rapid, and bounding pulse, the cardiac impulse being also
proportionately violent and extended. Exercise much increases this
hyper-pulsation.
Pulsation of the jugular veins is ordinarily explained by tricuspid
regurgitation, a portion of the blood being sent back to the vena cava
with an impulse reaching to the jugulars. In some instances, however,
as the writer has repeatedly observed, jugular pulsation takes place
without any abnormality in the action or condition of the heart, from
a local inflammation (as tonsillitis) causing a marked exaggeration of
the muscular contractility resident in the larger veins.
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when the pressure is withdrawn.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.
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.