Part 29

A tendency to dropsical effusion is generally first shown, besides a puffiness of the face, in the feet and ankles, the shoe or slipper marking off the enlargement above its margin. Often this has no other cause than debility, with a watery condition of the blood. Varicose veins, with old and resultant ulcers, are also among the possible things to be found in examination of the legs and feet.

{161} Movements of the hands are incessant and jerking in chorea; perpetually trembling in delirium tremens, and often in one arm and hand only, in paralysis agitans; with tremor, seen in voluntary motions alone, in multiple cerebro-spinal sclerosis. More unusual is the rhythmical closing and opening of the hand, successively, of athetosis.

In the walk of patients able to be upon their feet there may be much significance. A hemiplegic subject will circumduct the feeble limb after the other; one suffering with paraplegia will shuffle the feet slowly along the floor; the hysterical paralytic drags the lame limb behind the other; the patient with spastic spinal paralysis rises on his toes in walking, with his legs held close together; the shaking paralytic rather trots forward, with the body bent; and the subject of locomotor ataxia lifts his feet and kicks out forward or sideways, then bringing down the heels with a stamp at each step. In progressive muscular atrophy and advanced pseudo-hypertrophic muscular paralysis a waddling or rolling gait is seen. Choreic patients are very irregular in their walk, as in all other movements. Hip disease (coxalgia) shows itself in a child by its lifting the pelvis and limb of the affected side and bending the knee, so as to touch only the toes to the ground. Club-foot and other deformities require no description in this place.

Sensibility of the extremities and of other parts of the surface of the body needs to be examined into, with all its possible variations (hyperæsthesia, anæsthesia, analgesiæ, etc.), especially when the nervous apparatus is for any reason supposed to be involved. Motions of an unusual character must likewise be carefully noticed. "Westphal's symptom" is regarded as having considerable diagnostic value. It is otherwise called the tendon-reflex, with its modifications. When a person in health is seated with one leg crossed over the other or with the legs dangling over the edge of a high bench or table, and a sudden blow is struck upon the tendon of the patella, the leg and foot will be spontaneously jerked forward. In locomotor ataxia, even from an early period, this tendon-reflex is abolished. In spastic spinal paralysis (lateral spinal sclerosis) it is exaggerated. Quite analogous to this is the ankle-clonus. This is obtained by firmly flexing the foot and then tapping sharply upon the tendo Achillis. The foot is then involuntarily extended and flexed several times in succession. There is more doubt in regard to the associations of this symptom than as to the knee movement, but it has been clinically shown to be exaggerated in spastic spinal paralysis.

At our first acquaintance with a case of disease, while making inquiry into its nature, the genital organs must not be forgotten. Not that we need always make examination of them, but any pointing in symptoms toward them must be borne in mind, so as to guide us in or toward further procedures in diagnosis. In making, in obscure cases, a diagnosis by exclusion, we are sometimes driven to a scrutiny of the genital system.

We have now, however incompletely, touched upon the greater number of obvious signs or symptoms which a view of a patient would furnish without making minute inquiry of himself or others concerning his or their knowledge of the illness. Such are the objective signs of disease, which must be still more exactly and extensively discerned and understood by means of the processes of physical and instrumental diagnosis. {162} But the subjective symptoms also, and all those observed and described by the patient and his or her friends, must receive very careful attention. Much practical skill may be shown by the kind of questions asked and the use made of the answers given.

First, as to the alimentary apparatus:

Taste is very commonly altered in disease, being sour in indigestion, bitter in disorders of the liver, saltish in hæmoptysis, rotten in gangrene of the lungs.

Dryness of the mouth is the rule in fevers. Sometimes the saliva is viscid and adherent. Increased flow or salivation was formerly frequent in practice under large doses of mercurials. Jaborandi or its alkaloid pilocarpin will generally produce it. Iodide of potassium occasionally has the same effect in less degree.

Loss of appetite nearly always attends serious diseases of any kind. Excessive craving for food (bulimia) is rare. Tapeworm accounts for it in some instances. Desire for strange articles of food, as slate-pencils, ashes, etc., is met with in some instances of chlorosis and of hysteria. A return of natural appetite is one of the best signs toward the close of any acute attack of illness.

Thirst is seldom absent in fever. It is also usually present in the state of collapse, as from cholera, pernicious intermittent, or the shock of severe (especially railroad) injuries.

Dysphagia or difficulty of swallowing may result from simple debility, as in the moribund state; inflammation of the fauces, tonsils, or pharynx; stricture of the oesophagus; obstruction by a foreign body or by a cancerous or aneurismal tumor; retro-pharyngeal abscess; paralysis of the muscles of the throat, such as sometimes follows diphtheria. Soreness of the throat is present in some, but not in all of these examples of dysphagia, being most marked in the inflammatory condition of pharyngitis, tonsillitis, scarlet fever, and diphtheria. Ulceration of the throat should always be carefully looked for, and if present investigated to ascertain whether it is simple, diphtheritic, or syphilitic. We must be careful not to mistake a mere local accumulation of mucus, or aphthous vesicle, or the curd-like formation of thrush or muguet, either for ulceration or pseudo-membranous deposit. Aphthæ and thrush are most frequently met with in children, though small aphthous ulcers frequently appear toward the close of wasting, and especially cancerous, affections. If there be a doubt, pass a moistened hair pencil lightly over the apparent deposit, or allow the patient to gargle the throat with water, and then re-inspect it.

Many causes may produce nausea and vomiting, which almost always occur together; that is, vomiting rarely takes place without previous nausea, although the latter may exist without the former. In the manner of vomiting there are some differences more or less characteristic, as the distressing retching of sea-sickness and of tartar emetic or other irritant poisoning, and the spasmodic out-spurting of rice-water fluid in malignant cholera. The matter vomited is often very important in diagnosis. In mere indigestion the food taken is apt to come up, and the same may happen in flatulent colic. When the liver is involved, as in bilious colic, bile also is ejected. Nothing peculiar exists in the ejecta of morning sickness in pregnancy. The ejecta contain mucus in gastritis, blood in ulcer and in cancer of the stomach, stercoraceous {163} material in obstruction of the bowels, black vomit in bad cases of yellow fever. Hysterical vomiting sometimes closely imitates the latter in appearance. Other affections attended by vomiting are cholera morbus, remittent fever, brain disease, Bright's disease of the kidney, etc.

Spitting blood may be either hæmatemesis or hæmoptysis proper. If the former, nausea generally precedes the ejection of the blood by vomiting, and it is apt to be mingled with food partly digested. It is coughed up, bright red and frothy usually, when coming from the lungs or bronchial tubes. But blood may proceed from the gums or throat, or may run back through the posterior nares from the nose, and then it gives alarm by seeming to proceed from the chest. It is necessary to inquire very particularly into all such possibilities in every case of hemorrhage.

Between vomiting of blood from ulcer and from cancer of the stomach we have mostly these distinctions: in ulcer it follows soon after taking food, in cancer (this being generally at the pylorus), an hour or more after eating; ulcer is attended also by tenderness on pressure at a certain spot over the stomach, without tumor; cancer presents a tumor, with much less marked tenderness on pressure. By aid of the microscope in examination of the matter vomited this diagnosis may be completed.

Constipation is an exceedingly frequent symptom under many and diverse circumstances. Pathologically, we account for it in several ways: 1, torpor of the muscular coat of the intestinal canal; 2, deficiency of secretion in the glands of the bowels and in the liver; 3, imperfect innervation of the abdominal organs; 4, mechanical obstruction, as by a foreign body, intussusception, strangulated hernia, cancerous or other tumor, stricture of the rectum, etc. Dyspeptic persons are ordinarily constipated. So are almost all patients at the beginning of attacks of measles, scarlet fever, small-pox, and other acute febrile maladies. Typhoid fever is scarcely an exception to this; although the bowels in that affection become loose after a few days, they seldom are so at the very beginning of the attack. Sea-sickness is commonly accompanied by total or nearly total inaction of the bowels, the secretion of the intestinal glands being almost null, often for many days together. Torpor of the brain is sometimes attended by marked constipation. The latter may be a contributing cause of the former, as in certain severe cases of scarlet fever, in which threatening coma may be relieved by active purgation. We must not, however, occupy space here by attempting to enumerate the many conditions under which constipation may present itself as a symptom.

Almost as various are the associations of the opposite state of the bowels, diarrhoea. Excessive or abnormally frequent discharges from the bowels may be either fecal, bilious, mucous, membranous, purulent, bloody, fatty, or watery, and they may occur with or without pain and straining (tenesmus).

If, with frequent disposition to pass something, only small quantities of bloody mucus escape, with pain and bearing down, we recognize dysentery. When, instead, a large quantity of colorless fluid, with or without floating flakes (rice-water), comes from the bowels at short intervals, with vomiting of the same sort of material, we suspect epidemic cholera, and must inquire for corroborative or corrective indications in {164} reference to that suspicion. Very bad cases of cholera morbus also may, at a late stage, present this symptom. So may exceptional cases of pernicious malarial fever. The diarrhoea of typhoid fever exhibits usually liquid stools of a brownish color (gutter-water passages). Occasionally, hemorrhage from the bowels adds to the danger of this fever, as well as to that of malarial remittent fever. In phthisis pulmonalis, at a late stage, colliquative diarrhoea, like colliquative perspirations, shows the breaking up of the system by excessive waste. Very foul, offensive discharges from the bowels may always be understood as showing that in the alimentary canal, whether originating there or in the blood, morbid changes have been going on. The indication is to promote the elimination of such material as soon and as thoroughly as possible.

Clayey stools show absence or deficiency of bile in the intestines, whether from its non-secretion by the liver or from obstruction to its entrance by a gall-stone in the common gall-duct. Green stools are not uncommon in sick children. The cause of the color has been much disputed. Probably it depends chiefly on a modification of the bile-pigment, with some admixture of altered blood. When mercurials have been taken sulphide of mercury may give a green color to the discharges.

Blood, nearly or quite unmixed, coming from the bowels, may have its origin in internal hemorrhoids, intestinal ulceration, cancer of the rectum, intussusception, rupture of an aneurism, typhoid or yellow fever, or vicarious menstruation.

Pus is discharged per anum in cases of dysenteric or other ulceration of the bowel; also when an abscess occurring in any part of the abdomen (most frequently hepatic) opens into the intestine. Pseudo-membranous discharges, shreds or other fragments of fibrinous material, appear sometimes in what may be called diphtheritic dysentery. Tubular casts are occasionally seen (diarrhoea tubularis), which, however, are most likely to consist of thickened and accumulated mucus. Fatty discharges from the bowels are rare. Authors report observation of them in cases of disease of the liver or pancreas, as well as in phthisis, typhoid fever, diabetes mellitus, cholera, and tubercular enteritis of children.

Lientery is the term applied when imperfectly changed food appears in the stools. It shows, of course, great deficiency in the process of digestion.

Urination affords symptoms often of extreme consequence in disease. Suppression of urine is one of the most alarming of signs; an approximation to it only is likely to be met with in cholera, a late stage of scarlet fever, typhus or typhoid fever, in acute yellow atrophy of the liver, and in advanced kidney disease. Careful examination of the abdomen, by inspection, palpation, and percussion, as well as by inquiry of attendants, is needful in all cases of fever or other disorders with delirium or stupor, to ascertain the presence or absence of retention of urine. Dysuria--i.e. difficult urination, strangury--may have several causes. Cantharides, absorbed from a blister, may produce it temporarily. The more continuous states which cause it are--stricture of the urethra, enlargement of the prostate gland, and calculus in the bladder. In stricture, when the patient can pass water, it is apt to be in a twisted stream. Dribbling often occurs when the prostate is enlarged. When a stone is present the {165} stream may flow naturally for a time and then suddenly cease from obstruction at the outlet of the bladder. Enuresis, incontinence of urine, is often very troublesome in children; its diagnosis presents no difficulty.

Diabetes properly means simply excessive flow of urine. It may be attended by no change in the secretion except dilution of its solids (diabetes insipidus), as in certain nervous cases or after very large imbibition of fluids. More serious is diabetes mellitus, in which large amounts of sugar are found in the urine.

Variations in the quantity and in the composition and solid ingredients of the urine, as ascertained by aid of chemical analysis and the microscope, will be fully considered in other portions in this work.

Menstruation in the female requires scrutiny in every case of deviation from health. Its abnormities will be elsewhere treated of. The subject of the signs of pregnancy belongs of course to treatises on Obstetrics.

Pain is one of the most important of the signs of disease. We must always examine its character, location, and associations. As to character, that of pleurisy is sharp and cutting, increased by deep breathing or coughing. In pneumonia and in myalgia it is dull or aching. Rheumatic joints or muscles suffer a gnawing, tearing pain. In neuralgia it is darting, shooting, lancinating; and the last of these expressions is often applied to the pains of cancer. Griping pains occur in colic, and bearing-down pains in dysentery, as well as in the second stage of labor. Besides these varieties we have the pulsating pain of an acute external inflammation, as of the hand, especially before suppuration has occurred; the burning and smarting of erysipelas; and the stinging, nettling sensations (formication) of urticaria.

Tenderness on pressure is significant either of local inflammation, whose other signs are then to be discerned, or of non-inflammatory hyperæsthesia. The origin of the latter may require careful examination of various organs for its discovery. If pain is relieved by pressure, we may be sure of the absence of severe acute local inflammation.