(In
following, are described
only auscultatory percussion reflexes, signs, manoeuvres and tests,
which are routinely assessed, in order to perform Biophysical Semeiotics.
Other interesting reflexes, specific and useful in ascertaining both
physiological and pathological particular conditions, are exhaustively
illustrated in previous articles: See Bibliography). Manoeuvres. 1)
Erythropoietin
Evaluation (Baserga's Sign): with the subject to be examined as usually psichophysically
relaxed and in supine position, doctor assesses for the first time the
RESHS (See later on); soon thereafter, doctor
must stimulate trigger-points of the the skin at the level of VII
– VIII thoracic dermatomeres (i.e., right and/or left quadrants of
abdominal surface), by pinching with mean intensity for about
15 sec. Kidneys size increases, due to renal congestion and, then,
appears their decongestion, which stimulates also Erythropoietin
secretion. 2)
Ferrero-Marigo’s Manoeuvre. At
rest, one evaluates muscle biceps-gastric aspecific and/or – caecum
reflex (NN= 12 sec. age-dependent). After insulin acute peak secretion,
provoked by lasting pinching of mean intensity of VI thoracic
dermatomer (skin above costal arch, right or left, along
middle-parasternal clavicular line), for 12 sec. exactly,
doctor has to estimate lt.
of reflex for a second time: in healty, it results unchanged, whereas in
case of hyperinsulinemia-insulinresistance lt. appears to be >
12 sec., e.g. 14 sec., in direct relation to receptor disorder , i.e.
hyposensitivity. 3)
Restano’s
Manoeuvre. It is composed of the simultaneous application of boxer’s
test plus apnea test (See
later on), i.e. a dynamic sensitized test, since it induces sympahetic
hypertone. Restano’s Manoeuvre is very useful, for instance, in
evaluating RESHS in case of numerous diseases, when basal value (lt. =
10 sec. intensity 1 cm.) seems to be normal, but after the
manoeuvre becomes clearly pathological : lt lowers to 3 sec., with
intensity > 1 cm. and enhancing lt. of 8 sec.or less (Restano’s
Manoeuvre type B); in type A intensity is £
1 cm. and enanhing lt. 9 sec. 4)
Valsalva’s
Manoeuvre. Notoriously, this manouvre
provokes increasing of acetyl-choline, unavoidable, for instance,
in the biophysical evaluation of endothelial function evaluation.
This manoeuvre is so well
known, that I leaves out to describe it. Reflexes. 1)
Caecum
reflex. Stimulating
a large number of trigger-points of all biological systems, after
a variable latency time (lt), in healthy fixed in well defined tissue,
brings about caecum dilation: physiologically, the reflex lasts £
4 sec., and then the viscera volume returns to basal size for >3
<4 sec., i. e. for the same time
as the fractal dimension, calculated in a more sophysticated and
refined manner. 2)
Caecum-esophageal
reflex. Digital pressure on cutaneous projection of caecum provokes
esophageal dilation, whereas LES contracts physiologically for 4-6 sec.
In case of colon diverticuli LES contraction persists for 10 sec.
precisely in a characteristic manner, . 3)
Caecum-gastric
aspecific reflex. In healty, digital pressure, as described above,
brings about gastric aspecific reflex of intensity <
1 cm., whereas in case of gastritis
intensity of reflex
raise to ³
1 cm. 4)
Caecum-duodenal
reflex. In
healthy, stimulating caecum trigger-points evokes duodenal dilation fo 3
sec., followed by duodenal contraction of ³
1cm.. In case of duodenitis the duodenal contraction does not
arise, indicating a duodenal disorder, even silent. 5)
Caecum-ureteral
reflex. Light digital pressure on caecum projection area provokes
three ureteral reflexes, i.e. upper, middle and lower ureteral reflex,
which allow doctor to evaluate vasomotility and vasomotion of
this viscera. 6)
Cerebral-gastric
aspecific reflex. Digital pressure (type I) and/or nail pressure (type
II = pathological) bring about gastric aspecific reflex. In
healthy, lt. of type I reflex is 6 sec., while type II reflex, absent
under physiological condition, araise in case of epileptic focus,
even silent, i.e. in asymptomatic patients, as well as in other cerebral
pathologies, as meningitis, tumour, a.s.o., in association with type I ,
which reveals a lt < 6 sec. 7)
Cerebral-caecum
reflex. Cerebral trigger-points stimulation provokes caecum dilation;
these parameters, however, appear
to be the same as those of cerebral-gastric aspecific reflex. Obviously,
it can be utilized particularly in patient, who underwent complete gastrectomy.
8)
Cerebral-ureteral
reflex. Digital pressure of low-mean jntensity, on cerebral
trigger-points, provokes three ureteral reflexes, upper, middle a lower
ureteral reflex. They are unavoidable
also to evaluating cerebral
vasomotility and vasomotion, even in well localized area. 9)
Cerebral
cholecystic reflex. Under above-described conditions, stimulating
cerebral trigger-points causes the cholecystic reflex, i.e. cholecyst
dilates. 10)
Cholecyst-esophageal
reflex. Digital pressure on cholecyst cutaneous projection area brings
about esophageal reflex and His’s angle raising. 11)
Cholecyst-gastric
aspecific reflex. Digital pressure on cholecyst trigger-points (See
earlier) provokes gastric aspecific reflex. 12)
Cholecyst-caecum
reflex. Under above-illustrated condition appears caecum dilation. 13)
Cholecyst-ureteral
reflex. In healthy, the light stimulation of cholecyst
trigger-points induces the three ureteral reflexes, described above:
upper, middle and lower ureteral tracts dilate and, then, fluctuates in
a chaotic-deterministic manner. 14)
Colon
descending-caecum reflex. Stimulating trigger-points of descending colon
provokes caecum dilation (See V. 9). 15)
Colon
descending ureteral reflex. Once more, light digital pressure on
the descending colon causes three ureteral reflexes, illustrated above, unavoidable
in evaluating both vasomotiliy and vasomotion of descending colon. 16)
Descending
colon-esophageal reflex. Intense digital pressure on descending colon
causes esophageal dilation, while His’s angle raises clearly and LES
contracts for 4-5 sec. physiologically. On the contrary,
LES contraction lasts characteristically 10 sec. in case of
descending colon diverticula, allowing doctor to identifying this
disease. 17)
Descending
colon-gastric aspecific reflex. Under the same condition, described
above, appears the gastric aspecific reflex. 18)
Esophageal
Reflex.
A large number of
reflexes, starting from nervous receptors localized in almost all
biological systems, end in esophageal wall, causing its dilation and LES
contraction, lasting for diverse time, organ-depending, in both
physiological and pathological conditions.
19)
Gastric
aspecific reflex. In daily practice represents the most frequent reflex
to be ascertained, under both physiological and pathological situations,
due to the fact that in the stomach, notoriously, bring to an end
numerous reflexes, originating from everywhere in human body.
“Vagale” gastric aspecific reflex : fundus and body of stomach are
dilated, whereas antral-pyloric region contracts. Less frequent is
“sympathetic” gastric aspecific reflex, in which
the stomach dilates completely. 20)
Liver-gastric
aspecific reflex. Intense digital pressure on liver projection area of
the skin provokes the gastric aspecific reflex. 21)
Liver-caecum
reflex. Under above-described condition, caecum dilates. 22)
Liver-ureteral
reflexes. Light
digital pressure on liver projection area brings about three ureteral
reflexes, useful in evaluating vasomotility and vasomotion. 23)
Oculo-gastric
aspecific, -esophageal, caecun and
–ureteral reflex. Analogously, light-mean digital pressure on
an eye-ball (when eye is closed, of course) causes the known reflexes
after a latency time different, in relation to local condition. 24)
Pancreatic-caecum,
-gastic aspecific, -ureteral and –esophageal reflex. Prolonged
pinching at level of VI thoracic dermatomere (skin of right or left
hypochondrium, i.e. the skin covering costal arch,
right or left, along middle-parasternal-line) causes the well
known reflexes. 25)
Splenic
reflex. Stimulating numerous trigger-points provokes splenic reflex,
i.e. the size of spleen
increases for about 6 sec. due to it congestion, and thereafter it comes
back to normal, basal value. 26)
Splenic
gastric aspecific, -caecum, -ureteral reflex. Digital pressure of mean
intensity, applied on cutaneous projection area of spleen causes the
well known reflexes. 27)
Ureteral
reflex. Ureteral reflex (es) is (are) provoked by the stimulation of
numerous trigger-points of all tissues; there are three important
ureteral reflexes, which really play a primary role in evaluating vasomotility
and vasomotion of all biological systems, because their fluctuations
parallel those of arterioles (= upper ureter), interstitum (ureter
“in toto”) and, respectively, nutritional capillaries and
venules (= lower ureter). These ureteral reflexes enabled
me to investigate clinically tissue-microvessel-units of every
biological systems, allowing thus the foundation of the Clinical
Microangiology. Signs. 1)
Bella’s
sign, classic and variant. In case of retrocaecal appendicitis,
until now really difficult to recognize clinically (but not only
at the bed-side) with the aid of old, accademic, physical semeiotics,
the patient bends its stretced right leg towards abdomen: the
“spontaneous” GTC rapidly appears (100% of cases), after a
gastric aspecific reflex of only 1-2 sec.
lt and lasting 3 sec.: Bella’s Sign “classic” (Bella’s Sign “variant”:
patient bends the left leg in identical manner, as described
earlier, with the same results in case of appendix located in left
ileo-pelvic region). In healthy,
under identical above-described conditions, lt of gastric aspecific
reflex is 10 sec., duration > 5 sec. and GTC intensity is < 2 cm.
Interestingly, the degree of reflexes paramaters results the same
in next signs, pointing out internal and external coherence of
biophysical semeiotic theory. 2)
Berti-Riboli’s sign. The patient is invited “to press down its abdomen as to evacuate” (simulated
evacuation test; practically, patient
carries out Valsalva’s manoeuvre): immediatly stomach
dilates (i.e. the gastric aspecific reflex suddenly appears), then,
after 3 sec. precisely, stomach contracts rapidly in intense
manner: GTC Sign
of ³
2 cm.. In healty individual, under identical condition, lt of gastric
aspecific reflex is 10 sec., duration > 5 sec. and, finally, GTC
< 2cm. : Berti-Riboli’s Sign. 3)
Curri’s
sign. In patients, former involved by myocardial infarct, upper
ureteral reflex is spontaneously present, and fluctuates in
chaotic-deterministic manner, although with low fractal dimension. 4)
Daneri’
sign. In healthy, minimal vertical diameter of broncho-vascular-hilar
system in both lungs appears to be < 2 cm.. 5)
Domenichini’s
sign. During apnea test, the diameter of broncho-vascular-hilar
system decreases to minimal value, physiologically, for exact 3,5 sec.;
in case of lung disorder or BALT activation increases in characteristical
manner: duration 4,5 sec. in infections due to Gram-positive agents,
rheumatic diseases, tumours; duration 5,5
sec. in infections caused by Gram-negative bacterial agents,
and finally 7 sec. (most intense of all) in flu viruses. 6)
Gastric
Tonic Contraction Sign: stimulating numerous trigger-point causes
stomach tonic contraction, after a gastric aspecific reflex which lasts
only a few sec. (< 6 sec.): interestingly lt., duration and
intensity of these reflexes are correlated with the seriousness
of underlying disorder, allowing thus a “quantitative”
clinical monitoring. 7)
Massucco’s
sign.
In presence of
prostatic cancer, since early stage, cutaneous pinching of prostate
trigger-points (the skin of inguinal region, right and left), provokes
gastric aspecific reflex after 3-4 sec. lt, and, soon thereafter, the
Gastric Tonic Contraction. In healty, lt is >6 sec. and GTC is always
absent. 8)
Provoked
splenomegaly sign. In healthy, intense digital pressure on liver
projection are, induces splenomegaly, due to its congestion, wich lasts
only for 3-4 sec. In case of porta vein hypertension splenomegaly
persists longer, in direct relation to the severity of liver disorder. Syndromes 1)
Autoimmune
syndrome. Stimulating
trigger-points, where immunocomplexes are deposited, causes Gastric
Tonic Contraction and spleen decongestion, after
a gastric aspecific reflex and spleen congestion lasting only 3
sec. 2)
Cystic
syndrome. In presence of cyst in whatever organ as well as of dilation
of an artery, e.g., or viscera, as
ureter, digital pressure stimulates local trigger-points, carrying out
esophageal, gastric aspecific, and ureteral “in toto” reflex (=
ureter dilates in every part). 3)
Congenital Acidosic Enzyme-Metabolic Histangiopaty Syndrome (CAEMH).
This syndrome points out a mitochondrial, inherited, functional
cytopathology: digital pressure on cutaneous projection area of right
cerebral hemisphere provokes the gastric aspecific reflex, which appears
more intense than that brought about by identical stimulation applied on
left cutaneous area of homolateral cerebral hemisphere,
indicating the prevalence of right Planum temporale. 4)
Reticulo-Endothelial System Hyperfunction Syndrome
(RESHS). This very
useful syndrome corresponds to both erythrocyte sedimentation rate (ESR)
and proteins electrophoresis, but is more sensitive and specific. This
syndrom has to be ascretained most often
in daily pracice. In healthy, digital pressure of mean intensity,
applied on medial sternal-body line, iliac crests and cutaneous
projection of spleen, after 10 sec. exactly, provokes gastric aspecific
reflex (besides caecum dilation and spleen decongestion). Tests. 1)
Apnea
Test : the subject to be evaluated is invited to not breath, bringing
about sympathetic hypertone. 2)
Boxer’s
Test: closing intensively both hands (fists) an individual provokes sympathetic
hypertone. We have to remember, at this point, Restano’s
manoeuvre, i.e. simultaneous application of both tests: apnea and
boxer’s test. 3)
Simulated
Defecation Test: doctor asks the patient “to
press down its abdomen as to evacuate” (simulated evacuation
test; practically patient
is invited to carry out Valsalva’s manoeuvre) and acetyl-choline
concentration increases, allowing to evaluate,e.g., endothelial
function. 4)
Simulated
Feeding Test: doctor obtain identical results, illustrated above. 5)
Simulated
Stress Test: an individual thinks to speek in public or remember an
earlier doleful events, inducing thus sympathetic hypertone. 6)
Tests
of Diabetes Melitus Identification: in presence of diabetes mellitus, light-moderate hand or digital
pressure on internal site of an arm (or, for instance,
internal /external site of breast) after lt. > 3 sec. causes
gastric aspecific reflex lasting 3 sec. before reinforcing.
Interestingly, in Diabete Mellitus lt. is £
3 sec. in inverse relation to glucose concentration. In case of
glycosilated proteins enhancing, digital pressure on finger-pulps
provokes, after a lt of 3-4 sec., a first gastric aspecific reflex (wich,
in characteristical manner, increases slowly and persistently),
and then, after 4-5 sec. (NN = 6sec.) one observes another reflex: the
second lt. is in inverse
relation to glycosilated proteins concentration. Of greatest interest, stimulating
pancreas trigger points (VI thoracic dermatomere, i. e. the skin on
costal margine, right or left, along para-sternal- middle-clavicular
line) provokes ureteral
reflex “in toto” of intensity > 1 cm.: characteristic sign of
Non-Insulin-Dependent DM. Moreover,
digital pressure on trigger-points of SST-RH neuronal centre (i.e., 2
cm above and 2 cm. before external acoustic meatus) in diabetic
patient causes, after lt 6 sec. exactly,
a first pancreatic congestion of intensity ³
2 cm. (NN = 2 cm.), which lasts for 6 sec.( if oncological
terrain is absent), followed by pancreatic decongestion for exact 25
sec. Finally, a second pancreatic congestion appears and persists only
6-7 sec. (NN = 8 sec. exactly), in inverse relation to diabetes mellitus
seriousness. Of interest, in case of Hyperinsulinemia-Insulinresistance
later parameter appears more lasting: > 8 sec., directly
correlated with the severity of this pathological situation. 7)
Fist
Test: The subject closes intensively a hand. In healthy, after lt.
³
7 sec., appears the caecum reflex (and gastric aspecific reflex),
indicating tissue acidosis. Opening the hand, after 3 sec. exactly
of interruption, doctor evaluates for a second time this parameters:
physiologically, lt. increases to ³
10 sec.. On the contrary, in case of circulatory disorder, e.g. ATS,
arterial hypertension or when arterial peripheral resistances are
increased and Microcirculatory Functional Resrve is altered, lt. of
caecum reflex (or gastric aspecific reflex) is clearly lowered:
£
6 sec., but the intensity is increased > 2 cm. 8)
Simulated
Movement Test: thinking to
move arm, hand, finger
a.s.o., brings about hyperemia in relative cerebral centre, i.e.
there is localized microcirculatory activation type I, associated. 9)
Simulated
Urination Test: an individual is invited to press its abdomen as to
urinate. In healthy, appears suddenly ureteral reflex “in toto” as
well as gastric aspecific reflex, which last only for 3-4 sec. and then
rapidly disappears. On the
contrary, in case of urinary tract disorder, non neoplastic in origin,
including Benign Prostatic Hypertrophy, both reflexes persist for longer
time. Interestingly, in
case of malignancy of urinary tract, after 3-5 sec. gastric
aspecific reflex is rapidly followed by the characteristic Gastric Tonic
Contraction. In case of renal cyst, apart from its size and
degree, the test causes cystic syndrome: in practice, ureter dilates
“in toto”. Particular
Evaluations. 1)
Cholesterol
and Triglycerid (tissue) Evaluation. Digital (hand) pressure of mean
intensity, applied on cutaneous prjection of the liver, physiologically
provokes gastric aspecific reflex after lt. of
³
7 sec. with a
duration < 4 sec.
and intensity £
2 cm. Thereafter, the reflex diseappears completely for > 3
sec. < 4 sec.(differential latency time, which notoriously
parallels to fractal dimension: 3,81). When lipids synthesis is
pathologically increased, the liver-gastric aspecific reflex presents a
typical behaviour: lt. < 7 sec., intensity > 2 cm. e duration >
4 sec. Interestingly, the
reflex does not entirely
disapear, residuing a small gastric aspecific reflex, the intensity
of which is directly related to that of lipids synthesis. Of particular
interest is the sensibilized evaluation by mean of Ferrero-Marigo’s
Manoeuvre (See earlier): apart from present lipids concentration,
the persisting gastric
aspecific reflex – the residuing one -
appears to be > 2cm., although its basal value is in normal
ranges, as in patient with earlier hyperlipidemia but normal at the
moment. 2)
Hyperinsulinemia-Insulinresistance
Test. By means of
renogram as well as surrenogram,
the assessement of this dangerous and insidious situation,
because almost always asymptomatic, can be easily performed. As a
matter of facts, in healthy, acute insulin secretion peak provokes
augmentation of kidney size of 3 cm., after lt. of about 10 sec.; kidney
fluctuations (Phase C in diagrams) last for 8 sec.
(NN = 6 sec.). On the contrary, due to receptors
down regulation, kidney size increasing is smaller
or completely absent, in correlation with the seriousness of
hyperinsulinaemia-insulinresistance. Under identical condition, surrenogram
provides to doctor the same information: in healthy, the first
oscillations persist in normal intensity ranges, but in case of
hyperinsulinaemia-insulinresistance, starting from the third normal
fluctuation , one observes fluctuation lowered, lasting AL +PL
only 5 sec. (NN = 6sec.), due to microcirculatory inactivation ,
provoked by the hormon, under pathological condition. 3) Natriuretic Atrial Peptides (A and B) Evaluation: in order to assess NAD type A, i.e. NAD synthesized by heart, doctor applies “intense” digital pressure on cutameous heart projection area and simultaneously evaluates kidney behaviour, namely congestion of the kidney. In healthy, starting 5 sec. from the beginning of pressure application on precordium, kidney transverse diameter augments of about 3 cm. and its fluctuations show the maximal intensity, 1,5 cm., i.e. Highest Spikes, with AL + PL (duration) lasting 8 sec. On the contrary, in presence of heart coronary disease, excluding early stage, kidney congestion appears to be clearly smaller than normal value, in direct correlation with the seriousness of underlying disorder. In fact, in case of severe myocardial ischaemia, kidney size does not change, because NAD level is really increased, but receptors sensitivity is lowered, due to receptors down-regulation. The assessement of NAD type B (B = brain), synthesized also by cardiac ventricles, doctors applies intense hand or digital pressure on cutaneous projection area of the parietal lobe, right and/or left, because other cerebral convolutions cannot synthesize NAD type B, and simoltaneously estimates - See above – kidney behaviour: the response is normal in patient with coronary heart disease, whereas in brain vascular disorder as well as in other cerebral pathologies, response appears to be smaller than normal or completely absent, in correlation with disease seriousness. In conclusion, my findings allow to state that in both cerebral and myocardial ischaemia, due to renal receptors down-regulation, although NAD secretion is really intense, augmentation of the kidneys size, secondary to congestion, is absent or statistically not significant. 4) Renal Function Evaluation by load of water. It is an original bed-side evaluation of renal function, related in a satisfactory way to RPF and GFR. At first, in a indivual in supine position and psycho-physically relaxed,doctor assesses renal diameters, evaluated as minimal degree, renogram, i.e the chaotic-deterministic fluctuations of kidney besides period, duration and intensity of ureteral peristaltic wave. In healthy, following data are observed: 6 cm. x 12 cm., Phase C (kidney congestion) duration 6 sec., oscillation intensity varying between 0,5 cm. and 1,5 cm. in a chaotic-deterministic manner, period fluctuating between 9 sec. and 12 sec. In addition, the peristaltic wave period at base-line is 18 sec., intensity < 1 cm. and, finally, duration of urether dilation is 3 sec. exactly. Soon thereafter, subject is administered 250 cc. water and then, after a latency time of 3 minute, the degree of above- mentioned parameters, are evaluated for a second time. “Minimal” kidney diameters increases (> 6 cm. and respectively > 12 cm.), renogram appears to be of “vagal” type,i.e. Phase C is clearly augmented with 7-8 sec. duration and all fluctuations are identical, as far as intensity and period are concerned. In addition, ureteral peristaltic wave shows an incresed intensity (³ 1 cm.) lasting for 6 sec. (doubled than that at base-line) and a period decreased to 12 sec. exactly. Actually, the degree of the numerous renal parameters are related in a satisfactory manner to RPF, while ureteral parameters are correlated with GFR. 5)
Uric
Acid Pool Expansion. In healthy, pinching
(or digital pressure, applied on)
bended auricular helix, between thumb and finger, provokes
gastric aspecific reflex after lt. of exact
10 sec. On the
contrary, when acid uric pool expansion is present, for instance during renal
colic, above-mentioned stimulation causes the reflex after a shorter latency time
(e.g. < 7 sec.), in inverse correlation with the severity of
underlying disorder. Of interest, in case of articular or abarticular
gout, both digital and ungueal pressure on the diseased
“sinovium” induce gastric aspecific riflex and lt is in inverse
correlation with disease seriousness.
Finally, of special interst is the sensitivized
assessement by means
of Ferrero-Marigo’s manoeuvre
(See earlier): even in previous episode of uric acid pool
expansion, in at moment only apparently healty individual, i.e. apart from
actual acid uric blood level, doctor observes pathological values of the
reflex. Velocimetry Assessement
of the velocity of peristaltic wave 1)
Esophagus. Physiologically, cutaneous pinching
at the level of sternal manubrium brings about
a peristaltic wave, which reaches cardias region after 5-6 sec.
along great stomach curvature. Doctor can observe this event with the
aid of auscultatory percussion of the stomach. On the contrary, in
esophageal pathology, independent from it origin, including thus hiatal
hernia, lt. or time of conduction araise to 7-8 sec. in directe
correlation with intensity of disorder. 2)
Cholecyst-Choledochus.
Cutaneous pinching at right of cholecyst projection area
originates a peristaltic wave in this viscera, wich is perceived at the
level of mean third of choledochus after 5 sec. precisely. In case of cholecystitis,
cholelithiasis, adenoma or tumour, conduction time increases to 8
sec. 3)
Colon.
Cutaneous pinching and/or digital pressure on the right iliac fossa
provoke a peristaltic wave, which reaches descendent colon-sygma after
30 sec. exactly: with the
bell-piece of stethoscope located on
left abdominal quadrants, doctor applies percussion of descent colon ,
estimating easily the time of wave conduction. 4)
Stomach-Duodenum.
Auscultatory percussion of the stomach and duodenum allows doctor
to assess the time of conduction of a peristaltic wave,
originated as usually at cardias level, due to cutaneous pinching
immidiately under sternal xiphoid process, which reaches antral-pyloric
region in 5 sec. and duodenum (II duodenal segment) in 7 sec.
Last update: March 18, 2018 |