and in detail in areas with detected changes; if necessary - with the mouth open and closed and in different body positions. Cardiovascular system. It is most advisable to begin the examination of each patient by determining the pulse in the sitting, standing, and recumbent positions, noting the main properties: tempo, excitability, rhythm, filling, tension, character of the pulse wave, unequal filling in different hands (p. differens), often depending on the anomalous position of one of the radial arteries (p. dif. spurius), properties of the arterial wall. Next to be investigated are visible pulsation, tortuosity and density of superficially lying arteries, development and filling of subcutaneous veins in the hands; pulsation of carotid arteries, pulsation of the aorta in the suprasternal fossa by sight and by touch; filling and undulation of jugular and neck veins (most visible in the recumbent position); location and character of the apical impulse (its size, tension and spread over the surface), pulsation in the overlying intercostal spaces and in the epigastrium. Percussion determines the size of the heart and aorta, expressed by relative and absolute dullness in centimeters; auscultation - heart sounds and murmurs, aorta, carotid arteries, femoral arteries; inspection and palpation - positive venous and capillary pulse and character of peripheral circulation in the extremities (cooling, cyanosis of hands and feet); pulsation of the dorsal artery of the foot (in obliterating arteritis); varicose veins of the lower extremities. - Examination of the abdomen - see Abdomen. - Area of the anus and rectum. Inspection (hemorrhoids, fissures, fistulas, condylomas). Examination with a finger of the external part and ampulla of the rectum (to determine accumulation of feces, internal hemorrhoids, polyps, infiltrates, tumors) and prostate gland. Urinary organs. Inspection, palpation and percussion (Pasternatsky's method) in the kidney area from behind. Deep palpation from the front and sides, bimanual palpation of the kidneys to determine their mobility, respiratory mobility, enlargement and other changes. Palpation along the course of the ureters. Inspection, palpation and percussion of the bladder area. Determination of residual urine. Direct determination of properties of freshly excreted urine in several portions. Determination of development of external genital organs: type of hair distribution; edema; signs of urethritis. - Muscles. General development and tone (by sight and touch); strength of contraction and resistance; local hypertrophy and atrophy; indurations, infiltrates, hematomas, tumors, calcareous deposits. Bones: changes in individual bones, periosteum, cartilage, enlargement of hands and feet, fingers, terminal phalanges. - Joints: deformation, subluxations, contractures, thickening of the capsule, effusion, active and passive mobility, tenderness, character of crepitus. - Spine: its curvature, mobility, protrusion of individual vertebrae, tender points. - Psyche and nervous system - see below - Examination of the neuropsychic sphere. 3. Supplementary examination includes many diverse examination techniques that can extremely supplement and clarify the data established by general and systematic examination. Some simple supplementary examination techniques can be entrusted to middle medical personnel, while other clinical and laboratory techniques must be performed by the attending physician himself or at least with his participation. Finally, examination by specialty should mostly be entrusted to representatives of individual branches of clinical medicine, having appropriate facilities and equipment. According to their basic nature, supplementary examination methods can be divided into the following categories: 1) Clinical measurements and digital determinations: a) height, circumference of the chest, abdomen, neck, extremities; diameters of the chest, pelvis; distances between reference points (e.g., from the xiphoid process to the navel and from the navel to the pubis, etc.); epigastric angle; anthropometric coefficients, angles of flexion in joints, etc.; b) weight, comparison with height; c) body temperature; d) daily amount of urine, sputum, etc.; e) strength of hands - dynamometry; ergography; f) spirometry; g) sphygmomanometry and others. 2) Graphic methods: a) sphygmo-, phlebo-, cardio-, pneumography; b) electrocardiography; c) plethysmography. 3) Functional tests - of corresponding organs. 4) Fluoroscopy and radiography: a) direct - of the skull, skeletal system and organs of the chest; b) after introduction of contrast substances - of the digestive tract, bronchi, gallbladder and renal pelvis; c) after insufflation of air into the abdominal cavity and perirenal fat. 5) Endoscopy: ophthalmo-, oto-, rhino-, laryngo-, broncho-, esophago-, gastro-, procto-, cysto-colposcopy. 6) Extraction of material for laboratory examination: a) probing of the stomach and duodenum and small intestines, catheterization of the bladder, ureters; b) extraction of blood from skin vessels, from large subcutaneous veins; c) trial punctures into the pleural cavity, pericardium, abdominal cavity, joints, into the accessory nasal cavities, into the spinal canal and subdural space; into the bone marrow of the sternum, into limited collections in tissues (pus, blood, etc.); d) trial excision of tissues for histological examination (biopsy). 7) Laboratory examinations: chemical, microchemical, physico-chemical, colorimetric, microscopic, serological, bacteriological, etc., of all secretions and excretions that can be obtained directly, of blood and material obtained by trial puncture (puncture fluid). Indications for the use of the listed methods are determined by the nature and essence of the disease, as needed. However, for every case in clinical examination, the following determinations can be considered mandatory: height, chest circumference; periodically - weight, systematically - body temperature, diuresis; repeatedly - urine (at least for reaction, specific gravity, protein and formed elements), feces (at least for parasites and blood pigments); blood (for hemoglobin and blood cell count, their pathological forms, leukocyte formula and sedimentation). Correct evaluation of the data obtained by all special supplementary examination methods is best ensured by the participation of the physician who conducted the general clinical examination and observation.

Many of the detected deviations from normal, even such as the presence of Koch's bacilli in sputum, sugar in urine, etc., as well as data from x-ray examinations, acquire true significance only in comparison with the overall clinical picture of a given disease. Transferring responsibility for the correct determination of the disease to specialists who, on the observing physician's orders, performed one or another special examination is completely unacceptable. The history of the disease, i.e., the registration of research data, should reflect only the factual data established by the examination of the patient, and this in a strictly defined order and according to a known scheme. For this purpose, ready-made printed forms are usually used, the compilation of which requires thoughtful technical editing. - A rational scheme for the history of disease can be presented as follows: in the heading - the name of the medical institution, the form number according to the annual journal and the archive, and the date. In consecutively arranged sections - departments: 1) Reference information. 2) Data on admission to the medical institution and stay in it. 3) Diagnosis. 4) Outcome. 5) Interrogation: a) present illness (anamnesis morbi), b) additional inquiry about the patient's condition (status subjectivus), c) general anamnesis (anamnesis vitae). 6) Examination: a) general and b) systemic (status praesens objectives). 7) Special examination (special methods of investigation). 8) Graphic representations. 9) Therapeutic prescriptions. 10) Diary. 11) Accounting for patient care. 12) Epicrisis. - 1. Reference information. This section is compiled in the form of a printed questionnaire, into which the corresponding information about the patient is entered, obtained upon admission to observation, through inquiry, or based on documents. 2. Data on the patient's admission and stay in the medical institution. This section provides the following information: when admitted (or transferred, referred) and from where; when discharged (or transferred) and to where, or died; the number of days spent in the medical institution, and the time needed for restoration of working capacity; further - diagnosis upon admission, the department to which the patient was sent by the on-duty physician, initial prescriptions, including diet and, if necessary, special supervision (signed by the on-duty physician). 3. Diagnosis is entered in the appropriate column only after comparing the data from the interrogation and examination with the data from special examinations and changes detected during the period of observation. In formulating the diagnosis, the following should be taken into account: the essence of the disease, etiology and pathogenesis, localization, anatomical and clinical character of the process, course, complications, and concomitant diseases. For example, in a stomach ulcer, the correct formulation of the diagnosis might be as follows: recurrent penetrating peptic ulcer of the lesser curvature of the stomach in the stage of exacerbation, with a tendency to bleeding and with signs of perigastritis and perihatitis; or chronic gonorrheal urethritis; subacute gonorrheal purulent inflammation of the right knee joint. In this same section, the diagnosis established during surgery is entered; in case of death - the diagnosis at autopsy. 4. The outcome of the disease and the conclusion about working capacity, determined upon discharge, as well as the diagnosis, for convenience of registration, are placed on the first page. 5. In the interrogation section, all presentation should be as clear as possible, but concise. In column 'a' - complaints and narrative of the present illness - it is most practical to directly begin by indicating the time, conditions, and cause of the appearance of the most disturbing disorders of the patient and to pay greatest attention to a detailed characterization of these disorders, i.e., to outline the development of the dominant symptom complex from the beginning of the disease in the form of a coherent narrative. In column 'b' - additional inquiry - as necessary, disorders that may be in close or more distant connection with the outlined dominant symptom complex are recorded, but also other data characterizing the general condition, the state of the most important functions of the patient, and various disorders not included in the main symptom complex. The order in which to present this data depends on the nature of the disease. In column 'c' only that which may have substantial interest in relation to the given disease should be recorded from the 'general anamnesis' data. 6. Examination. In column 'a' of the general examination, at least a brief description of the patient's appearance should be given with a general objective assessment of his condition and indication of directly perceptible indicative symptoms. For example: tall, stout figure, but markedly pale, drops of sweat on the forehead, barely able to stand on his feet, short of breath; frequent, tense dry cough with nausea. In column 'b' the data from all systemic examinations performed are entered in the corresponding order indicated above, in a clear but concise form, with conventional abbreviations. When indicating the location where characteristic changes were found, as already indicated above, it is preferable to use topographical designations (in Russian) in a conventionally abbreviated form. If in the examined organ the changes expected based on the narrative and general examination are not found, this must be noted. 7. Data from special examinations are recorded with the date indicated, in a uniform form, with conventional abbreviations. 8. Graphic representations. To each history of disease, if possible, graphic representations of the most important functions should be attached in the form of curves of temperature, pulse, respiration, weight, diuresis, blood pressure, etc. 9. Initial therapeutic prescriptions. For this section in the history of disease form, special, sufficient space should be provided (which is usually not the case), and it is practical to divide it into 4 separate longitudinally arranged columns for various therapeutic procedures, keeping in mind the following: a) general instructions: personal hygiene, regimen, diet, mineral waters, prolonged rest, spa treatment; b) various therapeutic procedures: counter-irritants, stomach lavage, enemas, inhalation, rubbing, compresses, baths, etc.; c) physiotherapy: hydro-, therm-, photo-, mechano-, electro-, radiotherapy, etc.; d) drug therapy: internal, external, per rectum, subcutaneous, intravenous, etc. 10. Diary. The corresponding pages should be divided into 3 longitudinal columns for repeated recording of data: a) interrogation, b) examination (and special examination) and c) therapeutic prescriptions. 11. Accounting for patient care in the medical institution. It is very advisable to have such a section in the history of disease, which is usually not provided. Here are entered the totals of: a) medical examinations, consultations, various types of special clinical, laboratory, x-ray examinations, etc.; b) the various therapeutic procedures administered. For convenience of registration, this section can be placed on the first page of the history of disease, before the 'outcome' section. 12. Epicrisis. For this section too, special space should be allocated in the history of disease form. Here are entered the following data: a) justification of the diagnosis and general assessment of the case with highlighting of peculiarities in the manifestation of the disease, complications, etc.; b) justification of the treatment methods used; c) assessment of the treatment results, the patient's condition at the time of completion of observation compared with the initial condition; d) necessary future preventive and therapeutic measures; e) further information about the patient: data clarified during surgery, long-term results of treatment, and in case of death - the immediate cause of death and, if possible, autopsy data. III. Examination of the nervous system. Due to the division of functions of the nervous system into motor, sensory, reflex, vasomotor, and trophic, the examination of the nervous system should be directed toward clarifying the state of these functions (status praesens of the nervous system). The study of the functions of the nervous system should follow after careful collection of the anamnesis (see), examination of the general status and condition of internal organs. General appearance and nutrition; body weight, height, length of trunk, limbs; skull, its structure; measurement of skull circumference (using a centimeter tape), individual parts of the head, skull diameter (using a thick compass by Mathieu); cranial index (derived from the ratio of the transverse index to the longitudinal one); facial angle (using a B-Jakard goniometer). Sometimes it may be necessary to determine the ratio of one or another area of the skull bones to the brain convolutions or vice versa, and for this projection of the brain convolutions onto the skull, special instruments have been proposed - encephalometers (Zernova), brain topograph (Rossolimo). Attention must be paid to the condition of the spine - curvature, limitation of movement, tenderness, normal development of spinous processes, presence of splitting (spina bifida). Examination of the skeleton of the limbs by inspection, palpation, measurement. All parts of the skeleton (skull, spine, limbs) should be examined radiographically and radioscopically. Condition of the skin - color, blood supply, pigmentation, edema, dryness or moisture. Cranial nerves (I, II, VIII and IX) see below - sense organs. Oculomotor nerves.

N. oculomotorius, trochlearis, abducens (III-IV-VI) are investigated together as controlling eye movements. When examining the motor apparatus of the eyes and eyelids, attention must be paid to the width and evenness of the palpebral fissures, the position of the upper eyelid (ptosis), the position of the eyeballs, the presence of exophthalmus and enophthalmus (protrusion and recession of the eyeball); the symptoms of Graefe and Möbius (see Basedow's disease). The position of the visual axes is determined; deviation of the eyes from the midline position causes strabismus, which can be convergent, divergent, as well as upward and downward; each of these forms of strabismus will indicate paralysis or paresis of the corresponding eye muscle. Then the mobility of the eye is determined, by asking the patient to look in different directions (the head and trunk must remain immobile); limitation of movement in one direction or another will indicate paralysis or paresis of the corresponding muscles or spasm of the antagonists. In addition to the limitation of movement of individual muscles of one eye, associated disorders of movement are observed (see Paralysis of gaze). Disorders of eye movement, in addition to strabismus, cause double vision, or diplopia (see); it is investigated with the help of colored glass. Disorders of eye movement also include nystagmus (see), especially well detectable at the extreme positions of the eyes. Then the state of the pupils is examined - dilation (mydriasis), constriction (miosis), unevenness (anisocoria), contours; pathological states of the pupils - jumping pupil - and finally the pupillary reflex. N. trigeminus (V) - motor function, controlling the movements of the lower jaw; when examining the patient, they are made to chew, close, open the mouth, make movements to the sides; during movements, the belly of the masticatory muscles is palpated; in their atrophy, the wasting of the cheek is already visible to the naked eye. In tonic spasms of the masticatory muscles (trismus), the patient cannot open the mouth. N. facialis (VII) controls facial expression; when examining it, attention is paid to the contraction of muscles in various parts of the face, for which the patient is made to perform a series of facial movements: close the eyes, wrinkle the forehead, bare the teeth, puff out the cheeks, whistle, etc.; it is necessary to compare the movements on both sides. In diseases of the VII nerve, movements in the muscles innervated by the affected nerve become impossible; the face is distorted, as the healthy half of the face pulls the sick half to its side; in addition to paralyses, spasms (tics) are observed. N. vestibularis (VIII) see below - motor sphere. N. glossopharyngeus (IX) et vagus (X) (motor portions) control the movements of the soft palate, pharynx, larynx; when examining them, the position of the soft palate, larynx is first inspected with the naked eye, then the patient is made to produce individual sounds and words and make swallowing movements; in bilateral paralysis of the soft palate, it is lowered and does not tense during phonation, swallowing is difficult, especially of liquid food; the condition of the vocal cords, larynx is determined by laryngoscopy; in addition to paralyses, spasms of the corresponding muscles can also be observed, which also leads to disturbance of swallowing and phonation. N. accessorius (XI) - the movement of the head to the sides (m. sternocleidomastoideus) and the elevation of the shoulders upward (m. cucullaris) are examined. N. hypoglossus (XII) controls the movements of the tongue; the examination begins with a simple inspection of the position of the tongue in the oral cavity (whether it lies symmetrically, whether it deviates to one side or the other), then the patient is made to protrude the tongue from the mouth and again it is looked for any deviations, they are made to perform all possible movements with the tongue; in paralysis of the XII nerve, movements are difficult or impossible, the tip of the tongue deviates to the affected side; spasms of the musculature and twitching are also observed in the tongue. Motor sphere. When examining the motor apparatus, attention is paid to the position of the subject's body and its parts; this position can be passive, active, or forced. Then passive and active movements are examined; the subject is made to perform all possible movements in all four limbs and in the trunk, then they are asked not to offer any resistance, and the examiner performs all these movements himself; when examining passive movements, it is necessary to pay attention to the state of tone - whether there is a decrease (hypotonia) or an increase in tone (hypertonia or rigidity); in severe hypertonia, contractures develop; an increase in the tone of the flexors of the leg gives the symptom of Kernig (see Kernig's symptom); an increase in the tone of the entire muscular system gives wax flexibility. When examining active movements, attention is paid to their amplitude, speed, complexity, strength and energy of muscle contraction (using dynamometers, ergometers - Duchenne-Charrière, Sternberg, Rossolimo), the ability to perform repeated movements, muscle fatigue (Moss's and Dubois's ergograph); the strength of movements is also measured by the resistance offered by the subject to the examiner. The excitability of muscles and nerves to external stimuli - mechanical and electrical excitability - is examined. Mechanical excitability is examined by striking the muscle with a percussion hammer; with increased excitability, a muscle roll is formed at this impact, and the symptoms of Trousseau, Chvostek can also be observed. Electrical excitability of nerves and muscles to faradic and galvanic currents; quantitative and qualitative change, increase or decrease in excitability, reaction of degeneration complete or partial, myasthenic reaction, myotonic reaction, complete non-excitability. Chronaxia (see) or egerzimetry of nerves and muscles (Stroy's egerzimeter). Investigation of static and dynamic coordination of movements, i.e., correct execution of movements: in case of disturbance of coordination, ataxia is observed; to determine locomotor ataxia, the subject is given certain tasks - to touch the tip of the finger to the tip of the nose, the heel of one foot to the knee of the other, to describe with the toe of an outstretched leg some figure in the air. To examine static ataxia, the patient is asked to stand and move the feet apart: in mild ataxia, swaying is noticeable, which increases when the eyes are closed (see Romberg's symptom); disturbance of coordination gives asynergy, adiadokokinesia, mimopokazivanie, flexion combinee (see respective words). Since disturbance of coordination is often impaired in diseases of the vestibular apparatus, it is necessary to examine it; methods of mechanical stimulation (rotation of the subject in a special rotating chair), thermal (Barany's test) and electrical (see Voltaic reaction, Barany's method of investigation) are used. The gait (see) is examined, its peculiarities, disturbances (different types of gaits), a record of the gait is made using an ichnogram (see). The facial expression is also examined and various types of its disturbance are noted; oral and written speech and its disturbances: 1) aphasic disturbances - motor aphasia (paraphasia, jargonaphasia), sensory aphasia [word blindness and deafness, agraphia, amusia, apraxia (see)]; 2) disturbances of articulation - anarthria, dysarthria (see); 3) dysgraphic disturbances - change in handwriting; disturbance of abilities to draw (see Agrafil, Handwriting). When examining the motor apparatus, attention is paid not only to phenomena of loss (paralyses, pareses), but also to various involuntary, forced movements - hyperkineses (see); they can be local and generalized, tonic or clonic; they are examined with the help of a kymograph, tremograph or G.I. Rossolimo's clonograph, by the method of Kenko, a cinematographic film is made. In the presence of seizures, attention is paid to their peculiarities, duration, frequency and the accompanying phenomena. Sensibility. When examining the sphere of sensitivity, subjective complaints are first noted - the presence of pains, paresthesias, their character, localization, time of appearance, duration; dizziness, their character, intensity, accompanying phenomena; the feeling of fatigue, heaviness, fullness, etc. Objective examination of sensitivity should be carried out, if possible, on a non-fatigued subject, in complete silence, completely calmly, without haste and without agitation, trying not to suggest sensations to the subject, for which one should not ask whether he feels pain, warmth, cold, etc., but only ask what he feels: the subject himself should sort out his sensations. When examining, attention should be paid to the strength of sensations during irritations, to their character, to the correctness of localization, to the speed of perception, to the summation of sensations, to their irradiation, etc. First, the simpler types of sensitivity are examined; two types of sensitivity are distinguished: 1) superficial, or cutaneous sensitivity and 2) sensitivity of deep organs. From superficial sensitivity, tactile sensitivity is examined with the help of a finger, cotton wool, a brush; special instruments have been proposed - Mochutkovsky's tactiometer; one can also use irritation of the skin with the help of faradic current. The found changes are outlined on the skin along the border with a dermograph, and then transferred to special diagrams.

Pain sensitivity is investigated by means of a pin, with which light pricks are applied with as much force as possible to various parts of the body; the subject must identify them as a painful sensation; the determination of the boundaries with altered sensitivity is performed by the same method. There are various instruments for investigating pain sensitivity - the algheziometer of Mochutkovsky, Volevich (in practice they are not commonly used, but are applied for scientific research); pain sensitivity is also investigated by means of faradic current: with a weak current, a sensation of slight tingling is obtained (electrocutaneous tactile sensation), with a stronger current - clear painful sensations (electrocutaneous painful sensation). Temperature sensitivity: the sensation of cold and the sensation of heat are investigated; for rough investigation, cold and hot objects are used (one should avoid too high or too low temperature, so as not to also involve pain sensitivity). For quantitative measurement of temperature sense, the minimum differences between two temperatures that are perceived by the investigated areas are determined; for this, Rot's thermesthesiometer is used. This apparatus consists of a hollow metal cylinder, the flat bottom of which serves for touching the patient's body; two tubes and a thermometer pass through the lid; a balloon is placed on one of the tubes, and a rubber tube on the other; with their help, water of the desired temperature is pumped into the cylinder, measured by a thermometer in the cylinder. In one cylinder, warm water is poured, in another cold; placing first one cylinder, then the other on the same place, one asks the subject which cylinder is warmer - the first or the second; if he perceives the difference, it is reduced until it becomes imperceptible; if the subject does not distinguish the temperature difference, it is increased until it becomes clear; in the corresponding places on diagrams, the temperature difference perceived by the subject is recorded. From the sensitivity of deep organs, the following are investigated: 1) the sense of pressure; for precise investigation, weights of different weights but identical in base size are used; the investigated part of the body should not be hanging, but should lie on a table or generally on an immobile support to avoid the sensation of muscle tension; baresthesiometers are also used; 2) the sense of passive movements - with one hand the investigator fixes the subject's arm, and with the other produces displacement in various directions of the distal segment of this arm, and the subject with closed eyes must determine the direction of the movements; 3) the sense of weight - a loop of cloth is placed on the subject's limb, which is hanging, a weight is placed on it, and the subject is asked to remember the weight, then a new weight is placed on the limb and he is asked to determine how much lighter or heavier this weight is than the first. Of the complex types of sensitivity, the following are investigated: 1) the sense of localization, or place - the subject must determine not only the touch or prick, but the exact place on the skin that was touched; to determine the sense of localization, a finger or the tip is touched to various places on the surface of the body, and the subject is asked to specify exactly which place was touched; this also includes the investigation using Weber's compass (see Weber's tactile circles); 2) vibratory sense indicates the state of bone sensitivity; the investigation is performed with a tuning fork with a wide shank; the tuning fork is made to sound and placed on the place where the bone is most in contact with the surface, and the subject is asked if he hears the vibration of the tuning fork, how long this sensation lasts and with what strength; the duration of perception is measured by the second hand of a clock; 3) the sense of the position of the body and its parts - the subject's limbs are placed in a certain position and he is asked to describe this position or to bring his other limb into the same position; 4) stereognostic sense - the subject with closed eyes is given small objects in turn, asked to feel them and say what they are, or describe them as accurately as possible; 5) transcortical sensitivity is also determined by means of small objects, which are placed with the subject's eyes closed on his outstretched palm and asked to determine, without feeling, what these objects are. - In addition to the general types of sensitivity, special types of sensitivity, or sense organs, must also be investigated. Sense organs. I. Smell. When investigating smell, one nostril is closed, and non-odorous and odorous substances of various consistencies are brought to the other, and the subject is asked to distinguish odorous from non-odorous and odorous substances from each other; an olfactometer is also used. From disorders of smell, hyperosmia, anosmia, dysosmia, parosmia are distinguished (see Smell).-II. Vision. When investigating vision, the following are determined: a) visual acuity by means of special tables, b) field of vision with a perimeter, c) color perception by the method of Holmgren, d) ophthalmoscopic examination of the bottom of the eye is performed, complaints of the subject are noted. From disorders of vision, one should note: decrease in vision, its complete loss; concentric narrowing of the field of vision, various hemianopsias, decrease in vision or blindness to colors, to all or selectively. From changes in the bottom of the eye, hyperemia, neuritis, primary and secondary atrophy of the optic nerve, stagnant papilla are observed. From subjective disorders, scotomas, 'flying flies', sparks are noted. (See also Vision.)-III. Hearing. The following are investigated: 1) acuity of hearing with an audiometer, tuning fork, or ordinary conversational speech - loud and in a whisper; 2) conductivity of sound through air and bone, also with a tuning fork; for investigation, Weber's, Rinne's (see Weber's test, Rinne's test) and Schwabach's experiments are used; 3) the ability to locate sounds in space with a tuning fork or pocket watch; 4) otoscopic examination of the ear is performed. Disorders of hearing can be subjective and objective; subjective ones include spontaneous auditory sensations - noise, whistling, ringing and various other sounds; among objective disorders of hearing, one should note: decrease in hearing, reaching to deafness, unusual heightening of hearing, disturbance of correct localization of perceived sounds.- IV. Taste. Investigation of taste is performed with solutions of different chemical compounds of certain concentration, which excite the sensation of bitter, salty, sweet, sour (quinine, salt, sugar and vinegar). A drop of one of the above-mentioned substances is placed on a corner of the subject's tongue; he must determine to which category of taste substances this solution belongs; in this case, one should communicate by signs, not by speaking, to avoid the spreading of the irritating drop over the tongue and oral cavity, which is inevitable with verbal explanation. Taste is also investigated with galvanic current: the sensation of salty taste at the negative pole and sour at the positive. Disorders of taste can be subjective - various taste paresthesias - and objective - increase in taste irritability (hypergeusia) and decrease in it (hypogeusia, s. ageusia). Reflexes. When investigating the nervous system, determination of the state of reflexes has very important significance; reflexes are divided into several types depending on the organ from which they are elicited: 1) tendon reflexes - muscle contraction is obtained by irritation of tendons or with a hammer (percussion, special hammers for reflexes of Dejerine, Babinski) or the inner edge of the hand or finally with a fist. Of tendon reflexes, the following are investigated: knee reflex (various methods of obtaining - see.

Knee reflex), Achilles reflex (see), reflex from the tendon of m. biceps brachii, reflex from the tendon of m. triceps brachii, with masseter (mandibular reflex). 2) Periosteal reflexes: reflex from the processus styloideus radii is elicited by tapping the periosteum of the lower end of the radius, resulting in flexion of the forearm (reflex is inconstant); reflex from the periosteum of spinae scapulae is obtained by percussion on the medial end of spinae scapulae and consists in contraction of m. teres minor, m. supraspinatus, and m. infraspinatus. 3) Skin reflexes are characterized by contraction of muscles under the influence of irritation applied to the corresponding area of skin; they are investigated a) abdominal reflexes, b) reflex from cremaster, c) gluteal reflex-contraction of m. gluteus maximus when the skin of the buttocks is irritated, d) plantar reflex-when the sole of the foot is irritated with the handle of a hammer, a match, or a pinprick, the foot and toes flex, sometimes flexion not only of the toes but movement of the entire leg occurs (protective reflexes). 4) Reflexes from mucous membranes-conjunctival and corneal-are elicited by irritating the conjunctiva or cornea with some unclear object and are expressed by closure of the eyelids, contraction of m. orbicularis oculi; palatal reflex-irritation of the uvula causes contraction of the muscles of the soft palate and elevation of the palatal curtain; pharyngeal reflex is obtained by irritating the posterior wall of the pharynx with a tongue depressor-contraction of the pharyngeal constrictors and vomiting movement occur; anal and vulvo-anal reflexes are obtained by irritating the 10S4 skin of the anus with a blunt object, after which m. sphincter ani contracts, and in women simultaneously m. sphincter cunni also contracts. 5) Reflexes of deep organs: pupillary reflex (see Pupillary fibers, reflexes); reflexes of the bladder, rectum, and sexual apparatus. Under the influence of pathological conditions, reflexes can change in the direction of increase or decrease, which must be noted during examination. A significant increase in reflex excitability leads to the appearance of so-called clonus, most commonly observed is clonus of the foot and patella (methods of eliciting them-see Clonus). Besides strengthening and weakening of normal reflexes, their perversion or so-called pathological reflexes are observed, to which belong: finger tendon reflex (Mendel-Bechterev reflex, Rossolimo reflex), Babinski reflex, Oppenheim reflex, Gordon reflex, Schaeffer reflex, Redlich reflex, Bing reflex, Piotrowski reflex; to pathological reflexes also belong protective reflexes (see), their variety is the reflex of Marie and Foix. When examining pupillary reflexes, attention is paid to their presence or absence, liveliness, and uniformity in both eyes (see Pupillary fibers). Disorders of bladder and rectal reflexes manifest as either incontinence of urine and feces or, conversely, retention. From disorders of the sexual apparatus, it is necessary to note strengthening or weakening of erection, etc. Autonomic nervous system. Its motor function manifests in all organs supplied with smooth muscle fibers: in the skin it manifests as contraction of the muscles of the hair (arrectores pilorum), chest nipples, and scrotum; the state of these muscles is investigated by mechanical irritation (passing a hard object over the skin), thermal (touching with a wet sponge or something cold), electrical (touching with a faradic brush); on the skin, bulging of the hair follicles-goose skin, pilomotor reaction occurs; when the nipple is irritated, its erection occurs, and irritation of the scrotum causes it to wrinkle. The cardiovascular apparatus is connected with vasoconstrictor phenomena, which are determined on the basis of studying 1) the state of superficial arteries (dilation of veins indicates paralysis of vasoconstrictors), 2) the reaction of vessels to irritation (mechanical irritation of the skin with a percussion hammer, which gives slight pallor, quickly passing into redness-dermographism; with increased vasoconstrictor irritability, this reaction is more intense, redness lasts longer-red dermographism; white dermographism occurs). Simple examination with the eye can indicate localized vasoconstrictor disorders, such as syncope localis, asphyxia localis, local arterial hyperemia; to vasoconstrictor disorders also belong abnormal accumulation of fluid in the skin, in the joints (hydrops articulorum intermittens) and various rashes-urticaria, herpes zoster, etc. Reflex changes in the activity of the heart are investigated by means of a series of reflexes and experiments-Hering reflex, Cermak experiment, Erben reflex, eye-heart reflex of Apgar, orthostatic and clinostatic reflexes. Violation of motor functions of the stomach and intestines is objectively revealed by means of the intestinal reflex of Dapievopolu and radioscopic examination, and motor disorders of the bladder-by the eye-bladder reflex of Dapievopolu (description of reflexes-see respective words). The secretory function of the autonomic system manifests as the function of many glands-sebaceous, sweat, lacrimal, salivary, glands of the digestive tract (secretion of gastric juice, secretion of mucous glands of the intestine/), secretion of urine (anuria, polyuria).-Disruption of the trophic function of the autonomic system manifests on the skin in the form of various changes-atrophy, pigmentation, hyperkeratoses, formation of rashes, torpid ulcers (malum perforans pedis), bedsores; in bones-in the form of arrest in development, atrophy, abnormal brittleness; trophic changes in joints-arthropathies are also observed. Besides local trophic disorders, the trophic influence of the autonomic system affects the composition of the blood, certain metabolic processes. Excitability of one or another part of the autonomic nervous system, besides clinical manifestations, is determined by the body's reaction to the introduction of various pharmacological agents under the skin or into the blood; at present, the test with adrenaline (local reaction of Levi and general reaction), with calcium chloride, pilocarpine, and atropine is used.-Examination with X-rays gives valuable and sometimes irreplaceable data; with the help of radiography, one can more closely acquaint oneself with the shape of the skull, the thickness of the cranial bones, the state of the sutures, etc. Any changes in the bones of the skull are demonstratively recorded with the help of radiography. In some diseases of the brain, it can provide reference points for diagnosis. Radiography of the spine gives irreplaceable data in all kinds of processes (traumatic, destructive, in neoplasms, etc.). In recent times, examination of the nervous system by the method of encephalography (see Encephalography, Ventriculography) and the method of Sicard with the introduction of lipiodol into the subdural space of the spinal cord are widely used.-Cerebrospinal fluid. In many cases, if not in all diseases of the nervous system, it is necessary to examine the cerebrospinal fluid (see). Mental sphere. The neuropathologist has to resort to examining the psyche of his patients in a number of cases, where to one degree or another it is affected simultaneously with the lesion of the somatic sphere, either due to a process in the brain or a functional disorder of the nervous system in its entirety (see below). K. Kononova. IV. Examination of the psyche. Medical examination of the psyche differs in its methods and the very content of examination from other types of medical examination. It lacks instrumental methods of examination and is based on questioning and observation of the patient. Although Zakharyin (and many other outstanding internists-see above) attached primary importance to the method of questioning, however, for the internist it is to a certain extent auxiliary-introduction to objective examination, and, secondly (and this is the most essential and fundamentally important), in this questioning of the internist, in essence, formal information about past diseases and way of life in that part which could lead to one or another dysfunctions of the body are of interest. The matter is completely different in psychiatric examination. Here the method of questioning-conversation with the patient-acquires paramount importance and together with observation is one of the main ones in the study of mental disorders. In questioning, those questions that remain outside the attention of the somatic physician should usually be of interest. Here, in the first place, is the identification and study of the dynamics of personality development, the structure and dynamics of character, the experiences of the personality and its reactions to them, the phenomenological development of one or another pathological conditions, etc. When collecting anamnesis, unlike ordinary medical examination, objective anamnesis, collected from the patient's close ones, from the place of work, etc., acquires main value, while subjective anamnesis often characterizes the status of the patient, because in a number of cases due to dementia, delirium, memory disorders, lack of criticism, subjective information acquires an insufficient character and reveals rather the presence of one or another disorders of mental activity.

In other cases (disorders of consciousness, negativism, etc.) it is completely impossible to obtain any information and even to make contact with the patient. The same applies to questioning the patient about their complaints, which may be completely absent when there is no criticism of their pathological condition (when the patient does not realize it and considers themselves healthy), and in cases of delirium (in particular hypochondriacal) they may distort actual pathological phenomena. Along with clinical-psychopathological research or rather within it, a large place is given to somatic examination of the organism as a whole (anthropometry, physical and neurological status, endocrine system, biochemical and serological studies). Since psychiatric research is based not on a formal examination of the patient but consists in the ability to observe the state and behavior of the patient, to correctly analyze it, to be able to establish contact with the patient, to win their trust, to be able to reveal the psychopathological picture and to critically evaluate every statement of the patient, psychiatric research presents considerable difficulties. Breaking down into the usual stages of any medical research (collecting data on heredity and anamnesis, describing the status itself), psychiatric research in the content of each of these stages presents certain differences. The analysis of heredity data should first of all reveal the qualitative characteristics of the entire genealogical tree of the proband. The psychiatric study of heredity data should reveal not only pathological predisposition (all cases of mental and nervous diseases in the family, alcoholism, suicides, cancer, tbc, arteriosclerosis, etc.) but also characterological variants among relatives, cases of social pathology, etc. Information is collected about each of the relatives (father-mother, grandfathers-grandmothers, brothers-sisters, uncles-aunts, etc.) separately. It is advisable to collect genetic material at the end of the research. Since the time of Krafft-Ebing, there have been various schemes for studying the psyche. In Russia, such schemes were developed by Korsakov and later by Rybakov. Krepelin proposed an extensive scheme for examining the status in the form of a questionnaire containing over 150 questions. Of course, all these schemes give only a general framework for the research (blind and uniform following of them gives rather a negative result, giving the research a mechanical character and ignoring all the diversity of each individual case). The compilation of the psychiatric history of the patient, which gives a vivid and bright reflection of the patient's personality and their life, is a major synthetic work. When collecting anamnesis, the following brief scheme can be recommended as a basis. Prenatal period and early development. Retardation and delay in development. Seizures, fainting states in early childhood. Injuries suffered. Arrest of mental development. Preschool period. Capriciousness, irritability, anger, fearfulness. Fears. Obsessive states, tics, stuttering. Enuresis, somnambulism. Fluctuations in mood. Lying. Features of development in school and pubertal age, interests, academic performance. Intellectual growth. Loss or decrease in interests. Deceptions of perception. Headaches, dizziness. Sexual life (in women, menstruation, pregnancies), masturbation, perversions. Exogenous factors, their role, reactions to them. Infections. Venereal diseases. Physical and mental trauma. Intoxications. Alcoholism, hangovers. Smoking. Narcotics. Working life. Professional anamnesis. Relations with the collective. Age of reverse development. Changes in personality in later years. Onset of the disease, its symptoms. Course of the disease. Type of course. Nature and duration of attacks. State between attacks. Changes in personality. Presence of defect, its nature. Degradation. Attitude toward one's pathological condition. We begin the study of the patient's status with observation and evaluation of the appearance and behavior of the subject. Often, just the way the patient enters the doctor's office already creates a certain impression of the patient (not to mention the markedly expressed cases of catatonia, parkinsonism, etc.). Next, we must pay attention to the preservation of orientation (both autop-sychic and allopsychic). The latter constitutes the most important component, which often allows us to assess the state of consciousness. In cases of impaired consciousness, we will distinguish between dream-like, stuporous, twilight, delirious, and amnestic states of consciousness. In cases of formally clear consciousness, we identify the presence of criticism of one's pathological condition, the accessibility of the patient. It is also necessary to identify the presence of cerebral symptoms (headaches, dizziness, fainting, seizures). Next, we proceed to the study of the emotional sphere: mood, its nature, stability, fluctuations, changes in affectivity (excitability, dullness, fears, apathy). Then we identify the presence of delusional, obsessive (see Obsessive states) and overvalued ideas, their nature and content, their persistence. Then we study the disorders of perception, which find their expression in illusions and hallucinations (see) (auditory, visual, olfactory, tactile, general sense). We proceed to the study of the state of intellect (see). This last research is carried out both on the basis of direct conversation with patients, which reveals the stock of ideas and information, the preservation of school knowledge, familiarity with the main events of socio-political life, and with the help of auxiliary experimental-psychological research, which reveals combinatorial ability, ability to judge, etc. Closely connected with intellectual work capacity are disorders of attention and memory, which relate less to the intellect itself than to its equipment. Regarding the latter, we distinguish the impairment of the ability to remember, retain in memory certain information and the ability to reproduce. In disorders of memory, we deal with amnesia (see) in its various forms. In a number of cases we encounter disorders of thinking, in some (more severe) cases-incoherence, fragmentation, etc., in others-disorders of the structure of thinking, which is especially characteristic of schizophrenia (see). We conclude the status study with the will sphere, revealing the activity of the personality, its interests. At the same time, we study the psychomotorics of the patient, for which there are special schemes (Gurevich and Ozeretsky). We conclude the study of the psych status with an assessment of the general preservation of the personality (intellectual, emotional and socio-labor) and the peculiarities of character. When studying the psyche, of course, it is necessary to take into account the age peculiarities of the psyche. Psychiatric research is supplemented by experimental-psychological. In addition to the above-mentioned study of intellect, memory, attention, thinking are studied, for which there are a number of special techniques (see Rossolimo methods, Binet-Simon method, Bernstein, Nechaev, etc.). The study of somatic status is conducted according to general schemes, and special attention, in addition to the examination of internal organs, is paid to the data of somatoscopy-type of build (usually according to Kretschmer), endocrine system, neurological and serological studies. The widespread development of mass psychohygienic examinations places even more complex and demanding requirements on the technique of medical research of the psyche than in ordinary clinical psychiatric research, since we are dealing with people who are formally healthy in the mass, and therefore the task of such psychohygienic research is to identify the peculiarities of personality and character, to capture subtle changes in the psyche and microsymptomatology, which allow one to judge the initial phenomena of one or another disease. However, it is necessary to resolutely warn against overestimating the significance of individual microsymptoms, as has often been the case in recent years. Only clear syndromes, taken in their dynamics in the light of the entire course of the disease, allow one to determine their clinical significance. The research scheme in psychohygienic examinations remains basically the same as in clinical, with the only addition that special attention is paid to the production environment, professional anamnesis, and in examinations in higher educational institutions-to intellectual activity. Psychiatric, as well as psychoshygienic, research requires from the physician analytical-synthetic ability and the ability to generalize and evaluate the personality in all its connections and mediations.

A. Edelstein. V. Examination of the surgical patient. The examination performed by the surgeon depends on the state of surgical therapy: in those times when anesthesia and antisepsis were not yet known and surgery was limited almost exclusively to interventions on the surface of the body and on the extremities, the surgeon examined mainly bones, joints, and the body's coverings; medicine was then justified in distinguishing the examination of internal organs as the domain of therapists and the examination of external diseases as the domain of surgeons. In the present time, the position of surgery has fundamentally changed; now there is no organ that remains inaccessible to the surgeon; surgical pathology has covered all areas of the human body; it is clear that the surgeon must also extend his examinations to all tissues and organs without exception and thus destroy that line which separated the area of his examination from that of the therapist. The surgeon began to use, like the therapist, the data of the anamnesis, the examination of the present state, laboratory analyses, and roentgenological data. The surgeon became a physician with a general medical outlook, however, a complete coincidence of the activity of the surgeon and therapist in examining the patient has still not occurred, but now the difference is no longer in the object of examination, as it was before, but, first, in the goals that guide the surgeon and therapist in their examination, and, second, in certain technical advantages that the surgeon possesses. Let us first dwell on the first of these peculiarities. In making a diagnosis in the broad sense (taking into account etiology, pathogenesis, and the condition of individual systems and organs), the surgeon always has in mind the main factor of his treatment, which distinguishes him from the therapist—namely, operative intervention; besides the general diagnosis, his examination must always answer the questions: will operative intervention be advisable; are there any contraindications for it, and if not, where and how to make incisions to have good access. The general diagnosis is conducted as already indicated in the section on examination of therapeutic patients, but specific surgical questions require clarification of the following details: surgeons consider the operation advisable when, having a chance of success, it is not more severe or more dangerous than the disease itself. Let us take as an example a patient suffering from cancer of the esophagus; when the tumor causes significant narrowing and the esophagus barely allows liquid food to pass, the question arises about the creation of a gastric fistula, however, this will not be advisable in all cases, and preliminary clinical examination should determine whether the patient is actually starving, since in a number of cases cachexia with complete loss of appetite plays a predominant role, and the creation of a fistula will only cause unnecessary suffering and inconvenience to the hopelessly sick person, without bringing any benefit. Another example: appendicitis on the third-fourth day from the onset of the attack; intervention at this time is dangerous: it can cause the spread of peritonitis due to the disruption of recently formed adhesions and can cause sepsis if the infected thrombi in the veins are disturbed; in these cases, daily careful examination of the patient himself as well as laboratory analyses of his blood and urine are required, in order to refrain from intervention as long as possible, but also not to miss the beginning of general peritonitis or severe intoxication, when it will be necessary to urgently perform the operation. The question of contraindications for surgery gives rise to a whole special series of examinations; the respiratory, circulatory, and urinary systems are examined by the surgeon from the point of view of the permissibility of one or another trauma, one or another type of anesthesia; inflammatory diseases of the lungs, tuberculosis of them prompt to refuse the use of ether; degenerative changes in the heart muscle will force to abandon chloroform; low blood pressure—spinal anesthesia; decreased kidney function with increased residual nitrogen in the blood—any kind of general anesthesia; the question of anesthesia is particularly acute in Basedow's disease; these patients are sometimes very sensitive to drugs and die on the operating table; their death is attributed to status thymico-lymphaticus. Therefore, the surgeon, when examining a Basedow patient, has to resort to all known methods for determining this condition, starting from percussion of the sternum, examination of the root of the tongue, and ending with roentgenograms, hematological analyses, and anthropometric measurements. There are operations that give rise to certain specific methods of preliminary examination; thus, for example, operations for jaundices, often complicated by severe postoperative bleeding, have given rise to particularly precise instruments for determining blood coagulability (Lychkovsky's, Sitkovsky's apparatuses); the operation of blood transfusion has introduced the reaction of isoagglutination into surgical departments, which the surgeon now has to perform more often than any other physician of other specialties. Before operations on vascular aneurysms, the surgeon has to determine the presence and strength of collateral circulation; this has forced the development of a special technique for examining collaterals (Korotkov), hitherto unknown and distinguished by particular accuracy. Finally, the question of a technical nature regarding the choice of place and direction of the incision requires particular detail in diagnosis: for example, it is not enough to know that the patient has an abscess in the lung, it is also necessary to establish to which part of the chest wall it is closer, i.e., from where it is more advantageous to approach it; then for the surgeon the condition of the pleura in this area is of actual importance: if the pleura is free, then the operation will more likely be conducted in two stages, if the pleura of the lung is adhered to the parietal pleura, then the opening of the abscess can be done immediately. Another example: gallstone disease; it is not enough for the surgeon to know that there is a stone in the bile ducts; he needs to determine more precisely where this stone is located, and usually, following the research plan developed by surgeons, it is possible to establish whether there is a stone only in the gallbladder or also in the bile duct, whether it is movable and in what condition the liver function is. The second peculiarity of surgical examination is that the surgeon has certain technical advantages over the therapist: namely, he more widely uses trial punctures, trial incisions and biopsies are in his power. Punctures to determine the presence of fluid and its character are performed to obtain cerebrospinal fluid, large amounts of blood, ascites, and exudates from the pleural, pericardial, articular, and tunica vaginalis cavities. Biopsies are of equally important, sometimes decisive importance; they are resorted to in cases of unclear character of ulcers on the lips, tongue, cervix uteri, rectum, as well as certain deeper tumors; often histological examination of a piece of tumor or lymph gland has to be done during the operation; in these cases, the laboratory's answer suggests to the surgeon the solution to the question of the nature of the tumor and the adoption of a corresponding plan for further operation. Finally, the most heroic means available to the surgeon for diagnosis in the most difficult cases are trial incisions; most often incisions of the abdominal wall are resorted to for examination of the abdominal cavity; in extremely rare cases—incisions of the lumbar region for examination of the condition of the kidney. Trial incisions, of course, should be used only in exceptional cases, since compared to other methods of examination they appear significantly more dangerous for the patient; but, on the other hand, one must remember that every operation in general begins with the examination of the opened area and is thus the final link of the surgeon's preliminary examination. In cases of urgent surgical diseases, the examination of patients is reduced to minimal limits; here one often has to be content with a very general clinical diagnosis like 'internal bleeding' or 'intestinal obstruction,' and already during the operation the examination of one or another area clarifies the details and dictates the further plan of operation. Among surgical patients, traumatic cases and cases of acute inflammatory diseases stand out as a special group; from the point of view of examination, they have the peculiarity that in them it is necessary to begin the examination with the present state, and not with the anamnesis, as is usually customary; then the examination more quickly leads to the goal. Chronologically, the examination of the surgical patient falls into three parts: preoperative, postoperative, and examination of long-term results. All that has been stated above refers mainly to the preliminary examination; the postoperative course with a number of possible complications (bleeding, infection, thromboses, embolias, weakening of cardiac activity) gives rise to a group of specific examinations, of which after clinical examination at the patient's bedside, the examination of the blood is in the first place, and then the urine. These examinations have been developed by surgeons with special care.

The third part of the examination of surgical patients is provided by the remote results; most often here one has to use questionnaire material, written information sent by patients, and more rarely direct examination of the operated patient, although the latter examination is the most valuable.

m. Egorov. VI. Examination of women. Special examination of a pregnant woman and special gynecological examination see Obstetrical examination, Gynecological examination. Here will be given some purely methodological data, which must be taken into account by every practical physician, not to mention the specialist obstetrician-gynecologist, when examining a sick woman. These data, which determine a special approach when examining a sick woman, have special significance in diseases belonging to the so-called border areas. The main starting points in the examination of a sick woman (ultimately these will also be the basic prerequisites for the etiological recognition of one or another disease) are connected with the peculiarities of the physical and mental constitution of the female organism and primarily with the various periods of her sexual life. As we know, the entire somatic sphere and the mental life of a woman are intimately connected with her sexual sphere. Hence the course and intensity of all physiological and pathological processes will be different depending on at what moment of sexual life we examine the sick woman. In this regard, for practical purposes it is useful to keep in mind the following three periods of a woman's sexual life: 1) before sexual maturity and development, 2) full sexual development, and 3) menopause. Between the first and second periods there is still an intermediate, or transitional period - the time of the onset of the first menstruation (menarche), a moment particularly important for all processes of the female organism; such a period or, as it is called, 'critical age' (climax), separates the second period from the third. When examining a woman in the first period, before the onset of sexual maturity [we exclude the indifferent period (Desoar) of the child], every physician, taking into account the physiological peculiarities of the woman, must first of all take into account that he is dealing with a woman who has not yet been formed physiologically. In assessing pathological phenomena in such a subject, the same physician must also remember that the only endocrine organ of the ovary, according to modern views playing an exclusively important role in this period of a woman's life, is its follicular apparatus together with the interstitial gland. When considering pathological conditions in a woman before her period of maturity, one must always remember that in this period infection does not play such a role in the pathology of the female sexual sphere as in the subsequent periods, and conversely - here diseases belonging to the group of developmental defects (infantilism, asthenia universalis congenita, asthenic infantilism of Mathes' type, etc.) are particularly often encountered, as well as those pathological processes which are connected with general diseases of the entire organism. The first period is quite sharply separated from the second by the moment of the onset of the first menstruation (menarche). Just as the first impulse toward the appearance of old age comes from the sexual gland, so the onset of the period of sexual maturity is determined by it. When examining a sick woman in this period, the physician will act correctly if he clarifies all the details of the appearance of the first bleeding from the sexual organs of the girl. This moment is often the starting point for many, especially mental, diseases of the woman. One must never forget that in this period sometimes there is a slight enlargement of the thyroid gland, and this so-called puberty goiter should not be considered something pathological, but rather should be attributed to the category of physiological phenomena accompanying the menarche period. The onset of menstruation, the character of the first menstrual cycles, the strength and intensity of menstrual bleeding in many cases will give the key to understanding a whole series of constitutional peculiarities of the sick woman being examined. Here already traits of infantilism, asthenic habitus, etc., can be revealed. The premature onset of menstruation (menstruatio praecox) will give the physician reason to think about the presence of pathological changes in the pineal brain gland (teratomas) or in the ovary itself (sarcoma, cystomas), the presence of hirsutism (premature abundant development of hair on the external genital parts, in the armpits, strong development of muscles, weak growth of the sexual organs).

The special form of early sexual development forces the examining physician to pay attention to the adrenal glands (tumors), etc. After menarche comes the period of female sexual maturation. On average, it lasts about 30 years (15-45 years). V. F. Snegirev, again for the purpose of facilitating the examination of a female patient, advised dividing this period of time into three periods: the preparatory period (15-25 years), when not all the specific functions of the female organism (especially coitus) reach their climax; the period of the full bloom of a woman's sexual life (25-35 years), when all physiological processes reach the acme of their development; and finally the third period (35-45 years)-the period of greatest calm, constancy and stability of the female sexual sphere. A woman is finally formed only in the second period (25-35 years). The examining physician should especially remember that only by this time do all the physiological processes of the female organism, in terms of proper uninterrupted functional activity, receive their final completion; ovulation, menstruation, coitus, the reproductive function, etc.-all are connected into a single whole. The internal secretory activity of the ovary is most clearly expressed here. When conducting a comprehensive examination of a female patient, the physician must take into account that during this period of the full bloom of a woman's sexual life, along with the follicular apparatus and the interstitial gland, the maturing follicle and the corpus luteum (the menstrual corpus luteum and the corpus luteum of pregnancy) begin to play a dominant role. Their work, in connection with the activity of other internal secretory organs, especially under pathological conditions, acquires a complex, sometimes extremely intricate character, thereby creating for the physician examining the female patient a difficult task in terms of etiological diagnosis of this or that disease. In this respect, it is useful to remember the approximate scheme of relationships between the sex gland and its allied and secretory apparatus on the one hand, and the internal secretory organs working in an antagonistic position on the other. At one pole here are the ovaries, the anterior lobe of the pituitary gland, the parathyroid glands and the cortical layer of the adrenal glands (the allied secretory group), and at the opposite pole-the thyroid gland with its components-the chromaffin system, the posterior lobe of the pituitary gland and the mammary glands. In the presence of functional diseases in a woman (functional abnormalities of the uterine and ovarian cycle, e.g., hemorrhagic metropathies of the Schröder type, secretory disorders, abnormalities of a sexual nature, essential pruritus, etc.), the given scheme provides the examining physician with a certain guiding thread, allowing him to sort out sometimes rather complicated pathological cases. Furthermore, when examining a female patient during the bloom of her sexual life, whatever form of disease he is dealing with, the physician must always remember that during this period all phenomena in the female organism proceed under the sign of cyclic, rhythmic moments, which are clinically expressed in the form of the ovarian-uterine cycle. One should never forget that in different phases of the ovarian-uterine cycle, the entire female organism lives differently. All the vital functions of the organism reflexively perceive the waves that arise in the ovary. Menses is a process of the entire organism, and at the height of the wave, in its phase of intensification (premenstrual period), the pulse quickens, blood pressure rises, the percentage content of hemoglobin in the blood increases, the number of red and white corpuscles increases, lung capacity increases, metabolism changes, etc. In the descending phase of the wave (beginning of menstrual bleeding, the phase of desquamation and regeneration), the opposite phenomenon is observed: the intensity of vital processes comparatively quickly falls, only to wave-like increase again after some time. Every physician, whatever his specialty, when examining a female patient, must take into account all changes associated with these wave-like physiological fluctuations. Also, when examining women, the moment concerning their intimate sexual life (coitus) should not be ignored. Here very often lies the cause of the disease or at least one of its stimulating etiological agents. If menstruation is an act of the entire female organism, this should be kept in mind all the more in relation to pregnancy. Pregnancy is indeed a function of the entire organism (Repreev). Hence all pathological processes associated with pregnancy or menstruation, as well as all diseases observed during them, should receive from the examining physician a broad interpretative explanation. Pathological phenomena during the period of female sexual bloom proceed with particular intensity and typicality. If, as we have seen, before the beginning of sexual maturity infection did not play the primary role in the pathology of the female sexual sphere, then during sexual maturity infectious inflammatory processes (septic, gonorrheal, colibacillary) occupy first place. As a special feature of the female organism, which the examining physician must take into account, one should point to the diverse reflex phenomena with which this organism responds to various pathological processes. Reflex pains affecting the female organism as a whole should constitute the subject of particularly persistent examination by the physician. Here it is sufficient to recall the so-called dysmenorrhoea nasalis (the sexual points of Fliess on the middle of the lower nasal concha), reflex pains in the presence of abdominal and pelvic plethora (so-called plethoric pains, according to Snegirev, obtained by pressing with a finger on a point located two fingers below the navel on the white line), the painful points characterizing the syndrome of endometritis dolorosa, according to Snegirev (five painful points: 1) near the crista ilii on the middle of its outer surface; 2) near the inner edge of the anterior superior iliac spine; 3) in the region of the tuberculi pubici; 4) a transverse finger above and somewhat outward from the third; 5) on the inner surface of the thigh slightly below the inguinal fold), etc. Alperin recommends, when examining a female patient, to be guided by reflex pains obtained by pressing with a finger on the region of the solar plexus (the prominence of the 12th thoracic vertebra). In the presence of inflammatory processes in the pelvic organs, reflex pain is felt in the epigastric region (endometritis) or in the region of the navel (perimetritis), sometimes in the region of the back and lumbar region (metrites, presence of venous hyperemia), in the inguinal region (adnexitis), etc. If no reflex pain is obtained on pressure on the lumbar plexus, then, according to Alperin's data, there are no inflammatory processes within the pelvis.-When considering various complaints from the patient being examined, the physician will act correctly if he also concentrates his attention on hysteria, which so often complicates various diseases of the female sexual sphere. Finally, mention should be made of that group of diseases which is given the collective name-'acute abdomen' (acutely developing, catastrophic diseases of various organs of the abdominal cavity). While focusing attention on the sexual sphere, the physician must never forget about ectopic pregnancy, torsion of the pedicle of an ovarian cyst, incarceration of a pregnant, retroverted uterus, etc. After the period of the full bloom of a woman's sexual life comes an intermediate, so-called climacteric period, when there is a gradual winding down of all physiological processes of the organism. When examining women during this period, the physician must always remember and know well all the manifestations of the so-called climacteric symptom-complex, which in a mild form resembles Basedow's disease (the antagonistic group of secretory glands gains the upper hand with unleashing and disinhibiting the sympathetic nervous system). Among the new growths playing a primary role in this period, malignant new growths, especially cancer, are of main importance. During the subsequent menopause and old age, the female patient differs little from a sick man in terms of examination. M. Malinovsky. VII. Examination of the child. The examination of an older child differs little from that of an adult, but in small children, especially in infants, it acquires a number of distinctive features. A small child is unable to give subjective information about the illness or gives it in an unclear, unreliable form. He very often hinders the examination by crying and resisting. Information regarding complaints and anamnestic data is obtained indirectly from parents or persons caring for the child, and much here is colored by subjectivism. The collection of certain secretions for examination is difficult in small children: urine, feces, sputum, etc. All this creates many difficulties in the examination of a child. In addition, it must be borne in mind that the findings of the examination have to be interpreted differently in a child than is done in the case of an adult.

This depends, first, on the fact that in small children we encounter more pronounced general reactions, both in some purely local diseases and especially in infections, reactions that mislead the researcher: such are, for example, convulsions at the beginning of any infectious disease in children with tetany or, for example, acute gastrointestinal phenomena in local diseases of the nasopharynx and infections 'etc.'; second, on the fact that the conclusions obtained as a result of the investigation often have to be interpreted differently depending on the age of the child, nutritional status, etc. For example, the sound of a broken pot on percussion of the chest of a child in the first months of life and an older child has completely different meaning; similarly, temperature in normotrophics and atrophics must be interpreted differently and many other things. Successful examination of a child (especially a small one) depends to a large extent on a skillful approach to the child and to his mother. In general, one should not immediately begin with examining the child; the favorable atmosphere necessary for the examination can be created only gradually, when the child gets used to the new person. It is best to start by questioning the mother or persons caring for the child. It is useful to allow the mother to tell the doctor everything she wants, as this will help later: having spoken, the mother will be calmer. Later, however, it is more advantageous, as some authors (Filatov) advise, to put to the mother a series of systematic questions about the disease and changes in the functions of various systems and organs, and then ask the mother to supplement what, in her opinion, was not clarified. After questioning about the child's age, one proceeds to clarify the complaints (when the illness began, what phenomena were present initially, what others appeared). Collecting the history is one of the most important parts of examining a child-often made difficult by the fact that everything reported about the child by the mother or others is based not on facts, but on arbitrary interpretation of them. It must also be known that in older children, who are able to report about themselves, collecting correct historical data can be hindered by simulation (e.g., a schoolchild who does not want to study) or, conversely, by concealing painful phenomena (for example, out of fear of treatment, unwillingness to stay in bed, etc.). The history (see) should be collected according to general rules with special attention to hereditary data. Moving on to the specific child, one asks which number he is, where exactly and in which month he was born, whether full-term or not; then the nature of the labor, the course of the postpartum period, diseases of the newborn and the nature of the child's development up to the present disease: how his weight increased, when he began to hold his head, sit, stand, walk; also the beginning of teething, speech, development of motor skills and psyche. It is extremely important to clarify this (especially for small children) the 'feeding history': whether the child was breastfed, with what intervals, how he suckles (calmly or often breaking away), how he behaves in the intervals between feedings, etc. The amount of breast milk cannot be established by questioning; it is sometimes established by examining the nursing mother's breast, and most accurately by weighing the child before and after feeding, or indirectly: by weight gain and the number of urinations. Next, the time of starting supplementary feeding, its nature and results are established; the time of transition to artificial feeding, the order, regularity of feedings, the size of each portion, the usual menu, etc. Attention is paid to the presence of overfeeding or underfeeding, as well as how the child tolerates one or another food. Data regarding constitutional peculiarities of the child, insofar as they have not been clarified from acquaintance with the constitutional peculiarities of the parents, are obtained by asking about the child's reaction to food, to infection, and to the external environment, and about various manifestations of constitutional anomalies during development. Finally, information is sought about the nature of diseases previously suffered, their duration, and how the child tolerated them. It is very important to know whether the child had infectious diseases and whether serum injections or vaccinations were performed. Moving on to the recent history of the present illness, one clarifies when and how it began and what its course has been; next follows questioning by systems and organs. It is very important to obtain from the mother temperature records and to plot a curve; it is very useful if the mother saves for the doctor samples of various secretions and excretions (urine, sputum, diapers with feces). A properly collected history even before examining the child can give much for understanding the disease and in any case clarify the guiding lines for diagnosis. However, no less important is such a method as observation of the patient. One must not frighten or upset the child, one should not touch or undress him; it is best if the child does not notice that he is being observed. If he is sleeping, he should not be awakened. Observation can be conducted in part already during the questioning. Attention is paid to the child's position in bed, his mood and general condition; many symptoms that, being weakly expressed, might have remained unnoticed during direct examination in crying, restlessness, etc., can be noted incidentally: for example, slight paralysis of the facial nerve, mild degrees of rigidity of the neck or extremities, increased respiration, tension of the fontanelle, and many others. If the child is restless, crying, then auditory impressions should also be used: the nature of the cry, cough, respiration can explain much.- Moving on to direct examination, one must again try not to disturb the child's calmness. Examination should never begin with force-making the child hold tightly, etc.; this should be left as a last resort; it is often possible, by appealing to the child's independence ('do it yourself!'), to achieve the result that he will undress himself, raise his arms, stick out his tongue, etc. One should also not deceive the child, but warn what is going to be done. A child from 1 to 3 years old is best examined on the mother's lap. The child should be completely undressed, otherwise much of importance can be missed during examination. One must wash hands and instruments before beginning and after examination. Good lighting is also important to ensure. Examination of a sick child is conducted according to general rules (see above-examination of the sick). It is only necessary to note that in small children percussion of the chest organs is associated with some difficulties, therefore one should not percuss in the prone or lateral position, but only in the sitting position, with symmetrically supported arms. Percussion should be weak for the same reasons. During auscultation the character of respiration can also change from the above-mentioned reasons, which is why auscultation should be done in the same position as for percussion. It is most convenient to use a phonendoscope (without a membrane) of the Filatov type with rubber tubes for the ears. However, one can also listen with a regular stethoscope or directly with the ear. When examining the abdominal organs, one should not forget to examine the anal and hernial areas. Palpation of the liver and spleen is done very carefully, by no means overcoming the resistance of the abdominal wall with sharp movements. When examining the spleen, it is sometimes more advantageous, after pressing several fingers into the abdominal wall, to wait until the spleen itself touches the fingers on inspiration. Next, the urinary and reproductive systems and sense organs are examined. Determination of ear tenderness on pressure on the tragus is usually done when examining the skull, however this method is not always reliable; to judge the condition of the eardrum, mirror examination is necessary. Examination of the child's nervous system is carried out according to the same scheme as in an adult, but one must individualize the approach to the child according to age, and also take into account some psychophysical peculiarities of childhood in connection with anatomical data; at the moment of birth the development of the child's nervous system is not yet fully complete-some parts are already fully developed and ready for activity, while others are in a period of development and cannot yet serve as a basis for psychophysical functions. The incompleteness of the child's organism due to unfinished development is manifested in the examination by the detection of various signs-some of the symptoms existing in a normal adult are either not elicited at all or are obtained in a distorted form (increased or decreased), while other symptoms that appear in an adult only under pathological conditions are very well expressed in a child. One must be familiar with all these peculiarities in order to take them into account when analyzing the data obtained for diagnosis. Attention is paid to general cerebral phenomena (excitement, drowsiness, etc.), to the state of the central and peripheral nervous system (convulsions, paralyses, contractures, etc.), to meningeal symptoms, and to the reflex sphere (skin reflexes, abdominal reflexes, cremaster reflex, tendon reflexes, pupillary, corneal reflexes).

The state of the autonomic nervous system is judged by the condition of the pupils, by the injection of the eyeball vessels, by the tone of Müller's muscle, by perspiration, by the gooseflesh phenomenon, by the Ashner phenomenon, by the nature of dermographism, etc. When examining the nervous system in children, one must take into account its features characteristic of childhood, for example, a number of reflexes that are pathological in adults represent a normal phenomenon in infancy. Examination of the pharynx and throat, as the most unpleasant and exciting procedure for the child, is performed last. To examine the pharynx in a small child, one person is asked to hold the child on their arms, placing a foot on a chair and sitting the child on their knee, holding the child's hands, while another person needs to firmly hold the head from behind. During this examination, it is also not recommended to use force unless absolutely necessary, but it is desirable to persuade the child to open their mouth and then quickly examine the tongue and, using a spatula or spoon, examine the mucous membranes of the cheeks, palate, pharynx, and nasopharynx. The examination should be conducted near a window. In older children, almost all instrumental examinations performed on adults are possible (examination of blood pressure, sphygmography, electrocardiography, examination of excitability, X-ray examination, examination of sensitivity and autonomic reflexes, laryngoscopy, esophagoscopy, and bronchoscopy, encephalography, examination of the fundus of the eye). In small children under 1 year, many of these methods are very difficult. Methods of blood examination, taking gastric juice (by catheter), duodenal juice, pleural, lumbar, and suboccipital punctures are also widely practiced in children. In infants, ventricular puncture is performed. Taking blood from a vein in infants is done from the neck vein or from the sinus. Methods of functional diagnosis are also applicable in older children; for example, water and dry food urine tests, Widal test, pharmacological examination of the autonomic nervous system. Measurements of height, head and chest, and weighing the child are extremely important.

a. sokolov. VIII. Examination of the oral cavity and teeth. Odontostomatological examination extends to the organs and tissues of the oral cavity, namely: jaws with their alveolar processes and teeth, tongue, mucous membrane of the mouth and gums, hard and soft palate, maxillary cavity. Examination of the patient begins with questioning, which indicates the localization of the process and often the etiology of the disease. For example, loss of the hard substance of the teeth of endogenous or exogenous origin; gangrene of the pulp as a result of inflammation or trauma; mercurial or catarrhal gingivitis, etc. Through questioning, the time of onset and course of the disease are also established; accompanying subjective symptoms, which have diagnostic value for directing the course of the investigation towards establishing an acute or chronic process, a benign or malignant tumor, an ulcer of one kind or another, etc. External examination begins with the facial, submandibular, and chin areas with the naked eye. A flattened nasolabial fold, asymmetry of the face, neck may indicate the presence of an exudative process or tumor in the area of the jaw processes. Clinical examination of the oral cavity requires special conditions. During the examination, the patient's head is fixed immovably in a special chair. A good source of light is necessary. For examining easily accessible areas (lips, front of the tongue, gums, hard and soft palate, front teeth and partly the oral mucosa), scattered daylight is sufficient. For examining, for example, carious cavities in teeth, a brighter, solar or artificial light from a frontal, standing or hanging reflector is needed. For areas not accessible to the naked eye, it is necessary to use a dental mirror that concentrates the rays of the light source and reflects the area being examined. A number of diseases are determined much more accurately by palpation (touch) than by the eye. This includes determining the presence of a tumor, hardening, swelling, the condition of the submandibular and other lymph glands, etc. In addition to a mirror, the set of instruments for examination includes dental tweezers, dental and button probes, excavator, water syringe, blunt and flat hooks for retracting the lips. With a sharp probe, hidden carious cavities are found, the degree of sensitivity of the dentin, the presence of an exposed pulp horn, the entrance to canals, the presence and depth of pyorrhea pockets; with a blunt button probe—the direction of the fistula tract, the presence of a sequester, etc. With the help of an excavator and probe, the degree of softening of the dentin and its sensitivity are determined. Percussing the tooth with a hard instrument (handle of a probe, mirror, or tweezers), the condition of the root sheath of the tooth is determined. The presence of pain indicates an inflammatory process in the area of the periodontal membrane. Thermal examination—using a stream of cold water, hot air blown from a heated instrument, heated gutta-percha—is important for clarifying the nature of the pulp disease. A reaction to cold, especially a sharp and prolonged one, indicates an inflammatory condition of the pulp, the absence of a reaction to thermal irritation is observed in pulp gangrene. Examination of teeth by means of induction current, obtained using special instruments (pantostat, Schrader, Spamer devices, distribution board). In this case, first, on an equivalent healthy tooth, the strength of the current is established at which sensitivity occurs in the tooth of this subject. Only after this is the suspicious tooth examined, placing one electrode on the tooth being tested and the other on the hand. It should be borne in mind that enamel is a poorer conductor than dentin. This should be taken into account when examining, for example, a canine with a significant enamel coating or when there are worn tooth surfaces. Depulped teeth and teeth with dead pulp do not react to a medium-strength current; with chronically inflamed pulp, they react below normal, with acutely inflamed, they give an increased reaction. X-ray examination in the field of odontostomatology has acquired no less importance than in other areas of medicine. With the help of X-rays, 1) the condition of the roots (fractures, perforations) is determined; 2) the condition of periapical tissues (granulomas, cysts); 3) hidden carious cavities in teeth (on proximal surfaces and in artificial crowns not reaching the gum); 4) foreign bodies in root canals (broken needles, pins); 5) concretions and denticles in the pulp; 6) retained teeth, anomalous roots, and roots left as a result of unsuccessful tooth extraction; 7) the condition of the alveoli (in alveolar pyorrhea and other atrophic processes) and generally the condition of the jaw bones; 8) fractures and foreign bodies of the alveolar process and generally the jaw; 9) the relationship between the teeth and the maxillary cavity; 10) the condition of the maxillary cavity; 11) the location of the intraosseous canal and mental foramen; 12) tumors of the jaws, etc. Bacterioscopic examination is important in cases of suspected actinomycosis, tuberculous ulcer, ulcerative stomatitis, to determine the nature of pus in alveolar pyorrhea. Patho-anatomical examination is widely used both for the purpose of establishing a diagnosis (biopsy) and for checking and controlling it after surgical intervention. In addition to special examination of the oral cavity, it is often also necessary to examine the general state of health by organs and systems. Thus, in alveolar pyorrhea, it is necessary to examine the condition of metabolism. In trigeminal neuralgia—the general condition of the nervous system. In the presence of a tuberculous ulcer—the condition of the lungs. In some forms of aphthous stomatitis, in foetor ex ore—the condition of the gastrointestinal tract, etc. Multiple caries of the teeth should also direct the physician's thoughts to studying the general condition of the patient. How important the condition of the oral cavity is in connection with other general conditions is evident from the latest teaching on the oral genesis of chronic sepsis (oral sepsis) by American authors (see Chronic sepsis).

I. Peker. IX. Examination of the eye patient. The examination of eye patients must be strictly methodical. The general examination of the patient and critically collected anamnesis can also provide certain points of reference for subsequent conclusions. The subjective complaints of the patient at the time of examination may sometimes be characteristic of a specific disease, and sometimes common to many diseases. The objective examination of the eye begins with the external examination of the eyelids: their shape, position, reflex movements, condition of the skin, muscles, cartilage of the eyelids, their free edges, eyelashes, and finally the palpebral fissure formed by the eyelids. During this examination, the patient sits facing the light opposite the physician. Then, making the patient look upward and pulling the lower eyelid downward with a finger, the conjunctiva of the lower eyelid and the lower fornix are examined. To examine the conjunctiva of the upper eyelid, the patient is made to look downward, the edge of the eyelid and eyelashes are grasped with the index and thumb of one hand, the eyelid is pulled down, the index (or thumb) of the other hand is applied above the upper edge of the cartilage, and the eyelid is everted upward on this finger as on a hinge. Instead of a finger, sometimes, especially in children, it is necessary to use some kind of stick. On the conjunctiva, its color (hyperemia), transparency, thickness (edema, infiltration), surface (granules, papillae), discharge, and deposits should be noted. For a detailed examination of the upper fornix, sometimes (for foreign bodies), after cocaineization, the everted eyelid must be lifted with a stick or forceps. Simultaneously with the conjunctiva, the condition of the lacrimal passages must also be examined: lacrimal puncta (narrowing, their recession from the eyeball, foreign bodies in them), lacrimal canals (thickening and concretions in them), and especially the lacrimal sac (accumulation of catarrhal discharge, ectasia), by pressing with a finger on the area of the lacimal fossa. In case of suspicion of narrowing of the lacrimal passages with persistent epiphora--a test with irrigation through the lacrimal canals with an Anel syringe (see Anel syringe), instillation of a 1% solution of fluorescein, or careful probing. When examining the conjunctiva and the sclera itself, main attention is paid to the nature of the hyperemia, distinguishing between conjunctival, pericorneal, scleral hyperemia, and hyperemic congestion and tortuosity of vessels in glaucoma. In the examination of the cornea, simple examination in daylight can be used, but finer changes are noted only with side illumination in a dark room, by concentrating with the help of a magnifying glass (about 20 diopters) on the cornea the rays of light from a lamp placed somewhat in front and to the side of the patient's face. For examining the details of the illuminated area, a simple magnifying glass, a binocular magnifying glass, or the Chapsky-Zeiss corneal microscope is used. Side illumination was further developed in the recently so-called slit lamp by Gullstrand, where magnification of more than 100 times can be obtained and where it is possible not only to see but also to localize in various layers of the cornea a series of fine histological changes. In the examination of the cornea, the following are noted: changes in its size and shape (microcornea, flattening, keratoconus, keratoglobus, staphyloma), surface (ulcers), transparency (infiltrates, scars), presence of vessels and their nature (superficial vessels as a continuation of conjunctival vessels and deep vessels emerging in the scleral limbus), changes in sensitivity. For examining the shape and reflectivity of the cornea, the so-called keratoscope by Placido is sometimes used. After the cornea, the anterior chamber is examined using simple examination, or preferably with side illumination, in which its depth (decrease, increase, unevenness of depth), condition of the aqueous humor (opacities, hypopyon, hyphema, deposits on the posterior surface of the cornea--precipitates) are noted. Using the same methods, the iris is then examined, noting changes in its pattern (blurring of the pattern), color (hyperemia, exudation, siderosis), volume (edema, infiltration, nodules, defects), position (displacement forward in adhesions with the cornea and backward in the absence of the lens), mobility (trembling with eye movement), as well as changes in the pupillary edge in adhesions with the lens capsule and changes in the area of the pupil itself in terms of its closure by exudate. At the same time, the condition of the pupils themselves is examined, preferably in a dark room--with side illumination: their position, shape, size, inequality of both pupils, and their reaction to light, accommodation with convergence, consensual reaction. The presence of the lens in the eye is established by the so-called Purkinje figures, i.e., reflected images of the light source on the anterior and posterior surfaces of the lens. Placing a weak light source in front of the eye, e.g., a candle, we obtain two direct mirror images--from the surface of the cornea and the anterior surface of the lens, and one inverted image--from the posterior surface of the lens. With side illumination, the presence of opacities in the anterior layers of the lens and the nature of such opacities are established, but here side illumination must be combined with examination in transmitted light, when, using an ophthalmoscope in a dark room, placed in front of the patient, beside which stands a lamp, a beam of light is directed through the pupil to the bottom of the eye, and through the opening of the ophthalmoscope, the rays reflected back from the bottom of the eye are received. On the red background of the pupil, all opacities of the transparent media of the eye are visible as dark areas. By observing the movement of such opacities with eye movements, their localization can be more precisely determined. Opacities of the vitreous body, in contrast to others, move freely, float with eye movements. In the examination of the iris, lens, and anterior segment of the vitreous body, the examination with a slit lamp gives very valuable information. After completing the examination of the refractive media of the eye, ophthalmoscopy is performed, the examination of the fundus of the eye in indirect, and where required, in direct form. Ophthalmoscopy recently proposed in red light can sometimes give details that are not visible in ordinary ophthalmoscopy. The examination in the dark room ends with the objective determination of refraction by skiascopy (see), and the determination of astigmatism can be checked and supplemented on the Javal-Schiotz ophthalmometer. Having thus obtained an idea of the structure of the eye and pathological changes in its tissues, the examination of the functions of the eye is undertaken, and first of all, the determination of visual acuity. The latter is performed in a light (optical) room with the help of special charts placed at a distance of 5 m from the patient sitting with their back to the light, in daylight or preferably with a special Rot illuminator. Each eye is examined separately. By applying appropriate lenses to the eye and watching for improvement in visual acuity, the data on the refraction of the eye obtained by skiascopy are checked by the subjective method. At the same time, the condition of the accommodation of the eye (see) should be determined, especially in presbyopes (see Presbyopia) and hypermetropes (see Hyperopia), in order to prescribe glasses for work. At the same time, the condition of the internal and external rectus muscles of the eye is checked with the help of the Maddox small scale or by the method of Graefe (see Graefe examination) to detect muscle insufficiency or latent strabismus (see Heterophoria). In the presence of manifest strabismus, its angle is determined with the help of the Maddox large scale; in the case of concomitant strabismus, it is very desirable to determine the comparative strength of the internal and external rectus muscles (adduction and abduction) according to Bely. In paralytic strabismus, where the angle of deviation of the eye increases when the fixation object is moved in the direction of action of the affected muscle, a special examination for double images is performed to determine which of the eye muscles is paralyzed. Following the determination of visual acuity, the visual field should be examined with a perimeter, where the movable test object for precise examination should not be more than 3 mm in size. For examining defects in the central part of the visual field (scotoma), it is preferable to use a campimeter, where the presence and size of scotomas can be more easily and accurately determined than on a perimeter. Along with the examination of the visual field, the examination of color perception should be conducted, which is performed by the methods of Nagel, Stilling, and Holmgren (preferably in the modification of Roshevsky). In all cases where there is even the slightest suspicion of changes in intraocular pressure, the latter must be measured not only by palpation with the index fingers of both hands, but also with a tonometer (Schiotz, Maklakoff, in an outpatient clinic, one can also use Fik-Livshits). Thus, the eye patient, during their examination, must go from the examination room to the dark room and from there to the optical room, and only with a strictly methodical examination of the eye can we obtain an idea of the condition of the eye at the time of examination.

A. Pokrovsky. X. Examination of the ear, throat, and nose. Compared to other medical disciplines, the examination of an otorhinolaryngological patient presents a number of peculiarities and requires a special external environment, thorough preparation in studying the anatomy and physiology of these organs, and skill in using many auxiliary diagnostic instruments. The examination is conducted in a dark room with artificial lighting, since sunlight is not always available, and scattered daylight is not strong enough to illuminate deeply situated parts. It is necessary to always use the same source of light, so that the eye becomes accustomed to distinguishing the condition of one or another organ by its external coloring, which can often be of decisive importance, for example, when determining the light shades of the eardrum. It should be noted that when examining organs through their natural openings, the observed picture can change greatly under the influence of slight variations in anatomical structure and, due to this, be incorrectly evaluated. The sitting position of the patient, involuntary reflex movements, for example, from the pharyngeal and laryngeal muscles, and artificial lighting also present significant difficulties for an inexperienced physician in orienting themselves with respect to the organ being examined, even when it is in a normal state. The illumination of the organ being examined is produced with the help of a frontal reflector with a diameter of 9-10 cm and with a round opening in the middle. Experience is required to be able to control the reflected rays of the reflector—the 'shadow'—and to direct it instinctively to the place being examined, both from the outside and in the depths of the organs. Considerable practical exercises are also required to learn how to use the simplest elementary instruments, whether it be a nasal mirror, ear funnel, spatula, or laryngeal and nasopharyngeal mirrors. Examination with the help of a probe also requires experience. After taking the anamnesis (see), one can establish whether one is dealing with an acute or chronic disease, whether the disease of the nose, ear, or throat is an independent affliction or accompanies some general disease. It is extremely important to find out precisely about all the patient's complaints, concerning not only the ear, throat, and nose, but also the general condition, since the latter is in the closest connection with these organs. Having clarified the onset, course, and possible cause and connection with other diseases, one proceeds to the examination and palpation of the externally situated parts: the external nose, auricle, and external auditory canal, the area around the ear, especially the mastoid process. The neck is palpated for the larynx, thyroid gland, and lymph glands. Whatever the patient complains about, the ear, throat, and nose must all be subjected to internal examination, because when one organ is diseased, the patient may complain of another. Thus, for example, pain in the ear can be caused by a disease of the larynx or pharynx, a persistent, treatment-resistant cough may depend on a sulfur plug or chronic rhinitis, chronic tonsillitis, etc.; diseases of the ears are in most cases connected with diseases of the nose or nasopharynx. The internal examination of the nose is performed with the help of nasal mirrors in the anterior, middle, and posterior parts—anterior, middle, and posterior rhinoscopy. The examination is conducted in a specific order so as not to overlook any point. During anterior and middle rhinoscopy, the identifying points are: the nasal septum, the anterior ends of the inferior and middle turbinates, the inferior and middle nasal meatuses, the space under the middle turbinate, and the posterior parts of the nose, insofar as they are visible from the front. During posterior rhinoscopy, the nasopharynx, its vault, the ridges of the Eustachian tubes, the posterior surface of the vomer, the choanae, and the posterior ends of the nasal turbinates are examined. In most cases, one examination is not sufficient for making a diagnosis; when the anterior ends of the inferior turbinates are swollen, it is necessary to resort to smearing the nasal mucosa with cocaine or adrenaline and probing with a nasal probe; at this time, the density and consistency of tumors, hypertrophies, growths, and protrusions on the septum, the mobility and origin point of polyps, sequestra, foreign bodies, and other abnormalities are determined. During anterior rhinoscopy, the discovery of a purulent streak in the middle nasal meatus gives reason to conclude about a disease of the paranasal sinuses, however, to precisely establish which cavity is involved in the inflammation, it is only possible with the help of other research methods, which include: diaphanoscopy, trial puncture, X-ray, photographs. Further, the nasal cavity is examined for its air permeability, the acuity of smell, and the tactile sensitivity of the mucous membrane, which is important for determining its reflex sensitivity. The ear is examined from the point of view of its anatomical changes and functional ability. With the help of an ear funnel, the condition of the external auditory canal and eardrum (see Otoscopy) is examined. This examination is of great importance, as on its basis diseases of the external auditory canal and middle ear are diagnosed. The external appearance of the eardrum gives the physician data by which one can to some extent judge the changes in the middle ear; thus, redness or perforation indicate acute or chronic inflammation of its mucous membrane, retraction, changes in contour and color allow one to suspect narrowing of the Eustachian tube and impaired mobility of the auditory ossicles. During the examination, the eardrum is observed sequentially according to identifying points, of which the most important are: the malleus, its short process, the anterior and posterior folds, the light reflex, and the color of the eardrum. The mobility of the eardrum is determined with a funnel (Siegle). In the external auditory canal, its 4 walls are separately noted: the superior, inferior, anterior, and posterior, as well as its width and length. The middle ear is further examined from the point of view of the patency of the Eustachian tube; the most common method is to insufflate it with a catheter inserted through the inferior nasal meatus, whereby each tube can be insufflated separately; this method differs from the Politzer method, in which both tubes can be insufflated simultaneously, since insufflation is achieved by increasing pressure in the nasopharynx by blowing air from a rubber bulb through one nostril at the moment of raising the soft palate. The Politzer method is indispensable in children, as they resist the insertion of a catheter. The Valsalva maneuver is now almost completely abandoned; it can cause a rush of blood to the head and worsen the patient's condition. The patency of air is controlled by the characteristic noise that is heard through an otoscope, one end of which is inserted into the patient's auditory canal and the other into the examiner's ear. In recent years, radiography has been added to the physical methods of research, with which one judges the anatomical structure of the mastoid process and the spread of the inflammatory process in it. Functional examination of the ear is conducted in two directions: from the point of view of its acoustic and vestibular function. For the diagnosis of ear diseases, these examinations are of great importance, since anatomical data often do not clarify the nature and localization of the affliction at all. The acuity of hearing is judged on the basis of examination with speech (whisper) and tuning forks. A sharp drop in hearing for whispering does not yet give the right to conclude a disease of the sound-perceiving or sound-conducting apparatus; the matter is decided by tuning fork examination. With the help of tuning forks, the degree of loss of air and bone conduction is determined, and data characteristic of diseases of the middle and inner ear and the auditory nerve are obtained. These data are obtained through a series of special experiments: Weber, Schwabach, Rinne, and Gelle. For the functional examination of the vestibular apparatus, the method of irritating the semicircular canals and the otolith apparatus is used, by means of which characteristic motor phenomena from the eyeballs (nystagmus) and the muscles of the limbs and trunk are caused. The technique for detailed examination of the semicircular canals and the vestibular apparatus is very complex and not yet sufficiently developed. Nystagmus is caused by the method of rotation around the body's vertical axis, by caloric reaction, and by galvanic current; sometimes the method of thickening and rarefying air in the auditory canal (pressure nystagmus) is also used. The research data indicate a decrease or increase or loss of vestibular function. Disorders of movements in the limbs are examined by the pointing test and observation of gait. For judging diseases of the inner ear, it is also necessary to take into account subjective sensations, such as deafness, noise in the ears, dizziness, nausea, etc. The examination of the fauces, oral part of the pharynx is performed with illumination by a reflector while pressing the tongue down with a spatula; the condition of the tonsils is mainly determined; the oral cavity is also examined in passing. The nasopharynx is examined during posterior rhinoscopy. The examination of the larynx is done with the help of a laryngoscopic mirror (indirect laryngoscopy) or by inserting a straight tube or special spatula into the entrance of the larynx; this direct method is closely connected with the technique of tracheobronchoscopy.

L. Rabotnov. XI. Examination of a urological patient. The examination of urological patients should begin with questioning, and since the main symptoms are pain, disorders of urination, and changes in the character of the urine, special attention should be paid to these points. A number of urological diseases proceed so characteristically that it is often possible to make a diagnosis already on the basis of the history alone, and objective examination is only a method of confirming the diagnosis. The nature of the painful sensations, their radiation, the moment causing their onset (walking, bumpy rides, urination) are of great importance. Pains originating from the kidneys, renal pelves, and ureters usually spread downward and radiate to the inner surface of the thigh, the lower part of the abdomen, and the external genital organs. In relation to bleeding, it is extremely important in each individual case to establish the nature of the bleeding (initial, terminal, profuse, macro- or microscopic, depending on walking or rest, whether it is accompanied by the formation of clots in the urine, painful sensations, etc.). The sensations during urination are of great practical importance: at what moment they occur - before the appearance of urine, during urination, or after its completion, the frequency of urination during the day and at night, the presence of false urges, changes in the urinary stream and its arc, the duration and ease of urination. When taking the history, one should inquire about previous infectious diseases, especially gonorrhea, and clarify its course and the complications with which it was accompanied. Traumatic injuries, professional intoxications, and past syphilitic infection play a major role, especially in various functional diseases of the urinary tract. In each individual case, it should be determined whether there is an endemic or familial diathesis. After collecting the history, both relating to the given disease and the general one, one proceeds to the direct examination of the patient, and this should begin with the inspection of the external opening of the urethra, taking discharge from it for microscopic examination on a slide, macroscopic examination, and inspection of the urine voided right there in one or several portions. The urine should then be subjected to the usual chemical and microscopic examination. After this, the patient is placed in a recumbent position on a flat hard table and the area of the kidneys and ureters is examined systematically by palpation. The examiner should obtain an idea of the palpability of the individual organs of the abdominal cavity, their relationships, mobility, consistency, sensitivity to palpation, shaking, and percussion. In normal conditions, the kidneys and ureters cannot be palpated; their area is painless on examination. In individuals with well-developed musculature of the anterior abdominal wall or with significant fat deposition in the abdominal coverings, palpation should be performed with the patient lying on the side opposite to the side being examined, with the limbs slightly flexed. If there is a movable tumor in the kidney area, for differential diagnosis as to which organ this body belongs to, it is extremely important to examine the urine 1-2 hours after palpation. The appearance of protein in the urine (palpatory albuminuria) after the examination indicates that the palpable body is the kidney. Palpation of the bladder usually does not provide great diagnostic data, and percussion is of much greater importance, on the basis of which one can judge the degree of bladder filling. In the normal state of the walls and normal functions of the bladder, percussion is completely painless, and dullness over the pubis cannot be detected after urination. If dullness is present in the suprapubic area, a catheter should be inserted into the bladder and, after emptying the urine if it is there, percussion should be performed again; the presence of persistent dullness will indicate disease of the organs adjacent to the bladder - parametrium, uterus, peritoneum. Then one proceeds to palpation of the urethra, penis, and organs of the scrotum, paying attention to the presence and character of the cremasteric reflex, the presence of infiltrates here, their painfulness, their relationship to the underlying organs and skin (adhesions, fistulas). In the presence of tumors in the scrotum, their relationship to the abdominal cavity and the inguinal ring (reducibility) and to transmitted light (translucency) should be established. - Next, one proceeds to the palpatory examination of the prostate and seminal vesicles. The patient is on the right side with limbs drawn up to the abdomen and flexed, in the knee-elbow position, or on the back with limbs spread and flexed, or finally stands leaning on elbows on the table, with the trunk bent forward at a right angle. The index finger of the right hand, protected by a rubber finger cot and well lubricated with vaseline, is inserted into the rectum. Attention should be paid to the shape, size, painfulness, consistency of the prostate, to the palpability, painfulness, configuration of the seminal vesicles, and to the microscopic and bacteriological examination of the secretion from these organs. The examination of the patellar and anal reflexes concludes the palpatory examination. - Having established in this way which of the organs of the urinary system is affected by the pathological process, one should resort to instrumental and laboratory examinations by organs. In the presence of diseases of the urethra, discharge from it should be taken on a slide for examination, and the patient should not have urinated for several hours before this. If discharge cannot be expressed, threads from the first portion of voided urine should be caught with a pipette and subjected to microscopic and bacteriological examination. After the patient has urinated, the patency of the urethra is examined by introducing bougies into it, starting with larger numbers and gradually progressing to thinner ones. In a normal urethra, the passage of a bougie No. 22-24 should not meet with obstruction, and the patient should feel not pain, but only an unpleasant sensation. In prolonged purulent processes in the urethra, in bleeding, urethroscopy should be used to determine the source of blood and pus in each individual case. The instrumental examination of the bladder begins with determining its motor function. The patient should void as much urine as possible, after which a soft or elastic catheter is inserted into the bladder and the amount of residual urine is determined; the latter should be collected in sterile vessels and examined separately, as not containing urethral secretion and flora. By gradual slow filling of the bladder through the same catheter with indifferent warm liquid, its capacity and distensibility are determined. If a stone is suspected, the bladder should be subjected to radiography, cystography, or its interior examined with a special bladder probe-sound. In a number of individual cases, direct visual examination of the bladder should be resorted to (see Cystoscopy). In surgical diseases of the kidneys, a radiogram should be taken, not only of the kidney but of the entire ureter along its course. In cases of negative radiographic findings or uncertainty as to which kidney is diseased, the patient should be subjected to chromocystoscopy and ureteral catheterization. In a number of individual cases, pyelo-ureterography should be resorted to. In all diseases of the urinary system, the urine after movement (evening) and after rest (morning) should as a rule be examined separately. If blood and pus are present in the urine, the possibility of their coming from the urethra and the organs surrounding it (vagina) should be excluded by catheterization of the bladder, and then the patient should be subjected to cystoscopy. If the sources of blood or pus in the bladder cannot be found, chromocystoscopy with catheterization of the ureters should be performed. p. Fronshtein. XII. Examination of an acute infectious patient. Before the direct examination of an acute infectious patient, it is necessary to conduct an epidemiological investigation on the spot (see Infectious diseases). This investigation has important, and sometimes even decisive, significance for making the diagnosis. Having clarified the epidemiological situation of the case and taking into account the epidemiological condition of the given locality, one proceeds to clinical and, finally, laboratory examination. - The clinical examination of an acute infectious patient must be carried out according to a definite plan, with strict observance of precautions. Otherwise, it is possible not only for the physician himself to become infected, but also for the infection to be transmitted to others. From these considerations, the patient is examined in a gown, and in some cases a respirator is also worn (pulmonary forms of plague, anthrax, glanders). Surgeons are recommended to wear rubber gloves or finger cots when examining contagious patients (erysipelas, scarlet fever, diphtheria, anthrax, etc.). During the examination, one should touch the patient only with hands and instruments, and in no way with clothing or gown. If the gown is not used properly, it can even contribute to the spread of infection.

To protect oneself from crawling insects, the physician conducts the examination while sitting on a hard chair or in a standing position. It is impermissible to sit on the patient's bed. Medical instruments used during the examination of the patient are subjected to disinfection. The clinical examination begins with collecting the anamnesis from the patient, their relatives, and those around them. Acute infectious processes are characterized by certain signs common to many forms, developing more or less quickly, sometimes suddenly. Complaints of weakness, chills, feeling of heat, headache, pains throughout the body, insomnia, loss of appetite, nausea, and vomiting are very common. Questioning the patient in the indicated direction can not only to some degree determine the presence of acute infection but also provide valuable indications of its nature. When collecting the anamnesis, special attention is paid to clarifying previously endured infections, the possibility of contact with contagious patients, and conditions of work and daily life (profession, nutrition). The rate of development of the disease is thoroughly clarified; the sequence of development of all subjective signs and objective signs noticed by the patient or those around them; and therapeutic interventions undertaken before the physician's arrival. Questioning the patient also makes it possible to judge the clarity of their consciousness, the presence of excitement or depression, and the character of their speech. After the anamnesis, one proceeds to objective examination, first determining the general status of the patient, then the body temperature, which provides valuable indications when suspecting acute infectious disease. While the patient has not yet been disturbed by the examination and is lying quietly, one becomes familiar with their pulse and the characteristics of respiration. Inspiratory retractions of pliable parts of the chest wall are characteristic of certain infections (e.g., croup). For the success of further examination of the patient, it is necessary to ensure good and uniform lighting. External examination of the patient begins with careful examination of their skin. Rashes have great diagnostic value. When examining a rash, the background of the skin (normal, yellowish, or pink coloration) is analyzed, then the individual elements of the rash, i.e., their mutual arrangement, distribution by parts of the body, and the characteristics of each individual spot. One should not forget that diffuse scarlatinoid reddening of the skin often appears in small children during crying (erythema e clamo) or in older individuals due to excitement (erythema e pudore). After the patient calms down, the erythema disappears. In certain infections, hemorrhages into the skin are observed, occurring due to bacterial emboli or due to changes in vessel walls under the influence of toxins. Small hemorrhages may be mixed with roseolas, from which they differ in that they do not disappear under pressure. Acute swelling of the lymph glands of the subcutaneous tissue (lymphadenitis) should be considered a frequent companion of contagious diseases, which is local or general. For recognizing lymphadenitis, both inspection and palpation are necessary, since acute enlargement of the glands is often accompanied by pain. Glands at the angles of the lower jaw often swell depending on inflammatory processes in the pharynx. While examining the glands, the condition of the muscles (their tension, painfulness) and joints is clarified. Then one proceeds to examination of the tongue, paying attention to its size, color, moisture, presence of coatings, ulcers, etc. Sometimes the changes are so typical that diagnosis can be suspected or established exclusively on their basis (scarlet fever). In febrile patients, the tongue cracks due to decreased salivation, in most it is coated, in severely ill patients it is covered with thick dark crusts (fuliginous coatings). The formation of coatings usually depends on the patient not eating solid food and not mechanically cleansing the oral cavity. When examining the tongue, one can judge how well the patient can move it, which sometimes indicates the presence of certain infectious processes, e.g., difficulty in protruding the tongue, despite the desire to comply with the physician's request, is a frequent symptom of severe typhus. After the examinations described above, the physician, using ordinary methods, proceeds to determining the condition of internal organs (nervous system, lungs, heart, liver, spleen, gastro-intestinal tract, kidneys), paying special attention to the size, consistency, and sensitivity of the spleen, which so often reacts to acute infection. During examination, it is necessary to avoid straining the patient or making sharp changes in their position, which can cause severe complications, collapses, and even death of the patient (typhoid fever, diphtheria, etc.). Examination of the oral cavity and pharynx is performed only at the end of the clinical examination, since this procedure, unpleasant even for adults, is often agonizing for small children, causing prolonged resistance, crying, and sometimes vomiting. As a result of excitement and crying, redness may appear on the body, as already mentioned, simulating scarlatinal rash. It is also necessary to consider that under the influence of vomiting movements, often appearing when pressing on the tongue with a spatula, hyperemia of the pharyngeal mucosa quickly develops, which can be confused with that observed in catarrhal angina. Examination of the mouth and pharynx is performed using a spatula or the handle of a spoon. One sequentially examines first the changes on the outer surface of the lips (especially the corners of the mouth—diphtheria), then the inner surface of the upper and lower lips, the mucosa of the cheeks (aphthae, Filatov-Koplik spots), gums, frenulum of the tongue (whooping cough), mucosa of the hard palate (enanthema), and finally the area of the pharynx and posterior wall of the pharynx. For examining the pharynx, it is better to use a forehead reflector. In a home setting, it is convenient to use a candle, shielded from the physician by a tablespoon, which serves as a reflector. The patient's head must be fixed in a straight position with the left hand, placed on the occiput or vertex of the patient. Turning the head to the side distorts the normal configuration of the pharynx and throat. The spatula should be inserted to the root of the tongue without touching it. The movements should be precise and decisive, but cautious. In small children, with strong pressure on the root of the tongue, it is possible to examine the epiglottis. At the same time, attention is paid to the odor from the mouth, which sometimes has diagnostic value. It is characteristic in noma, Vincent's angina, and especially in the malignant form of diphtheria. In many cases, it is necessary to resort to laboratory examinations, for which bacteriological, serological, histological, and less frequently physicochemical methods are used. Blood, urine, feces, vomitus, duodenal contents, secretions, tissues, and pathological excretions are subjected to bacteriological analysis. For the success of bacteriological examinations, the method of collecting material for examination, the time, and the method of delivering it to the laboratory often have great, sometimes decisive importance. Blood cultures should be made at the patient's bedside. Of the serological reactions, agglutination, precipitation, and complement fixation reaction have great practical importance. Blood for serological examinations should be taken not from the finger but with a syringe from the bend of the elbow vein and in a sufficient quantity for repeated examination. In many cases, it is necessary to examine the morphological composition of the blood, with particular importance attached to determining the quantity and type of elements of the white blood (typhoid fever, sepsis, scarlet fever, etc.). When performing a serological analysis of blood in acute contagious diseases, information about preventive vaccinations previously received is collected first, as they can affect the result of the examination. Not only active but also passive immunization has significance in this regard. In serodiagnosis, e.g., of syphilis, it should be remembered that in most diphtheria and scarlet fever patients who have received the corresponding therapeutic serum for a short time, all reactions for syphilis are positive, despite the absence of active or latent syphilis (Hent-Schel and Szego).

V. Stefansky. XIII. Examination in Skin Diseases. Examination of persons suffering from skin diseases is based on the following main points: 1) collecting the anamnesis, which has special importance in the diagnosis of nervous rashes and intoxications (e.g., in urticaria); 2) topographic study of the rash, which in certain diseases, e.g., in scabies, provides a key point for diagnosis in the localization of the rash; 3) evaluation of subjective sensations, which are very diverse in skin diseases; 4) study of anatomical changes, which has a decisive role in the examination of skin diseases; it involves careful study of the morphological elements of the rash and often requires a series of auxiliary methods for correct diagnosis, which include histological examination of affected tissue by biopsy (see), as well as methods of diagnosis grouped under the concept of dermoscopy (see), diascopy (see), and capilloscopy (see).