>^. 1c. O^Ul. Columbia (Hnitiers^itp intljeCitpofBtttigark THE LIBRARIES jWebical Hibrarp ^;l 4^ HARVARD MEDICAL SCHOOL. Theory and Practice. 1900-1901. BOSTON : THOMAS GROOM & COMPANY. 1900. Copyright, 1900, By Elbridge G. Cutler. INDEX. PAGE The History 5 General Examination of the Body 8 Urine ii Blood 12 Sputum 13 Stomach Contents 16 FiECES . ^9 Apparatus and Chemical Reagents 21 V5 Digitized. by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/theorypractice1900harv The History. A^RITE down first the name of the patient, married or single, age, residence and birthplace (malaria, hydatid, etc.), occupation (eye strain, writer's cramp, stone cutter, painter, etc.) and the date on which he is seen. The patient should be questioned first about the present illness, whether his disease is acute or chronic. Having ob- tained a general idea of its nature, the family history and personal history should be taken and the present illness obtained in detail. If the patient is very ill, depend largely on the friends for data and obtain other necessary information during later visits. Avoid embarrassing questions in the pres- ence of a third person. As a rule, let the patient tell his story, simply guiding his narrative into profitable channels. Avoid leading questions. Do not be misled by his medical expressions. Lay diagnoses of meningitis, influenza, gastric catarrh, rheumatism and dys- entery are untrustworthy and should be independently diagnos- ticated by the doctor. Note the difference between chilliness and a true chill. Sometimes the history obtained is incorrect because of the dulness of the patient, either natural or due to the disease. Here repeated questioning alone secures a satis- factory result. Histories obtained from hospital patients are proverbially unreliable. These people are for the most part ignorant, over- worked and unobservant. No matter what methods are em- ployed to obtain the histories, it is well to be sceptical about their accuracy, especially when the physical examination fur- nishes contradictory evidence. In children this is even more important. Most children are unable to furnish information about themselves, and their histories must be obtained from people in charge. Children usually answer questions incorrectly which concern their present sensations. This may be from fear, embarrass- ment, misunderstanding, etc. Information obtained in this way often leads to incorrect diagnoses. General questions as to heredity are equally unsatisfac- tory. Definite interrogations must be put, but where one has fears for the truthfulness of an answer, the information must be obtained in a more roundabout way, — e. g., such patients will agree to a parent having had " nerve trouble " or " brain trouble " who might deny the presence of family insanity. Tubercular ancestry is important, but it is also desirable to know whether the relative died years ago or has lived in contact with the patient. In the personal history illnesses are often forgotten, so it is well to mention specifically the infectious diseases, — chorea, rheumatic fever, etc. As a rule, one can get a more satisfactory answer regarding habits toward the end of a visit than at the beginning, but in no case must one neglect inquiries concerning alcohol, tobacco, tea, coffee, times and methods of eating and sleeping and venereal disorders. In this last matter, indirect questions are often best. A patient will admit having had a "strain" or frequent and scalding urine, who will deny gonorrhea. On the other hand, inquiries about pregnancy, catamenia, etc., should be simple and straightforward, not sug- gested in a roundabout prudish manner. Present Illness. The first question should always be " How long have you been ill?" " How long in bed ? " and the next, "What was the first symptom?" - "the next symptom?" and so on tracing the course of the disease. The patient's answers suggest other subjects important in the differential diagnosis and it is here the doctor or student shows the extent and accuracy of his medical knowledge by asking enough, but not too much. Individual symptoms ( e. g. abdominal pain, etc. ) should be analyzed according to their mode of onset, frequency, duration, character and severity. Always consider the temperamen^t of the patient when statements are made dealing with pain, discomfort or fatigue. The following ques- tions are very valuable in summing up the case : — " How long ago did you call yourself perfectly well?" " When did you stop work ? " "What one thing troubles you most? " " If 5^ou were cured of x, y and z would you consider your- self well?" It is desirable to include in the history a few general ques- tions concerning the appetite, the bowels (daily or otherwise), ability to sleep and work (as an index of the sufferings), also questions about the functions of the various systems not in- cluded in the patient's statement. {e.g.) Digestive. Nausea, discomfort after eating, vomiting, bowels. Respiratory. Cough, sputum, pain in chest. Circulatory. Dyspnoea, palpitation, oedema. Nervous. Headache, convulsion, paralysis. Urinary, {a) Renal: headache, amount of urine, oedema. {b) Vesical: dysuria, anuria, frequent micturition. The mere fact that a patient vomits or expectorates is of little value. The amount, color, presence of blood and mucus are all important. *^General Examination of the Body. General Nutrition. Muscular development, size, weight, figure, attitude, decubitus. Skin and Mucous Membranes. Pale, flushed (hectic), cyanosed, pigmented (jaundiced, bronzed skin and buccal mucous membrane). Cold, hot, dry, moist, satiny (alcoholic), rough. Scars, eruptions (Koplik's sign), oedema, emphysema, calluses, rheumatic nodules. Temperature. Mouth, axilla or rectum. Pulse. Rate, tension for compressibility), volume (or wave), rise (or shape of wave) ; compare radials. Capillar}^ pulse. Water-hammer pulse (Corrigan). Arteries: Size, abnormal course, arterio-sclerosis, auscul- tation of. Veins : Size, pulsation (systolic or slow presystolic, fill from below ?) auscultation of, varicosity. Respiration. Frequency, painful, shallow, costal, diaphrag- ma.tic. Dyspnoea (expiratory, inspiratory, Cheyne-Stokes). Glands. Suboccipital, mastoid, parotid, sub-maxillary, superficial and deep cervical, supaclavicular, axillary, epitro- chlear. inguinal (bronchial, mediastinal, mesenteric). Glands are either small, large, hard, soft, fluctuating (adhe- rent or non-adherent), discrete or conglomerate. HEAD. Size, shape (rachitic, hydrocephalic, microcephalic), fonta- nelles, tender spots, cranio tabes, hair. Facies. Placid, stupid, anxious, pinched, puffy, adenoid, alcoholic, heimatrophic, myxoedematous, acromegalic, mask- like (Paralysis Agitans). Eyes. Pupils (size, equality, shape, reflexes, Argyll-Rob- ertson), ophthalmoplegia (strabismus, ptosis), nystagmus, conjunctivitis, exophthalmos; vision (condition of retina, hemi- anopsia, amaurosis). Oedema of lids (Pertussis), * Physical examination is not dependent upon a knowledge of the patient's previous history and present sensations. It is a good plan, therefore, for students to examine the patient before the history is taken. The examination will be made more systematically and accurately in this way. 8 Nose. Deformities, hypertrophies, tumors. Lips. Color, herpes, fissures, hare-lip. Breath. Sweet, foul, alcoholic, uraemic ; acetone, gas poisoning. Tongue. Pale, red, cyanosed, dry, moist, coated, fissures, smooth, rough, indented by teeth, geographical tongue, devia- tion, salivation, stomatitis, leucoplakiabuccalis, mucous patches. Gums. Color, spongy, lead line (use lens and insert a slip of white paper behind gum), sordes, scurvy. Teeth. Number, carious, deformed (Hutchinson). Pharynx. Tonsils, adenoids, membrane, elongated or oedematous uvula, retropharyngeal abscess, pharyngeal re- flexes and paralyses (tabes, diphtheria). Larynx. Voice, laryngoscope. Ear. Hearing, tympanum, mastoid tenderness, tophi, stig- mata. Neck. Venous fulness, pulsations, tracheal tug, parotid, thyroid, high spinal abscess, spinal curvature, torticollis. CHEST. Inspection. Size, form (barrel chest, paralytic chest, pigeon breast, rosary), symmetry and comparative mobility. Rate and character of respiration, Litten's phenomenon. Location and character of cardiac movements. Apex beat, retraction (Broadbent's sign). Pulsation (aneurism, aortic regurgitation, uncovered or displaced heart. Character of cough — dry, loose, constant, paroxysmal. Palpation. Rales, tactile fremitus, apex beat, thrills, fric- tion, pulsation, accentuated heart sounds, tender points. Percussion. Pulmonary resonance, mobility and location of lung and heart borders. Size and position of heart. Respir- atory percussion. Sense of resistance. Auscultation. Respiration, rales, voice sounds, friction rub, succussion. Heart sounds, diminution, accentuation, rhythm, doubling. Murmurs: in erect and dorsal position, time, character, transmission, relation to heart sounds. ABDOMEN. Inspection. Size, shape, abdominal walls (thickness, ten- sion, striie, umbilicus, superficial veins, peristalsis), herniae. Palpation. Position, outline and mobility of liver, gall bladder, spleen, kidneys, stomach, bladder (and pancreas) : tumors (see below), relation to inflated colon, stomach and to other organs. Local tenderness (superficial or deep) and resist- ance, friction, fluctuation wave, succussion, pulsation (aorta), enteroptosis. Percussion. Outline of liver, gall bladder, spleen, stomach, bladder, uterus, resonance of tumors, gas, ascites (movable dulness), curve of dulness (ascites, cyst). NERVOUS SYSTEM. 1. Mental State. Intelligence. Psychoses, hypochon- driasis, apathy, stupor. 2. Motion. 1. Paresis or paralysis. 2. Gaits : spastic, ataxic. 3. Reflexes : pupillary, knee jerk, ankle clonus, plan- tar (Babinski), Kernig's sign, 4. Ataxia (Romberg), localized and general convul- sions, tremor, chorea, athetosis, fibrillation. 5. Electrical Reactions. 3. Sensation. 1, Tactile, pain, temperature. 2, Delay, paraesthesias, muscle sense. 3, Special sense : sight, hearing. 4. Speech Disturbance. Aphasia, paralysis. 5. Trophic Disturbances. 6. Sphincters and Sexual Power. Extremities. Clubbed fingers, flat-foot, oedema, tender- ness (neuritis, trichinosis). Bones and Joints. Redness, tenderness, swelling, crepi- tus, mobility, epiphyses, deformity, (spinal curves, bow-legs, arthritis deformans, Heberden's nodes). Muscles. Atrophy, hypertrophy, tone (firm, flabby), paraly- sis, spasm, tremor, contracture, fibrillation. Rectum. Prolapse, fissure, fistula, abscess, piles, impacted faeces, stricture, tumors (prostate, vesiculae seminales), intus- susception. Genitals. Urethra, character of stream, discharge, glans penis, testes, vagina, uterus, tubes, ovaries, tumors. Tumors. Location, shape, size, color, consistency, surface, tenderness, mobility (by respiration, by hand), dulness, pulsa- tion, relation to organs. 10 Urine. Amount in twenty-four hours. Color. Odor. Reaction. Specific Gravity. Sediment. Turbidity. Shreds. Albumin. Heat — boiling upper half of urine in test-tube ; observe if precipitate disappears on adding dilute acetic acid. If a precipitate appears on heating and disappears on boiling, suspect albumose. Estimate the per cent, of albumin by the nitric acid test. Sugar. I. Fehling's Test lo c. c. of Fehling's solution are reduced by 0.05 gram glucose. 2. Fermentation Test using yeast. Difference in specific gravity before and after complete fermentation, muliplied by 0.23 gives percentage of sugar. Acetone. To one-sixth of a test-tube of urine add a crystal of sodium nitro- prusside. Make strongly alkaline with NaOH. Shake. Addition of glacial acetic acid gives purple color to foam. Diacetic Acid. Add strong aqueous solution of ferric chloride. A Burgundy red shows presence of diacetic acid. B. Oxybutyric Acid. If ferric chloride reaction is strongly positive, B. oxybutyric acid is probably present. Urea. Amount in twenty-four hours. Squibb's method. Bile. I. Shake up and look at foam. 2. Iodine test. (Tr. iodine, i ; alcohol, 8.) Pour on top of urine. A green ring at border of two fluids shows bile. Diazo. Saturated solution sulphanilic acid in H CI. Sodium nitrite, 0.5 per cent. Ammonia. To 4 c. c. sulphanilic acid in H CI add a few drops sodium nitrite. Now add equal part of urine. Shake and add ammonia. A carmine color shows diazo. Chlorides. Ag NO3. Sediment. Macroscopic and microscopic examination. Staining for tubercle bacillus ; see sputum. For gonococcus, use Gram's stain. 1. Smear cover glass as thin as possible. 2. Anilin oil-gentian-violet (fresh). 3. Heat to steaming point. 4. IKI solution thirty seconds. 5. Decolorize with 95 per cent, alcohol until alcohol runs clear. 6. Wash in water. 7. Counterstain with saturated aqueous solution Bismarck brown. Diplococci within leucocytes which have been de- colorized by Gram and have taken counterstain of brown are gonococci. II Blood. {a) Examination of fresh blood for leucocytosis, fibrin parasites, Miiller's bodies, etc. (3) Examination of stained specimen. Triple stain -|- Loffler's Methylene blue. Red Corpuscles. \^ariation in size and shape (poikilocy- tosis). Loss of color (acromia). Tendency toward a general increase or decrease in size. XT u r i Normoblasts ) in one or more stained speci- Number of \ Megaloblasts, | mens. White Corpuscles. Estimation of number of white cor- puscles. Differential Count. Leucocytosis: — presence, kind. Number of Basophiles (lymphocytes and large mononuclear) Neutrophiles. Oxyphiles (eosinophiles). Myelocytes (neutrophilic, oxyphilic). (c) Blood count. Number of red corpuscles. " " white " {d) Color estimation. Haemoglobin per bulk blood {%). " per corpuscles (color index)^ {e) Parasites. Malaria. Filaria. (/l Serum reaction. (^) Coagulation time. 12 Sputum. Sputum is sometimes very difficult to obtain for examination, especially in the case of young children. If a cotton stick is inserted into the pharynx it causes coughing, and sputum com- ing from the trachea may be wiped out upon the cotton before it can be swallowed. Swallowed sputum may be obtained by stomach washing. Orig-in. May be from mouth, nose, pharynx, larynx, lung (or stomach), one or more or all. Amount expectorated in twenty-four hours may vary within wide limits, — small, as in beginning tuberculosis of the lungs, or large, as in chronic bronchitis. Odor. Ordinarily there is no odor to sputum. Under cer- tain circumstances, however, as in abscess or gangrene of the lung the odor may be foetid and disagreeable. MACROSCOPIC EXAMINATION. Inspection. Sputum may be, — (a) Mucous : viscid. {d) Purulent : seen in pure form only in perforation into the lung or bronchi of foci of pus such as abscess of lung or empyema. (c) Muco-purulent: most common form and not character- istic. {d) Serous: thin, often slightly red in color (blood) and frothy ; pathognomonic of oedema of the lungs. (