other hand, it must always be borne in mind that symptoms are frequently either entirely absent or of no definite significance, even in cases of grave organic diseases of the cardio-vascular system; while local sensations are often referred to the region of the heart, or disturbances of its action complained of, which are really of little or no consequence. Therefore it is necessary to guard against placing too much reliance on these phenomena from a diagnostic point of view.
2. The systematic examination of the heart and pericardium, as well as of the great vessels, by the ordinary physical methods—inspection, palpation, percussion, and auscultation—has been progressively worked up to its present position, and is now established on a comprehensive and practical basis. It is on the intelligent application of these methods, separately or in combination, that the diagnosis of morbid conditions of these structures must be mainly founded; and as a rule they are fully adequate for the purpose, if properly carried out. It would be quite out of place to attempt to discuss this aspect of my subject at any length, but there are a few points to which I should like to refer. The comprehensive and detailed investigation of the cardiac impulse and movements is of the utmost importance in a large number of cases, but I doubt whether this part of the examination receives even now, as a matter of routine, the attention it deserves. For this purpose inspection and palpation are obviously essential; as
