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 FIFTH EDITION

CASE FILES®
Obstetrics and
Gynecology
Eugene C. oy, MD Patti Jayne Ross, MD
Assistant Dean or Educational Programs Pro essor
Director o Doctoring Courses Program University o exas H ealth Science Center
Director o the Scholarly Concentrations Department o O bstetrics and Gynecology
in Women’s H ealth McGovern Medical School at T e University
Pro essor and Vice Chair o Medical Education o exas H ealth Science Center at H ouston
Department o O bstetrics and Gynecology (U H ealth)
McGovern Medical School at T e University H ouston, exas
o exas H ealth Science Center at H ouston
(U H ealth) John C. Jennings, MD
H ouston, exas Pro essor o O bstetrics and Gynecology
exas ech University H ealth Sciences Center
Benton Baker III, MD Odessa, exas
Fellow, American College o O bstetricians and
Gynecologists
Retired, Pro essor o O bstetrics and Gynecology
McGovern Medical School at T e University
o exas H ealth Science Center at H ouston
(U H ealth)
H ouston, exas

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 DEDICATION

T is f th edition o Case Files®: Obstetrics and Gynecology is dedicated to Dr. Sean

C. Blackwell, who is my chairman, and whose leadership and riendship I cherish.
I have watched him work tirelessly rom be ore dawn to well a ter dusk, and be
available or telephone calls and consultation regardless o the hour. H e is the rea-
son I am able to continue to grow as an educator, writer, and teacher. Most precious
to me, he strongly supported me (shortly a ter joining the department ull time) to
keep my commitment to lead our medical mission team to Cambodia to serve hun-
dreds in the rural province o Kratie. H e is probably the biggest reason this edition o
Case Files®: Obstetrics and Gynecology could see print.
Sean C. Blackwell, MD is a Pro essor and Chair (appointed 2011) o the Depart-
ment o O bstetrics, Gynecology and Reproductive Sciences at McGovern Medical
School at T e University o exas H ealth Science Center at H ouston (U H ealth).
Dr. Blackwell completed his undergraduate degree as a double major in the classics
and biology at Wabash College in Craw ordsville, Indiana. H e matriculated medi-
cal school at the University o Illinois College o Medicine in 1993 and completed
both his obstetrics and gynecology residency and maternal etal medicine ellowship
at Wayne State University in Detroit, Michigan. H e joined U H ealth in 2007,
and also serves as the Director o the Larry C. Gilstrap MD Center or Perinatal
and Women’s H ealth Research and as an Assistant Dean or H ealthcare Quality
in Perinatal Medicine and Women’s H ealth. Dr. Blackwell is the Chie o Service
or O bstetrics and Gynecology or Children’s Memorial H ermann H ospital– exas
Medical Center. In 2014, Dr. Blackwell earned his Six Sigma-Lean Black Belt at the
University o H ouston.

Eugene C. oy, MD
iv DEDICATION

o my Chairman o Obstetrics o Gynecology, Dr. Sean Blackwell,

whose work ethic, leadership, and vision inspire everyone around him
to excellence and whose heart o generosity touches thousands o
pregnant women and their babies.
—ECT
With love and gratitude, to Mom, Joy, Ben, Anne, Jessica, Jim, John,
and Col. Alvin Sholk.
—BB III
o Dr. James Knight, and ulane Medical School, or giving me the
opportunity to ulf ll my dreams. o my parents, Mary and Jimmy Ross,
or their love, inspiration, and devotion.
—PJR
o my wi e, Sue Ellen, my three daughters, Beth, Allison, and Amy,
their husbands, and my f ve grandchildren.
—JCJ
Finally, to the wonder ul medical students rom the McGovern Medical School
at T e University o exas Health Science Center at Houston (U Health),
who graciously gave constructive eedback
and enthusiastically received this curriculum.
—TH E AUTH ORS
 CONTENTS

Contributors / vii
Pre ace / xiii
Acknowledgments / xv
Introduction / xvii
Listing o Cases / xix

Section I
How to Approach Clinical Problems ...................................................................1
Part 1. Approach to the Patient ................................................................................................. 3
Part 2. Approach to Clinical Problem Solving ....................................................................11
Part 3. Approach to Reading ....................................................................................................13
Part 4. Approach to Surgery .....................................................................................................18

Section II
Cases...................................................................................................................19
Obstetric Topics (Cases 1-28)...............................................................................................19
Gynecologic Topics (Cases 29-60)................................................................................... 289

Section III
Review Questions ...................................................................................................................... 565

Index / 577
This page intentionally left blank
 CONTRIBUTORS

Mazen Elias Abdallah, MD

Assistant Pro essor o O bstetrics and Gynecology
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Delayed Puberty
Michael . Adler, MD
Assistant Pro essor o O bstetrics and Gynecology
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Amenorrhea, Intrauterine Adhesions
Elizabeth E. Brackett
Medical Student
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Herpes Simplex Virus In ection in Pregnancy
Shao-Chun R. Chang-Jackson, MD
Assistant Pro essor o O bstetrics and Gynecology
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Ectopic Pregnancy
amika K. Cross, MD
Resident in O bstetrics and Gynecology
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Domestic Abuse and Sexual Abuse
Cynthia Donna, MD
Resident in O bstetrics and Gynecology
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Contraception
Erin G. Dressel
Medical Student
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Hypertensive Disease in Pregnancy

vii
viii CONTRIBUTORS

Amy E. Dudley
Medical Student
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Bacterial Vaginosis
Jenny Duret-Uzodinma, MD
Assistant Pro essor o O bstetrics and Gynecology
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Pyelonephritis in Pregnancy
Russell Edwards, MD, FACOG
Faculty, O bstetrics and Gynecology Residency Program
T e Methodist H ospital—H ouston
H ouston, exas
Galactorrhea and Hypothyroidism
Konrad Harms, MD, FACOG
Assistant Clinical Pro essor o O bstetrics and Gynecology
Weill Cornell Medical College
Program Director,
O bstetrics and Gynecology Residency
T e Methodist H ospital—H ouston
H ouston, exas
Shoulder Dystocia
Sara B. Holcombe, DO
Assistant Pro essor o O bstetrics and Gynecology
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Domestic Abuse and Sexual Assault
Steven Blaine Holloway
Medical Student
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Cystitis
Katlyn Hoover
Medical Student
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Placental Abruption
 CONTRIBUTORS ix

Lina Wael Irshaid

Medical Student
Weill Cornell Medical - Qatar
Dohn, Qatar
Intrauterine Growth Restriction
Randa J. Jalloul, MD, FACOG
Assistant Pro essor o O bstetrics and Gynecology
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Breast Cancer
Erin Josserand
Medical Student
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Pulmonary Embolism in Pregnancy
Joy Y. Kim, MD
Assistant Pro essor o O bstetrics and Gynecology
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Contraception
Patricia C. Lenihan
Medical Student
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Approach to Labor
Hypertension in Pregnancy
Pelvic Organ Prolapse
Principal manuscript reviewer
Chunhua Lu, MD, PhD
Resident in O bstetrics and Gynecology
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Breast Cancer
Fangxian Lu, MD, PhD
Assistant Pro essor o O bstetrics and Gynecology
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Postpartum Hemorrhage
x CONTRIBUTORS

Michael S. MacKelvie, DO
Resident in O bstetrics and Gynecology
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Placenta Accreta
Violet Maldonado
Medical Student
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Preterm Labor
Dalia M. Moghazy, MD
Resident in O bstetrics and Gynecology
T e Methodist H ospital—H ouston
H ouston, exas
Intrahepatic Cholestasis o Pregnancy
Alyxandra O’Brien, MD
Resident in O bstetrics and Gynecology
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Ectopic Pregnancy
Christine Pan, MD
Resident in O bstetrics and Gynecology
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Postpartum Hemorrhage
Urinary Incontinence
Virginia A. Rauth, MD, MBA
Pro essor o O bstetrics and Gynecology
Chie o Women’s H ealthCare at Galveston
University o exas Medical Branch
Galveston, exas
Approach to Perimenopause
John W. Riggs, MD, MS, FACOG
Pro essor o O bstetrics and Gynecology
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Postpartum Endometritis
 CONTRIBUTORS xi

Reem Sabouni, MD
Resident in O bstetrics and Gynecology
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Amenorrhea, Intrauterine Adhesions
Placenta Previa
Mary Alice Sallman
Medical Student
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
Manuscript reviewer
Viviana C. Salom-Ellis
Medical Student
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Placenta Previa
Priti P. Schachel, MD, FACOG
Associate Program Director
O bstetrics and Gynecology Residency Program
T e Methodist H ospital—H ouston
H ouston, exas
Intrahepatic Cholestasis o Pregnancy
Nicholas R. Spencer
Medical Student
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Parvovirus In ection in Pregnancy
Lauren Jane T arp, MD
Administrative Chie Resident in O bstetrics and Gynecology
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Postpartum Endometritis
Aida L. Vigil, MD, MPH
Resident in O bstetrics and Gynecology
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Pyelonephritis in Pregnancy
xii CONTRIBUTORS

Joaquin Andres Villegas Inurrigarro

Medical Student
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Septic Abortion
Cristina M. Wallace, MD
Assistant Pro essor o O bstetrics and Gynecology
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Polycystic Ovarian Syndrome
Amberly Nesbitt Winley, MD
Resident in O bstetrics and Gynecology
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Polycystic Ovarian Syndrome
Nikolaos Zacharias, MD, FACOG
Assistant Pro essor o O bstetrics and Gynecology
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Placenta Accreta
 PREFACE

I have been deeply amazed and grate ul to see how the Case Files®books have been
so well received, and have helped students to learn more e ectively. In the 13 short
years since Case Files®: Obstetrics and Gynecology irst made it in print, the series
has now multiplied to span most o the clinical and basic science disciplines, and
been translated into nearly 20 oreign languages. Numerous students have sent
encouraging remarks about the changes in the ourth edition, which divided up
into O bstetrics in the irst hal , and Gynecology in the second hal to be more “user-
riendly” during the clerkship since most students have their rotation divided in
those two categories. In this i th edition, we have retained the grouping o related
cases closer together to allow students to use in ormation rom one case to rein-
orce principles to another case, and cross-re erenced-related cases. Although space
is always a premium, we have also retained and expanded Section III which is a col-
lection o strategic questions that can be used or review, but also to tie in the prin-
ciples rom the cases. Questions have been improved to better re lect the USMLE
ormat, and explanations have been expanded to help the student understand the
mechanisms and the reason that the other choices are incorrect. wo completely
new cases (Sexual Abuse/ Intimate Partner Violence, and Chronic Pelvic Pain) have
been written. Updated or new sections include cervical cytology screening, con-
traception, labor management, hypertension in pregnancy, etal assessment, and
ovarian cancer. his i th edition has been a collaborative work with my wonder-
ul coauthors and contributors, and with the suggestions rom ive generations o
students. ruly, the enthusiastic encouragement rom students throughout not just
the United States but worldwide provides me with the inspiration and energy to
continue to write. It is thus with humility that I o er my sincere thanks to students
everywhere … or without students, how can a teacher teach?

Eugene C. oy

xiii
This page intentionally left blank
 ACKNOWLEDGMENTS

he curriculum that evolved into the ideas or this series was inspired by two talented
and orthright students, Philbert Yao and Chuck Rosipal, who have since graduated
rom medical school. It has been a tremendous joy to work with my riend, colleague,
and my ob/ gyn program director, Dr. Bentor Baker III. It is also a privilege to work
with Dr. Ross, who has been a steady hand in administrating the medical student
clerkship or so many years. It is a personal honor and with extreme gratitude that I
am able to work with Dr. John Jennings, a visionary, brilliant obstetrician gynecolo-
gist, leader, and riend. Also, I am awed by the many excellent contributors who con-
tinue to work under the deadlines and pleas o per ectionists. I am greatly indebted
to my editor, Catherine Johnson, whose exuberance, experience, and vision helped
to shape this series. I appreciate McGraw-H ill’s believing in the concept o teach-
ing through clinical cases. I am also grate ul to Catherine Saggese or her excellent
production expertise, and Cindy Yoo or her wonder ul editing. At the University o
exas Medical School at H ouston, I appreciate the support rom my chairman
Dr. Sean Blackwell, who is an amazing leader with a brilliant intellect, an unparalleled
work ethic, and a generous heart that inspires beyond our department; and Dr. Patricia
Butler who as Vice Chair or Educational Programs o our school exempli ies all
that is excellent in medical education, and has served as a role model and mentor
or me. I appreciate Yaki Bryant, who has aith ully and energetically served as the
extraordinary student coordinator or literally thousands and thousands o students
at the University o exas Medical School at H ouston. I want to acknowledge the
many medical students who have helped to sharpen the ocus o this book, especially
Patricia Lenihan, who served as principle manuscript reviewer. Most o all, I appre-
ciate my loving wi e, erri, and my our wonder ul children, Andy and his wi e Anna,
Michael, Allison, and Christina, or their patience and understanding.

Eugene C. oy

xv
This page intentionally left blank
 INTRODUCTION

Mastering the cognitive knowledge within a ield such as obstetrics and gynecology
is a ormidable task. It is even more di icult to draw on that knowledge, to procure
and ilter through the clinical and laboratory data, to develop a di erential diagnosis,
and inally to make a rational treatment plan. o gain these skills, the student o ten
learns best at the bedside, guided and instructed by experienced teachers, and
inspired toward sel -directed, diligent reading. Clearly, there is no replacement or
education at the bedside. Un ortunately, clinical situations usually do not encom-
pass the breadth o the specialty. Perhaps the best alternative is a care ully cra ted
patient case designed to stimulate the clinical approach and decision making. In an
attempt to achieve that goal, we have constructed a collection o clinical vignettes
to teach diagnostic or therapeutic approaches relevant to obstetrics and gynecology.
Most importantly, the explanations or the cases emphasize the mechanisms and
underlying principles, rather than merely rote questions and answers.
his book is organized or versatility: It allows the student “in a rush” to go
quickly through the scenarios and check the corresponding answers, and it pro-
vides more detailed in ormation or the student who wants thought-provoking
explanations. he answers are arranged rom simple to complex: a summary o
the pertinent points, the bare answers, an analysis o the case, an approach to the
topic, a comprehension test at the end or rein orcement and emphasis, and a list o
resources or urther reading. he clinical vignettes have been arranged as O bstetri-
cal in the irst hal , and Gynecology in the second hal , and related cases grouped
together. Section III contains Review Questions designed to require higher level
integration o in ormation. A listing o cases is included in Section IV to aid the
students who desire to test their knowledge o a speci ic area, or who want to
review a topic including basic de initions. Finally, we intentionally did not use a
multiple-choice question (MCQ) ormat in our clinical case scenarios, since clues
(or distractions) are not available in the real world. N evertheless, several MCQs are
included at the end o each case discussion (Comprehension Questions) to rein-
orce concepts or introduce related topics.

HOW TO GET THE MOST OUT OF THIS BOOK

Each case is designed to simulate a patient encounter with open-ended questions.
At times, the patient’s complaint is di erent rom the most concerning issue, and
sometimes extraneous in ormation is given. he answers are organized into our
di erent parts:

CLINICAL CASE FORMAT: PART I

1. Summary: he salient aspects o the case are identi ied, iltering out the extra-
neous in ormation. Students should ormulate their summary rom the case
be ore looking at the answers. A comparison to the summation in the answer will
help to improve their ability to ocus on the important data, while appropriately

xvii
xviii INTRODUCTION

discarding the irrelevant in ormation—a undamental skill in clinical problem

solving.
2. A Straightforward Answer is given to each open-ended question.
3. he Analysis of the Case is comprised o two parts:
a. O bjectives of the Case: A listing o the two or three main principles that
are crucial or a practitioner to manage the patient. Again, the students are
challenged to make educated “guesses” about the objectives o the case upon
initial review o the case scenario, which helps to sharpen their clinical and
analytical skills.
b. Considerations: A discussion o the relevant points and brie approach to
the speci ic patient.

PART II
Approach to the Disease Process: It consists o two distinct parts:
a. Definitions: erminology pertinent to the disease process.
b. Clinical Approach: A discussion o the approach to the clinical problem in
general, including tables, igures, and algorithms.

PART III
Comprehension Q uestions: Each case contains several multiple-choice questions,
which rein orce the material, or which introduce new and related concepts.
Q uestions about material not ound in the text will have explanations in the
answers.

PART IV
Clinical Pearls: Several clinically important points are reiterated as a summation of the
text. This allows for easy review, such as before an examination.
 LISTING OF CASES

LISTING BY CASE NUMBER

CASE NO. DISEASE CASE PAGE

1 Labor (Latent Phase) 22

2 Anemia in Pregnancy ( halassemia rait) 42
3 Uterine Inversion 52
4 Shoulder Dystocia 60
5 Fetal Bradycardia (Cord Prolapse) 68
6 Postpartum H emorrhage 76
7 Serum Screening in Pregnancy 86
8 win Gestation with Vasa Previa 96
9 H erpes Simplex Virus In ection in Labor 104
10 Placenta Previa 112
11 Placental Abruption 120
12 Placenta Accreta 128
13 Abdominal Pain in Pregnancy (Ovarian orsion) 136
14 Pruritus (Cholestasis) o Pregnancy 146
15 Pulmonary Embolus in Pregnancy 154
16 Preeclampsia with Severe Features 166
17 Preterm Labor 180
18 Preterm Premature Rupture o Membranes (PPROM)
and Intra-Amniotic In ection 190
19 Parvovirus In ection in Pregnancy 198
20 Chlamydial Cervicitis and H IV in Pregnancy 208
21 hyroid Storm in Pregnancy 218
22 Intrauterine Growth Restriction 226
23 Pyelonephritis, Unresponsive 236
24 N ecrotizing Fasciitis 244
25 Postpartum Endomyometritis 250
26 Breast Abscess and Mastitis 256
27 Diabetes in Pregnancy 264
28 Prenatal Care 278
29 H ealth Maintenance, Age 66 Years 290
30 Perimenopause 298
31 Sexual Assault 306
32 Ureteral Injury a ter H ysterectomy 318
33 Pelvic Organ Prolapse 326
34 Fascial Disruption 334

xix
xx LISTING OF CASES

35 Urinary Incontinence 340

36 Salpingitis, Acute 350
37 Chronic Pelvic Pain 362
38 Bacterial Vaginosis 370
39 Syphilitic Chancre 378
40 Urinary ract In ection (Cystitis) 388
41 Uterine Leiomyomata 394
42 hreatened Abortion and Spontaneous Abortion 404
43 Ectopic Pregnancy 416
44 Contraception 424
45 Abortion, Septic 438
46 Fibroadenoma o the Breast 444
47 Dominant Breast Mass 452
48 Breast, Abnormal Mammogram 460
49 Amenorrhea (Intrauterine Adhesions) 466
50 Galactorrhea Due to H ypothyroidism 474
51 Amenorrhea (Sheehan Syndrome) 482
52 Polycystic O varian Syndrome 490
53 H irsutism, Sertoli– Leydig Cell umor 496
54 Pubertal Delay, Gonadal Dysgenesis 504
55 Amenorrhea (Primary), Müllerian Agenesis 512
56 In ertility, Peritoneal Factor 520
57 Postmenopausal Bleeding 530
58 Cervical Cancer 540
59 Ovarian Cancer (Epithelial) 550
60 Lichen Sclerosis o Vulva 560

LISTING BY DISORDER (ALPHABETICAL)

CASE NO. DISEASE CASE PAGE

13 Abdominal Pain in Pregnancy (Ovarian orsion) 136

45 Abortion, Septic 438
49 Amenorrhea (Intrauterine Adhesions) 466
55 Amenorrhea (Primary), Müllerian Agenesis 512
51 Amenorrhea (Sheehan Syndrome) 482
2 Anemia in Pregnancy ( halassemia rait) 42
38 Bacterial Vaginosis 370
26 Breast Abscess and Mastitis 256
48 Breast, Abnormal Mammogram 460
58 Cervical Cancer 540
20 Chlamydial Cervicitis and H IV in Pregnancy 208
 LISTING OF CASES xxi

37 Chronic Pelvic Pain 362

44 Contraception 424
27 Diabetes in Pregnancy 264
47 Dominant Breast Mass 452
43 Ectopic Pregnancy 416
34 Fascial Disruption 334
5 Fetal Bradycardia (Cord Prolapse) 68
46 Fibroadenoma o the Breast 444
50 Galactorrhea Due to H ypothyroidism 474
29 H ealth Maintenance, Age 66 Years 290
9 H erpes Simplex Virus In ection in Labor 104
53 H irsutism, Sertoli– Leydig Cell umor 496
56 In ertility, Peritoneal Factor 520
22 Intrauterine Growth Restriction 226
1 Labor (Latent Phase) 22
60 Lichen Sclerosis o Vulva 560
24 N ecrotizing Fasciitis 244
59 Ovarian Cancer (Epithelial) 550
19 Parvovirus In ection in Pregnancy 198
33 Pelvic Organ Prolapse 326
30 Perimenopause 298
12 Placenta Accreta 128
10 Placenta Previa 112
11 Placental Abruption 120
52 Polycystic O varian Syndrome 490
57 Postmenopausal Bleeding 530
25 Postpartum Endomyometritis 250
6 Postpartum H emorrhage 76
16 Preeclampsia with Severe Features 166
28 Prenatal Care 278
17 Preterm Labor 180
18 Preterm Premature Rupture o Membranes (PPROM)
and Intra-Amniotic In ection 190
14 Pruritus (Cholestasis) o Pregnancy 146
54 Pubertal Delay, Gonadal Dysgenesis 504
15 Pulmonary Embolus in Pregnancy 154
23 Pyelonephritis, Unresponsive 236
36 Salpingitis, Acute 350
7 Serum Screening in Pregnancy 86
31 Sexual Assault 306
4 Shoulder Dystocia 60
39 Syphilitic Chancre 378
42 hreatened Abortion and Spontaneous Abortion 404
xxii LISTING OF CASES

21 hyroid Storm in Pregnancy 218

8 win Gestation with Vasa Previa 96
32 Ureteral Injury a ter H ysterectomy 318
35 Urinary Incontinence 340
40 Urinary ract In ection (Cystitis) 388
3 Uterine Inversion 52
41 Uterine Leiomyomata 394
 SECTION I

How to Approach
Clinical Problems

Part 1 Approach to the Patient

Part 2 Approach to Clinical Problem Solving
Part 3 Approach to Reading
Part 4 Approach to Surgery
This page intentionally left blank
 SECTION I: HOW TO APPROACH CLINICAL PROBLEMS 3

Part 1. Approach to the Patient

The transition from textbook and/ or journal article learning to the application of
the information in a specific clinical situation is one of the most challenging tasks in
medicine. It requires retention of information, organization of the facts, and recall
of a myriad of data in precise application to the patient. The purpose of this book
is to facilitate this process. The first step is gathering information, also known as
establishing the database. This includes taking the history, performing the physical
examination, and obtaining selective laboratory examinations or special evaluations
such as urodynamic testing and/ or imaging tests. Of these, the historical examina-
tion is the most important and useful. Sensitivity and respect should always be
exercised during the interview of patients.

CLINICAL PEARL
» The history is usually the single most important tool in obtaining a diag-
nosis. The art of seeking the information in a nonjudgmental, sensitive,
and thorough manner cannot be overemphasized.

HISTORY
1. Basic information:
a. Age: Age must be recorded because some conditions are more common
at certain ages; for instance, pregnant women younger than 17 years or
older than 35 years are at greater risk for preterm labor, preeclampsia, or
miscarriage.
b. Gravidity: Number of pregnancies including current pregnancy (includes
miscarriages, ectopic pregnancies, and stillbirths).
c. Parity: Number of pregnancies that have ended at gestational age(s) greater
than 20 weeks.
d. Abortuses: Number of pregnancies that have ended at gestational age(s) less
than 20 weeks (includes ectopic pregnancies, induced abortions, and spon-
taneous abortions).

CLINICAL PEARL
» Some practitioners use a four-digit parity system to designate the num-
ber of term deliveries, number of preterm deliveries, number of abor-
tuses, and number of live births (TPAL [Term, Preterm, Abortions, Living]
system). For example, G2P1001 indicates gravidity 2 (two pregnancies
including the current one), parity 1001; 1 prior term delivery, no preterm
deliveries, no abortuses, and 1 living.
4 CASE FILES: OBSTETRICS AND GYNECOLOGY

2. Last menstrual period (LMP): The first day of the last menstrual period. In
obstetric patients, the certainty of the LMP is important in determining the
gestational age. The estimated gestational age (EGA) is calculated from the
LMP or by ultrasound. A simple rule for calculating the expected due date
(EDD) is to subtract 3 months from the LMP and add 7 days to the first day
of the LMP (eg, an LMP of 1 N ovember would equal an EDD of 8 August).
Because of delay in ovulation in some cycles, this is not always accurate.
3. Chief complaint: W hat is it that brought the patient into the hospital or office?
Is it a scheduled appointment, or an unexpected symptom such as abdomi-
nal pain or vaginal bleeding in pregnancy? The duration and character of the
complaint, associated symptoms, and exacerbating and relieving factors should
be recorded. The chief complaint engenders a differential diagnosis, and the
possible etiologies should be explored by further inquiry. For example, if the
chief complaint is postmenopausal bleeding, the concern is endometrial cancer.
Thus, some of the questions should be related to the risk factors for endome-
trial cancer such as hypertension, diabetes, anovulation, early age of menarche,
late age of menopause, obesity, infertility, nulliparity, and so forth.

CLINICAL PEARL
» The first line of any obstetric presentation should include age, gravidity,
parity, LMP, estimated gestational age, and chief complaint.
Example: A 32-year-old G3P1011 woman, whose LMP was 2 April and who
has a pregnancy with an EGA of 32 4/7 weeks’gestation, complains of lower
abdominal cramping.

4. Past gynecologic history:

a. Menstrual history
i. Age of menarche (should normally be older than 9 years and younger
than 16 years).
ii. Character of menstrual cycles: Interval from the first day of one menses
to the first day of the next menses (normal is 28 ± 7 days, or between 21
and 35 days).
iii. Quantity of menses: Menstrual flow should last less than 7 days (or be
< 80 mL in total volume). If menstrual flow is excessive, then it is called
heavy menstrual bleeding.
iv. Irregular and heavy menses is called abnormal uterine bleeding (AUB).
b. Contraceptive history: Duration, type, and last use of contraception, and any
side effects.
c. Sexually transmitted diseases: A positive or negative history of herpes simplex
virus, syphilis, gonorrhea, Chlamydia, human immunodeficiency virus, pelvic
inflammatory disease, or human papillomavirus. Number of sexual partners,
whether a recent change in partners, and use of barrier contraception.
 SECTION I: HOW TO APPROACH CLINICAL PROBLEMS 5

5. Obstetric history: Date and gestational age of each pregnancy at termination,

and outcome; if induced abortion, then gestational age and method. If deliv-
ered, then whether the delivery was vaginal or cesarean; if applicable, vacuum
or forceps delivery, or type of cesarean (low-transverse vs classical). All compli-
cations of pregnancies should be listed.
6. Past medical history: Any illnesses such as hypertension, hepatitis, diabetes
mellitus, cancer, heart disease, pulmonary disease, and thyroid disease should
be elicited. Duration, severity, and therapies should be included. Any hospital-
izations should be listed with reason for admission, intervention, and location
of hospital.
7. Past surgical history: Year and type of surgery should be elucidated and any
complications documented. Type of incision (laparoscopy vs laparotomy)
should be recorded.
8. Allergies: Reactions to medications should be recorded, including severity and
temporal relationship to medication. N onmedicine allergies, such as to latex
or iodine, are also important to note. Immediate hypersensitivity should be
distinguished from an adverse reaction.
9. Medications: A list of medications, dosage, route of administration and fre-
quency, and duration of use should be obtained. Prescription, over-the-coun-
ter, and herbal remedies are all relevant. Use or abuse of illicit drugs, tobacco,
or alcohol should also be recorded.
10. Review of systems: A systematic review should be performed but focused on
the more common diseases. For example, in pregnant women, the presence of
symptoms referable to preeclampsia, such as headache, visual disturbances,
epigastric pain, or facial swelling, should be queried. In an elderly woman,
symptoms suggestive of cardiac disease, such as chest pain, shortness of
breath, fatigue, weakness, or palpitations, should be elicited.

CLINICAL PEARL
» In every pregnancy greater than 20 weeks’gestation, the patient should
be questioned about symptoms of preeclampsia (headaches, visual dis-
turbances, dyspnea, epigastric pain, and face/hand swelling).

PHYSICAL EXAMINATION
1. General appearance: Cachectic versus well-nourished, anxious versus calm,
alert versus obtunded.
2. Vital signs: Temperature, blood pressure, heart rate, and respiratory rate.
H eight and weight are often placed here.
3. Head and neck examination: Evidence of trauma, tumors, facial edema, goiter,
and carotid bruits should be sought. Cervical and supraclavicular nodes should
be palpated.
6 CASE FILES: OBSTETRICS AND GYNECOLOGY

4. Breast examination: Inspection for symmetry, skin or nipple retraction with the
patient’s hands on her hips (to accentuate the pectoral muscles), and with arms
raised. With the patient supine, the breasts should then be palpated systemati-
cally to assess for masses. The nipple should be assessed for discharge, and the
axillary and supraclavicular regions should be examined for adenopathy.
5. Cardiac examination: The point of maximal impulse should be ascertained, and
the heart auscultated at the apex of the heart as well as base. H eart sounds,
murmurs, and clicks should be characterized. Systolic flow murmurs are fairly
common in pregnant women due to the increased cardiac output, but signifi-
cant diastolic murmurs are unusual.
6. Pulmonary examination: The lung fields should be examined systematically
and thoroughly. W heezes, rales, rhonchi, and bronchial breath sounds should
be recorded.
7. Abdominal examination: The abdomen should be inspected for scars, dis-
tension, masses or organomegaly (ie, spleen or liver), and discoloration. For
instance, the Grey Turner sign of discoloration at the flank areas may indi-
cate intra abdominal or retroperitoneal hemorrhage. Auscultation of bowel
sounds should be accomplished to identify normal versus high-pitched, and
hyperactive versus hypoactive sounds. The abdomen should be percussed for
the presence of shifting dullness (indicating ascites). Careful palpation should
begin initially away from the area of pain, involving one hand on top of the
other, to assess for masses, tenderness, and peritoneal signs. Tenderness should
be recorded on a scale (eg, 1-4, where 4 is the most severe pain). Guarding,
whether it is voluntary or involuntary, should be noted.
8. Back and spine examination: The back should be assessed for symmetry, ten-
derness, or masses. In particular, the flank regions are important to assess for
pain on percussion because that may indicate renal disease.
9. Pelvic examination (adequate preparation of the patient is crucial, including
counseling about what to expect, adequate lubrication, and sensitivity to pain
and discomfort):
a. The external genitalia should be observed for masses or lesions, discolor-
ation, redness, or tenderness. Ulcers in this area may indicate herpes simplex
virus, vulvar carcinoma, or syphilis; a vulvar mass at the 5:00 or 7:00 o’clock
positions can suggest a Bartholin gland cyst or abscess. Pigmented lesions
may require biopsy because malignant melanoma is not uncommon in the
vulvar region.
b. Speculum examination: The vagina should be inspected for lesions, discharge,
estrogen effect (well-ruggated vs atrophic), and presence of a cystocele or
a rectocele. The appearance of the cervix should be described, and masses,
vesicles, or other lesions should be noted.
c. Bimanual examination: Initially, the index and middle fingers of the one
gloved hand should be inserted into the patient’s vagina underneath the cervix,
while the clinician’s other hand is placed on the abdomen at the uterine
 SECTION I: HOW TO APPROACH CLINICAL PROBLEMS 7

Figure I–1. Bimanual pelvic examination. The examiner evaluates the patient’s uterus by palpating
her cervix vaginally while simultaneously assessing her uterine fundus abdominally.

fundus. With the uterus trapped between the two hands, the examiner
should identify whether there is cervical motion tenderness, and evaluate
the size, shape, and directional axis of the uterus. The adnexa should then
be assessed with the vaginal hand in the lateral vaginal fornices. The normal
ovary is approximately the size of a walnut (Figure I– 1).
NOTE: At the time of this writing, there is debate about the utility or necessity of
the annual internal pelvic examination for low-risk, nonpregnant, asymptomatic
women. While the American College of Physicians states that the internal pelvic
examination is not helpful, the American College of Obstetricians and Gynecolo-
gists states that there is no definitive evidence either way and that the decision
should rest with the patient and her physician.
d. Rectal examination: A rectal examination will reveal masses in the posterior
pelvis, and may identify occult blood in the stool. Nodularity and tender-
ness in the uterosacral ligament can be signs of endometriosis. The poste-
rior uterus and palpable masses in the cul-de-sac can be identified by rectal
examination.
10. Extremities and skin: The presence of joint effusions, tenderness, skin edema,
and cyanosis should be recorded.
Discovering Diverse Content Through
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would be opposed to all that is probable regarding the etymology of
these suffixes, and also to the fact that so many nouns are included
in the sex-denoting classes to which the distinction of sex can only
be applied by a great effort.... If the word for ‘man’ were formed
with one suffix (-p), and the word indicating ‘woman’ (be it
accidentally or not) by another (-s), then other nouns would be
formed with the same suffixes, in analogy with these, until the
majority of the nouns of each sex were formed with certain suffixes
which would thus assume a sex-denoting character” (p. 298).
Brugmann’s view on Aryan gender has not been unchallenged. The
weakest points in his arguments are, of course, that there are so few
old naturally feminine words in -a and -i to take as starting-points for
such a thoroughgoing modification of the grammatical system, and
that Brugmann was unable to give any striking explanation of the
concord of adjectives and pronouns with words that had not these
endings, but which were nevertheless treated as masculines and
feminines respectively. It would lead us too far here to give any
minute account of the discussion which arose on these points;[99]
one of the most valuable contributions seems to me Jacobi’s
suggestion (Compositum u. Nebensatz, 1897, 115 ff.) that the origin
of grammatical gender is not to be sought in the noun, but in the
pronoun (he finds a parallel in the Dravidian languages)—but even
he does not find a fully satisfactory explanation, and the Aryan
gender distinction reaches back to so remote an antiquity, thousands
of years before any literary tradition, that we shall most probably
never be able to fathom all its mysteries. Of late years less attention
has been given to the problem of the feminine, which presented
itself to Brugmann, than to the distinction between two classes, one
of which was characterized by the use of a nominative in -s, which is
now looked upon as a ‘transitive-active’ case, and the other by no
ending or by an ending -m, which is the same as was used as the
accusative in the first class (an ‘intransitive-passive’ case), and an
attempt has been made to see in the distinction something
analogous to the division found in Algonkin languages between a
class of ‘living’ and another of ‘lifeless’ things—though these two
terms are not to be taken in the strictly scientific sense, for primitive
men do not reason in the same way as we do, but ascribe or deny
‘life’ to things according to criteria which we have great difficulty in
apprehending. This would mean a twofold division into one class
comprising the historical masculines and feminines, and another
comprising the neuters.
As to the feminine, we saw two old endings characterizing that
gender, a and i. With regard to the latter, I venture to throw out the
suggestion that it is connected with diminutive suffixes containing
that vowel in various languages: on the whole, the sound [i] has a
natural affinity with the notion of small, slight, insignificant and weak
(see Ch. XX § 8). In some African languages we find two classes,
one comprising men and big things, and the other women and small
things (Meinhof, Die Sprachen der Hamiten 23), and there is nothing
unnatural in the supposition that similar views may have obtained
with our ancestors. This would naturally account for Skr. vṛk-ī ‘she-
wolf’ (orig. little wolf, ‘wolfy’) from Skr. vṛkas, napt-ī, Lat. neptis, G.
nichte, Skr. dēv-ī, ‘goddess,’ etc. But the feminine -a is to me just as
enigmatic as, say, the d of the old ablative.

XIX.—§ 19. Final Considerations.

The ending -a serves to denote not only female beings, but also
abstracts, and if in later usage it is also applied to males, as in Latin
nauta ‘sailor,’ auriga ‘charioteer,’ this is only a derived use of the
abstracts denoting an activity, sailoring, driving, etc., just as G. die
wache, besides the activity of watching, comes to mean the man on
guard, or as justice (Sp. el justicia) comes to mean ‘judge.’ The
original sense of Antonius collega fuit Ciceronis was ‘A. was the co-
election of C.’ (Osthoff, Verbum in d. Nominal-compos., 1878, 263 ff.,
Delbrück, Synt. Forsch. 4. 6).
The same -a is finally used as the plural ending of most neuters, but,
as is now universally admitted (see especially Johannes Schmidt, Die
Pluralbildungen der indogerm. Neutra, 1889), the ending here was
originally neither neuter nor plural, but, on the contrary, feminine
and singular. The forms in -a are properly collective formations like
those found, for instance, in Lat. opera, gen. operæ, ‘work,’ comp.
opus ‘(a piece of) work’; Lat. terra ‘earth,’ comp. Oscan terum ‘plot
of ground’; pugna ‘boxing, fight,’ comp. pugnus ‘fist.’ This explains
among other things the peculiar syntactic phenomenon, which is
found regularly in Greek and sporadically in Sanskrit and other
languages, that a neuter plural subject takes the verb in the singular.
Greek toxa is often used in speaking of a single bow; and the Latin
poetic use of guttura, colla, ora, where only one person’s throat,
neck or face is meant, points similarly to a period of the past when
these words did not denote the plural. We can now see the reason
of this -a being in some cases also the plural sign of masculine
substantives: Lat. loca from locus, joca from jocus, etc.; Gr. sita from
sitos. Joh. Schmidt refers to similar plural formations in Arabic; and
as we have seen (Ch. XIX § 9), the Bantu plural prefixes had
probably a similar origin. And we are thus constantly reminded that
languages must often make the most curious détours to arrive at a
grammatical expression for things which appear to us so self-evident
as the difference between he and she, or that between one and
more than one. Expressive simplicity in linguistic structure is not a
primitive, but a derived quality.
 CHAPTER XX
SOUND SYMBOLISM
§ 1. Sound and Sense. § 2. Instinctive Feeling. § 3. Direct
Imitation. § 4. Originator of the Sound. § 5. Movement. §
6. Things and Appearances. § 7. States of Mind. § 8. Size
and Distance. § 9. Length and Strength of Words and
Sounds. § 10. General Considerations. § 11. Importance of
Suggestiveness. § 12. Ancient and Modern Times.

XX.—§ 1. Sound and Sense.

The idea that there is a natural correspondence between sound and

sense, and that words acquire their contents and value through a
certain sound symbolism, has at all times been a favourite one with
linguistic dilettanti, the best-known examples being found in Plato’s
Kratylos. Greek and Latin grammarians indulge in the wildest
hypotheses to explain the natural origin of such and such a word, as
when Nigidius Figulus said that in pronouncing vos one puts forward
one’s lips and sends out breath in the direction of the other person,
while this is not the case with nos. With these early writers, to make
guesses at sound symbolism was the only way to etymologize; no
wonder, therefore, that we with our historical methods and our wider
range of knowledge find most of their explanations ridiculous and
absurd. But this does not justify us in rejecting any idea of sound
symbolism: abusus non tollit usum!
Humboldt (Versch 79) says that “language chooses to designate
objects by sounds which partly in themselves, partly in comparison
with others, produce on the ear an impression resembling the effect
of the object on the mind; thus stehen, stätig, starr, the impression
of firmness, Sanskrit lī ‘to melt, diverge,’ that of liquidity or solution
(des zerfliessenden).... In this way objects that produce similar
impressions are denoted by words with essentially the same sounds,
thus wehen, wind, wolke, wirren, wunsch, in all of which the
vacillating, wavering motion with its confused impression on the
senses is expressed through ... w.” Madvig’s objection (1842, 13 = Kl
64) that we need only compare four of the words Humboldt quotes
with the corresponding words in the very nearest sister-language,
Danish blæse, vind, sky, ønske, to see how wrong this is, seems to
me a little cheap: Humboldt himself expressly assumes that much of
primitive sound symbolism may have disappeared in course of time
and warns us against making this kind of explanation a ‘constitutive
principle,’ which would lead to great dangers (“so setzt man sich
grossen gefahren aus und verfolgt einen in jeder rücksicht
schlüpfrigen pfad”). Moreover blæse (E. blow, Lat. flare) is just as
imitative as wind, vind: no one of course would pretend that there
was only one way of expressing the same sense perception. Among
Humboldt’s examples wolke and wunsch are doubtful, but I do not
see that this affects the general truth of his contention that there is
something like sound symbolism in some words.
Nyrop in his treatment of this question (Gr IV § 545 f.) repeats
Madvig’s objection that the same name can denote various objects,
that the same object can be called by different names, and that the
significations of words are constantly changing; further, that the
same group of sounds comes to mean different things according to
the language in which it occurs. He finally exclaims: “How to explain
[by means of sound symbolism] the difference in signification
between murus, nurus, durus, purus, etc.?”

XX.—§ 2. Instinctive Feeling.

Yes, of course it would be absurd to maintain that all words at all

times in all languages had a signification corresponding exactly to
their sounds, each sound having a definite meaning once for all. But
is there really much more logic in the opposite extreme, which
denies any kind of sound symbolism[100] (apart from the small class
of evident echoisms or ‘onomatopœia’) and sees in our words only a
collection of wholly accidental and irrational associations of sound
and meaning? It seems to me that the conclusion in this case is as
false as if you were to infer that because on one occasion X told a
lie, he therefore never tells the truth. The correct conclusion would
be: as he has told a lie once, we cannot always trust him; we must
be on our guard with him—but sometimes he may tell the truth.
Thus, also, sounds may in some cases be symbolic of their sense,
even if they are not so in all words. If linguistic historians are averse
to admitting sound symbolism, this is a natural consequence of their
being chiefly occupied with words which have undergone regular
changes in sound and sense; and most of the words which form the
staple of linguistic books are outside the domain of sound
symbolism.
There is no denying, however, that there are words which we feel
instinctively to be adequate to express the ideas they stand for, and
others the sounds of which are felt to be more or less incongruous
with their signification. Future linguists will have to find out in detail
what domains of human thought admit, and what domains do not
admit, of congruous expression through speech sounds, and further
what sounds are suitable to express such and such a notion, for
though it is clear—to take only a few examples—that there is little to
choose between apple and pomme, or between window and fenster,
as there is no sound or sound group that has any natural affinity
with such thoroughly concrete and composite ideas as those
expressed by these words, yet on the other hand everybody must
feel that the word roll, rouler, rulle, rollen is more adequate than the
corresponding Russian word katat’, katit’.
It would be an interesting task to examine in detail and
systematically what ideas lend themselves to symbolic presentation
and what sounds are chosen for them in different languages. That,
however, could only be done on the basis of many more examples
than I can find space for in this work, and I shall, therefore, only
attempt to give a preliminary enumeration of the most obvious
classes, with a small fraction of the examples I have collected.[101]

XX.—§ 3. Direct Imitation.

The simplest case is the direct imitation of the sound, thus clink,
clank, ting, tinkle of various metallic sounds, splash, bubble, sizz,
sizzle of sounds produced by water, bow-wow, bleat, roar of sounds
produced by animals, and snort, sneeze, snigger, smack, whisper,
grunt, grumble of sounds produced by human beings. Examples
might easily be multiplied of such ‘echoisms’ or ‘onomatopœia’
proper. But, as our speech-organs are not capable of giving a perfect
imitation of all ‘unarticulated’ sounds, the choice of speech-sounds is
to a certain extent accidental, and different nations have chosen
different combinations, more or less conventionalized, for the same
sounds; thus cock-a-doodle-doo, Dan. kykeliky, Sw. kukeliku, G.
kikeriki, Fr. coquelico, for the sound of a cock; and for whisper: Dan.
hviske, ON. kvisa, G. flüstern, Fr. chuchoter, Sp. susurar. The
continuity of a sound is frequently indicated by l or r after a stopped
consonant: rattle, rumble, jingle, clatter, chatter, jabber, etc.

XX.—§ 4. Originator of the Sound.

Next, the echoic word designates the being that produces the sound,
thus the birds cuckoo and peeweet (Dan. vibe, G. kibitz, Fr. pop. dix-
huit).
A special subdivision of particular interest comprises those names, or
nicknames, which are sometimes popularly given to nations from
words continually occurring in their speech. Thus the French used to
call an Englishman a god-damn (godon), and in China an English
soldier is called a-says or I-says. In Java a Frenchman is called
orang-deedong (orang ‘man’), in America ding-dong, and during the
Napoleonic wars the French were called in Spain didones, from dis-
donc; another name for the same nation is wi-wi (Australia), man-a-
wiwi (in Beach-la-mar), or oui-men (New Caledonia). In Eleonore
Christine’s Jammersminde 83 I read, “Ich habe zwei parle mi franço
gefangen,” and correspondingly Goldsmith writes (Globe ed. 624):
“Damn the French, the parle vous, and all that belongs to them.
What makes the bread rising? the parle vous that devour us.” In
Rovigno the surrounding Slavs are called čuje from their exclamation
čuje ‘listen, I say,’ and in Hungary German visitors are called vigéc
(from wie geht’s?), and customs officers vartapiszli (from wart’ a
bissl). Round Panama everything native is called spiggoty, because
in the early days the Panamanians, when addressed, used to reply,
“No spiggoty [speak] Inglis.” In Yokohama an English or American
sailor is called Damuraïsu H’to from ‘Damn your eyes’ and Japanese
H’to ‘people.’[102]

XX.—§ 5. Movement.

Thirdly, as sound is always produced by some movement and is

nothing but the impression which that movement makes on the ear,
it is quite natural that the movement itself may be expressed by the
word for its sound: the two are, in fact, inseparable. Note, for
instance, such verbs as bubble, splash, clash, crack, peck. Human
actions may therefore be denoted by such words as to bang the
door, or (with slighter sounds) to tap or rap at a door. Hence also the
substantives a tap or a rap for the action, but the substantive may
also come to stand for the implement, as when from the verb to
hack, ‘to cut, chop off, break up hard earth,’ we have the noun hack,
‘a mattock or large pick.’
Then we have words expressive of such movements as are not to
the same extent characterized by loud sounds; thus a great many
words beginning with l-combinations, fl-: flow, flag (Dan. flagre),
flake, flutter, flicker, fling, flit, flurry, flirt; sl-: slide, slip, slive; gl-:
glide. Hence adjectives like fleet, slippery, glib. Sound and sight may
have been originally combined in such expressions for an uncertain
walk as totter, dodder, dialectical teeter, titter, dither, but in cases of
this kind the audible element may be wanting, and the word may
come to be felt as symbolic of the movement as such. This is also
the case with many expressions for the sudden, rapid movement by
which we take hold of something; as a short vowel, suddenly
interrupted by a stopped consonant, serves to express the sound
produced by a very rapid striking movement (pat, tap, knock, etc.),
similar sound combinations occur frequently for the more or less
noiseless seizing of a thing (with the teeth or with the hand): snap,
snack, snatch, catch, Fr. happer, attraper, gripper, E. grip, Dan.
hapse, nappe, Lat. capio, Gr. kaptō, Armenian kap ‘I seize,’ Turk
kapmak (mak infin. ending), etc. (I shall only mention one derivative
meaning that may develop from this group: E. snack ‘a hurried
meal,’ in Swift’s time called a snap (Journ. to Stella 270); cf. G.
schnapps, Dan. snaps ‘glass of spirits.’) E. chase and catch are both
derived from two dialectically different French forms, ultimately
going back to the same late Latin verb captiare, but it is no mere
accident that it was the form ‘catch’ that acquired the meaning ‘to
seize,’ not found in French, for it naturally associated itself with
snatch, and especially with the now obsolete verb latch ‘to seize.’
There is also a natural connexion between action and sound in the
word to tickle, G. kitzeln, ON. kitla, Dan. kilde (d mute), Nubian killi-
killi, and similar forms (Schuchardt, Nubisch. u. Bask. 9), Lat.
titillare; cp. also the word for the kind of laughter thus produced:
titter, G. kichern.

XX.—§ 6. Things and Appearances.

Further, we have the extension of symbolical designation to things;

here, too, there is some more or less obvious association of what is
only visible with some sound or sounds. This has been specially
studied by Hilmer, to whose book (Sch) the reader is referred for
numerous examples, e.g. p. 237 ff., knap ‘a thick stick, a knot of
wood, a bit of food, a protuberance, a small hill;’ knop ‘a boss, stud,
button, knob, a wart, pimple, the bud of a flower, a promontory,’
with the variants knob, knup.... Hilmer’s word-lists from German and
English comprise 170 pages!
There is also a natural association between high tones (sounds with
very rapid vibrations) and light, and inversely between low tones and
darkness, as is seen in the frequent use of adjectives like ‘light’ and
‘dark’ in speaking of notes. Hence the vowel [i] is felt to be more
appropriate for light, and [u] for dark, as seen most clearly in the
contrast between gleam, glimmer, glitter on the one hand and gloom
on the other (Zangwill somewhere writes: “The gloom of night,
relieved only by the gleam from the street-lamp”); the word light
itself, which has now a diphthong which is not so adequate to the
meaning, used to have the vowel [i] like G. licht; for the opposite
notions we have such words as G. dunkel, Dan. mulm, Gr. amolgós,
skótos, Lat. obscurus, and with another ‘dark’ vowel E. murky, Dan.
mörk.

XX.—§ 7. States of Mind.

From this it is no far cry to words for corresponding states of mind:

to some extent the very same words are used, as gloom (Dowden
writes: “The good news was needed to cast a gleam on the gloom
that encompassed Shelley”); hence also glum, glumpy, glumpish,
grumpy, the dumps, sulky. If E. moody and sullen have changed
their significations (OE. modig ‘high-spirited,’ ME. solein ‘solitary’),
sound symbolism, if I am not mistaken, counts for something in the
change; the adjectives now mean exactly the same as Dan. mut,
but.
If grumble comes to mean the expression of a mental state of
dissatisfaction, the connexion between the sound of the word and its
sense is even more direct, for the verb is imitative of the sound
produced in such moods, cf. mumble and grunt, gruntle. The name
of Mrs. Grundy is not badly chosen as a representative of narrow-
minded conventional morality.
A long list might be given of symbolic expressions for dislike, disgust,
or scorn; here a few hints only can find place. First we have the
same dull or dump (back) vowels as in the last paragraph: blunder,
bungle, bung, clumsy, humdrum, humbug, strum, slum, slush,
slubber, sloven, muck, mud, muddle, mug (various words, but all full
of contempt), juggins (a silly person), numskull (old numps, nup,
nupson), dunderhead, gull, scug (at Eton a dirty or untidy boy)....
Many words begin with sl- (we have already seen some): slight,
slim, slack, sly, sloppy, slipslop, slubby, slattern, slut, slosh.... Initial
labials are also frequent.[103] After the vowel we have very often the
sound [ʃ] or [tʃ], as in trash, tosh, slosh, botch, patch; cf. also G.
kitsch (bad picture, smearing), patsch(e) (mire, anything worthless),
quatsch (silly nonsense), putsch (riot, political coup de main). E.
bosh (nonsense) is said to be a Turkish loan-word; it has become
popular for the same reason for which the French nickname boche
for a German was widely used during the World War. Let me finally
mention the It. derivative suffix -accio, as in poveraccio (miserable),
acquaccia (bad water), and -uccio, as in cavalluccio (vile horse).

XX.—§ 8. Size and Distance.

The vowel [i], especially in its narrow or thin variety, is particularly

appropriate to express what is small, weak, insignificant, or, on the
other hand, refined or dainty. It is found in a great many adjectives
in various languages, e.g. little, petit, piccolo, piccino, Magy. kis, E.
wee, tiny (by children often pronounced teeny [ti·ni]), slim, Lat.
minor, minimus, Gr. mikros; further, in numerous words for small
children or small animals (the latter frequently used as endearing or
depreciative words for children), e.g. child (formerly with [i·] sound),
G. kind, Dan. pilt, E. kid, chit, imp, slip, pigmy, midge, Sp. chico, or
for small things: bit, chip, whit, Lat. quisquiliæ, mica, E. tip, pin,
chink, slit.... The same vowel is found in diminutive suffixes in a
variety of languages, as E. -y, -ie (Bobby, baby, auntie, birdie), Du. -
ie, -je (koppie ‘little hill’), Gr. -i- (paid-i-on ‘little boy’), Goth. -ein,
pronounced [i·n] (gumein ‘little man’), E. -kin, -ling, Swiss German -
li, It. -ino, Sp. -ico, -ito, -illo....
As smallness and weakness are often taken to be characteristic of
the female sex, I suspect that the Aryan feminine suffix -i, as in Skr.
vṛkī ‘she-wolf,’ naptī ‘niece,’ originally denotes smallness (‘wolfy’),
and in the same way we find the vowel i in many feminine suffixes;
thus late Lat. -itta (Julitta, etc., whence Fr. -ette, Henriette, etc.), -
ina (Carolina), further G. -in (königin), Gr. -issa (basilissa ‘queen’),
whence Fr. -esse, E. -ess.
The same vowel [i] is also symbolical of a very short time, as in the
phrases in a jiff, jiffy, Sc. in a clink, Dan. i en svip; and
correspondingly we have adjectives like quick, swift, vivid and
others. No wonder, then, that the Germans feel their word for
‘lightning,’ blitz, singularly appropriate to the effect of light and to
the shortness of duration.[104]
It has often been remarked[105] that in corresponding pronouns and
adverbs the vowel i frequently indicates what is nearer, and other
vowels, especially a or u, what is farther off; thus Fr. ci, là, E. here,
there, G. dies, das, Low G. dit, dat, Magy. ez, emez ‘this,’ az, amaz
‘that,’ itt ‘here,’ ott ‘there,’ Malay iki ‘this,’ ika ‘that, a little removed,’
iku ‘yon, farther away.’ In Hamitic languages i symbolizes the near
and u what is far away. We may here also think of the word zigzag
as denoting movement in alternate turns here and there; and if in
the two E. pronouns this and that the old neuter forms have
prevailed (OE. m. þes, se, f. þeos, seo, n. þis, þæt) the reason (or
one of the reasons) may have been that a characteristic difference of
vowels in the two contrasted pronouns was thus secured.

XX.—§ 9. Length and Strength of Words and Sounds.

Shorter and more abrupt forms are more appropriate to certain

states of mind, longer ones to others. An imperative may be used
both for command and for a more or less humble appeal or entreaty;
in Magyar dialects there are short forms for command: írj, dolgozz;
long for entreaty: írjál, dolgozzál (Simonyi US 359, 214). Were Lat.
dic, duc, fac, fer used more than other imperatives in commands?
The fact that they alone lost -e might indicate that this was so. On
the other hand the imperatives es, este and i had to yield to the
fuller (and more polite) esto, estote, vade, and scito is always said
instead of sci (Wackernagel, Gött. Ges. d. Wiss., 1906, 182, on the
avoidance of too short forms in general). Other languages, which
have only one form for the imperative, soften the commanding tone
by adding some word like please, bitte.
An emotional effect is obtained in some cases by lengthening a word
by some derivative syllables, in themselves unmeaning; thus in
Danish words for ‘lengthy’ or ‘tiresome’: langsommelig,
kedsommelig, evindelig for lang(som), kedelig, evig. (Cf. Ibsen, Når
vi døde vågner 98: Du er kanske ble’t ked af dette evige samliv med
mig.—Evige? Sig lige så godt: evindelige.) In the same way the
effect of splendid is strengthened in slang: splendiferous,
splendidous, splendidious, splendacious. A long word like aggravate
is felt to be more intense than vex (Coleman)—and that may be the
reason why the long word acquires a meaning that is strange to its
etymology. And “to disburden one’s self of a sense of contempt, a
robust full-bodied detonation, like, for instance, platitudinous, is,
unquestionably, very much more serviceable than any evanescing
squib of one or two syllables” (Fitzedward Hall). Cf. also
multitudinous, multifarious.
We see now the emotional value of some ‘mouth-filling’ words, some
of which may be considered symbolical expansions of existing words
(what H. Schröder terms ‘streckformen’), though others cannot be
thus explained; not unfrequently the effect of length is combined
with some of the phonetic effects mentioned above. Such words are,
e.g., slubberdegullion ‘dirty fellow,’ rumbustious ‘boisterous,’
rumgumption, rumfustian, rumbullion (cf. rumpuncheon ‘cask of rum’
as a term of abuse in Stevenson, Treas. Isl. 48, “the cowardly son of
a rum-puncheon”), rampallion ‘villain,’ rapscallion, ragamuffin;
sculduddery ‘obscenity’; cantankerous ‘quarrelsome,’ U.S. also
rantankerous (cf. cankerous, rancorous); skilligalee ‘miserable gruel,’
flabbergast ‘confound,’ catawampous (or -ptious) ‘fierce’ (“a high-
sounding word with no very definite meaning,” NED); Fr. hurluberlu
‘crazy’ and the synonymous Dan. tummelumsk, Norw. tullerusk.
In this connexion one may mention the natural tendency to lengthen
and to strengthen single sounds under the influence of strong
feeling and in order to intensify the effect of the spoken word; thus,
in ‘it’s very cold’ both the diphthong [ou] and the [l] may be
pronounced extremely long, in ‘terribly dull’ the [l] is lengthened, in
‘extremely long’ either the vowel [ɔ] or the [ŋ] (or both) may be
lengthened. In Fr. ‘c’était horrible’ the trill of the [r] becomes very
long and intense (while the same effect is not generally possible in
the corresponding English word, because the English [r] is not
trilled, but pronounced by one flap of the tip). In some cases a
lengthening due to such a psychological cause may permanently
alter a word, as when Lat. totus in It. has become tutto (Fr. tout,
toute goes back to the same form, while Sp. todo has preserved the
form corresponding to the Lat. single consonant). An interesting
collection of such cases from the Romanic tongues has been
published by A. J. Carnoy (Mod. Philol. 15. 31, July 1917), who justly
emphasizes the symbolic value of the change and the special
character of the words in which it occurs (pet-names, children’s
words, ironic or derisive words, imitative words ...). He says: “While
to a phonetician the phenomenon would seem capricious, its
apportionment in the vocabulary is quite natural to a psychologist. In
fact, reduplication, be it of syllables or of consonants, generally has
that character in languages. One finds it in perfective tenses, in
intensive or frequentative verbs, in the plural, and in collectives. In
most cases it is a reduplication of syllables, but a lengthening of
vowels is not rare and the reinforcement of consonants is also found.
In Chinook, for instance, the emotional words, both diminutive and
augmentative, are expressed by increasing the stress of consonants.
It is, of course, also well known that in Semitic the intensive radical
of verbs is regularly formed by a reduplication of consonants. To a
stem qatal, e.g., answers an intensive: Eth. qattala, Hebr. qittel. Cf.
Hebr. shibbar ‘to cut in small pieces’ [cf. below], hillech ‘to walk,’
qibber ‘to bury many,’ etc. Cf. Brockelmann, Vergl. Gramm., p. 244.”
I add a few more examples from Misteli (428 f.) of this Semitic
strengthening: the first vowel is lengthened to express a tendency or
an attempt: qatala jaqtulu ‘kill’ (in the third person masc., the former
in the prefect-aorist, the latter in the imperfect-durative, where ja, ju
is the sign of the third person m.), qātala juqātilu ‘try to kill, fight’;
faXara jufXaru ‘excel in fame,’ fāXara jufāXiru ‘try to excel, vie.’
Through lengthening (doubling) of a consonant an intensification of
the action is denoted: Hebr. šāβar jišbōr ‘zerbrechen,’ šibbēr
jẹšabbēr ‘zerschmettern,’ Arab. ḍaraba jaḍrubu ‘strike,’ ḍarraba
juḍarribu ‘beat violently, or repeatedly’; sometimes the change
makes a verb into a causative or transitive, etc.
I imagine that we have exactly the same kind of strengthening for
psychological (symbolical) reasons in a number of verbs where
Danish has pp, tt, kk by the side of b, d, g (spirantic): pippe pibe,
stritte stride, snitte snide, skøtte skøde, splitte splide, skrikke skrige,
lukke luge, hikke hige, sikke sige, kikke kige, prikke prige (cf. also
sprække sprænge). Some of these forms are obsolete, others
dialectal, but it would take us too far in this place to deal with the
words in detail. It is customary to ascribe this gemination to an old n
derivative (see, e.g., Brugmann VG 1. 390, Streitberg Urg pp. 135,
138, Noreen UL 154), but it does not seem necessary to conjure up
an n from the dead to make it disappear again immediately, as the
mere strengthening of the consonant itself to express symbolically
the strengthening of the action has nothing unnatural in it. Cf. also
G. placken by the side of plagen. The opposite change, a weakening,
may have taken place in E. flag (cf. OFr. flaquir, to become flaccid),
flabby, earlier flappy, drib from drip, slab, if from OFr. esclape, clod
by the side of clot, and possibly cadge, bodge, grudge, smudge,
which had all of them originally -tch. But the common modification
in sense is not so easily perceived here as in the cases of
strengthening.
I may here, for the curiosity of the thing, mention that in a
‘language’ coined by two English children (a vocabulary of which was
communicated to me by one of the inventors through Miss I. C.
Ward, of the Department of Phonetics, University College, London)
there was a word bal which meant ‘place,’ but the bigger the place
the longer the vowel was made, so that with three different
quantities it meant ‘village,’ ‘town’ and ‘city’ respectively. The word
for ‘go’ was dudu, “the greater the speed of the going, the more
quickly the word was said—[dœ·dœ·] walk slowly.” Cf. Humboldt, ed.
Steinthal 82: “In the southern dialect of the Guarani language the
suffix of the perfect yma is pronounced more or less slowly
according to the more or less remoteness of the past to be
indicated.”

XX.—§ 10. General Considerations.

Sound symbolism, as we have considered it in this chapter, has a

very wide range of application, from direct imitation of perceived
natural sounds to such small quantitative changes of existing non-
symbolic words as may be used for purely grammatical purposes.
But in order to obtain a true valuation of this factor in the life of
language it is of importance to keep in view the following
considerations:
(1) No language utilizes sound symbolism to its full extent, but
contains numerous words that are indifferent to or may even jar with
symbolism. To express smallness the vowel [i] is most adequate, but
it would be absurd to say that that vowel always implies smallness,
or that smallness is always expressed by words containing that
vowel: it is enough to mention the words big and small, or to point
to the fact that thick and thin have the same vowel, to repudiate
such a notion.
(2) Words that have been symbolically expressive may cease to be
so in consequence of historical development, either phonetic or
semantic or both. Thus the name of the bird crow is not now so
good an imitation of the sound made by the bird as OE. crawe was
(Dan. krage, Du. kraai). Thus, also, the verbs whine, pipe were
better imitations when the vowel was still [i·] (as in Dan. hvine,
pibe). But to express the sound of a small bird the latter word is still
pronounced with the vowel [i] either long or short (peep, pip), the
word having been constantly renewed and as it were reshaped by
fresh imitation; cf. on Irish wheen and dialectal peep, XV § 8. Lat.
pipio originally meant any ‘peeping bird,’ but when it came to
designate one particular kind of birds, it was free to follow the usual
trend of phonetic development, and so has become Fr. pigeon [piʒɔ̃],
E. pigeon [pidʒin]. E. cuckoo has resisted the change from [u] to ʌ
as in cut, because people have constantly heard the sound and
fashioned the name of the bird from it. I once heard a Scotch lady
say [kʌku·], but on my inquiry she told me that there were no
cuckoos in her native place; hence the word had there been treated
as any other word containing the short [u]. The same word is
interesting in another way; it has resisted the old Gothonic
consonant-shift, and thus has the same consonants as Skt. kōkiláḥ,
Gr. kókkux, Lat. cuculus. On the general preservation of significative
sounds, cf. Ch. XV § 8.
(3) On the other hand, some words have in course of time become
more expressive than they were at first; we have something that
may be called secondary echoism or secondary symbolism. The verb
patter comes from pater (= paternoster), and at first meant to
repeat that prayer, to mumble one’s prayers; but then it was
associated with the homophonous verb patter ‘to make a rapid
succession of pats’ and came under the influence of echoic words
like prattle, chatter, jabber; it now, like these, means ‘to talk rapidly
or glibly’ and is to all intents a truly symbolical word; cf. also the
substantive patter ‘secret lingo, speechifying, talk.’ Husky may at first
have meant only “full of husks, of the nature of a husk” (NED), but it
could not possibly from that signification have arrived at the now
current sense ‘dry in the throat, hoarse’ if it had not been that the
sound of the adjective had reminded one of the sound of a hoarse
voice. Dan. pöjt ‘poor drink, vile stuff’ is now felt as expressive of
contempt, but it originates in Poitou, an innocent geographical name
of a kind of wine, like Bordeaux; it is now connected with other
scornful words like spröjt and döjt.
In E. little the symbolic vowel i is regularly developed from OE. y,
lytel, whose y is a mutated u, as seen in OSax. luttil; u also appears
in other related languages, and the word thus originally had nothing
symbolical about it. But in Gothic the word is leitils (ei, sounded [i·])
and in ON. lítinn, and here the vowel is so difficult to account for on
ordinary principles that the NED in despair thinks that the two words
are “radically unconnected.” I have no hesitation in supposing that
the vowel i is due to sound symbolism, exactly as the smaller change
introduced in modern E. ‘leetle,’ with narrow instead of wide (broad)
[i]. In the word for the opposite meaning, much, the phonetic
development may also have been influenced by the tendency to get
an adequate vowel, for normally we should expect the vowel [i] as in
Sc. mickle, from OE. micel. In E. quick the vowel best adapted to the
idea has prevailed instead of the one found in the old nom. forms
cwucu, cucu from cwicu (inflected cwicne, cwices, etc.), while in the
word widu, wudu, which is phonetically analogous, there was no
such inducement, and the vowel [u] has been preserved: wood. The
same prevalence of the symbolic i is noticed in the Dan. adj. kvik,
MLG. quik, while the same word as subst. has become Dan. kvæg,
MLG. quek, where there was no symbolism at work, as it has come
to mean ‘cattle.’ I even see symbolism in the preservation of the k in
the Dan. adj. (as against the fricative in kvæg), because the notion
of ‘quick’ is best expressed by the short [i], interrupted by a stop;
and may not the same force have been at work in this adjective at
an earlier period? The second k in OE. cwicu, ON. kvikr as against
Goth. qius, Lat. vivus, has not been sufficiently explained. An [i],
symbolic of smallness, has been introduced in some comparatively
recent E. words: tip from top, trip ‘small flock’ from troop, sip ‘drink
in small quantities’ from sup, sop.
Through changes in meaning, too, some words have become
symbolically more expressive than they were formerly; thus the
agreement between sound and sense is of late growth in miniature,
which now, on account of the i, has come to mean ‘a small picture,’
while at first it meant ‘image painted with minium or vermilion,’ and
in pittance, now ‘a scanty allowance,’ formerly any pious donation,
whether great or small. Cf. what has been said above of sullen,
moody, catch.

XX.—§ 11. Importance of Suggestiveness.

The suggestiveness of some words as felt by present-day speakers is

a fact that must be taken into account if we are to understand the
realities of language. In some cases it may have existed from the
very first: these words sprang thus into being because that shape at
once expressed the idea the speaker wished to communicate. In
other cases the suggestive element is not original: these words
arose in the same way as innumerable others whose sound has
never carried any suggestion. But if the sound of a word of this class
was, or came to be, in some way suggestive of its signification—say,
if a word containing the vowel [i] in a prominent place meant ‘small’
or something small—then the sound exerted a strong influence in
gaining popular favour to the word; it was an inducement to people
to choose and to prefer that particular word and to cease to use
words for the same notion that were not thus favoured. Sound
symbolism, we may say, makes some words more fit to survive and
gives them considerable help in their struggle for existence. If we
want to denote a little child by a word for some small animal, we
take some word like kid, chick, kitten, rather than bat or pug or slug,
though these may in themselves be smaller than the animal chosen.
It is quite true that Fr. rouler, our roll, is derived from Lat. rota
‘wheel’ + a diminutive ending -ul-, but the word would never have
gained its immense popularity, extending as it does through English,
Dutch, German and the Scandinavian languages, if the sound had
not been eminently suggestive of the sense, so suggestive that it
seems to us now the natural expression for that idea, and we have
difficulty in realizing that the word has not existed from the very
dawn of speech. Or let me take another example, in which the
connexion between sound and sense is even more ‘fortuitous.’ About
a hundred years ago a member of Congress, Felix Walker, from
Buncombe County, North Carolina, made a long and tedious speech.
“Many members left the hall. Very naïvely he told those who
remained that they might go too; he should speak for some time,
but ‘he was only talking for Buncombe,’ to please his constituents.”
Now buncombe (buncome, bunkum) has become a widely used
word, not only in the States, but all over the English-speaking world,
for political speaking or action not resting on conviction, but on the
desire of gaining the favour of electors, or for any kind of empty
‘clap-trap’ oratory; but does anybody suppose that the name of Mr.
Walker’s constituency would have been thus used if he had
happened to hail from Annapolis or Philadelphia, or some other place
with a name incapable of tickling the popular fancy in the same way
as Buncombe does? (Cf. above, p. 401 on the suggestiveness of the
short u.) In a similar way hullaballoo seems to have originated from
the Irish village Ballyhooly (see P. W. Joyce, English as we speak it in
Ireland) and to have become popular on account of its suggestive
sound.
In loan-words we can often see that they have been adopted less on
account of any cultural necessity (see above, p. 209) than because
their sound was in some way or other suggestive. Thus the Algonkin
(Natick) word for ‘chief,’ mugquomp, is used in the United States in
the form of mugwump for a ‘great man’ or ‘boss,’ and especially, in
political life, for a man independent of parties and thinking himself
superior to parties. Now, no one would have thought of going to an
Indian language to express such a notion, had not an Indian word
presented itself which from its uncouth sound lent itself to purposes
of ridicule. Among other words whose adoption has been favoured
by their sounds I may mention jungle (from Hindi jangal, associated
more or less closely with jumble, tumble, bundle, bungle); bobbery,
in slang ‘noise, squabble,’ “the Anglo-Indian colloquial representation
of a common exclamation of Hindus when in surprise or grief—Bap-
rē! or Bap-rē Bap ‘O Father!’” (Hobson-Jobson); amuck; and U.S.
bunco ‘swindling game, to swindle,’ from It. banco.

XX.—§ 12. Ancient and Modern Times.

It will be seen that our conception of echoism and related

phenomena does not carry us back to an imaginary primitive period:
these forces are vital in languages as we observe them day by day.
Linguistic writers, however, often assume that sound symbolism, if
existing at all, must date back to the earliest times, and therefore
can have no reality nowadays. Thus Benfey (Gesch 288) turns upon
de Brosse, who had found rudeness in Fr. rude and gentleness in Fr.
doux, and says: “As if the sounds of such words, which are distant
by an infinite length of time from the time when language
originated, were able to contribute ever so little to explain the
original designation of things.” (But Benfey is right in saying that the
impression made by those two French words may be imaginary; as
examples they are not particularly well chosen.) Sütterlin (WW 14)
says: “It is bold to search for such correspondence as still existing in
detail in the language of our own days. For words like liebe, süss on
the one hand, and zorn, hass, hart on the other, which are often
alleged by dilettanti, prove nothing to the scholar, because their form
is young and must have had totally different sounds in the period
when language was created.”
Similarly de Saussure (LG 104) gives as one of the main principles of
our science that the tie between sound and sense is arbitrary or
rather motiveless (immotivé), and to those who would object that
onomatopoetic words are not arbitrary he says that “they are never
organic elements of a linguistic system. Besides, they are much less
numerous than is generally supposed. Such words as Fr. fouet and
glas may strike some ears with a suggestive ring;[106] but they have
not had that character from the start, as is sufficiently proved if we
go back to their Latin forms (fouet derived from fagus ‘beech,’ glas =
classicum); the quality possessed by, or rather attributed to, their
actual sounds is a fortuitous result of phonetic development.”
Here we see one of the characteristics of modern linguistic science:
it is so preoccupied with etymology, with the origin of words, that it
pays much more attention to what words have come from than to
what they have come to be. If a word has not always been
suggestive on account of its sound, then its actual suggestiveness is
left out of account and may even be declared to be merely fanciful. I
hope that this chapter contains throughout what is psychologically a
more true and linguistically a more fruitful view.
Though some echo words may be very old, the great majority are
not; at any rate, in looking up the earliest ascertained date of a
goodly number of such words in the NED, I have been struck by the
fact of so many of them being quite recent, not more than a few
centuries old, and some not even that. To some extent their recent
appearance in writing may be ascribed to the general character of
the old literature as contrasted with our modern literature, which is
less conventional, freer in many ways, more true to life with its
infinite variety and more true, too, to the spoken language of every
day. But that cannot account for everything, and there is every
probability that this class of words is really more frequent in the
spoken language of recent times than it was formerly, because
people speak in a more vivid and fresh fashion than their ancestors
of hundreds or thousands of years ago. The time of psychological
reaction is shorter than it used to be, life moves at a more rapid
rate, and people are less tied down to tradition than in former ages,
consequently they are more apt to create and to adopt new words of
this particular type, which are felt at once to be significant and
expressive. In all languages the creation and use of echoic and
symbolic words seems to have been on the increase in historical
times. If to this we add the selective process through which words
which have only secondarily acquired symbolical value survive at the
cost of less adequate expressions, or less adequate forms of the
same words, and subsequently give rise to a host of derivatives,
then we may say that languages in course of time grow richer and
richer in symbolic words. So far from believing in a golden primitive
age, in which everything in language was expressive and
immediately intelligible on account of the significative value of each
group of sounds, we arrive rather, here as in other domains, at the
conception of a slow progressive development towards a greater
number of easy and adequate expressions—expressions in which
sound and sense are united in a marriage-union closer than was
ever known to our remote ancestors.
 CHAPTER XXI
THE ORIGIN OF SPEECH
§ 1. Introduction. § 2. Former Theories. § 3. Method. § 4.
Sounds. § 5. Grammar. § 6. Units. § 7. Irregularities. § 8.
Savage Tribes. § 9. Law of Development. § 10.
Vocabulary. § 11. Poetry and Prose. § 12. Emotional
Songs. § 13. Primitive Singing. § 14. Approach to
Language. § 15. The Earliest Sentences. § 16. Conclusion.

XXI.—§ 1. Introduction.

Much of what is contained in the last chapters is preparatory to the

theme which is to occupy us in this chapter, the ultimate origin of
human speech. We have already seen the feeling with which this
subject has often been regarded by eminent linguists, the feeling
which led to an absolute taboo of the question in the French Société
de linguistique (p. 96). One may here quote Whitney: “No theme in
linguistic science is more often and more voluminously treated than
this, and by scholars of every grade and tendency; nor any, it may
be added, with less profitable result in proportion to the labour
expended; the greater part of what is said and written upon it is
mere windy talk, the assertion of subjective views which commend
themselves to no mind save the one that produces them, and which
are apt to be offered with a confidence, and defended with a
tenacity, that are in inverse ratio to their acceptableness. This has
given the whole question a bad repute among sober-minded
philologists” (OLS 1. 279).
Nevertheless, linguistic science cannot refrain for ever from asking
about the whence (and about the whither) of linguistic evolution.
And here we must first of all realize that man is not the only animal
that has a ‘language,’ though at present we know very little about
the real nature and expressiveness of the languages of birds and
mammals or of the signalling system of ants, etc. The speech of
some animals may be more like our language than most people are
willing to admit—it may also in some respects be even more perfect
than human language precisely because it is unlike it and has
developed along lines about which we can know nothing; but it is of
little avail to speculate on these matters. What is certain is that no
race of mankind is without a language which in everything essential
is identical in character with our own, and that there are a certain
number of circumstances which have been of signal importance in
assisting mankind in developing language (cf. Gabelentz Spr 294 ff.).
First of all, man has an upright gait; this gives him two limbs more
than the dog has, for instance: he can carry things and yet jabber
on; he is not reduced to defending himself by biting, but can use his
mouth for other purposes. Feeding also takes less time in his case
than in that of the cow, who has little time for anything else than
chewing and a moo now and then. The sexual life of man is not
restricted to one particular time of the year, the two sexes remain
together the whole year round, and thus sociability is promoted; the
helplessness of babies works in the same direction through
necessitating a more continuous family life, in which there is also
time enough for all kinds of sports, including play with the vocal
organs. Thus conditions have been generally favourable for the
development of singing and talking, but the problem is, how could
sounds and ideas come to be connected as they are in language?
What method or methods have we for the solution of this question?
With very few exceptions those who have written about our subject
have conjured up in their imagination a primitive era, and then
asked themselves: How would it be possible for men or manlike
beings, hitherto unfurnished with speech, to acquire speech as a
means of communication of thought? Not only is this method
followed, so to speak, instinctively by investigators, but we are even
positively told (by Marty) that it is the only method possible. In
direct opposition to this assertion, I think that it is chiefly and
principally due to this method and to this way of putting the
question that so little has yet been done to solve it. If we are to
have any hope of success in our investigation we must try new
methods and new ways—and fortunately there are ways which lead
us to a point from which we may expect to see the world of primitive
language revealed to us in a new light. But let us first cast a rapid
glance at those theories which have been advanced by followers of
the speculative or a priori method.

XXI.—§ 2. Former Theories.

One theory is that primitive words were imitative of sounds: man

copied the barking of dogs and thereby obtained a natural word with
the meaning of ‘dog’ or ‘bark.’ To this theory, nicknamed the bow-
wow theory, Renan objects that it seems rather absurd to set up this
chronological sequence: first the lower animals are original enough
to cry and roar; and then comes man, making a language for himself
by imitating his inferiors. But surely man would imitate not only the
cries of inferior animals, but also those of his fellow-men, and the
salient point of the theory is this: sounds which in one creature were
produced without any meaning, but which were characteristic of that
creature, could by man be used to designate the creature itself (or
the movement or action productive of the sound). In this way an
originally unmeaning sound could in the mouth of an imitator and in
the mind of someone hearing that imitation acquire a real meaning.
In the chapter on Sound Symbolism I have tried to show how from
the rudest and most direct imitations of this kind we may arrive
through many gradations at some of the subtlest effects of human
speech, and how imitation, in the widest sense we can give to this
word—a wider sense than most advocates of the theory seem able
to imagine—is so far from belonging exclusively to a primitive age
that it is not extinct even yet. There is not much of value in Max
Müller’s remark that “the onomatopœic theory goes very smoothly
as long as it deals with cackling hens and quacking ducks; but round
that poultry-yard there is a high wall, and we soon find that it is
behind that wall that language really begins” (Life 2. 97), or in his
other remark that “words of this kind (cuckoo) are, like artificial
flowers, without a root. They are sterile, and unfit to express
anything beyond the one object which they imitate” (ib. 1. 410). But
cuckoo may become cuckold (Fr. cocu), and from cock are derived
the names Müller himself mentions, Fr. coquet, coquetterie, cocart,
cocarde, coquelicot.... Echoic words may be just as fertile as any
other part of the vocabulary.
Another theory is the interjectional, nicknamed the pooh-pooh,
theory: language is derived from instinctive ejaculations called forth
by pain or other intense sensations or feelings. The adherents of this
theory generally take these interjections for granted, without asking
about the way in which they have come into existence. Darwin,
however, in The Expression of the Emotions, gives purely
physiological reasons for some interjections, as when the feeling of
contempt or disgust is accompanied by a tendency “to blow out of
the mouth or nostrils, and this produces sounds like pooh or pish.”
Again, “when anyone is startled or suddenly astonished, there is an
instantaneous tendency, likewise from an intelligible cause, namely,
to be ready for prolonged exertion, to open the mouth widely, so as
to draw a deep and rapid inspiration. When the next full expiration
follows, the mouth is slightly closed, and the lips, from causes
hereafter to be discussed, are somewhat protruded; and this form of
the mouth, if the voice be at all exerted, produces ... the sound of
the vowel o. Certainly a deep sound of a prolonged Oh! may be
heard from a whole crowd of people immediately after witnessing
any astonishing spectacle. If, together with surprise, pain be felt,
there is a tendency to contract all the muscles of the body, including
those of the face, and the lips will then be drawn back; and this will
perhaps account for the sound becoming higher and assuming the
character of Ah! or Ach!”
To the ordinary interjectional theory it may be objected that the
usual interjections are abrupt expressions for sudden sensations and
emotions; they are therefore isolated in relation to the speech
material used in the rest of the language. “Between interjection and
word there is a chasm wide enough to allow us to say that the
interjection is the negation of language, for interjections are
employed only when one either cannot or will not speak” (Benfey
Gesch 295). This ‘chasm’ is also shown phonetically by the fact that
the most spontaneous interjections often contain sounds which are
not used in language proper, voiceless vowels, inspiratory sounds,
clicks, etc., whence the impossibility properly to represent them by
means of our ordinary alphabet: the spellings pooh, pish, whew, tut
are very poor renderings indeed of the natural sounds. On the other
hand, many interjections are now more or less conventionalized and
are learnt like any other words, consequently with a different form in
different languages: in pain a German and a Seelander will exclaim
au, a Jutlander aus, a Frenchman ahi and an Englishman oh, or
perhaps ow. Kipling writes in one of his stories: “That man is no
Afghan, for they weep ‘Ai! Ai!’ Nor is he of Hindustan, for they weep
‘Oh! Ho!’ He weeps after the fashion of the white men, who say,
‘Ow! Ow!’”
A closely related theory is the nativistic, nicknamed the ding-dong,
theory, according to which there is a mystic harmony between sound
and sense: “There is a law which runs through nearly the whole of
nature, that everything which is struck rings. Each substance has its
peculiar ring.” Language is the result of an instinct, a “faculty
peculiar to man in his primitive state, by which every impression
from without received its vocal expression from within”—a faculty
which “became extinct when its object was fulfilled.” This theory,
which Max Müller propounded and afterwards wisely abandoned, is
mentioned here for the curiosity of the matter only.
Noiré started a fourth theory, nicknamed the yo-he-ho: under any
strong muscular effort it is a relief to the system to let breath come
out strongly and repeatedly, and by that process to let the vocal
chords vibrate in different ways; when primitive acts were performed
in common, they would, therefore, naturally be accompanied with
some sounds which would come to be associated with the idea of
the act performed and stand as a name for it; the first words would
accordingly mean something like ‘heave’ or ‘haul.’
Now, these theories, here imperfectly reproduced each in a few
lines, are mutually antagonistic: thus Noiré thinks it possible to
explain the origin of speech without sound imitation. And yet what
should prevent our combining these several theories and using them
concurrently? It would seem to matter very little whether the first
word uttered by man was bow-wow or pooh-pooh, for the fact
remains that he said both one and the other. Each of the three chief
theories enables one to explain parts of language, but still only
parts, and not even the most important parts—the main body of
language seems hardly to be touched by any of them. Again, with
the exception of Noiré’s theory, they are too individualistic and take
too little account of language as a means of human intercourse.
Moreover, they all tacitly assume that up to the creation of language
man had remained mute or silent; but this is most improbable from
a physiological point of view. As a rule we do not find an organ
already perfected on the first occasion of its use; it is only by use
that an organ is developed.

XXI.—§ 3. Method.

So much for the results of the first method of approaching the

question of the origin of speech, that of trying to picture to oneself a
speechless mankind and speculating on the way in which language
could then have originated. We shall now, as hinted above (p. 413),
indicate the ways in which it is possible to supplement, and even in
some measure to supplant, this speculative or deductive method by
means of inductive reasonings. These can be based on three fields
of investigation, namely:
(1) The language of children;
(2) The language of primitive races, and
(3) The history of language.
Of these, the third is the most fruitful source of information.
First, as to the language of children. Some biologists maintain that
the development of the individual follows on the whole the same
course as that of the race; the embryo, before it arrives at full
maturity, will have passed through the same stages of development
which in countless generations have led the whole species to its
present level. It has, therefore, occurred to many that the
acquisition by mankind at large of the faculty of speech may be
mirrored to us in the process by which any child learns to
communicate its thoughts by means of its vocal organs. Accordingly,
children’s language has often been invoked to furnish illustrations
and parallels of the process gone through in the formation of
primitive language. But many writers have been guilty of an
erroneous inference in applying this principle, inasmuch as they have
taken all their examples from a child’s acquisition of an already
existing language. The fallacy will be evident if we suppose for a
moment the case of a man endeavouring to arrive at the evolution
of music from the manner in which a child is nowadays taught to
play on the piano. Manifestly, the modern learner is in quite a
different position to primitive man, and has quite a different task set
him: he has an instrument ready to hand, and melodies already
composed for him, and finally a teacher who understands how to
draw these tunes forth from the instrument. It is the same thing
with language: the task of the child is to learn an existing language,
that is, to connect certain sounds heard on the lips of others with
the same ideas that the speakers associate with them, but not in the
least to frame anything new. No; if we are seeking some parallel to
the primitive acquisition of language, we must look elsewhere and
turn to baby language as it is spoken in the first year of life, before
the child has begun to ‘notice’ and to make out what use is made of
language by grown-up people. Here, in the child’s first purposeless
murmuring, crowing and babbling, we have real nature sounds; here
we may expect to find some clue to the infancy of the language of
the race. And, again, we must not neglect the way children have of
creating new words never heard before, and often of attaching a
sense to originally meaningless conglomerations of sound.
As for the languages of contemporary savages, we may in some
instances take them as typical of more primitive languages than
those of civilized nations, and therefore as illustrating a linguistic
stage that is nearer to that in which speech originated. Still,
inferences from such languages should be used with great caution,
for it should never be forgotten that even the most backward race
has many centuries of linguistic evolution behind it, and that the
conditions therefore may, or must, be very different from those of
primeval man. The so-called primitive languages will therefore in the
following sections be only invoked to corroborate conclusions at
which it is possible to arrive from other data.
The third and most fruitful source from which to gather information
of value for our investigation is the history of language as it has
been considered in previous chapters of this work. While the
propounders of the theories of the origin of speech mentioned above
made straight for the front of the lion’s den, we are like the fox in
the fable, who noticed that all the traces led into the den and not a
single one came out; we will therefore try and steal into the den
from behind. They thought it logically correct, nay necessary, to
begin at the beginning; let us, for variety’s sake, begin with
languages accessible at the present day, and let us attempt from
that starting-point step by step to trace the backward path. Perhaps
in this way we may reach the very first beginnings of speech.
The method I recommend, and which I think I am the first to
employ consistently, is to trace our modern twentieth-century
languages as far back in time as history and our materials will allow
us; and then, from this comparison of present English with Old
English, of Danish with Old Norse, and of both with ‘Common
Gothonic,’ of French and Italian with Latin, of modern Indian dialects
with Sanskrit, etc., to deduce definite laws for the development of
languages in general, and to try and find a system of lines which can
be lengthened backwards beyond the reach of history. If we should
succeed in discovering certain qualities to be generally typical of the
earlier as opposed to the later stages of languages, we shall be
justified in concluding that the same qualities obtained in a still
higher degree in the earliest times of all; if we are able within the
historical era to demonstrate a definite direction of linguistic
evolution, we must be allowed to infer that the direction was the
same even in those primeval periods for which we have no
documents to guide us. But if the change witnessed in the evolution
of modern speech out of older forms of speech is thus on a larger
scale projected back into the childhood of mankind, and if by this
process we arrive finally at uttered sounds of such a description that
they can no longer be called a real language, but something
antecedent to language—why, then the problem will have been
solved; for transformation is something we can understand, while a
creation out of nothing can never be comprehended by human
understanding.
This, then, will be the object of the following rapid sketch: to search
the several departments of the science of language for general laws
of evolution—most of them have already been discussed at some
length in the preceding chapters—then to magnify the changes
observed, and thus to form a picture of the outer and inner structure
of some sort of speech more primitive than the most primitive
language accessible to direct observation.

XXI.—§ 4. Sounds.

First, as regards the purely phonetic side of language, we observe

everywhere the tendency to make pronunciation more easy, so as to
lessen the muscular effort; difficult combinations of sounds are
discarded, those only being retained which are pronounced with
ease (see Ch. XIV § 6 ff.). Modern research has shown that the
Proto-Aryan sound-system was much more complicated than was
imagined in the reconstructions of the middle of the nineteenth
century. In most languages now only such sounds are used as are
produced by expiration, while inbreathed sounds and clicks or
suction-stops are not found in connected speech. In civilized
languages we meet with such sounds only in interjections, as when
an inbreathed voiceless l (generally with rhythmic variations of
strength and corresponding small movements of the tongue) is used
to express delight in eating and drinking, or when the click
inadequately spelt tut is used to express impatience. In some very
primitive South African languages, on the other hand, clicks are
found as integral parts of words; and Bleek has rendered it probable
that in former stages of these languages they were in more
extensive use than now. We may perhaps draw the conclusion that
primitive languages in general were rich in all kinds of difficult
sounds.
The following point is of more far-reaching consequence. In some
languages we find a gradual disappearance of tone or pitch accent;
this has been the case in Danish, whereas Norwegian and Swedish
have kept the old tones; so also in Russian as compared with Serbo-
Croatian. In the works of old Indian, Greek and Latin grammarians
we have express statements to the effect that pitch accent played a
prominent part in those languages, and that the intervals used must
have been comparatively greater than is usual in our modern
languages. In modern Greek and in the Romanic languages the tone
element has been obscured, and now ‘stress’ is heard on the syllable
where the ancients noted only a high or a low tone. About the
languages spoken nowadays by savage tribes we have generally
very little information, as most of those who have made a first-hand
study of such languages have not been trained to observe and to
describe these delicate points; still, there is of late years an
increasing number of observations of tone accents, for instance in
African languages, which may justify us in thinking that tone plays
an important part in many primitive languages.[107]
So much for word tones; now for the sentence melody. It is a well-
known fact that the modulation of sentences is strongly influenced
by the effect of intense emotions in causing stronger and more rapid
raisings and sinkings of the tone. “All passionate language does of
itself become musical—with a finer music than the mere accent; the
speech of a man even in zealous anger becomes a chant, a song”