A system of practical medicine. By American authors. Vol. 1

by Unknown

Following the natural method, we may suppose a call to visit a patient. Arriving in his presence, the first question (mostly left out of view and rarely expressed) may be, Is it a case of real or only imaginary indisposition? Army medical officers, more than most others, can appreciate the possibility of this inquiry sometimes disposing of the whole case.

Supposing it to be real, is it an illness or an accident or other injury? Is it severe or of trifling account? Acute or chronic? We observe the position of the patient, lying quietly in bed, sitting up, or walking restlessly about the room. Then the countenance is observed—pale or flushed, tranquil or excited in expression. We feel the forehead, touch the cheek and hand. Is the skin hot or cold, dry or moist? The pulse is felt; the breathing also is counted.

Of the patient himself or of another (in serious acute cases better of his care-taker, in another apartment) we ask questions whose answers give us the general history of the case. When not before known these should include his antecedent personal history, even extending to that of the family, as far as can be learned. What tendencies have they, or has he or she, shown by previous attacks and their results?

So we come to the present attack: When did it begin, and how? What have been its prominent symptoms since? Questions are then to be put concerning the heat of the body, appetite, complaint of pain, sleep, movement of the bowels, discharge of urine: in the female, menstruation; if married, pregnancy or parturition, how often and when occurring last. Thus the practitioner is enabled to get a clue to the diagnosis, to be followed out through his own observation and closer examination. If the patient be a child and the attack be acute and febrile, an early question must be as to its having passed or not through the different diseases of childhood—viz. the exanthemata, mumps, and whooping cough, and also what exposure to any of these it may have been recently subjected to.

Going farther into particulars, let us review some of the possible developments obtained in the above questioning of symptoms.

When lying in bed the decubitus may be significant, as, upon the back with the knees drawn up in peritonitis; with the hands pressing the abdomen in colic; tossing to and fro in the delirium of fever or of early cerebral inflammation; on one side constantly in acute inflammation of the liver or in pleurisy. Or the patient may be obliged to be propped in a sitting posture (orthopnoea) from heart-disease, asthma, or ascites, or leaning forward upon the back of a chair or a pillow with aneurism of the aorta. More remarkable still may be the subsultus tendinum of low fever, the opisthotonos of tetanus, the respiratory spasms of hydrophobia, or the clonic movements of epileptic, hysterical, or occasional convulsions.

In the face we see pallor in syncope and in anæmia in any of its varieties and with varied associations; a general redness in some cases of apoplexy and in remittent fever; flushing of the forehead and eyes especially in yellow fever; dusky redness in typhus, and a more purple hue in typhoid fever; yellowness in jaundice, in some cases of remittent and in most of yellow fever; sallowness in cancer; a bright central glow upon each cheek in early pneumonia or the hectic of phthisis; a blue or ashen appearance in the collapse of cholera, and blackish-blue in cyanosis or carbonic acid poisoning; bronzed in Addison's disease; puffy about the eyelids in Bright's disease; the surface swollen, yet resistant to the touch, in myxoedema. The eyes (one or both) glare prominently in exophthalmic goitre; squint in advanced cerebro-meningitis; roll to and fro often in the prostration of cholera infantum and in convulsions; are clear and bright in phthisis; yellowish in hepatic disorder; dull and clouded in low fevers; without expression in imbecility and general paralysis.

Contraction of the pupil is observed in inflammation of the retina or of the brain, narcotism from opium (until near death) or eserine, or apoplectic effusion near the pons varolii. Dilatation of the pupil is seen in most cases of hydrocephalus and of apoplexy; in nerve-blindness (amaurosis), glaucoma, cataract, and narcotism from atropia, duboisia, or hydrocyanic acid. Inactivity of the pupil (Argyll Robertson) under changes of light and darkness is common in locomotor ataxia. Different states of the two pupils under the same light show disorder, either ophthalmic or cerebral in site, or may indicate pressure on the cervical sympathetic ganglia, as from aortic aneurism.

In elderly persons we ought always to look for the arcus senilis, which is a sign of a tendency to fatty degeneration. It is a ring, or part of a ring, with ill-defined edges, best seen by lifting or depressing an eyelid, at the junction of the cornea and sclerotic coat of the eye. In some quite healthy old persons there may be seen at the same junction a clearly-defined circular line of calcareous nature. This must be distinguished from the true fatty arcus senilis.

Of the face we may also notice the pinched nose, hollow eyes, and falling jaw of the facies Hippocratica, presaging death; the square forehead of the rickety child (not common in this country); ulcers on the forehead, scars at the mouth-corners, or copper-colored eruptions in syphilis; the full, flabby lips of scrofula. In peritonitis or gastritis the mouth is apt to be drawn up with a peculiar expression of suffering and nausea. Very striking is the characteristic one-sided appearance in facial palsy, from lesion of the seventh nerve. There may be a smile, a frown, or other expression on the sound side of the face, while the paralyzed side is quite immovable. As the seventh nerve (portio dura) supplies the orbicularis muscles, its paralysis (so often temporary) may cause inability to close the eye upon the affected side. Ptosis, or inability to open the eye, involving the levator palpebræ, which is innervated by the third nerve (motor oculi) is more significant of cerebral lesion.