actions of his own and other bodies in health, yet a more exact
knowledge of the movements of respiration, circulation, secretion,
etc., as well as the form, size, and relative location of all the
organs of the body, is needed. Physiology and medical anatomy furnish
such information. The more thorough this knowledge is appropriated,
the better fitted the student is for practical diagnosis. For its
application, however, cultivation of all the perceptive powers is very
important. Some men have a genius for quick and clear discernment of
symptoms and for their interpretation, as well as for that of physical
signs. But all can much improve their senses, and their sagacity in
using them, by experience. For this, if for no other reason,
scientific training, in field or laboratory studies, affords the best
introduction to the work of the medical student and physician. The
traits most needed for success in diagnosis are exactness and
comprehensiveness. First, to be sure precisely what each sign is that
comes under observation; next, to overlook no existing symptoms or
physical signs; and, last, so to combine them into a mental map,
diagram, or picture, as to make a coherent and rational whole. This
nosogram may then be compared with the descriptions of standard
authorities, to find its place (if it has one) in technical
classification. First, however, ascertain the thing, the morbid state
or combination of states; afterward the name, or morbid species, when
practicable. It is always to be remembered that complication of
diseases, or at least the existence of some irregular manifestations
along with those which are characteristic, is more common than the
occurrence of purely typical cases. The portraits of most diseases in
the books are averages, like the composite class-photographs of
Douglas Galton. Not nearly every case will correspond with such an
average in all respects. Moreover, so great is the possible variety of
alterations among the different organs of the body that the chances of
two instances of disease being precisely alike in every particular are
hardly greater than those in favor of every move being the same in two
games of chess with the same opening.
In an essay like the present it is not easy to decide upon the best
manner of treating the subject before us. Too much or too little may
be said. With advanced readers the whole history of symptoms and
physical signs might be left to the special discussions occurring in
articles upon different diseases. But it may be taken for granted that
those who consult the present work will do so either at a
comparatively early stage of their studies or when time has made
desirable a renewal of what may have been once known and then
forgotten. Since, then, it is impossible {150} to anticipate what may
be the exact needs of either class, a somewhat elementary statement of
main facts appears justifiable here.
Following the natural method, we may suppose a call to visit a
patient. Arriving in his presence, the first question (mostly left out
of view and rarely expressed) may be, Is it a case of real or only
imaginary indisposition? Army medical officers, more than most others,
can appreciate the possibility of this inquiry sometimes disposing of
the whole case.
Supposing it to be real, is it an illness or an accident or other
injury? Is it severe or of trifling account? Acute or chronic? We
observe the position of the patient, lying quietly in bed, sitting up,
or walking restlessly about the room. Then the countenance is
observed--pale or flushed, tranquil or excited in expression. We feel
the forehead, touch the cheek and hand. Is the skin hot or cold, dry
or moist? The pulse is felt; the breathing also is counted.
Of the patient himself or of another (in serious acute cases better of
his care-taker, in another apartment) we ask questions whose answers
give us the general history of the case. When not before known these
should include his antecedent personal history, even extending to that
of the family, as far as can be learned. What tendencies have they, or
has he or she, shown by previous attacks and their results?
So we come to the present attack: When did it begin, and how? What
have been its prominent symptoms since? Questions are then to be put
concerning the heat of the body, appetite, complaint of pain, sleep,
movement of the bowels, discharge of urine: in the female,
menstruation; if married, pregnancy or parturition, how often and when
occurring last. Thus the practitioner is enabled to get a clue to the
diagnosis, to be followed out through his own observation and closer
examination. If the patient be a child and the attack be acute and
febrile, an early question must be as to its having passed or not
through the different diseases of childhood--viz. the exanthemata,
mumps, and whooping cough, and also what exposure to any of these it
may have been recently subjected to.
Going farther into particulars, let us review some of the possible
developments obtained in the above questioning of symptoms.
When lying in bed the decubitus may be significant, as, upon the back
with the knees drawn up in peritonitis; with the hands pressing the
abdomen in colic; tossing to and fro in the delirium of fever or of
early cerebral inflammation; on one side constantly in acute
inflammation of the liver or in pleurisy. Or the patient may be
obliged to be propped in a sitting posture (orthopnoea) from
heart-disease, asthma, or ascites, or leaning forward upon the back of
a chair or a pillow with aneurism of the aorta. More remarkable still
may be the subsultus tendinum of low fever, the opisthotonos of
tetanus, the respiratory spasms of hydrophobia, or the clonic
movements of epileptic, hysterical, or occasional convulsions.
In the face we see pallor in syncope and in anæmia in any of its
varieties and with varied associations; a general redness in some
cases of apoplexy and in remittent fever; flushing of the forehead and
eyes especially in yellow fever; dusky redness in typhus, and a more
purple hue in typhoid fever; yellowness in jaundice, in some cases of
remittent and in most of yellow fever; sallowness in cancer; a bright
central glow upon each cheek in early pneumonia or the hectic of
phthisis; a blue or ashen appearance in the collapse of cholera, and
blackish-blue in {151} cyanosis or carbonic acid poisoning; bronzed in
Addison's disease; puffy about the eyelids in Bright's disease; the
surface swollen, yet resistant to the touch, in myxoedema. The eyes
(one or both) glare prominently in exophthalmic goitre; squint in
advanced cerebro-meningitis; roll to and fro often in the prostration
of cholera infantum and in convulsions; are clear and bright in
phthisis; yellowish in hepatic disorder; dull and clouded in low
fevers; without expression in imbecility and general paralysis.
Contraction of the pupil is observed in inflammation of the retina or
of the brain, narcotism from opium (until near death) or eserine, or
apoplectic effusion near the pons varolii. Dilatation of the pupil is
seen in most cases of hydrocephalus and of apoplexy; in
nerve-blindness (amaurosis), glaucoma, cataract, and narcotism from
atropia, duboisia, or hydrocyanic acid. Inactivity of the pupil
(Argyll Robertson) under changes of light and darkness is common in
locomotor ataxia. Different states of the two pupils under the same
light show disorder, either ophthalmic or cerebral in site, or may
indicate pressure on the cervical sympathetic ganglia, as from aortic
aneurism.
In elderly persons we ought always to look for the arcus senilis,
which is a sign of a tendency to fatty degeneration. It is a ring, or
part of a ring, with ill-defined edges, best seen by lifting or
depressing an eyelid, at the junction of the cornea and sclerotic coat
of the eye. In some quite healthy old persons there may be seen at the
same junction a clearly-defined circular line of calcareous nature.
This must be distinguished from the true fatty arcus senilis.
Of the face we may also notice the pinched nose, hollow eyes, and
falling jaw of the facies Hippocratica, presaging death; the square
forehead of the rickety child (not common in this country); ulcers on
the forehead, scars at the mouth-corners, or copper-colored eruptions
in syphilis; the full, flabby lips of scrofula. In peritonitis or
gastritis the mouth is apt to be drawn up with a peculiar expression
of suffering and nausea. Very striking is the characteristic one-sided
appearance in facial palsy, from lesion of the seventh nerve. There
may be a smile, a frown, or other expression on the sound side of the
face, while the paralyzed side is quite immovable. As the seventh
nerve (portio dura) supplies the orbicularis muscles, its paralysis
(so often temporary) may cause inability to close the eye upon the
affected side. Ptosis, or inability to open the eye, involving the
levator palpebræ, which is innervated by the third nerve (motor oculi)
is more significant of cerebral lesion.
Even the ears may have language, as when their lobes are full and
glistening red in the gouty diathesis, or wrinkled in prolonged
cachexiæ, or when they are running with discharges in the struma
(scrofula) of childhood. The hair becomes dry and lustreless in
phthisis, and falls out during convalescence from many acute diseases.
If we look at the gums in a case of lead-poisoning, we may expect to
find a blue line along their edges. Scurvy is betokened by a swollen,
spongy, and easily-bleeding state of the gums. Many scorbutic cases,
however, lack this so-called pathognomonic feature. It may be
remarked, by the way, that absolutely pathognomonic signs of
particular diseases, never absent and exclusively seen in them, are
very few. Albuminuria, for example, is not always present in Bright's
disease, and is {152} also met with in a number of other affections.
Sugar in the urine may follow inhalation of chloroform or an attack of
cholera, as well as diabetes mellitus. Rice-water discharges may be
absent in the collapse of cholera, and patients may die with yellow
fever without black vomit. Still, these symptoms have great diagnostic
value, and, taken with others associated with them, may often enable
us to attain to a diagnosis of much importance.
Perfect teeth in an adult in this country are rather the exception
than the rule. In the notched incisors of inherited syphilis, however,
there is something quite distinctive. The notches in Hutchinson's
teeth are vertical, not horizontal.
Old as medicine is the examination of the tongue in disease. It may be
protruded with difficulty, as in low fevers, in apoplexy, and in
cerebral paralysis (bulbar sclerosis, glosso-labio-pharyngeal
paralysis) or thrust to one (the paralyzed) side in hemiplegia. It is
pallid in anæmia; yellow in bilious disorder; red in glossitis (then
swollen also), in scarlet fever, and in gastritis; furred in
indigestion, gastro-hepatic catarrh, and the early stage of various
febrile attacks; dry, brown, cracked, or fissured in typhus or typhoid
fevers and in the typhoid state of malarial remittent fever; bare of
epithelium in advancing phthisis and in imperfect convalescence from
severe acute diseases. Coldness of the tongue is one of the worst
signs in the collapse of cholera.
As we examine the throat internally we look for signs of faucial
inflammation in redness and swelling, with or without enlargement of
the tonsils, or relaxation and elongation of the uvula, or ulceration,
or the gray or brown membranous deposit of diphtheria. In the mouth of
a child we may find the little white vesicular patches called aphthæ,
the curd-like exudations of thrush, or possibly the much worse grayish
ulcerations of cancrum oris, or the rarer ashen sloughs of gangrene of
the mouth.
Outside of the throat we must remember the significance of glandular
swellings or scars of suppurated glands in children; nor overlook, if
present, stiffness of the muscles, or torticollis, or goitrous
enlargement of the thyroid gland. Observation should be made also of
the site of the carotid artery on each side, and of the jugular veins,
since aortic regurgitation may be indicated by violent action of those
arteries or tricuspid regurgitation by pulsation of the veins in the
neck.
Long before vaso-motor physiology had any place in science the pulse
was known to afford valuable indications in disease. Either of the
accessible arteries will answer instead of the radial; its convenience
merely makes the wrist the common place of comparison. By careful
examination of the pulse something may be learned of several of the
factors concerned in its production. These factors are--1, the
muscular force of the walls of the heart; 2, the state of the cardiac
valves; 3, the muscularity of the arteries; 4, the elasticity of the
arterial coats; 5, the state of the capillary circulation; 6, the
qualities of the blood; 7, the condition of the nervous system as to
excitability or apathy.
A feeble heart must induce a feeble pulse. Moderate debility may be
attended by slowness of the pulse, but usually a weak circulation is
marked by frequent, small beats, like the vibrations of a short
pendulum. A strong heart-beat (other things being equal) is relatively
slow, with a proportionate pause after the second sound.
{153} Valvular lesions produce various effects upon the pulse. Most
notable are the irregularity connected often with mitral insufficiency
and the jerking pulse (Corrigan) of aortic regurgitation.
Believing, as the present writer does, in the existence of a true
arterial systole following and supplementing the ventricular
contraction,[38] it must be urged that a vigorous muscularity in the
arteries promotes strength in the pulse--not by resistance, but by
auxiliary propulsion of the blood. Another condition altogether is
tonic, spasmodic contraction of the arteries. This is not often met
with pure and simple, but a measure of it is seen in the corded or
wiry pulse of acute enteritis or peritonitis.
[Footnote 38: This view, although advocated by Sir Charles Bell,
Legros and Onimus, Hermann of Zurich, and others, is opposed to the
most prevailing vaso-motor physiology. Several complications and some
contradictions in pathological discussion at the present time would be
cleared up by the abandonment of the now commonly-held stopcock theory
of arterial function, which has really nothing whatever to support it
except the misinterpretation of some experiments upon arteries made
many years since.]
Deficient elasticity of the arteries is not easily separated in
observation from muscular relaxation. When arteries undergo
degeneration (atheromatous, fatty, or calcareous), their middle coat
suffers the deterioration of both elastic and muscular tissues, these
being substituted by materials either more or less yielding, and
always less resilient, than the natural fabric of the vessels.
The influence of the condition of the capillary circulation upon that
of the arterial system and the heart is manifest in inflammations. By
reflex excitation the arteries are made to contract actively and impel
the blood more forcibly than in the normal state toward the centre of
impeded nutrition (stasis). This has been abundantly proved by the
comparison of the amount of blood flowing through the arteries of a
sound limb and those of its fellow, when the latter is the seat of a
violent acute inflammation.
Blood-states also affect the pulse by the differences in direct
stimulation to which the heart and arteries are subjected according to
the qualities and composition of the blood. It is probable that the
fever-pulse of typhus, typhoid, the exanthemata, septicæmia, and
pyæmia has its origin in morbid conditions of the blood, acting in a
twofold manner--directly upon the heart and arteries themselves, and
mediately through the vaso-motor ganglia.
Lastly, the nervous system stands in an important relation to the
action of the heart and arteries, and thus to the pulse. In a nervous,
excitable person, changes in the rate of the pulse may take place,
with slight significance, which in a different constitution might be
of serious import.
To understand the language of the pulse care must be taken in several
respects:
1. Both wrists should be felt. Sometimes there is an abnormal
variation in the course of the main radial trunk which may pass over
the thumb. Again, an aneurism may cause a great difference between the
two radial pulses, or, possibly, an embolus may occlude one of the
radial vessels, annulling its pulsation.
2. Other arteries also, especially the carotids, should be
examined--in all obscure cases at least. Visibly beating, distended,
and tortuous temporal arteries are occasionally met with. They are not
pathognomonic of any one malady, although often referred to the gouty
diathesis. They {154} may attend irregular malarial attacks, or may be
connected simply with a hyperæmic state of the brain.
3. The heart's impulse should always be compared with the arterial
pulsation. The former may be strong and regular, while the latter is
small, feeble, or intermittent. Something must then be wrong, either
in the aortic valves or in the arterial system.
5. On account of possible nervous agitation, the pulse should usually
be examined more than once, during each visit to the patient.
6. Sex, age, position of the body, and time of day must all be taken
account of. In men the average rate of the pulse is between 65 and 75
per minute; in women, between 70 and 80. The pulse-rate of early
infancy varies from 100 to 120, and is very easily hurried. That of
old persons is commonly between 60 and 70, until, at a very advanced
age, with debility, its frequency may be increased, especially upon
exertion. Lying down, we find the slowest pulse; sitting, somewhat
more rapid; and most so in the standing position. In health the time
of day makes no constant difference apart from the effects of food and
exercise. In disorders attended by fever there are important changes
to be regularly observed. Excepting the variable paroxysms of
remittent and intermittent, which are a law unto themselves, in
febrile affections the pulse may be expected to be slowest in the
morning and most excited in the early part of the night. A diminution
of this difference is a favorable sign. Sleep generally slows the
pulse decidedly. The ordinary statement is, that the pulse is always
slower during sleep, but I have several times found that in states of
exhaustion without fever it may be considerably more rapid while the
patient is asleep. Nothing is more sure to increase the strength and
rapidity of the pulse than high temperature.
7. Very important is the relation between the pulse and respiration.
Normally, four pulsations occur to each respiratory act. In pulmonary
affections, while the circulation is often disturbed pari passu with
the breathing, it may be quite otherwise. Great acceleration of the
rate of breathing, with little increase in the rapidity of the pulse,
should lead us to suspect disease involving the respiratory organs.
Conversely, a much hurried or otherwise perturbed pulse, with little
or no change in the breathing, points toward the heart as either
functionally or organically the seat of disorder.
Let us further consider, briefly, the kinds of pulse to be met with
and interpreted in practice.
A natural pulse is always, per se, a good sign. Yet in the history of
a disease usually so well marked as yellow fever some fatal cases have
been recorded (walking cases) in which the pulse, almost to the last,
was natural.
Strength of the pulse, to a certain degree, belongs to it normally.
But this is often exaggerated, and we may have the strong, hard, full,
perhaps bounding, pulse of an inflammatory affection (of the brain,
for example, or of the joints in acute rheumatism) in a person of
vigor. A bounding pulse often accompanies mere palpitation of the
heart, whose source may be the sympathetic influence of indigestion or
nervousness. A similar pulse is apt to be constantly present in
hypertrophy of the heart. In this case it is made more forcible as
well as more rapid by {155} active exertion; while palpitation,
without organic trouble, is usually diminished by moderately active
exercise.
A full pulse is not always strong, nor is a small pulse necessarily
weak. Mention has been made already of the tense, corded pulse met
with in acute peritonitis, and sometimes in enteritis. Gastric
inflammation, with nausea, may exhibit a depressed pulse, weak and but
little accelerated. Under still other circumstances we may find a full
pulse which is soft, easily compressible, even gaseous. Most
frequently a feeble pulse is rapid, and a very rapid pulse is weak.
Slowness, in marked degree, attends apoplexy, opium narcotism, and
fracture of the skull compressing the brain. Functional disturbance of
the heart may occasionally exceed in effect these causes of
retardation. I have met, under such circumstances, with a pulse of 20
in the minute; one of 18 has been recorded. A few apparently healthy
persons have habitually a pulse with but 40 or 50 beats in the minute.
Quickness in each beat may occur, while a long interval makes the rate
per minute slow. The jerking pulse of aortic regurgitation is the most
remarkable example of this. Galabin asserts that without imperfection
of the valves of the aorta a decidedly abrupt pulse may attend great
lowering of arterial tension. Something of the same kind may be
noticed in the temporarily excited pulse of very nervous subjects
under agitation.
Dicrotism, or reduplication of the pulse-beat, is not uncommon in
typhus and typhoid fever. Here relaxation of the heart as well as of
the blood-vessels appears to allow a momentary interruption in the
succession of the arterial upon the cardiac systole.[39]
[Footnote 39: An exceptional phenomenon, noticed by a few observers,
is the recurrent pulse; _i.e._ a pulsation felt below the finger,
whose pressure interrupts the flow of blood through an artery. It may
be explained by supposing unusual fulness of the vessels (local, if
not general) with, at the same time, relaxation of their walls;
bearing in mind, also, the manner of anastomosis of the radial and
ulnar branches which favors recurrence.]
Intermittence and irregularity of the pulse are not exactly the same
thing. Occasional intermittence may be merely a nervous symptom or a
muscular twitch of the heart, like the twitches now and then occurring
without significance in voluntary muscles. Persistent intermittence,
with feebleness of the pulsations (these being generally somewhat
rapid), is among the signs of dilatation of the heart.
It is possible for intermittence of the radial pulse to accompany
regularity in the heart-beat. This usually results from narrowing
(stenosis) of the aortic valvular outlet from the left ventricle. Only
a certain number of impulses fairly reach the more distant arteries.
This symptom may result also from fatty degeneration of the heart.
Absence of pulse in one radial vessel, while it is present in the
other, shows the presence of an obstacle to the circulation on one
side, which may be an aneurism, or an embolus plugging the artery.
Irregularity of the pulse, a total derangement of its rhythm, while
not often important in young children, is a serious symptom at other
times of life. In one disease most common in childhood, acute
hydrocephalus, the pulse in the first stage is apt to be hard and
rapid, in the middle stage slow and tolerably full, in the third
rapid, feeble, and often irregular. Mitral disease frequently presents
considerable irregularity of the pulse; and so does dilatation, even
without mitral lesion. Brain trouble, especially late in life, whether
structural or functional, may produce the {156} same symptom. B. W.
Richardson has pointed this out as one of the effects of the excessive
use of tobacco, even in young persons.
The pulse of continued, relapsing, and remittent fevers is, during the
febrile exacerbation, rapid (100 to 120); in the earlier part of the
attack full, but only moderately hard, or even soft and yielding. As
the attack passes its height and critical defervescence occurs, the
pulse grows slower, unless great prostration has supervened; in which
case it increases in rapidity, while it fails more and more in fulness
and resistance.
The pulse of the moribund state is nearly always small, very rapid
(130-150), and thready, without force or fulness. It may become
imperceptible before death. A pulse of 140 beats in the minute is
always alarming; if much beyond that rate the case is desperate. A
pulse of more than 150 beats in the minute is very difficult to count
accurately.