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.
Not infrequently the seat of disease may be at some distance from that
of pain, as in the familiar instances of pain at the top of the head
in uterine derangement; in the glans penis from calculus in the
bladder; in the knee from hip-joint disease; under the shoulder-blade
in liver disorder; about the heart or between the shoulders from
dyspepsia.
Anæsthesia, loss of sensibility, has much value as a symptom in
neurotic affections, as paralysis, etc. Its discussion will find place
in connection with diseases of the Nervous System in other portions of
this work.
As an example of the diversified associations of pain, cephalalgia
(headache) may be mentioned as having at least the following possible
causes: congestion of the brain, neuralgia, rheumatism of the scalp,
uterine irritation, disease of the kidneys, early stage of remittent,
typhoid, or yellow fever, alcoholic intoxication, chronic disease of
the brain.
Abdominal pain may, in like manner, be traced, in different cases, to
many morbid conditions, such as flatulent colic, lead colic, neuralgia
or rheumatism of the bowels, intestinal obstruction, dysentery,
passage of a gall-stone or of a nephritic calculus through one or the
other duct {166} respectively; cancer, aneurism of the aorta, caries
of the spine; in the female, dysmenorrhoea, metralgia or
ovaralgia--_i.e._ neuralgia of the uterus or ovaries.
Similar diversity in the origins of pain might, but for want of space,
be pointed out in morbid states of the contents of the chest and of
other parts of the body.
Subjective symptoms often affect the special senses.
Taste and touch have been already referred to. Of sight we may have
photophobia, connected with exaggerated sensibility of the retina or
of the brain; muscæ volitantes, specks, rings, or chains of spots from
floating semi-opaque particles in the vitreous humor; diplopia, double
vision; hemiopia, seeing only half of an object at a time; amblyopia,
indistinctness of vision of all objects.
Hearing is affected, besides all possible degrees of deafness, with
the subjective sensations of ringing, whistling, or roaring
sounds--tinnitus aurium. One form of this (as I conclude from
observation in my own ears) depends upon spasmodic vibration of the
tensor tympani or stapedius muscle. Sometimes the seat of the
sensation is in the auditory nervous apparatus proper. It has, not
seldom, a marked connection with brain-exhaustion. An attack of
Menière's disease (labyrinthine vertigo) is often preceded by it. No
constant signification, however, can be attached to aural tinnitus.
Large doses of quinine or of salicylic acid will occasion it in many
patients.
Very briefly, deafness may be here disposed of by mentioning that, in
greater or less degree, it may be produced by accumulated wax in the
ear; obstruction of the Eustachian tube; thickness of the membrana
tympani; perforation of that membrane; mucus or pus in the middle ear;
disease of the ossicles of the ear; paralysis of the auditory nerve;
typhus or typhoid fever; excessive doses of quinine or salicylic acid.
Vertigo is chiefly of two kinds, dizziness or giddiness (swimming in
the head), and reeling vertigo, or a disposition to fall or turn to
one side or the other. Giddiness is produced by running or whirling
many times in a circle, or, in some persons, by swinging rapidly or
sailing. Reeling vertigo is mostly observed in connection with
disorder of the brain or of the labyrinth of the ear (Menière's
disease). Dizziness, with nausea, is common as a symptom of cholæmia
(cholesteræmia of Flint) in what is popularly called a bilious attack.
Delirium is present in many acute disorders, and not infrequently at a
late stage in pulmonary phthisis. Its special study will be taken up
in connection with the special articles upon these affections.
Coma, or stupor, is met with chiefly in the following morbid states:
severe typhus or typhoid fevers; malignant scarlet fever; small-pox;
rarely in measles; pernicious malarial fever; uræmia; apoplexy; opiate
narcotism, or that from chloral or alcoholic intoxication; asphyxia
from inhaling carbonic acid gas, ether, chloroform, etc.; fracture of
the skull with compression of the brain.
For an account of aphasia and other morbid psychological
manifestations the reader is referred to the articles on Aphasia,
Insanity, Hysteria, etc. in this work.
Physical and Instrumental Diagnosis will be treated in connection with
those diseases in which they have special importance.
{167} PROGNOSIS.
The elements of medical prognosis are essentially involved in
diagnosis. Our ability to anticipate the mode of progress, duration,
termination, and results of any case of illness depends upon our
knowledge--1, of the nature of the malady, with its tendencies toward
death, self-limitation, or indefinite continuance; 2, the soundness or
imperfection of the patient's constitution, with or without special
predispositions or the consequences of previous ailments; 3, the
present state of his system as to the performance of the general
functions, his strength, and vital resistance or persistence; 4, the
probable modifying influences of medical treatment, and also those of
situation, surroundings, and nursing--_i.e._ the care of those
attending to the patient during the absence of the physician and
having the duty of carrying out his directions.
1. As to the nature of the malady. While every sickness must be
supposed to encroach somewhat upon the vital energy of its subject,
very few diseases (leaving aside deadly poisons and surgical injuries)
are, ab initio, certainly fatal. Hydrophobia (rabies canina) has been,
until latterly, regarded as incurable, and always mortal within a few
days or a week or two. A few cases have, during the last few years,
been reported as cured, but the diagnosis of these continues to be
somewhat doubtful.
Cancer exhibits a tendency to extend its destructive malnutrition so
as to render death inevitable unless it can be removed early and
completely, or unless the morbid process can be arrested in some
manner not yet known. Remedies, such as condurango and Chian
turpentine, which furnished hope of such an effect, have, after
prolonged trial, been abandoned as not justifying the confidence of
the profession.
Tubercular phthisis was once considered to be almost necessarily a
fatal disease, although with a very indefinite period of duration.
Under improved hygienic management, with mild palliatives and
recuperative medication, a not inconsiderable minority of cases now
end in recovery. This term may be properly applied when, with
cicatrization of a cavity or cavities in the lungs, no more tubercle
is deposited and lung-substance enough is left for good respiration,
even although the structurally changed portions of pulmonary tissue do
not undergo entire repair.
Tubercular meningitis is a nearly always incurable affection. Yet a
few instances of lasting recovery have been reported where the
diagnosis was as certain as it can be in that disease in the absence
of post-mortem examination. A child attended by myself, in whom the
symptoms had been of the most unfavorable kind, became apparently
quite well, and continued so for a month. Then it was attacked
suddenly with convulsions, which were almost unremitting until it died
within a day or two.
Gangrene of the lung is very seldom recovered from, but, unless the
diagnosis from examination of putrescent sputa has been at fault,
there have been cases in which, with the limited destruction of the
affected lung, it was not fatal.
Pseudo-membranous croup destroys life in the majority, but not in
nearly all the cases of its occurrence. It is most likely to end in
death when distinctly a part of an attack of epidemic or endemic
diphtheria.
{168} Valvular heart lesions were formerly regarded as incurable, in
the sense of restoration of the normal condition and action of the
valves impaired, yet not incompatible with years of life. This
restoration certainly very seldom takes place. But the experience of
many close observers leads to caution in anticipation of necessary and
permanent disability of the heart because of murmurs, or even
functional disturbances, seeming to prove either aortic or mitral
insufficiency or stenosis.
Aneurism of the aorta is very seldom recovered from, but, besides a
variable duration, whose period can almost never be anticipated with
exactness, there appear to have been some cases of disappearance, or
at least prolonged quiescence, of the tumor and of its morbid effects.
Yellow atrophy of the liver is one of the disorders most rarely ending
otherwise than in death.
With a course altogether indefinite in time, there appears to be a
tendency to exhaust vital energy, without self-limitation, in the
different forms of organic degeneration, such as fatty heart,
Addison's disease, chronic Bright's disease, diabetes mellitus,
cirrhosis, and amyloid degeneration of the liver, etc. The same may be
said also of the different forms of cerebral and spinal sclerosis, of
pernicious anæmia, and of myxoedema.
Lastly, it is an exception to a very general rule of fatality when a
case of trichinosis, with well-marked abdominal, muscular, and general
symptoms, ends otherwise than in death within a few weeks.
Self-limitation is familiar in the natural history of typhus and
typhoid fever, relapsing fever, yellow fever, cholera, diphtheria,
whooping cough, mumps, small-pox, varicella, scarlet fever, and
measles. In the sense of a definite duration of each paroxysm
intermittent and remittent fevers are self-limited. Are they so also
in tending toward recovery, without curative treatment within a
certain time? This has been asserted, and in the case of remittent
there is evidence that spontaneous cures do sometimes happen. Some
observers aver that ague tends toward cessation of the chills after
six, eight, or ten weeks. The obstinacy of the attacks in many
instances under anti-periodic medication seems to make it probable
that spontaneous recovery from intermittent hardly belongs to the
typical natural history of the disease.
Whether the term self-limited can or cannot with propriety be applied
to pneumonia and other acute inflammations, as pericarditis, etc., has
been a mooted question. If it be so, it appears to the writer to be
true in a different meaning of the word self-limitation from that in
which it is applied to variola or typhoid fever. Yet some nosologists
deny this distinction, and regard pneumonia as strictly a lung fever.
Some of the facts supporting this view belong to the history of
pneumonia as complicating malarial fever; _e.g._ in the winter fever
of some parts of our Southern States. It must be admitted, however,
that the inflammatory process, though morbid, is generally eliminative
or corrective of a disturbing cause which produced it, and, unless
that cause is continued or repeated in action, a limitation belongs to
the succession of stages, ending either in resolution or in adhesions,
serous accumulation, suppuration, or gangrene.
2. It is not necessary to dwell here upon the significance in
prognosis of the patient's original constitution and hereditary or
acquired {169} predispositions, or on that of results left by previous
attacks of illness. These are all obviously of importance. In a member
of a family predisposed to consumption a bronchial attack following
exposure may be much more dangerous than in others. So also a cause of
mental agitation may produce insanity in a person who inherits a
tendency thereto or who has before had an attack of mental
derangement, while it would be innocuous to another who has no such
proclivity. A second or third attack of delirium tremens is much more
dangerous to life than a first attack. On the other hand, if yellow
fever occurs at all in a patient who has before had it, the course of
the disease is apt to be milder than usual. The most striking example
of the influence of previous disease is seen in the comparative
mildness of varioloid--_i.e._ small-pox modified by the system having
been placed under the action of the vaccine virus.
3. Most important of all data in prognosis are, in most cases, the
indications of the present state of the patient's system as to the
performance of the organic functions, his sum of energy, and vital
resistance and persistence. Especially must these indications be
regarded comparatively; that is, ascertaining whether, in a period of
weeks, days, or, sometimes hours (in malignant cholera even of
minutes), the patient's general condition has been and is gaining or
losing in the evidences of strength and healthy function of the great
organs.
Every student of clinical medicine must become acquainted, as soon as
possible, at the bedside, with these tokens and evidences, which make
almost the alphabet of practice: What is a good, a doubtful, and a bad
pulse? How does a patient breathe when moribund from simple
exhaustion, and how does such respiration differ from the toil and
struggle of asthma or the stertor of narcotism? Why does a glance
suffice to make known to a surgeon the state of collapse after a
railroad accident, or to a physician that of cholera or pernicious
intermittent? What is the impression given to the finger upon the skin
by intense fever, and what by the relaxation which precedes death?
These and many other such questions are to be answered fully to each
student only by the use of his own senses, with such interpretation as
is to be obtained by the careful comparison of cases, with the aid of
books and didactic instruction.
To a well-trained eye and hand a look and a touch will often suffice
to make known the commencement of convalescence or of the precipitous
decline toward death. Yet a wise physician will be very cautious in
acting upon even seemingly obvious prognostications. Changes may be
going on in important organs whose effects have hardly yet begun to
show themselves, and which may after a while materially alter the
aspect of the case. Particularly near the beginning of an attack of
enthetic disease, such as scarlet fever, small-pox, typhus or typhoid
fever, the physician should beware of too confidently forecasting the
progress of the case for better or for worse. In nothing, probably, is
the prudence of a practitioner more often or more severely tested than
in his answers to inquiries made concerning prognosis.
4. Anticipation of the modifying action of remedies is undoubtedly a
proper factor in our estimate of the probable result of any case of
illness. Few diseases, however, are as yet so subject to control by
specific medication as to allow certainty in such expectations. In a
first attack of ague we may look with much confidence toward the
speedy cure of our {170} patient under quinia. In one who has had
chills all winter even this confidence may need qualification. A
sufferer with syphilitic rheumatism may generally be promised relief
under the use of iodide of potassium, or one afflicted with scabies
under the application of sulphur ointment. We seldom have misgivings
about our ability to give relief in colic, constipation, or diarrhoea.
Yet the first two of these may prove to be symptoms of intestinal
obstruction resisting treatment, and the last may depend upon chronic
ulceration of the bowel, giving it unexpected continuance. In all such
instances careful and (when practicable) accurate diagnosis must
precede prognosis; our estimate of the action of remedies becomes then
a secondary, although often a valuable, part of the calculation of the
probabilities of the case.