CHAPTER XIII. GENERAL CONSIDERATIONS. (Part 1)

CHAPTER XIII. GENERAL CONSIDERATIONS. Physician and Patient. One of the most essential things is the patient's confidence, and tliis can not be obtained by lond, boisterous talking, scolding, fault-finding, or undue jocularity. On the other hand, undue timidity or lack of self-confidence is equally bad. The patient must be in complete ''en rapport" with the exam- iner if the most is to be accomplished. In no other field is it more important to have ac- curate knowledge of anatomy. It is essential that the examiner be familiar with regional anatomy — know the location and size of the organs in health and their physiological variations before any accu- rate idea can be had of pathological conditions. The examiner must be alert, and use all his per- ceptive faculties. Often observations of a patient during conversation give very definite information. It is essential that the physical examinations be conducted in a routine manner. More errors of diag- nosis come from the want of system than from the lack of knowledge. Never attempt to make a physical examination through the clothing. It is impossible to elicit physical signs through heavy clothing, starched 272 PHYSICIAN AND PATIENT. 273 linen, or tlie corset, while the crackling, friction sounds of certain fabrics will obscure auscultation. Remember that careful study in the post-mortem room is essential to good work at the bedside. Fre- quent study of mistakes is always beneficial. Be thorough in physical examination, but that does not mean that you should be rough. There is nothing else that will so quickly secure complete co-operation of the patient as gentle manipulation. This can be done only by taking plenty of time, with the patient in an accessible position, and know what you are trying to do. Never mistake a guess for a diagnosis. These "snap" diagnoses are only guesses, and have J:)rought more disappointment than glory, but, if only the physician's reputation suffered, it would not be so bad. Always obtain a history, not only of the mode of onset of the present ailment, but the past complaints and of the family, especially of any fatal illness of the family. This will give a clew as to the inherited tendencies of the patient. Where a patient is confined to his bed, always note his posture in bed. Where the attitude is lax and his position controlled by gravity, and he re- mains in cramped and uncomfortable postures, such a patient is very weak, helpless, or unconscious, and is said to assume the passive position. On the other hand, the less the general feelings are affected, the more natural and unconstrained will be his position. 274 GEXEEAL COXSIDEEATIONS. Again, a patient with respiratory, cardiac, or renal affections, associated witli much dyspnea, can not lie upon his back, because the accessory muscles of respiration can be used to advantage only in sitting posture. Patients are constrained to lie upon one side be- cause of unilateral affection of the thoracic viscera. The patient usually lies upon the abdomen in colic, cardialgia, and sometimes intestinal obstruction, while in peritonitis the abdomen is tender and the patient lies upon his back. The state of nutrition should be noted. Chronic conditions are usually associated with emaciation. Edema of the skin and subcuticular fat should be distinguished. Eemember that edema pits on pres- sure with the thumb and the depression very slowly disappears. Observe the color of the skin. Note whether there be pallor. Don 't forget the peculiar, waxy pallor of nephritis. Again, cyanosis of the skin and mucous membranes denotes either an insufficient oxidation or an obstruction to the venous return. Remember that jaundice is significant of biliary trouble. The darker shades signify an obstruction of long duration. Many of the serious diseases cause undue pigmen- tation of the skin. Thus, melanosarcoma is accom- panied by a diffuse gray to a black discoloration, pul- monary tuberculosis is sometimes associated with a decided brownish discoloration of the face, while PHYSICIAN AND PATIENT. 275 Addison's disease causes a smoky-gray to a bronze discoloration. Remember that enlarged veins or arteries in the skin suggest collateral circulation, due to some deep- seated obstruction. The veins of the thoracic wall are enlarged with mediastinal or pulmonary tumors that compress the big veins within the chest. En- larged veins may also be found over the abdomen, due to portal obstruction. The veins about the navel become enlarged, forming the caput madusae. Ab- dominal tumors will cause obstruction by pressure. Examine the skin over the abdomen for nodular growths, and, when found, remember they are ex- tremely significant of malignant growths of the ab- jiominal cavity. Observe the fingers, and note whether they are clubbed. The clubbing is due to a swelling of the terminal phalanges, and is seen only in congenital heart disease, chronic pulmonary disease, most fre- quently in bronchiectasis and empyema, but some- times in phthisis. In fever it is very important to watch the daily course of the temperature, as many affections have a somewhat characteristic course, as typhoid, ma- laria, lobar pneumonia, etc. Always observe the respirations. Note their fre- quency, the type — whether costal or abdominal — the expansion of the two sides of the chest, and note any impairment or bulging of either side or the intercostal spaces. 276 GENERAL CONSIDERATIONS. In observing the pulse, note the frequency, volume, tension, and regularity. Palpate the wall of the vessel to determine the presence of arterio- sclerosis. A good method to determine sclerosis is to grasp the patient's wrist with the left hand and elevate the forearm. With the forefinger of the right hand make compression on the radial artery strong enough to destroy the perception of the pulse with the middle finger just below the point of com- pression. Then, if the vessel can be rolled under the middle finger, sclerosis exists. Remember that the pulse rate is increased by fever, during digestion, and by coughing. The tem- perature and pulse curve in fever usually run par- allel. The pulse increases eight beats for every degree of fever. In some conditions we find high temperature with slow pulse, as in febrile brain disease and tubercular meningitis. A slow pulse rarely occurs as an individual pecu- liarity, but it is found in "fatty," infiltrated heart and sclerosis of the coronary arteries. A capillary pulse is most frequently observed in aortic insufficiency. It is best appreciated by ob- serving the alternate blushing and pallor of the finger nail. A clean glass slide pressed lightly upon the extended lower lip will sometimes bring it out when it can not be observed in the finger nail. An- other useful method is to rub a spot on the forehead until it becomes hyperemic and look for an alterna- tion of redness and pallor. PHYSICIAN AND PATIENT. 277 A liver pulse may be felt as a pulsation along the lower border. It is found most often in valvular lesion of the heart. Always examine the excretions and secretions of the body. For methods and significance of findings consult some work on that subject. Remember that palpation is the most valuable of the methods of examining the abdomen. The pa- tient should lie in bed and the abdomen should be bared. The hands of the physician should be warmed, and palpation should be done by gentle pressure. Frequently the tips of the fingers used in palpating reveal more than the palms. There are two ways of palpating the abdomen, Tind the one to use depends upon the part to be pal- pated. Thus, bimanual palpation may be from side to side, the wall of the abdomen being deeply folded between the hands. Any accessible organ or tumor may thus be studied. Or the lateral regions of the abdomen are best palpated by placing one hand posteriorly and the other anteriorly. In this man- ner the liver may be raised against the anterior wall and the lower border examined, or a palpable kid- ney brought within the grasp of the palpating hands, or the splenic enlargement studied, or carcinoma of the sigmoid flexure palpated. By this method deep fluctuation may be elicited in renal or appendiceal abscess or a hydronephrosis studied. Where tender- ness exists, it is better to watch the expression of the patient's face than to depend upon any state- ment he may make. 278 GENERAL CONSIDERATIONS. In palpating an abdomen, always distinguish be- tween superficial and deep tenderness. The super- ficial is due to hyperesthesia of the skin, and a light touch causes more pain than firm pressure. This condition is frequent in hysterical women. Pain caused by deep pressure signifies an inflamed or congested organ. Excessive abdominal fat will prevent obtaining accurate information by palpation. When the abdominal muscles become tense, due to apprehension, excitement, or other nervous causes, elevate the head upon pillows and have the limbs flexed at hips and knees. Use should be made of respiration in palpating abdominal organs. Thus, continuous deep breath- ing will be very helpful in determining either the borders of an organ or to what organ a tumor prob- ably belongs, or, again, rapid breathing will assist. There must be a systematic examination of the ab- domen. The following outline will be of assistance and is given merely as a guide: 1. Condition of the abdominal wall. 2. Fluctuation, general and local. 3. Pulsation, thrill, and fremitus. 4. Eespiratory, postural, and manipulative move- ments of organs or tumors. 5. Peristaltic and fetal movements. 6. Outline and relation of palpable tumors. 7. Density and elasticity of the tumors. 8. Nature of the surface of the tumors. INDEX. Abscess of the liver (see Diseases of the liver) Acute bronchitis (see Diseases of the lungs and pleurse) endocarditis (see Diseases of the vascular system) enteritis (see Diseases of the in- testines) nephritis (see Diseases of the kidneys and bladder) pancreatitis (see Diseases of the pancreas and peritoneum) peritonitis (see Diseases of the pancreas and peritoneum) pleurisy (see Diseases of the lungs and pleurse) yellow atrophy (see Diseases of the liver) Addison's disease (see Diseases of the ductless glands) Alcoholic cirrhosis (see Diseases of the liver — Portal cirrhosis) Amebic dysentery (see Infectious diseases) Anemia, pernicious (see Diseases of the blood) Angina pectoris (see Diseases of the vahnilar system) Appendicitis (see Diseases of the intestines) Arteriosclerosis (see Diseases of the valvular system) test for, 276 Arthritis deformans (see Constitu- tional diseases) Asthma, bronchial (see Diseases of the lungs and pleurse) Atrophy, acute yellow (see Dis- eases of the liver ) B Bacillary dysentery (see Infectioiis diseases ) Biliary cirrhosis (see Diseases of the liver ) Bladder, diseases of the (see Dis- eases of the kidneys and bladder) Blood, diseases of the (see Dis- eases of the blood) Bowel, obstruction of the (see Dis- eases of the intestines) Bronchial asthma (see Diseases of the lungs and pleurae) Bronchiectasis (see Diseases of the lungs and pleurse) Bronchitis, acute (see Diseases of the lungs and pleurse ) chronic (see Diseases of the lungs and pleurae) Broncho-pneumonia (see Diseases of the lungs and pleurse) C Cancer, gastric (see Diseases of the stomach) of the liver (see Diseases of the liver) Carcinoma of the pancreas (see Diseases of the pancreas and peritoneum) Cholangeitis, suppurative (see Dis- eases of the gall bladder) Chlorosis (see Diseases of the blood) Chronic bronchitis (see Diseases of the lungs and pleurae) constipation ( see Diseases of the intestines) enteritis (see Diseases of the in- testines) interstitial nephritis (see Dis- eases of the kidneys and bladder) interstitial pneumonia (see Dis- eases of the lungs and pleurse ) pancreatitis (see Diseases of the pancreas and peritoneum) parenchymatous nephritis (see Diseases of the kidneys and bladder ) 279 280 INDEX. Cirrhosis, alcoholic (see Diseases of the liver — Portal cir- rhosis ) biliary (see Diseases of the liver ) Lsennec's (see Diseases of the liver — Portal cirrhosis ) portal (see Diseases of the liver) Colitis, mucous (see Diseases of the intestines) Considerations, general (see Gen- eral considerations) Constipation, chronic ( see Diseases of the intestines) Constitutional diseases, 260 Arthritis deformans, 260 Heberden's nodes, 261 joint changes, 260 joint destruction, 260 joint distortion, 262 joint restoration, 260 joint swelling, 261 muscular atrophy, 261 onsets vary, 260 pain spontaneous, 260 pigmentation of skin, 261 pulse, 261 simulating rheumatism, 260 symptoms, 261 Treatment, 262 baths, 262 diet, 262 Fowler's solution, 262 massage, 262 medicinal, 262 rest, 262 superheated air, 262 Diabetes mellitus, 267 coma, 268 diabetic tabes, 268 examination of urine, 268 gangrene, 268 signs, 267 symptoms, 267 urinalysis, 268 Treatment, 269 clothing, 269 coma, 270 diet, 269 exercise, 269 fatality, 271 massage, 269 Constitutional diseases — cont'd medication, 269 prescriptions, 270 skin, 269 venesection, 270 Gout, 263 aortic second sound, 265 arteriosclerosis coexistent, 263 arthritis, 263 causes, 263 family history, 264 gastrointestinal catarrh, 264 gouty diathesis, 264 leucocytosis, 264 liquor as cause, 263 lithemia, 264 nutritional disorder, 263 occupation, 264 premonitory signs, 263 recurrent attacks, 263 symptoms, 263, 264 uric acid, 263 Treatment, 265 acute attack, 265 diet, 266 exercise, 266 lithemic patients, 267 medication, 265 prescriptions, 265, 266 relief of pain, 265 symptoms of poisoning, 266 uric acid, 266 Cystitis (see Diseases of the kid- neys and bladder) Cysts, pancreatic (see Diseases of the pancreas and perito- neum) D Diabetes mellitus (see Constitu- tional diseases) Diphtheria (see Infectious dis- eases) Disease, Addison's (see Diseases of the ductless glands) Hodgkin's (see Diseases of the blood — Pseudoleukemia ) of the heart, valvular (see Dis- eases of the vascular sys- tem) INDEX. 281 Diseases, constitutional (see Con- stitutional diseases) infectious (see Infectious dis- eases) Diseases of the blood, 102 Chlorosis, 102 anemia test, 102 capricious appetite, 102 causes, 102 hyperacidity of stomach, 103 sjTnptoms, 102 Treatment, 103 atony of bowels, 104 Eland's pills, 104 constipation, 104 diet, 103 electricity, 103 exercise, 103 gastralgia, 104 massage, 103 prescriptions, 104-106 rest, 103 Leukemia, 108 enlargement of lymph glands, 109 enlargement of spleen, 109 enlargement of tonsils, 109 hematemesis, 109 lymphemia, 109 necrosis, 109 onset insidious, 108 symptoms, 108 Treatment, 110 diet, 1 10 Fowler's solution, 110 fresh air, 110 rest,- 110 x-ray, 110 Pernicious anemia, 106 circulatory disturbances, 107 examination of blood, 107 jaundice, 106 nervous symptoms, 106 onset insidious, 106 peripheral neuritis, 106 pulse, 107 spastic paraplegia, 106 symptoms, 106 tabes dorsalis, 106 Treatment, 107 diet, 107 Fowler's solution, 107 Diseases of the blood — cont'd fresh air, 107 hypodermoclysis, 108 rest, 107 Pseudoleukemia (Hodgkin's dis- ease), 110 blood count. 111 chronic tonsillitis, 110 enlargement of the axillary glands. 111 enlargement of the inguinal glands. 111 examination of blood, 110 examination of teeth, 110 histologic changes. 111 periadenitis. 111 pressure symptoms. 111 pruritus, 111 recurring boils. 111 temperature curve. 111 tubercular adenitis, 111 tuberculous glands of neck, 111 Treatment, 112 Fowler's solution, 112 prescriptions, 112 surgery, 112 x-ray, 112 Purpura, 113 erythematous eruptions, 113 hemorrhage, 113 macular eruptions, 113 papular eruptions, 113 purpura rheumatica, 113 symptoms, 113 tonsillitis, 113 urti carious eruptions, 113 Treatment, 114 cathartics, 114 diet, 114 prescriptions, 114, 115 Diseases of the ductless glands, IIG Addison's disease, 116 asthenia, 117 gastric disturbances, 116 muscular prostration, 117 onset insidious, 116 pigmentation, 116 symptoms, 116 tubercular degeneration of glands, 117 tuberculin test, 117 282 IN'DEX. Diseases of the ductless glands — cont'd Treatment, 117 diarrhea, 117 diet 117 organotheraphy, 118 prescriptions, 117, 118 rest, 117 Exophthalmic goiter, 118 common in women, 118 edema of feet, 120 emaciation, 120 exophthalmos, 118, 119 goiter, 118 Grafe's sign, 119 Joffroy's sign, 119 mental condition, 120 Mobius' sign, 119 pulsation, 118, 119 Stellwag's sign, 119 sweating, 120 symptoms. 118 tachycardia, 118, 119 test for tremor, 120 tremor, 118, 120 tumor, 118 Treatment, 120 Beebe and Eogers' serum. 122 diet, 121 electrotherapy, 121 Foreheimer's method, 122 fresh air, 121 hydrotherapy, 121 medication, 121 Merck's serum, 122 Ortner's method, 122 prescriptions, 121 rest, 120 rodagen, 122 surgery, 122 Myxedema, 123 atrophy of thyroid, 123 causes, 123 cretinism, 123 facial expression, 124 mental dullness, 124 onset insidious, 124 symptoms, 123, 124 Treatment, 125 extract of thyroid gland, 125 Diseases of the ductless glands — cont'd Foreheimer's dosage, 125 infantile form of cretin- ism, 125 prescriptions, 125 symptoms in children, 126 Diseases of the gallbladder, 57 Gallstones, 57 area of tenderness, 58 catarrhal inflammation, 57 causes, 57 friction sound, 58 gallstone colic, 57 gastralgia, 58 hematemesis, 58 peptic ulcer, 58 pulse, 57 sweating, 57 symptoms, 57 yomiting, 57 Treatment. 58 acute attack, 58 chloroform inhalations, 58 dissoh'ing stones, 59 gallstone colic, 58 hypodermatic, 58 inter^-al, 58, 59 prescriptions, 59 surgery, 60 Suppuratiye cholangeitis, 60 causes, 60 gallbladder, 61 icterus, 60 infection, 60 leucoeytosis, 61 malaria, 61 pain yariable, 60 pancreatic ducts, 60 progressiye hepatic enlarge- ment, 60 symptoms of active infection, ' 60 Treatment, 61 surgery, 61 Diseases of the intestines, 26 Acute enteritis, 26 albumin casts, 26 causes, 26 colic, 26 diarrhea dominant symptom, 26 INDEX. 283 Diseases of the intestines — cont'd edema, 26 fever, 27 pain varies, 26 Treatment, 27 cathartics, 27 colon irrigation, 28 continual seepage, 29 diet, 28 hypodermatic, 27 medicinal, 28 prescriptions, 28, 29 sudorifics, 27 teehnie of continual seep- age, 29 Appendicitis, 37 dyspepsia in masked, 38 diarrhea in masked, 38 examination in masked, 39 fever, 37 gangrene, 37 masked, 38 masking of symptoms, 38 pain in masked, 39 palpation in masked, 39 perforation, 37 symptoms, 37 tenderness about rectum, 38 tenderness at McBurney's point, 38 typhoid bacilli, 38 Treatment, 39 continuous seepage, 39 Ochsner's method, 39 perforation probable, 39 peritonitis probable, 39 surgery, 39 washing out stomach, 39 Chronic constipation, 34 causes, 34 colic, 35 colonic ulceration, 34 diarrhea, 34 dysmenorrhea, 34 occlusion of bowel, 34 perforation, 34 piles, 34 sacral neuralgia, 34 symptoms^ 35 Treatment, 35 diet, 35 drugs, 35 Diseases of the intestines — cont'd enemata, 35 massage, 35 physical exercise, 35 prescriptions, 35, 36 stools, 35 Chronic enteritis, 30 colicky pains, 30 colitis, 30 constipation, 30 diarrhea, 30 examination of stools, 30 indications of enteritis, 30 sago-pearls, 30 Treatment, 30 astringents, 31 colon irrigation, 31 diet, 30 examination of stools, 30 laxatives,