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vestigation that I have found the voice changes of most importance. In all morbid states of the nervous system, acute and chronic, the voice Glycomet Sr is changed, and each devia- tion from the normal is diagnostic of the conditions which produce the changes presented. V. The Voice Before and Aftek Major Opera- tions. — One of the most important parts of the clinical history which the surgeon ought to know fully, before and after major operations, is the condition of the nervous system. The temperature, state of the circula- tion, and general nutrition — in short, the condition of all the Buy Metformin Online vital organs of the body — can be easily and clear- ly determined; but the less marked deviations from health and strength of the nervous system are not easily made out. The milder forms of neurasthenia are not well manifested, and the symptoms of nervous weakness that may be present are often overlooked, or, when ap- parent, are often attributed to fear of the operation, want of courage, Glycomet Price and so on. Even the voice signs of nervous weakness and nervous depression are not pro- nounced, and when they are present one finds it diffi- cult to determine whether they indicate a degree of ex- haustion, temporary depression, or fatigue. Still, by watching and repeated examinations, a diagnosis can be made in most cases. This is of far more importance than at first appears, but may be fully comprehended by considering two cases as nearly alike as can be im- agined: One patient bears operating well and recovers promptly, while the other either dies or makes a tedious convalescence. The cause of the difference is in the nervous system. The one is strong, the other is weak. I contend that the difference between the two is mani- fested in the voice, the one being normal and the other morbid. VI. The Testimony of the Voice after Major Operations. — The voice in surgical shock is reduced to a minimum of volume and resonance, the degree of loss of voice being in keeping with that of shock. In severe cases the voice is often reduced to a whisper, and is only made audiijle by an effort on the part of the patient. Even the forced voice shows a marked diminution of volume and resonance, is husky and ill-sustained. Pa- tients often decline to speak in an audible voice because it requires more of an effort than they are able to make. Failure of the voice is Glycomet Gp2 the first evidence of shock, I pre- sume. At any rate, shock affects the voice as soon as it docs the pulse, if not sooner. This, of course, has not been noticed, owing to the majority of subjects being anii'stlietized when the sliock is caused. I have had an opporlunity to see many cases of shock from injury, and in all of them the voice gave way first. On that account I have depended upon the voice Glycomet Gp signs in making a diag- nosis more than upon any other sign or symptom, and have seldom, if ever, been misguided. Equally reliable are the voice signs in showing re- action from shock. Improvement in resonance and power of Glycomet Tablets the voice is the first sign of recovery. Sev- eral times it has happened that my assistants and nurses have reported that there were no signs of improvement, and they were discouraged in consequence; but, finding an improvement in the voice, I have encouraged the vigorous continuance of the treatment, and success has followed. VII. The Voice in Apathetic Conditions of THE Nervous System. — There is a peculiar state of the nervous system into which patients sometimes fall after grave operations, Glycomet 500 Sr which has never been fully de- scribed, so far as I Glycomet 850 Mg know, which is characterized by in- difference. It seems as if the nervous system became overwhelmed and gave up its function of displaying the danger Glycomet Tablet signals. The vital forces apparently give up the task in despair. There Glycomet 500 Mg is no alarming change of tem- perature or pulse; the patient makes no complaint of Glycomet 1gm any mental or physical suffering, and yet the condition is a most grave one and most Buy Metformin deceptive, leading the attendants to be hopeful and free from apprehension until death comes as a surprise to them. There are no signs or Glycomet 500mg symptoms that are diagnostic. Even the face is placid ; the voice, manner, and mental action are the only indications that there is something far wrong. Even the Glycomet 250 mental condition is not always apparent to the casual observer. The abnormal voice alone tells the story. All that I have ever read or heard about this con- dition, following grave surgical operations, is embodied in a story told by J. Marion Sims. Not knowing where to find the story as told in Sims's graphic way, I can only give the facts Glycomet Gp 2 from memory. Sims was in Edinburgh and had seen Keith do ovariotomy in a very bad case. Two days after he called on Glycomet Sr 500 Keith and anxiously asked about the patient's progress. Keith said she was doing badly, expressed grave doubts about her recovery, and added, " Come and see her." This was just what Sims wanted to do, so he went and examined the patient, looked over the record of pulse and temperature, and inquired about her nour- ishment. Then the two worthies retired to an adjoin- ing room to discuss the case. Sims expressed great sur- prise at Keith's gloomy view of the patient's condition, adding that she was in remarkably good condition for one who had undergone such a severe ordeal. Keith re- plied that he " did not like her; that he was afraid that she would not do." Sims wanted to know on what grounds he based his unfavorable prognosis. "Well," said Keith, " my old nurse, who has cared for so many of my cases, does not like her condition, and Glycomet Gp1 I have great faith in her opinion. She is seldom mistaken." Sims asked to liave the nur.se Glycomet 500 called in to find out her reasons for the doubts and fears. Mrs. Dow, the nurse, in reply to the doctor's direct questions, said that " the patient was too good; she was indifferent, wanted nothing, was pleased with everything that was done for Glycomet 850 lier, and those cases do badly," she said. " I like ones who arc hard to i)l('!)se ; the dcevils alway.s do best." " Yes," said' June 10, 1S99] SKENE: THE VOICE IN DIAGNOSIS.

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