Part 28

Retardation of the flow of blood through the veins is manifest during the collapse of epidemic cholera. On pressing the blood back in a vein upon the hand, for example, and then lifting the finger, instead of the movement being, as in health, too swift to be seen, it is so slow as to be easily followed.

Capillary movement may be estimated in a similar manner. If it be very sluggish, pressure upon the cheek, forehead, or hand will cause a pallor which remains for some seconds, instead of disappearing at once when the pressure is withdrawn. This is, it may be noticed, entirely different from the pitting upon pressure, without much if any change of color, in local oedema or general anasarcous effusion. The tache méningitique of Trousseau is a pink or rose-red line left for a time after drawing the finger across the forehead or abdomen in cases of acute hydrocephalus (tubercular meningitis).

Respiration must be watched carefully in all cases of disease. Normally, in the adult, while at rest, from 16 to 18 respiratory movements occur in each minute. The number is somewhat greater in women, and is considerably increased in children, at birth being about 40 in the minute. Men breathe most by the diaphragm; in women there is a greater lifting of the ribs. In either sex a disorder attended by pain in breathing may modify this proportion. If pleurisy, for example, be present, the ribs will be but slightly lifted, abdominal breathing taking predominance. When peritonitis makes every movement of the abdomen painful, costal respiration is maintained almost alone. Likewise, a unilateral pleurisy or pneumonia will check the respiration on the affected side, with an increased movement on the sound side. This difference is less manifest to the eye than to the ear in auscultation. In all febrile {157} affections respiration is hurried proportionately with the pulse, unless some complicating local disorder disturbs the relation.

Dyspnoea may be produced by many different causes, whose possibility must be remembered in its interpretation as a means of diagnosis. In asthma violent efforts are made to compel the entrance of air into the lungs by the intercostal muscles and diaphragm, aided by all the accessory muscles of respiration, including the sterno-cleido-mastoid and others of the neck. Expansion of the nostrils may occur in sympathy with these efforts. Yet the amount of resistance may be shown by a partial sinking-in of the lower ribs, as well as by the patient's distress. These last signs are sometimes very marked in the collapse of one or both lungs now and then occurring in whooping cough.

Croup induces a similar struggle for breath, although the obstruction is differently located. Early in the croupal attack a hoarse sound may accompany each inspiration and expiration. Later, when the danger to life from apnoea becomes more imminent, a hissing or whistling sound succeeds. This last-mentioned kind of sound results temporarily, also, from the spasmodic obstruction to breathing in laryngismus stridulus.

Besides the affections of the lungs which impede respiration (as pneumonia, hydrothorax, etc.), we may have dyspnoea induced by extra-pulmonary causes, such as dilatation of the heart, aneurism of the aorta, mediastinal cancer, pleuritic effusion; also by abdominal dropsy, extreme elephantiasis, etc. Mention need hardly be made here of respiratory obstruction from defective or injurious qualities of the air, threatening or producing asphyxia.

Sighing respiration takes place in heart disease not infrequently. A peculiar modification of the breathing movements has been associated especially with fatty degeneration of the heart. From the distinguished authors who first described it this is called the Cheyne-Stokes respiration. Intervals of suspension of breathing occur, after which short, shallow inspirations begin, and gradually increase for a time in depth; then they grow shorter and shallower again, until apnoea is reached. Such a cycle may occupy from half a minute to a minute and a half, with from fifteen to thirty increasing and decreasing respirations in all. It has been shown by several observers that this type of respiration is not peculiar to fatty degeneration of the heart. It has been met with in cases of cardiac dilatation, aortic atheroma, cerebral hemorrhage, tubercular meningitis, and uræmia.

Sometimes a kind of dyspnoea common in advanced disease of the heart, especially in mitral lesion with dilatation, has been confounded with this. Here the breathing is constantly labored (orthopnoea); but the patient from time to time dozes off into an imperfect sleep, in which the breathing almost entirely ceases. Then he is awakened with a start of distress, perhaps out of a painful dream. This succession of dozing apnoea and waking dyspnoea belongs to a late stage of heart disease, and usually ends in death.

Stertorous respiration is familiar in apoplectic coma, as well as in that of brain compression from injury or from opium or alcoholic narcotism. In uræmic coma true stertor is less apt to be observed; sometimes the respiration in this condition has a hissing sound.

Along with the movements of respiration we may notice that the breath {158} is hot and has a heavy odor in the early stages of all febrile disorders. Disagreeable breath is common, however, in persons not ill, from bad teeth or from indigestion. It is worst of all, putrid, in gangrene of the lung. Certain cases of chronic or subacute bronchitis (as well as of ozæna) also have very offensive breath. Coldness of the breath is a very bad sign; it is observed sometimes before death in the collapse of cholera.

Hiccough (singultus) is a spasmodic affection of the diaphragm. It is innocent, though annoying, in most cases, resulting from indigestion or from nervous disorder; in children, occasionally, from long crying. When it takes place in cases of general prostration it betokens threatening depression or exhaustion of vital energy.

The voice is mostly altered by serious disease. It may be feeble and whispering, from debility; hoarse, from laryngeal inflammation and tumefaction; thick, from cerebral oppression; lost (aphonia), in some cases of chronic laryngitis and in paralysis of the vocal muscles. The manner of articulating words is often changed in disorders of the nervous system. A marked example of this is the monotonous scanning speech of cerebro-spinal sclerosis.

Cough is an extremely variable symptom, always to be understood in connection with the attendant circumstances. Usually, however, the character of the cough itself is more or less distinctive. A dry, hard cough may be merely sympathetic or nervous, or it may belong to the first stage of acute bronchitis. A hacking cough, with little expectoration, is not infrequently observed for a time in incipient phthisis. Pneumonia has, if any, a short and rather sharp cough. Progressing bronchitis is recognized by the deepening and greater or less loosening of the cough. In advanced phthisis there are distressing spells of deep, laborious coughing, especially in the night or in the morning after sleep. Croup is known (whether sporadic or in the form of laryngeal diphtheria) by the barking cough of the early stage and its whistling character toward the fatal end. Nearly the same sort of hissing or whistling sound in breathing has been mentioned already as occurring in laryngismus stridulus. Paroxysms of coughing, with or without whooping, are pathognomonic of pertussis.

Expectoration often affords important signs. Briefly, it may suffice to say here that it is mucous, whitish, or colorless in early bronchitis; more or less yellowish and muco-purulent in severe and protracted bronchitis; rusty, from admingling of the coloring matter of blood, in pneumonia, early and middle stages; bloody and muco-purulent in early and of heavy roundish (nummular) masses in late pulmonary phthisis; putrid, rotten, in gangrene of the lung.

Continuing our survey of obvious symptoms, we must now take account of the conditions of the general surface of the body. Temperature is of great consequence. Most precisely determinable by the thermometer, the touch, when educated, will give very useful indications of its changes. It is difficult, and not commonly desirable, to separate variations of moisture from those of temperature. Reserving for another place the special consideration of medical thermometry, it may be here said that the skin is hot and dry in the typical condition of fever, whatever its special associations. Heat and moisture of the skin are more often met with together in the fever of acute articular rheumatism than in any other {159} affection. As a rule, perspiration lessens febrile heat. Copious (colliquative) sweating is habitual in many wasting diseases, notable in pulmonary phthisis. It is then a sign of great general relaxation of the system.

Coldness of the surface attends prostration, either from temporary collapse or from positive exhaustion. The skin is perceptibly cold in the algid stage of cholera. It may be so in very severe cases of sporadic cholera morbus. In the chill of intermittent, while the patient has the subjective sensation of coldness, his temperature is seldom reduced, and is often higher than natural, although lower than during the febrile exacerbation.

The color of the skin is pallid in anæmia, phthisis, dropsy, etc., and in syncope; ashen or livid in cholera collapse and in the cold stage of pernicious malarial fever; yellow in jaundice, remittent, and yellow fever; sallow in chlorosis, cancer, and chronic dyspepsia; purple, almost black (especially the lips and ends of the fingers), in asphyxia; dark, as if stained with ink, after long use of nitrate of silver; bronzed in Addison's disease; bright red in scarlet fever, etc. The eruptions of this and other exanthemata, and of the different cutaneous diseases, will be best considered in the special articles treating them of in this work.

Odor is perceptible and peculiar (though not easily described) in some bad cases of typhus fever and of small-pox; less often in aggravated chlorosis. Lunatics and paralytics (especially when assembled together in institutions) often give off a noticeable smell. Most distinct, however, is the cadaverous odor, sometimes perceptible for hours before death. Corroborative of this, in summer, is the flocking of flies around the bed of a dying patient. In a hospital ward this selection amongst a number of patients may be quite observable.

Emphysema, from the presence of air in the connective tissue under the skin, is rarely met with except as the consequence of an injury or of local gangrene.

Oedema is local watery effusion, which may have various causes and significance. Anasarca must have a general causation, either connected with the state of the blood or with disorder of the heart, kidneys, or liver, or of more than one of those organs at once. Pitting on pressure is the sign of watery effusion. Soft crackling under the touch distinguishes emphysema. A firm enlargement of the surface of the face and upper part of the body occurs in myxoedema.

Swellings of all kind must be carefully observed, and their nature inquired into--whether they be inflammatory or other chronic enlargements of joints, tumors, fibrous, fatty, or cancerous, aneurisms, hernial protrusions, or of any other character. In protracted disease of the liver (cirrhosis) it is not uncommon to find the superficial abdominal veins dilated and tortuous.

Abdominal enlargement may result from adipose accumulation (obesity), distension of the bowels with wind (meteorism), ascites, ovarian cysts, cancerous or other tumors, aneurism of the aorta, abscess, retention of urine, or pregnancy. By the methods of physical diagnosis, along with careful inquiry into the history of each case, we are to make out the distinctions amongst these different conditions.

Emaciation always marks either defect of nutrition or morbid excess of tissue-waste. It is counterfeited in the sudden collapse of malignant {160} cholera, and exaggerated in appearance during the analogous condition of cholera infantum. On recovery from these states, especially the latter, roundness and fulness of the face and limbs may return much too soon for the actual restoration of fat and flesh. A young child may be plump and chubby to-day, seemingly wasted with acute illness to-morrow, and, if soon relieved, the next day almost as rotund as ever.

Continued diarrhoea, phthisis pulmonalis, mesenteric disease, cancer, and aneurism of the aorta are among the most frequent causes of great emaciation. Sometimes, as in progressive pernicious anæmia, we are struck with the comparatively slight degree of wasting of the body while the disease is advancing toward death.

In myxoedema there is a swelling or general enlargement, especially of the upper portions of the trunk. This is not anasarcous, but depends upon a morbid change in the connective tissue throughout the body.

Articular enlargements may be (particularly in the knee in children) scrofulous, or gouty (in the smaller joints), rheumatic, with evidences of inflammation, acute or chronic; or, what is not well named, rheumatoid arthritis. In this last affection there is a gradual swelling and stiffening, with but little inflammation, of several, sometimes all, the joints of the extremities. Locomotor ataxia is in some cases attended by a degenerative alteration in one or more of the larger joints.

The limbs may furnish to the eye many expressive signs of disease or disability. In the listlessness of one arm and hand, while the other can perform various movements, we see reason to suspect hemiplegia. If the fingers are rigidly contracted, as well as powerless, we have this diagnosis confirmed, whether the rigidity be early or late in its stage. We must then look for a similar condition of the lower extremity on the same side. Paraplegia and general paralysis have their more extended (bilateral) indications in like manner. Characteristic also are the wrist-drop, from paralysis of the extensors of the hand, in lead-palsy; weakness or incapacity of the flexors and extensors in writer's cramp; the hand fixed helplessly in the position for writing in paralysis agitans (advanced stage); the main en griffe, with shrunken muscles and drawn tendons, of progressive muscular atrophy (wasting palsy). In the legs at first and chiefly, but in time also in the arms, increase of bulk with loss of power in the muscles shows the existence of pseudo-hypertrophic muscular paralysis.

Gouty fingers have their joints not only swollen, but distorted by deposits of urates and carbonates. Clubbed finger-ends, in the adult, are seen mostly, with incurvation of the nails, in advancing consumption. The nails are sometimes striated after attacks of gout, the lines disappearing gradually during the interval. In many acute diseases, transverse ridges are noticeable on the nails, marking the date when their growth was arrested and subsequently resumed. These are specially remarkable after attacks of relapsing fever.