To recognize fully the various evidences of an unhealthy action of the system, a long course of study, including both healthy and morbid anatomy, is necessary. If, however, the several points referred to in this chapter be carefully studied, they will aid us in arriving at a tolerably accurate idea of the nature and severity of the disease we have to treat. The following are common and well-known diagnostic signs.
13.- The Pulse.
The pulse is produced partly by the forcible expulsion of blood from the heart, through the aorta (the great arterial trunk), and thence into the a various arteries of the body, by each contraction of the left ventricle of the heart; and partly by the innate contractility of the arterial walls. Its character will consequently be modified by the condition of the heart and the blood vessels.
In feeling the pulse, great gentleness should be observed, so as not to excite the action of the heart, which would defeat the object tin view. The pulse may be examined in any part where an artery is so close to the surface that its throb can be plainly felt; but in general the most convenient locality is at the wrist. While examining the pulse, there must be no pressure exerted upon the artery in any part of its course, by tight sleeves, ligatures, etc. The examiner should place three fingers just above the root of the thumb and the joint of the wrist, with his thumb on the opposite side, so as to be able to regulate the pressure at will. Its frequency may thus be measure by the seconds-hand of a watch; but its peculiar characteristics, as indicative of various phases of disease, can only be appreciated by the educated hand of a medical man. By this method we can detect its rhythm, its fulness, or softness; whether by compression it may be rendered less perceptible; whether it is strong and bounding, forcing the fingers almost from the arm, or hard, or small and wiry, like the vibration of a string; or intermittent, striking a few beats, or whether the pulsations flow into each others, small and almost imperceptible.
HEALTHY PULSE.- The healthy pulse may be described as uniform, equal, moderately full, and swelling slowly under the fingers;it is smaller and quicker in women and children. In old age the pulse becomes hard, owing to increased firmness or to structural change in the arterial coats. The average number of beats in the healthy pulse in the minute, at different ages, is as follows- At birth, 140; during infancy, 120 to 130; in childhood, 100; in youth, 90; in adult age, 75; in old age; 65 to 70; decrepitude 75 to 80.
The pulse is influenced, however, by the following and other conditions, which should be considered in estimating the character of the pulse as a diagnostic sign. It is faster in the female than the male, by from six to fourteen beats; but this difference only occurs after about the eighth year. It is quickened by exertion or excitement; it is more quickened by exertion or excitement; it is more frequent in the morning, nd after taking food; it beats faster standing by cold, step, fatigue, want of food, and by certain drugs, especially Digitalis.
PULSE IN DISEASE.- In estimating the differences of the pulse as signs of disease, allowances must be made for those sudden irregularities which are often observable under transient excitement or temporary depression, especially of nervous persons.
The rapid pulse, especially if strong, full and and hard, indicates inflammation or fever; if small and very rapid, it points to a stage of great debility, such as is often present in the last stage of Enteric fever.
The jerking pulse is marked by a quick and rather forcible beat, followed by a sudden, abrupt cessation, as if the direction of the wave of blood had been reversed, and excites suspicion that structural disease of the valves of the hear may be present.
The intermittent pulse is that in which a pulsation is occasionally omitted, and is frequently owing to some obstruction in the heart or lungs, or Inflammation or softening of the brain, Apoplexy, etc.; also in some forms of valvular disease of the heart. Prolonged over-exertion, watching, want of rest, anxiety, etc., may produce it. In minor degrees, Indigestion with flatulence may produce it. It is often a symptom of the gouty constitution without indicating the presence of any organic disease.
The full pulse occurs in general plethora, or in the early stages of acute disease; while the weak pulse denotes impoverished blood and an enfeebled condition of the system.
When the pulse resists compression, it is said to be hard, firm or resistant; if it is small as well as hard-it is said to be weak. Of late years much attention has been paid to the condition known as the blood-tension. This depends on a variety of factors in the action of the heart and the condition of the arteries. It can be to some extent estimated by the fingers, but instruments have been devised for its more exact measurement. These require the expert, however, both to apply them and to estimate the value of the readings obtained.
14.- Temperature and the Clinical Thermometer.
For many years now considerable help has been derived in the diagnosis and treatment of disease from the use of the clinical thermometer. In all cases of illness, to count the pulse and the respirations is not more important than to measure the heat. The thermometer aids the physician in arriving at definite conclusions, and relieves him of much mental anxiety, and in many cases gives him a clue to the disease even before characteristic symptoms have made their appearance. In temperate regions the normal heat of the human body, at sheltered parts of its surface, is 98.4* Fahr., or a few tenths more or less; and a persistent rising above 99.5*, or d a persistent depression below 97.3* are signs of some kind of disease. The maintenance of a normal temperature, within the limits above stated, gives a complete assurance of the substance of anything beyond local and trifling disturbances; but any acute disease unnaturally elevates the temperature or animal heat, and many diseases are thus indicated some time before they could be detected by any other means.
The thermometer enables us to diagnose decisively between an inflammatory and a non-inflammatory disease; it also helps us to determine the severity of the inflammation by the number of degrees to which the thermometer is raised. Hysteria, it is well known, often simulates inflammatory disease; but the temperature of hysterical persons is normal, whereas that of persons really suffering from inflammation is always raised. A case is recovered of a girl supposed to be suffering from Hysteria presenting symptoms indicative of inflammation of the membranes of the brain. The hysterical tendency of the patient led to the supposition that there was only an apparent symptom of inflammation; the thermometer determined the genuineness of the symptoms; for it showed a temperature of 103.5* F., proving the actual existence of grave inflammation, afterwards confirmed by the fatality of the disease. Hysterical patients sometimes become very skilful l in manipulating the thermometer and apparently recording high temperatures. Therefore if there is any suspicion of hysteria or malignering the temperature should be taken by the physician with the utmost care.
In acute fevers, the thermometer affords the best means of deciding in doubtful cases; it is often the best corrective of a too hasty conclusion, and is indispensable for prognosis. Thus, a Typhoid fever, the rise of temperature, or its abnormal fall, often indicates, what is about to happen some time before any change in the pulse, or other sigh of mischief, may be observed.
In Tuberculosis, the thermometer affords us most valuable diagnostic information. The symptoms and signs are often obscure, or their true cause may be doubtful; especially in the early stage of the disease, when treatment is likely to be greatest avail. The importance of the aid of the thermometer in this case will be recognized by the fact that during the deposit of tubercle in the lungs, or in any organ of the body, the temperature of the patient is always raised from 98*, the normal temperature, to 102.3*, or even higher; the temperature increasing in proportion to the rapidity of the tubercular deposit. A persistent elevation of the general temperature of the body has often been found general temperature of the body has often been found to exist for several weeks before less of weight of physical signs indicating tubercle in the lungs could be appreciated. Hence an elevated temperature not only affords us certain information as to the existence of Phthisis, but the degree of that elevation enables us to estimate the extent and progress of the disease; for a persistent rise shows that the disease is progressing, or that unfavorable complications are setting in.
In Measles, the thermometer is almost the only means of learning at an early stage the invasion of Pneumonia.
In Ague, several hours before the paroxysm, the temperature of the patient’s body rises considerably.
In Acute Rheumatism, a temperature of 104* is always an alarming symptom, grave complication, such as involvement of the valves of the heart. In short, a temperature of 104* to 105* in any disease indicates that its progress is not checked, and tat complications are liable to arise.
In all cases of convalescence, so long as the decreases of temperature proceeds regularly, as measured by the thermometer, no relapses need be feared; on the other thermometer, no relapses need be feared; on the other hand, delayed decrease of temperature in Pneumonia, the persistence of a high evening temperature in Typhus or Enteric fever, or in the eruptive diseases, and the incomplete attainment of normal temperature in convalescence, are of great significance. They indicate convalescence, are of great significance. They indicate incomplete recovery, approach of other diseases, unfavourable changes in the products of disease, or the continuance of other sources of disturbance requiring careful examination. The onset of even a slight elevation of temperature during convalescence is a warning to exercise careful watching over the patient, and especially for the maintenance of a due control over hid diet and action (Aitken).
These remarks might easily be extended, and illustrations multiplied of the value of the thermometer as an aid to diagnosis; but beyond recommending a small, straight instrument, with a correct scale, self-registering, and taking the observations regularly at the same hours daily throughout the disease, noting at the same time the pulse and the breathing, we have only space for the following directions –
The best way to take a temperature is to place the bulb of the thermometer under the tongue, by the side of the last molar- wisdom tooth-and request the patient to close the lips around the stem. The time required to ascertain the temperature correctly is from three of five minutes. Another way is to place the bulb under the armpit; but the former plan is better wen practicable.
Healthy inspiration is performed with great ease by a nearly equal elevation of the ribs and enlargement of the chest, and by descent of the diaphragm. Expiration is the natural return of the chest to its proportions during rest, which is produced by the pressure of the external air, the ascent of the diaphragm, and contraction of the abdominal muscles. An adult breathes about twenty in a minute. Disease and exertion quicken the rate of breathing.
Dyspnoea, or difficult breathing, may result from wasting disease of the lung substance; adventitious deposits in these organs (these conditions necessarily lessening the amount of breathing surface); formations of false membranes in the air passages, as in Diphtheria and inflammation and swelling of the tonsils or tongue – all of which conditions obstruct t he entrance of air into the lungs, and thus cause Dyspnoea, as does also Asthma, which seems to be a spasm of the muscular coat at the air-tubes, or a swelling of the mucous membrane.
Effusions into the pleurae or pericardium, the serous membranes surrounding the lungs and heart, also induce Dyspnoea by causing compression of the lungs, and fracture of the ribs may naturally impede the respiratory movements. Intrinsic organic and functional diseases of the heart also cause Dyspnoea. Disease of the nerves which preside over the respiratory movements, or in that part of the nervous centres from which they proceed, may also produced serious and even fatal difficulty of breathing. In Apoplexy, and cases of great exhaustion, when an insufficient supply of blood is sent to the great nervous centre-the brain-the respiratory movements are deranged, and otherwise greatly or even fatally obstructed.
16.- The Tongue.
This organ affords important indications – Dryness points to diminished secretion, and is common in acute and febrile diseases; moisture is generally a favourable sign, particularly when it succeeds a dry or furred condition. A preternaturally red tongue is common in the course of the eruptive fevers; in Gastric and Bilious fevers, and in bad cases of Indigestion, the redness is often limited to the edges and tip. The Strawberry tongue is a symptom of Scarlet fever; the fissured tongue of Typhus and Enteric fevers. When the tongue is livid or purple, there is defective oxygenation of the blood. The furred tongue is the most marked, and is common in inflammation and irritation of the mucous membranes, in diseases of the brain, in all varieties of fever, and in almost all acute and dangerous maladies. Some persons have usually a coated tongue on rising, without any other symptom of disease. This is especially the case with tobacco smokers. A uniformly white-coated tongue indicates gastric or intestinal disorder, but not as a rule of a serious kind; a yellow coat is indicative of disordered action of the liver, or more profound alimentary disorder; a brown or black, of a low state of the vital powers, and contamination of the blood. The gradual cleaning of the tongue, first from the tip, and edges, shows a tendency to health, and indicates the cleaning of the whole intestinal tract; in less fortunate cases, as the tongue gets browner, dirtier, and drier each day, the nervous and muscular systems get weaker, and hope is gradually extinguished; when the fur separates in patches, leaving a red, glossy surface, it is also unfavourable; when the crust is rapidly removed, leaving a raw or dark-colored appearance, the prognosis must still be unfavorable.
This is often a most important indication of the nature and seat of disease, pointing to an interruption of the harmony of the bodily organs. When attended with a throbbing sensation, consequent upon the heart’s action, it is called pulsating pain; when with a feeling of tightness, tensive; when with heat, burning. Nervous Neuralgic pain may be recognized by its disposition to follow a certain course, without being rigidly limited to one particular part; by its being subject to perfect intermissions; and by the suddenness with which it comes and goes. Spasmodic pain is mitigated by pressure, by frictions, and by applications of heat; it comes on suddenly with greater or less severity, terminating abruptly. Inflammation pain is constant, attended by heat and quickened pulse, is increased by movement of the affected part, by touch or pressure, and usually mitigated by rest. Frequently pain occurs, not in the part diseased, but in a distant one. Inflammation of the liver often first shows itself by pain in the right shoulder; inflammation of the hip-joint, by pain in the knee; stone in the bladder, by pain at the end of the penis; disease of the heart, by pain down the left arm, etc.
18.- The Skin.
In health the skin imparts to the touch the sensation of an agreeable temperature, with just sufficient moisture to preserve its softness; it is also elastic, smooth, and neither too tense nor loose. A harsh, dry, burning heat of the skin is indicative of fever, and must ever be regarded as unfavorable, especially in inflammatory conditions of internal organs. If this condition be followed by perspiration, coincident with general improvement, it is a favourable indication. Great relief is usually experienced on the occurrence of the sweating stage in Ague, Inflammatory fevers, etc. On the other hand, complications may be feared if perspiration ensue without any amelioration of other symptoms.
Partial or local symptoms indicate a deranged condition of the nervous system, or an affection of the organs beneath the perspiring surface. If perspirations occur after trifling exertion, they point to excessive weakness. Night sweats, of frequent occurrence, not only show debility, but when preceded by chills and fever, may indicate Tuberculosis.
The colour of the skin is also diagnostic. A bluish tint of the skin indicates structural disease of the heart. A yellow colour points to biliary affections. A rich blush of the cheeks, especially if it be circumscribed, and the surrounding parts pale, may indicate an irritable condition of the nervous system, or a diseased state of the lungs.
19.- The Urine.
The urinary organs are, the kidneys and bladder, with their appendages. The kidneys secrete the urine from the blood, and by this process the blood is relieved of many impurities, which if retained, would give rise to decease in the whole system. The secretion of the kidneys reaches the bladder through the channels (ureters), and the urine is ultimately discharged through the urinary canal (urethra).
Healthy urine is of a brightish yellow or amber colour, a tint darker in the morning than in the afternoon, yielding a slight ammoniacal smell, devoid of unpleasant odour, and precipitating no deposit on standing, or only the merest trace of mucus, or of urates from a low temperature. In advanced age the urine becomes darker and slightly offensive; it is darker in persons who lead a very active life; different varieties of food also produce a marked effect both on the colour and odour of urine. The stream of urine should be round and large, and it should be passed about four to six times in twenty-four hours without any pain or straining.
The average specific gravity of healthy urine is between 1, 015 and 1,925, being in excess of water, which is the standard (1,000), and the normal quantity in adults about forty or fifty ounces in the twenty-four hours. A urinometer indicates the specific gravity.
In disease, the urine presents many varieties, and furnishes valuable indications to the pathologist. Thus it may be of a dark yellow or saffron colour, as in Jaundice, or disease of the liver; it may be red or high-coloured, and scanty, with quickened pulse, as in fever; it may be bloody or slimy, as in affections, of the kidneys or bladder; it may be pale and copious when metabolism is checked, less urea excreted, and the unrenewed blood furnishes no colouring matter, as in nervous and hysterical ailments; it may bone heavy, muddy, showing an unfavourable condition of the system. The urine may be passed too copiously or scantily, with pain, with effort, or it may be retained with difficulty. There may be a frequent or uncontrollable desire to micturate, with burning or scalding pain; or the pain may be only experienced in passing the last few drops; in either case local inflammation is indicated.
The specific gravity of urine in Bright’s disease is 1,015 to 1,004; diabetic urine, 1, 025 to 1,040; in Hysteria it may be as low as 1,007.
In Rheumatic fever, in Gout, etc., the urine is abnormally acid; while, on the contrary, when the bladder is inflamed (cystitis) the urine will contain much mucus, and is frequently alkaline. Heat will produce a deposit in acid urine if albumen is present, but not so in alkaline, however large a proportion of albumen it may contain. If urine is kept some time before being examined, if often becomes alkaline and therefore before testing for albumen any natural or artificial alkalinity must be removed by the addition of a suitable quantity of acetic acid. On the other hand, an excess of strong acid added may in its turn interfere with the albumen test. The acidity should be definite, but not excessive. The microscope enables us to detect casts of tubes, etc., but it should be remembered that many substances may have found their way into the vessel, as fibres of deal, flannel, or cotton, etc., which bear a sufficient resemblance to be mistaken for the above.
When urine has to be examine, a little should be taken from the whole quantity that has been passed during twenty-four hours, as it varies greatly in its properties at different periods of the day, and after food.