Even the ears may have language, as when their lobes are full and glistening red in the gouty diathesis, or wrinkled in prolonged cachexiæ, or when they are running with discharges in the struma (scrofula) of childhood. The hair becomes dry and lustreless in phthisis, and falls out during convalescence from many acute diseases.
If we look at the gums in a case of lead-poisoning, we may expect to find a blue line along their edges. Scurvy is betokened by a swollen, spongy, and easily-bleeding state of the gums. Many scorbutic cases, however, lack this so-called pathognomonic feature. It may be remarked, by the way, that absolutely pathognomonic signs of particular diseases, never absent and exclusively seen in them, are very few. Albuminuria, for example, is not always present in Bright's disease, and is also met with in a number of other affections. Sugar in the urine may follow inhalation of chloroform or an attack of cholera, as well as diabetes mellitus. Rice-water discharges may be absent in the collapse of cholera, and patients may die with yellow fever without black vomit. Still, these symptoms have great diagnostic value, and, taken with others associated with them, may often enable us to attain to a diagnosis of much importance.
Perfect teeth in an adult in this country are rather the exception than the rule. In the notched incisors of inherited syphilis, however, there is something quite distinctive. The notches in Hutchinson's teeth are vertical, not horizontal.
Old as medicine is the examination of the tongue in disease. It may be protruded with difficulty, as in low fevers, in apoplexy, and in cerebral paralysis (bulbar sclerosis, glosso-labio-pharyngeal paralysis) or thrust to one (the paralyzed) side in hemiplegia. It is pallid in anæmia; yellow in bilious disorder; red in glossitis (then swollen also), in scarlet fever, and in gastritis; furred in indigestion, gastro-hepatic catarrh, and the early stage of various febrile attacks; dry, brown, cracked, or fissured in typhus or typhoid fevers and in the typhoid state of malarial remittent fever; bare of epithelium in advancing phthisis and in imperfect convalescence from severe acute diseases. Coldness of the tongue is one of the worst signs in the collapse of cholera.
As we examine the throat internally we look for signs of faucial inflammation in redness and swelling, with or without enlargement of the tonsils, or relaxation and elongation of the uvula, or ulceration, or the gray or brown membranous deposit of diphtheria. In the mouth of a child we may find the little white vesicular patches called aphthæ, the curd-like exudations of thrush, or possibly the much worse grayish ulcerations of cancrum oris, or the rarer ashen sloughs of gangrene of the mouth.
Outside of the throat we must remember the significance of glandular swellings or scars of suppurated glands in children; nor overlook, if present, stiffness of the muscles, or torticollis, or goitrous enlargement of the thyroid gland. Observation should be made also of the site of the carotid artery on each side, and of the jugular veins, since aortic regurgitation may be indicated by violent action of those arteries or tricuspid regurgitation by pulsation of the veins in the neck.
Long before vaso-motor physiology had any place in science the pulse was known to afford valuable indications in disease. Either of the accessible arteries will answer instead of the radial; its convenience merely makes the wrist the common place of comparison. By careful examination of the pulse something may be learned of several of the factors concerned in its production. These factors are—1, the muscular force of the walls of the heart; 2, the state of the cardiac valves; 3, the muscularity of the arteries; 4, the elasticity of the arterial coats; 5, the state of the capillary circulation; 6, the qualities of the blood; 7, the condition of the nervous system as to excitability or apathy.
A feeble heart must induce a feeble pulse. Moderate debility may be attended by slowness of the pulse, but usually a weak circulation is marked by frequent, small beats, like the vibrations of a short pendulum. A strong heart-beat (other things being equal) is relatively slow, with a proportionate pause after the second sound.
Valvular lesions produce various effects upon the pulse. Most notable are the irregularity connected often with mitral insufficiency and the jerking pulse (Corrigan) of aortic regurgitation.
Believing, as the present writer does, in the existence of a true arterial systole following and supplementing the ventricular contraction,38 it must be urged that a vigorous muscularity in the arteries promotes strength in the pulse—not by resistance, but by auxiliary propulsion of the blood. Another condition altogether is tonic, spasmodic contraction of the arteries. This is not often met with pure and simple, but a measure of it is seen in the corded or wiry pulse of acute enteritis or peritonitis.