AUC ks PR ee wey Ter aah Cuneo) real oes: eee Pee bd et Ty wey i a G 7 3 3 Cie eet e ey ek hath Ane ave ey, eee cc sect Phin BABS c a Mp Fe oy ey a eee Me rat! ned ae pak CORNELL UNIVERSITY THE Hlower Peterinary Library FOUNDED BY ROSWELL P. FLOWER for the use of the N. Y. STATE VETERINARY COLLEGE 1897 Cornell University Library ' RC 71.B98 1909 | [Thi wi A | 3 1924 000 347 967 vet THE DIAGNOSTICS OF INTERNAL MEDICINE A CLINICAL TREATISE UPON THE RECOGNISED PRINCIPLES OF MEDICAL DIAGNOSIS, PREPARED FOR THE USE OF STUDENTS AND PRACTITIONERS OF MEDICINE BY GLENTWORTH REEVE BUTLER, M.D., Sc.D., LL.D. Physician-in-Chief, Methodist Episcopal Hospital; Attending Physician to the Brooklyn Hospital; Consulting Physician to the Bushwick Central Hospital, and to the Coney Island Hospital; formerly Associate Physician, Departments of Diseases of the Chest and Diseases of Children, St. Mary’s Hospital, Brooklyn, N. Y.; Fellow of the New York Academy of Medicine; Member of the Medical Society of the County of Kings; Fellow of the Society of Science, Letters, and Art (Lond.), etc. WITH FIVE COLOURED PLATES AND TWO HUNDRED AND SEVENTY-TWO ILLUSTRATIONS AND CHARTS IN THE TEXT THIRD REVISED EDITION NEW YORK AND LONDON D. APPLETON AND COMPANY T9090 Beal. Toots shel 1907, 1909, By D. APPLETON AND COMPANY PRINTED AT THE APPLETON PRESS, NEW YORE, U. s. a. PREFACE TO THIRD EDITION Tue third edition of this work—the preparation of which has nat- urally been an agreeable task—is now offered by the publishers. It again becomes a pleasure, as well as a duty, to acknowledge a number of suggestions from widely separated localities, some of which have been incorporated in this revision. There is, perhaps, no more in- teresting and reliable measure by which one can estimate the progress of our art, than the omissions, modifications, and additions which are required in successive editions of a medical book. There are few of prime importance, but many which afford much encouragement for the present and for the future. The section on Kryoscopy has been omitted, as occupying space which can be used to better advantage. The section on X-Ray Diag- nosis has been curtailed for a similar reason. I am again indebted to Dr. Henry G. Webster for essential aid. Dr. Archibald Murray has made some useful changes in the section on Examination of the Blood. The section on Examination of the Stom- ach Contents and the Feces has been much improved by Dr. Dudley D. Roberts. The section on the Nervous System has been carefully gone over by Dr. Smith Ely Jelliffe and Dr. Frederick Tilney. Dr. Thomas ©. Craig, Surgeon, U.S.A. (retired), has prepared a new sec- tion on Life Insurance Examination. A new section on Diseases of the Tropics has been compiled by Dr. Hartwig Kandt. The recent - tuberculin tests have been described and valued by Dr. Edward R. Baldwin. As in previous editions, the matter of illustration has been in the hands of Mr. Howard J. Shannon. G. R. B. 229 Gates AVENUE, BoroueH oF BROOKLYN, Crry or New York. iii PREFACE TxHIs book has been written from the point of view of practical clinical work. The physician meets primarily symptoms and signs —the evidences of disease; subsequently it is decided that the symptoms found indicate the presence of a specific ailment. This volume, therefore, naturally divides itself into two parts: first, a study of symptoms and their indications ; and, second, a study of diseases and their characteristics. Part I—The Evidences of Disease—comprises: (1) A brief con- sideration of the clinical anatomy and physiology of certain organs and systems; practical points of everyday utility. (2) A description of the approved methods of examination. It has been well said by a capable reviewer that “the basis of the art of diagnosis is a thorough knowledge of clinical methods.” (3) A careful considera- tion of the many signs and symptoms encountered in the practice of internal medicine. (4) A statement of the diagnostic significance of each sign and symptom—i. e., the disease or diseases, the pres- ence of which is more or less stronely suggested by the finding of a given sign or symptom. While a prominent symptom seldom leads directly to the discovery of a disease, yet it is of importance to know the diagnostic value of individual symptoms. Part II—Diagnosis, Direct and Differential—contains: (1) Suc- cinct descriptions of recognised diseases and their symptoms, with (2) special reference to the diagnosis, direct and differential, of each disease. The qualifying terms applied to diagnosis are scientifically indefensible, but clinically useful. The two parts are, indeed, complementary. For example, if in Part I it is stated that the finding of a persistently rapid pulse may be explained by the presence of exophthalmic goitre; or of a dry tongue and an inordinate thirst, by diabetes, one can turn to Part II and compare his case with the symptom-group of the disease in question. Conversely, when in Part II a high-tension pulse is mentioned as a symptom of angina pectoris, or Kernig’s sign of meningitis, a reference to Part I will discover the method of esti- mating high tension or of eliciting Kernig’s sign. . vi PREFACE It is hoped that, owing to its choice of material and method of arrangement, the book contains between two covers practically all that is essential for the making of a diagnosis, and that no helpful clew in obscure cases has been overlooked. The value of modern laboratory methods has been fully appreciated; so also has the importance of symptoms, subjective and objective. No one can write upon the subject of this book without lying under obligations for the major portion of his material to the Mas- ters of Internal Medicine, but, as space forbids detailed references, this brief acknowledgment must stand as a very inadequate voucher for a heavy debt. Everything, indeed, has been subordinated to the main purpose of the book, which is to facilitate in a practical way the making of a thorough examination and a correct diagnosis. It is believed that the Synopsis of Examinations, which immediately precedes the body of the book, will be found useful. Special care has been taken to secure clearness of arrangement by. the liberal use of italics and bold-face type to catch the eye; and to promote ease of reference by varying the odd-page headings, as well as by the provision of an ample, but not too bulky, index. Plates III and IV are composed of selections reproduced (with the kind permission of the authors and publishers) from the excel- lent illustrations in Cabot’s Examination of the Blood and Simon’s Clinical Diagnosis, mainly from the former; Plate V of similar selections from Thayer’s fine drawings of the malarial parasite. A large proportion of the illustrations are either original or redrawn, without, it is believed, sacrificing utility for originality. Mr. Howard J. Shannon has put my rough sketches into workmanlike and, so far as compatible with the subject, artistic form. For his aid I am indebted to the liberality of the publishers, whose imprint is a guarantee of good work and good material. The bulk of the volume (pages 1 to 908) is from my own pen. Of the remainder, Dr. Frank W. Shaw, my associate at the Metho- dist Episcopal Hospital, has prepared the sections on Parasites and the Intoxications; Dr. Henry G. Webster, my associate at the Brooklyn Hospital, those on’ Diseases of the Kidney and Constitu- tional Diseases; Dr. Henry P. De Forest, of Brooklyn, that on Dis- eases of the Blood and Ductless Glands; and Dr. Smith Ely Jelliffe and Dr. A. B. Bonar, of Manhattan, that upon Diseases of the Ner- vous System—assistance kindly given and gratefully received. Dr. J. P. Warbasse has made valuable criticisms. G. R. B. 229 Gates Avenur, BoroueH or Broox.yn, City or New York. CONTENTS ScHEDULE oF EXAMINATIONS PRELIMINARY CONSIDERATIONS . Diagnosis Difficulties in . Obtaining evidence Keeping case histories . PART I THE EVIDENCES OF DISEASE Section I. Considerations which may suggest or qualify a Diagnosis . Family history Age... Sex Nationality Occupation . ee ee ee Residence Habits Previous diseases Section II. History of Pressuk: Hliness Ssection III. Diagnostic Indications from the General, Appearance Dress and behaviour - Height and weight Amount and character of adipgas ar muscular tissue Conformation of body . Diatheses and cachexias Section IV. Posture in Bed—Mode of Moving —Gait—Station Section V. Pain a ee eo «xs j Tenderness Paresthesias Section VI. Vertigo . : Section VII. Temperament —Peyehiedl Cendiden—Tasomnia : Section VIII. Disturbances of Consciousness Diagnostic significance of Coma . Diagnosis of the varieties of Coma Section IX. General Convulsions Section X. Cutaneous Surface. Colour of skin Heat of skin vii PAGE xXXV Oow ee 13 13 15 18 “19 19 21 22 22 25 27 27 28 29 30 31 33 38 60 62 66 68 74 74 75 79 83 83 89 viii CONTENTS Moisture of skin Rash or eruption Cicatrices Dropsy, cedema, anasarca Condition of veins . Emphysema of skin Condition of joints ‘ Bo Ge ok. us. Se Section XI. The Temperature of the Body — Fever : Terminology of : Diagnostic classification of . Chills Section XII. General Diagnostic Evidence from the Digestive and Genito-urinary Systems Appetite . Thirst Vomiting and gross @iartter of the vomitus Indications from presence of vomiting Indications from macroscopic character of vomitus Defecation and gross character of the stools Constipation Diarrhea Fecal incontinence Painful defecation Rectal tenesmus Character and abnormal soiiients of steals Urination Symptoms belonging to ‘the genitalia Males Females Section XIII. Symptom Groupe of Clinical Significance Coma: Dyspnea: Fever Hyperpyrexia: Internal hamnearhiage: Shock or collapse Syncope: Weakness or aceite 4 Irritant poisoning: Jaundice: Obstructed portal circulation: Suppura- tive or hectic fever: Pyemia: Tympanites: Typhoid status Section XIV. Head and Face Size and contour Fontanels and sutures . Cranial bones . The facies of disease Colour of the face . Skin of the face The hair . (Edema or swelling rat the fine Abnormal movements of the head Abnormal fixity of the head. Facial spasm . on ois Facial paralysis PAGE 91 94 95 99 100 101 104 109 111 115° 120 122 122 123 123 126 132 135 136 138 140 141 142 142 155 160 160 162 165 165 166 167 168 169 170 170 174 176 176 179 180 181 182 182 183 183 185 CONTENTS Srction XV. The Ear Section XVI. The Eye The eyelid The conjunctiva, slaiotic and cornea The pupil The eyeball Vision : : ; Section XVII. The Nose . Section XVIII. The Mouth Lips é Buccal cavity . Gums Teeth Tongue Section XIX. The Palate, Toneils, and Pharynx. Section XX. Dysphagia : Section XXJ. Examination of Larynx Laryngeal paralysis ‘ Section XXII. Voice and Speech Aphasia Section XXIII. Cough Section XXIV. Sputum and its Gross Chanel Section XXV. The Neck . Section XXVI. The Extremities Nails Hand and fingers Arm Foot and leg Section XXVII. The Bugle Section XXVIII. Theory and Practice ‘s Palpation,, heacaleation, ne Percussion 5 Srecrion XXIX. The Chest (Thorax) Section XXX. Anatomical Landmarks and "Popdsraphical Areas of the Thorax Secrion XXXII. Examination of the Circulatory Syste : Pathological physiology of valvular defects Topographical anatomy of the heart and its valves Physical examination of the heart and its neighbourhood Inspection and palpation Percussion of the heart Auscultation of the heart . Endocardial sounds (murmurs) Exocardial sounds Physical examination of the blood oaasels {ineluding he pulse) The pulse ‘ The sphygmomanometer . The sphygmograph Section XXXII. Examination of hie Lungs and Pleuns ; Topographical anatomy Physiology of the lungs B ix PAGE 191 196 196 199 201 206 219 228 235 235 236 239 240 242 250 254 255 257 260 263 273 276 280 288 288 289 295 296 301 304 314 322 326 332 338 341 341 350 359 367 380 383 387 388 407 411 411 413 x CONTENTS Inspection and palpation with reference to the lungs Percussion of the lungs x tal 8 mH eet Technic Results of permieauas in apriial lungs Results of percussion in disease of lungs or pieiee, or ‘ai neal bouring organs Auscultation of lungs Technic ‘ Varieties and dliavaaleviaties ae the normal breath aounda . The breath sounds in disease ‘ The voice sounds in health and disease . Adventitious sounds or accompaniments Srecrion XXXIII. The Abdomen. Methods and Results of its Gaba Examination Topographical marks, areas, and ‘adatenae of the abdomen Methods and general results of abdominal inspection Methods and results of general abdominal palpation and petoussion Section XXXIV. Examination of the Digestive System The esophagus, Sy oh. Ja The stomach 3 Anatomy and surface relations Physical examination Interpretation of the results of the aivstedtl examination of the stomach Intestines and peritoneum Topographical anatomy of intestines Examination of intestines The liver and gall bladder Topographical anatomy of liver Physical examination of liver and gall bladder ._ Diagnostic results of physical examination of liver and gall biadaat The pancreas . : Section XXXV. Bieriantion of the Spleen Topographical anatomy Physical examination Results of examination Section XXXVI. Examination of Riders Ureters, and Bladder Kidneys , ; Topographical stony Physical examination Diagnostic results of physical cami Bladder and ureters Section XXXVII. Examination of the Nervous Buster Physiological artd anatomical data Deviations (degeneracy ) Examination of the muscles with reference to their nutrition, tone, and motor power Motor disturbances Increased motility ‘ncaa’ Decreased motility (paralysis) PAGE 416 427 427 429 430 441 441 442 445 449 450 455 455 459 462 479 480 482 482 483 491 492 492 493 497 497 499 503 506 507 507 507 510 511 511 511 512 515 516 517 517 541 543 548 548 554 CONTENTS Sensory disturbances Methods of examination Diagnostic significance of . The reflexes Superficial Deep Electro-diagnosis oe ae cianaple) Apparatus and technic Diagnostic indications from Vasomotor and trophie disturbances Cranial nerve functions Cerebral localization Summary of diagnostic points Section XXXVIII. Examination of the Blood Technic of clinical examination of the blood Counting red cells Counting white cells Estimating the hemoglobin Microscopical examination of the blood ‘ Order of procedure in the clinical examination of the ‘bloga The results and diagnostic significance of the clinical examination of normal and abnormal blood The red cells The leucocytes. Blood plates and Miiller’ s blind dust Parasites in the blood Plasmodium malarie Spirochete of relapsing fever Filaria hominis sanguinis Serum test (Widal) for typhoid fever Blood tests for diabetes Iodine reaction in suppuration Obtaining blood for bacteriological examination Determining the coagulation of the blood Results of hemanalysis in special diseases Section XXXIX. Microscopical Examination of the Sputum Secrion XL. Examination of the Stomach Contents Physiology of digestion The chemical examination of tthe ioriaeh contents, and the determi- nation of the motor power of the stomach Test meals . The chemical tests and thet technic Testing the motor power of the stomach The microscopic examination of the stomach contents Diagnostic value of an examination of the stomach contents Secrion XLI. Microscopical Examination of the Feces Secrion XLII. Diagnostic Inferences from the Results of Urinalysis Evidence from physical examination of urine (quantity, colour, odour, consistence, specific gravity, deposits, etc.) . x1 PAGH 562 563 565 570 571 573 578 578 583 585 586 589 591 595 595 595 602 605 613 618 619 620 623 631 631 631 635 635 639 641 642 642 643 649 650 658 658 659 659 660 665 667 670 674 681 681 xii CONTENTS PAGH Evidence from chemical examination of urine (reaction, chlorides, phosphates, oxalates, sulphates, indican, urea, uric acid, albumin, blood and its compounds, the diazo-reaction, etc.) 686 Evidence from microscopical examination of urine (fat, pus, casts, etc.) 703 Collective results of urinalysis in special diseases and conditions . 709 Section XLIII. Diagnostic Puncture and the Evidence derived therefrom 712 Technic of puncture ° . . 712 Examination of fluid ‘ ; . 713 Characters of the fluid according to its source . 714 Section XLIV. The Uses of the Réntgen Light in Medical Diiagaoes . 718 Secrion XLV. The Technic of Life Insurance Examination .. 722 PART II DIAGNOSIS, DIRECT AND DIFFERENTIAL SECTION I.—Inrectious Diseases Typhoid fever . 731 Paratyphoid fever 744 Typhus fever 745 Relapsing fever 747 Dengue 748 Spotted fever . : 749 Trypanosomiasis 7 750 Cerebro-spinal meningitis 751 Influenza : : ‘ 754 Whooping cough 756 Epidemic parotitis (mumps) ; ar: 757 Smallpox (variola) : 758 Vaccinia (cowpox) 762 Varicella (chicken pox) ‘ 762 Scarlet fever (scarlatina) 763 Measles (rubeola) 767 Rubella (rétheln) 768 Diphtheria 769 Erysipelas , 772 Toxemia, septicemia, pyemia 773 Yellow fever 778 Dysentery 779 Cholera Asiatica 783 Bubonic plague 785 Malarial fever . 785 Rheumatic fever 790 Lobar pneumonia 792 Tuberculosis ; 803 Syphilis : 819 Gonorrheeal Hiecnintign ‘ ‘ . 824 Anthrax . : 3 F 825 Glanders (farey) : 2 é ‘ 826 Actinomycosis ‘ fo ote 5 : . 827 CONTENTS xili PAGE Leprosy . . . . : : 827 Tetanus . s ‘ A : , : . 7 828 Hydrophobia ; ; e, os Joe lot 829 Beri-beri . : 4 ‘ ; : : Z . 830 Mountain fever and situa : ; : 2 831 Ephemeral fever—febricula . . ; 5 E . 831 Malta fever. : ‘ , 832 Weil’s disease . . 832 Glandular fever ; : 832 Milk-sickness . a 833 Miliary fever (sweating sddlenassh ‘ 833 Foot and mouth disease ‘ 833 SECTION II.—Distases or THE DiGcestivE System Diseases of the mouth , 834 Diseases of the tongue bys . 836 Diseases of the salivary glands ‘ 837 Diseases of the pharynx : 837 Diseases of the tonsils 4 839 Diseases of the esophagus ‘ ‘ 5 5 ‘ . 841 Diseases of the stomach 7 3 844 Diseases of the intestines 860 Diseases of the liver, gall bladder, arid bile ducts : 884 Diseases of the pancreas ‘ 900 Diseases of the peritoneum “ : : 904 SECTION III.—Duistases or THE ReEspiraTORY SYSTEM Diseases of the nose. j ° 912 Diseases of the larynx i 914 Diseases of the bronchi ; : 917 Diseases of the lungs 925 Diseases of the pleura (and mediastinum) 940 SECTION IV.—Diseases or THE CrircuLATORY SYSTEM Diseases of the pericardium . , 954 Diseases of the heart : . 959 Diseases of the arteries . : . 984 SECTION V.—Diseaszes OF THE Bioop aND DucTLEss GLANDS Anemia . : : 993 Leucemia ‘ : ; ‘ . 996 Pseudo-leucemia . : . 998 Purpura . ‘ : ; 5 1001 Hemophilia . : ‘ eh 1004 Scurvy Wy eS RR 1004 xiv CONTENTS Addison’s disease Diseases of the spleen Chronic cyanosis Diseases of the thyroid gland Diseases of the thymus gland SECTION VI.—Disrases or THE KIDNEY Movable kidney Renal congestion Uremia Acute Bright’s disease Chronic Bright’s disease Amyloid kidney Pyelitis Hydronephrosis Nephrolithiasis Tumours of the kidney Cysts of the kidney Perinephritic abscess SECTION VII.—Disrases or THE Nervous System The psychoneuroses: Diseases of undetermined pathogeny A. Sensori-motor neuroses B. Motor neuroses C. Trophoneuroses Diseases of the peripheral nervous Se ayeten: A. Diseases of the peripheral sensory neurones B. Diseases of the peripheral motor neurones Diseases of the spinal cord and medulla Systemic cord diseases . Posterior column group Antero-lateral column group Posterior and lateral column group Inflammation of the spinal meninges . 3 Inflammation of the membranes of the brain Diseases of the cerebral substance Syphilis of the nervous system SECTION VIII.—Diszases or THE Minp % Supsection I General symptomatology of the psychoses Disorders of perception Disorders of thinking Disorders of the train of thought Disorders of volition (Willing) Disorders of the emotions Disorders of memory PAGE 1008 1009 1011 1012 1015 1016 1017 1017 1019 1020 1022 - 1023 1024 . 1025 . 1026 1027 . 1028 1029 1037 1045 1047 1052 1061 1076 1076 1079 1080 - 1082 . 1084 . 1086 . 1096 1099 1099 . 1104 . 1106 1108 - 1108 CONTENTS Sussection II The Psychoses (Diseases of the Mind). Infection-exhaustion psychoses (type—acute confusion) General characterization . Auto-toxic psychoses Thyroigenous psychoses Toxic psychoses é Miscellaneous intoxicants . Psychoses of obscure or unknown pathology Psychoses of known pathology Psychoses associated with other diseases Psychoses of the involution period Borderland and episodic states Idiocy and imbecility SECTION IX.—Distases or THE MUSCLES Myositis ‘ Myositis ossificans progressiva Myotonia Paramyoclonus cenubetples (myoalanias SECTION X.—ConstiTuTIONAL DISEASES Chronic rheumatism Muscular rheumatism Diabetes insipidus Diabetes mellitus Gout Arthritis deformans Rickets Obesity Adiposis dolorosa (Dereain’ s disease) SECTION XI.—Tue InroxicaTions: SUNSTROKE Aleoholism Morphine habit (Morphiniem) Acute opium-poisoning . Lead-poisoning Arsenic-poisoning Food-poisoning Sunstroke SECTION XII.—Diszases purz To ANIMAL PARASITES Distomiasis Nematodes Cestodes ‘ Parasitic arachnida Parasitic insects xv PAGE 1109 1109 1111 1112 1112 1118 1118 1121 1123 1128 1129 1130 . 1130 1131 1132 1132 1132 . 1133 . 1133 1134 . 1135 . 1137 1139 1140 1141 1142 1144 . 1144 1145 1149 1149 1151 1153 1153 1156 1159 1159 xvi CONTENTS SECTION XIII.—Diseases or THE TROPICS Acute febrile icterus Febrile tropical splenomegaly Tick fever ‘ 3 Epidemic dropsy Tropical ulcer . Yaws : 2 F : Tropical sloughing phagedena Madura foot Climatic bubo Ainhum Goundou . Guinea-worm disease Endemic hemoptysis Bilharzia disease Schistosomum Japonicum Intestinal fluke-worms . Cestodes . PAGH . 1160 . 1161 . 1161 . 1161 . 1161 . 1162 1162 1162 . 1163 . 1163 . 1163 . 1163 . 1164 . 1164 . 1165 1165 . 1165 PLATES, CHARTS, PLATE I. Il. III. IV. CHART I, II. II. IV. V. VI. VII. VIII. IX. X. XI. XII. XIII. XIV. XV. XVI. XVII. XVvur. ~ XIX. XxX. XXII. XXII. AND ILLUSTRATIONS FACING Tuer SHapPe AND RELATIONS OF THE THORACIC AND ABDOMINAL VisceRA, ANTERIOR Aspect (Semi-diagrammatic) Tue SHare AND RELATIONS OF THE THORACIC AND ABDOMINAL ViscerRA, Posterior Aspect (Semi-diagrammatic) Rep Corpuscies, NoRMAL AND ABNORMAL . Tue Varieties or LeucocyTes Tue PuLasmopium MALARIM, SELECTED AND REPRODUCED FROM THAYER’s PLATES Abortive pneumonia “ Types of fever. Continued, remittent: quotidian suri ert types of intermittent ‘ Types of fever. Intermittent, quartan tye son pueaties ai hectic fever Diagnostic indications Homi 4 a sudden invasion of fopeey No. 1, Diagnostic significance of a gradual rise of temperature Diagnostic significance of a gradual termination of fever Diagnostic indications from a sudden invasion of fever. No.2 . Diagnostic indications from a sudden fall of temperature Blood chart and hemanalysis card for recording examinations Typhoid fever. Showing typical temperature curve and promi- nent symptoms Typhoid fever. Fatal Neragrlinee Typhoid fever. Bathing chart. Recovery Typhus fever . ; 3 7 s Relapsing fever Smallpox Varioloid Varicella . Scarlet fever . Measles . Pyemia, post-operative, with puladonaey gangrene Lobar pneumonia. Pulse, respiration, and temperature Broncho-pneumonia ose, ae 2 xvii PAGE 1 1 622 626 632 PAGE 106 112 112 115 116 116 117 118 596 733 738 739 746 747 758 760 762 764 767 776 792 929 xviii PLATES, CHARTS, AND ILLUSTRATIONS FIGURE 1. Example of a case-history card—cardiac . 2. Example of a case-history card—gynezcological 3. Box for keeping history cards 4. Card for recording urinalysis 5. Showing the location of transferred pains 6. Showing the location of transferred pains. 7. General indications from seat of pain in head and iaee 8. Causes of localized headache according to its site 9. Causes of localized headache according to its site 10. General indications from seat of pain in face and neck 11. Showing the possible causes of pain according to its locality 12. The same 13. The same z ‘ = 14. The same 15. The same 16. The same ee : Sis 17. The same 18. The same 19. The same 20. The same 21. Possible causes of pain in fend said heel 22. Charcot joints 23. Diagram of vomiting centre in medulla 24. Roberts’s stool sieve 25. Ascaris lumbricoides 26. Oxyuris vermicularis 27. Scolex and segments of Tenia apie 28. Scolex, egg, and ripe segments of Tenia solium 29. Head of Bothriocephalus latus 30. Male and female Uncinaria . 31. Cephalic end of Uncinaria americana 32. Posterior extremity of male Uncinaria americana . 33. Ova and embryos of Uncinaria americana 34. Posterior extremity of female Uncinaria americana 35. Beginning hydrocephalus 36. Rachitic head ; 37. Sporadic cretinism 38. Acromegaly 39. Face of myxcedema 40. Facial hemiatrophy 41. Leontiasis ossea 42. Leontiasis ossea 43. Composite photograph of wiputh breathers 44, Varieties and causes of facial pao 45. Base of the brain 46. Base of the skull and exits of nerves ae 47. Communications between superior moe ae and external sinuses and external veins. 48. Communications between lateral and cavernous sinuses na antennal veins PAGE 10 43 45 46 47 48 49 50 51 52 53 54 55 56 57 59 * 60 103 125 145 149 150 151 151 152 153 153 154 154 155 171 171 172 173 173 174 175 175 178 186 188 189 197 198 PLATES, CHARTS, AND ILLUSTRATIONS FIGURE 49. Nervous mechanism of the iris ‘ 50. Showing ocular muscles and their innervation. 51. Structures in right cavernous sinus 52. Relation of structures passing through aphenotdal Fiasure 53. Showing optic tracts, visual fields, and causes of hemiopia 54. Visual colour field, right eye 55. Rhinoscopic view of posterior nares . 56. Syphilitic ‘“screw-driver’’ teeth . 57. Unilateral atrophy of tongue 58. Showing motor and sensory supply of tongue . 59. Photographs of normal larynx 60. Showing paralyses of the vocal cords ‘ 61. Showing localization of cerebral motor and ee funchions, outer surface, left hemisphere 62. Showing principal convolutions and fissures, guitar sietuce) left hens sphere 63. Showing functions, eneehitions: and Faaunee inner aspect, right hemisphere 64, Showing association tracts, left hentlapher 65. Gland groups of head and neck 66. Diagram of right external and internal jugulars 67. Diagram showing systolic and presystolic jugular pulse 68. Normal hand (cast drawing) 69. Spade hand 70. Claw hand 71. Morvan’s disease . 72. Hand of pulmonary seepaheepaay 73. Skiagraph of hand in Fig. 53 74. Hands of arthritis deformans 75. Hand showing Heberden’s nodes 76. Skiagraph of hand in Fig. 56 77. Gland groups in groin . 78. Sabre-shaped tibia 79. Pes equinus 80. Pes varus 81. Pes calcaneus 82. Paralysis of serratus magnus 83. Rhizomelique spondylitis 84. Diagram—varying force of panoussion 85. Diagram—auscultatory percussion 86. Diagram—lines of percussion 87. Section of emphysematous chest 88. Sections of healthy and rachitic chests 89. Funnel chest . 90. Section of unilaterally contracted chest 91. Section of scoliotic chest 92. Topographical areas of thorax, eatertne er 93. 94. 95. Topographical areas of trunk, posterior aspect Showing events of cardiac cycle and sounds of heart Nervous mechanism of the heart xix PAGE 203 212 216 217 221 224 230 241 243 244 256 258 266 266 267 268 283 285 287 290 290 290 291 292 292 293 294 295 296 297 299 300 300 302 303 309 310 310 317 318 319 320 320 324 325 329 330 xXx PLATES, CHARTS, AND ILLUSTRATIONS FIGURE 96. Diagram explanatory of arterial tension 97. Showing vasomotor nervous mechanism 98. Semi-diagrammatic section of heart 99. Diagram showing insufficiency and stenosis . 100. Showing indirect effects of valvular lesions 101. Showing relations of heart to chest walls 102. Normal boundaries of heart and great vessels 103. Position of apex beat and other pulsations 104. Site and rhythm of thrills and friction fremitus 105. Exposed and covered dulness of normal heart 106. Percussion lines for determining cardiac dulness . 107. Two modes of using the finger as a pleximeter 108. Normal area of entire cardiac dulness 109. Dulness in hypertrophy of left ventricle 110. Dulness in hypertrophy and dilatation of right heart 111. Dulness in dilatation and hypertrophy of both ventricles 112. Dulness due to large pericardial effusion 113. Dulness due to modérate pericardial effusion 114. Heart valves and their areas of audibility 115. Two variations from normal cardiac rhythm 116. Chronological types of murmurs 117. Relative frequency of anemic murmurs 118. Diagram—umitral presystolic murmurs 119. Diagram—varieties of murmur of mitral eae: 120. Diagram—amitral systolic murmur 121. Diagram—aortic systolic murmur 122. Diagram—aortic diastolic murmur 123. Diagram—tricuspid presystolic murmur 124, Diagram—tricuspid systolic murmur 125. Diagram—pulmonary systolic murmur 126. Diagram—combined murmurs . 127. Diagram—combined murmurs . 128. Cook’s sphygmomanometer 129. Stanton’s sphygmomanometer . 130. Janeway’s sphygmomanometer 130a. Normal venous pulse tracing 131. Sphygmograms—diagrammatic aad actual 132. Sphygmograms—actual 133. Dudgeon’s sphygmograph . 134. Showing lobes of right lung 5 135. Showing lobes of both lungs poststionly 136. Diagram of the respiratory centre 137. Showing auscultatory areas of apices 138. Showing relative resonances of thorax 139. Dulness of fluid in reflected pleura (left) 140a. Showing variations of lessened resonance 140b. Grocco’s triangle : 141. Conditions causing hyperresominee 142. Percussion and auscultation above conadlidafions. or diustons 143. Findings over open cavities or pneumothorax PAGE 331 332 333 334 337 339 340 346 349 352 353 354 356 356 356 357 357 357 360 366 369 371 372 373 374 375 376 377 377 378 379 380 389 389 390 396 404 405 408 412 413 415 428 429 432 433 434 435 436 439 FIGURE 144. 145. 146. 147. 148. 149. 150. 151. 152. 153. 154. 155. 156. 157. 158. 159. 160. 161. 162. 163. 164. 165. 166. 167. 168. 169. 170. 171. 172. 173. 174, 175. 176. 177. 178. 179. 180. PLATES, CHARTS, AND ILLUSTRATIONS Gerhardt’s and Wintrich’s phenomena Coin percussion : Normal bronchial and pronehe wectoular ‘breathing, sticrinny i Normal bronchial and broncho-vesicular breathing, posteriorly Varieties of breathing and vocal resonance in disease . Results of auscultation over pleural effusion . Adyentitious respiratory sounds Surface and bony landmarks of abdomen Showing nine topographical areas of abdomen Quadrants of abdomen. Locating lesions Contents of topographical areas of abdomen . Central tympanicity and lateral dulness of fluid Dulness of both flanks in ascites, dorsal posture Change of line of flatness in ascites Dulness and tympanicity in abdominal futons Cross section explanatory of Fig. 158 . . . Cross section of tympanitic abdomen Showing tumour areas of abdomen . Possible findings in hepatic and appendical areas Possible findings in splenic and sigmoid areas Possible findings in gastric and pelvic areas Possible findings in umbilical area Shape and relations of the normal stomach Undulatory waves of peristalsis Showing marked gastroptosis Gastrodiaphanic picture in normal stomach Gastrodiaphanic picture in dilated stomach Gastrodiaphanic picture in gastroptosis . Gastrodiaphanic picture in gastroptosis Showing gastroptosis and gastrectasia Topographical relations of colon and appendix Auscultatory percussion of colon V-shaped colon Auscultatory percussion of tumour of colon “ Determining size and position of normal liver Surface relations of liver, right lung, and pleura Results of percussion of normal liver 181, 182. Determining by auscultatory percussion whether a tumour is or 183. 184. 185. 186. 187. 188. 189. 190. 191. 192. 193. is not connected with the liver Showing the relations of the pancreas Topography of the spleen Tympanicity of colon over tumour of kidney Anterior surface relations of kidney Posterior surface relations of kidney Section through kidney and lumbar muscles . Diagram of the neurone Diagram of motor pathways Diagram of sensory pathways Relation of spinal cord to dorsal surface of trunk Functions of fibres of anterior and posterior roots Xxi PAGE 440 441 443 444 445 446 451 455 457 458 459 466 466 466 467 467 469 471 472 473 474 475° 482 486 487 489 489 489 489 491 493 494 495 496 497 498 500 502 506 508 509 512 513 515 518 520 521 522 523 Xxll PLATES, CHARTS, AND ILLUSTRATIONS FIGURE PAGE 194. Columns of cord and diseases affecting them . §23 195a. Tracts of spinal cords and their names . : : . 624 1956. Functions of tracts of spinal cord ee 525 196. Relation of skin areas to spinal segments (anteriorly) . . . 582 197. Relation of skin areas to spinal segments (posteriorly) ; ; 533 198. Relation of skin areas of head and neck to spinal segments . . 6534 199. Sensory supply of skin of trunk and leg (anteriorly) , 535 200. Sensory supply of skin of trunk (posteriorly) : : . 536 201. Sensory nerves of skin of arm (anteriorly) : . 538 202. Sensory nerves of skin of arm (posteriorly) : . 538 203. Sensory nerves of skin of leg (posteriorly) . ‘ ‘ ‘ . 538 204-207. Sensory nerves of skin of foot : ‘ 539 208. Showing arteries of base of brain es : 7 : . 640 209. Arterial supply of cerebral hemispheres . ‘ : : ! . 540 210. Infantile spinal paralysis of left leg é F ‘ 543 211. Pseudo-muscular ce ; : ‘ ‘ 3 é 5 544 212. Wrist-drop A ‘ Q & ‘ é . 546 213. Foot-drop . .. ; 5 Ron ; : 547 214. Athetoid movements : ; ‘i a é 550 215. Hand of tetany . i : : 552 216. Contractures of hand... ; : . 553 217. Relative positions of cranial nerve mantel, nastenon sapect . 656 218. Relative positions of cranial nerve nuclei, lateral aspect. ; . 557 219. Effects of lesions of motor path in brain and cord . 559 220. Mono-anesthesia, bilateral anesthesia, hysterogenic zones 567 221. Showing hemiesthesia and disseminated anesthesia 568 222. The Babinski toe-reflex 572 223. Showing segmental localization of reflexes and automatic centres in spinal cord , 573 224. Showing re-enforcement of percussing finger 574 225. Showing mechanism of deep refiexes, and two main types of paralysis. 576 226. Motor points of head and neck ba 578 227. Motor points of arm i 579 228. Motor points of arm . : 580 229. Motor points of thigh, anteriorly ‘ 581 230. Motor points of thigh and leg, posteriorly 582 231. Motor points of leg, laterally ‘ 583 232. Sensory supply of skin of face and neck 587 233. Moore’s hematospast ‘ : . 697 234. Thoma-Zeiss pipettes . . . 598 235. Blood counting slide, plan : . 598 236. Blood counting slide, elevation 599 237. Thoma counting chamber . , 599 238. Tiirck counting chamber L 599 239. Zappert-Ewing counting chamber 3 . 599 240. Group of sixteen squares under microscope : ‘ : 600 241. Durham’s blood pipette ‘ 2 601 242. Von Fleischl’s hemometer : . 605 243. Gowers’ hemometer . : : . 607 244a. Sahli’s hemoglobinometer oo) Bl ae oe ow Me we «2610 PLATES, CHARTS, AND ILLUSTRATIONS FIGURE 244b. 245. 246. 247. 248. 249. 250. 251. 251a. 2516. 251e. 252. 253. 254. 255. 256. 257. 258. 259. 260. 260a. 261. 262. 263. 264. 265. 266. 267. 268. 269. 270. 271. 272. Dare’s hemoglobinometer ‘ Resting attitudes of culex and anopheles Filaria alive in blood . 5 Male and female of Bilharzia hematobia Egg of Bilharzia hematobia Swimming embryo of Bilharzia hematobia Trypanosoma gambiense in human blood Incomplete and complete coagulation Biffi-Brooks Coagulometer Wasserman-Noguchi test Positive reaction to Wassorman-Noguchi test Elastic tissue, from lung, in sputum Bronchial cast from case of plastic bronchitis Curschmann’s spirals in sputum Charcot-Leyden crystals Echinococcus hooklets Actinomyces in sputum ‘Microscopical view of vomited matter Boas-Oppler bacillus Undigested meat fragments in feb Apparatus for Schmidt’s fermentation test Ova, of entozoa Amoeba dysenterize ah. 045 Crystals in ‘‘Cammidge” reaction . Tuberculous consolidation of both apices Aneurism of the descending arch of the aorta, posterior view Showing stricture of esophagus Emphysematous chest Cross section of thorax Pseudo-leuceemia (Hodgkin’s disease) Parts first attacked in muscular dystrophies atid atrophies Mode of rising in pseudo-muscular hypertrophy Adiposis dolorosa (Pearce) 7 XXiii PAGE 611 632 635 636 637 637 637 643 644 647 648 652 653 653 654 654 655 667 669 677 678 679 680 701 719 720 721 935 987 999 . 1058 . 1059 . 1141 “TI do not know . . . I will investigate."—Pastzur. “First tell me what I am to look for.”—Farapay. SYNOPSIS (OR SCHEDULE) OF EXAMINATIONS CONSTITUTING AN ORDER OF PROCEDURE, AND A SYMPTOM- GUIDE; WITH REFERENCES TO PART I OF THIS BOOK To insure completeness in the examination of patients and for purposes of record, it is desirable to have a definite and comprehen- sive order of procedure. The subjoined schedule, which may be modified according to personal requirements, is based partly on sci- entific necessities, partly on clinical convenience. Incidentally, the symptoms indicating disease of a particular viscus or system are grouped, in order to direct attention to the organ at fault. Further- more, for convenience, references are given to the pages upon which special symptoms, signs, or methods of examination are described in detail. The three main divisions of the schedule comprise : I. The History or Anamnesis. II. The General Examination t Present Condition or III. The Special Examinations Status Preesens. I. THE HISTORY OR ANAMNESIS Ascertain the name, age, sex, civil condition (single, married, widow, widower), nationality, occupation, and residence. Note the date of examination. Family History.—Inquire concerning the diseases which have prevailed and the causes of deaths (if such have occurred) among father, mother, brothers, sisters, or children; also as to the diseases, if any, which prevail among the living. Consider whether or not the stated ailments are of an hereditary character (pages 13 to 15). Previous Personal History.—Bear in mind the diseases which predominate : (1) At the age period of the patient (pages 15 to 18). (2) In the sex (pages 18, 19); and if the patient is @ woman, in- quire regarding the menstrual life, pregnancies, and miscarriages. (3) In the race or nationality (page 19). (4) What is the character of the occupation, and does it predis- pose toward special diseases (pages 19 to 21)? XxXVv xxvi SYNOPSIS OF EXAMINATIONS (5) Consider the residence, bearing in mind the geographical dis- tribution of disease (pages 21 to 22). (6) Inquire concerning the habits: of men, with reference to the daily amount and kind of alcoholic beverages taken, whether before or after meals; tobacco, kind, amount, and manner of using; sexual indulgence, frequency; of both men and women, with reference to the amount and strength of tea and coffee taken (page 22). (7) Inquire with reference to previous injuries and diseases (pages 22 to 25), ascertaining their date, duration, character, and whether or not recovery was considered to have been complete. Are the previous diseases of such a nature that a second attack is probable; or is it unlikely; or are sequela to be expected? Search especially for previous gonorrhea, syphilis, nephritis, rheumatism, or malaria. History of Present Illness.—Inquire regarding the possible cause of the illness; the date and manner of its onset, never failing to fix in mind the nature of the earliest symptoms, and, if possible, the organ or system to which they belong—e. g., stomach, circulatory apparatus—the subsequent symptoms and their order of appearance to the present time; the symptoms now present; and the previous treatment, if it can be ascertained (pages 25 to 27). Il. THE GENERAL EXAMINATION 1. Observe the dress and general behaviour (pages 27, 28). 2. Estimate (or measure) the height and weight, and note the amount and character of the adipose and muscular tissue (pages 28 to 30). 3. Study the shape and general configuration of the body (pages 30, 31). 4. Note the complexion, and colour of hair and eyes (pages 31, 181, 199). 5. So far as possible, determine the diathesis (usually done at the end of the examination), and note the presence of any cachexia (pages 31 to 33). 6. Observe the posture and manner of moving (pages 33 to 35), 7. If practicable, test the station or power of standing, and ob- serve the gait or manner of walking (pages 35 to 38). 8. Pain.—If pain is a subject of complaint, make due allowance for susceptibility (page 39) and manner of statement (pages 39, 40). Can any diagnostic inference be drawn from the character (pages 40, 41) or the seat (pages 42 to'60) of the pain? 9. Tenderness.—Is there tenderness (pain on pressure), and is its location significant (pages 60 to 62)? HISTORY AND GENERAL EXAMINATION XXVil 10. Paresthesias.— Are there abnormalities of sensation not amounting to pain (paresthesias)? If so, consider the site, variety, and possible significance (pages 62 to 66). 11. Vertigo.—Inquire for the existence of vertigo, having in mind both its common and less frequent causes (pages 66 to 68). 12. Temperament.—What is the temperament (mainly psychical) of the patient (pages 68 to 70) ? 13. Psychical State-—What is the present psychical state of the patient as shown by the facial expression (pages 70, 71); the emo- tional state (page 71); and the condition of intellection (pages 71 to 73); the abnormalities of the latter, embracing mental dulness, loss of memory, delusions, or delirium? Inquire as to sleep (page 73). 14. Consciousness.—Is the patient fully conscious? If not, what is the degree of disturbance (page 74); what may it signify in gen- eral (pages 74 to 76); and to what is it due in this particular case (pages 76 to 79)? 15. Convulsions.—If general convulsions have occurred or are present, to what may they be attributed (pages 79 to 82)? 16. Cutaneous Surface.—Observe and examine the cutaneous sur- face with reference to colour (pages 83 to 89), heat (pages 89, 90), moisture (pages 90, 91), rash or eruption (pages 91 to 94), scars (pages 94, 95), dropsy (pages 95 to 98), condition of the veins (page 99), and emphysema (pages 100, 101). 17. Pulse-—Take the pulse (pages 387 to 392). Observe its fre- quency, rhythm, tension, and other qualities. Note the condition of the arteries. If variations from the normal are found, consider their significance (pages 392 to 407). 18. Respiration—Take the respiration. Observe its frequency, type, rhythm, and other characteristics (pages 416 to 425). 19. Temperature.—Take the temperature of the body (pages 104 to 109). If fever is present, consider its height, type, manner of invasion, course, and termination (pages 109 to 114). What diag- nostic inferences may be drawn from these observations (pages 114 to 120)? Has the fever been preceded or accompanied by chills (pages 120, 121)? If the temperature is subnormal what may it indicate (page 120)? 20. Inquire concerning the appetite and thirst (pages 122, 123); vomiting (pages 123 to 131) and the gross characters of the vomitus (pages 132 to 135) ; defecation (pages 135 to 142) and the gross char- acters of the stools (pages 142 to 155); the character and frequency of urination (pages 155 to 160); and certain genital symptoms in men and women (pages 160 to 165). Xxvili SYNOPSIS OF EXAMINATIONS II. SPECIAL EXAMINATIONS By means of a more or less discursive examination, as just out- lined, the observer obtains a conception of the general condition of the patient; and also, in the majority of cases, an indication for a special examination of a particular part, organ, or system. The spe- cial examinations embrace the signs and symptoms which occur in connection with various parts of the body—e. g., head and face, tongue; or which belong to an organ—e. g., spleen; or a system— e. g., respiratory. 1. Head and Face.—Observe the size and contour of the head and face; in infants, the condition of the fontanels and sutures; and the consistence and surface of the cranial bones (pages 170 to 176). Study the expression of the face and consider whether it is indicative of certain diseases (pages 176 to 179). Note the colour of the face and the state of the skin of the face (page 180). What is the colour of the hair, and is it abundant, or scanty (page 181)? Is there general or circumscribed swelling of the face (page 182)? Are there abnormal movements of the head, or does it lack normal mobility (pages 182, 183)? Are the facial muscles in a state of clonic or tonic spasm (pages 183, 184), or are they paralyzed (pages 185 to 190)? 2. Har.—Has the patient complained of pain in the ear (page 191)? What is the colour and shape (pages 191, 192) of the ear? Is there a discharge from the external meatus (page 192)? Does the patient complain of tinnitus (pages 192, 193)? Does the patient hear well; is he deaf, and, if so, is the deafness due to nerve lesions or aural lesions (pages 193 to 195)? Is the hearing hyperacute (page 196) ? 3. Hye.—Are the eyelids swollen or ulcerated; in a state of spasm ; too widely opened; or abnormally drooping (pages 196 to 199)? What is the colour of the sclerotic, the state of dryness or moisture of the eye, and the condition of the cornea (pages 199 to 201)? Are the pupils large or small, equal or unequal; do they respond to light and to accommodation (pages 201 to 206)? Are the eyeballs painful; do they protrude, or are they more sunken than normal; what is their position (pages 206 to 214)? Are the eyeballs normally mobile, or are there symptoms of ocular paralysis; and if ocular paralysis is found, what is its cause (pages 214 to 219)? Does the patient complain of any abnormality of sight (page 219)? If alterations in the shape or size of the visual fields have been found, what may be their significance (pages 219 to 225)? If an ophthal- SPECIAL EXAMINATIONS Xxix moscopic examination of the eye grounds has been made, do the findings indicate extra-ocular disease (pages 225 to 228) ? 4. Nose.—The following symptoms demand an examination of the nose: Pain in or around the nose (page 230), frontal headache, or trigeminal neuralgia. Mouth-breathing and its typical facial ex- pression due to nasal stenosis (page 178). Snoring and restless sleep. Nasal voice. Nasal discharges (page 232), epistaxis (pages 232, 233), or bad odour of the expired air (pages 236, 237). Deafness. Cough or bronchial asthma. To Examine the Nose.—Having noted the shape and colour of the nose, together with such other points as may be observed by ordinary inspection, examine the nasal chambers (using the probe) by anterior and posterior rhinoscopy (pages 228 to 230). Test the sense of smell (pages 233 to 235). 5. Mouth.—Examine the lips, buccal cavity, gums, and teeth (pages 235 to 242). Note the condition of the tongue with reference to colour, size, spasm, tumour, paralysis, scars, fissure, ulcers, etc. (pages 242 to 249). Does the tongue present an appearance which is of general diagnostic value (pages 247 to 249)? ‘Test the sense of taste (pages 249, 250). 6. Examine the palate, tonsils, and pharynx (pages 250 to 254). What is the shape of the palate; is it paralyzed, anesthetic, or otherwise abnormal? Are the tonsils acutely swollen, chronically enlarged, ulcerated, or covered with exudate? What is the colour of the pharynx; is there exudate or ulceration ; is there bulging posteriorly ; is it paralyzed or anesthetic ? %. Does the patient complain of dysphagia, and, if so, to what may it be due (pages 254, 255) ? 8. Larynx.—The following symptoms demand an examination of the larynx: Pain, burning, or soreness over and around the larynx. Alterations in the character of the voice sounds, viz., apho- nia or hoarseness (dysphonia). Inspiratory dyspnea, especially if accompanied by stridulous (wheezing or squeaking) respiration. Cough, particularly of the laryngeal type (tight or croupy). Dyspha- gia, difficulty or pain in swallowing. To Examine the Larynx.—(See pages 255 to 260.) Do not omit an inspection of the lingual tonsil. 9. Cough.—Has the patient a cough? If so, observe its character and consider its causes (pages 273 to 276). Examine the sputum (if any) with reference to its character (pages 276 to 278 and 650 to 657). Has he had hemoptysis (pages 278 to 280) ? 10. Speech.—Note alterations in the voice or the manner of speaking (pages 260 to 263). Is there aphasia (pages 263 to 272) ? XXX SYNOPSIS OF EXAMINATIONS 11. Neck.—Observe the shape of the neck; is it rigid? Are the sterno-mastoids or clavicles prominent; is the thyroid gland enlarged or atrophied (page 281)? Does the trachea descend with inspiration, or can tracheal tugging be felt (page 282)? What is the condition of the cervical glands (pages 282 to 284); of the arteries of the neck (page 284); of the veins of the neck (pages 284 to 288), 12. Extremities.—Examine the nails (pages 288, 289); the hand and fingers (pages 289 to 295); the arm (page 295); the foot and leg (pages 296 to 300); and the joints (pages 101 to 104). 13. Back.—Examine the back for alterations of shape, promi- nence of the scapula, stiffness, and swellings or eee (pages 301 to 304). 14. Chest.—Examine—perhaps measuring and outlining =the chest with reference to bilateral or unilateral deformities, flexibility of ribs, and the presence of enlarged veins (pages 314 to 321). 15. Heart and Blood-vessels.—The following symptoms de- mand an examination of the heart and blood-vessels: Dyspnea (per- haps orthopnea), especially if made worse by physical exertion or accompanied by cyanosis. Cidema, especially of the feet and ankles. Palpitation, precordial pain, anxiety, or distress, particularly if in- creased by exertion. Sudden vertigo. Restless sleep, dreaming, start- ing during sleep. Cough, especially if chronic; or an unusually persistent attack of bronchitis. Chronic digestive disturbances. Hemorrhoids. Great obesity. If such symptoms are present inquire further (with reference to causation) concerning: Prolonged and severe muscular exertion. Many years of constant mental excitement or anaiety. Excessive eating and drinking, especially of rich food and alcoholic beverages ; these, and the foregoing, partly with reference to artertosclerosis. Excessive use of tobacco, tea, and coffee (in relation to cardiac neu- roses). Previous attacks of chorea, gout, rheumatic fever, or other, usually acute, infectious diseases, especially scarlatina, diphtheria, typhoid fever, tonsilitis, syphilis. The family history: does it reveal rheumatism, gout, angina pectoris, apoplexy, or organte cardiac disease ? To Examine the Heart.—Inspect and palpate the thorax, noting, if present, distended veins, pulsating jugulars, epigastric pulsation, and pulsating liver. Note, as of prime importance, the position, character, and extent of the apex-beat (pages 341 to 350). Percuss the heart (pages 350 to 359). Auscultate the heart with reference to the intensity and character of the sounds (pages 359 to 366), and the presence of adventitious sounds, either endocardial (pages 367 to SPECIAL EXAMINATIONS Xxxi 380), or exocardial (pages 380 to 383). Examine the pulse (pages 387 to 407). Use the sphygmograph (pages 407 to 411). To Examine the Blood-vessels.— Inspect, palpate, and auscultate the accessible arteries and veins (pages 383 to 387). Note any ab- normal capillary pulsation (page 288). 16. Lungs and Pleurse.—The following symptoms demand an examination of the lungs and pleure: Cough, with or without expec- toration. Hemoptysis or spitting of blood. Pain in the side of the chest. Dyspnea. Night sweats. Loss of flesh and strength. Additional evidence should be sought for, viz., a family history of consumption, asthma, bronchitis, or scrofulous (tuberculous) dis- eases; and a personal history of enlarged cervical glands, or tuber- culous disease of bone, or association with a consumptive, or an occu- pation predisposing toward pulmonary disease. To Examine the Lungs.—Inspect and palpate the chest with reference to its shape (pages 314 to 321). Measure it. Count the respiration (pages 416, 417) ; determine its type, degree of expansion and retraction, and its rhythm and other characters (pages 416 to 425). Is fremitus obtained (pages 425 to 427)? Is dyspnoea pres- ent? If so, what is its character? Percuss the lungs—front, sides, and back (pages 427 to 441). Auscultate the lungs—tfront, sides, and back, determining the character of the breath sounds (pages 441 to 450) and the presence and variety of adventitious sounds (pages 450 to 454). 17. Abdomen.—If complaint is made of abdominal pain or dis- comfort, inspect the abdomen (pages 459 to 462). Palpate and per- cuss the abdomen (pages 462 to 478). Auscultate the abdomen (pages 478, 479). 18. Stomach.—The following symptoms require an examination of the stomach: Pulness, sinking feelings, pain or discomfort in ept- gastrium, lower sternum, between the scapule. Increased or lessened appetite or increased thirst. Nausea or vomiting (of stomach con- tents, or blood). Pyrosis, eructations, or flatulence. Mental depres- sion. Rapid emaciation. ‘ To Examine the Stomach.—Incidentally inspect the lips, mouth, gums, teeth, and tongue. If the food is arrested in the throat, or before it enters the stomach, and is regurgitated, palpate, auscultate, and instrumentally examine the esophagus (pages 479 to 481). In- spect and palpate the stomach (pages 483, 484). Percuss the stomach by ordinary and auscultatory percussion (pages 484 to 488). Inflate the stomach (page 488). Obtain the contents of the stomach (pages 490, 491) after a test meal, and examine by chemical and microscop- ical methods (pages 658 to 673). XXXii SYNOPSIS OF EXAMINATIONS 19. Intestines.— Constipation, diarrhea, and abdominal pain are the symptoms which require an examination of the intestines. To Examine the Intestines.— Inspect the stools (pages 142 to 155). Inspect, palpate, percuss, and auscultate the abdomen in general (pages 459 to 478), and the intestines (including a digital examina- tion of the rectum) in particular (pages 493 to 497). 20. Liver and Gall Bladder.—The following symptoms de- mand an examination of the liver and gall bladder: Pain, of the hepatic type, over the right hypochondrium. Jaundice, dark urine, clay-coloured stools. Irregular chills and fever. Cutaneous pruritus. Hematemesis. Digestive disturbances. If sueh symptoms are present, inquire further (with reference to causation) concerning: Previous attacks of jaundice with or without hepatic colic. Previous catarrh of the stomach, or acute indigestion (catarrh of bile ducts). Strong emotions (anger or fright). Chronic alcoholism (hepatic cirrhosis). Syphilis, tuberculosis, or long-con- tinued suppuration (amyloid disease). Possibility of phosphorus poisoning. To Examine the Liver and Gall Bladder.—Rarely inspection and auscultation are of use, ordinarily palpation and percussion (pages 499 to 506) are to be relied upon. 21. Spleen.—The size, shape, and position of the spleen should be determined, mainly by palpation and percussion (pages 507 to 511), in the following conditions and diseases: Emphysema, left pleural effusion, and left pneumothorax. Ascites, tympanites, and large abdominal tumours. In all acute infectious diseases (e. g., typhoid fever, malarial fever). Leucemia. Cirrhosis or amyloid dis- ease of the liver. 22. Kidneys.—The following symptoms demand a physical ex- amination of the kidneys, and a chemical and microscopical exami- nation of the urine: Pain in the posterior lumbar region, especially if of the renal type. Cidema or puffiness of the face, especially about the eyelids in the morning. General edema (anasarca). Painful or frequent urination. Smoky or turbid urine; notable increase or diminution in its amount. Headache, drowsiness, nausea, and vomit- ing. Dyspnea or asthma, without other discoverable cause. Dim- ness of vision. Convulsions or paralyses. Irregular chills and fever (pyelitis). If such symptoms are present, inquire further (with reference to causation) concerning: A family history of nephritis, apoplexy, or gout. A personal history of alcoholism, gout, lead-poisoning, renal colic, chilling of the surface of the body, acute infectious diseases (such as scarlet fever, malaria, tonsilitis, diphtheria), and long- SPECIAL EXAMINATIONS XXxill continued suppuration, tuberculosis, tertiary syphilis, and malaria (amyloid disease). To Examine the Kidneys.— Inspect and palpate anteriorly; in- spect, palpate, and percuss posteriorly (pages 511 to 516). Examine also the heart and blood-vessels for cardiac hypertrophy and general arteriosclerosis. Examine the urine physically, chemically, and mi- eroscopically (pages 681 to 712). If necessary, examine the bladder and ureters. 23. Nervous System.—The following symptoms require an examination of the nervous system: Frequent or continuous headache. Frequent vomiting. General convulsions, or localized spasm. Paral- yses (ocular or skeletal). Vertigo. Speech disturbances. Difficulty in slanding or walking tf not due to weakness, injury, or disease of joints. Mental disturbances. Dysphagia (sometimes). If such symptoms are present, inquire further (with reference to etiology) concerning: 1 family history of psychoses (insanity), hys- teria, chorea, epilepsy, neurasthenia, paralysis, convulsions, or hered- itary syphilis. A personal history of alcoholism, syphilis, injury; discharge from the ear; any of the acute infectious diseases; potson- ing from lead, mercury, arsenic, tobacco, or naphtha; and exposure to cold, To Examine the Nervous System.— Note the presence of the stig- mata of degeneration (pages 541 to 543). Examine the muscles with reference to their nutrition, tone, and motor power (pages 543 to 548). Are there motor disturbances? If so, is there increased motility (spasm, pages 548 to 553), or decreased motility (paralysis, pages 554 to 562)? Are there disturbances of sensation (pages 562 to 570) ? What is the condition of the superficial reflexes (pages 571 to 573) ; of the deep reflexes (pages 573 to 578)? What is the electrical reaction of the muscles and nerves (pages 578 to 585)? Are there vasomotor and trophic disturbances (pages 585, 586)? What is the condition of the cranial nerve functions (pages 586 to 589)? What are the findings from an examination of the eye grounds (pages 225 to 228) ? 24. Blood.—The following symptoms require an examination of the blood: Dyspnea and palpitation upon exertion. Pallor of the skin and mucous membranes. Headache and vertigo. Debility. Dis- turbances of digestion and gastric pain. Cdema of the feet. If such symptoms are present, inquire further (with reference to causation) concerning: Hereditary or personal hemophilia. Loss of blood (injury, menorrhagia, bleeding piles, hemoptysis, hematemesis, etc.). Malaria, rheumatic fever, lead-poisoning. Chronic gastric or intestinal catarrh; or a long-continued diarrhea. Worry and mental excitement. Wasting diseases. 3 XXXIV SYNOPSIS OF EXAMINATIONS To Examine the Blood.—Count the red and white cells (pages 595 to 604). Estimate the hemoglobin (pages 605 to 613). Stain a dried specimen of the blood and make a differential count of the leucocytes (pages 613 to 631). Examine a fresh specimen of the blood (espe- cially for the malarial organism, pages 631 to 638). 25. Diagnostic Puncture.—If desirable, obtain fluid by punc- ture (pages 712, 713) from cavities or cysts; examine the fluid, and from its character endeavour to determine its source (pages 713 to 718). THE SHAPE AND RELATIONS OF THE THORACIC AND ABDOMINAL VISCERA, ANTERIOR ASPECT (SEMI-DIAGRAMMATIC) THE GHAPE AND RELATIONS Gf THE THORACIC ANT: ABOCMINAL VISCERA, POSTERIOR ASPECT iSEM:.DIAG: THE SHAPE AND RELATE ABDOMINAL ANTERIOR AS THE SHAPE AND RELATIONS OF THE THORACIC AND ABDOMINAL VISCERA, POSTERIOR ASPECT (SEMI-DIAGRAMMATIC). PLATE Ill. | A i It. Shannon.cie di wean | THE SHAPE AND RELATIONS OF THE THORACIC AND ABDOMINAL VISCERA, POSTERIOR ASPECT (SEMI-DIAGRAMMATIC): THE DIAGNOSTICS OF INTERNAL MEDICINE PRELIMINARY CONSIDERATIONS Diagnosis.—This, in its narrowest sense, consists in bestowing a name upon a certain assemblage of pathological phenomena. It should include also a knowledge of the causal factors of the disease ; a determination of its character with reference to type and severity; an estimate of the amount and kind of damage, both general and local, which has been sustained by the organism; a forecast of the probable course and duration of the morbid process; and a cogni- zance of the personal characteristics of the patient, whether psychic or physical, inherited or acquired. Its final object is to be able to treat disease intelligently, and the application of scientific meth- ods to the completest discrimination and recognition of disease con- stitutes the art of diagnosis. A diagnosis is made by means of symptoms, which constitute the evidence upon which is based a judgment as to the nature of the case. Symptoms, the phenomena caused by morbid processes, are divided into sudjective, those which can be appreciated only by the patient, and objective, comprising those which are detected by the personal examination made by the physician. The term physical signs is by common consent applied to the objective symptoms revealed by special methods of examination, used mainly in deter- mining the condition of the organs containéd in the chest and abdomen. In addition to a knowledge of the symptoms, subjective or objec- tive, which may exist at the time of examination, it is necessary to ascertain the presence or absence of hereditary taints or tendencies, to know something about the habits and occupation of the patient, to learn of past illnesses or injuries, and to obtain a clear idea of the manner of onset and subsequent evolution of the present disease. Finally, it is well to study the temperament and personal character- istics, mainly psychical, of the individual patient so far as practicable. The family and personal history, the history of the present illness, and the results of the examination constitute the evidence upon 1 2 THE DIAGNOSTICS OF INTERNAL MEDICINE which the final judgment as to the nature of the case is to be based. A necessarily heterogeneous collection of facts must be classified with reference to their relative value and significance and compared with the previous knowledge and experience of the diagnostician, after which a judgment may be rendered as nearly as possible in accordance with the facts. This constitutes the second and final step in the making of a diagnosis. The process is thus seen to con- sist of two elements—odservation, in its broadest sense, and reason- ing, applied to the results of the observation. Certain terms of some practical value and convenience are used to qualify a diagnosis, as follows (the definitions are largely from Foster) : LIST OF DESCRIPTIVE TERMS EMPLOYED WITH REFERENCE TO DIAGNOSES, SYMPTOMS, AND SIGNS Diagnoses : 1. Anatomical.—Based on a knowledge not only of symptoms or phenomena, but also of definite anatomical alterations on which the phenomena depend ; or a post-mortem diagnosis. 2. Clinical.—Based upon the symptoms manifested during life. 3. By Exclusion—Reached by a deductive process, all the affec- tions which present salient points of similarity with the one to be diagnosticated being reviewed in turn, and each suc- cessively discarded as one or more of its essential features are missed in a given case, until but one possibility remains, which is accepted as the true one. 4. Differential—tThe process of distinguishing between different diseases which resemble one another more or less closely. 5. Direct.—The symptoms are of such a nature that they point to the presence of one special disease, and are not capable of misinterpretation. 6. Pathological.—Of the nature of a lesion, without regard to its situation. %. Physical.—By means of physical (objective) signs, irrespec- tive of subjective symptoms, as by palpation, auscultation, etc. 8. Presumptive.—Not regarded as certain. 9. Retrospective.—Of some antecedent disease or injury, the nature of which can be deduced only from the history given and from the persistent effects. 10. Symptomatic.—Consisting simply in the determination of the most striking symptoms. 11. Topographical.—Of the seat of a lesion. PRELIMINARY CONSIDERATIONS 3 Symptoms : 1. Constitutional—Those that may result from unbalancing of the organism as a whole, and are common to affections of many kinds. Direct.—Those that depend directly upon the disease. General.—Constitutional. (See above.) Indirect.—Which are the indirect consequences of the disease. Local.—Which result from localized disease, and are usually confined to the site of the diseased organ or tissue. 6. Negatively Pathognomonic.—Which seldom or never occur in a certain disease, and consequently, if present, show that the case is not one of that disease. %. Pathognomonic.—Which undeniably indicate the existence of a certain disease. 8. Reflez—Which are caused by local disease, but manifest them- selves by means of the nervous system in an otherwise unre- lated organ or part of the body. 9. Sympathetic.—Which appear with the essential ones, but for the presence of which no cause can be assigned except that of sympathy. Ste oo pO 1. Physical.—Already defined. 2. Rational.Signs and symptoms, subjective or objective, cor- responding to the alterations in structure and mechanical conditions discovered by physical examination. 3. Stethoscopic.—Those discovered by auscultation. Difficulties in Diagnosis.—For various reasons it may be difficult or impossible to make a diagnosis. The most important of these reasons are as follows: (1) The subjective symptoms may be puzzling or incongruous. (2) The objective symptoms and signs may be ill-defined, obscure, or, if present, as discovered later, may be impossible of detection by the most searching examination—e.g., a beginning, small peri- nephritic abscess in an unusually obese patient, which can not be palpated until it reaches a certain size. (3) Certain symptoms essential to a diagnosis may not appear until the disease has advanced to a certain stage—e. g., the splenic enlargement and rose rash of typhoid fever. (4) Several diseases, each of which in other cases may constitute the sole morbid process, may co-exist, one as the primary or main disease, the others attending as complications or sequele. One or more of the secondary lesions may be recognised, and the underlying or primary disease or condition be overlooked—e. g., pleurisy with 4 THE DIAGNOSTICS OF INTERNAL MEDICINE effusion occurring as a result of previously unrecognised pulmonary tuberculosis, and masking the primary lesion in the lungs. (5) The rarity of a disease may lead to its non-recognition be- cause of unfamiliarity with its history and symptomatology, and perhaps the consequent failure to elicit all the diagnostic data. (6) The lack of a full and accurate history is at times a serious hindrance in making a diagnosis. The patient may be deaf and dumb or speak an unfamiliar tongue, or he may be unconscious, delirious, mentally unsound, or so ignorant and stupid that no reli- able information can be obtained from him, and intelligent friends or relatives may not be available. On the other hand, in conse- quence of a variety of motives, essential facts may be concealed by the patient or the friends. (7) Drug symptoms, unless known and due allowance made for them, may so disguise, add to, or simulate certain diseases that the diagnosis may be shrouded in uncertainty. (8) The diagnostician must be a good observer, and at the same time be able to reason correctly. As Huxley well says: “Scientific reasoning differs from ordinary reasoning in just the same way as scientific observation and experiment differ from ordinary observa- tion and experiment—that is to say, it strives to be accurate ; and it is just as hard to reason accurately as it is to observe accurately. In scientific reasoning general rules are collected from the observation of many particular cases; and, when these general rules are estab- lished, conclusions are deduced from them, just as in everyday life. If a boy says that ‘marbles are hard,’ he has drawn a conclusion as to marbles in general from the marbles he happens to have seen and felt, and has reasoned in that mode which is technically termed induction. If he declines to try to break a marble with his teeth, it is because he consciously, or unconsciously, performs the converse operation of deduction from the general rule ‘marbles are too hard to break with one’s teeth.’ . . . The man of science, in fact, simply uses with scrupulous exactness the methods which we all, habitually and at every moment, use carelessly.” While medicine is to a certain extent a science, and requires sci- entific modes of reasoning, medical art is, in a large proportion of cases, obliged to reason from probabilities as premises, and its final results can not be expressed in the exact formule of the mathema- tician. In obedience to some law which we do not yet know, 2 and 2 do not always make 4 in the reactions of the human body, otherwise patients would not be encountered who present serious symptoms after a medicinal dose of morphine, or blaze out with urticaria after eating strawberries. PRELIMINARY CONSIDERATIONS 5 To study and to compare ; to approach a case with a mind open to impressions, and without preconceived or fixed ideas as to its nature, based upon previous hearsay; to review and balance the evidence from time to time in the course of the disease; to ques- tion one’s self “Is there any other disease or condition which may better explain these symptoms than that which I have already assigned, ? ”—these and other habits of thought make the difference between the man who sees without learning and he who learns by seeing. Obtaining Evidence.—The diagnostician acquires the facts upon which he is to form an opinion: (1) By Jnterrogation—in- quiry of the patient or his friends; (2) by Odservation—an ex- amination, mainly objective, of the patient. Information obtained by interrogation is called the History or Anamnesis (remembrance) ; that derived from observation, the Present Condition or Status Presens. From a purely scientific and diagnostic point of view, the first questions addressed to the patient will be with reference to his an- cestry; next, in regard to his personal history antecedent to the present disease ; then as to the existing disease, followed by a care- ful and systematic examination, first of the general condition, then of special organs, one by one, together with such chemical, micro- scopical, bacteriological, and other investigations as appear to be demanded. But for obvious reasons this order of pursuing the inves- tigation is for the most part impracticable, and consumes an un- necessary amount of time. - In the vast majority of cases the facts are acquired by the physi- cian in the reverse order. The first question asked is, “In what way do you feel ill?” “Of what are you complaining?” Or, the patient will volunteer a statement as to his subjective sensations. The question or the statement will direct attention at once to the probable or possible seat or nature of the disease. Further in- quiries are put as to the duration and character of the morbid sensations. During these interrogations the physician attentively scrutinizes the general aspect of the patient in search of obvious objective symptoms. The pulse, respiration, and temperature are taken. The organ or part which appears to be most at fault is first examined, after which due attention is paid to other por- tions of the body. Finally, the family and social history may be ascertained. This is the logical order of investigation, as conditioned by actual circumstances. It is a matter of indifference as to the sequence in which the symptoms are learned, provided that the examination is 4 6 THE DIAGNOSTICS OF INTERNAL MEDICINE sufficiently intelligent and systematic to be sure of eliciting all the facts, and that the facts when obtained are so arranged in the mind of the physician that they form a clear and coherent picture, and are capable of being recorded in an orderly manner. It is to be remembered in this connection that in many cases it is just as neces- sary to note negative facts—i. e., the absence of certain symptoms or signs—as it is to ascertain the presence of others. Keeping Case Histories.—This habit promotes accuracy of observation, completeness in examination, and affords trustworthy material. The physician who keeps adequate records acquires facil- ity in describing symptoms, signs, and morbid conditions. The drawbacks are the time consumed and the amount of work involved, but by late methods the time and labour required are reduced to a minimum. To accomplish this requires certain materials and acces- sories. The essential elements (Dicxinson) of the outfit are of two kinds: (1) Cards made and handled according to the card cata- logue system, and (2) rubber stamps made to suit individual re- quirements. (1) Card Outfit—Records are made (Figs. 1 and 2) upon cards (6 by 6% inches), one or more being used for each case, standing on edge in a box or drawer and ranged under an alphabetical index, each letter printed on a buff Bristol card (guide or index cards) which stands higher than the history cards. The size of the history card is such that, by folding once (the line of the fold must be vertical), it will fit into the pocket-book or visiting list. The cards are kept in a box with a sliding top, or with a lid which is the upper third of the box (Fig. 3). When Mr. A. or Mrs. S. enters the consulting room, the cards under A or § are picked up and shuffled through until the desired one is found. The necessary record or entry is made and the card returned to its proper place. For patients ill at home, cards are picked out and placed in the pocket-book before starting on morning rounds. Cards of convalescents are dropped. If two or more cards are found to be necessary for a long case, they may be fastened together with a brass clip. , Cards differing in colour are useful for special purposes, i.e., buff- coloured cards for consultation cases, salmon colour for surgical cases, and the like. Another method of special classification is to have two or more alphabetical indexes, the cards which belong to a special class of cases being ranged under the corresponding separate index, in the same box or drawer. Loose notes, letters, or sketches may be pasted to the case card or kept in envelopes of the same size as the cards and filed. Tong Por Z7 -7 cf Ferwlpertz Se HE a RE ne ee A / POY IPA PPD), FORK 2 - Pig? LID OL SIT oo GR OMe f OLEGs PRELIMINARY CONSIDERATIONS / 9 Temperature cards (Chart I), urinalysis cards (Fig. 4), and cards for blood examinations (Chart IX) have been devised by De Forest. (2) Rubber Stamps.—These are of two kinds—outline stamps and stamp forms for recording special data. Outline Stamps.—These, as the name indicates, are rubber stamps representing in more or less detail various regions or organs of the body, and employed when it is desired to represent by the graphic method any changes of structure, the exact location and character of physical signs, the outline of tumours, ete. An ink pad is required, Fig. 3.. preferably red or blue. The case card is placed upon a level surface, the stamp inked, and adjusted on the desired place, and a quick, light blow given with the palm of the hand. On the outline thus printed may be sketched or written with pen or pencil whatever abnormalities it is desired to represent. Further changes which occur may be entered on the same outline, the date being appended, or a new print may be made. The use of the outline stamp has - proved invaluable, because of the increased accuracy of observation to which it leads, even leaving out of consideration its value as a record. (See Figs. 1 and 2, red outlines.) SEX, AGE, NATIONALITY. We cts Urinalysis QUANTITY IN COLOR ODOR REACTION SPECIFIC GRAVITY ALBUMIN SUGAR UREA BILE cH PEPTONES ADV MORPHOLOGIC CASTS DIAGNOSIS REMARKS Fie. 4. PRELIMINARY CONSIDERATIONS 11 Type Stamps.—These are used in noting any set of answers which require frequent asking, or which may be involved in special investi- gations, like the following example : SHORT MED TALL FT IN: STOUT THIN WEIGHT LBS: BLON BRU INDETER: EYES BLU BR BLK: SLIGHTLY VERY NEUROTIC: MENTALITY HIGH MED LOW: SLEEPS WELL POORLY: APPT GOOD POOR: VOMITG ERUCTS FULNESS DISCOMF PAIN IMMED HRS AFTER BEFORE EATING: BOWELS HABITUAL OCCAS CONSTIP LOOSE RE@ FLATULENCE: URINATION NOT FREQ PAINFUL: URINE AMT INCREAS DIMIN: MENSES PAIN SLIGHT SEVERE NOT REG FREE SCANTY VAG DISCH LABOURS SEVERE NO FEVER: TOBACCO HABIT OCCAS MOD EXCESS: COFFEE TEA BOTH HABIT OCCAS MOD EXCESS: PULSE RATE NOT REG TENSION HIGH LOW: ARTERIES HARD SOFT: RESP RATE COSTAL ABDOM EXPANS GOOD POOR: TEMP A large amount of writing is saved by this device. The imprint is made in the same manner as with the outline stamps. The words required are underlined, special emphasis indicated by double under- lining, and doubtful points followed by a question mark. Any de- sired set of words can be made to suit individual requirements. The set should not cover a space greater than 14” x 3”, or 2” x 4", a8 a larger size will not print evenly. The stamp may be a self-inker or ahand stamp. The hand stamp is less expensive and, with care in printing, answers perfectly. PART I THE EVIDENCES OF DISEASE SECTION I CONSIDERATIONS, NEITHER SYMPTOMS NOR SIGNS, WHICH MAY QUALIFY OR SUGGEST A DIAGNOSIS THE considerations which may qualify or suggest the diagnosis in a given case relate to the family history or hereditary tendencies, and the personal history up to the date of the present illness. The personal history includes age, sex, nationality, occupation, residence, habits, and previous diseases or injuries. Such considerations em- brace also the chronological occurrence, seasonal or diurnal, of cer- tain diseases, and the comparative infrequency of others. I. Family History.—The family history of the patient is of much importance, because of the light which may be cast by it, not only upon the present illness, but also upon the constitution and tenden- cies of the patient. Unfortunately, it is not always possible to obtain a complete and accurate family history. It is usually necessary to cross-examine the patient with some particularity, inquiring into the symptoms and duration of illnesses attributed to ancestors, and bearing in mind the approximate meanings of various popular terms, such as “ gastric fever,” “dropsy,” “blood-poisoning,” “teething,” “cold,” “nervous prostration,” which latter may cover insanity or hysteria. “Old age ” is frequently assigned as a cause of death, which has, of course, little meaning. “Childbirth,” when assigned as a lethal cause, not infrequently proves to be a rapid phthisis pulmonalis. Inquiries regarding certain diseases should be made very cau- tiously, because of the possibility of arousing feelings of shame or fear in the patient. It is better to ask if there is “lung trouble” in the family than to use the word “consumption.” So, too, it is strongly advisable to ask after the symptoms without mentioning the names of suspected syphilis, tuberculosis, or cancer. There is a certain reproach to family or personal pride in the acknowledg- ment of the existence of some ailments, which may lead to the con- cealment of important information. 13 14 THE EVIDENCES OF DISEASE A full statement of the family history includes the nature of the illnesses (with the age of the living) and the causes of deaths (with the age at death) which may have occurred in the patient’s parents, paternal and maternal grandparents, brothers and sisters. It is requisite at times to ascertain similar facts with reference to aunts, uncles, and cousins. It should be borne in mind that transmissible tendencies may pass over one generation. It is important during this inquiry to bear in mind that certain diseases are either frequently associated or are manifestations of a common cause. In some cases there is a curious alternation between two diseases, one replacing the other—e. g., migraine and epilepsy. This may occur in the individual, or in alternating generations. Heredity may be direct, the offspring showing the lesions of the disease at birth, as in syphilis. In the majority of cases, a certain stamp or type of tissue and organization is transmitted which ren- ders the individual vulnerable to special micro-organisms, as in tuberculous subjects, or liable to perversions of the nervous system, or prone to degenerations and disturbances of metabolism. CONGENITAL AFFECTIONS The following diseases and conditions may be congenital : Malformations. Syphilis. Idiocy. Dislocated hip-joint. Acute fatty degeneration Hydrocephalus. Angeioma. (Buhl’s disease). Tetanus neonatorum. Neevi. Achondroplasia. Myotonia congenita Ichthyosis. Osteomata. (Thomsen’s disease), Pemphigus. Hemophilia. Infantile hemiplegia. Sclerema. Hemoglobinuria. Progressive muscular at- Dermatitis neonatorum. Hypertrophy of pylorus. rophy. Icterus neonatorum, Atelectasis. A list of diseases and conditions which are considered to be trans- missible in varying degrees follows. The bracketed groups are com- posed of those which have affiliations either of conjoint occurrence or common causes. HEREDITARY DISEASES AND CONDITIONS ( Rheumatism. ( Insanity. | Cardiac diseases. Hysteria. | Chorea. Hypochondria. Nephritis. Epilepsy. Renal calculus. | Migraine. Emphysema. Neuralgias. | Bronchitis. Neurasthenia. | Psoriasis. Many neuroses. AGE—INFANCY AND CHILDHOOD 15 Tuberculosis. Phthisis pulmonalis. Tuberculous glands. Tuberculous disease of bones. Tuberculous peritonitis. Tuberculous meningitis. { Hydrocephalus. Premature senility. Hemophilia. Diabetes. Obesity. Syphilis. Alcoholism. Acne. Eczema. Ichthyosis. Psoriasis. Leprosy. Lichen. Nevus. Malformations. New growths. Arthritis deformans. Gout. Diseases of the liver. Chronic nephritis, especially cirrhotic. Renal calculus. Angina pectoris. Cardio-vascular disease. Apoplexy. Asthma. Hernia. Dupuytren’s contraction. Disseminated sclerosis. Hereditary cerebellar ataxia. Pseudo-hypertrophic paralysis. Progressive muscular atrophy. Hereditary peroneal atrophy. Facio-scapule-humeral atrophy. Laryngismus stridulus. Tetany. Paramyoclonus multiplex. Huntington’s chorea. Thomsen’s disease. Friedreich’s ataxia. Adiposis dolorosa. Il. Age.—Anatomical structure varies with age, and physiological processes have peculiarities which are characteristic of different periods of life. Moreover, the effects of environment, occupation, habits, the beginning and end of sexual life, and the wearing out of the organism by constant friction, are necessarily manifested at vary- ing ages. Consequently there is a distinct preponderance in the fre- quency of certain diseases or classes of disease at special age periods. The diseases of youth are often the direct progenitors of those of old age, and the life of the individual may be a constant struggle with diseased conditions which began in antenatal life. (1) Infancy and Childhood.—At this age there is a special liability to digestive disorders, because of the relatively large amount of work required to meet the pressing needs of a rapidly developing organ- ism, and because of the peculiar susceptibility to infection of the gastro-intestinal tract in children. Inflammations of the respiratory apparatus are frequent, because of the tendency of the cells of the mucous membranes to undergo rapid proliferation under slight and unaccustomed irritations. Nervous diseases and reflex disturbances are common for the reason that the cerebro-spinal and sympathetic apparatus is developing, and has not yet settled into habits of regular 16 THE EVIDENCES OF DISEASE innervation. This is also the age, above all, others, at which the or- ganism is susceptible to certain infectious diseases—the exanthemata. The following diseases are those which are most common at this age period. Some are congenital. Diseases mentioned under a given head may begin later than the period under which they are classed. Eczema. Intertrigo. Impetigo contagiosa. Pemphigus. Seborrheea. Strophulus, Ringworm. Malformations. Nevi. Soft cataract. Bronchitis. Broncho-pneumonia. Laryngismus stridulus. Spasmodic laryngitis. Laryngeal diphtheria. (Edema of larynx. Adenoids. Post-pharyngeal abscess. Noma. Amyloid disease. Chloroma. Rachitis. Hemophilia. Infantile scurvy. Endocarditis. Primary renal sarcoma. Hypertrophic cirrhosis of liver. Diarrheal diseases. Intussusception. (2) Puberty and Adolescence: Acne. Seborrhea. Anemia. Chlorosis. Myoma. Chondroma, Myeloma. Exostoses. Sacro-iliac disease. Acute tuberculosis. Lumbrici. Congenital syphilis. Diphtheria. Mumps. Measles. Roseola. Rotheln. Scarlatina. Cerebro-spinal meningitis. Varicella. Variola. Tuberculosis of bones and lymph glands. Cretinism. Idiocy. Convulsions. Chorea. Epilepsy. Hydrocephalus. Infantile paralysis. Pseudo-hypertrophic paralysis, Progressive muscular atrophy. Tetany. Nodding spasm. Meningitis. Friedreich’s disease. Thomsen’s disease, Little’s disease. . Mollities ossium. Addison’s disease. Diabetes insipidus. Chloroma. Myxcedema. Exophthalmic goitre. Simple goitre. Disease of lymph glands. Catalepsy. Trance. AGE—ADULT AND MIDDLE AGE 17 Pulmonary tuberculosis. Typhoid fever. Mumps. Rheumatic fever. Réotheln. Diphtheria. Pharyngomycosis. (&dema of the larynx. Gastric ulcer. Appendicitis. Myocarditis, acute. Endocarditis. (8) Harly Adult Age: Acute rheumatism. Endocarditis. Peliosis rheumatica. Pharyngomycosis. Acute tuberculosis, Pulmonary phthisis. Acute yellow atrophy. Typhoid fever. Actinomycosis. Gastric ulcer. (4) Middle Age: Exophthalmic goitre. Myxedema. Diabetes. Gout. Mollities ossium. Addison’s disease. Cirrhosis of liver. Acute yellow atrophy. Weil's disease. Gallstones. Gastric ulcer. Stricture of rectum. Colonic ulcer. Chronic nephritis. Cysts of kidney. Myocardial diseases. Endocarditis. Aneurism. Angina pectoris. Dupuytren’s contraction. Leucemia. Pernicious anemia, Epilepsy. Hysteria. Acute dementia. Meningitis, all varieties. Cerebral embolism and thrombosis. Syringomyelia, beginning. , Cerebellar ataxia. Friedreich’s disease. Spasmodic spinal paralysis. Periodic paralysis. Spinal apoplexy. Gastralgia. Myoma. Cerebral embolism, Cerebral abscess. Hemorrhage into cord. Disseminated sclerosis. Syringomyelia. Landry’s paralysis. Progressive muscular atrophy. Periodic paralysis. Myoma. Epithelioma. Carcinoma. Apoplexy. Intracranial tumours. Hypochondriasis. Melancholia. Psychosis polyneuritica. Locomotor ataxia. Myelitis. Anterior poliomyelitis. Intraspinal hemorrhage. Syringomyelia. Landry’s paralysis. Ataxic paraplegia. Progressive muscular atrophy. Dementia paralytica. Paralysis agitans. Disseminated sclerosis. Sciatica. Paralysis of serratus magnus. 18 THE EVIDENCES OF DISEASE (5) Old Age: Pruritus. Myocardial diseases. Ecthyma. Aneurism. Pemphigus. Angina pectoris. Epithelioma. Broncho-pneumonia. Carcinoma, Bronchitis. Gout. Cerebral apoplexy. Prostatic disease. Pachymeningitis. Cataract. Paralysis agitans. Arteriosclerosis, Melancholia. Gangrene. Ill. Sex.—Putting aside the diseases due to differences in struc- ture and function between male and female, there remain certain maladies which occur more frequently in one sex than in the other. These discrepancies are caused mainly by the manner of life. Men suffer especially from diseases induced by exposure, hard physical or mental work and worry, and by the acquirement of injurious habits. Women lead an indoor life, and many are harassed by household and domestic anxieties. If not occupied by domestic cares, or if without definite aims and interests, a habit of morbid self-examina- tion is apt to be formed. Moreover, the nervous system in women is normally more unstable in its equilibrium. Because of all these factors, functional nervous diseases (neuroses) are much more com- mon in women than in men. The following list, which is by no means exhaustive, contains some of the more common diseases, classified according to sex fre- quency. The figures are only approximate. ; (1) Males: Alcoholism. Cysts of kidney, 2 to 1. Gout. Carcinoma of kidney. Diabetes insipidus and mellitus, 2to1. Colour blindness. Addison's disease, 2 to 1. Hematoma auris. Peliosis rheumatica. Hemophilia, 11 to 1. Leucemia, 2 to 1. Pseudo-leucemia, 3 to 1. Chloroma, 19 to 7. Hemoglobinuria. Diseases of larynx. Pneumonia. Emphysema. Valvular diseases of heart. Malignant endocarditis, 3 to 1. Angina pectoris. Exostoses. Angeioneurotic edema. Dupuytren’s contraction, 20 to 1. Typhoid fever. Cerebro-spinal meningitis. Mumps. Actinomycosis, 3 to 1. Apoplexy. Cerebral abscess. Simple meningitis, 2 to 1. Pachymeningitis. Bulbar paralysis. SEX—NATIONALITY 19 Myocarditis. Fatty heart, 2 to 1. Aneurism, of all varieties. Aneurism of abdominal aorta, 8 to 1. Chronic gastritis. Carcinoma of stomach. Gastric cirrhosis. Appendicitis, 7 to 3. Intussusception. Carcinoma of rectum. Cirrhotic liver, 3 to 1. Weil’s disease. Pancreatitis. Interstitial nephritis, 2 to 1. (2) Females: Anemia. Chlorosis. Erythema nodosum. Lupus erythematosus, 5 to 1. Scleroderma. Gastralgia. Gastric ulcer. Enteroptosis and floating kidney, 15 to 1. Constipation. Pulsating aorta. Mucous colic. Stricture of rectum. Acute yellow atrophy. Gallstones, 7 to 2. Tuberculous peritonitis, 2 to 1. Intraspinal hemorrhage. Spinal meningitis. Landry’s paralysis, 3 to 1. Amyotrophic lateral sclerosis. Progressive muscular atrophy. Syringomyelia, 2 to 1. Paralysis agitans. Pseudo-hypertrophic paralysis. Ataxic paraplegia. Thomsen’s disease, Dementia paralytica. Epilepsy. Hypochondriasis. Mitral stenosis. Myxcedema. Goitre, simple and exophthalmic. Osteomalacia, 30 to 1. Diphtheria. Pharyngomycosis. Acute dementia. Catalepsy. Trance. Hysteria. Neurasthenia. Acropareesthesia. Chorea, 3 to 1. Facial hemiatrophy. Adiposis dolorosa. Raynaud’s disease. In women the regularity, profuseness, and attendant pain of the menstruation, the number of pregnancies and miscarriages and their sequele should be ascertained, for the reason that deviations from the normal in these respects may be of much importance as possible causes of subsequent disease. IV. Nationality.—The susceptibility or its opposite, immunity, possessed by certain races has been commented upon by some observers. Among these may be noted the liability of the Jewish race to diabetes, of the Scandinavian and African to phthisis pul- monalis, and the comparative immunity of the African to yellow fever. V. Occupation.—With reference to the effects of occupation in causing disease, it will be found necessary to ascertain the details of 20 THE EVIDENCES OF DISEASE the patient’s employment, whether active or sedentary in character, and whether or not it requires the handling or breathing of toxic or irritating substances. Possible overuse of the eyes, playing wind instruments, and the care of domestic animals, are other details a knowledge of which may be useful. All previous occupations should be ascertained. It should be remembered that the state of health sometimes enforces the occupation. (1) Diseases Incident to Active Occupations : Aneurism. Pneumonia. Rheumatism. (2) Diseases Incident to Sedentary Occupations, including Mental Work: Anemia, Hypochondriasis. Chlorosis. Neuroses. Constipation. Obesity. Digestive disorders. Gout. Gallstones, Ulcer of the stomach. Hemorrhoids. Phthisis pulmonalis. Hysteria. (3) Diseases Incident to Special Occupations : Pulmonary phthisis. — Accountants, book- keepers, clerks, compositors, printers, pressmen, marble and stone cutters, miners. fibroid phthisis, or chronic laryngitis from dust.—Grinders, file cutters, potters, glass polishers, wool and cotton spinners, millers. Anthraz.—Skin handlers. Lichen.— Grocers, bakers, and bricklayers. Internal anthrav.—Wool and rag sorters. Glanders and tetanus.—Hostlers. Actinomycosis.—Grain handlers. Aspergil- losis. —Bird dealers and grain handlers. Psittacosis.—Bird dealers. Anemia, gastric ulcer, eczema, erythema nodosum.—Domestic servants (female). Varicose veins,—Coachmen, shop girls, and others accustomed to long maintenance of the standing or part standing position. Writer's cramp (scrivener’s palsy).— Clerks and writers. Septic infection.—Butchers and slaughterhouse employees. Conjunctivitis. —Electric-light workers. Probably caused by actinic rays. Mys- tagmus.—Miners. Emphysema.—Players upon wind instruments. Insomnia, _ dyspepsia, disease of liver and kidneys, neurasthenia, irritable heart, apoplexy, and paralysis.—Brain workers. Typhoid fever, pneumonia, cardio-vascular and renal disease, morphine and cocaine habits.—Physicians. Lead poisoning, gout.— Lead miners and smelters, potters, painters, glass-polishers, gilders, plumbers, dyers, makers of white and red lead, seamstresses (from silk thread loaded with acetate of lead), makers of artificial flowers. Mercurial poisoning.—Cin- nabar miners, makers of cheap looking glasses or mirrors, makers of felt hats (from the bath of acid nitrate of mercury used to promote felting), furriers. Arsenical poisoning.—Wall-paper workers (formerly), workers on artificial flowers and fancy glazed-paper boxes, furriers. Phosphorus poisoning.—Match- makers, Chromium and zine poisoning.—‘‘ Founders’ ague” in brass foundries, OCCUPATION—RESIDENCE a1 Disease of hair follicles. Operatives in oil refineries and paraffin works. Deaf- ness.—Boiler-makers. Caisson disease.—Divers and workers in compressed air. Laryngeal spasm.—Speakers, cornet and flute players. Clonic or tonic spasms of one or more extremities.—Typewriters, pianists, telegraph operators, violinists, blacksmiths, tailors and seamstresses, shoemakers, professional dancers. VI. Residence.—A knowledge of the place of residence may be of considerable importance, if not with regard to diagnosis, at least with regard to the prophylaxis of future attacks. In the diagnosis of sus- pected cases of cholera, yellow fever, and the pernicious or severe malarial fevers, the fact of the patient having visited or lived in countries or localities where they are prevalent may furnish a clew otherwise lacking. Goitre, rachitis, calculus, cretinism, dysentery, and lung diseases have at times special affinities with certain localities. The following list comprises the more important geographical associations of disease, which may be of diagnostic value in connec- tion with a patient fresh from residence in the countries named : Africa.—Dengue, Guinea-worm disease. Africa, South.—Bilharzia hematobia. Africa, West Coast.—Yellow fever, frambeesia. America, South.—Chigoe, ainhum (negro). Arabia.—Bilharzia hematobia. Canada, New Brunswick, Cape Breton.—Leprosy. China.—Beri-beri, bilharzia heematobia. Egypt.—Bilharzia hematobia, plague. England, Certain Counties. —Renal calculus. Europe, Large Cities. —Rachitis. France, South of.—Pellagra. India, East.—Beri-beri, Delhi boil, dengue, bilharzia hematobia, Asiatic cholera, frambesia, Guinea-worm disease, ainhum (negro). West Indies.—Chigoe, dengue, yellow fever, frambeesia. Italy.—Goitre, cretinism, pellagra. Japan.—Beri-beri, bubonic plague, bilharzia hematobia. Malta.—Malta fever. Morocco.—Plague. Naples.—Malta fever. Norway.—Leprosy. Spain.—Pellagra, goitre (Pyrenees). Switzerland, Alps.—Goitre, cretinism. Syria.—Plague. Tropical Regions in General.—Epidemic dysentery, pernicious intermittent and remittent fevers, acute hepatitis and hepatic abscess, leprosy, filaria san- guinis hominis. United States, Southern Portion, especially the Gulf States.—Pernicious intermittent and remittent fevers, yellow fever (epidemic), dengue, leprosy, filaria sanguinis hominis, ainhum (negro). 22° THE EVIDENCES OF DISEASE Other items embraced under the head of residence concern the effects of climate, city or country, seashore or inland residence, and the sanitary condition of dwellings with reference to ventilation, drainage, heating, cleanliness, and water supply. VII. Habits—The habits formed by individuals are so closely interwoven with age, occupation, and residence that it is only neces- sary to include here the possible existence of alcohol, opium, cocaine, or other drug addiction. Diet; the use of tea, coffee, and tobacco; clothing, sleep, and exercise are largely governed by the social condi- tion and environment. In men, the habits as to the frequency of sexual intercourse and a history of early self-abuse require investiga- tion. Ascertain also the kind and amount of alcoholic beverages taken and the time of taking—i.e., before, during, or between meals (with reference to the causation of sclerotic changes in stomach, liver, kid- neys, arteries, etc.). How much tobacco is used, of what kind, and in what manner (with reference to naso-pharyngeal catarrh, nervous- ness, cardiac neuroses). Both men and women should be interrogated as to the amount and strength of tea and coffee taken daily. The “ tea-and-bread ” habit is mainly found in women. VIII. Previous Diseases or Injuries—A knowledge of prior ill- nesses and injuries is of value, provided that their date, nature, and severity can be ascertained, for three reasons : (1) The history of a previous attack of certain diseases renders subsequent attacks probable. Among such diseases are : Malarial fevers. Nephritis. Influenza. Renal colic. Erysipelas. Intermittent hemoglobinuria. Diphtheria, Lead poisoning (colic). Pneumonia. Appendicitis. Acute rheumatism. Angina pectoris. Tonsilitis (follicular and phlegmo- Neuralgias. nous). Migraine. Gout. Delirium tremens. Bronchitis. Convulsions (infantile or epileptic). Asthma. Apoplexy. (2) With other diseases, a previous attack, as a rule, negatives its subsequent occurrence. Among these are: Measles (not uniformly). Parotitis (epidemic). Pertussis. Rétheln. Scarlatina. Typhus fever. Variola. Varioloid. Varicella. Yellow fever. Typhoid fever. (3) A history of the previous existence of certain diseases or in- PREVIOUS OR INFREQUENT DISEASES 93 juries may throw light upon present conditions which stand in the relation of sequele to the primary ailments. Examples of these are: Syphilis, followed by skin eruptions, alopecia, ulcers, periostitis, gummata, amyloid diseases, locomotor ataxia, dementia paralytica, and other affections of the nervous system, arterio-sclerosis, etc. Gonorrhea, with reference to gonorrheal rheumatism, orchitis, stricture, conjunctivitis, and pelvic tubal inflammations in the female. Scarlet fever, with subsequent middle ear inflammations, renal disease, and rheumatism. Rheumatism, initiating chronic proc- esses which result in valvular cardiac lesions, and renal disease; also associated with chorea. Septic or suppurating foci, leading to subsequent embolic or general inflammations of heart, lungs, liver, pleura, or peritoneum. Lead poisoning causing gout; and gout or lead poisoning producing a chronic interstitial nephritis. A history of a fall or other injury may be of some value in con- nection with suspected meningitis, disease of the spine, Jacksonian epilepsy, and arthritis. A previous surgical operation may point to the possibility of a recurrence of the condition which required oper- ative interference. (4) There are certain diseases of which a diagnosis should be made with caution because of the infrequency of their occurrence, or the difficulty of their recognition. A provisional diagnosis is justi- fied in many cases, but a positive diagnosis of the diseases in the following list demands good evidence, not mere conjecture. This list applies to the general practitioner. The specialist in certain lines may and does have a different experience. Leprosy. Hemophilia. Scleroderma. Peliosis rheumatica. Morphea. Banti’s disease. Acanthosis nigricans. Leucemia. Keloid. Hodgkin’s disease. Lichen ruber. Chloroma. Sclerema. Myxcedema. Trichiniasis. Pancreatic disease, except carcinoma. Actinomycosis. Hydatids (except of liver). Inflammation of spleen. Chyluria. Psittacosis. Infantile hemoglobinuria. Paratyphoid fever. Atrophy of brain and porencephalus. Noma. Amyotrophic lateral sclerosis. Hydrophobia. Spinal intermeningeal hemorrhage. Anthrax. Syringomyelia and Morvan’s disease. Pharyngomycosis. Acute myelitis. Glanders. Hematomyelia. Aspergillosis, Pseudo-hypertrophic paralysis. 4 24 THE EVIDENCES OF DISEASE Polymyositis. Spondylitis. Osteomalacia. Myositis ossificans. Osteitis deformans. Leontiasis ossea. Acromegaly. Achondroplasia (foetal rickets). Addison’s disease. Acute yellow atrophy. Weil’s disease. Dextrocardia. Tuberculosis of pericardium. Pyo- or pyopneumopericardium. Abscess, aneurism, or rupture of heart. Coronary thrombosis. Primary tricuspid valve lesions. Acquired pulmonary valve lesions. Aortic stenosis (relatively rare). Aortitis. Aneurism of pulmonary artery. Periarteritis nodosum. Stokes-Adams’s syndrome. Fat embolism. Scapulo-humeral paralysis. Facio-scapulo-humeral atrophy. Hereditary peroneal atrophy. Friedreich’s disease. Hereditary cerebellar ataxia. .Landry’s paralysis. Spastic cerebral paralysis. Adiposis dolorosa. Erythromelalgia. Reynaud’s disease. Meralgia pareesthetica. Acroparesthesia. Nodding spasm. Huntington’s chorea. Dubini’s chorea. Athetosis. Catalepsy. Myasthenia gravis. Hysteria (in men). Myotonia congenita. Tetany. Periodic paralysis. Ophthalmoplegia. (5) There is little of diagnostic value to be gained from the vary- ing statistics of the seasonal prevalence of disease, beyond the broad statement that diarrheal diseases predominate during the summer months, while pulmonary disorders and rheumatic affections are most prevalent in the winter and early spring. Zymotic diseases occur in largest number during the cold season, but this is to be explained rather by the opening of the schools and the closing of house win- dows than by the effect of season per se. Typhoid fever has a notable seasonal incidence in the autumn months. (6) It may be mentioned here that certain diseases either begin or show an exacerbation of symptoms at special diurnal periods. Bronchial asthma is apt to make its onset or to intensify in severity in the early morning hours; spasmodic croup, as well as diphtheritic stenosis of the larynx, between 10 and 12 at night. The suffering from painful diseases is usually worse at night, and in febrile disor- - ders the temperature generally reaches its highest point between 7 and 8 p.M. The paroxysms of whooping-cough are more frequent -and severe at night. The pain due to diseases of the bones and joints presents a nocturnal aggravation. (7) It is well to remember that some ailments present a more or less regular periodicity of recurrence. Among these are neuralgias, HISTORY OF THE PRESENT ILLNESS 25 migraine, pseudo-angina, epilepsy, periodic paralysis, relapsing fever, malarial infections, ulcerative endocarditis, paroxysmal hemoglobi- nuria, pyelo-nephritis, bronchial asthma, and menstrual disorders. (8) A history of alcoholism is important as explanatory of the presence of the following diseases; in their prognosis; or as sug- gestive in regard to their possible occurrence in a given individual: Myocarditis, arteriosclerosis, aneurism, cirrhosis of liver, chronic pharyngitis, chronic gastritis, pneumonia, emphysema, tuberculosis, chronic nephritis, apoplexy, delirium tremens, neuritis, pachymen- ingitis, Korsakoff’s disease, and gout. (9) The following diseases are essentially chronic (figures from Leftwich) : Chorea (1 to 4 months). Acromegaly (10 to 20 years). Dementia paralytica (months to years). Exophthalmic goitre (months to years), Idiopathic muscular atrophy (years). Addison’s disease (2 to 3 years), Locomotor ataxia (1 to many years). Lymphadenoma (2 years). Chronic myelitis (6 months to 10 years). Leucemia (6 months to 7 years). Disseminated sclerosis (5 to 10 years). Interstitial nephritis (4 to 10 years), Syringomyelia (5 to 20 years). Amyloid disease (years). SECTION I THE HISTORY OF THE PRESENT ILLNESS Iv is desirable to obtain a full and accurate history of the present illness, as in all cases it is more or less necessary, in some absolutely essential. The greater part of this history is subjective, but there may have been some symptoms sufficiently objective to have been observed by the patient, such as edema or hemorrhages. It is in obtaining this history that the largest draughts are made upon the tact and experience of the physician. The patient may be one of the odd people from whom it is difficult to extract more than a monosyllabic answer, or may be so talkative that a question is slipped in only after patient waiting for a pause. Dense ignorance may be an obstacle, so also may false modesty or shame. Exaggera- tion of symptoms, a not uncommon failing, must be guarded against ; less often its opposite, a stoic pride in making light of pain. These and other difficulties (e. g., malingering) require the exercise of some skill in the art of cross-examination. Except in the case of suspected malingering, where the answer may flatly contradict the alleged condition, leading questions are to be avoided, especially with impressionable or ignorant patients. For 26 THE EVIDENCES OF DISEASE instance, it is better to say, “ Did you have any pain in the head?” than “You had pain in the head, did you not?” The first ques- tion is a simple interrogation, which may elicit the reply, “ Yes” or “No.” The second almost forces the answer “Yes.” Care is to be taken lest the patient’s story should be too narrowly limited, otherwise a knowledge of important symptoms may not be gained. It is better to expend additional time and patience, which may be utilized in a careful scanning of the general appearance, behaviour, and temperament of the patient, than to miss a possibly vital point in the history. The physician’s object in this portion of the examination is to gain a clear conception of the origin and course of the disease up to the present time. The inquiry should therefore be conducted with reference to the following points : (1) Possible Exciting Causes —The most important, with refer- ence to early diagnosis, is a known exposure to some infectious disease. Other causes of consequence are fatigue of mind or body, dietetic imprudences, toxic agents, and chilling of the body or “ tak- ing cold.” This last factor is frequently assigned by patients as a satisfactory etiological explanation of the most diverse ailments, and is a convenient substitute for other demonstrable causes. (2) Date and Manner of Onset.—A definite statement of the time of onset will generally place the disease in one of two categories, acute or chronic. Nevertheless it must not be forgotten that an acute attack may be an expression, perhaps the first, of some under- lying and causal disease or condition ; for instance, uremic convul- sions in renal disease. As a rule, however, acute diseases begin sud- denly, while with chronic maladies a long period may elapse before the symptoms force themselves upon the attention of the patient. Lobar pneumonia and cirrhosis of the liver may be cited as illustra- tions, respectively, of acute and chronic diseases. The manner of onset should be accurately ascertained, strictly separating the symptoms which initiated the attack from those which appeared at a later period, for otherwise their relative importance may not be appreciated. Closely connected with the date and manner of onset are the— (3) Subsequent Symptoms in the Order of Appearance up to the Present Time.—The value of a strict chronological history of the symptoms which succeed the onset of any disease, can not be over- estimated. In some, as typhoid fever, the diagnosis may depend largely upon the order of evolution of the present symptoms. Each symptom should be elicited and the time of its appearance borne in mind. INDICATIONS FROM THE GENERAL APPEARANCE oT (4) Symptoms now Present.—The present sufferings and com- plaints of the patient should be attentively listened to, as in connec- tion with previous symptoms they may determine the direction of the first step in the special objective examination. Thus, a colicky pain in the abdomen will prompt an immediate palpation of the appendical region. Moreover, the present condition may demand instant palliative or other treatment, as in pulmonary hemorrhage, before the physician is able to proceed with his special investigations. One thing more is needed to complete the antecedent history— namely, information as to— (5) Previous Treatment.—It is rarely possible to obtain reliable information in regard to previous treatment. The statements of patients with reference to the therapeutic agencies used by previous physicians are ordinarily quite untrustworthy. But, if such knowl- edge can be obtained from authoritative sources, it may be of con- siderable value. Thus, certain symptoms, otherwise unaccounted for, may be explained as due to the administration of certain drugs (acne from bromides, dilated pupils from atropine, etc.). The “thera- peutic test” may have been applied, and the result weigh for or against a certain diagnosis (quinine in malaria, in the absence of a blood examination; mercury and iodides in suspected syphilis). SECTION III DIAGNOSTIC INDICATIONS FROM THE GENERAL APPEARANCE THE general appearance is studied with reference to the dress, height, and weight; amount and character of adipose and muscular tissue; complexion, colour of hair and eyes; diathesis and cachexia. I. Dress and General Behaviour.—An occasional hint may be derived from the clothing. Omission to use fastenings which may be needed for common decency, the coat or trousers buttoned with the wrong buttons, a vest soiled with droppings of food, may indi- cate the mental enfeeblement of a psychosis or chronic alcoholism. Clothing wet and of an ammoniacal odour is found in cases of incon- tinence of urine and cystitis. Diabetic urine in drying may leave a white deposit of glucose. The patient may be so crowded and bulg- ing in his clothes as to suggest a recent rapid increase of bulk from obesity or general dropsy. The shoes may be left partly or entirely unfastened from forgetfulness, gout, rheumatism, or cedema; or slit for similar reasons, or because of corns, bunions, or injury; or worn 28 THE EVIDENCES OF DISEASE more on one side, or in front, or at the heel, because of paralysis, deformity, or disease of the joints. In meeting people -unprofessionally one forms an unconscious judgment of character and peculiarities based upon the observation of small details of behaviour. These judgments are often useful outside of strictly technical lines in estimating the value of infor- mation received, its reliability, completeness, and freedom from exaggeration. The furtive look and the inability to meet squarely the eye of the physician may indicate mental weakness, morbid suspicion, or an intention to deceive. This manner, however, is not always to be interpreted as stated, for there are absolutely upright people who, because of ingrained timidity or bashfulness, will present a most striking but quite baseless hangdog manner and expression. II. Height and Weight should be ascertained, if practicable, by actual measurement, but the statements of the patient, and the rough estimate which may be made by the eye, are sufficient for diagnostic purposes. Height is qualified by the adjectives dwarfish, short, medium, tall, very tall. Similar qualifying terms with refer- ence to weight comprise emaciated, thin, spare, medium, stout, obese. When emaciation is extreme, and attended with a general failure of strength and vitality, it is called marasmus. The relation of height to weight is by no means a fixed ratio, and is of little consequence in diagnosis. Very considerable variations may exist without indication of disease and without creating a pre- disposition thereto. An abnormally large disparity, other things being equal, shows that the balance of nutrition is disturbed, and in consequence the chances of longevity are lessened. HEIGHT-WEIGHT RATIO 5 feet 0 inches in height should weigh 115 pounds. 66 ce TF oe 120 . oy 5 1 5 9 77 ve “ 125 6 5 66 3 a “ce rr 130 ce 5 “ 4 “ “ oe 135 6 5 5 «6 66 46 140 “ 5 6 6c “ oe 145 66 5 4 66 “ 73 150 4 5 6c 8 “cc oe oe 155 rc 5 9 “ a 66 160 6 5 * 610 “ 66 we 165 r7 5 oe 11 cc oe t9 170 4 6 cc 0 “ce oe be 175 oe 6 « 1 6c ry & 180 6 6 “ 2 ce [T4 6c 185 rT 6 (74 3 oe 6 iT) 190 (79 ADIPOSE AND MUSCULAR TISSUE 99 Although the weight of the body at any one time has compara- tively little diagnostic value, it is otherwise with increase or loss of weight as compared with former measurements. Change in the weight of the body, especially in some chronic diseases, such as tuberculosis, is in most cases a reliable index of the tendency of the malady, progressive loss indicating an advance of the disease, while progressive increase in weight follows a lessened activity. In this connection it is important to remember that general anasarca, ascites, and bulky abdominal or other tumours may cause a mislead- ing increase of body weight. In general, persons of moderate height and weight are best adapted to pass successfully through the ordinary trials of life and the extraordinary ordeals of disease. But, just as the thin, “ wiry” individual may accomplish an enormous amount of work without excessive fatigue and emerge triumphantly from severe illness, so there are stout (in the sense of obese) and hearty people who decline to grow thin or to be worn out or to degenerate, and will live to old age in spite of serious acute diseases. III. Amount and Character of Adipose and Muscular Tissue.—The subcutaneous fat is a large element in the weight. Normally it is distributed quite equally over the body, but may accumulate excess- ively on some particular part, especially the abdomen. In women after the menopause, and in men after the age of 45, there is fre- quently a marked increase in its amount. This increase is most commonly seen in sedentary persons who consume large quantities of food, although not uncommonly it appears to be an inherited tendency. The quality of the subcutaneous fat is to be estimated by the touch: good, if firm and elastic; poor, if soft and flabby. Loss of weight is ordinarily first observed as a diminution of the subcutaneous fat. When this diminution is extreme, the skin becomes loose, owing to the loss of its foundation, is wrinkled, and can be raised in folds. On the other hand, in obese persons the skin may be overstretched, so that lines resembling the familiar linex albicantes of pregnancy can be seen upon the buttocks and abdomen. The muscles may be large or small as compared to the bones. Size, however, is not of so much importance as quality. It is better to possess muscles which are soft and of moderate bulk, but yet firm, elastic, and quick-acting. Flabby, relaxed, firm, large, small, are the terms employed in describing the quality of muscles. The bones, by comparison, may be large, thick, and prominent, or small, slender, and inconspicuous. To a considerable extent, the visibility of bony angularities depends upon the amount of subcuta- neous fat. The characteristic rounded curves of well-developed 30 THE EVIDENCES OF DISEASE women and children arise not only from the smaller bones, but also from the thicker covering of fatty tissue which belongs normally to the sex and age. Special deformities and alterations in the shape of the skeleton, either in whole or in part, are caused by certain morbid processes, and, with associated symptoms, constitute recognised forms of disease. Tur Diagnostic Import oF CHANGES IN WEIGHT As alterations in weight are largely dependent upon changes in the volume of the subcutaneous fat and the muscles, it is proper to summarize the principal conditions in which the weight progressively increases, progressively decreases, or remains stationary, omitting normal conditions (rich food, sedentary life, middle age, menopause ; or hardships and poor food). It is stationary or increases slightly in chloro-anemia, and slight continuous or frequently recurring hemorrhages, as from bleeding hemorrhoids. It progressively increases in pathological obesity; often also in alcoholism, rachitis, adiposis dolorosa, myxedema, cretinism, demen- tia, pseudo-hypertrophic paralysis, and disseminated sclerosis. It progressively diminishes in Addison’s disease, Marasmus, Hysterical anorexia, Stricture of esophagus, Cancer, Obstruction of pylorus, Diabetes (especially), Ulcer of stomach, Chronic diarrhea, Chronic suppurations, Long-continued fevers, Obstruction of thoracic duct, Prolonged lactation, Tuberculosis (all varieties). Asa symptom, progressive emaciation is most important in chronic diseases, and during convalescence from acute diseases. Continuing loss of weight in the latter case may point to approaching or co- existing chronic disease. IV. The Conformation of the Body.—From the purely esthetic point of view the painter or sculptor rarely, if ever, finds a figure corresponding to the ideal which is in his mind. Certain of the im- ported photographs used as a basis for illustrative diagrams in this volume have been made from professional models, and yet in nearly all there are obvious defects when a comparison is made with the acknowledged masterpieces of figure painting. From the medical point of view one may rather easily recognise certain abnormalties in the configuration of the body which are (a) congenital and predispose toward disease, or (4) acquired as results, and are signs of disease. DIATHESES AND CACHEXIAS 81 (a) There are two congenital types of body which predispose to disease. 1. Tall, thin subjects, with small bones, slender ribs, anda long, narrow thorax, are predisposed toward tuberculous disease of the lungs. 2. Short, stout, thick-boned persons are predisposed toward obesity and its attendant evils. IZf the thorax is wide and round, emphysema is liable to occur, although this shape of chest is more often a con- sequence than a cause. (6) Certain abnormalities of shape result from the following dis- eases (g. v.): Rachitis, acromegaly, myxcedema, pulmonary osteoar- thropathy, osteitis deformans, and osteomalacia. The colour of the hair and eyes is of little importance, but it is of service in forming a complete conception of the case to note the “complexion.” Light or blonde, dark or brunette, indeterminate, may be employed as qualifying terms in the white races. The colour of the hair and its amount (g. v.) as symptoms are considered else- where. V. Diatheses and Cachexias.—There are some differences among lexicographers as to the meaning of the terms diathesis and cachexia. Following and defining the modern usage, it is to be understood that diathesis refers to a congenital habit of body, and cachexia to a con- dition of anemia and debility, as follows: 1. Diathesis.—A diathesis is a congenital condition or habit of body which predisposes to certain constitutional or local manifesta- tions of disease. The recognition of a diathesis is, as a rule, dependent upon the presence of a certain disease, or a history of its past occurrence in the individual. After the history is taken and the examination com- pleted, it is of service in conveying an idea of the patient and the general trend of his pathological life, to state the diathesis with its qualifying adjective. The qualifications are as follows: (a) Gouty, Arthritic, Uric-acid, or Lithemic Diathesis.—A dis- position to gout and its sequent renal and cardio-vascular changes— aneurism, angina pectoris, and cerebral hemorrhage. The physical characteristics of the individual of this diathesis are said to be a robust, well-developed body, florid face, thick hair, and good teeth, hearty appetite, good digestion, and a strong heart with high-pres- sured arteries. (6) Tuberculous (Phthisical, Strumous, Scrofulous) Diathesis.— A habit of body which is vulnerable or predisposed to tuberculous disease of glands, bones, or other forms of tuberculous infection. The older writers recognised two types which are not infrequently 32 THE EVIDENCES OF DISEASE seen in classical perfection—viz., the tuberculous, with oval face, bright eyes, delicate skin and colouring, and long, slender bones; and the strumous, with a heavy, round face, thick, muddy skin, lumpy figure, and thick bones. (c) Catarrhal Diathesis—There are many persons who appear to be so liable to various chronic inflammations of mucous membranes that it is convenient to characterize them as belonging to the catar- rhal diathesis. (d) Fatty Diathesis (Bazix).—A term applied to those who are obliged to battle, oftentimes unsuccessfully, against a tendency to pathological obesity and fatty overgrowth. (e) Rheumatic Diathesis—A predisposition to various rheumatic affections—an indefensible but useful term. (f) Hemorrhagic Diathesis——The equivalent of hemophilia (q. v.). (9) Neuropathic Diathesis.—A predisposition, frequently hered- itary, to diseases of the nervous system, most commonly the various neuroses. It is among this class that drug idiosyncrasies are most apt to be encountered. The diatheses a, d, e, f, and g can not be said to present physical traits which are in any degree characteristic. (h) Status Lymphaticus—Under diatheses may be classed the status lymphaticus (lymphatism), a condition not often encountered, occurring mainly in children and young persons. The lymph glands, especially the pharyngeal, thoracic, and abdominal, are universally enlarged; the lymphoid marrow of the bones is increased in amount and red marrow may replace the yellow marrow in young adults; the thymus gland and the spleen are enlarged; and there is defi- cient development (hypoplasia) of the heart and aorta. The body as a whole is undeveloped, and in shape retains many of its infan- tile characteristics. Rachitis frequently co-exists. Such individuals have a very small power of resistance, and sudden death may occur either without apparent cause or as a result of ailments or causes which are ordinarily attended by danger—e. g., unexpected death during convalescence from infectious diseases; sudden and inex- plicable deaths in children ; or while bathing; or during anesthesia; or following the injection of diphtheria antitoxine. 2. Cachexia.—A yellow, waxy face, associated with anemia, gen- eral debility, and more or less emaciation, are the characteristic signs of a condition which is spoken of as “cachetic,” or a “ cachexia.” The anemia and the yellow or brownish-yellow colour of the skin are the indispensable signs of this condition. It is usually associated with some grave organic disease or a chronic poisoning of the blood. While the meaning of the word is somewhat vague, yet to the physi- POSTURE IN BED 33 cian of considerable experience, like some other terms, as “ very ill,” “sinking,” “collapse,” it expresses very graphically a state which would otherwise require many words of description, and the recogni- tion of which is often of diagnostic value. The various cachexie of a more or-less well-defined character and importance are as follows: (a) Cancerous Cachexia.—Debility, emaciation, anamia, and a dirty yellowish, yellowish-brown, or brownish-green complexion. (0) Syphilitie Cachexia.—Pronounced anemia, with a muddy pallor, and perhaps a light yellowish tint of the skin and conjunc- tivee. (ce) Malarial or Paludal Cachexia.—Puffy, pallid face, profound anemia, and a greatly enlarged spleen (ague cake). There may be bronzing and discoloration of the skin and general edema. (4d) Cachezia Strumipriva (Kocuzr).—A condition of anemia and myxcedema resulting from the total extirpation of the thyroid gland, and attended by peculiar nervous phenomena. SECTION IV POSTURE IN BED—MODE OF MOVING—GAIT—STATION INSPECTION may reveal certain facts in regard to the posture and the movements of the patient, which may be of little value or may furnish important suggestions as to the general condition of the patient or the nature of the disease. I. Posture in Bed.—The patient usually takes to bed in acute ill- ness or in chronic ailments, because of general weakness or some special interference with the use of the limbs, as in certain diseases of the nervous system. Remembering that many persons in health habitually assume certain attitudes while in bed, and that their cus- toms in this respect may not be changed by illness, the postures assumed in disease and their diagnostic associations are : (a) The dorsal strong or active posture, in which the patient lies upon the back comfortably and without constraint. It is seen in health, and in slight illness unattended with great pain. (4) The dorsal inert or passive posture. The patient lies upon the back, but is constantly slipping toward the foot of the bed, thereby putting the body in a posture which is uncomfortable, and which interferes with the respiratory movements. It is observed in conditions of great weakness, most frequently in the acute infectious diseases. It is especially characteristic of typhoid fever, even at an 34 THE EVIDENCES OF DISEASE early period, because of the marked muscular weakness and mental apathy so characteristic of this disease. (c) A rigid dorsal position, with both legs drawn up, in order to di- minish abdominal tension, is the rule in general peritonitis and in many cases of pelvic peritonitis. In appendical peritonitis the right leg alone may be flexed. In hip disease also there is flexion of one knee. (d) The patient may lie upon the side, and the manner of lying may be active or passive, as in the dorsal position. Patients having acute affections of the chest usually lie upon the affected side to limit the movements of the affected side and lessen the pain caused by pleural friction, as well as to afford greater free- dom of compensatory motion to the healthy side. Moreover, if a large pleural effusion exists, the pressure due to its weight will not burden the heart and the healthy, uncompressed lung. The posture of a patient with a cavity in the lung is of some significance, that posi- tion being chosen which brings the opening of the cavity uppermost, thus allowing secretions to accumulate and be discharged at infrequent intervals instead of constantly trickling into the bronchial tubes and causing an incessant irritating cough. The rule of lateral decubitus is not invariable, as the patient may find other positions preferable. In sciatica the subject usually lies upon the unaffected side. The lateral position with the legs drawn up to meet the trunk (the “coiled” posture) is seen in meningeal, cerebral, and cerebellar disease (due to spasm), hepatic, renal, and intestinal colic. (e) Optsthotonus.—This is the name given to an uncommon dorsal position in which the body rests upon the head and heels, the trunk being arched upward. It is observed in strychnine poisoning, teta- nus, and uremia, as well as in some peculiar manifestations of hys- teria and hystero-epilepsy. A modification of this position is ob- served in the characteristic contraction of the posterior neck muscles in meningitis, whereby the back of the head bores into the pillow. (f/f) Emprosthotonus.—An attitude in which the upcurved body rests face downward upon the forehead and feet. It is the opposite of opisthotonus and is rarely seen, but may be observed in tetanus, strychnine poisoning, paralysis agitans, and cerebro-spinal meningitis. The prone position, without tonic contraction of the muscles, is occasionally witnessed in the various forms of colic, the patient usu- ally lying with the abdomen resting upon a pillow or bolster in order to secure firm abdominal pressure for mitigation of pain. This pos- ture, without the pillow, is sometimes assumed because of the relief afforded in erosion of the vertebre resulting from aneurism, or in tuberculous disease of the spine. Less frequently it may be seen in gastric ulcer and mediastinal disease. MODE OF MOVING 85 (g) Orthopnea.—tin diseases attended with excessive dyspnea the patient instinctively sits upright, with the hands or elbows resting upon some point of support, in order, by fixing the shoulders, to facilitate the action of the accessory muscles of respiration. If an attempt is made to assume the horizontal position, the feeling of dyspnea becomes so intense that the upright attitude is quickly retaken. Orthopneea attends spasmodic asthma, emphysema, and diseases of the heart in their later stages. It is common with large effusions into the pericardial and pleural cavities, and is often en- countered in abdominal dropsies of sufficient size to press the dia- phragm upward. If the diaphragmatic pleura is inflamed, the patient is apt to sit erect with the trunk leaning toward the affected side. Extreme dyspnea of the inspiratory type, requiring the sitting pos- ture, attends obstructive or paralytic disease of the larynx, as in laryngeal diphtheria and paralysis of the dilators of the glottis. II. Mode of Moving.—(qa) In certain ailments, some of which have been mentioned in the preceding paragraphs, there is unusual immo- bility and a striking look of helplessness, due to the increase of pain upon motion, as in rheumatism, scurvy, and rachitis, or a disinclina- tion to move because dyspncea is made worse by exertion. Paralysis or tonic spasm of large muscular groups is another cause of enforced quietude. (2) An opposite condition, restlessness, exists in many diseases, as in fevers and large hemorrhages. Agitated and irregular move- ments are seen in chorea, in hysteria with its manifold manifesta- tions, and in other diseases of the nervous system. Severe griping or colicky pain, gallstone, or renal colic will induce the patient to throw himself about in the hope of relieving his suffering. III. Station —One should observe the manner in which the pa- tient stands; whether or not he is firm upon his feet; the shape and carriage of the head and shoulders; whether he is. erect or bends forward (as in paralysis agitans) or backward (as in ascites or abdom- inal tumour); and the position and shape of the limbs., Station, the power of standing more or less steadily, is greatly disturbed in some forms of nervous disease. A healthy person standing with the feet close together and the eyes open will sway forward and back 1 inch and from side to side 2 of an inch. In locomotor ataxia the swaying is extreme, owing to the loss of muscular, articular, and tendonous sense, and if the eyes are closed the patient may fall. Disease of the middle cerebellar lobe and aural vertigo (Méniére’s disease) will also cause swaying, and in paroxysms of the latter malady the patient may be absolutely incapable of standing or walking. Loss of the power to stand steadily is called static ataxia (gq. v.). 5 36 THE EVIDENCES OF DISEASE IV. Gait—The manner of walking is closely associated with station, and when possible should be attentively observed, as it is of much importance in the diagnosis of certain conditions or ° diseases. When observing the manner in which the patient walks, it is very desirable, if circumstances permit, to have the legs stripped and the patient in his bare feet. In women patients the nightdress may be pulled through from the back between the legs, snugged up, and pinned in front; or a T-bandage may be improvised out of a couple of towels. First eliminate, by inquiry and examination of the abdomen, bones, and joints, the various causes of abnormal progression enumerated in (a) and (bd) below. Then desire the patient to walk away from and back to the observer ; to walk at right angles to the line of sight; to walk along a crack between the floor boards or a seam of the carpet. During this time he is to be attentively watched in order to discover any peculiarities of gait, the manner of putting down and raising the feet, reeling, unsteadiness, or deviation from the straight line. The peculiarities in the manner of walking, and the conditions in which they possess more or less diagnostic importance, are as follows : (a) In pregnancy, ascites, large abdominal tumours, cretinism, pseudo-hypertrophic paralysis, and obesity, the body leans backward and the feet are widely separated while walking. (6) Painful or disabling affections of one or both lower extremi- ties, such as corns, rheumatism, gout, sciatica, metatarsal neuralgia, hip- or knee-joint disease or injury (recent or old), sacro-iliac disease, sprains, inflammatory disease of extremity, short leg, and paralysis of one leg, give rise to a limping or hobbling gait. So also may ab- dominal aneurism, and subacute or chronic appendicitis. Intermit- tent claudication is a condition in which there are pains and pares- thesias in the feet and legs on walking. The gait becomes limping, and finally a rest must be taken, after which the progress is resumed until a similar pause becomes necessary. Variously there are sensa- tions of tension and stiffness in the calves; heat and redness, or cold- ness and blueness of the feet. The principal objective sign is the presence of sclerotic changes, with a small or absent pulsation in the arteries of the foot. The majority of cases are in men over forty years of age. In some instances the condition is due to angio-spasm, without sclerosis of the vessels. (c) The most characteristic methods of progression are seen in diseases of the nervous system : (1) Ataxic Gait.—In walking, the foot is raised suddenly and too high, the leg is thrown forward with unnecessary vehemence, and the foot is again brought to the ground heel first, or flat-footed with a stamp. The feet are usually planted wide apart, and while they are GAIT 37 we in the air they move as if the patient was doubtful where to put them. The body is bent forward, and the eyes are fixed upon the ground in order to supplement as far as possible the loss of muscular and articular sensation. This gait is extremely characteristic of loco- motor ataxia. (2) Cerebellar Ataxic Gait.—The manner of progression resembles -that of an intoxicated person. The patient walks with short steps, and with his feet wide apart, staggers, reels, sways to and fro, and reaches a set point by zigzagging toward it. The swaying is relieved if he is supported by the hands of the observer placed under the arm- pits. This gait is significant of a tumour of the vermis or middle lobe of the cerebellum, and is often called the titubating gait, or simply cerebellar ataxia (g. v.). A somewhat similar gait is seen in Fried- reich’s disease, hereditary cerebellar ataxia, dementia paralytica, ataxic paraplegia, labyrinthine disease, and, to some extent, in vertigo from any cause. (3) Steppage Gait.—This variety of gait is due to paralysis of the extensor muscles of the foot, whereby, when the foot is lifted, its an- terior part tends to hang or drop down. In order to prevent the toes catching and tripping against the ground, the leg carries the foot somewhat forcibly forward, raising it at the same time unusually high, thus throwing the toes upward and bringing the foot to the ground heel first. It resembles the gait of a man who is walking through thick grass or brushwood, and has been described as “prancing” or “high-stepping.” It is evidence of peripheral neuritis (diabetic, arsenical, alcoholic, etc.) of the anterior tibial nerve, and, because of a certain resemblance to that of locomotor ataxia, is sometimes termed the pseudo-tabetic gait. (4) Spastic Gait.—The legs are rigid, move stiffly, and there is apparent difficulty in bending the knees. In consequence the foot is dragged along, the toes catching and scraping on the ground. In some instances, owing to spasm of the adductors of the thigh, the legs and knees touch and cannot be separated, causing cross-legged progres- sion—i. e., the legs and feet overlap at each step. This gait depends upon the excessive tension and spasticity of the muscles arising from lesions of the upper motor neurones. It is therefore, when bilateral, significant of sclerosis affecting the lateral pyramidal columns of the cord. The mode of walking in hemiplegia (g. v.) is a unilateral form of the same gait. The paralyzed leg, by a tilting of the pelvis, is swung outward and around to the front (“ mowing” gait), the toes often scraping the ground. (5) Festination—The head and body are bent forward and the patient takes short, shuffling, hurried steps, his speed tending to 88 THE EVIDENCES OF DISEASE increase as he progresses, exactly as if he was being constantly pushed forward and was trying to preventit. This gait is termed festination or propulsion. In some instances, if the patient is pulled rather sud- denly backward, he will take a number of backward steps (retropul- sion), although the body remains in its forward-leaning attitude. This gait is characteristic of paralysis agitans. (6) Waddling Gait.—The shoulders are thrown back, the back is hollowed (lordosis), and the abdomen protuberant, the body some- times actually leaning backward. In walking, the feet are planted wide apart and the body swings from side to side at each step—the “waddling” or “goose” gait. It resembles somewhat the gait de- scribed under (a), and is a very characteristic symptom of pseudo-hy- pertrophic muscular paralysis. It is seen also in disease, or congenital dislocation of both hip-joints. (7) In Thomsen’s disease, on attempting to rise or walk the leg muscles immediately become stiff and cramped, without pain. The cramp relaxes in a few seconds, but returns when the muscles are again called into use. In saltatory spasm (very rare), when the weight of the body is put upon the feet, strong and rapid contractions of the leg and thigh muscles take place, causing the patient to jump violently. In hemiplegia, one foot is dragged. Dragging of doth feet is seen in multiple neuritis, hereditary peroneal atrophy, spasmodic spinal paralysis, and in spinal and syphilitic spinal paralyses. The gait is tottering in those who have taken large doses of the bromides for long periods; so also in hydrocephalus, psychosis polyneuritica (Korsakoff’s disease), paralysis agitans, and idiopathic muscular atrophy. SECTION V PAIN; TENDERNESS; PARASTHESIAS THERE are certain subjective sensations which are of much, although varying, importance in diagnosis. Although a subjective symptom does not constitute decisive evidence, it may furnish an important clew to the nature of the disease—e. g., the “tender point” in appendicitis. On the other hand, there may be an absolute absence of tenderness over the kidney in pyelitis and an occasional PAIN 39 lack of pain in peritonitis, gastric ulcer, perforating duodenal ulcer, latent pleurisy, and various pelvic lesions, by which a most important guide symptom is missing. The subjective symptoms which are considered in this section comprise pain, tenderness, and paresthesias. Other disorders of sensation, such as anesthesia, hyperewsthesia, etc., are dealt with else- where (Examination of the Nervous System). It j is, of course, impos- sible within reasonable limits to describe all the multiple forms and sites of pain and other subjective sensations. Only those are con- sidered which may prove helpful in diagnosis. I. PAIN 1. Differences in Susceptibility—As pain is a purely subjective symptom, its intensity must be estimated by the statements of the sufferer, by the manifestations of its presence, and by the nature of any lesion which may be discovered as its probable cause. Much depends upon the skill and experience of the observer in judging individual susceptibility. The variations in pain sensibility are very great, and are racial as well as individual. The Semitic stock, and the Celtic and Italic groups, appear to possess an average greater sensibility to pain than the Teutonic and Slavonic groups. The most important variations, however, are personal or individual. The congenitally neurotic patient will complain bitterly of pain from a cause which in one of dull sensibilities will give rise to simple dis- comfort. It is to be remembered that the pain suffered by the abnormally sensitive person has as real an existence in consciousness as the slight discomfort felt, from the same cause, by those of less acute pain perception. 2. Modifications of Susceptibility——The manner of life and occu- pation may modify the susceptibility to pain. The habitual endur- ance of hardship blunts the pain sense, and, conversely, the person guarded from rude mental or physical contact, will be more acutely sensitive to pain. A strong mental prepossession (religion, excite- ment of battle, etc.) may interfere with the registration of painful impressions upon the consciousness. The sensibility to pain is apt to be increased by its long continuance, and it is a common observa- tion that each recurrence of pain, during the course of a disease, finds the patient less able to bear it. Fright or expectant apprehension invariably increases pain, and sometimes originates it. 3. Manner of Statement.—There are also differences in the manner of statement. Some patients as a matter of pride practise understate- ment of their subjective sensations, while others from various motives habitually magnify their sufferings, and in most instances without 40 THE EVIDENCES OF DISEASE the slightest intention of deceiving the physician. It arises largely from the unconscious egotism of illness and a desire to obtain relief by impressing the medical attendant with its pressing necessity. In estimating the severity of pain, the facial expression and bodily mani- festations of pain are of much value.