Physical diagnosis

Front matter

Class.

COPYRIGHT DEPOSIT m

5*

Preface

This book endeavors to present an account of the diagnostic methods and processes needed by competent practitioners of the present date. It differs from other books on the subject in that it makes no attempt to describe technical processes with which the writer has no personal familiarity and gives no space to the description of tests which he believes to be useless.

To gain genuine familiarity with all the technical processes described in most books on physical diagnosis — such familiarity as makes one competent to use them with due regard for the sources and limits of error inherent in them — needs more than the life-time of one man. But unless one has one's self used a technical process long enough to gain this sort of mastery over it, one cannot properly describe it, far less recommend it to others. Because of my lack of personal acquaintance with such methods as cystoscopy, ophthalmoscopy, and laryngoscopy I have attempted no description of them, although I believe they should sooner or later be mastered by every internist. All that I have described I know by prolonged use.

A book constructed on this basis should make obvious what its writer considers important and what unimportant, and reveal therein not only his opinions but his personal limitations. Bat I believe there is no longer a demand for books that attempt impartially to present all that has been or is now thought of value by some one. The personal equation cannot and should not be ignored. In diagnosis as in therapeutics " What do you find valuable ? " is the question that our contemporaries ask of any one of us, not " What has been recommended ? "

In the endeavor further %o break down the false distinction be-

VI PREFACE.

tween clinical diagnosis and laboratory diagnosis I have described all the methods of getting at an organ — e.g., the kidney — in a single section. Palpation, thermometry, urinalysis are different processes by which we may gather information about the kidney. The student should be accustomed to think of them and practise them in close sequence.

For the same reason the most important methods of investigating the stomach have been grouped together without any distinction of "clinical" and "laboratory" procedure.

For the illustrations I owe many thanks to many persons, especially to Drs. Frank Billings, A. E. Boycott, E. G. Bradford, E. E. Carson, J. Everett Dutton, K. T. Edes, Joel E. Goldthwaite, J. S. Haldane, Frederick T. Lord, R. W. Lovett, H. C. Masland, S. J. Meltzer, Percy Musgrave, R. F. O'Neil, J. E. Schadle, William H. Smith, W. S. Thayer, and G. L. Walton ; also to the editors of the Boston Medical and Surgical Journal, the St. Paul Medical Journal, American Medicine, The Journal of Experimental Medicine, and The Lancet.

My assistant, Dr. Mary W. Rowley, has helped me very much with the index as well as with other parts of the book.

190 Marlboro St., Boston.

June, 1905.

Chapter I. Data Relating To The Body As A Whole

PAGE

1. Weight, 1

(a) Causes of Gain in Weight, 1

(b) Causes of Loss in Weight, 2

2. Temperature — Technique and Sources of Error, ... 2

(a) Causes of Fever, 2

(b) Types of Fever,' 2

(c) Subnormal Temperature, 2

(d) Chills and Their Causes 2, 3

Chapter II. Diseases Of The Head, Face, And Neck

I. The Cranial Vault 5

1. Size, Shape, ; . 5

2. Fontanels, 6

3. Hair, 7

II. The Forehead, 8

III. The Face as a Whole 9

IV. Movements of the Head and Face, 13

V. The Eyes, 13

(a) Ocular Motion, 16

(b) The Retina, 16

VI. The Nose, 17

VII. The Lips 18

VIII. The Teeth, 20

IX. The Breath, 21

X. The Tongue, 22

Vlll

TABLE OF CONTENTS.

PAGE

- XI. The Gums, 24

XII. The Buccal Cavity, 25

XIII. The Tonsils and Pharynx, 26

XIV. The Neck, 29

(a) Glands, 29

(b) Abscess or Scars, 31

(c) Tumors and Cysts, . 31-34

(d) Vertebral Tuberculosis, .33

(e) Actinomycosis, 34

(/) Cervical Rib, 34

Chapter III. The Arms And Hands; The Back

The Arms.

I. Paralysis 35

II. Wasting of One Arm, 37

III. Contractures, 37

IV. (Edema, 38

V. Tumors, 38

VI. Miscellaneous Lesions of the Forearm, 40

I. Evidence of Occupation, . 41

II. Temperature and Moisture, 42

III. Movements, 42

IV. Deformities, . . 46

The Nails, 52

The Back, 53

II. Sacroiliac Disease, 53

III. Spinal Curvature, . . . . - 54

IV. Tumors of the Back, . . . 54

V. Prominent Scapula, . . . 55

VI. Spina Bifida, 55

TABLE OF CONTENTS.

IX

Chapter IV. The Chest

TECHNIQUE AND GENERAL DIAGNOSIS.

Introduction,

I. Methods of Examining the Thoracic Organs, II. Regional Anatomy of the Chest,

PAGE

. 56 . 56 . 56

INSPECTION.

I. Size,

II. Shape, ....

(a) The Rachitic Chest, .

(b) The Paralytic Chest,

(c) The Barrel Chest,

III. Deformities,

(a) Curvature of the Spine,

(b) Flattening of One Side of the Chest,

(c) Prominence of One Side of the Chest,

(d) Local Prominences, .

IV. Respiratory Movements,

(a) Normal Respiration,

(b) Anomalies of Expansion, .

1. Diminished Expansion,

2. Increased Expansion,

(c) Dyspnoea, ....

V. The Respiratory Rhythm, .

(a) Asthmatic Breathing, (5) Cheyne-Stokes Breathing,

(c) Restrained Breathing,

(d) Shallow and Irregular Breathing

(e) Stridulous Breathing,

VI. Diaphragmatic Movements (Litten's Phenomenon)

VII. The Cardiac Movements,

1. Normal Cardiac Impulse, .

2. Displacement of the Cardiac Impulse

3. Apex Retraction, ....

4. Epigastric Pulsation,

5. Uncovering of the Heart, .

61 62 63 64

67 68

69 69 69 70 71 71

74 74 74 75 75 76

79 79

82 84 85 85

X TABLE OF CONTENTS.

PAGE

VIII. Aneurism and Other Causes op Abnormal Pulsations of

the Chest Wall, 86

IX. The Peripheral Vessels 87

(a) Venous Phenomena, . . . . . . . .88

(b) Arterial Phenomena, 89

(c) Capillary Phenomena, .91

X. The Skin and Mucous Membranes, 92

1. Cyanosis, 92

3. Pallor, 93

4. Jaundice, 93

5. Scars and Eruptions, 94

XL Enlarged Glands, 94

Chapter V. Palpation And Study Of The Pulse

I. Palpation 96

1. The Cardiac Impulse, 96

2. Thrills, 97

3. Tactile Fremitus, 98

4. Friction, Pleural or Pericardial, . . . . . .99

5. Palpable Rales, 101

6. Tender Points, 102

7. Abnormal Pulsations, . . . . . . . . 102

8. Tumors 102

9. Temperature and Quality of the Skin 103

II. The Pulse, 103

1. The Rate, . 105

3. Compressibility, 106

4. Size and Shape of Pulse Wave, . . . . . . 106

5. Tension, 108

6. Size and Position of Artery, 109

7. Condition of Artery Walls, 110

III. Arterial Pressure and the Instruments for Measuring It, 111

1. Gaertner's Tonometer 112

2. The Riva-Rocci Instrument, 113

3. The Instrument of Hill and Barnard, 114

4. The Oliver Instrument, 115

TABLE OF CONTENTS. xi

Chapter VI. Percussion

PAGE

I. Technique, .... 118

^ a ' ( Immediate Percussion, . . . . . . j"

(b) Auscultatory Percussion, 125

(c) Palpatory Percussion, 127

II. Percussion-Resonance of the Normal Chest, .... 127

(a) Vesicular Resonance, 128

(b) Dulness and Flatness, 129

(c) Tympanitic Resonance, 130

(d) Cracked-pot Resonance, 134

(e) Amphoric Resonance, 135

(/) The Lung Reflex, 136

III. Sense of Resistance, 136

Chapter VII. Auscultation

1. Mediate and Immediate Auscultation, 137

2. Selection of a Stethoscope, .138

3. The Use of the Stethoscope . . . 143

A. Selective Attention and What to Disregard, . . . . . . 143

B. Muscle Sounds 146

C. Other Sources of Error, 147

4. Auscultation of the Lungs, . 149

I. Respiratory Types 150

(a) Vesicular Breathing, ........ 151

(ft) Tubular Breathing, . .153

(c) Broncho-vesicular Breathing, 154

(d) Emphysematous Breathing, 155

(e) Asthmatic Breathing, 155

(/) Cog-wheel Breathing, 156

(g) Amphoric Breathing, 156

{h) Metamorphosing Breathing, 156

II. Differences between the Right and the Left Chest, . . . 157

Xll

XI. Page

Pathological Modifications of Vesicular Breathing, . . . 157

(a) Exaggerated Vesicular Breathing, 157

(b) Diminished Vesicular.Breathing, 158

Bronchial Breathing in Disease 160

Broncho-vesicular Breathing in Disease, 160

Amphoric Breathing, 161

(a) Moist, 161

Cough. Effects on Respiratory Sounds, 165

Pleural Friction, 165

Auscultation of the Voice Sound, 167

(a) The Whispered Voice, 167

(b) The Spoken Voice, 168

(c) Egophony, 169

Phenomena Peculiar to Pneumo-hydrothorax, .... 169

(a) Succussion, 169

(b) Metallic Tinkle, 170

(c) The Lung Fistula Sound, 170

Chapter VIII. Auscultation Of The Heart

1. The Valve Areas,

2. Normal Heart Sounds,

3. Modifications in the Intensity of the Heart Sounds,

(a) Mitral First Sound,

1. Lengthening,

2. Shortening,

3. Doubling,

(b) The Second Sounds at the Base of the Heart,

1. Physiological Variations, ....

2. Pathological Variations, ....

(a) Accentuation of Pulmonic Second Sound ;

(b) "Weakening of Pulmonic Second Sound,

(c) Accentuation of the Aortic Second Sound

(d) Weakening of the Aortic Second Sound,

(e) Accentuation of Both Second Sounds, (/) Summary,

TAbLE OF CONTENTS. xiii

PAGE

(c) Modifications in Rhythm of Cardiac Sounds and Doubling of

Second Sounds, 181

(d) Metallic Quality of the Heart Sounds, ...... 182

(e) " Muffled " Heart Sounds, ........ 182

4. Sounds Audible Over the Peripheral Vessels. . . .182

(a) Arterial Sounds, 182

(b) Venous Sounds, 183

CHAPTER IX. (Auscultation of the Heart, Continued.)

CARDIAC MURMURS.

I. Terminology, 184

1. Mode of Production, 184

2. Place of Murmurs in the Cardiac Cycle, 186

3. Point of Maximum Intensity, 187

4. Area of Transmission, 188

5. Intensity, Quality, and Length, 190

6. Relation to Heart Sounds, . 193

7. Effects of Respiration, Exertion, and Position, .... 193

8. Metamorphosis of Murmurs, 194

II. Functional Murmurs, 194

III. Cardio-Respiratory Murmurs, . . . . . . . . 197

IV. Venous Murmurs, . 198

V. Arterial Murmurs, 198

Chapter X. Diseases Of The Heaet

VALVULAR LESIONS.

1. Valvular and Parietal Disease, 199

2. The Establishment and Failure of Compensation, . . . 202

3. Hypertrophy and Dilatation, 205

4. Valvular Disease, 210

I Mitral Regurgitation, 210

(a) Pre-compensatory Stage, . . . ... . 212

(b) Stage of Compensation, . 213 xiv TABLE OF CONTENTS.

PAGE

(c) Stage of Failing Compensation, 217

(d) Differential Diagnosis, 218

II. Mitral Stenosis, 220

1. First Stage, . . . 222

2. Second Stage, . . 224

3. Third Stage, 225

III. Aortic Regurgitation, 229

(a) Arterial Jerking, 231

(b) Capillary Pulsation, 232

2. Palpation, 233

5. Summary and Differential Diagnosis, 237

7. Complications, 238

IV. Aortic Stenosis, 239

(b) The Pulse, 242

(c) The Thrill, 243

(d) Feeble Aortic Second Sound, 244

V. Tricuspid Regurgitation, . . . . . . . . . 246

1. (a) The Murmur, 247

(b) Venous Pulsation, 247

(c) Cardiac Dilatation 248

(d) Feeble Pulmonic Second Sound, 248

VI. Tricuspid Stenosis, 250

VII. Pulmonary Regurgitation, 251

VIII. Pulmonary Stenosis, . 252

IX. Combined Valvular Lesions, . . 253

(a) Double Mitral Disease, . . . . . . . 254

(b) Aortic and Mitral Regurgitation, 255

(c) Aortic Stenosis and Regurgitation 256

Chapter XI. Parietal Disease And Cardiac Neuroses

I. Parietal Disease of the Heart, 257

1. Acute Myocarditis, ........ 257

TABLE OF CONTENTS.

xv

PAGE

2. Chronic Myocarditis, 258

3. Fatty Overgrowth, 260

4. Fatty Degeneration, 260

II. Cardiac Neuroses, 261

1. Tachycardia, 261

2. Bradycardia, 262

3. Arrhythmia, 263

4. Palpitation, 264

III. Congenital Heart Disease, 265

Chapter XII. Diseases Of The Pericardium

I. Pericarditis,

(a) Dry or Fibrinous, ....

(b) Pericardial Effusion,

1. The Area of Dulness, .

2. The Cardiac Impulse and the Pulse,

3. Pressure Signs, ....

(c) Adherent Pericardium,

1. 2. 3. 4. 5.

Retraction of Interspaces, . . .

Limitation of Respiratory Movements,

Absence of Cardiac Displacement with Change of Position,

Hypertrophy and Dilatation not Otherwise Explained,

Capsular Cirrhosis of the Liver,

268 271

Chapter XIII. Thoracic Aneurism

Abnormal Pulsation, . 280

Tumor, .281

Thrill, ; 282

Diastolic Shock, 282

Tracheal Tug, 283

Pressure Signs, 284

Percussion Dulness, 284

(a) Murmurs, . . 285

(b) Diastolic Shock Sound, 286 xvi TABLE OF CONTENTS.

PAGE

9. Radioscopy, 287

11. Diagnosis, 288

Chapter XIV. Diseases Of The Lungs And Pleura

BRONCHITIS, PNEUMONIA, TUBERCULOSIS.

1. Tracheitis, 292

2. Bronchitis, 292

(a) Physical Signs, 293

(b) Differential Diagnosis, 294

3. Croupous Pneumonia, 296

(a) Inspection, 296

(b) Palpation, 297

(c) Percussion, 297

(d) Auscultation, . . . 298

4. Broncho-Pneumonia, . . . . 302

5. Pulmonary Tuberculosis, 304

(a) Incipient Tuberculosis, 304

(b) Moderately Advanced Cases, 308

(c) Advanced Phthisis, 311

(d) Anomalous Forms of Pulmonary Tuberculosis, .... 315

Chapter XV

v dlseases of the lungs, continued.)

1. Emphysema, 317

(a) Small-Lunged Emphysema, 317

(b) Large-Lunged Emphysema, 317

(c) Emphysema with Bronchitis and Asthma, 320

{d) Interstitial Emphysema, 321

(e) Complementary Emphysema, 321

(/) Acute Pulmonary Tympanites, 321

2. Bronchial Asthma, 322

TABLE OF CONTENTS. XVll

PAGE

3. Syphilis of the Lung, . . .323

4. Bronchiectasis, 323

5. Cirrhosis of the Lung, . 324

6. Examination of Sputa, 324

(a) Origin, 324

(b) Odor and Appearances 325

(c) Staining . .326

(d) Microscopic Examination, . 327

(e) Description of Commoner Organism, 328

Chapter XVI. Diseases Affecting The Pleural Cavity

I. Hydrothorax, . . 330

II. Pneumothorax, 330

III. Pneumoserothorax and Pneumopyothorax, ..... 332 Differential Diagnosis of Pneumothorax and Pneumohydrothorax, . 334

IV. Pleurisy, . . . .336

1. Dry Pleurisy, 336

2. Pleuritic Effusion, 338

(a) Percussion, . . 339

(b) Auscultation. 345

(c) Inspection and Palpation, 347

3. Pleural Thickening, . . . . . . . . . .349

4. Encapsulated Pleural Effusions, . . . . . . . 349

5. Pulsating Pleurisy and Empyema Necessitatis 350

6. Differential Diagnosis of Pleural Effusions, 350

V. Cyto-Diagnosis of Pleural and Other Fluids, 353

(a) Technique, 354

{b) Interpretation of Results, 355

Chapter XVII

ABSCESS, GANGRENE, AND CANCER OF THE LUNG, PULMO- NARY ATELECTASIS, GEDEMA AND HYPOSTATIC CONGESTION,

1. Abscess and Gangrene of the Lung, 357

2. Cancer of the Lung, 358

3. Atelectasis, , 359

4. (Edema and Hypostatic Congestion, . 360 xvm TABLE OF CONTENTS.

Chapter XVIII

THE ABDOMEN IN GENERAL, THE BELLY WALLS, PERITO- NEUM, OMENTUM, AND MESENTERY.

PAGE

Examination of the Abdomen in General, 362

1. The Omentum, Mesentery, and Peritoneum, ..... 362

2. Technique, 362

4. Palpation, . . 364

5. What can be felt Beneath the Normal Abdominal Walls, . . 365

6. Palpable Lesions of the Belly Walls, .367

7. Abdominal Tumors, . 368

Diseases of the Peritoneum, 370

1. Peritonitis, Local or General, . . 371

2. Ascites, 372

3. Cancer and Tuberculosis, 372

The Mesentery, 373

1. Glands, 373

2. Thrombosis, . . .373

Chapter XIX. The Stomach, Liver, And Pancreas

The Stomach, 374

1. Inspection and Palpation, 374

2. Estimation of the Size, Position, Secretory and Motor Power. . 376

3. Examination of Contents, 379

(a) Qualitative Tests, 380

(b) Quantitative Estimation of Free HC1 and of Total Acidity, . 380

4. Incidence and Diagnosis of Gastric Diseases, . . . . . 382

The Liver, 384

(ffi)-Pain, s ' 385

(b) Enlargement, 386

(c) Atrophy, .389

(d) Portal Obstruction, v . .389

(e) Jaundice, 390

(/) Loss of Flesh and Strength, ... .392

(g) The Infection Group of Symptoms, 392

(Ji) Cerebral Symptoms of Liver Disease, ...... 393

TABLE OF CONTENTS. XIX

PAGE

The Gall Bladder and Bile Ducts, 393

1. Differential Diagnosis of Biliary Colic, 393

2. Enlarged Gall Bladder, 394

3. Cholecystitis 394

4. Results of Cholecystitis, 395

The Pancreas, 395

2. Acute Pancreatic Disease, 396

4. Bronzed Diabetes, . 396