Continued diarrhoea, phthisis pulmonalis, mesenteric disease, cancer, and aneurism of the aorta are among the most frequent causes of great emaciation. Sometimes, as in progressive pernicious anæmia, we are struck with the comparatively slight degree of wasting of the body while the disease is advancing toward death.
In myxoedema there is a swelling or general enlargement, especially of the upper portions of the trunk. This is not anasarcous, but depends upon a morbid change in the connective tissue throughout the body.
Articular enlargements may be (particularly in the knee in children) scrofulous, or gouty (in the smaller joints), rheumatic, with evidences of inflammation, acute or chronic; or, what is not well named, rheumatoid arthritis. In this last affection there is a gradual swelling and stiffening, with but little inflammation, of several, sometimes all, the joints of the extremities. Locomotor ataxia is in some cases attended by a degenerative alteration in one or more of the larger joints.
The limbs may furnish to the eye many expressive signs of disease or disability. In the listlessness of one arm and hand, while the other can perform various movements, we see reason to suspect hemiplegia. If the fingers are rigidly contracted, as well as powerless, we have this diagnosis confirmed, whether the rigidity be early or late in its stage. We must then look for a similar condition of the lower extremity on the same side. Paraplegia and general paralysis have their more extended (bilateral) indications in like manner. Characteristic also are the wrist-drop, from paralysis of the extensors of the hand, in lead-palsy; weakness or incapacity of the flexors and extensors in writer's cramp; the hand fixed helplessly in the position for writing in paralysis agitans (advanced stage); the main en griffe, with shrunken muscles and drawn tendons, of progressive muscular atrophy (wasting palsy). In the legs at first and chiefly, but in time also in the arms, increase of bulk with loss of power in the muscles shows the existence of pseudo-hypertrophic muscular paralysis.
Gouty fingers have their joints not only swollen, but distorted by deposits of urates and carbonates. Clubbed finger-ends, in the adult, are seen mostly, with incurvation of the nails, in advancing consumption. The nails are sometimes striated after attacks of gout, the lines disappearing gradually during the interval. In many acute diseases, transverse ridges are noticeable on the nails, marking the date when their growth was arrested and subsequently resumed. These are specially remarkable after attacks of relapsing fever.
A tendency to dropsical effusion is generally first shown, besides a puffiness of the face, in the feet and ankles, the shoe or slipper marking off the enlargement above its margin. Often this has no other cause than debility, with a watery condition of the blood. Varicose veins, with old and resultant ulcers, are also among the possible things to be found in examination of the legs and feet.
Movements of the hands are incessant and jerking in chorea; perpetually trembling in delirium tremens, and often in one arm and hand only, in paralysis agitans; with tremor, seen in voluntary motions alone, in multiple cerebro-spinal sclerosis. More unusual is the rhythmical closing and opening of the hand, successively, of athetosis.
In the walk of patients able to be upon their feet there may be much significance. A hemiplegic subject will circumduct the feeble limb after the other; one suffering with paraplegia will shuffle the feet slowly along the floor; the hysterical paralytic drags the lame limb behind the other; the patient with spastic spinal paralysis rises on his toes in walking, with his legs held close together; the shaking paralytic rather trots forward, with the body bent; and the subject of locomotor ataxia lifts his feet and kicks out forward or sideways, then bringing down the heels with a stamp at each step. In progressive muscular atrophy and advanced pseudo-hypertrophic muscular paralysis a waddling or rolling gait is seen. Choreic patients are very irregular in their walk, as in all other movements. Hip disease (coxalgia) shows itself in a child by its lifting the pelvis and limb of the affected side and bending the knee, so as to touch only the toes to the ground. Club-foot and other deformities require no description in this place.
Sensibility of the extremities and of other parts of the surface of the body needs to be examined into, with all its possible variations (hyperæsthesia, anæsthesia, analgesiæ, etc.), especially when the nervous apparatus is for any reason supposed to be involved. Motions of an unusual character must likewise be carefully noticed. "Westphal's symptom" is regarded as having considerable diagnostic value. It is otherwise called the tendon-reflex, with its modifications. When a person in health is seated with one leg crossed over the other or with the legs dangling over the edge of a high bench or table, and a sudden blow is struck upon the tendon of the patella, the leg and foot will be spontaneously jerked forward. In locomotor ataxia, even from an early period, this tendon-reflex is abolished. In spastic spinal paralysis (lateral spinal sclerosis) it is exaggerated. Quite analogous to this is the ankle-clonus. This is obtained by firmly flexing the foot and then tapping sharply upon the tendo Achillis. The foot is then involuntarily extended and flexed several times in succession. There is more doubt in regard to the associations of this symptom than as to the knee movement, but it has been clinically shown to be exaggerated in spastic spinal paralysis.
At our first acquaintance with a case of disease, while making inquiry into its nature, the genital organs must not be forgotten. Not that we need always make examination of them, but any pointing in symptoms toward them must be borne in mind, so as to guide us in or toward further procedures in diagnosis. In making, in obscure cases, a diagnosis by exclusion, we are sometimes driven to a scrutiny of the genital system.