Diagnosis in the office and at the bedside...

Front matter

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In the diagnosis of a given disease it is essential that the physician rest his opinion not upon one or two symptoms, but upon a series of symptoms which when properly put together give him a complete, or nearly a complete, picture of the malady. It is as futile for a physician to attempt to base a diagnosis upon a single symptom as for an architect to attempt to determine the appearance of a house by seeing one of the stones which has been removed from its walls.

Preface To Seventh Edition

This volume is essentially devoted to a plan whereby a recognition of symptoms will lead the physician to a diagnosis. To accomplish this the symptoms used in diagnosis are discussed first, and their application to determine the character of the disease follows. Thus, instead of describing locomotor ataxia or myelitis, there will be found in the chapter on the Feet and Legs a discussion of the various forms of loss of power in the legs, so that the physician who is consulted by a paraplegic patient will be able readily to reach a diagnosis. In the chapter on Cough and Expectoration it is pointed out that hemoptysis may be due not only to pulmonary tuberculosis, but also to cardiac valvular disease, to pulmonary infarction, thoracic aneurysm, bronchiectasis and purpura, and these facts lead to differentiation. So, too, in the chapter on Vomiting, its significance, both local and remote, is discussed. In other words, this book is written upon the plan which is actually followed in practice, namely, the upbuilding of a diagnosis by grouping the symptoms. Under the older methods the reverse of this plan was followed, whereby the physician was compelled to make a supposititious diagnosis and then to turn to his reference book to compare the symptoms of his patient with the text dealing with the supposed disease. If the description failed to coincide with the symptoms of his case he was forced to make another guess and read another article.

Laboratory diagnosis is now so highly developed that it requires special volumes for its description. As there are several excellent books of this character, the author has omitted laboratory methods from his text in order that his intention of considering symptoms as they appear in the orifice and at the bedside may be the better carried out.

H. A. H.

N. W. COR. EIGHTEENTH AND SPRUCE STREETS, PHILADELPHIA, JANUARY, I9I4.

Introduction

GENERAL DIAGNOSTIC CONSIDERATIONS.

Chapter I. The Face And Head

The expression and color of the face — Facial deformity — Facial paralysis, unilateral and bilateral — Ptosis — Facial spasm — The shape of the head — The movements and position of the head and neck ... 25

Chapter II. The Hands And Arms

The general appearance of the hands and arms — The shape of the hands in disease — Spasms of the fingers — Tremors of the hands — Paralysis of the hands and arms 49

Chapter III. The Feet And Legs

The general appearance of the feet and legs when clothed — The gait — Spastic paraplegia — Paraplegia without spastic contraction — Crural monoplegia — Deformities of the feet and legs — The joints — Alterations in the nutrition of the feet and legs aside from a change in the muscles 73

Chapter VII. The Tongue, Mouth, Pharynx, And (esophagus

The general appearance of the tongue — Its coating — Its appearance in poisoning — Fissures and ulcers of the tongue — Eruptions on the tongue — Atrophy and hypertrophy of the tongue — Paralysis — Tremor and spasm of the tongue — Tonsillitis — Diphtheria — Pharyngitis — Disease of the oesophagus 191

Chapter VIII. The Thorax And Its Viscera

The inspection of the normal and abnormal chest — Their topography — Alterations in the shape of the thorax — The rhythm of the respirations — The results of using inspection, palpation, percussion, and auscultation in health and disease — -The characteristic signs and symptoms of the various diseases of the thoracic organs . ... . 208

Chapter IX. The Pulse, Bloodvessels, And Blood-pressure

Feeling and counting the pulse — The condition of the bloodvessels on palpation — The quality, force, tension, and volume of the pulse in health and disease — Blood-pressure in health and disease . . . . 278

Chapter X. The Abdomen And The Abdominal Viscera

The surface of the abdomen — Changes in the appearance and shape of the abdominal wall — The signs and symptoms of disease of the abdominal organs 298

Chapter XI. The Bowels And Feces

Constipation and diarrhea — The cause of these two symptoms and their diagnosis — The diseases in which these symptoms occur — Choleraic diarrhea — Dysentery— The color of the feces— Intestinal parasites . 329

CONTENTS XI

Chapter XII The Urinary Bladder And The Urine

Disorders and diseases of the urinary bladder — Retention of urine — Incontinence of urine — The characteristics of normal and abnormal urine . • • 343

Chapter XIII. The Eye

The general diagnostic indications afforded by the eye — Diplopia and disorder of the external ocular muscles— Strabismus and squint — Disorder of the internal ocular muscles — The pupil — Hemianopsia — -The visual fields — Color vision — The optic nerve and its lesions — Retinitis — Amblyopia and blindness 359

Chapter XX. Pain

The kinds of pain — The significance of its locality — Colic . . . . 478

CHAPTER XXL

TENDON REFLEXES AND MUSCLE TONE.

The knee-jerk and ankle clonus — The arm-jerk — The significance of

decreased and increased reflexes 494

DIAGNOSIS.

INTRODUCTION.

GENERAL DIAGNOSTIC CONSIDERATIONS.

A clear understanding by the physician of the value of the symptoms of disease which he sees and of those described by the patient is of vital importance for the purpose of diagnosis and treatment, and one of the advantages of older physicians over their younger brethern is the ability which they have gained through long training to grasp the essential details of a case almost at their first glance at the patient. Much of this ability is unconsciously possessed because it is gained by a gradual process, yet it is none the less valuable, and its possession often impresses the patient with the insight which his physician has into his case. At first it is impossible for the novice to cast aside the minor symptoms, which the patient emphasizes as his major ones, and to perceive clearly that one or two facts that have been belittled in the narration of the story of the illness are in reality the stalk about which everything else in the case must be made to cluster.

While the physician should train his eye to take note of all variations from the normal which are shown by the patient, he must be careful not to permit himself to depend for his diagnosis on these signs alone nor upon those described by the sick man. On the contrary, he should carefully train his senses of touch, hearing, sight, and discover the so-called physical signs which can be elicited only by auscultation, percussion, palpation, and mensuration. The objective symptoms seen by the physician, the subjective symptoms described by the patient, and the so-called physical signs elicited by the methods just named, are to be joined together in forming a diagnostic view of the case. Unless this combination is made, a faulty diagnosis will often be reached. In many instances chemical and microscopic examinations of the blood, the urine, the feces, and even of the tissues themselves, may be needful to determine in a given case what the ailment may be.

Again, it is never to be forgotten that negative signs are as important as positive signs in many cases. The absence of a heart

1 8 INTRODUCTION

murmur in a case of failing circulation is not a sign that the heart valves are healthy, but that the heart is too feeble to make a murmur, and the absence of rales or clearly heard breath sounds in a lung may be due to engorgement without exudate instead of indicating that the lung is not diseased.

The Art of Observing the Patient. — Let us suppose the patient before the physician is one who has been able to walk into the office or dispensary. The attentive physician can at once gather much information about the case from the clothing, the gait, the build, the voice, the expression, and the manner. The thin man, with a peaked face and provided with an unusually warm overcoat, and still further wrapped up with a muffler almost to his eyes, is in all probability a sufferer from some pulmonary or throat difficulty, while the heavily built, phlegmatic individual, with a large head and well-filled paunch, is much more apt to suffer from gastro-intestinal or biliary catarrhs. Such a person will probably be one who habitually wears his coat open on the coldest days. Again, chronic drunkards, or persons whose mental powers are failing, often are exceedingly careless about their clothing, buttoning the coat or the trousers with the wrong buttons, and keeping the garments dirty and spotted. Some cases of diabetes have first been discovered by the white spots on the trousers, as the result of the patient having allowed a few drops of urine to fall on the cloth, where they have dried. Old men who have incontinence of urine often wear trousers which are stained in front, and they often have an ammoniacal odor about them from this cause.

The various forms of gait which indicate actual disease will be found discussed in the chapter on the Legs and Feet, but it may be mentioned in passing that, in addition to these changes, which are dependent upon actual disease of the legs or the nervous system supplying them, the bearing and stride of a patient will often give a clear idea of his general tone. The neurasthenic patient walks feebly or with a step that might be called ataxic, while the strong, hearty man of good physique strides along with a gait quite different from this, or from that of an individual who is delicate and feeble.

Similarly, the patient's build betokens disease or health. The thin, tall, and hollow-chested person is recognized as a fair mark for the tubercle bacillus, and the heavy, closely knit, phlegmatic man as one who may suffer from hepatic or circulatory disorders. Again, the bearing of a person possessing a highly organized nervous system shows itself in the constant activity of his mind and body. No part is quiet for more than a moment, and drugs are more apt to produce extraordinary symptoms as the result of idiosyncrasies in this type of patient than in any other,

The breath of the patient may call the physician's attention to

GENERAL DIAGNOSTIC CONSIDERATIONS 1 9

some important facts in connection with the case. If it is sweet or vinous in odor, this -may be due to diabetes mellitus; or if it be ammoniacal or urinous, uremia may be present. The previous use of bismuth may give it a garlic-like smell, due to the contaminating tellurium and various aromatic or volatile drugs, such as turpentine or copaiba, may be eliminated in the breath. In cases of advanced bronchiectasis the breath is often foul, and is insupportably so in gangrene of the lung and sometimes when an empyema has ruptured into a bronchus. It is similarly offensive in gangrenous stomatitis, and often very disagreeable in tonsillitis. In diphtheria it has a peculiarly sickening and sweetish odor. When the odor is not dependent on these causes it may be due to ozena, or chronic atrophic nasal catarrh, to the presence of decaying food between the teeth, or secretions in the crypts of the tonsils. Moderate fetor is usually due to disordered digestion and constipation.

When the physician has gathered as much information as possible as to the age and general condition of his patient, by a careful scrutiny of his face and extremities, of which scrutiny, however, the patient should be unconscious, he should ask him to tell what brings him for advice, and, as a rule, this will be the opportunity the sufferer seeks to pour out the story of his ailments as he sees or feels them. Often the story will seem wearisome, and, to the educated mind of the physician, wandering or unnecessary; but to the patient every word seems of the greatest importance, and to show any lack of interest may give the impression of carelessness, or it may interrupt the story just as a most important symptom is about to be described. Even if the patient is unable to convey in words a very clear idea of his condition, the manner in which his story is told, the character of his speech, and the expression of his face while speaking may give useful information as to his ailment or general state.

If, instead of the patient being an office or dispensary case, he is one who is being visited at home, the fact that the patient meets the physician in one of the living-rooms rather than in a bed-room indicates either that there is little immediate danger in the case, or at least, that the difficulty is not acute, but chronic in type, as some slowly progressing form of pulmonary, cardiac, or renal disease. Of course, there are exceptions to this rule, as in the case of a patient who, having caught a heavy cold, is remaining indoors, but not in bed, for prudence's sake. Or, again, if on seeing the patient we find him sitting in a chair only partly dressed and propped up with pillows, or instead leaning forward upon the back of a chair placed in front of him, we know that he is the subject most probably of an acute or chronic heart disease, most likely an acute exacerbation of the latter. A glance at the face of such a patient, revealing a trembling nostril, blue lips, or an anxious

20 INTRODUCTION

fades, will aid still further in directing attention to the heart or lungs, and the hands, if examined, will appear relaxed and livid or darkened in hue, indicating capillary stasis and deficient oxidation in the blood. In other cases, however, the patient found sitting propped up with pillows may be a convalescent from some Jong illness; but if so, the general atmosphere of the patient is better, and the surroundings are apt to be more tidy.

If we find the patient in bed, he may be lying abnormally quiet as the result of faintness or acute nausea, or, perhaps, from partial or complete coma due to cerebral or renal disease, or from the effects of some drug; or, again, he may be rolling about the bed from the pain of acute belly-ache, or be keeping his legs and body very still while his hands and head are ever on the move to prevent anything from suddenly approaching or touching his abdominal wall, as in peritonitis. The striking difference between the activity of the head and the fixation of the lower part of the body, in peritonitis, is notable. Sometimes, however, anxious restlessness indicates acute internal or external hemorrhage; but here the movements are minute though active, and the patient does not expend so much strength as he does when suffering from pain.

In acute articular rheumatism the patient lies, if many of his joints are involved, in a peculiarly helpless position, as if he were glued fast to the bed, although the active movement of the eyeballs as they follow persons moving about the room gives quite a different aspect from that of a patient immovable from stupor.

Usually a patient who is lying on his side turns on his back as the physician or nurse approaches, in order to face his visitor; but if he persistently remain on the side without moving, except partly to turn his head, we may suspect that in that posture he is most comfortable, and that the position is assumed for its comfort or to relieve pain or dyspnea, which are suffered from when another attitude is taken. Thus, in acute pleurisy the patient lies with the affected side uppermost, because it is too sore to permit him to touch it to the bed; whereas if the stage of effusion has arrived, he lies on the affected side, in order to give the side which is healthy free play in compensatory respiratory movements, and to remove the pressure of the effusion from the healthy lung. If the patient lying in this posture is not suffering from pleurisy, his position may be due to an effort to relieve the discomfort caused by an enlarged liver. The fact that the patient lies constantly on the back is also a characteristic of grave and advanced disease in some instances. Very ill persons almost never lie on the side and the fact that a desperately ill patient of yesterday is found lying on the side today is encouraging.

Persons with severe heart disease, emphysema, or chronic bronchitis are rarely, if ever, able to lie prone in bed, and have to be

GENERAL DIAGNOSTIC CONSIDERATIONS 21

more or less propped up with bed-rests and pillows. Large growths in the abdominal cavity producing pressure on the diaphragm also necessitate this semiprone posture, and double pleural effusions, or pulmonary consolidation or edema, require the upright or halfreclining attitude in order that the upper parts of the lung may be used to advantage.

In asthma the patient frequently is found sitting up in bed with the arms reaching back of the hips as props to fix the chest and to hold the body erect. So too in advanced cardiac and renal disease the patient will often take a seat in a chair and rest the head and hands on the back of another chair placed in front of him, both eating and sleeping in this attitude.

Again, if the patient wakes when spoken to and then drops off to sleep at once, some form of poisoning may be present, as from opium, or the poisoning of advanced hepatic or renal disease may be present.

(For the significance of picking at the bedclothes, see chapter on the Hands and Arms.)

The Art of Questioning the Patient. — We can next pass to a consideration of the objects to be sought in questioning a patient as to the illness from which he is suffering. Often much information can be gained by a well-directed question, and a favorable impression can be made upon the patient by the manner in which it is put and the bearing which it has on his case. Thus, if a man is evidently much emaciated and his clothes fit him loosely, a question in regard to his loss of flesh is very appropriate; but if he is manifestly too stout for comfort such a question will be most unwise. Or, again, if a young married woman comes complaining of constant sickness of the stomach and a fanciful appetite, and the physician directs all his questions to the condition of the stomach without an eye to a slight increase in size about the waist or below it, his professional acumen is in grave danger of being libelled by that same woman, who knows, or soon finds out, that her discomfort is due to pregnancy.

If the woman is unmarried and there is no evidence of gastric disorder on her tongue, it is well to remember what Battey, of Georgia, said in regard to this condition: "Always believe a young unmarried woman with abdominal tumor, of high social position and unimpeachable virtue, if she has been watched over by a platonic and abstemious young cousin of the male persuasion while the mother went out, to be pregnant."

Again, if a married woman of some years tells her physician that she has no children, the physician naturally asks some questions which elicit the fact that she has had frequent miscarriages. He in this way finds out quite as much about probable syphilitic infection as if the question had been put: "Have you ever had a

2 2 INTRODUCTION

sore on your privates?" which would embarrass the patient, produce domestic troubles, and probably be lied about if her husband is forced to answer the question.

Again, when asking a woman about the health of the living parents, or the cause of death of the dead, care should be taken not to ask a direct question, as, for example, whether the mother has died of cancer, for the patient may be already greatly worried lest she has that disease. It is better to ask the cause of death, or of the illness she is suffering from. If the story is that the parents died of "bronchitis," the real cause of death was probably tuberculosis of the lungs.

If the patient complains of pain, past or present, the best way in which to discover its true seat is to ask him to place his hand on the affected part, as in this way errors in his description of his anatomy will not be committed, and false impressions will not be conveyed to the physician's mind. Even this direct method, of showing the area of pain is not to be absolutely relied upon, for often pains are referred to parts in which there is no disease. Thus, the pain of coxalgia is apt to be felt in the knee and ankle, and in children the pain of pulmonary or cardiac disease is often described by the patient as felt in the abdomen. If the pain has been really abdominal, there will, in many cases, have been diarrhea or free passage of flatus. It is not to be forgotten, on the other hand, that a question which discovers the fact of several movements of the bowels does not prove the presence of true diarrhea, because a purgative may have been taken by the patient.

In asking questions as to constipation, the physician must not forget that the opinion of the patient as to what constitutes regularity of bowel movement is of very little value in many instances. A daily movement is not known to many patients, and a movement every few days may be quite sufficient to justify the statement, in their opinion, that no constipation is present.

The young physician, in particular, in asking questions of women patients of the better class, should not hesitate to ask direct questions as to the state of the bowels or of the menstrual function. To hesitate or ask indirect questions about such matters simply produces embarrassment which otherwise would not exist, and intimates that the question is one of doubtful propriety, when in reality it is most important and proper.

The Examination of Children. — If the patient to be examined is a child, it is well for the physician to remember that his presence as a stranger may be a source of alarm, and that the association in the child's mind of sickness and the doctor, and badly tasting medicines, is sufficient to render him a much-to-be-dreaded individual. Generally it is best, on entering the room where the child is, to pretend to pay no attention to it whatever, but to engage in con-

GENERAL DIAGNOSTIC CONSIDERATIONS 23

versation with the mother or other person, speaking of the case in a way which the child will not understand. Very often this very lack of attention will result in the child forcing the recognition of his presence upon the physician by making the first advances toward friendship, and this is particularly apt to be the case if the child is already spoiled by overattention by the family and friends. Time should always be given the child to grow accustomed to the peculiarities of the visitor, and if any instrument for diagnosis is to be employed it is best to hold it in the hand as if it were a plaything before attempting to put it into actual use. The tact which the physician must exercise in diverting a sick child is essential to the successful treatment of children. Some physicians are welcomed to a house by the sick and well as Santa Claus would be, and others, devoid of the trait of amusing children, are fled from as if they were dragons.

During the time that the physician is allowing the child to get accustomed to his presence he should be gaining much useful information about the case by observing the movements and expressions of the child; its color, size, nutrition, breathing; the shape and size of its head; the condition of its lips, whether moist or dry, red, livid, or pale; and, if the child is speaking, the tone of its voice, or, if crying, the character of its cry. It is needless to state that a child may cry from fright, pain, anger, or hunger. Constant screaming is, however, nearly always due to the pain of earache or hunger, for abdominal colic is usually intermittent. If there be pain in the ear, the hand will often be rubbed over the affected side of the head, and the child will not be pacified by the offer of the breast. If the child coughs, and then rjegins to cry, pneumonia or pleurisy may be present; or in other cases the pain is so great that the child is cryless. A sharp, piercing shriek indicates the pain of earache or of meningitis in many cases. (See chapter on Headache.)

If a crying child be placed at the breast, which it takes with avidity only to drop the nipple in a moment with a cry of pain or anger, one of several conditions is present: either the child has stomatitis or the breast is empty; or, again, if it seizes the breast and then lets go with a gasp, it may have coryza or syphilitic snuffles, which prevents it from breathing through the nose while sucking. Similar signs may be present in any other condition producing shortness of breath.

If a child over four months of age cries and sheds no tears in the course of an illness, this is an unfavorable sign.

It is important to notice whether there is languor or a tendency to play. A healthy infant, when awake and well fed, is always kicking^ and cooing and moving its arms about, and has a happy expression on its face; whereas if any cerebral trouble is present

24 INTRODUCTION

it often has an anxious frown, or its hands are placed on the side of its head or rubbed over the vertex.

In a perfectly healthy child which is sleeping, the respiration should be practically inaudible, and it is a good practice to note the regularity of the breathing in all patients while they are asleep, as it is then unaffected by voluntary effort. In children a sighing breathing, or one disturbed in rhythm, often indicates a disturbed digestion or fever.

The physician should always, by careful questioning of the nurse or mother, find out how long the illness has lasted, the manner in which it began, the fact as to whether a similar attack has occurred before in this or other children of the family, and the state of the temper, appetite, bowels, and urine of the patient, for an irritable temper in a child means ill health, as does also a poor appetite, constipation, diarrhea, or abnormal urine.

The expression of the face, shape of the head, and similar noteworthy points in the diagnosis of the case will be more thoroughly discussed in the chapter devoted to these parts. (See chapter on the Face.)

When it comes to a close examination of an infant, great care must be exercised. The character and rapidity of the respirations are best studied at a distance before excitement has disturbed them, and the best way to listen to a young child's chest is when it is held over the shoulder of the mother, as if she were carrying it for a walk, or, if the infant can be taken in the physician's arms, its buttocks should rest on one hand, while the front of its chest rests against the other. In this way the physician can listen to the back of the chest without difficulty, keeping the child amused by walking up and down the room while it is in his hands.

If it is not possible by any bribe to cause the child to protrude the tongue for examination, the physisian will often be able to see this organ when the mouth is widely opened in crying.

In taking a child's pulse it is best to take it while it is asleep, if possible, as the excitement of the physician's visit or the crying on awakening will greatly increase the pu]se-rate.

Chapter I. The Face And Head

The expression and color of the face — Facial deformity — Facial paralysis, unilateral and bilateral — Ptosis — Facial spasm — The shape of the head — The movements and position of the head and neck.

So much can be learned by the physician from the expression and general appearance of a patient's face and the carriage and shape of his head that a careful inspection of these parts should always be made. For this reason, in the consulting-room and at the bedside, the physician should always arrange his chair in such a way that the light falls upon the face of his patient, while his own is in the shadow, and this is of importance not only because the facial expression of the patient can thus be well seen, but also because it prevents the patient from making a too close scrutiny of the physician's face with the object of detecting encouragement, lack of sympathy, or alarm.

THE FACE.

The Expression. — The expression is produced by the formation of creases, or alterations in the contour of the skin and subcutaneous tissues by trophic and muscular action, and these changes are in time brought about and perhaps made permanent by the mental tendencies and habits of the patient, his temperament, his intellectual development, his exposure to outdoor or indoor influences, and, finally, and these are very important, by pathological processes which may be going on somewhere in his body. The temper of the man also affects his expression, particularly as he approaches middle life, and he looks amiable, capable of sudden anger, or sullen, as the case may be.