Inspection

Inspection reveals the general condition of the patient and his con­sciousness. Many diseases of the blood system are characterized by a very grave condition and loss of consciousness at their terminal stages. These are progressive anaemia, myeloid aplasia, and leucoses.

The skin and mucosa should be inspected at diffused daylight. Their colour is important: anaemia is characterized by pallor of the skin and visi­ble mucosa, the hue differing in various types of anaemia. For example, the skin of patients with juvenile chlorosis is "alabaster" pallid, sometimes with a greenish hue. The skin of patients with vitamin B_I2 deficiency is slightly yellowish and waxy. The yellow hue of the skin and visible mucosa are more pronounced in haemolytic anaemia. It should be remembered that a mild yellow hue can be easier revealed on the sclera. Pallid skin does not always indicate anaemia and can also be due to special anatomic pro­perties of the skin (deep vascularization), spasm of the peripheral vessels

(collapse, nephritis), and some other factors. Moreover, pallor of the skin can also be masked by its hyperpigmentation (tan due to exposure to the sun). A more informative sign is therefore pallor of the mucosa. Anaemization can easier be revealed by inspecting the conjunctiva of the upper and lower eyelids. In chronic leucoses the skin becomes greyish. Erythraemic patients have "plethoric" cherry-red skin, the colour being especially marked on the face, the neck, and the hands.

Haemorrhagic spots of various size and shape (from petechia and ec-chymoses) develop on the skin and mucosa of patients with haemorrhagic diathesis; large haemorrhagic spots are called bruises. Haemorrhagic le­sions are first red but as haemoglobin converts into biliverdin, bilirubin or its other coloured products of oxidation, the colour changes to cherry-blue, green, and yellow (before the ecchymosis resolves). In contrast to inflam­matory rash and telangiectasia, haemorrhagic spots do not disappear when they are pressed upon.

Trophies of the skin is also important. The skin is dry and sometimes scaling in patients with iron deficiency anaemia. Hairs become brittle and their ends break.

Changes characteristic of some diseases of the haemopoietic system can be revealed during inspection of the mouth. Pronounced atrophy of the tongue papillae is characteristic of vitamin B₁₂ deficiency anaemia: the tongue surface becomes smooth, as if varnished (Hunter's glossitis). In­tense caries of the teeth and inflammation of the mucosa round dental necks (alveolar pyorrhoea) often occur in patients with iron deficiency anaemia. Nectoric ulcerous tonsillitis and stomatitis are frequent symp­toms of acute leucosis.

Regional swelling on the neck, above the clavicles, in the armpits and the groin, less frequently swelling of other location can be revealed by in­spection of patients with certain forms of leucosis. This is explained by a considerable enlargement of the corresponding lymph nodes that become palpable (see below). The left part of the abdomen is distended in con­siderable enlargement of the spleen (e.g. in chronic myeloleucosis), which can also be confirmed by palpation.

PALPATION

Patients suspected for leucosis or some forms of anaemia should be palpated to examine the bones: palpation of flat bones or epiphyses of tubular bones (and also tapping over them) is painful in the presence of marked hyperplasia of the bone marrow.

Palpation of the lymph nodes and the spleen is however more infor­mative. Enlargement of lymph nodes is most pronounced in lym-pholeucosis, lymphogranulomatosis, and lymphosarcoma. These diseases

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are characterized by regular and multiple affection of the lymph nodes. The lymph nodes of only one group are first affected, but later other groups become involved too (both surface and deep nodes of the mediastinum and the abdominal cavity). It should be remembered that lymph nodes can be enlarged not only in diseases of the blood system but also in some other diseases, such as tularaemia, tuberculosis, cancer metastases, etc.

Enlarged lymph nodes in leucoses and malignant lymphomas are painless, they never fuse with the skin, do not suppurate or form fistulae, as distinct from affections of other aetiology (e.g. in tuberculosis). The nodes are pasty and elastic in lymphoid leucosis; in lymphogranulomatosis, and especially in lymphosarcoma, they are firm and fuse into con­glomerates, sometimes as large as 15—20 cm in diameter.

The spleen should be palpated with the patient in the recumbent posi­tion or on his right side. In the former case the patient should lie on a low pillow, the arms and the legs being stretched. If the patient lies on his right side, his head should be slightly down, the left elbow bent and resting freely on the chest; the right leg should be stretched and the left knee bent and drawn up to the chest. The prelum is relaxed to a maximum. In this posi­tion, the spleen is displaced anteriorly to facilitate its palpation even if it is slightly enlarged. The physician sits on the right side of the patient and faces him. The left hand of the physician is placed on the left part of the patient's chest, between the 7th and 10th ribs in the axillary lines and slight­ly presses on the chest to limit its respiratory movements. The physician's right hand is placed on the anterolateral surface of the patient's abdominal wall at the edge of the costal arch, at the point of junction of the costal arch and the 10th rib, or (if preliminary inspection and percussion suggest enlarged spleen) at the antero-inferior edge of the spleen. During expira­tion the physician moves his hand gradually into the abdomen to form a pouch and the patient is asked to make a deep inspiration. If the spleen is palpable (and provided the palpation is performed correctly), it is displaced during inspiration by the descending diaphragm to come in contact with the palpating fingers of the right hand and to slip over them. This manipulation should be repeated several times in order to examine the en­tire palpable edge of the spleen. The size, shape, sensitivity, density, mobility, and configuration of the anterior edge of the spleen should be determined by palpation.

One or several notches on the anterior edge of the spleen can be palpated if its enlargement is considerable. The notches are used to identify the spleen (to differentiate it from other organs, e.g. from the left kidney). The anterior surface of the enlarged spleen emerges from under the costal arch and also becomes palpable.

A normal spleen is impalpable. It can only be palpated in rare cases of

extreme ptosis, and more frequently in enlargement of the organ. The spleen is enlarged in some acute and chronic infectious diseases (enteric and recurrent fever, Botkins's disease, sepsis, malaria, etc.), in liver cirrhosis, thrombosis or compression of the splenic vein, and also in many diseases of the haemopoietic system (haemolytic anaemia, thrombocytopenic purpura, acute and chronic leucosis). A considerable enlargement of the spleen is called splenomegaly. The greatest enlargement of the spleen is observed at the terminal stage of chronic myeloleucosis: it often occupies the entire left part of the abdomen, while its lower pole is found in the small pelvis. After the size of the spleen is determined by palpation and its contours marked on the skin of the abdomen by a dermograph, a skin test is sometimes per­formed with subcutaneous injection of 1 ml of a 0.1 per cent adrenaline solution (Frey test) by which the contractile function of the spleen is deter­mined. In most cases the smooth muscles of the spleen contract in response to adrenaline to diminish 2-3 times. The spleen does not diminish ap­preciably in this test in the presence of its fibrosis, in perisplenitis, or in the presence of its tumours or cysts.

The spleen is not firm in acute infectious diseases; it is especially soft (the consistency of dough) in sepsis. In chronic infectious diseases, liver cir­rhosis, and leucosis the spleen is firm, especially in amyloidosis.

In most diseases the spleen is insensitive to palpation. It becomes tender in infarction, perisplenitis, and in distension of the capsule, due to the rapid enlargement, e.g. in venous blood congestion due to thrombosis of the splenic vein. The spleen surface is usually smooth; the edges and the surface are irregular in perisplenitis and old infarctions (depressions in the surface). In syphilitic gummas, echinococcosis, cysts and very rare tumours of the spleen its surface is tuberous.

The spleen is normally quite mobile, but the mobility becomes limited in perisplenitis. A markedly enlarged spleen remains motionless during respiration but it can however be displaced by the palpating fingers.

Not only the spleen but also the liver sometimes becomes enlarged due to metaplasia (as determined by palpation).

PERCUSSION

Percussion is not important for the study of the haemopoietic organs; it is only used to outline tentatively the spleen. Since the spleen is surrounded by hollow organs (the stomach, the intestine), which give loud tympany during percussion, it is impossible to determine accurately its borders by percussion.

During percussion, the patient stands upright or lies on his right side. Light percussion should be used with transition from clear resonance to

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dullness. Obraztsov's percussion is recommended. In order to determine the transverse dimensions of the spleen dullness, percussion is carried out in the line passing 4 cm laterally of the left costoarticular line (the line con­necting the sternoclavicular articulation with the free end of the 1 lth rib). Normally spleen dullness is determined between the 9th and 11th ribs. It is 4-6 cm wide. The long axis of the spleen is percussed by the 10th rib; nor­mally the anterior edge of the spleen does not extend beyond the costoar­ticular line; its dullness zone is 6—8 cm long.

AUSCULTATION

Auscultation is used to study the spleen: peritoneal friction sound can be heard in perisplenitis in the region overlying the spleen.