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m ^"^"eTTs^^^c^HS^ 'HX64121623 RC71.C971898 Manual of differenti l«w FERENTIAL EOiCAL UlAGNOSIS RC7f C^7 Columbia ©nitJe«itj)/g g^ mt^fCttpofamigork r College of $lf|>fi;tcians( anb ^urgeonsf Hibrarp WORKS BY CONDICT W. CUTLER, M.S.. M.D Manual of Differential Medical Diagnosis. — (In Students' Manuals Series) i6mo, cloth . . . $1.25 Differential Diagnosis of the Diseases of the Skin. — (In Students' Manuals Series) i6mo, cloth 1.25 Essentials of Physics and Chemistry, Written Especially for the Use of Students in Medicine. Third edition, revised and enlarged, 8vo . . 2.00 Practical Lectures in Dermatology. — Compri- sing a Course of Fifteen Lectures Delivered at the University of Vermont, Medical Department, during the Session of 1892 and 1893. 8vo . 2.00 G, P. PUTNAM'S SONS, New York & London MANUAL OF Differential Medical Diagnosis BY CONDICT W. CUTLER, M.S., M.D. Professor of Dermatology at the University of Vermont ; Physician-in-Chief to the New York Dispensary : Fellow of the New York Academy of Medicine : Member of the Society of the Alumni of Bellevue Hospital: Member of the New York Dermatological Society ; Member of the American Dermatological Society : Author of ^^ DifFerential Diag- nosis of the Diseases of the Skin^'' etc, etc. NINTH EDITION G. P. PUTNAM'S SONS NEW YORK LONDON 27 WEST TWENTY-THIRD STREET 24 BEDFORD STREET, STRAND %\z ^ttichE-ibcfKei; ^rcss 1898 COPYRIGHT BY CONDICT W. CUTLER 1C7 cn Electrotyped, Printed, and Bound by Ube Iknici evbocftec ipress, mew ^oxk G. P. Putnam's Sons TO MY PRECEPTORS Drs. CHARLES H. WILKIN and FREDRICK W. OWEN THIS SMALL VOLUME IS DEDICATED AS A TOKEN OF APPRECIATION FOR THEIR FAITHFUL AND VALUABLE INSTRUCTION BY THE AUTHOR PREFACE TO THE SEVENTH EDITION. The author feels grateful to the medical profession and students in medicine for the favorable reception this little work has had at their hands. Although the book was not intended as a complete work on medical diagnosis, it has met the requirements of the student by affording him an easy method of learning the m.ost characteristic symptoms of medical diseases and their diagnosis ; and the busy practitioner by furnishing him differential- diagnosis tables of such diseases most liable to be confounded one with another. Since the first edition was issued corrections have been made from time to time, and new material added which has increased the value of the work and kept it abreast of the times. ?6o West 57TH Street Sept., 1893 CONTENTS Introduction «... Diseases of the mouth and throat Diseases of the lungs and pleura Diseases of the heart and blood-vessels , Diseases of the digestive tract and peritoneum Diseases of the liver Diseases of the kidneys and bladder Acute general diseases — fevers, etc. Chronic general diseases — ^blood diseases, etc. Diseases of the nen'^ous system . . Coma • • • • • Index e • 9 • • PAGE 1 13 21 37 51 75 89 107 127 137 159 167 INTRODUCTION. A CAREFUL examination of a patient is the first requisite tow- ard establishing a diagnosis. To conduct this properly and to the best advantage a systematic examination of the patient will lead to the quickest and surest results. First locate the disease, and then balance the symptoms struck, and the diagnosis is recast. The following schedule will serve as a guide toward the proper examination of the patient, and lead the observer quickly and in the right channel to the seat of the disease, and then to the estab- lishment of a correct diagnosis of his case. I. — History of the Patient. a. Hereditary predisposition. b. Previous general health. c. Previous diseases or injuries. d. Habits of life. e. Cause of the present sickness. f. Date of the present attack. g. Mode of invasion. h. Subsequent symptoms in order. 2 nVTRODUCTION. II. — Condition of the Patient. a. Position. b. Aspect. c. Skin. d. Pulse. e. Respiration. f. Temperature. g. Tongue. h. Digestion. /. Urinary secretion. j. Sensations, k. Intellection. /. Examination of special organs. Hereditary Predisposition. Many diseases, among the most important of which are syphi- lis, cancer, tuberculosis, scrofula, etc., are hereditary. The ob- server, by establishing a family history of hereditary disease, is often aided materially in coming to a correct diagnosis of the case. Previous General Health. The usual general health of the patient is often of great im- portance for the diagnostician to know. If the patient's health has always been good up to the present attack he is able at once to exclude certain wasting and debili- tating diseases. While, on the other hand, if the patient's previous condition has been a poor one, we at once look for a chronic ailment as being in some way connected with the present sickness. lA^TRODUCTION. 3 Previous Diseases or Injuries. The thorough knowledge of this important history will fre- quently lead to a correct diagnosis, for injury of an organ often results in its disease, while previous disease makes the patient either more or less susceptible to a similar attack. Thus if the patient gives a history of having had an eruptive fever, as small-pox, we would naturally at once exclude small-pox from our list of pos- sible diseases which might be the cause of his present symptoms. If, however, the patient had once suffered from Bright's disease of the kidneys, we would immediately inquire further into the condition of the urinary organs. How simple many diagnoses v/ould appear could we but get a syphilitic history from our patients. Habits of Life. The habits of men predispose them to certain diseases, hence the importance of inquiring into the regular habits of our pa- tients. Thus, for example, sedentary habits lead to gastric, hepa- tic, and intestinal disorders ; alcoholism, to cirrhosis of the liver, mental and nervous derangements, etc. The CAUSE of the present attack, its date, its mode of inva- sion, and the subsequent symptoms in the order of their devel- opment are of the utmost importance, for by obtaining a full history of the same, the physician is often at once led to an im- mediate and correct diagnosis of his case. Having thus obtained XSaq previous history of the patient, let us now consider his present condition. Position. Is the patient in bed or out of bed ? If in bed, what is his po- sition ? If feverish and in pain, he is restless and tossing about. 4 INTRODUCTION, If suffering from acute peritonitis, there is dorsal decubitus and flexion of the thighs. If lying fixedly upon one side there is a probability that the action of the lung on this side is impaired. If there is orthopnoia there is probably disease of the heart or respiratory organs. If the patient is out of bed, we should notice his movements. In nervous disorders they are uncertain and trembling, and the gait often unsteady and staggering. In rheumatism, joint-dis- ease, etc., affecting the lower extremities, the patient limps, while in many diseases of the back there is rigidity of the spine and a bending forward. Aspect. By noting the general aspect of the patient we at once derive knowledge as to the occurrence of oedema, corpulency, wasting, cyanosis, etc. Expressions of the face denote pain, stupor, apa- thy, collapse, etc. The eye frequently tells us at once the condi- tion of the patient — whether delirious, stupid, or approaching death. The pupils are contracted in opium-poisoning (pin head) and hemorrhage into the pons (pin point) ; unequally dilated in apoplexy and compression of the brain, and rapidly dilate upon the approach of death, etc. Skin. By the state of the skin we judge of the activity of the circu- lation and secretions. Coldness of the surface indicates weakness of the capillary circulation, often due to interference of nervous power by some acute disease or nervous shock. A cold, clammy skin denotes diminished vital force. Jaundice occurs with de- rangements of the liver and blood-diseases. Eruptions occur with skin diseases pnd the exanthemata. INTRODUCTION, 5 Pulse. The pulse affords one of the most valuable means of informa- tion, and although it cannot be exclusively relied upon as a means of diagnosis it comes greatly to our assistance. The pulse enlightens us as to the action of the heart, and the condi- tion of the arteries. The pulse differs in frequency, rhythm, vol- ume, and resistance. Th.Q frequency of the pulse is usually greatly increased in all acute affections and in fevers. In shock, in pressure on the brain, and in inflammation of the meninges of the brain a slow pulse is the rule. The rhythm of the pulse is often perverted. The irregular action of the heart may arise from digestive disturbance, from the excessive use of tobacco or stimulants, from nervous exhaus- tion, but most frequently in cerebral or cardiac diseases. The vohcme of the pulse often varies with its strength. Usually a full pulse is a strong pulse, but this is not always the case. A full, weak pulse, or " gaseous pulse," indicates great debility and loss of tone in the arterial system. A " gaseous pulse " is com- mon in yellow fever and ether narcosis. On the other hand a small pulse is usually a weak pulse, but it may be tense and wiry as observed in peritoneal inflammations. The resistance of the pulse is perhaps the most important guide as to the real condition of the patient. A hard pulse de- notes a forcibly contracting heart and increased contractility of the arteries. A hard pulse is also associated with degenerative changes taking place in the arterial walls. A soft pulse is the pulse of low fevers and debilitated conditions. By means of the sphygmographic trachigs, we are afforded very delicate means for obtaining slight variations in the pulse, and may thus be assisted in diagnosing valvular diseases of the heart, aneurisms, etc. O INTRODUCTION. Respiration. By noting the frequency and character of the respiration we can frequently make a correct diagnosis of thoracic diseases without further examination. If dyspnoea is present, we at once suspect disease of the heart or respiratory apparatus. If pleurisy is present, the respirations will be hurried, short, and catching in character. The breathing is " panting " in pneumonia, and "labored " in capillary bronchitis. The pulse and respiration should bear a nearly constant ratio to each other of about 4 to i. If this relation is increased, car- diac failure may be suspected, but if the ratio is diminished, and the respirations are much increased in frequency, an examina- tion of the respiratory organs will probably discover the cause. Opium-poisoning, compression of the brain, diseases of the respiratory centre, etc., will reduce the frequency of the respira- tions. Temperature. The temperature of the patient is of the utmost importance in making a diagnosis. In all acute cases the temperature is, as a rule, elevated. Usually the pulse and temperature rise synchronously ; that is, for every degree rise in temperature, we may expect an in- crease of ten beats in the pulse rate. In some diseases, as typhoid fever, every week presents characteristic variations in the temperature. Although we are apt to gauge the condition of our patient by his range of temperature, it must not be forgotten that in condi- tions of prostration, collapse, shock, etc., the temperature is often normal, or even subnormal. In cholera the temperature falls as low as 94°, while in sunstroke the temperature is frequently ob- INTRODUCTION. 7 served to be at 112°. A patient seldom recovers if the tempera- ture remains for any length of time over 108°. Tongue. The tongue not only indicates the condition of the digestive tract, but also gives us information concerning the state of the secretions, the blood, nervous power, etc. If the movements of the tongue are tremulous, one-sided, or crippled, we are dealing with a disease of the nervous system. If the tongue is dry and cracked, or covered with sordes, there is good reason to suspect some acute febrile affection or marked depression of the vital forces. A simply coated tongue occurs frequently with some digestive disturbance. The color of the tongue is red in the exanthemata, especially scarlet-fever (strawberry tongue), blue in asphyxia and obstructed circulation, etc. Digestion. The state of the digestion should always be inquired into Vomiting occurs in many disorders, but frequently in diseases of the stomach and bram. Diarrhoea denotes a disordered state of the bowels. Chronic constipation is frequently the result of tor- pidity of the liver. Fcecal vomiting and obstinate constipation result from intestinal obstruction. Urinary Secretion. An examination of the urine should never be neglected. The kidneys are affected in so many diseases, that to establish a diag- nosis it is often essential to know the condition of the urine. Jn Bright's disease the urine contains albumen and casts ; iJ» 8 INTRODUCTION. cancer of the kidneys, blood and cancer cells ; in suppurative nephritis and pyelitis, a large number of pus cells ; in cystitis, ropy mucous, etc. Many poisons may be detected in the urine. In pneumonia the chlorides, and in carbolic-acid poisoning the sulphates are greatly diminished in the urine. Sensation. Frequently the most-marked symptom by which we can locate the disease is the pain. Most all affections are painful, and the pain is usually referred to the seat of the disease. Thus, diseases of the brain are asso- ciated with headache ; pleurisy, with pain in the side ; sciatica, with pain along the course of the sciatic nerve, etc. Not only is pain an important symptom, but disordered sensa- tions, as numbness, hyperaesthesia, anaesthesia, and subjective sen- sations, lead us at once to associate the symptoms with affections of the nervous system. Intellection. In affections of the brain and in many acute forms of disease a deranged intellect is among the first symptoms. The de- rangement va,ries from a mere confusion of the mind to its entire perversion and prostration. Acute diseases are associated with stupor, delirium, and coma, while in chronic affections loss of judgment, memory, etc., are essentially noticeable. Examination of Special Regions or Organs. Having thus obtained a general history of the case, we are now prepared to examine some of the special organs of the body for the seat of the disease. INTRODUCTION. 9 If we ha,ve reason to believe that we are dealing with a general disease, it is more than likely that some local lesion or complica- tion may also exist. It is therefore well to examine the special organs, as the heart, lungs, etc., and thus determine if some of the symptoms present are not due to, or modified by, some complicating condition. Having thus determined the seat and character of the disease, let us by a differentiation of the symptoms arrive at a correct diagnosis. DIFFERENTIAL DIAGNOSIS OF THE DISEASES OF THE MOUTH AND THROAT. DIFFERENTIAL DIAGNOSIS OF THE DISEASES OF THE MOUTH AND THROAT. NAME OF DISEASE. Thrush . . , , Cancrum Oris . Cancer of Tongue Acute Laryngitis (croup) , Chronic Laryngitis = CEdema Glottidis Thrush. 1. R.einoval of the white patch leaves an ulcer. 2. Disease parasitic in nature. 3. Redness around each spot. 4. Exudation not soluble in ether. DISEASES TO BE DIFFERENTIATED- Follicular stomatitis. Malignant pustule. Ulcerative stomatitis. Syphilitic ulcer of tongue. False croup. Retro-pharyngeal abscess. I CEdema of glottis, t Diphtheria. ( Thoracic aneurism. ( Hysterical change of voice. Croup. Thoracic aneurism. Asthma. Retro-pharyngeal abscess. Follicular Stomatitis. 1. Removal of the exudation leaves a red surface. 2. Vesicular disease. 3. No zone-inflammation about exu=. dation. 4. Exudation soluble in ether. 13 14 DIFFERENTIAL DIAGNOSIS OF THE NAME OF DISEASE. Thrush. 5. Severe gastro-intcstinal symptoms. 6. Excoriation about anus and geni- tals. 7. Acid diarrhoeal movements. 8. Oidium Albucans found under the microscope. Cancrum Oris. 1. Begins on the cheek, 2. Some constitutional symptoms. 3. Rapid progress of the disease. 4. Ulceration extends rapidly. 5. Discoloration of the cheek. 6. Cheek greatly svv^ollen. 7. Constant flow^ of bloody pus and mucus from the mouth, Cancrum Oris. 1. Begins in the mucous membrane. 2. No severe constitutional symptoms at first. 3. Breath very fc/ul. 4. Pus and blood flow from the mouth. 5. Some pain. 6. Glands enlarged. Cancer of Tongue. 1. History of hereditary cancer. 2. Appears on the side of tongue. 3. Usually single. 4. Progress rapid and painful. DISEASES TO BE DIFFERENTIATED. Follicular Stomatitis. 5. Slight intestinal disorder. 6. No redness about anus. 7. Diarrhoeal movements may be alka^ line. 8. Oil globules under microscope. Ulcerativo Stomatitis. 1. Begins on the gums. 2. Local symptoms. 3. Disease develops slowly. 4. Slow ulceration. 5. No discoloration of cheek. 6. Cheeks but little swollen. 7. Salivation. Malignant Pustule. 1. Begins in the skin. 2. Constitutional symptoms severe from the first. 3. Breath not offensive. 4. No bloody discharge from mouth. 5. No severe pain. 6. No enlarged glands. Syphilitic Ulceration of Tongue. 1. History of syphilis. 2. Usually appears on dorsum. 3. Usually multiple. 4. Progress slow and not very painful DISEASES OF THE MOUTH AND THROAT. 15 9 10 NAME OF DISEASE, Cancer of Tongue. Ganglionic swelling. Rare before middle life. Ulcer has indurated base. Microscope shows an epithelial structure. Medical treatment no eflfect. True Croup. . Begins with hoarseness or sore throat. . Advent slow. . Temperature high. . Exudation fibrous. , Bronchial s}Tnptoms. 6. Subsides slowly. 7. Continued cyanosis. 8. Aphonia frequently complete. Change in voice. Well-marked constitutional symp- toms. DISEASES TO BE DIFFERENTIATED. Syphilitic Ulceration of Tongue. 9- 2. 3- 4- 5. 6. 7. 8. 9- 10. No large ganglionic swelling. Appears at any age. Ulcer not especially indurated. Microscope shows a small-cell infil- tration. Medical treatment curative. False Croup. No prodromata. Advent sudden. Temperature about normal. No membranous exudation. Absence of lung complications. Disease disappears rapidly. Cyanosis of short duration. Loss of voice uncommon. Voice often natural. No severe constitutional symp- toms ; rarely fatal. Acute Laryngitis. 1. History negative. 2. Fever. 3. UsuaUy a disease of childhood.